Hearts

by Thomas Thompson

  The artificial heart was tested, Cooley said, by implanting it into seven calves. Though all died, one lived 44 hours. This seemed enough experimentation, he said, “to get this thing on.” The use of the apparatus in a human came about only because the man lay dying on the operating table and there was no donor heart available. The artificial heart was there, its large console was there, the patient was there. “Everything came together at once,” said Cooley, “everything.” And, in something of a side-bar remark, Cooley said he had heard that the Russians were planning to use an artificial heart, and he wanted American medicine to be first.

  In his most impassioned remarks, Cooley reminded the investigators of his long experience within the human heart, of the thousands upon thousands of judgments he had made. “I have done more heart surgery than anyone else in the world,” he told a reporter in a statement that seemed to sum up his case. “Based on this experience, I believe I am qualified to judge what is right and proper for my patients. The permission I receive to do what I do, I receive from my patients. It is not received from a government agency or from one of my seniors.”

  DeBakey built a careful case against Cooley. Amassing an array of witnesses, documents, invoices, medical sketches, illustrations, diagrams, even careless, forgotten remarks by Cooley that he had made in past speeches—remarks such as his once calling the artificial heart “impractical wishful thinking,” and “science fiction”—DeBakey charged:

  —That Cooley deliberately lured Domingo Liotta away with visions of a promised land, which must have seemed overwhelming to a man who had spent more than half a decade inside a surgical laboratory.

  —That the Karp operation was well planned in advance and not a life-or-death one-minute-to-midnight decision made in the operating room. Indeed, the large console power source is not standard equipment in an operating room, nor are the movie cameras and equipment necessary to photograph an operation from start to finish. One Baylor surgeon said he was asked by Cooley days prior to the operation to participate in it.

  —That the seven calves used in the artificial heart experiments all died of severe kidney failure brought on by the device, which should have been a warning that the machine held potential peril for a human. The calf that lived 44 hours was, according to DeBakey, “essentially a cadaver from the time of implantation.”

  —That Cooley did little but change the valves in the artificial heart to make it different from the one that DeBakey thought was being developed exclusively in his own laboratories.

  —That no appeal for a donor heart was made until the day after the artificial heart operation, when Karp’s wife went on television. What DeBakey left unsaid here was that if Cooley was truly using the mechanical apparatus only as a resuscitative device, he should have made an instant appeal.

  —That by using the human heart flown in from Massachusetts to replace the artificial one was the waste of a “scarce organ.”

  —That DeBakey was shocked and grieved that such an event had taken place within the confines of Baylor.

  An observer of the days in which the hearings were held recalled DeBakey as “a man possessed … possessed with the need to punish Cooley for what he had done.” His eyes, the man said, were “on fire.”

  Vengeance for DeBakey was quick, and it would have appeared, thorough. Liotta was fired from Baylor, though immediately hired by Cooley for his Texas Heart Institute and empowered to begin a new artificial heart development program. Cooley himself resigned, with sadness, from Baylor, the school he had served for eighteen years. His reason, he said, was that he would not sign the newly imposed restrictions of both the school and the National Institute of Health on experimental human surgery. It was not that he disagreed so much with these guidelines, he said privately, but that he felt if he signed them, he would be bowing to DeBakey. Baylor itself, and its president, were cleared of any inattention and misuse of federal grant money. All the official blame—the guilt—was placed at the neighboring doorstep of Denton Cooley. He was even found guilty by his local medical society on eight counts of “publicity,” to which he pleaded speedily, and wearily, “guilty.” None of the decisions against him kept him from his surgical practice, and he returned to the operating rooms with renewed vigor, still puzzled about the uproar. There were no outward marks of his flogging, nor had anyone challenged his surgical ability.

  But DeBakey would not let the matter drop. Scores of angry letters went out to physicians and hospitals not only in America but in foreign countries, spelling out what Cooley had done and what the investigations had proved. More than one major scientific society felt the wrath of DeBakey when it scheduled an appearance by Cooley (much in demand) to speak on the Karp operation. One such meeting gave Cooley a fervent, standing ovation. DeBakey withdrew many of the classic motion pictures from Baylor’s film library of Cooley’s famous open-heart surgery in children, some of the definitive work in the field. Suddenly no more reprints were available of papers coauthored by the two men. When The Harvard Lampoon published a satire on transplant mania, writing maliciously of a surgeon in Texas named Desmond Coma, who transplanted everything, DeBakey’s office photostated copies and mailed them out, thoughtfully underlining the “D” in Desmond and the “C” in Coma, in case anyone missed the point.

  His name was not to be spoken, printed, or, it would seem, remembered. Five times Cooley telephoned DeBakey. Five times he left his name with the secretary. “I felt we should at least declare a truce to discuss the future of our respective institutions,” said Cooley. “Even the Vietnamese declare a Christmas truce.” But DeBakey never called back. “Even when people have a particularly nasty divorce,” observed Grady Hallman, “they sit down and divide things up and arrange what’s best for the children. But Mike refused to even speak to Denton.”

  Once, months later, the two men found themselves in the same room at a medical meeting in San Francisco. Everyone present felt the tension might suddenly shatter, that the two men would break from the clusters of admirers who surrounded them, that they might stride toward the center of the room and clasp hands and return to Houston as one, a uniting of their strengths, their skills, their destinies. Cooley, it was said, looked twice across his shoulder at DeBakey. But the older man, it was further said, no longer acknowledged that Denton Cooley was either present, or even alive.

  CHAPTER 15

  The transplant year in Houston’s two hospitals essentially lasted from May 3, 1968, when Cooley first transplanted Everett Thomas, until April 7, 1969, when he used the artificial heart on Haskell Karp. Both Cooley and DeBakey did another transplant or two after that, but none lived very long and the spirit was gone. “It ended with a whimper, not a bang,” said cardiologist Jim Nora.

  What did it all prove? It proved that the surgeon was eminently capable of lifting a heart from one man and sewing it into the chest cavity of another. It also proved that the rest of medicine was not yet ready to take it from there. It had been thought that the transplanted heart would behave like the transplanted kidney, that the body would struggle against the foreign organ, but eventually, with the aid of medication, accept it. Immunologists learned that the heart is a peculiar, particular organ, not only a pump, but a creature of some internal, unknown majesty—its depths not fully divined by a hundred-thousand microscopic slides and tissue examinations. Moreover, the heart, unlike the kidney, could not be put back onto a machine to tide it over during a period of rejection.

  The transplant year legally defined death, which, curiously, had not been legally defined before, as it related to medicine. In 5,000 years of man’s history, a definition had not been required. Legislatures in more than forty states hurriedly passed laws with varying definitions of life’s final act. The American Medical Association passed a resolution setting up guidelines for those who would transplant. “The cause of death,” resolved the AMA, “must be evident and of an irreversible type. The fact of death must be established and must be demonstrated by adequate current and accepta
ble scientific evidence in the opinion of the physicians making the determination. The determination of death in organ donors must be made by no less than two physicians not associated with the surgical team performing the transplant.” The Texas Legislature concurred with a similar bill to protect, its sponsor said, “not only the patient, but the surgeon.”

  Transplantation blemished more than one distinguished career. A heart surgeon in Asia was brought up on criminal charges that he deliberately neglected a dying patient so that he could take the heart and use it in someone else. Another surgeon in America was sued for $1 million on similar charges of neglect.*

  On the third anniversary of human heart transplants, December, 3, 1970, the American Heart Association totaled up the worldwide statistics and announced that 166 heart transplants had been done since Barnard opened the door and that only 23 were still alive, giving the procedure an overall mortality rate of more than 85 percent. Ten of the 23 still living, however, had survived for more than two years. The only place in America where there remained enthusiasm for the procedure was Stanford University. Dr. Norman Shumway could count nine transplants alive out of the 26 he had performed. In the fall of 1970, he superseded Denton Cooley as the surgeon who had done more heart transplants than any man in the world.

  Shumway could not resist criticizing Cooley in a published interview. Shumway said: “It’s not a surgical business, primarily. If it were merely a surgical exercise, they’d all have survived. In transplants, you see diseases come into being that people had never dealt with. You need a lot of people with a lot of disciplines. You can’t have Sonny Jurgensen [the professsional football quarterback] win games without a good line in front of him. You can’t do transplants in a specialty hospital. The leader of the team can’t be a character who dominates every conversation and never has anybody around him who can’t contribute beyond him. Bright people must be heard. The guy that does cultures in the lab must feel as important as the guy who sews the heart in.… Cooley said, ‘The prescription for success in heart transplants is “cut well, tie well, get well.”’ … That’s naïveté. The problems come after surgery. They’re not surgical problems.”

  Shumway had been the man whom American medicine thought would usher in the era of transplanted hearts. Instead he became the principal surgeon to survive it. Mercifully, the race was no longer a race. The spectators had gone home; all the runners save one had dropped out. He could afford to take all the time he needed to reach the finish line.

  In Houston, Jim Nora and the other Baylor scientists interested in immunology and rejection went back to work. Using tiny, tweezerlike instruments and a miniature scalpel, Nora and his team began removing the hearts from pure-bred white mice and transplanting them into the ears of other mice. There they usually thrived and could actually be seen on the face of the ear, beating away under a thin layer of membrane. The purpose was to test various formulas of immunosuppressive drug administration and the mouse’s tolerance of a foreign body. One mouse, a favorite of the scientists, lived for several months with another’s heart beating in his ear.

  With no great enthusiasm, Nora discussed with me three potential breakthroughs in managing transplant recipients against rejection.

  The first, he said, would be to cook up a pool of transplanation antigen that could be made from pieces of the heart, thymus, and spleen taken from cadavers, plus pieces of thymus taken from a living patient during open-heart surgery. Hopefully, all possible human antigens would be dwelling within these bits and pieces and could be made into a serum. In what is called “low zone” induction of tolerance, the patient about to receive a donor heart would receive over a period of weeks carefully planned injections of this serum, beginning with infinitesimal amounts, working up to larger and larger doses—in much the same way an allergist desensitizes a patient to ragweed. Theoretically, a recipient could accept any new heart, even a badly matched heart, because his body would already have all known antigens swimming about and would not recognize the new heart as “non-self,” but “self.”

  A second and corollary procedure would be to create the same serum from a pig’s organs, inject it over a period of weeks into a human patient, and then transplant a pig’s heart into the man.

  A third, crash plan or “high zone,” method would be to go ahead and transplant a heart into a dying man, then inject him with a serum made from the cadaver donor’s liver, spleen, and those pieces of the heart not used in the operation. “The patient would be so flooded with soluble antigen that his body would be unable to recognize and reject the new heart,” said Nora.

  When would the immunologists be ready to go ahead with one or more of these procedures?

  “In point of fact, about five years,” he said. “In point of medical and moral priority, 50.” When the transplant era ended in his hospital, Nora was so burdened with guilt and disenchantment that he made plans to move himself and his family to Haiti, where he and his wife, a hematologist, would work for a year at the Schweitzer Hospital. An unexpected second child appeared, however, and Nora instead stayed in Houston and began writing an angry novel of transplantation set in a Southwestern city and called The Upstart Spring. “It was a purge for me,” he said. “Nothing else.” In December, 1970, he would accept a position as head of the pediatric cardiology department at the University of Colorado and move to Denver.

  “Was the transplant year a major disappointment of your life?” I asked Cooley one quiet summer morning in 1970. He was sitting in his second office, a small, windowless room in the basement of St. Luke’s; behind him was a color portrait of the transplant team made the moment after an operation, with an inscription from Gide, “Man cannot discover new oceans unless he has the courage to lose sight of the shore.” Cooley is the kind of man who will answer impertinent if not cruel questions, and he did not hesitate. He explained the failure by believing that it was not a failure. Our conversation:

  “There are many blind alleys we must go down in making progress,” he began. “If you’re charting unexplored territory, you can’t expect to be riding down a freeway. You’ve got to go out there where there are no paths, many times you may go through one canyon and meet a cliff. To get from Plymouth Rock to San Francisco Bay, the pioneers didn’t go straight over the hill to the valley on the other side. Sometimes blind alleys may be only temporarily blind, subsequently we’ll blast them open.”

  “Then I take it you have no regret over the transplant year?”

  “No.” Emphatic. “I don’t think I have any regrets about having tried. I followed to the best of my ability those principles of selection of patients, of taking desperately ill patients whose hearts were in advanced deterioration. I can’t recall any of that group that I could do anything more for today. So that’s reassuring to me.”

  “None of them would be candidates for the coronary artery bypass surgery which seems so popular these days?”

  “Out of the twenty-one, I can’t think of any. Because they had ventricular aneurysms, diffuse areas of scar tissue that would make them entirely unsuitable for the bypass. We didn’t stretch the indications for transplant surgery. Even though some of the patients may have had their lives shortened by a few months, none of them had their lives shortened by a matter of years. The few months of life would have been unsatisfactory.… I look back on transplants as just one of those procedures which we tried, and for the time being, discarded.”

  “Was there a time when they all began coming in and rejecting and dying when you felt your skills had deserted you?”

  “Well, I couldn’t help but ponder why some other surgeons have had patients who are still alive, after two years, and my longest survivor was sixteen months. But I think that our initial results are as good as anyone’s. What happens to them three months later is not a reflection of the surgical technique! Surgeons don’t control these things anyway.… People say, well his results were worse than others, but look at some of the things we tried. We tried a newborn infant, nobody else ha
d pulled one off the table. We got a heart and a lung out of that one. We did a five-year-old. We took people who were flat-out dead and put a new heart in, and they lived! It was an opportunity, a time for testing things, and, by God, we tested them.”

  Would Cooley consider using the artificial heart again?

  “Of course! I’d have implanted it two weeks ago if I had had one ready to go. There was a man with a healthy body who died on me because his heart was diseased. It wasn’t time for him to die. I’ll tell you one thing—by the end of this decade we won’t be letting people die on our tables. Some patients will live for a year with an artificial heart inside them.”

  Only in a laboratory one floor above DeBakey’s surgical suites was there unqualified enthusiasm in Houston for transplants, not because they were a valuable surgical procedure, but because—as an ironic side product—they provided a tantalizing clue to the very nature of heart disease. The principal investigator there was a biochemist named Arnold Schwartz, a friendly, engaging scientist, one of the hundreds drawn from the eastern United States, lured by the aura of DeBakey. “I enjoy being a pearl on DeBakey’s necklace, but it is a symbiotic relationship,” he said. “DeBakey never comes around because he knows who is producing and who isn’t.”

  Schwartz long ago had accommodated himself to the lesser role of working as a researcher in a house of surgery, even though he was and is often skeptical of the surgeon. “Surgery to me is not creativity,” he explained. “It’s plumbing, very exquisite plumbing, but plumbing. What we do with the hearts is creative. When you start humanizing something in science, I’m not sure you can create.”

  During the time of heart transplants, Schwartz—for the first time in his career—was able to obtain fresh heart tissue for study. “Short of going out and killing somebody and taking their heart, I had never been able to examine fresh tissue. When DeBakey and Cooley started doing transplants, I went right into the operating room with a mask and gown on and they snipped off a little piece for me. They called me ‘The Ghoul from the School.’” Schwartz also was given the entire recipient heart to study after the natural owner received a new one.