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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

Dr. Thomas Dent Mütter
Dr. Thomas Dent Mütter (1811-1859)

Dr. Thomas Dent Mütter

(1811-1859)

Thomas Dent Mutter was born on March 9, 1811, in Richmond, VA. His mother died in 1813, and his father died of tuberculosis in 1817. Thomas was orphaned when he was barely 8 years old. His father left him a somewhat meager inheritance and in his early life had to do with less that others with his objectives in life. He was well educated under the tutelage of Robert Carter, his guardian, and in 1824 he started his studies at the Hampden Sidney College of Virginia. He continued with a medical apprenticeship with a Dr. Simms in VA. He was well respected and even at his early age he would do home visits for his medical benefactor with great results. He started medical studies at the University of Pennsylvania, where he earned his MD in 1831. The new young doctor, Thomas Dent Mutter, MD was only 20 years of age.

At the time, Europe was the place to go to if you wanted advanced medical studies. Dr. Mutter had no money, so he applied as a ship surgeon to be able to cross the Atlantic. Once in Europe, he spent time in Paris, where he studied under the tutelage of Dr. Guillaume Dupuytren. He later studied for a short time in England where he met Dr. Robert Liston. Following Dupuytren's teachings, Mutter was fascinated by plastic surgery.

A chance encounter with what was to become his first well-known acquisition of a medical curiosity, Mutter started thinking on how to help those people that were known at that time as “monsters”, patients who the general public did not see, because they did not appear in public. The curiosity in question was a wax reproduction of the face of a French woman who had a “horn” arising from her forehead. This piece is on exhibit at the Mütter Museum.

Back in the United States in 1832, Thomas Dent Mutter changed his last name to give it a more “European” sound and added an “umlaut”, so now he was Thomas D. Mütter, MD. It may also be that he wanted to pay homage to his Scottish-German heritage, who knows? He opened his medical office in Philadelphia and although it took time, eventually he had a thriving practice. One of his specialties was the work on “deformities” so common at the time because of facial scars born out of the use of open fires in houses, and deformities caused by burns and loss of tissue due to chemicals used in local industry. Dr. Mütter is the pioneer of what we call today “Reconstructive Surgery”.

In 1835 he was asked to join the Medical Institute of Philadelphia as an assistant professor of Surgery. He was an instant success. Dr. Mütter was adored by his students because, he would question the students and guide them to discovery instead of just lecturing and leaving. In his Discourse eulogy of Dr. Mütter by Joseph Pancoast he writes:” The power of attracting students near him by his mingled gentleness, energy, and enthusiasm; of fixing their attention by the lucid and methodical arrangements of his Subject, by his clear demonstrations, and sprightly oral elucidations, came so readily to him, and was so early displayed) as to seem almost intuitive.” In 1841 Dr Mütter was appointed Professor of Surgery at the Jefferson Medical College in Philadelphia.

Dr. Mütter had always had poor health, even in childhood, and his dedication to his passion, long hours, took its toll on his body. In 1956 he set sail for Europe and resigned his teaching duties. He was named Emeritus Professor of Surgery. Unfortunately, the trip did not help, and he returned to the US in early 1958. Fearful of another winter in cold Philadelphia, he moved to Charleston, SC, where he died on March 19, 1859.

Dr. Mütter’s story does not end here. He was an avid collector and throughout his short life he had pulled together an impressive collection of medical oddities, samples, and curiosities. Knowing that his life was at an end, he negotiated with the Philadelphia College of Physicians to have them host his collection in perpetuity as well as the creation of a trust fund that would ensure that the public and medical students would have access to this incredible collection. Through the years this collection has increased and is known today as the Mütter Museum of the Philadelphia College of Physicians. I strongly urge our readers to visit this incredible museum. For more information, click here.

Personal notes: In the late 90’s, I attended a meeting of the American Association of Clinical Anatomists.  During the meeting I met Gretchen Worden, who at the time was the Curator of the Mütter museum. Gretchen was inspirational, fun, and a great conversationalist! I had the opportunity to visit Gretchen at the Mütter museum and had the luck to be treated to a “behind the scenes” tour. What an experience! I was saddened to hear that Gretchen Worden passed on August 2, 2004. Still, in my recent visit to the Mütter Museum, I was glad to see a new section at the museum that remembers Gretchen. Her biography can be read here.

I would like to thank Dr. Leslie Wolf for lending me the book by O’Keefe that lead to me writing this article. Dr. Miranda

Sources:
1. “Dr. Mütter’s Marvels: A True Tale of Intrigue and Innovation at the Dawn of Modern Medicine” O’Keefe, C. 2015 Penguin Random House, LLC
2. “A Discourse Commemorative of the Late Professor T.D. Mütter” Pancoast, J. 1859 J Wilson Publisher
3. “Thomas Dent Mütter: the humble narrative of a surgeon, teacher, and curious collector” Baker, J, et al. The American Surgeon, Atlanta 77:iss5 662-14
4. “Thomas Dent Mutter, MD: early reparative surgeon” Harris, ES; Morgan, RF. Ann Plast Surg 1994 33(3):333-8
5. “5 Things I Learned from Thomas Dent Mütter” O’Keefe C.


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Esophageal hiatus hernia

UPDATED: An esophageal hiatus hernia (also known as a hiatal hernia) is caused by a dilation of the esophageal hiatus and its component structures, the phrenoesophageal membranes (ligaments).

Since the intraabdominal pressure is higher than the intrathoracic pressure, abdominal contents -usually stomach and greater omentum- can herniate through the dilated esophageal hiatus into the mediastinum, the central region of the thoracic cavity. This presents as a hernia sac whose walls are formed by endothoracic fascia, phrenoesophageal membranes and parietal peritoneum. 

There are two main types of esophageal hiatus hernias. Type I is known as a "sliding hiatal hernia" and is characterized by a complete ascension of the esophagogastric junction and abdominal esophagus into the thoracic hernia sac. This is usually accompanied by a typical "hourglass image" in a radiographic assessment, and also presents with gastroesophageal reflux disease (GERD). Type I esophageal hiatus hernias are more common.

Type II esophageal hiatus hernia is known as a "paraesophageal hernia" and represent about 5 - 15% of esophageal hiatus hernias. In this case, the esophagogastric junction maintains its anatomical position inferior to the respiratory diaphragm, but the fundus and body of the stomach, along with some greater omentum herniate alongside the esophagus into the mediastinal region of the thoracic cavity. Although there can be GERD, this type of hernia usually presents with little symptomatology, and when it does, symptoms are related to ischemia or partial to complete obstruction. There are variations of type II hernia, which are classified as Type III and IV. Type IV, although rare, will include other viscera in the hernia sac, including colon, spleen, or even small intestine

Esophageal hiatus hernia in situ.The arrow points to stomach and greater omentum herniating into the thoraxEsophageal hiatus hernia, reduced. The dotted line shows the edge of the enlarged esophageal hiatus.

Images property of: CAA.Inc. 
Photographer: David M. Klein

The accompanying images above depict a Type I esophageal hiatus hernia. The superior image shows the hernia in situ where the stomach and greater omentum are still in the hernia sac. The inferior image shows the contents reduced and the abdominal esophagus being pulled into the abdominal cavity. The dotted line shows the dilated esophageal hiatus that needs to be repaired to prevent recurrence of the pathology.

The image below answers a question by Victoria Guy Ratcliffe, who asked via Facebook "What would it be if it feels like you've got a blockage right at the level of the heart? That's too high for a hiatal hernia, isn't it? " The image answers the question. It shows a dissection of the left side of the thorax. The anterior thoracic wall and the left lung have been removed. The heart is immediately superior and anterior to the esophageal hiatus, and the hernia sac of a Type I esophageal hiatus hernia is seen immediately posterior and in contact with the heart. Whether this means that you will "feel" the hernia, it is up for debate, as all these structures have visceral innervation. Most probably, a well-developed Type II esophageal hiatus hernia might interfere with swallowing at this level, causing the sensation she mentions. Thanks for the question, Tori.

Type I esophageal hiatus hernia<em>.</em>The hernia sac can be seen posterior to the heart

For additional information: "Approaches to the Diagnosis and Grading of Hiatal Hernia" Kahrilas et al Best Pract Res Clin Gastroenterol. 2008 ; 22(4): 601–616.


The seven hiatuses (openings) of the respiratory diaphragm

The term [hiatus] derives from the Latin word [hiare], meaning to "gape" or to "yawn". In human anatomy this term is used to mean an "opening" or a "defect". It must be pointed out that in anatomy (and surgery) the term "defect" does not necessarily mean "defective". In most cases a "defect" is a normal opening in a structure, such as the esophageal hiatus. The plural form is either [hiatus] or [hiatuses].

In the case of the respiratory diaphragm, there are seven such openings, seven normal hiatuses. On top of this, you can find an abnormal opening caused by incomplete congenital closure of the dome of the diaphragm, a congenital diaphragmatic hernia (CDH), also known as Bochdalek's hernia, found in the posterior aspect of the respiratory diaphragm.

The seven hiatuses of the respiratory diaphragm are:

• Esphageal hiatus

• Aortic hiatus

• Inferior vena cava hiatus

Respiratory diaphragm (www.bartleby.com)
Images and links courtesy of Bartleby.com
• Hiatuses (2) for the superior epigastric vessels, which are the inferior continuation of the internal thoracic (mammary) vessels. Also known as the hiatuses of Morgagni. A hernia in a newborn through this hiatus is also considered a CDH.

• Hiatuses (2) for the splanchnic nerves

Based on the above it is wrong (maybe not wrong, but incomplete) to say that a patient has a "hiatal hernia", as the term does not include which hiatus is involved. In fact the hernia of Morgagni is also a "hiatal hernia" as the hernia passes through a normal defect in the respiratory diaphragm. Come to think of it, it could also be a hernia in a hiatus somewhere else in the body, such as a hernia of Schwalbe, a type or pelvic diaphragm hernia.

Note: Thanks to DHREAMS of the Columbia University Medical Center for the link on CDH.


Esophageal hiatus

UPDATED: The esophageal hiatus is one of the seven hiatuses found in the respiratory diaphragm allowing passage of structures between the thorax and abdomen. As it name implies, the esophageal hiatus is the passageway for the esophagus. It also allows passage of the anterior and posterior vagus nerves, (CN X).

The hiatus is bound by two muscular crura, both of which arise from the right tendinous aortic crus. Since the intraabdominal pressure is higher than the intrathoracic pressure, there is a series of structures at the phrenoesophagogastric junction to close the esophageal hiatus.

The infradiaphragmatic parietal peritoneum reflects off the diaphragm towards the stomach to form its serosa layer (visceral peritoneum). At the same time the infradiaphragmatic fascia, also known as the  endoabdominopelvic fascia, splits into two components or limbs. These are the superior and inferior phrenoesophageal ligaments or phrenoesophageal membranes. (the root [-phren-] means "diaphragm"). These phrenoesophageal ligaments create a disc-like plug between the abdomen and the thorax. This "plug" is reinforced by a circular infradiaphragmatic fat pad. The phrenoesophageal ligaments are reinforced on their thoracic aspect by the endothoracic fascia.

Esophageal hiatus

Images property of: CAA.Inc. Artist: Dr. E. Miranda

The lower esophagus has a dilation (evident in the image) called the "esophageal ampulla", in relation to this dilation the circular muscle layer of the esophagus slightly thickens creating the so-called "lower esophageal sphincter". This area is not a true anatomical sphincter, but rather is a functional sphincter. 

The esophagogastric mucosal junction shows a marked transition in the shape of a wavy line. This is called the Z-line or the ora serrata. Extensions of the gastric mucosa and submucosa inferior to the ora serrata create a valve-like flap called the "gastroesophageal flap valve". When viewing this mucosal flap through and endoscope, it looks corrugated and flower-like, hence it is also called the "rosette". 

The congenital or pathological dilation of the esophageal hiatus can predispose to esophageal hiatus hernia.


Acetabulum

The word acetabulum is formed by the combination of the Latin root [acetum], meaning "vinegar", and the Latin suffix [-abulum] a diminutive of [abrum], meaning a "cup", "holder", or "receptacle". Thus formed, the word acetabulum means "a small vinegar cup".

Roman soldiers liked to drink their water mixed with a small quantity of vinegar, so as to reduce the sensation of thirst. This mix was called "Posca". An acetabulum was used to add specific quantities of vinegar to the water, so over time the acetabula (plural form of acetabulum) were considered measuring devices. It is said that they measured one cup, or 2 1/2 oz. of wine.

The anatomical acetabula are bilateral cup-like depressions in the os coxae which serve as a component of the coxofemoral joint (hip joint). They are found at the intersection of the three bony components of the os coxae, the ilium, ischium, and pubic bone and look anteroinferiorly.

Acetabulum
Image property of: CAA.Inc. 
Photographer:
David M. Klein
The acetabulum has several components:

• Acetabular margin: An incomplete circular bony edge or border that marks the edge of the acetabulum

• Acetabular notch: The area where the acetabular margin is incomplete

• Acetabular labrum: Labrum (Lat. :lip). The acetabular labrum is a complete circular ring of fibrocartilage found on the acetabular margin that helps maintain the head of the femur in place. It is not shown in the accompanying image

• Lunate surface: A smooth, half-moon shaped area on the floor of the acetabulum. It is covered with hyaline cartilage and allows for articulation with the head of the femur

• Acetabular fossa: The non-articular region of the floor of the acetabulum. It contains fat, vessels, and the ligament of the head of the femur

Interesting fact:  You may find that in older English anatomy books the acetabulum is referred to as the cotyloid cavity. The word cotyloid arises from the Greek [κοτυλοειδές] and means "similar to a cup". This separation in terms still exists when studying anatomy in other languages. For example, in Spanish the acetabulum is called "cavidad cotiloídea" or "cotilo", and in French it is called "cavité cotyloïde" or "cotyle". I guess the Greek soldiers did not drink vinegar with their water...


Sternal angle (of Louis)

UPDATED:The sternal angle is the term used to denote the angulation at the  joint between the manubrium and the body of the sternum. This transverse joint is called the "manubriosternal joint" and is a secondary cartilaginous joint of a type known as a symphysis. The angle varies between 160 and 169 degrees.

It is know eponymously as the "angle of Louis" named after Antoine Louis1 (1723-1792), a French physician. The importance of the sternal angle is that of an anatomical superficial landmark, which forms a horizontal plane which indicates a series of anatomical occurrences, as follows:

• Location of the cartilages of the second rib
• Beginning and end of the aortic arch
• Boundary between the inferior and superior mediastinum
• Location of the bifurcation of the trachea
• Posteriorly, the plane of the sternal angle passes trough the T4-T5 intervertebral disc
• Highest point of the pericardial sac, etc.

Sternal angle - Angle of Luis

Click on the image for a larger version.

Thoracic anatomy, pathology and surgery, are some of the many lecture topics developed and presented by Clinical Anatomy Associates, Inc.

1. Some authors contest the eponym, adjudicating it to Pierre Charles Alexander Louis (1787-1872), another French physician.
Image property of: CAA.Inc.. Artist: David M. Klein

In Search of Andreas Vesalius The Quest for the Grave, Lost and not yet found

My partner in crime and fellow traveler, Theo Dirix, has just published a new account of our common quest for the lost grave of Andreas Vesalius. Until the scientific results of our latest mission in Zakynthos in September 2017, will become public, this collection of articles published since 2014 represents a detailed and complete status quaestionis of a search that will never be the same anymore.


I'm proud and grateful to be part of a team he describes a most tenacious.

Following is a remarkable quote from the book: "The beast you have in your hands may appear as aged and stubborn: indeed, the texts collected here are not new and they regularly echo each other. The beast barks and growls: these words do not intend to examine or research but were meant to sell a project to potential sponsors. I feel the taste of the creature’s spit in my face, but pleading not guilty to any accusation of self-glorification, I do hope I managed to teach it a few tricks you will enjoy. While continuing to write about Vesalius’s death and his grave, black dogs may still be scratching at my hermitage. When I will finally throw open the doors to the beauty beyond, here’s hoping the encounter with the female spider will taste as fresh as a first kiss and be the beginning of something else."

No surprise some have described the book as: "a truly captivating story (a Live Adventure!) written in a fascinating, passionate and inspiring way. Theo Dirix, with his unique style is describing facts from his adventure to locate the grave of Vesalius and he is mentioning with great respect all his collaborators, the friends of Vesalius and those who share the same passion for Anatomy and Art." (Vasia Hatzi on Med in Art).

Cover of the book by Theo Dirix
Cover of the book by Theo Dirix.
Click on the image for a larger depiction

The book can be ordered here: https://www.shopmybooks.com/US/en/book/theo-dirix-32/in-search-of-andreas-vesalius. (English version of the website). More information about the author on his website www.theodirix.com. or here.


Personal note: Thanks to Pascale Pollier, a contributor to this website, for allowing us to publish this article, originally published on Vesalius Continuum.

I received a personalized copy from the author, Theo Dirix; Thank you very much for the recognition and the use of this website as reference in some of your comments. It is a great read for anyone even mildly interested in the life and specially the death and disappearance of the grave of Andreas Vesalius. There are several passages in the book that I will have to research and transform in articles for this blog.

For those who collaborated in the GoFundMe campaign because or our article entitled Do you want your name in a book? The Quest for the Lost Grave.... this is the book and the name of all the contributors are listed in it! 

The quest continues... Dr. Miranda