With no textbooks or antibiotics, this WWI surgeon pioneered facial reconstruction

The First World War, which lasted from 1914 until 1918, ushered in a new kind of mechanized warfare. Bodies were maimed, burned and gassed, and as many as 280,000 combatants were left with ghastly facial injuries. Medical historian Lindsey Fitzharris says soldiers who suffered facial injuries were often shunned in civilian life.

"The reactions could be very extreme," she says. "This was a time when losing a limb made you a hero, but losing a face made you a monster."

In Britain, soldiers with facial injuries were called the "loneliest Tommies." When they left the hospital grounds, they were forced to sit on brightly painted blue benches so that the public knew not to look at them. The field of plastic surgery was still in its infancy, but one surgeon in England — Dr. Harold Gillies — endeavored to treat the wounded. Fitzharris tells Gillies' story in the new book, The Facemaker: A Visionary Surgeon's Battle to Mend the Disfigured Soldiers of World War I.

It was pioneering work. Any surgeon willing to rebuild a soldier's face had to consider the loss of function — such as the soldier's inability to eat or to speak — as well the aesthetics of what would make the face socially acceptable by the standards of the day. And there were no textbooks to guide the way, nor were antibiotics available.

"Gillies is really operating without a net. ... He doesn't have anybody teaching him how to do this. He's really got to make this up," Fitzharris says. "You really do have to come up with creative solutions, which he absolutely does."

Gillies lobbied the British War office to establish a hospital to treat facial injuries, and he banned mirrors in some wards so the newly injured wouldn't be traumatized by their own unrecognizable faces. He spent the war replacing lost skin and restoring jaws, noses and teeth to give thousands of veterans a chance to return to civilian life.

"What Harold Gillies is able to do for these men is not just mend their broken faces, but also mend their broken spirits," Fitzharris says. "That's what's at the core of The Facemaker: It's about identity and what happens to you when you lose that and how do you regain that back? And that's ultimately what Gillies was able to do for these men to help them restore their identities."

Interview highlights

On her use of the word "disfigured" in the book

I actually worked with a disability activist named Ariel Henley, who is the author of a book called A Face for Picasso, and we discussed the language and how I would end up describing some of these injuries in these men's experiences, and I do use the word "disfigured" in this book, which we might not use today. We might use a word like "facial difference." But I felt it was important that I didn't lessen that experience for the reader, because these men really were disfigured to the society they lived in.

On the challenge of getting injured soldiers off the battlefield

A face wound is very bloody. It's very ghastly. Anybody who's even had a minor cut on their face will know it bleeds and it bleeds and it bleeds. And so a lot of times these stretcher bearers just didn't think that these wounds were survivable. They had never seen anything like this before. And of course, they're in the midst of the terror of the battle as well, which doesn't help. So they would leave these men behind.

There are stories, for instance, of Private Walter Ashworth who lays on the battlefield after the first day of the Somme for three days without a jaw, unable to scream for help. And it's mind-boggling to us that somebody could just be left there for so long. But again, these stretcher-bearers, they just didn't think that these were survivable wounds. The other challenge was that often when they did remove these men, they would, with good intentions, place these men on their backs, on the stretchers, and inadvertently they would kill [them] because they would end up drowning in their own blood, or they would choke on their tongues because they didn't have the anatomy to hold their tongues [in] a normal position. So the medical challenges were immense. Just getting off the battlefield was a real challenge for these men.

On Gillies having to repair the work done by trauma surgeons in field hospitals

A lot of times these men were pulled off the battlefield. They were pulled from the trenches. They fell into the hands of trauma surgeons. Now, you could imagine close to the front in these hospitals, there was a lot of chaos around these surgeons. And really their focus is to save people's lives. So a lot of times they were just stitching these wounds very quickly, trying to stop the hemorrhaging, trying to save lives. And in doing so, often they were sealing these men's fate because they were suturing the bacteria from the battlefield into the face and into the wound. So when these men would get to Gillies, Gillies would often have to unpick a lot of what had been done near the front and start over. The process of rebuilding a soldier's face at this time could take many months, sometimes years, and even over a decade in some instances.

On why Gillies banned mirrors in the hospital ward

Gillies banned the mirrors because he was really trying in his mind to protect them so that they wouldn't be shocked by their faces for the first time. Also, as you're going through facial reconstruction, your face could look worse before it looks better. And he didn't want them to become depressed or frustrated with that process. So we can understand that. But also, he inadvertently instilled in these men a belief that they had faces that weren't worth looking at.

On the state of plastic surgery history at the time of the war

Plastic surgery predated the First World War. In fact, the term "plastic surgery" was coined in 1798. At the time, "plastic" meant something that you could shape or you could mold — so in this case, a patient's skin or soft tissue. But attempts at rebuilding or altering a person's face tended to focus on very small areas, such as the ears or the nose. You don't really get attempts at the wholesale restructuring of face until the mid-19th century during the American Civil War. And even then, there are a lot of differences between what's going on in the Civil War and what ultimately is happening in the First World War. And one of those is the fact that Civil War surgeons are just not interested in the aesthetics because the infection rates could be quite high at the time. That's before the wholesale adoption of germ theory. So they really only just go as far as restoring function, making sure the patient can eat and can speak.

On Gillies' collaborative methodology

[Gillies] was working in a very collaborative manner. He brought in X-ray technicians, mask makers, artists, dental surgeons as well, which was really important ... They are the ones who kind of build that scaffolding for Gillies. ... But the challenges were immense and ... an important principle of Gillies was that you replace like with like so you replace bone with bone, skin with skin. So there [were] no artificial implants that were going into the face at this time.

On where Gillies would get bone from to reconstruct a jaw

A lot of times they were grafting the bone from the patient himself. They would take cartilage from the ribs. They would take bone from the thigh. Anywhere really they could get it and they would be placing it into the face to rebuild that hard structure. It's absolutely mind-boggling when you consider this was before antibiotics. What Gillies and his team [were] able to accomplish was really miraculous on so many levels.

On the masks that some patients wore

A lot of people will be familiar with masks from World War I through the fictional character Richard Harrow and Boardwalk Empire. There were these wonderful artists who offered these nonsurgical solutions to disfigured soldiers at this time. People like Anna Coleman Ladd, who had a studio in Paris. And whenever I put up these still images of these masks online on Twitter, on Instagram, they tend to go semi-viral because they are startlingly realistic. But you have to remember that when you are looking at a still photo, it's very different than sitting in front of someone who might be wearing this mask, because the mask doesn't operate like a face. It doesn't age, it's fragile. It's difficult to wear over a wound. It's uncomfortable to wear. And for all those reasons, the mask didn't really offer that long-term solution that many of these men sought.

On Gillies' career after WWI

I think that Gillies is crucial to what plastic surgery ultimately becomes. After the war, he continues to work on the disfigured soldiers, of course, because the war isn't over for them. But he knows that if he is going to establish plastic surgery as a subspecialty in its own right, he's going to have to expand the practice. So he does move into the realm of cosmetic surgery as well. If people think of plastic surgery as a heading and underneath you have cosmetic and reconstructive — they're both important parts of plastic surgery and they both continue even to today. And so Gillies did both.

Lauren Krenzel and Thea Chaloner produced and edited the audio of this interview. Bridget Bentz, Molly Seavy-Nesper and Laurel Dalrymple adapted it for the Web.

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