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

Follow me on:

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)

Fun Fact: Anatomy

Anatomy Def: Ha, ha – anatomy defines anatomy! No, just joshing. Anatomy is the science of the body (human and other organisms) and its parts.

Outlander Def: Claire’s first day in Dr. Simms’ anatomy theater as the only female first year medical student. Don’t touch my blade, young lady! <G>  Grateful Joe Abernathy was at her side and she by his.

Learn the history of this topic in Anatomy Lesson #34, The Amazing saga of Human Anatomy.

Human Anatomy is the oldest of the medical sciences. The word derives from the Greek ana-, meaning up combined with temnō, meaning I cut. It doesn’t take rocket science to recognize this term infers the use of  dissection to discern an organism’s design.

Fun Fact: This is important. Do you ken how to pronounce the word, dissection? It is pronounced dis-section not di-ssection. Thus, we dis-sect an organism but we bi-sect a line. Got it? Yay, students!

Anatomy covers the structure of cells, tissues, organs, and organ systems throughout all stages of life. The anatomist is concerned with name, shape, size, position, texture, relationship, blood supply, and innervation of such structures.  Classically, physiologists study function and biochemists follow processes, although nowadays, these distinctions tend to blur.

The roots of human anatomy arguably began with the Ancient Egyptians (2,600 BCE), a culture which believed a soul could retrieve its mummified body before journeying to the underworld. These embalmers understood some anatomical regions quite well. But, if we include animal anatomy, first prize goes to creators of Australian Aboriginal rock art, some of which date to 40,000 years ago!

Human anatomy with dissection has been the foundation of western medicine for the last several hundred years. Why? Well, if your beloved computer goes haywire, you don’t want joe blow tinkering with it, do you? Likewise, who places their body in the hands of a practitioner who knows little about its design? Nope!

Early western medical schools used three individuals to present a dissection.  A lecturer stood on a raised dais and read from an ancient anatomical text (Galen). A barber surgeon performed the dissection. An individual wearing a black hat pointed to the structures using a baton.  Over the years, barber surgeon and black hat fused into a single position, the Demonstrator of Anatomy, a position I held at my institution for almost two decades.

Then, a huge leap in anatomical knowledge occurred in the 16th century, due largely to the genius of Flemish physician and anatomist, Andreas Vesalius (1514-1564), Father of Modern Anatomy. Andreas championed dissection coupled with direct observation, thereby dispelling wrongful ideas that had endured for over 1400 years!

Following the work of Vesalius, human anatomy enjoyed a burst of anatomical discovery and illustration! Today’s anatomical “bible” is, of course, Gray’s Anatomy. My own edition weighs in at 10 pounds, appears in size 8 font, and boasts 1500+ pages. And, it still doesn’t cover the entire breadth and depth of human anatomy!

Read about Claire’s commitment to anatomy, medicine, and surgery in Voyager book. From the “pen” of Herself:

I picked up his right hand and transferred it to my own knee. He let it lie there, warm, heavy and inert, and didn’t object as I felt each finger, pulling gently to stretch the tendons and twisting to see the range of motion in the joints.

“My first orthopedic surgery, that was,” I said wryly.

“Have ye done a great many things like that since?” he asked curiously, looking down at me.

“Yes, a few. I’m a surgeon—but it doesn’t mean then what it means now,” I added hastily. “Surgeons in my time don’t pull teeth and let blood. They’re more like what’s meant now by the word ‘physician’—a doctor with training in all the fields of medicine, but with a specialty.”

“Special, are ye? Well, ye’ve always been that,” he said, grinning. The crippled fingers slid into my palm and his thumb stroked my knuckles. “What is it a surgeon does that’s special, then?”

I frowned, trying to think of the right phrasing. “Well, as best I can put it—a surgeon tries to effect healing … by means of a knife.”

His long mouth curled upward at the notion.

“A nice contradiction, that; but it suits ye, Sassenach.”

See Claire’s anatomy course in Starz ep 302, Surrender.  Six scalpels lay before Dr. Simms. Where are the scissors? But the truth is, a scalpel is useful for skin incisions but it is then laid aside and replaced with the finest dissection tool of all: a pair of long-bladed scissors!

The deeply grateful

Outlander Anatomist

Postscriptum: I have had the privilege of teaching dissection using more than 500 donor bodies. I thank them and their families for the privilege of learning from their temples of flesh. Dissecting the human body is an honor that has changed me, forever.

Photo Credits: Starz

 

Anatomy Lesson #34: The Amazing Saga of Human Anatomy

Welcome, all anatomy students to Anatomy Lesson #34, The Amazing Saga of Human Anatomy! This topic is a divergence from our usual Outlander themes but before you decide to skip it, please consider that herein lays oodles of interesting illustrations and startling titbits about the checkered past of human anatomy. This blog doesn’t have the luxury of covering all of anatomical history as entire books have been written on the topic so it covers only major milestones relating to western medicine.

But first, is tying the history of anatomy into Outlander a reach? Nay, anatomy, especially abnormal anatomy (pathology) is all over the place in Diana’s books and the Starz series. Anatomy follows Nurse Claire, like… well, like girls cling to Jamie! From the moment she steps into Davie Beaton’s surgery (Starz episode 101, Sassenach), her senses are on high alert: déjà vu, sixth sense, the training of a scientist? Hmm…there’s something mighty eerie about this place.

ep-101-Claire-at-surgery-KLS-edited

Claire’s  anatomical knowledge is required during her first encounter with Jamie as Herself wrote in Outlander book:

You have to get the bone of the upper arm at the proper angle before it will slip back into its joint,” I said, grunting as I pulled the wrist up and the elbow in. The young man was sizable; his arm was heavy as lead.

Claire successfully realigns Jamie’s humerus and glenohumeral joint thereby reducing the dislocation (Starz episode 101, Sassenach). Read about the technique Claire used in Anatomy Lesson #2, “When Claire Meets Jamie” or “How to Fall in Love While Reducing a Dislocated Shoulder Joint!”

ep-101-Jamie's-arm-KLS-edited

Now for our lesson: anatomy is the oldest of the medical sciences with a rich and very blemished history. The word “anatomy” derives from the Greek ana “up” and temnō “I cut”, implying dissection (pronounced dis-section not di-section) of an organism to discern its design. Anatomy is the study of the structure of organs, tissues and cells through all stages of maturation. The anatomist is concerned with names, shape, size, position, relationships, blood supply and innervation of structures while physiologists study function and biochemists follow processes, although these distinctions typically blur in the research lab.

Nowadays, anatomy is a tree with many branches: Zootomy is the anatomy of all animals; phytotomy is the anatomy of all plants. Comparative anatomy contrasts anatomy between species. Anthropotomy (an-thro-pot-o-my) is the proper (but rarely used) term for anatomy of the human body. Gross anatomy describes structures that are visible with the naked (unaided) eye. Microscopic anatomy (histology) uses magnification to study cell, tissue and organ structure. Surface anatomy focusses on an organism’s external features. Developmental anatomy (embryology) studies structures of the developing organism. Radiologic anatomy employs imaging modalities such as x-ray, ultrasound, MRI or CT to reveal internal structures. The following images are examples of two such fields of anatomy.

This image shows comparative anatomy of the upper limb from four different animals: shape, size and disposition of corresponding upper limb bones are contrasted and compared. Homologous (comparable) bones are color coded for ease of identification (Image A).

Homology_vertebrates-en_svg-copy-KLS-edited

Image A

The next image shows a poignant example of radiologic anatomy: an MRI scan reveals brain anatomy of a mother tenderly cradling her sleeping child as they nest within the tube of an MRI scanner (Image B). The neuroscientist overseeing this work pursues the field of brain development. Surprisingly, she informs us, “… I am a neuroscientist, and I worked to create this image; and I am also the mother in it curled up inside the tube with my infant son.”

mother-and-child-KLS-edited

Image B: MRI from Smithsonian, December 2015

Human anatomy is the foundation of medicine and is typically the first course taught in medical curricula; when appropriate, cadaveric dissection lies at its core (Image C). Why is this so? Well, if your beloved dishwasher, car, or god forbid, computer goes on the blink, you wouldn’t want joe blow tinkering with it would you? Likewise, who hands their body over to a practitioner who knows next to nothing about its design? Not me!

As course director of gross anatomy (now retired), I routinely told my first year medical students: “The human body is a living, breathing, basic science laboratory and you get to take care of it; it is best that you know your anatomy well!”

human-body-KLS-edited

Image C: Dissection by Body Region

An important consideration: Religion and science are periodically at odds in the anatomical time line as they are often viewed as opposing forces – in my thinking, they are not because they ask and answer different questions.

The roots of human anatomy arguably began about 2,600 BCE with the religious practices of ancient Egypt; a culture that believed mummification allowed a soul to retrieve its preserved body before journeying into the underworld. Heart, lungs, liver and bowels were removed and stored in canopic jars (Image D) or treated and replaced into body cavities. The brain was removed (encephalectomy) via the nostril (preferably the left) but was destroyed in the process. These incursions into the body revealed anatomy to embalmers albeit for religious purposes. Egyptian physicians likely benefitted from such anatomical expertise because ancient papyri (e.g. Edwin Smith and Ebers papyri, ca. 1600-1500 BCE) contain highly sophisticated medical instructions for surgeons and physicians including such details as the first known appearance of the word for “brain”.

anubis-copy-KLS-edited

Image D: Anubis Oversees Embalming – from Sarcophagus of Pedusiri

After Alexander the Great founded the ancient city of Alexandria, the Greek Ptolemaic dynasty began – a culture that deeply valued the natural realm much like the ancient Egyptians pursued the religious realm. Ptolemy I (367-283 BCE), successor to Alexander the Great, conceived the Library of Alexandria (Image E) aiming to make it the center of western knowledge.

Although forbidden in the ancient world, Ptolemy I legalized dissection and released the bodies of condemned criminals for this purpose (unethical by today’s standards). Thus, in the 3rd century BCE,  Greek physicians Herophilus and Erasistratus began the first known human dissections for scientific purposes. Their meticulous work laid the foundation of human anatomy and corrected many misconceptions embraced by practitioners of medicine but their texts were destroyed with the Alexandrian library.

Three hundred years later, following the rise of Christianity, both anatomists were denounced as “butchers of Alexandria” and accused of dissecting living humans. This denouncement came centuries later and although widely circulated as truth, the accusations are based on inference. Subsequently, human dissection was deemed blasphemous and outlawed leaving practitioners of western medicine woefully ignorant of human anatomy.

tumblr_m6nf0kCtNA1ryfivao1_500-KLS-edited

Image E: Library at Alexandria

Enter one Claudius Galenus (Galen) of Pergamon (130 – c. 200 CE), a Greek who was born and raised in present day Turkey (Image F). Widely educated, he chose a career in medicine, eventually settling in Rome as physician to the gladiators. There, he achieved fame through accurate diagnoses, treatments, public lectures, discussions, demonstrations and writings. He correctly diagnosed Emperor Marcus Aurelius’ ailment as indigestion, for which he was appointed court physician.

Galen performed animal dissections and the anatomy was inferred to humans. His writings and teachings were marked by brilliant observations and wise therapeutic application but also by colossal error and pompous hubris. His ego was monumental as evidenced by this quote:

Never as yet have I gone astray, whether in treatment or in prognosis, as have so many other physicians of great reputation. If anyone wishes to gain fame all that he needs is to accept what I have been able to establish.

Galen was the last great Greek physician-scientist of the ancient world. His writings in Greek were lost but survived in Latin, Arabic and occasionally, Hebrew translations. After Galen, anatomical research ceased and his flawed texts became the ultimate medical authority for over 1200 years!

galen-Robert-Thom-KLS-edited

Image F: Galen by Robert Thom

Over the next millennium, anatomical images became firmly linked with astrology and magic. Mistress Claire was confronted with this reality when Colum assigned her to Davie Beaton’s “closet of horrors” at Castle Leoch. Lifting the lid of a medicament chest, the top displayed the woeful state of anatomical knowledge at Beaton’s “Skulkery”: a rudimentary image of human organs linked to signs of the zodiac (Starz episode 103, The Way Out). The sight draws a faint smile from our resident anatomist. And, Herself recorded:

There were a number of more or less harmless substances in Beaton’s jars, as well as several containing dried herbs or extractions that might actually be helpful… I discarded jars of dried snails; OIL OF EARTHWORMS which appeared to be exactly that; VINUM MILLEPEDATUM millipedes, these crushed to pieces and soaked in wine; POWDER OF EYGYPTIANE MUMMIE an indeterminate-looking dust, whose origin I thought more likely a silty streambank than a pharaoh’s tomb; PIGEONS BLOOD, ant eggs, a number of dried toads painstakingly packed in moss, and HUMAN SKULL, POWDERED. Whose? I wondered…

ep-103-Beaton-surgery-KLS-edited

Returning to our anatomical time line, let’s fast forward a brief millennium (ha!) during which political and religious powers outlawed human dissection. However, gradually, religious authorities changed their attitudes and legislations were enacted to allow human dissection for teaching purposes.

These events culminated in the first officially sanctioned human dissection since Herophilus and Erasistratus, performed by physician-anatomist Mondino de Cuzzi (1275-1326) of Bologna. Human dissection quickly spread to other European universities, the process immortalized in a woodcut from the first anatomical text ever printed (Image G). This puzzling image requires a note of explanation: three individuals were involved in the aforementioned dissection. A lecturer orchestrated the affair from a raised dais while reading from anatomical texts, usually Galen. A barber surgeon performed the dissection and the individual to his right (your left) identified the structures. The elevated position of the lecturer is thought to be the origin of the term chairman of the department. The individual using the baton to identify structures became known as the demonstrator of anatomy.

 ap0000000263_1281937716-KLS-edited

Image G: First print of Human Dissection

The history of anatomy would be incomplete without mentioning archetypal Renaissance man, Leonardo da Vinci (1452-1519). During his lifetime, only physicians or barber surgeons could legally dissect human cadavers but da Vinci received a special church dispensation to perform his own dissections; from these, he created the earliest and most accurate anatomical sketches (Image H). Although his paintings were famous, only a few close associates knew of his anatomical research. Unfortunately, da Vinci never worked as a professional anatomist; he never taught the subject and never published his observations which would have greatly advanced the science of anatomy (Anatomy Lesson #20, Arms! Arms! Arms! – Redux). In the meantime, dissection at universities continued to involve lecturer, barber surgeon, demonstrator of anatomy and Galen.

Leonardo-di-Vinci-KLS-edited

Image H: Human Skeleton by Leonardo Da Vinci

Our next major milestone is embodied by one Andreas Vesalius (1514 – 1564); born in Brussels, he descended from a long line of medical men. During his studies at University of Paris, he became convinced that human dissection was vital to understanding structure and function (Image I). To that end, he visited gallows and cemeteries to obtain specimens which he studied until he could identify any human bone blindfolded. Later, at the University of Padua, he graduated as Doctor of Medicine with highest distinction and the following day, at 23 years old, he was appointed Professor of Surgery! With good reason Vesalius is generally considered the “father” of modern human anatomy.

edouard-hamman-andreas-vesalius-1848-KLS-edited

Image I: Andreas Vesalius by Edouard Hamman

Understand that at this time, professors believed Galen’s teaching so infallible that should dissections yield information contrary to his writings then either the cadaver was abnormal or mankind’s decadence and degeneration had caused anatomy to change since Galen!

Discovering by direct observation that 1400 years of Galen’s anatomy were wrong, Vesalius performed a public dissection to demonstrate correct anatomy and dissuade those attached to Galen’s theories (Image J – yes, it was a woman). His public demonstrations continued and proved so successful they attracted medical students, physicians, civic officials, sculptors, and artists. While admired, Vesalius’ work also incurred wrath and vilification by those who considered Galen to be infallible.

The following is a brief list of Vesalius’ work that corrected Galen’s mistakes; his accomplishments are staggering:

  • Accurately described sphenoid and temporal bones (bones of skull)
  • Human sternum made of three fused bones (Anatomy Lesson #15)
  • Sacrum made of five fused bones (Anatomy Lesson #10)
  • Hepatic veins (of the liver)
  • Azygos vein (of thorax – Anatomy Lesson #15)
  • Ductus venosus (fetal blood vessel)
  • Omentum (large abdominal membrane)
  • Stomach and its pyloric region plus spleen, colon and appendix
  • Pleurae (membrane surrounding each lung)
  • Lungs
  • Brain and most of the cranial nerves (nerves arising from the brain)
  • Four chambers of the heart (Galen declared there were two)
  • Great vessels carrying blood to and from heart
  • Mandible as a single bone (Anatomy Lesson #26)
  • Ventilation (respiration)

Vesalius also proved that the human spine does not contain the revered bone of Luz, a bone that by religious and cultural tradition was deemed indestructible and required for resurrection of the body.

Vesalius-KLS-edited

Image J: Vesalius’ Public Dissection by Robert Tomm

In 1543 Vesalius wrote the monumental De Humani Corporis Fabrica (On the Fabric of the Human Body), the most comprehensive anatomical text yet written and arguably the greatest single contribution ever made to human anatomy. Fabrica displayed brilliant illustrations created as intricate woodcut plates by various artists from the “studio of Titian”. Bodies in varying degrees of dissection are arranged in allegorical poses complete with pastoral environs (Image K). During the 20th century, Vesalius’ original plates were housed in Munich but, sadly, a World War II bombing raid destroyed them.

Vesalius_Fabrica_p174-KLS-edited

Image K

Again in 1543, Vesalius conducted a public dissection on the body of a notorious felon. Later, he assembled the bones and donated the skeleton to the University of Basel. This preparation (“The Basel Skeleton”) is the world’s oldest surviving anatomical preparation and is still displayed at the Anatomical Museum of the University of Basel (Image L).

Later, Vesalius served as court physician to Emperor Charles V and his son. He died at the age of 50 on a Greek island during a return trip from the Holy Land. To the present day it is claimed that Vesalius was forced on the pilgrimage for performing an autopsy on an aristocrat while the heart was still beating. Modern historians consider this story without merit because it was circulated by a competitor. There is an odd bit of wisdom that states, academic fights are so bitter because there is often so little at stake (grin)!

vesaliusesskeletons-KLS-edited

Image L

Time for a brief break and another anatomy lesson from Mistress Beauchamp! This time she ascertains that Geordie’s femoral artery (Anatomy Lesson #9, The Gathering or Gore By a Boar) was not severed by the wild boar’s tusk so she should be able to stem the bleeding (Starz episode 104, The Gathering) . Sadly, this hopeful thought was quickly amended as she spied puir Geordie’s fatal abdominal wound. We read in Outlander book:

There was a deep wound, running at least eight inches from the groin down the length of the thigh, from which the blood was gushing in a steady flow. It wasn’t spurting, though; the femoral artery wasn’t cut, which meant there was a good chance of stopping it.

ep-104-Geordie-leg-KLS-edited

Following the work of Vesalius, human anatomy enjoyed a brilliant burst of anatomical illustration; artists and anatomists sometimes competing for elegant form versus anatomical accuracy. The result is some of the most famous and astonishingly beautiful anatomic illustrations ever created. Consider the priceless 1632 painting by Rembrandt “The Anatomy Lesson of Dr. Nicholaes Tulp” (Image M). This painting recreates another public dissection and while undeniably elegant and riveting, it is also anatomically incorrect. Why? Well, because Rembrandt wasn’t an anatomist so details such as the correct origin of the long flexor muscles of the digits (see Anatomy Lesson #22, Jamie’s Hand – Symbol of Sacrifice) were misrepresented.

anatomy-lesson-01-KLS-edited

Image M

Then, in 1871 an eight volume compendium Traite’ complet d’anatomie de l’homme (Complete Treatise of the Anatomy of the Man) was published by French anatomist Bourgery, and illustrator Jacob (Image N)! Their anatomical images combined accuracy with elegance and are amongst the most beautiful ever rendered.

Anatomical illustrations were created by other famous Renaissance artists such as Bidloo, Donatello, Michelangelo, Titan, Rembrandt, Albinus, D’Agoty, Genga, and Ruben. And, models depicting human anatomy exploded on the scene: carved from ivory, made of papier-mȃché, copper engravings, woodcuts, chalk, wax, bronze, and finally by the end of the 19th century, photography.

back-muscles-KLS-edited

Image N

Today’s anatomical “bible” is, of course, Gray’s Anatomy. My own 39th edition is a real door stopper! Weighing in at 10 pounds, the single-spaced text appears in size 8 font and more 1500+ pages in length! And, it still doesn’t contain all that currently is known about human anatomy.

The size of this giant tome is somewhat amusing as the book was conceived in the 1850s by 28 year old Henry Gray (Image O), a teacher at St. George’s Hospital Medical School, London. Sharing his idea with artist and colleague, Dr. Henry Vandyke Carter, who was also Demonstrator of Anatomy at St. George’s, the pair conceived a light weight (hee hee), well-illustrated, and accurate pocket text designed for students. The first edition (1858) was an instant success; periodically updated and enhanced, it has been published continuously for over 150 years!

Poor Henry enjoyed a successful but short life. While attending to a nephew ill with smallpox (Anatomy Lesson #21, Small Pox and the Devil’s Mark), Henry fell victim to the disease and swiftly died at the youthful age of 35.

220px-Henry_Gray_bw_photo_portrait

Image O

Please understand that a discussion of anatomical history is incomplete if limited to structures discoverable in a dissection lab as our bodies are made of cells and tissues elements that are invisible to the naked eye. Identifying these structures required the invention of magnifying lenses.

Enter Antonie van Leeuwenhoek (1632-1723), a Dutch draper (merchant of fabrics). Wishing to assess the quality of woven threads, Van Leeuwenhoek determined to improve their visibility. Microscopes existed in his time but the best could only magnify 9x – meaning 9 times the size of the object observed. Self-taught, Antonie began experimenting with glass processing and lens making. Working in a hot flame with small rods of soda lime glass, he created tiny, high-quality glass spheres to use as single lenses which he housed in small silver or copper frames – these became his simple microscopes (with one viewing lens). These tiny handheld instruments were only about 5 cm (2”) long but capable of 275x magnification! He created 25 simple microscopes, several of which still  survive (Image P).

vl_scope_with_labels-copy-KLS-edited

Image P

Turns out, van Leeuwenhoek examined much more than threads! Eventually he sent The Royal Society a manuscript, Microscopiorum, complete with written descriptions and meticulous drawings of single-cell life (called animalcules) including spermatozoa, red blood cells (erythrocytes), bacteria, yeasts and life forms in a drop of water, all observed with his microscopes. Although his lens research was heartily embraced by the Society, his biologic findings were initially met with skepticism and derision, an old but common experience in the field of science (Image Q).

1019960-anton-van-leeuwenhoek-1632-1723-dutch-pioneer-microscopist-KLS-edited

Image Q: 3rd edition of Microscopiorum

Fast forward three hundred years to a modern compound light microscope (Image R). Like the earliest microscopes, compound microscopes use light from the visible spectrum to illuminate an object but they also employ two lenses to achieve greater magnification: one near the eye and one near the object viewed, hence the term, compound.

03911_45-KLS-edited

Image R

In the 1930s, the electron microscope was invented substituting a electromagnetic lens for glass. It also used a high voltage electron beam not light waves to illuminate an object. Today, there are different types of electron microscopes including the transmission (TEM) and scanning or (SEM) electron microscopes (Anatomy Lesson #6).

Typical TEMs magnify objects about 500,000x although some can magnify much more and are able to reveal subcellular structures. Image S shows a 1,000,000 volt electron microscope at the Max Planck Institute in Germany, one of only a handful in the world. In the ‘80s I took micrographs (photographs taken with a microscope) on one of these big boys in Colorado. The instrument was three stories tall and hummed like Luke Skywalker’s light saber!

Microscopes have opened a new world to researchers and students allowing health practitioners to understand the cellular and subcellular basis of health and disease.

image002-KLS-edited

Image S

Time for another example of Claire’s anatomical expertise: who can forget the image of Jamie’s puir hand mangled by Black Jack the Ripper (Starz episode 116, To Ransom a Man’s Soul)?

Claire reveals her anatomical chops once again by describing the extent of Jamie’s wounds. Here from Outlander book:

I took his good hand as well, and felt carefully down each finger of both the good hand and the injured, making comparisons. With neither X rays nor experience to guide me, I would have to depend on my own sensitivity to find and realign the smashed bones… I began to lose myself in the concentration of the job, directing all my awareness to my fingertips, assessing each point of damage and deciding how best to draw the smashed bones back into alignment. Luckily the thumb had suffered least; only a simple fracture of the first joint. That would heal clean. The second knuckle on the fourth finger was completely gone; I felt only a pulpy grating of bone chips when I rolled it gently between my own thumb and forefinger, making Jamie groan.

What a woman! What a man!

ep-116-Jamies-hand-03-KLS-edited

Back to our timeline: unfortunately, the explosion of anatomic knowledge and illustration from the time of Vesalius forward was marred by a dark underbelly: from 15th through the 19th centuries, bodies of executed criminals were relegated to the dissection lab as apt punishment for crimes. But, as capital punishment decreased, fewer bodies of criminals were available so some turned to grave robbing,  body snatching and even murder to meet supply and demand (Image T). Bodies were then sold for dissection to students, teachers and schools of medicine.

Body snatching, by the way, is the surreptitious disinterment of bodies after burial. Those practicing body snatching were called resurrectionists or “bag ‘em up boys” (urban speak has a different meaning, och!). These practices became such a problem that some cemeteries built watchtowers and families hired guards to protect the graves of their loved ones.

There follows some heartily unsavory tales: 1827-1828, two Irish fellows, Burke and Hare, immigrated to Scotland where they murdered 16 citizens near Edenborough to supply corpses for medical dissection. Not to be outdone, across-the-pond cities of Philadelphia, Baltimore, and New York were also  notorious for body snatching. But, England was the first to address such atrocities; the Anatomy Act of 1832 halted these activities by allowing unclaimed bodies and those donated by relatives to be used for the study of anatomy, and requiring the licensing of anatomy teachers. Unfortunately, many unclaimed bodies were those of poor people relegated to workhouses during a time when dissection was considered a just punishment for being poor!

220px-Bodysnatchers-Penicuik-KLS-edited

Image T: Painting from a public house in Penicuik, Scotland

Finally, during the second half of the 20th century, universities, medical schools and hospitals employed trained anatomists for teaching and research. In addition, voluntary body donation programs arose as primary sources of bodies for anatomical dissection.

Nowadays, worldwide innovative programs are being introduced into body donation programs by medical schools to teach students respect, compassion and empathy towards the human body, dead or alive. Thus, human dissection is indispensable for many reasons:

  • Teaches structure of the human body
  • Provides the language of medicine
  • Forms student’s first health care team
  • Increases powers of observation
  • Demonstrates anatomical variations as no two bodies are alike!
  • Introduces student to pathology  (abnormal anatomy)
  • Becomes  the student’s first patient
  • Promotes humane qualities among future health care providers
  • Allows surgeons and other specialists to safely develop new surgical techniques
  • Provides new anatomical knowledge through research

At my university, I served three major roles: course director of gross anatomy, director of the body donation program, and demonstrator of anatomy (state legislated position). I also taught microscopic anatomy and embryology.

At the termination of the gross anatomy courses for which I was responsible, students (under supervision) organized and presented memorial services to honor body donors and their families. Poems, readings, music and numerous thank you messages were shared by the students with the families, after which donor families were invited to respond. No dry eyes in that auditorium!

I’ve enjoyed teaching human anatomy to almost four decades of students: medical, physical therapy, physician assistants, respiratory technologists, and nursing students as well as surgeons and surgical residents, and the public (Image U – the excited grins are because a person recognized an anatomical structure they had always wondered about – no one was being disrespectful).

2011 Body World Exhibit 01 KLS edited

Image U: 2011 Body World Exhibit

I have had the privilege of dissecting and teaching dissection with more than 500 donor bodies and I deeply thank them for the privilege of learning from their temples of flesh. I can candidly state that dissecting the human body is an awe-inspiring honor that has forever changed me (Image V).

2011-Body-World-Exhibit-03

Image V: 2011 Body World Exhibit

This brings our saga of human anatomy to an end and will be my last anatomy lesson for 2015. I will continue to post anatomy Fun Facts until January of the New Year and then, a new anatomy lesson! Wishing you all the grandest and most glorious season ever!

Och, but dinna despair. The last words of this lesson are from Claire (and Jamie) who gave the world the finest appraisal and greatest appreciation of male human anatomy in the history of written literature (Starz episode 107, The Wedding). Snort!

Herself writes:

Because I want to look at you,” I said. He was beautifully made, with long graceful bones and flat muscles that flowed smoothly from the curves of chest and shoulder to the slight concavities of belly and thigh. He raised his eyebrows. “Well then, fair’s fair. Take off yours…”

Whew! Alrighty then – amen and amen!

ep-107-Jamie-KLS-edited

A deeply grateful,

Outlander Anatomist

Photo creds: Starz,, Bender, G. A. Great moments in Medicine. Northwood Institute Press, 1966 (Images F and J), Delaunay, ed., 1829 (Image N), Fasciculus Medincinae (compendium, authors unknown), 1491 (Image G), Greenspan, Robert E. Medicine Perspectives in History and Art, 2006 (Images H & M), Jean-Baptiste Marc Bourgery and Nicolas-Henri Jacob. Traite’ complet d’anatomie de l’homme, 1832- 1851. (Image N), Moore, Keith L. and Dalley, Arthur F. Clinically Oriented anatomy. Philadelphia: Lippincott, Williams & Wilkins, 2006. (Image B), Outlander Anatomist, private collection (Images U & V), Smithsonian, December 2015. (Image C), www.anatomymyatlases.org (Image L), www.ancientpeoples.tumblr.com (Image E), www.colepaler.com (Image R), www.en.wikipedia.org Images A, K, O & T), www.fotolibra.com (Image Q), www.steninageo.com (Image S), www.study.com (Images D & P), www.thephysicianspalate.com (Image I)