105: In Which Ned Smokes a Pipe for his Health

Episode 105:  Rent

Rent Party
source:  Starz

The rent party travels through the MacKenzie lands collecting payment and drumming up support for the Jacobite cause. The medical highlights are the 18th century treatment of asthma and more bumps, bruises and lacerations for our Highlanders.

 

Here we meet the lovely Ned Gowan.  Claire and Ned seem to be kindred spirits, recognizing their shared love for the poetry of John Donne.

ned and claire meet
source:  Starz

It becomes clear Ned is suffering from a respiratory ailment with a persistent cough. He explains to Claire that this cough happens every year, in the same season. Ned suspects it is something in the wind that “sets my lungs afire.”

coughing ned
source:  Starz

Claire has just the solution. She prepares Ned a pipe of thornapple to smoke. Ned sees the irony in this but tries it and indeed is relieved of his symptoms.

lighting the pipe 2
source:  Starz

 

Asthma is a lung disease that causes inflammation and narrowing of the airways in the lungs. The airways of asthmatics are sensitive to particular triggers which vary from person to person but can include airborne allergens (pollen, dander, mold, dust mites), respiratory infections, physical activity, cold air, air pollutants, certain medications, and gastric reflux disease.

Asthma_attack-illustration_NIH
Effects of asthma on the airways / source

These triggers cause the airways in the lungs of asthmatics to become constricted and inflamed, and often obstructed with mucous, what we call an asthma attack, characterized by difficulty breathing, cough, wheezing and chest tightness.

Treatment varies based on the severity of symptoms. Depending on the frequency of symptoms, patients will take asthma controller medications to prevent asthma attacks as well as a “rescue inhaler” to use when attacks occur, specifically, a beta-2-selective adrenergic agonist.

inhalers
© Can Stock Photo Inc. / Merinka

In a nutshell, these medications are modified forms of epinephrine, or adrenaline. Adrenaline stimulates receptors in many parts of the body, particularly in the heart, as well as blood vessels in the body, smooth muscles of the body and smooth muscles of the bronchus and bronchioles, which are part of the airways in the lungs. The inhalers used for the symptoms of asthma primarily have their effect on the group of receptors that relax the airways, minimizing the cardiac side effects.

Less available now, epinephrine inhalers like Primatene Mist have been sold over the counter to treat asthma. As they are not specific for the receptors in the lungs, they effect the beta 1 receptors in the heart and the alpha receptors in the blood vessels, leading to elevated blood pressure, tachycardia (fast heart rate), irregular heart rhythm, chest pain and the risk of stroke.

 

Options were limited, though, for our 18th century friends. Claire has indeed provided Ned with something to relieve his symptoms of asthma.

thornapple
source:  Starz

Thornapple, also called Jimson Weed, is actually in the same family of plants as the belladonna that Claire used to reverse the effects of the poison on the young Tammas Baxter (episode 103:  The Way Out).  Thornapple does not have action on the adrenergic receptors like the medications used for asthma attacks today. Rather, its action in relieving asthma is due to atropine which you’ll recall was the active compound in belladonna as well! In this case, atropine causes bronchodilation, or opening of the airways in the lungs, and reduces the production of mucous in the airways by inhibiting a different receptor in the cells. Thornapple acts more strongly on the lungs than belladonna, making it the preferable choice.

450px-Jimson_Weed_(Datura_inoxia),_opening_flower
Thornapple source

Thornapple, or Jimson weed has long been known to help in asthma and respiratory ailments. As recently as the 1950’s, “asthma cigarettes” containing Jimson weed were widely used. However, as an anticholinergic, it also causes dilated pupils, blurred vision, hallucinations, confusion, competitive behavior and difficulty urinating. Severe toxicity can cause coma and seizures. Of late, it has become a concern of public health officials and the DEA as a drug of abuse.

Ned likely suffers from allergic asthma and reacts to an airborne pollen, given that these symptoms always occur each year during the same season. In the book, Claire falls through the stones near Beltane, in May, and the rent party would be traveling in late spring.  In the Starz adaptation, Claire travels back in time near Samhain so now we are deep in autumn.  Despite Claire’s lovely fur-trimmed traveling coat, perhaps we can still assume the Highlands has not yet had its first frost of the season and autumn allergens are still in the air.

 

A very interesting tidbit I came across was that Scotland has the highest allergy rates in the world with 1 in 3 Scots affected by asthma, eczema and allergies! Researchers suspect this is due to low levels of Vitamin D absorbed from the sunlight, particularly during the long winter months. I do wonder, though, whether the 18th Scots would have been affected by the lack of sunlight as much as their 21st century countrymen as the very nature of their day to day life had them outside quite a bit more.

 

Rent collecting continues. Claire is winning the respect of the men. At the last tavern, the MacKenzie men defend Claire’s honor, resulting in 3 split lips, 2 bloody noses, 12 smashed knuckles and 4 loosened teeth. And a partridge in a pear tree? Claire is becoming very experienced in caring for bruised and battered Highlanders.

poor angus
source:  Starz

 

The episode closes with Dougal questioning Claire again about her identity when they are approached by a large group of redcoats. This can’t be good.

 

Resources:

https://www.aacc.org/community/divisions/tdm-and-toxicology/toxin-library/jimson-weed

http://www.australianprescriber.com/magazine/26/2/33/5
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5904a3.htm

http://www.deadiversion.usdoj.gov/drug_chem_info/jimson_w.pdf

http://www.deadlinenews.co.uk/2012/10/26/lack-of-sunlight-could-explain-why-scots-have-worlds-highest-allergy-rate/

http://medplant.nmsu.edu/Diseases/asthma/asthma_JimsonWeed.htm

http://www.ncbi.nlm.nih.gov/m/pubmed/9274142/

http://www.deadlinenews.co.uk/2012/10/26/lack-of-sunlight-could-explain-why-scots-have-worlds-highest-allergy-rate/

Malick, MJ.  (2014).  21st Century Herbal:  A Practical Guide for Healthy Living Using Nature’s Most Powerful Plants.  New York, NY:  Rodale

Orr, S.  (2014).  The New American Herbal.  New York, NY:  Clarkson Potter.

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103: Demonic Possession, Woodlice and Tetanus, Oh My!

Episode 103:  The Way Out

title card with title
source:  Starz

This beautiful title card promises an episode about medicine!

The medicine bottle reads “ELIX: PECTOR: WED.”  I found on the Smithsonian Institute website’s online collection a very similar bottle, labeled “ELIX PECTORAL WED” which dates from the 18th century and would have held Wedel’s Pectoral Elixir, made by Georg Wolfgang Wedel (1645-1721) for chest ailments.  This medicine consisted of benzoic acid, ground irises, sugar, fennel oil and sulphur for the treatment of cough and congestion.  I love the attention to detail both in this series of books and the show!

 

Claire spends time exploring the surgery and all of the tools and medicines Davey Beaton has left behind.

davey beatons chest
source:  Starz

 

Among them are slaters which, it turns out, are live wood lice.

woodlice
source:  Starz

Apparently, in the past these have been thought to be medicinal and helpful for digestive ailments when swallowed whole.  No, thank you!

 

Claire busies herself, caring for the residents of Leoch.  Here, she fashions a splint for an injured wrist.

wrist splint close
source:  Starz

 

She is summoned to Colum’s chamber where he tells her that Davey Beaton used to massage him to ease his pain and make movement easier.  He hopes Claire will do the same for him.

colum legs in mirror
source:  Starz
colum legs on table
source:  Starz

Indeed this is likely very helpful to Colum in easing his pain, stretch sore or atrophied muscles and reduce muscle spasms.

 

Claire later visits Geillis Duncan’s home to stock up on medicines she may need when the clan has gathered at Leoch, in particular white willow bark for whiskey headaches!  Aspirin, even its earliest forms, has a long history with hangovers!

geillis study
source:  Starz

Claire witnesses a crowd surrounding the tanner’s lad who has been accused of stealing two bannocks. Geillis Duncan’s husband, Arthur, is the procurator fiscal for the district and must determine the boys fate.

caustic arthur duncan
Poor Arthur is feeling caustic again / source:   Starz

Arthur Duncan seems to suffer perhaps from both indigestion or acid reflux as well as quite a bit of flatulence.  He asks Geillis for peppermint to help.  Peppermint has been used medicinally for over 10,000 years and is often used for digestive problems.  It has anti-inflammatory and antispasmodic properties and also is a cholagogue (promotes discharge of bile from the biliary tract).  We don’t yet know what ails Mr. Duncan (though readers of the book know we soon will), but the peppermint seems to do the trick for him and he leaves in better spirits, much to the benefit of the tanner’s lad who will get to keep his hand today.  Instead, he will be sentenced to “one hour in the pillory and one ear nailed.”

 

pillory ear 2
One ear nailed / source:  Starz

The poor tanner’s lad.  In addition to the risk of bacterial infection of his wound and obvious lasting deformity, this (hopefully rust free) nail through his ear puts him at risk for tetanus.

Tetanus is a life-threatening disease caused by the bacteria Clostridium tetani.  The spores of this organism can survive in soil or on surfaces for years.  Most cases follow an injury such as puncture wound, laceration or abrasion, particularly from a rusted nail or similar object.  Infection occurs at the site of injury and an exotoxin produced by C. tetani, called tetanospasmin, spreads to the nervous system causing muscle rigidity, violent muscle contractions and instability of the autonomic nervous system. Difficulty swallowing, difficulty breathing, heart abnormalities and even sudden cardiac arrest can occur.  Patients will suffer from stiffness and pain in the masseter muscles of the face responsible for chewing, resulting in lockjaw, the common name for tetanus. Symptoms begin in the face and progress downward.

Tetanus is almost completely avoidable with vaccination.  Vaccination for tetanus began in the US in the 1940s, when there were approximately 580 cases of tetanus reported in the US and 472 deaths.  Most recent data shows this has decreased significantly to 41 cases and 4 deaths in the 2000s.

Modern day treatment of tetanus includes administration of tetanus immune globulin to neutralize the tetanospasmin toxin, muscle relaxants, temporary induced coma if needed and medications to mitigate the effects of the autonomic nervous system dysfunction. Mortality of tetanus is around 10-20 percent.  Of the cases reported in the US, about 90 percent had not received appropriate tetanus vaccination and indeed this disease primarily affects non-vaccinated and under-vaccinated people.  Remember to get your tetanus booster every 10 years!

 

Throughout the course of this episode, Claire has been learning that the son of Colum’s chambermaid has died after visiting the Black Kirk.  His friend, Tammas Baxter, who visited the kirk with him is possessed by the devil and near death.

Claire, of course, suspects otherwise.

home of poisoned boy
Young Tammas, seized with evil / source:  Starz

She visits the boy and notes he has no fever and likely does not suffer from an infection. Rather, she notes that his heart rate is slow and his pupils are constricted to pinpoints and she suspects poisoning.

Jamie accompanies her to the Black Kirk where her fears are confirmed.  Jamie explains that the boys who visit the kirk to prove their manhood often eat berries and wood garlic there. Wood garlic is an edible plant related to chives.

black kirk
The Black Kirk, where demons roam free / source:  Starz

Except it isn’t wood garlic.  It is lily of the valley.

black kirk plant 3
source:  Starz

Lily of the valley is a highly poisonous plant that contains cardiac glycosides. These chemicals act by inhibiting cellular function leading to dangerously elevated potassium levels, slowing of the heart rate and potentially fatal abnormal heart rhythms, as well as nausea, vomiting, diarrhea, abdominal pain and confusion.

Allium_ursinum0
Wood Garlic (source)

 

Convallaria_majalis_0002
Lily of the Valley (source)

Claire has identified the poison and now has to figure out a way to counteract the effect of the poison using the tools and medicine she has at her disposal in the 18th century.

 

The cardiac glycosides of lily of the valley are very closely related to the modern day medicine digoxin. Digoxin is used to treat patients with heart conditions like atrial fibrillation, where it controls ventricular rate and in heart failure in which it can increase contractility of the heart. If a child like this young boy presented today with cardiac glycoside poisoning, either from consuming plants like lily of the valley or oleander or from ingesting digoxin, digoxin-specific antibodies would be administered. These would bind to the cardiac glycosides circulating in his body and they would be excreted from his body via the kidneys.

However, this wouldn’t be on Claire’s radar as they were not developed until later in the 20th century.

She must figure out a way to counteract the effects of lily of the valley, in particular his slow heart rate, and our brilliant heroine recalls that another toxic plant, deadly nightshade or belladonna, contains atropine as an active component. She knows that atropine will act to increase the heart rate. Belladonna in this case will potentially act to counteract the slowed heart rate which can be fatal to our patient Tammas.  The hope would be that she can mitigate the dangerous effects of the poison until the boy’s body has metabolized and excreted it.

This is risky business, though, as Claire points out. “…but if I was wrong about the dosage or the original poison, it will cause convulsions and kill the boy just as quickly.”  Indeed belladonna is a poison in its own right. She has no way of knowing the quantity of active medication she is administering and she is taking a big gamble, but it appears the boy will die without her intervention and it is a risk that proves successful in the end.

She administers a concoction of belladonna to the boy and within minutes he is awake and talking and recovering.  A miracle!

Happy Family
source:  Starz

 

Claire hopes that this has garnered favor with the brothers MacKenzie and will persuade them to allow her to travel to Inverness.  Jamie, however, informs her that Colum is taking credit for bringing Claire and her gift of healing to the MacKenzies and likely won’t want to see her leave any time soon.

Yet Claire is determined to get back to the stones and to frank. Or die trying. And we know our girl is stubborn, resourceful and not averse to big risks…

 

Resources:
http://americanhistory.si.edu/collections/search/object/nmah_993857
Adams, C. (2014). Herbal Medicine: 100 Key Herbs With All Their Uses As Herbal Remedies for Health and Healing. CreateSpace.
Fauci, AS, Braunwald E, Isselbacher KJ, Wilson JD, Martin JB, Kasper DL, Hauser SL, Longo DL. (Eds.). (1998). Harrison’s Principles of Internal Medicine (14th ed.). New York, NY: McGraw-Hill.
Roush, SW, Murphy TV and the Vaccine-Preventable Disease Table Working Group. Historical Comparisons of Morbidity and Mortality for Vaccine-Preventable Diseases in the United States. JAMA. 2007;298(18)2155-2163.
Tintinalli, JE, Kelen, GD, Stapczynski, JS. (2000). Emergency Medicine A Comprehensive Study Guide (5th ed.). New York, NY: McGraw-Hill.