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Jacques Bénigne Winslow (1669-1760) and the Misnomer Cavernous Sinus
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Jacques Be´nigne Winslow (1669-1760) and the Misnomer Cavernous Sinus
Key words Cavernous - Neuroanatomy - Parasellar -
Abbreviations and Acronyms ICA: Internal carotid artery From the 1Department of Neurosurgery, Louisiana State University for Medical Sciences, Shreveport, Louisiana, USA; and 2Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA To whom correspondence should be addressed: Anil Nanda, M.D., M.P.H. [E-mail: [email protected]] Citation: World Neurosurg. (2014) 81, 1:191-197. http://dx.doi.org/10.1016/j.wneu.2012.06.030 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2014 Elsevier Inc. All rights reserved.
Sinus cavernosi, or the cavernous sinus, was coined by Jacques Bénigne Winslow in the 18th century. Among the neurosurgeons and the modern-day neuroanatomists, Winslow is mainly known for erroneously using the term cavernous sinus. As the anatomical understanding of the parasellar space advanced during the next 200 years, it was unclear as to why Winslow compared this space in the brain with that of a male reproductive organ (corpus cavernosum). Our primary objective was to study the historical treatise on anatomy written by Winslow in the 18th century and analyze his anatomical dissections and nomenclature for the parasellar compartment. In addition, his pertinent contributions to neuroscience are highlighted in this vignette.
translation of Winslow’s 1732 descriptive treatise entitled An Anatomical Exposition of the Structure of the Human Body (Exposition anatomique de la structure du corps humain; Figure 2) (21, 23). His other pertinent contributions to neuroscience are also highlighted in this vignette.
THE PARASELLAR COMPARTMENT BEFORE WINSLOW Claudius Galen (130-200/219 AD), who served as a physician to gladiators, transferred his knowledge of anatomy gained through dissecting animals to human beings (10, 13, 18). His description of the parasellar compartment as “a parasellar
INTRODUCTION The parasellar compartment, more commonly known as the cavernous sinus, represents a challenging neurosurgical domain. Dr. Dwight Parkinson, who helped lay the foundation for approaching lesions to the parasellar compartment, appropriately described it as the anatomical jewel box (13). Understanding neuroanatomy and neighboring structures was critical for the evolution of neurosurgical approaches. Revisiting the historical figures who contributed to the understanding of the parasellar anatomy, one recalls Jacques Bénigne Winslow (Figure 1). He coined the term sinus cavernosi in the 18th century (12, 13, 17). Winslow is known for erroneously using the word cavernous sinus. As the anatomical understanding of the parasellar space advanced during the next 200 years, it became unclear as to why Winslow compared this space in the skull to the male reproductive organ (corpus cavernosum) (12, 13, 17). Was his contribution to neuroanatomy restricted only to coining a misnomer? Why did he study this area when his contemporaries neglected the anatomical jewel box? To address these questions, we reviewed the English
Figure 1. Jacques Be´nigne Winslow (1669-1760). Professor of Anatomy, Physiology, and Surgery. Image courtesy of History of Medicine section, National Library of Medicine.
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Figure 2. Exposition anatomique de la structure du corps humain is the descriptive anatomical treatise published by Jacques Be´nigne Winslow in 1732. Image courtesy of Google books available in public domain.
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LEGACY Figure 3. Raymond de Vieussens (1641-1715) apparently gave the first description of the parasellar compartment as a “receptacle.” Image courtesy of the History of Medicine section, National Library of Medicine.
carotid retia bathed in venous blood” persisted for more than 15 centuries. Surprisingly, the great renaissance anatomist
WINSLOW AND THE CAVERNOUS SINUS
Andreas Vesalius (1514-1564) did not describe the parasellar space in his famous treatise De humani corporis fabrica’ (3, 10, 13, 19). He followed the Galenic concepts of the cranial nerves with no mention of the trochlear or abducens nerves. He considered the trigeminal nerve as the third and fourth cranial nerves (6). Raymond de Vieussens (1641-1715), a French anatomist from Saint Eloys in Montpellier (Figure 3), was the first anatomist to appreciate the parasellar area as a well-defined space (4, 10). He named it “receptacle” in his popular treatise on the brain and spinal cord, Neurographica universalis, published in 1684 (4, 20). Vieussens is best known for describing novel concepts in cardiac anatomy, physiology, and pathology. Dr. A. E. Best, in his work Pourfour du Petit’s Experiments on the Origin of the Sympathetic Nerve, described the raw understanding Vieussens had of the cranial nerves entering the receptacle located besides the “Turkish saddle” (sella turcica) (4, 10, 20). Sadly, his contributions to neuroanatomy did not gain much attention. Humphrey Ridley (1653-1708), published in 1695 the first anatomical treatise in English, The Anatomy of the Brain
Containing Its Mechanisms and Physiology: Together With Some New Discoveries and Corrections of Ancient and Modern Authors Upon That Subject (14). James T. Goodrich mentions that Ridley did his anatomical dissections on freshly executed criminals. Ridley injected cadaveric heads with wax and mercury to highlight the minute anatomical structures (8). He used these heads to study the venous anatomy of the parasellar compartment and their communication through the circular sinus (aka “Ridley’s sinus”). His description of the internal carotid artery (ICA) within the parasellar space did not include the presence of other tissues (10). WINSLOW’S CAVERNOUS SINUS Winslow introduced the word cavernous sinus into textbooks with this description: “The cavernous or lateral sinuses of the Os Spenoides are reservatories of a very particular kind, containing not only blood but considerable vessels and nerves, as we shall see thereafter; and likewise a spongy or cavernous substance full of blood, much like that of the spleen or corpus cavernosum..” (23). Winslow’s written
Table 1. Winslow’s Perception of the CN and the ICA in Relation to the Cavernous Sinus (23) Description CN III
“. They pierce the Dura mater behind the lateral parts of the posterior apophysis of the sella sphenoidalis and pass afterwards each in the neighboring Sinus Cavernosi, by the side of the carotid artery and all the way to the broad portion of the superior orbitary fissure .”
CN IV
“The fourth pair called Nervi Trochleares, Musculares Obliqui Superiores, and most commonly Pathetici are very small and tender and in proportion very long. They arise each behind the Tubercula Quadrigemina . where on each side they enter the duplicature of the dura mater and advancing into the sinus cavernosi, they accompany the third pair to the superior orbitary fissure.”
CN V
“The fifth pair called Nervi Innominati or Trigemini are at first large trunk arising chiefly from the lateral and posterior parts of the great transverse protuberance and a little from the corpora olivara and pyramidalia. They run down obliquely forward on the extremity of the upper or anterior side of the apophysis petrosa, very near the side of the sella sphenoidalis, where they enter the duplicature of the dura mater and sinus cavernosi. At their entry into the sinus, they form kind of flat irregular ganglion, from which some filaments are sent off to the dura mater and immediately afterwards each of them is divided is divided into three great branches . . The first branch which may be termed Ocularis or Ophthalmicus, accompanies the nerves of the third and fourth pairs, to the superior orbitary fissure ..”
CN VI
“. They arise partly from the oblong inferior Eminences, immediately behind the transverse protuberance . they pierce the dura mater behind the occipital symphysis of the sphenoidal bone. They run on each side in the duplicature of the dura mater to the cavernous sinus and having entered the sinus, each of them accompanies the first branch of the fifth pair to the superior orbitary fissure. In this course they communicate with the first branch just mentioned and are increased on the forepart by a filament or two, which arise from the great sympathetic nerve, and run up with the carotid.”
Course of the “The internal carotid on each side enters the cranium by the great canalis petrosus, in an angular or winding course..The inner surface of this canal is intracranial lined by a production common to the dura mater and inferior pericranium, to which the artery adheres only by a loose filamentary substance, in which ICA the plexiform filaments run, that belongs to the great sympathetic nerve, commonly called the intercostal. Have passed through the bony canal, it immediately bends upwards towards a notch in sphenoidal bone, and through that notch it enters the cranium. Immediately, after this, it penetrated the Cavernous sinus on the side of the sella sphenoidalis, where having formed a third curvature, it goes out from it, from below, upwards, and is bent a fourth time round the anterior clinoide apophysis, from before backwards. By this course it is in a manner bathed in the blood of the cavernous sinus, together with third, fourth, fifth and sixth pairs of nerves.” CN, cranial nerve; ICA, internal carotid artery.
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trabeculated venous anatomy, he uses an expression “likewise a spongy or cavernous substance full of blood, much like that of the spleen or corpus cavernosum.” Finally, he was criticized for asserting that the ICA was bathed in the blood of the cavernous sinus. In his treatise (23), he explicitly writes that the ICA “in a manner bathed in the blood of cavernous sinus together with third, fourth, fifth and sixth pairs of nerves” (Table 1). The association Winslow made of the trabeculated venous anatomy of the cavernous sinus with that of the intrinsic structure of the spleen remains quiescent. He is better known for relating the parasellar compartment with the corpora cavernosa of the penis; misleading generations of surgeons for more than 200
years. Analyzing the detailed encounter Winslow had with the “cavernous/lateral” sinus, it is evident that the misnomer was popularized more from the subjective interpretation of his treatise. Even though his description of the parasellar space was not precise, there remains no doubt that his anatomical dissections provided the initial building blocks for improving the anatomical understanding of the cavernous sinus.
WINSLOW’S PERSONAL HISTORY Origins Confusion surrounds the birth date of Jacques Winslow, which is reported as
Figure 4. Danish-born Anatomist Neils Stensen, who played a significant role in the anatomical works published by Winslow. Image courtesy of the History of Medicine section, National Library of Medicine.
perceptions of the cranial nerves and the ICA in relation to the cavernous sinus are reproduced in Table 1. Winslow was the third anatomist, after Vieussens and Ridley, to describe the course of trigeminal nerve and its ganglion. Vieussens observed that a swelling in the fifth nerve gave rise to the ramus major anterior and ramus major posterior, but Winslow correctly described that the flat irregular ganglion gave rise to three branches (Table 1) (14, 20). There is no mention of the word trigeminal relating to the fifth nerve before Winslow. Only after he named the fifth cranial nerve, nerf trijmeaux, was it popularized as the trigeminal nerve among the English-speaking scholars (6). In his treatise (23), he expresses his understanding of the intracranial venous sinus as “The dura mater contains in its duplicature several particular canals, into which the venal blood not only of that Membrane, but of the whole brain is carried.” Although Winslow lists cavernous sinus/lateral sinus while enumerating other intracranial sinuses, he clearly notes that it is of a “very particular kind.” To explain the
Figure 5. Illustrations used by Winslow in his treatise were courtesy of Bartolomeo Eustachio, famous anatomist of the Renaissance. Images available from the public domain at: http://gallica.bnf.fr/ark:/12148/ btv1b23006650.
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famous barber-surgeon Johannes de Buchwald. In 1696, because of his brilliance in anatomical dissection, Winslow became the prosector of Caspar Bartholin the Younger (1655-1738; renowned for describing the Bartholin’s duct). Swayed by Winslow’s public anatomical demonstrations, Bartholin promoted him to a prestigious “anatomicus regius” post. Winslow’s initial studies were supported by the legendary astronomer and physicist, Ole Rømer, known for quantifying the speed of light. In 1697, the King of Denmark sanctioned the royal grant in favor of Winslow, allowing him to pursue his studies from the various universities of Europe. He spent 14 months in the Netherlands and then moved to Paris. Professor of anatomy and surgery at Jardin du Roi, Paris, Joseph-Guichard Duverney was regarded as the best-known man in science in the reign of Louis XIV (7). His courses attracted foreign scholars from all parts of Europe; Winslow was among them. In short time, Winslow came into the good favors of Duverney. Although Paris was meant to be a temporary stage of knowledge acquisition for Winslow, it proved otherwise. Against his family wishes, Winslow changed his religious faith from Protestantism to Catholicism; consequently, he lost the financial support from the King of Denmark and his family. Figure 6. Illustrations used by Winslow in his treatise were courtesy of Bartolomeo Eustachio, famous anatomist of the Renaissance. Images available from the public domain at: http://gallica.bnf.fr/ark:/12148/ btv1b23006650.
either April 2, 1669 (7), or April 17, 1669 (16). However, it is clear that he was born in Odense, capital of the Island of Funen located in the middle of Denmark, traversing a region commonly popularized as the “Garden of Denmark.” More than two generations of his family embraced the ecclesiastical ministry. His father, Peder Jacobsen Winslow (real name was Mansen), was the dean of the Protestant Church of Our Lady in Odense. “Winslow” was tagged to his father’s name because he was from the city of Winslöe, a village in the province of Scania, Denmark (which now belongs to Sweden). Martha Nielsdatter Bruun was his mother, whose father had also held the same post as her
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husband. His mother was the great niece of the revolutionary Danish-born anatomist, Neils Stensen (Latinized name: Nicolaus Steno; Figure 4). Early Academics Following in the family tradition, Winslow began his studies of theology at the University of Copenhagen in 1687 and even delivered several sermons. After befriending a medical student and becoming intrigued by his profession, Winslow decided to pursue medicine. His conviction and persistent nature overcame the hesitation of his family, and he was able to attend Borch’s College from 1691 to 1696, where he primarily worked under the
Life in Paris Under the mentorship of Joseph-Guichard Duverney, Winslow was able to continue his medical studies. In addition, JacquesBenigne Bossuet (Bishop responsible for Winslow’s religious transformation) petitioned Louis XIV to grant pension to Winslow to complete his degree of licentiate, which he received on October 4, 1704, at the Hôtel-Dieu hospital. Winslow remained a faithful student of Duverney and served as his assistant in anatomy and surgery at the Jardin di Roi. Only because of Duverney’s personal recommendation was Winslow accepted at the Academy of Sciences, Paris in 1707. He published nearly 30 treatises in anatomy and physiology from 1711 to 1743. His treatise on descriptive anatomy, Exposition anatomique de la structure du corps humain (21) was studied often. Scholars from across Europe travelled to observe his dissections. Among his numerous pupils, one
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Figure 7. King Louis XIV visiting the French Academy of Sciences, where comparative anatomy dissections were performed in the 17th century. Winslow carried out the unfinished work on comparative anatomy of his mentor Joseph-Guichard Duverney. Image courtesy of library of Louisiana State University Health Science Center Shreveport.
highlight was Albrecht von Haller (1708e1777), a Swiss anatomist and physiologist known for his influence and controversy in the history of 18th-century European medicine. Although trained under Bernard Albinus, another famous contemporary of Winslow, Haller admired the in situ dissections skills of Winslow as compared with the former, who removed the organs before dissecting (9). In 1743, Winslow was embraced as a full Professor and the Chair of Anatomy at the Jardin Du Roi. He was in possession of the chairmanship until 1758, when he retired as the result of his severe deafness. Winslow never returned to his native land and remained in Paris throughout his academic career. He married Maria Catharina Gilles in 1711, with whom he had a son and a daughter. Winslow died on April 3, 1760, impoverished, because he chose not to ask for any pension from the King.
Other Contributions of Winslow Exposition anatomique de la structure du corps humain was considered an historical classic preceding the French revolution. The treatise was originally published in French and soon was translated into several languages, including English, Latin, Italian, German, and Belgian (7, 11). In his treatise (23) he clearly acknowledges the source of his inspiration to be Nicolaus Steno, Danish anatomist (and his granduncle; Figure 4) “I conclude by acknowledging with sincere gratitude, that the late N. Steno’s discourse on the Anatomy of the Brain, was the sole original source and general rule of my conduct in all that I have done in Anatomy .” Winslow also included Steno’s dissertation in his descriptive anatomical treatise (23). The artistic nature of anatomical illustrations so distinctive of medieval anatomy was missing in his treatises. The images
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used by Winslow were from Tabulae anatomicae, courtesy of Bartolomeo Eustachio (Figures 5, 6). He mentions in the foreword (23) “With regards to the figures, as I wanted only the original ones drawn according to nature under my eyes, and that the eagerness of some respectable people does not give me all the time necessary to finish the ones that are already in the process of being drawn, I offered to include them in a separate work .” Unfortunately, Winslow was never able to accomplish this task. In contrast to Galen’s silent transference of animal’s anatomy to humans, scientists of the medieval and the postmedieval era paid attention to comparative anatomy. The French Academy of Sciences in 1666 established the Department of Comparative Anatomy (Figure 7). Claude Perrault, a leading architect and anatomist of his time, spearheaded the program. After his death, Joseph-Guichard Duverney took over for couple of decades before the responsibility for comparative anatomy was entrusted in the hands of Winslow (5). Winslow’s contribution to the understanding of the sympathetic nervous system deserves special mention. He observed that the chain of ganglia lying outside the spinal cord between T1 and L2 was connected and may account for unconscious “sympathy” across the different body parts. Therefore, he named the nerves emerging from the ganglia as “nervus sympathicus” (1, 11). Furthermore, while addressing the commencement of intracranial sympathetic fibers, he replaced the expression of “intercostal nerve” by that of “great sympathetic nerve” (Table 1) (1). Acknowledging the physiological functions of facial and vagus nerves, he named them “small” and “middle” sympathetic nerves, respectively. It was initially believed that the internal carotid nerve and its related plexus corresponded to the postganglionic fibers, which, ultimately end in the superior cervical ganglion. Winslow changed the concept and asserted correctly that these fibers do not end; rather, they arise from the superior cervical ganglion (1). Following the work of the renaissance anatomists Andreas Vesalius and Leonardo da Vinci, Winslow published his original work on mobility and function of the spine, where he elaborated on the spinal disk (15). Away from neuroscience, the most significant eponym attached to his name in
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Among his contemporaries and pupils he was known for his modesty, intellectual, and scientific inquisitiveness. He was always regarded as a gentleman who never feared to recognize his errors and who refused to be honored with the discoveries he was not certain (2). CONCLUSION After examining his treatise and understanding it in the light of the science prevalent in the 17th and the 18th centuries, we believe that Winslow’s contributions counteract the criticism leveled against him for his misplaced nomenclature. Given the current microanatomical understanding of the parasellar compartment, the term cavernous sinus is eligible to join the leagues of older terminologies; nevertheless, the work of Jacques Bénigne Winslow on the parasellar compartment in the nonmicrosurgical and non-histological era described the anatomy others would appreciate and continue to study. ACKNOWLEDGEMENTS
Figure 8. Illustration depicted in Winslow’s book The Uncertainty of the Signs of Death and the Danger of Precipitate Interments and Dissections, Demonstrated of a grave robber running away from a corpse that has apparently risen from the grave. Image courtesy of the History of Medicine section, National Library of Medicine.
We thank Ms. Nidhi Setya for her assistance in obtaining the original microfilm copy of Winslow’s treatise from the Texas A & M Evans Library, College Station. We also wish to thank Ms. Talicia A. Tarver for her assistance in collecting the biographical data and images from the Louisiana State University Health Science Center, Shreveport. Of note, all images used in the manuscript are either from the public domain or from books for which copyrights have expired. REFERENCES
accreditation to his discovery is the Foramen of Winslow (i.e., the epiploic or omental foramen). Winslow’s Concern for Premature Burial The postmedieval Europe of the 17th and 18th centuries grappled with the act of premature burial. Instances of people waking up from shrouds were considered ghosts (Figure 8). Winslow wrote in Mortis incertae signa: “It is evident from experience, that many apparently dead, have afterwards proved themselves alive by rising from their shrouds, their coffins and even from their graves.” He realized the fears of being buried alive and said “death is certain, since it is inevitable,
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but also uncertain since its diagnosis is sometimes fallible” (22). He published his treatise in an effort to address the act of premature burial: Dissertation sur l’incertitude des signes de la mort, et l’abus des enterremens, et embaumens précipités. He advocated that the onset of putrefaction should be taken as a convincing sign of death. Although his dissertation had little impact initially, a skilled linguistic French physician, Jacques-Jean Bruhier, translated his treatise into English with a touch of his own flavor and stories: “The uncertainty of the signs of death and the danger of precipitate interments and dissections, demonstrated,” which became immediately popular (22).
1. Ackerknecht EH: The history of the discovery of the vegatative (autonomic) nervous system. Med Hist 18:1-8, 1974. 2. Bariety M, Bréhart J: Winslow’s tercentenary: Bossuet, anatomist and physiologist. Presse Med 77:1491, 1969 [in French]. 3. Benini A, Bonar SK: Andreas Vesalius 1514-1564. Spine 21:1388-1393, 1996. 4. Best AE: Pourfour du Petit’s experiments on the origin of the sympathetic nerve. Med Hist 13: 154-174, 1969. 5. Cole F: A History of Comparative Anatomy From Aristotle to the Eighteenth Century. London: MacMillan and Co; 1944. 6. Flamm ES: Historical observations on the cranial nerves. J Neurosurg 27:285-297, 1967.
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7. Garraud RM: An architect of the French-Danish friendship: Hacques-Bénigne Winslow, a Danish anatomist, professor at the Hardin du Roy de France. Presse Med 63:1589-1590, 1955 [in French]. 8. Goodrich JT: A millennium review of skull base surgery. Childs Nerv Syst 16:669-685, 2000. 9. Janjua RM, Schultka R, Goebbel L, Pait TG, Shields CB: The legacy of Johann Friedrich Meckel the Elder (1724-1774): a 4-generation dynasty of anatomists. Neurosurgery 66:758-770; discussion 770-771, 2010. 10. Newman S: A prospective study of cavernous sinus surgery for meningiomas and resultant common ophthalmic complications (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc 105:392-447, 2007. 11. Olry R: Winslow’s contribution to our understanding of the cervical portion of the sympathetic nervous system. J Hist Neurosci 5:190-196, 1996. 12. Parkinson D: Carotid cavernous fistula. History and anatomy. In: Dolenc VV, ed. Cavernous Sinus. Austria: Springer-Verlag/Wien; 1987:3-29. 13. Parkinson D: Lateral sellar compartment O.T. (cavernous sinus): history, anatomy, terminology. Anat Rec 251:486-490, 1998.
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14. Ridley H: The Anatomy of the Brain Containing Its Mechanisms and Physiology: Together With Some New Discoveries and Corrections of Ancient and Modern Authors Upon That Subject. London: Smith; 1695. 15. Snorrason E: Jacques-Benigne Winsløw and his original research on the mobility and function of the spine. Dan Medicinhist Arbog:9-58, 1995 [in Danish].
21. Winslow J: Exposition anatomique de la structure du corps humain. Paris: aux dépens de la Compagnie; 1732.
22. Winslow J: The Uncertainty of the Signs of Death and the Danger of Precipitate Interments and Dissections, Demonstrated. Dublin: George Faulkner; 1748.
16. Snorrason E: Complete Dictionary of Scientific Biography. Michigan: Charles Scribner’s Sons; 2008.
23. Winslow J: An Anatomical Exposition of the Structure of the Human Body. 3rd ed. Printed for R. Ware, J. and P. Knapton, S. Birt, T. Longman, C. Hitch, C. Davis, and T. Astley; London. 1749.
17. Taptas J: Must we still call cavernous sinus the parasellar vascular and nervous crossroads? The necessity of a definite topographical description of the region. In: Dolenc VV, ed. Cavernous Sinus. Austria: Springer-Verlag/Wien; 1987:30-31.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
18. Toledo-Pereyra LH: Claudius Galenus of Pergamum: surgeon of gladiators: Father of experimental physiology. J Invest Surg 15:299-301, 2002.
Received 23 March 2012; accepted 14 June 2012; published online 18 June 2012
19. Vesalius A: De humani corporis fabrica. Basil: Ex Officina Joannis Oporini; 1543.
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20. Vieussens R: Neurographia universalis. Lyon: Lugduni, Apud Joannem Certe; 1685.
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Citation: World Neurosurg. (2014) 81, 1:191-197. http://dx.doi.org/10.1016/j.wneu.2012.06.030
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Jacques Be´nigne Winslow (1669-1760) and the Misnomer Cavernous Sinus
Key words Cavernous - Neuroanatomy - Parasellar -
Abbreviations and Acronyms ICA: Internal carotid artery From the 1Department of Neurosurgery, Louisiana State University for Medical Sciences, Shreveport, Louisiana, USA; and 2Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA To whom correspondence should be addressed: Anil Nanda, M.D., M.P.H. [E-mail: [email protected]] Citation: World Neurosurg. (2014) 81, 1:191-197. http://dx.doi.org/10.1016/j.wneu.2012.06.030 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2014 Elsevier Inc. All rights reserved.
Sinus cavernosi, or the cavernous sinus, was coined by Jacques Bénigne Winslow in the 18th century. Among the neurosurgeons and the modern-day neuroanatomists, Winslow is mainly known for erroneously using the term cavernous sinus. As the anatomical understanding of the parasellar space advanced during the next 200 years, it was unclear as to why Winslow compared this space in the brain with that of a male reproductive organ (corpus cavernosum). Our primary objective was to study the historical treatise on anatomy written by Winslow in the 18th century and analyze his anatomical dissections and nomenclature for the parasellar compartment. In addition, his pertinent contributions to neuroscience are highlighted in this vignette.
translation of Winslow’s 1732 descriptive treatise entitled An Anatomical Exposition of the Structure of the Human Body (Exposition anatomique de la structure du corps humain; Figure 2) (21, 23). His other pertinent contributions to neuroscience are also highlighted in this vignette.
THE PARASELLAR COMPARTMENT BEFORE WINSLOW Claudius Galen (130-200/219 AD), who served as a physician to gladiators, transferred his knowledge of anatomy gained through dissecting animals to human beings (10, 13, 18). His description of the parasellar compartment as “a parasellar
INTRODUCTION The parasellar compartment, more commonly known as the cavernous sinus, represents a challenging neurosurgical domain. Dr. Dwight Parkinson, who helped lay the foundation for approaching lesions to the parasellar compartment, appropriately described it as the anatomical jewel box (13). Understanding neuroanatomy and neighboring structures was critical for the evolution of neurosurgical approaches. Revisiting the historical figures who contributed to the understanding of the parasellar anatomy, one recalls Jacques Bénigne Winslow (Figure 1). He coined the term sinus cavernosi in the 18th century (12, 13, 17). Winslow is known for erroneously using the word cavernous sinus. As the anatomical understanding of the parasellar space advanced during the next 200 years, it became unclear as to why Winslow compared this space in the skull to the male reproductive organ (corpus cavernosum) (12, 13, 17). Was his contribution to neuroanatomy restricted only to coining a misnomer? Why did he study this area when his contemporaries neglected the anatomical jewel box? To address these questions, we reviewed the English
Figure 1. Jacques Be´nigne Winslow (1669-1760). Professor of Anatomy, Physiology, and Surgery. Image courtesy of History of Medicine section, National Library of Medicine.
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Figure 2. Exposition anatomique de la structure du corps humain is the descriptive anatomical treatise published by Jacques Be´nigne Winslow in 1732. Image courtesy of Google books available in public domain.
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LEGACY Figure 3. Raymond de Vieussens (1641-1715) apparently gave the first description of the parasellar compartment as a “receptacle.” Image courtesy of the History of Medicine section, National Library of Medicine.
carotid retia bathed in venous blood” persisted for more than 15 centuries. Surprisingly, the great renaissance anatomist
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Andreas Vesalius (1514-1564) did not describe the parasellar space in his famous treatise De humani corporis fabrica’ (3, 10, 13, 19). He followed the Galenic concepts of the cranial nerves with no mention of the trochlear or abducens nerves. He considered the trigeminal nerve as the third and fourth cranial nerves (6). Raymond de Vieussens (1641-1715), a French anatomist from Saint Eloys in Montpellier (Figure 3), was the first anatomist to appreciate the parasellar area as a well-defined space (4, 10). He named it “receptacle” in his popular treatise on the brain and spinal cord, Neurographica universalis, published in 1684 (4, 20). Vieussens is best known for describing novel concepts in cardiac anatomy, physiology, and pathology. Dr. A. E. Best, in his work Pourfour du Petit’s Experiments on the Origin of the Sympathetic Nerve, described the raw understanding Vieussens had of the cranial nerves entering the receptacle located besides the “Turkish saddle” (sella turcica) (4, 10, 20). Sadly, his contributions to neuroanatomy did not gain much attention. Humphrey Ridley (1653-1708), published in 1695 the first anatomical treatise in English, The Anatomy of the Brain
Containing Its Mechanisms and Physiology: Together With Some New Discoveries and Corrections of Ancient and Modern Authors Upon That Subject (14). James T. Goodrich mentions that Ridley did his anatomical dissections on freshly executed criminals. Ridley injected cadaveric heads with wax and mercury to highlight the minute anatomical structures (8). He used these heads to study the venous anatomy of the parasellar compartment and their communication through the circular sinus (aka “Ridley’s sinus”). His description of the internal carotid artery (ICA) within the parasellar space did not include the presence of other tissues (10). WINSLOW’S CAVERNOUS SINUS Winslow introduced the word cavernous sinus into textbooks with this description: “The cavernous or lateral sinuses of the Os Spenoides are reservatories of a very particular kind, containing not only blood but considerable vessels and nerves, as we shall see thereafter; and likewise a spongy or cavernous substance full of blood, much like that of the spleen or corpus cavernosum..” (23). Winslow’s written
Table 1. Winslow’s Perception of the CN and the ICA in Relation to the Cavernous Sinus (23) Description CN III
“. They pierce the Dura mater behind the lateral parts of the posterior apophysis of the sella sphenoidalis and pass afterwards each in the neighboring Sinus Cavernosi, by the side of the carotid artery and all the way to the broad portion of the superior orbitary fissure .”
CN IV
“The fourth pair called Nervi Trochleares, Musculares Obliqui Superiores, and most commonly Pathetici are very small and tender and in proportion very long. They arise each behind the Tubercula Quadrigemina . where on each side they enter the duplicature of the dura mater and advancing into the sinus cavernosi, they accompany the third pair to the superior orbitary fissure.”
CN V
“The fifth pair called Nervi Innominati or Trigemini are at first large trunk arising chiefly from the lateral and posterior parts of the great transverse protuberance and a little from the corpora olivara and pyramidalia. They run down obliquely forward on the extremity of the upper or anterior side of the apophysis petrosa, very near the side of the sella sphenoidalis, where they enter the duplicature of the dura mater and sinus cavernosi. At their entry into the sinus, they form kind of flat irregular ganglion, from which some filaments are sent off to the dura mater and immediately afterwards each of them is divided is divided into three great branches . . The first branch which may be termed Ocularis or Ophthalmicus, accompanies the nerves of the third and fourth pairs, to the superior orbitary fissure ..”
CN VI
“. They arise partly from the oblong inferior Eminences, immediately behind the transverse protuberance . they pierce the dura mater behind the occipital symphysis of the sphenoidal bone. They run on each side in the duplicature of the dura mater to the cavernous sinus and having entered the sinus, each of them accompanies the first branch of the fifth pair to the superior orbitary fissure. In this course they communicate with the first branch just mentioned and are increased on the forepart by a filament or two, which arise from the great sympathetic nerve, and run up with the carotid.”
Course of the “The internal carotid on each side enters the cranium by the great canalis petrosus, in an angular or winding course..The inner surface of this canal is intracranial lined by a production common to the dura mater and inferior pericranium, to which the artery adheres only by a loose filamentary substance, in which ICA the plexiform filaments run, that belongs to the great sympathetic nerve, commonly called the intercostal. Have passed through the bony canal, it immediately bends upwards towards a notch in sphenoidal bone, and through that notch it enters the cranium. Immediately, after this, it penetrated the Cavernous sinus on the side of the sella sphenoidalis, where having formed a third curvature, it goes out from it, from below, upwards, and is bent a fourth time round the anterior clinoide apophysis, from before backwards. By this course it is in a manner bathed in the blood of the cavernous sinus, together with third, fourth, fifth and sixth pairs of nerves.” CN, cranial nerve; ICA, internal carotid artery.
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trabeculated venous anatomy, he uses an expression “likewise a spongy or cavernous substance full of blood, much like that of the spleen or corpus cavernosum.” Finally, he was criticized for asserting that the ICA was bathed in the blood of the cavernous sinus. In his treatise (23), he explicitly writes that the ICA “in a manner bathed in the blood of cavernous sinus together with third, fourth, fifth and sixth pairs of nerves” (Table 1). The association Winslow made of the trabeculated venous anatomy of the cavernous sinus with that of the intrinsic structure of the spleen remains quiescent. He is better known for relating the parasellar compartment with the corpora cavernosa of the penis; misleading generations of surgeons for more than 200
years. Analyzing the detailed encounter Winslow had with the “cavernous/lateral” sinus, it is evident that the misnomer was popularized more from the subjective interpretation of his treatise. Even though his description of the parasellar space was not precise, there remains no doubt that his anatomical dissections provided the initial building blocks for improving the anatomical understanding of the cavernous sinus.
WINSLOW’S PERSONAL HISTORY Origins Confusion surrounds the birth date of Jacques Winslow, which is reported as
Figure 4. Danish-born Anatomist Neils Stensen, who played a significant role in the anatomical works published by Winslow. Image courtesy of the History of Medicine section, National Library of Medicine.
perceptions of the cranial nerves and the ICA in relation to the cavernous sinus are reproduced in Table 1. Winslow was the third anatomist, after Vieussens and Ridley, to describe the course of trigeminal nerve and its ganglion. Vieussens observed that a swelling in the fifth nerve gave rise to the ramus major anterior and ramus major posterior, but Winslow correctly described that the flat irregular ganglion gave rise to three branches (Table 1) (14, 20). There is no mention of the word trigeminal relating to the fifth nerve before Winslow. Only after he named the fifth cranial nerve, nerf trijmeaux, was it popularized as the trigeminal nerve among the English-speaking scholars (6). In his treatise (23), he expresses his understanding of the intracranial venous sinus as “The dura mater contains in its duplicature several particular canals, into which the venal blood not only of that Membrane, but of the whole brain is carried.” Although Winslow lists cavernous sinus/lateral sinus while enumerating other intracranial sinuses, he clearly notes that it is of a “very particular kind.” To explain the
Figure 5. Illustrations used by Winslow in his treatise were courtesy of Bartolomeo Eustachio, famous anatomist of the Renaissance. Images available from the public domain at: http://gallica.bnf.fr/ark:/12148/ btv1b23006650.
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famous barber-surgeon Johannes de Buchwald. In 1696, because of his brilliance in anatomical dissection, Winslow became the prosector of Caspar Bartholin the Younger (1655-1738; renowned for describing the Bartholin’s duct). Swayed by Winslow’s public anatomical demonstrations, Bartholin promoted him to a prestigious “anatomicus regius” post. Winslow’s initial studies were supported by the legendary astronomer and physicist, Ole Rømer, known for quantifying the speed of light. In 1697, the King of Denmark sanctioned the royal grant in favor of Winslow, allowing him to pursue his studies from the various universities of Europe. He spent 14 months in the Netherlands and then moved to Paris. Professor of anatomy and surgery at Jardin du Roi, Paris, Joseph-Guichard Duverney was regarded as the best-known man in science in the reign of Louis XIV (7). His courses attracted foreign scholars from all parts of Europe; Winslow was among them. In short time, Winslow came into the good favors of Duverney. Although Paris was meant to be a temporary stage of knowledge acquisition for Winslow, it proved otherwise. Against his family wishes, Winslow changed his religious faith from Protestantism to Catholicism; consequently, he lost the financial support from the King of Denmark and his family. Figure 6. Illustrations used by Winslow in his treatise were courtesy of Bartolomeo Eustachio, famous anatomist of the Renaissance. Images available from the public domain at: http://gallica.bnf.fr/ark:/12148/ btv1b23006650.
either April 2, 1669 (7), or April 17, 1669 (16). However, it is clear that he was born in Odense, capital of the Island of Funen located in the middle of Denmark, traversing a region commonly popularized as the “Garden of Denmark.” More than two generations of his family embraced the ecclesiastical ministry. His father, Peder Jacobsen Winslow (real name was Mansen), was the dean of the Protestant Church of Our Lady in Odense. “Winslow” was tagged to his father’s name because he was from the city of Winslöe, a village in the province of Scania, Denmark (which now belongs to Sweden). Martha Nielsdatter Bruun was his mother, whose father had also held the same post as her
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husband. His mother was the great niece of the revolutionary Danish-born anatomist, Neils Stensen (Latinized name: Nicolaus Steno; Figure 4). Early Academics Following in the family tradition, Winslow began his studies of theology at the University of Copenhagen in 1687 and even delivered several sermons. After befriending a medical student and becoming intrigued by his profession, Winslow decided to pursue medicine. His conviction and persistent nature overcame the hesitation of his family, and he was able to attend Borch’s College from 1691 to 1696, where he primarily worked under the
Life in Paris Under the mentorship of Joseph-Guichard Duverney, Winslow was able to continue his medical studies. In addition, JacquesBenigne Bossuet (Bishop responsible for Winslow’s religious transformation) petitioned Louis XIV to grant pension to Winslow to complete his degree of licentiate, which he received on October 4, 1704, at the Hôtel-Dieu hospital. Winslow remained a faithful student of Duverney and served as his assistant in anatomy and surgery at the Jardin di Roi. Only because of Duverney’s personal recommendation was Winslow accepted at the Academy of Sciences, Paris in 1707. He published nearly 30 treatises in anatomy and physiology from 1711 to 1743. His treatise on descriptive anatomy, Exposition anatomique de la structure du corps humain (21) was studied often. Scholars from across Europe travelled to observe his dissections. Among his numerous pupils, one
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Figure 7. King Louis XIV visiting the French Academy of Sciences, where comparative anatomy dissections were performed in the 17th century. Winslow carried out the unfinished work on comparative anatomy of his mentor Joseph-Guichard Duverney. Image courtesy of library of Louisiana State University Health Science Center Shreveport.
highlight was Albrecht von Haller (1708e1777), a Swiss anatomist and physiologist known for his influence and controversy in the history of 18th-century European medicine. Although trained under Bernard Albinus, another famous contemporary of Winslow, Haller admired the in situ dissections skills of Winslow as compared with the former, who removed the organs before dissecting (9). In 1743, Winslow was embraced as a full Professor and the Chair of Anatomy at the Jardin Du Roi. He was in possession of the chairmanship until 1758, when he retired as the result of his severe deafness. Winslow never returned to his native land and remained in Paris throughout his academic career. He married Maria Catharina Gilles in 1711, with whom he had a son and a daughter. Winslow died on April 3, 1760, impoverished, because he chose not to ask for any pension from the King.
Other Contributions of Winslow Exposition anatomique de la structure du corps humain was considered an historical classic preceding the French revolution. The treatise was originally published in French and soon was translated into several languages, including English, Latin, Italian, German, and Belgian (7, 11). In his treatise (23) he clearly acknowledges the source of his inspiration to be Nicolaus Steno, Danish anatomist (and his granduncle; Figure 4) “I conclude by acknowledging with sincere gratitude, that the late N. Steno’s discourse on the Anatomy of the Brain, was the sole original source and general rule of my conduct in all that I have done in Anatomy .” Winslow also included Steno’s dissertation in his descriptive anatomical treatise (23). The artistic nature of anatomical illustrations so distinctive of medieval anatomy was missing in his treatises. The images
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used by Winslow were from Tabulae anatomicae, courtesy of Bartolomeo Eustachio (Figures 5, 6). He mentions in the foreword (23) “With regards to the figures, as I wanted only the original ones drawn according to nature under my eyes, and that the eagerness of some respectable people does not give me all the time necessary to finish the ones that are already in the process of being drawn, I offered to include them in a separate work .” Unfortunately, Winslow was never able to accomplish this task. In contrast to Galen’s silent transference of animal’s anatomy to humans, scientists of the medieval and the postmedieval era paid attention to comparative anatomy. The French Academy of Sciences in 1666 established the Department of Comparative Anatomy (Figure 7). Claude Perrault, a leading architect and anatomist of his time, spearheaded the program. After his death, Joseph-Guichard Duverney took over for couple of decades before the responsibility for comparative anatomy was entrusted in the hands of Winslow (5). Winslow’s contribution to the understanding of the sympathetic nervous system deserves special mention. He observed that the chain of ganglia lying outside the spinal cord between T1 and L2 was connected and may account for unconscious “sympathy” across the different body parts. Therefore, he named the nerves emerging from the ganglia as “nervus sympathicus” (1, 11). Furthermore, while addressing the commencement of intracranial sympathetic fibers, he replaced the expression of “intercostal nerve” by that of “great sympathetic nerve” (Table 1) (1). Acknowledging the physiological functions of facial and vagus nerves, he named them “small” and “middle” sympathetic nerves, respectively. It was initially believed that the internal carotid nerve and its related plexus corresponded to the postganglionic fibers, which, ultimately end in the superior cervical ganglion. Winslow changed the concept and asserted correctly that these fibers do not end; rather, they arise from the superior cervical ganglion (1). Following the work of the renaissance anatomists Andreas Vesalius and Leonardo da Vinci, Winslow published his original work on mobility and function of the spine, where he elaborated on the spinal disk (15). Away from neuroscience, the most significant eponym attached to his name in
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Among his contemporaries and pupils he was known for his modesty, intellectual, and scientific inquisitiveness. He was always regarded as a gentleman who never feared to recognize his errors and who refused to be honored with the discoveries he was not certain (2). CONCLUSION After examining his treatise and understanding it in the light of the science prevalent in the 17th and the 18th centuries, we believe that Winslow’s contributions counteract the criticism leveled against him for his misplaced nomenclature. Given the current microanatomical understanding of the parasellar compartment, the term cavernous sinus is eligible to join the leagues of older terminologies; nevertheless, the work of Jacques Bénigne Winslow on the parasellar compartment in the nonmicrosurgical and non-histological era described the anatomy others would appreciate and continue to study. ACKNOWLEDGEMENTS
Figure 8. Illustration depicted in Winslow’s book The Uncertainty of the Signs of Death and the Danger of Precipitate Interments and Dissections, Demonstrated of a grave robber running away from a corpse that has apparently risen from the grave. Image courtesy of the History of Medicine section, National Library of Medicine.
We thank Ms. Nidhi Setya for her assistance in obtaining the original microfilm copy of Winslow’s treatise from the Texas A & M Evans Library, College Station. We also wish to thank Ms. Talicia A. Tarver for her assistance in collecting the biographical data and images from the Louisiana State University Health Science Center, Shreveport. Of note, all images used in the manuscript are either from the public domain or from books for which copyrights have expired. REFERENCES
accreditation to his discovery is the Foramen of Winslow (i.e., the epiploic or omental foramen). Winslow’s Concern for Premature Burial The postmedieval Europe of the 17th and 18th centuries grappled with the act of premature burial. Instances of people waking up from shrouds were considered ghosts (Figure 8). Winslow wrote in Mortis incertae signa: “It is evident from experience, that many apparently dead, have afterwards proved themselves alive by rising from their shrouds, their coffins and even from their graves.” He realized the fears of being buried alive and said “death is certain, since it is inevitable,
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but also uncertain since its diagnosis is sometimes fallible” (22). He published his treatise in an effort to address the act of premature burial: Dissertation sur l’incertitude des signes de la mort, et l’abus des enterremens, et embaumens précipités. He advocated that the onset of putrefaction should be taken as a convincing sign of death. Although his dissertation had little impact initially, a skilled linguistic French physician, Jacques-Jean Bruhier, translated his treatise into English with a touch of his own flavor and stories: “The uncertainty of the signs of death and the danger of precipitate interments and dissections, demonstrated,” which became immediately popular (22).
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7. Garraud RM: An architect of the French-Danish friendship: Hacques-Bénigne Winslow, a Danish anatomist, professor at the Hardin du Roy de France. Presse Med 63:1589-1590, 1955 [in French]. 8. Goodrich JT: A millennium review of skull base surgery. Childs Nerv Syst 16:669-685, 2000. 9. Janjua RM, Schultka R, Goebbel L, Pait TG, Shields CB: The legacy of Johann Friedrich Meckel the Elder (1724-1774): a 4-generation dynasty of anatomists. Neurosurgery 66:758-770; discussion 770-771, 2010. 10. Newman S: A prospective study of cavernous sinus surgery for meningiomas and resultant common ophthalmic complications (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc 105:392-447, 2007. 11. Olry R: Winslow’s contribution to our understanding of the cervical portion of the sympathetic nervous system. J Hist Neurosci 5:190-196, 1996. 12. Parkinson D: Carotid cavernous fistula. History and anatomy. In: Dolenc VV, ed. Cavernous Sinus. Austria: Springer-Verlag/Wien; 1987:3-29. 13. Parkinson D: Lateral sellar compartment O.T. (cavernous sinus): history, anatomy, terminology. Anat Rec 251:486-490, 1998.
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14. Ridley H: The Anatomy of the Brain Containing Its Mechanisms and Physiology: Together With Some New Discoveries and Corrections of Ancient and Modern Authors Upon That Subject. London: Smith; 1695. 15. Snorrason E: Jacques-Benigne Winsløw and his original research on the mobility and function of the spine. Dan Medicinhist Arbog:9-58, 1995 [in Danish].
21. Winslow J: Exposition anatomique de la structure du corps humain. Paris: aux dépens de la Compagnie; 1732.
22. Winslow J: The Uncertainty of the Signs of Death and the Danger of Precipitate Interments and Dissections, Demonstrated. Dublin: George Faulkner; 1748.
16. Snorrason E: Complete Dictionary of Scientific Biography. Michigan: Charles Scribner’s Sons; 2008.
23. Winslow J: An Anatomical Exposition of the Structure of the Human Body. 3rd ed. Printed for R. Ware, J. and P. Knapton, S. Birt, T. Longman, C. Hitch, C. Davis, and T. Astley; London. 1749.
17. Taptas J: Must we still call cavernous sinus the parasellar vascular and nervous crossroads? The necessity of a definite topographical description of the region. In: Dolenc VV, ed. Cavernous Sinus. Austria: Springer-Verlag/Wien; 1987:30-31.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
18. Toledo-Pereyra LH: Claudius Galenus of Pergamum: surgeon of gladiators: Father of experimental physiology. J Invest Surg 15:299-301, 2002.
Received 23 March 2012; accepted 14 June 2012; published online 18 June 2012
19. Vesalius A: De humani corporis fabrica. Basil: Ex Officina Joannis Oporini; 1543.
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20. Vieussens R: Neurographia universalis. Lyon: Lugduni, Apud Joannem Certe; 1685.
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