A review by ergative
The Facemaker: A Visionary Surgeon's Battle to Mend the Disfigured Soldiers of World War I by Lindsey Fitzharris

dark emotional informative inspiring

5.0

 I love the history of science and medicine. I also love voyeuristic gruesomeness about horrible things happening to people who are long dead, especially if it includes all the gooey details. They’re skeletons by now, regardless of what happened to them, so I don’t feel bad about it. My fascination with this topic began in middle school, when I ran across some history textbook in the school library that included the picture here from Antonio Branca’s 15th-century approach to rhinoplasty. (In retrospect, a weird image to put in a book for 11-year-olds, but at the time I was blown away by how clever that strategy was to preserve tissue viability until it had grown attached to its new home.) This fascination has persisted into adulthood: A history of murder by poison? Awesome, count me in. An account of the Great Plague of 1665? Super, I’ll take two, please. A history of antisepsis, before which cutting off a single guy’s leg could have a 300% mortality rate? I’m still telling that anecdote to anyone who will listen. I have a tag on my blog just for this sort of thing—’Gushy ways to die’. So, naturally, when I learned that Lindsey Fitzharris—the very same from whom I first learned about the triply deadly amputation—had a written a new book about advances in facial reconstruction surgery during the First World War that developed out of the need to address the needs of soldiers who’d had their faces blown up in the trenches, I jumped on the chance, settled down with a glass of wine, and started to read.

Reader, it is still too soon. That voyeuristic gruesomeness that gives me such pleasure only works if the people are long dead, and the worse the things that happened to them, the longer dead they need to be. These boys are dead now, and their children are dead too, but they are not long dead, and their experiences are all the more immediate because Fitzharris makes heavy use of first-hand accounts. We don’t start with dry or clinical descriptions of what happened once they got into the hospital. We get first person narrations of what it was like to lie in the mud for three days, unable to scream without a jaw. And after that, those who survived lived to marry, have careers, have children and grandchildren, and were still playing with their grandchildren while my parents were in school. It is impossible to approach this topic with the sort of gallows humor that leads to jokes about 300% mortality rates. I think this is why Fitzharris leans into the gruesomeness so hard: There was absolutely nothing funny about World War I, and it is impossible to separate the astonishing medical reconstructions from the barbarity that made them necessary in the first place.

For this reason, the book is not comfortable reading. You can’t settle down with it to enjoy with a glass of wine the way you might settle down with an account of the murder of Sir Thomas Overbury (Chapter 18, if you’re curious). But it is fascinating reading. It focuses on the career and work of Harold Gillies, a surgeon who rebuilt countless soldiers’ faces after they had been exploded in battle. Everything you think would be relevant is included: Gillies’s education and professional training, the context of medical knowledge at the time, case studies of individual soldiers, from the moment of injury to their experiences getting from the battle to Gillies, to step by step descriptions of their treatment—including a collection of pictures showing the progress of the surgery. These pictures are, naturally, quite difficult to look at, but the end result is astonishing. You can still tell that the poor fellows had been through a bad time, but they have mouths and noses and jaws again, and the only holes in their faces are where holes are supposed to be.

Yet the pictures also contradict, slightly, an otherwise very moving refrain that Gillies would employ every time he met a new patient. ‘Don’t worry, sonny,’ he’d say, ‘you’ll be all right and have as good a face as most of us before we’re finished with you.’ That’s simply false in the case of the pictures in the book. But it seems, from the quotations and reminiscences, to have been true in many other cases. There’s one anecdote about a conversation at a dinner party, in which a lady talks favorably about what she’s read of Gillies’s work to her handsome dinner companion, only for him to say that he takes her approval of Gillies’s work as a personal compliment, since he himself was one of Gillies’s patients. The lady said later, ‘His face bore no sign of ever having been under a surgeon’s hand.’ I would have liked to see pictures of this sort of result. Maybe these cases didn’t start off in such a bad place as the men whose photos are included in the book, and so their transformation was not as astonishing, but the tender reassurance of Gillies’s refrain rings slightly false when the only pictoral evidence we get shows that he was lying through his teeth.

Beyond the primary reconstruction work that Gillies conducted, this book is full of fascinating details about related topics. For example: trench warfare was deadly not just from the shells and gas, but from infection as well, even with modern antisepsis. This is because the mud of the killing grounds was a soup of bacteria, regularly fed by new blood and bodies and rot and decay, and battlefield triage’s first priority was to stop the bleeding. And while this rush to close wounds might stop immediate death by blood loss, it only made it easier for infection to kill later, because sealing the wounds ensured a perfect inoculation of pathogens to find a home deep inside the tissues of the wounded soldier.

For example: rhinoplasty is a very old form of plastic surgery, and has been seen as morally suspect since the beginning. This is because, back in the Renaissance, syphilis dissolved a lot of noses, and people were keen to hide the mark of their infection. But because syphilis was seen as a moral failing, rather than a medical condition, getting surgery to hide it was akin to hiding your mark of shame, and frowned upon. (And it didn’t tend to work very well anyway then, either.)

For example: One groundbreaking technique that Gillies discovered, known as the tubed pedicle, was (a) developed independently at about the same time by two other surgeons and (b) claimed by one of Gillies’s colleagues as his own invention, despite Gillies’ possession of extensive medical records showing that he had used it a week before the colleague used it. As far as I can tell no one ever really believed the colleague, but the colleague nursed a grudge for decades afterwards.

For example: Gillies collaborated extensively with an artist named Henry Tonks, who created many paintings of battlefield medicine, and also painted portraits of Gillies’s patients. These portraits were a useful addition to photographs, because Tonks could capture the colors of the wounds, bruising and infection, in ‘angry crimson, lurid purple, and moldy greens’. Yes, we were turning STEM into STEAM over a hundred years ago.

For example: Long after WWI was over, Gillies continued to pioneer novel plastic surgery, and conducted the first FtM bottom surgery in the UK. This was legal because, although the UK had laws against the removal of a penis (because it didn’t like trans women even then; we have always been TERF island), it did not have laws against the creation of a penis.

It’s rather wonderful to discover that a man who was a hero 100 years ago was not a bigot who must be forgiven because he was ‘of his time’. And, indeed, in other ways, too, he showed values that resonate surprisingly well with current progressive thought. For example, he started carrying out cosmetic as well as reconstructive plastic surgery after the war was over, and although such practice was criticized by people who believed it was just an excuse to make money, Gillies felt no shame about it: Yes, it brings in money, but ‘to see the lasting pleasure that often follows makes me wonder who we are to refuse a patient.’ It was, he concluded, justified by ‘the little extra happiness [it brings] to a soul who well needs it.’ And so important was this desire to bring a little extra happiness to Gillies that he operated on a sliding scale, performing procedures for reduced prices or even for free if the patient needed treatment and couldn’t afford it.

This goal of improving happiness, rather than shaming perceived vanity, strikes me as quite modern and progressive, just as much as Gillies’s lack of transphobia. How does it hurt you if someone gets a nose job? Let people live their lives, and if you help them do that, you are a good person.*

This book is due to be released 7 June, and if you have the stomach for it, it will repay your attention handsomely.

NB: I received an advanced copy of this book from Netgalley. Inasmuch as I can be sure of such things, I believe that this has not affected the content of my review.

*I sincerely hope that Gillies was not a complete misogynistic fascist dick in other domains of his life. If he was, Fitzharris doesn’t mention it.