Book review

Paul Craddock’s “Spare Parts” – Book Review

My review of the new book by Paul Craddock, "Spare Parts: A Surprising History of Transplants"

Paul Craddock is a British science historian. His newly published book debut “Spare Parts” brings us the history of body parts transplants, which began much earlier than we would expect, already in the Ancient India, with autologous skin transplants to reconstitute a lost nose. The skill is rediscovered in the 16th century Europe, and the book proceeds through attempts at revitalising by blood transfusion, the horrid practice of teeth transplants, and more or less ends with the famous (or rather infamous) heart transplant by Christiaan Bernard, to rather uncritically discuss the futuristic promises of transplant surgery, like 3D bioprinting and decellurisation. This is in my view the only chapter where the book disappoints.

My regular readers will quickly point out which more recent developments Craddock, who is a surgery fellow at UCL (of all places!) neglected to discuss, be it out of naivety, ignorance or whatever other reasons. Yes, the Paolo Macchiarini scandal of deadly trachea transplants which also happened at UCL, in fact UCL still continues supporting their scientists in pursuing Macchiarini’s technology of airway replacement with decellurised scaffolds seeded with what these scientists call “stem cells”.

Even the nose reconstruction, something which Craddock describes as the ancient dawn of transplant surgery and dedicates many pages to, was part of that wider Macchiarini affair at UCL. Did he really never hear of what went on in his own university? Or was Craddock and his book censored by the regenerative medicine entrepreneurs at UCL?

Studying history only makes sense if you draw lessons for the present and the future, when you see recognise the past in the present, otherwise we just reassure ourselves how great and righteous we modern people are. Craddock does a good job addressing ethical issues and even suspicions of research fraud of which pioneers like the duo Alexis Carrel and Charles Lindbergh were accused (the author also never neglects to mention that both these gentlemen were also nasty eugenicists, misogynists and Nazi sympathisers). The book deconstructs these and other titans of medicine, while duly crediting some less known real heroes, and I wish the author carried on in this spirit into the 21 century. Alas, it is as if the book was written twenty years ago.

The book is structured quite straightforward, with the chapters titled “1. Skin (1550-1597)“, “3. Blood, Animals to Humans (1666-1670)“, “4. Teeth (1685-1803)“, “6. Organs, Heart (1967-)“, with the last chapter “7. Transplant Future” being the only disappointing one.

Nose reconstruction, from the book by Gaspare Tagliacozzi (1545-1599)

The first transplants were those of the patient’s own skin. Craddock narrates that the skill was already known in ancient India and recorded in the Vedic scriptures. It then re-emerged in the 16th century Europe, where the demand for nose reconstruction was apparently quite high, noses being regularly lost in wars and duels, but also to mutilating punishments and to syphilis. The nose reconstruction was done by making a cut on the arm and pressing it to a face wound where the lost nose used to be, the patient had to kept the position for a number of weeks. The wounded skin healed and the skin of the arm grew attached to the face, an approach learned from agriculture, where “grafting” was a standard practice. The skin flap on the arm was fashioned into a nose, the details of the procedure were a much guarded trade secret which even Craddock doesn’t really explain in detail. But he tells us of the people who did such surgeries. They were neither university scholars nor certified doctors of those times, but a few barber families in Italy, and it was only a certain doctor named Leonardo Fioravanti who sneakily stole the secret skill. Fioravanti, his trainees and successors then popularised the method in books.

The medicine of the 16th-17th centuries was in the process of changing. The university education of medicine was based on Aristotle and first and foremost on the Roman-period physician Galen. It had a number of flaws, those of theoretical and those of practical nature. The practical problem was that Galen only dissected animal cadavers (human corpse dissection was forbidden by Roman law), which resulted in certain anatomical mistakes (e.g., Galen taught the liver had 5 lobes, but humans have just 4). When human corpses were dissected in Medieval European universities under the guidance from Galen’s texts, the inconsistencies seen with one’s own eyes were plainly ignored because Galen could never be wrong. In 16th century, Andreas Vesalius managed to reform the medieval anatomy by teaching students to using their own eyes instead of blindly trusting Galen’s writings. Fioravanti meanwhile was reforming medicine bottom-up, having only disregard to spare for the university scholars.

Vesalius undertaking a dissection, frontispiece ‘Epitome’ (1543).

In those medieval times, medicine was part of astronomy or astrology (these two used to be basically the same science). That had to do with the Galenic system and its model of the balance of four humours (blood, phlegm, yellow bile and black bile). Which was of course wrong, and resulted clinically, aside of horoscopes and nutrition advice, in the most common therapy of bloodletting. The latter ideas of blood transfusion had their difficulties to be accepted not only because of the technical limitations and blood type incompatibilities, but also because the concept of adding blood, especially the blood of someone else, seemed just wrong. That was why the first blood transfusions were attempted between humans and young sheep, because a lamb of God is at least pure and innocent. Luckily for the participants, the blood coagulated during transfusion and not much of the sheep’s blood reached its recipients, who then went to claim to have been invigorated (clearly a placebo effect). The latter transfusions from human to human were anecdotally successful, probably for same reason.

Source: Wikipedia

Now, Craddock rightly exposes all that 17th century hype about the rejuvenating power of blood and the silliness of the concept. Ridiculous, those ignorant quacks and their customers from hundreds of years ago, lucky to have survived because the method of blood transfusion wasn’t quite working yet, from technical point of view. But I don’t know if Craddock really believes that now, in the 21st century, all this mumbo-jumbo about blood from young people as a fountain of youth has been long banished and forgotten. I mean, it’s just peer reviewed science in Nature and multi-million dollar biotech startups…

The new research into blood circulation is also where the cruel practice of vivisection started in Europe. The main “model organism” in such surgery experiments was the dog, and the practice continued into 20th century, at least the dogs were anaesthetised by then. The book chapters 2 and 3 tell of the discoveries of blood circulation by William Harvey and other researchers in the 17th century, like Robert Boyle or Christopher Wren, and the vivisection experiments which those findings were based on. A master of torturing animals became Richard Lower, now recognised as a pioneer of blood transfusion. He just didn’t believe that animals suffer any pain.

Tooth transplant, satirical print by print is by Thomas Rowlandson (1756-1827)

A chapter is dedicated to the practice of tooth transplants, much popular in the 18th century England, but also in USA. It worked in a way Ayn Rand and her followers would have approved of: rich people with teeth rotten from eating too much candy paid starving poor children and young adults to have their healthy teeth pulled and grafted straight into the buyers’ gums. Besides being cruel and evil, the method had absolutely no benefit even for its paying customers, at least in the medical sense. Of course the grafted teeth never grew in and eventually fell out, there was no difference between using sterilised cadaver teeth as practised elsewhere, and “live” tooth transplant, except in latter case for the cruelty towards the “donor” and the danger of infection for the rich customer which sometimes ended deadly. Eventually, porcelain teeth became an accepted standard and the horrid practice fizzled out by the begin of 19th century.

In the book, we meet the “Father of vascular surgery”, Alexis Carrel, a French surgeon from the turn of 19th/20th centuries who made a huge career in USA. Carrel’s achievement was to design a method for stitching blood vessels together, a skill which strangely was sorely lacking in the medical art until then. But the stitching technology did exist, just not among the doctors, and Carrel’s real stroke of genius was to learn from someone who mastered it: a professional embroiderer, Marie-Anne Leroudier, whose name was then purged from Carrel’s biography because she was neither a man nor a doctor. Carrel sure helped by becoming an outspoken women-hater himself.

In 1930ies USA, the star surgeon Carrel met the flight pioneer and inventor Charles Lindbergh. Both men became friends and collaborators, their common interests was tissue culture, life extension, eugenics and admiration for the Nazis in Germany. Craddock mentions in passing that their experiments of keeping cat organs in tissue culture vats, alive and infection-free for months and even years, may have been not as successful as claimed. Basically, research fraud may have happened.

Source: Wikipedia

In this regard, also with the Russian experiments from same period by Sergei Brukhonenko, who allegedly kept a severed dog’s head alive with the help of his “autojector” device, and even transplanted a front part of one dog, head and forelimbs, onto the back of another dog, we cannot entirely exclude research fraud.

Craddock ends by deconstructing the legend of Christiaan Barnard‘s first heart transplant. The South African surgeon was a narcissist seeking to win a race, he broke many ethical rules to get there, and most importantly: the heart transplant certainly was of no use to his patients and likely shortened their lives. To beat the competition in the US, Barnard took advantage of South African laws where death was determined not by cessation of heart beat (the concept of brain death didn’t exist yet), but by signatures of two doctors. So a female traffic accident victim donated her heart while it was still beating because Barnard bullied his colleagues into operating. For all we know, the donor could have even survived, but then neither she nor the transplant recipient did.

In itself, a heart transplant was no big surgical skill, after the vascular anastomosis technique was established by Carrel. What was needed to perform a heart transplant (or any major heart surgery) in the first place, was a bypass machine for external blood oxygenation, so the patient doesn’t die during the operation when their heart isn’t beating. That machine was developed, among others, by the Dutch physician Willem Kolff, who previously designed and successfully applied the world’s first ever dialysis machine – an artificial kidney (Craddock spends many pages telling Kolff’s story).

Kolff’s dialysis patient with his artificial kidney device. Source.

But the main issue with a heart, or any other donor organ transplant, is the immuno-rejection. If the rejection is not properly dealt with, a transplant is not just useless, but a sure thing to kill the recipient, slowly and painfully. That was well known precisely because there were many prior experiments on dogs, with various organs and even legs transplanted. Back in 1967, the pharmacology to suppress rejection was not yet sufficiently advanced, the only successful organ transplants were kidneys exchanged between identical twins. Yet all that certainly did not bother Barnard, he wanted to win the heart transplant race. That is also why all his patients died soon after the operation. But Barnard became a star, with media fame, money showers and affairs with celebrities included.

Paolo Macchiarini always defended his unethical human experiments with artificial trachea transplants by comparing himself to Barnard. All considered, the two men are very similar in their narcissism and their disregard for basic ethics and their own patients. Barnard had the luck that heart transplants became doable later on when working anti-rejection drugs arrived, that’s why we still worship Barnard, but not Macchiarini (anymore).

In the last chapter, Craddock tells us about the future of transplant surgery: the 3D bioprinting of living organs, or the creation of custom-made ones with stem cells seeded on decellurised scaffolds (the decell-recell method), scaffolds which can even be from plant parts. Now, I don’t know what the point of seeding a decellurised spinach leaf with cardiomyocytes was (which impressed Craddock a lot), except of cause clickbaity publicity which is what much of regenerative medicine is about.

But I can tell you about things Craddock forgot. The alleged miracle of decell-recell bladder transplants by Anthony Atala in USA from around 20 years ago which are still being celebrated by gullible journos who never ask, uhm, why were the transplants stopped if they worked so great? Or Harald Ott, another star of regenerative medicine, in Harvard even, who claimed he can grow entire limbs with the decell-recell method, we used to admire his genius, the pictures of a decellurised rat leg looked so sci-fi! Or the lab-grown hearts by Doris Taylor, we still celebrate those as science breakthroughs, maybe those decell-recell hearts were never transplanted because unlike a bladder or a trachea, a non-functional dud heart kills a patient right away, so where is the fun in that.

And then of course the former UCL professor Paolo Macchiarini, I can’t still quite believe Craddock never heard of him. Especially since Macchiarini and his UCL colleagues Martin Birchall, Paolo De Coppi, Martin Elliott and Mark Lowdell treated no less than 4 patients with trachea transplants at UCL, three children and a young woman, only one has survived as far as we know, details a British state secret.

There was a huge investigation at UCL into the Macchiarini transplant affair which ended with foreigners getting the full blame for everything and the white English male doctors told to carry on with trachea transplants at will. The UCL scientist and regmed enthusiast Alexander Seifalian, who used his nanotechnology skills to make scaffolds for his surgeon colleagues, was sacked. UCL decided that Macchiarini was evil, but his technology a scientific success. A retraction of a joint Macchiarini-Birchall paper in The Lancet, which celebrated the first ever decell-recell trachea transplant, was successfully prevented because truth, ethics and facts do not matter when lies, fraud and patient abuse have passed peer review.

But then a proper scientist, the Liverpool professor Patricia Murray interfered, and achieved the cancellations of those clinical trials with decell-recell trachea transplants, both in UK and in the EU.

UCL still didn’t give up, they keep using the technology for other clinical indications and who knows, maybe even trachea transplants still happen through the loophole and under the secrecy of “compassionate use”, as last admitted in 2017. Someone tell Craddock about this, for a follow-up book.

Disclaimer: As usual, I received no payment or incentive to write this review, but I did receive the books gratis from the publisher upon request

Update 29.10.2021: an earlier version of this article said, Paul Craddock was a trained surgeon. He explained to me he is not, and also that he indeed missed out on the Macchiarini affair, his main interest being the history of medicine prior to the 20th century.


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