Musings on Surgery

D. J. Larrey (8 July 1766- 25 July 1842), Chief Surgeon for Napoleon’s army, is regarded as the father of modern military surgery. His was a remarkable career. Seeing how many injured soldiers lay on the battlefield, sometimes for a day or more, before being transported to where medical care could be rendered, he created small, fast carriages that could swiftly dash onto the battlefield, pick up the injured, and transport them back to the rear- the first ambulances. He advocated for early amputation of severely injured limbs. Until then, in the pre-antibiotic era, injuries were allowed to fester in the mistaken belief that infection and pus were a necessary first stage of healing. Unsurprisingly, those who survived their initial injury usually died of sepsis as a result. Early amputation dramatically reduced the fatality rate of such injuries. Although the first general anesthetic, ether, would not be discovered until after his death, Larrey’s surgical skill was such that he could perform major amputations with a remarkable survival of over fifty percent. He reportedly once performed 200 amputations in a period of 24 hours.

Perhaps Larrey’s greatest legacy was his indifference to who he was treating. General or private, friend or enemy, the injured received the same care. The story is told that, during the Battle of Waterloo, the Duke of Wellington was surveying the battlefield and recognized Larrey treating the wounded of both sides in the thick of the battle. Legend has it that Wellington ordered his troops to fire away from the area in which Larrey was working. Such was the respect in which he was held. In later years, Napoleon called him “the most virtuous man I have ever known.”^[1]

I remember my own trauma training and experience as a general surgeon. When we were notified that EMS (emergency medical service) was bringing in a trauma victim or victims, the emergency room would mobilize the seemingly chaotic, but carefully orchestrated bustle of activity that is modern, high-level trauma care. The injured could be members of a family in a terrible automobile accident or the drunk driver that hit them. It could be a policeman shot in a routine traffic stop or a wanted murderer shot resisting arrest. None of this mattered. We did not ask about the race, ethnicity, gender identity, or religion of the trauma victim, nor how they were injured except in so far as these might help us prepare to care for them. All received our utmost efforts to save their lives.

It was not our place as surgeons to inquire into irrelevant personal details about the patient before us. It only mattered that this was a human being with a dire need that we were trained to meet. There was always a sense of pride in knowing that, in a world full of strife, violence, prejudice, and suffering, we were above all of that. We did not seek public affirmation or acclaim, financial or other reward. It was our job to save lives and we did it calmly, dispassionately, and competently as befitted professionals trained in an ancient and revered art.

No, the incentive for us as surgeons, whether in trauma or elective surgery, was our oath taken before our peers, our professors, and our families. Medicine is one of the few professions in which initiates are bound by a sacred oath. The Hippocratic Oath reads like a quaint anachronism, with its promise to the Greek god Apollo and reference to antiquated practices. It is, however, timeless in its command to honor those who taught us, to teach our craft to our students, and to do our best for our patients and refrain from willful harm or injury regardless of their status. The latter is encapsulated in the dictum, “primum, non nocere”, which means, “first, do no harm.”

That, and the legacy of such as D. J. Larrey.

We are heirs to the legacy of Larrey and the countless physicians who preceded him and came after. Selflessness is, or should be, a hallmark of all physicians when it comes to treating patients. We call this Hippocratic medicine in homage to the oath of the same name. Medicine today is in trouble. There is mounting pressure on physicians to conform to ways of practicing that are antithetical to Hippocratic medicine. Corporate takeover of medicine wherein more than 80% of physicians are now employees rather than owners of their practices^[2] has shifted the focus from patient care first and foremost to productivity, profit, efficiency, and metrics. The loss of a sense of ownership of their practices and patients by employed physicians has arguably contributed to dissatisfaction, burnout, and decline in quality of care.^[3]

For nearly forty years, I have been proud to be a surgeon, first a general surgeon and, later, a plastic surgeon. I hope that I have practiced my craft in a manner that honors Larrey and the countless surgeons like him who paved the way for me and my colleagues. Their honorable legacy of selflessness and clinical excellence should be lifted up as an example to us who are their heirs.