Perspectives
The art of medicine Faces of war See Perspectives page 716 For The Gillies Archives from Queen Mary’s Hospital, Sidcup see http://www.gilliesarchives. org.uk
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There are not many rheumatologists who have an interest in surgery during World War 1, let alone facial injury and its management. But my interview merry-go-round stopped at the UK’s Queen Mary’s Hospital, Sidcup—a district hospital where it so happened modern plastic surgery of the face was invented. There were few photographs to prove the groundbreaking work at Sidcup—no more than a dozen or so—but once my interest in collecting things became known I became the Honorary Consultant Archivist—a grand title for the custodian of a few modern press cuttings books and two hospital reports that covered the work at Queen Mary’s Hospital from 1917 to 1929. But serendipity led to riches. Over 3 years I discovered, and recovered, nearly 2500 case notes of the New Zealand and British surgical teams from World War 1. They are the only surviving medical notes of any unit of this era from the war (apart from some Australian records also from Sidcup) and are thus unique. The case notes represent the beginnings of modern facial reconstruction and are testament to the extraordinary drive of Sir Harold Gillies, widely regarded as the father of modern plastic surgery, and his colleagues. As I immersed myself in the work (and character) of Gillies, I also spent my lunchtimes entertaining a stream of surgeons, researchers, writers, and artists who wanted to know more about the Sidcup archives. One of these, Paddy Hartley, was instrumental in organising an exhibition at the National Army Museum in London based on the work at Sidcup. I also met patients’ relatives, heard stirring (and tragic) stories, and received information from the descendants of the surgeons. If I have one message, it is that we should not just remember the dead, laid out in tidy rows in beautiful cemeteries, but should also remember those who did not die, but were condemned to a life of disfigurement and made of it what they could, or could not. Many accounts of surgeons and nurses allude to the problems of disfigurement and its repair. From the outset there are issues with infection, surgical failure, and anaesthesia. The psychological effects of disfigurement are apparent. However it is only rarely that the people who underwent what was often experimental surgery expressed themselves. The Sidcup archives suggest that many soldiers seemed to internalise their memories: most accounts are non-committal, even robustly positive— perhaps to reassure folks at home that all was just as before. Curiously, despite the tribulations, several of the essays written by men at Sidcup (the occupational rehabilitation service there contained a writing class) express how their lives were positively transformed by their military life, despite their injuries. One feels almost that they are like actors when the run has ended, with the constant adrenaline rush suddenly replaced by nothing. It is oddly jarring, knowing
what we know of modern war and its horrors, yet never understanding the scale of World War 1, the war that was supposed to end them all. There were triumphs and tragedies in lives after Sidcup and I found that I got to “know” Gillies’ patients through the archives. Bob Seymour, who lost part of his nose on the first day of the Somme, appears in a photo of “Your Grateful Patients” and became Gillies’ secretary. Sidney Beldam, a machine gunner, was his chauffeur and had a large and happy family. William Spreckley had a cosmetically satisfactory repair of his missing nose, but his personality was scarred forever, while RAMC corporal Bob Davidson stayed on at the hospital into the 1960s, but would not eat dinner with guests because of the snuffling noise he made while eating. Norman Wallace, a Canadian disfigured in an aircraft fire, spent years in surgery, married one of the nurses, and lost her to an abdominal emergency but a year later. He went to a remote part of Wales for a holiday to collect his thoughts, and stayed in the hotel for the next 40 years. Walter Ashworth was confined to the back room of the tailor that he worked for, and his fiancée threw him over; her best friend was appalled by her behaviour, went out with Walter herself and married him; he made his fortune in Australia, and returned to Bradford to set up his own business. Micky Shirlaw, a Scots miner, suffered the attentions of the dental workshop and ended his life as a highly respected dental technician in Tunbridge Wells. Some men retrained for a life in the shadows; cinema projection was a taught trade, where a broken gargoyle—to use the words of Ward Muir—could, werewolf-like, arrive before the audience and leave after. The stories of these men have inspired fiction and three novelists have captured the Sidcup scene. Conny Braam’s The Cocaine Salesman is a gripping, though black tale, centred on a Sidcup patient who flees the country because of his appearance, and becomes addicted to the cocaine he used for his pain while selling it to both sides of the conflict. By contrast Louisa Young’s tale My Dear, I Wanted to Tell You is the first of a planned trilogy that has a happy ending that mirrored the endpoint of several Sidcup men. Pat Barker’s Toby’s Room centres on pupils of the surgeon-artist Henry Tonks who worked at Sidcup. Those who have read the Regeneration trilogy will be familiar with Barker’s style, and its disturbing undertones of sexuality, which reappear here. I find it gratifying that the story of Sidcup’s role in the development of facial surgery has been brought to a wider public through fiction. All too often I have had to dispel the myth that the origins of modern plastic surgery lay in World War 2 thanks to Sir Archibald McIndoe at East Grinstead. The pioneering reconstruction that was done at Queen Mary’s Hospital was remarkable. The surgeons considered www.thelancet.com Vol 381 March 2, 2013
the patient as part of the multidisciplinary team, allowing them, for example, to choose their own new noses. The care and compassion of the surgeons such as Gillies and Kelsey Fry at Sidcup is exemplary even by today’s standards of patient-centred medicine. Surgical autocracy was replaced by a true multidisciplinary approach that involved surgeon, anaesthetist, dentist, radiologist, technician, artist, photographer, and sculptor. Sidcup was also international, with staff from the Antipodes and Canada as well as the USA. One or two of the younger surgeons at Sidcup were appalled by Gillies’ lighthearted approach to such a serious business. New Zealander Tommy Rhind’s daughter wrote to me “My father felt that what he considered the overuse of humour, was not always appropriate…many other staff and patients were at a loss to find anything amusing or encouraging about their predicament.” But when you think about it, being serious, gloomy, and dark was hardly beneficial. Gillies was way ahead of his time in the art of positive thinking but his careful attitude is summed up by the development of his “Principles” that were outlined in his 1957 textbook The Principles and Art of Plastic Surgery written with Ralph Millard—my favourite being “Never do today what can be honourably put off until tomorrow”— backed up by the description of cases that failed because the surgery was done in too much of a hurry. His critical attitude is exemplified by his observation, surrounded as he was by other careful people, that it was “more difficult to hide a bad case than get a good one”. Operations would go on for years, yet—it was everyone’s lot, and the old hands helped the new arrivals to cope. Some people will find the three novels about Sidcup disturbing. Some commentators have suggested that the tales are incredible. They aren’t. We are rarely allowed behind the scenes to see the damage war does. Tonks, whose remarkable pastels of Gillies’ patients capture far more than photographs, refused to send these works to the Imperial War Museum where, as he put it, they would be viewed by a bloodthirsty public seeking vicarious gratification. Today we are shielded from atrocity by the sensibility of broadcasters who have much material that they will not show. But if we do not see these images, if we do not read the stories of these men, we will never understand the realities of war and will, perhaps, continue to send men off to fight in distant places with an imperfect understanding of the benefits when we remain blind to the risks. Consider David Howard, who was wounded in February, 1918, and admitted to Sidcup in August of the same year. He had lost his lower lip and part of his jaw. After nine procedures, on Dec 26, 1920, he was found dead in a local cottage by one of the surgeons. The cause of death is given as acute alcohol poisoning. What really happened we do not know. The bald facts conceal a mystery. Was it an accident? Did he kill himself? Alcohol was forbidden at the hospital. Could it be that he could see no future? I traced him in the www.thelancet.com Vol 381 March 2, 2013
Courtesy of the archives, Royal College of Surgeons, London
Perspectives
Pte David Howard showing a double tube pedicle Inability to close the mouth leads to continuous dribbling of saliva (bottom left).
1911 census, where his occupation was listed as chimneysweep. Had he had some sudden realisation that he would, after all the excitement of war, be condemned to life as a menial worker, all the more despised by those he had to visit because of his face? There are stories of Sidcup we will never be privy to, but those that we do know should be told. And I see no harm in inventing stories when it is done by master storytellers, when they seem so true, and when they reveal the true horror, and pity, of war. I thank Marilyn McInnes, Alex Kingman, the late Shelagh Davidson, Jeremy Stevenson, Diane Smith, and Pauline Pratt for information on Beldam, Spreckley, Davidson, Wallace, Ashworth, and Shirlaw (the case notes for all of these are now in the Royal College of Surgeons of England), and Gillian Martin, Rhind’s daughter.
Andrew Bamji Consultant Rheumatologist and Gillies Archivist, British Association of Plastic, Reconstructive and Aesthetic Surgeons, Norman House, West Street, Rye TN31 7ES, UK
[email protected]
Further reading Braam C. The cocaine salesman. Amsterdam: Uitgeverij Niew Amsterdam, 2009 Young L. My dear, I wanted to tell you. London: HarperCollins, 2011 Barker P. Toby’s room. London: Hamish Hamilton/Penguin, 2012
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