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A History of Organ
Transplantation
A History of
Organ
Transplantation
Ancient Legends to Modern Practice

David Hamilton
With a Foreword by
Clyde F. Barker and Thomas E. Starzl

University of Pittsburgh Press

Published by the University of Pittsburgh Press, Pittsburgh,
Pa., 15260
Copyright © 2012, University of Pittsburgh Press
All rights reserved
Manufactured in the United States of America
Printed on acid-free paper
Designed and typeset by Kachergis Book Design
10 9 8 7 6 5 4 3 2 1

Library of Congress Cataloging-in-Publication Data

Hamilton, David, 1939–
A history of organ transplantation / David Hamilton ;
with a foreword by Clyde Barker and Thomas E. Starzl.
p. cm.
Includes bibliographical references and index.
ISBN 978-0-8229-4413-3 (hardcover : acid-free paper)
1. Transplantation of organs, tissues, etc.—History.
2. Organ transplantation—History. I. Title.
RD120.6.H36 2012
362.1979´5—dc23 2012008954
 Contents

Foreword, by Clyde F. Barker and Thomas E. Starzl vii

Acknowledgments xi
Introduction: Toward the Impossible xiii

1 Early Transplantation 1
2 The Eighteenth Century 31
3 The Reawakening 49
4 Clinical and Academic Transplantation in Paris 65
5 The Beginning of Organ Transplantation 88
6 The “Lost Era” of Transplantation Immunology 105
7 Anarchy in the 1920s 126
8 Progress in the 1930s 154
9 Understanding the Mechanism 173
10 Experimental Organ Transplantation 195
11 Transplantation Tolerance and Beyond 221
12 Hopes for Radiation Tolerance 254
13 The Emergence of Chemical Immunosuppression 269
14 Support from Hemodialysis and Immunology in the 1960s 296
15 Progress in the Mid-1960s 314
16 Brain Death and the “Year of the Heart” 340
17 The Plateau of the Early 1970s 359
18 The Arrival of Cyclosporine 380
19 Waiting for the Xenografts 413
Conclusion: Lessons from the History of Transplantation 423

Notes 431
Bibliographic Essay 527
Index 539
Foreword

David Hamilton has been a senior transplant surgeon at the Western

Infirmary, Glasgow, Scotland, and also the first director of the Wellcome
Unit for the History of Medicine at Glasgow University. In addition, he is
steeped in the lore and the basic science of the field because of his early
training under the great transplantation biologist Peter Medawar. Thus, it
is no surprise that he has written a history of transplantation that is un-
matched in its scope, perceptiveness, and readability.
The masterly account he has crafted comes at an appropriate time,
since organ transplantation has now become widely accepted as the best
therapy for many otherwise fatal diseases. The surgeon-author of this book
has watched and participated in many of the events as the field evolved
over the last half century. Having looked back as an informed insider, he
has added his historian’s detachment and insight to the narrative.
Within living memory, organ transplantation existed only in science
fiction. As a handful of surgeons and other dreamers set off in the 1960s
“toward the impossible,” they met huge challenges. The attitudes of that
early time are vividly re-created in this book and will remind future read-
ers that major innovation, clinical or scientific, is never easy and indeed
can be a lonely business. Surgical replacement of a diseased organ consti-
tuted a paradigm shift. Its success altered forever the practice of several
medical specialties while enriching multiple areas of basic and clinical
science. Arguably, transplantation created the field of modern immunol-
ogy rather than the other way around. And it had ripple effects in law,
public policy, ethics, and even religion. Not omitted from Hamilton’s ac-
count is the now-forgotten attitude of many in the medical profession that
this journey was futile and should not be attempted.
The momentous scientific events of the 1950s are often taken as the
starting point for organ transplantation, but there is a surprisingly long
international prehistory, one that is highlighted in this book for its signifi-
cance. The book is the first to tell the complete story of these earlier times,
and this careful account in the first half of the book at last replaces earlier

vii
short, patchy, and often patronizing versions. The reader will be surprised
at the vitality of the “lost era,” as Hamilton calls it, of transplant stud-
ies before World War I. Also sharply delineated, analyzed, and explained
are the events in the anarchic 1920s, when good science was at a low ebb
and the monkey and goat gland transplanters assumed a license to mis-
lead the public.
In the daunting task of taking on the technical challenge of organ
transplantation, surgeons formed a fruitful partnership with some of the
world’s greatest scientists to probe the biology of graft rejection. The au-
thor examines this partnership closely and offers the shrewd conclusion
that the surgeons were by no means the junior partner in the relation-
ship. The reductionist approach of immunologists and their in vitro mod-
els were often misleading, resulting in faulty paradigms. Time and again,
surgical empiricism led to unpredicted outcomes and advances that sent
the immunologists back to the lab to think again.
Here also is an account, in this niche endeavor, of the so-called scien-
tific method in action. The author is clear that, in surgery at least, there is
no single method of discovery but rather a rich variety of methods. In the
minor supporting strategies, Hamilton winkles out fascinating examples
of good luck, bad luck, serendipity, personal rivalry, and arguments. Add-
ing to his text are extensive scholarly citations that provide a helpful road
map into the vast literature on organ transplantation.
As this book clearly shows, developing transplantation as a clinical ser-
vice was not simply a surgical matter, limited to the attainment of tech-
nical success. Hamilton crucially re-creates the multiple influences, help-
ful and otherwise, that came into play. Transplantation generated a raft of
ethical issues, funding challenges, and continuous contact with lawmak-
ers and governments, all of which had national and international nuances.
Running through this book are interesting asides on the use of trans-
plant themes in the fictional literature of the day, a reminder of the pub-
lic’s interest and involvement. Any undue hubris on the transplanters’
part meant that nemesis followed—a drop in public confidence and hence
a decrease in the donation of organs essential to the service. Nor were the
media always supportive. In the aftermath of the transplants of the 1968
“Year of the Heart,” as it is called here, there was an international crisis of
confidence in transplant circles, one which should not be forgotten.
Throughout, the patients were the heroes, supporting the transplant
surgeons from the first and disarming nay-saying critics simply on the
grounds that, as patients, they would rather be alive than dead.
Limitations of space preclude a complete consideration in the book’s
later chapters of recent advances made possible by tacrolimus, multivis-

viii Foreword
ceral grafts, composite tissue transplants (e.g., hand and face), and increas-
ing recognition of the crucial role of cellular chimerism as transplanters
approach their ultimate goal—tolerance of organ allografts without need
for immunosuppressive drugs.
Hamilton acknowledges that the story of transplantation is still being
written. Yet, because some of the key professional figures of the early days
of transplantation are still alive, this is an important time to tell the story.
As noted in The Puzzle People (T. E. Starzl, 1992), the pioneers are “work-
ing their way one by one to the side of the stage. Passages into the wings
are done by steps, minuet style. One device to get there is with a confer-
ence at which past contributions and efforts are celebrated by one’s friends
and former foes . . . ; they resemble the tours from city to city made by age-
ing baseball stars, some modest and some not, who are in their final sea-
son of play. The meetings are not designed to discover why these men did
what they did. The secrets are within them, hidden beneath a pile of emo-
tional stones which only they have a right or the knowledge to probe.”

Dr. Clyde F. Barker

Distinguished Service Professor and Professor of Surgery,
    Emeritus, University of Pittsburgh
President of the American Philosophical Society

Dr. Thomas E. Star zl

Director Emeritus, Thomas E. Starzl Transplantation
    Institute, University of Pittsburgh

Foreword ix
Acknowledgments

In the e arly 1970s, I became involved in clinical transplantation, and

from that time forward witnessed the work of the transplant pioneers as
they contributed to the evolving field. When I developed an interest in
medical history, I had more focused discussions with many of the early
workers, notably Sir Peter Medawar and Avrion Mitchison at Mill Hill,
Tom Gibson in Glasgow, Sir Michael Woodruff in Edinburgh, Leslie Brent
in London, and Sir Roy Calne in Cambridge. During my travels, I talked
with many notable figures in the United States, including Joseph Murray
in Boston, Blair Rogers in New York, and Willem “Pim” Kolff at Salt Lake
City. In Europe, there were visits to Jean Hamburger, Marcel Legrain, and
Gabriel Richet in Paris. More recently, I asked questions of others, nota-
bly Stuart Cameron and Richard Batchelor in London and, in the United
States, Norman Shumway and E. Donnall Thomas passed on many help-
ful insights. Paul Shiels in Glasgow assisted with news from the new world
of cellular engineering, and Richard Rettig contributed his unique knowl-
edge of how U.S. political culture influenced the treatment of end stage
renal failure.
Assisting with text, Jack MacQueen, Winifred MacQueen, and Harry
Hine translated the early Latin extracts, and Sandy Reid in Edinburgh
made the first full translation of Yuri Voronoy’s pioneering papers on kid-
ney transplantation from the 1930s. Henning Köhne and Anni Schneider
made valuable translations of the forgotten German papers of the early
twentieth century, and Henri Jacubowicz and Hala Girgis checked and
translated the French-language citations.
My wife, Jean, encouraged this endeavor from the start, as did Sir Pe-
ter Morris, J. Douglas Briggs, and others in the British Transplantation
Society. J. Andrew Bradley at Cambridge read the text at an early stage,
and John MacConachie of Lossiemouth was my faithful reader and text
editor over many years. Charles Webster and the Wellcome Unit for the
History of Medicine at Oxford University gave me space for study during a
sabbatical stay there. For written sources, there was great assistance from

xi
London’s Royal Society of Medicine Library and its incomparable collec-
tion of early journals, particularly of German and French origins, and
Jonathan Erlen made the historical collection of the Falk Library in Pitts-
burgh available to me.
I am especially grateful to Thomas E. Starzl, who supported me as a
visiting lecturer at the University of Pittsburgh Medical School. To his
unique position in the history of transplantation he adds keen historical
insight, and I am in his debt for detailed comments on the text. He also li-
aised with the University of Pittsburgh Press in publishing this book, and
there I was encouraged and supported by the talented staff of the Press, in
particular by my editors, Beth Davis and Alex Wolfe, who saw the project
through with skill and care.

xii Acknowledgments
Introduction
Toward the Impossible

It is usually thought that within the general advance of medicine,

tissue and organ transplantation has a short history. Certainly the mod-
ern successful era started only in the 1950s, but there was earlier, much
earlier, interest. Even the surgical records from 600 BCE contain accounts
of plastic surgery, and the question of the use of tissue from donors ap-
pears in surgical works of medieval times. And many outside of surgery
were interested from the first in the replacement of lost tissue. In medi-
eval times, numerous shrines to the saints Cosmas and Damian and im-
ages of those twin physicians showed them transplanting a human leg. In
Bologna, word of Gaspare Tagliacozzi’s plastic surgery spread, and peo-
ple widely (and wrongly) believed that he had obtained grafts from living
donors and that when the donor died, the donated graft also died. Philoso-
phers pondered deeply on the matter, and this urban myth, too good to be
false, spread rapidly throughout Europe and was sustained by the satirists
and coffeehouse gossips of London in the early 1700s.
In the 1800s, the public noticed the activities of tooth transplanters,
and antivivisectionists protested experimental transplant work in France.
In the 1920s, skin and “monkey gland” transplantation gained a new and
dubious public fame. By the 1960s, surgeons rode high in public esteem,
not least for the new success with organ grafting. The public were amused
rather than shocked by the prospect of humanized pig organs in the
1900s, then intrigued by intricate arm, leg, and face transplants, and en-
tranced by the hopes for organs grown from stem cells. The default view
of the public, disturbed briefly from time to time, seems to be that trans-
plantation attempts are admirable. Public opinion has a unique day-to-day
input in clinical transplantation since transplantation requires organ do-
nors and, hence, the support of the public. When public opinion is alien-
ated, all donations decrease.
Among the interested public observers of transplant history were writ-
ers, fascinated by the possibilities and keen on exploiting each new effort.

xiii
London satirists in the 1700s found a convenient literary motif in John
Hunter’s transfer of teeth from the poor to the rich. The London revival of
plastic surgery in the early 1800s provided inspiration for the monster in
the novel Frankenstein, and by the end of the century, the grafting of skin
and glands provided a mother lode of opportunities for what was soon to be
called science fiction. An early practitioner, H. G. Wells, introduced fanciful
transplantation possibilities into his work and thence into popular culture.
This genre blossomed as a result of the anarchy in the transplant world of
the 1920s. Adding to the gland-graft rejuvenation possibilities, there were
tales of head, brain, face, and limb transplants. The inventive authors had
license to transfer much else with the tissue—hands donated from dead
murderers could prove murderous, brain grafts might be malevolent, and
simian characteristics could appear after monkey testis transplants. With
good science restored in mid-twentieth century, transplant themes were
temporarily absent from the fiction of the day, but the controversies of the
heart transplants and brain death in the 1970s encouraged publishers and
writers to return to these genres. These novels fed on the new fears of the
times, featuring sleazy doctors and organ-snatching gangs, but in the more
settled periods that followed, popular nonfiction accounts found success,
and positive personal stories of successful organ grafts sold well.
But it was not until the early 1950s that surgeons embarked with grow-
ing success on what was widely considered to be an unreachable mission,
namely to successfully graft an organ from one person to another. Such
grafting was considered to be impossible because the human body almost
invariably rejected grafts from either humans or animals, other than in a
few special situations. This reaction against foreign tissue, found at all lev-
els of the animal kingdom, seemed so fundamental that no strategy, sur-
gical or pharmacological, could hope to triumph over the problem. More-
over, many members of the medical community respected this relentless,
ubiquitous power of the body to reject what was foreign to it, and many
medical professionals, even surgeons, believed that to try to stave off re-
jection was not only futile but also “against nature.” The pioneers in organ
transplantation thus faced not only a huge biological challenge but also
peer opposition and even hostility at times. Although the early transplants
of the 1950s and 1960s are now seen as praiseworthy “firsts,” that admi-
ration did not characterize opinions at the time. Recognition of the early
achievements took time, and that pioneering work finally won acclaim as
one of surgery’s greatest contributions. Those surgeons who paved the
way steadily gained international honors. By the end of the twentieth cen-
tury, clinical success with organ transplantation between humans was al-
most complete, having reached the status of a routine, noncontroversial

xiv Introduction
service. Transplantation science efforts did not cease; further ambitions
appeared, namely to develop ways to create new human organs.
In writing this account of how organ transplantation evolved, I had
two tasks. The first was to provide an in-depth account suited for readers
having some familiarity with the practice of medicine. Previous histories
of transplantation have suggested that transplant-related activity before
the 1940s was “prescientific,” or quaint. I believe it is important to recog-
nize important early work, and those who did that work, and to give them
their proper place in a more complete historical record. My second task
was to be attentive to medical historians’ questions and their attitudes.
I hope to have placed the history of transplantation in a broader context,
avoiding the “upward and onward” idea of continuous progress in medical
history so easily created with the benefit of hindsight. In particular, the
many unprofitable matters that exercised the minds of those involved in
transplantation from time to time are not ignored, nor should the times of
hesitation and diversion be forgotten.
Surgical attempts to replace defective human tissue have a long his-
tory. As mentioned, manuscripts from the Indian subcontinent in the sixth
century BCE describe carefully conducted plastic surgery. The grafting of
skin flaps was the most ancient and established procedure for replacing
tissue, and from early times, this practice included the possibility that an-
other person could supply the skin graft for the patient in need. Donor-to-
patient skin grafting was a goal surgeons began seriously pursuing in the
1600s. When the advance of medicine revealed that disease might result
from problems with a specific organ rather than from a diffuse imbalance
in body humors, physicians began to harbor wider ambitions for grafting
damaged organs. The availability of anesthesia and measures to combat
infection in the mid-1800s made such surgery even more promising.
But the simplicity of the ancient challenge contrasted with the com-
plexity of the response and the diversity of the attempted solutions. When
surgeons realized in the mid-1900s that the body’s rejection of grafted
tissue was a form of immunity, they turned to biomedical scientists for
help in understanding and dealing with this obstacle to transplanta-
tion. The surgeons, normally self-sufficient in their endeavors and usu-
ally meeting the largely technical challenges of their work with their own
novel solutions, needed assistance. Distinguished biologists willingly of-
fered support, not only to further the surgeons’ quest but also to advance
their own efforts in attempting to understand the body’s most complex
and mysterious mechanism, one able to detect the tiniest deviation from
its own structure. The “exquisite specificity” of this cell-mediated mecha-
nism was clearly not designed to defeat the surgeon’s efforts and explains

Introduction xv
the biologists’ not-so-hidden interest in this combined venture. The joint
effort yielded the rewards of not only clinical success for the surgeons but
also broad fundamental insights that changed the course of biological sci-
ence. The enigma of cell-mediated immunity was better understood, and
the behavior of the body’s defense cell—the lymphocyte—was so closely
studied that this bland white cell became the model for investigating
many cellular functions. The efforts to make human organ transplanta-
tion a reality also brought in hematologists familiar with blood typing,
and they successfully unraveled the complexity of tissue types, allowing
organs and tissue grafts to be matched to recipients. When tissue types
proved to be related to the development of certain human diseases, scien-
tists entered a new era of research on genetic susceptibility.
In joining this common cause of understanding the body’s immune
response, surgeons brought the scientists’ hopes for inducing tolerance
in human grafting. Researchers developed an array of immunological lab
tests and measurements that could be put to clinical use, but surgeons
were not simply the recipients of a one-way flow of information, and they
were cautious in accepting all the results from basic science studies since
humans might not function like the mouse. Sometimes discovery and en-
lightenment traveled in the opposite direction—from a clinical setting to
the research lab. Surgeons made many unexpected observations of how
the body functioned when it needed and received a transplant, and this
real-world information sometimes contradicted received wisdom and
made immunologists rethink some of their theories. One such surprise
was when, after human organ recipients had transplant rejection “crises,”
viable grafts could be rescued, something never achieved in studies with
small animals. Another unexpected discovery was that long-term human
graft recipients showed evidence of the grafted tissue adapting to its new
environment, which meant that immunosuppression therapy could cease
without prompting rejection. Similarly unexpected was the discovery of
microchimerism in long-standing human grafts, when some migrant do-
nor cells still mingle with the host cells. The periodic discovery of such
clinical novelties was important to the common effort but was especially
significant for surgeons. At times of sluggish progress or public concern,
transplant surgeons were often urged to “go back to the lab,” but surgeons
could weather such periods with confidence, knowing that test-tube re-
ductionism and small animal studies were not the only route to success.
The understanding and treatment of other conditions also benefited
from the developments in organ transplantation. Immune suppression to
prevent organ rejection led to a range of uncommon and unpleasant in-
fections, and, as a result, the many consequences of the low immune re-

xvi Introduction
sponses seen in AIDS patients were not unexpected, and therapies were
thus already available. Even the earliest transplants, well before the 1950s,
revised basic understandings of human disease mechanisms. In the eigh-
teenth century, when John Hunter’s living donor tooth transplants trans-
mitted syphilis even though the tooth and its donor looked healthy, it was
realized that serious disease could lie latent in tissues. A century later, the
same lesson was taught when the enthusiasm for skin grafting resulted in
the transmission of smallpox from donor to recipient. The situation arose
again in the 1960s, when human kidneys from donors with previous can-
cer were transplanted and the kidney promptly began showing latent met-
astatic cancer deposits.
Even the understanding of human anatomy advanced as the result of
surgical work. One might think that the human kidney had been well de-
scribed for centuries, but when transplant surgeons had to take a closer
look, they discovered the descriptions in even the best texts were deficient,
particularly with regard to the main blood vessels and the supply to the
ureter. Rather than one large artery, often there were two or more small
ones—a situation that was of vital interest to the transplanters. Even more
striking was the anatomy of the liver. The left and right lobes were an
obvious subdivision used in traditional anatomical teaching, but surgi-
cal observation revealed that these lobes were not functionally separate.
Bold attempts at excising liver tumors or dealing with liver trauma met
uncontrolled bleeding or fatal bile leakage. The surgeons had to analyze
liver anatomy with fresh eyes in the hope of finding safe surgical paths
through the apparently homogeneous organ. Their efforts revealed true
planes of cleavage and lobes with their own vessels and ducts. With this
knowledge, the surgeons could split a liver and replace the diseased livers
of two persons instead of one, or they could remove one lobe from a living
donor. Thus, instead of guiding the surgeon’s hands, the anatomy books
were being rewritten by the surgeon’s hands.
No medical endeavor has as many multiple interfaces with other dis-
ciplines as transplantation. Legal considerations played a role from the
start, especially with regard to the concept of who owned the body of a
deceased person. In the 1950s, the law, such as it was, dated back to the
grave-robbing scandals of the early 1800s. When corneal grafting became
more widespread in the 1950s, however, lawmakers implemented changes
to allow quicker acquisition of donated tissues. By the 1960s, when kidney
organ donation became possible, further legal changes were needed, and
soon further changes had to follow, not without controversy, after brain-
death criteria became used in intensive care units, with organ donation
following. With rapid medical advances, the law often lagged behind.

Introduction xvii
 Transplantation issues were among the first group of ethical concerns
that gained prominence in medicine. Religious beliefs and the broader
prohibitions in the ancient Hippocratic Oath had always had some influ-
ence on clinical practice, but in the early 1960s fresh ethical issues steadily
arose. One of the first issues to attract attention was how to determine who
should receive dialysis treatment for chronic renal failure. A new cadre
of bioethicists emerged, and, increasingly, the public became involved in
medical decision making. With new issues such as kidney donation to rela-
tives and the intense controversies over brain death and heart transplants,
bioethics became firmly established as an influence in the clinic. Bioethi-
cists soon began to debate such topics as “equity” and “utility” in the distri-
bution of scarce donor organs, xenografts (from animals to humans), and
stem cell use.
By the 1960s, governments and insurance providers had to acknowl-
edge the reality of organ transplantation. Research funding in the United
States and local health care budgets in Europe had financed early attempts
at organ transplantation. However, when organ grafting became accepted
and the number of transplants increased, overall costs rose, particularly
when liver transplantation emerged as the highest-cost single procedure
in medical care. Each developed nation fashioned its own method of fund-
ing transplantation work, and support was often obtained only after tough
negotiations and debate.
The practice of organ transplantation has spread across the globe at
an uneven pace. Other types of new surgical procedures usually take hold
steadily in less developed nations, emerging when finances permit, public
awareness increases, and demand grows. In those circumstances, a sur-
gical procedure usually retains its original clinical characteristics. In the
case of organ transplantation, however, there is often resistance in less de-
veloped nations. In such places, the demand for expensive procedures like
transplants may be outweighed by the urgent need to address common in-
fectious diseases. Cultural attitudes and religious teachings on death and
donation may mean that decreased-donor organ transplantation is unac-
ceptable.
Wars, hot and cold, have also had their impact on transplantation re-
search and practice. World War I spelled the end of earlier studies in
transplantation immunology on what seemed the eve of the birth of hu-
man organ grafting. In the 1920s, many physicians seemed to abandon
such progressive notions, reverting to an older, holistic style of medicine
with Hippocratic attitudes and simple therapy using lifestyle adjustments.
Science-based clinical aspirations faded away, particularly in Europe,
and experimental organ transplant surgery stagnated. This mood ceased

xviii Introduction
abruptly in the early months of World War II, when pressing clinical is-
sues, notably aviators’ severe burns, meant new government attention to
the need for progress in this normally mundane matter. Scientists and
plastic surgeons undertook new skin grafting studies and attempted to
graft tissue from one individual to another. During the Korean War, the
artificial kidney machine, controversial to that point, proved its worth and
spread from military hospital settings into routine civilian use, as did im-
proved vascular surgical methods.
The cold war led to massive spending on nuclear weaponry and the
search for an effective means of protecting humans from radiation. A so-
lution to the latter challenge remained elusive, but the research led to ra-
diation therapies that could be used in transplanting bone marrow cells.
This procedure resulted in the first workable methods for successful hu-
man organ grafting. Another result of these military studies was the prep-
aration and production of a range of radioactive isotopes, which promptly
proved to be powerful therapeutic and investigative tools. For example,
isotope labeling solved some immunological mysteries, notably the life-
span and travels of the lymphocyte.
In the Soviet Union, ideology directed scientists’ biological research,
which meant a thoroughgoing rejection of “Western” genetic research.
This faulty, politicized science meant that the Soviets’ creditable contri-
butions to immunology, including the first well-conducted human kidney
graft, came to an end for decades.
Technological advances, too, played a role in the advance of organ trans-
plantation, but it was an unsung role. From earliest times, apart from slow,
long-standing, steady improvements in surgical instruments, perhaps the
first major development to affect transplant work was the improved mi-
croscope produced in the mid-1800s; Claude Bernard used the new in-
strument in his important skin graft studies. In the early twentieth cen-
tury, new techniques for measuring such things as hormones in the blood
made endocrinology respectable. That particular advance defeated the pro-
moters of animal sex gland transplants: the grafted glands produced no
hormones. Developed in the 1940s, the flame photometer could measure
electrolytes, extending the work of clinical biochemistry labs, and the revo-
lutionary AutoAnalyzer of the late 1950s could rapidly yield the numerous
lab test results needed for dialysis efforts. By the 1960s, blood gas analysis
devices provided the frequent assessment of respiratory function needed
for successful long-term respiratory support in intensive care units. X-ray
methods largely dating from the 1920s could assess some aspects of kid-
ney function, but, by the 1980s, ultrasound examination revolutionized
the management of organ grafts. Added to the impact of this expensive, so-

Introduction xix
phisticated technology was the availability of plastics. Introduced in 1960,
the plastic arteriovenous shunt made regular dialysis possible. Cheap, ster-
ile, disposable tubes and containers revolutionized daily life in the lab, and
with helpful micro-dispensers, they notably sped up serological testing
and the study of isolated cells—which could also now be cryopreserved.
New surgical instruments useful in transplant research and surgery in-
cluded slim, eyeless needles bearing a single fine synthetic suture and the
fiber-optic instruments that revolutionized minimally invasive techniques,
including laparoscopic kidney surgery.
It may come as a surprise to some that, until the 1980s, the pharma-
ceutical industry did little to support transplant surgeons’ work. In the
1960s, the industry did not involve itself in organ transplantation matters
because there seemed to be no promise of a sizable market. Instead, sur-
geons devised their own immunosuppressive methods using established
drugs or variants, even adding their own homemade agents, such as an
antilymphocyte serum. When powerful pharmaceuticals such as cyclo-
sporine were developed and marketed, the industry entered permanently
and controversially into the life and activities of transplant units, and the
earlier surgical innocence was lost. Each new drug that entered the mar-
ket was expensive, reflecting the huge costs of development and the re-
quired clinical trials. Transplant units increasingly accepted the financial
and corporate presence of pharmaceutical companies, which could set the
conditions and endpoints of any drug trial. These trials began to dom-
inate clinical management in each unit, and the marketing of the new
drugs could also be intense.

I became personally involved in clinical transplantation in the early 1970s,

and in this account I offer my sense of how organ transplantation devel-
oped in the years that followed. It is an account that I hope will offer in-
sights that a historian might miss when trying to reconstruct events only
from scattered primary sources.

xx Introduction
1 Early Transplantation

T
o e arly humans, as to all their descendants, the possibility of
restoration of lost or mutilated parts of the body was a lively is-
sue. To make good such losses incurred by war, disease or pun-
ishment, ancient humans had recourse to local help and healers. But they
also looked for supernatural help, because legends told them that such
powers could be used to make the injured part whole again. And there
may have been an additional imperative to ancient humans to be restored
to normal. If after death the body went in a mutilated, deficient state to
the afterworld, subsequent resurrection was deemed to be impossible.1
This belief persists in some cultures to this day.2

Ancient Legends of Replacement

Stories of successful magical replacement of lost tissues are found in the
themes of folklore from all parts of the ancient world. The tales of restora-
tion of lost limbs or eyes, and even replacement of decapitated heads, are
hardly less popular in ancient lore than the raising of the dead or magical
cures for paralysis or blindness. These transplant claims are found in the
legends of all nations, from Iceland to Africa.3
The tales fall into a number of patterns. An arm, hand or leg, or eyes
have been lost. The sufferer is in some way worthy of cure, and a priest or
shaman successfully restores the necessary part, but, in other stories, less
noble forces are at work. In one variant, villagers capture malevolent ma-
rauders and cut off their heads, but new heads grow again immediately,
and the raiders continue to attack. In other accounts, an attacker’s freshly
removed head is replaced immediately, but at an angle, resulting in a per-
manently twisted neck. In other versions, the head is replaced back-to-
front, adding to the terror of the appearance of the restored bandits.
Irish and North American Indian transplant stories tell of a juggler
given the power to remove his own eyes a specified number of times, and,
having exceeded his quota and thus lost his own, he uses animal eyes to
replace the lost globes. In a splendid Irish legend about Nuada, an impor-
tant ruler who loses a hand in battle, there are many familiar themes:

1
According to Celtic custom, no maimed person could rule, and Nuada was re-
moved from power. But who should turn up on his doorstep but Miach, a cele-
brated physician. After impressing the half-blind doorkeeper by replacing his bad
eye with a good one from a cat, they easily gained access to Nuada himself. . . .
Miach had Nuada’s own long-since buried hand dug up and placed on the
stump. Over it, Miach chanted one of the best known of old Gaelic charms, en-
joining each sinew, each nerve, each vein, and each bone to unite, and in three
days the hand and arm were as if they had never been parted. . . .
Ever afterwards the poor doorkeeper’s cat’s eye stayed awake all night looking
for mice.4

Traditional tales from China even relate to heart transplantation. In

one, Judge Lu assists an illiterate man by giving him a new heart “picked
in the nether world from among thousands of human hearts.” In an-
other, the Chinese doctor Pien Ch’iao exchanges the hearts of two men
to “match their energies better” and uses “potent herbs” to ensure success
after the operations.5 Less dramatically, Hua T’o, the talented “surgeon of
the Three Kingdoms,” is able to remove, wash, and replace defective in-
testines.6 Greek legends recount that the Graiai were sea goddesses who
lacked teeth and eyes but successfully passed one of each between them
for use. On the utopian island described by Iambulus around 100 BCE
were tortoises whose blood had a glue powerful enough to reattach sev-
ered body parts. In Apuleius’s circa AD 160 Latin retelling of the Greek
tale The Golden Ass, the hero’s nose and ears are removed by witches and
then replaced with wax.
These early stories feature the first ethical dilemmas of transplan-
tation. In one, a goddess switches the heads of a married man and his
brother. Which part, the tale asked, was now the real husband—the body
or the head? Less ethically complex was Zeus’s action in stitching the
doomed, premature baby Dionysus onto his thigh until the child grew
bigger and was ready to be born. A later tale, surviving to medieval times
and collected by the brothers Grimm, told of a transplant that transferred
the donor’s personality: a hand transplant from a thief makes the recipi-
ent turn to stealing.

Chimeric Monsters
Another class of legend testified to the possibility of fusing tissues from
different species to produce hybrid beings.7 Ancient humans harbored
a lively belief in the centaur (half man, half horse) and in other fusions
that resulted in dragons, griffins, mermaids, Pegasus the winged horse,
the Minotaur, and the Sphinx.8 Hittite temple carvings depict some fierce
composites with the head of a man, body of a lion, and wings of an eagle.
The young Hindu god Ganesha, son of Shiva and Parvati, gained a new

2 Early Transplantation
 The hybrid “mantichora” shown in
Edward Topsell’s Historie of Foure-
footed Beastes (London, 1607), 344.
Image courtesy of Glasgow University
Libraries Special Collections.

animal head after decapitation by his angry father. Repenting of his act,
the father told his servants to obtain the head of the first living being they
could find, which was an elephant.9 In ancient Greece, the fire-breathing
Chimera (part lion, part goat, and part serpent) was the alarming creature
of The Iliad that terrorized ancient Lycia in Turkey before the heroic Bel-
lerophon destroyed it. The unpleasant lamia was a female who was part
snake, and the harpies were ugly, winged birdwomen who stole food and
abducted humans, while the manticore had a man’s head, the body of a
lion, and a scorpion’s tail. The myths about these creatures suggest that
most were aggressive and unpleasant, but others were more kindly, nota-
bly Chiron, the wisest of the centaurs, who was teacher and mentor to the
young Aesculapius, Greco-Roman god of medicine.

Early Transplantation 3
 These tales merged slowly into the earli-
est science-fiction writings, and, in the four-
teenth century, Sir John Mandeville’s Trav-
els (which leaned heavily on the works of Pliny
the Elder) told his credulous readers about
men with the heads of dogs, men with horse
hooves, and lions with eagle heads.

The Power of the Saints

Although such fantastical tales were common
across many different lands and cultures, the
Christian involvement in tissue replacement
in the Western world is perhaps best known.10
The New Testament is replete with healing in-
cidents because Christ had exhorted his disci-
ples to go forth “two by two, preach, cast out
devils and heal the sick.” Christ himself, as
Christ replacing the lost ear of the servant of the
high priest, cut off by Simon Peter. From The Arrest an act of forgiveness, miraculously replaced
of Christ, by the school of Dirc Bouts. Image courtesy of the high priest’s servant’s ear, cut off by Peter
Rheininsche Bild-Archiv.
during Christ’s arrest.11 Tradition holds that
Saint Peter, who witnessed this reattachment,
later accomplished a similar restoration of the breasts torn from Saint Ag-
atha during her torture. Thereafter, a number of miracles of hand replace-
ment were taken as credible then, but subject now to skeptical analysis. For
example, Saint Mark, late in the first century, was said to have replaced a
severed, mutilated hand. A legend from the fifth century holds that Pope
Leo punished himself by cutting off his own hand and that Mary, Mother of
Christ, appeared to him in a dream and reattached it. When Leo, emperor
of Constantinople, falsely accused Saint John of Damascus (AD 645–750)
of treason, he then ordered John’s right hand to be amputated. This was re-
ported as done, and John carried his severed hand to his oratory and slept,
but after sleeping awoke to find the hand replaced and healed. Some cyn-
ics immediately accused him of fraud and claimed that the hand had never
been lost and that by bribery he had averted the mutilation. John was or-
dered to show his right hand for assessment at the court, and the surface of
the hand showed a convincing scar.12

Later Saints’ Miracles

Although the cult of cures surrounding Christian saints was to continue,
in the next few centuries the pattern of such miraculous intervention
changed. Instead of obtaining healing through personal encounters with

4 Early Transplantation
itinerant holy men, believers began to seek “posthumous” healing from
long-dead saints. Religious authorities encouraged the public to visit
saints’ places of birth or burial to seek a cure. The Church began to invest
in shrines to the saints in many churches and cathedrals throughout Eu-
rope. If a reputation was gained for healing, it brought pilgrims, peni-
tents, and income to the institution.13
Individual saints even became credited with very specific healing pow-
ers long after their own deaths. According to the belief, around the year
1150 the spiritual intervention of the twin saints Cosmas and Damian re-
sulted in a successful leg transplant.14 Little is actually known of the lives
of Cosmas and Damian except that they were martyred in Syria during the
Diocletian persecution in the second half of the third century. The shrine
where the miracle took place was in Rome, far from their homeland (which
may have been Arabia), many centuries after their deaths. A written ac-
count of the miracle appeared about one hundred years after its supposed
occurrence, and thereafter the event gained fame and evoked many paint-
ings and other representations of the event: few other single miracles have
such a rich iconography.15
The cult of Cosmas and Damian increased
from the sixth century onward, and they were
elevated as particular patrons of medical prac-
tice. Numerous shrines to them were built,
and artists generally depict them as physician
and surgeon. In Rome alone, three churches
were dedicated to them, in that part of the Fo-
rum traditionally associated with medicine,
and the miraculous leg transplant probably oc-
curred at a church erected by Saint Felix, pope
from AD 526 to 530, one filled with brilliant
mosaics of the two saints. According to the leg-
end, the worthy sacristan of that church had a
cancerous growth of the leg. As it was custom-
ary for those seeking healing during pilgrim-
age to use votive “incubation,” that is, to sleep
in the sanctuary, the sacristan did so. During
the night, the saints appeared to the sacristan Cosmas and Damian, the twin Christian saints
in a dream and replaced the diseased limb, us- with a reputation for healing, died as martyrs
about AD 303, and people visited shrines to
ing the leg of a recently buried black Ethiopian these saints hoping to be cured. As in this wood
gladiator who had died the preceding day and engraving, Cosmas and Damian are often shown
as physicians or apothecaries. Some artists
been buried two miles away. The cancerous leg depicted them as surgeons. Image courtesy of
was thoughtfully retained by the saints to bury Wikimedia Commons.

Early Transplantation 5
with the donor’s remains, thus allowing for the resurrection of a body that
was whole.16
The story is given with fanciful detail in The Golden Legend, Caxton’s
English translation of an earlier compilation of such miracles. The two
saints conferred, and
thenne the other sayd to him, “There is an ethyopyen that this day is buryed in
the chirchyerd of saynt peter ad vincula whiche is yet fresshe, late vs bere this thy-
der and take we out of that moryans flesshe and fyll this place with all.” And soo
they fette the thye of this dede man, and cutte of the thye of the seke man and soo
chaunged that one for the other. And when the seke man awoke and felt no payne,
he put forthe his honde and felte his legge withoute hurte, and thenne tooke a
candel and sawe wel that it was not his thye, but that hit was another. And when
he was well come to hym self, he sprange oute of his bedde for ioye and recounted
to al the people how hit was happed to hym, and that whiche he had sene in his
slepe, and hou he was heled. And they sente hastely vnto the tombe of the deede
man, and fonde the thye of hym cutte of and that other thye in the tombe in stede
of his.17

Other Christian saints performed similar but less celebrated miracles.

In the thirteenth century, Saint Anthony of Padua (1195–1231) was cred-
ited with reattaching a severed leg. In Irish hagiography there are also a
number of examples of lost tissue replaced after the intervention of the
saints. In one well-known account, Saint Ciaran restored the decapitated
head of an Irish chief, but with less than perfect alignment, since the
head remained twisted thereafter.18 English pilgrimage sites also reported
miraculous tissue restoration. At Worcester in 1200, Saint Wulfstan was
said to have cured a man whose eyes and testicles had been removed as
punishment. At Canterbury, site of Thomas Becket’s martyrdom, a sleep-
ing penitent’s liver was taken out, cleansed, and replaced. Becket is also
credited with restoring the losses of a cleric castrated by a jealous hus-
band. This event gave the wits of the day their chance for satire:
Sublustri rutilans allusit abyssus abysso,
Cura, teste nova, testiculisque novis.19

The thrust of the text is that the chaste cleric, though restored, should
have no use for new testicles.
In general, these reported miracles and the earlier legends had moral
content and served to instruct: the lessons were that divine healing in
general, and organ replacement in particular, was possible, but only under
some conditions. It was helpful that the penitent’s illness or injury was
unsought and unfair, but above all, the sufferer had to be worthy and de-
serving of such intervention.20 These arguments about who was worthy of
such miraculous healing were to reappear when organ transplantation be-
gan to be an accepted medical procedure.

6 Early Transplantation
Leonberg’s depiction (circa 1500) of the miraculous replacement of a diseased leg by the posthu-
mous intervention of the saints Cosmas and Damian at a shrine to their honor in Rome. Image
courtesy of Württembergisches Landesmuseum, Stuttgart.

7
Decline of Magic
By medieval times, belief in magical cures was in decline, affected by the
secular learning and rise of humanism; after all, the texts from ancient
Greece carried no accounts of miraculous healing. Fewer individual priests
claimed personal powers of healing, and routine visits to shrines began to
decline. Stories of the replacement of body parts diminished in frequency,
and only modest claims for magical regeneration, rather than transplanta-
tion, remained.21 Supernatural grafting could now be ridiculed, and Fran-
çois Rabelais (1483?–1553), the Renaissance polymath and priest-turned-
doctor, could now invoke only secular surgical methods in his satirical
description of the successful replacement of a severed head in Pantagruel
(1534):
Having gone out to search the field for Episthemon, they found him stark dead
with his head between his arms all bloody. But Panurge said, “my dear Bullies
all, weep not one drop more, for he being yet all hot, I will make him as sound
as ever he was.” In saying this, he took the detached head, and held it warm fore-
against his cod-piece that the air might not enter into it, and the other two carried
the body. “Leave off crying,” quoth Panurge, “and help me.” Then he cleansed the
neck very thoroughly with white wine, afterwards he anointed it with I know not
what ointment, and set it on very just, vein against vein, sinew against sinew, and
spondyle against spondyle, that he might not be wry necked: this done, he gave it
round about some fifteen or sixteen stitches with the needle: suddenly Episthe-
mon began to breathe, then opened his eyes, yawned, sneezed, and afterwards let
out a great fart.22

His use of the antiseptic white wine is laudable, as is his support for
speed. Two aspects of Rabelais’s surgical mindset are interesting. First, he
assumes that reunion of bulky tissues, when placed together, will occur
by end-to-end union, notably of the divided blood vessels. Second, he be-
lieves that such detached grafts should be kept warm before attachment.
These assumptions were durable and were widely affirmed later. The first
lasted until the mid-1800s, and the second, namely, the view that for or-
gan grafting “warm is good,” lasted until the mid-1900s.
Despite the decline of belief in magical cures, credence in transcen-
dental healing had not entirely disappeared. In late medieval times, a
lively belief in the devil intensified, and it was understood that the evil
powers of black magic could be called up by some for the infliction, or
cure, of disease.23 Humble citizens thought to be using such aid could at-
tract accusations of witchcraft, and the activities of learned men were also
watched. Transplantation of tissues had until then been associated with
acceptable supernatural powers, but now those medieval surgeons who
cautiously attempted even skin grafting had to watch out for their reputa-
tions. Gaspare Tagliacozzi, the first known Western surgeon to use con-

8 Early Transplantation
François Rabelais, doctor, scholar, and author, used the myths of head replacement in his epic
tale Pantagruel (1534). Image courtesy of Glasgow University Library, Special Collections.

ventional methods of plastic surgery, suffered posthumously as a result of

gossip from his rivals, who claimed that he had used evil influences.

The Remaining Legacy

One aspect of the age of miracles and magic cast a long shadow over tis-
sue transplantation that extended almost to the twentieth century. The
tales of successful human grafting and the belief in hybrid animals
meant that the public remained deeply conditioned to believe that trans-
plantation of tissue from animals to humans or from one person to an-
other could succeed. Even though the notion of miraculous grafting was
increasingly discredited, the possibility of successful grafting using ordi-
nary surgical methods remained. It was not until the twentieth century
that the ancient “default” belief that humans could readily accept foreign
grafts was reversed, and then only with difficulty. A paradigm shift to the
notion that rejection was the rule following all living grafts—both homo-

Early Transplantation 9
grafts (from other people) and xenografts (from animals)—was remark-
ably slow to emerge and difficult to establish.
However, there had also been some early, secular, nonmagical surgical
tissue replacements, using skin flaps moved from one part of the body to
another (autografts). Skilled operators did these procedures far from Eu-
rope, and their methods did not reach Europe until the Renaissance.

Early Plastic Surgery in India

One of the world’s oldest medical texts describes plastic surgery. The Hindu
Sanskrit text Suśruta Samhita, of about the sixth century BCE, describes
restoration of damaged ears or noses by methods similar to modern recon-
structive surgery.
The tradition is that Suśruta was a surgeon, teaching at Benares in In-
dia.24 His approach to tissue replacement in the face was to create a local
skin flap, rotate it to cover the defect, and fix it in place. The operation may
have been of some antiquity, and when it was discovered still in use in In-
dia in the nineteenth century, it initiated the rapid emergence of plastic
surgery in Europe.25
The ancient Indian operations were used for those disfigured not only
by disease but also by violence or warfare, notably when sword wounds
damaged or excised soft tissue from the head and face. In addition, some
sufferers had received mutilation in civil feuds or as revenge, or as judicial
punishments for serious crimes. Ruthless rulers would deal with threats
to their power by mutilating the faces of their opponents, notably by re-
moval of the nose.26 Such injuries humiliated the victim, equating them
with criminals, and would also leave them defective and handicapped
in the afterlife.27 The practice may have been widespread; facial mutila-
tion was common in Chile up to the time of the Spanish colonial period
and has persisted to this day in Afghanistan.28 In Peru, pre-Inca Chimú
pottery images placed in the graves of distinguished persons showed ev-
idence of such facial injuries.29 A Roman fort in Scotland was found to
have a collection of human hand and foot bones, doubtless removed from
local insurgents to discourage their fellows.
In Asian cultures, a less dramatic deformity of the ear was not caused
by punishment but by the use of beautifying heavy earrings or fenestrat-
ing ornaments, which intentionally stretched the lobe but could split the
thin ring of skin. Suśruta gives an elaborate typology of such defects.30 If
local repair of the ear deformity was not possible, the surgeon attempted
complete replacement of the ear lobe. The operative detail in Suśruta is
scanty, but the approach was clear: “A surgeon well-versed in the knowl-
edge of surgery should slice off a patch of living flesh [skin] from the

10 Early Transplantation
The ancient Indian plastic surgical procedures were illustrated in use late in the nineteenth cen-
tury in B. H. Baden-Powell’s Handbook of the Manufactures and Arts of the Punjab (Lahore, 1872).

cheek of a person devoid of ear-lobes in a manner so as to have one of the

ends attached to its former seat. The part, where the artificial ear-lobe is to
be made, should be slightly scarified and the living flesh, full of blood and
sliced off as previously directed, should be adhesioned to it.”31
The principle involved in the surgery is clear, and the operative detail
is convincing. A “rotation” flap was used, namely, one with its base re-
maining attached in its original position and, hence, still supplied by the
original blood vessels. After moving the free end and fixing it, sometime
later the base and the original blood supply could be safely severed.
The Suśruta is best known for its description of the method of restor-
ing damaged noses. The following passage describes the operation, which
was again a rotation flap from the cheek:
Now I shall deal with the process of affixing an artificial nose. First the leaf of a
creeper, long and broad enough to fully cover the whole of the severed or clipped
off part, should be gathered; and a patch of living flesh, equal in dimension to the
preceding leaf, should be sliced off (from down upward) from the region of the
cheek and, after scarifying it with a knife, swiftly adhered to the severed nose.
Then the cool-headed physician should steadily tie it up with a bandage decent to
look at and perfectly suited to the end for which it has been employed.
The physician should make sure that the adhesion of the severed parts has
been fully effected and then insert two small pipes into the nostrils to facilitate
respiration, and to prevent the adhesioned flesh from hanging down. After that,

Early Transplantation 11
the adhesioned part should be dusted with powders of Pattanga, Yashitmadhu-
kam, and Rasanjana pulverised together, and the nose should be enveloped in cot-
ton and several times sprinkled over with the refined oil of pure sesamum. Clari-
fied butter should be given to the patient for drink, and he should be anointed
with oil and treated with purgatives after the complete digestion of the meals he
has taken, as advised in the books of medicine.32

The method emphasizes that the flap should be cut accurately and
that special bandaging was important. As in other ancient surgical proce-
dures, exotic ointments were used for local application, and postoperative
medication and diet were important.
Indian surgical technique was advanced at the time. Those learning
the technique practiced suturing on fruit or leather, and models stood in
for humans for bandaging practice. The Suśruta text shows that student
surgeons learned anatomy by dissecting cadavers. It seems that surgery
had a high status at the time, and since it was taught together with inter-
nal medicine, it is likely that a distinguished and literate man like Suśruta
might perform the surgery he describes. In the centuries that followed,
however, manual work of any kind became offensive to the higher castes
in India, and with their cultural distaste for touching the human body
in life or death, the study of anatomy declined, as did the practice of sur-
gery among the learned.33 Later, when Western colonizers discovered that
the ancient Hindu plastic surgery techniques were still in use, the opera-
tions were being performed by artisan surgeons associated with the lowly
trades of potter and brick maker.
Early Indian surgeons may also have succeeded in transplanting skin
without use of flaps. They could use detached skin, that is, “free” grafts,
since some Indian texts mention the use of skin taken from the buttock
to replace defects elsewhere. This skin is too thick to use unchanged else-
where on the body, so donor skin was prepared in a special way. A suitable
area of the buttock was flayed by a whip, causing swelling and bruising,
and the skin was then removed and used. Since skin prepared in this way
was fissured and split by the trauma, this perhaps created, in later termi-
nology, a partial-thickness skin graft. This thin layer might heal in and
survive, unlike the thick, normal buttock skin.

Later Accounts of Plastic Surgery

These ancient methods used by indigenous healers probably continued un-
changed in India for centuries and certainly persisted there until the end of
the nineteenth century. It would be surprising if the methods were not in
use widely in the Middle East in ancient times, but the many Arabic medi-
cal texts are silent on this topic up to medieval times. The techniques are
hardly mentioned in the surgical texts of the great Greek medical writers,

12 Early Transplantation
beginning with the contributors to the Hippocratic collection, written about
the fifth century BCE. There is no evidence that such surgery was carried
out in ancient Egypt, but later, Alexandrian writers did briefly describe plas-
tic surgical methods.34 This knowledge must have passed to the Romans,
since the surgical techniques appear in the works of the medical authorities
Celsus (25 BCE–AD 50) and Galen (AD 129–216).35 Both writers describe
briefly, but vaguely, methods for replacement of lost tissue, and it may be
that these methods were merely copied from text to text. Learned medical
writers often included operations that were thought to be possible or were
in use by the humbler “artisan” surgeons, rather than in use by the learned
author.36 The Byzantine encyclopedists, notably Oribasius, used the same
material that had appeared in Galen’s work, and it also appears in the works
of Paulus Aegineta of Rome, written prior to the Muslim invasion of AD
640. Later Arab surgical works, notably that of Rhazes (circa AD 924), con-
tinued to give short references to techniques for addressing deformities.
By the tenth century, the caliphate of Córdoba was the most culturally ad-
vanced area in Europe, and, under the rule of Al-Hakam II, Muslim schol-
arship, manuscript collection, and translation flourished. It is significant
that plastic surgery is absent from the influential Chirurgia section of the
thirty-volume medical treatise by Al-Hakam II’s court surgeon and physi-
cian, Abulcasis (Abū ‘l-Qāsim Khalaf ibn ‘Abbās al-Zahrāwī, AD 936–1013).
It seems that the techniques had not reemerged in the western Mediterra-
nean at that time nor were they featured in the older Muslim texts held in
Córdoba.37 Possible explanations for this absence are that the need for plas-
tic surgery was small or that, in the Western world, attempts at plastic sur-
gical repair were now deplored as vanity and thus cosmesis was left to beau-
ticians.38 Abulcasis had another constraint on his practice. Distinguished
surgeons at the time avoided “capital” operations, which included pro-
cedures like cutting to remove bladder stones or for relief of strangulated
hernias, because they could have a fatal outcome. There were others in the
“medical marketplace” who might offer such surgery—notably the humble
local artisan or itinerant surgeons, who, being illiterate, left no writings.39
They had empirical skills guarded by semisecret trade practices.40

The Revival of Plastic Surgery

The Renaissance, starting in Europe in the fourteenth century, led to a
hunt for the ancient texts containing the knowledge and wisdom of Greece
and Rome. The visual arts were also liberated and reborn. In medicine, the
classical manuscript texts were sought and studied anew, and, in Italy, mi-
grant Greek scholars assisted with translation of the works of Galen and
Hippocrates. With the introduction of movable type printing in Germany

Early Transplantation 13
in 1438, wider dissemination of knowledge occurred by books rather than
via copied manuscripts. In Italy, soon to be a major printing and publishing
center, the new humanism first assimilated and built on the classical medi-
cal knowledge and finally began to challenge the revived Galenic wisdom.
The surgeon-anatomists were particularly innovative, and, in the north of
Italy, the universities at Bologna and Padua both taught surgery; the med-
ical teachers had salaries exceeded only by those of the professors of law.
The celebrated Italian surgeons with this new elevated status moved their
craft forward and, in doing so, accepted a scholarly obligation to share their
knowledge through publication of elegantly illustrated texts.
However, the ancient Indian use of methods of skin grafting by flaps
reemerged first in southern Italian practice, not in northern academic cir-
cles.41 The ancient Eastern learning entered Italy via Mediterranean trade
routes, and the passage of the Crusaders and streams of pilgrims visit-
ing the Holy Land further disseminated knowledge. Sicily was a central
point in these movements of people and information, and it grew to be
the major power in the Mediterranean under the rule of Roger II (1096–
1154). Economic confidence and a cosmopolitan attitude also aided schol-
arship, and Roger added distinguished scholars to his court. The need for
medical men in the armies of the Crusades grew and encouraged medical
teaching in Sicily, which notably flourished under the patronage of Fred-
erick II (1215–1250). The medical school at Salerno—the Schola Medica
Salernitana—had a laudable emphasis on empirical clinical study by ap-
prenticeship, rather than a traditional focus on theory and disputation. It
may have been medical practitioners or travelers returning from the East
or perhaps Sicilian naval campaigns that brought news of old, forgotten
surgical skills, including the Indian methods of facial plastic surgery,
back to the island. Whatever their route, these techniques probably first
appeared in Europe in Sicily in the fourteenth century, and it was the lo-
cal, craft-trained practitioners who used them.

The Sicilian Surgeons

The first Sicilian surgeons known to offer nose reconstruction (rhinoplasty)
were the Brancas, a father and son in Catánia on the east coast of Sicily, op-
posite Reggio de Calabria in mainland southern Italy. While Branca the el-
der used the original Indian method of rhinoplasty—using an adjacent flap
of skin swung over from the cheek or forehead—the son significantly im-
proved on the older Indian strategy, starting to use more distant flaps of
skin, notably from the arm.
The methods were a trade secret, but news spread and interest in the
Sicilian activities grew among the elite northern Italian surgeons.42 A con-

14 Early Transplantation
temporary account by one such surgeon describes his visit with the Bran-
cas and erroneously credits them with developing the rhinoplasty technique
that they had actually inherited from abroad. The northerner’s account
gives a version of the operation, though a flawed one; perhaps the Brancas
did not let him see too much:
Branca, the elder, was the inventor of an admirable and almost incredible thing.
He conceived how he might repair and replace noses that had been mutilated and
cut off, and developed his ideas into a marvelous art. And the son Antonius added
not a little to his father’s wonderful discovery. For he conceived how mutilated
lips and ears might be restored, as well as noses. Moreover, whereas his father
had taken the flesh for the repair from the mutilated man’s face, Antonius took
it from the muscles of his arm, so that no distortion of the face should be caused.
On that arm, cut open, and into the wound itself, he bound the stump of the nose
so tightly that the patient might not move his head at all, and after fifteen days,
or sometimes twenty, little by little with a sharp knife he cut away the flap, which
had become attached to the nose; finally he severed it entirely from the arm, and
shaped it into a nose with so much ingenuity that it was scarcely possible with the
eye to detect the flap that had been added.43

This otherwise clear account had a major error in describing the use
of the muscle of the upper arm, rather than skin flaps. This important
and improbable misunderstanding was to be a persisting source of confu-
sion for two centuries thereafter.
These face or forearm flap operations, performed by humble Sicilian
surgeons, were known in Italy for some decades before some of the dis-
tinguished university-based surgeons of the northern Italian towns ever
mentioned them. The professor of surgery at Padua, Alessandro Benedetti
(c. 1445–1525), knew of the work of the Brancas and gave a brief account
of it in his text Anatomice, sive historia corporis humani (1514). In that book
he included some advice regarding care of the new nose after its creation,
notably that it should not be roughly handled.44 This practical detail sug-
gests that he was studying patients who had returned from Sicily after
surgery and reported to him. Benedetti was, however, cautious about car-
rying out novel or heroic operations, sharing the attitude among the elite
surgeons at the time that one should seek to avoid professional disaster.45
It was only Gaspare Tagliacozzi who was prepared to try.

Tagliacozzi’s De curtorum chirurgia

Tagliacozzi (1545–1599) had studied under eminent teachers in Bologna,
notably Girolamo Cardano and Ulisse Aldrovandi. He then set up in that
town as a surgeon and teacher of anatomy, soon achieving a reputation
for wound management, and he succeeded Giulo Aranzio in the univer-
sity’s chair of anatomy. In 1597, at the age of fifty-two, Tagliacozzi pub-

Early Transplantation 15
 lished his first and only book. This famous, beautifully illustrated text, De
curtorum chirurgia per insitionem (On the surgery of mutilation by graft-
ing), contained a detailed description, based on Tagliacozzi’s years of treat-
ing many patients, of the theory and practice of plastic surgery.46 Taglia-
cozzi graciously made it clear in his text that his inspiration came from
southern town surgeons in Calabria who followed in the Branca tradition.47
But as one of the new academic surgeons, he had to distance himself from
the artisan surgeons’ approach and claim that his own methods were supe-
rior, since they were based on a university training that gave him a sophis-
ticated understanding of the physiology of healing. He gives verbose de-
scriptions of the erroneous biological science of the day and how it applied
to surgery, but his faulty theory did not hinder him in copying the Bran-
cas’ empirically successful surgery. In some matters, Tagliacozzi may have
improved upon the operative technique, notably in measuring and mark-
ing the bed and graft, and his text shows minute attention to the details
of pre- and postoperative management, together with some timeless, wry
asides. When operating, for instance, “the attendants must observe dili-
gently every nod of the surgeon, for many things happen during an op-
eration which need to be indicated by a nod, and not by speech. One must
be sparing of words.” The best operative environ-
ment for carrying out surgery, he wrote, was “two
nimble assistants, good light, and all others to
leave the room.”48
Tagliacozzi’s patients, as revealed by his text,
were wealthy. They came to him due to their loss
of a nose, ear, or lip, usually from warfare, vio-
lence, or dueling. Increasingly, however, a new
reason for patients to seek his help was syphilis,
which had spread rapidly from Naples through
Europe in 1495. In its tertiary stage, syphilis could
erode the inner nose. Tagliacozzi did treat such
patients but only after attempts to control the dis-
ease with mercury.
Tagliacozzi followed the younger Branca’s
technique by raising a flap of skin from the up-
per arm and applying it to the freshened bed of
Gaspare Tagliacozzi, surgeon of Bologna, the deficient nose. The numerous illustrations in
gained a lasting reputation because of his
celebrated text on plastic surgery and his his book show his attention to detail and that Ta-
manuscript text, shown in the background. gliacozzi had brought to perfection the design of
He was appointed professor of anatomy in
the University (Studium) of Bologna in 1570.
bandaging necessary to hold the donor arm and
Image courtesy of Wikimedia Commons. skin flap firmly in position against the face for

16 Early Transplantation
A wood engraving from Tagliacozzi’s De curtorum chirurgia per insitionem showing the use of
a flap of upper arm skin to replace tissue lost from the nose. The important system of support
for the arm is shown. This illustration has been used in the seal of the American Association of
Plastic Surgeons. Image courtesy of Wikimedia Commons.

some time. He also provided elegant shields to protect the new nose after
the surgery.
In his analysis of the mechanism of attaching the skin flap to the nose
bed, Tagliacozzi’s mindset was markedly conditioned by horticultural
practice. The urban Italian savants often owned country villas and had
estates to supervise, and there they might use the services of tree graft-
ers.49 Tagliacozzi freely used their word scion to describe his grafts, and
the term insitionem, used in the title of his book and throughout its text,
was a word then used for grafting in agriculture. Tagliacozzi at one point
uses the phrase “as in human surgery, as in the orchard,” and he trans-
ferred two specific technical insights directly from the orchard to his sur-
gical technique. The first was that the grafting of the upper part (scion) of
one type of tree or shrub into the root system of another (one more vigor-
ous or disease resistant) required prolonged close contact and fixation. A
second strategy from horticulture was the grafting variant of “layering,”

Early Transplantation 17
which meant lowering and burying living limbs of trees or plants into ad-
jacent soil, waiting until a new root system penetrated the soil, and then
dividing the original connection to leave a new, freestanding tree.
Although Tagliacozzi’s greatest contribution was in autografting (i.e.,
transferring tissue from one part of the body to another), his name was
drawn into a heated debate in the next century on homografting, that is,
grafting from one human to another (known as allografting in the later
nomenclature). He was incorrectly thought to support the use of human
donors to supply a new nose.
Tagliacozzi’s text contains nothing to suggest use of another person as
a donor, though it is less clear whether or not he was hostile to this idea.
In chapter 12 of his book, he dismisses the idea of using another person as
a donor, though it seems that some fearful patients had requested doing
so, hoping to avoid some of the pain of the procedure. He refused, mainly
because of the difficulty of binding the donor and recipient together dur-
ing the many days required for the graft to heal in. His view was that
no one in his right mind would argue that for some slight gain of beauty and sav-
ing of effort we should call the entire fate of the work into danger . . . which cer-
tainly happens if we try to perform this operation with the aid of another per-
son. . . . And so no one can fail to see from the difficulty of tying together and from
the necessity of inconvenience which two persons tied together encounter, how
doubtful, if not entirely vain, will be the outcome of the art. . . . Hence it appears
superfluous for us to reply to those who, either in the interests of the appearance
of the arm or pandering to their own sensibilities, refuse this operation on their
own persons.50

These technical objections to using a donor for the operation seemed

uppermost in his mind. However, in the final part of the chapter where he
makes these objections, there is a remarkable statement that might hint
that he dismissed the idea of grafting between humans for biological rea-
sons:
Now let it suffice that judgment in regard to the flap [from another person] is ex-
tremely difficult and almost impossible, and that the singular character of the
individual entirely dissuades us from attempting this work on another person.
For such is the force and the power of individuality, that if anyone should believe
that he could accelerate and increase the beauty of union, nay more, achieve even
the least part of the operation, we consider him plainly superstitious and badly
grounded in physical sciences.51

In this passage, Tagliacozzi seems to dismiss the idea of grafting be-

tween individuals because of an incompatibility—a “singularem illum in-
dividui characterem.” This concept of the “force and power” of individual-
ity, elegantly expressed on his part, may be a philosophical stance rather
than biological assertion of human individual uniqueness. But it is tan-

18 Early Transplantation
talizingly close to the understanding of the transplantation immunology
that emerged much later, and very slowly. One additional scrap of evidence
supports this conclusion. The Venetian adventurer Nicolò Manuzzi (1639–
1717) settled in India and left a travelogue manuscript, published much
later, in which he records that he had seen many natives with restored
noses. Manuzzi had acquired some surgical skills and was asked to repair
a nose but to use a slave donor for the skin. Manuzzi replied that “it would
be of no avail, for being another’s flesh it would not unite.”52
Tagliacozzi died in 1599. There were immediate tributes to his skill,
and requiem masses were said in his honor. But shortly after, the old al-
legations of links between successful transplantation and magical assis-
tance were invoked by his gossipy detractors, who put it about that his
surgical skills involved recourse to unacceptable supernatural powers.53
Helpful “white” magic was acceptable at the time, but the “black” magic
of the witches and others was condemned. Tagliacozzi’s reputation was
restored after an investigation, and a few surgeons, notably his pupil
Giovanni Cortesi, felt it was safe to follow his master’s lead cautiously, but
only for a while. There was sufficient interest in the long and detailed De
curtorum chirurgia per insitionem for a pirated edition to appear quickly
in Venice and then in Frankfurt. Nevertheless, Tagliacozzi’s innovative
surgery was mysteriously put aside. Remarkably, it was not revived until
about 1800.
Tagliacozzi’s surgery failed to be incorporated into the routine text-
based surgery of the day, and aiding this neglect were some added basic
misunderstandings, even about the technical surgical detail. It may be
that gossip and academic myths still had greater force and authority in the
medical discourse in the early days of printing than did the printed word.
The first continuing misunderstanding of the Tagliacozzi technique
was that the nose was to be buried into the arm, rather than a flap raised,
and that muscle was used to form the new nose, despite Tagliacozzi’s
clear engravings showing use of the skin. But the second and more seri-
ous misunderstanding of Tagliacozzi’s method was that the donor skin
for the new nose could be taken from another person. Commentators
wrote that Tagliacozzi used slaves or servants as donors of skin to restore
their masters’ mutilated faces, whereas his text shows not only the oppo-
site but also his hostility to such grafting. This error, with its assumption
that such homografts could succeed, was to intrude into the writings on
plastic surgery and transplantation for centuries.
Another dampening effect on the use of Tagliacozzi’s innovative rhi-
noplasties was that there was a safe alternative: a false nose could be fitted.
Such replacements were known to be in use from earliest times and have

Early Transplantation 19
 been found, still in place, on Egyp-
tian mummies.54 The surgeon Am-
broise Paré described a wide range of
such prosthetic devices for lost or ab-
sent human tissue, and these gold or
silver devices were skillfully enam-
eled to give a fleshlike appearance
when used to replace eyes, noses, and
ears. There were a number of distin-
guished users of such prostheses.
The duke of Urbino (1422–1482) had
one, and when Tycho Brahe (1546–
1601), the great Danish astronomer,
lost the bridge of his nose in a duel
in 1566, he opted for a skin-colored
metal prosthesis. This device, stolen
from his coffin after death, can be
seen in some portraits of him. How-
ever, having opted for the safety of
a prosthesis, it gave him little com-
Tycho Brahe, the Danish astronomer, had a nasal deformity as fort, and he was never reconciled to
the result of a duel, and he favored a prosthesis, which is de- his deformity. Brahe became “unap-
tectable in some portraits. Portrait by M. J. Mierevelt, image courtesy
of the Royal Society, London.
proachable, uninhibited, unsparing
and ever vengeful.”55
The neglect that overtook plastic
surgery in general, and Tagliacozzi’s work in particular, in the 1600s is
perhaps surprising. War was endemic in Europe, war wounds were com-
mon, and legal mutilation still existed. In 1637, the Puritan activist Wil-
liam Prynne was branded and had his ears “clipped” off as punishment
for antiroyalist pamphleteering, and there were similar mutilations dur-
ing the unrest in Scotland, mostly removal of hands and ears. But perhaps
the switch from swords to firearms as the main weapon in warfare made
damage to the nose or ear less common. Also, the virulence of syphilis
may have decreased after its rampage around Europe from 1495 onward,
and so there were fewer severe nasal deformities. The status of surgery
relative to medicine declined, and all forms of cosmetic work may still
have been shunned by established practitioners.

The New Biology

Other medical inquiry flourished during the 1600s, however. This pe-
riod witnessed the rise of investigation by experiment, and no longer was

20 Early Transplantation
study of the ancient texts seen as the primary means toward progress.
From Francis Bacon’s teachings in his influential book Novum organum
came a new method of advancing knowledge to replace the scholasticism
of the humanists and their dependence on ancient authority. Instead, data
were to be sought and gathered, then observations made and conclusions
inductively drawn. But there was a snag in this admirable new emphasis
on personal contemporary experience: at first, every experience was given
equal weight in the new mood of the times. In the little world of tissue
transplantation, every new, flawed tale, from whatever source, was looked
at eagerly and believed.
As direct knowledge of Tagliacozzi’s original textbook waned (de-
spite the three editions available in print), descriptions of his method
were still distorted, and new stories supported the myths about his work.
The most damaging claim was that human donors could be used for his
nose replacement. One widely believed report claimed that Tagliacozzi
had grafted the nose of a slave servant to a nobleman and, after a suc-
cessful outcome, the grateful recipient granted the slave his freedom. The
slave later died, and, it was said, the transplanted nose then also died and
fell from the nobleman’s face. This tale of the “sympathetic” loss of the
grafted nose—an urban myth too good to be false—caught the imagina-
tion of writers and philosophers keen to gather all information that might
help them understand the natural world. Scholars were steadily dropping
belief in miraculous intervention in disease, but now there were other
novel influences they could study, forces that could also act unseen. The
power of magnets and gravity and the forces influencing the compass
were of interest. It was not unreasonable to explain the slave nose donor
story as tissue loss at a distance via an invisible force.56
The influential philosopher Tommaso Campanella (1568–1639) ac-
cepted the slave donor story and then, reasoning metaphysically, con-
cluded that since the human soul was indivisible, the death of the donor
inevitably meant death of the graft, no matter how distant from the de-
ceased.57 This unity of the soul, he went on argue, also meant that grafts
could be used to send signals and thus could enable communication be-
tween donor and recipient. But the Jesuit polymath Athanasius Kircher
(1602–1680), writing in 1643, sternly denounced Campanella’s claim for
this imaginative use of reciprocal skin grafts: “By pricks inflicted upon
themselves according to numbers which had been agreed upon for the
various letters of the alphabet, and reciprocally felt, they could speak to
each other about anything whatsoever at any distance whatsoever.” He
then rebuked Campanella: “But away with such foolish absurdities and
stupid imaginings of crazy men, whose part it is, lacking true science, to

Early Transplantation 21
seek glory, which they could not otherwise attain, from dubious and false
arts with the aid of the devil.”58
The old allegation of satanic assistance being needed to achieve graft
success is overt in Kircher’s denunciation of Campanella. But the tale of
the paid slave donor would not go away, and there were hopes that it in-
volved a hitherto unknown force-at-a-distance. Jean Baptiste van Helmont
(1577–1644), one of the controversial new Paracelsian physicians who re-
jected the ancient teachings of Galen and sought to introduce chemical
therapy, robustly retold and supported the sympathetic graft loss story, us-
ing it as crucial evidence in a new, evidence-based medical world. He also
tried to dismiss supernatural influences:
This one experiment [i.e., the slave donor graft] of all others, cannot but be free
from all suspect of imposture, and illusion of the Devil. A certain inhabitant of
Bruxels, in a combat had his nose mowed off, addressed himself to Tagliacozzius
a famous Chirurgeon, living at Bononia, that he might procure a new one; and
when he feared the incision of his own arm, he hired a Porter [servant] to admit it,
out of whose arm, having first given the reward agreed upon, at length he dig’d a
new nose. About thirteenth months after his return to his own Contrey, on a sud-
den the ingrafted nose grew cold, putrified, and within a few days, dropt off. To
those of his friends, that were curious in the exploration of the cause of this un-
expected misfortune, it was discovered, that the Porter expired, neer about the
same punctilio of time, wherein the nose grew frigid and cadaverous. There are
at Bruxels, yet surviving, some of good repute, that were eyewitnesses of these oc-
currences. Is not this Magnetism of manifest affinity with mumy, whereby the
nose, enjoying, by title and right of inoculation, a community of life, on a sudden
mortified on the other side of the Alpes? I pray what is there in this Superstition?
What of attent and exalted Imagination?59

These hidden mechanisms, thought to perhaps be related to mag-

netism, found a welcome even in the influential writings of Sir Thomas
Browne (1605–1682). His influential Pseudodoxia epidemica, or, Enquiry
into very many received Tenents, and commonly presumed Truths, sought to
banish “vulgar errors” and replace them with sound knowledge based on
the data-collecting Baconian strategy. He concluded that the slave skin
graft had been linked in some way to its donor at death and that “this Mag-
neticall conceit how strange soever, might have some originall in reason.”60
These unseen forces that were surmised seemed related to another
class of influence, one advocated at the time by Sir Kenelm(e) Digby,
namely the power of “sympathy.” Digby, a polymath, diplomat, traveler,
and early member of London’s Royal Society, supported attempts to cure
injury by transferring the damage away from the sufferer, back to the
weapon that had caused the harm. He attempted this transfer by treat-
ing the weapon with a “weapon salve” or “powder of sympathy.”61 Dig-
by’s most important work dealing with sympathetic medicine was his A

22 Early Transplantation
Late Discourse Made in a Solemn Assem-
bly of Nobles and Learned Men at Mont-
pellier in France. In the Frankfurt edi-
tion of 1661, the work is prefaced by an
engraving with some vignettes show-
ing sympathetic power in action. One
of these panels shows the rejection of
the slave nose graft after the death of
the donor, the first illustration, albeit a
fanciful one, of homograft skin loss.62
Many other scholars added new frills to
the “learned myth” slave donor story in
the 1600s.63
The mood finally changed, and atti-
tudes outside of learned circles became
more skeptical. The savants’ flirtation
with these sympathetic powers attracted
the ridicule of writers. When Samuel
Butler published his mock-heroic tale
Hudibras in 1663, a satire on the puri-
tanical revolutionary regime that had re-
cently been overthrown, Butler did not
spare the fanciful ideas of sympathetic
medicine.64 He used the slave donor
story in a modified way, incorporating
Vignette from the frontispiece to the 1661 Frankfurt edition
the idea that the skin was taken in the of Sir Kenelm Digby’s A Late Discourse Made in a Solemn
ancient Indian way, from the flayed but- Assembly of Nobles and Learned Men at Montpellier in
France allegedly showing “sympathetic” loss of a living,
tocks. Word of this technique must have unrelated donor skin graft to the nose, after the death of
already reached British popular culture the donor. Image courtesy of James Tait Goodrich.
from India by an unknown route.
So learned Taliacotius, from
The Brawny Part of Porter’s Bum,
Cut supplemental Noses, which
Wou’d last as long as Parent Breech;
But when the Date of Nock was out,
Off dropt the sympathetic Snout.

But the wits missed the point. They as-

sumed that such an operation had oc-
curred, and this assumption helped fix
the myth that the innocent Tagliacozzi
had indeed used such donors.65

Early Transplantation 23
Surgical Opinion
Although the European literati of the day can be excused for accepting the
claim that Tagliacozzi used human donors, the practical surgeons should
have been better informed. One serious student of Tagliacozzi was the
Scottish-educated London surgeon Alexander Read, who translated part
of Tagliacozzi’s Curtorem and used it in his own text, Chirurgorum comes
(1687). Even though he had read the original Curtorem text, however, Read
thought that Tagliacozzi might have used human donors. Read, also in-
fluenced by botanical analogies, reasonably asked “what should hinder a
piece of one man’s body from being ingrafted into anothers, seeing both
are of the same kind, and nothing near as different as one kind of tree is
from another . . . ?”66
The standard English surgical text of the late 1600s was Mellificium
chirurgiae—The Marrow of Surgery, by James Cooke (1614–1688) of War-
wick. Cooke, after describing the Tagliacozzi operation briefly, repeats all
the old misconceptions about it, namely that muscle was used, that the
graft could be taken from a donor, and that the graft may be lost when the
donor dies:
The operation being so difficult and painful, besides the necessary preparation
for the Work, the Symptoms that fall out, the danger that follows the least neglect,
’tis almost altogether unattempted, yet to satisfy the curious, take somewhat of
it here, and then if any have lost a part and like the Operation let them take their
Penance. The Nose lost, may be restored both the former ways. To restore it from
the Body, it may either be from their own Body, or the Body of others. If the last,
let them be sure they can, that such be longer-liv’d than themselves, lest they lose
what they have got before they die. To perform this work, remove the Callous
Edges of what’s remaining of the Nose; after make Incision into the Biceps Mus-
cle of the Arm.67

London’s Royal Society

The upheaval of the English Revolution and the Civil War of the mid-
1600s reinvigorated many of London’s ancient institutions, and new radi-
cal groupings emerged. One venture was the College for the Promoting
of Physico-Mathematical-Experimental Learning, known from 1662 on-
ward as the Royal Society of London, one of the world’s first learned acad-
emies. The new society was a cooperative venture organized by a group of
men interested in advancing natural sciences, and this cooperation was a
change from the secrecy exhibited by some savants, notably the still-active
alchemists. The society was also largely free of the outside influence of
any institution or patron. Some of the European courts had a court “sci-
entist,” but his role might be to entertain rather than enlighten; one such
appointee, Francesco Redi (1626–1697), the distinguished Tuscan physi-

24 Early Transplantation
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