The book that established plastic surgery in the U.S.

One hundred years ago in July, a surgeon in Baltimore, MD, published a 770-page textbook, Plastic Surgery: Its Principles and Practice, reporting his personal experience and collecting from scattered sources the principles and methods of what was to become the discipline of plastic surgery. In the “preface” John Staige Davis, MD, FACS (see Figure 1), wrote, “About ten years ago my friend J.M.T. Finney MD, [FACS,] who knew of my interest in plastic surgery, suggested that I specialize in this work. He said that every general surgeon was operating on these cases because they had to be taken care of, but that no one in this country was doing the work properly and that the field was undeveloped.”1 In that preface, Dr. Davis broke with tradition and made two major disruptive proposals, and he did this in strong and forthright terms.

Figure 1. John Staige Davis

Figure 1. John Staige Davis

John Staige Davis. Oil on canvas by I.H. Parsons, circa 1940.
From the Portrait Collection, Alan Mason Chesney Medical Archives of the Johns Hopkins Medical Institutions.

Early efforts

During World War I (WWI), plastic surgery was limited by regulation to maxillofacial reconstruction to meet the demand for treatment of the inordinate number of nonfatal maxillofacial injuries associated with trench warfare and developments in helmet technology. At the close of WWI, a multidisciplinary clinical team was established at Walter Reed Hospital, Washington, DC, for the wounded coming home with complex maxillofacial injuries. The groundbreaking work done in this unit helped define the standard of care for plastic surgery of the face and train the first generation of maxillofacial plastic surgeons.

But for years prior to the Great War, Dr. Davis was developing therapeutic approaches and experimental support for a wider scope of techniques in reconstructive surgery. Graduating from Johns Hopkins Medical School, Baltimore, MD, in 1899, he completed a 12-month internship at Hopkins with William Osler, MD, FRCP, and William S. Halsted, MD, [FACS], followed by a three-year surgical residency at the Union Protestant Infirmary, Baltimore (later Union Memorial Hospital). At that time, surgical work being done in Germany was held in high regard, and in about 1901, Dr. Davis became interested in tissue grafting, flap transfer, and other surgical procedures being done in Berlin for the care of burns, chronic ulcers, vascular malformations, and facial and body defects. Treating patients with tissue loss and working in the Hunterian Laboratory through the courtesy of its head, Harvey Cushing, MD, [FACS], Dr. Davis was publishing about correcting burn scarring with skin grafts by 1907. His work was sufficiently recognized that when America entered WWI in 1917, the Surgeon General’s Office of the U.S. Army wrote to Dr. Halsted suggesting that Dr. Davis organize a course at Johns Hopkins to teach plastic surgery techniques to a select group of surgeons. Halsted refused, indicating it was unnecessary to train surgeons in these procedures.2

Textbook receives a chilly reception

In 1919, Dr. Davis amassed his own work with the advances in maxillofacial surgery coming out of combat experience and published Plastic Surgery: Its Principles and Practice (see Figure 2). In doing so, he specifically disputed the professional restriction of plastic surgery to maxillofacial work with the following argument:1

During the war (1914–1918) plastic surgery was arbitrarily limited, by regulation, to maxillofacial reconstruction. This, it is true, is a very important part of the subject, but it must be remembered—and the fact should be emphasized—that plastic surgery of the trunk and extremities is equally important. The results may be less spectacular, but surely are just as vital to the patient. The field of plastic surgery extends from the top of the head to the sole of the foot, and no properly trained plastic surgeon would be willing to limit his work to the face alone.

Figure 2­­­­­­­. Plastic Surgery: Its Principles and Practice

Figure 2­–3­­­­­. Plastic Surgery: Its Principles and Practice

Davis JS. Plastic Surgery: Its Principles and Practice. Philadelphia, PA: P. Blakiston’s Son & Co; 1919.

The textbook was a scholarly achievement with 25 chapters, 864 illustrations, and more than 2,000 references covering craniofacial surgery, vascular malformations, hand surgery, trunk and extremity reconstruction, genitourinary procedures, wounds, and cosmetic surgery (see Figure 3). Dr. Davis’ conviction about the comprehensive scope of plastic surgery was to become the standard in the evolution of the specialty.

Figure 3­­­­­­­. Plastic Surgery: Its Principles and Practice

Figure 3­­­­­­­. Plastic Surgery: Its Principles and Practice

Page 622: Illustrating techniques for closure of a defect of the trunk with adjacent flaps.

In addition to this revolutionary idea, Dr. Davis broke new ground by vigorously encouraging the separation of plastic surgery from general surgery.3 He was probably the first surgeon to restrict his practice entirely to plastic surgery and explained his conviction that the work required specialized training in the following statement:1

It has been commonly said that any surgeon who can successfully do an intestinal suture can do plastic surgery. Careful investigation of this point warrants the statement—without qualification—that few general surgeons do plastic surgery as it should be done. The possibilities are little understood by the practising physician, and hardly more by the general surgeon…. The time has come for the separation of plastic surgery from the general surgery tree. There should be a well-trained plastic surgeon on the staff of every large general hospital, in order that these patients may be cared for intelligently.

Dr. Davis paid a price for his unconventional ideas and outspoken opinions about plastic surgery. Dr. Halsted showed his aversion to the independent development of plastic surgery when Dr. Davis invited him to contribute a preface to the 1919 textbook; Halsted declined, stating there was no use for the book.4,5 Dr. Davis was on the faculty at Johns Hopkins Medical School for more than 20 years before being promoted to associate professor of surgery in 1923, and he was unsuccessful in obtaining a separate division of plastic surgery at Johns Hopkins Hospital. His operations and his teaching clinic were conducted at Union Memorial Hospital because no beds were assigned to plastic surgery at Johns Hopkins until 1943.

Dr. Davis rose above the chilly reception to his ideas and went on in later years to attain many honors, including appointment in 1946 to the Board of Regents of the American College of Surgeons. He was a founding member and first chair of the American Board of Plastic Surgery and in February 1938 presided at the first formal meeting of the Board. But without a doubt his most remarkable moment was in 1919 when he developed and published his vision of what plastic surgery could and would become.


References

  1. Davis JS. Plastic Surgery: Its Principles and Practice. Philadelphia, PA: P. Blakiston’s Son & Co; 1919.
  2. Tolhurst D. John Staige Davis (1872–1946). In: Pioneers in Plastic Surgery. New York City, NY: Springer Publishing; 2015: 45-53.
  3. Sargent LA, Morgan RF, Davis WB. John Staige Davis: Pioneer American plastic surgeon. Clin Plast Surg. 1983:10(4):653-656.
  4. Davis WB. The life of John Staige Davis, MD. Plast Reconstr Surg. 1978;62(3):368-378.
  5. Haddock NT, McCarthy JG. Key textbooks in the development of modern American plastic surgery: The first half of the twentieth century. Plast Reconstr Surg. 2013;132(1):130e-138e.

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Richard T Bosshardt
1 year ago

Kudos to Dr. McGrath on an excellent article which enlightened me on some of the history of my specialty with which I was, shamefully, unaware. It is true that we see further today in our specialty because we stand on the shoulders of giants. I was fortunate enough to train under one of the true giants, D. Ralph Millard, Jr., MD, FACS. Despite the fact the he had just turned 68 when I began my residency in 1987, he maintained a schedule of surgery that would have taxed a surgeon decades younger. I felt he was in his prime. I have now practiced this marvelous specialty for nearly 30 years and cannot imagine having done anything else. Unfortunately, we now live in a different world and I fear for the future of plastic surgery because of some of the current trends. Many young plastic surgeons now come out of integrated programs where they receive limited exposure to general surgery and even more limited exposure to the care of truly sick patients. They are incredibly well trained in procedures and perfectly comfortable under the microscope doing free flaps but not nearly so adept at patient care and that somewhat vague skill called “surgical judgement”l. Most do not seem to want a career such as mine; I am in independent private practice, still take emergency room call at age 66, and my practice includes a roughly equal distribution of cosmetic and reconstructive plastic surgery. Too many young surgeons want to walk into a fully established cosmetic practice with great pay (more than I earn after 30 years), regular hours, ample vacation time, and no night call. I am dismayed to see the trends on social media which have given us young colleagues posting scores of photos on Instagram and teaming up with non-surgeons, including internists, in so-called artistic liposuction practices, and spawned plastic surgery wannabes such as a dermatologist who has become the infamous “dancing surgeon” in Atlanta. I deplore the rapid growth of plastic surgery clinics and spas, with catchy names that are started by ‘investors’ who hire itinerant plastic surgeons to serve as employees and are unabashedly marketed as “world class.” Even ABPS plastic surgeons encourage unrealistic, lofty expectations. Nearly every website makes the surgeon to be among the very best at practically every procedure in the specialty. I am embarrassed that nearly 28 years after the breast implant crisis broke with the report by Connie Chung, we still do not have a coherent answer to the question, can breast implants make women sick? The plastic surgeons out there who are quietly doing good work and trying to take the best possible care of their patients are truly the “silent (I hope) majority.” These and other issues make me pessimistic about the future or our specialty. I wonder what Dr. Davis and Dr. Millard would think of the state of the specialty today. Could it be that our best days are behind us?

Franklin A. Rose, M.D.
7 months ago

Well I was a young premed student doing summer research at The University of Colorado School of Medicine (1972) when Dr. McGrath was being lectured by a venerable surgical faculty member about inherent risks of the somewhat new device, the bovie electrocautery. “It creates too much eschar predisposing to surgical infections”. Dr. McGrath stood her ground admirably (she I believe was Chief Resident in Surgery), and as a practicing plastic surgeon in Houston (trained by Melvin Spira and Tom Rees), have marveled at her career! Kudos to a very well written informative article!

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