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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. đŸ˜±

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? đŸ€”

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! đŸ€”

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! đŸ€—

   
Next. The aneurysm! đŸ€“

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! đŸ€©

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. đŸ€žđŸ»

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

Follow me on:

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

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Anatomy Lesson Outlander Trauma-Drama, Part 2

Hey, all.

Hope you had a grand couple of weeks awaiting part two of Outlander Trauma-Drama… Here it is. Yay!Â đŸ€—

Our last Anatomy Lesson, Outlander Trauma-Drama, Part 1, showed the system pathologists use to classify trauma. In that lesson, we covered different types of mechanical trauma including contusion, abrasion, laceration, incision, avulsion, projectile injury, and puncture wounds.

Remember? Yasss! 😊

    • Mechanical trauma
      • Contusion
      • Abrasion
      • Laceration
      • Incision
      • Avulsion
      • Projectile injuries
      • Puncture wounds
    • Thermal Injury
    • Radiation Injury
    • Personal Exposure (tobacco and alcohol)
    • Therapeutic Drugs
    • Air Pollution
    • Industrial Exposures
    • Agricultural Hazards
    • Natural Toxins
    • Oxygen Deprivation
    • Infectious Agents
    • Immunological Diseases
    • Genetic Derangements
    • Nutritional Diseases

Today’s lesson continues with the trauma-drama theme ‘cos there are still loads of Outlander owies to uncover and discover!

Again, examples from Diana’s big books and the Starz Outlander series will serve as anatomical models for the injuries. đŸ‘đŸ»

Today’s lesson will cover thermal injury and alcohol abuse. So, let’s get started!

There are six types of Thermal Injury:

    • Thermal burns
    • Hyperthermia
    • Chilblains
    • Hypothermia
    • Frostbite
    • Electrical injury

Here we go!

Thermal Burns: Thermal burns are caused by harmful exposure to heat, electricity, chemicals, or radiation.

Thermal burns are usually classified as first, second, or third degree burns. Occasionally, we hear of fourth degree burns, but do you ken there are also fifth and sixth degrees? Indeed there are! đŸ€“

Some students may have read Anatomy Lesson #5 and Anatomy Lesson #6 wherein we learned that skin is composed of epidermis (surface layer of skin cells) and dermis (underlying connective tissue). Thus, another useful way of grading thermal burns is to describe their relative depths.

Partial-thickness Burn: This type damages the epidermis or both the epidermis and outer dermis; it includes first and second degree burns. Such burns are red and may blister and are very painful. Most partial-thickness burns heal without scarring because hair follicle cells regenerate to cover the damaged surface. Even here, if a partial-thickness burn is too large, a skin graft may be required.

Full-thickness Burns: Full-thickness burns extend through both epidermis and  dermis and into underlying tissues. Such wounds are typically aesthetic (painless) because nerve endings are destroyed, although the rim of such a burn is usually painful. Full-thickness burns include third, fourth, fifth and sixth degree burns which may pass into muscle and bone. Fifth and Sixth degree burns are typically fatal.

We can imagine fifth and sixth degree burns suffered by poor Father Alexandre and Johiehon, his love interest in Outlander episode 412, Man of Worth.

Diana’s fourth big book, Drums of Autumn details the sad and horrific conflagration as the lovers burned to ash.

When the Indians had nearly finished with the priest, they untied him from the stake and fastened his hands instead to a long pole, held above his head, from which to suspend him in the flames….

… It was then that he had seen the Indian girl standing on Claire’s other side, with a cradleboard in her arms. … “She didna look to left or right, but walked straight into the fire.” … The flames had embraced the girl in moments. 

… “Her clothes caught, and then her hair. By the time she reached him, she was burning like a torch.” Still, he had seen the dark silhouette of her arms, raised to embrace the empty body of the priest. Within moments, it was no longer possible to distinguish man or woman; there was only the one figure, black amid the towering flames.

…The smell of burnt things hung in the air. We passed close by the pit and I couldn’t help seeing from the corner of my eye the heap of charred fragments, shattered ends frosted white with ash.

Hyperthermia: Hyperthermia  occurs if body temperature rises significantly above normal (>104 °F / 40 °C ). Many challenges, including infections, cause excessive body temperature.

Typhoid fever,  a.k.a. enteric fever, is caused by food and water contaminated with salmonella bacteria. Symptoms include:

    • High fever
    • Headache
    • Stomach pain
    • Constipation or diarrhea

A great example of hyperthermia appears in Outlander episode 310, Heaven and Earth. You remember Claire’s splendid  wee aide, Elias, who falls ill with typhoid? Claire is comforts him as he bravely succumbs to fever and dehydration. 😭

Cold temperatures đŸ„¶Â also cause thermal injury because the human body is poorly equipped to regulate and prevent heat loss; this is especially true of children and the elderly. Normally, fat deposits, heart, blood vessels, brain, skin, and muscles help combat cold. These organs provide insulation, induce shivering, re-direct blood flow from skin to vital organs, and reduce energy consumption.

However, exposure to cold temperatures over long periods of time overcomes our coping mechanisms and produces a range of thermal cold injuries such as chilblains, hypothermia, and frostbite.

Chilblains: Chilblains is a 16th century term for skin trauma due to repeated expose to cold, but not freezing, air. Digits are most commonly affected. The skin becomes red, swollen ,and itchy (next image), but usually heals without permanent damage.

Outlander TV episodes do not feature chilblains. But have no fear, our amazingly witty and resourceful Diana writes about it in her second book, Dragonfly in Amber, wherein Claire treats imprisoned men with chilblains.

She’s a wonder! Which “she” do I mean? Take your pick – either woman works!

I talked my way into the cells of the prison, and spent some time in treating the prisoners’ ailments, ranging from scurvy and the more generalized malnutrition common in winter, to chafing sores, chilblains, arthritis, and a variety of respiratory ailments.

Ouch, that looks a wee bit uncomfortable!

Hypothermia: Hypothermia occurs when the body’s core temperature drops below 95°F / 35°C as a result of extended cold exposure. Symptoms include low core temperature, vigorous shivering, confusion, sleepiness, slurred speech, shallow breathing, weak pulse, low blood pressure, changes in behavior, and slowed reactions.

Put simply, the victim of hypothermia experiences  the “umbles” meaning grumbles, mumbles, stumbles and fumbles because cold affects muscle and nerve response.

If the core temperature drops to 90Âș F / 32.2Âș C, then bradycardia (slow heart rate) and atrial fibrillation (fast and irregular contraction of the heart’s two upper chambers) may ensue.

The teenager, bad-lass Laoghaire, wasn’t suffering from hypothermia when she exposed her “ladies” to Jamie  in Outlander episode 109, The Reckoning, but she was well on her way!

Take a keek at that goose flesh! 😉

Frostbite: Frostbite is cold injury in which the body’s surface is exposed to freezing temperatures; it affects mostly feet, hands, noses, cheeks, and ears. And, as Prince Harry points out in his tell-all book, “Spare,” the todger must be protected from frostbite. This makes sense since it is also an appendage. 😉

Frostbite occurs in three stages:

    • Frostnip: Frostnip is a mild form of frostbite. Continued cold exposure leads to numbness in the affected area. As the skin warms, the sufferer feels pain and tingling but no permanent skin damage.
    • Superficial Frostbite: Superficial frostbite causes slight changes in skin color. The skin may begin to feel warm — a sign of serious skin damage. Rewarming at this stage causes the skin to appear mottled. The victim may notice stinging, burning and swelling. Fluid-filled blisters may appear over the next 12 to 36 hours (next image).
    • Deep Frostbite. As frostbite progresses, it affects all layers of the skin and underlying tissues. The skin turns white or blue-gray; all sensation of cold, pain, or discomfort is lost in the affected area. Joints or muscles may stop working. Large blisters form 24 to 48 hours after rewarming. The tissue turns black and hardens as it dies. Amputation is usually warranted.

Claire teasingly relates how she and Jamie avoid getting frostbite in this steamy tidbit from Drums of Autumn.

His mouth was warm and soft, and whether he approved of what he was doing or not, he did it awfully well.

…“Ooooh,” I said, and shuddered ecstatically as his teeth sank delicately into my earlobe.

….“Oh, well, if it’s like that,” he said in resignation, and taking my hand, pressed it firmly between his thighs.

..“Gracious,” I said. “And here I thought the cold 
”

…“It’ll be warm enough soon,” he assured me. “Get them off, aye?”

…It was rather awkward, given the cramped quarters, the difficulty of staying covered in order not to suffer frostbite in any exposed portions, and the fact that Jamie was able to lend only the most basic assistance, but we managed quite satisfactorily nonetheless. 😅

Electrical Injury: What is this? Electrical injury is damage to the skin or internal organs after a person comes into direct contact with a high-voltage source. An electric shock can be life-threatening.

Good advice: Get emergency help if the source of the injury is a high-voltage wire or lightning. Even those with minor injuries or no symptoms should be checked by a physician for internal injuries because these may not be evident to the non-professional.

Rare but life-threatening symptoms include severe burns, muscle pain and contractions, seizures, and unconsciousness. In some cases, heartbeat and breathing may be difficult to detect.

In the US, there are approximately 1000 deaths per year, as a result of electrical injuries. Of these, approximately 400 are high-voltage electrical injuries and lightning causes 50 to 300. There are also at least 30,000 shock incidents per year that are non-fatal.

If you think these stats are grim, consider the UK: Faulty electrical equipment and sockets cause approximately 70 deaths and 350,000 injuries in UK homes every year (RHA, 2022). Such figures show how important it is to follow electrical safety guidelines.

Outlander book and TV don’t really contain much about electrical injury. the closest I can come is Claire’s eerie encounter with Otter-Tooth’s ghost in Outlander episode 403, The False Bride. Here, she experiences the aftermath of a lightning strike.

Diana describes the scene in vivid detail. Again, from Drums of Autumn:

Sheet lightning shimmered far away, across the mountains. Then more bolts, sizzling across the sky, each succeeded by a louder roll of thunder. The hailstorm passed, and the rain resumed, pelting down as hard as ever. The valley below disappeared in cloud and mist, but the lightning lit the stark mountain ridges like bones on an X ray.

I woke all the way to the smell of burning, and sat bolt upright. The rain had stopped; it was the silence that wakened me, I thought. The smell of smoke was still strong in my nostrils…

…The ground rose in front of me to a small ridge. At the top of this stood a large balsam poplar tree, the source of the smoke. The tree had been struck by lightning; half of it still bore green leaves, the canopy bushy against the pale sky. The other half was blackened and charred all down one side of the massive trunk. Wisps of white smoke rose from it like ghosts escaping an enchanter’s bondage, and red lines of fire showed fleetingly, glowing beneath the blackened shell.

Echoes of the shock of impact wavered through my flesh, and I tried frantically to fit myself back into my body. Then I drew breath, a painful gasp, and found myself shaking, the shock turning to the first intimations of damage. I lay still, eyes closed, concentrating on breathing, conducting an inventory. 

…The rain was still pounding down onto my face, puddling in my eye sockets and running down into my ears. My face and hands were numb. My arms moved. I could breathe a little easier now.

Drenched in cold, relentless rain, Claire spies the spooky ghost of Otter-tooth. Careful, lest you get hyperthermic, Claire!

And, there he is. Sharp as an Otter’s Tooth!

That is it for thermal injury. But….

Here’s some exciting thermal news: The US Department of Energy is developing clothes with thermal properties that adapt to the environment and to the wearer’s body. By changing the make-up or shuttling heat to and from the body, the garments can keep people comfortable whatever the external temperature (30 January 2016, New Scientist). I’m ready for one of these jackets, how about you?

Onward! 

Alcohol: Alcohol is a colorless, volatile, and flammable liquid that is the intoxicating element of wine, beer, and other spirits (duh!); it is also used as a fuel and is an industrial solvent! 😼

How the body handles alcohol: The stomach lining contains alcohol dehydrogenase (ADH), an enzyme which metabolizes alcohol. The liver also has ADH plus other enzymes that help break down alcohol. But, bad news for the lassies: Women naturally have lower levels of GAD than men and often develop higher blood alcohol levels after drinking the same or even less alcohol. So, be wary if ye are an XX!

Claire offers a pithy analysis of alcohol in this quote from the big book, “Drums of Autumn,“wherein Jamie gets John Quincy Myers drunk in preparation for his hernia surgery.  (Psst…Non-book readers ken Claire performed this surgery on Edmond Fanning in episode 408, Wilmington.)

“Alcohol isn’t a good anesthetic at all,” I said, shaking my head. “It’s a poison. It depresses the central nervous system. Put the shock of operating on top of alcohol intoxication, and it could kill him, easily.”

And, there we have it in a nutshell!

Not surprisingly, alcohol is the most widely used and abused toxic agent in the world. (Not meaning to preach as I enjoy a wee bit now and then)

Alcohol injury ranges from binge drinking to full on alcoholism with a myriad of accompanying ailments. Most of us are well-versed on the effects of excessive alcohol intake and realize some effects are acute and others are chronic.

Acute Alcohol Intoxication: In the US, there are over 3,000,000 reported cases of acute alcohol intoxication (AAI) from drinking too much, too quickly. Symptoms include slurred speech, incoordination, mood and behavioral changes, and poor judgement. Acute alcohol intake effects breathing, heart rate, body temperature, gag reflex, and can lead to coma and death. (psst… I wager many more cases go unreported) đŸ«ą

Risk factors include:

      • Injuries, such as motor vehicle crashes, falls, drownings, and burns.
      • Violence, including homicide, suicide, sexual assault, and intimate partner violence.
      • Alcohol poisoning, a medical emergency that results from high blood alcohol levels.
      • Risky sexual behaviors, including unprotected sex or sex with multiple partners. These behaviors can result in unintended pregnancy or sexually transmitted diseases, including HIV.
      • Miscarriage and stillbirth or fetal alcohol spectrum disorders (FASDs) among pregnant women.
Alcohol intoxication is managed with rest, hydration, and abstaining from alcohol. It is worth noting that severe cases may require hospitalization, intravenous fluids, observation, and supportive care.

Oh, Jamie is in the throes of AAI at Lallybroch (episode 112, Lallybroch). He is stinking drunk as he stumbles into the bedchamber reeking of booze; Claire is not “amoozed.” 

But, he looks marvelous in his da’s splendid leather coat! 😜 

Chronic Alcohol Use: Alcohol Dependence Syndrome (ADS or alcoholism) is a condition characterized by long-term alcohol dependence and alcohol abuse that result in specific physiological and behavioral problems. ADS  includes ten or more different signs and symptoms, but from a medical standpoint, only two are required for diagnosis. Chronic use causes a host of problems, including:
    • High blood pressure, heart disease, stroke, liver disease, and digestive problems.
    • Cancer of the breast, mouth, throat, esophagus, larynx, liver, colon, and rectum.
    • Weakening of the immune system, increasing the chances of illness.
    • Learning and memory problems, including dementia and poor school performance.
    • Mental health problems, including anxiety and depression.
    • Social problems, including family problems, job-related problems, and unemployment.
    • Alcohol use disorders, or alcohol dependence

In season six of Outlander, we witness Fergus falling into ADS as he struggles with the cruelty and intolerance toward his dwarf son (episode 603, Temperance).  Alcohol  is commonly used to cope with personal tragedy and trauma.

You remember Colum MacKenzie back in Outlander, seasons 1 and 2?  Yes, of course ye do! 😊 Claire diagnosed Colum as a sufferer of  Toulouse-Lautrec Syndrome, also known as pycnodysostosis. 

Colum required large quantities of rhenish wine (9% alcohol content) to quell and dispel the agony of his existence (Outlander episode 102, Castle Leoch). 

…  “I beg your pardon?” I turned, having missed Colum’s words in the growing noise, to find him offering me the decanter, a lovely bell-shaped thing of pale green crystal.

The liquid within, seen through the glass, seemed green as the sea-depths, but once poured out it proved to be a beautiful pale-rose color, with the most delicious bouquet. The taste was fully up to the promise, and I closed my eyes in bliss, letting the wine fumes tickle the back of my palate before reluctantly allowing each sip of nectar to trickle down my throat.

“Good, isn’t it?” The deep voice held a note of amusement, and I opened my eyes to find Colum smiling at me in approval. I opened my mouth to reply, and found that the smooth delicacy of the taste was deceptive; the wine was strong enough to cause a mild paralysis of the vocal cords.

“Won—wonderful,” I managed to get out. Colum nodded.

“Aye, that it is. Rhenish, ye know. …”

Clearly, Colum suffered from his genetic disability but also from ADS . Near the end, when rhenish no long offered the needed relief, he turned to Claire to assist him in end of life options (Outlander episode 210 Prestonpans).

ADS is considered a medical emergency because it can lead to coma and death. Guidelines exist about the amount of alcohol the liver can metabolize per hour and these rates should not be exceeded. Again, please get informed if this is an issue in your life.

As a final example, we see wee Flora MacDonald taking a wee nip from her personal hip flask in Outlander, episode 605, Give Me Liberty!  Now, just because she carries a personal flask, it doesn’t mean she is suffering from either acute or chronic alcohol poisoning! 😉

Finally, this is an interesting tidbit. Some people carry a gene variant encoded for alcohol dehydrogenase (ALDH2*2) that stops the enzyme working, so these folks experience flushing soon after drinking. This happens because they have a lowered ability to metabolize alcohol and includes some 8% of the world’s population. Now, a link has been found showing that this gene raises heart disease risk in those who experience alcohol flush (New Scientist, 4 Feb. 2023). The risk of heart disease is four times greater in regular drinkers with the defective gene! if you flush immediately after alcohol ingestion, you may wish to consult your physician?

OK, that is our lesson for today. But before we call it quits let’s have a –

Pop Quiz! 

Name the injury (red arrow) Jamie sports after the Battle of Alamance, in Outlander episode 507, The Ballad of Roger Mac.

What was that you said?

An abrasion? Â đŸš«

A laceration? đŸš«đŸš«

An avulsion? đŸš«đŸš«đŸš«

What was that you said?

 

 

A contusion? Yep!

Well done, anatomy students! đŸ‘đŸ»đŸ‘đŸ»đŸ‘đŸ»

Next time, Part 3!

The deeply grateful,

Outlander Anatomist

Follow me on:

Photo creds: Sony/Starz, www.en.wikipedia, www.britannica.com

 

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Anatomy Lesson – Outlander Trauma-Drama, Part I

Greetings Outlander anatomy students!

I have not posted a lesson or fun fact since September of last year!  Time to get back into the dissection room. đŸ€“

I plan to post several lessons in succession, all dealing with trauma-drama on Outlander! And, as we all ken, there is plenty of this to go around.

Let’s get started with a couple of definitions. 

As many of you know, the term anatomy comes from the Greek ana– (up) + temnein (to cut). Taken literally, anatomy means to cut away or to reveal. 

Today’s Anatomy Lesson will reveal topics belonging to the science of pathology: Greek meaning pathos (suffering) + ology (to know). Interestingly, pathology is literally the study of abnormal anatomy so we are well within our lane! 

Although this topic is not light-hearted, it is an important one which may prove useful to you and yours.

Pathologists have meticulously developed a logical, useful, and understandable schema to classify the types of trauma which injure body cells, tissue, and organs. Major categories are mechanical trauma, thermal injury, alcohol, infectious agents, and so on. 

Today lesson will focus only on mechanical trauma, of which there are seven types:

    • Contusion
    • Abrasion
    • Laceration
    • Incision
    • Avulsion
    • Projectile injury
    • Puncture wound

Whew, that is quite a laundry list! Call it a miracle that any of us survive to adulthood. đŸ™đŸ»

Diana’s Outlander books plus the Starz Outlander series are rife with excellent examples of varied and sundry mechanical trauma-drama so it is time for Jamie.com to hop atop the dissection table. Up you go! 

As we explore Mechanical trauma, bear in mind this type of injury produces two types wounds: 

    • closed wounds – the skin is intact
    • open wounds – skin is scraped, torn, cut, or punctured 

You will see these terms appear in the lesson.

Almost every Outlander episode contains one or more of the seven types of mechanical trauma, so let’s go find some!

Contusion: The contusion is closed trauma  so the skin remains intact. Caused by blunt force, blood vessels are ruptured and blood seeps into surrounding tissues forming a hematoma (Greek, meaning blood tumor).

Known as a bruise in laymen’s terms, the appearance of a contusion is due to extravasated blood in the tissues. Press on a skin contusion and it does not blanch under pressure. Interestingly, hematomata (pl.) also occur in internal organs such as brain and liver.

Claire provides a heart wrenching example of contusion after she is kicked and bludgeoned by Lionel Brown and his band of hairy men! In the final scene of Outlander episode 512, Never My Love, her contusions caused by blunt force trauma are on full display! 

Chapter 28 of Diana’s sixth big book, A Breath of Snow and Ashes, describes the carnage in shocking detail; the blows were administered by thief-taker, Harley Boble:

“He was standing. He was kicking me and cursing, panting and half-sobbing as his boot thudded into sides and back and thighs and buttocks. I panted in short gasps, trying to breathe. My body jerked and quivered with each blow, skidding on the leaf-strewn ground, and I clung to the sense of the ground below me, trying so hard to sink down, be swallowed by the earth.”

The uneven mottling of Claire’s skin created by the FX crew is accurate.  A rainbow of blue, black, green, and yellow herald the normal healing pattern of contusions, although it takes a wee bit of time for the full range of colors to appear.

Puir Claire! Her emotional trauma will linger far after her physical wounds have healed. 😔

Abrasion: The abrasion is an open type of mechanical injury wherein the epidermis (Anatomy Lesson #5) is rubbed or scraped away. Superficial abrasions typically turn red whereas deep abrasions ooze blood making them easily distinguishable.  The good news is the skin repairs abrasions rather promptly and without scarring unless infection messes with the healing process.

Jamie is our victim for the abrasion!  Here in Outlander episode 608, I Am Not Alone, we see a mostly superficial abrasion of his right brow and cheek as a result of the Richard Brown and his men attempting to take Claire into custody for the murder of Lionel. His skin is scraped and bright red. Again, kudos to the special effects and detail folks.

Laceration: Our next trauma is a laceration, best defined as a slash or tear. Lacerations are open wounds with rough and ragged margins that may be contaminated with bacteria and debris. Most often, they are tears of the skin, but internal organs can also be lacerated.

In a flashback during Outlander episode 601 Echoes, Jamie relives his years at Ardsmuir as Mac Dubh wherein he takes responsibility for an illegal piece of tartan and receives lashes on his already scarred back. Trauma-drama for sure!

 The scene is poignantly described in Diana’s third big book, Voyager: 

He had nodded to the two privates, who seized the prisoner’s unresisting hands and raised them, binding them to the arms of the whipping post. They gagged him, and Fraser stood upright, the rain running down his raised arms, and down the deep seam of his backbone, to soak the thin cloth of his breeches.

“ 
 in contravention of the Diskilting Act, passed by His Majesty’s Parliament, for which crime the sentence of sixty lashes shall be inflicted.” 

“
Mr. Fraser, you will take your punishment.”

“
The sergeant-farrier paused only briefly between blows. He was hurrying it slightly; everyone wanted to get it over and get out of the rain. Grissom counted each stroke in a loud voice, noting it on his sheet as he did so. The farrier checked the lash, running the strands with their hard-waxed knots between his fingers to free them of blood and bits of flesh, then raised the cat once more, swung it slowly twice round his head, and struck again. “Thirty!” said the sergeant.

Puir Jamie. His back is broad and strong, but gah! đŸ˜”â€đŸ’«

Incision: An incision is an open wound that differs from the laceration because it is made by  sharp cutting instruments such as knife, razor, or glass edge. Thus, the margins of an incision are sharp and well-defined.

Today, incisions are closed with different suturing techniques depending on the site and type of wound. There are also different types of suture materials including thread, needles, stitches, and knots as well as closures without sutures such as staples and glue. The clean margins permit incision wounds to be closed tidily and these typically heal with minimal scarring.

Unfortunately, there was no suturing of Malva’s mortal wound although it is a perfect example of incision injury (Outlander episode 606, The World Turned Upside Down).

This poignant scene is captured, again from Diana’s sixth big book,  A Breath of Snow and Ashes:

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

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

Malva was a damaged young woman who, in turn, damaged others. Even so, she scarcely deserved to die in such a despicable manner. 😯 Puir lass.

Who did the dastardly deed? We will soon find out when Season seven airs!

(Pssst….Another excellent example of incision trauma would be Claire’s surgical repair of Tom Christie’s Dupuytren contracture. Yes, I did write a lesson on this topic.)

Avulsion: An avulsion injury is the forcible tearing away of a body part or structure. This type of trauma was the hardest to find in Outlander. I had to go all the way back to Season two!  But, find one, I did: a good example of avulsion is the tooth extraction Claire performed in Outlander episode 211, Vengeance is Mine!

Although avulsion more commonly describes a muscle pulled from its bony attachment or limbs (e.g. finger, toe) being torn off, a tooth being separated from its socket surely qualifies. Ouch! đŸ«Ł

Is Rupert is amused or scared s**tless? We miss you, man!  

Projectile Injury: Projectiles are objects that are propelled forward by an external force. Thus, a hurled stone is a type of projectile. Projectiles typically cause open wounds and probably the best-known is the gunshot wound (gsw).

The degree of tissue disruption caused by a projectile is proportional to its kinetic energy, yaw (twist), fragmentation of the projectile; all features that especially apply to a gsw.

I certainly am not a munitions expert but as I understand it, today’s standard NATO weapon (M16 rifle) fires a cartridge that measures .21” (5.56mm) in diameter. But an 18th century musket ball ranged from .51”-.75” (13-19mm) in diameter making it two to three times the diameter of the M16 cartridge – one humongous projectile!!!

Season six ended with a startling but effective example of a projectile (Outlander episode 608, I Am Not Alone).

Several of Brown’s men kidnapped Jamie, planning to put him aboard a ship bound for far off places. Chief Bird came to the rescue, shooting the abductor with a rifle given to him by Jamie. Bullseye (so to speak)! 😉

Chief Bird nods in satisfaction at Jamie:

“I told you I would fight with you, Bear-Killer.”

Until about 1880, the standard practice for treating gsw required that physicians probe and locate the path of a projectile with unsterilized fingers. Before this time, germ theory and Lister’s dilute carbolic acid treatment for “antisepsis surgery” were unknown.

Understand, the musket ball is not only large, it is a low velocity projectile, so its sheer mass literally plows (yikes!) a path through tissues. Little wonder that it leaves a gaping hole! In fact, in those by-gone days, one musket ball was sufficient to kill a man if it struck near any vital organ. And, if the victim survived a musket ball wound, he/she often succumbed to the effects of a subsequent amputation or infection.

I might add, that the impact of the musket ball would have knocked this kidnapper on his ass. But, for a second he remains upright for dramatic effect! 😼

Puncture Wounds: Puncture wounds are open wounds that pierce the skin and penetrate underlying tissues. These are difficult to cleanse and thus increase the risk of infection.

Further, if the puncturing object stays in the body, then it is a penetrating wound; if it passes through the body and emerges then it becomes a perforating wound.

Understand that it is not uncommon for wound classifications to overlap so, for instance, a gsw might be categorized as both a projectile and a penetrating or a perforating wound.

A great example of a puncture wound occurs during Ian’s voluntary adoption into the Mohawk tribe in the form of ritualistic tattooing. This was done with what appears to be a porcupine quill in Outlander episode 604, Hour of the Wolf.  Ouch! 

This is the description of Ian’s transformation from Diana’s fourth big book, Drums of Autumn: 

“Ian? Is that you?”

“Aye, Uncle. It’s me.”

His voice sounded odd; breathless and uncertain. He stepped into the light from the smokehole and I gasped, feeling as though I had been punched in the stomach.

The hair had been plucked from the sides of his skull; what was left stood up in a thick crest from his scalp, a long tail hanging down his back. One ear had been freshly pierced and sported a silver earring.

His face had been tattooed. Double crescent lines of small dark spots, most still scabbed with dried blood, ran across each cheekbone, to meet at the bridge of his nose.

Also, notice the abrasions on his left upper lip, nostril, cheek, brow and temple? His dash through the gauntlet took its toll, for sure! đŸ˜±

Whew! We covered all seven types of trauma drama, probably enough  for one lesson!

Final Thought: Here’s an important take-home message I learned from my surgical colleagues: if you encounter a projectile wound in which the penetrating object is still in the body, do not attempt to remove it in the field! Instead, transport the victim to the nearest emergency room ASAP so professionals can remove it under medically-controlled conditions.

Tempted to remove a projectile yourself? Don’t! (Well, maybe a sliver is OK.) Seriously, this advice is because the embedded object usually exerts pressure on nearby torn blood vessels squelching blood loss. After the object is removed, the resultant blood flow may not be easily staunched especially if a vital organ is involved.

This happened to the late, great Steve Irwin, Crocodile Hunter, who removed a stingray barb that penetrated his heart. Sadly, he bled to death in moments through the hole in his chest!

Stay tuned for a future lesson on trauma drama!

The deeply grateful,

Outlander Anatomist 

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Photo credits: Sony/Starz, www.en.wikipedia