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173 9 Understanding the Mechanism T he emergence of a new and lasting interest in tissue transplantation is usually dated to 1943, the year of publication of a reinvestigation by the surgeon Tom Gibson and biologist Peter Medawar. Entitled “The Fate of Skin Homografts in Man,” this Journal of Anatomy paper emerged from studies at the Royal Infirmary in Glasgow.¹ The conclusion from this careful work reaffirmed that homografts in general did not survive and that the mechanism of graft loss was an immunological one, a view now regarded as self-evident but one that was not yet widely accepted then. Their central finding was that after loss of a first set of skin grafts, the survival time of a second set of grafts taken from the same donor was shorter than on the first attempt. This change in tempo showed that an immunological mechanism was at work. The study was so carefully described, and with such convincing detail, that, together with Medawar’s later extensive studies in experimental animals, the wider surgical and biological worlds were prepared to accept the paradigm. This study of skin grafts had been stimulated by the pattern of combat injuries among members of the British Royal Air Force in World War II. Some American plastic surgeons were posted to Britain in the early phase of the war, and, as a result, they also took up an interest in skin homografting and transplantation in general, studies that were to continue long after the war was over. These plastic surgeons were to influence and sustain the revival of tissue grafting studies in the United States. Wartime Burns World War II brought a new degree of central direction to Britain’s affairs and new priorities in medical research. In this collectivist atmosphere, the national research interests were diverted toward matters of immediate clinical use. And it was from a government-directed study of a mundane type of injury, one of little intellectual interest in peacetime, that in- 174 Understanding the Mechanism sights of considerable consequence into tissue transplantation arose. The problem of burns was of interest to the wartime government because of the number and severity of such injuries suffered by the armed forces in this war. Increased mechanization of warfare, including aerial combat, meant that fighter pilots often suffered burns from fires in the aircraft’s single engine, often situated in front of the cockpit. The Battle of Britain and aerial battles over France resulted in about four thousand burn cases, of which six hundred were severe. Earlier naval accidents also had serious fires, notably in the HMS Furious disaster, and in a fire involving a North Sea convoy in 1941. When the Lancastria was sunk during the Saint-Nazaire evacuation of British troops from France in 1940, large numbers of service men were also badly burned. After the Battle of Britain, involving a defensive aerial conflict fought on the south coast of England in August and September 1940, British pilots who suffered burns required not only emergency treatment but also plastic surgery, and various military and civilian hospitals in southern England provided such treatment. The British Medical Research Council (MRC) organized a new War Wounds Subcommittee, which prioritized the study of burns, and the council also launched a journal called the Bulletin of War Medicine. For the war effort, the MRC’s “basic science only” policy was forgotten; trauma surgery, a lowly Cinderella among the glamorous specialties, quickly rose to prominence. For assistance, a Burns Subcommittee turned to Oxford University in June 1941. J.M.Barnes, at Oxford’s Radcliffe Infirmary, was appointed to be a research “burns officer,” and it was agreed locally that he have charge of all burns cases admitted to that hospital. Barnes and Peter Medawar, as well as Jean Taylor (later to be Jean Medawar), had earlier been brought in by Howard Florey, the talented Australian head of the university’s Department of Pathology, in his plan to make a concerted investigation of the mysterious lymphocyte.² Barnes was to study the enigmatic thoracic duct outflow, and Medawar and Taylor were to study lymphocytes in isolation. An additional experiment was to study the effect of total surgical removal of the lymphoid tissue in the rat. After inconclusive results from the lymphocyte studies and concerns about both the completeness and unpleasantness of the rat surgery, this grand project on the lymphocyte came to nothing. Only decades later did...

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