THE CLINIC OF PROFESSOR RENE LERICHE MICHAEL DEBAKEY, M. D. NEW ORLEANS and ALBERTO SALDARRIAGA Cotomptia, 8S. A. Reprinted from New Orleans AMledical and Surgical Journal pp. 606-609, Tal. 90, No. 10, -fpril, 1938 Reprinted from New Orleans Medical and Surgical Journal pp. 606-609, bol. 90, No. 10, April, 1938 * THE CLINIC OF PROFESSOR RENE LERICHE MICHAEL DEBAKEY, M. D.* + New ORLEANS and ALBERTO SALDARRIAGA** Cotomptra, S. A. In the extreme eastern part of France, tran- quilly reposing almost midway between the mountainous Vosges and the Black Forest and hugging the rapidly flowing Rhine with seem- ingly jealous fervor, is the city of Strasbourg. Apparently predestined to the costly glories as well as the adversities and vicissitudes of mili- tary order, this city has veritably lived up to its traditional origin. On this very soil Drusus, fifteen hundred years before the birth of Christ, established a fortified post in the name of the Roman people, with the object of stem- ming the increasing hostile raids of the savage and incursive Alains, Vandals, and Sarmades who inhabited the land beyond the Rhine. But despite the fact that it has been the center of the *From the Surgical Clinic A, Director: Profes- sor René Leriche, Strasbourg, France. TOn leave of absence, Department of Surgery, Tulane University School of Medicine, New Or- leans, La. **ix-interne of the Strasbourg Hospitals; now Professor of Clinical Gynecology, on the Medical Faculty of the University of Medellin | Colombia, S. A. 2 arena in which grim-visaged war has played many a leading role, it has progressively de- veloped into one of the most active commercial, industrial, artistic, and educational centers of Europe. Because of its unique geographical posi- tion, i. e., at the borders of two rival civilizations, willingly or not, it has always been enriched by the acculturation of one or the other of the two great nations with which it has been al- ternately united; and it is this extraordinary but harmonious commingling of the rich Teutonic and Celtic qualities that gives Alsace and _ its great center Strasbourg its characteristic and unique beauty. Far famed as the originator of sauerkraut, renowned for its inimitable paté de foie gras. and celebrated for the magnificent beauty and stately Gothic purity of its impos- ing cathedral, this great center has indeed a rightful and deserving place among the first cities of the world. But of all of its proud possessions there is none it could display with more pardonable pride than its great University. for here mod- estly resides one of the world’s most advanced centers of education. And no part of this Uni- versity is more progressive or has a nobler in- heritance than the medical school. Constructed on the same grounds and as an integral part of “Hospices Civil,” consisting of over fifty buildings, covering over seventy acres of ground, possessing its own electric power, water, and heating system, it is indeed a little city within itself forming one of the world’s largest medical centers. So old is this hospital and so vague are the early records that its origin is lost in antiquity. However, it may be said with some degree of authenticity that it was founded about the year 657 A. D., probably by the Duc d’Alsace Attic or Ettichon, the father of Saint Odile, and was administered by the bishops until the year 1263. At this time the administration of the hospital was given to the city by Bishop Henri de Géroldsack, and fifty years later the hospital was transferred outside the city bound- ary to its present site, In 1716 it was almost completely destroyed by fire. only the chapel of Saint Evard escaping, which, incidentally, dates back to the fifteenth century and remains yet a monumental commenioration of the admirable courage and unwavering determination of these early workers. With its reconstruction came a new epoch in the advancement of the medical school which became better organized, more firmly estab- lished, and began its rapid strides of progress and development. The chairs of pathology, anatomy and surgery were definitely as- signed, and here was founded in 1734 the first school of midwifery in the world. From this time until 1870 it continued to advance rapidly and flourish under the ever productive influ- ence of the French school. During the German epoch from 1870 to 1918, the great zeal and feverish activity that was displayed in enlarg- ing and enhancing the hospital and university has resulted in making it one of the largest medical centers of the world today. To attempt a further detailed historical and descriptive dis- cussion of the hospital and university would be inopportune as well as inexpedient. As our in- terest is admittedly confined. we may risk be- ing invidious and limit the description to one of the most conspicuously advanced and _ scien- tifically progressive departments, namely, the “Clinique Chirurgicale A”, It may be paren- thetically stated that the surgical department consists of two divisions: “Clinique Chirurgi- cale A” and “Clinique Chirurgical B,” but we are solely concerned with the former. The present edifice of “Clinique Chirurgi- cale A” was completed in 1881 and contains 205 beds. Constructed in simple style with large spacious hallways and vast airy wards, it possesses two operating pavilions, one of which is provided with a huge amphitheater; modern- ly equipped laboratories of surgical pathology and experimental surgery, its own department of radiology, an out-patient clinic, a urologic department, and a separate building devoted to septic cases. However, our interest in this clinic is aroused not by its modern facilities or its simple style of construction, but by the man who modestly works and presides as its director. Celebrated throughout the surgical world for his prolific and fructiferous activities, his un- ceasing originality of thought, his numerous perspicuous disquisitions, and his perennial ex- positions on the surgery of the sympathetic nervous system, Professor René Leriche has made this clinic a cynosure for students from all corners of the world. BIOGRAPHICAL SKETCH OF LERICHE In order to appreciate more fully the quality of his work it is necessary to know and appreci- ate the personality of this really great man, and to do this it would not be inappropriate to give a brief biographical resumé, Born on October 12, 1879, at Roanne, France, he completed his early medical training at the University of Lyon and immediately became the student of Jaboulay, who was early attracted by the unusual ability of this young interne. However, Jaboulay’s untimely and tragic death occurred soon after- wards and he then became the student and later the collaborator of that master surgeon, Antonin Poncet, until the latter’s death in 1913. It was under such careful training and in such a bril- liant environment that the firm foundation for his later development and success was laid. At the termination of his interneship in 1906 he presented his thesis: “The Resection of the Stomach for Cancer”, which remains yet a classic. and in 1910 he became Professor Agrégé. During the late War he devoted his entire time to military surgery and as a result of lis self-sacrificing and distinguished serv- ices, both the French and Belgian Governments 6 bestowed on him one of their highest honors. e\fter the World War he returned to Lyon and remained there until 1924, when he was called to Strasbourg to occupy the chair of surgery, which had recently been left vacant by the un- timely death of Sencert, and on which had previously sat such illustrious figures as Flam- ant, Cailliot, Begin, Sedillot, Madelung, and Boeckel. Since his establishment here he has con- tinued to add many achievements to his numer- ous innovations and advances that are so char- acteristic of his surgical enterprise, veritably conforming to the exordial remarks of his in- augural address in which he stated: “Vous ne me connaissez pas. J’avais besoin de prendre contact avec vous autrement qu’en paroles. J'ai préféré que vous me jugiez d’abord aux actes.” No better insight can be obtained to his sterl- ing qualities, his innate character, and his ideal- istic attitude. than to quote him again from this same eloquent address: “Ie professeur de clinique chirurgicale a une triple tache 4 remplir. ! doit soigner de son mieux les malades qui lw sont confiés; il doit apprendre aux étudiants tout ce que peut leur ctre utile dans leur vie professionnelle future; il doit enfin tacher de faire progresser la chirurgie. [’avenir me per- mettra, je lespere, de vous le montrer.” And he has indeed, for he has achieved these three idealistic tasks in his own characteristically medest but undeniably successful manner, The generous personality of Professor René Leriche is clearly revealed by his noble and im- posing Beethovenian countenance. The high fore- head, the clear blue, kind, but penetrating eyes, and the strong, determined chin vividly portray and reflect his keen sense of humor, his ef- fervescing vivacity, his beneficent cordiality, his contagious enthusiasm, and his indomitable resoluteness. The reassuring confidence and the understanding sympathy expressed at the patient’s bedside is only commensurate with his unlimited tolerance and patient considera- tion towards his students. The spirit of cam- araderie among his assistants, residents, and in- ternes, the prevading atmosphere of enthusiasm in his clinic, and the worshipful admiration of his patients vividly exemplify the charming per- sonality and the admirable characteristics of this great man. Tt is in his clinical lectures that he impres- sively demonstrates his incomparable ability as a masterful teacher. Although capable of beau- tiful oratorical cloquence, before his students he speaks in a concise and transpicuous manner harmoniously blending scientific simplicity with pleasing rhetoric. With explicit clarity he lucidly correlates the underlying pathologic physiology with the more obvious clinical man- ifestations, indelibly impressing in the minds of his students these essential and fundamental surgical principles. In the operating theater which is finished in 8 an agreeable ensemble of pale blue, one is strikingly impressed by the sheer simplicity as well as the technical perfection of the delicate operative manipulations of this master surgeon. Although a better demonstration of more dex- terous or less injurious dissection on the living subject would be difficult to conceive, he more forcibly stresses the primary essentials of modern surgery, that the present day surgeon must no longer be content with being a mere technician. He must attempt to correct the con- sequent manifestations of the patient’s dis- orders by first a thorough study and a com- prehensive correlation of the underlying patho- logic anatomy with physiologic function. And this statement so aptly illustrates the thorough manner in which each patient in his clinic is carefully studied in an attempt to discover the relative importance of the basic physiologic and pathologic processes, and thus ascertain the best corrective measures. The philosophic dissertations, the experiment- al contributions, and the surgical expositions and monographs of Professor Leriche are too numerous to list, and cover an astonishingly wide range of surgical endeavor. In all his work there is one outstanding characteristic which portrays the ideal and trend of modern surgery—the continuous search for a miore ratiocinative comprehension of the physiologic disorders consequent to the more apparent anatomico-pathologic processes, Leriche’s earlier publications were chiefly 9 concerned with abdominal surgery, especially that of the stomach. His keen analytical and ex- perimental work has added considerably to- wards a more rational conception and a hetter therapeutic attack of peptic ulceration. In col- laboration with his former chief, Antonin Pon- cet, he published a masterful dissertation on surgical tuberculosis. His invaluable contribu- tions on vascular diseases and surgery of the sympathetic nervous system have made his name inseparably linked with this branch of surgical endeavor. As early as 1913 he directed the attention of surgeons throughout the world to the operative procedure of periarterial sym- pathectomy as a means.of improving the circu- lation of a limb in the treatment of certain con- ditions consequent to vascular insufficiency. As the procedure was found also to relieve pain, it was quickly and widely adopted before a more rational understanding of the underlying physio- logic principles was developed. Naturally the results have been most varied and confusing and Professor Leriche himself, writing in the September issue (1928) of the Annals of Surg- ery. succinctly and truthfully expressed the present status: “The surgery of the sympa- thetic svstem meets two kinds of difficulties— those which spring from our physiologic ignor- ance, those which spring from our pathologic ignorance. On one side we do not know the exact significance of the branches we cut, on the other side we are ignorant, as a rule, of the cause and the exact mechanism of the di- seases we wish to cure.” Not long after the late War, his constantly probing scientific interests were directed toward the histo-biologic development of the osseous structures, which resulted in a newer conception of ossification, In collaboration with Policard he presented these more advanced ideas in a com- pendious and illuminating monograph, “La physiologie de l’os normal et pathologique”, which shed considerable light on this difficult problem, and opened new sources of possibili- ties in its therapeutic applicatidn. He has recently become intensely interested ir. studies of the endocrine glands, particularly the adrenals and the parathyroids, with special reference to their surgical consideration. His studious and perspicacious clinical and experi- mental investigations have already made him me of the foremost authorities in this newer field of surgical imquiry. The world-wide appreciation of the untiring industry, the unceasing efforts, and the ever- productive activities of Professor René Leriche are readily evinced by the numerous and de- serving honors which have been conferred up- on him. Respected by his colleagues, admired hy his associates, worshipped by his patients, he will always remain in the hearts of those who know him best, his surgical devotees, as a tolerant teacher and a kind and inspiring master. 11 And when the pages of this chapter of medical history have been completed, his name will ap- pear conspicuously among those who have done most towards advancing modern surgical pro- gress.