Neha Chauhan
Karnataka, India

“A skilful dissembler may disguise in a degree, the expression of mouth, the hat may be slouched over the eyes and the chin may be hidden in the impenetrable thicket of beard but the nose will stand out and make its sign inspite of all precautions. It utterly refuses to be ignored and we are, as it were, compelled to give it our attention”
— Samuel R. Wells, 1866

Circa 1792, India: The third Anglo-Mysore war was in progress between the East India Company (established in India in 1612) and Tipoo, the Sultan of Mysore.¹ Cowasjee, a Parsi bullock-cart driver commanded by Lieutenant Colonel Ward, and four other British soldiers were taken prisoner by Tipoo at Seringapatam (modern day Srirangapatna, Mandya, Karnataka). Their noses and hands were cut off and the men were sent back to the British army, along with their amputated noses, as a mark of humiliation. Nose amputation was a common punishment for adultery, witchcraft, theft, and for prisoners of war at that time in India, Arabia, Persia, Egypt, Greece, and Rome. These soldiers remained without a nose for nearly a year until Sir Charles Warre Malet, a British minister in the Peshwa court at Poona, came across an oilcloth merchant who had a scar on his nose.² The merchant explained that his nose had been amputated as a punishment for adultery and later reconstructed by a potter from Poona who used his forehead skin. The oilcloth merchant would have never imagined that this revelation would lead to a series of events that popularized the “Indian method” as the gold standard of nose reconstruction all over the world.

Sir Charles summoned the potter recommended by the oil-cloth merchant to reconstruct the noses of Cowasjee and the other four soldiers. This art of nasikasadhana (Sanskrit for “nose reconstruction”), had been practiced in complete secrecy and transmitted from one generation to another within one single family. Cowasjee’s nose reconstruction, however, was witnessed by two British physicians of the Bombay Presidency, Mr. Tho Cruso and Mr. James Findlay. Excerpts from the original procedure outlining the crucial steps were described as follows:

“A thin plate of wax was fitted to the stump of nose to make a nose of good appearance and then flattened and laid on the forehead. A line was drawn around the wax and the operator then dissected off as much skin as it had covered, leaving undivided a small slip between the eyes which preserved blood circulation till union took place between the new and old parts. Cicatrix of the stump of nose was pared off and an incision was made through the skin passing around both alae, along the upper lip. The forehead skin was brought down, twisted half around and inserted into this incision to form the new nose. The initial dressing was made of terra Japonica softened with water and spread on slips of cloth, five or six of which were placed over each other to secure the joining. Four days later it was replaced by cloths dipped in ghee. The connecting slip of skin was divided on the twentieth day and a little dissection necessary to improve the appearance of the new nose was done. The patient was made to lie on his back for 5-6 days after the operation. On tenth day, bits of soft cloth were put into the nostrils to keep them sufficiently open. The operation was always successful and the new nose looked nearly as well as the natural. Also the scar on the forehead was not very observable after sometime.”

Ten months later, in January 1794, Cowasjee’s portrait depicting the successful surgery was painted by the British painter James Wales. In March 1794 the copper portrait appeared in Bombay. On 4 August 1794, the news was published in the Madras Gazette³ and in October 1794 as a letter to the editor of The Gentleman’s Magazine, Sylvanus Urban, by a certain “B.L.” who described “a very curious chirurgical procedure” of “affixing a new nose on a man’s face” that was unknown to the Europeans but had been practiced in India for generations. The surgical procedure was published as “A Singular Operation” in January 1795 (Figure 1) and Cowasjee’s portrait was published along with the article. In response to B.L.’s letter, a certain “T.J.” wrote in the next issue of The Gentleman’s Magazine that B.L. was mistaken in thinking that similar reconstructions were not performed in Europe. T.J. then described a nose reconstruction done on a woman two years after being cut off by soldiers following a failed attempt to outrage her modesty during the war of 1590. John Griffonius, a famous surgeon of those times, reconstructed her nose at Lausanne by the Tagliacotian, or the “Italian Method.” T.J. acknowledged that though the patient’s nose looked “livid” during winters, it had an overall good appearance gauged by the fact that she “continued to be married.” In April 1795, The Courier published an article titled “Account of the method of supplying artificial noses as practised by the natives of the Malabar coast” which claimed supremacy of the Indian method. J.C. Carpue, a British surgeon, after a detailed discussion with Lieutenant Colonel Ward (Cowasjee’s commanding officer), successfully used this method on two patients in 1814 and published his paper in 1816, after which the procedure became widely popular in Europe as the “Indian Method.”⁴ Though the procedure has undergone many modifications since then, it has stood the test of time and remains the best method of nose reconstruction even today.

The publication of the forehead flap nasal reconstruction in The Gentleman’s Magazine and later by Carpue laid the foundations for modern plastic surgery. The “Indian Method” became popular all over the world, kindled the interest of the Western world, and brought recognition to India as the birthplace of plastic surgery.⁵ The first principles of plastic surgery were enunciated by Sushruta in 600 BC in his treatise Sushruta Samhita and translated to Arabic by Ibn Abi Usaibia in the eleventh century, travelling far into Arabia, Persia, and Egypt; but the Western world became aware of it only much later.¹

It is interesting to note that the “Italian method” of nose reconstruction using the medial arm tube flap, as described by the Branca brothers and popularized by Gasper Tagliacozzi in the fifteenth century, is less than satisfactory with regards to color and texture match. Moreover, the reconstructed nose has a tendency to droop over time. It also fell into disfavor because of the required prolonged immobilization in an uncomfortable position. Yet even today it enjoys popularity in medical circles, as shown by the use of Tagliacozzi’s image in the official symbol of the American Board of Plastic Surgery and the use of Tagliacozzi’s patient as a symbol of the American Association of Plastic Surgeons. Moreover, even though the more ancient Sushruta’s technique of using cheek flaps enjoys wide popularity, the originator of the “gold standard” forehead flap technique remains anonymous. These observations emphasize the significance of publications in the scientific community.

Also disconcerting is the question of why Cowasjee was immortalized in British publications, paintings, and engravings while the surgeon whose skills gave Cowasjee a near normal nose remains unrecognized. The answer would seem to be that by popularizing the reconstruction of a British soldier the British attempted to prove to the world that they took good care of their soldiers. Had they chosen to feature the surgeon instead, they would have popularized the scientific skills existing in India in those times, which would not have been consistent with their policies. This case is significant in being one of the rare cases in the history of medicine where the patient is more popular than the surgeon. Yet clearly the event that led to the loss of Cowasjee and other soldiers’ honor, led to the rightful recognition of India as the place of origin of plastic surgery, and reinstated its honor.

References

1. Saraf S. “Rhinoplasty in 600 BC”. The Internet Journal of Plastic Surgery 3, no 2(2006). http://ispub.com/IJPS/3/2/7839.
2. Mukherjee N S, Majudar S B. “A nose lost and honour regained: The Indian method of Rhinoplasty revisited.” Proceedings of the Indian History Congress 72, 1(2011), 968-977. https://www.jstor.org/stable/44146788.
3. Pennant T. View of Hindoostan. London: Henry Hughes, 1798; Vol 2(237).
4. Carpue J C. “An account of two successful operations for restoring a lost nose from the integuments of the forehead in the 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: Longman, 1816; 49-51.
5. Ackernecht E H. A short history of medicine. Baltimore:Johns Hopkins University Press,1982;41.