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Transplant: From Myth to Reality

Nicholas L. Tilney
Copyright Date: 2003
Published by: Yale University Press
Pages: 336
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  • Book Info
    Book Description:

    One of the most spectacular medical advances of the twentieth century, organ transplantation has become a generally effective and routine treatment for patients with organ failure. In this riveting book, a well-known expert in the fields of clinical transplantation and transplantation research traces the evolution of organ transplantation from its initial stirrings in the imaginations of the ancients to its current status as accepted treatment for nearly 40,000 patients each year. Drawing often on his own firsthand experience, Dr. Nicholas L. Tilney tells the story of the advances in organ transplantation, discusses how societal forces have driven its development, and reveals how its current success is marred by commercialism and exploitation of the less fortunate.Dr. Tilney describes early transplantation attempts, the first successful kidney transplant in 1954 between identical twins, the scientific advances for suppressing the immune system, the introduction of the concept of host tolerance, the new research on donor matching, and the issue of donor brain death. He explores innovations in heart, lung, liver, and other abdominal transplants and reflects on the attempts to make transplants between species. Finally he explains how organ transplantation has become a vast business, creating ethical and logistical conflicts about organ donations.

    eISBN: 978-0-300-14998-2
    Subjects: Health Sciences

Table of Contents

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  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
  3. Preface
    (pp. ix-xii)
  4. 1 Legends, Possibilities, and Disasters
    (pp. 1-35)

    THE PHYSICIAN ASSURED AN OFFICIAL VOICE ON the other end of the telephone that he was indeed familiar with Joe Palazola, who had recently (in August 1964) been discharged from the Peter Bent Brigham Hospital in Boston following a successful kidney transplant. What was the call about? Palazola, the voice responded, had just been arrested as a suspected bank robber. A passing state trooper had spotted Palazola in his car, wearing a mask and a porkpie hat pulled low over his eyes. He had been forced to stop at the side of the road, then taken to the police station....

  5. 2 Attempts and Failures
    (pp. 36-59)

    A POLITICAL TRAGEDY IN 1894 TRIGGERED A series of surgical contributions in two novel interrelated specialities, vascular surgery and organ transplantation. After centuries of rudimentary attempts to control hemorrhage or prevent arterial rupture, the development of methods to join or anastomose accurately two vessels for repair, rerouting, or reconstruction was a crucial advance. At the same time, application of the new techniques provoked investigations into the revascularization of solid organs after their transposition from their original location into another site in the same or a different subject.

    France at this time was in turmoil, with bombings, riots, and confrontations between...

  6. 3 Hopes and Occasional Successes
    (pp. 60-82)

    WITH THE SINGLE EXCEPTION OF GREGORIO Woloshin, all the relatively small number of kidney transplants performed in a handful of centers during the early 1950s failed within a few days. The death of the recipients generated a difficult period for all concerned. Immunosuppression lay in the future. Dialysis backup was rare, and what was available was rudimentary. Hopes of success were remote. The new field was in sore need of a positive event to prevent its dissolution. Remarkably, such a situation surfaced and provided dramatic impetus.

    Active and healthy at the age of 23, Richard Herrick developed high blood pressure,...

  7. 4 Host Defenses and Immunity
    (pp. 83-108)

    ONCE THE SURGEONS HAD CREATED AN EFFECtive and reproducible operative technique to transplant a kidney from human to human, they faced a more formidable barrier. Regardless of immunosuppression, within a few days most recipients experienced an intense local inflammatory reaction. The allograft became tender and swollen. Patients often developed high fevers and general malaise. If the process could not be reversed, renal function declined inexorably as cellular destruction progressed. Occasional rupture and hemorrhage of the enlarging organ required urgent surgical removal. If dialysis was unavailable, death was inevitable.

    Unique to transplanted foreign tissues, this phenomenon of acute rejection, as it...

  8. 5 Peter Medawar and Transplantation Biology
    (pp. 109-124)

    IT IS DIFFICULT IN RETROSPECT, EVEN FOR THOSE with a long-standing interest in the subject, to recall how rudimentary was the understanding of host immune responses against allografted tissues at midcentury. Only with ever-increasing numbers of wounded in World War II did it become obvious that theoretical knowledge of skin-graft behavior needed to be replaced with practical means to cover denuded body areas. Because of his experience with a badly burned airman, Peter Medawar (then working in Howard Florey’s laboratory) embarked on a series of studies that were to transform this relatively obscure subject into a notable new field of...

  9. 6 Innovation and the Struggle for Legitimacy
    (pp. 125-142)

    THE 1960S AND EARLY 1970S WERE YEARS OF TUmult. In Britain disquiet and anger emanated from the oil crisis, high levels of unemployment, and police intolerance. After years of national disputes involving Algeria and other social ills, ten million French workers struck in March 1968 for better working conditions and higher wages. The United States endured a series of political assassinations, fears of nuclear war, sporadic riots among the inner-city poor, and the national agony of the Vietnam War. The disgrace of Watergate forced the President from office. Events influencing daily life seemed out of control.

    Hospitals and laboratories were...

  10. 7 Prolongation of Life and of Death
    (pp. 143-163)

    THE HISTORY OF SCIENCE IS REPLETE WITH INstances in which a discovery or advance in one subject suggests an alternative approach in an associated area, or provokes the development of an unrelated specialty which in turn may stimulate advances in the two fields. Both the specialized support of patients with organ failure and the transplantation of organs exemplify this relationship by introducing a spectrum of ideas ranging from novel technologies and treatments to reappraisal of long-held medical, cultural, and ethical beliefs. Some of these changing perceptions have included concepts as unusual as extension of life by the dialysis machine, or...

  11. 8 New Departures
    (pp. 164-186)

    THE TRIUMPHS OF RENAL TRANSPLANTATION OF identical twins and the occasionally successful forays into immunosuppression encouraged a few surgical enthusiasts to consider replacing other abdominal viscera such as the liver, the pancreas, and even the small bowel. However, transplantation of organs in the chest—particularly that most symbolic of structures, the heart—generated the greatest excitement. The perception of the heart as the site of the more tender emotions, as the center of spirituality, as a vital force and a mystical place where noble sentiments are retained, has been invoked throughout the ages in poetry, literature, and the arts. The...

  12. 9 The Dracula of Modern Technology
    (pp. 187-198)

    ON GOOD FRIDAY OF 1969 IN HOUSTON, DENTON Cooley implanted an artificial heart into Haskell Karp, a patient dying of cardiac failure. After being sustained by the device for sixty-four hours, he received a heart transplant. The donor was flown by chartered air ambulance from Lawrence, Massachusetts, in response to a nationwide appeal by Karp’s wife on television and radio and in the newspapers. Her eloquence was striking: “Someone, somewhere, please hear my plea. A plea for a heart for my husband. I see him lying there, breathing and knowing that within his chest is a man-made implement where there...

  13. 10 The Abdominal Viscera
    (pp. 199-216)

    THE DESIRE TO GRAFT ABDOMINAL ORGANS OTHER than the kidney arose as a natural extension of Joseph Murray’s first successful transplant between identical twins in 1954. Within months, attempts to replace the liver in dogs were initiated; in less than a decade, the first patient received a hepatic allograft. Earlier forays into pancreatic transplantation were reexamined, refined, carried out in animals, and then in occasional patients. Small bowel and other viscera in combination were grafted. All attempts were unsuccessful. During the years that followed, a handful of single-minded surgical-scientists labored to wrest the technically demanding transplantation of these complex organs...

  14. 11 A Modern Minotaur
    (pp. 217-228)

    THE RECIPIENT OF AN ANIMAL ORGAN WHO REceived the most public attention over the years was Baby Fae, a child born prematurely in Los Angeles in 1984. Weighing just over a pound and in cardiac distress, she quickly came under the care of Dr. Leonard Bailey, an experienced pediatric cardiothoracic surgeon. Her diagnosis was hypoplastic left heart syndrome, an invariably fatal congenital anomaly characterized by an underdeveloped left ventricle unable to pump adequate amounts of blood to supply the body’s needs. With life support becoming necessary within days, surgical options were considered. The family ruled out any temporizing procedures, so...

  15. 12 Coming of Age
    (pp. 229-243)

    CLINICAL TRANSPLANTATION EXPANDED SUBstantially during the 1970s, becoming more visible as a potential treatment option for the swelling roster of patients seeking help. As hospitals in the United States in particular approached what was later to become a maelstrom of marketing forces, competition between institutions was fueled by incentives to provide “full-service” care with all current diagnostic technologies and treatment modalities. Tragically, some of the advances were limited to those who could pay. But after federal reimbursement of the expenses of individuals with renal failure became available under Medicare in 1972, adequate medical coverage for this population at least was...

  16. 13 The Industrialization of Transplantation
    (pp. 244-256)

    A FEW CLINICAL INVESTIGATORS, CONFIDENT enough to acknowledge the marginal effectiveness of the new modalities and their substantial hazards to the desperately ill patients willing to accept the risks, tentatively introduced total-body radiation then chemical immunosuppression to recipients of kidney transplants. Perhaps stimulated by the ongoing political and social restlessness of the 1960s, all parties involved may have been more ready than in calmer periods to exploit innovative concepts in science and nonconformist departures in medicine. Although this iconoclastic attitude persisted over the next decade, the majority of clinical scientists, like the population itself, were tiring of disorder and turmoil...

  17. 14 Unexpected Specters
    (pp. 257-275)

    MODERN TRANSPLANTATION CURRENTLY PROvides new lives for about forty thousand patients who receive organs each year throughout the world, and new hope for tens of thousands who await them. But the very success of the subject has opened a variety of challenges ranging from the logistical to the ethical. Clinical research is increasingly driven by industries devoted to the developing and marketing of immunosuppressive drugs, sometimes to the detriment of objectivity. Basic investigations are shifting from those potentially applicable to patient care to less immediately relevant studies in molecular biology and genomics. Most significant is the divergence between the ever-increasing...

  18. 15 Future Prospects
    (pp. 276-284)

    THE TRANSPLANTATION OF SOLID ORGANS AND its biology have advanced remarkably in the half century since the first successful kidney graft. Clinical conditions were primitive when I first became involved four decades ago, shortly after the introduction of chemical immunosuppression. At that time in our hospital, individuals dying with uremia were cared for in the general wards. If hemodialysis could be offered at all, it was performed not infrequently using the same dialysis bath for two different patients. As a result, hepatitis was rife—not only among those dialyzed but also among nurses, residents, and consultant staff. One of the...

  19. Time Line
    (pp. 285-288)
  20. Notes
    (pp. 289-312)
  21. Index
    (pp. 313-320)