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Halsted-Holman vascular trauma legacy

2010; Elsevier BV; Volume: 52; Issue: 2 Linguagem: Inglês

10.1016/j.jvs.2010.01.093

1097-6809

Norman M. Rich, Thomas M. Krummel, David Burris,

Shoulder and Clavicle Injuries

Emile F. Holman, who was the last Chief Resident to William Stewart Halsted at Johns Hopkins University, identified a number of contributions that Halsted made to vascular surgery.1Holman E. Arteriovenous aneurysms: abnormal communications between the arterial and venous circulations. MacMillan, New York1937Google Scholar Holman had been a Stanford University undergraduate, class of 1911, and a Johns Hopkins Medical School graduate in 1918. He became the first full-time Professor and Chairman of the Department of Surgery at Stanford Medical School in San Francisco, California, in 1926. Stimulated in part by the teaching and writing of Halsted, Holman continued with an interest in vascular surgery and, particularly, the management of vascular injuries. His classic monograph in 1937 on the pathophysiology of arteriovenous fistulas is a landmark contribution in the 20th century in vascular trauma.1Holman E. Arteriovenous aneurysms: abnormal communications between the arterial and venous circulations. MacMillan, New York1937Google Scholar This review, based in part on personal experiences, emphasizes the great value of mentorship and the legacy that can be passed on, as it has in the Halsted-Holman vascular trauma legacy, to continue to improve combined efforts in providing the best surgical management possible for those who have the misfortune to be injured. As the first Professor and Chairman of the Department of Surgery at the Johns Hopkins University School of Medicine, Halsted is known for many contributions to American medicine and surgery.2Rich N.M. Spencer F.C. Vascular trauma. WB Saunders, Philadelphia1978Google Scholar, 3MacCallum W.G. William Stewart Halsted: Surgeon. The Johns Hopkins Press, Baltimore1930Google Scholar This is particularly noted by his contributions to surgical education. Less has been emphasized about his interest in vascular surgery and the management of vascular injuries. In comments about Halsted, Holman indicated that Halsted's “… speculations and discussions on arterial lesions were a constant source of inspiration to his students and associates.”4Crowe S.J. Halsted of Johns Hopkins: the man and his men. Charles C. Thomas, Springfiled, IL1957Google Scholar Halsted encouraged Bertram Bernheim, working in the Hunterian Research Laboratory at Johns Hopkins University, to work with vascular anastomoses. In 1916 Halsted encouraged Bernheim to do the Lexer “Ideal Operation,” as had been done in Germany in 1907, and this was the first autogenous great saphenous vein repair of an artery in the United States.5Holman E. Sir William Osler and William Stewart Halsted—two contrasting personalities.Pharos AOA. 1971; 34: 134-137Google Scholar This became the most frequently used and highly successful repair of extremity arterial injuries in the 20th century.6Halsted W. Discussion in Bernheim, B.M: The ideal operation for aneurism of the extremity Report of a case.Bull Johns Hopkins Hosp. 1916; 27: 93-96Google Scholar As the first Professor and Chairman of the Department of Surgery at Stanford University School of Medicine, Emile F. Holman maintained those responsibilities for 29 years, retiring in 1955. Like Halsted, he had many and varied contributions to medicine and surgery, particularly on the West Coast. The pathophysiology of arteriovenous fistulas, published by MacMillan and Company in New York in 1937, was a sentinel contribution by Holman that is informative and interesting even today.1Holman E. Arteriovenous aneurysms: abnormal communications between the arterial and venous circulations. MacMillan, New York1937Google Scholar The title of that book was Arteriovenous Aneurysm: Abnormal Communications Between The Arterial And Venous Circulations.” One of the ironies, particularly considering the strong mentor relationship of Sir William Osler to Emile Holman, is Osler's comment in 1905 on arteriovenous communication: “The only problem with the operation is with the gangrene that is apt to follow.”7Osler W. Report of a case of arteriovenous aneurysm of the thigh.Johns Hopkins Hosp Bull. 1905; 16: 119-122Google Scholar It is possible that this dismal concern by Osler helped propel the interest that Halsted had and that he projected to many of his trainees, including Holman and Mont Reid, to successfully repair arteriovenous communications. During his undergraduate years, Holman was the personal secretary of the first Stanford University President, David Starr Jordan. Holman graduated in 1911 and went to Oxford University in England as a Rhodes Scholar. He did very well at Oxford University, coming under the mentorship of Sir William Osler, who wrote to Johns Hopkins University encouraging admission of Holman to the fourth-year medical school class, which was permitted after an examination.8Hughes C.W. Bowers W.F. Traumatic lesions of peripheral vessels. Charles C. Thomas, Springfield, IL1961Google Scholar Holman, who had also served during World War I in France in the Ambulance Corps, graduated from Johns Hopkins University School of Medicine after 1 year! Holman was accepted into the Halsted Surgical Program at Johns Hopkins University and enjoyed the close association and mentorship of Halsted until the latter's death in 1922. One of Holman's classmates and good friends at Stanford University was Otto E. Utzinger of Astoria, Oregon, who was a 1914 graduate of the Johns Hopkins School of Medicine (Fig 1). The primary author (N. M. R.) was influenced by Utzinger throughout his developing years in Ray, Arizona, a Kennecott copper mining community. Utzinger served in France with the American expeditionary forces in 1917-1918 after completing surgical training under John M. T. Finney at Union Memorial in Baltimore, Maryland, part of the Halsted-Johns Hopkins program. He regaled the primary author with many experiences, including the frustration of multiple amputations of combat casualties who were received in military hospitals with an average delay of 12 hours after wounding. Utzinger, like Holman, talked about the interest that Halsted had in vascular surgery and in vascular trauma. Despite being 51 years old and serving as Professor and Chairman of the Department of Surgery at Stanford University School of Medicine, Holman voluntarily joined the Navy to serve in World War II. Also, he voluntarily served in the South Pacific. In 1953 Holman delivered the first David W. Yandell Lecture in Louisville, Kentucky, “New Concepts Of Surgery in the Vascular System: The Immediate and Late Treatment of Our Arterial Injuries.” He included the following regarding the discouraging status of attempting to manage vascular injuries at that time, particularly during the Battle of Peleliu when he was serving with the United States Marines in one of their bloodiest battles in the South Pacific during World War I: “…and the Korean War to a fortunate concatenation of circumstances provided an opportunity to discard the disastrous treatment of an injured artery by ligation and to apply instead the principle of immediate reconstruction and repair, a method rarely employed successfully in World War II in 1943, I attempted the primary repair of the divided popliteal artery under primitive conditions in the South Pacific but it was saddening failure…”4Crowe S.J. Halsted of Johns Hopkins: the man and his men. Charles C. Thomas, Springfiled, IL1957Google Scholar It was this type of experience by Holman that added to his encouragement of Carl W. Hughes during the Korean Conflict8Hughes C.W. Bowers W.F. Traumatic lesions of peripheral vessels. Charles C. Thomas, Springfield, IL1961Google Scholar and Norman M. Rich during the Vietnam War6Halsted W. Discussion in Bernheim, B.M: The ideal operation for aneurism of the extremity Report of a case.Bull Johns Hopkins Hosp. 1916; 27: 93-96Google Scholar (Fig 2) to continue to work toward successful repair of both arteries and veins under less than ideal circumstances. In the relatively small community of clinicians, educators, and scientists, there are interesting interconnections among a number of surgeons. Rudolph Matas (1860-1957), considered by many to be the father of vascular surgery, and also the first American international surgeon, described his approach to the management of arteriovenous fistulas and false aneurysms with endoaneurysmorrhaphy in 1888.2Rich N.M. Spencer F.C. Vascular trauma. WB Saunders, Philadelphia1978Google Scholar Matas was operated on by Halsted in Baltimore, which is interesting historical documentation of its own. Matas, based on an exchange and international meeting in London in 1913, described the unique contributions of Vojislav Soubbotitch of Serbia during the Balkan Wars in the management of arterial and venous injuries.9Rich N.M. Clagett G.P. Salander J.M. Piscevic S. The Matas/Soubbotitch connection.Surgery. 1983; 93: 17-19PubMed Google Scholar The Matas Award, based in great part on the contributions in vascular surgery, was presented to Emile Holman and Michael DeBakey in New Orleans in 1954 (Fig 3). Michael E. DeBakey, who had trained at Tulane University in New Orleans and who had been influenced by Matas, served as the Army Consultant in World War II. With Fiorendo Simeone, he contributed a monumental review of the management of 2471 arterial injuries, all but 81 treated by ligation, among American injured in the European Theater in World War II.10DeBakey M.E. Simeone F.A. Battle injuries of the arteries in World War II: an analysis of 2,471 cases.Ann Surg. 1946; 123: 534-579Crossref Scopus (708) Google Scholar Dr DeBakey's contributions to vascular surgery are legion, and he remained highly supportive of the primary author throughout his career in the management of vascular injuries, culminating in 1978 in the publication with Frank C. Spencer of Vascular Trauma, with Dr. DeBakey writing the forward.2Rich N.M. Spencer F.C. Vascular trauma. WB Saunders, Philadelphia1978Google Scholar The Michael E. DeBakey International Professorship and the Michael E. DeBakey International Military Surgeons Award at The Uniformed Services University of Health Sciences (USUHS) continue the legacy. Harris B Shumacker Jr, who had surgical training under Alfred Blalock at Johns Hopkins University, was offered the opportunity by Blalock to remain at Johns Hopkins University during World War II because it was recognized that not everyone could serve in uniform and that there must be continuing medical education in the United States by those who would remain in their position of responsibility. Shumacker told Blalock that he must serve his country in uniform and he went to Southeast Asia. Later he was given the responsibility at one of three established vascular centers in the United States in Galesburg, Illinois.11Elkin D.C. Shumacker Jr, H.B. Vascular surgery in World War II.in: Elkin D.C. DeBakey M.E. US Government Printing Office, Washington, DC1944Google Scholar Matas noted that Shumacker had more experience in a relatively short period of 2 or 3 years in the management of vascular injuries than he had had in 50 years of practice. Dr Shumacker published extensively on the approach to managing arteriovenous fistulas and false aneurysms, and this adds to the combined legacy in the management of vascular injuries. Shumacker was the first full-time professor to join Rich in the new developing Department of Surgery at USUHS. Rich remains a Distinguished Professor of Surgery at USUHS, with a Harris B Shumacker Jr Distinguished Surgical Lecture named after him delivered annually at the Society for Military Vascular Surgery at USUHS. Carl W. Hughes, along with Frank C. Spencer, made significant contributions from experiences in the Korean Conflict (1950-1953).8Hughes C.W. Bowers W.F. Traumatic lesions of peripheral vessels. Charles C. Thomas, Springfield, IL1961Google Scholar Hughes had similar exchanges with Holman and with DeBakey. Hughes and Spencer had exchanges during the Korean Conflict. The primary author benefited from the mentorship of Hughes during his internship at Tripler General Hospital in Honolulu, his surgical training at Letterman General Hospital in the presidio of San Francisco, and at Walter Reed General Hospital during his Vascular Fellowship as the first Vascular Fellow in 1967. Hughes remained highly supportive of the Vietnam Vascular Registry, which extended though his retirement and during his years of leadership in the Veterans Administration. He has served on the USUHS Faculty. When Rich met Holman for the first time in 1954 in the operating room at Stanford University Hospital, assisted by the middle of three sons of Otto E. Utzinger, there were a number of directed questions to be answered. This meeting was arranged by William Utzinger, who was a Stanford surgical resident in Holman's program. Holman's questions to Rich focused on what the latter stated was his interest in training in surgery with a particular interest in vascular surgery and the management of vascular injuries. Holman asked what original thoughts had been developed. When he recognized that the answer was too challenging for a rapid response he proclaimed, “If you think you have an original idea it means that you have not read enough and you should go to the library and read more.” These were words that were remembered and followed. Holman also recommended that any specific interest in medicine and/or in surgery would be augmented and complimented by identification with a well-known individual who had a similar interest. He emphasized that this type of emphasis would draw an association, which others would remember as well. He stated that it would be good to invoke the contributions of William Stewart Halsted at every opportunity, such as the proclamation by the latter in 1912 in the Johns Hopkins Bulletin that, “One of the chief interests in surgery is the management of vascular injuries.”12Halsted W.S. The effect of ligation of the common iliac artery on the circulation and function of the lower extremity Report of a care of iliofemoral aneurism by the application of an aluminum band to the vessel.Bull Johns Hopkins Hosp. 1912; 23: 191-194Google Scholar This proved to be sage advice that allowed the new and enthusiastic developing young surgeon to feel a part of the Halsted-Holman legacy.13Holman E. Abnormal Arteriovenous Communications: Peripheral and Intracardiac, Acquired and Congenital.2nd ed. Charles C. Thomas, Publisher, Springfield, Ill1968Google Scholar This legacy was passed on through mentorship from Utzinger, Holman's Stanford undergraduate classmates, to the primary author. The ultimate result was the publication in 1978 of Vascular Trauma, coauthored with Frank C. Spencer of New York University, another graduate of the Johns Hopkins Surgical Program who had served in the Korean Conflict. The USUHS in Bethesda, chartered by Congress of the United States in 1972, provided neutral ground for those with varying interests and allegiances to work together toward a common goal in the latter part of the 20th century into the 21st century. This was particularly true in the management of vascular injuries in the first Gulf War in 1991 and in the subsequent wars that started in Afghanistan in 2001 and in Iraq in 2003.14Fox C.J. Gillespie D.L. O'Donnell S.D. Rasmussen T.E. Goff J.M. Johnson C. et al.Contemporary management of wartime vascular trauma.J Vasc Surg. 2005; 41: 638-644Abstract Full Text Full Text PDF PubMed Scopus (180) Google Scholar, 15Clouse W.D. Rasmussen T.E. Peck M.A. Eliason J.L. Cox M.W. Bowser A.N. et al.In-theater management of vascular injury: 2 years of the Balad Vascular Registry.J Am Coll Surg. 2007; 204: 625-632Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar The war continues in Afghanistan and in Iraq. We are pleased and proud to pass on this legacy to those who follow, extending our gratitude and best wishes to them.