112: Was BJR Responsible for the Death of Brian Fraser?

112: Lallybroch

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STARZ

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.

brian concerned in crowd
STARZ

“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

apoplexy

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.

brian falls
STARZ

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.

Cerebral_aneurysm_NIH
from NIH

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?

Maybe.  Or maybe not.

brian fraser grave
STARZ

Further Reading:

Virgins by Diana Gabaldon – an Outlander prequel novella

 

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111: What Was Ailing Arthur Duncan?

111: The Devil’s Mark

What was ailing poor Arthur Duncan, who always seemed so uncomfortable?

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STARZ

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!

confession
STARZ

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.

caustic arthur duncanpoor arthur 3

poor arthur 2poor arthur

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.

Paris_Green_(Schweinfurter_Grün)
source

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_trioxide
source

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…

red shoes
STARZ

110: The Scent of Almonds

110: By the Pricking of my Thumbs

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Starz

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.

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Starz

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.

feast
Starz

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.

colum raises toast
Starz

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.

arthur falls
Starz

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.

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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.

fruit-nutrition-seeds-skin-health

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.

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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.

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Arthur with frothy sputum from the mouth, evidence of pulmonary edema.  (Starz)
arthur with convulsion hand
Arthur convulsing as a result of cyanide poisoning  (Starz)

Can’t help but flashback to Angus’ lesson for Claire in self defense with a sgian-dubh…

poison is best weapon for a woman
Murtagh to Dougal: “I still say the only good weapon for a woman is poison.”  Starz

 

The episode ends on a painfully familiar note. Our Claire again sits locked up in the back of a wagon.

 

claire in wagon
Starz

Indeed something wicked this way comes!

leoghaire
Starz

 

Further Reading:

How to Make a Peacock Pye

109: Things That Go Bump in the Night

109: The Reckoning

titlecard better
source: Starz

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.

 

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Starz

 

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Starz

Ultimately, Jamie finally knocks out Black Jack with a non-fatal blow to the head. (And the audience groans, knowning what is to come).

jack ko

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.

brain

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
Amnesia
Altered mental state for up to 24 hours
Headache
Dizziness
Fatigue
Sleep disturbance
Balance problems
Tinnitus (ringing in the ears)
Sensitivity to sound
Difficulty concentrating
Irritability

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.

concussiondiagram-2

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!

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Starz

 

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107 (part deux): It’ll Cost More than a Shilling

A Night to Remember, but not the One You’re Thinking of!

Episode 107: The Wedding

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source:  Starz

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.

jamie slice
Blood of my blood and bone of my bone / source:  Starz

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!

neds new friend
Surely you can stay a while! / source:  Starz

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.

the dress is offered
He has found The Dress / source:  Starz

Indeed the dress is fabulous and so very perfect.  Well done, Ned.

ned likes what he sees
Verra nice, indeed!  / source:  Starz

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.

ned and his lady outside wedding
Does Ned look tired?  / source: Starz

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.

syphilismicro
Treponema pallidum, the organism responsible for syphilis.  (source)

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.

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The rash of secondary syphilis.  (source)  (source)

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.

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Bust of person with tertiary syphilis.  Musee de l’Homme, Paris.  (source)

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.

syphilispaintingfacialdeformity
Portrait of Gerard de Lairesse by Rembrandt van Riin, circa 1665-67.  de Lairesse had congenital syphilis leading to deformity of his face and eventual blindness.  (source)

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!”

15thcent syphilis treatment
Medical illustration of patients with syphilis, 1496. (source)

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.

Alexander_Fleming
Alexander Fleming, who is credited with discovering penicillin in 1928.  (source)

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!

448px-%22VD_CAN_BE_CURED_BUT_THERE'S_NO_MEDICINE_FOR_REGRET%22_-_NARA_-_515957
Poster from the US Office of War Information, 1941-1945.  (source)

 

Additional reading:

The Story of the Condom
Sin City:  One in Five Women in 1700s London were Prostitutes
Syphilis – Its Early History and Treatment until Pencillin and the Debate on its Origins

108: The Lass Needs a Sgian-Dubh!

108: Both Sides Now

titlecard
source:  Starz

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.

posters
source:  Starz

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
source:  Starz

Hugh presents Claire with a wedding present. A dragonfly in amber.

dragonfly_in_amber
source:  Starz

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.

below the sternum
source:  Starz

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!”

right in the kidney
source:  Starz

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.

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The position of the heart within 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.

tamponade
Illustration of tamponade, showing the pericardiac sac filling with fluid, increasing pressure to the point at which the heart can no longer pump normally (source)

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.

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Emergency Department Thoracotomy

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.

knife in the back

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.

kidneyanatomy

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.

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Anatomy of the kidney (source)

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.

knife in back
source:  Starz

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…

claire in wagon 2
source:  Starz

If only she had brought her sgian-dubh along.

 

Resources:

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.

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?