An Indian medical text dated to around 600 BC gives an idea of the sort of treatment Surpanakha would have received. First, the doctor would have cut a nose-shaped flap in her forehead – narrow at the bottom, above the nasal cavity, and wide at the top. The incision would have been around a quarter of an inch deep, down to the periosteum, the thin fibrous membrane covering the skull.* The doctor would then have peeled the skin away from her forehead, making sure not to tear the narrow part at the bottom. This strip of skin, rich in blood vessels, would become the pedicle and keep the skin flap alive. Twist the pedicle around and bend it down and there you have a new nose. You also have excruciating pain and an appalling (nose-shaped) scar on the forehead. It was a crude technique, but better than having no nose at all.
* Periosteum membrane covers all bones, but the forehead is one of the few places on the body where the skin is right against the bone. Periosteum contains tough fibres of collagen and nerves, as well as blood vessels to supply the bone cells.
Surprisingly, despite Tagliacozzi's advances, the cruder Indian technique was still being practised by surgeons well into the nineteenth century. Seemingly reluctant to try any surgery that took more than a few seconds, Robert Liston (see Chapter 1) dismissed the Italian method as too tricky. The Indian operation, on the other hand, was 'less difficult in execution, not so liable to failure, and more easily undergone by the patient'.
In his book Elements of Surgery, Liston describes in detail his own variation on what he termed the 'rhinoplastic operations'. Liston suggests making a wax mould of the nose and then flattening it out so that it becomes a template for the skin flap. However, he confesses that this can be a difficult process and it is often more convenient to use a piece of cardboard (you can guess which method he used).
The card was held firmly by an assistant as the surgeon traced around it with a pen, 'or at once with a knife carried deeply through the integuments'. It is hard to imagine Liston bothering with a pen first. With the template removed, Liston describes pulling the skin away from the forehead using his finger and thumb. If it becomes difficult, he suggests the use of a hook. Finally, the flap is twisted around and placed over the area of the nose, the wound in the forehead is dressed and a couple of straws are stuck up the nostrils so the patient can breathe. Understandably, many people opted for false tie-on noses rather than endure the horrors of Victorian surgery.
However, it was another Liston innovation that revolutionized plastic surgery: anaesthetic. Before pain relief, surgery was the last resort of a desperate patient – whether it was to remove a diseased limb or fix a disfigured face. Now, though, a whole glorious new world of surgery was about to open up. People were no longer coming to surgeons to fix their faces: they wanted to improve their faces. Nose jobs, smaller breasts, facelifts or bigger lips – there was nothing surgeons wouldn't try. And with infection defeated by antiseptic techniques, operations were becoming much safer.
A new era of cosmetic surgery had arrived, and surgeons (some more qualified than others) were, once again, in the exciting business of experimenting on their patients. Bizarrely, rather than perfecting operations to move flaps of skin around, they developed operations that involved inserting a whole range of novel substances beneath the skin. It seemed there were few products of the Industrial Revolution that weren't brought to the operating table. Surgeons attempted rebuilding noses with ivory, they experimented with metal, celluloid and gutta percha (a substance derived from tree sap); they tried oil and coal extracts; even bits of animal cartilage. One surgeon brought a live duck into the operating theatre, slit its throat and attempted to repair his patient's nose with the bird's breastbone. They notched up their failures to experience until, finally, they hit upon the perfect new substance.
GLADYS DEACON: A CAUTIONARY SURGICAL TALE
Paris, 1903
* * *
Twenty-two-year-old Gladys Deacon lay in bed contemplating her own beauty. She was, undeniably, exceptionally beautiful. She was also extraordinarily vain.
Intelligent, charming and wonderful company, Gladys was all these things and more. Why, hadn't a young gentleman told her that this very evening? He was handsome certainly, but a mere plaything to Gladys, who had set her sights on marrying into royalty (or landed gentry at the very least). Still, it was nice to be admired; although few people could come as close to admiring Gladys as much as Gladys herself.
Raised in Boston, Massachusetts, she moved in all the right circles. She then burst on to the European social scene, mixing with aristocrats and artists, princes and politicians. A friend talked of how Gladys traversed Europe 'like a meteor in a flash of dazzling beauty'. The press adored her, men courted her, other ladies envied her. She was becoming famous for being famous – a true Edwardian celebrity. But as she lay on her bed thinking about herself, she started to have doubts. Could she possibly become more beautiful?
Like many Edwardians, Gladys was fascinated with the classics and the concept of classical beauty. She toured the galleries and museums of London, Paris and Rome, examining statues and studying paintings. She admired the profiles of Hellenic faces; their strong foreheads and straight noses. She even took to recording the distances between the eyes and noses of statues to see how they measured up. But when she compared herself with them, her observations brought her to an alarming conclusion: she wasn't perfect after all. Her nose dipped between her forehead and the tip, creating a slight hollow. She wanted a straight classical nose, and she knew just what to do to get one.
Gladys went to see a professor at the Institut de Beauté in Paris. He examined her and advised that she try the latest advance in cosmetic surgery: paraffin wax. Unlike previous innovations, the wonder of this new treatment (invented only a few years before) was that there was no actual surgery involved. All the surgeon had to do was inject a measure of hot paraffin wax under the skin: as it hardened, he could mould and shape it to create the perfect profile. Paraffin wax had been injected into faces, breasts, buttocks and even the occasional penis. It really was a remarkable invention. It sounded almost too good to be true.
The surgeon wears thick, black rubber gloves as he prepares the paraffin. The solid white block of wax is gradually turning to a slushy liquid as he heats it on a small oil burner. The large glass syringe, with its formidable wide steel needle, is lying alongside in a basin of hot water. The surgeon has learnt from experience that unless the syringe is also hot (hotter by several degrees than the wax), the paraffin will solidify before it can be successfully injected. Reaching over, he checks the temperature of the paraffin with a thermometer. It is a careful balance: too cold and he can't inject it, too hot and it will burn the patient. The ideal temperature is around 30°C, but it is difficult to get it just right. He has heard of cases where the skin has simply sloughed away from the patient's face, presumably due to excessive heat. Still, there are risks with all types of surgery.
Gladys lies back on the couch. She has tied back her hair to expose her beautiful, smooth, (near) perfect face. The surgeon's assistant dabs the bridge of the young lady's nose with some dilute carbolic acid to clean her skin. The surgeon sits on a stool beside her, the pan of hot melted paraffin wax and warm syringe at the ready. She gasps as he makes a small nick in her nose with a scalpel. He places the tip of the needle in the hot wax and draws the asbestos piston (rubber would have melted) of the syringe upwards to fill it. Even with gloves on, the surgeon can feel the heat as he places his fingers through the loops at the top of the syringe and prepares for the injection.
Gladys is proud of how brave she is being. She has been warned that it will be painful, but pain is surely a small price to pay for perfection. As the surgeon sticks in the broad needle and depresses the plunger, Gladys feels as though molten metal is being injected into her head. The paraffin wax squirts out through the needle and beneath the skin of her nose. The surgeon keeps pressing until the syringe is almost empty, then he flings it aside and begins to mould Gladys's new face.
He has between fifteen and thirty seconds to get it right. The fingers of his bulbous gloves push, knead and press. He glances down at a picture Gladys has provided so that he can check his work. He runs his fingers along her nose, smoothing any bumps, moulding the paraffin like putty beneath her skin. The paraffin wax is hardening rapidly and time is running out. The surgeon presses as hard as he can to stop the wax clumping. A few seconds later and it has set; but he is finished. Gladys Deacon has a new nose.
The surgeon explains to Gladys there may be some swelling at first, but this will soon disappear. In just a few days, he tells her, she will have a classical nose to be proud of. He applies a compress of lint dipped in icy water to numb the pain and sends her home.
The swelling was indeed quite bad to start with. Only it didn't get any better. Instead it got worse, the bridge of her nose bursting into an angry open sore. Doctors were summoned to examine her, but when she was questioned Gladys denied having had any surgery. Instead she blamed her inflamed features on an accident, telling people she must have knocked it. But the nose got worse: the wax began to wander; lumps appeared beneath her skin. Her beauty was slowly being destroyed from within. Far from achieving the classic looks of a Greek statue, her quest for perfection was turning her into a freakish waxworks dummy.
It was little consolation to Gladys that she wasn't alone. Despite the ringing endorsement of many eminent surgeons, including England's Stephen Paget, who recommended the use of paraffin wax in the British Medical Journal,* others had begun to notice that these injections often led to unwanted side effects. In fact, the list of side effects was alarmingly extensive. The condition was even given a name: paraffinoma, although some doctors simply called it wax cancer.
* Stephen Paget was considered one of Britain's finest surgeons. In a gushing article in the September 1902 edition of the British Medical Journal, he described how paraffin wax was simple to use and produced excellent results. In his own practice, he said, the outcome was 'absolutely satisfactory'; he even gave the name of the company from which the paraffin wax could be purchased. To be fair, the wax did sometimes produce excellent results but, given that no one had carried out any proper trials, it is impossible to know what proportion of injections was successful and what proportion ended in disaster.
Symptoms ranged from the odd lump to wide abscesses where skin withered and died. Paraffinoma caused infection and destroyed muscle. If the paraffin got into the bloodstream it led to blood clots in the lungs and was held responsible for blindness, strokes and heart attacks. The price of perfection was quite possibly death.
In his 1911 book on plastic surgery, American surgeon Frederick Kolle highlighted the dangers of paraffin wax injections. He also warned doctors against the 'unreasonable' demands made by patients who were 'bent upon having the alabaster cheek ideal of the poets, the nose of a Venus, the chin of an Apollo'. He referred to these people as 'beauty cranks' – those seeking perhaps 'very desirable marriages'. Surprisingly, it seems he had never met Gladys Deacon.
By the 1920s the wax injection had really taken its toll on poor vain Gladys. She wore a hat low over her face to disguise the worst ravages of paraffinoma, but female rivals recorded bitchily how the wax had given her face the appearance of a gorgon. Others remarked that she looked heavy jawed, her hair too yellow, her lips too red. She no longer looked like a lady (the implication being that she looked more like a whore). A princess who had once been jealous of Gladys noted with ill-disguised satisfaction how the wax had run down her face to create blotchy patches in her neck.
However, while society mocked her for her medical mistake (behind her back, of course), Gladys continued her climb up the steps of the social ladder. In 1921 she finally made it into the British aristocracy by marrying the 9th Duke of Marlborough and taking up residence at Blenheim Palace in Oxfordshire. But despite being a duchess, she was becoming more and more depressed.
By the 1940s, her marriage having failed, she was to be found living in a ramshackle farmhouse. She slept on a broken mattress surrounded by the squalor of cats, rotting food, papers and books. Gladys was becoming increasingly frail, isolated and paranoid, and it wasn't long before four men in white coats came to literally drag her away.
Gladys Deacon died in her sleep in a Northampton psychiatric hospital in 1977. The funeral was poorly attended. Most people had forgotten Gladys Deacon, Duchess of Marlborough. People said that in her later years she would sit by the fire, letting the heat of the flames soften the paraffin beneath her skin so that she could move it around her face. Gladys never did get the perfect nose.
THE FACES OF WAR
Queen's Hospital, Sidcup, Kent, 1917
* * *
It was difficult to look at Lieutenant William Spreckley without experiencing a feeling of utter revulsion. Even the man himself sometimes wished he had been killed when the bullet hit him. His existence, he felt, was almost a living death. He had been passed from the trenches at Ypres to casualty station to hospital before finally ending up in Sidcup, but he didn't hold out much hope for his chances. He would be disfigured for the rest of his life, shunned by society – perhaps even by his own family.
William had a sad, haunted look in his eyes. Although lucky to be alive, he was feeling sorry for himself. Bullets sliced through whatever material they met – whether it was wood, metal or human flesh. Most of his comrades had been cut down: some were killed instantly, others wounded fatally, the rest permanently disabled. William could remember a bright flash of light but, strangely, experienced little pain. He was stretchered away to the crowded tents of the field hospital, where he expected to be left to die. Instead, over the next few weeks he started to recover. He knew his face was damaged, but the nurses and doctors refused him a mirror. The surgeons stitched him up and nurses changed his dressings. By the time William arrived at Sidcup his wounds had healed well. He was fit and healthy. Everything was fine, except for his face.
Instead of a nose he had an ugly, gaping hole. The skin had grown inwards, and what remained of the interior – red tissue and bone – could be seen through the black hollow. The left side of his face was distorted around the hole; a series of lateral scars had healed to draw down the skin beneath his eye, revealing the lower part of his eyeball. But this was nothing compared to the missing nose.
Queen's in Sidcup was the first hospital in the world dedicated to plastic surgery, and the surroundings couldn't be more different from what William had experienced in the trenches. Built in the grounds of a stately home, the hospital was encircled by gardens and tall trees, and even boasted a beautifully manicured croquet lawn. The single-storey wards, treatment rooms and operating theatres were arranged in a horseshoe shape around a central admissions block. Each ward was designed to hold twenty-six beds and included a veranda so that patients could lie outside in the fresh air to help their convalescence (fresh air was considered vital for recovery).
Queen's was the brainchild of surgeon Harold Gillies. He had entered the war as a junior Red Cross doctor in 1914, and had been horrified by the injuries he saw. But Gillies was even more shocked to discover how little British surgeons were able to do to piece soldiers back together. Their techniques were primitive and wholly inadequate. No one had anticipated the terrible carnage – the faces that were blown apart, the missing noses or jaws, the melted flesh and jagged scars. All the surgeons could do was draw the edges of the wounds together, wait for the scars to heal and post their patients back to the trenches to fight another day.
Gillies decided to dedicate his life to plastic surgery, and taught himself everything there was to know about facial reconstruction. Over the next three years (while continuing to work in hospitals in France and England) he studied obsessively, wading through textbooks and research papers. He even enrolled in an art school so that he could learn how to draw detailed diagrams of his surgery. Eventually, he managed to convince the army medical authorities that they needed a dedicated hospital to treat facial deformities. W
hen Queen's Hospital opened in the summer of 1917, Gillies – now Britain's foremost plastic surgeon – was appointed to run it. He was ready to put his vast knowledge of plastic surgery to the test.
William Spreckley was one of the first patients to be admitted to the new hospital. When Gillies examined the young soldier he decided he could do better than simply give Spreckley a new nose. He wanted to improve on the crude efforts of previous generations of surgeons and give Spreckley a nose that really looked like a nose, not some crude flap of skin twisted down from the forehead or grown from the upper arm. He made careful measurements of Spreckley's face and set about planning a series of intricate operations.
Because Spreckley's nose was missing completely, Gillies planned to re-create both the skin and the cartilage supporting it. Rather than repeat the disastrous experiments of his Victorian predecessors and use animal cartilage or synthetic alternatives, Gillies chose to take the cartilage from elsewhere on his patient's body. After drawing up a complicated set of diagrams and technical notes – he believed in the importance of preparation – he was ready to operate.
In the whitewashed, airy operating theatre, with its powerful electric lighting and enormous picture windows, Lieutenant Spreckley is put to sleep.* Gillies, dressed in his sterilized surgical gown, his hands washed in alcohol and covered with fresh rubber gloves, is ready to make his first incision. He cuts into William's chest. The first part of the operation is ingenious and involves removing a small, rectangular piece of cartilage from the soldier's ribcage. Gillies intends to shape this into the support for the nose.
Blood and Guts Page 19