213: Brown Eyed Girl

There has been a bit of a buzz in the Outlander world about eye color recently. In particular, many are questioning the eye color of Brianna.  How can two blue eyed parents (as are Jamie and Claire on the Starz production of Outlander) have a child with brown eyes?

People have two copies of most of their genes.  One copy is inherited from their mother and one copy from their father.  These genes come in different versions, or flavors, called alleles.

In the book series, Claire has whiskey colored (brown) eyes, Jamie’s are blue, as are Brianna’s. Recalling our high school biology days, we know that blue eyes are a recessive trait.  To have blue eyes, a person must inherit two copies of the recessive gene.  Claire must have carried Bb (a dominant and a recessive) and Jamie carried bb (both recessive), and Brianna inherited a recessive (blue eyed) allele from each parent, giving her bb.

book eyes2
The possible eye color of Book Jamie and Book Claire’s children

On screen, both Claire and Jamie have blue eyes and their daughter has brown.

Doesn’t this go against what we all learned about eye color inheritance in high school biology class?

TV eyes3
The possible eye color of TV Jamie and TV Claire’s children

As it turns out, eye color is not nearly that simple.

There are a number of genes influencing eye color, but two in particular are known to play a significant role in the the development of blue or brown eyes.  These are the OCA2 and HERC2 genes located on chromosome 15.

The OCA2 gene determines how much pigment is made, not only in the eyes but in the skin and hair as well. Lots of pigment results in brown eyes. Blue eyes are the result of little to no pigment in the eyes.

Lying next to the OCA2 gene on chromosome 15, the HERC2 gene functions much like a switch, controlling how much expression the OCA2 gene will have and thus how much pigment will be present in the eye. It is thought that originally, all humans had brown eyes, and a single mutation in the HERC2 gene created this “switch,” leading to the development blue eyes. It is now believed that all blue eyed people descended from one common ancestor who developed this mutation!

The OCA2 gene comes in two varieties:

O (brown – dominant) and o (blue – recessive)

Inheriting OO or Oo results in a message to make lots of pigment and thus, brown eyes

Inheriting oo results in message to make little to no pigment and thus, blue eyes

The HERC2 gene comes in two varieties:

H (switch is on) and h (switch is off)

HH and Hh code for allowing for expression of the OCA2 gene

hh results in a limitation of the expression of the OCA2 gene

If a person inherits two “h” copies of the HERC2 gene, it doesn’t matter what eye color the OCA2 gene carries. The switch is turned off and expression of the OCA2 gene is limited.  Little to no pigment is produced and blue eyes result.

OCA2 HERC2 phenotypes
The possible combinations of the OCA2 and HERC2 genes and their resultant eye color

Thus, a parent with blue eyes can carry the trait for brown eyes if they carry the OO or Oo version of the OCA2 gene, but with the mutated gene (hh) “switching off” the OCA2 expression.  Even though their OCA2 gene would signal the production of a lot of pigment, and thus brown eyes, the switch is off and little to no pigment is made.  The eyes are blue.

Here are two examples of how two blue-eyed parents can produce brown-eyed offspring:

blue eyed parents 1

blue eyed parents 2

In reality, eye color determination is even more complicated than this, as the OCA2 and HERC2 genes are often linked and travel together during the process of assortment and inheritance.  In addition, the effects of numerous other genes combine with those of OCA2 and HERC2 to create a continuum of eye color (and we do know from the Outlander books that the inheritance of green eyes is an important matter!)

Brown eye color in the offspring of two blue eyed parents is not a common phenomenon, but this is the Outlander world, after all.

Stranger things have happened…

the stones

Read More!

NIH Genetics Home Reference

LiveScience.com – One Common Ancestor Behind Blue Eyes

Stanford at The Tech – Understanding Genetics

Questions? Comments? Suggestions for future Outlander medicine topics? I’d love to hear from you! Leave a comment here or connect on Twitter or Facebook!

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212: If Mary Poppins Had A Medical Bag

212:  The Hail Mary

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STARZ

Claire’s amazingly well stocked medical bag seem to be the healer’s equivalent of Mary Poppins’ never ending carpet bag.

Always prepared and ready for anything, Claire has got right at hand the remedy for whatever might be ailing ye!  And for the record, this bag is FABULOUS and if anyone knows where I can get my hands on one, please share!

the bag
This bag is fabulous! / STARZ

Alex Randall’s condition has worsened significantly and he is dying of tuberculosis (more about TB here). As is sadly becoming a common theme in Outlander, nothing can be done to cure Alex.  In fact, prior to the mid-20th century, approximately 80% of people who developed active tuberculosis died of it. All that can be done is to provide comfort and dignity in his final days.

very ill alex
Alex in his final days / STARZ

Alex’s tuberculosis has significantly progressed, causing him to have excessive sputum, coughing and wheezing. Claire is able to mitigate his suffering a bit, allowing him to breathe a bit easier.  She prepares a pipe of thornapple and coltsfoot, and the smoke of these will provide some relief.  We’ve seen her use thornapple before, when Ned Gowan was suffering from asthma. (I do hope we see Ned again, he’s been missed!)

lighting the pipe 2
Relieving Ned Gowan’s asthma with the brochodilatory effects of thornapple / STARZ

Thornapple, also known as Jimson Weed, acts as a bronchodilator, opening Alex’s constricted airways via the action of atropine as well as reducing mucous production obstructing the flow of air.

The leaf of the coltsfoot plant has been used historically as an inhalant to ease cough and wheezing. Its scientific name is Tussilago fanfara, (tussis – “cough”, ago – “to act on”), very appropriate given its expectorant, antitussive and anti-inflammatory effects.

Smoking various medicinal herbs via pipe, cigarette, or cigar, was indeed an effective historical remedy for the symptoms of lung disease.  These often contained Stramonium, aka thornapple!

cigarettes-1267474_960_720
Kellogg’s Asthma Cigarettes c. 1920-1930 / source

However, Alex is in such severe distress, he cannot purse his lips and draw breath from a pipe. Ever resourceful, Claire has a solution.

blowing into tube two
Ever resourceful Claire! / STARZ

Claire has contrived a way to deliver the medication to Alex, much like an inhaler and spacer.  Alex can freely inhale the medicinal smoke without needing to try to take a forceful or deeper breath.  And indeed, it seems to provide him some relief.

Treating_Kids_with_Asthma
Inhaler and spacer for effective delivery of asthma medication / source

 

Claire splits her time between caring for Alex Randall in his final days, and attending to Colum MacKenzie, who continues to suffer debilitating pain from the destructive Toulouse-Lautrec Syndrome.

colum
“I would prefer something more final.” / STARZ

Claire offers Colum laudanum for pain relief.  Colum replies with “Laudanum just dulls the senses.  I would prefer something more final.”

What is laudanum?

An alcoholic solution containing opium.  Used primarily as a pain reliever.  Also used as a cough suppressant and for the treatment of diarrhea. Overdose and death can occur with as little as 3 teaspoons in those unhabituated to opiates.

Colum asks Claire to give him a quick death, like Geillis Duncan gave her husband Arthur.  Well, as it turns out, Arthur’s demise wasn’t all that quick.  (See the post What Was Ailing Arthur Duncan!)  After trying to kill him for months by poisoning him with arsenic, and causing unending gastrointestinal misery, Geillis ultimately dosed Arthur with cyanide and he dies a quick, though agonizing and quite public, death in the Great Hall.

arthur on ground far
Poor Arthur Duncan / STARZ

Claire points out that cyanide poisoning would be a terrible way to die and pulls from her well stocked medicine bag a vial, telling him, “This is yellow jasmine.  It will be like drifting off into a deep sleep.  For when you are ready.”

vial for colum two
Yellow jasmine / STARZ

Well, that sounds like a much better option.

Except for the fact that yellow jasmine might also cause an agonizing death.

Yellow jasmine, or Gelsemium sempervirens, is indeed extremely toxic, but rather than allow one to drift peacefully off to sleep, it suffocates the victim by paralysis:

The symptoms of yellow jasmine toxicity are depressed respiration, tremors, paralysis of the extremities, convulsions, urination, defecation, retching and salivation.  In large doses (as Claire gave Colum), it paralyzes the respiratory centers. Large doses paralyze the spinal cord and cause almost complete loss of muscular power.  Death is due to asphyxiation.

In order to allow Colum to drift peacefully off to sleep, perhaps Claire has added a very strong sedative?  It would have taken A LOT of laudanum to have this effect on Colum, as no doubt he has been taking large doses of laudanum regularly for many many years and is quite habituated to it.  But then, she does have that medicine bag of wonders and  perhaps is able to whip up something to quickly cause sedation so that the yellow jasmine could take its effect without causing undue distress.

However, this is an interesting excerpt, describing a poisoning with yellow jasmine which does sound like what Claire intended:

Gelsemium in lethal doses paralyzes the nerves, both sensory and motor. The motor nerves are first influenced, the paralysis of sensation more slowly following. The writer observed a case of poisoning where the patient had taken sixty minims of the fluid extract within forty-five minutes. A sensation of general oppression occurred rather suddenly. The patient rose to her feet, noticed that vision had failed almost completely, walked two or three steps, then fell in a mass upon the floor in a state of complete muscular relaxation. There was no alarm or fear, a rather tranquil feeling mentally, and in this case there was no great difficulty of breathing, although we have observed dyspnea from single doses of two or three minims of the fluid extract. The recovery of this patient was rapid, although muscular weakness was present for several days.

From the American Materia Medica, Therapeutics and Pharmacognosy by Finley Ellingwood, MD.  1919. Pages 225-6.

In the end, Colum ended his life on his own terms, and hopefully in the peaceful way Claire intended.

empty vial
On his own terms / STARZ

 

 

And here is a fun find for those who like quirky historical medicine facts…  Enjoy!

Other Applications for Medicinal Smoke?

Interestingly enough, tobacco smoke enemas were actually used in the past for the treatment of a number of different ailments such as gut pain and in the resuscitation of drowning victims.  Indeed, it is the origin of the term “blowing smoke up your arse!”  Let’s hope Claire doesn’t find a need to explore this modality further!

Resuscitation_set,_Europe,_1801-1850_Wellcome_L0057782
Resuscitation set containing the equipment necessary to inject the lungs, stomach or rectum, early 19th century. /  source

 

References:

Dutt, V., Thakur, S., Dhar, V. J., & Sharma, A. (2010). The genus Gelsemium: An update. Pharmacognosy Reviews, 4(8), 185–194. http://doi.org/10.4103/0973-7847.70916

Ellingwood, Finley. (1919).  American Materia Medica, Therapeutics and Pharmacognosy. (available to read online here)

Questions, comments, concerns, or suggestions for future Outlander medicine topics? I’d love to hear from you! Leave a comment here, email or find me on twitter @sassenachdoctor

211: Trauma, of Both the Minor and Major Varieties

211: Vengeance is Mine

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This was a fun one! There were so many great medical moments and hilarious lines that it is no coincidence that this episode was written by Herself, Diana Gabaldon.

written by DG

Vengeance is Mine opens on Claire operating a makeshift dental clinic. With the resources available to healers of the time, most dental problems were treated by extracting the offending tooth. Aside from perhaps a shot or two of whiskey, teeth were pulled without anesthetics, sedatives or pain relievers. No novocaine, no nitrous oxide (laughing gas), no gentle topical anesthetic gel applied before the novocaine to avoid even the pain of the needle. Nope, these folks of the 18th century with dental ailments are desperate for help and tough as nails, knowing that if they can just tolerate the excruciating tooth extraction, relief will be forthcoming.

pulling tooth open mouth rupert watch
No matter the temperature, those wristlets have gotta go during the dirty work!  / STARZ

This is in stark contrast to dental clinics of today which advertise painless dentistry with the aid of topical and local anesthetics, post-procedure pain relievers and even the option of sedation. The feared drill isn’t even always necessary any more as some cavities can be “drilled” with a rather painless laser. As lovely as that is, it doesn’t quite carry the same motivating weight when convincing children to brush their teeth!

“Brush your teeth well so you don’t end up with a cavity that needs to be drilled!”
is now
“Brush your teeth well so you don’t end up sitting for a half hour in the dentist’s chair while your cavity is painlessly fixed!”

All joking aside, anesthesia really is an amazing advance and we are fortunate to live in this time in that regard!

plate of teeth
What do we suppose Claire does with all of the teeth she has extracted?  / STARZ

As Jamie and his men march toward Inverness, they camp along a river where Ross has the misfortune of impaling his own finger with a fish hook.

good shot hook in finger
Steady hands / STARZ

We see Claire back the hook out of the skin along its path of entry, a method called the Retrograde technique. This works because this hook is smooth and lacks barbs that would otherwise catch and prevent it backing out easily.

Rupert: Ah ye big baby, Angus’d bite it off wi’ his teeth.
Fergus: Angus didn’t have front teeth.
Rupert: He’d use his gums then.

Most fishing hooks made today have one or more barbs which prohibit simply pulling the hook smoothly out the way it came.

Anatomyofafishhook
Anatomy of a Fish Hook / source

There are a number of techniques one can employ to remove a barbed hook depending on the type of hook.  It can be very helpful to know the type of hook one is dealing with to better plan the removal.

typesFishhookanatomy
Fish Hook Types / source

Various methods allow the backing out of a barbed hook avoiding further trauma, though at times the location and type of fishhook will require advancing it through the skin, cutting the end of the hook, including the barb(s), and then allowing the hook to be backed out the way it came.

hook removal two
image: Shutterstock

For multi-barbed hooks, it may be necessary to advance the hook past all of the barbs, cut off the eye of the hook, and continue advancing the hook out.

I learned quickly to add a small pair of wire cutters to my first aid bag after my son hooked his uncle’s arm on his first try at fishing! Oftentimes, hooks can be removed in the field, though some embedded fishhooks cannot be easily removed or are in areas in which removal should not be attempted (in or near the eye!) and medical care should be sought.

Claire: I do wish I could give you a tetanus shot…
Ross: Tetanus. Never heard of it, but I’d take a shot of anything just now.
Rupert: Sounds Spanish. Must be gin.

Indeed, this is a risk she is all too well aware of and, as discussed when the tanner’s lad had his ear nailed to the pillory, there isn’t much to be done in the era before tetanus vaccination but cross your fingers and hope the odds are in your favor.

Moments later, the Redcoats show up. That’s never good news.

shooting at rupert
He’s got his eye on Rupert!  / STARZ

Oh Rupert, this guy just can’t catch a break. His dearest friend died in combat just days ago and now this!

claire holding rupert
Amazing makeup and prosthetic work!  / STARZ

Rupert has sustained a gun shot wound to the eye. Fortunately, it seems that the bullet has remained in the eye socket or perhaps lodged in the bones of the orbit, but has not penetrated into the brain.  A devastating injury, yes, but one that he will likely survive, so long as he avoids infection.

 

Gray190
Shown here are the bones of the skull and the bony structure of the orbit, or eye socket (source)

Claire works to remove the bullet from Rupert’s eye socket and debride the area, or clean by removing dead or devitalized tissue and foreign matter, to allow it to heal.  Rupert lies quite still throughout, despite the unimaginable pain involved.  Again, the people of that time seem to have incredibly impressive pain tolerance!  She sutures shut his now-empty eye socket and places a dressing over the wound.

tying on eye patch
Are we ready for a crossover with Black Sails yet? / STARZ

Rupert: I suppose one eye is better than none…
Claire: We’ll get you a black eyepatch and you’ll look a proper pirate.
Rupert: Pirates have eyepatches?
Claire: Along with peg-legs and parrots.

Adventures in Medicine continue in this episode with one Miss Mary Hawkins, in the kitchen, with a knife.  Having identified Danton, one of her attackers in Paris, she takes vengeance of her own.

stab wound
Angus the knife skills instructor would be proud / STARZ

Danton is stabbed in the abdomen and collapses to the floor.  Mary may not have had the same benefit as Claire in a crash course in the proper use of a sgian-dubh (RIP, Angus Mohr!), but has success, aiming in the mid-abdomen, slightly to the left, possibly lacerating the aorta and other abdominal vasculature in addition to some of the bowel.  We don’t see Danton in the aftermath of this injury, though we may assume he has sustained a fatal injury. The action quickly moves to another case of significant trauma…

beheaded2
Ah, the foreshadowed fate of a bewigged Duke of Sandringham!  / STARZ

This one, though, is rather self-explanatory and doesn’t require much in the way of medical commentary!

 

There was so much to enjoy in this episode – the development of Mary’s character, the reappearance of Hugh Munro, fun medical snapshots, humorous lines so reminiscent of the books, and Murtagh’s delivery of vengeance to the feet of Mary and Claire.  I’ve read that Ms Gabaldon will not be writing a script for season 3 because it would take too much time away from writing book 9. This episode was truly a joy and hopefully we’ll see more scripts from her someday!

Will the release of book 9 coincide with the premier of season 3?  2017 is promising to be a pretty epic year for Outlander fans!

 

Questions, comments, concerns, or suggestions for future Outlander medicine topics? I’d love to hear from you! Leave a comment here, email or find me on twitter @sassenachdoctor!

210: When Nothing Can Be Done

210: Prestonpans

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STARZ

After six years of combat nursing in the Second World War, Claire knows what awaits and she is as prepared as she can be.  She has collected what she can in the way of medical supplies including strips of bandages sourced from petticoats and shirts, needles and thread, honey water for hydrating the wounded, alcohol for sterilization, laudanum and whiskey for pain relief and fortunately the medical bag of a Doctor MacPherson which has been left behind, containing useful medical instruments.  Along with her crew of willing and not-so-willing volunteers, she stands in nervous anticipation for an influx of wounded soldiers.

angus carries rupert
Selfless Angus – STARZ

Ever the stoic Highlander and loyal friend, Angus carries Rupert to the field hospital, where he can be cared for by Claire and her ready crew.  Rupert has sustained a large laceration to the left side of the chest.  The wound involves the skin and soft tissues of the chest wall, but remains superficial to the ribs and the vital organs and blood vessels of the thorax.  After a dose of what is likely laudanum for pain, Claire sutures the wound closed.  If he can avoid an infection in the wound, Rupert will recover.

As Murtagh so keenly notes,  “Dinna fash yerself, that blubber no doubt protected his innards.”

Rupert’s wound is actually the same type of wound Jamie sustained in Dragonfly in Amber in the Battle of Prestonpans:

It was a saber-slash, slanting across the ribs.  A lucky angle; straight in and it would have gone deep into the intercostal muscles between the ribs.  As it was, an eight-inch flap of skin gaped loose, red beginning to ooze beneath it again with the release of pressure.  It would take a goodly number of stitches to repair, but aside from the constant danger of infection, the wound was in no way serious.

From Dragonfly in Amber by Diana Gabaldon, Chapter 36.

For the TV adaptation, Rupert sustains this wound rather than Jamie.  The contusion and potential kidney trauma resulting from four-hundredweight of horse stepping on his flank will be plenty for Jamie to deal with for now (though if the show stays true to the book in this regard, he will be fine, pissing contests notwithstanding…).

As the episode progresses, subtle clues suggest Angus isn’t doing so well himself.

Angus is quite subdued and without the normal witty banter we have come to expect from him even in the most trying of times.  He begins to complain of headache and soon after, collapses to the floor.

internal bleeding
Ecchymosis (red/blue/purple discoloration of the skin) – a sign of internal hemorrhage / STARZ

What happened?

On the battlefield, Angus saves Rupert from a charging Redcoat and moments later is blown to the ground by a cannon blast immediately behind him.

angus in blast
Cannon blast just behind Angus as Rupert watches on / STARZ

Blast injuries result from explosions and have the capability to cause significant, life-threatening injuries.  What used to be a pattern of injury seen primarily on battlefields, blast injuries are sadly becoming more common in the civilian population as the result of terrorist acts.

Blast injuries are categorized by the mechanism with which the explosion causes injury:

Primary blast injuries are injuries caused by the direct effect of transmitted blast waves.  The lungs, bowel and middle ear  – air filled areas of the body – are the areas most susceptible to this type of injury.

Secondary blast injuries are those injuries sustained when a vicim is struck by airborne debris from the blast.

Tertiary blast injuries are caused by high-energy explosions when the victim is propelled through the air and strikes other objects or the ground.

Quaternary blast injuries are the injuries that occur as a result of all other forces, such as a resultant fire and building collapse following an explosion.

Angus has suffered a primary blast injury to his abdomen, which can cause perforation of the intestines, hemorrhage, lacerations of the solid organs such as the kidney, liver and spleen, and shearing injury to blood vessels throughout the abdomen.

angus from above with group at end
Angus’ final moments, surrounded by Claire, Jamie and Dougal / STARZ

Angus dies of massive internal bleeding in Claire’s arms, with his last words, “Save me, Mistress.”  She is helpless to save him.  There is nothing to be done, even if he had sought her help immediately.  The knowledge, tools and resources needed to surgically treat the trauma he sustained would not be available for two more centuries, and even today this injury would carry a substantial risk of death.  There is nothing Claire can do but provide comfort as he takes his final breaths.

Perhaps sensing the severity of his wound, Angus chose to spend his final moments by the side of his trusted friend, keeping watch over Rupert.

angus will watch ruperts belly moving
Keeping vigil at Rupert’s bedside, watching him breathe / STARZ

It was truly devastating to lose a member of the Highlander family.  The battle might have been won but not without heartbreaking cost.

“War leaves a bitter taste, no matter the outcome.” – Jamie Fraser

smiling angus
STARZ

Questions, comments, concerns, or suggestions for future Outlander medicine topics? I’d love to hear from you! Leave a comment here or find me on twitter @SassenachDoctor.

209: The Invisible Wounds of War

209:  Je Suis Prest

209 title

The field hospital at which I was stationed had been shelled three times.  Even knowing that the flimsy walls of our temporary structures would not protect us, still doctors, nurses and orderlies had all dashed inside at the first alarm, huddling together for courage.  Courage is in very short supply when there are mortar shells screaming overhead and bombs going off next door.

From Outlander by Diana Gabaldon, Chapter 7

combat nurse
STARZ

Claire spent six years as a combat nurse in the second World War.  In episode 209, the sights and sounds of men preparing for battle trigger terrifying flashbacks to her time in the war and she is seen reliving the trauma she has no doubt tucked away deep in her memory.  As a combat nurse, she would have spent her days caring for soldiers suffering horrendous injuries as well as the more mundane, as we see with her flashback to her time educating soldiers about trench foot.  She would be building relationships with the same men and women who would later be sick and seriously injured and in her care.  She would have witnessed innumerable tragic deaths, while often fearing for her own life.  When the war finally ends, Claire finds herself with only a brief time of peace and reunion with Frank before she is once again in harm’s way.

Since her arrival in the 18th century, Claire has suffered what seems to be a lifetime of traumas in the form of war, violence, assault, arrest and imprisonment, narrow avoidance of execution, witnessing the torture of her husband, and the devastating death of her daughter.

Claire holds deep within a long history of trauma.

claire covering ears
STARZ

Shell Shock and the World Wars

The psychological distress experienced by soldiers was first dubbed “shell shock” during World War I.  Physicians used the term to describe the “dazed, disoriented state many soldiers experienced during combat or shortly thereafter.”(1)  The condition was thought to be brought on by concussion and physiological damage caused by exploding artillery shells.  However, military physicians noted that the same symptoms were seen in other soldiers who had not been in close proximity to exploding shells and opinion shifted, with many contending that shell shock was “a variety of cowardice or malingering” and those who “cracked” under the pressure of war were considered weak.

After WWI, Sigmund Freud argued that shell shock was psychological in origin, recommending psychoanalysis for treatment.  The idea that brain injury from exploding artillery shells led to these symptoms fell out of favor and the opinion that the condition affected the psychologically “weak” persisted.  During WWII, draft boards attempted to “weed out” those deemed psychologically unfit to fight, finding over 1 million men ineligible to go to war.  Despite this, in the European theater, the US military had a rate of psychiatric casualties of 102 per 1,000 troops.(1)

Overall in WWII, 25% of US military casualties were caused by psychological war trauma.  The rate was approached 50% for soldiers engaged in long, intense fighting.(2)  Seeing that so many suffered these effects, despite already excluding over 1 million men in the screening process, opinion among most in the military began to shift to the acceptance that combat fatigue was not evidence of cowardice or pre-existing mental illness.

1,393,000 soldiers were treated for battle fatigue during WWII.  Treatment was often focused on a few days of complete rest, with quick return to the front lines.  50-70% returned to combat within three days.  Other treatment modalities included the administration of sodium pentathol (dubbed “truth serum”) to induce soldiers to “re-live their repressed battlefield experiences and thus reach a catharsis.”(2)  Other physicians found that providing liquor during debriefings was beneficial to the troops.  Some were treated with electric shock in an attempt to “jolt” the veteran out of his emotional turmoil.  Others were treated with large doses of insulin which dropped their blood sugar severely and caused a comatose state.  In the 1950s, some WWII veterans were even subjected to lobotomy, or surgical severing of the frontal lobes of the brain, in an attempt to relieve their psychological symptoms.  Whether dubbed shell shock, psychoneurotic disorder, anxiety neurosis, character disorder, or combat exhaustion, very little was understood about what would come to be known Post Traumatic Stress Disorder.

 

Defining PTSD

In 1980, after experience with troops returning from the Vietnam War, the American Psychiatric Association defined PTSD and published diagnostic criteria.

Post Traumatic Stress Disorder, or PTSD, is now defined as a mental disorder that can develop after a person is exposed to a traumatic event, causing at least one month of symptoms including a variety of the following:

  • Re-experiencing the trauma
    • flashbacks, bad dreams, frightening thoughts
  • Avoidance symptoms
    • staying away from places, events or objects that are reminders of the trauma
    • feeling emotionally numb
    • feeling strong guilt, depression or worry
    • losing interest in activities that were previously enjoyable
    • difficulty remembering the traumatic event
  • Arousal and reactivity syptoms
    • easily startled
    • feeling tense or “on edge”
    • difficulty sleeping
    • angry outbursts
  • Cognition and mood symptoms
    • trouble remembering key features of the traumatic event
    • negative thoughts about oneself or the world
    • distorted feelings like guilt or blame
    • loss of interest in enjoyable activities

The manner in which PTSD causes these symptoms is not yet understood.  Interestingly, MRI studies have shown decreased volume in key parts of the brain in patients suffering from  PTSD.  The hippocampus is involved in creating new memories and retrieving them in response to relevant stimuli.  The amygdala helps to process emotion and plays a role in fear response.  Both have been found to be smaller in PTSD patients.  These findings have raised the question of whether PTSD causes these brain changes or if those with these differences are more susceptible to PTSD, thus opening the door to research into strategies for prevention and treatment.(3)

1511_The_Limbic_Lobe
Location of the amygdala and hippocampus in the brain / source

Treatment today for PTSD includes cognitive-behavioral therapy, antidepressant medications, or a combination of both.  Many resort to self-medication with drugs and alcohol to dull their crippling symptoms of PTSD, only to battle addiction as well.

 

The Impact of PTSD Today

In the US, 3.5% adults have PTSD in a given year and approximately 9% will develop it at some point in their life.  Rates are higher in regions of armed conflict.  11-20% of veterans of Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF) suffer from PTSD in a given year.  About 12% of Gulf War (Desert Storm) veterans will have PTSD in a given year.  It is estimated that about 30% of Vietnam Veterans have had PTSD in their lifetime.(4)

Combat veterans are more likely to have suicidal thoughts, often associated with PTSD, and are more likely to act on a suicidal plan.  They are less likely to seek the help of a mental health professional for fear of social stigma or “appearing weak.”(5)

Each day, 22 US veterans take their own lives.(6)

There is significant work to be done to fully understand how PTSD works, why it happens and what we needs to be done to prevent it and help these patients.  Public awareness and understanding of PTSD and its effects is vital.   Bravo to the Outlander team for this compelling depiction of PTSD, and in a female veteran no less!

Resources for those suffering from PTSD and those who care for them:

Veterans Crisis Line

Stop Soldier Suicide

Real Warriors Campaign

 

Questions, comments, concerns, or suggestions for future Outlander medicine topics? I’d love to hear from you! Leave a comment here or find me on twitter @SassenachDoctor.

PTSD

 

1.  Scott, WJ.  “PTSD in DSM-III:  A Case in the Politics of Diagnosis and Disease.”  Social Problems.  37 (1990): 294-310.

2.  http://www.pbs.org/perilousfight/psychology/the_mental_toll/

3.  Morey RA, Gold AL, et al.  “Amygdala Volume Changes in Posttraumatic Stress Disorder in a Large Case-Controlled Veterans Group.”  Arch Gen Psychiatry. 2012;69(11):1169-1178.

4.  www.ptsd.va.gov

5.  Sher L, Braquehais MD, Casa M.  “Posttraumatic stress disorder, depression and suicide in veterans.”  Cleveland Clinic Journal of Medicine. 2012. 79(2): 92-97.

6. “Office of Public and Intergovernmental Affairs.” News Releases. VA Office of Public and Intergovernmental Affairs, 1 Feb. 2013. Web. Retrieved from www.va.gov/opa/pressrel/pressrelease.cfm?id=2427.

 

208: Changing the Future

Episode 208: The Fox’s Lair

208 title
Starz

Do Claire’s actions as a healer change the future?  To what degree?

It seems that on a daily basis, Claire is impacting the lives of those around her, whether by providing antidotes to poisoning, avoiding epidemics, cleaning and treating wounds that would otherwise fester, or suggesting certain crops to avoid future starvation.

Does each small change lead to larger consequences?  Will the lives touched by Claire lead to ripples that magnify over time to cause significant future changes?

Or is the future already written?  Was Claire always destined to travel back in time and touch these lives?

Does there exist some alternate future in which Claire Beauchamp Randall never travelled through the stones? A world where none of these people of the past would have had the opportunity to cross paths with Claire and therefore suffered death and disability she could have prevented?

Fortunately, for the purposes of Outlander, we have been given The Gabaldon Theory of Time Travel in The Outlandish Companion!

The Central Postulate of The Gabaldon Theory of Time Travel:
A time-traveler has free choice and individual power of action; however, he or she has no more power of action than is allowed by the traveler’s personal circumstances.

A Corollary:
Most notable historical events (those affecting large numbers of people and thus likely to be recorded) are the result of the collective actions of many people.

From The Outlandish Companion by Diana Gabaldon

future talk
Starz

From Episode 208: The Fox’s Lair:

Jamie: We know what will happen if the Jacobites lose the war. But what if they won?
Claire: But…they don’t. It’s the verdict of history.
Jamie: Have ye given up on changing the future then, Sassenach?
Claire: After Paris? Haven’t you?
Jamie: Aye, Paris was a bitter disappointment. But the future can be changed — you’ve proven it. Tammas Baxter lives because of you. Paris was spared an outbreak of smallpox because of you. Louise de Rohan will have the child of Prince Charles Stuart because of you.

So many lives have been touched by Claire, starting in the first episode of season one, “Sassenach.”  Had Claire not intervened and had left Jamie to the mercy of Rupert and Angus to reduce his dislocated shoulder by brute force, he could have been left with permanent nerve damage, deformity or weakness in his dominant arm.  How would that impair his ability to wield a sword and defend himself?

shoulder
Starz

When young Tammas Baxter was dying from poisoning after mistaking lily of the valley for wood garlic at the Black Kirk, Claire saved his life with an antidote of belladonna.  He now potentially will go on to grow into adulthood and have children of his own.  Will his descendants go on to change history as we know it?

home of poisoned boy
Starz

How many lives were saved when Claire identified smallpox among the crew in La Havre and prevented an epidemic?  To what degree do the dozens (hundreds?) of people she saved from smallpox go on to have a significant impact on the future?

i am a healer, comte
Starz

And what of the countless seemingly small actions Claire has taken with her patients such as care for wounds and mild ailments that could have become much more significant and potentially life-threatening without her intervention?

According to The Gabaldon Theory of Time Travel, with free choice and individual power of action, Claire has changed the future of those she heals.  However, these actions will likely not change notable historical events as those types of events would require the actions of many to take place.

Considering all of the potential descendants of the lives saved, what are the odds that one of them may act independently to change history, whether via assassination of a significant figure or a groundbreaking discovery?  What will the future look like in a world where Claire Beauchamp Randall Fraser has had the opportunity to heal, cure, and prevent illness in so many?

Fortunately, today brought the very exciting news that we will have another two seasons to consider this question as we see Voyager and Drums of Autumn brought to life on screen!

seasons 3 and 4

Questions, comments, concerns, or suggestions for future Outlander medicine topics? I’d love to hear from you! Leave a comment here or find me on twitter @SassenachDoctor.

 

207: No One Is to Blame

better titlecard

It wasn’t your fault, Claire.
Nor was it Jamie’s.
It wasn’t even Randall’s fault.

It wasn’t anyone’s fault.

All too often in medicine, as in life, simply horrific things happen to good people through no fault of their own.

claire in bed

We come to learn that Claire suffered a placental abruption.  The placenta has prematurely separated from the wall of the uterus, causing massive bleeding, contraction of the uterus and inadequate blood flow to her growing baby, ultimately resulting in the death of her daughter.

The raindrops beat on my face, on my throat and shoulders. Each heavy drop struck cold, then dissolved into a tiny warm stream, coursing across my chilled skin. The sensation was quite distinct, apart from the wrenching agony that advanced and retreated, lower down. I tried to focus my mind on that, to force my attention from the small, detached voice in the center of my brain, the one saying, as though making notes on a clinical record: “You’re having a hemorrhage, of course. Probably a ruptured placenta, judging from the amount of blood. Generally fatal. The loss of blood accounts for the numbness of hands and feet, and the darkened vision. They say that the sense of hearing is the last to go; that seems to be true,”

From Dragonfly in Amber by Diana Gabaldon, Chapter 23

 

Blausen_0737_PlacentalAbruption
source

Risk factors for placental abruption include history of a prior abruption, trauma to the abdomen in pregnancy, high blood pressure, cocaine use, smoking, abnormalities of the uterus, and prior cesarean section.  Sometimes it will occur in the absence of any risk factors.

Placental abruption occurs in about 1% of pregnancies, and even now carries a risk of stillbirth or death within 1 week of life of up to 60%.[1]   When an abruption occurs and the mother’s blood pressure is found to be low, indicating substantial blood loss, a significant abruption has likely occurred.  As described in Dragonfly in Amber, Claire’s placental abruption was a catastrophic event.  She describes symptoms of hemorrhagic shock from massive blood loss, with numbness in the hands and feet and loss of vision.  Even now in the 21st century, she would have a very high risk of losing her daughter.

There was nothing that could have been done to change the natural course of this pregnancy.  Placental abruption is not caused by emotional stress. The emotional anguish involved in Claire’s learning of the duel and subsequently witnessing it was not responsible. Bed rest would not have prevented the placental abruption.  A change in Claire’s activities, less exposure to stress and highly emotionally charged events, less whisky and wine – none of this would have prevented this placental abruption.  She does not have any identifiable risk factors for abruption that we are aware of. This was a tragic and unavoidable event, despite our desire to discover a way we could have saved Faith.

Somewhere deep down, Claire knows this.  Overcome with grief now, she will blame herself and those she deems responsible for the circumstances surrounding the tragic loss of their daughter.  In the end, though, with time and healing, she hopefully will come to accept that this could not have been prevented.

holding hands at grave

Questions, comments, concerns, or suggestions for future Outlander medicine topics? I’d love to hear from you! Leave a comment here or find me on twitter @SassenachDoctor.

References:

  1. Am. J. Epidemiol. (2001) 153 (4): 332-337.

206: The Fraser Family Recipe for Faking Smallpox

Episode 206:  Best Laid Schemes…

206 titlecard

Need to feign illness with smallpox?  Want to impress your friends, alarm the local harbormasters, and make a bonny prince squirm?  The Frasers have you covered!

The Fraser Family Recipe for Faux Smallpox

Ingredients:

  • Essence of Rosemary
  • Bitter Cascara
  • Mash of Nettles
  • Rose Madder

Method:

  1. Drink a concoction of essence of rosemary and bitter cascara to cause flushing and realistic ill appearance
  2. Apply mash of nettles over the area of skin where the characteristic rash of smallpox is desired
  3. Drink a small vial or rose madder to mimic blood in the urine
  4. Prepare to be quarantined!
a family that schemes together
A family that schemes together…

 

Essence of Rosemary

In Dragonfly in Amber, rosemary was used to cause redness or flushing of the skin to mimic the fever of smallpox.  Rosemary is thought to increase blood flow, though topical application rather than ingestion of rosemary may produce more redness.  Other uses of rosemary include the treatment of stomach upset and flatulence, gout, cough, headache and high blood pressure.  If its mechanism for treating elevated blood pressure is via dilation of the blood vessels, such dilation of the small capillaries may explain a mechanism for flushing and redness to mimic how one might look while febrile.

I handed him the second bottle, this one of green glass filled with a purplish-black liquor. “This is concentrated essence of rosemary leaves. This one acts faster. Drink about one-quarter of the bottle half an hour before you mean to show yourself; you should start flushing within half an hour. It wears off quickly, so you’ll need to take more when you can manage inconspicuously.”

From Dragonfly in Amber by Diana Gabaldon, Chapter 23

 

Bitter Cascara

Cascara seems to be a popular choice with Claire and Master Raymond!  Hopefully he keeps it well stocked in the apothecary!  In Dragonfly in Amber, the use of cascara had been discussed but decided to be too harsh.

The plan took several days of discussion and research to refine, but was at last settled.  Cascara to cause flux had been rejected as being too debilitating in action.  However, I’d found some good substitutes in one of the herbals Master Raymond had lent me.

From Dragonfly in Amber by Diana Gabaldon, Chapter 23

However, the cramping and abdominal pain will make for a realistic picture of an ill patient and as we see, Jamie had immediate symptoms just as Claire did when she drank cascara-laced wine.

 

Nettles

685px-Urtica_dioica38_ies
Stinging nettle / source

There is a reason that the medical term for hives, urticaria, comes from the Latin urtica, the word for nettle!  Also known as Utica dioica, the nettle plant is native to Europe, Asia, northern Africa and western North America.  It grows to a height of 3-7 ft tall and has stinging hairs (trichomes) along its leaves and stems which, when touched, transform into needles that can inject several chemicals including histamine, formic acid and leukotrienes.  This causes a painful stinging sensation to the victim and a characteristic rash with red itchy wheals and itchy white bumps.

His fair skin had flushed dark red within minutes, and then settle juice raised immediate blisters that could easily be mistaken for those of pox by a ship’s doctor or a panicked captain.

From Dragonfly in Amber by Diana Gabaldon, Chapter 23

800px-Nettle_Sting
Rash from stinging nettle / source

 

Rose Madder

The root of the madder plant has been used throughout history as a source for red dye.  Medicinally, it has been used for preventing and disintegrating kidney stones.  When taken orally, it causes red colored urine, saliva, perspiration and breast milk.

Rubia_tinctorum_-_Köhler–s_Medizinal-Pflanzen-123
Rubia tinctorum with its red colored root / source

A rare and severe form of smallpox, hemorrhagic smallpox, or the “bloody pox”, causes active bleeding in the gastrointestinal tract as well as blood in the urine.  The appearance of blood in the urine would be particularly alarming for those familiar with smallpox!

And should any doubt remain, the madder-stained urine gave an absolutely perfect illusion of a man pissing blood as the smallpox attacked his kidneys.

“Christ!” Jamie had exclaimed, startled despite himself at the first demonstration of the herb’s efficacy.
“Oh, jolly good!” I said, peering over his shoulder at the white porcelain chamber pot and its crimson contents. “That’s better than I expected.”

From Dragonfly in Amber by Diana Gabaldon, Chapter 23

 

Jolly good work, indeed, Frasers! And well executed by wee Fergus!

 

Questions, comments, concerns, or suggestions for future Outlander medicine topics?  I’d love to hear from you!  Leave a comment here or find me on twitter @SassenachDoctor.

205: A Historical Perspective on Alcohol in Pregnancy

205 screenshot

When viewed through our 21st century eyes, it does seem as though our pregnant heroine is drinking an awful lot of alcohol.

Throughout history, alcohol was not always thought to be something to avoid in pregnancy.  Alcohol was often medicine – whisky for colds or laryngitis, hot brandy punch for cholera, rum-soaked cherries for a cold.  Doctors prescribed champagne as a treatment for morning sickness. Pregnant women in labor would take a shot or two of liquor to ease their discomfort. Wine was often recommended during pregnancy to help pregnant women relax.

beehive-brandy

General opinion maintained that alcohol was not dangerous in pregnancy, though throughout the years, some have voiced concern. Aristotle is quoted to have warned against the hazard of drinking during pregnancy, “foolish, drunken, and harebrained women most often bring forth children like unto themselves, morose and languid.”  In 1899, English physician William Sullivan noted that among his patients in a Liverpool prison, stillbirth rates were 250% higher for his alcoholic female prisoners than for their sober counterparts. He also noted that the children of women with no (or limited) access to alcohol during pregnancy were healthier, leading him to hypothesize, “a direct toxic action on the embryo, owing to continued excesses during pregnancy.”

In an issue of the Quarterly Journal of Inebriety published the same year, an editorial contended, “habitual intemperance on the part of the female when pregnant must tend to impair the development of the fetus in utero by impairing cell growth. What we know now is that maternal use of alcohol during pregnancy can have deleterious effects on the growing fetus and lead to a number of problems.”  Many other physicians observed and reported similar findings in the 19th and early 20th century, describing outcomes that would later come to be recognized as symptoms of Fetal Alcohol Syndrome.

slides_196parents600
World’s and National Woman’s Christian Temperance Union, 1914   source

It seems, though, that as soon as prohibition ended in the US, attitudes regarding alcohol in pregnancy shifted again, and public discussion of the risk and medical research on the question, seemed to disappear.  The medical community seemed to turn direction completely, with a statement in 1953 in Clinical Obstetrics stating, “alcohol, as such, is not injurious and need not be eliminated during pregnancy.”   As recently as the 1960s-1980s in the US, alcohol was given intravenously to women in preterm labor as a tocolytic – a medication to stop uterine contractions calm and halt preterm labor.

A fetus is vulnerable to alcohol particularly because alcohol crosses the placenta, yet the fetus has lower levels of the enzyme alcohol dehydrogenase to metabolize the alcohol than does the mother. The fetus is thus exposed to alcohol for a much longer period of time.

The effects of alcohol manifest in different ways depending on the stage of pregnancy. Exposure in the first trimester can lead to characteristic abnormalities in the face as well as devastating heart defects and abnormalities of the bone structure, kidneys, eyes and hearing. Second trimester alcohol exposure increases the risk of miscarriage and stillbirth. In the third trimester, fetal exposure to alcohol affects weight, length and brain growth.

FASkid
By NIH/National Institute on Alcohol Abuse and Alcoholism

Fetal Alcohol Spectrum Disorders are the conditions that may occur in persons who were exposed to alcohol in utero. Problems can include abnormal appearance with characteristic facial abnormalities, short height, low body weight, small head size, poor coordination, low intelligence, behavioral problems and hearing and vision problems. It is thought to affect 2-5% of people in the US and Western Europe. Worldwide incidence is approximately 1 in 2000 live births.

It wasn’t until the 1970s that Fetal Alcohol Syndrome was defined and fully recognized. Work to educate pregnant women of the dangers of alcohol in pregnancy began in earnest after researchers at the University of Washington identified a pattern of abnormalities in infants born to alcoholic mothers.  Animal studies in monkeys then followed that confirmed that alcohol was indeed responsible.  Rather than naming the syndrome after themselves, as is common in the discovery of medical syndromes historically, the University of Washington researchers, Drs Kenneth Lyons Jones and David Weyhe Smith, chose the name Fetal Alcohol Syndrome after the agent responsible for the problem, to raise awareness of the problem alcohol in pregnancy.

1988 brought the Alcoholic Beverage Labeling Act in the US, mandating that the labels of alcoholic beverages carry a government warning.

warning

Today, the official statement from American Congress of Obstetricians and Gynecologists reads:

“Women should avoid alcohol entirely while pregnant or trying to conceive because damage can occur in the earliest weeks of pregnancy, even before a woman knows that she is pregnant.”

Other societies of providers of obstetric care phrase it a bit less stringently, with the European Board and College of Obstetrics and Gynecology advising:

“Based on what is known as well as the continuing uncertainty as to whether any safe consumption threshold exists […] women should ideally abstain from alcohol during pregnancy or when planning pregnancy.”

Similarly, the Royal College of Obstetricians and Gynaecologists in the UK advises:

“If you are pregnant or planning a pregnancy, the safest approach is not to drink alcohol at all, to keep risks to your baby to a minimum. Drinking in pregnancy can lead to long-term harm to the baby, with the more you drink the grater the risk. […] The risk of harm to the baby is likely to be low if a woman has drunk only small amounts of alcohol before she knew she was pregnant or during pregnancy.”

Pregnancy in the 18th century was a scary proposition indeed. Reliable records of maternal death in the time are difficult to come by but studies of death records in the UK in the time suggest about 2.5-3% maternal death rate per baptism recorded.  Given an average of 5-6 pregnancies per woman, this would result in 11-16% risk for the average 18th century mother to die in childbirth or shortly after in her lifetime, and perhaps even higher given that the risk subsequent births are not necessarily independent of previous births.  Maybe we can understand why the women of the time (and their concerned partners) would encourage alcohol to help them relax and briefly forget about the fact they may not survive childbirth, especially without knowledge the alcohol would be doing any harm.  Compare this to the current risk of maternal mortality today in the US of 0.019%.

Even with her medical knowledge, Claire is coming from the reference point of the 1940’s when the medical community was of the opinion that alcohol was not hazardous to pregnancy, and actually was considered beneficial.  Seeing these huge shifts in the medical community’s understanding of the risk of alcohol, it makes one wonder what we will come to know in the future as an undeniable risk we assume is healthy today!

camels_doctors_whiteshirt
source

Questions, comments, concerns, or suggestions for future Outlander medicine topics?  I’d love to hear from you!  Leave a comment here or find me on twitter @SassenachDoctor.

204: The Bonesetter

204: La Dame Blanche

titlecard
STARZ

The image in the title sequence of a nail hammered into a leg has made many fans squeamish and curious for 3 episodes now.  Tonight we finally meet the poor owner of that leg.

title sequence nail
STARZ

In classic Claire style, despite of the dinner plans for the evening in which the “who’s who” of Jacobite France will be hosted at Chateau Fraser, Claire rushes to L’Hopital to help following news of an explosion at the armory. She assists Monsieur Forez in treating a man with a significant injury to his leg – an open fracture to the tibia is shown.

open tibia fx
STARZ

It seems that despite his primary job as executioner, Monsieur Forez is an empathetic healer who has employed a technique to minimize the pain of reducing an open leg fracture.

As we’ve seen already in Outlander, with Jamie’s dislocated shoulder and the leg amputation in the tavern, anesthestic options of the day were mostly limited to whisky, laudanum and a strong stick to bite. Monsieur Forez, however, presents an additional option.

He reached into his capacious pocket one more, this time coming out with a small brass pin, some three inches in length, with a wide, flat head. One bony, thick-jointed hand tenderly explored the inside of the patient’s thigh near the groin, following the thin blue line of a large vein beneath the skin. The groping fingers hesitated, paused, palpated in a small circle, then settled on a point. Digging a sharp forefinger into the skin as though to mark his place, Monsieur Forez brought the point of the brass pin to bear in the same place. Another quick reach into the pocket of marvels produced a small brass hammer, with which he drove the pin straight into the leg with one blow.

The leg twitched violently, then seemed to relax into limpness.

From Dragonfly in Amber by Diana Gabaldon, Chapter 14.

Monsieur Forez has performed what may be considered the 18th century version of a nerve block! He has injured the femoral nerve, causing the (hopefully) temporary interference of transmission of signal along that nerve.

Nerve blocks are widely used today, and probably the most familiar is at the dentist’s office when a portion of the mouth is temporarily numbed and part of the face paralyzed by the injection of local anesthetics (lidocaine, bupivacaine, etc.) to block the nerve to that respective area. Other common applications of nerve blocks:  repair of lacerations, spinal anesthesia for surgeries, nerve blocks in the upper and lower extremities for surgery, nerve blocks to help control chronic pain.

In Dragonfly in Amber, Claire’s patient has a fracture of the femur in the thigh as well as the tibia in the lower leg.  She describes a block of the femoral nerve – piercing the femoral nerve in the front of the upper thigh near the groin.  This block primarily was for the femur fracture – it provided anesthesia to the front of the leg where the bone protruded from the thigh and additionally, made the reduction of the fracture (or realignment of the bones by Monsieur Forez) easier by temporarily paralyzing the strong muscles of the thigh that would be forcefully contracting in response to the trauma, allowing him to more easily maneuver the bones into anatomical position.

The image below shows the areas of the leg numbed by the femoral nerve block.  All of the colored areas of the front of the leg as shown below are numbed:

pic4b
Source:  NYSORA.com

Claire’s patient in Dragonfly in Amber suffered different injuries from our patient in the Starz adaptation:

The leg, though, was something else;  an impressive double compound fracture, involving both the mid-femur and the tibia.  Sharp bone fragments protruded through the skin of both thigh and shin, and the lacerated flesh was blue with traumatic bruising over most of the upper aspect of the leg.

From Dragonfly in Amber by Diana Gabaldon, Chapter 14.

Instead, in episode 204, Claire and Monsieur Forez are dealing with only a lower leg fracture – an open fracture of the tibia and possibly the fibula as well.  Monsieur Forez performs a nerve block just below the knee on the medial (inner) side of the lower leg.  It would appear he has performed a saphenous nerve block with a below the knee approach.  This would result in numbing of the lower leg on the medial (inner) side.

Same image, but with this saphenous nerve block, only the blue-gray colored area on the lower leg labeled saphenous n. would be numb:

pic4b
Source:  NYSORA.com
lower leg wound wide
STARZ

 

The nerve block made a lot of sense in the book for dealing with a femur fracture as it provided anesthesia to the front of the leg in the area of the thigh with broken bone protruding.  Additionally, paralysis of the strong thigh muscles helped facilitate the reduction (realignment) of the fractured bone.  For the lower leg fracture in the show, the nerve block performed to just the lower leg may have provided some pain relief but wouldn’t have been quite the game changer of the femoral block in a femur fracture.

 

Some other medical musings on this episode:

thigh bite again
This scene suggests that Jamie has obtained these bite marks just prior to returning home to her.  While I appreciate a good look at Jamie’s thighs as much as the next girl, I’m wondering about the timing of these bites.  The yellowish discoloration around the bite suggests they are at least a few days old.  Perhaps he has numerous bites, in varying stages of healing.  Further examination of those thighs must be in order…/ STARZ

 

monkey bite
As it turns out, “brunette whores” are not the only Parisians with a biting fetish this week.  Bonny Prince Charlie should be careful – monkey bites can transmit herpes and rabies! / STARZ

 

claire doesnt feel so good
Claire accepts a glass of wine from a servant at Versailles, takes a drink and immediately doubles over in pain.  As we learned from Mater Raymond in episode 203, cascara is a good “faux” poison, causing severe symptoms that later resolve spontaneously without lasting effects.  In therapeutic doses for the treatment of constipation, cascara acts in 6-8 hours.  Now, Claire has received a dose larger than normal in order to produce these severe symptoms, but still the symptoms would not have come on instantaneously.  Perhaps she was dosed in an earlier glass of wine that day and now it is beginning to take effect. /  STARZ

 

gotta wash hands.png
Yes, Mary.  PLEASE go wash your hands.  Hangman’s grease.  (shudder) / STARZ