MEDICINE OUTSIDE THE BOX
The World ’ s First Successful Hand Transplants : A Breakout From 20 th Century Immunology Concepts
by GORDON R . TOBIN , MD , CHRISTOPHER M . JONES , MD , & CHRISTINA KAUFMAN , PHD
( Fig . 1 ) The first hand transplant , at Jewish Hospital , Louisville , KY , January 1999 .
Limitations arising from immunology dogma held back progress in transplantation of skin-bearing structures until the very end of the 20 th century . American psychologist , J . P . Guilford , is credited for originating the term , “ thinking outside of the box ” to characterize escaping such limitations . In his studies on human intelligence , he used the now-familiar nine-dot puzzle as a test of creative thinking . The nine dots formed a square , but no “ box .” Escaping that illusion requires a creative leap .
The “ box ” that transplanting skin and skin-bearing structures , such as the hand , was impossible became a universally accepted “ fact ” in 20 th century transplantation science . The founder of transplantation science , Nobel Laureate Peter Medawar , D . Sc ., did thousands of skin grafts between genetically dissimilar animal of the same species ( allografts ), without success . 1 He envisioned today ’ s many organ transplants but saw no hope for skin-bearing structures . In 1968 , he wrote , “ One day the transplantation of tissues and organs should become an ordinary clinical procedure . Kidney transplantation leads the field ; but liver and lungs are in the running . Only skin is a nonstarter .” 2 Laboratory studies by Nobel Laureate , Joseph Murray , MD , the plastic surgeon who did the first successful kidney allograft , showed that skin immunogenicity exceeded that of other tissues .
The first challenge to these accepted barriers was the 1964 hand transplant by Ecuadorian Surgeon , Roberto Gilbert , MD , in 1964 .
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It survived for three weeks but was lost to irreversible acute rejection . 4 The impossibility of transplanting skin and skin-bearing structures seemed confirmed , and this became accepted dogma throughout the 20 th century .
When Drs . Warren Breidenbach , Jon Jones , and I contemplated experimentally revisiting skin-bearing allograft research in the mid-1990s at the University of Louisville , we were aware of the preceding science and “ established ” judgements . I credit Dr . Jones
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