Book Review

The Puzzle People: Memoirs of a Transplant Surgeon

N Engl J Med 1993; 328:818March 18, 1993

Article

The Puzzle People: Memoirs of a Transplant Surgeon
By Thomas E. Starzl. 364 pp., illustrated. Pittsburgh, University of Pittsburgh Press, 1992. $24.95. ISBN: 0-8229-3714-X

Peter Medawar, the late doyen of transplantation biology, once noted that the lives of scientists usually make dull reading. But books about the struggles of clinicians (particularly surgeons) to cure disease, or at least to keep it at bay, captivate the public. The autobiography of Thomas Starzl (who coincidentally is first author of the original article that begins on page 745 of this issue), a major force in transplantation surgery for almost four decades, is in this tradition.

Starzl was born in a small town in Iowa. He became interested in neurophysiology while in medical school at Northwestern, then in cardiac physiology during his surgical training at Johns Hopkins. But the subject of organ transplantation piqued the fancy of this restless young man, who describes himself as a “missile looking for a trajectory.” Starzl's intense and occasionally diffuse recollections of the field of transplantation as it developed in the 1960s and 1970s, and as it involved patients, colleagues, pupils, friends, and enemies, swell the pages of the book. His interest in a “hepatotrophic factor,” later shown to be insulin, hurried his move from the increasingly routine subject of kidney transplantation to the more complex one of engraftment of the liver. Indeed, Starzl in the United States and Roy Calne in the United Kingdom together forced the development of that procedure past the Luddites and nurtured it to its present remarkable level of success. Starzl's investigations of immunosuppressive methods, along with research from other transplantation centers, made liver transplantation widely accepted. His persistence in forwarding potentially interesting (and occasionally less interesting) immunosuppressive agents continues to this day.

What creates a man like Starzl? In reading his book, one is reminded of the Elizabethan adventurers Drake and Raleigh, who through force of will, exuberance, and unbridled elan opened new lands, new visions, and new ideas. Starzl has engendered controversy throughout his life, beginning as early as the eighth grade. Wanting to become independent of his publisher father, he was drawn to the unconventional personality of a successful and mysterious uncle. One of his early mentors in research taught him well that true accomplishment in investigation lies in the development of broad concepts, not merely in learning ever more about ever less. Starzl has considered and reconsidered several themes throughout his frenetic career. One that continues to surface is his persistent advocacy for the individual patient, often with adverse political consequences and risks to his own health. His use of those in high office to help him in his endeavors is a tribute to his focused persistence. Starzl summarizes the philosophy of his career by quoting the medical historian T.S. Kuhn's statements that “progress consists of a series of great and small revolutions against authority” and “a great advance necessitates the overthrow of an established dogma.”

Starzl tells a fascinating story, not only in giving his distinctly personal view of the evolution of organ transplantation, but also about himself. His book is recommended for anyone with curiosity about transplantation, or with broad interests in current medical events and the remarkable successes in clinical and biologic sciences during the latter half of the 20th century.

Nicholas Tilney, M.D.
Brigham and Women's Hospital, Boston, MA 02115