Anatomies: A Cultural History of the Human Body (19 page)

In the end, neither the shape nor the number of kidneys matters as much as their function. One in 400 of us in fact possesses a single kidney formed by the fusion across a central isthmus of two normally placed kidneys. Such ‘horseshoe’ kidneys often work perfectly well without producing any symptoms or evidence of their presence. It is typical of the kind of abnormality that can pass utterly without notice because it is internal, and yet which if found on the surface of the body can so easily cause people to recoil.

Its redundancy has made the kidney the trailblazing organ in human tissue transplantation. The kidney that remains in the body of a living donor soon grows by some 80 per cent, practically restoring full renal function. Surgeons at Harvard Medical School carried out the world’s first successful kidney transplant operation in 1954, using identical twins as donor and recipient in order to reduce the risk that the organ would be rejected. The recipient lived for another eight years; the donor only died in 2010, at the age of seventy-nine. In the United Kingdom, 2,732 people received a new kidney in the year to 2011, with just over 1,000 of these being transplants from living donors, but there are nearly 7,000 people on the waiting list. In the United States, around 15,000 operations are performed annually, but the waiting list is approaching 100,000 and rising fast. It is estimated that by 2015 this number of patients
each year
will be experiencing renal failure, for whom a kidney transplant may be their only hope.

Broadening the range of donors is fraught with both medical and ethical difficulties. For example, potential donors unrelated to the prospective recipient have been assessed in the past, but found to be borderline ‘psychopathological’. ‘Emotionally related donors’ are thought to be more reliable. Another controversial proposal is to grant clemency to death-row prisoners in exchange for a kidney. This almost Swiftian idea seems tempting when one remembers that there are more than 3,000 inmates facing the death sentence in the United States. However, since this number has remained virtually static since 1996, it seems more of a political gesture than a practical solution.

The idea of transplantation follows readily enough if we believe that parts are discrete and separable from the body that contains them. Greek surgeons carried out experiments transplanting human bones as early as 400
BCE
. Reasons for failure were medical – there was no understanding of rejection and the immune system. But there were also powerful moral reasons for hesitation – such as the forcible means by which the body parts were then obtained, and the obvious infringement of the first injunction of the Hippocratic oath to do no harm.

The success of the first kidney transplants in the mid twentieth century was quickly eclipsed by the more glamorous and symbolic transplant of the heart. Being unique, a heart could not be provided by a perfectly matched donor, such as a twin, as with a kidney. Instead, much greater pre- and post-operational care was required in order to ensure a functional result, as well as great skill from the surgeon. Christiaan Barnard, the Cape Town surgeon who became a household name when he performed the first successful operations, practised first on dog hearts, performing more than fifty transplants. (He also grafted a second head on to a dog, simply, it seems, because he could.) Barnard’s first human heart recipient survived for eighteen days; the second for eighteen months. After these early successes, however, the image of heart transplantation suffered setbacks when others began to perform the operation with much lower rates of survival, and when some of Barnard’s own patients quite coincidentally began to exhibit psychotic behaviour after recovering from surgery.

Today, though, transplants are a standard if extreme option in the surgeon’s repertoire. Transplantation is broadly accepted not least for pragmatic reasons because of soaring demand for replacement organs. But it remains, in the words of Columbia University anthropologist Lesley Sharp, ‘simultaneously wondrous and strange’. It is a medical procedure, to be sure, but no amount of mechanistic jargon – the heart characterized as just a pump, the liver and kidneys mere filters – can disguise the fact that it is also a personal act, a gesture from one person to another that seems as if it ought at least to obey the usual social rules of giving. As Sharp explains: ‘donated cadaveric organs simultaneously emerge as interchangeable parts, as precious gifts, and as harboring the transmigrated souls of the dead.’

Surgeons and neurologists refute the notion that aspects of personality can be transferred from person to person during transplant operations. But nothing can prevent recipients from imagining things about the donor of their new organ, especially when that organ is the heart. Patients who express the sense that another person dwells within them – only a very few, medical agencies insist – are labelled as victims of ‘Frankenstein syndrome’. Fay Bound Alberti gives the example of Claire Sylvia, a heart recipient, who had been a healthy-eating dancer before her operation and inexplicably became a lover of chicken nuggets afterwards. More natural is the guilt that a recipient may feel at having received a replacement organ and given nothing in exchange. Michelle Kline, for one, felt so guilty about receiving her brother’s kidney that she was unable to talk to him at all until she had shown herself worthy by becoming Miss Pennsylvania and a finalist in the Miss America beauty pageant. When her brother saw her crowned, he remarked: ‘We looked good up there on stage.’

For their part, a deceased donor’s kin may feel that the donor’s identity lives on in the ‘new’ body. Donor anonymity rules mean that direct connection is not usually made between the donor’s kin and the recipient, but occasional breaches have occurred. Ralph Needham received a double lung transplant from a donor who had died following a severe head trauma. He commented of the donor’s wife: ‘Her husband gave me two good lungs. She thinks that her husband lives on in me, but I feel uncomfortable about that – I feel they are
my
lungs now.’

The social understanding of an organ as a gift sits uncomfortably with the way that modern medicine actually operates. Though organs are usually transacted within state-run health authorities or non-profit organizations, it’s not long before the language of money makes its appearance. Putting a price on human organs is frowned upon to say the least, and trade in them is widely banned, and yet we store them in banks, for example. In fact, a single cadaver can yield 150 usable parts, ‘worth’ more than $230,000 in all. Though organ donation depends on selfless givers who gain no monetary reward, transplantation is said to be ‘among the most profitable medical specialties’ in America.

I raise some of these ethical puzzles with James Neuberger, the associate medical director of the UK National Health Service Blood and Transplant authority and a liver transplant surgeon himself. He begins by noting the sharp disparity in attitudes from country to country. ‘Where death is more freely discussed and accepted, donation is more accepted, for example in Catholic countries. But in Southeast Asia donation after death is very rare. Whether it’s religion or culture, I’m not sure.’

On some aspects of donor psychology, he takes the medical materialist view I expect. ‘The concern is for the body, and perceptions of what happens to your body and your organs after death, but when you’re dead you’re dead, so far as I’m concerned. People don’t see what a body looks like after six months – there isn’t much of it left.’ But then he surprises me with this: ‘My personal view is that what makes humans different from the animals is not the body but the spirit.’ He is scathing about resistance to donating one’s organs based on the idea that one would not then be going to God intact. ‘I’ve never heard that when people have had their tonsils out.’ But he immediately tempers the thought, adding that he knows of cases where amputees have wished to be buried along with their preserved cut-off limb. ‘The first thing is to know what people really feel, and why they have concerns.’

Neuberger is hopeful that transplantation as we presently understand it may turn out to be a short-lived episode in medical history. At a technology conference in March 2011, Anthony Atala, director of the Wake Forest Institute for Regenerative Medicine in Winston-Salem, North Carolina, described how three-dimensional printing machines of the kind beginning to be used to fabricate customized items in plastic could be adapted to ‘print’ human tissue. In this case, a patient’s wound is optically scanned, and the digital information thereby gathered used to determine the size and shape of the tissue required to occupy the void. This shape is then fabricated by depositing healthy cultured cells layer by layer in a suitable matrix where they can fuse together to form a functional organ. Atala printed out a specimen kidney for the benefit of the conference audience. ‘It’s just like baking a cake,’ he told them.

Blood

From the experimental data that he amassed revealing the awesome power and capacity of the heart, William Harvey concluded with irresistible logic that the blood that pumps through it cannot possibly be generated afresh at the necessary rate, and that therefore it must be carried in a circuit repeatedly around the body. Chapter 14 of his
De Motu Cordis
draws his thinking to a crisp conclusion. It reads in its entirety:

And now I may be allowed to give in brief my view of the circulation of the blood, and to propose for it general adoption.

Since all things, both argument and ocular demonstration, show that the blood passes through the lungs, and heart by force of the ventricles, and is sent for distribution to all parts of the body, where it makes its way into the veins and porosities of the flesh, and then flows by the veins from the circumference on every side to the centre, from the lesser to the greater veins, and is by them finally discharged into the vena cava and right auricle of the heart, and this in such a quantity or in such a flux and reflux thither by the arteries, hither by the veins, as cannot possibly be supplied by the ingesta, and is much greater than can be required for mere purposes of nutrition; it is absolutely necessary to conclude that the blood in the animal body is impelled in a circle, and is in a state of ceaseless motion; that this is the act or function which the heart performs by means of its pulse; and that it is the sole and only end of the motion and contraction of the heart.

It is exemplary scientific reporting, plainly and fully descriptive, and utterly lacking in the kind of baroque literary flourishes that characterize so much seventeenth-century writing. The circularity especially pleased Harvey, leading him to draw an analogy with the water cycle as described by Aristotle. Before long, the healthy circulation of blood discovered by Harvey would inspire metaphors of other healthy circulations, such as that of trade within the nascent British Empire.

The circulation of the blood began to explain formerly puzzling phenomena such as how an infection in one part of the body could quickly spread to other parts. But traditional views of the blood itself – the red liquid that runs from our wounds and for which our bodies are apparently the container – hardly needed to change at first. The fact that the blood was circulated rather than generated gave no cause to modify established medical treatments such as bloodletting (in which a vein is cut open to release a quantity of blood) and cupping (in which a heated vessel is placed on the skin in order to draw blood to an affected area); indeed, in Harvey’s view, the circulation of the blood explained their supposed efficacy for the first time. Harvey’s discovery marked a radical shift from the Galenic view in which blood was manufactured in the liver, given ruddy life in the heart, and then sent out to all parts of the body, never to return, like the light of the sun. But this revolution in one of the four Hippocratic humours – phlegm, black bile and yellow bile being the others – did little to upset the balance of this system of medicine, which continued to guide physicians for another couple of centuries after Harvey. Other ancient beliefs to do with the blood – the horror and fear of it, and rituals and taboos surrounding its appearance – all continued intact.

In Judaism, all blood is regarded as the source of life. Animal flesh only is to be eaten; the blood is to be poured away on the ground or poured sacrificially on the altar of the Lord, according to Deuteronomy. Human blood is unclean. The privileging of the blood in this way stems in the view of some anthropologists from a folk memory of human sacrifice, but it is surely also evidence of a primitive awareness that the blood may be infected with disease.

Although Christianity arose out of Judaism, its attitude towards blood is sharply different. Because the Christian God is revealed in the bloody sacrifice of Jesus, blood is a central part of the ritual. Until the Fourth Lateran Council of 1215, the Christian ceremony involving bread and wine was merely symbolic of the Last Supper. The Council decreed that the bread and wine was to be regarded as the actual body and blood of Christ, and in doing so invented a ritual, the Eucharist, that could be replicated in every church in Christendom, in which the faithful could engage in a physical communion with Christ. Thus is blood seen, meditated upon, and even drunk. By the miracle of transubstantiation, believers can share in the body of Christ without disgust, neatly sidestepping any suggestion of cannibalism. That far older ritual is inevitably what springs to an anthropologist’s mind, however, and the Christian altar will always carry a faint echo of the pagan sacrificial table.

Blood is unclean or polluted as soon as it leaves the body. It shares this property with other bodily emissions, such as urine, faeces and phlegm. But it does not
normally
leave the body like these other substances, and so its appearance in the outside world is always remarkable. Often, of course, it is an ill omen. John Keats, the one-time trainee surgeon, recognized his own impending death from tuberculosis at the age of twenty-five when he saw on his pillow ‘arterial blood. I cannot be deceived. That drop of blood is my death warrant.’ Destined to die from the same disease a century later, Kafka interpreted his blood rather differently when ‘in the swimming bath I spat out something red. That was strange and interesting, wasn’t it?’ A normal stool or a gobbet of phlegm is neither strange nor interesting. But blood demands notice.

Men found menstrual blood especially disturbing. A penance of some weeks of fasting was traditionally demanded of women who entered a church while they were menstruating. The ‘churching’ of women was a ritual of forty days’ ‘decontamination’ of a new mother after giving birth, during which she was required to withdraw from the church and from society, a custom followed in some places well into the twentieth century. The sexual inequality is set from birth: according to Leviticus, a baby girl is double the trouble, rendering the mother fourteen days unclean compared with seven for the birth of a boy. Menstrual blood was feared as a reminder of the uterus, the organ of female fertility that might so easily form an alternative basis for worship to the elaborate system erected by the male priesthood. Menstrual blood is not a universal taboo, as the anthropologist Mary Douglas demonstrates with reference to the Walbiri people of central Australia, whose women are subject to brutal physical control by their husbands, apparently obviating the need for more nuanced rules of sex pollution. But it was and remains widespread (think of tampon advertisements that puzzlingly use blue ink to demonstrate their efficacy). In general, the appearance of blood is a sign of weakness and ineptitude in man, as when he is wounded in battle or, more likely these days, cuts himself shaving. But in women it is a reminder of life-giving strength, and in male-dominated societies this leads to social division, expressed for example in the slander that contact with a menstruating woman has the power to tarnish mirrors, sour wine, stifle infants in their cradles and fatally weaken a man in all sorts of unpleasant ways.

I find a few of these observations in
A History of Women’s Bodies
, written by a man, Edward Shorter, ‘the somewhat lurid title’ chosen, he announces epiphanically in his preface, ‘to make the point that women’s bodies have a history of their own’. My library copy of this 1982 work has been liberally annotated with expressions of incredulity by recent generations of women students, not so much at the tales themselves but at Shorter’s constant problematizing and medicalizing of his subject, women’s bodies, which seems in its way to perpetuate ancient patriarchal prejudice. Nearly half the book is given over to the subject of childbirth, for example, and one chapter is entitled ‘Did women enjoy sex before 1900?’

Before we knew about genes, blood was understood also as the medium of our heredity. Blood is family. ‘Am I not consanguineous? am I not of her blood?’ demands Sir Toby Belch in
Twelfth Night
in reference to his niece Olivia. Blood is also tribe. ‘For blood of ours, shed blood of Montague,’ exhorts Lady Capulet in
Romeo and Juliet
. And blood is race. Racial purity is often gauged in terms of blood, as was the case with the notorious ‘one-drop rule’ adopted as law in many southern American states in the early twentieth century. Under the rule, any person with the slightest African heritance (‘one drop’ of blood) was legally defined as black (in more liberal states, one-eighth or one-quarter African ancestry was the definition). Enforcement was impossible, of course, and in practice court cases drew on evidence of recent ancestry. Genetic tests today suggest that more than a quarter of ‘white’ Americans would fail the one-drop rule.

I find that many of these old beliefs seem to persist when, for the first time, I enrol to give blood. First, I must complete an online questionnaire. By doing this, I consent to allow ‘medical, religious or other sensitive personal information submitted by me to be used by the National Blood Service’. The form asks many of the expected questions about my general health and likely exposure to infection. There is also a section about ‘lifestyle’, demanding to know about my likelihood of exposure to HIV and hepatitis viruses, and whether I have had acupuncture, piercings or tattoos, as well as probing gently at my sexual tastes. There are several questions which it is impossible to answer with complete certitude, such as have I ever ‘had sex with anyone who has ever injected drugs’, or have I ‘had sex with anyone who may ever have had sex in parts of the world where AIDS / HIV is very common (this includes most countries in Africa)?’ Neither can I be totally sure that I have not, in the last four weeks, ‘been in contact with anyone with an infectious disease’.

Any new disease immediately prompts the fear that it is carried in the blood. Scientists were at first highly reluctant to believe that AIDS was carried in blood, because of the awful implications for infectivity. Conversely, once a particular infection
is
associated with the blood, it may prove very hard to revise the general opinion. In Canada and other places, declared gay and bisexual men have been debarred from giving blood. However, more effective methods of screening donated blood for HIV and hepatitis, and the reduced likelihood that such men are carrying these viruses, owing to better education, have now led the Canadian authorities to contemplate relaxing the ban. But first, to see whether this would be a wise move, further research was required, for which half a million dollars’ funding was offered. Most untypically, no scientists came forward to take on the work.

Odder still are the questions on my form about ‘Travel outside the UK’. These seem to assume that the nation’s borders should be impervious barriers to disease and impure blood. They put me in mind of John of Gaunt’s speech in
Richard II
: ‘This fortress built by Nature for herself / Against infection and the hand of war’. I am asked whether I have been abroad within the last twelve months, and made to feel it is somehow improper that of course I have. The questionnaire also demands to know if I have ‘ever lived or stayed outside the UK for a continuous period of 6 months or more’. My national loyalty is again found wanting. I tick the yes boxes, and the online questionnaire promptly shuts down, thanking me for my trouble with this confusing consolation: ‘You may still be able to give blood.’ Out of curiosity, I re-enter the site and lie my way through to the end. This time, it rewards me with the message: ‘It seems you are able to give blood’, which I interpret as their way of saying: ‘We think we can accept your blood.’

I wonder what will happen to my blood if I am allowed to donate. Will it be mixed with the blood of people of other ethnicities, of foreign parentage, lovers of exotic holidays? Is the tendency of health policy towards a global blood bank that recognizes our common humanity (while distinguishing between blood groups to ensure antibody compatibility)? Or is the countervailing movement stronger, and which I have heard is growing, especially in the United States, for people to build up banks of their own blood for their exclusive use?

On the day of my appointment, I make my way to my local town hall. There, half a dozen couches are laid out, with people in blue uniforms bustling around them. I sign in, and am encouraged to help myself to a large glass of water or sugar-free juice. I have been relaxed about the idea of becoming a blood donor up until this point, but now I find I have butterflies in my stomach, and my left arm is tensing in anticipation of the needle. The majority of the donors on this day are women. Ages seem to span the full range permitted for donors, seventeen to sixty-six years old. I sit down to wait, idly flipping through leaflets that seek to reassure me as to what I am about to undergo. One has a photograph of a mournful spaniel on the cover. Puzzled as to how it can possibly be relevant, I open it and read that the first blood transfusion, noted by Samuel Pepys in his diary, took place in 1666, when, according to the minutes of the Royal Society, a spaniel received blood from a ‘little mastiff’. The copy continues with more honesty than judgement: ‘The spaniel survived (although the mastiff was less fortunate), and scientists were encouraged to move on to human subjects.’ I’m just wondering quite why everybody felt so chipper given the demise of the donor dog when my name is called.

A nurse first runs through my questionnaire responses. We discuss the answers I have left blank. I explain that I have been abroad – to Italy and the Netherlands. I’m in the clear: had I been to the northeast of Italy or one or two other places, I might have been ruled out because of the risk that I had picked up West Nile virus. I had hesitated, too, over a question about hospital operations. Did out-patient treatment to have my wisdom teeth removed count? What about the time they set my broken leg? This requires the nurse to consult with a colleague. Finally, I am judged acceptable, and passed to a second nurse, who checks my blood density by placing a drop of it in a solution of copper sulphate. This will confirm whether I have at least the average level of iron in my blood, which is the threshold for donation. The drop hovers, then sinks. I have passed.