Anatomy Lessons – Page 27 – Outlander Anatomy

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.

April 28, 2015April 28, 2015

Arms! Arms! Arms! – Redux

Welcome to today’s Anatomy Lesson #20: Arm and Forearm! Dapper Edward Gowan, romantic soul he, introduces our topic. Bless neat Ned’s heart – he is the only inhabitant of Castle Leoch courageous enough to defend our beloved Claire at the witch’s trial (Starz episode 111, The Devil’s Mark). Not only is he clever and adroit at turning an argument on its head but after Claire and Geillis are sentenced to burn, he brandishes a pistol and threatens the entire assembly: “Wait, you cannot do this. I forbid this!” Who knew he was armed mayhap with the same firearm he used to shoot a Grant from 20 paces (Starz episode 108, Both Sides Now)! Reminds me of an apropos John Wayne quote: “Courage is being scared to death and saddling up anyway.”

Way to go Ned. You are the man!

Today’s lesson will build on Anatomy Lesson #19: “To Arms, Too arms, Two Arms” wherein we learned about clavicle, scapula and humerus and the 17 muscles that move these bones. Today’s lesson adds more details of the glenohumeral joint and covers eight additional muscles that move arm and forearm. Do the math and realize that five muscles of arm and pectoral girdle haven’t been covered. We will return to those in a future lesson.

Let’s begin by reviewing arm movements (Photo A). Hopefully you memorized these from our last lesson: flexion, extension, adduction, abduction, medial (internal) rotation, lateral (external) rotation and circumduction. Understand that arm movements can involve combinations of the above.

Photo A

Now, onto the bony foundations of the upper limb; yes, there is more to learn. Movement enjoyed by humans requires a bony endoskeleton (endo from Greek meaning within) for muscular attachments. This haunting artistic rendering reminds us of scapula, clavicle (together the pectoral girdle), humerus and forearm bones all of which provide attachment for upper limb muscles.

Photo B

As you may recall the glenohumeral joint is the articulation between humeral head and glenoid cavity of scapula (Photo C). The glenoid cavity is roughly ¼ the size of the much larger humeral head meaning this ball and socket joint is highly mobile but easily dislocated as happened to our bonny Jamie (Anatomy Lesson #2 and Starz, episode 101, Sassenach).

Examine Photo C (slice through shoulder joint) and see that a blue layer covers humeral head and lines glenoid cavity; this is hyaline (articular) cartilage which covers most joint surfaces. The body contains three different types of cartilage but the most common type is hyaline. Cartilage is one of several body tissues that are avascular (lack blood vessels). Thus, in the case of cartilage, oxygen, nutrients and protective/repair cells are delivered and waste products are retrieved more slowly. The significance is this: if damaged, cartilage repair is slower to repair than vascular tissues. Warning: piercing cartilage (e.g. ears, nose) demands extra caution to keep wounds disinfected during the healing process. Once infected, the damage to cartilage can be fulminating because the tissue is avascular. The structure labelled glenoid labrum is important and will be discussed next.

Photo C

Some readers have inquired about the glenoid labrum, a part of the glenohumeral joint that is made of fibrocartilage (different than hyaline). It enlarges and deepens the glenoid cavity to more effectively surround the humeral head (Photo D – side view of right joint). Labrum injuries are fairly common and include symptoms such as pain, locking, popping, joint instability and decreased range of motion. Because the labrum is made of soft tissue, it cannot be visualized by x-ray and thus requires other imaging modalities.

Photo D

The glenohumeral joint (Anatomy Lesson #2 & Anatomy Lesson #19) is further reinforced by the rotator cuff, an incomplete collar of four muscle tendons (Photo E – superior view, black arrows). Rotator cuff muscles are: supraspinatus, infraspinatus, teres minor and subscapularis. Some anatomists prefer the less common term fibrous cuff because not all cuff muscles rotate the humerus as the name implies. And, in case you are not aware, tendons are connective tissue (collagen) elements that anchor muscle to bone; ligaments are connective tissue elements that attach bone to bone.

Photo E

Referred to by the acronym SITS, rotator cuff muscles cover and reinforce top, back and front of each glenohumeral joint. Photo F (left humerus, left hand) employs a simple visual technique for recall: S (index finger) = supraspinatus; I (middle finger) = infraspinatus; T (ring finger) = teres minor and S (thumb) = subscapularis.

Photo F

The first SITS muscle is supraspinatus so named because it arises from back of scapula superior to the scapular spine (Photo G). Its tendon passes over the top of glenohumeral joint and inserts into side of humerus. Called the workhorse of abduction, it actively raises the arm from full adduction to full vertical abduction as in hands up, partner!

The second SITS muscle is infraspinatus so named because it arises from back of scapula inferior to the scapular spine and inserts into back of humerus. Upon contraction, it produces lateral (external) rotation of the arm.

The third SITS muscle is teres minor, a small muscle that arises below infraspinatus and inserts into back of humerus. Often fused with infraspinatus, it may be indistinct. Teres minor contributes to lateral rotation of the arm.

Photo G

The fourth and last SITS muscle is the fan-shaped subscapularis which takes origin from front of scapula and inserts into front of humerus (Photo H). Its contraction produces medial (internal) rotation of the arm.

In summary, all SITS muscles rotate the humerus except one abductor, supraspinatus.

Again, the tendons of the four SITS muscles reinforce the glenohumeral joint as the rotator cuff (Photo H – dashed red line). One or more of these tendons is a common cause of shoulder pain, tears, impingement and/or inflammation. I cannot demonstrate subscapularis with Starz images because it is situated deeply between scapula and rib cage.

Photo H

But, I can demonstrate three SITS muscles using our fav model, Jamie! Aye, the obliging laddie hopped up on the dissection table again – he’s so accomodating helping us all learn about human anatomy. Thank ye, Jamie! In the next image, Claire’s graceful right index, middle and ring fingers rest over his awesome trapezius (Starz episode 108, The Wedding). Supraspinatus lies deep to the yellow arrow; it doesn’t create a distinct bulge (hehe) because it is covered and overshadowed by the more powerful trapezius. Nevertheless, we can identify its location.

Can we see Jamie’s infraspinatus? Definitely yes! In fact, there are so many fine examples from Starz episodes it is difficult to choose. But here are a couple of favorites. Jamie’s infraspinatus is verra well-developed – doubtless from pitching hay all day at Lallybroch and wielding his, erm, heavy dirk! In the next image, a relaxed infraspinatus underlies the elevated flesh between the yellow arrows. Here Jamie welcomes lovely Claire’s slow and sensuous kiss (Starz episode 109, The Reckoning). Although most of his back is covered with flogging scars, skin overlying infraspinatus remains largely untouched. Herself explains the extent of those scars (Outlander book):

…Even by candlelight and having seen it once before, I was appalled…The scars covered his entire back from shoulders to waist. While many had faded to little more than thin white lines, the worst formed thick silver wedges, cutting across the smooth muscles.

The following image shows a contracted infraspinatus (yellow arrow) as Jamie’s upper limbs strain against his manacles. The red arrow points to deltoid (Anatomy Lesson #19) which is demarcated from infraspinatus by a skin groove. An orange arrow marks teres major, our next muscle. Here Jamie is shackled to the whipping post at Fort William and nearly beaten to death by the unholy vulture (Starz episode 6, The Garrison Commander). Herself describes it (Outlander book):

….“Well, I was tied to that post, tied like an animal, and whipped ’til my blood ran! I’ll carry the scars from it ‘til I die.”

The next muscle moving the humerus, teres major, is not a rotator cuff muscle (Photo I). This strong and substantial muscle arises from the back of scapula just below teres minor and inserts into the front of humerus. Teres major has three functions: it adducts, extends and medially rotates the humerus.

Photo I

Oops! Just lost me train of thought gawking at the next image (Starz episode 107, The Wedding)! What was the topic? Ah, I remember….. Here on their wedding night, Jamie gets the idea – aye, the lad is a quick study! He no longer crushes Claire as he contracts teres major (blue arrow) and infraspinatus (yellow arrow) to help support his weight.

Teres major also helps form an important topographical landmark. In Anatomy Lesson #10, The Chest, we learned that pectoralis major forms the anterior axillary fold as it passes from chest to humerus (Photo J). Now, in anatomy, if there is an anterior there is a posterior so the posterior axillary fold contains both latissimus dorsi (Anatomy Lesson #19) and teres major muscles. The armpit or axilla (anatomical term) lies between these two folds.

Try this: If you can, abduct one arm to the vertical position. Place the opposing fist into your axilla. Now open the hand and grip the front fleshy fold; this is the anterior axillary fold formed by pectoralis major. Move your fingers backward and grip the back fold of tissue: this is the posterior axillary fold containing teres major and latissimus dorsi muscles and scapula. Good job, students!

Photo J

Let’s find the above features using a Starz image. Here, Jamie’s wrists are bound and his arms elevated to about 95° of abduction (slightly above horizontal). In this position, the hollow of the axilla (turquoise arrow), anterior axillary fold (red arrow) and posterior axillary fold (black arrow) are clearly visible. Here, at Lallybroch, he receives his first beating from that ghastly and gruesome garrison commander (Starz episode 2, Castle Leoch). Herself writes (Outlander book):

They stripped off my shirt, bound me to the wagon tongue, and Randall beat me across the back with the flat of his saber. He was in a black fury, but a wee bit the worse for wear, ye might say. It stung me a bit, but he couldna keep it up for long.”

Try this: Grab a friend right inbetween the red and blue arrows and see what happens… You might want to jump back quickly once you make the grab. Just joshing! You probably dinna want to do that after all…..although I bet Rupert and Angus would be game.

Lets return to the humerus and study its distal (far) end which helps form the elbow joint (Photo K – anterior view). The shaft of the humerus flares near the elbow ending in two bony side knobs, medial epicondyle and lateral epicondyle. The tip of humerus bears two oddly shaped parts: trochlea (Latin meaning pully) and capitulum (Latin meaning small head), structures that articulate with two forearm bones.

Try this: Grip one arm about midway down with the opposite fingers and feel the hard bony shaft of humerus. Now, with elbow bent and palm turned to the sky, grip the elbow joint between thumb and index finger. Feel the bony knobs? The medial epicondyle lies nearest the body and the lateral epicondyle is away from the body. You cannot palpate trochlea or capitulum as they lie too deeply.

Photo K

In Anatomy Lesson #19, we learned that the upper limb between elbow and wrist joints is the forearm and it contains two bones, radius and ulna (Photo L – anterior view of right forearm). With palm up or facing forward, the longer ulna lies medially (little finger side) and the shorter radius lies laterally (thumb side). The bluish layers represent hyaline cartilage that covers the joint surfaces. The bones are united by a tough fibrous interosseous membrane. The top of ulna bears a bony projection, the olecranon with a large trochlear notch. With the bones parallel, the forearm is in a position known as supination: palms face forward or upward.

Try this: With a bent elbow and palm facing up palpate the bone along the back of forearm; this is the ulna. Most people can only palpate the distal (far) half of the radius as it nears the wrist on the thumb side; please feel yours. Find the bony olecranon or point of the elbow.

Photo L

Both ulna and radius participate in the elegant elbow joint. Here, the trochlear notch of ulna grips the trochlea of humerus like a pipe wrench; together they form a hinge joint that opens with extension and closes with flexion (Photo M – flexion). The disk-like head of radius (red arrow) cups the humeral capitulum and pivots on it during supination and pronation (described below). Thus, radius, ulna and humerus together form the two-part elbow joint.

Photo M

Although the head of radius and capitulum are loosely associated, a strong annular ligament holds the radial head against the ulna (Photo N – anterior view right elbow joint): red arrow marks the trochlea and yellow arrow indicates the capitulum of humerus.

Photo N

Now for a wee but important Clinical Correlation: In young children, the radial head is small and loosely seated in the annular ligament (Photo O). A quick jerk of a child’s upper limb can subluxate (partially dislocate) the radial head meaning it is pulled from the grip of the annular ligament. Also known as pulled elbow or nursemaid’s elbow, radial head subluxation is the most common upper-extremity injury in infants and young children who present at an emergency room (ER). It most often occurs as an adult holds a child’s hand and jerks the arm or pulls on it to prevent a fall; understand that the jerk can be minor or even trivial. Happily, reduction of the subluxated radial head is easily performed in the ER.

Photo O

Now let’s discuss forearm movement. Returning to this earlier image (Photo P), note radius and humerus lie roughly parallel in a forearm position known as supination. Here, palms may face either upward (flexed elbow joint) or forward (extended elbow joint).

Photo P

With palm turned downward (flexed elbow) or backward (extended elbow) the distal (far) end of radius crosses in front of distal ulna, a forearm position known as pronation (Photo Q). Due to ligament and muscle tension, pronation is the typical resting position of forearm and hand as it is more comfortable than supination. Lastly, with elbow joint extended and palms facing the body, the forearm lies between pronation and supination.

Try this: With bent elbow, turn palm up and palpate the forearm bones: they are parallel, the thumb points away from the body and the forearm is supinated. Keeping the bent elbow slowly turn forearm so the palm faces down. Watch the distal radius move from the side to the front of ulna and come to rest so the thumb points toward the body; the forearm is now pronated. Feel the radius move as you alternately supinate and pronate the forearm. Notice that the hand is passively carried with the forearm movements. Pronation and supination are possible because the radial head spins freely on the capitulum as distal radius swings back and forth. This ingenious design adds significant mobility to the upper limb enabling us to bring our hands in front of the face for fine manipulation of the environment!

Photo Q

Okey dokey, let’s find pronation and supination using dazzling images from Starz episodes. The first image is of Herself! Yes! And, this is the first time I have used Herself to teach anatomy: here in the form of fine-fabulous-fictitious Iona MacKenzie (Starz episode 104, The Gathering). Diana can now add actress to her prodigious resume!

Question: Is Iona’s left forearm pronated or supinated? Is her elbow joint flexed or extended?

Answer: Elbow joint is flexed. Forearm is pronated (pronation) meaning distal radius is crossed over distal ulna. You can determine this immediately even though her forearm is covered by lace and wool because the palms face down and thumb points toward the body. Ummm, Mrs. Fitz are ye are being a wee bit meow-meow towards Iona?

In the next image, Jamie is dismayed, defeated and deflated after his passionate battle of words with Claire (Starz episode 109, The Reckoning). His palms face up in an attitude of supplication. Herself describes it best (Outlander book):

…His voice cracked. “And when ye screamed, I went to you, armed wi’ nothing but an empty gun and my two hands.” … “You’re tearin’ my guts out, Claire.”

Question: Name the position of Jamie’s forearms.

Answer: Supination (supinated) meaning ulna and radius are parallel, palms face up, and thumbs point away from the body.

Let’s challenge ourselves with more complexity in arm and forearm movements. Here a gentleman walks his hounds at the farmer’s market (Starz episode 110, By the Pricking of My Thumbs). Forearms are behind his back. Palms face backwards.

Question: Name the position of his arms. Name the position of his elbow joints. Are forearms pronated or supinated?

Answer: Arms are extended. Elbow joints are flexed. Forearms are pronated. Remember: if palms face downward or backward, the forearm is in pronation. Do you get the idea? You can assess the overall position of the upper limb by considering its component parts and determining their individual positions.

Simple Simon met a pieman. Ha! Well, this Simon is anything but simple; he is the dirty Duke of Sandringham! Have ye ever witnessed a more dramatic pie cutting? Ye would think he was preparing to stab a boar! Hmmm….wish Black Jack Randall was hiding under that crust.

Question: Name the position of the Duke’s right arm and forearm. Hint: palms face toward the body.

Answer: His right arm is flexed. Now the forearm position is tricky. Place your own forearm in the same duke-position and judge the relationship of ulna and radius. Weel, it turns out that with the palm facing the body, the radius is between supination and pronation. Whaaat? No fair ye say? Dinna kill the messenger! The body does its own thing and we do our best to explain. Snort!

Enough of bones, let’s now examine three more muscles of the humerus and forearm: biceps brachii, brachialis and triceps brachii. Muscles of the arm are divided between two compartments: biceps and brachialis occupy an anterior compartment (in front of humerus) and triceps brachii occupies a posterior compartment (behind the humerus). Another image of Jamie at the Lallybroch beating (Starz episode 102, Castle Leoch) clearly shows the pronounced groove between the arm compartments: biceps and brachialis muscles lay above the red arrow and triceps lies below. Appreciate how beautifully muscles of chest, shoulder, arm and forearm interweave to produce the bonny ebb and flow of body contour; each muscle plays its part in this anatomical ballet.

Now for the muscles: biceps brachii (Latin meaning two-headed muscle of the arm) has a long head and a short head both of which take origin from the scapula and cross the glenohumeral joint. The two heads fuse into a single muscle belly that splits into two tendons that cross the elbow joint: a flat tendon joins the superficial forearm fascia (bicipital aponeurosis) and a sturdy tendon inserts near the head of radius (Photo R – anterior view). Because biceps brachii crosses two joints, it acts on both: it aids arm flexion but its major action is on the forearm where it supinates and then flexes the supinated forearm. Think about opening a bottle with a corkscrew: first the biceps unscrews the cork (supination) and then it pulls out the cork (flexion).

Try this: With bent elbow, grip your biceps and supinate the forearm (palm up). Now, alternately flex and extend the elbow joint. Feel the biceps contract and relax with this movement? Now pronate the forearm (palm down) and repeat; the biceps is mostly flaccid because it activates with the forearm in supination.

Photo R

Jamie provides a splendid example of his right biceps brachii as he is manacled to the flogging post at Fort William (Starz episode 106, The Garrison Commander)! BRJ circles like the depraved jackal he is. Most of the bulge seen at the red arrow is created by biceps brachii although some is due to the deeper lying brachialis muscle. Read on, please.

A short cautionary tale: A couple of years ago, a lady at my gym avulsed (detached) the short head of biceps from its scapular origin giving the muscle a “Popeye” appearance. The cause: she was lifting weights that exceeded her biceps strength. Unfortunately, she delayed seeking medical care for a few months by which time the biceps had scarred and the tendon was no longer eligible for surgical reattachment. If you suspect a tendon tear, prompt assessment and treatment promotes optimal outcome! A better weight-lifting strategy is to reduce weight load but increase number of repetitions.

The next muscle is brachialis; it lies deep to biceps brachii (Photo S – anterior view). Brachialis arises from humerus and inserts on ulna. Although overlaid by biceps, brachialis is actually the workhorse of the elbow joint because it flexes the joint regardless of forearm position.

Try this: With a bent elbow, return forearm to pronation, grasp the biceps region, now flex the elbow joint. The deep contraction you feel is brachialis.

Photo S

I can’t demonstrate brachialis with Starz images because it lies too deeply so let’s move on to the last muscle of this lesson, triceps brachii. As the name implies, triceps has three heads: a long head arises from scapula, a lateral head arises from upper humerus and a medial head arises from lower humerus (Photo T – posterior view). The heads unite as one muscle mass that turns into a stout tendon above the elbow joint and then inserts into the olecranon of ulna. The long head helps adduct and extend the shoulder joint but together all three heads extend the elbow joint especially against resistance such as with push-ups.

Try this: Grip your triceps in back of the humerus and alternately flex and strongly extend the elbow joint. Feel the triceps contract with extension and relax with flexion?

Photo T

The triceps brachii are clearly visible in well-muscled individuals such as JAMMF. Here the long head of triceps is marked by the yellow arrow and the red arrow points to the lateral head of triceps (Starz episode 107, The Wedding). The medial head cannot be identified because it lies deeply. Claire, the expression on your face … wowzers!

How about we entertain a short pop quiz using images from the latest Starz episodes? To set the mood, let’s consider the beautiful murmuration of starlings at the outset of Starz episode 111, The Devil’s Mark. If you have yet to see a significant murmuration, take a few and watch this one set to Johann Pachelbel’s Canon. Here, the murmuration dips, sways and undulates like a single living organism.

In the thieves’ hole, Claire recalls seeing starling murmurations as a child visiting Brighton. She explains that starlings perform their aerial ballet because there is safety in numbers from predators. Intentional or not, I swear I saw a murmuration of the mob at the trial and it is bloody brilliant! Watch again and see the crowd shout and surge forward each time Claire is skelped with the whip! Between blows, they fall back moving as a single organism. Safety in numbers to be sure, but this time the mob is predator and two accused are victims. Riveting and fascinating. Props to the extras and Claire!!!

Now for the pop quiz:

The first image is of that lousy, long-haired lass Laoghaire looking verra guilty, as she should (Starz episode 110, By the Pricking of my Thumbs)! Weel, she tried her best to seduce Jamie and left a nasty ill wish under Claire’s bed. If she had a firearm right now, she would likely fire it at Claire! Puir Mrs. Fitz, she hasna a clue about her cunning, manipulative “darling granddaughter.”

Question: What is the position of Laoghaire’s arms? What is the position of her elbow joints?

Answer: Both arms are abducted to 45°. If you answered just abduction, that is fine. But, feel free to modify an answer for further accuracy. Both elbow joints are flexed.

Here’s kindly Mrs. F. anointing motherly Mrs. F. with salve. Och, those deadly ovens at Castle Leoch have burned her yet again (Starz episode 110, By the Pricking of my Thumbs)! But, as per Letitia, she bakes yummy bannocks!

Question: Name the position of Mrs. Fitz’s right forearm.

Answer: Right arm is pronated (palm faces downward).

Our fabulous hero barely has time to draw his dirk after a sneak attack by Alexander MacDonald (Starz, episode 110, By the Pricking of my Thumbs)! Fear not, his retaliatory move is breath-taking! Like Joshua or David of the Old Testament, Jamie drops to his knee and fells his opponent with a single blow to the right hamstring. Take my word for it, Alex willna be walking well after that. Hummmm, cowardly Duke cowers behind the tree.

Question: Name the positions of Jamie’s right arm, elbow joint and forearm.

Answer: His right arm is flexed, elbow joint is extended and forearm is pronated (palm down). By golly, this is fun!

Jamie didn’t emerge Scot free (haha) from that “common brawl” – his own blood was spilled (Starz, episode 110, By the Pricking of my Thumbs)… “You’re not normally a closed-mouth woman, Claire. I expected noisier displeasure!” Claire’s lips are sealed as she stitches Jamie’s wound. He attempts to sooth her with “’Tis but one more scar, Sassenach. Nothing to brood over.” You wanna bet? Ouch! Her stitching of that gaping wound sans anesthesia isna tender. She is royally pissed! He kens he’s getting the silent treatment; that needle speaks more eloquently than a thousand words! Stalwart Jamie sits with shoulders back and weight supported by his hands.

Question: Name the position of Jamie’s elbow joints and arms (this question harkens back to the arm movement review at the start of this lesson).

Answer: Lateral rotation of arm. Elbow joints are extended.

Here’s our Highland hero with both sword and dirk drawn (Starz episode 111, The Devil’s Mark). He barreled down the steps scattering men like pins in a bowling alley! His intent is clear “first man forward will be the first man down.” Lads, odds may be five or six against one but Jamie means it! Back off! Outlander book sets the stage verra well:

“I draw it in defense of this woman, and the truth,” he said … Jamie looked the judges over coolly…”I swore an oath before the altar of God to protect this woman. And if you’re tellin’ me that ye consider your own authority to be greater than that of the Almighty, then I must inform ye that I’m no of that opinion, myself.”

Question: Name the position of Jamie’s arms, elbow joints and forearms:

Answer: Arms are abducted to 90 ° (a.k.a. horizontal abduction), elbows are extended, forearms are between pronation and supination (palms face toward the body if arms are lowered).

Students, you did very well on the pop quiz. Thanks for playing along!

Now, let’s end this lesson with a bit of history. Human anatomy (Greek meaning to cut away) is considered the oldest medical science. Millennia passed before western culture permitted and embraced dissection of the human body thus keeping in place centuries of inaccurate concepts and teachings. More pertinent to today’s topic, accurate anatomical drawings of the upper limb have been available for not quite 500 years. Some of the earliest and most elegant anatomical drawings were done by Renaissance genius, Leonardo Da Vinci (1452-1519). Although not the first to draw the upper limb, he broke ground because his images included comparative anatomy between species as well as drawings of the living and the dead. Although his paintings were widely known during his lifetime, only a few associates were aware of his anatomical research. He never worked as a professional anatomist, he never taught the subject and unfortunately, he never published his anatomical observations which would have greatly advanced the science of anatomy. Photo U shows his wonderful progressive drawings of shoulder, arm and forearm musculature. Although not quite anatomically correct, they are very close. This image is a replica of one of 600 Da Vinci drawings housed in The Royal Library at Windsor Castle, one of the finest private collections in the world. BTW, upper right image is a rendering of hard and soft palates and tongue. Not sure why it appears on the same page as the upper limb; mayhap to save paper?

Photo U

Hope you enjoyed the lesson on the arm and forearm. Knowledge is power: forearmed is forewarned!

A deeply grateful,

Outlander Anatomist

Photo creds: Starz, Netter’s Atlas of Human Anatomy, 4^th ed., Clinically Oriented Anatomy, 5^th ed., Human Anatomy, Martini and Tiimmons, 1st ed., Gray’s Anatomy for Students, 1^st edition, www.baycarehealth.adam.com, www.eorthopod.com, www.methodistorthopedics.com, www.stephanierose156.blogspot.com, www.Wikipedia.com

April 14, 2015August 9, 2018

“To Arms, Too Arms, Two Arms!”

Welcome to Anatomy Lesson #19: The Arm. Wonderful arms of all types inhabit the Outlander books and the Starz series including BJR’s “long arm of the law” (he has too many arms; the blackguard is a heartless squid), Jamie’s willingness to “give an arm or a leg,” anything to be free of that mad Captain of Dragoons, the highlanders who are frequently “up in arms” fetching Claire from her scrapes and Claire’s efforts “to keep at arm’s length” the teenage witch, Laoghaire (Lass, stay away from me and my hubby!). An anatomy lesson on this topic serves us well!

Let’s review…In Anatomy Lesson #4, you learned that anatomists divide the upper limb into shoulder, arm, forearm and hand (Photo A). The shoulder extends from base of neck to shoulder joint (Anatomy Lesson #2). The arm extends from shoulder joint to elbow joint. The forearm is between elbow and wrist joints. The hand lies distal to (away from) the wrist. The human upper limb enjoys a high degree of mobility with the ability to grip, strike and conduct fine motor skills. Although many of these abilities are rightfully credited to the hand, the shoulder joint is the most mobile joint of the entire human body and thus adds its credentials to upper limb versatility.

Photo A

We’ll begin the lesson with dem bones (shades of Joe Abernathy): The bony skeleton of the upper limb provides the foundation for its functions. Anatomy Lesson #2 and Anatomy Lesson #3 discussed three bones of the upper limb that are important again today: clavicle, scapula and humerus (Photo B). Each upper limb contains 32 bones but the remaining 29 bones will be postponed for later lessons.

Photo B

First, the clavicle: As noted in previous lessons, human clavicles act as struts holding each upper limb away from the torso and allowing for increased range of motion. Viewed from the front (Photo B) the clavicles appear to be straight bones but this is not so. Viewed from above (Photo C – superior surface) each clavicle is S-shaped: The sternal half curves toward the viewer, the acromial half curves away from the viewer and the acromial end curves forward again to complete the S-shape.

Due to muscle pull, the clavicle curves more deeply in athletic individuals or manual laborers such as our hard-working farm-lad, JAMMF. The sternal end articulates with the manubrium at the sternoclavicular joint (Anatomy Lesson #15). The acromial end articulates with the acromion at the acromioclavicular joint (Anatomy Lesson #2). Both joints are typically visible in the lean and fit.

Try this: Demonstrate the S-shape by placing fingers on the sternum and following one clavicle towards the shoulder point. Near the sternum, the clavicle is subcutaneous, but nearer the side it becomes more difficult to palpate because it curves backward; at the acromioclavicular joint, it curves forward again.

Photo C

For our viewing pleasure, Claire presents us with a perfect pair of, erm, sternoclavicular joints (Starz episode 107, The Wedding)!

And, several students have asked if the knobs on Jamie upper chest are due to prior injuries (Starz episode 107, The Wedding). No, these are normal acromioclavicular joints.

The next bone is the weird-looking scapula which on side view resembles a ship’s propeller (Photo D). The red arrow marks the acromion or point-of-shoulder; the green arrow shows the pear-shaped glenoid cavity for articulation with the humeral head; the yellow arrow marks the inferior angle.

Photo D

Each scapula is large, thin and triangular in shape (Photo E – posterior view). The medial border lies parallel to the vertebrae. A large scapular spine arises near the medial border and ends as the acromion. The inferior angle lies at the 7^th intercostal space and is used as a clinical landmark. The small glenoid cavity is at the side. Like puzzle pieces, acromion and clavicle meet at the acromioclavicular joint (green arrow) and the humeral head glides in the glenoid cavity at the glenohumeral joint (red arrow); strong ligaments and muscles stabilize these bony interactions.

Try this: Only a few scapular landmarks are readily palpable. Feel the subcutaneous acromion or point of shoulder. Cop a yoga pose or choose a partner and feel the long medial border and inferior angle. Follow the scapular spine which is mostly subcutaneous. You cannot palpate the glenoid cavity because it lies too deeply.

Photo E

Clad only in her low-backed shift, trim Claire is our beautiful model for her right scapula (Starz episode 107, The wedding). The long medial border (red arrow) lies parallel to the vertebral spines, the scapular spine lies mostly horizontal (green arrow) and her shift covers the inferior angle (yellow arrows).

Together clavicles and scapulae form the pectoral girdle, an incomplete bony ring that supports both upper limbs. An aerial view (Photo F) shows the pectoral girdle sans skull and humeral bones (Can you identify the dens of C2 vertebra?). The sternum (yellow arrow) stabilizes both clavicles (blue arrows) at the sternoclavicular joints (green arrows). Scapular spines are marked by the red arrows. Clavicles articulate with acromia at the acromioclavicular joints (pink arrows).

Hopefully this visual clarifies how the clavicles serve as struts holding upper limbs away from the torso and how both upper limbs hang from the bony pectoral girdle. Lastly, force from a blow to either arm is transmitted along the clavicle to the sternum where it is absorbed by the bony thorax. It’s quite an ingenious and elegant design from which to hang our arms, ye ken?

Photo F

Radiograms increase understanding so this x-ray (Photo G) shows a left pectoral girdle including clavicle (blue arrow) and scapular spine (red arrow). The yellow arrow marks the articulation between head of humerus and glenoid cavity of scapula at the glenohumeral joint. The humeral shaft is stretched to your right.

Photo G

Despite his well-muscled physique, Jamie’s pectoral girdle (Starz episode 109, The Reckoning) can be appreciated from Claire’s perspective. The red arrow marks the medial upper border of scapula, yellow arrow points to acromioclavicular joint and green arrow marks scapular spine. We can be certain that while we might value this anatomical perspective we all know that Claire is most appreciative and well-deserving and all that…ahem and amen! Gah, what a sublime pectoral girdle and bonny hair!

Each arm contains only one bone, the humerus (Photo H); its large head glides within the small, shallow glenoid cavity at the glenohumeral joint (GHJ). A ball and socket joint, the GHJ is highly moveable but not very stable because of the size differential between head and socket although a cartilage labrum (lip) helps deepen the socket and ligaments and muscles help stabilize the joint. Just below the humeral head is an anatomical neck. The region marked surgical neck is noteworthy because it is the mostly likely site to sustain a fracture to the upper humerus. A bony elevation halfway down the humeral shaft is the deltoid tuberosity. The lower end of humerus helps form the elbow joint but it will be covered in a later lesson.

Photo H

Being a ball and socket joint, the glenohumeral joint is multi-axial meaning the humeral head moves with many degrees of freedom inside the glenoid cavity. Basic movements are shown in Photo I but other movements of the arm are combinations of these basics. Flexion draws the arm forward. Extension draws the arm backward. Abduction moves the arm away from the body midline. Adduction moves the arm toward the body midline. Lateral rotation turns the arm outward and away from the body center. Medial rotation turns the arm inward and toward the body center. Circumduction is a circular motion of the arm as in back stroke or baseball pitch, a movement that may be performed clockwise or counterclockwise. A bent elbow joint is not required to perform these motions.

Try this: execute each of these movements with one arm.

Photo I

Can we see these arm movements in the Starz Outlander episodes? Oh, to be sure!

This is a wonderful example of a horrible man “up in arms” when things don’t go his way. BJR’s arm is in flexion as he fires an empty musket at Jamie. Surprise! (Starz episode 109, The Reckoning)!

And this is a great example of humeral extension at the start of the best make-up-sex-ever-filmed (Starz episode 109, The Reckoning)! Jamie canna wait to remove his sark. Both arms are draw backwards as he sheds that garment…off ye damn shirt!

Try this: extend both arms behind your back. Most people can extend the arms to a 45° angle. If ye are flexible, extend arms behind your back and interlock fingers. Gently lift your arms more than 45° but not if it hurts. Good job!

Handsome Dougal is next (Starz episode 109, The Reckoning). Yes! An army of leddies have been clamoring for more of our bold Highland war chief! Both arms are drawn against his sides in full humeral adduction as he awaits Colum’s tongue-lashing. I love this scene! With little more than a sideward glance, a twitch of the ‘stache and some brow crunch, Dougal conveys fierce frustration with his meddling Laird-bro.

Next, Claire offers a fine example of humeral abduction with arms akimbo awaiting Professor Angus’ stabbing lesson (Starz episode 108, Both Sides Now). Two arms are drawn away from the body midline although bent elbows aren’t required for this action. Doesna that gown look fantastic on her trim torso?

Now, I dinna want to rekindle a fire storm with this next image, but Laoghaire offers (weel, it’s not all she offers) an excellent example of lateral rotation of the arms (Starz episode 109, The Reckoning). Here she sheds her cape while aiming her 16 year-old charms at new hubby Jamie. Two arms are turned outward and away from the body center. She knows this position gives her better advantage to show off her, um, well to show off! Geez, where did she find that corset with the wee side vents? Mayhap she raided Granny Fitz’s hidden trunks where Claire’s awesome closet resides (kudos to Terry & Co on another unique costume that tells a story all its own)!

Here are contracted arrector pili muscles. Mmmphm, must be a tad chilly by the burn! Oops, wrong lesson! Goose flesh belongs wit’ the skin in Anatomy Lesson #6. But, if ye ken yer anatomy verses, ye can pretty much identify anything! Moving on….

I always laugh at this image of our elegant Claire caught in a not-so-elegant squat (Starz episode 105, Rent). As she hikes up her skirts to pee in the pot, her right arm is turned inward and towards the body center as in medial rotation. Geez, Angus you buamastair (oaf), knock next time! Who knew wild women waulked wool?

Finally, Dougal’s guilty rampage over the death of his not-so-bonny wife Maura presents several outstanding displays of humeral circumduction (Starz episode 110, By the Pricking of My Thumbs). The image below shows counterclockwise circumduction (as in pitching baseball). Watch the entire scene again to see his arm movements; they are fantastic! Dougal is a sad Shakespearean mess in this scene but his acting chops are top shelf. Good thing Nurse Claire ministers one of her Spanish potions before he slices and dices everyone and everything in the hall brawl!

Now that we ken arm movements, let’s discuss arm muscles: a whopping 17 muscles per side move the shoulder and arm. Eight of these muscles move the pectoral girdle which indirectly alters humeral position. Nine muscles directly move the humerus. Any wonder humans enjoy such versatility in shoulder and arm movement? There is no way 17 muscles can be covered in a single lesson so today we will review trapezius, latissimus dorsi and pectoralis major and learn a new muscle, the deltoid.

Trapezius was discussed in Anatomy Lesson #2 and Anatomy Lesson #3 (Photo J). This muscle acts directly on the shoulder joint and indirectly on the humerus. Arising from skull and vertebrae, it inserts on scapular spine, acromion and clavicle. Upper fibers lift the shoulder joint dragging the humerus along for the ride; middle fibers retract (pull back) shoulder joint and humerus and lower fibers depress (pull down) shoulder joint and humerus. The bottom line: more shoulder movements = more arm movements. Trapezius creates the web between base of skull and acromion and is most prominent in the muscular.

Figure0407A trapezius 01 KLS edited

Photo J

Here’s a delightful example of Claire’s beautiful trapezius as she reaches for Jamie’s mouth (Starz episode 109, The Reckoning). Jamie was out to master Claire but discovers there’s a price to pay. Sorry laddie, every coin has its flip side. Herself’s magic pen strikes again (Outlander book):

“Oh, aye, Sassenach,” he answered a bit ruefully. “I am your master … and you’re mine. Seems I canna possess your soul without losing my own.”

The next review muscle is latissimus dorsi (Anatomy Lesson #10). These large flat fan-shaped muscles arise from vertebrae, sacrum and hip bones via the thoracolumbar fascia. Fibers wrap around the body, converge and insert into each humerus (Photo K). Latissimus is the only human muscle connecting upper and lower limbs, making it a potential powerhouse for lifting body weight!

Photo K

As latissimus dorsi nears the armpit (axilla), it turns tendinous before inserting on the humerus (Photo L – front view). It extends, adducts and medially rotates the arm. Latissimi dorsi (pl.) are the pull up (palms face forward) and chin up (palms face backward) muscles.

Photo L

Jamie is our poster boy for latissimus dorsi (Starz episode 106, The Garrison Commander). Here his left muscle clearly sweeps from the lumbar spine, around the body and upward to end on the humerus. Captain Randall is our poster boy for the maddest-baddest villain in literary and TV history!

The third review muscle is pectoralis major (Photo M). It has two heads: one from the clavicle and a second from sternum and ribs (Anatomy Lesson #4). A wee slip comes off abdominal structures but anatomists often ignore it. Muscle fibers converge as they approach the humerus where they insert near latissimus dorsi. Pec major flexes, adducts and medially rotates each arm.

Oh, and many students ask the name of the large vein traversing the arm and disappearing between deltoid and pectoralis major muscles. This is the cephalic vein, so named because it carries blood in a headward direction. And, the groove it runs in between deltoid and pectoralis major is the deltopectoral triangle.

Photo M

Half-clad Jamie is our model yet again (Starz, episode 105, Rent). Well-developed pec majors are clearly visible under the skin. Red arrows mark clavicular and sternocostal heads. Puir lad, he dinna get no Dougal R-E-S-P-E-C-T!

The fourth and last muscle is the deltoid, named because it resembles an inverted capital delta Δ, 4th letter of the Greek alphabet. Viewed from the side, the shape is clear: broad at the top narrowing to an apex at the bottom. Each deltoid arises from clavicle, acromion and scapular spine (Photo N) and inserts on the deltoid tuberosity of humerus (Photo H). Middle fibers contract to abduct the arm; front fibers flex and back fibers extend the arm.

Photo N

The next image shows Jamie’s fantastic right deltoid when he and Claire are still vertical (Starz episode 109, The Reckoning). The posterior border is marked by a red arrow, anterior border by a green arrow and insertion (hehe) on the deltoid tuberosity (hehe) by a blue arrow (canna help it, anatomists have a ribald sense of humor).

Okey-dokey, we are done with the arm muscles. For fun, let’s examine images from Starz episode 109, The Reckoning, for more arm movements. See if you can you identify the arm positions – some are combos.

1: Name the position of Jamie’s right arm and of his left arm.

Answer: Jamie’s right arm is flexed and his left arm is abducted. Get the idea? I knew ye would like it – this is gobs of fun!

2: Next, for our viewing pleasure, BJR has just taken an assisted face plant on the desktop and is out for the count: 10-9-8-7-6 …… name the position of his left arm.

Answer: flexion

Let’s take a keek-peek at our first couple’s first fight! Whew, as much passion here as on the mattress, um, floor! Claire’s aboot to knock some brains into that hard-as-an-iron-pot highland skull!

3: Name the movements of Claire’s left arm (there are two).

Answer: Abduction and flexion.

No question here, but I call this “the slap heard round the world!” Ouch Jamie, she wallops you in front of yer three best bros? Whew, they are going at it “hammer and tongs.”

In the next image, Jamie’s right arm is lifted up, up and away from the body midline (his button line). Aye, he is blistering Claire’s bum with his doubled belt. Weel, Claire, ye did put the entire party in peril and you promised Jamie you would be at the grove when he returned. Och, dinna make promises ye canna or willna keep. Herself explains Claire’s view of the spanking (Outlander book):

I felt deeply betrayed that the man I depended on as friend, protector, and lover intended to do such a thing to me. And my sense of self- preservation was quietly terrified at the thought of submitting myself to the mercies of someone who handled a fifteen- pound claymore as though it were a flywhisk.

4: What movement is performed by Jamie’s right arm?

Answer: vertical abduction (as in “Reach for the sky, partner!”). The downward smack is adduction.

Here, Jamie tap dances for his beloved (mayhap he enjoyed that abduction/adduction a bit too much?). Lad, if ye ever want to do the horizontal boogie with Claire again ye better buckle on those show-biz shoes and get on wi’ it! You’ve done considerable damage spanking yer new wife. Herself explains (Outlander book):

“Whatever the justice of the situation—and I had to admit that at least some of it lay on his side—my sense of amour-propre was deeply offended….”

Ohhhh, she is royally pissed – in such a cold fury she brushes that same curl at least 200 strokes and we all ken that 100 does the trick!

5: Name the position of Jamie’s arms.

Answer: the begging position…Hah. No, both arms are abducted.

Good job with identifying arm movements! Before this lecture ends, I canna help but offer a few wee anatomical observations from Starz episode 109. We ken well that Jamie was shot through his right trapezius so I was happy-happy to see scars! First we see the exit wound (blue arrow)….

and we also see the entrance wound (red arrow)! Yessss, the special effects folks remembered that Jamie’s gunshot wound must have two scars!

Whaaat? – Entrance wound in back and exit wound in front? Well yes, Herself being the final arbitrator of such supreme-court issues (from Outlander book)!

No, when we were running from the English, I realized we were near the edge of the Fraser lands, and I thought I’d take my chances there. So I spurred up and cut to the left, around Dougal and the rest. There was a good deal of shooting goin’ on, mind ye, but the ball that hit me came from behind. Dougal, Rupert, and Murtagh were back of me then. And the English were all in front—.“

In the afterglow of bliss-land, our newly-wed redhead looks a bit worse for wear after Claire extracted her own measure of justice! We book readers expect cheek scratches but did ye ken his neck gouges (red arrows)? Herself writes (Outlander book):

It had been a most unpleasant night. My reluctant acquiescence had lasted precisely as far as the first searing crack of leather on flesh. This was followed by a short, violent struggle, which left Jamie with a bloody nose, three lovely gouges down one cheek, and a deeply bitten wrist.

Weel, if ye bed a vixen … Come here vixen and bite me again!

To arms! To arms! While not anatomy-related, did ye see the mushroom-shaped cloud over Fort William – proof that toxic waste in the form of BJR resides inside that stony edifice!

This last image is verra funny. Jamie’s right arm is in fine fettle as he sends many rocks artfully skipping across the burn. But as soon as Laoghaire sidles up, his verra next toss goes kerplunk! The stone drops like, well, like a rock. Let that rock-flop be a warning to ye laddie; she is NO a good girl … she’s armed, dangerous and on a stealth mission!

To Arms! Too Arms! Two Arms! That’s it for the bones, muscles and movements of the arms. Raise yours in grateful joy! Aren’t they grand?!

A deeply grateful,

Outlander Anatomist

Photo creds: Starz, Gray’s Anatomy, 39^th ed., Netter’s Atlas of Human Anatomy, 4^th ed., Clinically Oriented Anatomy, 5^th ed., Hollingshead’s Textbook of Anatomy, 5^th ed., www.bestperformancegroup.com, www.ceessentials.net/article31.html, www.wikipedia.com