The Birth of a Common Procedure

TO THE EDITOR:

I enjoyed the quotation from Banting and Best that appeared in your 1 January 1994 issue (p. 70). It occurred to me that many housestaff physicians regularly do a procedure for which Werner Forssmann (along with Cournand and Richards) received the Nobel prize in 1956.

Forssmann was a 26-year-old intern at a community hospital on the outskirts of Berlin at the time. When the article was published, he was a surgical resident in the department of Ferdinand Sauerbruch at the Charite in Berlin. The two-page article caused such a furor that Sauerbruch, a man of more bravado than insight, fired poor Forssmann only to rehire him after the hubbub died down. He refired him later.

I thought that younger readers might be interested in this story and have inserted a few paragraphs translated from Forssmann's original German:

In cases of shock, such as those engendered by sudden cardiac standstill, or during anesthetic emergencies and poisonings, it may be desirable to deliver medications directly to the heart itself. In such patients, injections of drugs into the heart may be life saving. Nevertheless, intracardiac puncture is a dangerous procedure for several reasons, including injury to the coronary arteries and its branches, pericardial tamponade, injury to the diaphragm, and pneumothorax. Thus, the administration of intracardiac medications is a measure of last resort, which results in loss of time and opportunity. For these reasons, I considered a new method to approach the heart in a less dangerous fashion, namely the catheterization of the right heart from the venous system.

Experiments on a cadaver were productive. I was able to catheterize any vein in the antecubital fossa and was able to regularly reach the right ventricle, before encountering resistance. Subsequent dissection showed the catheter, which was also palpable, present in the cephalic or basilic vein, extending through the subclavian and innominate veins, to the superior vena cava and into the right heart itself. I next undertook experiments on a living subject, namely on myself. I first convinced a colleague to puncture a vein in my right antecubital fossa with a large needle. I next advanced a well-oiled ureteral catheter size 4 Charriere in diameter through the needle into the vein. The catheter allowed itself to be advanced with trivial ease to 35 cm. Because my friend objected to our proceeding with these experiments further, we broke them off even though I felt perfectly well. One week later, I tried again alone. I anesthetized my own left antecubital fossa and because I was not able to manipulate the needle by myself, I constructed a “cut down” and advanced the catheter along its full 65 cm length. From surface estimates, I reasoned that the catheter tip would be at the level of the heart.

I documented the position of the catheter with roentgenograms that I obtained by standing in front of the fluoroscope while observing the catheter in a mirror held by a nurse. In conclusion, I would like to point out the utility of this technique in providing new opportunities to research the metabolic activities and the actions of the heart [1].

• Copyright ©2004 by the American College of Physicians