[T]he Nobel award casts a glow of pride over all those associated with the recipient, through their field of science, their professions, or their institutions.1
As I walked across the stage to meet King Gustav iv as he approached me from the opposite side, the whole experience seemed like a fairy tale. Here I was â a clinical doctor, a surgeon whose professional life was devoted primarily to taking care of patients â receiving the worldâs most prestigious scientific prize.2
These two quotes by surgeons, the first by Francis D. Moore and the second by Joseph Murray (Nobel laureate in physiology or medicine in 1990), show the extent to which surgeons consider the Nobel Prize to be the strongest symbol of scientific excellence in our time â this despite the fact that it has rarely been awarded to surgeons. Given the significance of the award, it is not surprising that its effects on the scientific community have inspired burgeoning scholarship by historians of medicine and science.3 The Nobel Prize archives in Sweden, made accessible for each year after a fifty-year delay (e.g., the records for 1969 will become available in 2019) offer scholars the opportunity to peer behind the curtain and study the selection process for Nobel laureates. Historians have payed particular attention to the Nobel committeeâs special investigations to reconstruct how the nominees were evaluated and a few were chosen to become laureates. In this chapter, we will focus not on the evaluation process but on the Nobel Prize nominations themselves in order to examine the standards of excellence, originality and credit used in and for surgery. What accomplishments were emphasized when a surgeon was nominated? When possible we also examine the jury investigations to study the mechanics of the
Nobel Prizes for the development of surgical procedures as such are relatively rare. To date, only four laureates are obvious: Theodor Kocher in 1909 âfor his work on the physiology, pathology and surgery of the thyroid glandâ, Alexis Carrel in 1912 âin recognition of his work on vascular suture and the transplantation of blood vessels and organsâ, António Egas Moniz in 1949 âfor his discovery of the therapeutic value of leucotomy in certain psychosesâ, and Joseph Murray in 1990 âfor discoveries concerning organ and cell transplantation in the treatment of human diseaseâ (official motivations by the Nobel Committee).4
However, the actual laureates represent only the tip of the iceberg. The nominations for the award are much more numerous. The first Nobel Prize was awarded in 1901. Nominations for surgeons soon followed. William Mayo, for instance, one of the founders of the acclaimed Mayo Clinic, was nominated by surgeon Albert John Ochsner in 1909:
The motive for this proposal lies in the fact that through his incessant scientific work, Dr. Mayo has increased the usefulness of surgical methods to so great an extent during the past ten years that the surgical profession from all parts of the World has followed his teaching both by visiting his clinics and by studying the great number of scientific monographs which he has produced to such an extent that virtually the entire surgical world has been able to increase its efficiency in the treatment of the sick.5
Lord Joseph Lister received a nomination the following year, having âdone more for the good of humanity than any other member of the medical profession of all countries at present livingâ.6
The rhetoric in these two examples is typical of Nobel nominations in their characterization of surgical candidates as scientific heroes, geniuses, world-leaders, and influential men of action.7 Following the lead of recent
Surgery is a particularly interesting field to study for this purpose because, as Jacalyn Duffin points out, â[no] medical heroes have enjoyed greater prestige than the surgeons of the late nineteenth and early twentieth centuries, surgeons who devised daring and previously inconceivable responses to internal pathologyâ.10 However, the lines of separation between surgery and internal medicine were often indistinct in the twentieth century, with both collaborations and overlap with other specialties. This makes it sometimes difficult to determine if a Nobel Prize candidate should be categorized as a surgeon. Topics such as hyperthyroidism, or certain neurological and psychiatric diagnoses, moved between the fields of surgery and medicine. The 1909 Nobel Prize for the surgeon Theodor Kocher, for instance, underlined his achievement in the physiology, pathology and surgery of the thyroid gland. For the purposes of this study, we have decided to view all candidates as surgeons if they were at least listed once as surgeons under the headline âtherapy/surgeryâ in the yearbooks of the Nobel Prize committee. The yearbooks were divided into sections for different thematic and disciplinary areas. Many specialists appeared under
Considering the rareness of Nobel Prizes in surgery, one might wonder if there was something about surgery as a field that made it less suitable for a prize. Alfred Nobelâs will of 1895 provides little specific guidance. It stipulated merely that the prizes should be given to âthose who, during the preceding year, shall have conferred the greatest benefit to mankindâ. Surgeons have certainly made innovations. They have opened up new domains of therapeutic action. Many patients have benefited. So what is the problem? Is it that surgeons develop techniques or devices instead of discovering new facts about nature? Is it that it is rarely possible to identify the one, two, or three people who deserve the prize for a particular innovation in surgery? In the following, we will discuss some possible reasons. Our main focus lies on transplant surgeons, cardiac surgeons, and brain surgeons. They represent three fields of surgery that received much attention from nominators and the Nobel Prize committee over certain periods of time.
Transplant Surgery
In the late nineteenth century, the idea that complex internal diseases could be successfully treated by replacing a failing organ was still met with skepticism. Thus the Amsterdam surgeon Otto Lanz wrote in 1897 that one should not make light of the idea of organ transplants even though the method looks like
The Nobel laureate Theodor Kocher was crucially involved in discovering the concept of organ replacement. In 1882, he performed the first organ transplant in the modern sense of replacing an organ to treat a complex internal disease when he implanted thyroid tissue into one of his patients to alleviate the symptoms occurring after a total thyroidectomy. This first transplant became the model for numerous experiments and therapeutic operations in organ transplantation and eventually led to the acceptance of the concept.14 As Ulrich Tröhler has shown, Kocher was nominated at least six times for the Prize starting in 1907, before he became the first surgeon to receive it. In his Nobel speech, Kocher mentioned the potential implications of his discovery of the function of the thyroid gland for transplantation as a new revolutionary mode of surgical therapy of internal diseases.15
The Nobel Prize for Alexis Carrel in 1912 was officially awarded to him in recognition of his suture technique that resulted in reliable vascular anastomoses without the formation of blood clots. The method allowed repairing injuries of the larger blood vessels, but, from the start, Carrel also aimed at using it to facilitate organ transplantation, as vascular reattachment was essential for the success of most transplanted organs. Among surgeons at the time, Carrelâs techniques were widely perceived as a breakthrough that would make organ transplants clinically viable.
Interestingly enough, Carrel was only nominated a few times, the first time in 1910 by Carl Beck with a short motivation: âThanking you for the honor conferred upon me I beg to submit the name of Alexis Carrel of the Rockefeller Institute of New York for his work on Surgery of the blood vesselsâ.16 Other nominations also mentioned his experimental work on new ways of transplanting animal tissue, and on its survival outside the body and its behavior after transplantation into a different animal, including Carrelâs attempts at growing adult animal and human tissue on artificial culture media in the context of cancer research.
In the first and last special investigation on behalf of the Nobel committee in 1912, the reviewer, surgeon Jules Ã
kerman, envisioned a huge potential for
Carrel received a diploma, a medal, and $39,000 (corresponds today to a value of $950,000), but the international renown was probably more important, as one commentator has suggested: âIf ever Carrel had been an ugly duckling, he was certainly now a swan. His laboratories on York Avenue became increasingly a place of pilgrimageâ.19 Carrelâs award was considered the first American Nobel Prize in physiology or medicine, although Carrel was a French citizen. In reaction, leading journals underlined the outstanding reputation of the award and at the same appreciated the choice made by the Nobel Committee. Soon after the prize had been announced, the Lancet emphasized Carrelâs âwonderful manipulative dexterity, his extraordinary originalityâ, and that the honour âdoes not come as a surpriseâ.20 Similarly, the Boston Medical and Surgical Journal (in 1928 renamed New England Journal of Medicine) stated that Carrel now âtakes his place formally and officially among the great ones of the earth by the award of the Nobel Prizeâ.21 The New York Times presented Carrelâs work as a âmiracle in surgeryâ.22
Our examination of the discussions about the Nobel Prize for Alexis Carrel in 1912 suggests that the Prize was meant to be a reward for a visionary new treatment strategy. Transplantation was seen as a promising technological fix for various complex internal diseases. Excellence in medicine was in this case
Cardiac Surgery
If one asked surgeons about the most dramatic developments in medicine in the twentieth century, cardiac surgery would certainly be on their list. Historians of medicine would probably agree. Surgeons had long been frightened of operating on the heart, as seen with the famous â and possibly apocryphal â warning of Theodor Billroth in 1882 (âAny surgeon who wishes to preserve the respect of his colleagues would never attempt to operate on the heartâ).24 The high caution towards this organ lasted until the 1940s, when it gave way to extraordinary surgical bravado and progress through the 1960s, embodied in first attempts to repair congenital heart disease through the drama of open heart surgery, heart transplantation, and artificial hearts.
Many of the key figures of this era were nominated for the Nobel Prize, including Evarts Graham for his work on thoracic surgery; Robert Gross, Clarence Crafoord, and Russel Brock for their work on vascular malformations; Alfred Blalock and Helen Taussig, for the famous âblue babyâ operation; and John Gibbon and Walt Lillehei for the heart-lung machines that made open heart surgery possible. Non-invasive procedures on the heart by thoracic surgeons also received some attention. In 1963, U.S. cardiac surgeon Claude S. Beck nominated William B Kouwenhoven, James R Jude, and Guy Knickerbocker for their work on closed chest massage for patients who suffered cardiac arrest. Beck used the opportunity to criticize the exaggerated attention paid to open heart surgery:
This contribution makes it possible to reverse the fatal heart attack outside the hospital, without opening the chest, without getting dirty and it
can be done by laymen [â¦]Society is heart-conscious â receptive to high recognition. Surgical operations on the heart are dramatic. They are technical, involve the use of the hands and to a lesser extent medical science. Surgical developments are important but they are primarily technical and their import is limited to the individual patient.25
The Nobel Prize nominations indicate the diversity of innovation that nominators valued. Sometimes they praised originality. Sometimes they highlighted fundamental contributions to surgery and to medical science. In other cases, they credited surgeons with opening up whole new areas of surgical therapeutics. For instance, when LM Freeman nominated Gibbon in 1959, he argued that
the tremendous strides made in the field of cardiovascular surgery overwhelm all other developments. In attempting to determine the reason for the remarkable achievement, many contributions come to oneâs mind. However, there appears to be a common denominator from which all of the advances stem. This is the pump oxygenator apparatus and to its first useful adaptation in both animals and man credit goes to John Gibbon.26
The heart was obviously an organ that elicited respect and fascination. The new ability to operate on it successfully was widely described as a revolution worthy of particular appreciation. This shows up clearly in the wording of the more than forty nominations for Alfred Blalock and Helen Taussig for their development of surgical repairs of congenital heart disease. A 1955 nomination, for example, argued that Blalock has had âa profound influence throughout the world of investigators, clinicians and surgeons to attack these problems from different angles for the improvement of mankindâ.27 Despite this enthusiasm, the Nobel committee never awarded the pair a prize. It requested confidential expert opinions on Blalock and Taussig, a brief examination of their case in 1947, and thorough special investigations in 1949, 1954, and 1956. The committee had different concerns in different years. In 1954 the two heart specialists were critiqued for having provided only palliation with their new techniques, and not a cure of the underlying disease. Timing proved to be important in this
As the Nobel archives become available for the late 1960s and 1970s, it will become possible to see how the committee responded to two other crucial innovations in cardiac surgery, each launched in 1967: heart transplantation and coronary artery bypass grafting. No prize was awarded for either technique. Why? Consider the case of bypass surgery.28 It is reasonable to assume that bypass surgery might have been nominated for a prize. The operation provided a successful treatment for coronary artery disease, a disease that was the leading cause of death in Europe and the United States throughout the twentieth century. It is now the leading cause of death worldwide. After the first large case series on bypass surgery was reported in 1968, the procedure quickly caught on. By 1977 US surgeons performed over 100,000 coronary bypass operations each year. The procedure quickly spread around the globe.
Despite its impact on cardiac surgery and on the lives of millions of patients worldwide, bypass surgery has not been recognized with a Nobel Prize. While it is only possible to speculate at this point, there are many reasons why it might have been difficult to award a Nobel for bypass surgery. First, it would be hard to define exactly what innovation the prize would be awarded for â for the idea, for its first clinical use, or for its first success in a large case series? Second, it would be hard to decide which individual should receive the prize.
Most surgeons give most of the credit for bypass surgery to two Cleveland surgeons: Donald Effler and René Favaloro.29 In 1967 and 1968 they used the procedure in hundreds of patients and convinced their colleagues that it was a viable and valuable approach. But Favaloro simply adapted a technique â saphenous vein grafting â that was already used by vascular surgeons in other parts of the body, for instance to repair renal artery stenosis. Moreover, many other surgeons in the 1950s and 1960s had tried the technique (using either a saphenous vein graft or an internal mammary artery graft) before Favaloro, including Gordon Murray (in animals), Robert Goetz, David Sabiston, Michael DeBakey, and Leningrad surgeon Vasili Kollesov.30 Consider the case of DeBakey, then the most famous surgeon in the United States, who led a large team of surgeons to develop new techniques of vascular surgery. His team tested coronary bypass surgery in dogs in the early 1960s, but they could not get the technique to work reliably. The grafts, for instance, often did not remain patent
Even though recent nominations are not yet available in the Nobel Archive, we know from other sources that DeBakey was nominated for his work on open heart surgery by Joseph Murray in 2003 (again, surgeons tend to nominate surgeons). The nomination emphasized DeBakeyâs many contributions to open-heart surgery, as well as his work in medical diplomacy:
Open-heart surgery has been a major contribution to the treatment of patients world-wide in the past half-century. Its import has not yet been recognized by the Nobel Foundation⦠One of the greatest achievements of the 20th century was the development of cardio-pulmonary bypass surgery by Michael DeBakey ⦠Dr. DeBakey has earned a worldwide reputation as an international medical statesman and humanitarian. He has served as advisor to almost every President of the United States over the past fifty years and to heads-of-state throughout the world. â¦He often took his team to perform and demonstrate cardiovascular operative procedures, while training his foreign colleagues throughout the globe. For his pioneering contributions to medicine and to humanity, Dr. DeBakey is nominated for the 2003 Nobel Prize in Medicine or Physiology [sic].32
This brief review demonstrates a few important points. First, the idea of bypass surgery itself was widespread in the 1960s. Whether the idea had occurred independently to many surgeons, had spread from one surgeon to another, or had been adapted from techniques already in use by surgeons operating on other parts of the body, there were many people who had the idea of using a graft of some sort to restore blood flow to the coronary arteries. Second, many people who did early procedures either did not publish their results (DeBakey and Sabiston), or published them in a way that obscured (Goetz) or undermined (Kolessov, whose article was accompanied by a critical commentary from the
Why was the idea so widespread? It may simply have been intuitively obvious to surgeons in Cleveland, New York, Leningrad, Baltimore, and Houston. It is also possible that there was a common ancestor of all of these ideas. The earliest account that we have found of bypass surgery is provided by none other than Alexis Carrel. Carrel described his attempt to use a segment of carotid artery to bypass the proximal coronary artery in a dog in 1910.34 However, he could not make the procedure work: the surgery took him five minutes, but the dog went into ventricular fibrillation after just three minutes and died. He speculated that it might be possible to perform the technique more quickly, using a Payr ring, which was exactly the technique that Goetz utilized fifty years later. So perhaps no prize was awarded for bypass surgery in the 1960s and 1970s because the committee concluded that the prize-worthy aspect of the innovation had already been awarded to Carrel.
As in many Nobel-worthy innovations, it is difficult to determine whether credit should go to the person who developed the idea, the person who first performed the operation on a patient, or the person who developed the procedure into a large clinical program. Perhaps the committee feared getting drawn into a priority fight between the US and ussr at the height of the Cold War. It could also be that they did not see the procedure as important enough, either because it was only US surgeons who were thoroughly enthusiastic about the procedure, or because it was quickly over-shadowed by coronary angioplasty â a technique that likely produced its own Nobel nominations. It is also possible that the committee saw bypass surgery as a trivial adaptation of Carrelâs work, in which case the rise of bypass surgery in the 1960s simply demonstrated the value of the committeeâs 1912 decision. We look forward to seeing what secrets the archives reveal when they are made accessible for historical research.
Neurosurgery and Brain Surgery
Like transplant and cardiac surgery, brain surgery was also seen as a spectacular transgression of the traditional limits of surgical work and a triumph
It seems to me that the contributions made by Harvey Cushing to neurological surgery through the development of his admirable technique, to the anatomical knowledge of the tumors of the brain, and to the physiology of the hypophysis are analogue to those made by Theodor Kocher to the surgery of the thyroid gland many years ago, and for which the Nobel Prize was awarded to him.35
Cushing was neither the first nor the last nominee in the field. During the first decade of the Prize, Alfred London put forward Victor Horsley (who later, in 1913, also was nominated by Theodor Kocher),36 and still during the 1950âs, scholars like Wilder Penfield and John Farquhar Fulton were proposed. According to the Nobel committee evaluator in 1954, Fultonâs work had links to Monizâ research recognized with the Prize in 1949. Thus, it would be impossible to hand it to him âpost festumâ.37
Victor Horsley, Harvey Cushing, and Wilder Penfield ended up on different shortlists of the Nobel Committee in various years.38 However, although both Horsley and Cushing were viewed as prize-worthy by some individuals in the prize jury, only António Egas Moniz was eventually awarded the prize in 1949 for the introduction of frontal lobotomy, an intervention that would no longer be prize-worthy from todayâs perspective. Moniz had been nominated by 18 scientists from 1928 to 1950 for two achievements: cerebral angiography and lobotomy.39 In 1936, Moniz published a monograph which described the operation of prefrontal lobotomy and the impressive results of its application to twenty cases of psychosis. At first, lobotomy received mixed reports from some reviewers, because it was mutilating and the negative side effects were still unclear. However, in the Nobel evaluation written in 1949, it was argued
We could not find much information in the nominations that mentioned patients who had benefitted from the innovations in question. One exception was the highlighted boldness of brain surgeons, leading to discussions concerning patient risk. In 1909, the Nobel Prize reviewer Frithiof Lennmalm suggested that Horsley âdares to perform bold new interventions on the brain. However, even if he has a breathtaking experimental skill, he sometimes thinks more like an experimental physiologist than as a reflective clinicianâ.42 This insinuation of recklessness indirectly pointed to a Horsleyâs possible indifference towards the patient as the potential victim of such boldness. The role of the patient was later brought up again in the Nobel nominations of Wilder Penfield. Besides describing how Penfieldâs work that had âmade possible the mapping of a part of the human cortex and should open a new chapter in the physiology of the brainâ,43 his nominators, here Albert Bertrand, stressed his patient-centered care:
Dr. Penfield has organized controlled clinical observation of the physiology and patho-physiology of the human brain to an extent not hitherto achieved, using techniques of stimulation and excision. These techniques were always applied for the benefit of the patient, not simply for experiment. From these operations have come outstanding contributions to the problems of focal epilepsy, cerebral sensory and motor elaboration and the localization of memory patterns and sensory perception. [â¦] Respectfully yours, W.R. Ingram.44
Cushing, with around 40 nominations but no prize, therefore falls into a category of what historian Franz Luttenberger provocatively has called âhighly
Conclusion
Historians and sociologists have long been interested in the role of excellence, credit and priority in medicine. Case studies of Nobel Prize nominations and Nobel committee reports offer important contributions to this discussion. As Robert Friedman has pointed out, winning a Nobel Prize has never been an automatic process.49 We believe it is important to look into how excellence has been attributed in order to deepen our understanding of reward mechanisms in medicine. In our case study of nominated (or possibly nominated) transplant, cardiac, and brain surgeons, we have found an emphasis on ideas of genius, scientific heroism, boldness, as well as utopian visions of the scientific solution of seemingly insurmountable problems.
In the discussions at the various levels of the prize awarding procedure one can see certain patterns. It is clearly not enough to be an excellent surgeon, not even to be âthe best surgeon in the worldâ, âthe teacher of all surgeons in the worldâ, or the researcher behind an eponym, may it be Cushingâs disease, Murphyâs button, or the Blalock-Taussig-shunt. Judging by the four individuals who have been awarded the Nobel Prize for the development of surgical procedures, excellence was measured by the potential impact of a particular discovery or innovation, especially when that innovation opened up a new area of surgical work. The construction of devices (like the heart-lung-machine), whether used in surgery or not, have also mostly not convinced the Nobel jury (the exception that proves the rule is Willem Einthovenâs Nobel Prize in 1924 âfor his discovery of the mechanism of the electrocardiogramâ). The same is true for mere technical improvements or a contribution to an ongoing development in the field. Similarly, a broad range of achievements, or gradual successful work was also not a route to a Nobel Prize. Instead, nominators had to highlight a âbreakthroughâ discovery or innovation that had broad consequences. In addition, it had to be a breakthrough that could clearly be attributed to one, two or three individual scientists. Surgery offered a unique way of impressing the committee with innovations that went beyond the traditional limits of medical possibilities or even broke âtaboosâ. Transplant, brain, and heart surgery all fit that mold. But that is a very narrow way of defining excellence, one that fits surgery only in a few specific cases. It includes Moniz, whom we would no longer reward with a Nobel Prize, but not Cushing, Penfield, Blalock and Taussig, all of whom remain prize-worthy in the eyes of modern surgeons. They embody an excellence that is more typical for surgery today. It may be that surgical excellence, as generally understood does not align well with the excellence that is normally recognized with a Nobel Prize.
As mentioned before, the question for us is not so much whether the decisions of the Nobel Committee were the right or the wrong ones, or whether a given surgeonâs achievements ought to have been impressive enough to win the prize. Instead, it is more a question of what kind of achievement was considered the most important and the most excellent at a particular time. There is no way to objectively measure such a thing. It is not a question of the presence or absence of excellence, or of âhow muchâ excellence there was. Instead, it was a question of the nature of excellence. The decision-making process and the award of the Prize itself is an example of enacting excellence, in the sense that we look at excellence as being dependent of its acknowledgment and attribution. Excellence as a category for surgery comes into being by being determined and performed in that process. Seen that way, awarding the âcrown jewel of excellenceâ to António Egas Moniz, for example, was not âwrongâ, it
Acknowledgments
Files on surgeons in the Nobel archive were kindly provided by the Nobel Committee for Physiology or Medicine. Translations from Swedish, German and French into English were made by the authors.
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