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SPINAL EXTENSION; ITS MODES, MEANS, AND

MOTIVES.

BY BENJAMIN LEE, M.D., PH.D., F.A.A.M.,

PENNSYLVANIA.

EXTENSION of the spinal column, like most brilliant modern discoveries in medicine and surgery, is at least as old as the "Old Man of Cos." Mechanical therapeutics, which, under the paralyzing influence of the mysticism of the middle ages-an influence from which the profession is still struggling to emancipate itself was consigned to an inferior and most degraded position, was indeed highly prized by his acute and profound intellect. Not only as a means for treating affections themselves mechanical in their nature, such as the various deformities, but as an agent for the relief of manifold disorders dependent upon or accompanied by blood-stasis and exudations, he assigns to mechanical therapeusis the very highest rank as a method of medicine, both on scientific and on experimental grounds. The modes in which spinal extension may be practised are three: Vertical, Inclined, and Horizontal. The means for carrying out these different modes, which have been or are still in use, I will briefly glance at under the same heads.

First, Vertical Extension.-The earliest apparatus which we find noticed for this purpose is described by Hippocrates in treating of succussion as a means of rectifying spinal curvatures. It made use of the weight of the body as an extending force with the superaddition of a powerful momentum. It was certainly a heroic mode of treatment. His advice was that when the disease was situated high up in the spine succussion should be performed with the feet downwards, in order to secure a greater extending weight; but when in the lower part of the column with the head down, for the same reason. He describes the mode of attaching the patient to the ladder with a minute-" ness of detail, which shows him to have had practical acquaintVOL. XXXI.-51

ance with the method
I call your attention to this plate illus-
trating the process, not simply as a matter of historical curiosity,
but with a view to relieving the apprehensions of those who
hesitate to adopt the gentler modes of extension which I advo-

cate.

You notice that the apparatus consists of an ordinary ladder somewhat longer than the patient. Hippocrates directs that it should be padded with leather or linen cushions, laid across, and well secured to one another, to a somewhat greater extent, both in length and breadth than the body will occupy." The patient is then to be laid on the ladder upon his back, and the feet at the ankles are to be fastened at no great distance from one another to the ladder. He is to be similarly secured above and below the knees and at the nates. The arms, as you see, are strapped to the body. "When you have arranged matters thus," he says, "you must hoist up the ladder either to a high tower or to the gable end of a house." When raised to the requisite height it was allowed to come down by the run, a firm piece of ground being carefully selected to receive it. pretty clear that "something must give" in the due performance of this operation, which, however, nothwithstanding its apparent danger, continued to be practised until the middle of the sixteenth century. It certainly afforded convincing evidence of the wonderful strength of the spinal ligaments.

It is

Less violent methods of vertical extension were later employed. Among these perhaps that best worth noticing is the "spine elongator," of Mr. R. E. Stafford, of London, author of "Two Essays on Diseases of the Spine." He says in treating of lateral curvature: "Lateral exercise, however, will not always recover a lateral curvature. The spine is sometimes so completely distorted, and the vertebral column so entirely thrown out of the centre of gravity that the muscles have lost their power. They are so stretched on the convex, and so contracted on the concave side of the curve that they cannot act. In such cases lateral exercise will not alone be sufficient. More must be done. The spine itself must be elongated; and the best method of accomplishing this is by gravitation of the body. To effect this object I have invented a machine by which the patient can be raised up from the ground by the upper part of the body, while the lower part hangs suspended. Hence the lower part, by its own gravitation and by additional weights being hung around the

1

hips, gradually elongates the spinal column until it becomes nearly if not quite, for the time being, straight." Mr. Stafford's essays were published in 1844.

Mr. John Shaw made use of weights and pulleys to draw the head and shoulders upward, the patient being in the sitting posture. Prof. J. K. Mitchell of the Jefferson School in Philadelphia and a physician of New York, whose name at this moment escapes me, both used extension with flattering results, the former especially in the shape of a contrivance known as the spine car, which united the advantages of locomotion with those of extension, and which is now seen in its perfected form in my improvement of Darrach's wheel crutch with elastic head sling. Mitchell's simple suspension apparatus is shown in Fig. 1.

Fig. 1.

Mitchell's Spinal Suspensor.

My own experiments in vertical extension date back about fifteen years, when Dr. Weir Mitchell, of Philadelphia, kindly called my

attention to his father's mode of using it, and the gratifying success which had attended its employment in his hands. They resulted in what I believe to be the very important modification of self-suspension, which by placing the extending force in the patient's own hands, robs the operation of all its terrors, converting it, in fact, into a pleasant amusement. My instrumentmaker, Mr. Spellerberg, of Philadelphia, has, as you see, by means of a folding tripod brought the entire affair within very reasonable limits for transportation (Fig. 2). The tripod, how

Fig. 2.

Spinal swing with folding tripod. The tripod folded is seen on the left.

ever, is not an essential feature, as the hook can be screwed up in a very few moments over a door-way or to a joist in the ceiling. You observe the mode of application. The patient taking hold of these ovoid handles makes traction downwards on the cord. As this cord passes over a pulley, and is attached by its other end to the patient's head by means of chin and occipital straps, the force which he exerts draws the head upwards, slowly unbending the curves of the spine and relieving the diseased vertebræ, if it be a case of caries, from superincumbent weight. If it be a case of lateral curvature, the patient grasps the higher handle with the hand corresponding to the depressed shoulder. The exercise is rarely painful. It is oftener necessary to check than to encourage the patient in its use.

Secondly, Inclined Extension has, however, found more general favor, especially in England, than vertical.

Among the means for its employment, I notice Verral's Prone Couch, Shaw's Inclined Plane, Sheldrake's Inclined Bed, and

Harrison's Spinal Couch. These apparatus, as you see by the plates to which I now point, all have the common feature of making use of the weight of the limbs and lower part of the trunk as an extending force, which, owing to the partial recumbency of the patient, can be exerted through long periods of time; and, therefore, as was claimed by its advocates, will accomplish more satisfactory results than the more powerful traction of vertical extension, which can be tolerated for but a comparatively short time. One of its most useful forms, in lateral curvature, is a modification of Lonsdale's couch, in which the patient's trunk is supported by a broad band passing under the projecting shoulder, while the limbs rest upon a counterpoised, hinged support, which not only affords an opportunity for using their weight as an extending force, but also for active exercise of the muscles of the spine and of the sides of the trunk.

Thirdly, Horizontal Extension has had many advocates. Hippocrates describes its mode of application minutely. Paré, whose work on surgery was translated into English as early as 1665, quotes extensively from the former, and adopts his method in this operation. It was performed, as will be seen in this plate, by manual force, a bandage being carried around the chest, under the axillæ, and another around the hips, and traction being made on these, at either end of the table by a stout attendant, while the physician himself made pressure downward upon the projecting vertebræ. Paré says that, "Unless extension be made, restitution is not to be hoped for."

Among the more recent apparatus for this purpose, I instance Darwin's Bed, Delpech's Couch, and Cole's Orthopedic Sofa, which are represented in these diagrams. In all of these, traction is made simultaneously upon the head or arms or both in one direction, and upon the hips in the reverse direction, the force being either in the shape of a screw or of a windlass.

The most perfect piece of mechanism ever constructed, however, for the purpose of producing horizontal extension of the spine, is that to which I now have the pleasure of calling your attention. It is the product of the inventive brain of Mr. W. H. Johnstone, of Philadelphia, the manufacturer of the Adaptable Porous Spinal Jacket, and was devised by him, at my suggestion, for the purpose of taking the plaster cast, in order to obtain a counterpart of the patient's body in a state of extension, with a view to moulding the felt jacket upon it. It consists of a strong

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