Journal of Vascular Surgery
Volume 22, Issue 2 , Pages 188-194, August 1995

Norman Freeman: The "first" American specialist in vascular surgery☆☆☆★

  • John E. Connolly, MD
    • ,
  • From the Department of Surgery, University of California, Irvine.

Irvine, Calif.

Received 14 December 1994; accepted 9 March 1995.

Article Outline

 

Norman Freeman was a controversial genius whose contributions to vascular surgery and, in turn, its development as a specialty are unfortunately not widely known or appreciated (Fig. 1).

Health reasons aborted his unusual career, requiring him to retire at age 59, and clouded the subsequent 13 years before his death at age 72.1

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FAMILY BACKGROUND AND EDUCATION 

Norman Freeman was born in Philadelphia in 1903, the son of a prominent otolaryngologist, the brother of a noted neurologist, Walter Freeman, who was the innovator of lobotomy in the United States, and the grandson of the renown William W. Keen, professor of surgery at Jefferson Medical College from 1889 to 1921. Freeman's father died when he was 17, and his grandfather thereafter exerted a major influence. Keen was editor of the famous eight-volume Keen's Surgery, and, although he was a pioneer of many general surgical procedures, he is often referred to as the "Father of Neurosurgery." His admonition to a graduating class of Rush Medical School students obviously articulated the inspiration he gave to his grandson Norman,

"Make it a point not to let your intellectual life atrophy through nonuse. Be familiar with the classics of English literature in prose and verse; read the lives of the great men of the past and keep pace with modern thought in books of travel, history, fiction, and science. Let music and art shed their radiance upon your too often weary life and find in the sweet cadences of sound or the rich emotions of form and color, a refinement which adds polish to the scientific man." 2

Freeman had an excellent education, attending secondary school at St. Paul's and college and medical school at Yale, where he received honors. He served a 2-year internship at the University of Pennsylvania under Isidor Ravdin, who recognized the brilliance of his student and arranged for him to spend 2 years as a National Research Council Fellow doing research under the famous Harvard professor of physiology, Walter B. Cannon. It was during those years that he became interested in the physiology of the vascular and sympathetic nervous systems and coauthored a number of studies with Dr. Cannon. He subsequently served a 3-year surgical residency under Edward D. Churchill at the Massachusetts General Hospital, followed by a fourth year as the Dalton Fellow in Surgery.

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PROFESSIONAL CAREER 

In 1936 Ravdin brought Freeman back to his department at the University of Pennsylvania as the J. William White Assistant Professor of Surgical Research. In 1938 he was made the Chief of Vascular Surgery at the Pennsylvania Hospital and thereafter confined himself entirely to vascular surgery. It appears that he was the first surgeon in the United States to do so.

During those prewar days, Freeman was extraordinarily productive in his research, both in the laboratory and in the hospital. His studies, which were started in Boston and continued in Philadelphia, were on the physiology of peripheral blood flow, shock, gangrene, and the effects of the interaction of temperature, epinephrine, the sympathetic nervous system, and blood loss on them. Clinically his efforts were directed at the mysteries of Buerger's disease. Noteworthy among his many published studies during those early years were "Decrease in Blood Volume after Prolonged Hyperactivity of the Sympathetic Nervous System" (Am J Physiol 1933;103:185-202), which was published while he was a National Research Fellow at Harvard and "The Peripheral Blood Flow in Surgical Shock" (J Clin Invest 1936;15:651-64), a work performed while he was a resident at the Massachusetts General Hospital. This later work demonstrated that surgical shock is the clinical manifestation of a process that has its origin in the physiologic reactions of the body to various traumatic stimuli. These reactions preserve the organism through diversion of the blood supply to the vital centers robbing blood from the outlying tissues. "The Effect of Temperature on the Volume Flow of Blood Through the Sympathectomized Paw of the Dog with Observations on the Oxygen Content and Capacity, Carbon-Dioxide Content and pH of the Arterial and Venous Blood" (Am J Physiol 1937;120:475-485) contained work performed while Freeman was a Dalton Fellow in Surgery at the Massachusetts General Hospital. The observations in this study are consistent with the hypothesis that the circulation through regions deprived of vasomotor control is determined by the metabolism needs of the tissues. "Hypertension Produced by Constriction of the Renal Artery in Sympathectomized Dogs" (Am Heart J 1937;14:405-14) contained work performed while Freeman was Chief of the Vascular Clinic at the University of Pennsylvania in conjunction with the famous cardiologist, Irving Page of New York City.

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MILITARY SERVICE IN WORLD WAR II 

Freeman continued to pursue clinical research during his 4 years of military service in the Army Medical Corps from 1942 to 1946. He spent the first 3 years with the Twentieth General Hospital in Assam, India, serving the Chinese forces who were building and defending the Burma Road; he also taught himself the Chinese language. His publications continued to be numerous during this period, largely dealing with clinical vascular problems experienced during care of his patients.3, 4, 5, 6 Noteworthy was "The Treatment of Causalgia Arising from Gunshot Wounds of the Peripheral Nerves" (Surgery 1947;22:68-82). This was a report of the efficacy of sympathectomy on causalgia in 114 Chinese casualties. His tentmate at the time, the distinguished Philadelphia thoracic surgeon, Julian Johnson, stated that the worst time for Freeman was when there were no patients to care for.7

His vascular surgical expertise was recognized by his assignment in 1945 as Chief of Surgery at DeWitt General Hospital in Auburn, Calif., one of three designated army vascular centers. There he pioneered many direct reconstructive vascular surgical techniques. As an example, at that time, arteriovenous fistulas were commonly treated by quadruple ligation. Matas had described a technique of endoaneurysmorrhaphy in which an arteriovenous fistula was closed through a transvenous route. Freeman's contribution was to divide the arteriovenous communication and directly reconstruct the vessels with restoration of normal blood flow. In 1946,8 he reported 18 such successful cases before the American Surgical Association. In the discussion of this study, Matas praised Freeman for his brilliant contribution of repair and conservatism in arteriovenous surgery.

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POST WAR – SAN FRANCISCO AND THE UNIVERSITY OF CALIFORNIA 

After the war, Freeman was enticed by Dr. Howard C. Naffziger to join the Department of Surgery at the University of California in San Francisco rather than return to Philadelphia. The surgeon, whom the staff of the University of California in San Francisco met in 1946, was a true physiologist, an innovative clinician, teacher, and investigator. At the same time, however, he was controversial because his temperamental qualities frequently brought him into conflict with authority. He was appointed Associate Clinical Professor and Chief of the Vascular Clinic and given space in the animal laboratory designated exclusively for vascular research. When Freeman first arrived, Jack Wylie was a third-year resident and Frank Leeds was a surgical research fellow. In 1948, Rutherford Gilfillan, a young academic surgeon from the University of Buffalo, came west to pursue vascular research under Freeman. Each of these three surgeons was inspired by Freeman, and in 1948 Wylie and Gilfillan joined him in the group practice of pure vascular surgery. This relationship was dissolved in 1951, at which time Leeds joined Freeman in practice.

Freeman felt the need at that time also for a vascular physiology laboratory where accurate clinical quantitative evaluation of patients by various techniques, including digital plethysmography, skin temperature, and reactive hyperemia tests, could be carried out before and after operation and also as part of the general evaluation of patients with vascular disease. In 1947 it was established at the affiliated Franklin Hospital (now the Ralph K. Davies Medical Center) because of space limitations at the University (Fig. 2).

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  • Fig. 2. 

    Physiological Vascular Laboratory of Franklin Hospital, San Francisco, Calif., in 1948. Technician seen in photograph is Kathleen Coffin Hunt, who became Mrs. Rutherford Gilfillan.

This was truly a forerunner of our now indispensable, noninvasive diagnostic units. As his pupil and associate Frank Leeds later wrote, "Freeman had an overwhelming desire to do investigative work and teach. He enjoyed his responsibility for patient care but only as an integral part of his responsibility for teaching and investigation."1 Dr. Ellen Brown, professor of medicine at the University of California, first met Freeman in June of 1946, after she had returned from a period of study with Eugene Landis in Boston. She is now Emeritua but remembers, "How excited I was to find a surgeon who was applying physiological concepts to the evaluation and treatment of patients, but what I remember most was his love of teaching. On vascular rounds, after learning the history and confirming it or eliciting new findings, he would give a beautiful, spontaneous lecture on the pathophysiology of the disease or findings. He was a great teacher who put a lot of young surgeons on the right track. Gilfillan, Wylie and Leeds would not have done what they did if Freeman had not started them." (Verbal communication, November, 1994). Gilfillan went on to concentrate more in the laboratory, whereas Leeds and Wylie became outstanding clinicians. In 1950 Gilfillan was placing Dacron interposition aortic grafts in dogs in the laboratory at the University of California Hospital, only to have the Chief of the Experimental Laboratory subsequently order these survival animals destroyed because, as he stated, "foreign prostheses will never be tolerated by human tissue!" This led this innovative young researcher to relocate his work from the University to the Children's Hospital. In 1951 Wylie,9 Freeman's pupil, performed the first aortoiliac endarterectomy in the United States, to be followed by Freeman less than a month later.10

Although Freeman was recruited by Naffziger to start a vascular service and research laboratory, both of these distinguished surgeons possessed strong personalities and soon clashed over Freeman's dictum that all sympathectomies would be performed on the vascular service, which was not well received because the chairman was a neurosurgeon whose service also was doing the procedure. Although Freeman was allowed to initiate the vascular service and clinic, he never received a full-time appointment at the University of California, and after several years he relocated his activities to the associated Franklin Hospital, and Jack Wylie became the Director of the Vascular Service at the University and ultimately guided it to international recognition. During these early postwar years, Freeman had introduced arteriography, both by retrograde injection or direct translumbar needle,11, 12 and phlebography and lymphangiography in the University. He also worked closely with engineers to develop the rapid cassette changers and pressure injectors used.13 It is of interest that he discovered that the brake pump used in Packard automobiles was superior to others and thus used it in his homemade pressure injector. Freeman had originally started performing arteriography and phlebography before the war in Philadelphia and later at the DeWitt Army Hospital, which reputably was the only Army Vascular Center carrying out routine arteriography at that time. In San Francisco he was also clinically active, and he performed some of the first operations for coarctation, patent ductus ligation, Blalock shunts, and direct repair of arteriovenous fistulas on the West Coast.

On February 26, 1951, Freeman performed the first successful replacement of an abdominal aortic aneurysm with autogenous tissue, with use of iliac vein.14 He had previously performed a similar procedure with death from an apparent blowout of the interposed iliac vein. To bolster the interposition vein graft in this second case, the anterior wall of the aneurysm was preserved and closed over the graft, and blood was introduced between the two (Fig. 3).

Records from The Franklin Hospital vascular laboratory show that this patient was doing well with normal plethysmography results in May 1952. A month after Freeman's success, on March 29, 1951, in Paris, France, Dubost resected an abdominal aortic aneurysm with homograft replacement,15 a procedure that has generally been regarded, but we now know incorrectly, to be the first direct operation for abdominal aortic aneurysm. In 1952 Freeman16 performed the first direct surgical revascularization procedure to effect cure of renal hypertension. In this patient an aortoiliac endarterectomy was carried out, including removal of atheroma at the orifice of the renal artery through the open aortotomy. This case was not reported in detail until more than 2 years later because he wanted to be able to document long-term reversal of the hypertension. At about the same time, he reported the first extraanatomic bypass, a femorofemoral conduit with an eversion endarterectomized superficial femoral artery that was translocated to provide flow beyond an occluded iliac artery (Fig. 4).17
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  • Fig. 4. 

    Use of left eversion endarterectomized superficial femoral artery as femorofemoral bypass. Reprinted by permission of the Western Journal of Medicine (formerly California Medicine). Freeman NE, Leeds FH. Operations on large arteries. 1952(Oct.);77:229-33.

In 1953 (Fig. 5) he reported the ligature of an aortic aneurysm in situ with distal flow reconstitution by the translocated splenic artery anastomosed to an iliac artery.17
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  • Fig. 5. 

    Bypass of ligated abdominal aortic aneurysm with translocated splenic artery. Reprinted by permission of the Western Journal of Medicine (formerly California Medicine). Freeman NE, Leeds FH. Operations on large arteries. 1952(Oct.);77:229-33.

The aneurysm subsequently ruptured, but he then used the same splenic artery bypass technique in a patient whose aneurysm was concomitantly resected. When examined 4 months later, the patient was able to walk 1 mile on the level.17, 18 Freeman, also in the 1950s, stimulated Frank Leeds, his associate, to pioneer endarterectomy of the profunda femoris for revascularization of the ischemic limb.19 Another disciple of Freeman was Samuel Etheredge, of Oakland, Calif., who was inspired by his preceptor's innovative spirit and encouragement to perform the first successful resection of a suprarenal aortic aneurysm20 on September 20, 1954, at the Oakland Veterans Administration Hospital, where Freeman was Chief Vascular Consultant (Fig. 6).
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  • Fig. 6. 

    Technique of first successful resection of suprarenal aortic aneurysmectomy. From Etheredge SN, et al. Successful resection of a large aneurysm of the upper abdominal aorta. Surgery 1955;38:1071-81.

These were golden years of innovative vascular surgery spawned by a very creative surgical mind. It was during this time in San Francisco that I was a surgical resident and junior faculty member at Stanford and had the opportunity to know Freeman and his pupils, both professionally and socially.

It is of particular interest that Freeman wrote an editorial in California Medicine in 194821 in which he addressed the question, "Is there room or actual need for vascular surgery as a specialty?" His answer was, "Yes, as long as the specialist takes advantage of his opportunities to contribute to the knowledge of the disorder he specifically treats." Thus, he was the first to discuss vascular surgery as a specialty as we now know it. It is of interest that correspondence between Freeman and both his teacher Churchill and his friend Blalock indicated that they were very much opposed to the development of vascular surgery as a specific specialty, much like the opposition that his pupil Wylie subsequently met in 1982, when he led the successful battle for a certificate of special qualifications in vascular surgery.

Freeman's nonmedical interests were not well known to his surgical colleagues; however, they were very important to him. In secondary school, he belonged to the Forestry Club and the Missionary Society along with membership in the Literary and Scientific Associations, and early on, he developed a love of English literature. When he had a particularly worrisome operation or personal problem, he would characteristically seek the solitude of the outdoors. His frequent walks among the trees, trails, and ocean of his home near Mt. Tamalpais across the Bay from San Francisco were not primarily for exercise, but rather to be alone among nature.

Unfortunately, Freeman's mental health forced him to retire from active surgical practice at the relatively early age of 59, and he subsequently died of heart disease at age 72. It is ironic that I unexpectedly encountered Freeman working as a file clerk in the Radiology Department of the Palo Alto Veterans Hospital some 5 years after his retirement. He had been admitted for severe depression, and the job was part of his subsequent rehabilitation. Once his presence was discovered, we used him as an unofficial vascular consultant for the Stanford residents until he was discharged as a patient! Few, if any, of these young surgeons realized that they were being guided by one of the most innovative surgeons of his time.

It is interesting that, at the time of his death, he was pursuing a favorite hobby, camping, near Ensenada, Mexico. At his memorial service, his son David said, in part, "I saw dad – then as now – as a man strongly shaped and motivated by great causes and events. Not only in the distress of his later years, but throughout his life, Dad was committed and dedicated to enormous undertakings, vast efforts which could not possibly be completed in a single lifetime. In the 12th century, he would have been an outstanding crusader; in the 19th century, he would have been a captain of industry or an overseas Apostle of the Faith. However, he lived most of his life in the middle of the 20th century where he found himself 'out of joint' with the times in many respects. But so also are many prophets and poets, great inventors, business men — and surgeons."

To those of us who knew him well, Norman Freeman was a many sided person — at his best, he was magnificent.

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Acknowledgements 

I thank the following for supplying helpful information for this paper: Frank H. Leeds, MD, Samuel N. Etheredge, MD, Kathleen Gilfillan, Ellen Brown, MD, Bradford Cannon, MD, and Robert Combs, MD.

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References 

  1. Leeds FH, Norman E. Freeman (1908 1975), a pioneer of vascular surgery. J Cardiovasc Surg. 1989;30:803–807
  2. Schwartz SI. Do ye ken Will Keen. Contemp Surg. 1993;42:8
  3. Freeman NE. Secondary hemorrhage arising from gunshot wounds of the peripheral blood vessels. Ann Surg. 1945;122:631
  4. Freeman NE. Arterial repair in the treatment of aneurysms and arteriovenous fistulas with a report of 18 successful restorations. Ann Surg. 1946;124:888–919
  5. Freeman NE. Direct measurement of blood pressure within arterial aneurysms and arteriovenous fistulas. Surgery. 1947;21:646–658
  6. Freeman NE, Storck AH. Successful suture of the abdominal aorta for arteriovenous fistula. Surgery. 1947;21:623–629
  7. Johnson J. Obituary of Norman E. Freeman. In: Trans Am Surg Assoc. 94:Philadelphia: JB Lippincott; 1976;p. 55–57
  8. Freeman NE. Arterial repair in the treatment of aneurysms and arteriovenous fistulae, a report of eighteen successful restorations. Ann Surg. 1946;124:888–919
  9. Wylie EJ. Thromboendarterectomy for arteriosclerotic thrombosis of major arteries. Surgery. 1952;32:275–292
  10. Coelho HM, Leeds FH, Freeman NE. Arteriosclerotic occlusion of the terminal aorta and common iliac arteries treated by thromboendarterectomy. Surgery. 1955;37:105–114
  11. Freeman NE, Miller ER. Retrograde arteriography in the diagnosis of cardiovascular lesions: — visualization of aneurysms and peripheral arteries. Ann Intern Med. 1949;3:330–342
  12. Freeman NE, Fullenlove TM, Wylie EJ, Gilfillan RS. The Valsalva maneuver: an aid for the contrast visualization for the aorta and great vessels. Ann Surg. 1949;130:398–416
  13. Freeman NE, Gilfillan RS, Fullenlove TM, Leeds FH. Surgery of Large Arteries. In: Carter  editors. Monografts of surgery. Philadelphia: Williams and Wilkins; 1952;p. 385–415
  14. Freeman NE, Leeds FH. Vein inlay graft in the treatment of aneurysms and thrombosis of the abdominal aorta. Angiology. 1951;2:579–587
  15. Dubost C, Allary M, Oeconomos N. Apropos du traitement des aneurysmes de l'aorte. Mem Acad Chir. 1951;77:381–383
  16. Freeman NE, Leeds FH, Elliott WC, Roland SI. Thromboendarterectomy for hypertension due to renal artery occlusion. JAMA. 1954;156:1077–1079
  17. Freeman NE, Leeds FH. Operations on large arteries. Calif Med. 1952;77:229–233
  18. Freeman NE, Leeds FH. Resection of aneurysms of the abdominal aorta with anastomosis of the splenic to the left iliac artery. Surgery. 1953;34:1021–1031
  19. Leeds FH, Gilfillan RS. Revascularization of the ischemic limb. Arch Surg. 1961;82:25–31
  20. Etheredge SN, Yee J, Smith JV, Schonberger S, Goldman MJ. Successful resection of a large aneurysm of the upper abdominal aorta. Surgery. 1955;38:1071–1081
  21. Freeman NE. Vascular surgery: editorial. Calif Med. 1948;68:43–44

☆ Reprint requests: John E. Connolly, MD, University of California Medical Center, 101 The City Dr., Bldg. 53, Route 81, Orange, CA 92668.

☆☆ J VASC SURG 1995;22:188-94.

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Journal of Vascular Surgery
Volume 22, Issue 2 , Pages 188-194, August 1995

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