Relations Links and Connections
“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.
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.
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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.
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
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Bonds Cement Bridges Joints Interstitium Connective Tissue Ligaments Sutures Vessels
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From Head to Toe
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Vessels Nerves and Lymphatics – The Cables
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Other Biological Units Connecting
Other Units Connecting
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Links and Connections in Disease
Disease of One Causes Disease of the Other
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