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.

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