Tuesday, July 15, 2014

To the heart of things

Over the last few weeks I have been forced to watch a lot of soccer.

This is a problem because I don't like soccer.  I suspect I am not the only person currently suffering in this manner.  Fortunately it is now all over for another four years and from what I can understand, it's all about Germany.

Hopefully my saying that hasn't spoiled someone's day.

Anyway in honor of their win I thought today I would talk about a German surgeon who did some (mostly) pretty cool things - which, to me, is generally more interesting than kicking a ball around a field and faking serious injury.

Werner Forssman (public domain image sourced from Wikipedia)

Werner Forssman was a nobel prize winning physician born in 1904 who did his most memorable work in 1929, while a resident.  In the preparation of his doctoral thesis he became interested in the idea of finding a safe way of accessing the heart while the patient was awake.  Previously this had been done on an anaethetised horse via the jugular vein.  Forssman believed the best way was via the cubital vein.

However his chief wouldn't allow experimentation in their small department. Forssman suggested experimenting on himself but was also denied. The fear was that accessing the heart on an awake patient could prove fatal.

Undetterred, Forssman began by practicing on cadavers.  Convinced that the procedure would work he enlisted the help of a nurse to hold a mirror so he could see the progress of a catheter on a fluoroscope.  Nervously, and uncertain if he might actually kill himself, Forssman inserted 60cm of a ureteric catheter through his cubital veins, subclavian vein and, he hoped into his heart.  He went to radiology with the catheter dangling out of his arm and confirmed the tip was in the right ventricle with an X-ray. 

Although his Boss was (probably quite reasonably) somewhat irritated with the wayward junior doctor, he couldn't dispute the results and permission was granted for a second cardiac catheterisation on a terminally ill patient and used for medication administration.  Although the patient did not survive, the short term effects showed that medication administered this way was more effective.  In addition post mortem comfirmed the catheter was in the correct location.

Unfortunately for Forssman his penchant for flouting the rules and self experimentation meant that his career was adversely affected.  When his paper on cardiac catheterisation was published he was dismissed from his position, ostensibly for not asking permission to publish, although more likely because of the publicity the self experimentation brought.  He was eventually reinstated only to be dismissed again for not meeting scientific expectations.  He was eventually simply unable to continue a career in cardiology owing to his reputation, eventually opting to pursue urology instead.

In 1933 he married Dr Elsbet Engel, also a urology specialist. They had six children.

Being German, of course, this story has a darker side in that Forssmann was a member of the Nazi party from 1932-1945.  Like many doctors in the era he joined early.  He  worked as an army surgeon through WWII rising to the rank of major, until he was captured and placed in an American POW camp.  He was released in 1945 and joined his family in the Black Forest where he worked first as a lumberjack and then as a general practitioner.  He was unable to get a surgical appointment for three years, then beginning to work as an urologist.

While Forssman has been a POW two Americans, Andre Cournaud and Dickinson Richards read his paper and extrapolated his technique to the diagnosis and treatment of heart disease.  Convinced his cardiac catherisatiom discovery had gone nowhere , Forssman was astonished post-war to walk into a functioning cardiac cath lab in Basel.  In 1951 he flew to meet Andre Cournaud and see his developments first hand.

However in 1956 when the woman rang from Bonn Switzerland to inform him he had won the Nobel Prize his response was still, "for what?"

And even that win did not open up the surgical opportunities in Germany that Forssman craved. He was fond of saying that only the Americans has ever really appreciated his work.

He died of heart failure, following two myocardial infractions in 1979 at the age of 74.  The irony and perhaps the greatness of his input to medicine, to that is that modern advances and applications of  cardiac catheterisation mean that in this day and age -  the procedure he performed on himself nine times might today have been able to extend his life.

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JA Meyer, 'Werner Forssman and cathetrization of the heart, 1929'
Ann Thorac Surg, 1990, 49 (3): 497-9

HW Heiss 'Werner Forssman: A German problem with the nobel prize'
Clinical Cardiology, 1992, 15: 547-549


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