American plastic surgery in the South since 1906.

When the Southern Medical Association was founded in 1906, specialization in American medicine was uncommon and subspecialization was incredibly rare. To be a good physician at that time required a very broad knowledge but less of the in-depth knowledge that is the hallmark of the medical or surgical specialist today. Most doctors in the southern United States at that time were general practitioners. They provided whatever services that were necessary and within their capabilities. These included medicine, surgery, pharmacology, pediatrics and obstetrics. They practiced in relative isolation in small to medium sized towns throughout the region.

Socially and culturally, this time in world history is sometimes referred to by historians as the "Belle Epoque" (French for "fine period"), describing the period of settled and comfortable life before the First World War (and from a medical prospective, the influenza pandemic of 1918 that killed an estimated 20-40 million people world wide [the deaths from WW I were only 8.5 million]). In this pre-Flexnerien area of medical education in the United States, the quality of a physician's training was quite variable. Many medical schools were proprietary schools operating more for profit than for education. Abraham Flexner's report entitled, "Medical Education in the United States and Canada" was published in 1910. It sent shock waves throughout US medicine and resulted in massive reforms of the system of medical education in America. Flexner recommended the adoption of the European, primarily German, method of medical education. Following his report, many medical schools closed or were completely reorganized to provide a solid medical curriculum with a foundation in basic and natural sciences.

Despite the overall poor quality of medical schools in 1906, there were notable exceptions. Among them was the then relatively new (opened in 1889) Johns Hopkins Medical School in Baltimore, Maryland, within the Southern Medical Association's territory. Hopkins had already adopted the German method of physician training, both in its undergraduate and in its graduate programs. William Halsted was the professor of Surgery at Hopkins and in 1904 delivered an address at Yale University entitled, "The Training of a Surgeon." In this speech, he outlined the system of graduated responsibility with increasing autonomy throughout a period of training leading to culmination as a fully trained and highly competent surgeon. Along with his colleague in Internal Medicine at Hopkins, William Osler, this modification of the German system was introduced widely and remains the standard for medical education across all specialties still today.

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In 1906, plastic surgery was particularly nascent. There were no divisions or departments of plastic surgery at any US medical school, although many European universities had such services. Because plastic surgery does not have an anatomic area all to itself, it shares interest with many other medical and surgical specialties including general surgery, otolaryngology, ophthalmology, orthopaedics, dermatology, urology and gynecology. It was primarily through the efforts of Dr. John Stage Davis at Johns Hopkins Hospital in Baltimore that plastic surgery was ultimately recognized as an independent surgical specialty and separated from general surgery. Great strides in reconstructive plastic surgery were made during the First World War with experience gained from the treatment of the war wounded. Dr. Davis wrote the first American textbook on plastic surgery entitled, "Plastic Surgery, Its Principles and Practice" published in 1919. By the end of Dr. Davis's career, there were major divisions of plastic surgery at most of the medical schools in this country.

The American Board of Plastic Surgery was founded in 1937 at about the same time as many other medical and surgical specialties were founding their Boards and became a member of the American Board of Medical Specialties which had been established in 1933.

Throughout the entire 20th century and extending into the first years of the 21st century, there has been rapid development in medicine, including plastic surgery. Cities and medical centers within the Southern Medical Association's territory have contributed mightily to the expansion of plastic surgery. Early on there were only a few plastic surgeons in the South. John Stage Davis in Baltimore, James Barrett Brown and Vilray Blair created a dynasty of Plastic Surgical Education at Barnes Hospital in St. Louis. Other pioneers included William Hamm at Emory in Atlanta, Beverly Douglas at Vanderbilt in Nashville, Neal Owens at Tulane in New Orleans, Samuel Upchurch in Birmingham, Claude Coleman in Charlottesville, Robert Hagerty at the Medical University of South Carolina in Charleston and Truman Blocker and Steve Lewis at the University of Texas Medical Branch in Galveston. The next generation of leaders in the South included Jack Hoopes at the Johns Hopkins Medical School in Baltimore, Milton Edgerton at the University of Virginia in Charlottesville, Josh Jurkiewicz at Emory in Atlanta, J.B. Lynch at Vanderbilt in Nashville, Paul Weeks at Barnes in St. Louis, Charlie Horton at the University of Eastern Virginia in Norfolk, Kenneth Pickeral and Nicholas Jeorgiade at Duke in Durham, North Carolina, Ralph Millard at the University of Miami in Miami, Hal Bingham and Leonard Furlow at the University of Florida in Gainesville, Kel Cohn at the Medical College of Virginia in Richmond, Robert Ryan at Tulane in New Orleans and undoubtedly many others that I have not included.

Suffice it to say that the traditional territory of the Southern Medical Association has been deeply involved in the advance of medicine, in general, and plastic surgery, in particular. Microsurgery, including microvascular and microneural surgery, craniofacial, cleft lip and cleft palate surgery, hand surgery, head and neck surgery and esthetic surgery have all seen major breakthroughs as the result of research and the development of surgical techniques within the Southern Medical Association's domain. Of this we can all be very proud.

The practice of plastic surgery has evolved and grown over the past century in ways that were unimagined by its pioneers, much as every other aspect of human life. Technical and pharmacological advances have affected plastic surgery along with the rest of medicine. The ability of the plastic surgeon today to reconstruct complex defects of all parts of the body safely and effectively has given the discipline a special role in the management of cancer patients, trauma and bum victims and those afflicted with birth defects. The esthetic portion of plastic surgery has also benefitted from these same scientific advances. The growth of plastic surgery continues and the future of our specialty is indeed very bright. The number of medical students and surgery residents in other fields who apply for training in plastic surgery continues to increase annually.

While the esthetic aspect of plastic surgery has been given a lot of attention of late, the basis of our specialty remains grounded in reconstructive surgery. One of the earliest surgeons to practice plastic surgery in Europe was the Italian Gaspar Tagliacozzi.

He described most elegantly in the sixteenth century the mission of plastic surgery:

"We repair or restore lost, injured or deformed parts of the body, not
so much to please the eye of the beholder as to buoy up the spirit of
the afflicted."

R. Bruce Shack, MD

From Department of Plastic Surgery, Vanderbilt University, Nashville.

Reprint requests to R. Bruce Shack, MD, Vanderbilt University, Department of Plastic Surgery, 2100 Pierce Avenue, Suite 230 MCS, Nashville. TN 37232. Email: [e-mail]