107: Gueule de bois (The Hangover)

The end of The Garrison Commander left us with Claire drinking large amounts of whisky and coming to terms with the fact she would tomorrow be marrying a Scot.

wedding contract
source: Starz

One James Alexander Malcolm MacKenzie Fraser, to be exact.

One of my few criticisms of the TV adaptation of the Outlander story was Claire telling Jamie on their wedding day that she couldn’t marry him because she didn’t even know his name. As we just saw above, at the end of The Garrison Commander, Claire is reading the marriage contract which we can see lists Jamie’s full name. However, let us assume perhaps she forgot because of all the whisky.

claire takes the bottle from dougal
source:  Starz

And how about all that whisky?

The next morning, Murtagh wakes a very hungover Claire.  It is time to dress for the wedding in the absolutely breathtaking gown which Ned Gowan has obtained (and hopefully he hasn’t obtained any other lasting gifts from his new friends that night – more on that in a future post!)

hangover claire
source:  Starz

The symptoms of hangover are universally known but scientists are still working to determine what exactly causes it. Some theories include:

1. The effect of the byproducts of ethanol as the body digests it.
After ingestion, ethanol is converted to acetaldehyde by the enzyme alcohol dehydrogenase. It is then converted to acetic acid. Acetaldehyde is more toxic than alcohol itself and remains at elevated levels for many hours after ethanol is ingested.

2. The effect of other substances in the beverage, known as congeners
Many alcohol drinks also contain other substances, either as flavoring or as a byproduct of the fermentation or aging process. These can include amines, amides, acetones, polyphenols, methanol, histamines, esters and tannins, many of which are toxic.

Different types of alcoholic beverages have differing amounts of congeners and in general, the darker the liquor, the higher the concentration. The amount found in bourbon is 37 times higher than that found in vodka.  This doesn’t bode well for our whisky drinking Scots!

3. Dehydration
Ethanol increases urine production (diuresis) and dehydration may be responsible for some of the symptoms of a hangover – thirst, dizziness and lightheadedness. Initially thought to be contributory, studies show that electrolyte changes are minimal after drinking, though.

4. Stomach acid
Nausea and vomiting may be due to the effect alcohol has on the stomach by stimulating the production of hydrochloric acid and delaying stomach emptying.

5. Low blood sugar
Alcohol can cause blood sugar to fall, causing fatigue, weakness and shakiness

6. Effect on blood vessels
Alcohol causes blood vessels to expand, leading to headaches

7. Immune response
Alcohol can cause an inflammatory response, causing the concentration of several cytokines (immune system communication signals) to be significantly increased. In fact, researchers have found if healthy subjects are injected with cytokines, the persons will have the symptoms of hangover such as nausea, headache, chills and fatigue!

8. Genetics
Some ethnic groups have a mutation in the alcohol dehydrogenase gene making the conversion from ethanol to acetaldehyde very fast. Others convert acetaldehyde to acetic acid more slowly and see a larger buildup of the more toxic acetaldehyde than other groups. Accumulation of acetaldehyde causes an alcohol flush reaction – redness to the face, neck and shoulders, or even the entire body, nausea and tachycardia (rapid heart rate).

Remember Henri de Toulouse-Lautrec from our discussion of Colum’s deformed legs?  He was an artist in France at the end of the 19th century who suffered from the condition and for whom it was named.  Below is one of his works depicting a hangover.

lautrec painting hangover
“Gueule de bois” (The Hangover), 1888 by Henri de Toulouse-Lautrec (1846-1901) / (source)

What to do?
1. Hydrate!  
2. Anti-inflammatories! If the mechanism of hangover is an inflammatory response, then anti-inflammatory medications may be the key. In fact, we already saw Claire thinking ahead and stockpiling willow bark for hangovers in preparation for The Gathering!
3. Eat! Get that blood sugar up and eat some carbs. Hopefully Murtagh has brought something for Claire when he came to wake her.
4. Caffeine! If the headache in a hangover is due to dilated blood vessels, then caffeine may counteract this with its action to constrict the blood vessels in the brain.

And if you are in modern day Scotland, packing fluids, caffeine and carbs in the form of  Irn-Bru is the thing to try!
irnbru

An older Scottish cure was the “Highland Fling” –  mix a tablespoon of cornflower into a pint of buttermilk.  Add salt and pepper and drink!

Cornflower has anti-inflammatory properties, so between that, the hydration and fats/carbs it provides, this remedy may be helpful!

cornflower
Cornflower / (source)

Throughout the course of the wedding night, Claire drank no less than eight glasses of whisky by my count.

what claire did all day
source:  Starz

Perhaps someone will be nice enough to prepare a Highland Fling for her!

 

Resources:

Top 10 Hangover Cures from around the World

Hangovers, Why?

A Few Too Many – is there any hope the hungover?

 

 

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106: Surgery in a Tavern

Episode 106: The Garrison Commander

title card
source:  Starz

The opening of The Garrison Commander finds Claire trying to assure the chivalrous Lieutenant Jeremy Foster that she is indeed a guest of the Clan MacKenzie and in no danger. Alas, he doesn’t seem fully convinced and informs Claire that she must accompany him to speak with his commander.

travelling party wide 2
source:  Starz

The Red Coats, Claire, and Dougal arrive in the village which Red Coats have occupied and Claire finds herself feeling some relief, sitting at a lovely meal of venison and charming her countrymen with lively conversation.

meal with countrymen
source:  Starz

Her momentary relief is interrupted first by Captain Jack Randall (more to come) and then by a soldier who rushes in to inform the commander of an attack. Three enlisted men have been fired upon just outside of the camp. One man is dead, two are wounded, one severely, and no one can find the surgeon!

can't find the surgeon
source:  Starz

Claire, of course, is on her feet and ready to help.

Downstairs in the tavern, the wounded soldier is carried to a tavern table. His arm is significantly injured and Claire realizes it cannot be saved. The arm will need to be amputated. Claire takes charge, applying a tourniquet above the wound and instructing the men to bring boiling water and clean cloth.

onto the table
source:  Starz

The surgeon arrives and asks Claire whether she is going to faint when he begins to sew. He clearly doesn’t know our Claire. She assures him that she has seen worse and she directs the other soldiers to hold down the wounded man.

claire takes charge
source:  Starz

The surgeon hands Claire a vial of opium to administer to the wounded soldier. He is given a stick to bite and told to “bite until your teeth crack.”

wood to bite
source:  Starz

Having administered all available methods of anesthesia, the surgeon begins to saw.
The injured soldier is screaming, onlooking soldiers are sprayed with blood and in the corner, patrons of the tavern are still casually enjoying their ale.

tavern onlookers
source:  Starz

 

starting to saw
The gruesome work begins / source:  Starz
amputation tools
Sharp, Samuel. (1761). A treatise on the operations of surgery, with a description and representation of the instruments used in performing them: to which is prefix’d an introduction on the nature and treatment of wounds, abscesses, and ulcers. London: J and L Tonson.  (source)

 

This tavern is far from the sterile operating rooms of today. Surgeries then took place often on kitchen tables with unwashed bare hands, dirty floors and tools that may have at most been wiped with a rag after their last use. It wouldn’t be until the second half of the 19th century that the work of Louis Pasteur, Joseph Lister, Robert Koch and others would revolutionize infection control.

800px-Amputations_18c
Amputations in the 18th century. / source

In 1862, French chemist and microbiologist Louis Pasteur published his findings on the germ theory of infection, challenging the thinking of the time that infections were the result of “bad air” arising from rotting organic matter. In 1867, English physician Joseph Lister demonstrated a reduced mortality rate in his patients by using a carbolic acid on the tools and hands of the operating team as well as in the surgical wound.

Dr. William Stewart Halsted, surgeon at Johns Hopkins Hospital, adopted carbolic acid for antisepsis but it soon became clear that carbolic acid was quite rough on the hands of the surgical staff. In 1889 or 1890, Caroline Hampton, Halsted’s chief operating nurse, developed dermatitis on her hands from contact with the disinfectant. Halsted, who she would marry shortly thereafter, requested the Goodyear Rubber Company make her a pair of thin rubber gloves with gauntlets. They were such a success that within 10 years, surgeons and nurses alike were wearing them.  Dr. Joseph Bloodgood, a protege of Halsted, published a report of a nearly 100% drop in infection rate from data on 450 hernia surgeries after he began routinely wearing surgical gloves.

In 1881, Robert Koch developed sterilization processes using steam and hot air and soon after, sterilization by boiling was introduced. Everything used during an operation from the tools to dressing and gowns were boiled.

These advances led to a marked decrease in post surgical infection and mortality. Prior to the introduction of aseptic techniques, most surgical wounds became infected and drainage of pus was actually expected. In fact, finding “laudable pus” – creamy yellow ooze – on a wound within the first 4 days was considered a sign of good healing. Mortality of surgical infections reached 70 percent. Today, with aseptic techniques in surgery and the use of antibiotics, the incidence of surgical site infection ranges from 2-7% with significantly lower rates of mortality.

modernOR
source

 

It is unimaginable the pain these brave patients would have endured in these invasive surgeries with just a swig of opium and a bite block, if that.

Ancient methods of anesthesia for surgery included ingestion of opium or wine and herb mixtures, inhalation of opium and herbs from a sponge held near the nostrils and even application of cocaine by which Incan shamans chewed cocoa leaves and vegetable ash and let their cocaine-laden saliva drip into the wounds of their patients. It wasn’t until the 1800s that significant progress was made toward adequate anesthesia for surgery.

surgerypainting
“Die Operation” by Gaspare Traversi, 1753. / source

 

Nitrous oxide was first discovered in 1772 by English Scientist Joseph Priestly when he tested it on himself, discovering that the gas made him laugh and would have possible anesthetic properties. In 1844, dentist Horace Wells volunteered to have one of his own teeth extracted under nitrous oxide. He then used it successfully over a dozen more times, and was invited by Dr. John Collins Warren at Massachusetts General Hospital to perform a public demonstration of its use for Warren’s students in 1845. Unfortunately, the gas was administered improperly and the patient cried out in pain and Wells was humiliated, ultimately committing suicide.

Dr. Warren, however, then invited Dr. William TG Morton to demonstrate the use of ether (diethyl ether gas, historically called “sweet vitriol”) to anesthetize a patient as he excised a small neck tumor.  The patient remained unconscious throughout the procedure to the amazement of the audience. Thereafter, the use of inhaled anesthetics spread and evolved so that now, the 18 gauge needle used to start an IV in the pre-op holding area might be the most painful part of a surgery!

 

Later in the episode, Claire is alone with Black Jack Randall. A long discussion could be had about his psychiatric condition, but for today, we’ll discuss the brutal punch he gave Claire and the kicks that he ordered Corproral Hawkins to administer to Claire.  Hit directly in the abdomen, Claire has suffered diaphragm spasm, or more commonly, she had the wind knocked out of her.

gasping2
source:  Starz

When we inhale, the diaphragm contracts, drawing the lungs down and expanding the rib cage. A temporary vacuum is created and air is pulled through the nose and mouth into the lungs. In exhalation, the diaphragm relaxes, the lungs deflate, and air is expelled out of the mouth and nose. A strong kick to the abdomen causes the diaphragm muscles to spasm, unable to contract and relax normally and thus leaving the victim unable to draw a breath. While it is terrifying and panic inducing, having the wind knocked out of you is not life threatening, and resolves on its own in a few moments.

diaphragm
source

Caitriona Balfe is an amazingly gifted actress and this scene is painful to watch. Claire’s gasping, panicked breaths are heartbreakingly realistic.

gasping for air
source:  Starz

Dougal rushes in and saves Claire, leaving Randall under the impression that Claire will be delivered to Fort William before sundown tomorrow.

After proving she is not a spy when her gizzards are not burned out at St. Ninian’s spring, Dougal presents to Claire his plan for keeping her out of the hands of the English.  The episode ends with Claire downing a bottle of whisky as she considers the prospect of marrying a strapping young Scot.

claire takes the bottle from dougal
source:  Starz

Hopefully she has stocked her traveling medical kit with plenty of willow bark to ease the hangover she’ll no doubt have tomorrow!

 

Resources:

Pruitt, BA. (2006). Combat Casualty Care and Surgical Process. Ann Surg. 243(6): 715-729.
https://archive.org/details/treatiseonoperat01shar

A brief history of sterilization

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2312162/pdf/annrcse00248-0008.pdf
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2943454/
http://www.sciencescribe.net/articles/Surgery_in_the_1700s.pdf

105: In Which Ned Smokes a Pipe for his Health

Episode 105:  Rent

Rent Party
source:  Starz

The rent party travels through the MacKenzie lands collecting payment and drumming up support for the Jacobite cause. The medical highlights are the 18th century treatment of asthma and more bumps, bruises and lacerations for our Highlanders.

 

Here we meet the lovely Ned Gowan.  Claire and Ned seem to be kindred spirits, recognizing their shared love for the poetry of John Donne.

ned and claire meet
source:  Starz

It becomes clear Ned is suffering from a respiratory ailment with a persistent cough. He explains to Claire that this cough happens every year, in the same season. Ned suspects it is something in the wind that “sets my lungs afire.”

coughing ned
source:  Starz

Claire has just the solution. She prepares Ned a pipe of thornapple to smoke. Ned sees the irony in this but tries it and indeed is relieved of his symptoms.

lighting the pipe 2
source:  Starz

 

Asthma is a lung disease that causes inflammation and narrowing of the airways in the lungs. The airways of asthmatics are sensitive to particular triggers which vary from person to person but can include airborne allergens (pollen, dander, mold, dust mites), respiratory infections, physical activity, cold air, air pollutants, certain medications, and gastric reflux disease.

Asthma_attack-illustration_NIH
Effects of asthma on the airways / source

These triggers cause the airways in the lungs of asthmatics to become constricted and inflamed, and often obstructed with mucous, what we call an asthma attack, characterized by difficulty breathing, cough, wheezing and chest tightness.

Treatment varies based on the severity of symptoms. Depending on the frequency of symptoms, patients will take asthma controller medications to prevent asthma attacks as well as a “rescue inhaler” to use when attacks occur, specifically, a beta-2-selective adrenergic agonist.

inhalers
© Can Stock Photo Inc. / Merinka

In a nutshell, these medications are modified forms of epinephrine, or adrenaline. Adrenaline stimulates receptors in many parts of the body, particularly in the heart, as well as blood vessels in the body, smooth muscles of the body and smooth muscles of the bronchus and bronchioles, which are part of the airways in the lungs. The inhalers used for the symptoms of asthma primarily have their effect on the group of receptors that relax the airways, minimizing the cardiac side effects.

Less available now, epinephrine inhalers like Primatene Mist have been sold over the counter to treat asthma. As they are not specific for the receptors in the lungs, they effect the beta 1 receptors in the heart and the alpha receptors in the blood vessels, leading to elevated blood pressure, tachycardia (fast heart rate), irregular heart rhythm, chest pain and the risk of stroke.

 

Options were limited, though, for our 18th century friends. Claire has indeed provided Ned with something to relieve his symptoms of asthma.

thornapple
source:  Starz

Thornapple, also called Jimson Weed, is actually in the same family of plants as the belladonna that Claire used to reverse the effects of the poison on the young Tammas Baxter (episode 103:  The Way Out).  Thornapple does not have action on the adrenergic receptors like the medications used for asthma attacks today. Rather, its action in relieving asthma is due to atropine which you’ll recall was the active compound in belladonna as well! In this case, atropine causes bronchodilation, or opening of the airways in the lungs, and reduces the production of mucous in the airways by inhibiting a different receptor in the cells. Thornapple acts more strongly on the lungs than belladonna, making it the preferable choice.

450px-Jimson_Weed_(Datura_inoxia),_opening_flower
Thornapple source

Thornapple, or Jimson weed has long been known to help in asthma and respiratory ailments. As recently as the 1950’s, “asthma cigarettes” containing Jimson weed were widely used. However, as an anticholinergic, it also causes dilated pupils, blurred vision, hallucinations, confusion, competitive behavior and difficulty urinating. Severe toxicity can cause coma and seizures. Of late, it has become a concern of public health officials and the DEA as a drug of abuse.

Ned likely suffers from allergic asthma and reacts to an airborne pollen, given that these symptoms always occur each year during the same season. In the book, Claire falls through the stones near Beltane, in May, and the rent party would be traveling in late spring.  In the Starz adaptation, Claire travels back in time near Samhain so now we are deep in autumn.  Despite Claire’s lovely fur-trimmed traveling coat, perhaps we can still assume the Highlands has not yet had its first frost of the season and autumn allergens are still in the air.

 

A very interesting tidbit I came across was that Scotland has the highest allergy rates in the world with 1 in 3 Scots affected by asthma, eczema and allergies! Researchers suspect this is due to low levels of Vitamin D absorbed from the sunlight, particularly during the long winter months. I do wonder, though, whether the 18th Scots would have been affected by the lack of sunlight as much as their 21st century countrymen as the very nature of their day to day life had them outside quite a bit more.

 

Rent collecting continues. Claire is winning the respect of the men. At the last tavern, the MacKenzie men defend Claire’s honor, resulting in 3 split lips, 2 bloody noses, 12 smashed knuckles and 4 loosened teeth. And a partridge in a pear tree? Claire is becoming very experienced in caring for bruised and battered Highlanders.

poor angus
source:  Starz

 

The episode closes with Dougal questioning Claire again about her identity when they are approached by a large group of redcoats. This can’t be good.

 

Resources:

https://www.aacc.org/community/divisions/tdm-and-toxicology/toxin-library/jimson-weed

http://www.australianprescriber.com/magazine/26/2/33/5
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5904a3.htm

http://www.deadiversion.usdoj.gov/drug_chem_info/jimson_w.pdf

http://www.deadlinenews.co.uk/2012/10/26/lack-of-sunlight-could-explain-why-scots-have-worlds-highest-allergy-rate/

http://medplant.nmsu.edu/Diseases/asthma/asthma_JimsonWeed.htm

http://www.ncbi.nlm.nih.gov/m/pubmed/9274142/

http://www.deadlinenews.co.uk/2012/10/26/lack-of-sunlight-could-explain-why-scots-have-worlds-highest-allergy-rate/

Malick, MJ.  (2014).  21st Century Herbal:  A Practical Guide for Healthy Living Using Nature’s Most Powerful Plants.  New York, NY:  Rodale

Orr, S.  (2014).  The New American Herbal.  New York, NY:  Clarkson Potter.

104: Quite a Show of Force for a Pig Hunt!

Episode 104:  The Gathering

All of Clan Mackenzie is making their way to Leoch for the Gathering and Claire hopes the crowds and excitement of this will mean an easy escape for her.  She busies herself with learning the lay of the land and leaving crumbs for herself in the form of hair ribbons, all under the guise of childsplay as the sentries watch on.

If only she could figure out a way to lose Angus and Rupert who have been tasked with watching her every move.

claire's shadows
Claire’s ever-present shadows / source: Starz

Geillis surprises Claire in her surgery one day amidst all of the preparations.  She has brought a bottle of port Claire requested.  Geillis notices that Claire seems to have a very large supply of valerian root and explains that she doses her husband with it so make him sleep so in turn she can too.  Claire’s plan for diversion for her ever-present shadows Angus and Rupert is becoming clear.

Valerian root is known as “herbal Valium” due to its ability to calm the central nervous system and relax muscles.  In fact, valerian root contains a chemical that activates parts of the brain similar to those affected by benzodiazepines like Valium and Ativan.  Benzodiazepines act by enhancing the effect of the neurotransmitter GABA (gamma-aminobytryic acid), resulting in sedative, hypnotic (sleep-inducing), anxiolytic (anti-anxiety) and muscle relaxant effects.

Claire indeed has a plan.  She has added valerian root to the port she has obtained from Geillis.  The addition of a sedating medication like valerian root to alcohol will make the sedative effect even stronger.  After Angus takes his oath before Colum, Claire begins to head back to the surgery, to prepare for the hunt, she says.  Poor Angus does not want to miss out on the festivities and begs Claire to stay at least until he “bags a lass for the evening.”  Our smart Claire seems to surrender and takes a swig of the port she has in her pocket and then offers it to Angus but she spits out the doctored port while Angus is too busy drinking a good half of the bottle in one swig to notice.

claire offers port
Bottoms up! / source:  Starz

Ah, Angus.  Gotta love him.

“That’s no Rhennish!”
“Its port. Very expensive.”
“Port. ‘Tis very strong.”
“’Tis.”
“Canna seem to keep my legs!”
“Its a sedative.”
“Is that Spanish?”

silly angus drinking
‘Tis verra strong!  / source: Starz

Claire offers Angus the bottle of port to share with his friends and he is quickly off into the crowd.  Claire can now escape to the surgery to gather her supplies and disappear from Leoch.

But alas, her plans again are foiled when she literally stumbles upon Jamie in the stable.  He points out that there is no hope of escape tonight, when Dougal has reinforced the guard around the castle during the Gathering.  Back to the castle they head and Jamie is unexpectedly presented to take his oath as well.

 

Early the next morning after the oath taking, the men are preparing for the boar hunt. Claire in unimpressed. “Quite the show of force for a pig hunt.” Little does she know… A healer will be needed!

boar
source:  Starz

We spy the hairy beast and its sharp tushes (actually the long, sharp, continuously growing canine teeth of the animal) and shortly after, we have our first victim. A hunter is off of his horse with a leg wound.  Claire examines him and reports that the wound needs to be sutured but as she does not have any sterile instruments out here, he should be brought back to the castle for Mrs Fitz to provide hot broth and blankets and await her return to suture up the leg.

Asepsis, or performing medical procedures under sterile conditions, was not developed until the 19th century.  Claire would be well versed in it, of course, having trained in the 20th century, and while her Highland companions likely think her ideas bizarre, they have a gift in Claire who is likely making a significant improvement to the outcomes of their traumatic injuries.

 

Claire then hears screaming and is off running.  She hears the grunting of the boar.  It is near.  The animal comes charging at Claire but she is saved by a clean shot from Dougal, dropping the beast at her feet.  They then hear the cries of an injured man.

dougal holds geordie
source:  Starz

Claire finds Dougal holding a dying Geordie.  He has been gored and has a large wound to his thigh.  Blood is rushing out of it in a steady flow, but not spurting.  Claire feels confident it is not an arterial bleed and likely can be stopped.  A tourniquet is applied above the leg wound, but then we see the extent of his other injuries.  Poor Geordie suffers from a substantial penetrating wound to his abdomen, which has resulted in eviscerated and punctured small intestine.  This is a life-threatening injury, even now, and Claire knows that with this horrifying injury, Geordie will surely die of infection.  Even at the end of World War 2, with the availability of antibiotics and surgical repair, mortality from penetrating abdominal trauma was as high as 36%.  Perforation of the intestine leads to bacterial contamination of the abdominal cavity.  This in turn leads to sepsis, multi organ failure and death.  Indeed, during that era, mortality of penetrating abdominal wounds with involvement of the small bowel was about 100%.

Dougal loosens the leg tourniquet and allows Geordie to bleed out.  He dies in the fresh air, quickly, of blood loss, rather after spending days in the castle with a festering abdominal wound and a slow painful death.

A better death, perhaps, was what Dougal was giving him – to die cleanly under the sky, his heart’s blood staining the same leaves, dyed by the blood of the beast that killed him.
From Outlander by Diana Gabaldon, Chapter 10.

 

The somber hunting party arrives back at Leoch amidst a game of shinty.  Claire watches on, no doubt counting the casualties she will soon see in her surgery as all of the men limp inside at the conclusion of the game.

Claire watching shinty
Counting the shinty casualties /  source: Starz

Dougal arrives in the surgery and, in his own way, praises Claire’s healing work with Geordie and the other residents of Leoch.  He intends to bring her along on the rent party. “I think it would be wise to have a healer along.  Especially one that does well under strain and there’s a lot of that on the road.”

Claire sees this as an opportunity to escape.  Ever the optimist, little does she know what lies ahead.

 

Resources:

Malick, MJ.  (2014).  21st Century Herbal:  A Practical Guide for Healthy Living Using Nature’s Most Powerful Plants.  New York, NY:  Rodale.
Orr, S.  (2014).  The New American Herbal.  New York, NY:  Clarkson Potter.
Porter, R (Ed.).  (1996).  The Cambridge Illustrated History of Medicine.  Cambridge, UK:  Cambridge University Press.
Pruit, BA. (2006). Combat Casualty Care and Surgical Progress. Ann Surg, 243(6): 715-729.
Rignault, DP.  (1992).  Abdominal trauma in war.  World Journal of Surgery, 16, 940-946

103: Demonic Possession, Woodlice and Tetanus, Oh My!

Episode 103:  The Way Out

title card with title
source:  Starz

This beautiful title card promises an episode about medicine!

The medicine bottle reads “ELIX: PECTOR: WED.”  I found on the Smithsonian Institute website’s online collection a very similar bottle, labeled “ELIX PECTORAL WED” which dates from the 18th century and would have held Wedel’s Pectoral Elixir, made by Georg Wolfgang Wedel (1645-1721) for chest ailments.  This medicine consisted of benzoic acid, ground irises, sugar, fennel oil and sulphur for the treatment of cough and congestion.  I love the attention to detail both in this series of books and the show!

 

Claire spends time exploring the surgery and all of the tools and medicines Davey Beaton has left behind.

davey beatons chest
source:  Starz

 

Among them are slaters which, it turns out, are live wood lice.

woodlice
source:  Starz

Apparently, in the past these have been thought to be medicinal and helpful for digestive ailments when swallowed whole.  No, thank you!

 

Claire busies herself, caring for the residents of Leoch.  Here, she fashions a splint for an injured wrist.

wrist splint close
source:  Starz

 

She is summoned to Colum’s chamber where he tells her that Davey Beaton used to massage him to ease his pain and make movement easier.  He hopes Claire will do the same for him.

colum legs in mirror
source:  Starz
colum legs on table
source:  Starz

Indeed this is likely very helpful to Colum in easing his pain, stretch sore or atrophied muscles and reduce muscle spasms.

 

Claire later visits Geillis Duncan’s home to stock up on medicines she may need when the clan has gathered at Leoch, in particular white willow bark for whiskey headaches!  Aspirin, even its earliest forms, has a long history with hangovers!

geillis study
source:  Starz

Claire witnesses a crowd surrounding the tanner’s lad who has been accused of stealing two bannocks. Geillis Duncan’s husband, Arthur, is the procurator fiscal for the district and must determine the boys fate.

caustic arthur duncan
Poor Arthur is feeling caustic again / source:   Starz

Arthur Duncan seems to suffer perhaps from both indigestion or acid reflux as well as quite a bit of flatulence.  He asks Geillis for peppermint to help.  Peppermint has been used medicinally for over 10,000 years and is often used for digestive problems.  It has anti-inflammatory and antispasmodic properties and also is a cholagogue (promotes discharge of bile from the biliary tract).  We don’t yet know what ails Mr. Duncan (though readers of the book know we soon will), but the peppermint seems to do the trick for him and he leaves in better spirits, much to the benefit of the tanner’s lad who will get to keep his hand today.  Instead, he will be sentenced to “one hour in the pillory and one ear nailed.”

 

pillory ear 2
One ear nailed / source:  Starz

The poor tanner’s lad.  In addition to the risk of bacterial infection of his wound and obvious lasting deformity, this (hopefully rust free) nail through his ear puts him at risk for tetanus.

Tetanus is a life-threatening disease caused by the bacteria Clostridium tetani.  The spores of this organism can survive in soil or on surfaces for years.  Most cases follow an injury such as puncture wound, laceration or abrasion, particularly from a rusted nail or similar object.  Infection occurs at the site of injury and an exotoxin produced by C. tetani, called tetanospasmin, spreads to the nervous system causing muscle rigidity, violent muscle contractions and instability of the autonomic nervous system. Difficulty swallowing, difficulty breathing, heart abnormalities and even sudden cardiac arrest can occur.  Patients will suffer from stiffness and pain in the masseter muscles of the face responsible for chewing, resulting in lockjaw, the common name for tetanus. Symptoms begin in the face and progress downward.

Tetanus is almost completely avoidable with vaccination.  Vaccination for tetanus began in the US in the 1940s, when there were approximately 580 cases of tetanus reported in the US and 472 deaths.  Most recent data shows this has decreased significantly to 41 cases and 4 deaths in the 2000s.

Modern day treatment of tetanus includes administration of tetanus immune globulin to neutralize the tetanospasmin toxin, muscle relaxants, temporary induced coma if needed and medications to mitigate the effects of the autonomic nervous system dysfunction. Mortality of tetanus is around 10-20 percent.  Of the cases reported in the US, about 90 percent had not received appropriate tetanus vaccination and indeed this disease primarily affects non-vaccinated and under-vaccinated people.  Remember to get your tetanus booster every 10 years!

 

Throughout the course of this episode, Claire has been learning that the son of Colum’s chambermaid has died after visiting the Black Kirk.  His friend, Tammas Baxter, who visited the kirk with him is possessed by the devil and near death.

Claire, of course, suspects otherwise.

home of poisoned boy
Young Tammas, seized with evil / source:  Starz

She visits the boy and notes he has no fever and likely does not suffer from an infection. Rather, she notes that his heart rate is slow and his pupils are constricted to pinpoints and she suspects poisoning.

Jamie accompanies her to the Black Kirk where her fears are confirmed.  Jamie explains that the boys who visit the kirk to prove their manhood often eat berries and wood garlic there. Wood garlic is an edible plant related to chives.

black kirk
The Black Kirk, where demons roam free / source:  Starz

Except it isn’t wood garlic.  It is lily of the valley.

black kirk plant 3
source:  Starz

Lily of the valley is a highly poisonous plant that contains cardiac glycosides. These chemicals act by inhibiting cellular function leading to dangerously elevated potassium levels, slowing of the heart rate and potentially fatal abnormal heart rhythms, as well as nausea, vomiting, diarrhea, abdominal pain and confusion.

Allium_ursinum0
Wood Garlic (source)

 

Convallaria_majalis_0002
Lily of the Valley (source)

Claire has identified the poison and now has to figure out a way to counteract the effect of the poison using the tools and medicine she has at her disposal in the 18th century.

 

The cardiac glycosides of lily of the valley are very closely related to the modern day medicine digoxin. Digoxin is used to treat patients with heart conditions like atrial fibrillation, where it controls ventricular rate and in heart failure in which it can increase contractility of the heart. If a child like this young boy presented today with cardiac glycoside poisoning, either from consuming plants like lily of the valley or oleander or from ingesting digoxin, digoxin-specific antibodies would be administered. These would bind to the cardiac glycosides circulating in his body and they would be excreted from his body via the kidneys.

However, this wouldn’t be on Claire’s radar as they were not developed until later in the 20th century.

She must figure out a way to counteract the effects of lily of the valley, in particular his slow heart rate, and our brilliant heroine recalls that another toxic plant, deadly nightshade or belladonna, contains atropine as an active component. She knows that atropine will act to increase the heart rate. Belladonna in this case will potentially act to counteract the slowed heart rate which can be fatal to our patient Tammas.  The hope would be that she can mitigate the dangerous effects of the poison until the boy’s body has metabolized and excreted it.

This is risky business, though, as Claire points out. “…but if I was wrong about the dosage or the original poison, it will cause convulsions and kill the boy just as quickly.”  Indeed belladonna is a poison in its own right. She has no way of knowing the quantity of active medication she is administering and she is taking a big gamble, but it appears the boy will die without her intervention and it is a risk that proves successful in the end.

She administers a concoction of belladonna to the boy and within minutes he is awake and talking and recovering.  A miracle!

Happy Family
source:  Starz

 

Claire hopes that this has garnered favor with the brothers MacKenzie and will persuade them to allow her to travel to Inverness.  Jamie, however, informs her that Colum is taking credit for bringing Claire and her gift of healing to the MacKenzies and likely won’t want to see her leave any time soon.

Yet Claire is determined to get back to the stones and to frank. Or die trying. And we know our girl is stubborn, resourceful and not averse to big risks…

 

Resources:
http://americanhistory.si.edu/collections/search/object/nmah_993857
Adams, C. (2014). Herbal Medicine: 100 Key Herbs With All Their Uses As Herbal Remedies for Health and Healing. CreateSpace.
Fauci, AS, Braunwald E, Isselbacher KJ, Wilson JD, Martin JB, Kasper DL, Hauser SL, Longo DL. (Eds.). (1998). Harrison’s Principles of Internal Medicine (14th ed.). New York, NY: McGraw-Hill.
Roush, SW, Murphy TV and the Vaccine-Preventable Disease Table Working Group. Historical Comparisons of Morbidity and Mortality for Vaccine-Preventable Diseases in the United States. JAMA. 2007;298(18)2155-2163.
Tintinalli, JE, Kelen, GD, Stapczynski, JS. (2000). Emergency Medicine A Comprehensive Study Guide (5th ed.). New York, NY: McGraw-Hill.

102: Herbs, Mushrooms and Leeches

Episode 102:  Castle Leoch

leoch
source:  Starz

Claire and the Highlanders arrive at Castle Leoch to a warm welcome.

Does anyone else see a bit of Mrs. Patmore in Mrs. FitzGibbons?

happy fitz
source:  Starz
patmore smile
source:  PBS

After giving Claire the once over, Mrs. Fitz guides Claire inside and allows her to tend to Jamie’s wound.  In addition to the shoulder dislocation, Jamie has suffered a gunshot wound to the shoulder which Claire tells Mrs. Fitz has not been cleaned or dressed properly.

 

Mrs. Fitz brings supplies to Claire including rags, garlic and witch hazel with which to boil the rags, and comfrey and cherry bark as what seems to be a compress for the wound.

Garlic has anti-inflammatory properties, as well as antibiotic, anti fungal and antiviral properties, which make it a good choice for the treatment of a wound.  Witch hazel is used as a remedy for skin sores, bruising and swelling.  Comfrey contains allantoin which is a substance thought to aid in wound repair and possess anti-inflammatory activity.  Cherry bark as well is used to soothe rashes and skin ailments.  Mrs Fitz is a wise woman and healer in her own right!

Claire examines Jamie’s wound and begins to clean it.

cleaning wounds
source:  Starz

Claire dresses the wound and puts Jamie’s injured arm in a swathe, wrapping fabric around Jamie to hold his arm against his body to immobilize it.

swathe
source:  Starz

 

A very travel weary Claire (travel weary may be an understatement after where she has been!), Mrs. Fitz dresses Claire.  It is time to meet The MacKenzie.

Claire is brought to Colum’s chamber where she meets him for the first time. She sees the deformity of his legs and identifies that he likely suffers from Toulouse-Lautrec Syndrome.  Despite years of medical school, residency and medical practice, I had some learning to do myself regarding this disease!  It is impressive that Claire is able to retrieve from her mind the name and characteristics of the disease.  My guess is she must have had a reason to remember it, perhaps from caring for a patient with it during her years as a nurse.

centered colum legs back
source:  Starz

Toulouse-Lautrec Syndrome is a disease which causes abnormality in the process of breaking down and rebuilding bones.  Throughout our lives, bones are continuously undergoing remodeling, with osteoblast cells forming new bone and osteoclast cells breaking down bones in a process to maintain bone mass.  In adults, approximately 10% of bone mass is replaced each year.

Also called Pycnodysostosis (sometimes spelled Pyknodysostosis), this disease is caused by an abnormal gene responsible for an enzyme called cathepsin K. Cathepsin K is important in the cells of normal bone that are responsible for bone reabsorption.  Without the normal function of this enzyme, bones do not undergo their normal process of bone reabsorption and they become dense and brittle.  This leads to fragile bones and frequent fractures with poor healing, as well as other hallmark findings such as large skull, short stubby fingers, dental abnormalities, small chin, hooked nose and an open fontanelle (or soft spot as we are familiar with in infants) in the skull.

The disease is named for one of the most famous patients to suffer of it, artist Henri de Toulouse-Lautrec.

Photolautrec
source

 

Shortly thereafter, Claire meets Geillis Duncan, who seems to share Claire’s love of botany and medicinal plants.

“Those kind are poison,” Geillis notes of the mushrooms Claire is examining.

poison mushroom
source:  Starz

As I am not a mycologist, I haven’t positively identified the mushroom which Claire is holding in this shot.  And in fact, she is not holding a mushroom of the same variety  described in the book, this one being whitish in color and the book referring to the bright red Ascaria variety.

It was on one of the fruit-picking expeditions to the orchard that I first met Geillis Duncan. Finding a small patch of Ascaria beneath the roots of an alder, I was hunting for more. The scarlet caps grew in tiny clumps, only four or five mushrooms in a group, but there were several clumps scattered through the long grass in this part of the orchard.
[…]
“Those kind are poison,” said a voice from behind me.  I straightened up from the patch of Ascaria I had been bending over, thumping my head smartly on a branch of the pine they were growing under.
As my vision cleared, I could see that the peals of laughter were coming from a tall young woman, perhaps a few years older than myself, fair of hair and skin, with the loveliest green eyes I had ever seen.
“I am sorry to be laughing at you,” she said, dimpling as she stepped down into the hollow where I stood. “I could not help it.”
“I imagine I looked funny,” I said rather ungraciously, rubbing the sore spot on top of my head. “And thank you for the warning, but I know the mushrooms are poisonous.”
“Ooh, you know? And who is it you’re planning to do away with, then? Your husband, perhaps?  Tell me if it works, and I’ll try it on mine.” Her smile was infectious, and I found myself smiling back.
I explained that though the raw mushroom caps were indeed poisonous, you could prepare a powdered preparation from the dried fungi that was very efficacious in stopping bleeding when applied topically. Or so Mrs. Fitz said;  I was more inclined to trust her than Davie Beaton’s Physician’s Guide.

From Outlander by Diana Gabaldon, Chapter 9

I’m unable to identify the Ascaria mushroom in my research and I wonder if it was indeed the Amarita muscaria mushroom which is a poisonous mushroom of bright red color.

Fly_Agaric_mushroom_05
source

The A. muscaria mushroom contains the toxins muscimol and ibotenic acid.  Both compounds mimic neurotransmitters in the brain, and ingestion of them causes nausea, low blood pressure, sweating, auditory and visual hallucinations, mood changes and loss of equilibrium.  Severe poisonings can cause coma and seizures.

There is no antidote for A. muscaria poisoning.  These patents are treated with supportive care, meaning supporting the function of the body until the effects have worn off.  Today, this may include activated charcoal and gastric lavage (“pumping the stomach”) to prevent absorption of the toxins, if presenting for emergency care early in the course of illness. Benzodiazepines like Ativan or Valium may be given for agitation or seizures.  Intravenous fluids and electrolyte replacement are generally needed.  With good supportive care, the outcome is often good.

 

The end of this episode once again finds Claire tending to a wounded Jamie. This poor man.  After taking the beating in the hall for Laoghaire, Jamie has sustained lacerations and contusions to his face.

tending jamies face
source:  Starz

Again, Mrs. Fitz has arrived with useful medicines for our injured Jamie.  Willow bark tea would be the 18th century version of aspirin.  Willow bark tea contains salicin which is a chemical very similar to acetylsalicylic acid, the active ingredient in aspirin. These wise Highlanders recognized the ability of salicilates to reduce inflammation and relieve pain.

Those who have seen the deleted scenes from episode 102 on the Season 1 DVD may remember an extended scene in which Mrs. Fitz applies leaches to Jamie’s swollen face.

She examines his eye and says, “Still bleedin’ under the skin. Leeches will help. Too many folk misuses leeches. Very helpful sometimes but you must understand how. When you use them on an old bruise, they just take healthy blood and it does the bruise no good.” She allows the leeches to remain on Jamie’s face for a bit and upon removing them, the swelling is markedly improved.

 

leeches
© Can Stock Photo Inc. / szefei

While modern medicine has moved past blood letting as a method of balancing the humours, leeches are indeed still used in healthcare!  Hirudotherapy, or the application of leeches, is used in reconstructive plastic surgery to aid in situations of venous congestion postoperatively to clear excess blood until normal blood flow is restored in the venous capillaries of the surgical site, generally over 2-6 days.  It would seem that Mrs. Fitz’s use of the leeches here to clear the excess blood in the contusions on Jamie’s face would be a very reasonable approach and will allow him, as she says, to see out of that eye tomorrow, rather than have it swollen shut!  I’m foreseeing potential applications for this technique on victims of bar room brawls that end up in the ER!

 

The episode closes with Colum informing Claire that she will not be transported back to Inverness but instead will remain at Castle Leoch.  The previous healer in residence has died and Leoch is in need of a healer.  Or so he says.  Claire finds herself more or less a prisoner now of the MacKenzie. A prisoner in the surgery. A victim of her own success?

prisoner in sugery
source:  Starz

 

Resources:
http://www.doctorsreview.com/history/picture-imperfect/
http://www.medicinenet.com/pycnodysostosis/article.htmAdams C. Herbal Medicine: 100 Key Herbs with All Their Uses as Herbal Remedies for Health and Healing, 2014.
Fauci, AS, Braunwald E, Isselbacher KJ, Wilson JD, Martin JB, Kasper DL, Hauser SL, Longo DL. (Eds.). (1998). Harrison’s Principles of Internal Medicine (14th ed.). New York, NY: McGraw-Hill.
Mumcuoglu KY. (2014). Recommendations for the use of leeches in reconstructive plastic surgery. Evidence-Based Complementary and Alternative Medicine. Volume 2014.
Porshinsky BS, Saha S, Grossman MD, Beery PR, Stawicki SP. (2011). Clinical uses of the medicinal leech: a practical review. J Postgrad Med. 57, 65-71.
Xue Y, Cai T, Wang W, Zhang Y, Mao T, Duan X. (2011). Clinical and animal research findings in pycnodysostosis and gene mutations of cathepsin K from 1996 to 2001. Orphanet Rare Dis. 6, 20.
Zaftig P, Hunziker E, Wehmeyer O, Jones S, Boyde A, Rommerskirch W, Mortiz JD, Schu P, Von Figura K. (1998). Impaired osteoclastic bone resorption leads to osteopetrosis in cathepsin-K deficient mice. Proc. Natl. Acad Sci. USA. 95, 13453-13458.

101: Soldiers and Shoulders

Episode 101:  Sassenach

From a medical standpoint, the first episode highlights the treatment of two trauma patients: one in 1945 and one in 1743.

101fieldhospwide.png
source:  Starz

Episode 101 opens in an open air World War 2 field hospital with Claire caring for a soldier with an extensive open thigh injury with a spurting femoral artery.  Claire is bare handed and up to her elbows in blood and trying to clamp the artery to prevent the soldier from bleeding to death.

101fieldhospworking
source:  Starz

The mantra of modern Emergency Medicine and Trauma is ABC.   Ensure your patient has a patent airway (A) and intervene as needed, asses whether the patient is breathing  (B) effectively and assist as needed, and evaluate the circulation (C) – heart rate, blood pressure, blood loss.

This soldier appears to have a patent airway without any apparent head trauma and appears to be breathing effectively.  Claire has applied pressure to the wound to stop the bleeding and prevent him from immediately dying from acute blood loss.  She is successful and soon the doctor comes to relieve her and gives the soldier an injection of what seems to be a medication for pain.  This was likely Morphine, possibly Demerol.  Penicillin was another injectable medication used during this time extensively among the Allied Forces, though the depiction on screen suggests the injection brought some immediate relief to the soldier and was more likely an analgesic (pain medication).

The femoral artery is the main blood supply to the leg and trauma to the artery can lead to massive blood loss and death.  For soldiers with such an injury, a significant femoral artery injury would have meant amputation of the leg if blood loss didn’t kill them first.  Advanced techniques for repair of arteries were not yet commonplace.  Today with a similar injury, vascular surgeons can repair these vessels and often avoid amputation.

Gray550
By Henry Vandyke Carter – Henry Gray (1918) Anatomy of the Human Body

 

Later in the episode, Claire meets for the first time an injured Jamie who is under the care of his fellow Highlanders who are discussing his dislocated shoulder.

101clairearrivescottage
source:  Starz

The shoulder joint has the greatest range of motion of any joint in the body and as a result, is the most susceptible to dislocation, accounting for 50% of all large joint dislocations.  In 95-97% of shoulder dislocations, the humerus is dislocated anteriorly, or toward the front of the body.  This generally occurs as a result of a direct blow to the extended arm or a fall on an outstretched arm. Less common are posterior and inferior dislocations.

101shoulderanatomy
© Can Stock Photo Inc. / bluering
101stockshoulderdisloc
© Can Stock Photo Inc. / alilia

 

…The men’s attention had shifted to a young man crouched on a stool in the corner.  He had barely looked up through my appearance and interrogation, but kept his head bent, hand clutching the opposite shoulder, rocking slightly back and forth in pain.

Dougal gently pushed the clutching hand away. One of the men pulled back the young man’s plaid, revealing a dirt-smeared linen shirt blotched with blood. A small man with a thick mustache came up behind the lad with a single-bladed knife, and holding the shirt at the collar, slit it across the breast and down the sleeve, so that it fell away from the shoulder.

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. But more shocking was the shoulder joint itself. A dreadful hump rose on that side, and the arm hung at an impossible angle.

Dougal grunted.  “Mmph.  Out o’ joint, poor bugger.”  The young man looked up for the first time.  Though drawn with pain and stubbled with red beard, it was a strong, good-humored face.

“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.”

From Outlander by Diana Gabaldon, Chapter 3

In lean patients with a shoulder that is dislocated anteriorly, the acromion will be prominent and the shoulder will have lost its normal rounded contour.  The arm will be held somewhat abducted (held away from then body) and externally rotated.

Jamie’s dislocated shoulder BEFORE:

101closeupshoulder
source:  Starz

Rupert, so invited, flexed his hands as though about to toss a caber, and picked up the young man’s wrist, plainly intending to put the joint back by main force; an operation, it was clear, which was likely to snap the arm like a broomstick.

“Don’t you dare to do that!” All thought of escape submerged in a professional outrage, I started forward, oblivious to the startled looks of the men around me.

“What do you mean?” snapped the bald man, clearly irritated by my intrusion.

“I mean that you’ll break his arm if you do it like that,” I snapped back. “Stand out of the way, please” I elbowed Rupert back and took hold of the patient’s wrist myself. The patient looked as surprised as the rest, but didn’t resist. His skin was very warm, but not feverish, I judged.

“You have to get the bone of the upper arm at the proper angle before it will slip back into its joint,” I said, grunting as I pulled the wrist up and the elbow in. The young man was sizable; his arm was heavy as lead.

“This is the worst part,” I warned the patient. I cupped the elbow, ready to whip it upward and in.

His mouth twitched, not quite a smile. “It canna hurt much worse than it does. Get on wi’ it.” Sweat was popping ut on my own face by now. Resetting a shoulder joint is hard work at the best of times. Done on a large man who had gone hours since the dislocation, his muscles now swollen and pulling on the joint, the job was taking all the strength I had. The fire was dangerously close; I hoped we wouldn’t both topple in, if the joint went back with a jerk.

Suddenly the shoulder gave a soft crunching pop! and the joint was back in place. The patient looked amazed. He put an unbelieving hand up to explore.

Excerpt from Outlander by Diana Gabaldon, Chapter 3.

There are numerous techniques for reducing an anteriorly dislocated shoulder.  Claire has employed the Kocher technique in which the arm is bent at the elbow to 90 degrees and the arm is slowly externally rotated, keeping the elbow against the body and rotating the wrist slowly out to the side.  Then the arm is lifted and internally rotated to bring the patient’s hand to the opposite shoulder.  The head of the humerus slips back into the glenoid fossa, generally with a satisfying “clunk.”  This method is associated with complications including tearing of the rotator cuff muscles, fracture of the humerus and vascular injury and other methods are now generally preferred.

Jamie’s newly reduced shoulder.  Well done, Claire!

101shoulderfixed
source:  Starz

After she successfully reduces Jamie’s dislocated shoulder, Claire asks for a belt to use as a sling, which Angus reluctantly provides.  She advises Jamie not to move the joint for 2-3 days.  Current medical recommendations for dislocated shoulders include immobilizing the shoulder for 3 weeks in younger patients, such as Jamie, as they are at higher risk for redislocation following the initial injury, but I can’t imagine Jamie would be able to comply with that!

101sling
source:  Starz

 

I’ve always loved Claire in the Outlander books and this first episode, showing Claire in her element caring for wounded soldiers and a wounded Jamie was, in my opinion, a great introduction to the our strong, smart and resourceful heroine.  These Highlanders seem to realize she will be useful to them after seeing her skill with Jamie’s shoulder, wet nurse or no…