The history of medicine through the history of transplant surgery
By Paul Craddock
“Spare Parts: The Story of Medicine Through the History of Transplant Surgery” by Paul Craddock opens in the middle of the operation, as a donor organ (“that lifeless gray lump”, as described by Craddock) is sewn in place. Clamps released, the new kidney comes alive or seems to come alive. “Before my eyes, the surgeon removed these devices and within seconds the kidney turned from gray to pink to almost red,” Craddock writes. “It was as if life itself had fallen from one man’s body into another.” The operation is described as state-of-the-art, but Craddock, a senior research associate in the division of surgery and interventional sciences at University College London’s medical school, is keen to show the ancient roots of the transplant. “Transplant surgery is far from an exclusively modern phenomenon,” he writes, “with a surprisingly long and storied history stretching all the way back to the pyramids.”
So off we go on an exciting and often terrifying journey through transplantation and the theories and techniques that have made it possible. It starts in Renaissance Italy, where the push for rhinoplasty came not from kings but from the general population, who had perfected skin grafting long before the European medical profession – such as it was. (The “Sushruta Samhita,” a Sanskrit text from 500 BC that Craddock cites, described skin grafts, among hundreds of other surgical procedures.) learned a way to graft skin from an arm on a nose, masking nasal bridge collapses caused by syphilis or duel mutilation, both common. “In Italy, skin grafting had evolved as a peasant operation, culturally and technically linked to the farmer’s plant grafting procedure.”
The book is listed chronologically by procedure: from 16th century skin grafting to 17th century blood transfusions and 18th century tooth transplants. It skips slightly over the 1800s (and the development of germ theory, anesthesia and nursing) and ends with 20th century kidney and heart transplants. Craddock explains the scientific theories behind each new technique – then he highlights a star, or several. In addition to nose repair, Leonardo Fioravanti claimed to have cured leprosy and discovered the antiseptic attributes of aquavit and urine; in 16th-century Bologna, he urinated on patients (literally) while metaphorically urinating on a medical establishment he saw as devoted to moribund classical texts. As Craddock puts it, “Fioravanti preferred to base his own medical system on the collective, intuitive wisdom of centuries – a living tradition with no written component – as opposed to a body of dead knowledge learned from books”.
The reigning text was by Galen of Pergamum, the first-century Greek philosopher, who was silent on skin grafts (Aristotle associated the body’s largest organ with the crust on a polenta) but described health in terms of four humors. – blood, yellow bile, phlegm and black bile, the outflow of which was thought to be affected by mood, personality and stars. Medicine was all about humoral balance, often regulated by bleeding. Galen’s anatomical descriptions, although still evangelical in the 16th century, were hampered by a Roman rule against the dissection of humans. When Andreas Vesalius, a Flemish anatomist, published “On the Tissue of the Human Body” in 1543, based on his own dissection of cadavers, it helped to emphasize the importance of scientific observation and to re-conceive the heart as a pump. He also underlined the idea that blood was better inside the body than outside, inspiring a host of experiences that made life in Paris and London horrible for dogs. The heart was now perceived as a ruler or king, “the seat and organ of all the passions”, prompting questions about dogs (“if a fierce dog being often again supplied with the blood of a cowardly Dog, maybe no more tame”) and then humans. In 1667, French doctors infused a man with calf’s blood partly “to improve his character”. Sheep, docile in the Bible, were a benchmark for human transfusion, although a butcher, infused by members of an English scientific society, angered doctors when he slaughtered and then ate his donor. In 1700, weak professional decorum, reinforced by public ridicule, put an end to the experiments.
Generally unsuccessful attempts at tooth grafting, according to Craddock, coincided with a view of the body as a machine, complete with transferable parts – complicating the work of philosophers and enriching that of salespeople. Walk into the dentist, offering advice (gargle with urine!) and private tooth transplants to whimsical clients put off by public tooth pullers. The new teeth were ultimately supplied by young and poor mouths: as Craddock points out, “the dystopian reality of body shopping has a dark precedent in the realm of teeth”. The search for what drove the human machine also led to theories of nerves and associated disorders observed to particularly affect the more “developed” upper classes. The soul was linked to the body, “a material thing that pulsated through it”.
Cut to 1901. Immunology is a new discipline, and the previous blood types – dog, cat, sheep, human – have evolved into our modern iteration, named after Viennese researcher Karl Landsteiner. The same year, Alexis Carrel, a young French surgeon whose mother owned textile factories, studied with Marie-Anne Leroudier, one of Lyon’s top embroiderers (and one of the few women featured in “Spare Parts”). Leroudier’s dexterity in manipulating “unfathomable complex” decaying tissue taught the young surgeon how to stitch up blood vessels, making kidney and heart transplants as well as bypasses possible, although his contributions were downplayed by Carrel and the essence of Western scientific history. After being expelled from Europe, Carrel, whose experiments make Dr. Frankenstein look like a genius Marcus Welby, arrives in 1930s New York, where his passion for eugenics earns him the friendship of Charles Lindberg. Together, they would invent an infusion device to maintain a viable organ outside the body, all with the goal of weeding out the weak in society. Carrel’s book, “Man, the Unknown,” was an American bestseller in 1936; the German edition praised the eugenics work of the Nazis.
Early heart transplant surgeons were less about health and more about rewards. As one doctor put it: Virtually all of the patients undergoing the procedure have died, “after satisfying the macho aspirations of their surgeons.” Meanwhile, any technical successes had more to do with deeper community understanding of the immunology of medicine – how to treat organ rejection – than with surgical breakthroughs.
Craddock’s conclusion is meant to give hope: “According to colleagues at UCL in London, the impression of a replacement full body part may be only a decade away.” But that doesn’t reassure as much as it worries a reader, especially given the case of Paolo Macchiarini, the famed UCL-affiliated surgeon (not mentioned by Craddock) widely hailed for performing the world’s first synthetic trachea transplants at using stem cells but currently on trial in Sweden for aggravated assault on his patients. In fact, what inspires the most hope is what ends up sounding like the accidental subtext of “Spare Parts.” This relates to how Italian Renaissance farmers saw themselves in trees: distinctly individual trees that, as Craddock notes, science has only recently become aware of, are in communication with each other, without talk about us. If we look more closely at the forest, the past indicates that we could repair ourselves through the trees.