Blood and Guts

by Richard Hollingham

  Kostakis was a visiting research fellow from Greece, but his mother was worried. She was particularly worried about English food, and with good reason. In 1976 English cuisine was, as a rule, lurid, processed and bland. Even the blandest of English foods, the potato, now came in freeze-dried granules; green vegetables were boiled to slime; and Angel Delight – a mousse-like substance with an indeterminate flavour – was considered a sophisticated dessert. Orange juice (in bottles) was a once-a-week treat and bread (white, sliced) had all the nutrients baked out of it as a matter of course. No wonder Mrs Kostakis was worried.

  She sent her son a bottle of finest Greek extra virgin olive oil. But before Alkis could drip it on to his salad (iceberg lettuce was probably the best he could hope for), he took the oil into the lab. More in hope than expectation, he decided to try mixing it with the cyclosporine. He had nothing to lose, so he carefully measured out the oil and ladled it over the precious fungus powder. The drug dissolved. He tried out his combination of olive oil and cyclosporine on a series of animal patients. The results were spectacular. They were so spectacular that Calne didn't believe him, so he sent Kostakis back to repeat them. But he got the same results again – cyclosporine mixed with olive oil worked wonders. Soon Calne could start trials in human patients; he would transform the world of transplant surgery. All he had to do was lay his hands on more cyclosporine.

  But Sandoz, the company that had discovered cyclosporine, was not convinced. The way things had been going with transplant surgery in recent years, they saw no future in cyclosporine. As far as they were concerned, it would only lose them money. Calne flew out to see them. He talked to their financial people, he argued, he cajoled, he badgered. He told them this was the best thing he had seen in all his years of transplantation. Finally, Sandoz gave in and agreed to conduct a limited drugs trial. They were still reluctant. It would, they warned, almost certainly lose them money.

  Surgeons began testing the drug on transplant patients in 1978. With the introduction of cyclosporine, survival rates rocketed. One year after their liver transplant operations some 70 per cent of patients were alive, and almost 80 per cent after kidney transplants. Cyclosporine wasn't without its own side effects, and the risk of infection was still a major problem, but it looked like the immune system had finally been overcome.

  In 1990 Joseph Murray was awarded a Nobel prize for his work on organ and cell transplantation (he shared the award with E. Donnall Thomas, who had developed drugs to minimize rejection). Roy Calne was knighted for his transplant research in 1986 and is one of the few surgeons to be elected a fellow of the Royal Society.

  In the bloodstained history of surgery, transplants stand out as an area where even the best surgeons have been defeated time and time again. From Spence's disastrous tooth transplants to Carrel's sinister laboratories, experiments with decapitated French criminals and total body irradiation, transplantation surgery is littered with illconceived ideas, gruesome experiments and procedures bordering on the unethical. It took until the mid-1980s for transplant surgery to become a safe, routine surgical treatment. After more than two hundred years the battle with the body's own defences had been won. Now anything was possible. Hearts, livers, lungs, kidneys; surgeons could even transplant a dead man's hand.

  CHAPTER 4

  FIXING

  FACES

  THE ITALIAN NOSE JOB

  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 constan
t 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.

  PROFESSOR TAGLIACOZZI INVENTS A CURIOUS OUTFIT

  * * *

  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. Tagliaco
zzi 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.

  Unfortunately, after Tagliacozzi died in 1599 his reputation collapsed. The Italian Church had been growing suspicious of his activities. Now that he was in no position to defend himself, the Church summoned its investigation team: the tribunal of the Inquisition.

  Tagliacozzi was accused of magical practices. He had modified the human face and in doing so had been interfering with the will of God. In the end the Church allowed his soul to rest in peace, although stories persist that Tagliacozzi's body was removed from its tomb and his bones dumped on unconsecrated ground.

  At the time Tagliacozzi's method was a major advance on anything that had gone before, although his techniques built on more than two thousand years of surgical practice. The first recorded case of plastic surgery took place in India around 1500 BC. The Hindu epic poem Ramayana tells the story of Surpanakha, a beautiful temptress (some say a demon with magical powers). With her bewitching personality, Surpanakha attempts to seduce a young prince who is promised to another. She is sentenced to a brutal punishment for her actions and her nose is cut off. However, this is far from the end of the story. Rather than live with the disfigurement, she goes for reconstructive surgery.