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ORGAN TRANSPLANTS AND LIMB REIMPLANTATION

Transplant Surgery and the Immune System

Between 1960 and 1969 numerous advances were made in the field of transplant surgery. In early 1960 the only major transplants performed were those of kidneys from one identical twin to another; surgeons had not yet learned how to suppress the body's natural tendency to reject tissue that is not its own. Each person's body has a unique chemical coding that is basic to the immune system. Body cells are protected by a complex system of protein that rejects foreign matter, including bacteria and viruses. Any matter that is not similar to the body's tissue is rejected (with the exception of some invaders, such as cold viruses). This system of protection also causes the body to reject organ implants from someone else's body.

Advances in the Field

Several developments during the 1960s revolutionized the field of transplantation. A major discovery was that certain anticancer drugs sup-press the immune system and can be used to delay or prevent rejection—at a price. The immune system constantly destroys the early cancers that form in the body as well as the microscopic intruders that occasionally get inside the body. Too much suppression of this system allows foreign bacteria and viruses to kill the patient; too little fails to keep the body from rejecting a transplanted organ, or graft. Another major advance was in the field of tissue typing. It was known that a patient could receive a blood transfusion from a donor with blood of the patient's type. Solid tissue used in transplants involves more-complex differences, however, which scientists started to decode in the 1960s.

Limb Reimplantation

The easiest way to avoid rejection is to transplant the patient's tissue from one place to another on his or her own body. Burn patients are given skin grafts in this manner, for example. But until 1960 surgeons had not learned how to graft severed limbs, a frequent need for patients involved in accidents. In order for the procedure to be attempted, there are basic requirements: the severed limb must be intact; the severed tissue must be kept alive until the transplant can be performed; and connective tissue, including muscles, bones, blood vessels, and, most difficult of all, nerves must be reattached.

An Attempt and Success

In 1960 foundry laborer Billy Smith's leg, cut off in an accident at work, was reattached by surgeons at Eden Hospital in Castro Valley, California. The operation was only a temporary success. After a few months the leg became infected and had to be amputated. The first permanent transplant success was with twelve-year-old Everett Knowles, Jr., of Somerville, Massachusetts, whose arm was severed when he jumped a ride on a train. The police took the boy to the Massachusetts General Hospital, where surgeons had been preparing for a reimplantation for ten years. The severed arm was placed in ice after the blood vessels were flushed out to prevent clots. The boy was given blood, fluids, antibiotics, and other drugs to prevent blood clotting and was taken for X rays. The blood vessels of the right arm were opened under X ray. The surgery, which started only three and a half hours from the time the arm was amputated, took eight hours and six pints of blood. It was gloriously successful.

Liver Transplant

The first human liver transplant was performed in 1963 at Denver's Veteran's Hospital on William Grigsby, a forty-seven-year-old merchant marine discovered during exploratory surgery to have advanced liver cancer. The donor was a fifty-five-year-old veteran who had died of a brain tumor and had been placed on a heart-lung machine to keep his liver alive while Grigsby's surgery was started.

The Liver: A Vital Organ

The liver performs a remarkable number of functions in the body. It prepares and stores nutrients from food, makes proteins, and chemically converts poisons to less toxic forms. Without a liver a person would live less than two days. A unique feature of the liver is its dual blood supply. It has the usual circulation system, with arteries from the heart connected to veins going back to the heart. It also has another blood supply from the intestines, called the portal circulation, that delivers nutrients from food. This portal circulation makes transplanting a liver more technically difficult than transplanting other organs.

The Operation and Its Aftermath

Surgeon William R. Waddell and his team connected plastic tubes between the portal vessels below the liver and the jugular vein in Grigsby's neck. Grigsby's cancerous liver was removed, and the dead man's liver replaced it. When all the attachments were finished, Grigsby's new liver started making bile (a digestive juice) at once, proving that it was working. After the operation Grigsby was given the anticancer drug Imuran to suppress his immune system. Grigsby improved rapidly for about three weeks; then he suddenly died. An autopsy showed that his death was caused by the movement of blood dots formed in the vessels of his legs moving to his lungs. His liver was functioning well until the end.

Heart Transplant

The first human heart transplant was performed in 1964 by Dr. James D. Hardy at the University of Mississippi Medical School at Jackson. The patient was a sixty-eight-year-old man dying of heart failure. Hardy explained to the patient that he was going to die and offered to attempt a risky heart transplant. The patient agreed, and a donor dying of brain damage was identified. While waiting for the donor to die, the heart patient started failing faster than expected. Convinced that he could wait no longer, Hardy tried a bold experiment. He transplanted a heart from a chimpanzee to keep his patient alive until the donor heart was available. The chimp's heart was too small to sustain the human patient, though, and he died an hour after surgery. Hardy was also the first to perform a heart-lung transplant. The patient died of kidney failure eighteen days later.

Lung Transplant

The first lung-only transplant was performed in 1963 at Pittsburgh's Presbyterian University Hospital by Dr. George Magovern and Dr. Adolph Yates, who had been doing the procedure on dogs for two years. The patient was Regis Sismour, forty-four, dying of emphysema; the donor was a thirty-three-year-old who had died of a brain hemorrhage. The donor lung (the left, because it is easier to transplant) looked like a black ball until it was completely reattached inside Sismour; then it turned pink as air expanded it. The transplant was too successful though. Sismour's body was used to low oxygen levels. The new lung suddenly worked so well that Sismour got too much oxygen all of a sudden, causing him to have seizures. The doctors had to give him low oxygen air and gradually increase the oxygen to get his body used to it again. Like many other early transplant recipients, Sismour recovered well briefly, but then disaster struck. Eleven days after surgery, Sismour suddenly noticed his lung "stiffening." He could barely force air in and out, and then he died. The exact cause of death was never determined.