Brifish &~mnl
of Plastic Surgery (1977). 30, 59-61
THE GILLIES MEMORIAL
LECTURE
1975l
By HALFDANSCHJELDERUP Department of Plastic Surgery, Haukeland Sykehus, 5000 Bergen, Norway
WHEN I was invited to give this lecture in memory of the late Sir Harold Gillies, it was suggested that I should try to describe Gillies as a teacher from the trainee’s point of view and also tell of the problems I have had in establishing plastic surgery in Norway since my return. My meeting with Sir Harold and the fact that I became a plastic surgeon at all, was due to one of these accidents of fate on which many careers depend. In rg# when Norway was under German occupation, I was doing pathology and had also some connections with the underground movement. In November of that year something went wrong, and I suddenly found myself wanted by the Gestapo. By 9th December I had arrived in a camp at Canons Park in north-west London, via the Shetland Islands by the famous “Shetland Bus”. When the British authorities had established my identity and made quite sure I was neither a quisling nor a spy, I was set free on Christmas Eve. On Christmas Day, after a service in the Norwegian Seamen’s Church in Whitechapel with Ring Haakon and Crown Prince Olav present, I met my former teacher, Professor Johan Holst who was well respected in British general and thoracic surgical circles and was then the senior medical officer to the Norwegian Forces in the United Kingdom. He recognised me when we were leaving the church and asked me what I had being doing since I qualified in 1938. I told him and he then ordered me to report at his office the day after Boxing Day where I learned that he had a trainee post in plastic surgery available in the unit of Sir Harold Gillies for 2 years. He felt that I had an adequate training in general surgery and a substantial training in pathology and urged me to take the job. I had only a faint idea what plastic surgery was all about and of course no idea whether I should make a good plastic surgeon or not. I met Sir Harold Gillies some days later and vividly recall him saying to me, “You say you are not sure you will be capable of doing plastic surgery. I shall soon find out, and rest assured you will be told in plenty of time”. I did not feel too happy when I first started work at Rooksdown House. As I learned later this was due to the fact that Sir Harold would go far out of his way to annoy any new trainee as much as possible. This was his method of finding out whether it was worth while training the person or not; if the trainee could not take this special treatment for the first 6 months, then he was not worth the bother. He would for instance ask me to sew up a long suture line. This would have been easy if he had not tried to cover up the field with his elbow. When I had finished he would look at the stitch line and say, “No good: Take them all out and start again!” He might even do this twice and only when I was given a free field of vision, might I succeed in putting the stitches in to his satisfaction. One day when he was sewing up a wound, he suddenly said to me, “Doctor Schjelderup, you have dirty feet”. I felt my blood pressure rising to dangerous levels and 1 A shortened version of the Lecture delivered at the Winter Meeting of the British Association Plastic Surgeons, December 1975. 59
of
60
BRITISH JOURNAL OF PLASTIC SURGERY
blurted out, “I beg your pardon, Sir, I have a bath every morning!” This of course was the phrase he used if any material became lodged in the jaws of his assistant’s forceps so that when the assistant picked up the suture ends to cut them, the forceps did not hold. But how was a Norwegian, in spite of a reasonable command of basic English, to know? It was a hard school but I did learn the basic principles of technique during these first 6 months of probation. Thereafter he put great emphasis on planning and tried to develop the ability to make plans reaching far into the future. I was put to draw flap repairs and to cut paper models, only to realise that paper did not behave like skin. On occasion he would let me, and other trainees, carry out a plan which he knew perfectly well would prove inadequate at the best, and at the worst was headed straight for disaster. He aimed to make us learn from our mistakes and acquire confidence. This is one way of doing so; it was, however, sometimes rather hard on the patient. I sometimes felt frustrated watching Sir Harold making small back-cuts and thereby sliding a flap beautifully into a defect which I had been unable to see how to close without a free graft. It certainly was a treat to watch him playing about with flaps after extensive scar excisions. On one such occasion he had literally pulled half a face to pieces and numerous flaps were lying about when he suddenly told his assisstant to sew it up and left the theatre. The poor trainee nearly fainted on the spot. Sir Harold could be rather naughty. Were I to try to summarise Sir Harold’s teaching I would put his planning first and his technique and delicate handling of the tissues second. One might of course just as well put it the other way round; still I believe good planning stands above technique. FROM BRITAIN To NORWAY The frustrations which Gillies and his colleagues suffered between the World Wars in trying to establish plastic surgery as a separate speciality are well known. By the time I joined him at Rooksdown House, the struggle in Britain was over. Maxillo-facial surgical units were serving in several battle areas and a number of plastic surgical units had been set up in the “temporary” hospitals built by the Emergency Medical Service; some units are still there. I little realised when I returned to Norway in 1948 that the struggle there had not even started. At first all seemed well, I felt confident that my future was ensured after the thorough training I had had in England with an additional round trip to a number of plastic surgical units in the United States of America. I was given a few beds in the Red Cross Clinic at Bergen and I started doing some private work pending the development of a plastic unit in Ulleval Hospital in Oslo which had been planned by Professor Holst. This unit did not materialise. When a meeting of the heads of various departments was held and the plan put before them the senior ear, nose and throat surgeon said he could see no demand for a plastic surgeon as his department carried out all necessary procedures concerning the ear and the nose and also dealt with oral cancers. The head of the oral surgical department claimed to be able to take care of any condition concerning the facial skeleton. The ophthalmologist felt quite confident in coping with the eyelids and the orbit and finally the orthopaedic surgeons had no trouble in skin-grafting any wound of the lower extremities if this should prove necessary. The plan was turned down and to this day this big hospital has no plastic surgical department. Beds in the municipal hospital in Bergen were out of the question. The head of the surgical department publicly ridiculed plastic surgery: “a plastic surgeon is similar to an ophthalmic surgeon claiming to be a specialist in the left eye”. In this situation, new plans for the future had to be made, First of all I had to turn
THE
GILLIES
MEMORIAL
LECTURE
1975
61
out as good, solid plastic surgery as I possibly could. There was no lack of patients; they knew where to go in spite of the official attitude towards plastic surgery. Secondly, I presented papers at the annual meetings of the Norwegian Surgical Association. Slowly over the years of uphill fighting, Norwegian plastic surgery has taken over the fields of congenital deformities, injuries, including burns and hands, and malignant tumours so long as they do not come too near the domains of the E.N.T. surgeons or their ophthalmic colleagues. It is only after things are going really wrong, because of inadequate treatment, that they call in the plastic surgeon for consultation. I sincerely hope that this is going to change before I retire. For quite a number of years now we have run a course in hand surgery mainly to tell young general surgeons what to do primarily to injured hands and fingers and lay the best foundation for later reconstruction. This course has become very popular and now the number of badly treated hands is decreasing while the number of cases referred to us is markedly increasing. From 1st January 1967 my “private unit” at the Betanien Hospital was incorporated in the University Clinic. The appointment as head of the department had to be advertised and was thus open for anyone to apply. I was the only applicant, however, since the advertisement virtually stated that the applicant “must be stocky, have grey hair and wear glasses”. I was appointed. Since 1958 I have been giving lectures totalling 22 hours to medical students, teaching them the basic principles of plastic surgery and how these are applied to various congenital and post-traumatic conditions but I have still no official appointment at the University. Gradually I have obtained the staff I wanted and I can truly say that we are now a very happy working team. Every Spring, since 1966, I have travelled to the northern part of Norway far within the Arctic Circle. In Norway the Sick Insurance Scheme pays all expenses for treatment and stay in hospital. The patient pays only 20 kroner for each of the 2 first consultations. The authorities realised that it would be less expensive to invite me to come up north than to send I 50 to 300 patients to Bergen, particularly as a substantial number of patients were children and had to travel with a relative which further increased expenses. I visit Bode, Harstad and the University Clinic in Tromsb. Apart from consultations I do some minor operations on patients whom I can safely leave for others to look after. Patients come to Tromso from Kirkenes close to the Russian border, from the coastal towns and hamlets and from the Finmark plain. Some of these people have fairly easy access by air but many have to face 24 to 72 hours across the Arctic sea. From my point of view the main object of these visits has been to build up a demand for a plastic surgical service at the University Clinic in Tromso. Now after IO such expeditions I still realise that this is going to be another uphill fight to secure a place for Norwegian plastic surgery. We are again encountering the tendency to split up plastic surgery into regional surgery. This is so much more maddening as we have quite a number of young, well-trained plastic surgeons who are unable to find a job. A new hospital is under construction in Bergen and it will house a plastic unit of 60 beds which should cover the needs of the region as far as we know them today. The building is, however, of such vast dimensions that it will not be completed until 1982 at the earliest. I am grateful to the British Association of Plastic Surgeons for the honour they have bestowed upon me in inviting me to read this year’s Gillies Lecture and thus making it possible for me to pay homage to a great man, my teacher of plastic surgery and my friend, Sir Harold D. Gillies.
of Plastic Surgery (1977). 30, 59-61
THE GILLIES MEMORIAL
LECTURE
1975l
By HALFDANSCHJELDERUP Department of Plastic Surgery, Haukeland Sykehus, 5000 Bergen, Norway
WHEN I was invited to give this lecture in memory of the late Sir Harold Gillies, it was suggested that I should try to describe Gillies as a teacher from the trainee’s point of view and also tell of the problems I have had in establishing plastic surgery in Norway since my return. My meeting with Sir Harold and the fact that I became a plastic surgeon at all, was due to one of these accidents of fate on which many careers depend. In rg# when Norway was under German occupation, I was doing pathology and had also some connections with the underground movement. In November of that year something went wrong, and I suddenly found myself wanted by the Gestapo. By 9th December I had arrived in a camp at Canons Park in north-west London, via the Shetland Islands by the famous “Shetland Bus”. When the British authorities had established my identity and made quite sure I was neither a quisling nor a spy, I was set free on Christmas Eve. On Christmas Day, after a service in the Norwegian Seamen’s Church in Whitechapel with Ring Haakon and Crown Prince Olav present, I met my former teacher, Professor Johan Holst who was well respected in British general and thoracic surgical circles and was then the senior medical officer to the Norwegian Forces in the United Kingdom. He recognised me when we were leaving the church and asked me what I had being doing since I qualified in 1938. I told him and he then ordered me to report at his office the day after Boxing Day where I learned that he had a trainee post in plastic surgery available in the unit of Sir Harold Gillies for 2 years. He felt that I had an adequate training in general surgery and a substantial training in pathology and urged me to take the job. I had only a faint idea what plastic surgery was all about and of course no idea whether I should make a good plastic surgeon or not. I met Sir Harold Gillies some days later and vividly recall him saying to me, “You say you are not sure you will be capable of doing plastic surgery. I shall soon find out, and rest assured you will be told in plenty of time”. I did not feel too happy when I first started work at Rooksdown House. As I learned later this was due to the fact that Sir Harold would go far out of his way to annoy any new trainee as much as possible. This was his method of finding out whether it was worth while training the person or not; if the trainee could not take this special treatment for the first 6 months, then he was not worth the bother. He would for instance ask me to sew up a long suture line. This would have been easy if he had not tried to cover up the field with his elbow. When I had finished he would look at the stitch line and say, “No good: Take them all out and start again!” He might even do this twice and only when I was given a free field of vision, might I succeed in putting the stitches in to his satisfaction. One day when he was sewing up a wound, he suddenly said to me, “Doctor Schjelderup, you have dirty feet”. I felt my blood pressure rising to dangerous levels and 1 A shortened version of the Lecture delivered at the Winter Meeting of the British Association Plastic Surgeons, December 1975. 59
of
60
BRITISH JOURNAL OF PLASTIC SURGERY
blurted out, “I beg your pardon, Sir, I have a bath every morning!” This of course was the phrase he used if any material became lodged in the jaws of his assistant’s forceps so that when the assistant picked up the suture ends to cut them, the forceps did not hold. But how was a Norwegian, in spite of a reasonable command of basic English, to know? It was a hard school but I did learn the basic principles of technique during these first 6 months of probation. Thereafter he put great emphasis on planning and tried to develop the ability to make plans reaching far into the future. I was put to draw flap repairs and to cut paper models, only to realise that paper did not behave like skin. On occasion he would let me, and other trainees, carry out a plan which he knew perfectly well would prove inadequate at the best, and at the worst was headed straight for disaster. He aimed to make us learn from our mistakes and acquire confidence. This is one way of doing so; it was, however, sometimes rather hard on the patient. I sometimes felt frustrated watching Sir Harold making small back-cuts and thereby sliding a flap beautifully into a defect which I had been unable to see how to close without a free graft. It certainly was a treat to watch him playing about with flaps after extensive scar excisions. On one such occasion he had literally pulled half a face to pieces and numerous flaps were lying about when he suddenly told his assisstant to sew it up and left the theatre. The poor trainee nearly fainted on the spot. Sir Harold could be rather naughty. Were I to try to summarise Sir Harold’s teaching I would put his planning first and his technique and delicate handling of the tissues second. One might of course just as well put it the other way round; still I believe good planning stands above technique. FROM BRITAIN To NORWAY The frustrations which Gillies and his colleagues suffered between the World Wars in trying to establish plastic surgery as a separate speciality are well known. By the time I joined him at Rooksdown House, the struggle in Britain was over. Maxillo-facial surgical units were serving in several battle areas and a number of plastic surgical units had been set up in the “temporary” hospitals built by the Emergency Medical Service; some units are still there. I little realised when I returned to Norway in 1948 that the struggle there had not even started. At first all seemed well, I felt confident that my future was ensured after the thorough training I had had in England with an additional round trip to a number of plastic surgical units in the United States of America. I was given a few beds in the Red Cross Clinic at Bergen and I started doing some private work pending the development of a plastic unit in Ulleval Hospital in Oslo which had been planned by Professor Holst. This unit did not materialise. When a meeting of the heads of various departments was held and the plan put before them the senior ear, nose and throat surgeon said he could see no demand for a plastic surgeon as his department carried out all necessary procedures concerning the ear and the nose and also dealt with oral cancers. The head of the oral surgical department claimed to be able to take care of any condition concerning the facial skeleton. The ophthalmologist felt quite confident in coping with the eyelids and the orbit and finally the orthopaedic surgeons had no trouble in skin-grafting any wound of the lower extremities if this should prove necessary. The plan was turned down and to this day this big hospital has no plastic surgical department. Beds in the municipal hospital in Bergen were out of the question. The head of the surgical department publicly ridiculed plastic surgery: “a plastic surgeon is similar to an ophthalmic surgeon claiming to be a specialist in the left eye”. In this situation, new plans for the future had to be made, First of all I had to turn
THE
GILLIES
MEMORIAL
LECTURE
1975
61
out as good, solid plastic surgery as I possibly could. There was no lack of patients; they knew where to go in spite of the official attitude towards plastic surgery. Secondly, I presented papers at the annual meetings of the Norwegian Surgical Association. Slowly over the years of uphill fighting, Norwegian plastic surgery has taken over the fields of congenital deformities, injuries, including burns and hands, and malignant tumours so long as they do not come too near the domains of the E.N.T. surgeons or their ophthalmic colleagues. It is only after things are going really wrong, because of inadequate treatment, that they call in the plastic surgeon for consultation. I sincerely hope that this is going to change before I retire. For quite a number of years now we have run a course in hand surgery mainly to tell young general surgeons what to do primarily to injured hands and fingers and lay the best foundation for later reconstruction. This course has become very popular and now the number of badly treated hands is decreasing while the number of cases referred to us is markedly increasing. From 1st January 1967 my “private unit” at the Betanien Hospital was incorporated in the University Clinic. The appointment as head of the department had to be advertised and was thus open for anyone to apply. I was the only applicant, however, since the advertisement virtually stated that the applicant “must be stocky, have grey hair and wear glasses”. I was appointed. Since 1958 I have been giving lectures totalling 22 hours to medical students, teaching them the basic principles of plastic surgery and how these are applied to various congenital and post-traumatic conditions but I have still no official appointment at the University. Gradually I have obtained the staff I wanted and I can truly say that we are now a very happy working team. Every Spring, since 1966, I have travelled to the northern part of Norway far within the Arctic Circle. In Norway the Sick Insurance Scheme pays all expenses for treatment and stay in hospital. The patient pays only 20 kroner for each of the 2 first consultations. The authorities realised that it would be less expensive to invite me to come up north than to send I 50 to 300 patients to Bergen, particularly as a substantial number of patients were children and had to travel with a relative which further increased expenses. I visit Bode, Harstad and the University Clinic in Tromsb. Apart from consultations I do some minor operations on patients whom I can safely leave for others to look after. Patients come to Tromso from Kirkenes close to the Russian border, from the coastal towns and hamlets and from the Finmark plain. Some of these people have fairly easy access by air but many have to face 24 to 72 hours across the Arctic sea. From my point of view the main object of these visits has been to build up a demand for a plastic surgical service at the University Clinic in Tromso. Now after IO such expeditions I still realise that this is going to be another uphill fight to secure a place for Norwegian plastic surgery. We are again encountering the tendency to split up plastic surgery into regional surgery. This is so much more maddening as we have quite a number of young, well-trained plastic surgeons who are unable to find a job. A new hospital is under construction in Bergen and it will house a plastic unit of 60 beds which should cover the needs of the region as far as we know them today. The building is, however, of such vast dimensions that it will not be completed until 1982 at the earliest. I am grateful to the British Association of Plastic Surgeons for the honour they have bestowed upon me in inviting me to read this year’s Gillies Lecture and thus making it possible for me to pay homage to a great man, my teacher of plastic surgery and my friend, Sir Harold D. Gillies.
