ADVANCES IN PLASTIC SURGERY

Gisborne Herald, Volume LXXIII, Issue 21964, 7 March 1946, Page 5

ADVANCES IN PLASTIC SURGERY

MODERN HEALING LESSONSjOF WAR SURGEONS’ METHODS VARIETY OF PROBLEMS (By Rainsford Mowlem in a Broadcast in the 8.8. C. Overseas Shortwave Service.) Now that the war is finished and we won't be confronted with new And dreadful injuries inflicted by the latest discoveries of science, we can look back and see what advances we have made. I want to talk particularly about plastic surgery, the name given to that particular specialty which deals with injuries and losses of the soft tissues covering our bodies. Of course advances in this field are not confined to it. They may often have arisen from some other special branch and they may be more important to others. That is at it should be, for no specialty is isolated, and each of them is directed, with the others, to the early and complete restoration of the patient to health.

So let me go back to the beginning, just over six years ago, we were busy in the out-patient department and wards with the ordinary routine of treatment and teaching. We were dealing with familiar problems babies with congenital defects, such as cleft lips and palates, or with any of the various deformities with which any one of us may have the misfortune to e born; children suffering from the accidents of youth; scalds and lacerations, and adults hurt by the machinery of their work places, by the traffic of our roads or by disease. Basic Requirements

It was true that we had been asked by the Ministry of Health to choose country hospitals and to provide lists of the basic requirements needed to equip them as plastic surgery centres in case of war. We had done that, and yet, in spite of the inevitability of it all, I think we tried to believe that somehow the worst would not happen.

By midday of September 3 it had happened, and by the afternoon of the same day most of us were out at the hospitals which for the next six years were to be our greatest worry. "We” were teams of surgeons, dental surgeons, and anaesthetists, together with all those other people who make and run a hospital, the nurses, the radiographers, the bacteriologists and chemists. the masseuses and the cooks and porters. Warned About Bombing The buildings were there, too, but they had been built to house patients suffering from mental disease and they did not have much in common with the sort of place in which we could be expected to cope with what was anticipated. We'd been warned that London would probably be bombed (that’s why we were twenty miles out), and that we were to expect casualties on a scale that, had they materialised, would have been overwhelming; and there we were with the few instruments we’d brought with us and nowhere to use them. The next few weeks were a rush to transform our requisitioned buildings. We had the unstinted help of the original staff but it must have been very galling for them to see their hospital almost wrecked in an endeavour to try to fit it for its new purpose. Temporary buildings were rushed up, to provide workshops lor dental mechanics, saline baths for out burns and recreation rooms for convalescents. Beds were crammed into every available space and operating theatres were improvised of barbers’ shops, bathrooms and sickrooms. Operating room lights were hurriedly manufactured and hung. Steam and water and gas was piped into all sorts of previously unexpected places, while all the time we waited for the siren which would herald the big raids on London. Fortunately, it did not come and so. before the end of September, we took in our first patients. They came from the waiting lists of our hospitals in town but their numbers were soon swelled by the inevitable casualties caused in army training. By the end of 1939, we had shaken down into teams and we had all our promised equipment. Quiet Period in Early 1910

The relatively quiet period continued well into 1940 and was a godsend in many ways because the new units were much bigger than our peacetime centres and so we had new colleagues and staff who were meeting for the first time. We soon learned each other’s likes and dislikes, and worked out methods which would allow each of us the fullest possible scope without interference with the others. It will be pretty obvious that, say in the case of an extensive facial injury, the problem may well concern the brain surgeon and the eye surgeon as well as the dental surgeon and plastic surgeon. Now during this time we helped in the training of teams of surgeons and dentists for the British, Australian, Canadian. South African, and New Zealand armies as well as for the R.A.F. and the Navy. Later on, we met and exchanged experiences with many men from the United States of America. Treating Serious Burns

The sort of injury with which we were confronted varied with the stages of the war and in each period we made some advances. The summer of 1940 brought the Battle of Britain and with it came the serious burns. Pilots were exposed to flaming petrol fanned by speeds of 300 m.p.h. Their hands and their faces bore the brunt of the damage and we soon found that our peacetime methods of burn treatment —which might well have been satisfactory for a scald—were useless. The familiar statement “One of our pilots is safe’’ was not much consolation if we could not rapidly carry his repair to a point tha.t would let him get back into the air. Well, what we really learned was that there isn’t any one method of treatment which is always .the best. There isn't even one which is the ideal for the same patient throughout the whole course of his recovery, and when .that lesson was learned the problem became less complicated. Of course we were given a much better chance of success bv the work done by the resuscitation experts. They not only saved lives which would otherwise have been lost but .they counteracted the. shock of the lesser burns to such an extent that repairs could be commenced much earlier than had ever before been possible. Use of New Drugs

About this time we had found out how to use the sulphonamide group of drugs, of which M. and B. is probably the most familiar. With these drugs we could control infection in the burnt area and this meant not only keeping

the patient fit but also the possibility of early operation. It also doubled our chances of a successful result when we did operate. This in itself was a veiy major advance and we owe it to the work, firstly, of the British chemists who produced the drugs and second to the great numbers of surgeons and physicians who worked to find the best i.thods of using them.

Dunkirk, and later on, the bombing of London brought us entirely different problems. All injuries from high explosives tend to be much the same, though in civilian bombing there is the hazard- of flying glass. In fact it may be no exaggeration to say .that bad there been no glass in London the casualties would have been about half as many as they were. This glass problem was with us until the last rocket had fallen. The later phases of the war produced bombs with such a high blast that, at .the end. injuries from glass were perhaps even more serious than in the early days. Sometimes a few large fragments made deeply penetrating wounds but more often the glass was shivered into thousands of tiny fragments which splashed the patient from head to foo.t. This was dangerous to the eyes, and caused hundreds of small wounds all over the body. Even apart from glass, the exposed face and hands tend to suffer serious damage and it is ouy job to carry out the necessary repairs. Adjusting racket Bones

First of all we had .to be sure that the skeleton of the face was undamaged. When i.t is damaged, toe broken bones must be replaced and fixed in the correct position as soon as possible. This is the equavalent ot having a broken limb bone se.t and put in splints, but in the face there are so many special structures, such as Hie eyes and the nose and the teeth, that it is essential to be correct in replacing bone, within extremely small limits. It is often necessary, therefore, to have the co-operation of a dental surgeon to prepare and fix tiny splints to the teeth so that .they can be firmly locked in correct relationship to each other and thereby hold the bone in which they are growing in good position until it joins up.

When this foundation has been laid there comes the repair of the face itself. If no tissue lias been lost the problem is very much like a jigsaw puzzle. Every fragment must go back into its correct position and be held there with fine silk stitches. If skin has been ios.t i.t is immediately replaced by a graft from elsewhere on the same patient. There are few exceptions to the rule that tissue losses have .to be made good from the patient himself. Loss of Chin or Nose If more than just the surface has been destroyed repair is a longer process. Loss °f, say, .the chin or the nose will mean skin and fat has to be transplanted from perhaps the chest or the belly to make good the defect, and tin; may mean several operations over two or three years. When this new .tissue is gafely in place, we shall have to replace tiie bone which should be underneath it. This process is now very different from what it was before .the war. The whole theory and technique has been altered and we can now use bone for rebuilding, say, a jaw or part of the skull with the certainty that the result will be good and that it will be obtained in a very few weeks. The new principle is also being applied to losses of bone in .the limbs and, if we can judge from the cases so far reported, it has about halved the time we used .to expect for such a repair to be complete. To a large extent, the application of .this new principle has been made ijossibie by .technical advances in the methods of fixing broken bone end? in .their correct relationship .to each other. Briefly, such methods depend on .the insertion of pins through the skin into the underlying bone so that a kind of remote control of the bone fragments is established, and in this particular field orthopaedic, dental and plastic surgeons have all had a hand. Casualties After D-Day D-Day came and from that time we were confronted with the .true casualties. Since just before that time we have had penicillin—another British discovery—.to help us. To some extent this new substance has replaced the earlier sulphonamide group and thus we now have many substances which will control most of .the infections which .tend .to restrict the range of our work or even to undo some of our results.

But now at last w e have done with the hazards of rockets and bombs, and casualties from the armies of occupation in Europe are no more than a handful of transport injuries. From Burma and .the Far East, we still have patients coming to us so that our units must go on for some time yet. We are a little too close .to see in true perspective how valuable our technical advances really are. Those which I have mentioned have stood the test of some years of intensive application, and on the whole, we can say .that the new methods and the new drugs are saving lives that would otherwise be lost and .that the repairs which are necessary can .be undertaken much sooner after injury. The methods of repair are much more speedy. This means that .the pa.ticnt will suffer less discomfort, will be a shorter time in hospital, and will much sooner be restored .to his maximum physical efficiency. The end of the war means that there will be no more battle casualties but there still remain many men, women and children, victims of battle or blitz, whose treatment is not yet complete. The accidents and injuries of peace are still with us, but our experiences of .the past six years mean that their chances of full recovery are much greater than ever before.