Anatomy Lesson 5: “Claire’s Skin” – “Ivory, Opal and White Velvet”

Greetings, followers of Outlander Anatomy! Today’s Anatomy Lesson #5:  The Skin – Part 1 is extraordinarily important (as are all anatomy lessons) and ye wouldn’t want to get skinned for skipping what is vital to yer own well-being as we learn about our skin!

WARNING! This post includes spoiler alerts and the image of a dissected human body. If you are a bit squeamish about such images, you may want to skip it. Dougal will give ye a second warning just prior!

OK, now, about skin….Herself writes about skin throughout all of the Outlander books where it is used to define characters, enhance scenes, and provide a substrate for Claire’s practice of medicine. As ye ken, the Starz Outlander series and the books are told in the voice of Claire, our braw and lovely heroine! Thus, we must rely on images or observations made by others to inform us as about Claire’s skin which I will use to segue into today’s anatomy lesson!

Let us begin…

In Starz episode 1, Sassenach, we see Claire and Frank driving through the Scottish countryside. On a second honeymoon, they are trying to reconnect after serving apart in WW II. We see that Claire has very pale, clear skin framed by a mass of curly, brown hair.

image

Herself informs us through polished, sophisticated and urbane Frank that Claire’s ”…skin glows like ivory.” Then Frank makes love to Claire in the grass at the base of Craigh na Dun where he tells her that her skin is like white velvet. Because I don’t have images to match these descriptions, I substitute one from a later episode (Starz episode 6, The Garrison Commander), so along with Frank, we may witness Claire and her beautiful skin!

image

Next, in a very telling scene from Starz episode 3, The Way Out, Mrs. Fitz helps bathe and dry Claire despite to her protestations; Claire avers that she is able to tend to her own ablutions! But a persistent Mrs. Fitz kindly observes:

Such beautiful skin ya’ have! I’ve never seen a woman past 8 or 9 with skin so unmarked by injury or illness. Yer next husband will be a lucky man!

Aye, that he will…chuckle!

image

To me, Claire’s beautiful skin is most telling (Starz episode 8, Both sides Now) during the assault by the redcoat deserter. She wears virtually no makeup, nor is any required in my opinion! Her skin is very pale, very clear and her nose and cheeks are endowed with a faint sprinkle of freckles.    Claire also looks very vulnerable, very young and absolutely LOVELY despite the unspeakable situation she finds herself in! I can say this without prejudice because I am an anatomist! Ye ken?

image

But, the ultimate proof comes from Jamie himself: in Outlander, he tells Claire that she has skin like anopalas he slowly traces a finger along her collar bone making her skin glow beneath his touch! And, again from our hero:

“Mo duinne,” he said softly. “But now I should say mo airgeadach. My silver one. Your hair is silver-gilt and your skin is white velvet. Calman geal. White dove”.

Again, no images to match the words, so let’s use this lovely substitute!

image

Hey! Mukker! Are ye still wit’ me?! One last image before we git on to our science lesson! In Starz episode 3, The Way Out, Claire is summoned by the MacKenzie. Colum removes his kilt asking her to massage his aching legs. He also asks Mistress Beauchamp if she sews as well as physicks to which Claire responds: “only flesh, a rather poor garment, I’m afraid.” My cue! Weel, I am athinkin’ that Claire’s answer to Colum was deliberately a wee bit coy and evasive because she would know that skin is NO a puir garment at all!

image

So, now we segue into Anatomy Lesson #5, The Skin…folks, I am here to tell ye that the skin is absolutely a remarkable garment! Ye will no be amiss to think of it as your own personal space suit that enables you to live a terrestrial rather than an aquatic life!  It is also the major barrier between a rather inhospitable world and yer insides! Yes, it gets diseased and injured because we are mortal, after all. But, it serves us verra well so please read on!

If ye are squeamish, ye may wish to skip the next image or heed Dougal’s advice…

image

A few years back, German anatomist, Professor Gunther von Hagens brought his world-renown Body Worlds exhibit to my neck of the woods. I was privileged to deliver the key note lecture before the event and was Professor of Anatomy on opening night where I gave mini-lectures and answered questions posed by attendees. Of the many extraordinary figures at that exhibit was one of a man holding his own skin and gazing at it in awe (Photo A). I hope after reading this post, you too will view your own skin with the awe it so richly deserves!

image Photo A

First off, skin is an organ. Yes, it is! It is also the heaviest organ of the human body! Really, ye say? Yup, it accounts for at least 8% of our body weight (some studies claim as much as 16%) and covers a surface area of about 20 ft2 or 1.9 m2! Want to determine the weight of your own skin? It’s simple! Just multiply your weight in pounds or kilos by .08 – the answer is the approximately the weight of your own skin!

Skin also produces all of our body hair, fingernails, toenails, sweat glands, sebaceous glands, the female breasts and the male nipples and areolas.  All of these appendages are skin derivatives and therefore part of the organ itself. Earlier, I mentioned Claire’s hair and now ye ken why because hair is part of the skin. But, as Claire’s hair makes for an interesting subject in its own right, I will address hair in my next post: The Skin – Part 2! And won’t it be fun to see the Outlander Starz results in it’s “hair as a character” poll this Saturday!

image

Ok, this next one is a gratuitous shot…sorry I just canna help it! Weel, not entirely gratuitous – it does show hair and skin and one other thing I havna yet told ye: the enamel of the teeth is derived from modified skin of the mouth. Geez, even his teeth are gorgeous! Get a grip prof! Focus!

image

Ahem…now, back to the lecture! Skin thickness varies throughout the body; some skin is thick for protection such as on the soles of our feet or thin as on our eyelids where thickness is not required. Skin is also more heavily pigmented in some areas (nipple and areola) than in others (belly). Most of the skin bears either fine or coarse hairs but some areas are completely devoid of hair: the so-called glaborous surfaces of the body such as the palms and soles where hair, if present, would interfere with grip.

Skin is composed of two important layers: a thin outer epidermis that sits atop a thicker inner dermis (See photo C). Deep to the dermis is the hypodermis; although not part of the skin, it is important because it helps anchor the skin to underlying structures such as muscle or bone (Photo B). In addition, some skin structures are actually anchored in the hypodermis.

imagePhoto B

The epidermis is composed of skin cells and some other cell types. It also completely replaces itself about every four weeks, with new cells forming at the base and advancing toward the surface where they die and slough. So, cells at the skin surface are flat and dead – these cells exfoliate naturally (did ye know that a large portion of house dust is shed skin cells?) or ye pay for exfoliation by costly products or at expensive salons (Photo C – this 3-D image was taken with a powerful scanning electron microscope or SEM)!  The supporting dermis houses two types of sweat glands, sebaceous glands, blood vessels, hair follicles, and special microscopic endings for sensation.

image Photo C

So what about sweat glands? The skin actually includes two different types: apocrine sweat glands are present only in the arm pits (axilla in anatomy, remember?) and our private regions (perineum in anatomy). The thicker sweat from these glands is initially odorless but when acted on by skin bacteria, it develops a pungent, acrid smell. This is the unwashed male that Claire muses on while sharing Jamie’s mount (Outlander book) – although females most certainly battle the same issue! A second type, the eccrine sweat gland, is ubiquitous throughout the remaining skin; sweat from this gland is watery and usually exudes an ammonia smell. Photo D shows the multiple openings (pores) of eccrine sweat glands on the finger pad.

image

Photo D

The process of sweating from eccrine sweat glands is captured in Photo E.  Here, following exercise, blue sweat droplets bead on skin from the back of the hand. This 3-D photo was again taken the powerful SEM. The colors, however, are not real – they were computer generated.

image

Photo E

As fer the sebaceous glands, I’ll be leaving those until my next post: The Skin – Part 2! Next, a question commonly asked by students: what causes the wide variation in human skin tones (see Photo F)?

image

Photo F

Weel, it turns out that there are a number of reasons for our individual skin color.  One cause is the number of blood vessels in the dermis and the color of blood surging through them (bright red arterial blood versus duskier venous blood).  Just fer fun, let’s compare and contrast the color of Claire skin wit’ that of Jamie’s in this image from Starz episode 1, Sassenach. We clearly see Claire’s naturally cool and pale complexion but partly because she is royally pissed, holding herself aloof from all the male funnin’ goin’ on around her. But, Jamie’s skin is strikingly different! Although Jamie is splattered in blood and he has naturally ruddy skin, it is enhanced in this scene having exerted himself in battle and during Claire’s recapture so ye can bet at this point there’s a whole lot of bright red arterial blood circulating through the vessels of his dermis!

image

Another contribution to overall skin color depends on how much carotene we consumed in our diets: carotene is an orange pigment prevalent in fruits and veggies such as cantaloupe, sweet potato and carrot (Photo G). Carotene absorbed from our food gets deposited in the epidermis where it adds to skin color and also helps protect epidermal cells from damage by UV light.

image Photo G

But, the most significant contribution to skin color comes from special cells of the epidermis, the melanocytes (Photo H). These scattered squid-like cells produce and package the pigment, melanin, into granules that are released into surrounding skin cells. Interestingly, the number of melanocytes in a given region of the skin is the same regardless of skin tone or gender. So, differences in skin color are due mainly to differences in the number and size of the melanin packets produced and this in turn is determined by genetics! In darker skins, the melanin granules are larger, more numerous, persist longer and are distributed throughout the epidermis.  Pale skin has fewer, smaller melanin granules that are confined to cells at the base of the epidermis and degrade more quickly.

imagePhoto H

Ye can deliberately increase the production of melanin granules and darken existing melanin in yer own skin by exposure to UV light either from the sun or from tanning beds. I ken the beds are a very popular trend, but I want to WARN ye: For some very sound medical reasons, ye should NOT expose yer skin to UV light from tanning beds and ye should also be judicious about tanning from the sun’s rays too, especially if ye are fair of skin like Claire! I urge ye to get informed about it!

Now, ye are all are probably aware of albinism (Photo I), a condition affecting animals (humans, spiders, snakes, apes, etc.) where the sufferer lacks an enzyme needed to make melanin (albinism occurs in plants too but is due to an absence of chlorophyll). Albinos (Latin: albus for white) do NOT make any melanin in the skin, hair or the irises of the eyes!  This is a difficult condition because their eyes are highly sensitive to light (photophobia) and they have difficulty tracking the eyes normally. The skin is also highly susceptible to skin cancers!  It is a condition which, at present, has no cure but there are steps that can be taken to protect the skin and aide the eyes.

image Photo I

Finally our skin has a battery of sensory endings specialized to detect changes in our environment and transmit these to our nervous system. The fingertips alone have about 2500 of these receptors per cm2 (about 0.2 in2) of skin!  I’ll not show pictures of these endings because they are a wee bit too technical. In summary, then, here is a short list of what skin does for Claire and for us all!

  1. It is an anatomical barrier against pathogens and damage.
  2. It provides sensation in the form of pain, touch, pressure, heat, cold and vibration.
  3. It regulates our body temperature by dilating or constricting blood vessels in the dermis and cooling the skin by the evaporation of sweat.
  4. It helps control fluid loss.
  5. Helps synthesize vitamin D via UV radiation.
  6. It aids in excretion of waste products.
  7. It aids in communication: others assess our mood, physical state or attractiveness by the state of our skin.

Impressed yet? I know I am and I’ve been teaching this subject for a verra long time!

Speaking of mood, let’s close wit’ this touching image from Starz episode 7 The Wedding, where Jamie pays homage to the skin of his bride of astonishing beauty with a soft murmur and a tentative touch!

image

Aye, Jamie, ye are ready!  And, so is Claire – she sure took long enough!  Snort!

I do hope ye have a better understanding and appreciation of the skin ye are in and have an increased desire to take verra good care of it!

A wee note of explanation: I will also continue my convention of typically using the character’s names rather than the names of the actors. This gives the cast at least one degree of separation and a wee bit o’ respect as I dissect their bodies on a blog! I hope ye all understand.

The deeply grateful,

Outlander Anatomist

Images are from Starz Outlander series. Microscopic images and drawings from Netter’s Atlas of Human Anatomy, 4th ed., Bailey’s Textbook of histology, 10th ed. or Bloom & Fawcett’s Concise Histology, 2nd ed, and the National Geographic, Skinned man from Body Worlds exhibit (sans the fig leaf), CGI image of epidermis and dermis from Loyola University Dermatology website, Baby photo from an older United Colors of Benneton ad, Photo of carrots from Gov. of West Australia and fig leaf from ClipArt, Archival photo of albino man taken by an unknown photographer – beginning of the 20th century.

Anatomy Lesson 4: “Jamie’s Chest – 8th Wonder of the World!”

Greetings friends of Outlander Anatomy and welcome to today’s lesson! Do you recognize the classic seven wonders of the world?

  • Colossus of Rhodes.
  • Great Pyramid of Giza.
  • Hanging Gardens of Babylon.
  • Lighthouse of Alexandria.
  • Mausoleum at Halicarnassus.
  • Statue of Zeus at Olympia.
  • Temple of Artemis at Ephesus.

The 8th wonder is, of course, James Fraser’s chest!

Getting in a mood, let’s take a wee keek at the breadth (Uncle Dougal, ye are a crud for exposing your nephew like this!)…

image

And the depth (BJR, man, ye are darkness itself!):

image

Of this very timely topic!

Now, we all ken that Claire gets her first TV looksee at Jamie’s blest-chest in Starz episode 102, Castle Leoch. But, Herself wrote in Outlander that Claire made touchdown with his chest when he fainted from blood loss after Cocknammon Rock:

“Stop! Help!” I yelled. “He’s going over!” … Jamie slid off headfirst like a sack of stones, luckily landing in someone’s arms. The rest of the men were off their horses and had him laid in a field by the time I had scrambled down. “He’s breathin’,” said one.

“Well, how very helpful,” I snapped, groping frantically for a pulse in the blackness… Putting a hand on his chest and an ear to his mouth, I could feel a regular rise and fall, with less of that gasping note. I straightened up. “I think he’s just fainted,” I said.

He groaned and opened his eyes… “I’m all right,” he said, trying to sit up. “Just a bit dizzy is all.” I put a hand on his chest and pushed him flat.

The instant the bandages were tied, the patient tried to sit up. I pushed him flat and put a knee on his chest to keep him there. “You are not to move,” I said fiercely.

So, leading up to Nurse Claire actually seeing his chest, let’s start with the castle courtyard. I have to begin the lesson here because I LOVE the courtyard scene with all its swirling undercurrents!

After dismounting, our bedraggled Claire stands there saying nothing but watching everything.

image

Puir lass, the front of her slip and dress have gone bye-bye, having given those up for Jamie’s field dressing. Left in her ruined, oxford walking shoes and hair in straggles, she stands out like a wee sore thumb! She is scairt and confused but tough as nails.

image

Our stalwart heroine stands completely IMMERSED in a maelstrom of male testosterone and ribald jokes. And, Jamie hovering…

image

…hovering I say!

Next, we witness a fabulous tete-a-tete between Claire, Mrs. Fitz, and Jamie where a lot is said, but a whole lot more remains unsaid!

image

Jamie says Murtagh found her and Dougal said to bring her along. But, it’s NO HIS FAULT that Ms. Fitz has another mouth to feed, bed to make, and body to clothe. Tcha! Just like a man!

image

Mrs. F is shocked at Claire’s scandalous appearance and doesn’t mind saying so!

image

And, Jamie still hovering in the background finding any inane thing to do with his horsey, even though there are several hostlers to do the work, all the while listening and watching the two lasses size each other up.

As Grand Dame, readies to drag Claire away for cleaning up, Claire is adamant that she must properly care for Jamie’s wound as Jamie brawly boasts “I can fend fer meself!”

image

Mrs. Fitz upon hearing Claire’s credentials, declares “Jamie, ye need fixin’, git yerself indoors!”  Ye heard the leddy, Jamie! 

And just like that, Jamie  finds himself seated on a stool covered with a blanket and ALONE with Mistress Beauchamp. (Being a wee bit nosey here, who washed Jamie’s face? Whoever it was, thanks – he cleans up nicely!). Claire gently removes the blanket to cleanse the wound and hears the awful truth that her hubby’s sixth, great grandfather gleefully produced the horrific scars on Jamie’s back.

image

Claire takes time to properly clean Jamie’s gunshot and apply an ingenious dressing involving a pressure bandage and strips of linen crossed under both oxters, an excellent technique for anchoring a shoulder dressing. Jamie tries moving the injured shoulder and winces, so Claire promptly straps his arm to his chest by the golden glow of firelight. Why? Claire knows the arm must immobilized for at least a week to promote wound healing, a truly complicated process! By next day, someone has replaced the strap with a sling, which is not the same at all!

image

Sadly, we must leave this tender scene to start Anatomy Lesson #4. Sniff!

Terms: Let’s come to terms with it, anatomists do not use the terms upper and lower arms.  Instead, the entire upper appendage is called the upper limb.  The region between shoulder and elbow joints is the arm and the region between elbow and wrist joints is the forearm (Image A). This is important to know for this lesson.

image

Image A

Rib Cage: The bony foundation of the chest is the thoracic (rib) cage, including 12 pairs of ribs, their costal cartilages (blue structures), sternum (breast bone) and 12 thoracic vertebrae (Image B).  This spring,  bony enclosure not only protects heart, lungs, airways, esophagus, and great blood vessels, it also provides attachments for important chest muscles! Above the thoracic cage lies the clavicle (collar bone) which articulates (forms a joint) with it.

image

Image B

Pectoralis Major: The chest muscles or “pecs” as trainers call them, actually include two pairs of muscles on each side of the chest. The word pectoralis derives from the Latin pectus meaning “breast.”

Pectoralis major muscles are the largest, most superficial, and most powerful of the two pairs. Each fan-shaped pec major covers half of the chest and is divided into three heads. The clavicular head (Image C) arises from the clavicle.

image

Image C

The larger sternocostal head arises from 1 through 6 costal cartilages and sternum (Image D).

image

Image D

A smallish, third part (Image E) arises from an abdominal muscle. This is a fairly insignificant part unless torn in which case, the pain surpasses all conscious thought. Just kidding, except it does hurt!

image

Image E

Pectoralis major muscle fibers converge toward the arm inserting into the humerus or arm bone (Image F).

image

Image F

Heh! Wake up, fledgling anatomists!

image

Yep, we can do pretty much anything for the Great Scot!

On their way to the humerus, pec muscle fibers create  the anterior axillary fold (Image G). This fold forms the front border of the arm pit, oxter, or axilla! (I still want to see Claire stick her foot in Jamie’s oxter!) Grab this fold on a pal or sibling and give it a wee pinch. Gives them a jolt, so not a fab idea to try someone without a sense of humor!

image

Image G

In this horrifying image from Starz episode 6, The Garrison Commander, Jamie’s massive right anterior axillary fold is very easy to spot. Our darling hero  near freezes to death as BJR parades, preens, and prepares for his fav outdoor sport!

image

Function: Each pec major is a very hard working muscle. And, because it has three heads, they do quite a bit of work!

  • raises arm forward (as in lifting a child)
  • returns arm against the torso (as in setting down the child)
  • pulls arm from spread eagle to the sides of torso (as in standing in mountain pose)
  • rotates arm (internally) toward the chest

And, for those who wonder, pec major is best developed by standard pushups (not triceps type!), bench presses and weighted flyes.

Try This: You can see the tendons of your own pec majors this way: place palms together about 6” in front of your chest as in prayer mode. Now, press the palms firmly together. Your own pec majors should stand out strongly as the anterior axillary folds. Just don’t get them pinched!

Pectoralis Minor: In anatomy (like baseball), if there is a major – there is a minor. So, deep to each pectoralis major is a pectoralis minor muscle (Image H). This smaller fan-shaped muscle is also very important.  It arises from the ribs (2, 3 & 4) and inserts on a small bony knob of the should blade known as the coracoid process (Greek for “like a raven’s beak”). Its contraction pulls forward on the corcoid process aiding in shoulder mobility and stability.

image

Image H

Applied Anatomy: OK, with the thoracic cage and two pairs of pecs  done, let’s find them on our wonderful warrior! After Claire trusses Jamie up, the only parts of his chest still showing are the verra fine sternocostal heads of his pec major muscles, covered with skin, of course (blue arrows). Ye can see them fair keeking out from under the dressing. Awesome sauce! And, good reason to consider them the 8th wonder of the world.

image

But, wait, here’s more! The clavicular heads of Jamie’s pec major muscles are unusually well developed! Check out this image (Starz episode 5, Rent) for prominent bulges just under those bonny clavicles (blue arrows). These are the clavicular heads of each pec major, an oft neglected part in body building – but not here! Props to the trainer! Gasp! They’re bloody awesome!

image

Finally, Claire has done all she can legally do for Jamie – he stands there with his glorious chest peeking through the bandages and his nipped waist and.. GAH! Lord, gimme a dram! 

image

Now, returning to anatomy (I am a professional after all)… about 1 in about 50,000 people are born without some or all of pec major and minor muscles. Known as Poland Syndrome, it may include hand and finger anomalies and shortened forearm bones. Interestingly, people with the syndrome compensate quite well using other arm and shoulder muscles. In fact, there’s a well-known PGA player, an Olympic boxer, and a Formula 1 World Champion (car racing) that have Poland syndrome and, clearly, it didn’t hinder them! The lady shown below (Image I), from a theatrical production, has it; she is missing the sternocostal head of pec major (blue arrow).

image

Image I

That’s it! Let’s close this lesson with a lovely poem nicely expressing the growing attraction between Nurse and Highlander!

Place your hand upon my chest.
It reminds me how it feels when it’s mended.
Then use it to cradle your head while you rest.
The worst of it, like the day, has ended.

 

I hope this lesson helps you more fully appreciate the chest muscles and their bony attachments.  Fare thee well for now.  Am thinking that Claire might be the subject of my next posting! We have ignored our amazing heroine for far too long!

How many days left before Starz episode 9? 156 days or so but who’s counting?! Sigh.

The deeply grateful,

 

Outlander Anatomist

Photo credits:

All photos are credited to Starz or Frank Netter’s Atlas of Human Anatomy, 4th edition. The lady with Poland’s syndrome is an archival photo from my lectures and I do not know the photographer.

Anatomy Lesson #2: “Claire and Jamie Meet at a Joint!”

Haha. Just joshing. Claire doesn’t meets Jamie at a joint. Claire meets Jamie because of a joint! Welcome to Anatomy Lesson #2, the shoulder joint. Now, hold on just a sec, please don’t leave this lesson! This is great stuff – truly – and I promise to keep it interesting. I’ll even throw in a gratuitous shot of our favorite #JAMMF just to hold yer interest! Hee, hee, here ye go…

image

Better? Great!  So, in Starz episode 101, Sassenach, Claire first sees Jamie seated on a low stool in a dimly-lit cottage. He is in pain. Herself enlightens us in Outlander book:

a dreadful hump rose on that side, and the arm hung at an impossible angle.

Now, what is the dreadful hump, what might have caused it, and how might it be resolved?

Anatomy to the rescue! Yep, it explains everything!

image

Hump: The hump is an bony part of the shoulder joint. The should joint is an essential part of each upper limb. Let me assure you, its anatomy is absolutely awesome! First, it is the MOST moveable joint of the entire human body (think of the shoulder joint during slow pitch or with a butterfly stroke). Second, the shoulder joint is a slightly misleading term because it is not one joint, but two – the glenohumeral joint and the acromioclavicular joint:

  • glenohumeral joint: between humerus (arm bone) and scapula (shoulder blade) –  note the spelling: humerus not humorous!
  • acromioclavicular joint: between clavicle (collar bone) and scapula – this one is oft ignored but is crucial for normal function.

Together both joints form the “shoulder joint!”

Glenohumeral Joint: At the glenohumeral joint, the head of humerus moves in the glenoid cavity (a.k.a. glenoid fossa), a small and shallow socket on the side of scapula.

The good news: because the glenoid cavity is shallow, the humeral head is highly moveable allowing for at least nine different defined motions.

The bad news: unfortunately, the shallow socket also allows the head of humerus to dislocate with relative ease! Get it? Grand!

Turns out that puir Jamie dislocated his glenohumeral joint (Image A – green arrow, right front view). Och! 

image

Image A

Acromioclavicular Joint: The acromioclavicular joint (green arrow in Image B – right front view) is a tight joint between acromion (also part of scapula) and clavicle. The clavicle acts as a strut holding the acromion away from the torso. Associated muscles contract to adjust positions of both clavicle and scapula (e.g. up, down, back, forward). And, amazingly, the acromioclavicular joint also guarantees greater range of motion at the glenohumeral joint.

Try this: Place fingers of one hand on the contralateral (opposite) clavicle. Now, move clavicle forward, backward, up, down. Now, roll it forward (as in doing the hoochie koo) and then backward. See how mobile the clavicle is? Amazing!

Now, move fingers to the scapula of the same side and repeat the same clavicular (adj.) movements. See how the scapula is carried along with the clavicle? This occurs because they are united at the acromioclavicular joint! And, increased scapular mobility means increased mobility of humerus as it is concurrently moved at the glenohumeral joint. Normally, the whole apparatus works together like a finely-oiled machine.

So, for example, each time you lift the clavicle and scapula, you can also raise your arm higher. Prove this to yourself: hold your scapula still and raise the arm of the same side. Find that you cannot raise the arm very high, but once you release the scapula to lift, the humerus can be raised to the full vertical position. Hoping this makes sense!

image

Image B

Acromion: The acromion (Image C – right back view) overreaches and protects the underlying glenohumeral joint. Acromion shares the same Greek word root with the Acropolis of Athens, meaning “peak” because both structures overlook what lies below. In lay terms, the acromion is better known as the “point of the shoulder.”

The “dreadful hump” on Jamie’s right shoulder is his right acromion, left high and dry because the humeral head is no longer in its socket (glenoid cavity). Gah! Deprived of the rounded contour normally provided by the humeral head, the acromion is revealed as a huge bulge of the shoulder area.

image

Image C

Try this: Palpate the point of one shoulder and feel the big bony chunk; this is the acromion of scapula. Now, check this area out on your wee dog or perhaps on a horse (‘cuz Jamie does like the horsies)! The acromion faces forward, coming to lie under the neck of these animals. Why? Because dogs and horses have no clavicles to hold the shoulder joint away from the torso, so, the entire scapula and its acromion are located on the sides of their chests – ours are on our backs.

The Bottom Line: Glenohumeral joints of dogs and horses are much more stable than ours but their range of motion is also greatly limited. We don’t see dogs running with front legs whirling like windmills. The photo is of a Vizsla, BTW.

Rotator Cuff:  Now, if the glenohumeral joint is relatively unstable, what holds it in place? This is accomplished by some very strong ligaments and four muscles forming the rotator cuff. Also, the powerful deltoid muscle (Image D – green arrow denotes head of humerus) covers the joint, ligaments and part of the rotator cuff with a thick, protective muscular padding (especially in a lad like Jamie – <G>!).

image

Image D

Ok, I can tell I am losing you. Wake up! Here, have another dose of our gorgeous hero!

image

Now, back to Starz episode 101, Sassenach: We hear the ever “tender” uncle Dougal mutter ”it’s out-o-joint, poor bugger.” Well, duh!

In  Outlander book, Jamie explains:

I fell wi’ my hand out, when the musket ball knocked me off my saddle. I landed with all my weight on the hand, and crunch!, there it went.

Now, folks, falling on an outstretched arm/hand is the classic cause of an anterior dislocation of the glenohumeral joint, wherein the humeral head is thrust forward (anterior) and out of the glenoid cavity. This stretches and tears ligaments and muscles and, sometimes, cartilage.

Back to episode 101, Sassenach Our favorite goof, Angus, delicately raises one brow and declares in his best practitioner’s voice:

I’ll have to force the joint back!

Yeah, right, Angus! He and his brawny pals start forward only to be stopped in their shoon by awesome Claire using her best Hospital Matron voice:

Don’t you dare…stand aside at once!”

She then enlightens Dougal, who, no doubt, is one of the brighter bulbs in that crofter’s cottage:

You have to get the bone of the upper arm into the proper position before it slips back into joint.

Now, at this point, our sweet hero is looking a wee bit dubious about this whole “girlie” thing. Well, it’s either Claire or Angus. Who would you choose?  I’d go with the shift, too, sweet lad.

image

After obtaining Jamie’s nod of assent, Claire grips his right wrist in one hand and his bent elbow in the other. Lifting with considerable effort, she rotates his forearm to his right side (external rotation), a maneuver that aligns the humeral head with glenoid cavity.

The considerable resistance Claire encounters (just look at our strong, winsome heroine!) is due to swollen muscles, torn ligaments, and the weight of his “heavy as lead” arm!

image

Then, warning Jamie that the worst is yet to come, Claire holds his bent elbow against his torso, and gripping his right hand, rotates his forearm to his left (internal rotation), a maneuver designed to reseat the humeral head in the glenoid cavity!

image

Suddenly, Jamie’s shoulder gives a soft, crunching pop as the humeral head slides home into the glenoid cavity and the dislocated joint is reduced.  And, folks, it hurts, especially several hours post-injury – truly! Kudos to the special effects crew for the CGI/prosthesis!

image

Just ask Angus…Och!

image

Next and this is very sweet, Jamie says he’s

takin’ a guess she’s done this afore.

Trust me, Claire assures him:

I’m a nurse!

Har, har! Jamie eyes immediately drop to her bosom and he responds:

Aye.

Ah, well, he may be injured, but his other brain seems intact! What was he thinking’? Do me eyes behold a sweet avenging angel? A wee demon? A biting vixen? But, whatever she is, thank the stones she’s NOT A WET NURSE!

image

Now, just in case ye missed it, take a look at Claire’s eyes when she sees Jamie’s muckle size as he rises off the stool. She even has the good sense to blink a few times. Yup, he got her attention alright and she got his. There’s a sizzle on the griddle, now!

image

Fun Fact: Did you know that Claire could have employed a much older method of reducing Jamie’s dislocation? Hippocrates (460-370 B.C.), father of western medicine, devised the Hippocratic maneuver, wherein the practitioner places the heel of his/her foot into the armpit of the dislocated side and pulls on the corresponding wrist to reduce the dislocation. I would love to see Claire pull that one off! Without a doubt, she is flexible enough to stick her foot in Jamie’s oxter. Check out her graceful dismount from Jamie’s steed in the castle courtyard, Starz episode 102, Castle Leoch! Watch out, Rockettes!

image

Realism: OK…question: was the scene from episode 101 realistic? Is it likely that a WWII combat-trained nurse such as Claire might know how to reduce the dislocated humeral head using the method shown? Oh, aye, because the procedure she employs looks verra much like the Kocher maneuver, developed in the 19th century by a Swiss surgeon of the same name. Although other reduction methods are now available, Kocher was widely used for over a century and Claire could very well have learned it in training or as a combat nurse.

Another realistic feature, check out Jamie’s eyes in episode 101. Throughout the entire scene, his pupils are VERY dilated. This is also highly realistic because the pain of dislocation would initiate the fright/flight/fight reflex, dilated pupil being a prime feature of that response! His pupils are soooo dilated that the rims of his irises are barely visible!

image

Overall, this vivid scene was realistic, dramatic, and extraordinary in most every detail. Congratulations to the cast and crew! If you readers are interested, here is a link to a YouTube demo of the Kocher reduction.

My next post may well review Jamie’s other injury sustained in Starz episode 101, Sassenach. Please stay tuned and see what’s next! After all, we have to keep engaged until April of 2015! Geez, Starz…soooo harsh!

Just for fun, consider a few shoulder idioms, use used to convey important emotions:

  • broad shoulders
  • cold shoulder
  • shoulder to cry on (I like this one)
  • have a chip on the shoulder
  • put shoulder to wheel
  • square one’s shoulders
  • on the shoulders of giants
  • a weight off the shoulders
  • rub shoulders with
  • looking over shoulder

Yadda, yadda, yadda. You get the drill.  Hope to see you at Anatomy Lesson #3!

The deeply grateful,

Outlander Anatomist

Photo credits:

Starz; Frank Netter’s Atlas of Human Anatomy, 4th edition, Outlander Anatomist private collection.