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Presidential address: Decay and revival of vascular surgery

1993; Elsevier BV; Volume: 17; Issue: 6 Linguagem: Inglês

10.1016/0741-5214(93)90668-c

1097-6809

Paul Friedmann,

Health and Medical Research Impacts

This presentation is dedicated to Ralph Alden Deterling, Jr., Professor of Surgery at Tufts University School of Medicine, who died on July 24, 1992 (Fig. 1).He received many honors during his distinguished career; he was the President of the International Society for Cardiovascular Surgery, the North American Chapter of the International Society for Cardiovascular Surgery, the Eastern Vascular Society, and the Boston Surgical Society. He was the second president, after Robert Linton, of the New England Society for Vascular Surgery. He served as editor-in-chief of the Journal of Cardiovascular Surgery. He was an outstanding surgeon, scholar, scientist, educator, leader, and, above all, a warm and faithful friend. How were some of the fundamental principles of vascular surgery developed? The achievements of men such as John Hunter, Astley Cooper, Rudolph Matas, and Alexis Carrel are legendary. But who else was there? Were there “more remarkable persons forgot than any that stand remembered in the known course of time”?1Osler W. Remarks on arterio-venous aneurysm.Lancet. 1915; 1: 949-955Abstract Scopus (3) Google Scholar In the great flowering of surgical thought and technique of the late nineteenth and early twentieth centuries, what were our predecessors in vascular surgery doing? What did they know, and when did they know it? In perusing the vascular surgery papers of William Halsted, I found a fascinating excerpt from a presentation made by Sir William Osler at a symposium on arteriovenous aneurysms in 1915.1Osler W. Remarks on arterio-venous aneurysm.Lancet. 1915; 1: 949-955Abstract Scopus (3) Google Scholar In a section entitled “Decay and Revival of Vascular Surgery,” Osler bemoaned the tragedy of the death in the West of the scientific system and the accomplishments of the Greeks. “Surgery as a progressive science and a successful art, died with its founders, the great Greeks of the Graeco-Roman Empire.” He credits the creation of surgery of the arteries to two comparatively unknown men, Rufus of Ephesus (ca. 100 AD) and Antyllus (ca. 140 AD). Rufus propounded the principles of hemostasis, including compression, cautery, and ligature. He was famous in the ancient and medieval worlds for his studies of anatomy and for his treatises on the pulse and on kidney disease. Antyllus is regarded by Broca2Broca P. Traité des aneurysms et leur traitement. 204. Labé, Paris1856: 437Google Scholar and Osler1Osler W. Remarks on arterio-venous aneurysm.Lancet. 1915; 1: 949-955Abstract Scopus (3) Google Scholar as one of the most daring and accomplished surgeons of all time, who created both operative medicine and the pathology of aneurysms. In a beautifully crafted and lucid essay, Antyllus recommended proximal and distal ligation of the artery with thread and lancing of the aneurysm to evacuate the contents. This operation remained the standard for more than 16 centuries. The details of Antyllus' life are unknown, and he “appeared like a comet on the surgical horizon and disappeared, leaving no competitors or equals.”3Major RH. A history of medicine.in: CC Thomas, Springfield, Ill1954: 202-204Google Scholar The contributions of Antyllus and Rufus, though monumental, are now essentially forgotten. Osler gives passing reference to the great medieval and Renaissance surgeons, including Ambroise Paré, but feels that progress in vascular surgery was essentially nonexistent until the emergence of scientific experimental surgery as epitomized by John Hunter. Paré's contribution to vascular surgery was to reintroduce and develop the use of the ligature to control hemorrhage. His methods were crude, but his influence was great, and others followed in his footsteps. Matthäus Purmann recommended ligation and excision of aneurysms in 1680. Dominique Anel, a French surgeon practicing in Rome, successfully ligated a brachial artery aneurysm in 1710,4Stimson LA. An inquiry into the origin of the use of the ligature in the treatment of aneurysm.Ann Surg. 1885; 1: 13-25PubMed Google Scholar using a single proximal ligature. Anel's technique generated controversy and was not widely practiced. The next major figure in arterial ligation is Pierre-Joseph Desault, surgeon of La Charité Hospital in Paris, who performed a proximal ligation of a femoral artery for aneurysm on June 22, 1785, six months before John Hunter's similar operation in December 1785.4Stimson LA. An inquiry into the origin of the use of the ligature in the treatment of aneurysm.Ann Surg. 1885; 1: 13-25PubMed Google Scholar Hunter is credited with developing a scientific basis for arterial ligation, but the correlation of his experiments with his operative procedure is open to question. Legend has it that Hunter conducted experiments on a stag from Richmond Park, in which he demonstrated the efficacy of collateral vessels in maintaining circulation to the stag's antlers. The stag experiment has crept into surgical folklore, but the details of this experiment were never reported by Hunter nor by anyone else. L.G. Stevenson notes that “Hunter, Everard Home, and the contemporaries and immediate successors of the Hunterian group are silent one and all about the experimental ligation now so famous.”5Stevenson LG. A further note on John Hunter and aneurism.Bull Hist Med. 1952; 26: 162-167PubMed Google Scholar Hunter's operation was reported by his brother-in-law, Everard Home in 1786, but no mention was made in that report of the importance of collateral blood supply.6Home E. An account of Mr. Hunter's method in performing the operation for the popliteal aneurism.London Med J. 1786; VII: 391-406Google Scholar In fact, Home indicated that surgeons were too concerned about collaterals and that the femoral artery could be ligated at any level, preferably where the artery was reasonably healthy. Home's lectures on comparative anatomy, based on the specimens in the Hunterian museum, review the relationship of antler growth to blood supply but do not discuss collateral blood flow.7Home E. Lectures on comparative anatomy. London: G&W Nichol, 1814-1828.Google Scholar Unfortunately, Home's destruction of many of Hunter's papers makes documentation of some of Hunter's work impossible. In the initial issue of the Annals of Surgery in 1885, Lewis A. Stimson4Stimson LA. An inquiry into the origin of the use of the ligature in the treatment of aneurysm.Ann Surg. 1885; 1: 13-25PubMed Google Scholar makes an eloquent plea, as did Broca2Broca P. Traité des aneurysms et leur traitement. 204. Labé, Paris1856: 437Google Scholar before him, for priority for the concept of ligation and the fundamental principles involved to be given to Desault. Clearly Desault's effort was not simply a fortuitous event because of his prior studies of the anatomy and pathology of popliteal aneurysm, and his contribution should be acknowledged. By the midpoint of the nineteenth century, vascular surgery was largely confined to ligation of vessels and compression techniques, but the results of all of these efforts were poor. The mortality rates for ligation remained appallingly high. Percival Pott, in his Surgical Works, says of arterial ligation, “I have tried it myself more than once or twice. I have seen it tried by others but the event has always been fatal.”4Stimson LA. An inquiry into the origin of the use of the ligature in the treatment of aneurysm.Ann Surg. 1885; 1: 13-25PubMed Google Scholar Medical treatment for aneurysm essentially was based on the concepts of Antonio Maria Valsalva of Bologna, incorporating perfect mental quietude, prolonged bed rest for months at a time, with periodic blood letting and semistarvation. Samuel D. Gross8Gross SD. System of surgery.in: Henry C Lea's Son and Co, Philadelphia1882: 725Google Scholar was moved to comment, “Whether Valsalva effected any cure by this method of treatment is not known: if he did they must have been very few, as the plan is with one or two exceptions, founded upon entirely erroneous principles.” Other methods to control aneurysms, such as the use of hypodermic injections of ergotine as recommended by Bernhard von Langenbeck or the use of galvanic currents, were tried without much success. Further developments in vascular surgery, indeed for surgery in general, awaited the epochal discoveries of the principles of antisepsis and the development of the methods of anesthesia in the middle of the nineteenth century. The stage was set for the veritable explosion of surgical activity in the late nineteenth and early twentieth centuries. The educational systems in surgery were also developing, so that the great surgical professors, such as Bernhard von Langenbeck in Berlin and Theodor Billroth in Vienna, were able to gather numerous disciples who went forward into the universities of Germany, Austria, and elsewhere in Europe. The rapid progress of surgical thought led to the development of journals devoted specifically to surgery. Von Langenbeck, assisted by Billroth and by Ernst Gurlt in Berlin, began the publication of Langenbeck's Archiv für Klinische Chirurgie in 1860. In the first volume of that journal, the lead article was an extensive study on the surgical pathology of veins, written by von Langenbeck himself.9Langenbeck B. Beiträge zur chirurgischen pathologie der venen.Arch Klin Chir. 1860; 1: 1-80Google Scholar In the third volume in 1862, the lead article was a study of the surgical pathology of the arterial system, with special consideration of ligation, by G.F.B. Adelmann, Professor of Surgery in Dorpat.10Adelmann GFB. Beiträge zur chirurgischen pathologie der arterien.Arch Klin Chirurgie. 1862; 3: 1-56Google Scholar Dorpat was a city in Prussia, now part of Estonia, near the Russian border. Its university was part of the German system and was the site of one of the great advances in vascular surgery, to which we will return. The modern history of vascular suture techniques dates to June 15, 1759, when a surgeon, Richard Lambert of Newcastle-upon-Tyne in England, suggested the use of a farrier's stitch to control bleeding from an artery.11Lobb AW Wagner CW Crystal DK. The history of vascular repair.West J Surg Gyn Obstet. 1956; 64 (615-8): 574-577PubMed Google Scholar, 12Lobb AW Wagner CW Crystal DK. The history of vascular repair.West J Surg Gyn Obstet. 1957; 65 (101-6): 44-49PubMed Google Scholar The procedure was actually performed by Hallowel and reported to the Society of Physicians in London in 1762. Ten years later in 1772, as reported in his Inaugural Dissertation at Groningen, Conradus Assmann conducted an animal experiment on four dogs, attempting to use the Lambert/Hallowel technique to repair wounds in the femoral artery. None of the experiments succeeded, and the procedure of vascular repair was branded as insecure and dangerous. This view was echoed by D. Hayes Agnew of Philadelphia in 1878, more than a century later.11Lobb AW Wagner CW Crystal DK. The history of vascular repair.West J Surg Gyn Obstet. 1956; 64 (615-8): 574-577PubMed Google Scholar In the meanwhile, some progress had been made with regard to the management of venous injuries. Benjamin Travers, a contemporary and companion of Astley Cooper, reported a lateral ligation of the femoral vein in 1816, and G.J. Guthrie reported a lateral ligation of the jugular vein in 1830.11Lobb AW Wagner CW Crystal DK. The history of vascular repair.West J Surg Gyn Obstet. 1956; 64 (615-8): 574-577PubMed Google Scholar Unfortunately, both patients died. Experimental work on venous suture was reported in 1833 by M. Gensoul in Lyon13Gensoul M. Note sur les blessés recus a L'Hôtel-Dieu de Lyon.Gazette Médicale de Paris. 1833; 43: 297-300Google Scholar and in 1857 by Leopold Ollier,14Ollier LXEL Des plaies des veines, These pour l'aggregation. Victor Masson, Paris1857Google Scholar who later would succeed to the great influence of that city on vascular surgery. Nikolai Eck of St. Petersburg developed his ingenious technique for a lateral anastomosis between the portal vein and the vena cava in 1877, based on a study by B.F. Lautenbach of Philadelphia.12Lobb AW Wagner CW Crystal DK. The history of vascular repair.West J Surg Gyn Obstet. 1957; 65 (101-6): 44-49PubMed Google Scholar, 15Child CG. Eck's fistula.Surg Gynecol Obstet. 1953; 96: 375-376Google Scholar He approximated the venous walls with sutures and used specially designed scissors to cut between the sutures to effect an anastomosis. The ninth decade of the nineteenth century saw several advances that mark the real beginnings of modern vascular surgery. The major events were the 1882 reports by Vincenz Czerny of Heidelberg16Braun H. Uber den seitlichen verschluss von venenwunden.Arch Klin Chirurgie. 1882; 28: 654-672Google Scholar and Max Schede of Hamburg17Schede M. Braun H. Verhand.Deutsche Gesellschaft fur Chirurgie. 1882; (In Discussion of): 9-12Google Scholar of their experience with venous sutures and the reports in 1882 by Themistokles Gluck18Gluck TL. Ueber zwei falle von aortenaneurysmen, nebst bemerkungen über die naht der blutgefasse.Arch Klin Chir. 1882; 28: 548-555Google Scholar of Berlin and in 1888 by Cajetan von Horoch19Von Horoch C. Die Gefassnaht.Allgemeine Wiener Med Zeitung. 1888; 22: 263-264Google Scholar of Vienna of their efforts at arterial suture. The venous sutures were much more successful than the arterial attempts, which were thwarted by persistent bleeding through suture holes (Gluck) or by thrombosis (v. Horoch). Schede continued to suture venous wounds and was able to report a personal experience of 25 to 30 successful cases in 1892.20Schede M. Einige bemerkungen uber die naht von venenwunden.Arch Klin Chirurgie. 1892; 43: 338-345Google Scholar Venous suturing became a standard part of the surgeon's armamentarium by the last decade of the nineteenth century. Attempts to deal with arterial aneurysm were marked by the successful modification of the old Antyllian operation by Rudolph Matas of New Orleans in 1888.21Matas R. Traumatic aneurysm of the left brachial artery.Medical News. 1888; 53: 462-466Google Scholar Osler referred to Matas was not to pursue his concepts of endoaneurysmorrhapy until after the turn of the century. The old Antyllian procedure had also been resurrected by von Horoch in 1883,22Von Horoch C. Ueber die behandlungen der aneurysmen nach der methode des Antyllus.Allgemeine Wiener Med Zeitung. 1883; 28: 184-185Google Scholar when he reported two successful cases of aneurysm repair. The most significant event of the ninth decade was the remarkable experimental study by Alexander Jassinowsky on arterial sutures, submitted in 1889 as his Inaugural Dissertation for the degree of Doctor of Medicine at Dorpat23Jassinowsky A. Ein beitrag zur lehre von der gefassnaht.Arch Klin Chir. 1891; 42: 816-841Google Scholar (Fig. 2).In a series of 26 experiments on the carotid arteries and aortas of calves, dogs, and horses, Jassinowsky was able to achieve successful repair of longitudinal, oblique, and partially transsecting wounds of the arteries in 22 instances. He used fine curved needles and fine silk interrupted sutures placed through the adventitia and the media but avoiding the intima. He concluded that the injuries healed by first intention and that no fear existed of secondary hemorrhage, thrombosis, or aneurysm formation. He believed suture attempts to be indicated in fresh wounds with clean longitudinal, oblique, or partial (up to½ circumference) transection injuries. He emphasized that strictest asepsis was essential and noted that the procedure itself was easily accomplished. The last decade of the nineteenth century saw additional experimental studies, which reached their culmination in the elegant work of Otto Silberberg in Breslau and of Julius Dörfler in Rostock. Silberberg, in his Inaugural Dissertation for the doctorate in medicine, experimented with arterial suture in femoral arteries, carotid arteries, and aortas of dogs. He was successful in eight of his 12 experiments. He used fine silk sutures through all layers of the vessel wall and used continuous and interrupted sutures.24Silberberg O. Ueber die naht der blutgefasse. Inaug Diss. Th Schatzky, Breslau1899Google Scholar Dörfler's studies confirmed Silberberg's results with the use of through and through and continuous sutures of fine silk. For control of the vessels Dörfler suggested finger compression, twisted strips of gauze, or the use of rubber-shod clamps. Dörfler gave credit to his chief, Karl Garré, and his predecessors in the field, including Silberberg and Jassinowsky, Burci and Muscatello in Italy, and Robert Abbe and John B. Murphy in the United States.25Dörfler J. Ueber arteriennaht.Beitrage zur Klin Chir. 1899; : 781-825Google Scholar In 1892, Robert Abbe26Abbe R. The surgery of the hand.New York Med J. 1894; 25: 33-40Google Scholar of New York conducted a series of experiments to determine whether sterilized thin glass tubes could be tolerated within an artery. He inserted glass tubes in the femoral arteries of dogs and the aorta of a cat with excellent results and ultimately proposed to transect the entire limb of a dog and to reimplant it. He does not seem to have carried out this experiment, but his work foreshadows the development of indwelling absorbable magnesium tubes by Erwin Payr of Graz, Austria, in 1900.27Payr E. Beiträge zur technik der blutgefass—und nervennaht.Arch Klin Chir. 1900; 62: 67-93Google Scholar John B. Murphy of Chicago (Fig. 3) attended the XI International Medical Congress in Rome in 1894 and presented his paper on cholecystoenterostomy.On the next day, a paper was presented by G. Clementi of Catania, describing his experiments on the restoration of arterial continuity with invagination techniques.28Clementi G. Trapiantazione di pezzi di tubi arteriosi per invaginamento. Atti Del XI Congresso Medico Internazionale.Roma. 1894; 4: 295-297Google Scholar It is not known whether Murphy was aware of Clementi's presentation, but clearly he took those concepts to the experimental laboratory in 1896. He conducted 34 animal experiments and was therefore prepared for the two clinical cases of arterial injury that he successfully repaired on October 4, and October 7, 1896, and reported in January 1897.29Murphy JB. Resection of arteries and veins injured in continuity.Medical Record. 1897; 51: 73-88Google Scholar To Murphy belongs the credit for the first successful repair of a transected artery in humans. Other surgeons, including Durante of Italy, Von Zoege-Manteuffel of Dorpat, Lothar Heidenhain of Greifswald, James Israel of Vienna, Djemil Pascha of Constantinople, and Sabanyeff of Odessa had reported successful repair of injured arteries. In 1908, Franz Faykiss of Budapest was able to collect 70 reported cases of successful arterial suture, of which 17 were circumferential repairs.30Faykiss F. Die Arteriennaht.Beiträge zur Klin Chirurgie (Tübingen). 1908; 58: 606-650Google Scholar One of the signal events of the last decade of the nineteenth century was the assassination of the President of the French Republic, Marie Francois Sadi Carnot. Carnot had assumed office at a critical time in the history of the French Republic, when the government was being challenged by General George Boulanger. France was on the verge of a coup d'etat, but it was thwarted, and Boulanger was forced into exile. Carnot was at the height of his popularity when he traveled to Lyon to deliver an address at the International Exposition in that city. On the evening of June 24, 1894, he was attacked by an Italian anarchist named Santo-Geronimo Caserio and stabbed in the abdomen. Carnot was taken back to his quarters at the Prefecture, not to the hospital. The surgical team that attended Carnot was headed by Antonin Poncet, chief of the surgical department at the Hotel-Dieu of Lyon, and by Ollier. Poncet proceeded with a “lateral laparotomy” without the benefit of anesthesia because the President was in deep “traumatic shock.” In spite of attempts at compression, Poncet and his colleagues were unable to stop the hemorrhage, and Carnot died 3 hours after the injury.31Poncet A. Récit authentique de la blessure, de l'opération, et de la mort du président de la République Française.La Semaine Médicale. 1894; 14: 309-310Google Scholar Autopsy of the President revealed a deep laceration of the left lobe of the liver and two injuries to the portal vein. An editorial by Raphael Lepine subsequently appcared in Lyon Medicine, asking the plaintive and rhetoric question of whether an injury to the portal vein must necessarily be fatal.32Lepine R. La blessure de la veine porte est-elle nécessairement mortelle?.Lyon Med. 1894; 76: 307-311Google Scholar The Lyon surgeons were clearly not prepared to deal with the vascular injury; but given the circumstances, the nature of the injury, and the degree of hemorrhage and shock, it is doubtful that anatomic repair alone would have been successful in saving the President's life. The unrepentant Caserio was captured, tried, and executed on August 16, 1894. At the time of the attack, Alexis Carrel of Lyon had begun his medical studies at the University. Carrel was supposedly so affected by the failure of the surgeons to repair the venous injury that he determined to study the problem of vascular anastomosis. However, Carrel was a very junior student, and it was not until 1901, seven years later, that he began his experimental work on vascular suture. It is probable that both Poncet and his colleague, Mathieu Jaboulay, were more directly affected by the events of 1894. Jaboulay (Fig. 4) was the President of the Editorial Board of Lyon Medicine at the time and must have been well informed about what had happened, although he apparently did not participate in the care of the wounded President. Jaboulay went to the laboratory and in conjunction with his student, Eugene Briau, performed a series of 10 experiments in which transected carotid arteries of dogs were reanastomosed and small arterial segments were interposed.33Jaboulay M Briau E. Recherches expérimentales sur la suture et la greffe artérielles.Lyon Med. 1896; 81: 97-99Google Scholar The suture technique used was an interrupted everting mattress suture (U stitch). Even though the arteries became obliterated by clot, Jaboulay foresaw that his concepts could transform clinical arterial surgery. He also foresaw the application of his technique to the venous system, especially to lateral anastomoses between the portal vein and the inferior vena cava. Briau, reporting for Jaboulay in 1898,34Briau E Jaboulay M. Suture artérielle.Lyon Med. 1898; 87: 305Google Scholar confirmed the successful suture of the transected carotid artery of a donkey. The basic principles of arterial repair had been well worked out by the end of the nineteenth century. The seminal contributions of Jassinowsky, Silberberg, Dörfler, Jaboulay, and Briau had shown the way. Annibale Salomoni35Salomoni A. Sutura circolare delle arterie.La Clinica Chirurgica. 1900; 8: 16Google Scholar of Messina, Italy, also described a method of simple interrupted sutures, which he had successfully used to repair the transected aorta of a dog. Alexis Carrel received his MD degree in 1900 from the Faculty of Medicine of Lyon (Fig. 5).His thesis on carcinoma of the thyroid gland was written under the guidance of Antonin Poncet, whose own research on the subject had been carried out in collaboration with Mathieu Jaboulay. Carrel began his clinical training under Jaboulay, who later became Professor of Surgery at Lyon after the death of Ollier in 1900. Carrel's first vascular experimental work was performed in 1901 and 1902.36Carrel A. La technique opératoire des anastomoses vasculaires et la transplantation des viscères.Lyon Med. 1902; 98: 859-864Google Scholar He described the technique of triangulation, which was basically a modification of previously described techniques, although he limited his sutures to the adventitia and media. He claimed that the technique was “très simple,” but his only documentation was based on a single experiment in which he had transplanted a kidney in a dog. The kidney began to function during an observation period of 30 minutes, but no further follow-up is provided. Carrel continued to work in the laboratories of Prof. Marcel Soulier, with the advice and counsel of Jaboulay. Carrel and Morel next reported experiments in which the carotid artery and jugular veins of dogs were anastomosed to create arteriovenous fistulas. Jaboulay felt that this approach could provide blood supply to the brain, and he indicated that he had advised Carrel to perform these studies.37Carrel A Morel P. Anastomose bout a bout de la jugulaire et de la carotide primitive.Lyon Med. 1902; 99: 114-116Google Scholar In a seminar on arterial suture in 1902, Jaboulay38Jaboulay M. Chirurgie des artéres.La Semaine Médicale. 1902; 22: 405-406Google Scholar was quick to give Carrel credit for his accomplishment. Carrel did not return the favor and later branded some of Jaboulay's concepts as “irrational.” Carrel was unsuccessful in his quest for a University appointment in Lyon, and he decided to emigrate to the United States. He began his work in the Hull Laboratory at the University of Chicago in conjunction with Charles Claude Guthrie. Their work expanded the studies begun by Carrel in Lyon, but their results were not very good until Guthrie suggested that the anastomotic sutures incorporate all layers of the vessel wall.39Harbison SP. Origins of vascular surgery: the Carrel-Guthrie letters.Surgery. 1962; : 406-418Google Scholar Their results apparently improved thereafter, and their work attracted increasing attention from the profession and from the public. Carrel and Guthrie worked together for 2 years and were very productive. Guthrie left Chicago to go to the University of Missouri, and Carrel took a position at the Rockefeller Institute in New York, which was directed by Simon Flexner, brother of Abraham Flexner. Carrel became increasingly controversial because of his alleged tendencies not to give appropriate credit to others, to overstate his accomplishments, and to promote himself by seeking publicity. Guthrie felt that he was not given sufficient credit for his contributions to the experimental work that he and Carrel had done together.39Harbison SP. Origins of vascular surgery: the Carrel-Guthrie letters.Surgery. 1962; : 406-418Google Scholar He accused Carrel of making “misleading statements” and noted that, in fact, there had only been one long-term success of Carrel's laboratory work in vascular anastomosis. Guthrie expressed “high regard for Dr. Carrel's persistence in the face of a long series of unsuccessful operations.”40Guthrie CC. On misleading statements.Science. 1909; 29: 29-31Crossref PubMed Scopus (10) Google Scholar Carrel seems to confirm that he was not uniformly successful by recognizing the work of Stephen H. Watts,41Watts SH. The suture of blood vessels.Bull Johns Hopkins Hospital. 1907; 18: 153-179Google Scholar a resident under William Halsted at Johns Hopkins University. Watts later became Professor of Surgery at the University of Virginia. Carrel wrote to Guthrie that Watts had achieved much better results in vascular anastomosis than he himself did, even though Watts was using the “old” Lyon technique.39Harbison SP. Origins of vascular surgery: the Carrel-Guthrie letters.Surgery. 1962; : 406-418Google Scholar Alexis Carrel went on to win the Nobel Prize for Medicine in 1912 for his work on vascular anastomosis and organ transplantation. His Nobel lecture described his early work, and he indicated that he was influenced primarily by the work of Payr and of Murphy. He mentioned Jaboulay only in the section on transplantation. He did not recognize Jaboulay's contributions to the technique of vascular anastomosis, nor did he mention Jassinowsky, Silberberg, or Dörfler. It has been argued that the transmission of medical information was much less effective in the early twentieth century than it is today and that Carrel may have been unfamiliar with their work.42Edwards WS Edwards PD. Alexis Carrel, visionary surgeon.in: CC Thomas, Springfield, Ill1974: 11Google Scholar On the other hand, both Payr and Murphy gave credit to Jassinowsky, with Murphy29Murphy JB. Resection of arteries and veins injured in continuity.Medical Record. 1897; 51: 73-88Google Scholar calling his work “the most extensive and indeed the only work of true merit performed in this line.” Payr27Payr E. Beiträge zur technik der blutgefass—und nervennaht.Arch Klin Chir. 1900; 62: 67-93Google Scholar gave credit to Jassinowsky, Silberberg, and Dörfler. Carrel also did not seem to have read the work of his mentor Jaboulay, who in his 1896 publication credited the prior work of Jassinowsky and Lothar Heidenhain.33Jaboulay M Briau E. Recherches expérimentales sur la suture et la greffe artérielles.Lyon Med. 1896; 81: 97-99Google Scholar If Carrel had been aware of the work of Payr, Murphy, and Jaboulay and if he had read their papers, the achievements of the other pioneers would and should not have been a mystery to him. Jassinowsky, Silberberg, and Dörfler made truly important contributions, but they were like the Antyllian comet, streaking brilliantly across the sky, only to disappear in silence. Jassinowsky moved to Odessa; Dörfler settled in Bavaria, and there the trails stop. After Carrel's departure from France in 1904, Jaboulay continued his work in vascular surgical techniques. He had studied various methods of achieving hemostasis with the use of gelatin and peptones. He also experimented with arteriovenous anastomosis in the treatment of gangrene with the thought of reversing the blood flow in the venous system and overcoming the resistance of the venous valves. He made major contributions to the study of the sympathetic nervous system,