It was the first half of the twentieth century. Joseph Murray had just returned from the Second World War. He was a Plastic Surgeon. He was back in Boston and doing his job.
He overheard some of his colleagues in general and vascular surgery talking about organ transplantation. Was it possible to transfer organs from one person to another who needed them? A human had two kidneys, but only one is needed to live normally. Can one be taken from a normal man and transferred to a patient with kidney failure?
What set off this excitement was the fact that Alexis Carrel had found out that injured blood vessels could be joined by fine stitches placed all around. It was a tricky job, but Carrel had perfected it in animals before trying it out on humans. He had succeeded.
It was generally agreed, Joseph Murray noted, that it was impossible. The artery and vein could be connected, and the transplanted organ would live. But what about the microscopic tubes called lymphatics and the even tinier nerves that were impossible to join? That was just a technical point. What about the body’s immune system, that fought off foreign invaders like viruses and bacteria? It was very well known by his time, that any cell from another human being would be fought off and destroyed by the body’s defence mechanism.
Murray was intrigued. He turned to the animal lab. He conducted a series of experiments. He became expert at taking out and putting back an animal’s kidney. Once, he removed both of the kidneys from an animal and put it back by joining the artery and the vein. He could do nothing about the lymphatics or the nerves. He expected the animal to die.
But the animal survived and the kidney produced urine. Murray was the first to show that you can do it, technically. The nerves and lymph flow were simply not needed.
One day, a man was brought to him, suffering from kidney failure. He was close to death. Murray looked at the array of friends and relatives accompanying the man and was startled to see a mirror image of the patient standing among them, healthy and sound. An identical twin!
Identical twins have the same genetic material. One is just a copy of the other. The body can’t distinguish one from the other. The identification molecules on the surface of every cell are the same. So, no rejection. Even siblings have these slightly different.
Murray grabbed this lucky accident. That was how the first organ transplant was done.
Murray later became active in finding out the drugs that could suppress immunity sufficiently to make organ transplant widely used. Everyone didn’t have an identical twin. There was a lot of resistance from colleagues, as there were many deaths. But all of them would have died anyway. Murray fought on.
Due to his efforts, organ transplantation became a reality. He got a Nobel prize for his efforts, as did Alexis Carrel before him.
Half a century and two decades later, a young man fought for the dignity of a woman with whom he was travelling in a train during one night in Kerala, India.
Manoj (left in the photograph) fought with a group of goondas who tried to manhandle a girl in his compartment. The rowdies responded, and pushed him out of the train, which was travelling at full speed. He didn’t die. But both his hands were crushed beneath the wheels. They had to be taken off below the elbow joint.
He was a hero. And like many heroes in our society, he paid the price.
It was six in the evening and my day was over. I was one of the Plastic Micro Surgeons in the Institute at Kochi. As I passed the surgical ICU, there was a commotion in front of it. Many were crowded around a middle aged lady.
“My son. No! Not my son.” The agonised wail pierced the hearts of the listeners.
‘Another tragedy’ – I thought with a mounting heaviness. Someone told me that the lady’s young son, an accident victim, had been declared ‘Brain-dead’. Brain-dead meant dead. The recently amended laws had made explicit rules for someone to be declared Brain-dead. It had to be confirmed by many experts. A panel of tests had to be done to make sure that no part of the brain was working. These patients are usually on ventilators that take care of their breathing. The heart doesn’t need the brain to keep beating.
Once a patient had been declared Brain-dead, he or she became a body. The person could be taken off the ventilator and all medicines that may have been keeping the heart alive could be switched off. The natural process of death can be allowed to continue, unto cremation or burial.
Or the ventilator and life support systems could be kept on temporarily. To keep the heart alive. He is now hope. Hope for a host of terminally ill patients who were waiting for kidneys, livers or hearts and rarely, some other organs.
I could picture Prasad, our transplant co-ordinator going in with one of the transplant surgeons to talk to the dead patient’s relatives, to get consent for organ donation. It must be one of the world’s most difficult jobs.
“Your son is dead. Many human beings are dying. They want your son’s liver, kidney, heart. Shall we take them?”
How on earth do you say that to a grieving mother? Time is ticking. The Brain-dead patient’s heart that keeps beating beyond its call of duty is on edge. It can give up at any moment. Then the organs can become useless.
You cannot use incentives. Money should not be offered. The organs are priceless. No price can be put to them. You cannot use emotional blackmail of any sort. The images of waiting patients can’t be used. Desperate people on the waiting list cannot plead with the sad next of kin.
The consent has to be given as just a sweet, voluntary act of will. It is one of the ultimate sacrifices one can make. And it can be made only by proxy. The closest and dearest have to speak for the still beating heart that will never be part of any decision again.
The liver transplant surgeons may have a busy night today. The urologists might spend the night transplanting the kidney to a recipient in the waiting list. The waiting patients were part of a state wide registry and the cadaver organs, whenever they became available, were allotted by a system of turns that was closely monitored.
That pioneer of human transplantation, Joseph Murray, was originally a Plastic Reconstructive Surgeon. But now we were far away from this area of surgery. The liver surgeons and the kidney surgeons were the ones usually involved. Rarer were the heart transplants, when the great cardiac surgeons jumped into the fray.
We Reconstructive Micro-surgeons were adept at joining arteries and veins, especially the tiny ones. Stitching together veins and arteries of diameter one millimetre or less under the microscope was the primary skill of a Reconstructive Micro surgeon. It was useful in re-attaching severed limbs, fingers etc and also in small vessel, nerve and tendon repairs. It was also used in free tissue transfer where skin, bone or muscle were to be taken from one part of the body and attached to an area where it has been lost, as by accidents or by cancer surgery.
In some centres, the micro surgeons were called to join the tiny hepatic artery as part of a liver transplant, especially in children. That was as far as our involvement with transplantation went, usually.
But there was a very slight possibility that I could be called. The Plastic Surgery chief, Dr.Subramania Iyer was a man with vision. For the past few years, he had moved systematically to make this centre a place where we could do….hand transplantation. Ours was the ideal hospital-world class facilities combined with cutting edge microsurgery expertise. The special government approval needed was already there.
But two or three brain-dead patient’s relatives had turned down the request. Take everything else, they had said. Not the hands. We had become resigned to the fact that we may never do the hand transplant. The hands were too external, too personal. It was like mutilating a dead person’s body. No one may give the hands, ever. All the parts of the body will rot or burn. And return to the elements. But facts always get buried in the cascade of emotions following a near one’s death.
For the past two years we were working on it. Giving lectures, making posters. We had journalists to write pieces on their newspapers about the unfortunate ones waiting for transplant. We had prepared a waiting list of patients. All the paperwork was done.
“Come, we may have to do the hand transplant today.” I got the call at eight in the evening. That was from Dr. Subramania Iyer, directing the whole thing from ground zero, as a true leader would. The day has come! I felt totally alive. Excitement got damped by humility as I silently thanked the relatives of the dead man.
Five of us micro surgeons were at the anteroom of the operation theatre at nine. We had a preparatory meeting and went through each and every step of the procedure. Mohit, Kishore and me had worked out and listed all the technical details almost three months back.
The surgery that we were about to undertake was an arduous procedure. The patient, Manoj, the hero that I mentioned before was the recipient. He was already in the hospital, having been summoned from his house two hours back. Both the hands were to be taken and given to Manoj. We felt that life-long immune suppression could be justified if both hands were restored to a patient who was helpless with no hands at all.
The two bones of the forearm had to be joined first by plate and screws. Then there were a mind boggling variety of fine structures that had to be joined to together. Two arteries and at least three to four veins had to be joined by circumferential sutures that were many times smaller than a human hair, under the microscope. This was what would infuse life into the attached hand. But the hands were useless without sensation. The fine muscles inside the hands will work and the sense of touch will come only when the nerves are joined and the nerve fibres grow over a period of months. Many nerves had to be tackled. The Ulnar nerve, the Median nerve and the various nerves to the skin. Then there were over twenty muscles that had to be dissected, tagged, identified and carefully joined. All this were for one hand, and we had to attach two.
It was a big deal. Only about a hundred hand transplants were ever done, all over the world. If we succeeded, this would be India’s first.
It was big for Manoj. I had seen the young man in the waiting room with stumps in the place of hands hanging by his waist. Hope gleamed in his eyes. His life was now riddled with distasteful dependence on others. Lifelong immune suppression was no joke. Patients on kidney or liver failure had no choice. They would die if they didn’t get an organ to be transplanted. Patients considered for hand transplant were, like Manoj, young men in the prime of their life. The ethics of the procedure were still being debated all over the world. But now it was generally agreed that, with full voluntary informed consent by the patient after a counselling outlining all the risks, the procedure was worth doing. Immune suppression drugs and related science is progressing rapidly every day. There is always the hope that after a few years, advances in this would bring down complications even further. Manoj had taken the plunge. He wanted hands. He wanted to work and make a living with dignity. He knew all the risks.
We had been through the drill six months ago, as a dress rehearsal. We were broken up into four teams. All our duties were assigned with precision.
The brain-dead patient was wheeled into the theatre at two in the morning. His name was Biju, I learned. Two teams, apart from ours, were ready and waiting. A liver team from another hospital had come to take the liver and one kidney. The urology team from our own hospital was to take the other kidney.
We were to go in first. I and Sundeep had to harvest Biju’s right hand and Subramania Iyer went to the left one. The main artery to the hand and forearm was exposed at the elbow joint and a special solution was infused by a tube into the artery. One main vein was cut open and the blood was allowed to flow out till the clear solution started coming out through the vein. The idea was to replace all the blood in the limb with the solution. After that we removed the hand at the elbow joint level after cutting all the structures and tying the blood vessels. A prosthetic hand was fitted on the body. The artificial hands should be there when the body was given back to the family.
We took the hands to the other room. They were placed on a slush of ice covered by a polythene sheet. This was to minimize the damage to the tissues that would ensue due to lack of blood supply. The forearms were opened and each artery, vein, nerve and tendon was tagged by stitching each with blue rubber sheets on which the name of the same was written. The final prepared forearm looked like an abstract pattern festooned with blue rectangles. The ice almost froze our hands.
While we were working on the donated hands, Manoj was already under anaesthesia in the next room. Doctors Kishore and Mohit were working on both the stumps of his amputated hands. They had opened his forearms and repeated the process of identifying and marking each structure- the cut ends in the stumps.
The bone ends were cut to the appropriate lengths and were connected by plates and screws. Our orthopaedic colleagues came down to help us with that.
We took turns joining the minute arteries and veins. I did one artery and two veins on one side. We released the clamps and allowed the blood flow to occur. Blood started flowing from Manoj’s hand to the attached hand.
Then the extensive task of joining the myriad tendons, muscles and nerves commenced. I again relieved Kishore to join one more artery and vein on the other side. We should have heaved a sigh of relief after clamp release but we didn’t.
There was no pink-up.
Pink-up was the term given to the immediate return of pink colour to the skin of an attached body part after the clamps were released and blood flow was returned to it. We see it almost immediately when we do a re-attachment of a severed digit etc or in a free tissue transfer when we take a body part from one site of the body to another by microsurgery. Here, the attached hands remained white. The arteries and veins were working satisfactorily.
“That is alright. Let us continue. It may take some time.” Subramania Iyer told us.
It was like a marathon run. We were used to long surgeries. But the sheer enormity of what we were doing wore us out. Overwhelming responsibility rested on our shoulders. The entire surgical community of the country and even abroad were watching over us with a critical eye. The surgery was almost over. It was about sixteen hours since we started.
Still, no pink-up.
Has something gone horribly wrong? But what? Is the patient too cold? Did he lose too much blood? Jerry, our anaesthesiologist, was checking and optimising everything.
Would our transplant turn out to be a dismal failure? Will Manoj get an even shorter stump? Would we be criticised for doing something that no one in the country had ever tried before? That was the thing about being a pioneer. If you fail, you fall flat. If you succeed, that is good. Only success condones risk. That is true of any medical procedure in general. Yet, failures are inevitable. If one becomes disheartened by them, then you might end up doing nothing.
But here, we may not get a second chance. If it is a primary failure, with the hands not working at all, even for a short time, it means our very technical capability may be questioned.
I prayed. At some points, one can do only that. I didn’t have much to eat for a full day. The cold theatre air was piercing me through the thick surgical gown. I shivered.
A young male nursing student stood watching the surgery. Males were getting rarer in nursing. I looked at his hands, smooth and brown. Serving hands. Hands that feed, clothe and minister patients. Hands that wipe the stools and spit off someone too infirm to do it himself. Or help someone who didn’t have hands.
In fact, his hands looked like the dead person’s hands. Suddenly I had a vision, a sort of day dream. It was the vivid image of a young man taking care of a very ill old one. The young man was wiping him with tenderness and love. He was putting a spoonful of food into his mouth. He was talking to him while looking into his eyes.
I felt a presence looking over my shoulder. I turned and looked, but there was no one.
“The dead boy’s soul must be watching us.” Dr. Kishore said to nobody in particular.
“It is pinking up” Mohit cried.
It was true. The hands were turning slowly from deathly pale to a faint pink. Soon it turned bright and rosy. Everyone cheered.
Not only the dead man’s soul, but the legacies of Joseph Murray and Alexis Carrel were there. Then the inventors of immunosuppressive drugs like cyclosporine and others. Louis Pasteur , Joseph Lister and the great Susruta were there. Thousands of patient men of science and their patrons who had built up the massive edifice of human intellectual endeavour and used it to help their fellow men.
Our patron and the people who built up and managed this excellent medical facility were there, in spirit. Without the canvas how will one paint a picture?
The surgery was a success. Years of follow-up, careful immune suppression and a score of hurdles probably lay in the future. But we had succeeded in this small initial step.
A few days later I learned that Biju, the young man who had died and donated the hands, had a paralyzed father who was still alive. Biju was taking care of most of his needs for the past fourteen years.
A handsome gift, from one hero to another.