Book Review
Die Erfindung der Organtransplantation: Erfolg und Scheitern des chirurgischen Organersatzes (1880-1930)
Thomas Schlich. Die Erfindung der Organtransplantation: Erfolg und Scheitern des chirurgischen Organersatzes (1880-1930). Frankfurt: Campus Verlag, 1998. 390 pp. DM 68.00; Sw. Fr. 64.00; öS 496.00 (paperbound).
Organ transplantation symbolizes the power and the problems of hi-tech medicine at the turn of the twenty-first century. The overcoming of immunologic barriers between individuals relied on research during and after World War II, but the celebrated dates--1954 for the first successful kidney transplant, and 1967 for the heart--can mislead; it was only with the new immunosuppressant cyclosporin in the 1980s that transplantation began to appear routine. So it might seem strange that Thomas Schlich's history, "The Invention of Organ Transplantation: Success and Failure of Surgical Organ Replacement," should begin in 1880 and end in 1930. He reminds us of the hundreds of human organs transplanted before (as immunology now teaches) they could possibly have survived. Surgeons' acceptance that in practice the grafts were rejected is the failure referred to in his title. The success is the invention of the very concept of organ replacement, on which postwar transplantation would also be based. What, this book asks, convinced surgeons that this was an ideal, if perhaps a utopian, therapy?
Against transplant surgeons' later searches for ever-more-distant forerunners, Schlich upholds their claims in the early 1880s that the functional replacement of a defective organ was radically new. The Bern surgeon Theodor Kocher had perfected the complete (instead of just the partial) removal of the thyroid gland as a cure for goiter. He noticed only afterward that especially younger patients who had suffered the total extirpations grew to resemble cretins; therefore in 1883 he replaced a resected thyroid, and thus went beyond plastic surgery's earlier transfers of living tissue. Removing too much pushed him into a repair [End Page 387] that inaugurated attempts to restore, not merely or necessarily anatomical structure, but above all physiological function. Modifying Ulrich Tröhler's periodization, Schlich presents transplantation surgery as a paradigmatic realignment of surgical innovation away from the resections that had acted as pathological anatomy's therapeutic arm. Surgeons seeking enhanced academic prestige reoriented their discipline toward the new queen of the sciences, experimental physiology. They now made scientific reputations by transplanting the organs their teachers had become famous for removing; Kocher was the first surgeon to win a Nobel Prize.
Schlich classifies transplantation as the "experimental medicine" of John Pickstone's historical typology, producing knowledge for fellow academics and promising control of disease. Control, as K. Codell Carter has argued for bacteriology, depended on isolating a necessary cause against which to intervene. Bacteriologists plated out microbes, surgeons cut out internally secreting organs. Both redefined disease in terms of their ability to master it. In the old diagnosis of cretinism, place had been decisive; treatment was either to improve living conditions by a whole set of political reforms, or for the patient to move away. Kocher created a new cretinism from the cases he could reclassify as "spontaneous" versions of his resections. Why the organ had failed was no longer the point.
In principle, either surgery with an organ or medical treatment with an extract--"organotherapy"--could restore function. In the 1880s and 1890s the two were mutually reinforcing, but in the 1910s and 1920s (as Merriley Borell showed) endocrinology constituted itself around the extracts' active principles, and transplantation risked appearing only a step on the way to a hormone. Yet as transplanting surgeons lost one source of legitimation, they gained the independence to extend the approach to nonendocrine organs. Between 1905 and 1915, they united plastic and vascular surgery and brought the replacement of various organs together to make a new field of "transplantation surgery." Why, by around 1930, Schlich asks, had this failed? He examines transplant surgeons' ever "stricter" criteria, their growing doubts about the feasibility of transplantation between individuals, research into biological individuality, and experiments to overcome immunity. After a little trouble in keeping at bay a more problematic question--Why did organ transplantation fail, when we know that after World War II it would succeed?--he abandons its teleology in favor of the suggestion that we look instead to the specific interests and resources that, especially in Boston after 1945, attracted surgeons to kidney transplantation again.
I have reservations about the organization of the book's major section. From the thyroid Schlich takes us on a tour of the transplantable body: presentation organ by organ allows him to illuminate important historical specificities, but it rather stalls the narrative. Gripped by the thyroid story, I was relieved when, by way of parathyroids, pancreas, adrenals, ovaries, testicles, and "other organs," we finished with the kidneys. Schlich does make good use, for example, of testicular transplants as the exception to prove the rule: transplanters like Serge Voronoff, the leading figure of David Hamilton's The Monkey Gland Affair (1986), could go [End Page 388] on for so long because private practice insulated them from academic criticism. But though it would have been much more complex to manage than letting the body organize the account, I would have preferred a historical geography of transplanting surgeons and institutions, their allies, enemies, and patients, from which patterns of specialization by organ would, secondarily, emerge. Schlich gives enough information to glimpse such a changing map. Actually to draft it would bring out the relations between research programs, disciplinary identities, and clinical practice more productively than do the rather general sections assimilating transplantation surgery to the Pickstonian types. It would also suggest more readily how to go beyond specialist arenas to include surgery's other publics.
This is not a physically handsome book: there are no pictures, the cover is coming off my copy, and a typo appears on every other page. But historians of medicine will appreciate Schlich's sense of contingency, clear expositions, and telling quotations--and his dialogue with Anglo-American literature prepackages the work for import. He brings a surgical perspective into what is usually told only as the prehistory of endocrinology, and shows how the most basic precondition of postwar organ replacement--its medical desirability--was established. Unusually, Schlich has also just written a short book for a more general audience, Transplantation: Geschichte, Medizin, Ethik der Organverpflanzung (1998), which combines his own historical work with an introduction to the medicine and ethics of the field.
Nick Hopwood
University of Cambridge
