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!

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

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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.