Medical Terminology Daily - Est. 2012

Medical Terminology Daily (MTD) is a blog sponsored by Clinical Anatomy Associates, Inc. as a service to the medical community. We post anatomical, medical or surgical terms, their 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

Marcia Crocker Noyes
(1869 – 1946)

Further to my comment on old books and research that started with an interesting bookplate (Ex-Libris). I continued my research and found that the person in charge of the Osler library bookplate was a fascinating individual that today maybe a ghost in the MedChi library and building in Baltimore... This is certainly an article that can be called "A Moment in History"

Marcia Crocker Noyes was the librarian at The Maryland State Medical Society from 1896 to 1946 and was a founding member of the Medical Library Association.[1][2][3]

Sir William Osler, MD. a famous Johns Hopkins surgeon was a noted bibliophile and had a large personal collection of books on various topics. When he became the President of MedChi in 1896, he was dismayed at the condition of the library and knew that with the right person and some stewardship, it could become a significant collection. Sir William asked his friend, Dr. Bernard Steiner, a physician and President of the Enoch Pratt Free Library in Baltimore for suggestions of a librarian, and Dr. Steiner recommended Marcia Crocker Noyes. A native of New York, and a graduate of Hunter College, Marcia had moved to Baltimore for a lengthy visit with her sister, and took a “temporary” position at the Pratt Library, which turned into three years. Although she had no medical experience or background, she was enthusiastic, and most importantly, she was willing to move into the apartment provided for the librarian, who needed to be available 24 hours a day.

The image in this article is Ms. Noyes on her first year on the job. Marcia developed a book classification system for medical books, based on the Index Medicus, and called it the Classification for Medical Literature. The system uses the alphabet with capital letters for the major divisions of medicine and lower-case ones for the sub-sections. The system was used for many years, but it's now dated and the Faculty's original shelving scheme was never changed. The card catalogs still reflect her classification and many of the cards are written in Marcia's back-slanting handwriting.

Marcia knew enough to ask the Faculty's members about medical questions, terminology and literature. She gradually won over the predominantly male membership and they became her greatest allies; Sir William at the start, and then for nearly 40 years, Dr. John Ruhräh, a wealthy pediatrician with no immediate family of his own. She made a point of attending almost every Faculty function, and in 1904, under guidelines from the American Medical Association, Marcia was made the Faculty Secretary. For much of her first 10 years, she was the Faculty's only full-time employee, only being assisted by Mr. Caution, the Faculty's janitor. Later in life Marcia would say that she hired him because of his name!

Within ten years, the library had outgrown its space, and plans, spearheaded by Marcia and Sir William before his move to Oxford, were made to build a headquarters building, mainly to house the library's growing collection of medical books and journals.

Marcia was instrumental in the design and building of the new headquarters. She travelled to Philadelphia, New York and Boston to look at their medical society buildings, and eventually, the Philadelphia architectural firm, Ellicott & Emmart was selected to design and build the new Faculty building. Every detail of the building held her imprimatur, from the graceful staircase, to the light-filled reading room, and all of the myriad details of the millwork, marble tesserae, and most of all, the four-story cast iron stacks. She was on-site, climbing up unfinished staircases, checking out the progress of the building, which was built in less than one year at a cost of $90,000.

Among the features of the new building was a fourth-floor apartment for her. She referred to it as the "first penthouse in Baltimore" and it had a garden and rooftop terrace. The library collection eventually grew to more than 65,000 volumes from medical and specialty societies around the world. Journals were traded back and forth, and physicians eagerly anticipated the arrival of each new issue. At the same time, Marcia was involved in the Medical Library Association as one of eight founding members. The MLA promotes medical libraries and the exchange of information. One of the earliest mandates of the MLA was the Exchange, a distribution and trade service for those who had duplicates or little-used books in their collections. Initially, the Exchange was run out of the Philadelphia medical society, but in 1900 it was moved to Baltimore and Marcia oversaw it. Several hundred periodicals and journals were received and sent each month, a huge amount of work for a tiny staff. In 1904, the Faculty had run out of room to manage the Exchange, so it was moved to the Medical Society of the Kings County (Brooklyn). But without Marcia's excellent administrative skills, it floundered and in 1908, the MLA asked Marcia to take charge once again.

In 1909, when the new Faculty building opened, there was enough room to run the Exchange and with the help of MLA Treasurer, noted bibliophile and close friend, Dr. John Ruhräh, it once again became successful. Additionally, Marcia and Dr. Ruhräh combined forces to revive the MLA's bulletin, which had all but ceased publication in 1908, taking the Exchange with it. This duo maintained editorial control from 1911 until 1926. In 1934, around the time of Dr. Ruhräh's death, Marcia became the first “unmedicated” professional to head the MLA. During her tenure, the MLA incorporated, the first seal was adopted, and the annual meeting was held in Baltimore. Marcia wanted to write the history of the MLA once she retired from full-time work at the Faculty, but her health was beginning to fail. She had back problems and had suffered a serious burn on her shoulder as a young woman, possibly from her time running a summer camp, Camp Seyon, for young ladies in the Adirondack Mountains. In 1946, a celebration was planned to honor Marcia's 50 years at the Faculty. But she was adamant that the physicians wait until November, the actual date of her 50 years. However, they knew she was gravely ill, and might not make it until then, so a huge party was held in April. More than 250 physicians attended the celebration, but the ones she was closest to in the early years, were long gone. She was presented with a suitcase, a sum of money to use for travelling, and her favorite painting of Dr. John Philip Smith, a founder of the Medical College in Winchester, Virginia. It was painted by Edward Caledon Smith, a Virginia painter who had been a student of the painter Thomas Sully.[4] She adored this painting and vowed, jokingly, to take it with her wherever she went.

The painting was not to stay with her for very long, for she died in November 1946, and left it to the Faculty in her will. Her funeral was held in the Faculty's Osler Hall, named for her dear friend. More than 60 physicians served as her pallbearers, and she was buried at Baltimore's Green Mount Cemetery. In 1948, the MLA decided to establish an award in the name of Marcia Crocker Noyes. It was for outstanding achievement in medical library field and was to be awarded every two years, or when a truly worthy candidate was submitted. In 2014, the Faculty began giving a bouquet of flowers to the winner of the award in Marcia's name, and in honor of her work. Much evidence exists for this tradition, as we know that the physicians, especially Drs. Osler and Ruhräh, frequently gave her bouquets of flowers. Marcia also cultivated flower gardens at the Faculty and decorated the rooms with her work.

Today, the MedChi building is open for tours and if the rumors are to be believed Ms. Marcia Crocker Noyes is still at work in her beloved library as the "resident ghost" [1][5]

Marcia Noyes handwriting

NOTE: This article has been modified from the original Wikipedia article on Marcia Crocker Noyes. The article itself is well-written with interesting images of the subject. I would encourage you to visit it. The second insert is from book 00736 in my personal library and shows in pencil, the incredibly small handwriting of Marsha C. Noyes.

Sources:
1. "Marcia, Marcia, Marcia" MedChi Archives blog.
2. "Marcia C. Noyes, Medical Librarian" (PDF). Bulletin of the Medical Library Association. 35 (1): 108–109. 1947. PMC 194645
3. Smith, Bernie Todd (1974). "Marcia Crocker Noyes, Medical Librarian: The Shaping of a Career" (PDF). Bulletin of the Medical Library Association. 62 (3): 314–324. PMC 198800Freely accessible. PMID 4619344.
4. Edward Caledon BRUCE (1825-1901)"
5. Behind the scenes tour MedChiBuilding


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Georg Eduard von Rindfleisch
G.E. Rindfleisch (1836 – 1908)

This article is an anatomical, physiological, and terminological discussion for two related cardiac structures: The Vincula Aortæ and the cardiac folds of Rindfleisch.

The topic of this article was triggered by a LinkedIn post by Dr. Guillermo Stöger, an Argentinian cardiac surgeon who works in the Cardiac Department of the Heart Center in Leipzig, Germany.

In his post, Dr. Stöger describes the Vincula Aortæ as “communication or adhesions” between the intrapericardial portion of the ascending aorta and the intrapericardial portion of the pulmonary trunk. In this segment these two vessels share their adventitia layer as well as a rich vascular supply. Dr. Stöger also describes the presence of small vessels in the area, which can cause a hematoma when a dissection or trauma of one of this vessels happens.

So, what is the Vincula Aortæ? It was first described by Georg Eduard Von Rindfleisch (1836-1902), a German pathologist and histologist in an article in German published in 1884 titled “Ligament-like connections between the aorta and pulmonary artery (vincula aortae)” [1]. In this article Rindfleisch describes the movement of the pulmonary trunk and ascending aorta caused by the pressure fluctuations between systole and diastole, forcing these two structures to twist and separate in opposite directions. While the ascending aorta tends to move towards the right sternoclavicular joint, the pulmonary trunk tends to move towards the left third intercostal space. Rindfleisch states that the presence of the intervascular “ligaments” reduces the mobility of these structures.  

Vincula Aortae
Click for a larger image

Being a histologist, Rindfleisch describes the structure of this intervascular structure (the Vincula Aortæ) as containing connective and fibrofatty tissue with vascular structures, encased in adventitia, and all of them covered by the visceral pericardium (endocardium). The accompanying image, modified from the original by WC Roberts [12], shows how the ascending aorta and pulmonary trunk share their adventitia; the arrows point to the area where there is connective tissue. Rindfleisch posits that the constant movement of the vessels and pericardium slowly causes the pericardium to wrinkle and fill with fat causing a semilunar elevation 2 -3 cm superior to the root of the aorta. He says that these fatty pads are more evident in people over 40 years of age.

It should be pointed out that Rindfleisch described the intervascular communication between the ascending aorta and pulmonary trunk, as a “clamp”, and also as “adhesions” or “ligaments”, and he named them “Vincula Aortæ”; but although he described the pericardial fatty fold caused by the movement of these structures, he did not name it. Later they were eponymically referred to as the “folds of Rindfleisch”. According to Netter [2] when more than one is present only the larger and usually most superior of these folds is so called.

The following mage is from Rindfleisch’s 1884 article and shows a tear in the ascending aorta with an aortic dissection. Interestingly, he says that the tears in the aorta (or pulmonary trunk) happen higher in these vessels, distal to the Vincula Aortae, which gives the lower segments additional strength.

Rindfleisch 1884 - Aortic dissection

In 2003 Morrison et al [3] published a description of the Fold of Rindfleisch stating that they were “unaware of a formal description of this structure”, naming it “crista aortæ ascendentis”. They described neurovascular bundles, fat and connective tissue in this structure, ending with a recommendation to do careful hemostasis to avoid hemorrhage intra and postoperatively, just as Dr. Stöger suggested recently.

Folds of Rindfleisch - Parke (1966)
Modified from Parke (1966)

In a “Letter to the Editor” following Morrison’s publication, Dr. Wesley Parke refuted it stating that the structure in question had already been described 40 years earlier in 1966 by himself [4], followed by a detailed study of the vessels in the region in 1970 [5]. Parke references brief statements on these folds by Davis in 1927 [6] and Hans Smetana in 1930 [7]. Parke calls this fold the “aortic ridge” and ascribes to it a cushioning function between the aorta and the right atrial appendage. No mention of Rindfleisch.

The image (modified from Parke's 1966 original) shows two specimens of the ascending aorta. The arrows point to the folds of Rindfleisch. Note that specimen 3 has a double semilunar fold. 

The importance of the work of Dr. Wesley Parke is the detailed description of the “vasa vasorum” that provide blood supply to the aorta and pulmonary trunk creating a plexus of vessels. Careful hemostasis is needed to prevent bleeding when working at the root of the pulmonary trunk and aorta. 

Parke mentions Hans Smetana (1894 - 1977). His paper "Vasa Nutritia der Aorta" describes the many vasa vasorum of the aorta and his work was followed by W. Parke who described the complex blood supply to the ascending aorta and pulmonary trunk. Following are two images modified from the original works by these authors. Again, it is critical to point out the importance of these vessels found in the area of the Vincula Aortae when performing surgery.

Aortic vasa vasorum - Smetana 1929
Smetana, 1929

Vasa vasorum of the aorta - Modified from the original by Parker 1970
Parke, 1970

There are research articles on the fatty ridges found in the proximal ascending aorta, but many have forgotten the contributions of Rindfleisch. In 1999 F. Unger named it the “plica transversa aortæ” [8]. This letter was criticized, by Falkowski et al [8] reminding that the structure was first named “Plica semilunaris nach Rindfleisch” by Julius Tanders (1869 – 1936) in his book “Anatomie des Herzens” [10]. Falkowski says “it is not the first time we have encountered self-given names to structures that have been previously studied and named a century, and sometimes centuries ago”.

Rindfleisch was the first to describe and name the common connective tissue and adventitia between the intrapericardial ascending aorta and pulmonary trunks (vincula aortae) and the fold of pericardial tissue that should bear his name: the aortic semilunar fold (plica semilunaris aortæ) of Rindfleisch.

 Sources:
1. “Uber Klammeratigae Verbindungen zwischen Aorta und Pulmonal arterie (Vincula aortae)”. Rindfleisch E Von. 1884. Virch Arch Pathol Anat Physiol Klin Med 96: 302–306.
2. “CIBA collection of medical illustrations” Netter F. 1971; vol 5, The Heart. section 1, plate 5.
3. “Surgically Relevant Structure on the Ascending Aorta” Morrison, JJ; Codispoti, M; Campanella, C. 2003 J Clin Anat 16:253-255
4. “The human aortic ridge and cushion” Parke, WW; Michels, NA 1966 Anat Rec, 154: 185-193. 
5. “The vasa vasorum of the ascending aorta and pulmonary trunk and their coronary and extracardiac relationships” Parke WW. 1970 Am Heart J 80:802– 810 
6. “The periaortic fat bodies” Davis DJ. Arch Path and Lab Med 1927 4:937-942
7. “Vasa Nutritia der Aorta: Smetana, H. 1929 Virchows Archiv für pathologische Anatomie und Physiologie und für klinische Medizin. 274: 170-187
8. “The Plica Transversa Aortae: An Addendum to the Anatomic Nomenclature of the Heart” Unger, F. 1999 Ann Thorac Surg 68:2383-91
9. “Plica transversae aortae—fold of Rindfleisch” Falkowski, G; Dzigivker, I; Bitran, D. 2001 Ann Thorac Surg 7:1-761-762
10. “Anatomie Des Herznes” Tandler, J et al. 1913. Publisher Gustav Fischer
11. “"Tratado De Anatomía Humana” Testut, L.; Latarjet, A. Barcelona, Spain: Salvat Editores, 1943.
12. “Aortic dissections: Anatomy, consequences, and causes” Roberts WC (1981). Am Heart J 101:195-214.
13 “The Fatty Ridge and Fatty Cushion of the Human Pulmonary Trunk” Nadkarni, SD, et al. Anatomical Record 1976 187: 107-112
14."Stedmans Medical Eponyms" Forbis, P.; Bartolucci, SL; 1998 Williams and Wilkins