Related to Material relating to the rehabilitation of spinal and spinal cord injuries
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'Denny-Brown and Robertson (1933) Learmonth (1930), Holmes (1933) and Watkins (1936) published important papers, on the neurophysiology of the normal and the cord bladder, and in the later 'thirties Munro (1935) in America was beginning to publish the earliest of his many articles on tidal drainage. There is, however, little literature directly bearing on paraplegic management in this period, but a paper read by Gowland to the Harveian Society in London in 1934 is particularly pertinent as it gives a very informative picture of the stage rehabilitation of these cases had reached at this time. Gowland was Medical Superintendent of the Star and Garter Home where there were a number of patients with chronic traumatic paraplegia, survivors from World War I. He writes: 'Perhaps somewhere about 11.30 a.m. the patient is dressed and placed in a wheelchair. . .. Two to three times a week the patient is bathed. This means he must be lifted from his bed to his ward chair and wheeled into the bathroom where his pyjamas and night clothes are removed and he is placed in a very warm bath and washed by an orderly.' These men were neither expected nor allowed to do anything for themselves. He continued: 'These painful contractures (spasms) are a very serious problem ... the pain is often terrible. I suppose there is more morphia, atropine and hyoscine used in this home which I look after than in any other place of the same size in the country, but when you consider that these patients cannot be cured ... .' With regard to the bladder and bowels he writes: 'Orderlies have instructions to go round between one and two a.m. to remove, empty and replace urine bottles. Not infrequently the patient 's bowels have moved and he is lying in his excrement.' ' ... Patients spend one or two days a week entirely in bed. These are called enema days.' Again with regard to bed sores: 'In all these cases the circulation of the skin below the injured area is deficient... the skin will break down under quite minor irritations'. These brief quotations serve to bring out several points, namely that these men were in no way able to look after themselves, nor were they encouraged to do so. It would appear probable that owing to the prevailing attitude of hopelessness many had been allowed to become drug addicts. Nothing could be clearer than that these survivors were but shadows of their former selves, pathetic wrecks, dependent and helpless and the recipients of much devoted but misguided care.' (174-175)

 

'to show the attitude of despondency it is only necessary to quote verbatim the Medical Research Council (1924) report previously mentioned: 'The paraplegic patient may live for a few years in a state of more or less ill-health'.' (175)

 

'Penicillin and the sulphonamides, to say nothing of the more modern antibiotics, were not available to this generation at war [during WWI]. Had they been, without doubt there would have been many more survivors to swell the numbers in these chronic homes. It seems probable that owing to the lack of such drugs, which help so much in tiding the patient over the early hazards of bedsores and urinary sepsis, a state of mind was engendered in which the future of these cases was regarded as hopeless.' (175)

 

'The importance of a high suprapubic incision [for drainage of the bladder] was not sufficiently appreciated in the early years of the war. While the vast majority of cases admitted to spinal injury centres had suprapubic cystotomies, many were situated very low on the abdominal wall, a method which became almost universally condemned. As to other aspects of therapy little was said or written. Knight in 1942 advocated the use of plaster beds. MacAlpine (1940) considered that when bedsores appeared in the form of black blisters the contents should be aspirated and the black skin left [(175-176)] intact - advice which all subsequent experience proved to be unacceptable. Nissen in 1940 and 1941, in the light of his recent experiences, also advocated plaster beds... Everts and Woodhall were able to write in 1944: 'It certainly cannot be said that any striking advance has been made in the late care of spinal cord injuries'.' (175-176)

 

 

'A Spinal Injury Unit in the North of England 1940-1944 (Winwick). This special centre at Winwick was a mental hospital in peace-time and was partially taken over by the Ministry of Health. Special centres in neurosurgery, orthopaedic surgery, medical neurology, peripheral nerve and spinal injuries were set up. General medical and surgical cases were to a limited extent also admitted. A neurosurgical team was in charge of this spinal injury unit, but no one member of the team devoted more than a part of his time to the care of spinal injury cases...

To facilitate the nursing problems, well-fitting anterior and posterior plaster beds were largely used, and while in no way advocating this method (the disadvantages of which had been stressed by Guttmann (1945) and Munro (1940) and others), undoubtedly healing of sores did take place in some cases though in others new sores formed and old ones were aggravated. This method, in view of the extreme shortage of nurses, did enable frequent turning to be easily and rapidly

carried out... There did not appear to be any definite plan of rehabilitation of even the more fit patients. In 1944 there were 40 paraplegics distributed over six different wards. In each of these wards there were also orthopaedic, neurosurgical and general surgical cases. The nursing staff looking after the spinal injuries did not specialise in that work and were required to nurse cases of other types and were frequently moved to other wards. The number of trained staff was so inadequate that a high proportion of dressings for the chronic and 'hopeless' cases was performed by untrained nurses. A very small proportion of the patients with cord or cauda equina lesions were able to sit out of bed in a chair. At that time the hospital did not possess a single padded wheelchair and the amount of physiotherapist's time available was ridiculously inadequate. The mental attitude of both patients and staff wasone of stoic apathy... [(176-177)] I was working on the Medical Neurology and Peripheral Nerve Injury Unit at that time and did not have anything directly to do with the cases of traumatic paraplegia. Sir Geoffrey Jefferson, Adviser in Neurosurgery to the E.M.S. and in particular Consultant Adviser to Winwick, asked me to give up some of my work on the Medical Neurology Unit and take charge of all the cases of traumatic paraplegia in the hospital.

Within a very short time I was voicing my complaints and ideas about concentration of cases into one unit, continuity of treatment, staffing inadequacy, etc. He listened patiently to my tale of woe and then said: 'You must go and see a chap called Ludwig Guttmann at Stoke Mandeville Hospital. He has got ideas about the rehabilitation of the paraplegics'...

I wrote a long report for Sir Geoffrey Jefferson about what I had learned, which was a great deal. What I found extremely difficult to convey to him and to others was Ludwig Guttmann's concept of the paraplegic as a disabled but healthy independent person, with an independent future in society. The enthusiasm for this concept, which emanated from Sir Ludwig and permeated the whole of his staff, was a break-through in new thinking. This was the vital thing, an idea which had never before been seriously entertained.' (176-177)