Christmas with Dupuytren and Lisfranc

       Statue of Baron Guillaume Dupuytren

Anne Jacobson
Oak Park, Illinois (Fall 2016)

 

It is Christmas afternoon and I am nestled under a decades-old afghan on my parents’ couch, watching snow drift and swirl across oak-studded fields beneath a pewter sky.  My left foot is wrapped and strapped in a comically oversized boot, and the companion crutches at my side reflect the steady on-off blinking of Christmas tree lights.  I am drowsy from eggnog and turkey, lulled into half-sleep by my father softly playing the organ inches from my nodding head— a lovely and somewhat random mix of Christmas carols, show tunes, church hymns, and polkas.  The stream-of-consciousness playlist is soothing and familiar, but was nearly lost to a degenerative condition of my father’s hands, bearing an eponymous title that no one in the house can remember or pronounce.  No one except the doctor daughter dozing on the couch, who is herself in possession of a swollen and misshapen foot, an injury that also bears the name of a long-dead physician.  In an ironic twist, the name bearers of our father-daughter afflictions were once colleagues and rivals in Paris two hundred years earlier, both surgeons engaged in an obsessive quest for excellence and notoriety.   This scene in my parents’ home is part Norman Rockwell, part comic strip; I doze and imagine the names of our hand-and-foot anomalies labeled in cartoon bubbles above our heads, standing out in sharp relief against the gauzy brushstrokes of the fading Christmas afternoon… “Dupuytren”… “Lisfranc.”

Those who have navigated the hallowed halls of medical education retain a half-buried mental file of variably useful and marginally interesting facts.  This file contains the limerick-like mnemonics from gross anatomy lab (often dissociated from the anatomy it was designed to remember), quirky medical anecdotes handed down from bow-tie-clad professors during bedside rounds, and esoteric illnesses that bear the discoverers’ names.  Many of these prodigious explorers revealed and named procedures, anatomy, conditions, and equipment that sometimes had little to do with one another, further confusing the modern student trying to link meaningful information with the eponym.  For example, Baron Guillaume Dupuytren (1777-1835), the powerful Parisian physician now best known for the identification and treatment of chronic thickening and contracture of the palmar fascia, also staked his claim on an abscess, a splint, a bandage, and cellulitis of the neck.  His partner-turned-nemesis on the other side of town, Dr. Jacques Lisfranc de St. Martin, was the most famous gynecological surgeon of his time, but achieved immortality for having named a disabling orthopedic injury of the foot.

My father’s condition, Dupuytren’s contracture, also known as “Viking’s disease,” mainly afflicts men of northern European descent.  As a German-Scandinavian who has lived his entire life in the town of Norway, Wisconsin, my father quite fits the Viking profile.  Bands of fibrous tissue form in the palm of the hand, causing callous-like nodules under the skin and limiting extension of the fourth and fifth fingers.  Although he had already retired as a teacher when the contracture became significant, he had to give up his favorite retirement activities: woodworking and playing the organ at church.  He eventually had surgery — a modern variation on Dupuytren’s technique — but the debilitation of his hands was closely followed by a series of other chronic conditions: spinal arthritis, diabetes, stroke.  In my parents’ home, Dupuytren’s name is now associated with the beginning of a contracture of another kind.

While Dad’s hands bent slowly over time, the bones of my foot exploded out of their anatomical positions in an instant.  In lieu of a concocted story about hiking in a remote canyon or skiing down an icy slope, the truth comes from the succinct “History of Present Illness” offered by the orthopedic surgeon that crunched all five metatarsals back into place: “Family Physician was jumping on trampoline, sustained Lisfranc injury.”  The orthopedist that resumed my care over the next six months carried a copy of my X-ray around on his iPhone, hauling it out at each visit to delight the team of students and residents gathered around him.  “Oh, this is a classic,” he would quip.  “Most people dislocate one or two bones with this injury.  She did all five!”

In the grand scheme of eponymous conditions, my father and I were fortunate to get away with Dupuytren and Lisfranc.  Thus far we have not had to struggle with debilitating illnesses such as Parkinson’s disease (James Parkinson, 1755-1824), Sydenham’s chorea (Thomas Sydenham, 1624-1689), Hodgkin’s disease (Thomas Hodgkin, 1798-1866), or Pancoast’s syndrome (Henry Khunrath Pancoast, 1875-1939).  I never want to receive a pathology report showing Mallory bodies (Frank Burr Mallory, 1862-1941), most forms of Neisseria (Albert Ludwig Sigesmund Neisser, 1855-1916), or suspicious Gram stains (Hans Christian Joachim Gram, 1853-1938).  Unless absolutely necessary, leave me out of any procedure by the name of Billroth (Christian Albert Theodor Billroth, 1829-1894) or Whipple (Allen Oldfather Whipple, 1881-1963).  And I would also prefer to avoid my old friend Lisfranc, and both the mid-foot amputation and the rectal excision that bear his name.

I wondered about these name bearers — ambitious and gifted scientists, practitioners, and scholars — whose names are still remembered and spoken aloud so many years after their work.  Within the medical field they may still receive deference and respect, or the condition or procedure they founded may have become so commonplace that it is now a noun or a verb all its own.  To the rest of the world, the names are most often associated with illness that is painful, degenerative, or life-threatening.  Were these eponymous titles self-proclaimed, or were they bestowed by others?

For some, the designation was conferred by colleagues in recognition of previous work.  Thomas Hodgkin, a British pathologist, wrote a paper in 1832 describing the appearance of enlarged lymph nodes and spleen.  The term “Hodgkin’s disease” was not introduced until 1865 by another British physician, Samuel Wilks.  He too had described the condition, but later learned of the earlier studies and bestowed Hodgkin’s name on the malady. Sister Mary Joseph’s nodule, an umbilical manifestation of metastatic cancer, was first pointed out to Dr. William James Mayo (1861-1939) by Sister Mary Joseph Dempsey (1856-1939), a nurse and hospital administrator.  Although Dr. Mayo did not use his assistant’s name in the paper he published, Sister Mary Joseph continued to be associated with the physical finding until it was officially named twenty years later in a surgical textbook. There is even evidence that some research pioneers were able to share the spotlight, even if working for different institutions.  George Milton Shy (1919-1967) and Glenn Albert Drager (1917 – 1967) were working for the National Institutes of Health and Baylor College of Medicine respectively, when they collaboratively described two patients with a symptom constellation that would be named for both of them: the autonomic nervous system disease known as Shy-Drager syndrome.

Dupuytren and Lisfranc, however, were not particularly interested in collaborating or spotlight sharing.  Guillaume Dupuytren grew up poor in central France, but attracted attention with his intelligence and good looks.  In addition to being abducted by a wealthy woman at the age of four and then returned to his family, he was later taken to Paris by a cavalry officer who paid for his education.  Dupuytren wished to become a soldier, but his father insisted he enroll in medical school.  He went on to become a surgeon with a military drive.  He would become chief of surgery at Paris’ Hotel-Dieu at the age of thirty-eight, a post he achieved in part by challenging and tearing down his mentor, who held the post before him.  He was brilliant, driven, and productive, attending 10,000 patients a year at the height of his career, which also made him one of the richest physicians of his time.  He would go on to be regarded as the greatest surgeon of the nineteenth century.  Yet his success and notoriety came with an arrogant disregard for his colleagues:  the names bestowed on Dupuytren by other physicians of the time included “The brigand of the Hotel-Dieu,” “The Napoleon of surgery,” “The beast at the Seine,” and “First among surgeons, last among men.”  His paper describing the palmar contracture that now bears his name was first published in 1832.  When it was translated into English and published in The Lancet the following year, the editors added a footnote questioning Dupuytren’s apparent ignorance of the paper published by Sir Astley Cooper a full ten years earlier, which had already described the condition in detail.

Jacques Lisfranc was one of Dupuytren’s best known medico-political rivals.  His father was a physician and Jacques observed and participated in the elder Lisfranc’s medical practice from a young age.  Perhaps Lisfranc entered the medical community with an expectation that his early aptitude and upbringing would pave the way for his success, while Dupuytren felt he had something to prove. Lisfranc arrived in Paris and trained under Dupuytren at the Hotel-Dieu, demonstrated exceptional skills rivaling those of his mentor, and launched decades of bitter rivalry between the two men.  Lisfranc would go on to distinguish himself as a military surgeon in the Napoleonic wars, and later become chief of surgery at L’Hopital de la Pitie across the river from his teacher-turned-rival, Dupuytren.  Lisfranc was recognized for pioneering several surgical techniques of the nineteenth century, but is best remembered for describing the mid-foot injury in a soldier who had fallen from his horse and trapped his foot in the stirrup.  While recognized as a talented professor and surgeon, Lisfranc, like Dupuytren, achieved status at the cost of collegial and personal relationships.

My father and I are connected to these long-dead men of blind ambition.  We owe them a debt for the modern treatments they set in motion almost two centuries ago.   I admire their vision and perseverance, but question whether the egoism and arrogance they employed to achieve their status by tearing down rivals was necessary… or worth it.  Isaac Newton famously said, “If I have seen further, it is by standing on the shoulders of giants.”  Dupuytren and Lisfranc were certainly giants of their field and in their time.  They have achieved orthopedic immortality, although both men might be surprised to note the one eponym that has survived from their vast and varied bodies of work.  Certainly there are countless other giants, quiet and steadfast, whose names were never immortalized, but whose labors contributed equally to the shoulders on whom I now stand, both as a physician and a patient.

Dupuytren and Lisfranc, these two bitter rivals, now flash through my turkey-and-eggnog clouded brain — twin Scrooges engaged in a Christmas battle with one another, with ambition, with perpetuity.  I adjust my throbbing foot and notice my father stretching his hands as he steps away from the organ and turns on the football game.  He and I will carry our imperfections quietly — treated and improved, but never quite the same.  Dupuytren and Lisfranc achieved the fame they desired and will live on in textbooks, operative dictations, X-ray reports, and medical trivia.  I, on the other hand, find myself drifting and content in the anonymity of this winter afternoon, grateful for the shoulders I stand upon, and ready to be part of a collective foundation for those who will see further than we now imagine.

 

Works Cited

Androutsos G., Karamanou M., and Kostakis A.  “Baron Guillaume Dupuytren (1777-1835): One of  the Most Outstanding Surgeons of 19th Century.  Hellenic Journal of Surgery 83:5 (2011), 239-243.
Corman, M.L. & Lisfranc, J. Dis Colon Rectum (1983) 26: 694. doi:10.1007/BF02553350
Jay, Venita.  “Baron Guillaume Dupuytren.”  Arch Pathol Lab Med 124 (2000): 955-56.
Surgeons-Net.  “Jacques Lisfranc de St. Martin.”  http://www.surgeons.org.uk/history-of-surgeons/jacques-lisfranc-de-st-martin.html
Whonamedit? – A Dictionary of Medical Eponyms.  “Baron Guillaume Dupuytren.”  http://www.whonamedit.com/doctor.cfm/1104.html
Whonamedit? – A Dictionary of Medical Eponyms.  “Jacques Lisfranc de St. Martin.”   http://www.whonamedit.com/doctor.cfm/2572.html

 


 

ANNE JACOBSON, MD MPH, is a family physician and writer.  Her published works may be found in JAMA: A Piece of My Mind, in the anthology At The End of Life: True Stories About How We Die (In Fact Books, 2012), Hektoen International, and forthcoming in The Examined Life Journal.

 

Highlighted in Frontispiece Spring 2017 – Volume 9, Issue 1