Blood and Guts Page 20
* A major advance in anaesthetics was made at Queen's Hospital. In 1919 Ivan Magill developed endotracheal intubation – the technique of passing a rubber tube through the patient's nose or mouth to allow the gas to flow directly into the trachea. This was not only a more precise means of delivering an anaesthetic, it also overcame a problem that had plagued reconstructive surgery. During the many hours surgeons spent leaning close to their patients' faces, and therefore the gas intake pipe, they often ended up breathing in the anaesthetic. It was not unknown for surgeons to fall asleep during operations.
Cutting the cartilage carefully, he bends it along the middle and then cuts away part of the central section to leave a narrow stem. He is left with a shape that resembles an arrow. It has a wide piece at one end, a narrow shaft and a bow-shaped tip. The wide part will form the bridge of the nose; the lower arrowhead will support the nostrils. Once Gillies is confident that the cartilage is the right shape, he slices open a flap of skin on William's forehead and transplants the cartilage under the surface.
When Spreckley recovered from the operation, he looked even more deformed than when he had first been admitted to the hospital. Instead of a flat forehead – which had been undamaged by the bullet – he now had a pronounced, arrow-shaped bump under his skin. The arrow was pointing diagonally upwards from the centre of his lower forehead towards the line of his hair. Gillies was, in effect, growing Spreckley a new nose in the middle of his forehead. Several weeks later, once Spreckley's forehead was fully healed, Gillies moved on to the next operation.
Cutting carefully, to leave the cartilage intact, Gillies slices a flap of skin from Spreckley's forehead. Making certain not to damage the pedicle, he twists the skin around to form a new nose. The cartilage keeps the structure from collapsing, although the resulting protrusion is hardly attractive. Beneath the angry, triangular-shaped scar on Spreckley's forehead, the new nose balloons out across the soldier's face. He has gone from having no nose to having a swollen, comic representation of a nose. It is horrible. Other patients joke that Gillies has transplanted a trunk in the middle of the poor man's face. Even the surgeon himself remarks in his case notes that 'the new, bloated columella stuck ahead like an anteater's snout and all my colleagues roared with laughter'. But the surgeon is far from finished.
The operations continue. The swelling gradually subsides and the pedicle is severed. Gillies closes the forehead scar and cuts away the excess tissue. He shapes the nostrils and defines the shape of the new nose, cutting or pulling in excess skin. By the time Spreckley is discharged his face is almost as good as new. The transformation is truly remarkable. Looking at him, you would never know that his nose had been rebuilt from his ribcage and forehead.
Spreckley was so grateful that he named his son Michael Gillies in honour of the surgeon who had restored his face.
The techniques Gillies had used for Spreckley were courageous, innovative and largely experimental. Although his operations were meticulous and his antiseptic techniques rigorous, there was always a risk that something could go wrong. The thing Gillies feared most was infection. If a wound became infected, there was little he could do.* Nevertheless, the cases that were coming to the hospital demanded that he try even more daring operations.
* There were no effective antibiotics until the discovery of sulphonamide drugs in the 1930s. By the end of the Second World War, military surgeons also had penicillin at their disposal, which dramatically cut the number of hospital deaths.
A STEP TOO FAR
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Second Lieutenant Henry Lumley of the Royal Flying Corps was barely recognizable as human. His face was no longer covered in skin – it had melted into a red shiny mask of thin epithelium. His eyes were wide sockets with no eyelids or brows. His nose was pulled upwards, his lips – if they could even be called lips any more – were wide and inflamed, and his mouth scarred.
Lumley had never seen combat. During his first mission, in the summer of 1916, his plane crashed to the ground in a ball of flames. Pilots were not issued with parachutes, so when the fuel tank caught alight, Lumley was trapped in a fireball of petrol. His face, scalp, hands, fingers and legs were all severely burnt. Some areas of his head were protected by his helmet and scarf, but no one knew how he had managed to survive. He might well have been better off dead. Lumley was admitted to Queen's Hospital on 22 October 1917. He had spent the previous year being patched up by various medical centres before he was finally referred to Gillies. It was the surgeon's toughest case yet.
Over the next month, Lumley was made as comfortable as possible while Gillies planned a series of operations. The surgeon proposed using skin from the pilot's chest to re-create his face. He would connect it with pedicles from the pilot's neck, and augment it with flaps of tissue from his shoulders. Gillies also decided to use paraffin wax and even attempt using a skin graft from another patient.
The first operation to prepare Lumley's face goes reasonably well and the patient seems to be making good progress. The second operation is about to begin. Lumley is anaesthetized on the operating table, his body propped up so his head is high. He has been stripped to the waist and his chest painted yellow with iodine. On the skin of his chest Gillies has drawn a face. There are spots for the eyes, marks for the nose and a long, narrow gap for the mouth. This outline will be Lumley's new face. It is a daring plan.
Gillies cuts and scrapes away the scar tissue from Lumley's face, leaving it horribly raw and red – blood seeping through to cover it in a glistening sheen. He then carefully cuts along the pencil lines on Lumley's chest until he has created a large (face-shaped) flap of skin. He lifts this up and places it across the airman's face, making sure to line up the holes for the eyes, nose and mouth. Then he begins to sew. Carefully and methodically, he attaches the new face across the remains of the old. When he has finished, he dresses the chest wound. The whole operation takes five hours. The surgeon is exhausted. The patient is terribly weak, his pulse faint. Now it is a question of waiting.
The first day after the operation, Lumley is definitely improving. The blood supply from the pedicles to the face seems to be working. On the second day, the graft starts to become infected. The doctors work desperately to stop the infection spreading. They try massaging the skin, pricking it with needles and cupping it (see Chapter 1) to increase the blood supply. By the third day, Lumley's new face is completely gangrenous. The pedicles from the shoulders are no longer supplying any blood and are gradually withering away.
By the tenth day, the dead skin has to be scraped off. Gillies records in the case notes that a foul discharge was expelled. The remaining pedicles are now only barely attached, and Gillies does what he can to save the blood supply. The doctors cleanse the wounds and spray them with paraffin wax. Later that day the patient is moved to an open-air hut in the hospital grounds.
Day fourteen and all the grafted skin has almost completely come away. For once, however, Gillies can report some good news. Lumley's chest seems to be healing and his face is no longer so infected. On 3 March Gillies starts a new treatment, using an ultraviolet lamp to encourage healing on the chest. By this time he has given up trying to save the face graft; he is now desperately trying to save the man's life.
Second Lieutenant Henry Lumley died of heart failure on 11 March 1918. Gillies had pushed plastic surgery to its limits, but with Lumley he realized that he had gone too far. Gillies wrote that his 'desire to obtain a perfect result somewhat overrode surgical judgement of the general condition of the patient'. He added, 'Never do today what can be honourably put off until tomorrow.'
Despite this terrible setback, Gillies achieved some fantastic advances in plastic surgery. Probably his greatest innovation was to adopt a Russian idea known as the tube pedicle. Instead of grafting exposed flat pedicles of skin which, as Lumley's case had proved, were prone to infection, he rolled the pedicle into a tube. This meant that all the delicate living tissue was enclosed within an outer layer of dead skin, providin
g it with a waterproof and infection-resistant cover.
But even the tube pedicle had its limitations. Skin could be moved only between adjacent sections of the body. A pedicle could be taken from the shoulder to the face, or the chest to the chin, for instance, but it was impossible to use the technique to take skin from the leg to the face unless the patient curled up in a ball for weeks on end. This made reconstructive surgery for a patient with burns across the whole upper body practically impossible.
As he was contemplating this problem, Gillies had a genuinely original idea; he called it the waltzing pedicle. What he would do was cut a pedicle from the leg and swing it upwards to attach it to the arm. Then, once the blood supply was established after a couple of weeks, he would cut the end still attached to the leg and swing it from the arm up to the face. By waltzing pedicles in stages to the site where they were needed he could safely take skin from anywhere on the body.
With the German push of 1918, more and more casualties were arriving at the hospital. Gillies worked all the hours he could while training up a new generation of plastic surgeons. Soon the wards were filled with patients covered in tubes of flesh; hoses of skin protruding from their legs, arms and faces; pedicles waltzing up their bodies.
Take the case of Private A.J. Sea, for instance, admitted to Queen's Hospital in June 1919. Since his injury, Sea had spent a year in military hospitals, but there was only so much the surgeons could do for him. In April 1918 he had been shot in the chin. The bullet had shattered his lower jaw, ripping away the floor of his mouth, taking the skin, bone and muscle with it. An ugly metal brace replaced his lower lip, keeping his jaw from falling apart. Sea's chin flopped uselessly, a few remaining teeth on his upper jaw stuck out at precarious angles. The twenty-three-year-old had to take all his sustenance through a straw. Like most patients who arrived at Sidcup, his eyes had the haunted look of a survivor who had endured more pain and suffering in a few months than anyone should experience in a lifetime.
The process to rebuild Sea's face was long and painful. The surgery was meticulously planned and the patient well prepared. The first operation was scheduled for August 1919, when a tube pedicle was cut from the soldier's chest and attached to his forearm. In October the end of the pedicle still attached to his chest was cut and attached to his missing chin, where it was held in position by straps. Six weeks later the surgeons took the end of the pedicle that was still attached to his arm and sutured it to his chin. The three operations were successful but, if anything, Sea's appearance was worse than ever. He now had a loop of skin passing beneath his mouth like a handle.
In March 1920 a large tube of skin was taken from his right shoulder. In September (more than a year after admission) a pedicle tube was taken from his neck, and work started to build the lining for the floor of Sea's new mouth. By December 1920 the private had undergone a total of ten operations, and in between he had received countless dressings, X-rays and examinations. By now Sea's chin was a dangling sack of skin covered in lines of stitches. Attached to it was a pedicle that passed around his neck and disappeared into the back of his shoulder. Another six operations followed over the next six months, until in August 1921 – two years after the surgery started – Private Sea was sent to a convalescent home to recover.
Sea was finally discharged from hospital in November 1922. His face was completely rebuilt. Although still disfigured, he had a mouth, jaw and lower chin. His broken teeth had been replaced by dentures, and his mouth had lips. Despite some scarring on his face and neck, he looked perfectly presentable. He would have only limited movement in his jaw, but at least he now had a jaw. Private Sea's life had been transformed. The last picture taken of him before he left the hospital even suggests that he was trying to smile.
In total, more than ten thousand operations were performed by the surgeons at Queen's Hospital. In all, only fifty men were lost – an incredible achievement given the ambition of the operations and the lack of antibiotics. Without surgery, many of the men might have survived, but with faces so damaged that their lives would have been a living hell. Gillies did his best to give his patients back their dignity.
Harold Gillies left Sidcup in 1919 to work on a definitive textbook of reconstructive surgery and set up a private practice. One of his first patients was recruited in an ethically dubious fashion while Gillies was staying at an inn during a fishing trip in Derbyshire. He noted that the daughter of the innkeeper was a 'comely lass' but she had a 'fearsome nose'. While he was out for the day, Gillies left a draft of his new book on the dressing table, open at the section about nose reconstruction. When he returned to London the girl contacted him and asked to be taken on as a patient. Gillies later admitted that it was a 'disgraceful' way of obtaining work, but at least the girl got a prettier nose.
Gillies was finally knighted for his services to surgery in 1930, although many people argued that the honour should have come years before. By that time he had accumulated piles of letters from grateful patients – from soldiers suffering with shattered jaws or burnt faces to children with harelips or cleft palates. Gillies' surgical skills had touched thousands of lives. He also had a reputation for kindness. He was known sometimes to waive the fee for those who could not afford to pay. The techniques he developed in Sidcup would be taken up by plastic surgeons around the world, and twenty years later would be adapted for a new conflict with even more terrible challenges.
MCINDOE'S ARMY
Somewhere over England, 16 March 1944, 11.20 p.m.
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Something had gone wrong and there was nothing the crew could do. The Wellington bomber was plummeting towards the ground. It dropped 300 feet in only a few seconds, then smashed into the earth, its tanks full of fuel. The explosion lit up the night sky and flames tore through the twin-engine plane. The Wellington's fuselage was covered in stretched fabric, and this burnt like paper, rapidly peeling away to reveal the metal skeleton underneath. Nineteen-year-old navigator Bill Foxley forced open the plastic dome* on top of the aircraft and began to scramble to safety. Remarkably, he was hardly injured; an incredibly lucky escape.
* The dome or 'astrodome' was usually used for navigation. It enabled the navigator to see the stars, and he could use a sextant to fix the aircraft's position. The dome also doubled as an upper escape hatch.
Then Foxley heard the wireless operator's cry for help. He could hardly leave his friend to be cremated, trapped within the disintegrating airframe. Foxley lowered himself back through the hatch. The heat was unbearable, a violent wall of scorching flame. With the adrenalin pumping and the aircraft falling apart around him, Foxley hardly noticed that the skin on his hands was being seared on the smouldering metal struts, or that the flesh on his face was being stripped away by the heat. He reached his comrade and pulled him out. It was only when Foxley was well clear of the aircraft that he realized how badly he was now injured. His whole body seemed to be on fire.
He was admitted to the Queen Victoria Hospital in East Grinstead, some forty miles south of London. The Queen Victoria was the Second World War equivalent of Gillies' Queen's Hospital at Sidcup, and most severely burnt airmen ended up there. The men's recovery was overseen by Gillies' cousin, the brilliant and charismatic surgeon Archibald McIndoe. His job was to rebuild the airmen – ideally so that they could return to battle – but at the very least so that they could live a normal life after the war. With aviation fuel burning at temperatures of around 700°C, the surgeon faced an enormous challenge.
At the beginning of the war the majority of casualties had been airmen in Hurricanes and Spitfires defending the skies over southern England during the Battle of Britain. It was a horrendously dangerous occupation, and almost every day pilots would fail to return from their missions. The high-performance aircraft were packed with fuel, so if they were hit, the pilots had a good chance of being incinerated.
Both types of aircraft carried fuel tanks between the cockpit and the engine, but the Hurricane also had a 25-gallon tank in
each wing. Unfortunately, a design flaw in the early Hurricanes meant that there was no fireproofing between the wing tanks and the cockpit. If a tank blew up, the cockpit became an oven surrounded by flame. Pilots were urged to keep the cockpit hood closed for as long as possible. Once they opened it, the flames tended to be drawn inwards. One airman described how he saw the dashboard melt and run like treacle before he was able to haul himself clear. Unlike in the First World War, at least these pilots had parachutes. However, bailing out into the English Channel was not a pleasant prospect because the icy salt water stung their wounds and hypothermia quickly took hold.
As the war progressed and the Allied raids on Germany intensified, more of the casualties were from bomber crews. There was a never-ending stream of new admissions to East Grinstead. Injuries ranged from shrapnel wounds to fuel burns. One patient was even admitted with frostbite. The rear door of his Lancaster had been blown open and his fingers had been frozen to the fuselage in his efforts to get it shut. To reconstruct these airmen, McIndoe had adapted and refined the techniques developed by Gillies during the First World War.
By 1944 the procedures were well established, the hospital well equipped and the staff well versed in caring for the victims of severe burns. Patients were immersed daily in specially designed saline baths to prevent infection and help their wounds to heal; new ways had been developed to deliver anaesthetics during the increasingly long and complex operations; and by the end of the war patients were being treated with penicillin. But, above all, McIndoe relied on the waltzing tube pedicle.
Ward Three of the East Grinstead hospital was bright and clean. There were fresh flowers on the tables, but nothing could disguise the nauseating smell of burnt flesh. Visitors, already desperately trying to cope with the visual onslaught, would frequently gag on the acrid stench. The beds were arranged in two long rows, and walking past them you could see the various stages of reconstructive surgery. Some patients were swathed in bandages, some had slings, but most had faces hung with pedicles – long hoses of skin that would soon be noses or jaws, lips or chins.