Extreme Medicine (5 page)

Having shot down no less than five Messerschmitt 109s while on patrol the day before, Gleave was in confident form. With reports of a large formation of enemy aircraft converging to attack Biggin Hill Airfield, Gleave turned with his section of three Hurricanes to assist in its defense.

Plowing north, Gleave searched the sky for evidence of the enemy. Suddenly he found the sky above him dark with aircraft: column upon column of Junkers 88 bombers. He and his section remained unseen, less than a thousand feet below and beyond them.

Keen to press the attack before the German turret gunners had a chance to fire, Gleave pulled the nose of his Hurricane up, took aim, and raked the
fifth bomber in the line with cannon shells. The smell of spent cartridges filled the cockpit; the Hurricane's nose dipped with the repeated recoil of the guns. Gleave pulled the control column, kicked hard on the rudder pedal, turned, and dived away. Leveling out, he began to climb again, attacking another bomber in the formation. For his third pass, he decided he would take on the lead aircraft, which had already begun its dive in preparation for a bombing run. But before he could maneuver into position, he heard the click of a round striking his aircraft and felt a sudden heat rising in the cockpit.

Gleave glanced down. Flames were pushing into the right side of the cockpit from below; the fuel tank buried in the root of his starboard wing was alight. He rocked the Hurricane hard and slipped it sideways in the vain hope that this would somehow quell the fire. But the flames only grew fiercer, wrapping round his feet and climbing to reach his shoulders. Plywood and fabric burst rapidly into flames around him, accelerated by fuel from the breached tanks. In a few short seconds, the center of Gleave's cockpit had become the head of a blowtorch. The aluminum sheet in which the dials of his control panel were set began to melt. But he was far too high to ditch the aircraft; there was nothing he could do but attempt to bail out.

Gleave was still tethered to his vehicle by the oxygen mask and radio cord attached to his helmet. He reached down to rip these from their attachments, but the searing heat beat him back. With his arms outstretched he could see the skin of his hands bubbling and charring. He unclipped his harness and tried to raise himself from his seat, but could no longer find the strength. Trapped with his plane ablaze and falling from the sky, Gleave's hand fell to the butt of his service revolver and momentarily he considered a quicker, less painful end.

However, there was one last chance. If he could open the canopy, pitch the aircraft forward and flip it over onto its back, then perhaps the maneuver would fling him out. Gleave tore his flying helmet off, severing his last connections to the Hurricane. He slid the canopy open, shoved the control column forward, and then everything around him exploded.

He found himself propelled for many yards, enveloped in a ball of flames, finally breaking free into thin air and then tumbling toward the ground. His burned hand now reached again, not for releases or a revolver, but for the D-ring of his ripcord.

Finding it, he pulled hard and felt the unfurling of his parachute and a comforting tug as its silk canopy inflated above him. The roar of his engine and the cockpit inferno had been replaced by silence and a serene view of the English countryside that oscillated gently as he swung to and fro beneath his parachute.

He hit the ground hard and fell onto his side, somehow managing to avoid further injury. Releasing his parachute, Gleave eventually found the strength to get to his feet. His boots and socks appeared to be intact and largely unburned. But that was where normality ended.

His trousers had gone except for a small patch protected by the parachute harness. Above his ankle, the skin over his right leg had blistered and ballooned along its whole length. His left leg was in much the same state, save for a patch of skin over his thigh which had been relatively spared. The underside of his arms and elbows were burned, and the skin hung in charred folds from his hands and wrists. His head and neck, too, had been exposed to the inferno, and his eyes were little more than slits. His nose had been all but destroyed.

Somehow he staggered across the field toward a gate on its far side, shouting for help as he went. “RAF pilot,” he blurted out. “I want a doctor.”

—

Y
OU CAN JUST ABOUT BEAR TO
hang on to a mug of hot tea at 42°C. (108°F.). That's just ten degrees higher than your normal core body temperature. It's pretty unimpressive, really, but that is where the limits of human endurance lie. The sensation that forces you to drop the cup is set in motion by a clever receptor: a weave of proteins in the dermis attached to an ion-channel control that opens or closes depending on how hot the channel is. The proteins convert the sensation of heat into pain.

For a species so wedded to exploration, such a modest thermal tolerance seems strangely limiting. But the proteins that that receptor is built from, and those that stack together to build everything from your digestive tract to your DNA, start to fall apart at 45°C. (113°F.). That's where the physiology of thermal injury starts. As temperatures climb, cells lose their capacity to self-repair; vessels begin to coagulate, tissues become irreversibly altered and later begin to die. All of this happens as you approach a temperature of around 60°C. (140°F.).

Aircraft fuel, properly supplied with oxygen, can burn at over 1000°C. (1800°F.).

—

T
OM
G
LEAVE WOKE UNDERNEATH
a bed in darkness. He was at Orpington General Hospital in the middle of an air raid; the bed was his makeshift shelter. He had survived, but the surgical teams at Orpington had little experience with such severe burns. They had covered his wounds in solutions of gentian violet and tannic acid, the former for its antiseptic properties, the latter as a kind of chemical dressing that would cover wounded areas and then harden as a supposed protective barrier to infection. As a therapy for significant burn injury these measures were at best ineffective. Worse still, they encouraged scarring and infection. The dressings, simple dry gauze and bandages, stuck hopelessly to Gleave's weeping wounds, pulling off skin whenever they were changed.

Inevitably sepsis set in, and Gleave spent many days slipping in and out of consciousness, hallucinating and delirious with fever. But he rallied and survived this, too. After several weeks, the medical team at Orpington decided to transfer him to the Queen Victoria Hospital in East Grinstead, which had developed a reputation for plastic reconstructive surgery under the leadership of Archibald McIndoe.

When the orderlies arrived to prepare Gleave for the journey, they dressed him in full military uniform, shearing dressings from delicate, partially healed layers of skin. The fact that the medical staff at Orpington allowed this reflects how little was understood about the nature and therapy of burn injuries at that time. But the hellish, seventeen-mile road trip to East Grinstead delivered Gleave to the care of McIndoe and his team and the start of his reconstruction and rehabilitation.

—

W
ARD 3 AT
Q
UEEN
V
ICTORIA
H
OSPITAL
was a wooden-walled hut linked to the main hospital building by covered walkways. Within resided a cadre of men disfigured by fire, and in 1940 the most severely injured of these were Hurricane pilots.

To the rear of the ward was an extension that housed a bath through which a warm, weak salt solution was circulated. The bath was arranged so that a flow ran through it, exchanging a gallon a minute. Afterward, drying was achieved by standing the men naked in front of large heating lamps, thus avoiding the abrasion of toweling. The pilots came to call this the Spa, and it was into this tub that Gleave, with some trepidation, found himself being lowered on the evening that he arrived.

He needn't have worried. His wounds were bathed properly for the first time, and old dressings floated away without pulling skin with them. Later his cleansed wounds were dressed with Vaseline-coated gauze: an invention of McIndoe's that covered the wound but kept the dressings from sticking.

A few days later, McIndoe came to Tom's bedside and explained what needed to be done. It would take many months and dozens of surgeries, McIndoe explained. “You won't like it,” he said, “but it'll be worth it.” Something in the manner of this surgeon, standing there peering at him through horn-rimmed glasses, gave Gleave confidence. And for the first time since the inferno, he felt as though he had been thrown a lifeline.

Archie McIndoe was a New Zealander, originally invited to the United Kingdom to join the practice of his esteemed older cousin Harold Gillies. Here McIndoe had gotten a taste for the possibilities that lay in reconstructive surgery. Harold Gillies had pioneered techniques of plastic surgery during the First World War, when a sailor burned at the Battle of Jutland was the first patient to undergo this type of surgery. In retrospect, the cosmetic results of these surgeries look primitive at best. But at the time, the idea that badly damaged faces might be reconstructed in this way was revolutionary. It would fall to McIndoe to refine and advance these techniques, and the air war of the Battle of Britain would provide his defining challenge.

First, Gleave got new eyelids pinched from the unburned skin of his thighs. These tiny islands of skin were removed and sculpted into place. They were so small they could rapidly establish themselves at their new location on Gleave's face, seizing upon the bed of vessels and perfused tissues that lay there waiting to be covered, like a minuscule sod of earth being transferred from one lawn to another. Oxygen and nutrients readily diffused into these small tokens of flesh. And the wounds left by taking these grafts were discrete enough that they could be left to heal spontaneously.

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 first and only 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.