Kiesselbach's plexus is named after Dr. Wilhelm Kiesselbach (1839 – 1902), a German otolaryngologist. It is an area in the anteroinferior aspect of the nasal septum where several arteries from different origins meet and anastomose.

This arterial plexus is also known as the "locus Kiesselbachii", Kiesselbach's triangle, or Little's plexus, or Little's area. This area of the anteroinferior nasal septum has a propensity for epistaxis or nasal bleeding. In fact, close to 90% of nose bleeds (epistaxes) happen in this area.

in this region, terminal branches of the anterior ethmoid artery, greater palatine artery, sphenopalatine artery and superior labial artery anastomose forming an anastomotic circle. The anastomoses are numerous enough to form a plexus.

Click on the image for a larger view

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

As some of you may know by now, I am a collector of antique medical books and books that relate to the history of anatomy and medicine.

Provenance is also important. Where was it printed? Who owned it? Who was the illustrator? etc. I recently acquired a second copy of the book “EPHRAIM MCDOWELL, FATHER OF OVARIOTOMY AND FOUNDER OF ABDOMINAL SURGERY. With an Appendix on JANE TODD CRAWFORD”. By AUGUST SCHACHNER, M.D. Cloth, 8vo.A p. 33I. Philadelphia, J. B. Lippincott CO., I921. Dr. McDowell has also been featured in this blog in the series "A Moment in History".

This second copy is most valuable because of the papers found within the book. There is a series of notes, newspaper clippings, and copies of letters! Here is a detail of what I have found:

The book seems to have belonged to Cecil Stryker, MD.,a physician in Cincinnati, and one of the founders of the American Diabetes Association (ADA). There is a copy of a letter by Dr. Ephraim McDowell to Dr. Robert Thompson (Sr.) dated January 2nd, 1829, a year before Dr. McDowell's death. 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"

Letter from Ephraim McDowell to Robert Thompson
Click on the image for a larger depiction

Last, there is a note dated September 16, 1974 from the wife of Dr. West T. Hill, Chairman of the Dramatic Arts Department at Centre College in Danville, Kentucky. In this handwritten note she mentions the McDowell family reunion that took place on June 15 and 16, 1974 in Danville. With the note comes the program and registration form for the festivities! Dr. West T. Hill was one of the many responsible for the restoration of the MacDowell Home and Museum. Today Danville has the West T. Hill community theatre that honors his name.

All of this in one book, as I always say "You know where you are going to start reading it, but you never know where are you going to end in researching it". This book will be a great addition to my library catalog. Dr. Miranda.

Rudi Coninx, MD  is a physician and Chief a.i. Humanitarian policy and Guidance at the World Health Organization (WHO), based in Geneva. He obtained his MD from the University of KU Leuven Belgium, a Doctorate in Tropical Medicine from the Prins Leopold Instituut voor Tropische Geneeskunde, and an MPH from the John Hopkins University School of Medicine.

His CV shows more than twenty five years of national and international experience in policy and strategy development and analysis, policy dialogue, technical advice and program management support to countries and WHO country offices. Considerable experience in strengthening WHO country offices and in working with partners and networks at the global as well as filed level. Coordinated the WHO Country Focus Policy for more than five years and worked as a member in various strategic planning, decentralization, and global and regional partnership groups, including national and international committees, taskforces. Published several articles on policy analysis, management and health and development in regional and international journals.

He is also an Associate Faculty, Bloomberg School of Public Health, Johns Hopkins University, USA.

He has held a series of positions with the International Committee of the Red Cross, and also within the World Health Organization. His LinkedIn profile can be found here.  

Thanks to Dr. Coninx for taking time of his busy schedule and collaborating with "Medical Terminology Daily" with the article "Did Andreas Vesalius really die from scurvy?" which he co-authored with Theo Dirix. We look forward to his future writings in this blog.

Wilhelm Kiesselbach (1839 – 1902) German otolaryngologist born in the city of Hanau. Started his medical studies in 1859 in Göttingen. Marburg, and Tübingen. Because of an accident that affected one of his hands and legs, his doctorate was delayed until 1875.

He specialized in otolaryngology in Vienna, although he also studied and specialized in ophthalmology. He had a number of positions such as assistant professor at the Medical Polyclinic in Erlangen, assistant professor for ophthalmological examinations at the Surgical Clinic in Erlangen, and senior physician for ophthalmology.

He died of an infection he contracted while working with patients at the clinic.

His name is eponymically tied to the locus Kiesselbachii, also known as Kiesselbach’s plexus, an area of the anteroinferior nasal septum known for propensity for epistaxis or nasal bleeding. In fact, close to 90% of nose bleeds happen in this area. in this region, terminal branches of the anterior ethmoid artery, greater palatine artery, sphenopalatine artery and superior labial artery anastomose forming a plexus.

NOTE:  In 2014  Pavlos Plessas presented the compelling theory that Andreas Vesalius died in 1564 from scurvy on the island of Zakynthos. With his permission his original article entitled "Powerful indications that Vesalius died from scurvy" was published in this blog in 2016.

His theory was later challenged by Theo Dirix and Dr. Rudi Coninx in this same blog with the article "Did Andreas Vesalius really died from scurvy?". Pavlos Plessas' rebuttal to the latter article is published here from a letter to Theo Dirix.

16. The study’s sample is small, not representative of a general population, based on answering a questionnaire and not observation

Clinical studies of this nature face obvious limitations. If the authors are prepared to disbelieve the testimony of people who lived in a confined space with many victims of scurvy until the final fatal outcome, it is no wonder they complain about the study. Doubting is their prerogative, however, the way to discredit the study is to either find an error in the data or its interpretation, or conduct their own study and come up with different results.

17. The quoted personality changes peak on day 107. Certainly not an early symptom

Do the authors consider a symptom only when it peaks? Is pain not pain until it becomes unbearable?

18. Elevation of this triad is also found in prolonged semi starvation, and deficiencies of B-complex vitamins

Pavlos Plessas
Click on the image for author information

19. These changes are characteristic of individuals who are physically ill, as the subjects were

Yes, but in the beginning they did not know that they were ill (no clinical signs). Besides, there is another study which indicates that “behavioural change in human scurvy patients has a physiological rather than a solely psychological basis” (6). And there is a suggested biological explanation. “Vitamin C is a cofactor in the biosynthesis of catecholamines, most notably in the conversion of dopamine to norepinephrine, which may explain the behavior and mood disorders associated with vitamin C deficiency” (7). “Acutely hospitalized patients experience emotional distress for many reasons; therefore, it may seem unexpected that simple correction of their vitamin C deficiency could account for such rapid and dramatic improvements in psychological well-being. There are several reasons why this possibility merits serious consideration. First, the result is biologically plausible. Psychological dysfunction is known to occur in vitamin C deficiency, presumably because of the involvement of ascorbate in neuronal transmission and in brain neurotransmitter and fuel metabolism.” (8)

20. Vesalius’ reaction was normal in the view of many passengers getting sick, dying and being thrown overboard

Did all the passengers start begging the crew not to throw their dead bodies overboard? Did Boucherus do it? Why did he then only report Vesalius doing it? Was it normal behaviour for a distressed 16th century aristocrat to beg lowly-born sailors?

21. The only known symptoms of Vesalius are consistent with many other diseases

I think the best way for someone to debunk the scurvy theory is to make a list of diseases that could have killed Vesalius. It appears that the authors do not consider it too great a challenge. But these diseases have to be compatible with the circumstances and the authors will have to do considerably better than the suggestion of food poisoning.

22. Vesalius died from exhaustion combined by illness

All sources agree that Vesalius died from an illness. He had gone through an ordeal, he was probably malnourished and dehydrated to some extent but there is no evidence of exhaustion. He was sick, not tired. He was a passenger on a ship, not a galley slave. The crew, who worked around the clock, were fine. The only exhaustion was that of his reserves of Vitamin C.

23. In order to have a definite diagnosis, it will be important to locate the grave of Andreas Vesalius

Amen. I have one more reason to wish it than most of the many people who wish Theo and Pascale good luck in the search for the grave. I expect to be vindicated. And I hope that maybe my work will contribute in the beyond doubt identification of Vesalius’ remains..

PERSONAL NOTE: My thanks to all the authors who are part of this ongoing discussion and who are also friends and contributors to this blog. Everybody is correct in the fact that the only way to find the truth of the cause of death of Andreas Vesalius is to find his grave. The quest is ongoing and hopefully we are closer every day to this objective. Dr. Miranda

Sources:

1. "Voyages and Travels in the Levant in the Years 1749, 50, 51, 52" London 1766, p. 147
2. "Medicina Nautica: an Essay on the Diseases of Seamen" Volume III, London 1803, p. 387
3. "De magnis Hippocratis" Lienibus Libellus, Antwerp 1564, pp. 26a – 31b
4. A voyage round the world in the years MDCCXL, I, II, III, IV, 5th edition, London 1749, p. 101.
5. Robert A. Kinsman and James Hood, Some behavioral effects of ascorbic acid deficiency, The American Journal of Clinical Nutrition, April 1971.
6. Fiona E. Harrison, Behavioural and neurochemical effects of scurvy in gulo knockout mice, Journal for Maritime Research, Volume 15, Issue 1, 2013.
7. Olivier Fain, Musculoskeletal manifestations of scurvy, Joint Bone Spine 72, 2005.
8. Wang et al, Effects of vitamin C and vitamin D administration on mood and distress in acutely hospitalized patients, the American Journal of Clinical Nutrition, 2013.

NOTE:  In 2014  Pavlos Plessas presented the compelling theory that Andreas Vesalius died in 1564 from scurvy on the island of Zakynthos. With his permission his original article entitled "Powerful indications that Vesalius died from scurvy" was published in this blog in 2016.

His theory was later challenged by Theo Dirix and Dr. Rudi Coninx in this same blog with the article "Did Andreas Vesalius really died from scurvy?". Pavlos Plessas' rebuttal to the latter article is published here from a letter to Theo Dirix.

8. Echtius’ treatise was only published after his death in 1556

This is incorrect. Echtius was alive almost a decade after that and heard Boucherus describe Vesalius’ death with his own ears. The treatise was first published in 1564, the year of Vesalius’ death, albeit was wrongly attributed to Wierus.

9. Echtius believed scurvy was caused by a blocked spleen, leading to an excess of black bile

Echtius believed that an excess of black bile (melancholic humour) caused scurvy. He wrote that in addition to eating preserved foods and mouldy biscuit, and drinking foul water, the following conditions led to an excess of black bile: warm air, lack of sleep, hard manual work, anxiety and fevers. Each one individually could cause scurvy even if the diet was good . The reasons for Vesalius’ illness as indicated by the sources are: eating rotten biscuit, drinking corrupt water, hot weather and extreme worrying. Please compare with the list of causes given by Echtius in his treatise.

10. It is claimed that extreme fear and irrational behaviour … are well known early symptoms [Plessas]. This is not the case

Pavlos Plessas
Click on the image for author information

11. This (absence of extreme fear and irrational behaviour) is also the observation of one of the authors (RC) having observed scurvy patients in Ethiopian prisons

Did any of Dr. Coninx’s patients see other inmates die from scurvy? Did he ever observe one of his patients witness an accident? Were his patients evaluated by a psychiatrist? I would hazard the guess that the answer to all the questions is no. I choose to believe Rev. Richard Walter.

12. The Italian Pietro Bizzari based his account on what he had been told by an anonymous Venetian goldsmith

Bizzari’s account is not credible. It clashes with the accounts of three different people, who saw Vesalius’ grave in Santa Maria delle Grazie.

13. Metellus describes the symptoms of Vesalius’ illness

No, he does no such thing.

14. The possibility of rotten food as a cause of death on the ship is plausible

I hope this is not a suggestion that a great physician like Vesalius could not recognise the symptoms of food poisoning in others. If he did, it would have been possible to identify the particular source and he would not have fallen ill himself. Even if that was not possible they could have resorted to sharing the supplies of the crew, who had suffered no cases of illness. Surely it is best to be malnourished than risk death from food poisoning. In addition, had the cause of death been food poisoning, the sources would not have blamed Vesalius’ worrying for his illness. Finally, since the authors seem to agree that Metellus’ version of events is the most reliable, how is it possible for a man on the verge of death from food poisoning to be walking on the seashore of Zakynthos? Food poisoning as a cause of death is not plausible even though the sources claim the disease was somehow related to food and water shortage.

15. A 1971 study by Kinsman and Hood which allegedly claims that personality changes are amongst the first symptoms of scurvy

Why allegedly? I quote from the study: The personality changes occurred at an earlier stage of depletion than the psychomotor changes, which did not appear until obvious clinical scurvy was present (5). So the study does claim that personality changes are amongst the first symptoms of scurvy, the very first as a matter of fact. According to figure 3 of the study the MMPI T-scores started increasing when the level of Vitamin C in the body was at the equivalent of 761 mg. Clinical signs of scurvy became apparent only when the level went down to 300 mg. 

Sources:

1. "Voyages and Travels in the Levant in the Years 1749, 50, 51, 52" London 1766, p. 147
2. "Medicina Nautica: an Essay on the Diseases of Seamen" Volume III, London 1803, p. 387
3. "De magnis Hippocratis" Lienibus Libellus, Antwerp 1564, pp. 26a – 31b
4. A voyage round the world in the years MDCCXL, I, II, III, IV, 5th edition, London 1749, p. 101.
5. Robert A. Kinsman and James Hood, Some behavioral effects of ascorbic acid deficiency, The American Journal of Clinical Nutrition, April 1971.
6. Fiona E. Harrison, Behavioural and neurochemical effects of scurvy in gulo knockout mice, Journal for Maritime Research, Volume 15, Issue 1, 2013.
7. Olivier Fain, Musculoskeletal manifestations of scurvy, Joint Bone Spine 72, 2005.
8. Wang et al, Effects of vitamin C and vitamin D administration on mood and distress in acutely hospitalized patients, the American Journal of Clinical Nutrition, 2013.