Authors: Richard Hollingham
Unfortunately, there were few effective treatments for acute
renal failure in the 1950s. The only alternative to transplants was
dialysis, but few hospitals offered it at that time. Dialysis used an
artificial membrane to filter waste products from the blood. The
process had been invented in the 1920s and developed by a Dutch
physician, Willem Kolff, during the Second World War. Kolff's
machine consisted of a large tank, cellophane tubing (made from
sausage casing) and a rotating drum that resembled a paddle
from an old steamboat. This artificial kidney was hooked up to
the patient with rubber tubing and the motor switched on.
Kolff's first patient, a twenty-nine-year-old woman, showed
dramatic improvements in her condition following dialysis. When
she had been admitted to the hospital her eyesight was failing, her
heart was enlarged and her breathing was laboured. After dialysis
her vision and breathing returned to normal and, reported Kolff,
'her mind was perfectly clear'.
The problem was that every time the doctor needed to use the
artificial kidney, he had to cut into major arteries and veins where the
blood pressure was strong. He could insert glass tubes into a patient's
arms, upper legs, even neck, but each time he did so the blood vessels
were irreparably damaged (doctors use the word 'exhausted'). Each
site on the body could be used only once, so patients could be
attached to the artificial kidney only so many times. Eventually, Kolff
ran out of suitable blood vessels. His first patient underwent twelve
treatments, but despite his best efforts, she eventually died. Although
he had proved that dialysis worked, he had merely prolonged the life
of his patients for a few weeks or months, not cured them.
After the war, a few hospitals in Europe and the United States
adopted Kolff's technology or built new types of dialysis machine.
However, they all ran up against the same problem. Dialysis was difficult,
cumbersome and often dangerous. It was a last resort to keep
people alive.
*
Surgeons needed an alternative, and kidney transplants
still looked like the best bet. But with only a limited understanding
of the immune system, how could they overcome the
problems of rejection?
*
The problems of dialysis were not solved until the 1960s, when a device made of new types
of artificial tubing (a combination of Teflon and plastic) was developed. This 'shunt' was
permanently connected to the patient's blood vessels so that they could be easily and repeatedly
attached to the dialysis machine.
Surgeons tried everything they could think of. One surgeon had
the idea of transplanting a kidney wrapped in a plastic bag. The
theory was that the bag would create a barrier against the immune
system. The patient survived for six months, but the relative success
of the operation was thought to have little to do with the plastic bag.
Surgeons suspected that the reason the kidney had lasted so long
was that the patient was reasonably well matched to the donor. This
seemed to be the key – if the donor and recipient could be matched
for blood, tissue type and immunity, the transplant would probably
be successful.
In Boston, Massachusetts, the surgeons at Peter Bent Brigham
Hospital had been working on the problems of kidney transplants
for many years and were becoming increasingly disheartened.
Would they ever manage a successful transplant? Finally, in 1954,
they hit on some extraordinary good luck.
Boston, Massachusetts, October 1954
Richard Herrick was in a terrible state. Since the twenty-three-year-old
had been admitted on 26 October he had caused nothing but
problems for the staff. He had knocked over equipment and pulled
out his catheter. He had cursed doctors and accused them of sexual
assault. He had even bitten one poor nurse on the hand while she
was trying to change his bedclothes. In the end he was moved to a
side room to keep him from disturbing the other patients.
None of this was Richard's fault. He was in the advanced
stages of kidney failure, and his psychotic behaviour was its
most pronounced symptom. He was only dimly aware of his
surroundings, he could no longer recognize people, had little idea
where he was and only a tenuous grasp on
who
he was.
Richard had been referred to the Peter Bent Brigham Hospital
as a last resort. If anyone could save his life, it was the surgeons here
– the most experienced transplant surgeons in the world. That
said, they had yet to perform a single kidney transplant operation
with any long-term success. However, Richard hadn't been admitted
just because of kidney failure – there was no shortage of equally
deserving cases – but because he had an unusual biological quirk.
He had a twin brother, Ronald, who was willing to donate one of
his own kidneys.
The surgeons knew from previous experiments that transplants
could be carried out between identical twins. They had tried transplanting
small skin grafts with some success. Identical twins seemed
to share the same immune system. Now they had the perfect opportunity
to try it out with a kidney. This was a case of the right patient
in the right place at the right time. Transplant surgeon Dr Joseph
Murray called it 'happenstance favouring a prepared mind'.
However, before making the decision to go ahead with the operation
the doctors wanted to be doubly sure that the brothers were
indeed completely identical twins.
Richard was given dialysis to stabilize his condition, and the
surgeons performed every test they could think of. They drew
samples of blood to check the blood groups matched. They
did. They rang up the brothers' family doctor to see if they had
shared the same placenta in the womb. They had. The surgeons
examined their eyes to see if they were exactly the same colour.
They were. Murray even took the brothers down to the local police
station to have the detectives check whether their fingerprints
were identical.
In all, the surgeons carried out some seventeen tests and the
brothers passed every one, but they would have to wait a month for
the results of the most crucial test. Murray had transplanted a small
piece of skin from Ronald to Richard. If the graft were successful,
the surgeons would be in a position to make the final decision as to
whether to go ahead with a kidney transplant.
The pressure on the surgeons to operate was building. The
press had got wind of the transplant operation. When the brothers
had been fingerprinted, crime reporters hanging around the police
station had started asking questions. Soon the news was all over the
newspapers. But the surgeons could deal with the media; the bigger
problem came from Richard himself. After more than a month in
hospital his condition was, once again, deteriorating. Despite the
dialysis, Richard's heart was starting to fail. His death would be only
a matter of time.
Ronald visited him every day at the hospital. The family knew
that Richard wasn't going to make it. The surgeons were certain
that his death was imminent. If the operation went ahead, there
was every chance that Richard could die on the operating table.
Even Ronald started to have second thoughts. He was young and
healthy – what were his own chances in life if he gave up a kidney?
Ronald loved his brother more than anyone else in the world (both
their parents were dead), but what if they both died during the
operation? Having a kidney removed was in itself a major operation.
Would the surgeon who operated on
him
be competent and
experienced? After a lot of soul-searching, Ronald came to the
conclusion that he would go ahead and donate his kidney. Then,
despite knowing he would definitely die without the operation,
Richard tried to persuade his brother to pull out. He even wrote a
note telling him to get out of the hospital and go home. But Ronald
had made up his mind.
Even the surgeons were beginning to wonder if this was the
right thing to do. They had been assured that removing a kidney
from a healthy adult had no adverse long-term effect on health or
life expectancy. Nevertheless, they consulted psychiatrists, lawyers
and even local clergy. Was it morally and ethically right to remove a
perfectly healthy kidney from a living donor? Richard was becoming
sicker by the day and time was running out. With the skin graft
showing no signs of rejection and with Ronald's full consent the
surgeons eventually reached a decision.
Peter Bent Brigham Hospital, 23 December 1954
The two operating theatres are next door to each other. Ronald and
Richard Herrick both lie unconscious, shrouded in linen sheets,
their bodies illuminated by the bright operating-theatre lights. Each
of the twins is surrounded by a team of masked surgeons, nurses and
anaesthetists. Every conceivable instrument that might be required
is laid out ready. Drips are set up for blood and plasma transfusions;
there are swabs, needles, knives and tweezers. The surgeons have
practised on cadavers. Joseph Murray has worked through the operation
a thousand times in his head. At 8.15 a.m. he is ready to start.
The surgeons removing the kidney from Ronald feel the strain
as much as Murray. This is the only compatible kidney on the planet.
If they mess it up, Richard will die and they could put Ronald's life
at risk. Each team works slowly and carefully, Dr J. Hartwell Harrison
on Ronald, Dr Murray on Richard. By 9.50, Harrison has exposed the
blood vessels leading to Ronald's kidney. He is ready to sever the
blood supply and remove the organ. In the operating theatre next
door Murray has prepared the site in Richard's pelvis where the
kidney will be reconnected. Everyone pauses. Murray takes a deep
breath and gives the instruction to remove Ronald's kidney.
At exactly 9.53 a.m. the surgeons wrap the donated kidney in a
cold wet towel and carry it through to Murray's operating theatre.
Murray knows he has to reattach the severed kidney as quickly as
possible to re-establish the blood supply. The fist-sized organ is
sitting in a stainless-steel bowl. Who knows how long it will last?
The clock is running.
Murray has already clamped off the iliac artery in Richard's
pelvis at the very top of his right leg. Now he begins to sew. As Carrel
had discovered, joining together blood vessels is a slow and precise
procedure, but half an hour later the surgeon has successfully
connected the artery of Ronald's donor kidney to the artery in
Richard's leg.
Murray works methodically and precisely. Everyone is anxious.
Is he taking too long? He tries not to look up at the clock. It
is 10.40 a.m.
Now he needs to connect the vein from the kidney to the vein
in Richard's leg. It is slow work but he can't get distracted by the
clock. After thirty-five minutes the veins are joined.
Murray makes a final check to see if everything is OK. Ronald's
donated kidney has been out of his body – and without a blood
supply – for a total of one hour and twenty-two minutes. Will
it still work?
Everyone goes quiet; they can hardly breathe with the tension.
The surgeons gently loosen the clamps around the blood vessels.
The blood begins to flow. The transplanted kidney becomes
engorged. It turns pink, pulsing with blood.
There is a collective sigh of relief; Murray even allows himself a
smile. Within minutes, urine starts spurting from a catheter on to
the floor. They mop it up and connect the ureter to Richard's bladder.
The transplanted kidney is working perfectly.
The next day Richard is feeling better than he has for months.
His eyes are bright, he is alert and hungry. Richard and Ronald are
discharged from hospital in February. They are both fit and healthy.
X-rays confirm that Richard's new kidney is functioning well. As the
newspapers put it, this surgery was truly a 'medical miracle'.
Richard went on to marry his nurse and father two children
(not identical twins). He lived for another eight years, eventually
dying of a recurrence of kidney disease. The surgeons had proved
that with identical twins the immune system could be beaten. Over
the next few years they tried the procedure on several more sets of
twins with equal success.
The surgical techniques developed by the Boston team
continue to be used to this day in the tens of thousands of kidney
transplant operations that take place every year. But twins represented
only a tiny proportion of the people who needed kidney
transplants. Understandably, Murray wanted to treat all his patients.
He wanted to be able to offer a kidney transplant to anyone in need.
The only way to do this was to take on the immune system, and he
believed he had just the thing.
United States, 1957
Welcome to the atomic age, where nuclear energy makes everything
possible. Why not vacation in Las Vegas – the 'Atomic City' – to see
the awesome power of the atom for yourself? While you're there,
you could get yourself an atomic hairdo and head off to a 'Dawn
Bomb Party' in the desert to witness the latest nuclear test. You
could take an atomic box lunch before heading back to the city to
sip an atomic cocktail while watching the Miss Atomic Bomb
contest. You might even get to see the lucky winner posing in her
dazzling white mushroom cloud outfit.
Nuclear tests were the biggest thing that had ever happened to
tourism in Nevada, and the crowds flocked from all parts of the USA
to see the flash, feel the heat and witness the cloud. But it wasn't just
in the desert that the atomic age was capturing the imagination.
Right across America there was talk of nuclear-powered rockets and
cars. Every home would soon have its own nuclear reactor; housewives
would preserve and cook food with the wonders of atomic
rays. The US military was spending some $70 million a year on a
nuclear-powered aeroplane (although it still had to overcome a few
issues with safety). The dream of cheap, clean, nuclear energy was
being realized. Nuclear was the future and the future was now!