1
History of Spinal Cord
Medicine
Ibrahim M. Eltorai, M.D.
he history of spinal cord injury is a
long one, dating back to ancient
Egypt. Five thousand years of
recorded history reveal the chronicles of those who labored to care for victims of this catastrophic injury. In this chapter, advances in the care of
spinal cord injury are related in chronological order, from
ancient times to the present. In addition, special attention
is paid to subjects such as surgery, rehabilitation, education, and spinal cord regeneration. Although medical
advances have benefited patients who suffer from spinal
cord disorders, as well as those who have sustained spinal
cord injury, the history of spinal cord disorders is outside of the scope of this chapter.
of spinal cord injury are found in cases 29–33 and 48 of
this ancient record. Case 31 states:
ANCIENT EGYPT
Case 33 is very similar. These cases describe the cardinal symptoms of complete cervical cord injury secondary to fracture of the cervical spine: tetraplegia, complete sensory loss, urinary incontinence, priapism,
involuntary ejaculation, and conjunctival congestion
caused by the loss of vasomotor control.
The Egyptians did not attempt surgical intervention
for spinal cord injury, although they did reduce fractures
and perform surgical decompression following skull fractures. They used bronze catheters for urinary drainage,
and described pressure ulcers.
T
The Edwin Smith papyrus, which dates to 3,000 to 2,500
years B.C. is the most authentic document in ancient
Egypt. It was written by an Egyptian physician, most
likely Imhotep (Figure 1.1), and later translated by the
famous Egyptologist, Dr. James Breasted of Chicago University (1,2,3). It contains accurate descriptions of complete injuries of the cervical spinal cord, as well as the
observation that the best treatment for the injured vertebrae is rest and support (Figures 1.2, 1.3). Descriptions
If thou examinest a man having a dislocation in a vertebra of his neck, shouldst thou find him unconscious
of his two arms and his two legs on account of it (and)
urine drips from his member without his knowing it, his
flesh has received wind, his two eyes are bloodshot: it
is a dislocation of a vertebra of his neck extending to his
backbone, which cause him to be unconscious of his two
arms and his two legs. If, however, the middle vertebra
of the neck is dislocated, has an emissio seminis which
befalls his phallus, thou shouldst say concerning him,
‘one having dislocation of vertebra of his neck while he
is unconscious of his two legs and his two arms and his
urine dribbles, “an ailment not to be treated [cured].”
3
INTRODUCTION
4
FIGURE 1.2
FIGURE 1.1
The Edwin Smith papyrus.
Imhotep.
ANCIENT INDIA
The Sushruta Samhita (4), written in India during the
third or fourth century A.D., describes the treatment of
spinal injury. The care of cervical dislocations involved
manipulative reduction, bandages, splints, and bed rest.
Fractures of the lower spine were treated by immobilization; the patient was placed on a board and tied down
by ropes to five pegs. The authors of the Sushruta did
not believe that spinal fractures were curable.
Vaidya (400 B.C.) distinguished different types of
ulcers using clinical examination and auscultation (5).
ANCIENT GREECE
Fragmentary records describe the contribution of the
ancient Greeks to spinal cord medicine. Aesculapius, god
of medicine, was believed to be the son of Apollo, god of
the sun. The religious cult of Aesculapius took the place
of scientific medicine. Hippocrates (460–370 B.C.) (Figure 1.4) disassociated medicine from religion, and
brought Greek medicine to its highest achievement (6).
His travels in Greece and Egypt greatly affected his medical advancements. He created a method called succession
on a ladder, as well as other methods of traction, for the
treatment of spinal cord injuries. He also described paraplegia with bowel and bladder dysfunction, pressure
ulcers, gibbosity at different levels, and paralysis accompanied by cold abscess (Pott’s disease). Indicating that
traumatic gibbosity is not correctable, he stated “wherefore succession on a ladder has never straightened anybody, as far as I know, it is principally practiced by those
physicians who seek to astonish the mob.... But the physicians who follow such practice, as far as I have known
them, are all stupid.” In Anatomy of the Spine, Hippocrates mentioned details of articulation, nerves and vessels, sheaths of the spinal marrow (cord), ligaments and
muscles. In regard to spinal injuries, he states:
In cases of displacement backward along the vertebrae,
it does not often happen, in fact, it is rare that one or
more vertebrae are torn from one another and displaced. For such injuries do not readily occur; as a
spine could not easily be displaced backward but by a
severe injury on the fore part through the belly (which
would prove fatal) or if a person falls from height and
HISTORY OF SPINAL CORD MEDICINE
5
FIGURE 1.4
Hippocrates.
FIGURE 1.3
Translation of the Edwin Smith papyrus.
should pitch on the nates or the shoulders (and even
in this case he would die, but not immediately). The
spinal marrow would suffer, if from displacement of
a vertebra it were to be bent, even to a small extent,
for the displaced vertebra would compress the spinal
marrow, producing insensitivity of many great and
important organs and many other ill consequences of
a serious nature.
He condemned the open reduction of such cases, and
favored spontaneous callus formation. He mentioned that
displacement of vertebrae forward is mostly fatal. If it is
not fatal, the patient loses the power of his legs and arms
(tetraplegia), and has torpor of the body and retention
of urine. He introduced the extension bench and other
methods for the reduction of deformities, particularly gibbous. Hippocrates did not distinguish between paralysis
caused by trauma or disease and considered treatment to
be the same for either of them.
Hippocrates recommended keeping ulcers dry and
exposed to the air, except when wine or a cataplasm is
applied. He used juices, honey, vinegar, oil, lead, alum,
lotus, and many other topical applications on decubiti.
He recommended wound irrigation with clean water or
boiled river water (7,8). Celsus advised cleaning with
vinegar and suturing small ulcers with women’s hair.
Greek medicine, especially from the school of Alexandria,
influenced and was succeeded by Roman medicine.
ANCIENT ROME
In the first century A.D., Aulus Cornelius Celsus, in his
treatise De Medicina, included a brief discussion on spinal
cord injuries, especially fractures of the spinous processes.
For incomplete spinal cord lesions, he recommended Hippocrates’ method of traction for vertebral dislocations. In
complete spinal cord lesions, death usually ensued.
Galen (131–201 A.D.) (9), who practiced in secondcentury Rome, was a physician to Marcus Aurelius. He
followed Hippocratic methods, adding very few new techniques to medical treatments, but as a founder of experimental physiology, he wrote over 400 separate treatises.
Not only did he describe the anatomy of the brain, but
also that of the spinal cord and the brachial and lumbosacral plexuses. In addition, he anticipated Brown–
Sequard’s hemisection. He described injuries of the first
INTRODUCTION
6
and second cervical vertebrae, stating that they are fatal,
and that respiration stops with injuries at the third or
fourth vertebrae. He also described other lower-level
injuries. Galen believed that evacuation of the bladder
was accomplished by contraction of the abdominal muscles, and eminent scholars such as Vesalius and Albrecht
von Haller promulgated this doctrine for centuries.
Oribasius (10) was born in Greece in the fourth century (324–400). He later went to Rome at the invitation
of the Emperor Julian, who requested that Oribasius compile his knowledge of Greek medicine. While in Rome, he
modified the Hippocratic table to correct spinal deformity
using forceful and brisk procedures.
Paul of Aegina (625–690) (11), also a GrecoRoman, compiled several books. Book VI described Hippocrates’ technique for treating spinal injuries and in
addition advised postreduction spinal splinting for the
treatment of dislocations. He is considered the originator of laminectomy for spinal cord decompression and the
removal of the offending bony fragments.
These discoveries and advancements influenced later
civilizations, just as Greek civilization had influenced that
of Rome.
most comprehensive of which is the Canon of Medicine,
in five volumes. This book was translated into Latin and
was the main reference used in European schools for
almost six centuries.
In relation to spinal injuries, Avicenna followed the
method of Paul of Aegina. To reduce dislocations of the
thoracolumbar spine, the physician placed the patient in
the prone position and stood with his heels on the gibbosity. To reduce dislocations of the cervical spine, the
patient was placed in the supine position and neck extension was followed by splint fixation. The Arab physician
Moses Maimonides (Figure 1.6) wrote on diet, hygiene,
and toxicology (15). He practiced in Cairo and followed
Avicenna’s system. His book, published in 1199, mentioned paraplegia as well as some neurologic signs.
Another Arab physician, Albucasis, recommended
removal of bone fragments from the spinal canal.
Western medicine at this time was very primitive.
Medicine was practiced not by physicians, but by monks
who used religious rites, herbs, salves, and brews to cure
disease. Although there are many references to the medical remedies of the time, there is nothing recorded about
spinal cord medicine.
THE MIDDLE AGES (700–1400 A.D.)
THE EARLY RENAISSANCE
With the gradual infiltration of the Roman Empire by
barbarian tribes, science was replaced by superstition and
intellectual stagnation. During this time, Jewish medicine
may have been the only type of medicine practiced (12).
In the seventh century, with the rise of Arabic and Islamic
civilizations, many works were translated from the Greek,
Latin, Persian, and Hindu languages into Arabic. Avicenna (980–1037) (Figure 1.5), a Persian physician, translated and made contributions of his own (13,14). During his life, he compiled about one hundred books, the
By the thirteenth century, the school of Salerno brought
European medicine out of the Dark Ages. Constantinus
Africanus (16) learned the Arabic language and practiced
Greco-Arabic medicine. Roland of Parma wrote his book,
Chirurgia, (17) in Salerno in 1210. He discarded the use
of Hippocrates’ bench and used new methods for spinal
cord injuries. For cervical dislocations, the patient was
placed in the sitting position and reduction was effected by
traction applied to the hair or by a cloth sling under the
jaw. For thoracic and lumbar dislocations, the patient was
placed in the supine position and the physician exerted
FIGURE 1.5
FIGURE 1.6
Avicenna.
Moses Maimonides.
HISTORY OF SPINAL CORD MEDICINE
traction on the legs, with countertraction applied to the
upper half of the body by an assistant. During this time,
several famous authors in France and Italy published
whole books on spinal cord medicine. A gradual transition
from the Latin and Greek languages to the French and
English languages paralleled the development of science,
mathematics, and philosophy in Western Europe.
THE LATER RENAISSANCE
Paul of Aegina’s book (18), written in 1465, recommended a process for the reduction of a spinal fracture.
While the physician exerts direct pressure at the fracture
site, traction is applied to the upper extremities by one
assistant, and to the lower extremities by another.
Ambroise Paré was a progressive surgeon who wrote
the Ten Books of Surgery (Dix Livres de Chirurgie) 1564
(19). As a barber-surgeon, he joined the army, and
advanced to be the chief army surgeon to four successive
kings. He adopted and modified the Hippocratic technique of fracture reduction by placing the patient in the
prone position. However, he cautioned against causing
more damage through manipulation. The spine was
immobilized by lead splints, and the patient remained in
bed in the supine position for a lengthy period of time.
Paré also went back to the work of Paul of Aegina, reviving laminectomy for fractures causing cord compression.
For fractures of the spinous process, he only recommended the removal of bony fragments if the patient was
in pain. If the fragments were still attached by periosteum
and the patient was not in pain, he reduced the fracture
and splinted the back until full healing occurred. For cervical dislocation, he had an attendant press hard on the
shoulders while he pulled up the head by two hands close
to the ears. With some turning of the head, the dislocation was reduced and a stabilizing bandage was applied
around the shoulders. France followed Paré’s technique
for a long time; in fact, Jean-François Calot used the same
techniques in the nineteenth century (20). Falicius Hildans
(1560–1634) used a clamp to reduce cervical dislocations,
and in some cases, removed bone fragments and repaired
ligaments.
SEVENTEENTH AND
EIGHTEENTH CENTURIES
By the seventeenth and eighteenth centuries, anatomic dissection was permitted in Europe. Despite this advancement, the management of spinal injuries was still primitive. Paré’s technique, with some modification, was used
widely in Germany, Holland, Italy, and England. In France,
during the year 1753, Geraud removed a musket ball from
the lumbar spine and the patient experienced partial recov-
7
ery. Almost a decade later in France, Louis removed a
metal fragment from a paraplegic officer who eventually
recovered. Trephining the lamina was suggested by
Chopart (20) (1743–1795) and Desault (20) (1744–1795).
The latter recommended trephining the laminae for
decompression even in the absence of visible fracture. In
1762 Antrine Louis (21) removed a bullet lodged in the
spine. In 1793, J. Soemmering wrote about dislocations
and fractures of the spine in his book, Bemerkungen ueber
Verrenkung uns Bruch des Ruckgraths (20). In the second
half of the eighteenth century, Jean Louis Petit (21) wrote
his treatise, Les Maladies des Os (Diseases of the Bones),
and his method was used almost exclusively during that
century. He reduced fractures by hyperflexion of the spine
in an attempt to disengage the spinous processes. Lorenz
Heister (22) was a leading German surgeon who used
Petit’s method for thoracic and lumbar injuries, but used
extension for cervical injuries. Hunzovsky in Germany
hyperextended the neck for cervical injuries by suspending the patient from the ceiling (23).
NINETEENTH CENTURY
The nineteenth century saw advances in anatomy, pathology, physiology, and surgery. Medicine became a more scientific discipline. The history of spinal cord medicine in
the nineteenth century was reviewed by Ohry and OhryKossoy (24), and in Garrison’s History of Neurology (25).
Sir Astley Cooper (26) described cauda equina lesions and
their management, as well as fractures and dislocations
of the spine resulting in paralysis. In 1860, Brown–Sequard
described different kinds of spinal paralysis based on vascular changes (27,28,29). Injuries were divided into thoracolumbar and cervical paraplegia until 1881, when Sir
William Gull coined the term quadriplegia.
With the adoption of Joseph Lister’s (1827–1912)
techniques of antisepsis, surgical morbidity and mortality decreased. Hence, surgeons were encouraged to intervene more frequently, and progress was made in the field.
In 1815, H. Cline recommended a controversial new procedure: The removal of the fractured spines and laminae
(laminectomy) in fracture dislocations. Because laminectomy weakens the spine, Burrell, in 1887, applied a plaster jacket for postsurgical stabilization. This jacket was
also used after manipulative reduction without surgery.
In 1895, Sir Victor Horsley presented his results for treatment of tuberculosis of the spine to the British Medical
Association (30).
Two famous world leaders were the victims of spinal
cord injuries caused by a gunshot wound, and both died.
Lord Nelson was injured at the battle of Trafalgar, and he
died a few hours after the injury in 1805 (31,32). In 1881,
James A. Garfield, the twentieth President of the United
States, was shot, and died in less than three months (33).
INTRODUCTION
8
TWENTIETH CENTURY
At the onset of the twentieth century, the prognosis for
victims of spinal cord injury remained poor, although it
had improved to some extent because of advances in bacteriology and disinfection by Pasteur and Lister, and
Roentgen’s discovery of X-rays and ether anesthesia. In
the Balkan wars, the mortality rate of spinal cord injury
was still 95 percent. Harvey Cushing (34) reported that
80 percent of the battlefield casualties with cervical spine
injuries died within the first two weeks. Those who survived had incomplete lower injuries. The British army
reported the same results. During the interwar period, the
prognosis was still poor, and those who survived led miserable lives as cripples.
The scientific advances of the latter half of the twentieth century were very great. Advances in the fields of
surgery, rehabilitation, education, urology, pharmacology, and special topics, and research in spinal cord regeneration are described separately.
SURGERY
In 1902 Italy, Lorenzo Bonomo developed the technique
of hemilaminectomy, which was adopted and modified
by many surgeons. In 1905, Harvey Cushing described
the categories of spinal injuries, and the indications and
contraindications for surgery in each case. Later advances
in surgery of the spinal cord included myelotomy, myelorraphy with or without interposition of nerves, and nerve
cell transplantation (autologous or embryonic).
Numerous advances in orthopedic surgery can be
reviewed in the orthopedic and neurosurgical literature
(35,36,37). Surgical orthopedic instrumentation such as
rods, fixators, wires, screws, meshes, plates, clamps, hooks,
and cements was developed. Different surgical approaches
to the spine came into use, including thoracoabdominal,
transoral, transthoracic, transabdominal, thorascopic, and
laparoscopic. Laminotomy, laminectomy, foraminectomy,
arthrodesis, and bone grafting were introduced.
After World War I, German experiences in spinal
medicine were recorded by Foerster (38), Lhermitte and
Roussy (34) did the same in France. In the United States,
dramatic changes began to occur in the early 1930s. Dr.
Donald Munro (Figure 1.7), a neurosurgeon with a background in general and urological surgery, developed an
interest in the care of spinal cord injury (SCI) patients.
He made great efforts to improve the rehabilitation of
SCI patients, as well as to meet their socioeconomic needs
(39–44). Many view Dr. Munro as the true founder of
modern SCI care. In England, on February 1, 1944, Sir
Ludwig Guttmann (Figure 1.8) established a unit at Stoke
Mandeville (44) in Aylesbury, and introduced multidisciplinary staffing for the comprehensive treatment and
rehabilitation of SCI. Under his leadership, this unit
became a world-renowned center for teaching, research,
and clinical care. After the inception of these two units
on either side of the Atlantic, many others followed. Drs.
Ernest Bors and A. Estin Comarr in Long Beach, California pioneered rehabilitation and urology protocols
that were followed in all the other centers. In Boston H.
Talbot began an SCI clinic, as did B. Moeller in Memphis, Tennessee. In the United Kingdom, a number of centers developed: Lodgemoor in Sheffield; the Robert Jones
and Agnes Hunt Orthopedic Hospital at Oswestry,
Shropshire; the Pinderfield Hospital, Wakefield, Yorkshire; the Liverpool Spinal Unit at Promenade Hospital;
the Edenhall Unit in Musselburgh, Scotland; Phillipshall
Hospital near Glasgow; and Rookwood Hospital,
Cardiff, Wales. Centers of excellence in Europe included:
Tobelbad, Austria; Fontainebleau (Paris), Invalides
(Paris), and Mulhouse, France; Brugman, Belgium;
Koblenz, Bachum, Amsburg, Frankfurt, Murnau, Tubingen, Ludwigshafen, Heidelberg, Cologne, and Berlin in
Germany; Aardenburg, Amsterdam, Holland; and
Dublin, Ireland. A list of other centers in Europe, Canada,
Australia, the Middle and Far East, and South America
can be obtained from The International Society of Paraplegia. At the present writing, the Department of Veterans Affairs in the United States has twenty-three centers
devoted to spinal cord injuries and disorders. The Department of Health and Human Resources has established
regional centers in different states. In 1945, Lyndhurst
Lodge was established in Toronto, Canada, and the
Canadian Paraplegic Association was founded. The
Canadian Veterans Administration has also established
wards for SCI care.
Many new diagnostic techniques were developed,
such as positive contrast myelography, radionuclide myelography, peridurography, discography, angiography,
computerized axial tomography (CAT), magnetic resonance imaging (MRI), digital subtraction angiography,
ultrasonography, electrophysiological studies, evoked
potentials (sensory and motor), and myelonoscopy.
REHABILITATION
In 1929, Alfred Taylor of New York used a traction halter fitted to the occiput and the mandible for cervical
spinal injuries. In 1933, William A. Crutchfield devised
cranial skeletal traction (45). Other traction devices were
made by Barton (1938), Vinke (1948), and Gardner
(1970s). In 1959, Perry and Nickel introduced halotraction, which is still in use.
The history of rehabilitation medicine is reviewed
in detail by DeLisa (46). In the three-volume work Principles and Practice of Physical Therapy (48), published
in 1939, there was no mention of SCI made under “Phys-
HISTORY OF SPINAL CORD MEDICINE
FIGURE 1.8
FIGURE 1.7
Donald Munro, M.D.
9
Sir Ludwig Guttman.
EDUCATION
ical Therapy of the Nervous Diseases,” probably because
the condition carried a mortality rate of 80 percent during World War I. In the 1930s, Donald Munro, a neurosurgeon at Boston City Hospital, developed an interest in and sympathy for the victims of SCI. He developed
a small center for the comprehensive care of SCI patients,
and functioned not only as a neurosurgeon, but also as
a rehabilitation specialist, urologist, psychologist,
socioeconomist, researcher, and teacher. He introduced
tidal drainage of the bladder (intermittent bladder irrigation), which reduced the risk of urinary tract infections. The U.S. Army initiated a SCI center in OxfordWingate, Massachusetts, where Munro’s methods were
adopted. Munro was a consultant to those Army hospitals having SCI sections in the Bronx, Long Beach,
Chicago, and elsewhere. Ernest Bors and A. Estin
Comarr carried the torch of care and research and
opened the way for better care of SCI patients. Advances
in rehabilitation were carried out by neurosurgeons acting as chiefs of paraplegia sections (Krueger in the
Bronx, Cramer in Memphis, and Scarffond Pool in
Atlantic City). Howard Rusk, Arthur Abramson, and
Harry Kessler were important figures in rehabilitation.
Subspeciality areas began to develop, such as genitourological rehabilitation, sex therapy, infertility therapy, driver’s training, educational counseling, functional
independence, and development of assistive devices (47).
The care of SCI was very briefly taught in medical schools
until Donald Munro introduced the concept of comprehensive care for SCI victims. His career heralded a turning point in the history of SCI treatment. His ideas on neurotraumatology and rehabilitation were first accepted in
the military hospitals. For the next 40 years, the Veterans
Administration led SCI rehabilitation, and remarkable
achievements were produced. Annual conferences were
held, and the papers presented were recorded in the annual
proceedings. In the 1970s, Erich Krueger, the national
director, initiated traineeships to prepare physicians qualified in the care of SCI. In the 1980s, Emanuele Manerino
initiated a two-year fellowship program, which graduated
many physicians specialized in the comprehensive care of
spinal cord injured patients. The Department of Health
and Human Services established eighteen SCI centers
across the United States, leading to the development of SCI
rehabilitation programs in many major universities. Joseph
Binard initiated annual courses in different regions and
established educational courses for non-SCI centers.
The American Paraplegia Society, founded in 1954
by A. Estin Comarr, incorporated in 1977 and sponsored
annual educational meetings. The American Paraplegia
Society also established the Journal of Spinal Cord Medicine, which has become a leading journal in the field. In
1978, the Society attempted to register as the American
INTRODUCTION
10
Board of Spinal Cord Injury, but was not approved by the
American Board of Medical Specialties. Through the
efforts of Joel A. De Lisa and other leaders in the field,
in 1995 Spinal Cord Injury Medicine was approved as a
subspecialty under the American Board of Physical Medicine and Rehabilitation. Dr. Margaret Hammond, Chief
Consultant to the VA, headed the task of specifying the
subject matter of the field.
The American Spinal Injury Association (ASIA),
founded in 1971, has made great contributions to the
diagnosis and comprehensive management of SCI
through annual meetings, teaching sessions, workshops,
and research grants. ASIA has sponsored several programs overseas and thereby furthered the spread of
knowledge in many countries.
In 1961, Sir Ludwig Guttman founded The International Medical Society of Paraplegia (IMSOP). This
was a major milestone in the care of SCI worldwide. The
Society holds annual meetings in Stoke Mandeville, U.K.,
and is affiliated with national societies all over the world,
including the Association Francophone Internationale de
Groupes d’Animation de la Paraplegie, the American
Paraplegia Society (APS), the American Spinal Injury
Association (ASIA), the Australian Branch of IMSOP, the
Deutschprachige Medizinische Gesellschaft für Paralegie
(DMPG), the Japan Medical Society of Paraplegia
(JMSOP), the Dutch-Flemish Society of Paraplegia
(NVDP), the National Institute for Care of Paraplegia in
Sri Lanka (NIP), the Nordic Medical Society of Paraplegia (NMSOP), the Southern African Spinal Cord Association (SASCA), the Spanish Society of Paraplegia (SEP),
and the Latin American Society of Paraplegia (SLAP).
IMSOP (now ISCOS) established Spinal Cord as their
official journal, previously known as Paraplegia.
SPINAL CORD REGENERATION
The work of Ramon y Cajal (1900–1920) showed that
“although severed central nerve fibers in young and adult
mammals commenced to regenerate, the attempts proved
abortive and the process did not functionally benefit the
animal ”(49). During the next two decades, experiments
on amphibia and reptiles showed that regeneration can
follow cord injury.
From 1950 to 1970, Windle worked with DOCA,
ACTH, Promin (bacterial polysaccharide), and millipore
tubules. He concluded that “there is little evidence, as yet,
that true physiological recovery, either motor or sensory,
has been attained in mammals” (50). From 1970 to 1980,
Kao used microsurgery to transplant autogenous brain
tissue, sciatic nerve, and nodose ganglion into the spinal
cord, and succeeded in demonstrating axonal growth
within the grafted tissue (51). Fetal neurons, as solid tissue and as suspension, were transplanted into the tran-
sected cord (52). At this time, research into genetic engineering and stem cell studies also began (53,54).
SPINAL SHOCK
In 1874 Goltz and Freusberg in Strasbourg clearly
described spinal shock in the dog (55). Sherrington produced spinal shock in the monkey, which he referred to
as a neurogenic condition, by transection of the cervical
cord. Although he did not use the term autonomic dysreflexia, he described a rise in blood pressure elicited by
skin stimulation, which appears after the resolution of
spinal shock (56).
AUTONOMIC DYSREFLEXIA
Head and Riddoch first described autonomic dysreflexia
in 1917 (57). Its significance and dangers were described
by Whitteridge (58); Guttmann and Whitteridge (59),
Thompson and Witham (60), Pollock et al., Bors and
French (61,62), Schreibert (63), and Arieff et al. (64).
Many other reports followed from Europe, America, and
Australia.
HETEROTOPIC OSSIFICATION
Para-articular osteoarthropathy was first described by
Riedel (1883) (65) and Eichart (1895). A detailed description of the condition in paraplegics was elaborated by
Madame Klumpke-Dejerine and Cellier (66) and Dejerine et al. (67). They were followed by many others, among
them Soule (68), Abramson (69), Abramson and Kamberg (70), Liberson (71), Damanski (72), Hardy and
Dickson (73), Paeslack (74) Freehafer and Yurick (75),
and Rossier et al. (76).
URODYNAMICS
The first measurement of intravesical pressure was made
by Rudolph Haidenhain (1837–897) in Breslau. He and
Colberg focused on sphincter tone; De Wittich and
Rosenplanter (1867) recorded intravesical pressure, and
Julius Budge (1811–1888) discovered that the third and
fourth sacral anterior roots were the motor nerves of the
bladder. Goltz experimentally transected the spinal cord
at the thoracolumbar level in dogs and noted reflex bladder evacuation, which disappeared by ablation of the
lower cord below this level. Schatz (1841–920) initiated
the use of human subjects for spinal cord medicine
research. Dubois (1848–1918) continued his work, measuring bladder pressure and rectal pressure in normal con-
HISTORY OF SPINAL CORD MEDICINE
trols and paraplegics. Other names in this field are
Quinke and Adler in Germany, Angelo Mosso and Paul
Pellacani in Italy, Fritz Born in Switzerland, and Guyon
and Duchastelet in France (77).
In Germany, Adler studied manometry in the neurogenic bladder and differentiated conal from supraconal
lesions. In Vienna, Schwartz studied cystometry in gunshot wounds of the spinal cord. In the United States,
Walker, Dalton, Roussy, and Rossi also made advances.
In Baltimore, Walker proposed simple devices for cystometry. In St. Louis, Dalton coined the term cystometry, and described the different types of neurogenic bladder. Roussy and Rossi studied cystometry in SCI at
different levels. In England, Henry Head and George Riddoch studied neurogenic bladders and described automatic micturition as a part of the mass reflex in supraconal lesions. Sir Gordon Holmes studied neurogenic
bladders in soldiers in France (1915–1916). In 1933 in
London, Denny-Brown and Robertson measured bladder
pressure, urethral pressure at the bladder neck, external
sphincter pressure, and rectal pressure. In 1935, Kenneth
Watkins described reflexic and areflexic bladders in cord
injuries. Donald Munro, who in 1947 introduced tidal
drainage, described the atonic cord bladder early in injury,
the autonomous cord bladder, the hypertonic cord bladder, and the inhibited cord bladder. Many others contributed to the field in the early years, including Nesbit,
Lapides, Tang, Ruch, Bors, Comarr, and Bradley.
PHARMACOTHERAPY
Numerous pharmacotherapeutic agents have been tried
in the treatment of SCI, including methylprednisolone,
alone (78) or in combination with the antioxidants alphatocopherol and selenium (79); lidocaine (80); alphamethyltyrosine (81); aspirin; dipyridamole (82); naloxone
(83); DMSO (84,85,86); immunosuppressive drugs (87);
nerve growth factor (88); enzyme therapy such as
hyaluronidinase, trypsin, and elastase (89); calcium-channel antagonists (90); gangliosides (91); thyrotropin releasing hormone (TRH) (92); neurotrophic factors (53); pregnenolone combined with lipopolysaccarides and
endothacin (93); and nitric acid inhibitors (94). Other
approaches have included genetic strategies (53); cooling
(hypothermia) (95); X-rays (96); electromagnetic stimulation (97,98,99); hyperbaric oxygen therapy (100,101);
revascularization (102); and acupuncture (103).
11
tified ulcers with five medicines. The bones were fortified with acid principle, the nerves with stinging principle, the pulse with salty principle, and respiration with
bitter principle (104). In ancient Egyptian practice, a wide
variety of topical remedies was offered for decubiti,
including honey, moldy bread, meat, animal and plant
extracts, copper sulfate, zinc oxide, and alum. Incantations and recitals were read before the dressings were
applied (105,106). In Persia, Avicenna applied a variety
of topical treatments (107). Among the Arabs, Maimonides made nutritional recommendations to promote
ulcer healing (108).
During the Renaissance there was no physician of
note until the time of Ambroise Paré, who insisted on gentle handling and meticulous cleanliness of wounds, and
made recommendations regarding diet and medication
(109).
During the nineteenth century, the discovery of bacteria by Pasteur and antisepsis by Lister improved the outlook of wounds in general. The discovery of X-rays by
Roentgen helped diagnose underlying bony pathology. In
the nineteenth century, Charcot believed in the trophic
theory of pressure ulcers, which holds that ulcers are
caused by the paralysis itself. However, Brown–Sequard
opposed this theory (110).
The twentieth century brought in the antibiotic era.
Sulfonamide (Prontosil) was developed by Domag K in
1935. Penicillin was discovered by Alexander Fleming in
1929, and clinically applied by Florey and Chain in 1940.
Since then, a tremendous number of antibiotics have been
developed to control wound infection. The role of nutritional factors, such as proteins, vitamins and minerals,
in ulcer healing, was recognized in the United States. The
biomechanics of bedsores has also received a great deal
of attention (111).
It is impossible to enumerate the topical medications
and other forms of treatment that have been tried for pressure ulcers. They include antiseptics and antibiotics
(112,113); antibacterials, which in some cases were cytotoxic (114,115); debriding agents such as enzymes, maggots, and synthetic materials (116); electrostimulation (117);
magnetic stimulation (118,119,120); low-intensity laser
(121); ultraviolet light (heliotherapy) (122); topical oxygen
therapy (123); hyperbaric oxygen therapy (124); ultrasound
(125); ozone (126); dry air (127); carbon dioxide laser (128),
occlusive dressing (129); placenta (130); aloe vera (131);
xenografts (132,133); dermografts (134); growth factors
(135); topical hyperalimentation (136); and surgical closure
techniques such as flaps (137–140) and grafts (141).
PRESSURE ULCERS
CONCLUSION
Pressure ulcers have been recognized since antiquity, and
physicians of different civilizations have proposed various treatments. Chinese ulcer physicians (Young) (97) for-
Throughout man’s history, SCI has been a catastrophic
condition, and the prognosis a very gloomy one. Only
INTRODUCTION
12
after World War II did the labor of distinguished clinicians and scientists improve the look of SCI victims. In
universities all over the world, researchers are working to
erase Imhotep’s dictum that spinal cord injury is “an ailment not to be cured.” As Professor Max Thoreck has
said, “La science n’a pas de patrie” (science has no homeland). It is hoped that the efforts of researchers around
the world will soon fulfill man’s wishes for a cure.
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