International Journal of 12 (2014) 998e1002

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International Journal of Surgery

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Arts and humanities The Limit of a strong Lobby: Why did August Bier and never receive the Nobel Prize?

* Nils Hansson a, , Udo Schagen b a Institut für Ethik und Geschichte der Medizin, Universitatsmedizin€ Gottingen,€ Humboldtallee 36, D-37073 Gottingen,€ Germany b Institut für Geschichte der Medizin und Ethik in der Medizin, Charite - Universitatsmedizin€ Berlin, Thielallee 71, D-14159 Berlin, Germany highlights

 Bier and Sauerbruch were two of the most influential German surgeons.  In 1937, prohibited all German citizens to accept a Nobel Prize.  Bier and Sauerbruch were jointly awarded Hitler's alternative Nobel Prize.  Their research was not evaluated as Nobel Prize-worthy.  Political factors did not play a major role according to the protocols. article info abstract

Article history: August Bier (1861e1949) and Ferdinand Sauerbruch (1875e1951) have remained two of the most Received 14 December 2013 influential figures during the first half of the 20th century in German and even in international surgery. Received in revised form They were jointly awarded Adolf Hitler's German Science Prize in 1937, but never the Nobel Prize for 9 July 2014 Physiology or Medicine, although no other German surgeons were nominated as often as Bier and Accepted 30 July 2014 Sauerbruch for the prestigeful award from 1901 to 1950. This contribution gives an overview of the Available online 2 August 2014 reasons why and by whom Bier and Sauerbruch were nominated, and discusses the reasons of the Nobel Prize Committee for not awarding them. Keywords: © History of surgery 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. Nobel Prize for Physiology or Medicine August Bier Ferdinand Sauerbruch National Socialism

1. Introduction insufficiently examined by historians of surgery [9,10]. It offers tremendous opportunities to reconstruct international trends in The archive of the Nobel Assembly for Physiology or Medicine in surgery over time, to understand the impact of and lobbying Solna/Stockholm, Sweden, is a remarkable repository that contains around outstanding surgeons and to determine political effects in reports and dossiers of Nobel Prize nominations of physicians from the scientific community. This overview will focus on the interface around the world. A study of Nobel Prize nominations of cutting- of these themes by discussing the Nobel Archive files on two of the edge-surgeons helps us to piece together a large part of the great most prominent German surgeons of the last 100 years: August Bier advances in the field of surgery over the last century. Fifty years (1861e1949) and Ferdinand Sauerbruch (1875e1951). Their nomi- after the nomination year, historians may view the corresponding nators portrayed them as outstanding contemporary surgeons with yearbook. The Nobel Prize Archive has gained scholarly attention numerous scientific interests. We will trace their major scientific among historians, primarily in recent decades [1e8], but it has been achievements, briefly discuss their accomplishments in their spe- cific historical context, and finally examine why the Nobel Com- mittee for Physiology or Medicine decided not to award them. The medical historian Thomas Schlich has in this journal * Corresponding author. E-mail addresses: [email protected], [email protected] (N. Hansson), udo. described the surgical approach of solving problems in the 20th [email protected] (U. Schagen). century in general by analyzing the work of four Nobel laureate http://dx.doi.org/10.1016/j.ijsu.2014.07.274 1743-9191/© 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. N. Hansson, U. Schagen / International Journal of Surgery 12 (2014) 998e1002 999 surgeons, Theodor Kocher (1909), Alexis Carrel (1912), Egas Moniz started a campaign against Nature that succeeded in banning the (1949) and Joseph Murray (1990). Schlich concludes that “surgical journal from German libraries [20]. healing strategy goes along with dividing the body into structural … constituents [ ] and reframing medical problems in such a way 2.1. August Bier that they can be solved by fixing these body constituents” [11]. Kocher, Carrel and Murray received their Nobel medals in recog- Bier, born 1861 in Helsen (Germany), studied medicine in Berlin, nition of achievements linked to organ transplantation. Kocher had Leipzig and Kiel. In 1899 he was appointed Professor in Greifswald, fi performed the rst organ transplant in the modern sense by four years later he moved to the and succeeded replacing thyroid tissue to treat a complex internal disease. Carrel Ernst von Bergmann in Berlin in 1907. From 1907 to 1932 Bier had developed a suture to make the transplantation of organs worked as Professor and Chief Surgeon at the first university hos- possible, and Murray shared his Nobel Prize with E. Donnal Thomas pital of Berlin University, where he was consulted by famous pa- “ for their discoveries concerning organ and cell transplantation in tients such as Kaiser Wilhelm II, Nicholas II of Russia, Friedrich ” the treatment of human disease [12]. In fact, no less than eight Ebert and Lenin [21]. Over the years, Bier received numerous fi Nobel Prizes have been given to contributors in that eld. The Nobel prestigeful awards and honorary degrees for his research: the Committee obviously saw transplant surgery as a promising strat- Kußmaul Prize in 1906, the Cameron Prize 1910, and an honorary egy for treatment of various diseases. These awards have rarely doctorate in Edinburgh in 1910, just to mention a few. been questioned, unlike the Moniz' Prize. From today's perspective, If we should pinpoint the core of most nominations of Bier, this Moniz' Nobel Prize for the implementation of lobotomy as treat- sentence, written by the Basel surgeon Eugen Enderlen in 1907, ment for severe psychotic disorders appears questionable, but would be a strong argument: around 1950 it was seen as a major breakthrough that had been fi acknowledged by a great part of the scientific community [13]. Bier has developed new ideas in almost all elds of surgery [...] However, not just Nobel Prize recipients are crucial for a medical all together, I know among all living physicians no man, who is historian in pointing out cuts, turning points or even paradigm worthier [as Nobel Prize recipient] than Bier [22]. shifts in the last 100 years of surgical history. The theories of those scientists who almost received the Prize are particularly interesting, since their ideas e as will be shown e in some cases were viewed as too visionary by the Nobel Committee.

2. Nobel Prize nominations of August Bier and Ferdinand Sauerbruch

Nobel Prize nominations, as well as reports by the Nobel Com- mittee, were collected in the Nobel Archive for Physiology or Medicine in Solna, to answer the following questions: Why were Bier and Sauerbruch nominated, from whom, and why didn't they receive the prestigeful award? We will argue that the Nobel Com- mittee decision not to hand the award to Bier and/or Sauerbruch was not dependent on political circumstances, in spite of their ambiguous roles in the “Third Reich” [14e17], but rather because of the fact that their research output was not interpreted as original enough. The nomination by the Frankfurt surgeon Victor Schmieden in 1923 reads: “The leading positions among all Germans are held by two world-renowned surgeons: August Bier and Ferdinand Sauer- bruch” [18]. His proposal was not unique. On the contrary, no other German surgeons came even close to reaching such high Nobel Prize nomination numbers in the first half of the 20th century as Bier and Sauerbruch. Bier was officially proposed 42 times for the Nobel Prize, and Sauerbruch no less than 65 times. They were both nominated over quite a long time period and they got attention for more than one Bier was presented as an all-round surgeon. Some nominators research interest. Neither of them was nominated between 1937 even stated that it would be as “carrying owls to Athens” to moti- and 1945, probably for political reasons: on 30 January 1937 Adolf vate why he was a good candidate [23]. August Bier was nominated Hitler prohibited all German citizens to accept a Nobel Prize. This 42 times for the Nobel Prize during 1906e1936 by scientists from was a reaction to the awarding of the Nobel Peace Prize in 1935 to Germany, AustriaeHungary, Switzerland and Japan. Mainly two the pacifist, socialist and concentration camp inmate Carl von themes were highlighted: Firstly, the artificially induced hyperemia Ossietzky. As an alternative to the Nobel Prize Hitler created the and how, when and where to apply it, and secondly, the intro- German National Prize for Art and Science [19]. It was to be awarded duction of spinal in practice. The Nobel Committee was annually in a ceremony on the main Nazi Party congress. At the first interested in both and chose to evaluate them in detailed reports. ceremony in 1937, Bier and Sauerbruch were honored equally, not These reports show the strengths and weaknesses of Bier's only for their surgical skills, but probably also because they had methods from the individual perspective of the referee. Hence, the supported National Socialism in public statements. The Nobel Prize Nobel Prize process might have been, as still today, marked by vendetta was only one arrangement made by the National Socialist “human frailties” [24]. While the second “invention” still is used government to isolate cutting-edge German research from the in- daily all over the globe, the first is not well-known any longer and ternational arena. In 1936, German scientists and politicians also therefore needs a short note. Bier's hyperemia ideas, explained in 1000 N. Hansson, U. Schagen / International Journal of Surgery 12 (2014) 998e1002 the book Hyperamie€ als Heilmittel in 1903, were highlighted by the US surgeon Herbert F. Waterhouse five years later: I, in common with those who practise Bier's treatment, look upon inflammation as an attempt on the part of Nature to rid the tissues of the microbic invaders that attack any part of the body. I might almost describe inflammation as having, as its main function, that of excreting microbes. Bier's treatment has as its object the artificial stimulation of this excretory function by the production of a hyperaemia (venous or arterial), thus employ- ing, to the greatest available extent, the antimicrobic action of the blood, the value of which Nature abundantly points out to those who study her methods of producing, or attempting to produce, a natural cure in cases of microbic invasion of various tissues of the body [25].

Bier's hyperemia concept was described as an ideal therapy, which included effects like arrest of the infective process, preven- tion of suppuration, diminution of pain, and stimulation of the natural repairing process [26]. The Nobel Committee acknowledged these effects in a report in 1906, but it was not fully convinced of the theory since it lacked theoretical support. Thus it was seen as too visionary by the Nobel Committee and not sufficiently proven at that time. Among Bier's strongest Nobel Prize competitors in that year, who also were thoroughly evaluated, we find famous physi- ologists like Ernest Overton and Jaques Loeb and the subsequent Nobel laureates of 1906 in recognition of their work on the struc- ture of the nervous system: the bacteriologists Camillo Golgi and Santiago Ramon y Cajal. Today Bier is described as “the father of spinal and intravenous regional neural blockade” [27]. In 1909, Bier's spinal anesthesia was an item of controversy in the Committee discussions. The benefitof the spinal anesthesia was questioned by the Nobel Committee member and surgeon Jules Åkerman in 1909, and there were sci- entific priority disputes concerning the method between , Thedore Tuffier, Heinrich Irenaeus Quincke and others. Spinal anesthesia would not be recognized as a major breakthrough until a few years later, so it was apparently not patients. The Prize committee chose to evaluate “the artificial hand” thought prizeworthy in 1909 e only Theodor Kocher (Nobel Prize and “the chamber”. 1909) and Victor Horsley made it to the shortlist of the Nobel It was not unusual that the Nobel Committee brought up medical Committee that year. advances that had emerged during war or which had proven to be of great benefit to war surgery. For example, Alexis Carrel was awarded 2.2. Ferdinand Sauerbruch the Nobel Prize because of his development of a vascular suture in 1912, which also had been of importance to treat gunshot wounds. The Nobel Committee received numerous nominations concerning Sauerbruch, born 1875 in Barmen, Germany, studied medicine prosthetics in 1919, probably as an effect of the vast numbers of in Marburg and Leipzig. In 1903, Sauerbruch started to work in injured soldiers in the First World War. On the German side alone, collaboration with Johann von Mikulicz-Radecki in Breslau on his there were 2 million casualties, six of ten of them with injured limbs. perhaps most important surgical invention: the negative-pressure Numerous surgeons and engineers invented more than 300 new chamber, which enabled open thorax operations. After 1905, Sau- kinds of arms and legs and other prosthetic devices to help, which erbruch worked in Greifswald and Marburg and later on, in 1910, he made it hard to pinpoint the work of one single scientist as was appointed to the chair of surgery at the University of Zurich, at groundbreaking. In 1919, Sauerbruch was the only surgeon on the Munich in 1918 and at Berlin Charite during 1927e1949. short list of the Nobel Committee. “Sauerbruch's artificial hand” was As already mentioned, Sauerbruch was nominated on 65 occa- evaluated by the Swedish surgeon Frans Westermark. According to sions from 1912 to 1951. Thereby he is the most often nominated Westermark, Sauerbruchs work was not truly original and therefore surgeon for the Nobel Prize in the first half of the 20th century. Still not considered prize-worthy [28]. today his name is well-known throughout Germany. Schools and Another kind of scientific priority dispute was current in 1931, streets are named after him, Deutsche Post made a Sauerbruch this time regarding the idea and the implementation of the stamp to honour his memory, and contemporary surgeons occa- negative-pressure chamber. Except for Sauerbruch, Harvey Cushing sionally refer to themselves as being Sauerbruch's “grandchildren”, was a strong candidate among the nominated surgeons in that year. since their former teachers were scholars of Sauerbruch. Primarily Cushing had been (vainly) nominated for his contributions to the four achievements were mentioned in the nominations: The field of brain surgery, especially concerning difficult brain opera- negative-pressure chamber, the development of limb prosthetics, tions on intracranial tumors. However, Sauerbruch and Cushing the parabiotic experiment (an artificial combination of two or more could not, according to the Nobel Committee, excel the work of the laboratory animals) and the dietary theories for tuberculosis German physiologist Otto Heinrich Warburg. Warburg received the N. Hansson, U. Schagen / International Journal of Surgery 12 (2014) 998e1002 1001

Prize in 1931 for his discovery of the nature and mode of action of who worked in Istanbul. However, both were former Sauerbruch the respiratory enzyme. students. Let us have a look on the evaluation of Sauerbruch in 1931. The The deciding factors why neither Bier nor Sauerbruch were referee of the Prize jury, the Swedish Internist Hans Christian considered worthy of the award, in spite of the high number of Jacobaeus came to the conclusion, that Carlo Forlanini from Pavia nominations for promising works of scholarship, ultimately were and Ludolph Brauer from Breslau should be considered ahead of that they could be seen as “the person(s) who shall have made the Sauerbruch in the order of priority, since they had developed most important discovery within the domain of physiology or similar apparatus before Sauerbruch. Forlanini was a strong medicine” (Will of Alfred Nobel) [35]. On the one hand, their ac- candidate for the Prize in 1913 and 1914 (no Nobel Prizes were complishments could not be classified as original enough, and on awarded 1915e1918 due to the war) [29]. Brauers positive- the other hand their scholar works were marked by scientific pri- pressure-ventilation subsequently became the established proce- ority disputes. They were both thoroughly evaluated by the Nobel dure in clinical practice. The treatment of lung tuberculosis was a committee decades before Hitler's Nobel Prize vendetta. Therefore, current theme in the Nobel Committee discussions in the first de- political reasons did not play a major role in the Nobel committee cades of the 20th century. Goran€ Liljestrand, the Secretary of the discussions. Nobel Committee from 1918 to 1960, explained that other scientists were also considered: Ethical approval GS Dettweiler was nominated in 1903 for his pioneer work on the treatment of pulmonary tuberculosis by a combination of None. physical and dietetic methods. The originality of his contri- bution was not regarded as sufficiently distinct, however, to Funding justify an award, especially as H. Brehmer had suggested a similar therapy as early as 1857. The Committee likewise felt None. some doubt (1913e14) as to the originality of C. Forlanini's technique of treating pulmonary tuberculosis by introducing Author contribution air into the pleural sac (artificial pneumothorax), even if the practical results of this procedure, which had been devised in Nils Hansson: conception and design of the study, analysis and 1882 but not tested in practise until 1894, seemed to be good. interpretation of data, drafting the article. When M. de Abreu introduces mass examination of the lungs Udo Schagen: assisted with conception and design of the study, by photofluorography (1936), the chances for an early diag- analysis and interpretation of data, drafting of the article, and nosis of pulmonary tuberculosis were greatly improved; approved the final version to be submitted. thanks to his means the treatment can be started before the disease has had time to develop very far, and artificial pneu- Conflicts of interest mothorax can now be induced under more favourable condi- tions than previously [30]. None.

Acknowledgements 3. The Limit of a strong Lobby Files on surgeons in the Nobel archive were kindly provided by In three aspects, the nominations of Sauerbruch and Bier are the Nobel Committee for Physiology or Medicine. All translations similar: First, both were nominated for several works, ranging from from Swedish or German into English were made by Nils Hansson. “pure” surgical inventions to interdisciplinary or even homeopathic An earlier version of this paper was presented by Nils Hansson at a concepts as Bier's hyperemia. Second, the nominators came e with work-in-progress seminar at the Department of Social Studies of few exceptions e from Germany, Austria (-Hungary) or Medicine, McGill University, Montreal, in March 2014. Switzerland, and third, the remarkable cut in the nomination flow of Sauerbruch and Bier in the 1930s. References Bier was nominated almost exclusively by his peers from Ger- e [1] F. Luttenberger, Arrhenius vs. Ehrlich on immunochemistry: decisions about many, Switzerland and Austria Hungary. The most extensive scientific progress in the context of the Nobel Prize, J. Theor. Med. 13 (1992) nomination (twenty-five typewritten pages) was written in 1925 137e173. by the surgeon Rudolf Klapp from Marburg, who had worked with [2] F. Luttenberger, Excellence and chance: the Nobel Prize case of E. von Behring and E. Roux, Hist. Phil. Life Sci. 18 (1996) 225e238. Bier for many years [31]. It is interesting to note that Bier himself [3] E. Crawford, German scientists and Hitler's vendetta against the Nobel Prizes, chose to nominate the Internist Heinrich Irenaeus Quincke in 1908, Hist. Stud. Phys. Sci. 31 (1) (2000) 37e53. 1910 and 1920, the pharmacologist and enthusiastic homeopath [4] E. Crawford (Ed.), Historical Studies in the Nobel Archives: the Prizes in Sci- ence and Medicine, Universal Academy Press, Tokyo, 2002. Hugo Schulz in 1931, and Sauerbruch in 1925 and 1931. The nom- [5] E. Norrby, Nobel Prizes and Life Sciences, World Scientific Publishing Com- inations of Quincke indicate that Bier admired his colleague in Kiel, pany, Singapore, 2010. who had introduced the technique of llumbar puncture [32], and [6] E. Norrby, Nobel Prizes and Nature's Surprises, World Scientific Publishing the nomination of Schulz shows Bier's interest in homeopathy, Company, Singapore, 2013. [7] N. Hansson, S. Daan, Politics and physiology: Hermann Rein and the Nobel which he chose to study at a time when such theories had been Prize, J. Physiol. 592 (14) (2014) 2911e2914. rejected by the allopathic community [33]. Accordingly, Bier was [8] N. Hansson, T. Schlich, A “Life dedicated to true science”: Eduard Pflüger and fl “not only a knife artist”, as one put it [34]. the Nobel Prize for physiology or medicine, P ug Arch. (2014) (in press). [9] U. Trohler,€ Theodor Kochers Nobelpreis: Voraussetzungen, Bedingungen, Correspondingly, a very large proportion of the numerous Sau- Folgen. Ein Blick hinter die Kulissen, in: H. Steinke, et al. (Eds.), Schnitten, erbruch nominators were his former pupils or close faculty col- Knoten und Netze. 100 Jahre schweizerische Gesellschaft für Chirurgie, leagues. Only two nominators worked in medical schools outside of Chronos Verlag, Zürich, 2013, pp. 87e110. [10] N. Hansson, U. Schagen, In Stockholm hatte man offenbar irgendwelche Germany, Austria or Switzerland: Hayari Miyake from Fukuoka GegenbewegungeFerdinand Sauerbruch (1875e1951) und der Nobelpreis, Medical College at Kyoto Imperial University and Rudolf Nissen, NTM (2014) (in press). 1002 N. Hansson, U. Schagen / International Journal of Surgery 12 (2014) 998e1002

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