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Liza Gross

Facing the Traumas of War

  Few books bring home the horror of war more powerfully than Dalton Trumbo’s “Johnny Got His Gun.”  Trumbo, if you don’t know, graphically reveals the appalling carnage left in the wake of the “war to end all wars” through the story of one man. World War I left more than 8 million soldiers dead and an incomprehensible 21 million wounded, many so mutilated and disfigured they wished for death. Such is the fate of Trumbo’s hero. In his withering indictment of war, Trumbo challenges you to feel, almost unbearably so, the terror of slowly realizing you have no hearing, sight, limbs—or face. This feeling came back to me recently while (finally) watching the first season of “Boardwalk Empire,” the HBO series (now in its third season) about Prohibition-era gangsters in Atlantic City starring Steve Buscemi. One of the characters, Richard Harrow, returns from the Great War missing an eye and a good portion of the left side of his face. He wears a metal half-mask with glasses, an eye, and mustache to hide his maimed features, albeit with a ghoulish glint that suggests far deeper psychological wounds. After the episode in which we meet Harrow, Terence Winter, the series’ creator, discusses the history of the masks, pioneered by English sculptor Francis Derwent Wood to help these horribly disfigured men reclaim some sense of their former self. Winter learned about the masks from “Faces of War,” a Smithsonian article about the artists who made them.  Facial injuries were a special hazard of trench warfare. Men popped their heads above a trench and caught face-shredding shrapnel, bullets, and grenades. The pioneering work of Harold Gillies, considered the father of plastic surgery, helped men survive physical traumas never before known. Some 5,000 soldiers underwent more than 11,000 reconstructive operations in just one English hospital between 1917 and 1925.   Gillies managed his reconstructive feats thanks in part to the drawings of surgeon-turned-artist Henry Tonks, whose pastel portraits of wounded soldiers testified to their grim fate in a temporary exhibition at the Durham Light Infantry Museum and Durham Art Gallery in England.  (The exhibit ended in June.) Tonks’ portraits, long stored away from public view in the archives of the Royal College of Surgeons, showed the men before and after surgery for teaching purposes. As Gillies refined his techniques for using healthy tissue to reconstruct half a face on fractured bones, Wood tried to restore a measure of each man’s shattered sense of identity, so bound to the sinews, idiosyncrasies, and expressions of his face, with a painstakingly crafted likeness, sculpted out of copper. Anna Coleman Ladd, an art deco sculptor, provided the same service in Paris. Both Wood and Ladd said they created the masks to help ease the disfigured men’s profound psychological stress. Gillies saw many of his post-operative patients collapse in despair after seeing themselves in a mirror. Only the blind, he said, kept their spirits up. Even with trench warfare nearly a century behind us, remarkably little has changed. Just as trenches protected bodies but left heads exposed, today’s state-of-the-art armor and helmets cover nearly every part of the body—except the face. Some military doctors think enemy forces now target a soldier’s unprotected face. Most facial injuries today are caused by improvised explosive devices (IEDs), which inflict devastating damage as high-energy fragments accelerate through the skin and underlying tissue. Where 15% of WWI soldiers sustained facial injuries, up to 30% of today’s soldiers suffer face and neck trauma. Many also suffer from traumatic brain injury. And just as the press provided scant evidence that soldiers came home from WWI with broken faces, even as it displayed no such taboo for amputees, few news accounts today have reported that contemporary soldiers endure a similar fate. Yet soldiers today, like those who came before them, are surviving injuries that would have killed them in battle a generation before. Many wounded by IEDs endure as many as 60 operations over several years in special reconstructive trauma units, like UCLA Medical Center’s Operation Mend program.  Eventually, they go home and have to cope with strangers on the street. In “The Divine Right to Appear Human,” a video produced for Operation Mend, a  soldier who lost most of his nose from an IED in Iraq, says the reconstructive surgery helps him cope. “It’s a big morale booster. I’m not gonna say I don’t get stared at, because I do. But it makes me feel a little bit more…I guess you could say more of a human being.” Only recently have military surgeons developed protocols for treating this new species of catastrophic injury. As American and Australian surgeons explained in a 2008 review in ADF Health, the journal of the Australian Defence Health Service, management of these injuries can require “very lengthy and complex treatment” and a team of at least six specialists. (Warning: The images of wounded soldiers in the article are indeed difficult to look at.) The team includes burn specialists, plastic surgeons, ear, nose and throat surgeons, anaesthetists, maxillofacial prosthodontists and oral and maxillofacial surgeons—but I saw no mention of psychologists. Post-traumatic stress for victims of severe facial trauma is well known, though not well understood. That’s why candidates for face-transplant surgery must undergo extensive screening protocols, including psychological assessments, to gain approval. Each war challenges medicine to cope with previously unimaginable injuries. And science has, in many ways, risen to the challenge, as the “progress through bloodshed” notion found in the social history of medicine literature suggests. But, even today, the science of repair cannot match the weapons of destruction. And injuries to the face continue to present a special challenge. Reconstructive surgery can configure a person’s eyes, nose, and skin to re-create  some semblance of a human face. But our identity isn’t tied to just any human face. When I was a little girl, my best friend’s sister, a teenage beauty with fine, chiseled features and a classic Roman nose, sustained serious facial injuries in a car crash. She recovered from her injuries within a few months. It took her far longer to adjust to her new face—a nose, now round and slightly smashed, once-high cheekbones, now flattened—even though she was still a beautiful girl. Try as we might to pretend that we relate to people based on who they are rather than what they look like, identity is intimately wrapped up in appearances. Not just for others but for ourselves. Facial injuries remain one of the most dehumanizing of injuries. Writing about the “rhetoric of disfigurement” in WWI Britain, art historian Suzannah Biernoff notes that, ultimately, Wood's masks testify to the limits of medicine as much as they fail to hide war’s human costs. But even more, Biernoff argues, “these fragile, intimate objects prove that being human is an aesthetic matter as well as a biological one.” Of course, Gillies knew full well how much appearance meant to his patients’ psychological well-being, as do the surgeons who perform thousands of reconstruction surgeries on the tattered faces of soldiers today. At some point, there’s nothing left to do. Wood’s and Ladd’s masks may seem crude. But there’s a poignancy about those metal masks, which suggest that the wounded understand our discomfort because they feel it too. They want to hide their injuries as much as we might flinch at their sight. But the masks also suggest that we’re complicit in their trauma by averting our eyes, or worse. Incredibly, the soldier who lost his nose in Iraq said people made fun of him on the street, in front of his children. Soldiers today don’t have the metal masks to help heal their inner pain. Last year, the nonprofit Center for New American Security reported that every 80 minutes a U.S. veteran of the wars in Iraq or Afghanistan attempts suicide. Vets with traumatic brain injuries—the fate of as many as 20% of the 2.3 million troops deployed to Iraq and Afghanistan since 2001, according to the military healthcare publication U.S. Medicine—face a 50 percent greater risk of suicide. And so, nearly a century after the war to end all wars, the wars continue, inciting, as Trumbo said, “one human being who wants only to live to kill another human being who wants only to live.” And again, the soldiers come back, many unrecognizable to themselves or their families, so badly broken they wish for death. Meanwhile, too many of us avert our eyes, both from the wars themselves and from their victims. There’s still plenty of bloodshed. But progress will come only when we as a society recognize that when the casualties of war, military or civilian, lose the features that define their identity, we too stand to lose a piece of our humanity.   Photo of a wounded WWI soldier drawn by Henry Tonks. (Courtesy of Royal College of Surgeons)            

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