The story of medical progress in the twentieth century nearly always places organ transplantation as the height of achievement . In the first round of breakthroughs, surgeons had to develop techniques to make impossibly tiny sutures in challenging, slippery conditions under a terrible time constraint. Once these first surgical techniques were mastered, a second round of challenges emerged: How to keep transplant recipients alive when their bodies constantly fought off the invading new organ. Even as the news media trumpeted the successful surgeries of the mid-centuryâa kidney transplant between the Herrick twins in 1954 or the âMiracle at Cape Townâ heart transplant in 1967âdoctors and patients struggled against the persistent problem of immune rejection . In the 1980s, a âmiracle drug,â cyclosporine, allowed doctors to manage the problems of rejection and prompted a third round of breakthroughs. Today, organ exchange has become a celebrated, even commonplace surgery, with tens of thousands of operations taking place in the USA each year.
In this story of setbacks and breakthroughs, however, it is easy to lose some of the truly radical nature of organ exchange. We celebrate the surgery as medical miracle , but there are other, darker stories that could be told of transplantation. After all, the bare realities of the surgery are the plot points of familiar horror narratives. Take a moment to truly consider this fact: We take organs from dead bodies and place them in the living. This practice flies in the face of many of our most enduring concepts, most particularly the strict separation between the dead and the living and between the self and others . Organ transplantation violates the most fundamental categories by which we understand health, identity, illness, and death. But how did we overcome these taboos? How did transplantation transform from something to be feared to something we celebrate? Although medical historians have told the story of transplantation as outlined aboveâthe story of technical challenges and triumphsâTransplant Fictions tells the cultural story of how transplantation became not just medically, but conceptually possible.
The cultural study of organ exchange begins with a medical miracle in the most basic sense. Cosmas and Damian were twin brothers, practicing doctors, and outlaw Christians living in Syria in the second half of the third century. After the twins refused to make sacrifices to the gods, the Roman authority in Syria ordered their execution. They were tortured, burned, crucified, stoned, and shot with arrows before a beheading finally accomplished their martyrdom. Like donated cadaver organs, however, the lives of these saints do not end with their death. Centuries later, they are credited with the âmiracle of the black leg,â typically cited as the first documented case of imagined surgical transplantation.
Versions of this story proliferate between 1200 and 1400, but the most popular is recounted in the medieval bestseller, The Golden Legend. According to the tale, a Christian living in Rome sought relief from the martyred saints because his leg was being consumed by a cancer, or what we would likely call gangrene. One night, as he slept in a local church dedicated to Cosmas and Damian, they appeared to him in a dream. Carrying with them the salves and instruments of their surgical trade, one said to the other, âWhere can we get flesh to fill in where we cut away the rotten leg?â1 The other replied, âJust today an Ethiopian was buried in the cemetery of Saint Peter in Chains. Go and take his leg, and weâll put it in place of the bad one.â He traveled to the nearby cemetery and returned with the âMoorâsâ leg. They cut off the leg of the sick man and attached the cadaver leg in its place. Then, they returned to the cemetery and attached the gangrenous leg to the body of the dead Ethiopian. Transplant accomplished, âthe man woke up, felt no pain, put his hand to his leg, and detected no lesion. He held a candle to the leg and could see nothing wrong with it, and began to wonder whether he was himself or somebody else.â2 He leapt overjoyed from his bed and ran out to tell the tale of his miraculous dream and cure. Finally, the community rushed to the Ethiopianâs tomb where they found his leg indeed cut off and the sick manâs laid in its place. A miracle of transplantation had occurred.
Even though written centuries ago, this first story of organ exchange reveals the many conceptual crossings required to even imagine transplantation. The doctor-saints are able to overcome differences of living and dead, diseased and healthy, Christian and Moor, European and Ethiopianâcategories that constitute many of our most enduring ideas of life and social organization. Despite an initial moment of deep insecurity, of wondering whether he is himself or somebody else, the cured patient and his community embrace the operation and celebrate the doctors for their miraculous achievement. By breaking down the steps of this evolution, my cultural study of transplantation chronicles the conceptual sleights of hand through which organ exchange becomes the crowning achievement of twentieth-century medicine. Quiet ruptures in our understanding of medical authority, funerals, and death have paved the way for a widespread embrace of a procedure as radical as organ transplantation. But it did not have to be this way.
Transplant Fictions brings together a diverse set of cultural representations to understand how organ exchange became possible. By âpossibleâ I do not mean the history of vein suturing, tissue typing, and immune suppression that has made this once-radical surgery now relatively routine. I mean: What concepts have emerged that allow us to overcome the profound ideological violations represented by transplantation? What changing notions of identity, death, medicine, and the social body have paved the way from imagination to experimentation to clinical practice?
These questions are embedded in the earliest seeds of our imagining. Even a millennium ago, we understood transplantation as a miracle with the power to remake fundamental categories. As the founding text in the genre, the miracle of the Black Leg deserves a closer reading. Perhaps the most resonant moment in the legend comes at the patientâs awakening to a new understanding of his embodied self. The seventeenth century Acta Sanctorum offers a slight elaboration of this scene: âWaking up, when he felt himself without pain, he placed his hand on his leg, and found no lesion. Putting a candle then nearby, when he saw nothing wrong in the leg, he thought that he was himself not who he was, but that he was rather someone else.â3 There are two phases of âdiscoveryâ here. First, the sufferer becomes aware of multiple absences: the lack of pain and the lack of lesions. Then, under the light of a candle, he visually confirms the health of the leg, but in so doing experiences a radical revision of self: âhe thought that he was himself not who he was, but that he was rather someone else.â This troubling of individual identity is not simply the product of medieval superstition. Interviews with contemporary transplant recipients both before and after surgery reveal anxieties about sense of self. Commonly reported post-surgical changes include changes to personality and taste, often attributed to taking on aspects of the donor. Vegetarians become meat lovers, and punk rockers develop a love for classical music. Even in the least sentimental accounts, the relatively immediate transformation from end-stage organ failure to relative health marks a radical change. In these reports, patients describe a profound sense of alienation from their pre-surgical self, often in terms that emphasize the play of opposites.4
In addition to asking what it means for the ill patient to incorporate the flesh of another body, the legend of the Black Leg attends to the body of the donor as well. In most retellings, the miracle is a true exchange, where Cosmas and Damian return the gangrenous flesh to the entombed corpse. As Leonard Barkan, a scholar of Early Modern culture, reminds us, the symmetry of this exchange reflects two fundamental concerns of the period: A belief in the completeness of the physical body and the doctrine of the original body needed at the second coming of Christ. In the latter formulation, each individualâs perfected body will rise to heaven at the resurrection . While this attention to the afterlife of the exchanged limbs may seem rigid or oddly specific, anxieties about the religious future of the body are not merely the province of the medieval era. In fact, the online frequently asked questions (FAQ) sections for many organ procurement organizations take such religious anxieties seriously, understanding the importance of such concerns for many prospective donors and their families. Today, every major world religion endorses transplantation , but it is important to place this endorsement in the context of centuries of understanding the corpse as sacred and inviolable. The early chapters of this book more closely explore the sea change necessary to move from reverence and clerical authority over the corpse to acceptance of near total medical authority over death and the body.
In the Cosmas and Damian story, transplanting the gangrenous leg onto the Ethiopian corpse also signifies a commitment to the principle of somatic wholeness. This notion is less doctrinally specific and, perhaps for that reason, more widespread and enduring. In modern Western conceptions, the body is understood as a sovereign self: closed, contained, unified, and under rational control. In restoring diseased flesh to a cadaver, Cosmas and Damian reflect an understanding of physical integrity rooted in wholeness. The same online FAQ sections are careful to assure families that open casket funerals are possible after donation. While failing organs are obviously not swapped back to donor cadavers, procurement and funeral personnel are careful to mask the intrusions caused by organ retrieval surgery. It is the symmetrical exchange of diseased and healthy flesh in this first imagined transplantation that reveals our deep-seated attachment to bodily integrity. After all, why transplant the diseased flesh to the corpse unless guided by a strong ideological preference for wholeness? The very conceptual categories of somatic wholeness and inviolability that are challenged by the achievement of transplantation are first emphasized in this earliest imagining. In particular, removing part of one body and locating it inside another raises important questions about the nature of identity. Where does the self reside and what level of incursion or addition will change that sense of self? What does it mean to wake up (e.g., from surgical anesthesia) and be restored to health? Is the patient âhimself or somebody elseâ?
After its late medieval inception, the legend of the Black Leg finds popular expression once more in Renaissance painting. The visual appeal of the story is evident as visual artists take advantage of the striking contrast between the white skin of the Christian sufferer and the black skin of the Ethiopian donor. Although many artists play with the scale and shape of the mismatched legs, thus emphasizing the fundamental difference between the donor and recipient, others take a different approach. As Leonard Barkan notes in his analysis of artwork depicting the miracle, these artists use strategies of mirroring and symmetry, placing the donor and recipient âin that curious territory where opposites are identicalâ (240). Barkan is also careful to caution...