Ludwig Guttmann’s Memorandum: a review on the surgical aspects of spinal cord injuries written in 1944 for the Nerve Injury Committee of the Medical Research Council: with notes and commentary

Introduction

During the Second World War, George Riddoch, chairman of the Nerve Injuries committee of the Medical Research Council (MRC), asked Ludwig Guttmann to carry out a review of the surgical aspects of spinal cord injuries (Figure 1). The resulting memorandum, written prior to the opening of the spinal unit at Stoke Mandeville Hospital in February 1944, was thought lost until it was unexpectedly found among a bundle of George Riddoch’s papers.¹ These recently (2017) came into my possession owing to Jill Blau, widow of Nat Blau (1928–2010), a neurologist at Queen Square. This newly discovered document provides a unique insight into the development of the speciality and reveals Guttmann’s debt to his predecessors. This debt to forefathers was aptly described by Isaac Newton in a letter to Robert Hooke in 1676 when he declared: ‘If I have seen further it is by standing on the shoulder of giants’. In view of (Sir) Ludwig Guttmann’s seminal contribution to the treatment of spinal injuries, this memorandum is published in full with a commentary that draws on the author’s long professional association with Ludwig Guttmann, which started in 1956, and his work over many years at Stoke Mandeville Hospital.

Figure 1

Ludwig Guttmann’s Memorandum: a review on the surgical aspects of spinal cord injuries written in 1944 for the Nerve Injury Committee of the Medical Research Council.

Born in Silesia in 1899, Ludwig Guttmann worked as a medical orderly at the accident hospital for coal miners in Konigshütte where Wagner had treated spinal injury patients 20 years previously. After the First World War, he trained as a doctor and qualified in 1923. He worked in Breslau under Otfrid Foerster who had a major influence on his future approach and philosophy towards spinal injury treatment. Foerster, who was a master in rehabilitation and the first neurosurgeon in Europe, was described as a doctor who could make the blind see and the lame walk.² Guttmann received a thorough training in neurology, neurosurgery and in rehabilitation of peripheral nerve injuries as Foerster treated over 4000 such cases.³ When the Nazis came to power, Guttmann lost his position as Foerster’s assistant and worked for 5 years at the Jewish hospital in Breslau. In 1939, he escaped to England but could not practice clinical medicine for 5 years as his qualification was not recognised. He worked in the Department of Surgery under Professor Hugh Cairns, carrying out research on peripheral nerve injuries but was extremely frustrated and considered leaving to enter general practice. His unique knowledge of rehabilitation of peripheral nerve injuries was recognised and he gave a lecture on the subject in the distinguished company of Geoffrey Jefferson at the Royal Society of Medicine, which was published in 1941.³ Guttmann was curiously reticent about this paper, although his ideas on peripheral nerve rehabilitation were subsequently incorporated into spinal cord rehabilitation.

Historical context

As Hitler’s aggression spread across Europe, a resumption of hostilities was inevitable. Unlike the First World War, when casualties had all been servicemen, many civilian casualties were anticipated because of bombing. In 1939, Riddoch was appointed consultant neurologist to the army with the rank of Brigadier. He was chairman of the MRC committee on peripheral nerve injury, with responsibility for setting up spinal injury units. On the eve of the Second World War, only three British doctors had any experience of treating spinal injury cases; George Riddoch who was Resident Medical Officer in charge of a spinal unit at the Empire Hospital during the First World War, and Gordon Holmes and Henry Head who had both treated cases during the First World War. The Staff were not appropriately trained; physiotherapy was not yet fully established so exercise was not being used to rehabilitate patients. Occupational therapy was in its infancy as a profession with an ill-defined role; 'any activity, mental or physical... hastening recovery from disease or injury'.⁴

A series of spinal units under the direction of Frank Holdsworth, an orthopaedic surgeon, and the neurosurgeons Geoffrey Jefferson and Norman Dott were opened on Riddoch’s recommendation to treat spinal injury cases; these units were not properly staffed and the patients lingered in appalling conditions.⁵ At 63 and 78, respectively, Holmes and Head were too old to take an active part in treating casualties with spinal injuries. In contrast, Riddoch was 51 and worked tremendously hard, not only setting up the units but visiting them, advising the consultants, treating the patients and offering to carry out the neurology at the spinal unit at Stoke Mandeville as there was no neurologist. Riddoch invited Ludwig Guttmann to write a review of the surgical aspects of spinal injuries for the nerve injuries committee of the MRC because of his extensive experiences in the rehabilitation of peripheral nerve injuries. This memorandum is written from the Department of surgery in Oxford where Guttmann, then aged 40, was working for Hugh Cairns until 1944. The background to this document is curious. No other copy could be found in the Guttmann archives at the Wellcome Library, in the Stoke Mandeville Hospital Library archives or in the Public Record Office. A comparison with his own handwriting confirms that Riddoch extensively annotated Guttmann’s draft document, mainly to correct the English and the use of medical terminology but also where Riddoch’s own work is discussed on pages 10 and 11. Unfortunately, these notes are in pencil and difficult to decipher.

This memorandum is valuable on three counts: firstly, it delineates the contemporaneous level of understanding of the treatment of spinal injuries. Secondly, it reveals Ludwig Guttmann’s early thoughts and opinions on how best to treat such patients and, finally, it marks the beginning of the comprehensive treatment of spinal injuries. These notes are not meant to be an exhaustive criticism armed with hindsight of the memorandum. It is the memorandum that is of prime importance as it marks the start of the comprehensive treatment of spinal injuries.

Overview

General remarks

Despite the fact that he had not treated patients for 5 years while he was carrying out research and for the previous 7 years he had been working at the Jewish Hospital, away from Foerster’s specialised unit, his observations are acute, practical and well thought out. Guttmann was erudite and scholarly in his research, and he provides a very detailed and thorough analysis of the literature, especially the German contribution. This was a formidable task in those days before the Internet, unlike today when a literature search is available at the press of a button. His knowledge was not just theoretical, derived from study of the literature; he clearly had treated patients in Foerster’s department and could evaluate the different forms of treatment in light of his own experience.

He repeatedly emphasises how the doctor should be in total charge of the patient, a cornerstone of his treatment. He does not discuss exercise in detail or occupational therapy as these have been addressed in a previous article on peripheral nerve injury (1941), but Guttmann uses the same methods to rehabilitate spinal injury patients as applied to peripheral nerve injury patients.³

Detailed remarks

Mechanism of spinal cord lesion

He knew about fractures in tetanus infections in metrazol shock therapy due to the strong contraction of the erector spinal muscles and multiple fractures at different levels. He describes the mechanics of injury and the dissociation of cord injury from the site of the injury, the contre-coup mechanism seen in gunshot wounds of the spinal cord with the fracture far away from the initial trauma.

First aid

With regard to the administration of first aid, his management of the patient cannot be bettered, stressing the need for a doctor to supervise the lifting and transfer of the patient and obtaining an accurate history from the outset.

Treatment of closed injuries of the spine

He reviews the literature with a careful analysis of the arguments for and against surgical intervention and fixation, and the whole passage can be read with profit today. He discusses two different forms of treatment, manipulative reduction followed by fixation as described by Boehler as opposed to Magnus whose method based on Kocher’s work that rejected manipulative reduction. He does not come to any conclusion but, fascinatingly, he adopted Magnus’s method, called it postural reduction, as his standard method of treatment, rejecting all forms of surgery on the basis that it destabilised the spine and could lead to deformity. He discusses the dangers of laminectomy, in that it destabilises the spine, and later in his own practice he became vehemently opposed to this, based on his own experience in the management of these cases and how general shock is contra- indication to any operation. This has been underlined by Riddoch in the document, suggesting that it is of prime importance. He devotes eight pages to the treatment of the fracture in spinal injuries. He discusses critically the indications for surgery and, contrary to his later views, he favours early operation where there is direct pressure on the cord, the rapid development of progressive paralysis or the presence of a haematoma. He would later abandon these views in favour of more conservative management of the fracture.⁴ He discusses palliative surgical treatment for spastic and flaccid paralysis where he discusses section of the posterior roots introduced by Foerster. He subsequently rejected this form of treatment and carried out an alcohol block.

Management of the bladder

In the First World War, the majority of patients died rapidly of urinary infection spreading to the kidneys. Thomson-Walker found that out of 339 patients with spinal cord injuries between 1915 and 1919, 47 died from urinary tract infection 8–10 weeks following injury.⁶ Guttmann discusses the methods of draining the bladder. This section is widely annotated by Riddoch who emphasises the danger of overdistension of the bladder. Guttmann only mentions the danger of infection spreading to the kidneys; he does not address the mortality. He discusses whether the methods of drainage should be continuous or whether there should be washouts. He does not fascinatingly discuss the method of intermittent catheterisation as practiced by Wilhelm Wagner, William Thorburn and John Hulke, and which he subsequently introduced at Stoke Mandeville Hospital.⁷ He does stress, however, that the overall care of the bladder must be the responsibility of the doctor and not the nursing staff.

Pressure sores

Despite the overwhelming danger of pressure sores, he only mentions these in a few lines. He does not discuss how pressure sores can penetrate the skin, involve the bone and cause death.

General care of the patient

He devotes a passage to the position of the patient to prevent contractures and shows his profound knowledge of physiotherapy and nursing. He was light years ahead of anything in the UK, and he taught the students of the School of Masseurs at Stoke Mandeville Hospital how to treat patients (Figure 2). His teaching and precepts served as an inspiration to physiotherapists throughout the UK and beyond.

Figure 2

Ludwig Guttmann teaching in the physiotherapy department at Stoke Mandeville Hospital. Personal photograph taken from History of the Treatment of Spinal Injuries, 2003, JR Silver, Chapter 3, p.86. Reproduced by kind permission of Springer Science+Business Media BV.

Thermoregulation

He stresses the impaired sweating caused by paralysis.

Conclusion

Ludwig Guttmann had direct experience of spinal cord injuries, which he drew upon to treat the patients. He stressed that a doctor should be in charge of all aspects of treatment. Despite the fact that it was a surgical paper, he dealt with pressure sores and the care of the bladder. Clearly at this stage his mind was open and various ideas that he had from his own experiences and review of the literature were not fixed into dogma. The cornerstone of his treatment, which he maintained throughout his professional career, was the holistic care of the patient that all aspects of treatment must be integrated as a whole.

‘The most skilful operation on the most suitable case will prove useless if the many little details of good nursing care are not fully understood’.

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