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Relations Links and Connections

The Common Vein copyright 2009

?No man is an island, entire of itself;

every man is a piece of the continent,  a part of the main. ?

John Donne?s ?Meditation XVII: ? Devotions upon Emergent Occasions?

In the introduction to parts we touched on the profound importance of organization, connection and integration.  The only way that ?units to unity? can materialize is through strong and meaningful connections.  This concept applies not only to the parts of the body but also to pieces of information.  Information in isolation is meaningless.  It is through connections and integration that information becomes knowledge.

The manner in which the parts are connected and related is the key to the genius of biology.  The connection of the knee bone to the thigh bone, the thigh bone to the pelvis and the pelvis to the sigmoid shaped spine, allowed homo sapiens to evolve into an upright animal, and liberated the upper limbs.  The upright posture, together with an advanced brain, afforded man the opportunity to develop tools, manipulate his environment, and think.  Thus humans were afforded a huge advantage in the biological environment.

At the molecular end of the spectrum, the exact pattern in which nucleic acids adenine, guanine, thymine and cytosine are sequenced or connected on DNA strands  an individual?s genetic fate.

At the cellular level the 250 billion cells of the liver need to be connected related and integrated in a way that enables them to act as a single unit, as the metabolic warehouse of the body.  The world population is currently (April 2009) estimated at a mere 6.8 billion.  The ability of nature to organize 250 billion cells into a single harmonious group is a lesson to be learned and an amazing story to be told.

For the liver to function, it is imperative that the transport systems be in intimate contact with cells in order that food, oxygen, and water are transposed and that waste products are removed.  Two hundred and fifty billion cells of the liver need to be connected, related, and integrated in a way that they are able to act as a single functional unit.  The elegant organization of liver cells and cords in the liver lobule was described in the section on Parts above.  The key element for the cell is how it can be connected to structures it depends on. The cells of each organ deal with this problem in a different way.  Therefore, when studying the histology of the gastrointestinal tract, the pancreas, or the lung, note will be made of differing organizational patterns that optimize function.  These patterns are relevant not only to marvel at the genius of nature, but also to understand that when disease distorts the structure, function will suffer.

At societal level, human connections are vital for the health of the individual and of society. An elderly patient whose children and grandchildren have moved out of state, and who lives alone, becomes disconnected from the pulse of life and society.  For the patient, incorporation into peer groups and into the mainstream is essential for well being and health.

The knowledge of how structures are physically and functionally connected forms the basis of clinical symptoms and signs.   Examination of the brain is carried out by examining the sensory organs and muscles. Consider a patient brought to the Emergency Room by a family member with a chief complaint of  expressive aphasia (inability to express), also called Broca?s aphasia .  ?We were eating dinner and suddenly he had difficulty speaking.  He seems to know and understand what I am saying but he cannot express himself? she explains.  Acute onset expressive aphasia usually occurs as a result of a stroke or a vascular accident (often thrombosis) in a branch of the middle cerebral artery that supplies the dominant hemisphere of the brain (left brain for dominant right handed people).  The involved artery supplies the insula and frontoparietal operculum.  The physician should immediately take a look at the patients face. The muscles of the face are controlled by inferior frontal gyrus, and a droop of the facial muscles, best seen as a droop of the right upper lip places the disease in the inferior frontal branch of the middle cerebral artery.   The experienced physician greets the patient with a warm smile and may elicit a return smile, at which time this droop is more easily appreciated.  Extending a hand to the patient for a handshake may reveal weakness in the hand or upper limb. The art of medicine is invoked in a warm and non provocative way by connecting the presenting problem with its relevant connections in the patient?s nervous system.  In addition, appropriate diagnostic connections and actions are invoked in the thought processes and actions of the physician.  The senses of the physician should be bristling all the time, with eyes and ears open to all and any clues, and reactions that are connected, integrated, respectful, kind, thoughtful and meaningful.

The Pulse

Examining the pulse, with its direct connection to the heart is another obvious example where the examination of one structure is truly the examination of a second connected structure.  The pulse has a history based in ancient medicine.  The Yellow Emperor Huang Ti of China (2698-2598 BC) understood that the pulse could be influenced by emotion. It is palpated with three fingers, and its evaluation was considered an art form linking it to the heart, kidney and liver.  The finger that assesses the pulse closest to the hand connects to the heart, while the middle part of the pulse relates to connection with the liver, and the most proximal to the kidney.

Hippocrates (460-370BC), the father of medicine introduced the concept of clinical inspection and observation. He was known to take the pulse of the patient while taking a history, but did not elucidate any overt connections.  According to Vesalius, Herophilus of Chalcedon (about 280BC) had major influence on the use of the pulse to diagnose disease, and made the observation that the pulse was not an innate characteristic of the arteries but was related to the heart.

There is a touching story of the pulse of a young lustful man, had relevance in history.  Erasistratus from Ioulis (about 310-250BC) served as court physician to King Seleucus I who was one of Alexander the Great?s commanders and a founder of the Seleucid dynasty.  King Seleucus had married a young and beautiful princess named Stratonice.  After the marriage the king?s son Antiochus fell ill and Erasistratus was asked to determine the cause of the disease.  Erasistratus noted that the pulse of the young prince (among other symptoms of passion) accelerated every time the beautiful princess, wife of his father, walked into the room.  Erasistratus cleverly and kindly explained to King Seleucus the of the cause of his son?s malady and the malady was solved by the king giving up his wife and his kingdom of all the provinces of upper east Asia to his son. Plutarch?s commentary on the event is a marvel to read, and a painting by Jacques-Louis David, 1774 ?Erasistratus Discovering the Cause of Antiochus? Disease? is equally enthralling to behold. http://www.mlahanas.de/Greeks/Erasitratos.htm

A similar story is told about Galen (130- 200AD)  (William Osler ? The Evolution of Modern Medicine see http://www.mlahanas.de/Greeks/Erasitratos.htm) who was summoned to evaluate a young woman who suffered from profound malaise.  On examination by Galen there was neither fever nor change in her pulse.  While he was chatting with her, with his finger on her pulse, he noted that her rate increased and became irregular when the conversation drifted to an actor called Pylades.  He concluded that she was suffering the same malady as Antiochus, son of King Seleucus.

Both these stories describe the connections of the mind, the autonomic nervous system, the heart and the pulse.

Galen wrote 18 books on the pulse. Connecting disease with the pulse, he described a ?pulsus celer?, collapsing pulse indicating a wide pulse pressure, due perhaps to aortic regurgitation or perhaps high output failure, and ?pulsus tardus?,  a slow rising pulse, indicating  perhaps aortic stenosis.  Other colorful examples include pulsus myurus (like a rats tail), pulsus caprizans with a double impulse, (like the leap of a goat), and pulsus formicans resembling the movement of an ant, indicating the weak and thready pulse of hypotension.  (Fleming)

The modern examination of the pulse has been enhanced and advanced by application of the sphygmomanometer, pressure transducers, and echocardiography.  These devices are routinely used to assess heart disease, and are far more accurate than palpation. Unfortunately they have superseded the art of pulse examination at the bedside. However, when faced with an acute situation, such as a person suddenly dropping to the ground, evaluation of the pulse is a rapid, useful, and sometimes lifesaving diagnostic maneuver.  Basic CPR demands an ABC approach:  Airway, Breathing, and Circulation.  The Circulation is assessed by feeling the pulse, and evaluation of the pulse will determine the next step.  A slow pulse, commonly implies a vagal reaction, or faint, and is often associated with pallor, sweatiness, and a complaint prior of nausea and dizziness or faintness.  In this instance the findings connect to an excess parasympathetic tone, or vagal reaction, also called a vasovagal reaction.  This reaction slows  the heart and also causes the veins to dilate, so insufficient blood returns to the heart which is already slowing.  The circulation becomes insufficient, and the patient faints due to lack of sufficient blood flow to the brain.   The first step is to lay the person down so that the blood does not have an additional uphill battle to get to its destination.  The second is to elevate the legs in order to empty the dilated veins of the pooled blood and return it to the heart, so there is more available for the heart to pump into the brain.   The return to a normal heart rate is accompanied by improvement in the patient?s symptoms.

If on the other hand, no pulse is felt when a patient suddenly collapses, then cardiac arrest is diagnosed, meaning an abrupt failure of pump function.  The most common cause includes ventricular fibrillation and ventricular tachycardia, which are responsive to defibrillation.  Other causes are less common and include asystole and pulseless electrical activity, which are not responsive to defibrillation.

The fact that the heart is connected to the arteries, allows the clinician to examine the pulse, and gain insight into the health of the heart. In early times this connection was not understood.  Today it is involved in basic lifesaving techniques.

Connections and connectedness are essential to biological structure. Bonds and bonding in the molecular environment are elemental and extend through all of biology and society.  The pathological equivalent of disconnectedness ranges from the simple to the complex.  Disconnectedness in the clinical world may be congenital or acquired.  Transposition of the aorta is a congenital abnormality where the aorta is connected to the wrong ventricle.  Survival is impossible if the disorder is not surgically corrected.  Acquired disconnectedness occurs in easily treated traumatic dislocation of a joint, but can be life threatening in traumatic rupture of the aorta.  Loss of connections to society occurs to many unfortunate individuals and societal awareness to this problem needs to be heightened.  Biology depends on strong and meaningful connections.

Principles

Positive and Negative
84154b04.698 positive and negative extreme states black and white Davidoff art Davidoff MD
Bonds Links Connections Atoms Molecules
70983.800 molecules atoms bonds links connections relations collage Davidoff art

At the Cellular Level

John Donne a clergyman and poet from the renaissance period stated that ?? No man is an island ??  In the same way no cell, organ, body or community is an island.  Each is connected and dependant on the other members of the society in which they live.  They are connected both structurally and functionally. 

Positioning of Liver Cells in Cords ? Reticulin Bond

The cells of the liver are organized in cords and plates and are organized like spokes of a wheel  around the central vein. The plates and cords are lined by the sinusoids which are the channels which carry blood to the liver.  Just below the sinusoids, between the wall of the sinusoid and the capsule of the liver there is a space called the space of Disse which carries the lymphatic fluid of the liver.   (Image courtesy of Barbara Banner M.D.) 13236
Holding the Lung Cells Together
Normal lung-  Lower magnification Note cup-shaped alveolar spaces outlined by delicate thin alveolar capillary membrane. Courtesy Armando Fraire MD. 32819 code lung pulmonary normal alveolus alveoli histology interstitium interstitial
Link between Liver Lobule and the Body ? The Hepatic Vein
13009 W I 13 liver + portal triad lobule + anatomy histology portal vein bile duct hepatic artery central vein hepatic vein Davidoff art

 

 

Bonds Cement Bridges Joints Interstitium Connective Tissue Ligaments Sutures Vessels

Skin and Muscle of the Buttock

Note the linear and parallel orientation of the muscle fibres of the gluteus muscles (charcoal) and the reticular pattern of the connective tissue of the skin of the buttock (light gray)

70885.800 skin muscle gluteus buttock folds skin interstitium connective tissue vessels links bonds connections MRI coronal view Davidoff MD

 From Head to Toe

From Head ? Coronal Suture ? Starting at the Top
46304b01 bone skull suture shape CTscan Davidoff art
To Toes ? The Phalangeal Joints
46712b01 bone foot feet phalanges interphalangeal joints metatarsophalangeal joints normal anatomy applied biology X-ray plain film Davidoff MD

 Vessels Nerves and Lymphatics ? The Cables

Cardiovascular System
32368b05.800 cardiovascular system heart cardiac artery arteries capillary capillaries arterioles venules veins negative firces positive forces road highway TCV the common vein applied biology Davidoff art Davidoff MD
Aorta Renal Arteries Iliacs and Lumbar Arteries
10254 Davidoff MD

Arterial Connections to Brain Cells
46352b19.800 head brain blood supply internal carotid artery branches circle of Willis MRA 3D TOF Davidoff MD normal anatomy tree of knowledge Davidoff tree Davidoff art
Veins From the Tip of the Fingers to the Tip of the Toes ? Connected
10392.800 vein arm basilic valve Davidoff MD
Veins and Valves
26032d.800 vein tube valve flow normal anatomy Davidoff MD
The Nerves ? Cauda Equina
46523.800 spinal cord cauda equina nerves anatomy applied biology normal Davidoff MD

Organs Connecting

Gastrointestinal Tract  ? Esophagus to Stomach to Small Bowel to Colon
45920.800 Courtesy Ashley Davidoff MD
Bones Connecting and Linking- Protection
49640 bone rib thoracic spine spinous processes scapula protection support CTscan volume rendering Davidoff MD

People Connecting

Spines Bonding ? Nerves on Edge
46570c05.800 man woman lovers spine backbone Davidoff art

Family

The Wedding  ? The Family
A large family wedding with 12 children. Note the complexion of the groom is completely different to bride?s and her family. Genetics goes deeper than we know, and the good and the bad surface t intermittantly. However there is no telling when this will occur or become phenotypic.Davidoff phtography. 68494
Friends
The red sweats ? the motto on the shirt ?You ?re here- there?s nothing I fear? ? 82084pb01.800 Davidoff photography
Team
71216.800 soccer team people uniform link connections unity united DAvidoff photography
Bonding in Defence of Rights
84015p.800 Lincoln Massachusetts Minuteman State PArk Reenactment of the days of the Revolution America circa 1775 army link connections bonds defence offence war men army gun horses Boston Davidoff photography

Other Biological Units Connecting

Other Units Connecting 

A Farm ? Links to The Earth ? Mountains Farms and Walls in Peru
0178.800 Peru farm wall units to unity mountains vertical agriculture food the common vein applied biology Davidoff photography Davidoff MD
Highways Byways and Waterways for the City
32165 code RS pulmonary lung alveolus arteriole venule epithelium drawing gas exchange anatomy physiology histology83557.800 highways waterways reservoirs storage stations factories homes transport systems bus cars Davidoff photography
System of Wires Nerves and Autonomic Ganglia
In this scene of Johannesburg taken from the highway, we can view the vital lines of electrical energy that are essential to maintain the city. In the distance we see the city that the electrical lines serves.  We also see other elements that have biological equivalents.  ? the fence that protects and prevents and forms a border between the highway and the property of the homes that reside on the other side.  An old goldmine dump to the left of the picture ? the tall post office tower for communication and a host of office buildings for collaborative effort. 57692 city electricity air energy essential community need Johannesburg South Africa fence capsule tcv the common vein Davidoff photography

83925 elctricity node ganglion nerve control telephone cable box

Links and Connections in Disease

Disease of One Causes Disease of the Other

Chronic Infarction Right Temporal Lobe and Right Occipital Lobe

? atrophy of the brain leads to a pull on the ventricles
71419c01.800 74 female with h/o ataxia incontinence memory loss brain cerebrum right PCA territory right posterior cerebral artery posteromedial aspect of right temporal lobe medial and inferior aspect of the right occipital lobe gliosis volume loss atrophy ex vacuo changes dilatation of temporal and occipital horns of the lateral ventricles dx old chronic infarction CTscan MRI a = Ctscan b = DWI c= sagittal T1 weighted d ? T2 weighted e = FLAIR f = FLAIR coronal Davidoff MD

An Obvious Dislocation

No Subtelties about this One 

Following a fall this young patient has an obvious dislocation of the elbow joint.  A dislocation reflects an abnormal position as well as an aberrant connection or link between the three structures ? humerus, radius and ulna.

aberrant connection72041.800 elbow bone olecronon fracture humerus ulna radius fx dislocation position trauma plain X-ray Davidoff MD