Is consciousness an emergent phenomenon? What does emergent even mean? Can we fit consciousness into a materialist world view, or does it necessitate some kind of dualism? These are the questions I'm trying to answer on the 49th episode of Patterson in Pursuit. Good day, might. I'm coming to you again from the Outback. This is really the city of Sydney, Australia, and we're talking again about a really difficult puzzle that I haven't been able to solve yet, and every time I try to solve it I end up with a conclusion, or many conclusions, that I don't like. It's the difficult conundrum of consciousness. Man, philosophy would be a lot easier if we didn't have to deal with consciousness. Every single thing that existed was just simply physical with no internal experience or conscious awareness of anything, or appearance of free will and self-control and personal identity. If everything was essentially just a little pool ball, the puzzle would be easily solved, and we could move on to other issues. But every time I talk to somebody about consciousness, I keep getting different answers, and I think that's for good reason, because this issue is really stinking difficult. So to help me out, I'm talking this week with Professor David Bradden Mitchell, who is a philosopher at the University of Sydney. We had a really good conversation about some basic questions in the philosophy of mind with a specific focus on this concept of emergence, which we get into in this conversation. If you're not familiar with emergence, it's essentially the orthodox way of explaining the phenomena of consciousness. The consciousness emerges from underlying physical phenomena, whatever emerge means. My wife and I now see an end to this leg of our journey in the East. We've got three, maybe four more countries on our list before we head back home to the States. So whenever that happens, I'm going to go from interviewing all these people in person, and I'm finally going to be able to interview a lot more people on Skype, where I have a reliable internet connection, and I got a big, gigantic and growing list of people that you guys are suggesting I interview, and I can't wait to get around to doing that. Following the show for a bit, and you think it's pretty neat the work that I've been able to do outside of academia, I've got some good news for you. One, this is just the beginning for me, and two, it can be the beginning for you as well. The world is radically changing, my friends, and your options have just greatly expanded for having a unique, exciting, independent career thanks to the internet. Not only are there lone wolf independent entrepreneurs out there who are working in the world of ideas, there are also companies that are entering into this space, namely the company that is sponsoring this episode, Praxis. 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Gets more information, you can even schedule a call with him to see if the program is right for you. So let's get to my conversation with Dr. Braden Mitchell of the University of Sydney where he teaches philosophy. He's also written a book called Philosophy of Mind and Cognition as well as co-authoring a book with a previous guest on the show, Robert Nola. The book that they edited together is called Conceptual Analysis and Philosophical Naturalism. So I think you guys are really going to love this conversation with Dr. Braden Mitchell. So first of all, thanks very much for sitting down talking with me today. I appreciate it. Pleasure. I need your help. Yeah. Because I have asked quite a lot of people about fundamental ideas and the philosophy of mind and I've made virtually no progress. Ask it somebody different and get a different answer. So I've got a few basic questions for you, all having to do with consciousness. What is consciousness? What is the mind? And hopefully we'll get to a little bit into intentionality and specifically one concept that I want to talk to you about, this idea of emergence. This is the term that gets thrown around. So let's start with a basic question. What is your conception of what the mind is from a metaphysical standpoint and why is it so hard for us to wrap our own minds around what the mind is? I think they're both two very good questions. I think the second question is actually almost as important as the first question because I'm going to give you a deflationary simple answer to the first question. But then that's going to leave the second question hanging there because if the basic deflationary story I'm going to tell you where it's right, how come it's not obviously right? How come people find it so unsatisfying? So perhaps I should start with the basic simple answer to the first question. Minds are complicated systems that respond to the world. They're kind of biochemical maps of the way the world is engineered by evolution to try and change the world in various ways. They're devices that respond to their environment so as to cause things to happen in an organism which then change the environment in a certain way. They're complicated maps of how things are and that they're geared to make changes in the world. That's what minds are. Okay. But you're going to say that somehow seems very unsatisfactory. And we have to have some answer about why it seems unsatisfactory. Yeah, so I like that from an outside perspective. If I could say, oh, what are minds and creatures and animals? I find that very satisfying. But I think about myself and I think, well, that's not what's going on. I have this experiential phenomenon. I'm aware of things. That doesn't seem to be captured by the idea of thinking of it as a map, like as an objective thing out there. I'm experiencing it from the inside, whatever that means. Yeah. So some stories got to be given about why everyone, including myself, on every second Tuesday and most of my undergraduate students and you, have got this sense that there's something unsatisfactory about that kind of answer. There's a lot of ways one could perceive. One of them is like this. This, I think, is part of the illusion about the unsatisfactoryness of that answer. Sometimes you say to someone, look, I'll tell you what a mind is. I gave you what's called a functional definition of a mind. I describe the mind in terms of what it does and says anything it does, that is a mind. But it follows that some of the things that do those things are physical objects, like our brains and our bodies. And so minds, in my view, then, are our brains and our bodies. Now, you say that to someone. I say it to you and do you think, yeah, but somehow from the inside, that doesn't seem right, right? Somehow it doesn't seem right that I'm just a, for example, a brain to keep it simple. I think the brain and the body are interacting in important ways. And it's a whole system that is in the mind. Why doesn't it seem to... Here's one reason I think it doesn't seem satisfactory. It's an illusion caused by doing some false comparisons. OK.  And then you stop imagining a brain and you start imagining your own thoughts and you start imagining the feeling you have when you listen to Beethoven's Opus 111 Piano Sonata and you're all carried away in those wonderful moments in the second movement or whatever it is that carries you away. I think those things just seem radically different.  But of course, that's a mistake because what you're actually doing is comparing two very different brain states. So all you can compare is brain states.  So you're comparing the brain state of thinking about brains with the brain state of thinking about music and the brain state of thinking about brains and the brain state of thinking about music are extraordinarily different brain states. OK. So of course they seem different. OK. That's my first take on what explains the kind of illusion. So I think about it this way. OK.  OK. Yeah, totally different experiences because totally different brain states. OK. There seems something that still seems unsatisfactory in this way. There's something about thinking about an experience which would be a particular brain state when we're thinking about the experience of something but that seems different than actually experiencing that thing. So it's different to say I'm thinking about the experience of experiencing red and thinking about how that would be but it's another thing to be in the experience itself. My same story will apply to that case too. You've got these two brain states. Brain state A, all you're doing is concentrating on redness. Brain state B, you're concentrating on redness and part of your brain is also thinking about redness. Tremendously different brain states. Not surprising that they're going to seem very different to you. OK. So is there any factor of the personal perspective that comes into this? So when I'm thinking about different brain states it seems like there's some kind of a boundary between your experience or your conscious goings on and mine. That still seems maybe not captured. It almost seems like if you and I were to think of the same thing that we would be having the same perspective on something. That seems like that wouldn't quite follow. It seems to me that what I'm calling the simple picture I've told you is one which actually crucially captures the idea that we each have an utterly individual perspective on things because what each of us is is a system located at a certain point in space and located at a certain place in time who when they respond to the world can only make interventions in a certain way. When I have thoughts, I can only move my own arms. I can only make my own words happen. I can't make your arms move except by very indirect methods. So each of us located in space and time very, very differently. That's what constrains I guess in my view this kind of individuality. Okay, so would you say that our perspectives, so when I'm talking about my perspective right now, the phenomena that I'm experiencing in my consciousness, that is the exact same thing, identical to the brain state that this, well, I'm pointing but the listeners can't see, that the goings on in my head is in, identical. That's right. That's the view. Okay. And I'll say what I think about emergence later if you want. Okay. What the relationship is between those claims. Okay, so before we get to that, to me that says something really remarkable about what we usually consider as physical objects and physical stuff. That implies that, you know, the phone that's here on the table and the paper and the boxes, all of this stuff is constituted by some substratum that if you fold it over just right, it gets this subjective experience going on that I'm, that is happening. Isn't that some kind of like a, some version of like a proto panpsychism maybe as it's called? Right. There's two ways of thinking about this. And one is going to lead you quite quickly in some sort of panpsychism. It's the idea that what you have is features of the physical world which have somehow rather got a mysterious power, which is such that when you combine those things with those power in the right way, you get consciousness. Yeah. I don't believe that because on the story I want to tell what consciousness is, is the things doing the ordinary things that they do when they're organized in a way that enables them to do the ordinary things that they do. So it doesn't require on picture I'm painting them, which is I guess a relatively orthodox physicalist picture. It doesn't require there to be anything special about the constituents of the thing over and above what it takes to contribute to it functioning in the world in the way that it does function. So there's no extra kind of magic source that even the atoms of my spectacles and even the bits of this paper have. There's various reasons why I think that the magic source story doesn't really work. One of them is this. It's that a protopansychist is someone who thinks that it's not true that the atoms of my phone are conscious, but they've got this special power such that when you combine them in the right way, you get consciousness. But the regular physicalist who's not a protopansychist already has the problem of how do you get things which definitely aren't conscious in any way, not even protoconscious, namely the atoms and molecules that make up my brain. In virtue of what do they get to count as conscious? And the ordinary physicalists say, well, in virtue of their organization and in virtue of what they do in the world, because functionalist, physicalist is someone who says that what minds are is physical systems that are minds in virtue of what they do, not what they're made of. Now the protopansychist has introduced this extra magic source, but they've got exactly the same problem of how to get from these protopansychic things which by definition aren't themselves, they're only protoconscious, right? They're not conscious in any way. They've got to say something about how it's all organized now, it's all put together and how organizing and puts together creates consciousness and that looks like exactly the same problem that the ordinary physicalist has. So it looks like they've added nothing to the solution. From my perspective, at least in the way that was formulated, it seems like those are actually kind of the same position though, right? Because isn't that actually what the physicalist would be saying? The only difference is that we say it's not magic source, it's just physical. The physicalist says it doesn't matter what the underlying substratum is so long as it can do these things. The protopansychist says it does matter. There's some special feature it has to have. So it's not enough just to be able to do the normal causal stuff. It's got to have this extra feature, X, which is the protoconscious feature. And it's only when you put protoconscious things together in a way that you get full-blown consciousness. So the regular physicalist says put together anything in the right way so that it does these things, you'll get consciousness. The protopansychist says, oh no, if you put the wrong things together you'll have something that looks like it's conscious but isn't conscious because it's not made out of the protopansychological stuff. I see. But there still seems to be a very fundamental agreement in the sense that whatever the underlying stuff is it is still you form it in such a way and you get what we call consciousness. That's right. That's the agreement. And so the agreement is there in as much as both the physicalist thinks that both the physicalist and the protopansychist faces the same problem. But the protopansychist introduces something extra which is supposed to help solve the problem but he doesn't help solve the problem. And so the physicalist says, that's one victory for me so far. He doesn't say I've solved the problem but that you guys, your extra thing is not helping. Okay, so this is a natural segue maybe to one physicalist explanation for a conscious phenomena which is that it's emergent. So just help me understand what does it mean to say just in the standard orthodoxy that consciousness is an emergent phenomena? I hope that the standard orthodoxy would be that emergence doesn't make sense therefore I can't say that. But maybe that's not the standard orthodoxy but let me tell you why I think that anyway. So emergence is often, because it means by emergence the problem is that so many people say so many different things about emergence. So one way of understanding what emergence is supposed to be is emergence is supposed to be a halfway house. A halfway house between kind of reductionism which says that all there really is in some sense of really is whatever there's there fundamentally and a kind of dualism which says look there's this stuff here that's fundamental and in addition there's other stuff which is entirely ontologically distinct. And the emergence is supposed to be some kind of halfway house between the two of them. Sort of seems like this fundamental stuff but then there's other stuff and it's sort of genuinely novel. It's genuinely novel but it's not new. It's sort of novel but not new. It's kind of new but not new. It's not the same as the fundamental stuff. It's not like dualism, that bad view. It says there's this extra stuff which is totally distinct. You could probably see from the way I'm fairly caricatured as the sort of general line I wanted to say about it. So the way I think of it is this. What does it mean to say something's novel? That's a really interesting question. What does it make something distinct? I've got a whole bunch of particles arranged in a certain way and there's a triangle as well say because they're arranged triangle wise. What would it be to say that the triangle is genuinely ontically distinct from the constituents that make it up? That's actually one of the really hard questions in philosophy. And the answer which I'm attracted to is an argument, an answer that depends on logical entailment. The story is this. If being arranged the way they are just logically entails as a triangle, although we might have different language to talk about triangles and particles arranged that way, in the world it's just the one thing. Because if you arrange that way it's just a fact of logic that you have a triangle as well. So no ontological distinctness. So conceptual distinction, distinctness perhaps, but not ontological distinctness. Triangles and the particles arranged triangle wise are the very same thing. So let me just ask you one question to clarify that. Are you saying that ontologically speaking there really is no triangle? That's a conceptual thing that we're bringing to the table. No, not saying that. I'm saying sure there's a triangle and sure there are particles arranged triangle wise and there are different ways of talking about the same reality. So but then don't you run into the trouble of at what point did the particles then become the triangle? Don't you run it like if you were to add one bit at a time would you have a new thing come into existence? Well if you added one bit at a time of course you've got a new thing coming into existence. Can you add it a bit? Okay now that's the part that you've got to help me out because this is where I get hung up on emergence a lot. This idea of something coming into existence that wasn't and then coming out of existence. Changing the triangle we add bit by bit and then there's the new thing and then we take off one bit when it goes away. I think the way I think of it is there's the underlying reality and then there's the right way to talk about the underlying reality. So I've got a bunch of particles arranged in a certain way and if they're arranged in a certain way it might be fine to talk about them as a bunch of particles that might not be fine to talk about them as a triangle because there's a gap somewhere. At another particle now I've obviously got a different fundamental reality now because there's got an extra particle in it, right? So something has changed in the world but in addition something else has changed which is this new fundamental reality it's still cool to talk about as particles arranged a certain way but it's now cool to talk about as a triangle but it's not like there's only particles and no triangle or it's not like there is a triangle and it depends on the particles there's just the one thing there which it's right to describe in these two ways. A moment ago there was a different thing there and it was only okay to talk about that thing in terms of particles being arranged a certain way because it wasn't arranged the right way for it to be also right to use triangle language. So what if I were to take this around and I would say it would be incorrect to say prior to that last particle bringing the triangle into existence it would be incorrect to say that there's one thing there and then there's a new thing there after you add the particle really the only thing that's there it's just the particles and our minds are the things that create boundaries over when we say oh this is a triangle that's not a triangle. So now we're leading into something outside of philosophy of mind and we're leading into I suppose some sort of that myriology myriology is the theory of parts and holes and stuff like that so what you might think some people do think is all there are is the symbols there are no extra things as it were made up out of the symbols that's kind of myriological nihilism it's the view that you know all there is is whatever is fundamental and simple and indivisible. There's another view which says that when you combine the simple things you get holes but not every combination of simple things generates a hole and there's a third view called myriological universalism which says look there are the simple things and then every possible way of combining them is another thing. It's a lot of things. It's a lot of things but the universalist normally says but these things are cheap. They're not really ontologically distinct from the underlying mass of components. So one way of being a myriological universalist is to say look there is many things as there are ways of combining all the fundamental things but that's just ways of talking about arrangements of the fundamental things. It's not like you're really adding stuff to the world. But if it's just ways of talking then that seems like it is still kind of the myriological nihilist position. That's why I'm certainly of the view that myriological universalism in this deflationary way and myriological nihilism actually really agree about ontology. They disagree about ideology. They disagree about the right way to use language. I'm probably in that category. I'm a myriological nihilist or a deflationary universalist. Okay. This seems like it has direct correlation to when we're talking about the mind especially when we're talking about if there's this correspondence between the resemblance of bits of matter which create a brain and the mind if there's some new thing that comes into existence. Which I would like to return just to that question if we could get an orthodox even if incorrect or the standard way that people talk about oh consciousness is an emergent analogy. I hadn't actually finished saying what I was going to say. Oh yes I interrupt you. That's alright. So I was trying to come up with an account of distinctness and what I was suggesting was that the best account of distinctness is that distinctness should be understood as something is not distinct if being one way logically entails being another way. These aren't distinct ways of being. In which case to be distinct would be for that logical entailment to fail. So in other words if being arranged in a certain way physically fails to logically entail being in a certain way mentally then being in a certain way mentally is distinct from being a certain way physically. So one way of understanding what emergence would be in which emergence is concerned with genuine novelty bringing about something that's genuinely new is that some state might be emergent provided being the way it is fundamentally doesn't logically entail being the way it is emergently. But if that's how you understand emergence emergence just is a brand of good old fashioned dualism because good old fashioned dualism is the view that there's some property that you have which is logically distinct from how things are. There's a possible world where they where things are physically the first way but the mental fails to be there. So that's why I think that trying to come up with a story about emergence which is a genuinely ontological story about emergence either fails or turns into dualism. Now there's another kind of emergence scientists often talk about emergence which I think is entirely harmless but it's fundamentally not really ontological. You might call it epistemological emergence. You might say look being a certain way entails incredibly complicated stuff that's hard to understand. It's much easier to think about in a more abstract way. Often you do better science when you don't concern yourself with the minute details but deal with abstractions over the things and that's what people often sometimes in those contexts mean by emergence. So I think you get in this literature you get this incredible confusion of people using emergent in these different sorts of ways. So for example people often talk about chaos theory as being a theory about emergence and in one sense emergence it's perfectly good. What it means is look there are fundamental bits of the universe they're moving according to simple deterministic laws governed by dynamic equations. Doing the math to figure out how things are going to behave based on those dynamic equations and based on how things are fundamentally so complicated it's essentially impossible and it requires infinite precision in your measurements as initial states, student calculations, it's tightly useless. You're much better off using meteorology or you're much better off using rules of thumb about how the macroscopic systems work or you're much better off using mathematical theories about how these systems work. That's all absolutely true but that doesn't tell you that as a matter of ontology there's anything more than the fundamental stuff. So would you say it's a fair criticism of this idea of this halfway house that the claim as it's usually repeated is something like okay you have the fundamental bits of matter and then you arrange them in a particular way and then you get this new thing that emerges but if it is genuinely an ontologically new thing that seems to be the definition of dualism and if it's not distinct then it's more of a linguistic thing that we're just calling it something new. That's my picture. So that's also my picture but you and I are in different camps because I'm forced into the dualist position and I don't like it. I call myself a reluctant dualist because there's these features that I think about physical phenomena I think of mental phenomena I think gosh these things seem so hard to reconcile. Actually I think you and I are not on such dissimilar camps so you might think. I mean we have different conclusions, right? You're driven to dualism but I think you're right to be driven to dualism. It seems to me that the big intellectual mistake people make is thinking that they can have this appearance of novelty without dualism. And if you really think that accepting the conscious state is a genuinely novel I think it requires you inconsistency to go to dualism. Okay well I'm open though. And I also accept by the way that it's the big counterintuitive pill you have to buy about physicalism to deny that genuine novelty. Okay but I'm ready. I mean the pill's there. I've talked to a lot of people who say that. It's a compelling coherent world view this physicalism. So can you help me, can you help persuade me into this camp that when I can see a physical phenomena maybe this is an incorrect way of conceiving a physical phenomena when I think of bits of matter, fundamental bits of matter the way that I'm conceiving of them is that there is no consciousness or potential for consciousness there. It's just a conscious list. It's not a word but it is a conscious. And yet if that's a correct way of thinking about physical phenomena then I think you're forced into this camp of there's something else going on unless we take what seems to be the panpsychist approach is to say okay well when you conceive of the fundamental constituents of the universe you must have a little addendum that says but if they're arranged in the right way you get this completely what seems to be categorically different phenomena than just being spatially extended and being bumped around you get first-person subjective experience. Okay so I guess I don't think that. I mean here's why it's just an intuitive story about how you might psychologically resist it. It's more therapy than argument right? It goes something like this is look the picture I was the simple picture I called it at the beginning everyone always calls there and makes you the simple picture. The simple picture is one where what consciousness is is a certain kind of doing. Consciousness is an activity. Consciousness is stuff that does something in a certain context. And doings are very impressive things. A star is a very impressive thing. If you saw a whole bunch of hydrogen you might find yourself thinking look at some hydrogen here. Man that's a star but someone telling me all that star is just hydrogen. But when the hydrogen does some pretty impressive stuff it's pretty impressive. And the doing that is consciousness on my story is this doing where massively complicated maps of the way the world is the way the world is outside gets encoded in a complicated physical system that then goes and changes the world. This complicated physical system has an encoding of both how the world is and another encoding of how the world could be and it tries to change the world to make the world actually more like the way it could be than like it is.  Doesn't surprise me that you would think that you would be really odd to think that a bunch of hydrogen in a balloon could be a star in the same way a bunch of oxygen and stuff. How could it be a mind? Two questions on that. One, I like the analogy with the hydrogen and the star but I have no difficulty conceiving of amazing physical phenomena taking place because it seems like a qualitative difference between the physical goings on in a star which is lots of explosion and light and stuff going on but that seems to be in a different at least in my conceptual framework that seems to be in a different category of experiential phenomena. You don't get qualia in a star but here you do get qualia so maybe that was more of a statement than a question. The question that I have for you is do you think then it's inconceivable to think of the philosophical zombie the bit of the assortment of the universe which let's say looks like me from your perspective looks like me, acts like me, behaves like me but doesn't have this qualitative internal experience. Do you think that's inconceivable? I have a very complicated story about the philosophical zombie. My story is strictly speaking it's inconceivable but that we ought rationally give a non-zero credence to it being conceivable and anything which you think might be conceivable is in some sense impossible to distinguish between something which is conceivable. I don't know who's listening to you out there in YouTube world I'm sure that made absolutely no sense to you let me try and say it again. Here's my story about how it can be both inconceivable but seen as though it is conceivable I agree it seems that it's inconceivable it seems that I can imagine a world which contains a physical duplicate of me and simply it has no consciousness. That's right, all the goings on but without the consciousness it seems as though that's conceivable in some sense conceivable. For those of you who are listening to this you don't know why we're talking about zombies it's for the following reason there's an argument that goes like this it's conceivable there could be something perhaps not in this possible world because maybe there are natural laws that make it so but in some other possible world that is an exact physical duplicate of us but lacks consciousness that's a conceptual error when I'm thinking that but if it's conceivable then what some people would think is that conceivability is a guide to what's possible in which case it's possible that there's an entity which is physically exactly like us and lacks all consciousness but if what consciousness just is is being exactly like us physically then of course it's impossible there could be something that's exactly like us and lacks consciousness so if we have an argument from it being conceivable to it's being possible it's false because physicalism is the view that what consciousness is is being physically like us it's guaranteed so you're essentially just denying the idea of the distinction between the conscious goings on and the visible going on right? I haven't got to say yet all I do is outlining why nobody would care about that argument so I was just giving you the dualist argument your argument which says that dualism is true because we can conceive of beings that are physically different from us without consciousness and therefore it's possible and if it's possible then dualism must be true and physicalism must be false so typically physicalists are put in the position where they have to say one of a couple of things either it's inconceivable and some kind of illusion of conceivability or else it's conceivable but conceivability is not a good guide to possibility and my guess is that most physicalists in fact take that second route they say look, yeah, lots of rubbish is conceivable that's not possible I have a different story the simple story I gave you at the beginning turns out to be a little bit too simple the simple story I gave you at the beginning was that as it were by definition what consciousness is is being physically organized in a certain way, functioning in a certain way and if that's true by definition a priori as most so-called a priori physicalists think then it just follows from that claim that it's impossible that something can be physically organized that way without being conscious because a priori if you're organized that way then you're conscious so it's impossible so if it's conceivable when either conceivability is no good guide to possibility or it's an illusion, it's not conceivable my view is that it's not a priori that things are conscious if they're organized a certain way something much more complicated is a priori and the more complicated thing is this it's if there is as a matter of fact in the actual world dualistic stuff if dualism is as a matter of empirical fact true about the world then dualism is a necessary claim dualism is if true a necessary truth so if there is dualistic stuff in the world you have to have dualistic stuff in order to have consciousness but if there's no dualistic stuff in the actual world then this functional thing is true that what consciousness is is just being organized in a certain way so my claim is all that's a priori is this conditional claim that if dualism is true as a matter of fact it's a necessary truth and if it's not then this functionalist story is true one of the reasons I think this conditionally story is true is that it seems to me there's no discovery we could make about the world to deny our own consciousness if I discover tomorrow that dualism is true I'm going to say great I must have dualistic stuff but having decided that having decided therefore dualism is a necessary truth and you have to have dualistic stuff in order to have a mind if I then discover the day after that that actually just been proved in nature no dualistic stuff the world only contains physical things I'm not going to go dang I'm not conscious I'm going to say oh in that case something else must be conscious it must be the stuff that we've got because one thing I'm sure of is that I'm conscious that's why I think this conditional has to be true now the conditional starts off with if there is dualistic stuff in the world and that's like is it an empirical claim it's something close to an empirical claim it's a claim about what the world contains and as it's a claim about what the world contains it's not something I can know a priori it depends on what you mean by a priori well yeah it does there are some reasons to believe it's false but I can't have an a priori okay you have to experience consciousness in order to know the answer of what the mind exists I wasn't going to say something like if I'm a physicalist I can't be certain that physicalism is true right because this is a kind of a contingent claim that the world contains so as a physicalist I'm claiming contingently the world doesn't contain this dualistic stuff since it's contingent as a rational being I have to give some credence to the world actually containing some dualistic stuff and if the story I gave you was true the complicated story if the world does contain some dualistic stuff then dualism is true and necessarily true so what that means is if I'm a physicalist and I'm rational I have to give some credence to being wrong because you know I'm a good Bayesian I think that I should give a credence of zero to anything so I'll give a credence of 0.05 to dualism being true so I think there's a 1 in 20 chance the world contains contains dualistic stuff but according to my own theory I mean I'm still a physicalist right I think that seeing a 19 in 20 chance that it doesn't contain any dualistic stuff but that means that I'm giving a 1 in 20 chance to the world containing dualistic stuff and in virtue of that conditional thing I told you before it follows that I'm giving a 1 in 20 chance to dualism being true and necessarily true but if dualism is true and necessarily true it's impossible so as a physicalist I have to give a 1 in 20 chance to zombies being possible now actually they're impossible because I give a 19 in 20 chance to them being impossible but so long as I think there's some reasonable chance that they're possible then I'm going to kind of think they're conceivable because I'm conceiving of them being possible even though I think they're impossible so as one of those cases of hyperintentional conceivability there are lots of things which as a matter of fact are impossible but which nonetheless so as rational beings we think well you know that theorem might not be a theorem after all maybe it is possible even though I think unbalanced it's not so that's why I think it's conceivable that's why I think we can kind of conceive of zombies it's because to the extent that we're rational we think that we might be wrong about our physicalism if we're wrong about our physicalism then dualism is true if dualism is true zombies are possible so I can you know in some there's got to be some sense of conceivability in which you can conceive of things that are impossible and despite you think you're unbalanced impossible even though you think there's some chance they really are possible does that not imply though that you're making at least a clear conceptual distinction between physical phenomena and what we consider to be conscious goings on that's a good question I don't think so because I'm making a clear distinction between physical phenomena and non-physical phenomena and then leaving it open where the consciousness is amongst the non-physical phenomena so let's say we're talking specifically about the philosophical zombies and what they lack is not the non-physical phenomena but specifically consciousness like the qualitative, the qualia stuff so in that sense wouldn't that still mean then there's still a clear conceptual distinction between physical goings on and qualia happening remember how this messy picture goes according to the messy picture if there is no non-physical stuff in the actual world then what qualia are are just these organizations of physical stuff I see, I see, I see in which case if that's how the actual world is then the possible world in which there's a physical copy of course contains a mental copy okay so you're saying that the qualia it's an open question as to whether or not the qualia are physical or non-physical phenomena is the existence of qualia that's right that's very interesting and it also accepts the conceptual priority of dualism right because notice I said something like if there is any dualistic stuff in the world then that's what consciousness is it's just I think as a matter of fact there are all these good reasons for believing it's not there in which case we have to accept this second best story which is it sounds like though if you make that conceptual distinction between the qualia phenomena it sounds like this position is something like a dualistic physicalism in the sense that we're granting radically different goings on in the world we're just not willing to grant the non-spatiality of it, of the one no it's granting, it's only granting the goings on of radically different things under certain assumptions so what it really is I think it's a common thing in philosophy it's a case where we've got a broad concept and then we've got these ideas about what it takes to have it and then we've got a suspicion that we haven't really got that special thing and the kind of a second best story so let me give you another example outside of philosophy of mind, let's think about free will right so a lot of people argue about whether free will requires the special amazing power to kind of intervene in the future and make it one way rather than another in a way which is not governed by the way things were in the past and some people think that what it takes to have free will is to have that and if you don't have that you haven't got free will and other people think that there could be some really deflation mixed with free will is just what happens when your brain behaves normally and no one's pointing a gun at your head right, this is the second best account you might just think they're not about the same topic at all but what I actually think about this kind of case is that look this first case has some kind of priority if we really do have this mysterious power in a way utterly unconstrained by the past and impose a will on the world in a way which is not just governed by the physical laws if any of us or most of us have that power gee wow, that's cool, that's what free will is that's what we always wanted right but if we don't have that should we say there's no free will hell no there's the second best thing and that will do in the absence of this thing which we've been pre-programmed by whatever it is our psychology and our background to think is what David Lewis once called the best deserving of what free will is and I suppose I think that about what's right about dualism it seems to me is that dualism is the best deserving of the name of consciousness yes we are pre-programmed to think all the things that dualists think and that I think every third Tuesday when I flirt with dualism and if there were stuff in the world that was not part of the physical world as we currently understand it and which was responsible for my experience or which is my experience whatever criteria are required if there were things in the world like that sure that would be the best deserving of what consciousness is but if it's not there and the various reasons think it might not be there then here's the second best thing the functionalist picture and I think that it's a conceptual truth that that second best picture will do and I think it's a conceptual truth because the dualists I've known who have become converted to physicalism haven't done what they ought to do if they were consistent to begin with said oh I've become converted to physicalism so damn I'm not conscious that's not what they say so everyone who's a physicalist who gets converted to dualism always seems to think oh no I'm converted to dualism I now see that the dualistic stuff is the conscious stuff and the dualists who get converted to physicalism don't say there's no consciousness they say oh now I see that you know there's only physical stuff but that's okay it'll still do and that's so coherent and so consistent I think it tells you something about the nature of the concept of experience yes it seems like this and this is what I think is the case that the qualitative the qualia the phenomena that we experience is as the indubitable stuff and then we try to give it an explanation we try to explain its existence and if you wind up with a theory that eliminates its existence it says you're not conscious well I think that's actually the definition of the inaccuracy of the theory because we just can't get rid of the qualia it seems but so let me ask you because again I'm I want to be a physicalist I want to be a monist and I don't want to be an idealist it pushes me in the other direction so about the qualia so we acknowledge qualia is a phenomena that is happening in the universe so you've got a red book over there and if I'm aware of the phenomena that I'm experiencing there is the experience of red that experience itself as I'm referencing it is something which is spatially extended that it is identical to matter yeah how can I understand that because I can say that okay that would explain it and then that persuasive and all the physical stuff I've ever seen if anybody's investigated it's not qualitative it's not yeah it is your brain is qualitative people might have investigated your brain but when they investigate my brain they're not investigating the actual phenomenological experience that's going on they've messed with you I mean people are giving you pills they've probably changed your actual phenomenological experience yes but even if you were to dissect I know you may not okay well let me ask for my listeners so if you were to take apart every single bit of atom every single bit of matter in my brain every single part down to the fundamental quarks of the universe plank units of the universe it does not seem to me that you would find the experiencing of red in there anywhere this actually takes me right back to how we began this discussion a little hour ago and I gave you my little example of looking at the microscope and looking at neurons on the one hand and closing your eyes about thinking your own experience on the other hand when you talk about going into the universe and dividing it up into quarks and so on what you're doing because you only ever have your own experience you don't have someone else's experience you are identical with this physical thing all you ever have is the experiences of this physical thing and the experience that I'm pointing at my own head by the way listeners and the experience of this physical thing the experience this physical thing has when it investigates quarks and it tears physical things apart and so forth is a different experience from the experience it has when it just closes its eyes and thinks about itself so of course those things will always seem tremendously different but isn't there's something on it I can't put my finger exactly on it but there's something about that that seems to deny this difference between the outside and the inside so it's like at least my conception of what is physical maybe this is the trouble is I'm not a physicalism because I don't have a broad enough conception of what is physical but it doesn't seem like there's any inside to external phenomena the atoms or the space time units whatever they are there's no internal going on there's no perspective it seems well there's all kinds of things that they might or might not have intrinsically which all we ever know about the world outside our own mind is how it affects us we've got no clue what things outside our own mind are like in themselves there's a doctor and I think the second I mentioned David Lewis this is a conversation we've mentioned the names of almost no philosophers except one guy and I mentioned his name twice there's a new he called Ramsey in humility and the Ray Lankman has called well canty in humility but that's a totally different view but Ramsey in humility is this idea that we need to be humble about the nature of things in the world outside ourselves because all we know about them is the effects they have on us scientific theories are in the end complicated theories about which explain the effects that the world has on instruments and ultimately the instruments have on us so if things in the world have natures other than causal natures other than the effects they have on other things then science is not in a position to tell us anything about that so it's not surprising that sitting here and looking at books that you won't learn anything about how things are in and of themselves all you'll ever learn about them what are the effects they have on you this seems like a very beautiful conception of what existing physical phenomena are because if you think about it again maybe this is them speaking a lot of my own thought process here if we expand what we mean by physical to include all of the goings on is kind of the explanation for everything then it's remarkable really really remarkable to think that in this world of bits you have the potential for every aspect of our conscious existence you have people or what we call people whatever those are you have the experience of love you have all these things that is constructed by whatever the universe is constructed by that's incredibly powerful if you think about it sure sure what I mean what I was trying to use it to say was it's not surprising that when you think about things outside the world they seem so tremendously different from when you think about yourself because when you think about things in the world all you're learning is about their effects on yourself so you're comparing how you are yourself under one circumstance and how you are yourself when you think about quarks and those two things are going to look a bit different that doesn't tell you that quarks are fundamentally different from our quarks because your quarks are the ones which are your experience those quarks out there they only affect you as far as they affect your experience so of course they seem very different doesn't mean that they are this has been a fantastic conversation I really appreciate your time I really enjoyed it there's so much more we didn't talk about intentionality or when you said my quarks versus your quarks what does that mean talking about the quarks that make up my head versus the quarks in that book but what is my part the ones that are here it's all indexicals thank you very much alright that was my conversation with Dr. Brad and Mitchell of the University of Sydney hope you guys enjoyed it I certainly did and I can't wait to break this one down don't know when I'll get around to it but it's certainly one on my list to go through if you're listening to this as a physicalist or as a monist and you think it's so evident that there's only one type of existing things in the universe I urge you put on your devil's advocate hat try your best to articulate and think through these arguments from a non-monist perspective and if it doesn't make any sense if you think there's no way to make sense of anything other than monism you're not trying hard enough you're not doing it right the dualists or the pluralists can certainly make sense of the allure and the promise of monism but if the monists can't make sense of the sensibility and the reasonability not necessarily the accuracy of dualism and pluralism then there's a problem unless you can find a logical contradiction there is no room for immediate dismissal of any of these ideas so thanks for listening everybody have a great week


Hi, my name is Dr. Ankit Shah and I'm a radiologist practicing at Wille Parle West at Grace Kill Imaging and Eclat Poly Clinic. My specialty is Muscular Skeletal Imaging and thank you for listening in. My name is Dr. Ankit Shah and I will be talking on ultrasound evaluation of carpal tunnel syndrome. Carpal tunnel syndrome or median nerve entrapment and the level of carpal tunnel typically presents with pain and parasthesias in the thumb, the index finger, the middle finger and radial half of the ring finger. Presence of night pains is one of the most characteristic features of carpal tunnel syndrome. This is because the patient sleeps on their affected hand or in that particular position for a prolonged period of time and suddenly they wake up in the night having numbness along the distribution of the median nerve. Advanced disease results in reduced grip as well as tenor muscle atrophy. The most important risk factors are hypothyroidism, diabetes mellitus and pregnancy. Now on the right side what we see is this considerable atrophy of the tenor musculature. The black arrow points towards the wasting that we see to compare that to the unaffected tenor eminence which is pretty smooth. Now let me tell you that by the time the patient comes to you for an ultrasound scan the diagnosis of carpal tunnel syndrome has already been made. Most of the times or maybe more than 85% of the times physical examination as well as history they are quite specific. So nobody is going to send the patient to you to make the diagnosis of carpal tunnel syndrome. What you are expected to do is comment on the nerve or any other pathologies which might result in compression of the median nerve. Nerve conduction studies and EMG is known to be the gold standard. However there are pitfalls because what happens is that nerve conduction studies evaluate only the large myelinated nerve fibres and the results are often normal in cases of early compression when only small unmyelinated fibres are affected. So that's where ultrasound really has an important role to play. So coming to the carpal tunnel anatomy it's typically a fibrocious tunnel whose floor is formed by the proximal and distal rows of the carpal bones and the roof is formed by a transverse carpal ligament or the flexor retinaculum. The transverse carpal ligament typically attaches to the paciform and the scaphoid proximally whereas distally it attaches to the hook of hammock as well as a trapezium tubercle. So the most important content of the carpal tunnel is obviously the median nerve and apart from that the other contents are the flexor tendons which are your flexor digitorum superficialis the flexor digitorum profundus tendons as well as the flexor polisus longus tendon. So if you have to remember the bony anatomy I would suggest that you remember the paciform as well as the hook of hammock as an important ocious landmarks we need to remember while we are scanning the carpal tunnel. As far as the surface anatomy of the carpal tunnel goes you have to remember that the distal pama gris forms the proximal edge of the carpal tunnel whereas the distal edge of the carpal tunnel is formed approximately at the level of the first web space. So what we see over here this yellow area marks the surface anatomy of the carpal tunnel. The primary pathology in carpal tunnel syndrome is a reduction in the volume of the carpal tunnel. Irrespective of the underlying cause reduction in the overall volumes of the carpal tunnel results in markedly increased pressures within the carpal tunnel. This can be regarded as compartment syndrome in C2. Alternatively there is another theory which says that the most common entrapment neuropathies are secondary to microtrauma to the nerves as it travels the osteofibrous tunnels. The carpal tunnel syndrome is divided into two main categories. One is an idiopathic form and the other is a secondary form. In the idiopathic form whenever the clinical features the nerve conduction studies or the ultrasound features a suggestive of median nerve entrapment but we don't find an obvious cause that's when we label it as idiopathic carpal tunnel syndrome. Whenever we see an extrinsic pathology causing compression of the median nerve or a space occupying lesion within the carpal tunnel such as a ganglion, accessory muscle, flexitin and dinocynovitis or even a lipoma we label it as secondary carpal tunnel syndrome. Irrespective of the nerve being involved in primary or secondary carpal tunnel syndrome all entrapment neuropathies undergo a series of changes. The earliest changes in paired venous flow which results in increased intranural edema. Chronic increased intranural edema results in ischemia and chronic ischemia results in internal fibrosis. Now mind you internal fibrosis is an irreversible change. Once the fibrosis sets in there's myelin sheath and axonal degeneration and this results in motor impairment wherein you get significant muscle weakness along with loss of muscle volume. The goal of imaging is to detect median nerve entrapment as early as possible because once internal fibrosis sets in the post-operative outcomes might not be that favorable. It is difficult to really differentiate between nerve ischemia versus intranural fibrosis on imaging alone. So the patient has been diagnosed with carpal tunnel syndrome. The nerve conduction studies have been done. Where does ultrasound fit in? Ultrasound will tell you about the median nerve morphology. It will tell you how significant is the nerve compression. How much is the intranural edema? Is the nerve just a single trunk or is it a biped median nerve? What is the anatomic location of the lesion? Is the nerve thickening proximal to the carpal tunnel or is it distal to the carpal tunnel? Are the branches of the nerve involved? What is the relationship of the median nerve to the surrounding soft tissues? We just discussed about secondary carpal tunnel syndrome. Areas which are difficult to assess with electro diagnostic testing can be easily seen on ultrasound and we already mentioned that ultrasound helps to identify peripheral nerve lesions which might not be that apparent on electro diagnostic testing. So we should all know that imaging gives an anatomical perspective to peripheral neuropathy which so far was just considered as functional pathologies which were evaluated on nerve conduction studies. Thankfully there is a lot of good literature coming up in recent times which actually supports the role of ultrasound in the diagnosis of carpal tunnel syndrome. So this is a very good article which got published last year in the American Society for Surgery of the Hand which says that if there is a dilemma of carpal tunnel syndrome they do recommend ultrasound to be used rather than nerve conduction studies. So from the concept diagrams we move into the real life ultrasound images. Here is a transfer section at the level of the proximal carpal tunnel which is obtained by placing the probe over the distal pama crease. Remember we spoke about the distal pama crease which forms the proximal edge of the carpal tunnel. The tautious landmark is a PC-formed bone at this site because the cross-sectional area of the median nerve is measured at this level. The red markers show the flexoretinaculum. The yellow arrow shows the median nerve which shows this honeycombed pattern and the structure marked FCR is a flexor copy radialis tendon. This tendon lies outside the tunnel. The significance of FCR is that during dynamic examinations movement of the median nerve is seen or calculated with respect to the flexor copy radialis tendon. Now moving in a little bit more we look at the flexor tendons more closely. They typically have an ecogenic appearance compared to the median nerve. However, as a beginner you might find it a little bit difficult to differentiate the median nerve from the flexor tendons of the wrist. However, how to differentiate between the two will come to that in a little bit later. Coming to the ultrasound microstructure of the nerve, you should know that all the axons are grouped together into bundles and they are arranged into fascicles. Now these multiple fascicles are grouped together and they are bound by the perineurium. Now this perineurium is this thick structure housing all the elastic fibres and the blood vessels and this perineurium is surrounded by the epineurium. This epineurium is also a active tissue with blends into the adjacent fat. What it does is it provides a cushioning to the nerve and prevents external compression. This epineurium is especially abundant around the nerves as they cross through the osteofibre tunnels. So once we've seen the concept of the cross section of the nerve, let's move on and see how the nerve looks on ultrasound and on the cross section. So on the cross section, your fascicles typically appear hypoechoic. Your perineurium looks ecogenic and even your epineurium looks significantly ecogenic and it almost blends into the surrounding fat. However, if you want to look at the epineurium properly, make sure that you look at them at the level of the osteofibre tunnels because that's where they're really significant. Typically, the nerve has a honeycomb structure. It looks like a honeycomb or if you want to call it a cut cable appearance. It's like if you cut a cable, you will see these multiple wires on the short axis. So that's what it looks like. On the long axis, the nerve typically has a filamentous pattern and may often resemble a tendon. So this is what the fascicle looks like. It's hypoechoic. Again, just the perineurium looks slightly ecogenic and the epineurium has a maximum ecogenicity. And if you look at the median nerve, it has almost a parallel course. This is a proximal end and as it enters the carpal tunnel, it still has this parallel appearance over here without any deformity. So how do we differentiate between a nerve and a tendon? What we do is we place our probe transversely over the carpal tunnel and what you do is you do this gentle rocking of the probe. So this is what I've shown over here. That's the carpal tunnel and I gently rock my probe back and forth. Now the tendons what they do is they show anisotropy. So if you see whenever there's anisotropy, the tendons become dark whereas the nerve remains more or less same. So this is how we differentiate tendons from the nerve. So okay, if you're not really comfortable with this, what you can do is you can take the nerve and trace it all the way approximately. You will see that the tendons they end into muscles or the muscular tendons is junctions whereas the nerve you can trace all the way up towards the elbow through the end of muscular fat planes. So that's going to be really helpful. A lot of ultrasound imaging findings and criteria have been described for ultrasound imaging of carpal tunnel syndrome. However, there are only a handful of findings that are of practical use and are clinically relevant. The hallmark of median nerve entrapment and the level of carpal tunnel is hypoequate enlargement of the median nerve, act and proximal to the level of entrapment. So what we see over here is the long axis view of the median nerve at the level of carpal tunnel. As the median nerve dips into the carpal tunnel, we see this waist formation or if you want to call it the notch sign. This is the area where there is deformity occurring within the nerve contours and this arrow shows this mild enlargement and eddy matters appearance of the nerve with typical loss of this fibrillary pattern. So this is a classic sign. So if you get this one image and if there are presence of symptoms, typical symptoms of carpal tunnel, you already have a diagnosis. So once you've seen the nerve on the long axis, you've seen this notch sign and you've seen this hypoequate enlargement of the nerve, what we try and look on the short axis is we try and look for intranural edema. We look for the nerve aquatexture. Now in this patient who already was critically diagnosed to have carpal tunnel syndrome, what we see that the nerve is enlarged as loss of typical honeycombed appearance. And the next thing what we do is we try and quantify it by measuring its cross-sectional area. Another patient with carpal tunnel syndrome, what we see is that as the nerve dips down, we see that there's a definite change in the contours which is shown by these markers. There's this subtle waist formation and just proximal to that, the nerve appears hypoequate with loss of this typical filamentous pattern and this is because of nerve edema. So I have evaluated the nerve on the grayscale image on the long axis. Now what I do is I turn on my power Doppler and what I see is hyperemia. Presence of hyperemia within the nerve is associated with nerve entrapment or nerve pathology. So there are these two or three findings which I have already seen and once again when I want to quantify what I do is I look at the nerve on the short axis. I measure the cross-sectional area at the level of the PC form bone and in this nerve the cross-sectional area measured almost 24 millimeters square. Now you know somebody would ask me when do I call that the nerve is big? Okay, there's so many criteria which are there. These are the two references which I have which I found really helpful. So what we do is we measure the cross-sectional area at the level of the PC form bone. When the cross-sectional area is less than 9 millimeters square it's definitely normal. If the cross-sectional area is between 9 to 12 millimeters square it's borderline. So it's at your discretion. You have a look at the patient if the findings are significant if the patient's complaints are significant yes it would fit into carpal tunnel syndrome and if it's more than 12 millimeters square it's definitely abnormal. Having said that if the patient is asymptomatic all right if the patient has no complaints then there's really no point in labeling the patient as carpal tunnel syndrome. What you can do is you mention it in the report that 12 millimeters square is high but since the patient has no symptoms it would be worthwhile to clinically evaluate the patient to rule out an underlying median of compression. So that's what I would do. Now another scenario when patient is typically symptomatic but you're not seeing those classical signs the nerve is not edematous you don't have a notch formation. The cross-sectional area is equivocal all right not fitting into anyway. So what do you do? This is something really important this is what I practice in my day to day ultrasound imaging practice. So what we do is we measure the cross-sectional area of the median nerve at two levels. One is in the distal forearm which is at the level of the pronator quadratus and the next level again I come to the PC form bone and I measure the cross-sectional area of the median nerve at this level. If the difference between the two cross-sectional areas is more than 2 millimeters square then it is considered as significant. Now this finding has almost a 99% sensitivity as well as 100% specificity. Coming back to looking at the nerve morphology you have to mention in your report is it a single nerve or is it a bifid nerve? A bifid median nerve is an anatomical variant wherein there are two nerve trunks you know just before it comes to the distal forearm it kind of splits into two trunks and this anatomical variant may or may not have a persistent median artery between the two trunks so it is very essential that you mention this in your report because when you mention this if the surgeon is planning to do an endoscopic carpal tunnel release they might want to change their surgical planning or maybe they would keep that little bit of information at the back of their mind so it is essential to do that. So coming to secondary carpal tunnel syndrome once you've really evaluated the median nerve what you do is you look for the rest of the structures in the carpal tunnel so if they are causing any compression. This was one 32 year old female with vague pain and parasthesias only along the tenor eminence there was a clinical suspicion of carpal tunnel syndrome so the median nerve we evaluated it was somewhere around 9.2 millimeters square but what we see over here is that we see a ganglion cyst right below the flexopolisis longest tendon on the short axis we see a typical anechoic appearance of the ganglion and long axis it has a similar finding this was one 47 year old female with night pains in the hand along the median nerve distribution she was a known case of rheumatoid arthritis so what we see over here is that there's hypoechoic soft tissue surrounding the echogenic tendons so this was typically flexor tendon tenor cyanobitis and what we see that the median nerve is pushed more along the volar surface so this one was secondary carpal tunnel syndrome because of flexor tendon tenor cyanobitis these are intra-op picture showing active panacea within the flexor tendon sheath this was a 56 year old male with carpal tunnel syndrome if you look at the cross sectional area of the median nerve it's around 7 millimeters square so pretty much normal however when you increase your depth you're done looking at the median nerve what we see is this soft tissue deep to the flexor tendons so this turned out to be low grade of flexor tenor cyanobitis which was subsequently turned out to be tuberculosis a lot of us are used to using high res hockey stick probes after you're done with evaluating the median nerve with the hockey stick probe it's a good idea to drop your depth and have a look at the base of the carpal tunnels just so that you don't miss out on any space occupying lesion or low grade tenor cyanobitis this was 60 year old female with a vague swelling over the volar aspect of the wrist and typical pain along the median nerve distribution so what we see over here on the transverse image there's this figure A that the nerve is enlarged see this echogenic soft tissue kind of causing separation of the nerve fibrils and color Doppler really doesn't show much vascularity on the long axis we see that there's separation of the fibrils with indefined echogenic soft tissue along the course of the nerve so we gave this as a infiltrative lipoma of the median nerve this is what the T1 weighted actual MR looks like and ultimately it turned out to be a fibril lipomata somatoma of the median nerve this is an interop picture wherein we see that the transverse carpal ligament is causing this indentation of the nerve that we see over here and this was this entire nerve which was significantly thicker so you've looked at the median nerve you've looked at the carpal tunnel it's a good idea to look at the end organ ultimately the tenor muscles because tenor muscle atrophy corresponds to disease severity so they say that atrophy of the abductive polycystic brevis is associated with poor outcome even in the post surgical period so it helps in counseling the patient and helps in treatment planning the median nerve looks normal at the level of the wrist is that the only reason is that the only reason for this pain so that's where I mentioned that the patient has to be diagnosed clinically first so your patient might be normal, your scan might be normal but then have other pathologies being ruled out like multiple sclerosis of bats, of apple disc disease, syringomylia, peripheral nerve sheath tumors once in a while you might see something like this brachial plexus neuritis and thoracic outlet syndrome so you should know when to alert the clinician that okay fine your scan is normal maybe he should look up for something else you know get an MR done so this is my last slide so this is my checklist for ultrasound evaluation of carpal tunnel syndrome I look at the median nerve ecogenicity and morphology I look it in the long as well as the short axis when I say morphology again is this a single trunk? is this a bifid median nerve? does it have a persistent median artery? I look for waist formation or the not sign on the long axis cross sectional area at the levels of PC form bone and the pronator quadratus alright if the difference is more than 2 millimeters squared it's significant I look out for secondary causes of carpal tunnel syndrome look out for you know tino sinovitis, ganglions lipomas, accessory muscles it's not always necessary to label what kind of a muscle is it as long as you identify it you know that should be good enough tenor muscle, equatexture and volume look at that as well and if you can try and look at the path of the pama cutaneous branch of the median nerve with respect to the flexor retinaculum sometimes some of the surgeons would like to know this because inadvertently if they injure that nerve the patient can have postoperative symptoms so with that we're done and thank you so much for listening again


Everybody forced here up in 22 23 UEFA sapphire Five box number one random teams find the results anytime a late sports cards calm. Let's go ahead and get started No idea Zach. No idea That news I think Has taken everybody by surprise. I don't think any of us all that coming So sapphire next is down to 10. All right, here we go First group rake of this stuff. I'm excited should get two parallels looking for variations as well Also a lot of baseball top. We'll top load every single card in the break At some point I didn't have to do it all now, but good luck y'all got inserts in this sapphire Which is interesting Baka Yoko and there's a sapphire Selections of Vinnie jr. Nice card. Those are not every box. Those are a little rarer for the inserts Bravo casado at least as of right now Vlahovic and sesco wonder kids boy inverts Sala a sugo sporting rookie and a messy variation. Yeah Right Yep, messy variation. Yep There you go PSG nice card What's up, Cameron? What's amendi? Hyroldsson on the rookie got Phillip Cohn and a green Phil Foden 60 of 70 Manchester City Green Foden Mount Stanisic Zlatan cungu Cruz Rashford Saka and wonder kids dayditch for Salzburg bourge vine morata Doku and Zara Emery Doku with the transfer today Colomuani. We got a purple. It was long go Degrassa and purple rookie is Matthias Suley one of 15. Hugh Ventus very nice You've a there you go. What's up, Kyle? Here's the sacred scripture It's just that had the thing have every box the broine Others Lane's boy. Tell me Abraham Gakpo and wonder kids by no gittens Alvaro Rodriguez Sadio Mane Ribeiro and Gabi every other card upside down. That's so much fun They do that all the time. Yeah, I think the Gabi's variation. Yep. Gabi's variation There you go Barça So the the see the the CMP 344 is image variation. I think three two four is base Right Yeah, three two four is base Erickson who to guard in an orange Marquinhos the PSG Marquinhos the 50 Wal-Mart Moreira, Jr Clem and Samacha, I know what your favorite planet Chuka make up Petrie and Bob a Julian Alvarez wonder kids minds the sun Rhone Suley Kalamwendo and a door Who's the far? Every night every time we break together there's always some high ground or some You're a chosen one got Suley My new and a yellow here is Tebow Courtois for Real Madrid. I'm choosing it for the means 99 Courtois, I don't think Donny has seen that the Will Ferrell as What's freaking in Courtois Paul Vaughner the Grasa and by no gittens Harry carry on SNL He was the Cubs play-by-play for a while Long time Benzema Sancho so many upside-down cards messy and Baka Yoko You're here a gear Bonucci do a and a Figo That is a variation on the Figo For real, I think it's one a box variation right one in every eight packs Looks like an on average, but around one a box Kaku Raphinha And nice a rashford out of 99 this time for man you Enzo rookie there we go Chelsea Lazatich Elliott Ignacio Suchich Gavi Laba Sheldorook rookie Rich Charleston And Muhammad Ali Cho for Sociedad Kokeshu Antony Verratti and orange mudreech that one's out of 50 Real Madrid another parallel for you live on where Torrey Sasa well, he's Diaz with a very nice scissor kick goal and a Gabriel Jay Zeus All right guys next one. We got to get it filled up still at 10 still at 10 10 to go 80 bucks a spot Pretty darn good. Actually we didn't hit an auto in one of these We still got an upper deck as well random pack style skybox metal universe champions at 11 to go as well 20 bucks a spot All right last spot a second last box is latin van dyke marine and zealouski James Julian alvarez Kane and holland The holland variation. Yep holland variation Man City green coming up Vanalsen sesco Gardeby and a green daizen maeda Celtic color match to 70 iragi de bala ikbal and a bucanon Got a nakai levendovsky kulesevsky And i'll lead show Yeah, kyle. How was the rager? pulisic matisse tell becker and amiel smith row Kyle threw a rager Yeah, sure. Oh, we got red We got red. There's kisa Skarls out of yummy That psg or was that inter there's like a circle with blue It is edin jeko 5 out of 5 on the red for inter milan 5 out of 5 red jeko for inter milan Pretty solid card there.  I'll do Foden abraham and sapphire selections this time is jude bellingham Or dortmund bvb Come on poppadea pride prasher Don't even like poppadeas or you just like poppadeons I just like poppadeons. I've never had a poppadea, but from what I heard it's not stress Yeah, if you ask one person it's very outspoken around here. Yes, technically too because one agrees with the other All right, eight to go on sapphire next Oh, so I thought you knew it was we were joking. However, it's jovic to ketel air and bargy Let's haro silva rois and museala All right, let's do something thursday night then Davies darmy garnacho base and a yellow trend alexander onald to 99 libra pool Ike bravo cold palmer mckinney and nusa verts rice Sean was gonna. Yeah, I'm sure he was bit shiabu and sesco He definitely wasn't playing fortnight with me at 11 p.m on saturday cruce stanisic cone and in kungku I think I may have passed the variation in this box. Maybe Casado bargy salla and a sugo Mount otamendi is on yolo. Nice a green orico lewis for manchester city 34 of 70 there we go manny Hello, manny Salutations my fellow fellow I think I missed the variation out in that last one Uh variations of holland figo gavi and messi. All right to 99 alexander onald rashford Cortua to 70 was rico lewis Mayeda and phoden to 50 was modrich and marquinhos to 15 sulle juventus very nice and red to five edin jacko Inter Milan. Thanks again everybody moving on to the next one number two


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