Obituary: Dorothy Mandelstam

Dorothy Mandelstam was sometimes called affectionately the Queen of Continence; and her life from her late forties was intertwined with the Continence Movement.

Working in a Cinderella branch of medicine where the general public and fellow professionals expected nothing but quiet warehousing of destitute and discarded old people, she took a single-minded interest in the causes, alleviation and management of incontinence - long a taboo subject.

Born Dorothy Hillier in 1923, she was evacuated from London during the Second World War to Llanelli in Wales, and billeted in a general practitioner's household, which must have encouraged her interest in medicine and led her to choose physiotherapy as a career. By good fortune she trained at King's College Hospital Physiotherapy School.

In those days physiotherapy was generally taught in an insular and enclosed atmosphere, in small schools attached to big medical teaching hospitals and the students were unexposed to other disciplines or indeed to anything outside the hothouse of hospital. King's was different. The Medical Director, Dr Frank Cooksey, was a pioneer medical rehabilitationist: helping disabled people back to functional life in the community. With a further two years post-qualification, working at the Red Cross Rheumatism Clinic in Peckham Rye and at the Roffey Park Psychiatric Centre, Dorothy's interest was assured in the psyche as well as the soma of illness and disability.

Having come under the influence of the philosopher and educationist Frank Coles as a student, she decided on a social science diploma and enrolled at the London School of Economics from 1946 to 1948. She then worked in the Children's Department of the London County Council, assisting unmarried mothers and adoption processes. This she continued after her marriage in 1954 to a South African scientist, Joel Mandelstam, later the Iveagh Professor of Microbiology at Oxford.

After the birth of her first child in 1956, she returned to part-time work as a physiotherapist in the Obstetrics Department of Edgware General Hospital in north London; five years later, true to her principles, she courageously allowed her second delivery to be filmed, and used the film in her classes. Edgware Hospital was also the home of a progressive department of geriatric medicine, and visitors were attracted to it from many parts of the world. The Principal of the Guy's Hospital School of Physiotherapy, Elizabeth Tanner, requested the opportunity to work voluntarily with the geriatric unit: she wanted to test a hypothesis that the practice of suitable exercise could prevent many present-day illnesses.

Her paramount speculation related to the high incidence of incontinence in elderly women. Did it relate to childbirth and damage to the pelvic floor muscles and lack of re-education of these muscles to function optionally afterwards? A link-up between Tanner, in the geriatric unit, and Mandelstam, in the obstetric department, was easily arranged.

When Tanner left the hospital, Mandelstam moved half her allegiance to the department of geriatric medicine. At that time, the labels senile, lazy, or dirty were often applied to sufferers of incontinence. Little or no training was given to medical students and nurses' training was mainly directed to containment: the pad, mop and bucket approach.

The department had close ties with the Disabled Living Foundation (DLF), created by Lady Hamilton, who had long been at the forefront of a movement to encourage professional interest in the demoralising subject of incontinence, underlining what a devastating effect it could have. When a vacancy occurred at the DLF in 1974, Mandelstam was appointed the first Incontinence Adviser to run the Incontinence Advisory Service (IAS).

The DLF's Annual General Reports from 1974 to 1992 record the speed with which the whole subject opened up. Through her contact with Edgware Hospital, Mandelstam was already working with the Open University in the production of a module on incontinence. Initial permission was refused for a television programme to support the incontinence chapter - it "might upset viewers". Two years later, the response to just such a broadcast came in shoals of letters to the DLF begging for help. Its Incontinence Advisory Service soon became a focal point for obtaining or disseminating information and testing new ideas nationally and internationally.

One of Mandelstam's first acts, in 1976, had been to organise a competition to design an "Emergency Pack for Incontinence" to be carried by district nurses. Radio and press interviews followed, giving the valuable oxygen of publicity to the subject. A leaflet on incontinence was produced by the Health Education Council in conjunction with the DLF - which they had refused to do before. In 1977, Marjorie Proops launched Mandelstam's first book, Incontinence - a guide to the understanding and management of a very common complaint; about a third of purchasers were professionals (in 1978 it went into a second edition). In the same year the Chief Nursing Officer recommended that a specialist advisory nurse be designated to every health district.

Mandelstam then compiled and edited a text book Incontinence and its Management (1980). In 1981, at a meeting at Bedford College, the Association for Continence Advisers was formed; it later became the Association for Continence Advice (ACA). Dorothy Mandelstam was appointed Chairman and remained so until 1990, when she was made an Honorary Life Member. By that time the ACA had 1000 members. In October 1996, the ACA Executive decided to call a bursary fund for tertiary education of its members the Dorothy Mandelstam Educational Award. This particular accolade gave her tremendous pleasure in her last weeks.

As a physiotherapist Mandelstam was consistently preaching the gospel of exercise for maintenance of the muscles of the pelvic floor. The first course paying serious attention to the pelvic floor was validated in 1988 by the Chartered Society of Physiotherapy (CSP), on the Promotion of Continence and Management of Incontinence. This closed the circle for her. The group later changed its name to the Association of Chartered Physiotherapists in Women's Health and proposed the election of Mandelstam to the highest honour the CSP awards, a Fellowship, in 1992.

After 17 years of outstanding service, Dorothy Mandelstam retired from the DLF in 1992, and, due to financial constraints, the IAS was subsumed into other departments. Mandelstam had foreseen this possibility, and with so many new organisations related to continence springing up, she had gathered together a collection of enthusiastic professionals to brainstorm a pattern for the future. The great need appeared to be for an over-arching organisation (much as the DLF had been) to be a focal point and umbrella for all the small groups; the Continence Foundation was launched at the House of Commons in March 1992, with the potential of becoming an international resource centre.

Retirement was stranger than Dorothy Mandelstam had realised, although she had always maintained a life apart from work. She continued to play tennis twice a week and started to play the piano again - taking lessons and playing in a trio with two friends, a cellist and violinist. It was only during the past year that she discovered an occupation that really lit her up in the same way that incontinence had - the National Trust house, 2 Willow Road, the former home of the modernist architect Erno Goldfinger, where she trained as a guide and revelled in being able to enthuse the visitors she was showing round.

Monica Stewart

Dorothy Alma Hillier, physiotherapist: born London 5 November 1923; married 1954 Joel Mandelstam (marriage dissolved 1974; one son, one daughter); died London 8 December 1996.