Sir Archibald Hector McIndoe (1900–1960) and the Guinea Pig Club: The development of reconstructive surgery and rehabilitation in the Second World War (1939–1945)

Introduction

Technological advances in the twentieth century meant that wars were being fought in a different way. By the Second World War (1939–1945), much importance was placed on aviation warfare and as a result of these changes in technology and warfare great pressure was placed on medicine and surgery to deal with the new and horrific injuries that presented, particularly burns. Many hospitals and surgeons had never been faced with such challenges. Reconstructive surgery was not well established, and there were few experienced surgeons but one such was Archibald McIndoe (Figure 1). OPEN IN VIEWER

Many injured pilots depended on McIndoe to restore their faces and hands from the terrible disfigurements. He was able not only to help reconstruct many deformities; he also helped them go on to integrate into society and lead normal lives. McIndoe’s approach changed people’s attitudes towards patients’ recovery particularly in reconstructive surgery and this is remembered today.

McIndoe's early career

Archibald McIndoe was born on 4 May 1900 in Dunedin, New Zealand. ¹ He attended Otago Boys’ High School and from there began his studies in medicine at the University of Otago. ² After completing a Fellowship in the Mayo Clinic in America, McIndoe moved to London in 1930 where he was appointed Chief Assistant in the Department of Plastic Surgery at St Bartholomew’s Hospital. His cousin Sir Harold Gillies (1882–1960), a Consultant ENT surgeon who worked at Queen’s Hospital, Sidcup in Kent, during the First World War (1914–1918) took on the role of McIndoe’s mentor in England and encouraged his career in plastic surgery. ³

McIndoe worked in many different hospitals in England including Chelsea Hospital for Women, St Andrew’s Hospital, North Staffordshire Royal Infirmary, the Hospital for Tropical Diseases and Croydon General Hospital. He went on to become a Consultant Plastic Surgeon to the Royal Air Force. In September 1939, he moved to the Queen Victoria Hospital in East Grinstead, West Sussex.

McIndoe's surgical work in the Second World War

The commonest injuries McIndoe faced at East Grinstead Hospital were due to shrapnel and the explosion of fuel tanks, ⁴ the latter especially common since aircraft cabins were not fire proof and unfortunately facial disfigurement was a frequent result of the severe burns. ⁴ McIndoe was presented with a case of frostbite in Alan Morgan (born 1923), a flight engineer. A door in Morgan’s aircraft burst open while he was flying over Germany. As he tried to help his fellow aircrew he lost consciousness which caused him to leave his hands hanging out of the open door, exposed to the freezing temperatures. ⁵

Although frostbite may have posed a seemingly unique challenge for McIndoe in the midst of burns and shrapnel injuries, despite technological advances in the safety of aviation, even in modern times, there have still been cases of pilots suffering from frostbite injuries. In 1990, the blowout of an aircraft window on a British Airways flight left Captain Tim Lancaster with his upper torso hanging out of the aircraft at 17,000 feet. Incredibly, he survived with only frostbite injuries and small fractures. ⁶

Most of McIndoe’s patients required skin grafts and a common method utilised the tubed pedicle, originally developed by Gillies during the First World War. Gillies was aware of previous skin graft methods and their limitations, which inspired him to adapt these to develop his tubed pedicle technique. ⁷ This involved rolling the skin graft, or pedicle, into a tube where the outer layer of dead skin would protect the enclosed living tissue from infection and keep it waterproof (Figure 2). The tubed pedicle was often superior to the flat skin graft since it reduced infection rates and allowed the blood supply to be maintained. An abdominal pedicle, for example, would have a root based on the inferior epigastric artery. ⁸ OPEN IN VIEWER

As well as the reduced risk of infection, the tubed pedicle also produced good cosmetic results as Gillies and McIndoe documented after treating patients with radiation burns before the Second World War. ⁹ Another advantage was that the tubed pedicle could be done in two or three stages, to move skin between distant regions of the body, the ‘waltzing tubed pedicle technique’.

McIndoe worked under the tutelage of Gillies and perfected his skin grafting technique. In order to diminish the effect of the patients’ deformities McIndoe also performed rhinoplasty (see Figure 3) and gave the patients glass eyes and sometimes wigs. Warrant Officer Bill Foxley (1923–2010) was one of the many patients on whom McIndoe worked extensively to restore the facial features. Foxley’s skin had been vaporised from the heat of the burning fuel. He had one eye irreversibly damaged and his hands had been so disfigured that they had lost all definition. McIndoe rebuilt the skin of his nose and his eyelids using tube pedicles and gave Foxley a glass eye and was able to separate his fingers so that his hands were partly restored. ⁴ OPEN IN VIEWER

McIndoe also believed in the importance of saline treatment and a particular dressing for burns. ¹⁰ He discovered that the burns injuries of pilots who had to land directly into the English Channel healed quicker than those who crashed on the land ¹¹ and hence a saline bath was used for those with burns. One example of McIndoe’s use of saline was with Wing Commander Derek Martin (born 1920), whose skull would not heal and it seemed that a steel plate might need to be inserted but McIndoe inserted tubes under Martin’s forehead to create a saline wash under the scalp; after several days of bed rest Martin’s skull began to heal. ¹² McIndoe also pioneered the use of a mesh of Vaseline and antiseptics to stop the skin becoming dry and infected.

While McIndoe was treating burns with saline baths, the standard medical procedure was to use tannic acid to coagulate the blood and provide a protective covering. McIndoe was horrified at the damage tannic acid could cause, hardening the skin and leading to necrosis of the fingers such that the hands never fully regained their function. He wrote in his minute book ‘God damn and blast this tannic acid. It shouldn’t be used. We’ve got to stop them using it’. With Gillies, McIndoe reported his findings with tannic acid to the Royal Society of Medicine in November 1940 ^{1 3} and thereafter some RAF medical chiefs banned it completely.

Treated as people, not just as patients

Despite all the restorative work that patients received and the numerous painful operations sometimes taking up to two years, many were still disfigured with consequential effects on the remainder of their lives, as Gillies had witnessed after the First World War.

Gillies’ former patients struggled to integrate into society when they tried to return to normal lives and many became isolated due to their physical appearances. Many ended up in menial jobs, one even in a travelling circus, labelled the ‘elephant man’. Depression was very common and sometimes suicide.

McIndoe had a keen interest in psychology and knew that the way his patients looked affected their mental health. He wrote in his notes ‘The impact of disfiguring injuries upon the young adult mentality is usually severe … they may be psychically lost, depressed, morose, pessimistic, and thoroughly out of tune with their surroundings’. He was honest with his patients and informed them about their operations and encouraged them to take part in decision-making about their treatment.

Early on, McIndoe wanted the hospital to be cheerful, insisting on flowers, lively music, friendly staff and attractive nurses who were not intimidated by the sometimes rowdy behaviour of their patients. He put a lot of effort into keeping his patients in a good mood, and would sometimes play the piano to them and they would sing along (Figure 4). He allowed his patients to keep beer under their beds and wear their own uniforms instead of the designated hospital uniforms which the patients burned. OPEN IN VIEWER

His methods sometimes brought him into conflict with the authorities but he was not afraid to challenge them when he believed it was for the benefit of his patients. He refused to be a serving member of the RAF in order that he could continue treating his patients in the way he saw fit and he hand-picked staff who he felt would work best with him and the patients. He was dedicated to the well-being of his patients and was intolerant of people who did not meet his expectations; he would make his feelings known, sometimes losing his temper with his staff.

As well as trying to maintain a cheerful and patient friendly hospital, McIndoe also realised that patients needed to feel as if they were living normal lives. This meant that they needed to get out of the hospital and he said of his patients ‘Half my battle is to see that their morale does not suffer through boredom’.

Most patients were still able to move around easily since most of their injuries were confined to the face and hands. This meant that many patients were able to leave the hospital and so McIndoe encouraged them to engage in normal activities. He arranged for the patients to play golf, go to the pub and watch films in the cinema. Remarkably, the patients even managed to play football with pedicles attached to their faces.

McIndoe also helped integration into the local community by speaking to the locals about the reconstructive surgery he was doing, enlisting the support of the Hospital Welfare Committee and he encouraged local people to visit the hospital and they accepted the patients among them and welcomed them as guests in their homes. Patients were respected in public in the town; seats were saved for them at the cinema and they went to the local dances. Bill Gardener who owned a local restaurant drank with them but made sure they never drank too much and he was always there to cheer them up.

Patients at the East Grinstead Hospital integrated so well with their local community and many later married local women and nurses. Some returned to flying, including example Derek Martin who returned to operational flying in 1942.

The Guinea Pig Club

The patients of the East Grinstead Hospital soon learned to be proud of their injuries and decided to form their own club. The Guinea Pig Club, as it came to be called, was formed from a hangover on the morning of Sunday 19 July 1941. Members initially wanted to form a simple ‘grogging club’ but it soon became much more.

The Guinea Pig Club was originally called the Maxillonian Club, named after the Maxillo-Facial Unit at the hospital. The members were called guinea pigs, as much experimental work had been done for them and they decided the club would be a way for them to keep in contact after leaving the hospital. It is a sign of how much McIndoe’s patients admired him and his work that not only did they often call him ‘Boss’ or ‘Maestro’ but they also asked him to be the President of the club.

The club grew to create three types of membership: first the ‘Guinea Pigs’, patients including former Squadron Leader Tom Gleave (1908–1992) as the Chief Guinea Pig; second, the ‘Scientists’ who included the doctors and other staff; third, the ‘Royal Society of Prevention of Cruelty to Guinea Pigs’ which was made up of the friends and families of the ‘guinea pigs’. The Guinea Pig Club created its own magazine, had its own emblem and its own song, the first two lines being ‘We are McIndoe’s army, we are his guinea pigs. With dermatomes and pedicles, glass eyes, false teeth and wigs’. The Guinea Pig Club encouraged discussion of future plans with their families in order to forget the painful operations. ¹⁴

There were 649 original members of the Guinea Pig Club who came from all over the world. In 2005, 121 members remained and many attend annual reunions in London and East Grinstead. ¹⁵ As well as the annual reunions, some of the Guinea Pigs have maintained strong friendship, and still meet up weekly for a drink. ¹⁶

The Guinea Pig Club not only allowed McIndoe’s patients to support and help each other and many Guinea Pigs went on to help others. Several supported Falklands burns victims. One of McIndoe’s former patients, Sandy Saunders (born 1923) was so inspired by the work of McIndoe and his team that he went on to become a GP which McIndoe greatly encouraged. ¹⁷ This is just one example of how McIndoe kept in contact with his former patients and encouraged them to lead full lives. Paul Hart (born 1919) had been a patient of McIndoe’s who actually went farming in Tanzania with him after the Second World War was over. ¹⁸

McIndoe's later achievements

McIndoe’s incredible work did not go unnoticed and he went on to achieve further. In 1944, he was appointed CBE and in 1947, he was Knighted. In 1958, he became Vice President of the Royal College of Surgeons and he helped establish the British Association of Plastic Surgeons. He was nominated as President of the Royal College of Surgeons in 1960 but sadly died before the successful candidate was announced.