The Theory of Everything

There was no better way to see in the New Year today than by watching the wonderful movie that is ‘The Theory of Everything’. For those of you unsure, this is the new film about the life of Steven Hawking and his progressive journey through life with Motor Neuron disease. He was given approximately two years to live but he is still with us today. As a future medic I found this film extremely thought provoking. One line particularly caught my attention,

‘Your thoughts won’t change, it is just that soon people won’t know about them’. 

This quote, I think,  profoundly sums up the suffering of those with motor neuron disease. To be totally aware of your decline, to have your thoughts as intact as they were from the days when you can still walk to the days where you require constant assistance must be torturous.

This movie has captured that struggle immensely well and I cannot commend Eddie Redmayne enough for his highly considered performance. I am so glad I watched this film as I think I understand this suffering to a greater level now.

I have a new found respect for Steven Hawking and the incredible hurdles he has overcome, both personal and professional. He is one of the greatest minds of our time and he has not let his MND sway him from his work. He is an inspiration.

I’ll leave you with this quote which contains a mentality I wish to adopt for the New Year:

‘However difficult life may seem, there is always something you can do and succeed at.’

Thank you, and Happy New Year!

Neuroanatomy: #1 Extraocular muscles!

Any medical students reading this probably just let out an audible groan. Let me take a moment to join you… *groans*.

Neuroanatomy is, at the present moment, running my life. Thankfully I do have an interest in it and I do want to learn but even then spending hours upon hours in the anatomy lab gets a little tiresome.

SO!

With that in mind I have decided to share and share alike my resources for neuroanatomy for any medical students dropping by who this might be relevant to. Sharing is caring people, and it might save us all a little time in the lab.

Without further ado I present to you, a brief overview of the extraocular muscles. This might be a bit of a strange topic to launch straight into but it is one that I am confident with and so wanted to share.

Extraocular muscles:

The extraocular muscles are responsible for the movements of the eyeball. There are 6 (7 if you count the lovely levator palpebrae superioris which moves the eyelid) and they are:

Superior oblique
Inferior oblique
Lateral rectus
Medial rectus
Superior rectus
Inferior rectus
(Levator palpebrae superioris) 

What do they look like I hear you ask. Well let me refer you to the following beautiful diagrams

Now these muscles are very difficult to see in an actual specimen and are much more easily identified on schematics and in plastinated models. Initially it can be difficult to know which is which but once you have identified them the first time it is becomes a lot easier and their names help substantially.

Let’s hear a little bit more about these muscles:

Superior rectus: originates from the common tendinous ring situated deep in the orbital cavity, it attaches to the top of the eyeball.

Inferior rectus: is in the same plane as superior rectus and has the same origin. It attaches to the base of the eyeball and is difficult to see unless superior rectus is dissected away.

Medial rectus: On the medial aspect of the orbit, also originates from the common tendinous ring. It attaches to the medial aspect of the eye ball

Lateral rectus: Same as the medial rectus but on the lateral side

Superior oblique: originates from the common tendinous ring and passes anteriorly on the medial wall of the orbit, it becomes tendinous and it’s tendon passes through a structure known as the trochlea. By passing through the trochlea which acts as a pulley system the tendon turns 90 degrees to insert on the posterior lateral aspect of the eyeball.

Inferior oblique: does NOT originate from the common tendinous ring. It instead originates from the maxillary bone. The muscle belly passes up under the eyeball before becoming a tendon and inserting on the inferior posterior aspect of the eyeball.

We’ll quickly cover the innervation of these muscles and we’ll in a later post/ a revision to this post look at the action of these muscles. The reason I’m delaying this is because the axis of the orbit is different to that of the eye so the action of the muscles, particularly the obliques, may not be as expected and I feel I can best explain this with a video which I need to film.

So!
The innervation of these muscles is very simple. Remember this: Oculomotor (CN 3) does all except LR6 SO4.
LR6 = Lateral rectus is innervated by cranial nerve 6 which is abducens nerve
SO4 = Superior oblique is innervated by cranial nerve 4 which is the trochlear nerve. (Incidentally another way to remember this is that the superior oblique passes through the pully called the trochlea and is innervated by the trochlear nerve)

Thanks for reading, hope you are somewhat enlightened! I promise to cover the action of the muscles soon!

An interesting case…

Fortnightly we at our medical school take the afternoon to go to a local GP surgery and get some teaching from current GP’s and meet a few patients.

We’ve been going for a few weeks now and I must say our GP is a fantastic teacher, one of those highly enthusiastic people who is ready to tell you absolutely everything he knows about a topic.

Back in our first week we were learning initially about general end-of-bed observations and taking an examination of the hands and face. We learnt first and then to practice what we had learnt on a few patients who had some interesting signs.

One of the patients had psoriasis which on examination of her hands was hardly noticeable but then she rolled up her sleeves and we saw that she was covered. From this I learnt not to just take the surface of things, to dig a little deeper and you might uncover something that you’d otherwise have missed. This would obviously have come out in the history but as we just examining the patient today we could have easily missed it.

By far the more interesting case for me, however, was her husband who just came in the capacity of taxi to bring her into the surgery. He had however had a pretty obvious and extremely interesting operation that I had never seen before or knew existed.

Before he even entered the room we could hear him chatting to our GP in a gravelly, very hoarse voice which at first I just thought was his voice until he walked into the room. It was immediately obvious that he was talking through a valve in the middle of his neck which he pressed in order to make sound and let go of to breath. I had truly never seen anything like it.

He told us that he had had a tumour of his true vocal cords and that in order to be cured he had, had to have a total laryngectomy (surgical removal of the larynx (voice box)). This obviously removed his power of speech however surgery can provide a solution to this. He had, had what is known as a tracheo-oesophageal puncture performed and then a prosthetic valve placed in to allow him to regain a form of speech known as oesophageal speech.

Apparently his degree of speech is very good in comparison to the normal outcome for these patients and I must say that apart from the gravelly tone of his voice his speech was entirely normal. He has learnt to use the valve very well.

The principal of the operation, from my understanding, is that a patient who has had a complete laryngectomy needs to breathe permanently through their neck. A hole (fistula) is made between the trachea and the oesophagus and the voice prosthesis is inserted which does not allow food down the trachea but does allow air into the oesophagus.
Air in these patients enters and leaves through the valve in their neck but when the patient occludes the valve and prevents air escape by this pathway air enters the voice prosthesis and enter the oesophagus and escapes through the mouth. As the air passes through the upper tissues of the oesophagus it vibrates replacing the vibrations previously produced by the vocal cords.

This is what it looks like in the flesh:

Oesophageal speech, I’ve been told, is hard to master especially initially but there are clinics for these patients to go to where they can learn to speak well using these prostheses and the result is truly astonishing.

There are of course implications on this man’s life, he will never be considered in the same way and there will be a prejudice that comes from the sound of his voice. He said himself that children are scared of him now and he does resent that, but for him the ability to still communicate close to how he used to succeeds that and once people get to know him they understand and there is no judgement.

It amazes me everyday the things that modern medicine can achieve and this man and his surgery reminded me why I decided medicine was the career for me in the first place.
Very cool!

Just to show those of you who haven’t seen this – here is a patients story:

https://www.youtube.com/watch?v=SaREnCLP3RM