History is selective and it very much depends on who is telling it. In 2001 a group of prize-winning transplant doctors held a consensus meeting to define the most important events in the history of transplantation, yet they did not include the contribution of Ruth Tucker.
Ruth Tucker was an amazingly brave lady and she had polycystic kidney disease.
In 1950, at the age of 44 she underwent a pioneering operation – a kidney transplant.
From 1902 onwards there had been technical success in transplanting kidneys in animals but none had lived for very long afterwards. There had even been a couple of attempts at transplanting animal kidneys into humans – I say “into” loosely because it appears that the organs were attached to the elbow or the thigh rather than intra-abdominally, presumably due to ease of securing a blood supply from the arm or leg. These resulted in the patient dying after a few days. Those sort of results would not have encouraged me to volunteer.
I have found it hard to see the steps that led to the transplant operation of 1950, it is almost as if the surgeon performed it on an impulse, circumstances just happened to exist that made it possible.
Richard Lawler (1895-1982), credited as the lead surgeon, was at the time a surgeon at Loyola University School of Medicine and Cook County Hospital, both in Chicago. He also held a position at the Little Company of Mary Hospital in Evergreen Park, Chicago, which is where Ruth Tucker was an inpatient in June of 1950. This little hospital was not exactly a centre of excellence, more a charitable hospital run by Catholic nuns. It is a wonder the surgeons were permitted to perform the operation here when the Church then was definitely not supportive of organ transplantation. The other surgeon involved, James Ward West (1914-2012), later was reported to say that they chose that hospital because the nuns trusted them – sounds almost as if he means “easier to get away with”. I suspect there has been significant retrospective change to the facts, especially given the response of Lawler’s peers, who ostracised him to the extent that he never undertook renal surgery ever again.
Lawler wrote up a Case Report of the surgery, but only after the story had been leaked to the press by a friend of Ruth Tucker. It is likely that he would have preferred a longer post-operative observation before announcing the success of his somewhat controversial procedure. The case report is available if you have a subscription to JAMA (144(10):p844-845). It is interesting reading, in a narrative style – “the patient was brought onto the operating theatre and the left polycystic kidney was removed”. But what struck me most was that Ruth was not actually in end stage renal failure when this was undertaken.
In medical note format, with terms used by Lawler:
Presentation: A white woman aged 44 c/o (complaining of) epigastric fullness, abdominal pains and some dysuria.
HPC (History of presenting complaint): 9 years duration, intermittent, progressively worse
PMH (past medical history): Cholecystectomy for presumed cholecystitis (aged 35yrs); IVP diagnosis of PKD 1 year ago (aged 43yrs)
FH (family history): Mother, sister and paternal uncle all died from PKD aged between 37 and 41 yrs. 1st cousin has PKD, alive (age 30yrs approx.)
O/E (on examination):
- well nourished
- well developed (Lawler’s phrase)
- BP 140/80
- T 98.6F
- RR 20/min (respiratory rate)
- head, neck and pharynx essentially normal
- large palpable mass in left abdomen extended to almost midline and down into pelvis
- smaller palpable mass in right hypochondriac
- both masses tender to pressure
- positive Murphy Kidney Punch (see below)
Xrays: Both kidney shadows decidedly enlarged
IVP: Scant amount of dye appeared at right renal pelvis but none seen at left kidney
Laboratory tests – blood
- Non-protein Nitrogen 46mg (all biochemistry tests are per 100cc)
- Creatinine 1.8mg
- Total protein 5.15g
- Serum albumin 3.44g
- Serum globulin 1.71g
- Red blood cell count 4,380,000
- White blood cell count 5,750
- Haemoglobin 81%
Laboratory tests – urine
- Specific gravity 1.012
- albumin – a trace
- sugar – negative
- 5-10 white blood cells per high power field
Phenosulfonphthalein excretion (May 17 1950) 13%
The Murphy Kidney Punch is not as dramatic as it sounds – it entails laying the left hand over the costophrenic angles (kidney region on the back) and percussing using the ulnar border of the right hand -a positive result is if it is tender for the patient. Murphy was a flamboyant surgeon who described and gave his name to several signs, this one is not the same as Murphy’s Sign!
While some of the tests may not be familiar, it appears from the high creatinine and non-protein nitrogen (equivalent to BUN) that she has some renal impairment. The phenosulfonphthalein (PSP)test had been in use since 1910 and was used as an estimate of tubular function. It is not the same as our modern day GFR (glomerular filtration rate). The comparison is that if the PSP excretion was greater than 20% then the glomerular filtration would most likely be greater than 50%. You can see it is by no means an accurate measure of renal function, more a guideline. So with a PSP excretion at 13%, Ruth Tuckers renal function was less than 50%, but we cannot really state it with any more accuracy.
That the specific gravity of her urine was low, suggests the kidneys were not concentrating urine as well as they should, but all the other tests are not too much different from a normal range.
The newspapers made a great deal about the patient being “hopelessly diseased” and “doomed to die”, and we can all appreciate that with that family history her outlook was not great, but it is also apparent that she did have some degree of renal function and was not in what we would now define as end-stage renal failure. How much say she had in the process or what she was actually consenting to is a totally unknown and undocumented fact.
The donor, in all probability, would not have consented. Consent in those days was more of a recommendation and “informed consent” did not come into play until late 1960s. The donor, very sadly, just happened to have died that morning, of cirrhosis and bleeding from oesophageal varices, she was 49 years old. It would not have been a good choice for a donor organ, but given the controversies there was not really any choice at all. The only “matching” was that they had the same blood group. Nor was there any immunosuppression, thats a few years away yet.
Lawler described the operation in detail, that he bathed the donor kidney in saline with heparin infused into the blood vessels, and that he used 4/0 black silk sutures to join the blood vessels, upon which the “vessels filled immediately with blood and the colour of the kidney changed from bluish-brown to reddish-brown”. Finally he joined the ureter ends and laid the kidney exactly where the left one had just been removed.
One month later Ruth Tucker was “discharged home and resumed an active lifestyle”. The picture of her above is apparently depicting this active life – dusting!
But was this really a success?
Ruth did indeed live a further five years, but the new kidney did not last that long and maybe Ruth would have had sufficient renal function for another five years in any case? The kidney was still working at 53 days after the operation – this was shown by an IVP, but it isn’t at all clear why that investigation was indicated. She must have continued to have abdominal pain because some ten months after the transplant she underwent an exploratory laparotomy – the kidney had shrivelled and was discoloured, clearly no longer functioning, and so was removed.
Ruth Tucker died of “coronary artery disease and pneumonia” in 1955 at the age of 49.
I think she was amazingly brave. I agree with the comment from Time magazine (July 3, 1950) that in many ways this was “a desperate experiment”. There are many things about this story that have shocked me – the consent issues, that the surgeons almost hid the operation away, that when she had her gall bladder removed nobody identified her polycystic kidneys then, that the surgeons were not aware of previous experimental transplants (and poor outcomes)in Russia – it was the Cold War so nothing from Russia was trusted even if it could be translated. I have also been struggling with misreporting of the story and apparent contradictions to be found across the internet – in some stories she was 49; others had the kidney working for 5 years; she was described as coming from Justice, Illinois or Jasper, Indiana; that this was the first and equally that this wasn’t the first human kidney transplant. Mostly the story is overshadowed by the success of Jospeh Murray who transplanted a kidney from one identical twin to another in 1954 – he had the support of his colleagues and hospital in Boston, while Lawler’s career seems to have fizzled out with none of the awards or accolade given to some of the transplant pioneers.
I am hoping this post will keep the memory of Ruth Tucker alive just a little bit longer. I wish she could know that her operation was the start of an amazingly steep learning curve to where we are today and that there are many many people with PKD who are forever grateful to her for being a guineapig in the field of kidney transplant.