Tag: Wilmington

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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! 🤗

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. 👍🏻

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! 🤓

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 🥶 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 90º F / 32.2º 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) 🫢

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?  🚫

A laceration? 🚫🚫

An avulsion? 🚫🚫🚫

What was that you said?

 

 

A contusion? Yep!

Well done, anatomy students! 👏🏻👏🏻👏🏻

Next time, Part 3!

The deeply grateful,

Outlander Anatomist

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

 

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Cape Fear River Basin and Alamance Battleground!

Hello, Outlander fans!

Season 5 blasts off in one month. I can scarcely wait! You? 🤗

Today, I post about my recent trip to  North Carolina, the US state that is integral to the Outlander saga beginning with Season 4 and beyond.

Now, please dinna run away. This is truly interesting stuff!

I visited several sites that appear in the fifth big book, The Fiery Cross (TFC), the source for Outlander, Season 5.

You will remember at the end of Voyager book and S3, Jamie and Claire survived a hurricane to land in the Colony of Georgia.

Mrs. Olivier smiled indulgently. “You are not on an island at all. You are on the mainland; in the Colony of Georgia.”

“Georgia,” Jamie said. “America?” He sounded slightly stunned, and no wonder. We had been blown at least six hundred miles by the storm.

“America,” I said softly. “The New World.”

At the beginning of  Drums of Autumn book, Jamie.com find themselves in Charleston, SC, and then they travel north to Wilmington. But, season four left out that bit of travelogue and opens in Wilmington, NC.

This quote from Drums of Autumn explains:

Out of the sun, with a large pewter mug of dark ale foaming gently in front of him, Jamie quickly regained his normal self-possession.

“We’ve the two choices,” he said, brushing back the sweat-soaked hair from his temples. “We can stay in Charleston long enough to maybe find a buyer for one of the stones, and perhaps book passage for Ian to Scotland on another ship. Or we can make our way north to Cape Fear, and maybe find a ship for him out of Wilmington or New Bern.”

I really wanted to see Wilmington for myself. So, hounding my son to drive me three hours to Wilmington was a must!

Yes, Wilmington, where Hayes met his sad fate at the end of a hangman’s noose!

Yes, Wilmington, where Brianna was handfast to Roger, on the most magical night of her young life.

Yes, Wilmington, where Brianna paid a horrific price for her mother’s iconic wedding ring, forged from the key to Lallybroch.

Why is Wilmington important beyond the Outlander story? When the Carolina region was divided in 1712, the line between North and South Carolina was established to ensure North Carolina received its own seaport, Wilmington.

Today, Wilmington is a lovely old city, a blend of modern and old including many beautiful homes boasting historic markers.

Wilmington straddles the Cape Fear River, which I filmed from the aft deck of the battleship USS North Carolina, as it (not the battleship 😉) flows toward the Atlantic Ocean. The battleship is permanently moored on this river!

I strolled along the Wilmington Riverwalk, a shop- and eatery-lined pathway following the river.

At Wilmington, the 200-mile-long Cape Fear River is large enough to accommodate sea-faring vessels, cargo crates and tugboats, as is befitting a true seaport. 

The Cape Fear River collects water from streams and rivers of the Cape Fear Water Basin, a 9,000+ sq. mi. area stretching beyond Greensboro, the city I just left!

Water from this massive land area drains into the Cape Fear River, ultimately flowing past Wilmington and into the Atlantic a few miles downstream.

Do you see Fayetteville, NC, on the map below? It sits on the Cape Fear River but further inland than Wilmington.

Fun Fact: Did you know Fayetteville started life in 1756 as Cross Creek, the settlement nearest to Aunt Jocasta’s River Run plantation. Truth! 

During the American Revolution, Cross Creek was a hotbed of wartime activity and home of divided loyalties, many of those conflicts involved Highland Scots! Its name was changed to Fayetteville in 1783.

Lastly,  Cape Fear, might sound familiar to you because Martin Scorsese’s 1991 film of the same name was situated in this region. Cape Fear is a prominent headland jutting into the Atlantic Ocean at the mouth of the Cape Fear River.

Aunt Jocasta’s splendid River Run plantation near Cross Creek (Fayetteville), most likely sat in the Cape Fear River Basin.

Moving on.

A couple of days later, my dear son drove me to the Alamance Battlefield. The Battle of Alamance was the final conflict in the War of Regulation, a rebellion in North Carolina over issues of taxation and control. Some historians and locals consider the Battle to be the opening salvo of the Revolutionary War!

The battleground is a beautiful, serene wooded site bordered by zigzagged split rail fencing and a few miles outside Greensboro .

The woods are quiet now but on May 16,  1771, the countryside rang with shots and shouts from Regulators and Tryon’s militia.

The  image below shows where the Regulators held ground on the rise in the background. Tryon’s forces would have been about six miles in the opposite direction across Great Alamance Creek.

As faithfully recorded in TFC, Herman (Harmon/Hermon) Husband was a leader in the rebellion who left the battlefield early.

I wondered what brought Hermon Husband here—and whether he was being followed. He owned a farm and a small mill, both at least two days’ ride from the Ridge; not a journey he would undertake simply for the pleasure of our company. 

Husband was one of the leaders of the Regulation, and had been jailed more than once for the rabble-rousing pamphlets he printed and distributed. The most recent news I had heard of him was that he had been read out of the local Quaker meeting, the Friends taking a dim view of his activities, which they regarded as incitement to violence. I rather thought they had a point, judging from the pamphlets I’d read.

Now one bit of history…. militia men did not wear uniforms; these were ordinary citizens on both sides of the conflict. We have all seen and speculated about Jamie Fraser appear in a redcoat in Outlander Season 5 footage.  So why is he wearing that redcoat? Time will tell, but I wager it has to do with advancing the story at the expense of historical accuracy. 😉

Psst… whatever the reason, he looks mighty fine!

Spoiler! The battle was fairly brief and the loss of life modest given that Tryon had 1,000 militiamen and the Regulators, 2000.  Tryon captured 13 Regulators: one was executed at camp and six were executed later in nearby Hillsborough. Hanging was the method of the day.

This bit of history is pertinent to Season 5, so ‘nuf said! 😉 😉

What a trip!

Thank y ou for joining me on my whirlwind tour of book 5 (excepting Fraser’s Ridge, an area I explored in 2015).  This trip, I visited Wilmington, where Bree was handfast to Roger and assaulted by the dread pirate, Steven Bonnet! I walked the Cape Fear River into which most rivers and streams of the Cape Fear Water Shed drain and home to Cross Creek and River Run. And, I visited the Alamance Battlefield, the site where Regulators clashed with Governor Tryon’s militia.

As always, I am deeply grateful. Yay!

The deeply grateful,

Outlander Anatomist

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Photo and Video Credits: Sony/Starz, Wikipedia, Outlander Anatomy, Wilmington-nc.com, nchistory.WordPress.com

 

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Anatomy Lesson #64: Inguinal Hernia

Hey, anatomy students! Are you interested in hernias? If yes, you came to the right place! Today’s lesson, Inguinal Hernia, is prompted by Dr. Claire performing a hernial repair in Outlander episode 408, Wilmington. Let’s pass through the stones and review the scene as it unfolds at a local 18th century theater!

Warning: Two images in this lesson show the groin area. One is of Jamie at Lallybroch millpond, the second is a clinical image. I think all readers are adults and will be OK with these. But, the warning is for those who might find such content objectionable.

After meeting Governor Tryon and his associate, Edmund Fanning, Claire observes Fanning in distress. Turns out, he suffers paroxysms of pain from a strange protrusion, incurred after standing against a mob in Hillsborough. His boots stayed in the mud as his body turned after delivering rum to appease rioters. Oh, my!

Talk about theater! Barely watching that dreadful play, Jamie learns his Godfather is in peril and devises a plan. Hum….mayhap a poke in the puir fellow’s aching belly will buy valuable time? A quick jab to the left and Fanning needs a surgeon!

Talk about belly aching! Call Surgeon Sasseynach….. STAT!

Claire to the rescue! She speedily diagnoses an inguinal hernia – confirming her earlier suspicions:

“The intestines have moved and the blood flow may be cut off!” 

Fanning is quickly laid on a table as Claire marshals helpers, knife, needle, thread, linens and rum. Lots of linens and lots and lots of rum!

That is quite the lump, Edmund! A left inguinal hernia but a bit too high on the abdominal wall!

She drapes and swabs the surgical field, sterilizes a knife in alcohol and flame, threads a needle, grinds the wheat and bakes the bread! <G> 

Claire begins surgery with the knife positioned near the hernia, poised to cut above the bulge and parallel to it. Good choice, Claire!

Then, inexplicably, she switches direction and cuts across the hernial bulge!!! Bad choice, Claire! 😱

She cuts very deep and there’s a lot of blood!

Then, with considerable effort, she shoves the hernia (see below) towards the midline of the body (linea alba). Pushing bowel the wrong direction, Claire!!! 😱

She skillfully sutures the wound with very what appears to be carpet thread. Not surprising, as it was likely salvaged from the costume department.

And, unlike the actors of that dreary, lugubrious play, Claire receives a standing ovation for a job well done!

Now for the science. Yay!

Hernia Defined:  Simply put, a hernia is a protrusion or bulge caused by an organ or tissue pushing through the wall enclosing it (Image A).

Image A

Types of Herniae: Hernae (pl) occur in different body areas, but the most common site is the abdominal wall (Image B). These include: 

  • epigastric (between tip of breastbone and navel)
  • inguinal (groin area)
  • femoral (upper thigh)
  • umbilical (navel)
  • incisional (surgical scar)

Image B

Understand that groin herniae are the most common type of abdominal herniae; these include both inguinal and femoral types. As Claire diagnosed an inguinal hernia, the lesson will cover only this type. 

Inguinal Region: Inguinal herniae occur in the inguinal region. But wait! Where, exactly, is the inguinal region? Our fav anatomical model volunteers to demo! Yay, Jamie! Here, from the sky-blue waters of the freezing mill pond (Starz ep 112, Lallybroch), Jamie kindly lends a sneak-peak!

Specifically, the inguinal region is the area between anterior superior iliac spine (ASIS) and the pubic tubercle (red arrows). Can you see it? Of course, you can. Focus, students!

Both ASIS and pubic tubercle are easily palpable landmarks of pelvic bones, especially in the lean and physically fit.

The very strong inguinal ligament spans these two bony points. The ligament is overlaid by a skin crease, the inguinal groove,  the site where torso meets thigh. Also, female inguinal grooves are more horizontal; male inguinal grooves are more vertical. This is because female hips are wider and the paired ASIS are further apart.

(Psst…..please forgive the blue mask overlying Jamie’s upper torso.  This is to discourage bots from tagging this image as sexually explicit and landing OA in FB jail!!!)

Try This: Lay on your back and feel the prominent point of one hip bone (ilium), this is the ASIS. Now, move finger to pubic bone and feel a bump at the upper-outer margin, this is the pubic tubercle.  The inguinal ligament spans these bony landmarks. 

Inguinal Hernia: The inguinal hernia is a bulge in the abdominal wall above the inguinal groove. There are direct and indirect inguinal herniae. Both types are strictly defined based on their relationship to an abdominal artery and vein (inferior epigastric vessels, IEV)

  • Indirect inguinal hernia produces a bulge above the inguinal ligament that is lateral to the IEV.
  • Direct inguinal hernia produces a bulge above the inguinal ligament that is medial to the IEV.

Why is it important to diagnose the type? Because this may help determine how the hernia will be treated.

Image C shows right-sided indirect inguinal herniae of a male (L panel) and a female (R panel); both herniae lie above the inguinal groove and developed lateral to the IEV. This image also shows how the female inguinal groove is more horizontal than the male.

Inguinal Herniae Statistics:

  • can develop at any age
  • direct inguinal hernia 10x more common in men than in women
  • indirect inguinal hernia 25x more common in men than in women
  • more common in men above age 40
  • more common on R than L side
  • more common in people with a family history

Image C

Symptoms: Symptoms of an inguinal hernia include (Image D): 

  • bulge of inguinal region which may extend into scrotum or labia
  • pain/discomfort with coughing, exercise or defecation
  • pain increases during the day and lessens when lying down
  • bearing down enlarges the bulge
  • heartburn, chest pain, pain with eating 
  • redness or other discoloration of the bulge

Importantly, some inguinal herniae may be asymptomatic! Regular physical exam and complete history should consider this possibility.

Image D

Descent of Testes: There are two very important reason why inguinal herniae are more common in males than in females:

  • Males tend to do more manual labor requiring heaving lifting thereby straining the abdominal wall. Usually accounts for direct herniae.
  • Testes descend through the inguinal area during intrauterine life. Usually accounts for indirect herniae. Wait! What???

Yes. Ovaries and testes develop in the abdominal cavity.  Over time, ovaries descend as far as the pelvis but testes continue to descend into the scrotum, a process that typically completes about week 28 of pregnancy.   

Testicular descent is complicated but Image E offers a simplified visual. Descent through the inguinal region involves passing through layers of abdominal muscle and connective tissue (fascia), layers which follow the testes all the way into the scrotum. In addition, a finger of peritoneum, the membranous lining of the abdominal cavity, is dragged along with the descent. This finger of peritoneum is the processus vaginalis.

The channel created by passage through the abdominal wall is dubbed the inguinal canal.  Now, this is not a canal in the usual sense, but rather a slit-like passageway. The canal also has internal (deep) and external (superficial) inguinal rings, but these are difficult to explain and not particularly useful in today’s lesson.

If all works as nature intends, each processus vaginalis closes after descent is complete. However, these may fail to close or reopen later in life, leading to an indirect inguinal hernia.

Females also develop an inguinal canal and processes vaginalis but these are smaller and usually close off more readily because no testicular descent is involved.

Image E

Indirect Inguinal Hernia: For your viewing pleasure, this simple cartoon illustrates testicular descent. As you view the video, notice the cream-colored “finger” that accompanies the testis into the scrotum. This finger is an extension of the peritoneum, the membrane that shrink-wraps all surfaces of the abdominal cavity and its organs.

Image E correctly labels this finger-like extension of peritoneum (tan in Image E) as the processus vaginalis. To reiterate, normally, after testicular descent, the processes vaginalis closes off.

If the processus vaginalis does not close off, or reopens later in life, then fluid, fat or loops of bowel may slither and slide down into the patent processus vaginalis forming a hernia. Not good!

Image F demos such unruly outcomes:

  • Left panel shows a testis in normal position in the scrotum – no remnant of the processus vaginalis is present (patient facing to your R)
  • Right panel shows a partially open processus vaginalis containing a loop of inflamed bowel.
  • Middle panel shows a more extreme situation where the processus vaginalis is open all the way and bowel has slipped down into the scrotum.

If bowel becomes trapped in the processus vaginalis, its blood supply may be diminished, a condition known as incarceration or strangulation. This is a medical emergency because if the bowel dies due to insufficient blood supply, its wall breaks down allowing bacteria to seed sterile body spaces. Untreated, this leads to septicemia and death, especially in the 18th century! So, Claire is correct about surgery being necessary to save Fanning’s life. 

A direct hernia works much the same way except the cause is a weaken lower abdominal wall usually from age, pregnancy, heavy lifting, etc. Here, a sac of peritoneum balloons out through the lower abdominal wall wherein bowel may become strangulated with similar fearsome outcomes. Here, intestine cannot enter the scrotum or labia because no processus vaginalis is involved.

Image F

Claire’s Repair: Today, various techniques are used to repair inguinal hernias. Mr. Fanning’s hernia required pushing the bowel back into place followed by suturing the muscle and fascia layers and then the skin. No mesh in those days!

Fanning’s special FX were pretty good. However, I must make the following observations:

  1. Fanning’s hernia lies too high on the abdominal wall for an inguinal hernia. It should be nearer the inguinal groove or pubic bone. Perhaps the site was chosen to avoid TMI?
  2. No surgeon worth their salt would dare cut across a hernial bulge for risk of cutting into the bowel itself! Claire’s initial knife position was correct, why she switched position was puzzling. Perhaps, to make FX more buzz-worthy?
  3. Too much blood oozed from the skin cut which is also too deep – inguinal skin doesn’t bleed that much and is thin. Again, this may have been designed to produce a collective viewer’s gasp.
  4. The FX that really caused me to cringe is the force Claire employs to push the bowel toward the body midline!  Nope. That direction, the bowel has no place to go. No wonder Fanning screams!  If his is an indirect inguinal hernia, Claire should push the bowel toward his upper left (toward ASIS) following the inguinal groove. If his is a direct inguinal hernia, Claire should push the bowel directly downward so it re-enters the abdominal cavity.
  5. That is one honking thread Claire uses to close the wound! It will likely cause a foreign body reaction accompanied by chronic discomfort but infinitely preferable to dying from an incarcerated bowel!
  6. As Edmund’s bowel was incarcerated, the overlying skin should have appeared inflamed. It didn’t.

Quotes from Outlander books always enrich any anatomy lesson and this is no exception. The inguinal hernia makes its debut In Drums of Autumn book, wherein Claire repairs one on mountain man, John Quincy Myers – atop Auntie Jo’s dining room table – in front of dinner guests!  Based on the description, Myers has an indirect inguinal hernia (see Image F, middle panel).

I checked that my supplies and suture needles were ready, took a deep breath, and nodded to my troops. 

“Let’s go.”

Myers’s penis, embarrassed by the attention, had already retreated, peeping shyly out of the bushes…Ulysses himself delicately cupping the baggy scrotum away, the hernia was clearly revealed, a smooth swelling the size of a hen’s egg, its curve a deep purple where it pressed against the taut inguinal skin.

I swabbed the perineum thoroughly with pure alcohol, dipped my scalpel in the liquid, passed the blade back and forth through the flame of a candle by way of final sterilization, and made a swift cut.

Not large, not deep. Just enough to open the skin, and see the loop of gleaming pinkish-gray intestine bulging down through the tear in the muscle layer. Blood welled, a thin, dark line, then dribbled down staining the blanket.

I extended the incision, swished my fingers thoroughly in the disinfecting bowl, then put two fingers on the loop and pushed it gently upward.

…I could feel the movement of his intestines as he breathed, the dark wet warmth of his body surrounding my gloveless fingers in that strange one-sided intimacy that is the surgeon’s realm. I closed my eyes and let all sense of urgency, all consciousness of the watching crowd drop away.

…Time stopped. I was acutely aware of each movement, each breath, the tug and pull of the catgut sutures as I tightened the inguinal ring, but my hands did not belong to me.

…Then it was done, and time began again.

“Done,” I said, and the hum from the spectators erupted into loud applause. Still feeling intoxicated—had I caught drunkenness by osmosis from Myers?—I turned on one heel and sank into an extravagant low curtsy, facing the dinner guests.

My favorite part of Fanning’s surgery comes when the 18th century physician bustles in declaring “What hath hell wrought?” Yeah, women didn’t do surgery or openly practice medicine in those days.

Then, he accused Claire of butchering the poor man, finishing with: “All he needed was some smoke up the rear.”  Bwahahaha! Priceless! 

This entertaining 10 minute video by Dr. Carlo Oller does a terrific job of summarizing much of today’s lesson as well as providing additional tips about hernia prevention and care. Hope you watch!

OK, anatomy students. That is it for today’s lesson.  Anatomy of the inguinal region and its associate pathology are complex, but it behooves us all to stay vigilant for signs and symptoms of a hernia.

Let’s close with this simple thought: as inguinal hernias occur more frequently in males than females, shouldn’t these be called, himnias? Wink. Wink.

A deeply grateful,

Outlander Anatomist

Photo Credits: Starz ep 112, Lallybroch, ep 408, Wilmington.

Image A www.study.com, Image B www.newsnetwork.mayoclinic.org, Image C www.laparoscopythane.com, Image D www.verywellhealth, Image E www.teachmeanatomy.info; Image F www.bodyadvances.com