Claire's Casebook from The Fiery Cross
Copyright © 1999 Diana Gabaldon, The Fiery Cross. All rights reserved.

From the Casebook of Claire Fraser, M.D.) [date]

Was called from churning to attend Rosamund Lindsey, who arrived in late afternoon with a severe laceration to the left hand, sustained with an axe while girdling trees. Wound was extensive, having nearly severed the left thumb; laceration extended from base of index finger to two inches above the styloid process of the radius, which was superficially damaged. Injury had been sustained approximately three days prior, treated with rough binding and bacon grease. Extensive sepsis apparent, with suppuration, gross swelling of hand and forearm. Thumb blackened; gangrene apparent; characteristic putrid odor. Subcutaneous red streaks, indicative of blood poisoning, extended from site of injury nearly to antecubital fossa.

Patient presented with high fever (est. 104 degrees F., by hand), symptoms of dehydration, mild disorientation. Tachycardia evident.

In view of the seriousness of patient’s condition, recommended immediate amputation of limb at elbow. Patient refused to consider this, insisting instead upon application of pigeon poultice, consisting of the split body of a freshly-killed pigeon, applied to wound (patient’s husband had brought pigeon, neck freshly wrung). Removed thumb at base of metacarpal, ligated remains of radial artery (crushed in original injury) and superficialis volae. Debrided and drained wound, applied approximately 1/2 oz. crude penicillin powder (source: rotted casaba rind, batch #23, prep. 15/4/71) topically, followed by application of mashed raw garlic (three cloves), barberry salve--and pigeon poultice, at insistence of husband. Administered fluids by mouth; febrifuge mixture of red centaury, bloodroot, and hops; water ad lib. Injected liquid penicillin mixture (batch #23, suspended in sterile water), IV, dosage 1/4 oz in suspension in sterile water.

Patient’s condition deteriorated rapidly, with increasing symptoms of disorientation and delirium, high fever. Extensive urticaria appeared on arm and upper torso. Attempted to relieve fever by repeated applications of cold water, to no avail. Patient being incoherent, requested permission to amputate from husband; permission denied on grounds that death appeared imminent, and patient “would not want to be buried in pieces.”

Repeated penicillin injection. Patient lapsed into unconsciousness shortly thereafter, and expired just before dawn, [date].

I dipped my quill again, but then hesitated, letting the drops of ink slide off the sharpened point into the small gourd I used as an inkwell. How much more should I say?

The deeply-ingrained disposition for scientific thoroughness warred with caution. It was important to describe what had happened, as fully as possible. At the same time, I hesitated to put down in writing what might amount to an admission of manslaughter--it wasn’t murder, I assured myself, though my guilty feelings made no such distinctions.

“Feelings aren’t truth,” I murmured. Across the room, Brianna looked up from the bread she was slicing, but I bent my head over the page, and she returned to her whispered conversation with Marsali by the fire. It was no more than mid-afternoon, but dark and rainy outside. I had lit a candle by which to write, but the girls’ hands flickered over the dim table like moths, lighting here and there among the plates and platters.

The truth was that I didn’t think Rosamund Lindsey had died of septicemia. I was fairly sure that she had died of an acute reaction to an unpurified penicillin mixture--of the medicine I gave her, in short. Of course, the truth also was that the blood poisoning would certainly have killed her, left untreated.

The truth also was that I had had no way of knowing what the effects of the penicillin would be--but that was rather the point, wasn’t it? To make sure someone else might know?

I twiddled the quill, rolling it between thumb and forefinger. I had kept a faithful account of my experiments with penicillin-- the growing of cultures on media ranging from bread to chewed paw- paw and rotted melon rind, painstaking descriptions of the microscopic and gross identification of the Penicillium molds, the effects of--to this point--very cautious applications.

Yes, certainly I must include a description of the effects. The real question, though, was--for whom was I keeping this careful record?

I bit my lip, thinking. If it was only for my own reference, it would be a simple matter; I could simply record the symptoms, timing and effects, without explicitly noting the cause of death; I was unlikely to forget the circumstances, after all. But if this record were ever to be useful to someone else...someone who had no notion of the benefits and dangers of an antibiotic...

The ink was drying on the quill. I lowered the point to the page.

Age - 44, I wrote slowly. In this day, casebook accounts like this often ended with a pious description of the deceased’s last moments, marked--presumably--by Christian resignation on the part of the holy, repentance by the sinful. Neither attitude had marked the passage of Rosamund Lindsey.

I glanced at the coffin, sitting on its trestles under the rain-smeared window. The Lindseys’ cabin was no more than half- built; not suited for a funeral in the pouring rain. The coffin was open, awaiting the evening wake, but the muslin shroud had been drawn up over her face.

Rosamund had been a whore in Boston; growing too stout and too old to ply her trade with much profit, she had drifted south, looking for a husband. “I couldn’t bide another of them winters,” she had confided to me, soon after her arrival on the Ridge. “Nor yet another of them stinkin’ fishermen.”

She had found the necessary refuge in Kenneth Lindsey, who was looking for a wife to share the work of homesteading. Not a match born of physical attraction--the Lindseys had had perhaps six sound teeth between them--or emotional compatibility, still it had seemed an amicable relationship.

Shocked rather than grief-stricken, Kenny had been taken off by Jamie for medication with whisky--a somewhat more effective treatment than my own. At least I didn’t think it would be lethal.

Immediate cause of death - I wrote, and paused again. I doubted that Rosamund’s response to approaching death would have found outlet in either prayer or philosophy, but she had had opportunity for neither. She had died blue-faced, congested and bulging-eyed, unable to force word or breath past the swollen tissues of her throat.

My own throat felt tight at the memory, as though I were being choked. I picked up the cooling cup of catmint tea and took a sip, feeling the pungent liquid slide soothingly down. It was little comfort that the septicemia would have killed her more lingeringly. Suffocation was quicker, but not much more pleasant.

I tapped the quill point on the blotter, leaving inky pinpoints that spread through the rough fibers of the paper, forming a galaxy of tiny stars. As to that--there was another possibility. Death might conceivably have been due to a pulmonary embolism--a clot in the lung. That would be a not-impossible complication of the septicemia, and could have accounted for the symptoms.

It was a hopeful thought, but not one I placed much credence in. It was the voice of experience, as much as the voice of conscience, that bade me dip the quill and write down “anaphylaxis,” before I could think again.

Was anaphylaxis a known medical term yet? I hadn’t seen it in any of Rawlings’ notes--but then, I hadn’t read them all. Still, while death from the shock of allergic reaction was not unknown in any time, it wasn’t common, and might not be known by name. Better describe it in detail, for whoever might read this.

And that was the rub, of course. Who would read it? I thought it unlikely, but what if a stranger should read this and take my account for a confession of murder? That was far-fetched-- but it could happen. I had come perilously close to being executed as a witch, in part because of my healing activities. Once almost burnt, twice shy, I thought wryly.

Extensive swelling in affected limb, I wrote, and lifted the quill, the last word fading as the pen ran dry. I dipped it again and scratched doggedly on. Swelling extended to upper torso, face, and neck. Skin pale, marked with reddish blotches. Respiration increasingly rapid and shallow, heartbeat very fast and light, tending to inaudibility. Palpitations evident. Lips and ears cyanotic. Pronounced exophthalmia.

I swallowed again, at the thought of Rosamund’s eyes, bulging under the lids, rolling to and fro in uncomprehending terror. We had tried to shut them, when we cleansed the body and laid it out for burial. It was customary to uncover the corpse’s face for the wake; I thought it unwise in this case.

I didn’t want to look at the coffin again, but did, with a small nod of acknowledgement and apology. Brianna’s head turned toward me, then sharply away. The smell of the food laid out for the wake was filling the room, minglng with the scents of oak-wood fire and oak-gall ink--and the fresh-planed oak of the coffin’s boards. I took another hasty gulp of tea, to stop my gorge rising.

I knew damn well why the first line of Hippocrates’ oath was, “First, do no harm.” It was too bloody easy to do harm. What hubris it took to lay hands on a person, to interfere. How delicate and complex were bodies, how crude a physician’s intrusions.

I could have sought seclusion in surgery or study, to write these notes. I knew why I hadn’t. The coarse muslin shroud glowed soft white in the rainy light from the window. I pinched the quill hard between thumb and forefinger, trying to forget the pop of the cricoid cartilage, when I had jabbed a penknife into Rosamund’s throat in a final, futile attempt to let air into her straining lungs.

And yet...there was not one practicing physician, I thought, who had never faced this. I had had it happen a few times before-- even in a modern hospital, equipped with every life-saving device known to man--then.

Some future physician here would face the same dilemma; to undertake a possibly dangerous treatment, or to allow a patient to die who might have been saved. And that was my own dilemma--to balance the unlikely possibility of prosecution for manslaughter against the unknown value of my records to someone who might seek knowledge in them.

Who might that be? I wiped the pen, thinking. T standards. My mouth twisted at the thought of some of the treatments I had seen described in those closely-written pages-- infusions of liquid mercury to cure syphilis, cupping and blistering for epileptic fits, lancing and bleeding for every disorder from indigestion to impotence.

And still, Daniel Rawlings had been a doctor. Reading his case notes, as I sometimes did, I could feel his care for his patients, his curiosity regarding the mysteries of the body.

Moved by impulse, I turned back to the pages containing Rawlings’ notes. Perhaps I was only delaying to let my subconscious reach a decision--or perhaps I felt the need of communication, no matter how remote, with another physician, someone like me.

Someone like me. I stared at the page, with its neat, small writing, its careful illustration, seeing none of the details. Who was there, like me?

No one. I had thought of it before, but only vaguely, in the way of a problem acknowledged, but so distant as not to require any urgency. In the colony of North Carolina, so far as I knew, there was only one formally-designated “doctor”--Fentiman. I snorted, and took another sip of tea. Better Murdock MacLeod and his nostrums--most of those were harmless, at least.

I sipped my tea, regarding Rosamund. The simple truth was that I wouldn’t last forever, either. With luck, a good long time yet--but still, not forever. I needed to find someone to whom I could pass on at least the rudiments of what I knew.

A stifled giggle from the table, the girls whispering over the pots of head-cheese, the bowls of sauerkraut and boiled potatoes. No, I thought, with some regret. Not Brianna.

She would be the logical choice; she knew what modern medicine was, at least. There would be no overcoming of ignorance and superstition, no need to convince of the virtues of asepsis, the dangers of germs. But she had no natural inclination, no instinct for healing. She was not squeamish or afraid of blood--she had helped me with any number of childbirths and minor surgical procedures--and yet she lacked that peculiar mixture of empathy and ruthlessness a doctor needs.

She was perhaps Jamie’s child more than mine, I reflected, watching the firelight ripple in the falls of her hair as she moved. She had his courage, his great tenderness--but it was the courage of a warrior, the tenderness of a strength that could crush if it chose. I had not managed to give her my gift; the knowledge of blood and bone, the secret ways of the chambers of the heart.

Brianna’s head lifted sharply, turning toward the door. Marsali, slower, turned too, listening.

It was barely audible through the thrumming of the rain, but knowing it was there, I could pick it out--a male voice, raised high, chanting. A pause, and then a faint answering rumble that might have been distant thunder, but wasn’t. The men were coming down from the shelter on the mountain.

Kenny Lindsey had asked Roger to sing the caithris for Rosamund; the formal Gaelic lament for the dead. “She wasna Scots,” Kenny had said, wiping eyes bleared from tears and a long night’s watching. “Nor even God-fearin’. But she was that fond o’ singin’, and she fair admired your way o’ it, MacKenzie.”

Roger had never sung a caithris before; I knew he had never heard one. “Dinna fash,” Jamie had murmured to him, hand on his arm, “all ye need to be is loud.” Roger had bent his head gravely in acquiescence, and went with Jamie and Kenneth, to drink whisky by the malting floor and learn what he could of Rosamund’s life, the better to lament her passing.

The singing vanished; the wind had shifted. It was a freak of the storm that we had heard them so soon--they would be headed down the Ridge now, to collect mourners from the outlying cabins, and then to lead them all in procession back up to the house, for the feasting and singing and story-telling that would go on all night.

I yawned involuntarily, my jaw cracking at the thought of it. I’d never last, I thought in dismay. I had had a few hours’ sleep in the morning, but not enough to sustain me through a full-blown Gaelic wake and funeral. The floors would be thick with bodies by dawn, all of them smelling of whisky and wet clothes.

I yawned again, then blinked, my eyes swimming as I shook my head to clear it. we were alone. She began to massage my shoulders, long thumbs moving slowly up the cords of my neck.

“Tired?” she asked.

“Mm. I’ll do,” I said. I closed the book, and leaned back, relaxing momentarily in the sheer relief of her touch. I hadn’t realized I was strung so tightly.

The big room was quiet and orderly, ready for the wake. The girls had lit a pair of candles, one at each end of the laden table, and shadows flickered over the white-washed walls, the quiet coffin, as the candle-flames bent in a sudden draft.

“I think I killed her,” I said suddenly, not meaning to say it at all. “It was the penicillin that killed her.”

The long fingers didn’t stop their soothing movement.

“Was it?” she murmured. “You couldn’t have done any differently, though, could you?”

“No.”

A small shudder of relief went over me, as much from the bald confession as from the gradual release of the painful tightness in my neck and shoulders.

“It’s OK,” she said softly, rubbing, stroking. “She would have died anyway, wouldn’t she? It’s sad, but you didn’t do wrong. You know that.”

“I know that.” To my surprise, a single tear slid down my cheek and dropped on the blotter, puckering the thick paper. I blinked hard, struggling for control. I didn’t want to distress Brianna.

She wasn’t distressed. Her hands left my shoulders, and I heard the scraping of stool-legs. Then her arms came around me, and I let her draw me back, my head resting just under her chin. She simply held me, letting the rise and fall of her breathing calm me.

“I went to dinner with Uncle Joe once, just after he’d lost a patient,” she said finally. “He told me about it.”

“Did he?” I was a little surprised; I wouldn’t have thought Joe would talk about such things with her.

“He didn’t mean to. I could see something was bothering him, though, so I asked. And--he needed to talk, and I was there. Afterward, he said it was almost like having you there. I didn’t know he called you Lady Jane.”

“Yes,” I said. “Because of the way I talk, he said.” I felt a breath of laughter against my ear, and smiled slightly in response. I closed my eyes, and could see my friend, gesturing in passionate conversation, face alight with the desire to tease.

“He said--that when something like that happened, sometimes there would be a sort of formal inquiry, at the hospital. Not like a trial, not that--but a gathering of the other doctors, to hear exactly what happened, what went wrong. He said it was sort of like confession, to tell it to other doctors, who could understand- -and it helped.”

“Mm-hm.” She was swaying slightly, rocking me as she moved, as she rocked Jemmy, soothing.

“Is that what’s bothering you?” she asked quietly. “Not just Rosamund--but that you’re alone? You don’t have anybody who can really understand?”

Her arms wrapped around my shoulders, her hands crossed, resting lightly on my chest. Young, broad, capable hands, the skin fresh and fair, smelling of fresh-baked bread and strawberry jam. I lifted one, and laid the warm palm against my cheek.

“Apparently I do,” I said.

The hand curved, stroked my cheek and dropped away. The big young hand moved slowly, smoothing the hair behind my ear with soft affection.

“It will be all right,” she said. “Everything will be all right.”

“Yes,” I said, and smiled, despite the tears blurring my eyes.

I couldn’t teach her to be a doctor. But evidently I had, without meaning to, somehow taught her to be a mother.

“You should go lie down,” she said, taking her hands away reluctantly. “It will be an hour at least, before they get here.”

I let my breath go out in a sigh, feeling the peace of the house around me. If Fraser’s Ridge had been a short-lived haven for Rosamund Lindsey, still it had been a true home. We would see her safe, and honored in death.

“In a minute,” I said, wiping my nose. “I need to finish something, first.”

I sat up straight and opened my book. I dipped my pen, and began to write the lines that must be there, for the sake of the unknown physician who would follow me.