Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6022_Библиотеки_им_академика_М_И_Перельмана
.pdf
I
Introduction
1
HistoryofSpinalCordMedicine
JohnF.Ditunno,Jr.,WilliamH.Donovan,andChristina
V.Oleson
INTRODUCTION
Inthis journey through the History of Spinal Cord Injury (SCI) Medicine, we
examine three distinct periods. The first is characterized by the “not to treat”
philosophythatprevailedfromancienttimestothenineteenthcentury,when,for
thefirsttime,advancesinanesthesiology,surgery,andcontrolofinfectionmade
the survival of severe neurological traumapossible. In 1914, the “Great War”
awakened military medicine to the challenge ofmassive casualties, leading to
thenexthistoricalperiodwhichwascharacterizedbyanorganizedapproachto
restore the wounded to health and function. This phase we explore in depth
because it marked the origin of the rehabilitation approach to SCI
comprehensivecare.Respondingtothedemandsposedby20th-centurywarfare,
the newly emerging disciplines of orthopedic and neurological surgery
developed models of categorical care, which integrated acute medical and
surgical treatment with systematic restoration of function through physical
trainingandattentiontovocationalandrecreationalcapacity.Pioneersintheart
and science of physical training (later Physical Medicine and Rehabilitation)
established standards in World War I (WWI) reconstruction (rehabilitation)
hospitals for triage of the wounded based on severity of disability and set
guidelines for rehabilitation facilities, equipment, and staff. This holistic
approach,asadoptedbytheperipheralnerveinjuriescentersinWWI,provided
thefuturemodelforSCIcenters.Withsuccessthroughinnovativetreatmentof
acute medical complications, the pioneers of SCI centers integrated the
restorationoffunctionlearnedfromcategoricalcareanddemonstratedthatSCI
wasacondition“tobetreated.”Survivalduetopreventionofbladderandskin
complications with restoration of mobility, self-care, and return to home and
workinveteransinjuredinWWIIrepresentedarevolutioninmedicine.
The third phase of our journey considers the role of organizations and
funding agencies in the development of SCI Medicine. The work of the
individual physicians and researchers during WWI and WWII has been
enthusiasticallyembracedbyorganizationscommittedtopatientcare,education,
and research. International organizations expanded the frontiers of SCI
Medicine, establishing standards for neurological assessment and defining the
principal characteristics of SCI centers: care from the moment of injury to
lifelongfollow-up,largedatabasesofthousandsofsubjectsforclinicalresearch,
and standards for professional certification. Consumers have been essential to
thesedevelopmentsinpatientcareandresearch.Thestrongestfinancialbasefor
comprehensive care in the United States exists in military and veterans’
facilities,withafewinsurersintheWorkersCompensationprogramthatdirect
patients to comprehensive SCI centers. This tradition of limited support was
evident in the creation of the first US SCI center in Boston in the 1930 and
1940s.CountriessuchasGreatBritainandCanadawithnationalhealthservices
provideamoreuniformsystemofcareforveteransandcivilians.
PARTI:EARLYHISTORYOFSCICARE(UNTIL
1916)
Toappreciatethe accomplishmentsand challengesthatfaceusnow andinthe
future,itisessentialtohaveacomprehensiveviewofthepast,whetherthefocus
is SCI or other areas of medicine. As George Santayana (1863–1952) said,
“progress…dependsonretentiveness…Thosewhocannotrememberthepast
arecondemnedtorepeatit”(1).PhysicianswhotreatpersonswithSCIshouldbe
awareofitsabsorbingpast,whichcanbetracedtothediscoveryof“TheEdwin
SmithPapyrus”byan American Egyptologist who purchased and named it in
1862(2).AsHughesexplains,itis(a)thefirstknownrecordextantthatcanbe
calledascientificdocument,(b)thefirstknownimportantmedicaltreatise,(c)
the first medical document concerned with trauma, and (d) the first
documentationofcasesofSCI(3).ThediscoveryoftheRosettastonein1799,
which contained the same hieratic language as the Papyrus as well as the
demoticandancientGreekscripts(nowlocatedintheBritishMuseum),enabled
Breastedtotranslate thePapyrus fromHieratictoGreekto English.Twoclear
cases of SCI are described. The treatment for such conditions that the author
(possibly Imhotep) advised was no treatment at all: “an ailment not to be
treated.” Given the battlefield conditions he described, certainly no treatment
wasavailable thatcouldreturn such awounded soldier toduty. Unfortunately,
thatsamehopelessattitudepersisteddownthroughthemillenniaasreflectedin
thewritingsofHippocrates,Galen,andphysiciansoftheMiddleAgesthatare
carefullyreviewedinarecenttext(4).Itwasnotuntiltheearly19thcenturythat
a “renaissance of medicine” yielded an interest in SCI, exemplified by the
polemics between Sir Astley Cooper,who favored operative intervention, and
SirCharlesBell,whodidnot(5).
ExamplesoffamouspeoplewhosustainedanSCIinrelativelymorerecent
timesinclude LordHoratioNelson (1758–1805),whowas felled bya sniper’s
bulletattheBattleofTrafalgarandsustainedathoracicSCI;JamesA.Garfield
(1831–1881), the 20th president of the United States, who was shot by a
disgruntledofficeseeker andsustaineda lumbarSCI, lingeredfor80 daysbut
succumbedtodeathsincenothingcouldbedonetoextendhislife;andGeneral
GeorgePatton(1885–1945),whosustainedacervicalSCIfromamotorvehicle
accidentshortlyafteralliedvictoryintheEuropeanTheater,andsinceheknew
nothingcouldcurehisparalysisherefusedallcareandsoonafterpassedaway.
Thesecasesillustratethediscouragingstateoftheartthatpersisteduntilthe20th
century.
Atthesametime,preludestothesubsequent advancesmust berecognized
because we could not have reached the point where life-saving and lifeextending treatments and subsequent improvements in quality of life (QOL)
could be offered to people with SCI unless certain barriers were overcome in
science overall. Significant progress occurred in the following realms: in the
mid- to late 19th century and early 20th century, discoveries in the field of
microbiology (e.g., Pasteur [1832–1895] and Koch [1843–1910]) proved that
diseases were caused by micro-organisms such that preventing and treating
infectionnotablyintheformofdrugscouldbeutilized(e.g.,Lister[1827–1912],
Halstead [1852–1922], and Fleming [1881–1955]); discoveries of anesthesia
(e.g.,Davy[1778–1829],Morton[1819–1858],andSnow[1813–1858])enabled
invasiveprocedurestobeperformedpainlesslyandmethodically;inhematology,
blood transfusions became a safe option (e.g., Landsteiner [1868–1943] and
Weiner [1907–1976]); and discoveries in the field of imaging, including x-ray
(Roentgen[1845–1923]),CTscanning(Oldendorf[1925–1992]), andmagnetic
resonanceimaging(MRI-TeslaUnit1956)(6).
Surgicaltreatmentswerealsoadvanced.DamadianandReidbothfacilitated
diagnosis and improved the accuracy of operative procedures to reduce
complicationsandimproveoutcomes.
Treatments included both closed, Crutchfield (1900–1972), Nickel (1918–
1993),andopenreductionandfixation,Harrington(1911–1980),Dubouset,and
others.Nevertheless,these discoveries could not have been applied topersons
with SCI unless certain pioneers had come along who recognized that tools
existed to translate this knowledge and thereby extend life, maintain health,
improve QOL, and enable participation in society. These individuals, to be
discussedinthecontextofthecenturyfollowingWWI,includeDonaldMunro
(1898–1978);SirLudwigGuttmann(1899–1980),HarryBotterell(1906–1997),
AlJousse(1910–1993), Ernest Bors (1900–1990), Estin Comarr (1915–1996),
JohnYoung(1919–1990),andAlainRossier(1930–2006)(5,7).
PARTII.SCIREHABILITATION(1916TO
PRESENT):ORIGINSINGERMANYANDNORTH
AMERICATOPRESENT
Restorationof functionthroughthe rehabilitation oflargenumbersofseverely
disabled persons had its origin in WWI and was documented in the Englishspeaking literature by articles and a handbook on physical therapy (8); these
writingsdescribethestandardofcareforBritish,Canadian,andAmericanforces
(9). McKenzie and Deavers’ work demonstrated that therapeutic exercises,
encompassing graded strengthening of weakened/partly paralyzed muscles,
mobilizationoflimbs,traininginwalking,self-care,dancing,andsportsaswell
as vocational and fitness training, restored function to thousands of wounded
soldiers(8,10).
Historians who recently reviewed the German literature document a long
tradition of therapeutic exercise originating in spas and employed by German
neurologists/neurosurgeons,includingHeinrichFrenkelandOtfridFoersterprior
to and during WWI and extending to Guttmann after WWII (11). In WWI,
German medical care for survivors of SCI was more advanced than that in
English-speakingcountriesasevidencedbytheSCImortalityrates:33%forthe
Germanforces(12)comparedwith80%amongAmericanforces(5).
In their analysis of the treatment of traumatic spinal injuries, Weiner and
SilverciteaspinalunitestablishedbyO.MarburginViennain1915:
Marburg,alreadya professor of neurology, established aspinal unit in
Viennawithateamofspecialistsinurology,neurology,neurosurgeryand
orthopaedic surgery. He described the importance of supervising the
nursing staff and monitoring the patient’s bladder. He incorporated
physiotherapy in his treatment regime and endeavored to return the
patientshome(12).
Foerster,aneurologistbytraining,hadinvestigatedtheeffectofexerciseonthe
restoration of function in patients impaired by neurological disorders and
advanced the field of neurology beyond diagnosis into practical therapeutics
(11,13)(Figure1.1).DuringWWI,heappliedhisunderstandingofneuroscience
tosurgeryasheadphysicianatthemilitaryhospitalinBreslauandself-trained
himselfasaneurosurgeon.Whenwarbrokeoutin1914,Foersterwasnameda
consulting physician of the Sixth Army Corps and head physician of the
Festungslazarett (military hospital) in Breslau—a position that he maintained
until1920.Duringthe4yearsofconflict,Foerstertreatedthousandsofgunshot
injuries to the nervous system. He reported almost 4,000 cases of war-related
peripheral lesions and almost 400 cases of lesions to the spinal cord. This
expansive experience during the war gave Foerster, who had never formally
trainedasasurgeon, legitimacy for his operative interventions onthenervous
system(11).
Foersterachievedrecognitionforsurgicalinterventionssuchasrhizotomyto
reduce severe spasticity, which facilitated retraining of some patients to walk
(14).Hisworkontherestorationoffunctionbyphysical therapyof peripheral
nerve lesions was cited by Guttmann as a model for the rehabilitation of
neurologicaldisorders (15). In 1931, Foerster published his classic treatise on
dermatome mapping, which would be adapted to become one of the major
metrics in SCI research on regeneration: the International Standards for
NeurologicalClassificationofSpinalCordInjury(ISNCSCI)(16).
AsSilverhasindicated(12,17),theGermantraditionoftherapeuticexercise
coupled with Foerster,who pioneered physical therapy in neurology (13) and
mentored Sir Ludwig Guttmann for 10 years prior to his escape from Nazi
Germany to England in 1939, must have influenced Guttmann’s enthusiastic
integrationofphysicaltreatmentinSCIcare(18).GuttmannreferencesFoerster
often in his SCI textbook (1973) on muscle and sensory testing, but not as a
source for physical therapy and rehabilitation of SCI. Ruskand Guttmannare
oftenpairedinthehistoryofcomprehensiverehabilitationfollowingWWII,but
there is no evidence that they formally recognized each other by citations.
Deaver, however, whose publications spanned WWI and WWII, was
characterized by Rusk in his autobiography (19) as “he who first taught
paraplegics to walk” and is cited by Guttmann (1973) for his work at the
Institute for the Crippled and Disabled (1938–1947) in New York City.
Guttmann also links Deaver’s work on physical rehabilitation to Munro’s
advocacyfor“industrialresettlement”inhiscreditstotheUnitedStates(20).
FIGURE1.1GuttmannTribute.
Source: Frankel HL. The Sir Ludwig Guttmann Lecture 2012: the contribution of Stoke
Mandeville Hospital to spinal cord injuries. Nature News. Spinal Cord. 2012;50: 790–796.
https://www.nature.com/articles/sc2012109
In his early publications (1946), Guttmann emphasized the importance of
physicalrestoration,whichhedefinesaspreventionofatrophy,contractures,and
“compensatorytrainingofthenormalpartsofthebody”toachievethehighest
levels of fitness (Figure 1.1). In the introduction to his first paper (18), his
physicalmedicinecolleaguesdrewattentiontothe“happypartnership”thatthey
achieved with an expert in neurological structure and function. Guttmann’s
comprehensiveapproachcombinedphysicalrestorationwithattentiontogeneral
nutrition, psychological aspects of SCI, care of skin, bladder, and bowel
management. His comprehensive vision for SCI rehabilitation dramatically
improvedsurvivalandbecamethestandardofcareinfuturespinalunitsandthe
foundation of the expertise of SCI physicians. Guttmann would recruit future
SCIphysiciansfrommultiplespecialtiesincludingorthopedics,urology,general
medicine,andpediatrics.Inadditiontopioneeringthismodelofcomprehensive
careforSCIintheUnitedKingdom,hefoundedthejournalParaplegiaandthe
InternationalMedicalSocietyofParaplegia(IMSoP)tofurthertheresearchand
disseminationofnewfindingsinthecareofspinalinjuredpersons.Hewasalso
responsible for gaining recognition for specialty training in SCI by the Royal
CollegeofPhysiciansandSurgeonsinUnitedKingdom(4).Guttmann’simpact
onthedevelopmentofspinalunitsandthetrainingofparaplegicsthroughoutthe
world in the latter partof the 20th century has rightly earned him the title of
“Father”ofSCIcare.AlthoughFoersterandtheGermantraditionoffitnessand
sports participation served as background, Guttmann’s ability to apply these
principlestotheseverelydisabled,particularlythosepersonswithSPI,inspired
theParalympicmovement.Hislegacyisrecordedinhis ownwords:“IfIever
did one good thing in my medical career, it was to introduce sport into the
treatment and rehabilitation programme of spinal cord sufferers and other
severely disabled” (21). His recognition that participation in sports was also
participation in society preceded the recognition by the World Health
Organization that involvement in sports was an essential element of
comprehensivecareofthedisabled.
InNorthAmerica,orthopedicandneurologicalsurgeonsandlaterurologists
involved in subacute and chronic care in military or veteran’s hospitals were
confrontedandrespondedpositivelytothetotalneedsofthepatientwithSCI.
Physicians with primary training in pediatrics, pulmonary medicine, and
physicalmedicineandrehabilitationencounteredsimilarchallenges,firstinthe
comprehensivemanagementofpoliomyelitisandlaterinSCI.
Orthopedic surgery had an interest in operative management and
rehabilitation,utilizing physical therapy and vocationaltrainingdating back to
WWIunder Joel Goldthwait at the Massachusetts General Hospital (MGH) in
Boston.Goldthwait,ChiefofOrthopedicSurgeryatMGH/HarvardandDirector
oftheOrthopedicDivisionof theAmericanExpeditionaryForce,worked with
FrankGranger,aphysicaltherapy physician(later physiatrist),duringWWI in
thereconstruction(rehabilitation)hospitalsinFranceandtheUnitedStates(9).
Granger, who was head of physical therapy at Walter Reed Hospital, had
founded the physical therapy department at Boston City Hospital (BCH), the
futuresite ofMunro’sspinalunit.Paul Magnuson,an orthopedicsurgeonwho
spanned both WorldWars, partnered with John Stanley Coulter to lead in the
establishment of rehabilitation units in the Veterans Administration following
WWIIandlaterfoundedtheRehabilitationInstituteofChicagoin1960(7).
Stabilization of the thoracic and cervical spine following fractureand SCI
led to early mobilization and rehabilitation (22). In 1962, Paul Harrington
developed metal rod fixation to correct scoliosis in polio and other
neuromusculardiseases—aninterventionwhichwassubsequentlyappliedtoSCI
(5).RanchoLosAmigosHospital,withleadershipbyJacquelinePerryandVern
Nickel, pioneered halo stabilization in polio patients and later applied it to
cervicalSCI(23).Withthedevelopmentoftraumacentersintegratedwithacute
SCIunitsinthe1970s,orthopedicsurgeonsatNorthwesternUniversitybrought
rehabilitation into the emergency room and acute care setting, a development
that would be embraced by the Model SCI Systems (24). While most
neurosurgeons were interested in acute surgical management, several notable
exceptionswereDonaldMunroandHarryBotterell.Munroiscreditedashaving
developed the first comprehensive SCI unit in the United States at BCH (5)
(Figure1.2).
Munro’strainingincludedayearofneurosurgicaltraininginPhiladelphiain
1916 under Charles H. Frazier, and may have been his first exposure to the
application of physical therapy (physical medicine) to neurological trauma.
FrazierandhiswifehadbecomeclosefriendsofMcKenzie,thefirstProfessor
ofPhysicalMedicinein thenation,whenhedidbas-reliefsof theirchildrenin
1906.Sincetherewereonly12chairsattheUniversityofPennsylvania(Penn)
at the time and Frazier was dean of the medical school, it was likely that
McKenzieandFrazierwereveryfamiliarwitheachother’swork(7,25).
FIGURE1.2DonaldMunro.
Source:CourtesyoftheJournalofSpinalCordMedicine.
Munro’s second exposure occurred when he established his neurosurgical
serviceatBCHin1929,ayearafterFrankGrangerdiedatage54.Granger,like
McKenzieatPenn,developed and led the physical medicine program at BCH
from 1908 to 1928, with academic appointments at Tufts and Harvard. When
appointed to the military in 1918, he was regarded as a “nationally known
pioneer in this field, well qualified to introduce this new form of treatment
[physicaltherapy]totheArmy”(26).Hisdepartmentof“physicaltherapeutics”
wasregardedastheforemostinthenationbycolleagues,andMunrowasheirto
thesetherapistsandphysicalmedicinecolleagues,althoughtheyarenotcitedin
hispublications.
Munro was the first spokesman for comprehensive rehabilitation of the
spinalcord–injuredperson,andmanyviewed himasone ofthefathersofSCI
care (5,27). His innovative approach to the reduction of bladder infection by
tidal drainage (drainage of the urinary bladder by means of an intermittent
fillingand emptyingapparatus) caughttheattention ofGuttmann, who praised
and cited him often (20). His vigorous attention to prevention of pressure
injuriesinvolvedbothturningpatientseveryhourandmeticulousnursingcareto
prevent skin maceration. Rhizotomy was used in selected cases to reduce
spasticityso thatpatients couldbe moreeasilyturned andtaught towalk with
braces.IntheirSCIunit,BotterellandJousse(1946)modeledtheirapproachto
Соседние файлы в папке Библиотека им академика М.И. Перельмана