1. Skin (1550–1597)
Figure 1 Gerard David: the flaying of Sisamnes from ‘The Judgement of Cambyses’, 1498, oil on wood.
The flaying of Sisamnes, a corrupt Persian judge, comprises one half of ‘The Judgement of Cambyses’, a 1498 diptych by Gerard David. Sisamnes is tied to a table, his modesty covered by a towel lest the sight of a penis should offend us as we witness four knife-wielding torturers peel the skin from his legs, arms and torso. His clenched teeth and veins popping in agony differentiate this still-living person from a body on an anatomist’s table. The action is freeze-framed just moments before his identity and humanity are peeled away like the skin of a rabbit, leaving only impersonal flesh and bone. After the flaying, the king appointed the judge’s son to replace his father at court. You can see him enthroned on the top right of the painting. The new judge’s chair is a gift from the king, who, for reasons of poetry and deterrence, had it upholstered in Sisamnes’s skin.
This image was painted around the time of the first modern skin grafts. It depicts a relationship between a person and their skin on the cusp of being dissolved, and gets its power from showing the fragility of the connection between our skins and ourselves.1 It’s hard to imagine ourselves without our skins. They distinguish us from meat, and such a prospect of extreme mutilation threatens to erase our very identities as humans. There are actually very few documented cases of flaying (though the Scythians were once famed for their skinning skills), but the first modern transplants were performed because the world was generally far more hostile to skin than it is now, and to noses in particular.
In the Renaissance (and earlier), losing a nose was a constant possibility. Some would have lost theirs in fights or duels. Many other noses would have been taken as punishment, an assault on a perpetrator’s sense of self. Cutting off the nose – rhinotomy – occasionally makes a shocking appearance in the news today but was once a routine punishment with a long history in ancient India, and at various times in Europe and the Middle East. The Egyptian penal code punished adultery through mutilation of the nose.2 In the mid-1160s BC, the Pharaoh Rameses III ordered the rhinotomy of his magistrates’ noses. They had colluded with Queen Teya – his secondary queen who wanted her son to be pharaoh – to slit his throat while he sat in his royal harem playing board games.3 The nose situation in Egypt, in fact, must have been particularly dire: Harper’s Dictionary of Classical Antiquities cites a city of ‘cut-off-noses’ – Rhinokoloura – a settlement built on the edge of the desert, populated entirely by criminals who’d been mutilated under the Aethiopian dynasty.
If you look for them, you’ll find people chopping off noses all over the place. In Rome it was permissible for a wronged man to cut off the nose of his cheating wife or her lover.4 Pope Sixtus V tried to deter highway robbers from invading Rome and the surrounding countryside by threatening nasal mutilation.5 Italian traveller and surgeon Niccolao Manucci similarly wrote about Mughal horsemen losing their noses when passing through the forests of Mysore. The forest inhabitants would run at them, spring up from behind and cut them off with a specially designed, half-moon-shaped blade.
We might also add syphilis – a virulent threat in sixteenth-century Europe – to the reasons someone might require a new nose. The disease was far more severe than the cases we see today. It started with sores around the genitals, moving on to ulcers, fever, blindness, abscesses and dementia. One of the most horrifying symptoms, though, was the rotting and collapse of the nose, leaving only a hole. As syphilis could be, but wasn’t always, transmitted sexually, the so-called ‘saddle nose’ of a sufferer came to signify low moral standards, compounding the general shame of being noseless. Losing a nose was so horrific that the sixteenth-century theologian Thomas Sanchez considered it grounds for the annulment of a marriage.6
Losing a nose removed the senses of taste and smell and impaired the voice, but the social isolation and rejection it brought would have been far worse. The only realistic solution for many was a nose mask. These were hardly convincing replacements – some were just false noses dangling from spectacle frames and looked more like party masks – but seem to have had formed part of the nasal landscape (literally in the case of Egypt, since archaeologists have dug up mummies with false noses7). Even famous people wore them.
Tycho Brahe was one example. He was the last major astronomer to use only the naked eye, and in the final year of his life took on the much more famous Johannes Kepler as an assistant. But in his youth, he got into a mathematical disagreement at a Christmas party with another twenty-year-old Dane, Manderup Parsberg. Whatever their difference, it was severe enough for them to leave the party and walk off to a pitch-black graveyard, where, amongst the gravestones, they drew swords. Blind with indignation as well as the absence of light, they flailed around, frantically jabbing and slashing in each other’s general direction. After a few seconds, Parsberg’s sword made contact, taking a good chunk out of the astronomer’s nose.
The two men eventually made up and years later became great friends, and even family, when Parsberg’s cousin married Brahe’s brother.8 In the meantime, though, Brahe was disfigured, and embarrassed at the idea of walking around with an ugly wound that would also be a constant reminder of his defeat. Consequently, he had a replacement nose created. A lowly material such as wax, his biographer claims, would have been beneath a man of his station, so he chose one of ‘silver and gold’, painted to match the shade of his skin. (This claim has since been debunked by Danish and Czech researchers, who in 2010 performed a chemical analysis on the artificial nose, which turned out to be brass.9) Portraits of Brahe show this splendid creation glued to his face, and it looks quite convincing. But, if one of his friends is to be believed, the nose would now and then work itself loose, so he took to carrying a little box filled with glue he could apply whenever it started to wobble.
Figure 2 Tycho Brahe (line engraving by J. L. Appold after J. de Gheyn, 1586).
The life of Emperor Justinian II in the late seventh century surely wins the prize for the story with the highest number of chopped-off noses and the most effective nose mask in history. It wasn’t a prerequisite for a Byzantine ruler to be of royal birth, but it was important to be free from physical imperfection. A physically imperfect man, the Byzantines believed, could never become emperor. With this in mind, Justinian’s father, Constantine IV, established his son as joint emperor and ordered the mutilation of his own brothers’ noses. In due course, Justinian became emperor, seated in Constantinople. Later, Justinian was usurped by one of his own soldiers, Leontios, who mutilated Justinian’s nose and tongue to secure his own position on the throne. Then Leontios was deposed by a naval officer calling himself Tiberius. Of course, Tiberius chopped off Leontios’s nose.
Justinian II – so badly deformed he was known as Rhinokopimenos, the man with the cut-off nose – had in the meantime been plotting his comeback from exile. He returned to Constantinople, entering the city through a disused water conduit that ran under the walls. Once inside, he roused supporters and fought for and reclaimed the throne, overturning the idea that the imperial leader had to be free from physical deformity. According to the writings of Agnellus of Ravenna, he was wearing a replacement nose made of pure gold.10
For those who knew about it, though, there was another possibility to help undo the curse of noselessness: a skin graft – an operation last heard of in ancient Rome. We have records of two families practising their own secret techniques in Renaissance Italy. The Branca family were from Catania in Sicily and are remembered as the surgeons who ‘rediscovered’ the skin-graft operation and later improved it by taking skin from the forearm rather than the forehead. Around 1460 a member of the family taught the skin-graft procedure to a German physician, a Teutonic knight called Heinrich von Pfolspeundt. A leading surgeon of the age, Guy de Chauliac, dismissed the knight as ‘curing all wounds with incantations, potions, oil, wool, and cabbage leaves’.11 Pfolspeundt published a description of the operation in German, but it never received much attention, and he represents something of a dead end in the history of transplantation. The second family, the Vianeo family, lived in Tropea, a tiny fishing village in Calabria, also famous for its red onions. Like the Branca family, Pietro and Paolo Vianeo had a special technique to take the skin from a person’s forearm and transplant it onto their face. They’d learned how to do this from their father, Bernardino, who had in turn been taught by his uncle Vincenzo.
Throughout the sixteenth century – and probably even earlier – a steady stream of wealthy and emasculated men would have wound their way to the family surgery, hands clasped over their noseless faces. Many of them would have been disfigured trying to protect their honour in fights or duels. Some might have been punished. Others would have come in shame, with the eroded ‘saddle nose’ of a syphilis sufferer. They might have tried a nose mask in the past but wanted a more natural-looking substitute. With their special procedures to replace a lost nose, the Branca and Vianeo families offered these men a much-valued restoration of dignity, a solution far more effective (but also a procedure far more daunting) than the alternative of a face mask.
The Human Tree
One day in 1549, the Vianeo brothers opened their door to find a bearded gentleman with a perfectly intact nose – a well-proportioned one sticking out above a full beard. The stranger clearly didn’t need their services himself, but with his servant on one side and his horse on the other, he stood at the door’s threshold and shared his story. He was from Bologna, and his relative had lost his nose fighting in Lombardy. The man had heard the family could perform miracles in such cases and wanted to see them in action before recommending that his own flesh and blood submit to their knives. It sounded like a reasonable request, so the surgeons invited him into their surgery. What the brothers didn’t know was that the man they’d just invited into their secret world was a fellow surgeon who wanted in on their special technique. Leonardo Fioravanti was his name, and he’d concocted this whole back-story knowing the family would never be open with another medical man.12 It’s thanks to this man’s medical spy capers that, eventually, skin transplants found their way from the secretive Vianeo family to more mainstream surgeons who adopted a slightly modified version of the technique – a technique, incidentally, that was in use as late as the Second World War.
Figure 3 Leonardo Fioravanti, 1582.
When the moment came, Fioravanti threw himself into his role, pretending to be shocked by the whole bloody affair. He made the appropriate displays of agitation, putting his hands to his face as any squeamish observer might. But peering through gaps in his splayed fingers, he made careful note of what he saw.
Wielding pincers, the brothers pinched some of the skin from the man’s left arm and used a knife to slice it away from the muscle. They didn’t separate the skin from the arm completely, though. It became a flap, attached at one end, the other drooping away from the body. Next, they passed a piece of linen under the flap, and medicated the skin until it toughened up. Once it was thick and strong enough, they moved their knives to the area where the nose should be, and cut around it, creating an open wound on the face. Working quickly now, they cut off the end of the arm flap to create a second open wound. So the wounds could heal together, and the patient’s face and arm unite as one, the brothers bound arm to face, the open wounds touching one another. The surgeons instructed their patient not to move his arm until its skin had ‘grown into the nose’. Once the body parts had fused, the surgeons cut the skin away from the arm and moulded it around ‘a form of metal’ until the new nose grew to the right dimensions. The result was convincing to Fioravanti, though he noticed the new nose was a little whiter than the rest of its owner’s face.
It’s not clear whether Fioravanti knew about the ancient Indian technique that used skin from the forehead instead of the forearm. He did, however, know that the same kind of operation had been practised for centuries on plants. The Chinese and Indians were grafting plants at least as far back as 2000 BC. And plant grafting was already commonplace in ancient Greece. In AD 70 the Roman agricultural writer Columella described the surgery: it required a tree with ‘moist, juicy and strong bark’, like a fig or an olive. A young and healthy branch was amputated from one tree, some of its bark removed and the same shape cut into the branch of a second, host, tree. If these two were bound together, the two open wounds touching, the trees would unite within twenty-one days. Following this technique (or one of three others Columella described in his book On Agriculture), would produce trees with more high-yield branches, and therefore more fruit. It was even possible to graft different species onto one another. Typically, these species would be closely related, for example apples and pears, but Pliny the Elder reported seeing a tree at Tivoli ‘bearing every sort of fruit; walnuts on one branch, berries on another, on others grapes, pears, figs, pomegranates, and apples’.13
Reporting on his observations later, Fioravanti was explicit about this connection between the agricultural and surgical operations. The only real difference between the two procedures was the material – bark versus skin. The healing process was otherwise the same. When bark is wounded and brought together with bark, the two organisms fuse to become one. When skin is cut and brought together with skin, the same thing happens. For the Vianeo brothers, Fioravanti or anyone else who wanted to perform a skin graft, this healing mechanism was an opportunity to use the skin as a material to help shape and sculpt the human form. A crafty surgeon could even apply these principles to form an entirely new appendage. Cultivating humans was so close to cultivating the land, in fact, that Fioravanti described this kind of transplant surgery as the ‘agriculture of the body’ and the ‘farming of men’.
As a surgical technique drawing on sophisticated agricultural procedures, the skin graft was ingenious. But it was also intuitive. Transplanting skin was part of a surprisingly universal inclination to learn more about ourselves by looking to plants and trees. In his twelve-volume masterpiece of early twentieth-century anthropology, The Golden Bough, the Scottish anthropologist Sir James George Frazer noticed this wider tendency. Having amassed thousands of stories and anthropological studies, Frazer marshalled them into an overarching narrative of human progress. ‘Primitive’ cultures, he concluded, engineered their societies around a belief in magic, but eventually realized magic didn’t work, and started to invent and appeal to gods of one kind or another instead. When they finally realized this didn’t work either, they alighted at the pinnacle of humanity – a society based on and guided by science. The dusty volumes have a whiff of Indiana Jones about them, with index entries like ‘ass in rainmaking ceremony’, ‘mock battle at festival of new fruits’, ‘walrus, taboos concerning’. And they’re what you might expect of an industrious old-school anthropologist who referred to people as ‘savages’ – the scale of vision admirable, but the argument simplistic and warped. Though his conclusions were based on a flawed premise, it’s nevertheless staggering how many civilizations he surveyed that had a deep cultural affinity with trees.
Figure 4 An eighteenth-century depiction of an agricultural graft, 1772.
From Australia to Zanzibar and throughout all time, people have taken their ties with trees seriously. We’ve set trees on fire when people die, secreted dead bodies in trees, embraced them in the hope of getting pregnant, even hammered extracted teeth into them. In ancient Germany the life of a tree was just as valuable as the life of a person. If you damaged the bark of a tree your fellow townsfolk would avenge it by cutting out your navel and nailing it to the injured limb. They would then have driven your body around the tree until all your guts entwined its trunk, and you wouldn’t live to harm another. That was the idea – ‘a life for a life’, your pulled innards replacing the dead bark with a living substitute. Fundamental and constant, human–tree bonds are everywhere. Human beings have used trees in rituals, as avatars, for medicine. An Indian tribe even married mango trees off to tamarind and jasmine trees to sanctify their crops.14
When trees age, their bark ages much like human skin – sagging, folding, wrinkling, blemishing. Making this observation in the first century AD, the Roman naturalist Pliny the Elder wrote about how trees have the equivalents of ‘skin, flesh, sinews, veins, bones, and marrow’, and a juice ‘which must be looked upon as their blood’.15 Four hundred or so years earlier, Aristotle brought plants and animals closer together by directly comparing a seed to an egg, referring to a plant’s roots as its ‘mouth’. So similar were plants and animals in his eyes, in fact, that he referred to a plant as a ‘rooted animal’.16
In their theories of digestion, some ancient philosophers like Aristotle saw a continuum between plants and humans as the former metamorphosed into the latter. Galen of Pergamon was the most influential doctor of all time – a Greek physician to the gladiators who lived, thought and wrote between the years 129 and roughly 210. As we’ll see, his works would sit on the shelves of almost every doctor from the third to the eighteenth century. When he described the process of digestion, he painted a picture of a real-life metamorphosis of plant into human. When we eat, Galen wrote, the top part of the stomach transforms into the shape of a hand. It reaches out to grab food from the gullet and draws it back into itself. This is the start of the transformation of food into flesh. Once the stomach-hand has grabbed the food, it’s sorted into nutritious and non-nutritious parts. The non-nutritious part floats off towards the spleen and becomes black bile. The nourishing part ends up being concocted into chyle, then fermented into a fluid and invested with a primal ‘vegetative spirit’. This spirit – the life force common to every living thing – rushes through the body’s veins as blood to heal any wounds we might have, to help us grow and to keep us alive. A human would eat plants (and animals, who themselves ate plants) and the body would use this material to grow, nourish and replace bits a hostile world had nicked, grazed or lopped off.17
Further entangling plants and people, Aristotle even lumped sexual reproduction into the category of digestion. Semen and menstrual blood, he thought, were both ultimately created out of digested food. And these two substances would together produce an entirely new body. These plant-derived raw materials remained visible in the body throughout life. You could see the remnants of semen in the hard, white and vital parts like bone and organs, while menstrual blood supposedly made up the squishy bits in between. Injuries to parts derived from sperm were (mostly) permanent, whereas sanguinary parts could regenerate, a so-called ‘nutritive soul’ – also from plants, and very similar to Galen’s ‘vegetative soul’ – literally helping to fill in any gaps.18
Although we don’t tend to interpret digestion in quite those terms any more, many centuries later we’re still discovering the extent of the correspondences between people and plants. Trees, it turns out, form networks with one another, connecting and communicating in their own language of smell, sound and electrical signals. They also sweat, form memories and in some ways can even be considered individuals. And while they don’t exactly have brains, trees learn and store information in their roots. As we deepen our understanding about the extent of our physiological kinship with trees, modern science seems to echo the timeless and intuitive observations shared by Aristotle, Pliny the Elder and the tribes in Frazer’s books.19 Early transplant surgeons like Fioravanti, too, observed human bodies to be behaving so much like plants they could explain the process of healing. And activities that draw on that process, like grafting, could be directly transposed from the plant kingdom to the animal kingdom.
With the phrases ‘agriculture of the body’ and ‘farming of men’, Fioravanti not only evoked an intuitive, universal, timeless kinship between trees and people, but also meant to pay tribute to actual farmers and to attribute skin-graft surgery to ordinary, everyday people. A year after his fishing trip to the Vianeo surgery, we find Fioravanti pottering around the east coast of Tunisia, near the town of Mahdia, where he got the chance to try out skin grafting for himself. It was 1550 and a conflict was raging between the Spanish and the Ottomans. Fioravanti’s companion, Andres Gutiero, was Spanish, and when they passed a group of (presumably Ottoman) soldiers, one decided to pick a fight. Lashing out with his blade, the soldier sliced into Gutiero’s face. His nose dropped into the dirt, rolled in some sand and came to rest on the ground in front of him. Blood welled from the gap where the nose used to be.
Luckily, Fioravanti wasn’t far away, and he sensed a chance to try out some of his new-found skills. He walked over to pick up the nose, turned it around in his hands, inspected the severed object and came up with an ingenious idea. ‘I pissed on it,’ he confided in a book thirty-two years later. Having washed away the sand, he stuck the urine-soaked nose back onto his friend’s face and applied stitches and balsam before bandaging it up. Even Fioravanti didn’t have much faith in this field surgery and was surprised when he untied the bandage to see the nose was attached again. If readers didn’t believe him, he wrote – and there was a good chance they wouldn’t – they could ask Gutiero, who was alive and well.20
He was right. It is hard to believe. It’s even harder to believe when we understand how practised a liar Fioravanti was. He was the kind of man to boast about visiting a hospital of incurables and curing everyone there. He claimed to have done just this, in fact, on a visit to Palermo.21 The Sicilians also learned of his genius, he tells us, because when he visited Sicily to learn about distillation, he managed to cure leprosy, scrofula and syphilis on the side. Elsewhere on his travels he discovered the antiseptic qualities of saltwater, aquavit and urine (which I presume is why he decided to piss on Gutiero’s nose). In one case while performing surgery on a patient’s spleen, he requested his assistants and spectators to unfasten their trousers and relieve themselves in the patient’s open abdomen (the patient survived).22 But just as the Vianeo brothers swallowed his story about being a gentleman from Bologna, his public seemed to accept the magnificent claims he made for himself. Wherever he went, the people assumed he must be bringing secrets from a distant land, and would gather around him, he wrote, ‘as to an oracle’.23
It’s also possible that ‘the people’ didn’t mind a bit of dishonesty because he went to great lengths to identify with them. He verified their unlettered experiences, took the trouble to learn their homespun medical wisdom and even insisted on its superiority over things written in books. Fioravanti would drag his horse far and wide, over land and sea, deliberately seeking out distillers, shepherds, countrywomen, peasants, soldiers – anyone who might have something to teach him. And he’d sit down and listen to them. In the Sicilian town of Messina, he met an old man who told him that he only ever took one medicine, soldanella, once per year, in spring. And every time he did so, he said, ‘it makes me vomit thoroughly and leaves my stomach so clean that for a year I cannot fall ill’. He’d reached the age of 104, all by observing this ‘natural way’ of healing.24
Fioravanti, reflecting on the practices of these rural folk, concluded that they learned their medicine from ‘the first physicians’ – animals. The old man was copying what dogs did when they became ill. When a dog feels sick, it ‘goes to the forest and finds there a certain sort of herb, which’, Fioravanti wrote, ‘immediately makes it vomit and evacuate from behind’.25 Dogs know when they’re diseased and intuit how to bring themselves back to health. Fioravanti let encounters like the one with the vomiting old man influence the medicines he concocted and sold as far as Elizabethan London. So that his patients could also purge their bodies and live a long life, Fioravanti created and marketed his own drugs to induce vomiting or diarrhoea, giving them theatrical names like Angelic Electuary, Leonardo’s Grand Liquor and Fragrant Goddess.26 With Arcadian origins, the skin graft took its place far away from the echoing halls of theory-bound universities, literally amongst the trees and those who dwelled closest to them.
With probably a few exceptions (like the deceived Vianeo family), the people seemed to admire him back. His writings validated some of the discontent ordinary folk felt, believing themselves powerless. Ruled as they were by so-called elites studying and living apart from the real world, they could easily believe Fioravanti when he told them an academic doctor’s impenetrable technical language was all part of his desire for exclusivity.27 Fioravanti preferred to base his own medical system on the collective, intuitive wisdom of centuries – a live tradition with no written component – as opposed to a raft of dead, book-learned knowledge. He believed ‘more in a little experience’, he wrote, ‘than in all the theories of the world taken together’.28
Figure 5 A dissection in progress: the anatomy professor at his lectern, 1493.
It’s easy to sympathize with Fioravanti and the sceptical Renaissance public when we take a look at some of this ‘conventional’ medicine. At least Fioravanti trusted what he saw. What most physicians in the Renaissance (and earlier) knew of the world around them, and what they thought about it, mattered little. Anatomy demonstrations, for instance, involved an instructor, or lector, sitting in his chair reading aloud from an ancient medical text. On a table in front of him would be an executed criminal, and a surgeon or barber would open up the body as directed. Another assistant – an ostensor – would point a wand at the parts being discussed. It was really an anatomy demonstration in name only, the performance’s main function being to repeat what was in the textbook. If what the audience saw was different from what the book described, they’d blame the inconsistency on bad translation, or even the body itself for being an anomaly.
Anatomy demonstrations like this had used the same format for over two hundred years. The anatomical textbook most likely to be on the lectern in Fioravanti’s time – Mondino de Luzzi’s Anathomia Corporis Humani – was the first book entirely devoted to anatomy, but had been written in 1316.29 This book would have been the most important part of this entire exercise, even in the mid-1500s, since it parroted the theories of Galen.
Copyright © 2021 by Paul Craddock