Episode 103: The Way Out
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.
Among them are slaters which, it turns out, are live wood lice.
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.
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.
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!
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.
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.”
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.
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.
Except it isn’t wood garlic. It is lily of the valley.
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.
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!
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…
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.