jamiefraser

“When Claire Meets Jamie” or “How to Fall in Love While Reducing a Dislocated Shoulder Joint!”

Anatomy Lesson #2: The Shoulder Joint 

Okay, now, wait just a minute, don’t even think about leaving this post! 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! Heh, here ye go…

Better? Great!  So, in Starz episode 1, Sassenach, Claire first sees Jamie seated on a low stool in a dimly-lit cottage. He is in pain and Herself writes “a dreadful hump rose on that side, and the arm hung at an impossible angle.” Now, what was the dreadful hump, what might have caused it, and how might it be repaired? 

Let me assure ye, the science behind the shoulder joint is bloody AWESOME, ya ken? First, it is the MOST moveable joint of the entire human body (think of the upper limb during slow pitch or the butterfly stroke). Second, the shoulder joint isn’t one joint, but two: one between the arm bone and the shoulder blade (glenohumeral joint) and a second between the collar bone and the shoulder blade (acromioclavicular joint).  Both are verra important!

Turns out that puir Jamie dislocated his glenohumeral joint (green arrow in Photo A – seen from the front)Here, the head of the humerus (arm bone) glides in a wee and verra shallow socket (glenoid cavity) at the side of the scapula (shoulder blade). Since the humeral head isna seated in a deep socket, the joint is highly moveable but dislocates with relative ease!

photo A

The acromioclavicular joint (green arrow in Photo B – seen from the front) lies between the acromion (part of the scapula) and the collar bone (clavicle). This joint isna verra moveable but is essential because it stabilizes the glenohumeral joint and holds it away from the torso allowing for increased range of motion.

 

photo B

The acromion (Photo C – seen from the back) overreaches and protects the underlying glenohumeral joint and shares the same Greek word root with the Acropolis of Athens, meaning “highest” because both structures overlook what lies below. The “dreadful hump” on Jamie’s right shoulder is the acromion! Deprived of the rounded contour normally provided by the humeral head, it is left high and dry (aye, we all know the hump is a prosthesis)!

photo C

Verify this on yerself! Palpate the point ‘o the shoulder and feel the big bony chunk. This is the acromion! Now, check this area out on yer wee dog or, perhaps on a horse (‘cuz Jamie does like the horsies)! The acromion faces forward and lies under the neck of these animals. Why? Because dogs and horses have no clavicles to hold the shoulder joint away from the torso so it falls into a forward position. Therefore, their shoulder joint is much more stable than ours but its range of motion is greatly limited.

Next, the joint is stabilized and held together by very strong ligaments and four muscles that form the rotator cuff. Finally, the powerful deltoid (photo D - green arrow denotes head of humerus) covers the joint and its accessories with a thick, protective muscular padding (especially in a man like Jamie – gulp!).

photo D 

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

Now, back to Starz episode 1, Sassenach: We hear the ever “tender” uncle Dougal mutter ”it’s out-o-joint, poor bugger.” Well, duh! 

In the book, Outlander, Jamie explains that he “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.” 

Weel, folks, falling on an outstretched arm/hand is the classic cause of an anterior dislocation of the shoulder joint where the humeral head moves forward (anterior) of the glenoid cavity.

Back in episode 1, Sassenach, our favorite goof Angus delicately raises a brow and says, “I’ll have to force the joint back!” Yeah, right, Angus! Yer going about it all wrong. At this point, our awesome Claire using her best Hospital Matron voice snaps: “Don’t you dare…stand aside at once!” She then instructs Dougal: “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. 

But, after obtaining Jamie’s nod of consent, Claire grips his wrist with one hand and his bent elbow with the other. Lifting and with considerable effort, she turns his forearm to his right (external rotation), a movement that aligns the humeral head with the glenoid cavity. 

Then, warning Jamie that the worst is yet to come, Claire holds his bent elbow against his torso, and gripping his hand, rotates his forearm to his left (internal rotation). 

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

Suddenly, the 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 like HELL - truly

Just ask Angus…Ouch!

Next and this is very sweet, Jamie says he’s takin’ a guess she’s done this afore. Claire assures him, ”I’m a nurse!” Jamie eyes immediately drop to her bosom…”Aye” - ah, well, he may be injured but there’s nothing wrong DOWN THERE! 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!

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 sense to blink a few times. Yup, he got her attention alright and she got his. The fat is in the fire now! 

A fun fact – Did ye 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 have loved to have seen 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, episode 2, Castle Leoch (snort)!

OK…question: was this scene in episode 1 realistic? Is it likely that a WWII combat-trained nurse such as Claire might know how to reduce the glenohumeral joint using the method shown? Oh, aye, because the procedure she employed looks verra much like the Kocher maneuver which was developed in the 19th century by a Swiss surgeon of the same name. Although other methods are now available, it has been widely used for over a century and Claire could very well have learned it in training or in the field.

Another realistic feature, check out Jamie’s eyes in episode 1, Sassenach. Throughout the entire scene, his pupils are VERRA dilated. This is highly realistic because the pain of the dislocation would initiate the fright/flight/fight reflex, the dilated pupil being a prime feature of that response! His pupils are soooo dilated that the rims of his irises are barely visible! 

Overall, this vivid scene was realistic, dramatic and extraordinary in most every detail. Congratulations to the cast and crew! If ye readers are interested, ye can watch a YouTube demo of the Kocher reduction on line. 

My next post may well review the remaining injury to our hero seen in Starz episode 1, Sassenach. Please stay tuned and see what’s next! After all, we have to keep ourselves somehow engaged until April of 2015! Geez, Starz…soooo harsh!

The deeply grateful,

Outlander Anatomist

All photos are credited to Starz or Frank Netter’s Atlas of Human Anatomy, 4th edition.

3

This was an undertaking that I didn’t fully understand when I cheekily thought “oh I know, I’ll draw Jamie smolder! And color it!”

I normally color in a conventional comic book method - of which I tried and it came out awful and I lost the likeness in the hard shadows. So I decided to go for a painted look, thinking that was gonna be somehow easier.

Well fuck.

That took me nearly all damn day and it’s overcooked. I don’t use a tablet, I use a mouse, and I have never used my smudge tool more than I did today in my life.

How colorists maintain likenesses when doing conventional comic methods is sorcery. I will likely never do this again (unless next weekend I’m compelled to make a Claire one and punish myself further because I’m insane…I’ll probably do it).

“Claire’s Hair - Jamie’s Mane” or “Jesus H. Roosevelt Christ!”

Anatomy Lesson #6:  The Skin – Part 2, Hair

Hallo again, friends of Outlander Anatomy! Today’s lesson will continue with the skin but will focus on hair, hair follicles, arrector pili muscles and sebaceous glands, all of which ye learned from Skin Part 1 are made by skin and are therefore part of that organ.

Now, afore we git on with today’s lesson, I must confess that I did a quiet switcheroo on ye in the last anatomy lesson. My first four lessons were confined to a part of human anatomy known as gross anatomy. This field encompasses human dissection. 

Nay…not that kind of gross, Rupert! It is termed “gross” not because it is yucky, but because it deals with structures visible to the naked eye. In Anatomy Lesson 5, I switched (without tellin’ ye) to another field of human anatomy, that of microscopic anatomy. 

Microscopes are used to magnify structures too wee for us to see with eyes unaided by magnifying lenses. Many of today’s images are drawings made from slides examined through a compound microscope such as this one (photo A):

 photo A

Once again there are 3-D images taken with a powerful SEM- scanning electron microscope (Photo B). I have used both types of microscopes many times in teaching and various research projects! 

 photo B

Now, gettin’ in the mood for today’s Anatomy Lesson: Skin 2 – the Hair! As with skin, Herself often writes about hair in the Outlander books, offering her audience a more intimate glimpse into characters and situations through vivid use of this physical trait. So, once again, I begin our lesson with images from the Starz Outlander series and with words from the Outlander books.   

Let’s begin with our heroine. Early in Starz episode 1, Sassenach, Claire emerges from the roadster standing in the picturesque village of Inverness.  We can clearly appreciate her dark brown hair – very full and very curly.

Later, during a lighting storm, Herself writes

The wind was rising and the very air of the bedroom was prickly with electricity. I drew the brush through my hair, making the curls snap with static and spring into knots and furious tangles!

The humid air makes Claire’s hair wildly curly and disobedient (Starz, episode 1, Sassenach) to which she exclaims: Jesus H. Roosevelt Christ!!

And, all the while, someone is awatchin’ her futile struggles through the window of her room.

 Nay, it isn’a a peeping tom, it is a keeking Jamie! Ha!

This next image of Claire always makes me laugh! In Starz episode 2, Castle Leoch, Mrs. Fitz unceremoniously rouses Claire from her sleep, seats her in a chair and hands her a cup ‘o brakfast fer her empty belly. Mrs. Fitz then whisks it away afore Claire even finishes! Look at Claire’s hair! It is absolutely fabulous! She certainly looks like the “wee milkweed” Jamie affectionately calls her later in the Outlander book.

"Fretful porpentine, was it?” he asked. He tilted his head, examining me inquisitively. “Mmm,” he said, running a hand over his head to smooth down his own hair. “Fretful, at least. You’re a fuzzy wee thing when ye wake, to be sure.” He rolled over toward me, reaching out a hand. “Come here, my wee milkweed.

Wit’ those great images ta set the mood, it is time fer our anatomy lesson on hair and with it a lot of verra juicy tidbits ta share! First, as ye know, the length of body hair varies a lot - from less than 1 mm (.04 in) on the forehead to well over 1 m (3.3 ft) in long scalp hair (Photo C)! But, the wee hairs of the eyelids (not the eyelashes) are so short they barely reach the skin surface! And, ye should ken that hair grows verra rapidly, about 0.3 mm/day or 1 cm/per month.

 photo C

Ye should also know that hair does not grow straight out of the skin; it emerges at a slant (Photo D). Check this on yer own skin as an example: place your forearm on a flat surface with the palm down. Examine yer forearm hairs and see that they are angled toward the little finger side of the forearm. That’s the slant I’m a talkin’ about.

 photo D

Hair is also denser in some areas than in others: the face has about 600 hairs/cm2 (.16 in2) compared to about 60 hairs/cm2 on the rest of the body.  Hair diameter also varies greatly but even the thickest hair is still only about .5 mm (.02 in) in diameter (Photo E). Even so, a scalp hair is strong enough to support the weight of 100 gm (3.5 oz)!

 photo E

Another interesting tidbit: Human hair grows autonomously; each hair cycles at its own pace through periods of growth and periods of quiescence. If all our hair were on the same cycle, we would molt!

And sometimes our hair does unspeakable things and we just have to pull it outta the way like Angus here who does prefer a wee bit o’ purple ribbon fer his scalp hairs!

Now back to microscopic anatomy! Using the same image from Skin - Part 1, I’ll be reminding ye that skin is divided into a thin outer epidermis that overlies a thicker dermis. And, although not part of skin the hypodermis lies deeper still. The dermis and hypodermis also anchor structures that we’ll cover in this anatomy lesson: hair, hair follicles, arrector pili muscles, and sebaceous glands (Photo F).  

 photo F

Hairs emerge from hair follicles which are down growths of the epidermis (Photo G). The internal anatomy of each follicle is verra complex so I’m simplifying it: the hair and its follicle are divided into a hair root and a hair shaft. At the root is a bulb where cells divide and push older cells toward the surface to form the hair shaft! 

 photo G

Along the way, hair cells harden and get plastered together so by the time the hair clears the skin surface, the cells are dead, flat and stiff with their free edges pointing toward the hair tip. They also overlap each other like shingles on a roof (Photo H). This is a SEM image of a single hair!

 Photo H

Ye should also ken that hair follicles are verra sensitive to the influence of hormones! These chemicals produce secondary sex characteristics such as hair distribution. In fact, the distribution of hair between the two sexes play an important role in socio-sexual communications!

In women, estrogens (oestrogens) cause most body hair to develop as short, thin vellus hairs that are anchored in the dermis. Both genders exhibit the coarse terminal hairs of scalp, eyelashes, eyebrows, axilla and pubis that are embedded deep in the hypodermis.

In men, androgens (testosterone being the most important) also convert facial and chest hairs into terminal hairs. Now then, isna this the right place to offer praises to Dougal MacKenzie who won Saturday’s Starz contest with his comely beard? Congrats! It looks mighty fine on ye, man! Tulach Ard!

And, no anatomy lecture is ever complete without at least one image of a half-dressed Jamie! So here is his chest hair just in case ye be forgettin’!  No verra damn likely! Gawd!

Something else: When viewed by SEM, straight hair has a round shaft as seen in this photo of scalp hair (Photo I –computer generated color); the surrounding dead skin cells look like scatter leaves on a forest floor.

 Photo I

Murtagh’s scalp offers a perfect example of straight hair – here he is explaining to Claire why Jamie is nowhere to be seen (Starz episode 5, Rent)! Plus, he has mighty fine eyes and braw eyebrows just in case ye been so focused on Jamie that ye havena been noticing!

Scalp hair that is curly like Claire’s…

…has a shaft that is flattened in cross-section as shown in this SEM image (Photo J). The flatter the shaft, the curlier the hair!

 Photo J

Now, onto a couple of other structures associated with the hair follicle. First, stretched between the follicle and the dermis is a thin band of tissue, the arrector pili muscle. Second, between the hair follicle and the arrector pili muscle lays one or more sebaceous glands with ducts opening into the hair follicle (Photo K). Sebaceous glands produce sebum, a complex mixture of fats, waxes and other materials.

 photo K

The arrector pili muscles are made of smooth muscle cells that are not under conscious control. They contract in response to cold or the fright, flight, fight reflex! Contractions of this muscle elevate the hair, forming goose bumps or goose flesh and help squeeze sebum from the sebaceous glands into the hair follicle and onto the hair shaft (Photo L).

 Photo L

Contraction of the arrector pili muscles in animals traps air between the erect hairs to retain body heat or to help the creature appear more fierce (Photo M)! This adaptation isn’t of much use to us short haired humans but the release of sebum does help lubricate and protect the hair itself.

 Photo M

Finally, on to hair color! Like the epidermis, hair color requires the presence of melanin; melanocytes in the hair bulb synthesize melanin and package it into granules that move up the hair shaft as it forms. Now, it turns out that there are a couple of different types of melanin!

Like Claire, most hair color is due to the presence of varying amounts of brown or black eumelanin. But, now, ye are in fer a BIG surprise! I bet ye dinna ken this! Flaming red hair in one such as our Great Scott, Jamie, contains a chemically different type of melanin known as pheomelanin and this molecule is red (or red-brown)! Thus, Jamie’s gorgeous mane of red hair is due to the presence of pheomelanin as seen from the back in this image (Starz episode 7, The Wedding)!

And just so ye won’t ferget it, here is Jamie’s hair from the front! We can literally see the words Herself wrote in Outlander about his hair:  

…a mass of auburn, copper, cinnamon and gold all gleaming together in the morning sun…

And one last point fer yer eddycation: Check out both upper corners of Jamie’s forehead. See how the hair line is squared off? This is known as the temporal notch; it is a secondary sexual characteristic in men brought about by the influence of testosterone. Women typically have an oval hairline in the corresponding areas of the forehead!

And now, folks, our journey through the skin and its appendages has come to an end! I do hope you have enjoyed learning about the skin ye are in and that of the Outlander cast while we are at it! At some point in the future, I will post Skin 3 – The Breast.

In the meantime, I’ll be leaving ye with these lovely words from Herself in the Outlander book and an image from Starz episode 7 (The Wedding):

You’ve the loveliest hair,” said Jamie, watching me.  ….”But it’s so .…curly,” I said, blushing a little….“Aye, of course.” ….He sat up and tugged gently on one curl, stretching it down so that, uncurled, it reached nearly to my breast…

And:

 “Mo duinne?”…“It means ’my brown one.’ ”He raised a lock of hair to his lips and smiled, with a look in his eyes that started all the drops of my own blood chasing each other through my veins. Rather a dull color, brown, I’ve always thought,”….”No, I’d not say that, Sassenach. Not dull at all.”  He lifted the mass of my hair with both hands and fanned it out. “It’s like the water in a bern, where it ruffles over the stones. Dark in the wavy spots, with bits of silver (auburn on Starz) on the surface where the sun catches it.” 

Gah, this man has a way with words! Does he ever say anything wrong?  Just look at the look on Claire’s face! She’s both enchanting and enchanted!

Psst…next time, I will be writing about someone’s thighs and knees…stay tuned!

The deeply grateful,

Outlander Anatomist

Photo credits to: Starz, Cat photo from goosecam Edmonton Journal, Goosebumps from genius.com, Basic Histology by Junqueira and Carneiro, 11th ed., University of Leeds, Rochester education Foundation, Wikipedia, WebMD, Loyola University Dermatology website, Histology Guide, University of Leeds, Wikimedia.org. CSIR - Council for Scientific and Industrial Research, South Africa. OA archival photos, Aersol Research – Washington University St. Louis