Concentric Hill Ridges, Saurashtra: Saurashtra photographed from over Aden is seen, right, to be made up of a perfect series of concentric circles at its middle. Once again, it is a result of continued erosion, this time on a volcanic terrain. The once underlying portions have been exposed. The centre probably marks the focus of volcanic lava emission and internal igneous activity.
Apollo 7's View of the Ganges: The photograph at right, made from Apollo 7 and shown in colour on the front cover, shows the Ganges river in a wide, oblique view from near Ballia, west of Patna, eastwards to the Assam Plateau (cloud decked "Meghalaya") where the Brahmaputra River swings around. Covering an area of more than 70,000 square miles, it was taken some 126 nautical miles above the earth. Landscape features are clearly seen: the meandering courses of rivers, abandoned meanders and oxbow lakes which indicate recent changes in river courses, the confluence of three rivers in the f~- .__ ground. At top are the Himalayas: the outer foothills appear dark, while the upper crests are snowclad and white with the Tibetan Plateau behind. Dark patches along the right margin are hills of the Chota Nagpur Plateau which show some structural trend lines.
HENRY DAVID THO APOSTIEOF NON-CONFORMITY
EARLYONE JULYEVENING in 1846, a small, wiry man with a large nose, blue-gray eyes, and black hair plastered above his high forehead, walked into the town of Concord, Massachusetts. He had left his cabin at Walden Pond about three kilometres from town to .pick up a shoe that was being mended. In front of the town jail he was stopped by Sam Staples, the jailer. "Henry-I'm afraid I'll have to take you in." "Take me in-!" The little man's eyes snapped. "What for, Sam?" "You know as well as I do, Henry. You ain't paid your tax for more'n four years. Now come along." The little man was Henry David Thoreau, one of America's greatest writers and its foremost apostle of civil disobedience. Thoreau had refused to pay a tax to the State of Massachusetts as a protest against a government that had failed to abolish slavery and was preparing to go to war with Mexico. Fiercely independent, non-conformist, and prizing freedom of action above all else, Thoreau spent the night in a whitewashed cell meditating on the nature of State coercion. Tradition has it that his friend, Ralph Waldo Emerson, renowned poet, philosopher and sage of Concord, strolled by the jail that evening. Seeing Thoreau behind bars, he exclaimed: "Henry, what are you doing in there?" "Waldo," Thoreau replied, 'what are you doing out there?"
On July 12, 1967, the American Government issued a postage stamp commemorating the 150th anniversary of the birth of Henry David Thoreau~ssayist, poet, naturalist, political polemicist, and, in our century, something of an international hero., Thousands of long-haired young men and women jammed post offices in New York, San Francisco, and other large cities, clamouring for postage stamps of their bearded idol. Thoreau's ringing polemics against State coercion, his implacable defence of individual freedom, and his
unassailable personal integrity have made him a hero . to all those who cherish freedom and resist oppression everywhere on the globe. "Under a government which imprisons any unjustly," he wrote, "the true place for a just man is also a prison ... the only house in a slave-State in.which a free man can abide with honour." In his day Thoreau was considered a man of little consequence-shiftless, irresponsible; eccentric. He had graduated from Harvard University in 1837 near the top of his class, but he failed to measure up to society's specifications or fill the niche expected of a college graduate in nineteenth-century New England. Thoreau remained an outsider all his life. A sometime teacher, handyman and surveyor, he worked for a while in his father's pencil-making shop where he invented a new process for making pencils, and did odd jobs in and around the town of Concord. Much of his time was spent in sauntering around the countryside, studying nature "and its woodnotes wild," learning the habits of beast, bird and the other denizens of the woods, studying the pristine lore of the Red Indians, and scribbling notes in a battered notebook about what he saw. When he travelled around Concord, he carried an umbrella and a brown-paper parcel, and wore outrageously old clothes. The thrifty, hard-working Yankees of Concord shook their heads in despair. But Henry Thoreau paid them little heed. He was too busy living his own life and shaping his experience into a written testament which generations to come would read, study and champion with reverence and enthusiasm. Thoreau's fame rests principally on two works: Walden, the artistic record of his two years' sojourn in the woods, confronting nature on its own terms; and Civil Disobedience, an essay recording his confrontation with an imperfect society. Each of these works has become part of the fibre of the' American character. Each continued
Thoreau is one of the major voices of the nineteenth century who speaks to the twentieth century in Europe, Asia, Africa and America with increasing resonance. of them has had an influence far beyond the boundaries of the mid-nineteenth century village of Concord, where they were written. As a writer, Thoreau was singularly unsuccessful during his lifetime. At his death he had published only two volumes: A Week on the Concord and Merrimack Rivers in 1849 and Walden in 1854. Both books were .commercial failures. The first sold only a few hundred copies, and Walden, Thoreau's masterpiece, caused scarcely a ripple in American literary circles. It took eight years to sell 2,000 copies of the first edition of Walden. Probably 2,000 are now sold every week. In the century since its publication, Walden has become one of the all-time best sellers of American literature. It has been issued in more than 150 editions, a.nd several of these editions have sold over half a million copies each. There are now at least twenty-four different editions in the United States alone, as well as English-language editions in England, India and Japan. It has been translated into at least fifteen foreign languages including French, Italian, Spanish, Portuguese, German, Dutch, Swedish, Norwegian, Finnish, Danish, Russian, Czech, Japanese and Sanskrit. There are probably more copies of it in print than any other American literary work of fiction that appeared in the nineteenth century. As though enacting penance for the neglect which intellectuals of the time heaped upon Walden, the presses of scholarly and critical publications pour out essays, estimates and footnotes until the literature concerning this single work, let alone¡¡the whole of Thoreau, has become too vast for one student to encompass. Today in the United States, Thoreau is the centre of a cult. The Thoreau Society, founded in 1941, meets once a year in Concord. Its membership includes people from all over the United States and Canada, and from many different walks of life. Some are interested in their hero's natural history, some in his politics and economics, and others in his prose style, his theology, his anarchism, etc. But above all, it is Thoreau's personality that draws these people together. The Thoreau Society issues a bulletin which contains writings of and about Thoreau and a column of every scrap of news its members can find about him. The interested reader will be told how Thoreau has been put to use in Seattle, Washington, what new translation has been made into Spanish, etc. Single sentences of his appear, we are told, on bus cards in such and such a city, and the curious fact is added that
My first introduction to Thoreau's writings was, I think, in 1907, or later, when I was in the thick of the passive resistance struggle. A friend sent me the essay on ÂŤCivil Disobedience." It left a deep impression on me .... The essay seemed to be so convincing and truthful that I felt the need of knowing more of Thoreau, and I came across your life of him, his "Walden" and other shorter essays, all of which I read with great pleasure and equal profit . -Mahatma Gandhi in a letter dated October 12, 1929, to H.S. Salt, biographer of Thoreau
You have given me a teacher in Thoreau who furnished me through his essay ((On the Duty of Civil Disobedience" scientific confirmation of what I was doing .... -Mahatma Gandhi in an open letter to the American people in 1942
these cards are often stolen. He also provides quotations to be used in the prestige advertising of great corporations. His name is invoked on behalf of all sorts of causes. Lovers of wildlife, conservationists, hikers and bird watchers find in him a patron saint. Nature faddists and vegetarians in the West have adopted him as their own. Thoreau is one of the major voices of the nineteenth century who speaks to the twentieth century in Europe, Asia, Africa and America with increasing resonance. As a political writer, he was the most magnificent polemicist this country has ever produced. Out of his one night in jail he fashioned an essay called On the Duty .of Civil Disobedience which has become one of the most influential pieces of writing in modern times. From Tolstoy to Gandhi to Martin Luther King, exponents of passive resistance have all come under the spell of Thoreau's essay. Tolstoy paid tribute to Thoreau's courage and idealism in a letter to Dr. Eugen Heinrich Schmitt, editor of the Austro-Hungarian journal, Ohne Staat. He wrote: "You write to me that people seem quite unable to understand that to serve the government is incompatible with Christianity .... It is now fifty years since a not widely known, but very remarkable, American
writer- Thoreau-not only clearly expressed that incompatibility in his admirable essay on 'Civil Disobedience,' but gave a practical example of such disobedience." Civil Disobedience powerfully marked the mind of Tolstoy and it was Mahatma Gandhi's textbook on which he based his campaign of passive resistance in India. It became a manual of ideology for the British Labour Party. It was a rallying tract among resisters of the Nazi occupation in EU'fope,and it has been the bible of countless thousands in totalitarian concentra.tion camps and democratic jails, of partisans and fighters in resistance movements everywhere. Thoreau's powerful words reverberate wherever they are read: "All men recognize the right of revolution-that is, the right to refuse allegiance to, and to resist, the government when its tyranny or its inefficiency are great and unendurable." Wherever men have nothing but principle with which to resist tyranny, Thoreau is among them. To the doctrine of naked expediency he would bring to bear only one weapon-principle. Not policy or expediency must be the test, but justice and principle. He sums up his beliefs on this point in one powerful sentence: "If I have unjustly wrested a plank from a drowning man, I must restore it to him though I drown myself." Thoreau's voice carries from continent to continent. People all over the world believe implicitly as Gandhi did that Thoreau "taught nothing he was not prepared to practise himself." Like Gandhi, many leaders, especially among young people, look to Civil Disobedience for a "new way" of handling political conflict. And Thoreau bids them to act: "Unjust laws exist: shall we be content to obey them, or shall we endeavour to amend them, and obey them until we have succeeded, or shall we transgress them at once?" Today Civil Disobedience serves as an inspiration for all sorts of protest movements and acts of individual conscience-civil rights marchers, anti-war demonstrators, opponents of nuclear weapons, and others. And perhaps in a less serious vein, there are also some Americans for whom Thoreau's essay serves as a classic document for resigning from society. It is reported that every now and then someone deciding he will no longer pay his income tax sends a copy of Civil Disobedience to the nearest Collector of Internal Revenue as an explanation. In Civil Disobedience, Thoreau rejected the idea that the highest responsibility of the individual must be to the State. The core of his politics was his belief in a natural or higher law. "It costs me less in every sense," he admitted, "to incur the penalty of disobedience to the State than it would be to obey." And he added, "They only can force me who obey a higher law than I."
.
Like all ideas, that of a higher law could become a weapon in the hands of groups and institutions. For Thoreau it meant no supremacy of church over State or vice versa, or of one State over another, or of one group over another. It meant rather the logical last step of individual action. "There will never be a really free and enlightened State, until the State comes to recognize the individual as a higher and independent power, from which all its own power and authority are derived, and treats him accordingly," he said. Henry Thoreau demanded of American democracy the right to go his own way at his own gait. He would not permit his conscience to be burdened with the responsibility of conducting himself according to standards that were not his. Civil Disobedience becomes a protest against coercion of the individual spirit by governments or any other organized force seeking to make individuals conform. Walden proclaims this same intransigent individualism, though in the larger context of a spiritual life. It has been remarked that outside the United States, Thoreau is' generally more famous for Civil Disobedience than for Walden. The rest of the world immediately comprehends what seems a programme for radical political action, but in Walden the flight from an advancing civilization to a communion with a patch of still unspoiled nature is something so peculiar to American experience that few Europeans or Asians quite understand it. In the spring of 1845, Henry Thoreau borrowed an axe, went into the woods outside of Concord, and built himself a log cabin in which he lived for the next two years. The book he fashioned out of his notes and reflections during his two-year sojourn has become one of the most popular and widely read ac~ounts of man confronting nature ever written. Walden, as Thoreau explains it, was an experiment in human ecology: "I went to the woods because I wished to live deliberately, to front only the essential facts of life, and see if! could learn what it had to teach, and not, when I came to die, discover that I had not lived.... I wanted to live and suck out all the marrow of life, to live so ¡sturdily and Spartan-like as to put to rout all that was not life ... to drive life into a corner and reduce it to its lowest terms, and if it proved to be inean, why then to get the whole and genuine meanness of it, and publish its meanness to the world; or if it were sublime, to know it by experience, and be able to give a true account of it in my next excursion." Thoreau moved into his one-room house at Walden Pond on the Fourth of July, declaring his independence of a culture that gave itself to owning people and things rather than to cultivating its mind and spirit. His strategy has since been called the one-man revolution. To change the world about him, he changed himself, hoping that others would follow suit. He refused to continued
In Walden) Thoreau attacked economic and social injustice and opposed inertial conformity. But he was not simply a deprecator of material progress, even though he resisted the current of advancing civilization-towards gregariousness in urban developments, towards commerce in the extension of the factory hire labour or hire out for labour, stayed out of organsystem, towards acquisitiveness in the westward moveizations, worked the soil with his own hands, minimized ment. He warned against an improved means to an his need for food, clothing and shelter and gave as unimproved end: m:uchtime as possible to his special creative impulse. "While civilization has been improving our houses, To most people Walden is a nature book. It was . it has not equally improved themen who are to inhabit considered so in Thoreau's day and it established a them." , standard for the natural history essay by which all Henry David Thoreau desired only the best for his subsequent writings in this genre have been measured. countrymen from both nature and civilization, past But Walden is more than an essay on natural history. and present. Despite his harsh criticism, he was firmly It can and does mean all things to all men. It is a hymn rooted in American earth and he clearly perceived the to the beauty of nature and the superiority of the simple meaning of America. It was an opportunity for new life, and in present day do-it-yourself America is still beginnings: "The Atlantic is a Lethean stream, in our the supreme textbook on how to get away from it all; passage over which we have had an opportunity to it is social criticism in the form of satire; it is one of the forget the Old World and its institutions .... " best examples of effective prose writing in American Clearly, he aspired to create for Americans "a new literature; and for many people it is a guidebook to heaven and a new earth." Thus far our progress had a richer, more spiritual life. been for the most part material rather than spiritual, The proof of the singular appeal of the book is its but' the time. was at hand for a spiritual rebirth-a continued popularity in an age which epitomizes many renewal and rededication of our lives to higher things. of the things Thoreau inveighed against. Walden is In the closing chapter of Walden he tells us that a newer infinitely more antagonistic towards our modern civ- and better life can be achieved if we but strive for it: ilization with its materialism and status-seeking, with "I learned this, at least, by my experiment: that if its often obsessive concern with gadgets, luxuries and one advances confidently in the direction of his dreams, other material acquisitions than it was to the relatively and endeavours to live the life which he has imagined, pastoral America of 1845. he will meet with a success unexpected in common And yet Walden continues to make the simple life hours .... If you have built castles in the air, your work appealing. It describes a haven of serenity in the midst need not be lost; that is where they should be. Now of hubbub. It tells us of some Eden of the soul in which put the foundations under them." at least one American held off the pressures of mateThoreau was a man of great personal courage and riality and mediocrity. The more harassing these conconviction. He rang the Concord court bell in 1844 on finements become, the more Thoreau's Walden takes the occasion of Emerson's speech on emancipation in on qualities of a symbolic serenity. Amid the distracthe West Indies, went to jail in 1846 for refusing to tions of industrial America, the image¡ of the youth pay taxes to a government he considered oppressive, beside Walden Pond who cried only for simplification defied the Fugitive Slave Act of 1851 by aiding Negroes becomes for thousands the dream of a green isle in to escape to Canada and stood up for the controversial the sea, a surcease from distraction, imparting energy abolitionist 10hnBrown at a most unpopular time, to those who admit to themselves, in sleepless nights, while the latter was still in jail. Perhaps more than¡ that they do after all "lead lives of quiet desperation." any other American of his time, Thoreau "was. a Thoreau believed that modern life was too complex speaker and actor of the truth." for anyone individual to embrace all of it. We must be Thoreau died at the age of forty-four when his selective, he tells us, but unfortunately selectivity tends reputation, such a towering oak today, was still only a to be imposed on us by the society we live in rather tender green shoot. Ralph Waldo Emerson, who spoke than based on our own personal interests and desires. at his funeral service, paid him this prophetic tribute: Consequently, it is up to each individual to follow his "No truer American existed than Thoreau .... The peculiar bent and map out the life best suited to him. country knows not yet, or in the least part, how great "I desire," he wrote, "that there may be as many a son it has lost. . . . Wherever there is knowledge, different persons in the world as possible, but I would wherever there is virtue, wherever there is beauty, he have each one be very careful to find out and pursue will find a home." his own way, and not his father's or his mother's or Today Henry David Thoreau has found a home his neighbour's instead." in the hearts of men in every corner of the globe. END
Wherever there is knowledge, wherever there is virtue, wherever there is beauty, said Ralph Waldo Emerson, Thoreau will find a home.
Because food distribution under the Central Kitchen Project is largely a matter of logistics, one observer said, "This is like feeding an army in the field."
As van arrives at a school, boys unload the food container, a heat-retaining vessel specially designed for the CKP. Below, little girl receives her midday meal, almost a pound in quantity. One day the children get rice and sambar, the next they receive a nutritious blend of cornmeal, bulgar wheat and a high-protein food called CSM. The school lunch programme has a noticeable effect on students' alertness, as suggested by the youngsters at left and on the opposite page.
ASSISTINGWITH projects in Tamil Nadu since 1955, CARE joined the government in 1961 to expand the Midday Meal Programme. Today foodgrains supplied by CARE make up half the quantity used in the lunch programme, with the state supplying the other half. The idea of the Central Kitchen Project was presented by CARE to the state government and the Sekkadu kitchen, started almost two years ago, is entirely supported by government funds. Future plans envisage the setting up of 375 such kitchens to cover the whole state. This expansion will be supported by the U.S. Agency for International Development. At the kitchen in Sekkadu, food is prepared in two batches. As each is ready, it is put into containers numbered for the individual schools, and then loaded into two vans which go from school to school, completing their rounds by lunchtime. One observer of CKP commented, "You're doing a great logistics job .... This is like feeding an army in the field." END
Are we going to deny (a transplant)
"THERE'S A TENDENCYamong surgeons to protect their mortality figures," says Dr. Denton Cooley. "It's a little like a baseball player protecting his batting average. I have ignored that in my approach. It's harsh on me because I don't take failure lightly. But as long as I can justify this in my own conscience, I'm satisfied with the results." In recent months, Dr. Cooley and his team of surgical specialists at St. Luke's Episcopal Hospital in Houston, Texas, have become the foremost American practitioners of the still-controversial heart transplant operation. A relentless pioneer, Dr. Cooley stunned the medical world last spring by transplanting three hearts in five days. A month later, he transplanted a sheep's heart in a desperate attempt to save a fatally-stricken patient. That operation failed, but two of Dr. Cooley's first heart recipients did so well that they were able to attend a baseball game in Houston less than two months after surgery. Dr. Cooley is probably the most experienced heart surgeon in the world. He has performed more than 4,000 operations, 1,000 of them on tiny infant hearts. Sometimes he completes as many as four complex heart operations in a morning, working out of a glass-walled office that overlooks an operating room. Though Dr. Cooley believes that the ultimate answer to failing hearts will.be the mechanical heart, he predicts that transplants will be routine in five years. Until then he expects to remain at the centre of the transplant controversy. "The real issue is not: are we going to offer a transplant to a patient," he says, "but are we going to deny it to someone who is in the last hour of his life?" (continued) Reprinted with permission (rom Life magazine of August 2, 1968. Š 1968 Time 1ncorporated.
"There is a certain amount of apprehension with each one of these operations. But 1think it is a healthy apprehension. 1know it makes me more alert. It stimulates me to try to comprehend every complication that could arise. When the first one was o I'('/". the apprehension vanished.~~
"I look upon the heart only as a pump, the servant of the brain."
Less than 48 hours after surgery, Dr. Cooley examines Fredi Everman, a retired barber and the HOl/ston te(lm's seventh transplant. At left, Cooley is flanked by his colleagues during his first heart transplant operation at St. Luke's.
"THE HEARThas always been a special organ," says Dr. Cooley. "It has been considered the seat of the soul, the source of courage. But I look upon the heart only as a pump, a servant of the brain. Once the brain is gone, the heart becomes ¡unemployed. Then we must find it other employment. " The high-speed surgical technique with which Cooley finds employment for unused hearts is an ingenious blend of fundamental procedure and innovation which the 47-year-old surgeon developed, using the basic approach of Dr. Norman Shumway of Stanford University. The Cooley method is described in the drawings above, which show the chest cavity after the recipient's heart has been removed and the donor heart (shaded) is being sewn in place. The procedure removes almost all of the recipient's diseased heart but leaves part of the back chambers-the open right and left atria in the drawing. Meanwhile, the donor heart is removed whole and slit open at the back of the atria to provide overlapping tissue for fitting. The nerve centre
controlling the heart beat is preserved. Cooley begins the extraordinary surgical sequence shown above by laying the donor heart alongside the remnants of the recipient's heart. Then, starting from the inside, he sews the two left atria together-the first fOUfstitches can be seen in the drawing at left. As he sews, he rolls the new heart over onto the site of the old and completes joining the two atria. Then he starts stitching the two right atria together (drawing above right), continuing to roll the heart into place. Finally, blood is directed through it. Sometimes the heart starts beating automatically, sometimes an electric shock is necessary. The whole sewing operation takes about thirty minutes, half the time that other procedures require. Transplants apart, Cooley has specialized in the most difficult of all heart surgery -that performed on infants. And in this field of highly-skilled miniaturized surgery, he is considered the world's greatest surgeon. He has performed more than 1,000 open-heart operations on babies less (continued) than one year old.
THE SERIESOF heart transplants which released so blood could start to flow began in December 1967on two continents, through the sewn-in heart, it would begin in South Africa and the United States, to flutter-not pulsate normally. But one focused world attention on spare parts swift electric shock and immediately there surgery-the salvaging of human life by', was a normal beat. the replacement of diseased organs with In the autumn of 1967, after ten years of healthy ones. work, Dr. Norman E. Shumway of StanWhen Dr. Christiaan Barnard in Cape ford University could report that he had Town replaced the failing heart of a mid- been able to scale up the survival rate in die-aged man with that of a young woman dogs with transplanted hearts to seventywho had died after an automobile accident five per cent. and the man lived for eighteen days, it was The dog successes were encouraging. As a dramatic first demonstration, soon to be a technical procedure, heart transplantafollowed by others, that the transplant a- tion in humans was expected to be much tion of even that vital organ may well simpler. The canine aorta, the main vessel become a practical reality before long. coming out of the heart, is fragile, far more Indeed, the heart transplants come on so than the human. Connecting it up withtop of mounting success with kidney trans- out damage to a transplanted heart had plants of which in the United States alone, . presented a challenge; surgeons had met it. in a recent twenty-month period, 725 were performed. They come, too, on top of promising work in transplantation of the liver, of ovarian tissue, and of kidneypancreas-duodenum combined. And they The big medical pr6blem to come as the result of progress already made, surmount in any transplant is in combating the major technical barrierrejection-the body's blind, the body's stubborn rejection of foreign stubborn effort to throw tissue--and as basic new studies now going off a foreign object, even a on promise to open more effective avenues potentially life-saving heart. to controlling the rejection phenomenon. So great are the strides and so rapidly are they being taken that problems of organ supply now are becoming of concern -and in the United States doctors are earnestly considering ethical, moral and Moreover, Dr. Shumway lately had legal questions. devised a brilliantly simplified operative The fact is that when Dr. Barnard, a technique. It had been customary in animal U.S.-trained surgeon, performed the ¡first work to remove the entire heart from the human-to-human heart transplant, trans- recipient animal. That meant severing two plant surgeons-after years of intensive arteries, plus two big veins returning used experimental work with animals-could be blood from the rest of the body, plus four likened to a group of men standing at the other major veins carrying back freshly edge of a swimming pool, all eager to test oxygenated blood from the lungs. Then it the water but waiting for someone to take meant attaching all eight vessels to the the first dive. Dr. Barnard took it. transplanted heart. Before the first human trial, laboratory Dr. Shumway had developed a way to experiments had been performed on dogs. leave just a little, about five per cent, of the The heart could be removed from a donor old beart in place-part of the walls of the dog and, after examination to make certain heart chambers to which the six veins are it was non-diseased, could be placed in a attached. Then the transplanted heart, cold saline solution at about 40° F. and with just that five per cent quickly cut massaged brieflY to fill all the chambers away, could be joined to the old heart with the cold solution. That would preserve section, saving much delicate sewing of it for thirty to sixty minutes. vessels, halving operating time, increasing A heart-lung machine then could be safety. attached to the recipient dog to maintain And there had been some important circulation through the body while the preliminary work with human hearts. Dr. recipient's heart was removed and the Lower in Virginia had removed hearts donor heart was stitched in place. And from persons dead of massive brain inafter the stitching was over and clamps juries, perfused them with blood, stored
them for up to an hour, then got them beating again. But there was a psychological barrier. Over the centuries, the heart has become entwined in mystical notions: It has been considered the seat of the soul and the emotions, and of man's noblest qualities. Most important, the beating heart has been considered the mark of life. To the layman, and to many doctors, death occurs only when the heart ceases to function -although many physicians today say that death should be considered to have occurred when the brain stops functioning, whether or not the heart still beats fitfully. Nonetheless, the barrier oflong-held beliefs about the heart still exists, and the surgeon who attempted a human heart transplant had to surmount it. Dr. Barnard did. As expected, there was less trouble in the surgical procedure with a human than there had been with dogs. The aorta was much less of a problem. Dr. Shumway's simplified technique, which Dr. Barnard used, worked beautifully. So did something else. In transplanting a heart, nerve connections to the central nervous system must be cut. Surgeons cannot re-establish them. But the lack of connection did not interfere with beating. The heart has a built-in automatic nervous mechanism of its own that could take over and regulate the beat. An electrocardiogram taken a few days after the operation on Dr. Barnard's patient, Louis Washkansky, showed the heart rhythm to be regular, far better than electrocardiograms had shown for the old heart. The big medical problem, as expected, was rejection-the body's blind, stubborn effort to throw off a foreign object, even a potentially life-saving heart. What is rejection really like? It is a system essential for protection against dangerous invading foes. When infectious organisms-bacteria. or viruses -get into the body, the defence system is alerted by antigens, chemicals produced by the organisms. White blood cells (lymphocytes) are rushed to the site. The lymphocytes produce antibodies, chemicals able to lock onto and destroy the invading organisms. But, to plague transplant surgeons, that same system operates when something beneficial-a heart, kidney or other organ -is implanted. Like bacterial or viral cells, organ cells produce antigens, inviting destruction by antibody-producing lymphocytes. (continued)
As lymphocytes converge on it, a healthy pink implanted organ first begins to swell. Eventually, as the army of lymphocytes infiltrates and overwhelms the donor tissue, individual organ cells swell and die. The patient now has a fever and shows through greatly increased white blood cell counts that damage is being done. Soon the graft stops functioning, shrivels and completely dies. The organ has been rejected. Transplantation efforts long had foundered because of the rejection problem. It was not until December 1954 that Dr. Joseph E. Murray in Boston achieved a successful internal human organ transplant -a kidney taken from one identical twin and implanted in the other. Because they were identical twins, identical genetically, an organ from one was not regarded by the other's body as foreign. The first successful transplant between non-identical twins came in 1958, and it took two more years before there was a successful case between less closely related persons. To try to prevent rejection, doctors first used massive X-ray doses. But the radiation acted like a biological sledge-hammer, killing the tissues that produce lymphocytes and leaving the patient defenceless against ordinary germs, and therefore wide open to death from pneumonia ox other infection. Then, cortisone-like drugs such as prednisone, plus certain anti-cancer drugs such as Imuran, were found to help suppress the rejection mechanism. By combining low-dosage radiation with the drugs, surgeons walked a kind of tightrope, trying to keep an organ from being rejected without so lowering body defences that the patient died from infection. It was touch and go. Matching tissues for better compatibility between donor and recipient could be a help. Matching began with blood types. Before any blood transfusion, red cells must be typed to make certain compatible blood is used or there may be a transfusion reaction, a kind of rejection process. Blood typing for organ transplantati~n has only limited value, but it is a step in the right direction. White cells are more helpful for matching. They have the same genetic characteristics as those determining survival of grafted organs. White cell analysis, very recently developed, calls for using a battery of typing materials, each to detect a particular antigen. Drops of serum full of
white cells from a potential donor are placed on little discs, each containing a typing reagent. The kind and intensity of reactions on the discs provide, in effect, a tissue profile of the donor which can be compared with a profile similarly obtained of the recipient. The idea behind matching, of course, is that the closer the compatibility, the less immuno-suppressive treatment needed and the less likelihood of death from infection. It did not work for Washkansky. After eighteen days, the heart still beating strongly, he died of pneumonia. For one thing, white cell analysis is still far from perfect, since not all critical antigens have yet been identified. And the treatment for immunosuppression evidently had been too intense.
Scientists today are seeking a solution to rejection by building up in advance a patient's tolerance to those specific antigens present in the organ to be transplanted.
But promlsmg new developments are beginning to pile up. One is a non-drug approach to immuno-suppression. It uses a preparation called anti-lymphocyte serum (ALS) and, in effect, it turns the tables on the antibody-producing lymphocytes by introducing antibodies against the lymphocytes themselves. ALS is made by injecting into horses a lymphocyte-rich extract from thymus glands, spleens and lymph nodes removed from human cadavers. The horses' rejection mechanism produces particles active against the human lymphocytes. Then ALS is extracted from the horses' blood and given to transplant patients with the hope it will keep their lymphocytes from attacking. And it is helping. Dr. David M. Hume of the Medical Col.lege of Virginia who, with his colleague, Dr. Lower, performed the world's sixteenth heart transplant, reports that in kidney transplants there, ALS has lowered the mortality rate from forty-four per cent in 1962 to seven per cent in the past year. At the University of Colorado, Dr. Thomas E. Starzl used it in twenty cases and has had only one death;
nineteen patients were living ten to sixteen months after operation. And it has made it possible for Dr. Starzl to transplant livers. The liver is a far more complex organ than the heart. From 1963 to 1967, before ALS was available, Dr. Starzl tried seven liver transplants but failed every time; since then he has had limited success-patients have lived months with transplanted livers. Can ALS help in heart transplants? Many surgeons believe it can. So can an effective monitoring method-a way of determining in a heart transplant patient exactly when a rejection crisis is actually beginning to develop so that immuno-suppression treatment could be concentrated then rather than have to be given continuously, lessening the risk of infection. The trouble has been that no conventional indicators of heart function-pulse, even usual electrocardiogram readingsare disturbed until rejection has become irreversible. But now one series of blips on the electrocardiogram called the QRS complex has been found to provide a reliable sign of early stages of rejection. With QRS blips as a guide, U.S. surgeons have been increasing survival time in dogs with transplanted hearts. They believe that as they gain experience they will be able to do the same for human heart transplant patients. A new aid in tissue matching to supplement the still not quite adequate white cell analysis comes from the work of Dr. Fritz Bach at the University of Wisconsin. White cells from both potential donor and recipient are mixed together directly. If they then stimulate each other to grow and divide, it is a sign that a graft from the donor would stimulate the recipient's rejection mechanism and have virtually no chance of acceptance. If there is no stimulation, it is safer to attempt the graft, reports Dr. Bach. He has used the test for six kidney transplants in the last ten months and all patients are living and have good kidney function. Still other developments could help materially in heart and other transplants. There is the lymph-draining' approach devised by Dr. Joseph E. Murray, the surgeon first to achieve a successful kidney transplant. Antibody-producing lymphocytes circulate principally in the body's lymphatic system: By inserting a plastic tube in a lymph duct just above the collarbone, Dr. Murray lets lymphocytes drain out by gravity into a plastic bag. With good
drainage as many as thirty-two billion are removed daily, separated from the lymph fluid which is then reinfused into the patient. The drainage, Dr. Murray reports, is making rejection crises half as common as previously. Elsewhere, investigators are working on another concept-antigen overloading. The idea is not to destroy or remove the lymphocytes but to divert the antibodies they produce with antigens that have nothing to do with a transplanted organ. It is a decoy strategy. Huge numbers of antigens are needed-and those obtained from bacteria are showing promise and are now being mass-produced in a programme sponsored by the U.S. National Institutes of Health. Meanwhile, at the Massachusetts General Hospital in Boston, scientists are working towards what they believe could be the ultimate solution-advance building up in a patient of tolerance to just those antigens that would be present in a transplant, leaving the immunological system still intact to fight infection. They have early evidence now that tolerance can be induced by very low doses of antigens, particularly if they are administered directly into the bloodstream. Already, working along somewhat similar lines, Dr. Barnard Pirofsky of the University of Oregon has blazed a pioneering trail. He has been able to give newborn infants tolerance for a blood type other than their own. With permission from their parents, he injected red cells from type A blood into sixteen babies with inherited type 0 blood. Result: Months later, the babies had virtually no antibodies to type A, indicating tolerance. Investigators also are working on improved organ preservation methods that could be helpful'in all transplants, especially heart. As it stands now, a patient who needs a kidney transplant can be kept alive with an artificial kidney machine until the right kidney comes along. But there are no comparable machines for the heart or liver. For these organs, transplantation depends upon having a patient in desperate need in a hospital at the same time that another patient in the same hospital dies and has a still healthy organ and reasonably suitable tissue profile to make a transplant seem feasible. The hope is to find some way of preserving organs and "banking" them for use when needed. It is a difficult problem: Nobody has yet found a way to freeze a
whole organ and get it to work effectively ients. In human-to-human transplants, there is no opportunity to try to precondiafter thawing. tion a donated heart. Dr. Hufnagel thinks In addition to kidney, liver and heart transplants, American investigators are this could work in potential animal donors and is concentrating on calves since their working on other possibilities. Meanwhile, in laboratories across the hearts, shortly after birth, are large enough country, research continues to probe into for human use. While all this is going on, some U.S. new and better ways of handling heart transplants. Recently, at Stanford Uni- experts believe that the ultimate solution in versity, surgeons have created temporary. heart cases will be a complete artificial two-hearted dogs as a means of keeping heart rather than a transplant. Famed Houston surgeon Dr. Michael DeBakey is alive hearts to be transplanted to other one. He has been working for years to animals. A heart removed from a donor develop a complete artificial heart. (Boostdog is stored in the neck of an intermediary dog, where it is nourished by blood flowing ers, or pumping aids, are available and through a large neck artery. Hearts have . have value for some patients, but there is been stored this way for as long as four no full artificial heart that could help the days before final transplantation. Such vast majority of patients with hearts too work has given rise to a hope of establish- far gone to be helped by anything but a ing a "living bank" in which hearts and complete substitute.) Dr. Walton Lillehei other organs from human cadavers might of Cornell University has developed an be implanted in baboons or other animals oxygen-powered device which is to be tried first as an external heart assist device and, and stored until needed for transplant. Nor has hope been abandoned for find- hopefully, later can be modified to be iming some suitable freeze-preservation tech- planted in the chest to do the full heart job. The ultimate hope for all heart diseases nique. With present methods, ice crystals form at the point of freezing and proteins lies in prevention. In 1963, the National in the tissues are quickly rendered unsuit- Institutes of Health decided that a suitable able. But almost certainly, some investi- therapeutic approach for incurable heart gators believe, an effective freezing method disease lay in a completely implantable artificial heart and 1972 was set as the will be worked out. target date. But in 1966 the Institutes broadened this goal to include artificial assist devices as well. The Institutes are currently supporting much research to develop such a heart and at the same time While research goes on are supporting research on better heart to solve the rejection problem, assist devices. artificial organs are being Unquestionably, artificial organs, when developed which, when perfected, perfected, would have major advantages will have major advantages over transplants, but would never completely replace transplants: artificial orover present human transplants. gans, for example, are not suitable for babies, i.e., the heart must grow as they do. Supply could be manufactured to meet demand; storage would be simple; there Meanwhile, at Georgetown University would be no immune or rejection problem. Medical School in Washington, D.C., Dr. And from a patient's viewpoint, there Charles A. Hufnagel, inventor of the first would not be the possible psychological artificial human heart valve, is taking a burden of using a second-hand organ from different tack to get a living heart bank. He an unknown corpse. But until effective, reliable artificial orhas a research project under way in which the aim is to precondition the hearts of gans come along, there is the likelihood unborn calves for ultimate transplanting that many people will have their lives extended by transplants. While there are into humans. Dr. Hufnagel's idea is to treat calf no accurate figures for how many people embryos, still in the womb, with drugs and might be candidates for heart transplants, radiation that might so change the organ for example, the number is large. Each tissues as to make them less likely to trigger year in the United States, about 6,500 rejection when implanted in human recip- infants die of birth defects of the heart. continued
They are among those who ,might be helped by heart transplants. Yearly, too, in the United States alone, some 406,000 people die of coronary heart disease. Many, of course, die suddenly of heart attacks and could not be helped, but there are those who could, with a transplant at the proper time, benefit from many added years oflife. And some American medical¡ men, aware of all the research effort going into transplantation, are becoming increasingly hopeful. At an American College of Surgeons meeting, Dr. David Hume of the Medical College of Virginia, viewing progress, predicted that 100 per cent acceptance of kidney, liver and heart transplants will be achieved in the near future-less than ten years. But there are legal and ethical problems to be solved if transplantation is to be anything more than a rare procedure, even when fully perfected. Common law in the United States, evolved over many years, generally holds that there are no property rights in a dead body. There is a right of possession for purposes of burial-usually belonging to surviving spouse, children or other next of kin. Under most State statutes, a person has no right to donate his own organs. Generally, to avoid civil or criminalliability, doctors must get written consent from surviving next of kin for removal of an organ, but in many cases of accidental or sudden death it may be too late to use an organ by the time the next of kin can be located. It was the late Pope Pius XII who said: "The removal of viable organs from the dead in the interest of science does not offend the mercy of the dead." Nor does it usually offend the next of kin, many U.S. doctors find. In the experience of Dr. Murray of Boston, relatives of dying persons, when asked, almost always have consented to organ removal. "They have gotten a tremendous feeling of satisfaction especially when the transplant was successful. I never heard any of them say they regretted it." Already, some States have begun to alter their laws so a person may declare before death that he wants his organs donated for transplantation. Such a declaration, under laws recently passed in California, Illinois, Kentucky, Louisiana, Michigan, Nebraska and Massachusetts, becomes binding on the next of kin. But still another problem must be faced. The law is fuzzy, even obsolete, in
defining death. So, in fact, are medical . could be a potential organ donor." dictionaries, which still call it "the apOn the other hand, many like Dr. parent extinction,of life, as manifested by Joseph Fletcher of the Episcopal Theothe absence of heartbeat and respiration." logical School in Cambridge, MassachuLaws in many American States do little setts, believe that speeding a donor's death, more than parrot that definition. when it is inevitable, may be justified if the Yet the fact is that medical advances transplant provides another human with make such a definition useless. Doctors valuable life. And it was the opinion of the have revived patients whose hearts and late Pope Pius XII that an oxygen tent may respiration have stopped. And, with ma- be removed "when all hope of recovery chines, they have kept still other hearts has been abandoned." pumping even though there has been. irIn May 1966, twenty-five eminent medireversible brain damage. And this latter cal and biological specialists, meeting ability raises the question: If there is mas- under the auspices of the National Acadesive brain destruction but the heart and my of Science~ to consider use of deceased lungs are kept functioning with mechanical donors for transplantation, declared: "The aids, is the person still a human beingdetermination of the time of death is a or merely a vegetable? matter of medical judgment. Support of the vital functions (respiration and circulation) by artificial means when cerebral death is obvious is an agonizing and useless prolongation of a false hope of recovery. The question then arises: When may these Recent medical advances have artificial supports be removed? It has been rendered the present definition stated that absence of cerebral circulation of death obsolete. "The time for three to six minutes is inconsistent with of death," many physicians brain life." argue, "should be advanced from Death, says Dr. Carl Wasmuth, presiheart death to brain death." dent of the American College of Legal Medicine, comes when the doctor "has done everything to save the patient's life and comes to the point where he feels the patient cannot live. Once a man makes up Many physicians in the United States his mind to stop that respirator or cardiac argue that death should be legally redefined pacemaker, from that minute the patient as occurring when the brain stops working. is dead." "The time of death," says Dr. Paul Russell, Many U.S. medical authorities suggest chief of surgery at Massachusetts, General that to ensure that a doctor does not "pull Hospital, "should be advanced from heart the plug" just to obtain a needed organ, death to brain death." Thus, a heart while no transplanter should be allowed to still beating, could be removed from an attend a dying potential donor. otherwise dead person. There is another side to the coinObserves surgeon Charles F. Zukoski III another kind of problem having to do of the Veterans Administration Hospital, with the potential recipient of a transplant, Nashville, Tennessee: "When a physician particularly a heart transplant. As Dr. decides to support a patient with mechani- Shumway has put it: "Choosing an apcal aids after the electroencephalogram propriate recipient for a heart transplant has gone flat, indicating brain death, he is more difficult than you might expect. runs the risk of letting the machine Even in the patient with advanced coronary become his master, Slowly but inexorably artery disease, who is incapacitated to a the blood pressure will fall until it can great degree, the surgeon would hesitate no longer support the kidneys or other to remove an organ which is, after all, vital organs. This.is an agonal type of death. supporting the life of th'at individual." Thus, as progress is made in transplan_ We can carry the prolongation of so-called tation, new problems of a fundamental life too far." moral and ethical-arise. Among religious leaders, some hold that nature-legal, And it is with these, as well as with further even when death is inevitable, when the progress in transplantation itself, that brain is hopelessly damaged, still "a fraction of life is precious. Therefore, n'o one medicine in the United States is now inmust hasten the death of a person who creasingly concerned. END
ON A SPRING DAY nearly a century ago, a single word clattered across telegraph lines throughout the United States: DONE. It was May 10, 1869, when two "iron horses" approached each other near Promontory Point in the State of Utah. With a silver hammer, Central Pacific Railroad President Leland Stanford, (who later founded famed Stanford University) pounded a gold spike to complete America's first transcontinental railroad. The new railroad united the nation with ribbons of iron and opened the way for unprecedented economic development. Plans for a transcontinental railroad had
been discussed as early as 1848 but became embroiled in controversy over routes. In 1862, although the nation was engaged in a civil war, Congress approved the "Overland Route," stretching from Council Bluffs, Iowa, the then end of the line to Sacramento, California. President Lincoln signed the bill on July 1 but construction did not begin until the Civil War ended in 1865. Soldiers from the mid-west who had fought in the war signed on to build the railroad. Chief engineer was Grenville M. Dodge who, as a major-general of volunteers, had made an outstanding record as a
builder of railroads and bridges. The Union Pacific Railroad built the section from Council Bluffs west; the¡ Central Pacific began laying track from Sacramento to the east. In those pre-computer days it seems unlikely that the final meeting place was more than an accident. Computers could not have predicted the hardships that the builders would face. The route cut through some of America's most rugged terrain: mountains, deserts, canyons, rivers. But former soldiers on the eastern sector and thousands of Chinese immigrants on the western branch finally bound the nation with rails. (continued)