THE DEVELOPMENT OF THE MODERN IDEAS OF TREATMENT OF SPINAL INJURIES John Russell Silver Submitted for examination for the degree of M.D. University of London Date 2001 ProQuest Number: U642623 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. uest. ProQuest U642623 Published by ProQuest LLC(2015). Copyright of the Dissertation is held by the Author. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code. Microform Edition © ProQuest LLC. ProQuest LLC 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106-1346 THE DEVELOPMENT OF THE MODERN IDEAS OF TREATMENT OF SPINAL INJURIES ABSTRACT 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 has been no improvement in treatment until the beginning of the 20th century. The development of treatment in the Ancient World and the Middle Ages until Paré is explored. After Paré medical traditions separated. In the 19*'^ 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 modern 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 19*^ 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. The failure of treatment to evolve is explored. TABLE OF CONTENTS Title Page 1 Abstract 2 Table of contents List of Tables List of Illustrations Acknowledgements 6 Introduction 7-9 Chapter One. Historical Survey 10-16 Chapter Two. The United Kingdom -19**^ century 17-28 Chapter Three. The United Kingdom -1®* World War 29-69 Chapter Four. The United Kingdom - Between the wars 70-87 Chapter Five. The United States 88-129 Chapter Six. Canada 130-141 Chapter Seven. The German-speaking World 142-178 Chapter Eight. France 179-223 Chapter Nine. The United Kingdom - Second World War 224-228 Chapter Ten. The First Spinal Units 229-248 Chapter Eleven. Sir Ludwig Guttmann 249-265 Chapter Twelve. Discussion 266-291 Chapter Thirteen. Conclusion 292-300 Bibliography 301-319 Glossary 320-323 LIST OF TABLES Table 1 : Review of the English First World War literature 36 Table 2: Statistics from The Royal Star and Garter Home Medical Reports. 59 Table 3: Review of the French literature 208 Table 4: Statistical data by Guillain & Barré (1916) 220 Table 5: Sources of information on the first spinal units 233 Table 6: Guttmann’s Methods of Treatment 254 Table 7: Contemporary views on Guttmann 263 Table 8: Historical Review of the Literature 269 LIST OF ILLUSTRATIONS Fig 1 : Reduction of a dislocated spine in Arabian medicine 12 Fig 2: The anatomy of the spine by Leonardo da Vinci 15 Fig 3: The pathology of spinal cord injury by Sir Charles Bell 21 Fig 4: Gordon Holmes (1876-1965) 36 Fig 5: The Empire Hospital 40 Fig 6: Tricycles at the Royal Star & Garter Home 63 Fig 7: Harvey Cushing (1869-1939) 94 Fig 8: Munro’s Tidal Drainage 107 Fig 9: Wilhelm Wagner (1848-1900) 155 Fig 10: Bohler’s method of treating spinal injuries 168 Fig 11 : Paré s method of reducing a dislocation by traction 182 Fig 12: Pierre Marie (1853-1940) 206 Fig 13: Aerial view of Stoke Mandeville Hospital 236 Figs 14-15: Photographs of the Spinal Unit at Stoke Mandeville Hospital 237 Fig 16: Intermittent catheterisation carried out on the Patient’s bed at Stoke Mandeville Hospital 238 Fig 17: Guttmann teaching 251 Fig 18: Wheelchair sports 259 Fig 19: Passages marked by Guttmann in his copy of Munro’s book Injuries to the Nervous System (1952) 284 ACKNOWLEDGMENTS I should like to thank Dr Hugh Baron for his meticulous monitoring of my ideas, his encyclopaedic knowledge of 20“^ century medicine, for restraining my wilder prejudices and for editing the text and pointing me in the direction of references. I would like to thank Professor W.F. Bynum’s and Dr A. Hardy’s formal supervision in showing me how my thesis should be constructed, Professor H. Cook for administrative supervision of my M.D. and Professor R. Porter and Professor M. Tremblay for valuable informal discussion at the Wellcome Institute for the History of Medicine. Although the majority of the work took place more than 60 years ago, the recollections and discussions with the following proved an original source of living history; Dr H. Baker, Professor R. Bowden, Mrs G. Buck, Dr J. Colover, Dr C. Dumurgier, Dr I. Eltori, Mr D.K. Evans, Dr H. Frankel, Mr N. Gibbon, Mrs E. Goddard, Dr A. Hardy, Dr P. Harris, Mr D. Le Vay, Mr M R. McClelland, Professor B. McKibbin, Dr M. Maury, 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. I am grateful for the meticulous translation of the German and French texts by Dr Frank Beck, Karin Band and Marie-France Weiner and the outstanding patience of my secretaries, Lindsay Cornell, Marie-France Weiner and Helena Bradbury, in putting this thesis together. This research was undertaken as a part-time self-funded student at the Wellcome Institute. INTRODUCTION I qualified in 1954 at the Middlesex Hospital Medical School, London University. As a student, my interest in orthopaedics was generated by Mr Josiah Grant Bonnin (1909-1989), Orthopaedic Surgeon at the Central Middlesex Hospital. My first job was in Accident Surgery at the Luton & Dunstable Hospital, dealing almost entirely with major trauma from Watling Street. After a six month appointment I was anxious to see ‘cold’ orthopaedics and visited both the Royal National Orthopaedic Hospital, Stanmore, which specialised in the correction of scoliosis and the repair of peripheral nerve injuries, and the National Spinal Injuries Centre at Stoke Mandeville Hospital where Dr Ludwig Guttmann (1899-1980) had already established an international reputation for the treatment of spinal injuries. The ward rounds, teaching sessions and the whole atmosphere at Stoke Mandeville were remarkably stimulating and uplifting. I decided to pursue a career in spinal injuries and after obtaining full registration, I returned to work at the National Spinal Injuries Centre. I believed that Guttmann had pioneered the treatment of spinal injuries and that prior to his work, all spinal patients died rapidly after injury from renal sepsis and overwhelming pressure sores. I spent my National Service as an orthopaedic junior specialist in the Royal Air Force (RAF). Following this, I expanded my neurological training by spending three and a half years on the neurology, neurosurgery and physiology units at the Middlesex Hospital, returning to Stoke Mandeville in a research post on the spinal unit until appointed consultant in charge of the Liverpool centre in 1965. At that time, although aware that there were spinal units at the Veterans’ Hospitals in the United States, I had always uncritically accepted that priority for the development of treatment rested at Stoke Mandeville, particularly because when Dr Ernest Bors (1900-1990), the leading spinal injury specialist in the Veterans’ Hospitals, visited the unit in 1963 he paid tribute, describing Stoke Mandeville as being the Mecca of spinal injury work. 8 This belief persisted until, in 1969, at a meeting at the Ministry of Health held to discuss the setting up of additional spinal units in the United Kingdom, Harold Jackson Burrows (1902-1981), told me that the original work had all been done in the United States by Donald Munro (1889-1973), from 1936 onwards. During the Second World War, although there were spinal units in the United Kingdom, treatment was not successful. Realising how advanced the Americans were, Guttmann, who was not working in spinal injuries at the time, had been sent with Frank Holdsworth (1904-1969), an orthopaedic surgeon from Sheffield, to visit Dr Munro in order to observe his methods and set up spinal units in the United Kingdom incorporating Munro’s ideas.