Considerations on neurologic therapeutics: past, present, and future

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By Douglas J Lanska MD MS MSPH

"Is it surprising that in the practice of medicine... that there should be those who... recommend some newly-invented instrument of the greatest utility in relieving existing difficulties, when a moment's reflection must not only show its utter worthlessness, but that its application may produce the very derangements for which it is proposed to be applied?" (D Humprheys Storer 1866).

Neurology developed as a specialty from about the middle of the 19th century. In the 19th century, neurologists promoted various therapeutic techniques that required special apparatus or skills, but these therapeutic technologies were often poorly supported by scientific evidence of efficacy, and such technologies were often viewed negatively by the rest of the medical profession. In many cases the criticisms were entirely appropriate. In fact, although numerous therapeutic techniques that required special apparatus or skills were developed and promoted for neurologic disorders, they were poorly supported by scientific evidence of efficacy and were eventually abandoned when increasingly critical reports appeared indicating either much lower success rates than initially reported, frequent post-procedure deterioration, or serious complications (Lanska and Edmonson 1990).

For example, one of the notable therapeutic fads of the late 19th century was the suspension therapy for tabes dorsalis. This treatment, which involved suspending patients by their necks in complex apparatus, was rapidly and widely disseminated in the United States in the late 1890s on the basis of enthusiastic case series, facilitated by endorsements of eminent neurologists such as J Charcot (1829-1914) and S W Mitchell (1829-1914), and by widespread publicity in professional journals and the lay press (Lanska and Edmonson 1990). However, as summarized in an editorial in 1890, "As is often the case with remedies advised in incurable disease, [the suspension therapy] has had transitory beneficial effects in some patients, it has been followed by no result whatever in others, and in a few it has been productive of evil, and even of fatal, consequence. A large array of devices for the purpose of stretching the spine has been placed upon the market, from a modification of the medieval inquisitorial rack... to the comparatively simple gibbet of Sayre. In many office corners, the latter stands idly by, a mute monument to many buried therapeutical hopes, or a three-legged mendicant acting as an office-servitor [Anonymous 1890]." C L Dana, one of the early proponents, acknowledged in a retrospective account of early neurology in the United States [Dana 1928] that "We all had our drawers and closets filled with great rolls of bandages loaded with plaster [in order to apply plaster jackets for suspension treatments with L.A. Sayre's apparatus [Sayre 1878]." Less than 2 years after its dissemination, the suspension therapy was discredited and abandoned.

Numerous other therapeutic technologies were similarly advocated and disseminated for the treatment of neurologic disorders during the late 19th century, including carotid compression for treatment or prevention of seizures (Corning 1882-1887; Lanska 2002), thermal baths, sulfur baths, "hydrotherapeutics" ("the cold-water cure"), electrotherapeutics (galvanic and faradic stimulation), surgical nerve stretching, cauterization of the back, and various internal remedies (Lanska 1998). According to Dana, "[Another] line was that of splitting the penal meatus and passing in large bougies to harden the deep urethra and thus 'curing' epilepsy, impotence and neurasthenia. Under the impulsion of this therapeutic phase I spent my first $25 in a set of sounds, once faithfully used and now rusting in oblivion... It was [also] held that serious nerve conditions could be relieved by cutting the eye muscles or by adjusting glasses and putting the patient through long educational training. There was something of value in this procedure, and neurology put in its contribution as a result of a special committee of our neurologic society to study the subject. Its report, covering a period of more than a year, showed the value and limitations of eye work. Incidentally, we all equipped ourselves with trial glasses, and I remember that I several times cut or stretched the internus and externus oculi" (Dana 1928).

Unfortunately, none of these therapies provided any sustained benefit (Lanska and Edmonson 1990).

Although 19th-century therapeutic techniques were generally ineffective and soon abandoned, they did add to the armamentarium of pioneering neurologists (Lanska 1997). The sophistication implied by these techniques (particularly in the absence of more effective and less complex treatments) afforded a certain amount of legitimacy to neurology and helped neurologists to distinguish themselves from the general practitioners, thereby fostering the development of neurology as a specialty (Lanska 1997). Nevertheless, many late 19th-century and early 20th-century neurologists recognized the limitations of available therapeutics for neurologic disorders; they focused their energies instead on improving diagnosis, studying clinical-pathologic correlations, and establishing various clinicopathologic disease states.

As a result, a pervasive opinion among medical professionals through at least the first half of the 20th century was that neurologists had little to offer as far as improving the clinical conditions of patients, even if they were often recognized as expert diagnosticians. Even today it is not uncommon to hear the disparaging remark about the practice of neurologists: "diagnose and adios," a phrase that may have originated with neurologist Labe Scheinberg in the 1950s concerning the futility then of treatments for multiple sclerosis (Rowland 2005). Similarly Richard Masland, a former director of the National Institute of Neurological Disorders and Stroke, reportedly said that "for all the good we do for multiple sclerosis, neurologists could be replaced by sympathetic nuns" (Rowland 2005). But that nihilism is thankfully changing as a result of the development of effective treatments for a growing number of conditions.

Consider some of the neurologic conditions for which major therapeutic progress has been made (generally during the 20th century), leading to marked declines in the incidence and prevalence of some neurologic conditions to the point where they are no longer a significant part of general neurological practice; indeed, for some conditions only the most senior or most widely traveled neurologists have ever seen a case. Prevention and treatment have largely eliminated some neurologic conditions in developed countries, including some vitamin deficiency disease (eg, pellagra) and some infectious diseases (eg, poliomyelitis, neurosyphilis in its most dramatic forms, tetanus, rabies, leprosy, and diphtheritic palsies). In addition, prevention and treatment have remarkably curtailed other neurologic conditions in developed countries, again including some vitamin deficiency disorders (subacute combined degeneration of the spinal cord, beriberi, and Wernicke-Korsakoff syndrome), some infectious diseases (eg, bacterial meningitis, trichinosis, botulism, and congenital rubella), and also some toxic conditions (eg, lead encephalopathy and neuropathy, and mercury poisoning).