REVIEW BY CALUM HENDERSON.
William Vicarage was just 20 years old when he sustained severe cordite burns aboard HMS Malaya during the Battle of Jutland in 1916. As well as extensive wounds to his hands and upper body, the able seaman’s eyelids and lower lips were turned inside out, leaving him unable to close his eyes or open his mouth. His injuries were horrifying – and also incredibly painful.
Months later, Vicarage came under the care of Harold Gillies, the legendary plastic surgeon and subject of this new book by Lindsey Fitzharris. ‘How a man can survive such an appalling burn is difficult to imagine,’ Gillies wrote of Vicarage’s injuries. ‘It required very considerable moral courage to attempt an operation such as could in any way radically cure the condition.’
Moral courage was not a quality Gillies lacked. Instead, he was a supremely confident individual of whom it was once said that talent was ‘mysteriously inherited rather than laboriously acquired’. As a young man at school, his precocious and rebellious nature rubbed along with a commitment to fairness and hard work. In the words of one of his patients, he was ‘a man of steel nerve and a great heart’.
Born in New Zealand in 1882, Doctor Gillies was newly qualified and newly married, and based in England, when the First World War broke out in 1914. Very quickly the conflict grew to a scale previously unseen in human history, posing a staggering challenge for the medical profession. As one battlefield nurse recalled, ‘The science of healing stood baffled before the science of destruction’. Men were being cut down quicker than aid could reach them. And those who came back did so with truly terrible injuries.
Gillies was interested in otorhinolaryngology – or ear, nose, and throat medicine – from the outset of the war. Among his first experiences in the field were those under the tutelage of the eccentric French-American dentist Auguste Charles Valadier, many of whose wartime patients had never so much as picked up a toothbrush. It was from Valadier that Gillies learned an early and crucial lesson: that facial repair was more than just skin-deep, that it required extensive rebuilding of the underlying structures of the skull. And that it was a team effort.
Frustrated by the lack of a centralised unit for facial injuries, Gillies persuaded the British Army’s chief surgeon, William Arbuthnot-Lane, to allow him to set up and run a specialist ward at the Cambridge Military Hospital, which was actually in Aldershot. After gathering a team of doctors and nurses there, he instructed medics at the front-lines to send him soldiers who would be suitable for his unique type of care.
In this sense, there was an experimental element to Gillies’ work, something of which he was acutely aware. Time and again he talks of trial and error, of ‘fumbling towards new methods and new results’, often from ideas literally scribbled on the back of an envelope. No doubt he enjoyed his work, despite how gruesome it could often be. This was clearly a man who liked a challenge.
And challenges there were. As the hospital was based in England and not France, many soldiers came back with their shattered mandibles, missing noses, and empty eye sockets already hastily patched up by front-line doctors, something which only gave Gillies further problems. He was forced to risk infection by reopening wounds to conduct deeper and more thorough reconstruction. This could involve 10 or even 20 operations, often without success.
To regrow tissue, he relied on creating ‘flaps’, which involved moving a piece of healthy skin, usually still attached to the body, to cover and regrow over an area of damage. This was fraught with difficulty.
And it was all done in the days of chloroform, an unstable anaesthetic which could cause heart failure and other issues. It had to be administered orally through a mask (endotracheal tubes had yet to be invented), which was doubly tricky on patients who had no recognisable mouth, nose, or lower facial structure.
Quite a few men under Gillies’ care were later sent back to the front, only to be killed. And even those who survived the war found civilian life immensely difficult. A facial injury, after all, was very different from a missing leg. Whereas one would evoke sympathy and understanding from the public, the other caused horror and revulsion. Many of the men led sheltered lives, often without loved ones they had met or even proposed to before the war.
Gillies clearly cared deeply about the psychological impact of the injuries. Later in the war, the hospital was expanded to a new site at Frognal House in Sidcup. The added space allowed his patients to convalesce together and engage in various therapeutic hobbies and pastimes, all of which had a noticeable impact on recovery.
With the war’s end in 1918, the number of wounded soldiers eventually dried up. Gillies later established his own private practice, treating those brave and rich enough to opt for early cosmetic surgery. In 1946, Gillies, still working hard, performed what must have been one of the earliest gender reassignment operations. Fourteen years later, he died, a month after suffering a stroke while operating on the damaged leg of a young girl.
Although The Facemaker is not an exhaustive biography of Gillies nor a comprehensive account of his work, it provides a fascinating insight into both. Fitzharris has an immensely readable style and brings out all the humanity in the many men under Gillies’ care. Her descriptions of the injuries are blunt, but never lurid. And the inclusion of pictures is a brave but necessary choice.
As for William Vicarage, Gillies was able to reconstruct his eyelids using a technique called an epithelial inlay, which involved another type of skin graft. The method was originally devised by a Dutch surgeon called Johannes F Esser, a reminder that Gillies was not always a pioneer, instead using methods from contemporaries, such as oral surgeons Hippolyte Morestin and Varaztad Kazanjian, as well as ancient figures such as Sushruta, the Indian surgeon born in 800 BC who conducted the first rhinoplasty.
But the point with Gillies was that he always thought of the individual, adapting procedures to suit specific cases (as he did with Vicarage and the epithelial inlay). He was no aloof doctor who shied away from close contact with his patients, operating on them only when they were anaesthetised.
As one sergeant recalled, ‘ordinary soldiers received as much care as officers’. Gillies, he added, ‘even dressed my wounds himself and visited me at night to see if I was comfortable, though he was up to his eyes in work.’ That was the remarkable thing about him. All of his patients got his full attention, all of them got to see him face to face.
The Facemaker: one surgeon’s battle to mend the disfigured soldiers of World War I, Lindsey Fitzharris, Allen Lane, hbk (£20), ISBN 978-0141999166.