dougal mackenzie – Page 12 – Outlander Anatomy

May 26, 2015January 3, 2021

Anatomy Lesson #22: Jamie’s Hand – Symbol of Sacrifice

Welcome, anatomy students, to Anatomy Lesson #22: The Hand. Anatomy of the human hand is daunting because it is complex. The hand is a true engineering marvel, containing four of the six classical simple machines as defined by Renaissance scientists: wedges, planes, pulleys, levers. This structural diversity makes the hand arguably the most mobile part of the entire musculoskeletal system (Photo A).

Languages include abundant references to hands so over emphasizing their importance might be a challenge. One English source on hand idioms records almost 300 common references: bird in hand, give me a hand, firm hand, hand-me-down, safe hands, helping hands, tie ones hands (shade #1 of BJR), throwing up one’s hands, wandering hands (shade #2 of BJR), wash ones hands of, lift a hand, lay hands on (shade #3 of BJR) to name but a few.

Photo A

In human anatomy, structure and function go “hand-in-hand” (another idiom): if a body part performs a particular function(s) its structure reflects that task and vice versa a body part that has a particular structure will reflect the function(s) it is designed to fulfil. There is no finer example of this axiom than the human hand.

More pertinent to our shared interest, holding hands and touching are important elements of the Outlander books and the Starz series (a.k.a. hand sex). Herself’s own words from Jamie and Claire’s wedding night (Outlander book):

Somewhat tentatively, he reached out and took my hands between his own … I felt a slight shock at the touch … “Aye. More scairt than you, I expect. That’s why I’m holdin’ your hands; to keep my own from shaking.” I didn’t believe this, but squeezed his hands tightly in appreciation. “It’s a good idea. It feels a little easier to talk while we’re touching.”

And, from Neil Diamond:

Hands, touchin’ hands

Reachin’ out, touchin’ me, touchin’ you

Sadly, this lesson must include images and analysis of Jamie’s hand after BJR adds his “aesthetic” twist. There will be a WARNING ahead of these images to give you the opportunity to skip them. They appear near the lesson’s end. Look for the warning sign before those images and the kitten when it’s safe to come out. I must also confess, that this chapter in the book and Starz episode 115 Wentworth Prison made it difficult for my usual sass to fly in this lesson. My sass is sad and worried about Jamie and Claire and ready to pull out a can of whoop ass on BJR. Here BJR, this is for YOU!

Back to the lesson at hand (haha)…Photo B of the upper limb has appeared in several prior Outlander Anatomy Lessons. But, to reiterate: the shoulder is from base of neck to shoulder joint, the arm is between shoulder and elbow joints, the forearm between elbow and wrist joints and the hand is the terminus of the upper limb. More precisely, the hand lies distal to (away from) the forearm.

Photo B

To better understand the hand, we must further consider the forearm. Remember supination? From Starz episode 107 The Wedding, we see a fine example of forearm supination (and elbow joint extension) as Dougal slices Claire’s wrist for her blood vow with Jamie. With the forearm in supination, ulna and radius are parallel, palm faces forward or up, thumb is directed away from body.

Recall pronation? Next is a great example of forearm pronation (and elbow joint flexion) as Claire removes Frank’s gold wedding band prior to marrying Jamie (Starz episode 107, The Wedding). In forearm pronation, distal radius crosses distal ulna, palm faces downward or back and thumb is directed toward the body.

Try this: To review, flex your elbow joint and alternately rotate forearm between supination and pronation. Review positions of radius, ulna and thumb in each of the two movements.

The forearm contains a whopping 20 muscles: eight in a flexor compartment and 12 in an extensor compartment! Flexor muscles lie anterior to ulna and radius and are best demonstrated with a supinated forearm. Photo C shows five muscles of the flexor compartment which arise from the medial epicondyle of humerus (red arrow). I’ll not drown you with the intricate names which reflect function and position. Suffice it to say that although the muscle bellies of the flexors lie in the forearm, they become tendons near the wrist (blue arrow) and then insert into bones of the hand and cause movement.

Photo C

Try this: Examine your wrist with palm up and see or feel various tendons: these are the flexor tendons that arise in the anterior forearm but insert on bones of wrist, thumb and fingers.

The 12 extensor muscles of the forearm lie posterior to radius and ulna and are best viewed from the back of a supinated forearm. Photo D (forearm viewed from the back) shows four extensor muscles which arise from the lateral epicondyle of humerus (red arrow). Again, naming all 12 extensors along with their actions truly would be tedious. However, the same theme repeats itself: the muscular part of the extensors lie in the forearm, they become tendons near the wrist (blue arrow) and insert into bones of wrist, thumb and fingers and cause movement.

Photo D

Try this: Examine your hand with palm down and see or feel various extensor tendons on the dorsum of hand. Next, grip your supinated forearm and make a strong fist. Now bend the wrist toward (flexion) and then away (extension) from your torso. Feel muscles of flexor and extensor compartments alternately contract and relax with wrist movement? Just doing their jobs!

Want to see an excellent example of extensor tendons (Starz episode 109, The Reckoning)? Here Claire threatens a shocked Jamie within an inch of his carotid arteries! The taut tendons (red arrows) on the dorsum of her hand belong to an extensor forearm muscle (extensor digitorum). Mmphm, she doesna even break rhythm. Jamie croaks “You have my word!” No surprise there! Erm, that’s one impressive looking dirk!

You may recognize Rembrandt’s famous 1632 painting The Anatomy Lesson of Dr. Nicholaes Tulp (Photo E – body likely a condemned criminal). As demonstrator of anatomy (a position I held for many years), Dr. Tulp was demonstrating left forearm and hand muscles to eager viewers. The painting records a real event: in that era, public dissections were not uncommon in Europe. But, did you know this fabulous work of art is anatomically questionable? Indeed, its anatomical accuracy has been debated for decades with advocates as well as detractors. One meticulous study recreated Dr. Tulp’s lesson and concluded that the work was anatomically incorrect, but posited that it was intended to be a symbolic rather than an accurate depiction of the dissection.

What is anatomically incorrect about Rembrandt’s masterpiece? Let’s reason together. The body’s right forearm is pronated but the left forearm is supinated (palm up and thumb directed away from body). Now, which humeral epicondyle gives origin to forearm flexors? If you answered medial epicondyle, congrats! But, the painting shows left forearm flexors arising from the lateral epicondyle and therein lays its major (there are minor ones too) anatomical inaccuracy! As such, the work is a valuable teaching aid for lectures and exams to promote observational skills.

Photo E

Now for the hand: in science, the term hand or manus (Latin for hand) is used to identify the termini of our upper limbs.

The front of the hand is its palmar surface (Photo F); it is fleshy because it includes intrinsic hand muscles (in a later lesson), forearm flexor tendons, blood vessels, nerves etc. Palmar skin is thick, hairless and lacks sebaceous glands (Anatomy Lesson #5 & Anatomy Lesson #6). The dermis is thrown into deep ridges which increase friction and help secure grip. Dermal ridges are also the anatomical basis for fingerprints. Compared with other skin, palm skin is lighter in color because its cells have genes inhibiting melanin production and the ability to tan (Anatomy Lesson #6).

Try this: Examine the whorls of one fingertip and realize that dermal ridges create the valleys and elevations of a finger print.

The hand back is its dorsum or dorsal surface (Photo F): this is covered with hair but the skin is thin, soft and pliable and it tans. This surface also has little flesh because it contains no intrinsic hand muscles and contains flat extensor tendons, blood vessels and nerves.

Try this: Alternately supinate and pronate (Anatomy Lesson #20) your forearm to compare and contrast palmar and dorsal skin, the presence or absence of hair and the relative thickness of the skin.

Photo F

The hand is divided into wrist (blue overlay), mid-hand (green overlay) and five digits (Photo G). Fingers can be folded individually or together over the palm allowing objects to be grasped. With the palm facing up or forward, the thumb or pollex (Latin meaning thumb) points away from the body. Also, our thumbs are opposable meaning they can be brought toward each or all fingers as in a pinch.

Photo G

An interesting tidbit about digits: in anatomy, the digits are numbered 1-5 beginning with thumb and ending with little finger (Table 1 -1^st column). But, the English word “finger” includes the thumb (Table 1 -2^nd column) and matches the anatomical digit number. Now in the U.S., digits are defined as thumb and four fingers (Table 1 -3^rd column) meaning the 1^st finger is also the 2^nd digit! This can be a problem. Why? Let’s say a patient is scheduled for a digital procedure – the correct digit must be designated: do written instructions refer to a finger or a digit?

The good news: nowadays U.S. anatomists and clinicians preferentially use the digit name (Table 1- last column): thumb for 1^st digit, index for 2^nd, middle for 3^rd, ring for 4^th and little/small for 5^th. This practice helps minimize medical error and most importantly, protects the patient! In this lesson, I use the digit naming system.

ANATOMICAL DIGIT NUMBER	ENGLISH FINGER NUMBERING SYSTEM	U.S. FINGER NUMBERING SYSTEM	DIGIT NAME SYSTEM
1^st	1^st (thumb)	Thumb	Thumb
2^nd	2^nd	1^st	Index
3^rd	3^rd	2^nd	Middle
4^th	4^th	3^rd	Ring
5^th	5^th	4^th	Little/small

Table 1

Try this: Starting with the thumb, assign numbers to digits and repeat using digit name.

Next, let’s consider nerves of the hand. Three large nerves innervate skin, blood vessels, muscles, ligaments, joints and bone coverings (periosteum) of the hand. Some fibers provide sensory information to the brain while others stimulate muscles to contract and glands to secrete. The three nerves of the hand are: radial, median and ulnar (Photo H).

Photo H

Palmar skin has one of the densest arrays of nerve endings in the human body and is an exquisite source of tactile info to the brain. Here, sensation in the form of pain, temperature, vibratory sense, pressure and touch is mostly provided by median (gold) and ulnar (blue) nerves (Photo I). And, yes, believe it or not sensation to the palmar surface of ring finger is split down the midline between median and ulnar nerves!

Photo I

Sensation to the dorsum of the hand is supplied mostly by radial (pink) and ulnar (blue) nerves but the median nerve (gold) supplies some fingertips (Photo J).

Photo J

Try this: Place index and middle fingers in the groove behind the medial epicondyle of one humerus (Anatomy Lesson #20) and move the fingers up and down. Feel a faint shocking sensation? Congrats! You found your ulnar nerve! Supinate the forearm and press deeply with the thumb just above the wrist. Feel the discomfort? You just found your median nerve (involved in carpal tunnel syndrome)!

Next, let’s examine the hand skeleton: each hand contains 27 bones. Together both hands contain more than 25% of the 206 bones of the entire human skeleton! This is not only amazing it also accounts for hand movements: more bones = more joints = more movements. Hand bones include (Photo K – palm faces the face): 8 carpal bones (purple) of wrist; 5 metacarpal bones (orange) of mid-hand; 14 phalanges of the digits. Finger phalanges are further named by position: proximal phalanges (green) articulate with metacarpal bones and intermediate phalanges; intermediate phalanges (blue) articulate with proximal and distal phalanges; distal phalanges (peach) articulate with intermediate phalanges. Note that the thumb has only two (proximal and distal) phalanges.

Photo K

Try this: Palpate your hand and locate all 5 groups of hand bones.

The carpus (Latin for wrist) consists of eight interlocking carpal bones arranged in two rows of four bones each (Photo L – supinated hand points away from body). The main roles of the carpus are to facilitate effective positioning of the hand, increase freedom of movement at the wrist, and form an arch (carpal tunnel) through which passes tendons and a nerve.

Carpal bones have Latin names meaning moon-shaped, boat-shaped, three-cornered, etc. They are named beginning on the thumb (metacarpal #1) side of the near row and moving to the thumb side of the far row.

Photo L: Figure0435A carpal bones KLS edited

How does one recall carpal names and positions? This is a fun and popular mnemonic used by anatomists and one designed to keep student attention: Some Lovers Try Positions That They Can’t Handle. This one is suitable for public consumption – some are not: anatomists being naughty!

ROW NUMBER	BONE NAME	BONE NAME	BONE NAME	BONE NAME
Proximal Row	Some (scaphoid)	Lovers (lunate)	Try (triquetrum)	Positions (pisiform)
Distal Row	That (trapezium)	They (trapezoid)	Can’t (capitate)	Handle (hamate)

The mid-hand (palm) region contains five metacarpals one for each digit and labelled #1- #5 beginning with the thumb (Photo M).

The digits contain phalanges: proximal and distal for thumb and proximal, middle and distal for each finger (Photo M). Do the math: yep, adds up to 27 bones! The hand also contains a few small sesamoid bones (red arrow) but their numbers are inconsistent and not included in the bone count.

Photo M

The number of joints in the hand is mind boggling! Here they are (Photo N):

Intercarpal (IC) Joints: between and among the carpal bones (purple arrows).
Carpometacarpal (CM) Joints: between distal row of carpal bones and metacarpal bones (blue arrow).
Metacarpophalangeal joints (MP) Joints: between metacarpals and proximal phalanges (green arrow).
Proximal interphalangeal (PIP) joints: between proximal and middle phalanges of fingers (red arrow).
Distal interphalangeal (DIP) joints: between middle and distal phalanges of fingers (orange arrow).
Interphalangeal (IP) Joint: Between two phalanges of thumb (black arrow).

Photo N

Try this: with your own hand, identify as many of these joints as possible.

This is a terrific example from Starz episode 107 The Wedding showing some of hand joints as Jamie reaches into his sporran to retrieve his brooch (green arrow = MP joint; red arrow = PIP joint). Murtagh just wants to spit-polish the pin. To be that pin…sigh…

An interesting and not uncommon congenital condition is the presence of supernumerary digits on hands/feet. Known as polydactyly, the additional digit(s) may or may not be functional. Photo O is an x-ray of a child’s hand with an additional normal metacarpal (red arrow) and digit (green arrow). Here, metacarpals crowd at the CM joints (blue arrow) to make room for the extra bone. Supernumerary digits may be surgically treated. The world record holder was born with 34 digits on hands and feet. Our Jamie could use another one of these for sure!

Photo O

As already noted, the hand is capable of many movements because of the numerous bones and joints. There are 16 classical hand movements although many more combos are possible. Five movements occur at the wrist (Photo P) giving it considerable flexibility: flexion, extension, radial deviation, ulnar deviation and circumduction. Contraction of forearm flexors causes wrist flexion and contraction of forearm extensors causes wrist extension. Interestingly, radial deviation (hand draws toward radius) occurs if radial extensor and radial flexor contract simultaneously. Ulnar deviation (hand draws toward ulna) occurs when ulnar extensor and ulnar flexor contract simultaneously. Circumduction (not shown) occurs as the wrist rolls in a circular motion.

Photo P

Try this: Mimic the four wrist movements as shown In Photo P. Try circumduction which is not shown.

How about examples of wrist movements from Outlander episodes? Here are two to keep you focused!

Claire has one major throwing arm! Here she extends her left wrist and elbow joint for balance (red arrow); her right wrist is also extended (blue arrow) but the same elbow joint is flexed as she launches crockery at Jamie! She’ll not let him beat her (Starz episode 109, The Reckoning) without opening up her own can of whoop ass!

Here in a steamy scene of make-up sex, Claire’s left wrist is in ulnar deviation (hand moves toward ulna – red arrow) as she gently touches the face of her warrior husband (Starz episode 109, The Reckoning). Gah! Scoop me up with a spoon…what a scene!

Next, let’s examine movements of the thumb, an extremely versatile digit. Photo Q shows 6 classic thumb movements: abduction (thumb moves 90° from palm and fingers); adduction (thumb returns to resting position); extension (thumb moves away from the fingers but remains in the same plane); flexion (thumb curls in front of the palm); opposition (thumb pinches one or all fingers). In the resting position or reposition, thumb is adjacent to palm and fingers. One last thumb movement is circumduction (not shown) wherein the thumb is rolled in a circular motion.

Photo Q

Try This: Move your thumb through all 7 movements as described above.

Thumb movements are plentiful in Starz episodes. Here is Claire using her left thumb to steady the beautiful ring placed on her right ring finger by The Big Red One (Starz episode 107, The Wedding). Her thumb IP joint (blue arrow) is flexed; MP joint (red arrow) is mostly extended.

We havena see Dougal for a while so here he executes one of his devious, seal-a-deals with Claire: if she canna free Jamie or he is dead, she will marry him (Starz episode 114, The Search). Uhhh…I dinna think Claire will marry Dougal –no way, no how – but a clever ruse to access his men for a rescue attempt.

Finally there are four finger movements: abduction wherein index, ring and little fingers move away from the middle finger (Photo R –purple arrows). By definition the middle finger abducts no matter which direction it sweeps (think windshield wiper). Adduction is returning fingers to the resting position (Photo R –green arrows). Finger abduction and adduction are carried out by intrinsic muscles of the hand which will be cover in a later lesson.

Finger flexion occurs when one or more fingers are curled toward the palm and includes some or all MP, PIP and DIP joints (Photo R –red arrows). Contraction of forearm flexors (and intrinsic hand muscles) produces these movements. Finally, finger extension (Photo R -blue arrows) occurs when one or more fingers are straightened. Contraction of forearm extensors produces these movements.

Photo R

Try this: Using the fingers, try flexion, extension, abduction and adduction.

Claire is in our sights once again as she circles Jamie (Starz episode 107, The Wedding). Her left fingers are extended and abducted; thumb is extended. Not only is this a great example of hand movement butt, oops, but, it is also…well, we all ken this hand gesture!

Finally, thumb and fingers provide various power grips the muscular force generated by the hands (Photo S). Grip is important in everyday life and for most athletic ventures.

- Cylindrical power grip uses thumb abduction and finger flexion to tightly grasp a rounded object.
- Spherical power grip is similar but thumb abduction and finger flexion is looser as in gripping a larger object.
- Hook power grip uses extended MP finger joints but flexed DIP and PIP joints (thumb may be flexed or abducted) as in carrying the handle of a bucket.
- Precision pinch grip is used to grasp small or delicate items.

Photo S

Jamie exhibits a hook power grip as his right hand clutches his dirk: MP joints extended, PIP and DIP joints flexed. He’s headed for Fort William with an empty gun and his own bare hands to rescue Claire from the redcoats (Starz episode 109, The Reckoning)!

Next, is a great example of precision pinch grip in which right thumb opposes right index finger as Jamie clutches his doomed petition of complaint for the Duke of Sandringham. Humm…wonder what those bloody MacDonalds are doing here…

Next is a terrifying example of a cylindrical power grip with BJR’s left thumb abducted and fingers flexed around Claire’s swanlike neck (Anatomy Lesson #12). He is hurting her and her face is sheened with tears and “the sweat of exertion” as narrated by BJR (Starz episode 115, Wentworth Prison).

Yet another example of the cylindrical power grip. Look familiar (Starz episode 108, Both Sides Now)? Remind you of anyone you know? Puir not-her-name Sally! She messed with the wrong guy…iffy spherical power-grip genes in that line.

As if we need a reminder, our beloved Jamie’s hands are nimble and elegant (Starz episode 107, The Wedding). In fact, his fingers and hands play their own characters just as Claire’s hair does (Anatomy Lesson #6) throughout the books. This was especially evident during his marriage to Claire. Here his left fingers drape gracefully over his right wrist as he utters his blood vow. His left thumb is slight abducted. His right hand executes a loose spherical grip around Claire’s right wrist and forearm. Stunning imagery!

WARNING: the time has come to examine the damage to Jamie’s hand. After the next few paragraphs, his torture will begin so skip to the kitten if you must.

Fast forward to Starz episode 115, Wentworth Prison, an episode thoughtfully rated “graphic violence”!

About midway through the episode, Jack makes an offer Jamie canna refuse: a swift and honorable death in exchange for free use of his body. But, Jamie does refuse: “I’ll not surrender to you or any man.” The foul fiend vows “I will have your surrender before you leave this world.”

Next, a great scuffle ensues given that Jamie is half starved, chained by an ankle manacle and weaponless against two men, one a minor league giant. Black Jack asks “why do you force me to hurt you?” Oh yeah, Jamie’s forcing your hand! As instructed, genius Marley slams Jamie’s left hand on the wooden table as Jack grasps the mallet (aye, he has it in a spherical power grip).

Jack smashes the mallet on Jamie’s left mid-hand followed by about three more strikes. The vulgar villain then launches a volley of totally insane queries: Why do you force me to treat you in such an abominable way? Why do you choose to spend the few hours left to you as a miserable cripple? Why do you force me to hurt you? Och, he’s a delusional devil!

Soon, Claire finds Jamie alone (from Outlander book):

“What has he done to you?” I asked … Moving with exquisite care, he used his left hand to lift the object he had been cradling. It was his right hand, almost unrecognizable as a human appendage. Grotesquely swollen, it was now a bloated bag, blotched with red and purple, the fingers dangling at crazy angles. A white shard of bone poked through the torn skin of the middle finger, and a trickle of blood stained the knuckles, puffed into shapeless dimples.”

But a minor detail, the left hand is mashed, otherwise the destruction is akin to the Outlander book’s version: swollen fingers, black and blue skin, blood, bone/tendon exposed. A heavy mallet messes with delicate hand anatomy!

Unfortunately the effing, sadistic piece of shite and his Igor return to find Claire with Jamie. An engrossing exchange ensues between the black bastard and Claire as Marley adds his own singular brand of visual horror. With a flare of desperate strength and courage, Claire shoves Marley and pushes BJR into a wall in a vain attempt to strangle him. Marley ends up dead and Claire ends up hostage.

Next arrives the pivotal moment in this entire episode: Jamie, accepting that he will die on the morrow offers himself in exchange for Claire’s life. “Let her go in safety and you can have me. I won’t struggle. You, you can do as you wish. You have my word!” His body is the only card he has left to play in this gruesome game and he uses it to ransom Claire. Diana explains (Outlander book):

Randall walked slowly…picking up the mallet as he went. He held it up, ironically questioning. “You’ll allow me a brief test of your sincerity?” “Aye.” Jamie’s voice was as steady as his hands, flat and motionless on the table. I tried to speak, to utter some protest, but my throat had dried to a sticky silence. Moving without haste, Randall… positioned the point with care and brought the mallet down, driving the nail through Jamie’s right hand into the table with four solid blows.

In the Starz episode, Jamie’s left palm faces up as Jack impales it to the table. Intentional or not and regardless of your philosophical bent, the shocking image of Jamie’s palm pierced by a nail driven into wood is the ultimate symbol of sacrifice in the Western world. And, a costly sacrifice it is.

ep 115 Jamies hand 02 KLS edited

peeking

It’s safe to come out now! Had to use two kittens just to make sure…

“I love you, mo nighean donn.”

What bolsters us, is the knowledge that Claire’s loving kiss will help sustain Jamie trapped in the vortex of Jack’s dark madness.

Again, from Neil:

Warm, touchin’ warm

Reachin’ out, touchin’ me, touchin’ you

ep 115 Claires hand KLS edited

Now, a few final comments for the sake of science: take heart all! in Outlander book Claire observes that Jamie handles a fifteen pound Claymore as though it were a mere flywhisk. Jamie is a warrior, an athlete whose limbs are heavily muscled. Many studies have shown that muscular activity thickens bones; ergo, Jamie’s hand bones will tolerate more abuse than most because he is so fit and fine.

Further, will the nail wound greatly damage Jamie’s hand? Actually, not so much! In the living, nerves, tendons and larger blood vessels are slippery and will likely slide away from the nail path. But, the pain is agonizing: pain receptors of the mangled hand are already on fire from the mallet and the nailing adds fuel to that inferno. But, of the two tools, the mallet is by far the greater destroyer.

Farewell for this lesson. Let us join hands in the hope that Starz episode 116 sees Claire redeem Jamie’s hand and his soul!

The deeply grateful,

Outlander Anatomist

Follow me on:

- Twitter: @OutLandAnatomy
- Facebook: OutlandishAnatomyLessons
- Instagram: @outlanderanatomy
- Tumblr: @outlanderanatomy
- Youtube: Outlander Anatomy

Photo Credits Starz, Gray’s Atlas of Anatomy for Students, 2005, Netter’s Atlas of Human Anatomy, 4^th ed., Clinically Oriented Anatomy, 5^th ed., www.breakingmuscle.com, www.britannica.com, www.cs.cmu.edu (types of grips) , www.pinterest.com, www.physioadvisor.com.au, www.pixshark.com, www.researchgate.net, www.slice-works.com, www.the anatomist.wordpress.com (thumb movements), www.ittcs.wordpress.com (arches of hand with grip), www.wikipedia.org, www.wikiradiography.com, www.webmd.com, www.heroesandheartbreakers.com, www.englishstackexchange.com.

May 25, 2015

Anatomy Lesson 22 Tomorrow!

Tomorrow, May 26th! Anatomy Lesson #22: “Jamie’s Hand – Symbol of Sacrifice”

The deeply grateful,

Outlander Anatomist

May 11, 2015August 30, 2024

“Smallpox” and “The Devil’s Mark”

Hallo and welcome to Anatomy Lesson #21: Smallpox. This lesson represents a departure from our usual discussions which emphasize gross anatomy. Today, we will learn about smallpox via microscopic anatomy, immunology and history! Please consider this but a brief respite from our studies of the upper limb – a topic we will return to in Anatomy Lesson #22. Outlander book readers will understand that we must make our way to the hand and very soon!

Now, how do we find ourselves learning a lesson about witches, devils and smallpox? Well, it is the machinations of that pretty little liar Laoghaire (not the actress, who is fantastic!). Yep, this 16-year-old got a witch-itch to dispose of Claire Fraser once and for all (Starz episode 111, The Devil’s Mark)! She exploited and manipulated the good and holy people of Cranesmuir to arrest, try and burn Mistress Fraser for witchcraft: she and that awful Father Bain (doesn’t he just give you the creeps?). Now, there’s a match not made in heaven!

ep 110 Lerry KLS edited

No surprise that Geillis was accused of witchcraft being a long-time practitioner of the murky arts. And, we all kent she was something wild ever since she drank port while sporting those awesome shoon (Starz episode 103, The Way Out)! Talk about Red Shoe Diaries…for haggis sake! Takes loads of grit to don those red 18^th century Christian Louboutins!

Fast forward through the trial, Claire’s skelping (ouch!) and Jamie’s bulldozer arrival: next thing Geillis pulls down her gown to reveal the devil’s mark. No more than a lowly smallpox vaccination scar (Starz episode 111, The Devil’s Mark) Geillis declares it proof that that she had lain with her master, beelzebub, and will now bear his spawn (Hum…….not a nice thing to say about Dougal!). Herself records (Outlander book):

“…It was something else I had seen that chilled me to the marrow of my bones. As Geilie had spun, white arms stretched aloft, I saw … A mark on one arm … Here, in this time, the mark of sorcery, the mark of a magus. The small, homely scar of a smallpox vaccination.”

Well, the fat is in the fire now as a gang of guys hoist Geillis off to the roasting spit! Headed for the witch’s pyre, Geillis still sports those awesome red booties: now, a girl has to look her best even if it’s for her own barbeque!

Whoa! What with all the brouhaha we shouldna forget that Claire bears her own smallpox vaccine scar! Yes, if you took the midterm practical exam (Anatomy Lesson #18) you witnessed foreshadowing: Claire’s left arm as she kisses Jamie (Starz episode 107, The Wedding). To be sure, the red arrow points to her vaccination scar proving she came from the 20^th century. We book readers (not meaning to sound snooty here) already knew this scar would become an issue in future episodes. It’s good thing that neither the villagers nor Father Bain saw that scar or Claire would have been kindling!

Next, let’s study smallpox: its history, cause, signs and symptoms and the vaccination that prevents it. Hey, now wait! Please don’t haste away in fear and loathing. True, smallpox isn’t a sexy topic but it is very interesting stuff. I’ll even throw in Starz images, book quotes and historical paintings to keep you focused on the lesson. And, I’ll warn you before any gruesome pics arise (because smallpox isn’t pretty). Promise!

In Europe, smallpox was originally known as the “pox” or “red plague”. The term smallpox was first coined in 15^th century Britain to distinguish smallpox (one word) from the great pox (two words). What is the great pox? Well, the great pox is syphilis, an entirely different disease, different cause, different symptoms and different treatment. Of the two diseases, however, smallpox is by far more deadly.

Sufferers of syphilis classically exhibit three stages but stage two is characterized by a non-itchy rash and hence the term “pox.” Photo A is a 16^th century woodcut illustrating the rash of secondary syphilis. But, enough great pox for now; we will return to it in a future anatomy lesson.

Photo A

Back to smallpox. We’ll approach this disease in an orderly manner by following its structure, history, signs and symptoms, treatment and prevention. Warning: this lesson includes three graphic images showing sufferers with full-blown smallpox. If such images bother you, an advanced warning will allow you to skip them.

Here is your warning sign:

Here is your “it’s safe to peek” sign:

Smallpox is an acute, contagious disease which derives its name from the Latin meaning “spotted” or “pimpled” referring to raised bumps or pustules that cover skin of the afflicted. Smallpox is not caused by a bacterium (sing.) but by the variola virus a large brick-shaped member of the poxvirus family (Photo B – transmission electron microscope – TEM image).

variola virus KLS edited

Photo B:

The following image (Photo C – TEM image) reveals the internal structure of the variola virus. Understand that the virus is essentially colorless – the image colors are computer generated. The red-orange dumbbells represent the complex viral core. Too technical? Then, let’s move to the history of smallpox.

Photo C

The history of smallpox is fascinating in that it altered the course of human history and even contributed to the decline of civilizations. It is no understatement to declare that smallpox ranks among the most devastating illnesses ever suffered by mankind and probably contributed to the vintage curse “a pox on thee.” Smallpox routinely killed at least one third of its victims. Sadly, the survivors of this dreadful pestilence were often left with major disfigurement or disability. Even more devastating is that governments have been known to intentionally infect groups of people with the disease to eradicate them from a desirable area. This lesson won’t be addressing those atrocities in detail but it bears mentioning because for centuries, people have known how crippling this disease is to communities.

Smallpox is believed to have evolved from a rodent virus between 16,000-68,000 years ago; the wide time range is due to different estimates of genetic change during evolution, the so-called molecular clock. Evidence suggests that smallpox jumped to humans about 10,000 BCE. The earliest physical evidence of the disease comes from Egyptian Pharaoh Ramses V who died in 1157 BCE (Photo D). His mummified remains show the telltale skin pockmarks. Numerous old manuscripts record what appear to be waves of smallpox epidemics that repeatedly struck the Eastern hemisphere.

Photo D

The clearest description of smallpox from pre-modern times is credited to a 9th century (860 – 925 CE) Persian physician and scholar, Muhammad ibn Zakariya ar-Razi ( Photo E – examining a child with smallpox). Known in the West by his Latinized name, Rhazes or Rasis, he was an important figure in the history of medicine as he was the first to differentiate smallpox from measles in his text, Kitab fi al-jadari wa-al-hasbah (The Book of Smallpox and Measles).

Photo E

Smallpox reached Europe between the 5th and 7th centuries CE and over time spread along trade routes into Africa and Asia finally reaching the Americas in 1519 via Spanish conquistadors. Indigenous peoples had no immunity to the disease so more than three million Aztec as well as many Inca succumbed to smallpox (Photo F – 16^th century woodcut).

Photo F

Moving to Jamie’s time of the 18^th century, smallpox is estimated to have claimed 60 million lives including five reigning monarchs and was responsible for a third of all blindness; it also marked the faces of more than half the population of Europe.

A genuine scourge, it killed 20-60% of all those infected and over 80% of infected children died from it. Jamie’s own family suffered smallpox when he was a lad. Here from Starz episode 113, The Watch and in Herself’s own words (Outlander book):

“Two red- haired, tartan- clad little boys stared solemnly out of the frame … Jamie, and his older brother Willie, who had died of the smallpox at eleven. Jamie could not have been more than two when it was painted … Jamie had told me about Willie … I remembered the small snake, carved of cherry wood that he had drawn from his sporran to show me.”

ep 113 Sawny KLS edited

To underscore its havoc during the 20^th century smallpox killed 300-500 million people globally. In 1967, the World Health Organization (WHO) estimated that 15 million people worldwide contracted smallpox with two million deaths the same year.

Smallpox is spread through direct contact with infected people or their body fluids or via fomites, contaminated objects that transmit disease (e.g. bedding). As a child at Lallybroch (Starz episode 113, The Watch – image below) Jamie had smallpox but his case was not serious. Herself explains (A Breath of Snow and Ashes book):

He considered for a moment. “I had the smallpox when I was a wean, but I think I wasna in danger of dying then; they said it was a light case.

Och! Is this possible? Could Jamie have had a light case of the smallpox? Would Herself make such an error? No problemo! Indeed, there are two main types of smallpox: Variola major, the common and most lethal form and Variola minor, a milder disease which was fatal in less than 1% of cases. We can even postulate that Jamie may have been exposed to the same variant as Willie but received a lower viral load or was less susceptible to its effects. Finally, a couple of rarer forms of smallpox invariable caused death but these lay beyond our present discussion.

The signs and symptoms of smallpox are very well known. WARNING: the next three images show full blown smallpox; please skip if you must. Watch for the kitten to know it’s safe to come out again.

After a victim inhales the smallpox virus or is infected via fomite, it has an incubation period of about 12 days during which the infected person is not contagious. During this time, the virus is busy infecting cells of mouth, throat and respiratory tract after which it distributes to lymph nodes and other structures. Like many viruses, it produces a 2-4 day prodrome (early symptoms) of mild fever, muscle pain, malaise, headache and prostration. By 12-15 days, large numbers of virus flood the bloodstream (viremia) and the first visible lesions appear on the mucosa (Anatomy Lesson #14) of mouth, tongue, palate and throat. By days 15-17 skin eruptions occur. Although smallpox is routinely categorized as a skin disease (Photo G – 1912 archival photo) understand that it also invades most mucous membranes of the body including exposed surfaces of the eye.

Photo G

Skin eruptions rapidly develop into fluid-filled pustules: sharply raised, round, tense and firm to the touch. The pustules traverse epidermis and dermis and are umbilicated meaning they demonstrate a central pit (Photo H – 20^th century). By the end of week two the pustules deflate, dry up and form crusts or scabs. By days 16–20, scabs flake off leaving depigmented (no skin pigment) white scars.

Photo H

Another defining characteristic of smallpox lesions is their distribution: pustules cover the entire body with concentrations on the head and upper and lower extremities including palms and soles (Photo I – 1886 archival photo).

Photo I

IT’S SAFE TO PEEK NOW!

Skin distribution helps practitioners distinguish smallpox from chickenpox lesions which are concentrated on the trunk and less numerous on the extremities (Photo J). In addition, all smallpox skin lesions are of the same maturity (see Photo I) whereas chickenpox lesions present in various stages of maturity: old healing lesions intermix with new developing lesions.

Photo J

Next, let’s consider how smallpox leaves scars or pockmarks as a “gift that keeps on giving.” If you read Anatomy Lesson #5 and Anatomy Lesson #6, you learned the structure of skin and its appendages. As a quick review, skin is divided into an outer epidermis and a deeper dermis (Photo K) which in turn is bound to subcutaneous tissue (not part of skin). Skin bears a number of appendages including hairs, arrector pili muscles, sweat glands and sebaceous glands. Sebaceous glands produce sebum, a waxy-oily substance that is secreted into hair follicles or via small ducts leading to skin surfaces. Sebaceous glands are found in all skin except that of soles and palms and they are most numerous on the face. The awful smallpox lesions extended deeply into the dermis where they destroyed sebaceous glands. In the aftermath of healing, deep white scars (pockmarks) were left everywhere on the skin but were densest and most disturbing on the face, the body part by which the world identifies us.

Photo K

If an individual survived smallpox, long-term complications included pockmarks, blindness, arthritis, osteomyelitis (bone marrow infection), pneumonia and encephalitis. On the plus side and there was only one plus, sufferers typically developed immunity to subsequent smallpox outbreaks.

Many famous historical people suffered the ravages of smallpox. These include Queen Elizabeth I who in 1562 was so scarred by smallpox that she was left half bald and dependent upon wigs and heavy lead-based makeup to cover her pockmarks (Photo L – Armada portrait by George Gower). During this era, ideal beauty and wealth was marked by very pale, white skin. To achieve this look, people applied a foundation of lead and vinegar, even using mercury in makeup, which presented it’s own health problems.

Photo L

Truly a global scourge, the following is an incomplete list of famous historical figures that either died of or were disfigured by smallpox:

Marcus Aurelius (Roman Emperor)
Chief Sitting Bull, Lakota Sioux
Ramses V of Egypt (20^th Dynasty)
Kangxi, Shunzhi and Tongzhi, Emperors of China
Date Masamune, regional strongman of Japan
Cuitláhuac, Aztec ruler of the city of Tenochtitlan
Huayna Capac, Incan Emperor
Guru Har Krishan, 8th Guru of the Sikhs
William II King of Scotland/William III of Orange (same man)
Queen Mary II
Joseph I, Emperor of Germany
Peter II, Emperor of Russia
Louis XIV, King of France
Louis XV, King of France
Henry VIII and his family: sister Margaret, Queen of Scotland, fourth wife, Anne of Cleves, daughters: Mary I of England and Elizabeth I of England, great-niece, Mary, Queen of Scots and only surviving son Edward VI (died of smallpox complications).
Holy Roman Empress Maria Josepha wife of Holy Roman Emperor Joseph II
William III’s mother (lead to permanent ousting of the Stuart line from the British throne)
William III’s wife, Mary II
Peter II of Russia
Peter III
George Washington, U. S President
Andrew Jackson , U. S President
Abraham Lincoln, U. S President (quarantined just after the 1863 Gettysburg address)
Joseph Stalin, Premier of Soviet Union
Wolfgang Amadeus Mozart (Photo M – Bologna Motzart – artist unknown)

Photo M

Hey, am I losing you? Well, here, this will jolt ye awake! I said this wasna going to be a sexy lesson, but the next image shows that I, um, clearly lied. Only Jamie could turn buttering and eating a piece of bread into global cardiac arrest. Grab the paddles! Stand clear!

Now let’s turn to treatment and prevention of smallpox. First the bad news and then the good: The bad news is treatment for smallpox is minimal. A smallpox vaccination given within three days of exposure can lessen the disease but otherwise supportive therapy such as fluid administration is the order of the day. The good news is smallpox can be prevented. A brief history of its prevention follows.

The earliest procedure to prevent smallpox was variolation wherein powered smallpox scabs (ugh!) were inhaled through the nose (oh!) or pus from smallpox lesions (yuck!) was scratched into the skin. Although disputed by some, this may have been practiced in India as early as 1,000 BCE. Undisputed are accounts of variolation performed in China by the 10^th century and widely practiced by the 16^th. If successful, variolation produced lasting immunity to smallpox. However, it was an iffy practice because a variolated person could get full-blown smallpox from the procedure and transmit it to others. Why then was it practiced? Because variolation caused 2% mortality rate compared to 30% + mortality rate for smallpox!

The next procedure to prevent smallpox is credited to Edward Jenner (1749-1823), an English country doctor of Gloucestershire. Jenner (Photo N) was a private student and lifelong friend of the great Scottish surgeon, anatomist and naturalist John Hunter (Anatomy Lesson #3).

Photo N

As a country doctor, Jenner heard dairymaids with cowpox pustules on their hands (Photo O) claim that they could not get smallpox: “I cannot take the smallpox, since I have had the cowpox.” Medical men of the day were aware of these claims but most dismissed them as folk lore. Jenner, on the other hand, was so intrigued he made observations and studied cowpox for over a quarter of a century. From John Hunter, he received the following famous bit of advice: “Why think? Why not try the experiment?”

Photo O

Finally in May of 1796, Jenner did the experiment: he removed “matter taken from the sore on the hand of a dairymaid” (Photo O – Sarah Nelmes) and inserted it into skin scratches on the arm of eight-year-old James Phipps, son of Jenner’s poor landless gardener (Photo P).

Are you horrified? But of course you are! In today’s western world of informed consent and scrutinized research protocols such a thing would be absolutely prohibited: different times, different rules.

Back to the story: seven days after the procedure, James experienced chills, loss of appetite and slight headache but the next day felt fine. Then on several occasions in 1796 Jenner did the unthinkable: he inoculated James with smallpox matter and the boy experienced no disease whatsoever! Jenner presented his findings to the Royal Academy, but more importantly, he had the foresight to publish them in a 1798 booklet explaining how inoculation with cowpox caused immunity to both cowpox and smallpox and thus was born the procedure later termed vaccination.

How did the vaccination work? Well, cowpox is caused by cowpox virus a poxvirus which is molecularly similar to the smallpox variola virus so the body’s immune system creates protective and memory cells that upon subsequent exposure will attack and destroy the smallpox virus.

In fairness, Jenner was not the first to inoculate people with cowpox virus to achieve smallpox immunity: others included Benjamin Jesty (farmer- Dorset, England) who performed the procedure on family members in 1774 and in 1791, Peter Plett from the Duchy of Holstein (now Germany) inoculated three children. The reason Jenner is credited with the feat is because he was the first to publish his findings as advised by the sage academic adage: publish or perish! His publication even included the drawing of Sarah Nelmes’ hand and a cupping horn in which he transported cowpox-infected matter for vaccination (Photo O).

Photo P

A wee bit more history and then we move on: In 1809, the first U.S. state began compulsory public vaccination against smallpox. England introduced compulsory infant vaccination via the 1853 Vaccination Act. Other European countries established similar programs but many were fraught with problems and rebellions by the general public.

The last and current smallpox prevention method involved switching from cowpox virus to a related virus for vaccination: Also known as vaccinia virus, this poxvirus is molecularly similar to both smallpox and cowpox and some think it may be a hybrid of the two; the precise origin of the modern vaccinia virus has become lost.

WARNING: If needles make ye queasy, ye may want to look for that kitten agin.

Here is how current day vaccinia vaccination is performed: The vaccine is not given with a hypodermic needle and thus is not a “shot” like many vaccinations. Rather, the vaccine is given using a bifurcated (two-pronged) needle (Photo Q).

Photo Q

The needle tip is dipped into vaccine solution such that the prongs retain a droplet of fluid (Photo R).

Photo R

The upper arm is then quickly pricked several times with the needle (Photo S). The pricking is not deep. Did you notice I use the present tense? Yes, the vaccine is still given even today but not to the general public.

Photo S

If vaccination is successful, 3-4 days later, red and itchy bumps develop at the vaccination site where the body’s protective cells (lymphocytes) react to foreign molecules of the vaccinia virus (Photo T). After a week, the bump becomes a large pus-filled blister. At week two, the blister dries up and forms a scab. The scab falls off during the third week, leaving a visible scar. The size of the scar depends on the intensity of an individual’s reaction to the vaccine.

Photo T

OK! IT’S SAFE TO PEEK NOW!

Back to smallpox history, after vigorous public vaccination campaigns throughout the 19^th and 20^th centuries, the last recorded case of naturally-occurring smallpox was in Somalia in 1977. Three years later, WHO declared that smallpox was eradicated from the world, a feat that is generally regarded as one of the greatest triumphs of modern medicine. So officially the deadly virus no longer exists in nature!

Personally, I cringe when humans make sweeping statements about nature as they evoke the follies of human hubris. Claire reflects on such an issue in The Fiery Cross (book 5 of Outlander series):

“This was in fact likely. However, I was quite aware of the old adage— “Man proposes and God disposes” … ” (From the Latin text by Thomas à Kempis: For man proposes, but God disposes; neither is the way of man in his own hands.”)

In the more colorful words from Scottish poet Robert Burns in his 1785 poem “Tae a Moose, on Turning Her Up in Her Nest with the Plough: The best-laid schemes o’ mice an’ men Gang aft agley.”!

In the words of Professor Ian Malcolm from the film, Jurassic Park: “Life finds a way.”

Will smallpox stay buried for good? We certainly hope so!

Let us end this lesson with more fun and games: we return to our hero and heroine in Starz episode 111, The Devil’s Mark. I love the trial wherein Jamie and Claire together witness Geillis’ confession. Take a gander at Claire’s glass face!

Oh, my! Jamie watches as Geillis exposes her “mark of the devil” and Claire suddenly kens that Geillis is a 1968 time traveler and her “devil’s mark” is naught but a lowly smallpox vaccination scar!

But, here is the moment of truth! Jamie’s nimble brain is churning fiercely as he realizes that Geillis has given him the chance to hie Claire out of that bloody inquisition. RUN! Wow. Jamie’s eyes could act all their own only that would be gross so…never mind…but ye ken what I mean! So expressive!

After getting Claire away from Cranesmuir and into a quiet wooded area, Herself records Jamie’s reaction (Outlander book):

“I said before that I’d not ask ye things ye had no wish to tell me. And I’d not ask ye now; but I must know, for your safety as well as mine.” He paused, hesitating. “Claire, if you’ve never been honest wi’ me, be so now, for I must know the truth. Claire, are ye a witch?” I gaped at him. “A witch? You— you can really ask that?” … “Yes, I am a witch! To you, I must be. I’ve never had smallpox, but I can walk through a room full of dying men and never catch it. I can nurse the sick and breathe their air and touch their bodies, and the sickness can’t touch me. I can’t catch cholera, either, or lockjaw, or the morbid sore throat. And you must think it’s an enchantment, because you’ve never heard of vaccine, and there’s no other way you can explain it.”

With her vaccination scar clearly on display, Claire tearfully explains her own “devil’s mark” to Jamie.

ep-111-Claire's-small-pox-scar-KLS-edited

Jamie (this man is a true wonder) does believe her and her heart; he kens she is telling him the truth and pledges that he will believe whatever she tells him. So, she tells him everything from the get-go including stone travel, combat nursing and boring Frank! Yikes! And all’s well that ends well for oh, say, two hours. Nice job to the entire cast and crew for that mind-numbing, stomach-rolling, breath-holding, teeth-grinding rollercoaster ride!

ep 111 Jamie believes KLS edited

However, honesty compels me to declare the true devil’s mark from Starz episode 111. Who is nominated for this honor? Drum roll!!!! And, the winner is: the puir, misunderstood little gal Laoghaire. Who is this bonny lass with more facets than a well-cut stone? Watch her face change as she hisses at Claire!

A daughter accused by her own father of loose behavior?

ep-111-Lerry-01-KLS-edited

The innocent “virginal” seductress of love-of-her-life Jamie?

The darling, needle-wielding granddaughter of Mrs. Fitz?

The cunning author of Claire’s imprisonment and verdict?

Or, a tiny dancer who will gladly execute (so-to-speak) a pirouette atop Claire’s ashes?

Hope ye all ken by now that if Starz episode 111 has a devil’s mark it surely is this calculating, cunning and cruel Bad-Lass!

Ending on this somber note of justice gone awry, I do hope you all learned something new today: “Let’s rise and be thankful, for if we didn’t learn a lot today, at least we may have learned a little…” (Born for Love: Reflections on Loving, Leo Buscaglia).

A deeply grateful,

Outlander Anatomist

Image creds: “Great Moments in Medicine”, 1961 paintings by Robert A. Thom, “Medicine: Perspectives in History and art, www.bioteach.unl.edu, www.crateandbarrel.com, www.dailymail.co.uk, www.dermatologyabout.com, www.healthline.com, www.mayclinic.org, www.ncbi.nim.nih.gove, www.who.int, www.wikimedia.com, www.wikipedia.com, www.onlinelibrary.wiley.com, www.2.lbl.gov, www.socialphy.com, www.momentummoonlight.com.