Grace E.F. Holmes, MD
Professor of Pediatrics and of Preventive Medicine Emerita
University of Kansas School of Medicine

In 1914, during the Great War, a remarkable woman surgeon - Miss Frances Ivens - was asked to head a newly-formed Scottish Women’s Hospital in France for the French Red Cross at the Abbey of Royaumont. She was part of a group of Scottish women doctors who set up hospitals in France and Serbia and she became Chief Medical Officer of this Scottish Women’s Hospital, (Hôpital Auxiliaire 301), situated about 30 kilometers north of Paris.

Born in 1870, she entered the Royal Free Hospital’s Medical School for Women in London in 1894, graduating in 1902 as a doctor with First Class Honours. She attained a Master’s in Surgery (with gold medal) in 1903, and later gained medical and surgical experience in both obstetrics and gynaecology in Vienna and Dublin.

Frances was born in Warwickshire, the youngest of five children of William - a timber merchant - and Elizabeth Ivens. After she had finished her medical education, Ivens developed a special interest in the health and welfare of women and children. She attended conferences and spoke out to improve conditions for women, and in October 1913 she was part of a panel discussion on the “Moral Education of the Young” at the National Union of Women Workers of Great Britain and Ireland Annual Conference.

Some of the Royaumount women - as they came to be known - were pacifists who had joined the Womens’ International League for Peace and Freedom which started in Geneva, Switzerland. However, the women who went to work at the Royaumount Hospital, put aside their anti-war beliefs to focus on their new responsibility, that of helping the men who were wounded in the Great War in which Britain, France, and Russia fought Germany.

Painting of a ward at the Royaumont Abbey Hospital showing Miss Ivens on rounds, the artist is Norah Neilson-Gray, 1920.

Ivens, as chief surgeon, and her colleagues arrived in France at the 12th century Royaumont Abbey in a very cold December of 1914. In this ancient building they found no electricity, no heat, and no furniture, all the while bombs were falling close by. They had little equipment or funds and faced an indifferent French military bureaucracy. But, in less than a month, they began to receive support from British women and women in other countries. Females, one and all, nurses and doctors, they opened a quickly-growing, working hospital that provided medical and surgical services for the Somme region, starting with six patients. By the end of the war in 1918, Ivens and her staff had treated over 10,800 patients.

Dr. Ivens knew of Dr. Antoine Depage, a Belgian surgeon, and his wife, a nurse, who earlier had worked to establish Belgian hospitals in the Balkan Countries. Based on his experiences with battle wounds in Serbia, Depage was convinced that more could and should be done to save wounded soldiers from loss of limb or life. He devised and practiced an organized strategy for better wound care both at the front and at hospitals in the rear. For patients who arrived at Royaumont Abbey from the front by ambulance trains during the night Ivens demanded that wounded patients who might be expected to develop gas gangrene would be treated by the Depage methods. Thus, they were made comfortable, wounds were cleansed and dressed, cultures were taken from the wounds to identify anaerobic bacteria, like Clostridia, bacteria that thrive without oxygen. The patient was then taken to radiology for any x-rays and allowed to get a good night’s rest, unless immediate surgery was indicated.

Trench warfare bred filth and mud leading to contaminated wounds

Depage had reintroduced the discarded French practice of wound incision and exploration – débridement, combining it with very wide excision of devitalized or dead tissue. Some form of this treatment had been used in the Napoleonic Wars (1803-1815), but when that empire collapsed, the practice was largely forgotten and considered to be a worthless and antiquated form of treatment. Minimalism of wound care became the rule on battlefields, including during the Civil War in the United States (1861-1865).

Thus, in the early months of WW-I, initial treatment available for wounds consisted of minimal exploration, and use of various “then-new” antiseptic solutions to pour onto and into wounds. However, those wounds were usually deep, caused by shrapnel which carried along with it, soil, manure, and pieces of dirty uniforms which could result in gangrene with extensive breakdown of tissues, including muscles and bones.

Applying the Depage principles of wound care, Ivens agreed that mortal complications needed immediate attention at the front. But, other wounds could be covered lightly, without pressure, until the wounded soldier could be moved from the frontline by ambulance to established hospitals in the rear for definitive care.

In spite of her many hospital duties and responsibilities, from a total of 2,267 French soldiers admitted between January 13, 1915 and October 30 1916, there were 1,694 surgical patients and she personally and carefully followed the group of 464 whose wounds appeared to show early infection from gas gangrene bacteria. She cleaned their wounds - débrided them - and took swabs from the wounds to identify through bacterial cultures which patients were developing or had actually developed anaerobic bacterial infections in the wounds.

Clostridium perfringens bacterial smear

She meticulously and repeatedly cleansed the injuries, swabbed the wounds for bacterial information from cultures grown in the laboratory, and left the wounds very widely open for delayed surgical closure. She stressed the importance of dissecting and maintaining wide incisions to improve the visability and vitality of the tissues. Of the 107 men who developed anaerobic bacteria in their wounds - usually Clostridia - only 25 developed full-blown gas gangrene infections and died, (23 %) . With exacting dissection and débridement of battle wounds, supported by consistently negative anaerobic cultures, Ivens was able to obtain a 77 % clean- closure rate in wounds initially heavily contaminated with Clostridia. Surgical closure of wounds was delayed until all of the anaerobic bacteria had disappeared from cultures. She was able to do this without antibiotics or without such modern wonders as hyperbaric oxygen chambers.

Ivens kept detailed written records of her findings, which she presented in December 1916 to the Surgical Section of the Royal Society of Medicine in London, and later published her findings in the Proceedings of the Royal Society of Medicine, 1917, 10 (Surgical Section):29-110. She received the French Legion d’Honneur and the Croix de Guerre for her medical and surgical contributions during WW-I. She returned to the practice of obstetrics and gynecology in Liverpool, married Barrister Charles Matthew Knowles in 1930, and retired to Truro in Cornwall. This remarkable woman surgeon - Miss Frances Ivens - died in 1944.

Images are from the Imperial War Museum in London, the Wellcome Library in London, and the University of Kansas Medical Center.