International Journal of Surgery (2007) 5, 129e133
www.theijs.com
REVIEW Nobel Prizes for surgeons: In recognition of the surgical healing strategy
Thomas Schlich*
Department Social Studies of Medicine, McGill University, 3647 Peel Street, Montreal, Quebec H3A 1X1, Canada
KEYWORDS Abstract Theodor Kocher (1909), Alexis Carrel (1912), Antonio Egas Moniz (1949) History of surgery; and Joseph E. Murray (1990) received Nobel Prizes for their accomplishments in the Nobel Prize; field of surgery. This essay puts these achievements in the context of the history of Thyroid surgery; surgery, in particular its recognition of a field of modern medicine. It characterizes Transplantation; the view of the body that is associated with modern surgery and the specific surgi- Psychosurgery cal healing strategy that the Nobel Prizes acknowledged. ª 2006 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
It has become possible within less than half medicine and less prestigious. Surgical practi- a century to expose all the organs of the body, tioners were mainly dealing with emergencies, brain and heart not excepted, without danger, and like broken bones, and minor manipulations at carry out the necessary surgical measures on the body’s surface, such as removing skin tumors them. or lancing boils. Surgical intervention was still This is Theodor Kocher’s triumphal account of associated with the horrors of pain and infection. the recent development of his field. It was part of Even more importantly, surgery seemed to make his lecture on the occasion of the Nobel Prize no sense in the treatment of most diseases award ceremony on December 11, 1909.1 It was anyway. Up until the early nineteenth century, the first Nobel Prize in Physiology or Medicine the body was understood as a functional whole, that went to a surgeon. To be given ‘‘to those interacting with its external environment. People who shall have conferred the greatest benefit of believed that diseases originated from disruptions mankind’’,2 the prestigious award sealed the re- in the balance of body fluids caused by the sick markable rise surgery had undergone not long ago. person’s way of life or some other environmental Traditionally, surgery was still a manual craft. It factor. Diseases could be treated by changing the was separate from the learned profession of environment or one’s way of living, or more technically, by restoring the humoral balance * Tel.: þ1 514 398 2059; fax: þ1 514 398 1498. through emetics, purgatives and blood letting. E-mail address: [email protected] Opening up the belly and cutting out some little
1743-9191/$ - see front matter ª 2006 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijsu.2006.04.012 130 T. Schlich part of the intestine, as today’s surgeons routinely remove the whole gland without any serious do in cases of appendicitis, would have looked short-term effects on his patients.7 However, absurd.3 As medical historian Christopher Law- those patients who had undergone total thyroidec- rence stresses, even the simplest surgical practices tomy developed a characteristic clinical picture, employ a theory of the body and disease, either which included all the symptoms we today associ- explicit or implicit. Even pulling a tooth, he ex- ate with a lack of thyroid function.8,9 Immediately plains, ‘‘implies a theory of the local origin of physiologists and surgeons started to use thyroid- pain and the relative harmlessness of removing ectomy in animals as a physiological experiment. a body part.’’4 The rationale that made modern This approach eventually led researchers to iden- surgery possible developed during the nineteenth tify the function of the thyroid gland and eventu- century, and it soon came to dominate modern ally to the development of endocrinology and medicine in general. It is based on the assumption organ transplantation.10 that the human body is a composite of organs and As surgical interventions in humans and planned tissues with particular functions. Diseases are experiments in animals showed, the removal of lesions of those organs and tissues that can affect particular organs resulted in specific syndromes. them at the structural or functional level. Surgery Vice versa, reinsertion of those organs could re- can rectify those disorders by removing the dis- verse these disorders. The procedure was adapted eased structures or restoring their function.5 to a number of other organs and diseases, linking The spread of the new view of the body and for example diabetes to the pancreas. As Kocher disease, together with the recently acquired pro- stated in his Nobel lecture, surgeons had taught fessional status of surgeons as university-trained the physiologists to bring the physiological activi- doctors provided the basis for the expansion of the ties of the organs to light.1 By literally separating field. Once anesthesia and asepsis had liberated organs from their bodily context, investigators surgeons from the problems of pain and infection, had elucidated the function of certain organs and they could start exploring the potential of their tissues and showed the way to understand and newly acquired abilities. Kocher’s extraordinary treat a number of enigmatic diseases. technical abilities led him to his discoveries about The idea of the divisibility the body and the ‘‘the physiology, pathology and surgery of the exchangeability of its constituents manifested thyroid gland’’6 that earned him his 1909 prize itself in the new field of organ transplantation, (Fig. 1). Systematically improving on his predeces- which was also initiated by Kocher. In July 1883 he sors’ procedures, the Swiss surgeon had developed tried to reverse the unexpected consequences of a technique of goiter resection that afforded an total thyroidectomy by reinserting thyroid tissue unprecedented degree of safety. He could even into the patient’s body. He thus performed the first organ transplantation in the modern sense of curing a complex internal disease by replacing an organ. Though the original transplant was sub- sequently replaced by better applicable methods of substituting the gland’s function, thyroid trans- plantation became the prototype of all other organ transplants. The principle was applied to the pancreas, testicles, ovaries, kidneys, etc.10 Thus, among many other transplants in animals and humans, in 1906 Mathieu Jaboulay in Lyons per- formed the first kidney transplant in a human being.11 It only seemed to be a question of time until all diseased organs and tissues could be re- placed by healthy ones, and surgeons were busy developing techniques to make that possible. The peak of technical perfection was reached by the French-American Alexis Carrel, who in 1912 won the second Nobel Prize for surgery in recognition of his work on blood vessel surgery and organ trans- plantation. His technical perfection made Carrel Figure 1 Theodor Kocher. Photograph by L. Zumbu¨hl, aware of the limits of exchangeability (Fig. 2). He Bern, courtesy of the Wellcome Medical Photographic noted that the success of allotransplants was Library. blocked by a problem that could not be solved by Nobel prizes for surgeons 131
surgical means. In an experiment Carrel grafted a dog’s kidney from its original site to the neck. His technical sophistication made sure that the kid- ney survived for an unlimited period of time, as long as it remained within the same animal. However, if the surgeon did exactly the same thing between dif- ferent individuals, the transplanted kidney invari- ably died.12 Apparently, the tissues of individuals of the same species possessed a biological individu- ality. Surgeons and scientist of the time described and analyzed this phenomenon and some of them even made the immune system responsible for what was increasingly called the ‘‘rejection’’ of for- eign tissues.10 Since this problem seemed to be insurmount- able, organ transplantation was temporarily aban- doned.10 It took until 1945 before scientists and doctors restarted transplant surgery. Despite continuing failures, they pursued their aim with remarkable optimism and perseverance.13 In 1954, surgeons at the Peter Bent Brigham hospital in Bos- ton transplanted a kidney from the healthy identi- cal twin brother to a man with severe renal disease. The transplant worked. It was considered a breakthrough and earned Joseph E. Murray the Nobel Prize in 1990. However, as he himself em- phasized in his Nobel lecture, ‘‘in a way, it was spying into the future because we had achieved our long-term goal by bypassing, but not solving, Figure 2 Alexis Carrel as a magician. Courtesy of the the issue of biological incompatibility’’ (Fig. 3).14 Wellcome Medical Photographic Library. In the early 1960s, the introduction of chemical
Figure 3 The first successful kidney transplantation, operating room, 7 doctors working, among them Joseph E. Murray. Courtesy of The National Archives of Plastic Surgery in the Francis A. Countway Library of Medicine. 132 T. Schlich immune suppression initiated a new phase in the Psychosurgery as a strategy of solving mental history of transplant surgery. The availability of disorders by surgical intervention, stood at the end more selective immunosuppressive agents since of an extended process of projecting social issues the 1980s accelerated the pace of growth of the into a particular organ of the individual’s body, the field.15,16 Transplantation became the technologi- brain. In pre-modern societies, deviant behavior cal fix of choice for the growing number of medical had been interpreted in a number of different problems that were redefined as being caused by ways, for example as a moral or a religious issue. organ malfunction. Instead of complicated and un- In modern times, strange behavior was declared to reliable measures for re-balancing the body and its be an illness and attributed to the medical domain. environment, a circumscribed intervention by Once the cause of mental illness was located in the a highly specialized expert sufficed to solve the brain, it seemed to be a logical step to try to solve problem (Fig. 4).17 the problem by fixing that organ. First attempts at Another such technological fix was awarded the psychosurgery in the late nineteenth century re- Nobel Prize in 1949. It was given to the Portuguese mained isolated experiments.21 It was only from the Antonio Egas Moniz for ‘‘the discovery of pre- 1930s to the 1950s that psychosurgery came to be frontal leucotomy’’, a surgical intervention to a widely used treatment option, especially in North relieve ‘‘morbid psychotic states accompanied by America, with lobotomy as its paradigmatic opera- affective tension . by destroying the frontal lobes tion. The procedure became popular after Egas or their connections to other parts of the brain’’, Moniz had published encouraging results from a se- as it was characterized in the official presentation ries of twenty operations on psychiatric patients speech.18 The case of lobotomy shows how in suffering from different kinds of problems in a certain historical context the strategy of the 1935.22 The surgeon offered an anatomy-based ex- technological fix can be particularly appealing to planation of his technique: for him, mental illness practitioners but fall into disgrace later on, so was a result of a ‘‘fixed loop’’ occurring in the nerve much so that today, many people consider the pathways of the neocortex, specifically the frontal Nobel Prize for Moniz an aberration.19 However, lobes, which were the seat of ‘‘psychic activity’’. at the time, this was not at all the case. Moniz Severing the white matter that connects the frontal got no less than 18 nominations for the Nobel Prize lobes to the sensory areas would interrupt the feed- between 1928 and 1950 (whereas Kocher had been back loops which were over-stimulating the pa- nominated six times, Carrel only once).20 tients. The visible short-term results in patients deeply impressed contemporary neurosurgeons. Some of them started to use the technique in the setting of mental hospitals on chronic schizo- phrenics. In the United States, in particular, this class of patient was seen as the most pressing prob- lem for the mental hospitals because there were no adequate treatments available for their condition. In the years following World War II, the use of psy- chosurgery reached its heyday, peaking at over five thousand such operations performed in 1949 alone.22 This was the year when Moniz was awarded the Nobel Prize for, according to the presentation speech, ‘‘one of the most important discoveries ever made in psychiatric surgery, because through its use a great number of suffering people and total invalids have recovered and have been socially rehabilitated’’.18 Lobotomy looked like a ‘‘natural extension’’ of existing somatic therapies, such as the various forms of ‘‘shock’’ therapy, and in some ways their fulfillment.22 Surgery proved to be a particularly attractive variety of somatic treatment. The imme- diately verifiable effects of surgical intervention, for instance, seemed to demonstrate that brain physiology and human behavior were connected Figure 4 Edgar Egas Moniz ª The Nobel Foundation. ‘‘in a way that was understandable to laboratory Nobel prizes for surgeons 133 science and open to practical intervention by 3. Schlich T. The emergence of modern surgery. In: Brunton D, trained physicians.’’22 This meant that psychiatry editor. Medicine transformed: health, disease and society e could claim to have a material basis. It also meant in Europe, 1800 1939. Manchester: Manchester University Press; 2004. p. 61e91. that through psychosurgery the field would be able 4. Lawrence C. Democratic, devine and heroic: the history and to catch up with other areas of modern medicine. historiography of surgery. In: Lawrence C, editor. Medical At that time, the best strategy for becoming ac- history and surgical practice. Studies in the history of sur- cepted as a part of ‘‘real’’ medicine was becoming gery. London and New York: Routledge; 1992. p. 1e47. like surgery. As Jack Pressman states in his analysis 5. Temkin O. The role of surgery in the rise of modern medical thought. Bull Hist Med 1951;25:248e59. of the lobotomy era, modern psychiatry seemed to 6. Mo¨rner KAH. Presentation speech. In: Nobel lectures. Phys- have advanced at last to the point where the treat- iology or medicine, 1942e1962. Amsterdam: Elsevier; 1967. ment of mental illness through repairing the brain p. 327e9. was ‘‘as mundane as when surgeons repair other 7. Kocher T. Die Indicationen zur Kropfexstirpation beim malfunctioning body parts.’’22 However, as the gegenwa¨rtigen Stande der Antisepsis. Correspondezblatt fu¨r Schweizer A¨rzte 1882;9:225e36, 260e57. use of lobotomy accelerated, the unease gener- 8. Kocher T. Ueber Kropfexstirpation und ihre Folgen. Verh ated by such a drastic intervention grew too. It Dtsch Ges Chir 1883;12(II):1e84. was still unclear what lobotomy actually did to 9. Tro¨hler U. Der Nobelpreistra¨ger Theodor Kocher 1841e the individual. The issue of a scientific validation 1917: Auf dem Weg zur physiologischen Chirurgie. Basel: could no longer be avoided. Follow-up studies pro- Birkha¨user; 1984. 23 10. Schlich T. Die Erfindung der Organtransplantation: Erfolg duced discouraging results. With the advent of und Scheitern des chirurgischen Organersatzes (1880e tranquilizers in the 1950s, lobotomy fell out of 1930). Frankfurt am Main: Campus; 1998 (English language favor. Clinical trials showed that the drug chlor- version forthcoming in 2007). promazine seemed to have the same effects as 11. Jaboulay M. Greffe de reins au pli du coude par soudures ar- a successful lobotomy, yet without the irreversible te´rielles et veineuses. Lyon me´dical. Rev Lyon Me´d 1906; 107:399e400. brain damage and disorientation associated with 12. Carrel A. Suture of blood-vessels and transplantation of 23 the surgery. Drug treatment became the new organs. Nobel lecture. In: Nobel lectures. Physiology or technological fix for mental disorders; a type of re- medicine, 1901e1921. Amsterdam: Elsevier; 1967. versible lobotomy, as contemporaries saw it.24 13. Fox RC, Swazey JP. The courage to fail: a social view of The surgical achievements that have been organ transplants and dialysis. Chicago: University of Chicago Press; 1974. honored with the Nobel Prize exemplify the spe- 14. Murray JE. Nobel lecture: the first successful organ trans- cifically surgical approach of solving problems by plants in man.