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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]
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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Tracheal bronchus (pig bronchus)
After writing an article on the tracheal bronchus, I was asked to describe the anatomy of the pig (Sus scrofa domesticus) lung and a comparison with the human lung. The function and general structure of the pig lung is similar to the human. Anatomy-wise... there are several differences.
It is important to understand that directional terminology used to describe the anatomy of the pig is different than that used for the human. We use the anatomical position for humans, but as the pig is a quadruped, there is no such position for the pig, and veterinary terminology is used.. For further information on this topic, click here.
Following are two images. The first one is an anterior view of the human lungs and their tracheobronchial tree. The second image shows a ventral view of the pig tracheobronchial tree and both lungs.
Anterior view of the human lungs and tracheobronchial tree
Ventral view of the pig lungs and tracheobronchial tree
The first difference with the human lung is that there are two cardiac notches, right and left (the left cardiac notch is larger) whereas the human has only one, on the left lung.
The structure of the tracheobronchial tree in both species is similar, with incomplete cartilaginous rings and a posterior (dorsal) membrane that closes both the trachea and bronchi. Similarly, as the bronchial tree is more distal, the cartilaginous rings break up.
The trachea in the human ranges between 10 to 12 centimeters, while in the pig the trachea is longer, between 25 to 30 centimeters. Both bifurcate at the carina into a right and left main stem bronchus. In both species there is a large number of lymphatic nodes at the tracheal bifurcation (carinal nodes) which drain the lungs.
In the pig, the bronchus for the right cranial lobe arises directly from the trachea, and is known as the "tracheal bronchus". This does not normally happen in the human, and when it does it is considered an anatomical variation called a "pig bronchus", "bronchus suis", or "tracheal bronchus", and it can cause serious problems during intubation in surgery.
In the human, there are normally three lobes on the right side (upper, middle, and lower), and two on the left side (upper and lower). Each lobe has its separate lobar bronchus.
The right lung in the pig has 4 lobes: Cranial, middle, caudal, and an accessory lobe that is ventral and is located in the midline. Each lobe has its own separate lobar bronchus.
The left lung in the pig has two lobes: Cranial and caudal. The left cardiac notch splits the cranial lobe in two segments, but since these segments arise from a common bronchus, they are considered one lobe.
Sources:
1. "Essentials of Pig Anatomy" Sack, W.O.; Horowitz, A. 1982 Veterninary Textbooks, Ithaca, New York..
2. “Bronchial tree, lobular division and blood vessels of the pig lung” Nakakuki, S. J Vet Med Sci. 1994 Aug;56(4):685-9.
3. “Bronchial anatomy and single-lung ventilation in the pig” Muton, WG. Can J Anesth 1999 46:7 p701-703
- Human tracheal bronchus endoscopic image modified from the original. Public domain.
- Anterior view of the human lungs and tracheobronchial tree image by . Patrick J. Lynch, medical illustrator, CC BY 2.5 <https://creativecommons.org/licenses/by/2.5>, via Wikimedia Commons.
- Ventral view of the Ventral view of the pig lungs and tracheobronchial tree image by Dr. Miranda, modified from the original. Public domain.
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Tracheal bronchus (pig bronchus)
The tracheal bronchus is a known anatomical variation first described in 1785 by Eduard Sandifort (1742 – 1814), a Dutch physician and anatomist. Sandifort was the first to describe in detail what we know today as the Tetralogy of Fallot, although Nicolaus Steno (1638-1686) mentions the components of this pathology, he did not investigate it in detail as Sandifort did.
It is mostly known as the “pig bronchus” because of its similarity with pig anatomy; it is also called “bronchus suis”. When present, the tracheal bronchus usually arises on the right side of the trachea, about 2 cm. superior to the tracheal bifurcation (carina). The location of the bronchial aperture can vary between the cricoid cartilage of the larynx superiorly, and the tracheal bifurcation inferiorly.
The tracheal bronchus is usually the only airway supplying the upper right lobe of the lung, although it can share the airway with a smaller right upper lobe bronchus. In this case the tracheal bronchus is called “accessory tracheal bronchus”.
In cases where the origin of the tracheal bronchus is higher on the trachea, the trachea may present with distal stenosis. In rare cases, the tracheal bronchus may be found on the left side supplying air to the superior portion of the left lung.
The incidence of a tracheal bronchus varies between 1 to 5%, where the prevalence on the right side is 0.1 to 2% and 0.3 to 1% on the left side. It is sometimes found associated with other congenital abnormalities.
It is usually asymptomatic, but it can be found related to recurrent pulmonary infections, bronchiectasis, chronic bronchitis, and partial airway obstruction. It is most often discovered incidentally, usually during the intubation process for thoracic surgery.
Personal note: My thanks to Dr. Randall K. Wolf for suggesting this article.
Sources:
1. “Observationes anatomico-pathologicae” Sandifort, E. (1785). Lugduni Batavorum: Apud S. & J. Luchtmans.
2. “Congenital bronchial abnormalities revisited” Ghaye, B., Szapiro, D., Fanchamps, J. M., & Dondelinger, R. F. (2001). Radiographics, 21(1), 105–119.
3. “Tracheal bronchus: A rare cause of right upper lobe collapse” Ngernchuklin, P., Sumanac, K., & Behrsin, J. (2006).. Canadian Journal of Anesthesia, 53(12), 1227–1230
4. “Tracheal bronchus” radiopedia.org. Elfeky, M. 2023.
5: ”Bronchus suis – Case presentation” radiopedia.org. Ian Bickle.
Image modified from the original, public domain.
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Original Facebook image
For those who follow this blog or my articles on LinkedIn you know that I have several pet peeves regarding the misuse of medical and anatomical terminology. You can read some of these articles in the following links:
- One of my pet peeves... pronouncing the word “dissection” wrong
- 11+ medical words that are used incorrectly
- Ramus intermedius, a cardiac anatomical variation
- Using vernacular terms as medical terms
- GIGO: The use of artificial intelligence in social media and education. “It looks good, so let’s use it (but it’s wrong)”
Recently, reading an article on Facebook, I realized that there are many people, some of them health care professionals, who use (and teach) anatomical directional terminology incorrectly. The post itself shows an image depicting directional terminology in humans.
The original image is shown here and if you hover your mouse on it you will see my concerns. If you click on it, you will see a larger depiction of these concerns.
1. Dorsal and Ventral and… 2. Caudal and Cranial
These four terms are used by many, referring to the human body in the anatomical position. The fact is that in the human anatomy, the proper terms to use are as follows:
1. Instead of ventral, the proper term to use is anterior.
2. Instead of dorsal, the proper term to use is posterior.
3. Instead of cranial, the proper term to use is superior.
4. Instead of caudal, the proper term to use is inferior.
Let’s look at the etymology behind the terms.
Ventral arises from the Latin [ventrum] and [venter] which means “abdomen” or “belly”. Some contend that the term means “towards the abdomen” and even say that the term is correct because the abdomen is the largest part of the anterior aspect of the body. In any case, never use the term “stomach” to mean abdomen (another pet peeve).
The term dorsal arises from the Latin [dorsum] which means “back”.
Click for a larger image
The term cranial arises from the Latin [cranium] meaning “skull”. Not mentioned in the image is the term “cephalad” which is Greek [κεφάλι] meaning “head”. The suffix [ad] means “toward”, so cephalad means “towards the head”.
Additional controversy is found with the term “caudal” or “caudad”. It originates from the Latin [cauda] which means “tail”. How can anyone say that the feet are “caudal” when the tail is the coccyx? Despite this, there are many who teach the term caudal and define it as “towards the feet”, even knowing the origin of the term.
The reason for these terms is that they are used in veterinary medicine and embryology. You see, in a quadruped, these four terms apply perfectly as you can see in this image.
The terms “cranial” and “caudal” are also used in embryology. Since the embryo is curved, we need terms that reflect this curvature, and since the upper and lower extremities have not yet developed, the tail is the “end” of the embryo! As for the terms “ventral” and “dorsal”, the image the follows is self-explanatory… the back of the embryo is almost all of it! See the following image:
Controversy also arises from the use of the term “dorsal” to refer to the superior aspect of the foot. It is just a consensus. The inferior aspect of the foot is referred a “plantar”, and “dorsal” was adopted to reflect this opposition.
Click for a larger image
In the comments to this Facebook article, C. Hartig mentioned “rostral”. The term [rostrum] is Latin and means “beak”. In Roman times the term was used to denote a speaker’s platform, as the dais was usually adorned with eagles that had a pointed beak. Through use, the term “rostrum” was used as “face” (some people have a very pointed nose).
In anatomy we use the term rostral as “face”. The term is used in neuroanatomy and refers to a plane that is transverse to the axis of the Central Nervous System. See the accompanying image. In the spinal cord, the terms “rostral” and “caudal” follows the transverse plane of the body. In the head, the axis of the brainstem changes and now an axial image of the brainstem is angled. In the cerebrum this changes again and now points anteriorly towards the face (or frontal lobe).
This leads to the misuse of the term “axial”. Yes, it can be used as “transverse plane, but only when referring to the body as a whole. This changes when we use the term “axial” referring to an organ or structure. An “axial” image of the heart is different from a “transverse image of the heart.
A word of caution. Because of the importance of embryology in neurogenesis of the nervous system, these embryological terms are used in adult neuroanatomy, Hence the terms "dorsal root ganglion", "ventral horn", ventral root", etc.
3. Sagittal Plane
The term “Axes of the CNS (Dr. Miranda, 1977)” arises from the Latin [sagitta], meaning “arrow”. An arrow would transfix someone from front to back. A sagittal plane is a vertical plane that divides the body into right and left portions. Since a plane has no width (geometrical definition) there are infinite sagittal planes. Only one divides the body into equal right and left portions. This is the midsagittal plane or median plane.
The image is correct in the sense that the median plane is one of many sagittal planes, but this representation forces many students to misuse the terms. If it is a median or midsagittal image, say so.
Disclaimer: I do not know the origin of the original image in the Facebook post, whether it is copyright-free or not. I used it because it has been posted publicly. All other images in this article are personal, copyright-free, or proper attribution have been posted as required by copyright law.
Sources:
1. "Tratado de Anatomia Humana" Testut et Latarjet 8 Ed. 1931 Salvat Editores, Spain
2. “The Origin of Medical Terms” Skinner HA 1970 Hafner Publishing Co.
3. "Medical Meanings, A Glossary of Word Origins" Haubrich, W.S. 1997. American College of Physicians, Philadelphia, PA.
4. "Elementos de Neuroanatomía" Fernandez, J.; Miranda, EA.
5. "Dorland's Illustrated Medical Dictionary" 28th Ed. W.B. Saunders. 1994
6. "Medical Terminology; Exercises in Etymology" Dunmore CW, Fleischer RM 2nd Ed. 1985
7. "Medical Meanings; A Glossary of Word Origins" Haubrich, WS. Am Coll Phys 1997
8. "Lexicon of Orthopædic Terminology" M. Diab. 1999. Amsterdam Hardwood Academic Publishers.
9. "Gray's Anatomy" 38th British Ed. Churchill Livingstone 1995
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- Written by: Efrain A. Miranda, Ph.D.
Peripheral nerve injuries can result from trauma, compression, thermal damage or systemic diseases, and their classification is essential for diagnosis, management, and prognosis. Three key terms are used to describe the severity and nature of these injuries: neurapraxia, axonotmesis, and neurotmesis. They describe the structural and functional integrity of nerve fibers after injury. The etymology of these terms derives from the Greek language.
These terms were initially proposed by Sir Herbert John Seddon (1903 – 1977), an English anatomist and orthopedic surgeon who published his initial findings in 1943, followed by Sir Sydney Sunderland (1910 – 1993), an Australian orthopedic surgeon who published a revised classification in 1951. The terms coined by Seddon and Sunderland and their classification system into 5 Grades of Nerve Injury remain central to the treatment of nerve injuries today.
Neurapraxia:
Neurapraxia represents the mildest form of nerve injury. It is characterized by a temporary block of nerve conduction without axonal disruption. Recovery is typically complete and occurs within days to weeks.
• No structural damage to the axon or surrounding connective tissue.
• Localized demyelination may occur, leading to a conduction block.
• Commonly results from compression or mild blunt trauma (e.g., “Saturday night palsy” or a "transient ulnar nerve palsy").
The term is derived from the Greek [νεῦρον] meaning “nerve” and [πρᾶξις] (praxis) meaning “action”. In medical terminology “a” or “an” means “without” or “absence of”. Thus, the word is constructed as [neur]-[a]-[praxia] meaning “absence of nerve function”.
Sir Herbert John Seddon (1903 – 1977)
Sir Sydney Sunderland (1910 – 1993)
Axonotmesis
Axonotmesis is a more severe injury in which the axon is damaged, but the surrounding connective tissue structures (endoneurium, perineurium, and epineurium) remain intact. Wallerian degeneration occurs distal to the lesion, and axonal regeneration following the intact connective tissue channels can allow for not only nerve regeneration but regain of function of the damaged nerve. This is the mechanism of action of cryoneurolysis devices used in surgery.
• Axonal continuity is lost, but the scaffolding remains.
• Regeneration can occur at a rate of approximately 1–3 mm/day.
• Often seen in crush injuries or prolonged compression.
The term is derived from the Greek [ἄξων] meaning “axis” and [τμῆσις], meaning “division” or “cut”. Axonotmesis means “division (cutting) of the axon.”
Augustus Volney Waller (1816 – 1870)
Neurotmesis
Neurotmesis is the most severe form of nerve injury. It involves complete disruption of the axon and surrounding connective tissue, as would happen when a nerve is transected or avulsed. It results in permanent loss of function, since when the axons start to regrow, there are no connective tissue “tunnels” to guide the growing axon to their terminal connections. One of the problems that may happen is the formation of a neuroma or neurinoma at the site of nerve transection.
The only way to attempt to restore function is with surgical intervention bringing the cut ends of the nerves together, sometimes using microsurgery. The results of surgery are not always optimal
• Wallerian degeneration occurs distal to the injury.
• Regeneration is not possible without surgical repair.
• Typically is the result from lacerations, severe traction injuries, or penetrating trauma.
The term is derived from the Greek [νεῦρον] meaning “nerve” and [τμῆσις] meaning “division” or “cut”. Neurotmesis thus translates to “division of the nerve.”
Accurate classification of nerve injuries can help guide prognosis and treatment:
• Neurapraxia: Managed conservatively with physical therapy and observation.
• Axonotmesis: May require surgical exploration if function does not return within expected time frames.
• Neurotmesis: Early surgical intervention is usually necessary to restore any function.
Note: The term “Wallerian degeneration” is associated eponymically with Augustus Volney Waller (1816 – 1870), an English physiologists know for his work on nerve injury and regeneration.
Personal note: Most people talk about "peripheral nerves", as if "central nerves" existed. This is not so. Within the Central Nervous System (CNS) the bundles of axons have different names such as "fascicles" (fasciculus lenticularis), tracts" (spinothalamic tract), lemniscus (medial lemniscus), etc. These central bundles of axons form structures that themselves have separate names, such as the corpus callosum, internal capsule, external capsule, anterior commissure, etc. All of these structures lack a well formed connective tissue wrap, which is the reason why transection of these structures usually does not allow recovery, such as in the case of spinal cord transection.
Nerves, which are only found in the Peripheral Nervous System (PNS). do have a well-formed connective tissue wrap formed by the endoneurium, perineurium, and epineurium. The presence of these connective tissue structures is what allows for nerve regeneration and recuperation of functionality.
To be precise then, using the term "peripheral nerve" is redundant, as all nerves are peripheral! Dr. Miranda
Sources
1. Seddon H. Three Types of Nerve Injury. Brain. 1943;66(4):237-88. doi:10.1093/brain/66.4.237
2. Seddon H, Medawar P, Smith H. Rate of Regeneration of Peripheral Nerves in Man. J Physiol. 1943;102(2):191-215. doi:10.1113/jphysiol.1943.sp004027
3. Sunderland S. A Classification of Peripheral Nerve Injuries Producing Loss of Function. Brain. 1951;74(4):491-516. doi:10.1093/brain/74.4.491
4. O'Brien, M. D., & Wade, D. T. (1992). Neurological rehabilitation. Chapman and Hall.
5. Liddell, H. G., & Scott, R. (1940). A Greek-English Lexicon. Oxford University Press.
6. "The Origin of Medical Terms" Skinner 1970
7. "Dorland's Illustrated Medical Dictionary" 28th Ed. W.B. Saunders. 1994
8. “Stedman’s medical eponyms” Farbis, P; Bartolucci, S. Williams & Wilkins 1998
9. https://radiopaedia.org/articles/sunderland-classification-of-nerve-injury
10. " Correlative Neuroanatomy and Functional Neurology" Chusid, Joseph. Lange Medical Publications
The image of H.J. Seddon is an AI composite of the few images and portraits available. Courtesy OpenAI.
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- Written by: Efrain A. Miranda, Ph.D.
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.
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.
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.
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.
Smetana, 1929
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
- Details
- Written by: Prof. C. Uribe
The anatomical framework of the seven books
that comprise Vesalius' Fabrica
As an educator with over 20 years teaching Human Anatomy, I have witnessed how accurate and up-to-date language can transform teaching and learning in health sciences.
The recent publication of Anatomical Terminology 2 (TA2), made freely available by the International Federation of Anatomists' Associations (IFAA), represents a significant advance that all professionals in the field should adopt as soon as possible.
Anatomical terminology is not simply a list of terms, but the basis for clear, effective and universal communication. The TA2 update addresses not only necessary changes resulting from new anatomical research and discoveries, but also substantial improvements in consistency and accuracy. This is especially relevant today, when globalization and digitalization demand accurate communication between professionals from different countries and specialties.
Using TA2 involves:
- Unifying anatomical criteria globally.
- Facilitating the teaching of anatomy with clear and precise terms.
- Improving the quality and safety of healthcare by reducing misunderstandings.
- Empowering scientific research by ensuring consistency in academic publications.
I invite fellow teachers, students and health professionals to familiarize themselves with TA2 and actively apply it in their academic and clinical practices. Let us take advantage of this tool to continue raising the standard of our work and the quality of anatomy education.
You can consult TA2 directly at this link: https://libraries.dal.ca/Fipat/ta2.html
What has been your experience with the update of anatomical terminologies?... Are you ready to integrate TA2 into your teaching and professional practice?