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The Puzzle People: Memoirs of a Transplant Surgeon
Reviewed by Marvin Robbins, M.D.
Am J Psychiatry 2011;168:556-557. doi:10.1176/appi.ajp.2011.11010008
View Author and Article Information
Aurora, Colo.

Book review accepted for publication January 2011.

The author reports no financial relationships with commercial interests.

Accepted January , 2011.

Copyright © American Psychiatric Association

From humble beginnings in Le Mars, Iowa, where he was born in 1926, Thomas Starzl became one of the most recognizable names in American medicine, truly the father of modern transplantation, the liver transplant in particular. As he recalls in this engrossing memoir—which is essentially a history of transplantation itself—his first few liver transplants were failures, and he was vilified by the media as engaging in human experimentation. Had Starzl given up at that point, hundreds of patients now living with a new liver wouldn't be. He perfected the technically complex operation to remove the damaged liver and put in the new, but he also advanced our understanding of rejection and how to overcome it.

Abraham Verghese, M.D.

Wall St. Journal, July 10, 2010, p. W8

Abraham Verghese respects Thomas Starzl and notes in his best-selling novel Cutting for Stone that Starzl is the model for one of the lead characters in the novel. He describes Starzl as a "surgeon's surgeon." He also notes that "[i]t is fair to say every organ transplant surgeon in the world was trained by Starzl or someone who trained with Starzl" (1, p. 662).

When I saw Verghese's review, it brought up memories of my medical school training at the University of Colorado in the early to middle 1960s. There was tremendous excitement in Starzl's early work on kidney transplantation. A number of my classmates were involved in laboratory work helping to understand how to do the procedure. In fact, one of my classmates became a transplant surgeon.

In the early 1980s, Starzl left Colorado to go to the University of Pittsburgh. About the same time, I met Keith LaGrenade, M.D., who went on to become, and still is, hospital director at the Colorado Mental Health Institute at Fort Logan. Keith had a kidney transplant done by Starzl in 1971 from a cadaver kidney, which he rejected, and then from the kidney of a relative in 1973, which is still working well. Keith corroborates what Starzl illustrates in his book, which is the intense devotion to his patients. He is able to remember patient histories and write about them in detail. These are people he clearly knew very well. It is obvious that his individual patient care was exquisite and caring. These were his "puzzle people."

Despite Starzl's ultimate success in developing the operation for liver transplantation, his fear of performing surgery was profound. Starzl admits that he harbored anxieties, which he was unable to discuss openly until more than 30 years later. At that point, he had stopped surgery. He says:

"I had an intense fear of failing patients who had placed their health and life in my hands. Far from being relieved by each new layer of skill and experience, the anxieties grew worse. Even for simple operations, I would review books to be sure that no mistakes would be made or old lessons forgotten. Then, sick with apprehension, I would go to the operating room, almost unable to function until the case began." (2, p. 59)

As psychiatrists, we can understand this terrible anxiety and the difficulties it would cause. It also may help explain why Starzl's most significant work and energy went toward the laboratory, where he developed new strategies to deal with the rejection phenomenon. Even as he trained a new generation of transplant surgeons, surgery would become secondary to his interest in solving the rejection problem. His major success was to develop a team of basic and clinical scientists that eventually gave him and his patients a clinically acceptable immunosuppression strategy.

The Puzzle People is an engaging and engrossing work, which takes the reader along the path of mastery. It is written in a friendly, personal manner, which speaks of the author's intense humanity.

Starzl devotes a brief chapter to a political conflict with Richard Lamm, who was governor of the state of Colorado from 1978 to 1986. I discussed this recently with Governor Lamm. The issue was regarding the cost of doing a liver transplantation versus how many other people could be treated with the same amount of money. Lamm notes his respect for Dr. Starzl and now sees transplantation as a successful medical option.

Verghese  A:  Cutting for Stone .  New York,  Random House, 2009
Starzl  TE:  The Puzzle People .  Pittsburgh,  University of Pittsburgh Press, 1992
References Container


Verghese  A:  Cutting for Stone .  New York,  Random House, 2009
Starzl  TE:  The Puzzle People .  Pittsburgh,  University of Pittsburgh Press, 1992
References Container

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