Historical review

The gunner with the silver mask: observations on the management of severe maxillo-facial lesions over the last 160 years

*Department of Anatomy, University Medical School, Edinburgh and §Department of Oral and Maxillo-Facial Surgery, City Hospital, Edinburgh, UK

We would like to present a case of severe maxillo-facial trauma occurring over 150 years ago. The case involves a French artillery gunner, Monsieur Alphonse Louis, who received shrapnel injuries from an exploding shell at the Siege of Antwerp in 1832. He sustained near fatal injuries. The fact that he survived is probably due to his rapid evacuation from the battle site, as the French did not like to leave their wounded lying in ‘no man’s land’, prompt surgery and subsequent expert medical and nursing care.

M. Louis’ maxillo-facial injuries included loss of the entire mandible. As a consequence, the patient had a grotesque appearance and was unable to eat or talk properly. At this time the surgeons of the day had no specialist knowledge of how to reconstruct the lower jaw. Where specialist knowledge or facilities were absent, then as now, improvisation was called for. A silversmith was duly approached and asked to construct a mask to act as a replacement for the deficient lower face. We describe here what an excellent cosmetic and functional result the mask gave, and how it led to the patient being successfully rehabilitated.

Almost a century later, during the First World War, pioneering work by Major Harold (later Sir Harold) Gillies and his colleagues led to the first attempts at anatomical mandibular reconstruction. His patients, like M. Louis, were soldiers injured in battle. We will describe his techniques and compare them with how this problem is approached in the modern era, although most reconstructive surgery to the maxillo-facial region these days follows the removal of comparably extensive areas of soft tissue and bone as a result of invasive tumour.

Keywords: mandibular reconstruction, maxillo-facial injuries, shrapnel, surgical management.

The case of M. Louis was first described in detail in the literature in the London Medical Gazette of 1833 by Sir William Whymper,’ of the Grenadier Guards, in an article entitled ‘The Gunner With The Silver Mask’. The first illustrations of this case appeared in 1842 in Sir George Ballingall’s brief account which appeared in the Edinburgh Medical and Surgical Journal (Figure 1).’ This case is also briefly described and illustrated in Ballingall’s Outlines of Military Surgery.’ Sir George Ballingall was the Regius Professor of Military Surgery at Edinburgh from 1823—1855^4-6.He established a museum collection to illustrate his lecture course in Military Surgery. What remains of this collection is now housed in the Anatomy Department of the University of Edinburgh. Two of the items in the collection are relevant to this case, a plaster cast taken of M. Alphonse Louis’ face, and a copy of the silver mask, both having been presented to Ballingall by his friend Mr Robert Nasmyth.⁷*

M. Louis, aged 22, was a private in the 5th company, 2nd regiment of artillery, in the army of King Louis-Phillipe of France. He was wounded in the trenches on 6 December 1832 acting as a gunner at the siege of Antwerp.§

*Mr Robert Nasmyth (1792—1870). Commenced the study of medicine in the anatomical class of Dr Barclay at the age of 15, in 1807, and later became one of Barclay’s assistants, or demonstrators. In the latter regard, he would have just failed to overlap with Ballingall who studied medicine in Edinburgh between 1803 and 1806, and was also for some years one of Barclay’s assistants. It is well known that Professor Goodsir commenced his career as an apprentice to Mr Nasmyth, and had a very high opinion of him. While still practising as a surgeon, he was elected FRCSE in 1823, he specialized in dentistry, and was Surgeon-Dentist successively to George IV, William IV and to the Royal Household of Queen Victoria. It is likely that it was because of his dental interests that the plaster cast and the copy of the mask of Louis came into his hands, and was in due course presented to Ballingall. He is said by Lousdale⁸ to be the father of Scottish Dentistry’.⁹

§The siege of Antwerp. The Belgians had become increasingly resentful of the union with Holland imposed on them by the Congress of Vienna—due to differences in culture, language and religion—and rose up against the Dutch in October 1830 and proclaimed their independence. After various diplomatic exchanges, the Belgian crown went to Leopold of Saxe-Coburg, who was acceptable to both France and Britain, rather than to the Duc de Nemours, the second son of Louis-Phillipe, the initial choice of the Belgian people. The Dutch refused to ratify the treaty contrived in London, and in August 1831 invaded Belgium. The French responded by sending a force into Belgium, and the Dutch rapidly withdrew their forces behind their own frontier. Despite the fact that a treaty was drawn up between the three parties, the British, French and Dutch, the Dutch refused to give up Antwerp. The city finally surrendered to the French forces on 23 December 1831 following its continuous bombardment from the 4 December (Figure 2). To support their French allies, the British fleet blockaded the Scheldt. Shortly afterwards, the French evacuated the city, but it was a further 6 years until the separation of Belgium and Holland was fully agreed.
It was only possible to settle the affair in this way because the Dutch initially wished to call on their allies the Prussians to invade Belgium, bus the Prussians were preoccupied assisting their allies the Russians in invading Poland in order to put down an insurrection in that country. The Polish diet had proclaimed their country’s independence on 25 January 1831. Poland was eventually annexed by Russia in 1832.^10,11

Figure 1 Plate IV from Ballingall’s account of the ‘gunner with the silver mask’.²(a) Drawing of the mutilated and disfigured face of Alphonse Louis. (b) Drawing of the mask worn by Alphonse Louis, with the straps and apparatus attaching it to the head. According to the original figure legend: ‘The chin piece A is made to turn aside on a hinge, by touching the button or spring marked B, and thus exposes the artificial mouth. The part marked C is capable of being alternately raised and depressed by touching the spring D, and thus admitting the introduction of the aliment. (c) Drawing of M. Louis shown wearing his silver mask. The upper margin of the flesh-coloured mask is adorned with a moustache and whiskers to add realism, and to help it blend with the upper part of his face.

Figure 2 Engraving entitled ‘Siege of Antwerp, view of the breach of the Lunette St. Laurent, as seen on the morning of the 13th inst. Sketched by H. Hallart, Captain of Engineers, Antwerp. (Copyright British Museum, reproduced with permission).

He was hit by a 7-lb. fragment of shrapnel from an exploding 12 inch shell which burst a few feet above the battery. The shrapnel splinter struck the left side of his jaw and removed his left cheek, soft palate and virtually the whole of the lower jaw. According to Whymper’s account:

The projectile first attacked the external part of the left jaw, carrying away almost the totality of the maxillary process, of which there only remained the edge of the extreme left posterior portion, the coronoid process and condyle. On the right side, the extremity of the bone was preserved as far forward as the first large molar tooth, inclusive. Besides this, the alveolar processes and teeth of the upper left jaw were partly fractured, the body of the hyoides laid bare, and left parotid duct lacerated, and the tongue furrowed on the same side with a deep wound.¹

Immense soft tissue loss was sustained involving virtually all of the fleshy part of the left cheek and a large portion of the upper lip; the injury to the soft tissues on the right side extended to within half an inch of the lobe of the ear. The soft palate was extensively lacerated, as was the upper part of the oesophagus. More particularly, the lower surface of the tongue was extensively lacerated as far as its base. Having lost its normal support, it hung down in front of the larynx, being swollen to about four times its normal volume. The lower jaw was almost entirely deficient, with the exception of four fractured molar teeth; only a small portion on the right side of the mandible was still intact. On exit, the shrapnel hit his right forearm resulting in a compound fracture associated with extensive soft tissue damage.

M. Louis was evacuated immediately to the military field hospital at Hoboken although it was felt that death was imminent. Once there Dr Forjet, the Surgeon-Major to the Army of the North, performed initial surgery to ensure maxillo-facial haemostasis and cleaned and dressed the wounds. Because of the extensive tissue trauma, amputation was also performed on the right forearm at this time, about two inches below the elbow joint.

The patient continued to receive a high level of medical and nursing care. His facial wounds, although tremendously swollen, were dressed daily ‘without any remarkable accident’. On the sixth post-operative day the sutures were removed from the amputation site, and the wound was re-dressed; the following day, his condition was considered to be sufficiently stable to allow him to be transferred ‘carefully’ to the reserve field hospital at Boom. Over the next few days his condition gradually improved, and for the first time his doctor was optimistic that his life might be saved. Both the facial and amputation wounds were septic, however, but in both cases the pus drained freely, although the facial wound had become increasingly painful. The wounds were dressed with ‘emollient cataplasms’. At the stump site, the bones were exposed, and clearly undergoing ischaemic necrosis. The dead fragments of bone were subsequently discharged from the wound site, following which healing commenced rapidly.

On the twenty-eighth day the patient was transported to the military hospital at Antwerp, although by now his facial wounds had turned gangrenous. He continued to receive ‘the most energetic treatment’ and ‘the most indefatigable attention’. This diet at first consisted of thin broth, then lemonade tinged with wine, and eventually he could manage jellies. He was fed using a narrow curved spoon placed at the base of his tongue, and from here the liquid food was poured into his oesophagus. Gradually his condition improved.

Having lost virtually his entire lower jaw the patient had a grotesque appearance. Functionally he found deglutition cumbersome, had a drooping tongue and dribbled saliva constantly. It was felt that an attempt should be made to construct a mask to given an improved cosmetic result and hopefully to aid rehabilitation. Two months following his injuries his wounds were sufficiently healed to allow a plaster cast to be taken of his face (Figure 3). Subsequent to the taking of the plaster cast, ‘small portions of bone exfoliated, or were removed, from a fragment of the lower jaw which remained at its articulation on the right side, leaving the face mutilated and disfigured, to an extent which will be readily understood from an inspection of the cast ...'.²

The plaster cast formed the basis for a cast-iron template. With the aid of the latter, designs for a suitable mask were produced by the surgeon caring for M. Louis, with the construction of the mask being the responsibility of a skilful artist in Antwerp named M. Verschuylen. The mask was constructed in silver, cost at the time the equivalent of £12 sterling (at present rates, this is equivalent to about £437 sterling), and weighed 3 pounds. It was then painted with oils and adorned with a moustache and whiskers to add realism (Figure 4). When in use, the inferior aspect of the mask was covered with a cravat while M. Louis’ own hair covered the posterior edge. From a short distance it was supposedly impossible to be aware of the artificial nature of the lower jaw (Figure 5).

Just how well it functioned can be ascertained from a description by Sir William Whymper in his concluding paragraph from the article in the London Medical Gazette:

‘The use of the mask is by no means painful or inconvenient considering the nature of the wound. It is, above all, of great assistance in attesting in their passage, and retaining in the cavity of the artificial chin, the salivatory and mucous secretions; it facilitates the action of the tongue, it has restored a face dreadfully mutilated to a human form; it has singularly softened the rigour of the sufferer’s fate, conduced to his comfort, and rendered his existence not only desirable, but comparatively happy. On our last visit to Alphonse Louis, the day previous to his departure for Lille, he appeared in high spirits; he walked about with agility; used the stump of the fore-arm with address; took off and readjusted his mask with his left hand; spoke not only intelligibly but easily; he was high coloured and fatter, as he stated, than he had ever been prior to his misfortune. He played at cards, and seemed to be as proud of shewing the mechanisms of his artificial jaw, as he was of the crosses of the Legion of Honour and Leopold, that glittered on his bosom.

While surgeons in Ballingall’s day were used to encountering patients in which the lower jaw had been partly or, in some cases, wholly removed either because of operations or by gunshot, he was clearly enthusiastic to commend the contrivance devised for M. Louis which added so much to his comfort and in the restoration of his appearance.³

The treatment of the French wounded at Antwerp was exemplary. Whymper¹ in his account of this case was at pains to stress that:

The advantages enjoyed by the French medical department, at the siege of Antwerp, were never before surpassed during any similar operation. The instant a man was wounded in the batteries or trenches, he was conveyed to the field hospital at Hoboken, where the first operations and dressings

were instantly performed. The slighter cases were then removed to the general hospital at Louvain and Malines; those of a graver nature to that of Boom or Antwerp.

Figure 3 Right lateral (a), frontal (b) and left lateral (c) views of the copy of the original plaster cast taken of the face of M. Louis. This was made approximately 2 months after he sustained his injuries, once his wounds had sufficiently healed to allow this procedure to be undertaken. The gross soft tissue deficiency involving both checks and the absence of the majority of the mandible may be clearly seen from analysis of these three views of the cast. It is believed that this copy of the cast was specifically made for Nasmyth, as was the replica of the mask (see below), when he visited Antwerp late in 1833.

The excellence of the treatment of the French wounded was undoubtedly due to the long-standing influence of Baron Dominique Jean Larrey, formerly Surgeon-in-Chief to the Imperial Armies of Napoleon, and Surgeon-Inspector of the Health Council of the Armies, who also served as a senior surgeon with the French army during the siege of Antwerp. His guiding principle was that the lives of many of the wounded soldiers could be saved by their speedy evacuation from the battlefield to the casualty field hospitals where they could receive immediate and often life-saving treatment. His son Hippolyte, at the age of 24, also served as a military surgeon during the siege of Antwerp. While his father was at one time Professor of Surgery at the Val-de-Grâce, he in due course was appointed to the Chair of Pathology at the same hospital.

In the late 1790s, Larrey had designed a light mobile horse-drawn ambulance wagon which allowed the surgeons to work in the actual area of fighting; they also allowed the wounded to be rapidly transported from the battlefield and out of the firing line. This clearly saved them from a lingering death on the battlefield and from the excesses of the enemy should the field of battle be over-run at a later time, but more importantly allowed them access to early surgical attention.¹⁰It is of interest that Larrey met Ballingall when he visited Edinburgh towards the end of 1826. He had a high opinion of Ballingall’s work, and indicated this in the Preface to his Clinique Chirurgicale.¹²

Many of the wounded servicemen operated on by Captain (later Major) Gillies and his team of dental surgeons and anaesthetists both during and shortly after the First World War had sustained severe maxillo-facial injuries which were remarkably similar to those sustained by M. Louis. In the vast majority of cases described by him in his monograph Plastic Surgery of the Face,¹³ these were a direct consequence of either gunshot or shrapnel injuries, though some resulted from motor accidents which occurred at the front.

A high proportion of the wounded undoubtedly survived their potentially life-threatening injuries because of the efficiency of the emergency care they received in the Casualty Clearing Stations located at or just behind the front lines. In nearly all of the cases described by Gillies, the first of the plastic and reconstructive surgical procedures was undertaken up to three or more months after the original injuries were sustained. While this period of time clearly allowed the lesions to fully heal, the facial features of these individuals were often seriously, and in many cases hideously, disfigured. For a typical example, see Figure 6(a, b).

Invariably, a series of plastic operations had to be undertaken in order to reform, as near as-was possible, the normal facial contours. Difficulties were particularly encountered when there were extensive mandibular deficiencies. Pedicle grafts were often employed to increase the area of skin over the lower face in order to accommodate

both the dental prostheses and the bony elements used to replace the deficient mandible. The appearance following plastic and reconstructive surgery in the case illustrated in Figures 6(a, b) is seen in Figures 6(c, d).

When parts of the mandible were still present, osteo-periosteal grafts from the tibia could be wired to the bony remnants. Bony union was usually achieved and a dental appliance could then be fitted in order to give a reasonable degree of normal mastication. In other cases, an excellent functional result was achieved when osteochondral grafts using the angle of the seventh or eighth rib, with its associated costal cartilage, were employed (Figure 7).

Figure 4 Three views of the model of the silver mask. As worn with the chin piece in the closed position (a), with the chin piece hinged in she open position with the artificial mouth, with its lower dentition in she closed (b) and open (c) positions. When this replica mask was examined in the 1970s, a report by Conroy & Hulserstrom¹⁴states that it contained the following inscription ‘Invente et Fair par IPA. Verschuylen Octevee et Ciseleur a Anvers 1833’. This suggests that this copy, fabricated in copper rather than in silver, was probably made from the original cast iron template by Verschuylen in October 1833, at Nasmysh’s specific request, as he is believed to have visited both Lille and Antwerp at about that time. Curiously, no evidence of this inscription is to he seen on the mask, and no reference is made to it either in Ballingall’s catalogue of his collection,⁷or in the catalogue of the Specimens in the Anatomical Museum of the University of Edinburgh¹⁵ where this item is also listed.

Figure 5 The cast with ‘silver’ mask in place, to give an indication of how M. Louis would have looked when wearing the latter. The presence of the tongue in the cast slightly impeded the correct positioning of the mask, as may be seen by reference to Figure lc.

It is of particular interest to note that in some of the more complex cases, plaster cast records were prepared as a preliminary to the reconstructive procedure, principally in order to define appropriate skin flaps.

Where indications of the duration of operations are given, these are often stated to be up to but not longer than 3 hours, presumably because of the technical difficulties and dangers associated with prolonged anaesthesia. The duration of the latter clearly also imposed constraints on the types of procedure that could safely be undertaken at any one time.

Since the First World War there have been marked improvements in anaesthetic agents, major changes in anaesthetic techniques and the establishment of intensive care units so that operative procedures lasting 12 hours or more can now be performed safely. This is in direct contrast to the multiple shorter procedures with a prolonged hospital stay as occurred in former times. A marked improvement has also been found in the quality and quantity of tissues that can be transferred from distant sites to replace soft

tissues and bone lost as a result of trauma or tumour in the maxillofacial region.

Figure 6 Four views of a patient with extensive maxillo-facial injuries from the series published by Sir Harold Gillies in 192O.¹³ Frontal (a) and right lateral (b) views of the facial region showing the extent of injuries in the healed state, and before surgical intervention. Frontal (c) and right lateral (d) views of the patient after the large double pedicle scalp flaps had been returned, and with prosthetic chin in position. The original figure numbers from Gillies¹³are as follows: (a) Figure 322, (b) Figure 323, (c) Figure 326 and (d) Figure 327. (Copyright Oxford University Press, reproduced with permission).

When there is loss of intra-oral tissue, segments of mandible and overlying skin, the current expectation is for immediate replacement with good aesthetics and a return to normal function as soon as possible. The use of myocutaneous pedicled flaps and more recently free flap tissue transfer can provide the elements required to replace such lost tissues.

A wide range of donor flaps both cutaneous and compound have been designed for use in the head and neck region; some donor sites are embarrassingly noticeable so these flaps have now become less popular, such as from the forehead and deltopectoral regions. Others, such as the pectoralis major myocutaneous flap,¹⁶are used more frequently and bone may be replaced with or without soft tissue using the distal radius,¹⁷fibula"’ or iliac crest.¹⁹The iliac crest requires exact sculpturing and the overlying skin is often too bulky to replace mucous membrane satisfactorily. Radial skin is ideal to replace mucous membrane but only up to 10 cm of thin bone can be harvested, whereas up to 30 cm of fibula may be grafted but again the overlying skin is thick.

Recently, there has also been a marked improvement in the range and quality of reconstruction and bone fixation plates used in maxillo-facial trauma so now bone grafts can be shaped to a desired contour and then rigidly fixed to the remaining bone. For example, in an advanced oral cancer case with mandibular and skin involvement, the defect left after resection of the tumour may be seen as a satisfactory comparison with the tissue loss described in the war casualties discussed previously. Such a defect was created when a tumour was resected for Mr W.K., aged 70 years, who presented in 1994 with an advanced oral cancer. The tumour involved the buccal and alveolar mucosa, extending from the right first molar to the left canine region and the anterior part of the floor of the mouth

Figure 7 Series of diagrams redrawn after Gillies(Copyright Oxford University Press, reproduced with permission) to illustrate his osteochondral graft for replacement of a deficient hemi-mandible. (a) The defect. (b) The opposite eighth or seventh rib, the source of the graft. (c) The graft in position. The original figure numbers from Gillies¹³ are as follows: (a) Figure 333, (b) Figure 334 and (c) Figure 335.

as a large necrotic ulcer. There was partial destruction of the right hemimandible and chin (for radiographic appearance, see Figure 8a) and the tumour had invaded the skin of the chin and upper neck. There was bilateral upper deep cervical lymphadenopathy.

In March 1994 the primary tumour was resected with the mandible from the right molar region to the left premolar area. Skin from the right chin and neck was excised and bilateral neck dissections performed. Reconstruction began simultaneously. Under tourniquet a vascularized osteofasciocutaneous graft using the left fibula and overlying skin was raised.’⁸An island of skin, 8 x 6 cm,

Figure 8 Radiographs of the mandible taken immediately before (a) and after reconstruction surgery (b). Note in particular (in a) the extent of bony destruction involving the right hemimandible produced by the tumour. The appearance of the graft site is shown after the removal of the titanium fracture plates used to maintain the shape of the mandibular graft and following recontouring of the chin (b).

centered over the junction of the soleus and peroneus muscles, supplied by fascioseptal vessels, was to be used to reconstruct the buccal mucosa and to replace the floor of the mouth. A template of the facial and neck skin lost in the resection was used to outline a skin island on the right chest wall. This skin and underlying pectoralis major muscle was raised as a myocutaneous flap.¹⁶Twelve centimetres of fibula was required for mandibular reconstruction; the mid shaft region was used leaving the fibula head and the distal five centimetres, to maintain the ankle joint²⁰. When the cut fibula was mobilized the vascular pedicle along the medial crest was dissected free and the graft left supported in situ. The tourniquet was released. While still attached to the vascular pedicle, the fibula was recontoured. The periosteum, where possible, was left attached to the bone and by removing two 1-cm wedges of bone a chin shape could be achieved. Both osteotomy sites were plated with suitable titanium fracture plates to maintain the shape of the mandibular graft. The graft on its vascular pedicle was transferred when the resection was completed. The artery of the osteocutaneous graft was anastomosed end-to-end to the right superior thyroid artery and the larger of the venae comitantes directly to the internal jugular vein. The bone was plated rigidly to the mandibular remnants. The island of leg skin was sutured to the mucosal edges intraorally to replace the buccal mucosa and floor of mouth. The skin of the pecroralis major myocutaneous flap filled the facial and neck defect and the muscle covered and protected the vascular anastomoses.

The recovery period in hospital was 3 weeks, feeding was initially by naso-gastic tube and the ankle joint remained in plaster for 6 weeks. One year later the plates were removed from the osteotomy sites and the square chin was recontoured to improve the appearance (Figures 9a, b). A radiograph of the bone graft taken in July 1996 is shown (Figure 8b).

Figure 9 Frontal (a) and right lateral (b) views of the patient (Mr. W.K.( showing the graft site following removal of the fracture plates and recontouring of the chin to improve the appearance.

While the treatment of M. Louis provides possibly one of the earliest examples of the successful rehabilitation of a severely disfigured individual who had extensive maxillo-facial injuries, the first effective surgical treatment of such patients had to await the experience gained by military surgeons exposed to large numbers of similarly afflicted casualties during the First World War. Numerous novel procedures had to be devised and tested, and these have formed the basis for much plastic and restorative work undertaken since that time. Even at that time it had been predicted that the techniques which had been developed could be used to treat a range of facial disfigurement encountered in civilian life, e.g. scars resulting from burns and accidents, congenital deformities of the facial region and deformities following operative intervention such as the removal of malignant growths.

Exploitation of the many advances made in medical and surgical practice during the exigencies of war, such as in the treatment of severe maxillo-facial injuries, are particularly well illustrated in the management of the recent case described here. This is in marked contrast to the situation with regard to M. Alphonse Louis where successful rehabilitation was achieved through a combination of prompt medical treatment, good luck, and a considerable degree of initiative and mechanical ingenuity on the part of his surgeon, Dr. Fodet, along with M. Verschuylen who perfected and constructed the silver mask.

We thank Mr R. D. McDougall for expert photographic assistance, Mr I. Lennox, medical artist, for his expert draughtsmanship and Ms V. A. Cook for drawing our attention to the article by Conroy & Hulterstrom¹⁴.

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14 Conroy B. & Hultersteom A. The history and development of facial prosthetics. Proc Inst Maxillo-Fac Technol. Int Facial Prosthet Workshop 1975; 1:99—116.

15 Anon. Catalogue of the Specimens in the Anatomical Museum of the University of Edinburgh. Edinburgh: I. Thin, 1891.

16 Anyan, S. The pectoralis major myocutaneous flap. Plast Reconstruct Surg 1978; 63: 73—81.

17 Soutar DS, Scheker IR, Tanner NSB, McGregor IA. The radial forearm flap: a versatile method for intra-oral reconstmction. BrJ Plastic Surg 1983; 36: 1—8.

18 Chen Z-W. & Yan W. The study and clinical application of the osteocutaneous flap of fibula. Microsurgery 1983; 4:11—16.

19 Taylor GI, Reconstruction of the mandible with free composite iliac bone grafts. Ann Plastic Surg 1982; 9: 361—76.

20 Taylor GI, Miller GDH & Ham FJ. The free vascularized bone graft. A clinical extension of microvascular techniques. Plastic Reconstr Surg 1975; 55: 533-44.

Correspondence: Professor M. H. Kaufman, Department of Anatomy, University Medical School, Teviot Place, Edinburgh, EH8 9AG, UK