By Paolo Savoia
Gaspare Tagliacozzi and Renaissance Rhinoplasty: Restoration, Enhancement, and the Limits of Nature
One of the few human features which is almost always visible is the face. We rely on it for emotional expression, view it as a site of beauty, and use it for communication. When we think about the history of medical operations that enhance the human form, one of the first places we might look is rhinoplasty. It’s well known that Gaspare Tagliacozzi, surgeon in Bologna during the late 16th century, wrote the first book on techniques that could restore mutilated noses, ears, and lips. And so he came to be known as the father of plastic surgery. Tagliacozzi ‘s methods still makes sense to us today, hence the epithet, but his book is concerned with a whole set of wider issues about the dignity and beauty of the human face, the management of pain, the construction of a certain ideal of masculinity, and the limits of nature. In other words, rhinoplasty as conceived and executed by Tagliacozzi in the 1500s was a historically specific practice which was very different to the operations which create the nose jobs of today. Counterintuitive as it sounds, Tagliacozzi’s operation did not claim to be about enhancement, but rather about restoring the natural human form which chance had disfigured. Let me explain.
Tagliacozzi was born in 1545 to a middle class family of silk workers. He greatly improved his social standing when he became a professor of surgery at the prestigious university of Bologna, as well as a powerful member of the College of medicine and philosophy. He benefited from the fact that surgery and anatomy had become established branches of medical education in Italy. Also a Bolognese citizen could enjoy the rewards of social mobility if he happened to choose the right career path and make wise political connections. Gaspare was aware of this, and he managed to enter the patronage orbits of both the Medici of Florence and the Gonzaga of Mantua. He grew to be admired for reconstructive surgery of noses, lips, and ears. With his fame also came popular skepticism, suspicion and criticism. [i]
Tagliacozzi’s two-volume masterpiece, De curtorum chirurgia per insitionem, was published in 1597. It not only described strategies for restoring mutilated faces, but also described tenets of physiognomy by which one could read the signs of the soul in the shapes and contours of the human face. Tagliacozzi’s primary technique was a grafting procedure, which he claimed was similar to methods found in agriculture. He describes how the operation begins by preparing a flap of skin from the upper region of the arm (the humerus), then making it adhere to the defective nose (one without a tip or nostrils, but not of course an entirely severed nose). This involved keeping the two distant body parts bound together for three weeks or so, severing the flap from the arm, shaping the new parts of the nose and finally ensuring that the outcome would last. Tagliacozzi also devised a set of surgical tools uniquely for this process. These range from modified knives and forceps to a special vest with a hood and bandages, which he called a “machine” to keep the arm afixed to the face. [ii]
Despite this being the first time such a description was put into print, it was not an entirely new operation. Reconstructive facial surgery has a long history which is still largely unwritten. Tagliacozzi’s surgical techniques have forebears in the ancient Indian text of Sushruta and in the writings of the Roman physician Celsus, an integral component of 9th century Arabic surgery and medieval Latin surgical literature. By the 15th century, two Southern Italian families, the Branca of Catania, Sicily, and the Vianeo of Tropea from the region of Calabria, made the significant innovation of taking a skin flap from the arm and grafting it to the face. The Southern Italian method which became popular was described as a wonder and a curiosity in travelers’ notebooks and journals of the time, finding its way to Bologna where it was finally deemed worthy to be taught by a university professor.
Given the lowly origins of the procedure, Tagliacozzi faced two problems. First, the operation came from an empiric tradition of barber-surgeons, not from the Hippocratic-Galenic tradition which was the central medical philosophy taught in medieval universities. Secondly, many contemporary surgeons and physicians (the illustrious Ambroise Paré and Vesalius among them) were critical from the outset and even denied that such a procedure was possible at all. Tagliacozzi addressed the first problem by minimizing the importance of the Branca and the Vianeo precedents in his book. He tackled the second problem by criticizing his contemporaries for having misunderstood the technique as something dangerous and new. Both Vesalius and Paré, he claimed, were mistaken in thinking that a hole in the flesh of the upper arm must be made, because actually only a superficial portion of the skin had to be used for grafting. [iii] Tagliacozzi ‘s book is littered with references to “malevolent people” who dared to criticize the operation without even having tried it. In spite of the naysayers, he insisted that reconstructive surgery had every right to be included in the realm of medicine.
Contrary to the popular image of the insensitive and careless surgeon of pre-modern times, Tagliacozzi did take seriously the repeated accusations that such operations were too painful for patients to bear. In a series of long chapters, he claims that the patient’s experience was not excruciating. He also emphasizes that the higher goal of the whole procedure, namely the restoration of the face, justifies any discomfort one had to suffer. [iv] Indeed, the human face is praised by Tagliacozzi from all perspectives: as the seat of our dignity, of our beauty, of our singularity (there can be no two identical faces) and of crucial physiological activity (for example, alimentation and respiration). As this was also the golden age of portraiture, the human visage held great importance in Renaissance philosophy of man, which prompted many anatomists and surgeons of the 16th century to express meticulous concern when dissecting the face. Even the most agonizing and horrible torture – which Tagliacozzi was quick to point out his procedure was not – could be tolerated if the integrity of the face was the reward. [v]
But despite Tagliacozzi’s protests, the division between enhancement and restoration remained blurred . Tagliacozzi’s ambition was to incorporate his technique into the realm of serious academic medicine by framing it as a curative operation. But at the same time, the aesthetic qualities of the human face were a powerful rationale on which to prove the worthiness of this branch of experimental surgery. Tagliacozzi describes every painful surgical operation performed or mentioned in the ancient and contemporary medical literature, claiming that the pain felt by the patient in reconstructive surgery was nothing by comparison. He then proceeds to sketch an ideal image of the brave patient who manly tolerates pain, steeled by the higher outcome in sight.
Tagliacozzi ‘s rhetoric of enduring discomfort in a manly way is an important, and to contemporary audiences surprising, feature of reconstructive surgery’s history:
“if by some change a patient were to faint, I would attribute it not to the violence of the procedure but rather to the patient’s abject soul. This type of effeminate and weak man is terrified at the prospect of suffering pain, and the only virile thing about him is the appearance. The cowardly man should not participate in this procedure”. [vi]
The world that emerges from Tagliacozzi’s book is distinctly male, characterized by certain key qualities including strength, virility, and intellect . Masculinity is simultaneously the outcome of becoming a good surgeon and of being a good surgical patient. The (very few) patients mentioned by name in Tagliacozzi’s work are high-class male victims of duels or military leaders who had sought surgery after contracting war wounds. The ideal surgeon and his assistants are similarly described as smart, brave and resolute men, [vii] further shoring up hegemonic forms of masculinity. Contrary to the modern image of rhinoplasty, not a single woman makes an appearance in De chirurgia. Once again, the Bolognese surgeon wanted to make clear that his operation was absolutely distinct from cosmetic enhancement. Frivolity and vanity were the province of female concerns. [viii]
Tagliacozzi’s distinction between cosmetic surgery (which had a medieval and early modern tradition) and reconstructive surgery is his work’s central medico-philosophical concern. This distinction is based around the opposition between the natural and the artificial:
“Human beauty, moreover, is of two kinds; one is true and inborn, harmonized with the ideal nature and proportions of the body because, according to Hippocrates, we can judge it by bodily actions. This kind of beauty does not declare itself in whiteness of complexion, effeminacy, smoothness of skin, or any other such niceties. The second kind of beauty is neither inborn nor natural but is counterfeit, impure, and artificial; it is of use to slave dealers who whish to make a profit and to silly women (muliericulis) who are overly concerned about their appearances.” [ix]
Nature teaches us how to imitate its beautiful forms and to restore the human face that mishap and violence might have disfigured. This is a matter of returning to a state of nature – the stated goal of every medical treatment and therapy – not a matter of enhancing beauty. However, beauty often creeps into the pages of Tagliacozzi’s book, and not just as the fortunate by-product of restoring natural forms. Tagliacozzi is openly proud of calling himself an artifex, or artisan. Despite his intention to keep the two separate, there remains an intimate connection between healing and enhancing. Even if a surgeon is supposed to be merely assisting nature, he cannot help but manipulate its forms as an artist. Indeed, Tagliacozzi can be heard at one point boasting that “our art seems here almost to overtake nature”.
His comparison between surgery and agriculture is also telling. The surgeon’s task has similarities to the practice of grafting different plant species, but requires even greater intricacy. When the branch of a fig tree is grafted to an olive tree, the horticultural fusion is over, Taglicozzi claims. But once a skin flap taken from the arm is attached to a mutilated part of the face, the artist-surgeon needs to carry out yet another step: modeling and representing the human form according to a certain ideal of the natural face.
There are two conceptions of nature at work in Tagliacozzi’s book: Nature is both an insuperable artist who makes beautiful forms (we might call this a metaphysical or religious conception), and also the agent behind a set of natural processes which makes possible the reconstructive procedure (we might call this a naturalistic conception). It is this second purpose where Tagliacozzi believes the surgeon overtakes nature in perfection. Surgeons are handmaidens to nature when healing the body, he argues, but sometimes the body needs the surgeon’s extra artistic assistance . This effort of expertise is only possible from an ideal male; an individual who is a brave, learned, and skilled to the extent that he can supersede pain and the limits of nature.
Ultimately, Tagliacozzi’s writings remain ambivalent about clarifying a distinction between the restoration or enhancement of nature. One can never be sure when the natural ends and the artificial begins. However, a wider view of Tagliacozzi in his historical context suggests that his ambivalence might well have been deliberate. In the light of the structure of Renaissance medical and cultural institutions, only ‘restoration’ could have given this new technique its respected credentials to become a serious medical practice. But the implicit promise of overtaking, improving, and enhancing nature ensured Tagliacozzi his enduring fame.
[i] Martha Teach-Gnudi and Jerome Pierce Webster, The Life and Times of Gaspare Tagliacozzi, Surgeon of Bologna (1545-1599). New York: Herbert Reichner 1950.
[ii] Gaspare Tagliacozzi, De curtorum chirurgia per insitionem libri duo, Venice 1597, Book 2, p. 46.
[iii] Andreas Vesalius, Chirurgia magna, Venice 1568, pp. 166-67 (now attributed to the editor); Ambroise Paré, Traité des playes de la tete (1561), in Oeuvres, Paris 1585, book 9, chapters 7-8.
[iv] Gaspare Tagliacozzi, De curtorum, Book 1, chapters 20-22.
[v] Gaspare Tagliacozzi, De curtorum, Book 1, chapters 1-4.
[vi] Gaspare Tagliacozzi, De curtorum, Book 1, p. 84.
[vii] Sandra Cavallo, Artisans of the Body in Early Modern Italy: Identities, Families, and Masculinities. Manchester: Manchester University Press 2009.
[viii] Robert McVaugh, The Rational Surgery of the Middle Ages. Florence: Edizioni del Galluzzo 2006; Monica Green, Making Women’s Medicine Masculine: The Rise of Male Authority in Pre-Modern Gynaecology, Oxford: Oxford University Press 2008.
[ix] Tagliacozzi, De curtorum, Book 1, pp. 10-11.