Harold Delf Gillies and the origins of modern plastic surgery of the face

10th October 2014

 

Dr Scroggy's War was performed at the Globe Theatre, London during September 2014, with a strong focus on the birth of modern plastic surgery in World War I, via the pioneering efforts of Harold Delf Gillies (the titular Dr Scroggy). Gillies Archivist Dr Andrew Bamji prepared the following notes, which were included in the programme for the play.

Bamji- GilliesPrior to 1914 war surgery was a hit and miss affair. There was little understanding of how to deal with infection and blood loss, and it was only in the first two years of the Great War that medical men came to appreciate the need for speed in transferring men from the front to hospitals where they could receive definitive treatment. After the battle of Loos steel helmets were introduced, reducing the fatalities from head injury and so increasing the numbers of those surviving with a face wound.

If war surgery was inadequate, facial surgery was almost non-existent. Rhinoplasty (reconstruction of the nose) had been done from antiquity with varying success; results from the American Civil War were dreadful.  Some continental surgeons had small series of patients and indeed had written books, but when Harold Delf Gillies was posted to France in early 1915 and found a French-American dentist called Valadier struggling to deal with facial wounds, he became fascinated with the problem. Gillies was a New Zealander.  An ear, nose and throat surgeon by training (he had treated the famous opera singer Nellie Melba) he was an unconventional polymath. An undergraduate at Caius College, Cambridge he was No 7 in the winning Light Blue boat in 1904.  He was also a champion golfer, winning the St George’s Grand Challenge Cup at Sandwich in 1913, and a competent player of piano and violin.  Realising that casualties would be numerous he returned to England and bearded the head of army surgery, William Arbuthnot Lane, at the Cambridge Military Hospital in Aldershot, asking for a ward to accommodate facial casualties.  Lane was amenable as he saw the potential benefit of a specialised unit.  Gillies built a small team of surgeons, dentists and anaesthetists complemented by an artist, sculptor and a photographer, together with a specialist in X-rays and a dental technician.  He also subverted the standard casualty tag system by having special facial injury labels printed, which instructed the clearing stations and base hospitals to send their wearers to Aldershot.

Gillies’ ward was overwhelmed on the first day of the battle of the Somme.  He was already developing a system to his work; men would have operations, then be rested in convalescent beds until they were ready for the next. The scale of the problem was beyond Aldershot’s capacity, and it was agreed that a new purpose-built hospital should be provided. Frognal House at Sidcup was available, and within a few months the Queen’s Hospital, with wards, operating theatres, X-ray and pathology departments, a dental workshop and rehabilitation facilities was constructed in its grounds. Remarkably it was funded almost entirely by private donations.

Bamji- Gillies charicatureGillies and his colleagues realised that the existing literature on reconstructing faces was useless. The books gave recipes, but no end results.  When they tried the techniques they failed, so had to start from scratch.  The delivery of anaesthetics was compromised because a mask covered the operative field.  With this background Gillies realised that even more concentration of patients and staff was important, so that all those involved could see a large caseload and learn from each other’s mistakes.  He therefore negotiated the transfer to Sidcup of small facial units established by the Dominions (Australia, New Zealand and Canada) and by the beginning of 1918 he had a humming hospital of 1000 beds including the convalescent units. A group of American surgeons was attached for training. Surgery was meticulously documented in photograph, pastel, watercolour and plaster cast. The case files contained detailed operation and progress notes with the idea that future surgeons could use these as a learning resource. Over 5000 men were treated and men might undergo up to 50 operations. Many new techniques were developed or refined; bone and cartilage grafts to reconstruct noses and cheeks, tube pedicle flaps to swing skin from distant parts of the body, eyelid reconstruction for burns victims (many of them airmen) and more. Tube anaesthesia was developed. Gillies maintained a jokey and relentlessly upbeat attitude with his patients much to the disquiet of some of his colleagues, but very much in tune with today’s thinking.  Because patients were in and around the hospital for prolonged periods they struck up new friendships, and later arrivals, often devastated by what they thought their future might be as a seriously disfigured man, saw the successes of surgery on those who had come before them. Morale was further boosted by the training programmes in occupational rehabilitation, which included work such as chicken-farming or cinema projection for men who might not want to face the world.

Although one might imagine that the nature and severity of disfigurement would leave a legacy of unhappy recluses that was far from the case.  It is true that some men led sheltered and private lives but many did not, going back into the world with a remarkable, devil-may-care insouciance.  They married (sometimes the nurses) and had families. One Scottish ex-miner ended his working life as a dental technician in Tunbridge Wells. Even after such injuries many men did not regret their military service, recording that they made new friends and would not have missed the excitement of war for anything. This jars with modern perceptions of the futility and horror of the war, fuelled by the war poets. Perhaps it reflects a different ethos in the early 20th century but underlines why we should not judge yesterday by the standards of today.

The standard postwar plastic surgery textbook was written by Gillies and published in 1920. It described technical successes and failures. Gillies was knighted in 1930.  He and two Sidcup colleagues, William Kelsey Fry and Tommy Kilner, were responsible for the organisation of facial surgery in the Second World War. Gillies, with his two practice partners, Rainsford Mowlem and Archie McIndoe, who joined him in 1929, and Kilner trained all of the first modern generation of British plastic surgeons who, in their turn, have trained those of today. Gillies continued to work almost until his death in 1960 at the age of 78 taking a special interest in teaching aspiring plastic surgeons in India.  He was never shy of sailing close to the professional wind; in 1946 he performed the world’s first female to male gender reassignment surgery.  Meanwhile he upset and amused colleagues in equal number with his relentless practical jokes.Dr Scroggie was a real alter ego. In 1929 Gillies had declined a golfing invitation in Devon, but was referred a patient there for an opinion.  He booked a hotel room leaving a message for his golfing friends that Dr Scroggie from South Africa was visiting, and would be pleased to join them.  He went to a theatrical outfitters, kitting himself out with wig, beard and moustache, a disguise which fooled his London valet.  However the characteristic way he held a cigarette after his hotel dinner gave the game away.
Known within the specialty as the father of plastic surgery, Gillies was truly a surgical giant. The Sidcup notes, now in the Royal College of Surgeons in London, are testament to his innovative techniques, his multidisciplinary approach, his desire to teach and learn and his compassion. His Great War patients remind us that we should not merely commemorate those who died in the war, but those who survived it.
 
Dr Andrew Bamji FRCP
Gillies Archivist, British Association of Plastic, Reconstructive and Aesthetic Surgeons

Illustrations:
1.    Gillies in 1915 as a Red Cross medical officer
2.    Self-caricature drawn for a patient in 1955

Further reading:
Reginald Pound : Gillies: Surgeon Extraordinary. London, Michael Joseph, 1964
Andrew Bamji: Harold Gillies: Surgical Pioneer. Trauma 2006; 8: 143-156

 

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