Cambridge Military Hospital, Aldershot

I was wearing a fur hat, walking through snow and approaching a palatial building fit for a czar. But I was nowhere near Russia. I was in the military town of Aldershot in Hampshire, regarded as the ‘home of the British Army’ since the establishment of the garrison in 1854. And the building was not a palace but a former hospital: Cambridge Military Hospital, which opened in 1879 and was named after the then Commander-in-Chief of the British Army, Prince George, Duke of Cambridge. It closed in 1996, due to high running costs and following the discovery of asbestos in the walls, and has been empty ever since.

The first thing that struck me was the sheer, unabashed grandeur of the place – a Victorian statement that nothing but the finest would do for the fighting forces of the mightiest nation on Earth. The yellow-brick façade is Italianate, with wings at each end. In the middle is a square tower with a belfry and clock turret commanding views of half of Hampshire and Surrey. It is indeed a magnificent monument, but not solely to the hegemony of the British military machine in the late nineteenth century. Something altogether more unexpected is memorialized in this fine old pile.

There are well-advanced plans to develop the site as a residential complex of flats and houses. But before the builders move in I was granted permission for one last look. More than two decades of dereliction have taken their toll, I was told. Ceilings are falling down, plaster is crumbling and paint is peeling. And many areas are out of bounds due to the presence of asbestos, which accounts for the ‘Danger’ and ‘Do not enter’ signs dotted about. But you’d hardly know it, looking from the outside. The old hospital maintains a dignified face – which is fitting considering that this is the place where men were once given new faces, new identities, after being robbed of both through the ravages of war.

Cambridge Military Hospital was the birthplace of reconstructive surgery in Britain – and has an extraordinary story with ramifications that echo to this day. But it started life with altogether more modest aims. It simply wanted to stem the horrendous haemorrhaging of lives among British soldiers wounded in action. To learn more, I enlisted the help of a man who has himself patched up wounds on the field of battle. Pete Starling is a former member of the Royal Army Medical Corps, who is now a military historian with a special interest in this hospital.

As we unlocked the front door and tiptoed among debris that has accumulated over the last twenty years, he pointed out that there is, after all, a Russian connection: the hospital was conceived in answer to questions raised by the Crimean War of 1853–6. This conflict between Russia and Allied forces from Britain, France, Sardinia and Turkey is perhaps remembered chiefly through its association with Florence Nightingale and Alfred, Lord Tennyson’s narrative poem ‘The Charge of the Light Brigade’ (‘Into the valley of Death/Rode the six hundred’), which was about the Battle of Balaclava in 1854. But as Pete told me, it was also significant as ‘a war that changed the way armies fought and survived war’.

The Crimean War was the first war of the modern era. ‘It was starting to get more industrialized,’ said Pete. ‘The warships were steam-powered. We had railways to carry supplies forward. We had photographers and war correspondents. They were able to get their stories and pictures back. And you could say that that was the problem.’ Due to reports from the front line, the families of serving soldiers and the wider public became aware for the first time of the true nature of life at the sharp end of war – in particular the fact that many more men were dying from diseases such as cholera than from battle wounds.

In response, the social reformer Florence Nightingale took a team of volunteer nurses to the British military hospital at Scutari in Istanbul, to which casualties were evacuated across the Black Sea. Shocked by the conditions she found, she instigated a new regime based on improved hygiene practices, better ventilation, proper sewers and a decent diet. And in the aftermath of the war she campaigned for lessons to be learned. ‘She’d got a lot of friends in high places in the Army and the government, so she was very influential,’ said Pete.

Nightingale’s exhaustive report on the limitations of medical care in the Crimean War formed the basis of a Royal Commission on the Health of the Army, which concluded that proper military hospitals should be built for our casualties of war. One of the first was the Herbert Hospital, which opened in Woolwich, south-east London, in 1865 and was named after Sidney Herbert, the politician who had sent Florence Nightingale to the Crimea. The Cambridge Hospital in Aldershot followed fourteen years later.

Both were designed on what Pete described as the Nightingale Plan: ‘A big, long, central corridor. Big wards. Plenty of space for the beds.’ We had now reached that central corridor and I paused to look up and down its rather dismaying length – measuring 528 feet, apparently. I knew this because Pete had brought along the original architect’s drawings, which we unfurled and held up against the peeling wall.

There was the central spine of the corridor and, coming off it at right angles, wards on both of the two floors, each with six large sash windows on either side. We walked along a few paces, took the first door on the right and stepped into a large room, where the air swirled with the dust we had dislodged with our feet. There were lines of windows on each side, the lower halves boarded up and some of the upper panes cracked or smashed. ‘Here you see an example of one of the big, high-ceilinged wards,’ said Pete. ‘Big windows. Plenty of light. Plenty of fresh air.’

When these wards were built no one could have envisaged the pressure they would be put under, the sheer volume of human suffering that would pass through them. The beds are long gone, of course. But now, as we stood there, we saw them in our mind’s eye, we saw them filling up with the terrible harvest of the Great War of 1914–18.

On 23 August 1914, British forces were engaged for the first time in the First World War at the Battle of Mons. It was also their first engagement on European soil since the Crimean War. Within hours the wounded were evacuated by ship across the English Channel to Southampton, and then on to Cambridge Military Hospital, which became the first army-base hospital in history to receive casualties directly from the battle front. But as the casualties mounted on the Western Front, the military authorities realized they would have to grade and prioritize the wounded.

Pete invited me to picture our surroundings as a shattered chateau (not so hard, actually), somewhere behind the front lines of the fighting. ‘If you can imagine I’m taking you into a ruined French building where we’ve got our dressing station, we can talk about triage, which means “to sort” – how we would prioritize our casualties. A man has a head wound. He doesn’t look too good. If it’s a penetrating wound of his skull his chances of survival are not that great. We don’t want to waste too much time on him.’ The reality was that he was allowed to die so that six or seven others could be saved. Such is the cruel reckoning of war.

Casualties with minor wounds were recycled back into front-line fighting. Those with more serious injuries were shipped back to England. In military parlance they were suffering from ‘Blighty wounds’, i.e. wounds severe enough to require prolonged treatment in a proper hospital at home. From 1915 the wards of Cambridge Military Hospital filled up with such men. In previous wars many may not have survived. But improved medical practice along the whole chain of rescue and care – from the stretcher-bearers who picked up the wounded in no man’s land to the hospitals back in Blighty – saved many lives.

There was, however, an unforeseen consequence. Yes, men were surviving – but many had sustained injuries that left them unrecognizable. It is estimated that more than 20 million soldiers, on both sides of the conflict, were wounded in the First World War. The weapons deployed on the Western Front brought death and destruction on an industrialized scale. Artillery shells – filled with shrapnel to cause maximum damage – machine guns and poison gas all created injuries never seen before. A single bullet from a standard-issue infantryman’s rifle, such as the .303 calibre Lee–Enfield used by the British Army, could leave an exit wound up to twenty times bigger than the entry wound.

The trench warfare that characterized the First World War made men’s faces particularly vulnerable as they risked being hit by a sniper’s bullet every time they took a peek over the top. In 1915 a young New Zealand doctor called Harold Gillies noted the high incidence of facial injuries while he was serving on the Western Front with the Red Cross. The Army had already established Queen Mary’s Hospital, Roehampton, as a specialist centre for amputees. Gillies now persuaded the authorities to sanction a unit in Aldershot dedicated to the treatment of facial injuries. Here, and later at Queen Mary’s Hospital in Sidcup, Kent, he was to perform miraculous feats of facial reconstruction.

My next interviewee, Andrew Bamji, is a retired consultant in rheumatology and rehabilitation, and has worked and written extensively on facial injury. He approached me down the long corridor carrying a cardboard box and, he said, feeling humbled to be walking, literally, in the footsteps of Harold Gillies.

‘Harold started from nothing and developed techniques for mending the face that had never been done before,’ Andrew told me. ‘He’s really the father of plastic surgery.’ He showed me a photograph of Gillies in his Army uniform, taken near the beginning of the First World War. He is balding and slight and, said Andrew, ‘doesn’t look particularly prepossessing, but he is only thirty-three’. Gillies assembled around him a team of physicians, dentists, photographers, artists and specialist nurses. His early efforts were confined to cosmetic masks, which is where Andrew’s box came in.

Opening it carefully, he lifted from the tissue-paper wrapping a pair of old-fashioned round glasses with a flesh-coloured tin panel attached. ‘What we can see here is a missing cheek, attached to a little bridge over the nose and a pair of spectacles,’ he said. ‘It’s a very, very thin plate, and painted quite nicely to match [the patient’s face], with a slight variation of colour under the eye, which would fit with the crease under the eye that most people have.’

It was an exquisitely crafted, strangely moving object – to think that a maimed survivor of that war of mechanized slaughter had worn this to save face and spare other people the sight of his terrible disfigurement. Andrew showed me another example of Gillies’ cosmetic masks in the form of ‘before’ and ‘after’ photographs of a man who had lost an eye. ‘In this case the patient has had a pair of glasses made with a face mask that contains a glass eye,’ he explained. ‘The eyelids are nicely made up, probably with silver wire for the eyelashes.’

Well intentioned and cleverly constructed as they were, these masks were soon superseded by an altogether more ambitious approach to facial injury. ‘Gillies moved away from trying to cover up a hole,’ said Andrew. ‘Structure is not the only thing that’s important. Function is also important. The problem with the masks, Harold Gillies found, was that patients didn’t like them. They were cold, they were unemotional, they were actually extremely uncomfortable very often.’

How, indeed, would I like to walk around with a piece of painted tin covering half my face? What Gillies intended was not merely to disguise facial disfigurement. He meant to mend it, using living tissue. It’s only now that I was beginning to appreciate the enormity of Gillies’ work in these now-derelict wards. He was not just performing groundbreaking surgical procedures, but was trying to make broken men whole again, to give them back their sense of self.

Our faces are our identity. Each day we see ourselves in the mirror and look for that reassuring symmetry. We smile, we frown, we wink. But what happens when we lose that symmetry, that familiar face, due to catastrophic damage? With a face changed beyond recognition, who are we? It’s a profound philosophical question and in the midst of the most destructive conflict in world history, Gillies wasn’t afraid to ask it, or to try to answer it.

To understand the complexities of the surgery Gillies pioneered I turned to Colonel Alan Kay, a consultant plastic surgeon who specializes in trauma reconstruction and has served with the British Army in Iraq and Afghanistan. He joined me in one of the wards in which Gillies would have worked. ‘The sorts of injuries he ended up dealing with were cases with large amounts of tissue missing – the nose, half the jaw, part of the skull,’ Colonel Kay said. ‘These sorts of injuries were historically unreconstructable.’

At this time reconstructive surgeons were severely limited in what they could do. Wounds too big to be stitched up could be patched with a simple ‘split’ skin graft from a donor site such as the thigh – ‘split’ meaning that the graft consists of the top layer of skin, the epidermis, but only half the layer beneath, the dermis. ‘But the trouble with the split skin graft is that wounds will always try to make themselves smaller,’ explained Colonel Kay. ‘Over a period of time it will contract and you will cause another deformity.’

An alternative, he said, would be to use a graft of the full thickness of the skin as that will not contract in the same way: ‘In terms of appearance it’s far superior. The trouble is, where you’ve got more complex reconstructions it’s not going to pick up enough blood supply and it will die.’ The challenge for Gillies was to somehow keep the flesh alive as he attempted to graft it from one part of the body to the damaged facial area.

His solution was to develop a technique known as the ‘tubed pedicle’ – a procedure so bizarre, to this layman at least, that it seems scarcely credible for it to have been tried in the first place, or that it worked in the second. It was, as is often the case in scientific breakthroughs, a case of accidental discovery. Gillies had been presented with a patient, Able Seaman Willie Vicarage, whose face had been badly burned at the Battle of Jutland, the largest naval battle of the war, on 1 June 1916.

Gillies set about taking grafts from the man’s chest and noticed that when he lifted a flap of skin it naturally formed a tube shape, and that this reduced the risk of infection to the raw areas and improved the blood supply. Rather than cut the skin flap entirely free, he decided to maintain the connection at one end to keep the blood flowing through the graft while moving the other end.

‘But now we’ve got to get this tissue up to here,’ said Colonel Kay, pointing at his face. ‘It’s not going to get up to there in a single go. We’ve got to go through an intermediary. And what was commonly used in Gillies’ time was the patient’s arm.’ I was not sure I was understanding this correctly, so Andrew Bamji showed me photographs, part of Gillies’ exhaustive and meticulous record of his pioneering work in plastic surgery.

Men with holes in their faces stared back as if defying me to look away, for their heads, shoulders and arms were covered in bizarre, trunk-like growths that showed the skin graft in transit, as it were, from the donor site to the face wound. These ‘tubed pedicles’ and the procedure of moving them in stages could take many months. ‘The term that was adopted was “waltzing”,’ said Colonel Kay. ‘They would “waltz” the pedicle.’

By this improbable but brilliantly conceived technique, Gillies performed near-miracles, returning to many men their identities and self-respect when they had given up hope of ever recovering either. ‘Men without half their faces; men burned and maimed to the condition of animals. Day after day, the tragic grotesque procession disembarked from the hospital ships and made its way towards us,’ wrote Gillies, recalling those days at Aldershot and Sidcup.

There were failures, notably the case of Henry Ralph Lumley of the Royal Flying Corps who crash-landed his plane on his first solo flight in 1917 and sustained horrific burns to the face. Gillies’ attempt to replace the skin of Lumley’s face with a skin graft from the chest went horribly wrong when the flesh became gangrenous. Sadly, Lumley died in 1918. But Willie Vicarage, the badly burned seaman, came through.

Andrew showed me a sequence of photographs showing Vicarage’s progress from a man without nose or lips to a chap who just looked as if he’d been in a bit of a punch-up. In between was a picture of tubed pedicles, having been cut from the chest, growing up from either shoulder to the middle of his face. ‘This triangular flap has been raised from the chest and he is the first British tubed pedicle ever done,’ said Andrew. ‘It was successful. You can see from the end result there that he got quite a reasonable appearance.’

I had heard of Harold Gillies but was only vaguely aware of what he achieved. It is no surprise to discover that he was knighted (somewhat belatedly) in 1930 for his medical achievements and services in the First World War. But he was not a man to rest on his laurels, or to devote the rest of his life to his favourite pastime of golf (at which, it was no surprise to hear, he excelled). The avenues he chose to explore in later life did not just extend the boundaries of medicine, however. They tested society’s morals and hovered on the edge of what was legal.

Before I learned about this extraordinary period of his life I wanted to know more about the experience of the patient who underwent the kind of radical medical procedures in which he specialized. For Gillies, I’m sure, would have been the first to admit that his achievements would not have been possible without the co-operation and bravery of the men who submitted to his scalpel.

Of course, none of Gillies’ patients is still alive. But there is someone who provides a direct link to the great man. His name is Doug Vince, he’s ninety-five years old and he was now striding towards me along that long corridor with a spring in his step. In 1945, he explained, he received reconstructive surgery from Gillies’ cousin and protégé Archibald McIndoe, who became famous in his own right as a plastic surgeon during and after the Second World War.

At the outbreak of the war McIndoe was assigned to Queen Victoria Hospital in East Grinstead, which specialized in burns injuries sustained by RAF aircrew. In 1945 Doug Vince was a twenty-two-year-old flight engineer on Stirling bombers. His plane came under attack from an enemy aircraft as it returned from a sortie over Germany. ‘A German fighter came back with us as we flew at night. He shot at us and set the plane on fire. And I passed out because of the smoke,’ he recalled.

‘When the pilot landed, the aircraft was in flames. I came round and saw a square of moonlight. I remember thinking, “I can live!” I clambered out of the escape hatch and ran along the wing. I thought it might explode as it was burning quite furiously. I was still running when I went off the end.’ His face and both hands were burned. His hands required reconstructive work, which McIndoe carried out at Queen Victoria Hospital.

‘They grafted my hands,’ said Doug, turning over his right hand and flexing the fingers of his left. The skin was a little paler and smoother, but you’d hardly have known he’d been in such a terrible situation. The skin, he said, came from his leg and stomach, and the grafts were straightforward. But it wasn’t just the physical repair I was interested in. That, if you’ll pardon the pun, was just skin-deep. Doug had a more significant story to tell and the tie he was wearing was a way into it. The tie was maroon-coloured, with blue and white stripes and an odd little repeat motif. ‘A tiny guinea pig with wings,’ he confirmed. This is the tie of the Guinea Pig Club, an exclusive group that is growing more exclusive by the year. ‘Out of six hundred and forty-something of us at the end of war, when we last met there were just six of us,’ he said.

The club was founded in the summer of 1941 at East Grinstead and membership was confined to members of the RAF who had had surgery at Queen Victoria Hospital and the surgeons who had operated on them. It wasn’t McIndoe’s idea apparently, but he went along with it enthusiastically. On one level it was just a bit of fun – the barrel of beer that became a permanent fixture on one of the wards was a sure-fire winner among the recovering young men.

But there was a more serious purpose. For, as McIndoe said, ‘It is one thing to cure the patient of his disfigurement and deformity, it is another to carry through such an arduous programme and end up with a normal human being.’ McIndoe was ahead of his time in regarding medical treatment in what nowadays might be called a ‘holistic’ way. Like his cousin Harold Gillies, he considered the lasting psychological effects of disfigurement and the need for patients to feel confident of their own identity and normality. It is telling that Doug’s most powerful memory of McIndoe is the moment he took his badly burned hand in his: ‘He held it, and looked at it like it was something very valuable. He said, “I think we can help you.” The three grafts made it nearly normal. I’m a lucky lad.’

In a sense, the next part of the story I was pursuing here was entirely logical. If a patient requires a physical fix, whether in wartime or peacetime, and a surgeon has the vision and expertise to provide it, should he not do so? My reaction would be to say ‘Of course’ – yet I was genuinely shocked and surprised to discover the later events of Harold Gillies’ life.

In these now derelict spaces, where damaged men once felt the extremes of pain and elation, I arranged to meet a woman who knows of the extremes to which desperate men will go. Diana Cowell, an elegant and friendly woman in her early seventies, is the daughter of a Second World War Spitfire ace called Robert Cowell, who became a dashing racing driver in the post-war years. She showed me photographs of him in his RAF flying helmet and behind the wheel of a racing car. He was the very image of male vigour and ‘normality’.

Diana has only vague memories of her father. For when she was four years old he left the family home to change his gender to female and she never saw him again. When she told me this I couldn’t for the life of me square such facts with the apparently masculine man in the photographs. But Diana, who has spent a lifetime coming to terms with her father’s behaviour, had a counter-intuitive explanation. ‘That’s probably why: “I am in a man’s body therefore I must prove I am a man,”’ she said.

The next part of the story struck me as even more shocking. For the surgeon who in 1951 facilitated Robert Cowell’s sex change to enable him to become Roberta Cowell, thereby performing one of the first-ever gender-reassignment procedures from male to female, was Harold – by now Sir Harold – Gillies. ‘He actually practised the night before on a cadaver because he’d never done the operation before. It had never been done in this country before,’ Diana told me.

In 1954, Roberta Cowell sold her story to the periodical magazine Picture Post for £8,000 (at least £200,000 in today’s money) and appeared on the front cover in a blue dress with a tumble of ginger-blonde curls. The shock of first losing her father, then discovering that ‘he’ was a woman, has affected Diana profoundly. ‘I don’t think I’ve ever got over it. I’m still very emotional about it because I will always have this little hurt child in my heart – “That’s not my daddy, that’s not my daddy!”’

There is a final, even more bizarre twist to this story. In a series of operations dating from 1946, Gillies had performed Britain’s first-ever female-to-male sex change, using the tubed pedicle technique. His patient was Laura (later Michael) Dillon, a medical student at the time he transitioned. Dillon, who wrote a book about the predicament of being transgender, became friends with Robert/Roberta Cowell and agreed to help her out in her own gender journey. Cowell’s problem was that she was still physically, and therefore legally, a man and it was illegal for a doctor to perform the surgical castration she required. Dillon obliged and this left Cowell free to approach Gillies for the vaginoplasty she needed to complete the change.

All this left me amazed, but not as shocked as I may have been a decade ago. Transgender and non-binary issues are just about the last taboo in terms of sexual identity. While homosexuality is now generally accepted by society, to the extent that legislation to allow same-sex marriages in the UK was passed in parliament in 2013, those who do not identify with the physical gender they were born with, or feel they are neither wholly masculine nor feminine but somewhere in between, have remained as fearful of expressing themselves as gay people once did.

But attitudes are slowly changing. As transgender and non-binary people are speaking out, mainstream opinion is catching up with what Gillies came to realize in Cambridge Military Hospital a century ago, that being comfortable in one’s body is vital to a sense of equanimity and identity. As his sex-change patient Michael Dillon wrote, ‘Where the mind cannot be made to fit the body, the body should be made to fit, approximately at any rate, to the mind.’

In visiting this hospital I uncovered a chain reaction of cause and effect that started with soldiers dying needlessly of disease in the Crimean War and concluded with gender-reassignment surgery. It was a bewildering journey, but it’s an object lesson in how things change for the better – not, as we like to think, in an orderly and logical progression but through fate and chance, and the instincts of brilliant minds.

None was more brilliant than Harold Gillies. When I arrived outside Cambridge Military Hospital I saw it as a monument to a bygone age. It looked grand but bleak in the snow, entirely irrelevant to the modern era. But in leaving it I reflected that what happened here, and what it led to, points us firmly towards the future.