Well, this doctor was the patient this week for a wee bit of knee surgery and recovering nicely (but where is Claire and her medicinal whisky when I need her?). I’m squeezing in a quick post about episode 304 just before the next episode is available on streaming in about a half hour!
What was this pressing surgery that Joe called Claire about?
Harry Greenbaum has abdominal pain, a positive Murphy’s sign, and calcifications on his x-ray. Hmmm. What’s going on?
What is Murphy’s sign?
Murphy’s sign is a test performed during physical exam of the abdomen that may indicate the presence of inflammation of the gall bladder. The examiner palpates the abdomen just under the rib cage on the right side as the patient inspires. During inspiration, the abdominal contents (including the gallbladder) move downward because the lungs are expanding. If the patient halts inspiration due to pain while the area is palpated, this is considered a positive Murphy’s sign. See below the location of the gallbladder in the right upper part of the abdomen just under the ribcage:
What about those calcifications?
Could they be gall stones? The could, though most gall stones are made up of cholesterol and are not visible on x-ray. In fact, only 15-20% of gallstones are visible on x-ray. Today, these are most commonly diagnosed on ultrasound.
The calcifications on Harry’s x-ray could also be a porcelain gall bladder, or a condition when the gall bladder wall becomes calcified due to chronic inflammation, generally associated with gall stones and occasionally associated with cancer of the gall bladder. This type of calcification is easily seen on x-ray.
Either way, it is time for Harry’s gall bladder to be removed. Because Joe made it a point to call Claire in Scotland to discuss this, my guess is that Harry is a long time patient of Claire’s and Joe wanted to give her the chance to perform the surgery herself if she would be back in time. Cholecystectomy, or surgical removal of the gall bladder, is a routine surgery and certainly not anything Joe would need Claire to return for, if there were not other circumstances surrounding this case.
Whew! Done with a few minutes to spare! On to episode 305 as this patient continues to enjoy a little bit of downtime recovering from surgery herself!
I’ll admit I’ve been on team #SaveMurtagh since season two and as soon as the music changed in the prison cell and the bearded face of everyone’s favorite BFF appeared, I was grinning ear to ear!
That’s right. Murtagh is back!
Murtagh Fitzgibbons Fraser seems to have nearly as many lives as Jamie. He has survived more battles than anyone cares to count and despite abysmal conditions at Ardsmuir, he is still hanging on. It does seem, though, he could use a little bit of help.
We learn that Murtagh has been struggling in the 9 years since Culloden, suffering frequently from La Grippe as well as festering wounds (from rat bites no less!).
What does this all mean?
La Grippe is a name for influenza, meaning “to seize suddenly,” likely a reference to violent shaking chills accompanying the fevers of an influenza infection. The term Influenza comes from the Medieval Latin “influentia,” from the belief that epidemics of this illness were due unfavorable astrological influences.
With influenza season now starting to revisit the northern hemisphere, we often hear the tips and tricks to try to avoid the flu. In addition to an annual influenza vaccine, we are advised to: avoid close contact, wash your hand frequently, avoid touching your eyes, nose, and mouth, get enough sleep, eat a healthy diet, avoid crowds. Hmm, that definitely doesn’t bode well for these men living in the squalid, tight quarters of Ardsmuir prison!
And what do these men have to treat influenza? A diet of thin barley brose and the occasional rat? The odds are stacked against them. Jamie is on the right track with his requests for blankets and improved food rations.
Did you miss the Outlander Science Club post and podcast all about La Grippe during the Voyager read along? Check it out here!
What about those festering wounds? Jamie seems to think greens are the answer. He is right!
Murtagh (and likely most of the men on the Ardsmuir diet) are suffering from scurvy. Scurvy is the result of a deficiency in vitamin C, which is required in the production of collagen in the body and plays a significant role in immune function. Without adequate intake of vitamin C, these men will begin to experience fatigue, malaise, inflammation and bleeding of the gums, bruising, joint pain, and poor wound healing. Thanks to his education from Claire, Jamie recognizes that Murtagh’s rat bite wounds are not healing and surmises this is due to a lack of greens in his diet. Watercress to the rescue!
Always the keen negotiator, Jamie has convinced Major Grey to provide Murtagh with needed medical help. I’ll admit I was waiting to see that doctor come in and bleed Murtagh dry in typical 18th century fashion, but it turns out that with help from this doctor and vitamin C rich foods from Jamie, Murtagh is back on his way to health…just in time for a long voyage to the colonies.
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.
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.
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…
The nurse has no malicious intent. Instead, she likely understands the Mendelian inheritance of red hair. A child born with red hair carries two copies of the recessive gene for red hair – one from the mother and one from the father. She of course then assumes that Claire or Frank likely has a redheaded family member they can recall in their line.
Of course, there is much more to the inheritance of hair color, including details of blonde, various browns, and black hair, but for today, lets focus on red.
We now know that the specific gene responsible for red hair is called melanocortin 1 receptor (or MC1R). Red hair is a recessive trait. Recalling back to genetics class, this means that for a person to be born with red hair, they must inherit a red hair gene from their mother and one from their father. If only one red hair gene is inherited, the child will have brown hair and simply be a carrier of the red hair gene.
Could Frank and Claire have a biological child with red hair? YES!
Setting aside the question of whether Frank Randall is indeed fertile to begin with (we will have to revisit that too!), here is an example showing how Claire and Frank might have a biological child with red hair. R indicates the dominant gene for brown hair and r indicates the recessive gene for red hair. If each of them is a brown haired person who carries the red hair gene, they will have a 25% chance of their child being a redhead:
Indeed, Frank and Claire could have a redheaded biological child, though it would have been much more likely for Jamie and Claire. Assuming that Claire carries the gene for red hair (and we know she does since we’ve seen Brianna!), each child of Jamie and Claire will have a 50% chance of having red hair.
Frank and Claire had better get used to answering the question of the red hair. No doubt this is only the first of hundreds of times they will be asked.
While on the topic of red heads, here are some fun facts:
Only 1-2% of the human population has red hair.
About 13% of the population of Scotland has red hair, the highest concentration in the world.
Redheads are more sensitive to pain! They require significantly more anesthetic to block pain. This is thought to be due to the fact that the MC1R gene responsible for red hair also codes for a receptor that is related to a family of receptors involved in pain perception.
They are also more sensitive to cold tempeteratures
Redheads have a higher risk of skin cancer, specifically melanoma.
Redheads are more likely to be left handed than people with other hair colors!
Redheads tend not to go grey. Their hair pigment lightens to blonde and white and avoids grey.
People with red hair actually have fewer strands of hair than those with other colors. However, their red hair is thicker so it appears just as full.
So glad to be back in the world of Outlander! Life has been pretty crazy and this is always a welcome diversion! What did you think of the Season Three premiere? I’ve been avoiding previews and teasers so I knew very little going in and loved it. So excited for what is to come!
A few months ago at a meet up with local Outlander fans, a lovely new friend commented that she’d read more than once of something called the morbid sore throat in the Outlander books and wondered what the heck it was. Strep throat? Abscess in the throat? Something else? With a name like morbid sore throat, it has got to be something pretty terrible!
References to the morbid sore throat are scattered throughout the Outlander books, including this excerpt from Dragonfly in Amber. Here, Claire learns the fate of the man against whom Jamie once dueled over his sweetheart Annalise de Marillac:
“A duel? With whom?” I asked, glancing around warily for any male attachments to the China doll who might feel inclined to follow up an old quarrel.
“Och, he isna here,” Jamie said, catching and correctly interpreting my glance. “He’s dead.”
“You killed him?”Agitated, I spoke rather louder than intended.As a few nearby heads turned curiously in our direction, Jamie took me by the elbow and steered me hastily toward the nearest French doors.
“Mind your voice, Sassenach,” he said, mildly enough.“No, I didna kill him.Wanted to,” he added ruefully, “but didn’t.He died two years ago, of the morbid sore throat.Jared told me.”
From Dragonfly in Amber by Diana Gabaldon, Chapter 11
The morbid sore throat, known now to us as diphtheria, was morbid indeed. Without modern treatment, half of those infected with diphtheria died, with the young and old particularly hit hard. Even now, with modern medicine, the fatality rate is 5-10%, but approaches 30% for those younger than 5 years or older than 40!
Much More than the Common Cold!
Transmitted through respiratory droplets from coughing or sneezing, or from touching a contaminated object, infection with diphtheria begins innocently enough. Initially, a person infected with diphtheria may experience symptoms of a typical cold – sore throat, fever, runny nose, body aches, cough, etc. However, within 2-3 days, it becomes clear this is no run of the mill cold. The diphtheria bacteria starts wreaking havoc by producing a toxin that acts by both suffocating and poisoning its victim.
The toxin begins to destroy the healthy tissues of the throat and upper respiratory tract. This dead tissue forms a thick grey substance called a pseudomembrane that adheres very tightly to the tissues and spreads over the lining of the nose, throat, tonsils, and even over the trachea, blocking the airway and suffocating the victim.
And as though that wasn’t enough, the toxin also spreads throughout the body causing damage in the heart and kidney as well as paralysis!
Prior to the era of antibiotics and vaccinations, diphtheria was one of the most dreaded of diseases, with frequent wide-spread outbreaks. Treatment options were few. Some attempts at intubation and tracheostomy were made to prevent suffocation from airway obstruction. No doubt many herbal and medicinal remedies were attempted, like this one from 18th Century New England. Devastating epidemics took countless lives, including as many as a third of all children under 10 in some New England towns from 1735-40. As recently as the 1920s, the US saw over 200,000 cases and over 15,000 deaths per year.
The start of widespread use of the vaccine in the 1940s led to a rapid drop in diphtheria cases. The CDC has had only 5 cases reported in the US in the past 10 years. However, it is still reported globally, with the WHO reporting 4,530 cases in 2015. Adults should receive the tetanus and diphtheria booster shot every ten years to remain protected!
Morbid sore throat is just one of many old wonderfully descriptive names for medical problems. Ague. Apoplexy. Dropsy. Quinsy. I’ve started a small glossary of them here and I’m sure there will be plenty more to add as we all read and re-read the big books!
Thank you to Gina for the question about the morbid sore throat! What archaic medical terms have you come across that you’d like to learn more about? Leave a comment here or find me on Twitter or Facebook if you have a suggestion for a post.
Stay strong, Outlander friends! September is coming!
A Dram of Outlander Voyager Read-Along Chapter 60 (LISTEN HERE)
Outlander Science Club
You’ve Got a Little Something in Your Eye… (Listen to the podcast HERE!)
“Jesus H. Roosevelt Christ,” I said. “What was that?”
What was that, indeed! In the search for Young Ian, Claire finds herself doctoring a young man in his twenties who is enslaved at Rose Hall. Lying quietly on a pallet in a dark corner of a kitchen pantry, he doesn’t seem to have a fever nor much distress. In fact, he appears rather well. Until…
As though in answer to my question, the slave suddenly wrenched himself away from my hand, let out a piercing scream, and rolled up into a ball. Rolling and unrolling himself like a yo-yo, he reached the wall and began to bang his head against it, still screaming. Then, as suddenly as the fit had come on, it passed off, and the young man sank back onto the pallet, panting heavily and soaked with sweat.
From Voyager by Diana Gabaldon, Chapter 60
Claire indeed finds a small worm moving underneath the surface of her patient’s eye.
The Loa loa worm and Loa loa filariasis
Nope, this isn’t one of Geillis’ hexes or the product of Diana Gabaldon’s imagination. This is a real disease and Loa loa, with its predilection for swimming under the surface of its victims’ eyes is the stuff of itchy nightmares, my friends!
Loa loa, AKA African eye worm, is a parasitic worm that is passed to humans by the bite of a deerfly. Endemic only to parts of West and Central Africa, Loa loa can only be spread by the bite of the deer fly and cannot be spread person to person. Claire’s patient at Rose Hall no doubt contracted the illness in Africa before he was enslaved and transported to the West Indies.
Humans are the only known hosts of the disease. No other animals are known to become infected with Loa loa. A deerfly carrying the Loa loa larvae bites a healthy human, depositing larvae into the wound. Once inside a human host, the larvae grow into adult worms over about 5 months and travel throughout the body. Adult worms prefer to live between layers of connective tissue, under the skin in the subcutaneous tissue, and between the thin layers of tissue that cover muscle (fascia). The adult worms can produce thousands of microfilariae (tiny larave) each day and spread throughout the blood stream. The deerfly can then bite an infected human, ingesting the microfilariae, which then evolve into their larval form within the fly, ready to infect the next unsuspecting human again when the deerfly bites again!
What happens to a person infected with the Loa loa worm?
Many patients with loiasis (infection with Loa loa worm) do not experience any symptoms. This is more true for those people who live in the endemic regions. Travelers to these regions are more likely to suffer symptoms. Most commonly, those infected will develop something called “Calabar swellings.” These localized swellings, several inches in diameter, are found on the arms and legs are caused by the body’s inflammatory response to the presence of dead worms or the metabolic products of the worms. Itching occurs around these areas and often all over the body.
Adult worms can be seen moving under the skin, as well as just under the surface of the eye.
Presence of the Loa loa worm in the eye causes itching, pain, and light sensitivity. The worm generally only remains in the eye for less than one week (often just hours) and causes very little damage, since it remains just under the surface, rather than deep within the eye.
Loa loa worms can also lodge in other sites of the body, causing complications in the intestines, kidneys, heart, joints and at times, the retina of the eye.
What would Claire do? Quickly requesting brandy and a small knife, Claire deftly made a small incision in the sclera of the eye with a sterilized knife. She hooked the needle under the worm and pulled it out.
Did this cure this poor man? Nope. But it certainly provided relief from the severe eye pain. Can you imagine the agony of that?
Treatment of Loa loa infection
Surgical removal of Loa loa worms is not curative since it is highly unlikely that a person is infected with a single adult worm. Treatment now is with medication diethylcarbamazine, or DEC, which kills both the adult worm and the thousands of microfilariae circulating in the body. Life-threatening complications including fatal encephalitis (inflammation of the brain) can occur when DEC is used in a person with very high levels of microfilariae in the body. Therefore, in some cases, other medications are given first to decrease the microfilariae load in the body before DEC is given. In endemic areas, treatment is reserved for those who have symptoms and also have low levels of microfilariae in the blood.
The good news?
Loa loa is only passed from infected deerflies to humans in certain rain forests of West and Central Africa. You cannot become infected with Loa loa from exposure to an infected person – you must be bitten by an infected deerfly to develop the infection. So, if you haven’t travelled to that region, you are safe! If you do find yourself traveling to West and Central Africa, there is medication that can be prescribed to prevent infection. In addition, wearing long pants and long sleeved shirts and avoiding times of day when the deerfly is most active will also help prevent infection.
Check out this video showing removal of a Loa loa worm from the eye of an infected patient by a physician in Nigeria. ***(Not for the squeamish!)
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”.
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.
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.
Up until the 1920s, however, suturing needles were eyed, much like a sewing needle, and this is what Claire would have used.
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?
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.comhere!
Thorns and Spines
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!
Young Captain Leonard describes a quite desperate state of affairs aboard the Porpoise. Beginning about four weeks prior, about half the crew is now sick with some sort of plague. 30 men are dead from an illness that starts with “griping pains in the belly, and a terrible flux and vomiting,” as well as headache, considerable fever, rash, and bleeding. Rather than shrink in disgust, Claire finds herself quite intrigued and is ready to jump at the chance to identify this plague and help those afflicted.
Claire quickly confirms her suspicion that Porpoise has been overcome by an epidemic of typhoid fever.
Typhoid fever, (AKA gastric fever, enteric fever, and nervous fever), is caused by the bacteria Salmonella typhi, but differs significantly from the more commonly known non-typhoid Salmonella, one of the bacteria commonly associated with food poisoning. While typical food poisoning generally affects the stomach and gastrointestinal tract, causing fever, vomiting, and diarrhea for about a week, typhoid fever causes weeks of progressively more severe symptoms that can be fatal.
Why is there such a difference between illnesses both caused by strains of Salmonella?
In contrast to non-typhoid Salmonella which only affects the gastrointestinal tract, Salmonella typhi, responsible for typhoid fever, produces a toxin that spreads throughout the body causing a severe systemic illness. The bacteria is ingested from contaminated water or food, and is able to survive the acidic environment of the stomach before entering the small intestine. Once in the small intestine, it penetrates the bowel wall, and from there spreads throughout the body via the lymphatic system or the blood stream.
Symptoms begin anywhere from 5-21 days after exposure and follow a characteristic pattern. In the first week, fever rises in stepwise fashion as bacteria spreads throughout the blood stream. Patients experience malaise, headache, and sometimes nosebleeds. High fever continues and the second week brings abdominal pain. About one third of patients will develop a characteristic rash on the abdomen. As Claire eagerly inquired, “do some of them have a rash on their bellies?”, many will develop faint salmon-colored spots on the trunk and abdomen.
The third week brings the potential for a number of life threatening complications. Significant hemorrhage in the intestines can occur and can be fatal. Intestinal perforation (rupture) in the small intestine can occur and is often fatal. Delirium can be significant. Encephalitis (inflammation and infection of the brain), pneumonia, and endocarditis (infection of the heart valves) can occur.
The fever subsides in the fourth week and symptoms resolve over weeks to months. A small subset of patients will continue to carry the bacteria and spread it to others while no longer being symptomatic themselves.
Interestingly, diarrhea is not the rule. While it is common and can occur 6-8 times per day, other patients with typhoid fever have constipation.
What Would Claire Do?
Claire quickly gets to work treating these men with three main goals in mind: 1. sanitize the ship, especially where the sick men are held, 2. avoid the spread of disease, 3. treat the men who are ill with the resources at hand.
The ailing sailors have been living in filth, too ill to even travel to the squalid bathroom facilities. Vomit and worse covers the floor. Claire undertakes to sanitize the area, boil and dry the hammocks, strip the men of their clothes and thourogly wash the sick men. She then quarantines the ailing sailors to minimize the transmission of disease to the healthy. She also ensures that the cook and galley crew are practicing safe food handling precautions (Claire’s unending quest to spread the wisdom of hand washing continues!). Finally, she must figure out how to treat her patients with the scant resources available.
Claire notes that the men need to be fed carefully, and will need a liquid diet until they are able to take solid food again. She asks the captain for milk, assuming there is no chance of a good supply of it, only to learn that there are goats on board! She plans to feed the sick men milk, boiled to kill any pathogens, and later, bisuits can be soaked in the milk, (preferably with the weevils knocked out first!). As they recover, fish soup will provide good nutrition and the ship’s purser offers up dried figs, ten pounds of sugar, coffee, and perhaps even a large cask of Madeira wine.
Would Claire’s penicillin have helped these men? Yes, but she would have needed to carry huge trunks full of it in order to have enough. Untreated typhoid fever carries a death rate of 10-30%. When effectively treated with antibiotics, fatality is about 1%.
Typhoid Fever Today
Typhoid fever is most prevalent now in impoverished areas around the world subject to crowded environments with poor sanitation. Incidence is highest in south central Asian and southern Africa. Transmission occurs only from person to person. Humans are the only known reservoir; it is not carried by any animals or insects. In resource-rich settings in developed countries, transmission is rare. In the US, there are 200-300 cases per year, mostly in people who have recently travelled to areas of the world where typhoid fever is endemic. World-wide, however, there are 22 million cases each year with approximately 200,000 deaths.
A vaccine is available and recommended in the US for travelers to endemic areas, as well as for those who have intimate exposure to a known carrier of Salmonella typhi or lab workers who could be inadvertently exposed in working with the bacterium. The vaccine, however, does not complete protection, with efficacy of approx. 60-70% depending on the form of vaccine used.
In the era before antibiotics or vaccines were available, about 4% of typhoid fever patients became chronic carriers of the bacteria. No longer ill and without symptoms, carriers still excrete the bacteria in their stool, and thus can infect others. One famous case in particular is that of Typhoid Mary.
Mary Mallon was an Irish woman working in New York from 1900-1907. Over those years, she was employed as a cook for seven different families and over that time 22 of the people she cooked for contracted typhoid fever and 1 young girl died. This caught the attention of a public health official and she was taken into custody. She was found to be an asymptomatic carrier of the disease with significant amounts of the bacteria in her gallbladder. The officials told her she had two choices – either have her gall bladder removed or stop working as a cook. She promised to stop working as a cook and was released.
She took up work as a laundress, but this paid much less than a cook, so Mallon changed her name to Mary Brown and once again began working as a cook. In 1915, she was working as a cook at the Sloane Hospital for Women in New York City when an outbreak of typhoid fever occurred, infecting 25 people and killing 2. Mary was arrested and placed in quarantine where she remained until her death from pneumonia in 1938.
Fortunately we have made great strides in antibiotic treatment and public health, but given the rise in antibiotic resistance, could we again see a day when we might find ourselves unable to treat infections like these?
The stench was overpowering. What air there was came down through crude ventilator shafts that reached the upper deck, but that wasn’t a lot. Wore than unwashed seamen was the reek of vomitus and the ripe, throat-clogging smell of blood-streaked diarrhea, which liberally spattered the decking beneath the hammocks, where sufferers had been too ill to reach the few available chamber pots. My shoes stuck to the deck, coming away with a nasty sucking noise as I made my way cautiously into the area.
From Voyager by Diana Gabaldon, Chapter 47
Can you imagine yourself in those filthy tween decks with the stench? The sticky floors? The death and despair? Claire eagerly accepted this job. It is her nature. Her calling. She must.
“I am not a lady, Elias,” I said tiredly. “I’m a doctor.”
From Voyager by Diana Gabaldon Chapter 47
Cheers to all of the unusual ladies out there!
I hope everyone had a chance to order an Unusual Lady shirt supporting World Child Cancer!
Marineli F, Tsoucalas G, Karamanou M, Androutsos G. Mary Mallon (1869-1938) and the history of typhoid fever. Annals of Gastroenterology : Quarterly Publication of the Hellenic Society of Gastroenterology. 2013;26(2):132-134. Accessed online 11/12/2016.
Jamie’s Kryptonite: Help For The Landlubber – Listen HERE!
The completest of landlubbers, he was not just prone to seasickness, but prostrated by it. He had been violently ill all the way from Inverness to La Havre, though sea and weather had been quite calm. Now, some six hours later, safe ashore in Jared’s warehouse by the quay, there was still a pale tinge to his lips and dark circles beneath his eyes.
From Voyager by Diana Gabaldon, Chapter 40
“Sailing on the sea shows that motion disorders the body.” – Hippocrates
What is seasickness?
First described by Hippocrates, seasickness is a group of unpleasant symptoms occurring in response to real or perceived motion. It is thought that the mismatch between what the eyes see and the movement the body feels. A classic example is a person sitting in the interior of a cabin on a ship, which seems to be stationary to the eye as one looks about the room, but the body senses ongoing movements of the ship. These conflicting messages to the brain are thought to be cause of motion sickness. This also can occur when when a person is not moving at all, but the eyes see motion, such as when looking at movement on a slide under a microscope or engaging in virtual reality games, though the body perceives no movement.
Symptoms include dizziness, nausea, belching, increase salivation, warmth, sweating, general feeling of malaise, hyperventilation, and feelings of impending doom. While thought to be due to this mismatch of input from the eyes and from the body, the exact mechanism by which this happens is not fully understood.
How does the body perceive motion?
We are able to sense motion via the input of cues from the eyes, the muscles and joints, and the vestibular system. Sensory receptors in the eyes send information to the brain that provide visual cues specifying how the body is positioned relative to other objects (Am I lying flat compared to the room around me? Am I upside down compared to the furniture in this room?).
Sensory receptors in the skin, muscles, and joints are sensitive to stretch and pressure and report back to the brain information about how the body is positioned in space. For instance, cues from the ankles and feet may indicate whether I am standing on solid ground or if I am on a tilting surface (like a boat) requiring the muscles of my ankles and feet to work against the sway of the boat to keep me standing.
Information about motion and balance is provided by the vestibular system via structures in the inner ear including the utricle, saccule, and three semicircular canals. The utricle and saccule sense linear movement via the movement of tiny hairs within, or cilia, as the head moves. The semicircular canals contain fluid and as the head moves in a rotational pattern, the fluid within moves, stimulating receptors that sense the movement of the head.
The brain then receives all of these signals from the eyes, muscles and joints, and the two sides of the vestibular system (one in each ear), and must make sense of it. Motion sickness symptoms are thought to arise when the input from these sources conflict with each other, such as when the input from the muscles and joints suggest the rolling movement of a boat while the eyes simply see the walls and furniture of a ship’s interior cabin. Interestingly, people who are blind can have motion sickness, but people who are completely deaf (and lack peripheral vestibular function in the ear) cannot! This would suggest that the vestibular system is playing the major role here. The exact mechanism by which this occurs is not well understood.
Why are some people so much more susceptible to motion sickness?
Motion sickness can be induced in nearly all adults, but certainly under typical situations of travel by boat, air, or car, or rides on roller coasters, not all are affected. Children under 2 are typically resistant to motion sickness. Symptoms seem to peak at approximately age 12 and then decrease (though of course this isn’t the case for all). Women are more commonly affected and pregnant women in particular are quite susceptible, raising the question of the role of hormones in motion sickness. Interestingly, migraine sufferers are also more susceptible to motion sickness.
Motion sickness tends to improve for most with repeated exposure to the stimulus. After 36-72 hours of continuous exposure, symptoms typically subside or resolve for most people. However, symptoms can occur upon returning to the pre-exposure environment (e.g. returning to land after a period of time at sea).
Treatments for Motion Sickness
Minimizing the discrepancy between the different cues from vision, muscles and joints, etc. can help. Looking at the horizon from the deck of a ship rather than remaining in an interior cabin allows the visual input to more closely match the other sensory input. Sitting in the front seat of the car and looking out the window, or better yet – being the person driving – can minimize symptoms. Self-generated movements don’t cause motion sickness, so those prone to motion sickness can avoid symptoms of car sickness by taking the wheel.
These are most effective when taken as a preventative before the symptoms start. The most frequently used medications include antihistamines like Benadryl, Meclizine, and Dramamine and the anticholinergic medication Scopolamine which is available in a skin patch form. Other medications that are used in the prevention and treatment of motion sickness include nausea medications, as well as medications like baclofen and gabapentin which influence the neurotransmitter GABA, thought to play a role in the development of motion sickness.
A traditional remedy for nausea, also has been found to be effective in motion sickness.
Was found to be beneficial in a study of naval cadets when given as a pre-treatment, resulting in less vomiting and cold sweats than placebo.
Thought to affect gastric motility as well as on serotonin receptors in the brain
Patients on certain medications, particularly blood thinners, should discuss this with their doctor before taking ginger, as ginger may also increase the risk of bleeding.
Frequently used to treat nausea
Works as an antispasmodic in the gastrointestinal tract
A traditional remedy for motion sickness, nausea, and vomiting
Biofeedback and Relaxation Techniques
It turns out that even pilots and astronauts are not immune to motion sickness. Biofeedback and relaxation therapy have been used by NASA to help mitigate the effects of motion sickness.
Acupuncture and Acupressure
Originating in China over 4000 years ago, acupuncture is the application of fine metal needles to particular areas of the body to maintain health and to prevent and treat certain ailments. After a thorough evaluation, a practitioner inserts thin needles into precisely defined points along the 14 main channels (or meridians) along the body associated with specific organs. Acupressure is similar in principle, involving the application of pressure, rather than needles, to specific points along the body. In particular, the P6 acupuncture point located above the wrist has been studied extensively and many find the use of this point is effective for reducing nausea and vomiting. Acupressure wrist bands that apply pressure to this point are widely used to prevent and relieve the symptoms of motion sickness.
His face relaxed slightly, making the slender gold needles that protruded from behind his ears twitch like ant’s feelers.
“It’s all right,” he said gruffly. “It’s only some rubbish of the Chinee’s, to cure the puking.”
Wide-eyed, Marsali came up to him, gingerly extending a finger to touch the needles embedded in the flesh of his wrist below the palm. Three more flashed from the inside of his leg, a few inches above the ankle.
“Does – does it work?” she asked. “How does it feel”
Jamie’s mouth twitched, his normal sense of humor beginning to reassert itself. “I feel like a bloody ill-wish doll that someone’s been poking full o’ pins,” he said. “But then I havena vomited in the last quarter-hour, so I suppose it must work.” He shot a quick glare at me and Mr. Willoughby, standing side by side near the rail.
From Voyager by Diana Gabaldon, Chapter 41
Jamie’s Experience with Acupuncture
Jamie has regained his sense of humor, a reassuring sign that he is feeling better, alarming though he may look to Marsali with needles protruding from various spots. Acupuncture needles are described on his wrist and lower leg and behind his ears.
Pericardium 6 (P6), the best known acupuncture point for preventing and treating motion sickness, is located 2cm above the wrist in the inner forearm. Used for treating vomiting, dizziness, and vertigo, motion sickness wristbands apply pressure to this point.
Spleen 6 (SP6) is a point in the inner lower leg, about 3 cm above the ankle that is said to help with digestive symptoms and dizziness.
Behind the Ears:
Gallbladder 8 (GB8) is a point on the head directly above the ear which is said to help with ceaseless vomiting. Other locations in this area also help with dizziness and vertigo.
How Does Acupuncture Work?
In Traditional Chinese Medicine, it is believed there is a universal life energy called qi (“chee”) present in every living being. This energy travels throughout the body along specific pathways called meridians. Health is maintained when the energy flows freely throughout these meridians. However, when the flow of energy is blocked, disrupting the system, pain and dysfunction occur. Acupuncture is thought to restore normal function by stimulating certain points on the meridians to free up the energy.
In Western medicine, some theorize that pain relief from acupuncture is due to the release of endorphins that occurs when needles penetrate the skin. It is also thought that acupuncture affects gastrointestinal disorders by effecting the parasympathetic and sympathetic nervous systems, promoting gastric and intestinal motility. Studies involving neuroimaging reveal that acupuncture has the ability to activate and deactivate particular areas of the brain. Research funded by the National Institutes of Health has indicated that acupuncture is effective in treating migraines, arthritis, and chronic pain.
Acupuncture was mostly unknown in the United States until the 1970s. When President Nixon’s Secretary of State Henry Kissinger travelled to China in 1972, he was accompanied by journalist James Reston. Reston developed appendicitis while in China and required an emergency appendectomy. He reportedly remained awake during the operation, with his pain controlled with acupuncture (though further reports, and Reston’s own account seem to suggest he had an epidural for anesthesia during the procedure, and acupuncture was used for post operative pain 2 days alter). Word spread, and US physicians began studying acupuncture and its use in anesthesia for pain control as well as other applications.
We will likely see acupuncture become more widely used in the US, particularly as we seek to minimize the use of opiate medications in controlling pain. It is interesting to see that despite our advances in medicine, we still depend on many of the thousands year old remedies, particularly in motion sickness treatment, in the form of acupuncture, acupressure, herbal remedies such as ginger!
Title Photo: Shutterstock
“Acupuncture: In Depth | NCCIH.” U.S National Library of Medicine. U.S. National Library of Medicine, n.d. Web. 08 Nov. 2016.
Grontved, A., Brask, T., Kambskard, J., Jentzer, E. “Ginger root against seasickness. A controlled trial on the open sea.” Acta Otolaryngol. 1988 Jan-Feb; 105(1-2): 45-9.
Hao, Jason J., and Mittleman, Michelle. “Acupuncture: Past, Present, and Future.” Glob Adv Health Med. 4 (2014): 6-8.
Lu, Dominic P., and Gabriel P. Lu. “An Historical Review and Perspective on the Impact of Acupuncture on U.S. Medicine and Society.” Medical Acupuncture 25.5 (2013): 311-16. Web.
Yes, indeed. Courtesy of one Mrs. Laoghaire MacKenzie MacKimmie Fraser, in fact.
Jamie has been shot. The bullet has pierced his upper arm, exited out the other side, and has come to rest about 1 inch deep in the soft tissue of his chest wall. Fortunately the bullet has avoided any bones and did not penetrate the chest wall deep enough to damage his lungs and vital organs. Jenny has cleaned the wounds as best she can and has removed the bullet but a serious infection has settled in Jamie’s arm.
The wound itself was a ragged dark hole, scabbed at the edges and faintly blue-tinged. I pressed the flesh on either side of the wound; it was red and angry-looking, and there was a considerable seepage of pus. Jamie stirred uneasily as I drew my fingertips gently but firmly down the length of the muscle.
From Voyager by Diana Gabaldon, Chapter 36
Gunshot wounds become infected frequently, and are considered to be contaminated wounds, which makes sense:
Soiled clothing is forced into the skin and various injured tissues during the penetration of the bullet
Debris and foreign material is forced into the wound canal
Trauma causes nonviable (dead) tissue which enables the proliferation of bacteria
The trauma causes the local blood supply to the area to become disrupted, decreasing the ability of one’s immune system to defend against bacteria
Throughout history, death in combat was more often due to infection than battle injuries. Things are not looking so good for Jamie. In fact, had young Ian not rode a full day’s journey to beg Claire to return to Lallybroch to help save Jamie, the Outlander story may have had a much more rapid resolution!
Fortunately for Outlander fans, Claire had the wisdom and foresight to include a special item in the pocket of her dress in her travel back through the stones. Or perhaps it was just plain good sense, knowing she was returning to Jamie Fraser, a man whom trouble seems to find!
I laid the small, flat case on the table and flipped the latch. “I’m not going to let you die this time either,” I informed him, “greatly as I may be tempted.” I carefully extracted the roll of gray flannel and laid it on the table with a soft clicking noise. I unrolled the flannel, displaying the gleaming row of syringes, and rummaged in the box for the small bottle of penicillin tablets.
“What in God’s name are those?” Jamie asked, eyeing the syringes with interest. “They look wicked sharp.”
I didn’t answer, occupied in dissolving the penicillin tablets in the vial of sterile water. I selected a glass barrel, fitted a needle, and pressed the tip through the rubber covering the mouth of the bottle. Holding it up to the light, I pulled back slowly on the plunger, watching the thick white liquid fill the barrel, checking for bubbles. Then pulling the needle free, I depressed the plunger slightly until a drop of liquid pearled from the point and rolled slowly down the length of the spike.
“Roll onto your good side,” I said, turning to Jamie, “and pull up your shirt.”
From Voyager by Diana Gabaldon, Chapter 36
Penicillin was indeed a game changer for Jamie, but also for the entire world, even playing a significant role in the success of the Allies in World War II. The discovery of penicillin was a fortunate accident and starts with Scottish scientist Alexander Fleming. The story goes that upon returning to his lab in the basement of St. Mary’s Hospital in London in late September 1928 after a two week holiday, Fleming noted an interesting phenomenon in a petri dish that had been left accidentally open.
The petri dish contained Staphylococcus bacteria he had been studying, but now also contained a blue-green mold which he suspected had contaminated his petri dish from an open window. Upon closer examination, he noticed that there was a clear zone around the mold where no staph bacteria grew, as though the mold and prohibited the growth of bacteria in that area.
Fleming identified the mold as penicillium, and thus named the active substance capable of killing the surrounding bacteria penicillin. He authored a paper describing his findings but this was met with little interest. Penicillin was unstable and Fleming had difficulty producing it in any significant quantity. No further progress would be made for another decade.
In 1939, a group of scientists at Oxford including Howard Florey and Ernst Chain developed a method for purifying and producing penicillin, though the yield still remained rather low. A year later, their experiments showed that penicillin could successfully treat strep infections in mice.
Florey and Chain showed that penicillin could treat infections in human in 1941 when they treated a 48 year old policeman by the name of Albert Alexander. Mr Alexander had scratched the side of his nose while pruning roses and developed a significant infection with abscesses involving the eye, face and lungs. He was treated with penicillin and within days had a remarkable recovery. However, the supply of penicillin ran out after 5 days. His infection worsened again and he died.
By this time, the world was fully engaged in World War II. The US drug company Merck started production of penicillin and successfully treated in 1942 a patient with streptococcal septicemia – an infection of strep in the blood. However, treatment of that one patient required half of the total supply of penicillin available at the time. Work began in earnest to figure out a way to mass produce large quantities of the drug.
The US government hoped to produce enough penicillin for mass distribution to the Allied troops in Europe. In 1943, the US War Production Board took over responsibility for the increased production of penicillin with the goal to have adequate supply for the planned D-day invasion in France. Ultimately, 2.3 million doses were available in time for the invasion of Normandy in the spring of 1944. During the war effort, penicillin was limited to military use, with rare exceptions made for civilians in cases where other treatments had failed. By 1945, increased production allowed for penicillin to be available to consumers for the first time without restriction. Fleming, Florey and Chain were awarded the Nobel Prize in Physiology or Medicine in 1945.
(L to R: Alexander Fleming, Howard Florey, Ernst Chain. From Wikipedia Commons)
Prior to the era of penicillin, seemingly minor infections were often life-threatening: strep throat, scarlet fever, dental infections, skin infections from simple scratches, etc. Infections like bacterial pneumonia, meningitis and endocarditis (infection of the lining of the heart and the heart valves) were often death sentences. In World War I, the death rate from bacterial pneumonia was 18%. With the availability of penicillin in World War II, that fell to less than 1%. Untreated skin infections from trauma as minor as a simple scratch carried an 11% mortality rate prior to the discovery of penicillin.
Fleming, though, foresaw the risk involved with this miracle drug and in his Nobel Lecture, provided this ominous warning:
But I would like to sound one note of warning. Penicillin is to all intents and purposes non-poisonous so there is no need to worry about giving an overdose and poisoning the patient. There may be a danger, though, in under-dosage. It is not difficult to make microbes resistant to penicillin in the laboratory by exposing them to concentrations not sufficient to kill them, and the same thing has occasionally happened in the body.
-Alexander Fleming, Nobel Lecture, December 11, 1945
Some suggest that we are headed to a post-antibiotic era – a time when we once again will be defenseless against seemingly simple infections. Now we have antibiotic resistant pneumonia, tuberculosis, blood infections and even gonorrhea and few, if any, effective antibiotics against them. The CDC estimates that antibiotic resistance has been responsible for over 2 million illness and 23,000 deaths each year.
Antibiotics resistance happens naturally as the bacteria adapt but we must avoid accelerating this process.
As patients, we can minimize antibiotic resistance by:
Working to prevent infection with good hand washing, food hygiene and common sense, avoiding close contact with those who are ill.
Always finishing the full course of prescribed antibiotics and not taking left over antibiotics or someone else’s
It is scary to think we could be headed toward a time when we are unable to effectively fight bacterial, viral, and fungal infections. Progress continues in the development of new antibiotics, but resistance continues to develop at an alarming rate.
Fortunately, the bacteria infecting Jamie’s wound was no match for penicillin. With no prior exposure to penicillin or similar antibiotics, the bacteria would have had no resistance and would easily succumb to the novel medication. And good thing, too – without antibiotics, this wound could have been fatal for Jamie. Thus, the Outlander saga could have ended much too early, and at the hands of Laoghaire no less (as though we needed any further reason to despise her)!
Title Image: Mold Cultures in Petri Dishes (Public Domain)