A Dram of Outlander Voyager Read-Along Chapter 53-55 (LISTEN HERE)
Outlander Science Club
Suture Options At Sea (Listen to the podcast HERE!)
What happens when the healer needs healing?
With a deep laceration extending from nearly shoulder to elbow on her dominant arm, Claire is in no position to suture her own wound, but who can she depend on to repair it? While there are physicians with upper extremity amputations who are able to perform all of the necessary procedures, Fergus has not spent the time (that we know of) mastering these skills. Jamie, with his large, rough hands, isn’t known for his fine motor dexterity. Marsali likely has skill with needle and thread, but it doesn’t seem that sewing human flesh is something she will tolerate.
Enter Mr. Willoughby. Renowned in China for his gift of composition and the fine motor skill necessary to pen volumes of poetry, he has the necessary dexterity for suturing. Along with his gifts as a healer in Chinese medicine, it seems we have found the perfect candidate for the job.
In typical clinical fashion, Claire describes her wound:
It was a long, clean-edged slash, running at a slight angle across the front of my biceps, from the shoulder to an inch or so above the elbow joint. And while I couldn’t actually see the bone of my humerus, it was without doubt a very deep wound, gaping widely at the edges.
It was still bleeding, in spite of the cloth that had been wrapped tightly round it, but the seepage was slow; no major vessels seemed to have been severed.
From Voyager by Diana Gabaldon, Chapter 54
The next question is what will be used to close the wound? What kind of needle or thread will be available?
The first sutures, thousands of years ago, were made of vegetable material – things like flax, hemp, and bark fiber. Later, animal sources such as hair, pig bristles, and animal skin were used for suturing. Catgut was first mentioned by Galen in AD 150. Catgut suture is made from the twisted intestines of herbivorous animals, generally sheep, goats or cattle and is also the material previously used in the strings of stringed instruments and tennis racquets. Catgut never had anything to do with cats, despite the name, and the term is thought to perhaps originate from the combination of “cattle” and “gut”.
What makes a good suture?
At first glance, sutures seem to be a pretty simple order: grab a thread and needle and sew up the wound. However, it is a bit more complicated when considering materials for sutures. Sutures must be strong enough to hold the tissue together but also flexible to securely knot. They must be hypoallergenic and must be able to be sterilized. Sutures should not be made of material like cotton that can act as a wick, allowing fluids to enter the wound.
Different wounds and different locations call for different types of sutures. Sutures come in non-absorbable varieties and absorbable varieties. Non-absorbable sutures are the most recognizable sutures – the typical black nylon or blue propylene we are familiar with that stay in place for 5-14 days for repair of lacerations to the skin, as well as silk, polyester and in some cases, stainless steel wire. Non-absorbable sutures are also used internally in cases when an absorbable suture would break down too easily or too quickly, such as when repairing the heart or a blood vessel, in which rhythmic movement of these structures would require a suture that stays longer than a few weeks to give the wound enough time to heal. Also requiring non-absorbable suture is the bladder, which contains fluids that make absorbable sutures dissolve much too quickly for the wound to heal. Non-absorbable sutures are also used to secure various temporary devices in place, such as chest tubes and central venous catheters.
Absorbable sutures are made from materials that break down in the tissues after a certain period of time, anywhere from a few days to 90 days, depending on the material. These are used in the internal tissues of the body, lacerations of the tongue and in the mouth, and for situations when the removal of stitches will be traumatic, particularly in some cases for children. Absorbable sutures are made from catgut as well as synthetic materials.
What about the needles?
Sutures today have an eyeless needle – the suture is crimped into the end of the needle.
Up until the 1920s, however, suturing needles were eyed, much like a sewing needle, and this is what Claire would have used.
The drawback of the eyed needle is increased trauma as the large eyed end of the needle is pulled through, as well as a larger hole left in the tissue, potentially allowing for leakage.
How did Claire manage to obtain appropriate needles and suture?
Mr. Willoughby is given a curved suture needle and length of catgut from Claire’s medical supplies.
While in Edinburgh, Claire would have had access to the many shops and artisans of the city. She likely sought out a local blacksmith to craft the small, eyed suture needles to her specifications. Knowing what she does about life in the 18th century, this was likely among her first stops in her work to re-build her medical supply.
As for the catgut, I had always imagined Claire manufacturing her own sutures from the intestines of sheep she may have acquired from a local farm or butcher. However, the process is rather involved, involving cleaning, trimming and isolating the useful membrane, soaking in potassium hydroxide, smoothing and stretching them out, before twisting them into uniform strings and finally sterilizing them. While I have no doubt Claire could have and would have undertaken this work if without other options, while in Edinburgh, she likely would have taken advantage of the fact that local musicians and craftsmen manufacturing catgut to string their violins and other stringed instruments.
Of course, without the resources of a city like Edinburgh, Claire would have no doubt found or made what she needed, but history has provided a few other options as you’ll see below, should she find herself low on resources!
Ants as Skin Staples?
The mandibles of certain species of biting ants have been used to close wounds! The edges of the wound is held together, and the head of the ant is allowed to bite across the wound edge. The body is then twisted off and by reflex, the jaws remain tightly clamped across the wound, effectively performing like modern day skin staples. Check out a video of these ants being used as sutures on http://www.discovery.com here!
Thorns and Spines
Thorns and spines of various plants were used as needles. The agave plant in particular is very useful – when the leaf of the agave plant is soaked for a long period of time, it leaves behind long stringy fibers connected to a sharp tip – essentially, a needle and thread once dried.
Had Claire’s injury been to her non-dominant arm, she no doubt would have sewn it herself, one-handed with her good arm, perhaps with some assistance from Jamie in tying the knots and cutting the ends. In doing so, she would have found herself in the company of many physicians in history of have had to do the same, including Russian Leonid Rogozov who as the only physician stationed in Antarctica on an expedition, developed appendicitis and performed his own appendectomy!
Now that we’ve received word that Mr Willoughby will in season 3, hopefully we’ll have this scene to look forward to, pillow-song and all!