Author: Outlander Anatomist

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Anatomy Lesson: The Eyes of Aunt Jocasta

Anatomy Def:  Jocasta’s Blindness – painful pressure in the eye

Outlander Def: Jocasta’s Joy – pain relieved by smoking hemp flowers

Greetings, anatomy students!

Let’s learn about the disease that robbed Jocasta Cameron of her eyesight: Glaucoma. Yep, that’s the one. Glaucoma (glaw-koh-muh), is a word derived from the Greek glaukommatos meaning “gray-eyed.”

But, first, a wee divergence for a quick anatomy lesson of the eye which, in my opinion, is the body’s most anatomically elegant structure. This brief review is necessary to glean any useful understanding about this disease. 

Eyeball: The next image shows a horizontal-section of the right eyeball (globe) as seen from above. The diagram shows in succession (from L to R) the cornea, iris, and lens; the opening in the middle of the iris is the pupil (red arrow). 

Two Chambers: The eyeball contains two important spaces (peachy-pink in the image, below). A large area behind the lens is the vitreous chamber – it is shaped like a sphere. In front of the lens is the smaller anterior chamber – it is shaped like a disc. The pupil supplies an open route between the two spaces.

Optic Nerve: At the back of the globe is the large optic nerve, an extension of the brain into the the eyeball. It is formed by filaments from cells of the retina. When photons (packets) of light excite retinal cells, they send signals via the optic nerve to the brain where it interprets the signals as the object viewed. 

Vitreous Chamber: The vitreous chamber is filled with the vitreous body, a jelly-like material that becomes more fluid with age. 

Anterior Chamber: The anterior chamber is filled with a watery substance known as aqueous humor.

Aqueous Humor: Aqueous humor is similar to blood plasma; it fills the anterior chamber (next image). Aqueous humor is produced 24 x 7 –  continuously made by tissues near the lens and constantly drained by tissues near the iris.  

Blue arrows show the direction of flow of the aqueous humor from its production site, through the pupil into the anterior chamber, and then into nearby exits to be carried away.

A very quick lesson, indeed!

Learn more about the eye in not one, but five anatomy lessons! 

Q:  Why so many lessons, prof?  

A: Because the eye is exceedingly complex! 🤓

The lessons are:

*Anatomy Lesson #29: The Eyes Have It!

*Anatomy Lesson #30: Aye, Eye, The Eyes!

*Anatomy Lesson #31: An Aye for an Eye!

*Anatomy Lesson #32: A Real Eye Opener!

*Anatomy Lesson #33: Eyemax!

Glaucoma: When a person suffers from glaucoma, aqueous humor is either overproduced or the production is normal but it does not drain properly, or both may be culprits.  If the fluid cannot drain, not only does it fill the anterior chamber, it also backs into the vitreous chamber. 

Symptoms: So, what happens when aqueous humor builds up? Well, several things, usually over time.

    • Eye pain or pressure
    • Headaches
    • Rainbow-colored halos around lights
    • Nausea and vomiting
    • Red eyes
    • Loss of side (peripheral) vision
    • Low vision, blurred vision, narrowed vision (tunnel vision)
    • Blind spots
    • Blindness
  • Not-So-Fun-Fact: Glaucoma is the leading cause of blindness in people over 60.

Comparison:  Let’s  compare a normal eye (panel A) with a glaucomatous eye (Panel B) so we understand how things work.

    • Panel A shows normal flow and removal of aqueous humor
    • Panel B shows aqueous humor accumulating in anterior chamber and in vitreous chamber because there is too much or it does not drain properly.

Jocasta: Now, we come to the root of Jocasta’s problem (next image). As intraocular pressure builds because of too much aqueous humor, it presses against the fragile retina (yellow layer) and optic nerve causing irreversible damage.  This means the normal response of the retina to photons of light and subsequent transmission to the brain are diminished or cease altogether. Such changes are typically accompanied by misery and pain.

Unfortunately, Claire lacks current methods and medicaments to treat glaucoma. She can provide, however, hemp flowers for a wee pipe!

Now, does this really work?

Yes. Yes. It does.

Smoking hemp decreases intraocular pressure, thus relieving the pain and discomfort of pressure against retina and optic nerve.

Note:  Hemp also reduces blood pressure throughout the entire body, a side effect which might not be beneficial to all individuals, depending on their general health.

But, our Auntie Jo feels better and is even giddy!

(I love those goblets! 😍)

I should clarify that research showing the effects of smoking hemp on glaucoma wasn’t proven until the 1970s, a few years after Claire’s return to the eighteenth century. In her defense, the good doctor may have learned anecdotally about such benefits before she took her long and winding road back to Jamie.

Etiology (cause) of Glaucoma: Although we speak of glaucoma as a single disease, it is not. Glaucoma is a group of eye diseases that cause vision loss and blindness. The two most common types are:

    • Open angle – drainage routes are blocked – progresses slowly
    • Closed angle – drainage routes are blocked –  progresses more rapidly and is usually more severe

Treatments: Treatments include eye drops and surgery. These  may be used separately or together for treatment.

    • Eye drops – reduce intraocular pressure. Glaucoma must be detected early to be effective
    • Laser Eye Surgery – Improves drainage via normal routes
    • Tube Shunt Surgery – Small device is placed in eye to augment fluid drainage
    • Trabeculectomy – Delicate surgery creating new drainage ports 

Claire’s solution of hemp smoking is entirely different than what she does in the book. Read on and you will see why.

Read about Claire’s gutsy and unorthodox treatment of Jocasta’s glaucoma in Diana’s sixth big book, A Breath of Snow and Ashes. Here, she pierces the eyeball with a carpet needle, allowing excess fluid to seep out and relieve the unrelenting pressure and pain.

(Pssst…..  The escaping fluid is aqueous humor, not vitreous 🤫)

Even as I talked, I’d got out the tiny spirit lamp I carried in my case. The fire had been allowed to burn down on the hearth, but there were still live coals; I bent and lit the wick, then opened the needle case I’d taken from the sitting room and abstracted the largest needle in it, a three-inch length of steel, used for mending carpets.

“You aren’t …” Jamie began, then broke off, swallowing.

“I have to,” I said briefly. “There’s nothing else. Hold her hands.”

He was nearly as pale as Jocasta, but he nodded and took hold of the clutching fingers, pulling her hands gently away from her head.

I lifted away the linen bandage. The left eye bulged noticeably beneath its lid, vividly bloodshot. Tears welled up round it and overflowed in a constant stream. I could feel the pressure inside the eyeball, even without touching it, and clenched my teeth in revulsion.

No help for it. With a quick prayer to Saint Clare—who was, after all, patroness of sore eyes, as well as my own patron saint—I ran the needle through the flame of the lamp, poured pure alcohol onto a rag, and wiped the soot from the needle.

Swallowing a sudden excess of saliva, I spread the eyelids of the affected eye apart with one hand, commended my soul to God, and shoved the needle hard into the sclera of the eye, near the edge of the iris.

…  I withdrew the needle carefully, though as fast as I could. Jocasta had stiffened abruptly, frozen stiff, hands clawed over Jamie’s. She didn’t move at all, but made small, shocked panting sounds, as though afraid to move enough even to breathe.

There was a trickle of fluid from the eye, vitreous humor, faintly cloudy, just thick enough to be distinguishable as it flowed sluggishly across the wet surface of the sclera. I was still holding the eyelids apart; I plucked a rag from the goldenseal tea with my free hand, squeezed out the excess liquid, careless of where it went, and touched it gently to her face. Jocasta gasped at the touch of the warmth on her skin, pulled her hands free, and grasped at it.

I let go then, and allowed her to seize the warm rag, pressing it against her closed left eye, the heat of it some relief.

Now, you might think this extreme, but the only other remedy Claire could offer would be to remove one or both of Jo’s eyes!

Well done, Claire! 👏🏻👏🏻👏🏻

See Claire treat Auntie’s glaucoma in Outlander episode 605, Give Me Liberty!

I think Aunt Jo might welcome the hemp just a wee bit more than that needle jab, eye? 😉

The deeply grateful,

Outlander Anatomist

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Photo Credits: Starz, www.aao.org, www.allaboutvision.com, www.majordifferences.com, www.ohioeyesurgeons.com, www.2020pittsburgh.com

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Mini Anatomy Lesson: Tom’s Travail

 

Anatomy Def: Claire confronts Dupuytren’s Contracture.

Outlander Def: A hand condition best dubbed as “Tom’s Travail!”  👋🏻

Tom’s right hand is disabled because he suffers from Dupuytren’s Contracture (DC). If you have not read my earlier Mini Anatomy Lesson about DC, you can access it here. 

Quick Review: Underlying the skin of the palm is a tough layer of connective tissue known as the palmar aponeurosis. Importantly, it aids in cupping the palm, maintaining grip, and protecting underlying flexor tendons (see figure below).

DC causes the palmar aponeurosis to form thick bands and nodules that contract over time, typically drawing affected fingers toward the palm. Sometimes the palmar skin also contracts, scars, and pits. 

What Claire Did:  So, Claire says to Tom, “a stitch in time, saves nine.” She can fix what ails you, you auld sour pus.

Let’s do a quick recap of what Claire did. 🔪

First, and foremost, Claire kept Tom waiting. How dare you madam? 

Tom’s at least as brave as Jamie so he’ll not be having any of yer potions, witchie Claire! If Jamie can stand it – so can Tom. (Jamie be like….hmmmm 🤔)

How about a wee stick to bite on ‘cos this WILL hurt! Nope, says Tom!

Alrightie, then….How about a big dram of whisky? Yep, says Tom! (Hey! It’s for medicinal purposes 🥃)

Claire buckles Tom’s hand to a nicely padded wee bed. Screaming is OK, but no move a muscle, Tom. Claire needs both hands to slice and dice. She canna be holding yours! 😷

Claire’s wee alcohol lamp gleams, brightly!  

Claire sterilizes her scalpel blade in the flame.

Erm, wait!  Isn’t that a modern scalpel with a disposable blade and with info stamped in the handle? Ah…… yep.

Trouble is, knives with disposable blades weren’t invented until 1901 by King C. Gillette (yep, that Gillette), followed in 1906 by John Murphy, a surgeon who adapted Gillette’s razors into a surgical tool.

OK. Then, from whence did this scalpel come? I thought Claire’s medical kit perished back in Season 3 with the Artemis.  

But, wait!  She still wore her bat suit after washing ashore. Mayhap her med kit survived in one of its capacious pockets? If so, that blade may be a wee bit dull! 🤭

A chance to cut is a chance to cure! And, Doc Claire is off and running!

Claire makes a quick swipe of her scalpel across the palm of Tom’s hand.

@#%$&*!  That HURTS!!!

Although that first transverse cut seems a wee bit deep and wide, let’s just accept the FX and move on. Aye?

Violet arrows point to the thick, tight bands of palmar aponeurosis that pull Tom’s fingers downward. Those must be cut away or divided.

Claire carefully makes zigzag cuts in the skin and frees it from the aponeurosis. She works to remove the thickened bands of connective tissue. 

And, all the while, Jamie reads from Psalms at the back of Tom’s Bible. 😂 (Doesna matter, Jamie probs has all the psalms verses memorized anyhow.)

All done! A few snips and stitches later, the fingers are straight and the zig-zag opening is zippered shut. Tidy mending, Claire!

Hum…I understand that Tom’s Thumb and index were not a problem, but what about Tom’s wee finger, didn’t it have DC, too? 🧐

A few hours later, Claire offers Tom with some gentle PT. Tom has a fever so why not some penicillin?

Madam, you have a great deal too much hair!!!!  Scary woman, why aren’t you a pious wife wearing a drab kerchief? 😈

So, how does Clair’s surgery compare to the real deal? Actually, pretty good. 

WARNING: The following surgical images may be a bit graphic for some.  If you are squeamish, you might wish to skip.

The following are five standard surgical approaches to DC:

    • Regional Fasciectomy: Removal of the entire tight band(s) and/or nodule(s).
    • Segmental fasciectomy: Removal of part of tight band(s) and/or nodule(s). 
    • Dermatofasciectomy: Removal of tight band plus overlying skin – requires a skin graft. 
    • Closed Fasciotomy: Dissection of the tight bands using needles. No skin incision. Available with patients who cannot tolerate fasciectomy. 
    • Finger Amputation: Amputation  is employed in severe cases and after other approaches have failed.

BTW, fasciectomy means “to cut away fascia.”  (Other names are fasciotomy and aponeurectomy).

It appears Claire performed a regional fasciectomy. Yay Claire! 🤜🏻🤛🏻

Now, let’s compare to a real surgery. The following image is a left hand with DC. A tight band extends into the middle finger (top arrow) and a nodule and band to the wee finger (bottom arrow). The ring finger appears less affected than middle and wee. 

The surgeon opens the palmar skin to reveal the palmar aponeurosis. The tight bands are removed or split. Fine scissors and forceps are required to work carefully and meticulously to protect nearby neurovascular bundles and other important structures (next image).

Notice – the skin cuts are zigzags like Claire employed.

Why is this done?

ZigZag Cuts: ZZ cuts are employed for three good reasons:

    • Scars from a straight line incision tend to contract more and may cause DC to recur early.
    • Zigzag cuts mobilize more skin than a straight cut so the finger straightens better.
    • Zigzag cuts rarely require skin grafting.

Lastly, thread tethers hold skin flaps out of the surgical field.

The next image shows a woman’s hand, post-surgery, wherein repairs were performed to middle, ring, and little fingers. The inked zigzags were drawn before surgery so the surgeon knows where to make the cuts. These are still visible, post-surgery.

Skin Graft: As mentioned above, If the overlying skin in DC is too damaged or it is not sufficient to close the surgical wound, a skin graft may be added; this permits the hand to be opened completely and laid flat (table top test). The follow image shows a skin graft of the little finger.

NOTE: Claire did not ink the intended zigzags on Tom’s palm although she had the means to do so. Also, the FX could have been improved by showing both ring and little finger repairs; only Tom’s ring finger showed Claire’s final handiwork. Over all, though, I thought the FX were good.

Genetics: Dupuytren’s Contracture, the most common of all connective tissue diseases, has a genetic basis. Two schools of thought explores the genetics of DC which runs in families and is more common in men and those of North European descent.

*Dominant Gene: This position claims DC is caused by a single dominant, non-sex-linked gene with incomplete penetrance. In common language:  

    • The person inherits only one DC gene from either parent.
    • The gene is carried by a somatic chromosome – not X or Y. 
    • The gene may or may not expresses itself.

*Recessive Gene: This school of thought suggests the sufferer must inherit a recessive gene from each parent to get the disease. If (s)he receives just one recessive gene, then they are a DC carrier and do not have the disease.

Despite the prevalence of DC, its exact cause remain somewhat obscured.

So will all this cutting and stitching by Competent Claire fill Tom Christie with  joy???? 🤔

The deeply grateful,

Outlander Anatomist

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Photo Credits: Starz, www.istockphoto.com, www.johnericksonmd.com, www.researchgate.com, www.sciencephoto.com

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Mini Anatomy Lesson: Abdominal Aortic Aneurysm (AAA)

 

Anatomy Def: An abdominal aortic aneurysm (AAA) is a bulge or swelling of the aorta that occurs in the belly.

Outlander Def: Mrs. Wilson’s untimely #death-resurrection-death wherein “kindly” fisher folk put Claire firmly on her witchy broom!!! 🧹😱

Hello, anatomy students! To date, I have not written a full lesson about the cardiovascular (CV) system. So, the following quick anatomy lesson of the aorta will be useful in understanding AAA. 🤓

And, we’re off!!! 🏇

Aorta: The aorta is the largest blood vessel of the body! 👏🏻👏🏻👏🏻

What Does it Do? The aorta is an artery, so it is tasked with carrying oxygen-rich (oxygenated) blood from the heart to general regions of the body. The direction of blood flow is indicated by the small black arrows in the next image.

Also, by convention, arteries are colored red to indicate these vessels carry oxygenated blood away from the heart and veins are blue to show vessels carrying oxygen-poor (deoxygenated) blood toward the heart. (pssst…there are two exceptions to this pattern, but I won’t confuse you by including those. 😜)

Along the entire course of the aorta, various arteries branch off to supply blood to the head and neck, upper limbs, chest and its organs, abdomen and its organs, and lower limbs. These branches are not labeled in the image below.

Divisions: Inside the chest is the thoracic aorta – the part within the belly is the abdominal aorta. The names switch where the aorta traverses the thoracic diaphragm (purple arrow).

The part of the thoracic aorta that rises is the ascending thoracic aorta, the curved part is the aortic arch, and the part that descends is the descending thoracic aorta.

Pathway:  The aorta starts at the left ventricle (chamber) of the heart, rises toward the neck, makes a 180º, descends through the chest, and enters the belly (abdomen) where it terminates at the 4th lumbar (L4) vertebra by dividing into left and right common iliac arteries (turquoise arrows). Whew! 😅

How can a practitioner locate L4 when looking at the belly?

Here’s how: the umbilicus (navel) can be used as a fairly reliable surface landmark for termination of the aorta because it lies slightly above L4. Thus, a finger’s width below the navel will locate L4. If a person is heavy or pregnant, this can distort the position of the navel. 

L4 is important because the practitioner must palpate above that level to detect a AAA.

Like other larger arteries, a pulse in the abdominal aorta can be felt (palpated). Sometimes the belly can be seen to rise and fall with the pulse especially after a meal, during pregnancy, or while lying down. This can be perfectly normal.

However, sometimes a pulse in the abdominal aorta can be a warning sign!🚫 

Aneurysm: If the aortic wall becomes damaged, it can developed a distinct bulge or balloon; this is an aneurysm. (Pssst…🤫 Aneurysms also can develop in smaller arteries and in veins.)

If an AAA is present, a practitioner may be able to detect the enlargement by palpating the abdominal wall. The care giver must press firmly enough to feel the abdominal aorta because it lies very deep, near the vertebral column. 

If a patient has a very taut abdominal wall (next photo) or the waist girth exceeds 100 cm, it is more challenging for the practitioner to accurately feel and identify any aneurysm that may be present. A tight wall or a fairly thick layer of belly fat inhibits the deep pressure required for the exam. Lastly, clothes worn by the patient may also impede effective palpation! 😮

Although the following informative video is designed to train students on how to palpate the abdominal aorta, it is easily understood by a lay person. This will give you an idea of how a pulse is felt and how an aneurysm is detected.

The big problem with AAA is it can enlarge to the point of rupture, allowing blood to seep into the wall of the aorta (dissecting aneurysm) or bleed into the abdominal cavity causing dangerous blood loss or even death. 

Rarely, an AAA can become so large, it is clearly visible in the abdominal wall (next image)! The left panel shows an huge bulge at the left side of a person’s abdominal wall. The right panel shows a cross-sectional CT scan of the same mass, identified as a huge blood clot (thrombus) in an AAA. 

OK. I hear the bell tolling…… Time to head back to the wee kirk on the Ridge! 

Germain’s “I spy with my little eye,” alerts Granny Fraser that something is amiss with Mrs. Wilson. 👀  

“LOOK!“     

“Stay back!”

Claire rushes to the other granny’s side and palpates her abdomen. Can she feel a possible aneurysm? Very likely, because Mrs. Wilson is fairly trim and her stays appear to be of the type that end near the waist, so Claire should be able to palpate – no problemo. 

Claire slips her fingers between the folds of the skirt and takes a wee feel. Yep! Just as Claire suspected…..the auld lady has an abdominal aortic aneurysm – it has ruptured and she is bleeding internally.

If Mrs. Wilson had been sans clothes, Claire might have witnessed something like this:

She hasn’t got long, Reverend Roger. Just minutes and she stands before her Maker! 

Wait! Wait! What? How could Claire ken the aneurysm had ruptured?

Well, here are some clues that Doc Fraser likely observed..…. 🤓

Signs and symptoms that an AAA has ruptured:

    • Sudden, intense and persistent abdominal or back pain – a tearing sensation
    • Low blood pressure
    • Loss of consciousness
    • Pasty, cold, and clammy skin 

Although Claire does not know if Mrs. Wilson experienced the back pain (no time to take a proper history), all the other symptoms are recognizable. Claire recognizes that given the lady’s advanced age, fainting is likely due to low blood pressure as a result of internal blood loss. Blood loss plus age suggest aneurysm as a likely cause. These coupled with palpation of the enlarged AAA leads Claire to tell Roger that Mrs. Wilson’s death is imminent! (She’s a lot closer to God than you, Roger Mac –  Bree will be grateful for that 🙏🏻)

Mrs. Wilson revives long enough to forgive her SIL – “You’ve been a good lad.” He did provide her with a hame these past 20 years. ♥️

… And she survives long enough to accept the sin-eater’s gift of devouring her sins. 😮

Lastly, you might be interested in what causes aneurysms and any risk factors. 

Common Causes:

    • Hardening of the Arteries (Atherosclerosis): Fat and other substances build up in the wall of the aorta (or other blood vessels) and weaken it.
    • High blood pressure: Prolonged, elevated blood pressure can damage and weaken the aortic walls.
    • Blood Vessel Diseases: Diseases such as Marfan Syndrome damage vascular walls. 
    • Infection: Although rare, a bacterial or fungal infection can cause AAA.
    • Trauma: Abdominal injury (e.g. serious car accident) may cause an AAA due to a tear in the aorta.

Risk factors: And, like many other diseases, there are risk factors for AAA. Most of these we cannot control but there is one clear exception! 🚬🚭

    • Tobacco use: Yep. Smoking is the strongest risk factor for AAA! Why? Because smoking weakens the aortic walls, increasing the risk of aortic aneurysm and the likelihood one might rupture.  The longer and more one smokes or chews tobacco, the greater the chances of developing an aortic aneurysm. (Doctors recommend a one-time abdominal ultrasound to screen for an AAA in men ages 65 to 75 who are current or former cigarette smokers.)
    • Age: AAA occurs most often in people ages 65 and older.
    • Being male: Men are 3-4x more likely to develop AAA as women.
    • Being white: People who are caucasian are at higher risk of AAA.
    • Family history: Having a family history of AAA increases the risk.
    • Other aneurysms: Having an aneurysm in another large blood vessel, such as the artery behind the knee or thoracic aorta can increase the risk of an AAA.

Read about Mrs. Wilson’s walk through the valley of the shadow of death in A Breath of Snow and Ashes, Diana’s longest big book (1,152 pages)! 

“No, Grannie! Look!” 

I followed his outthrust finger, and for a moment, thought he was pointing at his father. But he wasn’t. 

Old Mrs. Wilson had opened her eyes.

There was an instant’s silence, as everyone’s eyes fastened at once on Mrs. Wilson. Then there was a collective gasp, and an instinctive stepping back, with shrieks of dismay and cries of pain as toes were trodden on and people squashed against the unyielding rough logs of the walls.

“Give her a bit of air, please,” I said, raising my voice. The stunned silence was giving way to a rising murmur of excitement, but this quelled as I fumbled to untie the bandage. The room waited in quivering expectation as the corpse worked stiff jaws. 

“Where am I?” she said in a quavering voice. Her gaze passed disbelievingly round the room, settling at last on her daughter’s face.

I, meanwhile, had been doing my best to check the old lady’s vital signs, which were not all that vital, but nonetheless fairly good for someone who had been dead a moment before. Respiration very shallow, labored, a color like week-old oatmeal, cold, clammy skin despite the heat in the room, and I couldn’t find a pulse at all—though plainly she must have one. Mustn’t she?

I put my own hand on her abdomen, and felt it instantly. A pulse, where no pulse should be. It was irregular, stumbling, and bumping—but most assuredly there.

See Hiram Crombie’s MIL and her final moments before leaving her mortal coil in Outlander, Episode 602, Allegiance. A verra poignant scene, indeed!

Gobs of grannies in this episode! 😉

The deeply grateful,

Outlander Anatomist

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Photo Credits: Starz, www.familydoctor.org, www.feghalicardiology.com, www.nejm.org, www.oxfordmedicaleducation.com