We come to learn more about Jamie’s father, Brian Fraser, as Jamie shares with Claire his last memories of his father. Brian was present at Fort William when Jamie was flogged a second time and collapsed as he witnessed the torture of his son.
“It was…hard. I didna call out, or let them see I was scairt, but I couldna keep my feet. Halfway through it, I fell into the post, just – just hangin’ from the ropes, ken, wi’ the blood…runnin’ down my legs. They thought for a bit that I’d died – and Da must ha’ thought so, too. They told me he put his hand to his head just then and made a wee noise, and then…he fell down. An apoplexy, they said.”
“Mary, Mother o’ God, have mercy on us,” Ian said. “He – died right there?”
“I dinna ken was he dead when they picked him up or if he lived a bit after that.” Jamie’s voice was desolate. “I didna ken a thing about it; no one told me until days later, when Uncle Dougal got me away.”
From Virgins by Diana Gabaldon
What exactly is a stroke? A stroke is an acute injury to the brain that occurs one of two ways:
1. An ischemic stroke in which too little blood is delivered to a part of the brain, depriving the area of necessary oxygen and nutrients
2. A hemorrhagic stroke in which bleeding is present in the brain or within the closed compartment of the skull, exerting pressure on the brain.
Ischemic strokes generally occur when there is a blockage in the arteries that supply the brain, whether from a clot occurring in the artery or traveling to the artery from other locations in the body such as the heart or the aorta. The brain which is supplied by that blood vessel is deprived of blood supply, leading to symptoms correlating to the processes that area of the brain controls.
Hemorrhagic stroke is a result of bleeding in the brain itself or into the cerebrospinal fluid within the subarachnoid space that surrounds the brain. When a hemorrhage occurs within the brain, brain tissue is destroyed as pressure is exerted on the brain by the expanding mass of blood. Symptoms involve dysfunction of the portion of the brain that contains the hemorrhage.
When bleeding occurs within the subarachnoid space, the intracranial pressure (the pressure within the skull) rapidly increases, leading to devastating consequences.
The description we are given of Brian Fraser’s collapse aligns most closely with fatal subarachnoid hemorrhage. These are characterized by a very sudden, severe headache, pain spreading to the neck, often with vomiting. Altered level of consciousness, coma and sudden death can occur due to the severely elevated pressure on the brain. 10-15% of these patients die before arriving to the hospital and overall, the mortality rate of a subarachnoid hemorrhage is close to 50%.
According to Jamie’s account of Dougal’s description of the events, Brian put his hand to his head, let out a “wee noise” and collapsed.
Is BJR to blame?
Most subarachnoid hemorrhages are caused by ruptured aneurysms (bulging or ballooning) in an artery supplying the brain. Risks for development of these aneurysms include high blood pressure, smoking and family history of aneurysms. Approximately 5% of the US population have these aneurysms but most of them will not rupture and cause bleeding.
Bleeding of these aneurysms often follows identifiable triggers such as physical exertion or acute elevation in blood pressure. There is an association of ruptured aneurysms following a rise in blood pressure caused by caffeine consumption, sexual exertion and acute anger or startling.
Would Brian Fraser ultimately have suffered from this type of hemorrhage without the trigger of acute emotional distress and anger brought on from watching Jack Randall torture his son?
What was ailing poor Arthur Duncan, who always seemed so uncomfortable?
Claire and Geillis are unceremoniously dropped into the thieves’ hole where they have a bit of time to bond as they await their fate. Claire confronts Geillis about Arthur’s death and Geilis admits that she did poison him with cyanide but only after trying for months to kill him with arsenic!
Indeed, Arthur appears ill every time we see him, suffering from various stomach ailments and discomfort. Even Claire was stumped as to what may have been causing his trouble.
The symptoms were rather puzzling; not like ulcer, I thought, nor cancer- not with that much flesh still on his bones- perhaps just chronic gastritis, as Geilie insisted.
From Outlander by Diana Gabaldon, Chapter 24
But now it is all so clear. Arthur has been suffering the effects of chronic arsenic poisoning all these months.
Arsenic is ubiquitous in the environment, found in ground water most commonly, and also a byproduct of mining and smelting metals. It has been used medicinally for over 2400 years in traditional Chinese medicine and also used to treat syphilis in the western world before the development of penicillin. In the Elizabethan era, women used a mixture of vinegar, chalk and arsenic which they applied to their faces in hopes of preventing aging and creasing of the skin. Arsenic is an ingredient in green pigments used to color most anything – wall paper, textiles, paint.
Arsenic has been a favored poison throughout history. Tasteless and odorless, it was an easy choice. It is particularly known to have been used by the Borgias in Italy and is also thought to have been responsible for the death of Napoleon Bonaparte. In the 19th century, arsenic was dubbed “inheritance powder” because it was suspected that many impatient heirs ensured or accelerated their inheritance by means of poisoning with arsenic.
The most toxic form, white arsenic, or arsenic trioxide, is of course what Geillis chose.
Arsenic poisoning is due to ingestion most often, but also occurs via absorption through the skin and by inhalation. Arsenic is readily taken up by the red blood cells and distributed throughout the body, and is particularly toxic to the gastrointestinal system, kidneys, bone marrow, skin and nervous system.
White arsenic binds to and interferes with numerous enzymes in the cells of the body, wrecking havoc on normal cell function.
Symptoms after acute poisoning develop in minutes to hours and generally begin in the gastrointestinal system causing nausea, vomiting, abdominal pain and severe watery diarrhea. It can cause a garlic odor on the breath and in the stool. Severe poisoning leads to abnormal heart rhythm, shock, acute respiratory distress and death.
What Arthur suffered, however, is chronic toxicity – long term exposure of lower levels of arsenic. The symptoms come on more slowly but still have significant consequences. Chronic exposure leads to abdominal pain, nausea and diarrhea as well, but also skin lesions, peripheral neuropathy (numbness and tingling, then intense burning pain to the hands and feet), cancer of the skin, bladder, lungs and liver, type 2 diabetes, and respiratory problems.
We’ve witnessed Arthur suffering with abdominal distress just about every time we’ve seen him. He’s been treated with peppermint by Geillis and fennel from Claire for his discomfort. These provide temporary relief but won’t cure him.
But alas, when that doesn’t do poor Arthur in, Geillis employs another technique and Arthur meets his end by cyanide poisoning.
Ah, Geillis, we wanted so much to like you, what with the fabulous red shoes and talk of BBQs…
By the light of the full moon and clearly in her element, Geillis Duncan reveals to Claire that she loves Dougal MacKenzie and is pregnant with his child. Maura MacKenzie, wife of the war chief has conveniently and suddenly died, leaving only Arthur Duncan in the way of these star-crossed lovers, or so it seems.
The Duke of Sandringham has arrived at Leoch to take counsel with the Laird and hopefully to be of some help to Jamie in securing a pardon from the murder charges he faces. A banquet is held in his honor and all associated with the clan enjoy the lavish feast.
The Laird of the MacKenzie offers a toast to his longtime friend and ally, His Grace, the Duke of Sandringham. Everyone drinks, the food is passed, and merriment ensues.
Arthur Duncan suddenly stands, coughing and apparently choking. His hands grasp at his throat and he collapses to the ground. Claire rushes to his side to help but quickly it becomes clear that he cannot be saved. She smells bitter almond and recognizes the scent as that of cyanide. Arthur Duncan has been poisoned.
Knowledge of the poison cyanide may date back as far as ancient Egypt, as “death by peach” has been translated from Egyptian hieroglyphics. In more modern history, cyanide was used by the Nazis in extermination camps and later ingested by the Nazi leaders themselves as they committed suicide as the Russian forces approached in 1945. The mass suicide of 912 cult members in Jonestown in 1978 was due to a cyanide-laced kool-aid type drink. Saddam Hussein included cynanide among the chemical weapons used against the Kurds in the 1980s. The still unsolved mystery of cyanide poisoning in Chicago in the 1980s in which random containers of the medication were spiked with cyanide led to the universal tamper resistant packaging we now have in over the counter medications.
Cyanide is simply a carbon atom bound to a nitrogen atom and is a very potent poison, found in many foods and manufactured items. It is found in the pits and seeds of bitter almond, cherry laurel, apricot, plum, pear, peach and apple as well as in cassava root, bamboo and soy. Some species of centipedes, millipedes, beetles, moths and butterflies synthesize and excrete cyanide for defensive purposes. When burned, wool, silk, polyurethane and plastics like cyanoacrylate (superglue) emit cynaide gas. It has even been used as an insecticide and to fumigate ships and buildings. The major source of cyanide poisoning now is smoke inhalation from residential or industrial fires in which cyanide is released as plastics and textiles burn.
Cyanide exposure can occur by inhalation, ingestion or even absorption through the skin. It then enters the blood stream and is distributed rapidly throughout the body. Cyanide irreversibly binds to and inactivates energy pathways in the cells, leaving them unable to absorb oxygen or produce energy, resulting in cell death. The cells are in effect suffocating, unable to use the plentiful oxygen available. The heart and brain are especially dependent on the body’s oxygen supply and the effects on these organs is particularly deleterious.
Within minutes, the victim of cyanide poisoning will begin to experience symptoms: Headache, anxiety and confusion will progress to seizure and coma. An initially elevated heart rate and blood pressure will progress to severely low heart rate and blood pressure, heart block and cardiac arrest. Pulmonary edema, or accumulation of fluid in the lungs will cause coughing of frothy sputum and progress to respiratory failure. Vomiting, kidney failure and liver failure occur. Death occurs in minutes, depending on the dose.
Antidotes for cyanide poisoning are available. Those patients who receive a dose of cyanide that is not immediately fatal and receive prompt medical care can be treated with medication that binds the cyanide in the blood an allows it to be eliminated via the urinary system. However, cyanide is so quickly acting that those who receive a fatal dose will almost always die before they can reach medical care and receive such an antidote.
Jamie and the Highlanders sneak into Fort William to rescue Claire from the clutches of Black Jack, ready to fight with blades, fists and unloaded pistols. Given the price already on Jamie’s head, Ned Gowan has warned the men that they must inflict no fatal injuries tonight. Our Highlanders know how to fight, of course, and rise to the challenge.
The Redcoats are knocked on the head and fall one, by one, by one.
Ultimately, Jamie finally knocks out Black Jack with a non-fatal blow to the head. (And the audience groans, knowning what is to come).
What exactly is happening when someone is knocked out?
Weighing in at approximately three pounds, the brain resides in the protective shell of the skull. Additional protection is provided by layers of tough membranes called meninges covering the brain as well as cerebrospinal fluid in which the brain essentially floats. Within the brain are billions of nerve cells, called neurons. These cells are specialized to allow the gathering and transmission of electrochemical signals. Some travel short distances within the brain, others might travel as far from the tip of the finger all the way up the arm. Some neurons control muscle contractions, some are for sensation and others are messengers between neurons.
Mild traumatic brain injury (TBI) or concussion, is a traumatically induced disruption of brain function as a result of an external force. This trauma causes loss of consciousness, alteration of mental state for up to 24 hours, and post-traumatic amnesia for up to 1 day.
A direct blow to the head sets the brain tissue in motion within the skull, squeezing, stretching and sometimes tearing neurons in the brain. This leads to varying degrees of abnormality in how the brain processes information.
Loss of consciousness in these injuries is thought to be due to brain edema (swelling). The brain’s auto-regulatory mechanisms counteract this to protect against massive swelling by limiting blood flow. The effect of the limited blood flow is accumulation of lactic acid and changes in metabolism at the cellular level in the brain lasting weeks and making the brain vulnerable to further injury during this time.
Symptoms of mild TBI, or concussion, are many:
Loss of consciousness
Altered mental state for up to 24 hours
Tinnitus (ringing in the ears)
Sensitivity to sound
Symptoms can last months in some cases.
In mild TBI, imaging of the brain with MRI and CT will not show abnormalities but the stretching and swelling of the neurons has a significant impact on the brain’s neurologic circuits. A brain still healing from a concussion is vulnerable to further trauma. When a second concussion occurs before the first concussion has fully healed, patients are at risk for rapid and severe brain swelling with catastrophic results – Second Impact Syndrome. After the first concussion, the brain is still healing and has not yet regained its ability to auto-regulate intracranial pressure and blood flow pressure within the brain. Remember that the brain is encased within the protective skull so there is minimal room for swelling to occur. The massive swelling of the brain in second impact syndrome is rapid can lead to death within minutes.
The awareness of Second Impact Syndrome has led to strict policies and training, particularly in youth sports, regarding return to play after concussion, though the primary way to avoid this will but more research into avoiding first concussions. It is likely that we will see protective headgear for soccer players in the coming decades.
Another sequelae of repeated concussions is Chronic Traumatic Encephalopathy (CTE). Athletes and others who have received repeated blows to the head and concussions may manifest memory loss, mood and behavioral disturbances and progress to dementia decades after the trauma. Some may further develop Chronic Traumatic Encephalomyopathy (CTEM), a disease similar to ALS or Lou Gehrig’s disease causing profound weakness and muscle atrophy. Many former NFL players have been identified on autopsy as suffering from CTE or CTEM, as sadly there is currently no definitive test to diagnose the condition in the living. As science advances and we come to be able to identify and diagnose this earlier, it may mean significant policy changes in the future for sports and activities where the risk of head injury is high.
Great advances have been made in the understanding of brain injury in recent decades, leading to heightened awareness of concussion and protective devices for sport. A far cry from tricorn hats which would have offered no protection from head injury!
A Night to Remember, but not the One You’re Thinking of!
Episode 107: The Wedding
Ah, the Wedding. Claire and Jamie are in no immediate threat of danger, no one is attacked, there are no poisons, no boar hunts, and aside from the superficial lacerations to the wrists of the bride and groom in the ceremony, no real risk of trauma.
So what is there to talk about the medicine of Outlander?
Well, there is Ned Gowan and his new lady friend and one crazy night!
Ned is tasked with finding a suitable wedding dress for Claire and we find him shopping in a brothel for a dress and, as it turns out, a wee bit more.
Indeed the dress is fabulous and so very perfect. Well done, Ned.
However, we hope that the dress is all that he brings home that night. Ned has a new friend, it turns out, who later joins him at the wedding.
The world’s oldest profession also has a long story of infectious disease to tell! We will hope that Ned came away from his night in the brothel unscathed, and perhaps he has taken some precautions.
Ned Gowan is an educated man and hopefully he made use of the protection available at the time. First documented to be used in Greece around 3000 B.C., early condoms were made of goat bladder and of linen and had not changed dramatically by the time we arrive in the 18th century, though fortunately tortoise shell and horn were no longer popular materials! Condoms of the 18th century were made of either chemically-treated linen or from animal bladder or intestine. It is unclear how widespread their use was, though they were widely sold in pubs and markets in Europe.
Syphilis and gonorrhea were the most prevalent STDs of the time. Syphilis, in particular, has severe, life-changing consequences. Known by a variety of names depending on a person’s geographic locale (everyone blames everyone else!) including “great pox,” “the disease of Naples,” “the Spanish disease,” “the French disease,” “Persian fire,” and called “grandgore” by the Scots, the first documented epidemic of syphilis is among French soldiers in 1495. Symptoms included genital sores, abscesses, and ulcers over the body and severe pain. Remedies were few and of questionable efficacy.
Syphilis is a sexually transmitted infection caused by the bacterium Treponema palladium. The disease occurs in stages and can be very disfiguring and ultimately fatal. The first sign of infection is a skin lesion called a chancre at the location exposed to the bacterium, generally on the genitals. This is classically a single skin ulceration up to 3cm in size and generally painless. Enlargement of the lymph nodes in the area is common. Without treatment, the lesion persists for 3 to 6 weeks.
Approximately 25 percent of untreated patients infected with syphilis will progress to secondary syphillis. This occurs 1-2 months after the primary infection and manifests in many ways. Generally, this involves symptoms of the skin, mucous membranes and lymph nodes including non-itchy rash to the trunk and extremities including the palms of the hands and soles of the feet. Wart-like lesions may develop on mucous membranes. All of these lesions contain the bacteria and are infectious. Fever, sore throat, weight loss, hair loss and headache also occur. Rare complications include liver involvement, kidney disease, joint inflammation, and ocular (eye) abnormalities. These symptoms will last for another 3-6 weeks.
Approximately 30-60% of those who are exposed to the wounds of someone with primary or secondary syphilis will contract the disease. The bacteria die very quickly outside of the body so transmission from objects like toilet seats, hot tubs, sharing utensils, is not thought to be possible.
Syphilis can then enter a latent phase in which there are no symptoms of the disease but blood testing will still prove infection is present.
Without treatment, one third of people infected with syphilis will develop tertiary syphilis with devastating consequences. Chronic gummas, or soft, tumor-like balls of inflammation occur in the skin, bone and liver. Syphilis can infect the heart and vascular system, leading to aortic aneurysms among other complications. Infection of the nervous system (neurosyphilis ) results in meningitis, general paresis (a progressive severe dementia along with difficulty moving the muscles of the face and limbs) and tabes dorsalis – a disease of the spinal cord leading to severe pain, impaired sensation and bladder dysfunction.
Syphilis can be transmitted from mother to child during pregnancy or childbirth and can result in stillbirth, prematurity and a number of severe and disabling symptoms including deformity of the face and teeth, bony deformity and deafness. Women who receive prenatal care are tested for spyhilis during pregnancy and treatment with antibiotics can eradicate it. Congenital syphilis, however, does remain a problem in developing countries where prenatal care is not readily available.
Until the 20th century, mercury was the primary treatment for syphilis – either taken orally or made into ointment and rubbed onto the skin. Mercury, unfortunately, has many toxic side effects: kidney failure, severe mouth ulcers, loss of teeth, neurologic damage and even death. The cure was deemed by some to be worse than the syphilis itself: “A night with Venus and a lifetime with mercury!”
Ultimately, it was the discovery of penicillin by Scottish scientist and Nobel laureate Alexander Fleming in 1928 that would ultimately provide the cure. In 1943, physicians at the US Marine Hospital in Staten Island, NY, proved the effectiveness of penicillin on syphilis and cured infected soldiers with intramuscular injections of penicillin.
The total number of cases of syphilis in the US was 575,593 in 1943, the year penicillin was proven to be effective for syphilis. This dropped to a low in 2000 of 31,618 cases. However, this has steadily been climbing since 2000 and in 2014 there were 63,450 cases! Why? This article from The Atlantic in December 2015 is a good read and discusses a few of the reasons this may be happening including aps like Tinder facilitating more casual sex, the unfamiliarity of young Americans with the risks of untreated syphilis as it isn’t in the public conscience as it had been in the past, the fear of HIV may be declining from its peak in the 1990s, leading to less use of protection.
There is no vaccine for sphilis. Prevention and early diagnosis is key, as early treatment with antibiotics can prevent the devastating effects of this disease!
No progress has been made in the search for Claire in 1945. Frank is growing frustrated and the detective tries to lay it out for him that no body has been found, no signs of struggle were discovered and Claire likely disappeared willingly with the mysterious Highlander. Mrs. Graham suggests an alternate theory but Frank will hear nothing of it.
Meanwhile, our newlyweds enjoy a picnic on a rainy day and encounter Hugh Munro who has endured brutality at the hands of the Turks while enslaved in Algiers. He brings news of a man named Horrocks who may be able to exonerate Jamie.
Hugh presents Claire with a wedding present. A dragonfly in amber.
As the Highlanders work to make their way back to Leoch, it becomes clear that Claire must learn to defend herself. Angus is chosen to teach Claire how to fight with a knife and using himself and Willie as models, he explains that from the front, she must aim straight up just below the sternum to pierce the heart.
If approaching from the back, she must stab upwards just below the last rib in order to stab the kidney. “Straight up. He’ll drop like a stone!”
Indeed these Highlanders know a thing or two about fighting. A stab wound to the heart in the era before cardiac surgery and trauma centers would almost certainly have been fatal. The kidney stab wound, however, may or may not have been, depending on how much and which parts of the kidney were injured.
The photo below shows the position of the heart in the chest.
Stab wounds to the heart carry a high mortality rate even today. Many victims will die before they can be transported to the hospital. For those who actually arrive at a trauma center with signs of life with a penetrating heart injury, mortality reaches as high as 80%.
Death from penetrating injury to the heart is generally due to exsanguination (losing massive amounts of blood from the heart), cardiac tamponade (in which the injury bleeds into the pericardial sac surrounding the heart, accumulating enough as to impair the normal filling and pumping of the heart) or injury to the coronary arteries (thus cutting off blood supply to the muscle of the heart itself, rendering it unable to function. Without operative treatment, most patients with a penetrating injury the heart die within an hour.
These injuries require emergent surgical repair. Those who are too unstable or suffer cardiac arrest before they can be transported to the operating room will undergo emergency department thoracotomy in the ER. Literally this is “cracking the chest,” and is done in an effort to stabilize the patient enough to transport them to the operating room for definitive repair. The emergency department thoracotomy will allow control of bleeding by suturing lacerations to the wall of the heart, releasing of cardiac tamponade and allow access for internal cardiac massage (the internal version of CPR compressions for the heart in cardiac arrest). Once the bleeding has been controlled, any tamponade released and cardiac activity regained, the patient can be transported to the operating room.
Of course, shortly following her lesson in the use of the sgian-dubh, Claire deftly employs the skills she has learned and stabs the Redcoat in the back at the location of the kidney. Indeed he drops like a rock.
Kidney trauma is not quite as fatal as penetrating cardiac trauma. It very much depends on the location and the size of the injury to the kidney. As seen below, Angus’ anatomy lesson is right on – just under the last rib stab upward and into the kidney.
In fact, many kidney injuries will heal without surgery. Modern day management of kidney trauma is very much dictated by CT imaging to see exactly where the injury is located. Surgical exploration is done for the injury involves the hilum (see image below), injury to the ureters or renal pelvis, or persistent bleeding.
Claire has delivered a significant wound to this Redcoat and he seems to have lost consciousness immediately. Even with massive blood loss from injury to the renal artery at the hilum of the kidney or to the abdominal aorta, he would still be conscious and able to talk and have purposeful movements for a few moments. However, it is a poignant picture, with Claire lying beneath the dead body of a Redcoat with the knife in his back just as Angus had instructed.
This episode started so sweetly with the newlyweds getting to know one another and having some memorable moments together (wink, wink). But this is Outlander, after all, and the bliss is short-lived. Claire is again reluctantly on her way to meet Jack Randall…
If only she had brought her sgian-dubh along.
O’Connor, J, Ditillo, M, Scalea, T. (2009). Penetrating cardiac injury. J R Army Med Corps. Sep;155(3):185-90.
Shoobridge, J. J., Corcoran, N. M., Martin, K. A., Koukounaras, J., Royce, P. L., & Bultitude, M. F. (2011). Contemporary Management of Renal Trauma. Reviews in Urology, 13(2), 65–72.
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.
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.
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!)
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!
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!
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.
What to do?
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.
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.
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.
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!
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.
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.
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.”
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.
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.
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.
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.
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.
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.
Caitriona Balfe is an amazingly gifted actress and this scene is painful to watch. Claire’s gasping, panicked breaths are heartbreakingly realistic.
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.
Hopefully she has stocked her traveling medical kit with plenty of willow bark to ease the hangover she’ll no doubt have tomorrow!
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.
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.”
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.
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.
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.
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, 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.
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.
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.
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.
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.
Ah, Angus. Gotta love him.
“That’s no Rhennish!”
“Its port. Very expensive.”
“Port. ‘Tis very strong.”
“Canna seem to keep my legs!”
“Its a sedative.”
“Is that Spanish?”
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!
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.
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.
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.
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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