21st-century transplant doctors and patients continue to grapple with the ethics and practicalities of altering the body.
By Alanna Skuse
In 1624, a physician called Jean-Baptiste van Helmont told a strange story in his book of “magnetic cures” about a man from Brussels who had lost his nose. Having had his nose cut off “in combat”, the man went to a famous Italian surgeon, Gaspare Tagliacozzi, who promised to make him a new one “resembling nature’s pattern”. The problem was that Tagliacozzi wanted to use some of the man’s own skin to recreate the nose. Not keen on this idea, the noseless man decided to buy his way to a new face. He hired a local porter to donate some of his skin and had the surgeon fashion a new nose out of this foreign tissue.
All seemed well, recounted Van Helmont, until just over a year later, the man found that his new nose suddenly grew “frigid and cadaverous”. Over the next few days, it began to putrefy on his face, and within a week it had dropped off entirely.
Investigating the cause of the sudden misfortune, the man’s friends found out that the porter who supplied the flesh had died at just the same time that the nose first turned cold. Though Van Helmont admitted that the story seemed fantastical, he insisted that there were men “of good repute, that were eyewitnesses of these occurrences”. This, he insisted, was not superstition, but evidence of a powerful “affinity” between the borrowed tissue and its original owner.
When I read Helmont’s extraordinary story, almost four centuries later, it led me down a rabbit hole of 17th-century medical and philosophical writings, and eventually to writing a book on early modern surgery and embodiment. In the process, it emerged that the phenomenon Van Helmont described was based on philosophical and scientific speculation about the existence of a “sympathetic” connection between disembodied flesh and its original owner. This in turn reflected deep-seated belief in the importance of one’s body to identity, which led to anxious debates about the resurrection of the body after death.
I also found that though the concerns of Renaissance patients and physicians about “borrowed flesh” might seem outlandish and out of date, they are surprisingly relevant to the modern surgical landscape. Both commonplace cosmetic surgeries and more radical procedures, such as hand and face transplants, centre on the belief that how we look is a central part of our identity, at the same time that they offer us the chance to be our “real” selves by changing our appearance.
Like the early rhinoplasty described by Helmont, most elective cosmetic surgery is still undertaken for aesthetic reasons. The popularity of these “plastic” surgeries has remained steady for several years; 2019 saw 28,000 aesthetic surgeries performed in the UK, of which nearly 3,000 were rhinoplasties (nose jobs).
At the experimental edges of surgical endeavour, however, ever more ambitious attempts are being made to restore and transform patients with facial differences. In 2020, for instance, New Yorker Joe DiMeo became the recipient of the world’s first double hand and face transplant. DiMeo had suffered 80 percent burns in a car accident, and his reconstructive surgery was hailed as a medical breakthrough.
Though often life saving, these radical surgeries can raise issues of identity not dissimilar to those of the Renaissance nose job. The recipient of the world’s first hand transplant, an Australian named Clint Hallam, neglected the physical therapy and close medical supervision his doctors advised, on the grounds that he didn’t identify with his new hand. He then stopped taking his immunosuppressant drugs in order to force surgeons to remove the limb. “As it began to be rejected,” explained Hallam, “I realised that it wasn’t my hand after all.”
In the Renaissance, complete limb and face replacements like those performed on DiMeo or Hallam belonged in the realm of fantasy. Nonetheless, this period too had its surgical pioneers, and Tagliacozzi’s famous nose reconstruction was at the cutting edge of medical science. The operation was first described by Tagliacozzi in 1596; he had probably learned it from an Italian family called the Brancas.
In painstaking detail, Tagliacozzi outlined how a portion of the skin of the patient’s arm first had to be lifted with forceps and cut on two sides, before lint was placed underneath to prevent the skin reuniting with the flesh. When the swelling from this wound had died down, the surgeon was to cut the third edge of the skin flap, fold it back and bandage it, keeping the skin attached to the arm to maintain its blood supply.
After two weeks or so, the surgeon could consider suturing the flap – still attached at one end to the arm – to the mutilated nose, binding the area with specially made bandages. For the first week, it was essential that the patient avoided any movement, even talking, if the skin was to have a chance of adhering. Three weeks later, one might fully detach the skin from the arm and continue shaping the nose. But it would be a further six to nine weeks before the nose could be finished, complete with nostrils.
In an era before antibiotics or anaesthesia, the operation was dangerous and painful. Indeed, it’s unclear if anyone other than Tagliacozzi ever attempted this procedure. Nonetheless, it captured the public imagination, partly because it was so timely.
The 16th and 17th centuries saw an unprecedented need for facial surgery, driven by decades of war and rampant infectious disease. Syphilis, or the “French pox”, as it was known, was both the most commonplace and the most shameful way to lose your nose, as serious infections caused the nasal cartilage to disintegrate. Typically, men picked up the venereal disease in brothels and took it home to their wives, and children might inherit it from their parents.
There was also a social toll from syphilis, with vicious judgements passed on those with visible symptoms. In 1704, for example, the diarist Sarah Cowper was told by her friend about a mutual acquaintance whose husband had given her the pox. Hearing that the afflicted woman was “airy, brisk, and a great Dancer”, Cowper retorted that “by no means shou’d any Woman dance without a nose, tho’ never so innocently lost”.
For many years, people had attempted to hide their shame with false noses, often made of silver and enamelled to look like real flesh. But Tagliacozzi’s operation offered the chance of a real nose. No records exist to indicate how many nose operations Tagliacozzi performed, perhaps because he died aged 49 just two years after publishing his famous work on the topic. Nonetheless, he claimed to be able to make noses “so perfect” that some patients found them “better than the original ones which they had received from nature”.
Of course, this wasn’t easy to achieve. Even in modern hand transplants, the new limb is never a perfect match for the recipient body. The skin will differ in colour or texture, and the point of attachment is clearly visible. In the case of the 17th-century nose job, Tagliacozzi admitted that by using skin from another part of the body, the grafted nose would differ in colour and texture from the recipient’s facial skin, and might grow hair “so luxuriant that it must be shaved”.
These differences led to allegations such as the one made by Van Helmont that, contrary to Tagliacozzi’s original instructions, rich patients were buying flesh from other people to make their new noses. Though there was no evidence for this, it was soon treated as fact, both by other physicians such as Van Helmont and by contemporary satirists. The English poet Hester Pulter wrote a jesting poem to her fellow royalist Sir William Davenant, offering to donate a piece of her leg to repair his missing nose, while the satirist Samuel Butler claimed that:
… learned Talicotius from
The brawny part of Porter’s bum
Cut supplemental noses, which
Lasted as long as parent breech:
But when the date of nock was out,
Off drop’d the sympathetic snout.
In part, this idea of exchanging flesh between one person and another was fuelled by real scientific experiments. At the Royal Society, a coalition of scientists and physicians, men such as Robert Boyle were trialling blood transfusions and skin grafts between animals. They hoped to discover whether qualities such as aggressiveness or friendliness were innate in the blood of the animals they experimented on, though they were hindered by the tendency of their test subjects to run away at the earliest opportunity. In France, meanwhile, there was a bold but ill-fated attempt to transfuse the blood of a calf into a madman. The theory was that the meek nature of the calf would be transferred in its blood, and allay the madness, but instead the man died, and the Parisian medical authorities banned any more human infusions.
Rumours about “borrowed” noses also reflected growing public unease about the potential for cosmetics, prostheses and clothing to deceive onlookers. In the image-obsessed 1600s, fashion-conscious consumers could benefit from padding to fatten the cheeks and hips, corsets to whittle the waist, lead washes to whiten the complexion, rouge to redden the cheeks, and drops to brighten the eyes. More serious customers could even pay to have new teeth inserted, sometimes drawn from the mouths of corpses or servants. The diarist Samuel Pepys made it clear that he considered this to be deceitful:
Sir William Batten doth rail still against Mr Turner and his wife (telling me he is a false fellow, and his wife a false woman and hath rotten teeth and false, set in with wire) and as I know they are so, I am glad he finds it so.
Pepys was peeved to find that he couldn’t discern natural good looks from ones that had been paid for, but the stakes for nose operations were much higher. When a person’s face could be repaired in such a radical way, how could one tell the genuinely healthy apart from the merely wealthy?
Flesh, spirit and sympathy
As the story of the Brussels man who lost his nose reveals, there was another, more serious problem with the nose operation. Several sources alleged that if a patient had their new nose made from the flesh of another person, that nose could drop off when the donor died.
In 1658, for instance, the scientist and courtier Sir Kenelm Digby asserted that:
Artificiall noses that are made of the flesh of other men … do putrifie as soon as those persons out of whose substance they were taken come to die, as if that small parcell of flesh ingrafted upon the face did live by the spirits it drew from its first root, and source.
He was probably thinking back to a story told by the physician-astrologer Robert Fludd, who in 1631 relayed the story of a lord who had a new nose made from the flesh of a slave. All seemed well with the new nose, said Fludd, until “it happened, that the slave fell sicke and dyed, at which instant, the Lords nose did gangrenate and rot”.
What was the cause of this misfortune? Fludd and Digby claimed that the death of the grafted-on noses was proof of a quasi-scientific idea known as the doctrine of sympathy. This theory, which was esoteric even for its own time, held that atoms – a term used in this period to describe small, indivisible particles – had an identity. That is, they were blood atoms, nose atoms, or so on. Each atom had an in-built affinity with others of its own type, meaning that given the chance, atoms would travel through the air to where they were most plentiful (say, transplanted nose atoms travelling back to their original owner).
Proponents of sympathy claimed that using this principle, they could cure wounds at a great distance. For instance, by applying a special “wound-powder” to blood that had dried on a knife, they could cure the wound which the knife had inflicted, even if they had never seen the patient. The atoms of wound-powder would travel with the blood atoms from the knife to the patient’s body. The same principle also applied in reverse; as one anonymous text asserted, grafted-on noses were “nevertheless still animated with the Vitality of [the donor], of whom it was yet truly a part”.
The doctrine of sympathy never gained much credence among the medical establishment, who saw it as at best foolish and at worst evidence of witchcraft. But the idea that noses always “belonged” to their original owner tapped into deeper worries about what “belonged” to any individual body. Most early modern Christians believed that on the day of resurrection, those who were destined for heaven would be raised out of the grave in the same bodies which they had in life. The book of Corinthians reads:
So also is the resurrection of the dead. It is sown in corruption; it is raised in incorruption:
It is sown in dishonour; it is raised in glory: it is sown in weakness; it is raised in power
This was taken to mean that people who died old, sick or disabled would be resurrected strong and healthy, free from the sufferings they had endured on earth.
It was a comforting thought, but in practice, it raised many questions. Even in peacetime, the fate of amputated limbs was uncertain. For instance, in 1720, the London Journal newspaper reported:
On Monday last part of the right Leg of a man was found in a Cellar Window in Bartholomew Close, which probably may have belonged to some Patient in the neighbouring Hospital, that has undergone an Amputation.
The 17th century was far from peaceful, with decades of war at sea and on land, and many soldiers maimed far from home. What happened, then, if one lost a leg in the Atlantic sea and later had one’s nose disintegrate from syphilis? How were those parts to be restored at the resurrection? This wasn’t only a question of finding the missing parts. What happened if the leg lost at sea was eaten by a fish, which was then eaten by a person? The atoms which had made up the leg were now making up that other person, and they couldn’t be restored to both parties at the Last Judgement.
Philosophers and poets agonised over these issues. Some suggested that perhaps not all of the matter that had made up the body needed to be resurrected, and instead it would be enough if just the bones and the major organs were made of the same stuff as in life. Others pointed out that the body produced a lot more matter over the course of a lifetime than it needed, in the form of fingernails, hair and shed skin. Perhaps this superfluous material could make up any shortfall?
For the most part, however, writers on this subject followed the lead of poet and clergyman John Donne, who insisted (though a little too fervently) that God would sort everything out in His own mysterious way. God, preached Donne, “sits in heaven, and spans all this world, and reunites in an instant armes, and legs, bloud, and bones, in what corners so ever they be scattered”. It might seem to mere mortals that resurrection was fraught with problems, but good Christians should have faith that even their “scattered body” would be repaired and recompacted.
While Donne’s advice reflected the religious orthodoxy of the time, the actions of everyday people show that they still worried about these issues. Criminal punishments involving being cut up and one’s parts scattered about struck fear into audiences precisely because they feared that these parts might not be gathered up at the resurrection.
Some law-abiding citizens made efforts to make sure that their bodies stayed intact as much as possible by specifying in their wills that they didn’t want to share a tomb, even with members of their own family. People who had amputations might even bury their lost limbs, ready to be reunited at a later date. At a graveyard in west Wales, there is an 18th-century tombstone with the inscription:
Here lies the Leg of Master Conder:
But he’s alive, and that’s a Wonder.
It was cut off by Dr. Johnson,
The famousest Surgeon of the Nation.
All these controversies centred on the belief that a person’s identity could not be separated from their body. Grafted flesh would always “belong” to its original owner, and keeping one’s body together was important even after death.
To my surprise, a little research into modern transplantation showed that similar impulses still inform amputations and transplant surgeries, and especially hand and face transplants. While most amputated body parts are disposed of as medical waste, both the UK and US now offer patients the chance to preserve their limbs for burial. What is more, the donors of both hands and faces may now receive prostheses that restore them to bodily “wholeness” before they are buried.
Of course, these aren’t driven primarily by religious considerations, but by concern for the families and doctors involved. One 2007 article proposing use of silicone facial prostheses for face donors found that this intervention was welcomed by doctors involved in transplantation. In India, it’s now recommended practice to attach artificial hands to the bodies of deceased hand transplant donors, a step that’s undertaken more patchily in other parts of the world.
The donor of Joe DiMeo’s new face and hands received “replica parts” supplied by New York University’s LaGuardia 3D printing studio. Explaining the decision, DiMeo’s doctor Eduardo Rodriguez told the New York Post: “Despite the fact that they’re now declared deceased […] we still respect the dignity of the donor. It’s important for us to continue to care for the donor because that patient is still our patient.”
DiMeo has gradually regained physical function, but the immunosuppressants he has to take for the rest of his life are a reminder that in one sense at least, his transplants are still “borrowed” flesh. Like Van Helmont’s nose-buying nobleman, 21st-century transplant doctors and patients continue to grapple with the ethics and practicalities of altering the body.