Pertinencia de las estrategias que aplican los docentes para desarrollar

In Germany neurosurgery was not a separate speciality but was carried out by general surgeons, and was included in the department of psychology and general medicine.

Foerster was bom in 1873 in Breslau. He was a brilliant student. He worked with Carl Wernicke (1848-1904) and Emil Kraepelin (1856-1926), and in Paris he worked with Joseph Dejerine (1849-1917) and met Marie and Joseph Babinski (1857-1932). During the summers, he went to Switzerland where he observed Frenkel's neurological patients and published papers with him on ataxia (Foerster and Frenkel 1899 & 1900). Foerster was interested in practical therapy. In those days there was no curative therapy for syphilis (arsenic and penicillin therapy had not yet been introduced) and the underlying cause, just like spinal injuries today, could not be treated: only the secondary effects. Foerster tried to work out a scientific basis of practical therapy and never lost interest in the theme of physical therapy and physiotherapy. He had been impressed by the methods of Duchenne and Dejerine and by the English school of physiology, Hughlings Jackson and Sir Charles Scott Sherrington (1857-1952), whose work he referred to as his bible.

He had no laboratories or research institute. His research was carried out in the basement of the Wenzel-Hanke Hospital in Breslau, probably financed from his private practice until the Rockefeller Foundation built him a Neurological Research Institute in 1932. This was too late to significantly improve his research output. He was offered a Chair at the University of Heidelberg and a post in Berlin but chose to stay where he was. (McHenry

1969)

Foerster correlated function and the morphological substrate of Dejerine, by the concept of localisation. He was a medical scientist and his interest in the practical therapeutic efforts was a major part of his work. He studied co-ordination, which was the subject of his professional thesis in 1902. Following his work with Frenkel he demonstrated that hemiplegia of cerebral origin was spastic, whereas in tabetic paraplegia it was flaccid. He understood the significance of the spinal reflex arc and undertook the concept of posterior root section to eliminate spasticity in cerebral palsy. This became known as Foerster's operation. Having demonstrated that spasticity could be eliminated by posterior root section he showed that it removed root pain in tabes. He proceeded to delineate the sensory dermatomes, by operating on the posterior nerve roots. He then moved proximally and carried out anterolateral transection of the spinal cord for intractable pain. These procedures, root section and cordotomy, have been adapted today to treat pain in spinal patients by total destruction with alcohol block. (Haymaker and Schiller 1970)

His major work was on peripheral nerve injuries. He set up a peripheral nerve injury unit and operated on spinal patients.

He was criticised that so many of his staff were Jewish but he said he did not choose his staff on the basis of their religion but on the basis of their intelligence. This may have been because his wife was half-Jewish.

This is a sanitised account of a man who was, by all accounts a singularly unpleasant person with whom no one wanted to work. He was an enthusiastic therapist. His chief, Wernicke, once said of him:

“1 now have an assistant who makes lame walk and blind see.” (Haymaker & Schiller 1970, p.555)

When Guttmann in 1923 unsuccessfully applied for a job in paediatrics at Wenzel Hancke Hospital, he was told to go downstairs where he was given a job, without interview, working for Foerster. He worked in the neurosurgical department intermittently for ten years, initially unpaid, eventually becoming Foerster’s assistant. When people remonstrated with Guttmann in later life about his unreasonable and autocratic behaviour, he replied, “You think I am bad. You should have seen what Foerster was like”.

Guttmann fled to the United Kingdom in 1939 and was co-author of a chapter entitled Rehabilitation After Injuries to the Central Nervous System in

Rehabilitation of the War Injured (Doherty & Runes publication date unknown)

in which he acknowledged Foerster’s patterns of treatment of peripheral nerve injuries:

“General Organisation - The installation in this country of several centres for the treatment of peripheral nerve injuries is a great step forward. The congregation of cases is a single department under the same specialised staff, with continuous treatment under the same supervision, is certainly the best guarantee for the systematic study of the whole question, for better results. The success of a centralized treatment and the care of peripheral nerve injuries in other countries was shown by the ‘Peripheral Nerve Centres’ in the USA during the last war and particularly by Foerster’s work in Germany during and after the last war. His material included about 4,000 cases. Although he worked under conditions by no means ideal compared with those of a modem centre in this country, his results were remarkably good and better than those of many other authors of that time. Foerster has emphasized again and again the secret of his better results. It was only in some respects a specialized surgical technique; the main reason was a better and systematic after- treatment and after-care, in other words, a good understanding of

rehabilitation.

The installation of centres for peripheral nerve injuries, however, does not cover the whole problem of organisation in the rehabilitation work. In practice it is not possible to bring all cases into these centres, particularly in the early days after injury. Therefore precautions should be taken in all General and Military hospitals, particularly in military base-hospitals, that the injured can be seen immediately by a Nerve Specialist versed in the after-treatment of peripheral nerve lesions. Neglect of this vital principle of rehabilitation in the first period, even in the first days after injury, accounts for much of the

prolonged disability of the injured person, with all its economic consequences. The importance of this point can hardly be exaggerated. An integral part of the organisation of which might be called ‘Primary rehabilitation service’ is a thorough record of all treatment given in the first period after nerve injury. Undoubtedly such a service would greatly facilitate the work of the centres for peripheral nerve injuries and would play a big part in improving the end- results.

Of the same importance as the primary supervision immediately after injury is the late supervision of these cases after their discharge from hospital, from the centres and from the Army. This late supervision also includes the post-war supervision of peripheral nerve injuries. Experiences in all countries after the last war have clearly shown that any successful late supervision of these cases can only be achieved by a loyal co-operation of the medical authorities with the public health services and - as Cairns and Young pointed out (1940) - with the Ministry of Pensions, and last but not least, with the employers. Such an organised co-operation of the various authorities concerned with the rehabilitation work is of particular importance in the reconditioning period of the injured. One of the main tasks of the ‘after-care service’ is (1) to provide the injured man with light and graduated work in the former occupation until he is fit for heavy work, (2) to supervise this light and graduated work. In my own experience the best results in supervising the injured persons during the reconditioning period were obtained with the help of industrial medical officers and general practitioners. Experiences in all countries have shown that many patients, left alone in their reconditioning period, will never make sufficient effort to reach their full working capacity.

In discussing some methods of particular importance for a speedy and, if possible, complete rehabilitation only a few points can be considered. Cases with peripheral nerve lesions can be grouped into those in which restoration of nerve conduction is possible and those in which there is no chance of nerve regeneration. In regard to treatment, however, this distinction is not an absolutely strict one, as similar principles have to be considered in both cases up to a certain point.” (p. 107-109.)

All these methods were directly applicable to spinal cord injury. In fact the actual words have been used subsequently to describe spinal injury management. Guttmann’s chapter discussed the positioning of paralysed limbs, strengthening of the synergists, electrotherapy, remedial exercise and occupational therapy but it is remarkable that in this discussion there was no mention of spinal cord injury.

In retrospect Foerster’s major role in the history of the treatment of spinal injuries was that Guttmann spent 10 years working for him and learned from him how to be a fine neurologist and how to rehabilitate peripheral nerve injury patients. Later Guttmann adapted these methods for the treatment of spinal injuries. Guttmann also learnt about destructive procedures, that is, posterior nerve root section and cordotomy and popularised alcohol blocks, which he used to treat spinal patients with intractable spasm. Foerster was particularly interested in thermo-regulation and Guttmann took this further by studying sweating by means of spreading powder impregnated with starch which changed colour when it became wet. Guttmann’s interest was maintained in this field in the United Kingdom while he worked at Oxford and subsequently at Stoke Mandeville where I wrote papers with him on the subject.

Foerster wrote a seventeen-volume textbook of neurology (Foerster 1927-1936).

8. The decline of medicine in Germany in the inter-war period

Until 1933 Germany led Europe with a well-developed industrial, medical and social system. Under Wagner and Kocher, there was a tradition of research and treatment of spinal injuries. Before the advent of the Nazis there was a strange, abhorrent practice of eugenics in the United States, France and Germany, leading to legislation whereby mentally defective people were institutionalised and sterilised. Attempts in the

United Kingdom to legalise sterilisation and euthanasia did not succeed. In Germany the Nazi Third Reich eliminated its worthless citizens by its racial policies. Anti-semitism led to Jewish scientists and doctors being expelled from university and hospital appointments.

9. ‘Elimination of the Worthless’ (Nazi nomenclature) 9.1 Pre Nazi

During the First World War, owing to the Allied blockade, there was a shortage of food in Germany. People survived with difficulty, on rations and by buying food on the black market. This did not pertain in mental hospitals where the inmates could not obtain food by such means.

“During the First World War, 140,234 people died in German psychiatric asylums. Assuming an average peacetime mortality rate of 5.5% per annum, this means that 71,789 people died as a result of hunger, disease or neglect, about 30% of the entire pre-war asylum population. Psychiatrists watched and recorded mortality rates, weight loss and the progress of epidemic diseases, impotent in the face of governmentally decreed wartime rationing.” (Burleigh 1994, p.11)

These people died in squalor. The debate on the right to die and negative human worth began in the late nineteenth century. A law sanctioning voluntary euthanasia was drafted in 1913. Ernst Heinrich Philipp August

Haeckel (1834-1919), a Darwinist and Monist wrote:

"...fused the notion of killing as an act of mercy with the crudely materialistic argument that this would save a great deal of public and private money.” (Burleigh 1994, p. 13)

Euthanasia became post-war policy. Germany was impoverished and was paying heavy reparations. It was thought that the State could not afford to bear the burden of mental asylum provision:

“In future an impoverished state will be unable to bear the type of mental asylum provision which developed extensively in most of the regions of Germany before the war.” ( p.27)

The number of mental patients increased dramatically:

“Between 1924 and 1929 the number of psychiatric patients rose dramatically, from 185,397 to more than 300,000. There was no commensurate increase in

bed capacity.” (p.29) It became recognised that:

“...caring for chronic or geriatric patients was a ‘luxury that Germany could not afford’. A financially constrained nation was in the process of ‘caring itself to death’.’’ (p.36)

Psychiatrists began to recommend a selective programme of sterilisation for alcoholics, schizophrenics, manic-depressives and people who were seriously, physically malformed. People with congenital dislocated hips, childhood cataracts, harelips, cleft palates, short stature and muscular dystrophy were sterilised.

9.2 The Nazis

When the Nazis came to power in 1933 they set up a Reich Hereditary Health Court “to act as a court of highest appeal in sterilisation cases”, (p. 98).

This did not materialise or was renamed the Reich Committee for the scientific registering of serious hereditary and congenital illnesses. It was based at the Chancellery of the Führer. In 1939 Hitler’s physician, Theo Morrell, wrote a memorandum framing a possible law: “...for the destruction of life unworthy of life” ( p.98).

On 18 August 1939, the Reich Committee introduced the compulsory registering of all ‘malformed’ newborn children, echoing both the language and the methods of Morrell’s memorandum. In return for a payment of 2RMS (Reich Marks) per case, doctors and midwives were obliged to report instances of idiocy and Down’s syndrome, microcephaly, hydrocephaly, and physical deformities such as the absence of a limb or late development of the head or spinal column and forms of spastic paralysis.

The climate in Nazi Germany was that of selective killing of the mentally or physically abnormal adults, sterilisation to prevent hereditary medical and antisocial diseases, and killing defective children. The medical profession became the staunchest supporters of the Nazi regime and 45% were members of the Nazi party (Lifton 1986). This was not universally welcomed. Hindenberg protested, asking why patients from the First World War who drank excessively as a result of head injuries were being penalised. As a policy, defective people on psychiatric, physical and moral grounds were being

killed. The disabled were not valued and under such circumstances, rehabilitation of paraplegic patients could not take place. These Germans were looked upon as people unworthy of life who would be a drain on the resources of the state. If you were not a German, not only were you deprived of German citizenship, you had no fundamental rights before the law.

10. Declaration of War

The declaration of war in 1939 had many effects. First of all, medical training was aborted, doctors had only 18 months training and were sent to the Front virtually untrained. Even severely injured German soldiers were not treated and subjected to euthanasia (Lifton 1986). A backlog of reports developed because of the shortage of doctors so any guise of legality was lifted and patients who previously had been sterilised were exterminated. Hospitals became hotbeds of nepotism and intrigue:

“An inspection of the documents shows that professors denounced their fellow professors, assistants denounced other assistants, or their own professors, janitors denounced professors and professors denounced janitors. On one occasion. Professor von Verschuer told the police that the janitor of his institute was a saboteur because the tyres of the institute’s bicycle were flat...” (Müller-Hill 1988, p.76)

11. Anti Semitism

In the eighteenth and nineteenth centuries, there was structured anti- Semitism in Austria and the German principalities so that to obtain a university appointment you had to be a German citizen of the Christian faith. Consequently, Jewish doctors could not obtain official appointments. The well-publicised case of Freud, who initially trained in neurology but was unable to secure a position and instead founded psychiatry, is not the only example. Henie, a Jewish convert and Romberg, a Jew, both obtained official appointments. By contrast Remak could not obtain a post and worked in private practice. Oppenheim, the outstanding German neurologist, was not appointed to a university post but received an honorary title. Despite the stipulations of the Weimar constitution:

“...the stipulation of the Weimar constitution in respect of equality of treatment for all German citizens in all spheres were unacceptable to great and important segments of the population...on the eve of the Nazi take-over there were still only two Jewish professors in all Bavarian universities.” (Vital 1999,

p.810)

Jewish doctors had the greatest difficulty in obtaining university appointments and as neurology/psychiatry was not looked upon as prestigious, they gravitated to these fields. As soon as the Nazis assumed power the situation reached its climax with the Enabling Laws. Jewish doctors were forbidden, by law, to hold state appointments, university appointments or treat German patients but had to have a degraded title as 'attendants to the sick’ and could only treat Jewish patients. Guttmann had to cease his post as first assistant to Foerster at the Wenzel Hanke Hospital. He worked as Director of a Jewish Hospital and at the outbreak of the Second World War fled to the United Kingdom. Bors, who had worked in Czechoslovakia, went to the United States of America. Marburg, who remained the outstanding contributor to spinal injuries in the inter-war years, fled Austria in 1939 and also went to the United States. Thus Nazism’s gift was to expel all these pioneers from the Third Reich, bringing their outstanding training in spinal injury treatment to the Free World, where they were responsible for the development of today’s principles of spinal injury management.