Transplant Buccaneers: P.K. Sen and India’s First Heart Transplant, February 1968

Transplant Buccaneers: P.K. Sen and India’s First Heart Transplant, February 1968 Abstract On 17 February 1968, Bombay surgeon Prafulla Kumar Sen transplanted a human heart, becoming the fourth surgeon in the world to attempt the feat. Even though the patient survived just three hours, the feat won Sen worldwide acclaim. The ability of Sen’s team to join the ranks of the world’s surgical pioneers raises interesting questions. How was Sen able to transplant so quickly? He had to train a team of collaborators, import or reverse engineer technologies and techniques that had been developed largely in the United States, and begin conversations with Indian political authorities about the contested concept of brain death. The effort that this required raises questions of why. Sen, who worked at a city hospital in Bombay that could not provide basic care for all its citizens, sought a technology that epitomized high-risk high-cost, health care. To accomplish his feat, Sen navigated Cold War tensions and opportunities, situating his interests into those of his hospital, municipal authorities, Indian nationalism, Soviet and American authorities, the Rockefeller Foundation, and others. The many contexts and interests that made Sen’s work possible created opportunities for many different judgments about the success or failure of medical innovation. On 17 February 1968, Bombay surgeon Prafulla Kumar Sen transplanted the heart of a twenty-year-old woman into a twenty-seven-year-old shepherd suffering from a chronic, progressive cardiomyopathy.1 Although the recipient died within three hours, the surgical team praised their work: “The operation was technically a success. It was a perfect operation.”2 Sen was “flooded with congratulatory telegrams from eminent cardiac surgeons the world over.”3 He was the fourth surgeon to perform a heart transplant, the first in India, the first in Asia. He did it before surgeons in England, France, Canada, Australia, Japan, or the Soviet Union, and before Michael DeBakey and Denton Cooley, the giants of American cardiovascular surgery.4 The editor of the Journal of the Indian Medical Association considered Sen’s feat “a record for which the whole of India is proud.”5 The ability of Sen’s team to join the ranks of the world’s surgical pioneers raises important questions. Consider the question of how Sen transplanted so quickly. The key innovations in cardiac surgery had taken place outside of India and were actively pursued by surgeons in India. India’s acquisition of cardiac capability accelerated dramatically over the twentieth century. The lag between the first successful heart operation (repair of a stab wound to the left ventricle, Frankfurt, 1896) and the first in India (the same procedure, Bombay, 1944) was forty-eight years. The lag between the first successful use of a heart-lung machine (Philadelphia, 1953) and the first in India (Vellore, 1961) was nearly eight years. The lag between the first heart transplant (Cape Town, 3 December 1967) and the first in India was just eleven weeks. Sen’s team later claimed that they could have performed their transplant as early as 1965. It is possible to study the development of Sen’s clinical and research programs in order to understand how he moved so quickly when heart transplantation became possible. Sen navigated Cold War opportunities, exploiting ties to both the Soviet Union and the United States, to mobilize the knowledge, devices, and expertise of cardiac surgery and beat better-resourced surgeons to the feat of heart transplant. The question of why is equally puzzling. In the 1960s India struggled to provide basic medical care to its population. Sen, who spent his career at a municipal hospital, knew this well. Heart transplantation, meanwhile, epitomized the technologically-sophisticated, high-cost health care made possible by the wealth of post-war America. Sen’s pursuit of this technology triggered a debate in India about whether it made sense for heart transplants to take place in developing India. This became part of the emerging discourse on “appropriate technology.”6 Many interests shaped the trajectory of Sen’s work, from the reluctance of the Bombay Municipal Corporation to invest in academic medicine to the modernizing ambitions for Indian physicians to keep abreast of scientific advances in the west. Only by understanding how and why the transplant was done is it possible to understand the claims of success. Who, beyond the patient, stood to benefit from an attempted transplant? Why did Bombay surgeons and journalists celebrate despite the patient’s death? Sen’s operation was simultaneously an experiment, a demonstration project, and a therapeutic endeavor. The struggles by Indian surgeons to establish open heart surgery and the local, national, and transnational interests that made their work possible created a context in which there could be many different judgments about the success or failure of medical technology. Sen’s operation can be considered a failure at another level. His team attempted only two transplants; no one in India tried again for twenty-five years. Heart transplants had taken place in twenty countries between 1967 and 1969.7 The dynamics varied in each, depending on nationalist impulses, Cold War politics, the availability of resources and expertise, and countless other factors. Sen’s transplants and their aftermath reveal how Indian contexts shaped the reception of a globalizing technology. Sen thought India had enormous potential as a transplant center: its chaotic roads and railways generated a tragic abundance of potential organ donors.8 Yet he could not convince legal and legislative authorities to join other countries and adopt the concept of brain death and the therapeutic procedure that depended on it. Histories of an Epidemic of Transplants Heart transplantation, perhaps the most dramatic medical event of the twentieth century, has received enormous attention from journalists, historians, anthropologists, and sociologists. Lesley Sharp attributes the fascination to the ways in which transplantation “simultaneously epitomizes technical genius and medical hubris.”9 Existing scholarship focuses on three issues. Historians of medicine, especially Susan Lederer and Thomas Schlich, have traced the long pre-history of the transplant imaginary. While the first successful human kidney transplant took place in 1954, the idea of organ transplantation has existed for millennia. Active work began in the nineteenth century. Even as early efforts raised fraught moral questions, they met with great enthusiasm, “celebrated in the popular press as emblematic of surgical possibility and promise.” Movies, novels, and newspaper coverage helped “to establish the surgical imaginary, a trajectory of possibility about remaking the human body.”10 The tensions that would emerge in Bombay in 1968 were decades in the making. Historians, surgeons, and journalists have scrutinized Christiaan Barnard’s transplant and the dramatic year that followed. They have chronicled both the nitty-gritty details of experiments and clinical innovations, the melodrama of the rivalries between competing surgeons, and Barnard’s celebrity escapades: “Ambition and envy, compassion and resentment, dedication and despair, glory and infamy shadow this story.”11 This work both celebrates (e.g., medical and technological achievements) and critiques (e.g., Barnard’s ambition, the media frenzy). Excellent work has also examined the furor over brain death and the efforts to resolve it.12 Sociologists and anthropologists have examined the tensions that have accompanied heart transplantation since 1968. Reneé Fox and Judith Swazey, who followed developments in real-time, described how heart transplantation “epitomizes the bold, uncertain, and often dangerous adventure in which medical professionals and their patients are engaged.” They were interested in the ethics of the fraught transition from experiment to therapy, “Problems of uncertainty, meaning, life and death, scarcity, justice, equity, solidarity, and intervention in the human condition.”13 As transplants increased in the 1980s, they became disturbed by society’s increasing acceptance of “’spare parts’ pragmatism” and the investment in organ replacement when so many people lacked access to basic health care.14 Lesley Sharp has tracked “a simultaneously wondrous and disquieting medical field.”15 She focuses on what the “transplant imaginary” leaves unsaid: “At the heart of this work, so to speak, are deep concerns about the inevitable yet silenced nature of patient suffering.”16 Lawrence Cohen has explored the fraught ethics of organ harvesting in India.17 The extensive literature mostly ignores or dismisses Sen and the history of heart transplants in India. Many works describe the first five transplants (by Barnard, Adrian Kantrowitz, and Norman Shumway), but stop short of the sixth—Sen’s.18 When Sen does appear in historical writings, the coverage is rarely favorable.19 Shumway, in a 1997 oral history, is typical in his dismissal: “Some surgeons were attracted to the publicity and personal aggrandizement. Soon transplants were being done in India and places where you would not want to have any kind of heart operation.”20 Shumacker briefly acknowledged Sen’s research and clinical attempts.21 We have found only a few short biographies in medical journals that detail Sen’s accomplishments, but these rely on his publications.22 No one has attempted a thorough history of Sen’s research and clinical programs using archives, Indian newspapers, and other sources to reveal the details of his work, its stakes, and the controversies that played out in Bombay in 1968.23 The silence about Sen is informative, revealing scholars’ assumptions (often racialized) about where and how science and innovation take place. Many histories of heart transplantation, and of medical innovations in general, have focused on linear and progressive processes of discovery and diffusion, ones that foreground Europe and North America. Schlich and Crenner called on scholars to redirect their attention to the social, political, and economic contexts of innovation and recognize the ways in which historical actors faced complex and contingent choices between alternative paths.24 Sally Frampton has emphasized the importance of recognizing “the ripples of unease” that often accompany innovation.25 Our work demonstrates this complexity well. It highlights the ways in which innovation can occur in unlikely spaces.26 K.E.M., a municipal hospital, existed on the uncertain and unregulated margin of state practices, where weak control and “illegible” legal and institutional frameworks enabled experiments in cardiac surgery.27 Chronically under-resourced, K.E.M. provided Sen with few incentives or resources for innovation. Yet it allowed him to mobilize local and international allies and take advantage of the exchanges of people, ideas, and techniques between many countries made possible by the post-colonial order. The new technologies, however, did not have an inevitable trajectory. Indian physicians, officials, and citizens made complex choices about what path a particular surgical innovation—heart transplantation—should take in India. Heart Disease and Surgery in Independent India In 1950 few would have expected that India would soon host pioneering work in cardiac surgery, as neither surgery nor heart disease received much attention in India. Even though cardiologists had begun to describe heart disease as a “growing menace,” they understood that the traditional problems of public health deserved the lion’s share of attention.28 A 1958 study of coronary artery disease conceded this point: “We in India at present have to continue to think in terms of more important problems, such as those in infant mortality, infectious disease, nutritional disorders, overpopulation, and a host of other public health problems.”29 And while surgery had been present at colonial and mission hospitals in India since the nineteenth century, the Indian population had remained ambivalent about its practice.30 Surgical capacity remained limited into the 1940s. As one of Sen’s trainees later recalled, “the horizon of Indian surgery was largely limited to surgery of abdominal cavity which included simple operations for common ailments such as hernia, appendicitis and peptic ulcers.”31 After independence, Prime Minister Jawaharlal Nehru and his minister of health, Amrit Kaur, included surgery in their plans for India’s techno-scientific modernization. Kaur encouraged her audience at the annual conference of the Association of Surgeons of India in 1951: “Living as we are in a scientific and machine age there is no knowing what the surgeon of the future may be called upon to do.” Surgery of the brain and “even the heart” was within reach.32 Outsiders, confident in their opinions despite their modest knowledge of India, critiqued such ambitions. One Boston surgeon, who had spent three months teaching surgery in India, argued that Indian surgeons needed realistic aspirations, and that “in a nation that is leaping ‘from a cow dung fuel economy to the nuclear age it is more important to provide smallpox vaccine than Salk vaccine or heart surgery.’”33 Such restrictive ideas about the trajectory of scientific research and medical priorities in a “developing” nation were precisely what Sen and his contemporaries would challenge through the successes of their “failed” heart operations. Born in Calcutta, Sen studied medicine at Seth G.S. Medical College in Bombay and trained in surgery at K.E.M. Hospital from 1939 to 1942. He joined the staff at K.E.M. in 1942.34 Seth G.S. and K.E.M. had both been founded in 1926 as nationalist institutions in reaction against the refusal of Grant Medical College to appoint Indian physicians to its faculty.35 Sen imbibed his institutions’ nationalism. In 1958, he called on India to strengthen its own medical training programs and wean itself off its dependence on the West. Nowhere was this truer than in surgery. While he acknowledged the examples of John Hunter, Alexis Carrel, and Harvey Cushing, he sought inspiration in ancient India. Charaka “laid down four essential attributes of a surgeon 4000 years ago”: surgeons had to be scientists, technicians, teachers, and leaders of society.36 By linking his own work to India's classical medical traditions, Sen sought to create a discursive space for surgical innovation in India. With help from the Indian Research Fund Association (renamed the Indian Council of Medical Research (ICMR) in 1949), Sen began animal studies, chart reviews, and clinical research on diarrhea, tuberculosis, perforated ulcers, and traumatic shock, including new techniques developed by Soviet researchers at the Moscow Medical Institute.37 Seeking advanced training in surgical research, he applied for a fellowship from the Rockefeller Foundation in September 1949. The Foundation asked I.S. Ravdin, chair of surgery at the University of Pennsylvania, to accept Sen as a trainee.38 Ravdin obliged. He had directed the US Army’s 20th General Hospital in Assam on the Indo-China frontier during World War II.39 He had attended the 1944 All Indian Conference of Surgery and “was deeply impressed with the fact that we had to do something to help India if surgery was going to be raised above the level of a trade.”40 Ravdin arranged for Sen to work for six months with James Hardy, then a fellow on the thoracic surgery service (Hardy would later attempt the first heart transplant in a human—see below).41 They used radioisotopes to study the impact of surgery on adrenocortical activity and presented their research at the annual meeting of the American College of Surgeons in Boston in October 1950.42 This fellowship also exposed Sen directly to the problem of race in America and the inequities that existed with “modern” societies. When they traveled to Atlantic City to present at the American Physiological Society, the clerk at the Lyric Hotel barred Sen. Hardy reassured her that Sen was Indian and they were admitted, “somewhat unsettled.”43 Sen finished the year with a tour of surgical research centers in Chicago, Minneapolis, Rochester, Cleveland, Ann Arbor, Boston, New York, Baltimore, Montreal, London, and Sweden. When Sen returned to Bombay, K.E.M.’s Dean Dhayagude asked him to organize a department of “Experimental Surgery.” The hospital offered him space and the ICMR provided Rs. 6000 (c. $1300), but this was not enough. In July 1951 Sen asked the Rockefeller Foundation for help.44 In October 1952 Dhayagude followed up with the Foundation on Sen’s behalf, explaining that Sen’s research “requires some costly equipment which cannot be provided from the sources available to us.”45 He told Rockefeller official Richmond Anderson that “Sen is really taking hold of his work in experimental surgery and has aroused the interest of others in the institution.”46 The Foundation approved a grant of $3,500 in April 1953.47 Sen’s interests had turned in the meantime to cardiac surgery. In 1952 he performed his first, closed-heart operation (the first intra-cardiac operation in India), inserting his finger through an incision in the right atrium of a beating heart to force open a rheumatic mitral valve.48 Even in the early years of his career, he sought to engage with western experts, improve their techniques, and share his innovations. In this case, he studied American techniques and experimented on twenty-five dogs, eventually developing his own approach, one “more practical and less dangerous than the other choices available.”49 He used this technique in three patients and presented his results at the annual conference of the Association of Surgeons in India in December 1952.50 This was an exciting time. Cardiac surgery had not existed in the 1940s, in India or any place else. Ambitious surgeons made rapid progress after World War II tackling simple cardiac lesions (e.g., patent ductus arteriosus, mitral valve stenosis) that could be treated by anyone trained in thoracic surgery. They soon set their sights on open-heart surgery. The excitement reached India. In October 1952 the Times of India covered the annual meeting of the American College of Surgery: “Transplantation of heart, lung, and other vital organs, impossible now, is being studied in an increasing number of surgical centers.”51 Articles about the “miracle of modern surgery” appeared regularly in Bombay.52 Open-heart surgery, however, was a difficult challenge. As Hardy later explained, “relatively few made the long jump from tuberculosis surgery and closed-heart operations, on the one hand, to full-scale open-heart surgery when the field was rapidly developed after 1954.”53 Sen did. Open heart surgery required surgeons to protect the body as they stopped the heart, opened its chambers, and performed their repairs. Sen had read about two basic approaches. Surgeons in the United States, Sweden, and Russia had developed heart-lung machines, but he did not think these were ready for widespread use: “The prohibitive cost and the complicated nature of the apparatus militate against immediate general acceptance.”54 As he told his colleagues at K.E.M. in 1953, “like all artificial organs devised, a technical failure is inherent in its very nature.”55 The other approach, hypothermia or “artificial hibernation” cooled the body to reduce oxygen consumption and protect the brain. Sen considered this a “physiological approach.”56 Hypothermia was first used successfully at the University of Minnesota in 1952. Sen began his own experiments in 1953. He cooled dogs, opened their hearts, and then saw how many he could revive. Although half the animals died, mostly from ventricular fibrillation, Sen was not discouraged: “We feel that the procedure is a perfectly feasible one, and, with further knowledge in the management, may be rendered very much safer.”57 When Anderson visited in April 1954, he found Sen “doing some interesting work on refrigeration.”58 Sen’s first hypothermia patient died in 1954. After extensive and often “disappointing” research, they achieved clinical success in 1956, using four minutes of “total circulatory arrest” to repair an atrial septal defect.59 Eager to keep up with developments in the west, Sen obtained a second travel grant from the Rockefeller Foundation and toured leading cardiac centers in Europe and North America from September 1956 through May 1957.60 He also hosted foreign surgeons in Bombay. In February 1958, Sir William Heneage Ogilvie, an “eminent British surgeon,” spoke at Seth G.S. He “advised young doctors to approach surgery with the spirit of romance, as it called for adventure, courage, tact, perseverance, gentleness and originality.” Surgeons, especially transplant surgeons, often praised their own pioneering spirit.61 Sen, who welcomed Ogilvie’s vision, “proposed a vote of thanks.”62 The Turn to Transplant Even as Sen worked to master closed heart techniques and hypothermia, he turned his attention to heart transplantation. He attributed his interest to the “monumental papers” written by Alexis Carrel and Charles Guthrie.63 Working at the University of Chicago in 1905 and 1906, they developed techniques to repair blood vessels and then used these techniques to experiment with organ transplants. Described as a “Wizard of Oz,” Carrel won wide acclaim for heart transplants: “He has taken the heart of a little dog and introduced it into the neck of a larger dog and linked it up with the coronary circulation of the latter, and thus done literally probably what has never bene done before, all poetry and fancy to the contrary—made two hearts beat as one!”64 Even though Carrel won a Nobel Prize in 1912, surgeons did not rush to follow his lead. A team at the Mayo Clinic transplanted hearts in dogs in the 1930s, but simply to study the physiology of denervated hearts.65 In the 1940s Vladimir Demikhov began research in Moscow, transplanting hearts (and heads) in hundreds of dogs.66 Surgeons in Chicago and Philadelphia began similar work in dogs in the early 1950s. Sen began his own research on transplantation in 1954.67 Inspired by the work in Philadelphia, and with funding from the ICMR, he conducted a simple experiment: Will a heart, removed from an animal, survive the duration of a transplant procedure? He removed hearts from “profoundly hypothermised dogs” and watched. 68 Anderson, who visited the lab in June 1955, was dubious: “I am not certain of the purpose or value of this particular experiment though Dr. Sen is certainly working hard on his own time both in the laboratory and in clinical surgery.”69 Although Anderson saw one heart beat for twenty minutes, few did that well. Sen’s team conceded that “the period of effective cardiac contractions (average ten minutes) was not long enough to justify an immediate serious trial of the second phase of our undertaking, namely, actual transfer of a heart-lung preparation from one frozen animal to another.” Sen put his transplant program on hold in 1956: “This and many other technical and physiologic complexities have to be solved before heart-lung transplantation is generally feasible.”70 As Sen refocused his efforts on hypothermia, more surgeons took on the challenge of heart transplants. By the early 1960s teams of researchers worked in Moscow, Chicago, Philadelphia, Jackson (Mississippi), New Orleans, Cooperstown, St. Louis, Guelph, Palo Alto, London, Puerto Rico, and Czechoslovakia.71 The most influential work came from Stanford’s Norman Shumway and Richard Lower, who performed their first successful dog transplant in 1960.72 By 1963 they believed that they had mastered the surgical techniques needed to preserve the donor heart, support the recipient’s body during the procedure, and complete the transplant. They knew, however, that they had to prevent immunologic rejection.73 Adrian Kantrowitz, who had observed Demikhov perform valve surgery (but not transplants) in Moscow in 1959, transplanted hearts in puppies, whose under-developed immune systems tolerated the new heart; one survived 213 days.74 Other surgeons experimented with methotrexate and azathioprine to prevent rejection.75 In 1967 Lower, who had left Stanford for the Medical College of Virginia, reported 15-month survival after a heart transplant in a dog treated with methotrexate.76 Many teams felt ready to transplant by the late 1960s. Sen focused on hypothermia into the 1960s and conducted ongoing dog research and clinical attempts.77 In 1962 he described his experiences in eleven patients with atrial septal defects. The team was pleased with the “gratifying results” even though only six survived.78 Sen knew, however, that surgeons in the United States had made rapid progress with heart-lung machines.79 Despite his initial skepticism, his team began to test them in the laboratory in 1958. Early results disappointed: a “majority of the animals succumbed to the extracorporeal circulation, due to uncontrolled bleeding.”80 Sen realized that success with heart-lung machines would require skilled collaborators with American training. He convinced the Rockefeller Foundation to provide fellowships to K.E.M.’s cardiologist, Keshavarao Krishnanao Datey, to his pathologist and laboratory director, Suman Kinare, and to one of his surgical trainees, Tryambak Pandurang Kulkarni.81 Another trainee, G.B. Parulkar, also received funding to study abroad.82 Indian surgeons had to work hard to obtain and master heart-lung machines. Financial support from the Rockefeller Foundation allowed Sen’s team to dodge India’s restrictions on currency exchange and purchase equipment from European and American companies. However, this was never easy. Sen faced constant frustration and delays as he tried to import pumps, oxygenators, gaskets, filters, and spare parts.83 In 1961 two competitors in India, Kersi Dastur in Bombay and Nagarur Gopinath in Vellore, performed open heart surgery with heart-lung machines, motivating Sen’s team to move more quickly.84 On 30 March 1962 they used their heart-lung machine to repair a ventricular septal defect in a child.85 Even though the “entire operation was uneventful,” the outcome was tragic: “The patient did not wake up after the surgery, obviously due to the brain damage.” Despite this outcome, Parulkar saw a silver lining: “From this one single case we learnt much more than the hundreds of animal experiments that we had performed.”86 In January 1962 Sen asked the Rockefeller Foundation to underwrite another overseas trip: “I should like to get back to the ‘edge of progress’ even if it is for a short visit. It has been five years since I have been abroad and so much has happened.”87 The planned itinerary included Tokyo, San Francisco, Los Angeles, Palo Alto, Houston, Mexico City, New Orleans, Philadelphia, Detroit, Cleveland, Rochester, Boston, Philadelphia, Washington, New York City, London, Birmingham, Edinburgh, Amsterdam, Copenhagen, Leningrad, and Moscow. In July the Foundation approved $5800 for the four-month trip.88 As Sen traveled that fall, the Times of India celebrated the continuing progress of cardiac surgery and its “ingenious devices,” writing “the terrors are slowly receding as great strides of progress in diagnosis and treatment are made in the field of cardiovascular care and therapy.”89 At the end of his trip, Sen visited Demikhov in Moscow.90 Even though Demikhov had not published his work in English before 1962, his heart and head transplants had been covered in newspapers.91 A Times of India editorial in August 1959 reported that he had “engrafted a second heart on a lucky dog.” It described the news as “very heartening” before veering into jokes about romance with two hearts and transplanting a lion’s heart to fortify a coward.92 Sen’s ability to visit Demikhov provides a revealing glimpse into one aspect of Cold War science. Historians of science have documented the many challenges and opportunities that the conflict presented to scientists.93 Overt hostility between the United States and the Soviet Union interfered with some forms of scientific exchange. The Central Intelligence Agency, for instance, tracked the Rockefeller Foundation’s activities in India. In March 1956 agents asked Anderson about his “knowledge of Communist activities on the part of doctors in India.” Anderson, citing the “nonpolitical” orientation of the Foundation, denied knowing anything: “We tended to avoid political discussions with Indians with whom we worked, nor did we go around trying to determine indirectly their political views.”94 But the conflict also motivated other kinds of exchange. Many physicians, most famously cardiologist Paul Dudley White, used medicine to foster bonds between countries separated by Cold War tensions.95 Sen was freer to pursue ties with colleagues in the United States and the Soviet Union than were his peers on opposing sides of the Iron Curtain. The Indian government worked carefully to avoid falling under the sway of the United States and actively cultivated ties to the Soviet Union. This helped Indian physicians move easily between the scientific establishments of Cold War rivals. A.V. Baliga, one of P.K. Sen’s senior surgical colleagues at K.E.M. Hospital, directed the Indo-Soviet Cultural Society.96 He may have facilitated Sen’s contacts with Demikhov. Sen himself received the Vishinsky Medal from the Soviet Union in 1962.97 Sen and Hardy Transplant Sen returned to Bombay in early January 1963. That week Herbert Conway, a New York surgeon and editor of Transplantation, spoke at K.E.M. He told reporters that “he looked forward to the day when it would be possible to prolong life by the transplantation of an organ like the kidney or even the heart.”98 Inspired by his visit with Demikhov, Sen resumed work on heart transplants. Despite progress with open heart surgery, many patients had lesions that could not be corrected. In these patients surgeons had considered “a replacement or a support of the original heart with a new heart.” Sen knew that many problems “limit the execution of such an ambitious goal.” 99 In 1963 and 1964 Sen’s team conducted four sets of experiments on a total of 100 dogs.100 In sixty dogs, they transplanted hearts into the neck (the Mayo technique from the 1930s) to study both the behavior of the transplanted heart and methods to prevent rejection with methotrexate and steroids; in thirty, they transplanted a heart to replace the recipient’s heart (Lower and Shumway’s technique); in five, they transplanted the heart as an auxiliary booster heart (Demikhov’s technique); and in five, they performed heart-lung transplants, “using our own method suggested in 1956.”101 Their results disappointed. Dogs with heart transplants survived up to six hours, and those with heart-lung transplants up to twelve hours. They obtained the best results when the heart was taken from the donor while still beating.102 Despite such grim results, the research earned accolades in the Times of India. A front-page article with photograph on 11 October 1963 trumpeted “Dog with Two Hearts Is Normal: Miracle Surgery in City Hospital.” S.M.Y. Sastry, the acting Municipal Commissioner, “proudly announced the operation in the corporation.”103 Three days later the paper celebrated the “Daring Experiment” once again, adding that “the two-hearted dog behaved as normally as could be expected in the circumstances.”104 Anderson visited the lab in December and found Parulkar and Panday at work on cardiac transplantation. He noted, “One gets the impression that sound and important progress is being made.”105 When Sen updated Anderson three weeks later, he noted that a transplanted heart “has been able to support the circulation independently for a period of three hours.”106 By mid-January 1964 a breakthrough seemed inevitable: “Though no heart transplants in human beings have yet been made, there is growing belief by many prominent researchers that it will be accomplished—perhaps within the next decade.”107 Two weeks later news broke that James Hardy, Sen’s mentor in Philadelphia in 1950, had transplanted a chimpanzee heart into a human. Even though the heart beat for just seventy-five minutes, Hardy knew that his team had “breached the massive intellectual and emotional barrier which had previously prevented heart transplantation in man.” The news “fell like a bombshell on the world.”108 Reaction was swift and furious, in part because of the chimpanzee heart, and in part because of the racial tensions in Mississippi in 1964. When Hardy spoke two weeks later at the Sixth International Transplantation Conference at New York’s Waldorf-Astoria Hotel, he received a scathing introduction from Willem Kolff, a pioneer of dialysis who had survived the Nazi occupation of the Netherlands: “In Mississippi, they keep the chimpanzees in one cage and the Negroes in another cage, don’t they, Dr. Hardy?”109 The backlash dampened enthusiasm among heart surgeons about human transplants.110 It is not clear when Sen learned about Hardy’s transplant.111 However, Hardy visited Bombay in 1966 and spoke at Seth G.S. about “organ transplantation, with the emphasis on the heart and the lung.”112 Indian newspapers, meanwhile, continued to cover other developments, whether Shumway’s latest experiments or a Czech surgeon’s lecture in Bombay about transplants and artificial hearts.113 Sen’s team remained hard at work. They launched a second round of experiments to determine the best way to preserve the donor heart. They obtained 100 puppies, killed them in various ways (e.g., anoxia, neuromuscular blockade, electrical shock, and exsanguination), waited up to twenty minutes, and then tested different methods to perfuse the heart for an hour before transplanting it into the neck of another dog.114 Sen visited Demikhov a second time in 1965 and became intrigued by the hypothesis that rejection was caused by anoxic injury to the donor heart during the procedure. He learned to use stapling devices developed by Soviet surgeons to complete vascular anastomoses more quickly. In September 1966 Parulkar posted an advertisement for a surgical research fellow to work on an “Enquiry into the methods and fate of homologous heart transplant.”115 In their final experiments, they tried to replicate Kantrowitz’s work using hypothermia to enable transplants in puppies.116 By 1965 Sen’s team had gained considerable experience with heart transplant procedures in dogs. One had survived eight days. As Parulkar recalled in 2004, “our group felt technically competent to perform the human heart transplant in 1965.”117 This claim (which is not made in sources from the 1960s) is intriguing. Eight days of survival was not much, especially compared to the longer survivals reported by Demikhov, Kantrowitz, Shumway, and Lower. How could they consider human transplants based on that record? A.P. Chaukar, who joined Sen’s team as a surgical resident in 1965, offered an explanation: “In those days we were replacing a dog’s healthy heart with a worse (post-transplant) heart. In a human transplant we hoped to replace a failing heart with a better one, and so thought results would be better in humans versus dogs.”118 Regardless of their readiness, the team could not get approval from the government: “Permission to do the transplant however was denied by the State authorities.”119 They knew that optimal results required taking a beating heart from a human donor. But the concept of brain death had not been legislated in India or anywhere else in 1965: a beating heart meant a living person. As Chaukar remembered, “Nobody thought we could legally do it.”120 It might not have helped that Sen’s team had feuded repeatedly with the Bombay Municipal Corporation. The Corporation did not provide the funding it had promised when the Rockefeller Foundation invested in Seth G.S. Medical College in 1956 to create a full-time, research-based faculty (with Sen as the professor of surgery). As the commissioner explained in 1961, “the municipality has responsibility for medical care of the people in Bombay, but not for medical education.”121 The Corporation also denied Sen permission to admit paying patients to K.E.M., depriving him of a valuable source of revenue.122 The First Six Human Heart Transplants From 1965 through 1967, surgeons in many countries sought the right mix of expertise, donor, recipient, and legal framework. Kantrowitz almost attempted a heart transplant in June 1966, but the prospective donor died too slowly for the heart to remain viable.123 In November 1966 Delhi hosted the 5th World Congress of Cardiology. Elite cardiologists and cardiac surgeons from all over the world descended on India. K.E.M. cardiologist K.K. Datey, presiding, celebrated surgeons’ success replacing heart valves and believed that “replacement of the whole heart loomed on the horizon.”124 Commentators sought to distinguish realistic prospects from “Surgical Fantasy.” While one editorial dismissed an American proposal to equip astronauts with extra organs and limbs so that they could survive on Venus or Jupiter, it saw real potential in heart transplantation.125 Shumway, speaking at the American College of surgeons in October 1967, declared that he was ready to proceed: “The time has come for clinical application.”126 Kantrowitz sent out 500 telegrams to medical centers in hopes of finding an anencephalic infant whose parents would consent to heart donation.127 But Christiaan Barnard struck first. Barnard, who had trained in cardiac surgery at the University of Minnesota (where he overlapped with Shumway), returned to South Africa in 1958 and established open-heart surgery in Cape Town. He visited Demikhov in 1960 and discussed heart transplants. He made his own two-headed dog in 1962 and began experiments on hearts. In 1966 he traveled to the United States to study kidney and liver transplants. While there, he watched Lower perform a heart transplant in a dog. He returned to South Africa and began to search for appropriate patients. He benefitted from a quirk in South African law, which did not specify cessation of cardiac activity as part of a physician’s determination of death.128 Barnard performed the first human heart transplant on 3 December 1967 and unleashed a media frenzy.129 The Times of India provided front page coverage and near daily updates on this “landmark in the history of surgery.”130 It also described Kantrowitz’s first attempt, which came just three days after Barnard’s.131 Barnard’s patient died 21 December.132 An editorial on 25 December noted that despite what Barnard had accomplished, “the first ever human heart transplant operation must be deemed a heroic failure.”133 Skeptics foretold a dystopian future: “One need not be a science fiction writer to envision the possibility of future murder rings supplying healthy organs for black market surgeons whose patients are unwilling to wait until natural sources have supplied the heart or liver or pancreas they need.”134 Barnard, Shumway, and Kantrowitz each performed heart transplants in early January. Barnard’s patient, Philip Blaiberg, would survive for 18 months.135 The Times continued its intensive coverage, publishing twenty-two articles about heart transplants between 3 January and 16 February. This second round of transplants again provoked outcry. On 3 January the Soviet Health Minister critiqued Barnard’s transplants and announced that Soviet surgeons would be barred from attempting them.136 When Barnard imagined a future in which herds of specially bred animals served as organ donors, an editorial reassured readers that “This may shock the queasy, but there is nothing wrong with it.”137 Cardiac surgeon J. C. Callaghan denounced Barnard’s attempt as “medical sensationalism at its height.”138 On 14 January Howard Rusk, writing in the New York Times, condemned “the international epidemic of cardiac transplants.”139 News of Barnard’s “sensational transplant surgery” spurred Sen’s team to action.140 As they explained later that year, “With a breakthrough in South Africa and its obvious clinical implications, our laboratories went on a serious, concerted crash programme of organised, fully simulated animal exercises aimed at early clinical application.”141 They tweaked Shumway’s technique, practiced on human cadavers, and worked hard to convince Dean S.V. Joglekar to authorize taking the donor heart. As Chaukar recalled, Joglekar “took a heck of a lot of risk”: “He was the one who would be answering all the questions.”142 In January they identified a potential recipient, a twenty-seven-year-old man with chronic progressive cardiomyopathy, who had been admitted to K.E.M. Hospital in late summer 1967 with abdominal distension, peripheral edema, and worsening shortness of breath. He could only walk twenty meters.143 Five months of aggressive medical management had reduced his edema but had not improved his cardiac function. Surgeons recommended a transplant on 16 January 1968; the patient consented and was transferred to the surgical service on the 18th.144 He knew that he would be the first patient at K.E.M. to receive a transplant: “He was very aware of the risks.”145 In the absence of an intensive care unit (one did not open at K.E.M. until later that year), the surgeons planned to convert their cardiac operating room into a post-operative recovery room.146 After a four-week wait, they found a donor, a twenty-year-old woman who had suffered a severe head injury after falling from a train on 16 February. As her condition deteriorated, surgeons took her to the operating room and finished preparations for the transplant.147 The team waited for “total cessation of cardiac activity,” as documented by an electrocardiogram, before taking her heart.148 The heart was distended—an ominous sign—by the time it could be removed; the team, however, remained hopeful that it would work. The transplant procedure, which started just after midnight on 17 February, seemed to go well. When the donor heart was connected, “heart action was forceful and we felt very hopeful that the transplanted heart would be able to support the circulation.”149 However, after just fifteen minutes the right ventricle distended and failed, forcing the team to restart the heart-lung machine.150 The team tried “all measures” to salvage the transplant, but to no avail: “The transplanted heart gradually failed and went into fibrillation 3 hours after transplantation.”151 The Times of India and the Maharashtra Times provided detailed front-page coverage on 20 February (with the Indian Express following the next day), celebrating the procedure (“technically a success”) despite the patient’s death. Citing the team’s many years of animal research, it explained that the transplant had not been a rash act: “Though the transplant of a human heart is new in this country, the K.E.M. doctors are well-versed in the process.”152 An editorial, “Troubled Hearts,” put Sen’s transplant into broader perspective. Describing the progress made in South Africa, Europe, and the United States, it argued that “Whatever detractors may say, transplant surgery is here to stay.”153 Subsequent articles celebrated that Sen’s team had not simply replicated what others had done. They had modified Shumway’s surgical technique, they had modified Barnard’s perfusion technique, and they had developed their own serum to prevent rejection.154 There was a strong sense of national pride. As the Times of India noted, “The Indian doctors have the ability and there is sufficient teamwork to carry out this newest feat of cardiac surgery.”155 The Problem of Efficacy The operation was described as successful, but did it work? The question of efficacy is complex. As anthropologists and historians know well, there are many ways to judge the efficacy of a therapeutic intervention, and many look beyond the question of whether the patient benefitted.156 Charles Rosenberg argued that judgments of efficacy depend on the expectations that patients and doctors had for the intervention, something Jack Pressman demonstrated in his history of lobotomy. Schlich and Crenner emphasize the “fluidity and contingency” not just of “human technical creativity,” but also of the judgments made about it: efficacy is not a yes-or-no question but an on-going debate that shifts as contexts and the surgeries themselves change.157 In this case, it is possible that Sen’s team did not expect that the patient would survive, though they certainly hoped that he would. The attempt needs to be seen simultaneously as a treatment, as an experiment, and as a demonstration project. The many people involved in making the transplant possible in Bombay in 1968 had different ideas about the meaning of the work. Sen wanted to build a surgical research laboratory, train teams of physicians, technicians, and nurses, and be on the “edge of progress.” He could be there even if his initial patients did not survive. His primary patron, the Rockefeller Foundation, wanted to establish the American mode of academic medicine in India, with medical schools staffed by full-time, research-based faculty; Sen provided this, regardless of his outcomes. Indian officials wanted to demonstrate India’s scientific and technical prowess. The United States State Department, which facilitated bilateral scientific exchanges, presumably saw the extent to which Sen relied on American precedents as evidence of the success of its efforts to popularize the achievements of American science and medicine. By any of these standards, the bare fact that a transplant took place was success enough. What about the patient? Sen and his team wanted their patients to survive, and many of his other cardiac surgery patients did. However, it is not clear that the team expected their first transplant patient to survive. First, the team had never had a dog survive for more than two days.158 Second, they did not choose an ideal patient for their first attempt. In the aftermath of the transplant, Sen’s team wrote at length about transplant candidates. They wanted a patient with “incurable, incapacitating irreversible heart disease,” but with “Reasonably healthy pulmonary, renal, hepatic and central nervous system function,” and the “Absence of any other incapacitating disease.”159 Their twenty-seven-year-old shepherd had incapacitating cardiac disease, and also kyphoscoliosis, restrictive lung disease, emphysema, and pulmonary hypertension.160 This, according to the anesthetists, was the “crux of the problem.”161 Just fifteen minutes after turning off the heart-lung machine, the transplanted heart failed: its right ventricle, weakened by the donor’s dying process, could not pump blood through the recipient’s diseased lungs.162 The patient’s co-morbidities—in hindsight—made survival after a transplant nearly impossible.163 Why did the team choose this patient? The team believed that his death, without the transplant gamble, was imminent.164 His compromised medical status justified his enrollment into Sen’s experiments. It is also possible that his compromised status in society—a shepherd from India’s rural poor—facilitated this. Even though K.E.M. had cared for him for many months, in the end he joined Bombay’s stray dogs on the operating table of Sen’s demonstration project.165 There are other, more sympathetic, readings of the episode. Chaukar was a surgical registrar in 1968 and assisted Sen with the transplant. Interviewed in 2016, he agreed that, in retrospect, the fatal outcome was a foregone conclusion.166 The team knew about his pulmonary disease and high pulmonary vascular pressures: he had been on the surgery service since 18 January. But Chaukar made two points. First, the patient had no better options, having exhausted all other medical interventions. Second, the consequences of the patient’s severe pulmonary disease, while clear in retrospect, were not known at the time. Before December 1967, no physician had experience with heart transplantation in sick adults. Experimental work had used healthy dogs. Surgeons hoped that a healthy heart, taken from the donor, would be more effective than the recipient’s diseased heart had been. Given this, “it was not obvious in prospect that he was a bad candidate.” Barnard, who quickly learned about the attempt, defended Sen’s decision, saying “I would have performed a transplant in this case.”167 It is hard to know what to make of these assessments. Surgeons who imagined that a transplant was possible could also have imagined what might go wrong.168 The Aftermath After the six initial transplants (Barnard and Katrowitz in December, Barnard, Shumway, and Kantrowitz in January, and Sen in February), there were no further heart transplants anywhere for over two months. Heart transplantation, however, remained very much in the news in India. In March American cardiologists called for a three-year moratorium on heart transplants. Barnard, asserting that “Every man must follow his conscience,” rejected this call.169 He told the United States Senate that government oversight would be an “insult to doctors.”170 A Bombay pathologist, speaking at the Rotary Club in April, pushed back. Heart transplant was “not merely a technical or a scientific problem but involved moral issues and values that human beings have cherished for ages.” Civil authorities needed to get involved: “in the absence of definite legislation on this, surgeons were likely to perform acts which might be ‘unethical or illegal.’”171 A heart transplant in Paris on 27 April marked the start of another round of activity, with twelve heart transplants performed in May alone. One Bombay doctor, responding as transplants reports continued “to pour in from different parts of the world,” encouraged surgeons to complete careful research first, “so that an impression does not gain ground that every cardiac surgeon is trying ‘to get there first by experiments on human guinea pigs.’”172 In July Barnard invited the world’s heart transplant surgeons, from eight countries, to Cape Town to participate in a conference that promised to be “the most important medical meeting so far this century.”173 He included Sen, who again encountered racial exclusion. The surgeons first convened in Johannesburg. Sen, an Indian, was not permitted into either the bar where they met or the hotel where they stayed. The other surgeons demanded that Barnard fix the problem; he arranged for Sen to stay at the home of the Indian ambassador.174 Things went more smoothly in Cape Town. The Indian community there hosted a reception for Sen at City Hall where Barnard “paid tributes” to Sen, praising him for “entering a new field like heart transplantation so rapidly and so adequately.”175 The Times of India, which provided detailed coverage of the conference, added its own boasting: “If Prafulla Kumar Sen was not more respectful of Indian sentiments he would probably have been the first to perform a heart transplant and beat South Africa’s Dr. Barnard to the post.”176 Having worked on transplant since 1952 and having performed over 200 experiments, “what he needed was not courage to perform the operation, but courage to face social mores.” Sen added that while he knew heart that transplants faced “strange and involved problems of ethics, law and possibly genetics,” he was willing to take them on.177 Sen’s reputation in India likely benefitted from the favorable attention provided by the conference and its coverage of Sen in the company of the world’s great surgeons. Their desire to normalize cardiac transplantation may have benefitted, in turn, by Sen’s presence. He showed that heart transplantation would not necessarily be limited to the industrialized West but could be made available, and acceptable, in countries worldwide. Efforts to normalize heart transplantation gained momentum in August when the World Medical Assembly issued its Declaration of Sydney, which sought to clarify standards for determination of death.178 A group at Harvard Medical School went further and argued forcefully for the acceptance of brain death, something that would facilitate decisions about both withdrawal of life support and taking organs from people with irreversible brain injury.179 These early consensus statements never resolved the controversies.180 Sen’s team remained eager to perform a second transplant. Within days of their first attempt, they announced their readiness to try again, telling the Times they would begin as soon as they found the “right case.”181 However, as Chaukar explained they had “to let things settle down after the first case before doing the second.”182 They attempted their second transplant (the world’s 46th) on 13 September 1968. The procedure itself again went well, but the patient, who suffered from severe pulmonary and kidney disease, died of renal failure just fourteen hours after the surgery.183 Sen put an optimistic spin on the outcome: “We are getting nearer complete success. It is very encouraging.”184 Success was not simply a clinical outcome, but a process towards a longer-term goal. In December Sen’s team published an account of their first transplant in a special issue of the American Journal of Cardiology devoted to heart transplantation, alongside articles by Barnard, Denton Cooley, Hardy, Kantrowitz, Lower, Ross, and others: Sen was part of the pantheon.185 The team published its definitive account of its two transplants in the Journal of the Indian Medical Association that same month.186 Thirty pages of discussions examined the research background, clinical history, surgical procedure, postmortem studies, and ethical and legal issues. They documented in great detail exactly how and why the patient died. The Bombay doctors worked carefully to justify their decision to perform both transplants.187 The journal’s editor, N. Banerjee, defended Sen’s effort, “a record for which the whole of India is proud.” Why? Because India had to transplant: “The question so commonly asked, whether India should also undertake these risky and expensive operations, needs only one answer—India must. If India has sought the atomic reactor, built huge industrial complexes of steel, communicated through telstar, and has advanced jets for its defence, there must also be in the country a few top-class medical centres given the full freedom, finance and personnel where a quality of work equal to the best in the world can be carried out without interference. It is the only way to develop a consciousness for the high quality of work which is essential in this medical field today, or else the technological and scientific gap will be so large that it will never be bridged.” The Indian middle classes and political elite wanted evidence of its medical modernity; and Sen provided it. Banerjee did admit, however, that the “price paid for all this adventure has been high.”188 The Critics As heart transplants continued worldwide in the summer and fall of 1968, critics continued to attack the procedure. Surgeon Lyman Brewer, writing in JAMA in September, decried the “carnival atmosphere” and feared that surgeons transplanted more for their own glory than for the benefit of their patients: “Whatever aggrandizement accrues from such publicity to the individual surgeons or hospitals appears unjustified and unwarranted.”189 In October a Times of India editorial came to the defense of transplant surgeons (without mentioning Sen’s team specifically). Resistance to innovation was routine: “Public opinion, that amorphous body of views incoherently expressed by the faceless many, has always lagged behind the times. In many ways this has been a misfortune for humanity, for it has acted as a bar, not a spur, to progress in some of the frontier disciplines.” With the advent of heart transplantation, “the sceptic and the conservative were among the first to sneer and mumble about its ethics. Every kind of irrelevant objection has since been raised to making use of the organs of dead persons in order to give critically ill people a new lease of life.”190 This editorial prompted an angry response. While J. B. Morehead of Bombay acknowledged the promise of heart transplants, “a word of caution has to be sounded as far as our country is concerned.” Despite the “fanfare” that accompanied the two transplants in Bombay and Sen’s apparent satisfaction with the results, “the three- and fourteen-hour survival of the recipients after the transplant can only mean that the operations in Bombay were dismal failures.” India could not afford such misadventures: “When schemes of immense importance to thousands of persons are shelved for lack of funds and shortage of trained personnel, it seems criminal to waste so much on operations that are almost predictable failures.” India should wait until others had solved the problems of transplant: “It seems more practical to allow the better equipped and financed and more advanced Western centres to carry out these pioneering procedures, perfect the techniques involved and then, and then only, adopt them modifying the as necessary.”191 Morehead’s letter triggered two furious responses. Sudhir, writing from Ahmedabad, critiqued Morehead’s logic and added that “It is surprising that instead of congratulating the surgeons on their initiative and enthusiasm, Mr. Morehead laments the expenditure on these operations. Why should our surgeons wait till Western countries achieve success? In the initial stages, there are bound to be failures. But those imbued with the scientific spirit are not daunted by these failures.”192 Dr. D. V. Nadkarni, who wrote the next week from Bombay, celebrated India’s pioneers: “Every heroic forward step in research in every field of science is bound at first to seem a ‘criminal waste’ and no pioneer has been hailed in his attempts till he succeeds. We should appreciate the display of a pioneer spirit by anyone in this routine-minded country.”193 Sen, meanwhile, stewed. His team did not make a third attempt.194 He believed that India could be a world leader in transplants because of its abundance of potential organ donors. As he explained at the conference in Cape Town in July, India had many people with severe head injuries: “It is easier for us to find donors. We have a large population, many motor cars and, therefore, many road accidents.”195 His team reiterated this point in December. The ideal donor had to be “reasonably healthy prior to death.” As a result, “Young people dying from sudden trauma are therefore the best donors.” Such people were readily available in Bombay: “In an urban community, accidents like train accidents often cause fatal head injuries providing the donor-organ material.”196 But Sen’s program had been stymied. Speaking at the Indian Merchants’ Chamber in November, he decried the “‘world-wide neurosis’ about heart transplants.” Ethical concerns, rooted in a misunderstanding of the nature of death, led to controversies about heart transplants that left India with “More donors than recipients for heart transplants.”197 Nonetheless, Sen insisted that he “welcomed knowledgeable criticism,” knowing that “every innovation had to run the gauntlet of ignorance, fear and criticism.” The controversies persisted. When Sen spoke about his work at the Indian Science Congress in January 1969, one prominent researcher “lauded the pioneering work done by Dr. Sen and said it was good that India did not lag behind other countries in the field of cardiac surgery.”198 Two weeks later, however, a critic accused Sen of proceeding too quickly: “In their enthusiasm to put India on the cardiac map of the world, our surgeons should not forget that unsuccessful operations, for want of adequate post-operative care, technical expertise or organization, would be tantamount to playing with human lives.”199 Sen had a stoic, and at times opaque, response to the “furore” and “hysteria.” In January 1970 he gave his presidential address at the Association of Chest Diseases. He complained about the impact of legal constraints on his work: “The law may be an ass, but it is an animal whose hind quarters still carry a most powerful kick.”200 He defended the role of pioneers and innovation in medicine: “It is this desire to break away from colourlessness into the ambit of the unknown which makes scientific buccaneers of us. Transplant surgeons are just a case in point.”201 Even with his clinical heart transplant program on hold, his experimental work continued. That February he spoke in New Delhi and described methods to revive hearts up to two hours after a dog’s death.202 At the Maharashtra Medical Conference in October 1971, Sen again defended medical pioneers. He “made a strong plea for a renewed spirit of restlessness among medicos without which there could be no scientific progress. ‘Unless those in the medical profession rediscover themselves,’ he said, ‘we will have a society of educated ignoramuses.’”203 Had Sen been within the scope of Fox and Swazey’s fieldwork, they would certainly have diagnosed him with “pioneer syndrome.”204 His colleagues, however, saw his buccaneering as an asset: “There is no doubt that his adventurism accelerated the development of not only cardiovascular surgery but other surgical superspecialties he created.”205 Easy judgments are not possible here. Pursuit of innovation at any cost has many costs. Sen and his team, who knew the costs well, chose adventure.206 An extensive analysis of organ transplantation published in Times of India in November 1972 celebrated Sen’s work. It emphasized the many challenges that Indian surgeons faced (e.g., lack of resources, other health care priorities, lack of brain death legislation). Its author worried that India would miss out.207 This triggered yet another letter to the editor that assailed Sen’s 1968 transplants, which should never have been performed on patients with diseased lungs: “Does it mean that Dr. Sen’s exercises were designed more to bring personal glory than to further the cause of medical sciences?”208 By 1972, however, a near moratorium on heart transplants had taken hold. The global pace of heart transplants peaked in November 1968, with twenty-six operations. In January 1969 the Montreal Heart Institute announced that it would stop (after nine heart transplants). Most other programs followed suit.209 In September 1971 Life published a damning review of the experience, “The Tragic Record of Heart Transplants: A New Report on an Era of Medical Failure.”210 By the mid-1970s only four groups continued serious work on heart transplants: Shumway, Lower, Terrence English in England, and Chris Cabrol in France.211 The moratorium ended in 1983 when a new immunosuppressive drug, cyclosporine, was approved. In 1983 surgeons at twelve programs in the United States transplanted 172 hearts. Just six years later US surgeons performed 1673 heart transplants at 131 hospitals.212 Indian surgeons could not join the resurgent interest because of the problem of brain death. In 1972 Parulkar had explained “that when the definition of cerebral death is universally accepted it will be possible for the transplant team to maintain in a viable state other vital organs in the donor’s body for some time by artificial ventilation and modern means of artificial circulation. Such viable organs could be then successfully transplanted.”213 In 1974 Parulkar and six colleagues worked with an ICMR task force to draft both a definition brain death and rules that would govern heart transplant. They submitted their proposal to the government that year. And they waited. The government took twenty years and several revisions before passing the Transplantation of Human Organs Act of 1994. That August Panangipalli Venugopal led a team at the All India Institute of Medical Science and performed the first successful heart transplant in India.214 The first successful heart transplant in Mumbai (Bombay) did not happen until August 2015.215 The transplant did not simply require a well-trained clinical team and adequate facilities. It also required careful coordination of the traffic authorities so that the roads could be cleared of traffic to facilitate rapid transport of the donor’s heart from Pune to Mumbai. The “well-orchestrated symphony” provided “a testament to the massive coordination efforts between the Traffic authorities, medical teams and the community in both the cities.” The hospital quickly scaled up its program and by summer 2016 had completed another twenty heart transplants.216 Conclusions What was required to establish heart transplantation in India? It required not just the movement of ideas, devices, and praxis, but also broader arrangements for a technology to be viable both socially and politically, including (eventually) a new law, new values, and new modes of collaboration. Sen’s experiences demonstrate several important dynamics. To be able to transplant a human heart just eleven weeks after Barnard’s first attempt, Sen had tapped into global networks that moved information, people, money, and equipment between India, the United States, and the Soviet Union. This allowed him to keep abreast of developments in cardiac surgery from Minneapolis to Moscow. With support from the ICMR and the Rockefeller Foundation, he established a surgical research program at a municipal hospital in Bombay, fostered a team of skilled trainees and colleagues, and maintained an active research program despite the demands of his ongoing clinical responsibilities. He conducted initial research between 1954 and 1956 and then resumed research in 1962. This experience left him confident that he could join Shumway, Kantrowitz, Barnard and others as they moved towards clinical applications. Stymied by state authorities in 1965, Sen capitalized on the buzz created by Barnard’s first transplant to perform his two transplants. We can only speculate about what might have happened with Indian laws and mores had his first two transplants succeeded. Many factors motivated Sen’s efforts. He wanted to be a player in the emerging post-war world of global surgery. Heart transplantation provided a ticket of admission to an elite group. His personal interests complemented broader Indian interests and nationalism, as seen in the pride of his dean, the editors of JIMA and the Times of India, municipal officials, and many others. None of them wanted India to lag behind the West. He also desired to help patients crippled by heart disease. However, the enthusiasm of Sen and his supporters was matched by diverse concerns about the ethics of heart transplantation and its appropriateness in a country like India. Sen’s efforts prompted ongoing critiques from his fellow citizens of Bombay. Did it work? Therapeutic interventions require nuanced assessments. Sen’s first two transplants accomplished some of his goals, but not all of them. The clinical attempts represented the culmination of his experimental project, and they demonstrated the capacity of Indian surgeons and hospitals. His many patrons and international colleagues applauded his feat. However, neither patient made it out of the operating room alive. Sen’s failures, and the early failures of other surgeons worldwide, cast a pall over the field that would not be overcome for many years. Sen had become a scientific buccaneer, a role with complex connotations. Acknowledgements Shreeharsh Kelkar, Alison Kraemer, Alyssa Botelho, Avanti Nagral, Kiran Kumbhar, Purbasha Das, and Ganesh Gupta provided much-needed research assistance. The archivists at the Rockefeller Archives Center (especially Tom Rosenbaum), the Alan Mason Chesney Medical Archives of the John Hopkins Medical Institutions (especially Marjorie Kehoe and Phoebe Evans Letocha), the Countway Medical Library (Jack Eckert and Jessica Murphy), and the Maharashtra State Archives provided invaluable help with their collections. We owe special thanks to G.B. Parulkar, A.P. Chaukar, and R. Magotra for their generosity with their time, and to Professor Mridula Ramanna for her advice on state archives and public health history in Bombay. We received valuable feedback from colleagues at the History of Science, Medicine, and Technology Colloquium at the Johns Hopkins School of Medicine; the American Association for the History of Medicine; the Radcliffe Institute for Advanced Study; the Centre for the History of Science, Technology and Medicine at the University of Manchester; and the Workshop on the History of Cardiovascular Disease, and from two anonymous reviewers. This research was made possible by a collaborative research grant from the National Endowment for the Humanities (RZ-51759-14). Any views, findings, conclusions, or recommendations expressed in this article do not necessarily reflect those of the National Endowment for the Humanities. Footnotes 1 “Special Feature: Heart Transplantation,” Journal of the Indian Medical Association, 1968, 51, 539-568; Prufulla Kumar Sen, “Human Heart Homotransplantation,” American Journal of Cardiology, 1968, 22, 826-832. 2 Sen's surgical team, quoted in “First-ever Heart Transplant in India: Patient Dies,” Times of India, 20 February 1968, 1. See also “Successful Heart Transplant Operation in Mumbai: Death of the Patient after 3 Hours,” Maharashtra Times, 20 February 1968, 1 [translated from Marathi by Kiran Kumbhar]; “India’s First Heart Transplant,” Indian Express, 21 February 1968, 1. 3 “Doctors Ready for 2nd Heart Transplant,” Times of India, 23 February 1968, 1. 4 Jordan D. Haller and Marcial M. Cerruti, “Heart Transplantation in Man: Compilation of Cases, January 1, 1964, to October 23, 1968,” American Journal of Cardiology, 1968, 22, 840-843. 5 N. Banerjee, “Cardiac Transplantation,” Journal of the Indian Medical Association, 1968, 51, 539. 6 Franklin A. Long and Alexandra Oleson, ed., Appropriate Technology and Social Values—A Critical Appraisal (Cambridge: Ballinger Publishing Company, 1980). In 1993 the World Bank recommended that low-income countries not offer cardiac surgery to their populations: World Bank, Investing in Health: World Development Report (New York: Oxford University Press, 1993): 10. 7 Jordan D. Haller and Marcial M. Cerruti, “Heart Transplantation in Man: Compilation of Cases—II: January 23, 1964 to June 22, 1969,” American Journal of Cardiology, 1969, 24, 554-563. 8 “Dr. Sen Plans More Heart Transplants,” Times of India, 20 July 1968, 9. We discuss this in detail later. 9 Lesley A. Sharp, Strange Harvest: Organ Transplants, Denatured Bodies, and the Transformed Self (Berkeley: University of California Press, 2006), 1. 10 Susan E. Lederer, Flesh and Blood: Organ Transplantation and Blood Transfusion in Twentieth-Century America (New York: Oxford University Press, 2008), 210, 212 (quotations); Thomas Schlich, Origins of Organ Transplantation Surgery and Laboratory Science, 1880-1930 (Rochester: University of Rochester Press, 2010). 11 Donald McRae, Every Second Counts: The Extraordinary Race to Transplant the First Human Heart (New York: Simon & Schuster, 2006), 7. See also: James D. Hardy, The World of Surgery 1945-1985: Memoirs of One Participant (Philadelphia: University of Pennsylvania Press, 1986); Harris Shumacker, The Evolution of Cardiac Surgery (Bloomington: Indiana University Press, 1992); Tony Stark, Knife to the Heart: The Story of Transplant Surgery (London: Macmillan, 1996); Stephen Westaby, Landmarks in Cardiac Surgery (Oxford: Isis Medical Media Ltd., 1997); Ayesha Nathoo, Hearts Exposed: Transplants and the Media in 1960s Britain (Bastingstoke: Palgrave Macmillan, 2009); David K.C. Cooper, Open Heart: The Radical Surgeons Who Revolutionized Medicine (New York: Kaplan Publishing, 2010); Thomas Morris, The Matter of the Heart: A History of the Heart in Eleven Operations (London: The Bodley Head, 2017); Shelley McKellar, Artificial Hearts: The Allure and Ambivalence of a Controversial Medical Technology (Baltimore: Johns Hopkins University Press, 2018). 12 David J. Rothman, Strangers at the Bedside: A History of How Law and Bioethics Transformed Medical Decision Making (New York: Basic Books, 1991); Gary Belkin, Death Before Dying: History, Medicine, and Brain Death (New York: Oxford University Press, 2014); Silke Bellanger and Aline Steinbrecher, “Addressing Uncertainties: The Conceptualization of Brain Death in Switzerland, 1960-2000,” in Schlich and Tröhler, The Risks of Medical Innovation, 204-224; Helen Macdonald, “Crossing the Rubicon: Death in ‘The Year of the Transplant,’” Medical History 61 (2017): 107-127. 13 Renée C. Fox and Judith P. Swazey, The Courage to Fail: A Social View of Organ Transplants and Dialysis (1978; New Brunswick, NJ: Transaction Publishers, 2002), xl, xli. 14 Fox and Swazey, Spare Parts: Organ Replacement in American Society (New York: Oxford University Press, 1992), xv. 15 Sharp, Strange Harvest, 40. 16 Sharp, The Transplant Imaginary: Mechanical Hearts, Animal Parts, and Moral Thinking in Human Experimental Science (Berkeley: University of California Press, 2014), 3. 17 Lawrence Cohen, “Where It Hurts: Indian Material for an Ethics of Organ Transplantation,” Daedalus, 1999, 128 (4), 135-165. 18 Fox and Swazey, Courage to Fail, 110; Lederer, Flesh and Blood, 171; Cooper, Open Heart; McKellar, Artificial Hearts. 19 Westaby, Landmarks, 265; McRae, Every Second Counts, 266; Morris, The Matter of the Heart, 236; Macdonald, “Crossing the Rubicon,” 109. 20 Norman Shumway, “Oral History,” in Pioneers of Cardiac Surgery, ed. William S. Stoney, pp. 427-439 (Nashville: Vanderbilt University Press, 2008), 434. 21 Schumacher, Evolution, 323, 332-334. 22 G.B.P. [Parulkar], “Professor Prafulla Kumar Sen,” Indian Journal of Thoracic and Cardiovascular Surgery, 1982, 1, 92-94; C.V. Patel, “Life of a Legend,” Journal of Postgraduate Medicine, 1991, 37 Suppl 1:2-5; Chander Mohan Mittal, “Profulla Kumar Sen: His Contributions to Cardiovascular Surgery,” Texas Heart Institute Journal, 2002, 29, 17-25; N. Hosain, “Dr. PK Sen – The Bengali Surgeon of the Century,” Cardiovascular Journal, 2011, 3, 254-257. 23 While many sources allow this history to be written, they remain incomplete. Sen published extensively in Indian, European, and American medical journals, but the Indian journals did not routinely include editorials or correspondence that reveal the judgments of his peers (e.g., the Indian Journal of Surgery and the Indian Heart Journal did not include letters or editorials; the Journal of the Indian Medical Association included an editorial and single letter in most issues, but no relevant ones appeared in the six months after Sen’s team described their heart transplants). We have not found Sen’s personal papers. K.E.M. Hospital has a small archive, but no relevant information. The records of the Bombay Municipal Corporation, in the Maharashtra State Archives, do not include information about the municipal hospitals in the relevant years. The Rockefeller Archive Center has extensive materials, though these provide only scattered glimpses of Indian perspectives. India’s newspapers are a daunting resource. Bombay has many large and small papers published in Hindi, Marathi, and Gujarati, and a few national papers published in English. None had regular sections on medicine and disease. The Times of India is the only paper that is digitized and searchable; it has limitations (e.g., read by a narrow, English speaking middle class) and advantages (e.g., based in Bombay, it covered Sen’s work). We have made targeted searches of other papers, but these have not been as revealing. Bombay’s Maharashtra Times covered Sen, but with Marathi-language translations of the Times of India’s reporting. We have looked at national newspapers (e.g., The Hindu, The Patriot, The Indian Express, The Hindustan Times), but these did not cover the Bombay medical scene in detail. 24 Thomas Schlich and Christopher Crenner, “Technological Change in Surgery: An Introductory Essay,” in Technological Change in Modern Surgery (Rochester: University of Rochester Press, 2017), 1-20. 25 Sally Frampton, “Defining Difference: Competing Forms of Ovarian Surgery in the Nineteenth Century,” in Schlich and Crenner, Technological Change in Modern Surgery, 51-70. 26 We take seriously the role of non-western actors in western science and medicine. See Warwick Anderson, “Postcolonial Specters of STS,” East Asian Science, Technology and Society, 2017, 11: 229-233. 27 We draw here from Veena Das and Deborah Poole, Anthropology in the Margins of the State (Santa Fe: School of American Research Press, 2004). 28 Rustom Jal Vakil, “Modern Approach to Cardiovascular Problems,” Journal of the Indian Medical Association, 1955, 25, 520-523, 521. 29 R.P. Malhotra and N.S. Pathania, “Some Aetiological Aspects of Coronary Heart Disease: An Indian Point of View Based on a Study of 867 Cases Seen during 1948-55,” British Medical Journal, 1958, 2, 528-531. 30 Mridula Ramanna, “Gauging Indian Responses to Western Medicine: Hospitals and Dispensaries, Bombay Presidency, 1900-20,” in Deepak Kumar, ed., Disease & Medicine in India: A Historical Overview (New Delhi: Tulika Books, 2001), 233-48; 238. 31 Parulkar, “Architect of Modern Surgery,” in A.V. Baliga: Surgeon and Patriot, ed. Ravi M. Bakaya (New Delhi: Patriot Publishers, 1991), 27. D.V. Nadkarni’s 1944 Surgical Epitome belies this point, but only slightly. Nadkarni, who trained at K.E.M., provided over 2000 pages of outlines and summaries of surgical knowledge and procedures, with just ten pages on heart disease, including operations for coronary artery disease (e.g., thyroidectomy, sympathectcomy), peri-cardiac problems (e.g., pericardiectomy, ligation of a patent ductus arteriosus), and cardiac trauma. See Nadkarni, Surgical Epitome (Bombay: N.M. Tripathi, Ltd., 1944), 1017-1026. 32 Amrit Kaur, in “Proceedings of the XII Annual Conference of the Association of Surgeons in India,” Indian Journal of Surgery, 1951, 13, iii. 33 Edward Churchill, quoted in “India’s Great Medical Needs Pointed Out by Boston Doctor,” Boston Globe, 4 May 1958, 35. 34 Prafulla Kumar Sen, “Personal History Record and Application for Fellowship,” 9/10/1949, Rockefeller Archives Center (RAC), RF 4468/283/464/10.1. See also, [Parulkar], “Professor”; Mittal, “Profulla Kumar Sen.” 35 “Medical Relief: Governor of Bombay Opens New Memorial Hospital,” Times of India, 25 January 1926, 12. 36 Sen, “The Surgeon’s Training in India: A Plea for Reorientation,” JIMA, 1958, 31, 280-283, 280. Sen even invoked Charaka at a 1962 presentation to the American Association of Medical Colleges. He spoke of throwing off the legacy of “160 years of British domination” and its “imprint of an alien culture.” Sen, “The Present Position of Medical Education in India,” Journal of Medical Education, 1963, 38, 577-583, 583. 37 For the ICMR grant, see Sen, “Personal History Record.” For his early work: Sen, “Perforated Peptic Ulcer of the Stomach and Duodenum,” Indian Physician, 1945, 4, 7-14; Sen and K.P. Prabhu, “Treatment of Shock by Direct Stimulation of the Medullary Centers in the Brain,” Indian Journal of Surgery, 1950, 12, 125-130. 38 Wade Oliver to I.S. Ravdin, 1/4/1950, RAC, RF 4468/283/464/10.1. 39 I.S. Ravdin to Oliver, 1/5/1950, RAC, RF 4468/283/464/10.1 40 Ravdin to Gregg, 9/2/1953, RAC, RF 454/50/464/1.2. 41 “Fellowship for Dr. Prafulla Kumar Sen,” 11/18/1949, RAC, RF 4468/283/464/10.1; Wade Oliver to R.K. Anderson, 1/10/1950, RAC, RF 4468/283/464/10.1; Diary Entry [author not marked], c. 11/1/1950, RAC, RF 4468/283/464/10.1. See also Hardy, World of Surgery. 42 Hardy, Sen, and David L. Drabkin, “Factors Influencing the Postoperative Excretion of Salt and Water and Further Studies of the Relation of Body Fluid Compartments to Body Fat,” Surgical Forum (Philadelphia: W.B. Saunders Company, 1951), 477. 43 Hardy, The World of Surgery, 147. 44 Sen to Oliver, 7/27/1951, RAC RF 454/50/464/1.2. 45 R.G. Dhayagude to R.B. Watson, 10/30/1952, RAC RF 454/50/464/1.2. 46 Richmond K. Anderson, Diary, 11/24/1952, RAC, RF 6/12, Rockefeller Foundation Officer’s Diaries. 47 “Grant in Aid,” 4/20/1953, RAC, RF 454/50/464/1.2. 48 Hosain, “Dr. PK Sen,” 255. See also: G.B.P., “Professor”; Mittal, “Profulla Kumar Sen.” 49 Sen, S.N. Kothare, and M.M. Mehta, “The Surgical Approach to the Mitral Valve: An Experimental Study,” Indian Journal of Medical Sciences, 1953, 7, 281-287, 283. 50 Sen, “The Use of a Snare Tourniquet in Mitral Valvotomy—A Suggested Modification of Technique,” Indian Journal of Surgery, 1953, 15, 15-18. This technique survived in India long after it was replaced by open heart techniques in India. A.P. Chaukar, Interview by Author, 20 June 2016, Mumbai. This exemplifies David Edgerton’s “creole technology.” [see p12n82 for the other example] Edgerton, “Creole Technologies and Global Histories: Rethinking How Things Travel in Space and Time,” Journal of History of Science and Technology, 2007, 1, 75-112. 51 “Window on the World,” Times of India, 12 October 1952, 5. 52 “Preserved ‘Human Spares’ Help Miracle Healing,” Times of India, 3 January 1954, 8. 53 Hardy, World of Surgery, 160. 54 Sen, “The Present Status of Surgery of the Heart,” The Antiseptic, 1954, 51, 537-547, 547. 55 Sen, P.A. Bhatt, and R.L. Shah, “The Use of Artificial Hypothermia (Hibernation) in Open Cardiac Surgery,” Indian Journal of Medical Sciences, 1953, 7:694-703, 694. See also C. Walton Lillehei, “Historical Development of Cardiopulmonary Bypass in Minnesota,” in Glenn P. Gravlee, Richard F. Davis, Mark Kurusz, and Joe R. Utley, eds., Cardiopulmonary Bypass: Principles and Practice, 2nd. ed. (Philadelphia: Lippincott Williams & Wilkins, 2000). 56 Sen, “Present Status,” 547. 57 Sen and others, “Use of Artificial Hypothermia,” 698. 58 Anderson, Diary, 4/12/1954, RAC, RF 6/12. The original has “regrigeration.” 59 For the death, see Anderson, Diary, 4/12/1953, RAC, RF 6/12; Naidu, “Fifty Years,” 2. For the research, see Sen, K.K. Datey, R.A. Lewis, C.B. Shah, and B.B. Gaitonde, “Further Experiences with Acutely Induced Hypothermia,” Indian Journal of Surgery, 1956, 18, 112-119, 118. Of his first 48 dogs, 24 died. For the success, see Parulkar, “Developments in Cardiovascular Surgery in India during Last Five Decades,” IJTCVS, 2004, 20, S24-30, S24. 60 Sen, “Personal History and Application,” 5/1/1956, RAC RF 4468/283/464/10.1; Janet M. Paine to Sen, 6/8/1956, RF 4468/283/464/10.1. 61 Fox and Swazey, “A Sociological Portrait of the Transplant Surgeon,” in Courage to Fail. 62 “Romance of Surgery,” Times of India, 6 February 1958, 3. 63 Sen, “Heart Transplantation—The Triumph and the Muddle,” Indian Journal of Chest Diseases, 1970, 12, 66-72, 66. 64 Carl Snyder, “Carrel—Mender of Men,” Colliers, 1912, 50, 12-13, 13. See also: Shumacker, Evolution, 316, 321; Westaby, Landmarks, 254, 323; Lederer, Flesh and Blood, 22; Morris, Matter of the Heart, 217-218. 65 Shumacker, Evolution, 321; Westaby, Landmarks, 255. 66 For a discussion of Demikhov’s work, see: Igor E. Konstantinov, “At the Cutting Edge of the Impossible: A Tribute to Vladimir P. Demikhov,” Texas Heart Institute Journal, 2009, 36, 453-458. See also Shumacker, Evolution, 321; Westaby, Landmarks, 255-257; Morris, Matter of the Heart. 67 Sen, C.B. Shah, and R.S. Satoskar, “Studies on Isolated Heart-Lung Preparations in the Hypothermic Animal,” Journal of the International College of Surgeons 1956, 26, 32-37. See also Mittal, “Profulla Kumar Sen.” 68 Sen, Parulkar, and Panday, “Introduction and Experimental Base,” JIMA, 1968, 51, 543-544, 543. 69 Anderson, Diary, June 1955, RAC, RF 6/12 70 Sen and others, “Studies on Isolated Heart-Lung Preparations,” 35, 36. See also Sen and others, “Introduction and Experimental Base,” 543. 71 Shumacker, Evolution, 323-327; Westaby, Landmarks; McKellar, Artificial Hearts. 72 R.R. Lower and Shumway, “Studies on Orthotopic Homotransplantation of the Canine Heart,” Surgical Forum, 1960, 11, 18-19; Shumway, “Oral History,” 430-432. See also “Progress in Transplants,” Time, 27 June 1960, 75: 54-56; McRae, Every Second Counts, 93. 73 Shumway and Lower, “Special Problems in the Transplantation of the Heart,” Annals of New York Academy of Science, 1964, 120: 773-777. See also: Morris, Matter of the Heart, 223. 74 Westaby, Landmarks; McRae, Every Second Counts, 70-71; McKellar, Artificial Hearts. 75 Shumacker, Evolution, 323-327; Westaby, Landmarks. 76 Shumway, “Oral History.” See also Fox and Swazey, Courage to Fail, 69. 77 Sen, N.D. Chhabria, T.E. Udwadia, and A.J. Dhruva, “Open Cardiotomy under Temporary Cardiac Arrest in Hypothermised Animals,” Indian Journal of Surgery, 1960, 22, 529-535; Parulkar, Dhruva, P.M. Javeri, and Sen, “Experimental Closure of Artificially Created Ventricular Septal Defects Employing Hypothermia and Fluothane,” Indian Journal of Medical Research, 1963, 51, 289-292. 78 Parulkar, Dhruva, and Sen, “Atrial Septal Defect: A Report of Fourteen Cases Treated Surgically,” Journal of Postgraduate Medicine, 1962, 8, 60-66. 79 For ongoing coverage of American surgical progress, see “This Will Put New Heart into Cardiac Patients,” Times of India, 10 February 1957. 80 Parulkar, “Developments,” S24. They also tried cross-circulation: Anderson, Diary Excerpt, 10/11/1960, RAC RF 440/49/464/1.2. 81 Keshavarao Krishnanao Datey, “Personal History Record and Application,” 3/26/1958, RAC, RF 448/50/464/1.2; Tryambak Pandurang Kulkarni, “Personal History and Application,” 11/26/1959, RAC, RF 4336/271/464/10.1. For Kinare, see Henry W. Kumm, Interview with Sen, 16 November 1962, RAC, RF 4336/271/464/10.1. 82 Parulkar had funding from the American Association of Thoracic Surgeons and NIH; he declined a Rockefeller Fellowship: Parulkar, Interview by Author, 6/19/2016, Mumbai. 83 Jones and Sivaramakrishnan, “Making Heart-Lung Machines Work in India: Imports, Indigenous Innovation, and the Challenge of Replicating Cardiac Surgery in Bombay, 1952-1962,” in preparation. 84 Paruklar, “Open Heart Surgery-The Indian Scene,” IJTCVS, 1984, 3, 3-8, 4; Parulkar, “Developments,” S24. 85 “Heart Operation on a Child,” Times of India, 3 April 1962, 7. Mittal, “Profulla Kumar Sen.” 86 Parulkar, “Developments,” S24. 87 Sen to Gregg, 1/17/1962, RAC, RF 453/50/464/1.2. 88 Gregg to Anderson, 4/5/62, RAC, RF 453/50/464/1.2; Paine to Sen, 7/27/62; 8/1/62, RAC, RF 453/50/464/1.2. 89 “Care of the Heart,” Times of India, 10/15/1962, 6. 90 Sen and others, “Introduction and Experimental Base,” 543; Mittal, “Profulla Kumar Sen,” 20. 91 “Dog with Two Heads: Russian Creation,” Times of India, 25 September 1958, 7; “Pup’s Head Grafted on an Alsatian,” Times of India, 12 April 1959, 1; “Extra Heart for Dog: Soviet Experiment,” Times of India, 20 August 1959. These articles were attributed to the Associated Press. 92 “Heartening,” Times of India, 21 August 1959, 8. 93 Naomi Oreskes and John Krige, Science and Technology in the Global Cold War (Cambridge: MIT Press, 2014). 94 Anderson, Diary, 3/29/1956, RAC, RF 6/12. While this might have been true at the time, the Foundation certainly knew by 1962 that Sen had traveled to Moscow. 95 Oglesby Paul, Take Heart: The Life and Prescription for Living of Dr. Paul Dudley White (Cambridge: Harvard University Press, 1986). 96 Bakaya, A.V. Baliga. 97 Patel, “Life of a Legend,” 3. 98 “India Is Home of Plastic Surgery, U.S. Expert Says, Times of India, 6 January 1963, 5. See also “Heart Grafted on Baboon: Soviet Success,” Times of India, 20 February 1963, 1; “Heart Surgery,” Times of India, 31 August 1963, 6. 99 Sen, Parulkar, Panday, and Kinare, “Homologous Canine Heart Transplantation: A Preliminary Report of 100 Experiments,” Indian Journal of Medical Research, 1965, 53, 674-684, 674. 100 The Bombay Municipal Corporation, which owned K.E.M., was responsible for keeping dogs off the streets of Bombay; it euthansized roughly 250 each week and was more than willing to supply dogs to K.E.M. researchers. Parulkar, Interview, 6/19/2016; Chaukar, Interview, 6/20/2016. 101 Sen and others, “Introduction and Experimental Base,” 543. 102 Sen and others, “Homologous Canine Heart Transplantation,” 683. See also Mittal, “Profulla Kumar Sen”; Parulkar, “Developments.” 103 “Dog with Two Hearts Is Normal,” Times of India, 11 October 1963, 1. 104 “Current Topics: Daring Experiment—Heart Transplant,” Times of India, 14 October 1963, 6. 105 Anderson, Diary Excerpt, 12/6/1963, RAC RF 443/49/464/1.2. 106 Sen to Anderson, 12/24/1963, RAC RF 443/49/464/1.2. 107 John Foster, “Heart Disease: Scourge of Industrial Societies,” Times of India, 12 January 1964, 6. 108 Hardy, World of Surgery, 277 (breached), 248 (bombshell). See also Hardy, Carlos M. Chavez, Fred D. Kurrus, William A. Neely, Sadan Eraslan, M. Don Turner, Leonard W. Fabian, and Thaddeus D. Labecki, “Heart Transplantation in Man: Developmental Studies and Report of a Case,” JAMA, 1964, 188, 1132-1140; Westaby, Landmarks. 109 Hardy, World of Surgery, 278; McRae, Every Second Counts, 126; Lederer, Flesh and Blood, 200-201; Cooper, Open Heart, 323-324. 110 Hardy, World of Surgery, 279 (quotation), 285. See also Morris, Matter of the Heart, 226; McKellar, Artificial Hearts. 111 Although the operation was discussed in The New York Times (26 January 1964) and JAMA, it was not discussed in the Times of India. Sen never cited Hardy’s work in his publications: Sen and others, “Homologous Canine Heart Transplantation”; “Special Feature: Heart Transplantation”; Sen, “Human Heart Homotransplantation.” 112 Hardy, World of Surgery, 323. 113 Walter Fowler, “New Hope for Damaged Hearts,” Times of India, 31 May 1964, 5; “Plastic Heart Coming Soon: Human Life Can Be Prolonged,” Times of India, 15 January 1965, 5. 114 Sen and others, “Introduction and Experimental Base,” 544-545; Mittal, “Profulla Kumar Sen.” 115 “Classified Ad: Dean, Seth G.S. Medical College,” Times of India, 21 September 1966, 13. 116 This worked proved “interesting but essentially unproductive.” Sen and others, “Introduction and Experimental Base,” 546. 117 Parulkar, “Developments,” S28. See also Mittal, “Profulla Kumar Sen,” 24; Chaukar, Interview, 6/20/2016. We have not found a statement by the team from 1965 to 1968 asserting their readiness. 118 Chaukar, Interview, 6/20/2016. He added a revealing comment about the state of animal research and the causes of their poor dog survival rates in Bombay in 1965: “We also had problems of staff taking the food (bread and eggs) from the dogs for themselves, so some of the dogs starved.” 119 Parulkar, “Developments,” S28. 120 Chaukar, interview, 6/20/2016. 121 Anderson, Diary, 9/15/1961, RAC, RF RG 10/12. 122 Anderson, Diary, 11/21/1958, RAC, RF 8/12. As the commissioner explained, “K.E.M. Hospital is maintained primarily for that class of patient who is unable to obtain medical care through private channels. This is the wish of the tax-payers.” LAG Diary Note, 10/12-10/13/1959, RAC, RF 439/49/464/1.2. 123 McRae, Every Second Counts, 4-5, 139, 150-151; Morris, Matter of the Heart, 227. 124 “Cardiologists’ Talks in Delhi End,” Times of India, 6 November 1966, 7. 125 “Surgical Fantasy,” Times of India, 3 December 1966, 8. 126 Shumway, quoted in McRae, Every Second Counts, 172. 127 Westaby, Landmarks, 260-261. 128 Westaby, Landmarks, 256, 261; McRae, Every Second Counts, 92, 180; Cooper, Open Heart, 331-333. 129 Shumacker, Evolution, 231; Westaby, Landmarks, 261; McKeller, Artificial Hearts. 130 “First-ever Human Heart Transplant,” Times of India, 4 December 1967, 1; “Science: Surgery Gets New Tools,” Times of India, 10 December 1967 (landmark). See also coverage on 12/5, 12/6, 12/8, and there-after. 131 “U.S. Heart Transplant Operation Fails,” 8 December 1967, 9. The patient lived just seven hours. 132 “Heart Transplant Patient Dies,” Times of India, 22 December 1967, 1. 133 “Transplant Ethics,” Times of India, 25 December 1967, 8. 134 “Living Transplants—1984,” from the New York Times, glossed in “Black Market in Hearts Forecast,” Times of India, 26 December 1967, 11. See also Lederer, Flesh and Blood, 98. 135 “Bethesda Conference Report: Cardiac and Other Organ Transplantation,” American Journal of Cardiology, 1968, 22, 896-912; Fox and Swazey, Courage to Fail; Shumacker, Evolution; Westaby, Landmarks, 265; Lederer, Flesh and Blood, 170. 136 “Russia Not to Allow Heart Transplants,” Times of India, 9. 137 “New Pumps for Old,” Times of India, 6 January 1968, 6. 138 “Heart Transplant Have No Chance Yet,” Times of India, 12 January 1968, 11. 139 Howard Rusk, “Organ Transplants: Problem of Immunological Rejection Is Cited Despite Technical Advances,” New York Times, 14 January 1968, 86. 140 “Transplant Ethics,” Times of India, 25 December 1967, 8. 141 Sen, “Introduction and Experimental Base,” 546. See also Mittal, “Profulla Kumar Sen,” 22; Hosain, “Dr PK Sen,” 255; Chaukar, Interview, 6/20/2016. 142 Chaukar, Interview, 6/20/2016. 143 Datey, P.A. Kale, S.M. Deshmukh, and M.D. Kelkar, “Cardiac Assessment and Selection,” JIMA, 1968, 51, 546-547; S.R. Kumat, “Pulmonary Assessment,” JIMA, 1968, 51, 548. See also Kinare, “Autopsy,” JIMA, 1968, 51:558-562, 558. 144 Datey and others, “Cardiac Assessment and Selection,” 546-547. 145 Chaukar, Interview, 6/20/2016. 146 A. Bhattacharya, S.S. Jadhav, and N.D. Ghodke, “Special Preparations,” JIMA, 1968, 51, 548-549. 147 Sen, Panday, J. Daulatram, and Chaukar, “Description—Donor, Recipient,” JIMA, 1968, 51, 549-554. 148 Sen and others, “Description,” 550; Parulkar, “Developments,” S28, (total cessation). As Chaukar recalls, “we waited like vultures.” Chaukar, Interview, 6/20/2016. 149 Sen and others, “Description,” 553. 150 Parulkar, “Developments,” S28. 151 Sen and others, “Description,” 554. Chaukar described the “tremendous disappointment,” but added “I was so exhausted by 48 hours of work that did I not really feel it.” Chaukar, Interview, 6/20/2016. 152 “First-ever Heart Transplant in India,” 1. On 2/23 it added that his “team of doctors, technicians and nurses had practiced the operation routine to clock-work perfection.” “Doctors Ready for 2nd Heart Transplant,” 1. The Indian Express noted that Sen’s team “had been active in experimental heart transplants under the Indian Council of Medical Research in the last five years.” See: “Transplant Team Hopeful,” Indian Express, 23 February 1968, 1. 153 “Troubled Hearts,” Times of India, 20 February 1968, 8. 154 “Doctors Ready for 2nd Heart Transplant,” 1; “Heart Transplant,” Times of India, 24 February 1968, 5; “Haffkine Institute Making Serum to Aid Transplant,” Times of India, 26 February 1968, 1. 155 “Doctors Ready for 2nd Heart Transplant,” 1. See also: “Haffkine Institute Making Serum to Aid Transplant,” 1. 156 Charles Rosenberg, “The Therapeutic Revolution: Medicine, Meaning, and Social Change in Nineteenth Century America,” Perspectives in Biology and Medicine, 1977, 20, 485-506; John W. Warner, The Therapeutic Perspective: Medical Practice, Knowledge, and Identity in America 1820-1885 (Cambridge: Harvard University Press, 1986); Jack Pressman, Last Resort: Psychosurgery and the Limits of Medicine (Cambridge: Cambridge University Press, 1998); Robert A. Aronowitz, Unnatural History: Breast Cancer and American Society (New York: Cambridge University Press, 2007); Jeremy A. Greene, Prescribing by Numbers: Drugs and the Definition of Disease (Baltimore: Johns Hopkins University Press, 2007); Warwick Anderson, “Objectivity and its Discontents,” SSS, 2012, 43, 557-576; David Jones, Broken Hearts: The Tangled History of Cardiac Care (Baltimore: Johns Hopkins University Press, 2013). 157 Schlich and Crenner, “Technological Change in Surgery,” 12. 158 Chaukar, Interview, 6/20/2016. There is some ambiguity about this. In 2004 Parulkar, claimed that they had 8 days survival in a transplant recipient (Parulkar, “Developments”: S28). In the 1968 JIMA report, they only claimed six hours of survival after a transplant (Sen and others, “Introduction and Experimental Base,” 544). 159 Datey and others, “Cardiac Assessment and Selection,” 547. 160 Kumat, “Pulmonary Assessment,” 548. See also Kinare, “Autopsy,” 558. 161 Dhruva, Bhatt, S.S. Mehta, and P.N. Parikh, “Anesthesic Management,” JIMA, 1968, 51, 554. 162 Sen and others, “Description,” 553 As Kinare later admitted, “Unfortunately the patient was a wrong choice.” S. Kinare, “Dr. Sen’s Contributions to Cardiovascular Surgery,” Journal of Postgraduate Medicine, 1991, 37 Suppl 1:12-13, 13. 163 Kumat, “Pulmonary Assessment,” 548; Kinare, “Autopsy,” 558. The Times of India reported that the death, from pulmonary hypertension, was “a complication that was expected.” See “First-ever Heart Transplant in India,” 1. 164 The recipient’s “chances of survival were rated nil” without surgery. See “First-ever Heart Transplant in India,” 1. As the Indian Express noted, “As his heart muscle became entirely functionless, they had decided to give him the chance of transplantation.” See: “Transplant Team Hopeful.” 165 In Homo Sacer, Georgio Agamben argued that the rural and urban poor in India lacked the basic civic rights of ordinary people. They had become “bare life,” vulnerable, to violation and exploitation. Georgio Agamben, Homo Sacer: Sovereign Power and Bare Life, trans. Daniel Heller-Roazen (Stanford: Stanford University Press, 1998). See also Das and Poole, Anthropology in the Margins of the State. Similar vulnerabilities existed in the United States. See: Lederer, Flesh and Blood, 176. 166 Chaukar, Interview, 6/20/2016. 167 Barnard, quoted in “India’s First Heart Transplant.” Barnard, speaking from Argentina, knew the diagnosis, cardiomyopathy, but it is not clear if he knew about the co-morbidities. 168 Cardiac surgeons, who had witnessed high mortality in their early case series knew well the risks of innovation. Yet Sen and his team focused on what was possible, not on would likely go wrong—a mindset discussed below. For the emergence of risk thinking in medicine, see Schich and Ulrich Tröhler, The Risks of Medical Innovation: Risk Perception and Assessment in Historical Context (New York: Routledge, 2006). 169 “Heart Transplant Not Premature: Barnard,” Times of India, 5 March 1968, 6. 170 “Heart Transplants: Dr. Bernard Sees No Ethical Problem,” Times of India, 10 March 1968, 12. 171 “’Moral Issues Involved in Transplant,’” Times of India, 3 April 1968, 7. 172 Bhagwan J. Mani, “Letter to the Editor,” Times of India, 17 May 1968, 5. 173 “Heart-graft Experts Meet at Cape Town,” Times of India, 14 July 1968, 12. 174 Kantrowitz, “Oral History,” by Peer Portner, 19 April 2005, Project Bionics Pioneer Interview Collection, National Library of Medicine, #2009-028/2002-098/2003-042/2013-010. Kantrowitz explained that “we all knew P.K. Sen because he was one of the group. He'd been doing experimental work. We'd been at the meetings. We'd been yelling at each other. So we knew each other very well.” 175 “Barnard Praises Dr. P.K. Sen,” Times of India, 15 July 1968, 7. 176 “People in the News,” Times of India, 21 July 1968, 8. 177 “Dr. Sen Returns,” Times of India, 22 July 1968, 3. 178 Stanley S.B. Gilder, “Twenty-second World Medical Assembly,” BMJ, 1968, 3, 493-494; “Declaration of Sydney,” BMJ, 1968, 3, 449. See also Morris, Matter of the Heart; Macdonald, “Crossing the Rubicon.” 179 Ad Hoc Committee of the Harvard Medical School, “A Definition of Irreversible Coma,” JAMA, 1968, 205: 337-340; Belkin, Death before Dying. 180 For instance, see: Bellanger and Steinbrecher, “Addressing Uncertainties.” 181 “Doctors Ready for 2nd Heart Transplant.” Sen explained that “he hoped that they would be able to graft a heart into a ‘good risk patient’ and succeed in a major way.” See: “Transplant Team Hopeful.” 182 Chaukar, Interview, 10/20/2016. 183 Sen, “Addendum,” JIMA, 1968, 51, 563. The patient survived for 12 hours. For the global tally, see Haller and Cerruti, “Heart Transplantation.” See also Mittal, “Profulla Kumar Sen.” Chaukar recalled that the heart, taken after it had stopped beating, was distended and they could not get the patient off bypass. Chaukar, Interview, 6/20/2016. 184 “Dr. Sen Does His Second Heart Graft,” Indian Express, 16 September 1968, 1. 185 Sen, “Human Heart Homotransplantation.” 186 “Special Feature: Heart Transplantation.” 187 S.V. Joglekar, Sen’s dean, argued that after Barnard’s first attempt “It can now be said with emphasis that there is every possibility of success.” Joglekar, “Heart Transplant—Ethical and Legal Aspects,” JIMA 1968, 51, 557. 188 Banerjee, “Cardiac Transplantation,”539, 541, 540. The “price” referred not to Sen, but to the outcomes of the first 70 transplants performed worldwide. 189 Lyman A. Brewer, “Cardiac Transplantation: An Appraisal,” JAMA 1968, 205, 691-692, 691. See also Westaby, Landmarks, 265. 190 “On the Defensive,” Times of India, 3 October 1968, 8. We have tried to find debates about Sen’s transplant from sources other than the Times of India, including targeted searches of The Hindu, Indian Express, the Hindustan Times, and The Patriot. 191 J.B. Morehead, “Transplants in India,” Times of India, 12 October 1968, 8. Writing again on 18 October, he argued that “India does not as yet possess the necessary expertise, organization and technical know-how to proceed with what is probably the most major surgical procedure today. This has been amply borne out by the results of the first two operations here.” Morehead, “Transplants in India,” Times of India, 30 October 1968, 8. We do not know anything about Morehead, though he may have been connected to a J.B. Morehead who went to India as a missionary in the nineteenth century. Morehead likely reflects a colonial perspective on India, one distinct from the two Indian authors who replied. 192 Sudhir, “Transplants in India,” Times of India, 17 October 1968, 8. The letter does not include the author’s full name. Morehead understood Sudhir’s “patriotic fervor,” but remained unconvinced: Morehead, “Transplants,” 30 October 1968, 8. 193 D.V. Nadkarni, “Transplants in India,” Times of India, 24 October 1968, 10. This could be the author of the 1944 Surgical Epitome, but we are not certain. 194 By the fall “transplants were failing everywhere.” Chaukar, Interview, 6/20/2016. 195 “Dr. Sen Plans More Heart Transplants.” 196 R.A. Bhalerao and J.S. Patil, “Donor Selection and Management,” JIMA 1968, 51, 555-556, 556. 197 “More Donors than Recipients for Heart Transplants,” Times of India, 20 November 1968, 11. It added, revealingly, “About the ethics, law and morality of heart transplants, Dr. Sen remarked: ‘I am not a lawyer and my friends don’t call me a very moral man.’” 198 B. Mukherjee, former director of the Central Research Institute in Lucknow, quoted in “Keeping Dead Man’s Heart Going: Research Explained,” Times of India, 7 January 1969, 12. 199 Jaikrishna Pant, “Heart Transplants,” Times of India, 16 January 1969, 8. He highlighted the lack of an intensive care unit at K.E.M. (one had finally opened in December 1968) as evidence that India was not prepared for these procedures. For the opening of the ICU, see “India’s First Intensive Care Ward,” Times of India, 2 December 1968, 9. 200 Sen, “Heart Transplantation—The Triumph and the Muddle,” Indian Journal of Chest Disease, 1970, 12, 66-72, 69. 201 Sen, “Heart Transplantation,” 71. 202 “Time Vital Factor in Transplants, Surgeon Says,” Times of India, 7 February 1970, 13. 203 “A Year’s Rural Work by New Doctors Mooted,” Times of India, 17 October 1971, 6. 204 Fox and Swazey, Courage to Fail, 380: “This pioneer syndrome is closely related to an emphasis on optimism in the face of uncertainties, limitations, and high mortality rates.” They had a darker view in Spare Parts. The “courage to fail” mentality involves “a bellicose, ‘death is the enemy’ perspective; a rescue-oriented and often zealous determination to maintain life at any cost; and a relentless, hubris-ridden refusal to accept limits.” See Fox and Swazey, Spare Parts, 199. 205 Kinare, “Dr. Sen’s Contribution,” 13. 206 For a broader discussion of transplants in India, see: Lawrence Cohen, “The Other Kidney: Biopolitics beyond Recognition,” Body and Society, 2001, 7, 9-29; Cohen, “Operability: Surgery at the Margin of the State,” in Anthropology in the Margins of the State, 165-190. 207 T.M. Anantharaman, “Organ Transplants,” Times of India, 19 November 1972, A1 and A3, A1. 208 M.K. Ananthaswamy, “Letter,” Times of India, 10 December 1972, A3. 209 Fox and Swazey, Courage to Fail, 108, 312. 210 “The Tragic Record of Heart Transplants: A New Report on an Era of Medical Failure,” Life, September 1971. 211 Fox and Swazey, Courage to Fail, 312; see also Shumway, “Oral History,” 434. 212 Fox and Swazey, Spare Parts, 7. 213 Anantharaman, “Organ Transplants,” A3. 214 Parulkar, “Developments,” S28-29. See also Hosain, “Dr. PK Sen,” 256. 215 “First Ever Successful Heart Transplant Conducted in Mumbai Thanks to Efforts of Police,” Daily News and Analysis, 3 August 2015. 216 “Aurangabad Engineer’s Heart Give Thane Resident New Life,” Times of India, 22 June 2016, online. © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of the History of Medicine and Allied Sciences Oxford University Press

Transplant Buccaneers: P.K. Sen and India’s First Heart Transplant, February 1968

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Abstract

Abstract On 17 February 1968, Bombay surgeon Prafulla Kumar Sen transplanted a human heart, becoming the fourth surgeon in the world to attempt the feat. Even though the patient survived just three hours, the feat won Sen worldwide acclaim. The ability of Sen’s team to join the ranks of the world’s surgical pioneers raises interesting questions. How was Sen able to transplant so quickly? He had to train a team of collaborators, import or reverse engineer technologies and techniques that had been developed largely in the United States, and begin conversations with Indian political authorities about the contested concept of brain death. The effort that this required raises questions of why. Sen, who worked at a city hospital in Bombay that could not provide basic care for all its citizens, sought a technology that epitomized high-risk high-cost, health care. To accomplish his feat, Sen navigated Cold War tensions and opportunities, situating his interests into those of his hospital, municipal authorities, Indian nationalism, Soviet and American authorities, the Rockefeller Foundation, and others. The many contexts and interests that made Sen’s work possible created opportunities for many different judgments about the success or failure of medical innovation. On 17 February 1968, Bombay surgeon Prafulla Kumar Sen transplanted the heart of a twenty-year-old woman into a twenty-seven-year-old shepherd suffering from a chronic, progressive cardiomyopathy.1 Although the recipient died within three hours, the surgical team praised their work: “The operation was technically a success. It was a perfect operation.”2 Sen was “flooded with congratulatory telegrams from eminent cardiac surgeons the world over.”3 He was the fourth surgeon to perform a heart transplant, the first in India, the first in Asia. He did it before surgeons in England, France, Canada, Australia, Japan, or the Soviet Union, and before Michael DeBakey and Denton Cooley, the giants of American cardiovascular surgery.4 The editor of the Journal of the Indian Medical Association considered Sen’s feat “a record for which the whole of India is proud.”5 The ability of Sen’s team to join the ranks of the world’s surgical pioneers raises important questions. Consider the question of how Sen transplanted so quickly. The key innovations in cardiac surgery had taken place outside of India and were actively pursued by surgeons in India. India’s acquisition of cardiac capability accelerated dramatically over the twentieth century. The lag between the first successful heart operation (repair of a stab wound to the left ventricle, Frankfurt, 1896) and the first in India (the same procedure, Bombay, 1944) was forty-eight years. The lag between the first successful use of a heart-lung machine (Philadelphia, 1953) and the first in India (Vellore, 1961) was nearly eight years. The lag between the first heart transplant (Cape Town, 3 December 1967) and the first in India was just eleven weeks. Sen’s team later claimed that they could have performed their transplant as early as 1965. It is possible to study the development of Sen’s clinical and research programs in order to understand how he moved so quickly when heart transplantation became possible. Sen navigated Cold War opportunities, exploiting ties to both the Soviet Union and the United States, to mobilize the knowledge, devices, and expertise of cardiac surgery and beat better-resourced surgeons to the feat of heart transplant. The question of why is equally puzzling. In the 1960s India struggled to provide basic medical care to its population. Sen, who spent his career at a municipal hospital, knew this well. Heart transplantation, meanwhile, epitomized the technologically-sophisticated, high-cost health care made possible by the wealth of post-war America. Sen’s pursuit of this technology triggered a debate in India about whether it made sense for heart transplants to take place in developing India. This became part of the emerging discourse on “appropriate technology.”6 Many interests shaped the trajectory of Sen’s work, from the reluctance of the Bombay Municipal Corporation to invest in academic medicine to the modernizing ambitions for Indian physicians to keep abreast of scientific advances in the west. Only by understanding how and why the transplant was done is it possible to understand the claims of success. Who, beyond the patient, stood to benefit from an attempted transplant? Why did Bombay surgeons and journalists celebrate despite the patient’s death? Sen’s operation was simultaneously an experiment, a demonstration project, and a therapeutic endeavor. The struggles by Indian surgeons to establish open heart surgery and the local, national, and transnational interests that made their work possible created a context in which there could be many different judgments about the success or failure of medical technology. Sen’s operation can be considered a failure at another level. His team attempted only two transplants; no one in India tried again for twenty-five years. Heart transplants had taken place in twenty countries between 1967 and 1969.7 The dynamics varied in each, depending on nationalist impulses, Cold War politics, the availability of resources and expertise, and countless other factors. Sen’s transplants and their aftermath reveal how Indian contexts shaped the reception of a globalizing technology. Sen thought India had enormous potential as a transplant center: its chaotic roads and railways generated a tragic abundance of potential organ donors.8 Yet he could not convince legal and legislative authorities to join other countries and adopt the concept of brain death and the therapeutic procedure that depended on it. Histories of an Epidemic of Transplants Heart transplantation, perhaps the most dramatic medical event of the twentieth century, has received enormous attention from journalists, historians, anthropologists, and sociologists. Lesley Sharp attributes the fascination to the ways in which transplantation “simultaneously epitomizes technical genius and medical hubris.”9 Existing scholarship focuses on three issues. Historians of medicine, especially Susan Lederer and Thomas Schlich, have traced the long pre-history of the transplant imaginary. While the first successful human kidney transplant took place in 1954, the idea of organ transplantation has existed for millennia. Active work began in the nineteenth century. Even as early efforts raised fraught moral questions, they met with great enthusiasm, “celebrated in the popular press as emblematic of surgical possibility and promise.” Movies, novels, and newspaper coverage helped “to establish the surgical imaginary, a trajectory of possibility about remaking the human body.”10 The tensions that would emerge in Bombay in 1968 were decades in the making. Historians, surgeons, and journalists have scrutinized Christiaan Barnard’s transplant and the dramatic year that followed. They have chronicled both the nitty-gritty details of experiments and clinical innovations, the melodrama of the rivalries between competing surgeons, and Barnard’s celebrity escapades: “Ambition and envy, compassion and resentment, dedication and despair, glory and infamy shadow this story.”11 This work both celebrates (e.g., medical and technological achievements) and critiques (e.g., Barnard’s ambition, the media frenzy). Excellent work has also examined the furor over brain death and the efforts to resolve it.12 Sociologists and anthropologists have examined the tensions that have accompanied heart transplantation since 1968. Reneé Fox and Judith Swazey, who followed developments in real-time, described how heart transplantation “epitomizes the bold, uncertain, and often dangerous adventure in which medical professionals and their patients are engaged.” They were interested in the ethics of the fraught transition from experiment to therapy, “Problems of uncertainty, meaning, life and death, scarcity, justice, equity, solidarity, and intervention in the human condition.”13 As transplants increased in the 1980s, they became disturbed by society’s increasing acceptance of “’spare parts’ pragmatism” and the investment in organ replacement when so many people lacked access to basic health care.14 Lesley Sharp has tracked “a simultaneously wondrous and disquieting medical field.”15 She focuses on what the “transplant imaginary” leaves unsaid: “At the heart of this work, so to speak, are deep concerns about the inevitable yet silenced nature of patient suffering.”16 Lawrence Cohen has explored the fraught ethics of organ harvesting in India.17 The extensive literature mostly ignores or dismisses Sen and the history of heart transplants in India. Many works describe the first five transplants (by Barnard, Adrian Kantrowitz, and Norman Shumway), but stop short of the sixth—Sen’s.18 When Sen does appear in historical writings, the coverage is rarely favorable.19 Shumway, in a 1997 oral history, is typical in his dismissal: “Some surgeons were attracted to the publicity and personal aggrandizement. Soon transplants were being done in India and places where you would not want to have any kind of heart operation.”20 Shumacker briefly acknowledged Sen’s research and clinical attempts.21 We have found only a few short biographies in medical journals that detail Sen’s accomplishments, but these rely on his publications.22 No one has attempted a thorough history of Sen’s research and clinical programs using archives, Indian newspapers, and other sources to reveal the details of his work, its stakes, and the controversies that played out in Bombay in 1968.23 The silence about Sen is informative, revealing scholars’ assumptions (often racialized) about where and how science and innovation take place. Many histories of heart transplantation, and of medical innovations in general, have focused on linear and progressive processes of discovery and diffusion, ones that foreground Europe and North America. Schlich and Crenner called on scholars to redirect their attention to the social, political, and economic contexts of innovation and recognize the ways in which historical actors faced complex and contingent choices between alternative paths.24 Sally Frampton has emphasized the importance of recognizing “the ripples of unease” that often accompany innovation.25 Our work demonstrates this complexity well. It highlights the ways in which innovation can occur in unlikely spaces.26 K.E.M., a municipal hospital, existed on the uncertain and unregulated margin of state practices, where weak control and “illegible” legal and institutional frameworks enabled experiments in cardiac surgery.27 Chronically under-resourced, K.E.M. provided Sen with few incentives or resources for innovation. Yet it allowed him to mobilize local and international allies and take advantage of the exchanges of people, ideas, and techniques between many countries made possible by the post-colonial order. The new technologies, however, did not have an inevitable trajectory. Indian physicians, officials, and citizens made complex choices about what path a particular surgical innovation—heart transplantation—should take in India. Heart Disease and Surgery in Independent India In 1950 few would have expected that India would soon host pioneering work in cardiac surgery, as neither surgery nor heart disease received much attention in India. Even though cardiologists had begun to describe heart disease as a “growing menace,” they understood that the traditional problems of public health deserved the lion’s share of attention.28 A 1958 study of coronary artery disease conceded this point: “We in India at present have to continue to think in terms of more important problems, such as those in infant mortality, infectious disease, nutritional disorders, overpopulation, and a host of other public health problems.”29 And while surgery had been present at colonial and mission hospitals in India since the nineteenth century, the Indian population had remained ambivalent about its practice.30 Surgical capacity remained limited into the 1940s. As one of Sen’s trainees later recalled, “the horizon of Indian surgery was largely limited to surgery of abdominal cavity which included simple operations for common ailments such as hernia, appendicitis and peptic ulcers.”31 After independence, Prime Minister Jawaharlal Nehru and his minister of health, Amrit Kaur, included surgery in their plans for India’s techno-scientific modernization. Kaur encouraged her audience at the annual conference of the Association of Surgeons of India in 1951: “Living as we are in a scientific and machine age there is no knowing what the surgeon of the future may be called upon to do.” Surgery of the brain and “even the heart” was within reach.32 Outsiders, confident in their opinions despite their modest knowledge of India, critiqued such ambitions. One Boston surgeon, who had spent three months teaching surgery in India, argued that Indian surgeons needed realistic aspirations, and that “in a nation that is leaping ‘from a cow dung fuel economy to the nuclear age it is more important to provide smallpox vaccine than Salk vaccine or heart surgery.’”33 Such restrictive ideas about the trajectory of scientific research and medical priorities in a “developing” nation were precisely what Sen and his contemporaries would challenge through the successes of their “failed” heart operations. Born in Calcutta, Sen studied medicine at Seth G.S. Medical College in Bombay and trained in surgery at K.E.M. Hospital from 1939 to 1942. He joined the staff at K.E.M. in 1942.34 Seth G.S. and K.E.M. had both been founded in 1926 as nationalist institutions in reaction against the refusal of Grant Medical College to appoint Indian physicians to its faculty.35 Sen imbibed his institutions’ nationalism. In 1958, he called on India to strengthen its own medical training programs and wean itself off its dependence on the West. Nowhere was this truer than in surgery. While he acknowledged the examples of John Hunter, Alexis Carrel, and Harvey Cushing, he sought inspiration in ancient India. Charaka “laid down four essential attributes of a surgeon 4000 years ago”: surgeons had to be scientists, technicians, teachers, and leaders of society.36 By linking his own work to India's classical medical traditions, Sen sought to create a discursive space for surgical innovation in India. With help from the Indian Research Fund Association (renamed the Indian Council of Medical Research (ICMR) in 1949), Sen began animal studies, chart reviews, and clinical research on diarrhea, tuberculosis, perforated ulcers, and traumatic shock, including new techniques developed by Soviet researchers at the Moscow Medical Institute.37 Seeking advanced training in surgical research, he applied for a fellowship from the Rockefeller Foundation in September 1949. The Foundation asked I.S. Ravdin, chair of surgery at the University of Pennsylvania, to accept Sen as a trainee.38 Ravdin obliged. He had directed the US Army’s 20th General Hospital in Assam on the Indo-China frontier during World War II.39 He had attended the 1944 All Indian Conference of Surgery and “was deeply impressed with the fact that we had to do something to help India if surgery was going to be raised above the level of a trade.”40 Ravdin arranged for Sen to work for six months with James Hardy, then a fellow on the thoracic surgery service (Hardy would later attempt the first heart transplant in a human—see below).41 They used radioisotopes to study the impact of surgery on adrenocortical activity and presented their research at the annual meeting of the American College of Surgeons in Boston in October 1950.42 This fellowship also exposed Sen directly to the problem of race in America and the inequities that existed with “modern” societies. When they traveled to Atlantic City to present at the American Physiological Society, the clerk at the Lyric Hotel barred Sen. Hardy reassured her that Sen was Indian and they were admitted, “somewhat unsettled.”43 Sen finished the year with a tour of surgical research centers in Chicago, Minneapolis, Rochester, Cleveland, Ann Arbor, Boston, New York, Baltimore, Montreal, London, and Sweden. When Sen returned to Bombay, K.E.M.’s Dean Dhayagude asked him to organize a department of “Experimental Surgery.” The hospital offered him space and the ICMR provided Rs. 6000 (c. $1300), but this was not enough. In July 1951 Sen asked the Rockefeller Foundation for help.44 In October 1952 Dhayagude followed up with the Foundation on Sen’s behalf, explaining that Sen’s research “requires some costly equipment which cannot be provided from the sources available to us.”45 He told Rockefeller official Richmond Anderson that “Sen is really taking hold of his work in experimental surgery and has aroused the interest of others in the institution.”46 The Foundation approved a grant of $3,500 in April 1953.47 Sen’s interests had turned in the meantime to cardiac surgery. In 1952 he performed his first, closed-heart operation (the first intra-cardiac operation in India), inserting his finger through an incision in the right atrium of a beating heart to force open a rheumatic mitral valve.48 Even in the early years of his career, he sought to engage with western experts, improve their techniques, and share his innovations. In this case, he studied American techniques and experimented on twenty-five dogs, eventually developing his own approach, one “more practical and less dangerous than the other choices available.”49 He used this technique in three patients and presented his results at the annual conference of the Association of Surgeons in India in December 1952.50 This was an exciting time. Cardiac surgery had not existed in the 1940s, in India or any place else. Ambitious surgeons made rapid progress after World War II tackling simple cardiac lesions (e.g., patent ductus arteriosus, mitral valve stenosis) that could be treated by anyone trained in thoracic surgery. They soon set their sights on open-heart surgery. The excitement reached India. In October 1952 the Times of India covered the annual meeting of the American College of Surgery: “Transplantation of heart, lung, and other vital organs, impossible now, is being studied in an increasing number of surgical centers.”51 Articles about the “miracle of modern surgery” appeared regularly in Bombay.52 Open-heart surgery, however, was a difficult challenge. As Hardy later explained, “relatively few made the long jump from tuberculosis surgery and closed-heart operations, on the one hand, to full-scale open-heart surgery when the field was rapidly developed after 1954.”53 Sen did. Open heart surgery required surgeons to protect the body as they stopped the heart, opened its chambers, and performed their repairs. Sen had read about two basic approaches. Surgeons in the United States, Sweden, and Russia had developed heart-lung machines, but he did not think these were ready for widespread use: “The prohibitive cost and the complicated nature of the apparatus militate against immediate general acceptance.”54 As he told his colleagues at K.E.M. in 1953, “like all artificial organs devised, a technical failure is inherent in its very nature.”55 The other approach, hypothermia or “artificial hibernation” cooled the body to reduce oxygen consumption and protect the brain. Sen considered this a “physiological approach.”56 Hypothermia was first used successfully at the University of Minnesota in 1952. Sen began his own experiments in 1953. He cooled dogs, opened their hearts, and then saw how many he could revive. Although half the animals died, mostly from ventricular fibrillation, Sen was not discouraged: “We feel that the procedure is a perfectly feasible one, and, with further knowledge in the management, may be rendered very much safer.”57 When Anderson visited in April 1954, he found Sen “doing some interesting work on refrigeration.”58 Sen’s first hypothermia patient died in 1954. After extensive and often “disappointing” research, they achieved clinical success in 1956, using four minutes of “total circulatory arrest” to repair an atrial septal defect.59 Eager to keep up with developments in the west, Sen obtained a second travel grant from the Rockefeller Foundation and toured leading cardiac centers in Europe and North America from September 1956 through May 1957.60 He also hosted foreign surgeons in Bombay. In February 1958, Sir William Heneage Ogilvie, an “eminent British surgeon,” spoke at Seth G.S. He “advised young doctors to approach surgery with the spirit of romance, as it called for adventure, courage, tact, perseverance, gentleness and originality.” Surgeons, especially transplant surgeons, often praised their own pioneering spirit.61 Sen, who welcomed Ogilvie’s vision, “proposed a vote of thanks.”62 The Turn to Transplant Even as Sen worked to master closed heart techniques and hypothermia, he turned his attention to heart transplantation. He attributed his interest to the “monumental papers” written by Alexis Carrel and Charles Guthrie.63 Working at the University of Chicago in 1905 and 1906, they developed techniques to repair blood vessels and then used these techniques to experiment with organ transplants. Described as a “Wizard of Oz,” Carrel won wide acclaim for heart transplants: “He has taken the heart of a little dog and introduced it into the neck of a larger dog and linked it up with the coronary circulation of the latter, and thus done literally probably what has never bene done before, all poetry and fancy to the contrary—made two hearts beat as one!”64 Even though Carrel won a Nobel Prize in 1912, surgeons did not rush to follow his lead. A team at the Mayo Clinic transplanted hearts in dogs in the 1930s, but simply to study the physiology of denervated hearts.65 In the 1940s Vladimir Demikhov began research in Moscow, transplanting hearts (and heads) in hundreds of dogs.66 Surgeons in Chicago and Philadelphia began similar work in dogs in the early 1950s. Sen began his own research on transplantation in 1954.67 Inspired by the work in Philadelphia, and with funding from the ICMR, he conducted a simple experiment: Will a heart, removed from an animal, survive the duration of a transplant procedure? He removed hearts from “profoundly hypothermised dogs” and watched. 68 Anderson, who visited the lab in June 1955, was dubious: “I am not certain of the purpose or value of this particular experiment though Dr. Sen is certainly working hard on his own time both in the laboratory and in clinical surgery.”69 Although Anderson saw one heart beat for twenty minutes, few did that well. Sen’s team conceded that “the period of effective cardiac contractions (average ten minutes) was not long enough to justify an immediate serious trial of the second phase of our undertaking, namely, actual transfer of a heart-lung preparation from one frozen animal to another.” Sen put his transplant program on hold in 1956: “This and many other technical and physiologic complexities have to be solved before heart-lung transplantation is generally feasible.”70 As Sen refocused his efforts on hypothermia, more surgeons took on the challenge of heart transplants. By the early 1960s teams of researchers worked in Moscow, Chicago, Philadelphia, Jackson (Mississippi), New Orleans, Cooperstown, St. Louis, Guelph, Palo Alto, London, Puerto Rico, and Czechoslovakia.71 The most influential work came from Stanford’s Norman Shumway and Richard Lower, who performed their first successful dog transplant in 1960.72 By 1963 they believed that they had mastered the surgical techniques needed to preserve the donor heart, support the recipient’s body during the procedure, and complete the transplant. They knew, however, that they had to prevent immunologic rejection.73 Adrian Kantrowitz, who had observed Demikhov perform valve surgery (but not transplants) in Moscow in 1959, transplanted hearts in puppies, whose under-developed immune systems tolerated the new heart; one survived 213 days.74 Other surgeons experimented with methotrexate and azathioprine to prevent rejection.75 In 1967 Lower, who had left Stanford for the Medical College of Virginia, reported 15-month survival after a heart transplant in a dog treated with methotrexate.76 Many teams felt ready to transplant by the late 1960s. Sen focused on hypothermia into the 1960s and conducted ongoing dog research and clinical attempts.77 In 1962 he described his experiences in eleven patients with atrial septal defects. The team was pleased with the “gratifying results” even though only six survived.78 Sen knew, however, that surgeons in the United States had made rapid progress with heart-lung machines.79 Despite his initial skepticism, his team began to test them in the laboratory in 1958. Early results disappointed: a “majority of the animals succumbed to the extracorporeal circulation, due to uncontrolled bleeding.”80 Sen realized that success with heart-lung machines would require skilled collaborators with American training. He convinced the Rockefeller Foundation to provide fellowships to K.E.M.’s cardiologist, Keshavarao Krishnanao Datey, to his pathologist and laboratory director, Suman Kinare, and to one of his surgical trainees, Tryambak Pandurang Kulkarni.81 Another trainee, G.B. Parulkar, also received funding to study abroad.82 Indian surgeons had to work hard to obtain and master heart-lung machines. Financial support from the Rockefeller Foundation allowed Sen’s team to dodge India’s restrictions on currency exchange and purchase equipment from European and American companies. However, this was never easy. Sen faced constant frustration and delays as he tried to import pumps, oxygenators, gaskets, filters, and spare parts.83 In 1961 two competitors in India, Kersi Dastur in Bombay and Nagarur Gopinath in Vellore, performed open heart surgery with heart-lung machines, motivating Sen’s team to move more quickly.84 On 30 March 1962 they used their heart-lung machine to repair a ventricular septal defect in a child.85 Even though the “entire operation was uneventful,” the outcome was tragic: “The patient did not wake up after the surgery, obviously due to the brain damage.” Despite this outcome, Parulkar saw a silver lining: “From this one single case we learnt much more than the hundreds of animal experiments that we had performed.”86 In January 1962 Sen asked the Rockefeller Foundation to underwrite another overseas trip: “I should like to get back to the ‘edge of progress’ even if it is for a short visit. It has been five years since I have been abroad and so much has happened.”87 The planned itinerary included Tokyo, San Francisco, Los Angeles, Palo Alto, Houston, Mexico City, New Orleans, Philadelphia, Detroit, Cleveland, Rochester, Boston, Philadelphia, Washington, New York City, London, Birmingham, Edinburgh, Amsterdam, Copenhagen, Leningrad, and Moscow. In July the Foundation approved $5800 for the four-month trip.88 As Sen traveled that fall, the Times of India celebrated the continuing progress of cardiac surgery and its “ingenious devices,” writing “the terrors are slowly receding as great strides of progress in diagnosis and treatment are made in the field of cardiovascular care and therapy.”89 At the end of his trip, Sen visited Demikhov in Moscow.90 Even though Demikhov had not published his work in English before 1962, his heart and head transplants had been covered in newspapers.91 A Times of India editorial in August 1959 reported that he had “engrafted a second heart on a lucky dog.” It described the news as “very heartening” before veering into jokes about romance with two hearts and transplanting a lion’s heart to fortify a coward.92 Sen’s ability to visit Demikhov provides a revealing glimpse into one aspect of Cold War science. Historians of science have documented the many challenges and opportunities that the conflict presented to scientists.93 Overt hostility between the United States and the Soviet Union interfered with some forms of scientific exchange. The Central Intelligence Agency, for instance, tracked the Rockefeller Foundation’s activities in India. In March 1956 agents asked Anderson about his “knowledge of Communist activities on the part of doctors in India.” Anderson, citing the “nonpolitical” orientation of the Foundation, denied knowing anything: “We tended to avoid political discussions with Indians with whom we worked, nor did we go around trying to determine indirectly their political views.”94 But the conflict also motivated other kinds of exchange. Many physicians, most famously cardiologist Paul Dudley White, used medicine to foster bonds between countries separated by Cold War tensions.95 Sen was freer to pursue ties with colleagues in the United States and the Soviet Union than were his peers on opposing sides of the Iron Curtain. The Indian government worked carefully to avoid falling under the sway of the United States and actively cultivated ties to the Soviet Union. This helped Indian physicians move easily between the scientific establishments of Cold War rivals. A.V. Baliga, one of P.K. Sen’s senior surgical colleagues at K.E.M. Hospital, directed the Indo-Soviet Cultural Society.96 He may have facilitated Sen’s contacts with Demikhov. Sen himself received the Vishinsky Medal from the Soviet Union in 1962.97 Sen and Hardy Transplant Sen returned to Bombay in early January 1963. That week Herbert Conway, a New York surgeon and editor of Transplantation, spoke at K.E.M. He told reporters that “he looked forward to the day when it would be possible to prolong life by the transplantation of an organ like the kidney or even the heart.”98 Inspired by his visit with Demikhov, Sen resumed work on heart transplants. Despite progress with open heart surgery, many patients had lesions that could not be corrected. In these patients surgeons had considered “a replacement or a support of the original heart with a new heart.” Sen knew that many problems “limit the execution of such an ambitious goal.” 99 In 1963 and 1964 Sen’s team conducted four sets of experiments on a total of 100 dogs.100 In sixty dogs, they transplanted hearts into the neck (the Mayo technique from the 1930s) to study both the behavior of the transplanted heart and methods to prevent rejection with methotrexate and steroids; in thirty, they transplanted a heart to replace the recipient’s heart (Lower and Shumway’s technique); in five, they transplanted the heart as an auxiliary booster heart (Demikhov’s technique); and in five, they performed heart-lung transplants, “using our own method suggested in 1956.”101 Their results disappointed. Dogs with heart transplants survived up to six hours, and those with heart-lung transplants up to twelve hours. They obtained the best results when the heart was taken from the donor while still beating.102 Despite such grim results, the research earned accolades in the Times of India. A front-page article with photograph on 11 October 1963 trumpeted “Dog with Two Hearts Is Normal: Miracle Surgery in City Hospital.” S.M.Y. Sastry, the acting Municipal Commissioner, “proudly announced the operation in the corporation.”103 Three days later the paper celebrated the “Daring Experiment” once again, adding that “the two-hearted dog behaved as normally as could be expected in the circumstances.”104 Anderson visited the lab in December and found Parulkar and Panday at work on cardiac transplantation. He noted, “One gets the impression that sound and important progress is being made.”105 When Sen updated Anderson three weeks later, he noted that a transplanted heart “has been able to support the circulation independently for a period of three hours.”106 By mid-January 1964 a breakthrough seemed inevitable: “Though no heart transplants in human beings have yet been made, there is growing belief by many prominent researchers that it will be accomplished—perhaps within the next decade.”107 Two weeks later news broke that James Hardy, Sen’s mentor in Philadelphia in 1950, had transplanted a chimpanzee heart into a human. Even though the heart beat for just seventy-five minutes, Hardy knew that his team had “breached the massive intellectual and emotional barrier which had previously prevented heart transplantation in man.” The news “fell like a bombshell on the world.”108 Reaction was swift and furious, in part because of the chimpanzee heart, and in part because of the racial tensions in Mississippi in 1964. When Hardy spoke two weeks later at the Sixth International Transplantation Conference at New York’s Waldorf-Astoria Hotel, he received a scathing introduction from Willem Kolff, a pioneer of dialysis who had survived the Nazi occupation of the Netherlands: “In Mississippi, they keep the chimpanzees in one cage and the Negroes in another cage, don’t they, Dr. Hardy?”109 The backlash dampened enthusiasm among heart surgeons about human transplants.110 It is not clear when Sen learned about Hardy’s transplant.111 However, Hardy visited Bombay in 1966 and spoke at Seth G.S. about “organ transplantation, with the emphasis on the heart and the lung.”112 Indian newspapers, meanwhile, continued to cover other developments, whether Shumway’s latest experiments or a Czech surgeon’s lecture in Bombay about transplants and artificial hearts.113 Sen’s team remained hard at work. They launched a second round of experiments to determine the best way to preserve the donor heart. They obtained 100 puppies, killed them in various ways (e.g., anoxia, neuromuscular blockade, electrical shock, and exsanguination), waited up to twenty minutes, and then tested different methods to perfuse the heart for an hour before transplanting it into the neck of another dog.114 Sen visited Demikhov a second time in 1965 and became intrigued by the hypothesis that rejection was caused by anoxic injury to the donor heart during the procedure. He learned to use stapling devices developed by Soviet surgeons to complete vascular anastomoses more quickly. In September 1966 Parulkar posted an advertisement for a surgical research fellow to work on an “Enquiry into the methods and fate of homologous heart transplant.”115 In their final experiments, they tried to replicate Kantrowitz’s work using hypothermia to enable transplants in puppies.116 By 1965 Sen’s team had gained considerable experience with heart transplant procedures in dogs. One had survived eight days. As Parulkar recalled in 2004, “our group felt technically competent to perform the human heart transplant in 1965.”117 This claim (which is not made in sources from the 1960s) is intriguing. Eight days of survival was not much, especially compared to the longer survivals reported by Demikhov, Kantrowitz, Shumway, and Lower. How could they consider human transplants based on that record? A.P. Chaukar, who joined Sen’s team as a surgical resident in 1965, offered an explanation: “In those days we were replacing a dog’s healthy heart with a worse (post-transplant) heart. In a human transplant we hoped to replace a failing heart with a better one, and so thought results would be better in humans versus dogs.”118 Regardless of their readiness, the team could not get approval from the government: “Permission to do the transplant however was denied by the State authorities.”119 They knew that optimal results required taking a beating heart from a human donor. But the concept of brain death had not been legislated in India or anywhere else in 1965: a beating heart meant a living person. As Chaukar remembered, “Nobody thought we could legally do it.”120 It might not have helped that Sen’s team had feuded repeatedly with the Bombay Municipal Corporation. The Corporation did not provide the funding it had promised when the Rockefeller Foundation invested in Seth G.S. Medical College in 1956 to create a full-time, research-based faculty (with Sen as the professor of surgery). As the commissioner explained in 1961, “the municipality has responsibility for medical care of the people in Bombay, but not for medical education.”121 The Corporation also denied Sen permission to admit paying patients to K.E.M., depriving him of a valuable source of revenue.122 The First Six Human Heart Transplants From 1965 through 1967, surgeons in many countries sought the right mix of expertise, donor, recipient, and legal framework. Kantrowitz almost attempted a heart transplant in June 1966, but the prospective donor died too slowly for the heart to remain viable.123 In November 1966 Delhi hosted the 5th World Congress of Cardiology. Elite cardiologists and cardiac surgeons from all over the world descended on India. K.E.M. cardiologist K.K. Datey, presiding, celebrated surgeons’ success replacing heart valves and believed that “replacement of the whole heart loomed on the horizon.”124 Commentators sought to distinguish realistic prospects from “Surgical Fantasy.” While one editorial dismissed an American proposal to equip astronauts with extra organs and limbs so that they could survive on Venus or Jupiter, it saw real potential in heart transplantation.125 Shumway, speaking at the American College of surgeons in October 1967, declared that he was ready to proceed: “The time has come for clinical application.”126 Kantrowitz sent out 500 telegrams to medical centers in hopes of finding an anencephalic infant whose parents would consent to heart donation.127 But Christiaan Barnard struck first. Barnard, who had trained in cardiac surgery at the University of Minnesota (where he overlapped with Shumway), returned to South Africa in 1958 and established open-heart surgery in Cape Town. He visited Demikhov in 1960 and discussed heart transplants. He made his own two-headed dog in 1962 and began experiments on hearts. In 1966 he traveled to the United States to study kidney and liver transplants. While there, he watched Lower perform a heart transplant in a dog. He returned to South Africa and began to search for appropriate patients. He benefitted from a quirk in South African law, which did not specify cessation of cardiac activity as part of a physician’s determination of death.128 Barnard performed the first human heart transplant on 3 December 1967 and unleashed a media frenzy.129 The Times of India provided front page coverage and near daily updates on this “landmark in the history of surgery.”130 It also described Kantrowitz’s first attempt, which came just three days after Barnard’s.131 Barnard’s patient died 21 December.132 An editorial on 25 December noted that despite what Barnard had accomplished, “the first ever human heart transplant operation must be deemed a heroic failure.”133 Skeptics foretold a dystopian future: “One need not be a science fiction writer to envision the possibility of future murder rings supplying healthy organs for black market surgeons whose patients are unwilling to wait until natural sources have supplied the heart or liver or pancreas they need.”134 Barnard, Shumway, and Kantrowitz each performed heart transplants in early January. Barnard’s patient, Philip Blaiberg, would survive for 18 months.135 The Times continued its intensive coverage, publishing twenty-two articles about heart transplants between 3 January and 16 February. This second round of transplants again provoked outcry. On 3 January the Soviet Health Minister critiqued Barnard’s transplants and announced that Soviet surgeons would be barred from attempting them.136 When Barnard imagined a future in which herds of specially bred animals served as organ donors, an editorial reassured readers that “This may shock the queasy, but there is nothing wrong with it.”137 Cardiac surgeon J. C. Callaghan denounced Barnard’s attempt as “medical sensationalism at its height.”138 On 14 January Howard Rusk, writing in the New York Times, condemned “the international epidemic of cardiac transplants.”139 News of Barnard’s “sensational transplant surgery” spurred Sen’s team to action.140 As they explained later that year, “With a breakthrough in South Africa and its obvious clinical implications, our laboratories went on a serious, concerted crash programme of organised, fully simulated animal exercises aimed at early clinical application.”141 They tweaked Shumway’s technique, practiced on human cadavers, and worked hard to convince Dean S.V. Joglekar to authorize taking the donor heart. As Chaukar recalled, Joglekar “took a heck of a lot of risk”: “He was the one who would be answering all the questions.”142 In January they identified a potential recipient, a twenty-seven-year-old man with chronic progressive cardiomyopathy, who had been admitted to K.E.M. Hospital in late summer 1967 with abdominal distension, peripheral edema, and worsening shortness of breath. He could only walk twenty meters.143 Five months of aggressive medical management had reduced his edema but had not improved his cardiac function. Surgeons recommended a transplant on 16 January 1968; the patient consented and was transferred to the surgical service on the 18th.144 He knew that he would be the first patient at K.E.M. to receive a transplant: “He was very aware of the risks.”145 In the absence of an intensive care unit (one did not open at K.E.M. until later that year), the surgeons planned to convert their cardiac operating room into a post-operative recovery room.146 After a four-week wait, they found a donor, a twenty-year-old woman who had suffered a severe head injury after falling from a train on 16 February. As her condition deteriorated, surgeons took her to the operating room and finished preparations for the transplant.147 The team waited for “total cessation of cardiac activity,” as documented by an electrocardiogram, before taking her heart.148 The heart was distended—an ominous sign—by the time it could be removed; the team, however, remained hopeful that it would work. The transplant procedure, which started just after midnight on 17 February, seemed to go well. When the donor heart was connected, “heart action was forceful and we felt very hopeful that the transplanted heart would be able to support the circulation.”149 However, after just fifteen minutes the right ventricle distended and failed, forcing the team to restart the heart-lung machine.150 The team tried “all measures” to salvage the transplant, but to no avail: “The transplanted heart gradually failed and went into fibrillation 3 hours after transplantation.”151 The Times of India and the Maharashtra Times provided detailed front-page coverage on 20 February (with the Indian Express following the next day), celebrating the procedure (“technically a success”) despite the patient’s death. Citing the team’s many years of animal research, it explained that the transplant had not been a rash act: “Though the transplant of a human heart is new in this country, the K.E.M. doctors are well-versed in the process.”152 An editorial, “Troubled Hearts,” put Sen’s transplant into broader perspective. Describing the progress made in South Africa, Europe, and the United States, it argued that “Whatever detractors may say, transplant surgery is here to stay.”153 Subsequent articles celebrated that Sen’s team had not simply replicated what others had done. They had modified Shumway’s surgical technique, they had modified Barnard’s perfusion technique, and they had developed their own serum to prevent rejection.154 There was a strong sense of national pride. As the Times of India noted, “The Indian doctors have the ability and there is sufficient teamwork to carry out this newest feat of cardiac surgery.”155 The Problem of Efficacy The operation was described as successful, but did it work? The question of efficacy is complex. As anthropologists and historians know well, there are many ways to judge the efficacy of a therapeutic intervention, and many look beyond the question of whether the patient benefitted.156 Charles Rosenberg argued that judgments of efficacy depend on the expectations that patients and doctors had for the intervention, something Jack Pressman demonstrated in his history of lobotomy. Schlich and Crenner emphasize the “fluidity and contingency” not just of “human technical creativity,” but also of the judgments made about it: efficacy is not a yes-or-no question but an on-going debate that shifts as contexts and the surgeries themselves change.157 In this case, it is possible that Sen’s team did not expect that the patient would survive, though they certainly hoped that he would. The attempt needs to be seen simultaneously as a treatment, as an experiment, and as a demonstration project. The many people involved in making the transplant possible in Bombay in 1968 had different ideas about the meaning of the work. Sen wanted to build a surgical research laboratory, train teams of physicians, technicians, and nurses, and be on the “edge of progress.” He could be there even if his initial patients did not survive. His primary patron, the Rockefeller Foundation, wanted to establish the American mode of academic medicine in India, with medical schools staffed by full-time, research-based faculty; Sen provided this, regardless of his outcomes. Indian officials wanted to demonstrate India’s scientific and technical prowess. The United States State Department, which facilitated bilateral scientific exchanges, presumably saw the extent to which Sen relied on American precedents as evidence of the success of its efforts to popularize the achievements of American science and medicine. By any of these standards, the bare fact that a transplant took place was success enough. What about the patient? Sen and his team wanted their patients to survive, and many of his other cardiac surgery patients did. However, it is not clear that the team expected their first transplant patient to survive. First, the team had never had a dog survive for more than two days.158 Second, they did not choose an ideal patient for their first attempt. In the aftermath of the transplant, Sen’s team wrote at length about transplant candidates. They wanted a patient with “incurable, incapacitating irreversible heart disease,” but with “Reasonably healthy pulmonary, renal, hepatic and central nervous system function,” and the “Absence of any other incapacitating disease.”159 Their twenty-seven-year-old shepherd had incapacitating cardiac disease, and also kyphoscoliosis, restrictive lung disease, emphysema, and pulmonary hypertension.160 This, according to the anesthetists, was the “crux of the problem.”161 Just fifteen minutes after turning off the heart-lung machine, the transplanted heart failed: its right ventricle, weakened by the donor’s dying process, could not pump blood through the recipient’s diseased lungs.162 The patient’s co-morbidities—in hindsight—made survival after a transplant nearly impossible.163 Why did the team choose this patient? The team believed that his death, without the transplant gamble, was imminent.164 His compromised medical status justified his enrollment into Sen’s experiments. It is also possible that his compromised status in society—a shepherd from India’s rural poor—facilitated this. Even though K.E.M. had cared for him for many months, in the end he joined Bombay’s stray dogs on the operating table of Sen’s demonstration project.165 There are other, more sympathetic, readings of the episode. Chaukar was a surgical registrar in 1968 and assisted Sen with the transplant. Interviewed in 2016, he agreed that, in retrospect, the fatal outcome was a foregone conclusion.166 The team knew about his pulmonary disease and high pulmonary vascular pressures: he had been on the surgery service since 18 January. But Chaukar made two points. First, the patient had no better options, having exhausted all other medical interventions. Second, the consequences of the patient’s severe pulmonary disease, while clear in retrospect, were not known at the time. Before December 1967, no physician had experience with heart transplantation in sick adults. Experimental work had used healthy dogs. Surgeons hoped that a healthy heart, taken from the donor, would be more effective than the recipient’s diseased heart had been. Given this, “it was not obvious in prospect that he was a bad candidate.” Barnard, who quickly learned about the attempt, defended Sen’s decision, saying “I would have performed a transplant in this case.”167 It is hard to know what to make of these assessments. Surgeons who imagined that a transplant was possible could also have imagined what might go wrong.168 The Aftermath After the six initial transplants (Barnard and Katrowitz in December, Barnard, Shumway, and Kantrowitz in January, and Sen in February), there were no further heart transplants anywhere for over two months. Heart transplantation, however, remained very much in the news in India. In March American cardiologists called for a three-year moratorium on heart transplants. Barnard, asserting that “Every man must follow his conscience,” rejected this call.169 He told the United States Senate that government oversight would be an “insult to doctors.”170 A Bombay pathologist, speaking at the Rotary Club in April, pushed back. Heart transplant was “not merely a technical or a scientific problem but involved moral issues and values that human beings have cherished for ages.” Civil authorities needed to get involved: “in the absence of definite legislation on this, surgeons were likely to perform acts which might be ‘unethical or illegal.’”171 A heart transplant in Paris on 27 April marked the start of another round of activity, with twelve heart transplants performed in May alone. One Bombay doctor, responding as transplants reports continued “to pour in from different parts of the world,” encouraged surgeons to complete careful research first, “so that an impression does not gain ground that every cardiac surgeon is trying ‘to get there first by experiments on human guinea pigs.’”172 In July Barnard invited the world’s heart transplant surgeons, from eight countries, to Cape Town to participate in a conference that promised to be “the most important medical meeting so far this century.”173 He included Sen, who again encountered racial exclusion. The surgeons first convened in Johannesburg. Sen, an Indian, was not permitted into either the bar where they met or the hotel where they stayed. The other surgeons demanded that Barnard fix the problem; he arranged for Sen to stay at the home of the Indian ambassador.174 Things went more smoothly in Cape Town. The Indian community there hosted a reception for Sen at City Hall where Barnard “paid tributes” to Sen, praising him for “entering a new field like heart transplantation so rapidly and so adequately.”175 The Times of India, which provided detailed coverage of the conference, added its own boasting: “If Prafulla Kumar Sen was not more respectful of Indian sentiments he would probably have been the first to perform a heart transplant and beat South Africa’s Dr. Barnard to the post.”176 Having worked on transplant since 1952 and having performed over 200 experiments, “what he needed was not courage to perform the operation, but courage to face social mores.” Sen added that while he knew heart that transplants faced “strange and involved problems of ethics, law and possibly genetics,” he was willing to take them on.177 Sen’s reputation in India likely benefitted from the favorable attention provided by the conference and its coverage of Sen in the company of the world’s great surgeons. Their desire to normalize cardiac transplantation may have benefitted, in turn, by Sen’s presence. He showed that heart transplantation would not necessarily be limited to the industrialized West but could be made available, and acceptable, in countries worldwide. Efforts to normalize heart transplantation gained momentum in August when the World Medical Assembly issued its Declaration of Sydney, which sought to clarify standards for determination of death.178 A group at Harvard Medical School went further and argued forcefully for the acceptance of brain death, something that would facilitate decisions about both withdrawal of life support and taking organs from people with irreversible brain injury.179 These early consensus statements never resolved the controversies.180 Sen’s team remained eager to perform a second transplant. Within days of their first attempt, they announced their readiness to try again, telling the Times they would begin as soon as they found the “right case.”181 However, as Chaukar explained they had “to let things settle down after the first case before doing the second.”182 They attempted their second transplant (the world’s 46th) on 13 September 1968. The procedure itself again went well, but the patient, who suffered from severe pulmonary and kidney disease, died of renal failure just fourteen hours after the surgery.183 Sen put an optimistic spin on the outcome: “We are getting nearer complete success. It is very encouraging.”184 Success was not simply a clinical outcome, but a process towards a longer-term goal. In December Sen’s team published an account of their first transplant in a special issue of the American Journal of Cardiology devoted to heart transplantation, alongside articles by Barnard, Denton Cooley, Hardy, Kantrowitz, Lower, Ross, and others: Sen was part of the pantheon.185 The team published its definitive account of its two transplants in the Journal of the Indian Medical Association that same month.186 Thirty pages of discussions examined the research background, clinical history, surgical procedure, postmortem studies, and ethical and legal issues. They documented in great detail exactly how and why the patient died. The Bombay doctors worked carefully to justify their decision to perform both transplants.187 The journal’s editor, N. Banerjee, defended Sen’s effort, “a record for which the whole of India is proud.” Why? Because India had to transplant: “The question so commonly asked, whether India should also undertake these risky and expensive operations, needs only one answer—India must. If India has sought the atomic reactor, built huge industrial complexes of steel, communicated through telstar, and has advanced jets for its defence, there must also be in the country a few top-class medical centres given the full freedom, finance and personnel where a quality of work equal to the best in the world can be carried out without interference. It is the only way to develop a consciousness for the high quality of work which is essential in this medical field today, or else the technological and scientific gap will be so large that it will never be bridged.” The Indian middle classes and political elite wanted evidence of its medical modernity; and Sen provided it. Banerjee did admit, however, that the “price paid for all this adventure has been high.”188 The Critics As heart transplants continued worldwide in the summer and fall of 1968, critics continued to attack the procedure. Surgeon Lyman Brewer, writing in JAMA in September, decried the “carnival atmosphere” and feared that surgeons transplanted more for their own glory than for the benefit of their patients: “Whatever aggrandizement accrues from such publicity to the individual surgeons or hospitals appears unjustified and unwarranted.”189 In October a Times of India editorial came to the defense of transplant surgeons (without mentioning Sen’s team specifically). Resistance to innovation was routine: “Public opinion, that amorphous body of views incoherently expressed by the faceless many, has always lagged behind the times. In many ways this has been a misfortune for humanity, for it has acted as a bar, not a spur, to progress in some of the frontier disciplines.” With the advent of heart transplantation, “the sceptic and the conservative were among the first to sneer and mumble about its ethics. Every kind of irrelevant objection has since been raised to making use of the organs of dead persons in order to give critically ill people a new lease of life.”190 This editorial prompted an angry response. While J. B. Morehead of Bombay acknowledged the promise of heart transplants, “a word of caution has to be sounded as far as our country is concerned.” Despite the “fanfare” that accompanied the two transplants in Bombay and Sen’s apparent satisfaction with the results, “the three- and fourteen-hour survival of the recipients after the transplant can only mean that the operations in Bombay were dismal failures.” India could not afford such misadventures: “When schemes of immense importance to thousands of persons are shelved for lack of funds and shortage of trained personnel, it seems criminal to waste so much on operations that are almost predictable failures.” India should wait until others had solved the problems of transplant: “It seems more practical to allow the better equipped and financed and more advanced Western centres to carry out these pioneering procedures, perfect the techniques involved and then, and then only, adopt them modifying the as necessary.”191 Morehead’s letter triggered two furious responses. Sudhir, writing from Ahmedabad, critiqued Morehead’s logic and added that “It is surprising that instead of congratulating the surgeons on their initiative and enthusiasm, Mr. Morehead laments the expenditure on these operations. Why should our surgeons wait till Western countries achieve success? In the initial stages, there are bound to be failures. But those imbued with the scientific spirit are not daunted by these failures.”192 Dr. D. V. Nadkarni, who wrote the next week from Bombay, celebrated India’s pioneers: “Every heroic forward step in research in every field of science is bound at first to seem a ‘criminal waste’ and no pioneer has been hailed in his attempts till he succeeds. We should appreciate the display of a pioneer spirit by anyone in this routine-minded country.”193 Sen, meanwhile, stewed. His team did not make a third attempt.194 He believed that India could be a world leader in transplants because of its abundance of potential organ donors. As he explained at the conference in Cape Town in July, India had many people with severe head injuries: “It is easier for us to find donors. We have a large population, many motor cars and, therefore, many road accidents.”195 His team reiterated this point in December. The ideal donor had to be “reasonably healthy prior to death.” As a result, “Young people dying from sudden trauma are therefore the best donors.” Such people were readily available in Bombay: “In an urban community, accidents like train accidents often cause fatal head injuries providing the donor-organ material.”196 But Sen’s program had been stymied. Speaking at the Indian Merchants’ Chamber in November, he decried the “‘world-wide neurosis’ about heart transplants.” Ethical concerns, rooted in a misunderstanding of the nature of death, led to controversies about heart transplants that left India with “More donors than recipients for heart transplants.”197 Nonetheless, Sen insisted that he “welcomed knowledgeable criticism,” knowing that “every innovation had to run the gauntlet of ignorance, fear and criticism.” The controversies persisted. When Sen spoke about his work at the Indian Science Congress in January 1969, one prominent researcher “lauded the pioneering work done by Dr. Sen and said it was good that India did not lag behind other countries in the field of cardiac surgery.”198 Two weeks later, however, a critic accused Sen of proceeding too quickly: “In their enthusiasm to put India on the cardiac map of the world, our surgeons should not forget that unsuccessful operations, for want of adequate post-operative care, technical expertise or organization, would be tantamount to playing with human lives.”199 Sen had a stoic, and at times opaque, response to the “furore” and “hysteria.” In January 1970 he gave his presidential address at the Association of Chest Diseases. He complained about the impact of legal constraints on his work: “The law may be an ass, but it is an animal whose hind quarters still carry a most powerful kick.”200 He defended the role of pioneers and innovation in medicine: “It is this desire to break away from colourlessness into the ambit of the unknown which makes scientific buccaneers of us. Transplant surgeons are just a case in point.”201 Even with his clinical heart transplant program on hold, his experimental work continued. That February he spoke in New Delhi and described methods to revive hearts up to two hours after a dog’s death.202 At the Maharashtra Medical Conference in October 1971, Sen again defended medical pioneers. He “made a strong plea for a renewed spirit of restlessness among medicos without which there could be no scientific progress. ‘Unless those in the medical profession rediscover themselves,’ he said, ‘we will have a society of educated ignoramuses.’”203 Had Sen been within the scope of Fox and Swazey’s fieldwork, they would certainly have diagnosed him with “pioneer syndrome.”204 His colleagues, however, saw his buccaneering as an asset: “There is no doubt that his adventurism accelerated the development of not only cardiovascular surgery but other surgical superspecialties he created.”205 Easy judgments are not possible here. Pursuit of innovation at any cost has many costs. Sen and his team, who knew the costs well, chose adventure.206 An extensive analysis of organ transplantation published in Times of India in November 1972 celebrated Sen’s work. It emphasized the many challenges that Indian surgeons faced (e.g., lack of resources, other health care priorities, lack of brain death legislation). Its author worried that India would miss out.207 This triggered yet another letter to the editor that assailed Sen’s 1968 transplants, which should never have been performed on patients with diseased lungs: “Does it mean that Dr. Sen’s exercises were designed more to bring personal glory than to further the cause of medical sciences?”208 By 1972, however, a near moratorium on heart transplants had taken hold. The global pace of heart transplants peaked in November 1968, with twenty-six operations. In January 1969 the Montreal Heart Institute announced that it would stop (after nine heart transplants). Most other programs followed suit.209 In September 1971 Life published a damning review of the experience, “The Tragic Record of Heart Transplants: A New Report on an Era of Medical Failure.”210 By the mid-1970s only four groups continued serious work on heart transplants: Shumway, Lower, Terrence English in England, and Chris Cabrol in France.211 The moratorium ended in 1983 when a new immunosuppressive drug, cyclosporine, was approved. In 1983 surgeons at twelve programs in the United States transplanted 172 hearts. Just six years later US surgeons performed 1673 heart transplants at 131 hospitals.212 Indian surgeons could not join the resurgent interest because of the problem of brain death. In 1972 Parulkar had explained “that when the definition of cerebral death is universally accepted it will be possible for the transplant team to maintain in a viable state other vital organs in the donor’s body for some time by artificial ventilation and modern means of artificial circulation. Such viable organs could be then successfully transplanted.”213 In 1974 Parulkar and six colleagues worked with an ICMR task force to draft both a definition brain death and rules that would govern heart transplant. They submitted their proposal to the government that year. And they waited. The government took twenty years and several revisions before passing the Transplantation of Human Organs Act of 1994. That August Panangipalli Venugopal led a team at the All India Institute of Medical Science and performed the first successful heart transplant in India.214 The first successful heart transplant in Mumbai (Bombay) did not happen until August 2015.215 The transplant did not simply require a well-trained clinical team and adequate facilities. It also required careful coordination of the traffic authorities so that the roads could be cleared of traffic to facilitate rapid transport of the donor’s heart from Pune to Mumbai. The “well-orchestrated symphony” provided “a testament to the massive coordination efforts between the Traffic authorities, medical teams and the community in both the cities.” The hospital quickly scaled up its program and by summer 2016 had completed another twenty heart transplants.216 Conclusions What was required to establish heart transplantation in India? It required not just the movement of ideas, devices, and praxis, but also broader arrangements for a technology to be viable both socially and politically, including (eventually) a new law, new values, and new modes of collaboration. Sen’s experiences demonstrate several important dynamics. To be able to transplant a human heart just eleven weeks after Barnard’s first attempt, Sen had tapped into global networks that moved information, people, money, and equipment between India, the United States, and the Soviet Union. This allowed him to keep abreast of developments in cardiac surgery from Minneapolis to Moscow. With support from the ICMR and the Rockefeller Foundation, he established a surgical research program at a municipal hospital in Bombay, fostered a team of skilled trainees and colleagues, and maintained an active research program despite the demands of his ongoing clinical responsibilities. He conducted initial research between 1954 and 1956 and then resumed research in 1962. This experience left him confident that he could join Shumway, Kantrowitz, Barnard and others as they moved towards clinical applications. Stymied by state authorities in 1965, Sen capitalized on the buzz created by Barnard’s first transplant to perform his two transplants. We can only speculate about what might have happened with Indian laws and mores had his first two transplants succeeded. Many factors motivated Sen’s efforts. He wanted to be a player in the emerging post-war world of global surgery. Heart transplantation provided a ticket of admission to an elite group. His personal interests complemented broader Indian interests and nationalism, as seen in the pride of his dean, the editors of JIMA and the Times of India, municipal officials, and many others. None of them wanted India to lag behind the West. He also desired to help patients crippled by heart disease. However, the enthusiasm of Sen and his supporters was matched by diverse concerns about the ethics of heart transplantation and its appropriateness in a country like India. Sen’s efforts prompted ongoing critiques from his fellow citizens of Bombay. Did it work? Therapeutic interventions require nuanced assessments. Sen’s first two transplants accomplished some of his goals, but not all of them. The clinical attempts represented the culmination of his experimental project, and they demonstrated the capacity of Indian surgeons and hospitals. His many patrons and international colleagues applauded his feat. However, neither patient made it out of the operating room alive. Sen’s failures, and the early failures of other surgeons worldwide, cast a pall over the field that would not be overcome for many years. Sen had become a scientific buccaneer, a role with complex connotations. Acknowledgements Shreeharsh Kelkar, Alison Kraemer, Alyssa Botelho, Avanti Nagral, Kiran Kumbhar, Purbasha Das, and Ganesh Gupta provided much-needed research assistance. The archivists at the Rockefeller Archives Center (especially Tom Rosenbaum), the Alan Mason Chesney Medical Archives of the John Hopkins Medical Institutions (especially Marjorie Kehoe and Phoebe Evans Letocha), the Countway Medical Library (Jack Eckert and Jessica Murphy), and the Maharashtra State Archives provided invaluable help with their collections. We owe special thanks to G.B. Parulkar, A.P. Chaukar, and R. Magotra for their generosity with their time, and to Professor Mridula Ramanna for her advice on state archives and public health history in Bombay. We received valuable feedback from colleagues at the History of Science, Medicine, and Technology Colloquium at the Johns Hopkins School of Medicine; the American Association for the History of Medicine; the Radcliffe Institute for Advanced Study; the Centre for the History of Science, Technology and Medicine at the University of Manchester; and the Workshop on the History of Cardiovascular Disease, and from two anonymous reviewers. This research was made possible by a collaborative research grant from the National Endowment for the Humanities (RZ-51759-14). Any views, findings, conclusions, or recommendations expressed in this article do not necessarily reflect those of the National Endowment for the Humanities. Footnotes 1 “Special Feature: Heart Transplantation,” Journal of the Indian Medical Association, 1968, 51, 539-568; Prufulla Kumar Sen, “Human Heart Homotransplantation,” American Journal of Cardiology, 1968, 22, 826-832. 2 Sen's surgical team, quoted in “First-ever Heart Transplant in India: Patient Dies,” Times of India, 20 February 1968, 1. See also “Successful Heart Transplant Operation in Mumbai: Death of the Patient after 3 Hours,” Maharashtra Times, 20 February 1968, 1 [translated from Marathi by Kiran Kumbhar]; “India’s First Heart Transplant,” Indian Express, 21 February 1968, 1. 3 “Doctors Ready for 2nd Heart Transplant,” Times of India, 23 February 1968, 1. 4 Jordan D. Haller and Marcial M. Cerruti, “Heart Transplantation in Man: Compilation of Cases, January 1, 1964, to October 23, 1968,” American Journal of Cardiology, 1968, 22, 840-843. 5 N. Banerjee, “Cardiac Transplantation,” Journal of the Indian Medical Association, 1968, 51, 539. 6 Franklin A. Long and Alexandra Oleson, ed., Appropriate Technology and Social Values—A Critical Appraisal (Cambridge: Ballinger Publishing Company, 1980). In 1993 the World Bank recommended that low-income countries not offer cardiac surgery to their populations: World Bank, Investing in Health: World Development Report (New York: Oxford University Press, 1993): 10. 7 Jordan D. Haller and Marcial M. Cerruti, “Heart Transplantation in Man: Compilation of Cases—II: January 23, 1964 to June 22, 1969,” American Journal of Cardiology, 1969, 24, 554-563. 8 “Dr. Sen Plans More Heart Transplants,” Times of India, 20 July 1968, 9. We discuss this in detail later. 9 Lesley A. Sharp, Strange Harvest: Organ Transplants, Denatured Bodies, and the Transformed Self (Berkeley: University of California Press, 2006), 1. 10 Susan E. Lederer, Flesh and Blood: Organ Transplantation and Blood Transfusion in Twentieth-Century America (New York: Oxford University Press, 2008), 210, 212 (quotations); Thomas Schlich, Origins of Organ Transplantation Surgery and Laboratory Science, 1880-1930 (Rochester: University of Rochester Press, 2010). 11 Donald McRae, Every Second Counts: The Extraordinary Race to Transplant the First Human Heart (New York: Simon & Schuster, 2006), 7. See also: James D. Hardy, The World of Surgery 1945-1985: Memoirs of One Participant (Philadelphia: University of Pennsylvania Press, 1986); Harris Shumacker, The Evolution of Cardiac Surgery (Bloomington: Indiana University Press, 1992); Tony Stark, Knife to the Heart: The Story of Transplant Surgery (London: Macmillan, 1996); Stephen Westaby, Landmarks in Cardiac Surgery (Oxford: Isis Medical Media Ltd., 1997); Ayesha Nathoo, Hearts Exposed: Transplants and the Media in 1960s Britain (Bastingstoke: Palgrave Macmillan, 2009); David K.C. Cooper, Open Heart: The Radical Surgeons Who Revolutionized Medicine (New York: Kaplan Publishing, 2010); Thomas Morris, The Matter of the Heart: A History of the Heart in Eleven Operations (London: The Bodley Head, 2017); Shelley McKellar, Artificial Hearts: The Allure and Ambivalence of a Controversial Medical Technology (Baltimore: Johns Hopkins University Press, 2018). 12 David J. Rothman, Strangers at the Bedside: A History of How Law and Bioethics Transformed Medical Decision Making (New York: Basic Books, 1991); Gary Belkin, Death Before Dying: History, Medicine, and Brain Death (New York: Oxford University Press, 2014); Silke Bellanger and Aline Steinbrecher, “Addressing Uncertainties: The Conceptualization of Brain Death in Switzerland, 1960-2000,” in Schlich and Tröhler, The Risks of Medical Innovation, 204-224; Helen Macdonald, “Crossing the Rubicon: Death in ‘The Year of the Transplant,’” Medical History 61 (2017): 107-127. 13 Renée C. Fox and Judith P. Swazey, The Courage to Fail: A Social View of Organ Transplants and Dialysis (1978; New Brunswick, NJ: Transaction Publishers, 2002), xl, xli. 14 Fox and Swazey, Spare Parts: Organ Replacement in American Society (New York: Oxford University Press, 1992), xv. 15 Sharp, Strange Harvest, 40. 16 Sharp, The Transplant Imaginary: Mechanical Hearts, Animal Parts, and Moral Thinking in Human Experimental Science (Berkeley: University of California Press, 2014), 3. 17 Lawrence Cohen, “Where It Hurts: Indian Material for an Ethics of Organ Transplantation,” Daedalus, 1999, 128 (4), 135-165. 18 Fox and Swazey, Courage to Fail, 110; Lederer, Flesh and Blood, 171; Cooper, Open Heart; McKellar, Artificial Hearts. 19 Westaby, Landmarks, 265; McRae, Every Second Counts, 266; Morris, The Matter of the Heart, 236; Macdonald, “Crossing the Rubicon,” 109. 20 Norman Shumway, “Oral History,” in Pioneers of Cardiac Surgery, ed. William S. Stoney, pp. 427-439 (Nashville: Vanderbilt University Press, 2008), 434. 21 Schumacher, Evolution, 323, 332-334. 22 G.B.P. [Parulkar], “Professor Prafulla Kumar Sen,” Indian Journal of Thoracic and Cardiovascular Surgery, 1982, 1, 92-94; C.V. Patel, “Life of a Legend,” Journal of Postgraduate Medicine, 1991, 37 Suppl 1:2-5; Chander Mohan Mittal, “Profulla Kumar Sen: His Contributions to Cardiovascular Surgery,” Texas Heart Institute Journal, 2002, 29, 17-25; N. Hosain, “Dr. PK Sen – The Bengali Surgeon of the Century,” Cardiovascular Journal, 2011, 3, 254-257. 23 While many sources allow this history to be written, they remain incomplete. Sen published extensively in Indian, European, and American medical journals, but the Indian journals did not routinely include editorials or correspondence that reveal the judgments of his peers (e.g., the Indian Journal of Surgery and the Indian Heart Journal did not include letters or editorials; the Journal of the Indian Medical Association included an editorial and single letter in most issues, but no relevant ones appeared in the six months after Sen’s team described their heart transplants). We have not found Sen’s personal papers. K.E.M. Hospital has a small archive, but no relevant information. The records of the Bombay Municipal Corporation, in the Maharashtra State Archives, do not include information about the municipal hospitals in the relevant years. The Rockefeller Archive Center has extensive materials, though these provide only scattered glimpses of Indian perspectives. India’s newspapers are a daunting resource. Bombay has many large and small papers published in Hindi, Marathi, and Gujarati, and a few national papers published in English. None had regular sections on medicine and disease. The Times of India is the only paper that is digitized and searchable; it has limitations (e.g., read by a narrow, English speaking middle class) and advantages (e.g., based in Bombay, it covered Sen’s work). We have made targeted searches of other papers, but these have not been as revealing. Bombay’s Maharashtra Times covered Sen, but with Marathi-language translations of the Times of India’s reporting. We have looked at national newspapers (e.g., The Hindu, The Patriot, The Indian Express, The Hindustan Times), but these did not cover the Bombay medical scene in detail. 24 Thomas Schlich and Christopher Crenner, “Technological Change in Surgery: An Introductory Essay,” in Technological Change in Modern Surgery (Rochester: University of Rochester Press, 2017), 1-20. 25 Sally Frampton, “Defining Difference: Competing Forms of Ovarian Surgery in the Nineteenth Century,” in Schlich and Crenner, Technological Change in Modern Surgery, 51-70. 26 We take seriously the role of non-western actors in western science and medicine. See Warwick Anderson, “Postcolonial Specters of STS,” East Asian Science, Technology and Society, 2017, 11: 229-233. 27 We draw here from Veena Das and Deborah Poole, Anthropology in the Margins of the State (Santa Fe: School of American Research Press, 2004). 28 Rustom Jal Vakil, “Modern Approach to Cardiovascular Problems,” Journal of the Indian Medical Association, 1955, 25, 520-523, 521. 29 R.P. Malhotra and N.S. Pathania, “Some Aetiological Aspects of Coronary Heart Disease: An Indian Point of View Based on a Study of 867 Cases Seen during 1948-55,” British Medical Journal, 1958, 2, 528-531. 30 Mridula Ramanna, “Gauging Indian Responses to Western Medicine: Hospitals and Dispensaries, Bombay Presidency, 1900-20,” in Deepak Kumar, ed., Disease & Medicine in India: A Historical Overview (New Delhi: Tulika Books, 2001), 233-48; 238. 31 Parulkar, “Architect of Modern Surgery,” in A.V. Baliga: Surgeon and Patriot, ed. Ravi M. Bakaya (New Delhi: Patriot Publishers, 1991), 27. D.V. Nadkarni’s 1944 Surgical Epitome belies this point, but only slightly. Nadkarni, who trained at K.E.M., provided over 2000 pages of outlines and summaries of surgical knowledge and procedures, with just ten pages on heart disease, including operations for coronary artery disease (e.g., thyroidectomy, sympathectcomy), peri-cardiac problems (e.g., pericardiectomy, ligation of a patent ductus arteriosus), and cardiac trauma. See Nadkarni, Surgical Epitome (Bombay: N.M. Tripathi, Ltd., 1944), 1017-1026. 32 Amrit Kaur, in “Proceedings of the XII Annual Conference of the Association of Surgeons in India,” Indian Journal of Surgery, 1951, 13, iii. 33 Edward Churchill, quoted in “India’s Great Medical Needs Pointed Out by Boston Doctor,” Boston Globe, 4 May 1958, 35. 34 Prafulla Kumar Sen, “Personal History Record and Application for Fellowship,” 9/10/1949, Rockefeller Archives Center (RAC), RF 4468/283/464/10.1. See also, [Parulkar], “Professor”; Mittal, “Profulla Kumar Sen.” 35 “Medical Relief: Governor of Bombay Opens New Memorial Hospital,” Times of India, 25 January 1926, 12. 36 Sen, “The Surgeon’s Training in India: A Plea for Reorientation,” JIMA, 1958, 31, 280-283, 280. Sen even invoked Charaka at a 1962 presentation to the American Association of Medical Colleges. He spoke of throwing off the legacy of “160 years of British domination” and its “imprint of an alien culture.” Sen, “The Present Position of Medical Education in India,” Journal of Medical Education, 1963, 38, 577-583, 583. 37 For the ICMR grant, see Sen, “Personal History Record.” For his early work: Sen, “Perforated Peptic Ulcer of the Stomach and Duodenum,” Indian Physician, 1945, 4, 7-14; Sen and K.P. Prabhu, “Treatment of Shock by Direct Stimulation of the Medullary Centers in the Brain,” Indian Journal of Surgery, 1950, 12, 125-130. 38 Wade Oliver to I.S. Ravdin, 1/4/1950, RAC, RF 4468/283/464/10.1. 39 I.S. Ravdin to Oliver, 1/5/1950, RAC, RF 4468/283/464/10.1 40 Ravdin to Gregg, 9/2/1953, RAC, RF 454/50/464/1.2. 41 “Fellowship for Dr. Prafulla Kumar Sen,” 11/18/1949, RAC, RF 4468/283/464/10.1; Wade Oliver to R.K. Anderson, 1/10/1950, RAC, RF 4468/283/464/10.1; Diary Entry [author not marked], c. 11/1/1950, RAC, RF 4468/283/464/10.1. See also Hardy, World of Surgery. 42 Hardy, Sen, and David L. Drabkin, “Factors Influencing the Postoperative Excretion of Salt and Water and Further Studies of the Relation of Body Fluid Compartments to Body Fat,” Surgical Forum (Philadelphia: W.B. Saunders Company, 1951), 477. 43 Hardy, The World of Surgery, 147. 44 Sen to Oliver, 7/27/1951, RAC RF 454/50/464/1.2. 45 R.G. Dhayagude to R.B. Watson, 10/30/1952, RAC RF 454/50/464/1.2. 46 Richmond K. Anderson, Diary, 11/24/1952, RAC, RF 6/12, Rockefeller Foundation Officer’s Diaries. 47 “Grant in Aid,” 4/20/1953, RAC, RF 454/50/464/1.2. 48 Hosain, “Dr. PK Sen,” 255. See also: G.B.P., “Professor”; Mittal, “Profulla Kumar Sen.” 49 Sen, S.N. Kothare, and M.M. Mehta, “The Surgical Approach to the Mitral Valve: An Experimental Study,” Indian Journal of Medical Sciences, 1953, 7, 281-287, 283. 50 Sen, “The Use of a Snare Tourniquet in Mitral Valvotomy—A Suggested Modification of Technique,” Indian Journal of Surgery, 1953, 15, 15-18. This technique survived in India long after it was replaced by open heart techniques in India. A.P. Chaukar, Interview by Author, 20 June 2016, Mumbai. This exemplifies David Edgerton’s “creole technology.” [see p12n82 for the other example] Edgerton, “Creole Technologies and Global Histories: Rethinking How Things Travel in Space and Time,” Journal of History of Science and Technology, 2007, 1, 75-112. 51 “Window on the World,” Times of India, 12 October 1952, 5. 52 “Preserved ‘Human Spares’ Help Miracle Healing,” Times of India, 3 January 1954, 8. 53 Hardy, World of Surgery, 160. 54 Sen, “The Present Status of Surgery of the Heart,” The Antiseptic, 1954, 51, 537-547, 547. 55 Sen, P.A. Bhatt, and R.L. Shah, “The Use of Artificial Hypothermia (Hibernation) in Open Cardiac Surgery,” Indian Journal of Medical Sciences, 1953, 7:694-703, 694. See also C. Walton Lillehei, “Historical Development of Cardiopulmonary Bypass in Minnesota,” in Glenn P. Gravlee, Richard F. Davis, Mark Kurusz, and Joe R. Utley, eds., Cardiopulmonary Bypass: Principles and Practice, 2nd. ed. (Philadelphia: Lippincott Williams & Wilkins, 2000). 56 Sen, “Present Status,” 547. 57 Sen and others, “Use of Artificial Hypothermia,” 698. 58 Anderson, Diary, 4/12/1954, RAC, RF 6/12. The original has “regrigeration.” 59 For the death, see Anderson, Diary, 4/12/1953, RAC, RF 6/12; Naidu, “Fifty Years,” 2. For the research, see Sen, K.K. Datey, R.A. Lewis, C.B. Shah, and B.B. Gaitonde, “Further Experiences with Acutely Induced Hypothermia,” Indian Journal of Surgery, 1956, 18, 112-119, 118. Of his first 48 dogs, 24 died. For the success, see Parulkar, “Developments in Cardiovascular Surgery in India during Last Five Decades,” IJTCVS, 2004, 20, S24-30, S24. 60 Sen, “Personal History and Application,” 5/1/1956, RAC RF 4468/283/464/10.1; Janet M. Paine to Sen, 6/8/1956, RF 4468/283/464/10.1. 61 Fox and Swazey, “A Sociological Portrait of the Transplant Surgeon,” in Courage to Fail. 62 “Romance of Surgery,” Times of India, 6 February 1958, 3. 63 Sen, “Heart Transplantation—The Triumph and the Muddle,” Indian Journal of Chest Diseases, 1970, 12, 66-72, 66. 64 Carl Snyder, “Carrel—Mender of Men,” Colliers, 1912, 50, 12-13, 13. See also: Shumacker, Evolution, 316, 321; Westaby, Landmarks, 254, 323; Lederer, Flesh and Blood, 22; Morris, Matter of the Heart, 217-218. 65 Shumacker, Evolution, 321; Westaby, Landmarks, 255. 66 For a discussion of Demikhov’s work, see: Igor E. Konstantinov, “At the Cutting Edge of the Impossible: A Tribute to Vladimir P. Demikhov,” Texas Heart Institute Journal, 2009, 36, 453-458. See also Shumacker, Evolution, 321; Westaby, Landmarks, 255-257; Morris, Matter of the Heart. 67 Sen, C.B. Shah, and R.S. Satoskar, “Studies on Isolated Heart-Lung Preparations in the Hypothermic Animal,” Journal of the International College of Surgeons 1956, 26, 32-37. See also Mittal, “Profulla Kumar Sen.” 68 Sen, Parulkar, and Panday, “Introduction and Experimental Base,” JIMA, 1968, 51, 543-544, 543. 69 Anderson, Diary, June 1955, RAC, RF 6/12 70 Sen and others, “Studies on Isolated Heart-Lung Preparations,” 35, 36. See also Sen and others, “Introduction and Experimental Base,” 543. 71 Shumacker, Evolution, 323-327; Westaby, Landmarks; McKellar, Artificial Hearts. 72 R.R. Lower and Shumway, “Studies on Orthotopic Homotransplantation of the Canine Heart,” Surgical Forum, 1960, 11, 18-19; Shumway, “Oral History,” 430-432. See also “Progress in Transplants,” Time, 27 June 1960, 75: 54-56; McRae, Every Second Counts, 93. 73 Shumway and Lower, “Special Problems in the Transplantation of the Heart,” Annals of New York Academy of Science, 1964, 120: 773-777. See also: Morris, Matter of the Heart, 223. 74 Westaby, Landmarks; McRae, Every Second Counts, 70-71; McKellar, Artificial Hearts. 75 Shumacker, Evolution, 323-327; Westaby, Landmarks. 76 Shumway, “Oral History.” See also Fox and Swazey, Courage to Fail, 69. 77 Sen, N.D. Chhabria, T.E. Udwadia, and A.J. Dhruva, “Open Cardiotomy under Temporary Cardiac Arrest in Hypothermised Animals,” Indian Journal of Surgery, 1960, 22, 529-535; Parulkar, Dhruva, P.M. Javeri, and Sen, “Experimental Closure of Artificially Created Ventricular Septal Defects Employing Hypothermia and Fluothane,” Indian Journal of Medical Research, 1963, 51, 289-292. 78 Parulkar, Dhruva, and Sen, “Atrial Septal Defect: A Report of Fourteen Cases Treated Surgically,” Journal of Postgraduate Medicine, 1962, 8, 60-66. 79 For ongoing coverage of American surgical progress, see “This Will Put New Heart into Cardiac Patients,” Times of India, 10 February 1957. 80 Parulkar, “Developments,” S24. They also tried cross-circulation: Anderson, Diary Excerpt, 10/11/1960, RAC RF 440/49/464/1.2. 81 Keshavarao Krishnanao Datey, “Personal History Record and Application,” 3/26/1958, RAC, RF 448/50/464/1.2; Tryambak Pandurang Kulkarni, “Personal History and Application,” 11/26/1959, RAC, RF 4336/271/464/10.1. For Kinare, see Henry W. Kumm, Interview with Sen, 16 November 1962, RAC, RF 4336/271/464/10.1. 82 Parulkar had funding from the American Association of Thoracic Surgeons and NIH; he declined a Rockefeller Fellowship: Parulkar, Interview by Author, 6/19/2016, Mumbai. 83 Jones and Sivaramakrishnan, “Making Heart-Lung Machines Work in India: Imports, Indigenous Innovation, and the Challenge of Replicating Cardiac Surgery in Bombay, 1952-1962,” in preparation. 84 Paruklar, “Open Heart Surgery-The Indian Scene,” IJTCVS, 1984, 3, 3-8, 4; Parulkar, “Developments,” S24. 85 “Heart Operation on a Child,” Times of India, 3 April 1962, 7. Mittal, “Profulla Kumar Sen.” 86 Parulkar, “Developments,” S24. 87 Sen to Gregg, 1/17/1962, RAC, RF 453/50/464/1.2. 88 Gregg to Anderson, 4/5/62, RAC, RF 453/50/464/1.2; Paine to Sen, 7/27/62; 8/1/62, RAC, RF 453/50/464/1.2. 89 “Care of the Heart,” Times of India, 10/15/1962, 6. 90 Sen and others, “Introduction and Experimental Base,” 543; Mittal, “Profulla Kumar Sen,” 20. 91 “Dog with Two Heads: Russian Creation,” Times of India, 25 September 1958, 7; “Pup’s Head Grafted on an Alsatian,” Times of India, 12 April 1959, 1; “Extra Heart for Dog: Soviet Experiment,” Times of India, 20 August 1959. These articles were attributed to the Associated Press. 92 “Heartening,” Times of India, 21 August 1959, 8. 93 Naomi Oreskes and John Krige, Science and Technology in the Global Cold War (Cambridge: MIT Press, 2014). 94 Anderson, Diary, 3/29/1956, RAC, RF 6/12. While this might have been true at the time, the Foundation certainly knew by 1962 that Sen had traveled to Moscow. 95 Oglesby Paul, Take Heart: The Life and Prescription for Living of Dr. Paul Dudley White (Cambridge: Harvard University Press, 1986). 96 Bakaya, A.V. Baliga. 97 Patel, “Life of a Legend,” 3. 98 “India Is Home of Plastic Surgery, U.S. Expert Says, Times of India, 6 January 1963, 5. See also “Heart Grafted on Baboon: Soviet Success,” Times of India, 20 February 1963, 1; “Heart Surgery,” Times of India, 31 August 1963, 6. 99 Sen, Parulkar, Panday, and Kinare, “Homologous Canine Heart Transplantation: A Preliminary Report of 100 Experiments,” Indian Journal of Medical Research, 1965, 53, 674-684, 674. 100 The Bombay Municipal Corporation, which owned K.E.M., was responsible for keeping dogs off the streets of Bombay; it euthansized roughly 250 each week and was more than willing to supply dogs to K.E.M. researchers. Parulkar, Interview, 6/19/2016; Chaukar, Interview, 6/20/2016. 101 Sen and others, “Introduction and Experimental Base,” 543. 102 Sen and others, “Homologous Canine Heart Transplantation,” 683. See also Mittal, “Profulla Kumar Sen”; Parulkar, “Developments.” 103 “Dog with Two Hearts Is Normal,” Times of India, 11 October 1963, 1. 104 “Current Topics: Daring Experiment—Heart Transplant,” Times of India, 14 October 1963, 6. 105 Anderson, Diary Excerpt, 12/6/1963, RAC RF 443/49/464/1.2. 106 Sen to Anderson, 12/24/1963, RAC RF 443/49/464/1.2. 107 John Foster, “Heart Disease: Scourge of Industrial Societies,” Times of India, 12 January 1964, 6. 108 Hardy, World of Surgery, 277 (breached), 248 (bombshell). See also Hardy, Carlos M. Chavez, Fred D. Kurrus, William A. Neely, Sadan Eraslan, M. Don Turner, Leonard W. Fabian, and Thaddeus D. Labecki, “Heart Transplantation in Man: Developmental Studies and Report of a Case,” JAMA, 1964, 188, 1132-1140; Westaby, Landmarks. 109 Hardy, World of Surgery, 278; McRae, Every Second Counts, 126; Lederer, Flesh and Blood, 200-201; Cooper, Open Heart, 323-324. 110 Hardy, World of Surgery, 279 (quotation), 285. See also Morris, Matter of the Heart, 226; McKellar, Artificial Hearts. 111 Although the operation was discussed in The New York Times (26 January 1964) and JAMA, it was not discussed in the Times of India. Sen never cited Hardy’s work in his publications: Sen and others, “Homologous Canine Heart Transplantation”; “Special Feature: Heart Transplantation”; Sen, “Human Heart Homotransplantation.” 112 Hardy, World of Surgery, 323. 113 Walter Fowler, “New Hope for Damaged Hearts,” Times of India, 31 May 1964, 5; “Plastic Heart Coming Soon: Human Life Can Be Prolonged,” Times of India, 15 January 1965, 5. 114 Sen and others, “Introduction and Experimental Base,” 544-545; Mittal, “Profulla Kumar Sen.” 115 “Classified Ad: Dean, Seth G.S. Medical College,” Times of India, 21 September 1966, 13. 116 This worked proved “interesting but essentially unproductive.” Sen and others, “Introduction and Experimental Base,” 546. 117 Parulkar, “Developments,” S28. See also Mittal, “Profulla Kumar Sen,” 24; Chaukar, Interview, 6/20/2016. We have not found a statement by the team from 1965 to 1968 asserting their readiness. 118 Chaukar, Interview, 6/20/2016. He added a revealing comment about the state of animal research and the causes of their poor dog survival rates in Bombay in 1965: “We also had problems of staff taking the food (bread and eggs) from the dogs for themselves, so some of the dogs starved.” 119 Parulkar, “Developments,” S28. 120 Chaukar, interview, 6/20/2016. 121 Anderson, Diary, 9/15/1961, RAC, RF RG 10/12. 122 Anderson, Diary, 11/21/1958, RAC, RF 8/12. As the commissioner explained, “K.E.M. Hospital is maintained primarily for that class of patient who is unable to obtain medical care through private channels. This is the wish of the tax-payers.” LAG Diary Note, 10/12-10/13/1959, RAC, RF 439/49/464/1.2. 123 McRae, Every Second Counts, 4-5, 139, 150-151; Morris, Matter of the Heart, 227. 124 “Cardiologists’ Talks in Delhi End,” Times of India, 6 November 1966, 7. 125 “Surgical Fantasy,” Times of India, 3 December 1966, 8. 126 Shumway, quoted in McRae, Every Second Counts, 172. 127 Westaby, Landmarks, 260-261. 128 Westaby, Landmarks, 256, 261; McRae, Every Second Counts, 92, 180; Cooper, Open Heart, 331-333. 129 Shumacker, Evolution, 231; Westaby, Landmarks, 261; McKeller, Artificial Hearts. 130 “First-ever Human Heart Transplant,” Times of India, 4 December 1967, 1; “Science: Surgery Gets New Tools,” Times of India, 10 December 1967 (landmark). See also coverage on 12/5, 12/6, 12/8, and there-after. 131 “U.S. Heart Transplant Operation Fails,” 8 December 1967, 9. The patient lived just seven hours. 132 “Heart Transplant Patient Dies,” Times of India, 22 December 1967, 1. 133 “Transplant Ethics,” Times of India, 25 December 1967, 8. 134 “Living Transplants—1984,” from the New York Times, glossed in “Black Market in Hearts Forecast,” Times of India, 26 December 1967, 11. See also Lederer, Flesh and Blood, 98. 135 “Bethesda Conference Report: Cardiac and Other Organ Transplantation,” American Journal of Cardiology, 1968, 22, 896-912; Fox and Swazey, Courage to Fail; Shumacker, Evolution; Westaby, Landmarks, 265; Lederer, Flesh and Blood, 170. 136 “Russia Not to Allow Heart Transplants,” Times of India, 9. 137 “New Pumps for Old,” Times of India, 6 January 1968, 6. 138 “Heart Transplant Have No Chance Yet,” Times of India, 12 January 1968, 11. 139 Howard Rusk, “Organ Transplants: Problem of Immunological Rejection Is Cited Despite Technical Advances,” New York Times, 14 January 1968, 86. 140 “Transplant Ethics,” Times of India, 25 December 1967, 8. 141 Sen, “Introduction and Experimental Base,” 546. See also Mittal, “Profulla Kumar Sen,” 22; Hosain, “Dr PK Sen,” 255; Chaukar, Interview, 6/20/2016. 142 Chaukar, Interview, 6/20/2016. 143 Datey, P.A. Kale, S.M. Deshmukh, and M.D. Kelkar, “Cardiac Assessment and Selection,” JIMA, 1968, 51, 546-547; S.R. Kumat, “Pulmonary Assessment,” JIMA, 1968, 51, 548. See also Kinare, “Autopsy,” JIMA, 1968, 51:558-562, 558. 144 Datey and others, “Cardiac Assessment and Selection,” 546-547. 145 Chaukar, Interview, 6/20/2016. 146 A. Bhattacharya, S.S. Jadhav, and N.D. Ghodke, “Special Preparations,” JIMA, 1968, 51, 548-549. 147 Sen, Panday, J. Daulatram, and Chaukar, “Description—Donor, Recipient,” JIMA, 1968, 51, 549-554. 148 Sen and others, “Description,” 550; Parulkar, “Developments,” S28, (total cessation). As Chaukar recalls, “we waited like vultures.” Chaukar, Interview, 6/20/2016. 149 Sen and others, “Description,” 553. 150 Parulkar, “Developments,” S28. 151 Sen and others, “Description,” 554. Chaukar described the “tremendous disappointment,” but added “I was so exhausted by 48 hours of work that did I not really feel it.” Chaukar, Interview, 6/20/2016. 152 “First-ever Heart Transplant in India,” 1. On 2/23 it added that his “team of doctors, technicians and nurses had practiced the operation routine to clock-work perfection.” “Doctors Ready for 2nd Heart Transplant,” 1. The Indian Express noted that Sen’s team “had been active in experimental heart transplants under the Indian Council of Medical Research in the last five years.” See: “Transplant Team Hopeful,” Indian Express, 23 February 1968, 1. 153 “Troubled Hearts,” Times of India, 20 February 1968, 8. 154 “Doctors Ready for 2nd Heart Transplant,” 1; “Heart Transplant,” Times of India, 24 February 1968, 5; “Haffkine Institute Making Serum to Aid Transplant,” Times of India, 26 February 1968, 1. 155 “Doctors Ready for 2nd Heart Transplant,” 1. See also: “Haffkine Institute Making Serum to Aid Transplant,” 1. 156 Charles Rosenberg, “The Therapeutic Revolution: Medicine, Meaning, and Social Change in Nineteenth Century America,” Perspectives in Biology and Medicine, 1977, 20, 485-506; John W. Warner, The Therapeutic Perspective: Medical Practice, Knowledge, and Identity in America 1820-1885 (Cambridge: Harvard University Press, 1986); Jack Pressman, Last Resort: Psychosurgery and the Limits of Medicine (Cambridge: Cambridge University Press, 1998); Robert A. Aronowitz, Unnatural History: Breast Cancer and American Society (New York: Cambridge University Press, 2007); Jeremy A. Greene, Prescribing by Numbers: Drugs and the Definition of Disease (Baltimore: Johns Hopkins University Press, 2007); Warwick Anderson, “Objectivity and its Discontents,” SSS, 2012, 43, 557-576; David Jones, Broken Hearts: The Tangled History of Cardiac Care (Baltimore: Johns Hopkins University Press, 2013). 157 Schlich and Crenner, “Technological Change in Surgery,” 12. 158 Chaukar, Interview, 6/20/2016. There is some ambiguity about this. In 2004 Parulkar, claimed that they had 8 days survival in a transplant recipient (Parulkar, “Developments”: S28). In the 1968 JIMA report, they only claimed six hours of survival after a transplant (Sen and others, “Introduction and Experimental Base,” 544). 159 Datey and others, “Cardiac Assessment and Selection,” 547. 160 Kumat, “Pulmonary Assessment,” 548. See also Kinare, “Autopsy,” 558. 161 Dhruva, Bhatt, S.S. Mehta, and P.N. Parikh, “Anesthesic Management,” JIMA, 1968, 51, 554. 162 Sen and others, “Description,” 553 As Kinare later admitted, “Unfortunately the patient was a wrong choice.” S. Kinare, “Dr. Sen’s Contributions to Cardiovascular Surgery,” Journal of Postgraduate Medicine, 1991, 37 Suppl 1:12-13, 13. 163 Kumat, “Pulmonary Assessment,” 548; Kinare, “Autopsy,” 558. The Times of India reported that the death, from pulmonary hypertension, was “a complication that was expected.” See “First-ever Heart Transplant in India,” 1. 164 The recipient’s “chances of survival were rated nil” without surgery. See “First-ever Heart Transplant in India,” 1. As the Indian Express noted, “As his heart muscle became entirely functionless, they had decided to give him the chance of transplantation.” See: “Transplant Team Hopeful.” 165 In Homo Sacer, Georgio Agamben argued that the rural and urban poor in India lacked the basic civic rights of ordinary people. They had become “bare life,” vulnerable, to violation and exploitation. Georgio Agamben, Homo Sacer: Sovereign Power and Bare Life, trans. Daniel Heller-Roazen (Stanford: Stanford University Press, 1998). See also Das and Poole, Anthropology in the Margins of the State. Similar vulnerabilities existed in the United States. See: Lederer, Flesh and Blood, 176. 166 Chaukar, Interview, 6/20/2016. 167 Barnard, quoted in “India’s First Heart Transplant.” Barnard, speaking from Argentina, knew the diagnosis, cardiomyopathy, but it is not clear if he knew about the co-morbidities. 168 Cardiac surgeons, who had witnessed high mortality in their early case series knew well the risks of innovation. Yet Sen and his team focused on what was possible, not on would likely go wrong—a mindset discussed below. For the emergence of risk thinking in medicine, see Schich and Ulrich Tröhler, The Risks of Medical Innovation: Risk Perception and Assessment in Historical Context (New York: Routledge, 2006). 169 “Heart Transplant Not Premature: Barnard,” Times of India, 5 March 1968, 6. 170 “Heart Transplants: Dr. Bernard Sees No Ethical Problem,” Times of India, 10 March 1968, 12. 171 “’Moral Issues Involved in Transplant,’” Times of India, 3 April 1968, 7. 172 Bhagwan J. Mani, “Letter to the Editor,” Times of India, 17 May 1968, 5. 173 “Heart-graft Experts Meet at Cape Town,” Times of India, 14 July 1968, 12. 174 Kantrowitz, “Oral History,” by Peer Portner, 19 April 2005, Project Bionics Pioneer Interview Collection, National Library of Medicine, #2009-028/2002-098/2003-042/2013-010. Kantrowitz explained that “we all knew P.K. Sen because he was one of the group. He'd been doing experimental work. We'd been at the meetings. We'd been yelling at each other. So we knew each other very well.” 175 “Barnard Praises Dr. P.K. Sen,” Times of India, 15 July 1968, 7. 176 “People in the News,” Times of India, 21 July 1968, 8. 177 “Dr. Sen Returns,” Times of India, 22 July 1968, 3. 178 Stanley S.B. Gilder, “Twenty-second World Medical Assembly,” BMJ, 1968, 3, 493-494; “Declaration of Sydney,” BMJ, 1968, 3, 449. See also Morris, Matter of the Heart; Macdonald, “Crossing the Rubicon.” 179 Ad Hoc Committee of the Harvard Medical School, “A Definition of Irreversible Coma,” JAMA, 1968, 205: 337-340; Belkin, Death before Dying. 180 For instance, see: Bellanger and Steinbrecher, “Addressing Uncertainties.” 181 “Doctors Ready for 2nd Heart Transplant.” Sen explained that “he hoped that they would be able to graft a heart into a ‘good risk patient’ and succeed in a major way.” See: “Transplant Team Hopeful.” 182 Chaukar, Interview, 10/20/2016. 183 Sen, “Addendum,” JIMA, 1968, 51, 563. The patient survived for 12 hours. For the global tally, see Haller and Cerruti, “Heart Transplantation.” See also Mittal, “Profulla Kumar Sen.” Chaukar recalled that the heart, taken after it had stopped beating, was distended and they could not get the patient off bypass. Chaukar, Interview, 6/20/2016. 184 “Dr. Sen Does His Second Heart Graft,” Indian Express, 16 September 1968, 1. 185 Sen, “Human Heart Homotransplantation.” 186 “Special Feature: Heart Transplantation.” 187 S.V. Joglekar, Sen’s dean, argued that after Barnard’s first attempt “It can now be said with emphasis that there is every possibility of success.” Joglekar, “Heart Transplant—Ethical and Legal Aspects,” JIMA 1968, 51, 557. 188 Banerjee, “Cardiac Transplantation,”539, 541, 540. The “price” referred not to Sen, but to the outcomes of the first 70 transplants performed worldwide. 189 Lyman A. Brewer, “Cardiac Transplantation: An Appraisal,” JAMA 1968, 205, 691-692, 691. See also Westaby, Landmarks, 265. 190 “On the Defensive,” Times of India, 3 October 1968, 8. We have tried to find debates about Sen’s transplant from sources other than the Times of India, including targeted searches of The Hindu, Indian Express, the Hindustan Times, and The Patriot. 191 J.B. Morehead, “Transplants in India,” Times of India, 12 October 1968, 8. Writing again on 18 October, he argued that “India does not as yet possess the necessary expertise, organization and technical know-how to proceed with what is probably the most major surgical procedure today. This has been amply borne out by the results of the first two operations here.” Morehead, “Transplants in India,” Times of India, 30 October 1968, 8. We do not know anything about Morehead, though he may have been connected to a J.B. Morehead who went to India as a missionary in the nineteenth century. Morehead likely reflects a colonial perspective on India, one distinct from the two Indian authors who replied. 192 Sudhir, “Transplants in India,” Times of India, 17 October 1968, 8. The letter does not include the author’s full name. Morehead understood Sudhir’s “patriotic fervor,” but remained unconvinced: Morehead, “Transplants,” 30 October 1968, 8. 193 D.V. Nadkarni, “Transplants in India,” Times of India, 24 October 1968, 10. This could be the author of the 1944 Surgical Epitome, but we are not certain. 194 By the fall “transplants were failing everywhere.” Chaukar, Interview, 6/20/2016. 195 “Dr. Sen Plans More Heart Transplants.” 196 R.A. Bhalerao and J.S. Patil, “Donor Selection and Management,” JIMA 1968, 51, 555-556, 556. 197 “More Donors than Recipients for Heart Transplants,” Times of India, 20 November 1968, 11. It added, revealingly, “About the ethics, law and morality of heart transplants, Dr. Sen remarked: ‘I am not a lawyer and my friends don’t call me a very moral man.’” 198 B. Mukherjee, former director of the Central Research Institute in Lucknow, quoted in “Keeping Dead Man’s Heart Going: Research Explained,” Times of India, 7 January 1969, 12. 199 Jaikrishna Pant, “Heart Transplants,” Times of India, 16 January 1969, 8. He highlighted the lack of an intensive care unit at K.E.M. (one had finally opened in December 1968) as evidence that India was not prepared for these procedures. For the opening of the ICU, see “India’s First Intensive Care Ward,” Times of India, 2 December 1968, 9. 200 Sen, “Heart Transplantation—The Triumph and the Muddle,” Indian Journal of Chest Disease, 1970, 12, 66-72, 69. 201 Sen, “Heart Transplantation,” 71. 202 “Time Vital Factor in Transplants, Surgeon Says,” Times of India, 7 February 1970, 13. 203 “A Year’s Rural Work by New Doctors Mooted,” Times of India, 17 October 1971, 6. 204 Fox and Swazey, Courage to Fail, 380: “This pioneer syndrome is closely related to an emphasis on optimism in the face of uncertainties, limitations, and high mortality rates.” They had a darker view in Spare Parts. The “courage to fail” mentality involves “a bellicose, ‘death is the enemy’ perspective; a rescue-oriented and often zealous determination to maintain life at any cost; and a relentless, hubris-ridden refusal to accept limits.” See Fox and Swazey, Spare Parts, 199. 205 Kinare, “Dr. Sen’s Contribution,” 13. 206 For a broader discussion of transplants in India, see: Lawrence Cohen, “The Other Kidney: Biopolitics beyond Recognition,” Body and Society, 2001, 7, 9-29; Cohen, “Operability: Surgery at the Margin of the State,” in Anthropology in the Margins of the State, 165-190. 207 T.M. Anantharaman, “Organ Transplants,” Times of India, 19 November 1972, A1 and A3, A1. 208 M.K. Ananthaswamy, “Letter,” Times of India, 10 December 1972, A3. 209 Fox and Swazey, Courage to Fail, 108, 312. 210 “The Tragic Record of Heart Transplants: A New Report on an Era of Medical Failure,” Life, September 1971. 211 Fox and Swazey, Courage to Fail, 312; see also Shumway, “Oral History,” 434. 212 Fox and Swazey, Spare Parts, 7. 213 Anantharaman, “Organ Transplants,” A3. 214 Parulkar, “Developments,” S28-29. See also Hosain, “Dr. PK Sen,” 256. 215 “First Ever Successful Heart Transplant Conducted in Mumbai Thanks to Efforts of Police,” Daily News and Analysis, 3 August 2015. 216 “Aurangabad Engineer’s Heart Give Thane Resident New Life,” Times of India, 22 June 2016, online. © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com

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Journal of the History of Medicine and Allied SciencesOxford University Press

Published: Jan 10, 2018

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