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A nose by any other name
Histories
A nose by any other name WELLCOME TRUST PICTURE LIBRARY
“The patient leaped upon a table, and, laying himself on his back, with his head supported by a pillow, refused to be held; saying ‘I hope I shall behave like a man!’” The man on the table was a Captain Williamson, an officer in the British army. The man wielding the scalpel was London society surgeon Joseph Carpue. Both prayed the operation would be a great success. Williamson was desperate for a new nose; his own had been destroyed by disease. Carpue (left) was equally eager: he had waited 20 years for a patient who was both suitable and willing to submit to a new type of surgery. If all went well, the captain would be able to show his face in public once more and Carpue would win fame as a restorer of noses.
JOSEPH CARPUE had been pondering the possibilities of a new nose for years. He didn’t want one himself, but there were plenty of people who through no fault of their own had lost their noses and needed new ones. The noseless were shunned, their disfigurement assumed to be a punishment for their sins. With a new nose they could take their place in polite society again. As one of the most brilliant surgeons in Georgian London, Carpue was the man for the job. He had the skills. He knew the theory. All he had to do was find someone willing to be his first patient. Carpue’s urge to create a new nose was prompted by the appearance of a letter in The Gentleman’s Magazine on 9 October 1794. The letter, written by “B. L.”, a British army surgeon in India, described how the driver of a bullock cart, a man called Cowasjee, had lost his nose and acquired a new one. The replacement nose had been created from a flap of skin cut from his forehead and grafted onto the stump of the old one. It was a brilliantly simple piece of surgery. Carpue couldn’t wait to try it. People were fascinated by the bullock driver’s story and soon his nose was the talk of the town. In 1792, Cowasjee had been carting supplies for the British army, then at war with the great Tippoo Sultan, ruler of Mysore in southern India. He was captured by Tippoo’s men, who cut off one of his hands and his nose before sending him back to the British. “For 12 months he remained without a nose, when a new one was put on by a man of the 50 | NewScientist | 26 August 2006
060826_Op_Histories.indd 50
Brickmaker caste, near Poonah,” wrote B. L. The brickmaker moulded a nose from wax, squashed it flat to create a template, and laid it on Cowasjee’s forehead. Then he drew around the wax, cut along the line and lifted up the skin to create a thin flap, leaving a strip of skin, or pedicle, still firmly attached between the eyes. After paring away the scar tissue from the remains of the old nose, the brickmaker-surgeon twisted the flap over the stump, and inserted the edges into a series of neat incisions. The new nose was secured with slips of cloth soaked in a plant extract that dried to form a sort of cement. The pedicle
“Nasal amputation was a punishment for thieves and adulterers” kept blood flowing into the flap until the graft had taken, at which point it was snipped away. “The artificial nose is secure and looks nearly as well as the natural one,” reported B. L. Four years later, writer and traveller Thomas Pennant reported in The View of Hindoostan that Cowasjee’s nose was bearing up well. It could “sneeze smartly, distinguish good from bad smells, bear the most provoking lug, or being well blown without danger of falling into the handkerchief”. While Cowasjee’s story enthralled the British, in India it was not at all astonishing.
As B. L. pointed out, the operation had been practised there “from time immemorial”. No one should have been surprised that this early form of plastic surgery had been perfected in India. Noselessness was rife. Nasal amputation was a common punishment for thieves and adulterers, intended to humiliate and to deter others. The pressing need for new noses had led inevitably to the development of a highly effective technique for replacing them. In late-18th-century Europe, nasal amputation was rare. Occasionally a man might have his nose sliced off in battle or during a duel, but disease was the more common destroyer of noses. Cancer, liver disease and syphilis all ate away at noses, producing a pool of potential patients in need of new ones. Inspired, Carpue set about learning more. Building new noses this way had been common practice in India since around AD 1000, but there were even earlier techniques. Around 600 BC, an Indian surgeon called Sushruta wrote instructions for repairing noses using a flap of skin from the cheek. Skills developed in India spread west to ancient Greece and Rome, where many gladiators were grateful for them. The Byzantine emperor Justinian II had his nose amputated by his enemies during a coup in AD 695; he got himself a new nose and made a comeback nine years later. Replacement noses popped up again in 15th-century Sicily, where a family of barbers had a sideline in nasal www.newscientist.com
16/8/06 4:36:03 pm
To see more of the history of plastic surgery visit the Science of Surgery Gallery at the Hunterian Museum, London www.rcseng.ac.uk/museums
WELLCOME TRUST PICTURE LIBRARY
Captain Williamson’s new nose was created from a flap of skin cut from his forehead and scalp
surgery. And in the late 16th century another Italian, Gaspare Tagliacozzi, wrote a book outlining his version of the Italian nose job. He grafted skin from the inner arm, a procedure that required patients to sit for months with one arm strapped to their noses. This practice quickly died out: the church disapproved of it and there were malicious, but unfounded, rumours that a Tagliacozzi nose had a tendency to drop off. The ancient art of fixing noses vanished from Europe. Carpue lived in a more enlightened age and resolved to revive the art of restoring noses. www.newscientist.com
060826_Op_Histories.indd 51
He, though, would do it the Indian way: it might be older but it had the advantage of simplicity and from what he had heard it was almost always successful. Carpue had such confidence in the Indian method that he began to teach it to his students – even though he had yet to try it out himself. If he had expected a great rush for new noses, he was to be disappointed. He waited patiently, and in September 1814, after a wait of almost 20 years, Captain Williamson finally came along. He had heard that Carpue restored noses. He had suffered from liver
disease and had been taking mercury for it for years, he said. The mercury had destroyed his nose. Could Carpue fix it? Carpue was in a quandary. He wasn’t sure he wanted Williamson to be his first patient. After singing the praises of the Indian operation for so long, he had to get a good result. Williamson was not a well man. The mercury he had been prescribed had wrecked his constitution and might ruin his prospects of healing. And while he blamed his troubles on liver disease, the real culprit was syphilis. In India, amputation with a sharp blade left clean, neat stumps to work on. Syphilis was not so tidy: it would be risky to fix a new nose to such a diseased base. There was a good chance the graft wouldn’t take. On the pretext of preparing the captain’s face for the operation, Carpue made incisions around the ruined nose. The wounds healed well. He decided to operate. On 23 October, after several test runs on corpses, he went to work on Williamson’s nose. The captain was really not the best guinea pig. Apart from his syphilis, he had an unusually low forehead – too low to provide a nose-sized flap. Carpue would have to cut skin from the scalp too. What if the hair regrew along the base of the new nose? Would it push the nose off his face? He decided to risk it. Following B. L.’s instructions, Carpue modelled a wax nose, flattened it, laid it on Williamson’s head and drew around it with red paint. Then he began to cut, starting with the stump. First he made a cut beneath the nose to take the end of the flap and create a central septum. Next, he made cuts to the side of the nose to take the outer edges of the flap – what would become the wings of the nostrils. That done, he cut around the red line on the forehead, turned the flap around, fitted the edges into the cuts he had made, and stitched them in place. Finally, he stuffed pieces of lint into the nostrils to keep them open. The whole operation had taken 15 minutes. Three days later, in the presence of one of Williamson’s friends, Carpue removed the dressings. The friend, he wrote later, was amazed, shouting “My G-d, there is a nose”. It was a nose, but not one Carpue liked the look of much. He was alarmed by its flatness. Then it swelled hideously. For weeks the nose alternated between balloon and pancake. But after four months, Carpue was satisfied: the nose had healed. There was one last thing to do. He snipped through the pedicle and tidied up the wound. The nose job had arrived. Stephanie Pain ● 26 August 2006 | NewScientist | 51
16/8/06 4:36:23 pm
A nose by any other name WELLCOME TRUST PICTURE LIBRARY
“The patient leaped upon a table, and, laying himself on his back, with his head supported by a pillow, refused to be held; saying ‘I hope I shall behave like a man!’” The man on the table was a Captain Williamson, an officer in the British army. The man wielding the scalpel was London society surgeon Joseph Carpue. Both prayed the operation would be a great success. Williamson was desperate for a new nose; his own had been destroyed by disease. Carpue (left) was equally eager: he had waited 20 years for a patient who was both suitable and willing to submit to a new type of surgery. If all went well, the captain would be able to show his face in public once more and Carpue would win fame as a restorer of noses.
JOSEPH CARPUE had been pondering the possibilities of a new nose for years. He didn’t want one himself, but there were plenty of people who through no fault of their own had lost their noses and needed new ones. The noseless were shunned, their disfigurement assumed to be a punishment for their sins. With a new nose they could take their place in polite society again. As one of the most brilliant surgeons in Georgian London, Carpue was the man for the job. He had the skills. He knew the theory. All he had to do was find someone willing to be his first patient. Carpue’s urge to create a new nose was prompted by the appearance of a letter in The Gentleman’s Magazine on 9 October 1794. The letter, written by “B. L.”, a British army surgeon in India, described how the driver of a bullock cart, a man called Cowasjee, had lost his nose and acquired a new one. The replacement nose had been created from a flap of skin cut from his forehead and grafted onto the stump of the old one. It was a brilliantly simple piece of surgery. Carpue couldn’t wait to try it. People were fascinated by the bullock driver’s story and soon his nose was the talk of the town. In 1792, Cowasjee had been carting supplies for the British army, then at war with the great Tippoo Sultan, ruler of Mysore in southern India. He was captured by Tippoo’s men, who cut off one of his hands and his nose before sending him back to the British. “For 12 months he remained without a nose, when a new one was put on by a man of the 50 | NewScientist | 26 August 2006
060826_Op_Histories.indd 50
Brickmaker caste, near Poonah,” wrote B. L. The brickmaker moulded a nose from wax, squashed it flat to create a template, and laid it on Cowasjee’s forehead. Then he drew around the wax, cut along the line and lifted up the skin to create a thin flap, leaving a strip of skin, or pedicle, still firmly attached between the eyes. After paring away the scar tissue from the remains of the old nose, the brickmaker-surgeon twisted the flap over the stump, and inserted the edges into a series of neat incisions. The new nose was secured with slips of cloth soaked in a plant extract that dried to form a sort of cement. The pedicle
“Nasal amputation was a punishment for thieves and adulterers” kept blood flowing into the flap until the graft had taken, at which point it was snipped away. “The artificial nose is secure and looks nearly as well as the natural one,” reported B. L. Four years later, writer and traveller Thomas Pennant reported in The View of Hindoostan that Cowasjee’s nose was bearing up well. It could “sneeze smartly, distinguish good from bad smells, bear the most provoking lug, or being well blown without danger of falling into the handkerchief”. While Cowasjee’s story enthralled the British, in India it was not at all astonishing.
As B. L. pointed out, the operation had been practised there “from time immemorial”. No one should have been surprised that this early form of plastic surgery had been perfected in India. Noselessness was rife. Nasal amputation was a common punishment for thieves and adulterers, intended to humiliate and to deter others. The pressing need for new noses had led inevitably to the development of a highly effective technique for replacing them. In late-18th-century Europe, nasal amputation was rare. Occasionally a man might have his nose sliced off in battle or during a duel, but disease was the more common destroyer of noses. Cancer, liver disease and syphilis all ate away at noses, producing a pool of potential patients in need of new ones. Inspired, Carpue set about learning more. Building new noses this way had been common practice in India since around AD 1000, but there were even earlier techniques. Around 600 BC, an Indian surgeon called Sushruta wrote instructions for repairing noses using a flap of skin from the cheek. Skills developed in India spread west to ancient Greece and Rome, where many gladiators were grateful for them. The Byzantine emperor Justinian II had his nose amputated by his enemies during a coup in AD 695; he got himself a new nose and made a comeback nine years later. Replacement noses popped up again in 15th-century Sicily, where a family of barbers had a sideline in nasal www.newscientist.com
16/8/06 4:36:03 pm
To see more of the history of plastic surgery visit the Science of Surgery Gallery at the Hunterian Museum, London www.rcseng.ac.uk/museums
WELLCOME TRUST PICTURE LIBRARY
Captain Williamson’s new nose was created from a flap of skin cut from his forehead and scalp
surgery. And in the late 16th century another Italian, Gaspare Tagliacozzi, wrote a book outlining his version of the Italian nose job. He grafted skin from the inner arm, a procedure that required patients to sit for months with one arm strapped to their noses. This practice quickly died out: the church disapproved of it and there were malicious, but unfounded, rumours that a Tagliacozzi nose had a tendency to drop off. The ancient art of fixing noses vanished from Europe. Carpue lived in a more enlightened age and resolved to revive the art of restoring noses. www.newscientist.com
060826_Op_Histories.indd 51
He, though, would do it the Indian way: it might be older but it had the advantage of simplicity and from what he had heard it was almost always successful. Carpue had such confidence in the Indian method that he began to teach it to his students – even though he had yet to try it out himself. If he had expected a great rush for new noses, he was to be disappointed. He waited patiently, and in September 1814, after a wait of almost 20 years, Captain Williamson finally came along. He had heard that Carpue restored noses. He had suffered from liver
disease and had been taking mercury for it for years, he said. The mercury had destroyed his nose. Could Carpue fix it? Carpue was in a quandary. He wasn’t sure he wanted Williamson to be his first patient. After singing the praises of the Indian operation for so long, he had to get a good result. Williamson was not a well man. The mercury he had been prescribed had wrecked his constitution and might ruin his prospects of healing. And while he blamed his troubles on liver disease, the real culprit was syphilis. In India, amputation with a sharp blade left clean, neat stumps to work on. Syphilis was not so tidy: it would be risky to fix a new nose to such a diseased base. There was a good chance the graft wouldn’t take. On the pretext of preparing the captain’s face for the operation, Carpue made incisions around the ruined nose. The wounds healed well. He decided to operate. On 23 October, after several test runs on corpses, he went to work on Williamson’s nose. The captain was really not the best guinea pig. Apart from his syphilis, he had an unusually low forehead – too low to provide a nose-sized flap. Carpue would have to cut skin from the scalp too. What if the hair regrew along the base of the new nose? Would it push the nose off his face? He decided to risk it. Following B. L.’s instructions, Carpue modelled a wax nose, flattened it, laid it on Williamson’s head and drew around it with red paint. Then he began to cut, starting with the stump. First he made a cut beneath the nose to take the end of the flap and create a central septum. Next, he made cuts to the side of the nose to take the outer edges of the flap – what would become the wings of the nostrils. That done, he cut around the red line on the forehead, turned the flap around, fitted the edges into the cuts he had made, and stitched them in place. Finally, he stuffed pieces of lint into the nostrils to keep them open. The whole operation had taken 15 minutes. Three days later, in the presence of one of Williamson’s friends, Carpue removed the dressings. The friend, he wrote later, was amazed, shouting “My G-d, there is a nose”. It was a nose, but not one Carpue liked the look of much. He was alarmed by its flatness. Then it swelled hideously. For weeks the nose alternated between balloon and pancake. But after four months, Carpue was satisfied: the nose had healed. There was one last thing to do. He snipped through the pedicle and tidied up the wound. The nose job had arrived. Stephanie Pain ● 26 August 2006 | NewScientist | 51
16/8/06 4:36:23 pm