Resuscitation Dominique-Jean Larrey

Resuscitation 81 (2010) 268–271

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Resuscitation great Dominique-Jean Larrey: The effects of therapeutic hypothermia and the ﬁrst ambulance

Salomon Jasqui Remba a, Joseph Varon b,c,∗, Alma Rivera d, George L. Sternbach e a Universidad Anahuac School of Medicine, México City, Mexico b The University of Texas Health Science Center at Houston, USA c The University of Texas Medical Branch at Galveston, TX, USA d Universidad Autónoma de Chihuahua, Chihuahua, Mexico e Stanford University Medical Center, Stanford, CA, USA article info abstract

Article history: The fields of emergency medicine and resuscitation are indebted to the Baron Dominique-Jean Larrey Received 15 August 2009 (1766–1842) for significant advances in patient care. Larrey was a great surgeon who served in the Received in revised form 15 October 2009 French army during Napoleon’s rule. He developed one of the first ambulance services, utilized positive Accepted 5 November 2009 pressure ventilation, and introduced hypothermia as a form of therapy. He dedicated his professional life to improving the care of wounded soldiers on the battlefield. Larrey coined the term “Triage” to allocate Keywords: resources to those most in need of emergent care. Today, many of his techniques still prevail in modern Therapeutic hypothermia medicine. Amputations Mechanical ventilation © 2009 Elsevier Ireland Ltd. All rights reserved. Dominique-Jean Larrey Trauma History

1. Introduction him as an ample source of knowledge, which he would apply in the rest of his career as a surgeon. By 1792, he served the Army Dominique-Jean Larrey (Fig. 1) was born in Beaudéan Hautes- of the Rhine as Chirurgien aide-major, where the lack of care of Pyrénées, in the middle of a turbulent époque: the time was 1766 the wounded prompted him to consider the need of a more orga- and France was experiencing a social decline of its position as the nized system. He met Napoleon Bonaparte in 1794 and later served most powerful nation in Europe.1 Orphaned at 13 years old and under his command as Chief Surgeon of the Army of Italy. He would living in humble conditions, Larrey was tutored by a benevolent remain as Bonaparte’s Chief Surgeon for two decades, making such priest, Abbé de Grasset, who found him to be an eager and tal- a deep impression in le petit caporal that Bonaparte’s words have ented student. A few years later, influenced by his brother Claude been widely quoted referring to Larrey as “the most virtuous man I Franç ois Hilaire Larrey and his uncle Alexis Larrey, both surgeons, have ever known”.1,5–7 Dominique-Jean was attracted to medicine and went to Toulouse His groundbreaking vision and extraordinary perception of the where he started practicing his surgical skills. He was 15 when human body left the medical field a vast heritage. The concept of he became “dresser” and later on he would be appointed House triage and the “ambulance volantes” (flying ambulance) are only two Surgeon. When he turned 21, he walked to Paris where he took a of Larrey’s innovations that have already been broadly described in competitive examination after which he was appointed Auxiliary the article “Larrey and Percy-A tale of two Barons”.8,9 The aim of Surgeon in the Navy, assigned to the frigate Vigilante. He sailed for the present review is to delve into lesser known, but equally cap- the first time to Newfoundland in April 1788 and spent 6 months tivating, achievements that earned Larrey the title of “the father of on the ship; however, due to severe sea-sickness, he resigned. Back the emergency medical services” or “the father of modern military in Paris, he entered the hospital “Hôtel Dieu” in Paris under the medicine”.2,10 orders of a well-known surgeon named Dessault.2–4 The years he spent at Hôtel Dieu and later on at Hôtel Royal des Invalides served 2. Medicine and warfare

As an army surgeon, Larrey recognized that most injured sol- ∗ diers were dying without receiving any type of emergency medical Corresponding author at: 2219 Dorrington St, Houston, TX 77030-3209, USA. 4 Tel.: +1 713 669 1670; fax: +1 713 669 1671. care. As he spent more time in the trenches he realized that the E-mail address: [email protected] (J. Varon). common ambulances used for battle-torn soldiers “never arrived in

times: Xenophon, Hannibal, Galen, Aristotle, and Hippocrates all describe frostbite and cold-related sickness as one of the most powerful enemies of their legions.11–15 During these times little could be done to fight back against the hostile weather, and many soldiers perished inexorably in every battle. It was not until the 19th century when Larrey observed and described the effects of cold exposure that the panorama started to change. In his “Memoirs”, Larrey made impressive observations of his colleagues and recorded the inci- dents in a time linear manner. He described how the soldiers, who remained on duty in the snow bearing temperatures of 15◦ below zero, would not complain of any symptoms. However, when the temperature rose up to 18◦ or 20◦, soldiers started complaining of painful pricking sensations, numbness and stiffness. Arguably, one of the most interesting observations he made was that those soldiers who had the opportunity of warming themselves up by a fire were the most affected. This led Larrey to postulate that it was not the cold itself but rather the variability of temperature that actually predisposed the soldier to gangrene.16 Accordingly, Larrey advised his colleagues to repeatedly rub the affected parts with snow fol- lowed by the application of “spirituous and camphorated tonic’s” (i.e., brandy, wine, vinegar, etc.).16 “Heat suddenly applied to the parts which have been rendered torpid by cold may be considered as the exciting cause. Let this principle be once established, and it will be easy to prevent the effects of congelation”.16 After years of dealing with the negative effects of harsh weather, Fig. 1. Dominique-Jean Larrey. Larrey eventually realized that in certain situations cold temperatures could also have beneficial effects. He was intrigued by how wounded soldiers could tolerate the pain while the temperature less than twenty-four or thirty-six hours, so that most of the wounded remained cold, and he described in detail how injuries exposed 7 died for want of assistance”. In response, he introduced the con- to snow or ice would bleed less than those suffered in warmer cept of “ambulance volantes” (flying ambulance) which consisted weather. Larrey was far from imagining his discovery would be of horse drawn wagons that would collect and carry the wounded the basis of a technique that was to be perfected more than a to the base hospitals. The vehicles were light and equipped with century in the future: therapeutic hypothermia. His familiarity cushioned mattresses and pockets full of supplies. The system of the effects of cold in the human body can be witnessed in was well organized, and included a doctor, quartermaster non- his writings referring to the physiologic response to cold: “The 1 commissioned officer, a drummer boy and 24 infantry men. In a parts may remain for a longer or shorter period of asphyxia without display of humanity, Larrey introduced this system for the wounded losing their life; and if the cold be removed by degrees, or if the per- on both sides of the battlefield. It was one of Larrey’s most impor- son affected by it pass gradually into a more elevated temperature, tant and long-lasting contributions, surviving to modern times in the equilibrium may be easily reestablished with the function of the the form of the Red Cross. organs”.4 Moreover, battlefield conditions were extremely inhospitable; Extensive research on therapeutic hypothermia has confirmed constant explosions, arid weather, and violence were continual. Larrey’s theory that a cascade of events following the exposure Nonetheless, Larrey managed to excel in these conditions. They to cold are minimized as the process takes place gradually. Most forced Larrey to sharpen his medical organization skills, service in important, the rewarming period after hypothermia must occur at the field, and response time. As a result, he rapidly won the esteem a gradual pace of 0.5–1 ◦C per hour to avoid the further damage first 5 and admiration of his contemporaries. described by Larrey.17 In 1808, during France’s war with Spain, Lar- The prevailing political concept at the time viewed soldiers as rey used his knowledge of hypothermia to improve his technique of part of a machinery that were no longer useful when severely lower extremity amputations and the treatment of frostbite. Later, wounded. As Pierre Franç ois Percy remarked “one would believe during Napoleon’s ill-fated campaign in Moscow, he observed that that the sick and wounded cease to be men when they can no those with frozen legs felt almost no pain during an amputation, 5 longer be soldiers”. In contrast, Larrey’s profound humanity always and that low temperatures and ice could actually be used to prevent led him to act for the benefit of the wounded, and the rules shock. of war did not apply in his practice. He treated enemy sol- Larrey introduced a stepwise approach to the reheating of these diers as devotedly as he treated his comrades, and he never victims.4 In “Surgical memoirs of campaigns of Russia, Germany and discriminated the wounded according to rank or position in the France”, Larrey described skin blistering after freezing and ery- army. thema, and carefully noted the process of cooling tissue with ice and snow to facilitate amputations.18 3. Therapeutic hypothermia au début Today, therapeutic hypothermia is used by the most advanced health care providers worldwide in the treatment of vic- Cold related injuries have played a role in every war fought tims of cardiac arrest with return of spontaneous circulation, throughout history. Alexander the Great witnessed the deaths of acute myocardial infarction, cardiogenic shock, traumatic brain thousands during his campaign while crossing the wintry environ- injury, stroke, acute encephalitis, neonatal hypoxemia, post- ment of the Alps, and he himself suffered from hypothermia.4 Many cardiopulmonary bypass vasoplegia syndrome, and many other instances of cold related injuries have been reported since ancient conditions.17,19–21 270 S.J. Remba et al. / Resuscitation 81 (2010) 268–271

4. A prompt surgeon was extremely agitated. Larrey cut and evacuated a significant bloody effusion but was disconcerted about the internal extension Larrey’s experiences on the battlefield also prompted him to of the wound. After removing three more bottles of red fluid, he develop immediate responses to relieve the pain of those wounded inserted a probe following the direction of the wound and felt the in war. Larrey came to realize that an important factor in suc- close pulsations of the heart, leaving no doubt the fluid was coming cessful amputations was the timing of the surgery. Unlike others from the pericardium. who recommended waiting until the wounded could be evacuated, After this, Larrey held a series of experiments on corpses he preferred to perform amputations in the first hours following and finally came up with a groundbreaking technique for aspira- injury. He startled physicians of the time by performing a rapid tion of pericardial effusion and drainage of the hemothorax, and evaluation of the affected extremity and the immediate amputa- empyema, that still prevails in the present time.25 tion of the affected limbs of those with grave injuries.8 This meant approaching the wounded during the battles, thus risking his own 6. Other accomplishments life. It is easy to imagine the reaction of his medical colleagues Not only was Baron Larrey an outstanding surgeon, but he also as in the early 19th century, amputation through the joint was had a sharp clinical sense and creativity, attributes contributing to considered barbaric.8 While there were no qualified nurses or anes- success throughout his career. thesiologists at the time, Larrey’s amputations saved thousands of Amazing observations made by Larrey include the differentia- lives.1 Not only were his actions decisive and humanistic, but he tion of cases of goiter and cretinism among populations in the Alps had remarkable skills as a surgeon. Due to the violent nature of and the connection he made between drinking salt-free snow water the conditions he worked in, he operated on patients with wounds and these conditions, which were unknown at the time.16 from close-range musket balls to those created by the destruc- During his stay in Cairo, he found time to write about endemic tive cannonballs and canister shots, which had disastrous surgical diseases such as typhus bubonic plague, leprosy and even syphilis, consequences (i.e., compound fractures and torn muscles).8 a very common disease within the troops at the time. During the campaign he also worked at turning old, evacuated build- “I had carefully observed the phenomena attending gun-shot ings into fully-equipped military hospitals.26 Scurvy was a very wounds, and perceived the advantage of immediate amputation common disease among soldiers and Larrey was present during if the injury required it”.16 the terrible Egyptian ophthalmia suffered during the blockade of Larrey also performed daily drainages on all penetrated wounds, Alexandria. He worked courageously alleviating the symptoms of reduced fractures, and even introduced débridement in extensive more than 3500 affected men and despite losing several of his col- burns or to minimize the risk of infection in those wounds with leagues and nurses, he never lost the compassion that distinguished abundant nonviable tissue.7 Moreover, he advanced techniques him.26 for débridement, implementing an inverted-cone-like cut which Larrey was also known for operating in a meticulously clean allowed the complete drainage of the fluids in the wound.8 Fur- environment. He implemented linen moistened in vinegar and thermore, the very first cauterizations were performed by applying washed his surgical instruments thoroughly with brandy. Depend- an incandescent piece of iron over the dead tissues.1 ing on the wound he used solutions such as liquor sodae chlorinatae and saline lotion and not the customary greases and ointments. 5. Thoracic surgery pioneer He recognized what he called “bad water” as the cause of typhoid and even performed trepanations on soldiers’ craniums to reach As early as 1794, Larrey was assisting wounded soldiers with bullets.4 an artificial respiration method he created that consisted of bel- A pioneer in surgical techniques, Larrey never stopped believing lows blowing air into the lungs and then compressing the chest in the basics, as one of his quotes reveals: “...wholesome food, and to promote exhalation.1 This process has evolved into the ventila- above all, exercise, are the best antidotes to disease”.16 tion portion of CPR as well as treatment of respiratory distress or failure.22–24 7. A great man’s last days Historically, Larrey was the second surgeon to perform peri- cardiac interventions in 1810, 9 years after Francisco Romero, a Larrey served Napoleon in 25 different campaigns and 60 bat- brilliant surgeon whose technique was ahead of his time and thus tles. He was a recognized surgeon and despite his hard duty, he not recognized for several years. It was during a period of peace always found time to record his experiences and observations, in France that Larrey was working for the hospital of “La Garde” which included not only war surgery but diseases such as rabies, where he met his first pericardiotomy patient, Bernard Saint-Ogne, tetanus, aneurysms, elephantiasis scrota, and urine atrophy.6 He a soldier who, during a moment of frustration, had tried to com- was wounded in battle both at Austerlitz and Waterloo, and in the mit suicide by stabbing a knife into his chest. He was treated in latter he was captured and sentenced to death. Fortunately, he was the traditional way of the time, but the soldier was in great pain, recognized by a Prussian surgeon who had attended his lectures in very weak, and his heartbeat was barely audible. Larrey identified the past and interceded for Larrey with Marshall Blucher. Blucher these symptoms and performed an urgent pericardiotomy, cutting had not forgotten when Larrey saved his son’s life when he was directly under the left nipple and evacuating almost a liter of rust wounded in battle and captured by the French. Larrey was thus colored fluid that was compressing the soldier’s heart. In addi- released and escorted back to France.2 Larrey’s fame reached such tion, he placed a rudimentary drainage tube to allow continuous a magnitude that he was solicited by Alexander I, Tsar of Russia, drainage and the young soldier subsequently recovered from this and Pedro I of Brazil to take charge of their armies. However, Lar- wound. rey refused to leave his country and served as Chief Surgeon to the Larrey had six more patients with injuries in the heart or peri- Royal Guard.8 cardium. Of those, the most remarkable was a 22-year-old soldier, Larrey had two monuments built in his honor. One in 1850, at in whom Larrey discovered the perfect approach to the peri- Val-de-Grâce court (a military hospital in Paris), and the second at cardium. The soldier had a penetrated wound between the xiphoid the hall of the Academy of Medicine, with a sculpture by the famous process and the cartilage end of the left 7th rib, and by the time he sculptor David.6,26 He continued to practice on the field, showing was seen by Larrey, the wound was very swollen and the patient his devotion to duty and the importance of soldiers until his very S.J. Remba et al. / Resuscitation 81 (2010) 268–271 271 last days when he died as a result of pneumonia on July 25th, 1842, 10. Brewer III LA. Baron Dominique Jean Larrey (1766–1842). Father of modern mil- at the age of 76 in Lyons, France.7,8,10,26,27 itary surgery, innovater, humanist. J Thorac Cardiovasc Surg 1986;92:1096–8. 11. Lee JWI. A Greek army on the march: Soldiers and Survival in Xenephon’s Anaba- sis. Cambridge University Press; 2007. Conflict of interest statement 12. Galen on abnormal swellings. J Hist Med Allied Sci 1978;33:531–49. 13. Aristotle. The work of Aristotle: The famous philosopher. BiblioLife; 2005. p. 376 (ISBN-10: 0554336731/ISBN-13: 978-0554336732). None to declare. 14. Chadwick J. Hippocrates of Cos. Guys Hosp Rep 1951;100:210–22. 15. Connell. The medical works of hippocrates: a new translation. Br Med Bull Acknowledgments 1951;8:88–9. 16. Larrey DJ, Hall RW. Memoirs of military surgery, and campaigns of the French armies, on the Rhine, in Corsica, Catalonia, Egypt, and Syria; at The author’s would like to thank Richard Pistolese for his assis- Boulogne, Ulm, and Austerlitz, in Saxony, Prussia, Poland, Spain, and Austria. tance in the preparation and review of this manuscript. In: First American from the second Paris edition. Baltimore: Joseph Cushing; 1814. 17. Varon J, Acosta P. Therapeutic hypothermia: past, present, and future. Chest References 2008;133:1267–74. 18. Korpan NN. A history of cryosurgery: its development and future. J Am Coll Surg 1. Robb JC. Baron Larrey (1766–1842); Napoleon’s chief surgeon and his times. 2007;204:314–24. Ulster Med J 1952;21:101–13. 19. Li G, Xu RX, Ke YQ, et al. Effect of sub-hypothermia therapy on coagulopathy 2. Welling DR, Burris DG, Rich NM. Delayed recognition—Larrey and Les Invalides. after severe head injury. Chin Med J (Engl) 2008;121:2350–2. J Am Coll Surg 2006;202:373–6. 20. Koutouzis M, Nikolaou N, Lazaris E, Kourouklis S, Kyriakides ZS. Interventional 3. Pai-Dhungat JV, Parikh F. Medical philately (Medical theme on stamps). hypothermia and primary percutaneous coronary intervention in a patient with Dominique J. Larrey (1766–1842). Northern France Ambulance, 1918 stamp, anterior wall ST elevation myocardial infarction and aborted sudden death. Hel- Grenada-1970. J Assoc Physicians India 2006;54:811. lenic J Cardiol 2007;48:377–9. 4. O’Sullivan ST, O’Shaughnessy M, O’Connor TP. Baron Larrey and cold injury dur- 21. Kennedy J, Green RS, Stenstrom R. The use of induced hypothermia after cardiac ing the campaigns of Napoleon. Ann Plast Surg 1995;34:446–9. arrest: a survey of Canadian emergency physicians. CJEM 2008;10:125–30. 5. Richardson RG. Larrey: surgeon to Napoleon’s Imperial Guard. London: Quiller 22. Zambon M, Vincent JL. Mortality rates for patients with acute lung injury/ARDS Press; 2000. have decreased over time. Chest 2008;133:1120–7. 6. Russell TG, Russell TM. Medicine in Egypt at the time of Napoleon Bonaparte. 23. Morley PT. Improved cardiac arrest outcomes: as time goes by? Crit Care BMJ 2003;327:1461–4. 2007;11:130. 7. Skandalakis PN, Lainas P, Zoras O, Skandalakis JE, Mirilas P. To afford the 24. Hong SB, Oh BJ, Kim YS, et al. Characteristics of mechanical ventilation employed wounded speedy assistance: Dominique Jean Larrey and Napoleon. World J Surg in intensive care units: a multicenter survey of hospitals. J Korean Med Sci 2006;30:1392–9. 2008;23:948–53. 8. Bodemer CW. Baron Dominique Jean Larrey, Napoleon’s surgeon. Bull Am Coll 25. Van Thielen J, Van Hee R. Pericardiotomy: the first cardiac operation. Acta Chir Surg 1982;67:18–21. Belg 2008;108:133–8. 9. Baker D, Cazalaa JB, Carli P. Resuscitation great. Larrey and Percy—a tale of two 26. Ball OF. Baron Larrey. Mod Hosp 1952;78:84–6 [passim]. barons. Resuscitation 2005;66:259–62. 27. Robertson-Steel I. Evolution of triage systems. Emerg Med J 2006;23:154–5.