Tom Scotland, a retired orthopaedic surgeon, discusses the improvements in the care of the wounded in casualty clearing stations and base hospitals in France during the First World War.
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! 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.'
But nobody took any notice,
No one was prepared to refute
That the presence of shit was congenial
Compared with the presence of Shute.
And certain responsible critics
Made haste to reply to his words,
Observing that his staff advisers
Consisted entirely of turds
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.'
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 Second and the Fifth. 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.