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A Moment in History

Giovanni Domenico Santorini

Giovanni Domenico Santorini
(1681 – 1737)

Italian anatomist, Santorini was born in 1681 in Venice. The son of an apothecary, Santorini studied medicine at Bologna and Padua, receiving his doctorate in Pisa in 1701. He was appointed Public Professor of Anatomy at the Physicomedical College of Medicine when he was 22 years of age.

Santorini was praised for the clarity of his lectures and his dexterity as an anatomist.  He used magnifying glasses to study minute anatomical details, allowing him to clearly describe small structures hitherto unknown. Most of Santorini’s biographical data was written by Michael Girardi (1731 – 1797), one of his students. Girardi published Santorini’s work posthumously in 1775 in the book “Anatomici Summi-Septendecim Tabulae”.

Santorini’s himself wrote “Opuscula medica de structura” (Minute Medical Structures) in 1705. His most important book was “Observationes anatomicae”, published in Venice in 1724. One of the most interesting chapters in this book was “De mulierum partis procreationes datis” (Data on the female procreational structures ), making him a pioneer in the teaching of obstetrics. Santorini was physician to the Spedaletto (Hospital) of Venice, where he taught midwifery.

Santorini died in 1737 because of an infection he acquired during the dissection of a cadaver. At that time the rationale for infection and cadaver embalming were unknown.

With his posthumous publications, Santorini’s name and teachings became popular. Today his name is eponymically tied to several structures in the human body:

• Duct of Santorini: An accessory pancreatic duct that opens into a secondary duodenal papilla in the second portion of the duodenum
• Santorini’s valves: Mucosal folds found in the lumen of the primary duodenal papilla (of Vater) or hepatopancretic ampulla
• Santorini’s muscle: Risorius muscle • Santorini’s cartilages: The laryngeal corniculate cartilages
• Santorini’s veins: A plexus of vesicoprostatic veins found in the retropubic space) of Retzius
• Santorini’s concha: The superior nasal turbinate

Sources:
1. “The Dorsal Venous Complex: Dorsal Venous or Dorsal Vasculature Complex? Santorini’s Plexus revisited” Power NE, et al. BJU Inter (2011) 108: 930-932
2. “Giovanni Domenico Santorini: Santorini’s Duct” Edmonson, JM Gastrointest Endosc (2001) 53:6; 25A
3. "Santorini of the duct of Santorini" Haubrich, WS  Gastroenterol 120:4, 805
4. “Wirsung and Santorini: The Men Behind the Ducts” Flati, G; Andren-Sandberg, A. Pancreatology (2002)2:4-11
5. "A Historical Perspective: Infection from Cadaveric Dissection from the 18th to the 20th Centuries" Shoja, MM et al. Clin Anat (2013) 26:154-160

Original image courtesy of National Library of Medicine.


 "Clinical Anatomy Associates, Inc., and the contributors of "Medical Terminology Daily" wish to thank all individuals who donate their bodies and tissues for the advancement of education and research”.

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Sternal angle (of Louis)

UPDATED:The sternal angle is the term used to denote the angulation at the  joint between the manubrium and the body of the sternum. This transverse joint is called the "manubriosternal joint" and is a secondary cartilaginous joint of a type known as a symphysis. The angle varies between 160 and 169 degrees.

It is know eponymously as the "angle of Louis" named after Antoine Louis1 (1723-1792), a French physician. The importance of the sternal angle is that of an anatomical superficial landmark, which forms a horizontal plane which indicates a series of anatomical occurrences, as follows:

• Location of the cartilages of the second rib
• Beginning and end of the aortic arch
• Boundary between the inferior and superior mediastinum
• Location of the bifurcation of the trachea
• Posteriorly, the plane of the sternal angle passes trough the T4-T5 intervertebral disc
• Highest point of the pericardial sac, etc.

Sternal angle - Angle of Luis

Click on the image for a larger version.

Thoracic anatomy, pathology and surgery, are some of the many lecture topics developed and presented by Clinical Anatomy Associates, Inc.

1. Some authors contest the eponym, adjudicating it to Pierre Charles Alexander Louis (1787-1872), another French physician.
Image property of: CAA.Inc.. Artist: David M. Klein

In Search of Andreas Vesalius The Quest for the Grave, Lost and not yet found

My partner in crime and fellow traveler, Theo Dirix, has just published a new account of our common quest for the lost grave of Andreas Vesalius. Until the scientific results of our latest mission in Zakynthos in September 2017, will become public, this collection of articles published since 2014 represents a detailed and complete status quaestionis of a search that will never be the same anymore.


I'm proud and grateful to be part of a team he describes a most tenacious.

Following is a remarkable quote from the book: "The beast you have in your hands may appear as aged and stubborn: indeed, the texts collected here are not new and they regularly echo each other. The beast barks and growls: these words do not intend to examine or research but were meant to sell a project to potential sponsors. I feel the taste of the creature’s spit in my face, but pleading not guilty to any accusation of self-glorification, I do hope I managed to teach it a few tricks you will enjoy. While continuing to write about Vesalius’s death and his grave, black dogs may still be scratching at my hermitage. When I will finally throw open the doors to the beauty beyond, here’s hoping the encounter with the female spider will taste as fresh as a first kiss and be the beginning of something else."

No surprise some have described the book as: "a truly captivating story (a Live Adventure!) written in a fascinating, passionate and inspiring way. Theo Dirix, with his unique style is describing facts from his adventure to locate the grave of Vesalius and he is mentioning with great respect all his collaborators, the friends of Vesalius and those who share the same passion for Anatomy and Art." (Vasia Hatzi on Med in Art).

Cover of the book by Theo Dirix
Cover of the book by Theo Dirix.
Click on the image for a larger depiction

The book can be ordered here: https://www.shopmybooks.com/US/en/book/theo-dirix-32/in-search-of-andreas-vesalius. (English version of the website). More information about the author on his website www.theodirix.com. or here.


Personal note: Thanks to Pascale Pollier, a contributor to this website, for allowing us to publish this article, originally published on Vesalius Continuum.

I received a personalized copy from the author, Theo Dirix; Thank you very much for the recognition and the use of this website as reference in some of your comments. It is a great read for anyone even mildly interested in the life and specially the death and disappearance of the grave of Andreas Vesalius. There are several passages in the book that I will have to research and transform in articles for this blog.

For those who collaborated in the GoFundMe campaign because or our article entitled Do you want your name in a book? The Quest for the Lost Grave.... this is the book and the name of all the contributors are listed in it! 

The quest continues... Dr. Miranda


Coumadin ridge

The [Coumadin ridge], also known as the [Warfarin ridge], or a [left atrial pseudotumor]. is an excessive elevation or protrusion of a normal ridge found between the left superior pulmonary vein and the internal ostium of the left atrial appendage. Usually this ridge will extend inferiorly towards and anterior to the ostium of the left inferior pulmonary vein. The Coumadin ridge is considered an anatomical variation of the otherwise small ridge, which is nameless.

Because of its location and morphology, some cardiologists and radiologists have mistaken this elevation or fold of the internal anatomy of the left atrium for a thrombus and prescribed anticoagulant therapy (Coumadin or Warfarin) when none was needed, hence its name.

Pes anserinus. Image courtesy of Primal Pictures
Click on the image for a larger version
To understand the generation of the Coumadin ridge we must understand the embryology of this area of the heart. The left atrial appendage is the original left atrium in the embryo, which is displaced anteriorly and superolaterally when the veins that enter the atrium start to dilate at their distal end creating the left sinus venarum. After the left atrium proper has formed, the left atrial appendage is left as nothing more than an embryological remnant that can cause problems if the patient has atrial fibrillation (AFib). The ridge forms at the point where the left atrial appendage and the sinus venarum meet.

The Coumadin ridge can vary in morphology, from presenting as an elevated ridge, to a bulbous, pedunculated mass that seems to float within the left atrial appendage and undulate, following the cardiac motion, forcing the cardiologist into believing they are in the presence of a thrombus or a tumor within the heart.

This fold of tissue may contain the ligament of Marshall, autonomic nerves, and a small artery. In rare cases there may be an actual tumor arising from the location of the Coumadin ridge, but this is just a coincidence.

Now that the Coumadin ridge is a better known anatomical variation, cardiologist sometimes refer to their finding as a pseudotumor, a description that may scare the patient, but is only but a fold of tissue inside the heart.

Finding a Coumadin ridge in a patient with atrial fibrillation can be an interesting situation requiring differential diagnosis, as a patient with AFib can present with thrombi in the left atrial appendage. What to do? Is it or is it not a thrombus? Also, a differential diagnosis is needed in the case where the image is actually that of a left atrial tumor or an atrial myxoma.

The accompanying image an own work based on Sra (2004) and McKay (2008), and is a graphite on paper sketch. The image shown an internal view of the left atrium showing the left superior and inferior pulmonary vein, the ostium of the left atrial appendage and a segment of the area of the mitral valve.

We would like to thank Dr. Randall K Wolf, a contributor to Medical Terminology Daily for suggesting this article.

Sources:
1. “Coumadin ridge: An incidental finding of a left atrial pseudotumor on transthoracic echocardiography” Lohdi,AM, et al. World J Clin Cases. 2015 Sep 16; 3(9): 831–834
2. “Coumadin ridge” Tasco, V. https://radiopaedia.org/articles/coumadin-ridge
3. “Papillary fibroelastoma arising from the coumadin ridge” Malik, M, Shilo, K, Kilic,A. J Cardiovasc Thorac Res. 2017;9(2):118-120.
4. “‘Coumadin ridge’ in the left atrium demonstrated on three dimensional transthoracic echocardiography” McKay,T., Thomas, L. Europ J Echocard (2008) 9, 298–300
5. “Endocardial imaging of the left atrium in patients with atrial fibrillation” Sra J; Krum D; Okerlund D; Thompson H. J Cardiovasc Electrophysiol 2004 Feb; Vol. 15 (2), pp. 247


HOUSTON AFib PATIENT EXPERIENCE SEMINAR


If you arrived to this article looking for information on Atrial Fibrillation, you will find some in this article. If you need to contact Dr. Wolf, please click here.


HOUSTON AFib PATIENT EXPERIENCE SEMINAR

Saturday, April 21st, 2018 9am – 4pm
Westin at Memorial City, 945 Gesner Rd.
Houston, TX 77024
877-900-AFIB (2342)

This seminar is free and open to the public. To attend, please call the telephone number to register.

WELCOME MESSAGE FROM DR. RANDALL WOLF

In my experience over the last 18 years as a physician who specializes in the treatment of Atrial fibrillation (AFib), I have learned AFib sufferers want two things: Hope and a chance to feel better.

The first step to hope and to feeling better is to self educate. Learn about the latest medications, techniques and devices to treat AFib. Ask questions. Get a second opinion. Take charge of your health.

The purpose of the Houston AFib Patient Experience Seminar is to help AFib sufferers like you take charge of your health.

rwolfmf sm
About 30 million people worldwide carry an AFib diagnosis. Today seems everyone either has AFib or knows someone that has AFib. When I first held an Afib seminar in Beijing, China, over 1200 people with AFib signed up for the seminar. It was standing room only!

Despite the common occurrence of AFib around the world, a recent study found that in patients who were diagnosed with AFib, 40-50% of patients with an elevated risk of stroke were not treated with the best therapy, and the rate of stroke over the next five years was 10%.

Here in Houston, we can do better! Learn more about AFib right here today, and I guarantee you will have hope and be more likely to reach your goal of feeling better.

Towards an AFib free healthy life,

Randall K. Wolf, MD.


SEMINAR AGENDA

9:00 am     Introductions -  Randall Wolf, MD, FACS, FACC, Professor at McGovern Medical School, Cardiothoracic Surgery, Course Director for the AFib Patient Experience Seminar

9:15 am      The cost of AFib

9:30 am     Mechanisms

9:45 am     Blood Thinners – W. Ross Brown, MD, FACC, Comprehensive Heart Care, PA

10:15 am   Medications – Sunil Reddy, MD, Assistant Professor at McGovern Medical School, Cardiovascular Medicine

10:30 am   BREAK

10:45 am   Diet – Baxter Montgomery, MD, FACC, Clinical Assistant Professor of Medicine, McGovern Medical School, Department of Cardiology

11:00 am   Sleep Apnea – Murtuza Ahmed, MD, FAASM, Razzack and Associates, Houston

11:15 am   AF Monitoring – Sunil Reddy, MD, Assistant Professor at McGovern Medical School, Cardiovascular Medicine

11:30 am   Questions with panel

12 noon      LUNCH

Testimonials: Donna Roth, Houston, TX Gary Wight, Houston, TX Mac Peirson, Houston, TX Ross Wroblewski, Lompac, CA Michaela Senk-Eustace, Hartford, CT

1:00 pm     Catheter Ablation – Siddharth S. Mukerji, MD, Assistant Professor at McGovern Medical School, Cardiovascular Medicine

1:30 pm     Surgery – Randall Wolf, MD, FACS, FACC

2:00 pm     Stop AFib.org – Mellanie True Hills, President

2:30 pm     Panel Discussion

2:45 pm     Stroke – Ritvij Bowry, MD, Assistant Professor at McGovern Medical School, Vivian L. Smith Department of Neurosurgery

3:00 pm     LAA Closure – Siddharth S. Mukerji, MD, Assistant Professor at McGovern Medical School, Cardiovascular Medicine & Randall Wolf, MD, FACS, FACC

3:30 pm     Panel Discussion

4:00 pm     Adjourn – Meet with Faculty


ABOUT THE HOUSTON AFIB PATIENT EXPERIENCE SEMINAR

The University of Texas McGovern Medical School, Cardiothoracic and Vascular Surgery Department in Houston, is proud to host the inaugural Houston AFIB Patient Experience Seminar. The purpose is to educate the public in an interactive format allowing the audience to engage in conversation in a question/answer format with leading medical professionals. Our list of panel members and guest presentations include surgeons, cardiologists, neurologists, pulmonologists as well as testimonials from AFib patients. We are honored to be able to bring awareness to the resources and options available to patients suffering from AFIB.

NOTE: If you cannot attend the seminar, there is more information on Atrial Fibrillation at this website; click here.

 

Atrial fibrillation

What is atrial fibrillation?

Atrial fibrillation (AFib) is one of the most common heart conditions, affecting 4% of the adult population. Characterized by a rapid, irregular heartbeat, AFib is largely due to abnormal electrical impulses that cause the atria of the heart to quiver when it should be beating steadily. Blood flow is reduced and is not completely pumped out of the two small upper chambers of the heart, the atria.  This negatively impacts cardiac performance and also allows the blood to pool and potentially clot. At rest, a normal heart rate is approximately 60 – 100 beats per minute.  In a person with AFib, that heart rate can skyrocket to 180 bpm or even higher.  Thorough testing by your health care provider can spot abnormalities in the heart's rhythm before any obvious symptoms are noticed.

What are the symptoms?

EKG - Atrial Fibrillation, courtesy Dr. Randall K Wolf
Click on the image for a larger view

Whether it is caused by stress, exercise, or too much caffeine, most people experience a racing heart from time to time.  Most cases are harmless, but AFib is a serious medical condition that may often be long lasting.  Some people with AFib experience no symptoms at all.  But for others,  AFib may cause:

    Exercise intolerance
    Fatigue
    Severe shortness of breath
    Chest pain
    Palpitations
    Light-headiness

What causes atrial fibrillation?

Your heart is divided into four chambers: the two upper chambers called atria, and two lower chambers called ventricles. In order for blood to be pumped through your body, a group of specialized cardiac cells, the conduction system of the heart,  sends electrical impulses to the atria that tells your heart to contract. Contractions of the heart send approximately five quarts of blood through your body every minute. In people with AFib, however, the impulses are sent chaotically. The atria quiver instead of beat; the blood isn't completely pumped out and may pool and potentially clot.

Are you at risk?

Your chances of developing AFib increase with age.  AFib occurs more commonly in women than in men.  According to the Framingham Heart Study (http://circ.ahajournals.org/cgi/content/full/110/9/1042), AFib is associated with a higher risk of death for women than for men. You are also at greater risk of developing AFib if you suffer from an overactive thyroid, high blood pressure, a prior heart attack, congestive heart failure, valve disease or congenital disorders.

Diagnosis

AFib can sometimes be diagnosed with a stethoscope during an exam by a doctor or other health care provider and is confirmed or diagnosed with an electrocardiogram (EKG). There are several types of EKG’s. They are:

Resting EKG – Electrical activity in the heart is monitored when a person is at rest.
Exercise EKG – Activity is monitored when a person jogs on a treadmill or exercises on a stationary bike.
24-hour EKG (Holter Monitor) – A person wears a small, portable monitor that detects activity over the course of a day.
Transtelephonic event monitoring – A person wears a monitor for a period of a few days to several weeks. When AF is felt, the person telephones a monitoring station or activates the monitor's memory function. This type of EKG is particularly useful in detecting AF that occurs only once every few days or weeks. Unfortunately this type of monitor does not record heart events while you are sleeping.

The image on this article is a typical EKG AFib recording showing the flutter of the atria followed by the ventricular contraction. In the larger image (click on the image of the article) you can see how this fluttering of the atria causes an abnormal spacing of the ventricular contractions which some patients feel in their chest.

PERSONAL NOTE:Dr. Wolf will lecture on a seminar on this topic on April 21st, 2018 in Houston, TX. For more information on this event and on AFib, click here.

Thanks to Dr. Randall Wolf for the image and links
 

An analysis of a letter from Dr. Ephraim McDowell (1829)


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 seems to have 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,

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

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.