Neurosurgical developments of Thierry de Martel (1875–1940), French neurosurgery pioneer, during World Wars I and II

Johan PalludService de Neurochirurgie, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, Paris; and
Université de Paris, IMABRAIN, INSERM U1266, Institute of Psychiatry and Neuroscience of Paris, France

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Giorgia Antonia SimboliService de Neurochirurgie, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, Paris; and
Université de Paris, IMABRAIN, INSERM U1266, Institute of Psychiatry and Neuroscience of Paris, France

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Alessandro MoiraghiService de Neurochirurgie, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, Paris; and
Université de Paris, IMABRAIN, INSERM U1266, Institute of Psychiatry and Neuroscience of Paris, France

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Alexandre RouxService de Neurochirurgie, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, Paris; and
Université de Paris, IMABRAIN, INSERM U1266, Institute of Psychiatry and Neuroscience of Paris, France

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Marc ZanelloService de Neurochirurgie, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, Paris; and
Université de Paris, IMABRAIN, INSERM U1266, Institute of Psychiatry and Neuroscience of Paris, France

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Following France’s entry into World War I on August 3, 1914, Thierry de Martel (1875–1940), the French neurosurgery pioneer, served on the front line and was wounded on October 3, 1914. He was then assigned as a surgeon in temporary hospitals in Paris, where he published his first observations of cranioencephalic war wounds. In 1915, de Martel met Harvey Cushing at the American Hospital in Neuilly, where de Martel was appointed chief surgeon in 1916. In 1917, he published with the French neurologist Charles Chatelin a book (Blessures du crâne et du cerveau. Clinique et traitement) with the aim to optimize the practice of wartime brain surgery. This book, which included the results of more than 5000 soldiers with head injuries, was considered the most important ever written on war neurology at that time and was translated into English in 1918 (Wounds of the Skull and Brain; Their Clinical Forms and Medical and Surgical Treatment). In this book, de Martel detailed the fundamentals of skull injuries, classified the various craniocerebral lesions, recommended exploratory craniectomy for cranioencephalic injuries, recommended the removal of metal projectiles from the brain using a magnetic nail, and advocated for the prevention of infectious complications. Between the World Wars, de Martel undertook several developments for neurosurgery in France alongside neurologists Joseph Babinski and Clovis Vincent. Following France’s entry into World War II on September 3, 1939, de Martel took over as head of the services of the American Hospital of Paris in Neuilly. He updated his work on war surgery with the new cases he personally treated. Together with Vincent, de Martel presented his new approach in "Le traitement des blessures du crâne pendant les opérations militaires" ("The treatment of skull injuries during military operations") on January 30, 1940, and published his own surgical results in April 1940 in "Plan d’un travail sur le traitement des plaies cranio-cérébrales de guerre" ("Work Plan on the Treatment of Cranio-Cerebral Wounds of War"), intended for battlefield surgeons. On June 14, 1940, the day German troops entered Paris, de Martel injected himself with a lethal dose of phenobarbital. Thierry de Martel played a central role in establishing modern neurosurgery in France. His patriotism led him to improve the management of wartime cranioencephalic injuries using his own experience acquired during World Wars I and II.

ABBREVIATIONS

WWI = World War I; WWII = World War II.

Following France’s entry into World War I on August 3, 1914, Thierry de Martel (1875–1940), the French neurosurgery pioneer, served on the front line and was wounded on October 3, 1914. He was then assigned as a surgeon in temporary hospitals in Paris, where he published his first observations of cranioencephalic war wounds. In 1915, de Martel met Harvey Cushing at the American Hospital in Neuilly, where de Martel was appointed chief surgeon in 1916. In 1917, he published with the French neurologist Charles Chatelin a book (Blessures du crâne et du cerveau. Clinique et traitement) with the aim to optimize the practice of wartime brain surgery. This book, which included the results of more than 5000 soldiers with head injuries, was considered the most important ever written on war neurology at that time and was translated into English in 1918 (Wounds of the Skull and Brain; Their Clinical Forms and Medical and Surgical Treatment). In this book, de Martel detailed the fundamentals of skull injuries, classified the various craniocerebral lesions, recommended exploratory craniectomy for cranioencephalic injuries, recommended the removal of metal projectiles from the brain using a magnetic nail, and advocated for the prevention of infectious complications. Between the World Wars, de Martel undertook several developments for neurosurgery in France alongside neurologists Joseph Babinski and Clovis Vincent. Following France’s entry into World War II on September 3, 1939, de Martel took over as head of the services of the American Hospital of Paris in Neuilly. He updated his work on war surgery with the new cases he personally treated. Together with Vincent, de Martel presented his new approach in "Le traitement des blessures du crâne pendant les opérations militaires" ("The treatment of skull injuries during military operations") on January 30, 1940, and published his own surgical results in April 1940 in "Plan d’un travail sur le traitement des plaies cranio-cérébrales de guerre" ("Work Plan on the Treatment of Cranio-Cerebral Wounds of War"), intended for battlefield surgeons. On June 14, 1940, the day German troops entered Paris, de Martel injected himself with a lethal dose of phenobarbital. Thierry de Martel played a central role in establishing modern neurosurgery in France. His patriotism led him to improve the management of wartime cranioencephalic injuries using his own experience acquired during World Wars I and II.

Thierry de Martel (1875–1940), whose full name was Thierry Jean-Marie François de Martel de Janville, owes his international fame to the developments he undertook for neurosurgery (Fig. 1). He developed neurosurgical tools like the wire saw guide in 19081 and a motorized trephine with an automatic declutching mechanism in 1910 (Fig. 2).2 He introduced into France techniques he learned in the United States (US), such as ventriculography, retrogasserian neurotomy, and posterior medullary cordotomy.3 He codified the use of the seating position and of local anesthesia in cranioencephalic surgery:4,5 “He did much to fortify Harvey Cushing in his use of local anesthesia for operations on the brain, and to minimize bleeding, he introduced the sitting posture for the patient.”6

FIG. 1.
FIG. 1.

A: Thierry de Martel in 1914, while serving as a second-class medical assistant in the 292nd Infantry Regiment. Reproduced with the kind authorization of L’Illustration (www.lillustration.com). B: A portrait of de Martel drawn in 1915 by the artist Marie-Louise-Catherine Breslau (1856–1927). Public domain. C: Thierry de Martel, riding a bicycle in 1914, near Fontenoy (Aisne, France), where he was wounded on October 3, 1914, by shrapnel in the thigh during the First Battle of the Aisne. D: Upon recovering, de Martel (left) received the Chevalier de la Légion d’Honneur (Legion of Honor) in the presence of Harvey Cushing (right). He was awarded this highest French decoration in December 1914. E: Thierry de Martel in 1915 (center, wearing a white hat) practicing general war surgery on the hospital ship Charles Roux in the Strait of Gallipoli in the Mediterranean Sea. Panels C–E from Denet JC. M. le Dr Thierry de Martel. Pallas. 1939;18:3-14. Public domain. Source: gallica.bnf.fr, National Library of France.

FIG. 2.
FIG. 2.

A: The metal guide developed by de Martel in 1908 to guide the Gigli saw as it is introduced into the skull between separated burr holes. From de Martel T. Un point de technique opératoire dans la craniectomie. La Presse Médicale. 1908;81:641-643. Public domain. B: The electromagnetic extractor developed by de Martel and Dr. Mondain to extract metallic foreign bodies from the brain. From Chatelin C, de Martel T. Blessures du crâne et du cerveau. Clinique et traitement. Précis de Médecine et de Chirurgie de guerre. Masson et Cie; 1917. Public domain. Source: gallica.bnf.fr, National Library of France. C–E: The motor-driven trephine developed by de Martel in 1910, equipped with an automatic disengaging gear (D) that stopped the trephine as soon as it had penetrated the skull. From Chatelin C, de Martel T. Blessures du crâne et du cerveau. Clinique et traitement. Précis de Médecine et de Chirurgie de guerre. Masson et Cie; 1917. Public domain. Source: gallica.bnf.fr, National Library of France.

During World Wars I (WWI) and II (WWII), this pioneer of neurosurgery also put his patriotic energy at the service of France and his surgical skills at the service of neurosurgery. We present how the neurosurgical experience acquired on the battlefield led de Martel to improve the management of cranioencephalic war injuries.

The Early Years of Neurosurgery in France (1909–1914)

Thierry de Martel was born on March 7, 1875, in Maxéville (Meurthe et Moselle, France). His parents were Count Marie François Roger de Martel de Janville (1848–1920) and Sybille Aimée Marie-Antoinette Gabrielle de Riquetti de Mirabeau (1849–1932). His mother was a novelist who wrote under the pseudonym Gyp. Thierry de Martel had one brother, Aymar (1873–1900), and one sister, Nicole (1877–1968). He was a very athletic man who practiced cycling, boxing, and rugby. He won the first French rugby championship in 1896 with the Olympique Club.

In 1899, he started his medical studies at the Faculty of Medicine of Paris, and he was appointed as a resident of surgery in 1902. He graduated in 1907 and became a general surgeon at the Salpêtrière Hospital in the service of Professor Paul Segond. In 1911, de Martel began his private surgical practice in Paris.7,8 To cover the costs of his clinics, he developed a time-consuming surgical practice; it was initially the practice of general surgery that made it possible for him to maintain his nascent neurosurgical activity: “He had to redouble his activity and his courage. The brilliant surgeon he was becoming had to bring to life the neurosurgeon he was to be.”3

Thierry de Martel performed his first neurosurgical operations thanks to the trust of neurologist Joseph Babinski: an intracranial meningioma in 1909,9 two cerebral gliomas in 1910,10 and a spinal meningioma in 1912.11 In 1910, de Martel went to London every week to attend Victor Horsley’s operations at Queen’s Square Hospital.10 He readily admits the importance that Victor Horsley had in his neurosurgical training: “I have on several occasion heard de Martel acknowledge his great debt to Sir Victor Horsley, whom he regarded as the pioneer of neurosurgery … he stated many time that Horsley had been his inspiration and that he had learnt his neurosurgery from him.”6 In 1913, he reported his neurosurgical activity to the Society of Neurology (25 operated cases, 68% survival), and he was the only French surgeon to report personal neurosurgical experience at the 17th International Congress of Medicine in London.3,1214 In 1914, de Martel had a nationwide reputation as a general surgeon and became the main surgeon to perform neurosurgery in France.

World War I (1914–1918)

Following France’s entry into WWI on August 3, 1914, Thierry de Martel was incorporated into the 292nd Infantry Regiment as a second-class medical assistant.15 Acting on the front line during the First Battle of the Aisne near Fontenoy (Aisne, France), he was wounded on October 3, 1914. The regimental diary reports: “Mr. Martel de Janville’s Aide-Major Physician, while going into the line of fire to treat the wounded, he was himself wounded by shrapnel in the thigh; he continued despite the wound to treat the wounded of his battalion and only consented to enter the ambulance when all his wounded were treated.”16 Thierry de Martel was awarded the Chevalier de la Légion d’Honneur (Legion of Honor), the highest French decoration, created by the French Emperor Napoleon I, in December 1914 for his exceptional involvement in the care provided to soldiers, which was reported in the regimental diary reports:17

The ambulance cars left with the doctors de Martel, Laroche, the accounting officers Dillon and André, and brought back the greatest number of wounded who had remained on the battlefield…. A few forgotten had remained lying in the fields were collected only the next day and cared for with tireless devotion by Doctor de Martel and his staff…. Around 6 a.m. the German howitzers persisted in demolishing and burning all that remained of the Tower farm, pinning the defenders in place. These shells set fire to the buildings occupied by the wounded. Doctor de Martel de Janville, helped by his staff and a few men of good will, very quickly pulled all the wounded from the flames.

While he was recovering, de Martel was assigned as a surgeon in two temporary hospitals in Paris (the temporary hospital Chaptal, hosted in Collège Chaptal, Boulevard des Batignolles; and the Russian Hospital, Rue du Faubourg Saint Honoré) created because of the war. There he published his first surgical results of cranioencephalic war wounds,18 among the earliest ever reported during WWI. In May 1915, de Martel visited the American Hospital in Neuilly to see the neurosurgical practice of the North American teams. There he met Harvey Cushing, who reported: “Then back to find de Martel lunching at the ambulance with Heitz-Boyer and du Bouchet, and after a hurried bite we show them some of our cases—de Martel much taken with the wounds, some of which are pretty good, and he wants to know the secret of making ‘invisible’ scars.”19

After recovery, in August 1915, de Martel was assigned as a surgeon on the hospital ship Charles Roux, which left for the Mediterranean Sea to defend the Strait of Gallipoli (Les Dardanelles in French).7 There he tirelessly practiced general war surgery in difficult conditions. Stricken with malaria, he was repatriated to France in March 1916.7,8 Once he recovered later that month, de Martel was assigned to a temporary hospital in Paris (temporary hospital of the Panthéon, Rue Lhomond) and appointed the chief surgeon at the American Hospital in Neuilly until the end of the war.15 Also in 1916, he faced the death of his only son, Aymar, a volunteer, who died on July 14 on the front line at the age of 18.7

Throughout the war, de Martel recorded his own observations and surgical results of war wounds. With the French neurologist Charles Chatelin, he published two books aimed at rationalizing and optimizing the practice of brain surgery in the context of war: Blessures du crane et du cerveau. Clinique et traitement5 (Wounds of the Skull and Brain; Their Clinical Forms and Medical and Surgical Treatment) in 1917 and Traitement opératoire des plaies du crâne20 (Operative Treatment of Skull Wounds) in 1918 as a part of the book collection “Précis de Médecine et de Chirurgie de guerre" (Medicine and war surgery) (Fig. 3). Blessures du crane et du cerveau, which included the results of more than 5000 soldiers with head injuries, was considered the most important ever written on war neurology at that time. The success of this book led to an English translation in 1918: Wounds of the Skull and Brain; Their Clinical Forms and Medical and Surgical Treatment.21 In this book, de Martel detailed the fundamentals of the management of skull injuries:5

FIG. 3.
FIG. 3.

A: Cover of the 1917 monograph Blessures du crâne et du cerveau. Clinique et traitement (Wounds of the Skull and Brain; Their Clinical Forms and Medical and Surgical Treatment) by Charles Chatelin, neurologist, and de Martel, surgeon. Public domain. Source: gallica.bnf.fr, National Library of France. B: Cover of the book Wounds of the Skull and Brain; Their Clinical Forms and Medical and Surgical Treatment, published in 1918, which is an English translation of Blessures du crâne et du cerveau. Clinique et traitement by Charles Chatelin, Thierry de Martel, and F. F. Burghard. Public domain. C: Front page and title of the journal L’informateur Médical, volume 767, published on January 30, 1940, which summarized the discussions in “Le traitement des blessures du crâne pendant les opérations militaires” (“The treatment of skull injuries during military operations”) by de Martel (photograph on the left) and Clovis Vincent (photograph on the right) at the French Academy of Surgery. Public domain. Source: Bibliothèque Numérique Medica. D and E: Front page and title of the work plan established by de Martel, “Plan d’un travail sur le traitement des plaies cranio-cérébrales de guerre” (“Work Plan on the Treatment of Cranio-Cerebral Wounds of War”), which was published posthumously on January 15 and 21, 1941, by Louis Bazy, secretary of the French Academy of Surgery, on the basis of a text written by Jean-Charles Denet, the main collaborator with de Martel, based on original notes. Reprinted from Mémoires de L’Académie de Chirurgie. 1941;67:12. Public domain. Source: Bibliothèque Numérique Medica.

The preparation of the operating field must be very careful and, above all, very early. It must take place at the aid station…. A dry bandage will be carefully applied to avoid any new contamination during transport of the injured…. The injured person will be transported very gently and with as few jerks as possible to a point where he can be operated on and hospitalized…. There is generally no urgency to operate on skull injuries, they will all benefit from being transported immediately to a hospital…. The examination of the head injury makes it possible to prejudge the extent of the cerebral lesions and to note the improvement or the aggravation of the injured person’s condition…. It is necessary that the surgeon who operated on a wounded skull follow him for a long time. By following their wounded, they would have seen that many of them die late, after having been, for a few weeks, apparently healed.

Thierry de Martel described and classified the various craniocerebral lesions: “1) tangential wounds; 2) wounds in which the bullet entered the skull and came out almost immediately; 3) wounds in which the bullet struck the skull normally but without penetrating it; 4) cases in which the skull is crossed through by a bullet; 5) cases in which the skull is dented by a large projectile; 6) cases in which the skull and brain are plowed to a great extent and depth”5 (Fig. 4). He also insisted on the risks of infectious complications and tried to prevent them (Fig. 5):5

FIG. 4.
FIG. 4.

Illustrations from the 1917 monograph Blessures du crâne et du cerveau. Clinique et traitement (Wounds of the Skull and Brain; Their Clinical Forms and Medical and Surgical Treatment), in which de Martel described and classified the various craniocerebral lesions observed during war: tangential wounds (A); wounds in which the bullet entered the skull and exited almost immediately (B); wounds in which the bullet struck the skull normally but without penetrating it (C); cases in which the bullet entered and went entirely through the skull, exiting from the opposite side (D); cases in which the skull was dented by a large projectile (E); and cases in which the skull and the brain were plowed to a great extent and depth (F). Public domain. Source: gallica.bnf.fr, National Library of France.

FIG. 5.
FIG. 5.

Illustrations from the 1917 monograph Blessures du crâne et du cerveau. Clinique et traitement (Wounds of the Skull and Brain; Their Clinical Forms and Medical and Surgical Treatment), in which de Martel described the surgical steps to manage an open skull fracture by a war projectile. A: The surgeon sharpens the borders of the bone defect using a rongeur or gouge forceps. B: The wound is cleaned through the dura mater without enlarging its opening. Prolonged irrigation with warm saline allows for removal of foreign bodies. C: The scalp defect must be closed to cover the skull defect. D: The epicranium is incised and dissected in clean areas to allow for its closure at the center of the scalp defect. E: The epicranium is sutured to close the scalp defect. F: The scar immediately after surgery. The bone defect is covered by the epicranium and a drain is left in place. G: The scar several days after surgery. Public domain. Source: gallica.bnf.fr, National Library of France.

Wearing a helmet eliminates the presence in the wound of remnants of the kepi, which are a major cause of infection…. Care must be taken that men wear their hair very short. In this way, the soiling of the wound by long hair is avoided and the shaving and cleaning of the scalp is made much easier…. We must not forget the very great danger of opening and infecting the ventricular cavity…. How does the removal of a large part of even infected bone around the fracture help the injured person? These wounded never die of osteomyelitis of the skull. There is no danger there…. The immediate danger is almost exclusively meningitis, and against meningitis, the injured person’s natural defenses are much more effective than the illusory help of surgery…. Please note that the bullet is aseptic right until it comes into contact with the tissues as it was brought to a temperature of several hundred degrees a few moments before…. The surgeon must take care of treating the meningeal and cerebral lesions, taking particular care not to destroy the adhesions that already exist between the dura mater and the brain…. It is necessary to limit the work window through the dura wound as it is without enlarging it, and if one is obliged to enlarge it, it must then be sutured…. It’s good to leave a drain there.

Thierry de Martel’s innovative ideas, such as the recommendation of exploratory craniectomy for cranioencephalic injuries or the removal of shrapnel and metal projectiles from the brain using a magnetic nail, published as early as 1917, were adopted by Harvey Cushing in his later publications.22 Indeed, Harvey Cushing incorporated surgical techniques he observed in France from European surgeons, including de Martel, who advocated the complete shaving of the head, the use of local anesthesia, the use of a bone flap to expose the damaged brain, and the use of an electromagnet to extract metallic foreign bodies from the brain.22 Since their meeting in 1915 at the American Hospital in Neuilly, de Martel and Cushing maintained a friendly relationship and together attended the military parade organized in Paris on July 4, 1918, for the US Independence Day. Harvey Cushing wrote: “No possibility of seats, but he [de Martel] had secured three tickets for standing room reserved in a balcony.”23

The Advent of Modern Neurosurgery in France (1918–1939)

After WWI, Thierry de Martel resumed his civil surgical activity in his Parisian clinics and became an internationally recognized surgeon. In addition, he developed neurosurgery in France alongside the neurologist Clovis Vincent (1879–1947). Marcel David summarized the emulation between de Martel and Vincent, which gave birth to neurosurgery in France: “Both of them, under the aegis of Babinski, for years, were to form a medico-surgical symbiosis which was to be the starting point of French neurosurgery then in its infancy. Martel strove tirelessly to adapt his prodigious gifts as an operator to the requirements of nerve surgery. He devoted a large part of his activity and his personal resources to it.”24 At the end of his life, Joseph Babinski considered his greatest contribution to neurology to be his having pointed the way to de Martel and Vincent: “Le signe, oui. Mais ce n’est pas ce que j’ai fait de mieux. Le mieux, j’ai indiqué la voie à Martel et à Vincent” (“What I have done best? The sign, yes. But it’s not the best I’ve done. Best of all, I showed Martel and Vincent the way”).25 To meet the requirements of neurosurgical practice, de Martel traveled to the US several times.24,26 He summarized his travels as follows: “Discovered and perfected by Cushing, brain surgery has made immense progress. It is true that the Americans, in this as in everything, show an admirable organization. They went so far as to ‘standardize’ the various departments of the medical profession.”27 Clovis Vincent became a neurosurgeon with the help of de Martel, who kept repeating to him: “Knowing the brain as you know it, it is you who should operate in my place. You will learn surgery faster than I neurology.”24 Together, they created a French neurosurgical school.

World War II (1939–1940)

Following France’s entry into WWII on September 3, 1939, de Martel took over as head of the services of the American Hospital in Neuilly, as well as the service of the Laennec Hospital in Paris, both acting as military hospitals.

Wishing to improve the survival of French soldiers, de Martel resumed his work on war surgery, updating it with new cases he personally treated. Together with Vincent, de Martel presented his new approach in “Le traitement des blessures du crâne pendant les opérations militaires”28 (“The treatment of skull injuries during military operations”) on January 30, 1940, at the French Academy of Surgery in Paris. He highlighted the importance of neurosurgical training and of the experience of battlefield surgeons. He also refined the organizational aspect of the management of craniocerebral war injuries by making an inventory of available neurosurgeons, and he organized fundraising to provide the necessary neurosurgical instrumentation.28 In April 1940, de Martel published “Plan d’un travail sur le traitement des plaies cranio-cérébrales de guerre”29 ("Work Plan on the Treatment of Cranio-Cerebral Wounds of War"), intended for military surgeons on the battlefield. This work plan updated previous recommendations established during WWI and codified the care chain:29

Two questions to solve first: Where and when should these injured people be operated on? … The cranio-cerebral wound can wait. Not too much, however: thirty-six hours at most. It benefits from being operated under conditions of real stability…. The doctor in charge of triage must be chosen among the most experienced and knowledgeable…. In the presence of a polytrauma person, what should be done? In general leaving the skull for last, often having an important timespan which will be used to tone up and warm the injured person, sometimes to transfuse him with blood…. The degree of infection varies with different factors. One of the most important is the nature of the projectile. Smooth bullets are not very infective. Shrapnels are on the other hand highly infective…. A foreign body near the ventricle is a great danger…. Brain injured can die: 1) because they suffer from a lesion of the vital brain … 2) because an infectious encephalitis develops more or less late with all its consequences … 3) because of a series of hemodynamic disorders secondary to the injury and to the phenomena of aseptic necrosis that it entails.

This refinement of medical triage was a worthy continuation of a French tradition initiated by Baron Dominique Jean Larrey (1766–1842), a surgeon in the Napoleonic army and father of modern medical triage.30 At the same time, the first results of the patients wounded in WWII and treated according to de Martel’s method were published:29

64 cases of cranio-cerebral wounds were operated on at the American hospital by Dr de Martel or under his immediate direction and by the methods he advocated. Of these 64 injured: three died immediately after the operation, but these were three injured who fell into the category of those considered to be suffering from a fatal injury…. Two other patients died of acute meningitis…. Finally, one injured suffered two months after his trepanation, a cerebral abscess with meningeal reaction…. All the other injured, i.e. 58 cranio-cerebral wounds, left were discharged from the hospital in good health.

The Death of Thierry de Martel

In June 1940, the French defeat was imminent. On June 11, Paris was declared an open city. After failing to join a group to fight for and defend the city, de Martel asked William Bullit, US ambassador in France, if his presence in Paris was still necessary. William Bullit replied that it was preferable that the chief surgeon of the American Hospital in Neuilly remained at his post.7 Thierry de Martel felt deeply dejected: “I can no longer live. My only son was killed in the last war…. Until this one, I wanted to believe that he had died to save France…. And now France in turn is lost…. Everything for which I lived will disappear … I can’t take it anymore.”31 On June 12, 1940, during his last professional appearance at a session of the Société de Chirurgie, de Martel expressed his bitterness toward his medical colleagues, whom he considered not involved enough in the treatment of the war wounded: “The other patients are in perfect condition, always with excellent shreds that I will only be able to show off to the Germans, since no Frenchman has come to see these operations that I would have liked so much to present to some of you.”32

On June 14, 1940, the day German troops entered Paris, Ambassador William Bullit received a telegram from de Martel: “I promised you not to leave Paris. I did not say if I would remain in Paris alive or dead. To remain living in Paris would be a cashable check for our adversaries. If I remain here dead, it is a check without funds to cover it. Adieu. Martel.”7 By the time the ambassador had read the telegram, de Martel had already left. At dawn, after having shaved and perfectly dressed, and after having read Victor Hugo’s Hernani, of which he underlined the verse “Puisqu’il faut être grand pour mourrir, je me lève” (“Because one must be great to die, I rise”),7,34,35 de Martel injected himself with a lethal dose of phenobarbital.

The death of de Martel spread internationally, and many medical journals paid tribute to him. The British Medical Journal reported: “The tragic death by suicide of Thierry de Martel, on the day of which the Germans entered Paris, robs France of one of her most distinguished sons…. He will long be gratefully remembered as brave and distinguished gentleman who happened also to be a surgeon of international repute.”6 The journal Archives of Neurology and Psychiatry reported: “Dr de Martel was an ingenious operator and an independent thinker…. Perhaps the two things for which de Martel was most famous from the neurosurgical standpoint were his advocacy of local anesthesia and the employement of the sitting posture in cranial operations. In both of these innovations he was the pioneer…. The German occupation of the French capital was apparently too much for a man of de Martel’s intense patriotic spirit.”33 The World’s News of Sydney reported: “He was the incarnation of two Frances, the France of the century before the revolution and the France of today: D’Artagnan in the white gown and gauze mask of the number one surgeon of France.”26

Conclusions

Thierry de Martel, like Clovis Vincent, played a central role in establishing modern neurosurgery in France. His patriotism led him to improve the survival of wounded soldiers by codifying the management of wartime cranioencephalic injuries in the light of his experience acquired during WWI and WWII. In the words of René Leriche, as a final tribute to de Martel, “We have only to be silent and salute, with emotion, with respect, the one who, in full possession of himself, did not want to survive the mourning of what he had the most loved: France…. We all learned a lot from him. There is not one of us of whom he has not been master in some way. It is strict justice to proclaim it.”36

Acknowledgments

Dr. Pallud would like to thank Dr. Isabelle Maheo de la Tocnaye for providing the excellent thesis she published on de Martel in 1979; Emmanuelle Huet-Mignaton for providing an original letter from Gyp, the mother of de Martel; and Jean Sébastien Baschet and the journal L’Illustration for providing a photograph of de Martel.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Pallud. Acquisition of data: Pallud. Analysis and interpretation of data: Pallud. Drafting the article: Pallud, Simboli. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Pallud. Administrative/technical/material support: Pallud. Study supervision: Pallud.

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  • 6

    Obituaries. BMJ. 1940; 135:172173.

  • 7

    Maheo de la Tocnaye I. Thierry de Martel. Fils de la romancière Gyp. Pionnier de la neurochirurgie française. 1875-1940. Thesis. Université de Rennes; 1979.

    • Search Google Scholar
    • Export Citation
  • 8

    Pecker J. Thierry de Martel. 1875-1940. Surg Neurol. 1980; 13(6):401403.

  • 9

    de Martel T, Babinski J. Trépanation pour tumeur cérébrale: ablation de la tumeur—grande amélioration. Société de neurologie de Paris. Séance du 2 décembre 1909. Rev Neurol (Paris). 1909; 17:15211522.

    • Search Google Scholar
    • Export Citation
  • 10

    Jumentié J, de Martel T. Deux cas d’extirpation de tumeurs sous-corticales diagnostiquées et localisées par la clinique. Rev Neurol (Paris). 1910; 1:529532.

    • Search Google Scholar
    • Export Citation
  • 11

    Babinski J, de Martel T, Jumentié J. Tumeur méningée de la région dorsale supérieure: paraplégie crurale par compression de la moelle—extraction de la tumeur, guérison. Rev Neurol (Paris). 1912; 23:640644.

    • Search Google Scholar
    • Export Citation
  • 12

    Philippon J. Histoire de la neurochirurgie à la Pitié-Salpêtrière. Hist Sci Med. 1997; 31:173179.

  • 13

    Broussolle E, Reynolds EH. Anglo-French neurological interactions in the 19th and early 20th centuries: physicians, places and events. Rev Neurol (Paris). 2021; 177(8):859870.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14

    Marie P, de Martel T, Chatelin C. 18 mois de chirurgie nerveuse dans le service du Professeur Pierre Marie à la Salpêtrière. Rev Neurol (Paris). 1913; 22:132134.

    • Search Google Scholar
    • Export Citation
  • 15

    Recrutement militaire de la Seine. (1887-1921). Thierry Jean Marie François Martel de Janville de. Matricule 2145. Classe de mobilisation 1895. Archives de Paris. Accessed July 8, 2022. https://archives.paris.fr/r/195/recrutement-militaire-de-la-seine/

    • Search Google Scholar
    • Export Citation
  • 16

    Journal des Marche du 292ème Régiment d’Infanterie. J.M.0. 26N741/1, 12 aout 1914 au 18 juillet 1915, p. 14. Chtimiste.com. Accessed July 8, 2022. http://www.chtimiste.com/batailles1418/divers/journalmarche292RI.htm

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    • Export Citation
  • 17

    Journal des Marche du 292ème Régiment d’Infanterie. J.M.0. 26N741/1, 2 aout 1914 au 18 juillet 1915, p. 22. Chtimiste.com. Accessed July 8, 2022. http://www.chtimiste.com/batailles1418/divers/journalmarche292RI.htm

    • Search Google Scholar
    • Export Citation
  • 18

    Rochard ME. Extraction d’une balle de shrapnell du lobe gauche du cervelet sous anesthésie locale par M. Thierry de Martel. Bull Mém Soc Nat Chir. 1914; 40:1251.

    • Search Google Scholar
    • Export Citation
  • 19

    Cushing H. From a Surgeon’s Journal, 1915-1918. Little, Brown, & Co; 1936:52.

  • 20

    de Martel T. Traitement opératoire des plaies du crâne. Précis de Médecine et de Chirurgie de guerre. Masson et Cie; 1918.

  • 21

    Chatelin C, de Martel T, Burghard FF. Wounds of the Skull and Brain; Their Clinical Forms and Medical and Surgical Treatment. University of London Press; 1918.

    • Search Google Scholar
    • Export Citation
  • 22

    Carey ME. Cushing and the treatment of brain wounds during World War I. J Neurosurg. 2011; 114(6):14951501.

  • 23

    Cushing H. From a Surgeon’s Journal, 1915-1918. Little, Brown, & Co; 1936:394.

  • 24

    David M. Leçon Inaugurale. Faculté de Médecine; 1961.

  • 25

    Déchy H. Joseph Babinski. Rev Neurol. 2016; 172(suppl 1):A155A156.

  • 26

    Morand P. D’Artagnan in white. The World’s News. October 2, 1954:8.

  • 27

    Le Dr de Martel retour d’Amérique. Prog Med (Paris). 1930; 50:2184.

  • 28

    de Martel T. Le traitement des blessures du crâne pendant les opérations militaires. L’informateur Médical. 1940; 767:2.

  • 29

    Denet JC. Plan d’un travail sur le traitement des plaies cranio-cérébrales de guerre, par M. T. de Martel. Séance du 15 Janvier 1941. Mémoires de l’Académie de Chirurgie. 1941; 67:1220.

    • Search Google Scholar
    • Export Citation
  • 30

    Kennedy K, Aghababian RV, Gans L, Lewis CP. Triage: techniques and applications in decision making. Ann Emerg Med. 1996; 28(2):136144.

  • 31

    Maurois A. Tragédie en France. Edition de la Maison Française Inc; 1940:125127.

  • 32

    de Martel T. A propos des blessures du crâne par M. T. de Martel. Séance du 12 juin 1940. Mem Acad Chir (Paris). 1940; 66:612613.

  • 33

    Obituary. Thierry de Martel, 1875-1940. J Neurol Neurosurg Psychiatry. 1941; 45:330332.

  • 34

    Une des gloires de la science française, le Dr Thierry de Martel s’est donné la mort le lendemain de l’entrée des Allemands à Paris. Le Petit Marocain. 1940; 18:1.

    • Search Google Scholar
    • Export Citation
  • 35

    Maurois A. Il se tua, il s’appelait Thierry de Martel. L’Histoire pour tous. 1961; 9:798802.

  • 36

    Leriche R. Ce qu’était Thierry de Martel. Marianne. 1940; 25:3.

  • Collapse
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Captain Benny Brandvold stands "at the ready" outside of Dhahran, Saudi Arabia, during the early phase of Operation Desert Shield, fall of 1990. © Benny Brandvold, published with permission. See the article by Martin et al. (E16).

  • View in gallery
    FIG. 1.

    A: Thierry de Martel in 1914, while serving as a second-class medical assistant in the 292nd Infantry Regiment. Reproduced with the kind authorization of L’Illustration (www.lillustration.com). B: A portrait of de Martel drawn in 1915 by the artist Marie-Louise-Catherine Breslau (1856–1927). Public domain. C: Thierry de Martel, riding a bicycle in 1914, near Fontenoy (Aisne, France), where he was wounded on October 3, 1914, by shrapnel in the thigh during the First Battle of the Aisne. D: Upon recovering, de Martel (left) received the Chevalier de la Légion d’Honneur (Legion of Honor) in the presence of Harvey Cushing (right). He was awarded this highest French decoration in December 1914. E: Thierry de Martel in 1915 (center, wearing a white hat) practicing general war surgery on the hospital ship Charles Roux in the Strait of Gallipoli in the Mediterranean Sea. Panels C–E from Denet JC. M. le Dr Thierry de Martel. Pallas. 1939;18:3-14. Public domain. Source: gallica.bnf.fr, National Library of France.

  • View in gallery
    FIG. 2.

    A: The metal guide developed by de Martel in 1908 to guide the Gigli saw as it is introduced into the skull between separated burr holes. From de Martel T. Un point de technique opératoire dans la craniectomie. La Presse Médicale. 1908;81:641-643. Public domain. B: The electromagnetic extractor developed by de Martel and Dr. Mondain to extract metallic foreign bodies from the brain. From Chatelin C, de Martel T. Blessures du crâne et du cerveau. Clinique et traitement. Précis de Médecine et de Chirurgie de guerre. Masson et Cie; 1917. Public domain. Source: gallica.bnf.fr, National Library of France. C–E: The motor-driven trephine developed by de Martel in 1910, equipped with an automatic disengaging gear (D) that stopped the trephine as soon as it had penetrated the skull. From Chatelin C, de Martel T. Blessures du crâne et du cerveau. Clinique et traitement. Précis de Médecine et de Chirurgie de guerre. Masson et Cie; 1917. Public domain. Source: gallica.bnf.fr, National Library of France.

  • View in gallery
    FIG. 3.

    A: Cover of the 1917 monograph Blessures du crâne et du cerveau. Clinique et traitement (Wounds of the Skull and Brain; Their Clinical Forms and Medical and Surgical Treatment) by Charles Chatelin, neurologist, and de Martel, surgeon. Public domain. Source: gallica.bnf.fr, National Library of France. B: Cover of the book Wounds of the Skull and Brain; Their Clinical Forms and Medical and Surgical Treatment, published in 1918, which is an English translation of Blessures du crâne et du cerveau. Clinique et traitement by Charles Chatelin, Thierry de Martel, and F. F. Burghard. Public domain. C: Front page and title of the journal L’informateur Médical, volume 767, published on January 30, 1940, which summarized the discussions in “Le traitement des blessures du crâne pendant les opérations militaires” (“The treatment of skull injuries during military operations”) by de Martel (photograph on the left) and Clovis Vincent (photograph on the right) at the French Academy of Surgery. Public domain. Source: Bibliothèque Numérique Medica. D and E: Front page and title of the work plan established by de Martel, “Plan d’un travail sur le traitement des plaies cranio-cérébrales de guerre” (“Work Plan on the Treatment of Cranio-Cerebral Wounds of War”), which was published posthumously on January 15 and 21, 1941, by Louis Bazy, secretary of the French Academy of Surgery, on the basis of a text written by Jean-Charles Denet, the main collaborator with de Martel, based on original notes. Reprinted from Mémoires de L’Académie de Chirurgie. 1941;67:12. Public domain. Source: Bibliothèque Numérique Medica.

  • View in gallery
    FIG. 4.

    Illustrations from the 1917 monograph Blessures du crâne et du cerveau. Clinique et traitement (Wounds of the Skull and Brain; Their Clinical Forms and Medical and Surgical Treatment), in which de Martel described and classified the various craniocerebral lesions observed during war: tangential wounds (A); wounds in which the bullet entered the skull and exited almost immediately (B); wounds in which the bullet struck the skull normally but without penetrating it (C); cases in which the bullet entered and went entirely through the skull, exiting from the opposite side (D); cases in which the skull was dented by a large projectile (E); and cases in which the skull and the brain were plowed to a great extent and depth (F). Public domain. Source: gallica.bnf.fr, National Library of France.

  • View in gallery
    FIG. 5.

    Illustrations from the 1917 monograph Blessures du crâne et du cerveau. Clinique et traitement (Wounds of the Skull and Brain; Their Clinical Forms and Medical and Surgical Treatment), in which de Martel described the surgical steps to manage an open skull fracture by a war projectile. A: The surgeon sharpens the borders of the bone defect using a rongeur or gouge forceps. B: The wound is cleaned through the dura mater without enlarging its opening. Prolonged irrigation with warm saline allows for removal of foreign bodies. C: The scalp defect must be closed to cover the skull defect. D: The epicranium is incised and dissected in clean areas to allow for its closure at the center of the scalp defect. E: The epicranium is sutured to close the scalp defect. F: The scar immediately after surgery. The bone defect is covered by the epicranium and a drain is left in place. G: The scar several days after surgery. Public domain. Source: gallica.bnf.fr, National Library of France.

  • 1

    de Martel T. Un point de technique opératoire dans les craniectomie. Presse Med. 1908; 81:641643.

  • 2

    Segond P. Présentation d’instrument. Séance du 8 juin 1910. Bull Mém Soc Nat Chir. 1910; 36:689.

  • 3

    Tournay A. Allocution à propos du décès de M. Thierry de Martel. Société de Neurologie de Paris, séance du 7 novembre 1940. Rev Neurol (Paris). 1940; 72(7):753758.

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    • Export Citation
  • 4

    Crinon J. L’état actuel de la chirurgie cérébrale. L’informateur Médical. 1930; 304:13.

  • 5

    Chatelin C, de Martel T. Blessures du crâne et du cerveau. Clinique et traitement. Précis de Médecine et de Chirurgie de guerre. Masson et Cie; 1917:204209.

    • Search Google Scholar
    • Export Citation
  • 6

    Obituaries. BMJ. 1940; 135:172173.

  • 7

    Maheo de la Tocnaye I. Thierry de Martel. Fils de la romancière Gyp. Pionnier de la neurochirurgie française. 1875-1940. Thesis. Université de Rennes; 1979.

    • Search Google Scholar
    • Export Citation
  • 8

    Pecker J. Thierry de Martel. 1875-1940. Surg Neurol. 1980; 13(6):401403.

  • 9

    de Martel T, Babinski J. Trépanation pour tumeur cérébrale: ablation de la tumeur—grande amélioration. Société de neurologie de Paris. Séance du 2 décembre 1909. Rev Neurol (Paris). 1909; 17:15211522.

    • Search Google Scholar
    • Export Citation
  • 10

    Jumentié J, de Martel T. Deux cas d’extirpation de tumeurs sous-corticales diagnostiquées et localisées par la clinique. Rev Neurol (Paris). 1910; 1:529532.

    • Search Google Scholar
    • Export Citation
  • 11

    Babinski J, de Martel T, Jumentié J. Tumeur méningée de la région dorsale supérieure: paraplégie crurale par compression de la moelle—extraction de la tumeur, guérison. Rev Neurol (Paris). 1912; 23:640644.

    • Search Google Scholar
    • Export Citation
  • 12

    Philippon J. Histoire de la neurochirurgie à la Pitié-Salpêtrière. Hist Sci Med. 1997; 31:173179.

  • 13

    Broussolle E, Reynolds EH. Anglo-French neurological interactions in the 19th and early 20th centuries: physicians, places and events. Rev Neurol (Paris). 2021; 177(8):859870.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14

    Marie P, de Martel T, Chatelin C. 18 mois de chirurgie nerveuse dans le service du Professeur Pierre Marie à la Salpêtrière. Rev Neurol (Paris). 1913; 22:132134.

    • Search Google Scholar
    • Export Citation
  • 15

    Recrutement militaire de la Seine. (1887-1921). Thierry Jean Marie François Martel de Janville de. Matricule 2145. Classe de mobilisation 1895. Archives de Paris. Accessed July 8, 2022. https://archives.paris.fr/r/195/recrutement-militaire-de-la-seine/

    • Search Google Scholar
    • Export Citation
  • 16

    Journal des Marche du 292ème Régiment d’Infanterie. J.M.0. 26N741/1, 12 aout 1914 au 18 juillet 1915, p. 14. Chtimiste.com. Accessed July 8, 2022. http://www.chtimiste.com/batailles1418/divers/journalmarche292RI.htm

    • Search Google Scholar
    • Export Citation
  • 17

    Journal des Marche du 292ème Régiment d’Infanterie. J.M.0. 26N741/1, 2 aout 1914 au 18 juillet 1915, p. 22. Chtimiste.com. Accessed July 8, 2022. http://www.chtimiste.com/batailles1418/divers/journalmarche292RI.htm

    • Search Google Scholar
    • Export Citation
  • 18

    Rochard ME. Extraction d’une balle de shrapnell du lobe gauche du cervelet sous anesthésie locale par M. Thierry de Martel. Bull Mém Soc Nat Chir. 1914; 40:1251.

    • Search Google Scholar
    • Export Citation
  • 19

    Cushing H. From a Surgeon’s Journal, 1915-1918. Little, Brown, & Co; 1936:52.

  • 20

    de Martel T. Traitement opératoire des plaies du crâne. Précis de Médecine et de Chirurgie de guerre. Masson et Cie; 1918.

  • 21

    Chatelin C, de Martel T, Burghard FF. Wounds of the Skull and Brain; Their Clinical Forms and Medical and Surgical Treatment. University of London Press; 1918.

    • Search Google Scholar
    • Export Citation
  • 22

    Carey ME. Cushing and the treatment of brain wounds during World War I. J Neurosurg. 2011; 114(6):14951501.

  • 23

    Cushing H. From a Surgeon’s Journal, 1915-1918. Little, Brown, & Co; 1936:394.

  • 24

    David M. Leçon Inaugurale. Faculté de Médecine; 1961.

  • 25

    Déchy H. Joseph Babinski. Rev Neurol. 2016; 172(suppl 1):A155A156.

  • 26

    Morand P. D’Artagnan in white. The World’s News. October 2, 1954:8.

  • 27

    Le Dr de Martel retour d’Amérique. Prog Med (Paris). 1930; 50:2184.

  • 28

    de Martel T. Le traitement des blessures du crâne pendant les opérations militaires. L’informateur Médical. 1940; 767:2.

  • 29

    Denet JC. Plan d’un travail sur le traitement des plaies cranio-cérébrales de guerre, par M. T. de Martel. Séance du 15 Janvier 1941. Mémoires de l’Académie de Chirurgie. 1941; 67:1220.

    • Search Google Scholar
    • Export Citation
  • 30

    Kennedy K, Aghababian RV, Gans L, Lewis CP. Triage: techniques and applications in decision making. Ann Emerg Med. 1996; 28(2):136144.

  • 31

    Maurois A. Tragédie en France. Edition de la Maison Française Inc; 1940:125127.

  • 32

    de Martel T. A propos des blessures du crâne par M. T. de Martel. Séance du 12 juin 1940. Mem Acad Chir (Paris). 1940; 66:612613.

  • 33

    Obituary. Thierry de Martel, 1875-1940. J Neurol Neurosurg Psychiatry. 1941; 45:330332.

  • 34

    Une des gloires de la science française, le Dr Thierry de Martel s’est donné la mort le lendemain de l’entrée des Allemands à Paris. Le Petit Marocain. 1940; 18:1.

    • Search Google Scholar
    • Export Citation
  • 35

    Maurois A. Il se tua, il s’appelait Thierry de Martel. L’Histoire pour tous. 1961; 9:798802.

  • 36

    Leriche R. Ce qu’était Thierry de Martel. Marianne. 1940; 25:3.

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