TO REACH THE HEART:

CARDIAC CATHETERIZATION 

         

           In the operating room of a provincial Red Cross hospital in Eberswald, Germany, on an afternoon in 1929 a young intern, Werner Forssmann, stood behind the operating table, where a surgical nurse, Gerda Ditzen, was lying, unable to see him. Forssmann injected novocaine into his right elbow area, made a small incision, and

Werner Forstmann (Wikipedia)

inserted a needle through which he threaded a narrow ureteral catheter, 65 cm long, pushing it up a vein to the level of his shoulder. The nurse had initially volunteered for the catheterization and was awaiting the procedure, but Forssmann, having used her primarily to access the operating room, catheterized himself instead.

         To document the catheter’s position, Forssmann, catheter in place, and the nurse, furious but curious, headed down a flight of stairs to the X-ray room. Behind a fluoroscope, Forssmann viewed his thorax in a mirror held by Gerda as he pushed the catheter up until it reached his right atrium. Another doctor burst into the room, enraged, and tried to pull out the catheter, but the technician had already taken a few shots. 

         The general surgeon supervising Forssmann, Dr. Richard Schneider, had previously refused a request by Forssmann to perform the catheterization either on himself or a moribund patient and was now obliged to discharge him. Schneider saw, however, the importance of the experiment and helped Forssmann write a paper, published by the prestigious Klinische Wochenschrift.

X-ray published in Klinische Wochenschrift, 1929, of Forssmann with first documented
catheter placement. See reference below. (Courtesy Hathi Trust)

         Forssmann had prepared himself. As a student, he learned that French physiologists had catheterized animals for years without ill effects. Claude Bernard, for example, to settle an argument about whether most of the metabolism of the body (and the source of heat) took place in the lungs, the opinion favored by Lavoisier, or in peripheral tissues, the idea promoted by Gustav Magnus (who had shown that venous blood contained more CO2 and less oxygen than

Claude Bernard (Wikipedia)

 arterial blood). Bernard, using horses and    dogs, introduced thermometers on catheters   through the carotid artery into the left  ventricle and through the jugular vein into  the right heart, confirming a temperature  difference that favored Magnus’ opinion. 

         To settle arguments over the timing of the contractions of atria and ventricles a veterinary physiologist, A. Chauveau, and a Parisian physician interested in blood pressure, E. J. Marey (see last month’s essay), had also introduced catheters into animal hearts to produce tracings of the timing and the force of the contractions. 

         Additionally, Adolf Fick, a German physiologist in Würzburg, established in 1870 a formula for determining cardiac output: the amount of oxygen taken up by the lungs per unit time divided by the difference between arterial and venous contents of oxygen. This required the simultaneous collection of mixed venous and arterial blood coupled with measurements of gas exchange in the lungs. Mixed venous blood is found in the right atrium. 

         In Forssmann’s 1929 report he claimed that he had first tried catheterization on a cadaver and that a colleague had introduced the catheter into his arm but became uneasy and refused to continue, obliging Forssmann to finish the attempt alone. Both statements were false, as documented by the medical reporter, Lawrence Altman. It was a true self-experiment without preliminary trials. The medical community missed the significance of catheterization, however. His action aroused severe criticism and his surgical career suffered. Undeterred, a short time later Forssmann reported self-injections of contrast material through a catheter into his right heart to visualize the chambers. The medical community had little reaction. Overall, Forssmann catheterized himself nine times.

         Catheterization efforts were few and far between for several years. A young French physician, André Cournand, aiming to

André Cournand (Wikipedia)

practice pulmonary medicine, enrolled in 1932 as a resident on the Columbia Chest Service of Bellevue Hospital in New York. While there, he accepted an offer from Dickinson Richards to collaborate on research on pulmonary gas exchange. 

Richards, a graduate of Columbia’s College of Physicians and Surgeons, had begun a career in pulmonary physiology.  He and Cournand, studying emphysema, established abnormalities in the mixing of gases but for precision needed to measure blood flow through the lungs, a step requiring samples of right atrial blood. Cournand consulted a colleague in France, Pierre Ameuille, who had catheterized the right heart in over

Dickinson Richards (Wikipedia)

100 cases, introducing contrast solution to visualize the pulmonary circulation. Cournand reviewed the cases and, after trials in animals, he and Richards proceeded gingerly, in 1941, to catheterize humans. 

War influenced all three men. Forssmann had joined the Nazi party and served in WWII, spending three years near the eastern front treating wounded soldiers. After the war, barred from hospital posts as a former member of the Nazi party, he practiced urology in a small town. Cournand, when a first-year medical student, served in WWI as a medic, applying first aid and retrieving wounded from no-man’s-land between trenches. The two, from former enemy countries, first met in 1952 and Cournand later wrote the introduction to Forssmann’s autobiography. 

Richards served in WWI as an artillery officer and during WWII he and Cournand, using cardiac catheterization, worked on the wartime problem of the physiology of shock.  The three shared the Nobel Prize in 1956 for their contributions to cardiac catheterization. Research seemed to be a criterion for the prize.  As the Nobel Committee, speaking of Cournand and Richards, put it: “…the main point was that a well-known research group at a distinguished clinic had set their seal of approval on the method, which then made its triumphant entry into the world of clinical medicine.”

Cardiac catheterization is now a routine procedure, essential for modern cardiology and cardiac surgery.

         

 

 SOURCES:

 

Weibel ER, “Andre Frederic Cournand, 1895-1988: A Biographical Memoir.” Nat Acad Sci, Biographical Memoirs, 1995.

 

Cournand A F and Ranges HA, “Catheterization of the Right Auricle in Man.” Proc Soc Exptl Biol Med 1941; 46: 462-6. 

 

Buzzi A, “Claude Bernard on Cardiac Catheterization,” Amer J Cardiol 1959; 28: 405-9.

 

Altman L, Who Goes First: The Story of Self-Experimentation in Medicine. 1987, Random House.

 

Ameuille P, et al, “Remarques sur Quelques Cas d’Artériographie Pulmonaire chez l’Homme Vivant.” Le Concours Médical 1936; 58: 3308. (The report contains little information of a physiologic nature.)

Forssmann W, Experiments on Myself: Memoirs of a Surgeon in Germany. New York: St. Martin’s Press; 1974.

Cournand A F, From Roots to Late Budding: The Intellectual Adventures of a Medical Scientist. Gardner Press, N.Y; 1986 

Cournand A F, “Cardiac Catheterization.” Acta Medica Scandinavica 1975; 198 (issue S579): 7-32. (A history of cardiac catheterization).

A full index of past essays is available at: 

https://museumofmedicalhistory.org/j-gordon-frierson%2C-md

 

 

 

 

 

 THE SOUNDS OF KOROTKOFF

         Inflating a cuff on the arm and applying a stethoscope to record the blood pressure as the cuff is deflated is a routine procedure in any medical office. So routine that one rarely thinks about how it began.

         The idea of measuring the pressure impelling blood through the body arose primarily out of physiologic curiosity. Stephen Hales, an eighteenth-century clergyman, investigated it by inserting a cannula

Stephen Hales measuring a horse's 
blood pressure (from Haemastatics,
third edit)

into a major artery of animals, most notably a horse, and measuring the height to which the blood ascended in a calibrated tube. Other investigators followed suit, using mercury columns and other measuring devices. 

Was the blood pressure in man medically important? This was not understood for some time. In 1836 Richard Bright, at Guy’s Hospital in London, noted a “hard pulse” in cases of “albuminous urine” (chronic kidney disease) that were often associated with hypertrophy (thickening) of the left ventricle.

But many patients with ventricular hypertrophy turned out to have normal kidneys. Frederick Akbar Mahomed, also at Guy’s Hospital, picked up on the findings of William Gull and Henry Sutton who had described cases of normal or near-normal kidneys and ventricular hypertrophy that showed thickened walls of small arteries. Mahomed reported additional patients in 1881 as “Chronic Bright’s Disease without Albuminuria.” The report by Mahomed seems to be the first to describe the clinical picture recognized today as essential hypertension, a silent disease progressing from nosebleeds to heart failure and cerebral hemorrhages. Determining blood pressure became medically important.

Meanwhile, measurement techniques progressed. One of several investigators, Étienne-Jules Marey, a French

Étienne-Jules Marey (Wikipedia)

physician/cinematographer, had designed a varying pressure pad applied to the radial artery, recording the pulse curves on a tape and defining the systolic pressure as the level of compression to obliterate the pulse on recorded tracings. Marey was actually more famous as a developer of movies and “animated photography.” His technique revealed that all four hooves of a horse were raised briefly off the ground during a gallop, later confirmed by Eadweard Muybridge at Leland Stanford’s ranch. Mahomed, using a device similar to Marey’s, skipped the recordings and felt, below the pad, the onset of a pulse as the pad pressure loosened. 

Mahomed's blood pressure device, based on model of Marey, attached to wrist or arm.
(Med Times Gazette 1872)

Several other devices appeared but were impractical for clinical use. The earliest that resembles the modern cuff was designed by Scipione Riva-Rocce, an Italian physician. The use of a wider,

inflatable cuff attached to a mercury manometer, was the major improvement. The systolic pressure was still obtained by feeling the onset of a pulse below the cuff as it loosened. 

Riva-Rocci BP apparatus (Zimmerman
 instrument catalogue, 1903, Bauhaus
Universität Weimar)

The modern approach, determining systolic and diastolic pressures by using a stethoscope, was invented by Nicolai Sergeevich Korotkoff. Korotkoff began life in Kursk, the capital city of the region invaded recently by Ukraine. He studied basic sciences at Kharkov University and medicine at Moscow University, followed by postgraduate work at Moscow’s Alexander

Nicolai Korotkoff (Wikipedia)

Bobrov Surgical Clinic. In 1903, one of Russia’s finest surgeons, Sergei Fedorov, invited him to a residency in the Imperial Military Medical Academy in St. Petersburg, the most prestigious medical center in Russia. Fedorov was the founder of the urological association in Russia, a friend of William Mayo, and eventually “life-surgeon” to the imperial family. 

Korotkoff interrupted his studies at the Bobrov clinic in 1900 to join the Red Cross as a surgeon in a Russian military expedition to China to quell the Boxer Rebellion. He found traumatic arterial aneurysms (ballooning of the vessel after trauma) to be relatively common. He volunteered again during the Russo-Japanese war of 1904-5, going to Manchuria as chief surgeon in a Red Cross unit and encountering more post-traumatic aneurysms. A dictum of Nikolai Pirogov, perhaps Russia’s most famous surgeon (see essay of Dec 11, 2016) had been to always auscultate aneurysms, or lumps that might be aneurysms. Korotkoff heeded this advice in Manchuria. In addition to placing the stethoscope on aneurysms he applied Riva-Rocce inflatable cuffs to limbs and was able to determine with a stethoscope that the transmitted sounds corresponded to the palpable pulse felt below the cuff, thus correlating the palpated pressure with audible sounds. This allowed him to assess whether there was sufficient collateral circulation to preserve the involved limb. It also established a diastolic level that correlated with laboratory determinations.

Imperial Military Medical Academy, Saint
Petersburg (Wikipedia)

Korotkoff reported his experience in a brief (207 words) paper to the Military Medical Academy in December 1905. The method was validated in the hospital’s therapy department and adopted in Russia and elsewhere in Europe. In 1916 the American physiologist, Joseph Erlanger (who later shared a Nobel Prize for work on nerve

Joseph Erlanger 
(Wikipedia)

fiber functions) published detailed studies of the Korotkoff method, confirming its accuracy and ensuring its adoption in America.  

In 1910 Korotkoff published his thesis for Doctorate in Medicine on estimating collateral circulation. Unfortunately, Korotkoff, like his compatriot Anton Chekhov, whose stories he frequently read, had developed tuberculosis. Believing that cold, dry air would benefit him, he signed on for two years as physician at a gold mine facility in Siberia. On arrival, he was shocked and distressed at the workers’ desperate conditions, overworked and poorly fed. His protests led nowhere. During a strike many workers were massacred, a tragic event publicized worldwide. When his contract was up, he resumed hospital work in surgery, continuing through WWI and the 1917 Revolution. But his health deteriorated steadily and in 1920 he suffered a massive hemoptysis and died of the same disease that had felled his literary companion, Chekhov, in 1904. 

Korotkoff’s simple method of determining blood pressure, devised under battle conditions for reasons unrelated to general health, is now the standard method used worldwide.

 

SOURCES:

 

Fishman, A P, and Richards, W R, Circulation of the Blood: Men and Ideas. 1964, Oxford Univ. Press. Chapter VIII.

 

O’Rourke, M F, “Frederick Akbar Mahomed,” 1992; Hypertension 19 (2): 212-17.

 

Segall, H N, “How Korotkoff, the Surgeon, Discovered the Auscultatory Method of Measuring Arterial Pressure.” 1975; Ann Int Med 83: 561-2.

 

Konstantinov, I E, “Nikolai S Korotkov: A Story of an Unknown Surgeon with an Immortal Name.” 1998; Surgery 123 (4): 371-81.

 

Booth, J, “A Short History of Blood Pressure Measurement.” 1977; Proc Roy Soc Med 70: 793-99. (contains translation of original paper.)

 

Lewis, W H Jr, “The Evolution of Clinical Sphygmomanometry.” 1941; Bull N Y Acad Med 17: 871-81. (contains translation of original paper.)

  

A full index of past essays is available at: 

https://museumofmedicalhistory.org/j-gordon-frierson%2C-md