Tag: claire fraser

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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

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

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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

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

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Mini Anatomy Lesson: Puerperal Fever

Scientific Def:  Childbirth fever.

Outlander Def:  Claire’s Existential Crisis… Her loss of Faith! 😥

Following the devastating loss of her child, Claire becomes desperately ill. She diagnosis her illness as puerperal fever in Outlander, Episode 207, Faith.

Because L’Hopital des Anges staff lacked the knowledge to treat the condition, Claire rapidly deteriorates – that is, until Master Raymond surreptitiously heals her by the power of his hands! ✋🏻🤚🏻

What is Puerperal fever? Puerperal fever is a devastating disease that occurs within the first ten days following childbirth. Other names include childbed fever, childbirth fever, postpartum fever, postpartum pyrexia, and puerperal pyrexia (pyrexia = from Greek, meaning “fever”).

Merck Manual uses the term, puerperal endometritis, literally meaning “childbirth-associated inflammation of the uterine lining.” For those who may not know, Merck Manual is Western medicine’s “bible” of diagnosis and therapy.

What Causes Puerperal Fever? The disease is caused by a bacterial infection of the upper genital tract. The bacterium, Streptococcus pyogenes, is one of the more common infectious agents, although others have been identified.

Where does the Infection Originate? The infection originates in the  upper genital tract (vagina, cervix, uterus, uterine tubes, ovaries), most often at the raw site where the placenta detaches from the uterine wall. The infection may be limited to the uterine cavity or wall, but if it reaches the blood stream, as it did with Claire, it causes septicemia/septicaemia or blood poisoning!

What are the Symptoms? Signs and symptoms usually include the following: 

    • fever exceeding 38.0 °C (100.4 °F)
    • fever lasting for at least 24 hours
    • chills
    • abdominal pain and distension
    • headache
    • foul-smelling vaginal discharge (sometimes)

Risk Factors: A higher incident of puerperal fever is associated with premature rupture of fetal membranes, lacerations, multiple vaginal exams, manual removal of the placenta, prolonged labour, Caesarean section, miscarriage, and abortion. 

First Description: Amazingly, this disease has been recognized over several millennia – its description first appeared in the Hippocratic Corpus, a compendium of medical treatises dating to the fifth century B.C.E.! 😲 Still, the term, “puerperal fever” did not appear in the historical record until the early 18th century – just a few years before Claire experienced her unfortunate miscarriage.

How Common is it? Puerperal fever is absolutely not an affliction of the past. Although less common in today’s Western countries, puerperal fever afflicts some 5,000,000 women worldwide, causing the deaths of about 75,000!

Can it be Treated? Indeed, puerperal fever can be treated! Since antibiotics were discovered in the 1930s, death from puerperal fever has diminished, dramatically. Today, mild disease is treated with oral antibiotics;  intravenous antibiotics are recommended for more serious cases. Caesarean section typically calls for preventative doses of antibiotics to be administered around the time of surgery. Ergo, the outlook is much better these days, except in low-income countries where puerperal fever and subsequent death persists.

A Bit of History: Childbirth infections were a common cause of death during the 18th Century when Claire was a patient at L’Hopital des Anges. Louis Pasteur (1820-1895) had not developed the Germ theory, so physicians of earlier eras did not know that pathogens could cause diseases such as puerperal fever. Twentieth-century Claire knew the cause but was too ill to effect a remedy, even if one were available. 

For years Western physicians engaged in heated debates as to the cause of puerperal fever (bad humors, miasmas, etc.).  Decades passed. Then, in 1847,  Hungarian physician Ignaz Semmelweiss  headed the First Obstetrical Clinic of Vienna. He discovered that puerperal fever could be prevented if strict rules of hygiene and cleanliness were enacted. These efforts reduced puerperal fever related-death on his ward from 20 to less than two percent! 👏🏻👏🏻👏🏻

After bringing the disease under control, Semmelweiss courageously recorded this admission:

“Puerperal fever is caused by conveyance to the pregnant woman of putrid particles derived from living organisms, through the agency of the examining fingers……. Consequently must I make my confession that God only knows the number of women whom I have consigned prematurely to the grave.”

For these heroic efforts, his colleagues destroyed his reputation. He died in an asylum from a gangrenous wound to his hand, probably caused from a beating administered by his guards. He was 47. 😔

Learn about fever in Anatomy Lesson #37, Outlander Owies, Part 3. Briefly summarized, fever is a fascinating but complicated bodily response to infection and disease. I hope you take time to learn a wee bit more about it.

Read Diana Gabaldon’s second big book, Dragonfly in Amber, wherein Claire offers a poignant description of her own signs and symptoms!

My body felt bruised and tender, as though I had been beaten. My joints ached and felt loose, like teeth undermined by scurvy. Several thick blankets covered me, but they could do no more than trap heat, and I had none to save. The chill of the rainy dawn had settled in my bones.

All these physical symptoms I noted objectively, as though they belonged to someone else; otherwise I felt nothing. The small, cold, logical center of my brain was still there, but the envelope of feeling through which its utterances were usually filtered was gone; dead, or paralyzed, or simply no longer there. I neither knew nor cared. I had been in L’Hôpital des Anges for five days.

… Mother Hildegarde’s long fingers probed in relentless gentleness through the cotton of the bedgown I wore, probing the depths of my belly, seeking the hard edges of a contracting uterus. The flesh was soft as ripe fruit, though, and tender beneath her fingers. I winced as her fingers sank deep, and she frowned, muttering something under her breath that might have been a prayer.

The fingers had returned to their work, probing the crease of my groin in search of the lumps of enlarged lymph nodes that would signal infection. They were there, I knew; I had felt them myself, moving my hands in restless misery over my empty body. I could feel the fever, an ache and a chill deep in my bones, that would burst into flame when it reached the surface of my skin.

…  I slept, eventually. And I dreamed. Fever dreams of weariness and desolation, of an impossible task done endlessly. Unceasing painful effort, carried out in a stony, barren place. Of thick gray fog, through which loss pursued me like a demon in the mist. I woke, quite suddenly, to find that Bouton was gone, but I was not alone. Raymond’s hairline was completely level, a flat line drawn across the wide brow as though with a level.

… The shiver came back; it was as though the heat passed from me to him, but his hands did not warm. His fingers stayed cool, and I chilled and shook as the fever ebbed and flowed, draining from my bones.

See Claire’s heroic battle with puerperal fever in Outlander, Episode 207, Faith! 

The deeply grateful,

Outlander Anatomist

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Photo Credits: Starz