Hello, Hillary Health fans. Now, knowing this audience, there will be some repulsed by health matters being mentioned--after all, that's not polite. When it comes to somebody's mental competence to do the job of being President, it damn well should matter. My health issues--or your health issues--are nobody's concerns but our own--as long as we are not running for elected office.

Mea culpa: I apologize for posting the photo-shopped image of the brown blob. But the snake in the pant legs is definitely not a snake or a badly creased garment.

So here's the usual admonitions:
1. I'm biased--don't like Hillary. period.
2. The ideas in this essay are speculative
3. Peer reviewed medical literature supports my line of reasoning
4. Only evaluation of her medical records PLUS examination by independent specialists will resolve the speculation
5. The commentary does not refer to her sociopathy nor her political views (whatever they may really be)
6. I encourage medical criticism of the literature I cite
7. If you are squeamish about the medical realities of life, don't read this
8. But if you do read this yet disagree, then tell me why my conclusions are not supported by medical literature
9. No PC or Wikipedia please
10. Disagree if you will but play nicely with others.

Purpose of this health-related essays is this: to call attention to issues regarding sphincter control which MAY or MAY NOT reflect on HRC's mental capacity to govern.

Explanation of title:

As the essay will develop, there are several possibilities for urinary incontinence (UI) or urinary retention (UR). Definitions related terms are found in my last essay: drip, drip, drip, etc.. Specifically there are two major considerations here, relevant to the topic of mental fitness as related to urinary control.

The first element is if the cause of needing an indwelling urinary catheter is related to spinal cord, peripheral nerve, and or pelvic floor problems (which I call "Tails"), then there is no related-health reason diminishing her capacity to govern, at least as related to the fact of urinary tract dysfunction. In other words, the issue becomes a "nothing burger".

The second element is if the cause of the urinary control issue is due to central nervous system problems (meaning brainstem and cerebrum) then there is more ammunition to question her mentation.

Now many of you may be thinking right now how it is possible that urinary dyscontrol can reflect upon one's capacity to govern. In order to respond to this, we are going to take a guided tour of the urinary system--heads to tails. What's the head got to do with this? Patience, we will find out.

How this essay is organized:

Basic anatomy

Now as most of you are not in the medical field, we will start out with basic anatomy and a little neurochemistry to understand the issues. Now, after writing multiple essays about Hillary's health have taught me, that perhaps the best way to do this is with pictures. Therefor there will be lots of pictures with relatively little text. However all reference supporting the contents herein will be cited.

Okay. Does everybody think that the act of urination is simple? Everybody here who raised their hands to this question needs to read this article closely--pictures should help.

So, we all have a pretty good idea of the plumbing. The kidneys filter the blood, making urine. Urine is collected in the renal (kidney) collecting ducts which are continuous with the two ureters. Each ureter drains separately into the urinary bladder (or bladder, for short). The urine exits the bladder through the urethra, the male urethra being longer than the female version. Between the bladder neck (BN) and the urethra are two independently functionally but usually coordinated muscles. One is the detrusor muscle (DM), part of the bladder, which function is to contract the bladder, pushing the urine out--if you're continent, this means that bladder emptying is partially under conscious control. The other muscle is the urinary sphincter (US) which surrounds the urethra. When the US is contracted, no urine escapes the bladder. Generally these two muscles work by synergy: meaning that when US contracts, DM relaxes. And when DM contracts, US relaxes. That's the way things are supposed to work.

Let's look at the female pelvic floor. Click on the image to enlarge it further. You can also manipulate the field of view. This will be true of many other illustrations.

Another view of afferent nerves (bringing motor control) to the lower urinary tract primarily at the bladder level.

For a more generalized look from the lower spinal cord to pelvic level.

This next view includes the brainstem to pelvic neural circuitry in a simplified drawing.

This next figure is a schematic representation of parasympathetic pathways to DM. It is in this schematic that you start to seen the involvement of supraspinal activity on urinary circuitry.

A sagittal (side) view of the pons to lower pelvic pathway is seen in this illustration.

The above illustration was taken from the publication Integrated control of lower urinary tract--clinical perspective.

For a more involved look at central pathways, which means to and from brain and brainstem, we shall look at other illustrations.
This where the "Heads" part of the story gets interesting

Please note the names of the brain and brainstem areas involved. You don't have to memorize them as you always refer back to this illustration. This figure shows side-by-side BOLD (brain-oxygen level dependent) MRI and a simplified schematic of upper CNS (central nervous system) structures. You will see reference to these anatomical structures again, after we get the basic anatomy settled.

The above illustrations came from an article called: The neural control of micturition. Micturition is medicalese for urination but you know we doctors get paid by the syllable.

Here is an even more simplified view of higher center neural control of urination, concentrating on the brainstem region
An even more detailed view of the pontine-sacral "wiring" is seen in this illustration

The above illustrations are taken from the publication Organization of the neural switching circuitry underlying reflex micturition.

As promised, we will now get into the Neurochemistry of cranial-sacral control of sphincter function .

The above illustrations are from the publication: Neural control of the female urethral and anal rhabdosphincters and Pelvic floor muscles.

Does anybody still believe that urination is a simple subject? If you still do, there is a remedial third grade class where this topic will be reviewed.

The neural control of micturition

The storage and periodic elimination of urine depend on the coordinated activity of smooth and striated muscles in the two functional units of the lower urinary tract, namely a reservoir (the urinary bladder) and an outlet consisting of the bladder neck, the urethra and the urethral sphincter1,2. The coordination between these organs is mediated by a complex neural control system that is located in the brain, the spinal cord and the peripheral ganglia.

The lower urinary tract differs from other visceral structures in several ways. First, its dependence on CNS control distinguishes it from structures that maintain a level of function even after the extrinsic neural input has been eliminated. It is also unusual in its pattern of activity and in the organization of its neural control mechanisms. For example, the bladder has only two modes of operation: storage and elimination. Thus, many of the neural circuits that are involved in bladder control have switch-like or phasic patterns of activity, unlike the tonic patterns that are characteristic of the autonomic pathways that regulate cardiovascular organs. In addition, micturition is under voluntary control and depends on learned behaviour that develops during maturation of the nervous system, whereas many other visceral functions are regulated involuntarily.

Owing to the complexity of the neural mechanisms that regulate bladder control, the process is sensitive to various injuries and diseases. This Review summarizes the results of recent studies in animals and humans that have provided new insights into the sensory and motor mechanisms that underlie voluntary and reflex micturition, the changes in neural pathways that occur following disease or injury that alters lower-urinary-tract function, and new therapies for the treatment of neurogenic bladder dysfunction.

Continuing from this article:

In the brain, many neuron populations are involved in the control of the bladder, the urethra and the urethral sphincter. Some, such as the serotonergic neurons of the medullary raphe nuclei, the noradrenergic neurons of the locus coeruleus and the noradrenergic A5 cell group in the brain stem, are non-specific ‘level-setting’ mechanisms with diffuse spinal projections47. Others are specific for micturition: these include the neurons of Barrington's nucleus (also called the pontine micturition centre (PMC)) and those of the periaqueductal grey (PAG), cell groups in the caudal and preoptic hypothalamus, and the neurons of several parts of the cerebral cortex, in particular the medial frontal cortex

Of course, this neuroanatomy is quite complex but the purpose is to illustrate the extensive supraspinal (i.e., above spinal cord level) involved in urination. So, disordered supraspinal structures (whether they be gray or white matter or both) can impair the normal functioning of urination.

How Neuropathology (brain damage) affects urination:

The PAG has multiple afferent and efferent connections, not only with the thalamus, the prefrontal cortex and the insula, but also with other higher brain centres. The influence of these centres — the anterior cingulate cortex particularly — probably determines how much attention one pays to signals coming from bladder afferents and how one reacts to them, whether by deciding to void or by recruiting mechanisms (for example, urethral sphincter contraction) that allow voiding to be postponed. The anterior cingulate cortex (ACC) is an extensive region, and different parts were activated in different studies66. The dorsal part seems to be especially strongly activated by bladder distension in subjects with “poor bladder control” (REF. 69), suggesting a strong emotional reaction to a situation the subjects experienced as threatening. This pattern of abnormal activity might help to distinguish an abnormal sensation of urgency from a strong but normal desire to void.

Translation: structures in the anterior frontal lobes are major contributors to the conscious perception of need to urinate. If the
ACC is supersensitive, the urge to urinate occurs with less bladder dissension due to retained urine than if the ACC functions normally. The converse is also true, if the ACC is less sensitive than normal, the patient may have a subdued response to bladder filling, often leading to UR.

Brief lesson in the neurochemistry of bladder control:

excitatory transmitters include glutamic acid, tachykinins, pituitary-adenylate-cyclase-activating polypeptide, NO and ATP61. Glutamic acid, acting on NMDA (N-methyl-d-aspartate) and non-NMDA receptors, seems to be the essential transmitter in spinal and supraspinal reflex pathways that control the bladder and the external urethral sphincter. Inhibitory amino acids (GABA (γ-aminobutyric acid) and glycine) and opioid peptides (enkephalins) exert a tonic inhibitory control in the PMC and regulate bladder capacity. These substances also have inhibitory actions in the spinal cord. Some transmitters (dopamine, serotonin (5-hydroxytryptamine, 5-HT), noradrenaline, ACh and non-opioid peptides, including vasoactive intestinal polypeptide and corticotropin-releasing factor) have either inhibitory or excitatory effects, depending on the type of receptor that is activated, the receptors' location in the CNS and the specie. For example, dopamine elicits inhibitory effects on micturition through D1-like receptors and facilitatory effects through D2-like receptors.

This is further information, the connection to brain injury will certainly be obscure without further information. Here's the connection. Specific brain areas are responsible for secretion of some (but not all) neurochemicals affecting urinary function.

What are some of the brain areas affected besides the ACC? Note we are not discussing brainstem functions here, but cerebral problems:

The following comments are taken from the publication brain activation during micturition in women

Right inferior frontal gyrus

The activation of the right inferior frontal gyrus during micturition [scan 2 in article] in comparison with a full [scan1] or empty bladder [scan 3] is the same in men and women, although it is much less extensive in women. The inferior frontal gyrus, in addition to the dorsolateral prefrontal cortex, is involved with attention mechanisms and response selection. With respect to micturition, the area might play a role in deciding whether or not micturition
can take place. The observation that this region is activated during micturition is in agreement with specific involvement of the right prefrontal in micturition control (Kuriowa 1987; Griffiths 1998)…

Insular and opercular activation during filled bladder condition:

The right frontal operculum and/or right anterior insula were significantly activated (corrected for multiple comparisons) during the filled bladder condition [scan 1] compared with the other three conditions in the successful micturition group.

Predominance of the right brain in micturition control:

The micturition-related brain regions in women (frontal and cingulate cortices) were located predominately on the right side of the brain, which is similar to the result of the previous study in men. This finding corresponds with studies indicating that urge incontinence is specifically correlated with lesions in the right hemisphere.

The following quotation comes from the publication; Cerebral mechanisms and voiding function

The cingulate cortex, in particular the anterior cingulate, is part of the limbic system (“limbic motor cortex”), with several interconnections with other key areas, including the insula, hypothalamus and prefrontal cortex. The insult has a visceral sensory function, and was labelled as the “limbic sensory cortex”, with activation in response to gastrointestinal stimulation., pain, and sometimes during urinary storage. Earlier work based on clinical cases suggested the frontal cortex might have an inhibitory role during micturition; a more recent review by Griffiths extended this concept to show an association between frontal lobe under-perfusion, urge incontinence and reduced bladder sensation. Finally, cerebellar activation during storage and micturition experiments implies that its role might extend beyond motor control.

There several more publications relating to cerebral control of voiding. I will spare you the details. Now, let us make a connection between the neuroanatomy of micturition-controlling cerebral sites and sites prone to image due to TBI--and that includes mTBI.

For an overview of why I think the visual evidence indicates that Clinton has right frontal lobe damage, please see the essay: Hillary Clinton has right frontal lobe epilepsy

Here's the connection between Clinton's concussion and/or dural sinus thrombosis, by virtue of MRI studies on mTBI patients: Review of magnetic resonance imaging in mTBI

More specific reductions in volume in brain regions have also been observed, including in the hippocampus (Bigler et al., 1997; Himanen et al., 2005; Strangman et al., 2010; Tate et al., 2000; Warner et al., 2010a), amygdala (e.g., Warner et al., 20b10a), fornix (Gale et al., 1995; Tate et al., 2000), thalamus (e.g., Strangman et al., 2010; Warner et al., 2010a; Yount et al., 2002), regions involving the cingulate gyrus (e.g., Gale et al., 2005; Levine et al., 2008; Strangman et al., 2010; Yount et al., 2002), as well as increased lateral ventricles, temporal horns of the lateral ventricles, and/or ventricular brain ratio (e.g., Anderson et al., 1995; Bigler et al., 1997; Gale et al., 1995; Himanen et al., 2005; Wilde et al., 2006; Yount et al., 2002). Reduced volume in subcortical gray matter regions has also been reported (Gale et al., 2005), as has reduced volume in the putamen, precuneus, post-central gyrus, paracentral lobule, parietal cortex, pericalcarine cortex, and supramarginal gyrus (Warner et al., 2010a).

That's a lot of different brain real estate, not all of which will be affected in any particular mTBI. Referring to the essay on Clinton's right frontal lobe epilepsy, the interested reader can find citations to other publications regarding the loci of areas subject to damage in mTBI. The most common areas affected in mTBI are: prefrontal cortex, hippocampus, dorsolateral prefrontal cortex, corpus callosum, and somewhat less frequently the insula, amygdala and supplementary motor area.

Many of the brain areas commonly damaged in mTBI are those areas involved in urinary control.

Speculation, with reasonable literature support: Hillary Clinton has right frontal lobe damage (possibly also including other brain areas--like the right supplemental motor area) necessitating her use of a catheter. I cannot tell, without further information whether she has UR or UI--it matters not. The point being is that two separate lines of inquiry point to a damaged frontal lobe: seizures and incontinence.

Memory registration and, to some degree, memory retention are dependent upon healthy hippocampi. Most recently note her inability to remember the answers to 39 questions during her FBI interview.

Regardless of any political or personality-disorder controversies, I believe that Clinton has sustained sufficient brain damage to render her unfit for office.