Jean Baptiste Lucien Baudens: The father of trauma laparotomy

Introduction

Jean Baptiste Lucien Baudens (1804–1857), Figure 1, was a French military surgeon. He served in numerous military conflicts throughout his career. Baudens was an innovator and a leader. Going against traditional dogma, he was the first to attempt laparotomy in the setting of trauma. Although the first patient died, his second survived without further complication. Despite this historical landmark, little is known or written about him within the English literature. One must translate older French texts to truly understand and appreciate his life's work. Jean Baptiste Lucien Baudens was a pioneer of surgery and the father of trauma laparotomy. He was a passionate educator and dedicated to the training of future surgeons. His contributions to the field of surgery deserve recognition and appreciation.

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Figure 1.

Jean Baptiste Lucien Baudens (1804–1857).

Early life

Jean Baptiste Lucien Baudens was born in Aire-sur-la-Lys, in Pas-de-Calais, France on April 3, 1804. ¹ His parents were Marie-Adelaide Baclen and Jean-Louis Baudens, a sheet merchant. His parents were able to send him to the Lyceum d’Amiens, a prestigious preliminary school. ¹ From a young age, Baudens had decided to pursue a military career as a surgeon. His ambition led to him being appointed Chirurgien sous Aide Major (under-surgeon) in 1823, helping him to pass into medical school. ¹

He started his medical training with the French Defense Health Service, in a military training hospital at the University of Strasbourg in 1824. Over the next year, the work-ethic led to him being awarded a transfer to Val-de-Grace in 1825. ² Val-de-Grace was a historic institution in Paris, France. It was where Baron Dominique Jean Larrey (1766–1842), the father of French military surgery and the personal surgeon to Napoleon, had previously served. ³ Baudens was devoted during this training and in 1826 was awarded the highest prize given to students of the program. ¹ In 1827, he was promoted to Chirurgien Aide Major (assistant surgeon) for the remainder of his studies. ¹ Throughout training, Baudens had a particular interest in urology. He gave a dissertation on urethral strictures and his doctoral thesis was on stone removal by suprapubic cystotomy. ⁴ He completed his medical training and graduated in 1830. ²

In appearance, Baudens was described as “tall and spare, with an erect military carriage; his voice is rough and grating, whilst its tone is usually very loud, acquired from habits of command; his forehead extends far back on the head, and is at the same time quite high; with black hair, and dark eyes, and a pleasant expression of countenance, he is, particularly when dressed in his uniform, a man of remarkably prepossessing personal appearance.” ¹

Early military experience (Algeria)

Amid political strife, France began their Conquest of Algeria in 1830. Baudens, fresh from his training at Val-de-Grace, was immediately sent with the expeditionary corps to Algeria and was present at the outbreak of war. ² In preparation, he compiled all the treatises on firearm wounds and made a summary to guide him on the battlefield. As he wrote, “I landed at Sidi-Ferruch with a supply of science and theory which I believed to be complete and inexhaustible.” He was quickly promoted to Chirurgien Major (head surgeon) of the Sidi-Ferruch military hospital and served as surgeon-in-chief of the mobile field hospital.^1,5 This gave him the “double advantage,” not available to military surgeons before him, of caring for wounded on the battlefield prior to managing them in his own hospital. ⁶ The Algerian hospital he attended was a central point of the conflict and received a large number of wounded by evacuation. This provided him the opportunity to observe and compare the outcome of other treatments as opposed to his own. ⁶ Over the next 6 years, he would treat several thousand patients suffering traumatic injury. ⁶

Baudens also had a passion for teaching. In 1832, the military facility was formally transferred to the country house of the former Turkish Dey. Based on the effort of Baudens, the Dey military hospital was organized as a military training hospital and medical school. ⁵ This was the first institution of its kind on the African continent. ⁷ He ardently fought for the role of medical education, both for the African Army as well as the local populations. ⁵ He frequently lectured on anatomy and surgery.

Just a year into practice, in 1831, he was awarded Knight of the Legion of Honor, a prestigious French institution that recognized civil and military achievements. He quickly rose and was promoted to Officer in 1836. In addition to his own accomplishments, the rapid rise has been attributed to his close connections to the Duke de Nemours. Baudens served as his private surgeon and treated the Duke when he suffered a fracture of the humerus, ultimately healing without deformity. Baudens returned to France in 1837. His only publication during this time, Plaies D’Armes A Feu (Firearm Wounds), described his vast experience in managing such injuries. ⁶

The birth of trauma laparotomy

When it came to abdominal trauma, surgical dogma of the time dictated that men were not to be operated on, with the belief that the “healing forces of nature” were the only chance for survival. ⁸ Management of penetrating abdominal trauma consisted of wound dressings and rest with nothing by mouth. ² Large amounts of opiates were given, not specifically for analgesia but primarily for their antiperistaltic effects. ⁹ The wounded and inflamed peritoneum required rest. Other interventions included a semi-recumbent positioning, bloodletting with leeches and alcohol for stimulation. ²

Prognosis for men suffering penetrating abdominal injury was dire and most died. The few that survived were plagued by the development of intraperitoneal abscesses and enterocutaneous fistulas. Pierre-Francois Percy (1754–1825), surgeon-in-chief of Napoleon's Grande Armée, advocated for assisting in this natural process by opening the wound to allow drainage of pus and facilitate fistula formation. ¹⁰

While studying at Val-de-Grace, in 1829, Baudens led a pioneering study on colonic bowel anastomosis. He experimented on dogs by creating bowel injuries and repairing them in Lembert fashion. ⁷ Antoine Lembert (1802–1851) was a young resident at the nearby Hotel Dieu hospital in Paris. Lembert had recently published his technique for bowel anastomosis by inverting sutures that has now received his namesake. ¹¹ Most of the animals survived. Baudens came to respect the technique and concluded his thesis stating “I would not hesitate to use the same procedure on a wounded soldier, if circumstances allowed it.” ⁷

Baudens became intimately familiar with traumatic wounds. Initially, he followed his training. Prior to the advent of anesthesia, he would debride gunshot wounds with, as he described, “pity for the unfortunate people whom I cruelly tortured. I confess that the cries of suffering had ended up shaking my realism and even my convictions vividly.” ⁶ He managed penetrating abdominal trauma with rest and opiates but saw that the majority would succumb to their injuries and die. He performed numerous autopsies and discovered that death was most often due to peritonitis from visceral perforation. ² Based on this experience and his prior studies he gained the courage to go against the nonoperative dogma.

In 1831, he performed the first two trauma laparotomies in history. ⁶ The first patient was a soldier shot just to the right of the umbilicus and presenting in shock. ⁶ The wound itself was enlarged. Without general anesthesia, larger laparotomy incisions would have been more challenging. He identified two injuries of the small intestine, separated by 8 inches. The segment was resected and the bowel was anastomosed in Lembert fashion. The patient did not make a single cry through the operation and died on the third day. At autopsy, he found a missed perforation of the cecum with effusion of feces, although the small bowel repair remained intact. Encouraged, he believed that “if this complication had not existed, this soldier could have been saved.” ⁶

A short while later he encountered another wounded soldier that had been shot 3 inches to the left of the umbilicus. ⁶ This patient “was happier” than the other but upon digital inspection of the wound he found fecal matter prompting another attempt at surgical intervention. He again enlarged the wound itself and made the patient cough to force intestinal evisceration. He found a transverse colon injury which he repaired primarily, again in Lembert fashion. Bloodletting, being accepted practice of the time, led him to make “a few general bleedings” early in the course, and later “the belly was covered with leeches.” This second patient survived without further complication.

Baudens would continue to promote the operative treatment of penetrating abdominal trauma. Over the subsequent decades, he would advance his methods and refine indications. Throughout his final campaign, during the Crimean War (1853–1856), Baudens would advise placing a finger or small sponge into the abdominal wound to evaluate for blood, feces or gas. ¹² This would be used in determining the need for laparotomy.

Later career

Baudens served in many leadership roles. In 1837, he was appointed surgeon-in-chief and first professor at the Hospital of Medical Instruction in Lille, France. At the same time, he served as surgeon-in-chief at the busy military hospital of Gros-Caillou, Paris—an honorable position previously held by Baron Larrey. ¹³ “There [were] probably but few surgeons of his age who [had] seen as much practice, or had so great professional advantages as Monsieur Baudens.” ¹ He was renowned for his technically gifted surgical skill as well as his clinical acumen and innovation. Throughout his early career, despite this “advantage for observation and experience,” his numerous occupations and clinical obligations prevented him from seeking the literary publications and “aggrandizement” that other colleagues of the time had achieved. ¹

After concluding his service in Algeria and returning to France, he was able to devote more time to literature. Over the coming decades, he would publish over 20 works, chiefly about military medicine and surgery. He wrote on a variety of topics, including strabismus, hydrocele, and the artificial anus. ¹⁴ He continued to innovate, describing a new method of tonsillectomy as well as new procedures for the removal of ganglion tumors and ingrown toenails. ¹⁴ His writing on military medicine described the campaigns of Constantine and Tagdempt, the military missions in the orient, and a history of the Val-de-Grace military hospital. ¹⁴ He drafted the basic principles for the proper use of chloroform, a recent innovation, for the French Academy of Sciences in 1853 and considered it to be the most effective drug in military surgery. ¹⁵

Baudens was also active in the orthopedic literature. He designed “curative apparatuses” for the treatment of patellar ligament rupture and femur fracture. ¹⁴ He presented on the treatment of sprained ankles. ¹⁴ He described a new method for humoral head resection. ¹⁴ Baudens modernized amputation procedures to facilitate healing and early rehabilitation. He was one of the first to do a successful hip disarticulation. ⁷

He returned to Val-de-Grace in 1843 as head of the military school and hospital. He served as first professor and first surgeon. ¹ Back in his own prestigious alma mater, his passion for teaching was able to thrive. Baudens also served as a national corresponding member of the Societe de Chirurgie (Society of Surgery) and, in 1851, he became medical inspector for the army health service, a position that would ultimately lead to his death. ²

Personal life, final campaign and death

To date, there is no written information regarding the personal life of Baudens. A review of the French National Archive shows that he was married to Zelie Rose Adelaide. ¹⁶ They had at least one son, Maurice Marie Auguste Lucien Baudens, born April 17, 1846 in Paris, France. ¹⁶ Maurice followed in his father's footsteps, honorably serving in the military. He was awarded Knight, Officer, and then Commander of the Legion of Honor, similar to his father. ¹⁶

In 1853, France entered the Crimean War. As the army's medical inspector, Baudens was dispatched to Crimea to combat the raging typhus and cholera epidemics. The “Crimean Winter” of 1854–1855 and 1855–1856 saw thousands of deaths due to diverse disease processes. ¹⁷ This was largely related to inadequate supplies of food and clothing with poor sanitation and overcrowding. With little fighting during this period, more soldiers died of disease than from battle. ¹⁷ It was here that he worked alongside Florence Nightingale, the founder of modern nursing, and he was impressed by her sacrifice and noble mission. ¹⁸ He passionately argued for better facilities and improved the evacuation procedures. ¹⁸ Based on his services, he was further promoted within the Legion of Honor to the position of Commander in 1856. Sultan Abdulmejid, ruler of the Ottoman Empire, would award him Grand Officer of the Imperial Order of the Medjidie based on the care he provided their soldiers throughout the war.

As he described, the health officers remained among their typhoid patients “night and day… scarcely [leaving] them, except to follow in the funeral procession and attend the burial of one of their own.” ¹⁸ Dozens of physicians died of typhus while “bravely contesting its ravages.” ¹⁸ Tragically, Baudens himself fell ill with typhus and died in Paris on December 27, 1857. ¹⁷

His final text, reviewing his experience during the Crimean War, was released after his death. The editors noted: “Those who knew Doctor Baudens were able to appreciate the tireless worker and great doctor, devoted for thirty years to danger and suffering. We hope that the readers of this book (his last thought) as well as the scholars and the army, will grant the author a religious memory. This book will keep him in the first rank of famous men whose memory France [and the world] preserves with pride.” ¹⁸