After the seismic shock of the first day on the Somme, the system gradually recovered. On the second day, more than 33,000 wounded men were treated. Sloggett and Bowlby met with General Rawlinson, commander of Fourth Army, who was in direct command of the offensive. Medical officers were rushed in from quieter parts of the front with the intention of carrying out more urgent surgery in the CCSs. The evacuation system began to catch up with the massive congestion caused on the previous day. By the third day, the numbers being moved on from the CCSs actually exceeded the numbers arriving. And by the end of July the CCSs had treated about 96,000 men, of whom approximately 10 per cent had been operated on. It was a remarkable number to have coped with.
The battle rumbled on for several months, and when Haig visited a CCS in September, he was astonished to meet a surgeon who had carried out eighty-two operations in the previous ten hours.21 But he was encouraged by the cheerful mood of the wounded men he met; their morale seemed to be high, despite the horrors they had endured. Possibly it was for this reason that he felt able to continue with the offensive for another two months until the winter rains of November brought the fighting season to an end.
Haig lost 420,000 men killed, wounded, missing and captured during the Somme. But despite these appalling losses the British Army had survived intact. The hard-pressed medical services had played a large part in enabling the army to fight on and preventing a catastrophic collapse in morale.
The next major offensive, the Battle of Arras in April-May 1917, had the dubious distinction of causing the highest daily average death toll of any battle fought by the British during the war. Twelve CCSs and twenty-eight ambulance trains were prepared for the battle, proportionately far more than had been available at the Somme. Again, the medical systems struggled but finally coped with the vast scale of casualties. And again the local army commander, this time General Allenby, paid frequent visits to the CCSs to gauge conditions and assess morale. Once more, what he saw made him feel that the offensive could continue. And it did, although this time it lasted for only a month.
One consequence of the battles of the Somme and Arras was that the CCSs began to specialise. By the Third Battle of Ypres in the summer of 1917, many CCSs had in addition to dealing with all common injuries their own specialisms in the treatment of chest or abdominal injuries, fractures or gas casualties. This enabled the provision of better care nearer to the front and resulted in an increase to a rate of about 25 per cent of all casualties being operated on at CCSs. The numbers wounded in the battle were not quite so high as had been anticipated but the conditions at the front, especially the thick, exhausting, omnipresent mud, were the worst that had been known in the war. Sickness rates shot up, as did cases of infection, especially gas gangrene, for which the only remedy was amputation.
The process of treatment and evacuation had lasted through the great battles of 1916 and 1917 but was hard pressed in the aftermath of the German offensive of March 1918. With the return of a more mobile form of warfare, the established tiers of care were difficult to sustain. The Germans advanced up to twenty miles in places and some CCSs were overrun completely, many of the seriously wounded being left behind in the care of small teams of volunteers who faced inevitable capture. New systems had to be quickly improvised, and field ambulances and trains were used with increasing regularity to move the wounded further from the front line.
After the German offensive had petered out, and especially from August 1918, when the Allied armies began their own advance, mobility was key. New hospitals and CCSs were established as the armies moved forward. The medical corps had to show great flexibility in this final phase of the war, as inevitably they received very little advance notice that would allow them to plan for receiving the casualties of new assaults. Nevertheless, by the autumn of 1918, many new mobile CCSs had been set up, each one supported with forty motorised lorries. It was reckoned that a CCS, with 500 or so beds, operating theatres, X-ray machines and all its supplies, could be packed up, moved off and reopened in less than forty-eight hours. This was a creditable achievement, especially as the daily casualty rate was still counted in the thousands. Inevitably gaps developed between the advanced dressing stations and the CCSs as the armies advanced. Often the railway system could not cope, and more sidings and rail links had to be laid, all of which took time even if only a matter of days. ‘The difficulty is railways,’ wrote one exasperated senior medical officer in October.22 One answer was to use more ambulances to bridge the growing distances involved.
In addition, during the last two months of the war large numbers of German wounded were brought in and treated alongside Allied soldiers. A huge wing of the Etaples base hospital was given over to the exclusive care of German prisoners. Overall, the last few months of fighting in the summer and autumn of 1918 showed how well the medical services had been integrated into the operations of the British Army, and how flexible and capable those services had become in treating the large numbers of terribly wounded and mutilated men still being brought in.
For many of those with severe injuries, the problems were permanent. About 41,000 British servicemen with amputated limbs were given prosthetic replacement body parts. There were no major new developments in prosthetics during the war and the techniques remained essentially Victorian, with the use of wooden and leather limbs and attachments. But the scale of the demand for replacement legs, arms and hands provided a generation of doctors with a mass of experience that it would have usually taken a lifetime to pick up. Queen Mary’s Hospital in Roehampton was the centre of the use of prosthetic limbs and nearly two-thirds of all amputees were sent there; it became the centre of excellence for the use of prosthetics and for the care and rehabilitation of patients. The work carried out became important in the maintenance of morale, by showing soldiers and their families that everything possible would be done for those severely wounded to make them feel and act normally once again. A story filmed at Roehampton by British Pathé newsreel cameras recorded men showing off their prosthetic legs, walking, marching, taking part in tug-of-war and even playing football with some nurses. It was a propaganda exercise, of course. The fragments of film that survive show the men cheerful with a strong sense of camaraderie and proud of their artificial limbs.23 Although it was no doubt staged for the cameras, however, there are many comments about how cheerful groups of amputees could be. They were no doubt pleased still to be alive. The problems often came later as they struggled to assimilate back into civilian life. The concept of broken warriors’ and ‘help for wounded heroes’ was well established by 1918, and the sight of the blind and limbless victims of the Great War on crutches or struggling with artificial limbs and attachments became commonplace in the decades following the end of the conflict.24
A recurring issue throughout the war was finding the right balance between general care for the bulk of the wounded and specialist care for those with particular wounds. Military medicine traditionally favoured general care that could be applied quickly across the board. But the ghastly nature of the wounds suffered during the war years provided an opportunity for specialists to try out new ideas and develop new expertise. One of the most remarkable specialisations was that of Harold Gillies and the face reconstruction work that he carried out, first in Aldershot and then at Queen’s Hospital in Sidcup, south-east London.
The First World War seems to have generated an excess of head wounds – possibly because soldiers were exposed at times above the parapet of a trench, or perhaps simply because more patients with head injuries survived than in previous wars thanks to improved general medical treatment. Some of these wounds were monstrous: parts of the face had been blown away, jaws shattered, noses removed and cheeks destroyed. In the cases of explosions at sea, men suffered from terrible facial burns, as sailors did not then wear face masks. The only treatment at the start of the war for anyone who had suffered such a trauma and survived was to pull the edges of the wound together and sew up the face. This closed the wound but d
id not replace the lost tissue, and it was left for nature to do what it could. It was into this world that a young New Zealand surgeon entered in 1915.
Harold Delf Gillies had been a brilliant youth, a great sportsman, a fine artist in watercolours and a talented violinist. After attending school in both New Zealand and England, he went up to Gonville and Caius College, Cambridge in 1901 to study medicine. Although he was only slight, he rowed in the Oxford and Cambridge Boat Race three years later and helped Cambridge to a big win. He went on to play golf for the university, and the sport became a particular passion. He was an argumentative student who wanted to do things his own way and did not hesitate to speak his mind and disagree with his tutors, a trait which did not endear him to the academic community. He finished his medical training at St Bartholomew’s Hospital in London and qualified in 1906, becoming house surgeon to the senior lecturer on surgery and a specialist in ear, nose and throat surgery. Clearly a talented surgeon, he soon became assistant to Sir Milsom Rees, one of the leading London surgeons of the day.
In 1914, then aged thirty-two, Gillies volunteered for the Red Cross and worked in Belgium and France for a few months. While in France he visited Hippolyte Morestin, the most famous plastic surgeon in Europe, and was allowed to watch an operation in which Morestin removed a cancerous growth from the face of a patient and rolled up a flap of tissue from under the jaw to repair the cheek wound. For Gillies, this was a road-to-Damascus type moment, of which he later said that ‘it was the most thrilling thing I had ever seen’.25 He left Paris feeling ‘a tremendous urge to do something other than the surgery of destruction’. Instead he became passionate about the surgery of what he called ‘reconstruction’.26 He put the case to Sir Anthony Bowlby that the many face and jaw casualties of the war posed entirely novel challenges to the military surgeon and that a new establishment devoted to this work was needed. Bowlby in turn persuaded Sir Alfred Keogh of the necessity for such a unit and in January 1916, Captain Gillies was told by the War Office to report to the Cambridge Military Hospital in Aldershot and open up shop.
Before long a stream of men with terrible wounds began to appear at his unit. A nurse vividly remembered men arriving ‘with half their faces literally blown to pieces, with the skin left hanging in shreds and the jawbones crushed to a pulp’. None of the patients could eat solids and they were mostly fed on a mixture of whipped eggs, milk and sugar, known as ‘egg flip’. As the nurse recalled, ‘Hardest of all was the task of trying to rekindle the desire to live in men condemned to lie week after week smothered in bandages, unable to talk, unable to taste, unable even to sleep and all the while knowing themselves to be appallingly disfigured.’27 For Gillies, the reconstructive surgery he now began to apply was not just about learning the technical processes of how to replace bone, cartilage and skin, but was about restoring a man’s features and his confidence in himself. He called it ‘a strange new art’.28 He soon became very good at it.
There were no textbooks to guide Gillies in this new work, and he and the talented team he gathered around him had several elements to master. Applying anaesthesia to men with blocked or wounded air pipes was a problem that took some time to solve. Chloroform was often used, but this was extremely unpleasant for the patient and sometimes escaped, with the risk that it would affect the surgeon as well. Sometimes it proved better to operate on a man in a sitting position than lying down. A team of dental surgeons were also needed and a small group began to work closely with Gillies.29 And as a final sign of the artistic nature of how he saw his work, Gillies asked artist Henry Tonks to sketch men’s faces before and after treatment. Tonks had taught at the Slade School of Fine Arts before the war, specialising in anatomical drawing, and had taught such luminaries as Augustus John and Stanley Spencer. When war came he joined up as a humble medical orderly, and when Gillies discovered him at Aldershot he asked him to join his team. Tonks’s pastel drawings of faces before and after surgery provide a permanent tribute to the work carried out by Gillies.30
Gillies’ key technique involved reopening original wounds that had been stitched together at the CCS and adding flaps of skin tissue removed from other parts of the body. It was a slow process that often required more than one operation, but when it worked it could be extremely effective in restoring the features of a man’s face. At the start of an operation, Gillies would mark out, usually on the man’s chest, the shape of the face he intended to cut out, including the skin for the eyes, nose, cheeks, or for the whole face if needed. He soon developed a variety of different techniques for rebuilding different parts of the face, and gave them exotic names like the Bishop’s Mitre Flap, the Caterpillar Flap and the Transposition Flap. He also performed some bone grafting. With these techniques, noses were restored, jaws rebuilt and gaping holes filled, enabling men to face the world again – or, at least, in the case of some of the less disfigured, to return to the trenches.
The chief consultant at the hospital in Aldershot, Sir William Arbuthnot Lane, soon began to take an interest in Gillies’ radical techniques. In the summer of 1916, anticipating the arrival of a large number of cases from the Battle of the Somme, Lane showed his confidence in the new form of surgery by allocating an extra 200 beds to Gillies’ ward. But this was nothing like enough; within a ten-day period, two thousand men had arrived with desperate and grotesque face wounds that needed urgent attention. Some had had much of their face blown away. Many were encased in bandages, unable to speak or eat; some were unable to see. Gillies and his team worked around the clock, seven days a week, doing what they could to heal some of the worst wounds that any of them had witnessed. Gillies himself was constantly present, visiting the wards. He became a familiar figure, always encouraging and cheerful, known for his plain talking and for attending to all the wounded, officers and men alike. Sometimes a man had to endure up to twenty operations over several months before his face was put back together again. Aware of the need for patients to have faith in him in order to be able to confront the long process ahead of them, Gillies exuded an air of calm and confidence. ‘Don’t worry, sonny’ he would say to a horribly mutilated patient, ‘you’ll be all right and have as good a face as most of us before we’ve finished with you.’
The face is so much part of our identity, of our sense of who we are, that it is difficult to imagine the psychological effect of having one’s face so badly burned or disfigured that one is unrecognisable. Worse still, as was sometimes reported with Gillies’ patients, a man’s wife or children could be so repulsed at the ghastly sight of their husband or father that they did not want to see him again. Mirrors were consequently banned in the ward. But with many of the patients having lost the will to live, Gillies and his team did what they could to restore not only a man’s face but also his self-confidence and his ability to go out and interact with people once again. And Gillies had a remarkable success rate, although by no means did he solve every case. Slowly, the press began to pick up on the reconstruction work that he and his team were doing. When reports got back to the army about Gillies’ extraordinary achievements, without doubt they helped to lift morale and instil confidence that a man would be cared for no matter how cruel his wounds.
By the summer of 1917, the ward in Aldershot had become insufficient to deal with the number of cases arriving. Keogh decided the RAMC should set up a completely new hospital and acquired land at Sidcup in south-east London, taking over an eighteenth-century country estate. The nursing and medical staff moved into the mansion house and a large oval of single-storey wards were built in the grounds, equipped with operating theatres, X-rays, psychotherapy rooms and a large admission block, as well as a small area for Gillies to play golf. Tonks was given a studio in which to draw and another studio was provided for a group of sculptors who made plaster casts of patients’ faces in order for Gillies and his team to plan procedures in detail before operating. Gillies and the team arrived at Sidcup from Aldershot on 18 August 1917 and were almost immediately overwhelmed with patients
arriving from the Battle of Passchendaele. ‘We literally put down our suitcases and picked up our needle holders’ Gillies later wrote. ‘Is there a better way to open a hospital?’31
Once again, the team worked at full stretch, struggling to cope with the huge volume of patients. Sir William Arbuthnot Lane had great ambitions for the new establishment, and wrote to Gillies saying, ‘I want to make Sidcup the biggest and most important hospital for jaws and plastic work in the world and you consequently a leader in this form of surgery.’32 And indeed, Queen’s Hospital soon became famous for its reconstructive surgery. Surgeons came from Australia and Canada to practise alongside Gillies, and observers arrived from the United States to watch and learn, taking many ideas away with them.
On 3 October, Gillies was carrying out an operation on an able seaman who had been horribly burned in a cordite explosion at the Battle of Jutland, eighteen months before. It was one of the worst burn cases the team had ever had to deal with. The man’s nose, lips and eyelids had been destroyed. ‘Appalling’ was the word Gillies used to describe it. They cut a large piece of skin from the man’s chest and folded it over his face with the lower end still attached to ensure an adequate blood supply. When stitched into position it was given an additional blood supply from two thinner strips of skin raised from the shoulders. It was while raising these strips that Gillies had a flash of inspiration. ‘If I stitched the edges of those flaps together, might I not create a tube of living tissue which would increase the blood supply to the grafts, close them to infection, and be far less liable to contract or degenerate as the older methods were?’33 Two weeks later the growth of the new skin had progressed well and over a period of eighteen months the restoration of the seaman’s face was completed. This new technique using what Gillies called ‘tube pedicles’ transformed skin grafting. It increased both the likelihood of the new skin taking to the face and the possibility of making shattered faces recognisable once again. The tubes of skin could be applied to any part of the face and became a common feature in the hospital’s wards. The technique marked another significant breakthrough in the development of Gillies’ work.
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