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Anatomy Lesson: Mandy’s Malady

Welcome all anatomy students! It has been a while since I posted a lesson because, frankly, I have been dealing with my own malady – a shattered left ankle! Six months out and beginning to feel and function better. 🥳

Outlander fans recall that in episode Episode 702, “The Happiest Place on Earth,” Brianna gives birth to her second child, Amanda Hope Claire MacKenzie-Fraser. Dr. Claire is there to reassure Brianna and ease the process. The wee one is adored by all and affectionately nicknamed, Mandy.  Fraser’s Ridge is the happiest place on earth and all is well! 🥰

Young Mandy is quickly introduced to the Ridge’s denizens as Granda’ Jamie takes her on a wee stroll to meet a new foal at the stable. Do you see it, Mandy? It is a cutie-beauty like you! 😍 

Mandy’s doting Granny takes her on a guided tour of Claire’s fav room – the surgery! Mayhap she will follow in Granny’s footsteps? 👩🏻‍⚕️

Claire coos to Mandy, admiring the beautiful, wee lass. Then…. she sees Mandy’s fingernails. A closer look and a startled Claire exclaims: “Bloody hell!”  (Couldn’t have said it better myself)  

Ever observant Claire spies a bluish tinge at the base of Mandy’s wee fingernails (below, red arrows)!

Fun Fact: This is not hyperbole.  Fingernails and toenails give clues to at least a dozen possible medical conditions that require evaluation and followup. And, Mandy is no exception.

A quote from Diana’s 6th big book, “A Breath of Snow and Ashes,” documents the moment Claire observes Mandy’s nail beds: ”

“The minute nails were faintly tinged with blue.” 

Bree senses Claire’s concern and asks what is wrong.  She kens that look on her mother’s face. After Claire explains, Bree reports her own maternal observations: Mandy does not nurse well nor is she gaining weight like Jem. What is wrong? 😯

Claire determines that the wee lass has a heart defect requiring more advanced care than Claire is able to provide in the 1700s. She is clear that Mandy’s Malady is life-threatening and she likely will not survive for long without corrective cardiac surgery. Brianna and Roger decide to return with their children to the 20th century to obtain the necessary care to save Mandy’s life.

Arrangements are made for the MacKenzie family to travel through time at the standing stones on Ocracoke Island. Everyone agrees this is the best course of action, but this time and place is no longer the “happiest place on earth!” Will they ever see Fraser’s Ridge and one another again? 🤷🏻‍♀️

Time to start our lesson….What leads Claire to her startling diagnosis? The following are symptoms and clues that Doctor Claire considered:

    • Lethargy and weakness
    • Fast or labored breathing
    • Tachycardia (a heart rate exceeding the normal resting rate)
    • Cyanosis (blue-ish skin color due to a lack of oxygen), primarily seen in lower extremities
    • Dyspnea (shortness of breath)
    • Poor feeding
    • Failure to thrive
    • Distinctive murmur

Another pithy quote from “A Breath of Snow and Ashes:” 

I moved my stethoscope over the tiny chest, ear pressed to it, listening intently. It was my best stethoscope, a model from the nineteenth century called a Pinard—a bell with a flattened disc at one end, to which I pressed my ear. I had one carved of wood; this one was made of pewter; Brianna had sand-cast it for me.

The following image is a wooden Pinard stethoscope, currently for sale on the Internet for about $180 (there are much less expensive versions)! 💰

Claire placed her ear against the cup shaped disc at the top; the bottom of the tube was placed on Mandy’s chest. The stethoscope amplifies the sounds of blood rushing through the heart and striking its valves.  

What did Claire listen for? she was listening for a distinctive murmur: a soft, continuous shushing sound, particularly audible near the base of the neck. It is usually the first diagnostic sign of a problem with a fetal heart vessel.  

Although Mandy exhibits only some of the above symptoms, Claire diagnoses Mandy’s condition as a Patent Ductus Arteriosus (PDA).  

But, before we can understand PDA, let’s look at normal heart anatomy.

Heart Anatomy: To better understand Mandy’s Malady, let’s consider the normal anatomy of the heart and its great vessels. Now, I kid you not, the heart is a very complex organ, both anatomically (structure) and physiologically (function). We will only cover the basics. Understand that there are many more anatomical details that are beyond the scope of this lesson. But, we fearless folk press onward!

Chambers: The human heart has four chambers (next image). Right atrium and left atrium are thin-walled filling chambers. Right ventricle and left ventricle are thick-walled pumping chambers . The walls are composed of cardiac muscle, a specialized tissue found in the heart. (psst….don’t forget, the patient’s left is your right, and vice versa) 🤓 

Vessels: The heart has eight (!!!) vessels carrying blood to and from its chambers. These are (next image):

    • Superior vena cava – delivers blood from upper body into right atrium
    • Inferior vena cava – delivers blood from lower body into right atrium
    • Pulmonary artery – deliver blood from right ventricle to lungs
    • Four pulmonary veins – deliver blood from lungs to left atrium
    • Aorta – delivers blood from left ventricle to body 

Blood Flow: Next, let’s review the pattern of blood flow through the heart. As you read the details, check with the image below to verify the flow.

    • Deoxygenated blood (low oxygen – O2; high carbon dioxide -CO2) from  superior vena cava and inferior vena cava pours into right atrium and then into right ventricle.
    • Right ventricle contracts and ejects blood into the pulmonary artery which branches to supply left and right lungs. 
    • Blood releases carbon dioxide (CO2) in the lungs which is exhaled and picks up O2 from inhaled air.
    • Oxygenated blood (O2-rich) is carried to left atrium via four pulmonary veins. 
    • Blood pours into the left ventricle which contracts and ejects O2-rich blood into the aorta.
    • Branches of aorta carry blood to all other regions of the body (except lungs).  

OK, students, hang in there! With normal anatomy under our belt, let’s look at the fetal circulation. 

Fetal Circulation: Blood circulation in the fetus is different because the placenta provides the functions of lungs, gastrointestinal tract, and kidneys. Thus, a normal blood supply to these maturing organs is not required.

Ductus Arteriosus: The fetal heart has a vascular bridge between pulmonary artery and aorta that shunts blood exiting the right ventricle into the aorta and bypasses the lungs. This vascular bridge is the muscular ductus arteriosus (aqua arrow – below image). Again, because lungs do not process gasses during intrauterine life, most blood is shunted away from them. 

The ductus arteriorsus is patent (open) throughout fetal life and normally closes within 24 hours after birth as blood flow to the lungs is established. Within 2-3 weeks, it turns into a fibrous band, the ligamentum arteriosum. 

All of this is highly regulated by various chemical and physiological substances including oxygen levels. 

Patent Ductus Arteriosus: If the ductus arteriosus does not close soon after birth but remains patent (open), it is diagnosed as PDA, a congenital heart lesion. PDAs are most common in premature babies but can also occur with full term infants. 

Nowdays, if a ductus arteriosus does not spontaneously close after 8 weeks post-birth, it usually is treated with medications, plugged, or surgically closed. Small PDAs may not be a cause for concern and are often not treated.

Adding a bit of perspective – PDA is not new. It was known as early as 129 A.D. to Galen, a Greek anatomist and physician, although he didn’t understand its significance. It wasn’t until 1938, almost two millennia later, that Dr. Robert E. Gross of Harvard Medical School and Children’s Hospital in Boston, Massachusetts, perform the first successful ligation (closure) of a PDA. This was also the first congenital heart lesion to be successful corrected, surgically.

Now, let’s return to Mandy’s Malady. This was her problem. Mandy’s ductus arteriosus did not close after birth and she exhibited some of the concerning symptoms outlined above.  Blood from her aorta flooded her lungs subjecting fragile lung tissues to excessive blood pressure (hypertension). Allowed to go unchecked, the fragile lungs will be permanently damaged and she  eventually will experience right-sided heart failure.

Diana explains all of this with her usual magical writing skills in this excerpt from “A Breath of Snow and Ashes:” 

The ductus arteriosus is a small blood vessel that in the fetus joins the aorta to the pulmonary artery. Babies have lungs, of course, but prior to birth don’t use them; all their oxygen comes from the placenta, via the umbilical cord. Ergo, no need for blood to be circulated to the lungs, save to nourish the developing tissue—and so the ductus arteriosus bypasses the pulmonary circulation. 

At birth, though, the baby takes its first breath, and oxygen sensors in this small vessel cause it to contract—and close permanently. With the ductus arteriosus closed, blood heads out from the heart to the lungs, picks up oxygen, and comes back to be pumped out to the rest of the body. A neat and elegant system—save that it doesn’t always work properly.

The ductus arteriosus doesn’t always close. If it doesn’t, blood still does go to the lungs, of course—but the bypass is still there. Too much blood goes to the lungs, in some cases, and floods them. The lungs swell, become congested, and with diverted blood flow to the body, there are problems with oxygenation—which can become acute.

Lastly, this is a brief video about PDA which you might find useful. It is easy to understand and accurate: https://youtu.be/7DKaCqubuSg. 🤓

Fast forward! It is clear that the MacKenzies arrived safely in the 20th Century and Mandy received the medical intervention needed for her PDA repair. When we meet her next at Lallybroch, she is a healthy, happy, and feisty wee lass, played by Rosa Morris. 🤗

As William Shakespeare once wrote, “All’s Well That Ends Well!”

(Well, it would end better if they were all together, but we shall see) 🤞🏻

The deeply grateful,

Outlander Anatomist

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Photo creds: Sony/Starz; www.commons.wikimedia.org; www.heart.org; www.kidshealth.com; www.medicalsuppliesgh.com; www.medlineplus.gov; www.outlander.fandom.com; www.theoutlandermuse.com; www.twitter.com (now X)

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Mini Anatomy Lesson – William’s Wound!

Hello, anatomy students!

Good to see you again so soon. 😉

Today’s lesson explores the horrific circumstances leading to an intended amputation of William’s forearm.

Just so you know what to expect, this lesson does contain a number of rather gruesome images!

William’s wound appears in Outlander episode 704,  “A Most Uncomfortable Woman.”

A short recap: William hastily rides through the Great Dismal Swamp. His steed, Jupiter, is startled by a snake, which looks very much like a copperhead to me!

Jupiter unseats William who tumbles down a steep hillside hitting a fallen tree snag during his rapid descent.

As William comes to rest, he assesses the damage to his arm. Oh, dear,! A branch broke off the snag and buried itself into his right forearm. Ouch! 😱

Being of Fraser blood, he grits his teeth and pulls it out! 😬 Then, using his stock as a bandage, he wraps the wound under pressure and moves forward with his mission. This time, on foot, as Jupiter has hightailed it leaving William alone and without supplies or the notes from Captain Richardson! 😳 

Later,  he hears a sound. Looking up, he spies an “Indian” who speaks a Scot’s version of the King’s English. 😜  Wolf’s Brother (Ian Murray Jr.) in the flesh!

A very nice chit-chat ensues as they exchange bona fides.  Then Ian spies Williams’s wound. Um….best get that taken care of. Because, by now that oozing wound looks pretty yucky! 🤢

Ian sets about building a wee fire and boils a pot of water. Then he crouches beside William, pulls his knife from its sheath, and begins to free the wound of several splinters. Ouch! 😮

The blood clots are well done. 👍🏻

Then he pours boiling/hot water over the wound to try to cleanse and perhaps sterilize it? Oh, boy, that hurts! 🤯

Ian hustles William to the cabin of one Dr. Denzel Hunter and  his sister, Rachael. They help William onto a table and Denzel takes a quick keek. Oh, dear, that looks bad. Rachael, fetch me the saw!

After some protestations from Ian and William (it is his forearm, after all!), Dr. Hunter begins to saw. Suddenly, pus oozes from the wound and Denzel declares that the bile has been freed and there will be no need for a hack job today! 🪚

Much later, Williams shares his travail with fellow soldiers. Here, from “A Breath of Snow and Ashes:”

“Wandered round the Great Dismal Swamp for three days in a fever,” he said. “Some … Indians found me and got me to a doctor. I nearly died, and”–he lowered his brows and gave Zeb a piercing look–“the doctor was just about to cut off my arm, when the abscess burst and he cauterized it. You might not be so lucky, hey?”

Sometime later, Rachel tells William his scar has healed well. It looks like the star that guided the wisemen to the Christ child and it suits him. In the book, his scar looks like a comet.

A quote from “A Breath of Snow and Ashes:”

‘The wound was still red and puckered, the skin around it unpleasantly white and moist. It was, however, undoubtedly healing; the arm was no longer swollen, and the ominous red streaks had disappeared. “Well,” she said consideringly, “it’s a fine scar, I think. Well knit, and rather pretty.” 


Anatomy and Pathology: Now that the recap is over, let’s discuss the pathology of William’s wound. You may recall, that pathology, which literally translates to “knowledge of sorrow,” is abnormal anatomy, so we are not far off the mark. 🤓

I propose we review one issue at a time, so here we go!

The Accident:  I have been asked if I think the accident was plausible. My short answer is, yes. My reasoning is that William is a large man, rolling downhill, rapidly. All that weight with an extended arm and yes, it is possible. 🤔

Believe it or not, this issue is covered by Newton’s (next image) second law of motion which states that F = ma, in which net force is equal to mass times acceleration due to gravity.

Stated more plainly, the force with which William’s extended arm struck the wooded spike equals William’s mass times acceleration rolling downhill.

I asked my physicist son, Diedrich, to help with variables such as hypothetical mass, rate of descent, incline, size of branch, etc. He did the calculations and William  struck the branch with roughly 163 ft-lbs of force!  Consider that this force was expended onto a stick no more than 1” in diameter. Well, suffice it to say, that force is more than sufficient to snap the branch, break the skin, pierce the muscle, and even fracture one or both forearm bones (radius and ulna)! 😱

Make sense? Gooood! 🤗

Penetrating Wound: Poor William suffers what pathologists categorized as a penetrating wound. This occurs when a sharp object pierces the skin and creates a single opening into either tissues or a body cavity.  Clearly, there is one wound and the tissues in this instance are the meaty flexor muscles of his forearm. 💪🏻

Our flexor forearm (the palm side) houses eight muscles (15% of us have only seven). The spike would have driven deep into probably 2-3 of these muscles. This means any bacteria or other pathogens on the swampy branch would have sunk deeply into the tissues. This is why the wound became infected.

Inflammation: Ian unwraps William’s arm and spies a swollen,red, painful wound that will feel hot to the touch. These are four of the cardinal signs of acute inflammation, the body’s common response to injury and  infection.

Inflammation is heralded by five cardinal signs, four were described 2,000 years ago by Celsius. These are:

  • rubor (redness)
  • calor (heat)
  • tumor (swelling)
  • dolor (pain)

and….

  • functio laesa (loss of function) the fifth cardinal sign was added 200 years later by Galen, surgeon to Roman emperor, Marcus Aurelius.

    Does William’s Wound show all five cardinal signs of acute inflammation? Well, yes, yes it does! It is painful, swollen, red, hot, and he has lost normal use of the forearm. 

A current day example: The image below shows acute inflammation of the great toe (hallux) due to an ingrown toenail. The toe is red, swollen, warm, sore, and difficult to use.

Cleaning the Wound: I have to say, Ian was caring and compassionate to clean the splinters from William’s Arm.

But, I must protest! Ian has seen Auntie Claire take care of enough trauma to know that he should either cauterize that knife tip in the fire, or plunge it into the boiling water for a bit. Inserting the tip of a  dirty blade will introduce more pathogens into the already infected wound! 

And, pouring boiling/hot water into the wound? That  isn’t much help, either and was traumatic for William. Much better to let the water cool a bit and then cleanse the wound with the “sterilized “ liquid.

The amputation: When I saw this, I thought. Um……No! Denzel grabs his amputation saw and starts sawing away on William’s arm!  Now, this enactment exactly follows what is recorded  in “A Breath of Snow and Ashes:”

He had—he was told sometime after the fact—narrowly escaped loss of the arm: Dr. Hunter had grasped it and placed his amputation saw just above the wound, only to have the abscess that had formed below it burst in his hand. Seeing this, the doctor had hastily drained the wound, packed it with garlic and comfrey, and prayed—to good effect.

It was very dramatic, but you should know that a doctor with training like Denzel’s would not start sawing on skin. The saw teeth will rip and tear skin and muscle causing even more pain and morbidity for the patient. Instead, a practitioner used an amputation knife to slice the flesh around the bone and then saw through the bone. Below is an example of a typical amputation knife and an amputation saw of the time. 🔪🪚

As horrifying as this sounds, a capable practitioner could remove a limb very swiftly this way, reducing the trauma to the sufferer.

Finally, as Denzel puts pressure on the limb, pus bursts from the deep lying abscess. After removing the pus, the wound was carefully cleaned and wrapped..

Pus is a  thick yellowish or greenish opaque liquid produced in tissues infected with pyogenic bacteria such as Streptococcus or Staphylococcus (Not all infections elicit pus formation). Pus is formed of dead white blood cells, bacteria, tissue debris, and serum.

The term pus derives from the Latin and it has been used since the 14th C. Again, since Denzel is a well-trained physician, he would have likely used the term pus rather than bile.

Finally let’s consider William’s scar. Here, he recounts his travail to fellow soldiers…..from “A Breath of Snow and Ashes:”

Look,” he said, displaying the long, comet-shaped scar on his forearm. “That’s what happens when you get an abscess.”

Both Zeb and the doctor peered at the scar, impressed. It had been a splinter wound, he told them, caused by a lightning-struck tree.

Big, kudos to the FX folks. I thought the slightly reddened, puckered, and contracted scar was believable. Well done!

I hope you enjoyed this review of William’s Wound.

Until we meet again, fare thee well! 

The deeply grateful,

Outlander Anatomist

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Photo creds: Sony/Starz, www.myclevelandclinic.org, www.en.Wikipedia.org, www.teachmeanatomy.info, www.teachmesurgery.com

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Anatomy Mini-Lesson – Popliteal Aneurysm!

Greetings Outlander anatomy students!

Much time has passed since my last post partly because I am nursing broken bones of my left ankle. I am working off an iPad, instead of my desktop computer, so it is slow going. 😱

Today’s lesson details Mr. Walter Woodcock’s dilemma as presented in Outlander episode 705, Singapore.

You will recall, Walter lies in the infirmary at Fort Ticonderoga with a significant injury to his right foot. The wound has turned gangrenous so an amputation is required.

Claire arrives to witness a medical dispute between Dr. Denzel Hunter and the pompous, Lieutenant Stactoe.

Curious Claire asks, what is going on? 🤔

Denzel recommends an above-knee amputation for Walter. Stactoe is adamant that a below-knee amputation makes for a more functional limb.

Stactoe is correct that in most circumstances, every attempt is made to salvage as much of a limb as is possible.

However, Denzel explains that Walter has a popliteal aneurysm, thus, an above-the-knee amputation is necessary! Claire palpates Walter’s calf and agrees with Denny.

Oh, oh! This changes everything! 🤔

There ensues a wee strammash when Stactoe says Claire will not use boiling water on HIS instruments. This is a direct quote from Diana’s An Echo in the Bone:

You will ruin the temper of the metal, subjecting it to boiling water!”

“No,” I said, keeping my own temper—for the moment. “Hot water will do nothing but clean it. And I will not use a dirty blade on this man.”

“Oh, won’t you?” Something like satisfaction glimmered in his eyes, and he clutched the blade protectively to his bosom.”

In the episode, Stactoe stomps off. But, no worries, Denzel to the rescue with his own set of fine surgical instruments!

To understand the implications of a popliteal artery aneurysm, let’s look at the anatomy of the arterial supply to the knee.

Essentially all of the lower limb is supplied by the huge femoral artery which begins at the groin and descends through the front of thigh. Near the top of the knee, the artery passes to the back of the knee and is renamed the popliteal artery (next figure). It then descends behind the knee joint. At the bottom of the joint, it splits into two and then into a third artery, all of which receive new names and supply lower leg and foot.

The hollow behind the knee joint is the popliteal fossa.

Try This:  Make a fist, bend opposite knee slightly, and tuck your fist into the hollow behind your knee. This is the popliteal fossa. Remove your fist and insert middle and ring fingers into the hollow. Press. You may be able to feel the pulsing of the popliteal artery in the popliteal fossa.

Feel it? Good job, students! 🤗

   
Next. The aneurysm! 🤓

A popliteal artery aneurysm, known by the acronym PAA, is a weak spot in the wall of the popliteal artery. Pressure exerted by arterial blood causes the weak spot to balloon into a palpable bulge behind the knee joint. This is of concern because if the aneurysm should burst, the blood loss would be difficult to control especially in an amputee.

Some causes of PAA are:

  • Atherosclerosis
  • High blood pressure
  • Wear and tear of the popliteal artery due to over use of knee joint
  • Weakening of the artery wall

The image show a couple different types of PAA.


Now, back to the episode!

Claire palpates Walter’s leg and agrees with Denzel. An above-knee amputation is best to avoid the aneurysm bursting with uncontrolled hemorrhaging.

A clear view of his damaged, gangrenous foot can be seen in the next image.

Unfortunately, Claire places her hands on either side of his calf. She cannot feel a PAA in this location because there is no popliteal artery behind the calf. Her hands should be up in the hollow of the knee.

Nevertheless, she gets an A+ for trying! 🤩

Also, in real life, the stench of gangrene would likely require them to mask and use some type of ointment under the nose to distract from the odor. 😮

And, today, imaging modalities would be used to determine the type and extent of a PAA.

In the final scene with Walter, Claire breaks the sad news that his condition does not permit him to be evacuated with the other patients.  He is to be left behind. 😢

Claire has a wonderful bedside manner which comes from her compassionate and caring heart. Hopefully,  the British will treat Walter well. 🤞🏻

Mercy! 😉

I hope you enjoyed today’s lesson. Just remember, if you ever feel a pulsing bulge behind  the knee, make an appointment swiftly or get into urgent care. A PAA is no joke!

The deeply grateful,

Outlander Anatomist

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Photo creds: Sony/Starz, www.myclevelandclinic.org, www.uptodate.com