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.

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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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302: Phantom Pains

Ian. Rupert. Now, Fergus.

All may now find themselves suffering from phantom pains.

“My leg, it’s not there as anyone can plainly see.  And yet, it pains me terrible sometimes.  Even wakes me up at night.” – Ian Murray

Phantom Limb Pain:  a phenomenon characterized by the experience of pain, discomfort, or other sensation in the area of a missing limb or other body part.

In fact, one does not have to lose a limb to suffer from Phantom Limb Pain.  It also can occur with the loss of other body parts: eyes, tongue, nose, even breast.

The concept of phantom limb pain is not new.  First described by the 16th Century French Military Surgeon Ambrose Pare, the term was first coined during the American Civil War by surgeon Silas Weir Mitchell.  Up to 80% of patients who undergo amputation experience phantom limb pain with a range of symptoms including burning, shooting pain, “pins and needles,” twisting, crushing, electric shock feelings, itching, and vibration.

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Why does Phantom Limb Pain occur?

In brief?  The medical community don’t know exactly.  There are a number of working theories.

One mechanism thought to be responsible for these symptoms is due to the direct trauma of the nerves themselves during amputation. The severed nerves grow and form groups of nerve cells called neuromas which then generate impulses that travel back to the central nervous system and are interpreted as pain.

Another theory suggests that the part of the brain cortex that normally receives input from that body area finds itself no longer receiving input.  The cortex reorganizes and neighboring areas take over that part of the cortex.  Because of this, pain impulses from areas of the body near the amputated limb are now interpreted as pain in the missing limb itself.

Or perhaps the symptoms are due to the lack of input.  Deprivation of the normal perception of that limb causes abnormal signals to be transmitted which are interpreted as pain.

Whatever the exact mechanism (and there are likely more than one coming into play), unfortunately phantom limb pain remains a problem difficult to treat.

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Treatment of Phantom Limb Pain

When possible, controlling pain prior to amputation can help.  Phantom limb pain occurs more frequently in those who had significant pain in that area prior to amputation.

Medications including acetaminophen, NSAIDs, opioid medications (these are thought to diminish the cortical reorganization which is one of the potential mechanisms PLP develops), antidepressants, and anticonvulsants.

TENS (Transcutaneous Electrical Nerve Stimulation) has been found to be helpful for some.

Mirror Therapy is an interesting adjunct in treatment.  Some theorize that the symptoms of Phantom Limb Pain are in part due to the absence of visual feedback about the limb to the brain.  When a patient watches the reflection of their intact limb moving, the brain interprets it as the phantom limb moving, resolving the mismatch between the visual and sensory inputs about the limb.

Fortunately, the prevalence of phantom limb pain tends to decrease over time following the amputation.

What about broken hearts?

“Feeling a pain in a part of ye that’s lost. And thats just a hand. Claire was yer heart.” – Ian Murray

The pain of love lost.  So similar.  Jamie and Claire both feeling less than whole, the pain still raw, and a constant reminder of what they have lost.

If only there was an effective treatment for that…

 

All images property of STARZ

 

 

 

Cats, Ants, and Agave

OutlanderScienceClub_Facebook

A Dram of Outlander Voyager Read-Along  Chapter 53-55 (LISTEN HERE)

Outlander Science Club

Suture Options At Sea (Listen to the podcast HERE!)

 

What happens when the healer needs healing?

With a deep laceration extending from nearly shoulder to elbow on her dominant arm, Claire is in no position to suture her own wound, but who can she depend on to repair it? While there are physicians with upper extremity amputations who are able to perform all of the necessary procedures, Fergus has not spent the time (that we know of) mastering these skills.  Jamie, with his large, rough hands, isn’t known for his fine motor dexterity.  Marsali likely has skill with needle and thread, but it doesn’t seem that sewing human flesh is something she will tolerate.

Enter Mr. Willoughby.  Renowned in China for his gift of composition and the fine motor skill necessary to pen volumes of poetry, he has the necessary dexterity for suturing.  Along with his gifts as a healer in Chinese medicine, it seems we have found the perfect candidate for the job.

In typical clinical fashion, Claire describes her wound:

     It was a long, clean-edged slash, running at a slight angle across the front of my biceps, from the shoulder to an inch or so above the elbow joint.  And while I couldn’t actually see the bone of my humerus, it was without doubt a very deep wound, gaping widely at the edges.
It was still bleeding, in spite of the cloth that had been wrapped tightly round it, but the seepage was slow; no major vessels seemed to have been severed.

From Voyager by Diana Gabaldon, Chapter 54

The next question is what will be used to close the wound? What kind of needle or thread will be available?

The first sutures, thousands of years ago, were made of vegetable material – things like flax, hemp, and bark fiber.  Later, animal sources such as hair, pig bristles, and animal skin were used for suturing.  Catgut was first mentioned by Galen in AD 150.  Catgut suture is made from the twisted intestines of herbivorous animals, generally sheep, goats or cattle and is also the material previously used in the strings of stringed instruments and tennis racquets. Catgut never had anything to do with cats, despite the name, and the term is thought to perhaps originate from the combination of “cattle” and “gut”.

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Catgut Suture (Public Domain)

What makes a good suture?

At first glance, sutures seem to be a pretty simple order: grab a thread and needle and sew up the wound.  However, it is a bit more complicated when considering materials for sutures.  Sutures must be strong enough to hold the tissue together but also flexible to securely knot.  They must be hypoallergenic and must be able to be sterilized.  Sutures should not be made of material like cotton that can act as a wick, allowing fluids to enter the wound.

Different wounds and different locations call for different types of sutures.  Sutures come in non-absorbable varieties and absorbable varieties.  Non-absorbable sutures are the most recognizable sutures – the typical black nylon or blue propylene we are familiar with that stay in place for 5-14 days for repair of lacerations to the skin, as well as silk, polyester and in some cases, stainless steel wire.   Non-absorbable sutures are also used internally in cases when an absorbable suture would break down too easily or too quickly, such as when repairing the heart or a blood vessel, in which rhythmic movement of these structures would require a suture that stays longer than a few weeks to give the wound enough time to heal.  Also requiring non-absorbable suture is the bladder, which contains fluids that make absorbable sutures dissolve much too quickly for the wound to heal.  Non-absorbable sutures are also used to secure various temporary devices in place, such as chest tubes and central venous catheters.

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Simple interrupted sutures of a thumb laceration with non-absorbable Prolene (propylene) sutures.  (Public Domain).
Absorbable sutures are made from materials that break down in the tissues after a certain period of time, anywhere from a few days to 90 days, depending on the material. These are used in the internal tissues of the body, lacerations of the tongue and in the mouth, and for situations when the removal of stitches will be traumatic, particularly in some cases for children. Absorbable sutures are made from catgut as well as synthetic materials.

 

What about the needles?

Sutures today have an eyeless needle – the suture is crimped into the end of the needle.

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Eyeless suture needles (Public Domain)
Up until the 1920s, however, suturing needles were eyed, much like a sewing needle, and this is what Claire would have used.

instruments_used_in_sutures_from_dictionnaire_encyclopedique_des_sciences_medicales_18841
Eyed suture needles, circa 1884.  (Public Domain)
The drawback of the eyed needle is increased trauma as the large eyed end of the needle is pulled through, as well as a larger hole left in the tissue, potentially allowing for leakage.

 

How did Claire manage to obtain appropriate needles and suture?

Mr. Willoughby is given a curved suture needle and length of catgut from Claire’s medical supplies.

While in Edinburgh, Claire would have had access to the many shops and artisans of the city. She likely sought out a local blacksmith to craft the small, eyed suture needles to her specifications.  Knowing what she does about life in the 18th century, this was likely among her first stops in her work to re-build her medical supply.

As for the catgut, I had always imagined Claire manufacturing her own sutures from the intestines of sheep she may have acquired from a local farm or butcher.  However, the process is rather involved, involving cleaning, trimming and isolating the useful membrane, soaking in potassium hydroxide, smoothing and stretching them out, before twisting them into uniform strings and finally sterilizing them.  While I have no doubt Claire could have and would have undertaken this work if without other options, while in Edinburgh, she likely would have taken advantage of the fact that local musicians and craftsmen manufacturing catgut to string their violins and other stringed instruments.

Of course, without the resources of a city like Edinburgh, Claire would have no doubt found or made what she needed, but history has provided a few other options as you’ll see below, should she find herself low on resources!

 

Ants as Skin Staples?

800px-dorylus_gribodoi_casent0172627_dorsal_1
Dorylus ant, with a pincer-like mandible capable of closing a wound (Creative Commons/ www.antweb.com)
The mandibles of certain species of biting ants have been used to close wounds!  The edges of the wound is held together, and the head of the ant is allowed to bite across the wound edge. The body is then twisted off and by reflex, the jaws remain tightly clamped across the wound, effectively performing like modern day skin staples.  Check out a video of these ants being used as sutures on http://www.discovery.com here!

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Skin staples. (Creative Commons/Mathrock)

Thorns and Spines 

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Agave plant (Creative Commons/Naamsvermelding vereist)

Thorns and spines of various plants were used as needles.  The agave plant in particular is very useful – when the leaf of the agave plant is soaked for a long period of time, it leaves behind long stringy fibers connected to a sharp tip – essentially, a needle and thread once dried.

Had Claire’s injury been to her non-dominant arm, she no doubt would have sewn it herself, one-handed with her good arm, perhaps with some assistance from Jamie in tying the knots and cutting the ends.  In doing so, she would have found herself in the company of many physicians in history of have had to do the same, including Russian Leonid Rogozov who as the only physician stationed in Antarctica on an expedition, developed appendicitis and performed his own appendectomy!

Now that we’ve received word that Mr Willoughby will in season 3, hopefully we’ll have this scene to look forward to, pillow-song and all!

 

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.

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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.

 

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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.

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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…

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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.

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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.

204: The Bonesetter

204: La Dame Blanche

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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:

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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

 

109: Things That Go Bump in the Night

109: The Reckoning

titlecard better
source: Starz

Jamie and the Highlanders sneak into Fort William to rescue Claire from the clutches of Black Jack, ready to fight with blades, fists and unloaded pistols.  Given the price already on Jamie’s head, Ned Gowan has warned the men that they must inflict no fatal injuries tonight.  Our Highlanders know how to fight, of course, and rise to the challenge.

The Redcoats are knocked on the head and fall one, by one, by one.

 

hit 2 again
Starz

 

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Starz

Ultimately, Jamie finally knocks out Black Jack with a non-fatal blow to the head. (And the audience groans, knowning what is to come).

jack ko

What exactly is happening when someone is knocked out?

Weighing in at approximately three pounds, the brain resides in the protective shell of the skull.  Additional protection is provided by layers of tough membranes called meninges covering the brain as well as cerebrospinal fluid in which the brain essentially floats.  Within the brain are billions of nerve cells, called neurons.  These cells are specialized to allow the gathering and transmission of electrochemical signals.  Some travel short distances within the brain, others might travel as far from the tip of the finger all the way up the arm.  Some neurons control muscle contractions, some are for sensation and others are messengers between neurons.

brain

Mild traumatic brain injury (TBI) or concussion, is a traumatically induced disruption of brain function as a result of an external force.  This trauma causes loss of consciousness, alteration of mental state for up to 24 hours, and post-traumatic amnesia for up to 1 day.

A direct blow to the head sets the brain tissue in motion within the skull, squeezing, stretching and sometimes tearing neurons in the brain.  This leads to varying degrees of abnormality in how the brain processes information.

Loss of consciousness in these injuries is thought to be due to brain edema (swelling).  The brain’s auto-regulatory mechanisms counteract this to protect against massive swelling by limiting blood flow.  The effect of the limited blood flow is accumulation of lactic acid and changes in metabolism at the cellular level in the brain lasting weeks and making the brain vulnerable to further injury during this time.

Symptoms of mild TBI, or concussion, are many:

Loss of consciousness
Amnesia
Altered mental state for up to 24 hours
Headache
Dizziness
Fatigue
Sleep disturbance
Balance problems
Tinnitus (ringing in the ears)
Sensitivity to sound
Difficulty concentrating
Irritability

Symptoms can last months in some cases.
In mild TBI, imaging of the brain with MRI and CT will not show abnormalities but the stretching and swelling of the neurons has a significant impact on the brain’s neurologic circuits.  A brain still healing from a concussion is vulnerable to further trauma.  When a second concussion occurs before the first concussion has fully healed, patients are at risk for rapid and severe brain swelling with catastrophic results – Second Impact Syndrome.  After the first concussion, the brain is still healing and has not yet regained its ability to auto-regulate intracranial pressure and blood flow pressure within the brain.  Remember that the brain is encased within the protective skull so there is minimal room for swelling to occur.  The massive swelling of the brain in second impact syndrome is rapid can lead to death within minutes.

concussiondiagram-2

The awareness of Second Impact Syndrome has led to strict policies and training, particularly in youth sports, regarding return to play after concussion, though the primary way to avoid this will but more research into avoiding first concussions.  It is likely that we will see protective headgear for soccer players in the coming decades.

Another sequelae of repeated concussions is Chronic Traumatic Encephalopathy (CTE).  Athletes and others who have received repeated blows to the head and concussions may manifest memory loss, mood and behavioral disturbances and progress to dementia decades after the trauma.  Some may further develop Chronic Traumatic Encephalomyopathy (CTEM), a disease similar to ALS or Lou Gehrig’s disease causing profound weakness and muscle atrophy.  Many former NFL players have been identified on autopsy as suffering from CTE or CTEM, as sadly there is currently no definitive test to diagnose the condition in the living.  As science advances and we come to be able to identify and diagnose this earlier, it may mean significant policy changes in the future for sports and activities where the risk of head injury is high.

Great advances have been made in the understanding of brain injury in recent decades, leading to heightened awareness of concussion and protective devices for sport.  A far cry from tricorn hats which would have offered no protection from head injury!

tricorns
Starz

 

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