Healing By Sculpture
A. E. POWLEY
AROUND a table in a café in the Sussex village of East Grinstead voices roared a song. The tune was from the hymn book but the words weren’t. They went:
“We are the Winco’s army We are his guinea pigs,
With dermatomes and pedicles,
Glass eyes, false teeth and wigs.
And when we get our discharge We’ll cry with all our might:
Per ardua ad astra
We’d rather drink than fight.”
The singers looked different from the rest of the people in the room but nobody took any notice. If I hadn’t been told what to expect the scene would have been surprising. For the dozen young men in Air Force uniforms who sang that song and others so lustily were men whom you mightn’t expect to find making merry in public. Some of them had cruelly disfigured faces; some had hands that looked like remnants; they were all hospital patients in the process of being remade by plastic surgery.
And I give you the scene and the song because they’re both significant in the story of how modern surgery and an equally important psychological conditioning can repair some of war’s most grievous injuries.
Since the internal combustion engine plays such a large part in this war, the proportion of burn casualties is higher than in the last. And a fair proportion of these are Air Force men. Therefore it is natural that one of the principal burn treatment centres in England should be largely a Royal Air Force affair, and that in it the Royal Canadian Air Force should have established its own Canadian-staffed wing. The Plastic Surgery Centre at the Queen Victoria Hospital, East Grinstead, was where I went to find out about the cure of men burned and maimed by fire.
There were a lot of wonderful things to find out, but at the outset I received the same earnest request from about half a dozen people. Each time it was something like this:
“PLEASE don’t go away and write a lot of stuff about the miracles of plastic surgery. We don’t do any miracles and it’s only harmful if people think we do.”
I promised, but if there are no miracles in plastic surgery, at least there are marvels.
Wing Commander A. R. Tilley, O.B.E.—the winco of the song—took me around the RCAF wing, of which he is commanding officer and surgeon. Ross Tilley has spent nearly three years at East Grinstead, in close association with the centre’s famous chief surgeon, Archibald Mclndoe. He moved into his own command when the RCAF wing opened in July, and his staff speak of his surgery with reverence. Incidentally,
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Tilley gets madder than almost anyone else at the word “miracle.” “It’s just plain straightforward surgery,” he says.
We were walking down a corridor when a room door opened and out stepped a youth wearing a sergeant’s stripes and an air gunner’s wing.
“Hi, Sandy, how are the hands?” said the winco.
“Good enough for 10 rounds with you any day now, sir,” said Sandy; then, after feinting a couple of body punches, he unclenched, as far as they would unclench, a pair of hands whose unnaturally thin fingers, abbreviated and without nails, were permanently bent inward at the second joint, like claws.
But it wasn’t his hands it was his face that I noticed first. Obviously it had been a badly burned face. It looked like a slightly oversize mask, on which none of the features matched very well.
Along the corridor came a stretcher cot wheeled by
two orderlies, who joked with the bandaged man lying on it. They went through a door labelled “saline baths,” and we went on into the ward. Some of the patients lay or sat propped up in bed; one moved about in a wheel chair; others strolled around or sat talking on the edge of other people’s beds. It was illuminating to see how the winco greeted them and they greeted him. Obviously the people here were all friends. A lot of these men had facial disfigurements too and were in various stages of reconstruction.
But I was worrying about Sandy. “Will his face always be like that, or is there more that you can do?”
The winco laughed. “Oh, we’ve got a lot more to do for him; more than we’ve done so far. He’s got a new nose and lower lip and new eyelids—four of them. But we’ve got some more to do on them, and then we’ll do some grafting to replace some of that scar tissue on his cheeks. And some of it will soften in naturally.
We’ll have him here for quite a time yet—but look here.”
He led the way into an office and took a file of photographs from a cabinet. Every patient at East Grinstead is photographed when he’s admitted, and thereafter once a week, as well as before each operation. The two VAD nurses who look after this take 1,000 photographs a month between them.
The picture the wing commander handed me was Sandy’s, taken when he was admitted. It was something to make you gasp. The mask that Sandy now wore had been put on over practically nothing. But if it was horrifying it was also reassuring. If a job of surgery not yet half-finished had achieved so much, Sandy was going to be well-mended.
I asked what chance there was of his new face, when finished, looking like the one he’d had before he was burned, but Wing Gommander Tilley shook his head. “We can’t make a new face identical with the old one,” he said, “although we can generally make it recognizable. Sometimes, though, we have to be content with making it a reasonably presentable face.”
The winco showed me the first pictures of other patients—sometimes heads and faces so swollen and featureless that it didn’t seem possible that they could belong to living people. But the subsequent pictures all showed progressive improvement.
We met several men with hands like Sandy’s, the fingers bent inward at the second joint, and I asked if they couldn’t be straightened out.
“Yes, but why?” was the answer. “We want them the way they are. That’s the way we set them. If the joints are gone a man’s fingers are of no use set straight out. He can’t close his hand. And they’re no use clenched; he can’t open his hand. But when they’re in mid-position he has a perfectly useful hand that can do anything required of it.”
“Function is more important than appearance,” Wing Commander Tilley remarked later. “So the main job is to restore function as far as possible.”
That was when I asked him for an elementary explanation of the purposes of plastic surgery. He gave it in those two sentences and the following two;
“All burned areas tend to contract. The problem is to replace them with normal skin, by means of skin grafts, and overcome the contracture while doing it.”
Two Kinds of Grafts
ALL SKIN grafts come under two headings—free IiL and pedicled. (A dermatome, in case you’re curious about the song the boys sang, is an instrument for taking skin grafts.) And it should be remembered that skin grafts can be taken only from the patient’s own body. No satisfactory method of transferring grafts from another person has yet been evolved.
The free graft is the simpler kind. It consists of detaching skin from one part of the body and sewing it onto another. But where there has been much destruction of tissue there will have to be a pedicled graft; that is, one that will be fed by its own blood supply while it is growing in. This means that the graft will have to remain connected with the part of the body it comes from while it forms its permanent attachment to its new location. Thus a man may spend weeks while a flap of skin and flesh, lifted from his shoulder, but still attached to it, grows in to his face.
When you’ve seen some of the wonders that plastic surgery does there is nothing gruesome about the operating room. It’s a fact, told me by surgeons and patients alike, that the boys at East Grinstead have no dread of operations at all. They take a keen and detailed interest in what’s going to be done to them next, and frequently a patient is allowed to watch a fellow patient’s operation. That’s not merely to gratify curiosity; it assists an objective attitude.
Pedicled grafts are likely to be weird-looking things while they are growing. And very frequently they have to be made through intermediate stages. There was a photograph of one man with a strange tubular arrangement of skin and flesh drawn up across his face from shoulder to forehead. It looked like a monstrous nose—and actually that one graft provided the patient with a new nose and chin.
These photographic files, by the way, are indispensable as records. “You can’t describe a burn in words,” says Wing Commander Tilley. “You’ve got to have a picture of it if you want a description that means anything.”
Few Recall Pain
FEW if any of the airmen who come to East Grinstead have any particular recollection of acute pain in the flaming moments that gave them their injuries. Apparently such moments have their own
anaesthesia, or at least provide their own amnesia. Every care and ingenuity is exercised to minimize the pain of new and unhealed burns. The nurses and orderlies, experts in deft gentleness, know the nearest possible to painless way of cleaning a newly admitted patient’s burns. The dressings that go on after cleaning are coated with vaseline so that they won’t stick. The removal of body dressings is especially ingenious; the patient is put in a bath—at blood temperature, or only a degree or so above, and saline to match the salt content of the blood so that the water won’t sting—and the bandages simply float off.
But emphatically there’s more at East Grinstead than expert surgery and nursing. You’re aware of that as soon as you get to the place and you are kept aware of it in nearly everything you see. By the easy, friendly relations between staff and patients; by the obvious comradeship of the men; and by scenes like the one in the café when the men were singing about dermatomes and pedicles.
For the explanation of this I went to Dr. Mclndoe. A. H. Mclndoe, C.B.E., F.R.C.S., is one of the most famous plastic surgeons in the world, as well as consultant to the Royal Air Force and chief surgeon and directing genius at East Grinstead.
“Well,” he said, “suppose you take the surgical part of the job as read. Naturally it’s basic, but it’s so basic as to be almost incidental. The other all-important thing is maintaining the morale of badly injured men while they’re being treated and cured, so that they’ll be properly equipped, when they leave, to go back either into the service or into civil life.
“So we had to do two things for a start.
“The first was to establish a hospital that would be as different as possible from what an institution generally is. We wanted one that would have a bracing effect on a man’s morale, instead of the usual effect of a long period of hospital treatment and operations — and there’s nothing more demoralizing and debilitating.
“The second thing was, having established such a hospital, to organize it so that life would go on within it the same as outside. There must be none of the isolation from the world that hospital life can mean. The men must not merely exist from operation to operation. Rather, operations must be more or less incidental interruptions of a life as nearly normal as possible.
“And we’ve found that however grievously injured a man may be, we can maintain his morale and his readiness to get back into life—by keeping him in it. By never letting him lose the idea that he is an essential member of society.”
That is why, for instance, the East Grinstead patients don’t wear hospital blues. Blues set a man apart from his fellows. Wearing them he can’t be served a drink in a pub. But it’s been over a pint of ale, in the easy atmosphere of an East Grinstead pub, that many a man who was afraid to be seen, and almost afraid to live, has made the initial discovery that he still belongs acceptably to the world.
Tribute to Grinstead
I’VE BEEN told that East Grinstead has interesting historical associations that fit its picturesque streets and generous sprinkling of Elizabethan houses. But it surely cannot have a better claim to fame than the way it has helped hundreds of disfigured and partly maimed men back to self-confidence, principally by learning to take them for granted.
“It was a little difficult at first, five years ago,” said Dr. Mclndoe. “Some people didn’t like the idea of our men walking around the streets looking like frights. But by education and persuasion, and the people’s own good will and common sense and sympathy, we got them to play. Now we have an intelligent community giving effective and largely unconscious help to our scheme; a man can walk down town with a face that looks like the back of a cab and nobody pays the slightest attention.
“And that,” he went on, “is one of the reasons why after three months or so a badly disfigured man has got over his three worst fears—his fear of living, his fear that he’s quite the worst-looking thing that ever happened, and his fear that no girl will ever look at him again.”
But there are larger fields to conquer than the conditioned and co-operative local community. “We have to throw them into London,” says Mclndoe. “And when we do we don’t take them down back streets. We do it in style.”
The first trip to London is done in parties of 10 or a dozen. “We probably take ’em to a good musical comedy. And the seats are right in the front row, where everybody can get a good look at them and Continued on page 22
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they can get a good look at everybody. And there’s a bang-up party after the show.”
Later, men go up to the city in pairs or alone—and that is a venture that calls for moral heroism. Even in an unconcerned and civilized city like London there are people who will stare, or look horrified, or, worst of all, pitying. These men are the same normal individuals that they were before accident altered their looks; all they ask of the world is to accept them as such; and the thing they dread and resent most is anybody’s pity.
So much for the basic problems of morale maintenance. But East Grinstead looks beyond them, to find practical ways of fitting men back into life after they leave the hospital. Hence the factory unit.
This is the first industrial therapy unit ever established in an English hospital. It consists of a room with 26 work places, where patients make small parts for precision instruments. It was installed by a big instrument making firm, which pays the patients for their work at union rates. Working conditions are as close to reality as possible, and while the work is voluntary and the daily stint usually only an hour and a half to three hours, anyone going in for it must keep regular working hours. .
I remarked to Dr. Mclndoe that for a surgeon he seemed to have a lot of other occupations. He agreed.
“My job,” he said, “isn’t simply to do a piece of fancy sewing on a man’s face. What’s behind a man’s face is more important than what his face looks like. My responsibility begins when a man is injured. It ends when he’s once again an economically responsible member of society. And until that time I haven’t succeeded.”
There was a point I’d heard discussed in Canada, regarding those men whose injuries were so severe as to make it problematical whether their new faces would be really good-looking, or even recognizable. A rebuilt face, while a triumph of surgery, might be a shock to a man’s family and friends, who had no idea of the original injury and hadn’t seen any of the process of rebuilding. Wouldn’t it be a good idea if these men, instead of waiting in England until the job of rebuilding was done, were to be brought home some time during the process and have the work finished in one of the service plastic surgery centres now operating in Canada? Then their families would have a better
idea of the surgical problem and be less liable to disappointment.
I put the question and was told that while anyone who wanted to be sent home before the completion of his treatment was encouraged to go, only two men had ever asked. The patients prefer to stay and be fairly well restored before going home. “And I think their views are entitled to even more consideration than those of their relatives,” one doctor remarked.
For the benefit of families and friends it should be said that the Canadian boys at East Grinstead are in an ideal environment for recovery. The RCAF wing is a piece of Canada set down in the lovely Sussex countryside. It’s the last word in comfort, convenience and efficiency, and every member of its all-Canadian staff is hand-picked. All the amenities of the parent hospital are available to them.
As in the rest of the hospital there are separate wards for officers and other ranks. There are individual rooms, but they are allotted in accordance with need, not rank. The up-and-walking patients of all ranks share the same dining room and common room and live together without distinction.
“They’re nearly all air crew, and got their injuries at the same kind of job, and they wouldn’t want it any other way,” said Wing Commander Tilley. “We’ve had some very senior officers here as patients too—and they’ve liked the arrangements as much as everybody else.”
This absence of rank distinction is apparent in the wording of the plaque which hangs just inside the wing’s main entrance. It reads:
“Dedicated to the gallant young men of the Royal Canadian Air Force whose wounds have brought them here, and to the doctors and nurses who have cared for them, this building has been erected by the people of the Dominion of Canada.”
After the war, when its last casualty and its Canadian staff have gone home, the wing will remain as a Canadian memorial to air crew, within the larger structure of the East Grinstead centre.
Three Typical Cases
I’d talked to the doctors and the nurses, but I wanted a patient’s summation of the business of being injured and made over. By this time I understood enough of East Grinstead to know that one could ask such questions without being either embarrassing or embarrassed. Three men, all in an obvious state of mid-repair, told me something of their feelings about it.
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The first was an English lad, whose Wellington had crashed and burned on an English hillside as it limped back damaged from a raid. He’d been the only one they got out alive, but all that his face needed was some fairly routine repair to nose, chin and cheeks.
“I don’t think I was ever depressed,” he said. “You see I felt so very lucky to he alive at all, and by the time I realized that I loolted pretty awful 1 knew they’d be able to fix me up anyway.”
The second was Sandy, whose present face, strange though it was, gave little enough clue to the terrible plight in which he’d come to the hospital. Sandy’s out in the world with a vengeance now, between operations; travelling about the country, meeting new people, and learning an unfamiliar trade. He told me, though, that the first three months after his crash had been a hell of pain and helplessness and near-despair. Rut the pain had eased, the first operations had given him the beginnings of a new face, and he’d found that he had something to hope for. “And I began to get my courage back,” he said.
The third was a young United States Air Force lieutenant, who walked about
the ward with his shoulders very square. He said: “Let me show you
something. It may answer your question,” and he went to the desk beside his bed. On the desk was a framed photograph of a very beautiful girl.
He looked at it. “That’s my wife,” he said. Then he opened a drawer of the desk and took out another photograph. “That was me—three days before the accident.”
For a moment, as he looked from one picture to the other, I thought it was going to be tragic, for they had been a marvellous-looking couple.
But he took out another photograph. It was from the hospital files—his admission picture—and it matched the worst I had seen.
“Will you look at that—and imagine how I felt when I knew I looked like that—and see what they’ve done for me already,” he said. “Is it any wonder that I feel grateful?”
No, lieutenant, it isn’t. And I hope that when you and your Canadian comrades get home, although your looks may be altered a little or a lot, your wives and families and friends will be grateful too. And that they’ll see you as you want them to; as they must; as the men behind the scars.