Critical moment. I am so touched that so many people have come out and above all so honored that President Robinson is here with us the Ireland's great Human Rights Trailblazer. I asked how I should what the honorific was that I should use with Mary Robinson and you know was it president or commissioner, you know Mary that was the answer of Mary's. So thank you, Mary and and thanks to Jill Donahue for her persistence and for Barry Andrews and to both of them really for their amazing leadership of this Institute, which takes on ever more importance in a time of polarization, which I will talk about in a time of fake news at a time when the ground beneath our feet around facts and science seems to be shifting in pockets, but ever-expanding pockets, I think arguably in an ever-expanding number of countries institutions like this one that seek to ground policy in analysis and rigor become ever more important. When I got on the plane in Boston last night and we headed over the Atlantic in the quiet dimmed cabin of Erlingus it hit me about just how monumental the last few days in the United States have been. We had an incredibly contentious and expensive mid-term election breaking all records and of course an election that has huge consequences for the United States, but also potentially has very important knock-on consequences for the world, which I will talk about. A few key races are being contested at this very minute. The President has already fired his Attorney General throwing the federal investigation into ties to Russia into potential danger. He's also, I gather, threatened to shut down government if Democrats follow through on the pledges that some made to use their perch now in control of critical committees in the House of Representatives to investigate corruption in his administration. A key meeting between the North Korean and American teams negotiating over, hopefully, some version of denuclearization was canceled amid mutual familiar recriminations. All of this, and it's only Thursday, Democrats gained control of seven state-level legislatures by flipping a total of 367 seats from red to blue. Democrats gained seven governorships. This is huge. And I should note that one of the unanswered questions about the Obama years, which I was happily a part of, is how it was that the Democrats slipped so much across the country in terms of controls of state legislatures in terms of control of governorships. But we're just now in the process of clawing back, and this Tuesday election was huge in that regard. And it included really important wins for governorships in places like Wisconsin and Kansas, really difficult wins, in fact. So if I were President Trump, and it's no secret, I'm not, I would view the election as a warning, and that's not how he processes information. It appears. But remember, again, 2016, the election was won by 78,000 votes. I mean, think about it, with a country of 330 million people in the states, 78,000 votes spread across three states, Michigan, Wisconsin, and Pennsylvania. Those were the three states that Secretary Clinton had expected to win, that were lost. And on Tuesday, Democrats swept every race in these states for Senate and for governor. Shoring up President Trump's base in those states will be, for him now, priority one, as he looks, as he inevitably does, to 2020, most specifically and most importantly, the war in Yemen. Many Democrats are eager to do more than the Trump administration has done so far in responding to the murder of Jamal Khashoggi. And they may advance legislation that would halt arms sales to the Saudi government. This, by the way, raises questions about Europe, the United Kingdom and France, and what the posture will be. In the old days, when the United States, namely until January 20, 2017, when the United States, whether under Republican or Democratic administration, would have been contemplating a move like that, which would have been a rare thing in its own right to contemplate. But what you would seek to do is to multilateralize that move and sort of eliminate the prisoner's dilemma and get a bunch of countries to jump together so that the effect is greater. And then you use your leverage to try to secure the outcome that you seek, which in that case, of course, is complex. But beyond the gruesome and outrageous state-sponsored Khashoggi killing, I think the most urgent action you are likely to see is a long overdue, much more forceful and much more effective push to end U.S. support for the Saudi and Emirati war in Yemen. So what I think you can expect is some version of a bill that basically prevents the United States from providing aid, intelligence, and refueling to the Saudi-led coalition. This is support. I should stress that we in the Obama administration should have revoked long before we left office. And that's something I think that all of us have very significant regret about. Maybe in the discussion we can talk about the logic of that, which few at this point can understand. There is a bipartisan coalition for the bill along the lines of what I'm describing in the Senate. Rand Paul and Mike Lee and others have pushed actually something like this. So this is a rare issue where there's at least some bipartisanship. What is not clear is whether you could muster the votes in order to overcome a veto. So you'd need a veto-proof majority and that will be hard to come by. But again, the idea that now there'd be a body that can put issues like this on the agenda and force people to take really difficult votes, juxtapose those votes then with the images that you see with what aid workers. And I know we have people from concern and goal and others in the audience are saying is going to be the worst famine in any of our lifetimes. No matter our age in this room, no matter how we are, there will never have been a famine in our lifetimes like this one. And yet, you know, we're just on autopilot continuing to fund this madness and worse to fuel and to arm this madness. Interestingly, we already see statements from Secretary of State Pompeo and Jim Mattis seeming to want to get ahead of the legislation. I don't know if you noticed that, but just coming out last week, sensing I think that especially with some of the excellent reporting, sadly late reporting that has been coming out of Yemen, at least in the American press of late. And I think the Europeans and others were ahead of some of the mainstream American press. But Madison Pompeo came out, called for a ceasefire, called for a cessation of hostilities. And I think, you know, well and apart from the images, what that appears to be is an effort to get ahead of legislative action, because no executive branch wants to be seen to be doing anything, of course, in response to the Congress. The second big area of influence, which has bearing also on European budgets, is our American federal budget, whether that's foreign assistance, development assistance, support for the UN. The budget is negotiated through the House and Senate. And in fact, President Trump's very vocal and determined efforts up to this point to gut humanitarian aid, to gut UN peacekeeping. These efforts have actually up to this point been stymied largely by people like Lindsey Graham and other slightly more internationalist Republicans in President Trump's own party. But now there will be even more leverage on the side of, you know, in effect, a kind of bifurcation between President Trump's nationalist isolationists. We don't want to be a part of institutions. We don't believe in giving foreign assistance to anybody who doesn't vote with us 100 percent of the time at the United Nations or whatever that rhetorical view that he has articulated. Now you will have even more ballast on the side of a more internationalist set of investments in an international architecture that Trump has, with some exceptions, indicated very little patience with. So that could be quite significant and it could translate into some writing of the accentuated imbalance between our investments as a country, America's investments between defense and diplomacy. So that's a space to look to.  And perhaps that's something we can talk about in the questions about, you know, the American public and I'll come to some of the polling on this a little bit later. But this is the time now between November and January that you're going to see individuals, some of whom were involved in making foreign policy for the Obama administration, like our America's assistant secretary for human rights, Tom Malinowski, a Polish immigrant, a dear friend of mine and my families who helped work with John McCain in a bipartisan way. He was at that time the director of advocacy director of Human Rights Watch to reinstitute the torture ban and build it into US legislation, which boy, are we glad it's in legislation given again the change in presidency. He worked with John McCain also on the McNitsky Act, which is the human rights sanctions legislation that has been used under President Trump. Over the last, you know, nearly two years now. And now he's going to represent the seventh district of New Jersey as a congressman and he ran his entire platform was hashtag reject fear. And he actually just used his campaign to talk about how he had seen fear mongering in other countries and the way in which the other was sort of parodied and marginalized and demonized and stigmatized. And the ways in which that led to ruin for so many communities. And he managed to translate that into a message in New Jersey. A fun fact, Tom Malinowski, and you can follow him on Twitter. He's a he'll be an incredible voice, I think, for a sane and compassionate foreign policy going forward. But as it happens, President Trump's favorite golf property is in his district. And so one of Tom's slogans was, we're going to turn Trump's putting green blue. It worked barely. It was a very, very narrow victory. He beat a five term Republican incumbent. So foreign policy is not, again, on the tip of everybody's tongue, who voted of the 114 million who voted very few. I suspect with this have been a driving factor. But the third issue is the one that you have been reading about, which is the question of oversight. And here, again, oversight and accountability are very different than the ability to actually put through legislation yourself. So this is going to have to be coupled with some across the aisle outreach if actual legislation is to be achieved. But one should not diminish, again, the importance of the investigatory powers of the House, the hearings and also the ability to agenda set through the mandate that you have to summon. Administration witnesses to discuss, for example, what is being done to ensure that the election interference that occurred in the 2016 presidential elections will not be repeated, whether by Russia or by China or by a non-state actor, whether in an election season related to an election, or just on some big legislative vote, or just as it's being done now to exacerbate social divisions, which I'll come to in a second. Just summoning witnesses, getting them to be transparent about what is being done. The answer, unfortunately, is very disturbing. But that in itself, as we know, as any of us who've served in government know, when you have to go and publicly testify to what you are doing, you know, occasionally at the last minute, you see people saying, you know, I really don't like what I have to say. Can we can we do something about this so that I can actually have some more to say when we go from Wednesday to be amazed at how often that happens. So whether it's the Rehinga and the complete absence of U.S. Diploma Seaboard in even being a factor in trying to summon diplomats or create a kind of contact group to figure out some shared approach to either in the short term enhancing the dignity and the welfare of those people who've already been purged in what looks like it was basically a systematic genocide. Or North Korea to get more transparency on these negotiations, which appear mainly to be photo op to photo op. But whether it's climate change to understand again better what's being done to forget the national policy on climate change, but to actually the scientists who work within the U.S. government and where they have gone and what their welfare is and how science as a predicate for policy can do. Restored anyway, all of these topics and so many more are ones that Democrats will now have a chance to put forward when you're in the minority. You know, you're really at the mercy of the agenda that is set by the party in charge of your body and to an extent, I think that has surprised people. The GOP really has told the line, the Republican Party has told the line with what President Trump would have wished to be the topics of the day up on Capitol Hill. And again, that was predictable to some extent, but the extent of deference given that within the Republican Party, there are very different views on trade than the ones that President Trump has pursued. There are very different views on NATO, very different views on Russia on human rights. Perhaps not so many different views on climate change, unfortunately, or at least none that are articulated. Certainly very different views on how to engage dictatorial regimes like that of North Korea. I mean, look at all the sound bites about when we were talking to Iran, those all flipped again in deference to the president. So what will happen now when that debate gets opened up in a different way? Okay, so systemic risk of monumental proportions, not just to the global economy as I dealt with, but to the international order as we know it and to world peace. In the meantime, amid all these analyses and warnings, China is stepping up and stepping in to influence countries on issues where the United States has enduring interests. And issues where the United States has vacated willfully really a leadership role. So this was going to be a contested space no matter what, but what one wouldn't expect. Some of you might have read Thucydides' Trap, or the book is actually titled Destined for War, but it looks at rising powers, challenging status quo powers. There's no real model for an occasion where there is that tension, those tectonic plate shifts and potential clashes about to, not necessarily military clashes, but structural clashes about to happen where the status quo power kind of ducks out and hastens the rise of a rising power like China. And that book was written, of course, before Trump's election could was even a gleam in anybody's eye, even Trump's maybe. At the 19th Party Congress, President Xi described the 21st century as a new quote, era that will see China moving closer to the center of the world, end quote. He cited climate change and trade as the main areas where China was going to exert its influence. It would be interesting to hear President Robinson's views on China as a constructive force also in the climate space and whether that can be sustained in a manner that actually causes a race to the top. That's one area which I'll talk about where they've done incredibly important things as the U.S. steps away. But it goes without saying that on both climate change and trade, these two areas that President Xi has pinpointed, these are areas where there are substantial economic benefits for those countries that develop the rules of the road in those areas. China is the world's largest investor in renewable energy. It has launched the world's largest carbon trading system. Last year it accounted for half of all the solar installations in the world. Xi, who's going to be with us, it seems forever, is also pushing forward with a massive trade deal that will include 46% of the world's population, 30% of the world's GDP, and some of our allies who had been part of the Trans-Pacific Partnership that Trump abandoned, allies like Japan, Australia, New Zealand, Singapore, and Vietnam. But this new China-led partnership will not include the United States. The 16 countries involved in the deal are expected next week to announce that they will conclude negotiations on the mother of all trade agreements maybe in 2019. So again, that could be 46% of the world's population encompassed in that and very related to the decision by the United States, of course, to step away from the TPP. China is also turbocharging its diplomacy, and I know we have a number of Irish and other foreign ambassadors here in the room tonight. And I'm sure this is something that you and your colleagues have seen all around the world, the enhanced and ever-expanding Chinese diplomatic and foreign aid and development presence. At the UN, the US remains the world's largest donor, and I think at least for now still wields the greatest influence. But in 2019, just next year, China will overtake Japan as the second largest contributor to the UN regular budget. Now that sounds kind of normal and natural, but if you look at where China was just 10 years ago, because the amount that you pay is calculated on the basis of your GDP and per capita income and so forth, it's a complicated formula. But China was nowhere, and it's just every year steadily doing more and more, and the more you pay, the more leverage you have, of course, in changing the rules of the road as you see fit. Bloomberg estimates these are murky numbers, but that China's total foreign affairs budget has doubled since the beginning of President Obama's second term in 2013. That's a short time to double. We don't know the baseline, but these are the estimates that are out there. China's foreign aid, we know in Africa and Latin America, longtime friends of the US, has increased each year by an average rate of 22%. So think of that exponentially. It's controlling everything and getting to dictate what NGOs do, which is of course what would happen, what happens for any NGO that attempts to work within China, but this is an effort to internationalize the domestic norms. So we need somehow in the West to develop a foundation for a partnership with China that is mutually beneficial and order enhancing without succumbing to some pretty hard to resist temptations. So one is the temptation to reflexively resist China's rise, and the other is the temptation because China is so powerful to whitewash the deeply problematic domestic regional or global policies. We made the first of these mistakes in the Obama administration. We lobbied everywhere and totally unsuccessfully to try to prevent China's establishment of the Asian infrastructure bank. Again, just trying to fight this rival institution when the writing was on the wall. Trump, I think before the trade war, made arguably the opposite mistake of showering President Xi with praise in a seeming attempt to curry favor. One of Xi's most trusted and influential advisors is a man named Liu He. Some of you may have come across. He's a key counselor to Xi on how to manage relations with the U.S., and he has told Americans who meet with him, quote, I don't think that the U.S. and China are enemies, are real enemies, are terrorism, climate change, and the challenges arising from technological change. And so again, if you think about what forward-looking diplomacy, really hard diplomacy given conflicting views on how to manage norms, but these would be the areas that one could begin to build out a cooperative structure with. And we did this in the Obama administration through the Paris Accord starting first with Beijing. And again, the secret of effective multilateral diplomacy is that you don't start mega multilateral, you start with small groups and the most influential stakeholders, and then you seek to build out. I think that's one of the reasons the Paris negotiations proved a success. And its corollary is that one of the reasons Copenhagen failed, it was a big scrum without that kind of framework. So on that, on Iran's enlistment in the nuclear negotiations that gave rise to the JCPOA, excuse me, China's enlistment in that. I mean, these are great examples. Imagine the anti-poverty initiatives conceivably that could be hatched collectively if we were able to at this point, again, before things are too far gone, put our heads together on disease and hunger. And even on cyber, which is a very, an issue of great contention between the United States and China, you know, President Obama's second term, we were able with China to come up with a set of norms where we agreed not to conduct state-sponsored cyber attacks on private sector companies. And our intelligence community actually reported that in the wake of the agreement to these norms, which a lot of people are skeptical about, norms, norms, you know, will they do any good, but the number of attacks dropped precipitously. So thinking about how to broaden that agreement on cyber attacks so that it encompasses civilians and civilian infrastructure is the obvious next step. Again, if we had a rich and fulsome and aggressive diplomatic agenda. But we can't turn a blind eye either to aggressive actions in the South China Sea, the abduction of booksellers, extra-territorially. We're now seeing so many extra-territorial actions as people feel impunity. It seems to going beyond their borders, whether to poison somebody in London or to murder somebody at their consulate in Turkey. And China is very much a part of this despite its rhetoric about the importance of sovereignty, foreign policy. First, it'll be really hard to get bipartisan or fulsome support for ambitious foreign policy undertakings. So you're likely to see fewer ambitious foreign policy undertakings. For example, we can't even secure an authorization to use military force to replace the one passed 17 years ago in the wake of September 11th. Because bringing the parties together, if you say X, I want to be for the opposite of X. It is second, hard to agree across party lines on the lessons of foreign policy failures. So you can't kind of dig into something, even as we did in the 9-11 commission or in the 70s with all the Cold War excesses. You know, with the church committee and other reports when we looked into how to massively circumscribe covert operations. That could happen in part because you could look at things and try to do things differently, but from a bipartisan platform. There's a greater risk as we've seen with polarization of dramatic policy swings from one administration to the next. And these are extremely destabilizing globally given our connectivity. And it used to be that we had these things called international treaties that made it through the U.S. Senate in the U.S. George W. Bush's administration, hardly a tree-hugging embracer of international law, ratified 163 international treaties in those 8 years. The Obama administration, 20, and again because of the 67-vote threshold that we need in the Senate, not because we wouldn't have wanted to ratify more treaties. The Trump administration so far, 6, covering extradition and other bilateral legal issues. So the amazing thing is to see actually how Russia and others who interfered in the election, but how useful they see these divisions to be from their standpoint. And how do we measure that? Well, first we have the election interference, which we now know about bots and trolls, flooding social media, yes, pushing Hillary or Trump, but really much more systematically interested in taking the fissures within American society on race, on religion, on guns, on gender, and widening them. So here are some examples. Again, some of you may already be aware of, but when we had the Charlottesville Unite the Right, the kind of quasi-Neonazi rallies, Russia, we have evidence of this, amplified voices both from the alt-right, neo-Nazis, and from Antifa. So actually taking tweets done by those and amplifying them or doing their own tweets to create, again, both division, more division, and then the impression of more division, which is a bit of a doom loop when you begin to think about faith and democracy. The content Russia circulated was seen by at least 126 million Americans. We also see them do this on Black Lives Matter, pro and against. And again, now even the Marshall Project is tracking this and offers a daily snapshot, basically, of what Russian-linked bots and trolls are doing, and it's always some version of this. We saw this with the Parkland shootings, pro-gun control, pro-NRA all linked, again, back to these Russian accounts, and most recently with the very divisive Kavanaugh hearings, the same thing. So this is not, it's a mistake to think about interference as an election phenomenon or division as something which, of course, is exacerbated in election season, but this is a steady state phenomenon now. They believe that the more divided we are, that that's an asset for them. So it seems as though instead we have replaced the kind of end-of-history triumphalism that we experienced in the 1990s with its kind of doomsday opposite right now. And that's, I think, a challenge for all of us. Now, what has happened is a wake-up call, right? We can't take for granted even science, right, the resilience and the status of facts, the durability of liberal institutions, the fact that my husband can edit a book called, you know, Can It Happen Here? In 2017 is a reflection of the fact that people are not grappling with questions that we thought were the stuff of a prior era or indeed a different galaxy. And so that wake-up call, of course, is useful and many of the structural issues that I've described are really daunting to imagine tackling. But the despair is helping no one at the present. And so thinking through, again, the advantages of the resiliency of our institutions, the advantages of our possibility of self-renewal. You know, maybe we didn't get as wholesome and fulsome as self-renewal on Tuesday as some might have liked and across-the-board thumping, which would have been, from my standpoint, of course, preferable. But seeing, again, the ways in which people come out and vote with their feet and show the importance of citizenship, again, in the face of policies that they find disturbing, is just a reminder that the power to write the story of this century, the power to decide which of these two models ends up being one that takes adherence, more adherence, and not fewer. Which of these models is the model that gets to shape the rules for everybody else within the international order? That power fundamentally comes back to citizenship. And it is worth remembering that today, notwithstanding the backsliding that we all know about and the declines in freedom in a bunch of countries, there are more democratic countries in the world in 2018 by most metrics than ever before. So we're still in that world, but it doesn't feel that way. And so it does feel that a challenge for all of us, especially at institutions like this one, is to take up the cause of strengthening, of course, our democracies through voting and through serving and other means, but also taking that show on the road and not running for cover just because the geopolitical dynamics are changing. I come back to Churchill, who I know is so popular in Ireland, I just thought, everybody in Ireland's got to close with a Churchill quote, but democracy is the worst form of government except for all those other forms that have been tried from time to time, including now. Thank you so much.


Okay, so this is going to be a demonstration of some spaces and tunnels with their clinical significance. These are usually described in textbooks, but they're hardly ever shown in the sections. So to bring you up to speed, this is the prone cadaver and this is the right side. We are seeing it from the back. So we have to get the orientation clear. This is the trapezius muscle that we can see here. I'm going to reflect the trapezius. Then only we can see the deeper structures. So I have reflected the trapezius and then we can see the next muscle here. This is the supraspinatus. This is the spine of the scapula. And under that we have the infraspinatus. These were covered by a thick, tough fascia which has been removed. This is the deltoid muscle. This also we have cut and reflected to show the next muscle under the infraspinatus, this muscle. This is the teres minor. So therefore the supraspinatus, infraspinatus, teres minor and the subscapularis, which is deep inside here where my finger is located, they constitute the rotator cuff. They get fused with the shoulder capsule. To continue, this is the teres major. This is the long head of the triceps, taking origin from the intraglinoid tubercle of the scapula and this is the lateral head of the triceps. And this is the surgical neck of the humerus. Just to complete the story, since we have reflected the trapezius, we can see this muscle here. This is the rhomboidus major. This is the rhomboidus minor. And this is the levator scapulae. But we are not going to talk about that at this juncture. So having mentioned these muscles, I'm going to demonstrate the spaces and the triangles and the structures passing through them with the clinical correlations. Let's start with this space here. This is the quadrangular space. The quadrangular space is bounded by the teres minor above the teres major below. Above is also the head of the humerus and in front will be the subscapularis. Medially we have the long head of the triceps and laterally we have the surgical neck of the humerus. So this is the quadrangular space. This quadrangular space gives passage to this structure that we can see here. This is the axillary nerve. We can see the axillary nerve is giving a branch to the teres minor. But the main axillary nerve is deeper down and this is the main axillary nerve. And this main axillary nerve supplies the deltoid muscle from inside. And we can see it's giving multiple branches to the deltoid. And after it has supplied this deltoid muscle, it will pierce through and it will supply the skin on the upper lateral aspect of the arm. Accompanying this axillary nerve, we have these vessels here. This is the posterior circumflex humeral artery and the posterior circumflex humeral vein. So this whole neurovascular structure passes through the quadrangular space. The clinical coordination pertaining to this is in inferior dislocation of the shoulder joint. As I mentioned, the head of the humerus is just above the quadrangular space. Or in fracture of the surgical neck of the humerus, it can injure these structures, especially the axillary nerve. In which case, the paralysis of the deltoid will produce flattening of the shoulder and inability to abduct. This is a very serious disability. So this is the quadrangular space. Now we are going to move a little medially. We will still be between the teres minor and the teres major, but now we are going to move medial to the long head of the triceps. And that is this space here. This is the triangular space. And we can see the triangular space is giving passage to, again, some blood vessels. This is the circumflex scapular artery. The circumflex scapular artery enters into the scapula between the teres major and the teres minor. And it is accompanied by the circumflex scapular veins. The circumflex scapular artery is the smaller terminal division of the sub scapular artery, which comes out from the third part of the axillary artery, the other branch being the thoracodorsal. And it forms a scapular anastomosis. This scapular anastomosis basically is an anastomosis between the branches of the third part of the axillary artery with the first part of the subclavian artery. More specifically, the dorsal scapular artery and the suprascapular artery. Now this, again, is a very useful anastomosis. If there is any subclavian axillary thrombosis, then this anastomosis constitutes a main form of circulation to the upper limb. Likewise, if any surgical intervention has to be done or if the axillary artery has to be ligated, or if there is any injury to the axillary artery and it requires an intervention, then the axillary artery should be ligated above the origin of the subcappular artery so that the subcappular artery can give the circumflex scapular, which will participate in the scapular anastomosis and the circulation to the arm will be maintained. So that is about the clinical significance of the triangular space. Now from the triangular space, we will move below the T.D.'s major and we will be lateral to the long head of the triceps. This triangular space that we see here, this is called the triangular interval. So this is bounded above by the T.D.'s major, medially by the long head of the triceps and laterally by the lateral head of the triceps and again the humerus. So this is the triangular interval. And it is best seen when I reflect the long head of the triceps and now we can see the contents of the triangular interval. We can see the contents here much more clearly. We can see this structure here. This is the radial nerve. The radial nerve supplies the triceps. Before it enters into the radial groove, it supplies the long and the medial head of the triceps and then it enters into the radial groove. And then it runs behind and it supplies the lateral head of the triceps. Accompanying the radial nerve, we have this vein here and we have this artery here. This is the profunda brachii artery. We can see this is the brachial artery and arising from that is the profunda brachii artery and the profunda brachii vein. They also accompany the radial nerve and they run through the triangular interval. Just to bring you up to speed, this was the triangular interval we saw and now we are seeing it from the other side. So here again we have some important clinical correlations. In fracture of the mid shaft of the humerus, the radial nerve can be injured. In which case, it is likely to produce paralysis of the lateral head of the triceps because the long and the medial head of the triceps have already received branches before it enters the radial groove. Another important clinical correlation is sometimes abnormal insertion of these muscles can produce entrapment of these nerves or these vessels, namely the profunda brachii as well as the radial nerve. Likewise, if for any reason we have to ligate the brachial artery, we should do it below its profunda brachiae branch so that the profunda brachii can be given off and it can provide circulation of the arm through the elbow and osmosis. So this is the triangular interval with the neurovascular structures and finally, since we are looking at the structures from the posterior aspect, this is the right time to show yet one more structure. This nerve which I have picked up, this is the ulnar nerve and we can see the ulnar nerve, normally it runs behind the medial intramuscular septum and we have got the medial intramuscular septum so we cannot see it from the front but we can see it clearly from behind. The medial intramuscular septum is attached to the medial supra-condyler line. Ulnar nerve does not give any branches and arm, it just gives a few articular branches to the elbow and we can see those articular branches. The medial ulnar nerve then runs posteriorly and it runs behind the medial epicondyle and this is the medial epicondyle and we can see it is running here and while it is running, it enters into a tunnel and this tunnel, I am going to put my instrument now to show you, this is the tunnel. This is the cubital tunnel. How is this cubital tunnel formed? The cubital tunnel is formed by an apocalyptic expansion from the flexor carpi ulnaris. The flexor carpi ulnaris aponeurotic expansion comes like this and it bridges over the between the medial epicondyle and the posterior aspect of the ulnar and it fuses with the anti-brical fascia and it gets attached to the posterior aspect of the ulnar thus forming a bridge like this and we have cut open part of the bridge to show the cubital tunnel. This ulnar nerve passes through the cubital tunnel and here again we have two clinical correlations. In fracture of the medial epicondyle, the ulnar nerve can be insured and while the ulnar nerve is passing through the cubital tunnel it can get entrapped here and the condition known as cubital tunnel syndrome in which case there will be weakness of the intrinsic muscles of the hand and there may be a claw hand and loss of sensation on the medial side of the palm. So these are the structures that we wanted to show you with the clinical correlations. Thank you very much for watching. Dr. Sanjay Sanyal signing out. If you have any questions or comments please put them in the comment section below.


Okay, Barwazonim, look it up. Today we are going to discuss the ups and downs of the narcissist. Now, very many self-styled experts online confuse liability with dysregulation. Lability, for example, modulability, is cycling. Cycling between euphoria and dysphoria, feeling good and feeling bad, feeling up and feeling down. Modulability is very common in borderline personality disorder. Dysregulation is something completely different. Dysregulation is when you are overwhelmed by some internal process. It could be emotions and then this is emotional dysregulation, but it could be many other things. So dysregulation is simply being overwhelmed, drowning in some internal process takes over and disables you. You are no longer able to function. Bear this distinction in mind as we delve into the question, is the narcissist bipolar in some way? And what about the confusion between borderline personality disorder and bipolar disorder? Very common in Europe, this confusion. And of course utterly wrong.  Borderline personality disorder is, as the name implies, the personality disorder. So we are going to discuss the role of fantasy in regulating the narcissist moods, effects, and to some extent negative affectivity is negative emotions. Why the narcissist presents as an up and down cycling type of person when actually it's much more complex and intricate than this. My name is Sam Vaknin. I'm the author of Malignant Self-Love, Narcissism Revisited, a former visiting professor of psychology and currently on the faculty of SEAPS, Commonwealth for International Advanced Professional Studies. Phew! That was a mouthful. Start with a few service announcements. There is a new channel with translation to, translations to Portuguese of my videos. Shortly there will be two three videos available there. And the owner of the channel, Miuna Liz, is adding videos almost daily. So a channel in Portuguese with translations of my videos. The channel is called Narcissismo com Miuna. And I hope I know what I'm saying. And you can find the link in the description. The description is under the video, not over the video. And in the description, many many goodies and one of them is Miuna Liz's channel of Portuguese translated videos of the one and only, luckily for humanity, Sam Vaknin. Before I proceed to the topic at hand, I advise you to watch two videos. Again, the links are in the description. The narcissists three depressions and bipolar disorder misdiagnosed as narcissistic personality disorder.  It's a defense against intolerable, burdensome, unbearable reality. It's an infantile defense. It's an early childhood defense against trauma and abuse by primary objects, caregivers, parental figures, and so on and so forth.  I mean, abuse is any situation or any environment in which the child's boundaries are not recognized and the child is not allowed to evolve and to develop naturally, normally and in a healthy manner. So a reaction to such abuse is trauma and a compensation for the trauma is fantasy. I'm not here, says the child. I'm somewhere else. That's the paracosm. I'm not me. I am someone else. That's the false self. And this someone else is Godlike, omnipotent or powerful, omniscient or knowing, perfect, brilliant, handsome, and so on and so forth. So narcissism, pathological narcissism is a fantasy. It's a fantasy defense that starts in childhood. And then as adulthood creeps in, it goes awry. It is writ large. It's out of control. The fantasy takes over, subsumes the narcissist, consumes him and leaves nothing behind but the bones, the ossified bones of a true self sacrificed on the altar of the deity, the new deity, the false self. Now, when I say him or her or he, of course, you can easily interchange it with she and her and so on. The gender, gender pronouns are interchangeable. Everything I say applies to women, female narcissists, women narcissists, as well as to men. Okay. So narcissism is a fantasy. How does the fantasy survive in the face of reality? Reality keeps challenging the fantasy, undermining the fantasy, throwing at the narcissist, countervailing information that makes it very difficult to defend the fantasy and to believe in it. The fantasy becomes less and less convincing as life unfolds and unfurls as the narcissist gets in touch with other people. As other people mock the narcissist, criticize the narcissist, disagree with the narcissist, challenge the narcissist, undermine the narcissist, compete with the narcissist. I mean, there are like thousands of stimuli every year, which should have ruined the fantasy beyond repair. And yet the fantasy survives and actually grows stronger by the day. How is this accomplished via a mechanism known as cognitive distortions? The fantasy as a defense mechanism in the narcissist's life is mediated through and protected by firewall by cognitive distortions. Now cognitive distortion is an inability to perceive reality as it is. It is a form of impaired reality testing. The narcissist is no longer in touch with reality. He is in touch with an interface that somehow reframes reality, falsifies reality in a way that is rendered palatable and acceptable in a way that buttresses and supports and enhances the core underlying primary fantasy. Cognitive distortions are an essential feature of the fantasy. And we all acquainted with some of these cognitive distortions in narcissism. Grandiosity, for example, is a cognitive distortion. I'm Godlike. I'm perfect. I'm brilliant. I'm amazing. I'm infallible. I'm handsome. I'm a genius, etc. These are all fantasy defenses, but they are grandiose. They are inflated. And so grandiosity is a way of falsifying reality. Internalization is another way of avoiding external objects by converting them into internal objects by interjecting and internalizing them and later on identifying with them.  It's a cognitive distortion. Hyperreflexivity is a cognitive distortion.  And hyperreflexivity allows the narcissist to treat other people as if they were not separate, to not recognize the separateness of other people, to interact with other people as if they were extensions of the narcissist or internal objects within the narcissist's mind or some internal organ. So hyper reflexivity. And all these are forms of impaired reality testing, which is inherent in cognitive distortions, which are indispensable to the maintenance and enhancement of the fantasy defense. Take an example, a narcissist may consider himself to be awe-inspiring, respected and admired for his accomplishments, when actually people regard him with morbid fascination, ill-disguised contempt and utter disdain and derision. A narcissist may consider himself irresistible to the other sex, to women if he's a male.  Narcissists deceive themselves much more than they deceive anyone else around them. This self-delusionality, self-deception is at the core of the fantasy defense.  It is this process of self deception, reframing and falsifying reality to the extent of dispensing with reality altogether. It is this that causes the narcissist to experience euphoric fantasies, euphoria in fantasies. Some fantasies are elating the euphoric. They cause the narcissist to feel invincible, immune to the consequences of his action, manic, all accomplishing, unstoppable, relentless, etc., etc. Fantasy could be either euphoric or dysphoric. But the only case I'm aware of in psychology, where dysphoric fantasies are entertained regularly is with narcissism, with narcissists. There are dysphoric fantasies in psychotic disorders, in some other personality disorders, for example, paranoid personality disorder, but they are rare occurrences. The narcissist does an equal representation of euphoric and dysphoric fantasies, and I'll explain in a minute why. A euphoric fantasy is indistinguishable from the manic phase in bipolar disorder one. That's why I ask you to watch a video that I've made long, long time ago, when we were all much younger, to watch a video that I've made about misdiagnosing bipolar disorder as narcissism. But when the narcissist is in the throes of a euphoric fantasy, it appears to be totally manic. The euphoric fantasy involves grandiosity. Inflation, the narcissist expands outwards and subsumes the world, which is a psychotic feature. And incorporation, the narcissistic cooperates externally. You, his intimate partner, co-workers, neighbors, friends, you name it, incorporates other people in his insight himself as internal, totally controllable objects. At that point, the narcissist comes up with harebrained schemes of get rich quick or become famous quick. He misperceives his positioning in society, his accomplishments, academic or otherwise, his interactions with other people, sexual, social business. I mean, he totally misjudges and I'll say totally misjudges. Who is, how is perceived by others? What is happening? Where is it all going? And, and consequently, it all usually euphoric fantasies usually end in misery, devastation, destruction, and self-destruction. Euphoric fantasies are self-defeating, self-handicapping, self-trushing and self-destructive. The inability to read reality properly leads the narcissist to behave in ways that other people perceive as abusive or even as criminal. And he is unable to extract or to extricate himself to acquire a position of a disinterested observer. In short, he is unable of introspection. I gave you the example of a narcissist who believes that he inspires all and admiration and respect when actually he is hated or derided or decried or feared or disgusts people or causes disdain and contempt. This is an extreme, extreme detachment from reality, which could be dangerous in many situations. If the narcissist exactly like some people with autism spectrum disorder is incapable of reading cues properly, so his reactions may be such that he would end up coercing people, abusing people. And so this is the euphoric, euphoric fantasy. Euphoric fantasy involves an internal locus of control and auto-plastic defenses. So when the narcissist is embedded in a euphoric fantasy, he believes that he's in control. He believes that he's in charge. He's the mover. He's the shaker. He's a decision maker. He, he and only he settles on choices and alternatives. He dictates everyone's moves and decisions and choices and he is the prima causa is the first cause and the last cause. He is it. He's the pivot. He's the axis. Everything revolves around him. That's an internal locus of control and consequently the narcissist would attribute everything that's happening outside to himself and these are of course, auto-plastic defenses. He would say, I made it happen. This occurred because of me. I aimed for this to happen. I planned all this. I caused these behaviors in other people, etc, etc. So he would position himself. He would position himself as the engine of creation. Now this internal locus of control coupled with auto-plastic defenses completely flips when the narcissist transitions to the dysphoric fantasy. Separation individuation, which I keep reminding you is the main goal of the narcissist in intimate relationships. The narcissist converts his intimate partner into a maternal figure in order to separate from her and to individuate, to accomplish what he had failed to accomplish with his biological mother. Separation individuation is a private case of euphoric fantasy. When the narcissist separates, he feels free. He feels unshackled. He feels empowered. He feels new, refreshed. So this is a very good feeling. It's a cheerful feeling. It's a feeling of unbounded optimism and bounded rationality. So separation individuation is euphoric fantasy. Now, sooner or later the reality intervenes, pushes back and all the filters in the world and all the reframing and all the falsifying and all the self-deception and all the other deception and all the narratives and all the stories and all the pieces of fiction and everything, they don't work anymore because the evidence is overwhelming. Reality floods the gates, breaks all the dams and penetrates and invades the narcissist's consciousness willy-nilly and the narcissist is then forced to accept that he had been delusional, that all his life has been a fantasy, that he had misperceived and misjudged other people, situations, environments, processes, developments and events. This is terrifying. To recognize that you have been divorced from reality for so long is nothing short of terrorizing. So then there's a dysphoric fantasy, the reaction is a dysphoric fantasy. The dysphoric fantasy is indistinguishable from depression and that's why I ask you to watch the video The Three Depressions of the Narcissist. Having been overwhelmed by reality, the narcissist becomes essentially a borderline, dysregulated and depressive. But the dysphoric fantasy still involves the narcissist's habitual quintessential perennial cognitive distortions. Even the dysphoric fantasy involves grandiosity, but the shape of the grandiosity in a dysphoric fantasy is different. It's paranoid. Paranoid ideation, paranoia and referential ideation are two forms of grandiosity, the manifestations of grandiosity within the dysphoric fantasy. Paranoid ideation is grandiose, of course. Paranoid says, I am the center of a conspiracy. I'm sufficiently important and sufficiently crucial and sufficiently pivotal for other people to take interest in me. This interest is malevolent, malicious, but it's still there. I am at the core of whirlwind, a maelstrom of interests and conspiracies and designs and strategies. This is a very grandiose self-perception, paranoia. Paranoid is a grandiose self-perception. Paranoid ideation is a form of grandiosity, but it is dysphoric. It's dysphoric, it's frightening, it's depressing, and so it's dysphoric. So this is grandiosity in the dysphoric fantasy. Similarly, a referential ideation or ideas of reference is the belief, the misguided belief, that you are the center of attention of people. If they are laughing at the corner, they're laughing at you. If they are whispering to each other, they're gossiping about you. If they're doing anything, it's intended to harm you or refers to you somehow. This is referential ideation. Both paranoid ideation and referential ideation are delusional, they're grandiose, and they are at the core of dysphoric fantasies. Normally, dysphoric fantasy as distinct from euphoric fantasy, dysphoric fantasy involves an external locus of control and alloplastic defenses.  I'm God, I make everything happen. The dysphoric fantasy involves an external locus of control. I am the subject of the malign attentions of evil people. There is a conspiracy against me. My fate and destiny and life are decided by others. They are guilty for everything that's happening to me. All the mishaps and the defeats and the failures are attributable to people who are envious of me and want me dead or want to destroy me. These are alloplastic defenses within an external locus of control. Examples of dysphoric fantasies, the devaluation of a persecutory object, the inevitable phase in every relationship with the narcissist. Remember, idealization, devaluation. The devaluation part is a dysphoric fantasy. The idealization part is a euphoric fantasy. Narcissistic injury is a dysphoric fantasy because usually it's only in the narcissist's mind. The narcissist is hyper-vigilant. He imagines slides and insults where there are none, even in an innocuous speech, even in innocent situations. He sees only conspiracies and an attempt to put him down or to humiliate him in some way. This is narcissistic injury and of course it's a fantasy. It's a delusional fantasy and it's a dysphoric fantasy. Even more so, narcissistic modification. These are all cases of dysphoric fantasies. So I hope I gave you the keys to understand the mechanisms behind many, many a monopoly of narcissistic phenomena. It's all based on fantasy. Even your relationship, your intimate relationship with the narcissist, which goes through the phases of idealization, devaluation, discard and so on, even those are intimately connected to fantasies. First euphoric fantasies and then dysphoric fantasies. Even separation individuation is a euphoric fantasy. Even narcissistic injury is a dysphoric fantasy. Everything is a fantasy. Everything in narcissism can be reduced to a fantasy and of course fantasy defense.  This is one of the main reasons I'm proposing that narcissistic personality disorder is actually a post-traumatic condition, not a personality disorder. Okay, I hope you survived this lecture and I remind you again there's a new channel with translations of my videos into Portuguese. Shortly there will be two, three videos there but the owner of the channel will be adding more. I'm being told by her and the channel is titled Narcissismo Come Mirna. Mirna is and the link is in the description. Other channels with translations to Russian for example, Czech, other languages, these other channels are available at the very bottom of my YouTube channel's page. Scroll down the page of my YouTube channel and at the very bottom there are links to other channels. The total of 10 other channels is a link to other channels. This is one channel in Russian with more than 20,000 subscribers which I think could be of interest to you. Now there's this new channel in Portuguese. I just want to add that Dr. Claudia Wicken has been translating my videos into Portuguese from time to time here and there so you can find a few of these videos on her channel as well. She's a dear friend, neuroscientist in Sao Paulo, Brazil and the first person to introduce cold therapy at the time to Brazil. So have fun with the Portuguese renditions of my videos and see you next time. Those of you who are masochistic enough to listen to me again.


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Hey everybody Matt here for late in sports cards ripping 2022 Panini Chronicles football hobby six box break number 29 pick your team We have Alex H. Patriots. Alex Andrews S. Bill's Jets Bucks Andrew a Falcons commanders Andrew R Giants Brett W Vikings Connor M. Bengals Cooper B. Raiders Broncos Corey S. Steelers Danny M. Lyons Eric R. Chargers Saints Eagles and Niners Matt F. Colts Maximilian H. Ravens my Z Jags Patrick S. Brown's Paul B. Texans Seahawks chiefs Ray G. Titans Richard G. Cardinals Panthers Ryan K. Packers Dolphins Steven W. Bears Rams and Trevor T. Cowboys All right, here we go Broncos and Giants we have two spots left for the entire day Brady Kenneth Walker rookie photogenic red to 199 rock party flux Pierce Kenny Pickett great iron King sauce and Vikings Photogenic Jersey to 199 Justin Jefferson. There's one photogenic hard sub setting Trey McBride Playoff momentum rookie to 99. Is that a survival? No, Chris Olave score rookie Chrome Maybe someone appears go for it. There it is Aaron Donald photogenic J. The Petrae good iron Kings rookie blue Kenny Pickett flux rookie Skymore Stop Brett stop Jonathan and Patriots rookie Otto to 199 Tyquan, Fortin Demian Pierce rookie to 99 Chris Olave Legacy Chrome rookie Johan Datsun Kenny Pickett Veronica Ols rookie Jameson Williams prison black rookie silver Kyle Hamilton and Brock Purdy rookie magnitude Brock Purdy luminance rookie and Commanders prison black rookie silver Otto Johan Datsun I some Washington Drake London legacy rookie silver Datsun Ambulus Jones true favorite toto song They're like three. I think I can think of is it Rosanna Rosanna Africa What other toto songs are there we should know off the top of our heads? I mean I should Forest I'm a spring chicken.  I just turned 22 Brian Robinson to 99 Garrett Wilson dynagon rookie Yeah, right My wife, but they were they're working on like a like the ladies from where they work or like gonna go out to like eat tonight Brown's good iron Kings rookie on a red to 99 David Bell And she said they're meeting up at like like an eight at this over at this like brewery, and I was like that's so late It's a like a meet-up to eat on like a weeknight Like And I was like wait the Sun's still up at 8 p.m. In Florida this summer Like Willis. I was like that was an old thing to say Flux Brookie Crystal Lave that is Orange ish to 75. That's the official name of the parallel orange ish I was like that one Bowman Chrome where they the yellows are actually like kind of orange also They weren't like orange orange or we call them mango Yeah, I I don't see colors that well anyway So it doesn't take much to like make my brain spend on That's commanders one-on-one printing plate Antonio Gibson from Optic football It's gonna cool. I drafted him in the second round of my fantasy league a couple years ago. Oh That's not kind of Walker legacy rookie silver Rocks are good printing plates and chronicles this year. I'm guessing since they took out plates and patches Plates got a lot of plates. Oh job. Oh, this is Texans rookie Jersey to 199 Damian Pierce Ryan Robinson rookie to 99 Christian Watson Dynagon rookie and her Like moment at least yeah Except that one really annoying year where there was a plate in every box of NT This is Falcons prison black rookie Otto Silver Desmond Ritter nice hit Falcons As we had just the Broncos and Giants two to go on the next break Drake London 199 and Brock Purdy prison black rookie Traylon Here's a link for those last two spots You're a chief spanner The chiefs are my mistress. I'm I'm married to the bangles Ravens Jersey to 199 lamb Jack David Bell rookie to 199 Skymore and James and Williams from Watson Skymore rookie to 149. I Actually, I did jump on the chiefs bandwagon and then but And then bro Reached out and he said Matt sounds dramatic Try living it Lions rookie Otto to 75. Sure Aidan Hutchinson I'm like, dude. I just got an awesome new my home's jersey. There's a Kenneth Walker rookie blue 25 Seahawks Sauce and a lava prison black rookie Jalen Hurts 199 James Cook Texans rookie Otto purple to 49 John Mechie from Great Iron Kings Tom Walker rookie silver Cup and Johan Datsun prison black rookie Patrick Mahomes prison black silver Danny Gray and Chris Olave score chrome rookie Jalen Tolbert flux rookie silver Garrett Wilson flux rookie and Matt Corral This is Redemption Jets prison black rookie Otto Breeze Hall Nice. There you go Jets Breeze Hall getting hurt is kind of the beginning of the the beginning of the end for my fantasy team in our league Mine happened very early rock purdy rookie silver Hurts and Kenneth Walker, but didn't you go on some crazy winning streak near me? Yeah, I did but the start of my season my two quarterbacks for Trey Lance and Dak Prescott Lance hurt week two Dak For the first like five weeks. So it just kind of like Hutchinson Didn't even get started. Yeah Can you pick it? Okay, where is it the national? No Zero chance. I would wear SB's at the national. It's from Andre Stevenson Jersey to 199 Patriots No, I will be wearing these mostly George Pickins. Something comfy. Look you to 199 Walker nice concrete floor I'm gonna wear um Oh my gosh, I might get some of them like 40 bucks too, but 60 bucks. I'll get both Ryan Robinson The only bad thing about hey dudes is there's like like it hasn't started bothering me But I've heard people say because like there's no arch support It makes it really comfortable, but it can Mess up your feet. You know over time. Yeah, I'll find out because I wear I've worn them every day I think since the day I bought them Ravens rookie Otto to 199. David Ojabbo. You'll find out I wonder if uh insurance would make it worth thoughts I'll put those everywhere When I was leaving the loot combs concert on Friday I thought I'm 44 now. I think I'm finally ready for helis You wanted the zoom out of there? It would have been perfect. They had like the ramp going down at Raymond James stadium But then I also wanted a monster truck so I could just Plow through traffic because I waited an hour to get out of that parking field It's not good. It's not good in a lot of old venues drake london rookie silver mohomes prism black Well, and then like everywhere that you would turn to like make a u-turn GPS is telling me to turn there and they didn't have any signage or anything warning It was just all of a sudden they'd have it coned off. Yeah That is packers essentials rookie Otto red to 99 christian watson and another hit That is falcons momentum rookie Otto To 25 drake london These falcons did it really well. Yeah, nice break for lana sam howell chrome score chrome rookie silver You know pierce and sauce still just those two Let's get the last couple spots filled up um Broncos and giants guys we now have tribute baseball in stock for personals Not something we can control edward.  I'm telling you like dante hall won like two or three games Yeah with returns I feel like they were in positions where they're about to lose the game if he hadn't run one back They're like, yeah, they're all right, but yeah forever that year too lions patched 25 aiden hutchinson easy rookie to 99 hutchinson and laurence tibido raiders silhouette rookie jersey otto to 99 zamir white Thanks, nick Giants left just the giants left in chronicles brice hall prism black rookie red to 99 jets Pickens and McBride We have free international shipping snake The like we don't charge a shipping fee, but you'd still be responsible for your country's uh import fees Kenny pick it Which would be based off of the receipt to shon watson 10 bomb walker So it's based off of the receipt um not the Perceived or claimed value of the cards Garrett wilson Packers that is rookie triple jersey otto to 99 christian watson drake london store chrome uh rookie silver robinson and walker a hose zappy drake london dynegon rookie silver well equal as dynegon rookie And i say it's chaco My brain constantly auto-corrects that's isek pacheco Brady wasn't he a tigers prospect? Yeah, like 2020 bow and drape. I think dynegon rookie silver rock purdy bailey zappy flux rookie and drake london momentum All right, quick recap here Um just one spot left for the day. That's just the giant spot in the next break It's on sale at $39 There's a link for you if you'd like to grab that We have commanders one-of-one printing plate antonio gibson 2020 optic um relics texans rookie to 199 davion pierce patriots to 199 remandre stevenson Vikings to 199 justin jepperson ravens to 199 landjag Jags to 199 rookie trubon walker lions rookie to 25 aiden hutchinson autos jets prism black bruce hall chiefs dante hall um commanders john dotson falcons desmond ridder Patriots rookie to 199 tyquan thorton ravens rookie to 199 david ojavo browns rookie to 99 david bell Hacker's rookie to 99 christian watson lions rookie Aiden hutchinson That was the 75 texans rookie to 49 john mechie falcons rookie to 25 rake london Raiders Silhouette rookie jersey auto to 99 samir white Packers rookie triple jersey auto to 99 christian watson. I don't do it for the break. Thank you everybody's number 30s up next