Palm Reading

I love looking at people’s hands.

My fascination with hands started when I learned how to I.V cannulate.  I found myself subconsciously evaluating the potential ease or difficulty an I.V start would be, even absentmindedly tapping along the length of a vein (usually creeping out the boyfriend or family member).

Now that I’ve been learning so much about how many clues the hands and nails can reveal regarding systemic pathology, I’m becoming borderline obsessive about looking at the hands of people around me…hoping to see some obscure clue to illness.

Last night I came across a quote in my favorite textbook, “Hamilton Bailey’s Demonstrations of Physical Signs in Clinical Surgery” which I thought encapsulated my rekindled curiosity,

“Regarding the hands, ‘one does not need the mysteries of palmistry to read in them something of the past, a great deal of the present, and even a little of the future. In them is written the record of age and sex; of occupation and habits; of skill or ineptitude; of hard work or indolence’ (Cutler)."

When One Eponym Suffers Another

The Oxford Handbook of Clinical Medicine is full of charming and hilarious little gems, usually tucked away in the depths of information overload. I would love to meet the authors of this sanity-saving handbook and shake all of their collective hands (while buying them beers).

Today I came across this entry which I felt the need to share:

In 1931, Buerger's* disease caused gangrene in the toes of Harvey Cushing**--the most cantankerous (and greatest) neurosurgeon ever. He had to be wheeled to the operating theatre to carry on his brilliant art (and to continue terrifying his assistants). He had to retire partially, whereupon his colleagues presented him with a magnificent silver cigarette box, containing 2000 cigarettes (to which he was addicted)--one for each brain tumor he had removed during his long career, so verifying the truth that although we owe everything to our teachers, we must eventually kill them to move out from under their shadow.

-Herman Hesse, Demain

And so there is your CME in obscure medical history for the day.  You're welcome. 

--

*Buerger's disease (thromboangitis obliterans) is smoking related inflammation of veins, nerves, and middle-sized arteries (which thrombose, causing gangerene). Cause is unknown. Stopping smoking is vital. Most patients are men. 

**Cushing's disease is bilateral adrenal hyperplasia from an ACTH-secreting pituitary adenoma. He also is known for Cushing's syndrome, and Cushing's triad...but I think we've learned enough for today.

Sorry, Not Going to Happen

Another textbook gem from Ellis Clinical Anatomy (i.e. my current favorite anatomy resource):

"A carotico- cavernous arteriovenous fistula results with pulsating exophthalmos, a loud bruit easily heard over the eye and, again, ophthalmoplegia and marked orbital and conjunctival oedema due to the venous pressure within the sinus being raised to arterial level."

Sorry Ellis, if someone comes into my A & E dept with a penetrating injury to the skull, I am probably not going to put my stethoscope on their eye to determine if they have an EYE BRUIT.

How the hell would you be able to hear that anyway? And really if they've knackered their cavernous sinus I am pretty sure there will be other, less subtle clinical signs. Thanks though, for that tip.

Wouldn't That Make You A Sadist?

So, in my anatomy book, in the discussion about estimating pelvic measurements in a pregnant woman, I came across this gem of a phrase:

Another useful clinical guide is the subrapubic arch: the examiner's four knuckles (i.e. his clenched fist) should rest comfortably between the ischial tuberosities below the pubic symphysis. 

In other words, you should be able to comfortably rest your fist between the patient's sit bones, under their pubic bone.

Ehhh...author? You might want to come up with a better way of describing that. Especially for some of the borderline Asperger's very literal-minded males in my class. Thanks.

The Questions That Keep Us All Awake at Night

"The oxytocin causes increased rhythmical contractions of the uterus, which have been postulated to cause increased transport of the sperm. A few sperm have been shown to traverse the entire length* of the fallopian tube* in the cow in about 5 minutes, a rate at least 10 times as fast as that which the swimming motions of the sperm themselves could possibly achieve. Whether this occurs in the human female is unknown."

Thank you for that Guyton & Hall: Textbook of Medical Physiology, 11th ed.

I can't imagine why a woman would shy away from being involved in the study to finally crack that mystery. Nothing is sexier than a man in a lab coat with a stopwatch.

How is one supposed to be impressed by this time trial without the knowledge of the length of said cow fallopian tube?? I hope they pick up this oversight for the 12th ed.

Today's Textbook Quotable

"The knee joint is relatively weak mechanically because of the incongruence of its articular surfaces, which has been compared to two balls sitting on a warped table top". 

Come again Clinically Oriented Anatomy (6th ed.)?? Can you unpack that analogy a little for me please??

Reassuring Comments from Rang and Dale

With regards to drug treatment options for rheumatoid arthritis:

"The antirheumatoid action of most of these agents was usually discovered through a mixture of serendipity and clinical intuition. When the drugs were introduced, nothing was known about their mechanism of action in these conditions, and decades of in vitro experiments have generally resulted in further bewilderment rather than understanding."
                                   -Rang and Dale's Pharmacology, 6th ed. (2009)

I like the honesty in the statement, though it isn't overly reassuring considering the amount these drugs are prescribed. I guess that a lot of medicine is just knowing that it works, not necessarily knowing how it works...but no ones seems to want to admit that.