Downloaded from http://jramc.bmj.com/ on September 15, 2015 - Published by group.bmj.com
J R Army Med Corps, 1916;26:340–5
Then as now managing military wounding is the management of polytrauma patients, albeit with an improved evacuation chain, which now allows soldiers to be evacuated to a Role 4 UK facility within 24 h.
This description of impression taking could have been written to describe the process that is performed in today’s maxillofacial laboratories, as the specialty has taken the techniques employed in World War I and merely applied modern material science. This article reports the cases of two soldiers initially wounded in May 1915 with their subsequent treatment in the author’s unit occurring probably in 1917. The paper discusses a novel technique of prosthetic reconstruction of facial injuries using two clinical case reports. The first case described an injury leading to loss of the right orbit and nasal bridge with communication into the maxillary antrum. The second case described a similar injury on the left side but with loss of the nose. No operative treatment was necessary for the first case but the second required surgical debridement and local skin and mucosal flaps to close the orbital/antral communication. Given the extensive tissue loss, the only reconstructive option was prosthetic repair. Up until this time rubber materials had been traditionally used but the likely problems encountered with their use would have included difficulties with colour match, tone and surface detail, weight and bulk leading to difficulties with retention, distortion causing poor fit and difficulties with cleansing. Wood describes the use of lightweight metal plates for such reconstruction. As well as being of lighter weight, which would improve comfort and retention, they would probably be more cosmetically acceptable. He describes the technique of their
construction in considerable detail. The first stage was to take an impression of the face and the surgical defect using plaster of Paris. This impression was then cast to produce a positive model of the dressed wound and the surrounding healthy tissues. He then describes a ‘sitting’ with the patient who was seated alongside the model during which the areas to be covered with the plate were sculptured in wax using classical sculpting techniques. From this wax model, an exact reproduction in copper was created using an ‘electrotyper’; the copper plate was then silver plated prior to enamelling. During a subsequent sitting the plate was painted with enamel (Figure 1) and the surface detail and tone were adjusted. He experimented with artificial hair for the eyebrows and eyelashes but discovered they were not sufficiently robust and ultimately used tinfoil splint and pigment for these areas (Figure 2). Retention of the plates was either with strong spectacles or for larger plates, an elastic band worn around the head, rather like an eye patch. These were Wood’s first cases and he describes these as ‘experimental in nature’ and ‘a good deal of time was spent in their making’. He estimated that subsequent cases would probably have taken about 1 month to construct. This technique probably created a better contemporary cosmetic solution for this problem. The plates were likely to have been lighter, less bulky and easier to clean. It is an interesting example of a medical problem viewed and solved by a nonmedic. It has probably led to the true artistic techniques of modern facial prostheses.
CONTEMPORARY MANAGEMENT The problems faced by these authors during World War I remain today. Despite the explosion of autologous reconstructive techniques including free tissue transfer and local flaps, three problematic areas remain for facial reconstruction following traumatic loss or cancer ablation for which prosthetic reconstruction almost always offers a better cosmetic result which are the orbit, nose and external ear, although costochondral grafting combined with tissue expansion is an excellent autologous option in the case of congenital ear loss. Modern elastomeric materials offer the ability to construct lightweight prostheses with excellent colour matching and surface detail and consequently have become the ‘gold standard’ material (Figure 3). Retention of the prosthesis remains a problem but is aided with modern adhesives, furthermore we now have the option of osseointegrated implants; titanium
Williams M, et al. J R Army Med Corps 2014;160(Supp 1):i51–i53. doi:10.1136/jramc-2014-000298
i51
Downloaded from http://jramc.bmj.com/ on September 15, 2015 - Published by group.bmj.com
Figure 1 Sgt Derwent Wood at work (by kind permission of Imperial War Museum). screws that screw into and integrate with bone and when in situ offer the option of various retentive couplings including magnets or clips which offers convenient removal and replacement and excellent retention. Other than this the technique for their construction is essentially as described by Wood almost 100 years ago (Figure 4).
Figure 3 Present day orbital prosthesis (by kind permission of Dr Neil Waddell, School of Dentistry, University of Otago, Dunedin, New Zealand).
The authors of this paper worked at the Third London General Hospital, Wandsworth within a ward specialising in jaw injuries. The ward was only open for 2 years from 1917 to 1919.1 There is no record of the number of masks made, but it is thought to be in the region of several hundred. Unfortunately, Captain Cruise and Captain Hastings were Territorial Officers and as such their records would have been destroyed in the 1920s, therefore, it has not been possible to glean any further information on their military surgical careers. However, a substantial amount of information exists about Sergeant Wood and as this paper largely focuses on his contribution warrants recalling.
Wood was trained as a classic sculptor in Germany, Glasgow and London, but as he was too old, at 41 years, to enlist for service at the start of the war he volunteered for hospital duties. It was through this, and his exposure to facial injuries, that led him to open a special clinic: ‘The Masks for Facial Disfigurement Clinic’ where it is estimated that several hundred casualties were treated using his techniques.2 His sculptures after the war included a controversial representation of ‘Crucified Soldier’ known as Canada’s Golgotha3 which led to diplomatic problems between Canada and Germany, together with the Machine Corps Memorial at Hyde Park Corner which was also controversial. Wood died in 1926 at the age of 55 years and his grave is at St Michael’s Church, Amberly, West Sussex.
Figure 2 World War I orbital prosthesis, tin plate (by kind permission of Dr Andrew Bamji, Gillies Archivist).
Figure 4 Impression taking at Sgt Derwent Wood’s unit (by kind permission of Imperial War Museum).
THE AUTHORS
i52
Williams M, et al. J R Army Med Corps 2014;160(Supp 1):i51–i53. doi:10.1136/jramc-2014-000298
Downloaded from http://jramc.bmj.com/ on September 15, 2015 - Published by group.bmj.com
Mike Williams, D C Tong, M Ansell Correspondence to Maj Mark Ansell, Department of Oral & Maxillofacial Surgery, Monklands Hospital, Monkscourt Avenue, Airdrie, Glasgow, North Lanarkshire ML6 0JS, UK; [email protected]
To cite Williams M, Tong DC, Ansell M. J R Army Med Corps 2014;160(Supp 1): i51–i53. J R Army Med Corps 2014;160(Supp 1):i51–i53. doi:10.1136/jramc-2014-000298
The original article can be found online as supplementary file. To view please visit the journal online (http://dx.doi.org/10.1136/jramc-2014-000298). Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed.
REFERENCES 1 2 3
(Author unstated). The reception of the wounded. The London territorial hospitals. BMJ 1914;2:518. Wood, Francis Derwent (1871–1926): Oxford Dictionary of National Biography. Oxford University Press, 2004. Beaverbrook Collection of War Art Canadian War Museum.
Williams M, et al. J R Army Med Corps 2014;160(Supp 1):i51–i53. doi:10.1136/jramc-2014-000298
i53
Downloaded from http://jramc.bmj.com/ on September 15, 2015 - Published by group.bmj.com
Mike Williams, D C Tong and M Ansell J R Army Med Corps 2014 160: i51-i53
doi: 10.1136/jramc-2014-000298 Updated information and services can be found at: http://jramc.bmj.com/content/160/Suppl_1/i51
These include:
Supplementary Supplementary material can be found at: Material http://jramc.bmj.com/content/suppl/2014/05/20/160.Suppl_1.i51.DC1. html
References Email alerting service
This article cites 1 articles, 0 of which you can access for free at: http://jramc.bmj.com/content/160/Suppl_1/i51#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
J R Army Med Corps, 1916;26:340–5
Then as now managing military wounding is the management of polytrauma patients, albeit with an improved evacuation chain, which now allows soldiers to be evacuated to a Role 4 UK facility within 24 h.
This description of impression taking could have been written to describe the process that is performed in today’s maxillofacial laboratories, as the specialty has taken the techniques employed in World War I and merely applied modern material science. This article reports the cases of two soldiers initially wounded in May 1915 with their subsequent treatment in the author’s unit occurring probably in 1917. The paper discusses a novel technique of prosthetic reconstruction of facial injuries using two clinical case reports. The first case described an injury leading to loss of the right orbit and nasal bridge with communication into the maxillary antrum. The second case described a similar injury on the left side but with loss of the nose. No operative treatment was necessary for the first case but the second required surgical debridement and local skin and mucosal flaps to close the orbital/antral communication. Given the extensive tissue loss, the only reconstructive option was prosthetic repair. Up until this time rubber materials had been traditionally used but the likely problems encountered with their use would have included difficulties with colour match, tone and surface detail, weight and bulk leading to difficulties with retention, distortion causing poor fit and difficulties with cleansing. Wood describes the use of lightweight metal plates for such reconstruction. As well as being of lighter weight, which would improve comfort and retention, they would probably be more cosmetically acceptable. He describes the technique of their
construction in considerable detail. The first stage was to take an impression of the face and the surgical defect using plaster of Paris. This impression was then cast to produce a positive model of the dressed wound and the surrounding healthy tissues. He then describes a ‘sitting’ with the patient who was seated alongside the model during which the areas to be covered with the plate were sculptured in wax using classical sculpting techniques. From this wax model, an exact reproduction in copper was created using an ‘electrotyper’; the copper plate was then silver plated prior to enamelling. During a subsequent sitting the plate was painted with enamel (Figure 1) and the surface detail and tone were adjusted. He experimented with artificial hair for the eyebrows and eyelashes but discovered they were not sufficiently robust and ultimately used tinfoil splint and pigment for these areas (Figure 2). Retention of the plates was either with strong spectacles or for larger plates, an elastic band worn around the head, rather like an eye patch. These were Wood’s first cases and he describes these as ‘experimental in nature’ and ‘a good deal of time was spent in their making’. He estimated that subsequent cases would probably have taken about 1 month to construct. This technique probably created a better contemporary cosmetic solution for this problem. The plates were likely to have been lighter, less bulky and easier to clean. It is an interesting example of a medical problem viewed and solved by a nonmedic. It has probably led to the true artistic techniques of modern facial prostheses.
CONTEMPORARY MANAGEMENT The problems faced by these authors during World War I remain today. Despite the explosion of autologous reconstructive techniques including free tissue transfer and local flaps, three problematic areas remain for facial reconstruction following traumatic loss or cancer ablation for which prosthetic reconstruction almost always offers a better cosmetic result which are the orbit, nose and external ear, although costochondral grafting combined with tissue expansion is an excellent autologous option in the case of congenital ear loss. Modern elastomeric materials offer the ability to construct lightweight prostheses with excellent colour matching and surface detail and consequently have become the ‘gold standard’ material (Figure 3). Retention of the prosthesis remains a problem but is aided with modern adhesives, furthermore we now have the option of osseointegrated implants; titanium
Williams M, et al. J R Army Med Corps 2014;160(Supp 1):i51–i53. doi:10.1136/jramc-2014-000298
i51
Downloaded from http://jramc.bmj.com/ on September 15, 2015 - Published by group.bmj.com
Figure 1 Sgt Derwent Wood at work (by kind permission of Imperial War Museum). screws that screw into and integrate with bone and when in situ offer the option of various retentive couplings including magnets or clips which offers convenient removal and replacement and excellent retention. Other than this the technique for their construction is essentially as described by Wood almost 100 years ago (Figure 4).
Figure 3 Present day orbital prosthesis (by kind permission of Dr Neil Waddell, School of Dentistry, University of Otago, Dunedin, New Zealand).
The authors of this paper worked at the Third London General Hospital, Wandsworth within a ward specialising in jaw injuries. The ward was only open for 2 years from 1917 to 1919.1 There is no record of the number of masks made, but it is thought to be in the region of several hundred. Unfortunately, Captain Cruise and Captain Hastings were Territorial Officers and as such their records would have been destroyed in the 1920s, therefore, it has not been possible to glean any further information on their military surgical careers. However, a substantial amount of information exists about Sergeant Wood and as this paper largely focuses on his contribution warrants recalling.
Wood was trained as a classic sculptor in Germany, Glasgow and London, but as he was too old, at 41 years, to enlist for service at the start of the war he volunteered for hospital duties. It was through this, and his exposure to facial injuries, that led him to open a special clinic: ‘The Masks for Facial Disfigurement Clinic’ where it is estimated that several hundred casualties were treated using his techniques.2 His sculptures after the war included a controversial representation of ‘Crucified Soldier’ known as Canada’s Golgotha3 which led to diplomatic problems between Canada and Germany, together with the Machine Corps Memorial at Hyde Park Corner which was also controversial. Wood died in 1926 at the age of 55 years and his grave is at St Michael’s Church, Amberly, West Sussex.
Figure 2 World War I orbital prosthesis, tin plate (by kind permission of Dr Andrew Bamji, Gillies Archivist).
Figure 4 Impression taking at Sgt Derwent Wood’s unit (by kind permission of Imperial War Museum).
THE AUTHORS
i52
Williams M, et al. J R Army Med Corps 2014;160(Supp 1):i51–i53. doi:10.1136/jramc-2014-000298
Downloaded from http://jramc.bmj.com/ on September 15, 2015 - Published by group.bmj.com
Mike Williams, D C Tong, M Ansell Correspondence to Maj Mark Ansell, Department of Oral & Maxillofacial Surgery, Monklands Hospital, Monkscourt Avenue, Airdrie, Glasgow, North Lanarkshire ML6 0JS, UK; [email protected]
To cite Williams M, Tong DC, Ansell M. J R Army Med Corps 2014;160(Supp 1): i51–i53. J R Army Med Corps 2014;160(Supp 1):i51–i53. doi:10.1136/jramc-2014-000298
The original article can be found online as supplementary file. To view please visit the journal online (http://dx.doi.org/10.1136/jramc-2014-000298). Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed.
REFERENCES 1 2 3
(Author unstated). The reception of the wounded. The London territorial hospitals. BMJ 1914;2:518. Wood, Francis Derwent (1871–1926): Oxford Dictionary of National Biography. Oxford University Press, 2004. Beaverbrook Collection of War Art Canadian War Museum.
Williams M, et al. J R Army Med Corps 2014;160(Supp 1):i51–i53. doi:10.1136/jramc-2014-000298
i53
Downloaded from http://jramc.bmj.com/ on September 15, 2015 - Published by group.bmj.com
Mike Williams, D C Tong and M Ansell J R Army Med Corps 2014 160: i51-i53
doi: 10.1136/jramc-2014-000298 Updated information and services can be found at: http://jramc.bmj.com/content/160/Suppl_1/i51
These include:
Supplementary Supplementary material can be found at: Material http://jramc.bmj.com/content/suppl/2014/05/20/160.Suppl_1.i51.DC1. html
References Email alerting service
This article cites 1 articles, 0 of which you can access for free at: http://jramc.bmj.com/content/160/Suppl_1/i51#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
