Resuscitation Dominique-Jean Larrey

Resuscitation 81 (2010) 268–271 Contents lists available at ScienceDirect Resuscitation journal homepage: www.elsevier.com/locate/resuscitation 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 0300-9572/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2009.11.010 S.J. Remba et al. / Resuscitation 81 (2010) 268–271 269 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.

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