Plague Ship

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

Outlander Science Club

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.

800px-forskeligeveje_ad_hvilkenbroen_kan_inficeres_medtyfusbaciller

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.

typhoid-spots

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

mary_mallon_typhoid_mary

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.

MaryMallon.stoolreport.1907.png

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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