Implementación de Tableros de Alimentación 1 Descripción de los elementos del tablero

By contrast, Watson-Jones was an excellent and practical communicator, whose book on fractures was the standard text in the United Kingdom after the Second World War until the 1960s. He was the first lecturer in orthopaedics in Liverpool and set up an outstanding fracture unit there. He eventually moved to London to run the fracture unit at the London Hospital.

In a series of papers between 1930 and 1936 he described the pathology of fractures of the spine using the two-table method, without general anaesthesia. He recommended a quarter grain injection of morphine as the maximum amount of local anaesthetic. The patient was laid on two tables, in the prone position, so that his spine sagged to the normal limit of hyperextension. The method reduced gross displacements without exerting undue force, and without the risk of over-reduction, which could cause further spinal cord damage. The patient was put into a plaster jacket while on the tables. The whole procedure took only 10 to 15 minutes. The patient was subsequently able to sit up wearing the jacket, which facilitated nursing.

Watson-Jones was of the opinion that general anaesthesia was unnecessary. He considered that the reduction was painless (possibly for the surgeon but certainly not for the patient) and the required position could best be maintained in conscious patients. He thought that anaesthesia aggravated the early complications of spinal fracture: shock and pneumonia.

He discussed the method of treatment in cervical and lumbar fractures. Unfortunately, he gave no follow up of the X-rays. He described 80 cases of lumbar fractures, of which 57 were treated personally and 23, who were treated by other surgeons. Amongst these there were 21 fracture dislocations with paraplegia, 9 of whom died. He recognised that the cord was transected. He was opposed to laminectomy, either early or late. He considered it to be a useless procedure because he realised that the pressure was in front of the

cord. He believed that immediate reduction of the displacement by hyperextension relieved further compression and allowed revascularisation of the injured area. He postulated that his treatment made the difference between permanent paralysis and complete recovery. He advocated face down transportation.

There were no controls, no statistical analysis, and this was largely speculation but, despite the unscientific nature of his regime, such was the force of his personality and the clarity of his exposition, that it had considerable influence on contemporary medical practice (Watson-Jones 1934)

11. The Outbreak of the Second World War

With the outbreak of the Second World War, large numbers of casualties were anticipated, so much so, that paper coffins were ordered and a series of papers were produced to instruct first-aiders and doctors on how to cope with emergencies.

Amongst these were two papers produced by Douglas McAlpine (1890- 1981) and Geoffrey Cureton Knight (1906-1994) prior to the opening of spinal units to instruct the uninitiated on the practical care of patients who had suffered spinal injuries.

McAlpine was a formidable neurologist, the first to be appointed to the Middlesex Hospital, who wrote a textbook on multiple sclerosis. He was a man of considerable presence and independent spirit, a keen teacher who had time for research as he was from the McAlpine building family. The neurological wards were built by generous donation from Sir Robert McAlpine. When the England Rugby captain, Lewis Cannell, evinced a desire to continue playing rugby, having finished his career at Oxford, McAlpine attempted to bring him to the Middlesex Hospital on a privately funded scholarship but was outbid by St Mary's Hospital by Lord Moran (corkscrew Charlie).

McAlpine’s summary of treatment followed the recommendations of Watson-Jones and Jefferson. He recommended immediate reduction of the

fracture and immobilisation in plaster beds. He drew attention to the effects of regular turning and advocated intermittent catheterisation and the tidal drainage of Munro, modified by Lawrie & Nathan (1939).

“A simple modification of such an apparatus, originally described by Munro, has recently been made by Lawrie and Nathan (1939); it has been used with success in the Neurological Ward of the Middlesex Hospital.” (McAlpine 1940, p.27)

It should be noted that the cases he was referring to at the Middlesex Hospital were not traumatic paraplegics but patients with multiple sclerosis. Peter Nathan has confirmed this in a personal communication.

Knight said;

“The immediate treatment of spinal injuries will therefore consist of efforts to limit the amount of cord injury resulting from the displacement of closed fractures...” (Knight 1938, p 248).

He describes how the patient should be carried to avoid movement. He discusses how to deal with an open wound, reduction and immobilisation, spasms, and different methods of bladder management, which he does not seem to know much about.

12. Conclusion

The treatment of spinal injuries between the wars is a sad reflection on the practice of medicine at the time. As a result of the First World War, recommendations had been made in the MRC monograph (Medical Research Council 1924), which set out a satisfactory method of treatment. This incorporated the outstanding work of Holmes, Head, Riddoch and Jefferson.

The fundamentals of treatment had been delineated. It was recognised that spinal patients should be segregated in specialised centres but Cairns did not operate at Queen Square because the neurologists there did not follow the Cushing approach and denied him facilities. The deleterious effects of plaster beds was not appreciated and only lip service was paid to the prevention of complications because patients had pressure sores and urinary tract infections. Attention was concentrated on the

management of the fracture by conservative means. The need for rehabilitation was recognised

The development of neurosurgery was tardy in the United Kingdom. It can largely be attributed to the work of Cairns at The London Hospital. He trained Joseph Buford Pennybacker (1907-1983) who went with him to Oxford where he set up a comprehensive training programme for neurosurgeons. Cushing also trained Jefferson, whose work centred in Manchester, and he, in turn, trained Rowbotham. Dott, another of Cushing's pupils, was responsible for Scotland. These three outstanding neurosurgeons, in a small world, split up the work between them during the war. They served on committees with Riddoch at the outbreak of the Second World War and took over responsibility for setting up spinal injury units.

The comparison with shell shock is instructive. The work done and the reports produced at the time were progressive with excellent accounts of aetiology, prognosis and treatment (Rows 1923, Holden 1998). As a result special units were set up close to the battlefront and the recognition of psychological symptoms with psychotherapy as a method of treatment was accepted. Psychotherapy became an integral part of medical practice between the wars and when the Second World War broke out, a coherent and intelligent programme of treatment for aircrews and other victims of shell shock, was in place.

In contrast, the chapter on spinal injuries in the Official History is poor (Thorburn 1922). After the First World War specialist units were closed. The same attitude of hopelessness and helplessness pervaded as had pertained prior to the opening of the units in the First World War. Lessons had not been learnt and at the outbreak of the Second World War, even after specialist units had been opened at the recommendation of Riddoch, patients were developing the same hideous complications as they had in the First World War with the same high mortality. These units were not properly staffed, not properly led and as a result, patients with spinal injuries were not being treated

much better than they had been in the First World War. Dick, in his MD thesis (1949), described the appalling conditions at Winwick Spinal unit.