War Surgery and Medicine
IN order to make clear the problems which confronted reconstructive surgery during the Second World War it is necessary to trace very briefly the development of plastic surgery from the beginning of the First World War.
In the 1914–18 War the fighting was largely static and trench warfare predominated. The result was a great number of distressing and mutilating, but not fatal, facial injuries. It became imperative, therefore, that these cases should receive expert attention, and it was in response to this demand that modern plastic surgery was born. Consequently, it is not surprising that the plastic surgeons devoted almost all of their time to facial surgery, and as a result plastic surgery came to mean facial surgery.
During the period between the wars considerable progress in plastic surgery was made, and the scope was increased, particularly in the direction of re-surfacing large superficial wounds resulting from industrial and civil accidents, and in treating contractures produced by the spontaneous healing of burns. In spite of this, plastic surgery still remained to a large extent facial surgery. At the time of the outbreak of the Second World War the general public, and indeed many members of the medical profession, thought of the plastic surgeon as a facial surgeon only.
During the Second World War, however, the nature of warfare was different. It became mobile on the land, on the sea, and in the air. It was a war of machines, most of which were driven by inflammable fuel. The result was that many extensive and unusual burns were caused, and this created a demand for plastic surgery, both in healing the burns and in after treatment of contractures produced. The ‘Airmen's Burn’, which was so common during the Battle of Britain, caused extensive damage to the eyelids, with marked cicatricial ectropion. Urgent plastic surgery was necessary to save the eye from corneal ulceration.
Extensive burns were caused to the dorsum of the hands, and here again a great deal of work was produced for the plastic surgeon in re-surfacing these lesions and restoring function.1page 358
On the land, land mines, aerial bombs, mortar bombs, and shells produced severe injuries to the limbs, and often necessitated amputation. It was, in some cases, impossible to cover the amputation stump with skin and soft tissue, and healing resulted in a tender, unstable terminal scar. In order to make it suitable for the wearing of a prosthesis it became necessary to import a large amount of skin and subcutaneous tissue to replace the scar.
In other cases compound fractures of the long bones of the legs were associated with soft-tissue defects, and although they united and the skin healed, the scar was of an unstable nature and was continually breaking down when weight-bearing and active use was resumed. The result was that many of these adherent and unstable scars had to be replaced with skin and subcutaneous tissue.
In other cases damage to long bones was followed by non-union, and in these cases, before a bone graft could be successfully inserted, the scar in relation to the fracture had to be excised and replaced with a large flap of skin and subcutaneous tissue. It was thus possible for the orthopaedic surgeon to do his bone graft through healthy skin, and in tissue with a good blood supply.
Facial injuries, though still present, and often difficult, were not so great in number. We can say, therefore, that during the last war there was a vastly increased scope for the use of plastic surgical principles, particularly in the limbs. There are few injuries in war which have no civilian counterpart, and if the war has served no other useful purpose it has made it possible to treat in large numbers civilian cases of types which before were for the most part untreated.
It is clear, therefore, that while modern plastic surgery as practised during the Second World War included a great deal of maxillo-facial work, nevertheless the scope was widened so as to include all superficial soft-tissue injuries, and a good deal of this article deals with plastic surgical reconstructive work on the limbs.
It will be convenient at this point to give a brief review of the methods used by the plastic surgeon.
When tissue is not missing but only displaced, he removes the scar-tissue fetters which hold the parts in their incorrect anatomical position. They will then be free to move back to their normal relationship with other parts, and they are kept there by stitching until healing is sufficiently advanced.
If, on the other hand, there is tissue actually missing, the plastic surgeon must then assess the loss in terms of skin, subcutaneous tissue, muscle, bone and mucous membrane. For restoring the loss there are only four methods available. They are:
Local Flaps: These are flaps of skin, subcutaneous tissue, possibly muscle or even bone, produced in the neighbourhood of page 359 the defect and redistributed in such a way as to make good the initial defect without producing a second defect worse than the first. These local flaps are particularly useful about the face when the amount of soft-tissue loss is not great. They are also of some value in certain limb repairs and they always give the best possible result provided they are suitable for the repair. It is the method always thought of first.
Free Grafts: These are grafts of skin, bone, cartilage, fascia lata, and sometimes fat, which are removed from the body completely and then placed in their new position. They have no connection with the vascular system of the body during the period of their transfer and depend for their continued existence on rapidly acquiring a new blood supply in their recipient area. When suitable, these methods give quick results and are of great value.
Pedicle Flaps: When neither local flaps nor free grafts will do, pedicle flaps may be used. These pedicle flaps are flaps of skin and subcutaneous tissue as a rule and they require to have a connection with the vascular system at every stage of their transfer. They may be long and narrow, when it is convenient to turn them into a tube, or they may be short and broad, when they remain untubed. Their use is slow and tedious, but for some aspects of repair they are indispensable. They are used in facial repairs and are also of pre-eminent value in repairing the defects of the limbs where skin and subcutaneous tissue, and even muscle and bone, have been lost.
Prosthetic Appliances: Sometimes when none of these plastic surgical methods will give a good result it is necessary to use a prosthetic appliance. Artificial eyes are good examples of this, but use is also made of artificial noses, artificial ears and other parts—in some cases with extremely pleasing results.
These methods are, however, seldom used alone and are frequently combined together to produce the particular repair required in any specific case.
No attempt is made to give a detailed account of all aspects of the work done, but merely to give a brief account of general principles followed; wherever possible methods are demonstrated simply by means of illustrations and their captions.
[See Illustration Section following p. 374.]