307: Back in the Saddle

It didn’t take long at all for Claire to rediscover the need for her medical skills in 18th century Edinburgh and she started off her new medical practice with a doozy!  I’m glad to finally learn about the patient we’ve seen for 7 episodes now int he season three credits.  I’ve been dying to know who the poor soul was who needed Claire’s trephination skills and today we learned the fate of the victim.

trephination
Property of STARZ

While the procedure Claire performed on her patient appears quite crude, it is actually one of the oldest medical procedures still used in practice today!

trepanning tools
Trephination tools, 1802.  Source: Creative Commons

The injury to his head resulting from his fall onto the stone hearth has caused the exciseman to develop an epidural hematoma.  This is a condition in which a strong blow to the head results in damage to an artery surrounding the brain, leading to the rapid accumulation of blood between the outer protective membrane (dura) of the brain and the skull.  Being quite solid, the skull is not going to bend or swell to accommodate this rapidly accumulating blood, so instead, the brunt of this expanding mass of blood is placed on the brain, compressing delicate brain tissues and increasing pressure to devastating effect.  In response to an epidural hematoma and the resulting compression of the brain, a patient characteristically experiences weakness or paralysis on the opposite side of the body.  Swelling of the brain then causes compression of other parts of the brain, including the third cranial nerve, resulting in dilation of the pupil of the eye on the same side of the head as the injury.

epidural ct
CT showing an epidural hematoma – note the lens shaped white hemorrhage.    Source: Wikipedia Commons

After hearing the sickening clunk of the exciseman’s skull on the hearth and allowing a moment for the shock of her attack to wane, Claire jumps into action.  It isn’t exactly clear how she so quickly landed on the diagnosis of epidural hematoma.  Classically (though of course not always), a patient with an epidural hematoma will initially have loss of consciousness, then awaken and experience a “lucid interval” before losing consciousness again as the hematoma grows and exerts its effects.  We didn’t see this play out in the episode.  Claire seems to make the diagnosis while he is still unconscious after the initial blow.  In modern times, these are diagnosed on CT scan or are suspected in a patient with a head injury along with a lucid interval and/or characteristic changes in the pupils.  Claire checks the patient’s pupils and states there is still time.  Does this mean the pupils are normal?  If they are normal, what are the clues she is using to deduce that he has an epidural hematoma?  If the pupils are not normal and the left pupil is ominously dilated, there isn’t much time to waste.  Hmm…

To relieve this pressure, a hole must be drilled into the skull to allow evacuation of the blood and relieve the excess pressure within the cranium.  When time allows, a neurosurgeon performs a craniotomy in the operating room.  However, this is quite time sensitive as the hematoma rapidly expands, causing significant injury to the brain.  In austere environments or in situations when transport to an operating room will take more time than the patient has, a burr hole is made to rapidly decrease the pressure.  While this is now done with a specialized hand-held drill rather than a hand crank trephine, the procedure is pretty much as Claire demonstrated.

wound retracted.png
Property of STARZ

As Claire readies for surgery and examines her patient’s pupils once more, she finds the left pupil is dilated, pressure is increasing, and she must move now.  She deftly drills a burr hole in the skull to allow the pressure to be relieved and to evacuate the blood.  However, despite her efforts, the exciseman has died of his injury.  Even today, epidural hematomas have a mortality rate ranging from less than 5% to as high as 41%, depending on the patient’s age, the size of the hematoma, the effect of the pressure on the brain, and timing of surgical intervention.  Claire gave the exciseman the best chance he could have had for survival in the 18th century and did what she knew to be morally right thing to do.

A Little Help from the Apothecary

Claire requested laudanum, ground yarrow root, and tormentil from the apothecary. Laudanum, for obvious reasons (though that apothecary seems to stock an amazing formula that works instantaneously!  That patient was OUT quickly!).  Yarrow root and tormentil have hemostatic properties to help stop bleeding, which also make good sense in this situation and my guess is they are for topical application to the wounds.

Herbal medicine was certainly not covered in any depth, if at all, in Claire’s medical education.  I always wonder whether she spent time on her own in Boston over the years learning about herbal remedies, storing those tidbits for possible future (past?!) reference?

I’m sure seeing Claire perform trephination on the exciseman wasn’t everyone’s cuppa tea, but my guess is that if you are reading this, you enjoy this stuff too.  Getting excited for the loa loa, plague ships, and hernias yet to come!   How about you?  What Voyager medical scenes are you hoping make it to the screen?

 

 

 

 

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212: If Mary Poppins Had A Medical Bag

212:  The Hail Mary

titlecard 212
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!

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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