A Semi-Centennial Report on the Participants Depicted in Joel Babb's Portrait, ‘The First Successful Kidney Transplantation'

Authors


Abstract

Joseph Murray performed the first successful human kidney transplant on December 23, 1954. Forty-three years later, he along with participants Francis Moore and Leroy Vandam, commissioned a painting of the event from artist Joel Babb (1). To document this unique record of medical history, we identify all those present at the operation and depicted in the portrait, describe how the artist created the work, explain irregularities and inaccuracies in the painting, provide a 50-year follow-up on everyone involved, and comment on any influence this landmark event may have had on their subsequent careers.

Introduction

Richard and Ronald Herrick were born on June 15, 1931. They were identical twins. After a normal childhood, Richard developed progressive kidney disease. At the age of 23, he arrived at his local hospital in extremis in December 1954. His physician, David C. Miller, referred him to the Peter Bent Brigham, suggesting to those who accepted him that his normal identical brother donate a kidney. He chose the Brigham because of a long-standing interest in kidney disease among members of its staff. In spite of this interest, however, the notion was startling at the time as the few prior kidney transplants in animals and in humans had been invariably unsuccessful. The Brigham team (Francis Moore, Surgeon-in-Chief; George Thorn, Physician-in-Chief; Joseph Murray, surgeon; John Merrill, nephrologist; and Hartwell Harrison, urologist) endorsed the possibility of transplantation despite general opposition by many of their peers.

Permission to carry out the pair of unprecedented operations was secured from the patients, their families, lawyers, ethicists, and the clergy. Both procedures went relatively smoothly. The kidney functioned immediately, and the patient felt well for the first time in months (2–4). He married his nurse and fathered two children before glomerulonephritis recurred in the transplanted organ after several years. Richard died of renal failure at age 31, on March 14, 1963. He is survived by his wife, Clara B. Herrick of Scarborough, Maine, and daughters Marjorie Hinrichs, a dialysis nurse, and Linda Winslow, a teacher. Ronald recovered from surgery and has suffered no long-term consequence as a result of the gift made over 50 years ago (5). A retired professor of mathematics, he and his wife, Cynthia, live in Belgrade, Maine.

The first successful organ transplantation in history opened a vast clinical field in which the replacement of a variety of failing organs with the healthy organs of others has become a routine part of the surgical armamentarium. Tens of thousands of recipients throughout the world have benefited from new hearts, lungs, livers, pancreases, intestines, and kidneys. In addition, this experience has contributed to a variety of sciences including transplant biology, immunology, genetics, and pharmacology. It is arguably the most exciting medical advance of the second half of the 20th century.

The Artist and the Painting:

Moore, Vandam, and Murray commissioned Joel Marvin Babb to depict the Herrick transplant (Figure 1). Born on May 31, 1947, in Waycross, Georgia, Babb majored in art history at Princeton and later spent time in Europe studying the old masters. He taught for several decades at the School of the Museum of Fine Arts, Boston and at the Harvard Extension School. In 2003, he gave up teaching to pursue fulltime work at his private studio in Maine.

Figure 1.

Joel Babb, The First Successful Kidney Transplantation, 1996. Oil on canvas, 70″× 88″. The Harvard Medical Library in the Francis A. Countway Library of Medicine, Boston, Massachusetts. Reproduced with permission.

Primarily a landscape painter, his works portray complex scenes realistically. Although a portrayal of an operation was outside his prior experience, and despite the fact that the scrub clothes, headgear, and masks hid many identifying features of the various participants, he created a remarkably authentic scene. He was aided greatly by his three patrons who gave him photographs of the surgery and created a mock operating room to serve as a model. Babb also had to learn how a surgical team functions, how instruments and lights are placed, and the relationship between teams working in tandem.

The completed painting now hangs in the Francis A. Countway Library of Medicine at Harvard Medical School, facing Robert Cutler Hinckley's masterpiece, The First Operation With Ether (6). Like Hinckley, Babb painted the event a half century after it occurred. Physical details had changed substantially. To emphasize the importance of the primary participants, he had to place them in locations in the picture that they would not have been at the time. As disposable paper gowns and drapes had also replaced cotton fabric in the interim, the color, quality, and movement of the material were different from the original. He showed the scrub area separating the two operating rooms in darker hues, suggesting a progression from darkness to light, from unconsciousness to consciousness, and from ignorance to enlightenment; these all heralded a new era in modern surgery.

The Participants

Compared to many other monolithic and multi-storey medical institutions of the time, the Peter Bent Brigham had only 150 beds. Completed in 1912, the long low pavilion-styled buildings connected by a central walkway were built on the older sanitarium concept of isolating infections and pestilence. Although the architect won a prize for the design, many considered the structure outdated shortly after it was built. However, its smallness also facilitated a friendly, nurturing and trusting work environment. Its personnel knew each other well, allowing members of several disciplines to work closely and effectively. We will consider those involved with the transplant operation individually (Figure 2).

Figure 2.

The full name, clinical role, and signature of all participants involved in the two surgical procedures associated with the first successful kidney transplant in man. Drs. Burnap, Pincus, Milch and Crowe, as well as nurses Maxwell and Wheet were not identified. Nurses Rhodes and Comiskey were incorrectly and incompletely identified when the painting was unveiled (1).

The staff

Francis Daniels Moore was born in Evanston, Illinois, on August 17, 1913, and had graduated from Harvard Medical School. After training at Massachusetts General Hospital, he joined its faculty and was recruited as Surgeon-in-Chief at the Brigham Hospital shortly thereafter. Credited primarily with advances in the treatment of burned patients and in defining changes in body composition after surgical injury, starvation, and convalescence, his guidance encouraged staff surgeons, David Hume, Charles Hufnagel, and then Joseph Murray, to pursue their nascent interest in kidney transplantation and explore the subject first in the laboratory and then in patients. An indefatigable and imaginative leader, his support, interest, and enthusiasm caused a variety of innovations in both patient care and research to pour forth in a torrent during his nearly three decade long tenure. He recruited many talented surgeons to the Brigham in several evolving fields. Of dramatic propensities, he liked to be in charge, and at the center of activity. Thus, he chose to participate in the historic procedure by carrying the harvested organ from donor to recipient. Moore authored several books including Metabolic Care of the Surgical Patient, and Give and Take – The Development of Tissue Transplantation (7,8). Retiring from clinical practice in 1981, he became the Book Editor of the New England Journal of Medicine. A man of protean interests, he was an expert musician, composer of songs, actor, and sailor. He died on November 24, 2001, at age 88, in Westwood, Massachusetts.

Born in Buffalo, New York, on January 15, 1906, George Widmer Thorn graduated from medical school at the University of Buffalo. On the staff at Johns Hopkins, he would have been sent to support the war effort had not Soma Weiss, the chief of medicine at the Brigham died unexpectedly. One of the hospital's trustees knew President Franklin Delano Roosevelt well, thus clearing the path for Thorn to be recruited as chief of medicine in 1942. He remained in that position for over three decades. Thorn had broad medical interests. Among other important contributions, he introduced the use of cortisone in the treatment of Addison's disease and delineated the role of the kidneys and the adrenal glands in hypertension. Generations of physicians knew him as an editor of Harrison's Principles of Internal Medicine (9). He became medical advisor to Howard Hughes in the 1940s, encouraging him to support medical research. His efforts led to the establishment of the Howard Hughes Medical Institute (HHMI), where he served as director of research for over two decades. In 1997, The National Academy of Sciences (NAS) selected him as recipient of its prestigious Public Welfare Medal. An expert tennis player, he competed into his nineties, at the same time developing a well-known arboretum near Boston. He died on June 26, 2004, at the age of 98, in Beverly, Massachusetts.

Joseph Edward Murray was born on April 1, 1919, in Milford, Massachusetts and graduated from Harvard Medical School. He trained in plastic surgery, becoming highly experienced in the grafting of skin and reconstruction of soldiers burned during World War II. Returning to the staff of the Brigham Hospital, he pursued ongoing work in kidney transplantation in animals and humans. Among his early contributions were development with a French surgeon of the retroperitoneal iliac approach with the ureter to bladder anastomosis for kidney transplants, and the unequivocal and hitherto not generally accepted observation that transfer of a kidney from one site to another in dogs did not affect function. He convinced many of his dubious peers of the efficacy of the new transplant operation in a successful series of identical twins. His research fellow, Roy Calne, and he introduced chemical immunosuppression in a large number of recipients of cadaver and living donor organs. Perfecting and refining preliminary and unsuccessful work begun by others, he devoted two almost decades to transplantation, ushering the new field through many growing pains. His true passion led him to devote much of his subsequent career to the surgical treatment of craniofacial deformities and other plastic surgical endeavors. For opening an entirely new field he received numerous awards, culminating in the Nobel Prize in Physiology or Medicine in 1990, a prize rarely awarded to clinicians. A humble man, Murray was also a fierce competitor on the tennis court and on the squash court. He has been a mentor and friend to many in his two distinct fields of endeavor. He retired from clinical practice in 1986, and lives with his wife Virginia (Bobby), in Wellesley, Massachusetts.

John Putnam Merrill was born in Hartford, Connecticut, on March 10, 1917, and graduated from Harvard Medical School. During World War II he was assigned to Kwajelein Island in the Pacific, where he was flight surgeon assigned to the Enola Gay, the aircraft from which the atom bomb was released on Hiroshima. He spent his entire career thereafter in the Brigham Department of Medicine, and was a principal in introducing hemodialysis into clinical use. His research interests included examination of the host immune responses to a transplanted organ and their suppression with total body radiation or chemical agents. He was the director of the Kidney Research Laboratory and one of the key members of the team that evaluated the medical issues involved in attempting this untried surgical procedure. An author of several hundred scientific articles, he wrote the seminal textbook, The Treatment of Renal Failure (10). As a result of early self-experimentation, Merrill had become sensitized to leukocytes. Decades later, he developed high fever while receiving a blood transfusion after hip surgery. During the frantic workup for malignant hyperthermia, Merrill offered his self-diagnosis. His condition improved soon after the transfusion was discontinued. A strong swimmer and an avid sailor, he died on April 4, 1984, at age 67, in Hopetown, Commonwealth of the Bahamas.

Leroy David Vandam was born in New York City on January 19, 1914. He graduated from the New York College of Medicine and trained as a surgeon until an illness caused him to lose vision in one eye. Changing career plans, he then trained in anesthesiology at the University of Pennsylvania in Philadelphia. Recruited by Moore, he became chief of the Division of Anesthesia in the Department of Surgery at the Brigham Hospital in 1954. He provided the anesthetic to Richard Herrick, the recipient of his identical twin brother's kidney, administering tetracaine via a spinal catheter, an unusual approach at the time, but chosen because the patient was uremic with little dialysis backup. Vandam set high professional standards for himself and others, often reacting ferociously to slipshod or inadequate efforts by residents or staff. One errant resident noted, ‘It took me some time to realize, when I met his gaze under such circumstances, that the eye with the kindly expression was the glass one!' (11).

Vandam published hundreds of articles on topics ranging from nerve blocks, the risks and sequelae of spinal anesthesia, to historical articles on prominent physicians. He was editor-in-chief at the journal Anesthesiology from 1962–70. Along with Robert D. Dripps and James E. Eckenhoff, he authored the first American textbook of anesthesiology, Introduction to Anesthesia – The Principles of Safe Practice (12). In 1977, he was awarded the Distinguished Service Award by the American Society of Anesthesiologists, its highest award. An accomplished artist, some of his watercolors appeared on the cover of the Journal of the American Medical Association. He died on April 8, 2004, at the age of 90, in Westwood, Massachusetts.

Gustave John Dammin was born in New York City on September 17, 1911. He graduated from medical school at Cornell University, training in pathology at Columbia University in New York, and at Washington University in Saint Louis. While serving in the army in Puerto Rico, he began a career-long interest in tropical medicine and parasitology. He received the Legion of Merit for distinguished service during World War II, and in 1971 the highest military award for civilians, the Distinguished Public Service Medal of the Department of Defense. As pathologist for the clinical team, his important contributions included ensuring that the twins were identical by serial gross and histologic assessment of skin grafts placed between them. He retired as Pathologist-in-Chief at the Brigham in 1974, having built his department into one of the foremost in the nation. In his retirement on Nantucket Island, he identified the type of tick that is responsible for Lyme Disease. A subspecies is named after him [Ixodes dammini]. He died on October 11, 1991, at the age of 80, in Boston.

John Hartwell Harrison was born in Virginia, on February 16, 1909. After attending medical school at the University of Virginia, he completed surgical training at the Brigham where he became chief of the division of Urology. He led the team that performed the left donor nephrectomy and was responsible for subsequent donor operations for years. A detail not mentioned in most descriptions of the procedure was the temporary loss of control of the renal vessels, a technical problem corrected in subsequent operations. Harrison was also responsible for the ureterovescicular anastomosis in many recipients. He was the editor of Urology, one of the principal textbooks on urological surgery (13). An author of more than 140 articles, Harrison was awarded the Amory Prize of the American Academy of Arts and Sciences. The quintessential Southern gentleman and surgeon, Harrison's heart was always in Virginia, even after 50 years at the Brigham. He died on January 20, 1984, at the age of 74, in Boston. He had served on the Board of the University of Virginia for many years, and he deeply desired to be buried on its campus. When approached for such permission, Mrs. Harrison was informed that the only person buried on the hallowed grounds of the university was Thomas Jefferson himself. Not to be deterred thus, she visited the grounds as if on a picnic, finished her sandwich, dug a hole under a tree, and buried his ashes there (11).

Thomas Kelvin Burnap, a staff anesthesiologist at the Brigham, graduated from medical school at the University of Southern California, Los Angeles, California before joining the faculty. He administered general anesthesia to Ronald Herrick, the donor, using ether as the primary agent. He introduced the concept of preceptorships in anesthesia for medical students, which led many to pursue careers in anesthesiology. He died on August 24, 1975, at age 51, in Greenwich, Connecticut.

Residents

John Loring Rowbotham graduated from Harvard Medical School in 1946 and assisted Murray during the transplant as chief resident. A surgeon in a Mobile Army Surgical Hospital [MASH] unit during the Korean War, he used stored arteries to revascularize damaged limbs of the wounded. Although against orders, this procedure enabled his team to prevent many amputations. He taught a popular course in aseptic technique to the medical students for many years, attracting many of them into surgery. He had a distinguished career in general surgery at the New England Deaconess Hospital in Boston before retiring in 1986. He currently lives in Franconia, New Hampshire.

Edward Barton Gray graduated from Harvard Medical School in 1948 and was the senior resident on the operation. He practiced as a general surgeon at community and teaching hospitals in Massachusetts until his retirement in 1993. He currently lives with his wife, Mary Frances, in Wellesley, Massachusetts.

Daniel Edgar Pugh III graduated from Harvard Medical School in 1954 and was the intern on the case. He joined the Navy in 1955, serving at the Aviation Medical School in Pensacola, and later in Hawaii. He died on October 1, 1965, at age 36, in Visalia, California.

Murray Benjamin Pincus graduated from medical school at the University of Virginia in 1947. Coming to the Brigham Hospital from military service, he was the urology resident who assisted Harrison during the donor nephrectomy. After completing his training he returned to his native New York and spent his entire career at Mount Sinai Hospital and the City Hospital at Elmhurst. At age 83, he is still in active practice at these hospitals.

Robert Austin Milch graduated from Columbia University College of Physicians and Surgeons in 1953, after which he began surgical residency at the Brigham Hospital. He was the junior resident assisting Harrison. He later went to Johns Hopkins Hospital for training in orthopedic surgery and spent most of his surgical career there. In 1981, he founded a biotechnology firm, Igene Technologies, and was its Chairman until his death in Overlook, Maryland on January 26, 1991.

Charles Peter Crowe graduated from Harvard Medical School in 1954 and served as surgical resident assigned to the anesthesia service at the Brigham Hospital. He helped anesthesiologist Thomas Burnap care for the donor. His residency training was interrupted by military service, after which he trained as a pediatric surgeon and spent most of his career at the University of Arizona College of Medicine. Having retired from clinical practice in 2000, he lives in the suburbs of Tucson.

Nurses

Maxine Rhodes trained at Wesley Hospital in Wichita, Kansas, and was the scrub nurse who assisted Murray. She worked at the Brigham Hospital until 1956, after which she returned to Kansas. Now retired, she lives in Wichita, Kansas.

Elizabeth Ann Comiskey trained at Peter Bent Brigham Nursing School. She was the circulating nurse with Murray and an assistant nursing supervisor. She was a veteran of the Brigham operating room scene for several decades before retiring in 1964. She died in Dover, Massachusetts on February 26, 1975.

Miss Alice Maxwell and Miss Marian Wheet were the scrub and circulating nurses in the donor room. Both trained at Peter Bent Brigham Nursing School. Currently retired in Massachusetts, they reside in Abington and Weston, respectively.

Irregularities

The room in which the donor was operated on is depicted in the upper portion of the painting. If the artist were to draw the scene accurately, either the donor would occupy the foreground or a front view of Merrill could not be accommodated, since he was operating from the recipient's right. As there was no alcove between the rooms, the nurse shown there is fictional. The presence of Thorn, Murray, Dammin, and Harrison at the doorway is also fictional. The former three certainly followed the progress of the 5-h operation closely, but were never present as a group in close proximity to the room. Scrub gear in the 1950s was made from green cloth, unlike the present-day style blue shown in the painting. Harrison is shown standing at the open door, yet he or an extra surgeon also appears to be at work on the donor. These inaccuracies are a reflection of artistic license, and may actually enhance the impact of the scene portrayed.

Conclusions

Many consider the discovery of anesthesia and the development of organ transplantation to be the most important surgical advances in the 19th and 20th centuries, respectively (3,4,14). Both these events were celebrated and rendered into masterful paintings in the imposing lobby of the Francis A. Countway Library of Medicine of Harvard Medical School; Hinckley's and Babb's paintings depicting the two events command attention while adorning opposite walls.

Here we provide many hitherto unavailable details and a 50-year follow-up of the participants shown in one of these paintings. Until now, not much was known about the donor team other than the surgeon, J. Hartwell Harrison. We have identified and explained several irregularities in the scene portrayed. All individuals are correctly identified, and copies of their signatures provided. Unfortunately, the noteworthy event that launched transplantation medicine did not significantly affect the careers of most of the participants.

Acknowledgments

The authors wish to thank Drs. Murray, Rowbotham, Gray, Pincus, and Crowe; Ms. Rhodes, Ms. Wheet, Ms. Maxwell, and surviving family members of participants for their help. In addition, we wish to thank the many members of Brigham and Women's Hospital who provided leads on how information and family members could be located. Lastly, we wish to thank the artist for providing details about how the work was created.

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