2016 marks the 200th anniversary of the publication of Joseph Constantine Carpue’s book An Account of Two Successful Operations for Restoring a Lost Nose from the Integuments of the Forehead. The 1816 publication was significant because it helped to reintroduce the lost operation of rhinoplasty into 19th century surgery and created new interest in the technique, an interest which would develop over the century and which eventually lead to the pioneering work of Harold Gilles in the first world war.
Rhinoplasty is an operation in which a skin flap is taken and used to recreate a lost nose. It might be used to treat someone who had lost their nose to a sabre cut or other sort of blow to the face, but it might also be used historically to treat patients who has lost their noses to syphilis. A shaped flap of tissue is taken from the arm or forehead, and with one part of it still connected to it’s original location to preserve blood supply during healing, the flap is shaped and sewn in place to make the new nose. Then finally, when it has healed, the tissue’s point of connection to it’s original location is then severed and the final piece is sewn in place.
This was actually an ancient technique. Details of it’s performance, for example, were written in the Sushruta Samhita, a collection of Sanskrit writings compiled around the middle of the first millennium BCE. In Western Europe, it was commented on by Vesalius and Paré, but it’s performance is most famously associated with the Italian surgeon Gaspare Tagliacozzi and his book De Curtorum Chirurgia per insitionem (On the Surgery of Mutilation by Grafting), which was published in 1597 and which described his modern reconstructive technique.
However, between the end of the 16th century and the beginning of the nineteenth centuries, it seems rhinoplasty was barely performed at all. There are very few accounts of it and almost no case histories. It was misunderstood, as many seemed to believe the tissue for the new nose came not from the patient, but from a donor. It was medically discredited according to contemporary beliefs about sympathy and magnetism and the viability of the survival of that donor tissue (Van Helmont). It became a subject for comedy and satire and patients could face accusations of inappropriate vanity, especially if it was immoral syphilis which had robbed them of their noses in the first place. Beyond some short-lived experimenting with tissue grafting at the Royal Society, fascination with polyps and John Hunter’s experiments with teeth, there seems to have been little interest in the possibilities and little regard for the operation.
When rhinoplasty was rediscovered at the end of the eighteenth century, it was not from a surgical text, but from an account of an operation published in the Gentleman’s Magazine in 1794. The account told the story of an operation, commonly done in India, to restore the nose of an Indian bullock driver called Cowasjee who had been with the English Army and who had been captured and mutilated as a collaborator by insurgents. It described how the technique was performed. There were several surgeons, notably in Edinburgh, who were interested and who revived talk of Tagliacozzi, but it was Carpue who actually performed the operation in 1814, and then in 1816 he published his illustrated book.
Carpue is probably best known today for this operation and for his involvement in the production of the anatomical crucifixion of James Legg for the Royal Academy. In the early 19th century, Carpue (who had come to surgery late, having previously considered acting, law, bookselling and a career in the Catholic clergy as possible professions) ran a private anatomy school on Dean Street and was surgeon to the Duke of York Hospital in Chelsea. The rhinoplasty he performed in 1814 was for a military officer who Carpue said had lost his nose due to necessarily inhaling mercury for an infection. An infection of this sort may have been the cause, but mercury was a common treatment for syphilis, and Carpue may have been being discreet about the patient’s condition.
Carpue’s publication had a great impact, because of the successful outcome of his operations, and it began to be taken up by other surgeons, among them the Prussian surgeon Karl Ferdinand Von Graefe, who had Carpue’s book translated into German and shortly afterwards, in 1818, published his own work in which he developed the technique and appears to have coined the term ‘plastic surgery’. The rhinoplasty had been revived after a long period of neglect, but soon new variations on the operation appeared, other reconstructive techniques were developed and there was a general revival of interest in the possibilities of tissue transplantation which was to go on to influence (among many others) the work of Gilles in the first world war and Archibald McIndoe in the second.
Ambroise Paré, “Opera Chirurgica” Francofurti (Frankfurt) 1594, folio
Andreas Vesalius, in Opera Omnia Anatomica et Chirurgica cura Herm. Boerhaave et Bern.Seigfr.Albini (Albinus)
Jan Baptist Van Helmont, “Opera Omnia” Francofurti, 1682 “On the Magnetic Healing of Wounds”
Samuel Butler, “Hudibras” (1663-1668) (epic satirical poem written over several years)
William Congreve, “Love for Love”, (play) 1695
Nils Rosen Von Rosenstein, “Respondente Issac Fritz, disseratation de chirurgiae curtorum possibilitate”, Upsaliae (Uppsala) 1742
Laurentius Heister, “Institutiones Chirurgicae”, Amstelodami (Amsterdam), 1750, pars secunda.
Anatomical Crucifixion of James Legg, http://www.racollection.org.uk/ixbin/indexplus?record=ART13544
Joseph Constantine Carpue, “An Account of Two Successful Operations for Restoring a Lost Nose from the Integuments of the Forehead. In cases of two officers of His Majesty’s army: to which are prefixed, historical and physiological remarks on the nasal operation; including descriptions of the Indian and Italian methods. London, 1816.
Karl Ferdinand Von Graefe, ‘Rhinoplastik, oder die Kunst den Verlust der Nase organisch zu ersetzen’ (Berlin, 1818)
To cite this post : Kirsty Chilton, “Joseph Constantine Carpue and the Revival of Rhinoplasty”, Museum Highlights (blog on oldoperatingtheatre.com), October 18, 2016. [On line] http://oldoperatingtheatre.com/joseph-constantine-carpue-and-the-revival-of-rhinoplasty/
Kirsty Chilton is assistant curator at the Old Operating Theatre Museum and Herb Garret.