Medical Terminology Daily - Est. 2012

Medical Terminology Daily (MTD) is a blog sponsored by Clinical Anatomy Associates, Inc. as a service to the medical community. We post anatomical, medical or surgical terms, their meaning and usage, as well as biographical notes on anatomists, surgeons, and researchers through the ages. Be warned that some of the images used depict human anatomical specimens.

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A Moment in History

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]

Marcia Noyes handwriting

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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This article was written by Claudio Rodrigo Molina, Josefa Catalán Lobo, and Carolina Becker Fehlandt. We thank them for their contribution to Medical Terminology Daily.

Lateral view, the arrow shows the location of the azygos lobe
Lateral view


The azygos lobe, also commonly referred to as the" accessory lobe of the azygos vein", was first described in 1877 by Heinrich Wrisberg. It is seen in 0,4 % of chest X-rays; 1,5% in high resolution CT, and 1% in anatomical dissections. It is not a true accessory pulmonary lobe as it does not have its own bronchus and does not correspond to a specific bronchopulmonary segment, the “azygos lobe”, is located at the apicomedial portion of the upper right lobe and it separated from the remainder of the upper lobe by a fissure (Denega et al, 2015; Özdemir et al, 2017)

A convex-shaped fissure is created by the course of the vein bearing towards the medial side of the right lung to join with the superior vena cava. Its formation is a result of an unusual embryogenic migration of the posterior cardinal vein; which is a precursor of the azygos vein (Denega et al, 2015).

Instead of sliding over the lung medially, the vein invaginates into the parenchyma of the lung and becomes enveloped by layer of pleural folds, forming a mesentery-like structure, also called “mesoazygos”. Further migration into the lung as it passes towards the right hilum creates a convex semicircular fissure with the vein located at the base of the fissure. This fissure can be identified in an X-ray chest image as a coma-shaped (“Teardrop sign”) or curved linear shadow in the paramediastinal region of the right lung; it terminates at the level of second costal cartilage (Akhtar et al, 2018; Caceres et al, 1993). The lower portion of the azygos fissure is teardrop-shaped and its contains the azygos vein (Özdemir et al, 2017; Kotovet al, 2017).

Instead of sliding over the lung medially, the vein invaginates into the parenchyma of the lung and becomes enveloped by layer of pleural folds, forming a mesentery-like structure, also called “mesoazygos”. Further migration into the lung as it passes towards the right hilum creates a convex semicircular fissure with the vein located at the base of the fissure. This fissure can be identified in an X-ray chest image as a coma-shaped (“Teardrop sign”) or curved linear shadow in the paramediastinal region of the right lung; it terminates at the level of second costal cartilage (Akhtar et al, 2018; Caceres et al, 1993). The lower portion of the azygos fissure is teardrop-shaped and its contains the azygos vein (Özdemir et al, 2017; Kotovet al, 2017).

Anterior view, the arrow shows the location of the azygos lobe
Images provided by the authors.
Click on the image for a larger depiction


The pathway of the vein within the lung is subject to individual variation, and this defines the position of the fissure within the apex of the upper lobe. The most superior portion of the fissure adopts a triangular form, called the trigone. The localization of the trigone determinates the size of the azygos lobe (Caceres et al, 1993; Fuad & Mubarak, 2016 ). A Left azygos lobe has been reported, but it is extremely rare (Özdemir et al, 2017)

Diagnosis of the azygos lobe may be complicated by morphologic variants of the fissure, physiological changes in the size of vein, and the projection of additional shadows within the lobe which may be misinterpreted as scar tissue, a calcified area of a post-infection process, or a malignant tissue or nodule.

It usually has no clinical implications and is an incidental finding in images but the azygos vein may undergo physiological variations, reflected by changes in the size of its shadow and its position in the imaging studies. Expiration, the Valsalva maneuver, or the upright position effect on the venous return to the heart, may enhance the size of the vein and its shadow. Changes in intrathoracic pressure may result in the “empty azygos fissure” phenomenon, in which the medial displacement of the azygos vein occurs after the reexpansion of the collapsed lung, secondary to pneumothorax or pleural effusion as well as a shortened mesoazygos.

In rare cases the azygos veins may undergo variceal changes that are usually located in the arc of the vein. They remained asymptomatic or may be accompanied by a “pressure like” or “tightness” sensation within the chest, recurrent hemoptysis with bright red blood dry cough and dyspnea. The initial differential diagnosis includes acute myocardial infarction, aortic dissection and myocarditis. On the chest X-ray it may present as a round or oval paratracheal shadow with a smooth surface or outline. Untreated, it may predispose the patient to the risk of rupture, thrombosis, or pulmonary embolism. Azygos thrombosis is extremely rare and most cases in the literature had an undelaying azygos dilation or some prothrombotic status like malignancy. In all lung tissue some pathological process can originate in the azygos lobe as bullous, bronchiectatic changes, pneumonia and tuberculosis. (Kotov et al, 2018; Denega et al, 2015)

Otherwise, it seems the mesoazygos fold serve as a barrier to dissemination of the infection or malignant cells.

For thoracoscopic procedures, recognition of the azygos lobe is particularly important as it can cause partial obstruction of the surgical site view during thoracoscopic sympathectomy. In the literature, two cases have been reported where the phrenic nerve was coursing within the azygos fissure (Kauffman et al, 2010; Pradhan, 2017; Özdemir et al, 2017; Paul, Siba & James, 2018)

Thoracic surgeons as well as treating physicians need to be aware of this rare anatomical variation.

NOTE: For an explanation of the etymology of the word "azygos" click here.

Sources:

1. Akhtar, Jamal & Lal, Amos & B. Martin, Kevin & Popkin, Joel. (2018). Azygos lobe: A rare cause of right paratracheal opacity. Respiratory Medicine Case Reports. 23. 10.1016/j.rmcr.2018.02.001.
2. Caceres, Jennelyn & Mata, Jonathan & Alegret, X & Palmer, J & Franquet, T. (1993). Increased density of the azygos lobe on frontal chest radiographs simulating disease: CT findings in seven patients. AJR. American journal of roentgenology. 160. 245-8. 10.2214/ajr.160.2.8424325.
3. Denega T, Alkul S, Islam E, Alalawi R. (2015). Recurrent hemoptysis - a complication associated with an azygos lobe. The Southwest Respiratory and Critical Care Chronicles, [S.l.], v. 3, n. 11, p. 44-47. ISSN 2325-9205.
4. Fuad, A.R., & Mubarak (2016). Two Cases of Azygos Lobe with Normal and Aneurysmal Azygos Vein on Computed Tomography. Int J Anat Res 2016, Vol 4(1):1843-45. ISSN 2321-4287
5. Kauffman, Paulo & Wolosker, Nelson & De Campos, José Ribas & Yazbek, Guilherme & Biscegli Jatene, Fábio. (2010). Azygos Lobe: A Difficulty in Video-Assisted Thoracic Sympathectomy. The Annals of thoracic surgery. 89. e57-9. 10.1016/j.athoracsur.2010.03.030.
6.Kotov G, Dimitrova I N, Iliev A, et al. (2018). A Rare Case of an Azygos Lobe in the Right Lung of a 40-year-old Male. Cureus 10(6): e2780. doi:10.7759/cureus.2780