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From Battlefield To Medical Specialty

War is hell. This simple yet dramatic phrase, coined in the Civil War, also applies to World War I, which brought unprecedented carnage and destruction. If there is a silver lining to such events, perhaps it is found in the advances they bring to the practice of medicine. The ugliness of battle forces field surgeons to find better ways to care for wounded soldiers. And after the war ends, these advances benefit civilians at home.

The weaponry available in the early 1900s and employed in World War I had the potential to cause horrific disfigurement. Single bullets from rifles were deadly, but the unceasing stream of bullets produced by that era’s new machine guns tore off noses, jaws and entire faces. The trench warfare practices of that time protected a soldier’s body, but if he raised his head, he was vulnerable to rapid-fire ammunition. And that war’s flamethrowers and mortar shells also caused severe head and face disfigurement, injuries that afflicted World War II’s military personnel as well.

“He lay with his profile to me,” wrote Enid Bagnold, a volunteer nurse (and later the author of National Velvet), of a badly wounded soldier. “Only he has no profile, as we know a man’s. Like an ape, he has only his bumpy forehead and his protruding lips — the nose, the left eye, gone.”

In 1912, just two years before the Great War began, Vilray Papin Blair, MD, a native St. Louisan and Washington University physician, published a book titled Surgery and Disease of the Mouth and Jaw. Blair’s expertise became invaluable when World War I began and he was appointed the U.S. Army Corps’ chief of oral and plastic surgery. To treat the wounded, he organized a plastic-surgery unit that included specialized teams of surgeons and dentists who used Blair’s book as an operating manual.

At the time, plastic surgery didn’t exist as a specialty and few surgeons were proficient in the field. Blair recognized that early intervention was critical in facial reconstruction, yet the realities of war didn’t always afford this option. During severe fighting early in the war, a shortage of surgeons meant all were needed to serve on general surgical teams. And dental equipment, including the splints needed to repair fractured jaws, became difficult to obtain. At one point, resourceful — and desperate — surgeons cut meat tins into splints and used telephone wires as they worked to repair the injured.

After the war, Blair used his firsthand experience to build one of the largest multidisciplinary teams in the United States to treat complex maxillofacial injuries at Walter Reed Hospital. He soon became known as this country’s leader in post-traumatic reconstructive surgery.

When Blair returned to St. Louis and what was then known as Barnes Hospital, he continued to advance the field of maxillofacial reconstruction, working on new methods of skin graft and cleft-lip repair. In 1925, he became the chief of plastic surgery at Washington University School of Medicine and helped form the American Board of Plastic Surgery, which established and maintained high standards in the newly recognized specialty.

Surgeon and scholar Jerome Webster, MD, wrote of Blair: “[His] place is assured as having done more than anyone in this country to advance the art and practice of plastic surgery, to have it recognized as a distinct specialty, and to formulate the means of educating ongoing generations of plastic surgeons in principles and techniques of reconstructive surgery that mean so much for the function, appearance and happiness of innumerable individuals.”

Blair was also known for his kindness and compassion; he had Barnes Hospital’s plastic-surgery operating room painted with cherubs, nursery rhyme characters, animals and fanciful plants to help both young and adult patients feel more at ease.

In 1929, Blair and James Barrett Brown, MD, a former trainee, performed the first reproducible cleft-lip repair and a pioneering split-thickness skin graft. In 1940, Blair invented the Blair knife for treating burn patients. Blair’s work as a mentor produced a number of plastic surgeons who practiced their specialty in hospitals across the country and contributed to a field of medicine that would prove invaluable during World War II.

Many talented surgeons remained at Washington University, including Brown, who eventually specialized in the treatment of cleft lip and palate conditions, and head and neck malignancies. During World War II, Brown served as a chief consultant in plastic and maxillofacial surgery on the European front and later led the department of plastic surgery at Valley Forge Hospital. There he worked toward the development of new techniques and strengthened the role of plastic surgeons in hand reconstruction.

Plastic surgeons who trained under Blair and Brown introduced more innovations in plastic surgery, including successful skin grafts, improved treatments of cleft lips and electrical burns, and a clearer understanding of craniofacial growth that led to improved surgical outcomes.

Since Blair’s tenure, the plastic and reconstructive surgery division at Washington University School of Medicine continues to make advances. Susan Mackinnon, MD, joined the program in 1991 and became its chief in 1996. She specializes in peripheral nerve surgery and pioneered nerve-transfer techniques that redirect healthy nerves to areas of paralysis. Mackinnon performed the world’s first donor nerve transplant, a procedure that can save what were previously considered irreparably damaged limbs.

Like Blair, Mackinnon also has employed her specialty to treat wounded soldiers. She and colleagues created an interactive website that includes step-by-step videos to train military surgeons in treating nerve injuries to arms and legs experienced by many soldiers serving in the Middle East. And specialists across the globe can access a website designed to teach nerve-transfer techniques.

Although war is hell whenever it is fought, the catastrophic injuries caused by World War I were the catalyst for significant advances in plastic and reconstructive surgery. Necessity — many soldiers’ disfigured futures — was the mother of an invention
that continues to evolve.

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