Wednesday, July 25, 2012

Larrey

One of the true heroes of the nineteenth century was a French military doctor named Dominique-Jean Larrey. Larrey was the chief surgeon of Napoleon's army and has claim to be considered one of the most important doctors of modern times. One of his important innovations was his idea of the flying ambulance. 'Flying artillery' is another name for horse-drawn artillery, which had been radically changing the face of battle. Originally, field hospitals (called ambulances, short form of hôpital ambulant = walking hospital) for the wounded were required to maintain a certain distance from the battlefield; they would have to be carried back to pick-up points, which meant in practice that they were simply left on the field until the battle was over. They would then have to be picked up and carried to where they could get treatment. It was pretty clear to everyone in those war-stricken days that this was not a very good way of doing things, but the big problem is finding alternatives that are genuinely better than what they are trying to replace. What Larrey proposed was that there should be horse-drawn ambulances that could go actually go out on the field in the wake of the horse-drawn artillery; hence the name 'flying hospitals' or 'flying ambulances'. This turned out to be trickier than it sounds; moving the wounded is difficult business, and most ordinary means of transportation are not very suitable for it at all, and this was particularly true in days before motorized vehicles with suspensions. In fact, what Larrey used after ruling out several alternatives was precisely the horse-drawn version of the same: light carriages mounted on springs to absorb some of the shock of rough terrain. As he summarizes this aspect of his ambulance (remember, 'ambulance' at here is just an abbreviation indicating a mobile hospital; it's the source of our sense of the word, but not the same, since Larrey's 'ambulance' is an entire field staff over three hundred with equipment, formed into divisions):

Each division of ambulance consisted of twelve light carriages on springs for the transportation of the wounded: they were of two sorts, some with two wheels, others with four. The former kind were calculated for flat level countries, the others to carry the wounded across the mountains. The frame of the former resembled an elongated cube, curved on the top: it had two small windows on each side, a folding door opened before and behind. The floor of the body was moveable; and on it were placed a hair mattress, and a bolster of the same, covered with leather. This floor moved easily on the two sides of the body, by means of four small rollers; on the sides were four iron handles through which the sashes of the soldiers were passed, while putting the wounded on the sliding floor. These sashes served instead of litters for carrying the wounded; they were dressed on these floors, when the weather did not permit them to be dressed on the ground.

When the army was engaged in rugged mountains, it was indispensably necessary to have mules, or packhorses, with panniers to carry the materials for dressings, with the surgical instruments, medicines, &c.

The small carriages, Were thirty-two inches wide, and were drawn by two horses. Two patients could conveniently Heat full length in them; to the sides were attach ed several pockets, to receive bottles or other articles necessary for the sick. These carriages united solidity with lightness and elegance.

The second kind of light carriages, on springs, was a chariot with four wheels; the body of which was larger and longer than those with two wheels, but of a similar form; it was also hung on four springs, and furnished with an immoveable mattress, and the pannels were stuffed a foot in height, like the bodies of the small carriages. The left side of the body opens almost its whole length, by means of two sliding doors, so as to permit the'wounded to be laid in a horizontal position. Small windows disposed at proper distances have a good effect in ventilating the carriage. A hand-barrow may be fix ed under these carriages for various useful purposes.

The large carriages also have pockets, and behind, a place to carry forage; they were drawn by four horses, and had two drivers. In these carriages four men might lie with their legs slightly contracted.

A hospital that moves. The idea, of course, worked brilliantly, although it took an extraordinary amount of practical ingenuity to get into feasible shape. Battles had become increasingly fluid, and field medicine had to become correspondingly fluid. There were other systems that attempted to address this; Larrey's just ended up being the most effective. But the influence was not merely one way: the introduction of Larrey-style ambulance divisions increased the chances of soldiers surviving increasingly dangerous battle situations and boosted morale of the soldiers. Whereas before a soldier might have to wait for hours or days, under Larrey's system a soldier could usually get treatment within fifteen minutes of having been wounded, and less than a few hours under the worst conditions.

But the single most important idea Larrey had was that of triage. Originally, when resources or time were limited (which is usually the case in the field), they would be distributed according to the perceived importance of the patient, which in practice came to rank and whether they could be restored to fighting condition. Larrey organized his field work on an entirely different principle: treatment decisions in such cases would be decided entirely on the basis of purely medical necessity in the pursuit of the purely medical ends of keeping alive and restoring to health, as they came up. It was a revolution in medical ethics, this notion of doctors not prioritizing patients according to preconceived notions but according to severity and urgency of purely medical need. It is a principle that, strictly followed, guarantees that the many judgment calls that have to be made in the field do not turn into slippery slopes; it is a principle admitting of a more reasonable justification than most alternatives; and it is one that treats human beings like human beings while at the same time doing justice to the hardships of extreme situations. Where it is newly implemented, there is medical and ethical progress; where it is forgotten -- and there is always temptation to mingle it with the very same kind of principle it was developed to replace -- medicine and especially medical ethics regress as practical disciplines. It is not a perfect solution, nor a universal principle; but as a way of handling situations with no perfect solution it was a medical and ethical revolution.

He saved extraordinary numbers of people in extraordinarily difficult situations, facing difficult conditions with genius and bravery. It is said that at Waterloo Wellington noted Larrey on the battlefield, ordered his men to avoid shooting him and his assistants, and doffed his hat in salute to him. Of course, he was very much a soldier as well; he once drew his sword and charged a group of soldiers trying to run away from a battle, screaming at them to stop being cowards and to help their comrades. And he was a great admirer of Napoleon, who in turn admired him. But in many ways he approached the ideal of a doctor and a physician: compassionate, brilliant, practical, fair, putting his patients above even his own safety.

Larrey died July 25, 1842, at the age of 76.

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