AFRICAN COLLEGE OF HEALTH (ACH)

MBBS YEAR 1 SEMESTER 3; WEEK 4 NOTES

MONDAY: Neuroanatomy (pg.2)
TUESDAY:

Physiology (pg.7)

WEDNESDAY: Ethics (pg.10)

THURSDAY: Neuroanatomy(pg.13)
FRIDAY: Physiology (pg.18)

QUESTIONS? Email: africancollegeofht@nokiamail.com

NEUROANATOMY (MONDAY)
Peripheral nervous system:
The nervous system develops from embryonic segments,
but in the adult state this is obvious only in the
connections of nerve roots with the spinal cord.
Segmental organization:
Spinal nerves have numbers derived from the vertebrae.
The highest spinal nerve penetrates the atlantooccipital membrane, above the arch of the atlas, which
is the first cervical vertebra or C1. The second
cervical nerve passes between the atlas (vertebra C1)
and the axis (C2).
There are 7 cervical vertebrae. The lowest cervical
nerve is therefore C8. Cervical nerves 1 to 7 go
through foramina above the numbered vertebrae. The
roots of nerve C8 pass below the arch of vertebra C7
and above that of T1. All the thoracic (T1 - T12),
lumbar (L1 - L5) and sacral (S1 - S5) nerves go through
foramina below the equivalently numbered vertebrae. To
complete the story, a single coccygeal nerve overlaps
with S5 in supplying the perianal skin.
The most obvious consequence of the segmental
organization of the spinal nerves is seen in the
Dermatomes, which are bands of skin that run
horizontally on the trunk and lengthwise on the limbs.
Each dermatome is centered on the distribution of axons
from a single dorsal root ganglion, but each ganglion
also supplies skin in the dermatomes above and below
its own level.
Consequently, it is necessary to transect three
adjacent dorsal roots or spinal nerves in order to

completely denervate the skin of one dermatome.

Transection of a single spinal nerve, or destruction of
its ganglion, diminishes but does not abolish sensation
in the affected segment of skin. The cutaneous lesions
of herpes zoster, a common virus that infects certain
pain-responsive neurons in individual sensory ganglia,
often neatly map the distributions of dermatomes and
also illustrate the extension of innervation into the
adjacent segments of skin.
The nerve supply to the skin of the limbs is delivered
by cutaneous nerves that are formed in limb plexuses
(brachial and lumbosacral) by complex interchanging and
mixing of fibers from different spinal roots. The areas
supplied by cutaneous nerves bear little resemblance to
the dermatomes. They are sharply demarcated, with
little or no territorial overlapping . The widely
overlapping dermatomes cut across adjacent areas of
skin supplied by cutaneous nerves. A cutaneous nerve
lesion, such as an injury or a mononeuropathy, results
in a well defined area of defective sensation, and
anatomical knowledge can be used to identify the
affected nerve.
Most of the skin of the head is supplied by the three
divisions of cranial nerve V. The areas are sharply
demarcated, and therefore do not correspond to
dermatomes. Cranial nerves VII, IX and X supply small,
overlapping areas of skin of the external ear, and the
dermatome of the second cervical nerve includes parts
of the head, ear, face and neck. (The first cervical
nerve lacks a dorsal root in most people.)
Muscles receive motor and sensory innervation. Most of
the muscles of the limbs are supplied nerves formed in
the limb plexuses from two or more roots. A stretch
reflex (tendon jerk) requires the integrity of both the

motor and the proprioceptive sensory innervation of the

muscle.
Relation of spinal cord and nerve roots to the
vertebral column:
The vertebral column is longer than the spinal cord,
which ends at the level of the upper border of vertebra
L3 in the newborn and at the upper border of vertebra
L2 in the adult. The lower spinal nerves must therefore
course caudally before passing through their
corresponding intervertebral foramina. Immediately
below the caudal end of the spinal cord, the neural
canal contains the roots of nerves L2-L5, S1-S5 and the
coccygeal nerve.
Cranial nerves:
Although the brain stem from segments (known as
neuromeres), their peripheral distributions and central
connections are most easily understood in terms of the
functions of each nerve. Note that the second cranial
"nerve," despite its traditional name, is not a nerve
but an outgrowth of the brain, as is the retina.
Functions of the cranial nerves:

Cranial Nerve(s)
I Olfactory

Function(s)
Smell.

II Optic

Vision.

III Oculomotor
IV Trochlear
V Trigeminal

Eye movements
Downward eye movements.
Muscles that open Skin of face; and
close the mouth; mouth, teeth,
Tensor tympani muscle nose,

sinuses, of middle ear. dura mater

of anterior & middle fossa.
VI Abducens

Abduction of eye

VII Facial

Muscles of face; Lacrimal and nasal

Taste: palate stapedius muscle of
glands (pterygo- anterior 2/3 of
middle ear. palatine ganglion);
tongue. sublingual & submandibular salivary glands
(submandibular ganglion).

VIII
Vestibulocochlear:

Vestibular Equilibration/Cochlear
Hearing.

IX
Glossopharyngeal

Parotid gland Pharynx, middle

Taste: (Otic ganglion) ear,
posterior third of tongue third of
tongue.

X Vagus

Muscles of larynx Slows heart;

Larynx, trachea, Taste: and pharynx
(cardiac ganglia) esophagus, dura
epiglottis. Increases gastric of
posterior acid secretion. fossa.

IX Accessory

Trapezius and
(Spinal
sternocleidomastoid component)
muscles

XII Hypoglossal

Muscles that move the tongue.

1. Afferent fibers in IX and X are of great importance

for regulation of cardiovascular and respiratory
function, but they do not give rise to conscious
sensations, and the physiological functions are not
usually disturbed by unilateral lesions that affect the
nerves or their central connections.

2. The names of the parasympathetic ganglia are

indicated in parentheses after the functions.
3. The small cranial root of XI carries motor axons
destined mostly for the larynx. These cross over into X
by way of a communicating branch, as the two nerves
pass through the jugular foramen in the base of the
skull. The fibers of the spinal root have their cell
bodies in segments C1-C5 of the spinal cord.

PHYSIOLOGY (TUESDAY)
SKELETAL

MUSCLE

PHYSIOLOGY:

Muscle contraction is through depolarization of a nerve

releasing ACh into the neuromuscular junction causing
an endpoint potential and triggering an AP in the
muscle and contraction. The strength of the contraction
is due to:
(i) the number of muscle fibers activated;
(ii) frequency of activation;
(iii) initial length of the muscle fiber. This was
studied through the sciatic nerve and the gastrocnemius
muscle (Achilles tendon).
Graded stimulation of the sciatic nerve-recruitment of
motor units
By increasing the stimulus strength (i.e. the electrode
voltage), an increasing number of nerve fibres were
recruited. There was a graded stimulation of the
sciatic nerve due to different thresholds of nerve
fibres and low voltages only recruited nerve fibres
near the electrode. Any stimulus above maximum tension
is a supra-maximal stimulus.
Effect of varying the frequency of the trains of supramaximal stimuli:
When a second stimulus occurs close a first one
without allowing relaxation [increasing frequency],
tension is additive. 'Tetanus: twitch' ratio is the
ratio of the peak tension during the tetanus to the
peak tension during a single twitch. 'Tetanus' is a
sustained muscular contraction resulting from a rapid
series of nerve impulses As the frequency of the pulses

increases, the tension between the twitches does not

return to baseline, so they fuse (tetanus).
The peak tension during the tetanus is greater than the
tension of a single twitch (because in a single twitch
there is not enough time to prestretch the elastic
elements and produce a full force), so as the frequency
increases, the tetanus: twitch ratio also increases.
Tetanus is 4x a single twitch strength. The fusion
frequency is when tension vs. time is a smooth
increase.
Influence of length on isometric contractions:
As the muscle length (and therefore also the passive
tension) increases, the force of the muscle contraction
increases to a point, reaches a peak and then decreases
again. This observation is evidence supporting the
sliding filament binding hypothesis, as it could be due
to sarcomere length -there is an optimal length at
which most of the actin and myosin are overlapping (so
maximum force can be produced by the myosin heads in
the actin binding sites), whereas if the muscle was
stretched too much or not enough, there would be fewer
binding sites available for the myosin heads to attach
[less interference]. This is calculated by measuring
passive tension in the muscle [due to elastic
properties] and subtracting from total tension to find
twitch/active tension.
MEMBRANE POTENTIALS
Concentration differences across membranes of living
cells are energy differences. If a membrane was
impermeable, no electrolytes can move between the two
partitions and no potential difference builds up. Semi-

permeability allows selective diffusion, transmembrane

potentials can develop.
This experiment creates two chambers to emulate the ICF
[150 mmol/L] and the ESF [variable] separated by a
polysuphonic resin membrane that is selectively
permeable.
Electrodes are: AgCl coated with Ag and a salt bridge
of 3M KCl in agar. It shows how different
concentrations of electrolytes give different
transmembrane potentials.
Both chambers were filled with 150 mM KCl with the ECF
after double washouts filled with 100mM to 1.5mM KCl
measuring the potential.
Using the Nerst equation, we can determine if it's more
selective for K(+) or Cl (-).
*From this we can see as we reduce the concentration of
KCl in the outside bath, either K+ or Cl- has to cross
to balance the concentrations. If K+ crosses into the
outside bath, there would be a negative charge in the
ICF and a negative membrane potential. Hence Membrane 1
is permeable to cations as it gives a negative charge.
Likewise, if Cl- crossed, it would leave a positive
charge in the ICF. Hence Membrane 2 is permeable to
anions.

ETHICS (WEDNESDAY)
Matters of life and death:
It has been noted that the right of a competent adult
to consent to and refuse treatment is unlimited,
including the refusal of life-sustaining treatment.
Probably the example most familiar to surgeons of this
is Jehovahs Witnesses who refuse blood transfusions at
the risk of their own lives. There can be no more
dramatic example of the potential tension between the
duties of care to protect life and health and to
respect autonomy, with autonomy always constituting the
trump card.
The tension does not stop here, however. For there will
be some circumstances where the protection of the life
and health of patients is judged to be inappropriate,
where they are no longer able to be consulted and where
they have not expressed a view about what their wishes
would be under such circumstances. Here a decision may
be made to with-hold or to withdraw life-sustaining
treatment on behalf of the incompetent patient. The
fact that such decisions can be seen as omissions to
act does not excuse surgeons from morally and legally
having to reconcile them with their ordinary duty of
care. Ultimately, this can only be done through arguing
that such omissions to sustain life are in the
patients best interests.
The determination of best interests in these
circumstances will rely on one of three objective
criteria, over and above the subjective perception by
the surgeon that the quality of life of the patient is
poor. There is no obligation to provide or to continue
life-sustaining treatment:
if doing so is futile when clinical consensus
dictates that it will not achieve the goal of extending
life. Thought of in this way, judgments about futility

should not be linked to evaluations of a patients

quality of life;
if patients are imminently and irreversibly close to
death in such circumstances it would not be in their
best interest slightly to prolong life (e.g. through
the application of intensive care) when, again, there
is no hope of any sustained success. Not needlessly
interfering with the process of a dignified death can
be just as caring as the provision of curative therapy;
if patients are so permanently and seriously brain
damaged that, lacking awareness of themselves or
others, they will never be able to engage in any form
of self-directed activity. The argument here is backed
up by morally and legally reasoning that further
treatment other than effective palliation cannot be in
the best interests of patients as it will provide them
with no benefit. When any of these principles are
employed to justify an omission to provide or to
continue life-sustaining treatment, the circumstances
should be carefully recorded in the patients medical
record, along with a note of another senior clinicians
agreement.
Finally, surgeons will sometimes find themselves in
charge of the palliative care of patients whose pain is
increasingly difficult to control. There will come a
point in the management of such pain when effective
palliation might only be possible at the risk of life
because of the respiratory effects of the palliative
drugs. In such circumstances, surgeons can with legal
justification administer a dose which might be lethal.
The argument employed to justify such action refers to
its double effect that both the relief of pain and
death might follow from such an action. As intentional
killing active euthanasia is rejected as
professional and legal medical practice throughout most
of the world, a potentially lethal dose is only

regarded as appropriate when it is motivated by

palliative intent.
Debates rage about whether or not it is realistic in
such circumstances to believe that surgeons can or
should keep all ideas out of their minds about helping
such unfortunate patients to die, especially as we have
seen that clinical decisions are already made that
foreshorten the lives of incompetent patients in
specific circumstances. Deciding whether or not
potentially lethal palliation is justified will require
an evaluation by either the patient, the clinician or
both of whether or not the life in question is too
valuable on other grounds to risk. Once a negative
conclusion is reached and the risks are incurred, it
seems impossible in the face of continued and dramatic
palliative failure then to purport to banish thoughts
of the desirability of death from the scene. What is
clear is that surgeons should document that their
intent is purely palliative through only gradually and
incrementally increasing doses of the drugs that they
administer for this purpose.

NEUROANATOMY (THURSDAY)
Peripheral nervous system:
The nervous system develops from embryonic segments,
but in the adult state this is obvious only in the
connections of nerve roots with the spinal cord.
Segmental organization:
Spinal nerves have numbers derived from the vertebrae.
The highest spinal nerve penetrates the atlantooccipital membrane, above the arch of the atlas, which
is the first cervical vertebra or C1. The second
cervical nerve passes between the atlas (vertebra C1)
and the axis (C2).
There are 7 cervical vertebrae. The lowest cervical
nerve is therefore C8. Cervical nerves 1 to 7 go
through foramina above the numbered vertebrae. The
roots of nerve C8 pass below the arch of vertebra C7
and above that of T1. All the thoracic (T1 - T12),
lumbar (L1 - L5) and sacral (S1 - S5) nerves go through
foramina below the equivalently numbered vertebrae. To
complete the story, a single coccygeal nerve overlaps
with S5 in supplying the perianal skin.
The most obvious consequence of the segmental
organization of the spinal nerves is seen in the
Dermatomes, which are bands of skin that run
horizontally on the trunk and lengthwise on the limbs.
Each dermatome is centered on the distribution of axons
from a single dorsal root ganglion, but each ganglion
also supplies skin in the dermatomes above and below
its own level.
Consequently, it is necessary to transect three
adjacent dorsal roots or spinal nerves in order to

completely denervate the skin of one dermatome.

Transection of a single spinal nerve, or destruction of
its ganglion, diminishes but does not abolish sensation
in the affected segment of skin. The cutaneous lesions
of herpes zoster, a common virus that infects certain
pain-responsive neurons in individual sensory ganglia,
often neatly map the distributions of dermatomes and
also illustrate the extension of innervation into the
adjacent segments of skin.
The nerve supply to the skin of the limbs is delivered
by cutaneous nerves that are formed in limb plexuses
(brachial and lumbosacral) by complex interchanging and
mixing of fibers from different spinal roots. The areas
supplied by cutaneous nerves bear little resemblance to
the dermatomes. They are sharply demarcated, with
little or no territorial overlapping . The widely
overlapping dermatomes cut across adjacent areas of
skin supplied by cutaneous nerves. A cutaneous nerve
lesion, such as an injury or a mononeuropathy, results
in a well defined area of defective sensation, and
anatomical knowledge can be used to identify the
affected nerve.
Most of the skin of the head is supplied by the three
divisions of cranial nerve V. The areas are sharply
demarcated, and therefore do not correspond to
dermatomes. Cranial nerves VII, IX and X supply small,
overlapping areas of skin of the external ear, and the
dermatome of the second cervical nerve includes parts
of the head, ear, face and neck. (The first cervical
nerve lacks a dorsal root in most people.)
Muscles receive motor and sensory innervation. Most of
the muscles of the limbs are supplied nerves formed in
the limb plexuses from two or more roots. A stretch
reflex (tendon jerk) requires the integrity of both the

motor and the proprioceptive sensory innervation of the

muscle.
Relation of spinal cord and nerve roots to the
vertebral column:
The vertebral column is longer than the spinal cord,
which ends at the level of the upper border of vertebra
L3 in the newborn and at the upper border of vertebra
L2 in the adult. The lower spinal nerves must therefore
course caudally before passing through their
corresponding intervertebral foramina. Immediately
below the caudal end of the spinal cord, the neural
canal contains the roots of nerves L2-L5, S1-S5 and the
coccygeal nerve.
Cranial nerves:
Although the brain stem from segments (known as
neuromeres), their peripheral distributions and central
connections are most easily understood in terms of the
functions of each nerve. Note that the second cranial
"nerve," despite its traditional name, is not a nerve
but an outgrowth of the brain, as is the retina.
Functions of the cranial nerves:

Cranial Nerve(s)
I Olfactory

Function(s)
Smell.

II Optic

Vision.

III Oculomotor
IV Trochlear
V Trigeminal

Eye movements
Downward eye movements.
Muscles that open Skin of face; and
close the mouth; mouth, teeth,
Tensor tympani muscle nose,

sinuses, of middle ear. dura mater

of anterior & middle fossa.
VI Abducens

Abduction of eye

VII Facial

Muscles of face; Lacrimal and nasal

Taste: palate stapedius muscle of
glands (pterygo- anterior 2/3 of
middle ear. palatine ganglion);
tongue. sublingual & submandibular salivary glands
(submandibular ganglion).

VIII
Vestibulocochlear:

Vestibular Equilibration/Cochlear
Hearing.

IX
Glossopharyngeal

Parotid gland Pharynx, middle

Taste: (Otic ganglion) ear,
posterior third of tongue third of
tongue.

X Vagus

Muscles of larynx Slows heart;

Larynx, trachea, Taste: and pharynx
(cardiac ganglia) esophagus, dura
epiglottis. Increases gastric of
posterior acid secretion. fossa.

IX Accessory

Trapezius and
(Spinal
sternocleidomastoid component)
muscles

XII Hypoglossal

Muscles that move the tongue.

1. Afferent fibers in IX and X are of great importance

for regulation of cardiovascular and respiratory
function, but they do not give rise to conscious
sensations, and the physiological functions are not
usually disturbed by unilateral lesions that affect the
nerves or their central connections.

2. The names of the parasympathetic ganglia are

indicated in parentheses after the functions.
3. The small cranial root of XI carries motor axons
destined mostly for the larynx. These cross over into X
by way of a communicating branch, as the two nerves
pass through the jugular foramen in the base of the
skull. The fibers of the spinal root have their cell
bodies in segments C1-C5 of the spinal cord.

PHYSIOLOGY(FRIDAY)
SKELETAL

MUSCLE

PHYSIOLOGY:

Muscle contraction is through depolarization of a nerve

releasing ACh into the neuromuscular junction causing
an endpoint potential and triggering an AP in the
muscle and contraction. The strength of the contraction
is due to:
(i) the number of muscle fibers activated;
(ii) frequency of activation;
(iii) initial length of the muscle fiber. This was
studied through the sciatic nerve and the gastrocnemius
muscle (Achilles tendon).
Graded stimulation of the sciatic nerve-recruitment of
motor units
By increasing the stimulus strength (i.e. the electrode
voltage), an increasing number of nerve fibres were
recruited. There was a graded stimulation of the
sciatic nerve due to different thresholds of nerve
fibres and low voltages only recruited nerve fibres
near the electrode. Any stimulus above maximum tension
is a supra-maximal stimulus.
Effect of varying the frequency of the trains of supramaximal stimuli:
When a second stimulus occurs close a first one
without allowing relaxation [increasing frequency],
tension is additive. 'Tetanus: twitch' ratio is the
ratio of the peak tension during the tetanus to the
peak tension during a single twitch. 'Tetanus' is a
sustained muscular contraction resulting from a rapid
series of nerve impulses As the frequency of the pulses

increases, the tension between the twitches does not

return to baseline, so they fuse (tetanus).
The peak tension during the tetanus is greater than the
tension of a single twitch (because in a single twitch
there is not enough time to prestretch the elastic
elements and produce a full force), so as the frequency
increases, the tetanus: twitch ratio also increases.
Tetanus is 4x a single twitch strength. The fusion
frequency is when tension vs. time is a smooth
increase.
Influence of length on isometric contractions:
As the muscle length (and therefore also the passive
tension) increases, the force of the muscle contraction
increases to a point, reaches a peak and then decreases
again. This observation is evidence supporting the
sliding filament binding hypothesis, as it could be due
to sarcomere length -there is an optimal length at
which most of the actin and myosin are overlapping (so
maximum force can be produced by the myosin heads in
the actin binding sites), whereas if the muscle was
stretched too much or not enough, there would be fewer
binding sites available for the myosin heads to attach
[less interference]. This is calculated by measuring
passive tension in the muscle [due to elastic
properties] and subtracting from total tension to find
twitch/active tension.
MEMBRANE POTENTIALS
Concentration differences across membranes of living
cells are energy differences. If a membrane was
impermeable, no electrolytes can move between the two
partitions and no potential difference builds up. Semi-

permeability allows selective diffusion, transmembrane

potentials can develop.
This experiment creates two chambers to emulate the ICF
[150 mmol/L] and the ESF [variable] separated by a
polysuphonic resin membrane that is selectively
permeable.
Electrodes are: AgCl coated with Ag and a salt bridge
of 3M KCl in agar. It shows how different
concentrations of electrolytes give different
transmembrane potentials.
Both chambers were filled with 150 mM KCl with the ECF
after double washouts filled with 100mM to 1.5mM KCl
measuring the potential.
Using the Nerst equation, we can determine if it's more
selective for K(+) or Cl (-).
*From this we can see as we reduce the concentration of
KCl in the outside bath, either K+ or Cl- has to cross
to balance the concentrations. If K+ crosses into the
outside bath, there would be a negative charge in the
ICF and a negative membrane potential. Hence Membrane 1
is permeable to cations as it gives a negative charge.
Likewise, if Cl- crossed, it would leave a positive
charge in the ICF. Hence Membrane 2 is permeable to
anions.

walesonmd@gmail.com