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

DAVE DAVIES, HOST:

This is FRESH AIR. I'm Dave Davies in today for Terry Gross. Injured war veterans are among society's most venerated figures, saluted and cheered at parades for all their days. But our guest, Lindsey Fitzharris, has the story of a cadre of seriously injured soldiers and sailors who were treated differently. The First World War brought a new kind of mechanized warfare in which heavy artillery, flamethrowers and chemical weapons inflicted ghastly wounds on combatants and left horrific facial injuries on many who made it off the battlefield alive. Fitzharris writes that in Great Britain, soldiers with gruesome facial wounds were not embraced by civilians back home. Fiances broke off engagements. Children fled at the sight of their fathers. Even some medical personnel would turn away in horror.

Fitzharris' new book tells the story of a surgeon who made a specialty of treating facial wounds at a time when plastic surgery was in its infancy. He got the British War Office to establish a hospital to treat the 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 these veterans a chance to return to civilian life. Lindsey Fitzharris is a writer with a Ph.D. in the history of science and medicine from the University of Oxford. Her first book, "The Butchering Art," was about the groundbreaking 19th century physician Joseph Lister. She's also the writer and host of the Smithsonian Channel series "The Curious Life And Death Of," which explores mysterious deaths in history. Her latest book is "The Facemaker: A Visionary Surgeon's Battle To Mend The Disfigured Soldiers of World War I."

Lindsey Fitzharris, welcome to FRESH AIR.

LINDSEY FITZHARRIS: Thank you so much for having me on the show.

DAVIES: You know, I think we should just first acknowledge that hearing about some of these injuries can be upsetting. And we will certainly talk about the injuries, but I think we'll try and do it in a way that is not overly graphic. But we should just warn people that some of this stuff can be a little disturbing. You would agree, I assume?

FITZHARRIS: Yes, definitely. You know, and it's interesting, too, because 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 we would - you know, how I would end up describing some of these injuries and 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.

DAVIES: Let's begin with how war changed in World War I. It was different. Why were these injuries, particularly those to the head and face, so serious?

FITZHARRIS: Well, the nature of trench warfare at this time led to a high number of facial injuries. There were an incredible number of advances in artillery and weaponry - so many, in fact, that a company of just 300 men in 1914 could deploy equivalent firepower as a 60,000-strong army during the Napoleonic War. And there were a number of ghastly inventions. There was the flamethrower, which belched forth fire that destroyed everything in its wake. There were tanks which left crews susceptible to new kinds of injuries that had never been seen in previous wars. And of course, there were chemical weapons. Even as gas masks were being rushed to the front, these lethal gas attacks became instantly synonymous with the savagery of the First World War.

Men were maimed. They were burned. They were gassed. Some were even kicked in the face by horses. Before the war was over, 280,000 men from France, Britain and Germany alone would suffer some form of facial trauma.

DAVIES: Losing a limb, you know, or more than one limb, of course, can be horrific and change the injured soldier's life forever. But you write that a facial injury has a different kind of impact. Take a moment...

FITZHARRIS: Yeah.

DAVIES: ...Tell us why.

FITZHARRIS: Absolutely. You know, I often say that this was a time when losing a limb made you a hero, but losing a face made you a monster to a society that was largely intolerant of these facial differences. And a lot of these prejudices go back hundreds, if not thousands, of years. And they're associated, for instance, to beliefs around disease. So in earlier periods, if you had syphilis, you might develop something called saddle nose, and that's when your nose caves into your face.

And so a lot of times, disfigurement was associated with disease. It was associated with criminality because certain crimes required purposeful disfigurement as a form of punishment. And this is very much alive on the eve of the First World War. Any surgeon willing to rebuild a soldier's face at this time not only had to consider the loss of function, such as the soldier's inability to eat or to speak, but that surgeon also had to consider the aesthetics so that the face was deemed socially acceptable by the standards of its day.

DAVIES: You know, you write about the reactions that civilians had to some of these injuries. I think there's a story about the Prince of Wales actually insisting on visiting one of these wards, which had among the most serious injuries, had to be carried out. Is this true?

FITZHARRIS: Yeah, that's right. One of the patients writes a letter about this, and he - the Prince of Wales had come to visit. He insisted on going onto these wards. He was warned that it could be quite disturbing. And apparently, he fainted, and he had to be carried out. So the reactions could be very, you know, extreme to these men's faces. And it was a really isolating experience. In fact, a lot of these men in Britain 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. It was a really awful time. And so what Harold Gillies is able to do for these men is not just mend their broken faces but also mend their broken spirits.

DAVIES: Right. So let's talk about treating these injuries. The man who is at the center of this story is a surgeon, Harold Gillies. Tell us about him.

FITZHARRIS: So Harold Gillies was born in New Zealand. He moves to Britain when he's 18. He goes to Cambridge University, and he goes to medical school. And he trains as an ENT - an ear, nose and throat surgeon. And so when the war breaks out, he goes to France with the Red Cross, and it's there that he meets this bigger-than-life character. His name is Auguste Charles Valadier. And he's a French American dentist. And he retrofits his Rolls-Royce with a dental chair, and he literally drives it to the front under a hail of bullets. This guy is bigger than life. He works for free the entire war.

And it's really Valadier who teaches Harold Gillies this desperate need for facial reconstruction near the front at this time. And he also demonstrates the importance of good dentistry when rebuilding a face. And that's how it really begins. Gillies feels really fired up about what he sees there, and he sees this great need, and he eventually goes back to Britain, and he petitions to open a specialty unit, which he does at the Cambridge Military Hospital in Aldershot.

DAVIES: You know, one of the first obstacles to effectively treating these facial wounds was getting them off the battlefield. That wasn't so easy given the trench warfare of World War I, was it?

FITZHARRIS: Yeah, you're absolutely right. You know, these stretcher-bearers, the moment that they stepped off onto the battlefield, they became targets themselves. It could take as many as 12 men to remove a single man at this time. It was very laborious. It was very dangerous. And so these stretcher-bearers really had to make split-second decisions about who was going to be removed from the battlefield and who was going to be left behind.

Now, 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. And 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 these men 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 into a normal position. So the medical challenges were immense. Just getting off the battlefield was a real challenge for these men.

DAVIES: Right. So you had to get them out and make sure that they were facedown.

FITZHARRIS: Yeah.

DAVIES: Now, Gillies, although he did go to the front initially, the serious work he did in treating these facial injuries was not done in field hospitals. He established this hospital back in England where he would do this in a serious way. One of the things that he confronted, you write, was that the surgeons who had initially taken care of the soldiers in the field when they were immediately taken away, was that they would have stitched up gaping wounds on a face just, you know, by pulling whatever adjacent skin was there and suturing it. This was kind of a problem for the more long-term treatment of a facial injury, wasn't it?

FITZHARRIS: So what happened a lot of times is 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.

DAVIES: Right. He had to - there were often sometimes missing teeth, missing jaws, missing noses - a lot of bone and cartilage that had to be reconstructed. That meant a lot of operations - right? - which required recuperation time in between.

FITZHARRIS: Yeah, absolutely. And that was a real challenge as well. So when he establishes the Queen's Hospital in Sidcup, which is the first-ever hospital dedicated entirely to facial reconstruction, one of the issues is that he's just overwhelmed by the sheer number of men requiring his help - remember, 280,000 men from France, Britain and Germany requiring some kind of facial reconstruction at this time.

And the other issue is, as you say, that there's long periods of convalescence. So you go through the initial operation, and then you have to wait perhaps several months before you can go through the next installment. And so a lot of times, especially at the beginning of this process, Gillies would move people out of the hospital or out of his specialty unit into other hospitals while they rested and they waited to go under further operations. So it was a real process. There's real machine to move men in and out of the hospital and to make sure they were getting the required help that they needed.

DAVIES: Let's take a break here. Let me reintroduce you. We are speaking with Lindsey Fitzharris. She is the author of the new book "The Facemaker: A Visionary Surgeon's Battle To Mend The Disfigured Soldiers Of World War I." We will continue our conversation in just a moment. This is FRESH AIR.

(SOUNDBITE OF THE WESTERLIES' "PLEASE KEEP THAT TRAIN AWAY FROM MY DOOR")

DAVIES: This is FRESH AIR, and we're speaking with writer Lindsey Fitzharris whose new book is about the efforts of a surgeon to repair ghastly facial wounds suffered by British soldiers and sailors in World War I. The book is titled "The Facemaker."

You know, you write that Gillies - you know, he took to this task with a lot of enthusiasm, but he knew he had a lot to learn. And I wonder, did he learn from experience that you can't rush it, that you can't try and make these operations too close together even though the soldiers wanted to get back to normal?

FITZHARRIS: Yeah, that's absolutely true. And he had no textbooks to guide him, so he really was sort of making this up as he went. But as you say, there were some hard lessons. And failure is a very important part of the history of medicine, and we really don't discuss failure enough and the role it plays in shaping what ultimately we discover does actually work for patients.

So the one case that I can refer you to is 2nd Lt. Henry Ralph Lumley. He was a pilot. He crashed his flight on the first day of graduation. It was terrible. He never even made it into battle. And it takes a year before he finally finds his way into Gillies' care. He's sent to different hospitals along the way. Now, you can imagine a terribly burned face and torso, what happens to the skin after a year of not getting the required treatment.

Now, when he gets into Gillies' care, he's also heavily addicted to morphine at this time. And he's just in overall bad state, but he's very despondent, and he begs Harold Gillies to do the operation as soon as possible. Gillies doesn't think he should operate quite yet because Lumley is in such a bad state, but he gives into Lumley. And as a result, Lumley ends up dying. This is personally such a sad story, but it's such an important story to the history of plastic surgery because it teaches Harold Gillies a tenet, or a principle, of plastic surgery, which is that when you are rebuilding a soldier's face at this time, you have to do it in piecemeal. You can't do it all at once, which is what Gillies tries to do with Lumley.

Now, I do include photos in "The Facemaker," and I wanted to make sure that this was done sensitively, that it wasn't medical voyeurism. But there is an exception. I don't include photos of Ralph Henry Lumley because he didn't get to complete his reconstructive work. And so I only include a photo of him before he's injured and then a surgical diagram of what Harold Gillies was hoping to do.

DAVIES: Yeah, I think the photos are really moving. And, you know, it's not for the squeamish, but it's an important visual representation of what these men suffered and what Dr. Gillies and the other surgeons faced. That said, it occurred to me as I looked at these photos that seeing them on a page is one thing; seeing them in real life would be another.

FITZHARRIS: Yeah. I mean, the photos are - as you say, they're important to helping the reader visualize the kind of work that Gillies was doing. But also, these men were forced to sit on brightly painted blue benches so the public knew not to look at them. I didn't want to put them on the metaphorical blue bench in 2022. But as you say, it was difficult to look at the photos as a reader but it - important process. And it would have been hard for the nurses and the doctors themselves to look at these men.

But Gillies always kept up this peppy attitude, and he would say, you know, don't worry, sonny. you'll have as good a face as any of us before I'm done with you. And he really instilled that confidence. And these men developed lifelong friendships and relationships with Gillies as a result.

DAVIES: Yeah, a couple of them went to work for him, you write.

FITZHARRIS: Yeah.

DAVIES: Did he really ban mirrors in all the wards?

FITZHARRIS: He did ban mirrors, you know? And this was something that I had originally put into the manuscript without really contemplating what that actually meant. And this is why talking to Ariel Henley, the disability activist, was very handy in helping me contextualize this, because 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. And I think that we do need to recognize that as amazing and wonderful as Gillies' work was, he also was a product of these biases towards these disfigured faces as well.

DAVIES: But those are really standards that we have in, probably, any human society, right? I mean, people would want most faces that they look like to - look at to be recognizable as faces. Although, I will say, looking at the photos in the book, the ones which - the final shots, which show the facial reconstruction complete, you can tell that these are people, in almost all cases, who have suffered serious injuries still, I think. Yeah. So let's talk about how he did this. A lot of the cases involved situations where a man's nose was missing or partially missing. How do you replace a nose?

FITZHARRIS: You know, and I'll go into some of this. But I'm a historian. I'm not a doctor. And so I actually did end up consulting with several doctors to make sure that all the descriptions were correct, because it could be really difficult to look at these case notes and translate that into what Gillies was doing. So I will just talk about flaps and graphs, or sort of the main components for rebuilding a face. And you can think of grafts as sort of the salami of plastic surgery. It's the thinner piece of meat. And it doesn't necessarily stay attached to the blood supply, so a skin graft. You can move a thin piece of skin from one area of the body to another area of the body to rebuild part of the face. The other important aspect is flaps. Flaps are like the steaks of plastic surgery. It's a thicker piece of tissue. It remains attached to one side, to a blood supply.

So with World War I, the damage to these men's faces was so extensive, you're really going to need thicker pieces of tissue to rebuild the faces. And you're going to need things like bone as well. So what Gillies is able to do is to take various flaps and grafts and rebuild the face. One of the oldest procedures in medical history is rhinoplasty. And that goes back thousands of years. If you take a piece of string from the tip of your nose to the top of your forehead, you will see that the length of your nose is roughly the length of your forehead. So one of the ways you can rebuild the nose is you move a flap down from the forehead. So you cut that from the forehead. You move it and twist it down over to the nose. And then you rebuild the nose that way. And you take...

DAVIES: And if I could just interrupt here, Lindsey, you're talking about skin, not bone, right?

FITZHARRIS: No, not bone, but not just skin either. So the tissue underneath the skin, so you can move all of that down over the nose to rebuild it. And then what you do is you take the remaining skin on the forehead, because it's quite stretchy, I'm told - I haven't ever done this procedure myself. And you can stretch it over the area where the flap was then taken. And so you can cover that area so that you don't have a visible scar. So this is a very ancient method for rebuilding the nose. It's one that Gillies would have used as well at the Queens Hospital. But of course, again, we're talking about extensive damage. Plastic surgery predated the first world war. In fact, the term plastic surgery is 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 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 can be quite high at that 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. So Gillies is really operating without a net. He doesn't have textbooks. He doesn't have anybody teaching him how to do this. He's really got to make this up. And so plastic surgery really is both a creative and scientific pursuit at this time because you have to visualize how you can rebuild someone's face. And you really do have to come up with creative solutions, which he absolutely does.

DAVIES: Let's take a break here. I'm going to reintroduce you again. We are speaking with Lindsey Fitzharris. She's an author with a Ph.D. in the history of science and medicine from the University of Oxford. Her new book about Dr. Harold Gillies is "The Facemaker: A Visionary Surgeon's Battle To Mend The Disfigured Soldiers Of World War I." She'll be back to talk more after this short break. I'm Dave Davies, and this is FRESH AIR.

(SOUNDBITE OF THE WESTERLIES' "FROM THE VERY FIRST TIME")

DAVIES: This is FRESH AIR. I'm Dave Davies in for Terry Gross. Our guest is writer Lindsey Fitzharris, whose new book is about the efforts of a surgeon to repair ghastly facial wounds suffered by British soldiers and sailors in World War I. It was a time when mechanized war did horrific damage to combatants, and plastic surgery was in its infancy. The book is titled, "The Facemaker."

Now, and some of these soldiers, they would have jaws that were missing, teeth that were missing. You essentially have to replace bone. How would you do that, like, replace a jaw?

FITZHARRIS: So one of the important things that happened during the First World War, there were a lot of other surgeons in different countries working on facial reconstruction because, again, that great need for this kind of surgery at the time. But the difference with Harold Gillies was that he was working in a very collaborative manner. He brought in X-ray technicians, mask makers, artists, dental surgeons, as well, which was really important. Remember, when he met Valadier in France, Valadier taught him how to rebuild a face but also taught him the need for good dental surgery - the scaffolding, the hard, you know, substances below the soft tissue.

So he is working with dental surgeons at the Queen's Hospital, and they are the ones who kind of build that scaffolding for Gillies, and then he can reshape the face above. But as you say, the challenges were immense. And there was really - an important principle of Gillies was that you replace like with like. So you replace bone with bone, you know, skin with skin. So there was no artificial implants that were going into the face at this time.

DAVIES: So where would you get the bone to replace a jawbone?

FITZHARRIS: So 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 was able to, you know, accomplish was really miraculous on so many levels.

DAVIES: Right. And you can also see why if you had to replace the bone and then the teeth and then the skin to make it aesthetically more acceptable, that would take many, many surgeries - dozens in some cases, right?

FITZHARRIS: Dozens in some cases. And also, Gillies did employ mask makers. Now, the mask makers - a lot of people will be familiar with masks from World War I through the fictional character Richard Harrow in "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 or 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 'cause the mask doesn't operate like a face. It doesn't age. It's fragile. It's, you know, difficult to wear over a wound. It's uncomfortable to wear. And for all of those reasons, it didn't - the masks didn't really offer that long-term solution that many of these men sought.

Gillies did employ mask makers, but he kind of hated it as well because they reminded him of the limitations of his own craft at the time. But they could be useful, for instance, while a patient was awaiting further surgery. In fact, there's an example of a man who wears one of these tin masks when he goes out into London, and sometimes it would be too hot, or he would just be uncomfortable, so he would take the mask off. And when he came back to the hospital, he would hold up one, two, three or four fingers to indicate how many people had fainted or reacted negatively to his face.

So I always remind people that as wonderful as these masks are - and you can find these images online - you have to remember these men were wearing the mask for you so that you could look at their faces, so that you would be able to accept them. They weren't wearing the masks for themselves because they were really uncomfortable to wear.

DAVIES: You know, anesthesia had been invented by the time of World War I, but it wasn't the specialty that it is today. I guess they used ether. They used chloroform. What challenges did they present in these complicated surgeries?

FITZHARRIS: Yeah, you're right. Anesthesia hadn't really progressed since 1846, when ether had been first discovered. So you're talking about a rag with chloroform over the face or a rudimentary mask to give ether to the patient. Now, when you look at the faces of these men, you will instantly understand why putting a mask over their faces was problematic. It would be very painful. It would also obscure the area that the surgeon was required to work on. In fact, there is a scene in the book where Harold Gillies is leaned over a patient, and the patient is breathing ether back into his face, and he's getting sleepy, which is, by the way, a terrible situation for your facial reconstruction surgeon, you know, doing this delicate work there.

So this was a real challenge for Gillies and his team. And so it's no wonder that anesthesia also progresses in parallel with facial reconstruction at this time. In fact, it is Harold Gillies' anesthetists, which is what they call them in Britain. It's his anesthetist, Ivan Magill, who ends up developing intratracheal anesthesia so that he can bypass the face altogether.

DAVIES: Do we have any idea how many of these faces Harold Gillies repaired over the course of the war?

FITZHARRIS: It was thousands of patients.

DAVIES: Really?

FITZHARRIS: But one of the struggles as a historian is that a lot of the case notes were destroyed during the Second World War. So a lot of this material was kept at the Royal College of Surgeons in London. And I talk about this in the epilogue. That building was bombed during the Second World War, so some of that was lost. Gillies himself did publish two very important books on plastic surgery, so we also have an idea through his own publications, and some of the case notes did survive, but we definitely don't have the complete picture of how many men he worked on during that time. And after the war, he continued to work on these men, of course.

And I also just want to say that, you know, I think a lot of readers will pick this book up, and they will gravitate towards this positive message that these wonderful medical advances came out of the First World War because nobody wants to think that we participated in this inhuman event and nothing good came from it. But halfway through my research, I came to the grim realization that as much as these advances, you know, have served us long after the guns fell silent on the Western Front, they also, in the moment, served to prolong the war because as doctors and nurses got better and better at patching these men up, they were often being sent right back to the front. They were feeding the war machine, and it was a vicious cycle. And I think that's a really important part of the story that needs to be acknowledged.

DAVIES: I was going to get to that. You know, you describe a private named Percy, I think, who went through a long, you know, set of surgeries and then gets this note saying, you're going back.

FITZHARRIS: Yes. You know, Percy Clare is the first soldier we meet. And the one thing I knew was that I wanted to drop the reader right into the middle of the battle. I wanted them to see what that was like. What were the trenches like? What did they smell like? What did it look like? What did it feel like to be left on that battlefield? Now, that was a difficult challenge because not all of these men wrote about their experiences in any kind of extensive way. But Private Percy Clare did. He left this beautiful diary behind about his experiences. And I actually have been corresponding with some of his family members.

So Private Percy Clare is shot in 1917. And as you say, later in the book, we find out that he receives this note; he's going to be sent back to the front. And that was, really, what happened to a lot of these men. It was frustrating for Harold Gillies, too, because he had a duty to the army. He had a duty to his patients. There's another man who gets sent back and ends up dying in the same casualty clearing station that he had originally been brought to. So imagine going through all of that extensive reconstructive surgery and then being sent back and being further injured or perhaps even killed. It was awful.

DAVIES: Right. And I'm happy to note that Percy Clare's picture is in the book after the war, and he is standing there in a suit and a cane, I believe. He made it.

FITZHARRIS: Yes, that was - you know what? I didn't have his case notes because they were destroyed during the Second World War. So he was one of those odd, you know, figures who he presented - as a history, he presented so much material to me through this diary. But then I don't have Harold Gillies' case notes on his actual face. So that was a bit frustrating.

Clare gets sent to the wrong hospital throughout the book. So we periodically check in with him, and I wanted to anchor the reader in the story to one particular soldier to just see how difficult it was, again, to get off the battlefield but also to get into the care of Harold Gillies and then what would happen once you were at the Queen's Hospital in Sidcup.

DAVIES: Let me reintroduce you again. So we're going to take another break here. We're speaking with Lindsey Fitzharris. Her new book is "The Facemaker: A Visionary Surgeon's Battle To Mend The Disfigured Soldiers Of World War I." She'll be back after a short break. This is FRESH AIR.

(SOUNDBITE OF RED HEART THE TICKER'S "SLIGHTLY UNDER WATER")

DAVIES: This is FRESH AIR, and we're speaking with Lindsey Fitzharris. Her new book is about the efforts of a surgeon to repair severe facial wounds suffered by British sailors and soldiers in World War I. The book is titled "The Facemaker." There's another soldier that you write about. He's called Corporal X. He was injured at the Battle of the Somme, which was a horrific conflict - face half blown apart. Tell us his story.

FITZHARRIS: Corporal X - we don't know his name. We only know the story through the retelling of it by a nurse who worked with Harold Gillies named nurse Catherine Black. And it's a really sad story. As you say, he was injured on the first day of the Battle of the Somme, which was an absolute bloodbath. If you don't know anything about the First World War, you probably recognize the Somme. Of the 100,000 British soldiers who took place in the advance that day, 60,000 were killed or injured, many of them gravely. So it was a terrible, terrible day.

Corporal X is injured. He's bandaged. He's sent to the Cambridge Military Hospital in Aldershot; that's where Gillies is working at that time. And he keeps talking about how, you know, he needs to get these beastly bandages off because his fiancee, Molly, will be frightened, and he really wants Molly to come visit him. And eventually, the bandages are removed. And unbeknownst to nurse Black and to Gillies, he had snuck in a shaving mirror. And he catches a glimpse of his face, and he becomes very despondent and depressed. And it turns out that he wrote Molly a letter. He lied about it. In the letter, he said that he had met a woman in France, and he broke off the engagement. So it was a really sad story.

In contrast, Private Walter Ashworth, who also is injured on the first day of the Battle of the Somme and lays on the battlefield for three days unable to scream for help because he has no jaw - he falls into the hands of Gillies. And a very similar situation happens. But what happens with Ashworth is that his fiancee breaks off the engagement after she learns of his injuries. And the fiancee's friend thinks this is rather terrible, and so she begins writing Ashworth at the hospital. And soon, the two fall in love. And soon, they get married.

DAVIES: Yeah, in the case of Corporal X, he did get his face reconstructed. Do we know anything about his life after he left the hospital?

FITZHARRIS: It was said by nurse Black that he went on to live a life of self-imposed isolation. Of course, I can't confirm this because I don't know his actual name. I only know the story through the nurse's retelling of it in her own diary. But that's what she said, that he went on to live a life of self-imposed isolation. And unfortunately, that did happen to some of these men. But what Gillies was able to do by rebuilding their faces did allow them to have that sort of second life. They could go back into society. They could be accepted by society, again, that was so prejudiced against these facial differences. And they could go to live, you know, quote, "normal lives" after the war.

DAVIES: You know, I do recall - I don't remember which one of the soldiers that you write about - went back and got maybe the job he had before, but a job working at a shop or a store. But the proprietor said, yeah, you're going to have to work in the back so that, you know, the shoppers don't see you. I guess that was...

FITZHARRIS: Yeah, that was really sad. So that was Private Walter Ashworth, again, whose fiancee broke off the engagement, and he marries the fiance's friend. So there's that bit of happiness. And then he's discharged from the army, and his boss tells him that he has to work at the back of the shop so that he doesn't, quote, "frighten the customers." Not all wounds were inflicted on the battlefield during this time. And so these men had to really overcome so many prejudices and biases against their injuries. And it was difficult for some.

Now, Walter Ashworth eventually moves to Australia. He starts a new life. He lives a very happy life on that side of the world. And many years later, he bumps into Harold Gillies. At this point, Gillies has really grown as a reconstructive surgeon, and Gillies offers to have another go at his face. He thinks that he can improve Ashworth's appearance even further. But Ashworth declines, and we don't really know why. It could be that he didn't want to undergo any further painful surgeries. Or maybe he had just made peace with the face that he had been given so long ago.

DAVIES: Mmm. You know, since our listeners can't see the photographs, give us a sense of how, quote-unquote, "normal" the reconstructed faces appear when the work was complete.

FITZHARRIS: That's - it's such a difficult question to answer because every patient was different. This is highly individualized surgery, of course. But I think, in my opinion, they look quite good for the photos that are included in "The Facemaker." To go back to Private Walter Ashworth - half of his lower face is nearly gone. And at the end, he has a jaw. He has some lips. And it looks relatively, quote, "normal" again - or typical, we might say today. So I think the result was extraordinary, especially given the challenges, the fact that there were no textbooks to work from. There was no antibiotics. I think what Gillies and his team was able to accomplish was miraculous.

DAVIES: After the war, Gillies did plastic surgery as a private physician. To what extent did the specialty grow and advance as a result of his work?

FITZHARRIS: 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 today. And so Gillies did both.

He was excited by the challenges of cosmetic surgery. He would say that reconstructive surgery was returning something to, quote, "normal," whereas cosmetic surgery was about surpassing the normal. So he does move into those different realms. He continues to operate on people with, you know, congenital defects, or they've had injuries, car crashes. In the 1920s, women were removing facial hair, if you can believe it, with X-rays, which I was shocked to learn, and as a result, they were getting cancer on their faces. And these surgeons were going in to remove the cancer, and then they were - these women were falling into the hands of Harold Gillies, who was reconstructing their faces.

So he does continue to do all kinds of surgeries at this time. And then he also introduces his cousin, Archibald McIndoe, to the strange new art of plastic surgery, and it's McIndoe who really overshadows Gillies' legacy because he ends up operating on the burned pilots of World War II. And these men become very famously known as the Guinea Pig Club. And because of the media and the way it works in World War II, this really overshadows what Gillies was doing in the First World War. But Gillies also operates during the Second World War as well.

DAVIES: You know, there's a scene in the book at the signing of the peace treaty to formally end the First World War at Versailles in June of 1919, and this involved some veterans with facial injuries. This is pretty moving. You want to share this with us?

FITZHARRIS: Yes. So, as you say, during the signing of the treaty, they invited these disfigured soldiers. They were French soldiers. And they were under the care of a surgeon named Morriston (ph). They go to the signing of the treaty. And it was really important, officials thought, that people see what the war did to men. And it was in the Hall of Mirrors in Versailles, which was really poignant to me because, again, a lot of times these men, they weren't allowed to look at their faces. So imagine walking into something like the Hall of Mirrors, and everybody's looking at you, and there's all these mirrors, and you're looking at yourself. And it was just a startling scene to the end of this terrible conflict.

So, you know, it was a powerful image to see these men who had been robbed of so much, you know, not just their livelihoods in some cases but their identities. And what happens to you when you lose that? And how do you regain that back? And, you know, that's ultimately what Gillies was able to do for these men - to help them restore their identities.

DAVIES: Right. And there's a photo of those four men in the book. Lindsey Fitzharris, thanks so much for speaking with us.

FITZHARRIS: Thank you so much for having me on the show.

DAVIES: Lindsey Fitzharris is a writer with a Ph.D. in the history of science and medicine from the University of Oxford. Her new book is "The Facemaker: A Visionary Surgeon's Battle To Mend The Disfigured Soldiers Of World War I."

(SOUNDBITE OF TODD GARFINKLE'S "GARDEN")

DAVIES: Coming up, John Powers reviews the series "The Bear," now on Hulu, about a brilliant chef who leaves the world of fine dining to run his family's sandwich shop. This is FRESH AIR.

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