Season 5 blasts off in one month. I can scarcely wait! You? đ€
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. âYou are not on an island at all. You are on the mainland; in the Colony of Georgia.â
âGeorgia,â Jamie said. âAmerica?â He sounded slightly stunned, and no wonder. We had been blown at least six hundred miles by the storm.
âAmerica,â I said softly. âThe New World.â
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.
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.
âWeâve the two choices,â he said, brushing back the sweat-soaked hair from his temples. âWe 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.â
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 hangmanâs 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 motherâs 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 đ) 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.Â
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!Â
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 Jocastaâs 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, Â 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 hereâand whether he was being followed. He owned a farm and a small mill, both at least two daysâ ride from the Ridge; not a journey he would undertake simply for the pleasure of our company.Â
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 Iâd 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. Â 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. đ
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. Â 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! đ đ
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). Â 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 Tryonâs militia.
Hey, anatomy students! Are you interested in hernias? If yes, you came to the right place! Todayâs lesson, Inguinal Hernia, is prompted by Dr. Claire performing a hernial repair in Outlander episode 408, Wilmington. Letâs 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. HumâŠ.mayhap a poke in the puir fellowâs 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!âÂ
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>Â
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! đ±
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!!! đ±
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:Â 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:Â
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.Â
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!
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 Jamieâs 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.Â
Inguinal Hernia:Â 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):Â
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 eatingÂ
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. Â
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.Â
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
Claireâs Repair: Today, various techniques are used to repair inguinal hernias. Mr. Fanningâs 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!
Fanningâs special FX were pretty good. However, I must make the following observations:
Fanningâs 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?
No surgeon worth their salt would dare cut across a hernial bulge for risk of cutting into the bowel itself! Claireâs initial knife position was correct, why she switched position was puzzling. Perhaps, to make FX more buzz-worthy?
Too much blood oozed from the skin cut which is also too deep – inguinal skin doesnât bleed that much and is thin. Again, this may have been designed to produce a collective viewer’s gasp.
The FX that really caused me to cringe is the force Claire employs to push the bowel toward the body midline! Â Nope. That direction, the bowel has no place to go. No wonder Fanning screams! Â 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.
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!
As Edmundâs bowel was incarcerated, the overlying skin should have appeared inflamed. It didnât.
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.Â
âLetâs go.â
Myersâs penis, embarrassed by the attention, had already retreated, peeping shyly out of the bushesâŠUlysses himself delicately cupping the baggy scrotum away, the hernia was clearly revealed, a smooth swelling the size of a henâs 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.
âŠI 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 surgeonâs realm. I closed my eyes and let all sense of urgency, all consciousness of the watching crowd drop away.
âŠTime 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.
âŠThen it was done, and time began again.
âDone,â I said, and the hum from the spectators erupted into loud applause. Still feeling intoxicatedâhad I caught drunkenness by osmosis from Myers?âI turned on one heel and sank into an extravagant low curtsy, facing the dinner guests.
My favorite part of Fanningâs surgery comes when the 18th century physician bustles in declaring âWhat hath hell wrought?â Yeah, women didn’t do surgery or openly practice medicine in those days.
Then, he accused Claire of butchering the poor man, finishing with: âAll he needed was some smoke up the rear.â Â Bwahahaha! Priceless!Â
This entertaining 10 minute video by Dr. Carlo Oller does a terrific job of summarizing much of todayâs 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.
Letâs close with this simple thought: as inguinal hernias occur more frequently in males than females, shouldnât these be called, himnias? Wink. Wink.
A deeply grateful,
Outlander Anatomist
Photo Credits: Starz ep 112, Lallybroch, ep 408, Wilmington.
Anatomy Def: Os frontale/frontal bone is a skull bone which forms the forehead and the roofs of eye sockets and of nasal cavities.
Outlander Def: Saucy, scary Geillis haunts Ian at Hayesâ graveside! Her clear, high forehead follows her gaze as she basks in a font of goatsâ blood. Run, Ian, Run!!!
The human skull contains 22 bones (six ear ossicles not included in the count). Many anatomists consider the frontal bone a keystone skull bone because it articulates with a whopping 12 other bones of the skull!
Fun Fact: At birth we have two frontal bones separated by a frontal suture which typically ossifies into one frontal bone around eight years of age. Some humans retain two frontal bones throughout life, a state consistent with most vertebrates, wherein paired frontal bones do not fuse into a single frontal bone.
Try this: Gently rub two fingers across the skin of forehead. Do you feel a slight ridge? if so, this is the remnant of the suture between the paired frontal bones.
Read about foreheads throughout all of Dianaâs big books. This passage from Drums of Autumn compares Brianna’s forehead with that of her paternal grandmother, Ellen MacKenzie, as Bree and Jenny view her Lallybroch portrait:
Ellen MacKenzie looked out at her now as she had then; long-necked and regal, slanted eyes showing a humor that did not quite touch the tender mouth. It wasnât a mirror image, by any means; Ellenâs forehead was high, narrower than Briannaâs, and the chin was round, not pointed, her whole face somewhat softer and less bold in its features.
But the resemblance was there, and pronounced enough to be startling; the wide cheekbones and lush red hair were the same. And around her neck was the string of pearls, gold roundels bright in the soft spring sun.
See Geillis high forehead as she prepares to rise from her ablution of blood in Starz episode 401, America the Beautiful. (I figure it would require blood from about 250 milk goats to fill that font!)
