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Do we cry because we’re sad – or are we sad because we cry?

My recent foray towards the humanities exposed me to the William James quote above which got me thinking on a recent holiday.

On this holiday I found myself on the Island of Capri (I was just there, it wasn’t some sort of spiritual epiphany). The Island has two towns, Capri and Anacapri, the later been known for its chairlift to the top of the Island.

I don’t really do heights but to put that into context, I took up skiing for my Duke of Edinburgh because I knew if I got good enough I would have to tackle cable cars and chair lifts and I took up amateur dramatics because I hated public speaking so, don’t like things but definite tendencies towards feeling the pain and doing it anyway.

And so, having declared that I was not going to ride this chairlift, I found myself at the base station, ticket in hand and my fit bit telling me that my resting heart rate was 110 – it’s usually low 60’s.

It was at this point, in an effort to think about something else, that I was reminded of the blog post title, and my favourite derivation of it ‘Do we stop playing because we get old or do we get old because we stop playing?’

Was my heart rate 110 because I was scared or was I scared because my heart rate was 110.

Having had a trip the previous year to Adelboden where we went on half a dozen cable cars and my pulse was over 100 for the whole day, I can confirm that it makes you feel very ill and you start to worry that something serious is going to happen. That is the start of a vicious cycle that leads to a full blown anxiety attack. You don’t want to go there when you are hanging in a chair from a cable all on your own.

So, what was happening? I was perceiving the chair ride as a threat to my life and limb and so my body was going into ‘fight or flight’ mode.

The second I thought about the chair lift, I was hijacked by my amygdala. A small almond shaped part of my brain which posed the eternal question, ‘Should I stay or should I go now?’ (You will remember the tune to the well known song.)

Because either option is going to require energy, the amygdala kicks your adrenal glands into action to produce adrenaline. (They are also called your suprarenal glands because they sit on top of your kidneys and adrenaline is also called epinephrine but that doesn’t sound so logical.)

It isn’t that simple though, far from it. Your amygdala tells your hypothalamus that there is cause for concern. This then produces a hormone called Corticotropin releasing hormone (CRH) which acts on the anterior (front part) of the pituitary gland. This is only a few centimetres away from the hypothalamus but they communicate by releasing the hormone into the blood stream – so now everywhere knows there is cause for concern.

The anterior pituitary responds to this by releasing adrenocorticotropic hormone (ACTH) which tells the adrenal glands to produce adrenaline. This whole network is called the Hypothalamic-Pituitary-Adrenal network or HPA for short (because everyone has to get a mention).

The end result is that your body is flooded with adrenaline along with steroids, corticosterone and testosterone. Your likely to be more snappy and aggressive (just speak to anyone who has shared a cable car with me), your heart rate will increase, you will sweat and feel sick.

This whole process takes milliseconds. It has developed so that in situations of real danger you are ready to act. A chair lift is not a real danger. Most of our stressors today are not real dangers. Robert Sapolsky has written a great book on it called ‘Why zebras don’t get ulcers’. You should read it.

Standing there waiting to be scooped up towards oblivion the summit, I was able to pull my frontal cortex into play, the part of my brain that had been bypassed; the part responsible for rational thought.

There must have been a moment when my brain decided I needed to be scared and yet I didn’t have the symptoms. The symptoms were caused by my reaction to the chemicals that my brain had caused to be released. My brain had decided I needed to be ready to act and that had caused me to be scared. (This encroaches on whether I am more than my brain – which is a whole different blog post).

Speculating on this got my pulse down to 80 and saw me arrive at the top of the Island.

Weirdly I don’t get the same reaction on the way down where the risks are exactly the same – go figure. Neuro is weird!

This art by @DrRabbitHeart sums up the process. Thanks for letting me use it!

Human remains as a tourist attraction?

I have just returned from a holiday in the South of Italy where we did the trip to Versuvius, Pompeii and Herculaneum.  For those of you who are not aware, Mount Versuvius erupted in 79AD and destroyed four Roman settlements; Pompeii, Herculaneum, Oplontis and Stabiae.  The first two have been excavated to some extent.

Pompeii was buried under 6m of ash killing many of the inhabitants before they could escape.  It attracts over 2.5 million visitors a year.

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This is an area on the main forum in Pompeii.  the enclosures contain artefacts that have been found over the site.  Guess which two contain human remains?

Pompeii is rather unusual in that when they were originally excavating the site, Giuseppe Fiorelli, the archaeologist, found cavities within the ash.  He wondered if these were where the people had been and so developed a technique of pouring plaster into these cavities before they were excavated.  What this process produced was very detailed life like casts of the people who had perished at Pompeii.  These casts are displayed around the site.image4

Some of these casts are fairly rough like this cast of a person who clearly huddled into hiding spot hoping they would be safe. Some are much more detailed like the group that were found within a garden.  The story is that they were a family group trying to escape the city.  The first figure does have a bag of some sort and the group is clearly a mix of adults and children.  The detail captured in the face of the man is amazing.

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I was prepared to believe that these were not human remains but were plaster casts of the spaces and then we came across this selection of the casts in a store within the city.

image2This is the cast of a four year old child.  you can see the roughness of the plaster that is the same as many of the other specimens.  Now look at the top of the child’s head.  That looks like very smooth bone.  When we got back to the UK I did a little research and found out that the 86 original plaster casts have been through a CT scanner.  The remains of that child are enclosed within the plaster; the smooth surface at the top is the actual cranium.  We did find multiple copies of the same casts around the city so it may well be that the originals containing human remains are not actually on display but these are the items that people come to see in Pompeii – why?  What is it that attracts us to human remains?

We moved from Pompeii to Herculaneum.  Herculaneum differs from Pompeii in that it was covered in pyroclastic material rather than ash and so much more of the city has been preserved including the original wooden beams.  The buildings were not destroyed under the weight of the ash resulting in many two storey buildings still being present.  Herculaneum suffered a pyroclastic surge which means that gases at a temperature of 250oC passed through the town at 100mph.  A little ash had fallen on the town in the first day of the eruption and it was thought that most people had evacuated the coastal town.  It is only in recent years (1981) that they have excavated down to the boat houses and discovered 55 skeletons with another 250 being discovered in the 1990’s.image1

The skeletons were found in the boat houses which are the arches at the bottom of this photo.  It is the highlight of the tour and people took multiple pictures.

Its difficult to know whether these are actual human remains or not.  You can find differing opinions, although the majority seem to think they may well be genuine.

I am troubled by this desire to see human remains.  Why do people flock to these sites?  It was clear from the crowd distribution at both sites that human remains are a big tourist attraction and there did not seem to be any qualms about photographing what were either the skeletons of people who were essentially vapourised or the cast of the final fearful moments of someone trying to escape a deadly ash cloud.

Did it add anything to the experience?  Did it allow people to connect to the human tragedy?  I would argue that it didn’t add anything that a model couldn’t have added but as one of my fellow tourists pointed out, that would have cost more than using the actual human remains.

I would have thought human remains couldn’t be equated to a financial equivalent, isn’t that what the Anatomy Act was all about?

Full disclosure – I am associated with the Anatomical Museum at the University of Edinburgh which, along with every other anatomical museum displays human remains.  Those that are not historical have consent.  I am the author of a book on William Burke whose human remains are on display and who people travel to see.  It was explicitly part of his sentence that his remains be on public display.  I have profited from that publication.  Those profits have been shared with the museum and the Oddballs charity (you will have to attend a talk, or read the book, to find out why.)
The irony of this post is not lost on me.

 

Technology. Does it help?

I have been at a few meetings recently where the use of technology has been discussed and I think it poses a few interesting questions.

Does technology help us?  Does it enhance our engagement and does it enhance our education system (I do not believe those are the same question.)

I have resisted the need to have a voice controlled device in my house.  I am perfectly able to walk across the room and turn the light switch on myself and I can pick my own play list – in fact last week I was listening to vinyl so even had to get up to turn it over.

I think you would have to be a dyed in the wool luddite to argue that technology hasn’t helped us in some ways – the off shoots, maybe not so much.

Has it helped with our engagement, and from my point of view, anatomy engagement?  I use the curioscope virtuali-tee to talk to people about their organs.  There is no denying that this is a magic bit of kit and this week it took a big step forwards.  Through some fancy technology, the t shirt can now show your actual heart beat!  You can put on the shirt and see your resting heart beat, run around the block and see the increase.  I can’t wait to show this to a class room of kids.  It blows their mind when they see the organs anyway, to see it actually responding to what they do is going to be great!

Does this technology help medical students learn?  You would think so wouldn’t you and yet there don’t seem to be too many studies looking in to the effect it has on grades – it’s a bit too early to tell and cash strapped Universities don’t want to invest heavily without any proof that it is beneficial to the students.

This week I got to try out a virtual reality anatomy teaching tool.

It was an unusual experience.  A group of 6 of us standing in a room wearing headsets looking at anatomical models that were not there.  You could push your face in towards the model and look at what was inside the chest.  You could look down through the layers of someones abdominal wall and see the layers of muscles.  Did it help me understand it any better than models and books – not sure.

The week before I saw a demo of another virtual reality set up from an Australian University.  They had one head set, and a corner of their room was cordoned off and had a crash mat on the floor.  In this set up you entered a virtual lab where shelves were full of models.  You could take a virtual model and place it on a virtual podium which then blew it up to massive proportions inside the virtual room.  Then you could walk inside!  This way you could end up standing inside someones skull looking at the blood vessels.  You could see how they all fitted together, you could understand the flow of the blood.  For something like neuro I could totally see that this would be a valuable learning tool but again, one headset, hard to produce any evidence it does effect grades.

Does technology always have to be computers?  I suppose it does now but I think there have also been advances with ancient technologies.

We have run several successful workshops on modelling facial muscles with wax.  Its not really a technology nowadays but I’m sure at some point, back in the day, it would have been thought of as ground breaking.

There has been some interesting developments in the UK using plasticine to model muscles in the throat.  Its not quite the wow factor of VR but its a lot cheaper to try out.  it would be an interesting little project to see which enhances learning more – the lump of clay or the VR head set?

 

Knee Injuries

We recently ran an anatomy workshop for Yoga Instructors with Meadowlark Yoga.  I ran a session on the most common injury in Yogis; left knee medial meniscus tears. It had such fantastic feedback that I thought I would repeat it here to help spread the message further.  Obviously it is here without the cadaveric specimens but I hope the drawings and your imagination can fill the gaps.

 

The most common injury in Yoga people in left knee medial meniscus tears.  Why should that be?  I’m hoping that if I explain a little of how the knee joint works you may be able to work out what the problem is and what can be done to mitigate it.

The knee is the most complex joint in the body.  You only have to look at the diagrams to appreciate all the tendons and moving parts that make up the joint.

To keep it simple, the joint is not a hinge joint as it is often described. The articulating surface of the femur is a lot larger than the articulating surface of the tibia in the lower leg.  As the joint hinges it also has to slide to ensure these surfaces stay in contact with each other.  It is the role of the cruciate ligaments, both anterior and posterior, to ensure that the femur does not slide too far in either direction

To further increase the surface area at the top of the tibia we find two semi circular shaped cartilage wedges (thicker at the edge of the knee, so almost triangular in cross section).  These increase the surface area and also help to hold the femur in place on top of the tibia.

These semi circular wedges are the menisci, one lateral – to the outside of the knee, and one medial – towards the inside of the knee joint.  As you can see in the diagram above, the lateral meniscus is not connected to the ligaments at the side of the joint and so it is held in place only at the two end of the C shape.  It can move around more easily inside the joint than the medical meniscus which is joined to the ligament at the inside of the knee joint.

As the knee flexes (foot moved towards your bottom) the menisci move to the back of the joint. If your knee is fully flexed then your menisci are quite safely held at the back of the joint.  How many people do you know who can get their foot all the way to their bottom?  If your leg isn’t fully flexed then the menisci are in the process of moving backwards.

The knee isn’t only a sliding hinge joint, it also has a degree of rotation.  If you have a straight leg and rotate the limb then all of that motion is coming from the hip.  If you now bend your leg you can get a few degrees of rotation at the knee joint.

If you medially rotate your lower leg, turn your big toe in towards the centre of your body then this will cause the medial meniscus to move forwards and the lateral one to move back.  Just pause for a moment and imagine the two bones on top of each other, rotating and you can see what would happen to the menisci if they are just held at the end of their C shape.

Now imagine what you are asking your knee to do if you medially rotate your lower leg whilst also flexing your knee joint.  This is the equivalent of reaching down, grabbing your foot and lifting it up towards your stomach, something you see quite a lot in an exercise setting.  The flexing motion is asking your menisci to move back and the medial rotation is asking your medial meniscus to move forwards.  You are trying to move the same piece of cartilage in two opposite directions at the same time!

So why left knee injuries?

It’s traditional to go into the lotus pose in yoga with your right knee first.  This means to bring the left knee into this pose you have to lift it over the right leg that is already in position.  It doesn’t matter how flexible you are – that is an impossibility.  The result, you are twisting a not fully flexed knee.  It is a potential risk for the meniscus.

What can you do to help it? Don’t do lotus or if you are not prepared to go that far – or you can’t do lotus anyway so you want to know how to protect your knees for other poses – try to laterally rotate your lower leg if it isn’t fully flexed.

Rather than reaching down and grabbing your toes, reach underneath and grab the heel.  Ensure that if you move your lower leg at all that the toes would rotate outwards rather than inwards.

I’ve written about anatomical issues with the lotus position for yoga moo if you want to see the article on hip rotation than click here

 

 

Lost in translation

How often have you heard something and thought that maybe the message has lost something in translation.  It’s a challenge in communicating to people about how their body works.

I have spoken before about how when you raise your arms above your head, you need to rotate the arm otherwise a lump of bone at the top of your arm bone (humerus) bangs into your shoulder bone (scapula) and your shoulders end up around your ears.  For years exercise instructors would tell people to correct this by pushing their shoulders down not realising they were asking them to do something anatomically impossible.

I was treated to an excellent example of this message getting corrupted last week.

In an exercise class, the instructor asked us to take our arm above our head.  The way we had approached this in the class meant that our arm was actually rotated anyway.  Then they added to not forget to rotate your arm so that your shoulders stay down.  At this point they then spun their hand over to face in the opposite direction.

Where to start?

Clearly they had heard about the shape of your arm bone affecting your shoulders.  Great!

They didn’t remember what side the lump of bone was (or maybe weren’t told) and so were suggesting the arm be turned the wrong way.  Not so great.

They rotated their hand to correct the problem. Doesn’t work!

Why doesn’t it work?

Your forearm is a master piece of engineering that can place your hand in a wide range of positions.  That is really the whole point of the arm; to position the hand in space.

You can turn your hand through almost 360 degrees.  This is achieved by a combination of shoulder rotation and a twisting action at the forearm in a movement called pronation or supination (depending which way you go). Supination is when the palm is facing up in a way you could put soup in it.

 In anatomy we have this position called ‘anatomical position’.  This is someone standing up with their hands by their sides and their palms facing forwards.  Anything towards the mid line is called medial, anything towards the edge of the body is called lateral.  Your thumb is lateral, your pinkie is medial.  Doctors use this language to ensure they are talking about the same part of the body.  It does not matter the position you are in, everything is referred to as if it were in the anatomical position.  Your thumb will always be lateral, even if you turn your hand around.

As you can see from the image, pronation and supination are movements that happen around the elbow joint – its actually a little joint at the side where the two bones in the forearm meet each other.  The radius (the lateral bone on the thumb side of your forearm) can rotate around the other bone (ulna) allowing the hand to face in the opposite direction.

So, we get in to position in the class and then flip our hand around to face the other way.  has it had any effect on our shoulder? No.

Has the instructor covered enough anatomy to know that was going to have no effect on the shoulder?

Does it matter?  Maybe not, but it is fairly fundamental.  You can’t look after your body to the best of your ability of you don’t know a little bit about how it works.

 

 

And on that Note

Last week I was at a concert (how on earth is she going to relate this to anatomy?)

Whilst the way in which we hear is fascinating and complex, I actually wanted to talk about public engagement and getting your message across.

We have all heard the message about how you should lift with your legs, keep your back straight and bend at the knees and hips.  It must be one of the most prominent messages about people’s anatomy, and yet, does anyone ever listen to it?

I watched as the young people cleared away the instruments.  This included lifting several heavy percussion instruments onto a stage that was about three foot high.  One of the lifts involved 8 people.

The kid at the left hand end was the only one that I saw keeping a straight back and lifting as instructed. (This is because he has had anatomy forced upon him at home)

Some of the lifting techniques being displayed were truly wince inducing and I’m sure they will be making physical therapists wealthy for a long time to come.

Why are we so bad at taking in messages that are meant to do us good?

It is the eternal battle of public engagement.  Engage without preaching. Make what ever it is fun and relevant.

Anatomy should be so easy to make relevant – we all have it.

As we enter the International Science Festival I wonder if we will be able to get our message across any better than those people who deliver manual handling courses.

 

 

Sum of your parts

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I was recently struck by a phrase in BBC’s silent witness.(This is not unusual, I have friends who work in forensics, I am often bombarded with phrases about silent witness, although I note that it is now much clearer that they are an independent lab and not part of the police force.  Do we sub contract out forensic investigations? – I digress)

 

The phrase was said whilst watching a post mortem when a body is reduced to weights and measures and it was ‘that we are so much more than the sum of our parts’

Never is this more true than in the case of Neuroanatomy.  We take a mass of grey and white cell matter and we divide it into areas, we name things (in fact, being anatomists we name things several times over; is that your putamen or your lentiform nucleus?)

We identify pathways we draw on areas but when it gets down to the fundamentals, we still aren’t sure how it works.

It’s great to get the opportunity to make people stop and wonder about the body that they are living in.

I recently had a conversation with some students about reflex arcs.  They had drawn out a lovely team diagram of a reflex arc showing a hand being pulled away from a flame. They clearly understood it and were finished earlier than the other groups.  How to keep them occupied?

Do you want to draw out the diagram for standing on a LEGO brick?

There was almost an audible tut, a few minutes later they had drawn out exactly the same diagram replacing the hand with a foot.

That’s great! Is that what actually happens?  You walk across the room, stand on a LEGO brick and lift your foot directly up?

‘No, you usually stumble a bit and swear.’

Ok, why do you stumble? What would happen if you just lifted one foot directly up?

‘You would fall over.’

Exactly, so what else has to happen?

‘You must tighten up the muscles down here’, ‘but wait you stumble so you must loose your balance.’  ‘It must go up to the cerebellum!’  ‘But how do you know you’ve lost your balance?’  ‘It must have inputs from the eyes and ears.’  ‘But wait, you swear, it must involve the speech areas.’ ‘Do you need to double check it’s appropriate to swear, do we need a feedback loop in there?’

Their diagram expanded, it drew in things they had learned about weeks before.  It had gone from a simple little loop to a series of pathways that all happen in the blink of an eye and all subconsciously.

We are so much more than the sum of our parts.