A few years ago in Weyburn I had a role in a play called “Duet for Two Hands.” It was a grim little gothic tale of a drunken Scottish surgeon (that would be me) who had sewed the hands of a convicted murderer onto the wrists of a concert pianist who had lost his own in an accident. In the course of the play, the spirit of the murderer seemed to take over the personality of the pianist.
Duet for Two Hands was written in the 1940s, when the idea of such transplants belonged strictly in the realm of science fiction. But over the past couple of decades we’ve become used to the idea of transplanting parts from one human being to another, and last week in France the fantasy of Duet for Two Hands became reality when a team of European and Australian surgeons performed the world’s first arm-and-hand transplant operation, grafting the arm and hand of an anonymous brain-dead donor onto the stubbed limb of Clint Hallam, a 48-year-old Australian businessman who lost his right arm and hand in an accident with a circular saw in 1984.
It’s too soon to say whether this particular operation will be a success, but the mere fact it was carried out at all is amazing, considering how relatively new the whole field of transplantation is.
Organ transplantation research begin in the mid-1950s in Boston, where doctors showed that dogs could survive perfectly well with one kidney transplanted from its usual location to another part of the body. This proved that surgeons could carry out the necessary delicate work, but it didn’t really answer the big problem of transplantation of a piece of one person’s body into another person, which is rejection: the body receiving the transplant recognizes that the transplanted piece is foreign, and as a result the immune system attacks it. The lymph system produces antibodies that are specifically designed to attach the foreign organ, and white blood cells infiltrate it and damage its blood vessels and tissue. At the time of the Boston experiments, doctors thought that organ transplants would be limited to identical twins.
Once surgeons knew they could carry out the necessary technical procedures to move an organ from one place to another and keep it alive, as in the Boston dogs, however, they began concentrating on the problem of rejection. They learned, for example, that there are “tissue types,” similar to blood types, and that people with similar tissue types were more likely to be able to exchange organs. Since tissue type is genetically determined, however, this means that the closely related someone is to you, the more likely that person would be able to successfully donate an organ that your body wouldn’t reject.
The other branch of this research focused on finding drugs that could counteract rejection. Doctors discovered that a combination of drugs called corticosteroids with an antileukemia drug called azathiprine could suppress the immune system, and give a transplanted organ a chance to settle in and avoid rejection. With these drugs in hand, doctors began trying more and different types of transplants in the 1960s. Probably the most famous was the first heart transplant, carried out by South African surgeon Dr. Christiaan Barnard in 1967; what fewer people are aware of (I know I wasn’t until I started researching this) was that an attempt was made to transplant a hand as far back as 1964, in Ecuador. The hand was rejected within two weeks.
Transplants of all sorts became more practical in the 1980s with the approval of a new anti-rejection drug called cyclosporine, which block the activity of T cells, one of the kinds of cells that attacks transplanted organs. (The drug, by the way, was first found occurring naturally in a Norwegian fungus.) Today, kidney, heart, pancreas, heart-lung, single-lung, skin and bone-marrow and liver transplants are regularly attempted. Thanks to cyclosporine, they’re successful much more often than they were in the past.
Cyclosporine’s anti-rejection capability led to the first experiments in whole-limb transplants. A few years ago, all four legs were transplanted from one rat to another and were not rejected.
For the last four years, doctors at the Jewish Hospital at the University of Lousville, Kentucky, have been discussing in public the best ways to achieve whole-limb transplants in humans, and in August they announce their plans to perform the world’s first hand-transplant operation, once they found a suitable volunteer recipient.
The European-Australian team beat them to the punch, however; they’d been quietly working on the same project for a year and a half. They chose to carry out the transplant operation in France, because under French law, all of its citizens are potential donors. (The biggest problem for organ-transplant surgeons is that the number of people waiting for organ transplants always greatly exceeds the number of donors.)
Early last Wednesday, a man involved in an accident somewhere in France was declared brain-dead. His doctors noted that his skin colour, the size of his limbs, the distribution of his hair follicles and the composition of his tissue matched what was needed for Clint Hallam. By lunch that day, the surgical team had amputated the donor’s right hand, his wrist, and 10 centimetres of his forearm. Using the same kind of powerful microscope and microscopic surgical tools surgeons have been using for years to reattach people’s own limbs after they were severed in an accident, they set the two bones in the arm, then connected half a dozen blood vessels and nerves and nearly two dozen tendons, which control movement of the wrist, fingers and thumb. Muscle also had to be combined and several layers of skin stitched together. In all, the operation took 13 1/2 hours.
As of the next day, said Dr. Jean-Michel Dubernard, who led the surgical team, Hallam was in excellent shape, and the grafted hand was warm and had taken on color. But Hallam’s not out of the woods yet. The doctors figure there’s only a 50-50 chance the hand won’t be rejected; the next month will be critical. If the hand does survive, it will be a year to a year and a half before Hallam gains any sensation or control. They expect him to be able to grasp with it, but they’r not sure about fine movements of the fingers.
Whatever happens, like the first heart transplants, the operation has opened up a whole new realm of possibilities for researchers. It seems likely that such transplants will grow more and more common, now that researchers have shown it can be done. That raises ethical flags for some doctors, who point out that current anti-rejection drugs can have serious side-effects, ranging from kidney damage to serious infections to cancer. While a heart transplant is a matter of life and death, and thus makes those risks worthwhile, can the same be true of a transplant of an arm or leg that the recipient has been managing without, in this case, for 14 years? Will this eventually lead to cosmetic transplants, where people get new noses or ears, or prettier feet, or a smoother complexion, grafted on simply for vanity’s sake?
The image the doubters conjure up is of Frankenstein, stitched together from the parts of many dead individuals; but for the doctors who carried out the operation, there’s no doubt as to its worth.
“This gives hope to millions of victims of workplace and domestic accidents, survivors of war or land mines and individuals born with hereditary deformities,” said Dr. Dubenard. And Hallam told his doctors he was “over the moon.”
One thing’s for certain: medical history was made in France last week, and a brave new world of possibilities has just opened up. We can only hope it’s not also a Pandora’s box.