Tag: claire fraser

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

Posted on

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

Follow me on:

Photo Credits: Starz

Posted on

Fun Fact: Consumption

Anatomy Def: Consumption is a progressive wasting away of the body, particularly from pulmonary tuberculosis.

Outlander Def: Sad demise of Mary Hawkins true love, Alexander Randall; age 30 – brother of Captain Black Jack Randall!

History: Back in the 1700s, the disease now recognized as tuberculosis was identified by the odd term, consumption. It was named consumption because the disease literally consumed the sufferer; health was ravaged, tissues lost (weight loss), and the patient wasted away.  This disease was so widespread and feared that it was depicted in many novels, operas, and paintings, such as “The Sick Child,” (1885-86) by Edvard Munch.

Types: The word consumption now has several meanings but all refer to the using of resources:

    • Conspicuous = consumerism (😉, 😉)
    • Economic = use of goods and services by households
    • Sociological = resource use at the national level
    • Tuberculosis =  TB!

Pandemic: We may think  that COVID-19 is the only current pandemic, but this is not so. Humanity suffers from another, much older pandemic: tuberculosis. Yep, tuberculosis is a global disease, found in every country in the world!  It is also the leading cause of infectious deaths worldwide. The WHO estimates that about 1.8 billion people are infected with TB, almost 1/4 of the world’s population! And, TB has been a scourge for thousands of years as signs of tuberculosis have been found in Egyptian mummies dating to 3000-2400 BCE.  

What’s in a Name? OK, consumption is now called tuberculosis. So, what does this word mean? Tuberculosis is Latin for tuberculum (tubercle) + -osis (condition). Ergo, tuberculosis is the condition of having tubercles. 

TB produces tubercles (rounded) growths in tissues, especially the lungs. This a bit gross, but over time, the centers of such nodules undergo cell death, a term known as caseous necrosis because to the naked eye, the areas resemble white creamy cheese! 🤢

Lung x-rays of advanced pulmonary TB typically show large “holes” surrounded by a white border (see arrow in image below). These are clusters of tubercles (white rim) with caseous necrosis in the center (the hole). 

Cause: TB occurs if the body is successfully invaded by a bacterium known as Mycobacterium tuberculosis (M.tb). But, M.tb isn’t the only culprit as four other species of Mycobacterium also cause TB, including one which survives in un-pasteurized milk! Moo…🐄

Body Distribution: Without question, TB is a ghastly disease that can attack any tissue of the body. Pulmonary TB harbors in the lungs; extra-pulmonary TB invades other body parts, including heart, lymph nodes, bone and joints, pancreas, gastrointestinal tract, and brain/spinal cord, to name a few.  Although about 90% of TB settles in the lungs, some poor victims suffer both pulmonary and extra-pulmonary disease! 😲

TB Symptoms:

    • Chest pain
    • Poor appetite
    • Night sweats
    • Weakness
    • Fever
    • Gastrointestinal symptoms
    • Coughing spells
    • Clubbing of the nails

As if this isn’t enough, TB may become dormant in a patient only to return with a vengeance causing prolonged cough with mucus and, eventually, blood if the tubercles erode through pulmonary blood vessels. 😳

Spread: TB is a disease to be feared and respected! When people with active pulmonary TB cough, sneeze, speak, yell, sing, or spit, they expel tiny infectious aerosol droplets. A single sneeze may release up to 40,000 such droplets, each one capable of transmitting disease. Especially horrifying, inhaling fewer than 10 M.tb particles is sufficient to infect a new host! 😲

There are other risk factors besides proximity. Here are a few:

What about Claire? Do I worry about Claire’s contact with Alex? Not so much because her contact with him was minimal. Mary, most assuredly, would be at risk for contracting TB  since she spent much time with Alex in his final weeks and carried his unborn child.

Treatment: Today, a number of drugs are used to treat active TB, including isoniazid, ethambutol, and rifampin.  Alarmingly, there is also growing resistance of M.tb to treatment regimens – more than a half million drug-resistant cases of TB were identified  in 2020.

In Outlander, episode 212, The Hail Mary, Claire cannot cure Alex, but she does offer palliative therapy using thorn-apple smoke as she did with Ned Gowan in Outlander, episode 105, Rent. (Note: Ned suffered from asthma, not TB). During prolonged coughing, airways undergo spasm making it difficult for the sufferer to breathe.

Thorn-apple smoke allayed the cough by relaxing the airways (bronchi) and quieting the patient.  Surprisingly, thorn-apple is considered a better cough-remedy than opium, but must be used with extreme caution, as it is a strong narcotic poison! ☠️

Read about Alex’s consumption (and congestive heart failure) in Diana’s second big book, Dragonfly in Amber (chapter 39): 

The man who lay on the mattress had thrown off the quilts, over-heated by the effort of coughing, I assumed. He was quite red in the face, and the force of his coughing shook the bed frame, sturdy as it was. 

…The coughing gradually eased, and Alexander Randall’s flushed countenance faded to a pasty white. His lips were slightly blue, and his chest labored as he fought to recover his breath. 

I glanced around the room, but didn’t see anything suitable to my purpose. I opened my medical kit and drew out a stiff sheet of parchment. It was a trifle frayed at the edges, but would still serve. I sat down on the edge of the bed, smiling as reassuringly at Alexander as I could manage.

“It was … kind of you … to come,” he said, struggling not to cough between words. 

“You’ll be better in a moment,” I said. “Don’t talk, and don’t fight the cough. I’ll need to hear it.” 

His shirt was unfastened already; I spread it apart to expose a shockingly sunken chest. It was nearly visible from abdomen to clavicle. He had always been thin, but the last year’s illness had left him emaciated. 

I rolled the parchment into a tube and placed one end against his chest, my ear against the other. It was a crude stethoscope, but amazingly effective. 

I listened at various spots, instructing him to breathe deeply. I didn’t need to tell him to cough, poor boy.

…What is it?” His dark hair was disordered by the coughing; trying to restrain the feelings it roused in me, I smoothed it for him. I didn’t want to tell him, but he clearly knew already. 

“You have got catarrh. You also have tuberculosis—consumption.” 

“And?” 

“And congestive heart failure,” I said, meeting his eyes straight on. “Ah. I thought … something of the kind. It flutters in my chest sometimes … like a very small bird.” He laid a hand lightly over his heart. 

I couldn’t bear the look of his chest, heaving under its impossible burden, and I gently closed his shirt and fastened the tie at the neck. One long, white hand grasped mine.

“How long?” he said. His tone was light, almost unconcerned, displaying no more than a mild curiosity. 

“I don’t know,” I said. “That’s the truth. I don’t know.” 

“But not long,” he said, with certainty. 

“No. Not long. Months perhaps, but almost surely less than a year.” 

“Can you … stop the coughing?” I reached for my kit. “Yes. I can help it, at least. And the heart palpitations; I can make you a digitalin extract that will help.” I found the small packet of dried foxglove leaves; it would take a little time to brew them.”

BTW, Alex’s congestive heart failure could be the result of extra-pulmonary TB or some other unidentified cause.

See Alex slow demise and decline played to perfection by actor, Laurence Dobiesz, in Outlander episode 212, The Hail Mary.  Puir lad! 😢

The deeply grateful,

Outlander Anatomist

Follow me on:

Photo Credits: Sony/Starz; www.aerzteblatt.de; www.infectioncontroltoday.com; www.munchmuseet.no; www.wikipedia.com