490 Proc. roy. Soc. Med. Volume 70 July 1977

Section of the Historyof MedicinePresident F F Cartwright FFARCS

Meeting 2 March 1977

Paper

Larrey - What Manner of Man?

by R G Richardson MA BM(Shortlands, Kent)1

Dominique Jean Larrey (Fig 1) was undeniablyone of the greatest of military surgeons. Yet hischaracter and achievements have never really beenappreciated on this side of the Channel. Mostpeople, if they have heard of Larrey at all, wouldsay he was Napoleon's surgeon and, if pressedfurther, might recall that he invented somethingcalled the flying ambulance (Fig 2) and wassurgeon-in-chief of the Grande Armee. But theseare only half truths. Larrey was never Napoleon'spersonal surgeon - this job was held by AlexandreYvan from 1796 until he deserted his master at thefirst abdication; Yvan was in any case far more toNapoleon's surgical taste as he held conservativeviews about amputation and the use of the scalpelgenerally. Larrey, therefore, had to limit his am-bition to becoming a surgeon to the ImperialHousehold.

Unfortunately, as chief surgeon to the ImperialGuard - an army of the elite within an army - hewas seen as an uncomfortable threat by those whosought power and influence at Court. Con-sequently, his ambition was thwarted over andover again by the devious actions of, in particular,Jean Nicolas Corvisart, physician to His Majesty,and Antoine Dubois and Alexis Boyer, surgeons tothe Household. In 1813, however, Larrey's claimcould be denied no longer and at this eleventh hourhe was appointed to a year-old vacancy among thesurgeons to the Imperial Household (Fig 3).As far as his achievements in battle are con-

cerned, Larrey should be remembered not just forinventing a flying ambulance but for establishingand putting into practice the whole principle of

1 Correspondence to: The Old Cottage, 258 Bromley Road,Shortlands, Kent, BR2 OBW

Fig 1 Dominique Jean Larrey, a painting probably by hisfriend, Anne Louis Girodet

Fig 2 Larrey's two-wheeledflying ambulance

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Fig 3 Larrey and Napoleon, an engraving after a paintingby Carl Steuben. (By courtesy of the Wellcome Trustees)

casualty evacuation as we understand it today. Hisflying ambulance was simply the first link of thesuperb system he built up, virtually from scratch,of caring for the wounded from the battlefield,through clearing stations to base hospitals (Fig 4).As early as 1797, after watching an ambulancedivision on manceuvres in Italy, Bonaparte re-marked 'Your work is one of the greatest con-ceptions of our age.' Unfortunately for the Frenchsoldier, Napoleon proved reluctant to proceedbeyond the compliment.

Larrey's problems probably began in Egyptwhen, as surgeon-in-chief to the Army of theOrient, he chose to remain with the soldiers ratherthan accompany Bonaparte back to France. Then,when he did return two years later in 1801, he puthis wife before his future emperor. I believe Napo-leon never truly forgave him; and when the new

appointments were made, Pierre FranSois Percywas appointed as surgeon-in-chief to the army,which became the Grande Armee, while Larreywas left as chief surgeon to the Consular Guard,later the Imperial Guard.

It could of course be argued that Larrey got thebest of the bargain, but so far as the army as awhole was concerned it meant that the Guardderived most benefit from Larrey's genius. How-ever, this is not to imply, as some have done, that

Larrey's excellent system was restricted to theGuard, for, whenever circumstances permitted, hewould go out of his way to help the casualties oftheline. In fact, Percy was frequently late on cam-paigns, and on many occasions Larrey was orderedto take complete surgical charge. This happened,for example, on the 1805 campaign leading up toAusterlitz; but at Jena the following year when theImperial Guard was not committed, MarshalBessieres, its commander, refused Larrey per-mission to assist his colleagues (Percy included) onthe field of battle. 'The Emperor and all thewounded did not cease calling my name on thatbrilliant but ghastly day', he wrote to his wife,Charlotte. Without his presence any attempt to dealmethodically with the casualties and to evacuatethem with any semblance of order fell apart at theseams.

Larrey succeeded Percy as surgeon-in-chief ofthe Grande Armee in February 1812, but onNapoleon's return from Elba Percy, who was bythen old and infirm, was re-appointed.An assessment of Larrey's character is difficult

to make, since contemporary diaries, memoirs, andother works tell us little. We have to rely mainly onthe judgments of Napoleon, first in his will: 'Themost virtuous man that I have known' (hereNapoleon was using the word 'virtuous' in theRoman Republican sense of courage with honour,valour and integrity - it is really untranslatabletoday as the concept no longer exists); andsecondly in his conversations with Dr BarryO'Meara and Dr Archibald Arnott on St Helena.Napoleon said to O'Meara that:

'Larrey was the most honest man, and the best friend tothe soldier that I ever knew. . He tormented the gen-erals, and disturbed them out of their beds at nightwhenever he wanted accomodations or assistance for thewounded or sick. They were all afraid of him, as theyknew he would instantly come and make a complaint tome. He paid court to none of them, and was theimplacable enemy of thefournisseurs (army contractors).'

And to Arnott, he said:

'I hold him in the highest esteem. If the army were to raisea monument to the memory of one man it should be tothat of Larrey.'

Apart from the words of Napoleon, we have thebrief comment of an American doctor, J MasonWarren, who wrote home to his father in 1832:

'I made a very pleasant and instructive visit, a few dayssince, to the H6tel des Invalides, where I attended Larreyin his wards. He is a short, corpulent man, with a veryagreeable face. His hair, which is grey, falls in curls overthe straight, ornamented collar of the military coat thathe wears during his visits. He was very polite to DrPierson . . .' (Fig 5).

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Fig 4 Larrey at the Battle ofEylau, 8 February 1807. (By courtesy of the Director, Ecole d'Application du Service deSante Militaire et de l'Hopital d'Instruction des Armees du Val-de-Grace, Paris)

Fig 5 Larrey in about 1832, a lithograph by F S Delpech(By courtesy of the Wellcome Trustees)

However, as Larrey himselfwas very well aware,he had his failings. John Waller, a British navalsurgeon, wrote in the introduction to his trans-lation of Larrey's 'Memoires' (1815): 'On thewhole, however, notwithstanding a tolerable pro-portion of disgusting egotism and vaunting, thebook, as a system of military surgery ... is anundoubted acquisition to the medical world'; andJohann Heinrich Kopp, writing about his trip in1824 to French hospitals, tells us how it hadbecome the fashion under the Bourbons to belittleLarrey's surgical ability, to emphasize his tendencyto boast and to exaggerate his past exploits.

Larrey deeply regretted those aspects of hischaracter that offended people. When his ship waslying in quarantine in the Toulon roads on hisreturn from Egypt he received news from Charlottethat some so-called friends (of whom Dubois wasone) had been spreading malicious gossip abouthim. He wrote back:

'It would give me the greatest pain to incur anyone'shatred. I know that my defects and my extreme self-assurance invite criticism from those who wish me ill; butif they understood my feelings and my generosity theywould be aware of my goodwill and my esteem.'

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There is no doubt, however, that he held a veryhigh opinion of himself and expected others to dolikewise. Nevertheless, if a man is to be judged bythe company he keeps, Larrey ranks very highindeed since he numbered among his closest friendsthree of Napoleon's finest soldiers: Desaix, killedin the moment of victory at Marengo, and Lannesand Duroc who both died in agony while Larreycould only watch, grief stricken and unable to help.

In a way these friendships were surprising, if weremember the social gap that existed (even in theglorious days of the Revolution) between thefighting man and the surgeon. Socially, the statusof an army medical officer was low and theconditions of service did nothing to attract the besttype of man. Pay was poor and, particularly onactive service, irregular; moreover, a medical offi-cer had neither military rank nor authority. Com-batant officers, on the other hand, lined theirpockets handsomely with the spoils of war andpetitioned their sovereign for rewards.

In such a situation an idealist could only be hisown worst enemy; and Larrey was an idealist. Lifein the army medical services of the Consulate andthe first Empire was not easy, but for a humanesurgeon who would not conform and who believedin the principles of the Revolution it could becrucifying. Larrey found petitioning for the re-wards which he maintained were his due, a dis-tasteful practice; and in treating casualties he tookthe wounded in order of their surgical need regard-less of rank or even nationality - a habit that didnot meet with the approval of those who con-sidered themselves more equal than the rest.

'To perform a task as difficult as that which is imposed ona military surgeon,' Larrey wrote in his 1813 campaignjournal 'I am convinced that one must sacrifice oneself,perhaps entirely, to others; must scorn fortune andmaintain an absolute integrity; and must innure oneselfto flattery.'

The extent to which he succeeded in his chosen taskcan be measured by the devotion he inspiredamong Napoleon's soldiers.

However, such emotions were not shared byothers. Napoleon, as I have said earlier, remarkedthat the Administration both hated and fearedhim - feelings that derived mainly from the incom-petence of its staff. Among his professional col-leagues jealousy was at the root of his troubles; hisbrilliance as a surgeon, both diagnostically andoperatively, was uncanny; by comparison, hiscolleagues were ignorant, and they lacked anycomprehension of what he was about. Larrey, inhis turn, could not understand why they failed tofollow his example. Again in his 1813 journal, hewrote:

'I often think that those who cling to conservatism mustrecognize the need for operation, even though it may callfor ingenuity, yet they fail to perform it through fear orsome equally futile reason. They are guilty men.'

The 1813 journal also contains soul-searchingpassages which, I think, bear comparison withBeethoven's Heiligenstadt testament. The passingof time had not mellowed Larrey - it never did -and he was still desperately concerned about howhe appeared to others. Thus, he wrote:

'I confess I have never had any desire other than that ofhelping the wounded, no intention other than that ofdoing right ... I have always been, and doubtless alwayswill be, the victim ofmy sincerity and openness. Often theEmperor has reproached me for being able to see merit inothers yet not in myself... I hate foolishness and poli-tics. The truth, even when others cannot see it, marchesalways before me; I follow it blindly and am in danger offalling into the abyss if that is where it leads me.

'The misfortunes of others affect me strongly. Seriousdisasters afflict my soul and plunge me into the deepestgrief; I often think I can do something to help, and evenattempt to remedy the situation. But such is my naturethat I am thrown off balance and reason is no longer incontrol.'

However, it was because of his 'defects' that hewas able not just to survive the horrors of Napo-leonic warfare, but to keep fighting injustice,corruption, and incompetence to the day he died.Others swam with the tide or were submergedcompletely; but Larrey never once allowed hiscompassion and gentleness towards the sick andwounded to be eroded to the slightest degree - as amilitary surgeon he stood alone.

However, I feel we might be able to make aclearer assessment of Larrey's character if we viewhim in the light of the Peter principle - this statesthat 'in a hierarchy, every employee tends to rise tohis level of incompetence'. Did Larrey exemplifythis principle when he became surgeon-in-chief ofthe Grande Armee, or was he thwarted by theobstructive tactics of the Administration and amedical staff that was inadequate both in numbersand in innate medical ability?

I have already mentioned one event that mightbe considered to show that the Peter principle isapplicable: Napoleon's appointment of Percy assurgeon-in-chief on his return from Elba. Percywas then 61 (Larrey was 49), moreover, he hadshown signs of heart trouble in Spain and had notseen active service since 1811. The fact that Percywas a disaster does not affect the argument - hewas chosen in preference to Larrey. Larrey retireddisgruntled and Napoleon had to send Drouot topersuade him to come back to his old job assurgeon to the Imperial Guard.At Ligny the regiments of the line, who bore the

brunt of the battle against Blucher, had no organ-

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ized system of casualty evacuation and when theFrench moved on the next day, amongst those leftbehind was Percy, complaining of his heart. Forthe last time Larrey stepped into the breach butthere was little he could do.

Moreover, despite the fact that Larrey hadconducted the surgical affairs of the Army of theOrient with impeccable skill and efficiency, Napo-leon probably believed him unsuited to the topposition in view of his seemingly greater concernwith the details of operation and dressing thanwith the broader sweep of administering the surgi-cal services. Once, in the Kremlin, Napoleon hadtaken Larrey to task for 'wasting time' on surgicaldetails when, as surgeon-in-chief he should havebeen better employed. But it is difficult to judgehow much of this was due to an inability todelegate and how much to the practical impossi-bility of doing so.

However, Larrey's turning up for the battle ofBorodino with only himself and two assistantswould seem to be a clear example of the Peterprinciple at work. His feelings when told byNapoleon to make arrangements for the forth-coming major battle scarcely do justice to theoccasion; 'I was', he wrote, 'greatly disturbed bythe news.' For the best of reasons he had left fiveambulance divisions and all the surgeons of thereserve at Smolensk; the one ambulance divisionhe had taken forward had become fully occupieddealing with the casualties after Volontina. Merci-fully, before the battle began, he found time toappropriate forty-five regimental surgeons to staffthe corps and divisional ambulances (dressing andclearing stations) and an unexpected delay allowedsome transport and supplies to catch up. Admit-tedly, everything had been against him: shortage ofstaff and equipment from the start of the cam-paign, a bloody-minded administration, and linesof communication that Napoleon seemed de-termined to stretch until they broke. However,whatever practical difficulties he faced, nosurgeon-in-chief should have got himself into sucha position. So was it incompetence or was itinevitability? Again, I would hesitate to judge,although a pointer in Larrey's favour is his per-

formance throughout the 1813 campaign inSaxony culminating with the immaculate evac-uation of casualties by road and river after theBattle of Montereau (a mere forty miles fromParis) on January 18, 1814.

If forced to take a decision, however, I would saythat the Peter principle did, in fact, apply toLarrey. He was a supe'rb chief surgeon to theImperial Guard where he could hold the entiresystem, both surgical and administrative, withinthe palm of his large hand - and the Guard was byno means small; it comprised fifty thousand of thenear half million men who crossed the Niemen intoRussia. The entire Army of the Orient was, bycomparison, about thirty-three thousand strong.But to be surgeon-in-chief of the Grande Armee, aman had to be an administrator first and a surgeonsecond. And this was something Larrey couldnever be; for him, the sick and wounded came firstwhatever the cost. Perhaps if the Administrationhad not obstructed the medical services and Larreyin particular, things might have been different; forwhilst Larrey was fortunate with the Guard wherehe could exercise both his surgical and his adminis-trative skills side by side, in the Grande Armee hewas exposed and at the mercy of the system.

However, conflict between medicine and itsadministrators is a perennial problem; Larreycould find no solution and today we are stillsearching, and with a desperation just as great. Inthis context the lesson we have to learn fromLarrey is that doctors must never allow the controlof their destiny to slip from the hands of thosewhose primary concern is the care of the sick.

BIBLIOGRAPHYKopp J H(1825) Aerztliche Bemerkungen, veranlasst durch eine Reise inDeutschland und Frankreich im Fruhjahre und Sommer 1824.Hermann, Frankfurt am MainLarrey D JUnpublished collection of letters, papers, his 1813 campaignjournal, and other documents in the Wellcome Institute of theHistory of Medicine, LondonPeter L J & Hull R(1969) The Peter Principle. Morrow, New YorkRichardson R G(1974) Larrey: Surgeon to Napoleon's Imperial Guard.Murray, London