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Rhinoplasty: Current
Therapy
Guest Editors
Consulting Editor
RICHARD H. HAUG, DDS
www.oralmaxsurgery.theclinics.com
ORAL AND MAXILLOFACIAL SURGERY CLINICS OF NORTH AMERICA Volume 24, Number 1
February 2012 ISSN 1042-3699, ISBN-13: 978-1-4557-3902-8
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Rhinoplasty: Current Therapy
Contributors
CONSULTING EDITOR
GUEST EDITORS
SHAHROKH C. BAGHERI, DMD, MD, FACS HUSAIN ALI KHAN, MD, DMD
Chief, Division of Oral and Maxillofacial Attending Surgeon, Division of Oral and
Surgery, Department of Surgery, Northside Maxillofacial Surgery, Department of Surgery,
Hospital, Atlanta; Clinical Associate Professor, Northside Hospital, Atlanta; Georgia Oral and
Department of Oral and Maxillofacial Surgery, Facial Surgery, and Eastern Surgical
Georgia Health Sciences University, Augusta; Associates and Consultants, Atlanta;
Clinical Assistant Professor, Department of Aesthetics International USA, Atlanta; Clinical
Surgery, School of Medicine, Emory University, Associate Professor, Department of Oral and
Atlanta; Georgia Oral and Facial Surgery, and Maxillofacial Surgery, Georgia Health
Eastern Surgical Associates and Consultants, Sciences, Augusta, Georgia
Atlanta, Georgia
ANGELO CUZALINA, MD, DDS
Associate Faculty, Oklahoma State University
Center for Health Sciences; Private Practice,
Tulsa Surgical Arts, Tulsa, Oklahoma
AUTHORS
Contents
Preface: Rhinoplasty: Current Therapy ix
Shahrokh C. Bagheri, Husain Ali Khan, and Angelo Cuzalina
History of Rhinoplasty 1
Louis S. Belinfante
Man has considered the nose to be a key feature, if not the key feature, of facial ap-
pearance, beauty, and dynamics. However, because of its central facial location and
weak cartilaginous support, the nose is susceptible to disfiguring infection, trauma,
pathologic entities, and human-associated carnages. This article discusses the var-
ious methods (eg, endonasal approach, external approach, and osteoplastic oper-
ations) surgeons have tried throughout history to give their patients a more
attractive face by altering the one physical anatomic structure that one usually
notices first.
alterations of the external and internal nose; however, many of the advancements
have been kept within the literature of their respective fields. It would be wise for rhi-
noplasty surgeons to have solid understanding of the form and function of the nose
so that they may bridge the gaps of their specialty and provide the best possible care
for their patients.
Index 149
viii Rhinoplasty: Current Therapy
Facial Plastic Surgery Clinics of North America, February 2011 (Vol. 19, No. 1)
Nasal Reconstruction
Daniel G. Becker, MD, Guest Editor
P re f a c e
R h i n o p l a s t y : C u r ren t T h e r a p y
Shahrokh C. Bagheri, Husain Ali Khan, MD, DMD Angelo Cuzalina, MD, DDS
DMD, MD
Guest Editors
Like any surgical procedure, rhinoplasty has evolved lasting, and enhanced cosmetic results of surgery
based on improved surgical techniques that without compromise of function.
survived the test of time and patients’ increasing Oral and maxillofacial surgeons have a unique
expectations. As in most cosmetic procedures, the training with extensive and expanding focus on
vast majority of advances for rhinoplasty are from many aspects of the face, including moving the
the teachings of surgical skill sets to younger maxilla in three dimensions, repairing frontal,
surgeons through operative training, textbooks, orbital, nasal, or zygomatic fractures, and treating
lectures, and symposia. The difficulty of developing benign and malignant tumors. Although currently
randomized or prospective cohort studies and multi- not all graduating oral and maxillofacial surgery
center analysis for cosmetic procedures contributes (OMS) residents are fully exposed to facial cosmetic
to the progression via traditional (non-research- surgery, it is only logical that cosmetic rhinoplasty,
based) modes of teaching. Cosmetic surgery is along with other facial esthetic procedures, should
unique among other surgical specialties due to be an integral aspect of OMS. This is particularly
changing trends and racial and regional ethnic pref- true because OMS training is so dedicated to all
erences that drive patients’ desires to what is aspects of the facial skeleton and the American
considered an esthetic result. In no other procedure Board of OMS tests all candidates in facial cosmetic
are such differences as clear as for rhinoplasty. The surgery and expects a certain level of knowledge.
operation is individually customized with respect to We also believe that a majority of training in
current ethnic and cultural norms. In modern rhino- cosmetic surgery is acquired beyond the residency
plasty surgery, no single procedure or approach years. Especially important in cosmetic surgery is
can provide a reproducible outcome for the vast the learned benefits of observing over time the
array of patient desires for beauty and functionality. results of one’s own surgical residency. Rhino-
Surgeons have to be armed with multiple techniques plasty should be thought of as a lifelong learning
that are utilized in concert to give predictable results. process due to its complexity.
Cosmetic rhinoplasty remains one of the most chal-
lenging facial cosmetic procedures. This is unlikely EDITORS’ PERSPECTIVE ON FUTURE
oralmaxsurgery.theclinics.com
none of the three residency specialties teaching surgeons to seek out further training and stimulate
rhinoplasty—oral and maxillofacial surgery, otolaryn- research and writing within this field.
gology, and plastic surgery—do an “exceptional” job
of teaching the surgical resident all the nuances of Shahrokh C. Bagheri, DMD, MD
rhinoplasty. This is why advanced training and Georgia Oral and Facial Surgery, and
continued education in the field of rhinoplasty and Eastern Surgical Associates and Consultants
cosmetic surgery following one’s residency is essen- 1880 West Oak Parkway, Suite 215
tial to master this truly challenging field. Surgical Marietta, GA 30062, USA
“superspecialty” fellowships are becoming more of
the norm to immerse the training fellow totally in prin- Husain Ali Khan, MD, DMD
ciples, techniques, and case volumes high enough to Eastern Surgical Associates and Consultants
give maximum training, experience, and education in 2795 Peachtree Road NE #2008
this demanding field. Atlanta, GA 30305, USA
The goal of this issue of Oral and Maxillofacial
Surgery Clinics of North America is to familiarize Angelo Cuzalina, MD, DDS
the reader with the most current principles of diag- 7322 East 91 Street South
nosis and treatment of the rhinoplasty patient as it Tulsa, OK 74133, USA
relates to our specialty. It is not intended as
a comprehensive review of the subject, but rather E-mail addresses:
to highlight the important topics, challenges, prin- [email protected] (S.C. Bagheri)
ciples, current thinking, and variations in rhino- [email protected] (H.A. Khan)
plasty surgery. We also hope to stimulate young [email protected] (A. Cuzalina)
H i s t o r y of R h i n o p l a s t y
Louis S. Belinfante, DDS
KEYWORDS
Rhinoplasty Endonasal approach External approach
Free grafting approach Cosmetic surgery
The word rhinoplasty is derived from 2 Greek At times, the treatment of nasal structural mutila-
words, rhino, meaning nose, and plasikos, meaning tion was surgically attempted by using rudimentary
to shape or mold. bronze instrumentation. Mutilation was a punish-
Since the beginning of recorded time, man has ment meted out for major civil offenses, for
considered the nose to be a key feature, if not the example, wives leaving the house without permis-
key feature, of facial appearance, beauty, and sion, adultery, and theft; even lack of female sexual
dynamics. However, because of its central facial response could lead to punishment causing the
location and weak cartilaginous support, the nose recipient visible and lasting humiliation. Captured
is relatively susceptible to disfiguring infection, enemies sometimes were made to suffer the
trauma, pathologic entities, and human-associated same ill fate as a warning to other would-be adver-
carnage. If a person were to be so afflicted, these saries. The treatment of medical problems involved
potential deformities could impose serious alter- the use of plugs, swabs, linen, and tampons. Strips
ations to work, social life and psyche. In fact, of adhesive plaster were used for drawing together
because the nose has been considered the “organ wound edges. More serious wounds were closed
of reputation,” the purposeful amputation of the with needles made of materials such as bone,
nose, rhinokopia, was, and is, meant to strip silver, and copper. Surgical sutures were fabri-
a person of his or her personal honor.1,2 cated from plant fibers, hair, or linen. Nasal frac-
tures were treated with stiff rolls of linen.
IN THE BEGINNING Other informational pieces concerning nasal
deformities were addressed in the Nuzi Tablets
A papyrus is an ancient form of paper made from (1600–1350 BCE), which originated in the ancient
the papyrus plant that grows wild in the marshes area of Nuzi, 10 miles southwest of the city of
of the Nile River. The first historical annotation Kirkuk in modern Iraq.6
regarding the surgical treatment of nasal defor- The Ebers Papyrus, which is the largest of the
mities is cited in a papyrus named after Edwin medical papyruses and is written in hieratic,
Smith. Smith, an American Egyptologist, bought devotes an entire section to nasal deformities
the papyrus from a dealer in Luxor, Egypt, in and their correction. The Ebers Papyrus was also
1862. The document dates back to approximately bought by Edwin Smith from an unknown source
3000 BCE. Dimensions of the papyrus measured but was sold early on to Georg Ebers, a German
4.68 m long and 33 cm wide, and was divided Egyptologist. The papyrus measures 20 m long
into 17 pages. and has 110 pages. It is dated at 1534 BCE, but
The first transliteration of the papyrus was made parts may have been copied from earlier texts
by James Henry Breasted in 1930. The papyrus dating back as far as 3400 BCE.5
was translated a second time in 2006 by James At approximately the same period of time, and
P. Allen, who was the then curator of Egyptian Art as an extremely dynamic, historically significant
oralmaxsurgery.theclinics.com
at the Metropolitan Museum of Art in New York, corollary, one must note with considerable res-
using a more modern understanding of surgical pect the fifth century BCE Ayurvedic physician,
verbiage. Forty-eight surgical cases were dis- Sushruta, who lived around the same period.
cussed beginning at the top of the cranium and Although born of a lowly priestly class, the Koomas
ending in the spinal column.3–5 (potters), he became a professor of medicine at
the University of Benares. Within his series of periods. Very little, if any, surgery to improve
texts, Sushruta Samhita, written in Sanskrit (a appearance was performed during the Dark Ages
historical branch of Indo-European languages), (fifth to fifteenth centuries).4
he outlined several surgical procedures (300) and In 1163, Pope Innocent III and the Council of
described several surgical instruments (121). Tours proclaimed that surgery was to be aban-
However, because his writings were in Sanskrit, doned by the schools of medicine and all decent
and the Egyptian writings were in hieroglyphics, physicians. The church believed that surgery was
the spread of shared medical knowledge was interfering with God’s plan.5 In fact, the perfor-
greatly mitigated because of expansive geographic mance of a surgical procedure (deemed a manual
communicative areas. In addition, there was operation) by an educated physician was consid-
a limited amount of commerce between the areas, ered below his dignity. However, surgical proce-
even though Alexander the Great from Macedonia dures were being performed surreptitiously and
in Northern Greece invaded India in 327 BCE. were being kept alive by passing on the principles
However, his troops lasted there for less than 10 from generation to generation and from one civili-
years. zation to the next. In this manner, the status quo
Since purposeful facial deformation was not was maintained but not advanced to any meaning-
exclusive to the area of the Fertile Crescent, in ful degree.
India also, there was much opportunity for inter- In 1442, an Italian surgeon from Sicily named
ested physicians to attempt to repair several Branca de’Branca introduced a method of using
contemporaneous facial mutilations. One of the forehead and cheek flaps for facial reconstruction.
most famous repairs that is associated with Sus- His son Antonius modified the technique by using
hruta is the surgical correction of cutoff noses by the arm as the primary donor site and delaying the
the transfer of pedicled forehead or cheek flaps initial transfer of the graft. The technique became
to the nasal deformity.3 Sushruta is also credited known as the Italian method. But because of the
with many other surgical procedures, such as potential for severe church reprisals, the surgeries
those associated with the treatment of cataracts, that were performed were veiled in secrecy with no
hernias, lithotomy, and cesarean sections.7–9 publications or even collegial comments.5
Nasal disfigurement was used not only on Pfalzpaint (1450), a German surgeon, described
people who made up the average populace but the suture of a biceps flap to the face, which was
also on societal members of prominent standing. initially held in position with bandages for several
Emperor Justinian II of the Byzantine Empire (circa days before the pedicle was separated to form
700) was overthrown and had his nose mutilated the nasal dorsum.4
(rhinokopia) and his tongue slit open (glossotomia). Gasparo Tagliacozzi (1546–1599) was an Italian
The mutilation was performed in front of thou- surgeon and anatomy professor from Bologna.
sands of cheering former subjects in the middle During this “dark intellectual era” when emphasis
of the Hippodrome, the sporting and social center was placed on the mundane, he produced scien-
of Constantinople, itself, the capital of the Byzan- tific writings about his surgical treatments and
tine Empire. The purpose of the mutilation of his was given the most credit for the arm flap to the
nose and tongue was to permanently discourage facial area procedures. His fame was great, and
him from future attempts to regain his throne as after his death, the city fathers of Bologna erected
emperor. However, after nasal reconstruction, in a statue holding a rose in his honor, which symbol-
the Indian manner, and a healed tongue, he was ized his artistic surgical endeavors. However,
able to return to power. The effects of the mutila- dogmatists in the contemporaneous prevailing
tion and repair may be noted in his Carmagnola religious faction had him excommunicated. They
marble statue likeness.10 thought that Tagliacozzi was “imperiously inter-
In the first century AD, Rome became a medical fering with the handiwork of God.” The religious
center. Two outstanding physicians who lived faction even exhumed his body from a hallowed
in Rome and discussed tissue transplantation church burial site and reinterred him in unconse-
and treatment of facial defects were Celsus and crated grounds. For the next 2 centuries there
Galen. Interestingly enough, both physicians were was very little advancement in the field of
Greek.11–13 rhinoplasty.5
forehead flap. The operation was performed by Warren expounded to the surgical attendees
a man from the caste of the tile and brick makers present, with his also famous remark about
in Poona, near the Indian coast. Lucas sent a Morton’s ether anesthetic, “Gentlemen, this is no
letter regarding the operation to the Gentleman’s humbug.”9,10
Magazine of London for the October edition. The Concurrently and fortuitously, 2 additional
account was read by Joseph Carpue, a British discoveries were made that had great impact in
surgeon at York Hospital in Chelsea, England. Car- broadening the interests of both the surgical and
pue was piqued by the concept and practiced the lay communities with regard to the functional
procedure on cadavers for approximately 20 and aesthetic advancement of rhinoplastic pro-
years. Finally in 1814, he performed nasal recon- cedures. They were the discovery of the antiseptic
structions on 2 patients. He published the cases qualities of carbolic acid (phenol) by an English
in an illustrated monograph where it gained great surgeon and the local anesthetic qualities of
recognition among European surgeons. Interest- cocaine.
ingly enough, though Carpue was elected as Joseph Lister in 1867 published his seminal and
a Fellow to the Royal College of Surgeons, he patient-altering paper on antiseptic principles to
was passed over by the same Royal College to reduce infection. The paper was based on the
sit on their Council. He was disdained by his own concepts of Louis Pasteur. Lister found that the
contemporaneous professional colleagues.4,5 use of carbolic acid (phenol) greatly mitigated
Carl Ferdinand Von Graefe in 1818 published his wound infection. As a professor of surgery at the
famous work, Rhinoplastik. It had 208 pages and University of Glasgow, he instructed surgeons
55 citations. Although he was born in Warsaw, under his charge to wash their hands before and
he was educated in Germany and was considered after operations with a 5% carbolic acid solution
German. In his book, he noted 3 different and to wear clean gloves. Instruments and the
surgeries: the Indian technique with the forehead operating theater were sprayed with the same
flap; the delayed Italian method of Tagliacozzi; solution. The rate of hospital infections dramati-
and the third, he called the German method that cally dropped.14
entailed a free graft from the arm. In addition to In 1455, the Spanish explorer Augustin de
his rhinoplastic work, he wrote original articles on Zarate discovered Peruvian coca. However, it
such subjects as blepharoplasty and cleft palate wasn’t until approximately 400 years later (1884)
repair. To many, he is considered the founder that Spanish soldiers while in South America as
of modern plastic surgery. His son became the conquistadors became familiar with the native
leading ophthalmologist in Europe. In 1840, use of the coca leaf. When brought back to Eu-
Von Graefe, the father, died while performing an rope, it was chemically refined into cocaine, which
operation.4,5 had local anesthetic properties.15
Johann Friedrich Dieffenbach succeeded Von One could readily conjecture that an operative
Graefe in Berlin with his professorial titles. Dieffen- procedure that increased the aesthetic value of
bach was one of the first surgeons to use local the face, was relatively comfortable and free of
anesthesia, and at a later date, ether anesthesia, pain for the patient, and in addition, greatly miti-
while performing his rhinoplastic techniques. gated the chances of infection might gain a poten-
His book, Operative Surgery (1845), discusses tial universal audience. And so it did!
nasal reconstruction for over 100 pages. He also In 1875, William Adams, a dentist, published an
discussed the endonasal or the subcutaneous article on nasal fracture reduction. He divided the
approach to nasal surgery. Some consider him fractures into those associated with bone and
the greatest plastic surgeon of his era.4,5 those associated with cartilage. Although for one
Nasal reconstruction was first performed in the of his patients, initial treatment was initiated at 6
United States by Dr J.M. Warren in Boston, years postfracture, his treatment was earlier and
Massachusetts, in the late 1830s. He had previ- more aggressive than most in an effort to avoid
ously visited Von Graefe. Dr Warren was related potential fracture-related traumatic deformities.
to John Collins Warren, also of Boston. It was He also fashioned forceps to reduce the fractures
the latter Warren who painlessly removed a tumor that are not unlike those that are still in use
on a patient’s neck with the aid of ether anesthesia today. His concept of external support is also
administered by William Thomas Green Morton, contemporaneous.16
a dentist, at the Massachusetts General Hospital Dr John Orlando Roe (1848–1915) was an otolar-
on October 6, 1846. Morton said to Warren, after yngologist from Rochester, New York. In 1887,
administering the ether general anesthetic to the he published an article regarding a “pug nose.” (A
proper surgical depth, his famous words, “Doctor, pug nose is one with large lower lateral cartilages
your patient is ready.” On finishing the procedure, plus or minus a concavity of the dorsum.) He
4 Belinfante
performed the surgery for purely aesthetic reasons, in Berlin. He published his first article on reduction
a literature first. Besides, he performed the surgery rhinoplasty using an external approach. He later
from an intranasal approach, also a first. acknowledged that Roe, Weir, and Dieffenbach
However, within the same article, Roe divided had preceded him with similar work.
the nose into 5 main morphologic classes. One Although Joseph performed plastic procedures
of the classifications was flagrantly anti-Semitic on other parts of the body, he is most recognized
with regard to its implications and the manner in for devising nasal operations and designing inven-
which it was further defined. This classification tive new instruments, which he used to achieve his
was probably based on the notations of Robert techno-anatomic goals.
Knox, a period physiognomist. (For the reader, Joseph developed a great ability to conceptu-
physiognomy has no scientific basis.)17–20 alize a reshaped anatomically deficient entity and
Four years later, in 1891, Roe published a second the biomechanical approach to achieve his well-
seminal paper on the correction of angular nasal thought-out goals. As an orthopedist, and for his
deformities with great emphasis on the subcuta- era, he understood how to transplant osseous
neous approach. (Dieffenbach, however, is given tissue like bone from the tibia to the dorsum to
credit for first introducing the endonasal approach correct saddle nose deformities. He studied and
in 1845.) In addition to working from the interior of classified several nasal deformities and devised
the nose, he routinely used external and internal individualized procedures for their correction on
splints to keep his postoperative results in their a scientific basis (unlike physiognomy). His artistic
best aesthetic position. Also, he was one of the first drawings and meticulous operative details defini-
to use presurgical and postsurgical photographs to tively established him as a rhinoplastic surgeon
illustrate his results. Some call him the true father of par excellence. Later, he insisted that photographs
aesthetic rhinoplasty. and plaster molds be taken for every patient.
Dr Robert F. Weir (1838–1927) is associated with Joseph developed a great many instruments to
several innovations and modifications in the perfor- use for various facets of his devised corrective proce-
mance of nasal surgery. For example, he altered dures. For example, for rhinoplasty, he designed
Adam’s forceps to make them thinner and more various saws to reduce nasal bony and cartilaginous
delicate for the reduction of fractures. In what he hypertrophies and to have greater control over the
termed an “osteoplastic operation,” he used an os- lineal separation of lateral nasal fractures for width
teotome to make his fracture reductions “more reduction. He also designed special scalpels for car-
even.” He used osteotomes and forceps to divide tilage modification to increase aesthetic contour,
the nasal bones in the midline. He also in- external nasal splints, and headbands to hold re-
fractured them at their juncture with the maxillae paired deviated septa in place. Although Dieffen-
to narrow bone width along with simultaneous bach, Roe, and Weir first discussed changes from
elevation of the bony dorsum. However, Weir is a subcutaneous approach, it was Joseph, who for
probably best known for his attempts to correct years taught and wrote scientific articles concerning
nasal dorsum deformities. He inserted the sternum the aesthetic reduction and augmentation involving
of a freshly killed duck to augment a saddle nose. In rhinoplastic procedures. Even today, many people
retrospect, as one might expect, the heteroge- believe that most rhinoplastic operations are just vari-
neous graft lasted but a few weeks. His use of ations of Joseph’s body of work. One might say that
a platinum strut was somewhat more success- rhinoplasty was born “fully grown” with the emer-
ful.21,22 However, it was James Israel, who in gence of his scientific articles and books.
1896 successfully augmented the saddle nose Joseph died under enigmatic circumstances,
with a tibial graft.23 Weir innovatively removed while fleeing Hitler’s Nazi Germany, in Czechoslo-
a wedge of the lower lateral cartilages at their facial vakia in 1934.5,24–32
angle to reduce interalar width and thus created Some who attended Joseph’s courses or
a greater morphologic symmetry. The latter opera- were contemporaneous with Joseph or his pupils
tion is still widely used and bears his name. were such great historical names as Gustave
Aufricht,33 Joseph Safian,34 Jacques Maliniac,35
ALONG COMES THE WUNDERKIND John M. Converse,36 Abe Silver (Silver WE, Abe
Silver, personal communication, 2010), and Sam
Dr Jacques Lewin Joseph (1865–1934) was born Foman,37 who in turn gave courses that included
and grew up in Königsberg, Prussia (now, Kalinin- Maurice Cottle38 and Irving Goldman.39
grad, Russia). He obtained his doctorate in It has also been said that Joseph was a bit
medicine in 1890 at the University of Leipzig, prac- quirky. During one of his courses, his instruments
ticed in Berlin for a short period of time, and then were placed on an operating room table that was
studied orthopedic surgery at the J. Wolff Clinic completely covered with a towel so that no one
History of Rhinoplasty 5
could discern their design. He operated gloveless. known Yugoslavian surgeon, Ivo F. Padovan,
Instruments were passed to him covertly from from the meeting city itself, presented a paper on
under the towel. One night while taking one the “The external approach to rhinoplasty.”46 His
of Joseph’s courses, Foman persuaded one 10-minute presentation was based on 400 of his
of Joseph’s assistants to show him his instru- own cases and 500 cases of his mentor, Ante
ments. And with lightning speed, Foman drew Sercer.47 Both their observations were based on
them all. When Foman returned to the United the work of Aurel Rethi of Budapest.48
States, he had a friend from the Klink instrument An attendee at the meeting, Dr Robert Simons
company manufacture the instruments. He later noted, “A revolutionary shot in the rhinoplasty
sold them at his rhinoplasty courses (Silver WE, world had been fired, but it was neither heard nor
Sam Foman, personal communication, 2010).40 appreciated immediately.”49
Cottle and Goldman, in due course, gave their However, William Goodman, from Toronto,
own rhinoplastic courses that influenced hundreds Canada, who was also in attendance at Pado-
of future rhinoplastic surgeons. Many of these van’s lecture, returned home to begin performing
gifted surgeons created alterations and some the “external approach” for several nasal defor-
newer rhinoplastic procedures (dome division, mities. He refined the “gull-wing” incision with
elevation of the upper lateral cartilages, additional a resultant greater patient acceptance. Goodman
instrumentation, greater aesthetic forehead flaps, published several articles regarding the positive,
improved postoperative splint dressings, and aesthetic, and structural outcomes that he was
many other modifications). However, the basic achieving.50–52
concept came to them, ‘fully grown’. As fate would have it, at around the same time,
In addition, one cannot exclude other such a young Canadian otorhinolaryngologist, Peter
names as Sir Harold Gillies,40 V.H. Kazanjian,41 Adamson, who was very much in tune with Good-
D.R. Millard,42 and J.E. Sheehan.43 man’s external approach, began a facial plastic
fellowship with Jack Anderson of New Orleans.
A MAJOR REASSESSMENT During this time, Anderson had a renowned repu-
tation for being one of the best known and most
For some surgeons, the endonasal approach had well-respected facial plastic surgeons with an
shortcomings. For example, in most instances, unquenchable fire in his belly for the art of rhino-
surgeons knew from their own formal education, plastic surgery. In addition to these qualities, he
or through observation of other surgeries, re- was also considered to be a great teacher.53
searched articles, and case repetitions the subcu- Before the Adamson fellowship, Anderson
taneous disproportionate anatomic morphology of thought that he could do basically anything endo-
nasal deformities. However, by not being able to nasally that one could do via an open method. He
directly visualize a problem in situ, the ability to was very passionate about nasal surgery but was
intensely comprehend the anatomic nature of not afraid to try something different if he thought
the problem and then treat was compromised. it was biologically just. His practice associate at
For example, as much subcutaneous fatty and the time was Calvin Johnson, a well-known facial
connective tissues (the so-called superficial mus- plastic surgeon in his own right. With Adamson’s
culoaponeurotic system layer) as possible might history with William Goodman and Anderson’s
not be removed from above a surgerized dome scientific inquisitiveness, they started performing
because of lack of total visualization. This, in external approach rhinoplasties using the midco-
turn, might compromise the amount of the final lumellar approach. In an assessment paper on
aesthetic acuteness of clarity and shape of tip open rhinoplasty, Anderson, Johnson, and Adam-
bulbosity. Thus, a great result might have been son performed several hundred open procedures,
diminished to a good result. and one of their significant conclusions was that
Another example might be a visualized actual they could not find fault with any surgeon who
comparison of the reduction right and left lower chose to perform all of their rhinoplasties via the
lateral cartilages after surgery, but before closure, open approach.54,55
relative to height, width, symmetry, convexity, and There have been several alterations in the pro-
so on. cedure but nothing that has altered the basic
On a similar note, Ellsworth Toohey once said in rhinoplastic surgery as postulated by Joseph.
Ayn Rand’s The Fountainhead, “The enemy of Newer alloplastic materials have been used in
excellence is good.”44 Good is not what we want. augmentation settings.56 Some new instrumentation
Then, in 1970, in Zagreb, in the former Yugosla- was developed that made the shaping of cartilage
via, at a meeting of the American Academy of Facial and osseous contouring more effective. However,
Plastic and Reconstructive Surgery,45 a modestly it is of interest to note, that one of the most
6 Belinfante
inventive rhinoplastic instrument designers who its entirety, it became obvious that the lower one-
also wrote and lectured on rhinoplastic surgery third of the face was severely “dished.” As oral
was a general medical practitioner and not and maxillofacial surgeons (OMS), we are well
a surgeon per se.57–59 aware that a potential treatment of bimaxillary
Rhinoplasty has come a long way, and along the horizontal retrusion is maxillary and mandibular
way many people have benefited from the many advancement surgery. This surgery is usually ac-
surgeons from antiquity to the present. These companied with a genioplasty.
surgeons have tried to give their patients a more The concept was presented to the patient’s
attractive face by altering the one physical family, and the surgeries were successfully per-
anatomic structure that one usually notices first. formed. Although the osteotomy sites began to
heal in their normal manner and the facial edema
NOW COMES ORAL AND MAXILLOFACIAL subsided, to even a casual observer the patient’s
SURGERY previously veiled nasal deformity became the focal
point of her face. The patient’s family sought the
And with this wonderful circuitous medical history, services of a rhinoplastic surgeon. The surgery
how did oral and maxillofacial surgery, a dentally was performed and I saw the patient several weeks
based specialty, become a player? later. She had become a swan! I was stunned. I
During the early part of the 1980s, after regular thought that out of all the facial surgeries recently
American Association of Oral and Maxillofacial performed on her, the nasal alterations made, by
Surgeons (AAOMS) board meetings, evening far, the greatest significant impact in her overall
blue sky sessions occurred, involving board and facial aesthetics.
staff members. Nagging questions continued to Although, at the time OMS were performing
arise relative to just what was our surgical scope. rhinoplasties to only the slightest moderate
Had we reached our zenith? Was our surgical degree, the thought occurred that as OMS, we op-
breadth already defined and finalized by us or, erate lateral to the nose, inferior to the nose, above
even worse, by others. the nose, and on occasion, within the nose. Why
Concurrently, at annual and midwinter meet- should we not perform aesthetic operations on
ings, orthognathic surgery programs were almost the nose in combination with other facial proce-
always assured that lecture halls would be filled dures, or as a stand-alone procedure? After all,
to capacity. we are OMS. And the nose is clearly in the center
The expanded version of orthognathic surgery of the maxillofacial region. Why not?
(or orthodontic surgery as it was then called) But who would teach an oral surgeon, and better
was developed to a great degree by European yet, one without a medical degree? Enter, Dr Wil-
colleagues during the post–World War II era liam (Billy) Silver, an otolaryngologist by formal
because of a lack of orthodontists and orthodontic post–medical school residency training. After
materials. Since they could not consistently rely on living in the same area for several years, Dr Silver
orthodontic care to aid in the treatment of the and I had become geographic friends who shared
many orofacial skeletal deformities, they inge- ideas, techniques, generalized information, and
niously devised technical intraoral methods to op- stories about people and events in our respective
erate simultaneously on both the maxillae, the specialties.
mandible, and their segmental components. Later, Dr Silver’s brother was an orthodontist, his
definitive biologic credence for these procedures father, a general dentist, and his uncle, Abe Silver,
was established by Bell and Levy in 1970 with rhe- a rhinoplastic surgeon. His uncle, Abe, was part of
sus monkey angiographic studies.60 Therefore, it New York’s well-known Mount Sinai Hospital’s rhi-
was obvious that facial aesthetics in the form of noplastic teaching group along with Irving Gold-
facial bone reconstruction was paramount in the man. Dr Goldman was the creator of the famous
minds of several members of the orthognathic nasal dome division for greater tip definition, which
surgical community. bears his name (the Goldman tip).
Serendipitously, for some, pieces of an arcane Dr Billy Silver received additional training after
puzzle started to swirl about during this period. The his formal otorhinolaryngology residency by
author’s own awareness started when a 17-year- spending much time with Drs Richard Webster of
old patient was seen for facial aesthetic evaluation. Boston, Jack Anderson of New Orleans, and
The patient had recently had orthodontic treatment Maury Parks of Los Angeles. This was the route
that involved 4 first bicuspid extractions. If one taken by many future facial plastic surgeons
were to evaluate her postorthodontic models even before there was an official subspecialty of
alone, the tooth alignment and achieved occlusion facial plastic surgery and, for that matter, facial
were excellent. However, if one assayed the face, in plastic fellowships. These members were indeed
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keskuudessa se on syntynyt. Syystäpä tätä lyriikan henkeä on
verrattu vienoon, sen tuotteista lehahtelevaan lemuun, joka
muistuttaa niiden syntymämaata ja kotoista ilmastoa ja ikäänkuin
siirtää meidät näiden keskelle. Jos eepillinen runous mahtavalla
siveltimellä maalailee eteemme loistavavärisen puutarhan, niin
laulurunouden lauhkea tuulonen puhaltelee luoksemme sen
kukkasien ihanaa tuoksua. Mutta kun kaikkien kansojen ja aikojen
lyyrilliset runoelmat yhdistetään, silloin näyttäytyy maailma
semmoisena, kuin se sisäkohtaisesti kuvasteleikse ihmismielen
syvyydessä. Oikeinpa sen oivalsi Herder kootessansa "kansojen
äänet" jaloksi yhteislaulannoksi ihmiskunnan mielialoja ilmoittamaan.
Nykyhetkessä — niin äsken sanottiin — lyyrillinen tunne tajuaa
entisyyden ja tulevaisuuden. Entisyys on nykyisen mielialan emo,
niinkuin vastaiset tunteet ovat sen lapsia. Lyyrillinen mielentila ja
siitä puhkeava runoilu on yksityisessä ihmisessä, samoin kuin
kansojenkin elämässä, runsaan kokemuksen hedelmä. Usein kyllä
tämä kokemus saattaa olla haikeata, surusta sukeunutta ja kaiho
antaakin enimmiten mielelle sen apean sumeuden ja hellän
hentouden, joka utuharsollaan verhoilee niin monta lyriikan tuotetta.
"Mene korpeen, elä siellä yksinäsi, ikävissäsi, ja sinä olet oppiva
runoilemisen taidon", oli vanhan eukon neuvo Castrénille, joka
häneltä runoja tiedusteli. Ja jos tarkastaa lyriikan kenttää, huomaa
pian surunvoittoisten runojen luvun suuremmaksi kuin ilomielisten.
Se tulee kaiketi siitä, että kaihoisa mieliala etupäässä vie ihmistä
omiin tunteisiinsa syventymään ja niitä runoissa ilmi lausumaan;
iloisena ollessaan hän harvemmin tuntee tällaista tarvetta, koska
hänen huomionsa pääasiallisesti kääntyy ulkonaisiin oloihin. Mutta
siitä ei saa päättää, ett'eivät iloinen mieli ja elämän valopuolet
kykene lyyrillistä runoutta tuottamaan; päinvastoin mielihyvän
tunteet aina ovat osoittauneet voimallisiksi vaikuttimiksi: saavutettu
onni, rakkauden riemu, hehkuva innostus ovat aiheuttaneet monta
lyyrillistä runoa. Ja onhan lyyrillisen runouden sisältö sangen usein
suorastaan leikillistä, koomillista laatua. Lahjat ovat monenlaiset ja
kullakin on omansa, — sanoo runoilija Jatgeir Ibsenin "Kuninkaan-
aluissa", ja vaikka hänellä on "murheen lahja", saattaa toisella olla
runoilemisen aiheena leikin tai tyytyväisyyden tunteet. Tai ehkä
Suomen runotar oikeimmin on osannut kuvata sitä tyyntä, ilon ja
kaihon sekaista mielialaa, josta laulun virta enimmiten kumpuilee,
kun immestä kertoo:
Ei se impi itkenynnä,
Ei varsin ilonnutkana,
Ilman lauloi itseksensä,
Lauloi iltansa kuluksi,
Sulhon toivossa tulevan,
Armahansa aikehessa.
Missä kukka,
Siellä kesä;
Missä tähti,
Siellä taivas;
Missä lempi,
Siellä autuus.
SEITSEMÄS LUKU.
Draama eli näytelmärunous.
Runouden lajeista puhuessa sanottiin, että näytelmärunouden
varsinainen pohja on tahto ja siveellinen toiminta; se kuvailee
ulkonaisen ja sisällisen maailman keskinäistä suhdetta osoittamalla,
miten tunteet ja ajatukset muuttuvat teoiksi ja tekojen seuraukset
vaikuttavat takaisin ihmisen kohtaloon ja mielentilaan. Draaman
pääluonne on niinmuodoin siinä, että se koettaa mitä selvimmin
esittää sitä yhteyttä, joka on kaikkien elämää muodostavain voimain,
ulkonaisten ja sisällisten, välillä, ja siitä johtuvatkin ne ominaisuudet,
jotka ovat erittäin näytelmärunoudelle omituiset. Draamallista siis ei
ole jokaisen tapahtuman tai toimen esittely, vaan ainoastaan
sellaisen, joka valuu sielun syvimmistä hetteistä ja tarkoittaa
sisällisten ajatuskuvien toteuttamista; yhtä vähän into tai pyrkimys
ilman varsinaista tekoa on draamallista, vaan ainoastaan into, joka
päättyy vapaaseen toimintaan.
Tästä jo huomataan, että näytelmärunous asettuu ihan toiselle
katsantokannalle kuin epopea. Eepillinen runotar mieluimmin
silmäilee ilmiöin kokonaisuutta, tapausten valtavaa virtaa, johon
yksityisten aikeet ja ponnistukset yhtyvät ja katoavat; vapaan tahdon
merkityksestä siis ei ole paljon puhetta. Draamallinen runoilija
päinvastoin näyttää, miten maailman meno muodostuu olevaisten
olojen ja yksilön toiminnan vuorovaikutuksesta, ja antaa siis vapaalle
tahdolle täyden arvon, — tietysti lukuun ottamatta niitä poikkeuksia,
joihin eri aikojen vaihteleva maailmankäsitys välisti antaa aihetta. Ja
kun draama näin esittelee ihmisen pyrkimysten ja ulkonaisten
tapausten keskinäistä suhdetta, voipi se paremmin kuin muut
runouden lajit kuvailla siveellistä maailmanjärjestystä. Eepoksen
esittämä kuva on kyllä ulkonaisesti laajempi, monivaiheisempi, mutta
draaman on sisällisesti runsaampi, täydellisempi. Se osoittaa, kuinka
ihminen on vastuun-alainen teoistaan ja niittää, mitä hän on
kylvänyt, mutta viittaa samassa siihen ikuiseen voimaan, joka
maailmanjärjestystä ohjaa ja kannattaa. Tästä jo selviää, mikä
tärkeä tehtävä draamalla on inhimillisen sivistyksen kehityksessä ja
miksi juuri näytelmärunouden historiassa paraiten ilmenee, minkä
vaiheitten alaisina ihmiskunnan ihanteet ovat olleet.
Draama, niinkuin jo ennen on sanottu, on luonteensa ja
tarkoituksensa puolesta eepillisen ja lyyrillisen runouden yhdistäjä, ja
sentähden siinä onkin kaksi osaa näitä molempia edustamassa:
toiminta, sen ulkonainen, eepillinen puoli, ja puhelu eli
puheenvaihtelu (dialogi), joka on lyyrillistä laatua, tuoden esiin
henkilöin tunteet ja ajatukset. Jälkimmäiseen on myös luettava
monologi eli yksinpuhe. Mutta nämä puolet eivät ole vaan vierekkäin,
erillään toisistaan, vaan punoutuvat kiinteästi yhteen, edistyen
rinnakkain toinen toisensa avulla. Toiminta tapahtuu suurimmaksi
osaksi puhelun kautta, saa siitä alkunsa ja viepi siihen; samoin myös
dialogin esittämät mielentilat purkaantuvat toimintaan tai ovat sen
seurauksia. Elämän molemmat puolet, sisäkohtainen ja ulkonainen,
— henkilöin katsantotapa, luonteet ja mielentilat sekä maailman olot
ja vaihtelevat kohtalot, — ilmaantuvat niinmuodoin kaikkialla
draamallisessa runoelmassa. Ja muutenkin näytelmärunouden
antama kuva on samalla sisäkohtainen ja puhtaasti objektiivinen.
Runoilija on kokonaan kätkeytynyt teokseensa ja lausuu ajatuksensa
ainoastaan esitettävien henkilöin kautta; hän ei edes tule kertojana
näkyviin niinkuin eepillisessä runoudessa, ja tämä on perin
objektiivista. Mutta toiselta puolen avautuu meille koko sisällisen
olevaisuuden rikkaus; saamme runoilijan kanssa sukeltaa henkilöin
sielun-elämän syvimpään syvyyteen ja nähdä tunteiden ja
mielenliikutusten alkukipinät, tarkastaa maailmaa muodostavain
tekojen salaisimman työpajan.
Tämä henkilöin sisäisen elämän paljastaminen, luonteenkuvaus,
onkin se, mikä draamassa enimmin viehättää. Sen kautta
tutustumme mitä erilaisimpiin ihmisiin, joiden omituista ajatus- ja
tuntemistapaa opimme ymmärtämään ja jotka sentähden meissä
herättävät myötätuntoisuutta, ja kun virkeällä osan-otolla
seuraamme heidän kohtaloitansa, syventyy katseemme
huomaamaan ihmis-elämää hallitsevia lakeja. Luonteiden
moninaisuudesta olen ennen puhunut ja niiden merkityksestä
runoudessa ylimalkain (vrt. II kirja); edelläolevasta selviää, kuinka
tärkeän tärkeitä ne ovat etenkin näytelmärunoudessa. Se
olijoitsemisen halu, joka vie runollisen mielikuvituksen
muodostamaan luonnonvoimia ja yksityisiä luonnonesineitä
itsenäisiksi, ihmisenkaltaisiksi olennoiksi, sisältää oikeastaan
vaistomaisen pyrinnön käsittää ilmiöitä meille ymmärrettävän
henkisen perusteen nojalla, ja niin ihmisiäkin tarkastaessa
tahdomme selvittää sitä pysyvää henkistä keskusta, josta heidän
olemisensa ja toimimisensa aiheutuu. Henkilöin sanoista ja teoista
päätämme — otaksuen niissä olevan johdonmukaisuutta —, millaiset
heidän luonteensa ovat. Tätä yleis-inhimillistä ominaisuutta runoilija
käyttää hyväksensä; hän antaa meille vaan muutamia piirteitä —
useampia tärkeämmistä, harvempia syrjäisemmistä henkilöistä —
mutta semmoisia, joiden johdosta oma fantasiamme luo selvän
kuvan esitettävistä luonteista. Tällaista luonteenkuvausta on tietysti
kaikkialla, missä persoonallisuuden yhteys himmentymättömänä
asettuu meidän eteemme. Mutta muutoin runoilija tässä kohden voi
menetellä monella eri tavalla; hän saattaa tuoda esiin henkilöitänsä
yleisemmillä piirteillä tai tarkemmilla värivivahduksilla, noudattaen
enemmän idealistista tai karakteristista taidetapaa; hän voi koota
kirkkaimman valon päähenkilöön, jättäen sivuhenkilöt varjopuoleen,
tai melkein samalla hellyydellä huolehtia kaikkia teoksessa esiintyviä,
j.n.e.
Hellin huolenpito tulee sittenkin aina päähenkilön osaksi, joka
draamassa on paljoa suuremmassa määrässä keskuksena kuin
eepoksessa. Muut henkilöt ovat oikeastaan vaan hänen tähtensä
olemassa, vaikka heillä osittain saattaa olla hyvinkin tärkeä tehtävä.
Ennen on jo viitattu siihen, kuinka epopean, romaanin ja draaman
pääsankarit ovat peräti erilaiset. Näytelmärunoudessa päähenkilö
aina on jyrkässä vastariidassa ympäristönsä kanssa; hän ei edusta
kansallista sankari-ihannetta, niinkuin epopeassa, esikuvana loistaen
heimolaistensa keskellä, eikä ole olojen muodostettavana ja
kasvatettavana, niinkuin romaanissa; vaan rohkeasti hän astuu omaa
tietänsä, taistellen olevaisia oloja vastaan ja koettaen kääntää ajan
ratasta itseviittomalleen uralle. Jotain tällaista pontevaa taistelua ja
vastustushalua tavataan kaikissa tosi-draamallisissa luonteissa,
silloinkin, kun ne joutuvat olosuhteiden johdettaviksi. Sentähden
näytelmän pääsankareiksi sopivat varsinkin tarmokkaat historialliset
henkilöt, tienraivaajat ja uusien aatteiden kannattajat, mutta
muutkin sellaiset individit, jotka ovat ristiriidassa olevaisten olojen
kanssa ja toimiessaan niitä rikkovat, noudattaen oman luonteensa
sisällistä pakkoa. Tämä koskee tietysti näytelmärunouden
vakavanpuolisia lajeja, tragediaa ja sovintodraamaa; komediassakin
tapahtuu jonkunlainen olevaisten olojen rikkominen päähenkilön
puolelta ja on jonkinlaista taistelua, jos niin tahtoo sanoa; mutta
tämä kaikki on koomillista laatua eikä ole taistelua sanan
varsinaisessa merkityksessä. Jotain yhtäläisyyttä siinä kumminkin on
huomattavana.
Hyvän luonteenkuvauksen ensimmäinen ehto on johdonmukaisuus.
Aivan epäjohdonmukaiset ihmiset eivät oikeastaan sovi draamallisesti
kuvattaviksi; jos semmoiset välttämättömästi ovat esiintuotavat, niin
niiden kuvailu vaatii erinomaista taitoa, jotta heidän toimintatapansa
tulisi käsitettäväksi. Pääasia on tietysti aina, että luonteen ydin, josta
teot kasvavat, tulee selvästi tajuttavaksi. Ihminen voi olla
horjuvainen ja näennäisesti menetellä epäjohdonmukaisesti, ja
sittenkin saattavat hänen tekonsa ihan luonnollisesti johtua niistä
tunteista ja mielikuvista, jotka hallitsevat hänen sisintä olentoansa.
Niin esim. Hamlet; ensi silmäyksellä hän tuntuu häilyväiseltä, vaan
satunnaisten mielialojen johtamalta; mutta tarkemmin katsoessa
hänet huomaa vaan mieleltään epätasaiseksi, herkkätunteiseksi,
vaikutuksille alttiiksi, mutt'ei epäjohdonmukaiseksi. Yhä hän hautoo
mustaa murhettansa, vastahakoista tehtäväänsä; hän epäilee eikä
ryhdy toimeen, sitten ponnistaa voimansa ja toimii, mutta
epäsuotuisena hetkenä; hän salaa tunteensa, sitten ne puhkeavat
esiin melkein mielettömyyden voimalla, niinkuin Ofelian haudalla.
Kaikki nämä jyrkät käännähdykset ja vastakohdat ovat luonnolliset
epäröivässä ja itseensä sulkeutuvassa luonteessa semmoisessa kuin
Hamletin.
Luonteessa tapahtuu kehitys, joka on erittäin huomattava
päähenkilössä. Mutta kuitenkin on paljon luonteita, jotka jo
näytelmän alkaessa ovat valmiita, draamalliseen intoonsa kypsyneitä,
ja joiden teot suorastaan puhkeavat esiin heidän omituisuudestaan
ja innostaan. Heidän sisällinen elämänsä on kumminkin niin valtavain
muutosten alainen, että se muistuttaa jonkunlaista kehitystä.
Sellainen on esim. Wallensteinin; hänen alkuperäinen
kunnianhimonsa tekee hänet kavaltajaksi. Syrjähenkilöt, joita
lyhyesti kuvataan, esiintyvät useimmin ihan valmiina. Näiden
vastakohtana ovat semmoiset luonteet, jotka joutuvat heille alkuansa
vieraan intohimon valtaan, niinkuin Othello, jonka hellä, luottavainen
mielenlaatu luulevaisuuden kautta kokonaan muuttuu. Välimuotoja
on useita. Tunne tai intohimo, jonka juuret on henkilön
alkuperäisessä luonnossa, kasvaa kasvamistaan ja valtaa hänet
kokonaan, esim. rakkaus monen monessa tapauksessa, niinkuin
Romeo ja Juliassa. Samoin Macbethin rajaton kunnian- ja vallanhimo
ilmenee jo alusta alkaen, vaikk'ei sen tuhoavaa voimaa havaita,
ennenkuin Lady Macbethin kehoitukset sen täyteen liekkiin
puhaltavat. Tai kohtalon iskut muuttavat tykkänään jonkun henkilön
mielentilan, vaikka hänen luonteensa pysyy entisellään; niin on Lear
kuninkaan laita.[107]
Kuinka tärkeätä draamassa on luonteenkuvaus ja sisäisen elämän
kuvailu, huomaa siitäkin, että on näytelmiä, joissa toiminta on
heikkoa tai höllästi yhdistettyä, mutta joilla kuitenkin on erinomainen
viehätysvoima ja suuri runollinen arvo, sentähden että henkilöin
sielun-elämää esitetään mainiolla tavalla. Ajatelkaamme vaan
Goethen Tassoa, jossa ei ole sanottavasti toimintaa, mutta jossa
meitä lumoo mestarillinen luonteiden ja mielentilojen kuvailu. Goethe
on syvimmältä sielultaan lyyrillinen runoilija ja siitä syystä tällä
puolella aina on etusija hänen teoksissaan. Yhteydessä sen kanssa
on olosuhteiden kuvailu; niin on Egmont sarja vaihtelevia kuvaelmia,
jotka eepoksen tavalla on aseteltu vierekkäin ilman varsinaista
yhdistävää sidettä; mutta näissä viehättää lukijaa henkilöin sisäisen
elämän esittely ja ajan tapausten heijastus ihmisten mielessä.
Shakespeare taas, jonka ominaisluonne on täysin draamallinen, luo
aina vilkkaan toiminnan; mutta monessa teoksessaan hän ei välitä
sen ankarasta johdonmukaisuudesta, vaan panee näytelmän
yhteyden etupäässä läpikäyvään tunnelmaan ja sielunhistoriaan,
laskien pääpainon luonteiden ja sisällisten olojen kuvaukseen. Niin
hän menettelee varsinkin, kun aine on satumainen tai aiheet ja
tapaukset semmoisinaan otetaan jostakin vanhemmasta
kertomuksesta. Näin on esim. Talvisessa tarinassa ja Cymbelinessa,
muita mainitsematta, ja kuitenkin nämä teokset ovat Shakespearen
runouden helmiä. — Mutta jos draamalliselta teokselta päinvastoin
puuttuu luonteiden kuvailu ja sisäisen elämän runsaus, ei vaiherikas
kantatarina ja johdonmukaisesti perille viety toiminta voi sitä
korvata; näyttämöllä esitettynä se kenties kelpaa pitämään kuulijain
huomiota pari tuntia vireillä, mutta runouden syvempiä vaatimuksia
se ei täytä. Tätä laatua ovat useat ranskalaiset näytelmäkappaleet,
joiden pääansio on niiden virkeästi kehkiävässä juonessa.
Tästä ei saa kuitenkaan tehdä sitä johtopäätöstä, että paljas
luonteenkuvaus ilman virkeätä toimintaa olisi draamallisessa
suhteessa pätevä. Päinvastoin. Toiminta on näytelmärunoudessa
ensimmäinen.[108] Mutta draamat ovat erilaisia; muutamissa on
pantu enemmän painoa luonteisiin ja sisällisen elämän kuvailuun,
toisissa tapauksiin.
Päähenkilön tärkeästä asemasta on jo puhuttu. Romaanissa saattaa
joskus olla epätietoista, mikä henkilö on kertoelman varsinainen
kannattaja; draama vaatii aina selvää henkistä keskustaa, josta
toiminta lähtee. Mutta tästä on näennäisiä poikkeuksia. Niin on
useastikin kaksi päähenkilöä, joita rakkaus yhdistää yhdeksi
persoonaksi ja joiden yhteiset kohtalot ovat draaman sisällyksenä:
esim. Romeo ja Julia y.m.m. Joskus suurempikin kokonaisuus vastaa
yksityistä pääsankaria. Schillerin Wilhelm Tellissä astuu koko
Schweizin kansa toimivana päähenkilönä näyttämölle; näemme,
kuinka sen vapaudentaistelu alkaa ja kehittyy kansan eri piireissä,
kunnes se Tellin teon kautta ratkaistaan. Tämä näytelmän laaja
pohja antaa sille suuressa määrässä eepillisen värin.
Päähenkilön luonteesta valuu toiminta, joka muodostaa näytelmän
varsinaisen perustuksen ja josta draama on nimensäkin saanut
(kreikaksi drama, toiminta). Ainoastaan Aiaan kaltainen sankari voi
joutua sen kohtalon alaiseksi, jota Sofokleen tragediassa kuvataan;
Johanna d'Arcin uskonnolliseen haaveiluun taipuva mielenlaatu tekee
hänet sopivaksi innostuttamaan Ranskan kansaa
vapaudentaisteluun. Daniel Hjortin luonne, niinkuin hänen asemansa
Flemingin talossa, hänen vastoinkäymisensä lemmen-asiassa ja vasta
saatu tieto hänen syntyperästään sen ovat muodostaneet, saattaa
hänet liittymään kansaan ja Kaarle herttuaan ja salaisilla vehkeillä
edistämään heidän asiaansa. Mikä sisimmässä sydämmessä elää, se
pyrkii toiminnassa purkaumaan ja olevaisia oloja uudistamaan;
päähenkilöä elähyttää paatos eli into, joka vaatii häntä
toteuttamaan, mitä hän sielunsa syvyydessä oikeaksi tuntee tai
luulee onnellisuutensa välttämättömäksi ehdoksi. Semmoinen into on
Antigonessa sisarenrakkaus, Marcus Brutossa (Shakespearen Julius
Caesarissa) Rooman tasavallan ihailu, Wallensteinissä pyrintö
itsenäisen aseman saavuttamiseen. — Mutta jos päähenkilön luonne
onkin se lähde, josta toiminta kumpuaa, niin toiminta toiselta puolen
määrää, mitkä luonteen ominaisuudet runoilija kuvauksessaan tuopi
esiin. Yksilön sielunelämä on runsaan runsas aartehisto, jonka
sisällys antaa aihetta mitä erilaisimpiin esityksiin, ja suuret runoilijat,
niinkuin Shakespeare, jotka samalla ovat suuria ihmistuntijoita,
valaisevatkin sitä monelta eri puolelta; mutta silloinkin annetaan
meille pääasiallisesti sellaisia piirteitä, jotka selittävät luonnetta
esitettävään toimintaan nähden. Sillä toiminta on sittenkin draaman
alku ja juuri eli, toisin sanoen, tapausten pääjuoni, kantatarina, on
se siemen, josta näytelmä luonteineen, erityiskohtineen kasvaa ilmi.
Luonteet siis kuvattakoon monipuolisesti, että ymmärrämme sen
kokonaisuuden, jonka ilmauksia yksityispiirteet ovat; mutta
karsittakoon pois semmoiset erityiskohdat, jotka eivät selvennä
kokonaisluonnetta eivätkä sen suhdetta siitä sukeuvaan toimintaan.
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