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1. Gordon Angus Mackinlay <email@example.com> 2. Jeffrey Grey <J.Grey@ADFA.EDU.AU> -----Message from: Gordon Angus Mackinlay <firstname.lastname@example.org>----- Reading through my emails after returning from the 'bush', I had to think as what you actually wanted. Professionally I have never heard of the expression "facially wounded " before, but, on reading what other correspondents have put up which have related to 'Maxillofacial' wounds and surgery, feel that this is what you wanted? The subject of 'MAXFAX' wounds, be they inflicted by war trauma or accident trauma have been well documented since the time of the Ancients. A MaxFax trauma is one which involves injury to the bony structure of the face, since the Maxilla (jawbone) is usually involved in such trauma = MAX. While the injury will also usually cause damage to the soft tissue of the facial structure = Facial. Whilst air pressure increases (such as in an explosion) can cause bone structure damage with none (or only minor) to soft tissue, the injured person has a very high incidence of death due to lung or brain damage. Reading into your message "Great War servicemen of Britain and the Dominions within the context of medical military history, repatriation history and social history." you need information re the initial survival, subsequent surgical treatment, treatment relating to the acceptance of horrendous injuries (not all, if not the bulk of MaxFax war wounds fitted into this criteria, and could be far less horrific), and their subsequent coping and acceptance in the wider community upon discharge from the forces. The medical/surgical, psychiatric and rehabilitation of such MaxFax patients both during and post the Great and Second World War's is quite huge. Subsequent conflicts, Korea, South Viet Nam, Northern Ireland to mention just a few is also well documented. In particular the British Commonwealth medical/psychiatric journals, such as : British Medical Journal Australian Medical Association Journal Lancet The Journal of Dentistry (the UK one, and I cannot remember its modern title) and many similar ones from the learned societies of the fields of surgery, psychiatry, dentistry, rehabilitation medicine and social work within the UK, Australia, Canada, NZ and South Africa. In particular for the Great War the Journals of the 'new' disciplines of such as plastic surgery in the 1920's> have much on the initial and subsequent treatments, in the 1930's there started to be articles upon the rebuilding of facial structures by a combination of MaxFax surgeons and 'plastics'. Modern societies being : http://www.projectfacade.com/index.php?/case/ The British Association of Oral and Maxillofacial Surgeons (BAOMS), with current charter being "The specialty of oral and maxillofacial surgery is unique in requiring a dual qualification in medicine and dentistry and is a recognised international specialty which within Europe is defined under the medical directives. The scope of the specialty is extensive and includes the diagnosis and management of facial injuries, head and neck cancers, salivary gland diseases, facial disproportion, facial pain, temporomandibular joint (TMJ) disorders, impacted teeth, cysts and tumours of the jaws as well as numerous problems affecting the oral mucosa such as mouth ulcers and infections." While : http://www.aaoms.org/ American Association of Oral and Maxillofacial Surgeons (AAOMS) "Oral and Maxillofacial Surgeons care for patients with problem wisdom teeth, facial pain, and misaligned jaws. They treat accident victims suffering facial injuries." The Journal of the BAOMS is superior to that of the American. As a daughter in law, who is a consultant surgeon in trauma surgery states 'the first is to enhance the body of knowledge of the practioners. The second to be published in order to advance within the profession'. A familiar story in many disciplines! Quite some years ago I had a fair amount of correspondence with in the UK a Dr Andrew Bamji FRCP, Consultant in Rheumatology & Rehabilitation, who has been Director of the Elmstead Rehabilitation Unit since 1985? Whilst a very well known consultant in the clinic management of rheumatoid arthritis, and rehabilitation of its sufferers, he whilst Director of Medical Education at Queen Mary's Hospital, Sidcup in the early 1980's, discovered the bulk of patients casenotes from the Great War of MaxFax casualties treated at Queen's Hospital. With the disbandment of Queen's due a so called 'efficiency' quest by the Labour Government (sitting on very valuable redevelopement land), all such were to be destroyed, he having them accepted into the National Army Museum's archives From these he has a very good website (WHICH IS VERY GRAPHIC IN ITS DEPICTION OF WOUNDS, SO ITS ILLUSTRATIONS SHOULD BE AVOIDED if you are tender of mind) at : http://www.projectfacade.com/index.php?/case/ is very well worth perusing. He also wrote a chapter on facial injury to CECIL Hugh, LIDDLE Peter "Facing Armageddon: The First World War Experienced" Pen & Sword Books, Barnsley, 1996, which is again well worth reading. Also many articles over many years to date to various medical journals; he particularly mentions those to "Journal of Audiovisual Media in Medicine" and "Current Anaesthesia and Critical Care", which in my professional point of view and opinion are excellent. The website gives his email address, and having corresponded with him for a time in the early 'naughties' found him to be a enthusiastic and very knowledgeable correspondent. Whilst the work of the great 'plastics' men of the Second World War, such a McIndoe, Gillies and others are well recorded for their work with such as "The Few" of the Battle of Britain, the men of the Bomber Offensive over Germany (British Commonwealth and USAAF) their work in development in plastic surgery techniques in the '20's and '30's is to anyone with any form of medical training truly unbelievable. Developing surgical instruments, ancillary equipment (such as operating theatre lighting) and produce (such as 'Bactigras Dressing'), anaesthesia techniques, skin harvesting, nursing and rehabilitation, as well as the all important 'first aid' of burns injury. This plastics work in the case of MaxFax patients to built upon the work of the MaxFax surgeon in reconstructing jaws, cheek bones and other bone structure. Whilst many of the plastics surgical techniques were adapted to rebuild soft tissue structures of the oral cavity (plastics and the ENT - Ear, Nose and Throat surgeons developing techniques to rebuild tongues.) In regard to statistics relating to MaxFac injuries, many of those from the Great War, and other conflicts relate to accidental injuries caused by various means. Very few actually related to a man actually being hit by a round fired from a rifle or machine gun, the kinetic energy of the round frequently causing brain or spinal cord damage, or the horrendous damage that such did to the soft tissue and related blood vessels. A quick look at an anatomy textbook shows the very close proximity of the Carotid Artery to the brain. Result of these death. Irrespective of 'common belief', very few soldiers were killed in the trenches by exposing themselves over the parapet, snipers usually killed those carrying out routine duties in the secondary lines, or such as stretching themselves after relieving themselves in the toilet and standing up to pull up their trousers - a Canadian Indian sniper claimed to have killed five Germans doing such! Gunshot wounds to the face in the Great War were usually of bullets or Shrapnel Balls close to the end of their trajectory, with having considerable loss of kinetic energy. The bulk of such MaxFax wounds were caused by secondary projectiles, ie. mortar bomb exploded in trench, man hit by wood fragment from a dugout door jar or a piece of trenchboard; a sandbag or solid piece of clay, a piece of barbed wire (that cause the most appalling injuries when the human body so hit), and many other items, the most bizarre of which that I have ever learnt about, being a pistol which after destroying the jaw ended up wedged between skull bone and skin! Others being such as close combat, with such as muzzle to jaw rifle firing, or the smashing of a rifle butt into a mans face. Exceptions of course did and still do occur, especially in trench raids where in close proximity such a 9mm or .455in pistols were used with effect and various smashing weapons. The use of hand grenades also produced such wounds due to the rapid reduction in velocity of the grenade fragments in such as the Mills Bomb, or the limited blast effect of the German weapons. The classic that needs to be read by anyone with a interest in the Great War is : DUNN Captain J.C., with an introduction by Keith Simpson. The War The Infantry Knew 1914-1919. Janes, London, 1987 reprint of 1938 original, HB, li, 640p., photos, maps, index. He a regimental medical officer, then a field ambulance commander throughout the Great War (awarded a Distinguished Conduct Medal in the 2nd Anglo-Boer War, a Distinguished Service Order, Military Cross and second award Bar, and twice Mentioned in Despatches) as good descriptions of such wounds and the immediate first aid and resuscitation, as well as their subsequent care in the field dressing station at brigade before evacuation. While Lord Moran's ; The Anatomy of Courage. Constable, London, 1945 and oft reprinted. Describes the effect of such horrendous injuries upon soldiers in the line amongst much more (the present of a copy by our battalion padre, subsequently sent me off into my current trade) and is also a necessity for Great War or any other reading. Equally so is : BARNES John. Morale : A Study of Men and Courage.- The Second Scottish Rifles at the Battle of Neuve Chapelle 1915. Cassell, London, 1967. In her excellent text on the wounded of the Great War : MACDONALD, Lyn. The Roses of No Man's Land. Michael Joseph, London, 1980. On pp.148-157, she describes well the plight of the MaxFax patient out of the front line and in 'Blighty'. With Dr Kazanjian, a American dentist who went to France with the volunteer 1st Harvard Medical Unit, who with an introduction to the trauma and its treatment at the Special Wound Hospital, 42 Brook Street (and always known by the street title), London, and kept up a impressive correspondence with the Hospital throughout the war. He quite probably the main driving force of MaxFac and Plastic surgery in the USofA from the 1920's. 42 Brook Street headhunted one Captain Derwent Wood, Royal Army Medical Corps, he a sculptor who had volunteered for the Territorial Army RAMC, was commissioned after he used his sculptors eye to developed splints from which wounds that they covered could be treated. He whilst serving as a Private Nursing Orderly had witnessed a number of soldiers with MaxFax wounds commit suicide in hospital in France upon realising the extent and horrific nature of their wound. Writing a paper relating to the use of masks for such patients upon healing of the wound(s). MacDonald describes this technique well. They were of course only temporary affairs that required constant replacing. The Australian War Memorial had a good selection of Wood's masks in its collection, these having come from deceased estates of soldiers so wounded and collected by the early collection staff (who were all Returned Men from the Great War) in the 1920-30's. I initially examined them in the late 1970's and again in the mid-1980's and was quite probably the instrument of their destruction having told one of the keepers of the collection that they had been worn by men with such injuries, being informed years later by a former senior member of the AWM staff that they had been destroyed as being a health and safety risk to staff around that time. Inexcusable, no photographic record was kept of them! Masks had been in use to cover such deformities since Roman times (and even today have been used, there was a very good US TV documentary in the 1980's of a soldier living in the northern Pacific States, the concussion of a 23mm anti-aircraft shell had caused immense facial bone and tissue damage, which had resulted in no points of fixation for reconstruction), and are well recorded in British writings from the 16th Century. At the time of the American Revolution a Dutch artist in Charleston produced such for Revolutionary soldiers and British alike, and the same company produced the same for the Civil War. Usually such made from light woods, the rich could afford ones made of a skeletal structure covered with silk "to cool the wound extremity". The German's favoured metal ones, and such described in the literature of the Thirty Years War and onwards, they normally with fine holes like a cheese scraper to allow air circulation, in the Great War from Cologne 'a face veil of fine rolled aluminium' which was a very expensive material at that time and more probably duralumin (often incorrectly today spelt duralinium) this again supposedly cooled the facial structure. Deliberate wounded to the facial structure were probably more common in the days before industrialised warfare, the concept of gentile fencing with rapier had no place on the battlefield, and such as swords more often used the hilt 'basket' to punch the face before slashing the stunned recipients face with the blade. Such weapons as axes, ball and chain and similar were intended to strike the head - if missing, the face was OK! The late and great Brigadier Peter Young (and sadly still missed by those who knew him), who in his second life was prodded by others to form in opposition to The Cromwell Society, one for the Cavaliers and the Stuarts; The Sealed Knot (becoming its Captain-Generall). He wrote (and lectured) a number of scholarly papers relating to the weapons of the English Civil War, one of which related to MaxFax injuries. One describing the helmet used by Cromwell's 'Roundhead' cavalry, its brim having a sharpened edge that could be used to provide a awful head butt to another's face (a modern Belfast or Liverpool Kiss, depending upon your religious belief) with resultant dreadful wounding. The helmet also having a steel wire facial shield to protect the wearer from the sword blow. Young the technical advisor to a BBC TV series, By The Sword Divided, using members of both societies, and the hand to hand combat scenes demostrated such to perfection. In the Great War (and WWII) British Commonwealth soldiers were taught similar techniques with their Steel Helmet, or to use it in their hand as a chopping weapon to a enemies face. And for trench raids weapons from antiquity were adapted to assault their German/Austrian/Turkish foes, with deadly effect. The use of the Steel Helmet with its rim did provide a certain amount of protection to the facial structure from flying projectiles. The design of such helmets have progressed over the years to such a level that they (and of course facial shields) provide a enhanced degree of support against facial wounds - but, they of course still occur. I only learned recently when looking at Schiffer book on US Aerial Armament of WWII that the use of the M1 Steel Helmet was not intended for solely head injuries but also MaxFax. The ever increasing of motor vehicles and accidents produced large numbers of MaxFax, as did armoured fighting vehicles either by accident or the 'rebound' effect inside a tank when hit. The use of cross chest seat restraints and AFV helmets have reduced these dramatically, a daughter in law (trauma surgeon) informed that the replacement in Canada and North America of the waist by the cross chest, dramatically reduced the incidence of severe MaxFax. During WWII the fitment of four point restraints virtually removed "Spitfire" facial injuries - the ramming forward of the face upon crashing into the gun sight of the aircraft. I have (had) a interest in MaxFax injuries when researching my Fellowship in the 1980's, and a thread took me off to look a suicides in such persona post Great and Second World War. A chance remark about Wood to a official of the then Department of Repatriation led me to their Repository in the Western Suburbs of Sydney, and a psychiatrist employed by the Department in the 1930-70's whose comprehensive files relating to such men under the Departments care. Whilst there was a quite high level of suicide in such persons depending upon the numbers and the State in which they resided, which leaped when the then Labour Government stopped the replacement of masks during the Depression, the majority died of other causes at a early age. They in the main died of infection resulting from the tissues becoming fly blown (the great Australian Blow Fly) such described by the writer as being identical to Sheep Mulesing - a minor wound, spot pimple etc infected by a flies dropping eggs, which in the heat of a Australian summer, combined with the humidity beneath a mask provided a idea and rapid breeding site of maggots, resulting usually in a rapid onset pneumonia from the faecal matter from the maggots and death. Others died from respiratory disease due to the lungs surfactant drying up due air not being moistened (normally by the soft tissue in the mouth, nares and air passages) prior to entering them, combined with the effects of heavy cigarette smoking. With the change over to the concept of the Department of Veterans Affairs and the massive reduction in services (again by a Labor Government), there was in the early 1990's a massive clearout of the now DVA records that were held for deceased members, and having pointed a couple of people in the direction of the files, they are now unable to be found!!! In my Registered Nurse training as a army apprentice in the 1960's, I worked in army hospitals in the UK in London, Colchester and Aldershot, these as did most such hospitals took civilian patients from the National Health Service. These hospitals having specialist training roles, one of which being MaxFax, the UK in the 1960's had truly horrendous rates of respiratory disease, due to the smoking of high level nicotine tobacco (snuff and chewing tobacco having a lower but still significant level) and very poor quality of air (you may have heard of the British 'smogs'), these also contributed to a equally high level of oral carcinoma (cancer) of the soft and bone tissue of the facial structures. The treatment of these was surgical intervention, usually involving the removal of the jaw and associated structures, and wholesale removal of soft tissue - which known in the trade as a 'commando raid', because it was surgically precise and everything cut off! These procedures only became viable in the 1950's, and to quote the old medical adage "the operation was a success, but, the patient died". Not because of poor medical or nursing care, but, because the patients were usually in late middle age >, and their psyche just could not cope with the trauma of such a appalling result and they just lost the will to live, a small percentage committed suicide, and only a very few had a long term future. But, I well remember the education at the time, it being stressed that those who were young had a greater resilience and therefore a better prognosis if such medical intervention occurred. The use of horrendous and similar to describe MaxFax severe trauma may seem over dramatic, but, believe me to both the patient and the staff of all kinds it is so. As a student nurse in teens I remember well being violently ill upon first seeing such, and I not alone. On active service in Borneo in 1965, we lived in 'forts' with underground bunkers. Due to the claustrophobic conditions of the bunkers and the huge rat population extant in them, virtually universally we all slept above ground. Some men though due to the real and constant threat of the Indonesians 'lobbing' 81mm Mortar Bombs over from their brand new American M29 Mortars, stayed underground (and usually did so even during the day). One of our lads, fast asleep with his mouth open, a rat entered the mouth and in the resultant trauma he had his soft tissue literally ripped to shreds and the jaw shattered (probably due to falling from his upper bunk and hitting some metallic object. His blind behaviour resulting accented his injuries and added more, upon being medevaced to Singapore due to infection and the extent of the damage due to the rats claws and teeth, surgical intervention resulted in a 'commando raid'. The soldier developed a Catonic psychiatric condition, and even though acceptable (but by no means perfect) surgical rehabilitation performed, he died some years later. The case was written up in the professional; Journal of the Royal Army Medical Corps, and the Journal of the Royal Army Dental Corps, both of which from the Great War have had a substantial amount of articles relating to MaxFax, surgical intervention right through to articles on the psychiatric conditions relating. I also have experienced the subject from the other side, being wounded in Aden in 1967, suffering amongst other wounds a triple compound fracture to the Mandible. Successfully repaired with residual loss of teeth, jawline scarring and a uneven bite. This has served me well in the (long term) treatment of persons will similar woundings/injuries including in the 1980's some gentlemen who had suffered such (to a severe but not horrendous degree) in the Great War, WWII, Korea, Malaya and Viet Nam. Fortunately to date, none of Australia's wounded in Afghanistan have suffered such. For a truly descriptive and very personal description of suffering MaxFax trauma and treatment : ASTON W.H, MM. _ no iron bars a cage : The adventures of three British prisoners of war 1940-1942. MacMillan, London, 1946. SGT Aston and a Captain C.F. Collie had very severe MaxFax wounds, with a Driver E Flack extensive closed facial fractures, Aston had also had a foot amputated and on crutches, all from the retreat to Dunkirk. They escaped from the Hospital Foch in Paris 8th April 1942, wearing civilian clothing given to them by an American émigré, and had purchased for themselves French insignia and decorations indicating they were 'sorely war wounded discharged with honour'. They made their way to Vichy France, and then across the Pyrenees on foot, having no support from the French Underground, but, relied upon the kindness to three Briton's by the ordinary French people (while due to their injury Aston and Collie could not speak French properly, they managed to communicate well. The only time they actually in danger when in the hands of the Spaniards. On return to the UK the three were presented to the King with their story told on the direction of Winston Churchill, they awarded respectively a Military Medal, Member of the British Empire and a Mention in Despatches. A book truly worth reading (if it can be obtained) and gives a tremendous insight, whilst years ago I tried to find out what happened to them, every avenue was a complete dead end, a shame. Anyway I have waffeled on far too much, but, it is truly a most interesting and little known or understood subject. From 1940 modern advances in reconstructive surgery along with the introduction of antibiotics dramatically enhanced the 'acceptable' appearance and the physical prognosis of severe MaxFax casualties. Equally, psychiatric and social rehabilitation dramatically enhanced the well being and life prognosis of such patients. I have seen photos of soldiers so wounded/injured in recent conflicts, and their before and after surgical intervention is amazing. Yours, G/. Gordon Angus Mackinlay <email@example.com> -----Message from: Jeffrey Grey <J.Grey@ADFA.EDU.AU>----- All true, but don't forget that the major development in treating facial wounds in the Second World war was burns treatment, beginning with pilots shot down and jumping from burning aircraft (pioneered by the Brits, I think, early in the war) and extending (as I recall) to tank crew etc successfully getting clear of burning AFVs but with often serious burns. Different technological emphasis creates new problems, requiring different/new solutions. Jeffrey Grey H&SS/ADFA Jeffrey Grey <J.Grey@ADFA.EDU.AU> ----- For subscription help, go to: http://www.h-net.org/lists/help/ To change your subscription settings, go to http://h-net.msu.edu/cgi-bin/wa?SUBED1=h-war -----