Smoking Ears and Screaming Teeth - Trevor Norton (2010)
A Change of Heart
‘For this relief much thanks … I am sick at heart’ – Shakespeare
The heart was many things before it was known to be the body’s engine for moving blood. It was the seat of courage and love and compassion. The heart was so important to the Ancient Egyptians that it was the only organ to be left in place when they stripped out the viscera during mummification, for it was to be weighed by the gods as a measure of the man’s conscience. In contrast, the Aztecs ripped out the hearts of human sacrifices to offer them to the gods, and reckless lovers offer their hearts to each other.
The heart beats out the rhythm of life, but it was not until the early nineteenth century that physicians began listening. A young doctor called René Laënnec was failing to sound the chest of an over-plump young woman and wondered if he dared to put his ear to her chest. Instead, he rolled a quire of paper into a tube and placed one end under her breast and the other to his ear. He could clearly hear the echo of her breathing and the pounding of her heart. A skilled woodturner, he made a proper listening tube that he called a stethoscope (Greek for ‘spy on the chest’).
It revealed that the chest was an auditorium for the internal music of the body. Laënnec was able to match the sounds he heard inside seriously ill patients with the symptoms later revealed at their autopsy. Thus he deciphered the sound of specific diseases, making the brilliantly simple stethoscope a major tool for diagnosis.
It was not universally accepted. Broussais, the lover of leech therapy, thought it was ‘a useless discovery’ and even into the twentieth century a few conservative doctors still preferred to use their ear pressed to the skin. For whose benefit is unclear. Were it not for the invention of the stethoscope, what on earth would medical students hang around their necks to give the impression that they are doctors?
Laënnec was a gifted pathologist and physician. He described and named peritonitis and cirrhosis of the liver. He also wrote a guidebook on using the stethoscope and, for a small extra charge, a stethoscope was included.
He contracted pulmonary tuberculosis, a disease for which a stethoscope was critical for diagnosis. He also suffered from acute angina and clinically described his own symptoms as being like ‘iron nails or the claw of an animal tearing asunder the front of the chest’. Although seriously ill, he slaved over writing a major revision of his book. In doing so he displayed the same courage and dedication as the self-experimenters. ‘I knew I was risking my life,’ he wrote, ‘but the book that I am going to publish will … be worth more than one man’s life … My duty was to finish it, whatever might happen to me.’ Shortly after its completion Laënnec died. He was only forty-five.
Most of the body’s organs go about their business quietly with little outward sign of activity. The heart, however, is an exuberant organ. It almost shouts ‘I am alive and kicking’, beating 100,000 times a day for every day of your life. Its pulse accelerates by a third during pregnancy and goes far higher when you are stressed or exercising. It generates enough force to pump blood through over 199,000 kilometres (123,000 miles) of blood vessels. Perhaps it can be forgiven for failing occasionally.
No wonder the heart fascinated and frightened surgeons. It was regarded as untouchable. How could one operate on something that was never still, and with the slightest wound could explode blood outwards in an unstoppable gush? If this happened, there were only four minutes left to save the patient’s life.
It was best to ignore the heart. Indeed, a highly influential surgeon of the day warned that anyone ‘who tries to suture a heart wound would deserve to lose the respect of his colleagues’.
In 1896 a distinguished British surgeon suggested that surgery had ‘reached the limits set by nature … no new method, and no new discovery, can overcome the natural difficulties that attend a wound to the heart’. Within seven years a German surgeon called Ferdinand Sauerbruch proved him wrong, albeit by accident. He had a patient with heart failure and thought that it might be because the membrane round the heart was constricting it. He managed to peel back the membrane and then, perhaps as an encore for the watching audience, he removed a cyst from the surface of the heart. It was a mistake. The cyst was in fact a protrusion of the heart’s wall. He had cut directly into the heart, which responded by propelling blood everywhere. Sauerbruch calmly plugged the hole with his finger and sewed up the wound, saving the patient.
The heart is difficult to get at as it’s protected within a cage of ribs. The problem lay not in cutting through the bones but in dealing with the lungs that immediately deflate when they are no longer encased in the chest. One way around this was to aerate the lungs artificially. John Hunter had used a bellows for this purpose 150 years earlier. It had enabled him to open the chest of a dog and observe the beating of its heart. Sauerbruch’s solution was to enclose the patient, operating table and the entire surgical team within a large sealed chamber in which the pressure could be kept as low as that in the patient’s lungs. Only the patient’s head and the anaesthetist were outside the chamber. This unwieldy and expensive apparatus never caught on for chest surgery but was the prototype for the iron-lung machines that kept poliomyelitis patients alive decades later.
The problem was that surgeons were approaching the heart from the wrong direction. There was another route, since all the main veins of the body led to the heart. Claude Bernard, a French physiologist, had passed tubes within the blood vessels of animals, and other researchers had used his technique to measure blood pressure and the concentrations of oxygen and carbon dioxide in horses, which have conveniently wide and robust veins. No one dared to try anything so dangerous on humans.
In the late 1920s Werner Forssmann was a student studying medicine in Berlin. After the humiliation of Germany’s defeat in the Great War, patriotism was on the rise. The emphasis was on ‘German science’. One lecturer who dedicated himself to manufacturing German words for every medical condition called an aneurysm caused by syphilis Hauptkörperschlagaderlustseuchenerweiterung.
Forssmann’s practical experiences were eventful. Once he assisted a doctor attending a girl who’d had a botched abortion. They operated on the rickety kitchen table. Her roommate held up the kerosene lamp but fainted, breaking the lamp and setting fire to the floor. Forssmann instantly wrenched a blanket from beneath the patient and smothered the flames. Unfortunately, the table collapsed, the patient fell off and the rest of the operation was conducted in near-darkness at floor level. But her life was saved. On another occasion, when Forssmann and his colleagues used chloroform for a delivery, the patient’s husband flung himself over his prostrate wife, convinced that they had killed her. To allow the delivery to proceed, Forssmann had to lock him in the privy. He shouted ‘Murder! They’re killing my wife!’ until she presented him with a son.
Forssmann was becoming interested in the challenge of the heart. Surgeons were developing new techniques to tackle diseases of almost every organ of the body. But if you wanted to know what was wrong with your heart, you had to wait for the post-mortem.
As a young intern he’d seen a drawing of a horse with a catheter (tube) in its neck and decided this technique would enable him to plumb the interior of the human heart. His boss would not hear of trying it out on a patient. Nor would he consider the idea of Forssmann doing it to himself.
Forssmann decided to try, and enlisted a surgical nurse called Gerda to secure the equipment he needed. He assured her that it was not dangerous even though he had no idea how the heart’s delicate lining would take to the probing. Even slight molestation can cause the heart to exchange its regular beat for erratic tremors that in those days were invariably fatal.
During the surgeons’ lunch break they sneaked into the operating theatre. Forssmann opened the vein in his arm and slowly slid sixty-five centimetres of tubing up towards his heart. They went to the X-ray room where he used a mirror to help him guide the tube into his heart. The technician took a photograph showing the tubing eerily snaking across Forssmann’s body and entering the heart. It might well have been a heart-stopping moment.
The next morning he was on the carpet for disobeying orders, but his boss was impressed by the experiment and took him out to dinner. During the following weeks Forssmann repeated his self-experiment five times without mishap. He was even allowed to deliver drugs to a terminally ill patient by means of a tube along a vein.
He wrote an account of his results for publication. His boss advised him that he should say he did preliminary trials on cadavers, rather than give the impression that it was an irresponsible stunt. Around this time Forssmann moved back to Berlin to work under the great surgeon Sauerbruch.
When the article containing the authenticating X-ray photograph was published in 1929 it caused a sensation. The hospital was besieged by reporters and one of them offered a large sum for permission to publish the picture. It also caused a stir in the academic community. Some medics said that they had done exactly the same thing years before, but none of them produced a scrap of evidence to support their claims. Sauerbruch was not thrilled by the controversy. He made it clear to Forssmann that ‘you might lecture in a circus about your tricks, but never in a respectable German University’. Forssmann was sacked.
He returned to his old hospital determined to take his research further. X-rays were now being used to diagnose problems in the gut by using substances that the patient swallowed to make the interior of the intestines show up on an X-ray screen. Perhaps with his catheterisation technique he could make the interior of a living heart visible.
This time Forssmann was advised to try some animal experiments first. With rabbits, the moment the tube touched the inside of the heart it stopped beating. So he switched to using dogs. The hospital had no facilities for keeping dogs so his mother housed them in her apartment. When required they were ferried to the hospital in a cab. The dogs fared better than the rabbits until he squirted a compound opaque to X-rays into their heart. Then they too died. When he switched to another contrast substance, sodium iodide, the dogs were fine and he was able to take lots of X-ray photographs and arrange them into a series to show the contractions of the heart.
But was it safe to use on humans? If rabbits and dogs reacted differently, perhaps dogs and humans might too. This was a more dangerous experiment than the original one. If that had gone wrong Forssmann could have withdrawn the tubing, but once he injected sodium iodide into his heart there was no going back. The chemical would flow throughout his body and who knew what it might do. He had dabbed some of it onto his skin and rinsed some round his mouth with no ill effect, but what did that tell him about how it might react in his heart, liver and kidneys?
Forssmann decided to push his luck by threading a tube into the vein in his neck and then down into his heart before releasing the chemical. The tube took a wrong turning, but he found the heart at the second attempt. He didn’t feel well afterwards but it wasn’t as bad as he feared. He made nine more insertions into the heart and not by the easiest route. The blood vessel he had used initially was now sewn up so instead he used a vein of his upper leg, pushing the tube into the main vein in the abdomen and then up into the heart. All this was done entirely by feel as he couldn’t see where the probe was going.
It was more hazardous than he imagined. Years later a surgeon who avoided self-experimentation by letting his patients bear the risk instead inserted a catheter into a main artery and then into the branch leading to the kidney. Half of the patients involved suffered ‘troublesome mishaps’ and on one of them ‘ill-advised force was used’, puncturing the wall of the artery and causing severe loss of blood.
Before he was done with experimentation, Forssmann tried to inject the X-ray-opaque substance directly into his aorta (the main artery leaving the heart) using a long needle and only a local anaesthetic. The first thrust of the needle was like an electric shock. It had hit a nerve and just missed his spinal cord, sparing him from perhaps permanent paralysis. Three more failures left him exhausted and bed-bound. His wife told him that was his last self-experiment.
Sauerbruch, having fired him, had a change of heart and invited Forssmann to rejoin his team. The condescending greeting from his immediate superior set the tone: ‘So you’re the gentleman from the provinces who’s going to teach us all about science, are you? Well, we’ll see about that. First we’ve got to whip you into shape.’ Even the word ‘gentleman’ sounded like an insult.
Sauerbruch was not the mentor that Forssmann hoped for. He hardly ever saw him or his patients and was given almost no operations to carry out. Nor did the great man, who had once been a pioneer himself, encourage Forssmann’s research ambitions. In the rigid hierarchy everyone knew their place. Initiative was not required, obedience and hard work were mandatory. Forssmann was not getting to bed until midnight, only to begin again at six a.m. An unsympathetic surgeon thought that with six hours’ sleep every night he was in danger of developing bed sores.
Sauerbruch’s way of boosting morale was to regularly line up the staff and find fault with each one in turn. Some he branded ‘complete idiots’. At least two of his ‘idiots’ went on to win the Nobel Prize. One of his extraordinary practices was to have all the patients who were to be operated on that day anaesthetised at the same time. This meant that those at the end of the list might be under for several hours before they even made it to theatre. Forssmann noted that perhaps because of this there was a high level of post-operative respiratory complications. Close attention to the patients’ recovery was needed. Thus Sauerbruch pioneered intensive-care nursing, out of necessity.
With the outbreak of the Second World War Forssmann served as a surgeon in field hospitals from the opening German offensive in Poland to the disastrous invasion of Russia. Most of what we know of his wartime experiences comes from his autobiography. He tells of being offered all the facilities he could desire for his cardiological experiments in a sanatorium run by the SS. There would, of course, be an unlimited supply of patients to work on. It was one of several SS appointments he turned down. When his field hospital was about to be overrun by the Russians he simply walked back home.
After the war ended it was difficult to find a job. For a while Forssmann was banned from practising medicine until his activities during the war had been investigated. He eventually became a doctor in a quiet rural area and faded into obscurity.
In Germany his achievements were wilfully ignored. Even a history of coronary heart disease published forty years after his experiments, by which time his techniques were well established, makes no mention of Forssmann or heart catheterisation.
But surgeons abroad had not forgotten his research. One day he came across an article on the ‘new cardiology’ that began: ‘The German Forssmann was the first …’ He was delighted but felt saddened that he ‘had planted an orchard and others had gathered the harvest’.
In 1956 a sponsor tried to secure an honorary professorship for him at his old university, but was snubbed by a response that made it clear that an ‘outsider’ was unacceptable to a German faculty. Later that same year they had a change of heart and invited him to take up a chair. Perhaps because he had just been awarded the Nobel Prize.
Forssmann’s experiments provided revolutionary methods for locating, diagnosing and treating heart disease. It was a quantum leap for cardiological surgeons. They had been given access to the interior of the heart without having to lift a scalpel. Conditions considered hopeless became curable. Drugs could be delivered directly into the heart instead of being injected and then diluted while travelling there in the bloodstream. The tips of the catheter were modified to scour the lining of a dangerously furred coronary artery and prevent blockage, the main cause of heart attacks. Other tubes now carry a tiny balloon that can be inflated to widen restricted vessels (angioplasty).
These techniques are now so commonplace that every patient with a heart problem is given an angiogram, an X-ray in which the blood vessels and the chambers of the heart are rendered visible, as in Forssmann’s second experiment. At this moment hundreds of catheters are sliding around patients’ bodies, into and through the heart to diverse destinations beyond. Every organ served by a blood vessel has been visited. Countless lives have been saved. All because of a brave man, who was fired, forgotten and finally rediscovered and rewarded when it was too late.
The labyrinths of the heart displayed.