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The Nobler Angels of Our Nature

2013; Lippincott Williams & Wilkins; Volume: 131; Issue: 4 Linguagem: Inglês

10.1097/prs.0b013e31828aaf23

1529-4242

Elof Eriksson, Rod J. Rohrich, David H. Sachs, Bohdan Pomahač, Francis L. Delmonico, Edward J. Caterson, Robert M. Goldwyn,

Organ and Tissue Transplantation Research

PERSONAL REFLECTIONS FROM THE EDITOR-IN-CHIEF One happy aspect of plastic and reconstructive surgery is that in our specialty, we have the privilege of contributing to the lives of patients. In the experimental, reconstructive, and aesthetic branches of our specialty, ours is the advantage of being able to help patients improve the quality of their lives. Regardless of how patients come to our offices or operative suites, they always leave functioning or looking better than when they arrived. Thankfully, morbidity and mortality in our field are exceptionally low. When we perform a surgery—the intentional mutilation of a patient's existent flesh, with the intention of correcting, fixing, repairing, or enhancing it—excellent outcomes are expected and achieved with the vast majority of patients. This ability to help patients remains a compelling and sufficient raison d'être for most plastic surgeons; it was what made me want to be a plastic surgeon many years ago. Such was not always the case, and the current generations of plastic surgeons owe their remarkable success and superlative outcomes to an initially more grim and perilous specialty: that of organ transplantation. Only 60 years ago, patients needing a new kidney, or liver, or lung, or heart, had little hope. Survival was not even the exception back then. In the face of this grave prospect, a few brave patients with nothing to lose willingly gave themselves over to a handful of pioneer transplantation surgeons who were equally desperate to find a way to give life to their patients. On December 23, 1954, the first successful organ transplant took place, a kidney transplant. The living pioneer who not only performed the first organ transplant but also bridged over to reconstructive surgery was our specialty's first (and currently only) Nobel Prize winner, Joseph E. Murray, M.D. Today we are the inheritors of many lessons that were hard-learned by people such as Dr. Murray. His renowned achievements and expertise are well known in many plastic surgery subspecialties: head and neck cancer surgery, trauma, craniofacial surgery, microsurgery, transplantation, skin grafts, and plastic surgery basic science. While winning a Nobel Prize certainly casts before its winners an aura of respect, significance, and perhaps even fear or intimidation, what is so striking about Dr. Murray was the very approachable, humble, and humane man who remained present after history ascribed him greatness. Despite the painful and withering defeats of his early career, when he saw patient after patient die; despite an overwhelming workload and curiosity that bordered on the insatiable; and then despite overwhelming notoriety and public success, Joseph Murray always retained his center and stayed true to his convictions. As Abraham Lincoln closed his first inaugural address with the impassioned plea for Americans to remain united and to be touched “by the better angels of our nature,” so Joe Murray's life served as an exhortation to us all, to be and give our best according to the nobler angels of our nature. The Journal has created an article collection of Dr. Murray's seminal articles on the PRSJournal.com Web site. I encourage you to read his articles and also see what others wrote about Dr. Murray during his lifetime. Below, Dr. Elof Eriksson provides an account of Dr. Murray's life, a chronicle of the man behind the Nobel Prize. We then move to personal vignettes from others who knew and worked with Dr. Murray. David Sachs, Director, Transplantation Biology Research Center, Massachusetts General Hospital, recalls how Dr. Murray made others feel important. Bohdan Pomahac, Director of Plastic Surgery Transplantation, Brigham and Women's Hospital, was impressed with the apparently contradictory simplicity, complexity, and curiosity embodied by Dr. Murray. Dr. Francis L. Delmonico, President of The Transplantation Society, reminiscences about Dr. Murray's wisdom in his seminal thoughts on death and on his opposition to the sale of human organs. Dr. Edward J. Caterson, craniofacial and plastic surgeon at Brigham and Women's Hospital, remembers the surgical (and life) lesson imparted by Dr. Murray: “Keep going! Do not stop!” Lastly, we stir the echoes of another giant of plastic surgery and reprint an editorial by Robert M. Goldwyn, friend and student of Dr. Murray. As for me personally, I most vividly and fondly remember Dr. Murray's visit to hear me lecture when I was a visiting professor at Harvard Medical School. I was pleased (but taken aback) that Dr. Murray attended all of my lectures—nearly 12 hours of talks!—and then came up to me afterward to ask me questions. He wanted to learn from me, and his questions simultaneously both impressed and humbled me. He was always a very positive man, full of questions, selfless, and generous. Dr. Murray was always thinking about what would come next, and he devoted himself to helping others get there. Enjoying what was good in life and making things even better were two of the driving forces of his life. Even now, I find myself smiling when I think of him, and he will always be “Dr. Murray” to me. May we thrive in his shadow, and move forward to honor his memory. Joseph E. Murray, M.D., 1919 to 2012 On April 1st of 1919, the Lord was particularly generous (modified from Jack London: An Odyssey to the North). Joe Murray was given a great mind, an athlete's body, common sense, compassion, and generosity. He excelled academically and on the field, where he played both offense and defense in football and also was captain of the baseball team his senior year. He later became a superb tennis player, as did his wife, Bobby; they played together every week (Fig. 1).Fig. 1: Dr. Joseph E. Murray (in 2004).At the College of the Holy Cross, he excelled in his studies in philosophy and English, earning a degree in humanities in 1940. Upon graduation he entered Harvard Medical School in 1940, just after the beginning of World War II. His class, 1943B, was abbreviated in order to educate more physicians to join the Armed Forces. After graduation, he did 1 year of surgical internship at Peter Bent Brigham Hospital. He subsequently joined the Army and served as a surgeon at Valley Forge Hospital. His chief and mentor there was Colonel James Barrett Brown, who later became chief of plastic surgery at Washington University in Saint Louis. He worked closely with another plastic surgeon there, Dr. Bradford Cannon, who later become chief of plastic surgery at Massachusetts General Hospital. Another major factor was his involvement in the treatment of soldiers with major life-threatening burns requiring transplantation with allografts for temporary wound coverage before definitive autologous transplantation. Barrett Brown liked Joe and made sure that he was not sent overseas. Barrett Brown also had a contagious fascination with skin allografts. He had postulated that the more closely related the donor was to the recipient, the slower the rejection of the transplanted skin. He had also cross–skin-grafted a pair of identical twins and found permanent survival of the skin grafts in both twins. The combination of Murray's burn care experience and Barrett Brown's and Cannon's mentoring created a strong motivation for Murray to become a plastic surgeon and to research transplantation. Joe Murray stayed at Valley Forge Hospital until 1947 and then returned to Peter Bent Brigham Hospital, in Boston, and completed his training in general surgery. After this, he trained in plastic surgery at New York and Memorial hospitals. He subsequently returned to the Brigham and Children's Hospitals, where he started the first plastic surgery training program in Boston. When Joe returned to Boston, coincidently, another Brigham surgeon, Dr. David Hume, was drafted to the Korean War. Hume had a laboratory studying transplantation, and Francis Moore, Sr., then the chief of surgery, asked Murray to take over Hume's laboratory. After his Valley Forge experience, Dr. Murray was ready to study transplantation biology, mechanisms of rejection, and immune suppressive agents. He also established collaboration with several outstanding basic scientists, including Sir Peter Medawar, 1960 Nobel laureate, Dr. George Hitchings and Dr. Trudy Elion, 1988 Nobel laureates, and others. This led to the first kidney transplant from an identical twin on December 23, 1954, the first kidney transplant from a nonidentical twin in 1959, and the first kidney allograft from a deceased donor in 1962 (Fig. 2). To date, more than 600,000 kidney transplants have been performed.Fig. 2: Joel Babb, “The First Successful Kidney Transplantation” (1996). Oil on canvas. Reproduced with permission from The Harvard Medical Library in the Francis A. Countway Library of Medicine.In 1990, Dr. Murray, along with E. Donnall Thomas, was awarded the Nobel Prize in Physiology or Medicine for their discoveries concerning “organ and cell transplantation in the treatment of human disease” (Fig. 3).Fig. 3: Joseph E. Murray receiving his Nobel Prize, December 10, 1990. Courtesy of Svenskt Pressfoto; photographer: Janerik Henriksson.Dr. Murray had two other clinical interests, head and neck cancer surgery and craniofacial surgery. As a plastic surgery resident at Memorial Hospital, he developed a strong interest in head and neck cancer surgery and reconstruction, and he was the first to champion the idea of immediate reconstruction. Together with his close friend and colleague Dr. Paul Tessier, of Paris, France, he also became a pioneer in craniofacial surgery and performed some of the first craniofacial procedures in the United States. During medical school, Joe Murray met Bobby Link, a niece of Edwin Link, who invented the flight simulator for pilot training. Bobby was studying music in Boston with faculty from the Longy School and the New England Conservatory. They married in 1945 and had six children, Ginny, Meg, Link, Kathy, Tom, and Rick. Bobby was already then an independent woman. Actively religious, she regularly attends her Episcopalian services, while Joe regularly practiced his Roman Catholic faith. Over the years, Bobby and Joe had been known for differing political viewpoints. They lived in Wellesley for 61 years and on Abbott Road in Wellesley for 51 years, and in 1971 they started to summer on Chappaquiddick Island, a place that Joe Murray loved. I was first introduced to Joe Murray after one of my interviews for the job as his successor. Joe's comment was, “I don't know you but that is probably good.” That was the beginning of a 27-year friendship. Joe was always there but he never got in the way. He invited me and my family to Chappaquiddick and to the Nobel festivities. His attitude was always upbeat. When he was asked, “How are things?” the usual answer was, “Couldn't be better.” He was a superb mentor and an inspiration to our entire Division of Plastic Surgery. He continued to be curious throughout his life. His optimism and compassion were contagious. He had a strong faith, and his spiritual leadership was legendary. When we put together the permanent exhibit in the Rotunda at the Brigham, honoring him, he wanted the title of the exhibit to be “Service to society is the rent we pay for living on this planet.” Joe Murray had a wonderful celebration with Bobby, his wife, and 25 family members on Thanksgiving Day 2012. An avid fan of the New England Patriots, he watched their game after dinner. (The Patriots beat the New York Jets by 49 to 19.) When the game was over, he turned off the television and went to retire for the evening. However, he then suffered a major intracerebral bleed, never regained consciousness, and died with his family present at the Brigham and Women's Hospital 4 days later on November 26, 2012. Joe Murray's passing has left a big hole in our lives. We will miss him for a long time, although his legacy of human compassion and scientific achievement will endure. FROM OUR PERSPECTIVE: THE JOSEPH MURRAY WE KNEW Making Others Feel Important I didn't get to know Joe Murray until I returned to Harvard Medical School from the National Institutes of Health in 1991, to direct the new Transplantation Biology Research Center in the Department of Surgery at Massachusetts General Hospital. This was just after Joe had received the Nobel Prize for his earlier ground-breaking achievement in the field of kidney transplantation. When I went up to introduce myself to him after one of his talks, I was surprised to learn that he already knew me. I was amazed to find out how much he already knew about me and my work. He offered me such a warm welcome back to Boston and to Harvard that I knew immediately we would always be friends. Over the years since then, Joe and I interacted frequently, lecturing together in several medical school courses and attending major lectures at our own and each other's institutions. At one point, when I had just presented some recent results from our laboratory on transplantation tolerance, he asked me for more details after my talk. His keen interest and enthusiasm were infectious, not only to me but also to many of the students who were listening, who probably learned more from that discussion than they had from my lecture! Indeed, it was always a pleasure to spend time with Joe anywhere. He was gracious, generous, and caring, and I never heard him say an unkind word about anyone. He always made me feel that I and my work were important to him and to our field. I am sure that this is how everyone felt about Joe. He will be sorely missed by all of us. Simplicity … Complexity … Curiosity One day I was driving Dr. Murray to Grand Rounds, and we looked at the old jailhouse near Massachusetts General Hospital being rebuilt and converted into a hotel. I mentioned something along the lines that it is a pity to ruin such a precious historical building. His answer was, well Bo, sometimes the old things get in the way of new ones. He always maintained the “big picture” view on medical progress, with a remarkable foresight. At the same time, he was very focused and liked simplicity. Looking back, many scientific questions regarding transplantation were very fundamental, such as, can the transplanted organ achieve adequate blood flow to live and function? What is the impact of disconnected lymphatics? What is the impact of disconnected humoral regulatory systems? Following one of the most complex immunological lectures that I recall, he told me quite honestly, Bo, you know, if I would have had any idea how complicated immunology is, I probably would have never got into it! One of his fundamental professional principles was to maintain intellectual curiosity and persistence, something that he served as a role model of for all of us. His wisdom and experience has been tremendous for me as I was starting the composite allotransplantation program at Brigham and Women's Hospital. I stopped many times at his house for advice. Nothing could be more comforting than his support: if you think you are ready, you probably are. Go for it! Dr. Murray was a giant, a link to the beginning of the field of transplantation, head and neck reconstruction, and craniofacial surgery. As new generations are rising, I am quite sure that he is still somewhere watching us saying, I got your back (i.e., you have my support)! Dr. Murray, you were our inspiration and will always remain a legend and a role model in our minds. We can all only hope to come close to the professional heights that you were able to accomplish helping hundreds of thousands of patients, a truly immortal legacy. Transplantation is again joining reconstructive surgery with a great promise, just like decades ago. Thank you. Seminal Thoughts on Death … Opposing the Sale of Human Organs My experience with Dr. Murray over the course of nearly four decades was to be his student by two aspects of his expertise that may not have been as widely recognized: (1) the concept of death and (2) his resolve that there be no markets for organs. Some may not recall that Dr. Murray was a member of the Ad Hoc Harvard Committee that initially proposed that the ultimate measure of life resides in the function of the brain. His co-authorship of the publication on the definition of irreversible coma in the Journal of the American Medical Association in 1968 was indeed seminal, in part propelling the field of organ transplantation. Meanwhile, throughout his career, Dr. Murray was a strong opponent of organ markets, and he rejected the notion that such markets for organs could be regulated. It was by his stimulus that The Transplantation Society developed its official position against organ sales consistent with Dr. Murray's perspective. Keep Going! Do Not Stop! Dr. Murray was generous with his time and approachable even to those much lower on the totem pole. My first interaction with him was a personal letter he sent to me when I was a fourth-year medical student applying to the Harvard plastic surgery program. Dr. Murray would invite those trying to follow his path into his extended family, and he would ask with keen interest what was new and how he could guide you toward success. I remember the first time he had Stef and me out to his home on Cape Poge, Chappaquiddick. In order to get out to the camp, we had to lower the tire pressure of the truck and drive a few miles across the tractionless soft sand dunes. Dr. Murray put me at the wheel and told me it was just like surgery: “Keep going once you are going. Do not stop. Do not turn too fast or push the gas too hard, or else you will lose traction or even get stuck.” Dr. Murray used to speak fondly to me about that drive when he was trying to mentor me on how to pursue craniofacial surgery in the Harvard system, because during that drive we nearly did get stuck, and at times we might have lost traction, but I can still hear his words as a mentor. “Keep going…. Do not stop.” I once asked Dr. Murray how he would give advice to a young plastic surgeon who wishes to pursue a career in clinical innovation, scientific research, and resident education. Dr. Murray, in his humble way, told me that he could not give this advice but rather that he could only serve as an example of one path, and he stated that instead of following advice one should always follow one's own path and passion. We will all miss Dr. Murray, and we who have received the gift of being inspired and mentored by him will know that we have to “keep going.” Rod J. Rohrich, M.D. Elof Erikson, M.D., Ph.D. David H. Sachs, M.D. Director, Transplantation Biology Research Center Head, Large Animal Transplantation Section Immunologist, Massachusetts General Hospital Paul S. Russell/Warner-Lambert Professor of Surgery Harvard Medical School Bohdan Pomahac, M.D. Director, Plastic Surgery Transplantation Medical Director, Brigham and Women's Hospital Burn Center Associate Professor, Harvard Medical School Francis L. Delmonico, M.D. President, The Transplantation Society World Health Organization, Advisory for Human Organization Professor of Surgery, Harvard Medical School Medical Director, New England Organ Bank Edward J. Caterson, M.D., Ph.D. Instructor, Harvard Medical School Craniofacial and Plastic Surgery Brigham and Women's Hospital