The Commonwealth Games began this week in Glasgow and will run until August 3. They are fully integrated and the able-bodied and disabled athletes will compete in the same stadium, on the same day, alternating able-bodied and disabled sport. The disabled will be accepted on equal terms, and their medals will count in the overall medal tally for their country, a triumph for the founder of the Paralympics Games, Sir Ludwig Guttmann, a German Jewish refugee from Nazi Germany.
The successful treatment of spinal injuries is widely attributed to Donald Munro (1936, USA) and Guttmann (1944, UK). However, this view has recently been contested by Dr Patrick Kluger, a German doctor, who has suggested that the treatment of spinal injuries originated not in the USA or Britain, but in Germany before the First World War. He argued that this knowledge had been suppressed and forgotten for political and social reasons in the inter-war period.
The first effective spinal unit was established by Wilhelm Wagner (1848-1900) in Germany at the end of the 19th century, at a small accident hospital at Königshütte.
Wagner founded the spinal unit to treat the many injured miners who had sustained spinal injuries as a result of the collapse of tunnels. Patients were turned regularly and their bladders were drained so that early deaths from pressure sores and urinary tract infection could be avoided. The unit was so successful that some patients were discharged home. But when Wagner died, the unit closed down.
Just as the congregation of injured coal miners led Wagner to found a spinal unit, so the First World War, with an unprecedented number of casualties, showed that the existing methods of treatment were unsatisfactory, as there was no triage and the soldiers were admitted indiscriminately to general military hospitals. Consequently, specialised units were established by all the belligerents for the treatment of abdominal wounds for orthopaedic and plastic surgery and for spinal injuries.
Guttmann set up the spinal unit at Stoke Mandeville using rigorous Prussian methods
Patients with spinal injuries were being treated in Vienna, Tübingen and Leipzig, in Berlin and in Breslau by a number of German doctors, many of them Jews.
France and Britain set up spinal units but the meticulous treatment pioneered in Germany, whereby nursing staff and physiotherapists worked as a team with the doctors, was not followed and the mortality was much higher. Marburg recorded 50 deaths out of 150 (33 per cent mortality) compared to a mortality of 82 per cent in France and 65 per cent in the UK.
When the war ended, the flow of injured soldiers ceased and the military hospitals closed down. The treatment of chronic spinal injury patients in France and the UK was unsatisfactory, despite French attempts at rehabilitation. In Britain, paralysed patients were treated by orthopaedic surgeons in general and voluntary hospitals, and there were very few doctors trained in rehabilitation. At the outset of the Second World War, spinal units were set up all over the country to treat casualties, but consultants rarely visited, staffing was inadequate and patients were no better after three years than when first admitted. A defeatist attitude prevailed.
Germany, in contrast, maintained its tradition of rehabilitation and neurology, with Otfrid Foerster a dominant figure. His particular interest in the treatment and the rehabilitation of peripheral nerve injuries started during the First World War, when he treated 4,748 such patients and operated on 775 of them. When he returned to his neurological department in Breslau after the war, he treated all forms of neurological diseases, including spinal injuries. Crucially, Foerster trained Ludwig Guttmann in neurosurgery, physiological research and the rehabilitation of patients with peripheral nerve injuries. It was this rigorous Prussian training that would later influence Guttmann in the founding of the only successful spinal unit in the UK at Stoke Mandeville Hospital.
After 1933, with the advent of Hitler, there was a dramatic decline in German medicine. The Nazis assumed control of the medical profession including training and appointment of doctors. Specialisation and specialist hospitals were opposed in favour of general practice.
The role of antisemitism has a particular significance on spinal injury management, since so many of the doctors, especially the neurologists caring for spinal injury patients during the First World War, were Jewish. There was institutional antisemitism in Germany prior to the Nazi regime. Racism was openly practised against anyone who was not Aryan. Distinguished Jewish scientists such as Fritz Haber and Paul Ehrlich, who subsequently won Nobel Prizes for their work, had experienced antisemitism earlier in their careers.
Guttmann confirmed that Jews were forced into careers in unpopular specialities such as neurology, radiology, rehabilitation or psychiatry (as was Freud) because through antisemitism, mainstream medical and surgical posts were not open to them. Consequently, a disproportionate number of Jewish doctors treated spinal injuries patients during the First World War in Germany and the Austrio-Hungarian Empire. Among them were Marburg, Ranzi, Borchard, Cassirer, Weil and Schwarz.
In 1933, all Jewish professors were dismissed from universities and Jewish books were burned and banned. Jewish doctors were dismissed from hospitals, could not continue their insurance work or their private practice, were only allowed to treat Jews and by 1939, had their qualifications stripped from them altogether so that they could not practise medicine at all. Jewish authors had their names removed from books and publications and were no longer allowed to publish scientific papers.
Antisemitism greatly affected the careers of Jewish doctors; many fled Germany and their knowledge was lost. Foerster wasn't Jewish, but he had a Jewish wife and his children were expelled from school. He was challenged as to why he employed so many Jewish assistants. He replied that he chose his staff for their intelligence, not for their religion.
Marburg, an Austrian, held a full university chair at the neurological institute in Vienna. He was a prolific and fundamental writer on neurology but when the Nazis came to power, he fled to America where he was again appointed professor and wrote a textbook on the management of spinal injuries.
Ludwig Guttmann was dismissed from his post as first assistant to Foerster and became director of the Jewish Hospital in Breslau, where his opportunities for research and treating patients were severely curtailed. Eventually, in fear for his life and that of his family, he fled to the UK with the aid of the Council for the Assistance of Refugee Academics (CARA).
In Germany, Ludwig Guttmann was trained to rehabilitate patients with peripheral nerve injuries. When he came to the UK in 1938 he had no practical experience of treating spinal injuries. He spent five years in Oxford carrying out research on peripheral nerve injuries, and bitterly resented not being allowed to treat patients.
In 1944 he was invited to lecture at the Royal Society of Medicine on the treatment of peripheral nerve injuries. As previously described, the treatment of spinal injury was desultory during the Second World War in the UK, and it was only when Guttmann was appointed as the only full-time Resident Medical Officer to Stoke Mandeville in 1944, that the situation changed. He instituted a Prussian regime in the Foerster tradition of medicine.
He trained and supervised the auxiliary and nursing staff and carried out the catheterisation himself; he did not accept the English hierarchical system of visiting consultants giving orders and departing. He was ever present and took overall responsibility for all aspects of the patients' care.
Kluger's contention that the treatment of spinal injuries originated in Germany, but was suppressed and forgotten, holds. Ludwig Guttmann, a despised refugee German Jew, trained by Foerster in the principles of rehabilitation, fled to England and because of his expertise in the treatment of peripheral nerve injuries, was put in sole charge of a ward of hopeless patients at the spinal unit at Stoke Mandeville, an unpromising and neglected field of medicine.
There, he treated spinal injury patients, giving them their lives back. He founded the sports movement as a means of rehabilitation which has straddled the world.
Guttmann was not unique. Other Jews such as Chain, Krebbs, Katz and Loewi, fled Germany and brought their expertise to bear in other fields of science and medicine. What unites them is a thorough scientific training. Armed with a rigorous methodology, they applied their knowledge and their methods to the great benefit of the countries which gave them refuge.