1980 Ludwig Guttmann, 3 July 1899 - 18 March D. Whitteridge, F. R. S. 1983 , 226-244, published 1 November 29 1983 Biogr. Mems Fell. R. Soc. Email alerting service here corner of the article or click this article - sign up in the box at the top right-hand Receive free email alerts when new articles cite http://rsbm.royalsocietypublishing.org/subscriptions , go to: Biogr. Mems Fell. R. Soc. To subscribe to on July 16, 2018 http://rsbm.royalsocietypublishing.org/ Downloaded from on July 16, 2018 http://rsbm.royalsocietypublishing.org/ Downloaded from
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1980Ludwig Guttmann, 3 July 1899 - 18 March
D. Whitteridge, F. R. S.
1983, 226-244, published 1 November291983 Biogr. Mems Fell. R. Soc.
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Ludwig Guttmann was born on 3 Ju ly 1899 in T o st, U p p er Silesia, w hich was then in Poland. H is father was an innkeeper and distiller, who w ith L u d w ig ’s elder sister and her husband all perished in A uschw itz. Both L u d w ig ’s g randfathers w ere farm ers, and he spent m any holidays in the coun try on his g ran d fa th e r’s farm w here he w atched his g randm other dispense herbal rem edies to the coun try people. H e was b rough t up in the Jew ish faith, b u t early rebelled against ‘m eaningless form s of o rthodoxy’. H e w ent to school at K onigshiitte , a coal m in ing tow n of 70000 inhabitan ts. W hile aw aiting call-up at the age of 17 he becam e an orderly at the local accident hospital. H ere he saw a m iner who had broken his back have the deform ity reduced by extension and d irect pressure, a m anoeuvre recom m ended by G alen. H e was told not to w rite case notes, ‘as he will be dead in a few w eeks’, and this defeatist a ttitude deeply im pressed him (Ross & H arris 1980). In later life he found fam iliarity w ith the duties and ways of m edical orderlies very valuable. H e picked up from a patien t a severe th roa t infection w hich was followed by a sub thyro id abscess and drainage tube. W hen he was called up in 1917 w ith the abscess drainage tube still in place he was rejected for m ilitary service and began m edical studies at Breslau. He recovered his health , was passed fit for service w ith the artillery, bu t w hen he was again called up on 9 N ovem ber 1918, he was, not surprisingly , sent home.
He continued m edical studies in W urzbu rg and F reiburg , w here he was exam ined in his finals by the d istinguished pathologist Aschoff and m issed a first class by one m ark. G u ttm an n jo ined a Jew ish studen t K orps and was a keen fencer, from w hich he carried a small facial scar. Even in 1923 there was some troub le betw een Jew ish studen ts and right-w ing studen t K orps, w hich were strongly antisem itic. For his M .D . degree, w hich he took in 1924, he w rote a thesis on tum ours of the trachea.
He applied for a post in paediatrics in Breslau to w hich his father had m oved in 1921, bu t the professor already had ‘one doctor to each baby’,
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and a friend suggested he should apply to the neurologist Professor O tfrid Foerster, w hose departm en t happened to be in the same building. T h is was successful, and he was w ith F oerster from 1924 until 1928. W hen som eone asked F oerster w hy he had so m any Jew ish assistants, he said he was m ore in terested in intelligence than in religion. A ssistants w ere expected to work for up to 18 hours a day, in w hat was the best centre for neurology and neurosurgery in E urope. In 1928 G u ttm an n was invited to s tart a neurosurgical un it in H am burg w here an operating theatre and beds had been bu ilt in a large university psychiatric hospital. H ere, at the age of 29, G u ttm an n was his own m aster, seeing neurological cases from the w hole hospital, operating, doing ventricu logram s and air encephalogram s, and his fu tu re looked assured.
In 1929 F o ers te r’s first assistant died suddenly , and F oerster invited G u ttm an n back to Breslau. T h is was a very difficult decision bu t in the end G u ttm an n decided reluctan tly tha t his obligations to his old teacher requ ired him to go. A t th is tim e F oerster was the leading neurosurgeon of E urope. T h o u g h he had trained in F rance as well as in G erm any, he ‘shared the scientific m ethodology of the A nglo-S axons’. H e had a m astery of the anatom y and physiology of the nervous system and he never lost an o ppo rtun ity of investigating the function of spinal roots and pain pathw ays, stim ulating roots at operation and study ing the effects of the ir section at leisure. D u rin g the 1914-18 w ar he had taken up neurosurgery , and had published his results on a series of twelve patients w ith spinal cord tum ours, w ith a re tu rn of function in nine of them . U nfortunate ly his neurosurgery was self-taught, and though he later visited H arvey C ushing, he never adopted C u sh in g ’s techn ique and used ne ither silver clips, electrocautery nor suction apparatus. C airns (1941) described him as a ra ther ungainly craftsm an, and his haem ostasis and even his asepsis were not above reproach. G u ttm an n was to find tha t a tra in ing in neurosurgical m ethods from F oerster was not a great re com m endation in Britain.
As well as from his exam ple as an investigator there w ere a num ber of specific areas in w hich G u ttm an n learnt from F oerster. F oerster was in terested in physical trea tm en t in-neurological conditions, w rote a long article on exercise therapy and supervised its application him self (1936 a , b ).H e encouraged his assistants to m aster physiological m ethods of investigation and to apply them to patients. G u ttm an n identified areas of sw eating, using at first starch-iodine pow der and later (1937) quini- zarin, and another assistant, A ltenburger, used plethysm ography to study vasom otor reflexes, and recorded m uscle action potentials w ith the string galvanom eter for skeletal reflexes. F oerster h im self was a skilful clinical pho tographer and his m onographs were extensively illustrated.
F o ers te r’s only relaxation was to invite his ju n io r colleagues to his house once or twice a week, w hen they drank R hine wine and pink cham pagne and talked till m idnight. A fter the N azis came to pow er in
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1933 F oerster was for a tim e u n d er surveillance as the governm ent d isapproved of the close contacts he had had w ith L en in w hen he was his chief neurological physician for a year before his death . G u ttm an n kept in touch w ith F oerster un til 1937 and organized a Festsch rift for his 60th b irthday , b u t was not allow ed to a ttend the official celebrations.
G u ttm an n becam e P riva tdozen t in 1930, and was F irs t Associate until 1933. T h e N azis then forced all Jew s to leave A ryan hospitals, and although they offered to m ake an exception for h im , G u ttm an n refused and becam e neuro log ist and neurosu rgeon to the Jew ish H ospital in B reslau, w hich had 600 beds, of w hich 75 belonged to the neurological service. In 1937 he was elected M edical D irec to r of the w hole hospital.
H e has left a tape-reco rd ing of his experiences as a Jew in Nazi G erm any from 1933 to 1939. H e was ne ither insu lted personally nor m ishandled . In 1934 he was p resen t at the bu rn in g of the books of non- A ryan au thors by the U n iversity of Breslau. T h e new R ector presided, m ade an an tisem itic speech and the s tu d en t fratern ities th rew books from the U niversity L ib rary on the fire. G u ttm an n stood on the edge of the crow d, tears ru n n in g dow n from his cheeks as he realized tha t this was not a tem porary aberra tion of two or th ree years as he had previously believed.
U n d er the 1935 racial laws Jew s lost all the ir civil rights; Jew ish doctors w ere allow ed to trea t only Jew ish patien ts. T h ey were no longer called physicians, b u t ‘Ju d en b eh an d le r’. A t tha t tim e the G uatem alan A m bassador to F ranco was a patien t of G u ttm a n n ’s, having ju s t had a spinal tu m o u r successfully rem oved. By special perm ission, the A m bassador was allowed to stay on in the Jew ish H ospital until he was fit to leave. In 1938 w hen pogrom s w ere frequen t and concentration cam ps w ere filling up, the G uatem alan governm ent offered the G u ttm an n s visas to em igrate, b u t these w ere declined.
W hen the G erm an d ip lom at von R ath was assassinated in Paris on 9 N ovem ber 1938, the te rro r was intensified. G u ttm an n gave orders that any m ale person en tering the hospital tha t n igh t — the K rystalnach t — was to be adm itted w ithou t question. N ext m orn ing G u ttm an n was sum m oned to the hospital w here th ree S.S . officers, a G estapo m an and all the consultan ts w ere w aiting. Asked to account for the 64 adm issions, G u ttm ann told the G estapo m an tha t all illnesses can be exacerbated by extrem e em otion. F ortunate ly on the ir jo in t w ard round the first m an had had a stroke, and his arm fell lim ply on the bed. T h e G estapo m an was discom posed. In the rest of the round each case was discussed as in a m edical m eeting, all sorts of diagnoses were invented and a variety of investigations were ordered . Sixty patien ts were saved; four, including two doctors, ‘behaved stu p id ly ’ and were taken away. It was still possible at that tim e to get people away to Czechoslovakia and this G u ttm ann organized. M any consultants and young doctors were taken to concentration cam ps and G u ttm ann was o rdered to report to the police every day w ith details of adm issions and discharges.
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G u ttm an n reported the irrup tion of the G estapo to the local leader, and found a few days later tha t it was con trary to orders, and tha t H itler had ordered the Jew ish hospitals to be kept going. T h is instruc tion filtered down very slowly, and it was some six weeks later tha t his colleagues began to reappear. T h e chief of the M edical D epartm en t had lost three stone from enteritis, and his own assistant, a young m an who, w hen asked about the concentration cam p, said ‘N ot too bad, not too b a d ’ b u t seem ed lifeless, and was adm itted . T h a t n igh t he tried to com m it suicide bu t was w atched and foiled. Several people reappeared w ith te rrib le bedsores. O ne m an of 63 w ith a weak heart was ‘m ishand led ’ and died in Buchenw ald very quickly, and his ashes w ere sent to his wife.
O n the n igh t of the pogrom , G u ttm an n was told tha t the Synagogue was burn ing . H e found the bu ild ing alight and the S.S. playing football w ith prayer books while the C hief R abbi was forced to w atch.
A few days later, G u ttm an n , who had had his passport im pounded, was asked by D r A dler of P rague to go there to operate on a w om an w ith a cerebellar cyst. He was given his passport back, flew to Prague and operated on the cyst. T h e patien t recovered and later was able to em igrate. T h is was G u ttm a n n ’s last operation on the C ontinen t. Early in D ecem ber D r A lm eida Dias, the neuropatho log ist to the fam ous surgeon M oniz, asked G u ttm an n to go to Portugal to see a patien t. T h e request came via D r Salazar and R ibben trop , the G erm an Foreign M inister. All facilities were given G u ttm an n for the trip . H e had to go to the G estapo for his passport and a certificate of political reliability , flew to Berlin and took a plane for Salam anca. H e was the only civilian on the plane; all the o ther passengers were officers going to F ranco. T h ere was some delay as the plane lost one engine in m id-air, bu t the pilot landed the plane safely on the rem aining engine at Berne. O n the plane he m et a Luftw affe doctor who was to replace a colleague over C hristm as on a w eather ship. H e said that after the war he was going to the Colonial Service. ‘But we haven’t any colonies’; ‘T h is tim e we will get th e m ’. All the adm in istration was already prepared .
W hen G u ttm an n arrived in L isbon his host said ‘T h an k G od we have got you out of the concentration cam p’, bu t G u ttm an n said, ‘N o, you see I am not shaven!’ T h e patien t had im proved and G u ttm an n decided not to operate. T h e patien t died later from m alignant m etastases tha t were not at the tim e visible in X -rays. G u ttm an n was offered a job in Portugal, w hich he refused, bu t applied for and was given perm ission to go to E ngland for two days at the end of D ecem ber. He had already m ade contact w ith the B ritish Society for the P ro tection of Science and L earn ing and was offered a gran t to be held at O xford. He w ent back to Breslau, having decided to em igrate w ith his wife and children. T he Board of his hospital gave him perm ission to go; m any at the tim e were on the way out them selves. At G u ttm a n n ’s m em orial service the officiating Rabbi revealed that they gave m ore than perm ission, for in m em ory of his
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efforts on behalf of the com m unity they gave him a M enorah , the seven- b ranched candlestick. Each of his houses in tu rn was called ‘M en o rah ’.
H e left G erm any on 14 M arch 1939 w ith his wife Else, a son of 9 and a daugh ter aged 6. T h ey arrived at H arw ich in possession of 10 m arks each, on a m orn ing of sleet, snow, w ind and rain, part of a long queue in the im m igration hall. W hen the im m igra tion officer saw the two small ch ild ren , he called the fam ily in first, saying tha t ch ild ren should not stay in a d rau g h t. T h is was no t language from officialdom to w hich M rs G u ttm an n was accustom ed, and she b u rs t in to tears. G u ttm an n said it restored his faith in hum an natu re .
In O xford they stayed w ith D r A. D . L indsay in the M aste r’s L odgings at Balliol for th ree weeks until they found som ew here to live. T h e wife of one of the Balliol dons arranged for the son D ennis to go to the D ragon School, w hich G u ttm an n described as a place w here English paren ts pu t dow n th e ir sons’ nam es before they are born . In O xford they lived in a small terrace house and in spite of g ran ts from the Society for the P ro tection of Science and L earn ing and from Balliol College they were som ew hat stra itened . L udw ig becam e a m em ber of the Senior C om m on Room of Balliol, and D enn is ob ta ined scholarsh ips to St E dw ard ’s School and la ter to M agdalen College. W hen L udw ig was appoin ted D irec to r of the N ational Spinal In ju ry C en tre at S toke M andeville, he com m uted for som e years — he was a forceful d river — b u t later w ent to live near H igh W ycom be. In 1972 Else G u ttm an n suffered a severe head in jury from a road accident w hich left her unconscious for the last 21 m onths of her life.
S c i e n t i f i c w o r k
T h e w ritings of O tfrid F oerster, w hich are extensive, provide a useful p ic tu re bo th of the state of know ledge in 1920-30 of neurology in general and of studies on paraplegia in particu lar, and also make plain w hat G u ttm an n owed to F oerster. T h e Handbuch der Neurologie of Bum ke & F oerster (1935-40) contains long articles by F oerster on pain pathw ays and the cerebral cortex and m ost usefully an article by him of 403 pages on the sym ptom atology of spinal cord in juries (1936a). T h is includes a detailed descrip tion of the sensory and m otor losses found w ith spinal transection at each vertebral level from u pper cervical to sacral segm ents, and also discusses the effects of transection on p ilom otor activity, sw eating and vasom otor control in the same detail. A ndre T hom as in Le reflexe pilomoteur (1921) m akes very clear the d istinction betw een p ilom otor activity triggered from the upper in tact spinal cord and that triggered from the isolated cord. F oerster does the same for the control of sw eating, w hich he m apped by using starch—iodine pow der and is quite clear on the d istinction betw een therm oregula to ry sweating triggered
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from the m idbrain , and reflex sw eating from the isolated cord. T ho u g h his available experim ental m ethods for displaying vasom otor activity were lim ited, he m ade the same distinction there. H e did not, how ever, go on to suggest tha t in patien ts w ith lesions of T horac ic 8, for exam ple, overaction of the upper segm ents still under central control m ight com pensate for undesirable activity in the isolated segm ents. T h is im portan t poin t was not m ade until 1945 w hen N eum ann, Foster & R ovenstine rem arked on the im portance of such com pensatory processes in the m aintenance of blood pressure in spinal anaesthesia.
Foerster m akes it qu ite clear tha t though a few patien ts exceptionally m ight survive 2, 4 or 6 years, a fatal outcom e from bedsores and urinary infections was inevitable, and he describes stages of recovery, stabilization and final decay as invariable. In the article in the Handbuch on the trea tm en t of spinal injuries by M arbu rg (1936), all the em phasis is on the need for early operation on the cord, and though he m entions bedsores and urinary infections the reader is given no guidance on the ir trea tm ent. T h e works of bo th A ndre T hom as and F oerster make disagreeable reading, from the con trast betw een the m ost elegant and precise n eu ro logical observations and the p a tien ts’ unh indered physical decay. In an obituary of Foerster, G eoffrey Jefferson (1941)(F .R .S 1947) described him as the best neurophysio logist G erm any ever had, and goes on to say that he was m ore in terested in establishing the physiological facts than in the fate of his patients. Perhaps th is is overstated , bu t it is not a rem ark tha t any one could ever make about G u ttm an n .
G u ttm a n n ’s own early publications are m ostly concerned w ith points of radiological techn ique in neurosurgical diagnosis. T h ere is a paper w ith F oerster on the trea tm en t of subacute com bined degeneration of the cord w ith extracts of gastric m ucosa, and a jo in t article on the effects of traum a on the nervous system . Scientifically the m ost in teresting is a series of papers arising from the use of an im proved m ethod of displaying active sweat glands using quin izarin , a dye tha t is light grey w hen dry and deep purp le w hen wet (G u ttm an n 1937, 1942a). "This he used to outline non-sw eating areas in lesions of peripheral nerves, and found considerable variations betw een subjects, in the d is tribu tion of the central area of com plete anhidrosis and bo rder zones of partial sw eating loss (G u ttm ann 1940). He also produced good evidence of a viscerocutaneous reflex; three patien ts w ith em pyem a of the gall-b ladder had areas of increased sw eating in the segm ental level of T 8 -T 9 (G u ttm ann 1938). (Incidentally th is is the last paper published by G u ttm ann from Breslau and was p rin ted in Sw itzerland.) T h is usually began on the right side and later involved both sides equally. He added tha t anhidrosis, hypohidrosis or hyperh idrosis lim ited to these segm ents could occur. O ne may speculate tha t the determ in ing factor is probably the degree to w hich the blood supply to these segm ents is also affected. A ccording to A dam s Ray & N orlen (1951), vasoconstriction in the skin can be
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produced by distension of the b ladder and dem onstra ted photoelectri- cally, b u t v iscerocutaneous reflexes still lack a system atic trea tm en t.
W hen G u ttm an n arrived in O xford , he offered his services as a neurosurgeon to S ir H ugh C airns, Professor of S urgery and C onsu ltan t in N eu rosu rgery to the A rm y, b u t was encouraged to continue his experim ental w ork on sw eating in m an, and to jo in the work on peripheral nerve in juries th a t was in progress in O xford. T h e m ain p rob lem s for w artim e w ere the regeneration of nerve after injury, w hether unm yelinated fibres grew faster than m yelinated fibres, and neurom a form ation and its inh ib ition . G u ttm an n used his experience in p lo tting sensory loss to follow the re-innervation of skin in the rabb it, w hether the first fibres grew in from adjacent areas or were regenerated fibres from the m ain trunk . In g row th of fibres from su rround ing areas was dem onstra ted by G u tm an n , E ., G u ttm an n , L. & W eddell, G .(1941) , b u t the re is som e evidence th a t th is process depends on m ild traum a of the anaesthetic area.
G u ttm an n also w orked w ith J. Z. Y oung and Peter M edaw ar (1942) on the rate of regeneration of nerve fibres, and there was some collaboration w ith F. K . Sanders and m yself w ho w ere m easuring conduction rates in nerves above and below the site of crush . H e also w orked w ith M edaw ar(1942) on the chem ical inh ib ition of regeneration and neurom a form ation. I t was of course M ed aw ar’s w ork on nerve grafts tha t led to his discovery of tissue im m unity . G u ttm an n show ed tha t galvanic stim ulation of m uscles, especially if started im m ediately after in jury , considerably reduced the ir rate of a trophy , and this he later applied to the trea tm en t of paraplegics (E. G u tm an n & L. G u ttm an n 1944).
G u ttm an n also taugh t o rthopaed ic surgeons how to exam ine and trea t peripheral nerve in juries, b u t he was at no tim e offered any neurosurgery , m ilitary or civilian. S t H u g h ’s College had becom e the M ilitary H ospital for H ead In ju ries, one of its p rincipal aims being the tra in ing of m obile surgical team s for neurosu rgery in the field. F o r th is, standard ization of techn ique and equ ipm en t was essential and it was C ush ing ’s tech nique tha t was adopted . M r J. Pennybacker, then S ir H ugh C airn s’s first assistant, has told m e tha t a lthough the C ushing techn ique produces very long slow operating sessions, it can be taught to aspiring n eu ro su rgeons, w hen m ore id iosyncratic m ethods cannot, though they may be successful in the hands of the ir developers. G u ttm an n had been his own m aster for eight years and was always an individualist, and it is not clear tha t he w ould have fitted into such team s. H e continued to carry out sw eating tests on patien ts at the Radcliffe Infirm ary and St H u g h ’s, w here the younger doctors, ignorant of his experience and background, did not take ‘sweaty G u ttm a n n ’ very seriously. F ortunately he w rote reviews for the M edical Research C ouncil, one in 1941 on rehabilitation after injuries of the nervous system and another in 1943 on surgical aspects of injuries of the spinal cord and cauda equina. N either is now
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accessible, bu t the text of the first is p robably sim ilar to the paper w ritten by G u ttm an n at the same tim e and published in Proceedings o f the Royal Society o f Medicine (1942 h).In it he is concerned w ith peripheral nerve injuries and not at all w ith paraplegia. In it he pu ts his continuing belief, ‘Experience in all countries has show n tha t m any patien ts left alone in the reconditioning period will never make enough effort to reach the ir full w orking capacity’. Both these reviews were read by B rigadier G eorge R iddoch, who had w ritten the classical paper w ith H enry H ead (1917) on spinal injuries in the 1914-18 war. R iddoch, who was consultan t N eurologist to the E m ergency M edical Service (E .M .S .) and the A rm y, was know n for his k indness to patien ts and to colleagues, and it is likely that he was aware of G u ttm a n n ’s under-em ploym ent and potentialities. In 1943 he sent for G u ttm an n and offered him the D irecto rsh ip of a new spinal un it tha t was to be opened in tim e for the casualties expected from the invasion of E urope. It was agreed tha t he should go to the hu tted one- storey E .M .S . hospital at Stoke M andeville and should have a reasonably free hand. So ended four fru stra ting years.
C entres had previously been set up u nder m ultip le m anagem ent in the U .K ., bu t they w ere repu ted to be places w here patien ts w ould inevitably die. T h ere was how ever one ray of hope: in Boston C ity H ospital under D r D. M unro , paraplegics were being rehabilita ted , m ade able to re tu rn to society and even to work. M unro had published on the best m ethods of trea ting urinary infections and ob ta in ing a reflexly autom atically em pty ing b ladder. In 1940 and 1943 he was trea ting bedsores by tu rn in g the patien t every two hours. It cannot be said tha t his publications had m ade m uch im pression at tha t tim e either in the U .S .A . or in the U .K .
T h e centre opened w ith 24 beds and one patien t, on 1 M arch 1944, w ard 10 soon began to fill up w ith service patien ts, and they m ust have done well because, in M ay, R iddoch gave orders tha t all paraplegics from the D -D ay landings w ere to be sent to Stoke M andeville. By A ugust, G u ttm an n had nearly 50 patients. D uring the next 22 years all G u ttm a n n ’s scientific activity was d irected to solving problem s that arose in the pathology, the physiological pathology and trea tm en t of paraplegics, and is unintellig ib le w ithou t a b rief outline of the clinical problem s.
He already knew that the two great dangers tha t th rea ten the paraplegic patien t were bedsores and urinary infection. Bedsores consist of necrosis of the skin overlying bony prom inences and, as they becom e infected, may extend deeply enough to cause necrosis of the underly ing bone. In norm al subjects, sitting or lying dow n in the same position will cause enough discom fort to produce a change of position, bu t w hen there is no sensation, relief m ovem ents do not occur. In 1940 M unro discussed pressure sores as due solely to tissue pressure and dism issed ‘trophic influences’. H is discussion is not in quantitative term s, unlike that in T ru m b le (1930), w hom G u ttm an n quotes from 1967 onw ards. T ru m b le
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m easured the pressure tha t could ju s t be to lerated over a considerable period from a bag resting on the do rsum of the foot, and concluded tha t 1.5 lbf i n -2 ( ‘1.5 p .s .i.’; ca. 10.3 kPa) will cause the death of tissue. T h is is about 8 0 m m H g , ju s t above the arte rio lar pressure, and enough to cause tissue ischaem ia, w hich the skin can only stand for about two hours.
G u ttm an n gave o rders th a t patien ts w ere to be tu rn ed prone to supine and back or from one side to the o ther every two hours, n igh t and day, w aking or sleeping. H is first orderlies had been released from the R .A .M .C . and had learned little there . O ne m an, asked w hat he had done in the R .A .M .C ., said ‘Shovelling coal, S ir ’. G u ttm an n had to be in the w ards for every h ou r of the n igh t un til his orders were carried out, and the benefits began to appear. G u ttm an n traced the outline of healing b ed sores on tran sp aren t film and m easured the ir area at regular intervals, and established tha t all an tisep tics reduced the rate of healing by dam aging epithelial cells. H e was fo rtunate in tha t penicillin was freely available and tha t strep tom ycin appeared soon after. U nfo rtunate ly , healing by g ranu la tion tissue and epithelialization was very slow, and the new skin was very th in and liable to break dow n. In suitable cases w here the site was clean, skin grafts of various k inds greatly speeded up the process of healing. O nly continual vigilance and a drill of m oving the body at regular intervals could p reven t the recurrence of bedsores, and the patien t had to be taugh t to be conscious of the danger for the rest of his life. O ne of his m any clashes w ith orthopaedic surgeons occurred at a m eeting in 1946 at w hich I was p resen t, w hen G u ttm an n denounced the practice of tran sp o rtin g paraplegics on p laster beds. T h e principle of spreading the w eight of the body so tha t there were no points of localized p ressure was adm irable . H ow ever, paraplegics, in pain and not eating, w asted so rapidly tha t they ceased to fit the p laster bed, and arrived at Stoke M andeville not only w ith the usual sores over the sacrum , the greater trochan ter and the ischial tuberosities, b u t also w ith a sore over each vertebral spine, a sight never seen except w ith p laster beds. C riticism from a civilian was not welcom e to the service orthopaedists, bu t the evidence was incontrovertib le . M easurem ents of the pressures developed betw een bony points and various supporting beds were not m ade until m uch later (R edfern et al1973).
Paraplegics can of course no longer void urine voluntarily; repeated catheterization at regular intervals is not only inconvenient while they are being evacuated by train , sea or air, bu t also carries a considerable risk of infecting the b ladder. It was therefore s tandard practice to open the b ladder in the m idline betw een the um bilicus and the pubis — sup rapubic cystotom y — and later to fix a box on the an terio r abdom inal wall to collect the urine. A fter weeks or m onths the b ladder begins to void reflexly, urine may be passed per urethrand w ith luck the abdom inal fistula may be closed. T h is p rocedure was supposed to reduce the risk of infecting the b ladder, w hich it alm ost invariably failed to do, and at best
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patien ts were left w ith a small scarred b ladder tha t em ptied reflexly at frequen t intervals. If the patien t has to travel far under prim itive conditions before reaching a spinal centre, this m ay be the only p rac ticable trea tm ent, bu t G u ttm an n stressed tha t im m ediate catheterization w ith stric t aseptic precautions carried ou t by a doctor and not by an orderly gave very m uch b e tte r later results. A t first he carried out all catheterizations h im self w ith great a tten tion to detail. W hen infection was avoided, and the b ladder had never been opened, the patien t was left w ith a b ladder of 600 ml capacity, instead of the 120 ml usual after suprapubic cystotom y. All civilians in a civilized country and all service patien ts evacuated by air can now be safely trea ted w ithou t suprapubic cystotom y. T h e m ajor danger for paraplegic patien ts of urinary infection is of developing an ascending infection w ith pyelonephritis. T h is condition is accom panied by high fever and was a m ajor factor in the previous fatal outcom e. T h an k s to appropria te antib io tics, these in fections can now be kept u nder control, bu t com plete eradication of infection is still only obtained in about 70% of cases. T h e need to wash out the b ladder in trea ting these infections led to the recognition of autonom ic dysreflexia, perhaps the m ajor advance in pathophysiology of paraplegia since H ead & R iddoch.
G u ttm an n considered tha t im m ediate operation on the in jured spinal cord was alm ost always irresponsible m eddling. In later life he was frequently asked to give evidence in the U .S . courts in cases w here operation had produced only financial benefit for the surgeon. M echan ical fixation of in jured vertebrae by screw ing them to m etal plates tha t straddled the lesion he held was useless, and he pub lished X -ray pho tographs of a badly angulated spine w ith the m etal plates detached from the vertebrae and th rea ten ing to ulcerate th rough the skin. One disadvantage for subsequen t experim ental work was tha t few of his patien ts had had the ir total transection verified at operation, and w hen they had, it had been done before arrival at Stoke M andeville.
W hile try ing in trathecal injections of prostigm ine for the relief of spasticity, G u ttm ann found tha t it p roduced erection and ejaculation in paraplegics. Subsequently he used prostigm ine to increase fertility either directly or w ith the help of assisted insem ination. One hund red and eight paraplegic m en have now had 205 children, a few by this m ethod, and 16 paraplegic w om en have borne 22 children. T h e fact that efforts were m ade to im prove the ir fertility had a considerable effect on the m orale of patients. Perhaps as a result of his earlier work in a psychiatric hospital G u ttm ann paid very special atten tion to the psychological difficulties of his patients and the m orale in his w ards. T h e Rev. A lbert Bull, a paraplegic A rm y C haplain who had spent 18 m onths in o ther hospitals and arrived at Stoke M andeville in A ugust 1944, has described the re tu rn of hope, hope of getting control of b ladder and bowels, hope of getting out of bed, and even hope of getting back to work (1979). He also m ade
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the m em orable rem ark tha t ‘T h e first du ty of the paraplegic patien t is to cheer up his v is ito rs’, who had difficulty in concealing the ir view tha t the patien t w ould be far b e tte r dead. G u ttm an n has w ritten repeatedly of the p rofound despondency into w hich patien ts frequently fall w hen they realize the full ex ten t of the ir incapacity and tha t there is no hope of cure. By a ‘social’ evening w ard round he learnt of his p a tien ts’ hopes, fears and backgrounds, and he used any and every available in terest to get them to tu rn back to the real w orld and to take responsibility for the ir own progress.
W hen a patien t took his first steps, often w ith light w alking callipers to fix the knees, he did so not in the physio therapy departm en t bu t in the m iddle of the w ard, so tha t o ther patien ts could see tha t there was hope for them too. E xperim ental p rocedures on patien ts w ere strictly confined to non-invasive m ethods by G u ttm a n n ’s instructions, not by orders of hospital ethical com m ittees. W hen it was explained to a patien t that the procedure was not part of his trea tm en t, bu t was in the in terests of paraplegics as a whole, no difficulties arose, perhaps because in the early days there were m any patien ts who were able to con trast the ir relative neglect in o ther hospitals w ith the effective trea tm en t at Stoke M andeville. G u ttm an n acquired the respect, confidence and ultim ately the adoration of his patien ts, w ho privately called him ‘P o ppa’. He could encourage, cajole and bully patien ts into m aking the m ost of their rem aining abilities w ithou t causing resentm ent.
As early as A pril 1944 G u ttm an n noticed in th ree patients w ith lesions at T 3 , T 4 and T 5 tha t w hen the b ladders were w ashed out, the ir faces and particu larly the ir necks w ent red, the ir nose seem ed to be blocked, the heart rate w ent dow n and they com plained of severe headache. In trigued by these changes in the head and neck produced by b ladder distension in spite of com plete cord lesions, G u ttm an n asked me to go over to Stoke M andeville and to bring a m ultip le skin therm om eter. T h is was m ade in the laboratory and subsequently I took over a m ore or less portable optical p le thysm ograph for recording finger blood flow and the volum e of pulsation in the toe. In our first patien t the skin tem peratu re w ent up as expected in the head and neck, bu t w ent dow n in the legs, and it was obvious that a m ajor red istribu tion of blood was going on. In our second patient we m easured arterial blood pressure, w hich rose from 90/60 m m llg to 220/140 m m H g and G u ttm ann insisted that we should look at patients w ith lesions at all levels. It rapidly becam e clear that although vasoconstriction of the toes occurred in all patients, the blood pressure rem ained steady in patien ts w ith lesions at and below' T 7, bu t rose sharply in all patients w ith lesions above T 6. W hat we had stum bled on was a viscero-cutaneous reflex triggered by distension and m ost effectively by contraction of the bladder. W e found later that the same reaction could be triggered by distension of the rectum , the intestine and the uterus. T h e stim ulus spread as far as it could in the isolated cord and
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excited sym pathetic vasoconstrictor fibres in the lateral colum n. It was (and is) our hypothesis tha t the outcom e depended only on the effectiveness of the m echanism of the brain and u pper cord concerned w ith the regulation of blood pressure. W ith low lesions, vasoconstriction in the legs was followed by com pensatory vasodilatation in the u pper half of the body. W ith lesions above T 6 , w hen vasoconstriction occurred m uch m ore w idely and was evident in the hands, the regulatory m echanism s still could produce slow ing of the heart, b u t the vascular te rrito ry they controlled was too small for effective com pensatory vasodilatation. W hat was called by others a ‘b izarre phenom enon’ tu rned ou t to be a sim ple exercise in the effectiveness of servo-control m echanism s tha t were com pletely effective in low lesions, bu t in high lesions they failed w hen the d istu rbances were greater and the surviving effector m echanism s reduced or abolished. C laude B ern ard ’s generalization on the constancy of the in ternal env ironm ent was com m onplace in physiological circles in the 1930s, bu t took ano ther 20-30 years to have m uch im pact on clinical th inking. In the recent literatu re , d istu rbances of control m echanism s are fully accepted (M atth ias et al. 1975).
W e showed tha t in patien ts w ith lesions above T 6 there was vasoconstriction in the fingers w ith in five seconds of beginning to fill the b ladder, and clearly no hum oral agent could be released into the venous system and recirculated to the fingers in tha t tim e. H ow ever, the question later arose of a circu lating hum oral vasoconstric tor agent tha t m ight con tribu te to the large rise in blood pressure seen in patien ts w ith high lesions. M atth ias, C hristenson , C orbett, F rankel & Spalding (1976) found tha t there is an increase in the level of circulating noradrenalin bu t not of adrenalin in patien ts w ith paroxysm al hypertension . T h ere is also an increase in circulating dopam ine-fl-hydroxylase, w hich reaches its peak some five m inu tes after the peak blood pressure. T h is m eans tha t the noradrenalin has been liberated from peripheral nerve endings and tha t the whole reaction is, as we th ough t in 1947, m ediated by the autonom ic nervous outflow and tha t hum oral vasopressor agents seem to play rem arkably little part.
C unningham , G u ttm an n , W hitteridge & W yndham (1953) showed that in paroxysm al hypertension there was a decrease in calf blood flow, w hich was to be expected, an increase in forearm blood flow, w hich rem ains unexplained, and no change in heart ou tpu t. T h is was done by the old-fashioned acetylene m ethod to avoid the use of intravenous catheters, bu t in the hands of O xford resp iratory physiologists its reliability was high. T h e absence of change in heart ou tpu t has been confirm ed by N aftchi et al. (1982) using the indicator d ilu tion m ethod.
A lthough sw eating and flushing form part of the ‘mass reflex’ described by H ead & R iddoch (1917) and triggered by b ladder distension, the fu llblow n ‘mass reflex’ is now rarely seen. F illing of the b ladder seldom if ever produced flexor spasm s in these patients, though m inor m ovem ents
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of the toes som etim es occurred . T h e status of the mass reflex as a prim itive reflex was effectively rid icu led by W alshe (1944). I t is m ost likely tha t th is decrease in the excitability and spread of flexor spasm s in G u ttm a n n ’s patien ts is due to the im provem ent in the p a tien ts’ cond ition , w ith far few er pain im pulses en tering the cord than in patien ts in 1917 w ith bedsores and small scarred bladders.
O ne very curious po in t is the appearance in patien ts, du ring the hypertensive paroxysm s, of c ircum scribed patches of d ila tation of the skin of the neck, docum ented by G u ttm an n & W hitteridge (1947). G u ttm an n said tha t the patches looked very m uch like those p roduced by F oerster by farad ization of the posterio r roots of C2 and C3 at operation.
It had long been know n tha t s itting up or tilting tetrap leg ic patien ts was likely to cause loss of consciousness. T h is becam e a m atter of practical im portance w hen G u ttm an n w ished to extend to te traplegics his practice of getting paraplegics up into w heelchairs. G ettin g patien ts m obile first into w heelchairs and then on to th e ir feet not only increased the independence of the patien t b u t im proved drainage of the whole u rinary trac t. W hen the te trap leg ic patien ts w ere tilted w ith in six weeks of the ir in jury , the heart rate rose to about 140 per m inute, the blood pressure fell to unrecordab le levels, and the patien t began to lose consciousness. M ore su rp ris ing was th a t after six weeks if he was m aking good progress and had had experience of being sat up in bed, the p a tien t’s heart rate still rose bu t the systolic blood pressure did not fall below 6 0 m m H g , and there was no loss of consciousness. Early investigations by Jonason (1946) and by G u ttm an n & W hitteridge (1947) failed to find any com pensatory processes going on in the region of the isolated cord. G u ttm an n , M unro , R obinson & W alsh (1963) claim ed tha t there was an increase in the catecholam ine levels in the blood w hen tetraplegics were tilted up, and th is was later found to be due to a small increase in noradrenaline levels. T h e re is, how ever, an im portan t increase in plasm a renin activity tha t seems to be due to pressure receptors in the kidney itself (M atth ias, C hristensen , C orbett, F rankel, G oodw in & Peart 1975).
It has also long been know n tha t paraplegics have difficulty in m ain tain ing the ir body tem pera tu re in cold conditions; as casualties picked up off the battlefield they have tem peratu res in the low th irties Celsius and they have even greater difficulties in surviving in tropical conditions. G u ttm an n , Silver & W yndham (1958) showed that norm al subjects, patients w ith lesions in the cervical region and at T 4 , and patien ts w ith lesions at T 8 all kept the ir rectal tem peratu re steady at 37 °C w hen exposed nude to a tem peratu re of 27 °C. A t an air tem peratu re of 18—20 °C the norm al subject and the patien t w ith a T 8 lesion both m aintained the body tem peratu re w ith the help of shivering, bu t the patien ts w ith cervical lesions and the T 4 patien t all cooled rapidly, the la tter w ith only a little shivering. W ith air tem peratu res of 35-37 °C the patients w ith cervical lesions did not sweat, and their rectal tem perature
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rose rapidly, w ith panting and distress. It seems likely that T 6 , the critical level for cardiovascular regulation, is also the critical level for tem peratu re regulation.
A num ber of problem s of less im portance w ere also investigated. In the classic descrip tion of patien ts w ith lesions at C8 or above, the intercostal spaces are sucked in du ring insp iration by the negative in trathoracic pressure created by the d iaphragm . D uring recovery this appearance becom es less m arked, w hich led to the suspicion tha t s tretch during inspiration m ight cause reflex contraction of the in tercostal muscles. G u ttm ann & Silver (1965) dem onstrated electrom yographically tha t this is so, bu t did not make the im portan t d istinction betw een external intercostals, w hich produce insp iration , and in ternal intercostals, w hich are active in expiration (D raper, Ladefoged & W hitteridge 1960). D raper, Ladefoged and I w ent to Stoke M andeville in 1959 to test in paraplegics the effect of the reduction of expiratory m uscle pow er on speech. A lthough G u ttm an n claim ed indignantly tha t patien ts w ith cervical lesions were fully able to speak the ir parts in the w ard C hristm as pantom im e, we found that the ir peak expiratory pressure was greatly reduced, as one w ould expect: they could only count up to about 15 on a single breath , and, like patien ts w ith severe em physem a, they were unable to stress the last w ord of an utterance on a single b reath , they could not say ‘Please pass the saltV T o find out som ething about his patien ts that G u ttm ann did not already know was very rarely achieved.
W ith the m ajor clinical problem s overcom e and the necessary in vestigations done, G u ttm an n was in a position to tu rn his energies to the social rehabilitation of his patients. T oy m aking as occupational therapy soon palled, and pre-vocational w orkshops were set up in the hospital in w hich patients could do w oodw ork, in strum en t m aking and clock and watch repairing. F ortunately a first experim ent of sending patien ts to a small factory in A ylesbury w here they could do a full day’s work was a great success and the M in istry of L abour was sufficiently im pressed to set up Industrial R ehabilitation C entres in various parts of the country , and Industria l R ehabilitation C entres are now to be found in m any parts of the w orld. M ore academ ic subjects were also encouraged; an officer adm itted w ith a com plete lesion at T 1 1—12 in June 1944 passed his first law exam ination at Stoke M andeville w ith in 10 m onths of his injury, w ent to O xford and passed his final exam ination in 1947. An ex-jockey w ith a lesion at T 5 , who at first w ished to refuse trea tm en t and die, becam e interested in sport, re-acquired a will to live, took co rrespondence courses in elem entary arithm etic and train ing in accountancy in the adm in is tra to r’s office, was given free articles by a chartered accountant and passed his final exam ination in accountancy.
A fter lunch one day in 1945 G u ttm an n came across a group of patients in their heavy leather padded w heelchairs sunning them selves on the concrete apron outside the w ards, and h itting a puck w ith reversed
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w alking sticks. H is eye b righ tened as he said som eth ing to the effect ‘G am es, sport, tha t is w hat we m ust have’. H e had been try ing exercise m achines in bed and had the im pression tha t a spell of m uscu lar exercise decreased spasticity in paralysed parts. H e and the chief physio therap ist took w heelchairs and tried out w heelchair polo in the gym nasium and m ade it a recognized gam e, using a ball and the w alking sticks. As long as one could avoid bum ping and boring w ith the chairs, th is was a great success, b u t according to M iss S cru ton , his secretary and later A dm in istra to r of the Sports C entre, on one occasion the carnage was such tha t the gam e had to be given up, and G u ttm an n started w heelchair basketball instead. T h is was an im m ediate success and led to the first Stoke M andeville G am es for the paraplegic in 1948 w hen 16 ex-service patien ts com peted. T h e D u tch b ro u g h t a team to Stoke M andeville in 1952 and the first O lym pic G am es for the Paralysed w ere held in Rom e i n '1960. T h e list of track and field events grew rapidly. A rchery was an early favourite, as paraplegics can com pete on equal term s w ith norm al people, as long as the ir lesion is below T l . F or patien ts w ith cervical lesions, special devices for releasing the s tring or ho lding the bow have to be fitted to the p a tien ts’ hands. T h e great h y pertrophy of the m uscles of the shoulder g irdle tha t patien ts develop from having to lift them selves by the arm s m ay even give them an advantage over norm al people. G u ttm ann succeeded in persuad ing the M in istry of Pensions to build a 10 m etre sw im m ing hath in 1953, and in 1969 a 25 m etre pool form ed part of the Sports S tad ium for the paralysed w hich was opened by H .M . T h e Q ueen. Sw im m ing provides excellent exercise for paraplegics, and some have even taken to the snorkel and aqualung.
A fter his re tirem en t from the D irecto rsh ip of the N ational Spinal In juries C entre, Sir Ludw ig G u ttm an n , as he then was, devoted the greater part of his tim e to the organization of gam es, national every year, O lym pic every fourth year, w ith C om m onw ealth and later regional games about every two years. W hereas the site was leased from the M in istry of H ealth , the cost of the build ings of the stadium was raised w ith the help of anonym ous donors. T h e com plex includes a large indoor bow ling green, a large indoor space for w heelchair basketball and table tennis, an all-w eather track for field events and a large hostel for com petitors. T h e organization expanded to cover disabled people of m any kinds.
T h is did not, how ever, occupy Sir Ludw ig fully. He travelled extensively both for G am es and for m eetings of the In ternational Society for Paraplegia w hich he had founded, and w hich m et at the same tim e as the G am es. Since 1946, those in terested in the trea tm ent of paraplegics had been com ing to Stoke M andeville, som etim es visiting, som etim es w orking there for a year or so before going hom e to set up equivalent facilities. On his journeys he found form er pupils to be reproved, encouraged and fought for. A ccording to Sir G eorge Bedbrook (1982), he
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could explode over poor trea tm en t in a w ard in A ustralia, and his reports to adm in istrato rs over the persisten t w ithho ld ing of facilities were designed to move m ountains. H is com m ents on w hat was then an indifferent Spinal C entre outside E d inburgh , though m ore tactfully phrased, were equally clear. H e had the satisfaction of seeing centres nam ed after him in Barcelona (1964), H eidelberg (1966) and at the H ashom er H ospital in Israel (1972). H e received the O .B .E . in 1950, the C .B .E . in 1960, and was knighted in 1966. H e was honoured by S tate aw ards from France, T h e N etherlands, Italy, the Federal R epublic of G erm any, Belgium , Spain, Japan and F in land . H e becam e F .R .C .S . in 1961, F .R .C .P . in 1962, F .R .S .A . in 1956, F .R .S . in 1976 and H on. F .R .C .P .(C ) in 1976). H e was given honorary degrees by D urham in 1961, Trinity College, D ub lin , in 1969, and by L iverpool in 1971. H is m ain work is sum m arized in two books, Spina l cord injuries: comprehensive management and research, 2nd edn 1976, and a Textbook o f sport fo r the disabled, 1976. H e founded the jou rnal , w hich becam ethe official journal of the In terna tional Society for Paraplegia, and edited it from 1962 to 1980.
Som e of the reasons for Ludw ig G u ttm a n n ’s trem endous im pact on the trea tm en t of paraplegia are easy to see. T h e arrival of the antib io tics m eant tha t effective trea tm en t of bedsores and u rinary infections becam e possible at the end of the w ar — L ady [Ethel] F lorey used to b ring over m inu te quan tities of penicillin herself. T h e a ttitude of society to the disabled, both service and civilian, changed about the same tim e. G u ttm an n was able to bring the exact know ledge tha t F oerster had had of the effects of spinal lesions at every level. F or every patien t the level of sensory loss of touch and pain was exactly charted , as were the m otor and autonom ic losses. N ew know ledge of the pathophysiology of bedsores and of autonom ic hyper-refiexia m ade these conditions easy to trea t because they were understood . T h e rest depended on G u ttm a n n ’s personality , his enthusiasm , his a tten tion to detail and his drive. A patien t said ‘He was the m ost determ ined m an I have ever m e t’. In the early days, a variety of trea tm ents were tried and the failures rapidly discarded. By the m id -1950s he felt he had final solutions for m ost problem s. D issent he could not tolerate, and he did not find it easy to collaborate w ith equals. He believed in concentration of pow er in his hands as D irecto r of the N ational Spinal In juries C entre, partly because this was G erm an practice and partly because a single D irecto r had been absolutely essential in the early days in the p a tien ts’ in terests.
Few men have so exem plified the real v irtues of the old G erm any: devotion to duty, system atic atten tion to detail, and unflagging p erseverance. If he had not had the tenacity to be in his w ards every night at first until his orders were fully carried out, his work w ould have foundered. T o these valuable bu t not always attractive virtues he added a host of acts of kindness to patients, staff and friends. In the pre-
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G u ttm an n period, patien ts no t only saw the ir lives in ru ins, bu t found them selves im prisoned in a paralysed and rapidly decaying body. In the tape record ing he m ade at the age of 80, he com m ents on a narrow escape half in earnest, ‘Perhaps G od was p reserv ing m e for m y m ission’. It does no t trivialize the w ords of Isaiah to apply them to L udw ig G u ttm ann :
T h e S p irit of the L ord G od is upon me, . . . he hath sent to m e to b ind up the broken hearted , to proclaim liberty to the captives,and the opening of the prison to them tha t are bound.
I am indeb ted for personal recollections to M r G . J. H adfield, D r Olive Jones, the late M r J. Pennybacker, M iss Joan S cru ton , D r H onor Sm ith and D r M arthe L. Vogt, F .R .S ., and to D r D ennis G u ttm an n for the loan of his fa th e r’s tape recording.
T h e pho tograph rep roduced was taken by Stoke M andeville H ospital Pho tograph ic D epartm en t in about 1979.
R e f e r e n c e s
[A complete bibliography has been published in Paraplegia 17, 131-138 (1979).]
Adams Ray, J. & Norlen, G. 1951 Bladder distension reflex with vasoconstriction in cutaneous venous capillaries. Acta physiol, scand. 23, 95-109.
Andre Thom as, A. H. 1921 Le reflexe pilomoteur. Paris: Masson.Bull, A. 1979 Sir Ludwig G uttm ann: from a grateful patient. Paraplegia 17, 16-17.Bedbrook, G. 1982 Ludwig G uttm ann, man of an age. Paraplegia 20 , 1-17.Cairns, H. 1941 O bituary of O tfrid Foerster. Br. med. J . ii, 634.Cunningham , D. J. C., G uttm ann, L., W hitteridge, D. & W yndham , C. H. 1953 Cardiovascular
responses to bladder distension in paraplegic patients. J . Physiol., Lond. 121, 581-592.D raper, W. H., Ladefoged, P. & W hitteridge, D. 1960 Expiratory pressure and airflow during
speech. Br. med. J . i, 1837-1843.Foerster, O. 1936a Symptomatologie der Erkrankungen des Ruckenmarks und seiner W urzeln. In
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