Making heart-lung machines work in India: Imports,indigenous innovation and the challenge of replicating cardiac surgery in Bombay,1952-1962

The desire for open heart surgery in independent India

In the first years of India’s independence, its national leaders celebrated the role that medical progress and technological autonomy could play in achieving modernization through economic and scientific self-sufficiency. Delivering the inaugural address at the 12th Annual Conference of the Association of Surgeons of India in 1950, Prime Minister Jawaharlal Nehru warned that progress in science and medicine in India ‘had stopped a long time ago and they had become stagnant’ (Indian Journal of Surgery, 1951: iv). Amrit Kaur, India’s Minister of Health, hoped that investment in institutions, research, and specialization would bring a better future: ‘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 (Indian Journal of Surgery, 1951: iii). ³

These must have been welcome words for the Indian surgeons. Cardiac surgery held considerable allure for ambitious surgeons in India. It had emerged quickly in the United States and England as a dramatic sector of postwar medicine (Shumacker, 1992; Stoney, 2008b). In the 1940s and 1950s, surgeons in England and the United States pioneered operations for congenital heart disease (malformations of the structure of the heart and its major arteries) and rheumatic heart disease (inflammation that damages cardiac valves). Surgeons began by designing operations that could treat or palliate congenital heart disease by operating on the great vessels. Surgeons quickly moved into the heart itself: They inserted a finger or surgical instrument through a small incision in the wall of a beating heart to force open stenotic valves (Bailey et al., 1952; Baker et al., 1952; Harken et al., 1948). News of the exploits of cardiac pioneers spread worldwide. Indian newspapers in the early 1950s trumpeted the ‘miracle in surgery’ and ‘surgery of future’ (Times of India, 1950c, 1952).

Indian surgeons wanted to be part of this history. Many of these early cardiac operations did not require special equipment, simply bravado. KM Shah, a surgeon at KEM Hospital, went first. On Diwali night, 15 November 1944, he saved a man who had been stabbed in the heart by placing four stitches to close the wound in his ventricle (Shah, 1945). In 1947, Shah’s chief, AV Baliga, removed the pericardium – the membrane that protects the heart – in a patient with cardiac tamponade (Naidu, 1996). In 1952, PK Sen performed the first intra-cardiac operation in India, pushing his finger through an incision in the left atrium to force open a rheumatic mitral valve (Hosain, 2011; Mittal, 2002; Parulkar, 1982). These surgeons operated on beating hearts, an endeavor with considerable risks; many patients died during these surgical adventures (Blackburn, 2012). However, by the early 1950s, many ‘closed heart’ procedures had become routine for congenital and rheumatic heart disease. Sen explained in 1953 that the repair of mitral stenosis ‘has evolved so rapidly that at the present moment it can no longer be called a therapeutic experiment’ (Sen et al., 1953b: 281). The next year, Sen (1954) wrote with confidence about repairs of patent ductus arteriosus, Tetralogy of Fallot, pulmonic stenosis, coarctation of the aorta, and constrictive pericarditis. However, other forms of congenital heart disease had proven too difficult. While some surgeons had attempted to use sutures to repair atrial septal defects (holes through an interior wall of the heart) without fully opening the atrium itself, Sen told members of the KEM Hospital Staff Society in July 1953 that such ‘blind procedures’ were ‘mostly doomed to failure’ (Sen et al., 1953a: 694).

Indian surgeons knew that better options were being developed to treat patients whose lesions could not be managed with closed heart surgery. In 1951, CS Patel, president of the Indian Medical Council, described experiments that would soon offer a new way to operate on the heart, in which ‘blood from the veins pouring into the heart is diverted into an apparatus, where, after being oxygenated, it is pumped back directly into the vessels, giving ample time to the surgeon to operate on the heart’. This ‘extra corporal circulation’ could sustain the body for several hours (Times of India, 1951a: 7). It would allow surgeons to open the chambers of the heart to repair valves and other intra-cardiac structures. Patel, who had performed a pericardiectomy at Bombay’s Sir Jamsetjee Jeejebhoy Hospital in 1950, knew well the advantages that circulatory support would provide (Times of India, 1950a). He hoped that the technique would be ready for human use within a year.

Patel’s hope was seventy years in the making. Physicians in Europe had begun research on heart-lung machines in the 1880s. By the 1930s many teams in Europe and the United States worked to overcome the many challenges. Their efforts came to fruition in the 1950s (Lillehei, 2000; Miller, 2000; Romaine-Davis, 1991; Shumacker, 1992; Stoney, 2008a). John Gibbon worked in Philadelphia with engineers from IBM to develop a sophisticated pump oxygenator. The Times of India celebrated his ‘amazing heart-lung machine’: ‘Its success will bring hope to hundreds of heart disease patients’ (Times of India, 1953a: 5). But only one of Gibbon’s four patients, in 1953, survived. Between 1951 and 1954 five other groups in North America attempted to use heart-lung machines without success (Lillehei, 2000). A Stockholm patient survived in July 1954 (Radegran, 2003). Prospects improved in 1955. John Kirklin brought Gibbon’s designs to the Mayo Clinic, which had the engineers and machinists needed to operate and improve the elaborate device. His team began successful human operations in March 1955 (Lillehei, 2000). C. Walton Lillehei led a team at the University of Minnesota that designed a simpler device with components adapted from dairies and breweries, and a defoaming agent developed by Dow Corning to remove air bubbles from the fuel lines of jet engines (DeWall, 2008; Lillehei, 2008). They began operations in May. Continuing modifications yielded a device that was inexpensive and easy to use. Lillehei and his colleagues opened their laboratories and operating rooms to surgeons worldwide who wanted to learn the techniques.

The challenge, however, was substantial. Open-heart surgery, as described by Lillehei in 1966, required many things: a laboratory to perform cardiac catheterization and angiography (for diagnostic purposes), a radiologist (or cardiologist) trained to perform these tests, blood gas apparatus, heart-lung machines and a pump technician, anesthesia and experienced anesthesiologists with monitoring equipment, defibrillators, a blood bank, a specialized recovery room with trained intensive care nurses, and an in-house doctor available 24 hours a day. He estimated that proper equipment alone cost $100,000 to $500,000. That did not include training or paying personnel (Lillehei, 1966).

How ideas traveled

Surgeons who wanted to establish such open-heart surgery in their own institutions had to acquire ideas, objects, and skills. This was a familiar task for surgeons. As Schlich (2016) has described, transnational exchange had been important for modern surgery since the late nineteenth century. Surgeons translated their textbooks into multiple languages, corresponded widely and followed news reports disseminated through telegraph networks. Surgeons even organized travel clubs to tour each other’s hospitals and share techniques and tips. Although World War I and World War II disrupted these networks of surgical exchange, they reemerged quickly in the late 1940s.

Ideas moved most easily, but even they faced constrained mobility and creative reconstitution in new contexts. Indian physicians corresponded with colleagues in England and the United States. Sen, for instance, exchanged letters with both Gibbon and Copenhagen’s Erik Husfeldt (Sen et al., 1953). Transit time for mail improved with the transitions from sea mail to airmail and from propeller to jet travel. The world’s first official airmail flight by airplane took place in India in February 1911. ⁴ By 1960, mail between India and the United States typically took about one week, but sometimes just half that time. ⁵ Telegrams remained in use, for instance between Rockefeller Foundation offices in Bombay and New York. ⁶ Wire services circulated international news. The Times of India reprinted or glossed reports from other outlets, excerpting its 1952 ‘surgery of the future’ (Times of India, 1952) from the New York Times (Plumb, 1952). ⁷

Some Indian physicians had access to international medical journals. Ratna Magotra, one of Dastur’s colleagues, explained that foreign journals were expensive and, since they typically came by sea, arrived after a three- or four-month delay. ⁸ Her recollections are consistent with Sen’s citation practices. One of his first cardiac articles, submitted in July 1953, had references to six different American journals and two American textbooks, with dates as recent as January 1953 (Sen et al., 1953). Over his career Sen’s published articles included scores of citations to Western journals, including JAMA, Annals of Internal Medicine, British Medical Journal, Surgery, British Journal of Surgery, Journal of Thoracic Surgery, and others (Sen, 1954). It is likely that he obtained them through a medical library or through informal networks. For instance, when Indian physicians went abroad for training, they often brought books and journals back to India with them. Some elite Indian medical schools had extensive subscriptions. The Christian Medical College in Vellore, for instance, had subscriptions to 63 British journals and 69 American journals in 1960. ⁹

Ideas also traveled with surgeons themselves. A British thoracic surgeon, J Leigh Collis, was stationed at a military hospital in Aundh, near Bombay, for sixteen months after the Japanese surrender in August 1945. He performed some of the first lung surgeries in India and trained Indian surgeons, several of whom became pioneers in cardiac surgery (Collis, 1948, 2003). Prominent English and American surgeons continued to visit India after independence. In February 1961, Michael DeBakey, ‘the world famous surgeon’, visited Bombay and operated at KEM It was a dramatic event: ‘Only the elite of the city surgeons were allowed to assist and witness this spectacle’ (Panday, 1992: 82). Sen described the visit as ‘a most impressive and fruitful experience’. ¹⁰ Indian surgeons, just like physicians, scientists and experts in other fields, traveled to Europe and increasingly the US for advanced training. Development grants and Cold War diplomatic outreach facilitated such trips. CS Patel, who spoke enthusiastically about the promise of heart-lung machines in 1951, had learned of them while touring medical centers in England and the United States.

The challenge of replication, especially for heart lung machines

Sen and Dastur could read about emerging developments in cardiac surgery in the United States and Europe, but it was far more challenging to establish a working system in a new location. Scholars in history and sociology of science have studied the challenge of replication in detail, from seventeenth-century experiments with barometers and air-pumps to late twentieth-century efforts to replicate a TEA laser (Collins, 1985; Middleton, 1964; Shapin and Schaffer, 1985). Replication is rarely easy. In these classic cases, no one who relied on written descriptions of the devices succeeded at replication. Scientists had to consult with the original researchers, visit their laboratories and sometimes share equipment, evidence of the importance of ‘tacit knowledge’ (Collins, 1985). Attempts to establish European technology in India often required workers and technicians who circulated between Europe and India to acquire tacit knowledge and mobilize the necessary expertise (Kumar, 2012; see also Dubow, 2006).

While the literature in science studies emphasizes the impossibility of replication based solely on written information, the history of medicine has cases in which replication occurred solely through the communication of ideas, without direct contact or the passage of tacit knowledge. Vaccination in 1798 and ether anesthesia in 1846 both crossed the Atlantic (in opposite directions) based only on written reports – though both relied on existing technology: ether frolics were a well-known entertainment for medical students, and vaccination built on the well-established precedent of inoculation with smallpox. Were heart-lung machines more like Boyle’s air pump or Jenner’s vaccine? They combined two distinct devices, a pump and an oxygenator. Reliable roller pumps that could move blood through tubing with minimal damage to blood cells had been available since the 1930s. Researchers developed several techniques to mix oxygen into blood, including bubblers, rotating metal disks, and wire mesh screens, each of which exposed a thin film of blood to oxygenated air. But oxygenators have a narrow therapeutic window: if they do not work perfectly, for instance if they leave oxygen bubbles in the blood, they cause devastating neurological injuries (Jones, 2013: 113–148). Surgeons also considered surgery to be a craft skill, something not easily transferrable through language alone. This had, in part, justified their travel clubs (Schlich, 2016).

Early experience in the United States suggested that the heart-lung machine developed at the University of Minnesota would be easy to mobilize. Surgeons came to Minneapolis from all over the world to learn their techniques. Lillehei and his colleagues did not attempt to impose strict control on the dissemination and use of the new techniques. The seemingly simple technology even tempted amateurs to try their hand at biomedical engineering. When Lillehei published an account of his heart-lung machine in Scientific American (Lillehei and Engel, 1960), he received letters from enthusiastic students who wanted to build their own devices and demonstrate them on rabbits or pigs at high school science fairs. ¹¹ By the late 1950s, heart-lung machines worked at many sites in the United States. As Houston surgeon Denton Cooley recalled, ‘Walt Lillehei brought the can opener to the cardiac surgery picnic’ (Stoney, 2008b: 34). Could they be made to work in India? Dastur took on this challenge.

Kersi Dastur, Parsi engineers, and the price of tacit knowledge

Dastur studied at Grant Medical College, the oldest medical school in Bombay, and then traveled to England to take exams to become a Fellow of the Royal College of Surgeons. He returned to Bombay in 1946, at the height of nationalist resistance against colonial rule, and joined the staff at B.Y.L Nair Hospital and the Topiwala National Medical College (Kalke and Magotra, 2010; Magotra, 1992). These institutions had been founded in the 1920s as part of Mahatma Gandhi’s non-cooperation movement: Since Grant would only appoint British physicians to its faculty, Indian nationalists established their own institutions. Dastur’s surgical practice was broad, including both abdominal surgery and urology. In addition to his work at Nair Hospital, he operated part time at a tuberculosis sanatorium (a position he obtained with help from CS Patel) and gained experience in thoracic surgery. His students later described that ‘a dream to do heart surgery had started to possess him’. He learned what he could about the work of Gibbon, Kirklin and Lillehei, and became ‘a self-trained cardiac surgeon’ (Kalke and Magotra, 2010: 229). ¹²

How exactly did Dastur do this? His colleague Ratna Magotra described him as a ‘voracious reader’. ¹³ But since he published just two articles about his experience with open heart surgery, and these had few citations, it is impossible to reconstruct specific influences. ¹⁴

Dastur tried, without success, to obtain financial support from the Bombay Municipal Corporation. This slowed his progress between 1956 and 1961 (Magotra, 1992). He had to rely on income from his surgical practice to support his family and his research, working long days in the clinic and operating room, and working late evenings in his dog lab. Moreover, even though he wanted a heart-lung machine, and even though these were available for purchase from the United States by 1957, he could not import one. Dastur had no source of foreign currency and could not avoid strict government policies of import substitution that limited currency exchange and foreign purchases in India (Bagchi, 1982; Kohli, 2005; Vanaik, 2004). As Dastur’s colleagues recalled in 2010, ‘It is extremely hard to imagine, in the current times of liberalized economy, the Herculean efforts required to import even a small component or device in those days’ (Kalke and Magotra, 2010: 229; see also Iyer, 2011). After studying American reports, he started to design his own machine and drew the first blueprints himself.

As Dastur moved from design to development, he benefitted from a fortuitous connection. Dastur was a member of Bombay’s bustling Parsi community, Zoroastrians who prospered as merchants and manufacturers. Godrej Industries, for instance, had been founded by Parsi entrepreneurs in 1897 to repair surgical instruments. It quickly diversified into the manufacture of safes, locks, bicycles, typewriters and sewing machines. By the 1950s, it had decades of experience importing, adapting and re-producing foreign technologies (Arnold, 2013a). Dastur, inspired by Gibbon, hired two engineers who had worked for Godrej. It is possible that his brother, an engineer at another Parsi enterprise, Tata Steel, provided an introduction. ¹⁵ Work began ‘in real earnest’ in 1957. The manufacturers saw little commercial value in the work and had little enthusiasm for it: ‘Dr Dastur had to personally and repeatedly visit the factories to goad the manufacturers on the cost of his time, private practice, and considerable expense’ (Magotra, 1992: 116). Whether through ties of kinship, social connections, or cash payments, Dastur tapped local social capital in pursuit of innovation.

By 1959 Dastur had a prototype with three roller pumps and a disc oxygenator (Kalke and Magotra, 2010). How could he tell if it would work? This has been a key question for users of scientific apparatus since Boyle’s air-pump. Initial trouble-shooting often relies not on whether the device achieves its desired goal, but on whether it produces a known, visible effect. Constantijn Huygens declared victory when a bladder suspended in the vacuum chamber of his air pump remained inflated all night (Shapin and Schaffer, 1985: 237). Such assessments are rarely clear cut: devices can work to varying degrees and different observers can offer differing assessments (De Laet and Mol, 2000).

For makers of heart-lung machines, animal research provided the crucial test. Richard DeWall led the development of the heart-lung machine at the University of Minnesota. When he had a device that had achieved acceptable results in dogs, he invited Lillehei to the laboratory to examine the animals. ‘I remember walking them out in the field in front of the grassy meadow by the research lab’, DeWall described years later. ‘We were just walking the dogs around and analyzing them and checking them over. There was no apparent damage to them. It was then that Walt decided that we would try this in the operating room’ (DeWall, 2008: 107).

Dastur also relied on extensive animal research to learn to use the machine safely. A.P. Chaukar, who worked in the dog lab at KEM Hospital in the 1960s, explained that the Bombay Municipal Corporation euthanized 250 stray dogs each week. Researchers could easily obtain 10 or 12 of them as needed. ¹⁶ Dastur’s lab made such extensive use of dogs that his neighbors complained about their barking at night; his assistants became adept at dosing them adequately with morphine to keep them quiet. ¹⁷ Dogs served two crucial functions. First, surgeons could use their existing competence in human thoracic and abdominal surgery and adapt that in dogs to develop skill – tacit knowledge – with cardiac surgery. Second, success in dogs provided proof of principle that surgeons could use heart-lung machines. Dastur presented his early dog outcomes at the 1959 scientific meeting of the Cardiological Society of Bombay (Dastur et al., 1964; Iyer, 2011). In 1960, his team had their first success, a dog named Victor who survived some time on the heart-lung machine and ‘roamed freely in the wards’, much to Dastur’s delight. This earned Dastur a ‘small grant’ from the Indian Council for Medical Research (ICMR) (Kalke and Magotra, 2010: 231). These dogs were not patients: none had heart disease. Instead, they were the means of testing and debugging a technological system. Once Dastur had a working system, the dogs became a demonstration of what ought to be possible in humans. DeWall had used post-operative dogs to convince Lillehei that the device was ready for human use. Did Dastur allow Victor into the hospital to impress colleagues and win their support, or to reassure potential patients? Both were possible. ¹⁸

How was Dastur able to succeed, having never seen someone else’s heart-lung machine in action? It is possible that he shared enough of a skillset with the US surgeons, based on his prior expertise with other operations and surgical technologies, that he could infer the unwritten steps needed to succeed. He also benefitted from the technical sensibility of his engineer collaborators. The knowledge needed to use the devices safely was hardest won, gained at the expense of Bombay’s surplus dogs. After several years of reading, designing, collaborating and dog surgery, Dastur felt ready to proceed. This was an ethically fraught decision, one faced by all surgical pioneers who must judge when they have enough skill and confidence with a new technique to justify an attempt in a patient (Fox and Swazey, 1974).

The move to human operations revealed the limits of Dastur’s autodidacticism. On 16 February 1961, the day before DeBakey’s visit to Bombay, Dastur used his heart-lung machine to repair an atrial septal defect in a 19-year old woman. The device ‘did “duty” for 40 minutes’ and the patient initially made ‘satisfactory progress’ (Times of India, 1961: 9; also Kalke and Magotra, 2010). In a narrow sense, the heart-lung machine worked: The woman survived the operation and was ‘doing well post-operatively’ (Dastur et al., 1964: 132). However, on the third day surgeons had to re-operate to drain blood from her chest. She developed fevers and sepsis, and died one week later. While doctors often test a specific intervention, that intervention is embedded as part of a broader ‘intervention ensemble’ (Kimmelman, 2012: 173). A problem anywhere in that ensemble can undermine the outcome. In this case, Dastur had successfully replicated open-heart surgery with a heart-lung machine: he had followed an established protocol and produced the expected result – the patient survived the repair. But the standard for clinical work is higher. Dastur needed not just for the device to work, as it had in dogs, but also for the operation to succeed such that the patient recovered from surgery and benefitted.

Dastur’s second attempt also failed, this time because of the device. The patient died in the operating room after ‘faulty handling of the oxygenator, when frothy blood was introduced into the arterial line’ (Dastur et al., 1964: 132–133). Concerned by these results, Dastur put his clinical program on hold. After more than a year of further experiments and modifications, he resumed clinical cases on 7 August 1962. Four of his next eight patients died, all from problems with the machine (e.g. pulmonary capillary damage in one, post-operative bleeding in one, and low blood flow rates in two). Dastur switched from a disc to a bubble oxygenator, from high- to low-flow perfusion, and from blood prime to hemodilution. After these modifications, he operated on twenty patients with five deaths, none attributed to his heart-lung machine. This success came even as Dastur operated on a wide range of patients, from three to thirty-five years old, with a wide range of cardiac diagnoses not amendable to closed heart techniques (mostly congenital heart disease, including atrial septal defects, ventricular septal defects, Tetralogy of Fallot, pulmonic stenosis, and rheumatic heart disease, specifically mitral valve incompetence).

Dastur’s patients paid a high price for his tacit knowledge. Eleven of his first thirty patients died, five from problems with the device. Dastur was not alone in experiencing dire mortality in his early experience. Gibbon lost three of his first four patients and left the field. Kirklin lost four of his first eight patients at Mayo (Lillehei, 2000). But Dastur, like Kirklin, Lillehei and other early cardiac surgeons, soon achieved proficiency and better outcomes. Had he achieved replication? Shapin and Schaffer described how a ‘range of commitments and investments bore on judgments whether replication had or had not been achieved, of whether or not a claimed phenomenon authentically existed as a fact of nature’ (Shapin and Schaffer, 1985: 226). In Dastur’s case the judgments did not involve facts of nature but prospects for therapeutics. At some point a threshold was crossed: Dastur’s device completed transitions from dog experiment to human experiment to therapeutic system. Convinced by the improving results in his first thirty patients, Dastur offered his services as cardiac surgeon to patients throughout Bombay, at least to those who could afford to access its private hospitals. He soon had a busy practice ‘lugging’ his machine to hospitals in and around the city (Kalke and Magotra, 2010: 232).

Indigeneity

Dastur left no record of his thoughts about the canine and human cost of his innovation. He may have justified the effort in part by his eventual clinical success, specifically his ability to offer treatments that had not previously existed in Bombay for patients with congenital or rheumatic heart disease. His work acquired another justification as well: the value of indigenous innovation.

The import restrictions that pushed Dastur to develop his heart-lung machine were part of India’s post-independence fiscal and industrial policy, but they had roots in nationalist thought. Indian nationalists had advocated for a swadeshi movement in the early twentieth century, calling on the Indian people to reject foreign goods. As advocacy for Indian independence intensified over the first half of the twentieth century, Gandhi and other leaders revitalized aspects of Swadeshi. Gandhi hoped to replace British imports with Indian manufactures and, in so doing, foster links between urban consumers and rural producers (Arnold, 2013a). Swadeshi sentiments emerged again after independence, though with different meanings. Welcoming surgeons to the Technical Exhibition at the 12th Annual Meeting of the Association of Surgeons of India, Association president NS Narasimhan reminded his audience that ‘[s]ince forty years the cult of Swadeshi has been preached in our country’ (Indian Journal of Surgery, 1951: xiv). Unfortunately, little progress had been made with Indian manufacture of medical supplies. Narasimhan called for collaboration between Indian surgeons, metallurgists and industry. He believed that India should produce its own surgical instruments, though he conceded ‘that it may be advisable to continue to import for some more years complicated precision instruments like microscopes, X-ray apparatus, etc.’ (Indian Journal of Surgery, 1951: xv). Narasimhan’s invocation of indigenous manufacturing in a post-colonial setting evoked Gandhian visions of autonomous and self-sufficient village communities even as it showed how surgeons could contribute to Nehru’s vision of planned industrialization, economic growth and eventual national self-sufficiency (Zachariah, 2003).

Dastur himself, in his sparse publications, did not raise these issues. In his 1964 account of the development of his open-heart surgery program, he mentioned both disc and bubble oxygenators, but said nothing about their provenance (Dastur et al., 1964). Nonetheless, he was rewarded in the press for his efforts. When Dastur performed his first operation in February 1961, the Times of India (in its Bombay edition) stressed that his heart-lung machine had been ‘manufactured in Bombay’ (Times of India, 1961: 9; also Magotra, 1992). Claims of indigeneity were carefully policed and contested. As mentioned earlier, when the paper mistakenly described Sen’s 1962 operation as the first to use a heart-lung machine in Bombay (Times of India, 1962b), a letter to the editor reminded readers of Dastur’s prior use of his ‘indigenous’ machine (Frydman, 1962: 6). The authorship of this letter is significant. It was submitted by Maurice Frydman, a Jewish engineer who had fled Warsaw in the 1930s to work in an electrical factory in Mysore. Taken with theosophy and spiritualism, he became a disciple of Gandhi, took a new name (Swami Bhartananda), and supported the Indian nationalist movement (Frydman, 1944; Pant, 1989; Rothermund, 1983). Inspired by Gandhi’s valorization of manual labor, Swadeshi and local manufacturing, he authored pamphlets on ‘micro-technology’ and village-centered economics, arguing that imported technology had to be adapted to the Indian context such that it answered local needs. He even designed a more efficient version of Gandhi’s iconographic technology, the spinning wheel. In defending Dastur’s achievements, Frydman asserted a Gandhian vision of the centrality of individual agency in devising innovations to foster community self-sufficiency. ¹⁹

The willingness of Frydman (and the Times) to defend Dastur’s achievements reveals that the stakes for indigenous and imported heart-lung machines reached beyond the surgical community and into the public sphere. Six years later, when Dastur performed the first human heart valve transplant in India, the Times again emphasized that he used ‘an India-made heart-lung machine’ (Times of India, 1968: 1).

It is impossible to ascertain whether Dastur was motivated by an ideological commitment to indigenous Indian innovation, by his inability to import a Western device, or both. Another colleague also left an ambiguous record. Meherji Mehta followed Dastur’s lead and started to use ‘an indigenously made’ heart-lung machine at Bombay’s JJ Hospital in February 1963. This was, in part, a pragmatic move. As he explained, JJ Hospital ‘did not have the influence to import foreign Heart Lung machine’. However, he was proud of his reliance on Indian technology: ‘Until 1975, that is, as long as I was in JJ Hospital, I never used imported pumps and rarely imported oxygenators’ (Mehta, 1984: 14, 15; Parulkar, 1983). Whether inspired by nationalist ideologies or pragmatic necessities, Dastur’s and Mehta’s indigenous pumps had become meaningful.

Sen and the effort to import heart-lung technology

As Dastur and Mehta worked to build their own devices, surgeons at several other hospitals managed to import foreign devices. ²⁰ The experiences of PK Sen demonstrate what this required. Sen spent his entire career – as medical student, surgical trainee and professor – at KEM Hospital and Seth Gordhandas Sunderas Medical College. ²¹ Like Nair Hospital and Topiwala National Medical College, GS and KEM were founded in the 1920s as nationalist institutions (Times of India, 1926). Sen turned away from what could have been a lucrative private practice to develop surgical research at KEM. ²² With some support from the ICMR, he began chart reviews, animal research, and clinical research on perforated ulcers, traumatic shock (including little known work by Soviet researchers), diarrhea and tuberculosis (Sen, 1945; Sen and Prabhu, 1950). ²³ To obtain advanced training in surgical research, he applied for a fellowship from the Rockefeller Foundation in September 1949 and spent six months at the University of Pennsylvania. ²⁴ He presented his research about the impact of surgery on adrenocortical activity at the American College of Surgeons in Boston in October 1950 (Hardy et al., 1951), and finished the year with a tour of major surgical research centers.

When Sen returned to Bombay, KEM’s Dean Dhayagude asked him to organize a department of ‘Experimental Surgery’. ²⁵ The hospital offered him space and the ICMR provided KEM 6000 rupees (about $1300), but this was not enough. As Dhayagude explained to the Rockefeller Foundation, Sen also ‘requires some costly equipment which cannot be provided from the sources available to us’. ²⁶ He asked the Foundation for help. ²⁷ Nearly two years later, in April 1953, the Foundation approved a grant of $3,500. ²⁸ In the meantime, Sen’s interests had turned to cardiac surgery. In 1952, as noted earlier, he performed his first closed heart operation, a finger-fracture repair of mitral stenosis. He developed a new surgical technique for this operation, tested it on 25 mongrel dogs, and then tried it on three patients. He presented his ‘vastly superior’ results in December 1952 (Sen, 1953: 17). Even in the early years of his career, he sought to engage with Western experts, learn their techniques, improve them and share his innovations. ²⁹

By 1954, Sen wrote confidently about the surgical management of simple congenital anomalies and rheumatic valves. However, he stopped short of open heart surgery, which remained ‘somewhat on the experimental plane’. Sen knew that Gibbon had ‘reported brilliant success’ with his heart-lung machine and he was aware that the ‘machines have been perfected in some places in America, Sweden and Russia’. However, he did not think the machines were ready: ‘the prohibitive cost and the complicated nature of the apparatus militate against immediate general acceptance’ (Sen, 1954: 541–547). As he told his colleagues at KEM in 1953, ‘like all artificial organs devised, a technical failure is inherent in its very nature’ (Sen et al., 1953: 694). Sen initially favored hypothermia, ‘or artificial hibernation’, a ‘physiological approach to the problem of cardiac surgery’ (Sen, 1954: 547). ³⁰ He attempted the procedure in 1954 and succeeded in 1956 (Parulkar, 2004; Sen et al., 1953, 1960). By 1962, his team had used hypothermia in eleven patients to provide up to six minutes of circulatory arrest. They reported ‘gratifying results’, even though only six of their patients survived (Parulkar et al., 1962: 65).

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 to May 1957. ³¹ This trip allowed Sen to establish broad connections to the surgical community and its device manufacturers. Sen also needed skilled collaborators. He convinced the Foundation to provide fellowships to KEM’s cardiologist, Keshavarao Krishnanao Datey, to his pathologist and laboratory director, Suman Kinare, and to one of his surgical trainees, Tryambak Pandurang Kulkarni, who spent fifteen months working with Denton Cooley in Houston. ³² Another trainee, GB Parulkar, also received funding to study abroad. ³³ Sen seized other opportunities as they arose. When DeBakey visited Bombay in February 1961, Sen convinced DeBakey, who had brought his own custom-designed surgical instruments, to leave them with him; DeBakey simply asked Sen to reimburse the manufacturer, George C Pilling & Sons of Philadelphia, for the cost. Sen passed the bill on to the Rockefeller Foundation. ³⁴

Surgeons in motion

Surgeons’ ability to travel played a key role in the development of open-heart surgery in India in the 1950s, as it did for the projects of other physicians, scientists, and development experts. In 1945, World War II had brought Collis to India, where he trained Mehta and others. Dastur traveled to England to become a fellow of the Royal College of Surgeons. The end of the war opened a new era in international travel. Sen made three trips to Europe and the United States. He arranged for many of his trainees to go as well. American and British surgeons traveled too. DeBakey visited Bombay in February 1961 (Panday, 1992). Donald Ross visited Bombay in August 1963 (Times of India, 1963). Dastur later hosted Walton Lillehei, Denton Cooley, and Christian Barnard (Kalke and Magotra, 2010).

Such travel required money. Sen and his team benefitted enormously from the patronage of the Rockefeller Foundation. It also required an invitation: Indian surgeons needed permission to visit and, ideally, to operate with their hosts. Surgeons had had a long tradition of hosting visitors (Schlich, 2016). When Sen applied to the Rockefeller Foundation in 1949, he hoped to study surgical research at the Mayo Clinic. Mayo, however, already had a full quota of fellows. The Foundation turned to the University of Pennsylvania and asked IS Ravdin, chair of surgery, to accept Sen as a trainee. Ravdin accepted immediately. He had directed a military hospital on the Indo-China frontier during the war. ³⁵ While there, he had attended the All Indian Conference of Surgery in 1944 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’. ³⁶ As he told the Foundation, ‘I, therefore, have a deep interest in Indians and would be very happy to have Doctor Sen work in the Harrison Department of Surgical Research.’ ³⁷ On each of Sen’s trips, Foundation officials sent dozens of letters of introduction on Sen’s behalf to American surgeons. Whether out of desire to help foreign surgeons or to win favor with the Rockefeller Foundation, they almost always obliged. ³⁸ American and European surgeons graciously hosted their visitors. In 1955, for instance, Lillehei welcomed visitors to the University of Minnesota from all corners of the United States, as well as from Canada, Sweden, France, Chile, Mexico, England and the Netherlands, and this is likely an incomplete list. ³⁹ DeBakey and Cooley welcomed visitors to Houston. When Kulkarni traveled to Houston in 1962 for his fellowship, Diana DeBakey, the surgeon’s wife, arranged a furnished apartment for him. ⁴⁰

Rapid innovation in international travel facilitated these migrations. Sen first traveled to America by boat. He departed Bombay for London on the SS Strathmore on 29 December 1949. He planned to leave from Liverpool on the Queen Mary on 20 January, but while rushing to catch a train from London to Liverpool, he fell down an escalator and ‘hurt himself rather badly’ – a ‘slight brain concussion’. He missed the train and the Queen Mary but managed to rebook on the Parthia and arrive in New York on 30 January, an eventful 33-day trip. ⁴¹ Six years later he flew. ⁴² He used Rockefeller support to visit twenty-six cities in nine countries between September and January (with an itinerary of: Bombay - Bangkok - Hong Kong - Tokyo - Honolulu - San Francisco - Los Angeles - Houston - New Orleans - Mexico City - New York - Philadelphia - Detroit - Lexington, Kentucky - Cleveland - Rochester, New York - Boston - Philadelphia - Baltimore - Bethesda - New York - London - Birmingham - Edinburgh - Amsterdam - Copenhagen - Leningrad - Moscow - Delhi - Bombay), something that would not have been possible before the era of international air travel. ⁴³

Although international air travel was newly possible, it was not always easy. In November 1962, Sen watched anxiously from Philadelphia as a Chinese border incursion into India threatened to turn into ‘the agonies of a full scale war’. He worried about his return flight to Calcutta: fearing that the airport there would become ‘the clearing house of all military personnel and equipment’, he arranged to fly through Delhi instead. ⁴⁴ Richmond Anderson, who traveled extensively to inspect Rockefeller medical programs in India and elsewhere, had one misadventure after another. An engine failed on a January 1952 flight from Trivandrum to Cochin. ⁴⁵ On a December 1955 flight from Hong Kong to Tokyo, he had to treat the navigator who ‘complained of terrific chest pain whenever there was a slight change in altitude’. ⁴⁶ When an engine failed between Tokyo and Seattle in June 1956, the crew prepared to ditch at sea. The Navy sent a flying boat and the Army three jets as an escort, but the pilot managed to coax the plane into Anchorage: ‘[W]e were all glad to be on terra firma again’. ⁴⁷

While Sen often arranged for stops in Europe on his return trips from the United States to India, his focus, and increasingly that of other Indian physicians, was the United States. This was a significant shift for Indian physicians, who had traditionally looked to England for training and credentials. Indians went to the United States to learn, while Americans traveled to India to teach, a bidirectional transit that was explicitly part of the United States’ Cold War strategy to combat Soviet influence. Indian physicians, however, resisted the rules of Cold War politics and maintained productive ties with Soviet surgeons. One of Sen’s mentors, AV Baliga, who had performed one of the first cardiac procedures at KEM, was president of the Indo-Soviet Cultural Society (Bakaya, 1991). The Times of India covered the exploits of Soviet surgeons, including their heart-lung machines (Krakovsky, 1961).

Indian physicians also networked extensively within India. As expertise emerged in Bombay, Vellore or elsewhere, physicians traveled to local, regional and national conferences to share their emerging expertise. Surgeons who could travel travelled widely.

Machines in motion

When Sen began to pursue open-heart surgery in 1954, he focused his efforts for many years on hypothermia. By 1958, however, he had begun to dabble with heart-lung machines. With financial support from the Rockefeller Foundation, Sen’s team imported two oxygenators (vertical screen and rotating disc models). The machines, however, were just one part of the puzzle. To make them operate, Sen also needed a steady supply of disposable components and spare parts.

Access to Rockefeller capital – specifically to United States currency – made it possible for Sen to import medical equipment but, as with international travel, this was never easy to do. Securing funding was just the first step of a long process. India’s restrictive import policies posed constant challenges for Sen and his Rockefeller patrons. The elaborate bureaucracy of import licenses delayed purchase orders. ⁴⁸ One license ran for nineteen pages and specified over 200 specific items (heart valves, image intensifiers, camera film, cables, transformers, graph paper, lamps, beakers, syringes and much more), from sixteen companies in the United States, England, Germany and Sweden (e.g. Siemens Engineering and Manufacturing, General Electric, Coleman Instruments, Hewlett Packard, etc.). ⁴⁹ The Rockefeller Foundation railed again Indian import duties. As one official wrote in 1957,

‘I do not think that the RF ought to have to pay 40% duty on equipment donated by us to a medical school in India. In this particular case, that could mean up to $80,000. It would simply be an unrestricted grant from the RF to the Government of India.’ ⁵⁰

Even when orders were approved and submitted, Sen faced long waits for the equipment to arrive. An April 1953 order remained incomplete in January 1955. ⁵¹ Some equipment broke in transit. ⁵² Other pieces got waylaid, possibly because of dock strikes in London. ⁵³ Electrical equipment required voltage transformers. ⁵⁴ When an angiocardiography unit finally arrived in March 1959, it could not be installed because the building being built to house it was still under construction. ⁵⁵ Outside events also interfered. When China invaded India in October 1962, the Indian government tightened its restrictions on imports and foreign exchange, disrupting Sen’s supply chains. ⁵⁶

None of this was unique to Sen or cardiac surgery: Many Indian physicians and scientists faced similar struggles to obtain foreign training or equipment. The movement of people and things required work, resources and connections. It is worth remembering that the verb ‘travel’ is derived from ‘travail’ – ‘to torment, distress; to suffer affliction; to labour, toil; to suffer the pains of parturition’ (Oxford English Dictionary, 2018).

Sen, his deans, and Foundation officials persevered. By January 1961, Sen’s Department of Surgery had made purchases totaling $157,440.99 from over 30 companies, mostly in the US and Europe. ⁵⁷ Nonetheless, access to supplies often held up their work. In July 1961, for instance, Dean SV Joglekar wrote to the Rockefeller Foundation asking for replacement gaskets. The gaskets were inexpensive, available for ¢25 each from a Massachusetts company, but Sen’s team needed them fast: ‘ship the goods by Air’. ⁵⁸ In December, they submitted a much larger order for catheters, gaskets, regulators, filters, bubble traps and other supplies for the complex devices. ⁵⁹ Access to complex instruments and apparatus, in all their nitty gritty details, had become essential for the practice of cardiac surgery (Jones, 2018a).

Sen began to test the devices in his laboratory in 1958, with disappointing results: a ‘majority of the animals succumbed to the extracorporeal circulation, due to uncontrolled bleeding’ (Parulkar, 2004: S24). He continued to rely on hypothermia for his patients in 1960 and 1961. But when Dastur used his heart-lung machine in a patient in February 1961, Sen’s team redoubled its efforts (Parulkar, 2004, 1984) Progress was slow. In February 1962, Sen continued to have ‘some difficulties in operating the heart lung machine.’ ⁶⁰ He approached the Rockefeller Foundation for a third travel grant so that he could ‘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.’ ⁶¹ But he did not wait for this trip before proceeding. On 30 March 1962, Sen’s team used their heart-lung machine to repair a ventricular septal defect in a 3-year old child. The machine did its job and the ‘heart was kept out of action for some time’ (Times of India, 1962b: 7; also Panday, 1992). 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’ (Parulkar, 2004: S24). ⁶² Despite the death, Sen’s team saw a silver lining. As Parulkar later wrote, ‘From this one single case we learnt much more than the hundreds of animal experiments that we had performed’ (Parulkar, 2004: S24). Sen’s team worked to debug their systems, enduring ‘trials and tribulations before this could be smoothened’ (Kinare, 1991: 13).

Even with his access to imported medical equipment, Sen invested in indigenous devices. His student Sharad Panday and their perfusionist had developed a reusable glass and steel bubble oxygenator: ‘It was nothing great. Not really an invention but an improvisation that was needed just at that time’ (Panday, 1992: 83). Sen’s team also used ‘a locally designed plastic bubble oxygenator’. ⁶³ He obtained another grant from the ICMR for such local purchases. When Rockefeller officials toured his department in December 1963, they were pleased to see Sen’s team working to wean itself off its dependence on imported equipment:

‘They have been able to make considerable progress in designing and building some of their own equipment such as cardiac pumps and several types of oxygenators, for example a type made from plastic sheeting which is considerably cheaper than rather similar models made in the US.’ ⁶⁴

In 1965, Sen praised ‘efforts made in Bombay and Calcutta for manufacturing certain thoracic surgery equipment like “heart-lung machines”’ (Times of India, 1965). While financial support from the Rockefeller Foundation allowed Sen to import devices, his desire to avoid dependence on imports and Foundation support motivated indigenous innovation.

Indian cardiac surgeons, however, preferred imports. ⁶⁵ Kulkarni, for instance, made the long trip from Houston to the Mayo Clinic to receive the gift of a bubble oxygenator before he returned to Bombay in 1963. ⁶⁶ Valuation of imported and indigenous products was, and remains, complex in India: There are many different kinds of value that Indian users have ascribed to material goods. ⁶⁷ Sen’s team took pride in what they had produced themselves, but imported medical equipment had prestige and capabilities beyond what Indian firms could initially produce.

Whether following Dastur’s path of indigenous production or Sen’s path of importation, Bombay surgeons prevailed. Optimism built slowly. In October 1962, the Times of India cited the heart-lung machine as ‘one of a series of ingenious devices’ that ‘raises great hopes’ in ‘the offensive against heart disease’: ‘the terrors are slowly receding as great strides of progress in diagnosis and treatment are made in the field of cardiovascular care and therapy’ (Times of India, 1962a: 6). By 1964, four hospitals in Bombay and one each in Vellore, New Delhi, Calcutta, Chandigarh and Miraj had begun open heart surgery (Parulkar, 1984). These surgeons had mobilized ideas, technologies, techniques and tacit knowledge. But did it work? To answer this question, it is important to understand what Sen, Dastur, and their allies sought to accomplish.

Foreign aid, foreign interests

Even though surgeons had imagined open-heart surgery since the late nineteenth century, as late as 1950 few would have called for it in India. Making the case for general surgery was hard enough. Talking to his colleagues at the Association of Surgeons of India, association president NS Narasimhan regretted that the people and government of India remained preoccupied with epidemics and public health and under-estimated the usefulness of surgery, which was ‘of inestimable value from infancy to old age’ (Indian Journal of Surgery, 1951: iv). After eminent Boston thoracic surgeon Edward Churchill spent just three months in Lucknow in 1958, he offered his own vision for India’s medical priorities: ‘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”’ (Burns, 1958: 35). Why and how did the situation change, such that Dastur and Sen could have heart-lung machines in use at municipal hospitals in Bombay by 1962? They tapped nationalist ambitions, the interests of municipal and national authorities, the Rockefeller Foundation, and Cold War strategists. Together these provided opportunities, obstacles, and many measures by which efficacy could be judged.

Many initiatives, from the 1944 Health Survey and Development Committee to India’s 1954 five-year plan, had called for investments in medical education and research (Amrith, 2006; Health Survey and Development Committee, 1946; Times of India, 1954). As Chief Minister BG Kher explained at KEM’s silver jubilee celebration in January 1961, ‘Research is the foundation of science and here also we have a great leeway to make up if we are to come up to the standards of other advanced countries’ (Times of India, 1951b: 7). Many individuals and institutions contributed to this goal. One, with particular importance for KEM and Sen, was the Rockefeller Foundation (Birn, 2014). Reproducing the work of the Flexner Report a half-century earlier, the Foundation had sent its vice-president, Alan Gregg, to survey all medical schools in India in 1952. Gregg found problems that were ‘exceedingly complex and enormous in magnitude’. ⁶⁸ Asserting an American vision of medical education based on the model of Johns Hopkins University’s, he encouraged Indian officials to invest in research-based schools with full-time paid faculty; in the existing British and Indian model, physicians in private practice worked part-time at hospitals and medical schools (Patel, 1991; Times of India, 1953b). The Foundation decided to support three medical schools, including KEM, hoping that these would provide transformative models of medical education. ⁶⁹ KEM appointed Sen as its first full-time professor of surgery.

The deans and the Foundation wanted Sen to be a researcher, and it was the act of research, not its topic, that mattered. Rockefeller officials sometimes seemed bemused by Sen’s research. When Anderson visited Sen’s lab in 1955, he found Sen testing how long he could maintain a beating heart after removing it from a dog. Anderson noted ‘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.’ ⁷⁰

The Rockefeller Foundation did not intervene unilaterally at KEM: its investment was contingent on matching support from the Bombay Municipal Corporation. City officials had sought to expand hospital capacity in Bombay since the 1920s (Ramanna, 2001). The Foundation agreed to fund the equipment needed to establish modern research laboratories in medicine, surgery, anatomy and pharmacology, and half the costs of new construction; the Municipal Corporation agreed to cover the other half of construction, as well as faculty salaries. ⁷¹ This relationship was not easy. Sen, Dean Joglekar, and Foundation officials complained that the Corporation failed to fund the promised positions. ⁷² The city commissioner blamed the lack of qualified candidates. ⁷³ The commissioner also expressed ambivalence about the project: ‘[T]he municipality has responsibility for medical care of the people in Bombay, but not for medical education.’ ⁷⁴

US physicians and officials had their own interests. Science was an explicit element of Cold War diplomatic strategy, from offering support to scientific education and training in the ‘Third World’, to showcasing the advances and spectacles of US science (Smith, 2014). There were formal (i.e. government sponsored) and informal (i.e. individual motivated) mechanisms. For some US physicians, most famously cardiologist Paul Dudley White, foreign visits built bridges in a world riven by Cold War tensions (Paul, 1986). The American College of Cardiology and the State Department, meanwhile, organized training courses in forty-four countries (including India) between 1961 and 1966. Cardiac surgeon Dwight Harken described how such a ‘selfless endeavor to teach and to learn constitutes an interface between the men that can transcend national and racial boundaries’. ⁷⁵ President Lyndon Johnson described the cardiologists as ‘ambassadors of goodwill’ and ‘envoys of hope’. But these trips were not simply about peace and kindness. Secretary of State Dean Rusk hoped that the courses would ‘demonstrate to the world America’s technical achievement’. ⁷⁶ At least one trip – to Saigon in 1964 – had the desired effect. As State Department officials described, ‘the materials and the data they presented were far beyond the comprehension of many of the doctors and students attending. This proved to be a favorable factor, since it dramatized American medical progress.’ ⁷⁷

Despite aggressive efforts by United States officials and doctors, Indian surgery, with inputs from many local and international interests, maintained a distinct character. ⁷⁸ Dastur and Sen studied and implemented US ideas, techniques and sometimes devices. But Dastur relied on his own local networks to enable his indigenous innovations in Bombay. Sen, meanwhile, sought to improve US techniques. He pursued training beyond the United States, making trips to Europe and the Soviet Union. He even received the Vishinsky Medal from the USSR in 1962 (Patel, 1991).

Replication, demonstration, or therapy?

By 1962, Dastur and Sen had implemented open-heart surgery with extra-corporeal circulation in India, having acquired heart-lung machines and the tacit knowledge needed to use them. But did they replicate operating room technology and practice as it existed in the West? Did they reverse engineer and innovate to produce something novel, with distinct meanings and purposes? Was it an exchange, translation, appropriation, or improvisation? Surviving sources provide a partial picture. At the broadest level, the situation for cardiac surgery in India and the United States remained quite different. In 1961, when Dastur performed the first open-heart operation in India, surgeons at 290 hospitals in the United States performed nearly 9000 open-heart surgeries (Crocetti, 1965). Lillehei’s team alone had done over 1000 open-heart operations (Lillehei and Engel, 1960). Dastur’s team, in contrast, repaired only fifty atrial septal defects between 1963 and 1968 (Desai et al., 1969). The KEM team performed only 700 open heart procedures by 1975 (Golden Jubilee Souvenir, 1976; Parulkar, 1984). Many factors contributed to this difference in scale. One was the ability of elite American surgeons to specialize in cardiovascular surgery. Surgeons in India often did not have this luxury. Dastur worked as a general surgeon throughout his career. ⁷⁹ Even as he developed open-heart surgery, Sen continued to publish about hernias, burns, duodenal perforation, reconstructive vascular surgery and liver surgery. One of Sen’s students, Chaukar was able to practice as a full-time cardiac surgeon starting in 1972, but such opportunities remained rare. ⁸⁰

Indian surgeons, who had to adapt to the challenges of Bombay’s unpredictable and often intransigent infrastructure, also worried that they had created sub-par surgical facilities. Lillehei had described the elaborate requirements of open-heart surgery, including dedicated spaces (laboratories, operating rooms, recovery rooms), apparatus (angiography equipment, heart-lung machines), a blood bank, and medical specialists (not just cardiac surgeons, but also cardiologists, radiologists, anesthesiologists, and perfusionists) (Lillehei, 1966). No institution in India in 1962 had all of these resources. Presiding over a meeting of the Indian Chapter of the International College of Surgeons, hosted by KEM in September 1950, Bombay surgeon RN Cooper acknowledged that ‘the hospital buildings in India were modest structures with equipment “hardly adequate for a modern up-to-date hospital”’ (Times of India, 1950b). Since Nair Hospital lacked a backup generator, Dastur’s intrepid team ran a backup power-line to the railway yard next door (Kalke and Magotra, 2010). As late as 1968, despite fifteen years of requests, Dastur had not managed to convince the municipal government to provide air conditioning in the operating room (Times of India, 1968). Sen’s team regretted the ‘obvious difficulty’ of ‘organising a truly “sterile–germ free” operating theatre, postoperative area, and attendants, particularly in conditions prevailing in a large general hospital in India’ (Kinare, 1968: 562). Other surgeons and anesthetists – both American and Indian – described similar problems in Indian surgical theaters in the 1960s and 1970s (Johnson, 2004; Punnoose, 2004). Improvisation was their only option.

Nonetheless, there is also evidence of successful transfer and translation. First, the Bombay surgeons were well versed in the medical literature of Europe and the United States. Sen, as described above, extensively cited Western journals. He analyzed the techniques of Western surgeons and sought to improve them. He then published his work in Western medical journals, including, among others, Surgery, British Journal of Surgery, British Heart Journal, Journal of Thoracic and Cardiovascular Surgery, American Journal of Cardiology, and Journal of Medical Education. Indian surgical ideas and practices could travel the globe.

Second, Bombay operating theaters were functional for open heart surgery. Dastur’s published reports included detailed accounts of anesthetic, perfusion, and surgical techniques (Dastur et al., 1964). When he attempted a heart transplant in 1968, Sen published exhaustive descriptions of every aspect of the procedure in both Indian and American journals (Jones and Sivaramakrishnan, 2018; Sen, 1968; Special Feature, 1968). A blinded reader would struggle to distinguish accounts of surgery published in Bombay, London, or Houston. Proof can be seen in the ability of Western surgeons, including DeBakey and London’s Douglas Ross to travel to Bombay and other Indian cities and perform sophisticated cardiac operations. Yes, Indian surgeons admitted that the visiting dignitaries ‘operated there in less than ideal conditions’ (Kalke and Magotra, 2010: 232). Yes, DeBakey had brought his own instruments with him, immutable mobiles that facilitated his work in foreign operating theaters. Nonetheless, Indian hospitals had assembled the basic facilities and personnel needed to enable such work.

Conclusions

By the end of the decade, Sen felt that the implementation of open-heart surgery had made a substantial contribution to India’s development. When he spoke before the Indian Science Congress in January 1969, an audience of India’s foremost scientists and science administrators, he lauded India’s medical progress and the part played by the successes in Bombay: ‘it was good that India did not lag behind other countries in the field of cardiac surgery’ (Times of India, 1969).

Indian physicians and health officials actively strategized to mobilize knowledge, technologies, and expertise and to bring them to India. They tapped international networks of medical exchange, facilitated by a newly fluid post-colonial order, and navigated its new power structures and actors. Some of the pathways were remnants and continuities of colonial medicine. Others were new and moved resources among diverse individuals and institutions (e.g. municipal hospitals in Bombay, hospitals and medical schools in the United States and England, charitable foundations, the Indian Council for Medical Research and the National Institutes of Health, etc.). Sen and Dastur achieved success in medical research not in the premier research institutes of the colonial era, but in new municipal institutions of independent India. By tracing the work required to make this possible, we have revealed the myriad interests that motivated the investments.

The complex interests, in turn, enabled multiple judgements of efficacy. Sen and Dastur had many goals and accomplishments: They built surgical research laboratories, they established collaborations with Bombay engineers, and they trained teams of physicians, technicians and nurses who acquired the tacit knowledge needed to perform the most technology-intensive forms of health care. They wanted to be on the ‘edge of progress’ and they could be there even if their initial patients did not survive. Their efforts imbued their devices with specific meanings, especially when the devices were manufactured in India. The Rockefeller Foundation, meanwhile, wanted Indian medical schools with full-time academic faculty. The deans of KEM wanted the prestige and funding that medical research could provide. Indian officials wanted collaborations between medicine and industry to develop indigenous manufacturing capacity so that they could boast on the world stage. United States officials and physicians, as well as the Rockefeller Foundation, pursued scientific diplomacy, technological expansion, and economic and political influence in the ‘Third World’, as did the Soviets. The State Department presumably saw the extent to which Sen and Dastur relied on US precedents as evidence of the success of the efforts to popularize the achievements of US science and medicine. These goals created multiple standards by which efficacy could be judged.

An equally complex concept of scientific mobility is also required. Whether developing local manufacturing capacity or orchestrating the networks required to import foreign devices, Indian surgeons and their allies made sustained efforts to bring heart-lung machine technology to India and to acquire the skills needed to use them. Diffusion does not capture the effort involved. Translation loses sight of the equipment and skills that traveled with words and ideas. Circulation and exchange miss the differentials of wealth and power. Transfer, meaning to bear across, describes literally what sometimes took place, with surgeons bringing heart-lung machines with them to India. It directs attention to the agency of actors, but does not convey the adaptation, appropriation, and improvisation that took place. Moreover, these were not simply scientific or medical processes, but were also economic, social, political and ideological transactions. Place and temporality were key: Bombay’s status as a center of commerce and industry, with philanthropic and professional networks (e.g. a tight-knit Parsi community with expertise in medicine and manufacturing), facilitated the establishment of heart surgery there. Rockefeller Foundation officials and elite international surgeons invested time and money in developing Bombay’s institutions and physicians. Intersecting interests colored negotiations among surgeons, engineers, government officials, funders and institutions, as each side hoped to gain from these transactions. Open-heart surgery in India exemplified individual enterprise made possible by complex networks of support. It demonstrated different modes of creativity as surgeons responded to state economic policies and restraints on imports either by circumventing them to tap foreign networks or accepting them and tapping local networks. This fostered complex valuations of indigeneity amid the politics of nationalist aspiration and decolonization. Simultaneously an experiment, a demonstration project, and a therapeutic endeavor, open-heart surgery in Bombay worked in many ways.