Tag: puncture wound

Greetings Outlander anatomy students! Today’s Anatomy Lesson #35 covers wounds and injuries; topics which belong to the science of pathology (Latin for knowledge of suffering). However, as pathology is the study of abnormal anatomy, the lesson will not go far afield. Although this topic isn’t as light-hearted as the title implies, it is an important one which may prove useful to you and yours.

Wounds are classified in different ways but pathologists have developed a logical, useful, and understandable schema. Under their model, body cells and tissues are injured by the following mechanisms:

• Mechanical trauma
  • Contusion
  • Abrasion
  • Laceration
  • Incision
  • Avulsion (body structure is forcibly detached from its point of insertion)
  • Projectile injuries
  • Puncture wounds
• Thermal Injury
• Radiation Injury
• Personal Exposure (tobacco and alcohol)
• Therapeutic Drugs
• Air Pollution
• Industrial Exposures
• Agricultural Hazards
• Natural Toxins
• Oxygen Deprivation
• Infectious Agents
• Immunological Diseases
• Genetic Derangements
• Nutritional Diseases

Whew, that is one long, laundry list! Call it a miracle that any of us survive to adulthood. Nevertheless we do survive because the body employs many protective and healing mechanisms; we will examine these in a future lesson.

Diana’s Outlander books and the Starz Outlander series are rife with excellent examples of varied and sundry wounds so Jamie.com once again serve as our models; up on the dissection table you go! Today’s lesson focuses on types of mechanical trauma.

Mechanical trauma produces closed wounds with intact skin or open wounds in which the skin is scraped, torn, cut, or punctured. Almost every Outlander episode contains one or more types of traumatic injury. Let’s find them!

Contusion: The contusion is a closed type of wound caused by blunt trauma which ruptures blood vessels (Anatomy Lesson #5). Blood seeps from the broken vessels into surrounding tissues and forms a hematoma (Greek meaning blood tumor). Known as a bruise in laymen’s terms, its appearance is due to extravasated blood. Press on a skin contusion and it does not blanch under pressure. And, just to be complete, hematomata (pl.) also occur in internal organs (e.g. brain, liver).

Jamie sports two major contusions, one on each shoulder, a matched pair! His first is of the right shoulder as a result of a dislocation exacerbated by a gunshot wound. The blunt force was the ground (!) which his shoulder strikes after falling from his mount. The fall dislocates his glenohumeral joint (Anatomy Lesson #2) tearing blood vessels and allowing blood to seep into subcutaneous tissues. Herself describes the event in Jamie’s own words (Outlander book):

“Fell wi’ my hand out, when the musket ball knocked me off my saddle. I landed with all my weight on the hand, and crunch!, there it went.”

The contusion covers most of his right shoulder (Starz episode 102, Castle Leoch). The uneven mottled appearance is very accurate; a rainbow of blue, black, green, and yellow herald the normal healing pattern of a contusion. We will cover the basis of these color changes in a future lesson. Good job special effect crew!

Later, another contusion covers Jamie’s left shoulder. The blunt force in this instance was administered by that bad bugger BJR who rained blows upon him at Wentworth Prison (Starz episode 116, To Ransom A Man’s Soul). Here from Outlander book, Claire is horrified by the inflicted damage:

Turning back the blankets in bits, I surveyed the damage… The sheer orderliness of the damage, speaking as it did of a deliberation that reveled in each punishing stroke, made me feel sick with rage. Something heavier, perhaps a cane, had been used with less restraint across his shoulders,.. I pressed a thick pad of lint gently over the worst of the mess and went on with the examination.

See that the skin over Jamie’s left shoulder is varying shades of red but not yet black and blue? Once again, this depiction is accurate because the contusion is fairly fresh; it takes time for the full range of colors to appear. Again, the scientific basis for the “rainbow” awaits a future lesson.

Oh, and speaking of contusions, several readers have asked why Claire’s beautiful nude belly didn’t show contusions on her wedding night (Starz episode 107, The Wedding). After all, the day before she suffered a gut punch from Captain Mad Maniac and a kick from Corporal Milksop (Starz episode 106, The Garrison Commander)! BJR murmurs in her ear (Outlander book):

“I trust you are not with child, Madam,” he said in a conversational tone, “because if you are, you won’t be for long.” I was beginning to make a rather odd wheezing noise, as the first wisps of oxygen found their way painfully into my throat.

Actually, this seeming disparity doesn’t trouble me for three reasons. First, the episode does not show where Milksop placed his kick; it may have struck her thigh (Anatomy lesson #7) or groin, areas not shown during the wedding night episode. Second, although we see BJR punch her in the belly, Claire is protected by corset and stays, petticoat, and a pleated wool gown in which each pleat is formed by three layers of heavy wool fabric! Such protective layers help dissipate the kinetic energy of the blow. Lastly, the anterior abdominal wall (Anatomy Lesson #16) is a fibromuscular layer overlying soft organs, making it pliable when struck; it sinks inward, reflexively tightens, and then rebounds (especially as breath returns). Because it is flexible, a direct blow is less likely to burst superficial blood vessels. Had the blows struck skin overlying bone, then a contusion would have been inevitable. Make sense?

Abrasion: The abrasion is an open type of traumatic wound wherein the superficial epidermis (Anatomy Lesson #5) is rubbed or scraped off by friction. Superficial abrasions typically turn red and deeper abrasions usually ooze blood. Repair occurs promptly and without scarring unless infection messes with the process.

Jenny is our first victim of abrasion (Starz episode 102, Castle Leoch)!  Jamie explains to Claire that on one “fine” October day near to four years ago, Captain Randall visited their farm:

Then I burst into the parlor, where I found two of the redcoats with my sister, Jenny. Her dress was torn a bit, and one of them had a scratched face.”

During the Starz encounter, it is Jenny who suffers the abrasions; four areas where the epidermis is scraped away. No despair as these superficial scratches should heal without scarring!

Lovely Claire suffers deeper abrasions at the Cranesmuir trial (Starz episode 111, The Devil’s Mark). Here from Outlander book:

The judge turned to MacRae. “Strip her and skelp her,” he said flatly. Through a daze of disbelief, I heard a collective inhalation, presumably of shocked dismay—in truth, of anticipatory enjoyment. And I realized just what hate really meant. Not theirs. Mine.

… he began, then hesitated, “I mean, the cuts are not deep. I—I think you’ll no be …marked.” He spoke gruffly, but his touch was very gentle, and reduced me to tears once more.

Later, Claire’s back very accurately depicts deep abrasions: her skin is scraped and bright red but not cut. During the skelping, I count nine blows striking Claire’s bared back and sure enough, it later shows nine abrasions (top two are faint but present). How fantastic when such details are addressed! Again, kudos to the special effects and detail folks.

Now, some vigilant Outlander fans ask why Claire’s back abrasions aren’t visible when she strips down to her undergarments at Lallybroch (Starz episode 112, Lallybroch). Great question but I don’t know the answer. In Outlander book, the journey to Lallybroch takes about a week but I don’t recall hearing the time frame between Starz episodes 111 and 112. Presumably, it was sufficient for Claire’s wounds to have healed. We all ken that serious fans scour and devour every Outlander word and frame available. No mossy brains in this group!

Then, eagle-eyed fans wondered why no abrasions show on Claire’s lovely bum as she “forgives” Jamie after strapping her with his sword belt (Starz episode 109, The Reckoning)! Well, at the risk of sounding like a broken record (remember those) perhaps because of elapsed time. In Outlander book, only a couple of days intervene between spanking and spectacular sex. What with the slow moving caravan, snowy weather during a stag hunt, quarrelsome clansmen vying for the bag of Stewart gold, and little lying Laoghaire of episode 109, mayhap there is sufficient time for welt-healing?

“I can tell you from my own experience that a good hiding” does leave marks for a bit (my dad believed in spanking, did yours?). Then again, mayhap the Starz folks were expecting a firestorm over the belting and didn’t want to remind or re-inflame “conscientious objectors.”

Laceration: The next wound is a laceration, best defined as a slash or tear of soft tissues. Lacerations of the skin are open wounds with rough and ragged margins that are often contaminated with bacteria and debris.

Claire treats a major laceration at the gathering; Dougal requires her medical expertise for the boar tynchal. Being the English lass that she is, Claire is rather cross and feels sorry for the hairy “pig” (scientific name: Sus scrofa). With tusks measuring 10-12 cm (3.9 – 4.7”) in length (Starz episode 104, The Gathering), these animals can run up to 40 km/hr (~25 mi/hr) and jump to a height of 140-150 cm (55-59”)! No wonder Rupert tells Claire, “you’ve clearly never seen a boar!” Here are Claire’s thoughts from Outlander book:

Seeing the large number of men who set out for the east wood, armed to the teeth with boar spears, axes, bows, quivers, and daggers, I felt a bit sorry for the boar.

Turns out, a young man riding his horse in the woods suffers a boar-gore (Starz episode 104, The Gathering)! Yep, it is major laceration that tears open skin, subcutaneous tissue, fascia and tibialis anterior muscle of his right leg (Anatomy lesson #9 and Anatomy Lesson #27). That wound is going to require a mess of stitches! Does Claire amend her opinion about boars? Aye, she does! Herself explains, again from Outlander book:

This attitude was revised to one of awed respect an hour later, when I was hastily summoned to the forest’s edge to dress the wounds of a man… “Bloody Christ!” I said, examining a gaping, jagged wound that ran from knee to ankle. “An animal did this?… “Never mind,” I said, and yanked tight the compression bandage I had wound about the injured calf. “Take him up to the castle and we’ll have Mrs. Fitz give him hot broth and blankets. That’ll have to be stitched, and I’ve no tools for it here.”

Sadly, the most horrific lacerations are suffered by our handsome Highland hero, Jamie. His back is scourged twice, the second time by cruel, cunning Jack-the-Ripper who uses a cat o’ nine tails enhanced with lead plummets, designed to rip and tear flesh! Herself explains in Outlander book:

A few minutes later, Randall came out, the whip tucked under his arm, and the lead plummets at the tips of the lashes clicking softly together as he walked. He had surveyed Jamie coolly, then motioned to the sergeant-major to turn the prisoner around to show his back.

and again:

Now, scourging a man is never a pretty business, but there’s ways to make it worse than it might be; strikin’ sideways to cut deep, or steppin’ in wi’ a hard blow ower the kidneys, for instance.” He shook his head. “Verra ugly.”

Images of Jamie’s horrific lacerations are permanently seared in our brains (Starz episode 106, The Garrison Commander). Geez, talk about open wounds!

BJR’s demented mind cooks up more dirty deeds: Jamie’s fingers are lacerated after the cray-cray Captain uses a mallet to tear skin and break bones (Starz episode 116, To Ransom a Man’s Soul). His laceration wounds are thoroughly described in Outlander book:

I saw the two heads close together for a moment, then Murtagh’s sinewy hand gently touch the younger man’s ear—one of the few uninjured spots available…

The compound fracture of the middle finger was the worst to contemplate. The finger would have to be pulled straight, drawing the protruding bone back through the torn flesh.

Jamie did scream—loudly—when I set his middle finger, exerting the considerable force necessary to draw the ends of splintered bone back through the skin… the sharp bone end slowly disappeared back through the skin and the finger straightened with agonizing reluctance, leaving us both trembling…

Learn more about Jamie’s puir hand in Anatomy Lesson #22 and Anatomy Lesson #23.

Incision: The incision is an open wound that differs from the laceration because it is made by a sharp cutting instrument such as knife, razor or glass edge. The margins of an incision are sharp and well-defined with “tidy” edges.

The opening credits of season one Outlander include suturing an incision wound, a treatment made easier by its straight, sharp margins. Mayhap this is an earlier version of the sword wound Jamie suffers during clan MacDonald’s Big Mac-Attack at the residence of the Duke of Sandringham (Starz episode 110, By the Pricking of My Thumbs)?

Using what appears to be an over and over continuous suturing technique, a carpet needle and sewing thread, Claire (?) stitches Jamie’s (?) incision wound. Today, many different suturing techniques are available depending on the site and type of wound. There are also different types of suturing materials, needles, stitches, and knots as well as closures without sutures such as staples and glue. The clean margins permit incision wounds to be closed and they may heal with minimal scarring. Notice the realistic swelling around the wound below? More about the science behind the swelling (not that one – snort!) in a future lesson!

Projectile Injury: Projectiles are objects that are propelled forward by an external force; thus, a launched stone is a type of projectile. Projectiles typically cause open wounds and probably the best-known type is the gunshot wound (GSW). The degree of tissue disruption caused by a projectile is related to its kinetic energy, yaw (twist), fragmentation of the projectile, etc., features that especially apply to a GSW.

I certainly am not a munitions expert but here is my understanding (Ed, if this is wrong, please correct!): today’s standard NATO weapon (M16 rifle) fires a cartridge that measures 5.56 mm (0.22”) in diameter. But an 18th century musket ball ranged from 13 to 19 mm (.51 – .75”) in diameter – one humongous projectile!!

The first musket-style weapon we see in Outlander is fired by the unruly hand of bad-ass, Angus as he shouts insults at pursuing redcoats (Starz episode 101, Sassenach)! Take a look at the length of the fireball issuing from the mouth of his pistol!

We do not see Angus’ pistol all that closely so let’s try again. The next image shows the huge gaping muzzle of darling, daring Dougal’s weapon (Starz, episode 104, The Gathering)! Indeed, that firearm is capable of launching a very large projectile, which it just did; one large hairy “pig” lies dead at Claire’s feet. Nice shot, hot shot! Gawd, Big D is one verra fine-looking Highlander!

OK, what about projectile wounds? Until about 1880, the standard practice for treating such wounds 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.

Now, a musket ball not only large, it is a low velocity projectile so, its sheer mass literally plows (yikes!) a path through the 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 (MBW), he/she often succumbed to the effects of a subsequent amputation or infection. Claire kens that full well as she assesses a redcoat’s gunshot wound (Starz episode 106, The Garrison Commander).

When Claire first sets eyes on Jamie in 1743, he is a mess. Along with the dislocated shoulder, he also suffers a MBW. Herself ’s words from Outlander book:

I gasped, as did several of the men. The shoulder had been wounded; there was a deep ragged furrow across the top, and blood was running freely down the young man’s breast… “Fell wi’ my hand out, when the musket ball knocked me off my saddle.”

Claire quickly discovers that the clansmen know zip about proper treatment of a projectile wound – no 20th century medical supplies for puir Jamie!

Eyebrows rose all around. “Disinfected?” said the small man*, carefully. “Yes, indeed,” I said firmly,… “All dirt must be removed from the wound and it must be treated with a compound to discourage germs and promote healing.” “Such as?” “Such as iodine,” I said. Seeing no comprehension on the faces before me, I tried again. “Merthiolate? Dilute carbolic?” I suggested. “Or perhaps even just alcohol?” Looks of relief.

*That will be Angus. hee, hee!

In Starz episode 101, Sassenach we see that the musket ball penetrated Jamie’s right neck web and traversed his trapezius muscle (Anatomy Lesson #2). Another quote from Outlander book:

“Well, a musket ball through the trapezius might be considered a good reason,” I said dryly. He looked amused, fingering the area in question. “Trapezius, is it? I didna know that.”

Jamie is one lucky laddie that Nurse Claire is around to properly treat that convincing MBW! See the BIG old hole that looks like crater? That is from the musket ball bulldozing its way through Jamie’s flesh. See the bright red blood draining from the wound and the darker red-black blood in its center? These are accurate and realistic special effects; such a projectile bursts blood vessels most of which carry oxygenated (bright red) blood. The base of the crater will quickly form the red-black blood clot. Again, way to go special effects team! Rah! Rah!

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

If the penetrating 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 a GSW might be categorized as both a projectile and a penetrating wound.

Horrible Horrocks meets-and-greets a terminal penetrating/perforating wound administered by the trembling hands of Ian Murray (Starz episode 113, The Watch)! Now, we can be assured that Ian did not attend Professor Angus’ stabbing lesson (Starz episode 108, Both Sides Now). Otherwise, Ian would have known that it is hard enough to slip a sword between the ribs with the blade in a horizontal position but impossible to stab through the thoracic cage (Anatomy Lesson #15) with a sword blade oriented vertically. No way, Jose! Why? Because the ribs are separated by a narrow 1/2” (1.25 cm) gap that follows a curved plane – no vertical blades allowed! Mayhap a verra looong ice pick? More visually dramatic, though, to be sure. Buh-bye Horrocks!

That’s all of the traumatic wounds for today. Turning serious again, let’s close this lesson with a sad anecdote, but one I always shared with students during heart lectures. Like me, you may miss “Crocodile Hunter”, Steve Irwin (1963-2006, Photo A), who died at the tender age of 44 in a bizarre accident. While filming an underwater documentary, a stingray barb pierced the chest wall and punctured his heart. The barb was removed aboard ship and he swiftly bled out through the hole left in his heart wall! This was a penetrating wound.

A similar accident occurred in the US state of Florida. One month after Steve suffered his fatal wound, an 81 y.o. Florida man was struck in the heart with a foot long stingray barb while fishing (Photo B). Leaving the barb in place, he rowed himself back to the dock (one tough hombre) for help. It took two surgeries, but doctors removed the barb, repaired the hole in his heart and he survived the attack. This was also a penetrating wound.

Here’s the take-home message I learned from my surgeon colleagues: if you encounter a penetration wound in which the penetrating object is still in place, do not attempt to remove it in the field! Instead, get the victim transported to the nearest emergency room ASAP so professionals can remove it under medically-controlled conditions.

Why not remove it yourself? Because the embedded object usually exerts pressure on surrounding torn blood vessels which helps to retard blood loss. When the object is removed, the resultant blood flow may not be easily staunched especially if a vital organ is involved.

So, did we find all the types of traumatic injuries in Outlander episodes? Well, we found six of seven!  We didn’t see an avulsion injury because there wasn’t one in the episodes. Hope you learned something new and useful!

See Roger’s cricothyroidotomy scar in Outlander episode 508, Famous Last Words.

Roger-the-dodger, dodged an awful fate. Kudos to MIL! 👏🏻👏🏻👏🏻

Wow! Dr. Claire continues to impress! 😲

The deeply grateful,

Outlander Anatomist

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Photo credits: Sony/Starz; Associated Press, 2006 newspapers (Photo B); www.en.wikipedia (Photo A); Kumar, Abbas and Fausto, 7th ed., Robbins and Cotran Pathologic Basis of disease, Elsevier and Saunders