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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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Adam and Eve: foundations of human biology

Essentials of Human Biology: 

The Story of Adam and Eve as they lay the foundations of humanity

Adam and Eve

Adam and Eve were the forerunners of human biology, who were charged with building society and humanity. They began with nothing but their common sense, human instincts, and a vision for the perfect person and community.

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As they stood observing the wonder of sunset and the ocean, they pondered the prediction that their seed would be multiplied as greatly as the stars of the heavens, and the sands on the shore.  This idea seemed unfathomable. They knew, however, that humanity needed a solid foundation.

From these early beginnings, they understood the most basic principles of life. The desired end was fulfillment of the physical, mental and spiritual needs of both the individual and the community. Their task was to design a template with universal application, one that could stand the test of time.

For the physical aspect they knew:

     1) Structure and Function were the basic elements of biology and life.

     2) Structure was made of parts.

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     3) Function consisted of 3 vital abilities: receive, process, and export.

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     4) Collaboration was essential, between:

          structure and structure, function and function, and structure and function

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     For the mental life, they knew essential elements were more abstract and included abilities in:

         sensory function

         memory

         thought

         judgment

         expressive function  

For the spiritual life:

the ultimate goal was to achieve Oneness, which conceptually was the most abstract and difficult to achieve.

Space and Time

Adam and Eve dealt with the physical constraints of space and time.  They understood that unlike space, time was progressive.  Time influenced both the individual life as well as the life of the species in perpetuity.

They knew the evolution of an entire species would require a long, almost indefinite amount of time. Since an individual life is relatively short, growth and especially reproduction in a single life cycle would be essential. Only a miracle could answer the challenge of creating a new life, and this miracle, unlike evolution, would be urgently necessary. Adam and Eve therefore turned to their Creator, and begged for this miracle as an immediate need.

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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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The Common Vein: Clarity in Complexity

Introduction 

The Common Vein (TCV) is a learning process that clarifies the complexities of biology and medicine.

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Complexity is the prodigy of the world.

Simplicity is the sensation of the universe.

Behind complexity, there is always simplicity to be revealed.

Inside simplicity, there is always complexity to be discovered

                                                                                                                        Gang Yu

The Common Vein is a tree of knowledge that brings simplicity to the complexity of human biology and medicine.  Its arborized organization enables a stepwise, progressive approach to self learning.  Any student who can read, and who is motivated, will advance through this rich network of material. Most principles begin with a simple word or concept, within which resides encyclopedic complexity.  The root elements of that word can be explained in a sentence, which then progresses in volume and complexity to a paragraph, then a chapter, then a book, and beyond.

Imagine a library with all of its books strewn over the floor.  It would be nearly impossible to navigate the available information. Efficient organization of information is the key to understanding it. This concept holds true in any field of education.

Organizing Information

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From a Background of Complexity to an Organized Simplicity 

The above art-piece shows a background of extensive, pixellated, and seemingly inaccessible information. As it organizes into the central, conical figure, it begins to make sense. The word at the bottom of the cone becomes defined into its key elements (the 5 different colors of the circle).  A definition follows, which succinctly describes the essence of those principles. These elements advance to greater complexity at the next level: the paragraph.  Each elemental principle is further expanded in a chapter.  The ladder of organized information progresses, while remaining connected to its source. Roots and branches, origins and growth, are recurring themes in The Common Vein.

As we learn, we acquire new knowledge. At the same time, we modify and enhance preexisting knowledge. Education should therefore be viewed as a process, rather than a collection of facts (Learning Wikipedia). TCV’s cumulative approach reinforces previous knowledge as it advances existing knowledge. With the understanding that memory and its application are so key to the learning process, TCV encourages beginning with the roots (basics) and building to the branches (details) in a logical fashion.

The Tree of Knowledge

Below is a diagram of knowledge in its bare form. From the central trunk extends an arborising framework, from roots to branches, which represents advancement, or growth.

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Roots and Branches: Sources and Growth

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Roots and Branches: Sources and Growth – Advancing Complexity

The trunk reflects a single idea or concept (tree), which is part of a continuum belonging to something beyond it (branches) and something before it (roots).  The tree’s roots and branches again exemplify the concept of building upon previous knowledge.  The trunk’s extensions, in the form of roots and branches, are complex yet logical in their organization. A tree’s growth is multifaceted, yet progressive. The parts work together for the sake of the single element: the tree. In the tree, complexity and simplicity coexist.

Principles

A distinct focus on principles, especially as a starting point, provides a useful framework for learning. The Common Vein’s is founded upon principles that grow in complexity, which helps the student navigate the daunting mass of biological and medical information.

Principles of Human Biology

The image below diagrams human biology in its basic parts:

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This diagram of human biology is structurally identical to the diagram above. This diagram shows that the roots of human biology lie in both the structural and functional sciences. Combined, those two sciences enable the miracles of the working body and working mind. This simple diagram captures the entirety of human biology. Beyond these base elements lies magical complexity, which we can never fully grasp.

Principles of Medicine

This diagram, again identical in structure to the two above, explains that the roots of human disease originate in the disorder of the structural and functional sciences. The branches of diagnosis and treatment have evolved in response to the need for order and health of the body and mind.

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This tree illustrates The Common Vein’s central theme. Each biological part has both a structure and a function.  When they are in order and work cohesively, there is health.  With disorder, conversely, comes disease. The field of medicine attempts to bring order using two major disciplines: diagnosis and treatment.

Because roots and branches remain connected, a change in one element means a consequence in the others. The disciplines of diagnosis and treatment are founded upon the ability to identify and treat disordered structure and function. For example, an obstructed coronary artery causes a heart attack.  The clot in the artery causes a structural problem, with a the functional consequence (damaged heart muscle).   Coronary arteriography diagnoses the structural abnormality, and a cardiac echocardiogram diagnoses the functional consequence (decreased muscle contraction).  The treatment aims to reverse the structural abnormality by dissolving the clot, as it also aims to reverse the functional abnormality.

The Common Vein

The Common Vein finds clarity in complexity. It navigates the learner through complex information in order to understand, remember, and apply the knowledge.  Two major elements are used:

  1. Basic principles, which are connected and advanced through
  2. An arborised organization.

The “common” in the common vein refers to basic principles, while the “vein” represents the arborised connections creating a tree of knowledge.

Learning starts from the most basic element, and with careful progression, advances in detail.  Learning evolves over time, as it builds upon and enhances previous knowledge. The tree’s roots of knowledge reflect the learner’s existing knowledge. They are connected to the branches, which symbolize the paths of growth.

The Common Vein requires requires the ability to read, and passion for the subject material. With those, the whole field of biology and medicine opens up, and eventually, students learn to apply this network of knowledge as thoughtful thinkers and practitioners.

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The Prostate and Its Magic Concoction

The One Who Stands Before 

A Poem About the Prostate  

by Ashley Davidoff MD Copyright 2016

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The Prostate 

You were named as the one who “stands before”

By the father of anatomy himself

Herophilus of Chalcedon who lived in the period BC

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Standing Before

Just before the coming of the great Jesus

And then you were forgotten

And then Galen briefly mentioned you 400 years later

And then you were forgotten once again

You have come and gone in the eyes of medical history

But you yourself remain unchanged

Lying quietly in the deep personal parts of the male

The mere size of a chestnut

Taking up central position

In structuire and function

Not many recognized nor knew of your genius

And even the great da Vinci never recognized you

Leaving Vesalius the first to make a little diagram

For some, you stood before the testy testes

And for others you have stood in front of the bladder

But it seems that most importantly you stand both before

And participate in, a great event

One that gives such pleasure to all mammalian males

And ensures survival for all

With great care you bring a magical brew together

Mixing 6 parts from the Seminals

With 3 parts of your own,

And a ½ a part containing the cells from the Testas

Leaving room for a tincture to be added downstream by the Cowpers

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Secret Concoction From the testes, Seminal vesicles, Prostate, and Cowper’s Gland

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Percentage Contributions

Your timing is impeccable

Ensuring that all come together

In the region of the verumontanum

The mountain of virility

So I imagine you in a dark and steamy room

Stirring up this magic potion

In a big brewing pot

With millions of cells and gallons of creamy fluid

Preparing for the great event

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Bubble Bubble Toil and Trouble

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

Uterus and Prostate on a Date .. and then..

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

The Date Progressed

And then it happens

Beautiful coordination

You shut the gates upstream with a clap

And open the gates downstream with a clang

And you add your squeeze

And you add your pleasure

And millions go rushing forth as the competition begins

To win the heart of the princess in waiting

Like a mother saying goodbye to her sons

On a mission in a far off land

You pack them with a whole bunch of goodies

For the long and arduous road ahead

And you know you will never see them again

In the pack you leave some food

And protective covers

Against the initial acid welcome

Of the cozy vagina

The brief respite

In the cocoon of coagulum

Slowly breaks down with your secret PSA

And when danger is all clear

And the medium liquid

Your boys are now reenergized

And the race begins once more

With a prize that only one in the millions

Will win

But they all race with their guts and gusto

For the heart of the princess in waiting

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Conception 

What pleasure you give us

Our backroom boy

What genius you and your buddies concoct

Standing before and in front of the great event

Without you we are infertile

How central you are to our survival

This poem previously published on  THE COMMONVEIN.com

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Art and Anatomy of the Prostate Gland

Prostate Gland  

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The Prostate – Mysterious Organ That Makes Love Potions

The prostate gland and seminal vesicles enrich the juice carried by the ductus deferens on the way to an important mission to ensure the survival of the human race.

The prostate is a part of the male anatomy. It surrounds the urethra, and lies immediately inferior to the urinary bladder. There is no analogous structure in female anatomy.

Structurally it is a chestnut-shaped bulb divided into concentric zones around the urethra.

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Three Concentric Rings Surrounding the Urethra and a Cap

The art piece shows a transverse view of the prostate and reveals the basic structural framework of the prostate.  It consists of  three concentric rings which include the peripheral zone, the central zone and the transitional zone which surround the urethra (U -yellow).  The most anterior surface consists of a cap of  fibromuscular tissue (pink). The prostate gland can be viewed as The peripheral zone, accounts for 70% of the parenchyma, the central zone accounts for 25% of the parenchyma, and the transitional zone with the  fibromuscular zone (anterior layer) account for the remaining 5% of parenchyma. 

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Parts of the Prostate in Sagittal View

The ART PIECE reveals the prostate in sagittal view. The peripheral zone (darkest maroon) is the largest portion and occupies the base, extending the entire length of the posterior wall to the apex. The central zone (medium red) lies inward of the peripheral zone and is that part through which the ejaculatory duct courses. The transitional zone (pearl white) surrounds the urethra, and the anterior fibromuscular layer (pink) runs from the base to the apex anteriorly. The ureter is overlaid in orange and the ejaculatory duct (yellow) empties into the widened portion of the urethra called the verumontanum

The prostate is comprised of approximately 30% glandular and 70% fibromuscular stromal elements.

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Glandular and Stromal Elements of the Gland

The diagram reflects the basic histological makeup of the prostate in axial projection. It is composed of 30% glandular tissue (white) and 70% stromal tissue (pink). The glandular tissue is made up of branching tubuloalveolar glands and the stroma consists of smooth muscle, collagen, elastic tissue and fibrous tissue. The compound tubuloalveolar acini feed into a system of ductules and finally form 30-50 excretory ducts that enter into the prostatic urethra. In this diagram the two ejaculatory ducts are shown posterior to the prostatic urethra, and represent the confluence of the ducts of the seminal vesicles and the vasa deferentia. At a slightly more inferior level of the axial cut, they will enter the prostatic urethra at the verumontanum

The function of the prostate is to secrete a fluid which combines with the secretions of the seminal vesicles, to form part of semen.  It is a truly a secret concoction and contains half of the recipe for all mammalian life.

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Love Potions Accumulate in the Prostatic Urethra Just Prior to the Opening of the Sluice Gates

The prostatic urethra serves as the mixing pot for the components of semen by acting as the receptacle of secretions from the prostate itself, the seminal vesicles and the vas deferentia. This artistic rendition shows the region of the verumontanum which is the site where the mixing pot stands receiving sperm from the testes via the vas deferentia (red), the secretions of the seminal vesicles (orange) and the secretions of the prostate gland white). The last component contributed by the bulbourethral glands (Cowpers’s glands – green) joins the secretions in the penile urethra to form semen.

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Volume Ratios of the Components of Semen Concoction

The diagram reveals the components of semen.  The fluid from the seminal vesicles account for 65-70% of the volume, prostatic fluid, 25-30%, sperm 2-5%, and fluid from Cowper’s gland represents less than 1% of the volume. Each ejaculate contains between .1-10mls (1-2 teaspoons) with an average of 3.5mls (Owen)

Common diseases include:  Prostate cancer, prostatitis, BPH, prostatism, and less commonly abscess

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Zonal Anatomy and Predilections For Carcinoma – Peripheral Zone

The diagram depicts the zonal morphology relevant to the locations where disease arises. The normal gland is seen in image (a). Image (b) shows BPH (benign prostatic hypertrophy) which is caused by hyperplasia and enlargement of the transitional zone (green). Image (c) shows carcinoma (bright lime green) arising from the peripheral zone which is the characteristic site of origin of this disease. Image (d) shows a combination of BPH in the transitional zone and carcinoma in the peripheral zone. This is a common combination of diseases in the elderly population.

Diagnostic evaluation is initially via rectal examination and the evaluation of a blood test called the PSA – prostate specific antigen.  Common modalities used for imaging the prostate include:  Ultrasound, MRI, CT scan

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Normal Zonal Anatomy – MRI T2 Weighted

The patient is a 60 year old man. His MRI was performed with a transrectal coil and the image shows the T2 weighted sequence in the axial projection (a,b). The scan shown demonstrates the normal zonal anatomy of the prostate. The outer peripheral zone  (maroon, pz) is often canoe shaped in the axial projection.  The central zone (dark pink, cz) accounts for 25% of the parenchyma. The transitional zone (light green), and the fibromuscular zone (light pink, fmz) account for 5% of the volume of the gland

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Normal Size Prostate 26 Year Old Male

The CT scan is from a 26 year old male with a normal prostate seen in the axial plane (a,b) and in the sagittal planes (c,d). The bladder (yelow) is distended. Note the shape of the gland in the transverse planer is heart shaped and in the sagittal plane almost rectangular when normal in size. The internal sphincter surrounds the top of the urethra at the base of the bladder and the urethra extends through the prostate as the prostatic urethra and into the penile urethra.

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Advantages and Disadvantages of Ultrasound

The series of US and CT scans are from a 50 year old man with an elevated PSA Image a is an ultrasound performed in the transverse plane, and show a minimally prominent nodular prostate. Image b shows the needle tip (teal blue arrow) in the left peripheral zone. Image c is a CT scan in the  transverse projection of the prostate and shows a nodular anterior surface while image d shows an almost 3cms external iliac node. The biopsy was positive for prostate carcinoma.

Whereas ultrasound is able to characterize the lesion and provide guidance for biopsy, it is unable to consistently visualise lymph nodes and hence CT is necessary for staging.  The combination of the two modalities is required.  PET CT is even more helpful.

Treatments Medical treatment includes the use of hormonal agents, antibiotics, and chemo therapy although in severe disease surgery and radiation are commonly employed.

The prostate is most easily conceptualised in the transverse plane by 3 concentric rings surrounding the urethra and topped off by an anterior cap

Histology

The prostate is comprised of approximately 30% glandular and 70% fibromuscular stromal elements.

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Glandular and Stromal Elements

The diagram reflects the basic histological makeup of the prostate in axial projection. It is composed of 30% glandular tissue (white) and 70% stromal tissue (pink). The glandular tissue is made up of branching tubuloalveolar glands and the stroma consists of smooth muscle, collagen, elastic tissue and fibrous tissue. The compound tubuloalveolar acini feed into a system of ductules and finally form 30-50 excretory ducts that enter into the prostatic urethra. In this diagram the two ejaculatory ducts are shown posterior to the prostatic urethra, and represent the confluence of the ducts of the seminal vesicles and the vasa deferentia. At a slightly more inferior level of the axial cut, they will enter the prostatic urethra at the verumontanum

Size

The prostate is smaller than one would expect.  It has been compared to a small kiwi fruit, small plum, an almond and a chestnut.  In fact after a small experiment involving the purchase of these fine fruits and nuts it was found that the chestnut was closest in size in all dimensions.

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Size of the Prostate

The diagram depicts the variety of structures that have been compared to the size of the prostate. After a shopping spree to Russo’s in Newton Massachusetts and some significant research into the true sizes of the fruits and nuts that have been compared to the prostate, it was found that the chestnut (e) is closest to the size of the prostate. The kiwi (b) and plum (c) were far larger and A-P dimensions particularly excessively large. The walnut (d) was close but A-P dimension too large, the plum tomato (f) too round, and the almond (g) too thin in the A-P dimension.

Shape

In the A-P projection it is cone shaped and almost heart shape with the apex directed inferiorly while the base is in contact with the bladder superiorly.

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The Shape of the Prostate and The Shape of the Chestnut 

The diagram depicts the chestnut and correlative artistic renderings in the A-P (a,b), transverse (c,d) and sagittal projections (e,f). The rounded anterior and lateral borders and flattened posterior border fit perfectly with the shape of the chestnut.  In the frontal projection the prostate is also heart shaped.

Position

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Frontal View of the Prostate – Central Position between the Bladder and the Penis

The diagram reflects the basic anatomy of the chestnut shaped prostate lying in the deep pelvis between the bladder above and the urogenital diaphragm below and surrounded by the obturator internus and levator ani muscles and the inferior aspect of the ischium and pubic bones. The prostatic urethra runs through the prostate and connects the bladder with the penile urethra.

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Immediate Neighbors of the Prostate

The CT scan reflects a normal prostate seen in the sagittal plane. The bladder is distended. Note the position of the prostate posterior to the pubic symphysis and anterior to the rectum (r =black bubble) covered posteriorly by Denonvilliers fascia. Superiorly it supports the bladder base and inferiorly it is supported by the perineal membrane.  (genitourinary diaphragm) The bladder is overlaid in yellow and the urethra is the channel overlaid in orange.

Character

Normal prostatic tissue feels rubbery, smooth, and symmetrical.

Blood Supply

The primary blood supply of the prostate comes from the prostatic artery which is a branch of the inferior vesical artery. Some accessory vessels to the prostate are supplied from the middle hemorrhoidal (rectal) and internal pudendal arteries.

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Blood Supply from the Anterior Branch of the Internal Iliac Artery

The diagram shows the blood supply to the prostate coming off a branch of the anterior division of the anterior division of the internal iliac artery.

Venous Drainage

The venous drainage of the prostate is via the prostatic plexus.  The plexus surrounds the prostate like a net and joins the venous drainage of the penis (deep dorsal vein) in Santorini’s plexus.  The periprostatic plexus consists of the anterior plexus called Santorini’s plexus that lies behind the pubic symphysis in the retropubic space of Retzius and the para-prostatic plexus called the pudendal plexus (vesicoprostatic plexus) which drains both the inferior aspect of the bladder as well as the prostate. The usual drainage of the prostate is via the internal pudendal vein which drains into the anterior branch of the internal iliac vein.  The plexus however does collateralize with the external pudendal vein which drains into the external iliac system, and the vertebral venous system or Batson’s plexus, which is the valveless system that drains the spinal cord and vertebral column. The intervertebral veins and the epidural venous plexus, collateralize at all levels of the spinal canal and vertebral bodies and also drains into the azygos system. Thus venous drainage goes three ways; internal iliac, external iliac, and azygos via the collateral systems of Santorini’s plexus, vesicoprostatic plexus and Batson’s plexus

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Venous Drainage of the Prostate

The diagram reflects the venous drainage of the prostate which is in common with the venous drainage of the penis and bladder. The dorsal vein of the penis divides into two forms a plexus anterior to the bladder called the preprostatic plexus of Santorini. This plexus collateralizes with the pudendal (para-prostatic ) plexus that lies on the lateral aspects of the prostate . The veins finally drain into the anterior branches of the internal iliac venous system via the internal pudendal vein.

Lymphatic Supply

Lymphatic drainage from the prostate is via the internal iliac, sacral, vesical, and external iliac nodes.

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Lymphatic Drainage

The lymphatic drainage from the prostate is accommodated by the external iliac nodes, internal iliac nodes which will both drain to the common and para-aortic systems.

Nerve Supply

The autonomic nervous system helps to control the function of the prostate gland.  The parasympathetic division of the autonomic nervous system regulates erection, whereas ejaculation is triggered by sympathetic impulses. (Ventura)   The hypogastric nerve (sympathetic) join the pelvic splanchnic nerves (parasympathetic S2-S4) to form the pelvic plexus.

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The Sympathetic Innervation by the Inferior Hypogastric Plexus with Contribution from L1 and L2

The diagram reveals the sympathetic nervous system of the body and in this instance attention is drawn to the innervation of the prostate by the inferior hypogastric plexus, with contributions of L1 and L2

Aging

At birth the prostatic acini are lined with squamous epithelia.  Stimulation of further development of the gland is dependent on maternal steroids, namely estrogens. As the levels of these hormones decrease, an involutional phase ensues during the first 5 months. Large transient surges of serum androgen, estrogen, and progesterone normally occur very early in postnatal life. This is usually between 2 to 3 months of age. At this time, levels may reach upward of 60 times normal prepubertal levels, approaching adult serum testosterone levels.  The prostate increases rapidly in size at puberty. During the fifth decade, it starts to show the effects of aging either resulting in atrophy but more commonly hyperplasia.

 

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Getting Older and Bigger – The Story of the Prostate

The artistic rendition is of the normal prostate enlarging with time most commonly due to hyperplasia of the transitional zone. The diagram shows the normal cone shaped gland in maroon in the center with the ductus deferens (yellow) and seminal vesicles. The normal prostate is about the size of a kiwi fruit usually weighs between 20-30gms and has a maximum transverse diameter of 4cms, but can double in size

Then I grew old… and bigger and then
“The eternal battle of the streams: initially both robust,
eventually, both to rust.

Like basketball in reverse,
first shoots, then dribbles.” (Hyde)

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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

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

 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 2016

Ashley Davidoff MD

 

 

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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!