Sir Ludwig Guttmann -
"The de Coubertin of the paralysed"

C. Lomi, S. Geroulanos, E. Kekatos

 

ABSTRACT
Ludwig Guttmann was born on the 3rd of July 1899, in Tost, Upper Silesia. He studied Medicine at Breslau and Freiburg. In 1939, because of World War II and his Jewish origin he emigrated to Great Britain. In 1943 he was asked to lead a spinal unit for injured servicemen at Stoke Mandeville Hospital, in Aylesbury, the National Spinal Injuries Centre. Dealing with limited resources, inexperienced staff, and the prevailing attitude that rehabilitation of patients who had suffered spinal cord injuries was impossible he developed an innovative comprehensive rehabilitation program for the victims of World War II. The main points of this program were first to prevent and manage the two most serious complications: pressure sores and urinary tract infections. Searching for ways to integrate the ex-soldiers back into society he incorporated Physical Therapy, Occupational therapy, work and sporting activities into an innovative treatment. Guttmann regarded sport as therapy as a means of communication and as a bridge to integration into society. Different kinds of team competitive sports were introduced such as wheelchair polo and basketball. These sports very soon developed to a sport movement for the disabled, which became known as the "Stoke Mandeville Games". The first time these Games took place abroad was in 1960 in Rome and since then are held in parallel to the Olympic Games. In 1969, with Guttmann's efforts for funding, the first of its kind in the world, sports stadium for the disabled was built in Stoke Mandeville, and it became an example to follow for many countries. In 1960 Guttmann founded the "British Sports Association for all types of Disabled" of which he was president until his death. He was also president of the International Sports Organisation for the disabled. In 1961 he founded the "International Society for Paraplegia" and in 1963 the journal "Paraplegia" He received many awards and distinctions and became Honorary Doctor of many English and American Universities. The title that he prized as amongst his highest though, was the way he was addressed by Pope John the XXIII in Rome in 1960: "Sir, you are the de Coubertin of the paralysed".

Key words: Injury of spinal cord, tetraplegia, paraplegia.

 

Picture 1. Professor Sir Ludwig Guttmann, German neurosurgeon, founder of the Stoke Mandeville Games and the Paralympic Games.
03. 07. 1899 - 18.03.1980, Source: www.iscos/org.uk/home.html

INTRODUCTION
During the Balkan War and World War I, about 95% of patients with spinal cord injuries died most of them within the first two weeks after injury mainly because of urinary sepsis[19]. It was not the lack of medical services during the war that caused the high death rate, but the belief at that time those spinal cord injuries could not be cured. In the face of a tetraplegic or a paraplegic, medical society, and society in general, could see nothing but a helpless patient entirely dependent on continuous medical care[20]. Ludwig Guttmann's conviction that these patients could move from the situation of being desperate and dependant and become active members of society again, gradually changed the opinion of medical society and consequently the lives of the patients with spinal cord injuries[1,2,16,17-20]. Within the framework of an innovative comprehensive rehabilitation programme that Guttmann developed for the victims of World War II, the integration of sports proved to be invaluable and gradually led to the development of international sports movements known today as the "Stoke Mandeville International Games" and "Paralympic Games"[10,11,12,16,21].

Ludwig Guttmann
Ludwig Guttmann was born on the 3rd of July 1899 in Tost, Oberschlesien Germany (picture 1). He was the eldest of 4 children whose parents were from rural families (pictrue 1). At the age of 3 his family moved from the little village of Tost to Konigshutte, Oberschlesien, a town of 70,000 inhabitants with a large foundry in a coal-mining district. A strapping young coalminer with a fracture of the spine was his first encounter with paraplegia. That was in 1917, when after school, he used to work as a volunteer in an accident Hospital for coalminers in Konigshutte. When he began to write up his notes he was told: "Don't bother, he'll be dead in a few weeks." (p. 154, 17). So it was. After five weeks urinary infections and massive pressure sores led to fatal sepsis. Guttmann remembered that patient for the rest of his life. This was however not to be a turning point for his later career[16].
In 1918 he started his medical studies in Breslau and a year later continued in Freiburg Germany. From 1919 until 1924 while he was studying medicine in Freiburg he became active in a Jewish fraternity, whose purpose was information and awareness against anti- Semitism in the Universities. This fraternity gradually evolved into a centre of physical training and sport, to acquire body strength, skills, confidence and self-esteem so that "nobody needed to be ashamed of being a Jew" (p. 4, 16). When Guttmann graduated medical school in 1924, financial reasons forced him to return in Breslau. He wanted to become a paediatrician so he tried to get hired at the paediatric clinic in Wenzel Hancke Hospital, without a salary, but there were no vacancies. A fellow student then advised him: "Try on the floor below" (p. 4, 16). There was a position in the neurological department of a distinguished professor named Otfrid Foester, which Guttmann was happy to accept. Probably that advise: "Try on the floor below", had more influence than anything else on his future life and career. Research in neuropathology and neurophisiology was very promising during that period. From 1928 he worked as a neurosurgeon in a 300 bed psychiatric clinic in Friedrichsberg at Hamburg University, and in 1929 became Foester's assistant. In 1930 he published a paper about "neuro-regulation of perspiration glands" which made him a lecturer in Breslau University[15,16].
In 1933 it was prohibited for Jews to practice medicine in public hospitals. Guttmann was fired on the 30.06.1933 but immediately took over as the director of the neurological and neurosurgical department of the Breslau Jewish hospital. During this period and while doing his clinical duties his research was focused on "neuro-regulation of perspiration". He was publishing papers continuously in German professional magazines until 1938. After Hitler's rise to power, the position of Germans with Jewish origin was getting more and more difficult. He had plenty of proposals to migrate abroad so he could carry on with his career. He did not accept any because he believed that Nazism would not last for long. He became president of the Jewish Medical Community and many times he exposed himself to danger by helping refugees and patients. In September 1938 he was ordered by the Gestapo to discharge all non-Jewish patients from the Jewish Hospital that he was managing. Later that same year, when thousands of Jews were taken to concentration camps, Guttmann was summoned by the local Gestapo Commisar to justify the presence of 63 patients that were admitted to his Hospital. He managed to save all but three that were send in concentration camps. It was then that he realised that he would have to leave Germany[16].

Picture 2. Paraplegic patient doing carpentry work, already in 1945, having adopted accordingly his workbench. The same patient became also an instructor for other patients in the rehabilitation programme.
Source: Guttmann L. New hope for spinal cord sufferers. Medical Times 1945; 318-26, p 345.

He arrived in Britain on the 14th March 1939, after he was invited by the "Society for the Protection of Science and Learning", with his wife, two children and no money. With the sponsorship of Hugh Cairns, one of the leading neurosurgeons of that period, he started his research in Oxford on the subject of the "perspiration dysfunctions of neurological nature and the of the peripheral nerve physiology"[15,16,19].
The mortality rate of traumatic paraplegia in British and American Armies during World War I was still very high reaching 80%. The few survivors carried on living as useless and hopeless cripples, unemployable and unwanted, condemned for the rest of their lives to institutions for incurable patients with no encouragement to return to a useful life. Even the legislation of the time regarding pension schemes for people disabled in war or workers compensations, made it impossible for these patients to return to any form of paid labour[14]. At the beginning of World War II, the rehabilitation of disabled people was a generally acceptable notion but not for the paraplegic patients suffering from spinal cord injuries. Guttmann reports, that in November 1941 during a symposium of the neurological department of the Royal Medical Association about the rehabilitation after central nervous system injuries, there was no mention of paraplegia despite the fact that several papers were presented about rehabilitation after cerebral injuries and peripheral nerves injuries[9]. This defeatist attitude of the Medical society towards these unfortunate patients is demonstrated typically with the following example: Soldiers who had suffered spinal cord injuries in battle were not instantly evacuated by air transport as were those with head injuries. That is because complications from spinal cord injuries were considered inevitable consequences[11].
In December 1941, Guttmann presents a review, required by the "Medical research council of England", with regards to the way patients suffering from spinal cord injuries, were dealt with and rehabilitated. As a result of that presentation, the "Peripheral Nerve Injuries Committee of the Medical Research Council of England", under the leadership of the distinguished neurologist Dr. George Riddoch, decided on the creation of special hospital units for patients with spinal cord injuries[20]. That decision was also a part of the greater preparation for the planned attack of the Second Front, the spring of 1944, as the number of such patients was anticipated to rise[9,14].
It should be pointed out that after the World War I, "Peripheral Nerve Centrer's" had developed not only in Germany (headed by Guttmann's teacher and mentor, Otfried Foester) but also in the USA. In England the first specialised "Spinal Cord Units" had been founded in 1930s[20]. The overall results from the operation of those centres though, were far from satisfactory as those units were part of neurosurgical and orthopaedic departments and nobody really devoted enough time to the care and management of spinal injury patients. There were other important factors too, lack of adequate technical facilities for the specialised care of such long-term patients including facilities for their domestic, social and industrial resettlement. Furthermore there were insufficient nursing and assisting personnel and the supervision and co-ordination of the unit was not undertaken by an experienced specialised physician. As a result, those units became concentration places for condemned demoralised cripples[6,9,14].

National Spinal Injuries Centre in Stoke Mandeville
The fact that Guttmann was a pioneer in G. Britain who, in his review on December 1941, pointed out the importance of rehabilitation for spinal injuries patients, urged Dr. George Riddoch to offer him a position in his new Centre that was to be created for these patients. In September 1943 the British government commissioned Guttmann as a director of that Centre at the Ministry Pensions Hospital, Stoke Mandeville, in Aylesburry. Guttmann accepted under the condition that he would be totally independent and that he could apply his philosophy as far as the whole approach to the treatment of those patients was concerned. His basic requirements for the operation of that new Centre were: The management would be under an experienced physician, there would be adequate technical facilities including physiotherapy, occupational therapy and pre-vocational training, sufficient in number nursing and auxiliary staff, as well as arrangements for adequate domestic and industrial resettlement for paraplegics[9,13]. Guttmann's goal was the integration of these patients into society as respectable and useful members despite their high degree of disability[6,11].
The Centre opened on the 1st of February 1944 with 26 beds and so a new era started for spinal injuries patients. Guttmann introduced a whole new approach to the way tetraplegic and paraplegic patients were treated, from the initial stages of injury until final resettlement. In June 1946, Guttmann presented in a paper read to a meeting of the British Association of Physical Medicine, held at Stoke Mandeville, the basic principles and goals of the rehabilitation programme of spinal injury patients, based on the experience of the first 160 cases in the Centre. The general treatment included avoidance of recumbence by encouragement of all forms of movement, even in the earliest stages after injury, restoration and maintenance of nutrition of the body, care of the skin, the bladder and the bowels as well as care of the mental disturbances found in paraplegics. One of the dominant activities of the Medical Officer in charge at this Spinal Centre was the planning and supervision of the physical treatment of paraplegics aiming at the patient's fitness to the highest possible degree, in order to restore his independence to as great an extent and as quickly as is possible[5].
In order to accomplish his goal, Guttmann used to stay in the Centre the whole day and a large part of the night, mainly because there was a shortage in personnel and it was necessary to train nurses and auxiliary staff [9,14]. A patient reports in 1945: "Guttmann was constantly around, early in the morning, late at night, always on his way to somewhere. Apparently he didn't need food or sleep!" (p. 11, 16).
Towards the end of the war the number of beds in the Centre had increased gradually to 100. By 1951, when Stoke Mandeville Hospital was taken over by the National Health Service, the Centre was designated as a National Centre, admitting patients from all parts of the United Kingdom. Soon it included special children's wards as well as hostels for tetraplegics and other severely handicapped that, for various reasons, could not be accommodated in their homes. The Centre also had departments for physiotherapy, occupational therapy, pre-vocational training and sports facilities as well. Since 1954 it has had its own research department with a biochemical and physiology laboratory[9].
Besides his clinical work in the Centre, Guttmann tried to teach and convince the authorities of medical and social services, in particular the Ministry of Labour and Housing Authorities, that paraplegia did not justify care in institutions for incurable people and rehabilitation to a useful life and employment was possible in the majority of spinal injury patients[9]. At the same time he had to battle against unskilled and pessimistic personnel that had to be convinced of the value of the new therapeutic approach. The ever repeated question "Is it really worth while?" asked by all visitors during the first two years that the Centre operated, was indicative as to how difficult it was to get over century old perceptions and prejudices (p. 116, 9). The defeatist attitude of the public was significantly expressed by one of Guttmann's early patients, a wounded clergyman, who wrote in an essay on his own reaction to his paraplegia: "One of the most difficult tasks for a paraplegic is to cheer up his visitors!" (p. 101, 14).
In spite of the unfavourable conditions, Guttmann managed to win over the trust and admiration not only of the patients but the Centre's personnel as well. His authoritative management quite often provoked discontent, though gradually everybody recognised the indisputable success of his approach that slowly led to the so-called " Spirit of Stoke Mandeville". The subjective impressions of a 19-year-old schoolboy who received his rehabilitation in Stoke Mandeville, is typical of what the attitude was like. "The magnanimity and spirit in Stoke Mandeville are characterised by not looking back but ahead into the future. The will to live, the will to survive, to simply get down to work, these were decisive" (p. 2, 18). "There was no way to refuse or get out of the strict schedule of events including lots of physiotherapy, occupational therapy, sport, etc... One had gone through a paramilitary rehabilitation, characterised by a strict agenda, obedience, and a bit of drill sergeant style... Any one who refused the offer could or had to leave... This was the rule for all that partook in the rehabilitation programme...Discipline was as in the military... That all sounds very authoritarian, especially from today's perspective, and so it was, and I think consciously so. These guiding principles could only work because the clinic personnel were committed to them and because the disabled patient could recognise a new perspective, one that could enable him to become a fully-integrated member of society - one sitting, to be sure, in a wheelchair, but otherwise healthy, not sick" (p. 3-5, 18). Guttmann's promise to the boy's father right after the accident: "I'll make a taxpayer out of your son" (p. 5, 18), was Guttmann's main maxim at Stoke Mandeville. 36 years later M. Sauer quotes: "I return something to society, to the community of solidarity from which I take and receive much. There is, I believe, nothing better for the disturbed psychological well-being of a disabled person, especially a quadriplegic, than balancing out the taking with giving" (p. 5, 18).

Picture 3. L. Guttmann integrated sports such as darts in the rehabilitation programme of the paraplegic patients.
Source: Guttmann L. New hope for spinal cord sufferers. Medical Times 1945; 318-26, p 324.

Guttman's rehabilitation programme
According to Guttmann, the basic presumption for the rehabilitation of these patients, was the coordination of the rehabilitation, the overall understanding of the patient's condition by every surgeon involved in the direct care of patients suffering spinal cord injuries, the continuous readiness and meticulous care of every aspect of the treatment and the co-operation with other categories of health professions[13]. With these presumptions Guttmann's rehabilitation programme developed into something pioneering for its time and opened up new horizons for patients with spinal cord injuries[19,20].
There were two main complications that often become fatal for the spinal injury patients. Pressure sores and urinary infections. Already in 1945, while reviewing the physical and psychological rehabilitation of 82 patients with spinal cord injuries, Guttmann points out the importance of early admission to a specialised centre in order to prevent pressure sores and urinary infections[4]. The usual therapy at that time was conservative, immobilising the traumatic paraplegics in plaster casts and plaster beds until the spine fractures healed. New methods such as gradual postural reduction on pillow or sorbo-rubber packs and regular turning replaced these every 2 hours day and night, with the assistance of the personnel[14]. In order to deal with the problem of the continuously increasing workload and the lack of staff, Guttmann in cooperation with Egerton Engineering Limited modified the electric bed that was used then, known as "Stryker frame". The disadvantage of the "Stryker frame" was that it did not allow the possibility of hyperextension of the spine when lying on the side or the back especially in fractures of thoracic and lumbar spine. There were two new bed types created (Egerton-Stoke Mandeville Turning Bed, and Egerton-Stoke Mandeville Tilting Bed) that could be used in traumatic tetraplegias following fracture of the cervical spine with any type of head traction[7].
The repeated urinary infections of spinal injury patients often resulted in sepsis and became fatal. In 1966 there was still considerable discrepancy of opinion among specialists in the field regarding the best method of preventing infection of the urinary tract in the immediate and early stages following spinal cord injuries. The indiscriminate use of suprapubic cystotomy was abandoned as the method of choice in the immediate management of the paralysed bladder. However there was still divided opinions as to whether catheterisation should be continuous or intermittent. At the National Spinal Injuries Centre intermittent catheterisation was always the method of choice in the acute stage of any cause of paraplegia, including in particular traumatic paraplegia and tetraplegia. The result was that during a period of 11 years out of 476 paraplegic and tetraplegic patients 62% did not have urinary infections at the time they left the hospital[8].
One of the dominant activities in this Centre was Physiotherapy. Guttmann emphasised the devotion and invaluable work of the physiotherapist as one of the most important members of the rehabilitation team of paraplegics. The main aims of physiotherapy were prevention of contractures and of atrophy in the paralysed parts of the body as well as compensatory training of the healthy parts of the body. This was achieved by proper position of the paralysed limbs in bed, by rejecting the plaster beds, electrotherapy, and by passive movements of all joints of the paralysed limbs which proved helpful not only for the prevention of contractures but for the management of flexor spasms as well[5].
Parallel to Physiotherapy Occupational Therapy played a central role to the rehabilitation of these patients. The aim was to mobilise all the compensatory mechanisms to replace the lost function of the lower part of the body. Guttmann believed that early vocational training is the best Occupational Therapy for paraplegics. For this reason vocational training and special instructors to the occupational therapy staff were introduced in the centre. Attempts were made to start this training early while the patient was still in bed. The vocational re-integration that followed included adaptation of the workspace. For example, since 1945 (picture 2), a paraplegic whose previous occupation was carpentry could practice his profession again by modifying and adapting his workbench and also become an instructor for other paraplegics[4].
Although Guttmann did not think of himself as Psychologist, the whole structure of the rehabilitation programme, shows, as other psychologists admit at a later stage, deep understanding of the psychology of the patient with spinal cord injury. He emphasised the development of a strong doctor-patient relationship[5]. The fact that he had to flee his own country and create the conditions for a new life, was probably the reason that made him so devoted on the victims of World War II. It was about young people who after their injuries had to rebuild their lives on a new basis[23].
Physical training and sports played an essential role during the Jewish revival after the end of the 19th century. It was not just an expression of a new Jewish self-confidence but also a way for the integration of Jews into a non-Jewish environment3. One can assume that Guttmann's involvement in sports activities during his youth in Germany, as a member of the Jewish fraternity, played an important part in the inclusion of sport in the rehabilitation programme for the spinal injuries patients.

Picture 4. L. Guttman introduced a special form of polo for patients in a wheel chair. This was the first team game, soon followed by basketball, which became the most popular game between the patients and spectators. These team games soon developed to a sports movement known as The Stoke Mandeville Games.
Source: Guttmann L. New hope for spinal cord sufferers. Medical Times 1945; 318-26, p 324.

Sport
Most of the patients were young and active before their injury. Guttmann's programme aimed at reintegration into a normal life which especially in a society such as the one of Great Britain, included sport. Besides work, sporting activities proved to be invaluable to the rehabilitation of patients with spinal cord injuries. They were very effective to motivate patients to exercise (picture 3). Besides their therapeutic value as complement to the traditional physiotherapy (in restoring the disabled person's strength, co-ordination, speed and endurance), sports events have a great advantage because of their recreational and psychological value. At the same time sport according to Guttmann, counteracts abnormal psychological and antisocial attitudes - a disabled person's attitude to himself deteriorate into an inferiority complex characterised by anxiety and loss of self-confidence and personal dignity, resulting in self-pity and self-isolation. The aims of sport are to develop self-discipline, self-respect, competitive spirit and comradeship - mental attitudes that are essential for the disabled person's integration into the community[10].
Archery for example was used therapeutically at early stages in the rehabilitation programme at the National Spinal Injuries Centre in Stoke Mandeville, as complement to conventional physiotherapy. This form of exercise was not as monotonous as the usual exercise with pulleys in the physiotherapy department and at the same time offered the possibility of exercising to balance in a standing position and the strengthening of the muscular system of the upper limbs and body. It also had beneficial results on the respiratory and cardiovascular functions while it provided the paraplegic patient the opportunity to compete against an able bodied athlete on equal terms. Archery soon became one of the most popular competitive sports between tetraplegics and paraplegics all over the world. A number of other games like table tennis or snooker were modified to meet the needs of the paraplegic and were also incorporated in their rehabilitation programme. Guttman also introduced a special form of polo for patients in a wheel chair. (picture 4). This was the first team game, soon followed by basketball, which became the most popular game between the patients and spectators[12].

Outcome of the rehabilitation programme
In 1954, on the occasion of the 10-year anniversary since the Centre of spinal cord injuries opened, Guttmann published a review of the rehabilitation results of the first 1000 patients. The Centre had a total of 150 beds and since 1946 the Ministry of pensions had created 4 auxiliary clinics for civilians and soldiers wounded in war. The mortality rate of traumatic paraplegia had decreased to less than 10% and 69% of the patients were employed[6].
Even the doctrine about the sexual life of these patients gradually proved to be wrong. In 1979 Guttmann published evidence that indicated that some paraplegics and tetraplegics, could have their own children. With regards to their professional resettlement, of 2012 paraplegics and tetraplegics, 54% had full time employment in 1979, in various jobs including professions such as education, law, accounting and medicine. It is mentioned that several paralysed medical postgraduates of Stoke Mandeville became managers of Spinal Units in different countries; one of them even became a professor at Harvard University. Including 11% of the patients who had part-time work and 19,9% engaged in home occupations, 85,4% (1.718 patients) were totally engaged in remunerative work as useful members of the community - and taxpayers[14].
The National Spinal Injuries Centre besides its clinical and research work, operated also as a training centre. The Stoke Mandeville centre became the Mecca for all those interested in these patients. Doctors, nurses and physiotherapists came from all over the world to get familiar with the therapeutic methods applied in Stoke Mandeville[6,16].
But beyond the achieved statistical results and the conducted research, the main achievement of this rehabilitation programme can be summarised in the words of an ex- patient of this centre who said: "Life is worth living now!" (p. 1.103, 6). These words are the most gratifying of all according to Guttmann, and indicative of the hope for a new life that Guttmann managed to inspire into patients with spinal cord injuries.

Picture 5. In 1952 the Stoke Mandeville Games became international with the participation of a team of Dutch paraplegic war veterans.
Source: Guttmann L. Development of sport for the spinal paralysed. Index to Olympic Review 1977;
110-3. www.aafla.org/olympicInformationCenter/olympicReview 1977, p 112.

 

The Stoke Mandeville Games
The team games that Guttmann incorporated in the rehabilitation programme soon developed into sports activities in which men, women and children could participate upon their dismission from the National Spinal Injuries Centre. Soon more patients from other Units all over Great Britain started participating. A sports movement was developed that became known as the Stoke Mandeville Games (picture 5). The first Games were held on the 28th July 1948, the same day that the London Olympic Games started. The date was not chosen by accident. Guttmann wanted his games to have a larger forum. He envisioned international Games. Since 1948 the Stoke Mandeville Games were held every year. Over 70 countries participated. In 1952 a team of Dutch paraplegic war veterans crossed the Channel to compete with their comrades at Stoke Mandeville in the first International Games for athletes with disabilities. The same year Guttmann founded the International Stoke Mandeville Games Federation. It decided that the games should be held in the country hosting the Olympic Games. This happened for the first time in 1960 in Rome right after the Olympic Games. 350 athletes with disabilities, men and women, from 24 countries, participated. These Games proved successful because not only high levels of records were achieved but also it had an educational effect on public opinion[12]. The effect of the Stoke Mandeville Games on society could not have been better expressed than by the late Pope John the XXIII in his audience to the wheelchair athletes and their escorts after the World Games for the Paralysed in Rome: "You are the living demonstration of the marvels of the virtue of energy. You have set a great example which we would like to emphasise, because it can be a lead to all. You have shown what one energetic soul can achieve in spite of apparently insurmountable obstacles imposed by the body" (p. 182, 12).
The Games of Rome were officially recognised as the 9th Annual International Games of Stoke Mandeville. The term "Paralympic Games" was adopted later in 1984 by the International Olympic Committee[26].
Guttmann pointed out the aims of the Stoke Mandeville Games: a movement of peace and understanding between nations. "As with the able-bodied, the will to win is always strong in national and international contests, but exaggerated nationalism and racial unrest, from which the Olympic Games have suffered greatly in recent years, is not allowed to develop" (p. 181, 12).
In 1964 the Games took place in Tokyo with 400 participants and 100,000 spectators in the Olympic stadium. They proved particularly important from the point of view of social reintegration. When the Japanese government realised what disabled people in wheelchairs could achieve in sport, it decided to build a factory, within 6 months, for employing people with severe disability. In 1977 there were 4 such factories under the leadership of a former patient of the National Spinal Injuries Centre, Stoke Mandeville. In the 1972 Olympics the Games took place in Heidelberg, Germany. 1000 wheelchair athletes and 400 escorting staff, representing 45 countries took part. In 1976 the Games took place in Toronto with the participation of at least 1400 disabled athletes and for the first time blind and amputees took part[11].
The enthusiasm and skill of the disabled athletes led to the development of other international sport events for the disabled. In 1960 the British Commonwealth Paraplegic Games (equivalents of the Commonwealth Games of the able-bodied) were founded and in 1967 the Pan-American Games. This unique sports movement was recognised by sports organisations of the able-bodied, and in 1967 on the occasion of the Olympic Games in Melbourne the International Olympic Committee awarded the Fearnley Cup to the International Stoke Mandeville Games Federation for outstanding achievement in the Olympic ideals[12].

Picture 6. The world's first sports stadium for the multi-disabled was inaugurated by Queen Elisabeth on the 2nd August 1969.
Source: Guttmann L. Development of sport for the spinal paralysed II. Olympic Review 1977; 179-82 . www.aafla.org/olympicInformationCenter/olympicReview 1977, p 180.

 

The world's first sports stadium for the multi-disabled
There was a great need for a sports stadium built primarily for disabled people for two main reasons. Firstly, there were architectural barriers in the existing stadiums. Access to these was difficult if not impossible, especially for wheelchair users. Furthermore the disabled athletes had to rely on the assistance of able-bodied helpers, which deprives them of their independence. Secondly, there was the existing psychological barrier: sport activities of the disabled were an embarrassment to the able-bodied, despite the fact that many severely disabled were employed in industry. In 1968 the Executive Committee of the British Paraplegic Sports Society decided to build a sports stadium accessible to people with all kinds of disability but also to able body athletes so that understanding was promoted (picture 6). That Stadium was built within a year and Queen Elisabeth inaugurated it on the 2nd of August 1969. The Paraplegic Sports Endowment Fund evolved into the British Paraplegic Sports Society, and one of its responsibilities was the financing and running of the Stadium under the chairmanship of Guttmann. A number of facilities have since then added (smaller halls for fencing, table tennis, snooker, weight lifting, Indoor Bowls Centre, a Social Club bar, a 25m heated swimming pool) as well as a large dining hall for 250 wheelchair users and a 150 beds accommodation block[12,21].
The Stoke Mandeville Sports stadium proved how important sport is to the social reintegration of the disabled and became an example to follow for other countries. Already in 1974 a magnificent sports stadium was inaugurated in Osaka, Japan, while in Toledo Spain, in the autumn of 1974 excellent sports facilities were inaugurated in the new Paraplegic Rehabilitation Hospital (200 beds)[12].

Guttman's Legacy
Guttmann directed the National Spinal Injuries Centre for 22 years and when he retired from his clinical work in 1966, the Centre had increased to 200 beds. The question today is would a Stoke Mandeville Centre have been created without the events and consequences in Germany? Would rehabilitation of spinal cord injuries have been his lifetime's work without emigrating? Would the world's negative prejudices about the "incurable" paralysis have changed without the refugee Guttmann? Guttmann himself answered these questions by referring to Winston Churchill: "Since the Nazis drove out Jewish scientists, British science has got ahead of the Germans" (p. 8, 16).
Today Guttmann is internationally recognised as a pioneer in the field of rehabilitation of spinal injury patients. Since 1948 he was council for many governments in the world in matters of paraplegic rehabilitation and he promoted the creation of many Paraplegic Centres. The Stoke Mandeville Centre became an example for 40 other rehabilitation centres around the world. In 1954 the first Paraplegic Unit was established in Australia under the Board of Management the Royal Perth Hospital20, and in 1966 the 1st Paraplegic Centre in a German University in Heidelberg was set up bearing his name "Ludwig Guttmann's home"[22].
Guttmann's foresight with regard to the importance of sports as a form of social reintegration for the victims of World War II was decisive in the promotion and development of sports for the disabled, world-wide. In 1960 he founded the British Sports Association for the Disabled of which he was president until the end. He was also the President of the International Sports Organisation for the Disabled[21]. In 1961 he founded the International Medical Society for Paraplegia of which he presided too. In 1963 he founded the journal "Paraplegia" of which he was the first editor. In 1966 the journal was renamed to "Spinal Cord" and until today continues to be an international forum for the evolution of knowledge and research for the care of spinal injuries patients15. His publications reached 15016,[17].
He received many distinctions and honours. In 1966 received the title of Knighthood from Queen Elisabeth. In 1957 he was named as Professor Emeritus in the medical school of the Cologne University. He was also Honorary Chairman of the Swiss Paraplegic Institute in Basil, which was founded in 1975. Basil, Switzerland was the First University in continental Europe in 1976 to award him the title of honorary Doctor, which many Universities in Britain and USA[24] had preceded. Many countries like G. Britain, France, Italy, Holland, Belgium, Japan, West Germany, and Finland had awarded him with the highest honours. Streets in Holland and Heidelberg bear his name15,24.
He was very active and visionary until the last moment. He always stood by the disabled people, tireless, either as an editor of the journal "Paraplegia" or as Chairman of the International Sports Organisation for the Disabled25. "There are a lot of things that still need to be done in the sector of social reintegration of the disabled people... I feel very young as long as I am not satisfied" pointed out the elegant 80 year old man in 1979 right after his visit to the Paraplegic Centre in Basil (p.32, 22). A few months prior to his death he declared in the journal "Paraplegia": "Stoke Mandeville is the Mecca, the Centre for a sports movement for disabled people. Here has been born an Olympic village for them of which you can see the drawings. The construction should be finished by 1981. It will offer lodging for 430 athletes and their escorting assistants" (p. 34, 22).
Guttmann did not make it to see that Olympic village. He died on the 18th March 1980 after a second heart attack, leaving behind him a rich legacy to all those involved in the rehabilitation and care of spinal injuries patients16,17. His main contribution, his colleges point out, and probably the most typical characteristic of all great men, is the fact that he trained others to continue his work, something that Guttmann did in many parts of the world[1]. His main message, that "spinal cord injured patients should be transferred as soon as possible to a specialised spinal injuries unit" is still valid today (p. 462, 2).
When Pope John the XXIII received Guttmann in an audition on the occasion of the first Olympic Games for the disabled in Rome in 1960, impressed by his work, exclaimed: "You are the de Coubertin of the Paralysed!" It sounds perhaps a quite strange tribute for a neurosurgeon but it is probably the best way one can summarise Ludwig Guttmann's contribution to mankind (p.55, 20).

Acknowledgements
The authors wish to thank kindly Mrs. Ida-Maria Maeder, in charge of the Library in the Swiss Centre of Paraplegics in Nottwil, Switzerland. This paper would not be possible without the bibliographic support offered with great generosity by Mrs. Maeder. We also thank kindly Spyros Dontas Chemist, PHD, who translated the German bibliography of this paper.

REFERENCES
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3. Gidal N.T. Die Juden in Deutschland von der Roemerzeit bis zur Weimarer Republik. Koenemann. 1997; 344-345.
4. Guttmann L. New hope for spinal cord sufferers. Medical Times. 1945; 318-26.
5. Guttmann L. Rehabilitation after injuries to the spinal cord and cauda equina. The British Journal of Physical Medicine. 1946; 130-137.
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7. Guttmann L. A new turning - tilting bed. Paraplegia. 1965; 3, 193-7.
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24. Zach G.A. Prof. Dr med. Sir Ludwig Guttmann - Ehrendoktor der Universitat Basel. Paraplegie. 1977; 11, 1, 12-13.
25. Zach G.A. Stoke Mandeville Games 1979. Paraplegie. 1979; 11, 3, 28-31.
26. http://www.paralympic.org/games/1960/content.asp

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