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A Moment in History 

Title page of Anathomia Corporis Humanis by Mondino de Luzzi. Image courtesy of the National Library of Medicine
Title page of "Anathomia Corporis Humanis" by Mondino de Luzzi

Alessandra Giliani

 
(1307 – 1326

Italian prosector and anatomist. Alessandra Giliani is the first woman to be on record as being an anatomist and prossector. She was born on 1307 in the town of Persiceto in northern Italy.

She was admitted to the University of Bologna circa 1323. Most probably she studied philosophy and the foundations of anatomy and medicine. She studied under Mondino de Luzzi (c.1270 – 1326), one of the most famous teachers at Bologna.

Giliani was the prosector for the dissections performed at the Bolognese “studium” in the Bologna School of Anatomy. She developed a technique (now lost to history) to highlight the vascular tree in a cadaver using fluid dyes which would harden without destroying them. Giliani would later paint these structures using a small brush. This technique allowed the students to see even small veins.

Giliani died at the age of 19 on March 26, 1326, the same year that her teacher Mondino de Luzzi died.  It is said that she was buried in front of the Madonna delle Lettere in the church of San Pietro e Marcellino at the Hospital of Santa Maria del Mareto in Florence by Otto Agenius Lustrulanus, another assistant to Modino de Luzzi.

Some ascribe to Agenius a love interest in Giliani because of the wording of the plaque that is translated as follows:

"In this urn enclosed are the ashes of the body of 
Alessandra Giliani, a maiden of Persiceto. 
Skillful with her brush in anatomical demonstrations 
And a disciple equaled by few, 
Of the most noted physician, Mondino de Luzzi, 
She awaits the resurrection. 
She lived 19 years: She died consumed by her labors 
March 26, in the year of grace 1326. 
Otto Agenius Lustrulanus, by her taking away 
Deprived of his better part, inconsolable for his companion, 
Choice and deservinging of the best from himself, 
Has erected this plaque"

Sir William Osler says of Alessandra Giliani “She died, consumed by her labors, at the early age of nineteen, and her monument is still to be seen”

The teaching of anatomy in the times of Mondino de Luzzi and Alessandra Giliani required the professor to be seated on a high chair or “cathedra” from whence he would read an anatomy book by Galen or another respected author while a prosector or “ostensor” would demonstrate the structures to the student. The professor would not consider coming down from the cathedra to discuss the anatomy shown. This was changed by Andreas Vesalius.

The image in this article is a close up of the title page of Mondino’s “Anothomia Corporis Humani” written in 1316, but published in 1478. Click on the image for a complete depiction of this title page. I would like to think that the individual doing the dissection looking up to the cathedra and Mondino de Luzzi is Alessandra Giliani… we will never know.

The life and death of Alessandra Giliani has been novelized in the fiction book “A Golden Web” by Barbara Quick.

Sources 
1. “Books of the Body: Anatomical Ritual and Renaissance Learning” Carlino, A. U Chicago Press, 1999 
2. “Encyclopedia of World Scientists” Oakes, EH. Infobase Publishing, 2002 
3. “The Biographical Dictionary of Women in Science”Harvey, J; Ogilvie, M. Vol1. Routledge 2000 
4. “The Evolution of Modern Medicine” Osler, W. Yale U Press 1921 
5. “The Mondino Myth” Pilcher, LS. 1906 
Original image courtesy of NLM
 


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Epistaxis

The medical term [epistaxis] refers to a “nose bleed”.

It is considered to be a Modern Latin term that originates from the Greek word [επίσταξη(epístaxí). The word is composed of [επί] [epi-] meaning "on", "upon", or "above", and [στάζει] (stázei), meaning "in drops", "dripping".

The term was first used by Hippocrates, but only as [στάζει] , to denote dripping of the nose, and was later changed to [επίσταξηto denote “dripping upon”. The term itself does not include or denote that the blood loss is from the nose, but its meaning has been implied and accepted for centuries. The plural form for epistaxis is epistaxes.

Skinner (1970) says that the term was first used in English in a letter by Thomas Beddoes (1760-1808) in a letter to Robert W. Darwin (1766-1848) in 1793. Robert Darwin was an English physician, father or Charles Darwin (1809-1882) author of “The Origin of the Species”.

Sources:
1. "The Origin of Medical Terms" Skinner, HA 1970 Hafner Publishing Co.
2. "Medical Meanings - A Glossary of Word Origins" Haubrich, WD. ACP Philadelphia 

Note: The links to Google Translate include an icon that will allow you to hear the pronunciation of the word.


Kiesselbach's plexus

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.

Kiesselbach's plexus
Click on the image for a larger view

There is a secondary area where epistaxis may happen, but this is a venous nose bleed. This is Woodruff's plexus, a venous plexus found in the posterior aspect of inferior turbinate on the lateral wall of the nose. 

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


Halsted’s “Rules of Surgery”

In my many years working with medical industry, surgeons, and surgery, I have heard many times that such and such surgical technique follows “Halsted’s Rules of Surgery”. The problem is that only two of these “rules” were mentioned and never did I receive an answer while working with Ethicon and Ethicon Endosurgery, and never did I receive an answer as to where could I find the reference regarding the other rules, if they even existed.

I recently read a great 1957 book by Samuel James Crowe, MD (1883-1952), titled “Halsted of John Hopkins; the man and his men”. Dr. Crowe lived for one year with Dr. William Stewart Halsted (1852-1922) and his wife as a medical student at John Hopkins. He was also an intern for Dr. Harvey Cushing, and although he wanted to follow Cushing into neurosurgery, Dr. Halsted placed him in charge of the newly created department of otolaryngology at John Hopkins, a position he did not want. Dr. Crowe went on to become a world-wide renown otolaryngologist.

Here are Halsted’s “Rules of Surgery” as explained by Dr. Crowe, based on Halsted’s research, experiments, and observations (with my own notes and comments):

1. Wounds are resistant to infection when no bits of tissue have been:

a. torn with clamps 
b. torn by the rough handling of retractors 
c. devitalized by hastily and carelessly applied ligatures

HalstedWilliam S. Halsted
mouseover for
Samuel J. Crowe

Note: this follows the ancient rule of “primum non nocere”: first and foremost, do not harm

2. Wounds or parts rich in blood vessels usually heal without any visible granulation, even when no antiseptic precautions have been taken.

3. Incisions should be closed carefully and gently, layer by layer

4. The approximating sutures should never put the tissues under tension, since tension interferes with the blood supply and may cause necrosis

Note: Tension-avoidance surgical techniques follow this, one of the prime rules of surgery.

5. The end of the forceps used to pick up bleeding points should be small, to avoid crushing and destroying the vitality of surrounding tissues

Note: This observation led to the creation of fine, multiple toothed thumb forceps used today in cardiovascular surgery , such as the Cooley, DeBakey, Castaneda, etc. type forceps.

6. A drain is essential when there is necrotic tissue and infection

7. Silk should never be used in the presence of infection

Note: This makes sense. Since silk is an organic material, infected tissues will react to the presence of this extraneous material causing more inflammation, and the phagocytic cells in the tissues will destroy the silk and its capacity to hold the tissues together

8. The silk (suture) employed should never be coarser (larger gauge) than necessary and it is well to employ a suture a thread that is not stronger that the tissue it holds

9. A greater number of fine stitches is better than a few coarse ones

Note: This also makes sense. Halsted was known to be extremely meticulous and he could place a hundred stitches of fine silk thread where other surgeons would place a lesser number of coarser stitches. Using a larger number of fine stitches distributes the approximating tension of the sutures over a larger area, thus reducing the chance for suture dehiscence.

10. Avoid when possible the combined use of silk and catgut in a wound

11. For sewing up an abdominal wound, when it is necessary to take heavy deep stitches perforating skin and muscles, silver wire serves admirably

Note: Remember the times when these guiding principles where laid. Nylon, polypropylene, and other synthetic absorbable and non-absorbable sutures had yet to be discovered. Today the same dictum would probably say “For sewing up an abdominal wound, when it is necessary to take heavy deep stitches perforating skin and muscles, a synthetic non-absorbable suture material serves admirably”

It must be noted that Halsted never called the above the “rules of surgery”, rather they are observations that have become guiding principles. These have influenced the world of surgery to this day.

SIDE NOTE: It has been said many times that Dr. Halsted was the first to use rubber gloves. This is not true, Dr. Crowe says that “it was an evolution rather than a happy thought” and it involved his wife Caroline Hampton. This will be the subject of another article.


Interesting discoveries in a medical book


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.

As important as the books themselves are, there are details beyond the book itself that can take hours of my time doing research. The first one is the bookplates (also known as Ex-Libris). The have been used  for centuries by book owners and collectors to identify the books in their collections, a tradition that seems to be falling in disuse. Not me, I have one that you can see here. Some of these can lead to places that you cannot imagine initially. One of these bookplates took me to research a potential resident ghost in a library!

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 Robert Thompson, MD. There is a copy of a letter by Dr. Ephraim McDowell to him 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
Letter from Ephraim McDowell to Robert Thompson
Click on the image for a larger depiction

There is a note from Dr. Cecil Striker to "Bob" dated 6/3/73 when he gifted a copy of this book to Dr. Thompson. In the note Dr. Striker explains that he bought several copies of the book and he is sending this copy to him. There is also a copy of Dr. McDowell's prayer (costs 25 cents), and a page of the Kentucky Advocate newspaper published in Danville, KY and dated Sunday April 15, 1973 on the restoration of Dr. Alban Goldsmith, a surgeon who assisted Dr. McDowell in his first ovariotomy (first in the world, that is).

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

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.  

Rudi Coninx

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


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.To search all the articles in this series, click here.

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.

Kiesselbach