First they joined together the two bones of the forearm to hold the limb stable. Then they connected the blood supply – the arteries and veins – to keep the tissue alive. Once the blood was flowing, they stitched together the muscles and tendons and reconnected the nerves. Finally, the surgeons were able to join together the skin.
At the inevitable press conference held shortly after the operation, Owen described himself as 'very happy'. It was a moment of surgical glory. 'We all have big smiles,' he said, and gave the operation a fifty-fifty chance of long-term success. Others were equally enthusiastic. Eminent British transplant surgeon Nadey Hakim called it an 'incredibly exciting breakthrough,' adding, 'to see a man restored with an arm is tremendously satisfying'.
The new arm had to be kept immobile for a few weeks while the graft healed, but everyone was optimistic that the patient would develop the full use of his limb. Hallam himself was overjoyed. It was incredible to see fingertips at the end of his arm again. With a new hand, he had been given a new life. It was a surgical miracle.
Hallam had spent years waiting for the operation. He lost his original hand in an accident with a circular saw in 1984 while he was serving time at a prison in New Zealand.* His severed hand had been sewn back on, and although it looked OK, it had little function and was all but useless. A few years later Hallam decided to get rid of the hand altogether and opted instead for a prosthetic limb. This hadn't worked out either, and he told the BBC that he had never been able to accept having a lump of plastic attached to his arm. It was not natural. Perhaps one day the technology would be available for a hand transplant.
* The circumstances of the injury remain somewhat vague. The surgeons who carried out the 1998 transplant operation were unaware that Hallam had sustained the injury in prison. Hallam's somewhat chequered past was revealed by the media following the operation. This did little to endear Hallam to the surgical team. Owen said later that although they had conducted psychiatric tests, they should have looked more closely into Hallam's background.
However, a few months after the 1998 operation Hallam was struggling to overcome his disappointment. It wasn't just the obvious mismatch between his new arm and the old one, so much as the practicalities. The new arm did not work very well. There was only limited movement: Hallam could move the limb and bend his new fingers to a limited extent, but he said he was almost more crippled with the hand than he had been with a stump.
There was a marked contrast between Hallam's experiences and the surgeon's rhetoric. They were claiming the operation as a great success and told the media how Hallam could grab things, pick up a glass and even write with a pen. They were also pleased that he could feel pain and temperature on both sides of the new grafted hand. But they weren't the ones who had to deal with the side effects.
To avoid the transplanted limb being rejected by his body's immune system, Hallam had to take a cocktail of different drugs. There could be eleven tablets to swallow in the morning, four at lunchtime and eleven more in the evening. The exact amount varied from week to week, but Hallam was usually being prescribed some combination of steroids, anti-rejection tablets and immuno-suppressants – drugs that, as the name suggests, suppressed his immune system. He was also taking pills to help his fingernails recover. Every day he had to count out the various tablets to make sure he didn't take too many or too few. The pills were keeping his arm alive, but they were also having other effects. Hallam had started to develop diabetes and needed to take insulin to control his blood sugar. Physically, he was also changing. Hallam was used to keeping fit and had been in reasonably good shape. Now he found he was growing breasts. Worse, the powerful drugs increased his risk of developing cancer.
And it was not just the physical limitations that were taking their toll. Hallam was beginning to realize that there was a psychological price to pay for having a dead man's hand attached to his body. Aside from the mental anguish for any man of growing breasts, the transplant increasingly looked and felt like it did not belong. Other people would comment, saying how white the transplant looked, or how the new hand was smaller than the other one. Hallam realized how angry he was with the doctors for not waiting for a hand that was better matched. It was as if, he said, they were more interested in the transplant than the person. He had dreamt for years of having a new hand, but the reality was proving increasingly uncomfortable. What happened next became inevitable.
By 2001, Hallam had begun to take fewer and fewer of his prescribed drugs. Every time he got sick his immune system struggled to cope, so he decided the answer was to cut down on the immuno-suppressants, but the effect on his hand was hideous. Attacked by his own body's immune system, the limb had all but died; the flesh was rotting away on the end of Hallam's arm. He had lost all feeling; it was a wonder the infection hadn't spread to other parts of his body. Hallam told the BBC he felt 'mentally detached' from the hand. He had had enough and begged the doctors to remove it.
In February 2001 Clint Hallam's hand was amputated by Nadey Hakim, one of the surgeons who had helped attach it in the first place. The procedure, at a private London clinic, took ninety minutes. Hallam was relieved to see it gone. Some of the surgeons who had enjoyed such acclaim only a few years before were angry that their work had been in vain; that their patient had not persisted with his medication.
In retrospect, Clint Hallam was probably the wrong person to receive the world's first hand transplant. If he had done exactly what he was told – had taken his medication, had followed doctor's orders – he might still be walking around with a dead man's hand. Even so, he would have had to cope with the physical symptoms, the strict drug regime and probably a shorter lifespan as a result of diabetes or perhaps cancer. Eight years after his transplant, Hallam was once again fitted with an artificial limb. He claims he has no regrets about having the transplant; his only regret is being the first.
The case of Clint Hallam illustrates the barriers that have to be overcome for successful transplantation – whether it is the transplantation of a hand, finger, kidney or heart. The first barrier is simply one of technique. It has taken more than a century to develop the surgery of transplantation. Stitching together blood vessels is difficult enough, let alone trying to join muscles, tendons and nerves. But the operation itself is only the start. Next there is the enormous problem of rejection. The body's immune system will fight any alien tissue. Even with the latest drugs, rejection is still a major hurdle for transplant surgeons.
The final problem is more subtle, and is downplayed or ignored by surgeons at their peril. Any transplantation involves overcoming a psychological barrier. What is the effect of having a dead man's hand transplanted on to your arm? It certainly bothered that woman on the plane. Did Hallam ever think about the motorcyclist who had died? Before the transplant that hand had been gripping a motorcycle handle – an essential part of a whole different human being. What about the psychological effects of a kidney or heart transplant or even a face?
The surgeons who had operated on Clint Hallam had overcome the technical problems. Until he stopped taking them, the drugs had countered his body's physical rejection. But the surgeons had failed to overcome the final barrier. Consciously or not, it was Hallam himself who had rejected the hand.
THE DEADLY DENTIST
James Spence (and Sons), Soho, London, 1765
* * *
James Spence was always very discreet. No one, he assured the young lady, need ever know that she had visited him. Of course, nowadays he rarely conducted these procedures himself. He left most of the day-to-day work to his sons. However, for this fine lady he would make an exception. She was fearful of going to see anyone else (there were so many charlatans about these days). Spence had already established the finest reputation in London for pulling teeth, and was proud to call himself a dentist, even though 'dentistry' was only just starting to establish itself as a respectable profession. There was no one better to go to for a tooth transplant.
Spence preferred t
o use living donors for his tooth transplants. They were easy to come by and it avoided the repulsion many people felt at the idea of eating food with teeth from the dead. Mind you, teeth taken from cadavers were a lot cheaper, and many dentists did a roaring trade in teeth extracted from the mouths of soldiers killed on the battlefield.
Nevertheless, today Spence needed teeth from the mouths of young women. Earlier that morning he had dispatched a servant to locate suitable donors in the neighbourhood – women who would be willing to give up their front teeth. They would be handsomely rewarded (well, it would be handsome to them; the expense would make only a small dent in Spence's substantial profit margin). By mid-morning, several young women were queueing in the alley behind Spence's offices. He planned to take a few teeth, maybe a couple from each woman, to see which ones produced the best fit.
His patient arrived accompanied by a friend for support. Spence ushered the women into his consulting room. The patient sat down on one of the plush, high-backed leather chairs. At first glance she was something of a beauty and would, he thought, have no shortage of suitors. But when he took a look at her mouth he realized it was little wonder she had come to him for help. Her teeth were in a terrible state. Her mouth stank of decay, with black rotten stumps emerging from raw, inflamed gums. She was worried about the pain she was going to experience. Spence reassured her that she would hardly feel anything; he stopped himself from telling her that most of the pain would be experienced by the donors.
Rotten teeth were the price the wealthy of Georgian England paid for their lifestyle. These days everything seemed to have sugar in it – from tea at breakfast to the sweets many sucked before bedtime. All this sugar was ruining the nation's smiles. If this lady ever hoped to find a husband, something would have to be done. She could have had some false teeth made – carved for her from ivory – but these rarely fitted well. No, thought Spence, in coming to him she had made the best decision.
Across Europe tooth transplants had been carried out for many years. The surgical textbooks gave detailed accounts of how to carry out transplantation operations, with some suggesting the use of animal teeth. Ambroise Paré (see Chapter 1) was one of the many eminent surgeons who wrote about the procedure, describing the case of a noblewoman who received a tooth transplant from one of her ladies-in-waiting. By 1780, transplanting teeth from poor donors to wealthy recipients had become commonplace. There were a few voices claiming that it was morally dubious, and others who came to realize that the transplants were rarely successful, but Spence backed neither of these views.
Spence went to examine the women queuing by the back door. Some of them he dismissed straight away, including one whose face was covered in sores and another who looked like she was in need of a tooth transplant herself (not that she would ever be able to afford it). The remaining three he ushered inside so that he could take a closer look. They all appeared to be in reasonable health – no telltale signs of venereal disease or TB. Spence remained unconvinced that disease could be passed on from the donors to recipients. Still, best to be on the safe side. He explained to the three women what was going to happen and how much they would be paid for their contribution. His servant went to fetch the pliers.
Spence seated his first donor down on a couch in a back room and asked her again if she was willing to go through with the extraction. She nervously agreed. Spence took the pliers and gripped an upper left canine. With his knee placed against the couch for leverage, he pulled sharply on the tooth, twisting it until it came away. The woman screamed as blood poured from her mouth and dribbled down her chin. The servant passed her a handkerchief to plug the wound and Spence headed next door to perform the transplant.
He instructed his patient to open her mouth and try not to make a sound. She grasped her friend's hand as Spence held her jaw steady. With the pliers he extracted one of her rotten teeth and with his lancet made a slit in her gums. He gave the new tooth a quick wipe with a cloth to remove the blood and jammed it into the cavity. The patient was sobbing with the pain but did her best to keep her mouth open. Her friend reassured her that she was being brave. Spence finished off by looping a thread around the new tooth and tying it to the adjacent teeth. The first transplantation completed, Spence went back to his donors for more teeth.
After an hour or so, the donors left with a few shillings and fewer teeth, and the patient nursed a swollen jaw. Nevertheless, she was very pleased with the outcome – a glance in the mirror was all she needed to be convinced that all the pain had been worthwhile. Spence assured his patient that the swelling would soon subside and congratulated himself on another successful operation.
Within a few days the swelling had indeed subsided, although the new teeth felt a little loose. After a fortnight she started to experience sores around her mouth and a rash developed across her body. A physician was sent for, but when a large abscess began to eat away at her nose it was obvious to everyone that she was suffering from syphilis. It could only have come from the teeth; the disease must have been passed on from the donor's blood. Within a few months the whole side of her once beautiful face was horribly disfigured. It wasn't long before the poor young woman was dead. All because she had wanted some nice white teeth.
Spence is said to have infected at least seven of his wealthy patients with syphilis. But it wasn't incidents like this that finally put a stop to tooth transplantation, or the fact that almost all tooth transplants failed through rejection. What brought the practice to an end was the invention of an alternative: ceramic false teeth. However, the idea that living matter could be taken from one person to be transplanted in another was an idea that was far too good to dismiss for long.
Although Spence's forays into transplantation often ended in disaster, his reputation as a dentist attracted the attention of a young surgeon, John Hunter, a man obsessed with understanding what made something alive – the 'living principal'. It is difficult to know how best to describe Hunter. Pioneering surgeon, teacher, naturalist, philosopher – he was to become all these things. His observations and 'scientific' experiments shed new light on biological processes. He advanced the understanding of the human body, both its anatomy and physiology, and devised daring new medical and surgical techniques. His collaboration with Spence not only yielded the first accurate scientific study into teeth, it also gave Hunter far more ambitious ideas.
After witnessing tooth transplants, Hunter started dabbling with other transplantation experiments. He cut the spur from the foot of a cockerel and grafted it on to its head; he took a human tooth and transplanted it on to a cockerel's comb; he even transplanted the testes from a cockerel and attached them to a hen. In a few cases his transplantation operations appeared to be completely successful, but most of them failed. It is thought that the transplants between animals succeeded only because, through inbreeding, the chickens were genetically very similar.
Hunter showed that transplantation was possible – albeit a little hit or miss – and made the first tentative steps towards understanding it. Future generations of dentists, surgeons and scientists, including Charles Darwin and Joseph Lister, would owe Hunter an immense debt of gratitude. People would visit the museum he founded and marvel at his scientific discoveries. But while Hunter would be commemorated as a great pioneer, other surgeons who pushed the limits of science would not be so lucky.
A CAREER THAT STARTS WITH MURDER
Lyon, 25 June 1894
* * *
French president Sadi Carnot had rarely received such a rapturous welcome – not only from the mayor and city officials of Lyon (which was only to be expected), but from the exuberant crowds that filled the streets everywhere he went. During the last few days, horses draped with the flag of the republic had led his carriage to banquets held in his honour, and from a balcony he had watched a torchlight procession and a display of fireworks and illuminations. He had marvelled at the wonderful exhibits on view at the Exhibition of Arts, Sciences and Industries. Finally, after all the exci
tement, he was looking forward to an evening at the theatre, where a gala performance had been arranged.
The president left the Lyon Chamber of Commerce, where he was guest of honour at yet another banquet, a few minutes after nine o'clock. Thousands of spectators cheered as he crossed the short distance to his open carriage waiting outside. Everyone was trying to get close, pressing to catch a glimpse of the French leader. The president didn't mind – it was wonderful to be greeted in such a way.
As he settled into his seat and the carriage started to move off, a young man in a light brown suit and peaked cap was pressing his way through the crowd. He was clutching a newspaper in his hand, but no one took much notice of him; he was just another person jostling for the best view. Suddenly, the man jumped on to the carriage step and flung aside the newspaper to reveal a dagger. The president barely had time to react before the knife was plunged into the left side of his chest and he slumped back against the seat.
President Sadi Carnot was still alive, but unconscious. The assassin had hardly withdrawn the dagger before he was seized by the crowd, their cheers having turned within seconds to screams of horror. The man was punched to the ground amid cries that he should be killed there and then. As the police did their best to protect him from the fury of what had now become an angry mob, the carriage containing the dying president was rushing towards the hospital.
As the assassin was bundled off to the police station, protected by police and mounted guards, the president was laid on a bed. His condition was worsening. A crimson stain on his shirt was spreading as blood seeped from the wound and dripped on to the sheets. Lyon's finest surgeon was summoned. At the police station the assassin gave his name as Cesare Giovanni Santo, a twenty-two-year-old Italian anarchist with a poor grasp of French and, as one reporter put it, 'a very small moustache'.
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