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Catalan Doctor Trueta and plastered war wounds (Time, 15 JAN 1940)

Various articles in Time Magazine between 1940 and 1947 mentioned the surgical advances my grandfather, prof. Josep TRUETA, made in the Spanish Civil War abd WW2.
Click here, if need be, to accessthe four articles.
Monday, Jan. 15, 1940

Medicine: Plastered Wounds

As the remnants of the Spanish Loyalist Army, ragged and footsore, fled last year over the Pyrenees into France, over 10,000 wounded stumbled along with them. Their torn, broken arms or legs were stiffly supported in filthy, foul-smelling plaster casts. French doctors, fearing development of gas gangrene, began to amputate, left & right. Before they had done much bone-sawing, they found to their amazement that cases of gangrene were very rare. Normally, even in arm or leg wounds which had been disinfected and bandaged, they could expect more than ten cases of gangrene per 1,000. But only a score of the wounded soldiers had become infected. And none of them had been given antiseptics; only thin gauze drains separated the plaster casts from their lacerated flesh.

The man who had fathered this necessitous technique was Dr. Josep Trueta, onetime head of the department of surgery at Barcelona's General Hospital of Satalunya, now in London. Last fortnight the British Medical Journal reprinted an address which Dr. Trueta made before the Royal Society of Medicine. Society members found Dr. Trueta's methods "iconoclastic," "revolutionary," "momentous." All agreed that "closed plaster casts" such as his might prove to be "the methods of surgical election" in World War II.

In treating compound fractures caused by bullets, bombs and toppling masonry, doctors aim to: 1) prevent infection; 2) immobilize the limb for best circulation and proper knitting of bones. To prevent infection, Dr. Trueta carefully snipped away all bits of bruised and dying flesh, for dead tissues, deprived of circulation, are a fertile breeding ground for germs. He used no antiseptics, for most of them, he believes, kill not only germs but the delicate growing cells, do more harm than good. After the wound is trimmed, cleaned and firmly packed with dry, sterile gauze, and while the patient is still anesthetized, Dr. Trueta applies a plaster of Paris cast directly over the wound, without a cotton-wool or stockinet lining.

Plaster has one great disadvantage: "it prevents examination of the wound at any given moment. Fortunately this examination is seldom necessary. When there is doubt about the vitality of the tissues that remain after injury ... it is essential to wait two or three days before putting on plaster." In that case, the wound should be left open to view, the limb strung up on special wires for immobilization. If the limb is "dying," it must be amputated. If the circulation speeds up within a few days, a cast is put on.

"The failures," continued Dr. Trueta, "can all be attributed to faulty technique: the surgeon had either tried to save a limb with insufficient blood supply or had not excised enough bruised tissue."

Dr. Trueta admitted that there is a minor objection to "closed" treatment: a terrible stench. Although it is best to keep the original plaster in place until the limb heals (usually from six to eight weeks), the cast sometimes has to be changed, when the smell becomes unbearable. Dr. Trueta discovered that a salve of brewers' yeast, applied directly to the wound, reduced the odor, did not interfere with healing. Since yeast was scarce in warring Spain, most of his cases stank to high heaven.


Monday, Jul. 08, 1940

Medicine: Plaster and Stench

Striking medical victories scored by British surgeons amid the muck and terror of the recent Allied withdrawal from Flanders were noted in London last week by the authoritative Lancet.

In their desperate need to deal at top speed with tens of thousands of wounded who had to be rushed on to steamers in the Channel with the Nazis only a few jumps behind, hard-pressed, sweating surgeons had to have some new and faster technique of treating wounds. Fortunately, most of them had read last winter the revolutionary work on wound surgery written after the small-scale war in Spain by brilliant Dr. Josep Trueta of Barcelona, now in England (TIME, Jan. 15). In treating 1,073 projectile fractures, Surgeon Trueta obtained wholly satisfactory results in 976 cases and there were only six deaths. His method: instead of lengthy and painstaking work in old-fashioned suturing and splinting (sewing up wounds and applying strips of wood in the bandage like stays in a corset), the wound is thoroughly trimmed of all germ-breeding dead tissues, soothed with vaseline gauze and sealed raw in a swiftly and easily wound-on cast of bandages soaked in plaster of Paris.

When Spanish wounded so treated began to hobble and be carried over into France as refugees, what was most noticeable was the terrific stench. This at first suggested to French surgeons that the plaster casts must be quickly ripped off and stinking human members amputated. The French soon learned, however, to let plastered Spanish wounded alone, observed that, while the odor for a time became almost unbearable, the end result was nearly always satisfactory. Last week the British Lancet said nothing about a heroic stench, said flatly that results of the Barcelona method have been so good in Flanders that from now on suturing applied on the battlefield must be considered "almost criminal."

Quoting Dr. William Heneage Ogilvie of London, especially enthusiastic about plaster, the Lancet summed up: "Once a wounded man has undergone efficient surgical treatment and has been put in plaster, he is safe—he may be blown out of an ambulance, derailed in a train, crashed in an aeroplane or torpedoed at sea, he may be left for weeks in a cellar . . . but so long as the plaster holds he will come to no harm." French surgeons in the War of 1870 pioneered the plaster closed method and in World War I it was used to some extent by U. S. Army Surgeon Hiram Winnett Orr, now of Lincoln, Neb., who contributed a preface to Dr. Trueta's book, Treatment of War Wounds And Fractures (Hoeber; $2.50).

The Lancet also reported that sulfanilamide administered to wounded in Flanders proved another victorious medical technique. After this treatment, said the Lancet, "The condition of the men who have received no surgical treatment . . . is ... far better than that of men evacuated under similar circumstances during the great German attack over the same country in 1918."


Monday, Apr. 05, 1943

Medicine: The Surgeons of Leningrad

Professor N. Blinoff of the Leningrad Postgraduate Institute did not know that his beleaguered city would soon be free (TIME, Feb. 1) when he cabled to Britain a description of care of the sick and wounded during 17 months of siege. So his account, printed in the British Medical Journal, is only a fragmentary outline of a historic chapter of medical improvisation.

In the early stages of attack (September 1941), when the population (some 3,000,000) was tripled by an influx of soldiers and civilians from outlying districts, shells and bombs caused many civilian casualties. At the same time wounded soldiers began to arrive. The military took over all the hospitals. New hospitals had to be set up for civilian wounded.

New surgeons had to be found, too, because most Leningrad surgeons were in the Army. The Institute gave courses which made emergency surgeons out of ordinary doctors in two weeks. Even then, nothing but wounds and emergencies could be attended to; "planned operations" had to wait.

Men in White.

Wound treatment was kept simple: gunshot wounds had their edges cut away, were not sewed up; wounds involving bone were usually put in plaster casts (the Orr-Trueta method which got its first full tryout in the Spanish War; TIME, July 8, 1940), and left alone, perhaps for weeks. "Some surgeons made a habit of using sphagnum moss* for surgical dressings."

"Then severe cold weather set in; . . . the electricity supply failed in most of the buildings, so work had to be done with the aid of oil lamps or night lights. Then the water supply gave out. . . . By using fences and wooden huts as logs the staffs of the hospitals were able to raise the temperature several degrees above freezing point."

Men in Furs.

"The doctors made their rounds in fur overcoats covered by white gowns. . . . The wounded often had to lie in bed fully dressed. [I] frequently had to do blood transfusions in a fur coat and a fur hat and keep [my] hands warm by putting them in warm water." Operating rooms in most hospitals were too cold to use and work on wounds had to be done in the wards.

"The severe cutting down of rations and the intensely cold weather produced a peculiar disease—an alimentary emaciation . . . with a variety of surgical complications such as gangrene of fingers, trophic ulcers [sores caused by poor nutrition] . . . avitaminosis."

Fortunately, all nonessential civilians had been evacuated and the bombardment lessened so that some beds could be devoted to medical as well as surgical cases. Never was there any lack of blood for transfusions: it came from volunteers, even though they were slowly starving.

Men at Study.

With the spring came proof "that surgeons were active even during the worst part of the blockade." Surgical conferences began in which men summarized what the winter's work had taught them. There were reports on wound treatment, conservation of blood, preparation of dried plasma, transfusions, treatment of alimentary emaciation, and a "detailed account of the biochemical changes in the blood of emaciated patients."

The first spring meeting was attended by only 150 doctors, but 400 surgeons attended the conferences held by the health department in September—"in spite of heavy gunfire and bursting bombs during the sittings, the hall was full all the time."

* Moss used by florists in packing and potting


Monday, Aug. 11, 1947

Medicine: Exciting Discovery

High blood pressure causes one-third of all U.S. deaths. Doctors have long considered it one of the most dangerous diseases of 20th Century civilization, and one of the least understood. They may have to modify the latter belief, for a group of British scientists have turned up what looks like a solid clue to the disease. Their discovery: high blood pressure seems to be due to a "short-circuiting" of blood circulation in the kidneys, caused by too much nervous excitement.

Crushed Legs. Like Sir Alexander Fleming's discovery of penicillin, the high blood pressure discovery was almost an accident. During London's 1941 air raids, doctors found that victims whose legs had been pinned under timbers or masonry for several hours sometimes died mysteriously of kidney failure. The puzzled doctors called this strange death "crush syndrome." To find out what a crushed leg had to do with the kidneys, Spanish-born Dr. Josep Trueta and four co-workers at Oxford's Nuffield Institute for Medical Research* began some blood-circulation experiments on rabbits.

They tied a tourniquet on a rabbit's hind leg, injected India ink or other opaque fluids into its arteries (to make the blood flow visible) and watched the results by X ray. The experiments soon solved the "crush syndrome" mystery: prolonged pressure on the leg arteries produced spasms of nearby blood vessels, which, among other things, blocked the normal circulation in the kidneys.

Starved Cortex. In the course of solving this puzzle, Dr. Trueta's research group happened on something with far more exciting possibilities. Physiologists have generally supposed that kidney blood circulation follows a fixed route, with most of the blood circulating through the tiny vessels in the kidneys' cortex (outer layer). The Trueta research showed that the kidneys have an emergency detour for the blood.

When circulation to the cortex is impeded, the blood bypasses the cortex and flows through bigger blood vessels in the kidney's medulla or interior (see cut). The cortex, starved for blood and oxygen, deteriorates. Results: 1) the production of urine slows or stops altogether; 2) the anemic cortex apparently secretes a substance (perhaps a hormone) that raises blood pressure throughout the body.

Following up this discovery, Trueta's investigators found that short-circuiting of the kidney cortex may be produced by many different stimuli. Direct electrical stimulation of certain nerves produced the same result; so did severe hemorrhages, heavy doses of certain hormones (e.g., adrenalin, pituitrin), and injections of the poison secreted by staphylococcus germs. All of these stimuli, the investigators decided, activate nerves which constrict the kidneys' blood vessels and divert the blood flow from the small vessels in the cortex to the larger ones in the medulla. Lack of blood in the cortex, in turn, raises blood pressure (an automatic adjustment of the body trying to force more blood intp the cortex).

Emotional Storms. Doctors have long been aware that certain types of hypertension (high blood pressure) are connected with kidney disturbances. They have also observed that anger or other emotional storms may raise blood pressure. What the Trueta group demonstrated was the physiological chain of events that leads to hypertension. And they showed that the hitherto unexplained form of high blood pressure known as "essential hypertension," which accounts for 95% of all cases, stems from the kidneys.

But the kidneys are only the trigger. What pulls the trigger? The Trueta group's guess: shocks to the nervous system, arising either from injuries or emotional stresses and strains.

Reporting their findings last week in a book published in Britain (Studies of the Renal Circulation; Blackwell Scientific Publications),* Trueta's group hopefully declared: "We believe that [the primary factors causing high blood pressure] will eventually be found in the central nervous system, even in the human mind itself, and that with their discovery will come a complete understanding of the condition known as 'essential hypertension,' affording a new hope for the victims of this disease of civilized man."

* A British counterpart of the Rockefeller Institute for Medical Research.

* It will be published this fall in the U.S., by Charles C. Thomas. Springfield, Ill.


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