When I began my cardiology fellowship in 2001, the dingy catheterization labs at Bellevue looked as if they hadn’t been renovated since André Cournand and Dickinson Richards did their seminal work on cardiac catheterization—a procedure used to measure pressures and flows in the heart’s chambers and the coronary arteries—at Bellevue in the 1930s. The paint was peeling, lights had a dusty glow, and angiograms were still recorded on rolls of film—not digitized, as they were at the other major Manhattan teaching hospitals. Rhoda, the stern charge nurse, and her cadre of graying, droopy-lidded assistants—they, too, looked like artifacts of World War II. Rhoda would never tell you what she wanted you to do. It was a lot easier to yell at you after you made a mistake. My first month in the cath lab felt a lot like internship—except now I was in my thirties, married, and seven years into my medical education. If I asked whether a patient needed preoperative blood work, Rhoda or her assistants would act as if I were stupid or arrogant because it was in their protocol, and they had been doing it for years, and shouldn’t I know this, and who was I to tell them what to do? There was so much to see to: take a history and examine the patient; X-rays, bloods, consent, and so on. The rhythm of the day got digitized into tiny to-do boxes, to be filled in at every hour. What motivated the long hours was fear: fear of overlooking something that could hurt a patient, of course, but more immediately fear of rebuke, of being dressed down for mismanagement or an oversight. And so I came to think of my cardiology training as being on dual tracks: learning about the heart, obviously, but also what was in my heart—what I was made of—at the same time.
Dr. Fuchs, the cath lab chief, didn’t ease the tension any with his intimidating stare, his patronizing admonishments to dress like him (blue scrubs, white sneakers only), and his pompous talk of Henry Green and other obscure novelists. The first time I scrubbed in with him, Fuchs went rapid-fire through a series of instructions on how to operate the baffle, a small-keyboard-sized plastic contraption with an array of stopcocks attached to fluid-filled lines that was the nerve center of every catheterization procedure. My hands shook in a fine tremor as he ran through the different ways to open and close the stopcocks to flush the catheter, get rid of bubbles, inject X-ray-opaque dye into the coronary arteries, and so on. “Whatever you do,” he said, tapping on a small white knob, “don’t inject unless you turn this stopcock.” Otherwise, he warned, a dangerous amount of pressure could build up in the catheter. A minute later, he advanced the catheter up the aorta, twisted it around the arch, and with some fine finger movements inserted it into the right coronary artery. “Okay, here we go,” he said, moving the table up and down and side to side, adjusting the position just right under the camera. He stepped onto the fluoroscopy pedal, which controlled the X-ray source that would take pictures of the coronary arteries. It produced a crackling sound, like kindling catching fire. “Inject!” he boomed. I reflexively stepped onto the pedal that released dye. “Stop!” he shouted. “I told you never to do that!” I stood frozen, wondering what I had done wrong. He quickly turned the critical knob to relieve the excess pressure in the catheter. Then, ordering me away from the table, he put one foot on the fluoroscopy pedal and the other on the dye pedal and did the angiogram by himself.
It got easier. I didn’t think it would, but it did. Lucas, a kind senior cardiology fellow, got me a baffle to practice on and methodically, professorially, went through all the knobs and combinations with which I should become familiar. Procedural cardiology, I quickly learned, was a craft; you got better with practice. I’d never been especially good with my hands, but after a few months I was able to do the first half of a cardiac catheterization on my own. The satisfaction I experienced doing an angiogram was something I’d never expected. The procedure became ritual: Lead apron, sterile gown, carefully arranging the instruments we were going to use with the precision of a sushi chef. Then a quick squirt of lidocaine to numb the groin. Needle finds the femoral artery. A burst of maroon fills the syringe. Blood spurts on the sterile drape (and sometimes the stone floor). Guide wire into the artery. Deep nick with a scalpel. Dilate the soft tissue to create a track for the catheter. Push, push. Blood gushing, don’t panic. Catheter slips over the wire, connect it quickly to the baffle. Okay, deep breath, deep breath, here we go …
Like the heartbeat itself, catheterization was mechanical, repetitive; we performed more than a few every single day. Procedural comfort eventually lent a certain balance, confidence, to my fellowship experience. For the first time that I could remember, physical action alleviated my anxiety, providing me with a zone of calmness in which to operate. When I was doing a cath, the world outside disappeared for just a few minutes. The procedure, with me as conductor, was all that mattered. In the cath lab, I was a doer, a craftsman, and not just a thinker. Seeing a plastic tube inside the heart quickly ceased to shock, which, in the end, was the most shocking thing of all.
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For most of history, inserting anything like a catheter into the human heart was considered madness. But things changed on a hot May afternoon in 1929, when a surgical intern named Werner Forssmann and a nurse named Gerda Ditzen tiptoed into an operating room at the Auguste-Viktoria Hospital in Eberswalde, Germany, a small town fifty miles northwest of Berlin. For more than a week, they had been planning a tryst, but not of the carnal kind. Quietly closing the door behind them, Forssmann ordered Ditzen onto a surgical table, where he tied her down, immobilizing her arm. Sweating profusely in the heat, she anxiously awaited his long scalpel, believing, as Forssmann had told her, that she was going to be the subject of an experiment that would change the course of medicine. But Forssmann had a different plan. Turning his back to her, he applied antiseptic soap to his own arm and quickly injected anesthetic into the skin and soft tissue. Then, armed with a scalpel, he sliced open the skin over his elbow pit with an inch-long incision. Droplets of fat and blood, like clusters of tiny grapes, followed the track of his blade.
Werner Forssmann, circa 1928 (Courtesy of The American Journal of Cardiology 79, no. 5 [1997])
Nothing in Forssmann’s background could have predicted such brazen, almost criminal action. He was born in Berlin on August 29, 1904, the only child of a lawyer and a homemaker. Blond and blue-eyed, he was raised in a Prussian household with Prussian rules and a Prussian respect for law and order. His father was killed in battle during World War I, leaving his mother and grandmother (a woman he affectionately referred to as “old corset bone,” because she was so rigid) to supervise his early education. However, it was his uncle Walter, a small-town physician with whom Forssmann made house calls in a yellow two-horse carriage, who encouraged him to study medicine. His hard-nosed uncle did not tolerate squeamishness. He once made the teenage Forssmann go to the local prison to cut down a prisoner who’d hanged himself in his cell.
In 1922, seven years before his tryst with Ditzen, the eighteen-year-old Forssmann entered medical school at the University of Berlin. In his first year, he was nauseated by animal experiments; like many, the wobbly youth did not enjoy pithing frogs. In the anatomy lab, Forssmann later recalled, a professor once joked that “the only way to a woman’s heart is through her vagina. You go from the uterus and the Fallopian tubes to the abdominal cavity, then via the lymphatic space into the lymphatic vessels and veins and thus to the goal!” Perhaps this, Forssmann cheekily wrote, is what inspired him in his later attempts to reach the heart through the vascular system.
In his first year in medical school, Forssmann became fascinated with the heart, particularly the experiments of the French scientist Claude Bernard, widely considered the father of modern experimental physiology. Bernard measured pressure in the cardiac chambers of horses and other animals by inserting rubber catheters through blood vessels and into their hearts. (In fact, he coined the term “cardiac catheterization.”) Bernard’s animal studies convinced Forssmann that inserting a catheter into a human heart would also be safe. The young medical student wanted to check the heart’s pressures
and flows, to understand and operationalize its basic functions, as one would a complex machine. No doubt he wanted to expunge the heart of its emotional connotations. But the idea that the human heart was just a pump, like an animal’s, was still anathema.
After graduating in the spring of 1928, Forssmann joined the surgical staff at the Auguste-Viktoria Hospital in Eberswalde. Not long after beginning his internship, Forssmann mentioned his interest in cardiac catheterization to his chief, Richard Schneider, a modest and reserved administrator who was also a Forssmann family friend. The young intern described an audacious plan to insert a thin, flexible tube into a vein and advance it along the superior vena cava and into the right side of the heart. Moreover, he wanted to do this on a living person: himself. Schneider immediately nixed the plan. The human heart was an inviolable sanctuary; invading it with a foreign object was a medical and cultural taboo. Like most mid-level academic administrators, Schneider had no appetite for such adventure. “Remember your mother,” the chief cried. “Imagine how it would be if I had to inform this lady, who has already lost her husband, that her only son had died in my hospital as a result of an experiment which I had approved.” However, Schneider was reluctant to discourage Forssmann completely. He suggested trying the procedure on animals first.
But Forssmann—brash, ambitious, and naive to the ways of academia—did not drop the idea. He persuaded a fellow intern, Peter Romeis, to help him perform the experiment. A week before his jaunt with Nurse Ditzen, the story goes, he met Romeis in an operating room at the hospital. With his colleague’s assistance, Forssmann made an incision in his left arm and inserted a rubber bladder catheter into the antecubital vein, which drains blood from the hand. Unfortunately, the thirty-five-centimeter catheter wasn’t long enough to reach the heart. (The typical distance from hand to heart in an adult is sixty to eighty centimeters.) When Forssmann insisted on walking to the fluoroscopy lab to take an X-ray to document the catheter’s position, Romeis panicked and yanked the catheter out.* He later said that he’d always found Forssmann to be “a rather queer, peculiar person, lone and desolate, hardly ever mingling with his coworkers socially. One never knew whether he was thinking or mentally deficient.”
Though the practice has been largely hidden, self-experimentation in medicine has a long history. Through the centuries, as the journalist Lawrence Altman has detailed, doctors and scientists have often decided to do research first on themselves. Some have done so for moral reasons, wanting to assume an experiment’s risk before imposing it on others. There were also practical considerations: identifying subjects to participate in research isn’t always easy. In the eighteenth century, for example, John Hunter, physician to King George III, intentionally injected his own penis with the purulent discharge of a patient with gonorrhea to investigate the transmission of that disease, contracting both gonorrhea and syphilis (the patient apparently had both). A hundred years later, Daniel Carrión, a medical student in Lima, injected himself with the blood of a boy with verruga peruana, then a common disorder in Peru, to prove that verruga and “Oroya fever” were manifestations of the same infection. Carrión fell into a coma and died thirty-nine days later.
Whatever Forssmann’s motivations, he eventually sweet-talked Ditzen, the surgical nurse who held the keys to the supply closet, into getting him a longer catheter, prowling around her “like a sweet-toothed cat around the cream jug,” as he later wrote. A week later, on the afternoon of May 12, 1929, while his colleagues napped in their call rooms, he was ready to try again. Ditzen believed she was going to be Forssmann’s first subject. Forssmann had a different idea.
After slicing open the skin over the elbow crease of his left arm, Forssmann widened the wound with metal forceps to get a better view. He dissected down to the antecubital vein, periodically dabbing the oozing blood to clear the view. He pulled the vein up taut to the skin surface; it had the color and consistency of an earthworm. He must have tied off the vein upstream from where he was going to cut to minimize bleeding. Then he transected the vein. It quickly drained of blood, collapsing on itself like a flimsy membrane. Forssmann inserted the sixty-five-centimeter catheter provided by Ditzen into the hole and advanced it. He later said that he experienced a warm sensation as the flexible tube scraped along the walls of his veins, as well as a slight cough, which he attributed to stimulation of the vagus, the main parasympathetic nerve in the body. With the catheter dangling out of his bleeding arm, he released Ditzen, who had apparently been protesting and struggling to get free, and ordered the angry nurse to follow him to the fluoroscopy lab to help him take a picture. Perhaps realizing they were about to make history—or maybe out of fear of the self-butchering intern—Ditzen acquiesced. They slipped downstairs. In the fluoroscopy lab, Forssmann lay down on a stretcher, while Ditzen held a mirror in front of him so that he could observe the catheter tip on a camera screen. The first X-ray showed that the catheter had not yet reached its destination, so Forssmann pushed it even farther until his arm had swallowed nearly all of it. In the middle of all this, Romeis, Forssmann’s colleague, hair tousled and still half-asleep, burst into the fluoroscopy lab and tried to stop Forssmann. Apparently, the word around the hospital was that Forssmann was trying to commit suicide. Romeis found Forssmann silent and pale on a gurney, sheets soaked with blood, catheter still in his arm, staring up at the ceiling. “What the hell are you doing?” he cried. Forssmann wrote that he had to give Romeis “a few kicks in the shin to calm him down.” As Forssmann pushed in the last few centimeters, the catheter tip clearly passed under his armpit and into the right atrium. It was a seminal moment—a violation, really—that philosophers and physicians had awaited—indeed feared—for centuries. Ditzen and a flabbergasted radiology technician snapped a photograph to document the catheter’s position. Then Forssmann pulled the tube out of his body.
When he learned what Forssmann had done, Schneider was incensed at the disobedience, even as he acknowledged (over drinks at a nearby tavern) that Forssmann had made an important contribution to medical science. “Say that you tried it on cadavers before you did it on yourself,” Schneider urged, hoping to keep Forssmann from appearing like a nut to the scientific community. In any case, there was nothing at Eberswalde for his protégé. He suggested Forssmann transfer to a more research-oriented facility to pursue his interests.
A few months later, Forssmann took an unpaid position at the Charité Hospital in Berlin. In November 1929, his selfexperiment was published in Klinische Wochenschrift, a leading journal. The paper, “Probing the Right Ventricle of the Heart,” received widespread press coverage, but Forssmann was ridiculed as a quack in the medical world. There were no obvious applications of his procedure—this would change within a few years—and Forssmann’s fanciful proposal to use cardiac catheterization for metabolic studies or cardiac resuscitation did not gain him any supporters. Moreover, Ernst Unger, a leading German surgeon, falsely claimed that he had already performed cardiac catheterization many years before and that Forssmann had not properly acknowledged his work, a claim that was repudiated by Klinische’s editor. With controversy swirling around him, Forssmann, just twenty-six years old, was fired. His chairman, Ferdinand Sauerbruch, one of the leading academic surgeons in Germany, reportedly told him, “You qualify to work in a circus, not in a reputable clinic.”
X-ray image of Forssmann’s self-catheterization, showing a catheter threaded through his arm and into his right atrium (circled ) (Reproduced by permission; from W. Forssmann, Klinische Wochenschrift 8 [1929]: 2085–87)
In January 1930, Schneider allowed Forssmann to return to Eberswalde, where the young doctor resumed his catheter experiments. He finally performed animal studies, keeping experimental dogs at his mother’s apartment, where he would inject them with morphine, put them in a sack, and lug them to the hospital on his motorcycle. Over the following year, Forssmann did more experiments on himself, too, injecting opaque dye into his own heart to better visualize its function under X-r ay. Tho
ugh the pictures were poor and his experiments largely unsuccessful, Forssmann kept going until he had scarred all the usable veins in his arms (as well as butchered a few in his groin). Despite the sacrifices to his body, at surgical conferences Forssmann’s talks would be placed last on the agenda and received little attention. Discouraged by the lack of progress and his work’s chilly reception, Forssmann abandoned cardiology and turned to urology. He eventually went into private practice, like his uncle Walter, in a small town in the Black Forest.
Forssmann’s self-experiments did not go unnoticed, however. In the late 1930s, two American scientists, André Cournand and Dickinson Richards, working at Columbia-Presbyterian Medical Center and later at Bellevue Hospital in New York City, came across Forssmann’s techniques and applied them to measure cardiac pressures and flows, first in dogs and chimpanzees and later in humans. With war looming, their work was encouraged by the federal government’s interest in supporting research on blood circulation that could help in the treatment of traumatic shock. Over a ten-year period, the Bellevue scientists used modified bladder catheters just millimeters in diameter to study the dynamics of blood flow in patients with congenital, pericardial, and rheumatic heart disease. American cardiology was brought into the modern age.*
In 1956, nearly three decades after Forssmann’s seminal experiment, Cournand, Richards, and Forssmann shared the Nobel Prize in Physiology or Medicine “for their discoveries concerning heart catheterization and pathological changes in the circulatory system.” In his Nobel lecture, Cournand paid homage to Forssmann, stating that the cardiac catheter was “the key in the lock” to discover the intricate physiology of the human heart. Indeed, cardiac catheterization was undoubtedly one of the greatest medical discoveries of the twentieth century, ushering in numerous applications, such as coronary angiography, coronary stenting, and right-heart studies, that have saved countless from premature deaths. For his part, Forssmann declared that he felt “like a village parson who has just learned that he has been made bishop.” Despite the Nobel Prize, he never returned to cardiac research, however. “The subject had progressed too far,” he wrote, “and when I considered it objectively I was certain I’d never catch up.” He decided “it was more honest to content myself with the role of leading fossil.” Forssmann continued his private urology practice. On June 1, 1979, he died of a heart attack.
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