Greetings, anatomy students! One might reasonably assume this lesson is about Billy Ray Cyrus, but, one would be wrong. This anatomy lesson discusses the very important, brachial artery, and its parent, the axillary artery

And, what spurs a lesson about these vessels? Why, twisted-sista, Laoghaire, is to blame (Starz Outlander episode 308, First Wife)! 

Who is in her sights – Jamie? Claire? Or, will she fell both with a single shot?

Blamo! A fouling piece discharges a fowling piece!

Dear Laoghaire: 

On the day that you were born,

The angels got together……

And, were severely reprimanded!

Shoot <g>! Laoghaire peppers Jamie with birdshot! Alas-lass, Granny Fitz probably wouldn’t be proud of her progeny. 

Laoghaire, Laoghaire, quite contrary,

How does your vengeance grow?

Jamie fell, amid bloody hell,

And, Claire became your foe!

Dinna mess with the Sassenach. Drop that weapon!  

Now, book readers ken that things didn’t go down quite this way in Voyager book. Herself envisioned Claire fleeing Lallybroch upon finding that Jamie has a harem. Young Ian (bless his wee Scottish heart), catches up to her in the mountains and says:

“But Auntie Claire, it’s not that!” 

“What’s not that?” Caught by his tone of desperation, I glanced up. His long, narrow face was tight with the anguished need to make me understand. 

“Uncle Jamie didna stay to tend Laoghaire!”

“Then why did he send you?” He took a deep breath, renewing his grip on my reins. 

“She shot him. He sent me to find ye, because he’s dying.”

Back to the TV version. Perhaps aiming for his heart, Laoghaire’s birdshot turns Jamie’s left chest, shoulder and arm into mincemeat. But, harboring absolute faith in his beloved he assures us:

 “It’s only birdshot, nothing serious…..It’s nothing Claire canna fix!”

Back to Voyager book, Claire assesses Laoghaire’s assault: 

“Let’s have a look at it.”

The wound itself was a ragged dark hole, scabbed at the edges and faintly blue-tinged. I pressed the flesh on either side of the wound; it was red and angry-looking, and there was a considerable seepage of pus. Jamie stirred uneasily as I drew my fingertips gently but firmly down the length of the muscle. “You have the makings of a very fine little infection there, my lad,” I said. “Young Ian said it went into your side; a second shot, or did it go through your arm?” 

“It went through. Jenny dug the ball out of my side. That wasna so bad, though. Just an inch or so in.”

A bit of difference between the two versions but either way, Jamie needs his Claire! BTW, the special effects are terrific!

Back to TV: No surprise – Claire must remove those pesky pellets! Following the surgeon’s creed: a chance to cut, is a chance to cure, Claire sets to work! 

Several big swigs of Scotch whisky and Jamie lolls unconscious… that stuff is potent! Armed with tools from her medical kit, Claire dives for those wee bits of lead!

One by one, she carefully retrieves the pellets.

Mostly, the bird shot is superficial but one sits in a precarious position. She cut downs to reach the deep-lying pellet explaining to young Ian, she must avoid damaging the artery!  Jamie could bleed to death if the vessel is injured by pellet or nicked by blade. 

The next image exhibits a high yuk factor for some students, but Clair dutifully digs, dives and delves for the perilous pellet! 

Into the brass vessel it goes –  joining its brothers in crime.  

Still royally pissed at Jamie’s deceit, Claire carefully stitches the incision (Anatomy Lesson #35, Outlander Owies!) and our Highland Hero is saved. This lass takes pride in her work!

Anatomy Lesson: Sigh… time to leave Outlander and get to our lesson! Now, which artery does Claire believe is at risk? Let’s tease out the answer. 

Judging from the location of the incision, we may reasonably surmise that Claire’s Concern is directed toward one of these two arteries:

  • Axillary artery
  • Achy brachial artery

Origins: To properly understand how these two arteries might be at risk from bird shot or scalpel blade, let’s study their ancestry.com. We begin at the heart. Image A is a highly simplified view of the heart (pink) and its major arteries (red and blue). 

Aorta: The ascending aorta, the large red vessel, arises from the heart (left ventricle) and curves, becoming the arch of aorta. The arch is then renamed the descending aorta as it dives downward through chest and abdomen.

Anatomic Note #1: Traditionally, arteries appear red to denote they carry oxygenated blood. However, some arteries carry de-oxygenated blood such as the two blue vessels shown in Image A; these are right and left pulmonary arteries (from right ventricle). Their blood becomes oxygenated as it travels through the lungs. Not critical to today’s lesson, so more about these vessels in a later session!

Aortic Branches: Typically, the aortic arch gives rise to three large arteries. In 75% of people, aortic branches follow the pattern shown in Image A. But in 25% of folks, a different branching pattern ensues. My experience in the dissection lab is that blood vessels show the greatest variation of any anatomical structure. None-the-less, the typical branching pattern is:

  • Brachiocephalic artery (dividing into)
    • Right common carotid artery 
    • Right subclavian artery
  • Left common carotid artery
  • Left subclavian artery

Anatomic Note #2: The left side (on your right) typically lacks a brachiocephalic artery, so left common carotid and subclavian arteries branch directly off the aorta. On the right, the short brachiocephalic artery soon branches into right common carotid and subclavian arteries. Embryonic development produces this odd asymmetry.

Image A 

Destination: Once the brachiocephalic artery divides, its branches follow the same pattern as the left side (Image B): 

  • Right and left common carotid arteries ascend to supply head and neck
  • Right and left subclavian arteries arch through base of neck.
  • Name change #1: At outer border of the 1st ribs, subclavian arteries are renamed right and left axillary arteries
  • Name change #2: At lower border of teres major muscle (Anatomy Lesson #10, Jamie’s Back or Aye, Jamie’s Back!), axillary arteries are renamed right and left brachial arteries

Gasp! Pray tell, who thought  so many name changes would prove helpful? Early anatomists are to blame, waaay back in 1578!

Image B 

Axillary Artery: Subclavian arteries give off branches and then, like many city streets, each changes its name to axillary artery

The word, axillary, comes from the Latin axillaris meaning “armpit,” because the axillary artery lies deep in the armpit, skirting outer ribs and angling through the oxter toward the arm (image C). Its important branches supply blood to:

Situated so deep in the armpit, axillary artery is protected and rather difficult to reach except by needle, open dissection, or bird shot! 

Image C 

Brachial Artery: At the lower border of teres major muscle, each axillary artery is renamed the brachial artery, the major artery supplying each arm (Image D). Brachial comes from the Latin brac(c)hium meaning “arm.”  The brachial artery continues into the arm supplying blood to its structures; then, ends near the elbow by dividing into radial and ulnar arteries (Anatomy Lesson #19, To Arms, Too Arms, Two Arms!).

Image D 

Importance: The brachial artery is THE major blood vessel of the upper limb (Anatomy Lesson #19, To Arms, Too Arms, Two Arms!), providing each with almost a liter of blood (.95 qt.) per minute! Understand, this is a huge blood flow given that the entire human body typically contains only 4.7 – 5.5 liters of blood.

Note #1: Blood flow through the subclavian artery, the parent of brachial artery, is difficult to measure because it lies so deep, but it’s blood flow would be slightly higher than the axillary artery.

Try This: This could be fun! The brachial artery carries so much blood, its pulse can be taken to determine heart rate. This is how you can find your brachial pulse. Identify your biceps with the contralateral (opposite) hand. Move middle and ring fingers along its inner border toward the inner elbow and apply moderate pressure (Image E). Feel it? Yay!

Note #2: Today, pulse is often taken using a finger clip device (pulse oximeter) but, a thorough education also includes the manual technique.

Horror: I see many examples on the Internet advising students to take a pulse with their thumb!!! These grieves me, because one should never take a pulse with the thumb. The thumb has its own substantial artery, the princeps pollicis, with its own pulse  – large enough to interfere with determining a patient’s pulse! In some people, the index finger also has a strong pulse, so using the middle and ring fingers are best. 

 

Image E 

Should you be interested, here is a nice video about locating the brachial artery pulse. The demonstrator uses a slightly different approach than the one described above, but either works well:

Conclusion: Two arteries are candidates for Claire’s Concern: left axillary or left brachial. Each has a huge blood flow and if their wall is torn or cut, a person could easily exsanguinate through the breach. 

But, which one? The location of her incision informs our choice. Back to an earlier image: Claire’s tools are inserted just under the outer border of Jamie’s pectoralis major muscle (mercy!) and above the armpit (oxter hair lies below).  One may reasonable conclude that her tools’ trajectory towards the armpit is most consistent with the pathway of the axillary artery; the brachial artery should be further out towards the arm. Ergo, Claire is concerned that birdshot or tools may harm the axillary artery

But, know this….it is difficult to be absolutely sure sans a proper visual evaluation of the area accompanied with palpation. I volunteer! He he.

So, we have answered our initial query: Likely, Claire was fearful of damaging Jamie’s axillary artery not his achy brachial artery, but either would suffice.  

Cosmic Question: Now, comes the most critical question of all!

How can a surgeon operate on an intoxicated patient, with dim lighting, using fairly cumbersome tools, answering questions from a curious nephew, removing multiple bloody foreign objects, and yet complete her tour of duty with an absolutely pristine apron????  Not a drop of blood in sight! 

Because, she is the Sassynach Surgeon in her bad-ass bat suit and Claire can fix pretty much anything!

Arteries might not be the sexiest of anatomical topics, but we can understand and appreciate their value, especially if they are damaged or dysfunctional. Let’s join Claire with a  toast to our awesome arteries: Slàinte Mhath!

A deeply grateful,

Outlander Anatomist

Photo Creds:

Starz: Outlander episode 308, First Wife; www.biology.stackexchange.com (Image B); www.earthslab.com (Image C); www.humananatomly.com (Image A); www.slideplayer.com (Image D, E)

Fun Fact: adductor

Posted by Outlander Anatomist | Fun Facts

picture of jamie fraser on battle field from outlander

Starz Outlander episode 301, The Battle Joined

Anatomy def: Brought in? Adductor means brought in? How do such words apply to anatomy?

Easy peasy: adductors are muscles whose contraction draws a body part toward the midline or toward another body part. Six adductor muscles draw the thigh toward the midline: gracilis, adductor brevis, adductor longus and adductor magnus, aided by pectineus and obturator externus.

Outlander def: Jamie’s thigh-high kilt <G> reveals powerful left thigh adductors forming a well-defined mass of the inner thigh (red arrow). A grinning Murtagh dispatches a red coat and helps Jamie rise from a seated position: “ye are welcome!” Adductors contract to lend balance and assist Murty’s lift: git up, man, there’s a battle raging!!! 

Learn about the thigh and its powerful muscles in Anatomy Lesson #7, Jamie’s Thighs or Ode to Joy

Read about thighs in all Diana’s works as Herself often writes about them – not specifically about adductor muscles, but about various thigh muscles, sinews, bones, skin and scars! Consider this wonderful bit from Voyager book; takes you right back to that intimate C + J reunion after 20 agonizing years apart:

I reached out and stroked his thigh, touching the long scar that ran down it. “I wish I could have been there to take care of you,” I said softly. “It was the most horrible thing I ever did—leaving you, knowing … that you meant to be killed.” I could hardly bear to speak the word. 

“Well, I tried hard enough,” he said, with a wry grimace that made me laugh, in spite of my emotion. “It wasna my fault I didna succeed.” He glanced dispassionately at the long, thick scar that ran down his thigh. “Not the fault of the Sassenach wi’ the bayonet, either.” 

See Jamie’s adductor muscles in Starz Outlander episode 301, The Battle Joined. They are admirably awesome (red arrow)!

A deeply grateful,

Outlander Anatomist

Prof! What in the world does  Formicidae mean and what might it have to do with anatomy? Well, folks, let’s find out. Today’s lesson includes a smidge of entomology, one of my fav college courses, so please read on!

In Starz episode 311, Uncharted, our heroic heroine jumps off Perilous Porpoise into unknown waters, at night no less! Anything to get away from Lousy Lieutenant Leonard!

After reaching land, Claire wanders through sandy scrub terrain seeking signs of human life. Lacking water, food and pretty much every creature comfort, she keeps moving onward. At the end of day one, she stokes a fire with fluff from her homemade bum roll – an impressive bum-roll burn (Image A) . Clever lass; a fie on all bum rolls!!

Image A 

Next morn, Claire is rudely awakened by a most unpleasant sensation (Image B). What the….????

Image B

Claire, wake up! Your gams are covered with busy black beasties (Image C)!

Image C

Claire, get up! Your rest-nest has been messed (Image D)!

Image D

Whoa! Horrified, Claire slaps at the creepy crawlers to dislodge them from her perfect pins (Image E).

Image E

What in the world happened? Well, unwittingly, Sassynach Surgeon bedded down over creature city, which didn’t care for Claire’s intrusion into its metro boundaries (Image F).

What are these wee demons? If you think ants, you are likely correct. Real ants or CGI magic?  We do not ken, but the overall effect was highly convincing! (Psst….update! A reader just shared the 311 script annotation with me and real but harmless ants were used and no ants were harmed in the filming <G>).

Image F

Classification of Life: Now, dinna run away screaming; this science is verra interesting! All life is divided into increasingly specialized groups (from top to bottom) based upon shared characteristics. In the case of ants, the ranking is:

  • Kingdom – Animalia
  • Phylum – Arthropoda
  • Class – Insecta
  • Order – Hymenoptera
  • Family – Formicidae <fȯrˈmisəˌdē>
  • Genus 
  • Species

The family name, Formicidae, comes from the Latin formica meaning ant + Greek eidos meaning appearance. (Hehe, this particular formica doesn’t grace kitchen countertops.) This extended family is loaded with some of our fav frenemies: sawflies, wasps, bees and ants! Here are some fascinating facts about ants: 

  • About 22,000 species of ants roam the earth. We know neither genus nor species of Claire’s attackers –  but, stay tuned – a guess is coming up!!
  • Ants have elbowed (jointed) antennae and thorn-like nodes at slender waists (Image G – red arrow).
  • Most ants form colonies, or superorganisms, because they operate as a unified entity.
  • Ants have colonized every continent except Antarctica. Greenland, Iceland, parts of Polynesia, and a few other remote islands also lack native ants.
  • The total number of ants alive at any given moment is estimated between 1 and 10 quadrillion; about 10x the biomass of all living mammals! Who knew? 

Image G

Truth or Fiction? Did episode 311 pull our collective legs or could Claire truly have had ants-in-her-pants on Hispaniola? Indeed, this tropical tête-à-tête was most certainly feasible! 

During the 1700s, eye-witness accounts reported several major ant invasions on Hispaniola and the Lesser Antilles. Ants became so prolific that people placed bedposts in pots of water in an attempt to exclude the party crashers! These accounts describe an ant with a painful bite that lived in colonies near the roots of trees. One current-day entomologist concludes the culprits were tropical fire ants, Solenopsis geminata (genus + species)! Perfect match for Claire’s pesky pests!

Armed with this bit of historical data, I bravely conclude that Courageous Claire likely was attacked by tropical fire ants

So, what did these pests do to Claire’s loooong lovely limbs (Image H)?

Image H

To Bite or to Sting? To bite or not to bite, that is the question! Some ants, such as the North American carpenter ant, sink mandibles (jaws) into their victims, delivering formic acid via the bite. But, other ants deliver venom via stingers! The venom is an alkaloid, a class of powerful compounds including morphine, atropine, etc. Such venom is potent and capable of producing anaphylaxis in those who have developed sensitivity to the venom.  

Fire ants fall into the latter category; they are aggressive, venomous insects with pinching mandibles on the head and sharp stingers at the rear which, in turn, are connected to internal venom sacs. Take a wee keek at that stinger (Image I). Och!

Image I 

Bite and Sting: So, get this: fire ants deliver an impressive coup de grâce because they bite and sting (Image J). Gasp!

Disturbed, as in an exhausted woman sleeping on their nest, fire ants grip the skin with paired mandibles, pierce the epidermis with stingers and deliver venom into the dermis (Anatomy Lesson #5, Claire’s Skin – Opals, Ivory and White Velvet)! Feet or legs are most often stung, usually after accidentally stepping on a fire ant mound. So, Claire was the perfect victim for a swinging-stinging fire ant soiree!

Image J 

And, should you choose to witness the little buggers in action, here is a fine example via YouTube:

What to do? Back at the island, Claire slaps and brushes the pests to dislodge them (Image K).

Is this a good idea? Some sources recommend killing fire ants by slapping them off your body, although they don’t die that easily. Others don’t recommend slapping because it further enrages the beasties. Probably best to pick them off or brush them away, although this is a challenge with clingly-Klingons, especially when they attack en masse!

Image K

Things to do for Relief:

  • Elevate affected area – Nope! Claire canna stop to elevate her legs; she must keep moving to find help for Jamie and herself!
  • Bathe stings with soapy water – No soap, much less water, available for cleansing stings; our lass is dying of thirst, here!
  • Use a cold compress or ice – If only!
  • Take an antihistamine or apply a hydrocortisone cream – Not on 18th century Hispanola!

So, Claire does the next best thing! After slapping away her tormentors, she assesses the red lesions covering her splendid shanks (Anatomy Lesson #27, Colum’s Legs and Other Things, Too!). She rips strands of fabric (18th century shifts come in mighty handy – <G>) to wrap her limbs (Image L). This helps keep air away from the wounds thereby lessening skin irritability and protecting the bumps from further depredation as she trudges through rough tropical vegetation.

Image L 

Then What Happens? Usually fire ant stings cause small, itchy lumps which resolve within a few hours. But, occasionally, the lumps turn into blisters filled with a fluid that looks like pus. Such is the fate of Claire’s fiery stings.

Much later, dragging through the tropical forest, she checks her legs and, oh sweet Claire, what will Jamie say!!!!  Her red bumps have converted into swollen, fluid-filled pustules that itch (Image M)! The pus-like fluid is a mixture of dead cells – a local demolition derby caused by the venom. Although such an intense local reaction occurs less often, the pustules are very obtrusive and extremely uncomfortable!

Disoriented from lack of water, thoroughly traumatized and alone, Claire scratches the pustules. No, Claire, dinna do that! Scratching breaks the skin barrier, leaving underlying tissues vulnerable to secondary infection. Remember, your penicillin is far far away, floating on the Artemis with Big Red.

Image M 

After Ludo – bless his wee doggie heart – finds Claire on a path, she awakens tied to a bed, her legs covered with greenish matter and she is damned thirsty. Gimme water!

Prickly Mamacita ‘splains: “This was the only way to keep you from scratching.” As inhospitable as Mamacita is, she is spot-on about the scratching bit. The pustules are itchy and uncomfortable but, as mentioned above, scratching can induce secondary infection, even ulceration and scarring!

Green Poultice: I immediately thought of aloe vera when the green goo came into view – a plant that could offer some soothing relief. But, unfortunately, aloe vera was not introduced to Hispanola until the 19th century, 100 years in the future. So nada aloe for our suffering sassenach! Abiding history,  possibly a clay poultice or some other macerated plant matter might have been applied for relief. Whatever it is, the sting lesions resolve shortly and she resumes “earnestly seeking Jamie.” 

BTW, kudos to Father Fogden for exhibiting gentlemanly behavior while helping Claire to a seated position (Image N). Well done, Father! 

Image N 

True Story: Some years ago, I lived adjacent to Buffalo Bayou in Houston, Texas, where cutting grass often is an absolute necessity. One fine summer day, wearing shorts and halter, I was mowing. Industriously tamping out grass collected in the mower bag, I tucked it under my arm to re-zip. Yikes, my oxter suddenly was on fire! Hah! Well, not really. Rather, my arm pit was filled with a writhing mass of wee nasty fire ants. Rushing to the faucet, I tried washing them off. A bad idea, as the water irritated them even more. Like Claire, I finally brushed them from my abused pit with my free hand! 

There is good reason why these beasties are called fire ants – the wounded area burns and stings like the dickens! Soon, the burning gives way to serious itching. My stings never turned into the large pustules that Claire suffered, but, I now know that during the summer, fire ants develop the greatest load of venom and therefore the stings are largest and most painful.

Warning! Keep your distance from fire ant mounds!

Image O illustrates the side of a knee covered with multiple fire ant lesions, giving you a keen idea of pustules, courtesy of fire ants!

Moral to the Story: Be careful where you tamp your grass! <G> 

Image O 

Always Pests? Ants are routinely treated as pests because they don’t offer a lot of plusses. But, did you know they aid soil aeration and decomposition by digging tunnels and turning over the dirt? Further, in Africa and South America, ants provide surgical sutures. There, wound margins are pressed together and ants applied. The ant seizes the edges of the wound with its mandibles (jaws) and locks them in place. The body is pinched off but head and mandibles remain closed until the wound heals. 

George Washington Williams (Samuel L. Jackson) applied ant mandibles to Tarzan’s (Alexander Skarsgȯrd) bite wound, in the 2016 film, The Legend of Tarzan. Yep, those black bumps are ant heads and mandibles (Image P)! 

Image P 

So, in episode 311, Claire faced a formidable Formicidae foe in the form of tropical fire ants. Not only did her legs burn, the sting wounds could have become secondarily infected, ulcerated and scarred. Or worse, she might have experienced anaphylactic shock from the fire ant venom, with no Jamie to rescue her! 

The terrific ant scene was written for TV Outlander only, as it does not appear in Diana’s Voyager book. However, in this splendid book, stranded Claire encounters red-throated birds  (Portugese-man-of-war birds?), tiny purple crabs, fish that walk on pectoral fins and appear to have four eyes, and one “Lawrence Stern, Doctor of Natural Philosophy, of the Gesellschaft von Naturwissenschaft Philosophieren, Munich.” Diana always provides such imaginative detail, we readers feel as if we are there with Claire. Thank you, Diana!

Claire the Girl Scout: Now, I must close with a special note of praise for Claire; despite stinging legs, desperate thirst, exhaustion and being lost, like a responsible camper, the good lass took time to douse her bum fire with sand (Image Q).  A fine example to us all. Go, Smokey-the-Bear, Claire! 

Image Q 

The deeply grateful,

Outlander Anatomist

Photo Creds: Starz, Outlander episode 311, Uncharted (Images A-F, H, K-N, Q); www.alexanderwild.com (Image J – fire ant stinging); www.en.wikipedia.org (Image G – ant node); www.bluebird-electric.net (Image I – fire ant stinger); www.healcure.org (Image O – fire ant stings); www.wegotthiscovered.com (Image P – Tarzan)