History of the Treatment of Spinal Injuries (review)

For the title of this book to be fully descriptive, it should have been "History of the Treatment and Rehabilitation of Spinal Cord and Cauda Equina Injuries." John Russell Silver is a retired British specialist in this subject. He was trained by the legendary Sir Ludwig Guttmann, who founded the National Spinal Cord Injuries Centre at Stoke Mandeville in 1944. In the course of his efforts, Guttmann also founded the Paralympics. Silver was a successor to Guttmann and director of the Centre from 1970 to 1993. Hence, the book is comprehensive about its subject, but it is not a history of neurology, neurosurgery, orthopedics, or rehabilitation in general. Those subjects are mentioned where appropriate, but the focus is on the subacute and chronic treatment of these unfortunate patients. Although Silver is not a trained historian, he is excruciatingly systematic, generally well balanced, and above all, completely dedicated to his subject. His historical method consists in surveying much of the published literature in English, as well as selected sources in French and German. Manuscript sources were used sparingly, but Silver did interview a large number of people in Britain.

The book is divided into chapters along national lines. There are thus chapters on the United Kingdom, the United States, Canada, the German-speaking world, and France. Immediately after the British chapter, a special chapter is devoted to "Sir Ludwig Guttmann (1899-1980) and the National Spinal Injuries Centre." Silver justifies this seemingly parochial organization by noting that communication between these countries was often limited by wartime circumstances, when most of these injuries occurred. In effect, he also shows that arrangements (or lack thereof) for the chronic treatment of spinal cord injuries are almost entirely dependent on the level of commitment of the societies in which the patients live. Indeed, the only riveting part of the book is Silver's stark description of Nazi ideology and the Nazi period in German medicine. He minces no words in condemning the majority of the German medical establishment for subscribing to an unethical racial theory. The theory resulted not only in the horrors we all know about, but also in the murder of the regime's own Aryan citizens, some of whom were deformed by birth accident and some by war injuries.

Being a disciple of Guttmann, Silver uses his mentor's principles as standards when he describes and analyzes the work and results in each country. The prevention of bedsores and urinary tract infections is the first criterion by which all efforts are judged; only when this is achieved is it possible to move on to genuine rehabilitation, which requires a positive attitude and commitment by the patients and by every member of the staff. Such commitment is feasible only in specialized units under the direction of a physician who is entirely devoted to this task. When Silver looked at developments in the countries under his purview through this Guttmannian lens, he did come up with one surprise: the American neurosurgeon Donald Munro used these principles first in a specialized unit at the Boston City Hospital, starting in 1936. Moreover, Guttmann knew this early on, although he did not visit the United States until after the Second World War. From the tone of Silver's text, I infer that Guttmann did not talk much about Munro when he was teaching. Silver's surprise seems to be not that Munro did it first, but how completely Munro anticipated Guttmann's methods.

One modest criticism: The author seems to be quite unfamiliar with the organization of North American medical academia and geography. On p. 125, he confers a surely inaccurate title on "Alain Rossier, . . . [who] was appointed Professor in Charge of the Veterans' Spinal Unit at West Roxborough" (i.e., West Roxbury, Mass.). On pp. 132-33, he says that he was once "invited to take charge of a spinal unit based at the Veterans' Hospital at St. Louis with a university appointment at Duke University...