The role of the London Hospital in the development of the treatment of spinal injury

JR Silver

At the London Hospital there was an interest in diseases affecting the nervous system. Generations of general physicians and surgeons devoted a considerable amount of energy to the study of diseases of nervous system and their observations and research have contributed to the development of the practice of neurology in the United Kingdom. James Parkinson (1755–1828) walked the wards of the hospital and subsequently became a general practitioner in the East End on London before describing the disease named after him. John Hutchinson (1828–1913), a distinguished surgeon and dermatologist, clearly described the manifestations of spinal cord transections at different levels. Hughlings Jackson (1835–1911) made fundamental discoveries on the function of the nervous system. Hugh Cairns (1896–1952) became the first full-time practising neurosurgeon in London and set up a neurosurgical unit at the London Hospital. He was responsible for the training of virtually all the neurosurgeons of the United Kingdom. Russell Brain continued this neurological tradition and firmly established neurology as an independent speciality at the London Hospital, a tradition which continues today.

While the role of the London Hospital in delineating diseases of the nervous system is widely accepted, its role in developing the speciality of spinal injuries in the United Kingdom has not been acknowledged. This article documents this important aspect of the London Hospital’s contribution. The responsibility for this rests with Henry Head (1861–1940), George Riddoch (1888–1947), and a lesser known figure, Julian Holland-Hibbert (1920–1986) who, in addition to a long philanthropic association with the London Hospital, fought for the rights of disabled people to live independent and active lives. Although not a doctor himself, he suffered a traumatic injury of the spinal cord and took the lead to show how disabled people could lead independent lives.

Henry Head (1861–1940) (see Figure 1)

Henry Head was the outstanding clinical scientist of his generation. He studied at Trinity College Cambridge, worked with Ewald Hering (1934–1918), Sir Michael Foster (1836–1907) and John Langley (1852–1925). Head qualified in 1890, worked at the National Hospital for Nervous Diseases (otherwise known as Queen Square and referred to as such) and developed a profound interest in the physiology of pain and in peripheral nerves and patterns of referred pain. He studied patients with Herpes Zoster at Rain Hill County asylum. Head was interested in the study of the segmental distribution of nerves. He delineated the neurological segment by observing the rash of Herpes Zoster which was confined to one segment. He did this by living for two years in the Rain Hill County asylum where there were many patients suffering from this condition. He studied 450 cases, obtaining confirmation through 21 post- mortem studies. ¹ He also studied the pattern of recovery of an injured nerve by cutting superficial nerves in his own arm and carefully observing the recovery of sensation. This painstaking and ground breaking work was confirmed by Otfrid Foerster many years later when he carried out sections of the posterior nerve roots in his patients. This led Head to study spinal reflex function. He was too old to serve in the First World War so he was assigned to the Empire Hospital for officers in Vincent Square (thereafter referred to as the Empire Hospital) where he set up a department for war injuries of the nervous system. Amongst these were many patients with spinal injuries. Just as his painstaking research on the peripheral nerves, so as a medical scientist he welcomed the opportunity to study these patients. His detailed day to day observations with their superlative clinical records can be employed to the present day in research work. He maintained his research just as he had done previously with his studies on Herpes Zoster. Gordon Holmes, the sole neurologist in the army, sent patients with spinal injuries to the London Hospital where Head was in charge of their care. When the hospital authorities wished to discharge patients from his beds to move them to other hospitals to make room for other casualties, he refused to discharge the spinal patients. Eventually, they were transferred to the Empire Hospital under his care where he could continue his research and clinical care. In conjunction with George Riddoch, who was in charge of their day to day care, Head made detailed observations on the level of injury, the physiology of the bladder, the mass reflex and spinal shock. He made clinical descriptions of the patients through the evolution of their condition. His studies were remarkable in their accuracy, clinical description and the research which he carried out confirming that the spinal cord in humans following a cord transection followed the same pattern of the return of reflex activity as Sir Charles Sherrington (1857–1952) had shown in animals. ²

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Figure 1.

Henry Head (1861–1940) reproduced by permission of the Wellcome Library London.

George Riddoch (1888–1947) (see Figure 2)

George Riddoch qualified in medicine from Aberdeen University in 1913. He was appointed as demonstrator in the university’s anatomy department and gained a detailed knowledge of anatomy, particularly of the nervous system. He went to London, without doing a medical or surgical house job, he was appointed resident medical officer at the West End Hospital for Nervous Diseases. During the First World War, he was one of a few doctors with neurological training and was appointed Captain in the Army, Officer in Charge of soldiers with injuries of the nervous system at the Empire Hospital (see Figure 3). He worked with Henry Head but had full responsibility for the day to day care of the patients. ³ He carried out every task and every responsibility fell on him, he had no junior doctors, no one else to blame, success would be attributed to him alone. Such a training was not unusual in those days and whilst demanding and challenging, it was a very valuable experience. (Guttmann experienced this as a single handed doctor when he was appointed at Stoke Mandeville Hospital in 1944 and John Silver (author) had a similar learning experience when he was appointed single-handed consultant without junior staff to run the Liverpool Paraplegic Centre in 1965, with sole responsibility for the regional unit of 34 beds.)

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Figure 2.

George Riddoch (1888–1947) reproduced by permission of the Wellcome Library London.

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Figure 3.

The Empire Hospital London reproduced from History of the Treatment of Spinal Injuries by JR Silver, 2003.

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Figure 4.

Julian Holland-Hibbert with the Queen Mother, 1977 reproduced by permission of Michael Holland-Hibbert.

Riddoch’s thorough grounding and understanding of the care of patients with spinal injuries is evidenced from his observations on managing the bladder by intermittent catheterisation, his emphasis on the prevention of pressure sores by regular turning and positioning of the patient and his observations on deep vein thrombosis causing swelling of the legs. Together with Henry Head, he carried out detailed observations on the return of reflexes following a spinal cord transection, the development of the mass reflex and the physiology of the bladder. ⁴ Their painstaking research work was published in detail and the observations are still of value today. At the end of the First World War Riddoch returned to the practice of neurology at the Maida Vale Hospital for Nervous Diseases and the London Hospital and he was responsible for the appointment of Hugh Cairns as neurosurgeon at the London Hospital and Queen Square. When the Second World War broke out and the need for spinal units was recognised, it was not sufficient to wish it to happen, train staff who understood how the patients should be treated and could devote themselves to them exclusively. Only three doctors in the United Kingdom had the necessary experience, Henry Head, Gordon Holmes, and George Riddoch. Head had already retired; Holmes was nearing the end of his career and Riddoch was overwhelmed with commitments: He was in charge of the Emergency Medical Services (EMS) neurological unit of the London hospital, which was evacuated to Chase Farm, he took a commission as Brigadier and was responsible, with Hugh Cairns, for the coordination of the Army neurological service. In addition, he was a member of the War Office Medical Board and the chairman of the peripheral nerve and spinal Injury Committee for the Medical Research Council. The situation was dire and despite his best endeavours, he could not stretch himself any further and provide first-hand management of the patients in the four designated spinal injury units: Agnes Hunt and Robert Jones at Oswestry serving the Midlands, the Royal National Orthopaedic Hospital Stanmore serving London, the E &S Hospital Winwick, Warrington serving the North West and Bangour Hospital, serving Scotland. By 1943, the provision for the acute treatment of spinal injuries in the South of England was inadequate. Riddoch made an inspired decision which would revolutionise the treatment of spinal injuries in the United Kingdom. ³ In 1941, Ludwig Guttmann was invited to lecture at the Royal Society of Medicine on the rehabilitation of peripheral nerve injuries. ⁵ Riddoch observed that Guttmann’s principles of treatment were just as applicable to spinal injuries so he asked him to write a memorandum on the surgical treatment of spinal injuries and appointed him as resident medical officer of a new spinal injury unit in the South of England at Stoke Mandeville Hospital. Guttmann’s vision and rigid Germanic approach soon yielded results and his unit became a beacon and a model for future generations.

Julian Holland-Hibbert, Viscount Knutsford (1920–1986) (see Figure 4)

The Holland family first became involved with the London Hospital in 1896 when Sydney Holland, later 2nd Viscount Knutsford, became chairman of the board of governors. He had exceptional organisational skills and fund-raising ability, and under his stewardship the hospital came to be provided with a new building and first-class nursing and medical staff. A great fundraiser, Knutsford was known as ‘The Prince of Beggars’ in the East End for his work at The Poplar Hospital for Accidents where he was chairman. He soon established that the London Hospital was in dire need of improvements and undertook to raise the funds necessary through letter writing and approaching wealthy individuals such as the ship builder Alfred Yarrow, and the Bankers Rothschilds. Julian followed in his great-uncle’s footsteps at the London Hospital where he served as a Governor for many years until in 1974 when, following a reorganisation, he was appointed a Special Trustee. He also acted as Chairman until his resignation in 1981, devoting many hours a month to the task and driving himself up to London in his Mini. Upon arrival at his destination, he would summon the nearest able-bodied man and ask for assistance in bringing his wheelchair from the rear seat to the drivers’ open door. This request was never refused. Julian’s greatest achievement however was his lifelong fight for the rights of disabled people and most specifically his desire to provide them with more independence in society. ⁶

Julian had personal experience of disability. In March 1943, when fighting in the Second World War, he was injured at the Battle of Mareth in North Africa. He suffered a spinal injury which left him paralysed from the waist down and wheelchair bound.

Prior to the Second World War, paralysed and disabled people were housed on a permanent basis in institutions or hospitals for the chronically sick, with no privacy or independence. In contrast, despite this life changing injury, Julian led an independent and fulfilled life. Conscious of his privileged circumstances, Julian devoted his energy to improving the opportunities and the rights of other disabled people. After inheriting the title on the death of his father in 1976, he became a Member of the House of Lords. He spoke on disability in the upper chamber on two occasions, in 1978 for a bill on voluntary organisations and once again in 1983 for a bill relating to chronically sick and disabled persons. ⁷

Julian made a greater impact as a member of the National Advisory Council on Employment of the Disabled resulting in the 1944 Disabled Persons Act which set a quota of disabled employees for firms with more than 20 employees and also provided for sheltered workshops and training so that disabled people could acquire the skills necessary for employment. Julian had his own adapted car, which he drove to visit the London Hospital. In 1961, he published recommendations on Wheeled Chairs and Tricycles suggesting that medical staff, particularly consultants, were not best qualified to advise on suitable equipment, and recommending that the provision of chairs should be centralised and overseen by physiotherapists, occupational therapists and technicians. ⁸ He also commented that Invacars, (the specially adapted cars provided by the Government scheme) should be allowed to be parked in the open-air rather than in a garage to allow more disabled people to obtain employment. His input was practical and based on his philosophy that the disabled have a contribution to make to society as important as the benefits they expect from it.

With his lifelong friend, Pat Stewart, another paraplegic victim of fighting in North Africa in the Second World War, they set out to raise funds for the establishment of a specially designed residential estate, the Kytes settlement at Garston near Watford. The objective was to provide individual adapted bungalows to allow married disabled ex-servicemen to lead a normal independent life. In contrast to other organisations, the charity which ran the estate did not support sheltered employment but encouraged residents to seek employment in mainstream companies or become self-employed working from home.

In 1948, Julian and Pat founded the National Association for the Paralysed (NAP), an independent branch of the British Council for Rehabilitation (BCR). The NAP set up a register of all paralysed people (which included congenital and chronic disabilities) and fought for their rights and opportunities. They acted in an advisory capacity making recommendations to existing agencies. They raised issues such as disabled access to public venues and entertainment, opportunities for going on holiday, advice on daily living equipment and facilities. Most important was access to training facilities such as the Queen Elizabeth Training College, where disabled people could acquire the skills necessary to secure employment and thereby independence. In 1958, Dorincourt, a residential facility, was opened at the College to admit over 40 residents, men and women. In 1957 Julian was created a Commander of the British Empire for his services to disabled people. On 17 February 1976 he was appointed Officer of the Most Venerable Order of the Hospital of St John of Jerusalem. This is a British royal order of chivalry first constituted in 1888 by Royal Charter.

Discussion

The research work and collaboration of dedicated neurologists with complementary skills at the London Hospital led to an understanding of how to treat patients with spinal injuries. Head, a research scientist, focused on the study of individual patients to gain a better understanding of the physiology of the nervous system and the pathology of nervous diseases. Riddoch, a practical man with excellent administrative skills had acquired a thorough knowledge of the anatomy and the pathology of the nervous system but also a meticulous understanding of how to treat patients with a spinal injury. His hands-on experience during the First World War taught him the importance and the necessity for specialised treatment centres and well trained dedicated staff. Armed with clear treatment directives, he set out to open spinal units across the country. Such a task was monumental for one man and despite visiting the units, sometimes carrying out the clinical work himself and supervising the staff, Riddoch could not achieve the impossible and the units were a calamity. Thomas B. Staveley Dick (1913 -1999) who worked in one of these units, Winwick, wrote his MD thesis on how unsatisfactory the treatment was due to lack of staff, lack of knowledge and the patients were no better off after three years of treatment in the unit than they were when they entered, covered in pressure sores. ⁹ The turning point came with the appointment of Ludwig Guttmann, a Jewish refugee from Germany, to head the newly opened spinal injury unit at Stoke Mandeville Hospital in 1944. Guttmann applied methods which mirrored Riddoch’s treatment directives and as a full-time doctor of the unit, he was able to supervise the work himself, train the staff and oversee the patients 24 hours a day. Riddoch’s influence and support did not cease when he ensured Guttmann’s appointment. He sponsored Guttmann’s appointment for membership of the Royal College of Physicians so that he could practice medicine in the United Kingdom, he sponsored his research and discussed it with him as an equal, and helped to get it published. He corresponded with Guttmann and Guttmann reciprocated his regard and dedicated his book on the treatment of spinal injuries to Riddoch: ‘Pioneer advocate of specialised units for the treatment of sufferers from spinal cord lesions.’ ¹⁰

He was a driven man, trained by Foerster, a like-minded teacher, and he ensured that his orders were carried out, not unlike Florence Nightingale:

She swept and in a generation revolutionized not just nursing but the practice of hospital medicine. It was not by gentle sweetness and womanly self-abnegation that she brought order out of chaos. By strict method, by stern discipline, by rigid attention to detail, by ceaseless labour, by the fixed determination of an indomitable will, in other words by the application of uncomfortable virtues. ¹¹

Conclusion

The pioneering efforts of Henry Head and George Riddoch provided the foundation for the successful treatment of patients with spinal injuries. Initially, to demonstrate that these patients could survive, then when the patients were ready for discharge, Julian Holland-Hibbert by his magnificent unselfish effort made sure that they could live independent, fulfilled lives in society.