© 2015 Wiley Periodicals, Inc.
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Why Did Alfred Blalock and Helen Taussig Not Receive the Nobel Prize? Nils Hansson, Ph.D.,* and Thomas Schlich, M.D.y *Department of History of Medicine and Medical Ethics, Cologne University Hospital, Cologne, Germany; and yJames McGill Professor in the History of Medicine, Department Social Studies of Medicine, McGill University, Montreal, Quebec, Canada ABSTRACT Background: From the 1940s to the 1960s, the number of cardiac surgeons nominated for the Nobel Prize for Physiology or Medicine grew rapidly. These nominations pinpoint major developments ranging from the first closed extracardiac operations to the era of complete intracardiac repair and treatment of congenital heart diseases. The aim of this article is to present the motivations for the numerous Nobel Prize nominations for the cardiac surgeon Alfred Blalock and the pediatric cardiologist Helen B. Taussig, and to show why the Nobel committee finally chose not to award them for the development of the Blalock–Taussig shunt. Methods: The authors have gathered and analyzed files on Blalock and Taussig from the Nobel Prize archive for Physiology and Medicine in Solna, Sweden. Results and conclusions: More than forty scholars, primarily from the United States and Europe, nominated Blalock and Taussig for the Nobel Prize for Physiology or Medicine. Such a strong transatlantic support is rare for nominated surgeons. The authors discuss why the number of Nobel Prize nominations for cardiac surgeons in general reached a climax around the 1950s and formulate open research questions on why relatively few surgeons have received the prestigious prize for the development of surgical procedures. doi: 10.1111/jocs.12552 (J Card Surg
2015;30:506–509)
The surgeon Alfred Blalock (1899–1964) and the pediatric cardiologist Helen B. Taussig (1898–1986) received international recognition for developing the Blalock–Taussig shunt to treat tetralogy of Fallot, the most common cause of the blue baby syndrome.1 Among other rewards, they shared the Albert Lasker Clinical Medical Research Award in 1954, and in 1959, the first Gairdner Award was given jointly to Blalock and Taussig. The aim of this article is to present the motivations for the numerous Nobel Prize nominations for Blalock and Taussig, and to show why the Nobel committee finally chose not to award them. We will shed light on aspects of the history of cardiac surgery by relating to nominations and Nobel committee reports from the Nobel Prize archive at the Karolinska Institute in Solna, Sweden. Although this archive recently has gained scholarly attention among historians, this
Conflicts of interest: The authors acknowledge no conflict of interest in the submission. Funding: None Address for correspondence: Nils Hansson, Ph.D., Department of History of Medicine and Medical Ethics, Cologne University Hospital, Joseph-Stelzmann-Str. 20, Geb. 42, 50931 Cologne, Germany. Fax: þ49 221 478-6794; e-mail: [email protected]
specific area has, to date, been neglected. It provides us with the unique opportunity to examine how priority and originality were attributed to particular surgeons. In his speech at the European Association for Cardiothoracic Surgery, the surgeon John Kirklin characterized the period from 1954 to 1970 as an era of innovation in thoracic surgery.2 Accordingly, from the 1940s to the 1960s, the number of cardiac surgeons nominated for the Nobel Prize grew rapidly. These nominations pinpoint major developments ranging from the first closed extracardiac operations to the era of complete intracardiac repair and treatment of congenital heart diseases, for example the ligation of patent ductus arteriosus (PDA),3 coarctation repair,4 controlled cross-circulation,5 and pacemaker for complete heart block.6 Thus, outstanding cardiac surgeons, such as Robert Gross, Clarence Crafoord, Russel C. Brock, C. Walton Lillehei, Evarts A. Graham, and John Gibbon, kept being nominated for the Nobel Prize during these three decades. Most of the proposed cardiac surgeons were based in the United States. Eventually, only Cournand, and Dickinson Werner Forssmann, Andre Richards were selected by the Nobel Prize committee in 1956 for their discoveries concerning heart catheterization and pathological changes in the circulatory system.7
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HANSSON AND SCHLICH BLALOCK AND THE NOBEL PRIZE
MATERIALS AND METHODS: NOBEL PRIZE NOMINATIONS FOR BLALOCK AND TAUSSIG Blalock and Taussig were nominated more than 40 times for the Nobel Prize for Physiology or Medicine. Other historical studies of Nobel Prize candidates have shown that, usually, nominations almost exclusively come from fellow colleagues from their own university or their former students or close friends.8,9 This is, in part, also true for cardiac surgeons. For example, Owen Wangensteen nominated his former assistant Lillehei in 1955: ‘‘It seems to me that if the work of any surgeon during the past two decades should be considered in the deliberations of the Nobel Prize Committee presently, it should very much be in order to cite the
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work of Dr. Lillehei. That is the reason that I feel that I am fully justified in bringing his work to the notice of your Committee. Surgeons from all over the world have been here to see his work. I feel that this is one of the most important contributions in surgery in my generation…In fact, I think he represents, perhaps, the best brains in American Surgery.’’10 Blalock and Taussig were nominated by some of their Johns Hopkins colleagues, but also by professors from Germany, Great Britain, Turkey, Sweden, Iceland, Israel, and other countries as well (see Table 1). Such strong transatlantic support is rare for nominated surgeons. Most of the nominations referred to the Blalock–Taussig shunt to treat tetralogy of Fallot. The original cardiac operation was done by dividing the subclavian artery and
TABLE 1 Scientists Who Nominated Alfred Blalock and/or Helen Taussig for the Nobel Prize for Physiology or Medicine From 1947 to 1961 Year
Nominator
Nominee(s)
1947 1948 1948 1949 1949 1950 1950 1950 1950 1950 1950 1950 1950 1951 1951 1951 1951 1951 1951 1951 1951 1952 1953 1953 1953 1953 1953 1953 1953 1953 1954 1954 1954 1954 1954 1954 1954 1954 1955 1955 1955 1955 1959 1961 1961 1961
RK Ghormley, Rochester AC Chakar, Istanbul GH Whipple, Rochester CJ Heymans, Ghent JV Meigs, Boston W Denk, Vienna H Hellner, Goettingen CFW Illingworth, Glasgow H Kleinschmidt, Goettingen P Plum, Copenhagen R Schoen, Goettingen F v Bruecke, Vienna JB Youmans, Chicago CF de Garis, Oklahoma MA Dogliotti, Turin N Dungal, Reykjavik GH Whipple, Rochester H Elbel, Bonn CG Johnston, Detroit H Wulff, Lund HN Harkins, Seattle H Knipping, Cologne H Bredt, Leipzig SJ Crowe, Baltimore € hr, Leipzig G Wildfu DF Proctor, Baltimore FF Schwentker, Baltimore WW Scott, Baltimore W v Brunn, Leipzig AE Walker, Baltimore A St G Huggett, Baltimore JH Dible, London R Zenker, Marburg S van Creveld, Amsterdam R Cobet, Halle REM Bowden, London P Formijne, Amsterdam W Budde, Halle L Halpern, Jerusalem G Rosen, New York M Rachmilewitz, Jerusalem J Webster, New York E Pick, New York WW Scott, Baltimore RA Robinson, Baltimore TB Turner, Baltimore
A Blalock, H Taussig A Blalock, C Crafoord, SA Waksman CS Beck, A Blalock, H Taussig, R Gross A Blalock, H Taussig, DW Woolley A Blalock A Blalock, H Taussig SA Waksman, H Taussig, A Blalock A Blalock, H Taussig SA Waksman, H Taussig, A Blalock H Taussig A Blalock, H Taussig, PS Hench H Taussig, A Blalock A Blalock H Taussig, A Blalock A Blalock A Blalock, H Taussig, R Gross CS Beck, A Blalock, H Taussig, R Gross H Taussig, A Blalock EA Graham, A Blalock R Gross, A Blalock, H Taussig A Blalock A Blalock, H Taussig G Domagk, A Blalock, H Taussig A Blalock A Blalock, H Taussig H Taussig, A Blalock A Blalock, H Taussig A Blalock A Blalock, C Crafoord H Taussig, A Blalock H Taussig, A Blalock A Blalock, H Taussig H Taussig, A Blalock A Blalock, H Taussig A Blalock, H Taussig A Blalock, H Taussig, R Brock A Blalock, H Taussig, C Crafoord A Blalock, H Taussig A Blalock, H Taussig, M Sakel A Blalock, H Taussig, R Gross A Blalock, H Taussig, C Crafoord, R Gross, R Brock A Blalock, H Taussig H Taussig A Blalock A Blalock A Blalock
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constructing an end-to-side anastomosis to the pulmonary artery without vein graft.11 Arthur St. George Huggett’s (Johns Hopkins) nomination mirrors how most nominators viewed the origin of the Blalock– Taussig operation: ‘‘[...] My reasons for this nomination, put briefly, are that Dr. Helen Taussig by logical and reasoned steps based on physiological and experimental investigation designed a new operative treatment for the relief of certain congenital cardiac disabilities of childhood. Dr. Alfred Blalock, accepting her suggestions, performed the new surgical operations which have enabled patients to be very much improved in health and to have their expectation of life prolonged almost to that of normal subjects.’’12 RESULTS: PRIZEWORTHY OR NOT? NEGOTIATIONS IN THE NOBEL COMMITTEE FOR PHYSIOLOGY OR MEDICINE It is the job of the Nobel committee at the Karolinska Institute in Sweden to each year single out one, two, or three laureates out of hundreds of nominated researchers. Only after a few nominations for Blalock and Taussig, the Nobel committee ordered confidential expert opinions on them, a brief examination in 1947, and more extensive reports in 1949, 1954, and 1956. This represents the next step in the usual procedure of the award mechanism. In his evaluation of 1949, the €derlund concluded that Gross, surgeon Gustaf So Crafoord, Blalock, and Taussig would be worthy Nobel Prize laureates. However, since Gross had not been nominated that very year, it was not possible to hand it to him, therefore he did not recommend the other candidates either. Five years later, a report was written by John €m, who, just as So €derlund, was a professor of Hellstro €m surgery at the Karolinska Institute. Although Hellstro greatly appreciated Blalock and Taussig, he also mentioned a critical aspect, namely that the Blalock– Taussig shunt merely relieved cyanosis, whereas the €m congenital cardiac malformation remained. Hellstro meant that it was hard to single out a few individuals as particularly formative in the enormous developments in the field of heart surgery, but that Blalock, Taussig, and Gross should be seen as prizeworthy. In 1956, €m wrote his third Nobel Prize report on heart Hellstro surgery, this time with particular consideration of CP Bailey, A Blalock, RC Brock, C Crafoord, RC Gross, EA Graham, DE Harken, and H Taussig. It was the first year that Bailey and Harken had been nominated for their surgical approach to mitral stenosis.13,14 €m did not find their achievements original Hellstro enough for a Nobel Prize. Instead, he once more recommended Gross, Blalock, and Taussig. This time he added that Blalock’s and Taussig’s method was not that relevant anymore (other methods of correction, which utilized ancillary techniques had been developed), but in light of its particular historical context, it was obvious that they had opened up a new path in cardiac surgery and, therefore, were prizeworthy.
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€derlund and Hellstro €m did not The evaluators So manage to convince the Prize jury of their dream candidates. Other scientists were finally chosen, probably because their research coincided with the interests of prize jury members. Also other factors beyond the actual achievement play important roles in the selection process, such as strong competition within one field and timing. This becomes clear when we look at all the discoveries that did not get awarded, such as Blalock’s and Taussig’s, but it is even more striking in those that would no longer qualify for the nio Egas Moniz’ Prize Nobel Prize later on, such as Anto for lobotomy in 1949.15 Blalock’s and Taussig’s work had been considered prizeworthy in the first place on the merits of its breakthrough character. One of the central points in the negotiations about awarding the Prize was the question of whether the discovery had opened up a new sphere of activity in research, diagnostics, or therapy. Small and incremental changes would not fulfill these conditions. It had to be something that removed some obstacle that was seen longstanding and difficult to overcome. In keeping with the idea of identifying prizeworthy individual achievements rather than collective progress in a field, some nominators stressed Blalock’s crucial role, for example William Wallace Scott in 1961: ‘‘Few milestones in the development of the fields of medicine and surgery have been so clearly marked by the contribution of a single individual. [...] To me, a surgeon, Dr. Blalock’s contributions to Surgery have been the most outstanding ones of any surgeon in America in the last 2 decades.’’16 Blalock’s assistant and surgical technician Vivien Thomas was never mentioned by name in the nominations or in the Nobel committee reports. However, it is possible that the Nobel committee knew about Thomas’ major contributions regarding the formulation and surgical success of the Blalock–Taussig shunt and that it, therefore, lessened Blalock’s chances. In our case, one of the obstacles that was overcome by the Nobel Prize candidates was the traditional taboo associated with the heart as an object of surgery. Theodor Billroth, for example, allegedly claimed as late as 1882 that ‘‘[a]ny surgeon who wishes to preserve the respect of his colleagues would never attempt to operate on the heart.’’17 Fourteen years later, in 1896, the English physician Stephen Paget wrote: ‘‘Surgery of the heart has probably reached the limits set by Nature to all surgery: no new method, and no new discovery, can overcome the natural difficulties that attend a wound of the heart’’.18 Even if the reliability of these two quotes has been questioned,19 it is not an exaggeration to say that the heart was an organ that elicited respect and fascination. Being able to successfully operate on and fix that organ must have felt like a revolution worthy of particular attention and appreciation. This shows in the wordings of the nominations, such as an ‘‘opening up an entirely new field for medical research’’20 that has ‘‘had a profound influence throughout the world of investigators, clinicians and surgeons to attack these problems from different angles for the improvement of mankind’’,21 a
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‘‘pioneering in methods of treatment’’,22 ‘‘path-breaking’’23…an ‘‘original discovery’’…which ‘‘extended the frontiere of surgery for the alleviation of human suffering’’…an ‘‘epochal advance’’.24 We can see an imagery of breakthrough, clearing off of obstacles, and liberation, which is typical for the rhetoric of high-profile scientific excellency in the context of the Nobel Prize. Open questions Nobel Prizes for the development of surgical procedures are rare (Alexis Carrel 1909, Emil Theodor nio Egas Moniz 1949, and Joseph Kocher 1912, Anto Murray 1990), but there have been several Nobel laureates who were trained as surgeons, such as Allvar Gullstrand 1911, Robert Barany 1914, Frederick Banting 1929, Alexander Fleming 1945, Walter Rudolf Hess 1949, Werner Forssmann 1956, and Charles Huggins 1966, as well as the previously mentioned Carrel, Kocher, and Murray. Our investigation about cardiac surgeons, who were repeatedly proposed for the Nobel Prize, but never received the award, highlights important research questions that need to be further explored in order to better understand scientific reward mechanisms: What does a surgeon have to achieve to receive the Nobel Prize, the most prestigious benchmark of scientific excellence in our time? Why have relatively few surgeons received the award for surgical work, and is this unfortunate trend likely to be continued in the light of the broad range of surgical investigations now being pursued? Acknowledgments: Files on the mentioned surgeons in the Nobel Prize archive were kindly provided by the Nobel Committee for Physiology or Medicine, Medicinska Nobelinstitutet, Solna, Sweden.
REFERENCES 1. Blalock A, Taussig HB: The surgical treatment of malformations of the heart in which there is pulmonary stenosis or atresia. JAMA 1945;128:189–202. 2. Turina M: Fifty years of cardiothoracic surgery through the looking glass and what the future holds. J Thorac Cardiovasc Surg 2008;136:1117–1122. 3. Gross RE, Hubbard JP: Surgical ligation of CNY a patent ductus arteriosus. Report of first successful case. JAMA 1939;112:729–731. 4. Crafoord C, Nylin G: Congenital coarctation of the aorta and its surgical treatment. J Thorac Surg 1945;14:347–361.
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5. Lillehei CW, Cohen M, Warden HE, et al.: The results of direct vision closure of ventricular septal defects in eight patients by means of controlled cross-circulation. Surg Gynecol Obstet 1955;101:446–466. 6. Lillehei CW, Gott VL, Hodges PC, et al.: Transistor pacemaker for treatment of complete atrioventricular dissociation. JAMA 1960;172:2006–2010. 7. Hansson N, Packy LM, Halling T, et al.: Vom Nobody zum Nobelpreistr€ ager? Der Fall Werner Forßmann Urologe 2015;3:412–419. 8. Hansson N, Schagen U: ‘‘In Stockholm hatte man offenbar irgendwelche Gegenbewegung‘‘—Ferdinand Sauerbruch (1875–1951) und der Nobelpreis. NTM 2014;22:133–161. 9. Hansson N, Schagen U: The limit of a strong lobby: Why did August Bier and Ferdinand Sauerbruch never receive the Nobel Prize? Int J Surg 2014;12: 998–1002. 10. Nobel Archive (NA): Nomination for CW Lillehei by O Wangensteen, Minneapolis, Jan. 10, 1955. 11. Yuan S-M., Shinfeld A, Raanani E: The Blalock–Taussig shunt. J Card Surg 2009;24:101–108. 12. NA: Nomination for H. Taussig and A Blalock by A. St. G. Huggett, Baltimore, Dec. 17, 1953. 13. Bailey CP: The surgical treatment of mitral stenosis (mitral commissurotomy). Dis Chest 1949;15:377–397. 14. Harken DE, Ellis LB, Ware PF, et al.: The surgical treatment of mitral stenosis. I Valvuloplasty. N Engl J Med 1948;239:801–806. 15. Hansson N, Schlich T: ‘‘Highly qualified loser‘‘? Harvey Cushing and the nobel prize. J Neurosurg 2015;2:1–4. 16. NA: Nomination for Blalock by William Wallace Scott, Baltimore, Jan. 16, 1961. 17. Translation by Westaby S. The foundation of cardiac surgery. Landmarks in cardiac surgery. 1997;Oxford, UK: Isis Medical Media Ltd, p. 15. 18. Altman LK: Who goes first?: The story of self-experimentation in medicine. 1987;University of California Press, p. 39. 19. Naef AP: The story of thoracic surgery. Milestones and pioneers. 1990; Lewiston, NY: Hogrefe & Huber Publishers, p. 75. 20. NA: Nomination for Blalock/Taussig/Manfred Sakel, by L. Halpern, Dept of Neurology, Jerusalem, December 22, 1954. 21. NA: Nomination for Taussig and Blalock by J. Webster, New York, Jan. 26, 1955. 22. NA: Nomination for Taussig, Blalock and Gross by G. Rosen, New York, Dec. 28, 1954. 23. NA: Nomination for Blalock and Taussig by S. van Crefeld, Amsterdam, Jan. 25, 1954. 24. NA: Nomination for Taussig and Blalock by CF de Garis, Oklahoma, Dec. 25, 1950.
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Why Did Alfred Blalock and Helen Taussig Not Receive the Nobel Prize? Nils Hansson, Ph.D.,* and Thomas Schlich, M.D.y *Department of History of Medicine and Medical Ethics, Cologne University Hospital, Cologne, Germany; and yJames McGill Professor in the History of Medicine, Department Social Studies of Medicine, McGill University, Montreal, Quebec, Canada ABSTRACT Background: From the 1940s to the 1960s, the number of cardiac surgeons nominated for the Nobel Prize for Physiology or Medicine grew rapidly. These nominations pinpoint major developments ranging from the first closed extracardiac operations to the era of complete intracardiac repair and treatment of congenital heart diseases. The aim of this article is to present the motivations for the numerous Nobel Prize nominations for the cardiac surgeon Alfred Blalock and the pediatric cardiologist Helen B. Taussig, and to show why the Nobel committee finally chose not to award them for the development of the Blalock–Taussig shunt. Methods: The authors have gathered and analyzed files on Blalock and Taussig from the Nobel Prize archive for Physiology and Medicine in Solna, Sweden. Results and conclusions: More than forty scholars, primarily from the United States and Europe, nominated Blalock and Taussig for the Nobel Prize for Physiology or Medicine. Such a strong transatlantic support is rare for nominated surgeons. The authors discuss why the number of Nobel Prize nominations for cardiac surgeons in general reached a climax around the 1950s and formulate open research questions on why relatively few surgeons have received the prestigious prize for the development of surgical procedures. doi: 10.1111/jocs.12552 (J Card Surg
2015;30:506–509)
The surgeon Alfred Blalock (1899–1964) and the pediatric cardiologist Helen B. Taussig (1898–1986) received international recognition for developing the Blalock–Taussig shunt to treat tetralogy of Fallot, the most common cause of the blue baby syndrome.1 Among other rewards, they shared the Albert Lasker Clinical Medical Research Award in 1954, and in 1959, the first Gairdner Award was given jointly to Blalock and Taussig. The aim of this article is to present the motivations for the numerous Nobel Prize nominations for Blalock and Taussig, and to show why the Nobel committee finally chose not to award them. We will shed light on aspects of the history of cardiac surgery by relating to nominations and Nobel committee reports from the Nobel Prize archive at the Karolinska Institute in Solna, Sweden. Although this archive recently has gained scholarly attention among historians, this
Conflicts of interest: The authors acknowledge no conflict of interest in the submission. Funding: None Address for correspondence: Nils Hansson, Ph.D., Department of History of Medicine and Medical Ethics, Cologne University Hospital, Joseph-Stelzmann-Str. 20, Geb. 42, 50931 Cologne, Germany. Fax: þ49 221 478-6794; e-mail: [email protected]
specific area has, to date, been neglected. It provides us with the unique opportunity to examine how priority and originality were attributed to particular surgeons. In his speech at the European Association for Cardiothoracic Surgery, the surgeon John Kirklin characterized the period from 1954 to 1970 as an era of innovation in thoracic surgery.2 Accordingly, from the 1940s to the 1960s, the number of cardiac surgeons nominated for the Nobel Prize grew rapidly. These nominations pinpoint major developments ranging from the first closed extracardiac operations to the era of complete intracardiac repair and treatment of congenital heart diseases, for example the ligation of patent ductus arteriosus (PDA),3 coarctation repair,4 controlled cross-circulation,5 and pacemaker for complete heart block.6 Thus, outstanding cardiac surgeons, such as Robert Gross, Clarence Crafoord, Russel C. Brock, C. Walton Lillehei, Evarts A. Graham, and John Gibbon, kept being nominated for the Nobel Prize during these three decades. Most of the proposed cardiac surgeons were based in the United States. Eventually, only Cournand, and Dickinson Werner Forssmann, Andre Richards were selected by the Nobel Prize committee in 1956 for their discoveries concerning heart catheterization and pathological changes in the circulatory system.7
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HANSSON AND SCHLICH BLALOCK AND THE NOBEL PRIZE
MATERIALS AND METHODS: NOBEL PRIZE NOMINATIONS FOR BLALOCK AND TAUSSIG Blalock and Taussig were nominated more than 40 times for the Nobel Prize for Physiology or Medicine. Other historical studies of Nobel Prize candidates have shown that, usually, nominations almost exclusively come from fellow colleagues from their own university or their former students or close friends.8,9 This is, in part, also true for cardiac surgeons. For example, Owen Wangensteen nominated his former assistant Lillehei in 1955: ‘‘It seems to me that if the work of any surgeon during the past two decades should be considered in the deliberations of the Nobel Prize Committee presently, it should very much be in order to cite the
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work of Dr. Lillehei. That is the reason that I feel that I am fully justified in bringing his work to the notice of your Committee. Surgeons from all over the world have been here to see his work. I feel that this is one of the most important contributions in surgery in my generation…In fact, I think he represents, perhaps, the best brains in American Surgery.’’10 Blalock and Taussig were nominated by some of their Johns Hopkins colleagues, but also by professors from Germany, Great Britain, Turkey, Sweden, Iceland, Israel, and other countries as well (see Table 1). Such strong transatlantic support is rare for nominated surgeons. Most of the nominations referred to the Blalock–Taussig shunt to treat tetralogy of Fallot. The original cardiac operation was done by dividing the subclavian artery and
TABLE 1 Scientists Who Nominated Alfred Blalock and/or Helen Taussig for the Nobel Prize for Physiology or Medicine From 1947 to 1961 Year
Nominator
Nominee(s)
1947 1948 1948 1949 1949 1950 1950 1950 1950 1950 1950 1950 1950 1951 1951 1951 1951 1951 1951 1951 1951 1952 1953 1953 1953 1953 1953 1953 1953 1953 1954 1954 1954 1954 1954 1954 1954 1954 1955 1955 1955 1955 1959 1961 1961 1961
RK Ghormley, Rochester AC Chakar, Istanbul GH Whipple, Rochester CJ Heymans, Ghent JV Meigs, Boston W Denk, Vienna H Hellner, Goettingen CFW Illingworth, Glasgow H Kleinschmidt, Goettingen P Plum, Copenhagen R Schoen, Goettingen F v Bruecke, Vienna JB Youmans, Chicago CF de Garis, Oklahoma MA Dogliotti, Turin N Dungal, Reykjavik GH Whipple, Rochester H Elbel, Bonn CG Johnston, Detroit H Wulff, Lund HN Harkins, Seattle H Knipping, Cologne H Bredt, Leipzig SJ Crowe, Baltimore € hr, Leipzig G Wildfu DF Proctor, Baltimore FF Schwentker, Baltimore WW Scott, Baltimore W v Brunn, Leipzig AE Walker, Baltimore A St G Huggett, Baltimore JH Dible, London R Zenker, Marburg S van Creveld, Amsterdam R Cobet, Halle REM Bowden, London P Formijne, Amsterdam W Budde, Halle L Halpern, Jerusalem G Rosen, New York M Rachmilewitz, Jerusalem J Webster, New York E Pick, New York WW Scott, Baltimore RA Robinson, Baltimore TB Turner, Baltimore
A Blalock, H Taussig A Blalock, C Crafoord, SA Waksman CS Beck, A Blalock, H Taussig, R Gross A Blalock, H Taussig, DW Woolley A Blalock A Blalock, H Taussig SA Waksman, H Taussig, A Blalock A Blalock, H Taussig SA Waksman, H Taussig, A Blalock H Taussig A Blalock, H Taussig, PS Hench H Taussig, A Blalock A Blalock H Taussig, A Blalock A Blalock A Blalock, H Taussig, R Gross CS Beck, A Blalock, H Taussig, R Gross H Taussig, A Blalock EA Graham, A Blalock R Gross, A Blalock, H Taussig A Blalock A Blalock, H Taussig G Domagk, A Blalock, H Taussig A Blalock A Blalock, H Taussig H Taussig, A Blalock A Blalock, H Taussig A Blalock A Blalock, C Crafoord H Taussig, A Blalock H Taussig, A Blalock A Blalock, H Taussig H Taussig, A Blalock A Blalock, H Taussig A Blalock, H Taussig A Blalock, H Taussig, R Brock A Blalock, H Taussig, C Crafoord A Blalock, H Taussig A Blalock, H Taussig, M Sakel A Blalock, H Taussig, R Gross A Blalock, H Taussig, C Crafoord, R Gross, R Brock A Blalock, H Taussig H Taussig A Blalock A Blalock A Blalock
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constructing an end-to-side anastomosis to the pulmonary artery without vein graft.11 Arthur St. George Huggett’s (Johns Hopkins) nomination mirrors how most nominators viewed the origin of the Blalock– Taussig operation: ‘‘[...] My reasons for this nomination, put briefly, are that Dr. Helen Taussig by logical and reasoned steps based on physiological and experimental investigation designed a new operative treatment for the relief of certain congenital cardiac disabilities of childhood. Dr. Alfred Blalock, accepting her suggestions, performed the new surgical operations which have enabled patients to be very much improved in health and to have their expectation of life prolonged almost to that of normal subjects.’’12 RESULTS: PRIZEWORTHY OR NOT? NEGOTIATIONS IN THE NOBEL COMMITTEE FOR PHYSIOLOGY OR MEDICINE It is the job of the Nobel committee at the Karolinska Institute in Sweden to each year single out one, two, or three laureates out of hundreds of nominated researchers. Only after a few nominations for Blalock and Taussig, the Nobel committee ordered confidential expert opinions on them, a brief examination in 1947, and more extensive reports in 1949, 1954, and 1956. This represents the next step in the usual procedure of the award mechanism. In his evaluation of 1949, the €derlund concluded that Gross, surgeon Gustaf So Crafoord, Blalock, and Taussig would be worthy Nobel Prize laureates. However, since Gross had not been nominated that very year, it was not possible to hand it to him, therefore he did not recommend the other candidates either. Five years later, a report was written by John €m, who, just as So €derlund, was a professor of Hellstro €m surgery at the Karolinska Institute. Although Hellstro greatly appreciated Blalock and Taussig, he also mentioned a critical aspect, namely that the Blalock– Taussig shunt merely relieved cyanosis, whereas the €m congenital cardiac malformation remained. Hellstro meant that it was hard to single out a few individuals as particularly formative in the enormous developments in the field of heart surgery, but that Blalock, Taussig, and Gross should be seen as prizeworthy. In 1956, €m wrote his third Nobel Prize report on heart Hellstro surgery, this time with particular consideration of CP Bailey, A Blalock, RC Brock, C Crafoord, RC Gross, EA Graham, DE Harken, and H Taussig. It was the first year that Bailey and Harken had been nominated for their surgical approach to mitral stenosis.13,14 €m did not find their achievements original Hellstro enough for a Nobel Prize. Instead, he once more recommended Gross, Blalock, and Taussig. This time he added that Blalock’s and Taussig’s method was not that relevant anymore (other methods of correction, which utilized ancillary techniques had been developed), but in light of its particular historical context, it was obvious that they had opened up a new path in cardiac surgery and, therefore, were prizeworthy.
J CARD SURG 2015;30:506–509
€derlund and Hellstro €m did not The evaluators So manage to convince the Prize jury of their dream candidates. Other scientists were finally chosen, probably because their research coincided with the interests of prize jury members. Also other factors beyond the actual achievement play important roles in the selection process, such as strong competition within one field and timing. This becomes clear when we look at all the discoveries that did not get awarded, such as Blalock’s and Taussig’s, but it is even more striking in those that would no longer qualify for the nio Egas Moniz’ Prize Nobel Prize later on, such as Anto for lobotomy in 1949.15 Blalock’s and Taussig’s work had been considered prizeworthy in the first place on the merits of its breakthrough character. One of the central points in the negotiations about awarding the Prize was the question of whether the discovery had opened up a new sphere of activity in research, diagnostics, or therapy. Small and incremental changes would not fulfill these conditions. It had to be something that removed some obstacle that was seen longstanding and difficult to overcome. In keeping with the idea of identifying prizeworthy individual achievements rather than collective progress in a field, some nominators stressed Blalock’s crucial role, for example William Wallace Scott in 1961: ‘‘Few milestones in the development of the fields of medicine and surgery have been so clearly marked by the contribution of a single individual. [...] To me, a surgeon, Dr. Blalock’s contributions to Surgery have been the most outstanding ones of any surgeon in America in the last 2 decades.’’16 Blalock’s assistant and surgical technician Vivien Thomas was never mentioned by name in the nominations or in the Nobel committee reports. However, it is possible that the Nobel committee knew about Thomas’ major contributions regarding the formulation and surgical success of the Blalock–Taussig shunt and that it, therefore, lessened Blalock’s chances. In our case, one of the obstacles that was overcome by the Nobel Prize candidates was the traditional taboo associated with the heart as an object of surgery. Theodor Billroth, for example, allegedly claimed as late as 1882 that ‘‘[a]ny surgeon who wishes to preserve the respect of his colleagues would never attempt to operate on the heart.’’17 Fourteen years later, in 1896, the English physician Stephen Paget wrote: ‘‘Surgery of the heart has probably reached the limits set by Nature to all surgery: no new method, and no new discovery, can overcome the natural difficulties that attend a wound of the heart’’.18 Even if the reliability of these two quotes has been questioned,19 it is not an exaggeration to say that the heart was an organ that elicited respect and fascination. Being able to successfully operate on and fix that organ must have felt like a revolution worthy of particular attention and appreciation. This shows in the wordings of the nominations, such as an ‘‘opening up an entirely new field for medical research’’20 that has ‘‘had a profound influence throughout the world of investigators, clinicians and surgeons to attack these problems from different angles for the improvement of mankind’’,21 a
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HANSSON AND SCHLICH BLALOCK AND THE NOBEL PRIZE
‘‘pioneering in methods of treatment’’,22 ‘‘path-breaking’’23…an ‘‘original discovery’’…which ‘‘extended the frontiere of surgery for the alleviation of human suffering’’…an ‘‘epochal advance’’.24 We can see an imagery of breakthrough, clearing off of obstacles, and liberation, which is typical for the rhetoric of high-profile scientific excellency in the context of the Nobel Prize. Open questions Nobel Prizes for the development of surgical procedures are rare (Alexis Carrel 1909, Emil Theodor nio Egas Moniz 1949, and Joseph Kocher 1912, Anto Murray 1990), but there have been several Nobel laureates who were trained as surgeons, such as Allvar Gullstrand 1911, Robert Barany 1914, Frederick Banting 1929, Alexander Fleming 1945, Walter Rudolf Hess 1949, Werner Forssmann 1956, and Charles Huggins 1966, as well as the previously mentioned Carrel, Kocher, and Murray. Our investigation about cardiac surgeons, who were repeatedly proposed for the Nobel Prize, but never received the award, highlights important research questions that need to be further explored in order to better understand scientific reward mechanisms: What does a surgeon have to achieve to receive the Nobel Prize, the most prestigious benchmark of scientific excellence in our time? Why have relatively few surgeons received the award for surgical work, and is this unfortunate trend likely to be continued in the light of the broad range of surgical investigations now being pursued? Acknowledgments: Files on the mentioned surgeons in the Nobel Prize archive were kindly provided by the Nobel Committee for Physiology or Medicine, Medicinska Nobelinstitutet, Solna, Sweden.
REFERENCES 1. Blalock A, Taussig HB: The surgical treatment of malformations of the heart in which there is pulmonary stenosis or atresia. JAMA 1945;128:189–202. 2. Turina M: Fifty years of cardiothoracic surgery through the looking glass and what the future holds. J Thorac Cardiovasc Surg 2008;136:1117–1122. 3. Gross RE, Hubbard JP: Surgical ligation of CNY a patent ductus arteriosus. Report of first successful case. JAMA 1939;112:729–731. 4. Crafoord C, Nylin G: Congenital coarctation of the aorta and its surgical treatment. J Thorac Surg 1945;14:347–361.
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5. Lillehei CW, Cohen M, Warden HE, et al.: The results of direct vision closure of ventricular septal defects in eight patients by means of controlled cross-circulation. Surg Gynecol Obstet 1955;101:446–466. 6. Lillehei CW, Gott VL, Hodges PC, et al.: Transistor pacemaker for treatment of complete atrioventricular dissociation. JAMA 1960;172:2006–2010. 7. Hansson N, Packy LM, Halling T, et al.: Vom Nobody zum Nobelpreistr€ ager? Der Fall Werner Forßmann Urologe 2015;3:412–419. 8. Hansson N, Schagen U: ‘‘In Stockholm hatte man offenbar irgendwelche Gegenbewegung‘‘—Ferdinand Sauerbruch (1875–1951) und der Nobelpreis. NTM 2014;22:133–161. 9. Hansson N, Schagen U: The limit of a strong lobby: Why did August Bier and Ferdinand Sauerbruch never receive the Nobel Prize? Int J Surg 2014;12: 998–1002. 10. Nobel Archive (NA): Nomination for CW Lillehei by O Wangensteen, Minneapolis, Jan. 10, 1955. 11. Yuan S-M., Shinfeld A, Raanani E: The Blalock–Taussig shunt. J Card Surg 2009;24:101–108. 12. NA: Nomination for H. Taussig and A Blalock by A. St. G. Huggett, Baltimore, Dec. 17, 1953. 13. Bailey CP: The surgical treatment of mitral stenosis (mitral commissurotomy). Dis Chest 1949;15:377–397. 14. Harken DE, Ellis LB, Ware PF, et al.: The surgical treatment of mitral stenosis. I Valvuloplasty. N Engl J Med 1948;239:801–806. 15. Hansson N, Schlich T: ‘‘Highly qualified loser‘‘? Harvey Cushing and the nobel prize. J Neurosurg 2015;2:1–4. 16. NA: Nomination for Blalock by William Wallace Scott, Baltimore, Jan. 16, 1961. 17. Translation by Westaby S. The foundation of cardiac surgery. Landmarks in cardiac surgery. 1997;Oxford, UK: Isis Medical Media Ltd, p. 15. 18. Altman LK: Who goes first?: The story of self-experimentation in medicine. 1987;University of California Press, p. 39. 19. Naef AP: The story of thoracic surgery. Milestones and pioneers. 1990; Lewiston, NY: Hogrefe & Huber Publishers, p. 75. 20. NA: Nomination for Blalock/Taussig/Manfred Sakel, by L. Halpern, Dept of Neurology, Jerusalem, December 22, 1954. 21. NA: Nomination for Taussig and Blalock by J. Webster, New York, Jan. 26, 1955. 22. NA: Nomination for Taussig, Blalock and Gross by G. Rosen, New York, Dec. 28, 1954. 23. NA: Nomination for Blalock and Taussig by S. van Crefeld, Amsterdam, Jan. 25, 1954. 24. NA: Nomination for Taussig and Blalock by CF de Garis, Oklahoma, Dec. 25, 1950.
