The wounds of wartime

At the outbreak of the Second World War, there were only four fully experienced plastic surgeons in Britain: Gillies, McIndoe, Rainsford Mowlem and T P Kilner. At the request of the Government, they were divided up to head up four separate plastic surgery units to treat the expected influx of injured servicemen from the different branches of the armed services. Sir Archibald moved to the recently rebuilt Queen Victoria Hospital in East Grinstead, where he founded a Centre for Plastic and Jaw Surgery and dealt with RAF casualties.

As airborne warfare began to deliver its first casualties, it became clear that this was the start of a stark new chapter in medical treatment. East Grinstead would see injuries of an unprecedented volume and severity. The phrase ‘airman's burn’ quickly became a medical term, referring to the similarities in injuries sustained to the face and hands of Allied airmen. These were mostly caused when aircraft fuel tanks ignited and pilots were caught up in the inferno, before they could parachute to safety. In Spitfires, the tanks were positioned just in front of the cockpit. Most pilots removed their gloves and goggles during flying in order to aid control of the aircraft, but unfortunately this also exposed them to even greater levels of injury.

The best treatment possible for the airmen was vital, firstly, because these men had volunteered to fight for their country and deserved the highest quality treatment. Secondly, pilots were an invaluable resource during the war, especially during the Battle of Britain. Burn injuries removed them from combat for weeks and sometimes months, so this most valuable resource needed rehabilitating as quickly as possible, under the threat of an air campaign failure. Luckily for the multitude of victims, there were men like Sir Archibald McIndoe and Ross Tilley.

For decades before the war, patients with severe burns were deemed terminal. They were given saline, morphine and orders to return home so they could be surrounded by their loved ones. It was the shock, and the inability of the medical profession to administer effective treatment to halt its progression, that killed patients. Severe burns would initiate a chain reaction of events, starting with massive fluid loss, followed by shock and the successive failure of multiple organ systems. If the patient persevered through the shock, the next hurdle was infection.

At this time, treatments were largely chemical interventions geared towards minor burns, and rarely involved surgery. Advances in shock therapy created a new patient population that needed treatment desperately and the doctors did all they could using the tools available.

Improving Treatments

It was clear to Sir Archibald and Ross Tilley that current burns treatment techniques were inadequate. When the first wave of severely burned airmen appeared, the major treatment method was coagulation. A coagulating agent would be applied to the burn, which created a tough scab-like tissue to encase the wound. This functioned as a physical dressing and was thought advantageous in its ability to protect the wound, prevent life threatening fluid loss and guard against sepsis. The coagulant that was administered was tannic acid, used in the leather industry to stiffen hides.

Metal tubes of tannic acid were so widely distributed that at the outset of the war, they could be found in almost every first-aid kit in Allied territory. In theory, coagulation therapy served both as immediate first aid, as well as a long-term treatment that remained in place until new tissue had grown underneath, after which the coagulum could be removed. The reality of treating airmen’s burns with tannic acid turned out to be so disastrous that it prompted Sir Archibald McIndoe to undertake a crusade against its continued use.

Fortunately for the hundreds of patients who suffered burns of the hands and face, McIndoe was able to persuade the majority of his colleagues, and the scientific community at large, that the results of tannic acid justified the banishment of its use across Europe. The new approaches cultivated by Sir Archibald and Ross at the Queen Victoria Hospital, including the use of saline to bathe wounds, served as the prototype for burn management, and were duplicated at centres across Europe.

They also improved previous plastic surgery techniques to make them more effective in restoring wounded skin and tissue. Most men would need between 10 and 50 operations, requiring them to be in and out of the hospital for at least three years. It was customary to plan eight surgeries per year, alternating three to four weeks in hospital, with two to three week breaks outside.

Not only did the pair push technical innovation but also the ideas around the rehabilitation and reintegration of burns survivors back into society, with McIndoe forming the Guinea Pig Club in 1941.