In their own words...
Personal, intimate exchange of the experiences, good or bad would be conducive to the future development of more experimental, new and clinical transplant. – H.M. Lee, MD
H.M. Lee, MD, retired in 1997 as Chairman of the Division of Vascular and Transplant Surgery at the Medical College of Virginia. Raised in North Korea, and escaping to South Korea as a young man, Dr. Lee obtained his medical degree from Seoul National University Medical School in 1949. Thereafter, he came to the United States and ultimately began training at the Medical College of Virginia under the tutelage of Dr. David Hume. Dr. Lee led the transplant service in Richmond for many years, and became increasingly active with important transplant organizations including the Southeastern Organ Procurement Foundation and the United Network for Organ Sharing. Dr. Lee was a charter member of the ASTS and served as its 11th President. Since retiring, Dr. Lee has earned a law degree and has continued his interest in numerous scholarly pursuits.
Robert Fisher: Dr. Lee, can you introduce yourself and the institution that you transplanted at for so many years?
H.M. Lee: My name is Dr. H. M. Lee; I am from Richmond, Virginia. I am stationed at the Medical College of Virginia.
Robert Fisher: Dr. Lee, in your memoirs, there is a note in 1959 of your first interview with Dr. David Hume. Did you have an interest in transplant surgery prior to that time or was that interview with Dr. Hume for the general surgery program the beginning of your longtime lifetime work and interest?
H.M. Lee: 1959... Excuse me. I was a surgery research fellow under Dr. Hume’s protection. This was before I was accepted into the residency training program at the College of Virginia.
Robert Fisher: In 1959, you wrote in your memoirs the interview that you had with Dr. David Hume at the Medical College of Virginia Hospitals, was that the beginning of the interest in your lifetime work in transplantation?
H.M. Lee: Correct.
Robert Fisher: And how was that interview, you must have as a young surgery resident meeting Dr. David Hume, what was that interview like? What was that like for the first time meeting him?
H.M. Lee: He was a very personable, not as you would image an almighty-God type of attitude, he was very personable, easy to approach and easy to have conversation.
Robert Fisher: And you mentioned that it was to see whether those foreigners would be capable of doing his residency program, but I don’t think he ever made you feel that you were a foreigner in his program, did he?
H.M. Lee: There was a reputation that he didn’t like foreigner proceeded all over the place, so I already knew he didn’t like foreigners when I met him.
Robert Fisher: So out of that meeting in 1959 when he decided to put you in the laboratory and can you describe who the residents were or who the faculty was with you in the laboratory at that time?
H.M. Lee: At that time, at the beginning Charlie Zukoski was a senior research fellow in the lab under who I was working in the kidney transplant program in the dog lab, what we called.
Robert Fisher: And at that time you actually spent almost day and night... My understanding was that you would even be doing research, transplants in the middle of the night because of Dr. Hume’s continuous energy and desire to have the research go on day and night?
H.M. Lee: Correct.
Robert Fisher: Is that true?
H.M. Lee: That is the impression I still hold.
Robert Fisher: And how long did you stay in the lab doing dog kidney transplants, looking at the different new drug therapies?
H.M. Lee: Three years.
Robert Fisher: And did you ever at that time see Dr. Hume feel that the radiation treatments or the new therapies were making this idea of kidney replacement something that you weren’t going to be able to see in your lifetime?
H.M. Lee: That was shortly after the atomic bomb explosion issue, so radiation biology was a heyday. So in kidney transplant, foreign tissue transplant was in based on the radiation biology.
Interview: But you also, with Dr. Zukoski, were the first to actually show that 6-mercaptopurine was beneficial and a very important drug, new drug, to establish renal transplantation.
H.M. Lee: Correct. First anti-metabolite of purine synthesis is 6-mercaptopurine produced by a drug company in North Carolina was introduced to our research lab. 6-mercaptopurine that was the first drug we used to prolong the kidney transplant in a dog.
Robert Fisher: Do you recall your presentation of that data at the first meeting?
H.M. Lee: At the Surgical Forum in San Francisco, we produced and published at the same time. How I explain it is 6-mercaptopurine in a dog kidney transplant.
Robert Fisher: I remember you saying that you were very excited initially to present that and then afterwards you felt let down after your presentation. Do you recall the other senior members in transplantation that were also doing the same experimentation at the time?
H.M. Lee: It so happened that professor Roy Calne from England who was working at the Peter and Brigham had started a research lab in Boston, with exactly the same data and the same result using the 6-mercaptopurine. It just so happened that we are doing the same thing at the same time. My friendship dates back to Roy Calne to those days.
Robert Fisher: And in that description, you talk about Dr. Hume in the operating room actually having a list-by-list, number-by-number description of how he did every surgery. Did you also follow that practice in your training as his resident when you were either in the dog lab or later when you began taking care of his kidney transplant patients?
H.M. Lee: Yes, I was emulating the bright young experiment-oriented surgeon, Dr. Hume. So I try to become like Dr. Hume.
Robert Fisher: And do you recall whether any of those actual lists of how I do the surgery were actually passed on with your future generation of surgeons that you have trained?
H.M. Lee: Yes. Dr. Hume was first had two nurses, one following his description of the surgery and one is helping the surgeon and he would do that first. The second time around, he would correct the first description and the third time, it was routine, it becomes routine. I tried to follow same sort of step of developing a new technique on any surgery.
Robert Fisher: And you mention that when you went into the clinics and there is a whole series... In fact Dr. Starzl says that three of the earliest successful kidney transplants came out of the Medical College of Virginia at a time when he was in Denver. And do you recall the particular patient that Dr. Hume had performed what was believed to be the first bilateral nephrectomy for hypertension and then later did the kidney transplant?
H.M. Lee: Yes, it is interesting that bilateral nephrectomy was done in the patient not really foreseeing the kidney transplant but because of uncontrollable hypertension. He did a bilateral nephrectomy, I handled the kidney transplant. That was the world’s first elective bilateral nephrectomy in a patient not particularly anticipating kidney transplant. It so happened hypertension became very easy to control after that, it was published at the time.
Robert Fisher: And you talk also about the fact that during those days the group in Boston and the group in Denver, Dr. Starzl, that there were almost daily conversations with how the teams were working. Do you recall some of those conversations or Dr. Hume discussing what was going on at that time?
H.M. Lee: As you may remember, Dr. Hume came from Boston after he did early probably one of the first in the world kidney transplant experiments and then he came to Richmond after he was called back to the Navy service. So he came to Richmond and he immediately started a kidney transplant program, starting small-scale of course.
Robert Fisher: Do you remember the year that he actually told the public or that the hospital that he was initiating the clinical center for kidney transplantation, what year was that?
H.M. Lee: I believe it was 1953 or 1956 he started the kidney transplant program; he started the living related kidney transplant program. We set up a “clinical transplant unit;” it was a first in the world deliberately set up for doing related kidney transplant.
Robert Fisher: Do you recall, I also remember from your memoirs that there were actually two long-term successes of the initial radiation concept that had failed in Boston and had failed in France and in other centers. Do you recall the length of time that those patients kept their kidney transplants?
H.M. Lee: One patient in fact surprisingly kept the kidney for seventeen years, that was one of the first total body radiation transplants. It was very difficult to manage total body radiation patients after surgery. They were put in the “protective biology” isolated unit and residents was taking care of after surgery was always put in the gown and total isolation and we would be looking at from outside and telling him what to do. Now looking back, how comical.
Robert Fisher: But so much work, too. And also you had a... Actually a group of grandmother, mother, daughter that were successful transplants that also proved that a baby, a successful pregnancy could occur after transplant in those early days.
H.M. Lee: Those early days... The first successful pregnancy and baby born out of that patient was in fact developed in Richmond. We didn’t know that the woman was getting pregnant, we were all caught by surprise and it so happened that patient’s lived a long, long time after that.
Robert Fisher: Do you recall who...? You note that there was an x-ray taken and that you actually saw the skeleton of the fetus and that’s how you knew she was pregnant?
H.M. Lee: Yes.
Robert Fisher: Do you recall the day that you looked at that?
H.M. Lee: The reason why we found out the patient was pregnant because we didn’t know. Total body radiation after that kidney transplant was followed by very frequent radiation, x-ray taking. That’s why this so happened we found out she was pregnant.
Robert Fisher: So how long in your training did you finally feel that Dr. Hume had changed his mind about foreigners becoming his own faculty and his senior transplant surgery faculty?
H.M. Lee: When I actually continued residency program, I became Chief Resident in 1973 and after I finished, I was picked to become junior faculty, that’s how I knew I am now in.
Robert Fisher: And you know it’s interesting when you talk about Dr. Hume, other leaders of the day, for example Dr. Starzl refers to Dr. Hume as a constantly in motion buzz saw. That’s how he refers to Dr. Hume. But you talked about Dr. Hume as always being this incredibly energetic teacher at all times. And it sounds like your relationship as his faculty even grew further as you assumed his Clinical Program Chief, is that correct?
H.M. Lee: Yes, we became “human-to-human” type of friendship, not only chief and underling. So I didn’t think he was eminent almighty thou type of chief. I just happened to like him, I followed his every move, every mindset.
Robert Fisher: And there are some things really that many of don’t understand or don’t know about him. For example, you recall the feeling at the time when Dr. Hume brought Dr. Lauer and all of the work that was going on with all transplant organs, including heart, and the very famous case, I wonder if you can recall? I believe you refer to as the Tucker Trial and what was the atmosphere and describe what that was about?
H.M. Lee: Dr. Hume slowly showed his ambition to set up the World Organ Transplant Center in Richmond. The first thing he did was he tried to get Dr. Shumway who started heart transplant in California. Shumway said he himself is not willing to leave California, but his underling, Dr. Lauer, would be maybe the guy to recruit. So Dr. Hume approached Dr. Lauer and Dr. Lauer at the time, a young man, his wife being pregnant expecting her first baby, he came to Richmond. So we are now set for the heart transplant also.
Robert Fisher: It must have been very difficult on you when I read the number of hours that were going on in the lab and with taking care of these patients in these special conditions. It seems like you had less sleep than any of us now do in present transplant dealing with how you decided which organ donor to choose and even how to obtain the organs to transplant. I am wondering how you did it; you describe Dr. Hume some days as being ashen from working all night long and still going on. I can imagine that how many days did you not even get a chance to go home to Mrs. Lee when you were doing all of this?
H.M. Lee: It so happened that I was lucky enough to marry a woman doctor who understood this program. So she shouldered all of the responsibility and let me go day and night, sometimes not going home for two or three days, I was lucky.
Robert Fisher: Do you recall the…? What happened in that, which was the Tucker Trial? The Tucker Trial was the trial that determined brain death, is that correct?
H.M. Lee: Correct.
Robert Fisher: Do you recall the specifics about that, I mean were you frightened that you might actually; Dr. Hume and Dr. Lauer might actually go to jail?
H.M. Lee: No we were not that worried. It so happened also the judge who presided over the case was the best type of the man. He is the one who actually declared brain death was legal death. At the time, death by legal definition is not heart beating cadaver. You were dead, death. So this was the first case, in fact when the judge declared that brain death is death, it was beyond at the time the legal definition of death.
Robert Fisher: And do you recall, there was the... Governor Wilder was actually the attorney for the patient that the heart had been taken from, is that correct?
H.M. Lee: Correct. Well of course we didn’t know who Mr. Wilder was, but he is the one who decided that the cadaver we took the heart out, that patient’s attorney he tried to prove that we committed a murder.
Robert Fisher: How long did that case take, H.M. Lee?
H.M. Lee: Almost one week, I believe.
Robert Fisher: One week?
H.M. Lee: Yeah.
Robert Fisher: And were there other transplant surgeons from around the country that were brought in to be part of the witnesses for that case?
H.M. Lee: No.
Robert Fisher: So it involved the Richmond community?
H.M. Lee: The most remarkable thing was minister who came from VA and decided that brain death can be death rather than legal heart-stopping death.
Robert Fisher: How did that change the transplant program clinically after that trial? Was there more public notice or more activity with the patients that must have been coming in already from all over with renal failure? How did the patients learn of this?
H.M. Lee: I’m not sure I remember how they perceived or they learned this fact. But in retrospective, this was the turning point of the cadaver transplant using the not heart beating, but brain death people. In retrospect, this was a remarkable event because legal death was heart-stopping death by the legal dictionary. So this is the first time not heart-beating but brain dead is also legal definition of death.
Robert Fisher: And Dr. Lee, as part of the program development, it seems like you together with Dr. Hume were always trying to expand transplantation to other programs and to other physicians and surgeons. Do you remember the meeting that started the sharing of organs that actually initiated the Southeastern Organ Procurement Foundation?
H.M. Lee: Yes. Dr. Hume was getting several institutions in Southern Virginia and North Carolina and organized and exchanged the idea and eventually exchanged organs based on the tissue typing. So this small simple group was called Southeastern Organ Procurement Center, which they now changed the name to UNOS, United Organ Network.
Robert Fisher: And do you remember, there was a comment I believe by one of the participants that Dr. Hume had the usual brown bag sandwiches brought up from the cafeteria and that when someone asked him why he ate such bland oats for breakfast, he said... Do you recall this? “Work like a horse, eat like a horse” that he had this very magical type of humor in everything that he did? Do you recall that?
H.M. Lee: Yes, he was a very humorous, not serious straight faced, so I wouldn’t be surprised he did say that comment, half joke and half serious thing.
Robert Fisher: And how long did it take you before this actually… This organization started sharing organs and that…? Was that the first time that organs had actually been shared between institutions?
H.M. Lee: Yes.
Robert Fisher: Between institutions?
H.M. Lee: Yes. Southeastern Organ Procurement Center, it was the first one in the country and slowly it spread all over the country. That’s why UNOS, United Network Organ Sharing which covers the entire country developed.
Robert Fisher: So it was all based on this meeting and just trusts in each other that this…
H.M. Lee: Right.
Robert Fisher: This all occurred?
H.M. Lee: Yes.
Robert Fisher: And there, very early in your career also, you established that a patient who would need organ replacement, you established the ethics of actually using a living donor very early or Dr. Hume and you did at the Medical College of Virginia. But do you recall the patient; he may still be alive with a functioning graft that was a prisoner at the time when you did his kidney transplant?
H.M. Lee: That man has died eventually, but we do have… I lost recent contact, but we do have cadaver kidney transplant who came from southeastern state, lived a long, long time. I lost track of it now.
Robert Fisher: But you would keep in contact?
H.M. Lee: Yes, a long time.
Robert Fisher: A long time, and it was interest because do you know whether at that time, would it have been in 1970 or 1967 whether you had actually transplanted prisoners for the first time who had need of organ replacement in the United States?
H.M. Lee: Yes, I remember it. I think it was the late sixties or early seventies.
Robert Fisher: Did you…? What did you have to deal with, with the community, either the academic community or the legal community in order to make that happen?
H.M. Lee: I don’t remember anything particularly was done. This was Dr. Hume’s idea. If it has to be done medically, he will do it regardless of the legal consequence. Legal consequence, that was afterward not before-hand.
Robert Fisher: And something that I know that you established in the clinical transplant unit at the Medical College of Virginia Hospitals was you comment about Dr. Hume sitting and talking with his patients and even picking up their bedpans at times to help and that he was a very personable man, a caring man for his patients. And that there was a tremendous group of nursing staff that maintained a loyalty specifically to the transplant unit that maintained that loyalty to you and to the unit to this day. Was it always that way?
H.M. Lee: Yes. That’s how Dr. Hume was. I used to tell the students and young residents Dr. Hume would go around the country giving lectures and so on and come back to Richmond, sometimes in the middle of the night he would make rounds himself. And sometimes all of the patients would cry out “Nurse, nurse, I need a bedpan.” So what does Dr. Hume do? He doesn’t tell the nurse to give him a bedpan; he will take bedpan himself and give it to the patient, that’s how I remember so vividly. So I would tell the young resident that’s how you should deal with patients.
Robert Fisher: What do you feel, Dr. Lee, from the time of all of these in-roads in transplantation and in fact there is a lot been made of even before the advent of cyclosporine of just the understanding that rejection was a cellular event and that steroids could be used to reverse that? Do you recall your first rejection patients that you actually reversed?
H.M. Lee: No I don’t.
Robert Fisher: And I believe that you also commented that in the time that some of the first transplants that were second and third successful transplants were being done in the late fifties if not early sixties. Do you recall the… Your first patient that had this second or third kidney transplant performed?
H.M. Lee: I remember one particular patient. It was a cadaver kidney transplantation, rejected that kidney and so he got a second kidney transplant shortly after. The patient lived a long time and that was the first one. It’s possible that you can have a second or third kidney transplant and live a long time, not an experimental period but a long time.
Thomas Peters: Gentlemen, we’re going to ask if anybody in the room has any questions of H.M. Lee. Do you want to ask him anything? H. M., would you still talking to Bob, would you talk a little bit about your early memories of the American Society of Transplant Surgeons and tell Bob a little bit about how you recall some of the meetings and some of the issues and so forth?
H.M. Lee: I don’t know exactly how he managed, but Fred Merkel in Chicago put people together at the time, a small number of people who did kidney transplants in Florida. Tom Starzl at the time insisted the gathering be a scientific learning experience. Fred Merkel may have a different idea of just a friendly gathering, but because of that the American Society of Transplant Surgeons was organized and set up after that.
Robert Fisher: Do you remember that meeting?
H.M. Lee: Yes.
Robert Fisher: It was in Chicago.
H.M. Lee: The meeting was in Florida.
Robert Fisher: Oh it was in Florida?
H.M. Lee: The first gathering was, so it sort of a fraternity type of meeting to begin with, but Tom Starzl insisted this being a scientific meeting and he became our first society president after that when he was asked to become an organized society president.
Robert Fisher: Do you recall, was Dr. Hume ever an officer in the American Society of Transplant Surgeons?
H.M. Lee: I don’t remember that distinctly. He was very resistant to become any kind of officer and he... Even though Tom Starzl did become, Dr. Hume did not become.
Robert Fisher: And when were you the President of the ASTS?
H.M. Lee: I think it was several years after that, I believe it was 1987-1988, that type of place.
Robert Fisher: And do you recall the way that the public or even the communities practicing transplantation, how it changed? When did this growth become from where the American Society of Transplant Surgeons was just a very small intimate group of surgeons to now a very large group where people didn’t even know you know everybody’s names?
H.M. Lee: I remember the early days; everybody knew each other, pretty much intimately and called by nickname or friendly name and so on. Once it is organized and start gathering steam, it became so big you don’t even know each other very much. Certainly there is competition, it’s kind of sad.
Robert Fisher: I can imagine when you mentioned and actually Dr. Starzl also mentioned in his memoirs about presenting at the old American Society of Transplant Surgeons meetings in the Drake Hotel. Do you recall some of those early meetings of the discussions? It sounds like they were much livelier than discussions are even in the recent past in the ASTS meetings?
H.M. Lee: Yeah because everybody’s experience was small, always somebody had a new finding. It was exchanging, I had this kind of problem and this kind of complication, and the other one will learn from that. So it was much more intimate, very personal communication exchange.
Robert Fisher: As we expand transplantation and all of the complexities of living donation and multiple other organ systems, what advice do you have from all of your experience in dealing with the basic institution of the revolutionary practice as we do today for us for the future that made it possible for you in the beginning?
H.M. Lee: Personal, intimate exchange of the experience, good or bad would be conducive to the future development of more experimental and more new and more clinical transplant.
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