Authors: Richard Hollingham
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, providing 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.
Somewhere over England, 16 March 1944, 11.20 p.m.
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.
For the staff at East Grinstead, Bill Foxley was another typical
case. Most of the skin on his face had been vaporized. It was
distorted and ugly. His upper lip was burnt away, and the lower part
of his nose had melted. It hung like dripping candle wax, leaving his
nostrils flared upwards. His flesh was blistered and glistening, red
and raw. His right eye was little more than a slit, blinded by the fire.
His left was inflamed. Neither eye had brows or lashes. Worse were
his hands. They resembled swollen gnarled stumps, the fingers
fused together into a ball of flesh – a coagulated mass of tissue, bone
and muscle all melded into one.
McIndoe's task was to rebuild Foxley's distorted face and do
what he could for the airman's horribly damaged hands. Over the
next few months Foxley had a series of operations to gradually
restore his features. First, the surgeons took a tube of skin from his
shoulder to his nose. Three weeks later it hung from his cheek to his
nose giving his head the appearance of a jug. Finally, after a further
three weeks, they used the tube to rebuild his upper lip. Nine weeks
later the waltzing pedicle had done its job: Foxley's face had been
successfully rebuilt.
The results of McIndoe's operations were even more impressive
than Gillies' achievements during the First World War. Although
Foxley's face was still somewhat distorted, in only a few weeks
McIndoe had given him a new nose, lips and glass eye. The surgeons
had also managed to separate what was left of his fingers and partly
rebuild his hands.
But McIndoe was more than just a great surgeon; he was also
a great psychologist. The patients at East Grinstead did not spend
their days lying in bed; they were encouraged to get out and about.
After all, most of these men were young and fit. Until their injuries,
they had lived life to the full. Indeed, airmen were notorious for
their fast living, and keeping them cooped up would do nothing
to help them.