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.
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!
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.
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.
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?