204: The Bonesetter

204: La Dame Blanche

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.

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.

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:

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:

Source:  NYSORA.com

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:

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

 

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 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

 

Yes, Mary.  PLEASE go wash your hands.  Hangman’s grease.  (shudder) / STARZ

 

106: Surgery in a Tavern

Episode 106: The Garrison Commander

source:  Starz

The opening of The Garrison Commander finds Claire trying to assure the chivalrous Lieutenant Jeremy Foster that she is indeed a guest of the Clan MacKenzie and in no danger. Alas, he doesn’t seem fully convinced and informs Claire that she must accompany him to speak with his commander.

source:  Starz

The Red Coats, Claire, and Dougal arrive in the village which Red Coats have occupied and Claire finds herself feeling some relief, sitting at a lovely meal of venison and charming her countrymen with lively conversation.

source:  Starz

Her momentary relief is interrupted first by Captain Jack Randall (more to come) and then by a soldier who rushes in to inform the commander of an attack. Three enlisted men have been fired upon just outside of the camp. One man is dead, two are wounded, one severely, and no one can find the surgeon!

source:  Starz

Claire, of course, is on her feet and ready to help.

Downstairs in the tavern, the wounded soldier is carried to a tavern table. His arm is significantly injured and Claire realizes it cannot be saved. The arm will need to be amputated. Claire takes charge, applying a tourniquet above the wound and instructing the men to bring boiling water and clean cloth.

source:  Starz

The surgeon arrives and asks Claire whether she is going to faint when he begins to sew. He clearly doesn’t know our Claire. She assures him that she has seen worse and she directs the other soldiers to hold down the wounded man.

source:  Starz

The surgeon hands Claire a vial of opium to administer to the wounded soldier. He is given a stick to bite and told to “bite until your teeth crack.”

source:  Starz

Having administered all available methods of anesthesia, the surgeon begins to saw.
The injured soldier is screaming, onlooking soldiers are sprayed with blood and in the corner, patrons of the tavern are still casually enjoying their ale.

source:  Starz

 

The gruesome work begins / source:  Starz

Sharp, Samuel. (1761). A treatise on the operations of surgery, with a description and representation of the instruments used in performing them: to which is prefix’d an introduction on the nature and treatment of wounds, abscesses, and ulcers. London: J and L Tonson.  (source)

 

This tavern is far from the sterile operating rooms of today. Surgeries then took place often on kitchen tables with unwashed bare hands, dirty floors and tools that may have at most been wiped with a rag after their last use. It wouldn’t be until the second half of the 19th century that the work of Louis Pasteur, Joseph Lister, Robert Koch and others would revolutionize infection control.

Amputations in the 18th century. / source

In 1862, French chemist and microbiologist Louis Pasteur published his findings on the germ theory of infection, challenging the thinking of the time that infections were the result of “bad air” arising from rotting organic matter. In 1867, English physician Joseph Lister demonstrated a reduced mortality rate in his patients by using a carbolic acid on the tools and hands of the operating team as well as in the surgical wound.

Dr. William Stewart Halsted, surgeon at Johns Hopkins Hospital, adopted carbolic acid for antisepsis but it soon became clear that carbolic acid was quite rough on the hands of the surgical staff. In 1889 or 1890, Caroline Hampton, Halsted’s chief operating nurse, developed dermatitis on her hands from contact with the disinfectant. Halsted, who she would marry shortly thereafter, requested the Goodyear Rubber Company make her a pair of thin rubber gloves with gauntlets. They were such a success that within 10 years, surgeons and nurses alike were wearing them.  Dr. Joseph Bloodgood, a protege of Halsted, published a report of a nearly 100% drop in infection rate from data on 450 hernia surgeries after he began routinely wearing surgical gloves.

In 1881, Robert Koch developed sterilization processes using steam and hot air and soon after, sterilization by boiling was introduced. Everything used during an operation from the tools to dressing and gowns were boiled.

These advances led to a marked decrease in post surgical infection and mortality. Prior to the introduction of aseptic techniques, most surgical wounds became infected and drainage of pus was actually expected. In fact, finding “laudable pus” – creamy yellow ooze – on a wound within the first 4 days was considered a sign of good healing. Mortality of surgical infections reached 70 percent. Today, with aseptic techniques in surgery and the use of antibiotics, the incidence of surgical site infection ranges from 2-7% with significantly lower rates of mortality.

source

 

It is unimaginable the pain these brave patients would have endured in these invasive surgeries with just a swig of opium and a bite block, if that.

Ancient methods of anesthesia for surgery included ingestion of opium or wine and herb mixtures, inhalation of opium and herbs from a sponge held near the nostrils and even application of cocaine by which Incan shamans chewed cocoa leaves and vegetable ash and let their cocaine-laden saliva drip into the wounds of their patients. It wasn’t until the 1800s that significant progress was made toward adequate anesthesia for surgery.

“Die Operation” by Gaspare Traversi, 1753. / source

 

Nitrous oxide was first discovered in 1772 by English Scientist Joseph Priestly when he tested it on himself, discovering that the gas made him laugh and would have possible anesthetic properties. In 1844, dentist Horace Wells volunteered to have one of his own teeth extracted under nitrous oxide. He then used it successfully over a dozen more times, and was invited by Dr. John Collins Warren at Massachusetts General Hospital to perform a public demonstration of its use for Warren’s students in 1845. Unfortunately, the gas was administered improperly and the patient cried out in pain and Wells was humiliated, ultimately committing suicide.

Dr. Warren, however, then invited Dr. William TG Morton to demonstrate the use of ether (diethyl ether gas, historically called “sweet vitriol”) to anesthetize a patient as he excised a small neck tumor.  The patient remained unconscious throughout the procedure to the amazement of the audience. Thereafter, the use of inhaled anesthetics spread and evolved so that now, the 18 gauge needle used to start an IV in the pre-op holding area might be the most painful part of a surgery!

 

Later in the episode, Claire is alone with Black Jack Randall. A long discussion could be had about his psychiatric condition, but for today, we’ll discuss the brutal punch he gave Claire and the kicks that he ordered Corproral Hawkins to administer to Claire.  Hit directly in the abdomen, Claire has suffered diaphragm spasm, or more commonly, she had the wind knocked out of her.

source:  Starz

When we inhale, the diaphragm contracts, drawing the lungs down and expanding the rib cage. A temporary vacuum is created and air is pulled through the nose and mouth into the lungs. In exhalation, the diaphragm relaxes, the lungs deflate, and air is expelled out of the mouth and nose. A strong kick to the abdomen causes the diaphragm muscles to spasm, unable to contract and relax normally and thus leaving the victim unable to draw a breath. While it is terrifying and panic inducing, having the wind knocked out of you is not life threatening, and resolves on its own in a few moments.

source

Caitriona Balfe is an amazingly gifted actress and this scene is painful to watch. Claire’s gasping, panicked breaths are heartbreakingly realistic.

source:  Starz

Dougal rushes in and saves Claire, leaving Randall under the impression that Claire will be delivered to Fort William before sundown tomorrow.

After proving she is not a spy when her gizzards are not burned out at St. Ninian’s spring, Dougal presents to Claire his plan for keeping her out of the hands of the English.  The episode ends with Claire downing a bottle of whisky as she considers the prospect of marrying a strapping young Scot.

source:  Starz

Hopefully she has stocked her traveling medical kit with plenty of willow bark to ease the hangover she’ll no doubt have tomorrow!

 

Resources:

Pruitt, BA. (2006). Combat Casualty Care and Surgical Process. Ann Surg. 243(6): 715-729.
https://archive.org/details/treatiseonoperat01shar

A brief history of sterilization

Click to access annrcse00248-0008.pdf

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2943454/

Click to access Surgery_in_the_1700s.pdf