Transplant Surgery and Organ Transplantation

by

Hyung Wook Park

• LAST MODIFIED: 17 April 2025
• DOI: 10.1093/obo/9780197768723-0030

Introduction

Organ transplantation is a surgical practice supported by scientific knowledge; systems of laws and policies; increasingly complex health care–pharmaceutical industries; dynamics among stakeholders, including patients and family members; and the global organ transactions that are partly illegal or unethical. This article offers an overview of the scholarly literature on its historical, cultural, and ethical dimensions as well as some key primary sources. Medical historians have traced the beginning of modern transplantation to the late nineteenth century, when laboratory medicine brought about many significant changes in health care. Then the Swiss physician Theodor Kocher (b. 1841–d. 1917) was a key figure through his first thyroid transplantation, which became the model for all other organ transplants. The French surgeon Alexis Carrel (b. 1873–d. 1944) pioneered experimental organ transplantation of animals in the early twentieth century, stimulating efforts of doing the same on human subjects. However, none succeeded in making transplants endure, owing to their lack of understanding of graft physiology as well as their inability to control immunological rejection. While this disappointment led to a temporary suspension of transplantation, the Second World War (1939–1945) renewed the interest due to more adequate knowledge on blood vessel suture and the increasing attention to burned soldiers who needed skin grafts during warfare. Around this time, the British biologist Peter Brian Medawar (b. 1915–d. 1987) demonstrated that extraneous tissues could survive on a mouse’s body permanently if the donor’s cells had been inoculated into the recipient during its fetal stages. Although this work had no clinical relevance, it showed that immunological tolerance is, in principle, possible and thus encouraged other researchers to start working on transplantation. One of them was the Harvard surgeon Joseph E. Murray (b. 1919–d. 2012), who succeeded in transplanting a kidney from a patient’s identical twin in 1954. Murray and his colleagues, including Jean Hamburger (b. 1909–d. 1992), Roy Y. Calne (b. 1930–d. 2024), and Thomas E. Starzl (b. 1926–d. 2017), subsequently tried to control immune reaction in various ways, including whole-body irradiation and removal of the spleen, but immunosuppressants became the standard way of controlling immune response. Starting with 6-mercaputopurine, surgeon-scientists tested numerous chemicals, finding that cyclosporine and tacrolimus were highly effective in preventing graft rejection during the 1980s and 1990s. This resulted in the worldwide endeavor, in which Starzl, Christiaan Barnard (b. 1922–d. 2001), and E. Donnall Thomas (b. 1920–d. 2012) became pioneers in transplanting the liver, heart, and bone marrow, respectively. The rise of transplantation after effective immunosuppressants attracted many doctors, governments, brokers, patients, and donors into the field. Entangled debates on justice, identity, and religious-philosophical views on life and death persisted despite the multiple efforts to establish standard policies.

General Overviews

Many popular histories state that organ transplantation evolved from humans’ ancient dream of exchanging body parts. Some even trace its origin in religious myths of Christianity, Hinduism, and Islam. Through a review of the entire span of history from the ancient to the contemporary world, Hamilton 2012 offers the latest scholarship in this line of literature. In contrast, Schlich 2010 focuses on the pivotal period from the 1880s to the 1930s and argues that transplantation was established as a surgical field only during this period. According to Schlich 2010, Kocher, through his thyroid grafting, formulated a new causal notion on organ function and its replacement, laying the conceptual foundation of the field. Other works of medical history, such as Obrecht 2018, have followed this view. While Kocher’s approach to treating disease was not accompanied by successful methods of making grafted organs survive in recipients’ bodies permanently, an increasing number of surgeons began to practice transplantation, drawing significant popular attention. Lederer 2008 offers a cultural history of organ transplantation in the United States before surgeon-scientists found a means to control immune reaction. Hamilton 1986 and Smith 2022 illustrate some surgeons’ efforts around this time to improve virility and reverse aging processes by transplanting animal organs to humans, which turned out to be fraudulent. A more relevant figure in this period was Carrel, who introduced new techniques of blood vessel suture that were crucial for transplantation (McKellar 2004). Barr 2019 explores Carrel’s role by detailing how his method inspired many later surgeons’ efforts to forge new methods of artery repair during the Second World War, which provided postwar transplant workers with a tool to extend patients’ postoperative survival. Another important development took place in immunology. The large number of patients with burn injuries in the war led some biologists to search for ways to overcome immunological boundaries in skin transplant surgeries. Park 2018 concentrates on Medawar’s research in this line of effort through Medawar’s skin grafting projects. Brent 1996 provides a historical sketch of transplantation immunology that substantially grew after Medawar. In the 1960s, the introduction of immunosuppressants brought about a considerable transformation. Park 2024 analyzes Murray’s effort using 6-mercaptopurine and azathioprine, following his earlier success in identical twins’ transplant. Peitzman 2007 historizes the first kidney transplantation by placing it in the changing medical views of kidney failure. Overall, however, the field was still deemed too risky for many years to come. Fox and Swazey 1978 investigates this respect of the field in analyzing motivations, frustrations, and debates among surgeons, counselors, nurses, and patients. Admittedly, the introduction of cyclosporine in the early 1980s made transplantation a more reliable therapeutic option, but it did not stop concerns and controversies in the field. According to Fox and Swazey 1992, the field redefined human bodies in terms of use-value in transplant rather than their wholes.

• Barr, Justin. Of Life and Limbs: Surgical Repair of the Arteries in War and Peace, 1880–1960. Rochester, NY: University of Rochester Press, 2019.

  DOI: 10.2307/j.ctvfrxs2h

  A unique historical study on the significance of surgical artery repair, which made possible a significant change in organ transplantation.

• Brent, Leslie B. A History of Transplantation Immunology. San Diego, CA: Academic Press, 1996.

  A historical overview of transplantation immunology offered by a former student member of Peter Medawar’s team at University College London.

• Fox, Renée C., and Judith P. Swazey. The Courage to Fail: A Social View of Organ Transplants and Dialysis. Chicago: University of Chicago Press, 1978.

  An influential classic that vividly captures how various participants in organ transplantation perceived their jobs as practitioners, patients, subjects, caretakers, and bystanders in the 1970s. Several key developments in the field and the cultural and technological concerns about them are extensively discussed.

• Fox, Renée C., and Judith P. Swazey. Spare Parts: Organ Replacement in American Society. Oxford: Oxford University Press, 1992.

  DOI: 10.1093/oso/9780195076509.001.0001

  Returning to the field after the use of more effective immunosuppressants, the two scholars were deeply disillusioned by technology’s role in designating the human body as sources of spare parts for efficient transplant operations. They were even more critical of artificial hearts, which seem to be an abusive biomedical technology with uncertain prospects.

• Hamilton, David. The Monkey Gland Affair. London: Chatto & Windus, 1986.

  A biographical study of Serge Voronoff, a Russian French surgeon, who claimed to cure the problems of old age by transplanting monkey testicles to humans. This claim was shown to be fraudulent in nature.

• Hamilton, David. A History of Organ Transplantation: Ancient Legends to Modern Practice. Pittsburgh, PA: University of Pittsburgh Press, 2012.

  DOI: 10.2307/j.ctt5hjpn3

  A comprehensive historical review of many aspects of the history of organ transplantation by a retired transplant surgeon. This book is very useful as a standard reference on key transplant practitioners and their contributions.

• Lederer, Susan E. Flesh and Blood: Organ Transplantation and Blood Transfusion in Twentieth-Century America. Oxford: Oxford University Press, 2008.

  DOI: 10.1093/oso/9780195161502.001.0001

  A cultural history of organ transplantation and blood transfusion in the American context. This book describes the debates about race, gender, class, and religion entangled with early transplantation practices. Surprising is that similar controversies are continuing in the twenty-first century when the practice became a regular therapy with the use of effective immunosuppressants.

• McKellar, Shelley. “Innovation in Modern Surgery: Alexis Carrel and Blood Vessel Repair.” In Creating a Tradition of Biomedical Research: Contributions to the History of the Rockefeller University. Edited by Darwin H. Stapleton, 135–159. New York: Rockefeller University Press, 2004.

  Traces Carrel’s efforts to develop blood vessel repair methods by following his surgical career starting in France and continuing in the United States.

• Obrecht, Sibylle. “Transplantation Surgery: Organ Replacement between Reductionism and Systemic Approaches.” In The Palgrave Handbook of the History of Surgery. Edited by Thomas Schlich, 411–433. London: Palgrave Macmillan, 2018.

  DOI: 10.1057/978-1-349-95260-1_20

  A concise analysis of the development of organ transplantation as a science and medical technology.

• Park, Hyung Wook. “Managing Failure: Sir Peter Brian Medawar’s Transplantation Research.” Notes and Records: The Royal Society Journal of the History of Science 72.1 (2018): 75–100.

  DOI: 10.1098/rsnr.2017.0020

  Analyzes the philosophical problems that Medawar’s team encountered during their effort to transplant skin patches on inbred mice. Their struggles to solve these problems enabled them to find a way to induce immunological tolerance and earned Medawar a Nobel Prize.

• Park, Hyung Wook. “Joseph E. Murray’s Struggle to Transplant Kidneys: Failure, Individuality, and Plastic Surgery, 1950–1965.” Journal of the History of Medicine and Allied Sciences 79.2 (2024): 143–162.

  DOI: 10.1093/jhmas/jrad042

  Investigates why Murray and his colleagues’ work in kidney transplantation remained an uncertain practice despite their strenuous efforts to overcome the barriers of the immune system, which looked akin to individual patient’s idiosyncrasy that Murray had struggled with throughout his training and career in plastic surgery.

• Peitzman, Steven J. Dropsy, Dialysis, Transplant: A Short History of Failing Kidneys. Baltimore: Johns Hopkins University Press, 2007.

  A comprehensive historical monograph on kidney failure and the medical attempts to control it, which resulted in the introduction of dialysis and transplantation in the mid-twentieth century.

• Schlich, Thomas. The Origins of Organ Transplantation: Surgery and Laboratory Science, 1880–1930. Rochester, NY: University of Rochester Press, 2010.

  DOI: 10.1017/9781580467674

  A historical account on the origins of the principle of organ replacement, its application to clinical medicine in the late nineteenth and early twentieth centuries, and the ultimate failure to overcome the biological obstacles during that time, which led to the temporary abandonment of transplantation until 1945.

• Smith, Philip C. “John R. Brinkley: A Quintessential American Quack.” Journal of Community Hospital Internal Medicine Perspectives 12.5 (2022): 1–5.

  DOI: 10.55729/2000-9666.109510.55729/2000-9666.1095

  A short biographical sketch of John R. Brinkley, an American surgeon, who claimed to cure older men’s sexual problems by transplanting goat testicles. His controversial surgical enterprise brought him both money and legal problems.