Category: Mini Anatomy Lesson

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Mini Anatomy Lesson: Corrugator Supercilii

 

Anatomy Def: Paired muscles of facial expression.

Outlander Def: Ian’s worry lines when he learns he must leave his beloved Emily! 😢

Don’t know about you, but for me, John Bell’s performance in Outlander episode 604, Hour of the Wolf was flawless. His facial expressions perfectly mirrored the stress roiling in his personal life.

Facial Expression: Humans enjoy 22 pair of muscles controlling facial expression, more than any other animal, blessing us with an amazing range of emotional aspects. 

As Ian hears the Mohawk’s decision about his and Emily’s fates, the skin wrinkles between his eyebrows. How does this happen?

Corrugator Supercilii: Well, his facial expression is caused by contraction of corrugator supercilii (CS) muscles, just one of the 22 pair! 😲

Super silly, huh? 😜

Meaning: Actually, this pair of muscles is so named because of their action and also by their placement in the face: 

    • Latin, con meaning “together” + rugare “wrinkle”
    • Latin, super meaning “over” + cilium ”eyebrow” 

Ergo, corrugator supercilii wrinkle the skin between the eyebrows.

Violà! 🤗

Anatomy: The figure below is a computer generated image of the paired CS shown as green slashes. CS originate from the forehead (frontal bone) about midway along each eyebrow and insert into the skin at the top of the nose (nasion). 

Function: As CS contract, the eyebrows are drawn together and downward, producing vertical wrinkles of the forehead skin.

Emotional Signal: CS belong to a group of frowning muscles, used to convey suffering! And, who does that better than our beloved Ian? 😢 

Frontalis: Just to complicate matters, let’s throw in a second pair of facial expression muscles – the frontalis. In the image below, frontalis fibers (dark green patches) run vertically through the forehead. They originate from the top of forehead (frontal) bone and insert into the skin above the eyebrows. 

Frontalis muscles raise the eyebrows and wrinkle the forehead skin but this time, the creases run horizontally. Consider Jamie in Outlander episode 606, The World Turned Upside Down. Here, a “worrit” Jamie attends to Malva’s chatter and seductive overtures.

So what happens if CS and frontalis muscles contract simultaneously? Let’s look again at Ian for the answer. Deeply concerned for the wee soul of his stillborn daughter, Iseabaìl, he confides in his beloved uncle! 

Ian contracts CS (red arrow), hence the vertical wrinkles between the brows, and frontalis (blue arrow) producing horizontal wrinkles in his forehead skin. Working together, both sets of muscles truly convey worry, anguish, and despair.   

Learn much more about the muscles of facial expression in my big Anatomy Lesson #11, Jamie’s Face or Ye do it Face to Face?

Lest you think that humans are the only creatures with muscles of facial expression, meet my year-old Vizsla puppy, Finnegan. Check out the wrinkles between his “brows”? 

Studies suggest dogs lack CS muscles but other facial muscles perform a similar function. Such muscles give them what is known as pedomorphic facial features (infant-like). Humans apparently prefer such features in domesticated dogs. 🥰

See Ian’s worry muscles in Outlander Episode 604, Hour of the Wolf.

Read about Ian’s distress in Diana Gabaldon’s sixth big book, A Breath of Snow and Ashes wherein, it is Brianna that comforts Ian:

“Aye, maybe. But …” He closed his eyes, hands clenched hard into fists on his thighs. “Where is she, then?” he whispered, and she could see tears trembling on his lashes. “The others—they were never born; God will have them in His hand. But wee Iseabaìl—she’ll not be in heaven, will she? I canna bear the thought that she—that she might be … lost, somewhere. Wandering.”

“Ian …”

“I hear her, greeting. In the night.” His breath was coming in deep, sobbing gasps. “I canna help, I canna find her!”

“Ian!” The tears were running down her own cheeks. She gripped his wrists fiercely, squeezed as hard as she could. “Ian, listen to me!”

He drew a deep, trembling breath, head bent. Then he nodded, very slightly.

She rose onto her knees and gathered him tight against her, his head cradled on her breasts. Her cheek pressed against the top of his head, his hair warm and springy against her mouth.

“Listen to me,” she said softly. “I had another father. The man who raised me. He’s dead now.” For a long time now, the sense of desolation at his loss had been muted, softened by new love, distracted by new obligations. Now it swept over her, newly fresh, and sharp as a stab wound in its agony. “I know—I know he’s in heaven.”

Was he? Could he be dead and in heaven, if not yet born? And yet he was dead to her, and surely heaven took no heed of time.

She lifted her face toward the cliff, but spoke to neither bones nor God.

“Daddy,” she said, and her voice broke on the word, but she held her cousin hard. “Daddy, I need you.” Her voice sounded small, and pathetically unsure. But there was no other help to be had.

“I need you to find Ian’s little girl,” she said, as firmly as she could, trying to summon her father’s face, to see him there among the shifting leaves at the clifftop. “Find her, please. Hold her in your arms, and make sure that she’s safe. Take—please take care of her.” 

Deep stuff!

The deeply grateful,

Outlander Anatomist

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Photo Credits: Starz, Sony, Outlander Anatomy,  www.kenhub.com 

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Mini Anatomy Lesson: The Belly Wall

Anatomy Def: The belly wall is known by anatomists as the anterolateral abdominal wall (why use a simple word when a complex one will do?). 😉

Outlander Def: Claire’s Despair – Malva’s Mutilation! 😱

Before we begin this lesson, I have a true story to share…. In 2016, I asked Diana Gabaldon if nominative determinism was involved in her choice of Malva’s name because “mal” is the Latin word root meaning “evil” or “bad,” which clearly could apply here.

Why did I ask this? Think about it…. There’s mal-ware, mal-nutrition, mal-adapted, mal-content, mal-practice, mal-evolent, mal-odorous, and Mal-va! 😳

Diana answered, “No, I got it off a bottle of black malva shampoo!”

Haha. Love it! 😜

OK, anatomy students, let’s get on with our lesson.

Warning: The following images detail the final events of episode 606, “The World Turned Upside Down.” If you couldn’t watch this part of the episode, you might not want to read this lesson! 

Recap: Claire was in her surgery under the influence while someone “stomped through the nasties” with Malva. 

Never dreaming her beloved garden would be the site of a massacre, Claire spies Malva’s lifeless body, throat thoroughly mangled! 😯

Realizing her infant may still be alive, Claire springs into action, slicing open Malva’s gown with her garden knife.

Moving with speed and surety, Claire slices Malva’s belly wall vertically and to the left of her navel, a vertical cesarean section. 

Claire works ruthlessly with such intent and determination that Malva’s lifeless body shutters from her efforts.

Claire releases the infant from the womb and realizing its life is fleeting.  She performs mouth to mouth resuscitation and chest compression using two fingers. But, alas, her efforts fail.

Goodness, this is hard to review, even using still images.

After this episode was over, my husband, who is not a book reader, turned to me and asked, “Is that in the book?” ‘Yes,” I answered. He remarked, “That is going to be hard to explain.” 

He then added, “ Now, they have to figure out who murdered Malva.

”Who do you think it might be,” I asked. 

“Well, I would look to the brother, first,” he said.

Amazed, I asked “Why?” 

His answer: “Because in patriarchal systems, male relatives often kill women who bring shame upon their families.”  (See footnote at end of lesson) 😲 

‘Nuff said!

With this horrific scene as backdrop, let’s talk anatomy of the belly wall.

Abdominal Wall: The abdominal wall is a cylindrical region of the body bounded above by costal cartilages, ribs, and sternum (xiphoid) and below by iliac and pubic bones (green area in image below). 

 

Anatomists typically divide the abdominal wall into anterolateral and posterior parts. The term, anterolateral, means the front (antero-) and sides (-lateral) of the wall. The term, posterior, refers to the back of the wall. 

These regions are best demonstrated in a cross-section (horizontal) through the torso. 

The figure below shows the two regions. The area bound by blue lines is the posterior abdominal wall. The remainder of the large pink oval is the anterolateral abdominal wall. (Psst….Dinna fret about all the names. Will explain below). 

Anterolateral Abdominal Wall (AAW): Succinctly put, the anterolateral abdominal wall is the flexible and expandable part…. a.k.a., the belly. The posterior abdominal wall has limited flexibility and is unable to expand to any significant degree.

The main reason the AAW can expand is because it is made of soft tissue layers (no bones). The layers vary depending on the site. The following image is a cross-section of the AAW above the navel. 

The central area marked as linea alba is a vertical line of connective tissue that unites right and left halves of the AAW. It is a nearly bloodless line and therefore can be cut with little blood loss.

On either side of the linea alba are right and left rectus abdominis muscles. These run vertically. 

Using the image below, at the sides of the AAW, three layers of muscle appear, from outer to inner: 

    • external abdominal oblique (EAO)
    • internal abdominal oblique (IAO) 
    • transversus abdominis (TA). 

The following image shows the muscle pattern  from a frontal (anterior) view. Note the linea alba. Clearly, the belly wall enjoys a good deal of muscular support.

So, how thick is the AAW? Well, that depends on the individual. Moving to the next image, a magnified cross-section through the AAW, we find that the lateral AAW is composed of nine layers (three are muscle layers)! 

    • Skin
    • Fat layer (we accumulate varying amounts of fat in this layer)
    • Superficial fascia
    • EAO
    • IAO
    • TA
    • Transversalis fascia (connective tissue)
    • Extraperitoneal layer (more fat and connective tissue)
    • Peritoneum (membrane lining abdominal cavity

Nearer the midline,  AAW is composed of seven layers because it has only one muscle layer, the rectus abdominis. 

Either way, that is a LOT of layers!

Functions of the AAW: You might ask why is this part of the body designed to be flexible and expandable? Here are some reasons:

    • Maintains upright position
    • Moves the trunk (rotation, flexion, extension, bending sideways)
    • Protects abdominal viscera
    • Absorbs shock (remember BJR punching Claire in stomach in ep 106?)
    • Supports pregnancy
    • Increases intra-abdominal pressure (coughing, vomiting, childbirth, sneezing, defecation)

It is a darn good thing the AAW is flexible, especially for a pregnant woman. The next image shows a fetus during the third trimester. The uterine wall is labelled. The red arrow indicates the muscle layer of the AAW.

It as well as the other layers expand dramatically over the course of a pregnancy. The relatively slow growth of the fetus allows the belly wall to accommodate to the stretching, usually without tears, although these do occur (hernia).  This image is close to Malva’s condition when she was murdered.

So, there we have it in a nutshell, albeit a rather large one. We need an intact AAW to function well in our lives as it serves multiple purposes.

Learn more about the AAW in Anatomy Lesson #16, “The Abdomen.” There is much more to learn about this part of our anatomy – Lesson #16 explores this in greater depth. 

NOTE: The AAW is essentially the same in females and males except the groin region, there we find differences. Lesson #16 explains these.

FX: Now, how well did Starz FX do with Outlander 606? Pretty darn good if you ask me. Here are some examples:

    • As Claire begins her cut, there is a small stream of blood-tinged fluid which is consistent with the location of the cut, that is, very near the linea alba (see above). There would be little blood flow at this point as the cut is only through the belly wall. 
    • Malva’s navel does not look realistic because it appears largely normal. In late pregnancy, it usually pooches outwards due to increased intra-abdominal pressure.
    • The pink tissue underlying the skin is fat. It is a bit thick for Malva who is a trim young woman.
    • After Claire’s knife pierces the uterine wall and she removes the infant, the C-section now appears dark red because the uterus receives a huge blood supply during pregnancy. Well done. 
    • Malva’s infant is covered with blood-tinged material, the vernix, a waxy coating to protect the infant’s skin. Yay!
    • Malva’s belly is slightly concave after the infant was removed. Horrible, but accurate. 
    • Mouth-to-mouth on such a tiny person should be done with less force than Claire used – third trimester lung volume is calculated at less than 2 tablespoons per lung! This can accommodate a very tiny amount of air.
    • Claire doing two finger chest compression to stimulate the heart is spot on.

Yay, Outlander! Kudos to the FX folks!

Read about Claire’s emergency C-section in Diana’s sixth big book, “A Breath of Snow and Ashes!”

I smelled the blood and saw her in the same instant. She was lying in the salad bed, her skirt flown out like some gigantic, rusty flower blooming amid the young lettuces. 

I was kneeling by her, with no memory of reaching her, and the flesh of her arm was warm when I grasped her wrist—such small, fragile bones—but slack, there was no pulse—Of course not, said the cold small watcher inside, her throat is cut, there’s blood everywhere, but you can see the artery isn’t pumping; she’s dead. 

Malva’s gray eyes were open, blank with surprise, and her cap had fallen off. I clutched her wrist harder, as though I must be able to find the buried pulse, to find some trace of life … and did. The bulge of her belly moved, very slightly, and I dropped the flaccid arm at once and seized my knife, scrabbling for the hem of her skirt. 

I acted without thought, without fear, without doubt—there wasn’t anything but the knife and the pressure, the flesh parting and the faint possibility, the panic of absolute need…

I slit the belly from navel to pubis, pushing hard through slack muscle, nicked the womb but no matter, cut quick but careful through the wall of the womb, dropped the knife, and thrust my hands into the depths of Malva Christie, still blood-warm, and seized the child, cupping, turning, wrenching hard in my frenzy to pull it free, bring it out from sure death, bring it into the air, help it breathe.… Malva’s body flopped and heaved as I jerked, limp limbs flailing with the force of my yanking. 

It came free with the suddenness of birth, and I was swiping blood and mucus from the tiny sealed face, blowing into its lungs, gently, gently, you have to blow gently, the alveoli of the lungs are like cobwebs, so small, compressing its chest, no more than a hand’s span, two fingers pressing, no more, and felt the tiny spring of it, delicate as a watch spring, felt the movement, small squirms, a faint instinctive struggling—and felt it fade, that flicker, that tiny spark of life, cried out in anguish and clutched the tiny, doll-like body to my breast, still warm, still warm. 

“Don’t go,” I said, “don’t go, don’t go, please don’t go.” But the vibrancy faded, a small blue glow that seemed to light the palms of my hands for an instant, then dwindle like a candle flame, to the coal of a smoldering wick, to the faintest trace of brightness—then everything was dark. 

I was still sitting in the brilliant sun, crying and blood-soaked, the body of the little boy in my lap, the butchered corpse of my Malva beside me, when they found me.

Puir Claire! Puir Malva! Puir wee one!

See Claire as she realizes that all is lost. Mother and child are gone – grief, loss, and futility grip the Good Doctor.

The deeply grateful,

Outlander Anatomist

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Photo Credits: Starz; www.aafp.org; www.anatomyqa.com; www.kenhub.com; www.musculoskeletalkey.com; www.quora.com; www.stanfordchildrens.org

Footnote: In 2017, the United Nations Office on Drugs and Crime reported 87,000 killings of women worldwide – 58% were killed  by family members  or intimate partners! Alarming stats!

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Mini Anatomy Lesson: Tom’s Travail

 

Anatomy Def: Claire confronts Dupuytren’s Contracture.

Outlander Def: A hand condition best dubbed as “Tom’s Travail!”  👋🏻

Tom’s right hand is disabled because he suffers from Dupuytren’s Contracture (DC). If you have not read my earlier Mini Anatomy Lesson about DC, you can access it here. 

Quick Review: Underlying the skin of the palm is a tough layer of connective tissue known as the palmar aponeurosis. Importantly, it aids in cupping the palm, maintaining grip, and protecting underlying flexor tendons (see figure below).

DC causes the palmar aponeurosis to form thick bands and nodules that contract over time, typically drawing affected fingers toward the palm. Sometimes the palmar skin also contracts, scars, and pits. 

What Claire Did:  So, Claire says to Tom, “a stitch in time, saves nine.” She can fix what ails you, you auld sour pus.

Let’s do a quick recap of what Claire did. 🔪

First, and foremost, Claire kept Tom waiting. How dare you madam? 

Tom’s at least as brave as Jamie so he’ll not be having any of yer potions, witchie Claire! If Jamie can stand it – so can Tom. (Jamie be like….hmmmm 🤔)

How about a wee stick to bite on ‘cos this WILL hurt! Nope, says Tom!

Alrightie, then….How about a big dram of whisky? Yep, says Tom! (Hey! It’s for medicinal purposes 🥃)

Claire buckles Tom’s hand to a nicely padded wee bed. Screaming is OK, but no move a muscle, Tom. Claire needs both hands to slice and dice. She canna be holding yours! 😷

Claire’s wee alcohol lamp gleams, brightly!  

Claire sterilizes her scalpel blade in the flame.

Erm, wait!  Isn’t that a modern scalpel with a disposable blade and with info stamped in the handle? Ah…… yep.

Trouble is, knives with disposable blades weren’t invented until 1901 by King C. Gillette (yep, that Gillette), followed in 1906 by John Murphy, a surgeon who adapted Gillette’s razors into a surgical tool.

OK. Then, from whence did this scalpel come? I thought Claire’s medical kit perished back in Season 3 with the Artemis.  

But, wait!  She still wore her bat suit after washing ashore. Mayhap her med kit survived in one of its capacious pockets? If so, that blade may be a wee bit dull! 🤭

A chance to cut is a chance to cure! And, Doc Claire is off and running!

Claire makes a quick swipe of her scalpel across the palm of Tom’s hand.

@#%$&*!  That HURTS!!!

Although that first transverse cut seems a wee bit deep and wide, let’s just accept the FX and move on. Aye?

Violet arrows point to the thick, tight bands of palmar aponeurosis that pull Tom’s fingers downward. Those must be cut away or divided.

Claire carefully makes zigzag cuts in the skin and frees it from the aponeurosis. She works to remove the thickened bands of connective tissue. 

And, all the while, Jamie reads from Psalms at the back of Tom’s Bible. 😂 (Doesna matter, Jamie probs has all the psalms verses memorized anyhow.)

All done! A few snips and stitches later, the fingers are straight and the zig-zag opening is zippered shut. Tidy mending, Claire!

Hum…I understand that Tom’s Thumb and index were not a problem, but what about Tom’s wee finger, didn’t it have DC, too? 🧐

A few hours later, Claire offers Tom with some gentle PT. Tom has a fever so why not some penicillin?

Madam, you have a great deal too much hair!!!!  Scary woman, why aren’t you a pious wife wearing a drab kerchief? 😈

So, how does Clair’s surgery compare to the real deal? Actually, pretty good. 

WARNING: The following surgical images may be a bit graphic for some.  If you are squeamish, you might wish to skip.

The following are five standard surgical approaches to DC:

    • Regional Fasciectomy: Removal of the entire tight band(s) and/or nodule(s).
    • Segmental fasciectomy: Removal of part of tight band(s) and/or nodule(s). 
    • Dermatofasciectomy: Removal of tight band plus overlying skin – requires a skin graft. 
    • Closed Fasciotomy: Dissection of the tight bands using needles. No skin incision. Available with patients who cannot tolerate fasciectomy. 
    • Finger Amputation: Amputation  is employed in severe cases and after other approaches have failed.

BTW, fasciectomy means “to cut away fascia.”  (Other names are fasciotomy and aponeurectomy).

It appears Claire performed a regional fasciectomy. Yay Claire! 🤜🏻🤛🏻

Now, let’s compare to a real surgery. The following image is a left hand with DC. A tight band extends into the middle finger (top arrow) and a nodule and band to the wee finger (bottom arrow). The ring finger appears less affected than middle and wee. 

The surgeon opens the palmar skin to reveal the palmar aponeurosis. The tight bands are removed or split. Fine scissors and forceps are required to work carefully and meticulously to protect nearby neurovascular bundles and other important structures (next image).

Notice – the skin cuts are zigzags like Claire employed.

Why is this done?

ZigZag Cuts: ZZ cuts are employed for three good reasons:

    • Scars from a straight line incision tend to contract more and may cause DC to recur early.
    • Zigzag cuts mobilize more skin than a straight cut so the finger straightens better.
    • Zigzag cuts rarely require skin grafting.

Lastly, thread tethers hold skin flaps out of the surgical field.

The next image shows a woman’s hand, post-surgery, wherein repairs were performed to middle, ring, and little fingers. The inked zigzags were drawn before surgery so the surgeon knows where to make the cuts. These are still visible, post-surgery.

Skin Graft: As mentioned above, If the overlying skin in DC is too damaged or it is not sufficient to close the surgical wound, a skin graft may be added; this permits the hand to be opened completely and laid flat (table top test). The follow image shows a skin graft of the little finger.

NOTE: Claire did not ink the intended zigzags on Tom’s palm although she had the means to do so. Also, the FX could have been improved by showing both ring and little finger repairs; only Tom’s ring finger showed Claire’s final handiwork. Over all, though, I thought the FX were good.

Genetics: Dupuytren’s Contracture, the most common of all connective tissue diseases, has a genetic basis. Two schools of thought explores the genetics of DC which runs in families and is more common in men and those of North European descent.

*Dominant Gene: This position claims DC is caused by a single dominant, non-sex-linked gene with incomplete penetrance. In common language:  

    • The person inherits only one DC gene from either parent.
    • The gene is carried by a somatic chromosome – not X or Y. 
    • The gene may or may not expresses itself.

*Recessive Gene: This school of thought suggests the sufferer must inherit a recessive gene from each parent to get the disease. If (s)he receives just one recessive gene, then they are a DC carrier and do not have the disease.

Despite the prevalence of DC, its exact cause remain somewhat obscured.

So will all this cutting and stitching by Competent Claire fill Tom Christie with  joy???? 🤔

The deeply grateful,

Outlander Anatomist

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Photo Credits: Starz, www.istockphoto.com, www.johnericksonmd.com, www.researchgate.com, www.sciencephoto.com