BRITISH WEST INDIES PEREGRINATIONS By D. RALPH MILLARD, jun., M.D., F.A.C.S. Clinical Assistant Professor, University of Miami School of Medicine, Miami, Florida; Honorary Consultant, Plastic Surgery, Government of ffamaica and KENNETH A. MCNEILL, F.R.C.S., F.A.C.S. Surgeon-in-Charge, Department of Plastic flaw Surgery, Kingston Public Hospital, Kingston, ffamaica IT was at the 1953 Rooksdown House garden party that McNeill and I first met. This was an annual affair where flaps, grafts, and surgeons returned, if not for a revision, at least for a reunion over a cup of tea. The geographical nearness of his Kingston and my Miami facilitated a second meeting in Florida and in 1959 precipitated an official invitation from the Ministry of Health for me to visit McNeill in Jamaica to review the problems of reconstructive surgery on the island. KINGSTON Baited by the promise of several bilateral lip clefts, McNeill lured me to Kingston Public Hospital one Sunday afternoon and then put me through a plastic limbo. Sixty patients filed through that Sunday clinic and they came in pairs, triplets, even quintuplicates, to emphasise the lack of depth in any problemmmule bites, molluscum fibrosums, malar-maxillary fractures, adamantinomas, maxillary turnouts, cleft lips, palate clefts, luetic faces, Treacher- Collins syndromes, facial deformities of yaws, hemihypertrophies of the face, keloids, nomas, a pair of leontiasis ossea, burn contractures, and post-priapisms. As this was known to be but a fraction of the plastic problem facing McNeill, it was impossible to query the magnitude of the challenge and now was the time to back out or cut in! During the following three days, eighteen operations were completed, for we both agreed that " two heads can make better faces than one." Recommendations to the Ministry of Health included a request that the Plastic and Reconstructive Surgical Department be recognised officially by the Government. It was suggested that funds be set aside to provide a secretary for medical records, a photographer for pictorial records, plastic surgical instruments, and suture material as well as a promise for more beds in the future. All requests were granted by an active Ministry of Health under the enthusiastic encouragement of Chief Medical Officer A. A. Peat. McNeill, of course, remained as chief plastic surgeon, and an invitation was made for me to continue my surgical visits five times a year as honorary consukant (Millard, 1961). Encouraged by our progress, I had written Sir Harold Gillies a note describing the programme. Lady Sam read the letter to cheer him during a rally in his final illness and one of his last messages to me was, " Carry on, boy." This plastic adventure is affectionately dedicated to him. Our Jamaican plastic symbiosis functioned so well that by my tenth visit McNeiU had planned expansion. Apart from our clinics and long operating 4 A 325
326 BRITISH JOURNAL OF PLASTIC SURGERY sessions we had gone into the "bush" to the country hospitals to observe conditions, advise on specific problems, and bring back to Kingston Public Hospital difficult cases. A teaching programme was set up to enhance the local surgeon's ability in basic plastic surgical principles. Stress was to be placed on early treatment of burns, technique of skin grafting, skilful suturing of lacerations, and diagnosis of facial fractures, these being factors considered of primary interest to local doctors who must face such problems without the aid of a specialist. FIG. I Standing, left to right--newman (Kingston Public Hospital), Douglas (Kingston Public Hospital), Carnegie (Savanna La Mar), Freeman (Spanish Town), Holmes (Lucia). Seated, left to right--campbell (Black River), Harry (Port Maria), Nurse (Savanna La Mar), Gosling (Kingston Public Hospital), Milner (Kingston), McNeill (Kingston). The first postgraduate course in plastic surgery extended over a four-day period from 27th to 3oth April z96i, with McNeill and his staff providing lectures, operating sessions, cadaver demonstrations, and instrument instruction. It was my privilege to give the final lecture and practical demonstration. Six key doctors from strategic local areas had been chosen to attend and their keenness was impressive (Fig. I). Several were persuaded to remain on for our regular clinic and the operating sessions. Surgery included the closure of unilateral and bilateral lip clefts, a double pharyngeal flap to a wide cleft palate, reconstruction of two ear. deformities, a stage in two forehead flap rhinoplasties, and several skin grafts. The doctors returned to their local areas not only better trained to deal with emergencies but more cognisant of the potential value of plastic surgery. Premier Norman Manley at this time was meeting with the other island leaders in Trinidad in an attempt to crystallise a British West Indies Federation. Inter-island co-operation has always existed and will continue with or without the,formation of an actual Federation. In this spirit a plastic surgical goodwill tour
BRITISH WEST INDIES PEREGRINATIONS 327 through the islands was phnned with the primary purpose of evaluating their plastic surgery problems and organising the best method of dealing with them. By letter McNeill encouraged the islands to call up their worst faces and we volunteered to discuss all problems and operate on as many as time permitted. This promised to be an exciting challenge as each reconstruction would be an "on the spot" planning and the surgery would demand a " one shot" execution. General medical and surgical teams have been trained in Great Britain, the United States, or University College of West Indies to cope with general problems on the islands. It is hoped that expansion of the plastic, surgical centres in Kingston and Trinidad will be used in three ways to handle plastic surgery problems. I. Offer special courses in general plastic surgery principles and techniques to facilitate the local surgeon's ability in handling emergency work at home more efficiently. 2. Promotion in the transporting of odd and difficult cases Fro. "Do you suppose," the walrus said, "that they back to the main plastic surgical centres, could get it clear? " 3. Annual visits by plastic surgeons from the centres to the islands to check conditions and advise on improvements. With this as our plastic blueprints we took off from Kingston on 3rd May with our first stop Antigua. ANTIGUA We landed at quaint St John's, the capital of tiny Antigua, and were escorted directly to the "Jabberwok" Inn which rests on a rock overlo0king an emerald sea. There before us on the sandy seaweeded beach was one of Lewis Carroll's seven maids with one of seven mops (Fig. 2). The fourteen island doctors collected by Dr Luther Winter at his home that evening attended our lecture and discussion on plastic surgery. We had been promised a tiny palate fistula and a flexed finger as a clinic the following morning but as McNeill confided, " It is seldom the cases scheduled, rather the ones wandering about the wards, which will be of interest." At IO A.M. we drove up to the small modern Holberton Hospital and there in front of us was a web of
328 BRITISH JOURNAL OF PLASTIC SURGERY Fro. 3 A large Z-plasty corrected the neck contracture.
BRITISH WEST INDIES PEREGRINATIONS 329 webs spanning out of the collar of a yellow dress. A I7-year-old girl at the age of 9 years had fallen into a coal fire. The severe burn had formed a contracture extending from her chin to what remained of her right nipple. Ridiculed by other children, she had refused to attend school and from time to time for eight years had haunted the hospital. The matron had asked permission for her to be seen this day and within ten minutes of our arrival the patient was on the operating table. Under local anmsthesia the scalpel sank 4 in. to the depth of the web. A Z-plasty was dramatic and by lunch-time the patient was sporting a new neckline (Fig. 3). While surgery was in progress McNeill had accompanied an enterprising young British-trained surgeon named Heath through the wards. They had uncovered several interesting problems, the most bizarre being a man with a combination of gynmcomastia and a neurofibromatosis involving his right lower extremity as well as his retropharyngeal space. Along the road from the hospital to the airport for our flight to St Lucia were thatched cottages, the ruins of old stone sugar mills, and a U.S. missiletracking station, a strange but comforting Caribbean blending of the new and old worlds. We left Antigua confident of her future. ST LUCIA Castries, the capital of St Lucia, seemed to be a clean city but, as was explained, only because it burns to the ground once every three years. Deposited in a charming old hotel on top of a hill we were enchanted by the view of the peaceful land-locked harbour and the lazy loading of vessels headed for Britain with sugar, bananas, and copra. Our special effort to visit this island had been promoted by news of the presence here of a ghastly nasal deformity. An hour on the island revealed that hand-to-hand fighting with the helminth was sapping whatever medical energy existed and chances of our ever finding and fixing the nose was unlikely. At the 2oo-bed Victoria Hospital one slightly bewildered Swiss surgeon, who had arrived on the island only two weeks previously, was queried as to his plastic surgical problems. He explained that he was inundated with emergencies-- "Respiratory obstructions wait at my doorstep while burn contractures are content to hide at home." Convinced that the fundamental reorganisation of the medical service in St Lucia should come through the Federation and deserved priority over the development of plastic surgery on the island, we retired to the beach. Floating in the sea near the shadow of Pigeon Island we discussed the lack of native doctors shouldering the medical problems of their people. In St Lucia the answer lies in making her medical and surgical appointments attractive enough either financially or with prestige to entice her own people to return after medical training in England, U.S.A., or the University College of the West Indies. Native participation is often essential to the vitality of a service. BARBADOS The island of Barbados, a " little England " 2I by 14 miles, has more sunshine, more British colour and charm, and more people and sugar cane per square mile than any other isle of the Antilles. Barbadian Jack Leacock, F.R.C.S.,
330 BRITISH JOURNAL OF PLASTIC SURGERY an outstanding British-trained general surgeon, and Dr Harold Forde, senior physician, met us at the airport. We were driven through the hubbub of Bridgetown, directed by negro London bobbies across Trafalgar Square past the bronze monument of Lord Nelson, older than the one in London. Once out of town, we picked up speed as the roads meander like old English lanes between fields of sugar cane and eventually ended at Leacock's home on the edge of a high cliff overlooking the sea. FIG. 4 Unilateral lympheedema following filiariasis. Our first evening had been spent at a meeting of the local doctors where presentation of our plastic surgery lecture was followed by an enthusiastic discussion. At the General Hospital the next morning Leacock had collected a macrostoma, an epispadias, an umbilical hernia surrounded by an obesity that would challenge even the most eager young surgeon, a penile and scrotal elephantiasis, and a Barbadian leg (Fig. 4). This elephantiasis of the lower extremity promoted the most interest. It is known that adult filari~e crawl into the lymphatics of the groin ; upon their death the protein foreign body reaction and subsequent fibrosis block lymph drainage from the leg and scrotum resulting
BRITISH WEST INDIES PEREGRINATIONS 331 in lymphcedema. Leacock was urged to try a Gillies' wick across the block at least in any elephantiasis which was thought not to have progressed to the irreversible stage (Gillies and Millard, 1957). The original arm flap as well as flank pedicles with lymphatics planned in the right direction were discussed. Leacock pointed out the probable involvement of scrotal lymphatics on the side of the involved extremity but was encouraged to try to tap a leg by attachment of the opposite side of the scrotum. Because of the limited time a rare macrostoma with an associated facial paralysis was chosen for surgery. A tracheostomy was performed prior to FIG. 5 Macrostoma and its associated facial paralysis before and after closure. excision of a gelatinous cyst in the cleft between maxilla and the mandible. A two-layer closure of the cleft was augmented by a Z-plasty of the skin and a vermilion flap from the cleft to turn the corner of the new commissure (Fig. 5). Both the main Z-flap and the vermilion flap were turned upward in an attempt to suggest a smile in the presence of the facial paralysis. After a visit through the impressive blue and white tiled $4 million hospital under construction in Bridgetown, we were permitted a Sunday rest on the windward side of the island at Sam Lord's castle. In the mid-nineteenth century Sam had been a wrecker who lured ships on to the coral reefs, murdered survivors, and seized their cargoes. Leacock took us down the path of palms where once Sam strung lanterns to simulate the lights of Bridgetown Harbour and there we swam in the surf that had pounded many a beguiled ship to its ruin. Late for lunch in the dining room at Sam Lord's castle, we were inspired to resort to chicanery reminiscent of old Sam's skulduggery to procure and consume five courses on the menu and still make our flight to Grenada.
332 BRITISH JOURNAL OF PLASTIC SURGERY GRENADA On Grenada, the isle of spice, we were met by Senior Medical Officer Dr Frank Alexis who had arranged our ride across the island to St George's for a lecture to the doctors and nurses of Colony Hospital. We ascended the ridge road 2,ooo ft. up to Grand Etang, a mirror lake in the crater of a volcano. Here the atmosphere was cool and invigorating, a rare relief in the tropics. Our descent toward St George's was green, lush, and fragrant amid the growth of spices, nutmeg, mace, cinnamon, and cloves. McNeill, once a planter himself, noted the abundance of cocoa skilfully planted in the shade of banana trees. C~guaF conversation with the driver revealed that up to 1956 there had been 8oo new cases of yaws reported in St George's annually. Doctors and nurses with penicillin and syringes had gone from door to door until only three new cases appeared in 1961. From the plastic surgical problems collected by Chief Surgeon Soltysik at Colony Hospital (Fig. 6, A) we chose a complete unilateral cleft lip for demonstration of the rotation-advancement method (Fig. 6, B and c) (Millard, 196o). TRINIDAD Trinidad is a cosmopolitan island where people dance to steel drum bands, where mosques, shrines, and churches stand side by side and where Calypso singers puncture prejudices with witty ballads. Port of Spain is a melting pot of a polyglot people. Over 60 per cent. of the island's 8oo,ooo population are negro descendants of African slaves, 33 per cent. are East Indian, with 5 per cent. English, Portuguese, and Oriental. E. L. S. Robinson, trained in plastic surgery at Oxford under Kilner, had arranged for our visit to begin at Harry Collymore's plastic surgical unit in the south of Trinidad. We found LaBond, an American oral surgeon, a member of this team. Here at San Fernando General Hospital we had the largest and most enthusiastic crowd of the trip. McNeill led off with his slides on Jaw Surgery in Jamaica. This was followed by my general plastic surgical lecture and we ended with a review of our united programme in Kingston. The next day ward rounds were followed by a cleft lip session in the surgical theatre. Collymore assisted and during the operation made the interesting observation that all the patients with cleft lips seen in the past two years had been of Indian descent. The only possible exception had been half Indian and half negro. Dr Strisiver, the senior medical officer in San Fernando, had prevailed on McNeill to carry out a " commando" that afternoon for a carcinoma of the floor of the mouth. This hemiglossectomy, mandibular resection, and block neck dissection got McNeill back to Port of Spain just in time for the lectures at the hospital. Ward rounds and clinic with Robinson at Port of Spain turned up several fascinating cases. It was of interest that both Robinson and Collymore had first been trained in orthopaedic surgery and later in plastic surgery. This is indeed a convenient combination as their wards indicated. There were a number of strictly orthopaedic cases such as extremity fractures and spine problems as well as a number of plastic cases including congenital anomalies and burn contractures. The greater percentage seemed to be cases requiring a combination
BRITISH WEST INDIES PEREGRINATIONS 333 of the two specialties, where cross-leg flaps and tube pediclcs were being utilised to facilitate orthopmdic procedures. Fro. 6 A, Old French fort on top of the hill in Grenada with Colony Hospital down to the left and nurses' quarters at the water's edge. B, Unilateral cleft of the lip with nasal deformity. C, After rotation-advancement closure. The evening programme began with Robinson's movie on the surgical excision of a lymphoedema similar to the technique described by Mowlem (1948) and Gibson and T o u g h (1954). With the leg suspended by the foot all skin
334 BRITISH JOURNAL OF PLASTIC SURGERY was shaved off as future grafts. The lymphoedematous tissue was excised in strips down to the muscle fascia and the skin grafts reapplied. Our jaw and plastic surgical lectures were followed by an appeal for Trinidad, like Jamaica, to help to share not only the plastic surgical problems of the West Indies, but the training of men to carry out this work throughout the other islands. Our host in Port of Spain had been Sir Henry Pierre, knighted for his surgical pioneering in Trinidad (Fig. 7). Late for our plane to British Guiana and with FIG. 7 Sir Henry Pierre. Sir Henry at the wheel of his 3-1itre Rover, we careered I6 miles along Churchill-Roosevelt Highway. As this pioneer surgeon, digressing for mule carts and stray Brahmas, cut a new route to the airport, we huddled together fully expectant of all becoming middle-third "pushbacks." BRITISH GUIANA British Guiana is a country on the northern mainland of South America the size of England, Scotland, and Wales, and composed of 54 per cent. Indian, 3o per cent. African, and the rest a mixture of Chinese, Portuguese, and other Europeans. Here we were graciously welcomed by an official party and presented a formal programme outlining our visit. Among the welcoming group was Dr Ray Rayman, a general surgeon with an interest in plastic surgery. Over the 25-mile ride to Georgetown we discussed the political crisis in British Guiana and clefts of the lip, interrupted occasionally m observe an elephantiatic leg loping along the road (Fig. 8). Immediately upon arrival in Georgetown it became evident that this city was seething with pre-election emotion and conflict between pro-communist and democratic factions. Our first reaction was to take our needle-holders and go home. Upon reconsideration we decided to stand our ground and present
BRITISH WEST INDIES PEREGRINATIONS 335 the progress developed in the free world in the specific field of plastic surgery. It was our prime desire to encourage British Guiana to become more closely associated with the islands of the British West Indies to facilitate training programmes for improvement in her standard of medicine and surgery. At Georgetown Hospital we met the other members of the excellent surgical team, Dr William Murray, ophthalmological surgeon (400 cataracts and I5o glaucomas a year), and Dr Neill Stracey, general and chest surgeon. The first case presented was a sensuous 22-yearold Indian girl with a cheek scar and an associated facial paralysis inflicted by a jealous husband. In some parts of British Guiana an Indian husband still enjoys the right of cutting off the end of the nose of an unfaithful wife. It is of interest that the early history of plastic surgery dates back centuries B.C. to an Indian cast of potters who cut forehead flaps to reconstruct the mutilated noses of unfaithful wives. As a modernised and imported cast of potters, we discussed fascial slings and Z-plasties for this mutilated lady. The next patient was a large man named Saul with severe acid burns of the left side of his face and neck and an extensive upper and lower lid ectropion. As the eye on the affected side was still functional, this patient was given Fro. 8 priority for surgery the following day. A Guianese with elephantiasis. The third case was another sulphuric acid burn, even more extensive than the first. The challenge was too great to bypass in spite of our limited time. Then came a man with a man-bite of the ear which was also included on the schedule for an immediate flap reconstruction. Several elephantiatic ulcers were seen and discussed. The final cases, which had been transported from the leprosorium, were arrested lepers marked by the typical saddle nose. These cases were not severe enough for the Gillies' (I923) inlay, but rib grafts to their nasal bridge were proposed. Anyone with the usual facial and hand deformities of leprosy are ostracised from society here much as in the days of Christ. Thus their leprosorium is bulging with 800 inhabitants when there are actually only 250 active cases. This unit alone could occupy a plastic surgeon for years, rendering healed lepers suitable for return to society. Saul's sulphuric acid burn was set as our first case for surgery the following morning. The conjunctiva and orbicularis oculi muscle were dissected out of the scar in the ectropion of his upper and lower lids. At the same time McNeill excised a large keloid of the cheek and neck region and thick split grafts were applied to all areas with pressure. We were ably assisted by Dr William Murray who had a special eye interest in this case (Fig. 9). The second operation of the morning was the ear deformity which was reconstructed by a one-stage flap and
336 BRITISH JOURNAL OF ]PLASTIC SURGERY FIG. 9 A, Sulphuric acid burn contracture of face with severe ectropion of upper and lower lids. B, Scar excisions and skin grafts to upper and lower lids as well as to the cheek, chin and neck area. FIG. IO A, Acid burn with vicious scarring of one side of the face and forehead and loss of eyebrow, musculature of lower eyelid and a portion of the nose. Insert, Diagram showing unscarred forehead to be used as flap for lower eyelid, nose, cheek, and lip with a hairy scalp flap attached for eyebrow. B, Scalp and forehead f l a p i n position. Skin grafts applied to forehead and upper lid.
BRITISH WEST INDIES PEREGRINATIONS 337 graft. The last sutures were being placed when word came that it was time for lunch at the Governor's house. Among the guests for cocktails at the Governor's mansion was the Chief of Police who, in way of polite conversation, queried what had occupied our morning. " Operated on a patient with his eyelids turned inside out and his face badly scarred from acid," it was explained. " That must be Milton Saul," said the Chief of Police. "We have five pages on him down at headquarters." Further investigation revealed Milton to be a thoroughly bad chap with a tendency toward violence. He had always been fond of the ladies, forcing his affections at the threat of mutilation. About four years ago a "lady" warned him to leave her alone and as he persisted she emptied a bottle of sulphuric acid over his face. This had put the fear of God into Milton, for since then he has been a model citizen with no further entries in the police ledger. Nevertheless, it occurred to us how convenient it would be if all the skin grafts were ioo per cent. successful. Weary from the tour and stuffed with the Governor's food, we returned to the hospital for the challenge of the day. The acid burn in this case had scarred a great part of the forehead, left eyebrow, upper and lower lids, cheek, lip, and one half of the nose. Scar excision left extensive raw areas, including the conjunctiva of the lower lid without the support of the orbicularis oculi muscle. With two-thirds of the forehead already scarred the remaining forehead, including a strip of hairy scalp for a brow, was planned for the total reconstruction. By this manoeuvre the greater portion of the face could be reconstructed with ideal forehead skin at the reasonable sacrifice of a tbrehead that deserved a skin graft in the first place (Fig. IO). That evening the West Indian peregrinations were concluded with our plastic and jaw surgery lectures to the British Guiana division of the British Medical Association. Tentative plans were discussed for surgeons to come to Kingston and Miami for plastic surgical training. As our plane droned home over the Caribbean Sea, a flashback revealed that this trip had been a series of zig-zags, not only from island to island but across each individual island. Then there had been variations of Z-plasties in each operating theatre, on a neck web in Antigua, a macrostoma in Barbados, lip clefts in Grenada and Trinidad. It had all climaxed in the clinic in British Guiana where sulphuric acid burns, human bites, mutilated wives, and ostracised lepers had presented a postgraduate study of man's inhumanity to man. This not only pointed out the importance of the role of plastic surgery in the relief of human misery but emphasised again the need for further education in underdeveloped areas of the world. This must come not only at the level of doctors becoming plastic surgeons but among all people to help them to help themselves toward a free and better life. REFERENCES GIBSON, T., and TOUGH, J. S. (1954). Brit. ft. plast. Surg., 7, 195. GILLIES, H. D. (1923). Brit. rned. J., 2, 977. GILLIES, H. D., and MILLAIm, D. R., jun. (1957). " Principles and Art of Plastic Surgery." London : Butterworth. MILLAI~, D. R., jun. (196o). Plast. reconstr. Surg., 25, 595- -- (1961). Arch. Surg., 83, 7o7. MOWI.EM, R. (1948). Brit. ft. plast. Surg., x, 48.