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3.29.2017

The Trueta Method



"... Orr began promoting his casting treatment after he returned to civilian practice in 1919. Over the next decade, one of his patients estimates, he wrote "almost two hundred articles... and delivered more than five hundred lectures, many of them illustrated with movies and lantern slides." Surgeons are a conservative lot. 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 cast. 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... . In 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 writes, "...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."


From "Hell and Good Company: The Spanish Civil War and the World it Made", by Richard Rhodes. (Simon and Schuster, 2015), pp. 104-106.

See also: http://drasticfolly.blogspot.com.es/2017/02/on-setting-bones.html
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