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. 🤓

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. 🙏🏻

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! 😵‍💫

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! 🫣

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! 😱

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

Fun Fact: incision

incision

Anatomy Def: Cut, opening, or slit in skin or flesh.

Outlander Def: Horrific wound in Rupert’s belly wall delivered by a sharp, sweeping redcoat blade at the Battle of Prestonpans!

Learn about incision wounds in Anatomy Lesson #35, Outlander Owies! – Part One. Learn the differences between incision wounds and lacerations!

Read about Jamie’s incision wound in Dragonfly in Amber book. Why Jamie? Because Rupert doesna suffer an incision wound in Diana’s books, so Jamie must do:

Leaving my head injury to mind himself for a moment, I stepped forward and opened the shirt, pulling it gently away from the injured side. Despite the quantity of blood, I knew it must not be a serious wound; he stood like a rock, and the blood no longer flowed. It was a saber-slash, slanting across the ribs. A lucky angle; straight in and it would have gone deep into the intercostal muscles between the ribs. As it was, an eight-inch flap of skin gaped loose, red beginning to ooze beneath it again with the release of pressure. It would take a goodly number of stitches to repair, but aside from the constant danger of infection, the wound was in no way serious.

See Rupert’s wound and watch Claire close it using a continuous, over and over surgical stitch in Starz episode 210, Prestonpans. Whew, many Highlanders are lucky that Claire went back through the stones!

ep-210-incision-02

A deeply grateful,

Outlander Anatomist

Anatomy Lesson #35: Outlander Owies! – Part One

Greetings Outlander anatomy students! Today’s Anatomy Lesson #35 covers wounds and injuries; topics which belong to the science of pathology (Latin for knowledge of suffering). However, as pathology is the study of abnormal anatomy, the lesson will not go far afield. Although this topic isn’t as light-hearted as the title implies, it is an important one which may prove useful to you and yours.

Wounds are classified in different ways but pathologists have developed a logical, useful, and understandable schema. Under their model, body cells and tissues are injured by the following mechanisms:

  • Mechanical trauma
    • Contusion
    • Abrasion
    • Laceration
    • Incision
    • Avulsion (body structure is forcibly detached from its point of insertion)
    • 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

Whew, that is one long, laundry list! Call it a miracle that any of us survive to adulthood. Nevertheless we do survive because the body employs many protective and healing mechanisms; we will examine these in a future lesson.

Diana’s Outlander books and the Starz Outlander series are rife with excellent examples of varied and sundry wounds so Jamie.com once again serve as our models; up on the dissection table you go! Today’s lesson focuses on types of mechanical trauma.

Mechanical trauma produces closed wounds with intact skin or open wounds in which the skin is scraped, torn, cut, or punctured. Almost every Outlander episode contains one or more types of traumatic injury. Let’s find them!

Contusion: The contusion is a closed type of wound caused by blunt trauma which ruptures blood vessels (Anatomy Lesson #5). Blood seeps from the broken vessels into surrounding tissues and forms a hematoma (Greek meaning blood tumor). Known as a bruise in laymen’s terms, its appearance is due to extravasated blood. Press on a skin contusion and it does not blanch under pressure. And, just to be complete, hematomata (pl.) also occur in internal organs (e.g. brain, liver).

Jamie sports two major contusions, one on each shoulder, a matched pair! His first is of the right shoulder as a result of a dislocation exacerbated by a gunshot wound. The blunt force was the ground (!) which his shoulder strikes after falling from his mount. The fall dislocates his glenohumeral joint (Anatomy Lesson #2) tearing blood vessels and allowing blood to seep into subcutaneous tissues. Herself describes the event in Jamie’s own words (Outlander book):

“Fell wi’ my hand out, when the musket ball knocked me off my saddle. I landed with all my weight on the hand, and crunch!, there it went.”

The contusion covers most of his right shoulder (Starz episode 102, Castle Leoch). The uneven mottled appearance is very accurate; a rainbow of blue, black, green, and yellow herald the normal healing pattern of a contusion. We will cover the basis of these color changes in a future lesson. Good job special effect crew!

ep 102 Jamie contusion 03

Later, another contusion covers Jamie’s left shoulder. The blunt force in this instance was administered by that bad bugger BJR who rained blows upon him at Wentworth Prison (Starz episode 116, To Ransom A Man’s Soul). Here from Outlander book, Claire is horrified by the inflicted damage:

Turning back the blankets in bits, I surveyed the damage… The sheer orderliness of the damage, speaking as it did of a deliberation that reveled in each punishing stroke, made me feel sick with rage. Something heavier, perhaps a cane, had been used with less restraint across his shoulders,.. I pressed a thick pad of lint gently over the worst of the mess and went on with the examination.

See that the skin over Jamie’s left shoulder is varying shades of red but not yet black and blue? Once again, this depiction is accurate because the contusion is fairly fresh; it takes time for the full range of colors to appear. Again, the scientific basis for the “rainbow” awaits a future lesson.

ep 116 Jamie bruise

Oh, and speaking of contusions, several readers have asked why Claire’s beautiful nude belly didn’t show contusions on her wedding night (Starz episode 107, The Wedding). After all, the day before she suffered a gut punch from Captain Mad Maniac and a kick from Corporal Milksop (Starz episode 106, The Garrison Commander)! BJR murmurs in her ear (Outlander book):

“I trust you are not with child, Madam,” he said in a conversational tone, “because if you are, you won’t be for long.” I was beginning to make a rather odd wheezing noise, as the first wisps of oxygen found their way painfully into my throat.

Actually, this seeming disparity doesn’t trouble me for three reasons. First, the episode does not show where Milksop placed his kick; it may have struck her thigh (Anatomy lesson #7) or groin, areas not shown during the wedding night episode. Second, although we see BJR punch her in the belly, Claire is protected by corset and stays, petticoat, and a pleated wool gown in which each pleat is formed by three layers of heavy wool fabric! Such protective layers help dissipate the kinetic energy of the blow. Lastly, the anterior abdominal wall (Anatomy Lesson #16) is a fibromuscular layer overlying soft organs, making it pliable when struck; it sinks inward, reflexively tightens, and then rebounds (especially as breath returns). Because it is flexible, a direct blow is less likely to burst superficial blood vessels. Had the blows struck skin overlying bone, then a contusion would have been inevitable. Make sense?

ep 106 Claire punch 02

Abrasion: The abrasion is an open type of traumatic wound wherein the superficial epidermis (Anatomy Lesson #5) is rubbed or scraped off by friction. Superficial abrasions typically turn red and deeper abrasions usually ooze blood. Repair occurs promptly and without scarring unless infection messes with the process.

Jenny is our first victim of abrasion (Starz episode 102, Castle Leoch)!  Jamie explains to Claire that on one “fine” October day near to four years ago, Captain Randall visited their farm:

Then I burst into the parlor, where I found two of the redcoats with my sister, Jenny. Her dress was torn a bit, and one of them had a scratched face.”

During the Starz encounter, it is Jenny who suffers the abrasions; four areas where the epidermis is scraped away. No despair as these superficial scratches should heal without scarring!

ep 102 Jenny abrasion

Lovely Claire suffers deeper abrasions at the Cranesmuir trial (Starz episode 111, The Devil’s Mark). Here from Outlander book:

The judge turned to MacRae. “Strip her and skelp her,” he said flatly. Through a daze of disbelief, I heard a collective inhalation, presumably of shocked dismay—in truth, of anticipatory enjoyment. And I realized just what hate really meant. Not theirs. Mine.

… he began, then hesitated, “I mean, the cuts are not deep. I—I think you’ll no be …marked.” He spoke gruffly, but his touch was very gentle, and reduced me to tears once more.

Later, Claire’s back very accurately depicts deep abrasions: her skin is scraped and bright red but not cut. During the skelping, I count nine blows striking Claire’s bared back and sure enough, it later shows nine abrasions (top two are faint but present). How fantastic when such details are addressed! Again, kudos to the special effects and detail folks.

Now, some vigilant Outlander fans ask why Claire’s back abrasions aren’t visible when she strips down to her undergarments at Lallybroch (Starz episode 112, Lallybroch). Great question but I don’t know the answer. In Outlander book, the journey to Lallybroch takes about a week but I don’t recall hearing the time frame between Starz episodes 111 and 112. Presumably, it was sufficient for Claire’s wounds to have healed. We all ken that serious fans scour and devour every Outlander word and frame available. No mossy brains in this group!

ep 111 Skelping

Then, eagle-eyed fans wondered why no abrasions show on Claire’s lovely bum as she “forgives” Jamie after strapping her with his sword belt (Starz episode 109, The Reckoning)! Well, at the risk of sounding like a broken record (remember those) perhaps because of elapsed time. In Outlander book, only a couple of days intervene between spanking and spectacular sex. What with the slow moving caravan, snowy weather during a stag hunt, quarrelsome clansmen vying for the bag of Stewart gold, and little lying Laoghaire of episode 109, mayhap there is sufficient time for welt-healing?

“I can tell you from my own experience that a good hiding” does leave marks for a bit (my dad believed in spanking, did yours?). Then again, mayhap the Starz folks were expecting a firestorm over the belting and didn’t want to remind or re-inflame “conscientious objectors.”

ep 108 Claire bum

Laceration: The next wound is a laceration, best defined as a slash or tear of soft tissues. Lacerations of the skin are open wounds with rough and ragged margins that are often contaminated with bacteria and debris.

Claire treats a major laceration at the gathering; Dougal requires her medical expertise for the boar tynchal. Being the English lass that she is, Claire is rather cross and feels sorry for the hairy “pig” (scientific name: Sus scrofa). With tusks measuring 10-12 cm (3.9 – 4.7”) in length (Starz episode 104, The Gathering), these animals can run up to 40 km/hr (~25 mi/hr) and jump to a height of 140-150 cm (55-59”)! No wonder Rupert tells Claire, “you’ve clearly never seen a boar!” Here are Claire’s thoughts from Outlander book:

Seeing the large number of men who set out for the east wood, armed to the teeth with boar spears, axes, bows, quivers, and daggers, I felt a bit sorry for the boar.

ep 104 boar gore 02

Turns out, a young man riding his horse in the woods suffers a boar-gore (Starz episode 104, The Gathering)! Yep, it is major laceration that tears open skin, subcutaneous tissue, fascia and tibialis anterior muscle of his right leg (Anatomy lesson #9 and Anatomy Lesson #27). That wound is going to require a mess of stitches! Does Claire amend her opinion about boars? Aye, she does! Herself explains, again from Outlander book:

This attitude was revised to one of awed respect an hour later, when I was hastily summoned to the forest’s edge to dress the wounds of a man… “Bloody Christ!” I said, examining a gaping, jagged wound that ran from knee to ankle. “An animal did this?… “Never mind,” I said, and yanked tight the compression bandage I had wound about the injured calf. “Take him up to the castle and we’ll have Mrs. Fitz give him hot broth and blankets. That’ll have to be stitched, and I’ve no tools for it here.”

ep 104 boar gore 01

Sadly, the most horrific lacerations are suffered by our handsome Highland hero, Jamie. His back is scourged twice, the second time by cruel, cunning Jack-the-Ripper who uses a cat o’ nine tails enhanced with lead plummets, designed to rip and tear flesh! Herself explains in Outlander book:

A few minutes later, Randall came out, the whip tucked under his arm, and the lead plummets at the tips of the lashes clicking softly together as he walked. He had surveyed Jamie coolly, then motioned to the sergeant-major to turn the prisoner around to show his back.

and again:

Now, scourging a man is never a pretty business, but there’s ways to make it worse than it might be; strikin’ sideways to cut deep, or steppin’ in wi’ a hard blow ower the kidneys, for instance.” He shook his head. “Verra ugly.”

Images of Jamie’s horrific lacerations are permanently seared in our brains (Starz episode 106, The Garrison Commander). Geez, talk about open wounds!

ep 106 Jamie lacerations 01

BJR’s demented mind cooks up more dirty deeds: Jamie’s fingers are lacerated after the cray-cray Captain uses a mallet to tear skin and break bones (Starz episode 116, To Ransom a Man’s Soul). His laceration wounds are thoroughly described in Outlander book:

I saw the two heads close together for a moment, then Murtagh’s sinewy hand gently touch the younger man’s ear—one of the few uninjured spots available…

The compound fracture of the middle finger was the worst to contemplate. The finger would have to be pulled straight, drawing the protruding bone back through the torn flesh.

Jamie did scream—loudly—when I set his middle finger, exerting the considerable force necessary to draw the ends of splintered bone back through the skin… the sharp bone end slowly disappeared back through the skin and the finger straightened with agonizing reluctance, leaving us both trembling…

ep 116 Jamie laceration 01

Learn more about Jamie’s puir hand in Anatomy Lesson #22 and Anatomy Lesson #23.

Incision: The incision is an open wound that differs from the laceration because it is made by a sharp cutting instrument such as knife, razor or glass edge. The margins of an incision are sharp and well-defined with “tidy” edges.

The opening credits of season one Outlander include suturing an incision wound, a treatment made easier by its straight, sharp margins. Mayhap this is an earlier version of the sword wound Jamie suffers during clan MacDonald’s Big Mac-Attack at the residence of the Duke of Sandringham (Starz episode 110, By the Pricking of My Thumbs)?

Using what appears to be an over and over continuous suturing technique, a carpet needle and sewing thread, Claire (?) stitches Jamie’s (?) incision wound. Today, many different suturing techniques are available depending on the site and type of wound. There are also different types of suturing materials, needles, stitches, and knots as well as closures without sutures such as staples and glue. The clean margins permit incision wounds to be closed and they may heal with minimal scarring. Notice the realistic swelling around the wound below? More about the science behind the swelling (not that one – snort!) in a future lesson!

Jamie incision

Projectile Injury: Projectiles are objects that are propelled forward by an external force; thus, a launched stone is a type of projectile. Projectiles typically cause open wounds and probably the best-known type is the gunshot wound (GSW). The degree of tissue disruption caused by a projectile is related to its kinetic energy, yaw (twist), fragmentation of the projectile, etc., features that especially apply to a GSW.

I certainly am not a munitions expert but here is my understanding (Ed, if this is wrong, please correct!): today’s standard NATO weapon (M16 rifle) fires a cartridge that measures 5.56 mm (0.22”) in diameter. But an 18th century musket ball ranged from 13 to 19 mm (.51 – .75”) in diameter – one humongous projectile!!

The first musket-style weapon we see in Outlander is fired by the unruly hand of bad-ass, Angus as he shouts insults at pursuing redcoats (Starz episode 101, Sassenach)! Take a look at the length of the fireball issuing from the mouth of his pistol!

ep 101 Angus musket 01

We do not see Angus’ pistol all that closely so let’s try again. The next image shows the huge gaping muzzle of darling, daring Dougal’s weapon (Starz, episode 104, The Gathering)! Indeed, that firearm is capable of launching a very large projectile, which it just did; one large hairy “pig” lies dead at Claire’s feet. Nice shot, hot shot! Gawd, Big D is one verra fine-looking Highlander!

ep 104 musket 01

OK, what about projectile wounds? Until about 1880, the standard practice for treating such wounds 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.

Now, a musket ball not only large, it is a low velocity projectile so, its sheer mass literally plows (yikes!) a path through the 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 (MBW), he/she often succumbed to the effects of a subsequent amputation or infection. Claire kens that full well as she assesses a redcoat’s gunshot wound (Starz episode 106, The Garrison Commander).

ep 106 amputation

When Claire first sets eyes on Jamie in 1743, he is a mess. Along with the dislocated shoulder, he also suffers a MBW. Herself ’s words from Outlander book:

I gasped, as did several of the men. The shoulder had been wounded; there was a deep ragged furrow across the top, and blood was running freely down the young man’s breast… “Fell wi’ my hand out, when the musket ball knocked me off my saddle.”

Claire quickly discovers that the clansmen know zip about proper treatment of a projectile wound – no 20th century medical supplies for puir Jamie!

Eyebrows rose all around. “Disinfected?” said the small man*, carefully. “Yes, indeed,” I said firmly,… “All dirt must be removed from the wound and it must be treated with a compound to discourage germs and promote healing.” “Such as?” “Such as iodine,” I said. Seeing no comprehension on the faces before me, I tried again. “Merthiolate? Dilute carbolic?” I suggested. “Or perhaps even just alcohol?” Looks of relief.

*That will be Angus. hee, hee!

In Starz episode 101, Sassenach we see that the musket ball penetrated Jamie’s right neck web and traversed his trapezius muscle (Anatomy Lesson #2). Another quote from Outlander book:

“Well, a musket ball through the trapezius might be considered a good reason,” I said dryly. He looked amused, fingering the area in question. “Trapezius, is it? I didna know that.”

Jamie is one lucky laddie that Nurse Claire is around to properly treat that convincing MBW! See the BIG old hole that looks like crater? That is from the musket ball bulldozing its way through Jamie’s flesh. See the bright red blood draining from the wound and the darker red-black blood in its center? These are accurate and realistic special effects; such a projectile bursts blood vessels most of which carry oxygenated (bright red) blood. The base of the crater will quickly form the red-black blood clot. Again, way to go special effects team! Rah! Rah!

ep 101 Gunshot wound

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

If the penetrating 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 a GSW might be categorized as both a projectile and a penetrating wound.

Horrible Horrocks meets-and-greets a terminal penetrating/perforating wound administered by the trembling hands of Ian Murray (Starz episode 113, The Watch)! Now, we can be assured that Ian did not attend Professor Angus’ stabbing lesson (Starz episode 108, Both Sides Now). Otherwise, Ian would have known that it is hard enough to slip a sword between the ribs with the blade in a horizontal position but impossible to stab through the thoracic cage (Anatomy Lesson #15) with a sword blade oriented vertically. No way, Jose! Why? Because the ribs are separated by a narrow 1/2” (1.25 cm) gap that follows a curved plane – no vertical blades allowed! Mayhap a verra looong ice pick? More visually dramatic, though, to be sure. Buh-bye Horrocks!

ep 113 Horrocks Incision

That’s all of the traumatic wounds for today. Turning serious again, let’s close this lesson with a sad anecdote, but one I always shared with students during heart lectures. Like me, you may miss “Crocodile Hunter”, Steve Irwin (1963-2006, Photo A), who died at the tender age of 44 in a bizarre accident. While filming an underwater documentary, a stingray barb pierced the chest wall and punctured his heart. The barb was removed aboard ship and he swiftly bled out through the hole left in his heart wall! This was a penetrating wound.

520px-Steve_Irwin

A similar accident occurred in the US state of Florida. One month after Steve suffered his fatal wound, an 81 y.o. Florida man was struck in the heart with a foot long stingray barb while fishing (Photo B). Leaving the barb in place, he rowed himself back to the dock (one tough hombre) for help. It took two surgeries, but doctors removed the barb, repaired the hole in his heart and he survived the attack. This was also a penetrating wound.

stingray-attacl

Here’s the take-home message I learned from my surgeon colleagues: if you encounter a penetration wound in which the penetrating object is still in place, do not attempt to remove it in the field! Instead, get the victim transported to the nearest emergency room ASAP so professionals can remove it under medically-controlled conditions.

Why not remove it yourself? Because the embedded object usually exerts pressure on surrounding torn blood vessels which helps to retard blood loss. When the object is removed, the resultant blood flow may not be easily staunched especially if a vital organ is involved.

So, did we find all the types of traumatic injuries in Outlander episodes? Well, we found six of seven!  We didn’t see an avulsion injury because there wasn’t one in the episodes. Hope you learned something new and useful!

See Roger’s cricothyroidotomy scar in Outlander episode 508, Famous Last Words.

Roger-the-dodger, dodged an awful fate. Kudos to MIL! 👏🏻👏🏻👏🏻

Wow! Dr. Claire continues to impress! 😲

The deeply grateful,

Outlander Anatomist

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Photo credits: Sony/Starz; Associated Press, 2006 newspapers (Photo B); www.en.wikipedia (Photo A); Kumar, Abbas and Fausto, 7th ed., Robbins and Cotran Pathologic Basis of disease, Elsevier and Saunders