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DISCUSSION
Sir Ludwig Guttman (Gt. Britain). Now, Ladies and Gentlemen, I think we have
heard a comprehensive survey about what is going on in various countries in developing
spinal injuries units and we will hear, I hope, more in the discussion which I now open.
Michaelis, L. S. ( Switzerland). I want to say a few words: the first will be, with all
due respect, words of warning. In the paper given to us by my good friend and colleague
Mr. Harris of Edinburgh I notice two things which worried me: Number I-the emphasis
on surgery, Number 2-a recurrence of a fault in the organisation of spinal centres which
we hoped we would be rid of for the future, and that is the division of the treatment
and rehabilitation into two parts. This, I believe, would be and will be a retrograde
step. It is vital, particularly for the patient, that he should be in one hand from beginning
to end, and no amount of close collaboration between the clinical and the post-clinical
treatment will replace the importance, unique importance, of the close personal contact
between the leading doctor with charge of him and everything around him and the
patient. I ask you, particularly, since I am going to say something about the need for
further new centres in a minute, not to consider any organisation which continues to
split treatment and rehabilitation. Rehabilitation starts at the moment of the accident.
Now, the next point is a very small one, but as we are concerned here with the
practical running of a centre, I dare mention it here. It is the importance and the great
difficulty of keeping good notes. I have, as you know, been asked by the people in
Basle to help them build up their new centre, and I have tried to provide a specimen set
of notes particularly for paraplegics. This specimen of notes has one disadvantage, it
is bulky. But it has the advantage that it lessens the amount of work required and
lessens the danger of forgetting individual items in our patients, particularly in the
sphere of neurology, of all the complications we know, and I am going to put a specimen
here for everybody to see; naturally it is in German, but you will find since many of the
terms are medical it is quite easy for anybody to understand. It follows a system
established in Basle at the Medical Department, I found it there and I tried, of course,
to put it as close to the established system as I could. I hope you will see it later and
you will have to tell me if you have serious criticism.
The next point: some of us, including myself, are getting on a bit, and it is our
duty, I think, to think about the kind of younger doctors we wish to attract to our
specialty. I have made a very quick survey of 44 members of this Society to whom I
have sent my enquiry form and I have found that about a dozen were originally ortho­
paedic surgeons, about a dozen physical medicine specialists, half a dozen neurologists,
half a dozen neurosurgeons, four urologists, only one general surgeon, and only, and this
is important, only three internists (physicians). We are now coming to the time when
our patients are getting older, and as the paraplegia and tetraplegia is established for
more than 20 years, internal medicine will take up a greater part every year in our care
for them. I am very lucky; I have a first assistant in Basle who is a first-rate trained
internist; he doesn't know anything about paraplegia yet, and he is honest enough to
admit that, but I am going to help him to learn that, but with his knowledge of pharma­
cology, biochemistry and clinical medicine he is going to ve a very important m.an indeed
in the future of that centre.
And thirdly, my enquiry about which I hope to talk on Saturday morning had one
little side-result. I counted the number of patients seen by the individual people who
answered my questionnaire and I found that the numbers came to about forty thousand
over about 20 years during which this specialty has existed. Forty thousand seen by
about 40 among our Society, which means between two and three thousand a year very
differently distributed of course, and if one calculates according to a formula that about
10 new paraplegics a year belong to about one million of the population of a country,
PAPERS READ AT THE
1967 SCIENTIFIC MEETING
18 1
we have seen about the equivalent of the paraplegics occurring in a population of about
200 million. Now, the countries from which I have made enquiries have a population
of 650 million, which means that very probably among ourselves we have seen less than
one-third of the paraplegics that occur. We shall have, in the next 10 years, to increase
the number of centres in the various parts of the world where centres already exist, let
alone the countries where there are none, we at least shall have to increase them by three,
and that gives us something to think about.
Lipschitz, R. ( South Africa). There are three points, which I think have cropped
up here today, which I find a bit worrying. The first is the organisation of paraplegic
centres. The one big point that is worrying me is that I think that most of us today
know what we want and where we want as far as adults are concerned. But recently
with the new work on meningo-myelocele in this island and our work at home-we find
that we are getting more and more child paraplegics. The figure is high-eight per
thousand of children have congenital defects, six per thousand are neurological and
. four per thousand are usually meningo-myelocele. In the old days they died, they
are now living. It means that thIS ISland alone, If my figures are correct, will have to
cope with something like 120 thousand in the next 50 years. We have got to make
provision for them, and I notice in none of the centres the big problem that is worrying
us, and that is teachers, psychologists, psychometrists, because two-thirds of these
are subnormal from a mental point of view as well. I think that in the building of new
units anywhere one must consider this point very, very carefully. To us it is becoming
a major problem and our schools for training are almost becoming larger than our training
centres for paraplegia, which these patients all have as well, naturally.
And the second point was to support-and I am afraid Dr. Michaelis stole a bit
of my thunder. I have been running a busy neurosurgical unit for many years and
paraplegia as a sideline, and more recently I took over the whole surgical division, and
the big lesson I have learned is that on no account must a paraplegic be admitted under
a specific unit other than one trained for treating paraplegia. I don't care if he moves
into an intensive care, nursing care unit, but he must be under the primary control of
people trained in paraplegia. Neurosurgeons may be called in, physical medicine people
may be called in, urologists may be called in, but he must remain the primary concern.
I find that it is an inter-disciplinary thing and the only man who can control the orchestra
is the man trained today in the specialty of paraplegia.
The third thing is interesting, and this is purely possibly a personal thing from my
point of view, I note Mr. Harris stated that the improvement was slower than expected
in one case which was operated on. I have great difficulty in knowing what the rate of
improvement should be; I wonder if he could explain that to me. And secondly, in those
cases, he stated the dura was opened, I don't think that is a problem because both he
and I for years have left the dura open, and those adhesions that were shown, are they
of any importance?-because when you remove adhesions you only get further adhesions.
This is purely from a technical point of view; I would like his advice on that.
Professor Roaf, R. (Great Britain).-I am sure we have all had a fascinating and very
enjoyable day. There seems to be widespread agreement on organisation, and everybody
I am sure would agree that the patient should be under the care of the paraplegic specialist.
But there has not been complete agreement about the location of units. In this country
I could almost say the dislocation of units, because most units have been put where there
was an empty building, they have not really been planned. There are, if I might say,
four logical alternatives; the separate unit in the isolated fever hospital or sanatorium,
part of a general hospital, part of a special hospital, whether this be orthopaedic, accident
or so on, or part of a rehabilitation centre. Now, Professor Henry Miller has calculated
that a general hospital should have at least three thousand beds to provide adequate,
all-round facilities, and I think we know that this is unlikely to occur on any large scale
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in this country. Because, it is clear, that in the initial stages a paraplegic may and does
require a great variety of skills-thoracic, urological, kidney machines, respirators, and
so on, not least, as quite a number of our patients are suicides or attempted suicides,
there may be need for expert psychiatric care, which has not been much discussed today.
And, of course, the question of transport-this general hospital must have a helicopter
landing-strip, because I am sure this will be the only form of transport which will be
tolerable in the future. The sad thing is at the moment if the patient is admitted to a
general hospital without a paraplegic unit it probably takes them longer to get out of
there than if they had been taken straight away to a spinal unit some hundreds of miles
away by air transport. The advantages, of course, of the rehabilitation centre at the
later stages are obvious because few general hospitals really provide the sort of programme
in games, retraining, vocational training, training of self-care, the whole adjustment
phase that is essential. And of course, at a later stage, in the resettlement phase, the
need for hostel accommodation, for proximity to industry, adapting the home and so on
are obvious. I don't think there is a cut and dried answer to the best location, and even
if there was I am afraid it would be not in 1968 but 2068 before we would see it. I think,
therefore, we will have to put up with what there is. And, in this respect, I think it is
true that the paraplegic expert of the future will have to, in addition to the primary care
of patients in his primary hospital, be much more mobile and have to superintend,
perhaps, or visit patients in intensive-care units in other hospitals and also visit them in
their hostels and resettlements. In this respect it is quite obvious what Dr. Michaelis
said is true, there will be much bigger needs for many more people who are primary
trained in paraplegia who don't, so to speak, enter the field by the trap-door, as perhaps
my colleague, Mr. Mc Sweeney, and I have.
Harris, P. H. ( Scotland). I would like to answer Dr. Michaelis' points by asking
these questions. How would he, as a paraplegic expert, investigate and treat these
patients for spinal cord damage? Firstly, a patient brought into him immediately with
an Atlanto-axial fracture dislocation with spinal cord involvement? Secondly, a patient
with cervical dislocation with or without spinal cord damage that cannot be reduced
by traction and other such measures? Thirdly, how would he treat a patient with an
acute disc protrusion in the cervical region causing spinal cord compression? Fourthly,
how would he treat a patient with the lumbar injury with damage to some of the cauda
equina roots and dural arachnoid tears? And in relation to Mr. Lipschitz's point the
difference, of course, between this situation and the clean surgical situation is that in this
situation we have contused damaged tissues, roots and other soft tissues, we have bone
fragments, we have fragments of disc. This is not a clean surgical wound, it is a traumatic
wound. Fifthly, a patient with a compound fracture of the spine brought in? Sixthly,
a patient with a traumatic paraparesis with a progressing neurological disability?
Seventhly, a patient with a spinal tumour, be it a neurinoma or an ependymoma of the
cord? Eighthly, a baby with myelo-meningocele, firstly one with hydrocephalus and
secondly one without hydrocephalus? Ninthly, the investigation and treatment of a
patient who may have a transverse myelitis?
Michaelis, L. S. ( Switzerland). May I answer, Nos. 1 to 5 are surgical, Nos. 6, 7,
8 and 9 are surgical problems which we also know of-the open wound, the ascending
lesion; they become subject to surgery as a matter of course or insight, so I hope I
have answered the points completely.
Professor Ascoli, R. (Italy). I should like that one of the colleagues who spoke
about organisation of spinal units would answer this question. What are the ideal
dimensions-in other words, what is the ideal number of beds for a paraplegic centre?
And what is better in a country, a small number of very rug centres or a great number of
centres or a minor number of patients? I should like someone to answer this question.
Kerr, W. G. ( Scotland). I think that in this debate on where a centre should be
PAPERS READ AT THE 196 7 SCIENTIFIC MEETING
sited, and the division of responsibility, we want a little bit of British or world-wide com­
promise; I think it is inevitable. And my criticism I have of Mr. Harris's paper,
my own personal one, was that he didn't mention how quickly the patient would be
transferred to rehabilitation. I think he gave the impression-I have discussed this
with him many a time-I think he gave the impression in his paper that the patient
should be admitted to a general hospital or a neurosurgical unit and kept there for
months and then go to rehabilitation. That is not the way we do it. The system is
much more like what is described for Perth, Australia, where the patient is admitted to
Casualty, he is assessed, he is detained in an emergency unit, he may require neuro­
surgery, there will be arguments as to how much neurosurgery is required, but that
depends on your individual centre and your individual opinions; but as soon as the
patient is fit for transfer he goes to a spinal unit, that may be one hour after his accident,
it may be one day after his accident, the great majority will be within 48 or 72 hours,
but the occasional case may have to be kept in the general hospital or the accident
hospital for a bit longer while further investigation and treatment is carried out. If you
have, as in Perth or as Dr. Meinecke described, your unit in velY close association with
a general hospital, that, of course, is the ideal, for the patient is in the next-door ward to
the neurosurgeons and so on, but if you have an autonomous unit then you must have
all the operating theatres, the investigatory facilities and everything and bring your
surgeon to the special unit. Now, this leads us to Dr. Ascoli's question, what is the
ideal size; if you have a 200- or a 500-bed spinal injury unit it is big enough to carry
all its services with it. If you have a unit in which one person can know personally
every patient who goes through, I think it is probably better to have a smaller unit with
a director who is working in close association with colleagues in the neighbouring accident
or general hospital. But, again, I feel that the patient on first initial accident should go
to his accident hospital and be transferred to the paraplegic unit as soon as possible.
Silver,J. R. (Gt. Britain). There has been quite a lot of discussion as to the question
of the situation of a unit. It seems that the majority of opinion here is that the unit
should be situated in close proximity to a general hospital where all the facilities are
available. I would like to extend on one point, on which I feel very strongly; that is
that the visiting consultants should be active in their own fields, they should not be
just surgeons to the spinal centre, because there are a limited repertoire of operations
required on the spinal patients. And if a surgeon gives up his plastic surgery or ortho­
paedic surgery, neurosurgery if you have a unit sufficiently large to justify such a surgeon,
I think he would lose so much of his knowledge that he could give and keep giving to
the Centre. I am very fortunate in Southport, and you have all heard surgeons of the
Southport Centre speaking here repeatedly; they come regularly to the Centre and keep
on bringing their skill into the Centre from the main stream of orthopaedic surgery,
neurosurgery, plastic surgery. And suggestions were made when I went up there that
I might take on some of the plastic surgery, but I said it is silly, I would only do one
operation a month or one operation a week, and I am not handling the tissues every
day as you are. So I would make this plea that one should always strive to get the best
surgeons possible to visit the Centre and be prepared to learn the techniques and the
work that is required, but they should stay and keep their skills and bring them to you.
Harris, P. ( Scotland). I think that Dr. Michaelis has answered his own question
and we must not keep our heads, or even think of putting them, in the sand. After all,
as Mr. Lipschitz has brought out and other people have brought out, in particular
Dr. Michaelis, there are thousands upon thousands of paraplegics and, unfortunately,
nowadays tetraplegic patients about. And there will be more and more and more. How
much can we afford, how much can any country afford in their care? Because these
patients represent only part of a bigger problem. How many hemiplegics are there?
I would suggest, and I agree with Professor Roaf in this, that one main function of a
PARAPLEGIA
spinal service is to educate others, our own colleagues, our nurses and so on, and this
can be done in many ways, by meetings, by television, and our job is to go out and
teach and help others, and the standard of the nursing and the rehabilitation should be
no different in other special units, such as neurosurgery, or paediatrics. At the moment
in my own ward I have four patients with spinal tumours and severe spinal cord
involvement.
Professor Weiss M. (Poland). In rehabilitation institutes set up in our country we
have to organise acute spinal units. Training of people who would be able to run small
departments in our country has to be organised in three ways: the first is training with
the help of a fellowship in a centre where all facilities exist for a complex rehabilitation
and treatment of paraplegics. The second one is to have a consultant service by air.
We have at our disposal fast planes from the Army which we can use to see patients in
other parts of the country because we are not able to admit all paraplegics from the
country; but we like to stimulate people to organise their own units and their own
services. And the third one is the training of paramedical personnel, so very important
for the creation of units in the country. Without that teaching and research centre
we are not able to organise more spinal units for paraplegics in our country. The most
difficult thing is the acquiring of knowledge of rehabilitation. We are sure that from
an economic point of view, apart from results of the rehabilitation programme, we have
to get acute spinal units in rehabilitation institutes. That seems to be a little contra­
diction in terms, but the first treatment, the first week, decides about the result, and for
that reason we think we are on the proper way and we are organising now three more
institutes in our country, in Silesia, in the north and in the eastern part of the country
to cover the country with that idea.
Dr. Yeo]. (Australia). May I say that it is of some interest that one has heard the
comments regarding training of younger people like myself and may I make a comment
regarding one of the problems I have already struck halfway across my tour of this
globe in search of knowledge regarding paraplegia. And this to me seems to be a
problem. How can we in organising our institutions develop a close liaison with the
neuropathologist? One thing that interests me is the dogmatism that comes from many
different specialties involved in paraplegia, and I have been particularly interested to
talk to our neuropathological friends seeking their advice as to how we can obtain material
from the patients we have treated along fairly definite lines to see whether these signs
and symptoms correlate with the pathological changes in the spinal cord. In Sydney,
Australia, most of our cases become coroner's cases and we lose the material. It is not
preserved well and it is not examined well, and I would have thought that in developing
this science and art in the treatment of paraplegia that one thing I would like to have
some advice on from the specialists who have commented today particularly as to how we
may develop this aspect of our training and of our treatment of paraplegia, and how we
can develop a co-ordination with our pathology department.
Dr. Lipschitz, R. ( South Africa). I should like to answer our friend. I agree that
the pathology is terribly important, and this is a problem that has worried us because
of our stab wounds-the detailed neurophysiology. I am afraid that it is not for many
of the generation that is sitting around here but it is for prosperity, and that is where
your note-taking at the moment is so very important. We have, for instance, a magnificent
neuropathologist, but unless I can give him sections of cords he can do nothing about it,
and he can only get that when our patients die. And I am afraid that if your centre is
good you have got to wait 20, 30 and 40 years. And I make an intensive plea, as Dr.
Michaelis did earlier, write good notes, preserve those notes and keep bringing those
notes up to date. We won't know, but posterity will know. This has been a problem.
Dr. Hingorani (Gt. Britain). May I ask Dr. Gregg a couple of questions. I think,
if I have understood him right, he mentioned catering for a population of 2·8 million
PAPERS READ AT THE 1967 SCIENTIFIC MEETING
and having 45 beds. I would like to know if he finds this adequate in numbers and also
what the proportion of males, females and children's beds is. And, secondly, he also
mentioned the use of clinical assistants who are general practitioners in the management
of paraplegic patients. I would like to know if he finds they take sufficient interest in
this very specialised field and also if they make themselves available at night when the
need arises.
Dr. Gregg, T. (Ireland). Regarding the number of beds, the paraplegics can have
as many beds as they wish. This is roughly what it works out at. For the 35 accident
cases we get a year, and then probably almost an equivalent of other non-accident
cases, and then the large flow of people coming back for review every year, which seems
to be increasing-every six months we bring them back indefinitely-and this is the
number of beds we find is usually occupied. Male to female must be something like
four to one and about the same number of children as female. At the neurosurgical
centre, at which we have also an attachment, they are there starting up the centre for
dealing with the spinal bifida problem, and we may get more and more children, but at
the moment the children we get are accident cases.
With regard to the assistants-the general practitioners-we pay them fairly well.
They are young members of our profession setting up in practice locally and they welcome
hospital attachments, even of this sort, and they get side benefits of X-rays and things
for their own patients in practice. They are very loyal, they are very enthusiastic, they
don't mind a bit about coming in at night, and we are very glad to have them.
Dr. Meinecke, A. (Germany). To answer Professor Ascoli about the size of a centre,
I think about 100 beds; and it would be better to have five centres with 100 beds each
than 20 centres with 35 beds each. I think they work much better.
Sir Ludwig Guttmann (Gt. Britain). We have to consider that a spinal unit has to
be also economical, and you need for a proper running of a spinal unit a great number
of staff and a great number of facilities. If you have a unit of only 25 beds you have to
have the same facilities and in relation a great number of staff as you would have in a
unit of 50 or 100 beds. I would say the lowest figure of an economical spinal unit would
be 50 beds but I agree entirely with Dr. Meinecke that the ideal would be to have two
or three or five of 100 beds. The difficulty, of course, to materialise this ideal is that
we have not enough medical staff who are prepared to devote their lives to this most
interesting and gratifying job. This is a hope for the future.
It is now my duty to summarise what we have heard today. It is a little more than
a quarter of a century that spinal units have been set up for the first time in this country,
followed very soon by spinal units in Canada and the United States and after the war
in many other countries. What a tremendous change has taken place in the whole
approach to the problem of paraplegia. That is probably the greatest satisfaction those
people can have who have done the pioneer work in the early years when very few people
believed that a paraplegic could be restored to a useful and happy citizen.
The question whether a spinal unit should be set up in a general hospital or
specialised hospital is really not of such importance. But whatever the hospital may be
-and here I agree entirely with Professor Roaf-this unit has to be a specialised unit
on its own with a specialised staff and with its own leader; whether you call him Director
or something else is of no importance. The unit must be a specialised unit as orthopaedic
units were in the beginning when orthopaedic surgery became a specialty and divided
from general surgery. It is the same today with chest surgery, E.N.T., plastic surgery,
ophthalmology and so on which have become specialties in themselves. The only
people who so far have been treated by everyone-and, it is fair to say, in the great
majority, not with great knowledge-are the poor paraplegics. The time has come that
this specialty should be recognised by the medical profession as well as by the govern­
ments in every country. If this International Society would be prepared to submit a
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PARAPLEGIA
memorandum to the governments in the various countries, I am sure this Society would
make a very great contribution in changing the whole sad picture of paraplegia. There­
fore, may I suggest that we think it over by tomorrow whether it would not be a good
idea to set up a small sub-committee to formulate such a resolution which could be sent
to the authorities concerned. I do feel that this would be a very great step forwards.
Imagine that, in this country, which has given a lead to the world in the modern treatment
of paraplegia, and I say this not in a spirit of boasting, there is no specialised adviser to
the Ministry of Health in this particular subject of medicine. From time to time we
were asked by the Ministry to give a report about the number of paraplegics in the
country. Sometimes a doctor from the Ministry is sent to us for information and he
becomes quite interested; he goes back and then the whole thing sinks into oblivion.
Here is a point where our Society could do a great deal to arouse the responsible
authorities in every country.
The main reason why I consider a general hospital as ideal for the setting up of a
spinal unit is that it has all the other facilities available, including the easy availability
of any specialist who is needed. On the other hand, the special facilities which a spinal
unit has for its own work will help the other units in their work. I would like to repeat
that, in this respect, the national unit here at Stoke Mandeville with its 195 beds-and
if we include our hostel, with 225 beds-has proved beyond any shadow of doubt that
even such a large unit in a general hospital is no detriment to the other units; on the
contrary, other units are using the facilities of the spinal unit most advantageously.
As you have heard from that interesting paper of my friend Ernest Bors, he, as a
urologist, came independently to the same conclusion.
However, I do not wish to be misunderstood. I am not at all dogmatic. It does
not really m.atter so much in what type of hospital or institution a spinal unit is set up.
What matters is that the spinal unit must be independent and must be led by one man
as its Director. In this connection I should like to refer to papers given today by members
of two outstanding orthopaedic hospitals. One is the University Orthopaedic Clinic
in Heidelberg, which was directed by my late friend Professor Kurt Lindemann. He
tried, as other orthopaedic surgeons have done, to tackle the problem of paraplegia by
himself with his many assistants. He put paraplegics in one ward, but that did not
work because there was nobody trained in this subject and he did not devote his full
time for this work. Lindemann came to Stoke Mandeville as a doubting Thomas.
But what he saw made him so convinced that he went back and worked very hard in his
own country to set up a proper spinal unit. This is now indeed a model of a spinal
centre set up within an Orthopaedic University Clinic under the leadership of a physician,
Dr. Paeslack, following his specialised training at Stoke Mandeville.
The other oustanding orthopaedic hospital is that in Oswestry. I was very im­
pressed by that very frank and clear paper of my friend Mc Sweeney. Here we have
exactly the same development. Sixteen orthopaedic surgeons tried to do individual treat­
ment of spinal injuries. It did not work and they came to exactly the same conclusion
as Professor Lindemann in Heidelberg, that there is a need for a spinal unit on its own.
We have here the same situation as in Heidelberg. A physician will be in charge of the
unit who will co-ordinate the whole management of these patients in co-operation
with his colleagues. Of course, as McSweeney told us, there are still shortcomings
in the new unit and some cases had to be transferred to a general surgical or urological
unit, but this will be, it is hoped, a matter of the past. If they really need a general or
specialised surgeon, he will have to come to Oswestry and do the work over there.
I quote another orthopaedic surgeon with great experience, George Bedbrook, in
Western Australia, in Perth. In 1957, when I visited his unit, there was at first a similar
condition to that in Oswestry and Heidelberg, but he also came to precisely the same
conclusion, namely, that a spinal unit must be responsible for the whole management of
these patients from the start.
PAPERS READ AT THE
1967 SCIENTIFIC MEETING
Referring to Mr. Harris's paper and Mr. Kerr's comments, I fully agree with the
comments made by Dr. Michaelis and Mr. Lipschitz, and I consider a division between
initial treatment and later rehabilitation a great mistake. I should like to stress my
personal view that the immediate, initial management of a paraplegic or tetraplegic
patient should be carried out either by the director of a spinal injuries unit or in con­
sultation with him if the patient was first admitted to any other medical or surgical
services.
With regard to the problem of post-traumatic arachnoiditis and adhesions, men­
tioned by Mr. Harris, my own experience is in accordance with that of Mr. Lipschitz
and other neurosurgeons.
And that brings me to the last point-the question of the relationship between the
spinal specialist and the neuropathologist or the general pathologist. The pre-condition
to establish a close relationship was discussed also last year, and you will remember
that in referring to one of my own cases of very late sensory recovery I pointed out how
important the initial neurological examination and the systematic follow-up examinations
of these cases are. Only then will the neuropathologist be in a position to tell us whether
there is a regeneration-I mean here a functional regeneration-as a result of outgrowing
fibres within the spinal cord, if he has at his side clear and proper clinical notes. I
support the appeal, which Dr. Michaelis brought up so clearly-to give greatest attention
to clinical notes. This will pay dividends in the future, not only with regard to neuro­
pathology but, which is even more important, to the renal pathology.
I would like to thank now all speakers and all discussants on this quite outstanding
discussion we have had today. This was a survey of the experience of many people in
various countries on the development of Spinal Injuries Centres, and I am sure it will
help in the furthering of our knowledge in this complex problem of paraplegia and
tetraplegia.
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ANNOUNCEMENT
ANNOUNCEMENT
Mr. Charles Macmillan, Chairman and Managing Director of E. & S. Living­
stone, Ltd. for many years, has retired as Managing Director but will continue to
serve the Company as Chairman of the Board of Directors.
Mr. Macmillan has been extremely helpful in launching and developing our
young journal PARAPLEGIA, and this Society takes this opportunity to express
to him its profound appreciation and gratitude and to wish him happiness
and indeed a very active retirement!
SIR LUDWIG GUTTMANN
C.B.E., M.D., F.R.C.P., F.R.C.S.
President, International Medical Society of Paraplegia
EDITOR