Tech Coloproctol (2008) 12:175–179 DOI 10.1007/s10151-008-0415-9

P I O N E E R S I N C O L O N A N D R E C TA L S U R G E RY

Henri Albert Hartmann (1860–1952): colorectal master

A.P. Zbar

Received: 23 January 2008 / Accepted: 28 March 2008 / Published online: 9 June 2008 © Springer-Verlag 2008

Abstract The life and times of the coloproctologist Henri Hartmann (1860–1952) is presented outlining his contribution to surgery in general and to the field of colorectal surgery in particular. Keywords Hartmann · Coloproctology · Pioneers

A.P. Zbar (쾷) University of New England and Newcastle Tamworth Hospital Tamworth, New South Wales, Australia Tel.: +61-3-95271817 E-mail: [email protected]

Henri Albert Hartmann (1860–1952) (Fig. 1) would be rightly recognized as one of the great pioneers of coloproctology of the 20th Century, perhaps single-handedly changing the nature of cancer resectional practice [1], with the rediscovery in the 1970s of the importance of his procedure (now eponymously named) for complicated diverticular disease [2] and selected cases of low leftsided large-bowel obstruction [3]. This approach has been made more attractive with the advent of stapled colorectal reconstruction for the restoration of intestinal continuity whether performed open [4] or laparoscopically assisted [5]. Hartmann was born in Alsace on June 16th 1860, deciding in early life to study medicine at the Sorbonne in Paris and completing his formal education by December in 1881 under the initial tutelage of Professor Pierre Merklen who was the Parisian doyen of syphilis management [6]. Given Hartmann’s death in the early 1950s, it is hard to grasp that at the time of his young apprenticeship in surgery, the Parisian salons of the 1860s were a vibrant environment, Charles Darwin had only just published his Origin of Species in 1859, and Charcot was a routine lecturer at the Salpêtrière to his students Sigmund Freud, Jospeh Babinski, Gilles de la Tourette and Alfred Binet. This was a time when there was the refutation of the theories of spontaneous generation in bacteriology by Louis Pasteur, the fledgling science of anaesthesia was commencing, and the foundation of the understanding of the cellular basis of biology was laid by Virchow in his seminal work Omnis cellula e cellula which was first published in 1858 [7]. Hartmann’s desire to apprentice in surgery led him to Louis-Félix Terrier, a contemporary of Ludwig Courvoisier who developed surgical asepsis in defiance of Listerian antisepsis at the Hôpital Bichat where

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Fig. 1 Henri Hartmann and his three assistants, Drs. Bergeret, Gouverneur and Huet in the operating room at the Hôtel-Dieu, Paris in 1920. (Reprinted with permission from the British Journal of Surgery and the Wellcome Foundation).

Hartmann spent some 16 years [8]. Hartmann was Terrier’s first intern, and for Hartmann, Terrier represented the greatest of all mentors (“C’est çe maître qui a fait de moi un chirurgien”—“it is this master who made me a surgeon”) [9]. Alongside his clinical responsibilities, in 1886 Hartmann became an anatomy prosector completing his thesis in 1887 on cystitis (Les cystitis douloureuses) as a result of a specific interest in the genitourinary system, winning the Prix d’Argenteuil under the holder of the first Parisian Chair of Urology, Jean Casimir Félix Guyon [10]. Hartmann’s interest was so stimulated that he assumed responsibility for urological services at l’Hôpital Lariboisière which had initially been opened in 1832 as a cholera hospital. However, Hartmann soon relinquished his position as Chief of Urology, returning to Terrier because of a wider interest in general surgery. Following his return, he was appointed as a Lecturer in Surgery in 1895, and was then promoted to Assistant Professor in 1898, Assistant Director in 1909 and finally Professor and Chairman of Surgery at Bichat in 1909. He then took up an appointment as Chief of Surgery at l’Hôtel-Dieu in 1914 where he stayed for 20 years until his official retirement in 1930. He was succeeded by Bernard Cunéo, and, as testament to his skill, at the time of his death seven subsequent chairmen of the Department of Surgery including Paul Lecène and Henri Mondor (whom he inspired to undertake a thesis on rectal cancer) had all been Hartmann’s students [11, 12]. By that time he had personally encoded over 30,000 of his cases currently kept in the Hôtel-Dieu archives. His surgical (and clinical) credo was articulated at Terrier’s eulogy: “Terrier a inculqué à ses élèves l’amour du travail, l’intégrité, le respect des malades, la simplicité

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dans la vie”—“Terrier inculcated into his students the love of work, integrity, respect for the patient and simplicity in life” [13]. Over the major part of his life in surgery Hartmann was a prolific writer publishing into his 91st year on a range of subjects dealing with war injuries, dislocations and solid cancers and including a major treatise published in two volumes, his famous Traité de la Chirurgie du Rectum (1895–1899). This was a multidisciplinary text in collaboration with fellow surgeon and anatomist Édouard Quénu and pathologist Jacques Ménétrier outlining the blood supply of the rectum and the perineal musculature and its fascial spaces [14]. Over a prolonged period of time he produced a nine-volume series Travaux de Chirurgie Anatomo-Clinique [15], the first volume of which was on the urinary tract published in 1903, the next on operative gynaecology [16], volume 5 on the biliary tract published in 1923, volume 7 on the stomach and duodenum published in 1928 [17], and volume 8 on rectal diseases published in 1931. The volume on gastric surgery was revised as part of his original work in collaboration with his old mentor Terrier from its original production in 1899 [18]. The last volume on the breast of this extraordinary series was published in his 90th year. The compendium included patient cases, operative surgery tips, laboratory data and clinicopathological correlations. Hartmann always acknowledged his collaborators and first described the archetypal differences between left- and right-sided colonic cancers with Quénu, Okinczyc and Mondor that we still discuss today in our surgical teaching. He also detailed the technique of hysterectomy, the surgical management of salpingitis and chorionepitheliomas (with Fredet), the lymphatic drainage of gastric cancer (with Cunéo), the anatomy of the coeliac axis with (Rio Branco) and the management and diagnosis of surgical and anal tuberculosis, and published a treatise on his abiding interest shoulder dislocation [19]. Today we recognize Hartmann for several seminal eponymous terms; for example, his gallbladder pouch which resulted from a series of meticulous dissections of the biliary tree and its arterial blood supply in 1891 [20, 21], a subject he subsequently revisited after his retirement [22]. His treatise on terminal vascular anastomoses between the sigmoid arteries published in 1909 [23] after that of Paul Sudeck [24] on what has subsequently become known as Sudeck’s point (a critical point of anastomosis between the terminal sigmoid artery and the superior rectal artery) has lost operative relevance since this critical anastomotic point of colectomy is incorporated as part of standard sigmoid and left hemicolectomy [25]. Despite his fame, we know Henri Hartmann really for his “procedure” which he first described at the 30th

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Congress of the French Surgical Association in 1921. He reported two patients with obstructing sigmoid tumours and their definitive management by a procedure that we have come to know and utilize as the Hartmann’s style resection [26], and which he reprinted from several noted congresses [1, 27]. This surgery was specifically standardized by Hartmann for all such cases. He advocated dissection of the rectum to the level of the pelvic floor with exposure and incision of what we now call Denonvillier’s fascia in accordance with the abdominal portion of Miles’ abdominoperineal resection [28, 29]. The rectal stump was formally closed as a cul-de-sac for the first time in two layers with closure of the pelvic peritoneum. He reported 34 cases with only three deaths [30] following the introduction of this procedure. This reduced his own reported mortality from abdominoperineal resection of 38% down to 8.8% with a course as “uneventful as that following an operation for a cold appendix” [31]. He specifically advocated that the patient should not undergo restoration of intestinal continuity, although others attempted such a procedure including reconstruction early after the introduction of the procedure [32]. The historical (and clinical) importance of this procedure at that time cannot be overstated. In obstructed colorectal cancer and in perforative diverticulitis, variants of the three-stage procedure originally developed by Mayo in 1907 largely held sway [31, 33–34], although Mikulicz in 1903 [35] reported his results showing marked reductions in perioperative mortality (43% vs. 12.5% for two-stage vs. single-stage procedures, respectively) using a modification of a two-stage extraperitoneal resection originally described in 1892 by Oscar Bloch [36]. These cumbersome approaches were finally abandoned in emergency colorectal surgery to be replaced by Hartmann’s operation [37, 38], and only more recently replaced in selected cases by primary anastomosis [39]. Hartmann who preferred to be referred to formally as H.H. [40] was renowned throughout Europe for his clinical examination method [41] performed with vigour every Tuesday at l’Hôtel-Dieu, some of the details of which he formally published [42]. These bedside teaching rounds became famous throughout Europe requiring the building of a new amphitheatre to accommodate packed audiences where he espoused the importance of detailed and precise history taking and meticulous gentle examination. During these sessions he would often quote his personal heroes Claude Bernard and Blaise Pascal. It is of interest that although championing radical hysterectomy for cervical cancer and radical mastectomy of the Halstead style for breast cancer that towards the end of his life he prophetically abandoned, the former in favour of radiotherapy and the latter because of its radicality. At

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the same time he added a curiethérapie section to his Department of Surgery [9], a pathology museum containing the cancer specimens he had removed, and an extensive personal library [43]. He was throughout his life known for his sarcastic toughness, often humiliating some poor unsuspecting student, and for suffering neither laziness nor smoking [44], peppering his rounds with profane expletives “like a mine always ready to explode” [14] and reproducing a historical brutality in teaching which he had endured under Terrier. It was said that “comme Stendahl, M. Hartmann avait deux bètes d’aversion, l’hypocrise et le vague” (“like Stendahl, Hartmann had two aversions, hypocrisy and indecision”) [12]. Against this backdrop, Hartmann was renowned for his flexibility, often abandoning ways of surgical practice when they were proven to be outdated. Indeed, Moulonguet reported that “never was such an imperious character so supple as his before facts which did not bend” [13]. It is said that he was the most meticulous of surgeons [45]. Quoting one of his heroes Johannes von Mikulicz: “I can recognize a good surgeon not by how he cuts but by how he sews” [10]. He was reported by his disciple Joseph Okinczyc to operate in total silence [9]. He was the first surgeon in France to report curative pyloric resection for cancer in 1897, surgery for choledochal cyst, a series of ampulla of Vater excisions and parotidectomies, and the first successful splenectomies in France for haemolytic jaundice. He was the first in France to report surgical excision of oesophageal diverticulae, the first to describe adult hypertrophic pyloric stenosis and the first to report the surgical management of appendiceal pseudomyxoma peritonei [13]. Over his time as Chair of Surgery at l’Hôtel-Dieu he performed about a thousand operations annually being widely respected for his surgical skills. Zachary Cope declared that “probably no French surgeon has been, in his day, better known or more widely respected … with English surgeons regarding him as a man of outstanding worth with the present generation furnishing few, if any, examples of such all-round surgical proficiency” [46]. Hartmann was awarded many honours during his life. He received an honorary FRCS (England & Ireland) in 1913, an honorary Fellowship of the American Surgical Association, election to the French Academy of Medicine in 1918, Presidency of the Academy in 1936, Presidency of the French Surgical Society in 1919, Presidency of the Congress of Surgery in 1921, Presidency of the International Congress of Surgery in 1929, and an Honorary Fellowship of the Philadelphia Academy of Surgery in 1929. He became a Grand Officer of the Legion d’Honneur, was elected to the Academie des Sciences in 1945 and was the

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cofounder of the French League Against Cancer. He had no children, but his home was a centre of Parisian surgical learning and renowned for the size of his personal medical library. After his wife died in 1951, the annual meeting at his home on the Place Malesherbes on the 1st of January in 1952 was attended by many students, and it was on this day that, after his guests had left, he slipped on the stairs and fell to his death at the age of 91 years [40]. During his working life and in retirement, Hartmann transformed the Hôtel-Dieu into a Mecca for surgeons visiting from Continental Europe and the Americas where his successor Cunéo was able to donate his handwritten detailed histories and notes, copies of which are now held in the Bibliothèque Interuniversitaire de Médicine (BIUM) in Paris. In the words of one of his biographers, Jean Patel, Hartmann did more than just lend his name to a specific technique of rectal resection, he recentralized the scientific approach towards French surgery and its illustrious heritage. He was a surgical “Seigneur” (master), and to quote Patel: “après d’Hartmann, a-t-il dit que j’ai appris ce que devait être la chirurgie, élevée à la hauteur d’une véritable science” (“after Hartmann, it is said that surgery had been elevated to a true science”) [12]. Conflict of interest statement The author declares that he has no conflict of interest related to the publication of this article. Acknowledgements The author is grateful for the assistance of Venita Paul, Senior Picture Researcher at the Photographic Library of the Wellcome Trust, London.

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