Mani M Mani MD.
Emeritus Professor, Department of Plastic Surgery
Kansas University Medical Center

John Fairbairn Binnie, a surgeon who trained in Scotland, was a professor of Surgery at the Kansas University Medical School and was the surgical leader of Base Hospital # 28 in Limoges France. Along with Lindsay S. Milne, Kansas City doctors staffed this base hospital for the six months it functioned. The patients were admitted into medical or surgical wards depending on the need for special service. Of the nearly 10,000 admissions in six months, 2,435 were classified as GSW. In addition to surgery for gunshot and shrapnel wounds, there was surgery performed on ear, nose, throat, and eye cases, and even many dental operations. During this phase of medical evolution in surgery and anesthesia, fast surgeons were considered the best surgeons.

Most of us understand that the word “Plastic Surgery” evolved in the 1930’s to describe a specialty that dealt with restoring deformities as part of birth defects and trauma in war and peace. The history of repair of deformities goes back to antiquity, the first records were those of Sushrutha in India. However it was WW I that brought the major advances in this field as a result of the enormous number of wounded soldiers and civilians in the “war to end all wars”. However, Dr. John Fairbairn Binnie, writing in the 1905 edition of his textbook, “Manual of Operative Surgery” in Part VII, Section IV under Unclassified Topics, names this specialty as “Plastic Surgery.” 

Title Page of John Binnie’s 1908 Classic, “Manual of Operative Surgery”

The photo album of Dr. Lindsay Milne who was second in command of the base hospital # 28 while it was in France shows a number of images of injuries sustained by soldiers in this war. We have selected a few of these photos to discuss what was done then and what has evolved from the knowledge gained over the last 100 years. It is impressive to realize that the surgeons, nurses, technicians, and others worked without man of the things we now take for granted. The ambulance service was minimal. There was no air evacuation. There was very little in the way of anesthetics, antibiotics, sophisticated laboratory or radiology investigations. The health professionals did the best they could do under the circumstances presented to them.

Most of the injured were taken to field hospitals for first aid, resuscitation, triage and transfer. Base Hospital # 28 was several hundred miles from the war front and there was a natural selection of who managed to get there after the injury. We can also assume that most of the soldiers were healthy and in a good physical state at the time of their injuries. We can also assume that the firearms used then were of lesser velocity than those used today. However trench warfare had its own problems and issues.

GSW Face

No. 1818, GSW right side of face is all we have in the history of this soldier. The picture shows a through and through injury going into the oral cavity. It implies that the skin, subcutaneous tissue, parotid gland, the facial nerve, and the oral mucosa are damaged and possibly the mandible and maxilla. There is no follow up picture and therefore we have to assume that the wound was primarily closed in layers. In many of the books from that era, there is mention of the use of salt solution for irrigations and Dakin’s solution as an antiseptic.
What would we do today? The ABC of trauma care will be the first step. The wound would be repaired under general anesthesia. We would spend time on irrigation and cleansing the wound. We would explore the parotid duct and look for facial nerve for injury. Parotid duct if severed will be repaired over a stent. Facial nerve repair will be done at a later stage but the nerve ending will be marked with a black suture for later identification. The wound would be closed in layers using absorbable sutures for the mucosa and deeper layers and a non-absorbable suture for the skin. A drain will be placed in the wound and the soldier will be given an antibiotic and tetanus prophylaxis.  Scar revisions and facial paralysis, if present, will be dealt with later.

Fracture of Sup. Maxilla

The cause of the fracture is not known. There is no external evidence of a gunshot wound.  Obviously the teeth have been wired and the outrigger used to prevent posterior displacement of fragments. This was the accepted form of management until about 30 years ago. The skull cap provided the anchor and the metal struts kept the maxilla secure. Today this will be managed by open reduction and with plates and screws holding the fragments in place.

GSW Left Hand

There is significant loss of skin and soft tissue. The tendons and nerves are exposed. The fingers are viable and so we assume that the blood supply is intact. Possibly the wound was dressed with gauze and bandages till granulations covered the exposed structures. One can assume that the exposed tendons became desiccated and had to be excised. Either the wound closed with contractures which would lead to major deformities or if it developed major wound infection it would have led to an amputation. Today we would do frequent wet to dry dressings and then consider the use of vacuum assisted closure (VAC). Interestingly the VAC concept was available in France at the time of WWI and it was used by Prof. Alexis Carrel.

Diagram of Carrel’s Apparatus for Continuous Wound Irrigation

We would consider coverage with local or a distantly procured flap to cover the open areas and secondarily consider tendon grafting and intense therapy to regain function of the fingers.

  
GSW face

 
GSW face

A remarkable series of images of a gunshot wound to the face. The wound must have been managed with irrigation, debridement, drainage and partial closure. Secondary repair has been done with fairly large sutures. The final picture shows remarkable healing. The scar is evident but this could be revised. We could not have done much better considering that this was a war wound that probably occurred in the trenches, far away from base hospitals, the time elapsed from injury to definitive treatment, lack of antibiotics and all that we take for granted. We need to salute all the people involved in the management of these patients under trying circumstances.

GSW Thigh

This appears to be a granulating wound and the injury must have been weeks or months previously. The wound looks clean. There is no necrotic debris or exposed bone or tendons. This could have been allowed to heal by secondary intention which would have taken months or years. Split-thickness skin grafting was known during this time period and it was called Thiersch graft. Dr. Binnie in his book describes the instruments used for cutting a graft and the methods of transplanting over the recipient site. It is hoped that this was the method of management in this case. Today, we would have done the same thing. We would prepare the wound and assure that the bacterial load was low. Under antibiotic coverage we would apply a split-thickness skin graft which would be meshed to assure a 100% take of the graft. We would follow through after complete healing with elastic compression to prevent edema and to provide support for the recently healed wounds. VAC may be considered to prepare the wound for grafting.