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By Root 1216 0

Despite increasing public criticism, Starzl didn't give up. He performed the first successful liver transplant in 1967. Soon others, Thomas Stone included, managed the same feat. It was still very high risk, but by publishing their experience with such tricks as bypassing portal blood to the superior vena cava during the long surgery, or using the “University of Wisconsin solution” to better preserve cadaver livers, results were improving. The problem was no longer technical, even though this was the most technically difficult operation anyone could perform, the equivalent of a pianist playing Rachmaninoff's “Rhapsody on a Theme by Paganini,” except that one dare not miss a note or fluff a phrase. The operation lasted ten, sometimes twenty hours. Starzl showed it could be done. The two new hurdles were finding sufficient organs to transplant, and of course the problem of rejection of the transplant by the immune system.

In 1980, the year of my internship, Starzl turned his attention increasingly to rejection, focusing on a promising new drug that Sir Roy Calne's group at Cambridge discovered—cyclosporine.

THOMAS STONE TOOK a different approach; he focused on the problem of the shortage of organs and pursued a solution that most others considered a dead end: removing part of a liver from a living healthy parent and giving that to a child whose liver was failing. At least in dogs, he found the liver grew in size to compensate for its loss, while the transplanted segment of liver sustained the recipient. But splitting the donor's liver introduced complications such as bile leaks and clots in the hepatic artery that feeds the liver. It also put a healthy donor's life in real jeopardy, as the liver, unlike the kidney, is unpaired. Even more promising and immediately useful was Stone's work using animal liver cells, trying to strip the cells of those surface antigens which made humans cells recognize them as foreign, and then grow them in sheets on a membrane and use them as a sort of artificial liver—a dialysis type of solution.

As I read about transplants, I was excited. It was clearly one of the most compelling stories in American medicine.

JUNIOR WAS THE CENTER of attention in our ICU. He was deeply sedated, eyeballs roving under closed lids. The kind of trauma hed been through resulted in “shock” lung, or Da Nang lung (recognized in GIs who were resuscitated on the battlefield, only to develop this strange lung stiffness), along with kidney shutdown. According to B. C. Gan dhi's rules, if you had more than seven tubes in you, you were as good as dead. Junior had nine. But one by one, over the weeks, the tubes came out and he got better. It required meticulous nursing care, and Deepak and me poring over his daily flowcharts, anticipating his needs, and intervening with ongoing problems. J.R., as his family called him, left the ICU for a regular room after forty-three days. A week later, smiling sheepishly, he walked out on his own steam with the ICU and trauma teams lined up on either side of the hospital entrance to cheer. If hed shot someone, the witnesses had all vanished, and the police had lost interest, so J.R. was going home. I think it was the sight of J.R. walking out of the hospital that set me on course as a trauma surgeon. His kind of recovery was by no means a rule in trauma surgery, but it happened often enough, particularly in those who were young and previously healthy, that it made the heroic efforts worthwhile. The mind was fragile, fickle, but the human body was resilient.

AS INTERNS we were allowed to attend one national conference, all expenses paid. I chose a liver transplant conference in May in Boston. I arrived on a lovely spring day. Boston's downtown fit every notion I had of what colonial America was like, and it felt steeped in history, completely different from my section of the Bronx. I told myself that it was coincidence that the conference was in Boston, walking distance from where Thomas Stone worked. I told myself I wasn't there to meet Thomas Stone, but to hear the keynote speaker,