Medicolegal Issues

The First Catheterization


 

It was very painful. I felt that I had planted an apple orchard and other men who had gathered the harvest stood at the wall, laughing at me.” Dr. Werner Forssmann said these words toward the end of his life on his unexpected scientific exile after having laid the foundations of modern cardiology.

Pacemaker Insertion, angioplasty, and valve repair might now be impossible without the daring of Dr. Forssmann, whose humble roots set into sharp relief the depth of his accomplishments.

Leading physicians in turn-of-the-century Europe said that investigation and treatment of conditions affecting the heart were anathema to mainstream medical society; the heart was off-limits. In 1896 Sir Stephen Paget went so far as to say that “no new method, and no new discovery, can overcome the natural difficulties that attend a wound of the heart.”

Enter Dr. Forssmann. Raised by in Berlin by his mother in a middle-class household after his father was killed in WWI, this young surgeon in training broached a bold idea with his surgeon-mentor Dr. Richard Schneider, a friend of the Forssmann family, in summer 1929.

Far from fantasy, Dr. Forssmann’s inspiration to perform what is now called cardiac catheterization came from a sketch in his physiology textbook depicting a long, thin tube being placed into a horse’s jugular vein and guided into the animal’s heart with balloon-assisted measurements of intracardiac pressures. Dr. Forssmann proposed to reach the heart of man—not through the jugular, but through the veins in the crease of the arm, which was more accessible

But how would this experiment happen? Dr. Forssmann elicited the help of Gerda Ditzen, a surgical nurse at Auguste Viktoria Home (Hospital), Eberswalde, near Berlin. In a month, Dr. Forssmann had convinced her to be his first human guinea pig. Dr. Forssmann, unbeknownst to Ditzen, planned on experimenting on himself. She held the keys to the closet, which was needed to obtain a long enough catheter.

As nurse Ditzen was strapped to the surgical table in the small operating room, sweating from both excitement and the sweltering

heat, Dr. Forssmann walked the distance of the OR and began his self-experimentation. With an incision in his left elbow crease, Dr. Forssmann identified the predominant vein and inserted the 65-cm-long ureteral tube into his arm, feeling progressive painless warmth as the tube coursed along. He had determined this was the only tube thin and long enough to safely and adequately reach the endocardium. However he still needed her help to conceal the tube hanging out of his arm. They went—tube in place—to the fluoroscopic X-ray facility, where images were obtained in the hospital basement.

The initial X-ray clearly indicated that the tube had not yet reached its destination. Dr. Forssmann forced the tube farther, resisting at one point the overwhelming urge to cough when the tube collided against his vein. When the tube was shown to be in the right auricle Dr. Forssmann had the technician snap the picture, finally obtaining the proof that he needed. Dr. Forssmann uneventfully removed the tube.

The real incident involved in this daring experiment was to come: Dr. Forssmann had to face the reactions—not only of his mentor Dr. Schneider, but also the medical community. The majority was ostensibly displeased with his methods, rationale, and approach, believing them too dangerous. After repeated self-experiments, Dr. Forssmann learned that his self-cath procedure could be safely performed; he submitted his findings with fluoroscopic proof to the German medical community at large. At least one prior researcher, the surgeon Ernst Unger, repudiated Dr. Forssmann’s claim, saying he had done the same thing many years earlier, but without hard evidence to back his claim.

Despite the rising tide of opposition to his findings, Dr. Forssmann pushed on. His subsequent experiments with rabbits and dogs (and ultimately himself) proved that catheterization angiography could not be achieved with simply sodium iodide. He developed the use of groin catheterization to reach the inferior vena cava through the femoral veins. Dr. Forssmann’s further experiments in aortography proved unfruitful. By this time, he had decided to stop his self-experimentation, having reached his limits with exploration. Instead he decided to seek work as a local urologist in a small German farming community.

In 1956, Forssmann was awarded the Nobel Prize in Medicine, which he shared with André Cournand, MD, and Dickinson W. Richards, MD, who were affiliated with Columbia University, New York City. When offered a job to head a German cardiovascular institute, Dr. Forssmann declined, citing his lack of knowledge about advancements in the field since his last self-experimentation in 1935. TH

Reference

  1. Altman, Lawrence K. Who Goes First: The Story of Self-Experimentation in Medicine. New York: Random House; 1987.

Historic Puzzler ANSWER: ”The Root of the Problem“

The answer to our third puzzler

By Jamie Newman, MD, FACP

There were several correct answers to the Historic Puzzler #3 (September, p. 10), but the best family effort award goes to Juan Solis, MD, a former hospitalist who now runs a private practice in internal medicine/geriatrics in Ohio, and his sisters—Rosa A. Solis, MD, a hospitalist in Binghamton, N.Y., and Regina A. Solis-Pastor, MD, a dermatologist.

Juan was showing off his name in The Hospitalist to his sisters when Regina pointed out Puzzler #3. Rather serendipitously she remembered seeing what we described on cable TV in the Philippines.

The captain of the expedition was James Cook, the naturalist was George Forster, and the root was kava kava. Juan looked up the herb and found the possible offending chemical component to be pipermethystine—seemingly found more on the leaves and stems of the plant than on the root itself. Neuro-ophthalmologic side effects include weakness, lack of coordination, lethargy, and change in mental status—even Parkinsonism. Dermatologic manifestations include xerosis (parchment-like, mosaic) and leprous ulcers. TH

Puzzler Special Recognition

Bijo Chacko, MD

And the best track record to date award goes to Collin Kroen, MD, of the Cleveland Clinic, the only one to solve all three puzzlers! Bijo Chacko, MD, the hospitalist program medical director at Central Brooklyn Medical Group, N.Y., and Alberto Burgos-Tiburcio, MD, Caritas Carney Hospital, Dorchester, Mass., are two for three.

So if you see a scaly, wild-eyed Polynesian lurching down the beach, have no fears, they may have been dipping into the coconut bowl once too often.—JN

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