“To Afford the Wounded Speedy Assistance”: Dominique Jean Larrey and Napoleon
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- Skandalakis, P.N., Lainas, P., Zoras, O. et al. World J. Surg. (2006) 30: 1392. doi:10.1007/s00268-005-0436-8
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Dominique Jean Larrey (1766–1842) has been described as the father of modern military surgery and is considered even today as the model military surgeon. He developed a plan of rapid evacuation of wounded soldiers from the battlefield during combat, using flexible medical units which he named ambulances volantes (“flying ambulances”). He won the admiration of Napoleon Bonaparte (1769–1821), who was amazed by the results of Larrey’s sanitary system. Larrey spent almost 18 years with Napoleon, accompanying him in 25 campaigns, 60 battles, and more than 400 engagements. Napoleon’s enormous military success was due not only to his strategy and skill but also to the medical services provided by Larrey. The surgeon became a master of wound management and limb amputation. In his vivid battlefield journals, Larrey documented the course of tetanus, the pathophysiology of cold injury, the effective control of hemorrhage, the drainage of empyema and hemothorax, the aspiration of pericardial effusion or hemopericardium, and the packing of sucking chest wounds. Larrey established a categorical rule for the triage of war casualties, treating the wounded according to the observed gravity of their injuries and the urgency for medical care, regardless of their rank or nationality.
It is said that history is made by great political figures. However, on many occasions, great medical figures have influenced the course of history, contributing to its final shaping. One such figure was Baron Dominique Jean Larrey (1766–1842), the courageous and humane surgeon of Napoleon Bonaparte’s Imperial Guard throughout the Napoleonic Wars. A man who has been described as the father of modern military surgery1 and of the modern ambulance;2 a man who is considered even today as the model military surgeon;3 and the man who moved one of the greatest military leaders of all ages, Napoleon, to bow to his genius and praise him in these terms: “Il est l’homme le plus vertueux que j’aie connu” (He is the most virtuous man I have ever known).4,5
The first effects of this concussion of the brain are sadness and a panick which seizes the individual; the face becomes pale, the eyes are suffused with tears, and the appetite for food is entirely removed. ... The nutrition of the body is suspended, because nothing can be retained in the stomach; emaciation ensues and increases. The faculties of the mind suffer in common with the organs of animal life, and this change takes place to such a degree that instead of dreading death, as in the commencement of the disease, their suffering is so intolerable that they desire it; and as I have seen, attempt to commit suicide.8
The misfortunes of others affect me strongly. Serious disasters afflict my soul and plunge me into the deepest grief; I often think I can do something to help, and even attempt to remedy the situation. But such is my nature that I am thrown off balance and reason is no longer in control.9
It was this humane but impulsive character that led him to publicly express his political concerns on 14 July 1789, when he led 1500 medical students to the storming of the Bastille.10 Three years later, while he was still in Paris, France went to war. The skilled and attentive Larrey was assigned as a divisional Surgeon-Major (Chirurgien-en-Chef) in the Army of the Rhine.2 This was a turning point in Larrey’s career and life.
His appointment to the Army of the Rhine provided the young surgeon the opportunity to see with his own eyes the medical problems of battlefield and realize the obvious dearth of succor for the wounded soldier. He was shocked by the low value that was attributed to soldierly life, mostly by high-ranking officers of the army, and was astonished by the nonexistence of measures for the salvage of injured soldiers. The wounded lost their humanity and were largely ignored. They were not considered to be suffering individuals, but problematic units that slowed the progression of an army. For a man whose life was driven by compassion and morality, the unjustified death of even one soldier who could be saved was unacceptable.
I now first discovered the inconveniences to which we were subjected in moving our ambulances, or military hospitals. The military regulations required that they should always be one league distant from the Army. The wounded were left on the field, until after the engagement, and were then collected at a convenient spot, to which the ambulances repaired as speedily as possible; but the number of wagons interposed between them and the army and many other difficulties so retarded their progress, that they never arrived in less than twenty-four or thirty-six hours, so that most of the wounded died for want of assistance. ... This suggested to me the idea of constructing an ambulance in such a manner that it might afford a ready conveyance for the wounded during the battle.11
We found it impossible to bring off our wounded, who fell into the power of the enemy. This misfortune induced me to propose ... the plan of an ambulance, calculated to follow the advanced guard in the same manner as the flying artillery. My proposition was accepted, and I was authorized to construct a carriage, which I called the “Flying Ambulance.”...
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 rolers [sic]; 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. ... The small carriages, were thirty-two inches wide, and were drawn by two horses. Two patients could conveniently lie at full length in them. ... These carriages united solidity with lightness and elegance...
With these ambulances, the most rapid movements of the advanced guard of an army can be followed up and, when necessary, they can separate into a great many divisions, every officer of the medical staff being mounted and having at command a carriage, a mounted overseer, and everything necessary for affording the earliest assistance on the field of battle....12
The total number of persons in each unit was 340: three ambulance divisions of 113 men and the surgeon-in-chief of the three divisions. Each ambulance division consisted of one surgeon-major first class in command, two surgeons-major second class, twelve medical officers (two were pharmacists), one lieutenant administrative officer, one second lieutenant (inspector of police and assistant), one adjutant, one ambulance sergeant-major first class, two sergeants third class, one trompette in charge of the surgical instruments, twelve mounted medical attendants (among them a farrier, a bootmaker, and a saddler), one sergeant-major first class, two quartermaster-sergeants second class, three corporals, one drummer boy, 25 unmounted attendants (soldiers) and twelve light and four heavy carriages with their own personnel.7 The medical officers carried portable surgical instruments, field dressings, and some medications on their saddles as well as in the carriages, creating the possibility for greater mobility and flexibility on the battlefield.13 The light vehicles, pulled by one or two horses, carried the wounded to heavier vehicles, which took them to dressing stations or hospitals stationed at the rear.2 These “flying ambulances” were tested for the first time in the battle of Metz in 1793, where they proved a complete success and were welcomed by the soldiers with excitement.2 This organized team of specialists with their equipment increased the chances of survival of the wounded soldiers during battle and lifted the morale and the confidence of the French troops. Larrey proposed an unprecedented and extremely organized sanitary system for the rescue of soldiers, which a few years later was adapted to the entire French army. However, due to political opposition, the “flying ambulances” were officially used for the first time during the campaign of Italy in 1796–1797,6 with the forces under the command of a young general who was to become a legendary figure of world history, Napoleon Bonaparte (1769–1821).14
The two men had met in Toulon in 1794, when Napoleon was a young and promising artillery commander and Larrey was Chief Surgeon of the French Army that aimed to recapture Corsica from the British.2 Larrey was impressed by the intelligence and dynamism of Napoleon, but he never imagined that he would spend almost 18 years with him, accompanying him in 25 campaigns, 60 battles and more than 400 engagements.15 During the campaign of Italy, he won the admiration of Napoleon, who was amazed by the results of Larrey’s sanitary system. Napoleon said to the magnificent surgeon: “Your work is one of the greatest conceptions of our age and alone is sufficient to ensure your reputation.”16
Larrey was the most honest man, and the best friend to the soldier that I ever knew. Vigilant and indefatigable in his exertions for the wounded, Larrey was seen on the field of battle, after an action, accompanied by a train of young surgeons, endeavoring to discover if any signs of life remained in the bodies. ... He tormented the generals, and disturbed them out of their beds at night whenever he wanted accommodations or assistance for the wounded or sick. They were all afraid of him, as they knew he would instantly come and make a complaint to me. He paid court to none of them, and was the implacable enemy of the fournisseurs (army contractors).3
Napoleon’s esteem for Larrey can be better understood if we embrace the view of many historians who believe that Larrey’s extraordinary medical organization of the army and his devotion to his commander were two key components of numerous victories by the French army during the Napoleonic Wars.
As Dible17 indicates, Larrey “was chronically plagued by some degree of financial anxiety.” Army surgeons, as noncommissioned military, were of lesser rank than senior officers. Generals were known to profit in many ways from their positions; the upright man of medicine did not enrich himself through his service to France as did others. During his foreign campaigns, Larrey’s material holdings also fell prey to two instances of malfeasance. An annuity granted with his baronetcy was not disbursed, despite his repeated pleadings, and his savings of thirty thousand francs was embezzled by an acquaintance.17 Larrey’s fortunes improved somewhat during his latter years in Paris, which included positions at various hospitals and service as Surgeon to the Royal Guard, where he continued to devote his efforts to the care of wounded veterans.
When Napoleon died in 1821, in an act of recognition, the greatest surgeon of his army was willed the extraordinary sum of 100,000 francs.3,14 Larrey surely must have felt extremely honored and pleased to receive such a manifestation of gratitude from the man he had served for almost two decades of military campaigns, following him through many countries and continents.
Larrey’s devotion to his commander plunged him into profound mourning at Napoleon’s death. On 14 December, 1840, in the bitter winter, the exhausted 74-year old surgeon once again donned his uniform to join in the ceremony of repatriation of Napoleon’s disinterred remains.2,6
We believe that Napoleon’s enormous success in the majority of his campaigns was not only due to his military strategy and skill, but also to the large numbers of soldiers saved by the “flying ambulances” and by the medical services provided by Larrey.
But it was not only Napoleon who admired Larrey. The surgeon’s reputation extended throughout France, as well as outside the country. During the decisive battle at Waterloo, he elicited the respect of Wellington, who stood amazed by the battleground sight of a French ambulance in direct proximity to the British army. When the general was informed that it was Larrey himself attending to the wounded, it is said that he exclaimed, “I salute the honor and loyalty of such a doctor,” and shifted his line of fire away from the surgeon.15,18 But the greatest admirers of Larrey were the French soldiers, who were buoyed by the deployment of the flying ambulances. For the first time, there was tangible evidence that somebody in authority was cognizant of the vicissitudes of combat. The troops were aware that even if they were wounded in the battle, Larrey’s organization and skill would, in most cases, save them from death. For this, they worshiped Larrey and called him “La Providence” (Savior).6,19
The love of the simple soldiers for Larrey was manifested many times during Napoleon’s campaigns. A telling incident occurred in 1812 during the Russian campaign. As the retreating French army attempted to cross the Berensina River by temporary bridges that were crowded and blocked by wounded men, broken vehicles, and fallen horses, Larrey realized that he had forgotten some of his surgical instruments on the side of the river and went back to recover them.3,5 When he attempted to cross against the human flood on the bridge, some soldiers who saw him cried to their comrades, “Save our Savior!!!”19 Instantly, the men formed a pathway for the extraordinary surgeon and helped him to cross the bridge quickly by carrying him hand-to-hand above their heads.19 Thus, he was safely brought to the opposite shore. A truly magnificent moment of recognition for the work of a noble man!
...those dangerously wounded must be attended first entirely without regard to rank or distinction and those less severely wounded must wait until the gravely hurt have been operated and addressed. The slightly wounded can go to the hospital in the first and second line, especially officers because the officers have horses.1
But the astonishing fact that surprises us even today is his attitude toward the wounded soldiers of the enemy, a stance that demonstrated his extremely high moral principles. On many occasions, he collected enemy soldiers who had been injured by French canons and weapons, then treated them in the same manner as he did his countrymen. He was a true military surgeon, who obeyed the rules of both medicine and humanity, not just the rules of war. And it was this service to a higher authority that permitted him to evade death. After the final defeat of the French army in the historic battle of Waterloo in 1815, Napoleon ordered Larrey to retreat and save his life. Unfortunately, the dedicated surgeon tarried to supervise the ambulances and the field injuries. He was overtaken and wounded by the Prussian cavalry. An order of execution was immediately issued, but it was never carried out. By a stroke of luck, Larrey was recognized by a young Prussian surgeon who had been taught by him during a surgical meeting in Berlin. He was then taken to see the famous Marshall Blucher, who welcomed Larrey as a friend. Blucher felt profound gratitude for the French surgeon, who had saved the life of his gravely wounded son in a previous campaign in Austria. He treated Larrey with respect, offering him food and money before allowing him safe passage to neutral territory. Thus, Larrey’s life was spared as a result of his devotion to the common soldier.2,3,15,22
Larrey’s devotion to the common soldier can be appreciated in his unflagging attempts to save as many wounded combatants under fire as possible. In his Memoirs of Military Surgery, Larrey sets the highest standards of selflessness for “young army-surgeons”: “...they should never go to the field of battle without taking with them all the instruments and dressings necessary to afford the wounded speedy assistance, even if they should be under the necessity of carrying these articles themselves.”23
Fearful of taking patients directly to the hospital, which would delay surgery and increase the risk of hospital infection, Larrey believed that early amputation and care reduced suffering, morbidity, and mortality.25,26 “The first twenty-four hours is the only period during which the system remains tranquil, and we should hasten during this time, as in all dangerous diseases, to adopt the necessary remedy.”27 This dictum stood in contradistinction to the prevailing surgical practice of postponing amputation for as long as twenty days.28 He strongly advised that treatment of the wound should be done as soon as possible after injury to reduce the risk of tetanus, wound shock, and late infection.1,2,10,15,25 Early amputation also favored greater success in more complicated operations such as multiple amputations.13
Not only was Larrey a proponent of the amputation of a gravely injured limb within hours; he also performed a complete debridement to provide a good stump. Thus, he minimized the aforementioned possibility of infection of nonviable tissue, which often proved to be fatal, and ensured satisfactory mobility of the limb.26 He devised the Larrey disarticulation of the shoulder and hip and an immobilization of the limbs involving a splint.15
The campaigns of the French army in regions of harsh winter conditions allowed Larrey to study injuries caused by extreme cold. He documented the pathophysiology of cold injury, observing that gangrene developed in frostbitten parts that were suddenly, instead of progressively, exposed to extremely warm temperatures. Larrey was one of the first clinicians to use effective precautions against the development of gangrene in such conditions.29 Some other surgical contributions by Larrey were the effective control of hemorrhage in the battlefield, the drainage of empyema and hemothorax, the aspiration of pericardial effusion or hemopericardium, and the packing of sucking chest wounds.1 His astute character permitted him to also make many non-surgical observations, such as the increased possibility of infection in a hospital setting and the related principle of contagious isolation.15 Larrey treated the inability to breathe by delivering air into the nares.1 His meticulous descriptions of the course of tetanus led him to propose the lifesaving immediate amputation of tetanus-affected limb injuries.1 Among many other observations, Larrey also noted the formation of liver abscesses when contaminated water was consumed, as well as the need for an operation for the treatment of meningeal hemorrhage.2 Undoubtedly, the contributions of this master of surgery to the medical world are multifaceted and unprecedented.
Dominique Jean Larrey died in Lyon on 25 July 1842. He was 76 years of age.6 He developed severe pneumonia during a trip back home to France from Algeria,19 where he had gone to inspect military hospitals with his doctor son Hippolyte (1808–1895).30 Although Larrey was in poor condition, he expended his strength in a precipitous return journey to reach his beloved wife, Elizabet Laville, who was herself terminally ill.19 Tragically, his wife died a few hours before her loving husband.6,19
Larrey’s death was a national event. However, his last wish, to be buried at Les Invalides among his soldiers, was not immediately respected due to opposition by the minister of War, Nicolas Jean de Dieu Soult. Soult had in the past disagreed with Larrey, who had proved him wrong in front of Napoleon about allegations of self-mutilations by soldiers. Soult never forgave Larrey for this public disagreement.6,31,32
As a “mere surgeon,” Larrey was denied a resting place among the marshals, generals, and soldiers; but his burial at the Père Lachaise cemetery attracted thousands of mourners.28 Two separate urns containing his heart and viscera were entombed in a vault in the chapel of the military hospital of Val-de-Grâce.6 However, Larrey’s last request was finally honored on 15 December 1992, when his body was transferred to the Hôtel des Invalides, close to those he selflessly and courageously served for many years. At the same time, another urn containing a fragment of Larrey’s intestine was placed in the National Academy of Medicine.6
This unique teacher and representative of medicine is considered one of the greatest medical figures of France, and a paragon of the healing arts. His magnificent skill, his meticulous observations, and his morality allowed him to become the first, and probably the greatest, military surgeon in history. Certainly, the conception of the flying ambulances is considered by many to be the basis of military emergency medicine. Larrey’s humanitarian attitude toward the troops, and his tremendous effort to save every last wounded soldier, regardless of rank or nationality, lifted his reputation and may even have saved his life on numerous occasions. Napoleon’s respectful attitude and admiring comments toward the surgeon who probably was the key to many of his victories ensured Larrey’s immortality and spread his fame worldwide.
To perform a task as difficult as that which is imposed on a military surgeon ... I am convinced that one must sacrifice oneself, perhaps entirely, to others; must scorn fortune and maintain an absolute integrity; and must inure oneself to flattery.9