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Enduring Eponyms: The Mystery of the Martorell Ulcer

Salcido, Richard “Sal MD

Advances in Skin & Wound Care: December 2012 - Volume 25 - Issue 12 - p 535
doi: 10.1097/01.ASW.0000423433.03586.a6
DEPARTMENTS: EDITORIAL
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Richard “Sal” Salcido, MD, is the Editor-in-Chief of Advances in Skin & Wound Care and the Course Director for the Annual Clinical Symposium on Advances in Skin & Wound Care. He is the William Erdman Professor, Department of Rehabilitation Medicine; Senior Fellow, Institute on Aging; and Associate, Institute of Medicine and Bioengineering, at the University of Pennsylvania Health System, Philadelphia.

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Fernando Martorell Otzet (1906–1984) was a Spanish professor of Pathological Anatomy and Surgical Therapeutics in Barcelona, Spain. In 1943, he was credited with developing a newly recognized specialty with the designation “angiology” or the study of vessels, including phlebology.1 In 1951, the inaugural meeting of the International Society of Angiology was held in Atlantic City, New Jersey, and among its members was the famed Dr. Michael De Bakey (1908–2008) of Houston, Texas. Martorell became the Editor-in-Chief of the Journal of Angiology, which is still published today.1

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The Eponymic Marathon

An eponym (from Greek) is a person, whether real or fictitious, after whom an item is named or thought to be named. The term marathon is an example of an eponym related to a town in Greece, the site of the battle of Marathon in 490 BC, which was a battle of endurance. The uses of eponyms in medicine have endured similar battles and some have been extremely contentious. Some argue that healthcare professionals may be baffled by terms that do not accurately outline a given condition, and that eponyms may not necessarily reflect the truth of discoveries or their exact anatomical nature. Others suggest medical eponyms should be abandoned in favor of more descriptive terms. Making matters more confusing for practitioners is the common issue of multiple eponyms ascribed to the same clinical entity. Similarly, some eponymous authors even have multiple conditions ascribed to them, so it may be taxing to distinguish which condition is being discussed.2

Eponyms may even vary by country; for example l’angiodermite nécrotique is the French term for Martorell or hypertensive ischemic leg ulcers.3,4 Moreover, the multiple eponyms used in wound care are also confusing. One year after the eponym “Martorell ulcer” was coined, Farber et al4 reported an association of such leg ulcers with the histologic presence of hypertrophic stenotic subcutaneous arterioles and coined the term hypertensive-ischemic leg ulcer (HYTILU). This month’s continuing medical education activity, “Martorell Hypertensive Ischemic Leg Ulcer: An Underdiagnosed Entity,” is found on page 563.

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Histologic Anatomical Precision

The taxonomy or nomenclature of a given ulcer should emanate from the anatomical, histological, and pathologic descriptions of the entity and not the eponyms. In the case of the Martorell ulcer, the more precise and conventional anatomical location description should be the anterolateral distal one-third of the tibialus region—overlying the lateral calf muscles and not the dorsal calf or the “crus,” which by convention is incorrect. Approximately 15% of Martorell ulcers will occur over the gastroc-soleus complex, more commonly termed the Achilles tendon.

Histological precision is not always possible; Martorell ulcer is a spectrum of diseases within the category of histopathologic subcutaneous arteriolarsclerosis. However, authors uniformly describe an arteriolar medial calcification as the ostensible pathognomonic histologic differentiation for the Martorell ulcer. Others describe it as medial arterial calcinosis or, if you would you have the appetite for yet another eponym, Mönckeberg medial calcinosis arteriosclerosis. Medial arterial calcinosis is strongly associated with neuropathy, amputation, and mortality through an unknown mechanism.5

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The Red Line

The line that cannot be crossed is the inadvertent confusing of Martorell HYTILU with pyoderma gangrenosum because it could be detrimental to the patient. In Martorell HYTILU, a necrosectomy (debridement of necrotic tissue), with skin grafting and antibiotic therapy as required, is the key to timely and effective treatment. The diagnosis of pyoderma gangrenosum, however, virtually excludes surgical measures from the therapeutic decision and requires the consideration of immunosuppressants.3,4

What is clear from all the literature is that the practice of eponyms is great for understanding the historical perspectives of pathology. Nonetheless, as we move into the age of more precise methods of quantitative diagnostics and visualization, the differentiation should be less confusing.

Eponymously yours.

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Richard “Sal” Salcido, MD

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References

1. Lozano FS, Cabot X, Silva I, Roche E, Callejas JM. Fernando Martorell (1906-1984): centenary of a pioneer in angiology. Angiology 2008; 59: 98–9.
2. Scully C, Baum B. Marathon of eponyms. Oral Dis 2009; 15: 185–6.
3. Hafner J, Nobbe S, Partsch H, et al.. Martorell hypertensive ischemic leg ulcer: a model of ischemic subcutaneous arteriolosclerosis. Arch Dermatol 2010; 146: 961–8.
4. Farber EM, Hines EA Jr, Montgomery H, Craig W. The arterioles of the skin in essential hypertension. J Invest Dermatol 1947; 9: 285–98.
5. Mayfield JA, Caps MT, Boyko EJ, Ahroni JH, Smith DG. Relationship of medial arterial calcinosis to autonomic neuropathy and adverse outcomes in a diabetic veteran population. J Diabetes Complications 2002; 16: 165–71.
© 2012 Lippincott Williams & Wilkins, Inc.