Let me begin, for this inaugural post in this series, with a few disclaimers: first, these discussions presume you have seen the episode listed above. If you haven’t seen this episode, there will be spoilers here. And second, this discussion isn’t about nitpicking. Make no mistake; I am a devoted Outlander Fan! I love this series (and the books it came from), the characters, the cast who bring them to life, the directors, producers, and screenwriters, makeup and special effects wizards, crew, and the incredible author, Herself. I think they’ve done a terrific job creating an amazing, realistic, enthralling cinematic and literary experience. I’ve watched all seasons (all available, which as I write this is through ep 708) from start to finish 19 times (so far, and of course I’m working on 20) and many of them double or triple dozens of times. Believe me, I’m not mindlessly nitpicking. I’m simply clarifying, illuminating, explaining, and educating from a scientific/medical perspective, because people I know have asked and it occurred to me that others might find it interesting. Where they get it right in the series, I’ll say, and where they used a lot of license or just plain get it wrong, I’ll explain. So, as they might say in Outlander…let’s get on wi’ it.
Relocating Jamie’s Shoulder
Claire’s scarcely through the stones when she comes face-to-face with her first 18th Century medical situation. Murtagh has rescued her from her recent harrowing up-against-the-wall encounter with Black Jack Randall and brought her back to a cottage where a band of Clan Mackenzie Highlanders are hunkered down hiding from the Redcoat patrols. Dougal, their War Chief, says they need to leave asap, but his nephew, Jamie, has suffered a shoulder dislocation (e.g. ‘it’s outta joint poor bugger’) and can’t ride. Angus declares he’ll have to force the shoulder back in place.
Credit: STARZ Outlander Ep 101 - Sassenach - Relocating Jamie’s Shoulder.
Claire, standing by watching and knowing from her combat nurse’s training that doing what he proposes would break bone or seriously damage his shoulder joint, intervenes saying basically: Don’t you dare! Then asserts that ‘You can’t force the shoulder back in! You’ll break his arm if you do it like that! You have to get the bone into the correct position before it slips back into the joint properly.’
Spot on! Absolutely true.
The rule of thumb of all joint dislocations is that you have to worsen the injury to fix it, by which it means that you have to distract the joint (in medical terms) which is to take the joint farther out of socket, and then once it’s free let the natural contraction of the stabilizing muscles guide it back in properly.
That’s not such a difficult proposition in a small joint, say a finger or toe or even an elbow. But a shoulder (or heaven forfend, a hip) is a different matter. There are big, strong muscles involved with the shoulder (or even more so the hip), and it takes considerable strength to overcome their spasm and distract the joint sufficiently that it can slip back in properly. And it would especially be difficult for a such a slender woman to attempt against the incredible strength of the bulging muscles we see in the handsome young Highlander in question in this Outlander episode – ie Jamie Fraser.
This procedure typically takes time and patience (or powerful muscle relaxant medications, which she didn’t have) to get the muscles to relax. It’s not something you just do in a whip it this way, whip it that maneuver. And a bit of whisky won’t do it. Obviously whisky’s better than nothing, but in reality you’d have swill a fair bit to get sufficient deep muscle relaxation.
There are different reduction techniques, depending on the type of shoulder dislocation (anterior, posterior, or inferior – referring to the location where the ball of the humerus (the upper arm bone) has popped out—ie, front, back, or down) but by far most are anterior dislocations, which just from looking at the shoulder (photo above) that we’re shown by firelight in that cottage seems to be the case.
And while I’m at it here, what a great kinetic prosthetic shoulder the team created to mimic the dislocation and even show the movement in it with the reduction. Kudos, Outlander team! The first time I saw it, I was astounded at how realistic it looked. All I could think was ‘how the hell did they do that??’ Amazing!
All of the relocation techniques for a shoulder require distraction of the joint by some method — traction and counter traction with the help of an assistant pulling one way and the practitioner pulling the other; or if flying solo, the practitioner holding the wrist of the injured arm and putting a heel of his or her foot into the patient’s armpit and then the pulling on the arm with all his or her body weight to overcome the muscle spasm and distract the joint; or one other method, which is the practitioner very slowly manipulates the patient’s injured arm away from the body, inch by inch, and then up over the head, bending it around the back into a position as if the patient were scratching him or herself between the shoulder blades — all designed to relax the pull of the muscles and let the shoulder slip back into place. None of that was done.
Instead, Claire holds his forearm/wrist at 90-degrees from his body, rotates it externally (away from the body) then snaps it back internally (toward the body) forcefully. Not sure this technique would have worked out without distraction and relaxation of the musculature. But hey, it’s tv. And even if it’s wrong, it’s exciting to be sure.
And perhaps more importantly it was the first encounter for Jamie and Claire and the beginning of something wonderful for them and, frankly, for all of us. And we’re right there with them praying the procedure works. Which, by some miracle of television, it does. And he is thankful… ‘truly’.
Credit: STARZ Outlander Ep 101 - Sassenach - Jamie’s shoulder, reduced.
She then goes on to bind the forearm across his torso – correctly – using Angus’s belt, and she tells Jamie not to stress it and to apply warm compresses. Excellent advice, were they not on the run from the British patrols, so instead they did a jolting 48-hour tandem ride in the freezing rain followed by a skirmish with a Redcoat ambush party at Cocknammon Rock during which we later discover (as if one serious injury to Jamie’s right shoulder weren’t enough in a single episode) Jamie suffered a clean pistol ball through his trapezius muscle, where his shoulder meets his neck.
And that’s what we’ll tackle next!
Overall Medical Verity Score for the shoulder relocation: About 90%. Got it right in what needed to happen — ‘you have to get the bone into the correct position before it slips back into joint properly.’ And though the doing of it was pretty slap dash Hollywood, it got the point across.
Jamie’s gunshot wound on the road from Inverness
Later in the episode, they’ve been riding through the frozen night. And they come upon a place Claire recognizes: Cocknammon Rock. She alerts the Highlanders that this is a place the British use for ambush. And ambush it turns out to be. There is a skirmish which thanks to her alert the Highlanders win, but with some injury. As it turns out, farther down the road, she realizes Jamie is injured, when he falls off their horse. With a cursory look in the dark on the roadside Claire is able to determine that he’s suffered a clean through and through wound of the trapezius muscle (the one connecting head to shoulder) and that it’s nothing much to worry about except blood loss. (Anatomically speaking, there’s a lot of stuff – like nerves – that could have been damaged in that region, none of which she checked for, but again, it’s tv and we only have so much time!)
Credit: STARZ Outlander Ep101 - Sassenach - Claire examining Jamie’s bullet wound the roadside
She asks for sterile bandages (LOL! But old habits die hard) and the anti-bacterial solutions iodine and merthiolate, neither of which had been invented yet (Iodine was first discovered as an element in 1811 and not used as a disinfectant until 1839 and merthiolate not until 1927).
Credit: STARZ Outlander Ep101 - Sassenach - Claire ‘disinfecting’ Jamie’s bullet wound with whisky
So she then settles for alcohol (in this case whisky, a beverage all the Highlanders are well acquainted with) which she pours on his open wound, getting Jamie’s full attention. Then she pours more on a strip of cloth torn off the hem of her filthy, grimy shift, which she wads up and stuffs onto the wound and wraps around his chest, though without enough pressure to actually stop any vigorous bleeding, if that were her aim.
While denatured alcohol (like the 70% to 99% isopropyl we use today) is a pretty good bactericidal agent, whisky is only about 40-50% alcohol and probably not as good. Granted it was the best she had at the time. And moreover, she’s putting it onto a muddy, rain-soaked strip of cloth that she’s going to stuff into the open wound. Again, with what she had at hand, there wasn’t much else she could do. Everybody’s clothing was filthy. Whisky’s all she had. And it was all very dramatic! (And best of all, the moment Jamie comes to consciousness again and sees her face in the dim moonlight is (according to Sam) the moment Jamie fell in love with her. So there’s that!)
What are the risks of infection? High. But thankfully she was able in a day or two to clean it with a boiled solution of garlic and witch hazel and dress it with comfrey and clean bandages at Castle Leoch. Right? Yes, but the risk in the intervening hours is that infection had already had plenty of time to get a head start by then. Fortunately, the King of All Men is made of tough stuff.
And we’ll look at that secondary treatment in Ep 102 next.
Overall Medical Verity Score: About 60%. She did what she could, but with her 20th Century knowledge of anti-sepsis and wound care, Claire had to know that what she was doing wasn’t likely to prevent infection — in fact might seed it — or be sufficient to stanch hemorrhage.
Good stuff. Brings back some memories of the early episodes. Can't wait for May 1st when it returns to Netflix!
Cool