Plague Ship

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A Dram of Outlander Voyager Read-Along  Chapter 46-47 (LISTEN HERE)

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Plague Ship (LISTEN HERE!)

A Desperate State of Affairs

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

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.

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1938 illustration showing the ways water may become infected with typhoid fever bacteria.  Artist Anonymous.  Source: Pubic Domain 

 

Symptoms

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.

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Characteristic Rash of Typhoid Fever with flat rose or salmon colored spots.  Source: Public Domain

 

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.

map

Incidence of Typhoid Fever.  Source: Wikipedia Commons

 

Vaccine

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.

Typhoid Mary

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Mary Mallon, in hospital while in quarantine, 1912.  Source: Public Doman

 

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.

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Photo of original stool culture report for Mary Mallon, 1907, testing positive numerous times for Salmonella typhi.  Source: Wikipedia Commons

 

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!

unusual-shirt

Feature Image Source: Wikipedia Commons
References:
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.
CDC: Typhoid Fever  http://www.cdc.gov/typhoid-fever/index.html
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Jamie’s Kryptonite

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Chapter 41:  We Set Sail

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

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Source: Wikipedia Commons

 

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.

sea-sickness_-_published_by_g-s-_tregear_96_cheapside

Source: Wikipedia Commons

 

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.

Anatomy_of_the_Human_Ear_en.svg.png

Source: Wikipedia Commons

 

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

Environmental Modification

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.

Medications

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.

Herbal Remedies

  • Ginger
    • 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.
  • Peppermint
    • Frequently used to treat nausea
    • Works as an antispasmodic in the gastrointestinal tract
  • Black Horehound
    • 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.

 

body
Source: Shutterstock
     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.

Wrist:

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.
Lower Leg:
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.

 

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Source: Wikipedia Commons

 

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!

seaband
 

The Sea-Band in action – Wearable acupuressure for motion sickness.  (Source: Personal Photo)

 

 

Title Photo: Shutterstock

 

References:
“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.