Limb Transplantation: Myth, Art, and Surgery

After the first kidney transplantation in identical twins (1954), advances in surgical techniques and the development of immunosuppression drugs made liver, lung, and heart transplantation possible. Arm transplantation started in the late 1990s. Ankle and face transplantation began to be performed in 2004 and 2005, respectively. Recently, hand and arm allografts in patients who have been maintained on low-dose tacrolimus monotherapy resulted in good-to-excellent functional recovery.1 The ancient Egyptians, Greeks, and Romans dreamed of morphologic changes in the structure and behavior of the human body. In their myths, some gods, heroes, sirens, tritons, and centaurs had animals’ wings, limbs, or tails on their bodies. From the perspective of the plastic surgeon, these can be seen as the “figuration” of xenotransplantation.2 The first known story of real transplantation is the Christian miracle tale of 2 brothers, Saints Cosmas and Damian. They were early Christian martyrs who practiced medicine without payment and, therefore, were represented to the public as symbols of the ideals of medicine. The source of this story is the “Golden Legend (Legenda aurea)” by Jacobus da Varagine, a collection of fanciful hagiographies written in about 1260. The book describes the story as follows: in Rome, a verger (a layperson who assisted in church services) had a disease that was eating away the flesh of his leg. One night, he dreamed that the 2 saints came and cut off his bad limb and, in its place, transplanted the leg of a dead Ethiopian man who had just been buried in a nearby churchyard. Upon awakening, the verger found that he had a healthy black leg, while it was discovered that the Ethiopian man’s body now lacked a limb.3 This dramatic cure by miraculous transplantation was attractive for many artists. Recently, I enjoyed an oil painting entitled A Verger's Dream (Wellcome Library no. 46009i, Fig. 1) created by Master of Los Balbases around 1495. In this Spanish altarpiece, Saints Cosmas and Damian are shown in the full finery of academic doctors as they perform a miraculous leg transplantation. The following discrepancies are present between this painting and classical anatomy: this painting shows only 1 bone (tibia) running through the limb below the knee joint and no blood coming out of the vessels (popliteal artery and vein). This fallacy is thought to be due to the lack of anatomic knowledge before Fabrica (1543) by Vesalius (1514–1564).Fig. 1.: A Verger’s Dream (Wellcome Library no. 46009i). Saints Cosmas and Damian perform miraculous leg transplantation. Oil painting attributed to the Master of Los Balbases, ca. 1495.Myths and fairy tales came from the imagination of humankind. These stories are passed down orally. These forms of orally transmitted literature can be written down by novelists or biographers. If a written story is composed in the form of a “legenda,” such as the “Golden legend,” it may become the subject of artists. Most artists make their paintings by imagining the contents of “legendae.” Some of them become altarpieces in churches or cathedrals. Hundreds of years later, the visions painted in “legendae” came true, thanks to the efforts of plastic surgeons. Through curiosity, imagination, and persistence over the course of the centuries, physicians and surgeons made many scientific advances. On the basis of these advances, plastic surgeons became able to translate these legends into reality. Needless to say, a good plastic surgeon must first be a good surgeon, and a good surgeon must first be a good physician.4