Details

Published: April 10, 2018

This article is part of the series "A Moment in History" where we honor those who have contributed to the growth of medical knowledge in the areas of anatomy, medicine, surgery, and medical research.

This article continues the musings of "Interesting discoveries in a medical book". In this book I found a copy of a letter written by Ephraim McDowell, MD; who on December 25, 1809 performed the first recorded ovariotomy in the world. The patient was Mrs. Jane Todd Crawford, who has also been the subject of several articles in this website, including a homage to the "unknown patient/donor".

The book belonged to Cecil Striker, MD, who practiced in Cincinnati. Dr. Striker was a faculty at the University of Cincinnati and one of the founders of the American Diabetes Association (ADA). He also was one of the first physicians to work in 1923 with a "newly discovered" drug by the Eli Lilly Company (Indianapolis) this drug was named Insulin. The medical application of Insulin had only just been discovered about a year earlier.

Inside the book there is a copy of a letter by Dr. Ephraim McDowell to Dr. Robert Thompson dated January 2nd, 1829, a year before Dr. McDowell's death. At the time (1829) Dr. Thompson (Sr.) was a medical student in Philadelphia. According to the note Dr. Thompson lived in Woodford County, KY, had three children and died in 1887. One of his children was also a doctor, but I have not been able to ascertain if this book was given to him by Dr. Striker.

The letter is shown in the image attached. In this letter Dr. McDowell describes in his own words the ovariotomy he performed on Jane Todd. He also describes other ovariotomies he performed and his opinion on "peritoneal inflammation".

Note how the letter has no paragraph separation. Apparently, at the time writing paper was expensive and the less pages used, the better! The text of the letter is as follows:

Danville, January 2, 1829

Mr. Robert Thompson
Student of Medicine
No. 59 Spruce Street
Philadelphia, Pennsylvania

Sir,

At the request of your father I take the liberty of addressing you a letter giving you a short account of the circumstances which lead to the first operation for diseased ovaria. I was sent in 1809 to deliver a Mrs. Crawford near Greentown of twins; as the two attending physicians supposed. Upon examination per vaginam I soon ascertained that she was not pregnant; but had a large tumor in the abdomen which moved easily from side to side. I told the lady that I could do her no good and carefully stated to her, her deplorable situation. Informed her that John Bell, Hunter, Hay, and A. Wood four of the first and most eminent surgeons in England and Scotland had uniformly declared in their lectures that such was the danger of peritoneal inflammation, that opening the abdomen to extract the tumor was inevitable death. But not standing with this, if she thought herself prepared to die, I would take the lump from her if she would come to Danville. She came in a few days after my return home and in six days I opened her side and extracted one of the ovaria which from its diseased and enlarged state weighed upwards of twenty pounds. The intestines as soon as an opening was made run out upon the table, remained out about twenty minutes and being upon Christmas Day they became so cold that I thought proper to bathe them in tepid water previous to my replacing them; I then returned them, stitched up the wound and she was perfectly well in 25 days. Since that time I have operated eleven times and have lost but one. I now can tell at once when relief can be obtained by an examination of the tumor if it floats freely from side to side or appears free from attachments except of the lower part of the abdomen. I advise the operation, having no fear from the inflammation that may ensue. I last spring operated upon a Mrs. Bryant from the mouth of the Elkhorn from below Frankfort. I opened the abdomen from the umbilicus to the pubis and extracted sixteen pounds. The said contained the most offensive water I ever smelt, and the attendants puked or discharged except myself. She is now living; from being successful in the above operation. Several young gentlemen with ruptures have come to me. I have uniformly cut the ring open, put the intestines up if down the cut the ring all around, every quarter of an inch then pushed the parts closely together and in every case the cure has been perfect. Therefore it appears to me a mere humbug about the danger of the peritoneal inflammation. Much talked about by most surgeons. After wishing you Health and Happiness,

I am yours sincerely
E. McDowell

P.S. Your father looks better than I have ever seen. Your sister is also in health

The most important point of this letter is how easily and publicly they name patients and their home addresses. Today this would be  a violation of the Health Insurance Portability and Accountability Act of 1996, commonly known as HIPPA, a legislation that provides data privacy and security provisions to safeguard patient medical information.

It is also interesting to see how Dr. McDowell explained to Mrs. Crawford how difficult and dangerous the procedure would be. He stated how four renown surgeons in England and Scotland said that opening the abdomen was "inevitable death". Another point was how long the intestines were outside the body ... twenty minutes, and the maneuver Dr. McDowell used to bring them back to normal temperature. Late December in Kentucky is quite cold, even with wooden stoves and such. I wonder how much the lower temperature helped the patient.

The last point refers to his success in hernia procedures in young males. In the 1800's the word "rupture" was the standard to name abdominal hernias. Without explaining the procedure in detail, Dr. McDowell says that "every cure has been perfect". At the time, this was unprecedented, as the recurrence of inguinal hernia procedures, when attempted, was close to 25%.

The house where Dr. McDowell lived and practiced is today a museum in Danville, KY. In February, 2017 I visited this museum and wrote an extensive article on it. I encourage those interested in the History of Medicine to visit the place.

Details

Published: April 04, 2018

Change the text of the image

UPDATED: [Pes anserinus] is the name given to a tri-flanged structure formed by the attachment of the flattened tendons of three muscles to the anteromedial surface of the superior aspect of the shaft of the tibia. The tendons correspond to the sartorius, the gracilis, and the semitendinosus muscles. The pes anserinus is related superficially to the the tibial insertion of the medial collateral ligament of the knee. 

There is a bursa deep to these tendons, the [bursa anserinus], which can be the cause of painful bursitis.

The term [pes anserinus] literally means “goose foot”, as early anatomists compared this structure to the foot of this bird. In Latin [pes] means “foot”, and [anserinus] or [anser] means “goose”.

For other anatomical structures whose names are related to birds, click here.

Thanks to Jackie Miranda-Klein for suggesting this post. Jackie is studying for the Physician Assistant Master's degree at Kettering College. Dr. Miranda.

Image modified from the original: "3D Human Anatomy: Regional Edition DVD-ROM." Courtesy of Primal Pictures

Details

Published: April 02, 2018

Click for a larger image

The word [torus] is of Latin origin and refers to “a rounded protuberance or swelling”. In science, it refers to a doughnut-shaped structure (see image). It also refers to the rounded, bulging, and circular base component of a pillar, found between the square plinth and the main body of the pillar. The torus can be seen in Egyptian, Greek, and Roman style pillars.

The term is used in anatomy and medicine to denote normal or abnormal circular or semicircular protuberances, as in the case of the “torus tubarius”, a normal semicircular elevation found at the ostium of the auditory tube (of Eustachius) in the lateral walls of the rhinopharynx. The torus tubarius elevation is due to the presence of lymphoid tissue which can get inflamed.

Torus mandibularis. An exostosis that develops on the inner side of the mandible
Torus palatinus: a benign, small exostosis that appears in the midline of the hard palate

In orthopedics it is used to denote a compression fracture where the cortex of a long bone close to one of its epiphyses buckles under longitudinal (axial) compression. The look of the fracture is similar to the location of the torus in a pillar. An example of this is the torus fracture (also known as buckle fractures) in children.

The term [torulus] is related to [torus], as it means a “small torus” and it refers to a small elevation, which is synonymous with the word “papilla”. An example of this is the term torulus tactiles palmaris, referring to small elevations on the palms of the hand. Another related term is [torulosis], referring to a large number of small elevations or pimples.

The following images are of a Greek pillar taken in 2014 in Athens showing the location of the torus. The next image shows a torus fracture. The image is from www.kidsfractures.com/forearm/ and we thank them for sharing the image with us. This is a great site for information on fractures in children.

Sources:
1. “Medical Meanings: A Glossary of Word Origins” Haubrich, WS. Am Coll Phys. Philadelphia 1997
2. “The Origin of Medical Terms” Skinner, HA 1970, New York. Hafner Publishing Company
3. “Taber’s Cyclopedic Medical Dictionary” 16th Ed. 1989. Philadelphia. FA Davis Company
4.  www.kidsfractures.com/forearm/

Torus image: By LucasVB [Public domain], via Wikimedia Commons

Thanks to Jackie Miranda-Klein for suggesting this post.  Dr. Miranda.

Details

Published: March 26, 2018

Excised bicuspid aortic leaflets

 The normal components of the aortic valve are part of the aortic root. The valve is composed of three leaflets, each of which are related to a sinus of Valsalva, and three interleaflet triangles. The anatomy of the aortic root, the aortic valve and the interleaflet triangles of the aortic root have been described in other articles in this website.

A bicuspid aortic valve (BAV) is probably the most common cardiac defect of congenital origin. The prevalence of BAV ranges from 0.9% to 2% in the general population with a 3:1 male-female ratio.

In spite of the anomaly, a BAV may achieve normal valvular function, but this probably does not last, as BAV tend to develop calcifications in the adult leading to valvular disease, dysfunction, valvar stenosis, so complications are common, the most common being dilation of the aortic root and ascending aorta.

The etiology of a BAV is commonly accepted as congenital and there are some studies that demonstrate a familial component, but it can appear in families where there is no known history of BAV.

There are several attempts at classifying BAV, as the leaflets that fuse are different, and so is the way of fusion.

There is one rare BAV called “pure”. This purely BAV is a true BAV, composed of two leaflets of similar size where there is no clear fusion line or “raphe” between the fused leaflets (see image). This valve has two well developed interleaflet triangles and the third can be absent or vestigial.  The image depicts the excised calcified leaflets where the left and right coronary cusps are fused.  

Other types of BAV have a well-developed raphe, have two well developed interleaflet triangles and the third may be large or anomalous. The leaflets may also be asymmetrical. The classification of the different types of BAV goes beyond the objective of this article, but they can be studied in the references at the end of this article. There is no doubt that the different types of BAV can cause valvar disease and hemodynamic chaos, so the surgical approach for these may be different, including valve repair, aortic annuloplasty, interleaflet triangle remodeling, and of course valve removal and prosthetic implant, either biological or mechanical.

Clinically, the pathologies related to the function of the aortic valve are stenosis, valvular incompetence, and in some cases intimal aortic dissection, which is a catastrophic complication. Some of these complications are triggered by the calcification of the bicuspid leaflets. Interestingly, although BAV is a congenital disease, only one in fifty children known to have BAV have clinically significant disease by adolescence.

PERSONAL NOTE: I have permission to publish the image in this article… because the bicuspid aortic valve depicted in this article is my own. My personal thanks to the medical and support personnel at the Memorial Hermann Heart & Vascular Institute, in Houston, TX., and my three cardiovascular physicians without whom I would not be back writing this article, Drs. Randall K. Wolf (contributor to this website), Dr. William Ross Brown (cardiologist), and Dr. Tuyen (Tom) Nguyen, who operated on me. Dr. Miranda.

Sources:
1. “Etiology of bicuspid aortic valve disease: Focus on hemodynamics: Atkins, SA, Sucosky, P World J Cardiol. 2014 Dec 26; 6(12): 1227–1233.
2. “A classification system for the bicuspid aortic valve from 304 surgical specimens” Sievers, HH., Schmidtke, C. J Thorac Cardiovasc Surg 2007;133:1226-33
3. “Bicuspid Aortic Valve Disease” Siu, SC, Silversides, CK. JACC Vol. 55, No. 25, 2010:2789 – 800
4. “Bicuspid aortic valve aortopathy in adults: Incidence, etiology, and clinical significance” Int J Card 2015:1;400-407
5. ”Sutureless valve in freestyle root: new surgical valve-in-valve therapy” Villa E, Messina A  et al. Ann Thorac Surg  2013:96:e155–e157
6.” Sutureless aortic bioprosthesis valve implantation and bicuspid valve anatomy: an unsolved dilemma?” Lona, M, Guichard JB, et al Heart vessels 2016.31:1783-1789

Details

Written by: Efrain A. Miranda, Ph.D.

Published: March 23, 2018

Hits: 139615

This is the most popular article on this blog by far!  Look at the hits counter above...
Let us know other topics that may interest you in our "Contact Us" page.

Click for a larger image

The ligament of Treitz is formed by a fold of peritoneum over the suspensory muscle of the duodenum. This muscle is also known as the "muscle of Treitz" or "musculus suspensorius duodenii". This muscle was first described in 1853 by Dr. Václav Treitz. 

The muscle (see the first image) has an unusual structure in that it is formed by a tendon with two muscular ends of dissimilar embryological origin and function. The superior muscular component is skeletal (voluntary) muscle and arises as a slip of muscle (Hilfsmuskel) from the right esophageal crus of the respiratory diaphragm, as well as muscular and ligamentous fibers arising in the region of origin of the celiac trunk and superior mesenteric artery. The inferior portion of the muscle is smooth (involuntary) muscle and has been described as continuous with both the longitudinal and circular muscle layers of the intestine at the duodenojejunal junction.

The ligament of Treitz is an anatomical landmark used by anatomists and surgeons to denote the duodenojejunal junction and the point where the small intestine passes from retroperitoneal duodenum to intraperitoneal jeunum. Surgeons use the ligament of Treitz to measure the jejunum to decide where to perform an anastomosis.

Original image of the "ligament of Treiz"

There is much discussion today on eponyms, that is, associating an individual's name to an anatomical structure or surgical procedure. In spite of the pressure to make eponyms dissapear, the ligament of Treitz is here to stay!

The second image is a copy of the original image published by Dr. Václav Treitz in his 1853 publication "Ueber einen neuen Muskel am Duodenum des Menschens" (On a new muscle in the duodenum of man). The 'muscle of Treitz" is marked by an arrow.

It is important to clarify that the term "ligament" in the abdominopelvic cavity has a different meaning and structure from a skeletal ligament found in a joint. For more information click here. The term "Ligament of Treitz" refers to the fold of peritoneum that attaches to the posterior aspect of the abdominal and lines the "muscle of Treitz".

Clinical anatomy, pathology, and surgery of the gastrointestinal tract are some of the many lecture topics developed and delivered to the medical devices industry by Clinical Anatomy Associates, Inc.

Sources:
1. "Clinically Oriented Anatomy" Moore, KL. 3r Ed. Williams & Wilkins 1992
2. "The origin of Medical Terms" Skinner, AH, 1970
3. "The suspensory muscle of the duodenum and its nerve supply" Jit, I.; Singh, S. J. Anat. (1977), 123, 2, pp. 397-405
4. "Anatomical and functional aspects of the human suspensory muscle of the duodenum." Costacurta, L. Acta Anat (Basel). 1972;82(1):34-46
Image property of: CAA.Inc. Artists: Dr. E. Miranda and D.M. Klein

Details

Written by: Efrain A. Miranda, Ph.D.

Published: March 22, 2018

Interleaflet triangles of the aortic valve by MTD.
Click for a larger image. 

The interleaflet triangles (ILTs) are three triangular regions found in the ventricular aspect of the aortic root. They are bound inferiorly by the virtual basal ring (VBR), laterally by the attachment of the leaflets (the hinge) to the aorta and left ventricular wall (muscular and fibrous), and superiorly by the commissures (site of attachment and meeting of adjacent leaflets) which are usually located at the sinotubular junction, also known as the sinotubular ridge.  

A review of the literature on the topic shows that although many speak of these ILTs, not many authors have clearly defined their boundaries. In fact, some only reserve the term ILT to the triangular region distal to the ventriculoaortic boundary. The description used in this article includes the ventricular wall found between the VBR and the ventriculoaortic junction as well as fibrous components found between these two boundaries. Based on this description, we have developed an image of the ILTs that, to our knowledge is not found in literature. (see accompanying images).

The virtual basal ring is a circular virtual line formed by the nadirs of the three aortic leaflets (cusps). The attachment of the three leaflets create a three-pronged coronet that is useful in defining the interleaflet triangles (see image)

The superior boundary of the ILTs is formed by three commissures, the points where the leaflets meet each other at the sinotubular junction. There are two posterior commissures, right and left. The right-posterior commissure is found between the noncoronary and the left coronary sinuses (of Valsalva). An important point about this commissure is that it is situated above the midpoint of the septal (anterior) leaflet of the mitral valve. The left-posterior commissure is found between the left and the right coronary sinuses. The anterior commissure is located between the right and the noncoronary sinus close to the membranous interventricular septum.

Based on the above description, there are three interleaflet triangles:

a. Right (posterior), left (posterior), and anterior. The right posterior ILT is located between the noncoronary and the left coronary sinuses, and just as the commissure at its apex, is located at the midpoint of the septal (anterior) leaflet of the mitral valve. Also, the superior aspect of this ILT is related to the transverse pericardial sinus.

b. The left posterior ILT is located between the right and the left coronary sinuses, and is lies immediately behind the right ventricular outlet.

c. The anterior ILT is found between the right and the noncoronary sinuses. It is related to the membranous septum and the right fibrous trigone, forming part of the central fibrous body (skeleton) of the heart. This ILT is a good anatomical landmark to the location of the bundle of His and the left bundle branch, both components of the conduction system of the heart. These structures can be compressed during the implantation of an aortic or mitral valve, causing transitory or permanent cardiac conduction problems.

Interleaflet triangles of the aortic valve by Sutton.
Click for a larger image.

The ILTs are important in the normal physiology and hemodynamics of the aortic valve. A small ILT will affect the diameter of the valve and the movement of the leaflets, causing stenosis. This is the case in bicuspid aortic valves where the fusion of two of the leaflets leads to the reduction in size of the ILT normally found between these two fused leaflets.

Since they are located within the functional portion of the left ventricle, the ILTs are subject to the pressures of the ventricle and can be areas that develop aneurysms.

Because of their importance in the hemodynamics of the aortic valve, new procedures and medical devices that reshape the ILTs are being developed. This is specially important in the case of a bicuspid aortic valve, where the interleaflet triangles may be abnormal.

Further to the images that are depicted in this article, the lower image is the classic image of the interleaflet triangles by Sutton (1995). As you can see, the base of the triangles is shown straight with no clear boundary, and it seems as though they are related to the ventriculoaortic junction.  The nadirs are not used as a point of reference. The upper image (developed by us and based on Sutton's original sketch) clearly shows the extent of the ILTs as well as their relation to the three landmarks that define the aortic root: The virtual basal ring, the ventriculoaortic junction, and the sinotubular junction.

NOTE: The pulmonary valve also has interleaflet triangles, with a somewhat similar description, but since they are under low pressure they do not develop or are cause of pathology as the ILTs of the aortic valve.

Sources:
1. The Anatomy of the Aortic Root: Loukas, M et al. Clinical Anatomy 27:748–756 (2014)
2. “Extracardiac aneurysm of the interleaflet triangle above the aortic-mitral curtain due to infective endocarditis of the bicuspid aortic valve.” Hori D, et al. Gen Thorac Cardiovasc Surg. 2008 Aug;56(8):424-6
3. “Anatomy of the aortic root: implications for valve-sparing surgery” Efstratios I. Charitos, HS. Ann Cardiothorac Surg 2013;2(1):53-56
4. “The Forgotten Interleaflet Triangles: A Review of the Surgical Anatomy of the Aortic Valve” Sutton JP, et al Ann Thorac Surg 1995;59:419-27
5.” The aortic interleaflet triangles annuloplasty: a multidisciplinary appraisal” Mangini, A., et al. European Journal of Cardio-Thoracic Surgery, Vol. 40:4, 2011, 851-857
6. “Structure and Anatomy of the Aortic Root” Ho, SH., Eur J Electrocar 2009 10; i3-i10
7. “In vitro study of the aortic interleaflet triangle reshaping” Vismara, R Journal of Biomechanics; 47:2; 2014. 329-33