A Singular Operation
In January 1795 London’s “The Gentleman’s Magazine”, published details of a remarkable surgical procedure.
The author, James Wales, a resident of then Bombay, described reconstruction of a British Army employed bullock driver’s nose using a pedicled flap of forehead skin. Cowasjee, one of the Mahratta peoples of central and Western India had been working for the British during the third Anglo-Mysore war of 1792. He was subsequently taken prisoner by Tippu Sultan’s army. They deliberately amputated his nose and one hand, a then common local punishment for both judicial and social transgressions.
Wales’s single page article “A Singular Operation”, showcased an engraving by renowned engraver William Nutter. This now iconic image of the alleged 10month post-operative result, was a reproduction of Wales’s own painting, itself deduced from a description of the procedure said to have been witnessed first-hand by two Anglo-Indian Army Surgeons based in Bombay, Thomas Cruso, and James Findlay. The page also carries the image
Wales describes the operation using a numbered diagram showing Cowasjee pre-operatively together with the wax mould used to plan the size and shape of the flap. The surgeon, a fellow Mahratta named “Kumar”, is said to have been from a family skilled in this procedure, which was undertaken near modern Pune. Indian surgeons had been reconstructing noses in this manner using flaps of tissue taken from the forehead and inner cheek for many centuries. They may also have used free skin grafts from this latter donor site. Similar procedures are described in the Susrutha Samhita, dating to at least 500 BCE, probably much earlier.
This operation would be very familiar to modern plastic surgeons, a refined version still being in widespread use today and considered the best way to deal with a substantial loss of nasal skin. However, without a skeletal support of bone or cartilage, and lining of the nasal passages, it is unlikely that Wales assertion that “This operation is always successful” is true.
Harold Gillies later re-learned this lesson during the First World war and discovered that another Indian Army Surgeon- Keegan, had already devised a solution.
However, The Gentleman’s Magazine article stimulated the interest of Joseph Constantine Carpue (1764-1846), surgeon to the Duke of York Hospital in Chelsea. Inspired by what he read, Carpue went on to perform the procedure himself, twice. He published his work in “An account of two successful operations for restoring a lost nose” (1816).
Carpue’s account was the first detailed description of a distinctive “plastic” procedure in Britain. Whilst the Italian Tagliacozzi, had first described a flap-based procedure for rhinoplasty in the 16th century, following his death, the technique and any like it were essentially forgotten. Carpue inspired a Europe-wide resurgence in the use of facial and forehead flaps initially for nasal reconstruction (rhinoplasty) and subsequently for wider applications. This effectively kick-started the modern era of plastic surgery. The Prussian surgeon Karl Ferdinand von Graefe rapidly translated Carpue’s work into German. He refined the forehead rhinoplasty and developed other facial flap procedures publishing his own book Rhinoplastik in 1818. It is likely that this work and his description of “Blepharoplasty” (eyelid surgery) gave origin to the term “Plastic Surgery”.
Images courtesy of the Wellcome Collection, under Creative Commons