SamHeughan – Page 8 – Outlander Anatomy

February 3, 2015September 16, 2019

Anatomy Lesson 12: “Claire’s Neck – The Ivory Tower”

In Voyager, third of the Outlander books, Herself writes about a character named Dr. Joe Abernathy. As he examines some human bones, he softly sings to himself:

“Oh, de headbone connected to de…neckbone…de neckbone connected to de…backbone…Now hear…de word…of de Lawd!”

This spiritual song, composed by African-American author and songwriter James Weldon Johnson (1871–1938), provides a fitting introduction for today’s Anatomy Lesson #12: The Neck.

We need a model for our lesson on the neck and can ye think of a better one than bonny Claire? Here’s Claire drinking celebratory bubbly at the end of World War II; her ivory, blood-smeared neck rises from her torso as a long column of muscle, bone and sinew (Starz episode 101, Sassenach).

Definition: The neck is the body region between base of skull and top of sternum. The anatomical word for neck is cervix (Latin meaning neck), applying the neck region or neck of the uterus. For simplicity, I divide the neck into posterior and anterior compartments:

Posterior neck contains cervical vertebrae muscles, nerves, ligaments, etc.
Anterior neck compartment contains respiratory and gastrointestinal viscera (organs), important blood vessels, a bone and numerous muscles

Image A shows the chin angled toward the right acromion (Anatomy Lesson #2), thus lengthening the left side and shortening the right.

Image A

Posterior Neck: The posterior neck is supported by the cervical spine (see Anatomy Lesson #10 for thoracic, lumbar, sacral and coccygeal spine). The cervical vertebrae are numbered C1 – C7 and extend from base of skull to first thoracic (T1) vertebra (Image B – cervical spine, right side).

Image B illustrates C2 – T1 vertebrae. Anterior cylindrical bodies face right and posterior unpaired spinous processes point left. The spinous processes form midline knobs under the neck skin. These vertebrae form the cervical curvature, convex anteriorly and concave posteriorly, allowing for a springy and flexible neck that adjusts head position for optimal sight and hearing.

Although not shown in Image B, intervertebral (IV) discs separate vertebrae C2-C7.

Image B

Ligaments: Viewed in situ (Latin meaning in position), several strong ligaments bind cervical vertebrae to each other and the skull base (Image C, right side). An unpaired ligamentum nuchae extends from skull base to C7 spine anchoring the cervical vertebrae and providing partial origin for the trapezius muscles (Anatomy Lesson #3).

In the neck, ligamentum nuchae covers the spinous processes and is aligned with the median furrow, a midline groove running the length of the back (Anatomy Lesson #10). Known as the paddywhack in sheep and cattle, ligamentum nuchae helps support head weight in four-legged animals. Dried paddywhack is sold as dog treats as suggested by the 19^th century Welsh children’s song This Old Man:

“With a knick-knack paddywhack, give the dog a bone…”

C7 bears a long spinous process, the vertebra prominens, because in most people it is most prominent.

Try This: Palpate your own C7 spine: Crop chin to chest and palpate the big bony knob of vertebra prominens at the neck base.

Image C

Claire’s slender, swan-like neck bears a visible vertebra prominens (red arrow) as she cries at Castle Leoch (Starz ep 103, The Way Out). She just teased Jamie in the dinner hall about kissing Laoghaire. She is envious of their intimacy and she misses her hubby!

C3 – C7 Vertebrae: Cervical vertebrae C3 – C7 are similar to thoracic vertebrae (Anatomy Lesson #10) except they are smaller and have paired transverse foramina (holes) to transmit blood vessels to and from the brain (Image D). The bodies are smaller and oval. Spinous processes project posteriorly and most are bifid – forked – just like Claire’s life line! Understand that the spinal cord passes vertically through the vertebral foramina (pl.).

Image D

Atlas: C1 vertebra articulates with skull above and C2 vertebra below. C1 is also known as the atlas because it supports the head like Atlas of Greek mythology held up the celestial spheres. Its anatomy is also unique. Viewed from above (Image E), the odd atlas has neither body nor spinous process! Rather, it bears a small articular facet for the dens (see below) and a small posterior tubercle. Two peanut-shaped depressions (superior articular surfaces) articulate with two matching bulges (occipital condyles) of the skull base.

Try this: Nod your head up and down (as in “yes”). This sets up a rocking motion between atlas and occipital condyles of skull. No IV disc intervenes between C1 and occipital condyles base as it would be shredded with this motion.

Image E

Axis: C2 vertebra, the axis, is also an odd vertebra (Image F). It articulates above with C1 and below with C3 vertebrae. It has an elongated body topped by the tooth-shaped dens (odontoid process). A strong ligament holds the dens against the articular facet of C1.

Wonder why C2 has a dens but C1 has no body? No one knows, but some biologists hold that the dens was once the body of C1 but became part of C2 during evolution.

Try this: Move your head from side-to-side (as in “no”) and understand that the dens acts as a pivot point around which C1 and the head rotates.

Image F

Try This: Insert a clean finger in your mouth and push it all the way to the back of your throat (stop if you start to gag…); the dens lies deep to your finger. For this reason, radiographs of the dens are taken via an open mouth. Image G (red arrow) is an x-ray of a normal dens; it projects upward like a large tooth (hence the alternative name, odontoid process). You can perhaps see the lower teeth embedded in the mandible?

Image G

Dens and Hanging: The history of hanging is gruesome but pertinent. With the standard or long drop type of hanging, the condemned is suddenly dropped from a specified height. Weight of the plunging body plus a properly prepared and placed noose breaks the neck, meaning the dens snaps off C2 and is driven upward into the brainstem causing instantaneous death.

In The Fiery Cross, 5^th book of the Outlander series, Herself explains:

“My horse moved suddenly, dodging past a group of men, and I saw them, three stick-figures, dangling broken in the tree’s deep shadow. The hammer struck one final blow, and my heart shattered like ice. Too late.”

The quote refers to the hanging of a character after sliding from the back of a horse. This type of hanging, known as short drop, results in a slow and agonizing death by strangulation because the body weight doesn’t drop far enough to break the dens! Had this character been hanged by long drop, the dens would likely have snapped from the body of C2 as shown in Image H (red arrow).

NOTE: I don’t have access to the medical history of the patient shown in Image H, so his/her fate is unknown. However, there are several types of dens fractures and treatment is possible.

I once had a medical student who fractured his dens in a skiing accident and survived! He was exceedingly careful when turning toward something or somebody: he rotated his upper torso and never rotated just his head for fear of dislodging the fractured dens.

Image H

Muscles: Viewed from the back, the cervical spine is overlaid with layers of muscles in the back and at the sides.

The paired trapezii (Anatomy Lesson #2, Anatomy Lesson #3 & Anatomy Lesson #10) form the most superficial layer (Image I – left side). These help extend, rotate and flex the neck.

Image I

Two pairs of intermediate neck muscles lie deep to trapezius: splenius capitis and semispinalis capitis (Image J – left side); these also flex, arch and rotate the neck.

Believe it or not, there are even more deep muscles of posterior neck but time requires us to move on. This lesson is rapidly becoming as long as a master’s thesis!

Image J

Three pair of muscles of the lateral neck are important. These are anterior, middle and posterior scalene muscles (Image K). These arise from the cervical vertebrae and insert on first or second ribs. Anterior and middle scalene lift the first rib and bend the neck towards the same side. Posterior scalene lifts the second rib and bends neck towards the same side. They all raise the ribs to increase the size of the thoracic cage and are thus secondary muscles of respiration.

Image K

Now, a question asked by many fans: why is Claire’s neck so long ( Starz episode 104, The Gathering)? It isn’t likely she has more than seven cervical vertebrae – an extremely rare variation! Two reasons likely account for her unusually elegant and swan-like neck.

First, the bodies of C2 – C7 vertebrae are probably a wee bit longer than most. Just a small additions to the lengths of each vertebrae and one’s overall neck length is enhanced!

Take for example the neck of an adult giraffe (Image L) which reaches 2 m (6.5’) in length even though this animal has only seven cervical vertebrae! Their neck length is achieved because each vertebral body can exceed 25.4 cm (10”) in height. Now, please dinna fash, I’m not suggesting Claire’s neck is like a giraffe’s! I use this extreme example to make the point.

Image L

The second reason for Claire’s long neck is because her trapezius muscles allow for a definitive angle between their slope and the column of her neck. This gives a looong profile to her ivory tower.

Here she weeps as a sick BJR relates the horrific account of Jamie’s scourging (red arrows – Starz episode 106, The Garrison Commander). Beautiful photography as we even see the reflection of a tear fallen on her left breast.

Now, compare and contrast Claire’s trapezii with Jamie’s which are super well-developed! His amazing trapezii slope downward from head and cervical spine to clavicles and scapulae (Anatomy Lesson #2) filling in the aforementioned angles. This widens the neck and effectively causes it to look shorter, but no less appealing. Make sense?

Anterior Neck: This region provides passage for pharynx (back of the throat), larynx (voice box), trachea (wind pipe) and esophagus (tube to stomach), viscera that will be left for later anatomy lessons.

We will, however, consider two superficial structures of the anterior neck. First, do you recall the paired platysmas in Anatomy Lesson #11? Each is a thin, flat subcutaneous muscle that pulls down the lower lip (green arrow) and webs the neck skin (red arrows).

Here’s Claire with platysmata (pl.) contracted as she tells Jamie that she had a wee bit too much of Colum’s rhenish (Starz episode 103, The Way Out). Och, she’s had waaay too much!

The second superficial structure of the anterior neck lies deep to each platysma; it is the external jugular vein. Each vein collects blood from its side of the face and empties it into a large vein at the base of the neck (Image M – black arrow).

Image M

Claire’s right external jugular vein (red arrow) shows vey well in this scene where she verbally spars with dirty Dougal (Starz episode 102, Castle Leoch)! She’s clearly pissed and for good reason – Dougal has her watched day and night by those hooligans, Rupert and Angus, thinking she’s an English spy! There are other scenes where this vein is apparent in both Claire and Jamie. Hope you watch for it!

Next, an important pair of muscles provides contour to the anterior neck. To understand them, we must first learn their bony attachments. The adult sternum (breastbone) is divided into three parts; the top part is the manubrium (Latin meaning handle). The other two parts will be left for a later lesson. At the top of the manubrium is a divot known as the jugular notch or suprasternal notch (Image N). The clavicles (Anatomy Lesson #2 & Anatomy Lesson #3) articulate with the manubrium at paired sternoclavicular joints (black arrow – right side).

Image N

The next image clearly shows Claire’s jugular notch (red arrow) as she watches a tense exchange between Colum and the wee tailor (Starz episode 103, The Way Out) who unfortunately misjudges the length of the laird’s standard frock coat!

Try this: Place fingers at the top of your sternum and feel the bony indent; this is your jugular notch.

Sternocleidomastoid Muscles: The large paired SCM provide anterior neck contour (Image O – right side). Each SCM has two heads: the sternal head takes origin from the manubrium, the clavicular head from the clavicle. The heads merge into one belly that inserts on the mastoid process, part of the skull (Anatomy Lesson #11).

Try this: Place your fingers in the jugular notch – drag chin towards your chest and feel a stout tendon on each side – the sternal head of each SCM!

Image O

Although his collar is a bit in the way, you can clearly see the sternal heads of both SCMs in BJR’s neck (Starz episode 106, The Garrison Commander) as he bellows at corporal milk sop to “kick her!” Nice guy, eh? Wouldna want to meet him in a dark alley. Hey, wait, we did meet him in a dark alley in Starz episode 108, Both Sides Now…or that was his 6^th times great grandson? Tcha, not much difference betwixt the two, at least in that episode!

The clavicular head of each SCM is thicker and wider than the sternal head creating a mound easily viewed in this image of Claire getting liquored up by Colum (Starz episode 102, Castle Leoch). Yep, a servant has just delivered a jug of his rhenish! Do ye also see the sternal heads of each SCM?

Now, see Claire in her bonny ribbon with both SCM tendons tensed? She is sooo pleased and relieved by Jamie’s clever handling of his scheming uncles at the Gathering (Starz episode 104); he is her patient, after all!

A comment about Claire’s SCM. Some folks have more than two SCM heads on each side. In Claire’s case, the inner pair of tendons (red arrow – right side) belongs to the sternal heads; the next pair (green arrow – her right side) belongs to her first set of clavicular heads. The wide tendon (aqua arrow – her left side) belongs to her second set of clavicular heads.

This doesn’t alter function – in my view, it makes her long neck even more splendid. The tendons look very bonny on her ivory tower enclosed like it is by a pert and lovely ribbon (kudos to Terry and team for the gorgeous costuming!). No one wears a neck ribbon quite like Claire! It is the best except, mayhap, when Jamie is taking it off? Snort!

Try This: Check out your own SCMs in a mirror. Do you have more than two heads?

The SCM performs three movements for us (other neck muscles assist with these movements). First, both sternal heads contract to arch the neck and depress (lower) the chin. Here you see Claire (Starz episode 102, Castle Leoch) contracting both sternal heads as Colum grills her about the proper pronunciation of Beauchamp and her distant famly from Compiègne, France.

The second function of SCM is turning the chin to look over one shoulder. This occurs when the clavicular head of only one side contracts. Again, we see Claire smile at Colum at the supper table afore he starts her grilling (Starz episode 102, Castle Leoch). Now, her left SCM muscle tendons are clearly visible because they are stretched. But, in fact, it is her right SCM that contracts to move her chin toward her right shoulder.

Try it yourself! You might also re-watch this entire scene to appreciate the array of gracious neck movements performed by our braw heroine!

The third movement occurs when both clavicular and sternal heads of one SCM contract to pull the same ear toward the shoulder. Here is Jamie (Starz episode 102, Castle Leoch) having his gunshot wound cleaned. How many times have we seen guys perform this neck movement? It seems a universal guy thing, but, I didn’t ken it was done in 1743 by 23 y. o. Scottish virgin! Yup, that’s both heads of his left SCM in action.

Next, the anterior neck compartment contains an unpaired bone (Image P – viewed from above). The U-shaped Hyoid bone is Greek meaning shaped like the letter upsilon, the 20^th letter of the Greek alphabet. In adults it measures roughly 2” (5 cm) side-to-side and front-to-back with a body and two cornua (Latin meaning horn). Unlike the other 205 human bones, the hyoid doesn’t articulate with any other bone!

Image P

The hyoid bone sits in a mostly horizontal orientation about a finger’s breadth below the bottom of the mandible (Anatomy Lesson #11) and at the level of C3 vertebra (Image Q). The hyoid is suspended in the neck by two strong ligaments attached to our styloid processes, a pair of gothic-looking bony spikes. Aye, our skulls really do have these wicked-looking projections!

OK. Let’s stop for a funny story: once a student asked me to examine his plastic skull model for accuracy. It looked fine until I turned it over and noticed it had no styloid processes! I voiced the observation and he responded that he had broken them off because he thought them to be leftovers from the modelling process! We got a good belly laugh over that one!

Image Q

Try this: Feel your own hyoid bone. Open thumb and index finger into a curved U and slip the opening over the front of your neck just below your jaw bone. Gently tighten your digits a wee bit and then cough or swallow. You should feel a hard bar move up and down on each side. This is the hyoid bone. If you push gently with your index finger your thumb feels the hyoid more easily on the contralateral (opposite) side. The hyoid is tucked so deeply under the mandible that it is rarely fractured except with compression during manual strangulation. Ugh!

Note: The hyoid bone appears in Diana’s 8th book Written in my Own Heart’s Blood but I will save that context for a later post. NO spoiler here!

A whopping nine pair of muscles attach to the hyoid. The thyroid cartilage (part of larynx) also hangs from it by a fibrous membrane. These muscles help control the tongue, floor of mouth, pharynx and larynx such that the hyoid plays important roles in breathing, speech, swallowing, chewing and coughing (Image R). Some muscles lift the hyoid forward or backward, others pull it down and forward or backward. Then there are combinations of movements between the muscles making for complex changes to throat, esophagus and airway. The arrows in Photo R indicate the directions the named muscle pull.

Image R

I won’t cover all nine pair of muscles attaching to the hyoid (only eight are listed in PhoImage R) because it is too much info. But, I will comment on the paired omohyoids. Each omohyoid (Image S – right muscle) has two bellies: an inferior belly arises from the scapula and ends at an intermediate tendon near the clavicle (Image S – black arrow) and a superior belly arises from the intermediate tendon and inserts on the hyoid. Although not shown in the image, the intermediate tendon is bound to the clavicle by fibrous tissue. As each omohyoid contracts, it pulls the hyoid bone downward and backward.

Image S

The omohyoid is rarely seen because it lies deeply. However, I saw this muscle in action during Starz episode 101, Sassenach. Now, I bet you watched this scene more than once but I encourage you to do it again. Here, Jamie has just chased Claire down (YES!). She spits “NO” ta his question: does she want him to pick her up and throw her over his shoulder (YES! erm…NO!). He says: “Well, then, I suppose that means yer comin’ wi’ me!” (oh YES, I mean NO!). Whew, gettin’ a wee bit dizzy here!

Now see the location of the red arrow on Jamie’s neck? Go back and watch this episode as he speaks the line about comin’ with him while keeping an eye peeled at the area indicated. Ye will see a bump rise and fall a couple of times. This is Jamie’s right omohyoid muscle contracting to depress his hyoid bone as he speaks. When I saw it, I nearly fell out of my chair! OMG it is bloody awesome! (Anatomists are a bit weird and easily entertained, ye ken?)

“Oh, de headbone connected to de…neckbone…

Let’s end this lesson with a final view of Claire’s magnificent ivory tower (not to mention Angus cleaning out a lug in the background)! Aye, she looks marvelous!

Before I close, I’d like to add a wee personal note at the request of a reader: I write my blog anonymously not because I have anything to hide but because I prefer to focus on Diana’s splendid books, the fabulous Starz Outlander series and fascinating human anatomy! I am a woman and a traditional one at that. If my blog encourages anyone, regardless of gender, to pursue an interest in science then I feel I have done my job. Namaste!

The deeply grateful,

Outlander Anatomist

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photo creds: Starz, Netter’s Atlas of Human
Anatomy, 4^th ed., Clinically Oriented Anatomy,
5^th ed., Hollingshead’s Textbook of
Anatomy, 5^th ed., www.teachmeanatomy.info, www.radiopedia.org,www.wikipedia.org, www.commons.wikimedia.org, www.medical-dictionary.thefreedictionary.com,

December 9, 2014September 3, 2015

Anatomy Lesson 8: “Jamie Takes a Beating and Claire’s Healing Touch”

Anatomy Lesson #8: Solar plexus, Respiratory Diaphragm, Kidneys and Cheekbone

Now, that’s a whole lot of anatomy, but dinna get into a swivet; this lesson is dictated by Rupert’s beating of Jamie. Well, now, Jamie is a warrior who has a knack for getting himself into a mess o’ messes. Claire is a warrior too, only her battle field is healing!

Getting started, let’s review the healing Claire has given thus far for young Jamie – showing that she is a real Healer-Dealer and how that rascal Rupert undoes some of her warrior work!

In Starz episode #1, Sassenach, Murtagh captures Claire on Saturday – likely the same day Jamie dislocates his shoulder. Several hours pass before Claire reduces Jamie’s shoulder (see Anatomy Lesson #2). “Tá Dia (I think this is what he says) – it doesna hurt anymore!” exclaims Jamie. Ha, the Highlanders hadna a clue that a feral Sassenach cat could perform such miracles!

Claire and her captors ride through Saturday night and into Sunday when Jamie is shot at Cocknammon Rock (See Anatomy Lesson #3). Later that night, after fainting from lack of blood, Claire securely binds his wound so he doesna have to stay and determine his own fate wit’ a loaded pistol (Starz episode #1, Sassenach).

On Monday they arrive at Castle Leoch (Starz episode #2, Castle Leoch). Claire insists on properly cleaning and dressing Jamie’s gunshot wound (See Anatomy Lesson #3), all the while conducting a thorough counseling session fer the sad-lad! She also binds his right arm to his chest (thorax in anatomy) to immobilize the freshly reduced shoulder joint. What a caregiver!

On Tuesday (Starz episode #2, Castle Leoch), Claire brings Jamie comfort in the form of lunch and fresh bandages but accidentally upsets his work at the stables. Jamie falls to his knees. Oooh, this clearly hurts his pride and mayhap messes a wee bit wit’ his injured shoulder? Oops, Claire better watch that hip padding – it gets in the way! After lunch, true confessions and a good deal of “facetime,” Claire begs Jamie not to get stabbed or flogged today.

By Friday, after having been a good lad fer far too long Jamie gallantly steps forth at the Hall to take punishment for “damn-her-eyes” LiarHair who clearly has been a verra bad lassie (Starz episode #2, Castle Leoch). Ye’ll ken this is about six days after his shoulder dislocation and only five days since his gunshot wound! This is important because at this point new blood vessels are growing (angiogenesis), cells are dividing (mitosis) and collagen is forming (fibrogenesis) to help heal pulled ligaments and strained muscles; everything in Jamie’s shoulder is tender and sore. But, braw showman that he is, he chooses fists no the strap!

Laird Colum allows it. Rupert will administer the fisticuffs delivering two consecutive blows to Jamie’s belly!

Now for some anatomy! Both blows strike Jamie in the pit of the stomach (Photo A). This type of blow affects three major regions of the body: the belly wall, the solar plexus and the diaphragm.

Photo A

As I will cover the belly wall in a future post, I won’t describe its full anatomy now. Suffice it to say that it is defined by the blue area seen in Photo B. In a warrior like Jamie, whose belly is very strong, two punches will not do much real damage. But consider the gut punch BJR gives Claire (Starz episode 6, The Garrison Commander) along with the belly kick by his weenie gopher. I suspect that Claire’s corset stays, several undergarments and that fabulous pleated tartan gown kept any real damage to a minimum; ye ken that each pleat includes three layers of wool? (Aye, Terry and her team create such splendid garments!)

Photo B

Now, just behind the stomach lies the solar plexus (Photo C – surface anatomy), so named because it resembles a sunburst; anatomists call it the celiac (coeliac) plexus.

Photo C

To understand the celiac plexus, let’s first visit the aorta the largest artery of the human body (Photo D – posterior abdominal wall – from the front with organs removed). It begins in the chest, pierces the diaphragm and enters the abdominal cavity where it lies in front of the spine.

Photo D

The celiac plexus (Photo E – black arrows) wraps the front and sides of the abdominal aorta. The white blobs in Photo E are ganglia, swellings that house nerve cell bodies. The white strings are nerves; arising from the cell bodies they connect with other ganglia and supply organs (viscera). The nerves cause viscera to contract or secrete and also carry pain sensation back to the central nervous system. A blow to the belly can bruise the stomach, shock the celiac plexus, cause pain and potentially interfere with visceral function.

Photo E

Finally, the last body part vulnerable to a belly blow is the thoracic diaphragm, a dome-shaped sheet of muscle and tendon between the chest and the abdominal cavities that sits surprisingly high under the rib cage (Photo F – from the front showing cut edge of diaphragm). It is attached to the inner surfaces of breast bone, ribs and vertebrae and is a powerful muscle of respiration: as we breathe in (inspire) it descends, as we breathe out (expire) it rises. Blows to the belly wall cause temporary paralysis of the thoracic diaphragm making breathing difficult – the sensation of “getting the wind knocked out of you” and perhaps the most uncomfortable part of a gut punch! The spasm is accompanied by pain, anxiety and difficulty sitting or standing. But, as with Jamie, the spasm passes, breathing resumes and equanimity is restored.

Photo F

Moving on…Rupert circles around to Jamie’s back and delivers a third blow causing him to stagger! As ye well ken, this is a kidney punch and it is verra painful!

The kidneys are paired bean-shaped organs that produce urine, extract wastes, balance body fluids and are vital for normal life! Each day they filter about 189 liters (200 qt) of blood but produce only about 1.89 liters (2 qt) of urine because normally most all the fluid is resorbed. The urine flows into paired ureters then to the urinary bladder and is subsequently voided through the unpaired urethra (Photo G).

Photo G

A blow to the kidney is painful but not always serious (unless, of course, Claire’s stabbing ye in the back wit’ her sgian dubh!). Why? Weel, because the 11^th & 12^th ribs protect much of the left kidney and 12^th rib protects part of the right (Photo H – from the back; kidney outlines shown as dashed lines). Also, strong back muscles absorb energy from a kidney punch. Kidney injury from blunt trauma ranges from bruising to serious tearing of tissues. Just so ye ken, blood in the urine is a good indicator of kidney trauma and the kidney punch is one of the meanest places to whack an opponent – although our fiery hero doesn’t seem that worse for wear.

Photo H

By now Rupert is sweating. So he checks wit’ his heid, “Dougal the Devil Man” ta see if it’s time to stop. Now, we all ken that Dougal is Colum’s war chief. So, take a peek at his menacing stance – splayed legs all covered wit’ his shiny high top boots. But, Dougal has no problem wi’ his nephew getting hurt and hurt badly. After all, the lad is still standing at this point and standin’ in the way of his best-laid plans. So Uncle Dougal directs Rupert to land a 4^th blow – this time to Jamie’s face and blood splatters the slates. As there is another punch coming to Jamie’s face, I’m saving facial anatomy until blow #6! Read on!

Hey, now, I thought the beating was supposed to stop once blood was drawn. Geillis says so and we all know she never lies. Next, Rupert hauls back and lands a mighty one ta Jamie’s right shoulder!

So, what was Claire thinking through all this physical plundering? Herself writes in Outlander:

“I was in agony of apprehension, lest one of the blows re-damage the wounded shoulder…”

Too late Claire…Och, Rupert, that was brutal, man!

Time fer more anatomy, heh. The shoulder blow is bad news because there’s nay been enough time for the wounds to have healed properly. The next photo shows the proper alignment of a normal glenohumeral joint (Photo I: x-ray right shoulder). Part of the humeral head (red arrow) sits in the glenoid cavity of the scapula (blue arrow).

Photo I

Nearly a week earlier Jamie suffered an anterior dislocation of the glenohumeral joint (Photo J: x-ray right shoulder). Here, the humeral head (red arrow) is typically displaced forward (anterior) and down (inferior) from the glenoid cavity (blue arrow) as shown in the following x-ray. Claire restored the normal anatomy of the joint, but as we learned earlier, the whole area remains inflamed and tender. Ouch! It hurts just ta look at it.

Photo J

Finally, Rupert delivers the last punch to Jamie’s face and knocks him to the ground!

Now, ye best understand the damage these facial blows can cause! In anatomy, the cheek bone is the zygomatic arch (Photo K). With color-coded skull bones, ye can clearly see that the zygomatic arch is made of two bones: the pink part belongs to the temporal bone and the orange part to the zygomatic bone. The two bones meet at a jagged suture (non-moveable joint). Although strong, the suture is at risk for fracture.

Photo K

Also, the zygomatic bone forms the outer rim of the bony orbit where the eye is housed (Photo L). Both zygomatic arch and bony orbit are subcutaneous structures (see Anatomy Lesson #5 – The Skin) and vulnerable to injury. The fact that Rupert’s blow didn’t fracture either of these bony areas is probably due to the fact that Jamie’s head is harder than an iron pot – or so says his sister Jenny!

Photo L

After the beating, Murtagh helps our hero out of the hall but not afore Jamie casts a look at Claire: “Sassenach., I need you!” Well, that does it. Claire has ta’ git outta that Hall – NOW! Make way, Geillis! Ah, have patience Claire, a few more weeks and ye’re going ta get all the healing touches of Jamie ye want. Lucky Lady!

Soon enough, Claire tenderly soothes Jamie’s bruises: he’ll be sore for a couple of days, but he’s no really damaged. She is dying ta know why he took Miss LongHare’s punishment! In Outlander book Jamie answers Claire:

“Why not me?”…Why not? I wanted to say. Because you didn’t know her, she was nothing to you. Because you were already hurt. Because it takes something rather special in the way of guts to stand up in front of a crowd and let someone hit you in the face, no matter what your motive.”

Friends, if you have yet to read the marvelous Outlander books, I urge ye to do so as well as follow the Starz episodes! There are lots more to these vignettes than can fit into a 60 minute episode!

Then Claire delivers the sad news that tomorrow (Saturday) she is headed back to Inverness with Pitre the tinker! Jamie groans as he stands to say farewell. He is devastated. Are ye sobbin’ yet? He is!

Ah…breathe a sigh of relief – fate has a surprise in store fer Mistress Beauchamp. Yep, Colum and his lil’ Big Bad Bro willna let her go wit’ the tinker. Claire has to stay and take her own Beaton – er, the surgery I mean – that little “chamber of horrors” needs her healing touch too!

Now, looking fer remnants of Jamie’s beating – were the continuity detailers attending to details? Yep, they were. Many films show heroes beaten within an inch of their lives but they emerge moments later wit’ nary a scratch – keeps me up at night!

Here’s a great example. Did ye see Jamie hobble along wit his right arm drooping as the Teenage Trollop hauls him into an alcove ta have her way wit’ him (Starz episode 3, The Way Out)? Yep, he’s still hurting after that thrashing!

At the pillory (Starz episode 3, The Way Out), we glimpse a dark shadow over his zygomatic arch (red arrow) and mayhap a bit o’ black eye as he helps Claire from a feigned swoon – she who canna stand the sight of blood. Hah. Looks like a big old nasty bruise ta me! Verra nice.

Finally, at the Black Kirk, Claire gives Jamie a botany 101 class explaining the difference between wood garlic and its deadly look-a-like, lily of the valley. This time we see up close the mottled bruising o’er Jamie’s zygomatic arch. Ahhh…he does have a lovely arch does he not?

I’ll leave ye now with three wonderful images from Starz episode 3, The Way Out. At Gwyllyn the Bard’s performance, Claire is deep into Colum’s Rhenish. Ever watchful Jamie escorts her safely to her Beaton dungeon under the guise of needing help wit’ his bandage. Jamie, ye are the man! Claire decides to check his gunshot wound anyway and starts ta take off his clothes -weel, she just unties his stock and unbuttons his shirt but…Gah!

She pulls back the bandage: “Scabbed over nicely; no drainage.” She isna going ta let Jamie leave her surgery without feeling his fair, fresh skin. After all she is the healer and she is in charge!

And, what is young Jamie’s thinking wit’ Claire half undressing him and putting her bonny fingers on him? Weel, look at his face. Ha’ mercy, lass! Ye are making it verra hard for the puir man. Snort! Jamie, he is silently taking’ the MacKenzie oath – only backwards. Jamie, man, ye BURN not shine!

OK, that does it fer this anatomy lesson. Thanks for joining me as we explored how Jamie’s wounds ne’er fail to bring on Claire’s healing touch! Hope ye all are hunkering down as the winter solstice approaches (in the Northern Hemisphere, anyway).

And fer those who are new to my blog, a note of explanation: I follow the convention of using the character’s names rather than the Starz actor’s names. This gives the cast at least one degree of separation and a wee bit o’ respect as I dissect their bodies with words! I hope ye all understand!

You can now follow me on Facebook and Twitter!

The deeply grateful,

Outlander Anatomist

Images courtesy of: Starz, www.wikihow.com, www.wikipedia.org, Kidney Health Australia, radiopaedia.org, Netter’s Atlas of Human Anatomy 4^th ed., Hollingshead’s Textbook of Anatomy, 5^th ed.

November 7, 2014July 31, 2015

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.

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!

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!

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?

But, the ultimate proof comes from Jamie himself: in Outlander, he tells Claire that she has skin like an “opal” as 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!

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!

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…

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!

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!

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!

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.

Photo 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.

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.

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.

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)?

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!

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.

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.

Photo 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.

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!

It is an anatomical barrier against pathogens and damage.
It provides sensation in the form of pain, touch, pressure, heat, cold and vibration.
It regulates our body temperature by dilating or constricting blood vessels in the dermis and cooling the skin by the evaporation of sweat.
It helps control fluid loss.
Helps synthesize vitamin D via UV radiation.
It aids in excretion of waste products.
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!

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, 4^th ed., Bailey’s Textbook of histology, 10^th ed. or Bloom & Fawcett’s Concise Histology, 2^nd 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 20^th century.