CLASSICS IN THORACIC SURGERY
Werner Forssmann and Catheterization of the Heart, 1929 John A. Meyer, MD Department of Surgery, State University of New York Health Science Center at Syracuse, Syracuse, New York
Invasive study of cardiac anatomy and function traces its origin to the work of a 25-year-old surgical trainee in a provincial German town in the pre-Depression years of 1929 and 1930. Only 1 year out of medical school and undeterred by the medical profession's fear of tampering with the heart, Dr Werner Forssmann explored methods for a more direct access to the cardiac chambers, finding
it necessary to make the observations on himself. Later he was able to show that the right-sided cardiac chambers could be visualized radiographically after injection of iodinated contrast materials through a catheter into the right atrium, and again he tried the method on himself.
DIE SONDIERUNG DES RECHTEN HERZENS*.
by which access could be gained to the heart without danger, and I sought to begin exploration of the right heart by way of the venous system (italics in the original) [l].
\'on
Dr.
\\'ERSER
F0Rssai.o-s.
des .4uguste Vihtoria-Hrims zu Ebcrsa..~lcle ( O k r x z t : San -Rat Dr. R . SCHSEIDER).
(Ann Thorac Surg 2990;49:497-9)
Aus der 11. Chinmgischrti Abteilung
Fig 1. Title and byline of Dr Werner Forssmann's landmark first paper, 1929. Translation: Probing of the right heart. From the 2nd Surgical Unit of the Augusta Victoria Home in Eberswalde. (Chief Physician: Health Councillor Dr R. Schneider.)
D
octor Werner Forssmann, aged 24 years and just awarded his medical degree from the University of Berlin, began postgraduate training in surgery at Eberswalde in 1928. Eberswalde was a provincial town some 45 km northeast of Berlin, but its hospital, the Augusta Victoria Home, was an affiliate of Professor Ferdinand Sauerbruchs program. One year after the start of his training, in 1929, Forssmann began a study of the feasibility of more direct access to the heart. In many emergency situations, patients may be threatened by stoppage of the heart's activity, as in acute collapse due to heart disease, or anesthetic accidents or poisonings, and will require immediate treatment on the spot. In such cases, the sole resort often is a trial of intracardiac injection, by which life may occasionally be restored. Nevertheless intracardiac injection will always remain a dangerous undertaking in many instances, since puncture of the wall of the heart may injure the coronary vessels or their branches so that bleeding into the pericardium may result in fatal cardiac tamponade. Also chest puncture may result in fatal pneumothorax. Such risks are likely to make a physician leave intracardiac injection to the last moment, so that he may lose the most valuable time for direct delivery of medications to the heart. These considerations encouraged me to seek for a new method Address reprint requests to Dr Meyer, 750 E Adams St, Syracuse, NY 13210. Excerpts from Forssmann's studies are in translation by Dr Meyer
0 1990 by The Society of Thoracic Surgeons
What tools might have been available to him, in what seems to us a comparatively low-technology era? Ureteral catheters similar to those of today were in regular use, and both radiographic apparatus and darkroom fluoroscopy equipment were installed in most hospitals. The autopsy suite was available for investigative purposes. To begin, Forssmann enlisted the help of an anonymous colleague. After successful tests upon a cadaver, I undertook the first study on a living person, in the form of an experiment upon myself. First, I submitted to a preliminary test of the method; for this, a colleague had kindly placed himself at my disposal, to puncture the antecubital vein with a large needle. I instructed him then, as we had done on the cadaver, to pass a well-oiled ureteral catheter of size 4 Charri&res*through the cannula into the vein. The catheter could be introduced with ease to a distance of 35 cm. At this point my colleague believed that further passage would be too dangerous and that we must terminate the experiment, a decision with which I was obliged to agree. One week later I undertook a further experiment by myself. I used a local anesthetic, and since it proved too difficult to do a venipuncture upon myself with a large needle, I did a venesection at my left elbow and passed the catheter without any resistance to its full length, 65 cm. This distance appeared to me, after having measured on the body surface, to correspond to the distance from the left elbow to the heart. During passage of the catheter I was aware only of a slight feeling of warmth from its sliding along the vein wall, similar to the feeling one notices during intravenous injection of calcium chloride. During repeated passages the catheter often encountered a partial obstruction at the upper margin of the subclavian vein; at these times I experienced a particularly warm sensation behind the clavicle, at the base of the neck; and at the same time because of stimulation of the vagus trunk, a slight irritating cough. * The same designation as our 4F, approximately 1 . 3 mm in diameter.
0003-4975/90/$3.50
498
CLASSIC MEYER WERNER FORSSMANN
Ann Thorac Surg 1990;4Y:497-Y 0
Fig 2. Original caption translated as "The catheter passes inward from the left cephalic vein (sic), turning downward as far as the right atrium [I]." Position of the catheter tip is marked by the arrow. (Reprinted from [I] by permission of Springer-Verlag, Munich, FRG).
I recorded the positions of the catheter by obtaining x-ray films, and I was able to observe the advancing catheter clearly on the fluoroscopic screen, by means of a mirror held for me by the Sister.
. . . Figure 2 is a film of the second observation: the catheter passes directly inward from the left arm, under the clavicle at the chest wall, and makes a downward bend at the place of junction with the jugular vein, lying near the margin of the great-vessel shadow and the shadow of the spine, and reaching as far as the right atrium. On another passage, the catheter did not reach any further than this. I watched carefully for any other effects, or signs of irritation of the cardiac mechanism, but could not identify any. In our institution there is a considerable distance between the operating rooms and the x-ray unit. To go from one to the other I had to climb staircases on foot and return, while the probe was lying within my heart, but I was not aware of any unpleasantness. Passage and removal of the catheter were entirely painless, accompanied only by the above-mentioned sensations. Later on 1 could find no sequelae to the procedure, except for a slight inflammation at the site of venesection, which clearly was a result of inadequate asepsis during the self-performed operation . . . (Closing, page 2087.) In conclusion I should point out that this method . . . has opened the prospect of many possible metabolic researches and studies of the function of the heart, some of which I have already begun [l].
The first study that he undertook was the injection of radiographic contrast materials through a right atrial catheter with x-ray filming, first in the hearts of dead animals and then in those of living ones [2]. The rapid film-cassette changer had not yet been invented, so timing of a single film-with the contrast injection was difficult
at first. Good pictures of the right-sided chambers and the pulmonary artery could be obtained, however, and Forssmann again used himself as an experimental subject. On two separate occasions he injected the contrast material through catheters (No. 8 Charrieres in these experiments) into his own right atrium, but on these occasions the x-ray exposures were mistimed and satisfactory films were not obtained. During the injections, he described a transient sensation of dizziness, and moments afterward, a sensation of warmth in the mouth, but no other adverse effects. He presented his findings before the Medical Society of Eberswalde on November 29, 1930, and published them in another journal in the following year [2]. Summary (p. 492): 1. Filling of the cadaverous heart with Rontgen-contrast materials can produce beautiful pictures, but does not demonstrate the corresponding functional relationships. 2. With the help of a cardiac catheter, it is possible to introduce contrast materials into the living right heart. 3. Rapid injection of sodium iodide in a 25 percent solution, and Uroselectan in 50 percent solution, were well tolerated by experimental animals and resulted in good (x-ray) pictures. 4. During two experimental trials on the same person, with rapid injections of sodium iodide and Uroselectan through a catheter into the right atrium, no unpleasantness or adverse reactions were observed. Satisfactory contrast photographs were not obtained, because of faulty technique on our part [2].
Epilogue Forssmann gave up pursuing these studies, possibly because of opposition from his colleagues and superiors. * * Subsequently he took additional postgraduate training in
CLASSIC MEYER WERNER FORSSMANN
A n n Thorac Surg 1990;49:497-90
urology at Berlin and Mainz and began his practice in Dresden. He served as a medical officer in the German Army during World War I1 and was taken prisoner on the Western Front. Released at the end of 1945, he returned to urological practice together with his wife, who was also a physician with similar training. A decade after his landmark report, catheterization of the heart was taken up by Andre Cournand and Dickinson W. Richards of Columbia University and developed into a systematic method for diagnostic study of the cardiac chambers. Dr Cournand (1895 to 1988), though not a surgeon, was for many years a member and senior
499
member of the American Association for Thoracic Surgery. Forssmann, Cournand, and Richards shared the Nobel Prize for Medicine or Physiology in 1956. Forssmann died in 1978 at the age of 74.
References 1. Forssmann W. Die Sondierung des rechten Herzens [Probing of the right heart]. Klin Wochenschr 1929;8:2085-7. 2. Forssmann W. Ueber Kontrastdarstellung der Hohlen des lebenden rechten Herzens und der Lungenschlagader [On contrast demonstration of the chambers of the living right heart and the pulmonary artery]. Miinchener Med Wochenschr 1931;78:489-92.
REVIEW OF RECENT BOOKS
Cardiac Arrhythmias, 3rd ed By Davis H . Bennett Butterworths (john Wright), 1989 206 p p , illustrated, $49.95
Reviewed by Richard M . Peters, M D This paperback volume reviews the clinical and electrocardiographic findings and treatment of patients with arrhythmias. The book is well organized with good electrocardiographic illustra-
tions and summary of the findings on each type of arrhythmia. The book is designed for those who are not at the level of electrophysiologists. It appears to be a good book for house officers and an advanced book for medical students. It will allow one to look up the arrhythmias that are associated with different conditions as, for example, myocardial infarction and atrioventricular blocks. Not only the electrocardiographic manifestations but also the suggested treatment modalities are given.
San Diego, California
Werner Forssmann and Catheterization of the Heart, 1929 John A. Meyer, MD Department of Surgery, State University of New York Health Science Center at Syracuse, Syracuse, New York
Invasive study of cardiac anatomy and function traces its origin to the work of a 25-year-old surgical trainee in a provincial German town in the pre-Depression years of 1929 and 1930. Only 1 year out of medical school and undeterred by the medical profession's fear of tampering with the heart, Dr Werner Forssmann explored methods for a more direct access to the cardiac chambers, finding
it necessary to make the observations on himself. Later he was able to show that the right-sided cardiac chambers could be visualized radiographically after injection of iodinated contrast materials through a catheter into the right atrium, and again he tried the method on himself.
DIE SONDIERUNG DES RECHTEN HERZENS*.
by which access could be gained to the heart without danger, and I sought to begin exploration of the right heart by way of the venous system (italics in the original) [l].
\'on
Dr.
\\'ERSER
F0Rssai.o-s.
des .4uguste Vihtoria-Hrims zu Ebcrsa..~lcle ( O k r x z t : San -Rat Dr. R . SCHSEIDER).
(Ann Thorac Surg 2990;49:497-9)
Aus der 11. Chinmgischrti Abteilung
Fig 1. Title and byline of Dr Werner Forssmann's landmark first paper, 1929. Translation: Probing of the right heart. From the 2nd Surgical Unit of the Augusta Victoria Home in Eberswalde. (Chief Physician: Health Councillor Dr R. Schneider.)
D
octor Werner Forssmann, aged 24 years and just awarded his medical degree from the University of Berlin, began postgraduate training in surgery at Eberswalde in 1928. Eberswalde was a provincial town some 45 km northeast of Berlin, but its hospital, the Augusta Victoria Home, was an affiliate of Professor Ferdinand Sauerbruchs program. One year after the start of his training, in 1929, Forssmann began a study of the feasibility of more direct access to the heart. In many emergency situations, patients may be threatened by stoppage of the heart's activity, as in acute collapse due to heart disease, or anesthetic accidents or poisonings, and will require immediate treatment on the spot. In such cases, the sole resort often is a trial of intracardiac injection, by which life may occasionally be restored. Nevertheless intracardiac injection will always remain a dangerous undertaking in many instances, since puncture of the wall of the heart may injure the coronary vessels or their branches so that bleeding into the pericardium may result in fatal cardiac tamponade. Also chest puncture may result in fatal pneumothorax. Such risks are likely to make a physician leave intracardiac injection to the last moment, so that he may lose the most valuable time for direct delivery of medications to the heart. These considerations encouraged me to seek for a new method Address reprint requests to Dr Meyer, 750 E Adams St, Syracuse, NY 13210. Excerpts from Forssmann's studies are in translation by Dr Meyer
0 1990 by The Society of Thoracic Surgeons
What tools might have been available to him, in what seems to us a comparatively low-technology era? Ureteral catheters similar to those of today were in regular use, and both radiographic apparatus and darkroom fluoroscopy equipment were installed in most hospitals. The autopsy suite was available for investigative purposes. To begin, Forssmann enlisted the help of an anonymous colleague. After successful tests upon a cadaver, I undertook the first study on a living person, in the form of an experiment upon myself. First, I submitted to a preliminary test of the method; for this, a colleague had kindly placed himself at my disposal, to puncture the antecubital vein with a large needle. I instructed him then, as we had done on the cadaver, to pass a well-oiled ureteral catheter of size 4 Charri&res*through the cannula into the vein. The catheter could be introduced with ease to a distance of 35 cm. At this point my colleague believed that further passage would be too dangerous and that we must terminate the experiment, a decision with which I was obliged to agree. One week later I undertook a further experiment by myself. I used a local anesthetic, and since it proved too difficult to do a venipuncture upon myself with a large needle, I did a venesection at my left elbow and passed the catheter without any resistance to its full length, 65 cm. This distance appeared to me, after having measured on the body surface, to correspond to the distance from the left elbow to the heart. During passage of the catheter I was aware only of a slight feeling of warmth from its sliding along the vein wall, similar to the feeling one notices during intravenous injection of calcium chloride. During repeated passages the catheter often encountered a partial obstruction at the upper margin of the subclavian vein; at these times I experienced a particularly warm sensation behind the clavicle, at the base of the neck; and at the same time because of stimulation of the vagus trunk, a slight irritating cough. * The same designation as our 4F, approximately 1 . 3 mm in diameter.
0003-4975/90/$3.50
498
CLASSIC MEYER WERNER FORSSMANN
Ann Thorac Surg 1990;4Y:497-Y 0
Fig 2. Original caption translated as "The catheter passes inward from the left cephalic vein (sic), turning downward as far as the right atrium [I]." Position of the catheter tip is marked by the arrow. (Reprinted from [I] by permission of Springer-Verlag, Munich, FRG).
I recorded the positions of the catheter by obtaining x-ray films, and I was able to observe the advancing catheter clearly on the fluoroscopic screen, by means of a mirror held for me by the Sister.
. . . Figure 2 is a film of the second observation: the catheter passes directly inward from the left arm, under the clavicle at the chest wall, and makes a downward bend at the place of junction with the jugular vein, lying near the margin of the great-vessel shadow and the shadow of the spine, and reaching as far as the right atrium. On another passage, the catheter did not reach any further than this. I watched carefully for any other effects, or signs of irritation of the cardiac mechanism, but could not identify any. In our institution there is a considerable distance between the operating rooms and the x-ray unit. To go from one to the other I had to climb staircases on foot and return, while the probe was lying within my heart, but I was not aware of any unpleasantness. Passage and removal of the catheter were entirely painless, accompanied only by the above-mentioned sensations. Later on 1 could find no sequelae to the procedure, except for a slight inflammation at the site of venesection, which clearly was a result of inadequate asepsis during the self-performed operation . . . (Closing, page 2087.) In conclusion I should point out that this method . . . has opened the prospect of many possible metabolic researches and studies of the function of the heart, some of which I have already begun [l].
The first study that he undertook was the injection of radiographic contrast materials through a right atrial catheter with x-ray filming, first in the hearts of dead animals and then in those of living ones [2]. The rapid film-cassette changer had not yet been invented, so timing of a single film-with the contrast injection was difficult
at first. Good pictures of the right-sided chambers and the pulmonary artery could be obtained, however, and Forssmann again used himself as an experimental subject. On two separate occasions he injected the contrast material through catheters (No. 8 Charrieres in these experiments) into his own right atrium, but on these occasions the x-ray exposures were mistimed and satisfactory films were not obtained. During the injections, he described a transient sensation of dizziness, and moments afterward, a sensation of warmth in the mouth, but no other adverse effects. He presented his findings before the Medical Society of Eberswalde on November 29, 1930, and published them in another journal in the following year [2]. Summary (p. 492): 1. Filling of the cadaverous heart with Rontgen-contrast materials can produce beautiful pictures, but does not demonstrate the corresponding functional relationships. 2. With the help of a cardiac catheter, it is possible to introduce contrast materials into the living right heart. 3. Rapid injection of sodium iodide in a 25 percent solution, and Uroselectan in 50 percent solution, were well tolerated by experimental animals and resulted in good (x-ray) pictures. 4. During two experimental trials on the same person, with rapid injections of sodium iodide and Uroselectan through a catheter into the right atrium, no unpleasantness or adverse reactions were observed. Satisfactory contrast photographs were not obtained, because of faulty technique on our part [2].
Epilogue Forssmann gave up pursuing these studies, possibly because of opposition from his colleagues and superiors. * * Subsequently he took additional postgraduate training in
CLASSIC MEYER WERNER FORSSMANN
A n n Thorac Surg 1990;49:497-90
urology at Berlin and Mainz and began his practice in Dresden. He served as a medical officer in the German Army during World War I1 and was taken prisoner on the Western Front. Released at the end of 1945, he returned to urological practice together with his wife, who was also a physician with similar training. A decade after his landmark report, catheterization of the heart was taken up by Andre Cournand and Dickinson W. Richards of Columbia University and developed into a systematic method for diagnostic study of the cardiac chambers. Dr Cournand (1895 to 1988), though not a surgeon, was for many years a member and senior
499
member of the American Association for Thoracic Surgery. Forssmann, Cournand, and Richards shared the Nobel Prize for Medicine or Physiology in 1956. Forssmann died in 1978 at the age of 74.
References 1. Forssmann W. Die Sondierung des rechten Herzens [Probing of the right heart]. Klin Wochenschr 1929;8:2085-7. 2. Forssmann W. Ueber Kontrastdarstellung der Hohlen des lebenden rechten Herzens und der Lungenschlagader [On contrast demonstration of the chambers of the living right heart and the pulmonary artery]. Miinchener Med Wochenschr 1931;78:489-92.
REVIEW OF RECENT BOOKS
Cardiac Arrhythmias, 3rd ed By Davis H . Bennett Butterworths (john Wright), 1989 206 p p , illustrated, $49.95
Reviewed by Richard M . Peters, M D This paperback volume reviews the clinical and electrocardiographic findings and treatment of patients with arrhythmias. The book is well organized with good electrocardiographic illustra-
tions and summary of the findings on each type of arrhythmia. The book is designed for those who are not at the level of electrophysiologists. It appears to be a good book for house officers and an advanced book for medical students. It will allow one to look up the arrhythmias that are associated with different conditions as, for example, myocardial infarction and atrioventricular blocks. Not only the electrocardiographic manifestations but also the suggested treatment modalities are given.
San Diego, California
