Introduction
Australian and New Zealand surgeons are recognised as pioneers in the development of modern plastic surgery.1–3 New Zealand-born Harold Delf Gillies is often credited with the modern birth of our specialty. His work in World War I (1914–1918) led to the publication of his seminal book Plastic surgery of the face based on selected cases of war injuries of the face including burns with original illustrations.4 Although the book in question was groundbreaking, it was not the first textbook of plastic surgery in the English language. That distinction belongs to a relatively lesser-known Australian surgeon named William (Jerry) Moore. In this article, we rediscover Moore’s 1899 textbook, aptly titled Plastic surgery: with illustrative cases.5 We further chronicle the author’s biography and outline the circumstances that led to his name being largely forgotten.
Plastic surgery texts in the nineteenth century
Historical documentation pertaining to what we now call plastic surgery is evident across diverse epochs. Tracing its roots back to antiquity, references can be discerned in Ancient Egypt (the Edwin Smith Papyrus), India (the Sushhruta Samhita), Imperial Rome (De Medicina), Early Byzantium (the Synagôgai iatrikai), and Imperial China (the Jin Shu annals).6 The preservation of many of these surgical techniques can be attributed to Byzantine figures such as Paul of Aegina, notably through the Pragmateia.7 Subsequently, during the Middle Ages, these procedures experienced widespread dissemination, facilitated by the scholarly endeavours of the great translation movement of the Middle East and medical authors like Albucasis.7 The dissemination of reconstructive knowledge was accelerated in 1794 by a contribution to The Gentleman’s Magazine by English engraver Barak Longmate who provided a comprehensive account of the Indian rhinoplasty.8 This informative letter motivated English surgeon Joseph Carpue to perform the procedure which he successfully executed in 1814 and eventually wrote about in 1816.9
German and French publications
The subsequent decades of the nineteenth century witnessed a prolific surge in European medical literature addressing various facets of reconstructive surgery, with prominent contributions from German and French surgeons. Nasal reconstruction stood as the predominant subject of the era. In 1818, Carl Ferdinand von Graefe (1787–1840), Professor of Surgery at Berlin University, published a groundbreaking work titled Rhinoplastik describing the Italian, Indian and German methods of nasal reconstruction.10 It marked the earliest use of the term ‘plastic surgery’ in the medical literature.11 Another prolific German, Johann Friedrich Dieffenbach (1792–1847), published two books: Chirurgische erfahrungen (Surgical experiences) in 182912 and Die operative chirurgie (Operative surgery) in 1845.13 The former delves into the Indian and Italian methods of nasal reconstruction; restoration of the lip, velum and urethra; auricular reconstruction; lacrimal duct repair; correction of ectropion and cleft palate closure.12,14 The latter—a two-volume general surgical textbook—contained sections on nasal reconstruction, otoplasty, cheiloplasty, cleft lip repair, genioplasty, cleft palate repair and blepharoplasty.14,15 It was immediately followed up by an associated atlas compiled by two of Dieffenbach’s students, Hermann Eduard Fritze and Otto Friedrich G Reich.14,16 In 1838, Eduard Zeis (1807–1868) published Handbuch der plastischen chirurgie (Manual of plastic surgery), with an introductory note by Dieffenbach.11 Zeis credited von Graefe for coining the term ‘plastik’ and chose ‘plastischen chirurgie’ as the most encompassing term to describe the newly emerging field. This text is recognised as the first comprehensive textbook dedicated entirely to plastic surgery.14 The manual provided a detailed review of the existing literature, the history of plastic surgery, the techniques employed and indications for surgery. It described specific operations, including rhinoplasty, blepharoplasty, cheiloplasty, stomatoplasty, genioplasty, otoplasty and cleft palate suturing. Zeis also addressed palmar fascia contraction, a procedure attributed to both Guillaume Dupuytren and Dieffenbach.14 A similar work to Zeis’ manual was published by Friedrich August von Ammon, with the collaboration of Moritz Baumgarten (a physician and ophthalmologist working in Dresden).17 Of immense importance to Moore’s book was the technique of split-thickness skin grafting advocated by Carl Thiersch in 1874.18
In France, a parallel interest in plastic surgery was also developing.14 Pierre Léon Auguste Labat, like Von Graefe, published a book entirely devoted to nasal reconstruction in 1834, again focusing on the Indian and Italian methods.19 Alfred Armand Louis Marie Velpeau, a surgeon and anatomist, published what Wallace called ‘the first systematic textbook of plastic surgery’20 (although this can be disputed after studying Mazzola and Foss).14 It was named Nouveaux elements de médecine opératoire accompagnés d’un atlas (New elements of operative surgery accompanied by an atlas)21 and was a four-volume text related to all surgical procedures of which 100 pages discussed autoplasty, nasal reconstruction, blepharoplasty, cleft lip and cleft palate.14 The term ‘autoplasty’ was introduced to the surgical lexicon in 1836 by Philippe Frédéric Blandin in his seven-part text Autoplastie ou restauration des parties du corps qui ont été détruites à la faveur d’un emprunt fait à d’autres parties plus ou moins éloignées (Autoplasty or reconstruction of parts of the body which have been destroyed by borrowing from other parts more or less distant).22 It focuses on the indications for reconstructive surgery with descriptions of local flaps, rhinoplasty, blepharoplasty, otoplasty, cheiloplasty, genioplasty, cleft palate, postoperative management and complications.14 Michel Serre published Traité sur l’art de restaurer les difformités de la face, selon la méthode par déplacement, ou méthode Française (Treatise on the art of restoring facial deformities by the sliding method, or French method) in 184214,23 in which he summarised the techniques of rhinoplasty, including those from von Graefe and Dieffenbach, and then proceeded to describe the French method using an advancement flap.14 ‘Chirurgie plastique’ was first introduced to the French literature by Antoine-Joseph Jobert de Lamballe in his two-volume Traité de chirurgie plastique (Treatise on plastic surgery) in 1849.24 This was followed by an ambitious project Quarante années de pratique chirurgicale (Forty years of surgical practice)14 by Philibert Joseph Roux who managed to only complete two volumes before his death in 1854. The first volume was devoted to plastic surgery and includes autoplasty, blepharoplasty, genioplasty, cheiloplasty, nasal reconstruction, cleft lip, cleft palate and repair of the female perineum.14 Over 20 years later, reconstructive surgery reappears again as the first volume of Aristide Auguste Stanislas Verneui’s Mémoires de chirurgie.25
English publications
In the English-speaking world, Thomas Spencer-Wells holds the distinction of being the first individual to attempt to amalgamate the techniques and methodologies elucidated in Europe.26,27 His efforts date back to 1854 when he authored ‘Practical essays on plastic surgery’. Published in the Medical Times and Gazette this was perhaps the first time the term plastic surgery was used in the English language (Figure 1).27 Within the essay’s pages, he earnestly sought both knowledge and the translation of pivotal works by the aforementioned figures in Europe. He also includes techniques of wound closure, suture selection, composite grafting and local flap reconstruction. Regrettably, the eruption of the Crimean War in 1853 redirected Spencer-Wells from his plastic surgery pursuits in London to the hospitals of the Dardanelles and it appears that he did not revisit the subject.26 The resurgence of interest in this subject occurred in 1878, thanks to Francis Mason (1817–1886), who published a work titled On the surgery of the face.28 The book was a dedicated exploration of facial surgery in relation to tumours, trauma, congenital malformations, nasal reconstruction, cheiloplasty and scar contractures.14
Of great importance to Moore’s work was the publication of John Reissberg Wolfe’s dependable technique for full-thickness skin grafting29 (although some argue that George Lawson described it first in 1871).14 It’s worth noting that Wolfe practised in Melbourne between 1893 and 1901 at the same Collins Street address as Moore.30,31 Their collaboration is evident in an 1898 letter addressed to Wolfe from Moore (Figure 2). Around the same time as Moore’s 1899 book, Charles Stonham published A manual of surgery in the United States, which covered some aspects of reconstructive surgery (cleft lip, cleft palate and wounds).32 Moore’s publication however holds the distinction of being the first English-language textbook devoted entirely to the field of plastic surgery.
Plastic surgery: with illustrative cases5
Moore’s book was originally serialised as individual chapters and cases within the pages of the Intercolonial Journal of Australasia (1896–1899), a publication reflecting the era before the federation of Australia. It was published as a textbook in 1899 (Figure 3). A cursory examination of the text reveals a comprehensive approach to reconstructive surgery, encompassing both general principles and specific procedures. Moore dedicates significant effort to explaining the precise positioning of incisions and the intricacies of suture techniques within the contemporary era of aseptic practices. Three chapters are entirely devoted to the methods of skin grafting described by Wolfe and Thiersch.
The text explores various local flap techniques, including the four-flap method for closing large mastectomy wounds (Figure 4). The discussion also encompasses the application of V-Y flaps in addressing conditions like ectropion, lip tumours and eyebrow deformities (Figure 5). Moreover, an innovative approach using a type of deltoid flap is presented as an effective strategy for releasing axillary burn contractures. In chapter four, Moore laments that numerous surgical textbooks of his era neglected the Tagliacotian arm flap procedure largely due to its perceived complexity and patient discomfort concerns. He emphasises that local flaps may not be suitable for numerous defects and recommends considering distant flaps as a preferred option before resorting to healing by secondary intention. He meticulously compiles a comprehensive set of indications and contraindications for distant flaps, providing a detailed procedural roadmap that encompasses defect site preparation, flap design, flap inset, splint application, dressing techniques, flap division and donor site closure. What stands out is Moore’s unflinching honesty as he candidly shares his difficulties with precision of flap design, the duration of the procedure within the constraints of chloroform anaesthesia and the occasional challenges of flap failure. He provides several case reports of his successes with the arm flap, including that of a seven-year-old girl whose right superior maxilla was eroded by cancrum oris (Figure 6). The text proceeds with several cases of nasal reconstruction, with Case II illustrating the use of the forehead flap to address long-standing disfigurement resulting from syphilis (Figure 7). Once more, Moore’s candid assessment of his outcomes stands out: ‘this case was a great disappointment, as I had hoped…to obtain a good nose…The final result can hardly be considered satisfactory, still it must be admitted to be an improvement on her condition prior to operation, and I believe it can be further improved.’5
Moore’s expertise transcends mere illustration of reconstructive cases. His mastery as a maxillofacial surgeon shines through in his duteous accounts of performing nasopharyngeal carcinoma resections on two adolescent patients. He eloquently delineates the intricacies of maxillectomy, providing exacting descriptions of the surgical incisions, strategies for managing unexpectedly large tumours and the delicate nuances of palate closure. The successful recoveries of both patients underscore the depth of his surgical acumen. In accordance with his general surgical background, Moore delineates a novel approach to address severe hypospadias and details his surgical methodology for managing imperforate anus. In the case of the former, characterised by a penoscrotal variety with a urethral opening located at the juncture of scrotal and penile skin, his technique involves rerouting the urinary flow through a perineal incision. The procedure entailed a transverse incision to rectify penile curvature, fixation of the penile shaft to the abdominal wall, and the application of skin grafts to address the resultant raw surfaces.
William (Jerry) Moore
Pioneer and reformist
Renowned Australian surgeon Sir Benjamin Rank (1911–2002), who trained under Gillies, provides the sole account of the life and era of William Moore.30 As a ‘Melbourne Hospital man’, Rank was intrigued by Moore’s inexplicable obscurity which was sparked by a casual comment from his anaesthetist, Leonard Lillies, in the operating theatre—‘I have not seen anyone do that since Jerry Moore.’ This inquisitiveness led Rank to delve into Moore’s enigmatic story, gathering insights from various primary sources, including case records preserved by Moore’s son, the Melbourne Hospital (now the Royal Melbourne Hospital) archives, the British Medical Association’s (BMA) records, and testimonies from Moore’s contemporaries.
In 1879, William Moore, an academically accomplished young man from Brisbane, left for Melbourne at the age of 18. He developed a passion for medicine during his time at Brisbane Grammar School, partly inspired by his second headmaster, Mr Crampton, who humorously nicknamed him ‘Jerry’ after a case of mistaken identity with a local cobbler’s son, Jeremiah Moore. Despite matriculating for Sydney University, William chose the University of Melbourne for what he perceived as a superior medical education. He graduated with top honours in 1883 (Figure 8). His career then took off as he quickly secured a role at Melbourne Hospital, specialising in skin diseases and outpatient surgery, a mere two years after graduating. During this time, he earned the titles of Doctor of Medicine and Master of Surgery (the first ever awarded by the University of Melbourne), completed a year’s residency at the hospital, and even served as a university anatomy demonstrator. Dr EM James, a respected surgeon at Melbourne Hospital, recognised Moore’s skills and frequently sought his assistance. Later, when Dr James returned to England, he offered Moore his medical practice and townhouse at 2 Collins Street, known as Alcaston House. While many of Moore’s colleagues initially doubted this decision, it marked a significant turning point in his career. Additionally, Moore corresponded with Dr James Beaney, another surgeon at the hospital who had frequent absences due to illness. During Beaney’s periods away, Moore stepped in as an inpatient surgeon, displaying a deep commitment to his patients by personally overseeing their treatment and closely monitoring their conditions.
Moore’s early career coincided with a transition from septic to antiseptic surgical practices. He advocated for Listerism and aseptic techniques, even in the face of resistance from senior colleagues. His introduction of Listerism at Melbourne Hospital led to a remarkable reduction in mortality rates for abdominal surgeries (up to 80%),2 ultimately gaining wider acceptance. Moore’s unwavering dedication to patient care, including round-the-clock postoperative visits, allowed him to promptly address issues at the source. This dedication ultimately earned him a position at St Vincent’s Hospital, where he served from 1899 to 1906.Those familiar with Moore often cited his deep dedication to the Baptist Church and his love for cricket. However, they also recognised his outspoken and principled nature, which sometimes led to controversy. A contemporary, Dr George Syme, wrote: ‘Both in writing and speaking he was lucid, logical, and dogmatic. He never seemed to have any doubts about anything, whether in surgery, hospital administration, cricket, politics, or religion. We often differed but one recognised the absolute sincerity of his views and actions.’30
Moore’s profound fascination with reconstructive surgery set him apart as a pioneering figure in the English-speaking world. His dedication to this field is evident through his extensive written contributions, including the 1899 book Plastic surgery: with illustrative cases.5 The exact source of Moore’s knowledge in the field of reconstruction remains a mystery. Although he was in communication with Wolfe, and while it is plausible that he encountered European techniques during his travels to the United Kingdom, Moore himself recounted that he ‘was eager to see old towns, old churches, country lanes and trees. Thinking what a lovely place England was kept me away from surgeons and hospitals.’30 Despite being an early proponent of the term ‘plastic surgery’ in English medical literature, his work was not recognised, even by prominent figures like Gillies. By 1900, Moore had significantly advanced reconstructive techniques, showcasing a meticulous and innovative approach to patient care. Moore’s meticulous approach is exemplified in his hospital records, where he left no detail unaddressed, from dressing patients personally over multiple days to designing intricate skin flaps.30 He demonstrated a profound understanding of flap vascularity management and advocated for primary repair of surgical defects using local flaps and skin grafts.5 While Moore excelled in many areas, he grappled with allografting due to the limited knowledge of graft rejection mechanisms at the time.
Throughout his career, Moore’s surgical skills, powers of observation, and courage in tackling complex cases earned him accolades from some contemporaries. His innovative techniques, such as perineal urethrostomy for hypospadias and ligating the saphenous vein for varicose ulcers, underscored his inventive spirit. However, in 1906, a series of unfortunate events led to professional and legal challenges, ultimately resulting in his resignation from the BMA in 1911 (see below). Despite this setback, Moore dedicated the latter part of his career to hospital management reform, focusing on issues like patient payment policies and electoral systems for honorary staff appointments. After retiring from Melbourne Hospital in 1914, Moore sought to serve in World War I but was retained in Melbourne for his expertise in plastic surgery. His later years were marked by a significant role in establishing the Carey Baptist Grammar School, where he served as the inaugural chairman from 1923 to 1925. In the last year of his life, he became a founding member of the new Royal Australasian College of Surgeons. Moore passed away in 1927 and the exact circumstances of his death remain undisclosed.
The regrettable events that marred the reputation of an esteemed individual30
In June 1906, an English shipping agent named EL Palmer, who was visiting Melbourne and staying at the Grand Hotel, sought medical assistance for a painful swelling in his mouth. He had already received advice and treatment in various cities during his travels, including Kobe, Shanghai, Rangoon and Calcutta. In Melbourne, he was under the care of Dr William Fox, a general practitioner who also specialised in X-ray work, electrotherapy and genitourinary medicine. After consulting Dr Fox, Palmer’s condition worsened, and he was due to sail for London. At the insistence of his friend, Mr Hutchinson, Palmer sought a second opinion from Dr William Moore. Moore diagnosed Palmer’s condition as malignant. Palmer eventually left for London and passed away during the voyage. Fox was incensed upon discovering that Moore had visited his patient without prior consultation, sparking a written exchange between them. Despite Moore’s diligent efforts to clarify his intentions, Fox remained resolute in his scepticism. In Moore’s ultimate correspondence to Fox, he lamented Fox’s reluctance to accept his straightforward explanation that he had merely sought to assist someone in distress, concluding ‘I regret that you do not accept my explanation in reference to Mr Palmer. It is also evident that no good purpose can be served by any further statement of mine.’30
The incident sparked a controversy, resulting in an extended legal battle and ongoing repercussions in the medical community. In fact, the case remained unresolved until August 1911 and overshadowed Moore’s legacy. Fox filed a formal grievance against Moore’s conduct with local medical associations and publications. When he found their responses unsatisfactory, he elevated the matter internationally to the head office of the BMA and its Central Ethics Committee. The escalation triggered widespread interest, resulting in an extensive exchange of letters and documents. Consequently, the involvement of the BMA and its Central Ethics Committee amplified the complexity and disagreements surrounding the case. Moore’s professional standing and reputation were challenged throughout the process. Eventually, Moore decided to resign from the Australian branch of the BMA, feeling isolated from the organisation and its members. The episode had lasting implications for Moore, impacting his professional and personal life. It also exposed the intricacies and challenges of resolving professional disputes within the medical community during that era.
Why was Jerry forgotten?
Moore’s remarkable contributions to the field of plastic surgery have, for the most part, lingered in relative obscurity. Rank put forth a number of factors that may shed light on the limited acknowledgment of Moore’s achievements.30
As surgical techniques evolved, placing a growing emphasis on abdominal surgery, many surgeons increasingly focused on visceral operations. Moore’s own career mirrored this shift after he visited renowned figures of the era, such as the Mayos (William and Charles), Edward Judd, George Crile, John Murphy, Howard Kelly, William Halstead, John Finney, Joseph Bloodgood and Roswell Park in the United States, as well as Berkeley Moynihan, Arbuthnot Lane and Victor Horsley in England.30 This period was a time of significant advancement in surgical science and its auxiliary disciplines, but a less progressive era for plastic surgery itself.
Furthermore, the radical surgical approach to malignant diseases, as practiced by Moore in his early career, began to wane in popularity in the early twentieth century, with the emergence of radiotherapy as an alternative. This new cancer treatment offered few opportunities for reconstructive surgery and the traumatic injuries prevalent in the industrial age were not as common. The medical community generally accepted the hardships of secondary intention healing as a normal consequence of severe injuries, while the infectious risks associated with primary wound closure remained a significant concern.
Lastly, Moore did not have a true protégé to whom he could pass on his skills. He lived a somewhat solitary life, isolated from other members of the medical profession which was catalysed by a five-year legal battle regarding an issue of minor consequence. He was not universally well-received by his contemporaries and did not align with the mainstream. He was a reformer, and his zeal for change often put him in conflict with the establishment. Such reformers do not necessarily rise to prestige through time served and agreeable conformity; instead, their recognition often comes in retrospect.
Conclusion
Moore’s extensive body of work serves as a testament to his surgical mastery, firmly establishing him as a pioneering visionary ahead of his time. His lasting legacy holds great importance in the realm of plastic surgery, notably as the author of the first English textbook dedicated to this discipline. It is deeply unfortunate that minor disagreements and the pervasive ‘tall-poppy syndrome’ have, to some extent, obscured his exceptional talents. Nevertheless, as we reveal the mysteries surrounding this remarkable figure, we fervently hope that William (Jerry) Moore finally receives the recognition he so rightfully deserves.
Conflict of interest
The authors have no conflicts of interest to disclose.
Funding declaration
The authors received no financial support for the research, authorship, and/or publication of this article.