HAMIlTON NAKI, HIS lIFE, AND HIS ROlE IN THE ...

Hamilton Naki

DOI: 10.1308/003588414X13814021679915

H A M I LTO N N A K I , H I S LIFE, AND HIS ROLE IN THE FIRST HEART TRANSPLANT Michael Cotton Médecin Associé1 Rosemary Hickman Retired Emeritus Associate Professor of Surgery and former leader of the Surgical Laboratory Team2 Anwar Suleman Mall Head of Surgical Research Laboratories2 1 Service des Urgences, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland 2 Division of General Surgery, University of Cape Town, South Africa

Hamilton Naki was a remarkable man. Despite having only a primary school-level education, he became adept in the techniques of animal liver transplantation and several other surgical procedures. For his scientific contributions, he received the Bronze Order of Mapungubwe, one of South Africa’s highest civil honours, in 2002 and an honorary Master of Medicine degree from the University of Cape Town (UCT) on 21 June 2003. Much controversy arose following his death in 2005, surrounding claims that he was involved in the first human heart transplant operation, which was performed by Christiaan Barnard in 1967.

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Hamilton Naki was born in Centani or Ngcingane, which is located south of Butterworth in the Eastern Cape Province, on 26 June 1926. He did not attend secondary school, but at the age of 18 left with his friend, James, to travel to Cape Town. While there, he received word that his family’s donkeys and cows had succumbed to disease and so decided to look for work. He was taken on by UCT to help in the garden – specifically to roll the grass tennis courts on the university grounds.

with his wife, Verena, who was also a cardiovascular physician. Experiments were carried out in the fire-damaged, disused pharmacology laboratory, where laboratory animals wandered around among the specimen bottles and flasks. Much of the equipment was homemade, but nonetheless Goetz established a vascular laboratory in 1940, developing digital plethysmography and performing the first femoral arteriogram in 1942. 3

At the same time, a defining influence in Naki’s career was establishing himself at UCT. Robert Goetz was a brilliant German whose medical diploma was refused him by Wilhelm Frick, the Nazi Minister of the Interior, despite obtaining the adulation summa cum laude in 1936, because he was considered ‘unreliable’.1 Goetz fled to Bern where his acquaintance with the Swiss former Professor of Anatomy in Frankfurt, Hans Bluntschli, gained him a post and a fiancée. From there he was accepted as a physiology research fellow by the celebrated Ivan De Burgh-Daly in Edinburgh. However, as a German citizen who was not Jewish, he was not allowed leave to stay beyond one year.1

Upon re-qualifying in 1944 with the South African MBBS, which he was forced to take, Goetz was offered a professorship in physiology in Pretoria, but his close collaboration with Charles Saint persuaded the latter to promote him to Associate Professor of Surgical Research.1 This appointment brought with it a full-time clinical assistant, Carl Goosen, and a workshop. Goetz taught Goosen histological techniques that enabled him to identify progressive systemic sclerosis in 1945. Wartime restrictions prevented postgraduates travelling overseas for training, and so the laboratory came into its own. By 1946 it had developed into a full-blown unit for research in vascular diseases with three full-time registrars, producing work of the highest quality.

So it was that Goetz came to Cape Town in 1938 as a postgraduate scholar to create a new research laboratory there from scratch, using funding from Jacobus Stephanus Marais.2 He was given initially only £100 to establish the laboratory but no provision was made for assistants, be they professional or technical. 3 The facilities were minimal and there was no animal house. He worked closely

By dint of being deemed an enemy alien, 3 Goetz was forced to stay within the university and the hospital precincts, and this is how he came to know Hamilton Naki. One of Goetz’s prime interests was the cause of hypertension, so he decided to investigate the vascular physiology of the giraffe and why it does not succumb on bending down to drink. Thus it was that in 1954, with Otto Butz-Olsen, he

THE ROYAL COLLEGE OF SURGEONS OF ENGLAND BULLETIN

took Goosen and possibly also Naki with him on an expedition to the Limpopo District of Northeastern Transvaal, where cardiac catheterisation of the giraffe was performed in the bush!4

an ad hoc basis, with no full-time doctor employed there until Christiaan Barnard returned in 1958 from Minneapolis with a gift from the Americans of a heart– lung machine.

The young Naki helped Goetz, who was a master of invention, in any way possible in the animal laboratory. This was dirty work, but he quickly progressed from animal husbandry to helping shave, weigh, and anaesthetise the animals, as well as assisting Goetz with many of his innovative ideas, which included mechanical ventilators. By 1954, with Val Schrire, Maurice Nellen and Louis Vogelpoel, Goetz had an unparalleled collection of completely worked-up cases ready for surgery – this would prove a boon later for Christiaan Barnard. Naki’s function, as well as anaesthetist of the animals, was as the ‘scrub nurse’, which included putting up intravenous drips, and stitching. 5 Some of the work at this time was experimenting with the use of Ivalon as a prosthetic material to replace the aorta in dogs. As a result of this work, Goetz and Professor Jannie Louw had a series of 150 successful aneurysm cases published by 1957.

However, with further funding from the JS Marais bequest, work at the laboratory moved up a notch. Initially research work was done in the old animal house, which was a maze of rooms under the charge of Mr Kooij. The potential for using the old pathology museum for operations was obvious, and when it became vacant, the laboratory was rehoused there. Malcolm McKenzie was recruited as research fellow and Carl Goosen continued as a medical technician of remarkable versatility. It was he who developed the UCT mitral heart valve on the basis of a Morris Minor motor car exhaust valve,

Assisted by Gershon Efron and Arthur Bull, who gave the anaesthetic, two dogs in 1955 were slowly profoundly cooled, before their hearts were removed and that of the first transplanted into the second. Upon rewarming, the transplanted heart started to beat; this was the first cardiac transplant procedure with which Naki helped. 3 Goetz always spoke highly of Naki, and encouraged him in his work. He made another visit with Goosen, and probably also to Naki, to study the circulation in the giraffe. In October 1956, they went to the farm of Hans Merensky, a successful platinum prospector who funded Stellenbosch University at Westfalia, near Duiwelskloof.6 Goetz’s wife Verena’s membership of the white women’s resistance movement, Black Sash, and Goetz’s strong antipathy to apartheid prompted them in 1957 to take up a professorship in New York. Here Goetz would go on to perform the first successful coronary artery bypass procedure7 and invent the intra-aortic balloon pump. After Goetz’s departure, work at the laboratory was very much on

in September that year to perform such a procedure in a human. Barnard took the time and trouble to teach Naki the anatomical names of the structures they were dealing with, and this fostered a close relationship that lasted many years. Barnard himself returned briefly in early 1967 to the US to gain further insights into heart transplantation techniques in Richmond, Denver, Virginia, and Palo Alto, California, leaving the laboratory in limbo. His brother Marius Barnard also returned from the US that year and worked on about 20 dogs in the laboratory, preparing for the first human heart transplant. Christiaan was determined to achieve success in this, and he alone had the charisma, drive, technical understanding and the attention to detail to make this a reality.

From left to right: John Roussouw, who had a depressed skull fracture that limited his function somewhat; Prescott Madlingozi, who had served in Egypt in the Second World War and was able to speak French and German with many of the international visitors to the laboratory after the first heart transplant; (unidentified person); Clifford Snyders (known as Boots), who became adept at anaesthetising baboons before they knew what was going on; Victor Pick, who was the principal assistant in the lab and wielded a huge mortuary knife; Hamilton Naki, as anaesthetist. The antiquated respirators, lights and hot water geyser show how basic equipment was then.

and manufactured them in his wife’s pressure cooker. 2,8 Thus Barnard’s experimental work on heart surgery with dogs began, with Naki functioning as the anaesthetist. Indeed, he is on record instructing Professor Arthur Bull how to anaesthetise a dog. On one visit Russell Claude Brock (later Lord Brock of Wimbledon), the celebrated pioneer cardiac surgeon of Guy’s Hospital, was amazed to learn Naki was not qualified at all!2 Experimental work on kidney transplantation was started in 1964 in these laboratories, and Christiaan Barnard became the first in Cape Town

Naki anaesthetised the dogs for the earlier work in heart surgery in the laboratory, which was on the establishment of open heart bypass, using an external heart pump. This was a finger pump that circulated blood through heat exchangers that were warmed or cooled by huge steel tanks of water. Such pumps were difficult to maintain and often broke down unexpectedly. Naki was by no means the only black man in the laboratory. The first surgical assistant there was Victor Pick, a mixed-race man who was very skilled. He shaved the animals, opened their chests, and exposed their arteries. The 225


He subsequently even taught himself how to manipulate the laparoscope, so gifted was he in his dexterity.12 On one occasion he organised everything, including anaesthetising and intubating 30 pigs (no mean feat itself), so that it was possible that 30 animals were operated on on four separate tables during a 6-hour period!9

Hamilton Naki in his later years

pump technician, Prescott Madlingozi, was also black, and was coincidentally captain of the black South African rugby team. They were ably helped by Lindela Mntoninitshi, who was black as well, Clifford Snyders and John Rousseau and made up a formidable team.9 Fame and fortune descended upon Groote Schuur Hospital and UCT in the wake of the first successful human heart transplant operation during the night of 2 December 1967. The AngloAmerican Corporation (Oppenheimer) subsequently donated funds for a brand new Heart Disease and Organ Transplantation Building in 1968, where work was directed by John Terblanche. 5 Naki then moved to a small laboratory near Barnard’s office. He fell out, however, with an intransigent visiting French surgeon, and so when Victor Pick, then the senior assistant at the JS Marais laboratory, was tragically killed in a road accident, Naki was asked to return. There he was responsible for the sterilisation and care of the instruments, and all the operative preparation. He began to assist David Dent and one of the authors (RH), who had started as research fellows, and took over the day-to-day running of the laboratory on a full-time basis. He learnt by meticulous observation rather than through specific teaching. In his own words, ‘he stole with his eyes’. Naki’s work continued to progress and his increasing skills were evident to all. RH, who had become a professor by then, recognised Naki’s innate ability to learn anatomical names and identify congenital anomalies, as well as his remarkable dexterity, speed and skill. Under RH’s mentorship, Naki became the principal surgical assistant in the laboratory. 226

As the most senior member in the laboratory, Naki came to be considered its leader and began to impart the knowledge he had acquired to a long series of trainees. He demanded high standards and became a strict taskmaster.9 Naki demonstrated dissection and surgical procedures to more than 12 trainees, who were later to become professors of surgery and heads of department as far afield as Tokyo and Tennessee.10 He helped train and guide his research colleagues Gerald de Vos, Edward Henry, Nolan Hendricks, Thomas Magxala and Johannes Williams into a highly competent team. Naki was always punctual, the first to arrive in the laboratory, and immaculately dressed. He was known to be friendly, kind and patient with foreign staff who did not have English as their mother tongue, and was always keen to demonstrate the intricate surgical procedures he had learned to others with his large yet nimble fingers. In this way, he was truly a pioneer, whose career in many ways paralleled that of Vivien Thomas in Alfred Blalock’s team in Nashville, USA.10 Many insights – including heterotopic piggy-back transplantation – apparently came from Naki but, unlike Thomas, no work was ever published in his name. He undoubtedly worked on baboons, rabbits, dogs, and pigs to advance the work of liver transplantation in particular. After almost 50 years at Groote Schuur, Naki was offered retirement in 1991 but, because he was ‘indispensible’, stayed on to help in the teaching.11

Upon his final departure from Groote Schuur, Naki received a senior laboratory assistant’s (not a gardener’s) pension and continued to canvas for funding for schools in his home area. He had acquired a house in Langa township, thanks to the generosity of one of his mentors, and supported a large family. Public acknowledgment was given to Naki by RH in a factual descriptive article published in 199913 and Christiaan Barnard recounted Naki’s surgical skills at a news conference in 2001. He received a number of public honours in 2002 and 200314 and gave an interview to Erlick Pereira, then a British medical student, in 2004.15 Shortly thereafter, on 29 May 2005, he died. Laudatory obituaries appeared in the press, suggesting that he was actually the surgeon who harvested the donor heart at the epoch-making first human cardiac transplant.16,17,18,19 These claims were inadvertently repeated by one of the authors (MC), who would like now to rescind. 20 That Naki was even present at this operation was strongly refuted by several writers, including Marius Barnard, who was the surgeon who actually performed this task alongside Terry O’Donovan. Subsequently various corrections were published in the press and medical literature. 21,22,23,24,25,26,27,28 Both in the press29 and in a telephone conversation with one of the authors (MC), Marius Barnard again vehemently rejected the notion that Naki was anywhere near the actual transplant operation carried out in the early hours of 3 December 1967. Further refutation of the claim that Naki was an integral part of the human transplant team came from John Terblanche in a letter to the South African Medical Journal, wherein he referred to the claim as fictitious, mischievous and simply false. 5


Naki’s role was hugely embellished in these obituaries and little had been done by the authors to establish the facts. Naki’s remarkable story as presented in the Cape Times11 and Cape Argus12 on his retirement was factual and restrained. In fact, the former specifically states that ‘his patients are animals, not people’. However, the story became more exaggerated when rewritten in the Associated Press. 30 What is beyond doubt is that Naki’s work was confined to the laboratories, for no photographs exist of him in the operating theatres. In fact, his expertise grew slowly and his work until 1967 was in laboratories that were rudimentary, to say the least. It was only after Groote Schuur became world famous because of the Barnard brothers’ innovative zeal that animal transplantation laboratory work took off. The notion, for example, that Naki trained 3,000 surgeons in a 20-year span31 is clearly physically impossible and as absurd as the idea that Naki would have been fetched from his single quarters in a black township in the dead of night to help with the transplant operation. Several journalists have sought to paint Naki’s life as grim and as difficult as possible, emphasising his poverty, his subordinate position as a gardener and even retiring on a gardener’s pension. 32 To dramatise this spectacular story was a particular aim of Dirk de Villiers, a South African film producer, who was a neighbour of Christiaan Barnard’s. 33

All this obfuscates Naki’s real achievements. Nonetheless, it is unclear why he did not overtly deny these incorrect rumours once they started to emerge. Pereira suggested he had a mischievous avuncular streak and probably found much of the press attention bizarrely amusing. 39 One of the authors (ASM) was a colleague of Naki and recalls the lighter and more sociable moments they shared. During the transition to democracy in South Africa in the 1990s many threats were posed to the fledgling state. The Afrikaner right-wing movements promised to derail the government, while violent opposition existed in KwazuluNatal between Gatsha Buthelezi’s Inkhata Freedom Party and supporters of the ANC. ASM found Naki’s analysis of unfolding events and personalities refreshing and a relief. Although they seemed superficial, he thought that there had been some deep thinking behind Naki’s reactions. Buthelezi was confined to the category of ‘naughty boy’ and the likes of Eugene Terreblanche were simply ‘stupid’. All this was followed by bellowing laughter on Naki’s part. This was his way of saying that these stirrers would come to nothing and he was proven right!40 Maybe Naki was just unconcerned about being used for propaganda. Yet it was known that he was a devout reader of the Bible and was humble and punctiliously upright in attitude and manner.41 It was not in his nature to dissemble.10

MANY INSIGHTS APPARENTLY CAME FROM NAKI BUT NO WORK WAS EVER PUBLISHED IN HIS NAME Hidden Heart, a film made in 2008 by Swiss writers Christina Karrer and Werner Schweizer, further stirred up the whole controversy. 34,35,36 In the film, Naki’s comments appear to refer to his involvement in surgery on humans, and transplantation in particular. However, it is highly likely these words are taken out of context, or that their meaning in Naki’s mind was different from that suggested in the film. Unfortunately, despite rigorous refutations, the myth persists. 37,38

It is evident, however, that Naki rose – with no more than primary education – to become a specialist in the field of liver transplantation, which even now is considered more complex than cardiac organ transfer.28 As such, Naki is an inspiration to those who, as clinical officers or surgical technicians, seek to learn the practice of operative surgery in rural district hospitals despite not being qualified as doctors. In 2007 Groote Schuur marked his contributions by launching a clinical scholarship bearing Naki’s name.42

The authors thank Professor Delawir Kahn and Emeritus Professors David M Dent and John Terblanche for their input in the preparation of this manuscript. References

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