Buying beauty

As might be expected in a work devoted to false appearances, this book is not quite what it seems from the cover. Elizabeth Haiken has not written a comprehensive history of cosmetic surgery - a medical speciality known to ancient and early-modern Europe alike, which rose to prominence on the Continent after 1850. Rather, she fixes her attention on 20th-century America alone, with only brief mention of developments elsewhere.

This exclusive preoccupation might seem understandable, given that, as Haiken convincingly shows, it has been the female beauty culture peculiar to the United States which has buoyed up that equivocal and often unsavoury speciality. But overall it is a shame, since some of the major centres these days, and certainly the fastest growing, are in Latin America and the Far East, where the surgical transformation of the face has assumed a significance that far transcends the individual quest for youth and beauty.

Haiken also privileges the face. Again, this is understandable, but it means that her book does not do justice to body resculpting as a whole. And apart from surgery for war casualties, there is also too little about males, given that nose jobs for Jewish men were once, perhaps, the field leader. Novel procedures such as penile enlargement are barely mentioned. Despite such limitations, however, and though one would have expected a book like this to carry additional and better-quality illustrations, Venus Envy is original, well-researched and a pleasure to read. It constitutes an astute analysis of the modern commodification of the body and the role of the medical profession in such developments.

American plastic surgery, Haiken shows, grew out of the need to treat the appalling battle injuries suffered in the first world war. Many of the first generation of American "artists" learned their craft in wartime Europe, some from the top British practitioner, Sir Harold Delf Gillies, stationed at Sidcup. Returning home, they rapidly grasped the peacetime potential of the technique. And the times were certainly ripe. So long spurned as little better than butchery, surgery was at last turning into a dynamic, fashionable and highly lucrative branch of medicine.

Initially, at least, practitioners - especially those accustomed to handling war wounds - were cautious in word and deed. Medicine, after all, had always been about healing the sick; primum non nocere (above all, do no harm) had been its ethical watchword. In line with such traditional ideals, early plastic surgeons announced that they would treat only genuine deformities and impairments. In their high-minded public statements, they insisted that they were healers not beauticians; they would not prostitute their talents by pandering to female vanity and making silk purses out of sow's ears. "I would not touch any woman at any price who came to me and asked me to remove the legitimate trace of her years," pontificated one surgeon. "A woman of forty years of age ought to be ashamed to have a face without a wrinkle." Posing as guardians of public morality, surgeons adopted the paternalistic stance that all such matters were for doctors to decide. Mindful of his colleagues' eyebrows, the prudent surgeon did not want to be accused of trivialising his craft.

The steady retreat from this lofty position is persuasively traced by Haiken. During the 1930s, nose jobs, face-lifts and many other enhancers of female beauty became first legitimate and then routine - truly cosmetic (or what was often called "featural") surgery was accepted. Why the change? It was partly, she explains, because of competition from cowboy operators who had no scruples at all about getting rich by giving the public what it wanted. In laissez-faire America, unscrupulous, self-promoting operators could literally get away with murder, notably Henry Julius Schireson, a swindler with a criminal record who nevertheless maintained a lucrative practice for 30 years. (Was Harley Street much different, one wonders.) Internal rivalries led to the setting up of the American Association of Plastic Surgeons (1921) and the later Board of Plastic Surgeons, with the intention of policing the procedure, but such bodies willy-nilly adopted an "if you can't beat them, join them" philosophy.

Other forces too were at work. In self-help America, the long-established grounding of individualism upon puritanism, hard work and integrity was yielding to a new stress upon getting on through style and sparkle. Women's magazines were preaching that attractiveness was the key to success: a woman's fortune lay in her figure, a new face for the New Deal. With beauty parlours and the cosmetics industry booming, cosmetic surgery was bound to fall in line. Surgeons were inundated with letters from Plain Janes begging or demanding to have their nose bobbed or their jowls "neatened". "Public demand", judges Haiken, dragged and drove the surgeons into relaxing their practice.

For this an ideological fig leaf was required, and such was provided by Alfred Adler's theory of the inferiority complex, all the rage in interwar America. It became received wisdom that hooked noses, puffy eyes or crow's-feet would erode self-esteem. Such clients were not expecting to become Hollywood stars (it was now maintained), they just wanted to be "normal", to melt into the crowd: what could be wrong with that? Hence procedures once condemned as extravagances pandering to narcissism were repackaged as items essential to mental health, and cosmetic surgery became an adjunct of psychiatry in an era when Americans were learning to love their shrinks. Beauty was thus not just skin deep, and cosmetic surgery became somatic psychotherapy: mens sana in corpore pulchro.

In due course all such rationalisations were cast aside as surgery's watchword became "can do, will do". In our age of multiple organ transplants, biotechnology and genetic engineering, today it is "anything goes" with body resculpting, and it has been accepted that individuals have the right (even perhaps the duty) to enhance their assets however they wish. How can it be maintained that there is an essential moral distinction between body-building in the fitness centre, taking steroids or Human Growth Hormone, and the once-derided facelift?

Haiken thus expertly traces the selling of cosmetic surgery. I would have liked to see a more detailed analysis of precisely which fantasies of beauty came to be espoused decade by decade. "When women beautify themselves," Barbara Sichtermann writes, "it is largely to adjust to the prevailing ideal" - so how do ideals of the right nose or breast angle become established, and what are the mechanisms by which they change over time? How influential has been the authority of "Greek" ideals of beauty - or the latest Hollywood sex kitten? What role have surgeons themselves played in shaping American dreams of the desirable breast? And what are the politics of such images at a time when more Afro-Caribbeans (and other ethnic groups) are going at least some way down Michael Jackson's road and getting their features made paler and more "Caucasian"? Given the racial politics involved in all this, it is a great pity that Haiken, while briefly discussing Orientals in the US, does not explore developments in Brazil and Mexico, Japan or Singapore.

This eye-opening book gives a convincing analysis of the transformation of surgery in the 20th century from an option of last resort to a commodity in the market-place of consumer culture. What new fantasies of the self will surgeons collude in creating next?

Roy Porter is professor in the social history of medicine, Wellcome Institute.