Authors
A Dinis da Gama
Topics
Global Healthcare and Medical TourismELSEVIER SCIENCE~PII: 80967-2109(97)00009-4Cardiovascular Surgery, Vol. 5, No.4, pp. 354-360, 1997 © 1997 The International Society for Cardiovascular Surgery Published by Elsevier Science Ltd. Printed in Great Britain 0967-2109/97 $17.00 + 0.00A. Dinis da Gama Av Das For~as Armadas. 133. LT-D16°ESQ. 1600 Lisbon. Portugal 'In August 27, 1946, the femoral artery was exposed under local anaesthesia. It looked very hard. A longitudinal incision was made and deepened until what seemed to be the central white organized thrombus was attained. At that level it was easy to find a plan of cleavage with the aid of a silver ophthalmic spatule... Then, with a forceps, the whole of the central block was grasped and twisted until it came out like a tooth, followed by a strong jet of blood. Under local anaesthesia, the femoral artery was again exposed at the level of the adductor ring. A second arteriotomy was performed. The ophtalmic spatule opened again the plan of cleavage and a laterally U-shaped stiletto worked once more from the groin towards the periphery, from the distal arteriotomy towards the groin and finally towards the periphery for a short distance until blood came, retrogradely. After the arteriotomies were sutured, good pulsations were present everywhere. An arteri ography was performed at once with a portable X-ray set and two cassettes under the limb. It revealed that the whole disobliterated segment was patent (Figure 1) although many irregu larities were present. It also revealed that the collaterals from the obliterated segment were functioning again ... Wohlwill's report on histopathological exam ination told me that the thrombus, the whole intima and part ofthe media had been removed. So, I really had performed a different operation from the one I originally intented to do; and I could conclude that, under heparin action, blood could flow against muscle without giving place to a thrombosis. It seemed unbelieveable...' (In: J. Cid dos Santos, From embolectomy to endarterectomy, or the fall of a myth. Journal of Cardiovascular Surgery, 1976, 17, 107-128.)Joao Cid dos Santos stands out in the history of vas c~lar surgery because of his great discovery, the tech ruque of endarterectomy, in 1946. It was naturally the result of his creative genius and of the atmos phere and men that surrounded and influenced him during that extremely rich and fertile historical per iod between World Wars I and II. Endarterectomy, or arterial disobliteration as it was initially called, was the first attempt to re-estab lish circulation in arteries affected by chronic occlusions, by removing the obstructing process and restoring their permeability. At a time when the treatment of occlusive arter iopathies depended upon physiopathological con cepts of a functional nature that made it legitimate ~o use sympathectomy as a therapeutic method, as Introduced and advocated by Rene Leriche, Cid dos Santos' proposal emerged simultaneously as heresy and hope. In fact, according to the principles then estab lished, inte~ention ~ithin an artery was invariably followed by Its occlusion, rendering it prohibitive to expose, manipulate or have contact with its intima. Cid dos Santos demonstrated, using endarterecCARDIOVASCULAR SURGERY AUGUST 1997 VOL 5 NO 4 ~gure 1 Control arteriography of first endarterectomy performed by J. Cld dosSantos on 27 August 1946 t~my, that such principles were not true and his tech Ulque eventually became the ideal treatment for seg mental occlusive arterial lesions in practically all surgically accessible arteries in the organism. It was in the sequence of the disclosure of endart erectomy that other revascularization techniques and methods appeared, using venous or synthetic grafts, allowing the emergence and expansion of present day arterial reconstructive surgery. This evolution took place only after Cid dos Santos demonstrated that the alleged role played by the endartery was a myth, preventing the development of direct arterial surgery, and that its dismissal had encouraged other methods of treatment for occlusive arterial diseases. It is therefore justifiable to consider endarterec tomy as being at the root of the reconstructive arterial surgery of our time.CARDIOVASCULAR SURGERY AUGUST 1997 VOL S NO 4Celebration of the50th anniversary of endarterectomy: A. Dinis da Gama Chronol~gyJoao Cid dos Santos, son of Reynaldo dos Santos, was born in Lisbon on 5 August 1907 and, from a very early age, and certainly under the influence of his father's eminence, he showed an interest in and an inclination towards medicine. In September 1927 he registered with the Faculty of Medicine of Lisbon and graduated in 1933. He went on to work with his father at the Arroios Hospital, in Lisbon. The basis of his surgical and pedagogical training date from that period: he performed the first surgical and anaesthetic interventions (at that time anaesthesia was administered by the younger surgeons) and delivered the first lectures to students and residents. At the same time he attempted the first steps in experimental surgery, studying various techniques of arterial surgery in animals, from simple sutures to anastomosis and venous grafts. In 1936, having acquired some initial personal experience in the clinical, surgical and experimental fields, he went to Strasbourg to work with Rene Ler iche for a year. The weight and prestige of Leriche and of his school projected throughout Europe and the World and attracted local and foreign surgeons, eager for new knowledge and experience. In Strasbourg, Cid dos Santos worked directly with Fontaine and met Jean Kunlin, Michael DeBakey, and Georges Arnulf, among others, estab lishing friendship links that extended throughout his life. This one-year period left a definite and perma nent impression on Cid dos Santos: ' ...Therefore, our practice with Leriche is a capital milestone in our life. The clash inside us between the person alities and corresponding orientation of our two Masters was the decisive fact in the moulding of the mentality that - good or bad - we still have ...', he admitted in a moment of reflection. After returning to Lisbon, he resumed his activity as a surgical resident at the Arroios Hospital and, in 1939 he joined the staff of the Faculty of Medicine as an Assistant Lecturer of Urology. In 1942, against competition, he obtained the title of Surgeon of the Hospitals and, in 1944, was drafted and left for the Azores, where he headed a military surgical team providing rearguard support to the allied troops involved in World War II. That same year he submitted his doctoral thesis, entitled 'General Pathology of the Ischaemia of the Limbs' at the Faculty of Medicine of Lisbon. In 1945 he was accepted as Associate Professor and, in 1949, became full Professor for the chair of Surgery at the Faculty of Medicine of Lisbon, located then at the Santa Marta Hospital. The inauguration of the new School Hospital of Santa Maria took place in 1953 and Cid dos Santos was appointed Chairman of the Surgical Clinical Services. He managed, at the age of 46, to rise to a Celebration 9f the 50th anniversary of endarterectomy: A. Dinis da Gama leadership position in surgery and in the academic milieu in his country. He organized, assisted by a dedicated group of collaborators, an exemplary ser vice and this allowed him to implement, deepen and expand a significant part of his scientific work initiated at Arroios and Santa Marta. At this stage in his life he achieved international notoriety and projection. He was approached and increasingly received invitations from all over the world, where he was noted for his scientific motivations and revealed himself as an eminent speaker; he was requested to speak to a large variety of audiences, who were attracted by his remarkable oratory gifts, his vigour and intellectual brightness. He was a veritable ambassador of Portuguese science and culture in his time. Joao Cid dos Santos died on 4 November 1975, from a heart attack, distressed by the events taking place during one of the most critical periods in Por tuguese society following the revolution of 25 April 1974. The greatest historical contributions ofhis creative genius were venography and endarterectomy, but unforgettable also are his cultural and humanist structure, his sensitivity and intelligence which made him a real 'citizen of the world' - esteemed and admired by all those who knew him and socialized with him.Like Reynaldo dos Santos, his father, ]odo Cid dos Santos performed his scientific work in the fields of general surgery, urology, angiology and vascular sur gery, always based on his fertile creative imagination; he produced several original contributions concern ing the diagnosis and treatment of a variety of con ditions. In the field of general surgery, Cid dos Santos described the deviation of false cysts of the pancreas into the stomach (cystogastrostorny) and created a technique for the intrapancreatic liberation of the choledochus, followed by external sphinc tertomy, for the obstructive lesions of the Oddi sphincter. In the field of urology he was a pioneer in the creation of the ileal neobladder and trans perito neal prostatectomy, but it was chiefly in the scope of vascular pathology that his discoveries earned greater resonance and projection. On top of several modest contributions, such as using a new surgical access (from the front) to perfom lumbar sympathectomy or performing for the first time a venous thrombec tomy in a case of deep venous thrombosis, it was the discovery of venography and endarterectomy that earned him the credits and merit of a great researcher and pioneer in contemporary vascular surgery.It was common belief among surgeons of that time that the manipulation of an artery's intima would be followed immediately by a local thrombosis; this belief was sustained by great personalities such as Matas (1909), Guthrie (1912) and Moure (1923). At the same time, in the area of embolisms, the for mation of a secondary thrombosis occurred fre quently after the removal of an embolus, especially in the case of embolisms of prolonged evolution. This resulted from injury of the endothelium, as a result of the impact of the embolus on the arterial wall. Eynar Key postulated that, in the case of any embol ism with an evolution going beyond 10 hours, treat ment by embolectomy should be discouraged because it would be systematically followed by sec ondary thrombosis, a concept equally shared by Ler iche. The 'untouchable' character of the arterial intima discouraged and even prevented any attempts at arterial disobliteration and the surgeons turned to surgery ofthe sympathetic nervous system, of a func tional nature, aiming at solving the 'grand' problem of the vasospasm-one that received great attention from Leriche, who even considered it an essential component in the physiopathology of ischaemia of the limbs. The development and gradual clinical utilization of arteriography brought about, in the eyes of the surgeons, a completely new 'world', especially the revelation of a new macroscopic pathology which assumed, with relative frequency, a segmental character in the various territories of the arterial tree. From the outset, Cid dos Santos was tempted to approach and treat directly those lesions, which Reynaldo dos Santos had stimulated in him. He went back to the laboratory with that aim, testing and reproducing the classic experiments of Carrel and Guthrie, with the objective of improving his technical execution. That is when, in 1943, a new fact emerged that would play a relevant role in the course of events: the possibility of using heparin in day-to-day clinical practice. '... I was in the position which is clearly defined through the words of the old fisherman to the young boy in one of Ernest Hemingway's books: the hooks were at the right place; then one had only to wait for the fish. In this case, the fish was hep arin...' wrote Cid dos Santos one day about this. It occurred to him to use heparin in the prevention of secondary thrombosis after an embolectomy (in which he succeeded); he then used it for belated embolectomies, with equally satisfactory results. Finally, he used it in the prevention of thrombosis following reconstructive surgery of aneurysms (endoaneurysmorraphy), again with good results. He then perceived that heparin's action couldCARDIOVASCULAR SURGERY AUGUST 1997 VOL 5 NO 4 serve as protection in the regeneration of the intima after removal of an old thrombus, formed as a conse quence of the process of endarteritis. It was important to demonstrate such possibility in clini cal practice. Cid dos Santos performed some peripheral arterial disobliterations on patients who were in a critical condition, and suffering from terminal illnesses, under the protection of heparin, and was able to con firm a few days later and after the patient's death that the arteries remained patent. He sent the fragments resulting from the disobliteration for histopatho logical study and verified that they were made up of a central organized thrombus, the whole ofthe affec ted endartery, and part of the muscular layer. These findings left him perplexed: he had in mind to remove the thrombus only, but the histological tests demonstrated that the removal always extended into the medial layer ofthe arterial wall! Faced with these facts, he immediately reached two conclusions which proved crucial for the continuation and success of his experimental work: (i) the discovery of the exist ence of a plane of cleavage right in the medial layer of the arterial wall, favouring the removal of the occlusive process; and (ii) that under those con ditions and under the protection of heparin, the blood could flow in the artery, in contact with the muscular wall, without occurrence of secondary thrombosis, which seemed unbelievable. . . Heartened by these revelations, ~e decI~ed Immediately to operate on some patients taking those findings into consideration. On 27 August 1~46 he performed, for the first time, a disobliter anon of an iliofemoral segment in a man aged 66, re-established arterial permeability, as confirmed by intraoperative arteriography, and verified that .~e method allowed re-establishment of the permeability of occluded collaterals. On 12 December of the same year he applied the same procedure to a 35-year-old woman with an Occlusion of the subclavia and axillary arteries of the Upper right limb. An excellent and prolonged ~e~~lt assured him that the method had every possibility of SUccess and he entitled it 'arterial disobliteration'. Later, Bazy designated it, more appropriately, as 'endarterectomy' and in circumstances of total , , occlusion, it was called 'thromboendarterectomy. Cid dos Santos decided to submit the results of his research and the ensuing therapeutic proposal to the French Academy of Surgery in the form of a report entitled 'Sur la desobstrucncn des thromboses arterielles anciennes' which represented a historical milestone of contemporaneous vascular surgery. The paper was presented by Rene Leriche, who ended. his address by congratulating the author and stanng, with prospective vision: 'For 25 years I tried, after arterectomy, to find favourable conditions for the. re establishment of arterial continuity through grafting.CARDIOVASCULAR SURGERY AUGUST 1997 VOL S NO 4 celebration of the 50th anniversary of endarterectomy: A. Dinis da Gama was never able to accomplish my program. I hope that the new method will enable us to reestablish a lost function. And this will be an immense progress.' The following years were dedicated to spreading the method and improving it. Edwin Wylie intro duced it into the United States of America. It was soon found that endarterectomy could be performed without the protection of heparin and that the con tinuance of the artery's permeability depended more upon the quality of the blood flow than from coagu lation. The introduction of the 'over-pass', the Kun lin stitches to fasten the severed endartery and patch angioplasty proposed by DeBakey were significant contributions aimed at improving the method and increasing its efficacy. This set of technical details, the creation and development of surgical instruments for their execution, the clinical indications and the results obtained with endarterectomy in the various arterial territories, were thoroughly analysed in Rome, in 1963, during the Congress of the International Car diovascular Society; fundamental rules for the pro cedure were established and Cid dos Santos called them the 'Rome principles'. This was the inter national recognition of the method of which he had been a pioneer (Figure 2). His greatest aspiration was to be able to write a book concerned with the endarterectomy technique. However, he was prevented from this very intimate wish materializing by the variety of requests he was subject to and by the great array of activities forced upon him. In September 1975, as president of the Inter national Cardiovascular Society, Cid dos Santos presented, in Edinburgh, the Leriche Memorial Lec ture entitled 'From embolectomy to endarterectomy or the fall of a myth', in which he describes, in a simple, profound and brilliant manner, the history of endarterectomy and events gravitating around the concept and its implementation. At the end of the conference, as if giving the final balance of the intense and agitated life he had lived, and in somewhat melancholic tone, Cid dos Santos stated: 'The consequence of all this [dispersion of activities] was that my work was practised mainly on units rather than on series of cases. Furthermore, and paradoxically, having worked hard all my life, with little sleep and without the benefit of real hol idays, I confess to be, by nature, extremely lazy, indeed. In fact, I have wasted much time. If it were not for all these evils, endarterectomy could have had its birth some years before. But, that is that...' Two months later came, brutally, the heart attack. Already in his hospital bed, he opened his eyes, greeted me with the usual salute 'Hello kid!' and told me: 'This time is for real' ... He died in the early hours of the following day.Celebration;of the50th anniversary of endarterectomy: A. Dinis da GamaFIgureZ Thromboendarterectomy. the operation of J. Cid dosSantosCid dos Santos was an outstanding figure, impressive at first sight. Tall, with angulated features and prominent nose, sharp and penetrating eyes pro tected by enormous eyebrows, with broad and expressive hands, he emanated naturally mixed feel ings of respect and sympathy (Figure 3). He was pol ite and affable in his personal relations, but he could be as harsh and severe as anyone, without ever becoming violent or coarse. He devoted a particular attention and affection to students and young doc tors to whose ideas and anxieties he listened with patience, and he was always ready to help and advise anyone who turned to him. He expressed himself in a fluent and elegant lang uage that revealed his ample erudition and cultural background. In his first lecture as full Professor to the students of Surgical Pathology, in 1949, he had admitted that three exceptional men had exerted a remarkable influence in the moulding of his mind: Reynaldo dos Santos, Rene Leriche, and the poet and man of letters, Afonso Lopes Vieira. It was prob ably Afonso Lopes Vieira who motivated him, to a large extent, to the world of literature and the arts. His passion was literature but he did not ignore painting and music, of which he was an excellent performer at the piano. In an unpublished document belonging to his literature legacy, he recorded some authors and works he hoped that he would never be separated from: Platao, Demosthenes, Seneca Cicero, Montaigne, Montesquieu, Pascal, Anatole: Plutarch, Hume, Wellington, Churchill, de Gaule Camus and Oscar Wilde. In the critical moments h~ had to go through, he sought refuge in these authors and their works, where he would find new breath and renewed energy to continue his journey. He liked social intercourse, always surrounded by friends and collaborators, and hosted with discretionCelebration of the 50th anniversary of endarterectomy: A. Dinis da GamaFigure 3 Professor Joao Cid dos Santos and elegance in his mansion, located in Rua da Rosa, in Alfama, with a superb view over the city of Lisbon. He enjoyed the good things in life and was a demanding 'gourmet'. He cultivated some culinary talents, still remembered in some of the old res taurants in Lisbon, in whose menus one can still find a course called 'scrambled eggs aProfessor', a recipe of his. Knowing several foreign languages that he spoke perfectly, he was a remarkable lecturer and conferen cist, both at home and abroad: some of his addresses became famous such as 'Medicine, the last romantic profession of the world', 'Forks, knives and spoons, or the adaptation of mind to clinical research'; 'Soc rates' olive trees and Hippocrates' platans', 'How to ~onsume time' or 'The problem of vascular lesions In war as seen by a surgeon in peace time'. He was also a biographer of eminent personalities in medicine such as Reynaldo dos Santos, Friedrich Wholwil, Jean Kunlin, Rene Fontaine and Edwin Wylie and also of men of the arts like Francisco de Lacerda or Raul Lino. Some sentences created by him became renowned and are today lapidary inscriptions in tribute to his memory, such as 'There are no timetables for thought' or 'It does not suffice to say that a doctor's life is hard, it must be hard.' He dedicated much of his time and concern, especially in the last years of his life, to social issues and to projects for the reform of hospitals and of the University; to that aim he decided to engage, tem porarily, in a political career, as a deputy to the National Assembly, but this did not last more than 3 years and ended in a state of disenchantment and frustration. His respect for principles and his rigor ousness - marks ofhis scientific training - soon madeCARDIOVASCULAR SURGERY AUGUST 1997 VOL 5 NO 4 him incompatible with the men and voluble world of politics. He was a systematic and irreverent critic of power, any power. In fact, he fully enjoyed sub mitting the reasons of power to the power of reason. He was still very young when he surrounded him self with a small group of collaborators that grew with time. They were particularly fond of him and held strong admiration for him. 'I will not forget my friends and collaborators. One cannot live with out them', he wrote one day as if in retribution. As a school master he was proud of having trained several university professors and influenced the edu cation of countless numbers of Portuguese and foreign surgeons. He was an active member and leader of numerous scientific and socioprofessional associations and societies, at home and abroad, among which can be counted the vice presidency of the European Chap ter and the presidency of the International Society for Cardiovascular Surgery. Similarly to his father, Joao Cid dos Santos was privileged, in a lifetime dedicated to the progress and development of angiology and vascular surgery, to see the worth and merit of his creative work recog nized. Evidence of this recognition took the form of 'honoris causa' doctorates bestowed by several foreign universities, honorary memberships in as many others and officialdom ofthe Legion of Honor, besides many decorations and prizes. He left us at a time of apogee and glory in his career, he had earned prestige and his name had received worldwide acknowledgement, respect and admiration. As a whole, this can be considered as the result of the combination of his genius and his human background, together with the universalist sense with which he looked at the world and conduc ted his destiny. Therefore, I believe it is fair and appropriate to consider him a 'citizen of the world'.Cid dos Santos, J., Curriculum Vitae, 1U Parte. Edicao do Autor, Lis boa, 1944. Cid dos Santos, J., Curriculum Vitae, 2" Parte. Edicao do Autor, Lis boa, 1948. Cid dos Santos, J., Li~i1o de Abertura do Curso de Patologia Cirurgica. Edicao do Autor, Lisboa, 1949. Cid dos Santos, J., Sur la desobstruction des thromboses artericlles anciennes. Bull. Melli. Academie de Chirurgie, 1947, June, 409. Cid dos Santos, J., Sur quelques veritees premieres oubliees ou meconnues de l'anatomo-physiologie normale et pathologique du systerne veineux, Leur application ala pathologic et ala therapcu tique. Amatlls Lusitannus, no. I, 148, 1946. Cid dos Santos, J., Tris homens de qualidade. Edicao do Auror, Lis boa, 1965. Cid dos Santos, J., As oliueiras de Socrates e os platanos de Hipocrates. Edicao do Autor, Lisboa, 1966. Cid dos Santos, J., Outro modo. Edicao do Autor, Lisboa, 1968a. Cid dos Santos, J., Reynaldo, Fontaine, Kunliu, Wylie. Edicao do Autor, Lisboa, 1968b. Cid Dos Santos, J., Adaptacao do espirito II investigacao clinica. J. Medico, 1969, 104, 880-885.Celebration of the 50th anniversary of endarterectomy: A. Dinis da Gama / Livro de Homenagem ao Prof. Cid dosSantos. Edicao '0 Medico', Lis boa, 1976. Sessio de Homenagem ao Prof. Joio Cid dos Santos. Jamal da Socie dade de Ciincias Medicas de Lisboa, 1976, Jan-Mar. Cid Dos Santos, J., Leriche Memorial Lecture, From embolectomy to endarterectomy, or the fall of a myth. Journal of Cardiovascular Surgery, 1976, 17, 113-128. Paper accepted 15 January 1997
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PublishedAug 1, 1997
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