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In the years leading up to World War I, a number of developments changed the practice of surgery in general and otolaryngology in particular. Before the turn of the century, much of otolaryngology was limited to the opening and drainage of abscessed cavities and the removal of pathological tissue. In the early twentieth century, medical advancements transformed otolaryngological surgery from destructive to constructive. Notably, anesthesia methods had been developed and antisepsis was known and routinely used, so that complex facial surgery could be attempted successfully. Edison’s development of the light bulb made it possible to operate in cavities and other areas previously not sufficiently illuminated for surgery. These developments reduced operating hazards and, combined with a better understanding of clinical physiology, allowed otolaryngologists to focus on reconstructive work. They began operating on harelips, cleft palates, paraffinomas, and other head and neck tumors. The success they achieved was remarkable even by today’s standards and nothing short of amazing given the absence of antibiotics, blood transfusions, and so on.
Still, no surgical advances to date adequately prepared physicians for the sheersavagery of warfare in the trenches of World War I. Sophisticated weaponry rained explosives onto hundreds of thousands of entrenched soldiers, producing a huge population of facially disfigured men to reconstruct. Surgeons of many specialties worked side-by-side on both sides of the trenches – otolaryngologists, oral surgeons, general surgeons, dental surgeons, ophthalmologists, and brain surgeons. They improvised and collaborated to meet each horrific need as it arose, inventing on the spot many of the procedures that comprise the repertoire of the modern facial plastic surgeon.
While Joseph worked in Berlin, Sir Harold Gillies, an otolaryngologist, headed a vast treatment center for allied casualties in Sidcup, Kent. During and after the war, Gillies, like Joseph, attracted surgeons from many countries who came to learn plastic surgery techniques from him. One otolaryngologist who was greatly influenced by his wartime experience with Gillies was Ferris N. Smith, who returned to the University of Michigan after the war and became one of the most important facial plastic surgeons of that era. Smith recorded his experience in a paper titled “Plastic Surgery… Its Interest to the Otolarynologist,” which he presented at the 1920 meeting of the AMA Section on Laryngology, Otology and Rhinology. Interestingly, the postwar practices of Gillies and Smith gradually evolved toward general plastic surgery, and both men eventually closed their training to fellow otolaryngologists. Among Smith’s trainees were two men, Clarence Straatsma and Reed Dingman, who later became chiefs of plastic surgery at Columbia University in New York and the University of Michigan, respectively.
When the war ended, wartime otolaryngologists were determined to practice and learn more about this fascinating new field of facial plastic surgery. Almost immediately they encountered difficulties. They found that their expertise was not recognized in certain quarters, nor were they welcome any longer to learn in certain operating rooms. Gillies himself was shut out by Hyppolyte Morestin, an outstanding reconstructive surgeon at whose side Gillies had worked throughout the war. The event marked the beginning of a turf war between general surgeons and otolaryngologists that continues to this day. It also underscored two needs that would challenge facial plastic surgeons for years to come: the need to develop formalized training within otolaryngology and the need to win recognition for their expertise.
Otolaryngology withheld its approval of facial plastic surgery until Foman’s course caught the attention of George Coates (left), AAOO president in 1939, and Dean Lierle (right), AAOO president in 1960. Lierle strongly believed that facial plastic surgery belonged in university otolaryngology training programs. (Photos courtesy of John Atkins and Richard T. Farrior)