Archives of Facial Plastic Surgery (September/October 2011, Vol. 13, No. 5)

In his path-breaking book Stigma: Unlike mental illness, or a criminal record—which might well afford opportunities for passing in public situations—facial disfigurement is highly visible in most cultures. Dark glasses, for example, can signify and indeed draw attention to visual impairment, while at the same time concealing any visible deformity or difference. I will spare you the sight of my face, the mask declares. Photograph of Rifleman E. Moss wearing a prosthetic plate attached to spectacles. How would one begin to reconstruct the experience of stigma from stoicism and silence?

Rather than attempt to answer this very difficult question which may well be unanswerable , I have taken a different tack, focusing on the rhetoric and visuality of facial injury in wartime Britain: Despite the considerable literature on the First World War and the male body—much of it inspired by Joanna Bourke's brilliant Dismembering the Male —the male face has remained absent from, or at best marginal to discussions of masculinity and suffering.

Innovations in reconstructive surgery and prosthetics were also part of the war's physical and medical legacy, which is why Derwent Wood is such an important and intriguing figure. In his case, the encounter between art and medicine was largely accidental. For him, and for many of his contemporaries, art had the potential to overcome the loss of identity associated with facial injury, and to humanise those whose bodies bore the proof of war's essential inhumanity.

Several colleagues have provided help and inspiration along the way. I am also very grateful to Andrew Bamji at the Gillies Archives for responding so generously to my requests for images and information. Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide. Sign In or Create an Account.

Close mobile search navigation Article navigation. The Anatomy of Aversion. The Art of Appearance. Summary During the First World War, the horror of facial mutilation was evoked in journalism, poems, memoirs and fiction; but in Britain it was almost never represented visually outside the professional contexts of clinical medicine and medical history. View large Download slide. London Metropolitan Archives, Clerkenwell, London.

The Times History of the War. Plastic Surgery of the Face: Observations of an Orderly: Re-Arming the Disabled Veteran: Materiality and the Human Body in the Great War. Bourke , p. Harold Gillies' surgical team had performed 11, major facial operations by the time the war ended. Pound , p. Bamji in Cecil and Liddle eds , p. Albee was famous for revolutionising bone-grafting techniques in orthopaedic as well as facial surgery. Tonks , n. On Tonks' portraits, see Biernoff and Chambers For a discussion of the politics and aesthetics of trauma in Weimar Germany, see Fox Published retrospectively in annual volumes, The Times History of the War is the most authoritative account.

See Callister , p. Gillies Archives image collection http: In the exhibition Future Face , curated by Sandra Gilbert at the Science Museum in London October —February , Tonks' drawings of mutilated servicemen were used to foreground the absence of the disfigured face from traditional portraiture.

The Anatomy of Aversion

Faces of Battle , for example, presented graphic documentation of facial injury alongside interpretive textile sculptures by the artist and curator Paddy Hartley. Although responses to the wounded and disfigured face tend to emphasise visual aversion, an idealised feminine gaze and touch surfaces in this literature as well. A woman's touch—that of a nurse, wife or even a stranger—could transcend the dehumanising and emasculating effects of mutilation.

See Biernoff in Pajaczkowska and Ward eds , pp. Macdonald , pp.

1. Sense: A Collection of Short Stories (University of Essex Graduates Book 1)?
2. Recommendations for the Use of Leeches in Reconstructive Plastic Surgery.
3. Well Done, Those Men: memoirs of a Vietnam veteran.
4. Rhetoric of Disfigurement in First World War Britain | Social History of Medicine | Oxford Academic.
5. St Antonias Return.
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Muir , p. Biernoff in Pajaczkowska and Ward eds On developments in prosthetic limb technology and attitudes towards disabled servicemen during and after the First World War, see Cohen ; Guyatt ; Koven ; Bourke , pp. Gilman , p. Mitchell in Smith , p. Quoted in Bamji in Cecil and Liddle eds , p. Kristeva , p. Winter , pp. In this sense, the surgical and prosthetic reconstruction of faces could be seen as continuous with the broader tendencies Winter identifies in visual and material culture.

Liddle Collection, University of Leeds. The essays are catalogued as Wounds, Item Written for an education class. See Millar , p. Best was a Private in the 2nd Battalion Royal Scots and was wounded in the cheek at Ypres in September after only a few days of action. He also edited Happy-Though Wounded , a fundraising publication with contributions from staff and patients at the 3rd London General.

Muir , pp. The stigma of syphilis a disease for which there was no reliable cure until probably accounts for the particular horror of the missing nose. Table of war pensions for physical injury, Ministry of Pensions Leaflet , c. Muir's description of the blind and partially sighted patients at the 3rd London General Hospital suggests that loss of sight was considerably less horrifying certainly for Muir than loss of appearance.

Albee , p. In The Times History of the War vol. It is not possible here to pursue this analogy with shell-shock, but it raises several questions deserving of further attention.

Did facial injury and shell-shock represent the loss of different aspects of identity or humanity? Might this parallel help to account for the relatively few images of shell-shock in the media, and its almost exclusively literary treatment? The residents of the Queen's Hospital were free to leave the estate during the day. Along the road into Sidcup there were reserved benches, painted blue, so that they would not have to sit next to members of the public.

See also Pound , p. The same story appears in the Morning Post , July The visit of the Queen and Princesses to an exhibition of toys, beadwork and woodwork made by patients at Sidcup is reported in The Times , 9 December , p. The Queen chose a small grey chimpanzee as a souvenir. McKenzie , p. The Canadian-born physician was celebrated as much for his sculptures of athletes and love of scouting as for his contribution to physical education and therapy.

Galsworthy in Howson ed. Guyatt , p. For a comparison of the treatment and experiences of disabled ex-servicemen in Britain and Germany, see Cohen Galsworthy , pp. Previously published under the title Recalled to Life , the quarterly journal for wounded servicemen acquired a broader remit under Galsworthy's editorship: Koven , p.

Quoted in Pound , p. Little , p. Pound , pp. Gillies and Millard , p. Albee also compared his work to that of the sculptor. See Albee , p. Additional biographical details are given in Crellin and Crellin See also Muir , p. Wood did, in fact, make at least one mask for a female civilian who had been treated for an extensive facial ulcer. Her case is documented in Wood , p. Film footage of Ladd at work in her studio can be viewed on the Smithsonian magazine website http: See also Romm and Zacher The Queen's Hospital, Sidcup, had its own masks unit.

See Crellin , p. Very few of the masks have survived. Thus, even after successful reanastomosis, secondary changes in the microcirculation can persist and prevent adequate outflow from being reestablished. Free flaps, pedicled flaps, and replanted tissues can survive arterial insufficiency for up to 13 hours, but venous congestion can cause necrosis within three hours. Medicinal leeches may be helpful in treating tissues with venous insufficiency by establishing temporary venous outflow, until graft neovascularization takes place [ 20 ].

In July , the FDA approved leeches as a medical device in the field of plastic and reconstructive surgery. A survey of all 62 plastic surgery units in the United Kingdom and the Republic of Ireland showed that the majority of these units uses leeches postoperatively [ 21 ]. The aim of these recommendations is to review the practical use of medicinal leeches in reconstructive plastic surgery by reporting our experience with leeches in cases of reimplanted digits and free-tissue transfers.

Once venous congestion has been identified and the patient has agreed to undergo leech therapy, it is important that the patient is informed about the benefits and potential risks of the treatment. There is a general consensus that antibiotic prophylaxis for the Aeromonas bacteria, which are symbionts of leeches and which could lead to complications, should be initiated before leech therapy [ 22 , 23 ].

Aeromonas species are sensitive to second- and third-generation cephalosporins, fluoroquinolones, sulfamethoxazole-trimethoprim, tetracycline, and aminoglycosides, while Aeromonas is resistant to penicillin, ampicillin, first-generation cephalosporins, and erythromycin [ 16 , 24 — 27 ]. However, out of 21 isolates of Aeromonas species isolated from the water collected from the leech tanks, All isolates were sulfamethoxazole-trimethoprim susceptible, which was also used as a prophylactic antibiotic regimen of choice for leech therapy [ 28 ].

A regular surveillance to detect resistant Aeromonas species in medical leeches, by controlling the water in which they are kept, was suggested. In the Iowa Head and Neck Protocol [ 30 ], levaquin is administered before the first leech is applied to the skin and continued until 24 hours after leech therapy is discontinued. Use of narcotics and benzodiazepines should be minimized, because they could negatively influence leech activity, while the treated area should be photographed under the same light conditions using the same camera periodically to follow the progress of decongestion [ 29 ].

According to the literature, in most cases the medicinal leech Hirudo medicinalis was used. In some cases, similar results were also obtained with Hirudo verbana and Hirudo michaelseni [ 17 , 31 ]. Using mitochondrial sequences and nuclear microsatellites, Siddall et al. Leeches should be purchased from recognized leech producing companies, where they are kept in appropriate farms and fed artificially with animal blood. In addition, leeches purchased from recognized leech farms are sufficiently starved prior to being sold and some of the leech farms have been approved by regulatory agencies.

Leeches, which were collected from a natural environment, should not be used for hirudotherapy. Leeches can survive one year or more without a blood meal. Therefore, it is recommended to keep a large number of leeches in the laboratory by changing the water once or twice weekly. A larger stone should be added into the container, which would help leeches during the process of shedding their integument.

When replacing leeches from one container to the other, the replacement water must be at the same temperature as the original. Approximately 8 leeches should be kept in 1 liter of water. Leeches should be handled gently by wearing nitrile or latex gloves, which would also prevent leeches from biting the health provider during maintenance of or treatment with leeches. Before application, leeches are thoroughly rinsed with deionized water.

The area to be exposed to leeches should be cleaned with sterile distilled water and ointments such as Doppler gel are removed. In general leeches should be applied on the darker spots of the reattached body parts or flaps. In the case of reimplanted fingers, leeches could be also placed on the region of the removed nail. For this purpose, the nozzle of the syringe is removed using a scissor or scalpel.

July 18, Issue of JAMA Facial Plastic Surgery | JAMA Network

The leech is placed in the barrel of the syringe and the open end of the syringe is placed on the area to be treated. When the leech starts feeding, the syringe is removed gently Figure 1. Leeches normally start feeding immediately, although in some cases the skin has to be punctured with a sterile needle so that oozing blood will stimulate the leeches to feed.

Pricking the site to be treated could also demonstrate whether there is sufficient blood-flow in the area. When the leech refuses to feed in a given place, the syringe is moved to the neighboring area, until an appropriate place is found as close as possible to the congested area. During feeding drops of clear liquid can be seen oozing from the leech Figure 2 ; this is the superfluous water in blood, which the leeches remove to concentrate the red blood cells in their digestive tract. During hirudotherapy the patient should be under permanent surveillance by a healthcare provider; leeches may seek other places to suck blood or after feeding may drop into the surrounding area.

In cases of intraoral leeching, the path to the oropharynx should be blocked with gauze to prevent leech migration into the more distal aerodigestive tract, and the perioperative tracheotomy is left in position to protect the airway [ 29 ]. Specially shaped glass containers can be used for this purpose [ 33 ]. It could be assumed that they are only attached but not feeding and should be replaced with other leeches or they should be transferred to other parts of the treated area.

The use of active swimming and larger leeches could be of help. Depending on the severity and the size of the congestion, 1—10 leeches are used for each treatment, although some authors recommend higher numbers of leeches. The degree of venous congestion is estimated from the percentage of violaceous color of flap skin pedicle, testing capillary refill, and color of the blood oozing from the bite site or after having been pierced with a needle. At the beginning of the treatment, the patient might need two or more treatments per day.

In the Iowa Head and Neck Protocol [ 30 ], leeches are applied every 2 hours. The number of treatments per day depends also on the bleeding of previous bite sites. In cases where the bleeding stops shortly after the leeches detach, or when leeches do not become fully engorged, a more aggressive treatment should be followed by using a larger number of leeches and more treatments per day. In fact, the decision regarding the duration of the leech treatment is empiric, based on subjective appreciation of the color of the skin, capillary refill, and the color of bleeding after pinprick [ 12 , 29 , 34 — 36 ].

However, the wound may continue to ooze up to 24 hours after the leech is removed. However, the number of hematocrit checks depends on the number of leeches used, frequency of sessions, and total duration of therapy. In Israel, Mumcuoglu et al. Of the 15 fingers, 10 fingers were saved Africa [ 31 ].

The degree of venous congestion can be estimated by describing the percentage of ruborous and violaceous color of the flap skin pedicle, testing capillary refill, and observing color and amount of blood oozing from leech bite sites. Serial photographs can help assess the intensity of venous congestion on a daily basis. The progress of treatment should be also documented.

It should be kept in mind that venous obstruction causes microcirculatory thrombosis, platelet trapping, and stasis. Thus, even after successful reanastomosis by leeches, secondary changes in the microcirculation can persist and prevent adequate outflow from being reestablished. Modern leech therapy is generally recognized as a relatively safe and well-tolerated treatment modality.

A patient who refuses to sign the consent form, refuses prophylactic treatment with antibiotics, or refuses blood transfusion should not be treated with leeches. Although the bite of a leech is felt as a slight pain on the intact skin, this is not relevant in the case of recently reattached digits and flaps, where the skin is anesthetic. Slight localized itching of the Y-shaped bite site Figure 4 persisting for several hours and up to 3 days is the most common In severe cases of generalized itching, topical corticosteroids and oral antihistamines should be prescribed.

Signs of regional lymphadenitis, slight swelling, and pain of regional lymph nodes on the side of leech application and subfebrile temperature can occur in 6. Apparently, such adverse reactions never appear when leeches are applied on oral, nasal, or vaginal mucosa.

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In very rare cases, allergic skin reactions have been observed. When leeches are applied to the esthetically important areas with thin skin and thin layers of subcutaneous tissue scarring after a leech bite could be a cosmetic problem. In some cases, application to a nearby mucosal surface could avoid these complications [ 33 ].

Leech-borne Serratia marcescens infections were also reported [ 24 ].