Valentine Mott and the Innominate Artery

BY MARK S. LESNEY

Well before the American Civil War, without benefit of anesthetics and without antiseptics, Dr. Valentine Mott performed some of the first successful operations on the large human arteries. He became best known for the first successful ligation of the innominate.

A native of Long Island who received his medical degree from Columbia College, New York, in 1806, he became one of the most highly regarded American surgeons in his own lifetime (1785-1865).

Throughout his long career, Dr. Mott occupied prestigious medical appointments at Columbia College (now University), the now defunct Rutgers Medical College in New York City (which he helped to found), and the University Medical College of New York (now New York University Medical College) where he was chief of operative surgery, and from which he finally retired. His contributions to vascular medicine were so significant that he has been given the title "father of American vascular surgery" by physician and medical historian, Dr. Ira Rutkow.

Dr. Mott summed up some of his own major vascular accomplishments in a letter written toward the end of his career:

"I have enclosed a list of my original operations. They were performed without having heard or read of their being done by anyone before. ... Tying the arteria innominata. Tying the primitive iliac. ... Cutting out two inches of the deep jugular vein inseparably embedded in a tumor and tying both ends of the vein. Closing with a fine ligature, wounds of large veins of a longitudinal or transverse kind, and even when an olive-sliced piece has been cut out.

"These I have seen, and by pinching up the wound with forceps and applying a small ligature, the wound has healed without obliterating the canal of the vein. In this way I treated successfully the great axillary and the deep jugular."

Although Dr. Mott became world renowned for being the first to ligate the innominate artery for aneurysm with the survival of the patient (in 1818, using a tincture of opium as the only anesthesia), that patient survived only 25 days, dying from a secondary hemorrhage. But this was enough to ensure Dr. Mott's reputation and to stir interest in attempting to repeat his success. But despite the efforts of more than a dozen surgeons in the intervening years, no second operation was successful, even in Mott's hands, until 1864.

Then, a single patient operated on by Dr. Andrew Woods Smyth at the Charity Hospital in New York had the good fortune to survive 11 years, in part due to luck, in part due to surgical improvements, but mainly due to the advent of anesthesia. With such poor results, the operation was considered deadly, with failure most often the result of ligatures cutting through the artery due to infection.

It was not until 1889, after the advent of antisepsis and decades after Mott's death, that a second patient showed long-term survival following ligature of the innominate. Thereafter, there were only four successful innominate ligations reported until after the turn of the century, when the operation became common.

In his own era, Dr. Mott was a political force in medicine and a visionary. He was commissioned to write a report to the U.S. Sanitary Commission during the Civil War, in which he extolled the role of modern anesthetics in pain management and in the improvement of surgical outcomes.

And although his writing often foreshadowed the goals and beliefs of modern pain management advocates, his perspective always remained that of the surgeon:

For after patient benefits and the humanity of pain management, "There is another reason for employing anesthetics which must not be forgotten. The insensibility of the patient is a great convenience to the surgeon," he wrote.

"How often, when operating in some deep, dark wound, along the course of some great vein, with thin walls, alternatively distended and flaccid with the vital current--how often have I dreaded that some unfortunate struggle of the patient would deviate the knife a little from its proper course, and that I, who fain would be the deliverer, should involuntarily become the executioner, seeing my patient perish in my hands by the most appalling form of death! Had he been insensible, I should have felt no alarm."

During his long and innovative career Valentine Mott performed at least 57 femoral artery ligations; 51 external carotid ligations; 10 popliteal ligations; 8 subclavian, 6 external iliac, 2 internal iliac and comon carotid artery ligations; and 1 each of the common iliac and innominate arteries. Even more remarkably, these operations were performed before the era of anesthetics and the antiseptics era, and without the benefit of blood transfusions.

Dr. Mott died April, 26, 1865, less than 2 weeks after Abraham Lincoln was assasinated.