882

alone. The experiments described are preliminary only,and in the 17-hour-delay group the rather large per-centage differences not only represent very few animalsbut are hard to translate into any number of wholerabbits (72% of 8 as against 44% of 9).

Despite these difficulties for the reader, the work isinteresting and deserves thoughtful attention and

repetition on a fuller scale. Meanwhile, the. authors areinterested in the possibility that the mucoproteins mayact by protecting crushed tissue against enzymes-secietedby the invading bacteria.

1. Schück, H., et al. Nobel, The Man and His Prizes. Oklahoma,1951. Stevenson, L. G. Nobel Prize Winners in Medicineand Physiology 1901-1950. New York, 1953.

2. Benatt, A. J. Lancet, 1949, i, 746.3. Forssmann, W. Klin. W schr. 1929, 8, 2085.4. Forssmann, W. Münch. med. W schr. 1931, 78, 489.

NOBEL PRIZEME NNOT many Nobel prizes in medicine and physiology

have gone to cardiophysiologists.l August Krogh in1920 and Corneille Heymans in 1938 won the prize fortheir important work on the regulating mechanism ofcapillary function, blood-pressure, and respiration. AlexisCarrel’s contributions on " vascular suture and the

transplantation of blood vessels and organs " (as theNobel citation put it in 1912) finally led to the morerecent achievements of vascular surgery and the triumphsof anastomosis in the treatment of cyanotic congenitalheart-disease became possible. Willem Einthoven’sstring galvanometer helped immensely to clarify thenature of almost all the cardiac irregularities and myo-cardial lesions. Einthoven received the Nobel prize in1924 for" his discovery of the mechanism of the electro-cardiogram." Cardiologists owe an equal debt to WilhelmRoentgen. His was the physicist’s prize-in fact, thefirst that was awarded, in 1901. Without radiologyanother considerable advance could hardly have beenachieved-namely, that based on cardiac catheterisationunder fluoroscopic control. By recording intracardiacpressures and taking blood for oxygen estimations, thenature of malformations can be identified ; and, byinjecting a contrast medium through the catheter, theheart and great vessels can be displayed. It is for thiswork that the 1956 Nobel prize in medicine and physi-ology will be shared by Dr. Werner Forssmann, a

urological surgeon of Bad Kreuznach in Germany, andDr. Andre Cournand and Dr. Dickinson W. Richards,jun., both physiologists of the Bellevue Hospital inNew York.The story of how Forssmann came to introduce a

catheter into his own heart has already been told in ourcolumns.2 In 1929, when he was a registrar in a smallhospital in Eberswalde, north-east of Berlin, he wasthinking about rapid ways of introducing drugs into theheart in an emergency on the operating-table. He was

opposed to direct intracardiac injections because of therisk of injuring a coronary vessel and thus producingcardiac tamponade. When he inserted a catheter intothe cubital vein of a human cadaver, he was amazed atthe ease with which it could be passed into the heart.This observation encouraged him to have the experimentcarried out on himself. But after the catheter had moved35 cm. into his vein, it was Forssmann’s colleague andnot he who flinched, and the experiment was abandoned.A week later he took matters into his own hands, andhimself manipulated a catheter from the antecubital veininto his right auricle. Radiographic evidence of thecatheter inside the right heart was then published.3 Inthe hope of seeing the heart chambers, he injecteduroselectan through a catheter in his femoral vein.4

Although he failed to get a contrast picture of his ownheart, beautiful angiocardiograms were later produced indogs.

It was several years later that Cournand and Richardsbecame interested in Forssmann’s technique in the course

of their studies on haemodynamics. In Richards’swords 5 :

’

.

" With the possible danger of clot and embolus formationit looked as if it might be a dangerous procedure and as amatter of fact, we had vacillated for 8 years with nothing buta series of somewhat desultory trials in animals and oneunsuccessful attempt in man to show for it. In the autumnof 1940, Dr. Cournand with Dr. Ranges finally carried theprocedure through successfully. The technique, clumsy atthe- starts has been perfected, especially by Dr, Cournand,Dr. Riley and Dr. Breed, and with practice proved to beremarkably easy, safe and painless’, no serious untoward effectshaving been encountered in over 250 catheterizations:’

First, Cournand and Ranges used the catheter tomeasure cardiac output in man by the Fick principle(in 1905 F. Bleichroeder passed catheters into his ownveins, but he had no X-ray control 2 ; and it was in 1930that Klein used Forssmann’s technique to measure

cardiac output in man by the Fick principle). ThenCournand and Richards, with many colleagues, did muchimportant work on cardiac output and pressure in animalsand man under normal conditions. Accounts of thedynamics of congestive heart-failure, chronic pulmonarydisease, and congenital malformations followed. Soonafter the technique was established, Richards used it forhis investigation into the haemodynamies of traumaticshock in man.

Cardiac catheterisation was soon adopted in thiscountry. McMichael s and Sharpey-Schafer applied it toinvestigate circulatory failure and conditions associatedwith high and low cardiac output. The great value ofthe method was established in the diagnosis of congenitalheart-disease 9 at a time when Taussig had completedher celebrated work and Blalock, Crafoord, and othershad begun their surgical ventures on the tetrad ofFallot and coarctation of the aorta. Cardiophysiologicallaboratories soon sprang up in many cardiac centres inthe United States and elsewhere. " Physiology hadbroken out of the laboratory and invaded the hospitalward." 10 Now, the physiologist has become a vitalmember of a team comprising a physician, radiologist,cardiac surgeon, and anaesthetist.

In experienced hands cardiac catheterisation is now asafe procedure. In 1953, a committee of the AmericanHeart Association,l1 under Dr. Cournand’s chairmanship,reported less than 0-1% mortality in 5691 catheterisations.They concluded that, in the light of our present know-ledge and experience, this mortality could be furtherreduced.

5. Richards, D. W. jun. Harvey Lect. 1944, 39, 217.6. Cournand, A. F., Ranges, H. Proc. Soc. exp. Biol., N.Y. 1941.

46, 462.7. Klein, O. Münch. med. W schr. 1930, 31, 1311.8. McMichael, J. Advanc. intern. Med. 1947, 2, 65.9. Cournand, A., Baldwin, J. S., Himmelstein, A. Cardiac Cath-

eterization in Congenital Heart-disease. Commonwealth Fund,1949.

10. Bing, R. J. Advanc. intern. Med. 1952, 5, 51.11. Circulation, 1953, 7, 769.12. Cmd, 9879. H. M. Stationery Office. 1956. Pp. 48. 2s.

H.M. MEDICAL INSPECTORS OF FACTORIES

IN announcing their plans for the enlargement andpartial decentralisation of the engineering and chemicalbranches of the Factory Inspectorate of the Ministry ofLabour, the Government do not go into the future ofthe medical branch.12 " Much thinking," they say, "isnow taking place on the best way to develop industrialhealth services and it would be inopportune to make anyfundamental changes in the organisation of the medicalside of the Inspectorate in advance of decisions on thesequestions of policy." It is satisfactory, at least, to havethis recognition that the development of industrialhealth services may call for considerable alteration inthe structure of the department. Such alteration is

thought by many to be already overdue.