The contributions of Alexis Carrel to the management of contaminated wounds.

Wound care through the ages has ranged from good to bad, and at times has been disgusting, with little scientific approach. von Eiselsberg's dictum of no touch for military wounds proved disastrous to patients with gunshot and shrapnel wounds in the First World War. Alexis Carrel, a brilliant experimental surgeon, spearheaded the research that led to the development and application of débridement and irrigation for combat wounds. Early in his career, Carrel reported on a miraculous cure that he had observed in Lourdes, France. However, this report resulted in a strained professional environment in his homeland of France, which persisted in spite of his subsequent moves to Canada and then to the United States. There he was awarded the Nobel Prize for Physiology and Medicine.

Nitric oxide synthesis inhibition does not improve the hemodynamic response to hemorrhagic shock in dehydrated conscious swine.

Nitric oxide (NO) may influence the hemodynamic response to hemorrhage. To test this hypothesis, the NO synthesis inhibitor N omega-nitro-L-arginine methyl ester (L-NAME) was administered to conscious, dehydrated swine during a 37% blood volume hemorrhage and a 180 min recovery period without fluid resuscitation. L-NAME (.75 mg/kg bolus plus constant infusion of .75 mg/kg/h) was given via a central intravenous catheter during the bleed. The selectivity and specificity of L-NAME as a NO synthesis inhibitor in pigs was validated in pilot studies. The present study shows that inhibition of NO synthesis with L-NAME had no significant effect on the major hemodynamic parameters during and after hemorrhage when compared to dehydrated and euhydrated control groups. Only stroke volume and A-VO2 were significantly different from controls. Mortality was 83% for the L-NAME group and 44% for controls at 180 min of recovery (NS). The results suggest that NO synthesis inhibition provides no hemodynamic benefit during hemorrhage in dehydrated, conscious swine.

Unplanned splenectomy--harbinger of complications.

Splenectomy alone or in combination with other major operative procedures has been implicated as the cause of excessive morbidity and mortality. We retrospectively studied 151 consecutive patients with splenectomy performed between 1985 and 1992. Subsets of patients according to indication for splenectomy were compared with a cohort of patients having elective open cholecystectomy. Morbidity with elective splenectomy (11.5%) was not significantly increased over that with elective open cholecystectomy (6.8%). Morbidity with nonelective splenectomy (40.4%) was increased when compared with that of elective splenectomy (11.5%) or with elective open cholecystectomy (6.8%). Mortality was significantly worse for nonelective (10.6%) than for elective splenectomy (1%). Nonelective splenectomy should be recognized as one event in a cascade of events leading to excessive morbidity and mortality. Splenectomy should not be implicated as the sole or primary cause of such excesses.

Gallstone jejunal perforation: surgical implications.

Spontaneous biliary-enteric fistulization is a rare complication of cholelithiasis. Much rarer yet is spontaneous jejunal perforation from an impacted gallstone. A case is presented from a suburban community general hospital. An aggressive surgical approach is endorsed and the impact of current economic constraints on surgical philosophy is reviewed.