sing. noun: phalange [fuh-lan-jee]; pl. noun: phalanges [fuh-lan-jeez].
From the Greek, phálanx, meaning military formation; later used for the bones of fingers and toes
Anatomy def: 14 bones in the digits of each hand or in the toes of each foot; 56 phalange bones in total. Each thumb and great toe bears two phalanges and remaining digits each contain three phalanges.
Outlander def: Smashed but healing finger bones of Jamie’s puir left hand (right hand in Diana’s books). Claire’s own loving hands diligently labor to mended them!
Jamie glanced dispassionately at his right hand. It really wasn’t too bad; a couple of fingers set slightly askew, a thick scar down the length of the middle finger. The only major damage had been to the fourth finger, which stuck out stiffly, its second joint so badly crushed that the healing had fused two finger bones together. The hand had been broken in Wentworth Prison, less than four months ago, by Jack Randall.
See Murtagh Fitzgibbons Fraser tighten the laces of Jamie’s amazing hand brace, in Starz episode 202, Not in Scotland Anymore. Designed to stabilize his healing phalanges, Clever Cunning Claire likely devised this awesome medical appliance!
My apologies this post took so many days to go live. Today, April 18th, is tax day in the states; otherwise, the taxman cometh, so I had to set aside my blog for the IRS!
This year, my Tartan Affair week began under the sunny blue skies of LA where I attended the Writer’s Guild Theater’s, “A Tribute to Outlander” on March 31. Many fans stood in line for hours in order to secure good seats. Gah, concrete is rough on the metatarsals!
The WGT panel included (from L to R – next two images): Tobias, Sam, Caitriona, Matt Roberts, Toni Graphia, Anne Kenny, Maril Davis, Ron D. Moore, and the panel moderator, Anne Thompson. Sadly, we wished Ira Steven Behr could have been there.
What followed was a riveting hour of fascinating exchanges, mostly between the writers/producers. We learned many things about them including that writers often advocate for their fav character (e.g. Matt for Geillis).
The writer’s war room boasts a variety of whiskies, presumably as calming anodynes. The group starts with one of Diana’s books broken into segments that are posted on a story board. Together they re-build a story segment that is compatible with the visual medium. Surprise! They often disagree!
We learned that Dragonfly in Amber for S.2 was more challenging to adapt than Outlander for S.1. Cait expressed delighted that the series gives the actors a wonderful range of acting opportunities to enjoy. Sam commented that it is almost as if he learns a new skill for each episode, and Ron noted that because the story goes in so many different directions, there is no cliché term to describe Outlander!
We heard a very charming Tobias tale about when he was bit by the acting bug…as a young lad, he attended a theatrical production of Wind in the Willows. Intermission found him in the bathroom where Badger was standing at a urinal (loved the way Tobias pronounced this word, ur-y-nal). This was a lightbulb-moment as he realized that Badger was a human actor and this set him on his path to stardom!
We learned that a production featuring magic by Merlin was the impetus for Sam to pursue an acting career and Cait was influenced by a school play in which she donned her Father’s coat and a pillow as a costume.
This event did not include a meet and greet for the admiring fans, but we did enjoy hearing from the writers about how the whole production thing works. Last but not least, we learned that Anne thinks Jamie is a bit of a caveman! what? No way, Anne! <G>
Headed back to the Pacific Northwest for one day and then off to NY Tartan Week! Let’s dissect Tartan Week, one day at a time!
Day 1 (Sunday, April 3)
Arrived in NYC. Met my roommate, and then dinner with pals at St. Andrew’s pub on W. 46th Street where I tentatively had my first haggis hookup! I felt a little Laoghaire…ooops, I mean leery, but it was surprisingly tasty! I kid you not!
Photo by JoKc
Day 2 (Monday, April 4)
Evening and we headed to the LeFrak IMAX Theater at the American Museum of Natural History for the Outlander S.2 Premier! We were pummeled by a cold rain but were quickly ushered inside. Fans without tickets waited patiently in the elements but were eventually admitted. So happy for them!
Inside the theater, Starz interviewed many fans. Turns out the interviewer reads Outlander Anatomy blog, bless her heart and its ventricles…but I did not catch her name. ?
Photo by JoKc
The evening portended well because I found myself seated next to the Outlander Herbalist! Then, we were quickly greeted with the “guess whose coming to dinner” image on the big screen!
Entertainment followed with a beautiful rendition of The Skye Boat Song, Season 2 version, performed by Bear McCreary on accordion, wife Raya Yarbrough on vocals, a bodhran and violin (sorry, don’t know the names of the last two artists).
The Premiere began with Claire on Craigh na dun (no photography allowed). By now, you all have seen ep 201 and like me, probably found yourself weeping in tune with Claire. She sure does emote a weepy, wobbly chin worthy of her grief! The first half of the episode contains some darned intense material and I couldn’t help drawing parallels between Frank and BJR. Utter silence from the audience such that you could have heard a pin drop until Jamie appeared grasping Claire’s fingers and then the entire theater erupted in shouts of joy and wild applause! Everyone I spoke with loved the adaptation of the episode…including me!
Day 3 (Tuesday, April 5)
As soon as stores opened, I promptly went for a shop in the garment district – beads and ribbons required. When what to my wondering eyes should appear but Outlander bus speeding down 7th Avenue! I ran but no one batted an eye as a grey-haired gal in snappy, red boots gave chase – it is NYC after all!
Then, three blocks later, Eureka! There it was, Outlander bus, taking a brunch break at curbside! Much more effective than a sandwich board!
That evening we braved the cold for a few more hours outside NYU Skirball Center for the Performing Arts awaiting the Outlander“From Scotland to Paris” event presented by the Television Academy (folks that bring us the Emmys!). After all invitees were seated, the overflow fans were welcomed in and we found wonderful balcony seats.
We were blessed with an excellent panel discussion on teamwork, collaborations, production, costume design, set creation, and music development. Beautiful slides flashed on the screen as Tobias, Cait, Sam, Ron, Terry, Maril, Jon Gary Steele, (Production Design) and Bear added commentary. The lively discussion flowed so easily and naturally between the panelists that it felt as if we were watching a large, diverse and friendly family at work: Outlander family, that is. Thrilling! Here is a link to the panel discussion and well worth watching!
Photo by Television Academy
Outside the Skirball Center, Tobias, Caitriona and Sam patiently gave autographs and selfies to avid fans. I am not very tall, so I had to stretch to get my eyeballs in this photo!
Guess who?
Day 4 (Wednesday, April 6)
My first ever trip to see Lady Liberty; she had me at “hello”! Tears flowed over this one. I canna help but feel sad for her puir right arm… her deltoid muscle must be exhausted after years of holding up that weighty torch!
Afternoon found us headed to the elegant Apple Store, SoHo for this event:
After waiting for several hours to be admitted to the theater (yes, it has one), we gave a rousing fan welcome to Maril, Cait, Sam and Tobias. A few narrator questions and then the audience got its chance.
I was chosen and promptly forgot my question. Hee, hee, I wonder why!
Photo by Joanne
Photo by Rachel
My question to the stars was: had they ever been surprised by a scene that ended up on the editing room floor (apparently, they don’t see scenes until edited), and if yes, which one surprised them the most? Two great answers. Cait wished a S.1 scene had been retained wherein Frank talked about how WW II had shaped him. Maril added that a scene with Fergus has been omitted from S.2, but didn’t elaborate. Thinking caps on: which scene do you think she had in mind? The next video captures some of that Q&A.
Video by Joanne
Turning girlie for a just a moment, everyone loved Cait’s classy black pumps with the wavy straps (and those awesome pins)! Oh là là là là!
After a few more audience questions, the quartet closed with a group-selfie! Quick autographs and more photo ops outside and then they were whisked away in a sleek SUV!
Day 5 (Thursday, April 7)
Rain again! Headed for Saks Fifth Avenue in the early afternoon for Outlander Season 2 window unveiling and costume display! Four windows featuring Terry Dresbach’s costuming genius were up for all of Tartan Week. Every costume was splendid with inventive details, superb workmanship, and stunning design!
A fine example is Claire’s Dior-inspired Bar Suit! Pssst: the following videos have black-outs near the bottom of each costume as the image is briefly lost…..this is where window signs video-bomb the images. You can also hear street noise. So sorry about this, but I’m a novice. Hand me a scalpel and I’m in my element. <G>
Details of the beautiful, curved Bar Suit sleeve! The oyster-shell color is both sophisticated and spectacular! Terry just posted a wonderful article about her inspiration and process; I highly recommend reading: Dior!
Next, let’s follow a video of Claire’s yellow-gloved garden number!
The next image shows a close-up of the embroidered skirt. A few images down is a video of Terry talking about this amazing fabric!
Photo courtesy of JoKc
Next is a video of Jamie’s court duds from trapezius to toes! Verra manly indeed!
This is a closeup of Jamie’s embroidered waistcoat and buttons. Love the spectacular but subtle color scheme!
But, today, the fifth and final window was unveiled to reveal THE RED DRESS!
The red-dress bodice features a flattering under-the-bosom criss-cross, a feature that is cleverly echoed in sleeve details! Add the drop-waist piping and itsy-bitsy, teenie-weenie pleats and, voila, scarlet perfection! A thin band of wispy stuff follows the neckline….very tasteful, very feminine, very alluring!
Mayhap Claire’s gold-colored fan will provide a modicum of modesty to that plunging neckline… a perfect 10!
Claire’s beautiful pumps complete the incomparable ensemble. Featuring five stone encrusted buckles and four straps (skirt covers the top strap), the shoe design again echoes the below-bosom banding of this absolutely breath-taking gown. Canna wait to see Jamie’s face as he spies Claire laced up in this daring dress. OK, I saw his face in ep 202 and was so happy because it appropriately registered shock and awe!
I asked the charming Mark Briggs, Executive Vice President of Saks Fifth Avenue, if partnering with future Outlander costume events lay on the horizon. He answered that it is a distinct possibility as Saks is always seeking the “finest in fashion.” I think Saks got it in spades with Terry’s designs and this flawless window display! What say you?
Next, I asked Ron D. Moore if he would kindly comment on Outlander mars and scars. He offered an erudite explanation of how his team creates Jamie’s back scar prosthesis and other more complicated injuries. He also mentioned an injury from S.2 wherein Claire volunteers at L’Hôpital des Anges and is confronted with a patient who has a significant wound to treat! Yay, another OutlanderOwie!
Then Cait and Sam made their way down the line looking happy, charming, and drop-dead gorgeous (both of them)! Thud!
My last question was for Terry. I asked her how the anatomy of the human body informs her costume design, using a specific element of the Bar Suit as an example. She said anatomy most certainly does play a role; she even has a term for this relationship. I hope to explore this topic with Terry at a future date.
In case you haven’t heard, Team Terry made 10,000 garments for S.2! Yes, her team stitched them all because there isn’t a clothing rack of ready-made 18th century costumes available for purchase. They also created those fab 18th century shoes (check out the little puff balls on Claire’s shoes in the bar suit video above)! Like others, I am thinking there are many hard-earned and well-deserved awards in store for Terry!
Erin Conrad of Three If By Space asked Terry to comment on the wonderful fabric for the yellow-glove garden gown. Terry shared an entertaining story about going to the basement of her fav SanFran fabric store where she found the embroidered fabric for the gown (shown in the window). Listen to her delightful experience.
Day 6 (Friday, April 8)
More shopping in the amazing garment district. Found a store that carried only zippers; every size, shape, color, pull, teeth, material, and length one can imagine. Another specialized in ribbons, others in beads, another in leathers, another in threads. Whew, the eye candy was almost (almost) overwhelming!
Night time found me and friends hoofing it to the Beer Authority for beverages and a “street fair” which wasn’t on a street at all; it was actually held on the pub’s 3rd floor. Belhaven Brewery, famous for Scottish beers and ales, was a sponsor of this event as well as all of Tartan Week. Fans got a photo op with Davie Stewart, Sam’s driver!
Thank you Davie! He was a real sweetheart as, oh, several bazillion fans all wanted him to pose for selfies!
The evening was still young so friends and I hiked to Grand Central Station to await the S shuttle between GCS and Times Square: four subway cars decorated outside and in with Outlander themes. Wooie, here it comes!
We rode the shuttle back and forth a few times, glorying in the beautifully applied portraits and decorations. Even the doors were embellished!
Coach seats were decorated to look like tufted lounge seats.
Jamie’s proud and fierce portrait greeted us as we entered the first car…. Actually, it appeared in all four cars!
Elegant and serene, Claire’s portrait also appeared in all four cars!
Even Murtagh sends his dour regards. Hi Murty!
Also present were portraits of Louise de Rohan, Comte St. Germain, Mary, Charles Stewart, and King Louis. The conductor took a few moments to talk with us about the shuttle and even happily posed for our excited cameras. Outlander out-landered itself with this exhibit. Sooo impressive!
Bellies full, we removed ourselves into cold wind and freezing rain, where Charlie and Lauri Fraser assembled the Fraser banner! They were our fearless, gracious welcoming hosts who generously adopted us step-kids for the day!
We gathered outside the Algonquin Hotel while awaiting the start of the parade. We were all totally pumped despite the challenging weather. Although we numbered only a dozen or so, we were the largest group ever to march with Charlie and Lauri (in the middle) Fraser!
Photo by JoKc
The march was fantastic. Fans and well-wishers lined ten city blocks for the march up Avenue of the Americas. At the end, as we passed the Outlander Bus, Charlie instructed us to shout in unison: “Je suis prest!” That garnered us a wave and grin from Grand Marshall, Sam-the-Man!
After the parade, we stood trembling (from cold and excitement) behind the buses for another 45 minutes where we were burrrr-to-the-bone! Then, Sam made his way to a waiting SUV and we began to chant (totally hoarse) “Clan Fraser” – he turned and strode over to us! He graciously posed for photos and videos with us cray cray fans and generously doled out hugs and cheek kisses. (He really is a big lad, making a couple of us look like wee folk).
This experience recalls a quote from Outlander book:
Suddenly the inn door opened, and the sun came out, in the person of James. If I was a radiant bride, the groom was positively resplendent. My mouth fell open and stayed that way.
Haha, spot on, Claire!
Photo NY Post
We hit the after parade party at Papillon Bistro and Bar on E. 54th Street where it was standing room only! Here thirty or so vigorous Vikings from the Shetland Islands treated us to an impromptu and hearty serenade-on-the-stairs! These lads make their own armor on islands that lie closer to the North pole than any other part of the British Isles. See the wee Viking in-the-making (center front)? He wore his own armor and marched in the rain. Hearty genes!
From Papillion, to a quick deli sammy, and then to the DGA (Director’s Guild of America) Theater on W. 57th St. for another screening of episode 201. Much to my surprise, I was interviewed by Paul English for Scotland Now. He was very interested in how an academic subject such as human anatomy could mesh with the Outlander books and TV series (very easily, actually!). Paul is a very skilled interviewer so we enjoyed a lively discussion!
Photo by JoKc
The DGA screening was preceded by entertainment in the form of the 78th Fraser Highlanders Pipe Band from Ontario, Canada (see video below). We were also charmed by singer, Elias Alexander with his very bawdy guitar, and spectacular Highland dancing by Kayleigh Boardman, accompanied by piper, Andrew Forbes.
Day 8 (Sunday, April 10)
Tumbled into bed at midnight and then up for a 4:15 am shuttle to JFK. I was whipped (fortunately, BJR was nowhere to be seen)!
What a Tartan Week! I cannot express how impressed I was with the Outlander staff, producers, writers and stars during this week of marvelous magic. They managed interviews, clamoring fans, and numerous commitments with kindness, grace, and style! Thank you, Starz. Thank you Outlander productions! Thanks to a very generous NYC and it’s people. Thank you, Diana Gabaldon!
Here’s a parting memory of my fabulous 2016 Tartan Affair; don’t know how, but we made it into Sunday’s New York Post!
Photo by NY Post
A deeply grateful,
Outlander Anatomist
Note: If I have failed to give appropriate photo credits or identifications, please notify me and I will make the necessary corrections. Thanks to all!
Hello, anatomy students! Today’s Anatomy Lesson #37 covers the ginormous topic of mars and scars, better known as wound healing. A mess of wounds and scars appear in the Outlander books and the Starz series so let’s learn from this perfect anatomical smorgasbord.
Surprise! Jamie is our model because he has more mars and scars than anyone else of Outlander fame! Let’s also enjoy a drinking game because Jamie’s wounds inspire one to drink more than any others, I ken! Down a wee dram each time you read “Och! Jamie’s puir…”
Drams in hand? Let’s begin…
Blood: Because blood is essential for healing and scar formation, it requires a brief brief mini-lesson of its own. Blood is a connective tissue (yes, it is!) composed of fluid plasma, in which two classes of blood cells are suspended: red blood cells (RBCs or erythrocytes) and white blood cells (WBCs or leukocytes). Blood also contains cell fragments known as platelets (thrombocytes) along with many other suspended or dissolved substances.
RBCs arise in bone marrow as nucleated cells but lose their nuclei just before entering the blood stream. Image A shows a 3-D SEM (Scanning Electron micrograph, Anatomy Lesson #34) image of a blood vessel containing blood cells. Understand that the colors in Image A were computer generated. RBCs are flat, biconcave discs (red in Image A), whose shape and lack of a nucleus allots them maximum oxygen-carrying capacity; think of them as tiny flat bags filled with hemoglobin (Hgb). As RBCs pass through lung capillaries, oxygen binds to Hgb molecules, turning RBCs bright red. As RBCs reach capillaries of other body regions, Hgb molecules release their oxygen burden into the tissues and the RBCs turn a dark, deep red color. Such color changes are important in wound formation and healing.
WBCs are the round, gray fluffy balls in Image A. They arise in bone marrow but retain their nuclei. There are five classes and several subclasses of WBC. All WBCs serve various defensive functions; more about these later in the lesson.
Platelets, which do not appear in Image A, play a crucial role in blood clotting.
Image A
That was a “quickie” blood lesson. Now, on to healing processes!
The outline for today’s Lesson is:
Healing Closed Wounds
Trauma
Contusion Development
Contusion Resolution
Healing Open Wounds
Trauma
Hemostasis
Inflammation
Proliferation
Remodeling
Scars
Healing Closed Wounds: Closed wounds are injuries wherein the skin remans unbroken. The contusion will serve as today’s example of a closed wound, although simple bone fractures are another. Anatomy Lesson #35 explained that a contusion is the medical term for a bruise. Bruises form in subcutaneous tissues (Anatomy Lesson #5: “Claire’s Skin” – “Ivory, Opal and White Velvet.”) where they are often visible through the skin, but they can also form in deep organs such as muscle. Symptoms may include a bump, a hard knot and tenderness. And, bruises do not blanch under pressure. A number of steps occur to form and heal a bruise including:
trauma
contusion development
contusion resolution
Let’s look at each of these steps.
Trauma: Contusions are caused by blunt force trauma wherein the skin is not broken. Claire’s foot presents an formidable blunt force directed at Jamie’s face (Starz episode 109, The Reckoning)! Weil, now, she did warn him not to belt her. This lass is not going down without a stramash!
Contusion Development: Contusions pass through an impressive array of colors during development and healing. The first color is redness which occurs because blunt trauma bursts local capillaries allowing oxygen-ladened RBCs (bright red) to spill into nearby tissues. Although time has passed since Claire’s kick, the skin overlying Jamie’s right bony orbit (Anatomy Lesson #30: Aye, Eye – The Eyes Part 2!) shows the redness typical of a fresh contusion (Starz episode 110, By the Pricking of My Thumbs). Or, mayhap he is just blushing because the Duke of Sandringham has a certain fondness for his hindquarters? <G> Och! Jamie’s puir right eyelid! Have a wee dram.
Redness is followed by purple and blue discoloration as Hgb molecules inside the spilled RBCs release their oxygen; the RBCs turn dark red-purple as do the tissues they occupy. Next image is a good example of purple/blue discoloration (Starz episode 116, To Ransom a Man’s Soul). Och! Jamie’s puir left shoulder! (And, another dram). A quote from Outlander book reminds us of the vicious swipe that produced such discoloration!
The spot on his left side where the mallet had struck was an ugly contused swelling…I bit my lip, feeling gingerly down the swell of his biceps. He had one of the worst bruises I had ever seen; a huge mottled splotch of purple-blue—but I was fairly sure the arm wasn’t broken.
Next, a contusion exhibits the classic black and blue discoloration as spilled RBCs rupture and release their iron-containing Hgb into the soft tissues of the injured area. Och! Jamie’s puir left fingers; they argued with that damnable mallet and lost (Starz episode 116, To Ransom a Man’s soul)! Quick! Take another sip!
Contusion Resolution: Yay! It rhymes! Now, the contusion begins to heal assuming first, green and then, yellow hues. These color changes occur because cells known as macrophages (Greek makros meaning large + phagein meaning to eat) devour freed Hgb, Macrophages break the Hgb into the green compound, biliverdin, (Latin meaning green) which turns the tissues an icky green color. This is followed by yellow hues as the biliverdin is metabolized into the golden chemical, bilirubin. As macrophages clear the last of the debris from the bleed, the yellow fades and if the contusion isn’t too profound, normal coloration and function are restored.
Ergo, changes oin Hgb molecules form the basis for color changes of a healing contusion. A single bruise can simultaneously display all of the above colors because the amount of spilled blood varies in different areas and the stages of healing overlap. Here is a gut-wrenching example (Starz episode 106, The Garrison Commander)! Och! Jamie’s puir back! (Another swallow!) Gah! Skin near the lash marks is red, purple, blue, black, green, and yellow! Herself writes in Outlander book:
Dougal grimaced. “A pitiful sight, it was, too—still raw, no more than half-healed, wi’ the weals turned black and the rest yellow wi’ bruises. The thought of a whip comin’ down on that soreness was enough to make me blench, along wi’ most of those watching.”
Now that we understand the healing of a closed wound, let’s consider open wounds.
Open Wound Healing: Open wounds entail skin breaks; abrasions, lacerations, and incisions (Anatomy Lesson #35) are good examples of open wounds. Such injuries undergo a cascade of events during wound healing.
Trauma: First, open wound healing requires trauma; finding good examples of open wounds in Outlander is a no-brainer – as they are pretty much everywhere! This is a fine one: Starz episode 110, By the Pricking of My Thumbs, shows the type of trauma-drama awaiting highlanders that mess with Jamie! The MacDonald lads hurl nasty insults and then attack Jamie. Thalla gu h-Iort – “to St Kilda with ye!” bellows Jamie. With a quick dirk-jerk, Jamie gifts one lad with an incision of his right hamstring tendons! Young MacDonald came to harm, E-I-E-I-Oooooh; that stings!
Open wound healing: Following trauma, the body immediately springs into action and initiates the following four steps of open wound healing (Image B):
Hemostasis
Inflammation
Proliferation
Remodeling
Wake up, students! Let’s examine each of these four steps.
Image B
Hemostasis: A fancy word for blood clot, hemostatsis comes from the Latin for blood + Greek for stop. Hemostasis is typically the first step in open wound healing. If trauma ruptures blood vessels, they bleed (duh!) and then undergo spasm to reduce bleeding. Next, platelets stick to the injured site forming a temporary platelet plug, followed by a complex, ten-step!!! cascade of events leading to blood clot formation. If all steps work normally, a clot stoppers each damaged blood vessel to halt blood loss. The dusky red plug of Jamie’s gunshot wound is a massive blood clot formed by the process of hemostasis (Starz episode 101,Sassenach). Och! Jamie’s puir right trapezius muscle! Slàinte!
And, just to keep us honest and abreast of Outlander time line, a common 17-century word for blood clot is grume!
A blood clot with its seeping fluids usually hardens into a scab, the body’s version of a Band-Aid! This firm shell protects the wound from infection and desiccation (drying). Tissues under a scab are repairing so best to leave it alone. If you pull it off, the healing process will be prolonged. Jamie kens better than to tear that scab off his gunshot wound! Nurse Claire will skelp his arse if she catches him doing that (Starz episode 103,The Way Out) From Outlander book:
“That’s good,” I said, clearing my throat of some obstruction that seemed to have lodged there. “It is healing well; it’s scabbed over nicely, and there’s no drainage at all. Just keep it clean, and don’t use the arm more than you must for another two or three days.” I patted the undamaged shoulder, signifying dismissal.
Inflammation:Hemostasis is quickly followed by acute inflammation, a rapid but brief response that is not the same as infection, although both may occur simultaneously. Just so you know, the body also experiences chronic inflammation (e.g. RA), a prolonged response that lies beyond today’s lesson content. So, let’s investigate acute inflammation.
About 2,000 years ago, the Roman, Celsus, described four signs of acute inflammation (rubor, tumor, calor, dolor). The fifth sign (functio laesa), was described centuries later by Rudolf Virchow, father of modern pathology. The signs, in Latin followed by their English equivalents, are:
Rubor (redness)
Tumor (swelling)
Calor (heat)
Dolor (pain)
Functio laesa (loss of function)
Acute inflammation is the topic of a terse tête-à-tête between Mrs. Fitz and newly arrived Claire (Starz episode 102, Castle Leoch). Claire declares she doesn’t want Jamie’s gunshot wound to become infected. Oops, she means inflamed! Why did Claire change her words? Because, she kens that the terms infected/infection, meaning invasion by micro-organisms, will not be accepted for another 140 years or so! Herself enlightens us from Outlanderbook:
“But he’s hurt. He was shot yesterday and stabbed last night. I bandaged the wound for riding, but I didn’t have time to clean or dress it properly. I must care for it now, before it gets infected.” “Infected?” “Yes, that is, I mean, inflamed, you know, with pus and swelling and fever.” “Oh, aye, I know what ye mean. But do ye mean to say as ye know what to do for that? Are ye a charmer then? A Beaton?” “Something like that.”
Hee, hee – more like a WW II combat nurse. If only Mrs. F. knew!
The five signs of acute inflammation are caused by dramatic changes in small blood vessels, WBC distribution, and chemical mediators. These changes are very complex so suffice it to say that intact blood vessels near the injury become leaky such that plasma and some types of WBCs pour into the injured tissues. The increased blood flow causes redness. Leaked plasma causes swelling. Freed WBCs release chemical mediators that initiate a host of tissue changes including more redness, swelling, pain, and heat. These responses are designed to eliminate the cause of cell injury, to remove damaged cells, and to initiate tissue repair. Because the injured area hurts, it is hard to use, so it undergoes loss of function. Got it? Grand!
Back to the present (or past): here’s a great example of an injury that leads to acute inflammation. Just before Jamie’s dirk-jerk, he is stabbed by one the MacDonald lads during the big Mac-Attack (Starz episode 110, By the Pricking of My Thumbs). Och! Jamie’s puir left side! Time for another swallow!
Turning to Claire for a wee bit of TLC (she isna very accommodating) and suturing…well, at least he gets stitched <G>, we see signs of acute inflammation in Jamie’s wound (Starz episode 110, By the Pricking of My Thumbs)? See the redness? See the puffy, swollen wound margins? It hurts even before not-a-closed-mouth-woman, Claire, jabs him with her needle! And, the wound will feel warm to the touch. Och, Jamie’s puir inflamed incision wound! Getting dizzy yet?
Four of the five cardinal signs of acute inflammation accounted for! Where’s the fifth?
Here’s the fifth sign of acute inflammation: Jamie grips his newly-stitched left side to protect and support it as Colum gives the Highlanders Holy Hell (Starz episode 110, By the Pricking of My Thumbs)! This is loss of function: the wound hurts too much to use and the pain is intended to stop the victim from using the wounded area while it heals. Och! Jamie’s puir left side! Another gulp! All five signs of acute inflammation present and accounted for! Now back to the steps of wound healing.
Proliferation: So, the wound has bled and is inflamed, what’s next? The wounded tissues undergo proliferation, a complex process (yes, another one) involving three parts: angiogenesis, fibroplasia, and re-epithelialization (Image C). Whew – more terms! What do these words mean?
Angiogenesis means that new blood vessels grow into the wounded site to supply the healing tissues with oxygen and nutrients and remove waste products (red arcs and loops in Image C).
Fibroplasia means that fibroblasts (connective tissue cells) make gobs of new collagen and other structural proteins to fill the gap left by an open wound. Although laid down in a haphazard fashion, the new collagen fibers provide a structural framework for the repairing tissues (represented by ellipsoid cells and brown and yellow stacks in Image C).
If the wound is minor, the three steps of proliferation occur rapidly and the wound closes with little trace. If the wound is deep and/or wide, then proliferation results in a scar (see below).
Image C
Remodeling: Finally, we arrive at remodeling, the fourth step of wound healing! Here, the randomly-arranged proliferated collagen is replaced with new collagen fibers that add strength by orienting along stress lines. Near the end of remodeling, scars contract and become smaller and paler. Image D shows that remodeling takes between 21 days for a minor wound and up to 2+ years for significant injuries! NOTE: This graph skips bleeding as the first step in open wound healing.
Image D
Necrosis: Before we move to scars, please know this…..If some process interferes with establishment or maintenance of normal blood flow following open wound injury, then injured tissues may undergo cell death, a process known as necrosis.
Scars or Cicatrix: We’ll end this lesson with a discussion about scars, the remnant of a healed wound. The Latin (medical) term for a scar is cicatrix or cicatrice, and has been around since the 17th century. Scars (pl.) are known as cicatrices. With the exception of minor injuries, all wounds (e.g. accident, disease, surgery) result in some degree of scarring. We are familiar with scars of the skin but did you know that our internal organs also scar and the nature of such scars is often organ-specific (e.g. fibrosis of liver).
Let’s address some common wound and scar questions.
Why are wounds stitched? Nowadays, wounds are stitched, stapled, glued, and taped. These processes align and hold together the edges of a wound to minimize bleeding, exclude infectious organisms, and reduce scar size. First recorded in 3,000 B.C., suturing is the oldest of these procedures. Approximating the edges of a wound by any the above methods permits healing by first intention.
Claire’s careful needlework on Jamie’s smashed fingers approximates his lacerated skin and restores it’s continuity, thus promoting healing by first intention and minimizing scar formation (Starz episode 116, To Ransom A Man’s Soul). She also uses interrupted stitches so if one knot releases, the entire line of stitching does not unravel. Och! Jamie’s puir left fingers! Gulp! Gasp!
Claire stitches Jamie up so many times, she might have welcomed help from this amazing little fellow!
What is the red, grainy “stuff” that fills gaping wounds? If the edges of a wound remain agape or the epidermis is gone (think floor burn), then the gap fills with granulation tissue; this red, grainy “stuff” is a combination of new blood vessels and new collagen. Known as healing by second intention, this type of healing is slower than healing by first intention and usually forms larger scars (Image E).
Image E
Have you heard the term, “proud flesh” (caro luxurians)? Noooo, I dinna mean the Kardashians, snort! Proud flesh is an oldish term for excess granulation tissue. Image F shows proud flesh, an overgrowth of granulation tissue that developed from a small finger cut. Such overgrowths are atypical but the image is useful because it clearly shows the red blood vessels and grainy appearance of granulation tissue.
Image F
What is a scar? Scar tissue is remodeled collagen fibers that aligned in one direction for added strength. Unfortunately, scar tissue is not as functional as the tissue it replaces. For example, scar tissue of skin lacks hair follicles and sweat glands (Anatomy Lesson #6: Claire’s Hair – Jamies Mane or Jesus H. Roosevelt Christ!) and is less pliable than normal skin. Scars of heart muscle lead to loss of muscular power during cardiac contractions. Scars of liver are due to death of liver cells and formation of excess collagen – less tissue to preform the ten life-giving functions carried out by the liver. Then, there’s amazing bone that often heals without any structural or functional loss.
Why do scars turn white? Scars usually turn white within a year or two after injury. They do so after collagen remodeling and scar contraction is complete and the need for increased blood flow has diminished.
Why do some scars remain red or purple for a long time? Scars remain red or purple as long as WBCs of the area produce chemical messengers to promote increased blood flow. Thus, it may be months or even years before redness completely fades. A good example is the persistent redness of Jamie’s gunshot scar which is apparent months after the event. Oh, no! More sass from Claire who gives him a thorough Sassynach scolding for being a lousy laird (Starz episode 112, Lallybroch). Have ye ever seen a sweeter, more innocent face? Ha, ha! He enjoys a good tongue lashing now and then (hee hee!).
Here is a great … ah, erm, … I forgot what I was writing about! Gah! Oh, I remember! The scar from the sword swipe is white at the millpond even though Jamie’s earlier gunshot scar is red in the same episode (Starz episode 112, Lallybroch). Ahem, students!! The red arrow helps focus your attention on the white scar! Now this can occur because tissues in different regions of the skin may heal at different rates. More likely, it is because that bloody freezing burn contracted Jamie’s skin capillaries: reduced blood flow = paler skin! Och, Jamie’s puir left side! Are we woozy yet?
Why are Jamie’s lash scars so prominent? Back skin is thick and when lacerate, it should be sutured or stapled; unfortunately, neither of these procedures were available to Himself at the time of injury. His deep, wide lash wounds filled with granulation tissue and healed by second intention so the resultant scars are wider and more significant. BTW, his lash scars are also shiny and raised, features of hypertrophic scars, an abnormal healing process due to overproduction of collagen. His lash scars were probably designed for dramatic effect, as Jamie’s skin is an unlikely candidate for hypertrophic scarring. Och! Jamie’s puir back! Glass refill STAT!
Jamie appears over and over in this lesson because the lad has suffered more than his fair share of mars and scars. Who is to blame for most of these owies? Why, that dark, dastardly devil, BJR, of course. Claire is constantly cleaning up that SOB’s messes! Sadist that he is, Jack-Jerk finds his handwork compelling and erotic (Starz episode 116, To Ransom a Man’s Soul)! Writer Ira Steve Behr explains:
To me, the line that was truest to Black Jack’s character was when he ripped open Jamie’s shirt and said with wonder, “How does it feel to be alive and wear so much dead flesh?”
I go on record as stating, au contraire, repugnant, reptilian Randall! Scars are NOT dead flesh, they are living tissue, the end game of the body’s ability to heal wounds. Scars are molded by our own private first responders; tiny “robots” that dart into action on our behalves. Let us be grateful that our bodies possess such marvelous repair mechanisms!
Shakespeare once wrote, “There’s nothing good or bad, but thinking makes it so” (Hamlet; Act two, Scene two, p. 11). Apparently Will never met BJR – as some handiwork is just plain E-V-I-L!
If you have yet to witness this riveting compilation of Black Jack’s dark and dirty deeds, watch this admirable video – created by Julia LaBlanc and posted by E. Jamie via YouTube. Just keep in mind it grimly showcases the depths of BJR’s depravity.
Image D
Image E
