Queen Victoria Hospital Archive Project: treatment of burns

We’re very pleased to introduce this guest post which has been written by distinguished plastic surgeon, Mr Tom Cochrane, who was not only consultant plastic surgeon at Queen Victoria Hospital for many years, but also honorary plastic surgeon to the Guinea Pig Club. Throughout this time, he has supported the Guinea Pigs in many other ways, giving his time selflessly towards advice on medical, social and pension problems for over 50 years.

The disregard with which our skin is often treated remains a lasting curiosity to those engaged in its repair when it has been severely damaged. It is no exaggeration to say that it is probably the most important structure of our body, having a multitude of functions, all of which are crucial to our survival. It is, too, the most difficult organ to replace, the most allergenic and thus the least available for transfer from one individual to another. Until relatively recently, a burn injury affecting greater than 30% of the body surface of an adult and 15% in a child was expected to prove fatal, either in the early post-burn period during which precious vital fluids are lost, or subsequently through the loss of its irreplaceable role in the prevention of infection.

Even now that we have learned to overcome some of the challenges, severe burn injuries remain a very real threat to life. Recovery is virtually always associated with prolonged disability. If skin is lost and not adequately and immediately replaced the body responds by attempting to close the open wound through the deposition of scar tissue which shrinks in its attempt to close the defect resulting in contractures, the formation of which cause loss of function and disfigurement.

Prior to World War Two, major burn injuries were largely cared for by general surgeons, few of whom had the expertise to manage the gross physiological changes occurring in the initial ‘shock phase’ and even fewer in techniques of skin replacement in quantities sufficient to heal extensive areas of loss. There were but four Plastic Surgeons in the United Kingdom and precious few worldwide. Of these, Archibald McIndoe as Consultant to the RAF was landed with the responsibility to care for men from this service, victims of severe burn injuries. Aged under forty he faced the task of establishing a specialist unit, admittedly in a brand new hospital but it was a ‘cottage’ hospital designed to fulfil the needs of a local community. He needed an immediate expansion of surgeons capable of treating an unknown, possibly and as it turned out, large number of cases. Support staff was urgently required, nurses prepared to face the noxious smells of burned flesh yet anxious to boost the sagging morale of virile young men during a lengthy recovery. Nurses capable and willing to spend nights on duty engaged in threading fine surgical needles, repairing punctures in rubber gloves, cutting up gauze to pack sterilising drums with dressing materials, all in a restricted space normally provided with large windows, now blacked out and protected from blast; thus an atmosphere of poor ventilation; and all this beneath skies full of dog-fighting aircraft.

Instruments for this type of work were in short supply. McIndoe was already skilled in harvesting sheets of tissue paper thin skin grafts using an open razor with a ten inch blade which had to be stropped and re-sterilised for each case. He demanded that his new recruits to the specialty should achieve similar skills for, after a relatively short introduction, they were to be dispersed to RAF hospitals throughout the country wherein immediate care was available. It was to these units that McIndoe later made regular trips and where he selected cases for transfer to East Grinstead. Ever conscious of the fundamental role of our faces and our hands in our interpersonal communication, (especially between a young man and his sweetheart!) and dexterity in employment (just those structures mutilated in the typical ‘airman’s burn’) he concentrated much of his effort on repair of these.

At the time there was but one commonly applied dressing, a gel containing tannic acid. This often produced disastrous consequences and its popularity had to be tackled. McIndoe designed and his nurses manufactured an alternative, a non-stick combination of curtain gauze and Vaseline – in various forms still in use today! His invention of the saline bath together with this ‘non-stick’ material contributed hugely to pain relief during dressing changes. Remember, there were no antibiotics and precious few anti-bacterial agents then!

Many of the surgical techniques employed came from the past, particularly from World War One. Some required adaptation. New procedures were designed but perhaps by far the most important innovation lay in the approach adopted to social and psychological support.

It was in the nature of the fighter squadrons and later in bomber crews to form ‘bands of brothers’ that cared deeply for one another. It is hardly surprising then that a similar formation developed amongst an enlarging number, all of whom had experienced ‘trial by fire’ and all of whom were facing a prolonged period of reconstruction through multiple operations. Thus the foundation of the Guinea Pig Club which McIndoe and his team thoroughly endorsed. They always willingly joined the boys in a drink and a sing song. He encouraged them to witness the treatment of fellow Guinea Pigs taking camaraderie into the realms of mutual support, building confidence in an ultimate victory over adversity.

He, McIndoe, realised that this mutual support that was developing between his patients was a powerful tool in the restoration of self confidence too, even amongst those who had suffered the most disastrous disfigurement and crippling hand injuries. He pursued this ‘therapy’ with the utmost vigour and much of his success is down to his skill in involving (often reluctant) ‘authorities’ together with the remarkably generous people of East Grinstead. His efforts in this regard were prodigious and he quite clearly, almost single handed, managed to alter the mindset of officialdom.

Post-war, rehabilitation at Headley Court and Chessington grew from this, the former becoming the renowned tri-service establishment that it now is.

Sadly, the records of this achievement were to be buried beneath those of his reputation for surgical excellence. Perhaps the moment has arrived to rethink history and link this fundamental part of the story to the careful preservation of the Guinea Pig’s medical archive.

Mr Tom Cochrane, FRCS

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