Standing on Tall Shoulders – The History of Cardiac Surgery Part 10 by Thomas N Muziani PA-C, CP
“Man is a clever animal who behaves like an imbecile” – Albert Schweitzer
1960’s – The age of organ transplantation
There is an age old expression, attributed to New York Senator William L. Marcy in 1828: “To the victor belongs the spoils”. Winston Churchill also stated: “History is written by the victors”. Heart failure was first described in the Ebers Papyrus in 1550 BC, which had been copied from earlier texts. Until the 1960’s, an individual with a very sick, failing heart had very few options. However, reparative operations on the heart became sublimely elegant from then on. But replacing the heart remained an experimental concept. Intra-animal experimentation with cross-species and same-species heart-to-heart transplantation proved extremely successful technically in non-humans. Homo sapiens required a much higher learning curve. From a purely historical perspective, the dawn of human heart-to-heart transplantation was strictly a “no option left”, the patient was dying…and involved only one human…the patient.
James D. Hardy grew up in Newala, Alabama, a small, very rural community in Shelby County. His father owned a lime plant in Newala. He attended University of Pennsylvania School of Medicine in Philadelphia, receiving his MD in 1942. With the continual fighting of World War II, he enlisted in the U.S. Army Medical Corp in 1944. After his term of service, he took a position at Stark General Hospital, Charleston, South Carolina. This lead to Hardy becoming Chair and then first Professor of Surgery at University of Mississippi School of Medicine, Jackson, MS in 1955.
World’s first lung transplant (1963)
John Russell was a 58 year-old convict serving a life sentence at Mississippi State Penitentiary for the capital offense of murder. His health had deteriorated so badly while in prison that he was transferred to University of Mississippi Medical Center in Jackson with recurrent pneumonia unresponsive to antibiotics. He also had squamous cell carcinoma of his left lung and severe emphysema coupled with end stage renal disease. He would awake during the night coughing up blood sputum until becoming cyanotic and barely able to breathe. Tests revealed he had only one-third of normal lung capacity.
During conference at the hospital, the decision was made to transfer Mr. Russell to the operating room and replace his left lung for the two primary reasons; to gain experience with the procedure and, hopefully, ease his breathing issues. Martin Dalton, who was a thoracic resident on Hardy’s service, obtained consent from the family of a recently deceased heart attack patient to harvest his lungs. Utilizing an endotracheal tube to ventilate the lungs and injecting sodium heparin into the heart to prevent clotting, they harvested the left lung and walked it over to the adjoining operating room.
On 11 June 1963, when Hardy and his team opened John Russell up, they realized his cancer had metastasized well beyond the left lung. The transplant would not save his life from cancer. However, knowing it might improve his breathing, they proceeded with the procedure. His cancerous left lung had severely atrophied, causing the left pleural space to collapse. Hardy and his team fashioned a new cavity for the lung. John lived another 18 days and then expired from kidney failure and infection.
World’s first heart transplant (1964)
Boyd Rush, who was described as a “deaf mute”, was a 68-year-old retired upholsterer. He had been discovered by neighbors in a comatose state with a thready, weak pulse. The ambulance rushed him to a community hospital on 21 Jan 1964. The community hospital quickly realized they did not have the physical nor physician means to treat Boyd Rush’s condition and transferred him to U of Mississippi Medical Center.
As the old Southern adage goes, Boyd Rush was about to: “Up and die”. On Thursday, 23 Jan. at 11:00 PM, Rush went into shock with very low blood pressure. James Hardy and his colleagues transferred Rush to the operating room. Rush’s stepsister, Mrs. J. H. Thompson signed the consent form that allowed for “the insertion of a suitable heart transplant if such should become available at the time”. Unfortunately, the consent form never included the possibility of a chimpanzee heart being inserted into her stepbrother. Dr. Hardy later stated under oath, that he discussed this possibility with Mrs. Thompson in detail and with the relatives…although there was only one relative present.
Hardy had purchased four chimpanzees to facilitate understanding the technical hurdles involved in his transplant experiments. He had become quite confident about the procedure itself, it was just gross sewing and the issue of tissue rejection and therefore immunosuppression, did not appear acute in chimps. However, this was just same-species transplantation. The extremely rapid deterioration of Boyd Rush…and the fact that he went into cardiac arrest prior to going onto the heart-lung machine presented Hardy with few options. Upon gaining a consensus with his colleagues, they all agreed to proceed with the xenotransplantation of the chimpanzee heart into Boyd Rush’s cardiac cavity. Just after 2AM in the early morning hours of Friday 24 Jan 1964, Hardy completed the implantation of a chimpanzee heart into Boyd Rush. With one defibrillation, the heart started beating and continued to beat for another 90 minutes…and then the chimp heart refused to come off the heart-lung machine. In an interview with Dr. Leonard Bailey of Loma Linda University many years later, he discussed Dr. Hardy and the chimpanzee xenotransplantation. “When they performed an autopsy on the chimpanzee’s heart, lo and behold, this old chimp was suffering from severe coronary artery disease. It probably wasn’t really a fair situation”. Dr. Hardy’s group had picked a chimp that was about ready to die.
The public information officer of the hospital (in typical guarded double speak) released a vague and confusing statement that read: “the dimensions of the only available donor heart” and conveniently never disclosed the donor heart was that of a chimpanzee. The Associated Press then broadcast the story which began with, “Surgeons took the heart of a dead man, revived it and transplanted it into the chest of a man dying of heart failure today”. This forced the hand of the Mississippi Medical Center to release the more accurate details. On 25 Jan., the New York Times printed: “Chimpanzee Heart Used in Transplant to Human”. James Hardy, recalling these events years later stated, “The publicity, the outcry and criticism were enormous. Public media reporters seemed to come out of the woodwork. We hunkered down and waited it out”.
Hardy, prior to the transplant, had made plans to attend the Sixth International Transplantation Conference in New York City several weeks later. James Hardy was introduced by Dr. Willem Kolff, the pioneer inventor of the dialysis machine and dialysis filtering membrane coil. Toward the end of the introduction Kolff turned to Hardy and flippantly stated, “In Mississippi they keep chimpanzees in one cage and the Negroes in another cage, don’t they, Dr. Hardy.” Author Donald McRae wrote that the impact of this offhand remark on an already unsympathetic audience was profound, especially since the audience knew that Kolff had lived through the Nazi occupation of Holland. Kolff later stated that he was merely joking in an effort to lighten the mood. When Willem “Pim” Kolff discussed the event with this author many years later while he was head of University of Utah’s Division of Artificial Organs, I still detected an introspective reflection of regret and remorse. Unkind or unscripted derogatory comments were anathema to Willem Kolff.
James Hardy later wrote, “For one of the few times in my professional career, I was taken aback and did poorly. The audience was palpably hostile, there was not a single hand of applause thereafter. Much later Hardy wrote, “I had noted that when one loses his academic post, for whatever reason, he is not likely to get another one of comparable significance. I decided to wait until Norman Shumway and his group (at Stanford) transplanted a heart in man”.
After a hiatus of more than three and a half years, Norman Shumway’s fellow resident at University of Minnesota under Dr. Lillehei’s cardiac service, performed the first human-to-human heart transplant. Christiaan Barnard in South Africa on 3 December 1967, operated on Louis Washkansky…who survived for 18 days.