Polymyalgia Rheumatica: A misunderstood but common condition.

      In the summer of 2008, as a veteran (victim?) of 33 years of medical practice, I was feeling ready to retire. I was planning to enter the world of retirees at the end of the year. But in July of that year I began getting some strange symptoms of painful knots developing over my scalp. The first of these nodules was located on my left temple and itched. But it was also sore to the touch or when compressed. At first I thought it was an insect bite because I know when we apply insect repellent we don't always apply it so close to the eyes. I reasoned that a mosquito might have found me there. But then I got another such nodule on the right side. I decided to seek out my internist. She didn't know what these were but when I mentioned the possibility of temporal arteritis, though she clearly doubted it, she ordered the confirming blood test, called a sedimentation rate. This is a non specific test but if abnormally elevated in the presence of the correct symptom complex, it makes the diagnosis of this autoimmune condition, one of a group of disorders called vasculitis, or inflammation of blood vessels. Well, at this early stage of the disease, the sed rate was normal. So we both pooh poohed my worries and I went home. But over the next month, these tender nodules began to appear all over my scalp. It became hard to put my head on the pillow while trying to avoid pressure on these nodules. Finally I decided I better take my symptom constellation to a rheumatologist in our clinic. He really didn't buy this as temporal arteritis either.
      I still ask myself why neither of these doctors thought that is what I had. The textbook description of the symptoms of temporal arteritis includes many things among them headaches, fatigue, fever, etc, but one of the classic symptoms is painful swellings over the scalp. So I don't know why these doctors had to be convinced. Maybe because I let them know what I thought I had and since I was a doctor, they had to stand defensively. I don't know ----.
     Anyway, the rheumatologist did order the sed rate and now a month later it was elevated to 3 times normal. The doctor called me back and immediately started me on 60 mgm of prednisone a day. There is a risk of blindness or stroke in temporal arteritis because this inflammation can block the blood vessel not letting oxygen get through to cause these severe complications. That is why treatment is done with such high doses of prednisone. I later had a biopsy of one of these temporal arteries and it confirmed the diagnosis. Usually this disease is self limited and eventually under the cover of the prednisone treatments goes away. The prednisone is weaned slowly down and then stopped usually over about 1 to 1 1/2 years. I was able to wean it down, but on one occasion with a return of the symptoms a little bit, I had to increase the dose back up a little. By February, 2010 I was able to get off the prednisone.
     But now a new problem raised its head. I began to get muscle pains. At the time I was changing my cholesterol medication and both I and my internist knew that those drugs could cause muscle pains. I mistakenly attributed the pains to that change in cholesterol meds. Also at that time we took our trip to Moldova and Eastern Europe. I suffered through that trip, sometimes almost unable to walk due to pains in the hips and back. Now there is a constellation of symptoms called polymyalgia rheumatica which often can be associated with temporal arteritis. The muscles hurt because there is inflammation in the small blood vessels going to the muscles, another form of vasculitis. I knew that this could be associated with temporal arteritis but I had never had these symptoms as a part of my symptom complex. Well when I got back from Moldova, I contacted the rheumatologist, we rechecked the sedimentation rate and it was back up a little bit. So apparently the very low doses of prednisone as I weaned off of it had held this disorder in check, and now my vasculitis was manifesting itself in this way only after stopping the prednisone completely. Well, the good part is that such high doses of prednisone are not required to treat this disorder and so I was able to get good relief by going just back to 10 mgm per day -- a dose that I could easily tolerate and which didn't mess up my sugar control like the 60 mgm did. I have now been slowly weaning down the prednisone over the ensuing year. (Usually like temporal arteritis, polymyalgia rheumatica take about 1 to 1 1/2 years to go away.) At a recent visit about 3 weeks ago, my rheumatologist and I decided since I had been on only 1 mgm prednisone for about 4 months without any symptoms, that I could try going off the drug which I did. Well, guess what. Within a week, my muscles were aching again. I thought to give it some time to see if this was just from working in the garden too much. (The symptoms are somewhat non specific, so sometimes it is difficult to tell them from just general achiness that we all have as we get older.) Now it has been 3 weeks and the aching is getting worse, is interfering with sleep, and is keeping me from doing the things I like to do, like my water aerobics, and my gardening. Today I put a call back in to my rheumatologist and I know I will have to go back on prednisone, probably at about 4 mgm or so and then wean down. What a bummer!

     Polymyalgia rheumatica (PMR) is confused with a number of other myalgias (muscle pains). First there is fibromyalgia which is far more common, though PMR is not uncommon. Fibromyalgia is somewhat of a mystery in cause, but it is thought to have to do with the pain nerve fibers leading from muscles which get into a habit of sending pain messages for no particular reason. Unlike PMR, there is nothing visibly or even microscopically seen to be wrong with the muscles or with the nerves. The cause of fibromyalgia is deduced more from the types of medications that helps it -- meds that are used to treat seizures, or nerve pain. There is another form of myalgia (pain in muscle) which is associated with inflammation in the muscle itself, not in the blood vessels like PMR. This is also an autoimmune disorder but the treatment is different, usually requiring medications that are used to treat rheumatoid arthritis. All of these muscle disorders and pain syndromes have one thing in common. The exact underlying cause is not known.
     I will have to let you know, but it looks like I will have to get back on prednisone. My visits to my doctors, and my encounter with the medical profession from the patient side of the desk continues.

Hot air ballooning over Kapadokya, Turkey

     These two old codgers did something very adventurous in Kapadokya, Turkey. We went hot air ballooning. Now we had done this before over the fields of southeastern Wisconsin. When I retired 3 years ago, several of my doctor partners didn't know what to give me as a retirement gift so they got me two tickets to a hot air balloon ride. This local balloon is fairly small; the basket holds at most 8 people including the pilot. That trip was scheduled and postponed several times because of winds being too strong. The night that we went turned out to almost be too calm. We did stir up some white tailed deer. They seemed much more spooked by our balloon than they are by cars, people, or other suburban structures. We only traveled about 2 or 3 miles. Therefore we landed in a subdivision that usually doesn't see the balloon coming down. As we floated over houses many people came out and begged the pilot to land us in their backyard. Of course, he wants to put the balloon down on a street because then the trailer can get there to load up the basket. Otherwise, the basket would have to be carried to the trailer -- much more work. The ride was nice, but the neighborhood event that the landing turns into was also neat. Neighbors are hanging around watching the balloon pack up process. As they greeted us they say: "Are you new to the neighborhood?" "Yes," I said, "by about 5 minutes. We were in the balloon." Oooohhhh! They are all excited to find out how the ride was. So half of the fun is the after events.
     Things are different in Kapadokya. First of all the basket is divided into 5 sections, each section just a little smaller than our entire basket for the Wisconsin trip. Twenty-four people plus the pilot can go up. These are big balloons. My biggest concern was climbing into the basket. I knew the balloon operators would help but I expected maybe some portable steps. No such luck! There were two holes in the side of the basket but that side leaned outward toward you so it was very difficult to put feet in those holes while leaning backward and swing yourself over the edge. Of course, I couldn't understand the Turkish but I think when all the crew saw us two old fat fogies, a call went up in Turkish: "All hands on deck for these two!" Well, they pushed and they shoved and I went in. But my shoe would not slide on the plastic covered rim of the basket and as they shoved, my knee flexed more and more with my foot bent underneath. I began to cry out: "Ouch, Ouch, Ow!" The pilot who heard and knew English, made a face as he saw what was happening and said "Sorry!" Well, eventually I got my foot untangled and the other foot down inside. When I put my foot down, there was no pain in the knee and I thought I had lucked out. We enjoyed the 1 hour long balloon ride very much. Believe me riding over Kapadokya is a lot different than riding over southeastern Wisconsin farms. My husband shot lots of photos and I include a few here. The pilot pulls some little stunts which my husband said he could have done without. He brings the balloon close to one of the fairy chimneys or to a sharp ridge of the valley, makes it look like we are going to hit it, and then turns on the gas, and we rise quickly just clearing the natural structure. We saw foxes running down below instead of deer. Finally it came time to land. The chase vehicle becomes visible and the pilot is in contact with them, mutually deciding on a flat landing place. As we came up over a ridge and fairly large flat patch became visible, we saw the truck and trailer waiting. But the pilot could not quite make it to that spot. He landed us off road and in a very rough field. We had been instructed how to crouch down inside the basket when we land, sort of wedging ourselves below the rim of the basket. It was a rough landing but we were upright. Almost immediately 4 of the crew were there hanging on ropes to hold the balloon down. Then the truck pulled the trailer right up alongside the basket with us still crouched inside it. Now the pilot made one bad decision: He advised his crew that he was going to give the balloon some gas, to just raise it enough to place it on the trailer. That would have saved so much work because the basket would not have to be unloaded of all the gas canisters and manually lifted up on the trailer. What the pilot had not figured on was a sudden increase in wind just as he pumped more hot air up into that big balloon. Suddenly it became clear that those four guys were not going to be able to hold it. They tried but that balloon wanted to fly. We were cautioned to stay in our crouched positions, luckily. Because the balloon flew over the road and found another rough field, came to earth but with a couple of bounces and with some slight dragging of the basket sideways. It was scary. But finally the crew got the thing under control and decided it was better to deflate the thing right away -- so they would have to do some extra work since the basket was not on the trailer. Everybody was OK, and we got out of the basket pain free. After we were out, everyone was congratulating the pilot, but I saw his face. He was very happy to have us all safely with our feet on the ground. It was a great balloon ride but I think this may be the last one that my husband and I do. My knee started paining that afternoon and for the rest of the trip I hobbled. We saw a lot but it was somewhat of a struggle for me.

     I have enclosed some of the views of this amazing valley. These rock structures are of volcanic tufa rock which is very easy to carve. The nearest I can compare this valley to is Bryce Canyon in Utah, except that the hoodoos in Kapadokya are 5-10 times larger so that they can be hollowed out and lived in. The plateau and edge of the plateau is much like the South Dakota Badlands. That should give you some idea of what this area looked like. In the 2nd century AD,  some Christians running from Roman persecution first came here and established a monastery, with churches and chapels with their painted frescoes, monks quarters, dining rooms and guest rooms.  Then when the place got such a holy reputation people began to use the rock formations for homes; they wanted to live near all this spiritual activity. The two saints who came here and became famous were St. George, and St. Basil. But also St Paul was in the area though the monastery had not been created then yet, or it may have been in a very early stage.

Eagle camara in Decorah, Iowa

One of our young eagles, August, 2010

     By now probably most of you know of the Eagle camera focused on an eagle's nest in Decorah, Iowa. It can be addicting to watch these eaglets in the nest, and just sit there waiting for one of the parents to bring breakfast, lunch or dinner. What most people don't realize is that it is very unusual for a pair of eagles to successfully raise 3 eaglets in a single year. Often 2 or 3 eggs are laid, but frequently one or two of the eaglets do not survive. This is either because there is not enough food to raise 2 or 3 such large birds or there are other environmental challenges such as cold, ice, wind. Also sibling eaglets are much like human siblings. There is competition and disagreement, but in the case of the eaglets, this disagreement can be a life and death issue. Frequently, a stronger nestling will push a weaker one away from the food source and may even push the weaker one out of the nest. I watched these Decorah eaglets for quite a while, and they seem to get along fairly well. This speaks to the abundance of food available for the parents at this site. Though I do think one of the three are significantly smaller and less developed than the other two. This might be because of receiving less food, or it might also have been the third to hatch. The last to hatch and especially if that hatching was delayed a day or two would be behind and would always get less food than the other two. The parents do not make any attempt to keep track of who eats and who doesn't. They put the food into any open mouth that is around. So if one eaglet is too weak to get close enough to demand food, it would be at a significant disadvantage.
     We are lucky enough to live on Lake Michigan about 1000 feet from an eagle nest tree. We can't see the nest but we see the eagles often. Last year  in their 4th year here they raised two eaglets which we thought was quite a remarkable fete. It was fun to see these two young eagles learn to soar and compete with each other riding the updrafts. Prior to that they had raised a single eaglet for 3 years in a row.
     Another indication that our adult eagle pair is pretty well off here on Lake Michigan is the fact that they allowed the yearling bird from 2 years ago to remain in the area even into the early nesting season last year. They did not allow that immature eagle to get near the nest but neither did they chase it out of the area. The latter would be more normal behavior. Again I think this means that there are lots of fish for the taking in that lake and probably plenty of varmits which fill in the gaps in the food cycle.
     Another interesting fact about eagles is their weak cry. From such a large bird, one would expect quite a cry but they have a very typical raptor's cry. The red tailed hawk has a similar cry. If you watch the Decorah video for a while, you can sometimes hear the parents approaching the nest with their relatively soft high pitched call. However, the parents do vocalize softly to their young during their caretaking duties.
     If by some chance you have not become addicted yet to watching our national bird in its most private duties, here is the website for the Decorah camera. Also there are several recordings from portions of this year's upbringing from the laying of the eggs, to the pipping, the hatching, and then the young eaglets in all their fuzzy glory.

http://www.huffingtonpost.com/2011/04/06/eagle-cam-decorah-iowa_n_845635.html

  Below is a link to nest in New Jersey. I haven't looked at this camera before but it also appears that this nest has two eaglets.

 http://www.ustream.tv/channel/eagle-cam

     I notice that yesterday, a fairly cold spring day with rain, the female (probably) is brooding the young ones, at least 1 1/2 of them. One eagle is completely and the other is partially covered by her body. But the fact that she is there at all indicates her instinctual  knowledge that these youngsters need protection from the cold and rain. On other sunny days, these three are old enough that both parents will often be gone from the nest at the same time searching for food. When the eaglets are younger, the parents never leave them alone in the nest. They take turns brooding and guarding the eaglets. I find these instinctual behaviors very fascinating. I guess that is why I am in the ranks of birdwatchers.

Mystery Photo 9: La Boca

     Mystery Photo 9 or rather the 5 photos are of La Boca, one of the 48 barrios of Buenos Aires, located near the old port, in the city's southeast corner.  It is a neighborhood of very colorful buildings, home of tango parlors and art galleries and artists' homes. The name probably comes from the "mouth" (boca) of the Riachuelo River which is in this neighborhood. La Boca has become a tourist stop in the capitol city. The area was settled by Italians and retains a European influence from such countries as Italy, Spain, Germany and France. The barrio has an interesting history as in 1882 the Genoese Italians who lived there, after striking for a long time, decided to secede from Argentina and raised the Genoese flag over the street called Caminito. That rebellion didn't last, but the area has always been a magnet for rebellious groups and was home to many demonstrations in 2001 when the government of Argentina was challenged. For we tourists, it is a nice little stop. There is usually some street tango dancing going on. You can buy nice souvenirs and take some photos and then move on relatively quickly.

     Below is a link to a great video of the neighborhood with music to give it the flavor of a true visit to barrio.

http://www.concierge.com/video/cental-and-south-america/buenos-aires/buenos-airesneighborhoods/2440494001/la-boca-buenos-aires/1830779229

Turkey: Interesting and confusing

     The topic of Islam and the Moslem lifestyle are very current today because of current events and the constant fear of increase in terrorism. We recently visited a country where 99.9% of the population is Moslem. That country is Turkey, where the desire to join the European Union has magnified all things European.. Istanbul is a very cosmopolitan city with all modern conveniences, up to date and even cutting edge public transportation, a desire to become a fashion leading city, and recently with a new nationalistic spirit in all things. When we were there, the annual Tulip Festival was apparent with beautiful beds in full bloom throughout the city. Our guide explained that Turkey wanted the world to know that the tulip originated in Turkey. Indeed the Ottoman Empire was the first to cultivate the tulip commercially. Of course, where did those hundreds of thousands of tulip bulbs planted around the city come from? Holland of course. Also while we were there a Shopping Festival was in progress. There were competitions for window decorations in shops and there were fashion shows and other events that celebrate the spirit of going out specifically to buy. What could be more Western and fit more into our known lifestyle than these two festivals?
     And yet in Istanbul and indeed in many Turkish cities there are mosques about every 10 to 20 blocks or so. Five times a day the recorded muezzin's call to prayer blares from the loudspeakers attached to the minarets. No longer does the muezzin need to climb up there and sing out his call to prayer. Someone just hits a button or more likely a timer turns the switch to play the recording. In one case, the call to prayer ended with three notes that were purely digital in sound, like the signals on a computer that ends a recording. Our guide told us that the current administration which is trying to increase the religious lifestyle has ordered that the volume on those loudspeakers be turned up. These calls to prayer are broadcast 5 times a day: at sunrise, at the zenith of the sun ie about noon, in the afternoon when an object's shadow reaches twice its own length, at sunset, and then when it is completely dark. The sunrise call to prayer seems to be a particularly long one or maybe that is just because that is when you most want the sound to cease. Our guide said that there are some extra sentences in that 5 AM call that say something to the affect: You must get up to pray. You would much rather be praying than sleeping. At any rate, hearing these loud broadcasts throughout the day and particularly at 5 AM makes you aware that you are not in a typical US or European city.     
     As a woman one thing that I was particularly conscious of was my own hair, and how the local women treated their own tresses, and for that matter their clothing and dress. My understanding is that in Islam a woman covers her hair to symbolize her purity and modesty, to indicate propriety, to demand the respect that a religious woman deserves, and to perhaps prevent the attraction or perhaps distraction that she would otherwise be to passing men. The degree of religious fervor varies from city to city and from one area to another in Turkey. Istanbul is decidedly cosmopolitan. Some interior cities are much more religious. Generally the cities along the Mediterranean, especially Antalya are much less religious. I only saw two women throughout our tour of turkey who wore the black hijab. But in general, I thought that about 60% of women covered their hair usually with decorative head scarves. Some of the older women wore typical silk head scarves, long coats, and long dresses underneath. They had sort of a "babushka" appearance. Many younger women wore a head scarf and even had an additional piece of head gear underneath like a wimple to hide the front hair more than the headscarf would do. And yet  with the head coverings, many of these young women wore very heavy facial makeup and wore fashionable boots, very close fitting leggings, and even blouses or tops that even this American would regard as revealing. I just am not sure what message this is sending. I asked our guide about this. He really didn't have an answer. He just said women tended to do what they wanted to do. I guess from my feminist Western view, this is a good sign. They are free to do what they want to do with their dress. There are certainly a fair percentage of women who do not wear any head covering at all. But inside the door of most mosques are head scarves provided for the member or visitor who enters.
     To increase the confusion, Mustafa Kemal Ataturk, first President of the Republic of Turkey in 1923 started a vast reform of political, economic and social institutions in Turkey. He more or less abolished the Sharia type law of the Ottoman Empire and instituted a secular movement. His government made it illegal for women to wear headresses in the Universities and in public buildings in Turkey. This law is still on the books, though not everyone follows it. Now the current government is striving for an return to more religious standards.
     I learned a lot about the mosques. Islam is not allowed to have any images of God or Mohammad or any other being inside the mosque. Only calligraphic writing of the names of God and the prophets are allowed to be displayed. That is why the interior of many mosques is somewhat plain, at least compared to what the Roman or Orthodox Catholic are used to. I learned that in my travels around the world when I have entered a mosque I have inadvertently transgressed accepted politeness. When Islamic worshipers are kneeling and praying and bowing, facing the niche in the mosque located in whatever direction is Mecca, if anyone walks between the prayerful individual and the niche, that person has to start his whole sequence of prayers over. That is why often inside mosques, people are kneeling next to pillars or against a railing so that no one can walk immediately in front of them. I will certainly be more careful in the future knowing this little bit of information. We Americans are not very good at learning some of the basic cultural requirements to become polite and welcome visitors when we travel around the world.
    Below are just a smattering of photos of the "huge" sites in Turkey. More may appear later in my blog. Or perhaps you will see something in the future as one of my Mystery Photos.

From the Bosphorus: Blue mosque on the left, Hagia Sophia on the right.



The silk market in Bursa



Memorial to Ataturk, Ankara, the capitol city.



Sunset over Cappadoccia, one of the most unique places in the world.



The Celsus Library, in Ephesus, the best preserved and largest Roman city ruins in the world.

Mystery Photo 9

     Here's a combination of photos of a famous neighborhood. Please tell me in what international city they were taken. In a few days, there may be a clue photo or two, but try to guess before the clue photos come.

Serendipity Finds a Family!

     I have had a strong interest in my family history for many years and thanks to former geneaologists in the family and some of my work, I have many branches of my family researched back up to 2.5 centuries. I have also worked on my husband's family and interviewed his parents and wrote a lot that they said down. But my husband never had much interest. In fact when he had to translate for the above mentioned interviews he would lose patience and then so would my interviewees. But this last summer a distant cousin visited us in Milwaukee and mentioned that there was a family member in Boston. Hubby called that person and learned of another individual with the same last name but who was thought to just be a friend of the family. After many phone calls back and forth between the Boston relative and many other possible relatives, a detailed family history was found. We were still not sure if this history was correct but finding a Duma Voters' List in Kishinev, Moldova which included names of voters and also the father's name helped us confirm the connections in this extensive family tree. After two months of multiple phone calls to family members now in Israel, sometimes to people who were elderly and had never learned Hebrew, spoke only Russian or Yiddish, we felt reasonably sure about these family connections. My husband decided to hold a family reunion in Israel this time when we visited there. We were able to host a gathering with 35 members of the family, 2/3 of whom never knew of the other branch's existence. Four of these attendees were in their 80s. My husband arranged a luncheon at Helena Restaurant inside the National Park at Caesarea in Israel. This venue is very nice, located right on the Mediterranean. It not only provided good food and an area that allowed us some separate space, but it also allowed attendees to also visit the National Park: ruins of the old Roman city of Caesarea. We posted the printed family tree on a wall of the restaurant in our little room and it became an immediate draw to people as they arrived. Each one wanted to find their family branch and point it out to others that were studying the tree. My husband gave an introduction and then had a representative of each family speak about what they knew about the family as a whole and where they fit in.
     Our lunch table was placed into a large square with people sitting around the outside. So we did not put name cards at the place settings. But I think if we did this again we would have to do just that. As much as our known cousins frowned at the contemplation of being mixed with other unknown relatives, that is probably what should have been done. For the most part people just sat down with their own known relatives and stayed there the whole afternoon. After the mixing at the posted family tree there was little other mixing. I tried to stir things up and went around to each family group like the mother of the bride at the reception,and struck up conversations and made introductions and utilized by digital recorder to record what people had to say. Of course if we put name cards at the table we would have to be sure that we paid attention to native languages. There were 3 people there who were over 80 years old, sort of the patriarch/matriarchs of their branches. We would have to make sure at least one family member was near them that could translate either into Russian, or Yiddish from the Hebrew that was the base language being spoken.
     One family member is Chaim Gutman who is an oncological surgeon. He comes to the US often for surgical meetings and will be in Chicago in June. We may be able to get together with him although I know the schedule is pretty full when you attend a medical or surgical meeting. The day is full of educational meetings and maybe even presentations you do yourself and the evening is also filled with dinners with colleagues and committee meetings. We will see what we will if there will be any time to get together.
     I met one young woman who kind of attached herself to me. She was the girl friend of one of the young cousins who asked to attend the reunion. She was quite intrigued in how I got interested in researching my husband's family. She asked if I had done the same for my own family and I said that I had, although in the case of my own family, I also inhertied a lot of family information from others who had gathered it. She asked what my background was; was I a history major that prompted such an interest. When I told her that I was a retired internal medicine physician, she said that made her even more intrigued. She is in medical school and just starting her clinical training. In Israel medical school is 6 years and includes the premed studies, the preclinical sciences and the clinical training years in that 6 years. She is a very nice young woman and I will definitely try to stay in contact with her.
     I think this gathering was a very good effort and a success for the first such meeting of this large family. We didn't even invite the younger generations because the group would have been too large. Another time I think I would like to have a good old fashioned American type family reunion picnic. Before I didn't know of any places that provide enough parking room and picnic tables for such a venture unlike here in the US. But now we know of a couple places where such a picnic could be held. Then we would be able to have all the younger members and their children because they would have a place to run around. I don't know if these newly discovered family members will get in touch at all, but I think it is a good first attempt. Maybe in another year or two we can try the larger complete family picnic.
     Here are a few pictures of our restaurant, our table arrangement and some of the family members.

Helena's is in the center, a very nice little restaurant with good food.

Our room with its square table. Mediterranean Sea beyond the windows.

Mystery Photo 8: Angkor Wat, Siem Reap, Cambodia

     I apologize that I left you dear readers hanging for almost a month regarding Mystery Photo 8, but I imagine you all have figured out where this place is. I now owe you some more photos of this amazing place. And I owe you an explanation for my absence. I have just returned from a trip to Israel and Turkey. I had thought I would be able to enter a post from some nice friendly Internet Cafe along the way, but the Turkish keyboard was just too much for me. Anyway, we are back home and I have much more grist for future photo blogs. You will be hearing more about this recent trip in the near future.

    Back to Siem Reap and its many many temples. I had always wanted to see Angkor Wat. I had read about the place in National Geographic, but I had no idea of its extent. The complexes of temples near Siem Reap in Northern Cambodia, were built over about 600 years, from 800 AD to 1400 AD by various rulers of the Khmer Dynasty. These were quite large and well developed cities. But the housing and other buildings were made of wood and possibly thatch and disappeared long ago. Only their temples were constructed of stone. And they were constructed mightily with beautiful stone work and very intricate carving and frieze work. Each emperor wanted to outdo his predecessor so he would move his capitol down the road a bit and build an entirely new royal temple. The temples were not meant to shelter a large group of people while worshiping as we are accustomed to with our synagogues and churches. Instead, the temple was to house the deity to which it was dedicated. Any reverence paid by the people was paid outside the temple from a distance. In fact in many of the temples, only royalty were allowed to approach. For most of these regimes, the religion was Hindu so temples were built to the Hindu gods, Vishnu, Shiva, Brahma, Indra, and Ganesha. But at times a Buddhist influence crept in and sometimes a Hindu temple was converted to Buddhist. There are over 100 temples scattered over the Siem Reap province. In spite of the ubiquitous heat and humidity that occurs in this area year round (we tried to pick the coolest time in November), in three days we were able to visit the highlight temples and get a very thorough feeling about this wonderful place.

 What I found the most magnificent was the frieze work. These often completely encircles the "porch" of the temple, and tell the whole story of that particular ruler and his exploits. Here are some photos and some brief comments about them.

                                Look at this stone work. So intricate and so beautiful

Promenade guarded by demons leading to south gate of Angkor Thom

The dozens of demons tugging on Naga and stirring the Milk of Creation, the Khmer Creation Story

Closeup of one of those demons

This is Bayon Temple inside Angkor Thom, famous for all its carved faces.

Look at the calmly smiling faces all around you.

All around the outside wall of Bayon are friezes showing the life of the Khmer royalty.

Getting ready for a major battle.

Shows all the preparations and support that needs to accompany the military.

Here a woman carries a turtle for food, and it bites the slave in front of her. Note the dirty look. They had a sense of humor.

Elephant Terrace in Angkor Thom. This was a long review stand for parades.

Seven headed Naga helps guard the terrace.

Angkor Wat, the largest religious structure in the world, reflects in its moat.

"Library" probably housed monks in the outer courtyard of Angkor Wat.

More than 300 types of apsaras (dancing deities) decorate the temples here.