Burton E. Sobel
Editor
Dickinson W. Richards won the Nobel Prize for Medicine and Physiology in 1956 with André F. Cournand and Werner Forssmann, for perfecting the technique of right-heart catheterization. This was the peak of his career, but by no means defined it. His bibliography includes over 150 publications spanning almost 50 years. His list of prizes and awards is equally long. There are numerous accounts of the history of right-heart catheterization, so I will not write much on that. My goal is to describe, through my own and others' recollections, with excerpts from his writings, his character and attitude (Fig. 1
).
In Medical Priesthoods and other essays [1], the extraordinary life and mind of a Nobel-Prize-winning physician is condensed to a 140-page book. The more of his articles I read, the more I'm convinced of his genius.
He was born in 1895 in Orange, New Jersey. His paternal grandfather was a Presbyterian Minister, his father a lawyer. On his maternal side, physicians were abundant [2]. He attended the Hotchkiss School in Lakeville, Connecticut, where he studied English, Greek, and History. At Yale, he continued his studies in the humanities, became fluent in Greek, and began studying mathematics and the natural sciences. After graduation in 1917, he joined the army, and, in 1918, crossed the Atlantic with an artillery unit in which he served as a lieutenant. Upon his return in 1919 he had to choose a career.
He decided to study medicine and received his MA in physiology in 1922 and his MD in 1923, both from Columbia University College of Physicians and Surgeons (CUCPS). From 1923 to 1927 he was an intern and resident at Presbyterian Hospital in New York. He worked in London for a year as a research fellow at the National Institute for Medical Research. In 1928 he returned to New York and joined the staff of Presbyterian Hospital and the faculty of CUCPS. In 1931 he was invited to head the first cardiopulmonary research laboratory in the USA and was introduced to Dr André Cournand, who had just arrived from France. Thus started the close working relationship between Richards and Cournand which proved so fruitful over the ensuing 40 years.
To summarize their research that eventually led to the Nobel Prize, Cournand and Richards began their studies of right-heart physiology in 1936 at Bellevue Hospital. Beginning in 1941, by using modified urethral catheters, they measured right heart pressures cardiac output simultaneously. They catheterized the right ventricle in 1942 and the pulmonary artery in 1944. They introduced double-lumen right-heart and radiopaque catheters [3]. Right-heart catheterization and its use in pressure recording, oximetry, and angiography quickly became so advanced that the technique used today varies little. In 1951, Charles T. Dotter, a vascular radiologist at the University of Oregon, who subsequently developed angioplasty, developed the first balloon-tipped angiographic catheter [3]. In 1970, Swan et. al. [4] developed the procedure used today, which allows pulmonary artery catheterization without fluoroscopic guidance. This revolutionized coronary care and intraoperative hemodynamic monitoring of patients.
The story is told in Medical priesthoods, starting with an essay on Lawrence J. Henderson, the Harvard biochemist whom Richards credits for having laid 'the foundation upon which [their] research chiefly rests.' [[1], p. 85]. The essays 'Right heart catheterization,' 'Cardiovascular physiology,' and 'The right heart and lung,' complete the story. Interestingly, these essays are categorized under 'Physiology,' whereas the more philosophical topics 'Medical priesthoods, past and present,' 'The hospital and the city,' 'The first aphorism of Hippocrates,' 'Hippocrates and history,' 'Homeostasis versus hyperexis,' and 'Homeostasis: its dislocations and perturbations,' are grouped under 'Medicine.' It is this approach to medicine, as an umbrella encompassing philosophy, history, social reform, religion, and science, that I find most compelling. It is the first essay, 'Medical priesthoods, past and present,' that illustrates this approach and that I shall discuss in detail.
Here he introduces the concept of medical priesthoods, namely the practice of medicine based on tradition, concerned with rites and symbols, with its own hierarchical successions sustained by mysticism and ancient myth. Until the great intellectual revolution in the fifth century BC 'when men's minds first became free,' thinkers tended to 'stay within their own minds, and failed to give to external observation the same intensity of effort that they gave to their own imaginations.' The Homeric gods, he says, were still in command, and ripe for attack by a mind willing to challenge them. That mind was Hippocrates, who, according to my grandfather, perceived clearly the inadequacies of the time: the influence of the gods and their active priesthoods, and idealistic modes of philosophic thought - and strove to attack them with vigor. 'It may well be, said [Hippocrates], that the gods rule in heaven and earth, but their fateful influence is remote. In medicine, natural causes immediately prevail. Diseases are natural events. They must be observed, followed, and treated by natural means. The place of the physician is not in the temple but at the bedside.' 'State the past, know the present, foretell the future,' wrote Hippocrates in the Epidemics [5]. 'Study this. Concerning diseases, strive for two things: to help, or at least not to harm. The art is threefold: the disease, the patient, the physician. The physician is a laborer for the art.'
It may seem from where we stand now, wrote my grandfather, that this empiricism of Hippocrates was obvious but it was not. Empiricism, the wholly objective description of experience, was new with this man and this was for science a great event. In medicine, Hippocrates exemplified, among other things, a clear distinction between the priesthood and the profession, and he chose the latter. The differences are basic, Dr Richards continues. A priesthood is concerned with tradition. It establishes its gods and worships them. Inspiration is derived from the temple, not from those who built it. The institution becomes more important than the people in it, or even than those whom it is supposed to serve. The profession is different. A profession is a group of men and women who claim, or profess, a special skill and are dedicated to this skill. They are not absorbed into an institution or bound by its traditions.
These concepts are highly relevant to the era in which Richards and Cournand began their research on catheterization, according to my great uncle Richard L. Riley, MD who worked in my grandfather's laboratory in the 1940s. In a recent letter to me Dr Riley wrote 'The medical priesthood of the early 1940s would never have dreamed of allowing anyone to pass a catheter into a live human heart, even though physiologists had passed catheters into animal hearts with impunity for years. Four special circumstances made it possible for Dr. Richards to get away with it. They [Richards and Cournand] had done the necessary preliminary work on animals and human cadavers, and they could make a strong case for sampling mixed venous blood in order to apply the Fick principle for determination of cardiac output. Secondly, it was war time, and the military needed answers on how to manage traumatic shock. To the Office of Scientific Research and Development (OSRD) the measurement of cardiac output seemed paramount.' (This research resulted in a fascinating lecture series on the human circulation in traumatic shock [6].)
Thirdly, 'in spite of the disparaging things your grandfather had to say about priesthoods, he had one foot in the medical priesthood and the other in the profession. This gave him the privilege of doing things that others, including Cournand, couldn't do on their own. There were no ethics committees prejudging every piece of clinical research at the time. The status of the person involved made all the difference. Fourthly, the early catheterisations were done at Bellevue, the other end of town from CUCPS, where fewer questions were asked. These practical considerations in no way detract from Dick Richards' inspired recognition … he had the right intuition and he seized the moment.'
In what ways are we still practicing medicine in the realm of a priesthood?
'In its essence, priesthood is not an institution at all: it is a state of mind. If its traditionalism is less militant now than it used to be, it is more complex, more insidious, and extraordinarily difficult to destroy.' [1],
He goes on to suggest a few of the priesthoods reigning then (many of which we still worship today). '… conformity, popularity, laxness, and fear. There is conformity of technique and of language, encouraging if not imposing conformity of thought. To worship popularity is to take the easy ride on an already surging tide; to plant more seed in an already well-ploughed field,' thereby discouraging us from making the effort to 'drive a new furrow into stony ground'. Laxness leads to 'the disregard of small errors, of deviations, of the unexpected response: the easy worship of the smooth curve'. Finally, there is 'fear of speculation; the overprotective fear of being wrong'. If we let ourselves to be ruled by fear we become 'forgetful of the curious and wayward dialectic of science, whereby a well-constructed theory even if it is wrong, can bring a signal advance.' [1].
He later summarized his message thus:
We are concerned over the widening gap between the clinic and laboratory, the interest in the measurement and the neglect of the person, the overwhelming weight of fine clinical and research laboratories imposing upon us the attitude that for the care of the patient they are our masters and not our servants, the remarkable predominance these days of the distant conference … and the unquestioning acceptance of all this.' [1].
He is not condemning the laboratory physician but simply advising clinicians:
If you would know about suffering, do not spend your time in the laboratory, or with the data on the chart, or even on the end of a telephone. If you would know about suffering, study your patient, as he lies there, as he looks at you, his eyes, his voice, how he moves, what he says, how he says it. Then from here you build up the whole structure of your care, a broad structure, as broad as the measure of his distress. Surely this is no denial of medical science but its fulfillment. [1].
Around 1960, Hippocrates became an obsession for Dr Richards. He began editing a book on the history of cardiovascular physiology [7], and wanted authentic portraits of leaders in medicine and physiology through the ages. It seems that his preoccupation with Hippocrates came when he needed a gratifying, consuming project. He seemed to find solace in studying and translating the words of the 'first physician-philosopher' to help explain his reflections during a period of great disillusionment and depression. According to an interview I conducted with his colleague Alfred Fishman, Dr Richards was a victim of the policy of mandatory retirement at age 65 years. Despite his stunning career, as soon as he retired he was demoted to a small office under the stairs.
Another admirable aspect of his career, in a profession in which there is always the temptation of going elsewhere, was how he endured the discomfort and inconvenience at Bellevue in the interest of good medicine. In 1945 Bellevue was notorious for overcrowded clinics, antiquated buildings, and understaffed wards, but, instead of moving on, he made do, and, as soon as he got the chance, namely when he got the Nobel Prize, he drew attention to conditions at Bellevue. In May 1957 he wrote a letter to the New York Times resulting in a major article the next day: 'Head of Columbia University Unit at Hospital charges Twenty years of Neglect.' As a member of the Bellevue Medical Board, he was outspoken in his criticism of the city's neglect of its hospitals and in his efforts to bring to bear such pressure as to oblige the city to erect a new hospital building.
One must give due weight to the qualities of the meticulous, profound thinker, his extraordinary capacity for work, and his ability to make all that he did cohere. He was a creative person, whose discoveries were based on the correctness of an idea pursued to its fullest implications. Finally, if I were to try to articulate the secret of his greatness, it would be in his essence: his sense of the human, which dominated his attitude and behavior, not a mere orientation of the intellect, but something profoundly involving his entire being.
Special thanks to Frank Ittleman, MD; Marcia Wright, PhD; Stephen Novak of the Archives Department of Columbia University Health Sciences Library; and Yale Enson, MD.
References
© 2001 Lippincott Williams & Wilkins, Inc.