IELTS Academic Reading Practice Test 393

Plastic surgery takes its name not from the synthetic material but from the Greek word plastikos, meaning able to be moulded, a term in use long before manufactured polymers existed. Reconstructive work on the face and hands was transformed by the First World War. Artillery shells, machine-gun bullets and shrapnel produced injuries on a scale that earlier surgeons had rarely encountered, leaving tens of thousands of men with shattered jaws, missing noses and destroyed eyelids. The doctor who did more than any other to meet that challenge was a New Zealander, Harold Gillies.

Gillies was born in Dunedin in 1882 and came to Britain as a young man, studying medicine at Cambridge and completing his clinical training at St Bartholomew's Hospital in London. By the time war broke out he was working as an ear, nose and throat specialist. In 1915, serving in France, he visited a Paris hospital where the surgeon Hippolyte Morestin was rebuilding the faces of wounded soldiers. Gillies watched him use skin from elsewhere on the body to repair defects, and returned to his unit convinced that similar work could be organised on an industrial scale.

Persuading the army to support such a scheme was not straightforward. Senior medical officers doubted that men with severe facial injuries could be made useful again, and there was no established specialty to accommodate the work. Gillies was nevertheless given a ward at the Cambridge Military Hospital in Aldershot, where he began treating patients in January 1916. The demand was so great that the unit rapidly outgrew its accommodation, and in 1917 it moved to a purpose-built hospital at Sidcup in Kent, where surgeons, dentists, anaesthetists and artists worked side by side for the rest of the war.

The central difficulty was that skin cannot simply be lifted from one place and stitched onto another. Every piece of skin depends on a network of tiny blood vessels, and once those are cut the tissue begins to die. Surgeons treating facial wounds before the war often pulled the edges of a wound together, which distorted the features and left scars that tightened as they healed. Gillies started from a different principle: a piece of skin had to remain connected to its original blood supply until it had established a new one where it was needed.

This idea led to his best-known invention, the tubed pedicle. A strip of skin and underlying tissue was cut from, say, the chest or shoulder, but was left attached at one end. The strip was then rolled into a tube and stitched along its edges, so that the raw surfaces were enclosed. The open end of the tube was attached close to the injury. After some weeks, during which the graft acquired a blood supply from its new position, the original attachment was divided. Where the distance was too great, the tube was moved in stages, down an arm and then up to the face, a manoeuvre his team called waltzing.

Skin alone was rarely enough. A nose needs shape as well as covering, and Gillies took pieces of cartilage from patients' ribs to build a framework beneath the skin. Lips and eyelids were reconstructed from flaps of skin folded back on themselves, so that the new feature had a lining as well as an outer surface. Such work was planned in stages, and men might remain in hospital for months or years, returning repeatedly for further operations as scar tissue settled and softened.

Record-keeping was as important as technique. The artist Henry Tonks, who had trained as a surgeon before teaching at the Slade School of Art, drew pastel portraits of patients before and after each operation. Plaster casts of faces were made so that the shape of a defect could be studied away from the ward. These records allowed Gillies and his colleagues to compare methods and to teach them to visitors from other countries, and they remain a remarkable document of what the patients endured.

Surgery of this kind also depended on advances in anaesthesia. Working inside a mouth or nose while the patient breathes is difficult, and blood tends to obscure the surgeon's view. Anaesthetists at Sidcup, notably Ivan Magill and Stanley Rowbotham, developed ways of passing a tube through the nose or mouth into the windpipe, so that the anaesthetic could be delivered and the airway protected while the face was left clear. The techniques they devised for these patients were subsequently adopted in operating theatres around the world.

By 1918 the unit had carried out many thousands of operations. The results were not miracles: most patients still looked different, and some needed further surgery for the rest of their lives. Gillies published Plastic Surgery of the Face in 1920, the first comprehensive textbook on the subject, and surgeons came from Europe and North America to learn from him. Among those who trained with him were Archibald McIndoe and Rainsford Mowlem, who later led their own units treating burnt airmen during the Second World War.

Gillies is often described as the father of plastic surgery, and the phrase is more than a courtesy. The principles his team worked out — that tissue must keep a blood supply, that reconstruction should replace like with like, and that complicated repairs are best done in planned stages — still govern the specialty. What began as an emergency response to industrial warfare became the basis of routine surgery for burns, birth defects and cancers of the head and neck.

Human skin is a two-layered organ with very different jobs. The outer layer, the epidermis, is a thin sheet of cells, mostly keratinocytes, that is constantly renewed and provides a waterproof barrier. It contains no blood vessels of its own and is nourished by the tissue beneath. The dermis, below it, is far thicker and is made largely of collagen, a fibrous protein that gives skin its strength and elasticity. It also holds the blood vessels, nerve endings, hair follicles and sweat glands. Beneath both lies a layer of fat that cushions the body and conserves heat.

A skin graft is a sheet of skin detached from one part of the body or from a donor and laid on a wound that has lost its own covering. For the graft to survive, the bed on which it is placed must be clean, healthy and well supplied with blood. If blood or serum collects between graft and bed, the graft cannot obtain nutrients and will die; surgeons therefore press grafts firmly into place and drain any fluid that gathers. Movement across the graft, known as shear, tears the delicate new connections and is another common cause of failure.

Most grafts are described as split-thickness or partial-thickness. A surgeon uses an instrument called a dermatome to shave a thin sheet consisting of epidermis and the upper part of the dermis from a healthy area, usually the thigh or buttock. The wound left behind is painful but heals by itself, because hair follicles and glands surviving in the deeper dermis supply cells that migrate across the surface. This is why the same donor site can be used more than once, a decisive advantage when burns cover a large part of the body. For a large burn, the sheet is often passed through a machine that cuts small slits, allowing it to be stretched over a wider area.

A full-thickness graft includes the whole dermis and is cut as an oval patch, with the donor area closed by stitches. Because it carries more of the skin's natural elasticity, it contracts less and looks better, and it is preferred for small defects on the face or hands. The price is a second wound that must be repaired surgically and a limited supply of suitable skin. Full-thickness grafts are therefore reserved for small areas where appearance matters most.

The earliest stage of take is easily observed but was long misunderstood. For the first day or two a graft has no working blood supply and survives by absorbing fluid from the wound bed, a process called plasmatic imbibition; the graft looks pale and slightly swollen. Within about 48 hours, capillaries in the graft link up with vessels in the bed, a phenomenon known as inosculation. For much of the twentieth century surgeons assumed that this was the main mechanism by which grafts were nourished.

It is now clear that a second process matters at least as much. New capillaries grow from the bed into the graft, a form of revascularisation that becomes established within a week. How much of the graft's blood supply comes from reconnection of existing vessels and how much from new growth is still debated, and much of the evidence comes from animal studies rather than from patients. What is not in doubt is that a graft which has not been revascularised is fragile: it can be wiped off by friction or lost to infection. Dressings that apply gentle suction to a graft are also widely used; they clearly help grafts to survive, although the reasons are not fully understood.

Skin taken from another person behaves differently. Cells in the epidermis carry marker proteins on their surface that identify them as foreign, and the immune system attacks them much as it attacks an infection. A graft moved from one site to another on the same patient is not attacked in this way, because the body recognises it as its own. Donor skin becomes inflamed, turns dark and dies, usually within about two weeks. Skin is an especially immunogenic tissue, one reason why skin grafts are harder to protect with drugs than transplanted kidneys.

Even so, skin from dead donors has a valuable role as a temporary dressing. On a patient with extensive burns it reduces water loss, protects against infection and relieves pain while the patient's own donor sites heal, and it is removed or replaced after a week or two. Skin from pigs has been used in the same way, though it carries a theoretical risk of transferring animal viruses, and manufactured dressings that contain no living cells are now often preferred.

The most ambitious approach is to grow a patient's own skin in the laboratory. In the 1970s, Howard Green and his colleague James Rheinwald showed that keratinocytes could be multiplied in culture if they were grown on a layer of feeder cells, and sheets of epidermis produced in this way have since been used on patients with burns too extensive for ordinary grafting. The method is slow, since several weeks are needed to produce enough cells, and the resulting skin is thin, fragile and lacks hair follicles and glands. Current research concentrates on dermal substitutes, made from collagen and other materials, which can be combined with laboratory-grown epidermis to produce a covering closer to real skin.

Each year, people whose kidneys, livers or hearts are failing join waiting lists for a transplant that may never come. Some die on the waiting list. Others spend years attached to a dialysis machine, which keeps them alive but leaves them exhausted and unable to work. The supply of organs depends on the willingness of families to agree to donation after a relative has died, and on a much smaller number of living people who are prepared to give away a kidney. In wealthy countries demand has outstripped supply for decades, and the gap has proved stubbornly resistant to public campaigns.

Two strategies have dominated the response, and neither has closed the gap. The first is to change the law so that consent is presumed: unless people register an objection during their lifetime, or their family does so after death, organs may be taken. Wales adopted such a system in 2015 and England followed in 2020, while Spain has had one since the 1970s and has long recorded the highest rate of deceased donation in the world. The second strategy is organisational rather than legal, relying on trained coordinators in intensive care units who raise the subject with grieving families. Both approaches work, but the improvement they produce is measured in percentage points, not in the elimination of waiting lists.

It is against this background that a more uncomfortable proposal keeps returning: that people should be paid for their organs. The idea is not new. Economists have argued for decades that a legal prohibition does not remove the demand for kidneys; it merely drives the trade underground, where donors are unprotected and recipients take appalling risks. A regulated payment, on this view, would bring the transaction into the open, allow donors to be screened and treated properly, and increase the number of organs available.

The case against is equally serious. The people most likely to sell a kidney are those with the least money and the fewest options, and a choice made under financial pressure is not really free. Surgery carries a small but genuine risk, and the long-term evidence on living donors, though generally reassuring, is not entirely settled: some studies have reported a modest rise in blood pressure among donors. The health benefit, however, would flow to patients who are, on average, richer. To critics, a market in organs is therefore not a fair exchange at all but a transfer of risk from the comfortable to the desperate.

There is also a cultural objection, which is harder to argue with because it rests on values rather than evidence. Certain things, the argument runs, should not be bought and sold, and the human body is one of them. Once a price is attached to a kidney, the gift becomes a commodity, and the solidarity that voluntary donation expresses is weakened. The claim is not absurd, but nor is it decisive; we already pay surgeons, nurses and hospital administrators for their part in transplantation, and nobody suggests that this corrupts the gift.

The most interesting evidence on this question comes from another kind of donation. In 1970 the social researcher Richard Titmuss published The Gift Relationship, a study of blood collection which argued that paying donors would drive out the altruistic ones and lower the quality of the supply. The book became enormously influential, and its conclusions are still repeated. Yet the empirical record is less clear-cut than is often supposed. Research on blood donation has generally found that modest rewards, such as vouchers or entry into a lottery, increase rather than reduce the number of people who give. The studies are not unanimous, however, and the effect may depend on how the reward is framed.

Practical objections are just as important. Almost every country forbids the sale of organs, and a government that legalised it would have to decide how much a kidney is worth and how to prevent brokers from taking most of the money. It would also have to stop patients from travelling abroad to buy organs instead. Payment would have to be generous enough to attract donors and modest enough not to attract the very poor, two aims that pull in opposite directions.

My own view is that the argument has been confused by treating two different proposals as one. Paying a price for a kidney is not the same as reimbursing a donor for the wages lost during recovery, the cost of travel to a distant hospital and the care needed by young children at home. The second is already permitted, in various forms, in several countries, and it is hard to see on what grounds it could be refused: the donor accepts discomfort and a small medical risk, and the least we can do is ensure that the experience does not leave them poorer.

So where does that leave the question in my title? I would not legalise a market in organs. The risk of exploitation is too great, and the benefit would go disproportionately to patients in rich countries. But I would go much further than most countries currently do in reimbursing donors' costs, in funding the coordinators who make deceased donation work, and in treating the shortage as a failure of organisation rather than as a fact of nature. Compensation for what donation costs is defensible; payment for a body part is not.