Christiaan Barnard

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Christiaan Barnard
Christiaan Barnard in 1969
Born
Christiaan Neethling Barnard

(1922-11-08)8 November 1922
Beaufort West, Cape Province, Union of South Africa
Died2 September 2001(2001-09-02) (aged 78)
Paphos, Cyprus
EducationUniversity of Cape Town
University of Minnesota
Years active1950–2001
Known forfirst successful human-to-human heart transplant.
RelativesMarius Barnard
Medical career
ProfessionSurgeon
InstitutionsGroote Schuur Hospital
University of Minnesota
Sub-specialtiesCardiothoracic surgery
Heart transplantation

Christiaan Neethling Barnard (8 November 1922 – 2 September 2001) was a South African cardiac surgeon who performed the world's first human-to-human heart transplant on December 3, 1967,[1] and the second overall heart transplant (Hardy did a xenotransplant in 1964[2]). Growing up in Beaufort West, Cape Province, he studied medicine and worked in that field for several years in his native country.[3] In 1955, he travelled to the United States for postgraduate training under open heart surgery pioneer Walt Lillehei, where he first became acquainted with the future heart transplantation surgeon Norman Shumway.[4] Upon returning to South Africa in 1958, Barnard was appointed head of the Department of Experiment Surgery at the Groote Schuur Hospital, Cape Town.[5]

On 3 December 1967, Barnard transplanted a heart from a person who had just died from a head injury, with full permission of the donor's family, into the chest of a 54-year-old Louis Washkansky. Washkansky regained full consciousness and lived for eighteen days, even spending time with his wife, before he died of pneumonia, with the reduction of his immune system by the anti-rejection drugs being a major contributing factor.[3][6] However, Barnard's second transplant patient Philip Blaiberg at the beginning of 1968 lived for nineteen months and was able to go home from the hospital.[3][7]

He retired as Head of the Department of Cardiothoracic Surgery in Cape Town in 1983 after developing rheumatoid arthritis in his hands which ended his surgical career. He became interested in anti-aging research, and in 1986 his reputation suffered when he promoted Glycel, an expensive "anti-aging" skin cream, whose approval was withdrawn by the United States Food and Drug Administration soon thereafter. During his remaining years, he established the Christiaan Barnard Foundation, dedicated to helping underprivileged children throughout the world. He died in 2001 at the age of 78 after an asthma attack.

Early life

Barnard grew up in Beaufort West, Cape Province, Union of South Africa. His father, Adam Barnard, was a minister in the Dutch Reformed Church.[8] One of his four brothers, Abraham, was a "blue baby" who died of a heart problem at the age of three (Barnard would later guess that it was tetralogy of Fallot). The family also experienced the loss of a daughter who was stillborn and who had been the fraternal twin of Barnard's older brother Johannes, who was twelve years older than Chris.[9] Barnard matriculated from the Beaufort West High School in 1940, and went to study medicine at the University of Cape Town Medical School, where he obtained his MB ChB in 1945.

His father served as a missionary to mixed-race people and consequently was largely shunned by South African white citizens. His mother, the former Maria Elisabeth de Swart, instilled in the surviving brothers the belief that they could do anything they set their minds to.[3]

Career

Barnard did his internship and residency at the Groote Schuur Hospital in Cape Town, after which he worked as a general practitioner in Ceres, a rural town in the Cape Province.[8] In 1951, he returned to Cape Town where he worked at the City Hospital as a Senior Resident Medical Officer, and in the Department of Medicine at the Groote Schuur Hospital as a registrar.[8] He completed his master's degree, receiving Master of Medicine in 1953 from the University of Cape Town. In the same year he obtained a doctorate in medicine (MD) from the same university for a dissertation titled "The treatment of tuberculous meningitis".

Soon after qualifying as a doctor, Barnard performed experiments on dogs investigating intestinal atresia, a birth defect which allows life-threatening gaps to develop in the intestines. He followed a medical hunch that this was caused by inadequate blood flow to the fetus. After nine months and forty-three attempts, Barnard was able to reproduce this condition in a fetus puppy by tying off some of the blood supply to a puppy's intestines and then placing the animal back in the womb, after which it was born some two weeks later, with the condition of intestinal atresia. He was also able to cure the condition by removing the piece of intestine with inadequate blood supply. The mistake of previous surgeons had been attempting to reconnect ends of intestine which themselves still had inadequate blood supply. To be successful, it was typically necessary to remove between 15 and 20 centimeters of intestine (6 to 8 inches). Jannie Louw used this innovation in a clinical setting, and Barnard's method saved the lives of ten babies in Cape Town. This technique was also adapted by surgeons in Britain and the US.[10]

In December 1955, Barnard traveled to the University of Minnesota, Minneapolis, United States, to begin a two-year scholarship for postgraduate training in cardiothoracic surgery under open-heart surgery pioneer Walt Lillehei.[11] It was during this time that Barnard first became acquainted with fellow future heart transplantation surgeon Norman Shumway.[4][8] Owen Wangensteen initially assigned Barnard more work on the intestines, which Barnard accepted even though he wanted to move on.[12] Simply by good luck, when Barnard needed a break from this experimental work, he could wander across the hall and talk with Vince Gott who ran Lillehei's lab. Gott had begun to develop a technique of running blood backwards through the veins of the heart so Lillehei could more easily operate on the aortic valve (about which McRae writes, "It was the type of inspired thinking that entranced Barnard").[13] In March 1956, Gott asked Barnard to help him run the heart-lung machine for an operation. Shortly thereafter, Wangensteen agreed to let Barnard switch to Lillehei's service. Barnard also became friendly with Gil Campbell who had demonstrated that a dog's lung could be used to oxygenate blood during open-heart surgery. (The year before Barnard arrived, Lillehei and Campbell used this procedure for twenty minutes during surgery on a 13-year-old boy with ventricular septal defect, and the boy made a full recovery.) Barnard and Campbell met regularly for early breakfast.[14] In 1958, Barnard received a Master of Science in Surgery for a thesis titled "The aortic valve – problems in the fabrication and testing of a prosthetic valve".[8] The same year he was awarded a Ph.D. for his dissertation titled "The aetiology of congenital intestinal atresia".[8] Barnard described the two years he spent in the United States as "the most fascinating time in my life."

Upon returning to South Africa in 1958, Barnard was appointed head of the Department of Experimental Surgery at Groote Schuur hospital, as well as holding a joint post at the University of Cape .[5][15] He was promoted to full-time lecturer and Director of Surgical Research at the University of Cape Town. In 1960, he flew to Moscow in order to meet Vladimir Demikhov, a top expert on organ transplants[16] (later he credited Demikhov's accomplishment saying that "if there is a father of heart and lung transplantation then Demikhov certainly deserves this title.")[17] In 1961 he was appointed Head of the Division of Cardiothoracic Surgery at the teaching hospitals of the University of Cape Town. He rose to the position of Associate Professor in the Department of Surgery at the University of Cape Town in 1962. Barnard's younger brother Marius, who also studied medicine, eventually became Barnard's right-hand man at the department of Cardiac Surgery.[8] Over time, Barnard became known as a brilliant surgeon with many contributions to the treatment of cardiac diseases, such as the Tetralogy of Fallot and Ebstein's anomaly. He was promoted to Professor of Surgical Science in the Department of Surgery at the University of Cape Town in 1972. In 1981, Barnard became a founding member of the World Cultural Council.[18] Among the many awards he received over the years, he was named Professor Emeritus in 1984.

Historical context

Following the first successful kidney transplant in 1953, in the United States, Barnard performed the second kidney transplant in South Africa in October 1967, the first being done in Johannesburg the previous year.[19][page needed][20]

On 23 January 1964, James Hardy at the University of Mississippi Medical Center in Jackson, Mississippi, performed the world's first heart transplant and world's first cardiac xenotransplant by transplanting the heart of a chimpanzee into a desperately ill and dying man. This heart did beat in the patient's chest for approximately 60 to 90 minutes. The patient, Boyd Rush, died without ever regaining consciousness.[2][21][22][23][24][25]

Barnard had experimentally transplanted forty-eight hearts into dogs, which was about a fifth the number that Adrian Kantrowitz had performed at Maimonides Medical Center in New York and about a sixth the number Norman Shumway had performed at Stanford University in California. Barnard had no dogs which had survived longer than ten days, unlike Kantrowitz and Shumway who had had dogs survive for more than a year.[26][27] [28]

With the availability of new breakthroughs introduced by several pioneers, also including Richard Lower at the Medical College of Virginia, several surgical teams were in a position to prepare for a human heart transplant.[8][29] Barnard had a patient willing to undergo the procedure, but as with other surgeons, he needed a suitable donor.[8][28]

During the Apartheid era in South Africa, non-white persons and citizens were not given equal opportunities in the medical professions. At Groote Schuur hospital, Hamilton Naki was an informally taught surgeon. He started out as a gardener and cleaner. One day he was asked to help out with an experiment on a giraffe. From this modest beginning, Naki became principal lab technician, helped teach over 3,000 surgeons, and assisted with Barnard's organ transplant program. Barnard said, "Hamilton Naki had better technical skills than I did. He was a better craftsman than me, especially when it came to stitching, and had very good hands in the theatre." People have differing recollections about whether Naki was present during the Washkansky transplant.[30]

First successful heart transplant

Barnard performed the world's first human-to-human heart transplant operation in the early morning hours of Sunday 3 December 1967.[1][3][31] Louis Washkansky, a 54-year-old grocer who was suffering from diabetes and incurable heart disease, was the patient.[6][32] Barnard was assisted by his brother Marius Barnard, as well as a team of thirty persons. The operation lasted approximately six hours.[28][33]

Barnard stated to Washkansky and his wife Ann Washkansky that the transplant had an 80% chance of success.[34][35][36] This has been criticized by the ethicists Peter Singer and Helga Kuhse as making claims for chances of success to the patient and family which were "unfounded" and "misleading".[37]

Barnard later wrote, "For a dying man it is not a difficult decision because he knows he is at the end. If a lion chases you to the bank of a river filled with crocodiles, you will leap into the water, convinced you have a chance to swim to the other side." The donor heart came from a young woman, Denise Darvall, who had been rendered brain dead in an accident on 2 December 1967, while crossing a street in Cape Town.[8] On examination at Groote Schuur hospital, Darvall had two serious fractures in her skull, with no electrical activity in her brain detected, and no sign of pain when ice water was poured into her ear.[38] Coert Venter and Bertie Bosman requested permission from Darvall's father for Denise's heart to be used in the transplant attempt.[39] The afternoon before his first transplant, Barnard dozed at his home while listening to music. When he awoke, he decided to modify Shumway and Lower's technique. Instead of cutting straight across the back of the atrial chambers of the donor heart, he would avoid damage to the septum and instead cut two small holes for the venae cavae and pulmonary veins.[40] Prior to the transplant, rather than wait for Darvall's heart to stop beating, at his brother Marius Barnard's urging, Christiaan had injected potassium into her heart to paralyse it and render her technically dead by the whole-body standard.[8] Twenty years later, Marius Barnard recounted, "Chris stood there for a few moments, watching, then stood back and said, 'It works.'"[8][28]

Washkansky survived the operation and lived for 18 days. However, he succumbed to pneumonia as he was taking immunosuppressive drugs.

Additional heart transplants

Barnard was celebrated around the world for his accomplishment. He was photogenic, and enjoyed the media attention following the operation.

Worldwide, approximately 100 transplants were performed by various doctors during 1968.[41] Only a third of these patients lived longer than three months. A U.S. National Institutes of Health publication states, "Within several years, only Shumway's team at Stanford was attempting transplants."[29]

However, Barnard's second transplant operation was conducted on 2 January 1968, and the patient, Philip Blaiberg, survived for 19 months.[3][7] Dirk van Zyl, who received a new heart in 1971, was the longest-lived recipient, surviving over 23 years.[42]

Between December 1967 and November 1974 at Groote Schuur Hospital in Cape Town, South Africa, ten heart transplants were performed, as well as a heart and lung transplant in 1971. Of these ten patients, four lived longer than 18 months, with two of these four becoming long-term survivors. One patient lived for over thirteen years and another for over twenty-four years.[43]

Full recovery of donor heart function often takes place over hours or days, during which time considerable damage can occur. Other deaths to patients can occur from pre-existing conditions. For example, in pulmonary hypertension the patient's right ventricle has often adapted to the higher pressure over time and, although diseased and hypertrophied, is often capable of maintaining circulation to the lungs. Barnard designed the idea of the heterotopic (or "piggy back" transplant) in which the patient's diseased heart is left in place while the donor heart is added, essentially forming a "double heart". Barnard performed the first such heterotopic heart transplant in 1974.[43][44]

From November 1974 to December 1983, forty-nine consecutive heterotopic heart transplants on 43 patients were performed at Groote Schuur. Survival rates for patients at one year were over 60% as compared to less than 40% with standard transplants, and survival rates at five years were over 36% as compared to less than 20% with standard transplants.[43]

Many surgeons gave up cardiac transplantation due to poor results, often due to rejection of the transplanted heart by the patient's immune system. Barnard persisted until the advent of cyclosporine, an effective immunosuppressive drug, which helped revive the operation throughout the world. He also attemptedxenograft transplantation in a human patient, while attempting to save the life of a young girl unable to leave artificial life support after a second aortic valve replacement.

Public life

Christiaan Barnard in Italy in 1968

Barnard was an outspoken opponent of South Africa's laws of apartheid, and was not afraid to criticise his nation's government, although he had to temper his remarks to some extent to travel abroad.[citation needed] Rather than leaving his homeland, he used his fame to campaign for a change in the law. Christiaan's brother, Marius Barnard, went into politics, and was elected to the legislature on an anti-apartheid platform. Barnard later stated that the reason he never won the Nobel Prize in Physiology or Medicine was probably because he was a "white South African".[45]

Personal life

Barnard's first marriage was to Aletta Gertruida Louw, a nurse, whom he married in 1948 while practising medicine in Ceres. The couple had two children — Deirdre (born 1950) and Andre (1951–1984).[8][46] International fame took a toll on his personal life, and in 1969, Barnard and his wife divorced. In 1970, he married heiress Barbara Zoellner when she was 19, the same age as his son, and they had two children — Frederick (born 1972) and Christiaan Jr. (born 1974).[47] He divorced Zoellner in 1982.[47] Barnard married for a third time in 1988 to Karin Setzkorn, a young model.[47] They also had two children, Armin (born 1990) and Lara (born 1997), but this last marriage also ended in divorce in 2000.[47]

Barnard described in his autobiography The Second Life a one-night extramarital affair with Italian film star Gina Lollobrigida,[8][48] that occurred in January 1968. During that visit to Rome he received an audience from Pope Paul VI.[49]

In October 2016, U.S. Congresswoman Ann McLane Kuster (D-NH) stated that Barnard sexually assaulted her when she was 23 years old. According to Kuster, he attempted to grope her under her skirt, while seated at a business luncheon with Rep. Pete McCloskey (R-CA), whom she was a staffer for at the time.[50][51][52]

Retirement

Barnard retired as Head of the Department of Cardiothoracic Surgery in Cape Town in 1983 after developing rheumatoid arthritis in his hands which ended his surgical career. He had struggled with arthritis since 1956, when it was diagnosed during his postgraduate work in the United States.[8] After retirement, he spent two years as the Scientist-In-Residence at the Oklahoma Transplantation Institute in the United States and as an acting consultant for various institutions.

He had by this time become very interested in anti-aging research, and his reputation suffered in 1986 when he promoted Glycel, an expensive "anti-aging" skin cream, whose approval was withdrawn by the United States Food and Drug Administration soon thereafter.[3] He also spent time as a research advisor to the Clinique la Prairie, in Switzerland, where the controversial "rejuvenation therapy" was practised.[53]

Barnard divided the remainder of his years between Austria, where he established the Christiaan Barnard Foundation, dedicated to helping underprivileged children throughout the world, and his game farm in Beaufort West, South Africa.

Death

Christiaan Barnard died on 2 September 2001, while on holiday in Paphos, Cyprus. Early reports stated that he had died of a heart attack, but an autopsy showed his death was caused by a severe asthma attack.[54]

Books

Christiaan Barnard wrote two autobiographies. His first book, One Life, was published in 1969 and sold copies worldwide. Some of the proceeds were used to set up the Chris Barnard Fund for research into heart disease and heart transplants in Cape Town. His second autobiography, The Second Life, was published in 1993, eight years before his death.

Apart from his autobiographies, Dr Barnard also wrote several other books including:

  • The Donor
  • Your Healthy Heart
  • In The Night Season
  • The Best Medicine
  • Arthritis Handbook: How to Live With Arthritis
  • Good Life Good Death: A Doctor's Case for Euthanasia and Suicide
  • South Africa: Sharp Dissection
  • 50 Ways to a Healthy Heart
  • Body Machine

See also

References

  1. ^ a b S Afr Med J, "The operation. A human cardiac transplant: an interim report of a successful operation performed at Groote Schuur Hospital, Cape Town", Barnard CN, 1967 Dec 30; 41(48): 1271–74.
  2. ^ a b Heart Transplantation in Man: Developmental Studies and Report of a Case, JAMA (Journal of the American Medical Association), James D. Hardy, MD; Carlos M. Chavez, MD; Fred D. Kurrus, MD; William A. Neely, MD; Sadan Eraslan, MD; M. Don Turner, PhD; Leonard W. Fabian, MD; Thaddeus D. Labecki, MD; 188(13): 1132-1140; June 29, 1964.
  3. ^ a b c d e f g Altman, Lawrence K. (3 September 2001). "Christiaan Barnard, 78, Surgeon For First Heart Transplant, Dies". The New York Times. Retrieved 30 January 2017.
  4. ^ a b Christiaan Barnard, J Invest Surg. 2010 Apr;23(2):72-8. " . . under pioneer surgeons C. Walton Lillehei and Richard L. Varco. Many future distinguished cardiac surgeons, such as Shumway, Cabrol, and many others, were his contemporaries at Minnesota. . "
  5. ^ a b Christiaan Barnard: his first transplants and their impact on concepts of death, Raymond Hoffenberg, BMJ, 2001 Dec 22; 323(7327): 1478–1480.
  6. ^ a b Louis Washkansky (1913 – 1967), Science Museum. Louis was born in Lithuania in 1913 and moved to South Africa in 1922.
  7. ^ a b Philip Blaiberg was dying—this time for certain, Chicago Tribune, Mrs. Philip Blaiberg, Oct. 12, 1969, page 68.
  8. ^ a b c d e f g h i j k l m n o Every Second Counts: The Race to Transplant the First Human Heart, Donald McRae, Berkley Publishing (Penguin Group), 2006.
  9. ^ Every Second Counts, McRae page 46.
  10. ^ Every Second Counts, McRae, pages 48–49.
  11. ^ Every Second Counts, McRae, page 49.
  12. ^ Every Second Counts, McRae, page 51.
  13. ^ Every Second Counts, McRae, page 53.
  14. ^ Every Second Counts, McRae, page 54.
  15. ^ Dictionary of African Biography, Volume 6, Emmanuel Kwaku Akyeampong, Henry Louis Gates, Jr., editors-in-chief, Barnard, Christiaan Neethling, Anne Digby, Oxford University Press, 2012.
  16. ^ Bosco, Teresio (1968) Uomini come noi, Società Editrice Internazionale
  17. ^ Fricke, T. A.; Konstantinov, I. E. (2013) Dawn and Evolution of Cardiac Procedures, Springer
  18. ^ "About Us". World Cultural Council. Retrieved 8 November 2016.
  19. ^ Barnard, Marius. Defining Moments.
  20. ^ Lederer, Susan E. (2008). Flesh and Blood: Organ Transplantation and Blood Transfusion in Twentieth-Century America. Oxford University Press. p. 174. ISBN 978-0-19-516150-2.
  21. ^ A brief history of cross-species organ transplantation, Baylor University Medical Center Proceedings, David K. C. Cooper MD, PhD, 2012 Jan; 25(1): 49–57.
  22. ^ James Hardy, Obituary, The Telegraph [UK], March 20, 2003.
  23. ^ Every Second Counts, McRae, Ch. 7 "Mississippi Gambling", pages 123–27.
  24. ^ "James D. Hardy, 84, Dies; Paved Way for Transplants – Obituary; Biography". NYTimes.com. 21 February 2003. Retrieved 24 January 2010.
  25. ^ Dr. James D. Hardy, University of Mississippi Medical Center (Bio Sketch).
  26. ^ A new heart, a new era, The Guardian, Donald McRae, June 25, 2006.
  27. ^ Every Second Counts, McRae, page 190.
  28. ^ a b c d "Memories of the Heart". Daily Intelligencer. Doylestown, Pennsylvania. 29 November 1987. p. A-18.
  29. ^ a b The Adrian Kantrowitz Papers, Replacing Hearts: Left Ventricle Assist Devices and Transplants, 1960–1970, National Institutes of Health, U.S. National Library of Medicine. " . . Two Stanford surgeons, Norman Shumway and Richard Lower, had started transplanting dog hearts while experimenting with hypothermia during the late 1950s. . "
  30. ^ Film on black surgeon in first heart transplant team rekindles controversy, The Guardian (UK), David Smith, 31 May 2009. Refers to documentary film Hidden Heart about Hamilton Naki.
  31. ^ Milestones in Cardiac Care, Los Angeles Times, Jill Gottesman, March 20, 1988.
  32. ^ 1967: First Heart Transplant Patient Goes Under the Knife, Haaretz, This Day in Jewish History, David B. Green, 3.12.2013. " . . When he was 9, his mother took him [Louis Washkansky] and his three siblings to Cape Town, to join their father, who had come ahead of the family . . "
  33. ^ Every Second Counts, McRae, 2006, pages 191-96.
  34. ^ Calculated Risks: How to Know When Numbers Deceive You, Gerd Gigerenzer, Simon & Schuster, 2002.
  35. ^ Every Second Counts, McRae, pages 176, 190.
  36. ^ Ethics of Scientific Research, Kristin Shrader-Frechette, Rowman & Littlefield, 1994, page 38. Along a similar line, this author states, "Barnard's failure to tell Washkansky's wife that her husband was dying," although it's not clear whether this was pre- or post-transplant.
  37. ^ A Companion to Bioethics, Second Edition, Helga Kuhse, Peter Singer, Wiley-Blackwell, 2012.
  38. ^ Every Second Counts, McRae, 2006, p. 188.
  39. ^ Every Second Counts, McRae, page 189, "Coert Venter . . [and] Bertie Bosman . . withdrew, stressing that he should take as long as he needed to consider their request. They would understand if he declined to give his consent." Edward Darvall took four minutes to reach his decision, mainly thinking about his daughter, including how she tried to help others. He then told the doctors, "If you can't save my daughter, you must try and save this man."
  40. ^ Every Second Counts, McRae, 2006, page 187.
  41. ^ MAJOR MEDICAL MILESTONES LEADING UP TO THE FIRST HUMAN HEART TRANSPLANTATION, Kate Elzinga, from Proceedings of the 18th Annual History of Medicine Days Conference 2009: The University of Calgary Faculty of Medicine, Alberta, Canada, Cambridge Scholars Publishing, 2011. " . . following Barnard's landmark heart transplantation on December 3, 1967, 107 human heart transplants were performed by 64 surgical teams in 24 countries in 1968. . "
  42. ^ "Dirk van Zyl, 68; Had '71 Transplant". New York Times. 7 July 1994. Retrieved 28 March 2009.
  43. ^ a b c Transplantation of the heart: An overview of 40 years' clinical and research experience at Groote Schuur Hospital and the University of Cape Town, South African Medical Journal, "Part I. Surgical experience and clinical studies." J Hassoulas, Vol. 102, No. 6 (2012).
  44. ^ "A tale of two hearts", Postgrad Medical Journal, 27 July 2016. "... HHT [Heterotopic Heart Transplantation] involves transplanting the donor heart without removing the recipient heart, effectively forming a 'double heart'. It was widely used in the pre-cyclosporine era when the donor was not strong enough (eg, the recipient had a much larger body) or the recipient had pre-existing pulmonary hypertension. Christiaan Barnard performed the first HHT ('piggy back' transplant) in 1974 ..."
  45. ^ "It's the quality of survival that's important". Hinduonnet.com (31 October 1997). Retrieved on 2015-06-30.
  46. ^ "Christiaan Barnard, celebrated pioneer of heart transplant surgery, dies aged 78", The Independent, 3 September 2001. Retrieved 18 September 2010.
  47. ^ a b c d "Christiaan Barnard Biography". Retrieved 10 June 2009.
  48. ^ Barnard, Chris (1994). Druhý dech [The Second Life] (in Czech). Prague: Lidové noviny. pp. 70–71. ISBN 80-7106-096-8.
  49. ^ "Pope Tells Barnard Of 'Heart' Prayers". Pittsburgh: Pittsburgh Post-Gazette. 30 January 1968. Retrieved 8 October 2016.
  50. ^ http://www.dailyherald.com/article/20161013/news/310139819/
  51. ^ http://www.nh1.com/news/rep-annie-kuster-tells-concord-monitor-famous-doctor-sexually-assaulted-her-decades-ago/
  52. ^ http://www.usnews.com/news/politics/articles/2016-10-13/trump-comments-prompt-congresswoman-to-share-assault-story
  53. ^ Cooper, David K. C. (3 September 2001). "Obituary: Christiaan Barnard". The Guardian. Retrieved 2 December 2013.
  54. ^ "Autopsy confirms asthma killed Barnard". Cyprus Mail. 5 September 2001. Archived from the original on 27 September 2007. Retrieved 15 March 2007.

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