For many years previous to Founding of The American Association for Thoracic "Surgery, discussions on vascular surgery neglected to encompass recorded experience. One text dismissed arterial suture as applicable only in tangential injury or minor injury to smaller vessels.^1. Another asserted:

To summarize the treatment of aneurysm ... Proximal ligation is the safer in the hands of those of moderate skill ... aneurysmorrhaphy or excision are to be preferred. Excision with transplantation of a segment of vessel is only to be attempted by those who have developed a satisfactory technique by much work on the lower animals.^2.

Such statements had little in common with the experience and hope of several Founders.

Dr. Rudolph Matas has pre-eminent rank in vascular surgery. Impressed by frequent failures in the treatment of aneurisms, he devoted much of his life to this field. On March 30, 1888, he sutured the bleeding orifices of a traumatic aneurism incurred by previous proximal and distal ligation. His paper on this operation merits careful reading: "TRAUMATIC ANEURISM OF THE LEFT BRACHIAL ARTERY, - Failure of direct and indirect pressure; ligation of the artery immediately above tumor; return of pulsation on the tenth day; ligation immediately below tumor; failure to arrest pulsation; incision and partial excision of sac; recovery." By Rudolph Matas, M.D. Visiting Surgeon Charity Hospital, etc., New Orleans, La.^3.

This quote mirrored the future:

It is plain that no other method would have succeeded but that which was adopted, i.e., the free opening of the sac and the closure of the orifices of supply in the sac itself. It is in accomplishing this last result that we have an opportunity of observing the advantages gained by the improved technique of the present day.

From further study, he detailed the incidence, anatomic and pathological characteristics and the usually fatal course of aneurisms. From a burning desire to devise some remedy for patients, he directed his efforts into the clinical rather than experimental field. In the fourteen years after the first "Matas Operation", his experience grew and enabled him to systematize his thoughts before the American Surgical Association. "Original Memoir - An Operation For the Radical Cure of Aneurism Based Upon Arteriorrhaphy"^4. is an abridged edition of the complete paper in "The Transactions of The American Surgical Association of 1902."

By 1906, Matas further refined endoaneurismorrhaphy into three groups: obliterative, restorative and reconstructive.⁵ His description is classic:

I therefore submit my definition of endoaneurismorrhaphy and the operations that are derived from it.

Matas - endoaneurismorrhaphy.

Matas - arterio-venous fistula.

Carrel - method of vessel anastomosis.

Carrel - method of kidney transplant.

Carrel - (Guthrie) - transplant of dog's head, 1908. This operation was performed by C. C. Guthrie as suggested to him by Alexis Carrel, using Carrel's technique.

Some articles illustrative of the type common in newspapers at the time of the operation on the Lambert baby in 1908. The article in the center tells of anti-vivisectionist speeches in Albany, that at the left describes the Lambert operation, that at the right tells of agreement reached on vivisection.

SYNONYMS AND DEFINITIONS

Endoaneurismorrhaphy. - The "Matas operation" (Bullock); "the radical operation for the cure of aneurism by the intrasaccular suture of the aneurismal orifices," essentially consists of two fundamental procedures: (1) the obliteration, by suture, of the vascular orifices which open into the aneurismal sac; (2) the obliteration of the sac by suture which brings its inner surfaces in apposition, or by methods of obliteration which leave the sac undisturbed and tend to secure primary healing by plastic union. In obliterating the vascular orifices that supply the sac, the parent trunk which nourishes the aneurism may be preserved or obliterated at the point of attachment according to the type of sac encountered. Hence the subdivision of endoaneurismorrhaphy into three varieties:

1. Obliterative endoaneurismorrhaphy (the fundamental procedure), essentially consists in opening the sac freely without disturbing it from its surroundings and closing all visible arterial orifices within the sac, by suture, thus securing complete hemostasis and permanently stopping all further access of blood into the aneurismal cavity. The sac is obliterated by approximating its walls with buried sutures, and closing the wound with or without drainage; or, in rigid cavities, by simply infolding the overlying skin flaps and lining the cavity with them (capitonnage of the French) or by one of the several procedures or variations I have suggested.

The indications for the application of this obliterative suture, or fundamental procedure, are: All aneurisms in which the sac is of the fusiform type, in which there are two or more orifices of supply and in which the parent artery is entirely lost at the seat of the aneurism by blending with the aneurismal sac throughout its circumference. In these cases no attempt is made to restore the continuity of the parent artery; the blood stream is interrupted in that part of the vessel which directly opens into the sac and the arterial orifices are simply closed by suture, thus shutting off the sac from all sources of blood supply.

Up to the present time twenty-two cases illustrating this mode of procedure (obliterative endoaneurismorrhaphy) are exhibited in the group of thirty-four aneurisms contributed by American operators. Possibly several of the foreign cases are of this type, but as the contribution of Dr. Lozano has not yet appeared, we are not yet in a position to state the type of cases included in his report.

2. Restorative endoaneurismorrhaphy. This variation in the procedure is solely applicable to aneurisms of the sacciform type, in which the parent trunk retains its continuity and normal outline, and the aneurism is a sac simply grafted on the vessel. By opening the sac freely and washing out the clot, the opening leading to the artery is exposed inside of the aneurism and is readily closed by a continued suture which penetrates through all the coats of the sac at the margin of the orifice of communication. By this procedure the blood supply of the sac is permanently arrested, the lumen of the parent artery remains patulous and the arterial stream supplying the limb, or dependent territory, is immediately restored through its normal channel. The sac is then obliterated by bringing its endothelial surfaces together with buried sutures and the surface wound is closed in the usual manner. Up to the present time seven operations of this type have been reported by American surgeons, all successful, and two, at least, of the foreign cases may be appropriately added to this list, making nine in all.

3. Reconstructive endoaneurismorrhaphy (arterioplasty) is applicable solely to fusiform aneurisms in which the coats of the sac are firm, elastic and resistant and the two openings leading to the main artery lie on the same level, in close proximity, and are situated at the bottom of a superficial or readily accessible sac.

In aneurisms of this type, especially those of traumatic origin, the continuity of the parent artery may be restored by making a new channel out of the sac walls which can be brought together by suture over a guide (catheter or drainage tube) inserted into the proximal and distal openings of the aneurism. Before tying the last sutures, the guide is removed and the channel is left behind corresponding to the outline of the original artery. The sac is then obliterated by approximating its surfaces with buried catgut suture, as previously applied in the first and second procedures. Thus far, five cases of this operation have been reported, all by American surgeons. Two of these patients have relapsed. The first, Morris' case, was followed in six months by an amputation of the thigh, though it is recognized that a secondary operation by the obliterative method would have obviated the necessity for this sacrifice. In the second case (Danna's) when relapse occurred the sac was reopened, the obliterative method was applied with permanent and perfect success. The surgeons in the other cases (Craig Barrow of Savannah, 2; Van Lennep of Philadelphia, 1) report that their patients continue to do well, and, thus far, without relapse.

Dr. Matas was completely informed on the basic advances being made by Carrel and others in experimental laboratories. Although he often expressed great hope for the future of excision and vessel grafting, he held this opinion after more than 30 years of work: ⁶

Thus the methods of extirpation of the sac with a lateral or circular suture of the artery ... the operation in which the aneurism is extirpated and a transplanted vein is substituted for the missing part of the artery ... and the method of grafting the popliteal artery ... from another subject as a substitute for the diseased artery and aneurism ... are interesting but too hazardous to be regarded as anything more than surgical experiments or adventures, which as best are justifiable only in a limited number of very exceptional cases.

It is perhaps unfortunate that Dr. Matas has been so inseparably connected with the subject of aneurism. This wide-ranging pioneer concerned himself with many problems. His ideas were often visionary and prophetic. The reader is referred to his many articles and particularly Keen's Surgery, which has been considered by some as a Bible in this field. Nothing can supplant a reading in the original of an originator such as Rudolph Matas.

Alexis Carrel, an experimental surgeon, made his contribution by way of the laboratory. The death of Sadi Carnot, President of France, from hemorrhage due to a vessel laceration inflicted by an assassin had seemed avoidable to him. The technique of blood vessel surgery needed perfection before he could pursue many of his other ideas. Most of his projects were considered ultravisionary by large segments of theprofession, but his persistence led to ultimate success with great benefits still accruing today.

Although lateral repair and end to end suture of vessels had previously been reported, the methods had not been widely adopted. Infection was common, subsequent thrombosis or stenosis or both often vitiated initial success. Carrel's answer was rigid asepsis and meticulous surgical technique. To reduce time during which the circulation was interrupted, he aimed at simplicity. With his methods, a few clinical successes began to appear.

However, for Carrel, the end of one problem generated new ones in the attempt to make his methods more applicable. He met them with enthusiasm, not dismay. To safely interrupt the circulation he devised "central and lateral derivation". In the former, the circulation continued through a paraffinized tube while in the latter, he used a by-pass shunt through either a tube or vessel graft. This provided ample time for repair by sustaining the circulation in critical areas. By anastomosing the left ventricle to the descending aorta and clamping the ascending aorta above the valve, he demonstrated that aortic flow could be reversed and that it was compatible with life. When the extent of injury made lateral or end to end suture impossible, he inserted vein grafts for arterial segments. He proved that they were satisfactory anatomical, pathological and functional substitutes. Anticipating the desirability of a vessel bank, he instituted cold-preservation of vessels which at a later date were also used as satisfactory grafts. He never ceased to search for expansion of his ideas. Organ transplant seemed a logcal project. His ingenuity overcame difficulties and he was soon able to report the successful transplantation of the kidney, ovary, heart, and an entire extremity, even a dog's head, the last, however, with only transitory success.

Dr. Carrel, at this time, confined his efforts to the experimental laboratory. His methods were applied sporadically by a few hardy surgeons. The ultimate place that such experimental work may play in future clinical surgery is not always clear during the investigation. Carrel's experimental work, however, received unusual and dramatic recognition through an operation performed on the infant daughter of Dr. Adrian Lambert. The child had been born apparently well following normal labor. A day after birth, she began to run temperature and there followed numerous symptoms, finally diagnosed as severe internal bleeding due to melena. She continued to grow worse and was, on the fourth day, almost thought hopeless. Dr. Lambert, however, was familiar with Carrel's work and, feeling that a direct transfusion might savehis child, persuaded Carrel to come to his aid. The following paragraph, from Dr. Samuel Lambert's account of the operation, ⁷ dramatically describes the event:

It was decided to attempt a direct transfusion of blood from the father of the infant by end-to-end anastomosis of the two blood vessels after the manner devised by Dr. Carrel of the Rockefeller Institute. This was done through the skillful surgical manipulation of Dr. Carrel himself and Dr. Geo. E. Brewer. The right popliteal vein of the baby was sutured to the left radial artery of the child's father, without anesthetic to either patient, and enough blood was allowed to flow into the baby to change her skin from a pale transparent whiteness to a brilliant red color. No measure of the amount of blood was possible, but the evidences of a sufficient quantity were manifold. She began to cry lustily and to struggle against the bandages which held her strapped to an ironing-board. The wound in the leg up to this time had oozed a slight amount of pale watery blood, which did not clot well. It began to bleed freely and the blood promptly clotted. The nosebleed stopped instantly. The pulse became full and strong and slowed down, and the respirations were deep and full. As soon as the wound was sutured and dressed the baby was fed an ounce of milk, which she took ravenously and retained, and immediately went to sleep.

The operation was reported, by memo, to John D. Rockefeller who quoted the entire account in his book "Random Reminiscences of Men and Events". Anti-vivisectionists were actively campaigning in Albany at the time and the Rockefeller Institute, a research institute, was in direct line of fire. The Lambert operation played a decisive role in stemming the anti-vivisectionist .tide and bringing into sharp, undeniable focus the incalculable value of experimental medicine.

Alexis Carrel's contributions were accorded magnificent recognition in 1912 when he was awarded the Nobel Prize in Medicine. This was the first time it had come to America, and the achievement actively stimulated the research attitude. Yet, it took almost another fifty years for his thinking to permeate the attitude and methods of the profession. Actually, in many respects, our vascular and some other surgery of today is not far removed from what Dr. Carrel did more than fifty years ago. He was indeed an illustrious founder and richly deserved the honors which came to him.