Authors: Richard Hollingham
Bologna, Italy, 1597
Bologna was fast becoming the syphilis capital of Europe. This
wasn't something anyone advertised or put on the signs. It wasn't
good for business – particularly if your business was prostitution –
but the ravages of the disease were clear for all to see. Syphilis
was debilitating, disfiguring and, in most people's opinion,
downright disgusting.
An unwelcome import into Italy from South America, syphilis is
caused by tiny coiled bacteria. The disease is spread through contact
and, as it needs moisture to survive, the contact is often of a sexual
nature. Without treatment, syphilis spreads rapidly through the
body. It starts with swelling around the site of the infection, but
within weeks the victims develop rashes, fevers and headaches. They
will suffer painful lesions in the mouth, throat and anus. As the
disease progresses, the body becomes covered with ulcers and
tumours, and clumps of hair fall from the head.
Worse is to come.
While the patient becomes increasingly disfigured on the
outside, the bacteria are conducting a hidden campaign of destruction
inside the body. They attack bones and muscles, covering them
with rubbery tumours that affect posture and movement. If the
victim has somehow managed to conceal the effects of the disease
up to this point, syphilis then launches a final nasty surprise. As
these tumours spread, they begin to erode the bones of the nose.
When the nose collapses, the victims are left deformed, their face
distorted, their appearance repulsive.
Doctors had all sorts of treatment on offer for syphilis. These
invariably involved bloodletting or expensive concoctions of herbs
and unlikely bits of animals. Nothing was effective. Within a matter
of weeks, the victim went from upright citizen to social pariah, with
a caved-in face to match. Sufferers were shunned as moral degenerates.
They would do anything to have their faces restored. Here was
the perfect market opportunity for any enterprising surgeon.
Gaspare Tagliacozzi was undoubtedly one of Italy's greatest
surgeons, renowned as a brilliant practitioner. He had risen
rapidly through the ranks of the University of Bologna Medical
School – Italy's foremost medical university. By the age of thirtyfive
he had been honoured with civil office, and had even been
granted the privilege of conducting public demonstrations of
anatomy. As his reputation spread, Tagliacozzi's rich, famous and,
importantly, influential clients came to include the very finest of
Italian nobility.
One of his earliest patients was the distinguished Count Paolo
Emilio Boschetti of Modena. The count had suffered a broken arm
that had healed badly. He came to Tagliacozzi seeking treatment for
the stiffness.
The surgeon examined the limb and diagnosed that there was a
problem with the 'materials within'. So that movement could be
restored, the tendons and ligaments needed to be softened.
Tagliacozzi had been schooled well and knew just what was needed.
He prescribed that the arm should be held in the warm entrails of a
sheep for an hour a day. Afterwards the arm was to be placed in a
hot bath of herbs for half an hour. Finally, it should be washed with
warm wine before being dried. It was important that the patient had
not previously eaten anything, so perhaps the count might consider
undertaking his treatment before breakfast? Although whether he
would feel like having breakfast after dousing his arm in bits of dead
sheep is debatable.
Tagliacozzi's treatments were in the finest traditions of the
self-appointed father of surgery, Claudius Galen (see Chapter 1).
Despite their dubious efficacy, they were well received by patients,
and Tagliacozzi soon had a thriving business, in addition to his
salary from the university. But while private clients made him
wealthy, it was his anatomical demonstrations that drew the
crowds and helped make his name as a surgeon. He had a reputation
as a fine teacher and commanded great loyalty among his
students.
Anatomical dissections were undertaken only by senior
members of the faculty. They were such rare events that the lecture
theatres were usually packed and the doors guarded by four of the
'most quiet and serious students'.
*
Their job was to make sure that
only students, doctors and perhaps, if there was room, 'those
persons of good qualities' entered the theatre. There had been a
few problems in the past with troublemakers from the lower orders
getting in (there had also been a few cases where enterprising
students had demanded payment from gawpers wanting to be
admitted). The authorities were keen to stress that these were events
for learning, not common entertainment.
*
This was according to the official decree that detailed the strict rules governing public
dissections.
The cadaver – a criminal allocated by the city authorities – was
laid out on a slab at the centre of the room. The dissection was
performed in constant reference to Galen's texts, and took place
over a period of several days. Incisions were made and organs
removed in strict order. The whole event was as much ceremony as
lecture, with enough religious overtones to keep the powerful
Church authorities happy. Tagliacozzi became so proficient at dissections
that he was soon appointed professor of anatomy. It is therefore
surprising that such a disciple of Galen and pillar of the surgical
establishment should also turn out to be a great surgical innovator.
Tagliacozzi was fascinated with the idea that a damaged face
might be restored. He started to develop a new branch of medicine:
what he called the surgery of 'defective parts'. Although syphilis was
one of the most prevalent causes of facial disfigurement, it was not
the only way people could lose their noses. It was not unusual for
them to be severed on the battlefield or in a duel. Unfortunately,
even if their noses had been hacked off in an honourable way,
syphilis had become so prevalent that people confused victims of
the sword with the sinful victims of syphilis. More and more people
were coming to Tagliacozzi desperate for a new face, but any
attempt at reconstructive surgery was fraught with difficulties.
To be fair to Tagliacozzi,
any
surgery in the sixteenth century
was fraught with difficulties. First, any operation had to be conducted
without anaesthetic. Patients generally only agreed to the pain if the
alternative was death, so surgery might be considered for a life-threatening
condition such as a gangrenous leg wound. But could
surgery be justified if it was only to restore a person's appearance?
The second problem was infection – the slightest cut in the
skin could become infected and ultimately kill the patient. The only
incisions surgeons made on a regular basis were for bloodletting;
otherwise they preferred to stick with external treatments involving
herbs, spices and possibly entrails. Overriding both these considerations
was the problem of technique. If a surgeon were going to
rebuild a nose, where was the skin going to come from? Attempts
had been made to take skin grafts from donors (slaves or servants
usually), but these had always been unsuccessful. The skin had to
come from somewhere else on the patient's body. Tagliacozzi chose
to take it from the arm.
However, it turned out you could not simply cut into the arm,
remove a slice of skin and stitch it to the face; the patch would
wither and die. There was also a good chance that the wound left on
the arm would become infected. To remain viable, the skin had to
remain connected to a blood supply. Tagliacozzi's solution was not
without considerable pain, inconvenience and embarrassment for
his patients (not to mention cost), but it was simple.
The patient had not left his house for many months. The shame of
being seen in public would have been too much to bear. His face was
shocking to look at – where he had once had a nose there were only
two scarred hollow sockets. Even his wife made every excuse not to
see him, although given that he lost his nose through syphilis, this
was hardly surprising. Whereas only a few months ago the man had
been out every day, he now lived for the most part in his bedchamber,
visited by only a few trusted servants. It was a grim existence,
and one that he hoped Professor Tagliacozzi would be able to
rectify. Otherwise, he believed he would probably take his own life.
Tagliacozzi's knife is razor sharp, his movements rapid and
precise. He slices the blade into the patient's flesh on the underside
of the upper arm, making a cut about as long as a nose. He removes
the knife and makes a further cut parallel to the first. He then
makes a cut between the top of the two lines. The knife is so sharp
and the incisions so quick that the patient feels hardly any pain. The
cuts redden as blood seeps out. It drizzles down the man's arm and
drips into a bowl on the floor. Tagliacozzi mops the wound with a
handkerchief and moves on to the next stage of the operation.
Sorry, sir, but this part is going to hurt.
The surgeon slips his knife through one of the cuts and passes
it horizontally underneath the skin. The patient screams in agony as
Tagliacozzi runs the knife backwards and forwards between the two
parallel incisions. He slices through nerves, blood vessels and fat,
gradually lifting the skin as he goes, pulling it away from the underlying
tissue. Now the pain is becoming unbearable. The man is
desperate for this terrible torture to end. Tagliacozzi's assistant
struggles to keep the patient's arm still. It takes only a few minutes
for the surgeon to finish, but for the man it feels like an eternity.
When all the cutting, slicing and scraping is finally over, the
patient is left with a rectangular flap of skin on his arm and a gaping
wound. Tagliacozzi carefully lifts the flap with his fingers and dresses
the raw tissue underneath with strips of bandage that soon become
sodden with blood. The raised skin, known as a pedicle, remains
connected to its blood supply at the lower end of the rectangle,
although the exposed edges are already healing. Now the surgeon
needs to graft the skin to his patient's face.
When the patient raises his arm in front of his face, the pedicle
rests across the empty sockets of the nose. Being connected to the
patient's arm, the pedicle is supplied with blood and, with the
help of a few stitches, will grow into the man's face. When the
thousands of tiny capillaries and veins in the face have made their
connections, the pedicle can be severed and the finishing touches
put to the new nose. The problem is that it takes at least two weeks
for the new blood supply to be established. In the meantime, the
patient has to hold his arm across his face.
Try holding your arm up in front of your face so that your upper
arm rests on your nose. Now try holding it there for two minutes.
Hurts, doesn't it? Imagine how it feels to hold it for two hours. Or
even two days. To get around this impossibly uncomfortable situation,
Tagliacozzi designed a novel item of headgear. It consisted of
a leather corset and helmet supporting a series of belts and straps.
The straps held the patient's arm in place so that the hand rested on
the back of their head. Their wrist was attached to the helmet to
restrain movement, and straps around their head prevented the
arm swinging from side to side and accidentally ripping the pedicle.
Tagliacozzi had this peculiar bondage outfit tailor-made for
each patient. Once on, it had to remain on for two weeks – the
patient's hand strapped across the top of their head, their elbow
jutting out in front of their face, their movement and vision
restricted. It was cumbersome and looked ridiculous, but people
were prepared to try anything to restore their features.
The jacket and headdress were only part of Tagliacozzi's elaborate
treatment plan. As the pedicle gradually started to grow into
the stump of the nose, the surgeon insisted that his patients follow
a strict diet. They were allowed meat – but it should be roasted, not
boiled – and he advised that they avoid fish. At least there weren't
any entrails involved. With the straps securely tightened on the
corset, the patient was left groaning on his (or her) bed.
A fortnight later the surgeon returns to see how the patient is
getting on. By now the top of the pedicle has grown into his nose.
The tissue is still healthy and Tagliacozzi can sever the connection
between the upper arm and the face. A quick slice with the knife
and, much to his relief, the patient can remove the leather jacket
and lower his arm.
After two weeks he, like most of Tagliacozzi's patients, finds his
muscles so cramped that he can barely move. The stench when he
takes off the leather jacket is somewhat overpowering. As for
his appearance, if anything it has got worse. Where he had once
had half a nose, he now has a flap of skin dangling in the middle
of his face. In true Renaissance fashion, Tagliacozzi needed to
become an artist.
Using splints, bandages and the occasional stitch, the surgeon
starts to rebuild the nose. Over the next few weeks, he slowly sculpts
his patient's new face. Three months after the first incision, the
skin has grown together, the splints have done their job and the
bandages can be removed. Carefully pulling out the final splint,
Tagliacozzi holds up a mirror. His patient's new nose is revealed
in its full glory. Slightly scarred and somewhat different in colour
from the rest of his face, it is still a considerable surgical achievement.
He can once again go out in public. Tagliacozzi was truly
a miracle worker.
The surgeon published the first-ever book on reconstructive
surgery in 1597. Within it he outlined his methods and included
detailed diagrams to illustrate the various stages of nasal and other
types of facial reconstruction. The techniques he devised would
remain familiar to surgeons well into the twentieth century.