Saturday, February 25, 2017

On Setting Bones

From: Richard Rhodes' Hell and Good Company
Like thousands of others in republican Spain during the war years, Robert Merriman soon found his shattered shoulder, wound and all, immobilized in a plaster cast. His cast extended out at a right angle to his body like a broken wing so that the shoulder joint could heal unstressed. The surgeons called it an airplane splint. And because the hospital had run short of plaster of paris-the lightweight, fast-setting gypsum plaster named after the historic gypsum mines under Montmartre, whose tunnels became the Paris catacombs-Merriman’s cast was molded of much heavier lime plaster, the kind used in construction. He felt the weight. 

Sealing open wounds such as compound fractures (the kind with exposed bone) under plaster was a major and lifesaving innovation of the Spanish Civil War. Earlier, during the Great War, a shocking 46 percent of American soldiers who suffered fractures were permanently disabled; 12 percent died. In contrast, in a series of 1,073 cases of infected fractures treated and tracked by the innovative Catalan surgeon Josep Trueta during the Spanish war, 91 percent healed satisfactorily, with a rate of 8.5 percent disabled and only six (0.5 percent) deaths. 

Sealing compound, infected fractures in plaster rather than leaving them open for disinfection was a medical innovation out of Lincoln, Nebraska. A Nebraska surgeon, H. Winnett Orr, one of the pioneers of American orthopedics, devised the technique in the 1920s after serving as a medical officer in the U.S. Army at hospitals in Wales and France. “We had our eyes opened to the very serious character of the war wounds," Orr writes in a memoir of his first exposure to war casualties in Wales. “It was almost beyond belief to see how very extensive was the physical damage done. The infections were appalling. Large open wounds involving bones and joints were bathed in pus. In those who had survived, there were some fearful evidences of the destructive power of gas gangrene.” 

Orr was an admirer of a colorful nineteenth-century Liverpool surgeon named Hugh Owen Thomas, the descendant of a long line of Welsh bone-setters. Thomas practiced among the poor in the Liverpool slums in Victorian times, when the standard treatment for arm and leg fractures was amputation. Thomas to the contrary emphasized immobilizing the broken limb-he invented the Thomas splint for that purpose-and his precept, “enforced, uninterrupted, and prolonged rest.” A direct line connected Thomas and Orr: Thomas’s nephew Robert Jones, who trained under his uncle in Liverpool, was appointed inspector of military orthopedics for Great Britain and Ireland early in the Great War, and recruited Orr among twenty American orthopedic surgeons who volunteered to help the British before the United States entered the war in April 1917. 

Despite Jones’s implicit endorsement, Orr’s idea of cleaning, packing, and immobilizing compound fractures in plaster received a hostile reception from British and American surgeons in the military hospitals where Orr served. Covering an open wound with plaster, he was told, Would leave any infection untreated and risk killing the patient. Only a captain, he desisted. His chance came at the end of the war. By then he was chief of orthopedics overseeing the main American hospital at Savenay, France, the transfer point for all American sick and wounded evacuated back to the U.S.
Within a few days after arriving at Savernay" Orr writes slyly, " our supply of splints ran out.... With my own fondness for plaster as a fixative dressing it therefore came into extensive use. Even a great many of our spine and fracture cases were put into plaster of Paris for transfer to the United States... we never heard of any serious effects as a result of this method.

"If I had sent some thousands of men shipboard for transportation to the United States without making windows in the casts for the daily dressing of open wounds I should probably have been censured or worse and at that time I should not have thought of doing so. Yet later observations show that most of those men would have had less suffering, fewer complications. and better ultimate results if they had been prepared according to the method now advocated. put in closed casts and left undisturbed during the entire period of transportation to the United States or longer." 

Perhaps because his courage had failed him Within the military. Orr began promoting his casting treatment after he returned to civilian practice in 1919. Most ignored his methods, but he made a decisive convert in Catalonia. 

Josep Trueta was a surgeon on the staff of the Hospital de la Santa Creu in Barcelona. Among other duties he served as chief surgeon for an accident insurance company. In Spain such organizations maintained medical clinics for the workers they insured. Trueta thus treated ind lured factory workers and victims of road accidents, which is probably why ltc noticed Orr’s papers. He decided to try Orr’s method: aligning the broken bones to their normal position (“reduction"), cutting away bruised or infected tissue (“debridement”), packing the Wound with sterile gauze, and then casting the limb in plaster, covering the wound, and leaving the cast on for two months or more while the wound and the bones healed. “At first i treated only unimportant wounds this way," ’I‘ructa writes; “but encouraged by the results I used the method in severe compound fractures of the tibia and fibula with a very satisfactory outcome." 

A practical advantage of the method was that it eliminated the daily nursing routine of dousing uncovered wounds with disinfectant. A disadvantage, Trueta notes. “was that the plaster cast soon stank unbearably from contamination" the wound draining its "products of tissue disintegration," as the surgeon delicately calls them, into the gauze packing and soaking into the east. Later, in the war. patients in Trueta casts would be banished together to stink up a dedicated ward or, in good weather, parked outside. They smelled like death warmed over. “but underneath," a prominent American surgeon discovered who toured the Barcelona hospitals in wartime, “when cleaned up. there were nice, pink, well-granulated wounds.” (Granulation is tissue matrix, the new growth that fills open wounds as they heal.) 

By 1929 Trueta had treated more than one hundred cases, which he summarized in a report to the Surgical Society of Barcelona. Like Orr's, his exciting success story “did not get a good reception... . lo the seven Years before the beginning of the Spanish war, I could not persuade more than a few surgeons to try my method." 

In the meantime, Trueta conceived of a further application that extended Orr's method beyond fractures. “Towards the end of 1929," he ”rites, “. . . I decided by simple reasoning that if this method of treating chronically infected bones nearly always worked there was no reason why it should not be successful as a preventive treatment of infection in recent open wounds.” Trueta realized he could use Orr’s method to treat large wounds regardless of whether broken bones were involved: clean up the wound, pack it with gauze, cast it in plaster, and leave it alone to heal. Later, after he escaped Spain ahead of Franco’s victory and found his way to England, a refugee stranger in a strange land, Trueta minimized Orr’s contribution to shine up his résumé (he eventually won appointment as professor of orthopedic surgery at Oxford University). He hardly needed to do so: his innovations were substantial and transformative. 

The war tested Trueta’s new methods. As chief surgeon of the largest hospital in Barcelona, he applied his casting technique on a large scale, keeping a record of his results. He treated wounded militiamen and, once the bombing started, injured civilians as well; published two papers in Catalan medical journals; and wrote a textbook. 

Even that wasn’t enough for Trueta’s fellow surgeons, however. It took the determined intervention of his colleague Dr. Joaquin d’Harcourt Got, chief of surgical services for the republican army, to command the use of Trueta’s methods in the Spanish Republic’s hospitals. D’Harcourt tested Trueta’s system at Teruel, a major battle fought between December 1937 and February 1938, where he and his assistants followed the Trueta protocol in treating around a hundred casualties. “On returning to Barcelona,” Trueta writes, “my friend told me how satisfied he had been with the results.” Before then, Robert Merriman worked at granulating under his massive airplane-splinted cast. 

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