Baron Guillaume Dupuytren
- Breschet's vein
- Dupuytren's abscess
- Dupuytren's bandaging
- Dupuytren's contracture
- Dupuytren's phlegmon
- Dupuytren's splint
- Mikulicz's enterotome
- Nélaton's tumour
- Pott's fracture
Biography of Baron Guillaume Dupuytren
The beast at the Seine
The brigand of the Hôtel-Dieu
The miser who would give the king one million francs
First among surgeons, Last among Men
The Napoleon of surgery
"Monsieur Dupuytren, voyez ma misère
Ma dextre rigide et mes doigts perclus
J'ai un annulaire qui n'annule guère
Et l'auriculaire n'auricle plus
The man who was to become one of the richest physicians in his time, if not the richest, was born in 1777 in the village of Pierre-Buffière, near Limoges in the Haute Vienne district of central France, where his father was an impoverished advocate. He was an extremely intelligent child, and must have been very attractive, as he was taken away twice. At the age of four years he was abducted by a wealthy lady from Toulouse, but later returned to his family. Later he attracted the attention of a cavalry officer in the town, who took him into Paris at the age of 12 where he paid for Guillaume’s schooling.
After his time at school in Paris Dupuytren wanted to enter the army, but in 1793, at the insistence of his father, he enrolled in the medical-surgical school of St. Alexis Hospital in Limoges. However, he soon – still aged 16 - decided to pursue his education in Paris. As a student Dupuytren for the next two years suffered hunger and desolation – while maybe plotting his triumphant future. It is said that he lived in a garret and used fat from the cadavers in the dissecting room to make oil for the lamp by which he studied. He attended classes at the Charité, the Salpêtrière, the École de Santé, and the Collège de Magnac-Laval, and by the time he graduated, in 1797, he had already caught the attention of the medical community in Paris.
When 18, in 1794, Dupuytren obtained a post as prosector of the École de Santé, where he gave anatomy lectures that were well attended, and was placed in charge of all the autopsies at the medical school, and this laid a foundation for his future interest. When he was 24, in 1801, he was appointed Chef des travaux anatomiques and soon had written a monograph on pathological anatomy based on his autopsy findings. Here he also gave a course in pathology with Antoine-Laurent-Jessé Bayle (1799-1858) and René-Théophile-Hyacinthe Laënnec (1781-1826) as assistants. He and Laënnec parted on very bad terms since Laënnec felt Dupuytren was endeavouring to gain credit for the work of Bayle.
Already as a lecturer of anatomy Dupuytren introduced macroscopic pathology to surgery - which up to then had been characterised more by optimism and audacity - by the surgeon - and a not too heavy load of knowledge of the causes of diseases and other anatomical finesses.
His acquisition of the doctorate of the University of Paris was delayed until 1803 as medical schools had been suppressed by the Revolutionary Government. After qualification Dupuytren taught anatomy and at the age of 25 years, through concours, was appointed Chirurgien en second at the Hôtel-Dieu, where he became a full member of the staff as Chief surgeon - Chirurgien en chef adjoint - in 1808.
First among surgeons and last among men
At the Hôtel-Dieu he immediately commenced a bitter struggle with his superior, Philippe Jean Pelletan (1747-1829). But by 1815 Dupuytren, after having refrained from no perfidity in his efforts to dispose of his boss and mentor, had vanquished Pelletan and replaced him as chief. Under his leadership the Hôtel-Dieu gained a leading position among the hospitals of Europe, with Dupuytren reigning as chief of surgery for more than twenty years.
Dupuytren was a merciless, obsessive-compulsive personality, an absolute perfectionist in everything he did. He had enormous energy, drive and intellectual ability allied to ruthless ambition and cynical disregard for the sensibilities of his students and colleagues. But he was also a spellbinding lecturer, his vast knowledge highlighted by his dazzling ability for total recall of case stories, clinical studies and medical details of any kind.
With good reason he was known to his contemporaries as Le Brigand d’Hôtel-Dieu (Jacques Lisfranc de St. Martin, 1790-1847), «first among surgeons and last among men» (Pierre-François Percy, 1754-1825) and the «Napoleon of surgery».
However, when the enemy stood at the gates of Paris, Dupuytren was there with his students to help the wounded.
Hard working beast
«The wild animal at the Seine» - one of his other popular names, introduced working routines in accordance with his own ambitions. The day began at 7 with a round, a rather lugubrious arrangement for both collaborators and patients in the dark and cold hospital rooms. Then followed operations and consultations. His meticulous study of the course of the disease and during the postoperative treatment was unequalled.
An outstanding diagnostician and teacher, Dupuytren was given to pronouncements which, while never questioned, were invariably correct. In the evening the staff and some hundred students from near and far came together to listen to Dupuytren’s lectures, which were based on the surgical experiences of the day. Thus, in an eloquent way, Dupuytren had the opportunity of developing his knowledge, his clinical logic - and his contempt of colleagues.
His writings – a feast
Dupuytren disliked writing and many accounts of his lectures and investigations were published by his students and acolytes, and published as Lecons orales de clinique chirurgicale, first published in 1832. To contemporary surgeons these lessons were priceless. They comprise reports covering the entire surgical panorama of that day, often casuistically disposed with anamnesis, pathological anatomy, differential diagnostics, therapy, postoperative course and unfortunate cases closed with an autopsy report.
Even a superficial reading of Leçons is a feast to modern clinicians with an interest in medical history. In the notes to the lectures we find epoch-making accounts on malleolar fractures, fractures of the radius, treatment of anus praeternaturalis (a then common complication in wedged hernia and intestinal gangrene), burns (classified in 6 degrees), lesions of the shoulder, and further a successful treatment of neglected luxations of the shoulder and hip joint - during one year adding up to no less than 35 cases. All of this in a time when the completion of the anaestheticum laudanum (opium) consisted of solid ropes and muscular hospital boys.
Dupuytren never operated if an operation could be avoided, but he was the first person to successfully remove the lower jaw. He not only described Dupuytren contracture, but devised an operation to cure it, and also the operation for correction of wry neck by sectioning the sternomastoid muscle. He developed an enterotome and his instrument or a modification of it was used by surgeons such as Astley Cooper and Mikulicz. In fact, as is the wont with eponyms, it is often called the Mikulicz enterotome.
Dupuytren’s account of the clinical manifestations and surgical management of the digital contracture which bears his name was published in 1832. Digital contractures had previously been reported by Sir Astley Cooper (1768-1841) but Dupuytren was either unaware of or unconcerned with this account. In any event, Dupuytren was the first to realise that the basic lesion lay in the palmar fascia rather than the skin or tendons and for this reason he deserves eponymous recognition.
Dupuytren’s report was translated into English and published in 1833 by Alexandre Louis Michel Paillard (1803-1835) and Edmond Marx (1797-1865). This report of the contracture was also published in Lancet. In a footnote the publisher commented the peculiarity that the chief of the Hôtel-Dieu was so unfamiliar with his surgeon colleague Sir Astley Cooper’s adequate description and treatment of the condition more than ten years previously. The second edition of Lecons orales, published after Dupuytren’s death, contains a report of seventeen cases of the contracture, comprising aetiology, symptomatology, differential diagnosis, treatment, and result. Could you wish for more?
The familial nature of the contracture was recorded by the French surgeon Jean-Gaspard-Blaise Goyrand (1793-1866) in 1833 soon after Dupuytren’s original description.
The first operation
It was in 1831 - some four years before his death - that Dupuytren operated the contracture that bears his name. After first having waited for several years for a man who suffered from the classical fibrosis, and then dissected the affected hand, he operated on a wine merchant - who thus entered medical history.
The operation consisted of fasciotomy - "la main du malade étant solidement fixée" - via traversing incision in vola and the little finger, all described in detail, including the postoperative swelling and the unavoidable wound infections. After eight weeks the finger had «normal» movements.
The miser and the king
At the height of his powers Dupuytren saw 10 000 patients in a year and became very wealthy. Although he was known for his parsimony, when Charles X was dethroned and needed money, Dupuytren offered him a million francs, stating that he was having another million for his daughter and a third for his old age. The king, however, declined the offer. Dupuytren had been created a baron by Louis XVIII after becoming his personal surgeon, and was appointed first surgeon to Charles X.
A painting (Opération de la cataracte par Dupuytren en présence de Chales X à lHötel-Dieu) in the Musée Carnavalet, Paris, shows Duputren presenting a patient on whom he had succesasfully operated for cataract to King Charles X during a royal visit to the Hôtel-Dieu in 1824.
End of a career
In 1833 he had a stroke whilst lecturing, but persisted and finished the lecture, but from that time on he was an invalid. In 1834 he had to withdraw from Hôtel-Dieu after more than 30 years of uninterrupted service, and travelled to Italy - in triumph. On his return he resumed his work as a physician, but his health failed ever more, and he died in Paris two years later, aged 58. Of his large fortune he left 200 000 francs to the medical faculty for the establishment of a chair of pathological anatomy. This had already been established by the state, however, and the money was used to found a pathological-anatomical museum instead - the Musée Dupuytren, which still exists - and at that on classic academic ground at the École-de-Médecine besides Sorbonne.
Through his 58 years of life Dupuytren experienced l’ancien régime, the Napoleoinc era and the Restoration - indeed a dramatic period in the history of France. He was a contemporary of René-Théophile-Hyacinthe Laënnec (1781-1826), Marc-Antoine Petit (1760-1840), Philibert Joseph Roux (1780-1854), Marie Francois Xavier Bichat (1771-1802), and baron Dominique-Jean Larrey (1766-1842) - «enjoying» a thoroughly unfriendly? relationship to the latter.
One of Dupuytren’s sayings was «rien n'est pas tante redouter un homme que la mediocrité» - ”nothing should be feared so much for a man as mediocrity.” Whilst he was nobody’s friend in Paris, he certainly was well liked and honoured in countries such as England and Italy.
Dupuytren has been described as a sombre, merciless, scornful and haughty. It seems certain that Dupuytren himself pursued all those who were against him, such as Alfred Armand Louis Marie Velpeau (1795-1867), throughout his life. Negative terms almost stumble on each other when his character is to be described. It is true that he was unfriendly towards colleagues and students, but he was indeed friendly and thoughtful towards his patients, in particular to children and the indigent. The usually quoted characteristic «first of surgeons and last of men» most probably stems from one of his colleagues, not from a patient.
Dupuytren was a member of the Conseil de salubrité and Inspecteur général of the university.
Dupuytren was first of all a clinician and a teacher, not an innovator like Pott, Hunter, or Petit, or a therapeutic operator like Roux, and what little he published was of surprisingly simple quality when judged against his vernal abilities. He himself wrote articles on a broad spectre of surgery, but a large part of his innovations are described by his pupils. He was the first to separate between Delirium nervosum and Delirium tremens.
«I prefer to die by the decree of God rather than by the hand of man.»
Quoted by Arpad G. Gerster in
Proceedings of the Charaka Club. 1916; 4: 113.
- Propositions sur quelques points d’anatomie, de physiologie et d’anatomie pathologique.
Doctoral thesis, Paris, 1803.
- Sur la lithotomie.
Concours thesis for the chair of operative surgery. 1812.
- [Anévrisme à l’artère poplitée par la compression.]
Bulletin de la Faculté de médecine, Paris, 1818; 6: 242.
A short report from the faculty meeting on November 19, 1818.
Dupuytren was the first to successfully treat anurysm by compression.
- Account of the tying of the subclavian artery.
Edinburgh Medical and Surgical Journal, 1819; 15: 476.
Dupuytren successfully ligated the subclavian artery on March 7, 1819.
- Observation sur une résection de la mâchoire inférieure.
Journal universel des sciences médicales, Paris, 1820; 19: 77-98.
Dupuytren was the first to successfully excise the lower jaw, in 1812.
- Observation sur un cas de ligature de l’artère iliaque externe.
Répertoire général d’anatomie et de physiologie pathologiques, Paris, 1826; 2: 230-250.
Successful ligation of the external iliac, October 16, 1815.
- Mémoire sur un déplacement originel ou congénital de la tête des fémurs.
Répertoire général d’anatomie et de physiologie pathologiques, Paris, 1826, 2: 82-93.
First clear pathological description of congenital dislocation of the hip-joint. Dupuytren distinguished this syndrome caused by failure of foetal development of the acetabulum from deformities due to tuberculosis and pyoarthrotic disease of the hip joint.
- Mémoire sur une méthode nouvelle pour traiter les anus accidentels.
Mémoires de l’Académie royale de médecine, Paris, 1828, Sect. Méd., 1: 259-316. Traité théorique et pratique des blessures par armes de guerre.
2 volumes. Paris, J. B. Baillière, 1834.
- Mémoire sur une manière nouvelle de pratiquer l’opération de la pierre . . . Terminé et publié par J. L. Sanson et par L. J. Begin.
Paris, Baillière, 1836.
Posthumously published by Louis Joseph Sanson (1790-1842), whose method of rectovesical lithotomy is considered here along with the controversial method of lithotrity. Dupuytren tried both but dropped them in favour of continuing the method of bilateral lithotomy, which he invented in 1812, and which was adopted as the normal procedure, with later modifications. On his work published by others:
- Leçons orales de clinique chirurgicale faites à l'Hôtel-Dieu de Paris; rec. et publ. par une société de médecins.
4 volumes, Paris, Germer-Baillière, 1832, 1834.
2nd edition under the same title, 3 volumes, Paris, Germer-Baillière, 1839.
2 Belgian reprints, Brussels, 1834.
German translation by Em. Bech and Rud. Leonhardi, Leipzig, 1832.1835, and by G. Weyland, Paris, 1832, 1834.
English by A. Sidney Doane, New York, 1833 and Boston, 1833.
Italian, Venice, 1834, 1835;
Danish by J. Rørbye, Copenhagen, 1835. Pp. 455-461: Dupuytren was the first to treat wry neck by subcutaneous section of the sternomastoid muscle. This he did on January 16, 1822. The operation was first reported in C. Averill: Short treatise on operative surgery. London, 1823, 61-64. Dupuytren’s classification of burns is on page 424.
- Lettre et leçons sur la siège, la nature et le traitement du choléra-morbus; rec. et publié par A. Paillard et Marx. 1832.
- Clinical Lectures on Surgery.
Lectures delivered at the Hôtel-Dieu, Paris, during the session of 1833. Revised (before translation) by the Baron himself in the fasciculi of his ” Leçons orales de clinique chirurgicale,” published periodically by G. Bailliere, Paris. Lancet, London, 1833, II, 222-225.
- Deuxième édition entièrement refondue par Brierre de Boismont et Marx.
6 volumes, Paris, 1839; German translation by H. E. Flies, Quedlinburg, 1840-1846.
- Traite théorique et pratique des blessures par armes de guerre. Rédigé . . . et publié sous la direction par A. Paillard et Marx.
Paris, 1834; German translation by M. Kalisch, Berlin, 1836.