Baylor University Medical Center Proceedings October 2017 - 476

aorta. They soon discovered that this procedure was extremely
diﬃcult, if not impossible, because there was no tissue left to
stitch and furthermore it was so fragile that the animal died
of hemorrhage. Then Lower had a brilliant idea: "Why don't
we use the heart of another dog so that there will be enough
tissue for stitching?" (3). After the ﬁrst failures, they started to
have survivals. When the ﬁrst dog had survived for a week, the
press and television became involved, besieging the department
chairman with questions. He was so annoyed that he demanded
the dog be put down, causing the researchers dismay. Soon the
chairman was dismissed for a diﬀerent reason, yet Shumway
wryly remarked: "Neither the dog nor the chairman lasted much
longer, so perhaps some kind of poetic justice was achieved!" (1).
The following year they reported to the American College
of Surgeons, before an empty auditorium, the stable survival
from 1 to 3 weeks of eight dogs. It was obvious that their work
was considered "utopian." However, the publication that followed-concise and lucid like the one by Watson and Crick
announcing in 1953 the discovery of the double helix of DNA,
which won them a Nobel prize-is still today a landmark in
the international bibliography (4).
During the next 7 years, the two researchers, Shumway at
Stanford and Lower, now in Virginia, widened the ﬁeld with innovative work and were considered by the experts to be the most
likely to perform the ﬁrst human heart transplant. However,
in 1964 they were almost overshadowed, ﬂeetingly as it turned
out, by James Hardy of the University of Mississippi. He lost
the race, though, when he implanted a chimpanzee's heart into
the chest of a dying man. The result was inevitable-hyperacute
rejection-although Hardy and his associates attributed the
failure to a size mismatch between donor and recipient resulting
in low cardiac output (5). Hardy was expelled for quite a few
years from the American College of Surgeons for unacceptable experimentation. When I was a fellow at Baylor University
Medical Center in 1973, he came as a visiting professor and
during a meeting with the housestaﬀ expressed his bitterness
over what, in his opinion, was an unjustly imposed penalty.
However, there was no reaction 3 years later when Lower, in
order to demonstrate the technical feasibility of a human transplant, grafted a human heart for which there was no suitable
recipient into the chest of a chimpanzee, where it functioned
for several hours. Well known for his cutting sense of humor,
inherited from Shumway and bequeathed to his own disciples,
Lower named the procedure "a reverse Hardy"!
Unfortunately, the great opportunity for an ethical reward
was lost to Lower in the fall of 1966, when there was the rare coincidence of a suitable donor and recipient. He did not proceed
then for what proved later to be a secondary incompatibility
of blood groups. Always conscientious and a perfectionist, he
did not want to risk this historic operation with something that
was a priori a negative factor on the scale of success, in spite of
insistent urging to proceed by David Hume, chairman of the
Department of Surgery at the Medical College of Virginia, who
was legendary for his drive and aggressiveness (6).
There was also a third serious contender for the victor's
wreath for the ﬁrst transplant: Adrian Kantrowitz, the charis476

matic, unbelievably industrious and persistent cardiac surgeon
of Maimonides Hospital in New York, with 200 experiments
under his belt. He had concentrated his eﬀorts on a transplant
in a baby on the assumption that its immature immune system
was less likely to trigger rejection (7).
So these three, Shumway, Lower, and Kantrowitz, were the
players in the arena, desperately trying to prepare a suitable
candidate and to locate the necessary donor. Unfortunately, all
three faced the same, seemingly insurmountable obstacle: the
possible donor was considered dead only after all heart activity
had ceased. The required wait until that happened usually meant
that the graft was unsuitable for transplantation. Therefore, there
was inactivity while the intensity of the rivalry reached its peak.
In 1966, the hitherto unknown Christiaan Barnard asked
Dr. Hume if he could come to Virginia to observe his pioneering kidney transplants. He stayed for about 3 months and, encouraged by his fellow-countryman, the pump technician Carl
Gosen, he took the opportunity to watch Lower in the animal
laboratory. Impressed by the simplicity of the technique-great
surgeons make any procedure look easy!-he came back a few
weeks later to consolidate his knowledge. As he was leaving, he
conﬁded to Gosen that on his return to South Africa he would
perform a human heart transplant. When Gosen questioned
how he could do that without experimental work, he made the
amazing statement: "Ja, I'll do a couple of dogs!" He also added:
"You here have too many prohibitions to negotiate before you
can ﬁnd a donor. We have no such obstacles in South Africa" (6).
His motive was his outsized ambition to make his mark and
surpass his former colleagues at the University of Minnesota,
among whom was Shumway. His excuse for doing an operation
for which he was not prepared was the inability of his American
colleagues to proceed because of the prohibitive legislation.
With great perspicacity he had realized his advantage: in South
Africa only the agreement of two doctors was required to declare
death in a case of irreversible brain injury, even before the heart
had stopped. It was the ace up his sleeve!
With this advantage, on December 3, 1967, Barnard transplanted the heart of 25-year-old Denise Darvall, victim of a road
traﬃc accident, into the chest of 53-year-old Louis Washkansky
(8) (Figure 2a). In spite of the legal protection and in order
to forestall any possible graft deterioration while waiting for
the heartbeat to stop, as the anesthesiologist was insisting, he
speeded up harvesting with the intravenous administration of
potassium (6). Thus, the transplant proceeded and history was
made. Its success was not marred, even by Louis's death 18 days
later of pneumonia. Three days after Barnard, Kantrowitz performed the ﬁrst transplant in America, but the baby lived for
only a few hours. At the beginning of January 1968, Shumway
carried out the ﬁrst transplant in Stanford and this patient, also,
lived for 18 days. In the interests of history, as Dr. Shumway
stated, "No experimental orthotopic heart graft had survived
more than a few hours in South Africa when Barnard's initial
clinical eﬀort took the world by surprise" (9). As a matter of fact,
by the time Christiaan Barnard had performed 48 transplants
in the laboratory, that was 250 less than Norman Shumway and
210 less than Adrian Kantrowitz had performed (6).

Baylor University Medical Center Proceedings

Volume 30, Number 4

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