Tag: diana gabaldon

Posted on

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

Follow me on:

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

Posted on

Mini Anatomy Lesson: Dupuytren’s Contracture

 

Anatomy Def: Dupuytren’s Contracture, a disease involving changes to deep tissues of the palm.

Outlander Def: Tom Christie’s right hand enjoys Claire’s touch waaay too much. Watch out, Jamie! 😉

History: Dupuytren’s Contracture (DC) is named after Baron Guillaume Dupuytren (1777-1835), a French anatomist and military surgeon who gained considerable notoriety treating Napoleon Bonaparte’s hemorrhoids! 😲 Although he was not the first to recognize the condition, he was the first to perform a successful repair on DC and published the results (The Lancet, 1834). Hence, the disease is named for him. 

Also Known As: Like Jamie, Dupuytren’s Contracture (DC) enjoys a number of aliases:

    • Dupuytren’s disease (DD) 
    • Morbus Dupuytren 
    • Viking disease
    • Celtic hand
    • Palmar fibromatosis/familial palmar fibromatosis
    • Palmar fascial fibromatosis.

Symptoms: Tight bands and/or firm lumps (nodules) appear in the tissues deep to the palmar skin. Gradually, the fingers may curl and pull sideways or toward the palm. Overlying skin may pucker. Sufferers may experience inflammation or sensations of tenderness, burning, or itching of the hand. Pressure or tension may be felt when attempting to straighten the fingers. Sometimes both hands and even the feet are affected. More fortunate individuals experience only mild cases that do not require medical intervention. The following image shows an example of DC involving the left ring finger.

Diagnosis: Care givers use the tabletop test to help diagnose DC: the hand is placed palm-down on a flat surface. If DC is involved, the hand cannot be laid flat.

Now, onto the anatomy. Yay! 🤓

Try This:  Look at your hand. Note that it has two main surfaces. The palm is known as the palmar surface; the back of the hand is its dorsal surface. See that the palmar skin is tightly adherent to underlying tissues, whereas the dorsal skin moves rather easily because it is loosely attached.

Palmar Aponeurosis: Deep to our palmar skin lies a thick fan-shaped layer of collagen known as the palmar fascia or, more formally, the palmar aponeurosis (next image). Collagen fibers (fasciculi) tightly bind the palmar skin to the underlying palmar aponeurosis. This anatomy enhances our grip, helps cup the palm, and protects underlying flexor tendons.

With the skin removed, the fan-shaped palmar aponeurosis is evident (next image): The point of the fan lies at the wrist (pink arrow), then it widens sending complex collagen bands to each of our four fingers (black arrows). 

In case of DC, the long bands of collagen, along with some cross fibers, thicken, tighten, and may form nodules. Ring and little fingers are most commonly affected; thumb, and index and middle fingers are less often involved. Sometimes DC affects both hands and even the feet. Although some sources claim there is no correlation between occupation and development of this condition, others cite manual labor as a predisposing factor. 

Learn more about the complex anatomy of the hand in Anatomy Lesson #22, Jamie’s Hand Symbol of Sacrifice and Anatomy Lesson #23, Harming Hands, Helping Hands, Healing Hands. 

Cause: Although poorly understood, several parameters suggest DC is likely is an autoimmune disease caused by a single dominant gene which is unaffiliated with either  X or Y chromosomes (the sex chromosomes). Even if present, the gene doesn’t always express itself. The reason for this is unknown.

Risk Factors: There are interesting risk factors associated with DC. 

    • Middle aged or older
    • Male – much less common in females
    • Scandinavian or Northern European descent (uncommon in Asian and African ethnicities)
    • Family history

Other Associated Factors: 

    • Liver disease
    • Long term use of phenytoin (anti-seizure med)
    • Cigarette smoking
    • Alcoholism
    • Diabetes 
    • Nutritional deficiencies

Treatment of DC: For many years, surgery was the only treatment for DC. In recent times, this has changed and new strategies have appeared.

    • Surgery: The most common treatment. Rarely, finger amputation is needed. 
    • Steroid injection: If a lump is painful, a steroid injection may help ease the pain. Repeated injections may be necessary.
    • Radiation therapy: Low energy X-rays are directed at the nodules to soften them and reduce contractions. Uncommon treatment in the U.S.
    • Enzyme injection: Newer, less invasive procedure. Hand is anesthetized, enzyme is injected. Over several hours, the enzyme breaks down and dissolves the tough bands.
    • Needle aponeurotomy: Newer, less invasive procedure. Hand is anesthetized. Surgeon uses a needle to divide and release the diseased tissue.

Read about Tom’s disease in Diana’s sixth big book, “A Breath of Snow and Ashes.” Dr. Claire describes Tom’s suffering: 🤒

He had been suffering from a condition in the right hand called Dupuytren’s contracture—or at least it would be called that, once Baron Dupuytren got round to describing it in another sixty or seventy years. Caused by a thickening and shortening of the fibrous sheet that kept the hand’s tendons in place when the fingers flexed, the result of it was to draw the ring finger in toward the palm of the hand. In advanced cases, the little finger and sometimes the middle finger as well were involved. Tom Christie’s case had advanced quite a bit since I had last had the chance of a good look at his hand.

See Claire’s assessment of Tom Christie’s Dupuytren’s Contracture in Outlander episode 601, Echoes! Stay tuned! Claire will operate on Tom’s hand in Outlander Episode 603, “Temperance!” 😲

The deeply grateful,

Outlander Anatomist

Follow me on:

Photo Credits: Starz, www.johnericksonmd.com, Netter’s Atlas of Human Anatomy, www.OrthoBullets.com, www.researchgate.net

Posted on

Mini Anatomy Lesson: IP Joint

 

Outlander Def:  Wait!  What???  Roger Mac has a joint? But, but….he is a Presbyterian minister (almost)!

No worries. NOT that kind of joint! 😉

Anatomy Def:  IP joints are between bones of each digit.

Let’s take a wee keek at hand anatomy to ken Roger’s bones and joints. The next figure shows bones of the (left) hand.

Collectively, the digits have 14 bones. Every finger  contains three tiny bones, each known as a phalange. The proximal (near) phalange is green, the middle plalange is blue, and the distal (far) phalange is pink.

But, alas, Mr. Thumb only enjoys two phalanges: proximal (green) and distal (pink). 

To identify the digits, anatomists number them from one to five: 

    • Thumb =  digit #1
    • Index =  digit #2 
    • Middle = digit #3
    • Ring = digit #4
    • Little = digit #5

But, wait for it….drum roll…. 🥁 Anatomists number fingers, from one to four:

    • Index = finger #1
    • Middle = finger #2
    • Ring = finger #3
    • Little = finger #4

Horror of all horrors…. This means that finger #1 is also digit#2!  😱

You  possible can see how this numbering system could get physicians into trouble. Adding fuel to the fire, anatomists in some countries regard the thumb as a finger and thus describe five digits and five fingers. Bottom line, US hand surgeons often prefer using terms (not numbers): thumb, and index, middle, ring, and little fingers to avoid confusion and mistakes! 🙄

Moving on!

In anatomy, a joint is the site where two or more bones meet and allow for movement –  the greater the number of joints, the greater possible movements. Thus, the many joints between phalanges of our five digits permit greater flexibility allowing digits to flex (bend) or extend (straighten).  Thumb also can oppose (touch) each finger, individually, and little finger also can oppose the thumb. These movements are possible because forearm and hand contain numerous muscles that move the bones.

Joints between phalanges are named interphalangeal meaning “between phalanges.” Because each finger has two interphalangeal joints, these are further defined (see next figure of right hand –  ignore metacarpophalangeal joints):

    • PIP (proximal interphalangeal) joint occurs between each proximal and middle phalange.
    • DIP (distal interphalangeal) joint occurs between each middle and distal phalange.

Puir wee thumb only has one joint between proximal and distal phalanges, so it has just a single IP (interphalangeal) joint. But, no tears for Mr. Thumb – he is verra special!

Whew! 😅 Took a bit to explain that!

Now, back to Roger’s anatomy! 😜 (I thought you would be up for that!)

Ergo, manly Roger is flexing the IP joint of his right thumb! 👏🏻👏🏻👏🏻  And, since in most people, the left hand is our shield hand while the right is our sword hand, it is just possible that Mr. Minister is contemplating a stramash! 

Try This: Flex (bend) one of your thumbs. Note it has one joint between its phalanges, the IP joint. Now flex any finger. Note it has two joints, the PIP joint nearest the palm and the DIP joint nearest the fingernail. Well done, student!

The hand and its fingers are elegantly engineered and staggeringly complex. If you wish to read more about them, I have written two long anatomy lessons of the hand.

Learn about  IP, DIP, and PIP joints in Anatomy Lesson #22, “Jamie’s Hand, Symbol of Sacrifice  and Anatomy Lesson #23, “Harming Hands, Helping Hands, Healing Hands.” 

Read about finger and thumb joints in Diana’s first book, Outlander. The following excerpt is from Jamie and Claire’s lovely outing in the countryside, shortly after the wedding : 

“Above one dark speckled pool, Jamie showed me how to tickle trout.

…  “All it is,” he said, “is to pick a good spot, and then wait.” He dipped one hand below the surface, smoothly, no splashing, and let it lie on the sandy bottom, just outside the line of shadow made by the rocky overhang. The long fingers curled delicately toward the palm, distorted by the water so that they seemed to wave gently to and fro in unison, like the leaves of a water plant, though I saw from the still muscling of his forearm that he was not moving his hand at all.

…  “There he is.” Jamie’s voice was low, hardly more than a breath; he had told me that trout have sensitive ears.

…  One finger bent slowly, so slowly it was hard to see the movement. I could tell it moved only by its changing position, relative to the other fingers. Another finger, slowly bent. And after a long, long moment, another. I scarcely dared breathe, and my heart beat against the cold rock with a rhythm faster than the breathing of the fish. Sluggishly the fingers bent back, lying open, one by one, and the slow hypnotic wave began again, one finger, one finger, one finger more, the movement a smooth ripple like the edge of a fish’s fin.”

See Roger’s IP joint in Starz season six outlander promo photo!

The deeply grateful,

Outlander Anatomist

Follow me on:

Photo Credits: Starz, www. geekymedics.com, www.quizlet.com