In June 1898, British newspapers reported an exciting medical story under the headline ‘Triumph in Surgery’. Their source was a case history published in that week’s edition of The Lancet. The author, Dr William Brown of Chester-le-Street, County Durham, was not a well-known figure; but for a few days, at least, he enjoyed a reputation as a pioneering surgeon.
On March 2nd, 1898, at about 4.30 P.M., when present at an auction, I was asked to attend to a boy, aged fourteen years, whose ear had been bitten off by a vicious horse.
Ouch.
He presented a hideous appearance, the greater portion of the pinna, together with a semi-circular flap of an inch radius from behind the ear, having been bitten off, leaving only the tragus with a quarter of an inch each of the helix and lobule.
The pinna is the external part of the ear. Almost the entire structure had been bitten off, except the little flap of tissue (the tragus) which sits just in front of the ear canal. The horse had also torn off a portion of the skin from the poor boy’s scalp, which gives some idea of how severe the injury was.
Although the case looked so hopeless (as regards disfigurement) I determined to make an attempt to save the ear, as the patient could be no worse off than he was then if the attempt failed. I asked for the ear and after about ten minutes’ search it was brought to me, having been found near the horse in the stable yard.
“Just go to the stable yard and find me an ear, would you?”
It was of a dirty drab colour and the posterior flap was curled up in a roll. I had no instruments or dressing with me, and it would have taken half an hour or more to procure them, which delay would have rendered the attempt to preserve the ear useless. I therefore procured some common needles and thread and after washing the ear in warm water I proceeded to sew it on by inserting a suture above and another below, followed by three behind and three before.
Admirable initiative: the doctor made the best of the situation and performed a repair with the implements he had to hand.
The posterior flap had to be unrolled before I could stitch it and owing to the needles being straight there was great difficulty in placing the sutures in the concha and the fossa of the antihelix.
The concha is the hollow next to the ear canal; the antihelix a ridge of cartilage around it.
I then placed a roll of cotton wool behind the ear to support it, and having wrapped it in cotton wool and covered it with a silk handkerchief sent the boy home.
All this was performed in far from ideal conditions, and the doctor knew that infection would be a danger, so at the earliest opportunity he took antiseptic precautions.
As soon after as possible I removed as much of the wool as I could without disturbing the wound, and after dusting the surface with iodoform wrapped the ear in cotton-wool and Gamgee tissue.
Gamgee tissue is a surgical dressing consisting of cotton wool between two layers of gauze. Invented in 1880, it is still in production today.
Five days after the injury the doctor changed the dressings. Another three days later he did so again, this time also removing the stitches.
On the 14th a small portion of the lobe sloughed away. On the 16th the patient looked rather anaemic and felt weak, so he was given a mixture containing sulphate of quinine and tincture of perchloride of iron.
The quinine was an effective means of reducing the patient’s temperature; the perchloride of iron (iron [II] chloride) was used as a disinfectant and antiseptic.
The same treatment was adopted throughout, the dressings being renewed every second or third day until April 7th, when they were allowed to remain on until the 12th, when the ear was completely healed and presented the appearance shown in Fig. 2.
The patient’s diet consisted of plain food, together with Bovril, beef tea, and eggs. He is a healthy, intelligent lad, who has survived several accidents, his body being covered with scars from burns. On one occasion it was necessary to transplant six skin-grafts from the calf of his leg to his thigh to replace skin which had been destroyed by burns.
Skin grafting, which was practised in ancient India and described in medical texts more than 2000 years ago, only reached mainstream Western surgery in the second half of the nineteenth century. It sounds as if this unfortunate young man was something of a pioneer, at least in the extent of the grafting he had undergone.
This case, I consider, shows what valuable results may be brought about by antiseptic treatment and making prompt use of whatever comes handy when the proper instruments, &c., are not available.
By any standards this was a remarkable case – so much so that in an article published in 1965, more than sixty years later, the great Scottish plastic surgeon Thomas Gibson described it as ‘one of the largest successful restitutions on record’. Gibson was writing at a time when more and more surgeons were starting to employ the microscope in the operating theatre, making it possible to suture tissues with unprecedented precision. The microsurgery revolution enabled surgeons to salvage fingers, toes and entire limbs that would previously have been chalked up in the column marked ‘accidental amputations’. In that context, it is pretty astounding that one of the great feats of plastic surgery was achieved in less than sanitary conditions, at a livestock auction in rural England.