PROFESSOR: Back
with blood vessels,
and the blood to the liver.
The liver is extremely
rich in blood vessels.
It will get oxygenated blood
through the hepatic artery.
So first we have
the hepatic artery,
and it will be
giving the O2 blood.
Does anybody know where the
hepatic artery comes from?
STUDENT: [INAUDIBLE].
PROFESSOR: No, good
guess but not right.
That's all right.
No, from the celiac.
Do you remember the celiac?
Not too well.
Where is Cecilia coming from?
STUDENT: The abdominal aorta.
PROFESSOR: The abdominal aorta.
Good for you.
Now the second blood supply
coming in to the liver
is your hepatic portal
vein, hepatic portal vein.
And it will be
bringing in nutrients
from the stomach
and small intestine.
So we'll learn what
it does with these
when we study the liver itself.
But I just wanted to give
you the livers blood vessels
because it is so rich.
Anybody know?
Anybody who's had an accident
and torn open the liver?
Yes, tremendous hemorrhagic
situation occurs after that.
All right, now let's look at
some of the disorders of blood
vessels.
We've talked about
aneurysms, let's just
look at one for a moment.
Sudden aneurysm is a
weakening and a swelling
of a vessel wall.
Weakening, swelling
of vessel wall.
So we're just going to take an
aneurysm of the aortic arch.
So we'll have our normal
arch, something like this
if this is our ascending
aorta, coming out of the heart,
giving rise to our aortic arch.
And if we have an
aneurysm, then it
will look something like
this with the swelling.
So this will be my aneurysm.
So we want to replace
it, so we have
to tie off the
input, the output,
and remove the
aneurysm, and replace it
with a Dacron sleeve.
We'll just put it up here.
Here's my Dacron sleeve.
So replace with Dacron sleeve.
And they always give
heparin, an anti-coagulant,
after they put in a
replacement because you
may have an un-smooth surface
as the bloods going through
and we may get clots.
So you administer heparin
to prevent clotting.
Now another disorder
with the vascular system
will be hypertension,
hypertension.
Which as you know is
high blood pressure.
Reportedly, one out of
five adults in America
have hypertension.
So what is normal
blood pressure?
120/80.
What does that stand for?
120 is the force of
systolic pressure, force
of systolic pressure, with
ventricular contraction.
And the 80 then represents the
force of diastolic relaxation,
as it's filling force
of diastolic relaxation,
while filling because we said
that's what diastole was.
So then what is
the threshold that
lets us know we're in trouble
with our blood pressure?
So the threshold for high
blood pressure is 140/90.
That's the threshold for
high or hypertension.
So it's important
that we learn how
to reduce high blood pressure.
All sorts of meditations
that we can learn,
our tai chi, our yoga.
Now one other.
Varicose veins, for
another disorder.
Varicose veins is
the swelling of veins
in the lower extremity.
The swelling of
superficial veins.
Swelling of superficial
veins in lower extremities,
called varicose veins.
What causes them?
Obesity.
You got all this fat
up here and there
are no muscles
contracting to keep
those veins getting rid of
the blood, so the veins swell.
So obesity, pregnancy--
I think we mentioned
this already--
that pregnancy can put pressure
on the inferior vena cava,
preventing all the blood coming
from the lower extremities
so the veins swell.
And also, hereditary.
Maybe your mom or dad
has varicose veins,
then you have to be alert
that you might as well.
STUDENT: [? How ?] about age?
PROFESSOR: How about age?
Age isn't a factor
if one's healthy
because to help
those veins you have
to have good skeletal muscle
in your extremities, right?
So if somebody in your
family has varicose veins
then you keep your legs,
go on the treadmills,
do all these good things.
Aha, any how.
You can work to prevent
them in most cases,
but this gives you some
examples of problems with veins.
So we're going now to
our lymphatic system.
How many thought about your
lymphatic system this morning?
How many have ever thought
about their lymphatic system?
It's like everything else,
you pay no attention to it
until something goes wrong.
So let's go to our
lymphatic system.
So what does it consist of?
Lymphatic tissue, and
lymphatic vessels, and what?
Lymph.
So what are our
lymphatic tissues?
We have the spleen,
lymph nodes, lymph nodes.
We've talked about a
mass of lymphatic tissue
that was sitting on
our great vessels.
What did we call it?
STUDENT: Thymus.
PROFESSOR: Thymus.
We'll see in a moment
where our tonsils are.
If you've heard of your tonsils,
and so-called Peyer's patches.
Ever heard of Peyer's patches?
Never knew you had them?
I'll show you slide of them.
You'd Be surprised
how many there are.
So Peyer's, after Mr.
Peyer's, a Dr. Peyer's who
first found them.
Peyer's patches.
So these are all examples
of lymphatic tissue.
So let's take them one by
one, see why we need them all.
Take the spleen to begin with.
You know, I tried at
the Rotary Club one day
too, a big audience
as big as this,
and asked how many knew
what their spleen did.
One hand went up.
How many had had
a spleen removed?
Same hand.
Has anybody in this class
had a spleen removed?
You know, I've had the same
thing happen in this class.
I'll have one student who
knows about the spleen.
And strictly, you don't care
about it till it goes wrong,
then you get it removed.
So, spleen.
It's the largest mass of
lymphatic tissue in your body.
So we'll start and give it that.
Largest mass of
lymphatic tissue in body.
How big is it?
It's five inches by
3 inches by 2 inches.
What does that tell you?
STUDENT: As big as your heart.
PROFESSOR: Same as
your heart, right.
So you don't forget the
size of your spleen.
Or talking to little
kids, size if your fist.
Makes it more tangible.
Or big kids if you want.
Now where is the spleen?
It's in the upper left
abdominal quadrant.
What do we mean by that?
Location, let's put it on our
diaphragm, our abdominal walls,
our inguinal ligaments,
and our umbilicus.
So this represents
our abdominal wall,
and we just make
it into quadrants.
You'll find those
going into surgery,
you talk about
this all the time.
So we've got the upper--
this is my upper left
abdominal quadrant.
Where are you going to tell
somebody the appendix is?
STUDENT: The lower right.
PROFESSOR: Lower right, sure.
Right down here.
But it immediately
helps you define area
with regarding
underlying organs.
So here we're going to have--
put in our spleen,
but we're going
to use the stomach coming
through the esophagus here.
And we have what's called
the fundus of the stomach,
it curves in this way,
and then the stomach
comes over onto the left side.
So I first have
put in my stomach,
and the swelling here--
sorry-- is the fundus.
And the spleen will sit between
the diaphragm and the fundus.
So it caps the fundus here.
So you can quickly tell
anybody, spleen is right here.
So in yellow is our spleen.
Now, why do you have a spleen?
What does it do for you?
It's designed, as we'll see
in a moment, to filter blood.
How long did we
say your RBCs last?
STUDENT: [INAUDIBLE].
PROFESSOR: 120 days.
So it destroys old RBCs.
And it's the largest mass of
lymphatic tissue in the body,
so it's producing lymphocytes.
So how is it built then to
carry out these functions?
It has a connective
tissue capsule.
This is our ct capsule made of
collagenous and elastic fibers.
Collagenous and elastic fibers.
It's covered by a
layer of peritoneum,
which we'll talk about when we
get to the abdominal cavity.
Your peritoneum, which
is a serous membrane
of mesothelial cells.
A serous membrane of
mesothelial cells.
Then to give it
internal support,
it has trabeculae, made
of a collagenous fibers,
that divided it off.
These represent trabeculae,
their collagenous fibers, just
giving the internal support.
As well as, a reticulum.
A reticulum means a network
of reticular fibers.
And we can just crudely sort
of put it in our network
because, see, we've got to
be filtering blood here.
Blood's got to be
able to go through.
So, equal a reticulum.
Many organs have
reticulums, which
is a network of
reticular fibers, much
thinner than collagenous.
And on those reticular
fibers sit macrophages.
So to destroy pathogens that
may be coming in, hundreds
of them-- just
illustrating a few--
macrophages destroy pathogens.
And we're bringing
in arterial blood--
splenic artery, splenic vein--
so it can filter through
all this reticulum.
But on the reticulum, we have
what is called the white pulp
and the red pulp.
White pulp-- just so when you're
getting an exam and you see
white pulp you know immediately
it's spleen and it's not
a lymph node for example--
red pulp.
And the white pulp consists
of a central artery surrounded
by masses of lymphocytes,
just a characteristic feature
of the spleen.
Central artery and lymphocytes.
So we'll see the
white pulp up here
in the cortex of the kidney--
looks like a kidney--
of the spleen.
So if you're asked to point
that out in your slide in a lab,
you go up here for it.
So there is an example of
what's called white pulp.
The majority of the
spleen is red pulp,
and it consists of just blood
sinuses with lymphocytes.
So all of this will have
blood with lymphocyte.
No specific structure,
but it gives you
the basic fundamentals
of how blood
can come in, be filtered, and
go out through the spleen vein.
Now in contrast we
have-- let's just
be sure I've covered
everything on the spleen
because it is important.
No, that's fine-- lymph nodes.
Lymph nodes, again, are oval
bodies, but it's much smaller.
Small oval bodies.
They can be anywhere
from one millimeter
to several centimeters.
To put it in something
that you're familiar with,
one millimeters could
be the head of a pin,
and several
centimeters, lima beans.
Does anybody eat lima beans?
A few.
Why don't you like lima beans?
I could tell you stories about
lima beans but I won't but--
just giving you an example.
Perhaps you don't even
know how big they are,
but I was putting lima beans
in here as an example for size.
And where do we
find lymph nodes?
They're usually in groups,
I'll give you just few.
Location, in-groups.
Let's give you the cervical
because most of you
probably know those.
Cervical lymph nodes,
obviously they're
going to be in the
neck, They're going
to be on the medial border
of your sternocleidomastoid.
So now you know your
sternocleidomastoid,
palpate it.
Go to your medial border.
You're not there.
There you are.
Do you feel lymph nodes there?
Probably if you
don't, you're healthy.
Anybody feel big ones?
You know when doctor
feels your lymph nodes
when you've got an
infection in your throat.
Right, you don't
get sore throats.
All right, so this will
be on the medial border,
over the sterno--
just another way for you
to review your muscles--
sternocleidomastoid.
Then we have the axillary
group lymph nodes.
So you know where
they are by the name.
Why do I give those?
These are in the axilla
or armpit if you prefer.
Because it's important that
women know their axillary lymph
nodes well because
with breast cancer
the breast cancer cells will
travel from the breast cancer
in the lymph nodes.
And the first ones it's going
to encounter the axillary lymph
nodes.
So we use the term
metastasize, that breast cancer
cells metastasize,
they mobilize, and go
to the axillary lymph nodes.
Metastasize to
axillary lymph nodes.
So women are always told to
palpate their own breast, told
to look for nodules, but you
palpate your axillary lymph
nodes as well.
Because when they do a
mastectomy, remove the breast,
they have to take out where
the cancer has traveled.
You'll find that cancer
travels all over,
the brain gets lung cancer.
We've had brains
in lab where just
filled with lung
cancer, metastasized
from lungs, gets in the
lymphatics, goes to the brain.
When you get into
the field you'll
find how important it is to know
your lymphatic system, what's
draining what.
So when you get
abnormal enlargements--
Let's just take one more.
The inguinal lymph nodes.
You remember studying
inguinal lymph nodes?
Do remember having N-A-D-E-L?
What did L stand for?
Lymph node.
So you know exactly
where they are.
You know where your inguinal
ligament is, you come medially,
and there you could palpate.
Has anybody had an
infection in your foot
and get swelling in
the inguinal region?
Nobody?
Nobody go barefoot when you were
little and get stung by an ant?
Really?
Anybody grew up in
Southern California?
We always had swollen
inguinal lymph nodes
because were little
kids with bare feet.
No?
All right, times have changed.
Nobody eats lima beans
and nobody got ant sting.
Modern population.
All right, the inguinal lymph
nodes, you know where they are
and you're never going to
forget your navel to remember
the relationships here.
So that gives us our
location of lymph nodes.
So now, let's see
what their function is
and then we'll look
at their structure.
So we've looked at function.
Well, lymph nodes
will filter lymph.
What did the spleen do?
STUDENT: [INAUDIBLE].
PROFESSOR: Pardon?
STUDENT: [INAUDIBLE].
PROFESSOR: Filtered blood.
A big difference
between the two.
We need these two
filtering systems.
The lymph nodes will
produce lymphocytes,
and will produce plasma
cells, which we've had.
So these are main functions--
there are others--
of our lymph nodes.
So let's see how
they're designed
in contrast to the spleen.
The spleen was filtering blood.
We have to filter lymph.
We have-- make them big
just so see you could see
them-- these oval lymph nodes.
We're again going to have a
connective tissue capsule.
We're going to have
some trabeculae.
But what is different
here is the arrangement
of the vessels coming
in and going out.
In the large
curvature here, we're
going to have afferent
lymph vessels.
These are afferent
lymph vessels,
and we'll have
efferent lymph vessels.
E for exit.
Efferent.
And again we'll have a
reticulum because we're
going to be filtering lymph.
And we'll see an arrangement
of lymphatic nodules
where lymphocytes
are being developed
in these compartments.
You'll have lots of them.
So the lymphocytes then
will come in, and go out
through the limb vessels.
And we'll have a constant
source of lymphocytes being
produced, no central artery.
Now what is lymph?
Hm?
What do you think lymph is?
Lymph is a tissue fluid, so it's
mostly water just like blood.
Consists of water, proteins,
sugars, and other things.
And in some cases, fat.
So the lymph vessels have to
convey lymph, convey lymph.
And at the blood capillary level
a certain amount of protein
goes out into the tissues.
At the blood capillary level,
protein out to tissues.
And then it's essential that
protein comes back to blood,
to blood vessels.
If you get excess
protein, and it's not
able to get back into the
bloodstream, what happens?
Death.
So it's a terribly
important relationship
here that blood vessels
and lymph vessels
play with each other.
They have to be permeable,
these lymph vessels,
to get the protein back
into the bloodstream.
Now the fat for some reason--
I don't know whether you've been
taught this in your classes--
why fat is so different
in its absorption
to get from the intestine
into the venous system?
It has its own
pathway, and the fat
is going to be absorbed
in the intestine.
A whole different pathway.
It's absorbed in small intestine
in lymph capillaries called
lacteals.
Lymph capillaries, which
are called lacteals.
Lacteals collect
in lymph vessels
and go into what's called a
cisterna chyli, cisterna chyli.
Ever heard of a cisterna chyli?
What's a cistern?
It's a reservoir, a reservoir--
sorry-- reservoir, and
chyli will be the white fat.
Thank you.
And so we've already absorbed
our fat into it's own channels.
And from the cisterna chyli,
the lymph, with the fat,
will go all the way up
to the base of the neck.
Say I've got,
here's my diaphragm,
and I'll have my stomach
here coming around
into my small
intestine, and the fat's
being absorbed in the
cisterna chyli will be--
we'll just put it
in here crudely.
From it will come
the thoracic duct,
which will go along
the thoracic aorta.
This is a thoracic duct
taking the lymph up
to the junction of
the internal jugular
with the subclavian vein.
So this is my left internal
juggler and my left subclavian.
And the fat will be distributed
into the venous system here.
That an interesting pathway?
Study the evolution of that.
Why is that essential?
To show you the
importance of lymph,
how much lymph is
produced in a day?
Here's your lymph.
The thoracic duct carries
1,000 milliliters in 24 hours.
It's a busy system here.
Thoracic duct carries 1,000
cc's lymph for 24 hours.
All right, we didn't
quite finish our lymphatic
but let's look at slides.
If you want to study
fat absorption,
you put in radioactive fat
and you can collect it.
That's what we did
as graduate students.
So you could get
rates of absorption.
First slide please.
This is just to show the
underside of the liver
to see how vascular it is,
just filled with blood vessels.
What's this?
What's that?
STUDENT: [INAUDIBLE].
PROFESSOR: No.
STUDENT: [? I ?]
[? think ?] gallbladder.
PROFESSOR: It's
gallbladder, right.
Those in 131 had a
whole lecture on how
to take out gallbladders.
In the next one.
And this now will be the spleen.
Here is the capsule,
here are the trabeculae,
and it's a little hard
to see, central arteries.
So the next one.
This is reticulum, reticulum.
You can see how blood could
flow freely through it.
These are reticular fibers.
Very different from
collagenous and they'll have
macrophages on them,
to clean the lymph.
In the next one.
Here is some very good, well
defined, central arteries
in white pulp of the spleen.
You will not see anything like
this in other lymphatic tissues
only the spleen.
In the next one.
And this is red pulp.
There's just blood flowing
in the venous sinuses
with a reticulum.
in blue.
In the next one.
And this is a thymus gland.
We didn't get to the thymus.
It's clear to see because it
has these so-called hassal's
bodies, which are
degenerating epithelial cells.
Has anybody in any class ever
learned what hassal bodies do?
I checked again this morning.
We still don't know,
but their there.
Next one.
And this will be the tonsil.
We'll have tonsil next time.
It's got stratified
squamous epithelium
because the mouth is-- the oral
cavity is stratified squamous.
None others.
It doesn't filter, it
just produces lymphocytes.
Next one.
These are Peyer's patches.
Look at all those.
There in your ilium, the lower
part of your small intestine.
What in the world
are they doing there?
Lots of them.
You'd might take a
section like that
and you say, oh, cancer
of the lymphatics,
but that's not true.
This is the normal amount of
lymphatic tissue in your lower
small intestine.
Next one.
And then this will show
what we were referring to.
Here are your inguinal lymph
nodes down here in the groin.
And then you have aortic ones.
Here's your cisterna chyli--
sometimes spelled with an
I and sometimes with a Y--
coming up to the
thoracic duct, which
will come into your
subclavian coming up
and your internal
jugular coming down.
Here would be the breast.
Here would be the
axillary lymph nodes.
And we have a right
lymphatic trunk that
will have to cover next time.
Here are your
cervical lymph nodes.
But you say it's an independent
system all of its own.
And yet closely aligned to
the blood vascular system.
All right.
