Alexis Carrel—the French dervish of surgery

In 1935, Alexis Carrel was at the height of his academic career. The first scientist in America to win the Nobel Prize in Medicine, he was internationally respected for his work in vascular and transplant surgery. Carrel was considered a war hero of World War I, having received the Legion of Honor from the French Army, the Medal of Officer of the Order of Leopold, and the Distinguished Service Certificate from the U.S. Army for his work in wound care and trauma. Carrel chose this time to come forth with Man, the Unknown, a widely popular book that described his views on philosophy, the nature of man, and the ills of society. Critical reviews for the book were mixed, and Man, the Unknown served to undermine Carrel’s credibility as a scholar. The endeavor characterizes a chronic struggle in Alexis Carrel’s life and career. He was a brilliant and versatile thinker with a remarkable number of accomplishments in several fields, which was frequently overshadowed by his unorthodox views and outspoken, often renegade opinions. Alexis Carrel is one of the most fascinating and controversial figures in the history of vascular surgery. Marie Joseph Auguste Carrel Billiard was born in a small town outside Lyon, France, in June of 1873. From a prosperous merchant family, Carrel’s circumstances changed when his father died suddenly from pneumonia. At the age of 5, Carrel acquired his father’s name, Alexis Carrel, and the responsibilities of “man of the house.” Alexis was serious and introspective, a slight child with one blue eye and one brown eye observing the world from behind wire-rimmed glasses. His first research projects took place at an early age. Alexis was a ready audience for the experiments, his uncle conducted in a garden shed. Admiration of his young uncle’s military career later tempted Alexis to enter the Colonial French Army, but nearsighted vision and academic passions rerouted his career. Carrel combined a love of physics and natural sciences by entering the Faculty of Medicine in 1890 and became an extern in surgery in 1893. Carrel combined impressive manual dexterity with imagination and vision; yet his forthright manner and criticism of the limitations of current surgical practices earned him an unsavory reputation as a troublemaker. Carrel was a gifted dissector and worked as an anatomy instructor, leading student Rene Leriche to remark that “he had certainly, along with Jaboulay, the best surgical hand that I ever witnessed in a career which allowed me to watch most of the greatest surgeons in the world.” His first great controversy centered around the assassination of Sade Carnot in 1894. The popular French president was stabbed in the abdomen, suffering a laceration of the portal vein. Surgical techniques of the day involved only ligation and not repair of blood vessels; thus, only duplicated vessels distal to the knee or elbow could be injured without loss of life or limb. Carrel balked against the idea that repair of the portal vein would be futile; he was convinced that blood vessels could be repaired similar to other tissues. Alexis Carrel’s arguments that the portal vein should have been repaired did not make him popular with his superiors; however, it inspired him to begin his historic research in vascular anastomosis. Carrel initially sought out the work of the founders of anastomotic research. Jaboulay, a former teacher, had devised a method of end-to-end anastomosis with interrupted mattress sutures. Payr used absorbable magnesium tubes as a stent around which to tether the proximal and distal ends of the blood vessel. Murphy used invagination and suture to produce his anastomosis. Great care was taken to expose only intima to the blood flow and to reduce the handling and damage to the vessels; however, these early designs were plagued by thrombosis and infection. While still an intern at various hospitals throughout Lyon, Carrel went to the laboratories of Auguste Lumiere and later Marcel Soulier to develop his own techniques. With the help of his mother’s embroidery circle, Alexis adapted fine “lace” needles and silk embroidery thread for use in delicate surgery. He adopted a strict aseptic technique and lubricated his suture material for easier handling. Anastomotic ends were everted before approximation, and only the serosal and muscular layers were included in the suture line in order to reduce exposure of suture material to the bloodstream. In the laboratory at Lyon, Carrel developed the triangulation technique, an innovation that would provide the basis for his future Nobel Prize. Anastomotic edges at that time required a great deal of handling for the complex suture lines. Bruised endothelium provides nidus for thrombosis. The triangulation technique uses 3 stay sutures, held 120° apart at equal tension, to allow the surgeon to run a continuous suture without hanCorrespondence: Inquiries to Mark A. Hardy, MD, Department of Surgery, Milstein Bldg. 7GS, Rm. 313, 177 Fort Washington Ave., New York, NY 10032.