Pioneering plastic surgery in World War I – by Jennifer Summers and Max Browne
The sight of “men burned and maimed to the condition of animals” returning from the trenches motivated a visionary volunteer surgeon, Harold Delf Gillies (1882–1960), to transform the field of maxillofacial reconstructive surgery. The techniques Gillies employed, such as the ‘tubed pedicle’, are the first pioneering examples of modern plastic surgery from World War I.
Facial and head injuries were common in the trenches. Around 15 per cent of those who survived and were evacuated back to Britain for treatment had some form of facial trauma. The typical Tommies’ training did not prepare them, either physically or psychologically, for the horrific conditions of the trenches or the aftermath. An American surgeon in France, Dr Fred Albee, noted that the soldiers “seemed to think they could pop their heads up over a trench and move quickly enough to dodge the hail of bullets”.
The complex nature of these wartime facial injuries, combined with the staggering number of victims, prompted Gillies to develop new techniques, which still underpin many principles of modern plastic surgery today. He was a New Zealander stationed in Britain who felt an “overwhelming urge to change something ugly and useless into some other thing more beautiful and more functional”. From 1916 Gillies worked with a multidisciplinary team of surgeons, nurses and dentists at the Cambridge Military Hospital based in Aldershot, and later at Queen Mary Hospital in Sidcup, Kent.
Responding to the avalanche of victims, Gillies built upon historic skin-grafting techniques used in Germany, France, India and Russia, to develop a radical new surgical procedure, known as the tubular pedicle. This allowed the first cases of modern facial reconstruction to take place.
The construction of the facial pedicles involved taking tissue from other parts of the body and fashioning a ‘tube’ of skin containing blood vessels to the damaged tissue. In this way infection was kept to a minimum, as the pedicle was essentially closed tissue and provided increased blood supply to the face. This was of critical importance during this pre-antibiotic era.
Gillies, himself an amateur artist, described plastic surgery as “a strange new art” and recognised the need to meticulously document this rapidly evolving and pioneering surgical field. He sought the help of an accomplished artist and by good fortune found the perfect candidate. Professor Henry Tonks (1862–1937) had a unique combination of expertise: coming from a successful surgical career as a Fellow of the Royal College of Surgeons, his stronger leaning towards art had driven him to become Britain’s leading drawing master at the Slade School of Art. Having also volunteered for War Service, Tonks was only too happy to produce before-and-after surgical illustrations for Gillies (even though he had previously declared Gillies was “not any use as a doctor”).
With Tonks’s extensive knowledge of human anatomy and devotion to the draughtsmanship of the Renaissance masters, his rigorous teaching of life drawing at the Slade became a powerful influence on the work of decades of British artists in the first half of the 20th century. In 1916, as a temporarily commissioned Lieutenant in the British Army Medical Corps, Tonks joined Gillies to become an artistic historian of facial injuries of the war. He once remarked that “faced with crushed faces and torn flesh, what is the surgeon artist to draw?”
Tonks’s contribution over the following year resulted in the now famous series of 69 before-and-after pastel drawings that helped Gillies to record the results of his surgical techniques.
At this time medical photography was only available in black and white, and Lieutenant Colonel Parkes noted that this specific limitation did “not depict the natural colour of the damaged tissues”. For a practical coloured medium Tonks chose pastel, a traditional choice of portraitists for centuries. As well as meeting the medical and military requirements to record Gillies’s work, the pastels enabled Tonks to capture a more artistic sense of plastic surgery. Renowned art critic Brian Sewell recently commented that Tonks “could not help, as an artist, making them beautifully hideous”.
A notable example, detailed in the Gillies Archives at the Royal College of Surgeons, is Private Walter Ashworth, West Yorkshire Regiment (no. 1071), from Bradford, who was wounded on the first day of the Battle of the Somme in 1916. Tonks’s first drawing (left) shows Ashworth waiting for a facial washout with sterile Milton solution. A rare surgical diagram (centre) shows the process to close the wound by suturing flaps of skin and tissue from the cheek and jaw. After three operations and discharge a year later, Gillies commented that it had been necessary to sacrifice some of the length of the lips to close the wound and that this had left his patient with a “whimsical, one-sided expression that, however, was not entirely unpleasant” (right). Unfortunately, on Ashworth’s return home this proved too much for his former employer and his fiancée to accept. However, he married one of her more supportive friends, and they successfully took up job opportunities offered by a move to Australia. Four decades later patient and surgeon met again, but the latter’s offer of further improvement was turned down – perhaps as a result of Ashworth’s having already undergone so much surgery, including shrapnel removal from his back, which had continued into the 1950s.
It was sometimes observed that the plastic-surgery patients benefited from the attention given to them by an artist, rather than a more perfunctory depiction by camera. However, Tonks was more concerned about another side-issue: that the pastels were “rather dreadful subjects for the public view”. While other works by the artist, such as ‘Saline Infusion’ (1915) and ‘An Advanced Dressing Station in France’ (1918), also depict intense wartime imagery, Tonks refused to allow the pastels to be displayed at the Imperial War Museum. He insisted that “they would be viewed by a bloodthirsty public seeking vicarious gratification”, so for most of the 20th century they remained hidden away, before being acquired by the Royal College of Surgeons in London. They have now become one of the most requested loan items in the College’s collection.
The extraordinary legacy created at Sidcup, enhancing and promoting the new medical field of plastic surgery, has also ensured that Gillies is often referred to as the “father of modern plastic surgery”. A recent exhibition and publication of the pastels he produced has brought their medical story to wide public and critical acclaim. Indeed the recent National Portrait Gallery exhibition The Great War in Portraits has provided continuing insights into the personalities and physical sufferings of the injured men. It is an historical irony that, despite Tonks’s personal misgivings about the public display of his pastels, they are now valued by many as a potent visual expression of an important and popular universal theme in this centenary year of the start of World War I: lest we forget.
Dr Jennifer A Summers was born in Wellington, New Zealand. She holds degrees in Psychology, Statistics and Public Health, and has a PhD in Historical Epidemiology from Otago University, specialising in the 1918–19 influenza pandemic in military populations of World War I. She is currently a Post-Doctoral Research Fellow in Medical Statistics at King’s College London (email@example.com).
Max Browne (BA Hons) is an independent art historian and documentary cameraman/photographer based in London. He specialises in 19th-century Romantic art (firstname.lastname@example.org).