WSHOMS Dec 5th 2015

Lecture 1: East to West and Back – Nasal Tales
Lecture 2: Toulouse Lautrec and his Muse, Jane Avril

[This post was written last year, but I have only just got round to uploading it. Hence the incongruous date in the title!]

Today’s lectures were a perfect finale to a wonderful season of lectures. The subject matter of these two could not have been more different: The history of nose replacement and Toulouse Lautrec and his muse, and yet I have found the perfect seguet linking the two.

Read on….

cosmetic-surgery-in-ancient-india

LECTURE 1: East to West and Back – Nasal Tales

First, the nose replacement story, titled: East to West and Back – Nasal Tales. This lecture, the Brian Owen Smith Memorial Lecture, was given by K M N Kunzru, MS FRCS DHMSA, Emeritus Consultant Orthopaedic Surgeon and Medical Historian. It was riveting.

One person who was not mentioned in this astonishing tale is one of my heroes, the great, flamboyant astronomer Tycho Brahe, which is amazing because not only did he have a metal nose, due to the loss of his own in a dual, but also, he had a ‘pet’ dwarf, which relates to our second lecture! But more of that later….

Tycho Brahe’s metal nose may have seemed like a great medical feat in his day, but plastic surgeons in ancient India were far more successful at reconstructive and cosmetic surgery.

Ravi Kunzru, our speaker, has not only been President of the Hunterian Society, as was Brian Owen Smith, and was proudly wearing the Society’s tie.  Having researched the work of Sushruta Samhita, the man credited as the author of the ancient medical text and given the epithet ‘the founding father of medicine’. This book, consisting of 184 chapters, and covering 1,120 different medical conditions, and the uses of over 700 medicinal herbs, is thought to date from the 6th Century BC. It is considered the basis of the Ayurvedic medical tradition. One of the most extraordinary aspects of Sushruta’s masterpiece is the description of surgery to restore amputated noses. Clearly, this operation was performed frequently enough for Sushruta to go into how not to do it as much as how to achieve a successful result.

I have not ever known anyone, nor thought about it too much, this particular injury was, it was apparently not uncommon in India. Dacoits (bandits) used this nasty punishment to intimidate and manipulate people, and so surgeons had to rise to the matter, and, clearly cracked it. Todays surgeons use the same method, re skin grafting, that were adeptly performed back in the first millennia BC thanks to those intelligent and observant surgeons who, even without modern scalpels, antibiotics, or anaesthesia, knew what they were doing.

In order to identify the exact nature of Sushruta’s surgical technique Dr Kunzru had to take lessons in the finer nuances of the ancient language of Sanskrit, and just as well he did. Here, for your delectation, is the verse as translated by our speaker and very slightly simplified by me, in order to eliminate some of the bracketed words that were in the copy we were handed. You will enjoy this instruction as to how to fix a severed nose:

Now I will speak of the severed nose and the exact method of joining it.

Hold a tree leaf and let it hang down (on the cut nose) to make a pattern of it (the nose).

By that ‘measure’ (pattern) elevate a flap from the side of the cheek/face and attach it to the front of the nose, after scraping it (the nose). It is quickly joined (sutured) and bound (dressed) by the (careful) doctor.

When well fixed and aligned exactly, and having ascertained this, by means of two tubes (in the nostrils) having raised the nose, fix it well then sprinkle powder of Patamga, Madhuyasti, and Rasanjana. (Sappan wood, Sandalwood, Liquorice root and Barberry)

Having suitably covered with cotton cloth soaked in sesame oil irrigate with sesame oil frequently. The patient is given ghee, well digested, orally and, after sufficient oil enemas he is evacuated by purgatives and emetics to remove excess dosas.

When the wound has come together and healed the remaining part is cut from the side away from the nose. If short the nostril is stretched, if the flesh is excessive it should be trimmed.

So, now you know what to do! In addition to the herbs this writer uses I would want to add powdered marigold flowers, as these are well known to stimulates the granulation tissue an essential stage in the healing of any wound. Here is a paper on this very subject published in April this year:

and another from a couple of years ago:

Between all of these time honoured herbal agents, these herbs would act as anti-microbials, anti-inflammatories, and wound healers, and the sesame oil which would keep the skin supple, the results could even have been better looking than poor old Tyco Brahe I imagine. Sure, scars might be visible, but with this method, cheek skin rather than forehead skin is used, so the ‘careful’ doctor would certainly be appreciated, as any scars would not be possible to cover with a strategically placed turban.

Whether the writings of this ancient surgeon were known by Harold Gillies, the New Zealander who made his home in England and who is seen by many as the father of plastic surgery for his pioneering work with soldiers with gun shot and shrapnel wounds and burns, is unknown, but they clearly were soul brothers. WSHOMS had a speaker on Harold Gillies a few seasons ago, before I was writing the blog of the meetings, but here, for the sake of it, is a photo of that great man, and below one of the original great physician Sushruta:

Harold Gillies – the father of plastic surgery

The original great Indian physician Sushruta


LECTURE 2: Toulouse Lautrec and his Muse, Jane Avril

The final lecture of the 2015 season of wonderful WSHOMS was by Dr Winston Leigh BA MB ChB MRCGP. He has delighted audiences at least nine times with many different subjects, including the ever enticing possible diagnoses of famous artistes of the past. I have written about some on this blog before (Beethoven, van Gough, Monet, so do take a look at those write-ups) and this one was as good as ever. The subject: Toulouse Lautrec and his Muse, Jane Avril.

We re-entered the lecture hall to the strains of jazz (not sure who or what the piece was, but definitely jazz) and this had been chosen to represent the jerky, unpredictable nature of Henri Toulouse Lautrec’s movement disorder, chorea, and that of the dance style of Jane Avril, who was one of his muses and who also had a neurological medical history, which apparently affected her dance style as an adult.

But first to Henri Toulouse Lautrec. Born in 1864, this highly gifted man had not only a short life, but was of decidedly short stature too. However, it turned out to be an extraordinary and incredibly productive life, as so often seems to be the case with the truly artistically creative. I was unaware of Lautrec’s prodigious output until this presentation. Though many more are lost or in unknown places there are known to be over 5,000 drawings, over 700 canvased paintings, getting on for 400 posters and nearly 300 watercolour paintings. For a man who died at the age of 36 it seems that he could have done little else but sketch, paint and accept commissions for poster designs!

As well as observing and sketching constantly, from an early age, he was sent for formal art lessons when he was 17, at the studio of Rene Princeteau, and he went on, famously, to spend most of the rest of his life amongst the night life, café culture, bars, brothels and music halls of Paris, in the company of prostitutes, their customers and other night dwelling folk, as well as other artists of the day such as Vincent Van Gough, who hung out in this milleu, and his brother Theo, the art dealer. Indeed Henri painted Vincent in the style, to my eye, of Vincent, and likewise he painted dancers à la Degas, who had a great influence upon him. And throughout, he sketched, without flattery and without malice, or so it seems to me. His work adds a great deal to the historiography of Paris around the Naughty Nineties

Henri’s parents Alphonse and Adele were first cousins, as their respective mothers were sisters, probably leading to the deformity of their first son, Henri, and the death of their second son, Richard, born with even more obvious deformities and dying at just a few months old. I am not sure if the marriage of Adele’s brother and Alphonse’s sister, who were clearly also first cousins, occurred before Richard and Henri were born but this familial habit of inbreeding resulted in four of this other union’s fourteen children having severe physical malformations too, leading to premature deaths, and one girl living in a bassinette, with severe skeletal abnormalities. Down at heal aristocrats such as this family have often married within the fold in order to keep what little money and property they still possess, in the family, but you would think that the dangers of such consanguinity would have been known about by then. There have been various named diagnoses of Lautrec’s condition, but most are descriptive, rather than explanatory. The term coined by doctors in 1962 is ‘pycnoodysostosis, which simply means small (‘pycno’), disordered bone (dysost) condition (osis) which anyone could tell by looking at all 4’ 8” of him!

Poor Henri clearly wasn’t growing normally from his earliest years with a large head, small chin, severe dental misalignment short arms. In his teen he suffered fractures to both femurs which failed to heal properly and may be the main reason for his short stature, but he also had a malformed head, bottom jaw, teeth and had short arms (which is just as well if you have short legs!) and clearly was not going to be a hit with the ladies.

But hold on, I hear you say. Wasn’t he a big hit with some ladies? Ladies of the night? Well, yes, he was. I reckon the prostitutes of Montmartre took him into their intimacy, probably from pity, and he no doubt pitied them back, and he stated , in 1888, “I am pitching my tent in a brothel, it is like living in an hotel, albeit with more mirrors, there is nowhere I feel more at home”, so it seems that he was satisfied with this arrangement, and he was certainly nearer to his subjects. One can clearly see, in the many pictorial representations of the world they inhabited, be it the dancing or the bar haunting, absinth sipping, brothel dwelling, that there is no joy in the faces he observed, no happiness, no hope, no delight, no peace. Mostly one sees resignation, depression, degradation, and making the best of a bad job. I believe that the inhabitants of this strata of Paris were glad to have their tale told to the world, and told honestly. Look at the faces of these women, as well as the remarkable ‘reality’ of the painting:

Jane Avril/Jeanne Beaudon, was one of these unfortunates. Daughter of one of the pithily named ‘grandes horizontales’ courtesans, she was sent to live with her mother’s parents when young, but when they died in very quick succession when she was just three years old so she was sent to a convent where she stayed until the age of nine when mama found her and took her back, and made a slave of her. Misery descended on the child, and she ran away when she was 13 and was taken in by the generous Barbariche family. While here she developed involuntary muscles spasms of her arms, legs and face which is thought to have been a sequel of rheumatic fever at some earlier age, known as Sydenham’s chorea. Fortunately, Monsieur Barbariche had a friend who was a physician at the Salpetriere Hospital and Jeanne was admitted there in 1882, aged 14, where she was a patient of the great Professor Charcot, no less, in the ward for the Grandes Hysteriques!

The treatment she received from Charcot is not known, but her nasty mother would visit her and sneakily bully and beat her, which increased the poor girl’s symptoms. We now know that raised cortisol and adrenaline as well as the whole array of physiological effects of Adverse Childhood Experiences (ACEs)), have a plethora of consequences, such as reduction of the amount of grey matter in the brain, the thalamus and the insula. There is a great deal of research going on right now on the impact of such ACEs and much is still to be determined about the finer details, but here is a paper on the subject which will be fully published in January 2016, to whet your appetite to read more:

The food on offer at hospitals in France in the late 1800s would have been pretty mediocre I imagine so it is not surprising to me that the young Jeanne Beaudon developed an array of neurological dysfunctions due to a combination of stress and malnourishment. We now know that continuous supply of omega 3 fatty acids, iodine, vitamin B12 and of course protein and dietary fats are essential for normal nerve development and ongoing function, and we also know that many people have a reaction to gluten which effects their brain rather than their intestines, as the current superb consultant neurologist at Royal Hallamshire Hospital, Dr Marios Hajivassiliou has shown again and again, illustrated here

and in a recent consensus paper here:

So I strongly suspect that poor old Jeanne Beaudon, and many others in Charcot’s care, were manifesting symptoms of gluten ataxia, hence her jerky dance style. How many in the past and today are suffering from such terrible malfunctions simply due to eating the cereal grains (in the form of bread, cakes, crackers, pastry, pasta and the now ubiquitous ‘breakfast cereals’)? Too many. If only doctors, consultants and general practitioners read the research as I do!

In Toulouse Lautrec’s paintings of Jane Avril one can see the strange movement (ataxia) and the unhappiness on her face. And I can’t say Toulouse looks much happier, even with the ‘Green Fairy’ (absinthe) working on him!

tossed about by life and for so long incapable of considering things normally; living in a perpetual dream without understanding the value of things or even seeking to find out!” She found solace at La Salpêtrière. Her account was published much later, in 1933: “There were crazy girls, whose illness, called hysteria, was mostly a matter of faking

 

 

 

 

 

 

 

 

 

 

 

 

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