The Man Who Touched His Own Heart

by Rob Dunn

  Forssmann imagined that if he could get to the heart, he could apply useful drugs, but he could also release small doses of dye, doses small enough that they would not kill the patient and could be used to see the patient’s heart, after which its problems might become obvious, and some of them might even be mended. When asked about his idea, Forssmann discussed the possibility of using his method to apply drugs to the heart. At the time, the only way to get drugs into the heart was to blindly stab at it with a needle.8 But the truth was, he wanted to explore. He imagined that there was more he could do in the hearts of patients, if he, if anyone, could only see.

  Forssmann stumbled forward another step. It was a drunk’s walk. He just needed to convince someone else to help, which he promptly did. He found an eager OR nurse, Gerda Ditzen, and slowly wooed her, convincing her of the beauty and importance of his idea and how it would change humanity. He started to, in his words,9 “prowl around her like a sweet-toothed cat around the cream jug.” He described the horse experiment by then etched in his mind. He explained the value of the procedure to the future of medicine. He even made the outlandish suggestion that he could perform the procedure on her. “Are you absolutely sure,” she said in response, “there’s no danger?” “Absolutely,” replied Forssmann. Ditzen decided to help. She would let Forssmann do the procedure on her. She looked at him and said, “I put myself in your hands.”10

  On the day of the procedure, Ditzen pulled out the equipment—gauze, painkiller, sutures, and a urethral catheter, the piece of tube typically used to drain urine from the bladder. It was going to have to do; he would send that up a vein. Ditzen readied everything. They had not yet tried this method on an animal, and, contrary to Forssmann’s later assertions, they had not even tried it on a cadaver. It was consensual madness. Forssmann had her lie back on the table, where he strapped her arms and legs down (for her safety, he said) and numbed her arm. She was ready.

  But while Forssmann numbed her arm he simultaneously, without letting her see, moved the surgical cart behind her head, sat down, and numbed his own arm at the crease in his elbow. He was going to do the procedure on himself after all! He paused briefly as he looked at his veins. He looked at the thick rubber tube he was about to insert. He had time to reconsider—he almost did—but this wasn’t the moment to stop, and that wasn’t his nature. And so he cut into the vein in his left arm, without Ditzen noticing. He then took the tube, with the needle at one end, and snaked it through the incision he had made and up; it was only then that Forssmann learned that there were no pain fibers inside the vein (it was, until that point, entirely possible that the endeavor would be ferociously painful). The tube moved easily, in the direction the blood flowed. It passed through the valves that Vesalius had so long ago detected. He pushed quietly in such a way that, at least initially, Ditzen did not suspect what was happening. She called over to ask when he would start, at which point he told her he was done—mostly anyway. Ditzen saw what was going on and screamed in frustration and then watched as he pushed the catheter farther and farther up his arm. He had pushed it far enough that it had made its way past his elbow and then to his shoulder and then farther still, up and over his shoulder and down toward the right atrium of his heart (he chose the left arm because the vein from the left arm takes a less sharp turn toward the heart than the vein of the right arm), but then he stopped just shy of finishing the job. There was a problem: Forssmann and Ditzen had chosen a room without an x-ray machine.11 Forssmann could feel his progress but could make no permanent record of it. He had no proof! Forssmann unstrapped Ditzen and begged her to call an x-ray nurse. She did, and then they began the unthinkable: together, they started walking to the x-ray department in the cellar.

  With a piece of metal bobbing near Forssmann’s heart, many things could have gone wrong. Forssmann walked alongside Ditzen out the door, toward the stairs. He then walked down two flights of stairs. He reached the bottom of the stairs and walked into the room with the x-ray machine. The second nurse, Eva, was there waiting, as was Forssmann’s friend Peter Romeis, who was furious and worried. He tried to rip the catheter out of Forssmann’s arm. Forssmann kicked Romeis in the shin to get him to step back (Forssmann’s arms were occupied). Forssmann, it seemed to Romeis, was frothing mad. Eva then took two pictures. But the catheter was still in his shoulder vessel, not quite in the heart yet. She paused, and Forssmann shoved it up a little farther, until it reached the right atrium. Its tip just hung in; he growled with success. Eva took another picture. In it, you can clearly see the lead hanging in his heart, touching its living interior. He had proof. His life, he imagined, was about to change.12

  The original chest x-ray of the catheter lead in the right chamber of Forssmann’s heart. With this lead, Forssmann touched his own heart. (Courtesy of The Werner Forssmann Family Archives)

  Quickly, news of the procedure traveled up and down the halls of the hospital. Forssmann was still high with excitement when his pissed-off boss, Dr. Schneider, called him into his office. Forssmann showed his boss the images, and the boss paused, his rage subsiding. Forssmann had done something amazing. Schneider, too, knew these experiments must continue. Forssmann was opening up an entirely new field of science. That night, Schneider took Forssmann to “an old-fashioned, low-ceiling wine tavern where the waiters wore formal evening dress.” They had good food and a lot of good wine and celebrated the birth of a new field of medicine, what would come to be called cardiology.

  Forssmann repeated the procedure on himself five more times, and then on a patient, using the catheter to release medicine into her heart. He also practiced on dogs, although, because he could not find any facilities to house the dogs, he kept them at his mother’s house, and she kept them in the bathtub (there, they were less likely to soil her carpets). Forssmann would sedate a dog in the bathtub and then drive the dog to the hospital to insert a catheter in a procedure that, just as with his own body, nearly always worked. The method was not just diagnostic; it could be used to cure. Both Forssmann and Schneider were hopeful that the new method would allow doctors and scientists to study and mend living hearts. But Forssmann still needed a real job; he could not advance the science of the heart working as an unofficial resident. He applied this time to Charité university hospital. The chairman of the hospital, Professor Ferdinand Sauerbruch, was the leading surgeon in Germany at the time; he would go on to pioneer a number of techniques for surgery on the heart himself. He was very skeptical of Forssmann’s procedure but allowed Forssmann to work at the hospital, without pay. One month later, Forssmann published a paper with Schneider about his new method, announcing it to the world (and boldly lying about the details of what he had done, to make it seem less insane).13 The article attracted attention in newspapers around Europe. This infuriated Sauerbruch. Forssmann, he thought, was turning medicine into a circus. Sauerbruch fired Forssmann from the job for which he had not even been paid in the first place.

  Forssmann never found a job in surgical research. There would be moments of hopefulness and opportunity, each followed by some defeat. While Forssmann’s work was very popular with the press, other surgeons, particularly in Germany, thought it too outlandish. Forssmann was largely exiled from research, left to poke around bodies and dream big ideas while spending most of his time conducting standard surguries and exams, and treating patients with ordinary maladies. His bold steps had amounted to little. Then World War II began, and Forssmann found himself working as a medical officer.

  What Forssmann did not know when he went to war was that in America in 1940, two physicians, André Cournand and Dickinson Richards, had read about his work and begun to follow up on it, refining his method and turning it into a simple and often-used tool. Cournand and Richards independently figured out how to use Forssmann’s technique to reach the left atrium (by puncturing it with a fine needle). They also figured out how to measure blood gas concentrations in both atria. Their approaches shone light on the story of respiration and also began to reveal
problems with the major chambers of many people’s hearts, problems Forssmann had imagined might be seen, though probably not quite so easily. By the end of World War II, Forssmann’s catheter was being used in U.S. hospitals to release dye into the chambers of the heart to visualize, via x-rays, how the heart was working.14 What began as a barroom brag had turned into modern medicine in the United States just as Forssmann was working hard to save lives on the wrong side of the most horrible war.15

  Forssmann does not appear to have been aware that his method had moved into common use in the United States. He was too busy surviving. After the war, things had gotten even more difficult (American troops found him at the end of the war pleading for his life, having no possessions other than his copy of Goethe’s Faust, which he clutched to his chest). Forssmann was held as a prisoner of war until 1946, whereupon he traveled with his wife and six children to a small town in the Black Forest. There, he did whatever he could to survive. Initially, his wife, who was a urologist, supported the family. Forssmann applied for a job at the local hospital but was rejected because he was Prussian. He was refused a loan to start a private practice too. He cut wood, and then, as he always did, he tried again. Finally, in 1950, four years after his release, he found a job as the chair of a small urology department in Bad Kreuznach. At this point, he and his family hoped for nothing more than a peaceful life.

  On October 11, 1956, Forssmann was again in a local pub, this one in Bad Kreuznach, when his wife phoned to tell him to return home immediately. Someone with a foreign accent had called. Forssmann didn’t care. He went back to drinking. He got home many hours later, at ten. There was another call; it was from Bonn. Someone wanted to interview him. He refused. The next day, he woke up and went back to work. He operated on two patients with kidney disease. He did his daily labor. That day, he heard that two Americans were going to be awarded the Nobel Prize for developing heart catheters, his technique, his telescope into the body. He didn’t feel anything. He was still numb from this news when the medical director of his hospital found him in the operating room and quietly announced, “Mr. Forssmann, I would like to be the first to congratulate you and your wife. You have received, with two Americans, this year’s Nobel Prize in Physiology or Medicine.”

  The prize let the world know what he had done. His family left Germany for the first time to receive the award. In a picture taken in Stockholm, a seated Forssmann looks at his wife, who sits beside him in her own chair, her arms folded over her dress. Behind them stand the six children. It is a happy moment. One of the boys is even making a silly face.16

  Forssmann was finally being given what he had so long felt he deserved. He might have ridden this success into contented retirement, but Forssmann’s life was never simple. Upon his return to Germany, Nobel Prize in hand, he applied for new positions. In the years before the prize, he had been offered, finally, a research position, with the University of Cologne. It was the sort of job he had dreamed of his entire life. He declined. He said it paid too little money to support his family. But perhaps also, after everything, he no longer had the heart for research. Then, in 1958 he was offered another position, the chair of surgery at the Evangelische Krankenhaus in Düsseldorf, where his role would be more administrative than creative; he accepted. There he worked until his retirement in 1969, at which point Forssmann and his family moved back to the Black Forest village where they had lived after the war. There, the Nobel Prize sat in the living room like a trophy from a high-school football championship. Ten years later, Forssmann died of a heart attack, but the truth was, his heart had been broken for decades. Months before his death he had commented on his life that “it was very painful. I felt that I had planted an apple orchard and other men who had gathered the harvest stood at the wall, laughing at me.”17

  The Forssmann family before the Nobel ceremony in Stockholm. The children, Renate, Bernd, Jorge, Knut, Wolf-Georg, and Klaus, stand behind Forssmann and his wife, Elsbet. (Courtesy of The Werner Forssmann Family Archives)

  Forssmann brought about a fundamental change in what could be seen in the heart. Whether or not he was able to appreciate them, the fruits of his orchard would nourish the next decades of cardiology. In 1991, after the reunification of Germany, the hospital in which he first performed his procedure was renamed the Werner Forssmann Krankenhaus. The room in which he performed his procedure is still used, and as Forssmann’s daughter reported when she visited it years later, it is still a long way from that room to the basement. Forssmann’s daughter and his sons are his other legacy. They have gone on to professional success around the world. And then there is the legacy of Forssmann’s procedure. Forssmann took the first step of gaining access to the heart. He also took the second step of releasing medicine, and he set the stage for visualizing the atria and ventricles using dye, but he did not see the problem with the heart that actually killed him: he did not see the coronary arteries.

  The hospital in Eberswalde where Forssmann performed his first surgery. It now bears his name. (Courtesy of The Werner Forssmann Family Archives)

  Forssmann’s technique came to save many lives by allowing surgeons to see the basic features of the heart before they cut, but it stopped short of being able to show doctors everything they needed to see. Forssmann knew that coronary arteries, even his own, could clog. Forssmann, among others, imagined that clogged arteries might be mended. But the blockages were invisible until death or until the heart was cut open, such as in the cadavers into which Forssmann had put his fingers. Dye could reveal these arteries, but the problem was that it would do so at the cost of death to the patient—clearly not an option. The dye used in visualizing the heart was safe when diluted in the big chambers of the heart, but in the narrow courses of the arteries, it was too concentrated and, as a result, toxic; even a wild man has limits. Forssmann would not release the dye into his own coronary arteries, and so he would not do it on anyone else’s either.

  Some thought coronary artery surgery would never happen, that the ability to see the heart had crossed the last safe bridge. In thousands of hearts in hundreds of hospitals, catheters found their way to the edge of the narrow passageways to the coronary arteries and stopped, much like surgeons had stopped at operating on the heart itself in the previous century. Progress would come, but it would take an accident, a stumble into those deeper and perilous caves.

  The man who stumbled was the chief of surgery at the Cleveland Clinic in Cleveland, Ohio, Frank Mason Sones. By the point in his life at which his story and that of Forssmann intersect, Sones was already famous in the circles of heart surgeons. He was bold. He was ambitious.18 He was crass, and he worked all the time, a cigarette hanging out of his mouth as he bent over patients. If Forssmann was the roguish lineman of the heart, Sones was its smash-faced, foul-mouthed quarterback. He was a tough leader who took to wearing stained white T-shirts at the hospital. He barked orders.19 He lavished praise on success and stomped upon failure. He fought openly with the surgeons around him and nearly always won. People either loved working with him or quit.20

  Yet, while people could say many things about Sones, and they did, no one ever accused him of being dumb or of missing an opportunity. Very early in his career, he became so good at using angiography, Forssmann’s technique, for identifying heart problems that his right-hand man, Don Effler, could treat things no one else could, simply because they had been identified; because they could be seen. Sones described research as being “like kicking down a door,”21 and he had kicked down his fair share. He shared with Forssmann a ferocious intent to move forward, to make breakthroughs that would save lives.22 Unlike Forssmann, he was also lucky and powerful. But luck can have its limits. One day, Sones was working in the basement of the Cleveland Clinic in a hole he had carved to stand in; the hole was necessary for the enormous image amplifier Sones had requested so he could see and capture supersize views of the heart. When he stood in the hole, he could look up at the x-rays of patients above him. It was one of many things he
did to improve his ability to diagnose disease (he also worked with Philips and Eastman Kodak to increase the power of x-rays). On this day, he was in this cave doing a relatively ordinary procedure. He was using a catheter to inject a small amount of dye into the aorta of a patient’s heart to examine what seemed to be a case of valve disease (of the mitral and aortic valves). Dye was, by this time, regularly injected into the aorta and the main chambers of the heart to see both the chambers and the valves. It was, in this alone, invaluable. The one thing Sones was incredibly cautious about, however, was allowing contrast dye into the coronary arteries.

  The thought, going back to the work of Forssmann, was that injecting dye into the coronary arteries would cause a deadly arrhythmia called ventricular fibrillation, in which the signals that keep the heart’s beat lose their rhythm, and the ventricles lose control of their beating, like a bird with one wing beating at a different time than the other.

  On this day, October 30, 1958, the patient was on his back, arms stretched out, looking up at cracks in the ceiling. He was awake. He had to be; it was the only way Sones knew if something was wrong and so was standard operating procedure at the Cleveland Clinic. The patient, like all the others, was the canary in the coal mine of his own body. Sones inserted the catheter, as he had done many times. He ran it up and into the heart. It was, based on the x-ray, in the right place. Then he instructed an assistant to release the contrast dye, 40 to 50 ccs, a large dose but an ordinary one. As the dye began to bleed into the heart, the catheter “jumped.” It jumped into the right coronary artery and started to spray dye. Sones gasped, “We’ve killed him!”