Tag: A Breath of Snow and Ashes

Posted on

Anatomy Lesson: Mandy’s Malady

Welcome all anatomy students! It has been a while since I posted a lesson because, frankly, I have been dealing with my own malady – a shattered left ankle! Six months out and beginning to feel and function better. 🥳

Outlander fans recall that in episode Episode 702, “The Happiest Place on Earth,” Brianna gives birth to her second child, Amanda Hope Claire MacKenzie-Fraser. Dr. Claire is there to reassure Brianna and ease the process. The wee one is adored by all and affectionately nicknamed, Mandy.  Fraser’s Ridge is the happiest place on earth and all is well! 🥰

Young Mandy is quickly introduced to the Ridge’s denizens as Granda’ Jamie takes her on a wee stroll to meet a new foal at the stable. Do you see it, Mandy? It is a cutie-beauty like you! 😍 

Mandy’s doting Granny takes her on a guided tour of Claire’s fav room – the surgery! Mayhap she will follow in Granny’s footsteps? 👩🏻‍⚕️

Claire coos to Mandy, admiring the beautiful, wee lass. Then…. she sees Mandy’s fingernails. A closer look and a startled Claire exclaims: “Bloody hell!”  (Couldn’t have said it better myself)  

Ever observant Claire spies a bluish tinge at the base of Mandy’s wee fingernails (below, red arrows)!

Fun Fact: This is not hyperbole.  Fingernails and toenails give clues to at least a dozen possible medical conditions that require evaluation and followup. And, Mandy is no exception.

A quote from Diana’s 6th big book, “A Breath of Snow and Ashes,” documents the moment Claire observes Mandy’s nail beds: ”

“The minute nails were faintly tinged with blue.” 

Bree senses Claire’s concern and asks what is wrong.  She kens that look on her mother’s face. After Claire explains, Bree reports her own maternal observations: Mandy does not nurse well nor is she gaining weight like Jem. What is wrong? 😯

Claire determines that the wee lass has a heart defect requiring more advanced care than Claire is able to provide in the 1700s. She is clear that Mandy’s Malady is life-threatening and she likely will not survive for long without corrective cardiac surgery. Brianna and Roger decide to return with their children to the 20th century to obtain the necessary care to save Mandy’s life.

Arrangements are made for the MacKenzie family to travel through time at the standing stones on Ocracoke Island. Everyone agrees this is the best course of action, but this time and place is no longer the “happiest place on earth!” Will they ever see Fraser’s Ridge and one another again? 🤷🏻‍♀️

Time to start our lesson….What leads Claire to her startling diagnosis? The following are symptoms and clues that Doctor Claire considered:

    • Lethargy and weakness
    • Fast or labored breathing
    • Tachycardia (a heart rate exceeding the normal resting rate)
    • Cyanosis (blue-ish skin color due to a lack of oxygen), primarily seen in lower extremities
    • Dyspnea (shortness of breath)
    • Poor feeding
    • Failure to thrive
    • Distinctive murmur

Another pithy quote from “A Breath of Snow and Ashes:” 

I moved my stethoscope over the tiny chest, ear pressed to it, listening intently. It was my best stethoscope, a model from the nineteenth century called a Pinard—a bell with a flattened disc at one end, to which I pressed my ear. I had one carved of wood; this one was made of pewter; Brianna had sand-cast it for me.

The following image is a wooden Pinard stethoscope, currently for sale on the Internet for about $180 (there are much less expensive versions)! 💰

Claire placed her ear against the cup shaped disc at the top; the bottom of the tube was placed on Mandy’s chest. The stethoscope amplifies the sounds of blood rushing through the heart and striking its valves.  

What did Claire listen for? she was listening for a distinctive murmur: a soft, continuous shushing sound, particularly audible near the base of the neck. It is usually the first diagnostic sign of a problem with a fetal heart vessel.  

Although Mandy exhibits only some of the above symptoms, Claire diagnoses Mandy’s condition as a Patent Ductus Arteriosus (PDA).  

But, before we can understand PDA, let’s look at normal heart anatomy.

Heart Anatomy: To better understand Mandy’s Malady, let’s consider the normal anatomy of the heart and its great vessels. Now, I kid you not, the heart is a very complex organ, both anatomically (structure) and physiologically (function). We will only cover the basics. Understand that there are many more anatomical details that are beyond the scope of this lesson. But, we fearless folk press onward!

Chambers: The human heart has four chambers (next image). Right atrium and left atrium are thin-walled filling chambers. Right ventricle and left ventricle are thick-walled pumping chambers . The walls are composed of cardiac muscle, a specialized tissue found in the heart. (psst….don’t forget, the patient’s left is your right, and vice versa) 🤓 

Vessels: The heart has eight (!!!) vessels carrying blood to and from its chambers. These are (next image):

    • Superior vena cava – delivers blood from upper body into right atrium
    • Inferior vena cava – delivers blood from lower body into right atrium
    • Pulmonary artery – deliver blood from right ventricle to lungs
    • Four pulmonary veins – deliver blood from lungs to left atrium
    • Aorta – delivers blood from left ventricle to body 

Blood Flow: Next, let’s review the pattern of blood flow through the heart. As you read the details, check with the image below to verify the flow.

    • Deoxygenated blood (low oxygen – O2; high carbon dioxide -CO2) from  superior vena cava and inferior vena cava pours into right atrium and then into right ventricle.
    • Right ventricle contracts and ejects blood into the pulmonary artery which branches to supply left and right lungs. 
    • Blood releases carbon dioxide (CO2) in the lungs which is exhaled and picks up O2 from inhaled air.
    • Oxygenated blood (O2-rich) is carried to left atrium via four pulmonary veins. 
    • Blood pours into the left ventricle which contracts and ejects O2-rich blood into the aorta.
    • Branches of aorta carry blood to all other regions of the body (except lungs).  

OK, students, hang in there! With normal anatomy under our belt, let’s look at the fetal circulation. 

Fetal Circulation: Blood circulation in the fetus is different because the placenta provides the functions of lungs, gastrointestinal tract, and kidneys. Thus, a normal blood supply to these maturing organs is not required.

Ductus Arteriosus: The fetal heart has a vascular bridge between pulmonary artery and aorta that shunts blood exiting the right ventricle into the aorta and bypasses the lungs. This vascular bridge is the muscular ductus arteriosus (aqua arrow – below image). Again, because lungs do not process gasses during intrauterine life, most blood is shunted away from them. 

The ductus arteriorsus is patent (open) throughout fetal life and normally closes within 24 hours after birth as blood flow to the lungs is established. Within 2-3 weeks, it turns into a fibrous band, the ligamentum arteriosum. 

All of this is highly regulated by various chemical and physiological substances including oxygen levels. 

Patent Ductus Arteriosus: If the ductus arteriosus does not close soon after birth but remains patent (open), it is diagnosed as PDA, a congenital heart lesion. PDAs are most common in premature babies but can also occur with full term infants. 

Nowdays, if a ductus arteriosus does not spontaneously close after 8 weeks post-birth, it usually is treated with medications, plugged, or surgically closed. Small PDAs may not be a cause for concern and are often not treated.

Adding a bit of perspective – PDA is not new. It was known as early as 129 A.D. to Galen, a Greek anatomist and physician, although he didn’t understand its significance. It wasn’t until 1938, almost two millennia later, that Dr. Robert E. Gross of Harvard Medical School and Children’s Hospital in Boston, Massachusetts, perform the first successful ligation (closure) of a PDA. This was also the first congenital heart lesion to be successful corrected, surgically.

Now, let’s return to Mandy’s Malady. This was her problem. Mandy’s ductus arteriosus did not close after birth and she exhibited some of the concerning symptoms outlined above.  Blood from her aorta flooded her lungs subjecting fragile lung tissues to excessive blood pressure (hypertension). Allowed to go unchecked, the fragile lungs will be permanently damaged and she  eventually will experience right-sided heart failure.

Diana explains all of this with her usual magical writing skills in this excerpt from “A Breath of Snow and Ashes:” 

The ductus arteriosus is a small blood vessel that in the fetus joins the aorta to the pulmonary artery. Babies have lungs, of course, but prior to birth don’t use them; all their oxygen comes from the placenta, via the umbilical cord. Ergo, no need for blood to be circulated to the lungs, save to nourish the developing tissue—and so the ductus arteriosus bypasses the pulmonary circulation. 

At birth, though, the baby takes its first breath, and oxygen sensors in this small vessel cause it to contract—and close permanently. With the ductus arteriosus closed, blood heads out from the heart to the lungs, picks up oxygen, and comes back to be pumped out to the rest of the body. A neat and elegant system—save that it doesn’t always work properly.

The ductus arteriosus doesn’t always close. If it doesn’t, blood still does go to the lungs, of course—but the bypass is still there. Too much blood goes to the lungs, in some cases, and floods them. The lungs swell, become congested, and with diverted blood flow to the body, there are problems with oxygenation—which can become acute.

Lastly, this is a brief video about PDA which you might find useful. It is easy to understand and accurate: https://youtu.be/7DKaCqubuSg. 🤓

Fast forward! It is clear that the MacKenzies arrived safely in the 20th Century and Mandy received the medical intervention needed for her PDA repair. When we meet her next at Lallybroch, she is a healthy, happy, and feisty wee lass, played by Rosa Morris. 🤗

As William Shakespeare once wrote, “All’s Well That Ends Well!”

(Well, it would end better if they were all together, but we shall see) 🤞🏻

The deeply grateful,

Outlander Anatomist

Follow me on:

Photo creds: Sony/Starz; www.commons.wikimedia.org; www.heart.org; www.kidshealth.com; www.medicalsuppliesgh.com; www.medlineplus.gov; www.outlander.fandom.com; www.theoutlandermuse.com; www.twitter.com (now X)

Posted on

Mini Anatomy Lesson – William’s Wound!

Hello, anatomy students!

Good to see you again so soon. 😉

Today’s lesson explores the horrific circumstances leading to an intended amputation of William’s forearm.

Just so you know what to expect, this lesson does contain a number of rather gruesome images!

William’s wound appears in Outlander episode 704,  “A Most Uncomfortable Woman.”

A short recap: William hastily rides through the Great Dismal Swamp. His steed, Jupiter, is startled by a snake, which looks very much like a copperhead to me!

Jupiter unseats William who tumbles down a steep hillside hitting a fallen tree snag during his rapid descent.

As William comes to rest, he assesses the damage to his arm. Oh, dear,! A branch broke off the snag and buried itself into his right forearm. Ouch! 😱

Being of Fraser blood, he grits his teeth and pulls it out! 😬 Then, using his stock as a bandage, he wraps the wound under pressure and moves forward with his mission. This time, on foot, as Jupiter has hightailed it leaving William alone and without supplies or the notes from Captain Richardson! 😳 

Later,  he hears a sound. Looking up, he spies an “Indian” who speaks a Scot’s version of the King’s English. 😜  Wolf’s Brother (Ian Murray Jr.) in the flesh!

A very nice chit-chat ensues as they exchange bona fides.  Then Ian spies Williams’s wound. Um….best get that taken care of. Because, by now that oozing wound looks pretty yucky! 🤢

Ian sets about building a wee fire and boils a pot of water. Then he crouches beside William, pulls his knife from its sheath, and begins to free the wound of several splinters. Ouch! 😮

The blood clots are well done. 👍🏻

Then he pours boiling/hot water over the wound to try to cleanse and perhaps sterilize it? Oh, boy, that hurts! 🤯

Ian hustles William to the cabin of one Dr. Denzel Hunter and  his sister, Rachael. They help William onto a table and Denzel takes a quick keek. Oh, dear, that looks bad. Rachael, fetch me the saw!

After some protestations from Ian and William (it is his forearm, after all!), Dr. Hunter begins to saw. Suddenly, pus oozes from the wound and Denzel declares that the bile has been freed and there will be no need for a hack job today! 🪚

Much later, Williams shares his travail with fellow soldiers. Here, from “A Breath of Snow and Ashes:”

“Wandered round the Great Dismal Swamp for three days in a fever,” he said. “Some … Indians found me and got me to a doctor. I nearly died, and”–he lowered his brows and gave Zeb a piercing look–“the doctor was just about to cut off my arm, when the abscess burst and he cauterized it. You might not be so lucky, hey?”

Sometime later, Rachel tells William his scar has healed well. It looks like the star that guided the wisemen to the Christ child and it suits him. In the book, his scar looks like a comet.

A quote from “A Breath of Snow and Ashes:”

‘The wound was still red and puckered, the skin around it unpleasantly white and moist. It was, however, undoubtedly healing; the arm was no longer swollen, and the ominous red streaks had disappeared. “Well,” she said consideringly, “it’s a fine scar, I think. Well knit, and rather pretty.” 


Anatomy and Pathology: Now that the recap is over, let’s discuss the pathology of William’s wound. You may recall, that pathology, which literally translates to “knowledge of sorrow,” is abnormal anatomy, so we are not far off the mark. 🤓

I propose we review one issue at a time, so here we go!

The Accident:  I have been asked if I think the accident was plausible. My short answer is, yes. My reasoning is that William is a large man, rolling downhill, rapidly. All that weight with an extended arm and yes, it is possible. 🤔

Believe it or not, this issue is covered by Newton’s (next image) second law of motion which states that F = ma, in which net force is equal to mass times acceleration due to gravity.

Stated more plainly, the force with which William’s extended arm struck the wooded spike equals William’s mass times acceleration rolling downhill.

I asked my physicist son, Diedrich, to help with variables such as hypothetical mass, rate of descent, incline, size of branch, etc. He did the calculations and William  struck the branch with roughly 163 ft-lbs of force!  Consider that this force was expended onto a stick no more than 1” in diameter. Well, suffice it to say, that force is more than sufficient to snap the branch, break the skin, pierce the muscle, and even fracture one or both forearm bones (radius and ulna)! 😱

Make sense? Gooood! 🤗

Penetrating Wound: Poor William suffers what pathologists categorized as a penetrating wound. This occurs when a sharp object pierces the skin and creates a single opening into either tissues or a body cavity.  Clearly, there is one wound and the tissues in this instance are the meaty flexor muscles of his forearm. 💪🏻

Our flexor forearm (the palm side) houses eight muscles (15% of us have only seven). The spike would have driven deep into probably 2-3 of these muscles. This means any bacteria or other pathogens on the swampy branch would have sunk deeply into the tissues. This is why the wound became infected.

Inflammation: Ian unwraps William’s arm and spies a swollen,red, painful wound that will feel hot to the touch. These are four of the cardinal signs of acute inflammation, the body’s common response to injury and  infection.

Inflammation is heralded by five cardinal signs, four were described 2,000 years ago by Celsius. These are:

  • rubor (redness)
  • calor (heat)
  • tumor (swelling)
  • dolor (pain)

and….

  • functio laesa (loss of function) the fifth cardinal sign was added 200 years later by Galen, surgeon to Roman emperor, Marcus Aurelius.

    Does William’s Wound show all five cardinal signs of acute inflammation? Well, yes, yes it does! It is painful, swollen, red, hot, and he has lost normal use of the forearm. 

A current day example: The image below shows acute inflammation of the great toe (hallux) due to an ingrown toenail. The toe is red, swollen, warm, sore, and difficult to use.

Cleaning the Wound: I have to say, Ian was caring and compassionate to clean the splinters from William’s Arm.

But, I must protest! Ian has seen Auntie Claire take care of enough trauma to know that he should either cauterize that knife tip in the fire, or plunge it into the boiling water for a bit. Inserting the tip of a  dirty blade will introduce more pathogens into the already infected wound! 

And, pouring boiling/hot water into the wound? That  isn’t much help, either and was traumatic for William. Much better to let the water cool a bit and then cleanse the wound with the “sterilized “ liquid.

The amputation: When I saw this, I thought. Um……No! Denzel grabs his amputation saw and starts sawing away on William’s arm!  Now, this enactment exactly follows what is recorded  in “A Breath of Snow and Ashes:”

He had—he was told sometime after the fact—narrowly escaped loss of the arm: Dr. Hunter had grasped it and placed his amputation saw just above the wound, only to have the abscess that had formed below it burst in his hand. Seeing this, the doctor had hastily drained the wound, packed it with garlic and comfrey, and prayed—to good effect.

It was very dramatic, but you should know that a doctor with training like Denzel’s would not start sawing on skin. The saw teeth will rip and tear skin and muscle causing even more pain and morbidity for the patient. Instead, a practitioner used an amputation knife to slice the flesh around the bone and then saw through the bone. Below is an example of a typical amputation knife and an amputation saw of the time. 🔪🪚

As horrifying as this sounds, a capable practitioner could remove a limb very swiftly this way, reducing the trauma to the sufferer.

Finally, as Denzel puts pressure on the limb, pus bursts from the deep lying abscess. After removing the pus, the wound was carefully cleaned and wrapped..

Pus is a  thick yellowish or greenish opaque liquid produced in tissues infected with pyogenic bacteria such as Streptococcus or Staphylococcus (Not all infections elicit pus formation). Pus is formed of dead white blood cells, bacteria, tissue debris, and serum.

The term pus derives from the Latin and it has been used since the 14th C. Again, since Denzel is a well-trained physician, he would have likely used the term pus rather than bile.

Finally let’s consider William’s scar. Here, he recounts his travail to fellow soldiers…..from “A Breath of Snow and Ashes:”

Look,” he said, displaying the long, comet-shaped scar on his forearm. “That’s what happens when you get an abscess.”

Both Zeb and the doctor peered at the scar, impressed. It had been a splinter wound, he told them, caused by a lightning-struck tree.

Big, kudos to the FX folks. I thought the slightly reddened, puckered, and contracted scar was believable. Well done!

I hope you enjoyed this review of William’s Wound.

Until we meet again, fare thee well! 

The deeply grateful,

Outlander Anatomist

Follow me on:

Photo creds: Sony/Starz, www.myclevelandclinic.org, www.en.Wikipedia.org, www.teachmeanatomy.info, www.teachmesurgery.com

Posted on

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 

Follow me on:

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