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Rudolph Matas and the First Endoaneurysmorrhaphy

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Rudolph Matas and the First Endoaneurysmorrhaphy View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector HISTORICAL VIGNETTES IN VASCULAR SURGERY Norman M. Rich, MD, Section Editor Rudolph Matas and the first endoaneurysmorrhaphy: “A Fine Account of this Operation” Michael C. Trotter, MD, Decatur, Ala The history of vascular surgery is embodied in the and connect it to the character of one of the greatest evolution of the treatment of arterial aneurysms. Rudolph teachers and mentors in the history of medicine. Matas, whose long life spanned the Civil War to the Atomic On March 30, 1888, Manuel Harris, a 26-year-old Age,1 successfully performed the technique of endoaneu- African-American laborer, was admitted to Charity Hospi- rysmorrhaphy on May 6, 1888, for which he received tal of New Orleans with an enlarging, painful, pulsatile mass professional immortality and became known as “the father of the left arm between the armpit and elbow. Two months 1 of modern vascular surgery.” Prior to this, the evolution of earlier, he had sustained an accidental shotgun wound of the treatment of this disorder can be traced from Antyllus the left upper back and arm while rabbit hunting. Two through Aetius, Anel, Hunter, Cooper, and others, with weeks following the injury, he noticed the arm mass. each making his own contributions. Probably no one could Rudolph Matas had been in practice for eight years (Fig have had a better command of all these contributions than 1). He made the clinical diagnosis of “traumatic aneurism Matas. This knowledge base profoundly impacted his con- of the brachial artery.” His initial effort at treatment in- duct of operation on that spring day in 1888. He was also a volved wrapping an Esmarch tourniquet above the aneu- physician and surgeon of the highest order, and this seminal rysm. However, after 10 minutes, this proved unbearably event in the evolution of vascular surgery was only one of his many contributions to medicine. painful for the patient. He then attempted to utilize a graduated compression device just above the aneurysm in A FINE ACCOUNT conjunction with forced flexion of the forearm, kept in The contributions of Matas to vascular surgery have place by bandaging to the head. This alternating compres- been well documented by others.2-6 Alton Ochsner suc- sion and relaxation lasted 21 days, required morphine for ceeded Matas as Professor and Chairman of the Depart- the discomfort, and was unsuccessful. In fact, the aneurysm ment of Surgery at Tulane in 1927 and kept a close associ- appeared to Matas to have become thinner, threatening to ation with him. He authored one tribute and three rupture. This prompted him to proceed further along his memorials to Matas between 1956 and 1962, including an therapeutic algorithm. account of the first endoaneurysmorrhaphy.7-10 However, On April 23, 1888, Harris was taken to the operating it is Isidore Cohn’s detailed narrative of the index operation room where Matas performed a Hunter (or Anel) proximal in his biography of Matas1 that John Duffy calls, “a fine ligation of the aneurysm with catgut ligature. The aneu- account of this operation.”11 It makes for an extraordinary rysm ceased to be pulsatile, and the radial pulse disap- read, as does Matas’ case report.12 These writings offer peared. The upper arm shrank 1.5 inches at its maximum interesting insight into the details of this index operation circumference. One week later (April 30th), the dressing was removed, and the wound was noted to be healing From Decatur Cardiovascular Surgery. Competition of interest: none. satisfactorily. Two days later (May 2nd), a student brought Reprint requests: Michael C. Trotter, MD, Decatur Cardiovascular Surgery, to Matas’ attention that the pulsation in the aneurysm had 3306 Indian Hills Rd. SE, Decatur, AL 35603 (e-mail: mtrotter0974@ returned and was again painful. At this point, Matas con- charter.net). The editors and reviewers of this article have no relevant financial relationships sidered amputation, an accepted treatment for peripheral to disclose per the JVS policy that requires reviewers to decline review of any aneurysms of the extremities at that time. However, he manuscript for which they may have a competition of interest. reasoned that this laborer would need both arms to make a J Vasc Surg 2010;51:1569-71 living; if not, he would be dependent on others. He also 0741-5214/$36.00 Copyright © 2010 by the Society for Vascular Surgery. reasoned that a collateral vessel was supplying the aneu- doi:10.1016/j.jvs.2010.01.059 rysm. Therefore, he decided to reoperate and ligate the 1569 JOURNAL OF VASCULAR SURGERY 1570 Trotter June 2010 Fig 1. Rudolph Matas circa 1884. (Courtesy of the Rudolph Matas Library of the Health Sciences, Tulane University; repro- duced with permission.) aneurysm distally. If that failed, he would open the sac Fig 2. Matas’ diagram of Manuel Harris’ aneurysm, reproduced under tourniquet control to identify the collateral vessels. from the original case report for his 1903 paper. (Matas R. Ann On May 6, 1888, Harris was returned to the operating Surg 1903;37:190.) room and anesthetized with chloroform. The surgical am- phitheater at Charity Hospital was packed with spectators, including Matas’ mentor, Dr. Edward Souchon. Matas proximally with the gum catheter as a guide. The collateral donned a clean operating smock, dipped his hands in a vessel entered under the area where the nerve plexus was 1:2000 bichloride solution, and made an incision just incorporated into the wall and thus precluded ligation. Up above the elbow on the inner aspect of the arm, exposing to this point, he had essentially performed the operation of the brachial artery just below the aneurysm. The artery was Antyllus. He then reasoned that suturing the arterial intima ligated with a catgut ligature, but the aneurysm continued together as he had done with intestinal serosa in the animal to pulsate. At this point, he decided to open the aneurysm. lab would likely heal in the same fashion as the bowel. He An Esmarch tourniquet was applied above the aneu- had no fine catgut sutures, so he used four interrupted fine rysm. He connected the two incisions and proceeded to silk sutures to close the mouth of the collateral vessel. The dissect the sac. However, he found the wall of the aneurysm Esmarch was relaxed, and the suture line was hemostatic. to be intimately associated with muscle and nerve, and the However, brisk bleeding continued from the proximal and median and ulnar nerves were both incorporated into the distal openings. The tourniquet was tightened, and Matas wall. His plan was to open the aneurysm, evacuate the clot, reasoned there were more collateral branches. He then pack it, and allow healing by granulation. If this were sutured the “lips” of the inflow and outflow openings. unsuccessful, he would amputate the arm. He proceeded Hemostasis was obtained, and history was made. A strip of with opening the aneurysm, excised an ellipse of “tough” acid sublimated gauze was left in the sac rather than a drain. aneurysm wall, evacuated the clot, and irrigated with an Matas wiped his sweaty brow with the tip of his gown. acid sublimate solution. He found a collateral vessel enter- The patient did well. He was discharged on May 21, ing the bottom of the aneurysm cavity as well as the inflow 1888, 15 days after surgery. Matas summarized the experi- and outflow openings of the native vessel. He passed a gum ence in his original case report, illustrating the aneurysm catheter proximally and distally and found the ligatures (Fig 2) and stating, “This procedure served me so satisfac- tight and intact. An additional catgut ligature was added torily, that I cannot but heartily recommend it to those who JOURNAL OF VASCULAR SURGERY Volume 51, Number 6 Trotter 1571 may be placed in similar circumstances.”12 He incidentally were often obscured and sometimes lost. It appears today saw Manuel Harris again in 1898. Harris was well, working, they are being recalled with increasing frequency. We have and the radial pulse had returned. benefited from his meticulous record keeping16 and his encyclopedic knowledge. He unceasingly used his knowl- OBSERVATIONS edge of the history of medicine to teach those under his In addition to his innovation, Matas credited the suc- tutelage and influence. Cohn’s “fine account” details Ma- cess of the operation to tourniquet control, animal-based tas’ extraordinary dedication to teaching. Mentoring has ligatures, antisepsis, and anesthesia.12 A number of inter- returned as an important component impacting the future esting observations can be made from this account. This of the specialty. He was a mentor for the ages. sentinel event has been generally accepted as the birth of I gratefully acknowledge Mary J. Holt, MLS, Rudolph modern vascular surgery; therefore Charity Hospital of Matas Library of the Health Sciences, Tulane University, New Orleans can be considered the birthplace of modern for her assistance. vascular surgery. (Charity Hospital no longer remains open after being severely damaged by Hurricane Katrina in AUTHOR CONTRIBUTIONS 2005). Conception and design: MT From a nomenclature standpoint, it is worthwhile to Analysis and interpretation: MT note that Manuel Harris’ aneurysm was a mature traumatic Data collection: MT pseudoaneurysm by today’s standards. From a clarity stand- Writing the article: MT point, the “first endoaneurysmorrhaphy” is not synony- Critical revision of the article: MT mous with “first aortic aneurysmectomy,” as is sometimes Final approval of the article: MT heard on student teaching rounds. In 1903, Matas pub- 13 Statistical analysis: MT lished a detailed treatise on the treatment of aneurysms. Obtained funding: MT He differentiates between Harris’ “obliterative endoaneu- Overall responsibility: MT rysmorrhaphy” and “restorative endoaneurysmorrhaphy,” in which arterial continuity is maintained.
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