Tag: Ashley Davidoff MD

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Pancreas – Hermit of the Abdomen

Pancreas – Hermit of the Abdomen

Ashley Davidoff MD

O’ Dear pancreas

You have been called the hermit of the abdomen
By whom I do not know
But in your dark and hidden way, you have
spoken without a word
from the gurgling depths of the abdomen
Yes – you have earned this lonely title
and a coin should be tossed
to the person who coined the phrase


 

But it took a long time to understand who this hermit was – and what he was doing in the darkness of the abdomen

From the day of antiquity
You have been looked upon by many
Herophilus, the father of anatomy had the first incisive insights into you
As he was one of very few who had the guts to explore the guts in open fashion

Aristotle at the same time seemed to have known something about you
But then you lay unharmed and unexplored for almost 500 years
Until Rufus mistook you for a piece of meat –
You must have laughed at the “pan kreas” thing
How wrong he was – you evasive little trickster

And then the Talmud – always seeming to be right
Thought you were the finger of the liver –
Little did they know how independant you were

While Vesalius was up to your “hide and seek” game
The magical eyes of da Vinci missed you completely
Even though he saw the serpiginous splenic artery snake right above you

Your ducts seemed to have intrigued the next generation, Wharton, Wirsung, and de Graaf
As you sustained the pain of the quill penetrating your inner gut
(I forget you were already dead but it must of hurt just watching!)

A little later it was that man called Vater and the little Italian Santorini found your minor duct and your nipple
And so by this time we had a good understanding of you in your nakedness
But of course, as said – you were dead

And so young Bernard explored your factories, and got a sense of your canine workings,
But you were able to hold on to your sweet secret for just a little longer
Until the Langerhans found the family jewels in the famous 2% of your population-
The islets – those beautiful eyelits – governess of all things sweet in the body

Eberle Bernard Danilevsky, and Kuhne joined up across the world to expose your antacid and enigmatic enzymatic brew
And once again your wonderful workings for a better world were exposed –
And we knew then, that you were the quiet and effective type –
A hermit who did good
But did not want the limelight

To see you as you lived and breathed in the flesh
was the mission of Wilhelm the X-Ray man
who crusaded the path to visualise 40,000 Angstroms under the skin

 

abdomen, pancreas, liver, gallbladder, kidneys, CT scan, Art in Anatomy, Ashley Davidoff MD

 

And then there was a slew of heroes who learned to slew your sickened parts – including the famous Whipple who was able to Whipple you in an inimitable way

And then a bone guy – for God’s sakes – a bone guy! – called Banting and his student Best
Exposed the insular chemistry of you insulin that had given you the power over the sweet
Never mind – in the end it was for the good of all –
And a new era was borne

And so we try to understand your form as our scans explore you as you live and breathe
And we stare in awe at your odd shape – why oh why did you choose that shape?
What are you supposed to look like? – we have no clue
And we are happy – so happy for you that you are well nourished by a double blood supply
And we wonder why you have no skin – we thought all the organs had a skin
Except for your tail – almost a foreskin

And you are off axis on two planes – what is that all about? – kinda crooked

And your twin origins and the intimacy with the duodenum, of the ventral twin
And the strange fusion of the Wirsung guy excluding the little Italian Santorini
It seems to me that your matrimonial fusion with Wirsung and the bile duct has led to more problems than the merger was worth
It does not seem in the long run, to have been a marriage made in heaven
What was that all about? Is there a grand plan to come?

 

And so we try to understand your diseases
And in some way we understand that the guy glugging down the bottle
Could be punished by your reaction
But why Oh why are you so nasty to those whose misfortune it is to have stones roll down and get no satisfaction.. down the green vile bile route
Have you not learned to live with the green secretion by now
And did you not know that by reacting the way you do, that you are cutting off your nose to spite you head?

While type 2 seems remote from you
We don’t know about this Type 1 business
Why are you made to suffer so much at the hands of your own body on your own body?
We feel sorry for you – to have your own buddies reject you – must be awful
And then to see so many young ones suffer because you don’t work
And we once again see and understand what power you control from that deep dark hermit home of yours

And the cancer thing … so silently it creeps on you causing your collagen to counter
And only making things worse as it strangles nerve, blood vessel, and your spouse duct – the green one, – without regard

And then I think of you in your prime and in your happiness
When you are with you two buddies – the splenic vein and the renal vein
And you all look so much alike, and happy swimming in that deep ocean where you hide
And I wish this was forever

 

 

Copyright 2017 Revised from previous publication in The Common Vein

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BEYOND THE WATER DROP

BEYOND THE WATER DROP

From Big Bang to Eternity –

From the explosive womb of Big Bang
Hydrogen, your progenitor was born
Consisting of single moving and opposite forces
Seeking companionship, and a need for Oneness
Bigger and more powerful than the self
And the atoms and elements and then the molecules of life
Were themselves given life

And then you my darling water
The purest of beings

Born with a gush from the amniotic sacs of Big Bang
Finding your way to virgin earth
Under forces beyond you
With forces in you
To enable all of life
For without you we would not be

The single droplet of rain hitting the puddle
With its kind but explosive kinetic force


Under the same original force that brought you to earth
Converting to a beautiful sound of the droplet on water
With an array of waves in perfect circle

As I ponder this wonder
The beauty of physics at its best
No energy destroyed, just converted
A simple yet not so simple action reaction of Newton
Snow, ice, vapor, waves of the sea, and a flowing river

Calming of the soul
Giver of life
From Big Bang to Eternity

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We the Cells of the Body, Want to Create a More Perfect Union

Adam and Eve Choose Cabinet Members for the Body’s Society of Cells

Arielle Davidoff and Ashley Davidoff  Copyright 2017

 Look deep into nature and then you will understand everything better – Einstein 

As Adam and Eve entered the Garden of Eden they heard the cry of the disparate cells of the body:

“Without each other we are nothing.  Please unite us in structure and function with your wisdom. E Pluribus Unum!”

E Pluribus Unum – Out of Many, One

The cells knew they would be around for a long time; their grand scheme was to pursue Oneness. They understood the consequences of bullying, selfishness, greed, and jealousy. They also knew the power of goodness, integrity, humility, and sharing.  The cells resolved to fight the evil aspects of humanity.  56 cells from all walks of life discussed the issue of collaborative community living, and drafted a constitution they all signed in Philadelphia.  The cells submitted this proposal to Adam and Eve. It read:

“We the Cells of the Body, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United Cells of the Body.”

50 representative cells overlying the stars

Adam and Eve realized that the cell was the key “person” in their society 

Adam and Eve, taken aback by the wisdom of biology, accepted the proposal and recognized the document as a marvel of humanity.  They knew it was imperfect, but accepted that as humanity learned through time, experience, and application, it could be amended and better understood.

And so what to do now?

Adam and Eve’s first task was to choose leadership for this noble effort.  Which type of cells did the society of the body need? The stakes were high; they needed to organize an efficient society in which each of the body’s 37.2 trillion individual cells would be fed, protected, fulfilled and free.  In the Garden of Eden, Adam and Eve examined the variety of cells that surrounded them, then turned to consider the needs of society. thinking about which to choose.

Essential Functions

They debated and discussed how to build a body to house and protect its contents and enable the person to live a full and free life.  They spoke through the night and on the sixth day they arrived at a basic plan of a successful body’s most important functions. Those functions would fulfill the direction of the constitution they had drafted earlier.

Their plan was a simple list of the body’s essential functions:

  1. control, manage, direct
  2. protect and support
  3. provide food, energy, and manufacture needed products
  4. transport
  5. maintain
  6. produce and prepare the next generation

In the Garden of Eden, Adam and Eve entered the society of the cells and began to select societal leaders for the various essential functions on their list.

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Adam and Eve in the Garden of Eden’s Cell Shop

 Adam and Eve ventured into the Garden of Eden Cell Shop with their shopping list of the functional needs for their society.

Finding the Leader Cell to Control, Manage and Direct

The cell to govern the body would need an overview of the whole situation of life and Oneness.  Its chief characteristics would be wisdom, honesty, humility and integrity. It also needed to sense and react appropriately to both the external and internal environment so that everybody could live a safe and fulfilling life. This cell also had to be able to communicate with every cell in the body – all 37.2 trillion of them – from the tip of the head to the tips of the toes.

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The Neuron – “Il Presidente”

They chose the brain cell or neuron for its leadership, and they playfully called  it “Il Presidente.”  Crucially, the neuron could connect not only with other brain cells, but also (directly or indirectly) with every cell in the body. The neuron could also react to the outside environment.

Adam and Eve Trying on the Brain Cell for Size

 Adam tried on the brain cell and sought Eve’s approval.  It was tailored for both the internal and external environments.

Modified public domain work of Henri Rousseau “The Dream”  1910 (MoMA)

“Il presidente” made his first speech referencing Hillel’s sage advice: “If I am not for the body of my person who will be?  And if I am only for the body of my person, then what am I?  If not now when then?”

Adam and Eve nodded at each other, satisfied with their choice.

Finding a Cell for Protection  

Adam and Eve lived in a dangerous environment.  Wild, predatory animals ranged in size from the dinosaurs to violent religious zealots, to the smallest virus particles.  They identified two principal needs – protection from the outside, and protection from the inside of the body.  They turned first to secure internal security.

Adam and Eve were aware of Voltaire’s wise words: “Beware of the words ‘internal security,’ for they are the eternal cry of the oppressor.”  They also knew, conversely, that Cicero stated “Salus populi suprema lex esto”  –  “Let the good (or safety) of the people be the supreme (or highest) law.”

The cell responsible for internal environmental control had to be highly intelligent, so it could sensitively identify the enemy without racial profiling.  Adam and Eve searched for a long time before they encountered an amazing, introverted cell genius, decorated with Einstein’s hairstyle. They called it the macrophage.  This cell had an exquisite memory for detail and an uncanny ability to spot and destroy the enemy of peace.  Rebels and terrorists in the body were no match for this cell.

 

The Macrophage Police Cell with a Crazy Hairstyle

The macrophage’s motto was the simple equation:   E = mc2

Enemy of the Common Good will be taken down by the Macrophage with Great Conviction for the sake of the peace of humanity

Finding a Cell to Manufacture Food, Energy, and Other Needed Products

The manufacturing function related to internal economy.  Adam and Eve knew that a successful internal economy required self sufficiency. All able bodied cells had a right and an obligation to work.  Adam and Eve remembered and appreciated the wise words of the famous John Kennedy who declared “My fellow Americans, ask not what your country can do for you, ask what you can do for your country.”

The body would need manufacturing facilities present in all of its parts.  Noticing, however, that the liver cell proved especially adept at manufacturing, Adam and Eve chose this cell to lead the body’s internal economy.

The Liver Cell – Key in Metabolic Function in the Metabolic Warehouse of the Body

 

Finding a Cell to Lead the Transport Function

Transport to and from the cells would be an essential bodily function.  Adam and Eve chose the red cell to lead the effort, since it could transport oxygen and carbon dioxide, which they knew is vital to life.  The red cell with its colorful hemoglobin was a natural choice.  They recognized its ability to rapidly exchange gases in the lungs and at the cell as a stunning accomplishment of nature.

Red Cell with Hemoglobin Responsible for the Transport of Oxygen and Carbon Dioxide

Finding the Cell to Lead Maintenance: Repair, Cleaning and Waste Removal 

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Stem Cell Maintenance and Repair

The stem cell can magically transform into many different types of cells necessary to repair and regenerate tissues, which can wear over time. Timed cell death, or apoptosis, is natural and regeneration is necessary. The adult stem cell is responsible for regeneration of blood cells, endothelia of blood vessels, and epithelia of skin, intestine, and respiratory tract.  Adult stem cells also repair tissues such as bone, cartilage, and non-cardiac muscle, which are prone to injury due to physical activity.  Adam and Eve chose the multipotential adult stem cell to maintain the body’s cell populations.

Preparation for the Next Generation 

The miracle of creation understood the importance of education.  Each generation would advance to wholeness only if it learned from the experience of prior generations.  Humanity has preserved history in archives, museums, and libraries.  Similarly, within the nucleus of each cell lies the accumulated experience of the generations in the library of the DNA.  Every cell contains all this valuable information, which continues to evolve as human experience advances.

The Library of Accumulated Experience in the Nucleus of the Cell
Courtesy of photograph provided by Ralf Roletschek / fahrradmonteur.de subsequently modified 

Best for Last: Reproduction

Nature drives men and woman together with the most pleasurable and profound experience to enable e plurabus unum of the female egg and male sperm.  The mechanical union is infused with a miraculous spark of life that enables the continuation of the species.
Sperm and Egg Meet and a Miracle (not to be taken for granted) Occurs
Adam and Eve rested, exhausted in each other arms, assured that the wonderful human experiment had begun.

And the next day…

…there was a meeting of the minds on the palace lawn.

 7 Cabinet Ministers Posing in Front of Government Center

The 7 cells chosen by Adam and Eve to  to advise the design of the structure and function of the body.

From left to right; Liver cell (manufacture), Macrophage (defense and protection) Ovum (reproduction) Neuron (government) Sperm (reproduction) Stem cell (maintenance and repair) and Red cell (transport)

 

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The Common Vein: Anatomy of Structure – Units and Connections

Structure – The First Step

Structure is a material unit or object, composed of smaller parts that are connected and organized so that it can stand alone but also  be part of a larger and more complex whole

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The Units That Make the Whole – The Brick and the Brick Principle

The brick is the unit that is the basis of the brick building.

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The Brick – An Individual Unit That Needs to Connect In Order to Function and Be Valuable

The brick by itself has no function and no value to the world.  In order to have value it needs to connect with other bricks.  When the brick, a structural unit,  connects with other bricks and they organize, a wall is built. The wall as a structural unit, connects with other walls and they organize to form a room, and eventually a building is built.  Although the brick is nothing by itself – a weak brick can bring the whole wall and the whole building down.

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The Power of the Brick

It is Nothing by Itself  

However the Whole is Only as Strong as the Weakest Brick

The Units That Make the Body – The Cell and the Brick Principle

I am like a brick. Amrish Puri

The cell is the unit that is the basis of biology.

cell, cells, liver, process, physiology, function, receive, process, produce, export, principles, nucleus, cytoplasm, cytology, anatomy, art, the common vein, art in anatomy, Ashley Davidoff MD

The cell by itself has no function nor value, unless it is a unicellular organism.  In order to have value it needs to connect with other cells.  When the cell, a structural unit,  connects with other cells and they organize, a tissue is built. The tissue as a structural unit, connects with other tissues and they organize to form an organ, and eventually a body is built.  Although the cell is nothing by itself – a weak cell can bring the tissue and the whole body down.

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When the 37.2 trillion cells in the human body connect and organize, they create a spark of life housed in the body and gifted with a mind.

The difference between the brick building and the person is really the life that biology brings.  It is truly a miracle and the secret of how this happens still eludes human endeavour.  This secret may never be unlocked.

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Subtract The Bricks From the Cells.  What is the Result?

What is very clear, is that as human biologic units build, the  result is larger and more powerful than the individual parts.  At a critical number a spark of life emerges within the body, and a mind emerges from both of them.  When and how that happens remains a mystery.

Our first project is not to delve into the yet unanswerable “hows” of life, but rather into the “hows” of structure.  Structure is complex, but the pattern of units connecting and organizing is universal and permeates structure from the  subcellular level to the whole body and even beyond into our communities.

Some Quotes About the Brick Principle

 “A great building will never stand if you neglect the small bricks.”

Ifeanyi Enoch Onuoha

“Love is like a brick. You can build a house, or you can sink a dead body.” Lady Gaga

“Brick and blood built Astapor, and brick and blood her people.”
George R R Martin – A Storm of Swords

14. “Genius too does nothing but learn first how to lay bricks then how to build, and continually seek for material and continually form itself around it.Every activity of man is amazingly complicated, not only that of the genius: but none is a ‘miracle.”
Friedrich Nietzsche

“I fear that in this thing many rich people deceive themselves. They go on accumulating the means but never using them; making bricks, but never building.”
George Eliot

“Faith. Trust. They don’t come naturally, but as we lay those first bricks, we notice that little by little, a foundation is forming. Eventually we can end up building the most beautiful things with faith and trust.”
José N. Harris

“Bricks without straw are more easily made than imagination without memories.”
Author: Lord Dunsany

“It takes a thousand bricks to build a wall, but only one to tear it down.”
Markus W. Lunner

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Pain, Pain -Go Away!

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You came with no warning and no invitation

You came with a single message of doom and gloom

I had no control

It was fate

It was no joke

I had to take you seriously

You seem to be endless and to be going nowhere

With the unintended intention to taunt and haunt me

You are the source of my suffering.

Since the dawn of man

You have accompanied us with a not so gentle reminder

That everything is not OK

Some say you are protective

But it is sometimes hard to understand

All I know is that I suffer

Nociceptors sense the feeling

They come in different forms

Transmitting pain from pressure, prick, or improper heat,

– or a severe lack of it

Quickly the sensation travels

On the A, delta, or C train-

 Impulses that run their course

From source to spinal cord

With sizzling hot news of my experience

Where they snap to a halt as they clap as a synapse

And get a second order of direction

At the gate of decision

Which waves them on to a new thoughtless action

On their way to master control.

And through and via the wire of the RAS

Which awakens an awareness of you;

And then to the thalamic relay

Where they get their new orders:

To whom they should turn

And what direction to take.

In the higher levels of limbic autonomic and homunculus centers

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The sense becomes real

And the feeling becomes severe

And after all the science

I know not what to do

But to increase my heart rate a little,

Contract a muscle and a gland or two

And perhaps let out a scream at the height –

And impugn your intrusive impudence that imposes on me.

pain, nociceptor, poem, prayer, sensory system, thalamus, A fiber, delta fiber, C fiber, Ashley Davidoff MD. The Common Vein, Art in Anatomy

 And then sometimes

We use the eyes and guise

Of X-ray Eyes

Or try a tincture of opiate

To extirpate the excruciate –

And then sometimes to no avail

Yet I could care less about your wonderful pathways of biology and science

I know that I hurt -but also in a different way

It is not only the pain that I feel

But the pain of fate as well

That was handed to me as a card in a bad deal of nature

And I have no choice but to deal with it …..

But it hurts!

person, old lady, emotional pain, aging, poverty, loneliness

 

 

See the BLOG about the Art and Science of Pain

The Common Vein Copyright 2017

Ashley Davidoff MD

Revised since publication as a Blog August 2016

 

 

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Pain – Art and Science

Pain

Pain is an unpleasant  sensation originating from our physical and or emotional environments.

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Faces of Pain

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Extreme Physical Pain

 

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Extreme Emotional Pain

Physical Pain

Pain is a symptom and as such reflects a derangement of either the external or internal environment.

All sensations start by stimulating a receptor of  a nerve that conducts the impulse to the spinal cord where low level control and discrimination occurs, and transfers  the stimulus to the brain, where higher centers process the stimulus and react to it.  The structures in the brain include the thalamus, somatosensory cortex, limbic system, and autonomic systems and they are involved in  perception, localization and integration.  They send out a stimulus with instructions of how to react which is executed by muscle contraction or tissue secretion.

Functionally, pain is protective. The physiology and pathophysiology relate to changing the mechanical stimulus into an electrical impulse, and then through a series of complex synapses the stimulus is transmitted with the intent of  protecting the person from further damage.

The causes of pain are innumerable and exist within the full spectrum of human diseases. Pain may result from pain receptors sensitive to pain, (pricking, cutting, tearing) extreme temperatures, pressure, or aberrant chemical environments. A myriad of processes then occur in response to tissue injury causing either irritation of a somatic nerve or distension and pressure on a visceral sensory nerve. Inflammation is one of the most common of these injurious processes that is classically and universally expressed with  pain – a concept first described by the second century philosopher Celsus.

The result of a pain impulse is usually withdrawal from the insulting stimulus, resting of the injured part, or seeking the help of a medical practitioner if the pain is unbearable and arises from an internal disorder.

Diagnosis of pain disorders should proceed with careful history taking and clinical examination, followed by appropriate laboratory tests, and imaging if necessary.

Pain is a very common symptom and most instances are treated with an analgesic or antiinflammatory agent.   For more serious pains, treatment is directed at the cause of the pain.

Classification

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The table explores the variety of ways of classifying pain.  The left hand column reveals the classification based on functionality, origin, mode of stimulation, pathological causes and relationship of pain to chronicity.  As for functionality it may be adaptive or nonadaptive.  The pain may originate from somatic or visceral nociceptors, may originate from damaged nerves in which case it is called neuropathic, or it may be psychogenic.  The causes are usually via the inflammatory process but may result from any of the disease listed.

Structural Basis of Pain

A pain impulse is initiated by sensory receptors called nociceptors which are located in almost all the tissues. A noxious stimulus say from a hand touching a hot stove is then transmitted by sensory nerves to the spinal cord where a direct spinal reflex causes immediate withdrawal from the source. Additionally the stimulus is modified in the spinal cord by a variety of influences from other sources and is then transmitted via the midbrain and reticular activating system to the cortex. Finally, the stimulus reaches the brain’s somatosensory area where it is perceived and localized with additional extension to other areas of the cortex for the provision of a variety of protective reactions to the stimulus.

We will now expand the detail of the structural pathway described above.

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Pain from the Joints

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Pain from Sinuses 

The Sensory Pain Receptors – Nociceptors

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Nociceptor

A pain impulse is initiated by sensory receptors called nociceptors which are located in almost all the tissues. They are tree like branching structures.

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Types of Receptors Subtending the A delta Fibers and C Fibers

The diagram shows sensory stimuli including sharp pressure, extreme heat and cold as well as chemical, stimulating the free nerve endings of the nociceptors  that are linked to the myelinated A delta fiber , and non myelinated C fiber.  The myelinated fiber will conduct the impulse between 3 and 15 times faster than the non myelinated fiber.

 These specialized receptors vary in structure and number throughout the tissue and viscera of the body. There are external nociceptors that are situated in the skin and cornea with higher concentrations in the coverings of the body including the skin, pleura, pericardium, peritoneum and periosteum. Internal nociceptors are found in muscles, joints, around blood vessels, and within the mucosa of some organs including the urinary bladder, genitourinary tract, and the gastrointestinal tract. There are nociceptors in varying concentrations in almost every organ in the body, but interestingly there are none in the brain substance itself .

First Order of Transmitting Sensory Fibers 

The first order of nerve fibers transport the stimulus from the nociceptor to the dorsal root ganglion

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The sensory receptors of the nociceptors are found in the tissues peripherally and are connected  by a long fiber that transmits the impulse to the ganglion cell that lies in the dorsal ganglion in the neural canal alongside the spinal cord. This diagram shows the three types of receptors and fibers that transmit impulses related directly and indirectly to pain . The upper fiber is called the C fiber and it is non myelinated, consists of the receptors in the top left hand corner that when stimulated transmit the impulse via a long afferent neuron to the cell body lying alongside the spinal column. This fiber is relatively thin, measuring between .4 to 1.2 micrometers, and conducts the impulse at about 2m/s. The second neuron is the A delta fiber and it responds to the pricking or sharp sensation that is first felt and reacted to. It is weakly myelinated and is about 2-6 micro meters thick, and conducts the stimulus with a velocity of between 15-30 meters per second. The last fiber is the A beta fiber and it is responsible for the pressure component which indirectly affects response to pain by affecting the gate mechanism of pain. It is greater than 10 microns thick due to heavier myelination and conducts impulses at 30-100 meters per second

The Dorsal Root Ganglia

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The Dorsal Root Ganglion of the Afferent Neurons

The dorsal root ganglion  is a focal accumulation of the first order nerve cells of the sensory component of the peripheral nerve. (orange)  It is situated  in the neural foramen of the vertebral body.  The central process emanates from the ganglion cell  and ends in the dorsal horn.

2nd  Order of Neurons

The second order sensory fibers are those fibers in the spinal cord.  They first cross to the contralateral side of the spinal cord and then connect to the thalamus via the spinothalamic tract. 

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Second Order Neurons  – Cross Over in the Spinal Cord and 3rd order are Found in the  Spinothalamic Tract 

The spinothalamic tract is the major sensory ascending pathway of 2nd order neurons and serves as the major pathway for pain, temperature, itch and crude touch. Within its construct, the spinothalamic tract has three merging bands of specialized fibers that conduct pain impulses. The anterior spinothalamic tract carries pain signals initiated by touch while the lateral spinothalamic tract carries slow and fast fibers for pain and temperature sensations. The anterolateral spinothalamic pathway, located in the anterolateral white column pathway in the anterior half of the lateral funiculus conducts a variety of somatic pain signals.

3rd  Order of Neurons – Connect the Thalamus with the Sensory Cortex

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The Three Orders of Neurons

Second Order Neurons From the Spinal Cord to the Brain and Perception of the Pain  The Three Orders of Neurons

 The stimulus is first converted into an electrical impulse which is taken by a first order sensory nerve (orange)  to the spinal cord (dorsal root ).  The second order neurons (blue) first transport the stimulus to the contralateral spinothalamic tract  which in turn transports the impulse  to the thalamus,.  The third order neurons (pink)  transport the impulse to the somatosensory cortex.

Role of the Thalamus

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Thalamus – Relay Station to the Cortex in the Pain Pathway
The thalamus (T) is the gateway to the cerebral cortex. It is a paired organ and represents the main part of the diencephalon and subserves both motor and sensory function. It is structurally and functionally situated between the cortex and the midbrain. The thalamus has specific nuclei with diffuse projections to and from multiple regions of cerebral cortex.  The thalamus functions as a translator for the cerebral cortex. It processes sensory and motor information and mediates the autonomic nervous system regulating sleep and arousal. The thalamus also contains reciprocal connections to the cortex that are involved in consciousness. It may also play a role in vestibular function.  The thalamus translates pain signals of the 2nd order neurons and gives rise to the third order neurons that extend to the cortex. Awareness and localization of the pain is then achieved at the level of the cortex. The thalamus however is not merely a relay station for nociception but also plays a role in processing the stimulus.  Axons terminating in the lateral thalamus mediate discriminative aspects of pain (somatosensory cortex) including the originating body part. The fibers ending in the medial thalamus mediate the motivational and affective aspects relating for example to the emotional and memory of pain. These third order neurons travel to the prefrontal cortex, insular and cingulate gyrus which contribute to the emotion and memorization of pain experiences. 

The Homunculus Man and Localization of the Pain 

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HOMUNCULUS MAN and Localization of Sensation in the Somatosensory Cortex of the Parietal Lobe

The homunculus man (literally the “little man”) is the distorted figure drawn to reflect the concept of size of organ paralleling the size of the sensory innervation. The diagram reflects the relative functional sensory space each body part occupies in the somatosensory cortex. Those structures with a high density of sensory receptors are represented by a larger size, while those with a lesser concentration of sensory apparatus are shown as being “smaller” in size. Hence the mouth lips, hands feet and genitalia have a relatively large representation. Nerve fibers from the spinothalamic tract in the spinal cord (blue line) are relayed to the thalamus (orange) which filters and then distributes the sensation to the somatosensory cortex.

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The Somatosensory Cortex in the Parietal Lobe – Home of the Sensory Homunculus

The somatosensory cortex in the parietal lobe  is the location of the the main sensory receptive area for all the senses including pain. It receives the stimuli from the thalamus and then integrates the information with other parts of the brain  that will modify the perception of the sensation

The function of the somatosensory cortex is that of a higher processing center for touch, temperature, pain, and proprioception serving to amplify awareness of the sensations enabled by the thalamus. Sensation from the left side of the body are processed in the right somatosensory cortex and similarly those from the right side are processed on the left. The higher function of the somatosensory cortex allows us to localize the pain to a specific site, perceive the character and intensity of the stimulus, and sometimes helps identify the shape of the originating object.

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The Higher Multicentric Levels of Pain Perception and Reaction

The somatosensory cortex relays impulses to other cerebral areas of perception that modulate the reaction to the pain  It forward the pain signals via the white matter to other centers in the cortex to enable integration with visual and auditory input, and with other higher cortical functions such as emotion and memory for example. The full experience is then “seen” by the brain enabling the consequent reaction to be as discriminating  and prudent relative to the nature and experience of the person. The difference between the reaction of an infant, child and an adult to the “shot at the doctors” speaks volumes about this latter function. 

Emotional Pain

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Pain of Poverty

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Pain of Addiction

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Pain of Loneliness

Pain .. Pain go away! – and please leave us alone!

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Anatomy of the Liver, Alcohol, and Addiction

The Liver – Just Another Normal Miracle of the Body

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24/7 Clockwork Purple 

The liver is the largest gland in the body and is central to many metabolic functions. It is known as the body’s “metabolic warehouse.”

The liver serves several important functions. It is integral to the digestive system, producing both internal and external secretions. The external secretion, bile, aids in the digestive process, while internal secretions are responsible for the metabolism of both nitrogenous and carbohydrate materials absorbed from the intestine.

Some of the liver’s functions take milliseconds and others take days and sometimes weeks. It secretes bile in order to  alter toxic substances chemically (e.g. converts ammonia to urea), converts glucose to glycogen, and can produce glucose from breaking down certain proteins. The liver also synthesizes triglycerides and cholesterol, breaks down fatty acids and produces plasma proteins necessary for the clotting of blood such as clotting factors I, III, V, VII, IX and XI. Nearly 30% of the blood pumped by the heart passes through the liver each minute.

One of the unique structural features of the liver is its dual blood supply. It is supplied both by an artery (hepatic artery) and a vein (yes a vein!) – the portal vein. The portal vein  drains the gastrointestinal tract of digested metabolic products and transports the nutrients to the liver for processing.

Four to five thousand  years ago, the sheep’s liver held godly powers in the Babylonian culture. The Babylonians, and many cultures thereafter, believed that since the liver was the largest organ, it certainly must be the organ of most importance.

The Cells

Hepatocytes are the major cellular component of the liver, comprising approximately 70% by volume. Structurally they are characterised by their large size and the absence of a basement membrane.  Functionally they are characterised by their remarkable metabolic and regenerative capability.  Kupffer cells are found within the space of Disse and they act as macrophages of the liver, identifying and removing substances and organisms toxic to the body.

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The Cells

The AiA rendering of cells in the round provide an image that is reminiscent of craters on the moon surface.  The thought process behind the image is the formation of tissues from cells.  The building of the whole from the parts starts with the cell and progresses to the tissue and finally the organ.  In this instance, groups of liver cells are artistically combined to form a tissue and an imaginary spherical organ.

Cellular Organization

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Organization of the Liver Cells in Cords Along the Rivers of Blood Flow

The liver  is a compound tubular serous gland. The cells are arranged in plates or cords alongside rivulets of a capillary network called  sinusoids.  The  spaces of Disse are spaces below the lining of the Kupffer cells. 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.

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Organization of the Liver Cells in Cords in the Liver Lobule

The cells of the liver are organized in cords and plates and are organized like spokes of a wheel  around the central vein.  The periphery of the lobule contains  groups of portal triads consisting of portal vein (dark blue), hepatic artery (red) and bile duct (green).

The structural liver unit is called a lobule.  Cellular plates branch and anastomose alongside and in parallel with the sinusoids.  Each lobule measures 1-2mm and is shaped like a hexagon. A central venule lies at the center of the lobule and is the destination of the sinusoids, which carry both hepatic arteriole as well as portal venous blood.  At the periphery of the lobules are sets of portal triads consisting of portal vein, bile duct and hepatic artery.  The biliary system collects bile from the liver and evolves into an independent network terminating in the common bile duct which empties bile, into the duodenum.  The hepatic artery and portal vein supply the liver with metabolic substrates via the sinusoids, and also collect metabolic  products produced by the liver to transport to the rest of the body.

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Anatomy of the Liver in a Nutshell– 

From its Embryonic Beginnings to Full Member of the Society of the Body 

Pleasure

Alcohol – Drink of the Gods in Moderation and Poison of the Devil in Excess

Anatomy of the  Initial Positive Effects of Alcohol

“Drink because you are happy, but never because you are miserable.”
― G.K. Chesterton, 

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Social Drinking: The Prostate Having a Drink with the Uterus

The uterus and prostate are out on a date and sharing a cocktail   The uterus approximates a rectangular shape as does the prostate, accounting for their fascination with each other and their similarity with the shape of the wine glass.  The uterus is accompanied by the ovaries and the vagina which forms the stem of the wine glass.  The prostate is accompanied by the Seminal vesicles and Cowper’s glands and the urethra which acts as the stem of the wine glass. The male secretion seen in the urethra consists of a mixture of sperm, prostatic secretions, and seminal vesicle secretions.

Social drinking to celebrate an event is a wonderful means to enable people to open up to each other  

As G.K. Chesterton wrote – “Drink because you are happy, but never because you are miserable.”  

William Shakespeare, in Othello, on the other hand wrote – “I would not put a thief in my mouth to steal my brains.”

Most cultures favor the use of alcohol in celebration of events, and the positive effects of alcohol when used judiciously is to promote a pleasurable feeling via the nucleus accumbens, and to reduce stressful feelings (often social interactions) by reducing inhibitions by acting on the amygdala

Anatomy of the Feeling of Pleasure and the Nucleus Accumbens

The nucleus accumbens is one of the most primitive part of the brain.  It is part of the  basal part of the forebrain.  It is a paired structure. Alcohol promotes pleasure by stimulating the nucleus accumbens.

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The Nucleus Accumbens

The coronal section of the brain shows the nucleus accumbens (ringed red) opposite its partner at the base of the brain.  It lies just inferior to the internal capsule and frontal horns, near the hypoyhalamus

Courtesy Department of Anatomy and Neurobiology at Boston University School of Medicine Dr. Jennifer Luebke , and Dr. Douglas Rosene

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Artistic Rendition of the Nucleus Accumbens on a sagittal T1 Weighted MRI

The nucleus accumbens, which is the site enabling the sensation of pleasure is shown as a red dot at the base of brain near the hypothalamus.

Stress

Anatomy of Stress and the Amygdala

The amygdalae are paired structures that are part of the limbic system that play an important part in emotional reactions including the reactions to stress.  Alcohol reduces the uncomfortable emotion of stress and distress.  Stress, in general is healthy, while distress on the other hand is not.  The distinction between the two is not always obvious.  Social situations are often stressful since in general people are “forced”into a position with “new” people they do not know too well.  Using alcohol in such a social situation disinhibits the individuals, reduces the feeling of stress and promotes a sense of social confidence.. The origin of the physiology is in the amygdala.

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Amygdala of the Forebrain in Sagittal Projection

The amygdala (red arrow)is a nucleus that is part of the limbic system.  It is a paired structure.  They are located deep in the temporal lobes and participate in emotional reactions, memory, and decision making.

 

Peer Pressure 

Stressful social situations are particularly prominent in adolescence when peer pressure is pervasive.  The college experience with new adventures of socialization,  combined with freedom from the constraints of paternal disciplines are ripe for the use of substance abuse.

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Peer Pressure

The scene: Party night – adolescent on the right, different innocent, alone and anxious. The in- crowd on the left are homogenous, powerful in number and stature, and encourage the newcomer to join in and be “one of us” – perhaps drink or smoke – and this is how it starts.
Educate, support, and love your children – Promote confidence in themselves so when they are confronted they can just say “no!”

Loneliness

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Loneliness

Alone and bored, some turn to alcohol to provide relief.  It is a short term, and short sighted relief to the problem

Early Addiction

Every form of addiction is bad, no matter whether the narcotic be alcohol or morphine or idealism.

Carl Jung

The signs of early addiction

There are a few early warning signs that are forebears of early addiction as they start to surface.

They include; drinking alone, hiding and lying about the habit, blacking out, neglecting responsibility, deteriorating relationships, drinking in dangerous circumstances (eg before driving) and inability to quit.

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Too Much of a Good Thing- can make your life tipsy turvy and turn you upside down –

shows bottles of alcohol in different positions and personify the state of inebriation.  Alcoholic intoxication is a form of poisoning, and can make your life tipsy turvy and turn you upside down. The art piece expresses the uncontrolled situation of inebriation.  When the liver cannot metabolize the alcohol due to excess in the blood stream drunkenness ensues. At lower blood levels there is a sensation of elation and lack of social reserve.  With higher levels of alcohol in the blood, cerebral and cerebellar dysfunction ensues with ataxia, imbalance and muscle incoordination.  Forebrain impairment includes disability to make appropriate decisions.  Coma and death can ensue when blood levels are extremely high.

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Drunk Man in the Town Square

A drunk man in the town plaza is toying with the idea of another swig.  His indifference to his environment, and lack of judgement suggests he is inebriated.  However his body language with an outstretched arm holding the bottle and the other hand pointed in another direction may suggest, at least idealistically, symbolically and hopefully subconsciously, that he realises he could go one of two ways “Decision time” he says to himself – “on the one hand I could take a swig .. Yet on the other I may take a different and more healthful course” Which way do you think he would go? (Photograph modified to enable anonymity) 

Cirrhosis

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Normal Liver and Cirrhosis

The left sided image shows the CT scan of a normal liver.  The liver is the biggest structure that you can appreciate on the CT scan and is triangular in shape. The scan on the right shows a liver with cirrhosis.  Alcohol pickles and scars the liver making it look like a knobby shrunken prune. The first image reflects healthy and romantic enjoyment of two people enjoying a beer at sunset. The colorful sunset transposes int a black and white background providing the mood of a lonely alcoholic. The alcoholic drinks in loneliness and in excess, until finally the person and the the bottle do not remain upright symbolically reflecting physical and psychosocial failure.

The Failing Liver

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Normal Liver and Cirrhosis and Ascites

The AiA rendering shows a normal liver on the left, and a person with cirrhosis on the right evidenced by a shrunken, knobbly and pickled liver, jaundice of the skin and a distended abdomen caused by the accumulation of litres of fluid (ascites). In the long run, the addiction results in much suffering, a miserable existence, and immediately life threatening hemorrhagic episodes.

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Alcoholism and Ascites

(Photograph modified to enable anonymity) 

Liver Cancer

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Liver Cancer 

Liver cancer, frequently arises as a complication of cirrhosis and most particularly from alcoholic cirrhosis. The  AiA rendering of the liver shows the inner workings of the organ, now inhibited by the large yellow cancer preventing the clockwork function of the liver. The liver starts to fail as a result of the cirrhosis so that the synthesis of biochemical products that  keep the body going are no longer produced to the degree which they are needed.

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Wasting of Body and Life 

The collage shows normal healthy liver cells (top left) with a healthy appearing torso (CT scan  reconstruction bottom left).  The top right image reflect cancerous hepatic cells where the nuclear to cytoplasmic ratio is too large meaning that the the nuclei are too big and the cytoplasm too scanty.  This finding is one of the typical findings in cancer.  An emaciated torso (bottom right) is seen in contrast to the healthy counterpart.

Artistically the stark reality of health and disease is exposed.  This terrible disease stares at us in stark graphic reality.

Philosophically – the cancer cell is like a rebel in the community, who only has selfish interests and contributes nothing to the welfare of the community.  As a result the whole community of the body  eventually fails, and hence the emaciation of the body.

Lessons?  Kick the Habit Early  or Kick the Bucket

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Life, Cells, the US Constitution, and Trees

Life, Cells,the US Constitution, and Trees  

is an odd combination of concepts.  At first glance the title of the blog reveals a wide discrepancy of ideas, but in fact there are unifying concepts that bring them together.

The United States is one of the advanced cultures of the modern world. Its magnificent constitution states “We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America.”   The wisdom rests firstly in the notion that “we the people” is the focus of all subsequent intentions resolutions and actions.  Secondly it provides hope and promise of a happy and safe society.  This statement of the constitution is satisfied in the biology of the cell, but not to the same extent in the dynamics of society.   We do not fully appreciate what perfection has been accomplished in the microcosm of our bodies nor how apt the opening statement is to the cells that make up living organisms. The cells in truth realise all the promises of the preamble, including a perfect union, justice, tranquility, defence, general welfare, liberty, and posterity.

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Trees, US Ideology, Cells, and the Body

Living structures are characterized by their ability to move, grow, reproduce, acquire and transport metabolic products, and protect themselves — all so they can function and contribute to the bigger community. The cell as the basic building block of life and living organisms performs all the described functions effortlessly, innately and automatically.  For the cell, life happens without struggle or effort.  People perform the same characteristics of life, but many individuals struggle to fulfil basic needs to satisfaction.

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Constitutional Makeup of the Body

The AiA art piece puts the cell in the centre of the body.  The cells, acting in combination with other cells, give life to their person in accordance with the preamble of the constitution. People in combination with other people give life to their society. 

From a physical perspective, biology has worked out a mechanism to keep all the 3.7 trillion cells of a single human being satisfied, fed, protected and fully functioning in their specific capacity. The liver cell is fulfilled in its capacity as a liver cell, and the same for the myocardial and brain cell.  In fact all animal cells live and do what they were born to do, and are fulfilled until disease or death. The world of botany has accomplished similar magnificence.cells-0005-catalogue-signed

Constitutional Makeup of the Tree

Tree cells in combination give life to the tree in accordance with the principles of the constitution.  

The 7.1 billion humans of the earth are still stuttering along, despite the lofty aspirations of the US Constitution.  Many citizens go hungry, innumerable are homeless and countless die in war.  The particular focus of this blog is to observe and appreciate the success of cells in the body, and try to understand and apply the processes that make them so successful to our society at large.

Branching Patterns in Nature – Success Story of Delivery and Waste Removal

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YinYang Tree – From Environment to Life in the Trees

The AiA rendering amplifies the arborising pattern of the roots and the branches in a background of the environment fuelled by the sun, air- filled atmosphere, and the earth.  The tree unit consists of two opposing forces just like the negative and positive forces of the atom.  The bare roots represent one force and the leaf filled flowering branches the other. They need each other and both need the environment (and the environment needs them) to develop, flourish and contribute.  They use a branching system at both ends to move nutrients and water efficiently .

What Do We as A Society Have to Learn from from the Yin-Yang Tree?

Opposing forces, when working together, enable both to flourish as individuals and as a new unit.  We need the man with the woman, the roots with the wings, the roots with the branches, the winter with the summer, the past with the future, the positive with the negative.  In the realm of tubes and flow we need a difference in pressure – a relative positive and a relative negative in order for the contents of the tube to flow.

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In the Leaves

The geometric arborising pattern is universal and is shown in veins of the ivy leaf 

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Heart Shaped Chines Lantern Flower

The dried flower reveals a delicate capillary-like infrastructure which is the transport mechanism for the petals. The flower enfolds and defends a barely appreciated, delicate fruit buried within its husk. The need to protect its fruit  manifests parental love which it can only do because it has an efficient transport mechanism to maintain itself.

 

Branching Patterns in the Body –The Vascular System

Supply and Removal of Metabolites and Waste

The transport systems of biology are exemplified by phenomenal branching tube morphology that is efficient.  The delivery and removal system in the form of arteries, capillaries and veins is 60,000 miles long (2.5 X the distance around the earth) – and with a pump that beats on the average of 72 times per minute,  3.7 trillion cells are continually fed and cleared of waste, and as a result can be  productive and fulfilled. Food is delivered and is waste removed from the front door of every cell constantly.  Each cell understands and applies the Goldilocks principle – “Take Not too much , nor too little, but what is just right for your needs.”

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The Pulsatile Miracle Circulation

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The Circulation; A Pump, Arteries, Capillaries, and Veins

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Capillary Network At the Front Door of the Cells

Specific Circulations

The Brain

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Arterial Tree of the Brain Under the Purple Moon

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Derivation of the Arterial Tree of the Brain Under the Purple Moon

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Arterial Tree of the Brain – External and Internal Carotid Systems

The Heart

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The Crown-Like Coronary Arterial Tree

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Derivation of the Artistic rendering of the The Crown-Like Coronary Arterial Tree

The Lungs

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The Pulmonary Circulation

The Gastrointestinal Tract

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Mesenteric Venous System of the Small Bowel

Note that the abdomen has been turned upside down in order to appreciate the tree like formation of the portal vein and small bowel.  

The liver is seen at bottom left in purple and the spleen (right) in orange

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The Splenic Arterial Tree

 

 The Kidneys

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Renal Veins By Doppler Ultrasound in Spring

 The Liver

 

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The Hepatic Venules

 

Ductal Systems

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Ducts of the Breast

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Histology of the Glands of the Breast

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Bile Ductal System Working Night and Day

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Dilated Biliary Ductal System and the Bonsai Tree

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The Tree of the Prostate Gland

Organs and Other Structures with Tree Like Shapes

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A Forest of Kidney Trees

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Ginkgo Lung Tree

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A Winter Tree of Hands Under the Moonlight

The Brain

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The Brain Tree

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Derivation of the Brain Tree – Artistic Recreation 

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The Arbor Vitae – Tree of Life of the Cerebellum

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Tree -Like Purkinje Cells 

Drawing of Purkinje cells (A) and granule cells (B) from pigeon cerebellum by Santiago Ramón y Cajal, 1899; Instituto Cajal, Madrid, Spain. Public Domain

Drawing by Camillo Golgi of a hippocampus stained using the silver nitrate method and digitally rendered by the artist

This treelike branching pattern of neurons responsible for consciousness seems to be a structural feature of the universe itself.

Realising “We the People” – First Step – Efficient Supply and Removal of Metabolites and Waste for the People of the World

Without adequate food and water, the promise of “We the people” of the preamble of the constitution cannot be fulfilled. Currently 1 in 9 people in the world do not have enough food. Without this basic need they are unable to lead an active and healthy life.  Is it because there is not enough food in the world? Is it because the 3rd world starving countries are too far away from the excess food of the farms of abundance? The skin cell at the tip of the most remote toe or the most remote cell at the top of the head are equally supplied according to their need.  In a healthy individual no cell gets left behind.  Yet many people get left behind in the world.

How to do it?

To some extent we have built and continue to build an arborising network for water supply and waste removal.  In the US 86% of the population have clean water delivered.  In developing countries efficient water supply and sewerage facilities are lacking.  One in 10 people lack safe access to clean water, and 1 in 3 lack access to a toilet (water.org).  Building a similar network that spans the world and delivers food to the front door of all the people of the world is the obvious first step.  Yet it seems like a pipe dream.  The network of information provided by the internet was also a pipe dream for people like Nikola Tesla who had a vision for  a “world wireless system” in the early 1900s. The ability to deliver real time information to the front door via the world wide web is only 30 years old.  Could anybody prior to 20th century imagine such a technological accomplishment?  If only we could deliver food via an innate arborising pattern.  What if, for example, a high calorie liquid energy food could be delivered alongside the arborising water system?  It may not be a classical meal but it is certainly more than nothing. The practical intent of this blog  is to  draw parallels between biology and society, which can learn from an almost perfect delivery and removal system, most commonly in the form of tree-like branching.

The universe has evolved over about 13.7 billion years and  in so doing has the wisdom of time on its side.  Over this time, it has developed systems that optimise energy and efficiency.  We as thinking biological beings have evolved highly developed biological processes over the last 2.4 billion years.  We have developed a mind and free choice.  The mind for us has been a double edged sword – both a gift and a curse.  A gift because it has given us an ego, individuality, tribalism, heterogeneous cultures, poetry, literature, art, theater, science, dance, athletics, religion, and organization, but a curse that has brought ego, selfishness, pride, religion, jealousy, murder, bigotry, prejudice, and tribalism. The desire to live in “a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity” requires that basic biological requirements are available and met.  The cells of the healthy body have acquired the aspirations of the US Constitution.

The cell has no mind nor ego and is therefore waiting only for evolutionary changes.  We as thinking beings want it all now, and continue to try and improve our lot in a lifetime and are too impatient to be happy with our lot.  We therefore push the double-edged envelope with our ego and in so doing while we are social beings we are competitive individuals at the same time.  This creates an internal conflict and conflict with others making perfect union a dream rather than reality.  The start for the world should be an efficient low energy, arborising delivery system, for food and water system for all people.  Without this the US Constitutional aspirations are only a dream.

Hillel recognized the conflict.  “If I am not for myself,” he said, “who will be for me?  And if I am only for myself, what am I.  And if not now when then?”  It is the balance of “I” and “they” that we have to find.  The cells have done it – Why can’t we?

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I am the Colon- In the Bowels of the Body, I Reside and Work

A Poem about the Colon

by Ashley Davidoff MD Copyright 2016

I am the Colon

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I have not captured the imagination of poets, artists, and historians.

Unlike my brothers and sisters the heart, liver, and the brain,

I am usually a subject that is avoided in cultured circles,

And commonly the butt of coarse  jocularity in casual circles. 

My contents are usually used as expletives of disgust and disagreement, 

While my tail end is used in reference to the last and the least. 

 

Let me tell you my story …..

I am the colon – they also call me the large bowel.

Some call me the “large howl” because of the noises that I make.

I do make noises – most of the time I sing a droning song while I go about my work,

Almost like a bass or double bass.

Sometimes I have to let off steam and then the wind instruments take charge,

With sounds that range from a piercing bleat to the beautiful alto furtive blurt.

When my contents are fluid I can tinkle along like a triangle in a percussion band.

Borborygmi they are called –quite a fancy name for a rather primitive sound.

Talking about music, I was surprised to read that Mozart took an interest in me.

His scatological letters are infamous, though admittedly his music is genius.

I am somewhat proud of his obsession for me.

 

So much for what people think or have thought. Let me give you my perspective.

My body is unique!  No other structure in the body comes close.

With my taenia coli and rounded haustra I am adorned in appendices epiploica.

The three beautiful, graceful and gracile taenia run along the entire length of my body.  

I really like these sleek muscles

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Sleek Tenia Coli Muscle and Voluptuous Haustra

So symmetrically positioned around my circumference.

They are always a tad tight, giving me my voluptuous bulges – the haustra.

I like those too.

They give me haughtiness and sometimes a naughtiness – those haughty naughty voluptuous haustra.

…and here it comes again: their fancy shmancy name: “appendices epiploica.”

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The Ugly Appendices Epiploica

I hate them! I don’t understand what function they play …

What in heaven’s name was God thinking when he put those fatty …things!… on my waist?

I detest them!  Do you hear me? D-E-T-E-S-T!

They may have been the fashion in the time of Adam and Eve,

But God, please get with the times – they are way out of fashion.

 

Now all riled up I continue my rant and rave.

Chyme they call it!

Chyme my ass! (Oops, I should not have said that.)

They give it a fancy Latin name to make you think it is elegant.

What would you feel like if you were dealt the grime and sludge that I am dealt?

It is pure muck with all the good things removed – dirty slimy muck!

And this is only the beginning.

Wait for the obnoxious gas that those bacteria fellows produce.

It presses on my sides and makes the jowls of my bowels howl.

Talk about noxious and obnoxious – we should bring OSHA down here.

 

I feel a little better now that I have let off some steam,

So I resign myself to my lot in life and I deal with it and in it.

My cryptic workers – God bless mein lieber kinder, the crypts of Lieberkuhn:

histology, epithelium, crypts of Lieberkuhn, gastrointestinal tract, gastrointestinal system, colon, large bowel, art, anatomy, art in anatomy, Ashley Davidoff MD

God Bless Mein Lieber Crypts of Lieberkuhn

They take that stuff into their crypts and work away at it for hours and sometimes days.

And voila – with bubble, bubble, toil and trouble,

A well molded product of dehydrated debris

Mixed with a tincture of mucus, a bead of sweat, and fermented gas for the rise,

To which I add a drop of color with my stercobilin

To form beautiful compacted nuggets called scybalae.

 

Getting rid of the product and passing it on into the free world is yet another story.

Some wondrous interactions are going on between me and my muscles (and you and your muscles, and your marvelous mind and body).

To cut a long story short, the coordination is quite something until we finally get the job done.

I heave a sigh of relief when I see the fruit of my labor out of the door.

In the end I am very happy to be part of your body,

To do my little thing, retrieve some water, and earn my keep.

So that you can experience another wondrous day, enjoy another meal,

And live to tell another tail … end story.

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The End

This poem has been modified from its original version published in the module on The Colon in the The Common Vein web site

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Anatomy of Endometriosis and Adenomyosis

Anatomy of Endometriosis and Adenomyosis

Ashley Davidoff MD

Endometriosis is a disease  caused by misplaced or ectopic endometrial tissues located beyond the uterus most commonly resulting in pain at the time of menstruation. The ectopic endometrial tissue is controlled by the oestrogen and progesterone cycles.  The ectopic tissue  bleeds at the time of menstruation and causes pain.  Since neither the ectopic endometrium nor the blood can be extruded from the body,  recurrent bleeding eventually results in  scar formation which may cause non cyclical chronic pain.

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Chronic Pelvic Pain is Unbearable

Endometriosis and adenomyosis cause horrific pain.  For some the pain  may only occur during the menstrual cycle but for others it can  be constant, day and night, excruciating in nature, invading every aspect of normal daily life .  Pain is a common symptom defined by the International Association for the Study of Pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” This statement characterizes the evolved nature of pain as a warning system and feedback mechanism that influences how we adapt to our environment. However, pain at its core it is  suffering and its persistence can be insufferable for people and diagnostically problematic to those who care for  the sick, as well being  a burdensome cost to society.  

The cause of endometriosis is not truly known.  Long standing hypotheses include spillage of endometrial tissue into the peritoneal cavity via the fallopian tubes or transvascular spread to remote areas .  More recent hypotheses include spillage of stem cells during embryonic development, metaplasia of coelomic epithelium, abnormal vasculogenesis, and environmental factors

Endometriosis occurs in 5-10% of women. When endometrial tissue is located outside of the uterus, it can cause pelvic and back pain, as well as pain with sexual intercourse (dyspareunia). It is also associated with infertility by  distorting  anatomy, (for example Fallopian tube adhesions) , or physiological changes that result in altered immune and hormonal environments with consequent impairment of ovum implantation .

From a structural standpoint, endometriosis most commonly affects the ovaries and Fallopian tubes but can affect any of the pelvic organs including the peritoneal cavity,  bladder, ureters, bowel, broad ligaments, uterosacral ligaments, cul de sac  and even the nerves. Implants range in size from small microscopic implants, but are are commonly about 1-2cm.

genitourinary tract, genitourinary system, uterus, woman, Art in Anatomy, Ashley Davidoff MD

The Intraperitoneal Aspect of the Pelvic Cavity

The peritoneal cavity or coelomic cavity is a large cell lined  space via which almost all the abdominal organs are connected .  It may be considered the suburban space around which the houses of the town are positioned.  The ova are released from the ovary into the peritoneal space, but they are quickly directed by the fimbriae into the Fallopian tubes.

Endometriomas 

Endometriomas are large hemorrhagic cysts that occur on the ovary and  may be up to to 20cms in size.  They are usually  round in shape, much like a large blood blister after they have bled.  The nodules can be red-blue to yellow-brown in color, (chocolate cysts) and occur just below the serosa of the organ to which they are attached.  As the lesions undergo recurrent hemorrhage, they can become associated with fibrosis as stated.  Rarely they may be associated with malignant transformation.(<1%).

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MRI of an Endometrioma

A T2 weighted image of the pelvis (left) with an overlay of colors on the right shows a 10cms endometrioma (overlaid in red) with internal debris better appreciated in the left image.  The large ‘chocolate cyst” lies above the uterus (pink) and compresses the bladder (yellow)

MRI has a 90% specificity and 90% sensitivity for endometriomas.  On T1 weighted images the endometriomas may be bright and do not lose signal on fat suppressed sequences.  Heterogeneity is due to the presence of degraded products.  Septations may also be present.  Both these features are present in the above image . On T2 weighted sequences “shading”   is caused by repeated episodes of bleeding reflecting  hemorrhagic contents in various stages of degradation.  The wall of the endometrioma may contain hemosiderin which leads to a loss of signal on the T2 weighted sequence.

Unusual Locations

Endometriosis is rarely can be more far reaching and may involve the kidneys, brain, diaphragm, and pleura.  When it involves the diaphragm or pleura, shoulder pain may be associated with the entity.  Pleural disease can cause life threatening catamenial pneumothorax induced by the menstrual cycle .

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Endometriosis on the Bladder

A CT scan through the pelvis (left) shows an endometriotic implant  on the bladder wall.  The image on the right shows the endometriotic implant overlaid in maroon on the right anterior surface of the bladder (yellow overlay).  The implant measures about 1.1cms.  The fornix of the vagina is overlaid in pink.  Most peritoneal implants are too small to be visualized by conventional imaging and require laparoscopic evaluation for diagnosis.

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Endometriosis in the Skin of the Groin

A CT scan through the pelvis (left) shows an endometriotic implant  in the subcutaneous region of the skin in the left inguinal region (image a, circled).  The region is magnified in image b and the endometriotic deposit is labelled “e” with maroon overlay.  An ultrasound of the left groin(c)  shows the implanted endometriosis (black) medial to the artery (red) and vein (blue).  In image d, the region of endometriosis (e) is overlaid in maroon.

Clinically the entity more commonly occurs in nulliparous women and the degree of pain is variable.  As endometrial tissue, it is responsive to the cyclical hormonal fluxes, and thus may  bleed in response to hormonal changes. Pain commonly occurs at the time of the menses.  The volume of ectopic endometrial tissue does not correlate with the severity of the pain, but rather with the depth of infiltration into the tissue, or the degree of distension that might occur.  The pain is usually recurring and commonly but not necessarily occurs during the menses. With induction of fibrosis, pain may be caused by other structural changes that are unrelated to the menses.

Diagnosis is suspected clinically and confirmed by ultrasound. When a woman in the reproductive phase of her life presents with pain, the imaging study of choice is a pelvic ultrasound.  Hemorrhage into evolving follicles is a common cause of pelvic pain and these could be also quite large.  This entity has to be differentiated from an endometrioma that has a characteristic ultrasonographic appearance shown below

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Endometrioma on Ultrasound

A transvaginal ultrasound of the adnexa shows an endometrioma with characteristic low level echoes reminiscent of the texture of the testes on ultrasound.  The image on the right is an overlay in a biloculate cyst.  Some through transmission is present. 

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Chocolate Cyst  on US and CT

A 25 year old female presents with painful menses. The ultrasound shows a cystic mass in the pelvis with a large amount of debris in the cystic cavity consistent with a chocolate cyst (a).  Image b is an overlay showing the fine granular appearance of the sediment.  When the patient is in decubitus position (c) , the sediment settles to the dependant portions with a clear supernatant.  Image (d) is a CT scan of the same patient, showing a non specific cyst in the left ovary. In this instance CT has little diagnostic value in the characterization of the abnormality other than localising a large cyst, and excluding other causes for the pain.  Although the appearance on the ultrasound is consistent with endometriosis, a hemorrhagic cysts is possible and the distinction may only be made pathologically.

When a female patient in the reproductive age presents with pelvic pain and ultrasound or  MRI are negative,  laparoscopy is indicated both for diagnosis of small or flat lesions lesions  as well as for therapy.    Microscopic deposits which may cause symptoms will not be identified by imaging techniques and will only be seen laparoscopically.  The reluctance to undergo an “invasive” procedure is understandable, but delaying or worse still missing the diagnosis will cause unnecessary long term suffering.

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Laparoscopy

Laparoscopic image of small blood blisters characteristic of endometriotic lesions of the pelvic wall in the peritoneum 

Courtesy Author Hic et nunc.  Acknowledged work is in public domain

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Blood Blisters in the Cul De Sac and Sacrouterine Ligament

Laparoscopic image of endometriotic lesions in the pouch of Douglas and on the sacrouterine ligament.
Courtesy Author Hic et nunc.  Acknowledged work is in public domain

Treatment options depend on patient preference, including whether fertility is desired, but include both medical and surgical options.  Medical management frequently involves suppression of regular menses/hormones .  Surgical options include removal of implants  or surgical induction of menopause (i.e. oophorectomy and hysterectomy).

Adenomyosis

Adenomyosis is a disease of the myometrium caused by misplaced or ectopic endometrium in the myometrium resulting in myometrial hyperplasia and smooth muscle hypertrophy clinically manifesting as pelvic pain and uterine enlargement.   The entity can be focal or diffuse

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Enlarged and Painful Uterus of Adenomyosis

The exact cause of the displacement is not known but it is presumed that a breach in the endometrial myometrial barrier enables a small amount of endometrium to translocate and remain viable.  There is a high prevalence rate with about 40% of hysterectomy specimens displaying the entity.

The junctional zone of the uterus is the epicenter of the structural abnormality The junctional zone is subendometrial smooth muscle that is more compacted, and contains less water in comparison to the outer myometrium. (McCarthy)  The junctional zone is functionally different from the outer myometrium.

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The Normal Junctional Zone on MRI

The normal sagittal view of the uterus is a T2 weighted MRI from a 16 year old female with pelvic pain. The myometrium consists of an outer part (dark red) and an inner more homogeneous part called the junctional zone (light maroon)  Since a T2 weighted image is sensitive to water, we understand from this image that the outer part has greater white signal and therefore contains more  water, and likely more vascularity. The junctional zone (light maroon)  on the contrary has less water and therefore is blacker.  The endometrial canal, cervical canal and vaginal cavity are outlined in yellow and the vaginal wall is overlaid in pink.

 Clinically the patient presents with pelvic pain, dysmenorrhea, menorrhagia and may contribute to infertility.  On exam the uterus is enlarged.

The diagnosis is best made by MRI which shows a thickened junctional zone (>10-12mms) s.  The deposition of acute blood, blood degradation products such as iron, or the presence of fluid filled microglandular deposits in the junctional zone make the MRI findings highly specific for the diagnosis.

Treatment options include pain management with NSAIDS, and hormonal manipulation.  Surgery and hysterectomy is the only current option for cure.

MRI

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Adenomyosis with a Thickened Junctional Zone and Enlarged Uterus 

A  T2 weighted MRI (a) shows fluid in the endometrial cavity, surrounded by a thick dark layer of the junctional zone, and then surrounded with a slightly brighter outer myometrium.  The  color overlay in b, shows a small amount of fluid in the endometrial cavity (yellow) surrounded by a thickened subendometrial  junctional zone (light maroon) measuring up to 13 mms characteristic of adenomyosis. The outer myometrium (dark maroon) is normal

The junctional zone thickening is key to the diagnosis of adenomyosis on MRI.  The  junctional zone normally measures 8mm or less.  Between 8-11mm it is considered  indeterminate, and when it measures 12mm or  greater, it is considered diagnostic for the disease.  The junctional zone may thicken normally in the first few days of the menstrual cycle or during myometrial contractions.  Cystic changes in the junctional zone are also characteristic and relatively common and represent small blood blisters.  Linear striations radiating from endometrium to myometrium are also seen but these are not as easy to discern.  These probably reflect a breech in the endometrium reflecting microscopic tears extending into the myometrium.

 Ultrasound

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The Normal Junctional Zone on Ultrasound

A transvaginal ultrasound of a premenstrual woman in the sagittal plane (left) reveals a normal view of the uterus with characteristic premenstrual appearance. Image on the right  is an overlay showing the components of the endometrium and subendometrial layers.  The stripe is almost homogeneously echogenic and thick but also shows a hypoechoic halo of the junctional zone or inner myometrium. (salmon) The homogeneous stripe is made up from two histological layers (barely distinguished by this ultrasound)– the inner stratum functionalis (deep orange) that will shed once the spiral arteries vasoconstrict, and the outer stratum basalis (deep yellow) that will not shed, and will be the basis for regenerating the endometrium in the next cycle. The next layer as stated above is the compact myometrium – the junctional zone (aka inner myometrium) , and is followed by the thicker outer myometrium (maroon).

The junctional zone is hypoechoic  due to decreased water content, and is formed by smooth muscle cells that are tightly packed.  The extracellular matrix and water content are sparse.  It usually measures less than 8mm.

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Adenomyosis with Ectopic Deposits in the Junctional Zone

Two echogenic nodules (overlaid in green in image on the right) are present  in the subendometrial layer, (junctional zone) in a woman with menorrhagia. The nodules are in close proximity and  have appositional relationships with the endometrial stripe (yellow overlay). They distort the endometrial lining. These findings likely  account for the menorrhagia.  Included in the differential diagnosis are dystrophic changes in prior foci of adenomyosis and submucosal fibroids.  An MRI would assist to characterize  the lesions in the subendometrial layer.