Related to 'Cob', '"I watched my chair roll gently over the precipice": a chapter of adventures and mishaps across the continent', The Cord 5 (3) (October 1952), pp. 25-30.
Description:

Account by paraplegic individual of experience of travelling through continental Europe 'by wheel chair and car' (25)

'I started on my homeward journey on a hot Sunday morning - alone and rather broke...

On the way to Ravenna there was a steep and nasty pass over the Appenines. About half-way up, the engine petered out and refused to start. The midday sun beat down. I waited. Eventually a motor cyclist ccme[sic] along and we managed to start the engine after pumping some petrol through the carburettor.

The engine stopped again near the top and I thought I could start it if only I could get the car pointing down-hill. Two youths appeared at this moment and helped me around. However, it still refused to fire, and as it was siesta time - just after lunch - it was unlikely that anyone would come along for a while, so I decided to get out and play around with the carburettor myself. I keep the chair in the back seat, so I got it out, lined it up for the transfer, let go of it for a moment to adjust the car seat - and looked up just in time to watch it roll gently over the edge of the precipice and out of sight. Miniature avalanches continued for some seconds, and it sounded as if the chair had come to rest about fifteen feet below. Five, fifteen, or fifty, I now had to wait.

... Quite soon afterwards a small Fiat drew up and an elderly lady and gentleman stepped out. My Italian was sufficient to explain that I couldn't walk and didn't have a chair... but... I had to resort to sign language, and it was a long time before I could make it clear that I did not want to go all the way down to San Godenza at the foot of the pass. I managed to direct them to the point where the chair had gone over and the discussion continued irrelevantly until one of them happened to look over the edge and saw the chair. The dawn of enlightenment broke rapidly. The man disappeared over the edge, and after many further avalanches and much wheezing he reappeared with the chair. It was a good effort and they were a very nice couple. I adjusted the carburettor, started up, and this time reached the top.' (29)

Related to 'Discussion of rehabilitation after injuries to the central nervous system (section of neurology)', Proceedings of the Royal Society of Medicine 35 (4) (1942), pp. 295-308.
Description:

Guttmann defines rehabilitation in terms of working capacity: 'Rehabilitation after peripheral nerve lesions means restoration of the working capacity of the injured person.' (305)

 

He places particular emphasis on the importance of beginning rehabilitation as soon as possible after an injury: 'Dr. E.A. Nicoll's opinion expressed on this subject in a recent paper on fractures "Rehabilitation starts on the first day of treatment" can be accepted in the full meaning of the words also for peripheral nerve lesions.' (305)

'precautions should be taken in all General and Military hospitals, particularly in Military Base-Hospitals, that the injured can be seen immediately by a Nerve Specialist versed in the after treatment of peripheral nerve lesions. Neglect of this vital principle of rehabilitation in the first period, even in the first days after injury, accounts for much of the prolonged disability of the injured person with all its economic con.sequienices.' (305)

 

He emphasises the importance of specialized centres for the treatment of nerve injuries: 'The congregation of cases in a single department under the same specialized staff, with continuous treatment under the same supervision, is certainly the best guarantee for a systematic study of the whole question, and for better results. The success of a centralized treatment and care of peripheral nerve injuries in other countries was shown by the "Peripheral Nerve Centres" in the U.S.A. during the last war and particularly by Foerster's work in Germany during and after the last war.' (305)

 

He also highlights the importance of continuing care of patients after discharge from hospital, especially in relation to returning to an occupation: Of the same importance as the primary supervision immiiediatelv after injury is the late supervision of these cases after their discharge from hospital... One of the main tasks of the "after-care service" is (1) to provide the injured man with light and graduated work in his former occupation ultil he is fit for heavy work; (2) to supervise this light and graduated work. In my own experience the best results in supervising the injured persons during the reconditioning period were obtained with the help of industrial medical officers and general practitioners.' (306)

 

He suggests ther should not be any absolute distinction between 'hopeful' and 'hopeless' cases: 'Cases with peripheral nerve lesions can be grouped into those in which restoration of nerve conduction is possible and those in which there is no chance of nerve regeneration. In regard to treatment, however, this distinction is not an absolutely strict one as similar principles have to be considered in both cases up to a certain point.' (306)

 

Guttmann considers maintenance of the 'elasticity' of muscles of paramount importance in rehabilitation: ''The position of paralysed limbs follows the principle of close approximation of the points of attachment of the paralysed muscles. The principle underlying treatment is to maintain and increase elasticity of the affected muscles. All experts on the subject agree that overstretching of a paralysed muscle even in the very first period after injury means a severe and often irreparable additional damage of the paralysed muscle.' (306) - these comments prompt a discussion of the importance of splints in maintaining appropriate body position.

Related to 'Living at Home - No. 3', The Cord 1 (3) (1948), pp. 18-20.
Description:

first-hand account of experience of living with paraplegia:

 

 'I congratulate the writers of the first two articles in this series. They feel they have got this business of living at home buttoned up. I haven't I have worked out some kind of a system, certainly, but it is untidy and bristles with problems which need to be cleared up; sex, pain and employment are three of them.' (18)

 

'it's hard as hell to find out what you are entitled to and it's not easy to get it when you do find out. Does everyone know that a paraplegic can get a clothing allowance of £5 a year? And extra coal? And extra soap? And extra milk? Nobody told me.' (18)

 

'A paraplegic more than most men needs a job. When a man is really at work he doesn't get much chance to think about himself... My old job was out of the question. And I went home after three years in hospital completely untrained for any kind of job. I had spent hours making rugs, doing needlework, trying to learn to draw and stuffing flannel dogs and rabbits. Occupational Therapy it was called. No doubt it served a purpose - prevented me from being more of a headache to the hospital staff than I might have been - but for all intents and purposes it was just a waste of time... I had no saleable skills. My wife came to the rescue. She borrowed a typewriter and taught me to type. A friend helped me into a job as a telephonist-clerk. The switchboard was a puzzle for a time, but I believe I can now hold down this job in competition with anyone. And any other paraplegic could do the same.' (18-19)

 

'At hospital I learnt to walk a little with calipers... At home it seems more and more to be simply not worth the trouble. If you go out to work you have more than enough to do already - there just isn't enough time and energy left. But I can't help feeling it would be a pity to lose the trick altogether after sweating so hard to learn it. What is the answer?' (19)

 

'I have what the doctors call "root pain", that is, a severe ache which never stops and which at moments is almost unbearable. These moments are either the result of something physical - like a bowel constriction - or something mental - like tiredness and worry... People who deal with paraplegics should always try to bear in mind the fact that a great deal of their physical energies are taken up in dealing with pain and in trying not to show it.' (19)

 

'Before I left hospital I spent a lot of time wondering whether I should get married - whether in fact I was justified in getting married... I new that marriage consists mostly of companionship, but I knew also that sex was very important. What I didn't know was whether, however much my wife-to-be might adapt herself to circumstances, she might not be badly frustrated by insufficient sexual satisfaction. I wasn't at all sure that unconsciously she mightn't be unhappy because her sister had kids and she probably wouldn't have any. I wasn't in the least certain either that I wouldn't be very frustrated myself. I seem to feel sexually the same, but I couldn't do much about it. It was a bit of a problem and, frankly, it still it. I think it is one of the biggest problems of paraplegia and I would like to know both from the doctors and other married folk what the answer is.' (19-20)

Related to 'Living at Home - No. 7', The Cord 3 (3) (Spring 1950), pp. 22-23.
Description:

First-hand account of living with paraplegia:

 

'this business of dealing with the problem of paraplegia is rather like coping with income tax in this country to-day. Your first £110 you get free of tax - that is your initial adjustment, the automatic one, the time when you are in hospital and you begin to realise that there are endless things that you can still enjoy, plenty of scope for ambition. Then come the tax-free allowances - the placidity of your type of mind, your lack of ambition, the apparent simplicities of your new existence... But it is after that, after you break away from the simplified life of hospital, once you start doing things, that the difficulties begin. It is then that the Collector of Taxes starts knocking daily on your door. For you begin to realise, not what you can't do, but that you do not know accurately what you can't do. And this is the taxation, this is what ends, when you have proved that you can do almost everything, at 19/6 in the £.' (22)

 

'How do you know this can't be done or that achieved?... to acquire that knowledge means that acceptance is not the first thing, but the last.

... between the first and last lies the process of discovery. Not just one discovery, but hundreds. You are not just Columbus, but you are Drake and Magellan and Henry the Navigator as well... You are always searching and always finding and always on the verge of discovery... That of course, is the problem. When do you settle back and reckon the existing maps are good enough?' (23)

Related to 'Motor cars for the disabled', The Cord 7 (2) (September 1954), pp. 15-16.
Description:

'Ex-members of the Forces and Mercantile Marine who are receiving Pension at the rate 100% for disablements due to War Service coming within one of the following categories are eligible to be considered for the provision of a car or for an annual allowance in respect of a privately owned car :-

Category A

Double leg amputation with one or both above knee.

Category B

Paraplegia causing total or almost total loss of use of both legs.

Category C

Other severe disablement directly affecting the legs to such an extent as to cause total or almost total loss of the use of the legs.' (15)

Related to Dog How, 'Matters at random: a Paraplegics' Committee?', The Cord 7 (3) (December 1954), pp. 13-15.
Description:

Notes dissatisfaction regarding arrangements for the representation of 'paraplegics' (including himself) in the British political systemt:

'I have followed more or less the affairs of paraplegics, but I must confess that I have paid far less attention to detail since I came out of hospital a long time ago. However, I believe there was never a body of paraplegics which could speak directly to the Minister or to his department. I remember experts who were notable, gifted and well grounded in their professions, who could and did make recommendations to the authorities on behalf of paraplegics; no dloubt on authority's side there were estimable individuals who received and considered points submitted. But I do not recall any one actually paraplegic - except one who was temporarily paraplegic; thus being more personally inspired and accepted as a representative of paraplegics.

Now why can we not have a Paraplegics' Committee? Its function would be to consider various problems and to present recommendations to the Ministry. It would, perhaps, be asking a lot for these recommendations to have a compulsive standing, but I feel sure that such a committee with official blessing and an assurance that its comments would be recieved and given due weight would go a long way towards reconciling the individual with the Ministry. It is absurd that those most concerned should have no voice in the solution of their own difficulties. The committee could receive suggestions from anyone interested and using their own experience of paraplegia could decide whether to pass it on, perhaps modified, or not.

I feel sure that two points (to mention only two) would receive early attention: that the disabled could do more paid work to fill many requirements of different Government departments, and that it MUST be possible for a disabled person to progress in his work and increase his earnings.

Maybe such a committee exists? I have never heard of it, bit I feel it should be very much alive.' (13)

Related to E. Gutmann and L. Guttmann, 'The effect of galvanic exercise on denervated and re-innervated muscles in the rabbit', Journal of Neurology & Psychiatry 7 (1-2) (1944), pp. 7-17.
Description:

'In a previous paper (Gutmann and Guttmann, 1942) it was shown that galvanic exercise of denervated muscles to a great extent counteracted the atrophyof the paralysed muscles and accelerated return to their initial volume after re-innervation...

The experiments which are described in this paper provide further evidences of the beneficial effect of galvanic exercise on denervated and re-innervated muscles. An attempt to find the optimum manner of application, time for starting, duration, and strength of treatment is also described.' (7)

 

'The experiments may be divided into two groups. (a) Treatment of denervated muscles without possibility of re-innervation. The peroneal nerve was cut and resected as far as possible on both sides, and the absence of re-innervation of the peripheral stump was confirmed at biopsy. A distinction was made between short-term denervation (37 days) and long-term denervation (67-150 days) and in the second group between early and late start of treatment also. (b) Treatment of muscles in which re-innervation was allowed: (1) after crushing the nerve; (2) after division and primary suture of the nerve; (3) after division and secondary suture by cross union...

Galvanic current only was used in all cases as this type of current is mostly used in man... The initial standard method of treatment was 20 minutes galvanic exercise daily at a current strength of 4-6 ma.' (7)

 

'muscles were excised... from the living animal at biopsy, put in a Petri dish with Ringer-soaked gauze and weighed after blotting twice with filter paper.' (8)

 

'In a previous paper it has been shown that after crushing the peroneal nerve with fine watchmaker's forceps, about 80 mm. from the M. peroneus longus, 20 minutes daily treatment with a current strength of about 5 ma. produced no significant difference in the time of onset of motor recovery (Gutmann and Guttmann, 1942).' (12)

 

'The results of all these experiments show clearly that the effect of galvanic exercise varies with its time and duration of application. The effect in preventing atrophy was found to be especially marked after daily application, with a current strength sufficient to elicit vigorous contractions of the muscles. The effect was greater the earlier the [(15-16)] treatment was started. Twenty minutes galvanic exercise gave very satisfactory results and has been used as the standard time of application, but 10 minutes daily exercise gave results only slightly inferior, while 30 minutes exercise showed little superiority to 20 minutes. No damage of denervated muscles was detected by the longer duration of daily treatment. These findings, which agree with those of Fischer (1939) and Hines,et al. (1943) do not support the view held by many physiologists and clinicians that galvanic exercise of paralysed muscles should not be used during the period of denervation, especially in the early stages. In fact no harmful effect of fatigue on denervated muscles of the rabbit was found and the results indicate that fatigue of denervated muscles by galvanic exercise in man may not be so harmful as formerly thought.' (15-16)

 

'After re-innervation of a muscle its "trophic state" will be restored spontaneously to a greater or less degree by voluntary impulses. Although there cannot be any doubt that in man active exerciseby voluntary impulses is the best treatment for a recovering muscle, it must be remembered that at the time of motor recovery muscle atrophy is still very marked and the power of voluntary or reflex movement is limited. Moreover, longer times of denervation and less successful re-innervation can be expected in most of the human cases. It is, therefore, advisable to continue electrical exercise until motor recovery is satisfactory, for as clinical experience has shown electrotherapy is most useful in augmenting active exercise in cases in which the patient co-operates poorly although re-innervation of the muscles is taking place (Guttmann L.,1942).' (16)

 

'The demonstration of the beneficial effect ofgalvanic exercise on denervated muscles has an important bearing on the problem of the cause of denervation atrophy which is still the subject of controversy. The theory of Langley and Kato (1915) that atrophy of denervated muscles is a fatigue phenomenon caused by ceaseless fibrillation was widely accepted until quite recently (Tower, 1937). The negative experimental results of Langley and Kato on electrotherapy and their statement that "the fact that the denervated muscles are in a state of continuous fibrillation makes it a priori an open question whether further activity caused by electrical stimulation will be beneficial" seems to have influenced many clinicians to condemn galvanic exercise...

Most of the negative results of electrotherapy have been due to inadequate technique. The effect of the condensor discharges used by Langley and Kato (1915) was very small and they stated "either then the daily induced contractions were insufficient in number to replace the normal contractions or the change in the muscles is not simply an inactivity atrophy." In fact, comparison of intensive within sufficient treatment, described here, indicates that the first explanation of Langley and Kato is the correct one (see also Fischer, 1943).' (16)

 

'The experiments described here reveal the great importance of activity as the leading factor in preventing muscular atrophy. Although the present experiments... do not prove that inactivity is the only cause of atrophy after denervation, they show clearly that the impulses which are responsible for the normal muscular activity and which are lost after denervation can be effectively replaced by galvanic exercise. Activity appears to be the important factor for the healthy "trophic state" of a muscle.' (17)

 

note: 'The authors are very indebted to Mr. J. Z. Young for his help and advice throughout the whole course of this work and for revision of the paper.' (17)

Related to F. Treves, A Manual of Operative Surgery (vol. 2) (1892 ed.).
Description:

'On June 12th, 1888, a paper was read before the Royal Medical and Chirurgical Society by Dr. Gowers and Mr. Horsley, which dealt with the case of a man from whose spinal cord a tumour had been removed with success. This paper may be said to form the foundation or starting-point of the more modern phase of spinal surgery.' (727)

 

'One of the earliest of the more formal operations was carried out in 1814 by the younger Cline. The patient died ; but the method of treatment excited considerable notice' and drew forth much adverse criticism. A successful case operated upon by Dr. Macewen in 1885 (Brit. Med. Journ., August 11th, 1888) marks a new era, and since then a laro-e number of successful cases has been recorded. Dr. William White, of Philadelphia, has given an admirable resume of these earlier cases in a paper published in the Annals of Surgery for July, 1889. He has collected thirteen recent examples of operation for fracture, with only one death.' (727)

 

'On May 9th, 1883, Dr. Macewen removed the lamince of the fifth, sixth, and seventh dorsal vertebrae in a case of complete paraplegia of two years' duration, depending upon angular deformity of the spine. The patient made a complete recovery. The number of cases of like character operated upon since this date has been numerous.' (727-728)

Related to H. Balme, 'The development of rehabilitation services in Great Britain', The Cord 5 (3) (October 1952), pp. 39-46.
Description:

'The first attempts to establish rehabilitation services in Great Britain took place during the first World War...

The excellent orthopaedic and rehabilitation hospitals organized by Robert Jones, and the similar chain ofAmerican hospitals established in Great Britain by Colonel Goldthwait, were unfortunately all disbanded at the end of the war'

 

Notes that nevertheless, after the First World War the BMA organized committee on fractures, and principles established by Jones were put into practice 'At two or three of the small hospitals - notaby the Hospital for Railwaymen at Crewe, under the leadership of Dr. Moore, and the Seamen's Hospital at the Albert Docks, where Sir Hugh Griffiths instituted the first full rehabilitation programme for injured dock-workers' (39)

 

Emphasises significance of WW2 for development of rehabilitation services

 

Describes rehabilitation practices current at the time of writing

 

Notes the importance of post-hospital rehabilitation centres: 'A very important group of residential rehabilitation centres, now under the National Health Service, was originally established by the Miners Welfare Commission, for the post-hospital rehabilitation [(43-44)] of coal-miners seriously injured in the pits. Eight such centres were opened, in close proximity to thhe chief coalfields, and by the spring of 1950 no less than 11,000 injured miners had passed through the centres, of which 96.2 per cent were back at work. When it is remembered that all these men had suffered from grave injuries - fractured spines and thighs, multiple wounds, etc. - the percentage returned to work is a truly remarkable figure' (43-44)

 

'With the passing of the Disabled Persons (Employment) Act immense progress has been made in the development of industrial rehabilitation services... whereas medical rehabilitation concerns itself mainly with the restoration of physical fitness, industrial rehabilitation is concerned with the recovery of confidence in ability to work, the training of those who need to find new vocations, and actual resettlement in suitable employment.' (44)

 

Notes that the Ministry of Labour has appointed a 'Disablement Resettlement Officer' 'at every Employment Exchange throughout the country', opened 'the Disabled Persons' Register', established 'thirteen Industrial Rehabilitation Units in large industrial areas, all but one of which are non-residential', provided 'training facilities for disabled persons' and built 'a large chain of sheltered workshops through the operation of the Disabled Persons' Employment Corporation, or Remploy' (44)

 

'These provisions [of the Ministry of Labour], coupled with the willingness of employers to accept a quota of 3 per cent. of disabled persons among their employees, have entirely changed the prospects of the disabled man or woman' (44-45)

 

'A very interesting experiment... has been the establishment of recuperative workshops in industry. This movement, which was started at Austin's Motor Works in Birmingham, and has since been greatly developed at Vauxhall Motor Works, Luton, and in other large firms, makes it possible for employees who have met with accidents or are recovering from illness to be put to work on machines which are suited to their reduced capacity, and which actually assist their full recovery by exercising muscles which need strengthening or joints which would otherwise become stiff.' (45)

Related to H.S. Talbot, 'Rehabilitation in a changing world', Paraplegia 7 (1969), pp. 146-152.
Description:

'From this troubled generation [of anti-Vietnam protesrtors], impatient, mistrustful, uncommitted, most of our patients now come. I must confess that it will sometimes toss us a queer one. Those of us who deal with veterans had become accustomed to patients who showed some slight evidence of the regimenting effect of military service. Far from having abandoned their individual prerogatives, they had at least learned the lesson of working in groups and of recognising that some sort of authority, however judiciously administered, was necessary to hold any enterprise together. The change began to be evident during the early days of the war in Vietnam; it was then that I encountered my first paraplegic beatnik. Lest you think I have fallen behind the times, I assure you of my awareness that beatniks are no longer the thing, as well as my confidence that the hippies who are now the vogue will in turn be replaced by abreed as yet unnamed. But to return to my patient; he was a young man of a little better than average intelligence and his military record was unimpeachable. He was long of hair and had a guitar which he played often until the other patients, in their own way, made known to him their musical preferences. He had a girl friend who was with difficulty convinced that his hospital bed was designed for single occupancy. Above all, he had his own idea of priorities. On admission he had a pressure ulcer which, after weeks of treatment, was almost healed. At this point he went absent without leave, returning unrepentant after a week or more to explain that he had driven to New York, some two hundred miles distant, to make a recording. The condition of the ulcer may be imagined, but he explained, quite reasonably, that making the record at that particular time was important enough to him to be worth a few more weeks of treatment in bed. He didn't deny the soundness of my advice; he simply chose not to take it. He didn't argue about my authority to order him to remain in the hospital, he just disregarded it. Some weeks later the incident was repeated. He was quite pleasant about it and when he was finally discharged we parted friends.' (150)

 

'We must, I think, bring a new and broader dimension to the concept of rehabilitation. It must be a holistic approach according to the Oxford English Dictionary's definition of holism: 'Tendency in nature to form wholes that aremore than the sum of the parts by creative evolution'. We must stop thinking of vocational rehabilitation or musculo-skeletal rehabilitation - or even of rehabilitation of the urinary tract - and focus upon the total rehabilitation of man or woman in terms of the society in which he or she must live. The parts are all essential but the whole will be greater than their sum if we devote our energies to the processes of creative evolution rather than to the defence of a fixed and no longer relevant pattern.' (151)

Related to J. Scully, 'Getting to grips with England', The Cord 5 (4) (December 1952), pp. 23-26.
Description:

'Trafalgar Square is one of those points where the lassies gather in happy anticipation of having a prince charming ride up on a white horse and sweep them off their feet. Nelson will climb down from his tower before that will come about. Unfortunately, most girls don't consider a prince charming riding up in a shiny chromium wheel-chair as an adequate substitute for one on a white charger.' (23)

Related to L. Guttmann 'New hope for spinal cord sufferers' Medical Times 73 (1945), pp. 318-326.
Description:

'Battle and air raid casualties involving injuries to the spinal cord and cauda equina with resulting paralysis excite our deepest sympathy and undoubtedly deserve the very best surgical and medical treatment available...

Until recently [however], the medical profession still seemed to be possessed with the old idea that little could be done for these unfortunate sufferers. Experience during the present war has shown that these cases are by no means as hopeless and helpless as was previously thought and that the modern principles of rehabilitation can be successfully applied to these men to prevent their being cast on the human scrap heap.

Rehabilitation after spinal injuries seeks the fullest possible physical and psychological readjustment of the injured person to his permanent disability, with a view to restoring his will to live and working capacity.' (6)

 

Recommends rapid evacuation of war casualties to maximize effectiveness of treatment: 'With rapid evacuation - i.e., within 48 hours - there is seldom need at this stage to tamper with the paralysed bladder or to subject the skin to the hazards of spinal immobilisation in plaster.' (7)

 

Identifies pressure sores and urinary infection as principal causes of post-injury complications: 'Two complications, which are the common cause of sepsis and death after spinal injuries, need special and permanent attention: pressure sores and urinary infection.' (8)

 

Discusses method of treating pressure sores: 'The patient is nursed on a special bed, which is rigid to prevent sagging and which is high to facilitate nursing, but not so high that nurses of average height cannot turn the patient without dragging. He lies on an air or sorbo mattress, but even more important than special mattresses are plenty of small pillows to support the paralysed limbs and trunk in the various positions adopted as a result of frequent turnings. The skin is kept scrupulously clean and the pressure points have gentle massage after each turning. Some patients were turned every t to I hour during the day and every 2 hours at night. This can only be carried out successfully if there is sufficient nursing staff available, and this is one of the reasons why a spinal ward needs a larger nursing staff than a general ward.' (8)

 

Suggests standard method of treatment of paralysed bladder by suprapubic cystotomy is not necessarily the most effective: 'In the present war, suprapubic cystotomy has been adopted by most of the surgeons as a routine emergency method in the early treatment of the paralysed bladder on the battlefield. Judging by the presence of urinary infection which has always existed in patients admitted to the Centre after suprapubic cystotomy (in a considerable number of cases of severe ascending type even), and by the presence of contracted bladders which have developed after this procedure, there is no real reason to consider this method as the method of choice in the treatment of every case of paralysed bladder.' (10)

 

Notes that in his own clinic (Stoke Madeville), 'Whenever practicable, suprapubic drainage is discontinued to encourage better voluntary action of the bladder.' (10)

 

Emphasises the importance of psychological as well as physical care: 'The sudden conversion of a vigorous man into a helpless cripple naturally tends to severe psychological shock and reactive depression. From the beginning, the patient's mental condition needs careful attention and treatment to prevent anxiety or resentment, which lead to apathy and inactivity...

the creation of a cheerful atmosphere and high morale in the ward is of vital importance. The whole unit must be impregnated with enthusiasm, and this inspires the patient to cooperate to the full... Indifference, anxiety and resentment, as well as the over-cheerfulness and self-deception which some of the cases show, also need attention in later stages.' (11)

 

'The idea is to mobilise all compensatory mechanisms in the paraplegic, in order to shift his psychomotor capabilities from the lower to the upper part of his body.' (11)

 

Suggests plaster beds can have deleterious effect on recovery: 'There have been patients - especially those who were admitted in plaster beds - whose recovery from paralysis was impaired by superimposed stiffness of all joints of the lower limbs and the spine.' (11)

 

Emphasises importance of movement for rehabilitation: 'From the first, physiotherapy is started with passive movements of the paralysed limbs to prevent stiffness of the joints... As soon as possible, especially when some voluntary function has returned, movements of joints by suspension methods in slings (as recommended by Guthrie-Smith, 1943) are added and have proved very effective.

Active exercises play a cardinal part in the rehabilitation of spinal injured, and these should be started early.' (11)

 

Cites wheelchairs as promoting of active exercise: 'As soon as possible...-the patient is promoted to a wheelchair. This in itself adds greatly to his range of activity.' (11)

 

Use of parrallel bars in rehabilitation: 'Most of the exercises are done in the wards, which are equipped with Balkan beams and parallel bars.' (12)

 

Highlights importance of game-playing for especially British patients, and own role in developing sports for patients: 'Games play an important part in the physical and psychological readjustment of paraplegics. In a country in which the play instinct is so highly developed, games are always appreciated by the patient as a good method of rehabilitation... The writer has introduced a special game, which is called 'wheel-chair polo'. The idea of this game is to distract the patient's attention from his disability, to keep the man's intelligence and concentration lively, to promote a good blood circulation, to keep his healthy limbs supple, and to invigorate the body.' (13)

 

Suggests wind instruments would also provide an appropriate mode of excersise: 'It is also planned to form a musical band with these men, with wind instruments. Besides proving a form of entertainment and increasing the men's independence, it will also help to strengthen their abdominal muscles.' (13)

 

Ultimate goal of recovery is to return men to work: 'in time, patients tire of making toys and crave for some serious employment...  it is hoped that, in future, vocational training of the spinal injured can be started at an early date, while the man is still in bed... 

We are still in the pioneer days with rehabilitation of spinal injured persons, and there is much more to be done for these tragic war casualties, especially for adjustment of employment to their permanent disability.' (14-15)

 

'The aim of physiotherapy and occupational therapy in paraplegics is to mobilise all compensatory mechanisms in the injured person, in order to shift his psychomotor capabilities from the lower part of the body to the upper. Games play an essential part in the rehabilitation of traumatic paraplegics. Wheel-chair polo has proved especially successful. Early vocational training is the best form of occupational therapy in paraplegics. The importance of special facilities for employment in the physical and psychological readjustment of paraplegics is emphasised.' (15)

Related to L. Guttmann, 'History of the National Spinal Injuries Centre, Stoke Mandeville hospital, Aylesbury', Paraplegia 5 (1967), pp. 115-126.
Description:

Characterizes rehabilitation of spinal injury as lagging behind change in attitude towards disability at the start of WW2: 'in the early stages of World War II, when the modern conception of rehabilitation of the disabled was generally accepted for amputees and other crippling disabilities, spinal paraplegia was not included in this concept.' (115)

 

Suggests that early specialized units in Britain suffered from a lack of staff members who could devote full-time attention to spinal nerve injuries: a fundamental step forwards in a new approach to the management of spinal paraplegia was taken in Great Britain by the Peripheral Nerve Committee of the Medical Research Council under the leadership of Dr. George Riddoch, Neurological Consultant to the British Army, Ministry of Health and Ministry of Pensions, when it was decided to congregate spinal cord casualties in special units... However, the first spinal units did not prove satisfactory as they were attached to neurosurgical or orthopaedic units and no one member of their staff devoted more than a part of his time to the care and management of spinal injury patients.' (115)

 

Suggests that during the early years of Stoke Mandeville unit it was necessary to demonstrate that rehabilitation was possible in the first place, as well as to ameliorate the adverse effects of estabished modes of treatment: 'Two groups of patients were admitted:

1. Those in the acute stages of paraplegia following gunshot injuries, fracture dislocations and transverse myelitis. These patients were of particular importance to prove that it was in fact possible to avoid those complications which, throughout the ages, were considered as inevitable and the causes of the paraplegic's early death, namely sepsis, due to pressure sores and ascending urinary infection leading to renal deficiency...

2. Those in later stages of paraplegia suffering from many complications as a result of incompetent initial treatment, lack of proper facilities, or sheer neglect. Their condition was often extremely serious, demanding greatest vigilence and prolonged intensive efforts on the part of all concerned with their management to restore them both physically and mentally.' (116)

 

Highlights tendency of authorities to classify paraplegically injured individuals as 'incurable', and the contrasting efforts at the hospital to return patients to working life: 'it was quite revolutionary to teach and impress on the authorities of medical and social services, in particular the Ministry of Labour and Housing Authorities, that the mere fact that a person was a paraplegic did not justify care in one of the institutions for 'incurables', but that in spite of his severe physical handicap, rehabilitation to a useful life and employment was possible in the great majority of cases. In this connection the first experiment to prove that paraplegics could work side by side and in competition with able-bodied workers was carried out with our first six rehabilitated paraplegic ex-servicemen at the end of 1944.

It was also during the war that sport and regular work were introduced as essential parts in the medical treatment of these patients which, in due course, proved so very successful for their physical, psychological and social rehabilitation.' (117)

 

Includes statistics on admissions, recovery rates, and rates of re-employment of patients. (118-123)

 

Notes the emergence of dedicated out-patient care between 1951 and 1962: 'A systematic out-patient service was organised to deal with routine clinical check-ups for the increasing number of patients discharged to their homes and other institutions, in particular, for those who had found employment and were anxious to have as little time off work as possible. This has proved to be a most essential part of our work in detecting and treating any deterioration in a paraplegic's condition and thus keeping as many of them as possible at their work.'  (123-124)

 

Emphaises importance of specialist unit as a research centre and for attracting scientific attention to spinal injury: 'From the beginning, intensive clinical and experimental research has gone hand in hand with the clinical work. Research workers from this country and abroad have visited the Centre and some of them co-operated in research on certain physiological problems of the spinal man...

Meetings of medical and scientific organisations such as the Neurological and Orthopaedic Section of the Royal Society of Medicine, the British Biochemical Society, the British Society of Biological Engineering and Sections of International Congresses have been held at the Centre throughout the years. Regular International Scientific Meetings of Paraplegia have been held since I954 on the occasion of the Annual International Stoke Mandeville Games. As a result of these meetings the International Medical Society of Paraplegia was founded in I96I at Stoke Mandeville' (124)

 

Notes growing importance of unit for training: 'Throughout the years the Centre has been engaged in teaching undergraduates and post-graduates of the medical profession as well as nursing, physiotherapy, and occupational therapy professions, and this activity has immensely increased in recent years...

Physicians, surgeons and medical students as well as administrators have visited the Centre from many hospitals in this country and abroad, and the Centre takes part in the regular post-graduate courses arranged by the British Council...

Apart from regular visits of groups of nurses sent to the Centre for formal lectures from the Royal College of Nursing, three-monthly Post-Graduate Courses have been introduced since I953 which are attended by nurses from this country and from all over the world. Some of these post-graduate nurses continue working in the Centre after the course to gain more detailed experience...

In addition to full-day visits of individuals and groups of physiotherapists and occupational therapists from teaching schools, annual post-graduate courses for physiotherapy are held which have become quite popular.' (124-125)

 

Finally, discusses the significance of sport for rehabilitation, and the hospital for the emergence of the paralympic movement: 'Since the inception of the Stoke Mandeville Centre, sport has played a very important part in the physical, psychological as well as social rehabilitation of the paralysed, and the profound value of sport in preventing these patients from retiring into inactivity cannot be exaggerated. As I have already pointed out, sporting activities are included in the medical treatment and this has encouraged many patients to continue sport for their physical well-being and recreation after discharge from hospital. Interest and enthusiasm in competitive sport increased steadily, and in 1948 the Stoke Mandeville Games were founded as a sports movement for the paralysed. These Games, which at first were held annually as a national event, have developed since 1952 into the first organised annual sports festival for severely disabled people in the world...

As off-shoots of these Games the British Commonwealth Paraplegic Games and, more recently, the Pan-American Paraplegic Games have been founded.' (125)

Related to L. Guttmann, 'Nursing in Spinal Paraplegia', in M.C. Wilkinson and G.R. Fisk (eds.) Orthopaedics for Nurses (Faber and Faber; London, 1961), pp. 255-280.
Description:

'It was a new approach [in 1944] to teach that bedsores and urinary infection were by no means inevitable consequences of a spinal paraplegia and to convince the nursing staff that the proper treatment of pressure sores could be as gratifying a life-saving achievement as the successful operation of a perforated duodenal ulcer or brain tumor.' (256)

 

'The rehabilitation of traumatic spinal paraplegics... cannot be one person's job - it is team work in which the physician or surgeon in charge has to act as the leader and co-ordinator until the paraplegic's return to a useful life. One of the fundamentals in team activities is that the various members of the team - nurses, physiotherapists, occupational therapists, vocational instructors and social workers [nb: no physician in this list] - learn to respect each other's work as that of equal partners. For, in the management of paraplegics there is not the same clear division in the activities of the nurse and the physiotherapist as exists, for instance, in the pre- and post-operative care of short-term surgical patients. A distinct feature in the management of these long-term patients is the close integration of the work of the various members of the team.' (257)

 

'When the patient has arrived at the hospital, the principle of care in lifting and turning the patient in one piece by four attendants from the stretcher on to his bed, X-ray or operating table, must be strictly adhered to, as this is the main factor in preventing further damage to the spinal cord or spinal roots. The routine procedure at Stoke Mandeville Spinal Centre in dealing with traumatic paraplegia in the initial stage after fracture or fracture dislocation is the employment of postural reduction on sorbo packs and regular turning, the technique of which is follows: The patient is placed on sorbo packs with one, two or three additional pillows underneath the fracture to produce hyperextension of the spine in the physiological position, in order to restore, as far as possible, the normal curvature of the spine (see Plate XLV). From the basic, supine position the patient is turned first on to one side (Plate XLVI), the hyperextended position being maintained by the use of a big sandbag to support the pillow in the back, then back to the supine position, and then on to the other side. The lifting and turning is carried out by three or four attendents working under the guidance of the sister or nurse in charge of the case, and they are made fully aware of the details of the fracture and the importance of carrying out the lifting and all movements simultaneously, so that the patient is turned in one piece without dragging.' nb: refs are to two v. clear images of 'supine' and 'side' positions.

Related to L. Guttmann, 'Physiotherapy for the paraplegic', The Cord 3 (1) (Winter 1950), pp. 14-19.
Description:

Emphasises walking exercises and archery as means of rehabilitation, general superfluity of support corsets.

Related to L. Guttmann, 'Readjustment to a new life. Part I - psychological aspects.', The Cord 2 (1) (Autumn 1948), pp. 52-54.
Description:

'When the body is shattered and thrown out of gear by a disaster of such magnitude as a spinal cord injury, it is inevitable that the mind, too, falls into chaos. Therefore everyone connected with the rescue and rehabilitation of aparaplegic, no matter in what capacity, is confronted in all stages of this work with the paramount task of rescuing not only a broken body but also a broken personality. The will to live, despite great physical handicap, has to be restored, and the patient's full co-operation has to be gained in order to win his mind and heart back to activity and useful work. The ultimate aim is to make him as independent as possible and to restore to him his rightful place in social life.

With this conception as the leading principle we commenced treatment and re-education of paraplegic patients at Stoke Mandeville Hospital four years ago.' (52)

 

'More and more it is realised by the paraplegic patients that the many details of physical training and re-education of movement, in combination with occupational therapy, training in our workshops, correspondence courses, and last but not least, recreational activities are not merely time-killing diversions but represent ways of restoring faith in themselves in order to master their disability and to prepare for a new life in the Big World outside.' - notes formation of choir esp. (53)

 

'most important of all, numerous paraplegics have already taken their places at work in the world, andmany more so are ready to do so one way or another, once society is ready to receive them - i.e., to give them a fair chance by providing homes and facilities for work adapted to their permanent disability. There can be no doubt that one of the most urgent problems in the present phase of readjustment of paraplegics to useful life is the reeducation of the public - in particular, employers - to a more co-operative understanding and helpful attitude towards these men and women.' (53)

 

'There is a group of paraplegics who, though physically well re-educated, have difficulty readjusting themselves to the new circumstances and strains of daily life once they have left the atmosphere of security of the Spinal Centre. These men need great attention, assistance and firm guidance by everyone concerned with their welfare at home. If they are not encouraged from the beginning to do all those things for themselves which they were capable of doing at the Centre, or are even discouraged to do them, they will inevitably lose the desire and capacity to become independent' (54)

Related to L. Guttmann, 'Readjustment to a new life. Part II - physical aspects' The Cord 1 (4) (1948), pp. 13-16, The Cord 2 (1) (Autumn 1948), pp. 23-28 and The Cord 2 (2) (Winter 1949), pp. 21-29.
Description:

describes physical risks associated with home life/domestic environments

Related to L. Guttmann, 'Readjustment to a new life. Part III - resettlement aspects', The Cord 2 (4) (Summer 1949), pp. 18-22.
Description:

''Most paraplegics spend a long period in hospital, and it is most essential that their physical readjustment should go hand in hand with their rehabilitation by work. This principle has been practised at this Centre from the start, and emphasis was laid on early vocational training, which no doubt has proved the best form of occupational therapy for paraplegics. (19)

 

'The aim of this work was not merely occupational therapy as a diversional measure... No, the aim, broadly speaking, was to use it as the first step in the patient's industrial rehabilitation, by regaining the lost power of concentration, reviving initiative and developing the mobility and dexterity of the fingers, upon which the future vocation of most paraplegics will depend in a large measure. And it should not be forgotten that several paraplegics, who showed particular interest and ability in toy or rug-making, needlework or leather work have actually continued this work later on and have started a business for themselves at home...

Soon after the Centre was started proper pre-vocational training was introducted, at first by correspondence courses in commercial arts, economics, banking and law.' (19)

 

'it was not to be expected that everyone would make full use of the various facilities offered. In numerous cases, it took a considerable time to rouse the patient out of that state of apathy resulting from a septic condition and enforced, prolonged inactivity. Moreover, other factors, such as education, temprement and individual inclination had to be taken into consideration, and obviously spinal cord injury does not necessarily change a man who has been work-shy previously into a first-rate worker.' (20)

 

- includes an associated plate depicting photographs of clock assembly and precision engineering being undertaken at Stoke Mandeville.

Related to L. Guttmann, 'The management of the spinal child', Mother and Child 31 (5) (August 1960), pp. 108-113.
Description:

The management of a paraplegic or quadriplegic child does not differ in principle from that of an adult paraplegic, and to return such an unfortunate child to a full and happy life, within the limit of his severe handicap, is a vast task. The rehabilitation embraces a great variety of medical and social aspects, and of paramount importance amongst the latter are the problems of education and domestic resettlement. It cannot be too strongly emphasised that, unless from the onset of paraplegia the parents and education authorities are included in the team of those concerned with its management, the rehabilitation of a paraplegic child cannot succeed.' (108)

 

example of 'Paul Wa., now aged 14 years 8 months':

'On admission to this Centre on 9th May, 1953, he was very restless and distressed and cried often for his mother. However, he gradually settled down...He attended our school but needed a good deal of guidance, because of his lack of concentration and emotional instability, which were aggravated by the over-protective of his parents, especially the mother... Gradually, he improved psychologically. His concentration was better and he became more and more independent and was able to dress himself. At school he also made slow but steady progress. He was discharged three years after admission and now lives at home in a bungalow with his parents.' (110-111)