I would like to thank the National Army Museum
for inviting me here today and I would like
to thank you all very much indeed for coming
along. I'm going to talk to you about casualties
sustained by the British Expeditionary Force
in France and Flanders between 1914 and 1918,
and I will be focusing particularly on the
evolution of the evacuation pathway and
the emergence of orthopaedic surgery as a specialty.
The talk comes with two warnings. The first is that
there is the occasional mildly gory photograph.
In fact, I've condensed it into
one photograph, so there's only one gory slide.
Perhaps of greater significance is that without
warning there may be poetry! [AUDIENCE LAUGHS]
So, without more ado, we'll get on.
Between 1914 and 1918 the British Army in
France and Flanders sustained no fewer than
2.7 million battle casualties. Of the 2.7
million just over a quarter were never seen
by the medical services. Those were the men
who had been killed, were missing or were
prisoners of war. Just under three quarters
of the total number of casualties were seen
by the medical services, of whom 5.6 per cent
of the total - 151,356 - died of their wounds.
The worst day, of course, in British military
history during the Great War was the first
day of the Battle of the Somme, Saturday 1 July 1916,
when there were just under 60,000 casualties,
20,000 of whom were killed or died of their wounds
mostly before 9 o'clock in the morning.
The Great War was first and foremost an artillery war
and the role of the artillery of the Battle of the Somme,
artillery as it was perceived in 1916, was
destruction of barbed wire, destruction
of the Germans in their deep dugout -
because they'd been there for two years -
and counter-battery work,
destruction of German artillery.
However, artillery in 1916 was inadequate.
They didn't have the expertise, they didn't
have the resources, for the most part the
wire was not destroyed and high explosives
in 1916 were unreliable, as can be seen from
the many shells still found in the fields
of France and Flanders today. The Germans
were secure in their deep dugouts and there
was very little effective counter-battery
work in 1916.
The result then, at 7.30am on Saturday 1 July
1916, was a complete disaster.
'Oh! Jesus Christ! I'm hit,' he said; and
died.
Whether he vainly cursed or prayed indeed,
The Bullets chirped - In vain, vain, vain!
Machine-guns chuckled, - Tut-tut! Tut-tut!
And the Big Gun guffawed.
Another sighed - 'O Mother, - Mother, - Dad!'
Then smiled at nothing, childlike, being dead.
And the lofty Shrapnel-cloud
Leisurely gestured, - Fool!
And the splinters spat, and tittered.
'My Love!' one moaned. Love-languid seemed
his mood,
Till slowly lowered, his whole faced kissed
the mud.
And the Bayonets' long teeth grinned;
Rabbles of Shells hooted and groaned;
And the Gas hissed.
When the Battle of the Somme petered out in
the mud in mid-November 1916, British casualties
amounted to 432,000, of whom 150,000 had been
killed or died of their wounds. Furthermore,
100,000 approximately were too seriously wounded
to serve in any capacity ever again. But:
Does it matter? - losing your legs?
For people will always be kind,
And you need not show that you mind
When others come in after hunting
To gobble their muffins and eggs.
Does it matter? - losing you sight?
There’s such splendid work for the blind;
And people will always be kind,
As you sit on the terrace remembering
And turning your face to the light.
Do they matter? - those dreams in the pit?
You can drink and forget and be glad,
And no one will think that you’re mad;
For they know that you've fought for your country,
And no one will worry a bit.
In an assessment of nearly a quarter of a
million casualties admitted to the casualty
clearing stations in France and Flanders the
majority were caused by high explosives or shrapnel.
When men went over the top, then rifle and particularly
machine-gun bullets took their toll.
Hand-to-hand fighting within the trenches,
moving from one segment of a trench to another,
resulted in wounds caused by handheld bombs
and grenades. Bayonet wounds were conspicuous
by their absence, either because they didn't
occur at all or because when inflicted
they were almost invariably fatal.
Gas in its various manifestations was responsible
for 18 per cent of admissions to
casualty clearing stations by 1918. Mustard gas caused
blistering and problems arose with mustard gas
when those blisters became secondarily
infected by bacteria.
The most deadly of the three was phosgene which
caused asphyxiation. It was always almost odourless.
There was a slight whiff of musty hay
and once you'd smelled that it was too late.
This [slide shows] post mortem changes in the lungs
of a soldier dying from phosgene gas poisoning.
The empty looking spaces are in fact air sacs,
or alveoli. This is where gas exchange occurs.
This is where oxygen diffuses into the bloodstream
and carbon dioxide comes out.
The pink area below the clear space - these
are also alveoli but they are filled with
inflammatory exudate. This patient essentially
drowned in his own secretions.
The most important thing about war wounds on the
Western Front was that they were absolutely filthy.
And the heavy bacterial contamination
of the soil, with organisms responsible for
tetanus and gas gangrene, meant that these
were particularly serious problems in 1914.
So much so that consulting surgeon to the
Expeditionary Force, Sir Anthony Bowlby, said:
'It is absolutely essential for success that
wound excision should be done as soon as possible
after the infliction of an extensive wound
because in such cases gas gangrene may become
widely spread within 24 hours. It is therefore
necessary to operate on such cases before
the patient is sent by train to the base.'
What did he mean by ‘wound excision'? Wound
excision meant removal of all dead, devitalised tissue.
It meant removal of all foreign material
- shell fragments, clothing driven into the
wound at the time the wound was inflicted,
and all the filth and debris from the battlefield
that goes deep into the body tissues. Only
healthy, bleeding tissue is left behind and
only then, only when you've got healthy, bleeding
tissue will the organisms responsible for
gangrene be deprived of the opportunity to grow
because they only grow in the absence of oxygen.
The one mildly gory slide is coming up now
and this is a high-energy civilian injury,
as opposed to a war wound. This is what happens
when human flesh meets steel and concrete.
If you look at the top-left slide, the left
leg is mangled beyond redemption and the only
solution is amputation. Ensure when the amputation
is performed to remove all dead, devitalised tissue.
The top-right slide shows a very nasty wound
in the right leg with much dead muscle.
That dead muscle has been completely excised and
the picture on the bottom-right was taken
three years later, showing healthy, bleeding
granulation tissue. That is what is meant
by ‘radical wound excision'. That is the
basic principle of war surgery as it is the
basic principle of civilian trauma surgery.
With that in mind, here is the evacuation pathway.
The top of the slide is the front line.
The bottom of the slide is the base
hospitals in Calais, Boulogne and Étaples.
The first person to treat a wounded soldier
was a regimental medical officer and he had
16 stretcher bearers. The stretcher bearers
went out into no-man's land and brought the
wounded back to the regimental aid post where
first aid was administered.
Then a field ambulance assumed responsibility.
You might think of an ambulance as a vehicle
with a siren and a blue flashing light.
That is merely an ambulance wagon. A field ambulance
is a mobile surgical hospital. It has a tent
section and the tent section is responsible
for making an advanced dressing station and
a main dressing station to treat the wounded.
It also has a stretcher bearer section and
the stretcher bearers go forward to the regimental
aid post, bringing the wounded back to the
field ambulance advanced dressing station
from where the wounded are transferred to
the main dressing station or to
the casualty clearing station.
In 1914 a clearing station was supposed to
be just that. It was to clear the casualties
back to the base hospitals at Calais, Boulogne.
But it took too long. The clearing stations
were far enough away from the front line to
be generally out of range of shell fire and
yet close enough that ambulance wagon convoys
could get there reasonably quickly.
So it was at the casualty clearing stations,
as the war went on, that most of the major limb
and life saving surgery was carried out before
the patient was sent by train to the base.
Here are some examples. Here's a regimental
medical officer in his regimental aid post
treating a wounded soldier. Note there is
a splint. It's called a Thomas splint and
a Thomas splint was used for treating compound
gunshot fractures of the femur or thigh bone
- one of the most serious orthopaedic wounds
in the Great War. I'll say more about that later.
One of the most important functions of the
regimental medical officer was preventive medicine.
Good hygiene, good sanitation. Absolutely
vital. To illustrate that I'll tell you a
story about the 63rd Royal Naval Division.
They were the brainchild of Winston Churchill
who, in 1914 as First Lord of the Admiralty,
realised that there were too many sailors
and not enough ships and the surplus sailors
were given a rifle and turned into a land-based
fighting division, the 63rd. They were at
Gallipoli in 1915, and 1916 saw them on the
Somme under General Shute.
General Shute did not like the Royal Naval
Division. They were sailors, they had beards,
they sat down for God Save The King, for heaven's
sake. Worst of all their trenches were like
latrines and General Shute lost no opportunity
in telling them so.
One of their number, AP Herbert, penned the
following lines about General Shute:
The general inspecting the trenches
Exclaimed with a horrified shout,
'I refuse to command a division
Which leaves its excreta about.'
[AUDIENCE LAUGHS]
But nobody took any notice,
No one was prepared to refute
That the presence of shit was congenial
Compared with the presence of Shute.
[AUDIENCE LAUGHS]
And certain responsible critics
Made haste to reply to his words,
Observing that his staff advisers
Consisted entirely of turds
[AUDIENCE LAUGHS]
For shit may be shot at odd corners
And paper supplied there to suit.
But a shit would be shot without mourners
If somebody shot that shit Shute.'
[AUDIENCE LAUGHS]
On a serious side to this, however, if you
look at the Boer War a mere 12 to 14 years
before the outbreak of the Great War, only
36 per cent of British deaths were caused
by enemy action. 64 per cent of deaths were
caused by disease. That disease was typhoid fever
caused by poor sanitation.
In contrast during the Great War on the Western Front
only 4.5 per cent of deaths were caused by disease.
The remainder were caused by enemy action.
It was the first war in British history
where deaths from enemy action exceeded deaths
from disease.
From the regimental aid post then, stretcher
bearers from the field ambulance take the
casualty back to the advanced dressing station
- no easy task in the mud of Flanders in 1917
during the third Battle of Ypres, the closing
stages of which are synonymous with a village
by the name of Passchendaele.
Squire nagged and bullied till I went to fight,
(Under Lord Derby’s Scheme). I died in hell -
(They called it Passchendaele). My wound was slight,
And I was hobbling back; and then a shell
Burst slick upon the duck-boards: so I fell
Into the bottomless mud, and lost the light.
At sermon-time, while Squire is in his pew,
He gives my gilded name a thoughtful stare:
For, though low down upon the list, I’m there;
‘In proud and glorious memory’ ... that’s my due.
Two bleeding years I fought in France, for Squire:
I suffered anguish that he’s never guessed.
Once I came home on leave: and then went west ...
What greater glory could a man desire?
When the wounded arrived at the advanced dressing
station they were assessed. They were divided
into one of three groups: minor wounds, hopeless
cases and severe but survivables.
The minor wounds would go back to the main dressing
station, the hopeless cases were put aside to die -
there was no point in wasting any
time on a hopeless case because you might
deprive someone with a severe but survivable
wound the opportunity to live.
There was a very limited place for surgery
in the early years of the war at the advanced
dressing station. Amputation was encouraged
in the completely mangled limb.
(Rather like the limb that you saw in the slide.) If you
removed a mangled limb from a badly wounded soldier
his general condition improved. These
legs were removed without anaesthetic or with
a local anaesthetic infiltration into nerves
to remove the totally mangled extremity.
Arrest of haemorrhage was another thing that
they had to do. Haemorrhage is what kills
people fastest. It's an easier said thing
than done sometimes to do. Bad conditions,
deep hole, blood welling up. Sometimes it's
very difficult to do that.
In appropriate cases, where the wound is more
distal in the limb, further down, you might
be able to get a tourniquet above it. But
it took a long time to get these casualties
back and there was a high risk - 80 per cent
of these patients ended up with an amputation.
By 1918 teams of experienced surgeons with an anaesthetist
would go forward to advanced dressing stations,
so by 1918 they were taking the medical services
further forward to do more major stuff.
Then from the advanced dressing station into
an ambulance wagon which was heated.
Very, very important. For the first time a soldier
who had lain in a wet shell hole,
who was hypothermic, began to feel warm. And as he
warmed up, so his condition improved.
Then he arrived at the casualty clearing station.
The casualty clearing stations had accommodation
for 800 to 1,200 wounded. They were grouped
together in groups of two or three, admitting
150 to 300 cases at a time before passing
the on call to the adjacent station with a
similar area of interest.
Those casualty clearing stations, treating
abdominal wounds, chest wounds and compound
fractures of the femur were closer to the
front line at a range of around 10,000 yards.
They were closer because these wounds above
all others needed early surgery.
Casualty clearing stations fulfilled three
important roles, depending on the severity
of the wound. Minor wounds were treated in
a minor operations theatre and the casualty
kept in the forward area and then sent back
to the front line. Wounds which were severe
but safe to send back were immediately transferred
to a train and put on a hospital train to
the base. Those wounds which threatened limb
and life and needed immediate surgery were
kept in the casualty clearing station where
they went to a major operation theatre
to have their surgery.
This is Casualty Clearing Station No. 10.
It's at a place called Remy Siding which is
near Poperinghe. Poperinghe is seven miles
west of Ypres. There were four casualty clearing
stations at Remy Siding in 1917 during the
Third Battle of Ypres, British 10 and 17 and
Canadian 2 and 3. And there is Remy Siding.
The four casualty clearing stations at Remy Siding.
There are other casualty clearing stations
at Dozinghem, Mendinghem and Bandaghem.
There are three casualty clearing stations further
forward at a place called Brandhoek.
And it was at Brandhoek that the abdominal stuff,
chest wounds and compound fractures
of the femur were dealt with.
The inside of an operating theatre in a casualty
clearing station was pretty standard.
Twin operating tables, three teams of surgeons and
anaesthetists working 16 hours on, eight hours off.
They kept two operating tables working round the
clock until the backlog was cleared.
During the Third Battle of Ypres, which raged
between 31 July 1917 and 10 November,
there were 24 casualty clearing stations which dealt
with the wounded from two British armies -
the 2nd and the 5th. Each army had about 150,000 men.
There were 379 doctors, 502 nursing sisters.
They processed over 200,000 casualties and
they operated on 30 per cent of them at the
casualty clearing stations. They operated on 61,423.
The overall percentage mortality
of admissions to the casualty clearing stations
was 3.7 per cent, a relatively small proportion,
but in absolute terms a lot.
The soldiers who did not get on the train
at Remy Siding stayed here at
Lijssenthoek Military Cemetery, where there are
10,821 burials.
From all this experience, from this huge volume
of work came development and research.
I'm going to say a bit about the development of
orthopaedic surgery and there are two very important names.
The first is Sir Robert Jones
who came from Liverpool and the second was
Sir Henry Gray who happened to come from Aberdeen.
Robert Jones was the nephew of the Welsh practitioner
Hugh Owen Thomas who worked in the docklands
of Liverpool and his patients were the poor
and the destitute. Many of these patients
had tuberculosis and Thomas invented a Thomas
knee splint for the treatment of tuberculosis.
His nephew, Robert Jones, became the Chief
Surgical Officer during the construction of
the Manchester Ship Canal and he used his
uncle's knee splint for the treatment of fractures
of the thigh bone, fractures of the femur.
Jones introduced the Thomas splint for the
treatment of compound gunshot fractures of
the femur during the Great War. But his principal
role was the development of orthopaedic services
in the United Kingdom for late orthopaedic problems,
because there was a real problem.
In 1914, by December, Jones recognised that
hospitals in France and hospitals in the UK
were full of crippled, discarded soldiers
who had been treated badly initially, who
were not fit to go back to the Army and they
were not fit for discharge into civilian life.
He opened an experimental orthopaedic unit
in Alder Hey in Liverpool in 1915,
for the very first time segregating orthopaedic patients.
And he opened what was called an 'orthopaedic centre'
here in London at the Hammersmith
Workhouse in Shepherd's Bush in March 1916.
It was opened for 800 patients.
What does an orthopaedic centre do? It provided
surgery for late orthopaedic problems.
These were problems invariably complicated by horrible
infection. There was mal-union of fractures,
non-union of fractures, there were nerve injuries
needing repair, there were tendon transfers
needing done, there were stiff joints needing
dealt with. So the late problems.
The orthopaedic centre also provided rehabilitation,
what was called then a curative workshop,
working in a variety of trades. Simply moving
a stiff joint was tedious and boring,
but moving it in association with an occupation
was good for morale and restored function.
In Aberdeen, for example, they were put to
work in making and mending deep-sea fishing nets.
So 1,000 of the first 1,300 cases returned
to some form of military service.
Jones became Director of Military Orthopaedics
in 1916, shortly after he opened his first
orthopaedic centre in Shepherd's Bush. But
he opened it against serious opposition from
the London surgical establishment of general
surgeons. They were jealous that these upstart
orthopaedic surgeons were taking away clinical
material from them. They tried to have Jones
removed from his office. However, they were
not successful.
By 1918 there were no fewer than 20 orthopaedic
centres, all round the United Kingdom,
with a total of 20,000 beds, and the hub was here
in London at Shepherd's Bush.
In 1918 the general surgeons in London once
again had an attempt to restrict the role
of orthopaedics, but they failed. And that
was largely due to the intervention of this
man, Sir Berkeley Moynihan, who later became
Lord Moynihan. He was from Leeds, an extremely
powerful general surgeon who was a steadfast
supporter of Robert Jones and was very influential
in Jones's appointment as Director of Military
Orthopaedics.
He was powerful enough not only to have Jones
appointed, he was also powerful enough to
keep him in the post for the rest of the war against the
jealous opposition from the London-based general surgeons.
Henry Gray was born in Aberdeen. He was a
son of a wholesale provision merchant.
He graduated in medicine in Aberdeen in 1895 and
became surgeon to the Aberdeen Royal Infirmary in 1904.
He's credited with bringing aseptic
surgery to Aberdeen and local anaesthesia
to surgery in the United Kingdom.
Gray and Jones and Moynihan all knew each
other well. They knew each other through the
Moynihan Provincial Surgeons' Club. Berkeley
Moynihan in 1909 began this surgeons' club
and it was basically to demonstrate to the
surgical establishment in London that it was
perfectly possible for surgical development
to take place elsewhere in the United Kingdom
apart from in London.
Gray's principal contribution was the development
of the acute orthopaedic services on the Western Front.
He served in France for three and a half years,
first of all in a group of base hospitals
in Rouen and then as Consulting
Surgeon to the British 3rd Army.
The main orthopaedic problem which confronted
Gray on the Western Front was this -
a compound fracture of the thigh bone, the femur. Gray
established that the mortality from this wound
in 1914 and 1915 was somewhere in the order of
80 per cent. Eighty per cent of these soldiers died.
Jones described this wound as the tragedy
of the war. It was a tragedy because many
deaths were preventable, because when the
British Army went to war in 1914 it did so
with a series of inadequate splints based
on the Liston splint, which simply is a pole
tied down the side of the extremity and the
leg with the fracture is tied to it.
It's quite ineffective. Bone end grinds against
bone end, resulting in excessive blood loss.
So by the time these wounded soldiers arrived
back at the casualty clearing stations,
they were completely clapped out with hypovolemic
shock and that's why most of them died.
The Thomas splint overcame the problems of
the Liston splint by applying longitudinal
traction to the limb and cords tied round
the bottom of the splint. Traction is maintained.
As a result it effectively immobilised the
fracture, diminishing the blood loss so that
wounded soldiers treated in a Thomas splint reached
casualty clearing stations in good clinical condition.
Jones introduced the Thomas splint to the
Western Front and it was Gray who ensured
its use in clinical practice. Never more so
than at the Battle of Arras in 1917 which
began on Easter Monday, lasted about six weeks
and Gray had 1,009 compound femurs in six weeks
admitted to his casualty clearing stations.
To put that into perspective it would take
every hospital in the United Kingdom collecting
all their cases of compound femur about two years
to collect that number of cases. Gray
had them in six weeks.
On the left you see before the battle of Arras,
using a variety of splints based on the Rifle splint,
the majority of patients reached the
casualty clearing stations in terrible shock
due to blood loss. The mortality in the casualty
clearing stations was 50 per cent.
Many had died before they got there. There was a
school of thought that the only way to treat a
compound femur was to do an amputation, because as
far as anaesthetics were concerned the only thing
they were fit for was a quick whiff
of gas and a short operation, and the only
short operation under the circumstances was
an amputation.
However, if you look at the right when they
had the Battle of Arras all compound fractures
were treated using the Thomas splint. Only
5 per cent reached casualty clearing stations
in clinical shock and the mortality was 15.6 per cent -
a very, very significant reduction in mortality.
Gray's amputation rate was only 17.2 per cent.
All regimental medical officers
were taught how to apply the Thomas splint.
The wounded were admitted urgently to casualty
clearing stations dealing with this wound.
It needed men who knew what they were doing
to treat these wounds effectively.
All the patients who were fit for surgery underwent
immediate radical wound excision. It was the
radical wound excision that saved their lives
but it was greatly facilitated by the good
condition of the wounded when they reached
the casualty clearing stations.
Once they'd had their surgery then they were
put on a train where they were ably looked
after by nurses from the Queen Alexandra Imperial
Military Nursing Service, reaching base hospitals in France.
Fractures of the femur had specially designated
hospitals. Most other wounds were treated
as and when they came without specialist resources,
but fractures of the femur were looked after
by dedicated personnel who knew how to treat
these.
They were kept in France for six weeks until
the fracture was sticky. By ‘sticky' I mean
that you can't actually wiggle it about any
more. It's not completely solid but it is
solid enough that you can transfer the patient back to
the United Kingdom to one of the orthopaedic centres
without losing the position of the fracture.
During the Battle of the Somme there
were 3,173 fractures of the femur treated
in France.
Henry Gray published very widely during the
war. He published in the British Medical Journal.
He also wrote a book entitled The Early Treatment
of War Wounds. A contemporary view of Henry Gray
is provided by Lieutenant Colonel Carberry who wrote
The New Zealand Medical History of the Great War.
Carberry wrote:
'Surgery, especially that of the front line, was a
specialty of the 3rd Army whose consulting surgeon,
Colonel HMW Gray, who was noted since 1916 for his
work in the treatment of compound gunshot fractures.
His memorandum, issued by the 3rd Army
in 1917 formed the basis of
the front-line surgical practice of this and
other armies. His well-known book,
The Early Treatment of War Wounds,
published at the end of 1918, epitomised
the advancing knowledge of that period.'
A contemporary opinion of Henry Gray provided
by Colonel Mount Stewart RAMC, lately
Defence Medical Surgery Consultant and advisor in
trauma and orthopaedics to the Surgeon General, states:
'Through three and a half years of concentrated
experience of war wounds on a scale hitherto
unimaginable and in collaboration with many
brilliant young surgeons, Gray was able to
define the principles of treatment in modern
war surgery. One cannot overstate the importance
of Sir Henry Gray's book, The Early Treatment
of War Wounds. I do not think there is another
text on war surgery that has since bettered
it. In terms of the casualty evacuation chain
our Role 3 military hospital in Camp Bastion
is equivalent to a casualty clearing station.'
Sir Berkeley Moynihan, later Lord Moynihan,
described the Great War as a war of orthopaedic
surgery, which indeed it was. I would really
like to pay tribute to a generation of surgeons
who pioneered modern war surgery. The vision
and action of Robert Jones in establishing
the principle of segregation, unity of control
and continuity of treatment of certain categories
of wounded soldiers on the Western Front and
the organisation of military orthopaedic centres
in the United Kingdom remains one of the glorious
chapters of British surgery.
Almost 100 years have gone by since those
terrible and yet rather amazing times of
Remy Siding casualty clearing stations. The figure
in the inset is Walter Sutherland, who was
with the Canadians, at Canadian Casualty Clearing
Station No. 3. He was a Scot who emigrated to Canada.
He became one of the original Imperial
War Graves Commission gardeners at Lijssenthoek
following the war. One of his jobs was to
bury the dead.
In my retirement I take groups of former colleagues
on cycling expeditions to the Western Front
where we invariably meet up with George Sutherland,
Walter's son, who followed his father into
the Imperial and then Commonwealth War Graves
Commission and retired in the 1980s and is
a sprightly 91-year-old who takes us round
Lijssenthoek every time we are there.
I leave the last word with Wilfred Owen, who
was killed on the 4 November 1918:
Shall Life renew these bodies? Of a truth
All death will he annul, all tears assuage?
Or fill these void veins full again with youth
And wash with an immortal water age?
When I do ask white Age, he saith not so:
'My head hangs weighed with snow.'
And when I hearken to the Earth she saith:
'My fiery heart shrinks aching. It is death.
Mine ancient scars shall not be glorified
Nor my titanic tears the seas be dried.'
Because of my passion for this subject I teamed
up with one of my surgical colleagues in Aberdeen
and we involved other specialists in various
fields and edited this book on War Surgery 1914-18
as a tribute to the generation of
surgeons who did so much for our specialty.
This is one of my avid readers.
Thank you very much.
This page was last edited on 31 December 2020, at 09:43