But larger patches can’t be moved in this way; their needs are more demanding. In plastic surgery, the battle, as Harold Gillies once put it, is between blood supply and beauty. A full-thickness flap of skin about the size of an adult’s palm, cut out and moved as a single slab, will die before it has a chance to pick up a new supply of blood.
To get around this problem, McIndoe would raise a flap of skin, leaving it attached at one edge like a trapdoor. This kept the flap alive, supplied by the vessels running through its attached edge, but left it fixed in position. McIndoe would then fold the sheet of skin into a tube, stitching its long edges to each other to protect its raw undersurface from infection.
To move this tube of skin, he would make an incision in the patient’s arm and form a pocket into which its free edge could be tucked. He would then stitch the flap into place, fastening arm to thigh in the process, and wait for it to heal into position. This healing could take weeks, during which the patient was handicapped by the strange new anatomical arrangement.
Once the flap had established itself in the pocket, its link with the thigh could be severed. This arduous process left a flap of skin, previously from the thigh, now drawing its blood supply from the patient’s arm and free to be moved to any location which the arm could reach.
This process of walking a tube of skin end-over-end from one part of the body to another was known as waltzing. Gillies had invented the technique, but McIndoe brought it to maturity, waltzing flaps from larger areas than ever before. It provided the plasticity in McIndoe’s reconstructive technique, allowing him to address larger areas of burn injury by walking skin up from distant uninjured sites.
But aesthetic considerations were at the heart of McIndoe’s work. It was not enough simply to provide protective coverage; cosmesis was essential. Skin is indeed one of the principal organs through which we are able to experience the world. But McIndoe understood that it is also the means through which the world experiences us. When the war started and the toll of burned airmen began to become apparent, it was thought that the best thing you could do with the victims was to institutionalize them away from society with the intention of protecting one from the other. But McIndoe was unwilling to accept this fate for his patients, and his efforts in reconstructing the injured went far beyond surgical innovation. McIndoe would give them new faces, but they in turn would be expected to face the world again.
Ward 3 became famous for its feats of plastic reconstruction and notorious for the antics of its resident airmen. McIndoe resisted the militarization of the ward. The Queen Victoria Hospital was his—quite literally. The Air Ministry had seen that control of the facility was signed over to McIndoe, and it was run by his rules. Military discipline was relaxed, and rank ceased to have significance among the men in the beds—except, of course, when it came to McIndoe, whom they referred to as the Maestro, the Boss, or simply Sir. Beer kegs stood freely accessible on the ward, and at times it came to resemble something like a workingmen’s club.
All of this did something to distract from the grimness of the pilots’ reality. Not only were they assaulted by disturbing odors of char and infection, but they were also exposed to a series of strange new procedures that left them with arms stitched temporarily to thighs, abdomens, and faces, initially leaving them looking more bizarre than even their injuries had.
Confronted with long drawn-out weeks of suffering, with free beer as their only real comfort, the patients of Ward 3 set up a drinking club. At first they stumbled with the name, coming up with the Maxillonians, in reference to their ongoing maxillofacial surgeries. But they quickly realized that this was unwieldy and didn’t quite capture the spirit of their circumstances. They were a new breed of casualty patient under the care of a pioneer surgeon armed with groundbreaking techniques. They knew at heart that they were the subjects of experimentation—however well intentioned. And so the drinking party reformed under a new name: the Guinea Pig Club, with Tom Gleave the chief guinea pig.
The club’s activities moved rapidly beyond drinking and singing around pianos to rehabilitation and support. McIndoe orchestrated trips to East Grinstead. There the soldiers were dispatched, often under protest, to mix with the local population. The people of East Grinstead grew to embrace McIndoe and his army of strangely reconstructed men. They would make every effort to accommodate them, removing mirrors from their pubs, cafés, and restaurants and taking care to give the lives of McIndoe’s Guinea Pigs a veneer of normality. In time East Grinstead became “the town that never stared,” and it served as the perfect preparation for the Guinea Pigs’ reentry into a world that inevitably would.
Gallows humor became de rigueur for the Guinea Pigs. They recruited a treasurer with badly burned legs, so that he wouldn’t run off with the petty cash, and a secretary whose fingers had been injured, so he couldn’t keep minutes. At the start of World War II, the Guinea Pig Club was tiny. But with the onset of the bombing campaign, those numbers rapidly swelled, and by the end, its membership numbered more than six hundred. They were testing times that saw McIndoe and his team forced to refine their techniques as they went, learning from successes as well as mistakes. But these lessons would transform the field of plastic surgery.
The practice of military medicine during the war focused principally upon the salvage of life and limb. McIndoe didn’t save the lives of the Guinea Pigs, at least not immediately. That task was achieved by the hospitals that received them. But McIndoe’s work and the experience of those he treated taught clinicians that there was something at least as precious as life that modern medicine might preserve.
Excerpted from Extreme Medicine: How Exploration Transformed Medicine in the Twentieth Century by Kevin Fong, M.D. Reprinted by arrangement with The Penguin Press, a member of Penguin Group (USA) LLC, A Penguin Random House Company. Copyright © Kevin Fong, 2014.
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