211: Trauma, of Both the Minor and Major Varieties

211: Vengeance is Mine

211 titlecard

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!

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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.