André Frédéric Cournand (1895 - 1988)

CournandAndré Frédéric Cournand was born in Paris, where he lived the first thirty-five years of his long life until his emigration to the United States. He felt very much French and European. His mother was the daughter of an Alsatian businessman, and his father descended from a Corsican author and poet who had participated in the French revolution of 1848.

As Cournand writes in his autobiography, the influence of his mother was to give him a strong sense for the arts and an inclination toward adventure: "In my mother the adventurous spirit expressed itself primarily through imagination and sympathetic recognition of the impetus of adventure in others. This same eager readiness for the new and the unexpected was to make its influence felt in my own life." He was to receive a classical education, but at the age of sixteen he left the lycée to split his time between private tutoring in philosophy and work in a private laboratory to learn about scientific techniques. He nevertheless completed his undergraduate studies and enrolled in the Faculty of Sciences in order to be admitted to the Faculty of Medicine, a decision prompted chiefly by the influence of his father.

In 1914 Cournand entered the Faculté de Médecine, just as World War I broke out. Even before his first year of medical school ended, he was enlisted in the army to serve as auxiliary battalion surgeon, for the most part in the trenches near the German enemy. For his distinguished services tending wounded soldiers at the front he was awarded the Croix de Guerre with three bronze stars. This experience in the battlefield lasted three and one-half years and left a deep impression on him: "It had been necessary to develop the attitudes of mind and feeling to face danger and take risks," and he believed that this was the undergirding of his emerging dual disposition to be open to the intellectually new and skeptical of received wisdom.

After returning from the war and recovering from some injury incurred at the end of his service, Cournand resumed his medical studies in 1919. During his internship he trained in pediatrics, chest diseases, internal medicine, and neurology in the Hôpitaux de Paris. He prepared his dissertation, required for the M.D. degree, on the topic of acute disseminated sclerosis ("La Sclérose en plaques aigue"), which involved experimental studies at the Institut Pasteur on isolating a virus from brain tissue. In his autobiography Cournand remains rather brief on his career as an intern in Paris, but he notes that his promotions came with difficulty. For one, his "conception of liberal thinking and action" did not help him in the still conservative French medical system marked by paternalism, but then also he spent much of his time and energy on a different type of activity.

During his service at the front he became friends with the young painter Jean Lurçat, who later became the famous designer of tapestries. This friendship brought Cournand into close contact with the so-called modern movement that determined the art life in Paris during the 1920s; he was introduced into the circle around Jeanne Bucher, whose gallery was an important meeting point for the modern artists. Here he met, among many other artists of renown, Jacques Lipschitz, one of the leading sculptors of the cubist period, with whom he maintained a lifelong close friendship. It was in this circle that he met his future wife, Sibylle, the younger daughter of Jeanne Bucher and her husband, the Swiss pianist Fritz Blumer. They married several years later and raised four children: three daughters, Muriel, Marie-Eve, and Claire, and Sibylle's son by a first marriage, Pierre Birel Rosset.

Around 1930 Cournand felt ready to go into private medical practice. But since he wanted to specialize in chest diseases he decided to enlarge his experience by working for one year in an American hospital. He felt fortunate to be admitted as resident to the well-known Chest Service at Bellevue Hospital in New York City. After a few months of service, partly in a sanatorium, Cournand was offered the possibility to participate in a long-range research project on pulmonary physiology by joining the group of Dickinson Wood-ruff Richards, a man of his own age but already quite advanced as an investigator. To accept this offer, however, meant not to return to France. Considering Cournand's exquisitely "French" or even "Parisian" life-style during the past decade this required a radical decision, but one taken by him and his wife with a positive mind. In his autobiography Cournand justifies this decision with several arguments. One was that the "free exchange of views in the United States had made a strong impression" on him and that here he would have "the prospect of an academic career where achievements count far more than nepotism." And he says that, in retrospect, the possibility to "leave behind a way of life whose disregard for the conventional bore little relationship to some values that constituted the treasure of my education" was an additional though unconscious element. Last, but not least, he felt excited "to participate in creating techniques to be applied to new protocols of clinical investigation and in rationalizing treatment." He returned to Paris briefly in 1932 to arrange his affairs after the accidental death of his father and then came back to New York to stay. But he always remained much attached to his home country. A large artistic map of Paris adorned one wall in his office at Bellevue, and he used to remark: "Je n'aime pas les départs . . . sauf pour Paris."

THE SHAPING OF AN INVESTIGATOR
Cournand's serious research activity began with what he called his "transplantation to the United States." In his bibliography he lists ten papers from his time in Paris, mostly case reports presented to French medical societies. When, in 1933, he published his first major paper he was already thirty-eight years old. It was a report on his work at the Bellevue Hospital Chest Service but was written in the European tradition, based purely on clinical evidence (1933,1); it makes no reference to pulmonary function tests that would be the main focus of Cournand's subsequent work, which, indeed, was already ongoing at the time of publication (1933,2). Cournand became an experimental investigator through his association with Richards, with whom he remained closely associated throughout their lives and with whom he won the Nobel Prize in 1956.1 Born in New Jersey the same year as Cournand, Richards also took up his medical studies in 1919 after some war service. Already during his residency he began with research projects that he extended during a fellowship in Sir Henry Dale's laboratory in London. Back in New York he directed his research to blood and circulation. One aspect of these studies was to improve on blood gas measurements, particularly of CO2, because this was needed for the estimation of cardiac output. The so-called indirect Fick method then in use calculated cardiac output (or total blood flow) as the ratio of CO2 output from the lung to the CO2 concentration difference between the blood entering and leaving the lung. Whereas CO2 concentration in arterial blood was easy to measure, CO2 concentration in mixed venous blood had to be estimated indirectly from the CO2 partial pressure in alveolar air. When Cournand joined Richards in 1932 he became involved with this line of work.

His first project was to test and improve a rebreathing method for estimating mixed venous CO2 content and to apply it to some cases of pneumo-thorax (1933,2; 1935,1). The results remained only partially satisfactory, which led Cournand and Richards, some eight years later, to develop the method of right heart catheteri-zation in order to obtain direct samples of mixed venous blood as it enters the lung. In the meantime they directed their attention to some problems that had emerged when studying diseased lungs, namely that gases do not mix evenly in the lung, particularly in cases with pulmonary emphysema (1937,1,2). An important series of studies were undertaken in collaboration with Robert Darling, who developed a breath-by-breath analysis of intrapulmonary mixing of inspired air, introducing the simple method of washing out intrapulmonary nitrogen through the inhalation of pure O2 (1940,1), a method that has been widely used and further improved by many other investigators. In the normal lung alveolar nitrogen is rapidly washed out, but in emphysematous lungs this is much slower because nitrogen is retained in the enlarged air spaces. In subjecting the closed-circuit method for estimating residual air volume mentioned above to a systematic critique (1940,2), they concluded that its failure was due to unequal distribution of gases within the lung. To overcome these shortcomings, a new open-circuit method with pure oxygen breathing was introduced (1940,3) that had theoretical advantages but still did not solve all the problems. At the time, these systematic studies of pulmonary ventilatory function, in which Cournand, Darling, and Richards themselves served as the normal subjects, made a very significant contribution to the advance of clinical respiratory physiology (1941,6).

With these methods in hand, Cournand and Richards proceeded to a systematic study of pulmonary insufficiency, which they classified according to the prevailing ventilatory, respiratory (i.e., gas exchange), or cardiocirculatory disturbances (1941,2). They developed the tests by which to differentiate between these functional disturbances. The efficiency of alveolar ventilation, studied at the time by several other groups, was combined with the measurement of arterial O2 saturation as a test for adequate matching of alveolar ventilation with capillary perfusion. It is of historic interest that two papers of this series (1941,3,4) use these concepts and tests to estimate the effects on "pulmono-circulatory" function of various types of collapse therapy: in the late 1930s pulmonary tuberculosis was still a major disease, and collapse therapy was one of the major modes of treatment.

By the early 1950s André Cournand had published about 100 papers on the physiology and pathophysiology of the cardiopulmonary system, several of which have become true classics as they have brought significant innovations. He introduced the nitrogen washout method for studying the gas compartment of the lungs. He greatly advanced the study of the role of uneven ventilation-perfusion relationship for gas exchange. He pioneered cardiac catheterization in humans and was the first to measure cardiac output with the direct Fick method using mixed venous blood samples and the first to record blood pressure in the right heart and the pulmonary artery. By that he has most significantly contributed to the development and innovation of cardio-pulmonary physiology. If one reads his early papers one is impressed by the scientific rigor of his approach as much as by the ingenuity of the meticulous techniques he had to develop. The artistic spirit of adventure inherited from his mother had blended with the imaginative inventiveness received from his father to bring about these advances.


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