Werner Forssmann & Cardiac Catheterization

^[1]2,022 words

In October 1956 a provincial German physician named Werner Forssmann received a telephone call from Stockholm, Sweden notifying him that he had been awarded the Nobel Prize in Physiology or Medicine.

Reportedly, his puzzled response was: “For what?”

Forssmann’s puzzlement was understandable. His early feat in 1929 of performing the first catheterization of a living human heart—his own—had been greeted with a mixture of hostility and indifference by his medical colleagues in Germany. As a result, he abandoned his pioneering work early on and became a urologist. Since the end of WWII he’d worked as an ordinary physician in Bad Kreuznach, a small city in southwestern Germany. He described his professional life as “the slave labor of a health insurance doctor.”

On top of everything else, Forssmann’s former membership in the National Socialist German Worker’s Party (NSDAP) had not been beneficial to his reputation.

“No one in West Germany has paid any attention to me,” he told reporters. “The Americans were the ones who recognized my work.” He added that in 1929, when he performed the first of nine dangerous catheterization experiments on himself, “the time was not yet ripe for this discovery.”  Still, it was “a very satisfying feeling to know that my research was right.”

First Intrusions Into the Living Human Heart

Forssmann was born in Berlin, the son of an attorney who died in WWI and a mother whose maiden name was Hindenberg. He may have been part Finnish.  Raised and confirmed a Lutheran, he studied medicine at the University of Berlin from 1922 to 1929, when he received his M.D. degree. During the hyperinflation of 1923 he worked part-time at a Berlin bank.

While employed at the August Victoria surgical clinic near Berlin in 1929, Forssmann formulated the theoretical basis of cardiac catheterization.

Also known as coronary arteriography, coronary angiography, or dye study of the heart, cardiac catheterization involves passing a thin flexible tube (catheter) into the heart, usually from the groin or an arm. The procedure is used for both diagnosis and treatment of coronary artery and heart disease.

Forssmann was convinced that the technique could be highly beneficial in studying diseased, living hearts through the measurement of volume, rate of blood flow, pressure, and oxygen content. He further desired to deliver drugs quickly to the heart in emergencies via catheter rather than by using the dangerous method of blind needle injection through the chest wall.

In 1929 it was believed that a catheter might become tangled in the heart’s chambers and cause it to stop beating. Therefore, the clinic at Eberswalde where Forssmann worked refused to sanction any such experiments by the 25-year-old physician.

Nevertheless, he practiced on cadavers, proving to his own satisfaction that he could successfully insert a catheter into the crook of an arm and advance it through a vein into the right side of the heart.

Convinced that the procedure would work, Forssmann persuaded a fellow resident to insert a large needle into a vein in Forssmann’s arm, secretly, at night, through which he then advanced a catheter toward his heart. However, fearful that Forssmann might die, the colleague refused to continue, compelling the determined young man to temporarily abandon his self-experiment.

A week later, with only a nurse to assist him by holding a mirror so that he could observe the tube’s progress on a fluoroscope, Forssmann tried again.

Uncertain whether the act would kill him, he nudged the catheter slowly forward into the cephalic vein, up through the bicep, past the shoulder and subclavian vein, then down towards the heart.

After inserting two feet of tubing, the amount he thought necessary to reach the heart, Forssmann walked to the X-ray room with the exterior portion of the tube dangling from his arm. He instructed the radiologist to take a picture as photographic proof that the tip of the catheter had indeed entered the right atrium of his heart.

Forssmann subsequently repeated the procedure on himself numerous times. He also used the method to inject drugs into the heart of a man very ill from a ruptured appendix.

In his 1956 Nobel lecture he elaborated:

At the same time I carried out my first experiments in angiocardiography. Here for the first time the living heart of a dog was successfully visualized radiologically with the aid of a contrast medium. Even at that time, the complete lesser circulation in the dog could be shown with the cinematographic radioscopy. Although no results could be attempted with human beings, because no apparatus had been devised, their possibility had at least been demonstrated in principle.

In November 1929 Forssmann published the results of his experiments as “Die Sondierung des Rechten Herzens” (“The Exploration of the Right Heart”). In it he suggested that catheterization would prove invaluable for injecting radiopaque dyes to obtain heart X-rays for the identification of cardiac abnormalities, and for measuring blood pressure inside the heart. It was this article that years later came to the attention of foreign scientists, encouraging them to apply and extend Forssmann’s pioneering techniques.

Unfortunately, Forssmann’s remarkable accomplishments were derided by his colleagues in Germany, who viewed his series of experiments as a circus stunt. As a result, his pioneering work led to nothing of immediate significance.

Discouraged by the skepticism and rejection he experienced, Forssmann turned to other work. From 1931 to 1932 he served under Germany’s most renowned surgeon, Dr. Ferdinand Sauerbruch, at the Charité in Berlin, where the latter enjoyed an international reputation due to his innovative operations. Sauerbruch was an early supporter of the National Socialist regime.

In 1933 Forssmann married Dr. Elsbet Engel, a urologist. About the same time, he obtained specialist training in urology at the Rudolf Virchow Hospital in Berlin. Thereafter he practiced urology, surgery, and general medicine.

Werner and Elsbet Forssmann had six children between 1934 and 1943. Two sons, Wolf, an anatomist, and Bernd, a physicist, developed important medical innovations of their own.

During the 1930s Forssmann was appointed Chief of the Surgical Clinic of the City Hospital at Dresden-Friedrichstadt, and of the Robert Koch Hospital in Berlin.

Party Member

Forssmann joined the NSDAP in August 1932, and remained a member until 1945.

He was also a member of the National Socialist German Physicians’ League (Nationalsozialistischer Deutscher Ärztebund, NSDÄB). Robert N. Proctor wrote that the purpose of the League was

. . . to coordinate Nazi medical policy and “to purify the German medical community of the influence of Jewish Bolshevism.” The league listed among its primary goals the promotion of knowledge of racial hygiene, racial science (Rassenkunde) and eugenics; the league summarized its principal task as one of “providing the party and future state leadership with experts in all areas of public health and racial biology. . . .”

The Nazi Physicians’ League was an immediate success. By the beginning of 1933 (that is, before the rise of Hitler to power), 2,786 doctors had joined the league. Doctors in fact joined the Nazi Party earlier and in greater numbers than any other professional group. The 2,800 doctors joining the league before Hitler’s rise to power represented 6 percent of the entire medical profession (whereas only 2.3 percent of all engineers and less than half of 1 percent of all judges had joined. (Racial Hygiene: Medicine Under the Nazis, 1988, 65)

Thus, Forsmann was an early joiner. Later, a crush of physicians attempted to join all at once. By October 1933, 11,000 were League members, and in 1934 the waiting list had grown so long that physicians were admonished to refrain from further applications until existing ones could be processed.

Between 1939 and 1945, Forssmann served as a medical officer in the German Army, with the rank of Major. Captured by the Russians, from whom he escaped, he was ultimately interned in an American POW camp. For a time after his release he worked as a lumberjack.

Postwar Re-Invention

After receiving the Nobel Prize in 1956, honors and recognition at last flowed Forssmann’s way. In 1958 he was named Chief of the Surgical Division of the Evangelical Hospital at Düsseldorf.

In 1972 Forssman published his autobiography in German, Selbstversuch: Erinnerungen eines Chirurgen (Eng. trans., Experiments on myself: Memoirs of a Surgeon in Germany ^[5], 1974, with a Foreword by his 1956 Nobel Prize co-recipient André Cournand ^[6], a naturalized US citizen whose adopted stepson died fighting with the Free French).

In the book, Forssmann recounted his heroic self-catheterization experiments, provided a vivid picture of the German campaign in Russia in which he served, and of his dramatic escape across the Elbe River. He also described the horrors of a military hospital outside Berlin during the final months of the war.

Beyond such straightforward matters, a degree of opportunistic self-re-invention reminiscent of Third Reich Minister of Armaments Albert Speer’s bestselling 1969 memoirs was discernible.

For example, one summary of Experiments on Myself states that Forssmann “vividly sketches the cultural and social forces that led him, like so many other young men during the Weimar Republic, to a brief flirtation [!] with Nazism, and speaks well of the humanist education which gave him the moral strength to reject overtures from Nazi leaders”!

The reviewer for the British Medical Journal declared that “the author shows how, without being silly and getting martyred to no purpose, a party member could save people from death and the SS by skillfully exploiting the rank stupidity of the controlling Nazis,” adding that in the next world Forssmann “will be remembered as the man who saved so many innocent victims from the Nazis.”

While stationed at the Brandenburg-Görden penitentiary in Berlin in 1943, Forssmann wrote, scores of political prisoners were being beheaded (by guillotine) at intervals of less than two minutes apiece. Despite Forssmann’s invocation of professional ethics, the warden refused to allow him to sedate condemned prisoners.

Forssmann also bad-mouthed selected colleagues by name. He depicted his former superior, surgeon Kurt Strauss, as “a butcher always skirting litigation, a habitué of parties, and a woman-chaser,” in the words of Jewish author Michael Kater.

Finally, several (but not all) accounts of Forssmann’s heroic self-catheterization experiment in 1929 appear to be derived from his autobiography. That story depicts the youthful resident’s alleged use of charm as a stratagem to obtain needed medical equipment from a beautiful young nurse, tying her to a table while he performed the experiment on himself, etc.—which struck me as, errr, embellished, so I adhered to more sober-sounding versions of the historic event in my description above. (The colorful variant is summarized in this 2005 editorial ^[7] from the Journal of the Indian Academy of Clinical Medicine, among other places.)

The Triumph of Cardiac Catheterization

Although Forssmann correctly predicted that catheterization could safely and successfully be used for diagnosis and treatment of heart ailments, it was not until after WWII that researchers in the US, Britain, and elsewhere developed comprehensive practical applications of the method.

In particular, André F. Cournand and Dickinson W. Richards ^[8] of Columbia University in the US were the first to fully develop safe, practical approaches to catheterization of the heart and lungs. As a result, they were co-recipients with Forssmann of the Nobel Prize for Medicine in 1956. Dr. Richards commended Forssmann’s “brilliant and courageous experiment in 1929 that showed the way which Dr. André F. Cournand and I followed some years later.”

The wall of resistance and skepticism that blocked Forssmann in Germany in 1929 lasted internationally for many years, as one medical historian has noted:

It was with much courage that these men performed this investigation for the first time as many of those around them considered they would be submitting their patients to unjustifiable risks, so that they well knew, therefore, that if anything untoward should happen they would be subjected to the most stringent criticism. The immediate success of their method quickly silenced their critics and before long it became an established diagnostic procedure in all cardiological units. (P. E. Baldry, The Battle Against Heart Disease, 1971, 175)

Today, thousands of heart procedures are conducted in the US every day, 365 days a year, the vast majority of them involving heart catheterization. In 2006 it was estimated ^[9] that 3.7 million cardiac catheterizations for both diagnostic and treatment purposes were being performed annually in the US alone. They are also performed daily in untold numbers around the world.