The Morbid Sore Throat

It has been a while, Outlander friends!  How are we all holding up?  What have you been watching and reading?  Any great recommendations?  We’ve got some time to fill between now and September…

In the meantime, for those who haven’t seen the season 3 teaser (or just want to watch again!):

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

In episode 202, this is changed to smallpox, which does tie in nicely with the smallpox epidemic at the docks in episode 201 and a later with Claire’s concoction to mimic the symptoms of smallpox in episode 206.

Analisse Husband Duel
A duel?  Do explain, Jamie! Source: STARZ

“The Scourge of Childhood”

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.

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Greyish-white pseudomembrane of diphtieria infection.  Source

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.

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Desperate attempts to cure diphtheria before the advent of antibiotics and vaccines.  This “Wizard Oil” remedy promises to cure a dozen ailments, including diphtheria. He looks skeptical…  Source: Library of Congress/Public Domain

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!

vintage-diphtheria-poster
Library of Congress / Public Domain

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!

Header image: STARZ

You’ve Got a Little Something in Your Eye…

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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.

africa_en_map
Image: WHO

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!

l_loa_lifecycle
From CDC – Public Domain

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.

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Image courtesy of Skydmark on Imgur

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.

WWCD?

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!)

Header Image: NIH NIAID on Flickr

 

Edited to add:  A June 15, 2017 article in Huffington Post explains more about how this disease continues to affect millions in Africa and the difficulties in treating those afflicted by it.

 

Cats, Ants, and Agave

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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”.

catgut-plain
Catgut Suture (Public Domain)

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.

simple-interrupted
Simple interrupted sutures of a thumb laceration with non-absorbable Prolene (propylene) sutures.  (Public Domain).
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.

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Eyeless suture needles (Public Domain)
Up until the 1920s, however, suturing needles were eyed, much like a sewing needle, and this is what Claire would have used.

instruments_used_in_sutures_from_dictionnaire_encyclopedique_des_sciences_medicales_18841
Eyed suture needles, circa 1884.  (Public Domain)
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?

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Dorylus ant, with a pincer-like mandible capable of closing a wound (Creative Commons/ www.antweb.com)
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.com here!

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Skin staples. (Creative Commons/Mathrock)

Thorns and Spines 

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Agave plant (Creative Commons/Naamsvermelding vereist)

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!

Now that we’ve received word that Mr Willoughby will in season 3, hopefully we’ll have this scene to look forward to, pillow-song and all!

 

Plague Ship

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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.

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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

Jamie’s Kryptonite

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Chapter 41:  We Set Sail

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     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.

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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.

 

544px-acupuncture_needles

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.

Wee Bugs And Wonder Drugs

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Chapters 34-37:

Wee Bugs And Wonder Drugs
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“I’ve germs in my arm, have I?”

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

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!

pcn-box

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

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.

petri
From Alexander Fleming’s Nobel Lecture, December 11, 1945

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.

quote

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.

pcn-poster
Credit: Research and Development Division, Schenley Laboratories, Inc., Lawrenceburg, Indiana

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

Antibiotic Resistance

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.

resist
From: Center for Disease Control

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)!

mold

 

Title Image: Mold Cultures in Petri Dishes (Public Domain)
References:
About Antimicrobial Resistance. (2015). Retrieved October 29, 2016, from http://www.cdc.gov/drugresistance/about.html
American Chemical Society International Historic Chemical Landmarks. Discovery and Development of Penicillin. Retrieved October 29, 2016, from http://www.acs.org/content/acs/en/education/whatischemistry/landmarks/flemingpenicillin.html
Antibiotic resistance. (2015, October). Retrieved October 29, 2016, from http://who.int/mediacentre/factsheets/antibiotic-resistance/en/
Markel, H. (2013, September 27). The real story behind penicillin. Retrieved October 29, 2016, from http://www.pbs.org/newshour/rundown/the-real-story-behind-the-worlds-first-antibiotic/
Sir Alexander Fleming – Banquet Speech. Retrieved October 29, 2016, from http://www.nobelprize.org/nobel_prizes/medicine/laureates/1945/fleming-speech.html

The Doctors Are In

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Chapters 32-33

The Doctors Are In
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“Jenny Murray had been the nearest thing I had ever had to a sister, and by far the closest woman friend of my life. Owing to circumstance, most of my close friends in the last fifteen years had been men; there were no other female doctors, and the natural gulf between nursing staff and medical staff prevented more than casual acquaintance with other women working at the hospital.  As for the women in Frank’s circle, the departmental secretaries and university wives…”  From Voyager by Diana Gabaldon, Chapter 32.

The past 20 years have been lonely for Claire.  She lived her calling as a physician but no doubt she longs for the close personal connections she knew in 18th century Scotland. Of course she did have Brianna and a close confidant in  Joe Abernathy, but her marriage with Frank was not an emotionally intimate relationship. For the most part, she was without female friends with whom to share the joys, insecurities, failures, and triumphs of motherhood, career, and life.

Female Physicians in the 20th Century

Claire entered medical school in 1955, a time when women made up only about 5-6% of medical students in the US. Realizing her calling as a surgeon, she then found herself even more of the exception as a surgical resident and then as a practicing surgeon.  The American College of Surgeons admitted its first woman in 1913, and thereafter only admitted between 0 and 5 women each year until 1975. While she would have interacted with numerous female nurses in the hospital, the paternalistic dynamic between physicians and nurses during that era would have prevented anything beyond purely professional relationships between Claire and the nurses.

It wouldn’t be until the 1970s, with the passage of Title IX and the Public Health Service Act, as well as the changing cultural tide, that the number of female physicians would begin to increase significantly.  We now have nearly equal numbers of men and women entering medical school, though the percentage of women entering surgery remains disproportionately low. According to the American Medical Association, as of 2006, women accounted for 12% of general surgeons in the US.

It is no surprise our stubborn, brilliant, tenacious, and brave heroine chose this path. Claire finds herself in good company with the trailblazing women of modern medicine.

Brave Women Paving the Way

Throughout history, women have played a central role in caring for the ill and injured, providing remedies at home, and working as nurses, midwives, and herbalists.  They were also physicians, dating as far back as ancient Egypt through medieval Europe.  However, when the education of physicians became more formalized, with the establishment of universities in the 1400s and the development of licensure for physicians, women were excluded.

Margaret Ann Bulkley, AKA Dr. David Barry

james_barry_surgeon05

Prior to the admittance of women into medical schools and inclusion in the licensing programs, women of course still found a way to practice medicine, whether by practicing informally within their communities or in some cases, attending medical school and practicing medicine while disguised as a man!  Margaret Ann Bulkley, born at the end of the 18th century in Ireland, lived her life as James Barry in order to practice medicine.  After receiving a medical degree at University of Edinburgh, Dr. Barry became a military surgeon in the British Army and practiced medicine for over 50 years in India, South Africa, and the Caribbean.  It wasn’t until an examination after dying of dysentery that it was discovered that Dr. Barry was actually a woman!

Dr. Elizabeth Blackwell

elizabeth_blackwell_nlm_02

Elizabeth Blackwell was the first woman physician in the US.  Upon receiving her application, the dean of New York’s Geneva Medical College presented her application to the students.  He asked the all-male student body to vote on whether the college would accept a female student.  Thinking this a great joke, the students unanimously voted to admit Ms Blackwell and she graduated in 1849, passing the qualifying exam with the highest average.  She would go on to co-found the New York Infirmary for Women and Children.

Dr. Elizabeth Garrett

eganderson

Inspired by Dr. Blackwell, Elizabeth Garrett was working to gain acceptance to medical school.  After she was denied medical school admission, she entered Middlesex teaching hospital as a student nurse, and began attending medical school courses.  Despite receiving outstanding marks, just before it was time to graduate, she was dismissed.  None of the other universities in England would allow her to continue her studies and earn a medical degree.  Out of options for continuing her medical studies, she decided to focus her efforts on studying to become an apothecary.  She completed an apprenticeship, but following this, official university matriculation was necessary to complete her apothecary education.  Again, England’s universities were closed to her.  Likewise, she was rejected at St. Andrews University and University of Edinburgh in Scotland.  Undaunted, she continued on, attending rounds with a number of practitioners in London, accumulating the required proof of training for her application to the Society of Apothecaries and taking the qualifying examination. She passed and became the first woman licensed by the Society of Apothecaries, officially becoming a physician.  After building a large private practice and proving care to the impoverished, she taught herself French and was permitted to take the exam for a medical diploma in Paris, finally earning an MD in 1870.  Dr. Garrett went on to serve as the dean of the London School of Medicine for Women for twenty years and is thought to be the first women in history to perform an oophorectomy (surgical removal of the ovaries).

Dr. Sophia Jex-Blake

sophia_jex-blake_aged_25

Many women experienced similar road blocks in their journey to become physicians.  Sophia Jex-Blake was officially accepted to study medicine at the University of Edinburgh, though it appeared that she was accepted her in error. Quickly realizing the application was submitted by a woman, the university blocked her from entering classes.  Undeterred, Ms Jex-Blake, along with other physicians, created the London School of Medicine for Women in 1874.  However, women graduating from the new women’s medical college found that despite earning an MD, they were refused privileges to work at all of the reputable hospitals. These pioneering women therefore founded their own hospital, the New Hospital for Women.

Women in Europe and in the US founded women’s medical colleges and women’s hospitals and most women physicians in the late 19th century received their medical education and training in these institutions.  Public opinion did begin to change, finally, and by the early 20th century, women were accepted into traditional medical colleges and women’s medical colleges began to close.  It would be another century, however, until women and men attended medical school in equal rates, and women physicians are still fighting the gender gap in pay and academic promotion.

No doubt Claire would have fought similarly for the right to practice medicine, should she have found herself in the same situation.  She surely faced much discrimination on her own path to becoming a surgeon. However, once back in the 18th century, she generally finds herself practicing in areas in dire need of her help, and once her expertise is witnessed, roadblocks are few. Of course, she is not one to worry overmuch about the opinions of others!

Claire has found herself in the 18th century right back where she belongs: living her calling as a physician with the support and companionship of family and friends.

53314-o

References:
Lorber, J., & Ecker, M. (1983). Career development of female and male physicians. Academic Medicine, 58(6), 447-56
Lyons, A. (n.d.). Medical History — Women in Medicine – Health Guidance. Retrieved October 23, 2016, from http://www.healthguidance.org/entry/6355/1/Medical-History–Women-in-Medicine.html
Ulrich, B. (2010). Gender Diversity and Nurse-Physician Relationships. Virtual Mentor, 12(1), 41-45.
Young, A., Chaudhry, H., Pei, X., Halbesleben, K., Polk, D., & Dugan, M. (2015). A Census of Actively Licensed Physicians in the United States, 2014. Journal of Medical Regulation, 101(2), 8-23. Retrieved October 16, 2016.
14-086 Physician Specialty Databook 2014. (n.d.). Retrieved October 23, 2016, from https://members.aamc.org/eweb/upload/Physician Specialty Databook 2014.pdf
Header Image: STARZ, Other Photos: Public Domain
wellbehaved

Claire’s Soothing Tonic for Margaret Campbell

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Chapter 29:  Culloden’s Last Victim
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Once a Physician, Always a Physician

After spending her entire adult life as a healer, first as a combat nurse and then as surgeon, Claire soon finds herself once again doctoring in 18th century Scotland.

Claire’s discussion of herbs and remedies with the apothecary reveals her extensive knowledge, and overhearing this, Reverend Campbell asks Claire to recommend a remedy to help with his sister’s “nervous complaints.” Never one to refuse a person in need of help, Claire of course offers to visit Margaret Campbell to evaluate her for herself.

According to her caregiver, Margaret suffers from mysterious episodes of silently staring off into space for as long as nearly two weeks at a time, followed by screaming to exhaustion, and falling asleep, only to awake unaware of what has happened.  Claire finds Margaret in a state of silent staring, seemingly oblivious to her surroundings. However, aside from evidence of vitamin C deficiency and physical inactivity, her examination of Margaret reveals no significant physical ailments.

What Has Happened to Margaret Campbell?

Margaret’s symptoms began after she was brutally attacked by English soldiers. She had been searching for her beloved, Ewan Cameron, in the aftermath of the Battle of Culloden, when she fell into the hands of a group of English soldiers.  Margaret was attacked, raped, and left for dead.  Later reunited with her brother, she was never the same and spent the next 20 years alternating between a normal state of mind, a catatonic state of silently staring, unaware of her surroundings, and continual screaming.

The description of sitting, staring off into the distance, not speaking, and being seemingly unaware of the people around her is consistent with catatonic behavior. Once a diagnosis of its own, catatonia is now a descriptor of rare subtypes of other disorders such as schizophrenia, bipolar disorder, major depression and PTSD.  Margaret may be experiencing catatonic symptoms as part of a rare form of PTSD as a result of the trauma she sustained at the hands of the English soldiers. It is also possible that she developed schizophrenia and began to display symptoms at this time (the peak period for the onset of schizophrenia is late adolescence and early adulthood, and she would have been around 17 years old at the time of the attack).

How Can Margaret Be Helped?

Treatment options for catatonia include antipsychotic medications, benzodiazepines, electroconvulsive therapy as well as supportive therapy.  The physical inactivity and refusal to eat in catatonia can result in muscle contractures, pressure sores, blood clots, weight loss, dehydration, electrolyte disorders, and vitamin deficiencies.  Some patients will require IV fluids and tube feedings to provide adequate hydration and nutrition, as well as anticoagulants to avoid blood clots.

With the resources available to her, Claire suggests a “soothing tonic” for Margaret, containing chamomile, hops, rue, tansy, verbena, and peppermint.

Claire’s Soothing Tonic for Margaret Campbell

Chamomile
chamomile
AKA German Chamomile
Used for: flatulence, travel sickness, nasal mucous membrane inflammation, nervous diarrhea, GI spasms, inflammation of the GI tract, restlessness, insomnia
Used topically for: hemorrhoids, leg ulcers, mucous membrane inflammation
Interesting fact:  Chamomile is a member of the Asteraceae/Compositae family which includes ragweed, chrysanthemum, marigold and daisy.  As a result, people who are sensitive to these may these (especially ragweed!) by experience allergic reaction to chamomile!

Hops
hops
Used for: restlessness, anxiety, sleep disorders, tension, excitability, nervousness, irritability, indigestion, as an antibacterial, as an appetite stimulant.  Also has been used for dysentery, leprosy and pulmonary tuberculosis.
Interesting fact:  Hops comes from the family cannabinaceae (hemp, marijuana)

Rue
rue
AKA Herb-of-Grace, Garden Rue, Common Rue
Used for: menstrual disorders, loss of appetite, heart palpitations, nervousness, hysteria, fever, headaches, weakness of the eyes.  Has been used for Multiple Sclerosis, Bell’s Palsy and cancers of the mouth.
Used topically for: skin inflammation, earaches and toothaches, as well as arthritis and sprains.  Has been used as an insect repellant.
Interesting fact: used as a bitter flavoring for food and beverages and as a fragrance in soap and cosmetics

Tansy
tansy
AKA Bitter Buttons, Daisy, Tansy Flower, Parsley Fern, Stinking Willie
Used for: regulating menstrual flow, treating roundworm infestation, migraines, neuralgia, epilepsy, rheumatism, stimulating appetite, flatulence and bloating, stomach ulcers, calming nerves, hysteria
Used topically for: scabies, bruises, sprains, sunburn, toothache and as an insect repellant
Interesting fact:  Thujone, a component of tansy, is thought to have a mind-altering effect similar to THC (the active component of marijuana).  It can be toxic to the nervous system and liver and can lead to seizures.

Verbena
verbena
AKA Pigeon’s Grass, Pigeonweed, Herb of Grace, Herb of the Cross, Juno’s Tears
Used for: sore throat, respiratory diseases like asthma and whooping cough, depression, hysteria, seizures, melancholia.
Used topically for: poorly healing wounds, burns
Interesting fact: used as a flavoring agent in alcoholic beverages

Peppermint
peppermint
AKA Brandy Mint, Lamb Mint
Used for: loss of appetite, spasms of the GI tract, flatulence, gastritis, enteritis, nausea and vomiting, morning sickness and soothing for cough and colds
Interesting fact: common culinary spice in foods and herbal teas

Benzodiazepines are one of the main treatments for catatonia today.  They are thought to have their action by binding to GABA receptors in the brain and increasing the efficiency of GABA in the brain.  Interestingly, chamomile also binds GABA and its sedative effects may be due to the same mechanism! Along with the sedating and calming effects of the other components of this soothing tonic, Margaret may well have some improvement in her symptoms.

 

Scurvy : The Ever-Present Scourge

scorbutic-gums

Margaret is also suffering from scurvy, as evidenced by her bleeding, spongy gums. Once the Campbells reach the West Indies, citrus fruits will be plentiful and will satisfy this need, but for now, Claire prescribes a tea of Rose Hips to provide vitamin C to reverse Margaret’s symptoms of scurvy.

Rose Hips
rose-hips
AKA Dog Rose, Hip Fruit, Hip Sweet, Hipberry, Wild Boar Fruit
Used for:  supplemental source of dietary vitamin C
Contains 1250mg of vitamin C per 100g of rose hip, making it one of the richest plant sources of vitamin C!
Interesting fact: itching powder (often used by pranksters to cause dreadful itching to their victims) is made from the fine hairs inside rose hips!

Check out the post It’s Green, Major, all about scurvy and Claire’s affinity for all things green!

All photos: Wikipedia Commons

 

References:

1. Sienaert, P., Dhossche, D. M., Vancampfort, D., Hert, M. D., & Gazdag, G. (2014). A Clinical Review of the Treatment of Catatonia. Frontiers in Psychiatry Front. Psychiatry, 5. doi:10.3389/fpsyt.2014.00181
2.  Jellin, J. M. (2003). Natural medicines comprehensive database. Stockton, CA: Therapeutic Research Faculty.
3. Srivastava, J., Shankar, E., & Gupta, S. (2010, November 1). Chamomile: A herbal medicine of the past with a bright future (Review). Molecular Medicine Reports, 3(6), 895-901. doi:10.3892/mmr.2010.377

Mr Willoughby’s Healthy Balls

Outlander Science Club

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A Dram of Outlander Voyager Read-Along
Chapters 25-26

Listen here!

This week’s installment of Outlander Science Club is inspired by Mr. Willoughby and his healthy balls. Ahem. No, not those. We are discussing Mr. Willoughby’s hangover remedy, Chinese Medicine Balls. (Need a refresher on the science behind hangovers? Check out this post from season one!)

Mr. Willoughby suffers from a hangover and an intense headache, and Claire apologizes, telling him she doesn’t have any medicines with her to help. He assures her he will be just fine because he has healthy balls.

Huh? Hold on a minute. Did we all miss the lecture in medical school discussing the connection between testicular health and headache?

Claire comes to learn that Mr. Willoughby is referring to a pair of jade spheres, “larger than marbles and smaller than baseballs,” – Chinese Medicine Balls or Baoding Balls.

baoding-balls
Photo: Wikipedia Commons

Baoding Balls are thought to have likely first originated in China during the Ming Dynasty (1368-1644). Initially made of iron, they came to be made from varied materials including steel and tungsten, and stones such as jade, agate and marble. Many contain a chime that rings as the balls are moved.

Both balls are held in the palm and rotated, initially maintaining constant contact, and eventually rotating without contacting each other at all as hand strength improves.

Health benefits attributed to the use of Baoding Balls:

  • improved strength and dexterity of the hand muscles
  • improved brain function and reduced stress
  • improved circulation in the body
  • relief of the pain and stiffness of arthritis
  • decreased blood pressure
  • increased energy levels
  • improved concentration

Mr. Willoughby found relief from hangovers by using the Baoding balls. An accupressure point called Joining the Valley is located on the hand in the web space between the thumb and index finger. Stimulation of this point is thought to relieve pain, especially frontal headaches related to hangovers.

In addtion to using the Baoding balls, Mr. Willoughby likely applied other remedies of Traditional Chinese Medicine, including the use of herbs:

  • Cayenne to reduce pain and improve blood flow
  • Meadowsweet for its anti-inflammatory properties
  • Chamomile for relaxation
  • Valerian for sedation (a favorite of Claire’s)
  • Chrysanthemum or Yarrow to soothe the liver

What else could Mr. Willoughby have tried? A quick search for Hangover Cures yields all sorts of remedies, some more appetizing than others…

Outlander Science Club encourages responsible drinking. These remedies are presented for your entertainment and general education and is not intended as medical advice!

 

Poland

pickles
Photo:  Wikipedia Commons

Drinking pickle juice or eating sauerkraut – the high sodium content is thought to replenish electrolytes

 

 

 

 

 

Ecuador

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Photo: Wikipedia Commons

Oregano tea to settle the stomach

 

 

 

 

 

South Korea

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Photo: Wikipedia Commons

Haejangguk, “a soup to chase a hangover,” containing dried napa cabbage, vegetables, beef broth and congealed ox blood. Said to soothe the stomach.

 

 

Japan

umeboshi
Photo: Wikipedia Commons

Pickled ume fruit, very sour in taste, is thought to help digestion and liver function and to prevent nausea.

 

 

 

Germany

fischbro%cc%88tchen
Photo: Public Domain

Rollmops – Raw pickled herring wrapped around pieces of gherkin and onion, thought to restore electrolytes.

 

 

 

USA

prairie_oyster_
Photo: Wikipedia Commons

The Prairie Oyster – a whole raw egg with hot sauce, salt, pepper and a few dashes of Worcestershire sauce, the thinking being that the spices will combat the alcohol toxins and the egg provides nutrients.

 

 

 

 

Haiti

doll_with_pins_in_it_museum_of_witchcraft
Photo: Public Domain

“Curse the Bottle” – stick 13 black headed pins into the cork of a bottle to curse the sickness that the bottle is attempting to curse you with!

 

 

 

 

 

Italy

linea_doubleespresso
Photo: Public Domain

Several cups of strong espresso to provide caffeine for headache relief.

 

 

 

 

 

 

Mongolia

1280px-tomato_juice
Photo: Wikipedia Commons

Tomato juice and pickled sheep eyes. Likely some hydration and electrolytes from tomato juice but it is unclear what the sheep eyes provide!

 

 

 

Bangladesh

coconut_drink_pangandaran
Photo: Wikipedia Commons

Coconut water provides hydration as well as a supply of potassium, magnesium and antioxidants

 

 

 

 

Las Vegas, Nevada

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Photo: Wikipedia Commons

Mobile hangover cure buses (and house calls) providing IV fluids, vitamins, and medications for nausea, pain and inflammation.

 

 

 

 

 

 

And my personal favorite, Eggs Benedict.

eggs_benedict
Photo: Wikipedia Commons

The story goes that in the late 1894, wealthy socialite Lemuel Benedict, hurting from a night of excess, ordered at the Waldorf Hotel “buttered toast, poached eggs, crisp bacon and a hooker of hollandaise,” the dish that would evolve into the beloved Eggs Benedict!

 

 

 

Mr. Willoughby’s remedy seems to be an easily tolerated and readily portable method to potentially treat some of the symptoms of a hangover, and greatly preferable to some of the less savory options outlined above (sheep’s eyes, anyone?). Always learning and generally quite open-minded, it is evident that Claire will appreciate learning a few new techniques from Mr. Willoughby, so long as she can keep her shoes on!

Who else is eagerly awaiting the casting news of Mr. Willoughby? Can’t wait to see these scenes on screen!

 

cahonasscotland

We here at Outlander Science Club encourage healthy balls of all kinds! Encourage the men in your life to do regular self exams and check out Cahonas Scotland, a Scottish charity working to increase awareness and decrease the stigma surrounding male cancers!

 

 

 

La Grippe – Influenza at Ardsmuir

Outlander Science Club

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A Dram of Outlander

Voyager Read-Along

Chapters 10-13

Ardsmuir Prison, May 15, 1755.
60 men are suffering from La Grippe. 15 are badly off.
Jamie is desperate to help his men but resources are scarce.

800px-Fönster_i_fångvalvets_logement
An 18th century prison (source)

What is La Grippe?
La Grippe is a name for influenza, meaning “to seize suddenly.”
The term Influenza comes from the Medieval Latin “influentia,” from the belief that epidemics of this illness were due unfavorable astrological influences.

Influenza
Influenza follows a seasonal pattern, peaking each year in the winter months. Additionally, worldwide pandemics occur approximately three times per century. Most famously, was the pandemic of 1918, termed the “Spanish Flu.” This illness had an extremely high rate of infection, with half of all those exposed developing symptoms, and generally severe ones. This epidemic killed approximately 2.5-5% of the world’s population. Many pandemics have been documented over time, including ancient Rome, Russia in 1580, asian influenza in 1958 and most recently the H1N1 (swine flu) pandemic of 2009. Whether termed epidemic catarrh, La Grippe, sweating sickness or the flu, influenza has plagued humanity for at least thousands of years.

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Symptoms of Influenza (source)

Symptoms
As we are all too well aware, influenza is a viral infection that causes fever, runny nose, body aches, headache, coughing, and fatigue.  Symptoms begin about 2 days after one is exposed to the virus. For most people, symptoms last about 1-2 weeks and resolve, sometimes with a lingering cough. However, complications can occur such as viral pneumonia, secondary bacterial pneumonia, worsening of chronic medical infections, and in some cases, death. Those at high risk for complications include young children, the elderly, pregnant women, people with compromised immune systems and those who have chronic lung or heart disease.

Catching Influenza
The problem with influenza is that a person is infectious for about a day before symptoms arise, so quarantine is not going to prevent transmission. The influenza virus is spread when an infected person sneezes, and another person in close proxmity comes into contact with those droplets or inhales them. It can also be transmitted from contaminated surfaces or direct personal contact like a hand shake, when a person then touches his or her own eye, nose or mouth with a contaminated hand. The virus can persist outside of the body on contaminated surfaces like light switches and door knobs for 1-2 days.

390px-TB_poster
(source)

Influenza outbreaks occur seasonally in the winter. This is thought to be because people spend more time indoors and thus in more close contact, promoting person to person transmission. Additionally, the virus survives longer on surfaces at colder temperatures.

How to minimize risk?
The annual influenza vaccine is recommended by the CDC to everyone over 6 months of age, and especially for those at high risk for complications of the flu including the young, the elderly, pregnant women and those with chronic diseases. The influenza virus has a high mutation rate so each year a new vaccine is developed to provide protection against the particular strains predicted to be circulating each season. When well matched to the strains circulating during an outbreak, the vaccine reduces the risk of influenza illness by 50-60% in the general population. The influenza vaccine reduces the risk of becoming infected with influenza and also decreases the severity of the symptoms of those infected.

394px-Fluzone
Influenza vaccine (public domain)

Treating Influenza
Also available today are antiviral medications. When started in the 48 hours of illness, these medications can shorten the duration of symptoms, reduce the severity of symptoms, decrease the length of hospital stay, and decrease mortality. This is of particular importance to those at high risk for complications of influenza.

In general, people with influenza are advised to keep themselves healthy and avoid infection by:

  • Avoiding close contact
  • Staying home when you are sick
  • Covering your mouth and nose when coughing or sneezing
  • Washing your hands
  • Avoid touching your eyes, mouth, or nose
  • Getting enough sleep
  • Reducing stress
  • Eating a healthy diet
  • Avoiding crowds

That doesn’t seem to be too difficult – eat well, rest, avoid close contact – unless of course, you are a prisoner of Ardsmuir Prison!

Keeping Healthy at Ardsmuir
Described by Jamie as “crowded cold squalor,” the prisoner cells of Ardsmuir seem an ideal breeding ground for an influenza epidemic.

  • Avoiding close contact – this is impossible with cells packed with as many as 46 men, huddled together for warmth.
  • Staying home when you are sick – not when “home” is a crowded cell with dozens of other men.
  • Covering your mouth and nose when coughing/sneezing – well, yes, they can cover, but there are no disposable tissues and likely no extra cloths/rags to use as a handkerchief. And what cloth there was to use for this would not be washed regularly, if at all.
  • Washing your hands – bathing occurred rarely, if ever. Water for washing was likely not much more readily available.
  • Avoid touching the eyes/nose/mouth – again, unavoidable without the ability to wash regularly, and disease transmission would easily occur.
  • Getting enough sleep – in a cold crowded cell, sleeping on the floor among dozens of other men, with the noises and movement inherent in a group that large, quality sleep would be hard to come by.
  • Reducing stress – these men are in prison. On the contrary, they likely live with a persistently high level of stress – stress of not controlling their fate, of worry about their families, of no privacy, of insecurity about the future, about lack of food and warmth and their basic needs.
  • Eating a healthy diet – According to Jamie, each Ardsmuir prisoner received 1 quart of oatmeal parritch and one small wheaten loaf of bread daily. Twice a week they would have thin barley brose and one a week on Sunday, a quart of meat stew. This is roughly 1600-1700 calories per day, supplemented twice a week with brose and once a week with stew. The daily calorie requirement for these men working 12-16 performing physical labor cutting peat would likely approach 4000, so clearly these men are significantly undernourished! Jamie does convince Lord John to allow the healthy men to set snares to catch additional meat to supplement the diets of the ill men.
  • Avoiding crowds – impossible, as outlined above.
outlander-season-1-both-sides-now-claire-returns-starz
Starz

What would Claire do?
Rest, good hydration and nutritious diet would have been a good place to start.

Additionally, for those not in prison, it would be easier to provide a less crowded, warm environment, protected from the elements. Claire would have insisted on good hand washing, no doubt, and regularly washed handkerchiefs. She also would have had a few other tools at her disposal in the form of her collection of herbs and healthy foods.

Vitamin D plays a role in immune function, and flu season coincides with the time of year when vitamin D stores are low due to limited sun exposure. Vitamin D enriched foods would be important to include in the diet, perhaps in the form of fish or eggs, if possible.

Vitamin C has been used as a treatment for the common cold, though with conflicting evidence. However, some studies suggest vitamin C may be helpful in preventing colds in people who are exposed to cold weather or undergoing extreme exercise (sounds like our men of Ardsmuir!), though it is unclear that this would also be a benefit in preventing influenza as well. Eating plenty of greens is an easy enough task and won’t hurt!

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The Outlander’s Vitamin C: Watercress (source)

A number of other plants and herbs may have been beneficial as well, and it is likely that Claire would have employed many of the following which have been used over time in the treatment of respiratory ailments:

To decrease the severity of symptoms: andrographis, echinacea, elderberry

For cough and nasal congestion: eucalyptus, golden seal, peppermint

For soothing of a sore throat: licorice, marshmallow, slippery elm

For fever and pain: willowbark

In general, Claire’s approach would be similar to what we do today: stay home, get plenty of sleep, drink lots of fluids and take some symptomatic remedies, whether it be cough syrup and pain medicine, or eucalyptus and willowbark tea!

362px-Illustration_Salix_alba0
Willowbark (public domain)

Sadly, Lord John reports to Jamie that there are no medications to be had at Ardsmuir but does send word to a cousin who is married to an apothecary to see about acquiring some. Lord John’s kindness is evident but we are reminded of the desperation and despair that is imprisonment in the “crowded cold squalor” of this Highland prison.

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Listen to this week’s episode of Outlander Science Club HERE!

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Learn More:

Information about Influenza – from the CDC
Herbal Remedies for Influenza – from University of Maryland Medical Center
The History of Influenza