Baylor University Medical Center Proceedings October 2017 - 477

Figure 2. Life covers in 1967 and 1971 documenting the early history of heart
transplantation. (a) Dr. Christiaan Barnard with his first patient, Louis Washkansky.
(b) The sad reality 3 years after the first heart transplant.

Barnard's boldness started a frenzy of heart transplants
all over the world, even by surgeons who had criticized him
at ﬁrst for being "premature." As Dr. Shumway put it in his
inimitable, sarcastic way: "Suddenly heart transplants were being done in places where one would hesitate to have his atrial
septal defect closed!" (9). In 1968, 104 such procedures were
carried out, with only 10 survivors, and results for the next
3 years were similar (170 transplants with 24 survivors) (10).
This made Life magazine in a 1971 issue withdraw its earlier
enthusiastic report about transplants (Figure 2b). Even the
demigod of American surgery, Denton Cooley, was forced to
stop, saying, "The prescription for success in heart transplantation 'cut well, tie well, get well' is a naïveté. The problems come
after surgery and they're not surgical problems" (10). The epitaph of this period was pronounced succinctly by the pioneer
of the 1948 mitral valvotomies, Charles Bailey, when he said
that "cardiac transplantation is 10 years too early" (6). And so
during the diﬃcult decade of the 1970s, the torch of transplantation was kept alight by Stanford, inventing new techniques
for the prevention and diagnosis of rejection and establishing
the "team project" as the necessary precursor to success (11).
The proof was the hitherto unsurpassed ﬁrst-year survival of
65% and 5-year survival of 45% (11, 12). However, a new
era started in 1976 after Borel's critical experiments and Sir
Roy Calne's clinical use of cyclosporine-A in kidney and liver
transplants in 1979 (13). This was the miracle antirejection
drug, again used for heart transplantation by Stanford in the
early 1980s (14).
What was gained by Barnard's audacity? Certainly not cyclosporine, as already mentioned. Some said that he speeded up the
acceptance of brain death (15). But again, during that period,
even without wanting to, it was Lower who was responsible.
When he carried out his ﬁrst transplant in May 1968, he was
accused of taking the heart of a brain-dead donor, as it was still
beating. He sat as a defendant along with 10 other physicians
involved in the operation in the famous Tucker v. Lower case in

October 2017

Richmond in May 1972. The judge, A. Christian Compton, in
his groundbreaking ﬁnal jury instruction, allowed: "You shall
determine the time of death . . . and in determining you may
consider . . . the time of complete and irreversible loss of all
function of the brain" (16). It opened the way for a change in legislation, which from that time has allowed us to do transplants.
Lower had been treated unfairly twice over. His labors were
enjoyed by someone else while the system almost sent him to
jail. I felt his bitterness one Saturday morning during grand
rounds, in the spring of 1980, when I was the second-year resident in his program. Before all the staﬀ of the Medical College of
Virginia, he gave the lecture on heart transplantation. His ﬁnal
comment has remained indelibly seared into my memory: "In
1966 I did not proceed with the heart transplant and God never
forgave me for my hesitation. So glory and reputation went to
Cape Town, South Africa, and not to Richmond, Virginia."
Two conclusions: Firstly, we only repent of what we have
not done. Secondly, the world respects thought, but worships
audacity. Perhaps with some justiﬁcation.
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14.

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16.

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Table of Contents for the Digital Edition of Baylor University Medical Center Proceedings October 2017