Hartmann's operation—Back to the future?

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    recommended the use of capillary drainage of the pelvis 5 whenever Hartmann's (modified) operation is performed. 2 If so, the leakage of the stump is simply signalled by a persis- tent discharge of pus through the drainage track, With no abscess for- mation and no diffusion of pus.

    Hartmann's operation today, with its modifications, is a useful tool in emergency surgery. Is it a problem if it differs from Henri Hartmann's description?

    Pascal Frileux, MD Anne Berger, MD

    H6pital Laennec Paris, France

    1. Rosenman LD. Hartmann's operation. Am J Surg. 1994;168:283-284. 2. Frileux P, Berger A. Hartmann's op- eration. Surgery of the colon rectum and anus. In: Fielding LP, Goldberg SM, eds. Rob and Smith's, Operative Surgery. 5th ed. Oxford: Buiterworth- Heinemann; 1993:489-496. 3. Hartmann H. Nouveau proc~d~ d'abla- tion des cancers de la partie terminale du colon pelvien. Trenti~me Congr~s Fran~ais de Chirurgie, Strasbourg, Asso- ciation Frangaise de Chirurgie. Proces Verbaux, M~moires et Discussions. Felix Alcan, Paris, 1921:411. 4. Quenu E, Hartrnann H. Tumeurs du rectum. Chirurgie du Rectum. Volume II. Paris: Steinheil; 1899:325-328. 5. Mikulicz J. Ueber die Ausschaltung todter R&ume aus der Peritonealh6hle mit besonderer RL~cksicht auf die Exstirpation der aus der BeckenhShle ausgehenden Geschw01ste. Archiv for Klinische Chirurgie. 1887;34:645-647.

    The Reply: I do not disagree with Drs. Frileux

    and Berger, except in their statement "risk of leakage allegedly due to poor blood supply." Later in their com- ments they write, "Problems of vas- culal:ization may Occur if a longer rec- tal stump is left in place, and this should be avoided." That is exactly to the point! My article emphasizes the uncertainty of the blood supply from inferior hemorrhoidal arterial sources if it must sustain the viabil- ity of a long distal segment when that segment has been deprived of the in- ferior mesenteric arterial source. I do not question that the long segment will remain healthy if the surgeon takes pains to preserve its mesocolic vessels. Such is the case when one re-

    sects fo r inflammatory disease rather than for cancer.

    1 thank Drs. Frileux and Berger for their comments.

    Leonard D. Rosenman, MD San Francisco, California


    To the Editor: The American Journal of Surgery

    January 1995 issue contains the papers from the meeting of The Society for Surgery of the Alimentary Tract that were presented at the 35th Annual Meeting of the Society in New Orleans onMay 16 to 18, 1994. Two of the ti- tles listed on the program contain the eponym, "whipple," written as "Whipple Procedure" in one, and as "Pylorus-Preserving Whipple" in the other. Neither Whipple's first name nor his initials appear in either the ti- tle or text.

    Presumably, anyone who reads these titles or articles will need no further information in order to identify Whipple. Some readers, however, may not be aware that in the United State s in the first half of this century there were two physicians named Whipple who achieved wide recognition for the notable contributions that they made to medical practice.

    George Hoyt Whipple, born in New Hampshire in !878, graduated from Yale and from the Johns Hopkins Medical School, where he continued for a time to study pathol- ogy under William Welch. During the period from 1914 to 1921, while he served as Professor of Research Medicine at The University of California at Berkeley, he demon- strated that in animals bled to dan- gerous levels, the regeneration of blood was dependent on the provi- sion of a diet high in animal protein, especially liver. His conclusions es- tablished the experimental basis for clinical studies by George R. Minot and W.E Murphy of Harvard, who cured pernic!ous anemia by the feed- ing of raw liver. In 1926, Whipple, Minot, and Murphy share d the Nobel Prize for this contribution. Allen Oldfather whipple, no rela-

    tion to George Hoyt Whipple, was born in Iran in 1881, the son of mis-

    sionary parents. He received his MD from Columbia in 1908 and subse- quently served as the Valentine Mort Professor of Surgery in that institution from 1921 to 1946. In 1935, in col- laboration with William Barclay Parsons and Clinton R. Mullins, he published his first of several papers dealing with the surgical treatment of pancreatic cancer. The pancreatico- duodenectomy in its various modifica- tions came to be known as the "Whipple Procedure."

    Other details concerning the origin and development of the pancreatico- duodenectomy, although readily avail- able in the literature, are not so well known. The 1935 paper, with Whipple as the senior author, was presented that year at the meeting of The American Surgical Association, not by Whipple, but by Parsons. In this and in four sub- sequent publications 1"5 all written by Whipple, it is disclosed that the origi- nal two-stage pancreaticoduodenec- tomy was performed by Parsons, with Whipple assisting him on only the sec- ond stage of the procedure. It can be argued with some justification that the pancreaticoduodenal resection should be known as the "Parsons procedure" rather than the "whipple procedure," or perhaps more appropriately as the "Parsons~whipple" or "Whipple- Parsons" procedure.

    Returning now to the present, one of the papers presented at the 1994 meet- ing of The Society for Surgery of the Alimentary Tract is by Robin S. McLeod and associates, of Toronto. It is entitled, "Quality of Life, Nutritional Status, and Gastrointestinal Hormone Profile Following the Whipple Pro- cedure." The bibliography of this arti- cle lists 23 references, but does not cite any of the publications of Whipple or Parsons. 6

    Another paper presented at this 1994 meeting is by Marcus W. Btichler and associates, o1: Ulm, Germany, and is entitled, "Randomized Trial of Duodenum-Preserving Whipple in Chronic Pancreatitis." In their 25 ref- erences, the authors do cite the first Whipple article, published in 1935 under the joint authorship of A.O. Whipple, W.B. Parsons, and C.R. Mullins. 7 Unfortunately, however, W.B. Parsons, who contributed so much to the development of the pan-