A rare but greatly feared complication in brain surgery is complete facial paralysis from damage to the part of the brainstem called the floor of the fourth ventricle. I saw this four times in my career, to my dismay. The patient, otherwise of normal appearance, is left with an immobile, mask-like face. It is a disaster, as facial expression is such a vital part of human life. You struggle to overcome an instinctive conviction that there is something weird and profoundly alien about such patients and that they are quite without feelings – evolution has so hard-wired us to judge people by their faces.
For every soldier killed in battle, many more are left seriously wounded, some of them with grotesque, disfiguring facial injuries. As Lindsey Fitzharris writes in her scholarly yet deeply moving book The Facemaker, about the First World War facio-maxillary surgeon Harold Gillies, it is said that in the Napoleonic Wars soldiers with disfiguring facial injuries would be killed by their comrades as an act of kindness, to spare them the miserable life that otherwise awaited them as social outcasts.
There was nothing new about facial injuries in wartime at the onset of the First World War, but the combination of the huge armies involved, trench warfare and modern munitions meant that the sheer scale of the problem was unprecedented. Civilian surgeons suddenly drafted into the army would have had no experience of such wounds, which were often contaminated with dirt and fragments of clothing and needed entirely different methods of surgical treatment from injuries in civilian life. Above all, there was – for want of a better word – the cosmetic problem. It is one thing to stitch a lacerated limb together, quite another to do the same for a face, especially when associated with major tissue loss.
Harold Gillies was born in 1882 in New Zealand but trained as a doctor at Cambridge University, where, apparently, he was regarded as a maverick with a remarkable lack of respect for authority. He had, however, great personal charm and was widely liked. He also had a highly organised and practical mind and was a fantastic golfer. All these were qualities that played an important part in his subsequent groundbreaking work in the treatment of facial injuries and the establishment of plastic surgery as a speciality in its own right. He started his career as an ear, nose and throat surgeon, working with the fashionable ENT surgeon Milsom Rees in Harley Street – Gillies claimed that he got the job because of his outstanding golf playing rather than his surgical skills.
With the declaration of war, he immediately volunteered and was soon treating horrific injuries at the front in Flanders. Fitzharris describes these in accurate detail, without ever losing sight of the human lives behind each injury. The book includes some graphic photographs of Gillies’ work and his exceptional results (though many of his records were destroyed in the Second World War when the Royal College of Surgeons was bombed).
Fitzharris has already shown herself to be a fine medical historian, writing for a non-medical audience, with her previous book about Joseph Lister. The Facemaker strikes a balance between describing Gillies’ extraordinary achievements and showing how other surgeons in France, Germany and the US were making progress in the same field – medical pioneers such as the French surgeon Hippolyte Morestin, who was described by one of his trainees as sometimes behaving like “a wild beast, swift and ferocious” when operating.
When Gillies, already a skilled surgeon himself, went to visit Morestin to see him at work – “my tongue… literally hanging out with the thirst of knowledge that I hoped to obtain” – he was refused entry to the theatre by Morestin. It is not unknown for surgeons to guard jealously their secrets, but such behaviour was entirely alien to Gillies, who always welcomed visitors to see him operate. What distinguished Gillies from other surgeons was not just his exceptional surgical abilities but also his skill as a leader in building a multidisciplinary team – a quality that is quite rare in surgeons, who are often intensely egotistic. He was very much ahead of his time in this regard.
From the beginning of the war, Gillies tried to improve the treatment of facial injuries, suggesting to an uninterested War Office that soldiers with these injuries be tagged with labels directing them to his specialist unit at the Cambridge Military Hospital. He bought the labels himself at a stationer in the Strand and asked the War Office to distribute them – which, rather surprisingly, it did.
Gillies established his own hospital, dedicated to soldiers with facial injuries, at Queen Mary’s Hospital, Sidcup, in 1917. The emphasis was on teamwork, and Gillies’ easy-going but highly efficient management was critical to develop the world-beating results the hospital achieved. (Forty years ago I worked in the hospital as a registrar in general surgery. It had become a district general hospital by then, and its glory days under Gillies were long gone, but its fame lingered on a little in the derelict historic Frognal House and its grounds, which had been the doctors’ residence.)
Facial injuries present unique problems: they require close cooperation between plastic surgeons, dentists, anaesthetists, artists and prosthetic craftsmen, as there is the vital cosmetic element to the work. The patients will often require dozens of procedures, slowly rebuilding the ruined face with skin, cartilage and bone grafts. And then, of course, there is the terrible psychological impact of disfigurement, and the need to maintain the patients’ morale as they undergo many procedures, often at first looking worse as their faces were rebuilt.
Mirrors were banned in Queen Mary’s Hospital. It is clear that Gillies was adored by his patients, and radiated confidence and optimism with them, even though in private he was sometimes reduced to tears by his failures. He treated his patients as equals – as all good doctors should. Education and technical training were available to the injured soldiers, and Gillies happily turned a blind eye to the consumption of alcohol. The patients described Queen Mary’s Hospital as a “paradise”.
Gillies’ surgical motto was, “Never do today what can wait until tomorrow” – advice all surgeons should follow whenever possible. He would often procrastinate before operating, sitting in his office smoking, pondering the operation ahead, and the many ways of tackling it. Fitzharris describes how artists such as Henry Tonks and the sculptor Kathleen Scott (widow of the Antarctic explorer) played a key role in planning the many procedures the men had to undergo over long periods of time.
This is a fascinating book about a remarkable man, and of how teamwork is such an important part of good surgery. Despite the grim subject matter, it is a deeply moving and uplifting story.
Conflict has now returned to Europe – thousands of young men and women are once again being killed or wounded, at the behest of old men. Some will be horribly disfigured. The treatment they will receive owes much to Gillies and other doctors like him. War is a great accelerator of the technology for killing people, but also for treating the injuries of the survivors. The trouble is that there has been rather less progress in politics and the conduct of human affairs.
The Facemaker
Lindsey Fitzharris
Allen Lane, 336pp, £20
Henry Marsh is an author and retired brain surgeon. “And Finally: Matters of Life and Death” will be published by Jonathan Cape in September.
This article was originally published on New Statesman.