Transplantation of limbs and organs
The question of the transplantation of tissues and organs must be considered from two points of view，the surgical and the biological.I began by seeking to develop a technique which would enable the circulation to be reestablished in the organs without delay.After that I endeavoured to ascertain to what extent the organs fulfilled their functions，according as the transplantations were autoplastic or homoplastic.I found that an entire anatomic region could be transplanted from one animal to another.The following observation is an illustration of the transplantation from one dog to another of the anatomic structures supplied by the external carotid artery.From a first dog the right part of the scalp and the auricle were extirpated in one mass with the auditory canal，the connective tissue and the glands of the retro-maxillary[59]space and the upper portions of the external jugular vein and of the common carotid artery.The dog was then chloroformed.The anatomic specimen was perfused with Locke's solution.Then it was wrapped in a silk towel saturated with Vaseline and placed on a table at the temperature of the laboratory.On a second dog the auricle[60]and the adjoining portion of the scalp were extirpated and the right part of the neck opened through a longitudinal[61]incision.The anatomic specimen was then placed in the wound，and the peripheral ends of the carotid artery and of the jugular vein were united to the central end of the corresponding vessels of the host.The circulation was then reestablished.An abundant haemorrhage[62]occurred from the little peripheral branches of the carotid artery，which were immediately ligated.Then the neck was closed by two rows of suture.The purpose of making the vascular anastomosis very far from the transplanted ear was to prevent the occurrence of thrombosis，if infection should be produced at the level of the external auditory canal[63].A few minutes after the establishment of the circulation the ear and the scalp assumed the normal appearance of the internal auditory canal.The new ear was fixed to the external auditory canal of the host.The auricular muscles were sutured and the operation was completed by continuous suture of the skin without drainage.During the days following the operation oedema of the auricle occurred，but the circulation remained excellent.The temperature of the transplanted ear was much higher than that of the normal ear.The cutaneous[64]wounds united by first intention，but subsequently a voluminous abscess appeared under the scalp and had to be drained eight days after the operation.The oedema[65]of the auricle diminished and disappeared，but the animal had some fever and a secondary abscess appeared in the left leg.The animal developed a slow form of pyaemia.Nevertheless，the local condition became excellent.The temperature of both auricles，normal and transplanted，were about the same.The transplanted ear was as thin and glossy as the normal one and its circulation was normal.The animal finally died，three weeks after the operation，of pyaemia.The transplanted parts were normal.I performed several other operations sim-ilar in character，without any infection arising.The transplanted ear remained normal for from six to eight days.After that the transplanted tissues became oedematous and in every case necrosis[66]of the skin developed.The animals had then to be chloroformed.In no case did the lesions appear to have been caused by a defect of the circulation，which was apparently normal.It is therefore safe to assume that they resulted from the reaction of the host against the transplanted anatomic region，a reaction which failed to take place in the first experiment.
In 1907 I commenced the study of the transplantation of limbs.This study had been preceded by various experiments conducted by other surgeons who had studied the subject of the replantation of limbs.In 1891 Robert Abbe amputated almost completely the fore-limb of a dog.He cut the entire limb with the exception of the femoral vessels.Then he sutured the bone，the nerves，the muscles and the skin，and the animal recovered completely.If he had had at his disposal an efficient method of anastomosing[67]blood vessels，he would have doubtless accomplished a real replantation of the limb.Hoepfner in 1903 amputated the thigh of a dog and replanted it immediately by suturing the bones and all the anatomic structures of the limb，and by uniting the vessels according to Payr's prothesis.In one case the circulation remained excellent.Unfortunately the animal died eleven days after the operation.The tissues of the limb were well united，but the bone had very little tendency to callus formation.In 1905，in Chicago，I performed with Guthrie several experiments of the replantation of the thigh.The tissues and vessels healed by first intention，but we were unable to keep any animal alive longer than eleven days.I performed no more replantations and after this I proceeded to study the transplantation of limbs from one animal to another.These experiments were made at the Rockefeller Institute in 1907 and 1908，and they consisted in transplanting the front or back limbs from one dog to another.The animals used for these experiments were of no special variety，and they belonged neither to the same race nor to the same family.I merely endeavored to procure two animals of the same size.First of all a dog was killed with chloroform，then the limb was amputa-ted circularly in its middle part，minute aseptic precautions being observed.In the case of the transplantation of the thigh a circular incision[68]was first made at the level of the upper part of the limb.The sartorius[69]muscle was cut and the femoral vessels dissected in such a way as to enable them to retain a considerable length.The limb was then amputated and the surface of the section，covered with a silk towel saturated with Vaseline.By means of a canula introduced into the femoral[70]artery the limb was completely perfused with Ringer's solution.It was considered advisable to eject all the blood from the limb，as by so doing there was no danger of embolisms arising upon the reestablishment of the circulation.The animal upon which the limb was to be grafted was anaesthetized[71]in the usual manner and the thigh was amputated transversely after dissection of the femoral vessels.It was necessary to calculate the exact length of the vascular pedicle，for tension on an arterial or venous suture is a dan-gerous thing.Moreover，if after a suture has been performed a vein is left too long，it doubles up and the circulation is impaired.Thus，whether the vessels be too short or too long，in either case congestion[72]of the limb would result.The operation was then begun by fixing the new limb to the stump of the host by means of an Elsberg splint.When the junction of the femur had been secured，the periosteum was sutured.After this the internal muscles of the thigh were sutured and the femoral vessels and nerves of the limb were united to the corresponding vessels and nerves of the host.The circulation was reestablished and the haemostasis[73]of the surface of the section of the member was performed.The operation was concluded by suturing with catgut each muscle and aponeurosis and then the superficial aponeurosis and the skin.The whole operation lasted about one hour and a half.
The technique of the transplantation of the front limb is somewhat different.The humerus was amputated a little above the elbow，whilst the nerves and vessels were severed much higher up.In some experiments the leg alone was transplanted and the tibia was cut a little below the knee.In this operation a large strip of skin was preserved，containing the saphenic vessels，which were dissected at the level of the femoral vessels.The circulation was reestablished by uniting these segments of the femoral vessels with the femoral vessels of the host.But the general lines of the operation were similar to those above described.The limb was next confined in a plaster-of-Paris cast and the animal was laid on a small bed，consisting of a sheet stretched on a metal frame.The animal was fixed there by means of two broad linen bandages and was watched night and day by a nurse.From time to time it was liberated and made to walk round the room，thus taking some exercise each day.It is difficult to keep an animal in good condition，after it has suffered transplantation of the thigh.Little by little we were led to observe all these minute details，in order to avoid various complications which invariably arose in cases where a simpler procedure was adopted.The immediate results of these operations were excellent.The limb resumed its normal temperature and color.The arterial pulsations could be felt，not only in the femoral artery，but also in the branches of the saphenic artery and in the interdigital[74]spaces.During the first few days there was no sign of oedema，the animal suffered no pain，ate in a normal manner，walked about and remained in excellent health.But after seven or eight days a difference was apparent，which produced very marked results.In nearly every case the oedema[75]appeared at the level of the toes，ascended to the leg and thigh and stopped at the line of suture.The circulation，however，remained normal.Next，the oedema became harder and the skin became bluish in places.Notwithstanding this fact，however，an incision made in the skin produced a flow of red blood.After several days the skin became necrosed[76]，although the inner circulation remained normal.At this stage the animals were chloroformed[77].It seems that this necrosis[78]of the epithelium[79]was not produced by the circulation but by a reaction of the organism against its new limb.In certain rare in-stances these phenomena did not occur and the limb seemed to adapt itself to its new conditions of life.
The best result was obtained in one of the first experiments，performed in April，1908.The leg of a fox-terrier was amputated at the level of its upper third.This was then immediately transplanted on to a white，young female foxterrier of the same size and shape as the first dog.In the evening of the day of operation the circulation was excellent and the foot was pink and warmer than the fellow foot.The animal recovered rapidly.She had a keen appetite and was gay and affectionate[80]as before the operation.Several times she broke the plaster cast and even twisted her leg a little.During the first few days the temperature of the new foot was higher than that of its fellow；it was oedematous too，but this feature entirely disappeared after a few days.A week later the temperature of the feet was the same.The new leg united with the stump of the host by first intention，and fifteen days after the operation it had quite healed.The skin had the same appearance above the line of suture as be-low it and there seemed to be no vasodilatation[81]of the new limb.Owing to the fact that the Elsberg splint had become twisted，the extremities of the bones had set somewhat imperfectly and in consequence the tibia was bent outwards a little.The other parts of the limb looked quite normal and it would have been impossible for anyone unacquainted with the fact to detect that the leg did not in reality belong to the animal.At this stage the animal began to cough.Then it refused to eat and rapidly grew thinner.On the twentieth day it was very sick.The plaster-of-Paris cast was removed and the leg examined.The new limb was in excellent condition and there was neither oedema nor any kind of trophic[82]trouble.The temperature was the same as that of the normal leg.The bone had hardened and the animal walked round the room on its three sound legs without attempting to use the new limb.The cutaneous anaesthesia persisted.The skin was as soft and the coat as bright on the transplanted leg as on the normal one.The general health of the animal rapidly grew worse and it died on the twenty-second day after the operation.The circulation of the leg remained normal until the end.The autopsy showed diffuse broncho-pneumonia，which carried off a number of other dogs about the same time.In two other experiments the results were almost identical.It should be mentioned that the three animals which showed the best local results were animals suffering from a general infection of a serious nature.The same fact had previously been observed in the transplantation of the auricle.This may be a matter of pure coincidence，although one may be permitted to conjecture that the tolerance shown by an organism towards its new member may vary in degree according to certain general conditions.
During the last seven years I have performed a large number of experiments in the replantation and transplantation of organs，in the course of which the technique relating thereto has been thoroughly worked out.In 1902，in conjunction with M.Morel，I performed my first experiment on the extirpation[83]and replantation of the thyroid gland of a dog.The vessels were sutured，but thrombosis[84]speedily occurred.In 1905，with the collaboration of Mr.Guthrie，I succeeded in replanting a thyroid gland，accompanied by a reversion of the circulation.The circulation remained normal.These experiments were confirmed in 1907 by Stich and Makkas，who found that the replanted glands remained normal from a histological point of view.After that I performed other experiments in the transplantation of the thyroid gland，the replantation and transplantation of the suprarenal gland，of the ovaries[85]，the intestine[86]，the heart and the spleen.Some of the animals operated on lived a long time and the anatomic results were examined several years after.The spleen is anatomically well adapted for use in these experiments，and the replantation of this organ can be taken as characteristic of this kind of operation.The abdomen of a large or medium-sized dog was cut open by a longitudinal incision and the spleen was drawn to the exterior.The gastrosplenic vessels were then separated，ligated and cut.The temporary haemostasis of the splenic vessels was secured by means of two serrefines[87]，after which the pedicle of the spleen was cut and the organ extracted.The organ was next washed as thoroughly as possible in Locke's solution，by means of a cannula placed in the splenic artery of the organ，after which it was placed in a jar containing the same solution.The central ends of the splenic vessels were prepared for anastomosis.The spleen was taken out of the jar，replaced in the abdominal cavity[88]and the central ends of the splenic vessels were united to the vessels of the organ.Immediately after the circulation had been reestablished the spleen became red and it greatly increased in size.The nerves were sutured，the organ was suspended in the large curve of the stomach by suturing the pedicles of the gastrosplenic[89]vessels，and the abdominal wound was closed up.This operation was performed in two cases，and both animals completely recovered.One of them，which was small in size，was examined fifteen months after the operation.The spleen had entirely disappeared.This atrophy[90]was doubtless caused by thrombosis of the splenic artery，which was very small.In the second case the animal was a large dog and the splenic vessels were of proper dimensions.The anatomical[91]result was examined twenty-one months after the operation.Both the spleen and its vessels were normal.The sutures were almost invisible and their exact location could only be detected after a close examination had been made of the internal wall of the vessels.
The largest number of experiments were performed on the kidney.These can be divided into two classes-autoplastic transplantations and homoplastic transplantations.The first autoplastic transplantation of a kidney was performed by Ullmann in 1902.He took out a dog's kidney and transplanted it into the neck，suturing the blood-vessels by means of Payr tubes.During the same year I similarly undertook two autoplastic[92]transplantations of a dog's kidney，but in each case septic complications arose.Similar experi-ments were also conducted by de Castello，Karl Beck and Floresco.In 1905，with the help of Guthrie，I succeeded for the first time in witnessing the functioning of a kidney that had been transplanted into the neck.We also succeeded in performing the first homoplastic transplantation[93]of the kidney，which consisted in grafting both kidneys of one dog“en masse”on to another dog.The majority of the subsequent operations were conducted at the Rockefeller Institute，where I was able to make a systematic study of the results of replantation and transplantation of the kidney.The operation of replanting the kidney was performed principally on dogs.After a few experiments it was found that the only way of enabling the kidney to carry on its normal function was to replace it in its proper position in the lumbar region.This operation consisted in removing one of the kidneys of a dog and of grafting it anew in the lumbar egion.The other kidney was removed during the same operation or fifteen days later.The technique of this operation，when performed on medium-sized dogs，was comparatively simple.The abdominal cav-ity was opened by means of a transverse incision，then the kidney with its peritoneum was extirpated，together with its cellulo-adipose atmosphere and its blood-vessels.By means of a cannula introduced into the renal aorta the organ was then perfused by Ringer's solution，whereupon it became whitish-yellow in color and a pale liquid escaped from the renal vein.Then the kidney was enveloped in a silk veil saturated with Vaseline and placed upon a table，while the central ends of the vessels were prepared for the anastomosis.After this the kidney was replaced in the abdominal cavity in its normal position and the arterial and venous ends were immediately sutured circularly.No suture of the nerves was made.After this，the serrefines，which served to secure the temporary haemostasis，were removed and the circulation was reestablished，after having been interrupted for 50 or 60 minutes more or less.The artery at once began to beat，the kidney became filled with blood，first blue then red，after which it resumed its normal size.After half an hour or an hour its colour had become the same as that of the other kid-ney.The phenomena of vasodilatation[94]，which resulted after the transplantation of limbs usually failed to appear in he case of transplanted kidneys.The ureter was sutured circularly，after which the kidney was fixed in its normal position by means of a suture of the peritoneum[95].These anastomoses were performed with very fine thread，the result of which was that the traces of the operation had almost completely disappeared in a few months'time.In some cases the other kidney was removed immediately，in other cases fifteen days afterwards；in others again，it was left intact，so that after several months a comparative study could be made of the anatomy of the replanted and of the normal kidney.A dozen of these operations were performed，and in every case the animals recovered.After the animals had undergone a double nephrectomy，their general health remained normal until some ureteral complication arose.In the first experiments the anastomosis of the ureter produced stenosis[96]and the animals died after a few weeks or months，showing lesions of hydronephrosis.The technique of the ureteral anastomosis was then modified and all the animals experimented on since have retained their health.The urine was normal and contained no albumen[97].The kidneys were examined after several months and their histological condition was always found to be normal.Ten months after the replantation of a kidney both the normal and the replanted organs were examined.They looked identical，and in the histological examination it was impossible to distinguish the normal kidney from the replanted one.The caliber of the renal artery and vein had not changed at the point of the anastomoses，which were hardly discernible.These results may safely be considered permanent.A female dog，upon which a double nephrectomy[98]and the replantation of one kidney had been performed，continued to live in perfect health for two years and a half，at the end of which time she died of a disease unconnected with the operation.The replanted kidney was normal.These experiments thus served to show that the extirpation of a kidney，its perfusion in Locke's solution，the complete interruption of the circulation for a period of 50 minutes and the subsequent suturing of its vessels and of its ureter did not occasion any interference with its functions，even after a considerable interval of time.It was thus shown that from a purely surgical point of view the grafting of an organ is possible.
In other series of experiments I examined the influence exercised by a transplanted kidney upon its host.The kidneys of dogs and cats were removed and replaced in the abdomen，not of the same animal，but of another animal of the same species.I used the same technique as that just described.One of the kidneys of a dog was removed and transplanted on to another dog.Seven experiments were conducted.During the first week more or less the animals remained in good health and the urine contained no albumen.During the second week a little albumen was found in the urine.Towards the twentieth day it was noticed that the kidney had slightly increased in volume.Then the quantity of albumen augmented more and more and in certain cases some haema-turia[99]even was observed.The animals，notwithstanding，remained in good health，for they had retained one normal kidney alongside the transplanted kidney..After six months all the animals operated upon showed albumen in their urine.The quantity of albumen[100]progressively diminished and the urine became normal.The anatomical examination performed a year or two after the operation showed that the transplanted kidneys had become completely atrophied.
The interactions of the host and of its new organs was further studied by means of the transplantation“en masse”of kidneys，these experiments being conducted on cats.The transplantation in mass of the kidneys consisted of extirpating from a first animal both kidneys，their vessels and the corresponding segments of the aorta and vena cava，their nerves and nervous ganglia，their ureters and the corresponding part of the bladder；of placing this anatomic specimen in the abdominal cavity of a second animal whose normal kidneys had been previously resected and the aorta and vena cava cut transversely；and also of suturing the vascular seg-ments between the ends of the aorta and vena cava，and of grafting the flap of the bladder on to the bladder of the host.In every case the reestablishment of the renal functions was observed.The secretion of urine began as soon as the arterial circulation was reestablished.In several cases clear urine flowed from the ureters while the flap of the bladder was being grafted on to the host.Oftener no urine was seen flowing from the ureters immediately after completion of the operation，but the secretion always began during the first twenty-four hours.In all the experiments the urinary secretion went on as long as the animal lived.Every cat urinated abundantly every day，but there arose in the animals sooner or later some complication，which modified in some measure the renal functions.The color of the urine was generally yellow，and often less dark than the normal urine of the cat.Its reaction was acid.Its quantity for the twenty-four hours varied from 120 to 160 cc，but，exceptionally，was as little as 25 and even 15 cc，though in another case，as much as 215 or 255 cc for the twenty-four hours.In this last case there was congestion of the kidneys produced by venous compression.The density was very far from constant；generally it varied between 1.018 and 1.030，going sometimes as high as 1.035 and 1.050.Among the abnormal constituents of the urine，albumen[101]only has been looked for.In some cases there was a little albumen during the first days，ranging from 0.50 to 0.25 per 1，000 cc.In other cases the albumen disappeared about one week after the operation.
The general condition of the animal can，in some measure，be said to indicate the perfection of the urinary excretion.In one case，the animal was in apparently normal condition four days after the operation.She walked about the room，played，and ate a great deal of raw meat，and her condition remained excellent for several weeks.Twenty days after the operation she was in good health，had glossy hair，was very fat，ate all kinds of food with a good appetite，and urinated normally.There was，however，albumen in the urine，and slow and progressive enlargement of the kidneys took place，which showed that she was not in an entirely normal condition.The animal remained in excellent health until the twenty-ninth day after the operation.Then gastro-in-testinal symptoms appeared and death occurred on the thirty-first day after the operation.Some of the animals were able to live in an excellent condition of health for 15 or 25 days and more after a double nephrectomy[102]had been performed and they excreted every 24 hours from 120 to 160 cc of urine through their new kidneys.Nevertheless，all the animals died less than 40 days after the operation.The histological[103]examination of the transplanted kidneys showed that the organs presented some lesions，very slight in some cases and more marked in others.The lesions were of diffuse nephritis.It is very probable that in the transplantation of the kidneys，as in the transplantation of the limbs，a reaction of the organism against the new organ takes place after a few days.The new organ may have a marked influence on the general condition of its host.In one experiment，the animal was a female cat which lived in the laboratory for several months.She was in excellent condition when she was operated on and recovered very quickly from the operation.Her life went on just the same as before.The kidneys were mov-able and small.She looked in excellent health and lived like any ordinary cat.On the eighteenth day after the transplantation albumen appeared in the urine and a direct examination of the kidneys was made to ascertain the cause.The general condition was little affected by the operation and the albumen disappeared almost completely.On the thirty-fifth day the animal was very weak and emaciated.She died on the thirty-sixth day.The autopsy showed that the whole arterial system was calcified.By exercising slight pressure the carotid artery or the aorta could be broken like a piece of glass tubing；but the renal arteries and the transplanted aortic segment were normal.The histological examination of the kidneys showed that they had undergone very slight morphological changes and that they were almost normal.This observation demonstrated that a change of organs may produce very marked modifications in the organism.The interactions of the organ and of its host have not been sufficiently studied thus far.In the course of these experiments the technique of transplantation was developed and their surgical study is now completed.Hereafter it will be necessary to investigate the reciprocal influences of an organism and of its new organ，and to ascertain under what conditions an organ taken from one individual can adapt itself to another individual.