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
a century to expose all the organs of the body,
brain and heart not excepted, without danger, and
carry out the necessary surgical measures on
them.
This is Theodor Kocher’s triumphal account of
the recent development of his field. It was part of
his lecture on the occasion of the Nobel Prize
award ceremony on December 11, 1909.1 It was
the first Nobel Prize in Physiology or Medicine
that went to a surgeon. To be given ‘‘to those
who shall have conferred the greatest benefit of
mankind’’,2 the prestigious award sealed the re-
markable rise surgery had undergone not long ago.
Traditionally, surgery was still a manual craft. It
was separate from the learned profession of
* Tel.: þ1 514 398 2059; fax: þ1 514 398 1498.
E-mail address: thomas.schlich@mcgill.ca
medicine and less prestigious. Surgical practi-
tioners were mainly dealing with emergencies,
like broken bones, and minor manipulations at
the body’s surface, such as removing skin tumors
or lancing boils. Surgical intervention was still
associated with the horrors of pain and infection.
Even more importantly, surgery seemed to make
no sense in the treatment of most diseases
anyway. Up until the early nineteenth century,
the body was understood as a functional whole,
interacting with its external environment. People
believed that diseases originated from disruptions
in the balance of body fluids caused by the sick
person’s way of life or some other environmental
factor. Diseases could be treated by changing the
environment or one’s way of living, or more
technically, by restoring the humoral balance
through emetics, purgatives and blood letting.
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
part of the intestine, as today’s surgeons routinely
do in cases of appendicitis, would have looked
absurd.3 As medical historian Christopher Law-
rence stresses, even the simplest surgical practices
employ a theory of the body and disease, either
explicit or implicit. Even pulling a tooth, he ex-
plains, ‘‘implies a theory of the local origin of
pain and the relative harmlessness of removing
a body part.’’4 The rationale that made modern
surgery possible developed during the nineteenth
century, and it soon came to dominate modern
medicine in general. It is based on the assumption
that the human body is a composite of organs and
tissues with particular functions. Diseases are
lesions of those organs and tissues that can affect
them at the structural or functional level. Surgery
can rectify those disorders by removing the dis-
eased structures or restoring their function.5
The spread of the new view of the body and
disease, together with the recently acquired pro-
fessional status of surgeons as university-trained
doctors provided the basis for the expansion of the
field. Once anesthesia and asepsis had liberated
surgeons from the problems of pain and infection,
they could start exploring the potential of their
newly acquired abilities. Kocher’s extraordinary
technical abilities led him to his discoveries about
‘‘the physiology, pathology and surgery of the
thyroid gland’’6 that earned him his 1909 prize
(Fig. 1). Systematically improving on his predeces-
sors’ procedures, the Swiss surgeon had developed
a technique of goiter resection that afforded an
unprecedented degree of safety. He could even
Figure 1 Theodor Kocher. Photograph by L. Zumbühl,
Bern, courtesy of the Wellcome Medical Photographic
Library.
T. Schlich
remove the whole gland without any serious
short-term effects on his patients.7 However,
those patients who had undergone total thyroidec-
tomy developed a characteristic clinical picture,
which included all the symptoms we today associ-
ate with a lack of thyroid function.8,9 Immediately
physiologists and surgeons started to use thyroid-
ectomy in animals as a physiological experiment.
This approach eventually led researchers to iden-
tify the function of the thyroid gland and eventu-
ally to the development of endocrinology and
organ transplantation.10
As surgical interventions in humans and planned
experiments in animals showed, the removal of
particular organs resulted in specific syndromes.
Vice versa, reinsertion of those organs could re-
verse these disorders. The procedure was adapted
to a number of other organs and diseases, linking
for example diabetes to the pancreas. As Kocher
stated in his Nobel lecture, surgeons had taught
the physiologists to bring the physiological activi-
ties of the organs to light.1 By literally separating
organs from their bodily context, investigators
had elucidated the function of certain organs and
tissues and showed the way to understand and
treat a number of enigmatic diseases.
The idea of the divisibility the body and the
exchangeability of its constituents manifested
itself in the new field of organ transplantation,
which was also initiated by Kocher. In July 1883 he
tried to reverse the unexpected consequences of
total thyroidectomy by reinserting thyroid tissue
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
aware of the limits of exchangeability (Fig. 2). He
noted that the success of allotransplants was
blocked by a problem that could not be solved by
Nobel prizes for surgeons
Figure 2 Alexis Carrel as a magician. Courtesy of the
Wellcome Medical Photographic Library.
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.
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,
the issue of biological incompatibility’’ (Fig. 3).14
In the early 1960s, the introduction of chemical
132
immune suppression initiated a new phase in the
history of transplant surgery. The availability of
more selective immunosuppressive agents since
the 1980s accelerated the pace of growth of the
field.15,16 Transplantation became the technologi-
cal fix of choice for the growing number of medical
problems that were redefined as being caused by
organ malfunction. Instead of complicated and un-
reliable measures for re-balancing the body and its
environment, a circumscribed intervention by
a highly specialized expert sufficed to solve the
problem (Fig. 4).17
Another such technological fix was awarded the
Nobel Prize in 1949. It was given to the Portuguese
Antonio Egas Moniz for ‘‘the discovery of pre-
frontal leucotomy’’, a surgical intervention to
relieve ‘‘morbid psychotic states accompanied by
affective tension . by destroying the frontal lobes
or their connections to other parts of the brain’’,
as it was characterized in the official presentation
speech.18 The case of lobotomy shows how in
a certain historical context the strategy of the
technological fix can be particularly appealing to
practitioners but fall into disgrace later on, so
much so that today, many people consider the
Nobel Prize for Moniz an aberration.19 However,
at the time, this was not at all the case. Moniz
got no less than 18 nominations for the Nobel Prize
between 1928 and 1950 (whereas Kocher had been
nominated six times, Carrel only once).20
Figure 4 Edgar Egas Moniz ª The Nobel Foundation.
T. Schlich
Psychosurgery as a strategy of solving mental
disorders by surgical intervention, stood at the end
of an extended process of projecting social issues
into a particular organ of the individual’s body, the
brain. In pre-modern societies, deviant behavior
had been interpreted in a number of different
ways, for example as a moral or a religious issue.
In modern times, strange behavior was declared to
be an illness and attributed to the medical domain.
Once the cause of mental illness was located in the
brain, it seemed to be a logical step to try to solve
the problem by fixing that organ. First attempts at
psychosurgery in the late nineteenth century re-
mained isolated experiments.21 It was only from the
1930s to the 1950s that psychosurgery came to be
a widely used treatment option, especially in North
America, with lobotomy as its paradigmatic opera-
tion. The procedure became popular after Egas
Moniz had published encouraging results from a se-
ries of twenty operations on psychiatric patients
suffering from different kinds of problems in
1935.22 The surgeon offered an anatomy-based ex-
planation of his technique: for him, mental illness
was a result of a ‘‘fixed loop’’ occurring in the nerve
pathways of the neocortex, specifically the frontal
lobes, which were the seat of ‘‘psychic activity’’.
Severing the white matter that connects the frontal
lobes to the sensory areas would interrupt the feed-
back loops which were over-stimulating the pa-
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
‘‘in a way that was understandable to laboratory
Nobel prizes for surgeons
science and open to practical intervention by
trained physicians.’’22 This meant that psychiatry
could claim to have a material basis. It also meant
that through psychosurgery the field would be able
to catch up with other areas of modern medicine.
At that time, the best strategy for becoming ac-
cepted as a part of ‘‘real’’ medicine was becoming
like surgery. As Jack Pressman states in his analysis
of the lobotomy era, modern psychiatry seemed to
have advanced at last to the point where the treat-
ment of mental illness through repairing the brain
was ‘‘as mundane as when surgeons repair other
malfunctioning body parts.’’22 However, as the
use of lobotomy accelerated, the unease gener-
ated by such a drastic intervention grew too. It
was still unclear what lobotomy actually did to
the individual. The issue of a scientific validation
could no longer be avoided. Follow-up studies pro-
duced discouraging results.23 With the advent of
tranquilizers in the 1950s, lobotomy fell out of
favor. Clinical trials showed that the drug chlor-
promazine seemed to have the same effects as
a successful lobotomy, yet without the irreversible
brain damage and disorientation associated with
the surgery.23 Drug treatment became the new
technological fix for mental disorders; a type of re-
versible lobotomy, as contemporaries saw it.24
The surgical achievements that have been
honored with the Nobel Prize exemplify the spe-
cifically surgical approach of solving problems by
circumscribed and controlled interventions into
the body of individuals. This surgical healing
strategy goes along with dividing the body into
structural constituentsdconceptually, but often
also literallydand reframing medical problems in
such a way that they can be solved by fixing these
body constituents.25 This has been an extraordi-
narily successful strategy. It has given modern
medicine new tools for saving lives and bringing re-
lief to suffering patients though it has also drawn
attention and resources away from alternative,
non-surgical treatment strategies. It is the appre-
ciation of this specific way of dealing with health
problems that is reflected in the Nobel Prizes given
for surgical developments in the course of the
twentieth century.
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