Clin. Cardiol. 15,547-549 (1992)
Pmfiles in Cardiology This section edited by . I Willis . Hurst, M.D.
Werner Forssmann: A German Problem with the Nobel Prize H.W. HEISS, M.D. Medical University Clinic, Department of Internal Medicine III,University of Freiburg, Freiburg, Germany
Imagine a cardiologist considering a ureteric catheter to perform a cardiac catheterization.Unbelievable, impossible. However, it took all the courage an determination of a young surgical resident to use exactly that means in order to achieve one of clinical cardiology’s greatest advances. The name of that resident was Werner Forssmann and he did it in 1929. Werner Forssmann (Fig. 1) was born on August 29, 1904 in Berlin. His father, a lawyer, was killed in action during World War I in 1916. At the time, Werner was a student at the humanistic Askanische Gymnasium, following a family tradition for this profound and highly esteemed education. Unable to provide for her family on her small pension, his mother had to work as an office clerk. Therefore, his grandmother supervised his education and the household. Werner often visited the office of his uncle Walter, a general practitioner living outside Berlin. From there came his resolve to become a physician. This intention was encouraged by a family gift-a beautiful Leitz microscope-n the occasion of his confirmation. He used this gift for studies of protozoa which he took from his aquarium. Shortly before graduation in 1922 his teacher, Semiller, asked him what profession he would pursue. Werner had changed his mind and said “Tradesman.” The teacher responded, “Forssmann, when you become a tradesman everybody will eam money but you. You must study medicine. This is your great talent.” And so it was.
Address for reprints: H.W. Heiss, M.D. Professorof Medicine University of Freiburg Medical Clinic Department of Internal Medicine 111 Hugstetter Str. 55 D-7800 Freiburg, Getmany Received October 18,199 1 Accepted: November 10, 1991
Forssmann entered Medical School at the FriedrichWilhelm-University in Berlin in 1922. Two of his most remarkable academic teachers were Prof. R. Fick, son of the great physiologist Adolf Fick, well-known to every cardiologist, and Prof. Dr. F. Kopsch, who planted the idea in Forssmann’s mind to reach the heart “atraumatically via the vasculature.” Passing the state examination in February 1928, Forssmann prepared his doctoral thesis, which was concerned with the influence of liver extract on blood chemistry. He also began his first self-experiment by taking daily one liter of that extract. After early futile attempts to obtain a residency in internal medicine, he was accepted at the Second Division of Surgery at the AugusteVictoria-Heim in Eberswalde. The chief of this small department was Sanitatsrat Dr. Richard Schneider, whose youngest sister, Margarete Ludes, had recommended Forssmann. She happened to be a dear friend of his mother. Dr. Schneider was well versed not only in general surgery but also in obstetrics and gynecology and wellexperienced in internal medicine. Through painful experience, Forssmann came to the realize the divergence between clinical diagnoses and postmortem findings. He was particularly interested in the development of pulmonary sclerosis in the course of mitral stenosis and the intriguing clinical question of whether a mitral valvular defect should be operated upon or not. Forssmann was convinced that the solution to the problem was to find a safe path to the heart without general anesthesia and without disturbing intrathoracic pressures or provoking vegetative reflexes. He was particularly fascinated by an old print published in the work of Marey which illustrated a man passing a tube via the jugular vein into the heart of a horse for measurement of ventricular pressure changes. Forssmann rejected the idea of jugular vein cannulation. Instead, he decided to try an approach via the cubital vein to pass a ureteric catheter toward the heart with the arm elevated. However, local anesthesia for incision was necessary. He discussed his well-prepared plan in detail with his chief. Permission was refused mainly because his chief could not permit experiments at his small department. He advised him to try animal experiments first. Forssmann suggested a self-experiment which also was refused be-
548
Clin. Cardiol. Vol. 15, July 1992
FIG.1 Werner Forssmann, 1904-1979. Reproduced with permission of Droste Verlag GmbH, Dusseldorf.
cause of Dr. Schneider’s apprehension for Forssmann’s safety. Forssmann then discussed his venture with Gerda Ditzen, the OR nurse, weighing all details and consequences of the procedure. Her approval was mandatory because she supervised the surgical instruments required for the procedure. A fortnight later she was convinced and offered her full support. She even volunteered to become the first subject for a cardiac catheterization. On a day early in the summer of 1929, Forssmann pretended to do the incision on Gerda Ditzen’s left arm.She wanted to sit on a chair, but he explained that it would be better to lie on the OR table because of the possible side effects of local anesthesia. As she positioned herself on the OR table, Forssmann strapped her legs and hands firmly in place. Unnoticed by her, he locally anesthetized his own left cubital region. To gain the time needed for the anesthesia to become effective, he continued to prepare her left arm for incision. Feeling the effect of the local anesthesia, Forssmann made the incision on his own left arm,introduced theureteric catheter for 30 cm, and covered the wound with sterile tissues. He then released the right hand of the nurse and asked her to call the x-ray nurse. Only then did Gerda Ditzen notice that it was not her arm to which the catheter was attached. She cried and grumbled her dismay. He then released her completely and both went to the x-ray room, one story below. Both were received by
nurse Eva who placed Forssmann behind the fluoroscope. At the same time, his friend, Peter Romeis, rushed into the room and tried to pull the catheter out of Forssmann’s vein. However, Forssmann overcame him. With Eva holding a mirror, he was able to see the fluoroscopic image of his chest and left arm.He noticed that the catheter had reached the area of the shoulder joint. He advanced the catheter up to the 60 cm mark and was able to see its tip in his right ventricular cavity, exactly as he had imagined. The position of the catheter was documented on chest x-ray film. Barely recovered from the excitement, Forssmann was summoned before his very annoyed chief. Forssmann, however, convinced him of his achievement by showing the film to him. After due congratulation, Forssmann was granted permission to do a second cardiac catheterization, this time on a terminally ill female patient. Forssmann used the catheter to apply medication directly into the right ventricle which proved in this case more effective than by the routine i.v. route. The catheter was advanced in the patient without fluoroscopic guidance merely by measuring the distance at the body’s surface. Postmortem examination revealed the exact position of the catheter in the right ventricle and proved that catheters could safely be advanced to the heart without fluoroscopic control. A report prepared and submitted to Klinische Wochenschriftwas accepted in a short time. Encouraged by his chief, Forssmann continued his surgical residency through October 1929 at the CharitC in Berlin. A few weeks later, on November 5 , 1929, his report “Ueber die Sondierung des rechten Herzens” was published. It caused some turbulence at this great institution due to the attention being paid to it by the media. Forssmann was forced to withdraw because he had not asked his new chief, Prof. Dr. F. Sauerbruch, for permission to proceed. At least that was the formal reason given for his dismissal without notice. Fortunately, he was allowed to return to Eberswalde. There, he started animal experimentsin rabbits and dogs to visualize the cardiac chamber by contrast media (Thorotrast) and he continued his self-experiments, altogether nine cardiac catheterizations. He had achieved incredible feats making him one of the great fathers of cardiology: cardiac catheterization, with and without fluoroscopic control, and interventional cardiac catheter therapy. Because of the attention his work attracted, Sauerbruch asked him in 1931 to return to the Charitd. He agreed and stayed there until the end of July 1932. He was discharged at that time, because he did not meet the scientific expectations of his chief. However, his surgical skills were acknowledged and he was recommended to the Stadtisches Krankenhaus in Mainz where he arrived on July 31,1932. This date was of particular personal importance because shortly after arrival he met a female resident in internal medicine, Dr. Elsbet Engel. They were soon engaged and were married in 1933. Because husband and wife were not allowed to work together, both had to leave the hospital. The couple went to Berlin where Forssmann started his career as a urologist at Rudolf-Virchow-Krankenhaus.
H.W. Heiss: Werner Forssmann During World War II Forssmanm served as a military surgeon mainly in the east and the north. As a postwar POW for a short time, he learned that his family had survived the war in the Black Forest village of Wambach. He rejoined his family there and worked as a general practitioner for almost three years. Because he could not gain a surgical position at a hospital, he applied as a urologist and so succeeded in Bad Kreuznach where he had an office and could operate at the Diakonie-Anstalten. During all those years he had given up hope that his idea to further develop cardiac catheterization and cardiac angiography could succeed. To his great surprise he learned soon after the war that a cardiac catheter lab was operating at the Paediatric Department in Basel. On entering such a lab for the first time, he was stunned. At the invitation of Professor Dr. John McMichael he visited London and participated in the making of a scientific film concerning heart catheterization.He also was invited by Prof. Dr. Wollheim, at that time President of the German Society for Cardiovascular Research, to present the opening lecture of the Annual Convention of that society. In 195 1 he also had his first meeting with Andr6 Cournand at the invitation of Prof. Dr. F. Eichholtz. It was in 1954 that he was awarded the highly esteemed Leibniz Medaille by the German Academy of Science in Berlin. He considered this period of his life “my comeback.” However, his efforts to receive a professorship at the University of Mainz, though supported by many of his friends, such as Profs. Knipping and Fassbender as well as the German Bundesprasident, were rejected because he had failed to complete a Ph.D. thesis and his position as an outsider was considered detrimental to the reputation of an German faculty. Then, on October 11, 1956, while meeting with members of the Vereinte Aquarienfreunde in a local pub, his wife told him to return home immediately because a woman with a foreign accent would call again from Bonn at 10 P.M. She had mentioned the Nobel Prize. The call indeed returned and an interview was requested for the next
549
day. Forssman refused. However, the next morning he received a letter from the Karolinska Institute asking him for a 13X 18 cm photograph. He was informed by a reporter that he and two Americans had been elected Nobel laureates. On Thursday, October 18, 1956, he had operated upon three patients with kidney disease in the morning and had just finished when the Medical Director of the hospital entered the OR and announced in a low and touched voice: “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.” This event changed the Forssmann family’s life completely. He did not consider himself to be a man of world renown, only a practicing physician as were many thousand others who had been awarded that outstanding honor. The ceremonies in Stockholm took place at the time of the Hungarian uprising. One of the many benefits derived from his award was that the Medical Faculty of the University of Mainz granted Forssmann the position of honorary Professor. Upon his return from the ceremonies in Stockholm, he tried again to obtain a better position. Although he was elected chief of the Surgical Department of the Evangelisches Krankenhaus in Diisseldorf in 1957, again local forces were against him. After retirement he returned to the Black Forest. He was particularly pleased by an invitation from Prof. F. Loogen to visit his department of cardiology, where everything he could have dreamed of was accomplished to Forssmann’s full satisfaction. Considering the life and fate of Prof. Werner Forssmann, one must pay tribute to a great character, gifted surgeon, and pioneer in cardiology. Werner Forssman died on June 1, 1979, following two myocardial infarctions.
Reference Forssmann W Selbstversuch. Erinnerungen eines Chirurgen. Droste-Verlag,Diisseldorf (1972)
Pmfiles in Cardiology This section edited by . I Willis . Hurst, M.D.
Werner Forssmann: A German Problem with the Nobel Prize H.W. HEISS, M.D. Medical University Clinic, Department of Internal Medicine III,University of Freiburg, Freiburg, Germany
Imagine a cardiologist considering a ureteric catheter to perform a cardiac catheterization.Unbelievable, impossible. However, it took all the courage an determination of a young surgical resident to use exactly that means in order to achieve one of clinical cardiology’s greatest advances. The name of that resident was Werner Forssmann and he did it in 1929. Werner Forssmann (Fig. 1) was born on August 29, 1904 in Berlin. His father, a lawyer, was killed in action during World War I in 1916. At the time, Werner was a student at the humanistic Askanische Gymnasium, following a family tradition for this profound and highly esteemed education. Unable to provide for her family on her small pension, his mother had to work as an office clerk. Therefore, his grandmother supervised his education and the household. Werner often visited the office of his uncle Walter, a general practitioner living outside Berlin. From there came his resolve to become a physician. This intention was encouraged by a family gift-a beautiful Leitz microscope-n the occasion of his confirmation. He used this gift for studies of protozoa which he took from his aquarium. Shortly before graduation in 1922 his teacher, Semiller, asked him what profession he would pursue. Werner had changed his mind and said “Tradesman.” The teacher responded, “Forssmann, when you become a tradesman everybody will eam money but you. You must study medicine. This is your great talent.” And so it was.
Address for reprints: H.W. Heiss, M.D. Professorof Medicine University of Freiburg Medical Clinic Department of Internal Medicine 111 Hugstetter Str. 55 D-7800 Freiburg, Getmany Received October 18,199 1 Accepted: November 10, 1991
Forssmann entered Medical School at the FriedrichWilhelm-University in Berlin in 1922. Two of his most remarkable academic teachers were Prof. R. Fick, son of the great physiologist Adolf Fick, well-known to every cardiologist, and Prof. Dr. F. Kopsch, who planted the idea in Forssmann’s mind to reach the heart “atraumatically via the vasculature.” Passing the state examination in February 1928, Forssmann prepared his doctoral thesis, which was concerned with the influence of liver extract on blood chemistry. He also began his first self-experiment by taking daily one liter of that extract. After early futile attempts to obtain a residency in internal medicine, he was accepted at the Second Division of Surgery at the AugusteVictoria-Heim in Eberswalde. The chief of this small department was Sanitatsrat Dr. Richard Schneider, whose youngest sister, Margarete Ludes, had recommended Forssmann. She happened to be a dear friend of his mother. Dr. Schneider was well versed not only in general surgery but also in obstetrics and gynecology and wellexperienced in internal medicine. Through painful experience, Forssmann came to the realize the divergence between clinical diagnoses and postmortem findings. He was particularly interested in the development of pulmonary sclerosis in the course of mitral stenosis and the intriguing clinical question of whether a mitral valvular defect should be operated upon or not. Forssmann was convinced that the solution to the problem was to find a safe path to the heart without general anesthesia and without disturbing intrathoracic pressures or provoking vegetative reflexes. He was particularly fascinated by an old print published in the work of Marey which illustrated a man passing a tube via the jugular vein into the heart of a horse for measurement of ventricular pressure changes. Forssmann rejected the idea of jugular vein cannulation. Instead, he decided to try an approach via the cubital vein to pass a ureteric catheter toward the heart with the arm elevated. However, local anesthesia for incision was necessary. He discussed his well-prepared plan in detail with his chief. Permission was refused mainly because his chief could not permit experiments at his small department. He advised him to try animal experiments first. Forssmann suggested a self-experiment which also was refused be-
548
Clin. Cardiol. Vol. 15, July 1992
FIG.1 Werner Forssmann, 1904-1979. Reproduced with permission of Droste Verlag GmbH, Dusseldorf.
cause of Dr. Schneider’s apprehension for Forssmann’s safety. Forssmann then discussed his venture with Gerda Ditzen, the OR nurse, weighing all details and consequences of the procedure. Her approval was mandatory because she supervised the surgical instruments required for the procedure. A fortnight later she was convinced and offered her full support. She even volunteered to become the first subject for a cardiac catheterization. On a day early in the summer of 1929, Forssmann pretended to do the incision on Gerda Ditzen’s left arm.She wanted to sit on a chair, but he explained that it would be better to lie on the OR table because of the possible side effects of local anesthesia. As she positioned herself on the OR table, Forssmann strapped her legs and hands firmly in place. Unnoticed by her, he locally anesthetized his own left cubital region. To gain the time needed for the anesthesia to become effective, he continued to prepare her left arm for incision. Feeling the effect of the local anesthesia, Forssmann made the incision on his own left arm,introduced theureteric catheter for 30 cm, and covered the wound with sterile tissues. He then released the right hand of the nurse and asked her to call the x-ray nurse. Only then did Gerda Ditzen notice that it was not her arm to which the catheter was attached. She cried and grumbled her dismay. He then released her completely and both went to the x-ray room, one story below. Both were received by
nurse Eva who placed Forssmann behind the fluoroscope. At the same time, his friend, Peter Romeis, rushed into the room and tried to pull the catheter out of Forssmann’s vein. However, Forssmann overcame him. With Eva holding a mirror, he was able to see the fluoroscopic image of his chest and left arm.He noticed that the catheter had reached the area of the shoulder joint. He advanced the catheter up to the 60 cm mark and was able to see its tip in his right ventricular cavity, exactly as he had imagined. The position of the catheter was documented on chest x-ray film. Barely recovered from the excitement, Forssmann was summoned before his very annoyed chief. Forssmann, however, convinced him of his achievement by showing the film to him. After due congratulation, Forssmann was granted permission to do a second cardiac catheterization, this time on a terminally ill female patient. Forssmann used the catheter to apply medication directly into the right ventricle which proved in this case more effective than by the routine i.v. route. The catheter was advanced in the patient without fluoroscopic guidance merely by measuring the distance at the body’s surface. Postmortem examination revealed the exact position of the catheter in the right ventricle and proved that catheters could safely be advanced to the heart without fluoroscopic control. A report prepared and submitted to Klinische Wochenschriftwas accepted in a short time. Encouraged by his chief, Forssmann continued his surgical residency through October 1929 at the CharitC in Berlin. A few weeks later, on November 5 , 1929, his report “Ueber die Sondierung des rechten Herzens” was published. It caused some turbulence at this great institution due to the attention being paid to it by the media. Forssmann was forced to withdraw because he had not asked his new chief, Prof. Dr. F. Sauerbruch, for permission to proceed. At least that was the formal reason given for his dismissal without notice. Fortunately, he was allowed to return to Eberswalde. There, he started animal experimentsin rabbits and dogs to visualize the cardiac chamber by contrast media (Thorotrast) and he continued his self-experiments, altogether nine cardiac catheterizations. He had achieved incredible feats making him one of the great fathers of cardiology: cardiac catheterization, with and without fluoroscopic control, and interventional cardiac catheter therapy. Because of the attention his work attracted, Sauerbruch asked him in 1931 to return to the Charitd. He agreed and stayed there until the end of July 1932. He was discharged at that time, because he did not meet the scientific expectations of his chief. However, his surgical skills were acknowledged and he was recommended to the Stadtisches Krankenhaus in Mainz where he arrived on July 31,1932. This date was of particular personal importance because shortly after arrival he met a female resident in internal medicine, Dr. Elsbet Engel. They were soon engaged and were married in 1933. Because husband and wife were not allowed to work together, both had to leave the hospital. The couple went to Berlin where Forssmann started his career as a urologist at Rudolf-Virchow-Krankenhaus.
H.W. Heiss: Werner Forssmann During World War II Forssmanm served as a military surgeon mainly in the east and the north. As a postwar POW for a short time, he learned that his family had survived the war in the Black Forest village of Wambach. He rejoined his family there and worked as a general practitioner for almost three years. Because he could not gain a surgical position at a hospital, he applied as a urologist and so succeeded in Bad Kreuznach where he had an office and could operate at the Diakonie-Anstalten. During all those years he had given up hope that his idea to further develop cardiac catheterization and cardiac angiography could succeed. To his great surprise he learned soon after the war that a cardiac catheter lab was operating at the Paediatric Department in Basel. On entering such a lab for the first time, he was stunned. At the invitation of Professor Dr. John McMichael he visited London and participated in the making of a scientific film concerning heart catheterization.He also was invited by Prof. Dr. Wollheim, at that time President of the German Society for Cardiovascular Research, to present the opening lecture of the Annual Convention of that society. In 195 1 he also had his first meeting with Andr6 Cournand at the invitation of Prof. Dr. F. Eichholtz. It was in 1954 that he was awarded the highly esteemed Leibniz Medaille by the German Academy of Science in Berlin. He considered this period of his life “my comeback.” However, his efforts to receive a professorship at the University of Mainz, though supported by many of his friends, such as Profs. Knipping and Fassbender as well as the German Bundesprasident, were rejected because he had failed to complete a Ph.D. thesis and his position as an outsider was considered detrimental to the reputation of an German faculty. Then, on October 11, 1956, while meeting with members of the Vereinte Aquarienfreunde in a local pub, his wife told him to return home immediately because a woman with a foreign accent would call again from Bonn at 10 P.M. She had mentioned the Nobel Prize. The call indeed returned and an interview was requested for the next
549
day. Forssman refused. However, the next morning he received a letter from the Karolinska Institute asking him for a 13X 18 cm photograph. He was informed by a reporter that he and two Americans had been elected Nobel laureates. On Thursday, October 18, 1956, he had operated upon three patients with kidney disease in the morning and had just finished when the Medical Director of the hospital entered the OR and announced in a low and touched voice: “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.” This event changed the Forssmann family’s life completely. He did not consider himself to be a man of world renown, only a practicing physician as were many thousand others who had been awarded that outstanding honor. The ceremonies in Stockholm took place at the time of the Hungarian uprising. One of the many benefits derived from his award was that the Medical Faculty of the University of Mainz granted Forssmann the position of honorary Professor. Upon his return from the ceremonies in Stockholm, he tried again to obtain a better position. Although he was elected chief of the Surgical Department of the Evangelisches Krankenhaus in Diisseldorf in 1957, again local forces were against him. After retirement he returned to the Black Forest. He was particularly pleased by an invitation from Prof. F. Loogen to visit his department of cardiology, where everything he could have dreamed of was accomplished to Forssmann’s full satisfaction. Considering the life and fate of Prof. Werner Forssmann, one must pay tribute to a great character, gifted surgeon, and pioneer in cardiology. Werner Forssman died on June 1, 1979, following two myocardial infarctions.
Reference Forssmann W Selbstversuch. Erinnerungen eines Chirurgen. Droste-Verlag,Diisseldorf (1972)
