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Medical Terminology Daily (MTD) is a blog sponsored by Clinical Anatomy Associates, Inc. as a service to the medical community, medical students, and the medical industry. We will post a workweek daily medical or surgical term, its meaning and usage, as well as biographical notes on anatomists, surgeons, and researchers through the ages. Be warned that some of the images used depict human anatomical specimens.

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A Moment in History

Thomas Willis, MD
Thomas Willis
(1621-1675)

An English physician and anatomist, Willis was born on his parents' farm in Great Bedwyn, Wiltshire, where his father held the stewardship of the Manor. He was a kinsman of the Willys baronets of Fen Ditton, Cambridgeshire. He graduated M.A. from Christ Church, Oxford in 1642. In the Civil War years he was a royalist, and was dispossessed of the family farm at North Hinksey by Parliamentary forces. In the 1640's Willis was one of the royal physicians to Charles I of England. He obtained his medical degree in 1646.

Thomas Willis might well be one of the greatest physicians of the 17th century.He is one of the founders of the Royal Society of London. He is remembered by his many publications, especially "Cerebri Anatome: Cui accessit Nervorum Descriptio et Usu", where he describes the arterial anastomoses at the base of the brain. This work is also the first detailed description of the vasculature of the brain. Willis described nine cranial nerves.

He is considered as the father of Neurology as a discipline. He used the term "neurology" for the first time in 1664. He described several neurological conditions

The Arterial Circle of Willis is a famous eponymous structure found at the base of the brain. It represents an anastomotic roundabout that connects the right and left sides as well as the carotid and vertebral arterial territories that supply the brain. Named after Thomas Willis, this structure was known well before him, but it was Willis who described its function.  If you click on the image or here, you will be redirected to a detailed description of this structure.

Sources:

1. "The legendary contributions of Thomas Willis (1621-1675): the arterial circle and beyond" Rengachary SS et al J Neurosurg. 2008 Oct;109(4):765-75
2. "Thomas Willis, a pioneer in translational research in anatomy (on the 350th anniversary of Cerebri anatome)" Arraez-AybarJournal of Anatomy, 03/2015, Volume 226, Issue 3
3. " The naming of the cranial nerves: A historical review" Davis, M Clinical Anatomy, 01/2014, Volume 27, Issue 1
4. "Observations on the history of the circle of Willis". Meyer A, Hieros, R.Med Hist 6:119–130, 1962


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Proximal / Distal

UPDATED:The term [proximal], from the Latin [proximus] meaning "next" and its counterpart [distal], from the Latin [distans] meaning "distant", have been poorly defined and this causes misunderstanding in the proper use of these terms. This is particularly true in the medical industry.

The classical definition of [proximal] are "nearest, closer to the origin, closer to the point of reference" and also "closer to the beginning", or "opposite of distal". [Distal] is, of course, the opposite. All of these definitions are lacking a consensus between the participants in a conversation. This lack of proper definition could potentially lead to problems in an interventional situation and a patient could be injured.

In our lectures and training materials we use a working definition1 as follows:

Proximal has two meanings:

1- Closer to the point of attachment, where one end of the attached structure is free, and

2- Closer to the point of origin of flow of a fluid”

Distal is of course, opposite to proximal.

In the first acception of the word, a clear example is the attachment of the upper and lower extremities. Moving away from the shoulder or the hip joint is a distal movement. “The wrist joint is distal to the elbow joint”. The same is true for the Fallopian (uterine) tube, where the proximal attachment of the tube is to the uterus and the free distal end of the tube is its fimbriated end.

In the second acception of the word, in any anatomical structure, organ, or system where there is flow of a fluid (food, urine, bile, blood, etc.) it is accepted that normal flow (antegrade flow) goes from proximal to distal and that abnormal flow (retrograde flow) goes from distal to proximal.

1. Use of this definition is permitted, as long as CAA, Inc. is credited, or a link to this article is posted with it.
Image property of: CAA.Inc. Artist: Victoria G. Ratcliffe


Prevention of Stroke in Atrial Fibrillation - Elimination of the Left Atrial Appendage


If you arrived to this website looking for information on Atrial Fibrillation, you will find some here and in this article.


Prevention of Stroke in Atrial Fibrillation;
Elimination of the Left Atrial Appendage.
An online educational video.

Randall, K. Wolf MD, FACS, FACC


This video educational program is hosted by the Houston Methodist DeBakey Heart and Vascular Center Education Center

Atrial fibrillation (AFib) is estimated to affect up to 4% of the population. Characterized by a rapid, irregular heartbeat, AFib is largely due to abnormal electrical impulses that cause the atria of the heart to quiver instead of beating steadily. Blood flow is reduced and is not completely pumped out of the two small upper chambers of the heart, the atria. This negatively impacts cardiac performance and also allows the blood to pool and potentially clot, especially in an extension of the left atrium, the left atrial appendage (LAA). At rest, a normal heart rate is approximately 60 – 100 beats per minute. In a person with AFib, that heart rate can increase to 180 bpm or even higher.

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The main concern with AFib and stagnant blood flow in the LAA is the potential for clot formation (thrombus). While this can happen in either atria (right or left) the anatomy of the right atrium and right atrial appendage are less conducive to clot formation. The LAA is exactly the opposite and the clots, should they float into the bloodstream, tend to enter the larger arteries that go towards the head and brain, increasing the chances for a stroke.

In this educational video Dr. Wolf discusses the above, as well as the benefits of the elimination of the LAA, decreasing blood pressure, decreasing the chances of a stroke, and helping return the heart to normal rhythm.

Dr. Wolf is a surgical innovator who since the year 2000 has been a pioneer in the minimally invasive surgical treatment of AFib. He has performed over 2000 Wolf MiniMaze procedures since the first one in 2003 and has demonstrated the procedure to over 800 heart surgeons worldwide. He has been visiting professor in 18 countries, including Oxford University, University of Tokyo and Peking University. Dr. Wolf has delivered hundreds of invited lectures at hospitals, academic meetings and seminars in the United States and abroad.

Dr. Wolf is currently a member of the DeBakey Heart and Vascular Center at Houston Methodist Hospital in the Texas Medical Center. He serves as the arrhythmia specialist of the group. In 2018 Dr. Wolf operated on AF patients from 32 US states. He was also the keynote speaker at the annual Japanese Society for Tobacco Control in Takamatsu, Japan and the annual Chinese Society of Cardiothoracic Surgeons in Shenyang, China.


videocover011  When you click the above image you will be taken to the YouTube DeBakey Education Channel
in a separate window

NOTE: Dr. Randall Wolf is a contributor to Clinical Anatomy Associates. My personal thanks to him and to the DeBakey Heart and Vascular Center for their invitation to participate in this educational video. Dr. Miranda.

 

 

Halsted’s “Rules of Surgery”

In my many years working with medical industry, surgeons, and surgery, I have heard many times that such and such surgical technique follows “Halsted’s Rules of Surgery”. The problem is that only two of these “rules” were mentioned and never did I receive an answer while working with Ethicon and Ethicon Endosurgery, and never did I receive an answer as to where could I find the reference regarding the other rules, if they even existed.

I recently read a great 1957 book by Samuel James Crowe, MD (1883-1952), titled “Halsted of John Hopkins; the man and his men”. Dr. Crowe lived for one year with Dr. William Stewart Halsted (1852-1922) and his wife as a medical student at John Hopkins. He was also an intern for Dr. Harvey Cushing, and although he wanted to follow Cushing into neurosurgery, Dr. Halsted placed him in charge of the newly created department of otolaryngology at John Hopkins, a position he did not want. Dr. Crowe went on to become a world-wide renown otolaryngologist.

Here are Halsted’s “Rules of Surgery” as explained by Dr. Crowe, based on Halsted’s research, experiments, and observations (with my own notes and comments):

1. Wounds are resistant to infection when no bits of tissue have been:

a. torn with clamps 
b. torn by the rough handling of retractors 
c. devitalized by hastily and carelessly applied ligatures

HalstedWilliam S. Halsted
mouseover for
Samuel J. Crowe

Note: this follows the ancient rule of “primum non nocere”: first and foremost, do not harm

2. Wounds or parts rich in blood vessels usually heal without any visible granulation, even when no antiseptic precautions have been taken.

3. Incisions should be closed carefully and gently, layer by layer

4. The approximating sutures should never put the tissues under tension, since tension interferes with the blood supply and may cause necrosis

Note: Tension-avoidance surgical techniques follow this, one of the prime rules of surgery.

5. The end of the forceps used to pick up bleeding points should be small, to avoid crushing and destroying the vitality of surrounding tissues

Note: This observation led to the creation of fine, multiple toothed thumb forceps used today in cardiovascular surgery , such as the Cooley, DeBakey, Castaneda, etc. type forceps.

6. A drain is essential when there is necrotic tissue and infection

7. Silk should never be used in the presence of infection

Note: This makes sense. Since silk is an organic material, infected tissues will react to the presence of this extraneous material causing more inflammation, and the phagocytic cells in the tissues will destroy the silk and its capacity to hold the tissues together

8. The silk (suture) employed should never be coarser (larger gauge) than necessary and it is well to employ a suture a thread that is not stronger that the tissue it holds

9. A greater number of fine stitches is better than a few coarse ones

Note: This also makes sense. Halsted was known to be extremely meticulous and he could place a hundred stitches of fine silk thread where other surgeons would place a lesser number of coarser stitches. Using a larger number of fine stitches distributes the approximating tension of the sutures over a larger area, thus reducing the chance for suture dehiscence.

10. Avoid when possible the combined use of silk and catgut in a wound

11. For sewing up an abdominal wound, when it is necessary to take heavy deep stitches perforating skin and muscles, silver wire serves admirably

Note: Remember the times when these guiding principles where laid. Nylon, polypropylene, and other synthetic absorbable and non-absorbable sutures had yet to be discovered. Today the same dictum would probably say “For sewing up an abdominal wound, when it is necessary to take heavy deep stitches perforating skin and muscles, a synthetic non-absorbable suture material serves admirably”

It must be noted that Halsted never called the above the “rules of surgery”, rather they are observations that have become guiding principles. These have influenced the world of surgery to this day.

SIDE NOTE: It has been said many times that Dr. Halsted was the first to use rubber gloves. This is not true, Dr. Crowe says that “it was an evolution rather than a happy thought” and it involved his wife Caroline Hampton. This will be the subject of another article.


Book: The Iconography of Andreas Vesalius (1925)

Recently I acquired the 1925 book “The Iconography of Andreas Vesalius” by Marion Harry Spielmann (1858-1948).  M.H. Spielmann was a well-published Victorian art scholar and critic. At the end of this article you can find the bibliographical information on this book.

The book is a serious detailed research of the known paintings, lithographies, sculptures, and medals that show the likeness of Andreas Vesalius, the date of publication and the author’s commentary on each one.

Andreas Vesalius is known as the “Father of Modern Anatomy”. He pushed for a description of the structure of the human body as seen in a dissection, going against the trend at the time where the anatomy was that described by Galen of Pergamon in his books. Galen’s anatomy was based on animal dissection and not a lot of human dissection. Furthermore, the lecturer would read from the book and the demonstrator pointing at the structures ignoring the discrepancies between the book and the body. For additional information and images click here.

Vesalius opus magnum (great work) was the publication in May 1543 of one of the most famous books in medical history. The title of the book is “De Humani Corporis Fabrica, Libri Septem” (Seven Books on the Structure of the Human Body). The book is now known as the “Fabrica”. This has led numerous artists to paint his likeness, many times based on past images or sometimes from pure imagination. The latest modern edition of the Fabrica was published in 2014.

We do know of only one portrait that depicts Vesalius’ likeness at the time of printing (1542)  and that is the second image in the Fabrica of 1543 (figure 1) This image was carved in a pear wood block later used for printing. The woodblock indicates the date of carving (1542) and the age of the great anatomist that year (28). The sketch from which the block of wood was carved is most surely made by Jan Stephan Van Calcar (1449-1546). There is only supposition as to who was the artist that carved the woodblock, and there are several research papers on the subject. The best suggestion is that the woodcarvers were Francesco Marcolini (1505-1560) and Domenico Campagnola (1500-1564), both mentioned in a paper by Jaffe and Buchanan (2016). Campagnola is actually thought to be the woodcarver for the title page of the 1543 Fabrica.

The Iconography book goes into great detail on this image of the great anatomist, and dedicates a detailed description of the title page of the 1543 and the 1555 editions of the Fabrica, descriptions that I can only encourage to be read by researchers interested in the life and works of Andreas Vesalius. The book can be read online the Internet Archive here. The book is written mostly in English, but has an introduction in French.

Vesalius Fabrica PortraitFigure 1: Vesalius Fabrica Portrait

1955 Fabrica Title PageFigure 2: 1955 Fabrica Title Page

 “The  Iconography of Andreas Vesalius” is a rare book, it is not easy to find, and probably the most important characteristic of the book is not mentioned in the many descriptions of the book found on the Internet, medical libraries, and antiquarian booksellers websites: The book originally included a separate, folded-in-four, high-quality linen paper print of the title page of the 1555 Fabrica. Most of the books found today have lost this print. Figure 2 shows a scan of the print found in the book I acquired. A 4.5 Mb watermarked actual size of this print can be seen here. If you want to download it, you can right click on the image and then click on "Save As".

This reprint of the Fabrica’s title page was done using the 1555 original woodblock, which makes it priceless. As shown in the accompanying image, the page leaves blank the two places where the title of the book and the dedication to the king and printer markings where placed. These would have been prepared in separate type and rearranged for a different use after printing. The print measures 16 7/8 by 12 1/4 inches (31.1 by 42.9 cms) The woodblock of the title page of the 1555 Fabrica was last used in 1934 when it was used to print the 1934 edition of the Icones Anatomicae, and then returned to the Louvain University in Belgium where it was destroyed by the German army in 1940. The Icones Anatomicae was the last print using the original woodblocks.  

The rest of the original woodblocks was burned during a WWII bomb raid on July 16, 1944.

The following information is from the Stanford Library and it is one of the few that indicate the existence of the reprint of the 1555 Fabrica title page in an envelope pasted on the book cover reverse.

Author/Creator: Spielmann, M. H. (Marion Harry), 1858-1948.
Subject:    Vesalius, Andreas, 1514-1564. History of Medicine. Physicians. 1500s
Genre: Biographical Information. Historical Works. Portraits

Bibliographic information:
Date: 1925
Series: Research studies in medical history ; no. 3, 1925
Note: Includes index. Title-page of De humani corporis fabrica libri septum by Andreas Vesalius, Second edition, 1555 printed direct from the original wood block in the pocket on verso of cover.

Personal Note: I am working on updating my library catalog to reflect the latest book acquisitions and gifts received. Dr. Miranda.

Sources:
1. “The Iconography of Andreas Vesalius” M.H. Spielmann. The Wellcome Historical Medical Museum London. John Bale, Sons & Danielson Ltd.

2. “The Andreas Vesalius Woodblocks: A Four Hundred Year Journey from Creation to Destruction” Acta Med Hist Adriat 2016; 14(2);347-372
3. "The identity of the artists involved in Vesalius Fabrica 1543” Guerra, F. (1969)  Medical History, 13(1), 37.


Coumadin ridge

UPDATED: The [Coumadin ridge], also known as the [Warfarin ridge], or a [left atrial pseudotumor]. is an excessive elevation or protrusion of a normal ridge found between the left superior pulmonary vein and the internal ostium of the left atrial appendage. Usually this ridge will extend inferiorly towards and anterior to the ostium of the left inferior pulmonary vein. The Coumadin ridge is considered an anatomical variation of the otherwise small ridge, known as the left lateral ridge.

Because of its location and morphology, some cardiologists and radiologists have mistaken this elevation or fold of the internal anatomy of the left atrium for a thrombus and prescribed anticoagulant therapy (Coumadin or Warfarin) when none was needed, hence its name.

Coumadin ridge
Click on the image for a larger version
To understand the generation of the Coumadin ridge we must understand the embryology of this area of the heart. The left atrial appendage is the original left atrium in the embryo, which is displaced anteriorly and superolaterally when the veins that enter the atrium start to dilate at their distal end creating the left sinus venarum. After the left atrium proper has formed, the left atrial appendage is left as nothing more than an embryological remnant that can cause problems if the patient has atrial fibrillation (AFib). The ridge forms at the point where the left atrial appendage and the sinus venarum meet.

The Coumadin ridge can vary in morphology, from presenting as an elevated ridge, to a bulbous, pedunculated mass that seems to float within the left atrial appendage and undulate, following the cardiac motion, forcing the cardiologist into believing they are in the presence of a thrombus or a tumor within the heart.

This fold of tissue may contain the ligament of Marshall, autonomic nerves, and a small artery. In rare cases there may be an actual tumor arising from the location of the Coumadin ridge, but this is just a coincidence.

Now that the Coumadin ridge is a better known anatomical variation, cardiologist sometimes refer to their finding as a pseudotumor, a description that may scare the patient, but is only but a fold of tissue inside the heart.

Finding a Coumadin ridge in a patient with atrial fibrillation can be an interesting situation requiring differential diagnosis, as a patient with AFib can present with thrombi in the left atrial appendage. What to do? Is it or is it not a thrombus? Also, a differential diagnosis is needed in the case where the image is actually that of a left atrial tumor or an atrial myxoma.

The accompanying image is own work based on Sra (2004) and McKay (2008), and is a graphite on paper sketch. The image shown an internal view of the left atrium showing the left superior and inferior pulmonary vein, the ostium of the left atrial appendage and a segment of the area of the mitral valve.

We would like to thank Dr. Randall K Wolf, a contributor to Medical Terminology Daily for suggesting this article.

Sources:
1. “Coumadin ridge: An incidental finding of a left atrial pseudotumor on transthoracic echocardiography” Lohdi,AM, et al. World J Clin Cases. 2015 Sep 16; 3(9): 831–834
2. “Coumadin ridge” Tasco, V. https://radiopaedia.org/articles/coumadin-ridge
3. “Papillary fibroelastoma arising from the coumadin ridge” Malik, M, Shilo, K, Kilic,A. J Cardiovasc Thorac Res. 2017;9(2):118-120.
4. “‘Coumadin ridge’ in the left atrium demonstrated on three dimensional transthoracic echocardiography” McKay,T., Thomas, L. Europ J Echocard (2008) 9, 298–300
5. “Endocardial imaging of the left atrium in patients with atrial fibrillation” Sra J; Krum D; Okerlund D; Thompson H. J Cardiovasc Electrophysiol 2004 Feb; Vol. 15 (2), pp. 247


The presence of Andreas Vesalius in Zakynthos (3)

Continued from "The presence of Andreas Vesalius in Zakynthos (2)"

According to Theo Dirix, Belgian Consul to Greece and Vesalius enthusiast, there are other reminders on the island such as a painting in one of the local schools.

On September 3rd, 2014, as part of the Vesalius Continuum meeting on Zakynthos Island, a new bronze statue was unveiled to celebrate the life and works of Andrea Vesalius and remember his death on Zakynthos. This statue is a representation of Vesalius’ style of depicting anatomy in his book “De Humani Corporis Fabrica Libri Septem” and is a “muscle man” mixed with the motif of the famous plate 20 of Book 1 that shows a skeleton musing over a skull. The statue also presents the Vesalius family coat of arms. The statue is the work of Richard Neave and Pascalle Pollier.

Pascale Pollier, a biomedical artist specializes in face reconstructions and made a new bust of Vesalius based on the only known portrait of the great anatomist found on the pages of his immortal book “The Humani Corporis Fabrica Libri Septem”.

The statue was unveiled in front of an international crowd of anatomists, medical historians, biomedical artists, and film makers. Following the ceremony a display of artistic works related to Vesalius was opened in the Zakynthos municipality.

These are today the signs of the presence of Vesalius on Zakynthos. We know today that his body is interred in the cemetery of the church of Santa Maria della Grazie in Zakynthos. Sadly this church was destroyed twice in earthquakes and in 1953 was completely demolished along with 85% of the city. It was not rebuilt and now lies under the new, rebuilt city. One of the research papers presented at the 2014 Vesalius Continuum meeting has rediscovered the location of the church with great accuracy. The account of this paper and how I was able to find this geolocation will be presented in another article.

Sources
1. “Andreas Vesalius of Brussels 1514-1564” O’Malley, CD. Los Angeles 1965
2. "Andreas Vesalius; The Making, the Madman, and the Myth" Joffe, SN. Persona Publishing 2009
3. “In Search of Andreas Vesalius – The Quest for the Lost Grave” Dirix, T. Lanoo Campus Belgium 2014

 


 

New Vesalius Statue in Zakynthos 

Bust of Vesalius made by Pascale Pollier

Unveiling of the New Vesalius Statue in Zakynthos

New Vesalius Statue in Zakynthos