Tag: #Outlander #Starz

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Anatomy Lesson – Outlander Trauma-Drama, Part I

Greetings Outlander anatomy students!

I have not posted a lesson or fun fact since September of last year!  Time to get back into the dissection room. 🤓

I plan to post several lessons in succession, all dealing with trauma-drama on Outlander! And, as we all ken, there is plenty of this to go around.

Let’s get started with a couple of definitions. 

As many of you know, the term anatomy comes from the Greek ana– (up) + temnein (to cut). Taken literally, anatomy means to cut away or to reveal. 

Today’s Anatomy Lesson will reveal topics belonging to the science of pathology: Greek meaning pathos (suffering) + ology (to know). Interestingly, pathology is literally the study of abnormal anatomy so we are well within our lane! 

Although this topic is not light-hearted, it is an important one which may prove useful to you and yours.

Pathologists have meticulously developed a logical, useful, and understandable schema to classify the types of trauma which injure body cells, tissue, and organs. Major categories are mechanical trauma, thermal injury, alcohol, infectious agents, and so on. 

Today lesson will focus only on mechanical trauma, of which there are seven types:

    • Contusion
    • Abrasion
    • Laceration
    • Incision
    • Avulsion
    • Projectile injury
    • Puncture wound

Whew, that is quite a laundry list! Call it a miracle that any of us survive to adulthood. 🙏🏻

Diana’s Outlander books plus the Starz Outlander series are rife with excellent examples of varied and sundry mechanical trauma-drama so it is time for Jamie.com to hop atop the dissection table. Up you go! 

As we explore Mechanical trauma, bear in mind this type of injury produces two types wounds: 

    • closed wounds – the skin is intact
    • open wounds – skin is scraped, torn, cut, or punctured 

You will see these terms appear in the lesson.

Almost every Outlander episode contains one or more of the seven types of mechanical trauma, so let’s go find some!

Contusion: The contusion is closed trauma  so the skin remains intact. Caused by blunt force, blood vessels are ruptured and blood seeps into surrounding tissues forming a hematoma (Greek, meaning blood tumor).

Known as a bruise in laymen’s terms, the appearance of a contusion is due to extravasated blood in the tissues. Press on a skin contusion and it does not blanch under pressure. Interestingly, hematomata (pl.) also occur in internal organs such as brain and liver.

Claire provides a heart wrenching example of contusion after she is kicked and bludgeoned by Lionel Brown and his band of hairy men! In the final scene of Outlander episode 512, Never My Love, her contusions caused by blunt force trauma are on full display! 

Chapter 28 of Diana’s sixth big book, A Breath of Snow and Ashes, describes the carnage in shocking detail; the blows were administered by thief-taker, Harley Boble:

“He was standing. He was kicking me and cursing, panting and half-sobbing as his boot thudded into sides and back and thighs and buttocks. I panted in short gasps, trying to breathe. My body jerked and quivered with each blow, skidding on the leaf-strewn ground, and I clung to the sense of the ground below me, trying so hard to sink down, be swallowed by the earth.”

The uneven mottling of Claire’s skin created by the FX crew is accurate.  A rainbow of blue, black, green, and yellow herald the normal healing pattern of contusions, although it takes a wee bit of time for the full range of colors to appear.

Puir Claire! Her emotional trauma will linger far after her physical wounds have healed. 😔

Abrasion: The abrasion is an open type of mechanical injury wherein the epidermis (Anatomy Lesson #5) is rubbed or scraped away. Superficial abrasions typically turn red whereas deep abrasions ooze blood making them easily distinguishable.  The good news is the skin repairs abrasions rather promptly and without scarring unless infection messes with the healing process.

Jamie is our victim for the abrasion!  Here in Outlander episode 608, I Am Not Alone, we see a mostly superficial abrasion of his right brow and cheek as a result of the Richard Brown and his men attempting to take Claire into custody for the murder of Lionel. His skin is scraped and bright red. Again, kudos to the special effects and detail folks.

Laceration: Our next trauma is a laceration, best defined as a slash or tear. Lacerations are open wounds with rough and ragged margins that may be contaminated with bacteria and debris. Most often, they are tears of the skin, but internal organs can also be lacerated.

In a flashback during Outlander episode 601 Echoes, Jamie relives his years at Ardsmuir as Mac Dubh wherein he takes responsibility for an illegal piece of tartan and receives lashes on his already scarred back. Trauma-drama for sure!

 The scene is poignantly described in Diana’s third big book, Voyager: 

He had nodded to the two privates, who seized the prisoner’s unresisting hands and raised them, binding them to the arms of the whipping post. They gagged him, and Fraser stood upright, the rain running down his raised arms, and down the deep seam of his backbone, to soak the thin cloth of his breeches.

“ … in contravention of the Diskilting Act, passed by His Majesty’s Parliament, for which crime the sentence of sixty lashes shall be inflicted.” 

“…Mr. Fraser, you will take your punishment.”

“…The sergeant-farrier paused only briefly between blows. He was hurrying it slightly; everyone wanted to get it over and get out of the rain. Grissom counted each stroke in a loud voice, noting it on his sheet as he did so. The farrier checked the lash, running the strands with their hard-waxed knots between his fingers to free them of blood and bits of flesh, then raised the cat once more, swung it slowly twice round his head, and struck again. “Thirty!” said the sergeant.

Puir Jamie. His back is broad and strong, but gah! 😵‍💫

Incision: An incision is an open wound that differs from the laceration because it is made by  sharp cutting instruments such as knife, razor, or glass edge. Thus, the margins of an incision are sharp and well-defined.

Today, incisions are closed with different suturing techniques depending on the site and type of wound. There are also different types of suture materials including thread, needles, stitches, and knots as well as closures without sutures such as staples and glue. The clean margins permit incision wounds to be closed tidily and these typically heal with minimal scarring.

Unfortunately, there was no suturing of Malva’s mortal wound although it is a perfect example of incision injury (Outlander episode 606, The World Turned Upside Down).

This poignant scene is captured, again from Diana’s sixth big book,  A Breath of Snow and Ashes:

I smelled the blood and saw her in the same instant. She was lying in the salad bed, her skirt flown out like some gigantic, rusty flower blooming amid the young lettuces. 

I was kneeling by her, with no memory of reaching her, and the flesh of her arm was warm when I grasped her wrist—such small, fragile bones—but slack, there was no pulse—Of course not, said the cold small watcher inside, her throat is cut, there’s blood everywhere, but you can see the artery isn’t pumping; she’s dead.

Malva was a damaged young woman who, in turn, damaged others. Even so, she scarcely deserved to die in such a despicable manner. 😯 Puir lass.

Who did the dastardly deed? We will soon find out when Season seven airs!

(Pssst….Another excellent example of incision trauma would be Claire’s surgical repair of Tom Christie’s Dupuytren contracture. Yes, I did write a lesson on this topic.)

Avulsion: An avulsion injury is the forcible tearing away of a body part or structure. This type of trauma was the hardest to find in Outlander. I had to go all the way back to Season two!  But, find one, I did: a good example of avulsion is the tooth extraction Claire performed in Outlander episode 211, Vengeance is Mine!

Although avulsion more commonly describes a muscle pulled from its bony attachment or limbs (e.g. finger, toe) being torn off, a tooth being separated from its socket surely qualifies. Ouch! 🫣

Is Rupert is amused or scared s**tless? We miss you, man!  

Projectile Injury: Projectiles are objects that are propelled forward by an external force. Thus, a hurled stone is a type of projectile. Projectiles typically cause open wounds and probably the best-known is the gunshot wound (gsw).

The degree of tissue disruption caused by a projectile is proportional to its kinetic energy, yaw (twist), fragmentation of the projectile; all features that especially apply to a gsw.

I certainly am not a munitions expert but as I understand it, today’s standard NATO weapon (M16 rifle) fires a cartridge that measures .21” (5.56mm) in diameter. But an 18th century musket ball ranged from .51”-.75” (13-19mm) in diameter making it two to three times the diameter of the M16 cartridge – one humongous projectile!!!

Season six ended with a startling but effective example of a projectile (Outlander episode 608, I Am Not Alone).

Several of Brown’s men kidnapped Jamie, planning to put him aboard a ship bound for far off places. Chief Bird came to the rescue, shooting the abductor with a rifle given to him by Jamie. Bullseye (so to speak)! 😉

Chief Bird nods in satisfaction at Jamie:

“I told you I would fight with you, Bear-Killer.”

Until about 1880, the standard practice for treating gsw required that physicians probe and locate the path of a projectile with unsterilized fingers. Before this time, germ theory and Lister’s dilute carbolic acid treatment for “antisepsis surgery” were unknown.

Understand, the musket ball is not only large, it is a low velocity projectile, so its sheer mass literally plows (yikes!) a path through tissues. Little wonder that it leaves a gaping hole! In fact, in those by-gone days, one musket ball was sufficient to kill a man if it struck near any vital organ. And, if the victim survived a musket ball wound, he/she often succumbed to the effects of a subsequent amputation or infection.

I might add, that the impact of the musket ball would have knocked this kidnapper on his ass. But, for a second he remains upright for dramatic effect! 😮

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

Further, if the puncturing object stays in the body, then it is a penetrating wound; if it passes through the body and emerges then it becomes a perforating wound.

Understand that it is not uncommon for wound classifications to overlap so, for instance, a gsw might be categorized as both a projectile and a penetrating or a perforating wound.

A great example of a puncture wound occurs during Ian’s voluntary adoption into the Mohawk tribe in the form of ritualistic tattooing. This was done with what appears to be a porcupine quill in Outlander episode 604, Hour of the Wolf.  Ouch! 

This is the description of Ian’s transformation from Diana’s fourth big book, Drums of Autumn: 

“Ian? Is that you?”

“Aye, Uncle. It’s me.”

His voice sounded odd; breathless and uncertain. He stepped into the light from the smokehole and I gasped, feeling as though I had been punched in the stomach.

The hair had been plucked from the sides of his skull; what was left stood up in a thick crest from his scalp, a long tail hanging down his back. One ear had been freshly pierced and sported a silver earring.

His face had been tattooed. Double crescent lines of small dark spots, most still scabbed with dried blood, ran across each cheekbone, to meet at the bridge of his nose.

Also, notice the abrasions on his left upper lip, nostril, cheek, brow and temple? His dash through the gauntlet took its toll, for sure! 😱

Whew! We covered all seven types of trauma drama, probably enough  for one lesson!

Final Thought: Here’s an important take-home message I learned from my surgical colleagues: if you encounter a projectile wound in which the penetrating object is still in the body, do not attempt to remove it in the field! Instead, transport the victim to the nearest emergency room ASAP so professionals can remove it under medically-controlled conditions.

Tempted to remove a projectile yourself? Don’t! (Well, maybe a sliver is OK.) Seriously, this advice is because the embedded object usually exerts pressure on nearby torn blood vessels squelching blood loss. After the object is removed, the resultant blood flow may not be easily staunched especially if a vital organ is involved.

This happened to the late, great Steve Irwin, Crocodile Hunter, who removed a stingray barb that penetrated his heart. Sadly, he bled to death in moments through the hole in his chest!

Stay tuned for a future lesson on trauma drama!

The deeply grateful,

Outlander Anatomist 

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

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Anatomy Lesson #64: Inguinal Hernia

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Now for the science. Yay!

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

Image A

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

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

Image B

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

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

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

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

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

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

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

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

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

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

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

Inguinal Herniae Statistics:

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

Image C

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

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

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

Image D

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

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

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

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

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

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

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

Image E

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

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

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

Image F demos such unruly outcomes:

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

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

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

Image F

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

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

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

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

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

“Let’s go.”

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

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

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

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

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

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

…Then it was done, and time began again.

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

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

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

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

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

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

A deeply grateful,

Outlander Anatomist

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

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

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Anatomy Lesson #63: Measles

Welcome to Anatomy Lesson #63, The Measles, or as Herr Mueller would say, the “measle.” This topic is timely as measles has raised its ugly head in recent outbreaks around the world. As usual, this lesson combines Outlander book quotes, TV series images and science. I hope you find it interesting and useful! 

Outlander episode 405, Savages, begins with a sweet harlequin doll removed from a shelf and wrapped in a checkered cloth. Gerhart Mueller and son Tommy are in Cross Creek, purchasing a gift for an expected grandchild. Remember the doll as we will return to it later in the lesson.

Meanwhile, at the Mueller cabin near Fraser’s Ridge, Dr. Claire has delivered a new baby girl, Klara. Grandmother, Rosewitha, and widowed mother, Petronella softly croon: 

Thy Mother shakes the little trees,

There Falls down one little dream.

Sleep, baby, sleep!

As always, Outlander books provide for our lessons, this time, measles. <G>

Days after delivery, Pastor Gottfried appears at Fraser’s cabin with terrible news.  In Drums of Autumn book, Lord John Grey is already a guest at Fraser’s cabin, has measles and serves as interpreter: 

“Do you know a family named Mueller?” 

“Yes,” I said, immediate alarm flaring at the name. “I delivered a child to Petronella Mueller, three weeks ago.” 

“Ah.” Grey licked dry lips and glanced at the ground; he didn’t want to tell me. 

“The—the child is dead, I am afraid. So is the mother.”

“Oh, no.” I sank down on the bench by the door, swept by a feeling of absolute denial. “No. They can’t be.” 

“He says it was Masern; I think that would be what we call the measle.”

Slightly different sequence, but in Starz episode 406, Blood of My Blood, Lord John and son William arrive on Jamie’s doorstep for an unexpected visit. Surprise!

Claire is less than happy but tables those insecurities after Lord John falls ill. She hastily summons her best doctoring skills for her imagined rival.

  • Did you pass through Cross Creek on your journey? Yes, he did.
  • Open your mouth. He does. 
  • Feels his jawline. Ow, that is tender.
  • Palpates his neck. Yep, swollen lymph nodes.
  • Orders Jamie to take his biological son, William, on a prolonged camping trip.

Buh bye, boys! 

Open, says me!

Swollen lymph nodes in the neck!

Jamie is instructed to whisk William away because Claire has correctly deduced that LJG has contracted measles and is highly contagious!

Her diagnosis is correct and soon she is caring for a very ill, Lord John. 

  • fever ✔︎
  • dry cough ✔︎
  • red, watery eyes ✔︎
  • headache ✔︎
  • rash ✔︎

Fever

Cough

Blood-shot eyes

Headache

Rash

All of this nursing causes Claire to muse (Drums of Autumn):

Nursing is hard work, and all of a sudden I was bloody tired of it.

Nevertheless, Claire honorably attends to Lord John throughout the course of the disease. As he leaves Fraser’s Ridge with Willie, she admonishes him to get plenty of rest and to eat squash, carrots and liver. He rewards her with a look of amused disbelief. Whaaat? Why? Read on.

OK, that is a quick review of the two episodes. Now for the science. Yay!

Cause: Measles is a disease of humans (no known animal reservoir) caused by the measles virus. Measles is also known as morbilii, rubeola, English measles or red measles. Sometimes, measles is confused with rubella, the German measles, or with roseola, but these are different diseases caused by different viruses. What’s with all the R’s???

The measle virus is a tiny innocuous-looking entity belonging to the Paramyxovirus family. Image A shows an electron micrograph  of a measles virus. Understand, the colors are not natural, these are computer-generated.

Image A

Exposure: Measles is a highly contagious disease contracted by contact with an infected person. Virus particles become airborne in droplets from coughs and sneezes or via contact with saliva or nasal secretions. The next victim breathes in the droplets or touches the secretions then unwittingly transfers to nose or mouth.

Measles is so infectious, 90% of people who share the same living space (and are not immune) will become infected!   (psst…not sure how Willie escapes the measles after sharing a bed with his father at Fraser’s cabin, but he does)

Once inside a new host, the measles virus binds to and infects cells lining the respiratory tract. The virus hijacks these cells to make new viruses which then seed lungs, blood stream and other sites such as GI tract and brain. 

Symptoms: Symptoms typically last 7-10 days and appear in two phases:

  • Phase 1: symptoms appear 7–14 days after exposure. Lord John exhibits all but the runny nose! Sniff.
    • high fever   > 40 °C/104.0 °F 
    • dry cough
    • swollen lymph nodes (usually)
    • inflamed conjunctivae of eyes
    • runny nose
  • Phase 2: symptoms appear 2-5 days after phase 1. Lord John exhibits both.
    • Koplik’s spots (2-3 days after phase 1)
    • flat, red rash (3-5 days after phase 1)

A few comments about  the last two symptoms.

Koplik Spots: Koplik’s spots are small white bumps scattered on the oral lining opposite 1st and 2nd molars (Image B). These are pathognomonic (specific) for measles. They may also appear on the roof of mouth, explaining why Claire peers directly into Lord John’s oral cavity in ep 406 (see image above). 

In Drums of Autumn, Herself includes Koplik spots in Claire’s diagnosis: 

I wrung out a cloth wetted with elderflower water, and wiped Grey’s face and neck. There was no rash yet on his face, but when I made him open his mouth, the small whitish Koplik’s spots on the lining were clear enough. “Yes, you have got the measles,” I said. “How long have you been feeling ill?”

Note: In the episode,  this symptom is wrongly timed because Claire sees Koplik spots early on. However, these spots don’t appear until 2-3 days after phase 1 symptoms. Because of the latency, they are often missed by practitioner or parent. But, no biggie. Say, ahhhhh!

Image B

Rash: 3-5 days after phase 1 symptoms, a flat, red rash appears on the face and then spreads to the rest of the body. Understand that victims are infective for at least four days before and four days after the rash – not just during the rash. Ergo, we must hope that Jamie and Willie spent at least 8-10 days foraging in the woods!

Image C is an archival photo of the typical measles rash. This puir little lad is covered with measles rash and feels poorly.

After Care: Generally, after care is the same for other communicable diseases: rest, hydration, etc. However, Claire admonished Lord John about his diet, remember? Here’s why.

Vitamin A therapy is recommended to reduce the risk of blindness from the measles, although it neither prevents nor cures the disease. Liver (yuk!), squash and carrots are high in Vitamin A or Provitamin A which is  why Claire recommends them to Lord John.  However, Vitamin A is only present in animal-sourced foods, such as liver. Provitamin A is high in squash and carrots but our genetics determine whether we can convert this compound into usable Vitamin A. Some can and some cannot, so supplements may be employed. Complicated!

Image C

Fomites: Fomites are inanimate objects or materials that transmit disease. After ep 405 aired, some fans blamed the doll for carrying measles to the Mueller household. Nope. The measles virus can survive on inanimate surfaces for a maximum of 2 hours. Cross Creek is miles from Fraser territory, so the chance the virus survived on the surface of the doll is basically, zero.

I pointed this out to a FaceBook group which was hell-bent on blaming the doll for infecting the Mueller family. One fan responded that Outlander was a fantasy so, if she wanted the doll to be the carrier, then it could be. I agree with her, Outlander is fiction … but, measles is not! 

The most likely source is Tommy Mueller. Why? Because both his parents had contracted measles years before and have lasting immunity (with few exceptions). Tommy was probably exposed in Cross Creek and unwittingly brought the virus to Petronella and baby Klara. Remember, a person is infectious some four days before the rash appears. Make sense? Yay!

Measles Complications: Just so you know, in addition to typical symptoms noted above, measles may cause more serious problems, including: 

  • diarrhea
  • middle ear infection
  • pneumonia
  • seizures
  • blindness
  • inflammation of the brain (encephalitis)
  • death

Passive Immunity: Mothers who are immune to the measles virus pass antibodies against the virus to their offspring while still in the womb.  Such antibodies usually confer newborn infants some immunity against measles, but these antibodies are gradually lost over the course of the first nine months of life.

Which brings us to the topic of vaccines!

Vaccination: This is a loaded topic, but must be addressed. Please don’t run away, anatomy students!

For 150 years, between 1855 and 2005, measles likely killed about 200 million people, worldwide. Vaccination saw a 75% decrease in deaths from measles between 2000 and 2013 alone, with about 85% of children worldwide  being currently vaccinated

In 1968, Maurice Hilleman, a US microbiologist, developed an effective vaccination against measles, part of the MMR regime still administered today (Image D). A moment to honor this prolific scientist who developed 40 vaccines of which 8 are still currently used. Thank you, Maurice!

In the Pacific Northwest, where I live, 76 new cases of measles have been verified in the first two months of 2019, most occurring among unvaccinated children under the age of 10.

Although a different disease, an Oregon child recently contracted tetanus, the first case in over 30 years! His hospital stay (at my university) was 57 days, cost almost $1,000,000 and required 100 nurses and doctors for his care. They turned for advice to other parts of the world because none had ever seen the disease!

Have you guessed? The boy was unvaccinated. And, amazingly, his parents refused to vaccinate him even after his ordeal (tetanus does not confer lasting immunity to its victims). Let us not forget that the poor child was extremely ill with involuntary contractions of his spinal muscles and other issues.

One reason my area of the US has been hit hard by measles is Washington and Oregon allow parents to opt out of vaccines based on undefined personal beliefs. The outbreak is causing a review of this policy perhaps to allow minors to make their own decisions about vaccination or to end non-medical exemptions all together (New Scientist, 23 Feb., 2019). 

Why are folks shunning vaccinations for their children? Well, some are afraid to do something they may regret. Some believe vaccines are the way a nefarious government could do harm.  Some don’t want to line the pockets of big Pharm (less than 2% of their earnings coming from vaccines). Still others believe the disproved theory that vaccines cause autism.

Image D

Herd immunity: Understand that in order to prevent an outbreak, a certain percent of the population must be immunized. This is known as herd immunity. For measles, this is 90% of people. Remember, there are always members of any community, such as the immunosuppressed,  who cannot receive vaccinations. Thus, it is crucial that healthy members of a community be vaccinated.

If you are unsure about vaccines, perhaps this TEDX talk will help. At the very least, it might give you food for thought.

All in all, ignorance serves humankind rather poorly, in my view.

Gerhart is a perfect example: the man thought measles was a curse brought on by savages so he exacted his revenge upon their healer, Adawehi (Nayawenne). Here from Drums of Autumn:

“They are dead,” he said. “Mein Mädchen. Mein Kind.” Tears welled suddenly in the bloodshot eyes, and ran slowly down the weather-beaten grooves of his face. The misery in his eyes was so acute that I reached out and took his huge, work-scarred old hand in mine.

…Her name meant. “It may be; it will happen.” Now it had, and all that was left me for consolation was her words: “She says you must not be troubled; sickness is sent from the gods. It won’t be your fault.”

Conclusion: Measles is a dreadful, highly contagious disease which has significance for individuals, their families and greater communities. It is not a new disease. For perspective, consider its description by the Persian physician Rhazes in the 10th century – he deemed measles “more to be dreaded than smallpox.”

OK, enough about heaviness. On a happier note, let’s close this lesson with serious kudos to the makeup artist (Ann McEwan?) who created Lord John Grey’s “measles.”  The special effects were terrific and convincing.  Armed with spray and sponge, she managed to produce a red rash typical for measles!

BTW, the application was done on David Berry’s birthday so he had birthday cake and rash. Brash! 

Lord John, you be a handsome dude, measles or no!!!

A deeply grateful,

Outlander Anatomist

Photo Credits: Starz, Image A www.pixels.com; Image B www.sciencephoto.com; Image C www.freep.com; Image D www.nlm.nih.gov