HISTORICAL VIGNETTES IN VASCULAR SURGERYNorman M. Rich, MD, Section Editor

Halsted-Holman vascular trauma legacyNorman M. Rich, MD, Thomas M. Krummel, MD, and David G. Burris, MD, Bethesda, Md;

and Stanford, Calif

Emile F. Holman, who was the last Chief Resident toWilliam Stewart Halsted at Johns Hopkins University,identified a number of contributions that Halsted made tovascular surgery.1 Holman had been a Stanford Universityundergraduate, class of 1911, and a Johns Hopkins Medi-cal School graduate in 1918. He became the first full-timeProfessor and Chairman of the Department of Surgery atStanford Medical School in San Francisco, California, in1926. Stimulated in part by the teaching and writing ofHalsted, Holman continued with an interest in vascularsurgery and, particularly, the management of vascular inju-ries. His classic monograph in 1937 on the pathophysiol-ogy of arteriovenous fistulas is a landmark contribution inthe 20th century in vascular trauma.1 This review, based inpart on personal experiences, emphasizes the great value ofmentorship and the legacy that can be passed on, as it has inthe Halsted-Holman vascular trauma legacy, to continue toimprove combined efforts in providing the best surgicalmanagement possible for those who have the misfortune tobe injured.

WILLIAM STEWART HALSTED (1852-1922)

As the first Professor and Chairman of the Departmentof Surgery at the Johns Hopkins University School ofMedicine, Halsted is known for many contributions toAmerican medicine and surgery.2,3 This is particularlynoted by his contributions to surgical education. Less has

From the Norman M. Rich Department of Surgery, F. Edward HébertSchool of Medicine, Uniformed Services University of the Health Sci-ences; and the Department of Surgery, Stanford University School ofMedicine.

Competition of interest: none.Presented in part as the Emile F. Holman Lecture in Surgery at Stanford

University School of Medicine, Mar 7, 2003, and at the Seventy-EighthAnnual Meeting of The Halsted Society, Stanford University, Sept 2004.

Reprint requests: Norman M. Rich, MD, FACS, DMCC, Department ofSurgery, F. Edward Hébert School of Medicine, Uniformed ServicesUniversity of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD20814 (e-mail: nrich@usuhs.mil).

The editors and reviewers of this article have no relevant financial relationshipsto disclose per the JVS policy that requires reviewers to decline review of anymanuscript for which they may have a competition of interest.

J Vasc Surg 2010;52:508-110741-5214/$36.00Copyright © 2010 by the Society for Vascular Surgery.

doi:10.1016/j.jvs.2010.01.093

508

been emphasized about his interest in vascular surgery andthe management of vascular injuries. In comments aboutHalsted, Holman indicated that Halsted’s “. . . specula-tions and discussions on arterial lesions were a constantsource of inspiration to his students and associates.”4

Halsted encouraged Bertram Bernheim, working in theHunterian Research Laboratory at Johns Hopkins Univer-sity, to work with vascular anastomoses. In 1916 Halstedencouraged Bernheim to do the Lexer “Ideal Operation,”as had been done in Germany in 1907, and this was the firstautogenous great saphenous vein repair of an artery in theUnited States.5 This became the most frequently used andhighly successful repair of extremity arterial injuries in the20th century.6

EMILE F. HOLMAN (1890-1977)

As the first Professor and Chairman of the Departmentof Surgery at Stanford University School of Medicine,Emile F. Holman maintained those responsibilities for 29years, retiring in 1955. Like Halsted, he had many andvaried contributions to medicine and surgery, particularlyon the West Coast. The pathophysiology of arteriovenousfistulas, published by MacMillan and Company in NewYork in 1937, was a sentinel contribution by Holman thatis informative and interesting even today.1 The title of thatbook was Arteriovenous Aneurysm: Abnormal Communica-tions Between The Arterial And Venous Circulations.” Oneof the ironies, particularly considering the strong mentorrelationship of Sir William Osler to Emile Holman, isOsler’s comment in 1905 on arteriovenous communica-tion: “The only problem with the operation is with thegangrene that is apt to follow.”7

It is possible that this dismal concern by Osler helpedpropel the interest that Halsted had and that he projectedto many of his trainees, including Holman and Mont Reid,to successfully repair arteriovenous communications. Dur-ing his undergraduate years, Holman was the personalsecretary of the first Stanford University President, DavidStarr Jordan. Holman graduated in 1911 and went toOxford University in England as a Rhodes Scholar. He didvery well at Oxford University, coming under the mentor-ship of Sir William Osler, who wrote to Johns Hopkins

University encouraging admission of Holman to the

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fourth-year medical school class, which was permitted afteran examination.8

Holman, who had also served during World War I inFrance in the Ambulance Corps, graduated from JohnsHopkins University School of Medicine after 1 year! Hol-man was accepted into the Halsted Surgical Program atJohns Hopkins University and enjoyed the close associationand mentorship of Halsted until the latter’s death in 1922.

One of Holman’s classmates and good friends at Stan-ford University was Otto E. Utzinger of Astoria, Oregon,who was a 1914 graduate of the Johns Hopkins School ofMedicine (Fig 1). The primary author (N. M. R.) wasinfluenced by Utzinger throughout his developing years inRay, Arizona, a Kennecott copper mining community.Utzinger served in France with the American expeditionaryforces in 1917-1918 after completing surgical trainingunder John M. T. Finney at Union Memorial in Baltimore,Maryland, part of the Halsted-Johns Hopkins program. Heregaled the primary author with many experiences, includ-ing the frustration of multiple amputations of combatcasualties who were received in military hospitals with anaverage delay of 12 hours after wounding. Utzinger, likeHolman, talked about the interest that Halsted had invascular surgery and in vascular trauma.

Despite being 51 years old and serving as Professor andChairman of the Department of Surgery at Stanford Uni-versity School of Medicine, Holman voluntarily joined theNavy to serve in World War II. Also, he voluntarily servedin the South Pacific.

In 1953 Holman delivered the first David W. YandellLecture in Louisville, Kentucky, “New Concepts Of Sur-gery in the Vascular System: The Immediate and LateTreatment of Our Arterial Injuries.” He included the fol-lowing regarding the discouraging status of attempting to

Fig 1. During the 1914 graduation of Johns Hopkins Univer-sity School of Medicine in Baltimore, a senior medical studentfrom Astoria, Oregon, and Stanford University took a numberof candid photographs of William Stewart Halsted and otherson the faculty. In the group picture above, Otto E. Utzinger(small circle) is standing behind Halsted (large circle). (Photocourtesy of David H. Utzinger.)

manage vascular injuries at that time, particularly during

the Battle of Peleliu when he was serving with the UnitedStates Marines in one of their bloodiest battles in the SouthPacific during World War I:

“. . . and the Korean War to a fortunate concatenation ofcircumstances provided an opportunity to discard the disas-trous treatment of an injured artery by ligation and toapply instead the principle of immediate reconstruction andrepair, a method rarely employed successfully in World WarII in 1943, I attempted the primary repair of the dividedpopliteal artery under primitive conditions in the SouthPacific but it was saddening failure . . .” 4

It was this type of experience by Holman that added tohis encouragement of Carl W. Hughes during the KoreanConflict8 and Norman M. Rich during the Vietnam War6

(Fig 2) to continue to work toward successful repair of botharteries and veins under less than ideal circumstances.

MATAS, DEBAKEY, SHUMACKER, HUGHES,SPENCER, AND OTHERS

In the relatively small community of clinicians, educa-tors, and scientists, there are interesting interconnectionsamong a number of surgeons. Rudolph Matas (1860-1957), considered by many to be the father of vascularsurgery, and also the first American international surgeon,

Fig 2. Emile F. Holman’s encouraging support of the VietnamVascular Registry was recorded in the second edition of his book,which was published by Charles C. Thomas Publisher.

described his approach to the management of arterio-

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venous fistulas and false aneurysms with endoaneurysmor-rhaphy in 1888.2 Matas was operated on by Halsted inBaltimore, which is interesting historical documentation ofits own. Matas, based on an exchange and internationalmeeting in London in 1913, described the unique contri-butions of Vojislav Soubbotitch of Serbia during the BalkanWars in the management of arterial and venous injuries.9

The Matas Award, based in great part on the contributionsin vascular surgery, was presented to Emile Holman andMichael DeBakey in New Orleans in 1954 (Fig 3).

Michael E. DeBakey, who had trained at Tulane Uni-versity in New Orleans and who had been influenced byMatas, served as the Army Consultant in World War II.With Fiorendo Simeone, he contributed a monumentalreview of the management of 2471 arterial injuries, all but81 treated by ligation, among American injured in theEuropean Theater in World War II.10 Dr DeBakey’s con-tributions to vascular surgery are legion, and he remainedhighly supportive of the primary author throughout hiscareer in the management of vascular injuries, culminatingin 1978 in the publication with Frank C. Spencer of Vas-cular Trauma, with Dr. DeBakey writing the forward.2

The Michael E. DeBakey International Professorship andthe Michael E. DeBakey International Military SurgeonsAward at The Uniformed Services University of HealthSciences (USUHS) continue the legacy.

Harris B Shumacker Jr, who had surgical training underAlfred Blalock at Johns Hopkins University, was offered theopportunity by Blalock to remain at Johns Hopkins Uni-versity during World War II because it was recognized thatnot everyone could serve in uniform and that there must becontinuing medical education in the United States by thosewho would remain in their position of responsibility. Shu-

Fig 3. Rudolph Matas (center) presenting his Award to Emile F.Holman (left) and Michael E. DeBakey (right) in New Orleans in1954, with recognition for contributions to vascular surgery in-cluding the management of vascular injuries. (Photo courtesyMichael E. DeBakey.)

macker told Blalock that he must serve his country in

uniform and he went to Southeast Asia. Later he was giventhe responsibility at one of three established vascular cen-ters in the United States in Galesburg, Illinois.11

Matas noted that Shumacker had more experience in arelatively short period of 2 or 3 years in the management ofvascular injuries than he had had in 50 years of practice. DrShumacker published extensively on the approach to man-aging arteriovenous fistulas and false aneurysms, and thisadds to the combined legacy in the management of vascularinjuries. Shumacker was the first full-time professor to joinRich in the new developing Department of Surgery atUSUHS. Rich remains a Distinguished Professor of Sur-gery at USUHS, with a Harris B Shumacker Jr Distin-guished Surgical Lecture named after him delivered annu-ally at the Society for Military Vascular Surgery at USUHS.

Carl W. Hughes, along with Frank C. Spencer, madesignificant contributions from experiences in the KoreanConflict (1950-1953).8 Hughes had similar exchangeswith Holman and with DeBakey. Hughes and Spencer hadexchanges during the Korean Conflict. The primary authorbenefited from the mentorship of Hughes during his in-ternship at Tripler General Hospital in Honolulu, his sur-gical training at Letterman General Hospital in the presidioof San Francisco, and at Walter Reed General Hospitalduring his Vascular Fellowship as the first Vascular Fellowin 1967. Hughes remained highly supportive of the Viet-nam Vascular Registry, which extended though his retire-ment and during his years of leadership in the VeteransAdministration. He has served on the USUHS Faculty.

NORMAN M. RICH (b. 1934 )

When Rich met Holman for the first time in 1954 inthe operating room at Stanford University Hospital, as-sisted 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 aStanford surgical resident in Holman’s program. Holman’squestions to Rich focused on what the latter stated was hisinterest in training in surgery with a particular interest invascular surgery and the management of vascular injuries.Holman asked what original thoughts had been developed.When he recognized that the answer was too challengingfor a rapid response he proclaimed, “If you think you havean original idea it means that you have not read enough andyou should go to the library and read more.”

These were words that were remembered and followed.Holman also recommended that any specific interest inmedicine and/or in surgery would be augmented andcomplimented by identification with a well-known individ-ual who had a similar interest. He emphasized that this typeof emphasis would draw an association, which others wouldremember as well. He stated that it would be good toinvoke the contributions of William Stewart Halsted atevery opportunity, such as the proclamation by the latterin 1912 in the Johns Hopkins Bulletin that, “One of thechief interests in surgery is the management of vascular

injuries.”12

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This proved to be sage advice that allowed the new andenthusiastic developing young surgeon to feel a part of theHalsted-Holman legacy.13 This legacy was passed onthrough mentorship from Utzinger, Holman’s Stanfordundergraduate classmates, to the primary author. The ulti-mate result was the publication in 1978 of VascularTrauma, coauthored with Frank C. Spencer of New YorkUniversity, another graduate of the Johns Hopkins SurgicalProgram who had served in the Korean Conflict.

VASCULAR INJURY IN CURRENT CONFLICTS

The USUHS in Bethesda, chartered by Congress of theUnited States in 1972, provided neutral ground for thosewith varying interests and allegiances to work togethertoward a common goal in the latter part of the 20th centuryinto the 21st century. This was particularly true in themanagement of vascular injuries in the first Gulf War in1991 and in the subsequent wars that started in Afghani-stan in 2001 and in Iraq in 2003.14,15 The war continues inAfghanistan and in Iraq. We are pleased and proud to passon this legacy to those who follow, extending our gratitudeand best wishes to them.

REFERENCES

1. Holman E. Arteriovenous aneurysms: abnormal communications be-tween the arterial and venous circulations. New York: MacMillan; 1937.

2. Rich NM, Spencer FC. Vascular trauma. Philadelphia: WB Saunders;

1978.

3. MacCallum WG. William Stewart Halsted: Surgeon. Baltimore: TheJohns Hopkins Press; 1930.

4. Crowe SJ. Halsted of Johns Hopkins: the man and his men. Springfiled,IL: Charles C. Thomas; 1957.

5. Holman E. Sir William Osler and William Stewart Halsted—two con-trasting personalities. Pharos AOA 1971;34:134-7.

6. Halsted W. Discussion in Bernheim, B.M: The ideal operation foraneurism of the extremity. Report of a case. Bull Johns Hopkins Hosp1916;27:93-6.

7. Osler W. Report of a case of arteriovenous aneurysm of the thigh. JohnsHopkins Hosp Bull 1905;16:119-22.

8. Hughes CW, Bowers WF. Traumatic lesions of peripheral vessels.Springfield, IL: Charles C. Thomas; 1961.

9. Rich NM, Clagett GP, Salander JM, Piscevic S. The Matas/Soubbotitchconnection. Surgery 1983;93:17-9.

10. DeBakey ME, Simeone FA. Battle injuries of the arteries in World WarII: an analysis of 2,471 cases. Ann Surg 1946;123:534-79.

11. Elkin DC, Shumacker HB Jr. Vascular surgery in World War II. In:Elkin DC, DeBakey ME, editors. Washington, DC: US GovernmentPrinting Office; 1944.

12. Halsted WS. The effect of ligation of the common iliac artery on thecirculation and function of the lower extremity. Report of a care ofiliofemoral aneurism by the application of an aluminum band to thevessel. Bull Johns Hopkins Hosp 1912;23:191-4.

13. Holman E. Abnormal Arteriovenous Communications: Peripheral andIntracardiac, Acquired and Congenital. 2nd ed. Charles C. Thomas,Publisher, Springfield, Ill, 1968.

14. Fox CJ, Gillespie DL, O’Donnell SD, Rasmussen TE, Goff JM, John-son C, et al. Contemporary management of wartime vascular trauma.J Vasc Surg 2005;41:638-44.

15. Clouse WD, Rasmussen TE, Peck MA, Eliason JL, Cox MW, BowserAN, et al. In-theater management of vascular injury: 2 years of the BaladVascular Registry. J Am Coll Surg 2007;204:625-32.

Submitted Dec 16, 2009; accepted Jan 29, 2010.