By Dr Suzannah Biernoff
Issue 2, Autumn 2010
Warning: This article contains disturbing images.
You know very well that he has examined himself in a mirror. That one eye of his has contemplated the mangled mess which is his face – all the more hopeless because ‘healed’.
– Ward Muir, from The Happy Hospital, 1918.
IN 1916 AND 1917 THE ARTIST AND FORMER SURGEON HENRY TONKS made a series of pastel drawings of wounded servicemen who had been referred to Harold Gillies’ pioneering centre for facial surgery at the Queen’s Hospital in Sidcup, Kent. Unlike conventional portraits, the drawings were neither commissioned nor owned by the men who appear in them; they don’t mark an occasion, celebrate an achievement, or promote a public image. A framed selection hung on the wall of Tonks’ office at the hospital and on these he has recorded the subject’s name, but the rest are identifiable only by cross-referencing their injuries with the case files in the Gillies Archives.
Tonks, who was 52 and an assistant professor of drawing at the Slade School of Art when war broke out, had started off with Gillies making diagrams of the operations, first in an official capacity, as a temporary Lieutenant in the Royal Army Medical Corps, then as a civilian when his contract with the War Office came to an end. Tonks’ biographer Joseph Hone notes that he would spend from one to four hours at an operation, mainly taking notes; the diagrams that were filed with the case notes would be produced later. Photographs, some in stereograph, were also taken of the patients pre- and post-operatively and filed with the case histories. What do the pastels add to this extensive visual archive, apart from colour? Were they simply “excellent practice,” as Tonks wrote to his friend, the artist and critic D. S. MacColl?
Naturalistic portraiture, as the art historian Joanna Woodall observes, has always been motivated by the desire to “overcome separation,” to make the absent present, to reconcile image and identity, to defy death. None of this is possible without an experience of recognition. Yet in Tonks’ drawings of wounded soldiers, the subject is doubly alienated from himself. In the first place, the institutionalisation of these men (first in the military, then as long-term and usually recurrent residential patients) disconnected them from the social and physical fabric of their ordinary lives, their sense of a past and future meaningfully connected to the present. As well, the privileged signifier of subjectivity, the face, now signifies trauma. To a surgeon, the damaged tissue may be a challenging text to read, but ultimately legible; to a pioneer in facial reconstruction the absence of a face may signify its potential surgical and prosthetic re-assemblage; but to most of us the injuries are a kind of abyss. In a cutting from the Manchester Evening Chronicle dated May/June 1918, facial disfigurement is described as the “Worst Loss of All” because it deprives a man of the “visible proof” of his identity.
The men Tonks encountered were capable of stoicism, even cheerfulness: one young man is “modest and contented” despite having had “a large part of his mouth … blown away,” but these touches of normality are as disorienting as the remnants of conventional portraiture: the residual fragments of individuality conveyed through posture, gaze, clothing and framing, fragments that only foreground the shocking violence of the injuries. These are anti-portraits, in the sense that they stage the fragility and mutability of subjectivity rather than “consolidating the self portrayed.” The achievements they celebrate are not those of the men we see (though to be alive at all was an achievement of sorts). The personality, the hero, of these untitled portraits is the pioneering surgeon, his inventiveness, skill and dedication told through the simple narrative structure of “before” and “after”.
In an entry on “War and Medicine” in the Companion Encyclopedia of the History of Medicine, Roger Cooter systematically unpicks the “progress through bloodshed” thesis that underpins the twin narratives of hope – heroic sacrifice and medical progress. He points out that medicine never develops purely in response to the medical needs of individuals. In times of war, medical progress is driven by a paradoxical ideology: “its primary goal is not to preserve health for the sake of individuals, but for the for sake of destroying the might of others … From the combatant’s perspective, war is not good for medicine so much as medicine is good for war.” Military medical archives embody this paradox, which is one of the reasons why they are so carefully controlled by the state.
A selection of the drawings was shown in 2002 alongside Tonks’ other work at a small exhibition in the Strang Print Room at University College London (to my knowledge, this was the first time the series had been publicly exhibited in a non-medical context). In the catalogue accompanying the UCL exhibition of Tonks’ work, entitled Art and Surgery, the curator Emma Chambers writes that: “The studies of wounded soldiers that Tonks drew at [the military hospital in] Aldershot … occupy an ambiguous area somewhere between portraiture and archival record, the aesthetic and the pathological …” She relates this ambiguity to the convergence, during the 1914-18 war, of Tonks’ early surgical training and his enduring passion for life drawing. When I first saw these pastels, I was struck by how difficult it would be to write about them: not just because the subject matter is disturbing, or because – as Chambers rightly observes – they defy categorisation, but because they ask questions of us in return. The challenge they pose is only partly historiographical (what and whose stories do they tell; where do they fit in the histories of art and medicine?). There are also ethical questions that draw all of us into the frame: how does one, might one, should one, look at such images and what can they tell us about the visual cultures of modern medicine?
There was no ethics committee to debate the legitimacy and uses of Tonks’ work with Gillies’ team, and the patients were not party to discussions about the exhibition, or potential propaganda value, of their wounded faces. Tonks himself thought the pastels “rather dreadful subjects for the public view” and discouraged the interest of officials in the government’s propaganda unit at Wellington House. We don’t know how the men felt about being drawn. We do not even know if they saw their own portraits; mirrors were prohibited in Gillies’ ward at Aldershot, although this didn’t prevent one corporal in the care of Nurse Catherine Black from getting hold of one: having seen his face he asked for a pen and paper so that he could write to his sweetheart, Molly. “‘You’re well enough to see her now,’ Catherine Black remembers saying, ‘Why not let her come down?’ ‘She will never come now,’ he said quietly …”
In a rare discussion of the patients’ experience of facial surgery, Andrew Bamji remarks that the “horror of facial disfigurement is universal and enduring …” Yet it is arguably possible to distinguish between the universal horror of facial disfigurement, and its particular historical and cultural configurations, or indeed exceptions. This is what I would like to do here: to begin to break down the monolithic “horror” of disfigurement by presenting several contrasting perspectives from the same historical moment. Tonks’ studies are highly idiosyncratic: they represent one possible way of seeing and picturing the wounded and disfigured face, rather than a cultural tendency or norm – although their absence from the illustrated news media and official histories of the war says something about what could not be represented.
Facial disfigurement was almost entirely absent from the visual account of the Great War in Britain; but it did attract journalistic commentary. Published in 1918, Ward Muir’s The Happy Hospital is a detailed account of the author’s experiences as a medical orderly at the 3rd London General Hospital in Wandsworth. We come to the facial ward in the final chapter of Muir’s otherwise sincerely titled book. There, he writes, it is “something of an ordeal …”
To talk to a lad who, six months ago, was probably a wholesome and pleasing specimen of English youth, and is now a gargoyle, and a broken gargoyle at that – the only decent features remaining being perhaps one eye, one ear, and a shock of boyish hair . . . You know very well that he has examined himself in a mirror. That one eye of his has contemplated the mangled mess which is his face – all the more hopeless because ‘healed.’ He has seen himself without a nose. Skilled skin-grafting has reconstructed a something which owns two small orifices that are his nostrils; but the something is emphatically not a nose. He is aware of just what he looks like: therefore you feel intensely that he is aware that you are aware, and that some unguarded glance of yours may cause him hurt. This, then, is the patient at whom you are afraid to gaze unflinchingly: not afraid for yourself, but for him.
Muir’s description of these patients is a particularly rich case study of the phenomenology of horror and its conceptual armature. The patients on the facial ward disturb and fascinate him: he is repelled by what he sees – a “mangled mess” where a face should be – but at the same time he is drawn in, imagining how it would feel to be horrified by one’s own reflection. Empathy alternates with disgust, an emotional conflict that is expressed as visual discomfort. These men are different: Muir says he has never experienced such acute embarrassment with another patient, “however deplorable his state, however humiliating his dependence on my services, until I came into contact with certain wounds of the face”.
The developmental psychologist Michael Lewis argues that self-conscious emotions like embarrassment, shame, pride and guilt involve a complex process of internal surveillance and evaluation, by which the self is judged according to internalised cultural standards, rules or goals (SRGs). If the comparison is favourable, one experiences pride, but the failure to meet one’s internalised standards results in embarrassment, guilt or shame (all of which can produce blushing, as Darwin observed). Lewis admits that, phenomenologically – at the level of subjective experience – embarrassment can be hard to distinguish from shame. It is often described as feeling like “a less intense experience of shame,” which suggests that shame and embarrassment may reflect a hierarchy of SRGs, with some standards or goals being less important to an individual than others, and failure to achieve them less damning. Now, clearly the disabled or mutilated body violates an array of corporeal ideals and conventions; but the embarrassment here is Muir’s. Aside from anecdotal reports of depression and stoicism, we have no archival evidence of the mental and emotional state of these patients. Muir believes he is reporting their embarrassment, their shame; but I suspect that the young orderly’s experience on the facial ward is not just embarrassing but “shaming” in a way that reflects on him, and potentially on us, as curious witnesses of the pain and suffering of others. Darwin’s observation that “the thinking about others, thinking of us … excites a blush” highlights the reflexive self-consciousness of embarrassment and shame, as well as their interaction with the visible self. It is precisely the degree of exposure associated with facial injury and disfigurement that contributes to the stigma.
It is hardly surprising that journalists writing about these injuries concentrated on the ‘miracles’ of modern medicine: they were, after all, writing for the mothers, fathers, wives and sweethearts of men who might well return home damaged beyond recognition. Henry Tonks, in comparison, was not constrained by questions of public morale, and he clearly wanted to capture more than the evidence of surgical success. Tonks wrote virtually nothing about his philosophy of drawing, disdained formal lectures, and generally disliked the theory propounded by “art boys”, as he called critics. Apart from a report on the teaching of drawing prepared for the Girls’ Public Day School Trust, and passing references in letters, we have to rely on the writings and reminiscences of his students. A set of maxims formed the backbone of his instruction: that drawing is very difficult; that practice is everything; that learning to draw is learning to see (and the inability to draw is an inability to see); that “literary” concerns (such as narrative or symbolism) have no place in pure drawing; that drawing is at its most truthful and affecting when it is directly observed, unidealised, and selfless. The most systematic account of Tonks’ philosophy of drawing is an essay by his student, John Fothergill, who edited an official volume on the Slade, published in 1907. In ‘The Principles of Teaching Drawing at the Slade’ Fothergill introduces a paradox that I think lies at the heart of Tonks’ portraits of wounded soldiers: drawing (or in this account, great drawing) is fundamentally tactile. Touch is for the draughtsman what sound is for the musician: a student who draws “by sight” is no better off than a deaf man who learns to play the piano by mimicking the movements of his instructor.
The history of surgery, too, is partly a history of touch: technologically extended and transformed by the invention and refinement of surgical instruments. In art and in surgery, touch (or hapticity, the visual approximation of touch) can be diagnostic, interrogative, analytical, instrumental or creative. Gillies describes how the initial examination of facial wounds could take up to a week, and involved the manual palpitation of the lesion to determine the extent and type of tissue lost (skin, soft tissue, bony substructure). The operation was planned with the aid of a sculptural model of the face, showing the missing contours, and radiographs to reveal any displaced bone or other material. The eventual operations demanded “the greatest delicacy of touch.” The visual appearance of injuries could be misleading: one patient’s “enormous gaping wound,” caused by an explosion, healed well with only minor surgery. Gillies’ point is well illustrated by the before and after photographs in his 1920 textbook, Plastic Surgery of the Face. The camera, he cautions, “occasionally represents an inaccurate conception of the wound.”
In an article for the New Yorker on the decline of the autopsy, Atul Gawande makes a similar point about medical imaging technologies. Our increasingly sophisticated ability to mechanically and digitally visualise the body and its pathologies has brought with it a dangerous faith, he argues, pointing out that autopsies, rarely performed these days, reveal major misdiagnoses in the cause of death in an estimated forty per cent of cases. Although he reminds us that “autopsy” means seeing for oneself, his description of post-mortem examination underlines the importance of touch, as a sensibility and a skill. “Surgeons,” he writes, “are taught to stand straight and parallel to their incision, hold the knife between the thumb and four fingers, like a violin bow, and draw the belly of the blade through the skin in a single, smooth slice to the exact depth desired.” To be sure, there is less regard for “delicacy” in the dissecting room, but even there he is affronted by the sight of a pathology assistant “practically sawing her way” through one of his patients. The kind of touch he has in mind is careful and enquiring. Gawande attributes its loss to the advent of medical images that promise to reveal all, instantly and incontrovertibly.
In Fothergill’s essay, the “exactitude of the photograph” is analogous to the drawing done purely by sight. The mechanical representation of nature, whether by means of a camera, or with the aid of measuring devices and techniques, reveals nothing. It has “merely duplicated the aspect of the model, minus the colour, and the spectator is no better off than he was before he saw the drawing. It has told him nothing. Being conceived with no ideas of tangible form, it gives him none.”
The comment is often made that Tonks’ knowledge of anatomy stood him in good stead as an artist and drawing instructor. Reading Fothergill’s essay suggests rather different priorities, to do with the embodied knowledge and manual, tactile experience acquired through surgical training and practice in the dissecting room. At the same time, Tonks interrogates the idea of beauty (and by extension, that of ugliness or the grotesque). Through dedication and practice one might, he believed, achieve “a kind of intimacy,” but “only by seeing the thing itself … from painting the thing.” To his friend Mary Hutchinson he admitted that such intimacy was not always pleasant: it might lead “us into the most squalid places, almost holding one’s nose.”
One might expect Henry Tonks to have been fascinated by the peculiar, emotionally charged visibility of his subjects’ injuries, in the way that Muir clearly is; but the surprising thing about Tonks’ drawings is that they perform a kind of alchemy on the faces, and the flesh, they depict. This is not aestheticised horror so much as a kind of perceptual discipline in which the object, the wounded face, is slowly and carefully examined rather than “portrayed” in any definitive sense (whether shot by a camera, or captured by an artist). Helen Lessore recalls being taught by Tonks in the 1920s:
In his preaching of “Truth to Nature” Tonks managed to convey a moral quality, a conviction that Beauty was somehow incidental, a side product of the pursuit of Truth; that it would be a reward unexpectedly discovered in the most unpromising material, provided that we followed certain disciplines and were faithful to our experience.
It is impossible to know what the experience of sitting for Tonks was like for the men who ended up at Aldershot or at Sidcup in the care of Gillies and his colleagues. When the portrait painter Mark Gilbert was artist in residence at the Royal London Hospital’s Oral and Maxillofacial Surgery Unit in 1999/2000, the hospital’s Ethics Committee advised on and monitored the project; the patients’ involvement was subject to informed consent; and a medical psychologist evaluated Gilbert’s work from a clinical perspective. Tonks, by contrast, was untroubled by the modern regulations governing patient confidentiality and consent, and his role and status was very different from Gilbert’s because of his military rank and medical training.
The servicemen who so patiently sat for Tonks were not, unlike Gilbert’s sitters, in a position to say no. Nevertheless, there is at least the possibility that Tonks’ work had a therapeutic dimension that parallels Gilbert’s involvement with patients at the Royal London. Paul Farrand, the psychologist collaborating on the project, conducted a series of semi-structured interviews with patients in order to find out whether the experience had been beneficial. In a brief report entitled “Portraiture as Therapy” he claims that the project “has brought numerous and often very idiosyncratic benefits,” depending on the personal circumstances of the patients and the nature of their surgery. The portraits helped some patients to adjust to their new appearance (the comment that “photographs did not serve the same function” was “often expressed”). Gilbert’s sitters were not given the paintings, but they were provided with photographs of them, and these portable records – sometimes of the surgery itself, as well as before and after portraits – seem to have been personally and socially cathartic. More important, for our understanding of Tonks, is Farrand’s claim that the portrait sittings were valuable in themselves; that the artist “was able to offer time and a “safe” space in which [patients felt able to] discuss their concerns and experiences.” We will never know what passed between Tonks and his sitters, but we do know something about the duration and quality of his visual engagement with their wounded and disfigured faces. This may not have been a “talking cure,” but then the chance to be seen – really seen – without embarrassment or disgust, may have spoken to an even deeper need.
Posted June 11, 2012
Dr Suzannah Biernoff is a lecturer in the School of History of Art, Film and Visual Media at Birkbeck College, University of London.