https://orcid.org/0000-0003-1993-8974
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ABSTRACT
Otfrid Foerster (1873–1941) is well known for his maps of human dermatomes. We have examined the history of the development of his protocols for mapping dermatomes by analyzing his lectures and publications from 1908 to 1939, focusing on his Schorstein Memorial Lecture in 1932 and his use of the isolation (Sherrington) method, in which a single dorsal root is spared in a sequence of resections (dorsal rhizotomies). Because of the absence of medical records for Foerster’s patients, we also review eyewitness accounts of his operating technique, his occasional comments on patients, and the issue of consent. There appears to be no medical justification—at that time or currently—for Foerster’s use of the Sherrington method to map dermatomes L1, L5, S1, and S2, and in our view, these results were obtained unethically. Hence, clinicians and researchers who use his maps should acknowledge those whom Foerster exploited in order to produce them.
Acknowledgments
The authors wish to thank Dr. Peter Arnold (Sydney), the Alexander von Humboldt Foundation (BF), the DAAD (JC), and the Max-Planck-Gesellschaft (BF, JC).
Disclosure statement
No potential conflict of interest was reported by the authors.
Notes
1 A dermatome is the area of skin that is innervated by the sensory nerves associated with a single spinal cord segment, as defined by the level at which the dorsal (sensory) roots join the spinal cord; the designations of the spinal cord segments include C, cervical; T, thoracic; L, lumbar; and S, sacral (see caption ). Foerster’s lecture was advertised in Medical News, BMJ (October 8, 1932, 697) and was presented in the Anatomical Theater of London Hospital; with a capacity of 120–150 people, it is now known as the Milton Lecture Theater in the Garrod Building.
2 The obituary includes an 11-page bibliography of Sherrington’s works compiled by the American neurophysiologist, neurosurgeon, and medical historian John Farquhar Fulton (1899–1960), who had studied under Sherrington in Oxford, England, in 1923–1925 and 1928–1930.
3 Namely, his photographic memory; his Germanic formality; his informality in his favorite Breslau coffee-house; his Anglophilia; his fluency in English, French, and Italian, and grasp of Polish, Russian, and Scandinavian languages; his interjections in Greek and Latin in lectures; his diligence and tireless out-of-hours editing of the Handbuch der Neurologie; his chain-smoking (40 or 80 cigarettes a day); his insistence on using a quill pen for writing; his generosity hosting annual dinners for students; his remoteness in domestic life and the rarity of family holidays; his short temper, impatience, and brittleness; his waiving of professorial dues from students; his skills as photographer, as flutist in the style of Frederick the Great, as a dancer, in tennis, and in theatricals (Bailey Citation1969; de Gutiérrez-Mahoney Citation1941; Gottwald Citation1995; Lewera Citation2018; Silver Citation2013; Tan Citation2003; Tan and Black Citation2001; Wroński Citation1991; Zülch Citation1954).
4 The obituary in the Journal of Neurophysiology is unique for the comprehensive bibliography of Foerster’s publications that was compiled by the senior author Margaret Alice Kennard (1899–1975). Kennard had been working at Yale from 1931 under the second author, John Farquhar Fulton, who had cofounded the journal in 1938. Fulton helped Kennard obtain a Rockefeller Traveling Fellowship, which enabled her to study in Amsterdam and Breslau, where she worked with Forester from February to August 1935. The third author, Carlos Guillermo de Gutiérrez-Mahoney (1904–1988), was one of the last disciples of Harvey Williams Cushing (1869–1939), who had sent Gutiérrez-Mahoney to Breslau to undertake graduate studies with Foerster.
5 Zülch himself published at least seven additional appreciations of Foerster between 1954 and 1973.
6 Hadda became chief physician at the Breslau Jewish Hospital before the rise of the National Socialist regime and continued to work there until 1939, when he was taken to the Theresienstadt concentration camp. He was a physician in the camp until early 1945, when the Swiss government assisted some of the victims to escape to Kreuzlingen; Hadda and his wife then migrated to the United States.
7 According to the bibliography in his obituary in the Journal of Neurophysiology, Foerster published 19 articles on dorsal rhizotomy in three languages in four years, 1908–1913 (Kennard, Fulton, and de Gutiérrez-Mahoney Citation1942).
8 The lecture title is recorded as, “The borders of the areas of anesthesia, analgesia and thermo-anesthesia in lesions at different levels of the sensory tract,” with discussion by Drs. Charles K. Mills (Philadelphia), Hugh T. Patrick (Chicago), W. W. Graves (St. Louis), and Otfrid Foerster (Breslau, Germany) and a vote of “thanks extended to Dr. Foerster for the presentation of his paper” (Journal of the American Medical Association 63, 1914, 124).
9 The 15 dermatomes mapped by vasodilatation were C3, C4, C5, C8, T1, T2, T3, T4, T5, T6, T7, T8, T9, T10, and T11.
10 In early 1928, both Otto Schwab (1891–1929) and Ludwig Guttmann (1899–1980) were friends and assistants of Foerster in Breslau when they applied for the position of first assistant; Schwab was appointed, and Guttmann left for a job as neurosurgeon in Hamburg. In November 1928, Schwab's wife and coworker Dr. Roszy Schwab died after giving birth to their first child and in May the following year, Schwab took his child’s life and then his own. Foerster, depressed for months by the tragedy, invited Guttmann to return to Breslau to become his new first assistant (Silver Citation2013; Zülch Citation1956).
11 Photographs show vasodilatation dermatomes for C3, C4, C5, C8, T2, T3, T4, T5, T7, T8, T10, T11, and L3.
12 Oskar Gagel (1899–1978) was an assistant to Foerster in Breslau; he published with Ludwig Guttmann and supervised the doctoral thesis of K.-J. Zülch in 1935/36, becoming director of the morphology department of Foerster’s institute in 1937. Gagel was appointed director of the Vienna Neurological Institute in 1940.
13 The article claims 29 “cases” but there are only 28 patients, of whom 16 (13 female, three males, all middle-aged) underwent dorsal rhizotomy. The same patient (Case 25) underwent anterolateral cordotomy before incomplete lumbosacral dorsal rhizotomies four years later (Case 27); the results for Case 2 were presented as Case 7 in an earlier paper on anterolateral cordotomy (Foerster Citation1927).
14 There is no discussion of dermatomal mapping for seven patients who underwent both cordotomy and dorsal rhizotomy in separate operations.
15 Figure 43 in the 1933 Brain article became a template for subsequent schematic diagrams of dermatomes other than L3.
16 The 1933 paper illustrated 14 vasodilatation dermatomes, adding T1 to the 13 shown in 1928.
17 The female patients of Figures 51 and 52 in the 1933 paper were described previously by Foerster and Gagel (Citation1932) as Case 1 (Abb. 13) and Case 17 (Abb. 55), respectively.
18 In Foerster (Citation1933), Figure 81 on p. 34 illustrates the same patient as described in Foerster (Citation1935), Abb. 71, p. 48.
19 In his memoirs, Вumke (Citation1953, 78) described his coeditor Foerster as (authors’ translation) “the greatest neurologist Germany has produced to date. There was a tremendous amount of energy in this mostly miserable, even sick-looking man. Of all the scholars with whom life has brought me together, I know of no other who was so filled, I would say obsessed, with his science as he was. He was so dominated by it that it was usually difficult for him to approach other subjects. It was only when we lived closely together for weeks in Moscow that I became acquainted with Foerster’s far above-average classical education, his intimate knowledge of German literature, and finally his excellent musical memory.”
20 Abb. 188b in Foerster (Citation1936) reveals the extensive scar on the back of the male patient who had resection of T11, T12, and L2 to S5 with preservation of L1; the same patient is shown in Figures 9 and 10 (Foerster Citation1933, 7).
21 Foerster’s lecture was presented in Wiesbaden on March 28, 1939, at the last joint meeting of the German Society of Internal Medicine and the Society of German Neurologists and Psychiatrists before the start of World War II in September. Following concluding remarks about physiological commands and outcomes, in which the human organism is “manifesting itself as the truly perfected National Socialist state,” Foerster stated, “The fact that imperfections have occurred, and will continue to occur, only goes to prove that in the National Socialist state, not a single person can dispense with the leadership,” ending with “Hail to our Leader!”
22 Especially in patients with insufficient local anesthesia, in a hot operating theater with poor lighting (see reports below by Bailey, Wroński, and others).
23 Concerning the use of dorsal rhizotomy with root sparing to suppress spasticity, Foerster’s protégé, Ludwig Guttmann, had given up on the procedure by 1933 because, in his experience, the sparing of any dorsal roots eventually allowed spasticity to recur (Silver Citation2013).
24 Codivilla (Citation1910) thought that Foerster’s claims of success with dorsal rhizotomy for spastic paralysis were obscured by the effects of secondary operations that his patients often underwent and the nature of their postoperative therapy. Codivilla claimed that similar results could be achieved by myotomies, tenotomies, tendon lengthening, tendon transplantation, and so on, without the unknown and possibly long-term sequelae of dorsal rhizotomy.
25 Wilder Penfield (1891–1976), who studied in Breslau in 1928, also witnessed Foerster operating: “He tolerates little help from his assistants. … Moreover, in his almost universal use of local anesthesia, the patients sometimes suffer acutely, although it must be admitted that the mortality is thereby lowered” (Penfield Citation1928, 15). Paul Bucy (1904–1992), who also attended Foerster’s operations, confirmed these descriptions, describing Foerster as “a very crude surgeon” who “wished he could operate as Cushing did” but who “made little effort to improve either his surgical technique or the conditions under which he worked” (Bucy Citation1978; Bucy Citation1984, 136). Curtis Marshall (1919–2001) wrote, “Operated under local anesthesia, his patients sometimes became restless and cried out if a posterior root were stretched or pinched. Foerster had no tolerance for such interruptions and would admonish, ‘Don’t be so touchy’” (Marshall Citation1967).
26 Zülch (Citation1954, 287) commented on Foerster’s prodigious memory, “In 1935, he still knew practically by heart the medical histories of the 80 patients in his neurology department.”