History of the Treatment of Spinal Injuries

History of the Treatment of Spinal Injuries

John Russell Silver Emeritus Consultant National Spinal Injuries Centre Stoke Mandeville Hospital, United Kingdom

Foreword by Sir Roger Bannister

Springer Science+Business Media, LLC

ISBN 978-1-4613-4750-7 ISBN 978-1-4419-8991-8 (eBook) DOI 10.1007/978-1-4419-8991-8

@2003 Springer Science+Business Media New York Originally published by Kluwer Academic/Plenum Publisbers, New York in 2003 Softcoverreprint ofthe hardcover Istedition 2003

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Dedication

This book is dedicated to all those people with spinal injuries whose courage and cheerfulness served as a constant inspiration for this work.

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Foreword

In this book Dr Silver who has devoted his life to the treatment of spinal injuries achieves a unique balance of historical perspective and neurological expertise.

Early in the last century several great neurologists directed their piercing intellects towards this neglected problem. The British pioneers were Head, Riddoch and Holmes in the First World War but interest lapsed after 1918. Early attempts at treatment in Gennany by Wagner and Foerster were stifled in the 1930s by the rise of Hitler: he removed all Jewish doctors from official posts, many in neurology and psychiatry. They were "decertified" and demoted to "attendants of the sick" and only able to treat Jewish patients. Meanwhile 'many Aryan doctors joined the S.S., broke their Hippocratic oath, and placed service to the state ahead of their service to their patients: eventually this led to human experimentation and death camps, which were organised by doctors who decided who should live and who should die.

Ludwig Guttmann lost his post working as assistant to the distinguished Gennan neurologist Otto Foerster whom Dr Silver interestingly describes as "a thoroughly unpleasant man". Guttmann had to work as director of the Jewish Hospital and in 1939 fled to Oxford where until 1944 he was employed in the Neurosurgical Unit under Sir Hugh Cairns, who refused to promote him. Then when no one else would employ him he was made the first Director of the new Stoke Mandeville Spinal Injuries Unit. After 11 years, since 1933, without proper clinical responsibility, he seized the chance of clinical power and independence, even though the field of spinal injuries was unpopular because results of treatment were so poor. His control of Stoke Mandeville was utterly complete. He appointed staff and was able to accept suitable patients and reject others, at will.

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Dr Silver worked with Dr Guttmann for 4 years and so developed the expertise to become the Consultant in charge of the Liverpool Regional Paraplegic Centre. His experiences entitle him to make a judgement of Dr Guttmann that we should accept. It is measured and, I think, fair.

Dr Guttmann owed much to Dr Munro in America and did not have original ideas. The major problems that then led to death of paraplegics were bedsores and bladder and kidney infections. These Guttmann meticulously tackled, at first catheterising patients himself to prove that infection could be avoided. He felt passionately about clinical research and used X-ray techniques to measure the depth of bedsores. All aspects of care were analysed and woe betide any member of the whole hospital staff from doctors to porters who were found deficient or were dilatory in obeying his instructions. Patients who did not cooperate and submit were in danger of expulsion. But his methods worked. Whereas patients in three wartime spinal units, if they survived, were no better on discharge after two years, Guttmann's patients were usually rehabilitated to lead useful lives, even if wheelchair bound. The most successful competed in the para-Olympics which he devised and which eventually became a recognised and worthwhile part of the Olympic Movement. Guttmann's dictates were widely repeated in the medical world ~ for example of pastes and cream for bedsores he commented, "you can put anything you like on a bedsore except the patient". Patients were turned two hands day and night. He himself at times got up at night to make sure it was happening.

Dr Silver was proud to have worked with him as were many others who survived the experience. Does it matter, if like Harvey Cushing the founder of modem neurosurgery, he sought to blame others when something went wrong but always took the credit when things went right. Silver muses philosophically that some very successful people are extremely difficult with socially unattractive traits, being egotistical, stubborn, disagreeable, and bullies. But Silver accepts Guttmann as a dynamic, even charismatic, leader who by his percepts and example changed world wide the treatment of spinal injuries. If his faults were obvious, so were his triumphs and how much the latter outweigh the former, which I suggest can be accepted mainly as a result of his frustration under Foerster and his rejection by Oxford. It is thanks to Guttmann's refusal to accept defeat that thousands of paraplegics, instead of turning their faces to the wall, fought on and recovered hope for their future in fulfilled and useful lives.

I can commend this book highly both to neurologists and to students of medical history.

Sir Roger Bannister

Preface

Injury of the spinal cord has been known since antiquity. The spinal cord cannot be repaired. Treatment consists of preventing complications until the spine has stabilised and the patient can be rehabilitated to an independent life. Surgeons have concentrated upon carrying out an operation on the spine. There was no improvement in treatment until the beginning of the 20th century. This book explores the development of treatment in the Ancient World and the Middle Ages until Pare. After Pare medical traditions separated and the developments and leading figures are discussed.

In the 19th century the controversies over surgery in the United Kingdom between Cooper and Bell are described. The First World War led to the setting up of the first spinal unit in the United Kingdom with outstanding work by Head, Riddoch and Holmes. This work ceased and patients were looked after on a custodial basis at the Royal Star and Garter Home. The Second World War led to the development of modem treatment in the United Kingdom and Guttmann's role is evaluated.

In the United States Munro developed the first spinal unit in 1936 and pioneered treatment. Initially Canada followed and then excelled the United States.

In Germany, the leading country in Europe medically at the end of the 19th century, work started with Wagner and Kocher and was developed by the anatomical and physiological work of Foerster. The failure of treatment to evolve in Germany was due to the advent of the Nazi party with its policies of euthanasia, anti-intellectualism and anti-semitism.

In France the descriptive work of Dupuytren, Duchenne and Charcot is presented. The therapeutic work of Dejerine and Marie, who set up the first French spinal units in the First World War, is evaluated.

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Consistency in nomenclature proven to be difficult with respect to the following two points: 1. The nomenclature of the hospitals keeps changing. For example, Queen

Square started off as the National Hospital for the Relief and Cure of the Paralysed and Epileptic, and then it changed to the National Hospital for Nervous Diseases. It is now the National Hospital for Neurology and Neurosurgery but is commonly referred to as Queen Square. Other hospitals have closed down such as the King George V Hospital, central London. There is another King George V Hospital at Ilford which is now known as the King George Hospital which is totally confusing for the researcher and I am sure for the reader.

2. The difficulty of how to refer to traumatic injuries of the spinal cord as so many different descriptions are used: paraplegia, tetraplegia, spinal injury, traumatic spinal cord injury. I have tried to make the nomenclature uniform throughout but quotations

cannot be altered and the task proved impossible. John Silver

Acknowledgements

This book is based on an M.D. thesis for London University undertaken as a part-time self-funded student at the Wellcome Institute.

In the production of this book I have been helped by a number of people particularly Mr A Gresford and Miss Joanna Lawrence who have guided me in turning my thesis into a book.

I should like to thank Dr Hugh Baron for his meticulous monitoring of my ideas, his encyclopaedic knowledge of 20th century medicine, for restraining my wilder prejudices and pointing me in the direction of references. I would also like to thank Professor W.F. Bynum, Professor H. Cook, Dr A. Hardy, the late Professor R. Porter, Mr M. Samuelson, Professor P. Thane and Professor M. Tremblay.

The greater part of the book details historical facts that took place more than 60 years ago. Nevertheless the recollections and discussions with the following proved an original source of living history: Dr H. Baker, Professor R. Bowden, Mrs G. Buck, the late Dr J. Colover, Dr C. Dumurgier, Dr I. Eltori, Mr D.K. Evans, Dr H. Frankel, Mr N. Gibbon, Mrs E. Goddard, the late Dr A. Hardy, Dr P. Harris, Mr D. Le Vay, Mr M.R. McClelland, Professor B. McKibbin, Dr M. Maury, the late Dr V.C. Medvei, Dr P. Nathan, Professor R. Roaf, Professor A. Rossier, Miss J. Scruton, Dr N. Watson and Dr G. Weisz.

I also wish to thank the archivists and librarians who were particularly helpful: Mr J. Evans, Archivist at the Royal London Hospital, Mr S. Wilson, Archivist at Queen Square, the Public Record Office, the British Red Cross, the Coal Industry Social Welfare Organisation, the Royal Society of Medicine, the Rockefeller Library Queen Square, the Royal College of Physicians, the Royal College of Surgeons, Stoke Mandeville Hospital, and the Wellcome Institute.

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Contents

INTRODUCTION .................................................................... .1

Chapter 1 HISTORICAL SURVEY ............................................................. 5

Chapter 2 THE UNITED KINGDOM ........................................................ .11

Chapter 3 SIR LUDWIG GUTTMANN (1899-1980) AND THE NATIONAL SPINAL INJURIES CENTRE ...................................... 85

Chapter 4 UNITED STATES ................................................................... 99

Chapter 5 CANADA ........................................................................... .135

Chapter 6 THE GERMAN-SPEAKING WORLD ......................................... 145

Chapter 7 FRANCE ....................................... : ................. , .................. 205

Chapter 8 DISCUSSION ....................................................................... 241

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Chapter 9 CONCLUSION ..................................................................... 261

BIBLIOGRAPHY .................................................................. 269

GLOSSARy ........................................................................ 281

ABOUT THE AUTHOR .......................................................... 285

INDEX ............................................................................... 287

List of Figures

Figure 1 Reduction of a dislocation of the spine, Avicenna .................. 6

Figure 2 Sagittal section of the body, Leonardo da Vinci ..................... 9

Figure 3 The pathology of spinal cord injury, Charles Bell ................. 14

Figure 4 Gordon Holmes ......................................................... 31

Figure 5 The Empire Hospital ................................................... 33

Figure 6 Patients using primitive tricycles at the Royal Star & Garter Home ............................................ 52

Figure 7 Aerial view of Stoke Mandeville Hospital .......................... 74

Figure 8 The Spinal Unit at Stoke Mandeville Hospital: bed ................ 75

Figure 9 The Spinal Unit at Stoke Mandeville Hospital: dining ............. 75

Figure 10 Intermittent catheterisation was carried out on the patient's bed ............................................................ 76

Figure 11 Sir Ludwig Guttmann teaching ....................................... 86

Figure 12 Wheelchair sports ...................................................... 92

Figure 13 Harvey Cushing ....................................................... 103

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Figure 14 Tidal drainage apparatus designed by Munro ..................... 114

Figure 15 Wilhelm Wagner ...................................................... 159

Figure 16 Bohler's method of treating spinal injuries ........................ 182

Figure 17 Pare's method of reducing a dislocation by traction ............. 207

Figure 18 Pierre Marie ........................................................... 226

Figure 19 Passages marked by Guttmann in his copy of Munro's book, The Treatment ofInjuries to the Nervous System (1952) ................................................. 255

List of Tables

Table 1 Review of the English First World War literature ..................... 29

Table 2 Statistics from The Royal Star and Garter Home Medical Reports ........................................................... .48

Table 3 Sources of information about the first spinal units .................... 72

Table 4 Guttmann's methods of treatment ....................................... 88

Table 5 Contemporary views on Guttmann ...................................... 97

Table 6 Review of the French literature ........................................ 228

Table 7 Statistical data by Guillain & Barre (1916) ........................... 237

Table 8 Historical review of the literature ....................................... 242

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