100 years ago at 11 am on the 11th November 1919 the first Service of Remembrance (Poppy Day) post World War One was carried out with due reverence at The Cenotaph in Whitehall, London, remembering the many thousands of UK and Commonwealth troops who had lost their lives during the war. Engraved on the UK and Commonwealth Victory Medal are the words The Great War for Civilisation 1914 – 1919; this was thought to be the war that would end all wars and it was hoped that Europe and the US would be brought together with the common aim of world peace under the League of Nations. For many surviving soldiers it carried a more potent awareness of what had occurred – psychological and physical scars that affected their lives and the lives of their families for years. The true understanding of which would not be fully known publically for many decades, this was the silent generations who did speak of the aftermath. Similarly, the links between advancements in medicine and World War One have also been buried in the medical literature rarely seen by the general public.

In a previous blog, I talked about the pioneering work of Dr William Rivers and ‘shell shock’. Today I want to focus on the physical scars inflicted on soldiers – battlefield wounds were horrendous they resulted from machine gun fire and bomb blasts – shards of shrapnel and/or bullets tore the skin apart, open wounds were often covered with trench-mud (contaminated by stench water and soil containing tetanus spores), no part of the face or body were spared from injury, body armour was not used and ‘tin’ hats often failed to protect the skull and brain. Associated internal injuries were often fatal. Close proximity to a blast meant a complete person would never be found. For those stretched to a first aid clearing station there was a chance of survival if the field surgeon acted quickly – early debridement of wounds, cleaning with carbolic lotion and then gauze soaked in the same solution was wrapped around the wound to prevent infection and aid healing. Next transfer to a field hospital and if ‘lucky’ back to England, packed on to a train and then ship, for further treatment and rehabilitation.

Plastic surgery was in it’s infancy in the early 1900s but a doctor named Harold Gillies (a New Zealander who studied medicine at Cambridge and who was commissioned into the Royal Army medical Corps) became inspired by the work of a dentist called Auguste Charles Valadier (Gillies had been sent to mind the French-American Valadier who was not allowed to practise unsupervised in the army hospital). Gillies observed Valadier experimenting with nascent skin grafts, he saw how these techniques could be used repair facial wounds – a simple facial reconstruction. Gillies persuaded the army’s chief surgeon that a hospital facility in the UK should be made available for this work. Queen’s Hospital (currently still standing as Queen Mary’s Hospital, Sidcup, Kent) opened in June 1917 and Gillies carried out around 11,000 operations (mostly facial injurers) on 5,000 men. His work was recorded by a surgeon-artist named Henry Tonks (who is featured in David Hancock’s book A Crisis of Brilliance: Five British Artist and the Great War – published 2009), he undertook to do a series pastel drawings of the men through their surgical journey (these pictures are now held by the Royal College of Surgeons in London, some can be seen online). Gillies worked without the benefit antibiotics or sulphonamides as they did not exist, infection both local and systematic would serious undermine any good work done. It was also a period where anaesthetics was still advancing (ether and chloroform by open drop mask along with a mixture oxygen and nitrous oxide by a ‘gas’ machine was a standard regimen). Anaesthesia could be more hazardous then the surgery being performed. Skin grafting often resulted in serious tightening of the skin resulting in serious facial distortion. In fact the army medical service set up a tin face mask department to help support men with serious disfigurements (Masks for Facial Disfigurement Department – 3rd London Field Hospital).

Many of the injuries meant the patient could not eat and swallow property – the risk of suffocation was high if they were laid flat, their survival rested with dedicated and observant nurses ensuring the patient were nurse upright, carefully feed and helped to sip water.

One of Gillies most success technique was the development of the tubed-pedicle-flap: taking skin still attached to the chest or forehead stitching it into a tube shape and anchoring the free end onto the face near to the site of the injury. As the flap remained attached to the original area it meant a good blood supply was maintained and this helped reduce infection. Once the pedicle had become firmly attached to the damaged site it could be removed from the donor area, opened and spread out to create the graft, (there are many online article that describe and illustrate this technique). Gillies’ work was observed by Henry Pickerill (New Zeeland Medical Corps) who went on to use the plastic surgery techniques himself, but importantly developed various teaching models and casts to show how this type of surgery was undertaken – some consider this the birth of plastic surgery!

Harold Gillies

How Gillies’ patients reacted to his pioneering surgery is interesting – many grateful but many unable to face the outside wold of The Queen’s Hospital…

‘We had two night watchmen, both wounded very badly in WW1. They had gone through facial reconstructive procedures after the War but the price they paid for their Country was unbelievable.
They were so disfigured, only night work was possible, they never looked us in the face, but we (the nurses) began to feel comfortable with them, feed them a sandwich and a cup of tea on a cold night… Stan the one I knew best told me he had never had a family, never been to a dance, never enjoyed a girlfriend even before the war.’

Nurse at Queen Mary’s Hospital Sidcup, 1950s (Source: https://www.nam.ac.uk/explore/birth-plastic-surgery)

Gillies continued to develop his plastic surgery techniques. During World War Two he acted as a consultant to the RAF and the Navy in the treatment of pilot and sailors who had had suffered severe burns. In 1946 he carried out the first sex reassignment surgery from a female to male on Michael Dillon – a qualified physician who autobiography is titled Out of Ordinary: A life of gender and spiritual transaction (2016).

The Gillies Achieves can be found at http://gilliesarchives.org.uk

So as we reflect in the two minute silence at 11am on the 11/11/2019 we can give thanks for medical pioneers like Gillies and Rivers for advancing clinical practice, we can give thanks to those patients who endured their treatments especially those who did not survive because of complications, and importantly remember all those who sacrificed their lives as result of war for us.

O valiant hearts who to your glory came
Through dust of conflict and through battle flame;
Tranquil you lie, your knightly virtue proved,
Your memory hallowed in the land you loved

(Sir John Stanhope Arkwright 1872 – 1954)

War Surgery 1914-18, edited by Thomas Scotland & Steven Heys (Hellon)

“Remembrance Day 2019” by Adrian Reyes-Hughes

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