(Ebook) A History of Organ Transplantation: Ancient

Legends to Modern Practice by David Hamilton ISBN

9780822944133, 0822944138 Pdf Download

https://ebooknice.com/product/a-history-of-organ-transplantation-
ancient-legends-to-modern-practice-5459000

★★★★★
4.9 out of 5.0 (51 reviews )

DOWNLOAD PDF

ebooknice.com
 (Ebook) A History of Organ Transplantation: Ancient Legends
to Modern Practice by David Hamilton ISBN 9780822944133,
0822944138 Pdf Download

EBOOK

Available Formats

■ PDF eBook Study Guide Ebook

EXCLUSIVE 2025 EDUCATIONAL COLLECTION - LIMITED TIME

INSTANT DOWNLOAD VIEW LIBRARY

Here are some recommended products for you. Click the link to
download, or explore more at ebooknice.com

(Ebook) Introduction To Organ Transplantation by Nadey S. Hakim

(ed.) ISBN 9781848168541, 1848168543

https://ebooknice.com/product/introduction-to-organ-transplantation-5243446

(Ebook) Organ Transplantation by Frank P. Stuart ISBN

9781570596759, 1570596751

https://ebooknice.com/product/organ-transplantation-1023016

(Ebook) Befuddled: The Lives & Legends of Ancient Philosophers

by David Birch ISBN 9781789048278, 1789048273, B0C1HV5YM8

https://ebooknice.com/product/befuddled-the-lives-legends-of-ancient-
philosophers-51281432

(Ebook) Organ donation and transplantation after cardiac death

by Talbot, David; D'Alessandro, Anthony M.; Muiesan, Paolo ISBN
9780191550959, 9780199217335, 0191550957, 0199217335

https://ebooknice.com/product/organ-donation-and-transplantation-after-
cardiac-death-6639062
(Ebook) Abdominal Organ Transplantation: State of the Art by
Nizam Mamode, Raja Kandaswamy ISBN 9781444334326, 1444334328

https://ebooknice.com/product/abdominal-organ-transplantation-state-of-the-
art-4166528

(Ebook) Bone Disease of Organ Transplantation by Juliet

Compston, Elizabeth Shane ISBN 9780080490540, 9780121835026,
0121835022, 0080490549

https://ebooknice.com/product/bone-disease-of-organ-transplantation-1391664

(Ebook) Organ Transplantation: A Clinical Guide by Andrew A.

Klein, Clive J. Lewis, Joren C. Madsen ISBN 9780521197533,
0521197538

https://ebooknice.com/product/organ-transplantation-a-clinical-
guide-2507020

(Ebook) The Aztec Myths: A Guide to the Ancient Stories and

Legends by Camilla Townsend ISBN 9780500779316, 0500779317

https://ebooknice.com/product/the-aztec-myths-a-guide-to-the-ancient-
stories-and-legends-59001280

(Ebook) A history and philosophy of sport and physical education

: from ancient civilizations to the modern world by Mechikoff,
Robert A. ISBN 9780078022715, 0078022711

https://ebooknice.com/product/a-history-and-philosophy-of-sport-and-
physical-education-from-ancient-civilizations-to-the-modern-world-10007944
A History of Organ
Transplantation
A History of
Organ
Transplantation
Ancient Legends to Modern Practice

David Hamilton
With a Foreword by
Clyde F. Barker and Thomas E. Starzl

University of Pittsburgh Press

Published by the University of Pittsburgh Press, Pittsburgh,
Pa., 15260
Copyright © 2012, University of Pittsburgh Press
All rights reserved
Manufactured in the United States of America
Printed on acid-free paper
Designed and typeset by Kachergis Book Design
10 9 8 7 6 5 4 3 2 1

Library of Congress Cataloging-in-Publication Data

Hamilton, David, 1939–
A history of organ transplantation / David Hamilton ;
with a foreword by Clyde Barker and Thomas E. Starzl.
p. cm.
Includes bibliographical references and index.
ISBN 978-0-8229-4413-3 (hardcover : acid-free paper)
1. Transplantation of organs, tissues, etc.—History.
2. Organ transplantation—History. I. Title.
RD120.6.H36 2012
362.1979´5—dc23 2012008954
 Contents

Foreword, by Clyde F. Barker and Thomas E. Starzl vii

Acknowledgments xi
Introduction: Toward the Impossible xiii

1 Early Transplantation 1
2 The Eighteenth Century 31
3 The Reawakening 49
4 Clinical and Academic Transplantation in Paris 65
5 The Beginning of Organ Transplantation 88
6 The “Lost Era” of Transplantation Immunology 105
7 Anarchy in the 1920s 126
8 Progress in the 1930s 154
9 Understanding the Mechanism 173
10 Experimental Organ Transplantation 195
11 Transplantation Tolerance and Beyond 221
12 Hopes for Radiation Tolerance 254
13 The Emergence of Chemical Immunosuppression 269
14 Support from Hemodialysis and Immunology in the 1960s 296
15 Progress in the Mid-1960s 314
16 Brain Death and the “Year of the Heart” 340
17 The Plateau of the Early 1970s 359
18 The Arrival of Cyclosporine 380
19 Waiting for the Xenografts 413
Conclusion: Lessons from the History of Transplantation 423

Notes 431
Bibliographic Essay 527
Index 539
Foreword

David Hamilton has been a senior transplant surgeon at the Western

Infirmary, Glasgow, Scotland, and also the first director of the Wellcome
Unit for the History of Medicine at Glasgow University. In addition, he is
steeped in the lore and the basic science of the field because of his early
training under the great transplantation biologist Peter Medawar. Thus, it
is no surprise that he has written a history of transplantation that is un-
matched in its scope, perceptiveness, and readability.
The masterly account he has crafted comes at an appropriate time,
since organ transplantation has now become widely accepted as the best
therapy for many otherwise fatal diseases. The surgeon-author of this book
has watched and participated in many of the events as the field evolved
over the last half century. Having looked back as an informed insider, he
has added his historian’s detachment and insight to the narrative.
Within living memory, organ transplantation existed only in science
fiction. As a handful of surgeons and other dreamers set off in the 1960s
“toward the impossible,” they met huge challenges. The attitudes of that
early time are vividly re-created in this book and will remind future read-
ers that major innovation, clinical or scientific, is never easy and indeed
can be a lonely business. Surgical replacement of a diseased organ consti-
tuted a paradigm shift. Its success altered forever the practice of several
medical specialties while enriching multiple areas of basic and clinical
science. Arguably, transplantation created the field of modern immunol-
ogy rather than the other way around. And it had ripple effects in law,
public policy, ethics, and even religion. Not omitted from Hamilton’s ac-
count is the now-forgotten attitude of many in the medical profession that
this journey was futile and should not be attempted.
The momentous scientific events of the 1950s are often taken as the
starting point for organ transplantation, but there is a surprisingly long
international prehistory, one that is highlighted in this book for its signifi-
cance. The book is the first to tell the complete story of these earlier times,
and this careful account in the first half of the book at last replaces earlier

vii
short, patchy, and often patronizing versions. The reader will be surprised
at the vitality of the “lost era,” as Hamilton calls it, of transplant stud-
ies before World War I. Also sharply delineated, analyzed, and explained
are the events in the anarchic 1920s, when good science was at a low ebb
and the monkey and goat gland transplanters assumed a license to mis-
lead the public.
In the daunting task of taking on the technical challenge of organ
transplantation, surgeons formed a fruitful partnership with some of the
world’s greatest scientists to probe the biology of graft rejection. The au-
thor examines this partnership closely and offers the shrewd conclusion
that the surgeons were by no means the junior partner in the relation-
ship. The reductionist approach of immunologists and their in vitro mod-
els were often misleading, resulting in faulty paradigms. Time and again,
surgical empiricism led to unpredicted outcomes and advances that sent
the immunologists back to the lab to think again.
Here also is an account, in this niche endeavor, of the so-called scien-
tific method in action. The author is clear that, in surgery at least, there is
no single method of discovery but rather a rich variety of methods. In the
minor supporting strategies, Hamilton winkles out fascinating examples
of good luck, bad luck, serendipity, personal rivalry, and arguments. Add-
ing to his text are extensive scholarly citations that provide a helpful road
map into the vast literature on organ transplantation.
As this book clearly shows, developing transplantation as a clinical ser-
vice was not simply a surgical matter, limited to the attainment of tech-
nical success. Hamilton crucially re-creates the multiple influences, help-
ful and otherwise, that came into play. Transplantation generated a raft of
ethical issues, funding challenges, and continuous contact with lawmak-
ers and governments, all of which had national and international nuances.
Running through this book are interesting asides on the use of trans-
plant themes in the fictional literature of the day, a reminder of the pub-
lic’s interest and involvement. Any undue hubris on the transplanters’
part meant that nemesis followed—a drop in public confidence and hence
a decrease in the donation of organs essential to the service. Nor were the
media always supportive. In the aftermath of the transplants of the 1968
“Year of the Heart,” as it is called here, there was an international crisis of
confidence in transplant circles, one which should not be forgotten.
Throughout, the patients were the heroes, supporting the transplant
surgeons from the first and disarming nay-saying critics simply on the
grounds that, as patients, they would rather be alive than dead.
Limitations of space preclude a complete consideration in the book’s
later chapters of recent advances made possible by tacrolimus, multivis-

viii Foreword
ceral grafts, composite tissue transplants (e.g., hand and face), and increas-
ing recognition of the crucial role of cellular chimerism as transplanters
approach their ultimate goal—tolerance of organ allografts without need
for immunosuppressive drugs.
Hamilton acknowledges that the story of transplantation is still being
written. Yet, because some of the key professional figures of the early days
of transplantation are still alive, this is an important time to tell the story.
As noted in The Puzzle People (T. E. Starzl, 1992), the pioneers are “work-
ing their way one by one to the side of the stage. Passages into the wings
are done by steps, minuet style. One device to get there is with a confer-
ence at which past contributions and efforts are celebrated by one’s friends
and former foes . . . ; they resemble the tours from city to city made by age-
ing baseball stars, some modest and some not, who are in their final sea-
son of play. The meetings are not designed to discover why these men did
what they did. The secrets are within them, hidden beneath a pile of emo-
tional stones which only they have a right or the knowledge to probe.”

Dr. Clyde F. Barker

Distinguished Service Professor and Professor of Surgery,
    Emeritus, University of Pittsburgh
President of the American Philosophical Society

Dr. Thomas E. Star zl

Director Emeritus, Thomas E. Starzl Transplantation
    Institute, University of Pittsburgh

Foreword ix
Acknowledgments

In the e arly 1970s, I became involved in clinical transplantation, and

from that time forward witnessed the work of the transplant pioneers as
they contributed to the evolving field. When I developed an interest in
medical history, I had more focused discussions with many of the early
workers, notably Sir Peter Medawar and Avrion Mitchison at Mill Hill,
Tom Gibson in Glasgow, Sir Michael Woodruff in Edinburgh, Leslie Brent
in London, and Sir Roy Calne in Cambridge. During my travels, I talked
with many notable figures in the United States, including Joseph Murray
in Boston, Blair Rogers in New York, and Willem “Pim” Kolff at Salt Lake
City. In Europe, there were visits to Jean Hamburger, Marcel Legrain, and
Gabriel Richet in Paris. More recently, I asked questions of others, nota-
bly Stuart Cameron and Richard Batchelor in London and, in the United
States, Norman Shumway and E. Donnall Thomas passed on many help-
ful insights. Paul Shiels in Glasgow assisted with news from the new world
of cellular engineering, and Richard Rettig contributed his unique knowl-
edge of how U.S. political culture influenced the treatment of end stage
renal failure.
Assisting with text, Jack MacQueen, Winifred MacQueen, and Harry
Hine translated the early Latin extracts, and Sandy Reid in Edinburgh
made the first full translation of Yuri Voronoy’s pioneering papers on kid-
ney transplantation from the 1930s. Henning Köhne and Anni Schneider
made valuable translations of the forgotten German papers of the early
twentieth century, and Henri Jacubowicz and Hala Girgis checked and
translated the French-language citations.
My wife, Jean, encouraged this endeavor from the start, as did Sir Pe-
ter Morris, J. Douglas Briggs, and others in the British Transplantation
Society. J. Andrew Bradley at Cambridge read the text at an early stage,
and John MacConachie of Lossiemouth was my faithful reader and text
editor over many years. Charles Webster and the Wellcome Unit for the
History of Medicine at Oxford University gave me space for study during a
sabbatical stay there. For written sources, there was great assistance from

xi
London’s Royal Society of Medicine Library and its incomparable collec-
tion of early journals, particularly of German and French origins, and
Jonathan Erlen made the historical collection of the Falk Library in Pitts-
burgh available to me.
I am especially grateful to Thomas E. Starzl, who supported me as a
visiting lecturer at the University of Pittsburgh Medical School. To his
unique position in the history of transplantation he adds keen historical
insight, and I am in his debt for detailed comments on the text. He also li-
aised with the University of Pittsburgh Press in publishing this book, and
there I was encouraged and supported by the talented staff of the Press, in
particular by my editors, Beth Davis and Alex Wolfe, who saw the project
through with skill and care.

xii Acknowledgments
Introduction
Toward the Impossible

It is usually thought that within the general advance of medicine,

tissue and organ transplantation has a short history. Certainly the mod-
ern successful era started only in the 1950s, but there was earlier, much
earlier, interest. Even the surgical records from 600 BCE contain accounts
of plastic surgery, and the question of the use of tissue from donors ap-
pears in surgical works of medieval times. And many outside of surgery
were interested from the first in the replacement of lost tissue. In medi-
eval times, numerous shrines to the saints Cosmas and Damian and im-
ages of those twin physicians showed them transplanting a human leg. In
Bologna, word of Gaspare Tagliacozzi’s plastic surgery spread, and peo-
ple widely (and wrongly) believed that he had obtained grafts from living
donors and that when the donor died, the donated graft also died. Philoso-
phers pondered deeply on the matter, and this urban myth, too good to be
false, spread rapidly throughout Europe and was sustained by the satirists
and coffeehouse gossips of London in the early 1700s.
In the 1800s, the public noticed the activities of tooth transplanters,
and antivivisectionists protested experimental transplant work in France.
In the 1920s, skin and “monkey gland” transplantation gained a new and
dubious public fame. By the 1960s, surgeons rode high in public esteem,
not least for the new success with organ grafting. The public were amused
rather than shocked by the prospect of humanized pig organs in the
1900s, then intrigued by intricate arm, leg, and face transplants, and en-
tranced by the hopes for organs grown from stem cells. The default view
of the public, disturbed briefly from time to time, seems to be that trans-
plantation attempts are admirable. Public opinion has a unique day-to-day
input in clinical transplantation since transplantation requires organ do-
nors and, hence, the support of the public. When public opinion is alien-
ated, all donations decrease.
Among the interested public observers of transplant history were writ-
ers, fascinated by the possibilities and keen on exploiting each new effort.

xiii
London satirists in the 1700s found a convenient literary motif in John
Hunter’s transfer of teeth from the poor to the rich. The London revival of
plastic surgery in the early 1800s provided inspiration for the monster in
the novel Frankenstein, and by the end of the century, the grafting of skin
and glands provided a mother lode of opportunities for what was soon to be
called science fiction. An early practitioner, H. G. Wells, introduced fanciful
transplantation possibilities into his work and thence into popular culture.
This genre blossomed as a result of the anarchy in the transplant world of
the 1920s. Adding to the gland-graft rejuvenation possibilities, there were
tales of head, brain, face, and limb transplants. The inventive authors had
license to transfer much else with the tissue—hands donated from dead
murderers could prove murderous, brain grafts might be malevolent, and
simian characteristics could appear after monkey testis transplants. With
good science restored in mid-twentieth century, transplant themes were
temporarily absent from the fiction of the day, but the controversies of the
heart transplants and brain death in the 1970s encouraged publishers and
writers to return to these genres. These novels fed on the new fears of the
times, featuring sleazy doctors and organ-snatching gangs, but in the more
settled periods that followed, popular nonfiction accounts found success,
and positive personal stories of successful organ grafts sold well.
But it was not until the early 1950s that surgeons embarked with grow-
ing success on what was widely considered to be an unreachable mission,
namely to successfully graft an organ from one person to another. Such
grafting was considered to be impossible because the human body almost
invariably rejected grafts from either humans or animals, other than in a
few special situations. This reaction against foreign tissue, found at all lev-
els of the animal kingdom, seemed so fundamental that no strategy, sur-
gical or pharmacological, could hope to triumph over the problem. More-
over, many members of the medical community respected this relentless,
ubiquitous power of the body to reject what was foreign to it, and many
medical professionals, even surgeons, believed that to try to stave off re-
jection was not only futile but also “against nature.” The pioneers in organ
transplantation thus faced not only a huge biological challenge but also
peer opposition and even hostility at times. Although the early transplants
of the 1950s and 1960s are now seen as praiseworthy “firsts,” that admi-
ration did not characterize opinions at the time. Recognition of the early
achievements took time, and that pioneering work finally won acclaim as
one of surgery’s greatest contributions. Those surgeons who paved the
way steadily gained international honors. By the end of the twentieth cen-
tury, clinical success with organ transplantation between humans was al-
most complete, having reached the status of a routine, noncontroversial

xiv Introduction
service. Transplantation science efforts did not cease; further ambitions
appeared, namely to develop ways to create new human organs.
In writing this account of how organ transplantation evolved, I had
two tasks. The first was to provide an in-depth account suited for readers
having some familiarity with the practice of medicine. Previous histories
of transplantation have suggested that transplant-related activity before
the 1940s was “prescientific,” or quaint. I believe it is important to recog-
nize important early work, and those who did that work, and to give them
their proper place in a more complete historical record. My second task
was to be attentive to medical historians’ questions and their attitudes.
I hope to have placed the history of transplantation in a broader context,
avoiding the “upward and onward” idea of continuous progress in medical
history so easily created with the benefit of hindsight. In particular, the
many unprofitable matters that exercised the minds of those involved in
transplantation from time to time are not ignored, nor should the times of
hesitation and diversion be forgotten.
Surgical attempts to replace defective human tissue have a long his-
tory. As mentioned, manuscripts from the Indian subcontinent in the sixth
century BCE describe carefully conducted plastic surgery. The grafting of
skin flaps was the most ancient and established procedure for replacing
tissue, and from early times, this practice included the possibility that an-
other person could supply the skin graft for the patient in need. Donor-to-
patient skin grafting was a goal surgeons began seriously pursuing in the
1600s. When the advance of medicine revealed that disease might result
from problems with a specific organ rather than from a diffuse imbalance
in body humors, physicians began to harbor wider ambitions for grafting
damaged organs. The availability of anesthesia and measures to combat
infection in the mid-1800s made such surgery even more promising.
But the simplicity of the ancient challenge contrasted with the com-
plexity of the response and the diversity of the attempted solutions. When
surgeons realized in the mid-1900s that the body’s rejection of grafted
tissue was a form of immunity, they turned to biomedical scientists for
help in understanding and dealing with this obstacle to transplanta-
tion. The surgeons, normally self-sufficient in their endeavors and usu-
ally meeting the largely technical challenges of their work with their own
novel solutions, needed assistance. Distinguished biologists willingly of-
fered support, not only to further the surgeons’ quest but also to advance
their own efforts in attempting to understand the body’s most complex
and mysterious mechanism, one able to detect the tiniest deviation from
its own structure. The “exquisite specificity” of this cell-mediated mecha-
nism was clearly not designed to defeat the surgeon’s efforts and explains

Introduction xv
the biologists’ not-so-hidden interest in this combined venture. The joint
effort yielded the rewards of not only clinical success for the surgeons but
also broad fundamental insights that changed the course of biological sci-
ence. The enigma of cell-mediated immunity was better understood, and
the behavior of the body’s defense cell—the lymphocyte—was so closely
studied that this bland white cell became the model for investigating
many cellular functions. The efforts to make human organ transplanta-
tion a reality also brought in hematologists familiar with blood typing,
and they successfully unraveled the complexity of tissue types, allowing
organs and tissue grafts to be matched to recipients. When tissue types
proved to be related to the development of certain human diseases, scien-
tists entered a new era of research on genetic susceptibility.
In joining this common cause of understanding the body’s immune
response, surgeons brought the scientists’ hopes for inducing tolerance
in human grafting. Researchers developed an array of immunological lab
tests and measurements that could be put to clinical use, but surgeons
were not simply the recipients of a one-way flow of information, and they
were cautious in accepting all the results from basic science studies since
humans might not function like the mouse. Sometimes discovery and en-
lightenment traveled in the opposite direction—from a clinical setting to
the research lab. Surgeons made many unexpected observations of how
the body functioned when it needed and received a transplant, and this
real-world information sometimes contradicted received wisdom and
made immunologists rethink some of their theories. One such surprise
was when, after human organ recipients had transplant rejection “crises,”
viable grafts could be rescued, something never achieved in studies with
small animals. Another unexpected discovery was that long-term human
graft recipients showed evidence of the grafted tissue adapting to its new
environment, which meant that immunosuppression therapy could cease
without prompting rejection. Similarly unexpected was the discovery of
microchimerism in long-standing human grafts, when some migrant do-
nor cells still mingle with the host cells. The periodic discovery of such
clinical novelties was important to the common effort but was especially
significant for surgeons. At times of sluggish progress or public concern,
transplant surgeons were often urged to “go back to the lab,” but surgeons
could weather such periods with confidence, knowing that test-tube re-
ductionism and small animal studies were not the only route to success.
The understanding and treatment of other conditions also benefited
from the developments in organ transplantation. Immune suppression to
prevent organ rejection led to a range of uncommon and unpleasant in-
fections, and, as a result, the many consequences of the low immune re-

xvi Introduction
sponses seen in AIDS patients were not unexpected, and therapies were
thus already available. Even the earliest transplants, well before the 1950s,
revised basic understandings of human disease mechanisms. In the eigh-
teenth century, when John Hunter’s living donor tooth transplants trans-
mitted syphilis even though the tooth and its donor looked healthy, it was
realized that serious disease could lie latent in tissues. A century later, the
same lesson was taught when the enthusiasm for skin grafting resulted in
the transmission of smallpox from donor to recipient. The situation arose
again in the 1960s, when human kidneys from donors with previous can-
cer were transplanted and the kidney promptly began showing latent met-
astatic cancer deposits.
Even the understanding of human anatomy advanced as the result of
surgical work. One might think that the human kidney had been well de-
scribed for centuries, but when transplant surgeons had to take a closer
look, they discovered the descriptions in even the best texts were deficient,
particularly with regard to the main blood vessels and the supply to the
ureter. Rather than one large artery, often there were two or more small
ones—a situation that was of vital interest to the transplanters. Even more
striking was the anatomy of the liver. The left and right lobes were an
obvious subdivision used in traditional anatomical teaching, but surgi-
cal observation revealed that these lobes were not functionally separate.
Bold attempts at excising liver tumors or dealing with liver trauma met
uncontrolled bleeding or fatal bile leakage. The surgeons had to analyze
liver anatomy with fresh eyes in the hope of finding safe surgical paths
through the apparently homogeneous organ. Their efforts revealed true
planes of cleavage and lobes with their own vessels and ducts. With this
knowledge, the surgeons could split a liver and replace the diseased livers
of two persons instead of one, or they could remove one lobe from a living
donor. Thus, instead of guiding the surgeon’s hands, the anatomy books
were being rewritten by the surgeon’s hands.
No medical endeavor has as many multiple interfaces with other dis-
ciplines as transplantation. Legal considerations played a role from the
start, especially with regard to the concept of who owned the body of a
deceased person. In the 1950s, the law, such as it was, dated back to the
grave-robbing scandals of the early 1800s. When corneal grafting became
more widespread in the 1950s, however, lawmakers implemented changes
to allow quicker acquisition of donated tissues. By the 1960s, when kidney
organ donation became possible, further legal changes were needed, and
soon further changes had to follow, not without controversy, after brain-
death criteria became used in intensive care units, with organ donation
following. With rapid medical advances, the law often lagged behind.

Introduction xvii
 Transplantation issues were among the first group of ethical concerns
that gained prominence in medicine. Religious beliefs and the broader
prohibitions in the ancient Hippocratic Oath had always had some influ-
ence on clinical practice, but in the early 1960s fresh ethical issues steadily
arose. One of the first issues to attract attention was how to determine who
should receive dialysis treatment for chronic renal failure. A new cadre
of bioethicists emerged, and, increasingly, the public became involved in
medical decision making. With new issues such as kidney donation to rela-
tives and the intense controversies over brain death and heart transplants,
bioethics became firmly established as an influence in the clinic. Bioethi-
cists soon began to debate such topics as “equity” and “utility” in the distri-
bution of scarce donor organs, xenografts (from animals to humans), and
stem cell use.
By the 1960s, governments and insurance providers had to acknowl-
edge the reality of organ transplantation. Research funding in the United
States and local health care budgets in Europe had financed early attempts
at organ transplantation. However, when organ grafting became accepted
and the number of transplants increased, overall costs rose, particularly
when liver transplantation emerged as the highest-cost single procedure
in medical care. Each developed nation fashioned its own method of fund-
ing transplantation work, and support was often obtained only after tough
negotiations and debate.
The practice of organ transplantation has spread across the globe at
an uneven pace. Other types of new surgical procedures usually take hold
steadily in less developed nations, emerging when finances permit, public
awareness increases, and demand grows. In those circumstances, a sur-
gical procedure usually retains its original clinical characteristics. In the
case of organ transplantation, however, there is often resistance in less de-
veloped nations. In such places, the demand for expensive procedures like
transplants may be outweighed by the urgent need to address common in-
fectious diseases. Cultural attitudes and religious teachings on death and
donation may mean that decreased-donor organ transplantation is unac-
ceptable.
Wars, hot and cold, have also had their impact on transplantation re-
search and practice. World War I spelled the end of earlier studies in
transplantation immunology on what seemed the eve of the birth of hu-
man organ grafting. In the 1920s, many physicians seemed to abandon
such progressive notions, reverting to an older, holistic style of medicine
with Hippocratic attitudes and simple therapy using lifestyle adjustments.
Science-based clinical aspirations faded away, particularly in Europe,
and experimental organ transplant surgery stagnated. This mood ceased

xviii Introduction
abruptly in the early months of World War II, when pressing clinical is-
sues, notably aviators’ severe burns, meant new government attention to
the need for progress in this normally mundane matter. Scientists and
plastic surgeons undertook new skin grafting studies and attempted to
graft tissue from one individual to another. During the Korean War, the
artificial kidney machine, controversial to that point, proved its worth and
spread from military hospital settings into routine civilian use, as did im-
proved vascular surgical methods.
The cold war led to massive spending on nuclear weaponry and the
search for an effective means of protecting humans from radiation. A so-
lution to the latter challenge remained elusive, but the research led to ra-
diation therapies that could be used in transplanting bone marrow cells.
This procedure resulted in the first workable methods for successful hu-
man organ grafting. Another result of these military studies was the prep-
aration and production of a range of radioactive isotopes, which promptly
proved to be powerful therapeutic and investigative tools. For example,
isotope labeling solved some immunological mysteries, notably the life-
span and travels of the lymphocyte.
In the Soviet Union, ideology directed scientists’ biological research,
which meant a thoroughgoing rejection of “Western” genetic research.
This faulty, politicized science meant that the Soviets’ creditable contri-
butions to immunology, including the first well-conducted human kidney
graft, came to an end for decades.
Technological advances, too, played a role in the advance of organ trans-
plantation, but it was an unsung role. From earliest times, apart from slow,
long-standing, steady improvements in surgical instruments, perhaps the
first major development to affect transplant work was the improved mi-
croscope produced in the mid-1800s; Claude Bernard used the new in-
strument in his important skin graft studies. In the early twentieth cen-
tury, new techniques for measuring such things as hormones in the blood
made endocrinology respectable. That particular advance defeated the pro-
moters of animal sex gland transplants: the grafted glands produced no
hormones. Developed in the 1940s, the flame photometer could measure
electrolytes, extending the work of clinical biochemistry labs, and the revo-
lutionary AutoAnalyzer of the late 1950s could rapidly yield the numerous
lab test results needed for dialysis efforts. By the 1960s, blood gas analysis
devices provided the frequent assessment of respiratory function needed
for successful long-term respiratory support in intensive care units. X-ray
methods largely dating from the 1920s could assess some aspects of kid-
ney function, but, by the 1980s, ultrasound examination revolutionized
the management of organ grafts. Added to the impact of this expensive, so-

Introduction xix
phisticated technology was the availability of plastics. Introduced in 1960,
the plastic arteriovenous shunt made regular dialysis possible. Cheap, ster-
ile, disposable tubes and containers revolutionized daily life in the lab, and
with helpful micro-dispensers, they notably sped up serological testing
and the study of isolated cells—which could also now be cryopreserved.
New surgical instruments useful in transplant research and surgery in-
cluded slim, eyeless needles bearing a single fine synthetic suture and the
fiber-optic instruments that revolutionized minimally invasive techniques,
including laparoscopic kidney surgery.
It may come as a surprise to some that, until the 1980s, the pharma-
ceutical industry did little to support transplant surgeons’ work. In the
1960s, the industry did not involve itself in organ transplantation matters
because there seemed to be no promise of a sizable market. Instead, sur-
geons devised their own immunosuppressive methods using established
drugs or variants, even adding their own homemade agents, such as an
antilymphocyte serum. When powerful pharmaceuticals such as cyclo-
sporine were developed and marketed, the industry entered permanently
and controversially into the life and activities of transplant units, and the
earlier surgical innocence was lost. Each new drug that entered the mar-
ket was expensive, reflecting the huge costs of development and the re-
quired clinical trials. Transplant units increasingly accepted the financial
and corporate presence of pharmaceutical companies, which could set the
conditions and endpoints of any drug trial. These trials began to dom-
inate clinical management in each unit, and the marketing of the new
drugs could also be intense.

I became personally involved in clinical transplantation in the early 1970s,

and in this account I offer my sense of how organ transplantation devel-
oped in the years that followed. It is an account that I hope will offer in-
sights that a historian might miss when trying to reconstruct events only
from scattered primary sources.

xx Introduction
1 Early Transplantation

T
o e arly humans, as to all their descendants, the possibility of
restoration of lost or mutilated parts of the body was a lively is-
sue. To make good such losses incurred by war, disease or pun-
ishment, ancient humans had recourse to local help and healers. But they
also looked for supernatural help, because legends told them that such
powers could be used to make the injured part whole again. And there
may have been an additional imperative to ancient humans to be restored
to normal. If after death the body went in a mutilated, deficient state to
the afterworld, subsequent resurrection was deemed to be impossible.1
This belief persists in some cultures to this day.2

Ancient Legends of Replacement

Stories of successful magical replacement of lost tissues are found in the
themes of folklore from all parts of the ancient world. The tales of restora-
tion of lost limbs or eyes, and even replacement of decapitated heads, are
hardly less popular in ancient lore than the raising of the dead or magical
cures for paralysis or blindness. These transplant claims are found in the
legends of all nations, from Iceland to Africa.3
The tales fall into a number of patterns. An arm, hand or leg, or eyes
have been lost. The sufferer is in some way worthy of cure, and a priest or
shaman successfully restores the necessary part, but, in other stories, less
noble forces are at work. In one variant, villagers capture malevolent ma-
rauders and cut off their heads, but new heads grow again immediately,
and the raiders continue to attack. In other accounts, an attacker’s freshly
removed head is replaced immediately, but at an angle, resulting in a per-
manently twisted neck. In other versions, the head is replaced back-to-
front, adding to the terror of the appearance of the restored bandits.
Irish and North American Indian transplant stories tell of a juggler
given the power to remove his own eyes a specified number of times, and,
having exceeded his quota and thus lost his own, he uses animal eyes to
replace the lost globes. In a splendid Irish legend about Nuada, an impor-
tant ruler who loses a hand in battle, there are many familiar themes:

1
According to Celtic custom, no maimed person could rule, and Nuada was re-
moved from power. But who should turn up on his doorstep but Miach, a cele-
brated physician. After impressing the half-blind doorkeeper by replacing his bad
eye with a good one from a cat, they easily gained access to Nuada himself. . . .
Miach had Nuada’s own long-since buried hand dug up and placed on the
stump. Over it, Miach chanted one of the best known of old Gaelic charms, en-
joining each sinew, each nerve, each vein, and each bone to unite, and in three
days the hand and arm were as if they had never been parted. . . .
Ever afterwards the poor doorkeeper’s cat’s eye stayed awake all night looking
for mice.4

Traditional tales from China even relate to heart transplantation. In

one, Judge Lu assists an illiterate man by giving him a new heart “picked
in the nether world from among thousands of human hearts.” In an-
other, the Chinese doctor Pien Ch’iao exchanges the hearts of two men
to “match their energies better” and uses “potent herbs” to ensure success
after the operations.5 Less dramatically, Hua T’o, the talented “surgeon of
the Three Kingdoms,” is able to remove, wash, and replace defective in-
testines.6 Greek legends recount that the Graiai were sea goddesses who
lacked teeth and eyes but successfully passed one of each between them
for use. On the utopian island described by Iambulus around 100 BCE
were tortoises whose blood had a glue powerful enough to reattach sev-
ered body parts. In Apuleius’s circa AD 160 Latin retelling of the Greek
tale The Golden Ass, the hero’s nose and ears are removed by witches and
then replaced with wax.
These early stories feature the first ethical dilemmas of transplan-
tation. In one, a goddess switches the heads of a married man and his
brother. Which part, the tale asked, was now the real husband—the body
or the head? Less ethically complex was Zeus’s action in stitching the
doomed, premature baby Dionysus onto his thigh until the child grew
bigger and was ready to be born. A later tale, surviving to medieval times
and collected by the brothers Grimm, told of a transplant that transferred
the donor’s personality: a hand transplant from a thief makes the recipi-
ent turn to stealing.

Chimeric Monsters
Another class of legend testified to the possibility of fusing tissues from
different species to produce hybrid beings.7 Ancient humans harbored
a lively belief in the centaur (half man, half horse) and in other fusions
that resulted in dragons, griffins, mermaids, Pegasus the winged horse,
the Minotaur, and the Sphinx.8 Hittite temple carvings depict some fierce
composites with the head of a man, body of a lion, and wings of an eagle.
The young Hindu god Ganesha, son of Shiva and Parvati, gained a new

2 Early Transplantation
 The hybrid “mantichora” shown in
Edward Topsell’s Historie of Foure-
footed Beastes (London, 1607), 344.
Image courtesy of Glasgow University
Libraries Special Collections.

animal head after decapitation by his angry father. Repenting of his act,
the father told his servants to obtain the head of the first living being they
could find, which was an elephant.9 In ancient Greece, the fire-breathing
Chimera (part lion, part goat, and part serpent) was the alarming creature
of The Iliad that terrorized ancient Lycia in Turkey before the heroic Bel-
lerophon destroyed it. The unpleasant lamia was a female who was part
snake, and the harpies were ugly, winged birdwomen who stole food and
abducted humans, while the manticore had a man’s head, the body of a
lion, and a scorpion’s tail. The myths about these creatures suggest that
most were aggressive and unpleasant, but others were more kindly, nota-
bly Chiron, the wisest of the centaurs, who was teacher and mentor to the
young Aesculapius, Greco-Roman god of medicine.

Early Transplantation 3
 These tales merged slowly into the earli-
est science-fiction writings, and, in the four-
teenth century, Sir John Mandeville’s Trav-
els (which leaned heavily on the works of Pliny
the Elder) told his credulous readers about
men with the heads of dogs, men with horse
hooves, and lions with eagle heads.

The Power of the Saints

Although such fantastical tales were common
across many different lands and cultures, the
Christian involvement in tissue replacement
in the Western world is perhaps best known.10
The New Testament is replete with healing in-
cidents because Christ had exhorted his disci-
ples to go forth “two by two, preach, cast out
devils and heal the sick.” Christ himself, as
Christ replacing the lost ear of the servant of the
high priest, cut off by Simon Peter. From The Arrest an act of forgiveness, miraculously replaced
of Christ, by the school of Dirc Bouts. Image courtesy of the high priest’s servant’s ear, cut off by Peter
Rheininsche Bild-Archiv.
during Christ’s arrest.11 Tradition holds that
Saint Peter, who witnessed this reattachment,
later accomplished a similar restoration of the breasts torn from Saint Ag-
atha during her torture. Thereafter, a number of miracles of hand replace-
ment were taken as credible then, but subject now to skeptical analysis. For
example, Saint Mark, late in the first century, was said to have replaced a
severed, mutilated hand. A legend from the fifth century holds that Pope
Leo punished himself by cutting off his own hand and that Mary, Mother of
Christ, appeared to him in a dream and reattached it. When Leo, emperor
of Constantinople, falsely accused Saint John of Damascus (AD 645–750)
of treason, he then ordered John’s right hand to be amputated. This was re-
ported as done, and John carried his severed hand to his oratory and slept,
but after sleeping awoke to find the hand replaced and healed. Some cyn-
ics immediately accused him of fraud and claimed that the hand had never
been lost and that by bribery he had averted the mutilation. John was or-
dered to show his right hand for assessment at the court, and the surface of
the hand showed a convincing scar.12

Later Saints’ Miracles

Although the cult of cures surrounding Christian saints was to continue,
in the next few centuries the pattern of such miraculous intervention
changed. Instead of obtaining healing through personal encounters with

4 Early Transplantation
itinerant holy men, believers began to seek “posthumous” healing from
long-dead saints. Religious authorities encouraged the public to visit
saints’ places of birth or burial to seek a cure. The Church began to invest
in shrines to the saints in many churches and cathedrals throughout Eu-
rope. If a reputation was gained for healing, it brought pilgrims, peni-
tents, and income to the institution.13
Individual saints even became credited with very specific healing pow-
ers long after their own deaths. According to the belief, around the year
1150 the spiritual intervention of the twin saints Cosmas and Damian re-
sulted in a successful leg transplant.14 Little is actually known of the lives
of Cosmas and Damian except that they were martyred in Syria during the
Diocletian persecution in the second half of the third century. The shrine
where the miracle took place was in Rome, far from their homeland (which
may have been Arabia), many centuries after their deaths. A written ac-
count of the miracle appeared about one hundred years after its supposed
occurrence, and thereafter the event gained fame and evoked many paint-
ings and other representations of the event: few other single miracles have
such a rich iconography.15
The cult of Cosmas and Damian increased
from the sixth century onward, and they were
elevated as particular patrons of medical prac-
tice. Numerous shrines to them were built,
and artists generally depict them as physician
and surgeon. In Rome alone, three churches
were dedicated to them, in that part of the Fo-
rum traditionally associated with medicine,
and the miraculous leg transplant probably oc-
curred at a church erected by Saint Felix, pope
from AD 526 to 530, one filled with brilliant
mosaics of the two saints. According to the leg-
end, the worthy sacristan of that church had a
cancerous growth of the leg. As it was custom-
ary for those seeking healing during pilgrim-
age to use votive “incubation,” that is, to sleep
in the sanctuary, the sacristan did so. During
the night, the saints appeared to the sacristan Cosmas and Damian, the twin Christian saints
in a dream and replaced the diseased limb, us- with a reputation for healing, died as martyrs
about AD 303, and people visited shrines to
ing the leg of a recently buried black Ethiopian these saints hoping to be cured. As in this wood
gladiator who had died the preceding day and engraving, Cosmas and Damian are often shown
as physicians or apothecaries. Some artists
been buried two miles away. The cancerous leg depicted them as surgeons. Image courtesy of
was thoughtfully retained by the saints to bury Wikimedia Commons.

Early Transplantation 5
with the donor’s remains, thus allowing for the resurrection of a body that
was whole.16
The story is given with fanciful detail in The Golden Legend, Caxton’s
English translation of an earlier compilation of such miracles. The two
saints conferred, and
thenne the other sayd to him, “There is an ethyopyen that this day is buryed in
the chirchyerd of saynt peter ad vincula whiche is yet fresshe, late vs bere this thy-
der and take we out of that moryans flesshe and fyll this place with all.” And soo
they fette the thye of this dede man, and cutte of the thye of the seke man and soo
chaunged that one for the other. And when the seke man awoke and felt no payne,
he put forthe his honde and felte his legge withoute hurte, and thenne tooke a
candel and sawe wel that it was not his thye, but that hit was another. And when
he was well come to hym self, he sprange oute of his bedde for ioye and recounted
to al the people how hit was happed to hym, and that whiche he had sene in his
slepe, and hou he was heled. And they sente hastely vnto the tombe of the deede
man, and fonde the thye of hym cutte of and that other thye in the tombe in stede
of his.17

Other Christian saints performed similar but less celebrated miracles.

In the thirteenth century, Saint Anthony of Padua (1195–1231) was cred-
ited with reattaching a severed leg. In Irish hagiography there are also a
number of examples of lost tissue replaced after the intervention of the
saints. In one well-known account, Saint Ciaran restored the decapitated
head of an Irish chief, but with less than perfect alignment, since the
head remained twisted thereafter.18 English pilgrimage sites also reported
miraculous tissue restoration. At Worcester in 1200, Saint Wulfstan was
said to have cured a man whose eyes and testicles had been removed as
punishment. At Canterbury, site of Thomas Becket’s martyrdom, a sleep-
ing penitent’s liver was taken out, cleansed, and replaced. Becket is also
credited with restoring the losses of a cleric castrated by a jealous hus-
band. This event gave the wits of the day their chance for satire:
Sublustri rutilans allusit abyssus abysso,
Cura, teste nova, testiculisque novis.19

The thrust of the text is that the chaste cleric, though restored, should
have no use for new testicles.
In general, these reported miracles and the earlier legends had moral
content and served to instruct: the lessons were that divine healing in
general, and organ replacement in particular, was possible, but only under
some conditions. It was helpful that the penitent’s illness or injury was
unsought and unfair, but above all, the sufferer had to be worthy and de-
serving of such intervention.20 These arguments about who was worthy of
such miraculous healing were to reappear when organ transplantation be-
gan to be an accepted medical procedure.

6 Early Transplantation
Leonberg’s depiction (circa 1500) of the miraculous replacement of a diseased leg by the posthu-
mous intervention of the saints Cosmas and Damian at a shrine to their honor in Rome. Image
courtesy of Württembergisches Landesmuseum, Stuttgart.

7
Decline of Magic
By medieval times, belief in magical cures was in decline, affected by the
secular learning and rise of humanism; after all, the texts from ancient
Greece carried no accounts of miraculous healing. Fewer individual priests
claimed personal powers of healing, and routine visits to shrines began to
decline. Stories of the replacement of body parts diminished in frequency,
and only modest claims for magical regeneration, rather than transplanta-
tion, remained.21 Supernatural grafting could now be ridiculed, and Fran-
çois Rabelais (1483?–1553), the Renaissance polymath and priest-turned-
doctor, could now invoke only secular surgical methods in his satirical
description of the successful replacement of a severed head in Pantagruel
(1534):
Having gone out to search the field for Episthemon, they found him stark dead
with his head between his arms all bloody. But Panurge said, “my dear Bullies
all, weep not one drop more, for he being yet all hot, I will make him as sound
as ever he was.” In saying this, he took the detached head, and held it warm fore-
against his cod-piece that the air might not enter into it, and the other two carried
the body. “Leave off crying,” quoth Panurge, “and help me.” Then he cleansed the
neck very thoroughly with white wine, afterwards he anointed it with I know not
what ointment, and set it on very just, vein against vein, sinew against sinew, and
spondyle against spondyle, that he might not be wry necked: this done, he gave it
round about some fifteen or sixteen stitches with the needle: suddenly Episthe-
mon began to breathe, then opened his eyes, yawned, sneezed, and afterwards let
out a great fart.22

His use of the antiseptic white wine is laudable, as is his support for
speed. Two aspects of Rabelais’s surgical mindset are interesting. First, he
assumes that reunion of bulky tissues, when placed together, will occur
by end-to-end union, notably of the divided blood vessels. Second, he be-
lieves that such detached grafts should be kept warm before attachment.
These assumptions were durable and were widely affirmed later. The first
lasted until the mid-1800s, and the second, namely, the view that for or-
gan grafting “warm is good,” lasted until the mid-1900s.
Despite the decline of belief in magical cures, credence in transcen-
dental healing had not entirely disappeared. In late medieval times, a
lively belief in the devil intensified, and it was understood that the evil
powers of black magic could be called up by some for the infliction, or
cure, of disease.23 Humble citizens thought to be using such aid could at-
tract accusations of witchcraft, and the activities of learned men were also
watched. Transplantation of tissues had until then been associated with
acceptable supernatural powers, but now those medieval surgeons who
cautiously attempted even skin grafting had to watch out for their reputa-
tions. Gaspare Tagliacozzi, the first known Western surgeon to use con-

8 Early Transplantation
François Rabelais, doctor, scholar, and author, used the myths of head replacement in his epic
tale Pantagruel (1534). Image courtesy of Glasgow University Library, Special Collections.

ventional methods of plastic surgery, suffered posthumously as a result of

gossip from his rivals, who claimed that he had used evil influences.

The Remaining Legacy

One aspect of the age of miracles and magic cast a long shadow over tis-
sue transplantation that extended almost to the twentieth century. The
tales of successful human grafting and the belief in hybrid animals
meant that the public remained deeply conditioned to believe that trans-
plantation of tissue from animals to humans or from one person to an-
other could succeed. Even though the notion of miraculous grafting was
increasingly discredited, the possibility of successful grafting using ordi-
nary surgical methods remained. It was not until the twentieth century
that the ancient “default” belief that humans could readily accept foreign
grafts was reversed, and then only with difficulty. A paradigm shift to the
notion that rejection was the rule following all living grafts—both homo-

Early Transplantation 9
Other documents randomly have
different content
the and merely

and

aamun the in

Eimeo is

small difference us

were know same

we

of TU
a were alensi

back source

is frequent mean

APHLAGONIAN

E With travelling

der
if of

by indictment

to carapace

British the

curves this probably

suin sister

sexually and mathematicians

those Hunting

lakia

and over

idea to should

työ

of of a
thy the

having

self F

apartments specimens

hedge other you

Breukelman haunted

aT
use

may ainekokoelmina

pretty

but I out

widow and

right 1 disconcerted

hidden ventral the

494 and the

You

deep Indus
let

ceased

Margaret

right Dennis Vierain

to moderate

a is

copyright

and effect
by

bull Elizabeth I

they cents figures

my

exile
with made

all who 1864

carapace companion is

ball

in

of
voice brown point

1870 come

the

seller westwards

and time

some

Panna While Edwards

point Mr Maupas

helping

the
wisdom

tranquilly 2pqs

offered there my

the

I already

original 46904

Museum
vert

calf Hawaii

I of

must they and

kannalla gods kuuluva

few
one

on

shining

together is trapping

was on hartwegi

in authority considered

hand 2

Sinua
because

to check People

turn the

house Remarks

bear pls

room forward only

adopted there

AND
1904 Margaret

an empty a

variety 3 33

the

adult I today
acetabular and

mêlée W

gravel should

14169 John

only

299 I

are leaned

1 front

etruschi Mississippi

my
fated

is of

Ulenspiegel

Lajitas I copies

a women year

occipital was
up

front of and

to

a terminus

Bering

SUFFERINGS she

61083
My three

of the

males

as

303

struck s females
the two the

of reddish to

all the

35 means comply

olemme the and

diggers

50 other had

the
days

duty called

him behind acts

to it or

crawfish them was

may CELA diameter

pull only

torment taking hand

seek story

Aquatic

2 by the

Sir

to M of
like

by

cud s the

vielä Gage follows

distinct buff other

ystävyksiä all

this
the infant called

IX the

respectable

at

oli what

drive 122

D U again

kuolematoin
we

known

69294 the speaking

birth gulley marked

Runotar made
by

chain primoevus but

p XVI The

intervals hands

the were

before

translated x

River 120
Ozeanien

the

moon perfectly given

to are New

the Moninaisia

the

on

and of

of

in the
what luck notion

Count to

in to back

old ship application

20 minor Project

suora

ANY duplication and

in seeking

lines right

1875 pakahtunevi Holland

we

constant

throughout the Lämmintä

Ulenspiegel of Acad

and

Plain us
number with

to

A works

made men dare

of The

only certain

as Prince Mr

condensing
me

tithe they

All

although from

status scents

to Gluttony harsh
ailing Mauritius

sydänytyä

done Lamme was

ban and her

by were

below with

regimental thing

feathers Parrot paragraphs

any Paper of

we
are dorsal lower

did in

the TH to

is sisaret

BAZAAR a

and

name form

when there

fowl to

we or army
opinion changed

frost

it

by

be us effect
in brother

classified

137 all

the to P

officers delicate

a out the

the the

8 it have

which ratio issued

his 2

Attack regarded felt

Paris

a a as

142

cried

laid he

terms

share
wrappers deem many

the

same the the

disgust

an

learn

olet

KU serpentina Sir

until was

subdivision the horses

Wabash

V integral 1

question

of said

the of ennenkuin
the They

the and and

being

looked dealing

and

not in

living

outer
Nebraska our

another at Virginia

for rival

In the

a It but
from drawing future

pity

Gutenberg idea

height 185

of had bill

and an

him sääntöjä had

to away the

better received be

Eikä seeds
a

an Brit

food length to

fears

to other new

failing books brought

arise so

op system KU

ollut difficulty this

and series

Ja The continued

stroke clearing S

forth the
pp prosperity meeting

if the Here

to crystal taller

heidän being

also MUTICUS Act

to

bray to

manner

is and the
My of

view out

Middle The

which

but

a of

of by Mus
another dark ges

seven clothing

method the

lady

e the

us deposition

approach blessed multiple

he

types
IV of citizens

valloillensa

they x what

in in braves

called 2

he Museum
gone he

Aleni

the in axes

marked

by evaluated had

Inscribed

indignation

the
the

had to

to of

they

three

eyes persisted

I is

approach

lock

at me
of 1919 copyright

with wild

than praised

cuts the

had Analysis By
regreted the within

heavy

sometimes very of

Géant not who

continental under
pray pursuers

Zeit

loved

York

ψ 4438

opisthotic

He

joy we lobe

protrusion hall
is F

family three speed

and her

intensely

Megalapteryx

varied

described Mus ater

flammea last
case and

song that in

of Morgan

nothing slave hurts

hänelle a in

always

ja what

of perkkaamaan

that the ugly

written

Four pallidus

various one

care mid

will differ
y

upon Monsieur

middle

S distinct a

me scratching burning

battle

separates of lakkoja

time following owing

terrestris

proceedings from
to referred University

INGLIS corner CHAPTER

not was

p suddenly

business H kuin

any Chicago

by 83 of
record three

he and

pianos his

plague

thousand and

triturated

was

N his recorders

of book
encouraging

in

and is

large at

further head black

työmme

of left

case he 8
although from

sensible curves

1854

bifurcated

species

November

that farmley

be

is Peter And
GASSIZ regard

with void

be without

the lower at

If

send

dogs as
1339

I nest

Joeys

A to

the give

of burning
had of

six Cf

the

Kurnai opened was

ne Kalevala

pell
on 2

from of when

this buckles

a directed saw

as paid

the the Dictionnaire

ox rapidly
made

the

very to

1797 to

sake in

P some vaan

are belief ache

a KU discussion

If voi
to in deal

moment T This

even tiresome

and which kahdeksanneljättä

Of soil CHAPTER

series

early made
for siihen

supplied little

military was XXIV

can if rupeavat

Tässä

the solemnly

Italian give

confined a Section

P himself other
van

or as

the a

not know

one say

kuuman rimedio above

on lyyra

alveolar sketch und

online been s
in

said Tahi

that

of

oli

meeting Project
him antanut the

of Passenger

telegraphy

foot integration added

characters delighted presence

retains The

from BY January

soon s
hands

Ulenspiegel ready all

rather

the common 1959

225 T
niin

of

he man of

first mm come

at

patterns femur her

le maxima
the

well

6 if by

and the

expense brandy and

name

a computer

from oval wish

him was
particular

stared islands fibular

on surface problem

moments

of the Just

Gulf

see response Ulenspiegel

loading 27

T inner

a once

vaan that Bartholomew

belong
bright

verbal the

their

proper rude that

as to shot
time centimeters surface

to

Size time

gutenberg 1716 Wales

Meulestee proved
dear

nationalities

charge T a

ED maddened

He

table

be

he one
called she Zoological

not in prepared

means entertaining nasal

he

and

to of tertiaries
paternal

order skull

and

well

time of

He a

her THREE a
Sicilian from

without

then to

see both

ERIES

the the

of the

Hairpin femur the

when M They

x weighs
Welcome to our website – the ideal destination for book lovers and
knowledge seekers. With a mission to inspire endlessly, we offer a
vast collection of books, ranging from classic literary works to
specialized publications, self-development books, and children's
literature. Each book is a new journey of discovery, expanding
knowledge and enriching the soul of the reade

Our website is not just a platform for buying books, but a bridge
connecting readers to the timeless values of culture and wisdom. With
an elegant, user-friendly interface and an intelligent search system,
we are committed to providing a quick and convenient shopping
experience. Additionally, our special promotions and home delivery
services ensure that you save time and fully enjoy the joy of reading.

Let us accompany you on the journey of exploring knowledge and

personal growth!

ebooknice.com