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The Puzzle People

The Puzzle People: Memoirs Of A Transplant Surgeon

Thomas E. Starzl
Copyright Date: 1992
Pages: 400
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    The Puzzle People
    Book Description:

    Given the tensions and demands of medicine, highly successful physicians and surgeons rarely achieve equal success as prose writers. It is truly extraordinary that a major, international pioneer in the controversial field of transplant surgery should have written a spellbinding, and heart-wrenching, autobiography.

    Thomas Starzl grew up in LeMars, Iowa, the son of a newspaper publisher and a nurse. His father also wrote science fiction and was acquainted with the writer Ray Bradbury. Starzl left the family business to enter Northwestern University Medical School where he earned both and M.D. and a PhD. While he was a student, and later during his surgical internship at the Johns Hopkins Hospital, he began the series of animal experiments that led eventually to the world's first transplantation of the human liver in 1963.

    Throughout his career, first at the University of Colorado and then at the University of Pittsburgh, he has aroused both worldwide admiration and controversy. His technical innovations and medical genius have revolutionized the field, but Starzl has not hesitated to address the moral and ethical issues raised by transplantation. In this book he clearly states his position on many hotly debated issues including brain death, randomized trials for experimental drugs, the costs of transplant operations, and the system for selecting organ recipients from among scores of desperately ill patients.

    There are many heroes in the story of transplantation, and many "puzzle people," the patients who, as one journalist suggested, might one day be made entirely of various transplanted parts. They are old and young, obscure and world famous. Some have been taken into the hearts of America, like Stormie Jones, the brave and beautiful child from Texas. Every patient who receives someone else's organ - and Starzl remembers each one - is a puzzle. "It was not just the acquisition of a new part," he writes. "The rest of the body had to change in many ways before the gift could be accepted. It was necessary for the mind to see the world in a different way." The surgeons and physicians who pioneered transplantation were also changed: they too became puzzle people. "Some were corroded or destroyed by the experience, some were sublimated, and none remained the same."

    eISBN: 978-0-8229-7252-5
    Subjects: History

Table of Contents

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  1. List of Figures and Photographs
    (pp. vii-viii)
  2. 1 The Puzzle People
    (pp. 3-5)

    At a meeting in Capri not long ago, I was asked by an Italian journalist, “Do you think that in the next decade a puzzle man with a heart, liver, and pancreas taken from other human beings might be feasible?” I answered, “There are already examples of puzzle men and women who have received a heart and kidney, a pancreas and kidney, a heart and lungs, liver and heart. Other and more complicated combinations will be forthcoming in the near future.”

    Later on, it occurred to me how incomplete and anatomic my answer had been. Every patient who went through...

  3. 2 Printer’s Ink
    (pp. 6-24)

    After I learned to read, the definition of a gyroscope in the dictionary did little to explain the fascination of my favorite toy: “gyroscope . . . device consisting essentially of a spinning mass . . . which maintains its angular orientation with respect to inertial coordinates when not subjected to external torques.”¹ I do not know anything more about gyroscopes now than when I was a child. My question then was how this mysterious object stayed upright. Its strength clearly came from rotary movement, and the movement required energy.

    Staying upright in a small town in western Iowa should...

  4. 3 Medical School (1947–52)
    (pp. 25-36)

    Northwestern University Medical School is located at 303 East Chicago Avenue, two blocks from the concrete “beaches” which were accessible by crossing North Lake Shore Drive. These had been constructed years before to replace the natural sand of Lake Michigan. Going west, the city layers in September 1947 were as thin as onion skin, changing so fast that a fifteen–minute walk or a five–minute ride on the Chicago Avenue trolley could lay bare a transformation from grandeur to misery.

    First came North Michigan Avenue and its expanse of fashionable shops, business centers, and professional offices. One block farther...

  5. 4 The Johns Hopkins Hospital
    (pp. 37-46)

    My interview for a surgical internship at the Johns Hopkins Hospital was arranged by Dr. Magoun and took place during my trip to Los Angeles in 1951 (see chapter 3). It was conducted by William P. Longmire, formerly a faculty surgeon at the Johns Hopkins Hospital and subsequently founding chair of the UCLA Department of Surgery. The starting date for the internship was July I, 1952.

    The heart (or perhaps today the soul) of the Johns Hopkins Hospital was the original infirmary at 5201 Broadway Avenue in East Baltimore. Just inside the front door was a giant statue of Christ,...

  6. 5 A Trip South
    (pp. 47-58)

    The job in Florida paid $300 per month—enough to live on without depending on regular support from my father, who still was recovering from his stroke of seven months earlier. I was not yet qualified on paper to practice surgery. Obtaining this credential was the reason to go to Miami. The starting date for the fifth–year residency was July 1,1956. My wife, Barbara, and I drove down the east coast with our sixteen–month–old son, Timothy Wakefield Starzl, in the same car I had used for the trip to Los Angeles five years before (see chapter 3)....

  7. 6 A Fertile Vacuum
    (pp. 59-69)

    The summer of 1958 started as the most unpromising period of my life. The rationale for returning to Chicago after a six–year absence was questionable. Was this a reasoned decision or merely a clumsy effort to delay one? The ostensible purpose of this final year of training was to become fully qualified to do chest (thoracic) surgery, or more accurately, to obtain a certificate saying that I met this condition. In fact, I already was highly experienced in this field. The perception of some of those closest to me was that I was avoiding for one more year the...

  8. 7 Substance or Stunts?
    (pp. 70-82)

    The work on liver transplantation by the Northwestern and Harvard teams resurfaced at the annual meeting of the American Surgical Association (ASA), held at White Sulphur Springs, West Virginia, on April 5, 1960. The ASA is not the oldest learned surgical society in America, but it is the most prestigious. Those who cannot gain membership call it the most pretentious. How precious admission to the inner circle is can be surmised by the active membership ceiling of 350 for the North American continent. All of the surgeons whom I have mentioned in this book already were members in 1960 or...

  9. 8 The Rocky Mountains
    (pp. 83-95)

    By moving west from Boston, Bill Waddell was coming back toward his desert roots, a process that he completed when he retired from the University of Colorado in 1982 and moved to Silver City, New Mexico. Now seventy–two years old, he still sees patients. Once a week, he drives 200 miles to Tucson where he teaches medical students and residents at the University of Arizona. They see in him the wisdom of the ages. I met him there in January 1991. Like a piece of fine leather, he looked the same as thirty years before. His life is peaceful...

  10. 9 The Failed Liver Transplant Trials
    (pp. 96-105)

    Bennie Solis was a tiny spot in the universe, and a flawed one at that. The son of poor Spanish American parents, he was born with biliary atresia, a condition for which there was no medical or surgical treatment, nor any hope of divine intervention. His liver was incomplete. Its cells still could fulfil their sophisticated duties to the rest of the body, such as building and breaking down proteins, sugars, and fats. But his liver lacked the tubular duct system that normally collects the bile produced by the liver as part of its function of eliminating the body’s waste...

  11. 10 Time
    (pp. 106-117)

    TheTimemagazine cover story of May 3, 1963, was about surgery. It recounted the advances already made in this field since World War II and those projected for the immediate future. Franny Moore was featured as the prototype surgeon of the new era, on a stage provided by the Peter Bent Brigham Hospital, and with a supporting cast of the talented physicians and surgeons who worked there. In the main body of the story, a surgeon identified as one of the most articulate men working at the Brigham was quoted as saying that “this little place with only 284...

  12. 11 Tissue Matching
    (pp. 118-124)

    Even before my bout with hepatitis and recovery from it, I had concluded that the imperfections of kidney transplantation had been so well defined that merely accruing a larger patient series would be a futile exercise. Better immunosuppressive drugs could be developed in the research laboratory. In the clinics, there was the possibility that tissue matching could improve the results, or at least permit the use of lower doses of the drugs. Such attempts for the selection of the best family donors were known to have been made in Paris by the kidney disease specialist Jean Hamburger and the immunologist,...

  13. 12 Why Not Two Livers?
    (pp. 125-131)

    By 1964 the University of Colorado had become a mecca for clinical kidney transplantation while the liver program had all but disappeared from view. However, our decision in 1963 to temporarily abandon liver transplantation following the initial failures was not the same as capitulation. The liver is an unpaired organ. Instead of removing and replacing it, why not transplant a second (auxiliary) liver in some convenient location in the abdomen? Theoretically, such an operation would be of lesser magnitude because it omitted the very difficult step of removing the recipient liver. Moreover, whatever function the diseased recipient liver still possessed...

  14. 13 A Counterattack on Rejection
    (pp. 132-144)

    My assumption in the strategy to develop liver transplantation was that advances in controlling kidney rejection would be applicable to the transplantation of all organs, essentially without change. This belief was the reason for developing a kidney transplant program as a pathfinder for the technically more difficult liver replacement. However, at the time K. A. Porter, the London pathologist, visited Colorado in October 1963, no one had been able to demonstrate truly long survival of dogs submitted to liver transplantation.

    This disquieting fact, plus the failure of the clinical trials in Denver, Boston, and Paris, caused a growing suspicion that...

  15. 14 The Donors and the Organs
    (pp. 145-154)

    As 1966 dawned, our moratorium on liver replacement had entered its third year. It seemed certain that improved antirejection treatment soon would be available with ALG. Whether this alone would allow resumption of the suspended liver trials was anything but clear. Two additional issues needed resolution, and both were on the agenda of the first symposium on the medical ethics of transplantation which was held in London at the Ciba Foundation house March 8-11, 1966.¹ One of these topics was human experimentation. The other was organ donation.

    For all practical purposes, organ transplantation still was synonymous with kidney grafting. Kidney...

  16. 15 A Liver Summit Team
    (pp. 155-161)

    In planning a perilous journey, it pays to know your companions and not to have too many of them. “Perilous” might be verbal overkill for the liver transplantation we had in mind, but in 1967 it came close to the truth for all concerned. For the surgeons, it seemed apparent that liver transplantation was not going to be a ticket to an academic career. The worldwide impact of the Colorado program had been in kidney transplantation, but this was fading now as other competent renal programs opened, many of them headed by our former fellows and faculty in the United...

  17. 16 A Pyrrhic Victory
    (pp. 162-172)

    The struts were in place for another attempt at liver transplantation: better antirejection therapy, improved means of organ procurement and preservation, and insight about what role tissue typing would play—or more correctly, would not. In the animal laboratory, dog recipients were living in their fourth year after receiving the livers of nonrelated mongrel donors. These accomplishments did not silence the opposition to further trials. Those who were opposed believed that what they said was inherently correct and virtuous, but in all fairness so did I. I publicly defended the impending liver trials and also what had been done in...

  18. 17 Icebergs and Hammer Blows
    (pp. 173-196)

    It might have been best in 1970 to declare victory and quit. In the United States, the 1970S became an era of national humiliation and introspection. There was the unfavorable end of a hated war, the forced resignation of a president, and the slow decline of American technologic and economic superiority. In my small world, as in the real one, disintegration lay ahead before fresh pathways or half-forgotten old ones could be found. This would be a bleak decade. Or was it all a mirage, and only a prelude to the next great surge?

    The decade of the sixties had...

  19. 18 Smokey
    (pp. 197-203)

    At the surprise party marking my fiftieth birthday on March II, 1976, the usual comments were made about the good fortune of surviving this long. If I had known in advance what the following six weeks would bring, I might have wanted not to reach the landmark. The world would never be the same again, but I could not withdraw from it. The prospect of returning to the operating room was uninviting. After a month passed, an urgent call for help came to my office from John Lilly, chief of pediatric surgery. He was operating on a five-month-old child with...

  20. 19 The Kidney Wars
    (pp. 204-214)

    After more than a four-year absence from the field, my resumption of kidney transplant activities began with a ceremonial function. On August 25, 1976, I was invited to give an overview of the present status of kidney transplantation for the Transplantation Society meeting in New York City. I wore a bright red tie. Afterward, an old friend, Erna Moeller of Stockholm, who had a vague idea of the disruptions in Denver, remarked how the tie symbolized coming back to life.

    In preparing, I began with the state of the art as it had been in 1972 and tracked what had...

  21. 20 A Tale of Four Cities
    (pp. 215-230)

    Throughout 1979 and 1980, Joy Conger, the missing member of our research team, was a thousand miles from Denver at the Parkland Hospital in Dallas where President Kennedy died. There, she had joined the research team of John Fordtran, the medical doctor whose son had received a cadaver kidney transplant in Denver in 1971. I no longer had any illusion that she could or would return to Colorado.

    My discussion with Jim Maloney in October 1978 about moving to UCLA also was receding into the background. A few days after we met in San Francisco, I had visited him in...

  22. 21 Letter in a Birmingham Jail
    (pp. 231-242)

    A standard dictionary definition of a minority is: “the smaller in number of two groups constituting a whole; a group having less than the number of votes necessary for control; a part of a population differing from others in some characteristics and often subjected to differential treatment.”¹ Most minority groups are peace loving, or begin that way. Nevertheless, a minority revolt occurred in Pittsburgh in 1981. The uprising was of the renal transplant population and the surgeons and physicians who were treating them.

    In hisLetter from Birmingham Jail(April 16, 1963), Martin Luther King addressed the benevolent master class...

  23. 22 The Liver Wars
    (pp. 243-266)

    The kidney transplantation trial with cyclosporine was the essential first step in Pittsburgh. This was the only kind of transplantation accepted as legitimate therapy by the medical establishment, and it was the only transplant procedure for which there was identifiable support for the costs of hospitalization. Dave Winter of the Sandoz Corporation had given us carte blanche for all other kinds of transplantation, creating the means to develop in our adopted new city a multiple organ transplant center of unprecedented variety and size. Bahnson reopened his long dormant heart program, which overnight became the largest one in the United States....

  24. 23 Politics
    (pp. 267-280)

    A few years ago, I went to the National Museum in Madrid (the Prado) to look again at a painting by Goya which had filled me with dread the first time I saw it in 1970. EntitledDuel with Cudgels,it shows two peasant gladiators in the countryside fighting to the death. They are flailing at each other with deadly weighted slings. The inhumanity in their faces can be seen by the lack of features, not by lines of cruelty or passion. With their feet and legs buried and transfixed in the ground, there is no escape. A small crowd...

  25. 24 Understanding Governor Lamm
    (pp. 281-287)

    Richard Lamm, governor of the State of Colorado from 1978 to 1986, was not the first person to question the cost efficiency of transplantation, but he became the most celebrated. Because I admired him so much, I was sorry to be chosen as his debating adversary. Few men or women in public life will speak their convictions so honestly as Lamm did routinely. This kind and courteous man already had provoked a fire storm by criticizing the wisdom of more than supportive medical care for the aged, and by suggesting that the old had an obligation to wither and die...

  26. 25 The Drug with No Name
    (pp. 288-308)

    Forty-five miles from Tokyo, the University of Tsukuba is located at the foot of the mountain from which the school and the village in which it is located take their name. Although the university is only two decades old, 10 to 15 percent of all the scientists in Japan are on its faculty. One reason is that more than 40 government institutes plus an additional 100 private institutes endowed and run by major corporations contribute to its campus. When I visited it in 1977, the village of Tsukuba was largely farmland. A decade later, it was an intellectual hotbed—and...

  27. 26 The Day the String Broke
    (pp. 309-317)

    I also would have a turn as a patient. Just after midday on May 29, 1981, I had realized that an unseen figure was waiting for me in the shadows. The day before, I had flown to Norfolk, Virginia, to remove a liver for a child from the state of Washington named Heidi Armeijo who had biliary atresia and was extremely ill in the intensive care unit of Children’s Hospital of Pittsburgh. Her swollen abdomen was crisscrossed with multiple scars from previous operations in the midst of which were two “rose buds”—the open ends of intestine that had been...

  28. 27 The Little Drummer Girls
    (pp. 318-333)

    Stormie Jones lost her anonymity and gained her life when she received a combined liver–heart transplantation on St. Valentine’s Day (February 14), 1984. Movie starlets might have envied her creative name and a smile that once seen was never forgotten. Notwithstanding these advantages, she had become a prisoner of intensive care units just after her sixth birthday because of a fast-forward version of a kind of heart disease usually reserved for older people.

    Stormie had been brought to the precipice by an inherited disorder of cholesterol metabolism which kills before or during the teenage years. What it is that...

  29. 28 Afterthought
    (pp. 334-340)

    When recognition comes to young men, it nourishes them like drops of gentle rain. With the burden of memories toward the end, honors can be like hailstones. In June 1991 in New Orleans, there were more prizes, beginning with a reception Saturday night. Remnants of the past moved in from the shadows, alive and well. Messages came from the first wave of kidney recipients—who had now entered their thirtieth year—and from the happy young wife who had been four years old when she received her liver more than twenty years before in January 1970.

    A Dallas contingent already...

  30. Epilogue
    (pp. 343-346)

    With completion of each further page ofThe Puzzle People, I realized that I was describing deeds and events without understanding what they meant. The most humbling gap, because it was so fundamental, was the inability to comprehend or even to have a plausible theory about how a transplanted organ was able to weather rejection and later to merge half-forgotten into its unnatural new home. Yet, on the first page, I had written: “It was not just the acquisition of a new part or parts; the rest of the body had to change in many ways before the gift could...

  31. Postscript
    (pp. 347-348)

    At the time the first epilogue was written in 1992, the patients who allowed their bodies to be searched for the presence of donor leukocytes already were the longest surviving “proof of principle examples of what could be accomplished with organ transplantation. During the eleven years since, they have demonstrated more and more convincingly that organ transplantation can be followed by a full and normal lifetime. Eight of the kidney recipients from 1962-63, including a now eighty-year-old man, have reached or passed the forty-year post-transplant mark with function of their original allografts. Seven years behind them, the first liver recipients...