To perform his experiment, he needed access to a phlebotomy kit, a urinary catheter, and an X-ray machine. He also needed an accomplice. He “started to prowl around Nurse Gerda Ditzen like a sweet-toothed cat around the cream jug.”
I made a point of dawdling in the canteen after lunch, hoping to meet Nurse Gerda as she left the nurses’ dining room. We’d often lent each other books, so it was easy to find something to gossip about; and she’d invite me back to her little office.… Gradually, carefully, I steered the conversation round to my hobbyhorse, and found she was interested.… So, little by little, I won over my essential disciple. When, about a fortnight after my conversation with Schneider, she said with a laugh, “What a pity we can’t do the experiment together!” I decided the time had come.
Forssmann showed Nurse Gerda pictures of Chaveau’s experiment and demonstrated how he would enter his patient through the arm and not the neck. They decided to try to sneak off together and do it in the early afternoon. “I knew I’d be able to carry out my black deed only during the afternoon siesta while everyone in the hospital was dozing.” Quietly, they went to the procedure room. Nurse Gerda offered up her body to him. She would be Forssmann’s patient, Gerda said. He could slide his catheter right into her heart. The doctor asked the nurse to lie on the operating table. “With the speed of light I strapped her down,” he wrote in his memoir.
With Nurse Gerda bound hand and foot, Forssmann turned his back on her. He anesthetized himself at his left elbow. Ignoring Nurse Gerda, he made an incision in his own skin and inserted a long aneurysm needle into his vein. Forssmann opened the aneurysm needle and pushed the catheter about a foot into his arm. He packed the incision point with gauze and a sterile split and displayed it to Nurse Gerda while the catheter was deep in his arm. As Gerda watched, he twisted the catheter deeper and deeper. He released her from her bindings and asked her to help him up the stairs, to the top floor of the hospital and the X-ray machine. Forssmann stumbled down the hospital corridor, trailing the catheter. He was climbing the stairs when his drinking buddy Peter Romeis saw him.
“You idiot, what the hell are you doing?” Romeis asked, then tried to grab the catheter and pull it out of Forssmann. As Forssmann describes it, “I had to give him a few kicks in the shin to calm him down.” Forssmann reached the X-ray room, Romeis and Nurse Gerda following. “I had a mirror placed so that by looking over the top of the screen I could see in it my thorax and upper arm. As I’d expected, the catheter had reached the head of the humerus. Romeis wanted me to stop at this point and remove it. But I wouldn’t hear of it. I pushed the catheter in further, almost to the two-foot mark. Now the mirror showed the catheter inside the heart, with its tip at the right ventricle, just as I’d envisioned it.”
In 1929, Forssmann’s pictures made newspaper headlines all over Germany. He was able to transfer from his small, provincial Red Cross Hospital to the Cherité Hospital in Berlin, the most prestigious hospital in the country, ruled over by the country’s most famous surgeon, Ferdinand Sauerbruch.
At Charité, Forssmann chafed under Sauerbruch’s strict hierarchy and conventional command. He disobeyed his superiors and was dismissed. He returned to Eberswalde, where he shot colored dye into his own heart to improve the quality of his X-ray images.
He hoped to develop new ways to deliver medicine directly to the heart, but his ideas did not catch on. This was due partly to his lack of collegiality and partly to his foggy conception of the cardiac catheter’s usefulness. Eventually Forssmann gave up on his work with the catheter and trained as a urological surgeon. He joined the Nazi Party in 1931, two years before Hitler came to power. Forssmann worked at Moabit Hospital, where 70 percent of the doctors were Jewish. As his colleagues were disappeared, Forssmann rose in the hierarchy. The hospital was renamed Robert Koch Hospital. The new chair of surgery was Kurt Strauss, a high-ranking SS officer. When all the Jews were gone, Forssmann became Strauss’s vice chair of surgery.
It is hard to know exactly what Forssmann did as a Nazi army doctor. In his memoir, he is always the innocent: turning down offers to experiment on prisoners, discovering the slaughters of mental patients only after the fact, and expressing horror. He claims not to share the eugenic zeal of his fellow officers and party members. Throughout, he wants to paint himself as a marginal, ignorant, innocent figure. But Forssmann can’t help boasting about his connections. “I put a call through to Goebbels,” he writes at one point, and then later he boasts that a colleague “wanted to tell Himmler about my work and introduce me to him.” With the German army, Forssmann went into Poland and then into Russia. After the war, he was banned from medical practice for three years because of his Nazi Party membership. In the late 1940s, he returned to work as a urologist. His research into the cardiac catheter never proceeded beyond his early experiments in Eberswalde, but his ideas were picked up by two doctors in the United States, and when they won the Nobel Prize, he won it with them.
Andre Cournand and Dickinson Richards were two thirty-seven-year-old military veterans and well-published Columbia professors working in the chest division of Bellevue Hospital. Their motive in experimenting with the cardiac catheter initially had nothing to do with heart surgery: they wanted to measure the effectiveness of their patients’ lungs. To do this they had to measure the difference in oxygen content in their patients’ arteries and veins. It was easy to get a decent sample of oxygenated blood by puncturing an artery in the arm or groin. The only place where they could get a pure and accurate sample of venous blood was in the right side of the heart. They developed the catheter to get this blood so as to more accurately calculate the effectiveness of a patient’s cardiopulmonary system.
Some medical histories claim that while in Paris in 1935, Cournand stumbled across an article describing Forssmann’s 1929 work. In Cournand’s telling, this is not true. He says that cardiac catheterization came up in a conversation with a former professor who had performed hundreds of pulmonary angiograms, experiments, according to Cournand, that “had been received very critically by the great cardiologists of the time, who told him it was ‘monstrous’ to do such a thing as introduce a tube into the heart of a patient.” When Cournand returned to New York, he and Richards began to use catheters to extract venous blood from the right side of the heart, first in dogs, then in monkeys, and then in human cadavers. Their work was progressing slowly when in 1941 the Japanese bombed Pearl Harbor. Then the US federal government began studying oxygen deprivation in soldiers. Alfred Blalock was put in charge of the “Shock Commission.” Cournand went to Washington and described his work to Blalock, and Blalock said, “You have your grant.”
New York offered a steady stream of victims of car crashes, industrial accidents, and violent crime, and Cournand and Richards used their catheters to explore these dying hearts. Cournand measured the pressure and flow. Richards produced exquisite pictures of the heart, representing it in unprecedented detail. After the war, their colleague, pediatric cardiologist Janet Baldwin, one of Helen Taussig’s protégées, began using their technology to take pictures of congenitally deformed hearts and to diagnose congenital heart disease more precisely.
All the while, federal investment in medical research continued to increase. The grant-giving budget of the National Institutes of Health (NIH) grew from $180,000 in 1945 to $4 million in 1947. Between 1949 and 1951, more than two-thirds of US medical schools applied for NIH grants to build cardiology research centers and cardiac catheter labs. Federal support was met with charitable contributions and private investments. Between 1941 and 1951 total national medical expenditure grew from an estimated $18 million to $181 million. The American Heart Association, founded in 1924 as a network of doctors interested in the new discipline of cardiology, reorganized itself in 1948 as a volunteer organization, raising money and awareness of heart disease. In Minneapolis, a combination of federal, charitable, and university support led to the construction of Variety Club Heart Hospital, with a forty-bed unit devoted to
kids with deformed hearts.
When Walt Lillehei came back from the war, he applied to only one medical residency program, the place where this new hospital devoted to heart surgery would be built. His interview with Owen Wagensteen was brief.
Wagensteen: When can you start?
Lillehei: Today.
Wagensteen: You’ll need a white coat.
29.
I EXPERIENCED OPEN-HEART SURGERY as pure blackness. Not death, but a little jaunt to the other side. When I woke up, I was surprised and satisfied to have returned. In bed in the cardiac ICU, I was aware, vaguely, of the nurses’ station out the doorway to my right. People bustled out there. I heard beeps and whistles and cries, and there was no appreciable difference between night and day. Anytime I managed to fall asleep, that was the moment someone came to check my vitals, to take my temperature, to make sure of my oxygen flow. There was a button for the morphine, but I was intent on being stoic. I didn’t want to take any more of that than I absolutely needed.
That was stupid. “Keep ahead of the pain,” my nurse told me.
I was surprised by the look of my chest, which was plucked clean of hair and taped shut and covered with gauze pads, tubes and wires, and stains—the brown ones looked like blood, and the yellow ones (I guessed) might have been antiseptic. My arms had a lot of tape and wires on them. Everything smelled bad.
There was a period of euphoria. Yippee, I wasn’t dead! Dr. Freed came by to check on me and told me gravely that my heart wasn’t beating on its own. I gave him a goofy, satisfied-customer smile. I told him that was just fine. But soon enough I began to get irritable. They made me stand up, but that only taught me what a mess I was. My whole torso was frail and frightened. I was tangled up in tubes and wires. My legs, my feet, everything was exhausted. It was impossible to get comfortable with the lousy pillow, and the rigid sheets, and the plastic-wrapped mattress.
Who brought the fucking flowers? I wanted them out. My older brother flew all the way from California. He came in with a pretty jar of marmalade. The sight of marmalade in the ICU just made me want to puke.
“Okay, okay,” he tried to mollify me. “But maybe you’ll want it in a couple of days. I’ll put it here, where you can’t see.”
“No,” I said. “Out!”
Marcia was the only person I wanted to see, the only one who didn’t rub my frazzled nerves. She made fun of my catheter and told me stories of baby Eliza’s day. She taped a little picture of Eliza by my bed, and that was my icon, my little prayer.
I tried to read. I’d brought along John Le Carré’s Tinker, Tailor, Soldier, Spy, but I didn’t have the focus or really the strength to hold the paperback in front of my face.
“Don’t strain yourself,” said Dr. Freed, when he caught me. “Just rest.”
The pretty night nurse, Brianna, rolled a TV and VCR into my room. She suggested Big, starring Tom Hanks. But the colors were glaring—the video light, the way it moved, the oversaturation of the reds, the mugging of the actors—it was intolerable. I had brought along CDs and headphones, but music bugged me, particularly the happy stuff—the Beatles, Mozart, or Marvin Gaye.
The nurses emptied the big collection sack at the end of the catheter. I could not believe that giant bag of urine all came from me or that the tube they held came out of my penis. Where was my penis, under those sheets?
Everything was a chore. The doctors made me stand again. My heart still hadn’t started beating on its own. I had those two wires in my chest that kept it beating. My legs didn’t really want to support me. Allie Brosch, in the web comic Hyperbole and a Half, describes depression as a loss of joy in everything, kind of analogous to growing up, when the life of her toy animals vanished. In her comic, she draws funny pictures of herself at twelve, trying to play with a little toy horse and failing. “Depression feels almost exactly like that,” Brosch writes, “except about everything.” That’s where I was. Music, books, movies, people, my father, my mother, my brothers, standing up, lying down, being awake, being asleep—it had all lost its magic. Throw it all in the garage, send it all to Goodwill.
There were occasional sparks. I didn’t want to be left all alone. I made Marcia tell me about Eliza. When Dr. Freed told me that my heart was beating without stimulation from the pacemaker, I was a little mystified. A hope had been confirmed, and yet I hadn’t realized all that time that I had been hoping. Out came those two thin wires; they just slid right out of my heart, out of my flesh, into the air, leaving little pinprick wounds. The first music I could listen to was heroin piano jazz, Bill Evans, Waltz for Debbie; the sly chords filled the runnels of my mind.
The kindest nurse in the history of the world took the catheter out of my penis, and she was frank and funny about it. I couldn’t see her hands at work, but I felt some kind of valve switching, and then out came a tube that went way, way further in there than I could have imagined.
“Get up! Get up!” said Michael Freed.
I began, step by step, to move around my hospital bed. I was weak and dizzy, but once I could do it, I kept doing it. I had the IV pole with me, and I kept going in wider circles, wearing two hospital gowns, one for the front and one to cover my ass. I learned the world around me. My bed was one bed in one alcove out of many patient alcoves around the nurses’ station. There were babies in cribs and old men in beds. “Look at him go!” the nurses teased me. “Slow down, buddy!” I ate normal food. I took my first trip to the bathroom to relieve myself. There was a nurse’s call button and a cripple’s bar, but I balanced myself, and I took a crap. You don’t know the pleasures of your body until you lose them.
I tried Le Carré again and became engrossed. I sorted through my CDs. Bach was okay. So was Billie Holiday. Then I put on New Morning, not the greatest Bob Dylan album ever but maybe his most cheerful: I’ve always associated the music with Dylan’s recovery from his famous motorcycle crash. The first four chords of the title track are all E minor, just Bob hitting the guitar, one, two, three, four, one chord for every beat. There’s something both tentative and assertive about his playing, like he’s figuring out his instrument after a time away and taking it out for a first dance. Then the music moves, skips on the half beat to A major. It’s wake-up time. The band cuts in. Dylan begins his cockadoodledoo.
“Can’t you hear that—rooster crowing?” he sings. He says that he’s happy to be alive, and that’s how I felt, though I wasn’t under Dylan’s “sky of blue.” I was still there, under the ICU’s fluorescents.
30.
THERE ARE NO more egotistical and more competitive people than surgeons,” Charles Bailey once said.
In 1945 and 1946, before the heart-lung machine, Bailey raced the great Dwight Harken to be the first to perform a curative heart surgery in a hospital.
“There is an old saying in India that you never find two tigers on the same hill,” said Bailey. “What they really mean is you don’t find two male tigers on the same hill.” That’s how he saw it: he and Harken against each other, playing king of the mountain. Bailey—less accomplished, less esteemed, but more aggressive than Harken—did all he could to win.
In the 1940s, before the widespread availability of penicillin, the most common cardiac complaint was rheumatic heart disease. Untreated streptococcus infections spread to the heart and left the valves scarred and stenotic. Bailey believed that, following the procedures Harken had pioneered in the Quonset huts in Cirencester, he could unclog the stuck valves.
Bailey was a small man, irascible, and prematurely bald. He had grown up in New Jersey. His father had been a banker but had lost his job when Charles was young, and the family struggled financially. “He died when I was only twelve,” Bailey remembered, “and when I saw him coughing up blood into a basin as my mother tried to soothe him, I just stared at this awful exhibition of how mitral stenosis could terminate a young man’s life. He was only forty-two.” Bailey was driven to cure the disease that had killed his father.
His mother was a domineering
figure, and she had decided early on that her son would be a doctor. “My mother had made up my mind for me before I was five, maybe before I was three.” She had wanted him to go into oncology, but the shock of his father’s death stuck with him, and Charles became interested in cardiology instead. He saw this as a rebellion against maternal influence. “At that very moment [his father’s death] I changed my direction, and [she] was never able to persuade me otherwise.”
Bailey went to Rutgers Medical School. “I didn’t come from any of the schools that are supposed to produce great people,” he said. “Partly because I didn’t have enough money to go to these schools. I was a bright boy; I probably could have made Harvard or Johns Hopkins if I had tried, but I would not have been able to pay the tuition.” He’d worked his way through college selling ladies’ underwear, and he felt that contributed to his skill as a surgeon. “Early on,” he said, he was “impressed by the similarity of the mitral valve structure to the old-fashioned feminine girdle.” Bailey was famous for his clever hands and cold focus in the operating room.
His plan was straightforward: He would make a circle of purse-string sutures like the ones Harken had made in Cirencester. He wasn’t going to pull out a piece of shrapnel from the middle of that circle. Instead he’d punch his finger into the heart and poke the stiff valve open. Then he would pull his finger out—Harken’s champagne pop—and pull the circle of sutures shut. Using the same kind of big needles swedged in silk that Harken had used, Bailey would suture up his incision.
He practiced his technique on dogs, and then in November 1945, Bailey opened the chest of Walter Stockman, a thirty-seven-year-old man dying of mitral stenosis. Bailey cut between the third and fourth ribs. He used a rib spreader. Then he cut through the pericardium and achieved a view of the left atrium of the beating heart, right above the closed mitral valve.
The Open Heart Club Page 22