The eye is a complex organ with many specialized parts and layers.

The eye is delicate and is protected from injury by the skull and eyebrows, and is kept clean by eyelids and eyelashes. The eyeball is a sphere about an inch in diameter. It is held in place inside the eye sockets of the skull by small muscles. These muscles are called extra ocular muscles and allow the eye to move up and down and side to side. On the outside of the eyeball is white protective layer of fibrous tissue known as the sclera, or the white of the eye. The sclera keeps the eyeballs round shape. At the front of the eye is a curved, clear, rounded membrane called the cornea. Behind the cornea is a chamber filled with fluid that is called the aqueous humor. The eye has a round circle of tiny muscles called the iris. The iris has pigment and can be green, hazel, brown, or blue, giving the eye its color. The iris surrounds a tiny hole called the pupil. Most of the time, the pupil does not look like a hole because it glints in the light. But what is seen as the sparkle in the eye is actually a clear, finely layered flexible lens. It can be seen by looking through the hole that is called the pupil. Tiny fibers hold the lens in place and connect it to eye muscles called ciliary muscles. Behind the lens, most of the rest of the eye is filled with a thick jelly-like fluid called the vitreous humor. Covering 65 percent of the lining of the back of the eye is a thin, light sensitive layer called the retina. The retina itself has many layers photosensitive cells called rods and cones that pick up light and color, bipolar cells which convert light into electrical impulses, and ganglion cells that form nerve fibers to transmit signals to the brain. Closest to the back of the eyeball is a single cell layer that contains pigment. Its purpose is to absorb light and prevent it from bouncing back through the eye once it has reached the retina. Vision is clearest at the center of the retina in an oval, yellowish area called the macula, or macula luteus. And at the center of the macula is an area known as the fovea. THE SENSES

8
Nerve fibers form bundles at the back of the eye. The bundles come together at the optic disk, or blind spot and pass out of the back of the eye to a large nerve called the optic nerve. The left and the right side optic nerves cross behind the eye and meet at an area called the optic chiasma. Nerve signals travel back to the areas in the brain where vision is processedthe thalamus, brainstem and visual cortex.

HEARING
After the sense of sight, the sense of hearing is the most developed sense in the human anatomy. The ear is a precise and efficient organ that performs its sensory duties in a compact area. The ear is comprised of three main partsthe outer ear, the middle ear, and the inner ear. The visible part of the ear is called the pinna (sometimes also called the auricle) and is made up of folds of cartilage covered in skin. At the base of the pinna is the lobule, or ear lobe. The pinna surrounds an opening called the external

auditory canal. This is a one-inch tube that tunnels through a bone in the skull known as the temporal bone. This tube is lined with tiny hairs, oil-producing sebaceous glands, and sweat glands called ceruminous glands, which produce earwax, or cerumen. As sound waves move down the external auditory canal, they come upon the final portion of the outer ear, the temporal membrane. Beyond the temporal membrane is the middle ear. The middle ear is madeup of three tiny bones, which are the smallest bones in the body. Collectively they are called the ossicles and individually they are known as the malleus, incus, and stapes. Their more common names come from their shapethe hammer, anvil, and stirrups. Both the outer ear and the middle ear are filled with air, while the inner ear is filled with fluid. Between the middle ear and the inner ear are two membranes, called the oval window and the round window.

9
What Are the Human Senses? The inner ear, or labyrinth, has three winding chambers deep inside the temporal bone of the skull. The front part is the cochlea, which is a coiled chamber that holds the organ of Corti. The organ of Corti is a mass of tiny hairs that are the sound receptor cells. The vestibule chamber, which contains sensory cells related to balancethe utricle and the sacculeconnects the cochlea to the final chamber, the semicircular
The human ear is made up of external parts located outside of the head, and a collection of tiny internal parts inside the skull.

THE SENSES

10
canals. Nerve signals leave the ear and travel to the brain through the vestibulocochlear nerve. This nerve is actually two nerves, the cochlear nerve, which transports information about sound, and the vestibular nerve that delivers information about balance.

PROPRIOCEPTION
The fifth sense, proprioception, or equilibrium and balance, is managed by sensors in the ear. Often called the vestibular system, the semicircular
Special hairs, called cilia, and other cells found in the inner ear help with hearing and balance.

11
What Are the Human Senses? canals and the vestibule region sense movement, speed, and stasis (the state of being still). The semicircular canals exist at right angles to each other. At the base of each of the canals lies a widened duct called the ampulla. Inside each ampulla is a jelly-like mass called the cupula. This mass contains hair cells that are attached to nerves. As fluid called endolymph circulates in the canals and vestibule it stimulates receptor cells. In the vestibule, the utricle and saccule sense movement and action

of the head.
Structures in the inner ear and brain allow a person to balance, stand upright, move, and perform athletic activities.

THE SENSES

12

TASTE
The sense of taste, or gustation, as it is also known, determines not only the flavor of food, but also provides an awareness of whether or not something put in the mouth is safe or good to eat. There are five basic tastes, one of which was not agreed upon in the scientific community until only recently. The tastes are salty, sweet, sour, bitter, and umami. Umami was established by a Japanese scientist named Kikunae Ikeda. He wrote about umami being a taste that responds to glutamate, a chemical found in foods, such as bacon, corn, mushrooms, tomatoes, some seaweed, fish, and other foods. The taste organ is a collection of specialized cells called taste buds. There are approximately 10,000 taste buds found on the top of the tongue, and more found in the throat, soft palate (soft tissue found at the back of the roof of the mouth), and the epiglottis (the flap of cartilage at the base of the tongue). Each taste bud bears between 50 to 150 sensory taste receptors. Along the top and sides of the tongue are various small bumps called lingual papillae.
The different parts of the tongue are responsible for various taste sensations.

13
What Are the Human Senses? There are four types of papillae, three of which contain taste buds. On the sides of the tongue are the foliate papillae, which appear as a series of ridges. Fungiform papillae are small, rounded projections found all over the tongue, especially at the tip and along the top of the sides. Each of this type of papilla contains up to five taste buds. There are only five to twelve of the largest papillae, called the circumvallate papillae, but they contain more than 250 taste buds each. They form a V shape near

the back of the tongue. The fourth type of papillae, filiform papillae, are found all over the tongue and though they are the most numerous, they do not carry any taste sensors. A nerve called the facial nerve carries sensory information from the taste receptors in the front of the tongue. The glassopharyngeal nerve carries information from the rear of the tongue. A third nerve, the vagus nerve, carries information from the back of the mouth. These nerves deliver taste sensations to part of the brainstem, then travel on to the thalamus, and finally arrive in the cerebral cortex of the brain.

SMELL
The olfactory sense, or sense of smell, is a powerful sense. The human nose can detect thousands of distinctly different odors. The sense of smell identifies odors in the air around us and assists the sense of taste by enhancing or discouraging appetite and contributing to the appreciation or the rejection of flavors. It also protects us from breathing unsafe air or fumes and stops us from eating anything spoiled or poisonous. The sense of smell also helps with human memory recall. There is a large cavity located between the roof of the mouth and the bottom of the skull called the nasal cavity. It is divided into left and right sections by a piece of cartilage called the nasal septum. Inside each side of the nasal cavity are three bony shelves folded with ridges called conchae. THE SENSES

14
The conchae create passageways for air to travel before entering the respiratory tract. The nasal cavity is lined with a membrane that contains mucus-producing cells. On the uppermost part of the nasal cavity is a layer of tissue called the olfactory epithelium. On one end of each olfactory cell are long hairs called cilia. The cilia are coated in mucus and contain sensory receptors. At the other end of each olfactory cell are nerve endings called axons. The axons of the olfactory cells come together to form the olfactory nerve. The nerve passes through the skull and enters the end of the olfactory tract, where a pair of olfactory bulbs is beneath the front of the brain. Inside the olfactory bulbs, nerve cells receive signals and transfer them to parts of the brain.

TOUCH
The sense of touch involves a wide network of nerve endings and sensory receptor cells. There are three overall types of receptor cellsvisceral cells, which are cells found in internal organs, somatic, which are found in joints and bones, and cutaneous, which are found in the skin. The skin, the largest organ of the body, contains most of the sensory receptors for touch.
Special olfactory cells aid in identifying smells and other information that comes in through the nose.

15
What Are the Human Senses? It is itself composed of several layers. The visible top layer of skin is called the epidermis and it provides protection for the layers of skin below and also protects the rest of the body. Of the many types of cells found in the epidermis, very sensitive touch sensors provide information to the brain. The second layer is a thick layer containing sweat glands, hair follicles, oil glands, blood vessels, nerve endings and touch receptors. There are four basic types of touch receptors: mechanoreceptors, thermoreceptors, pain receptors, and proprioceptors. Each is responsible for recognizing different types of sensation, such as pressure, pain, or temperature.
Nerves beneath our skin allow us to feel things and use our sense of touch to react to and interact with the environment.

17

How the Senses Work

2
M
VISION
Everything the eye sees comes from reflected light. In other words, the eye cannot view an object unless some form of light shines on the

object. As light hits the object and bounces off, it travels in the form of light waves. These waves of light enter the eye through the cornea.
The brain and the rest of the nervous system process all of the sensory information that is delivered by the sensory organs.

any different organs and body parts work together to form the human senses. Sometimes more than one sense rely on the same structures. THE SENSES

18 19
How the Senses Work The cornea slows down the speed of light. It is curved, causing the cornea to bend the rays of light toward each other. The process of bending light rays is known as refracting light. The refracted light waves move through the aqueous humor and pass through the pupil toward the lens. If the light is very bright, the muscles of the iris relax, decreasing the size of the opening of the pupil, and letting in less light. The iris also reduces the size of the opening of the pupil when the eye is trying to concentrate its focus on an object that is close by. Conversely, if the light is dim, or if the eye is viewing an object in the distance, the iris muscles contract. This dilates, or opens up, the pupil, to let in more light. The lens of the eye is extremely flexible. It is able to focus on an object that is just inches away, but is equally able to quickly adjust to viewing a distant planet in the sky. Bright light travels to the cornea in ever-widening waves. However, the cornea can bend the rays only so far. The lens must further refract the light in order to focus properly. The lens is composed of more than 2,000 fine layers called lamellae. As the light passes through each layer, the rays of light are bent in tiny degrees of refraction. When the eye focuses on closer objects or is receiving bright light, the muscles holding the lens relax causing the lens to become more rounded. The rounder the lens, the greater its ability becomes to refract light. On the other hand, light coming from a more distant source travels toward the eye in an almost parallel pattern. The eye does not need to refract light to the same degree. As a result, most of the refraction in this instance can be done by the cornea. The muscles holding the lens contract and flatten the lens. Light passes through nearly unchanged. After light has been focused by the lens, it passes through the vitreous humor. The thick liquid retains the sharp focus of the refracted light and ushers the light toward the retina at the back of the eye. The THE SENSES

20
retina receives the refracted light rays and turns them into electrical impulses that are fed to the brain. The retina is covered in arteries and

veins and is an uneven surface. Some areas of the retina are more light sensitive than others and are better able to perceive images with greater sharpness, or acuity. Arteries and veins bypass the most light-sensitive area of the retina, which is called the fovea. To achieve the most acute vision, light must fall on the fovea. However, light enters the eye from many directions, so the eye must compensate in order for light to be directed to the fovea. Eyes do so by constantly moving up and down and with increasing
prevalence of obesity more children are now presenting with type 2 diabetes, particularly from ethnic minorities. In the USA, in some areas, up to 50% of children with diabetes are now presenting with the type 2 form. Latent autoimmune diabetes in adults (LADA) is thought to comprise about 5% of all patients with type 2 diabetes. These people have autoantibodies usually seen in type 1 diabetes, but their clinical presentation is like someone with type 2 diabetes. This is a group that may present an excellent opportunity for subsequent prevention of diabetes if an effective intervention can be developed to prevent further beta cell destruction. Monogenic diabetes (previously referred to as maturity onset diabetes in the young, MODY) Monogenic diabetes is the term used for a collection of conditions that cause diabetes now shown to result from single gene defects. One feature of these conditions is that they show autosomal dominant inheritance patterns where the disease appears to be vertically transmitted (e.g. through several generations). It is also diagnosed before the age of 25 years, but, unlike type 1 diabetes patients, monogenic diabetes patients do not often require insulin for at least 5 years after diagnosis. Genetic testing in these cases

can confirm the particular sub-type of diabetes. This can have significant clinical implications. Patients with HNF1a (hepatocyte nuclear factor 1a) mutations, for example, exhibit exquisite sensitivity to sulphonylureas and can be successfully treated with tablets. Knowledge of the mutation, therefore, can help in the management of this disorder, even in children who would otherwise have been put onto insulin. This is also one form of type 2 diabetes where we would use a sulphonylurea in preference to metformin when initiating therapy. Patients with HNF1 have renal cysts. Patients with glucokinase mutations are less common but the diagnosis is significant for the individual and their families. Such patients are much less likely to develop complications of diabetes because they mainly have mild fasting hyperglycaemia without significant post meal hyperglycaemia. Maternally inherited diabetes with deafness (MIDD) This is a form of diabetes due to mutations in mitochondria, most commonly related to 3243A > G mitochondrial DNA mutation. Mitochondria in an individual are inherited from the mother rather than from the father, therefore one clue would be evidence of strong maternal transmission of diabetes, particularly when this is associated with a sensorineural deafness. Some patients may also have peripheral vision problems, particularly night blindness. These patientsAbuse is a complex psychosocial problem that affects large numbers of adults as well as children

throughout the world. It is listed in the Diagnostic and Statistic Manual of Mental Disorders (DSM-IV-TR) under the heading of Other Conditions That May Be a Focus of Clinical Attention. Although abuse was first defined with regard to children when it first received sustained attention in the 1950s, clinicians and researchers now recognize that adults can suffer abuse in a number of different circumstances. Abuse refers to harmful or injurious tlude not only the direct costs of immediate medical and psychiatric treatment of abused people but also the indirect costs of learning difficulties, interrupted education, workplace absenteeism, and long-term health problems of abuse survivors. Types of abuse Physical often require insulin. Infusion strategy
Initially reduce total daily insulin dose by 30%. Give half the daily insulin dose as the constant basal pump
rate (usually around 1 unit/hour). Give half the daily insulin dose divided between the three main meals, giving the insulin boost immediately before the meal. The patient is taught to count carbohydrate portions (see page 12) and thereafter will give the bolus doses in direct relation to the amount of carbohydrate consumed (for example, 1 unit for every 10 g of carbohydrate). During the first few days adjustments need to be made as follows: basal rate determined by assessment of fasting and 3 am blood glucose readings preprandial boosts are adjusted by assessment of postprandial blood glucose readings. Note: Specific instructions are given for exercise, and basal rates should be reduced during and after exercise.

Dose adjustment for normal eating (DAFNE)

A more liberal dietary pattern for Type 1 diabetic patients has become possible by using the DAFNE approach, ideal for some

which can be pulled off in strings), Phos. (black crusts). - tongue c. with mucus. Bell, (brown), Carbo. veg. (yellow-brown), Kali bi. (ropy), Merc, sol., Nitr.- ac. (tough, ropy, with ulcers), Phos. ac. (clammy, tough). Puls, (tenacious), Psorin,(whitish-yellow), Rhus. tox. (brown), Sil.(brownish). - tongue c. with ulcers. Caps, (flat, sensitive, spreading), Kali bi. (small, painful), Natr. mur. (also vesicles). - tongue c. with vesicles, Ars. (painful, burning), Apis* (stinging), Canth. (at base). Hell., Natr. mur. (smarting and burning when touched by food), Spong., Zinc. Cracked. Ailanth., Apis, Arum., Bapt., Bar., Bell., Benz. ac, Bry., Calc. fl., Cham., China, Cic, Cur., Hyos., Kali bi, I^yc, Magn. mur., Nux-vom., Phos., Phos. ac, Plb., Podo., Puls., Ran.sc, Rhus tox., Sacch., Spig., Sulph., Ver. alb. - edges, Nux vom. (rest black or red). - middle, across the, Cobalt. - tip, Lach. - tongue dry, parched and cracked, Ailanth. - tongue dry, parched and cracked in typhus, Bapt. - chronic inflammation of tongue; c, swollen and bleeding, Podo. - tongue swollen, dry, c, sore, ulcerated, covered with vesicles. Apis - tongue, painful and burning. Arum. - tongue yellow along center, first white with reddish papillae; followed by yellow-brown coating in center, edges dark red and shining; dry brown down center (Plb.); c, sore, ulcerated, Bapt., (Apis, Ars., Rhus tox). - smarting, burning pain in tip of tongue, sore and c. Bar. carb. - tongue rough, c, and often of a dark- brown color, Bry. - tongue dry, smooth, red, c. (in dysentery). Kali bi. - tongue dry, red, brown, c, and tremulous, Hyos. - tongue dry, red, c, black stiff, Lach., Rhus tox.

people who thus regain considerable freedom while at the same time maintaining good control. It is based on: a 5-day structured, group education programme delivered by quality assured diabetes educators the educational approach is based on adult educational principles to facilitate new learning two injections of medium acting insulin each day (see page 21) injections of short acting insulin every time meals are taken testing blood glucose before each injection. This programme enables people to eat more or less what they like when they like, and not to eat if they do not wish to do so. It depends on a quantitative understanding of the carbohydrate values of individual foods, and calculating by trial and error the correct amount of soluble insulin needed for a specified quantity of carbohydrate, developing an insulin/carbohydrate ratio for each individual patient. DAFNE has been used in continental Europe for many years: the- tongue covered with fur. Bell, (white and clammy,

- tongue coated yellow, burning with blisters, c, Spig. - tongue smooth, red and c, dry and red, coated - thick whitish-yellow, ulcerated. Kali bi. - mouth very sore, parched and dry, mucous membrane c. and bleeding, tongue swollen and covered - with blisters on each side, Lach. - dry, black or c. tongue, Lj^c. (Ars., Lach., Phos., Rhus tox. ) - tongue cold, dry, blackish, c, red and swollen, Ver. alb. - brown, parched, c. tongue, Sulph. - tongue c. or coated yellow, with red tip and edges, Ver. alb. - and burning, Arum tr.. Bell., Bry., Ran. sc., Sulph., Ver. alb. - black and dry, stiff as a board, Ars. - on edges, black or dark red, Nux. vom. - and dry (tip). Kali bi., Lach., Rhus tox., Sulph. Crack deep, Adverse reactions
Common: drowsiness. Serious: hypotension, bradycardia, tachycardia, confusion, respiratory depression, physical and psychologic dependence, addiction. Clinically important drug interactions: Drugs that increase effects/toxicity of narcotic analgesics: Alcohol, benzodiazepines, antihistamines, phenothiazines, butyrophenones, triyclic antidepressants, MAO inhibitors. Parameters to monitor Signs and symptoms of pain: restlessness, anorexia, elevated pulse, increased respiratory rate. Differentiate restlessness associated with pain and that caused by CNS stimulation caused by the drug. This paradoxical reaction is seen mainly in women and elderly patients. Monitor respiratory status prior to and following drug administration. Note rate, depth, and rhythm of respirations. If rate falls below 12/min, withhold drug unless patient is receiving ventilatory support. Consider administering an antagonist, eg, naloxone 0.10.5 mg IV every 23 min. Be aware that respiratory depression may occur even at small doses. Restlessness may also be a symptom of hypoxia. Monitor character of cough reflex. Encourage postoperative patient to change position frequently (at least every 2 hours), breathe deeply, and cough at regular intervals, unless coughing is contraindicated. These steps will help prevent atelectasis. Signs and symptoms of urinary retention, particularly in patients with prostatic hypertrophy or urethral stricture. Monitor output/intake and check for oliguria or urinary retention. Signs of tolerance or dependence. Determine whether patient is attempting to obtain more drug than prescribed as this may indicate onset of tolerance and possibility of dependence. If tolerance develops to one opiate, there is generally cross-tolerance to all drugs in this class. Physical dependence is generally not a problem if the drug is given for less than 2 weeks.
126 BUTORPHANOL

Monitor patients BP. If systolic pressure falls below 90 mm Hg, do not administer the drug unless there is ventilatory support. Be aware that the elderly and those receiving drugs with hypotensive properties are most susceptible to sharp fall in BP. Patients heart rate. Withhold drug if adult pulse rate is below 60 bpm. Alternatively, administer atropine. Respiratory status of newborn baby and possible withdrawal reaction. If the mother has received an opiate just prior to

delivery, the neonate may experience severe respiratory depression. Resuscitation, as well as a narcotic antgonist, eg, Narcan, may be necessary. Alternatively, the neonate may experience severe withdrawal symptoms 14 days after birth. In such circumstances, administer opium tincture or paregoric. Signs and symptoms of constipation. If patient is on drug for more than 23 days, administer a laxative. For patients on longterm therapy, administer a bulk or fiber laxative, eg, psyllium, 1 teaspoon in 240 mL liquid/d. Encourage patient to drink large amounts of fluid, 2.5 to 3 L/d. Editorial comments: This drug is indicated for treatment of moderate to severe pain. Intranasal formulation allows for rapid onset of pain relief.
BUTORPHANOL 127

Calcitonin
Brand names: Calcimar (salmon), Cibacalcin (human), Miacalcin (salmon). Class of drug: Calcium-lowering agent, treatment for Pagets disease, antiosteoporosis agent. Mechanism of action: Promotes renal excretion of calcium and phosphate, inhibits osteoclastic bone resorption Indications/dosage/route: IM, SC, intranasal. Note: Prior to treatment, a skin test must be performed (see Warnings/ Precautions). Pagets disease Adults, salmon calcitonin: Initial: SC or IM 100 units/d. Maintenance: 50 units/d. Adults, human calcitonin: Initial: SC 0.5 mg/d. Maintenance: 0.5 mg 2 or 3 times/wk. Hypercalcemia Adults, salmon calcitonin: IM, SC 4 units/kg q12h. Maximum: 8 units/kg q6h. Postmenopausal osteoporosis Adults, salmon calcitonin: IM, SC 100 units/d. Intranasal: 1 spray (200 units)/day. Combine with oral calcium carbonate, vitamin D. Osteogenesis imperfecta Adults: IM, SC 2 units/kg 3 times/wk. Combine with oral calcium. Children: Safety and efficacy have not been established.
Onset of Action Duration Hypercalcemia 2 h 68 h

Pregnancy: Category C. Lactation: No data available. Best to avoid. Contraindications: Hypersensitivity reaction to salmon calcitonin or its gelatin diluent.
128 CALCITONIN

Warnings/precautions When using salmon calcitonin determine whether patient is allergic by performing skin test before administration. One unit is injected into the skin. Observe for 15 minutes for development of erythema or wheal. Have emergency equipment available during administration. Potential for hypocalcemic tetany. Advice to patient Learn the correct way to use the nasal spray. Calcium and vitamin D supplements are part of the treatment for osteoporosis. Employ sterile techniques for injection. Alternate injection sites. Adverse reactions Common: None. Serious: Allergic reactions, hypocalcemia, tetany (overdose).

Clinically important drug interactions: None reported. Parameters to monitor Serum electrolytes, calcium, alkaline phosphatase. Signs of hypersensitivity reactions. BP, pulse, ECG. Signs and symptoms of hypercalcemia: bone pain, thirst, nausea, vomiting, anorexia, constipation.