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Positive-pressure ventilation, spinal anesthesia, and Rudolph Matas: the anesthetic contributions of an inquisitive surgical legend.

INTRODUCTION

Few surgeons have accomplished more during the span of their careers than Dr. Rudolph Matas (1860-1957) (Figure 1). An influential figure, not only in New Orleans, but also on the national stage, Dr. Matas was bestowed with many national and international surgical honors. He held several notable executive roles including President of the American College of Surgeons and the American Association for Thoracic Surgery. He received honorary degrees, honorary fellowships, and medals from surgical colleges in several countries. (1) His constant curiosity and inquisitive nature drove him to discover innovative approaches to common medical problems. His surgical techniques for aneurysm repair helped lay the foundation for modern vascular surgery. His innovations were not only limited to vascular and thoracic surgery, but also extended to the field of anesthesiology, which at that time was in its infancy. Two of his greatest contributions that shaped anesthesiology were his use of spinal anesthesia and advocacy of positive-pressure ventilation during thoracotomies. This essay explores the history of these approaches and presents the pivotal contributions made by Rudolph Matas.

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DR. MATAS' QUEST FOR KNOWLEDGE

Dr. Matas' love of learning and insatiable intellectual appetite were quite impressive. Even at an early age, he sought answers to questions which at that time had no answer, or at least not an answer which in his mind satisfactorily explained the mechanics of the question's solution. While still a medical student at the University of Louisiana Medical School (the precursor to Tulane University School of Medicine), he rejected the then-predominant theory that yellow fever was due to the electrical charges brought about by telephone lines. Matas read an 1881 paper entitled, "The Mosquito Hypothetically Considered as the Transmitter of Yellow Fever," and having agreed with the epidemiology and evidence of vascular injury, became a local proponent of the theory. (2) Nineteen years later, the mosquito theory was proven by Walter Reed's Yellow Fever Commission. At the age of 19, Matas received his medical degree, and by age 21 he not only had a well-established practice but also was editor of the New Orleans Medical and Surgical Journal, the oldest Southern medical periodical. His intellectual prowess and curiosity, and of course his surgical skill, were well recognized in New Orleans. In 1895, at the age of 35, Dr. Matas became the youngest physician to be appointed chairman of the Department of Surgery at Tulane University. He served as chair until 1927. During his career, Dr. Matas' curiosity and love of reading and learning were well known within the medical community. Dr. Michael E. DeBakey described Matas' home as "virtually a library, which I found out when I got there.. I later found out that almost all of the rooms had been converted into a library; in fact, they had to add additional foundational support to the house!" (Figure 2). (3) Dr. Matas was not shy in sharing his knowledge and opinions on medical problems. As he was known for his capability in talking for considerable lengths, he usually was scheduled as the last speaker at meetings of the Southern Surgical Association for fear that he may speak the entire length of the meeting. (2) He became so engrossed in writing about medicine that he failed to make deadlines, and his manuscripts were much longer than preferred by publishers. Such inquisitiveness and determination to understand and advance medicine undoubtedly played a large part in his vivid and colorful contributions to the metamorphosing canvas of surgical knowledge at the turn of the 19th century.

THE SPINAL-SUBARACHNOID METHOD OF DR. MATAS

One of his contributions was his role in the popularization of spinal anesthesia in the US. Until 1899, spinal anesthesia had not been used in patients in the United States. In fact, this technique for surgical pain relief was just in its infancy at the end of the 19th century. In 1885, J. Leonard Corning of New York injected hydrochlorate of cocaine into the space between spinous processes of two dorsal vertebrae in a dog. The result, while unclear whether spinal or epidural anesthesia, was anesthesia of the hind legs, verified by lack of response to painful stimuli. (4) Soon thereafter, Corning expanded his research to human subjects, injecting hydrochlorate of cocaine into a man who had been suffering from incontinence and lower extremity weakness. The cocaine was injected between the 11th and 12th vertebrae, resulting in anesthesia of the legs and genitals. Circa 1891, English physician Essex Wynter discovered lumbar puncture; concurrently, Dr. Quincke demonstrated the usefulness of spinal puncture as a diagnostic procedure. (4) Dr. August Bier of Germany had also been experimenting with spinal anesthesia during this decade, achieving satisfactory results initially with animals, and then with humans in a non-surgical setting. On August 16, 1898, Bier became the first physician to use spinal anesthesia for surgery. (5) In 1899, Theodore Tuffier described spinal anesthesia for lower abdominal procedures. Up to that point, spinal anesthesia had only been attempted for lower extremity procedures.

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On October 26, 1899, San Francisco physicians Tait and Caglieri were the first surgeons in the US to use spinal anesthesia, performing a tibial osteotomy in a painless manner. Dr. Matas, however, was the first US physician to officially report on the successful use of spinal anesthesia for an operation. His report appeared on December 30, 1899, detailing a successful spinal anesthetic for a hemorrhoidectomy. The exact date of the procedure is uncertain, as one author assigns November 19, 1899, and another describes December 18, 1899, as the correct date. (4,5) Regardless, Dr. Matas was the first to share his findings with the rest of the American medical community. For this anesthetic, which he called the spinal subarachnoid method, Dr. Matas injected hydrochlorate of cocaine in the L5-S1 space, confirming a subarachnoid placement by visualizing the return of cerebrospinal fluid. The patient consequently received adequate anesthesia from the neck down, and underwent the procedure without discomfort. (6) After this first case, Dr. Matas utilized cocaine- or eucaine-induced spinal anesthesia another 50 times. He was cautious in its use, however, because of the side-effects of the anesthetic approach. As he describes, "the chills, headache, vomiting and febrile rise which occurred so frequently made me doubtful of its advantage over general narcosis with ether." (7) It was not until the development of procaine, which was much less toxic, that Dr. Matas became a vivid advocate of spinal anesthesia. In fact, he was such an endorser of the method that, during his tenure as chairman of surgery, eventually much of the sub-diaphragmatic surgery (especially genitourinary and gynecological surgery) at Charity Hospital came to be performed under spinal anesthesia. Dr. Matas also shared his fervor for spinal anesthesia on the national stage, publishing numerous journal articles on his experiences with the spinal subarachnoid method. Charity Hospital served as an example to the rest of American health care institutions that neither abdominal nor lower extremity surgeries need be general-anesthetic procedures.

THORACOTOMIES, POSITIVE-PRESSURE VENTILATION, AND CONCURRENT ANESTHESIA

Charity Hospital was also the scene for Dr. Matas' other resoundingly significant contribution to anesthesiology, the use of positive-pressure ventilation during thoracotomies. As a vascular surgeon, Dr. Matas was faced with the probability of pneumothorax should the patient require thoracic surgery. Many of his contemporaries refused to operate on tumors of the thorax or mediastinum because of the fear of causing a pneumothorax, with accompanying cyanosis, oxygen desaturation, arrest of respiration, and even death. Intrathoracic surgery was rarely performed up to 1920, as it carried a 50% mortality rate. (6) The most common ways of attempting to prevent the occurrence of this unfortunate complication were rudimentary at best. In his essay "On the Management of Acute Traumatic Pneumothorax," Dr. Matas describes the ways in which surgeons of the 19th century would address this issue. One method indicated repeated injections of small quantities of air into the pleura, causing a partial and incomplete pneumothorax, decreasing the suddenness of the pneumothorax, and therefore, improving the body's homeostatic capabilities. Another method used to provide relief from a collapsed lung involved suturing the lung to the chest opening. Finally, creating patches of adhesions by the use of irritants and caustics on the pleura and chest wall was another approach to preventing pneumothorax upon making a pleural incision. (8) Not satisfied with the low effectiveness of these approaches, Dr. Matas was an advocate for the use of positive-pressure ventilation to prevent pneumothorax from even occurring. "The procedure that promises the most benefit in preventing pulmonary collapse in operations on the chest is the artificial inflation of the lung and the rhythmical maintenance of artificial respiration by a tube in the glottis directly connected with a bellows ... and can be used as an aspirator of gases in the pleura or for the purpose of administering anesthetics or oxygen by intubation." (8)

It is interesting to note that artificial respiration was not a new concept, by any means, during Matas' time. Indeed, Vesalius in 1543 showed that it was possible to keep an animal alive on artificial respiration by blowing air into a tube inserted in its trachea. (4) Through his animal studies, Vesalius also showed that artificial respiration could be provided via a tracheotomy cannula. In the 17th century, English scientist Robert Hooke also experimented with lung ventilation in animals through the use of a tracheotomy cannula. Significant work on artificial ventilation was sporadic at best during the 18th century, its primary emphasis being resuscitation. In 1754, Benjamin Pugh described an "air pipe" made of a wire spring covered with thin, soft leather, introduced into an infant's mouth digitally as far as the larynx in an attempt to resuscitate an infant. The following year, John Hunter used a double bellows system to maintain ventilation on a dog's lungs. The first significant document regarding artificial ventilation was an essay entitled, "Recovery of the Apparently Dead," written by Charles Kite in 1787. In this paper, he describes instruments to pass beyond the glottis, with an attached elastic tube, in an effort to keep patients with respiratory depression alive. Kite also explained that tracheotomy with consequent tube insertion for lung inflation by bellows should only be used as a last resort, but success should not be expected. (9) Significant work on the use of tracheal tubes as a delivery system for anesthesia did not begin until the mid 19th century, when John Snow experimented with chloroform delivered via tracheotomy on a rabbit. Friedrich Trendelenburg repeated the experiment on a man in 1871. Finally, in 1880, Sir William Macewen performed the first accepted account of endotracheal intubation for surgical anesthesia. Faced with a patient who required excision of a tumor at the base of the tongue, Macewen realized he could not rely on the standard facial rag soaked with chloroform as a way to provide anesthesia. Looking for a more adequate anesthetic delivery system, Macewen introduced a metal tube into the trachea through the patient's glottis, and chloroform was successfully administered, allowing a stable surgical field. By 1893, another significant contribution to endotracheal anesthesia was developed, the Fell-O'Dwyer apparatus. Presented at the International Medical Congress, this apparatus consisted of a tracheal tube with a graduated laryngeal tip, an inlet for fresh air from a bellows, and an exit hole for exiting air. However, the major use of the FellO'Dwyer apparatus was for resuscitation, particularly to overcome respiratory failure secondary to opioid narcosis.

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The Fell-O'Dwyer apparatus was certainly used at Charity Hospital for opioid resuscitation during Rudolph Matas' tenure. However, it was not given serious consideration for surgical purposes until Dr. Matas pointed out the potential of the device for preventing pneumothorax secondary to thoracic incision. Inspired by Tuffier and Hallion's animal experiments, in which pleural incisions made on artificially-respirated dogs did not result in any lung collapse, Matas realized the important utility the Fell-O'Dwyer apparatus could have in human thoracic surgery. Dr. Matas stressed that, regarding adequate respiratory function during intrathoracic operations, "the ideal indication can only be successfully met by a method of direct rhythmical insufflation of the lungs through the larynx or trachea which will neutralize the collapsing effect of atmospheric pressure by increasing the intrapulmonary tension." (10) In 1898, he suggested this technique to the Louisiana State Medical Society. Shortly thereafter, a surgical colleague, FW Parham, followed his advice and successfully resected a sarcoma from a patient's thoracic wall, without the patient suffering a pneumothorax.

Dr. Matas' support for the Fell-O'Dwyer apparatus was not limited to its use as a delivery system for positive-pressure ventilation. He was one of the first to suggest its utility as a method to administer both anesthetics and oxygen. In fact, by the end of the 19th century he had modified the FellO'Dwyer model by adding a new branch with regulating stopcock to the cannula (Figure 3). Attached to this new branch was a rubber tube that led to a funnel covered with flannel which could be impregnated with chloroform or ether. This configuration of a laryngeal cannula which could deliver both anesthetic agent and oxygen to the patient's lungs was momentous in the evolution of modern anesthesia. Dr. Matas had devised a way to provide optimal surgical field during thoracotomies, by providing adequate anesthesia to the patient and preventing the feared complication of acute pneumothorax.

CONCLUSION

Dr. Rudolph Matas was a significant influence on the development of anesthesiology in the United States. Spinal anesthesia, endotracheal delivery of anesthetic agent, and positive-pressure ventilation are methodologies that are used everyday in anesthetic practice. Tulane's Dr. Matas left a large imprint on the landscape of 19th and 20th century US medicine. His thirst for knowledge led him to be a pioneer in surgical research. His compassion drove him to improve his patients' outcomes, both in and out of the operating room. His quest to understand the intricacies of the human body led him to be an important frontiersman in anesthesiology as well as surgery.

REFERENCES

(1.) Cohn I. A tribute to Rudolph Matas. Ann Surg 1961;5:680-683.

(2.) Ocshner J. The complex life of Rudolph Matas. J Vasc Surg 2001; 34:387-392.

(3.) Gregory R. Rudolph Matas--how I remember him: an interview with Dr. Michael E DeBakey. J Vasc Surg 2001;34:384-386.

(4.) Keys T. The History of Surgical Anesthesia. New York, NY: Dover Publications;1963.

(5.) Cole F. Milestones in Anesthesia. Lincoln, NB: University of Nebraska Press; 1965.

(6.) Hutson LR, Vachon CA. Dr. Rudolph Matas: innovator and pioneer in anesthesiology. Anesthesiology 2005;103: 885-889.

(7.) Matas R. Local and regional anesthesia: a retrospect and prospect. Am J Surg 1934;189-196 and 362-379.

(8.) Matas R. On the management of acute traumatic pneumothorax. Ann Surg 1899;4:409-434.

(9.) Davidson MHA. The Evolution of Anaesthesia. Altrincham, UK:John Sherratt & Son;1965.

(10.) Matas R. Artificial respiration by direct intralaryngeal intubation with a modified O'Dwyer tube and a new graduated air-pump in its applications to medical and surgical practice. Am Med 1902;3: 97-103.

Alberto Enrique Ardon, MD, MPH

Dr. Ardon was an intern at Tulane University Health Sciences Center in the Department of Internal Medicine at the time this article was accepted. He is currently a resident in the Department of Anesthesiology at the University of Virginia Health System.
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Author:Ardon, Alberto Enrique
Publication:The Journal of the Louisiana State Medical Society
Geographic Code:1USA
Date:Jan 1, 2010
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