René Leriche and "Philosophy of Surgery" in the light of contemporary medical ethics

Abstract

Prof. Dr. René Leriche was a famous French surgeon who lived between 1879 and 1955. After working as a vascular surgeon in Lyon, he was appointed professor at the University of Strasbourg in 1924 and later the Paris Collége de France in 1937. Leriche had proposed vascular patches as the ideal treatment for obliterated vascular segments and advocated the necessity of sympathectomy in arterial diseases in the 1920s. He defined “Leriche Syndrome” in 1923 which is known by his name and which develops as a result of incomplete obstruction of the aortic bifurcation. René Leriche wrote a monograph entitled “La Chirurgie de la Douleur-Pain Surgery” in 1940 and he also became a pioneer in the sympathectomy procedure for pain treatment. René Leriche focused on topics that must be remembered again today, including surgery advanced into science, the physiological basis of surgery, research methods, as well as issues such as business technology, humanity in surgery, surgical essence and surgeon's qualifications in the book entitled “La Philosophie de la Chirurgie-Philosophy of Surgery” that he wrote in 1951. In this review, the issues that Prof. Dr. René Leriche addressed in middle of the 20th century were revised in the light of contemporary medical ethics.

Keywords: René Leriche, surgery, philosophy

Introduction

Prof. Dr. René Leriche was born in Roanne, central France, in 1879. Upon completion of his medical training in Lyon in 1906, he was appointed as Professor of Surgery in Strasbourg in 1924. During this period, Strasbourg has become a center of education attracting surgeons from all over the world. In 1937, he became the chairman of the Collège de France, where Claude Bernard was one of the past directors. In his experimental studies Leriche focused on the physiological mechanisms and translated these results into clinical practice. Especially his studies regarding the issue of pain and the nervous system have gained worldwide interest. He further developed his reputation with reports on periarteriel sympathectomy, normal and pathologic physiology, arterectomy in obliterated arteritis and pain surgery. The aorta-iliac occlusive disease is due to thrombotic occlusion of the abdominal aortic bifurcation and results in the clinical scenario of claudication, loss or weakness of femoral pulses, and impotence. This entity was first defined by René Leriche and named after him, as Leriche Syndrome [1].

Prof. Dr. René Leriche was much loved and respected among his patients and colleagues, not only because of his outstanding academic abilities, but also with his humility and heartfelt work. In 1951, he published his book “La Philosophie de la Chirurgie-Surgery of the Philosophy”. In this book, Leriche made important conclusions on the properties required in a physician and especially surgeons, as well as physiological basis of diseases. This book is a synthesis of the lectures Dr. René Leriche gave in Strasbourg since 1924 and in College de Paris since 1937 [2]. This review aimed to evaluate the chapters in which he focused on the qualifications of especially a surgeon rather than the medical and technical aspects of surgery with quotations from the book that also includes the issue of contemporary medical ethics.

Philosophy of Surgery
René Leriche’s book entitled “La Philosophie de la Chirurgie”, was published by the Ministry of Health in Turkey in 1960 under the title of “The Philosophy of Surgery” [3]. The book was translated by Dr. Nail Karabuda in a total of 247 pages. The book is divided into three main sections as “Preface”, “Evolution of Surgery as a Scientific Branch” and “Action Problem” [2].

The first part of “Evolution of Surgery as a Scientific Branch” contains the following sections; The Foundation of Pathology-Stages of Disease Knowledge, What is Disease, Humanism in Surgery, Research Tools, Clinical Research and Outcome- Some Surgical Research Objectives . The “Action Problem” part is composed of the following sections; Surgery serving Life-Today’s Surgeons, Physiological Basis of Surgery, Surgical Spirit and Healing Spirit, Business Technique, School of Thought Chiefs, Future of Surgery and Conclusion.

Foreword
Despite the lack of sufficient knowledge on philosophy after assertively naming his book (Philosophy of Surgery), René Leriche’s first words in the foreword are “I do not ignore the difficulties of the task I am into”. However, he states that this name is appropriate by specifying the purpose of the book as “thinking on surgery, its methods, and features required in those who serve”.

Following this introduction Leriche states that the main problem is a surgeon perceiving the word philosophy in a negative manner: “According to them philosophy means being distracted and wandering meaninglessly in the realm of abstraction. In this regard, I probably will not reach those I would like to contact on this issue. Nevertheless, it is worth the effort to trying to define the spirit of surgery “.

Unfortunately, nowadays philosophy lost its priority in standard education. Today, the success of high school education is evaluated by achievements in college selection/placement exams, not by how students are prepared to daily life. This situation results in ignorance of the necessity of philosophy in the young, and they even lack any idea about what it represents.

Actually, the word philosophy (Philosophie)derives from the ancient Greek word “philein” which means “love” and “sophia” meaning “ information/knowledge”, in combination the meaning becomes “love of wisdom, love of knowledge”. One of the main branches of philosophy that can be defined as “ the rational and critical inquiry to reach basic principles, correct information, a good life” is one that can also be applied to medicine ‘ethics’ [4]. This traditional branch of philosophy, ethics, can also be defined as a discipline seeking answers to questions like ‘the nature, essence and resources of wellness, being good, good behavior ‘, ‘what kind of life is a good life?’, ‘what kind of life is worth living?’, ‘ which choices should be made to live a just life?’, the type of questions trying to find out ‘ how to live? [4].

In this sense, it is obvious that the teaching of ethics as a branch of philosophy is appropriate and necessary in medical profession. By providing medical ethics education, the role of values in physician-patient, physician-physician and physician-community relations, their place and function in this profession’s identity is diffused into future physicians [5].

René Leriche then mentions the difficulties in predicting the future of surgery, and in the light of current developments (1950s) he foresees that surgery will be bound to “techniques” as the field expands, keeping in mind that at that times surgery was accepted as a self-sufficient branch. “These techniques are so diverse that it mandates breaking up into sub-specialties that stay further from each other and from now on it seems probable that surgery will entirely be performed as a ’ Technical Code’. “
According to Leriche, the real problem is the surgeon’s moving away from his roles by relying on evolving technology, and the fact that practice of medicine is becoming more mechanized. “Although intuition was formerly, inaccurately, accepted as a subjective interpretation, it was the result of small, and objective points recorded during observation. However now, the time in which the performer will be making the most serious decisions in the treatment of patients without any contact to be performed between the physician and the patient, are expected in the horizon. “. According to him, the most important surgical issue in the future will be the loss of personality and human aspects by serving to technology. Perhaps the most important part of the book is the part where he states these concerns: “The person we operate on is not just a physiologic mechanism. He has the properties of thinking, and fear. His poor body shakes with fear if he does not get sympathy from across. Nothing can replace the comforting contact with his operator, the mutual gaze and the absolute belief that surgery is accepted with the expectation of definite success (at least assumable). These are such delicate matters that they cannot be sacrificed. Creatures made as much of sense as flesh, require understanding and assistance in times of trouble”.

René Leriche makes the following statements in the preface regarding the art of surgery: “The art of operating is possible in part by habit, skills add a bit of excellence on top and everyone can achieve this art within a very short time. However, performing surgery in the right place and at the right time, knowing when it is necessary or if it can be avoided, the conditions that effect success or failure, the changes of plan in surgery based on these conditions, the outcome to be expected and the means to obtaining these results as much as possible: These are the difficult aspects of the art of surgery and the elements that constitute its science. “

According to him, surgery is a phenomenon by itself. Surgery’s becoming a scientific branch is possible through its ability to create a whole with the other main elements of medicine, i.e. using knowledge from internal medicine, pathology, physiology, psychiatry and all the other branches.

Actually with these words Leriche underscores the principals of being useful and at least doing no-harm, which are two of the four basic principles of the principalism view of contemporary medical ethics; being helpful, non-maleficence, respect for autonomy and justice [6]. We will discuss on these issues in the topics to come.

In conclusion of the preface, Leriche emphasizes the difference between being a surgeon and being a technician: “Now the era of condottiere (former partisan chefs in Italy) in surgery has come to an end. Today, no one performs surgery without complete information about the patient and his disease.”

This emphasis of René Leriche lives today in the 13th article of The Medical Ethics Regulation. According to this regulation, “physicians and dentists, make a diagnosis according to scientific requirements and applies appropriate treatment” [7].
Humanism in Surgery
Respect for humans and human life constitutes the basis of all ethical codes. In the practice of medicine, particularly in clinical medicine, the ethically emphasized “patient rights” concept is the reflection of “human rights”, “civil rights” or even “consumer rights” concepts in medicine. This era has developed by the gradual abandonment of “physician-centered” approach in which doctors form the center in clinical decision-making [5].

Leriche, who has lived through the initial stages of this transformation, did not have too much difficulty in seeing the future.

“The cost of the anxiety of concerns regarding masses of people with the benefits provided by social organizations, aiming for the high achievement of assistance, is paid by the sad ignorance of members who are left in anguish and suffering with the consequences of the disease alone. The ideas of charity and helping someone else are on their way to disappearing under the influence of administrative dictatorship and technical influences. Surgery is therefore faced with the danger of losing its soul. However, it never should lose.”

It is as if, René Leriche, in his book that he wrote in the 1950s, has pointed out the ethical problems that robotic surgery will bring in the future. Today theoretically, it is possible to perform intercontinental robotic surgery, and one of the biggest ethical problems is who will have the responsibility of the patient, the physician who examined him or the surgeon.

Leriche says:
“Maybe one day in the future such a time will come that the surgeon will perform surgery on a patient who he did not examine personally, the art will fall into a simple performance situation, so technique, inevitably, will become superior to therapeutics.”

The impending danger is expressed by these words: “Medicine, now in a hurricane of new discoveries, is almost in a dazed situation, with a bit of drunkenness by innovations and analysis, in need of passing into the era of synthesis and breathing under trees on the island of Cos. Medicine feels that the advances in technology will result in the disintegration and extinction of the oldest traditions and will lead to a danger that can not be avoided: The danger of forgetting the human, who are in the target beyond their humor, consisting of flesh and sense... Each surgeon should be a equipped with the deepest respect for the human being. “

One of the problems pointed out by Leriche is the physical condition of hospitals: “Everything in our hospitals is destructive for humanism. The degree of fusion of bodies in close proximity to each other, the noncompliance to privacy, neighborhoods that hurt the feelings of decency, continuous contact with the state of anguish, indifference to death and many others...”

While stating his ideas on state of hospitals René Leriche pointed out the principle of “justice”, that is one of the four basic principles of bioethics suggested by Beauchamp and Childress. The principle of justice in the field of health, expects the equal and honest allocation of medical resources including equipments and all kinds of services according to requirements [6]. In summary, the concept of justice that can be evaluated under the headings of planning and management of health services, health facility management and clinical diagnosis and treatment, is discussed here under the issue of how to distribute the available opportunities within the hospital to those who need. This state is also clearly stated in the World Medical Association Medical Ethics Manual [8]. At the end of this chapter, Leriche warns that not only surgeons, but also physicians should focus on remembering that patients are human:

“However, physicians have been brought up in a classical culture that helps to understand people. Nevertheless, the future physician is too young to understand the genuine nature of these very old human ideas when they are first brought up, and the physician who is sensitive to human suffering, only later and by himself penetrates into the meaning of this profession, by patient beds. Undoubtedly, most physicians are humanists. On the other hand, wouldn’t it be better if they were not to wait until they begin to learn from their own experience? For this reason, the tasks loaded with humanist ideas should be explained to surgeons, in order to maintain surgery functioning at the level that people deserve.”

Humanist Act against the Patient
Under this heading, René Leriche once again underlines the issue on remembering that patients are human beings. According to him, the most fundamental principle of surgery is to listen to the patient carefully and making sure he feels this:

“The conditions which require getting in touch with surgery, even when it is not tragic, are exciting.” ... “The fear of the suddenly appearing unknown, fear of pain, fear of death, fear of not regaining completeness of the body parts that has been lost or is in the danger of being lost.”... “The first humane duty of surgeons is to know to console this excitement. In order to achieve this, the first thing he should do is to listen to those who entrusted him with their bodies. “...” Trust can be gained through the simple act of listening very carefully. “

However, speaking about humanist duties towards patients, Leriche opposes the most current principle of bioethics: respect for autonomy. Respect for autonomy argues that the decisions regarding the individual, who gradually increases his voice, should be given by himself and independently. There are items that need to be included in the decision-making process. These are; the individual’s being autonomous, being able to make autonomous choices, and acting consciously and willingly. In order to achieve this, in general the individual and in particular the patient must receive general information about the disease completely, accurately and understandably [6]. This situation is secured by prohibition of any medical procedure without the consent of the patient, by Patient’s Rights Regulation in Turkey under the title of Patient Consent for Medical Intervention [9].
The Agreement on Protection of Human Rights and Human Dignity in Application of Biology and Medicine: Regulation for Human Rights and Biomedicine, signed in Oviedo, on 04.04.1997, also necessitates receiving informed consent from patients before any medical intervention. This agreement was signed by The Turkish Republic on April 4th 1997; approved by The Turkish Grand National Assembly on 03/12/2003. It was declared as a law under the title of “The Agreement on Protection of Human Rights and Human Dignity in Biology and Medicine: Regulation for Human Rights and Biomedicine: The Law on the Approval of this Regulation “. It was published in the Official Gazette numbered 25311 with the Law number of 5013 on 09.12.2003 and has been effective since then.

Leriche, on the other hand, parallel to the popular approaches of the 1950s, thinks that only physicians will know what is right for the patient. This situation, named paternalism in current ethical approach, remains to be an area of debate, often being the focus of criticism [10-13].

René Leriche’s opinions on informing patients are as follows:
“Some surgeons like to exaggerate dangers, express doubts and worries and let the patient choose the therapy, based either on their character or some concerns. They think this will decrease their liability. This is an unnecessary measure and inhumane cruelty. The surgeon should keep his doubts and concerns to himself. He should take every and any decision by himself and take full responsibility for the treatment that the patient requires.”

Humanist Duty in Operation
Leriche strictly adheres to the Hippocratic Oath when it comes to matters of actions in surgery. In parallel to the statement in the standard text of Hippocratic Oath, “I will leave the job to a specialist if it is necessary to remove a stone from the bladder”, he thinks one of the most important issues when operating is the surgeon knowing his boundaries. He defines leaving the scene to a superior when necessary as one of the most crucial point in surgery. Leriche emphasizes to surgeons that withdrawal when required is one of the greatest virtues. This situation is included in detail in the Medical Ethics Regulation’s articles on consultations and in the fourth section of The World Medical Association Medical Ethics Manual under the title of “Physicians and Their Colleagues” [7, 8]:

“When it comes to surgery if the surgeon believes the task to be difficult and has a sense that he does not possess all the required qualifications, his duty is nothing but to leave the scene with humility to those who are more competent on this particular task. The phrase of ‘knowing thyself’ is one of the cornerstones of morality in surgery. Humanism, which constitutes the moral essence of surgery, mandates that we should know our personal boundaries and that we shall not exceed this boundary. A well thought-out decision of withdrawal will never be a reason for humiliation.”

“Humanism expects from all of us, to act in each case to the extent of our information.”
“Today, the ability of operating is not enough by itself.”

In this section, René Leriche also underlines that surgeons should be open to innovations. Both the Human Rights and Biomedicine Convention signed in 1997 and the Turkish Medical Deontology Regulation [7, 14] protect this situation. Tenth article of the Medical Deontology Regulation prohibits the use of treatment methods that are being investigated, without thorough consideration and thus as a sub-text underlines the necessity of following current developments within the profession for the associated physicians. The 13th article of the same law states that the physician should diagnose and plan treatment according to scientific requirements [7].

Leriche’s ideas on following the contemporary are quite clear and meaningful. Leriche states that surgeons should follow new treatment methods and should be open to innovation, but underlines that all these do not mean that the surgeon should give up all their own experience:

“There is a most appropriate treatment for each case, and we should definitely know this. We all are obliged to follow the rules that match the characteristics of the case and to comply with any innovation.”

“Our absolute duty regarding new findings is to always be open-minded, and to accept new information in a positive manner. Nevertheless, this does not ever mean to give up on ‘sans critique.”

“A science like surgery, with its humanistic sense in permanent maturation state, mandates surgeons to keep their ideas open to innovations at all times.”

René Leriche states that following new treatment methods would be beneficial and effective only if the surgeon is sure about the diagnosis of the disease:

“But for us only following the continuous progress of our art is not enough. More importantly, our thoughts are occupied by concerns on if we were wrong in the diagnosis or if we performed bad surgery.”

Leriche highlights that making the correct diagnosis relies on being able to objectively reviewing past experience no matter if it was successful or not:

“We, with human feelings, forget our failures so quickly and underestimate our mistakes. We do not know to take benefit from their practical lessons.”

Teaching Position
René Leriche underlines that a surgeon’s task is not limited to performing surgery alone and that the duty of teaching is as important and necessary. “To be efficient, a perfect surgical technique, maximum care on observation, an eternal spirit of humility, patience and a permanent resourcefulness are required. The ideas are headed into the future, and do not give in the convenience of pessimism. “...” in summary, the humanistic rule mandates search of experience in the training of tomorrow’s surgeons.”

Means of Research
René Leriche constantly emphasizes the need of a surgeon listening attentively to the patients and requirement of close observation before surgery. According to him, observation and monitoring the patient are very important: The Share of Observation: “Doubt is the first step towards invention. If a point that is not compatible with the ordinary acceptance is felt, the experience should be overviewed again and this point should be focused on in no hurry to decide immediately and without going to a fictitious explanation. ... Should be returned to the point of search and the opportunity to re-observe and re-examine should never be missed.”

However, according to Leriche a surgeon will not get anywhere only with observation. He has to possess the ability to synthesize the data obtained in a way that it can be helpful in making a diagnosis. This feature also should be free from any financial concerns:

The Role of Intelligence: “Observation will remain as an inconclusive study without the help of intelligence that will turn it into something beneficial. Observation cannot be done just to observe. We are not butterfly collectors. Our observations should have an ideal objective. These objectives are to rank according to importance, to place each value wherever it is worth and to ensure order within information. This is the reason why intelligence is the utmost means of research. However, the type of intelligence that we require should be particular in a way and must be free from any material objective, especially in the subject of benefit.”

“Hoping to achieve definitive results in a great leap is an illusion.”

Surgery Serving Life and Today’s Surgeons
The next stages of the book list properties of surgeons. René Leriche emphasizes the importance of seeing a surgeon at work in order to make a decision about him. The best way to do that is to watch him in the operating room. In his book, he describes the surgeons he has observed in detail:

“For a surgeon, judgments can be made during their work. The operating room is the arena of truth for him. ... Until recently, there were many meanings of the test taken there. People were seen with all the bareness there, with all the virtues and vices. There were the talented as a juggler, the elegant, the quiet, the cold-blooded, the more cautious, the excited, those trying to finish the operation as quickly as possible as if it was a burden, and the anatomists. There were those who get confused, the arrogant, and finally those who chat to gain courage. Today it seems as if there is a monotonous uniformity. The tools placed around in order to prevent and fight diseases after surgery, application of technique, the progress in anesthesia, have all completely changed the atmosphere of the operating hall. The formerly completely personal art has been placed with a calm technical science with special laws and theoretically, surgeons throughout the world should act likewise.”
According to Leriche, performing surgery is not enough in order to become a surgeon. Experience is essential to perform surgical manipulations; however, this feature is not enough. In order to avoid a surgeon staying at the level of technicians he should accept surgery as a life style:

“Today, many people in fact perform surgery. However, unfortunately, not all of them are true surgeons. The true surgeon is a person equipped with pleasure of movement, attracted to risks, carrying a different type of soul. This indulgence and pleasure of movement share a common basis. This indulgence is a one towards full control, playing on the edge of cliffs, common sense, balance and equilibrium and towards an open and serious game that requires practical competence”.

René Leriche divides surgeons into three groups. The first group consists of extremely talented people; the most important feature of the second group who constitute the majority is not talent but planned and scheduled work. Both groups are praised by Leriche, who seems to be in favor of the third group of surgeons, who adopted acting with conscience as main principle:

“Furthermore, despite their similar results, surgeons at work are not alike. They may be separated into three classes.

First, are those who carry amazing dexterity as the old ones. ... They overcome apparent difficulties in such a play-like manner that those who watch assume the task to be easy.... Their works are perfect from the beginning to the end, giving the impression of an art. ...

The majority of surgeons are included in another class. They do not possess that innate skill. Nevertheless, they have other virtues. Surgery for them is like a pre-drawn picture of architectural work, everything is obvious, difficulties are not covered in a crafty manner, every movement is done on time, is well-measured and is complete. Spectators will see everything clearly; will understand where it is headed to. The whole surgery is carried out in silence by a perfect method. Fortunately, the anxious, angry, chatty type has now disappeared. ...

Suitable for any kind of surgery these operators in the second group always give the impression that they are in full control. They do not underestimate danger, but measure its degree to make sure it can be overcome with their abilities. Precautions and safety get well along with the daring composition in them.

Some rely on anatomy, and some act more on intuition. Some like a perfectly disposed surgery like a nice mounted movie. While others prefer complicated surgeries that require sudden creations and decisions, they only can find their identity in the face of great difficulty.
…

“Some surgeons always get a happy ending. These are called the fortunate ones. ... The fortunate operators are accurate and complete in diagnosis, and cautious for a right indication in the right time. It is worth the effort to insist on the accurate indication. The difference between surgeons becomes more obvious in this regard. Some people do not give too much attention for it. They remove any abnormal or a somewhat oversized thing, this is a huge mistake.”
…

“Exceptional and limited number of surgeons are inventors. They have the innovative ideas that can think on and find a solution to problems, facilitating surgery or a surgical movement.
…

Third category: These excellent professionals know the limits of their work and do not cross boundaries for things they accept beyond their experience. Their conscience does not allow any daring. Because they know too much courage in surgery might cost a person’s life or at least a disability, but in general, if they feel it is right they are capable of performing any kind of surgery.”
…

Leriche divides these three groups into three sub-groups based on their age. He talks about the courage of the young surgeon, the always fresh-kept interest in the advanced age, and emphasizes creativity as what makes them different in the last group without commenting too much on their age: “In all three categories I have mentioned, age has caused some minor differences.

The young surgeon: ... Young people are sometimes called more daring, but it is youth who produces great work. Young people are a bit harsh to those that came before them. They are relieved of hesitations of the past, which is so close, but is believed to be far away. The younger generation is ruthless, and may not always be fair, but is sympathetic.

The surgeon who will face anything and will not give his profession up although he grew old while working because the art has penetrated within his soul: This type shows great care for indications and is very restrained in judgment. Some do not like innovation; it is a sign of impending fatigue and inevitable senility. The hardest thing for an aging surgeon is to stand to not being consulted about innovations regarding the future. ... Accepting that their future is now left behind is a difficult task for them.

Essentially all surgeons are quite similar. Compassionate with human misery, passionate for the art, common in the belief of their services against humanity. They never fail in mutual respect when criticizing each other. Those they will not forgive at all are the ones considering their own during surgery and those preferring safe and easy operations only for statistics, or in order to increase the number.
…

The best surgeons are those who are able to maintain their fitness and comfort during the long-lasting jobs.”
…

Meanwhile, he puts emphasis on the importance of surgeons looking back and criticizing themselves objectively whatever the age and properties are from time to time.

Failure, even if it is relative, always hurts us. Each surgeon carries a sad one within, stacked with painful events that have occurred. Sometimes he thinks over these painful memories... looking for the cause.
…

There is a final category of surgeons separate from all the others: The Creators. They find new methods of treatment and experience it.
…

They ... will not attempt for anything unless spending a long time on maturation of the thought and experiencing the effects they envisioned on animals if needed.
…

It is necessary to fight, because not all ideas give their fruits in the first summer of flowering. Innovative methods cannot be accepted over one day. The creator faces the crops in a long time. He seeks truth, in the bitterness of indifference or even opposition, by changing the methods of proof and by himself. He has to endure but he cannot control time. It is as if some ideas wait for the owner’s death to thrive. Such belated success, leads to forgetting of the pioneer. For example in the contemporary surgery of pulmonary tuberculosis, does anyone still think of Tufferier, Wilms or Sauerbruch today?”

Surgical Spirit and Healing Spirit
In this part of the book, René Leriche defends the thesis that surgery has an individual spirit and lists the properties of this soul. According to him, the most important features of the surgical spirit are courage, self-belief, optimism, as well as being able to making quick decisions. The surgeon remains alert by constantly facing with dangerous situations. This situation leads to his assertiveness, not a blind one but a well-thought, measured situation:

What is actually the spirit of surgery?
This is a spiritual mood where virtues like courage, self-belief, being able to making quick decisions, and optimism maintains equilibrium according to the requirements of the moment.

This state inclines people to a continuous activity. In addition, directs him to overcome threats or danger in seemingly lost cases with intelligence, and dexterity of their hands but this is not a manifestation of a foolish self-reliance. In fact, it is a task undertaken after assessment of the real situation of the disease and technical possibilities, at a glance.

It is such a mood that the stimulus is the feeling of contact with danger. Sometimes the surgical soul is mixed with the ambitious state of a gambler. Surgery is not a job for the self-indulgent warm hearted.
…

However, the surgical spirit recovers surgeons from this fear and forces them to always experiencing fortune as though it will definitely succeed.

While ranking all of these features, Leriche never loses his humanist perspective. He underlines that the possibilities and powers in the hands of surgeons at the same time should put them under a heavy responsibility, therefore each surgeon being constantly in reckoning with their conscience:

The responsibility mentioned here is the responsibility of the surgeon for himself. A genuine surgeon knows very well that the failure of his attempts will cost the life of a human being and a family’s mourning. That is what is taken into account.
…

Surgeons like to be challenged until the end of his life; the surgical soul dies only with him.
…

Each operator may face a sudden great responsibility. At all times, he should be prepared for any possibilities, even those requiring mastery.
…

Therefore it should be clearly expressed that there is no, and will be no class of minor surgeon concerning future organizations. Operators should be perfectly equipped.
…

That is why the surgical spirit should co-exist with the healing spirit in every surgeon.

The Idea of Human in Treatment
Finally, René Leriche returns to the subject of humans. He clearly reveals his intentions to go into the philosophy of the subject at the beginning of the book. Therefore, he strongly emphasizes that the patient is far from being just an organism developing pathology. He indicates that the patient should be evaluated not only with their pathology in the organs but also together with their individual and social characteristics.

At this stage, perhaps the most critical question of medicine is reminded once more for surgeons: Does treatment mean just the elimination of pathology? Is it always a victory to provide people with a somewhat longer life, or should it be the patient’s right to speak on this issue? In this sense, he refers to the concept of euthanasia that is still being debated in the area of current medical ethics [15-18].

Dealing with therapeutics is attempting to deal with the disease itself or the destruction it has caused. Treatment is an act of trying to put an end to the pathology phase the patient is experiencing. During this action, we see people as who they are, we feel pity, and we struggle to strengthen their spirit. However, because we are brought up with books rather than people, our patients can easily become an ordinary case for us and with professional deformation, by relevance to pathology we forget the individual in the middle of life, in face of their familial and social world. We will be happy as if nothing will be expected from us once the manifestations of the disease and its reason disappears.
…

What I want to tell you is this: Since we have the emotion of human fear, the surgical cures we provide should not be judged in terms of pathology alone. This treatment should also be measured and evaluated according to the state of the individual, and the life that individual is returning to.

When reporting on our statistics, it would be helpful to add a column to express the human value of our operations besides those stating the results in terms of the disease.

We need to try to learn if the patient having surgery is satisfied with the new situation or not. Because if not satisfied could this be considered as healing?
…

In order to judge in this regard we need to follow them up in everyday life, we are obliged to receive information about their situation from our social workers. These helpers know a lot about what happens after our operations are done.
…

We all have heard from at least one of these brilliant results, namely the rescued ones, saying “would have done better if you had left me for dead.

With all these thoughts, Leriche reveals the importance of the struggle surgeons have with themselves. According to him, the surgeon who likes everything he does without question and disregards the thoughts of their patients has come to the end of his professional life.

We should always keep in mind that our decisions can lead to the worst result in a man’s or woman’s affective life. We should think on the purpose of our art and should understand especially the human side of some therapeutic problems. Our profession, has given us regalien (rights reserved for kings) rights and authority over people. However, we have to keep our duties superior to our authorization.
…

Many times, we would say, I apply my method all the time, because it does not give bad results. In fact, acting in this way, unknowingly, we resist innovation. We minimize its content and keep ourselves away from the trouble of learning.
…

The surgeon, who likes the work he has done easily, has entered the routine way, i.e. the end stage.
…

The therapeutic spirit considering human life besides the disease is essential for surgery.

Conclusion

René Leriche, who describes surgeons as a man of mercy as well as a man of action, underlines the requirement for surgeons to re-evaluate themselves in his book titled The Philosophy of Surgery. He once again emphasizes that within an increasingly mechanized, technology bound and individualized culture, each surgeon is a human being and as clearly expressed in The Medical Ethics Statute he should provide hope as well as comfort to those he serve.

This valuable piece written by an important thinker-surgeon, who did not take his place in the world medical literature just with his scientific studies, but also with his humanist approach, invited his colleagues to be more human than anyone else. This book undoubtedly deserves reading repeatedly and thorough discussing.

References

1. Editorial. In Memoriam: René Leriche (1879-1955). Honorary Fellow of the College; Membre de l'Institut de France. Ann R Coll Surg Engl 1956; 18: 132-133.
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