209: The Invisible Wounds of War

209:  Je Suis Prest

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The field hospital at which I was stationed had been shelled three times.  Even knowing that the flimsy walls of our temporary structures would not protect us, still doctors, nurses and orderlies had all dashed inside at the first alarm, huddling together for courage.  Courage is in very short supply when there are mortar shells screaming overhead and bombs going off next door.

From Outlander by Diana Gabaldon, Chapter 7

combat nurse
STARZ

Claire spent six years as a combat nurse in the second World War.  In episode 209, the sights and sounds of men preparing for battle trigger terrifying flashbacks to her time in the war and she is seen reliving the trauma she has no doubt tucked away deep in her memory.  As a combat nurse, she would have spent her days caring for soldiers suffering horrendous injuries as well as the more mundane, as we see with her flashback to her time educating soldiers about trench foot.  She would be building relationships with the same men and women who would later be sick and seriously injured and in her care.  She would have witnessed innumerable tragic deaths, while often fearing for her own life.  When the war finally ends, Claire finds herself with only a brief time of peace and reunion with Frank before she is once again in harm’s way.

Since her arrival in the 18th century, Claire has suffered what seems to be a lifetime of traumas in the form of war, violence, assault, arrest and imprisonment, narrow avoidance of execution, witnessing the torture of her husband, and the devastating death of her daughter.

Claire holds deep within a long history of trauma.

claire covering ears
STARZ

Shell Shock and the World Wars

The psychological distress experienced by soldiers was first dubbed “shell shock” during World War I.  Physicians used the term to describe the “dazed, disoriented state many soldiers experienced during combat or shortly thereafter.”(1)  The condition was thought to be brought on by concussion and physiological damage caused by exploding artillery shells.  However, military physicians noted that the same symptoms were seen in other soldiers who had not been in close proximity to exploding shells and opinion shifted, with many contending that shell shock was “a variety of cowardice or malingering” and those who “cracked” under the pressure of war were considered weak.

After WWI, Sigmund Freud argued that shell shock was psychological in origin, recommending psychoanalysis for treatment.  The idea that brain injury from exploding artillery shells led to these symptoms fell out of favor and the opinion that the condition affected the psychologically “weak” persisted.  During WWII, draft boards attempted to “weed out” those deemed psychologically unfit to fight, finding over 1 million men ineligible to go to war.  Despite this, in the European theater, the US military had a rate of psychiatric casualties of 102 per 1,000 troops.(1)

Overall in WWII, 25% of US military casualties were caused by psychological war trauma.  The rate was approached 50% for soldiers engaged in long, intense fighting.(2)  Seeing that so many suffered these effects, despite already excluding over 1 million men in the screening process, opinion among most in the military began to shift to the acceptance that combat fatigue was not evidence of cowardice or pre-existing mental illness.

1,393,000 soldiers were treated for battle fatigue during WWII.  Treatment was often focused on a few days of complete rest, with quick return to the front lines.  50-70% returned to combat within three days.  Other treatment modalities included the administration of sodium pentathol (dubbed “truth serum”) to induce soldiers to “re-live their repressed battlefield experiences and thus reach a catharsis.”(2)  Other physicians found that providing liquor during debriefings was beneficial to the troops.  Some were treated with electric shock in an attempt to “jolt” the veteran out of his emotional turmoil.  Others were treated with large doses of insulin which dropped their blood sugar severely and caused a comatose state.  In the 1950s, some WWII veterans were even subjected to lobotomy, or surgical severing of the frontal lobes of the brain, in an attempt to relieve their psychological symptoms.  Whether dubbed shell shock, psychoneurotic disorder, anxiety neurosis, character disorder, or combat exhaustion, very little was understood about what would come to be known Post Traumatic Stress Disorder.

 

Defining PTSD

In 1980, after experience with troops returning from the Vietnam War, the American Psychiatric Association defined PTSD and published diagnostic criteria.

Post Traumatic Stress Disorder, or PTSD, is now defined as a mental disorder that can develop after a person is exposed to a traumatic event, causing at least one month of symptoms including a variety of the following:

  • Re-experiencing the trauma
    • flashbacks, bad dreams, frightening thoughts
  • Avoidance symptoms
    • staying away from places, events or objects that are reminders of the trauma
    • feeling emotionally numb
    • feeling strong guilt, depression or worry
    • losing interest in activities that were previously enjoyable
    • difficulty remembering the traumatic event
  • Arousal and reactivity syptoms
    • easily startled
    • feeling tense or “on edge”
    • difficulty sleeping
    • angry outbursts
  • Cognition and mood symptoms
    • trouble remembering key features of the traumatic event
    • negative thoughts about oneself or the world
    • distorted feelings like guilt or blame
    • loss of interest in enjoyable activities

The manner in which PTSD causes these symptoms is not yet understood.  Interestingly, MRI studies have shown decreased volume in key parts of the brain in patients suffering from  PTSD.  The hippocampus is involved in creating new memories and retrieving them in response to relevant stimuli.  The amygdala helps to process emotion and plays a role in fear response.  Both have been found to be smaller in PTSD patients.  These findings have raised the question of whether PTSD causes these brain changes or if those with these differences are more susceptible to PTSD, thus opening the door to research into strategies for prevention and treatment.(3)

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Location of the amygdala and hippocampus in the brain / source

Treatment today for PTSD includes cognitive-behavioral therapy, antidepressant medications, or a combination of both.  Many resort to self-medication with drugs and alcohol to dull their crippling symptoms of PTSD, only to battle addiction as well.

 

The Impact of PTSD Today

In the US, 3.5% adults have PTSD in a given year and approximately 9% will develop it at some point in their life.  Rates are higher in regions of armed conflict.  11-20% of veterans of Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF) suffer from PTSD in a given year.  About 12% of Gulf War (Desert Storm) veterans will have PTSD in a given year.  It is estimated that about 30% of Vietnam Veterans have had PTSD in their lifetime.(4)

Combat veterans are more likely to have suicidal thoughts, often associated with PTSD, and are more likely to act on a suicidal plan.  They are less likely to seek the help of a mental health professional for fear of social stigma or “appearing weak.”(5)

Each day, 22 US veterans take their own lives.(6)

There is significant work to be done to fully understand how PTSD works, why it happens and what we needs to be done to prevent it and help these patients.  Public awareness and understanding of PTSD and its effects is vital.   Bravo to the Outlander team for this compelling depiction of PTSD, and in a female veteran no less!

Resources for those suffering from PTSD and those who care for them:

Veterans Crisis Line

Stop Soldier Suicide

Real Warriors Campaign

 

Questions, comments, concerns, or suggestions for future Outlander medicine topics? I’d love to hear from you! Leave a comment here or find me on twitter @SassenachDoctor.

PTSD

 

1.  Scott, WJ.  “PTSD in DSM-III:  A Case in the Politics of Diagnosis and Disease.”  Social Problems.  37 (1990): 294-310.

2.  http://www.pbs.org/perilousfight/psychology/the_mental_toll/

3.  Morey RA, Gold AL, et al.  “Amygdala Volume Changes in Posttraumatic Stress Disorder in a Large Case-Controlled Veterans Group.”  Arch Gen Psychiatry. 2012;69(11):1169-1178.

4.  www.ptsd.va.gov

5.  Sher L, Braquehais MD, Casa M.  “Posttraumatic stress disorder, depression and suicide in veterans.”  Cleveland Clinic Journal of Medicine. 2012. 79(2): 92-97.

6. “Office of Public and Intergovernmental Affairs.” News Releases. VA Office of Public and Intergovernmental Affairs, 1 Feb. 2013. Web. Retrieved from www.va.gov/opa/pressrel/pressrelease.cfm?id=2427.

 

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207: No One Is to Blame

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It wasn’t your fault, Claire.
Nor was it Jamie’s.
It wasn’t even Randall’s fault.

It wasn’t anyone’s fault.

All too often in medicine, as in life, simply horrific things happen to good people through no fault of their own.

claire in bed

We come to learn that Claire suffered a placental abruption.  The placenta has prematurely separated from the wall of the uterus, causing massive bleeding, contraction of the uterus and inadequate blood flow to her growing baby, ultimately resulting in the death of her daughter.

The raindrops beat on my face, on my throat and shoulders. Each heavy drop struck cold, then dissolved into a tiny warm stream, coursing across my chilled skin. The sensation was quite distinct, apart from the wrenching agony that advanced and retreated, lower down. I tried to focus my mind on that, to force my attention from the small, detached voice in the center of my brain, the one saying, as though making notes on a clinical record: “You’re having a hemorrhage, of course. Probably a ruptured placenta, judging from the amount of blood. Generally fatal. The loss of blood accounts for the numbness of hands and feet, and the darkened vision. They say that the sense of hearing is the last to go; that seems to be true,”

From Dragonfly in Amber by Diana Gabaldon, Chapter 23

 

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source

Risk factors for placental abruption include history of a prior abruption, trauma to the abdomen in pregnancy, high blood pressure, cocaine use, smoking, abnormalities of the uterus, and prior cesarean section.  Sometimes it will occur in the absence of any risk factors.

Placental abruption occurs in about 1% of pregnancies, and even now carries a risk of stillbirth or death within 1 week of life of up to 60%.[1]   When an abruption occurs and the mother’s blood pressure is found to be low, indicating substantial blood loss, a significant abruption has likely occurred.  As described in Dragonfly in Amber, Claire’s placental abruption was a catastrophic event.  She describes symptoms of hemorrhagic shock from massive blood loss, with numbness in the hands and feet and loss of vision.  Even now in the 21st century, she would have a very high risk of losing her daughter.

There was nothing that could have been done to change the natural course of this pregnancy.  Placental abruption is not caused by emotional stress. The emotional anguish involved in Claire’s learning of the duel and subsequently witnessing it was not responsible. Bed rest would not have prevented the placental abruption.  A change in Claire’s activities, less exposure to stress and highly emotionally charged events, less whisky and wine – none of this would have prevented this placental abruption.  She does not have any identifiable risk factors for abruption that we are aware of. This was a tragic and unavoidable event, despite our desire to discover a way we could have saved Faith.

Somewhere deep down, Claire knows this.  Overcome with grief now, she will blame herself and those she deems responsible for the circumstances surrounding the tragic loss of their daughter.  In the end, though, with time and healing, she hopefully will come to accept that this could not have been prevented.

holding hands at grave

Questions, comments, concerns, or suggestions for future Outlander medicine topics? I’d love to hear from you! Leave a comment here or find me on twitter @SassenachDoctor.

References:

  1. Am. J. Epidemiol. (2001) 153 (4): 332-337.

206: The Fraser Family Recipe for Faking Smallpox

Episode 206:  Best Laid Schemes…

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Need to feign illness with smallpox?  Want to impress your friends, alarm the local harbormasters, and make a bonny prince squirm?  The Frasers have you covered!

The Fraser Family Recipe for Faux Smallpox

Ingredients:

  • Essence of Rosemary
  • Bitter Cascara
  • Mash of Nettles
  • Rose Madder

Method:

  1. Drink a concoction of essence of rosemary and bitter cascara to cause flushing and realistic ill appearance
  2. Apply mash of nettles over the area of skin where the characteristic rash of smallpox is desired
  3. Drink a small vial or rose madder to mimic blood in the urine
  4. Prepare to be quarantined!
a family that schemes together
A family that schemes together…

 

Essence of Rosemary

In Dragonfly in Amber, rosemary was used to cause redness or flushing of the skin to mimic the fever of smallpox.  Rosemary is thought to increase blood flow, though topical application rather than ingestion of rosemary may produce more redness.  Other uses of rosemary include the treatment of stomach upset and flatulence, gout, cough, headache and high blood pressure.  If its mechanism for treating elevated blood pressure is via dilation of the blood vessels, such dilation of the small capillaries may explain a mechanism for flushing and redness to mimic how one might look while febrile.

I handed him the second bottle, this one of green glass filled with a purplish-black liquor. “This is concentrated essence of rosemary leaves. This one acts faster. Drink about one-quarter of the bottle half an hour before you mean to show yourself; you should start flushing within half an hour. It wears off quickly, so you’ll need to take more when you can manage inconspicuously.”

From Dragonfly in Amber by Diana Gabaldon, Chapter 23

 

Bitter Cascara

Cascara seems to be a popular choice with Claire and Master Raymond!  Hopefully he keeps it well stocked in the apothecary!  In Dragonfly in Amber, the use of cascara had been discussed but decided to be too harsh.

The plan took several days of discussion and research to refine, but was at last settled.  Cascara to cause flux had been rejected as being too debilitating in action.  However, I’d found some good substitutes in one of the herbals Master Raymond had lent me.

From Dragonfly in Amber by Diana Gabaldon, Chapter 23

However, the cramping and abdominal pain will make for a realistic picture of an ill patient and as we see, Jamie had immediate symptoms just as Claire did when she drank cascara-laced wine.

 

Nettles

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Stinging nettle / source

There is a reason that the medical term for hives, urticaria, comes from the Latin urtica, the word for nettle!  Also known as Utica dioica, the nettle plant is native to Europe, Asia, northern Africa and western North America.  It grows to a height of 3-7 ft tall and has stinging hairs (trichomes) along its leaves and stems which, when touched, transform into needles that can inject several chemicals including histamine, formic acid and leukotrienes.  This causes a painful stinging sensation to the victim and a characteristic rash with red itchy wheals and itchy white bumps.

His fair skin had flushed dark red within minutes, and then settle juice raised immediate blisters that could easily be mistaken for those of pox by a ship’s doctor or a panicked captain.

From Dragonfly in Amber by Diana Gabaldon, Chapter 23

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Rash from stinging nettle / source

 

Rose Madder

The root of the madder plant has been used throughout history as a source for red dye.  Medicinally, it has been used for preventing and disintegrating kidney stones.  When taken orally, it causes red colored urine, saliva, perspiration and breast milk.

Rubia_tinctorum_-_Köhler–s_Medizinal-Pflanzen-123
Rubia tinctorum with its red colored root / source

A rare and severe form of smallpox, hemorrhagic smallpox, or the “bloody pox”, causes active bleeding in the gastrointestinal tract as well as blood in the urine.  The appearance of blood in the urine would be particularly alarming for those familiar with smallpox!

And should any doubt remain, the madder-stained urine gave an absolutely perfect illusion of a man pissing blood as the smallpox attacked his kidneys.

“Christ!” Jamie had exclaimed, startled despite himself at the first demonstration of the herb’s efficacy.
“Oh, jolly good!” I said, peering over his shoulder at the white porcelain chamber pot and its crimson contents. “That’s better than I expected.”

From Dragonfly in Amber by Diana Gabaldon, Chapter 23

 

Jolly good work, indeed, Frasers! And well executed by wee Fergus!

 

Questions, comments, concerns, or suggestions for future Outlander medicine topics?  I’d love to hear from you!  Leave a comment here or find me on twitter @SassenachDoctor.

205: A Historical Perspective on Alcohol in Pregnancy

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When viewed through our 21st century eyes, it does seem as though our pregnant heroine is drinking an awful lot of alcohol.

Throughout history, alcohol was not always thought to be something to avoid in pregnancy.  Alcohol was often medicine – whisky for colds or laryngitis, hot brandy punch for cholera, rum-soaked cherries for a cold.  Doctors prescribed champagne as a treatment for morning sickness. Pregnant women in labor would take a shot or two of liquor to ease their discomfort. Wine was often recommended during pregnancy to help pregnant women relax.

beehive-brandy

General opinion maintained that alcohol was not dangerous in pregnancy, though throughout the years, some have voiced concern. Aristotle is quoted to have warned against the hazard of drinking during pregnancy, “foolish, drunken, and harebrained women most often bring forth children like unto themselves, morose and languid.”  In 1899, English physician William Sullivan noted that among his patients in a Liverpool prison, stillbirth rates were 250% higher for his alcoholic female prisoners than for their sober counterparts. He also noted that the children of women with no (or limited) access to alcohol during pregnancy were healthier, leading him to hypothesize, “a direct toxic action on the embryo, owing to continued excesses during pregnancy.”

In an issue of the Quarterly Journal of Inebriety published the same year, an editorial contended, “habitual intemperance on the part of the female when pregnant must tend to impair the development of the fetus in utero by impairing cell growth. What we know now is that maternal use of alcohol during pregnancy can have deleterious effects on the growing fetus and lead to a number of problems.”  Many other physicians observed and reported similar findings in the 19th and early 20th century, describing outcomes that would later come to be recognized as symptoms of Fetal Alcohol Syndrome.

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World’s and National Woman’s Christian Temperance Union, 1914   source

It seems, though, that as soon as prohibition ended in the US, attitudes regarding alcohol in pregnancy shifted again, and public discussion of the risk and medical research on the question, seemed to disappear.  The medical community seemed to turn direction completely, with a statement in 1953 in Clinical Obstetrics stating, “alcohol, as such, is not injurious and need not be eliminated during pregnancy.”   As recently as the 1960s-1980s in the US, alcohol was given intravenously to women in preterm labor as a tocolytic – a medication to stop uterine contractions calm and halt preterm labor.

A fetus is vulnerable to alcohol particularly because alcohol crosses the placenta, yet the fetus has lower levels of the enzyme alcohol dehydrogenase to metabolize the alcohol than does the mother. The fetus is thus exposed to alcohol for a much longer period of time.

The effects of alcohol manifest in different ways depending on the stage of pregnancy. Exposure in the first trimester can lead to characteristic abnormalities in the face as well as devastating heart defects and abnormalities of the bone structure, kidneys, eyes and hearing. Second trimester alcohol exposure increases the risk of miscarriage and stillbirth. In the third trimester, fetal exposure to alcohol affects weight, length and brain growth.

FASkid
By NIH/National Institute on Alcohol Abuse and Alcoholism

Fetal Alcohol Spectrum Disorders are the conditions that may occur in persons who were exposed to alcohol in utero. Problems can include abnormal appearance with characteristic facial abnormalities, short height, low body weight, small head size, poor coordination, low intelligence, behavioral problems and hearing and vision problems. It is thought to affect 2-5% of people in the US and Western Europe. Worldwide incidence is approximately 1 in 2000 live births.

It wasn’t until the 1970s that Fetal Alcohol Syndrome was defined and fully recognized. Work to educate pregnant women of the dangers of alcohol in pregnancy began in earnest after researchers at the University of Washington identified a pattern of abnormalities in infants born to alcoholic mothers.  Animal studies in monkeys then followed that confirmed that alcohol was indeed responsible.  Rather than naming the syndrome after themselves, as is common in the discovery of medical syndromes historically, the University of Washington researchers, Drs Kenneth Lyons Jones and David Weyhe Smith, chose the name Fetal Alcohol Syndrome after the agent responsible for the problem, to raise awareness of the problem alcohol in pregnancy.

1988 brought the Alcoholic Beverage Labeling Act in the US, mandating that the labels of alcoholic beverages carry a government warning.

warning

Today, the official statement from American Congress of Obstetricians and Gynecologists reads:

“Women should avoid alcohol entirely while pregnant or trying to conceive because damage can occur in the earliest weeks of pregnancy, even before a woman knows that she is pregnant.”

Other societies of providers of obstetric care phrase it a bit less stringently, with the European Board and College of Obstetrics and Gynecology advising:

“Based on what is known as well as the continuing uncertainty as to whether any safe consumption threshold exists […] women should ideally abstain from alcohol during pregnancy or when planning pregnancy.”

Similarly, the Royal College of Obstetricians and Gynaecologists in the UK advises:

“If you are pregnant or planning a pregnancy, the safest approach is not to drink alcohol at all, to keep risks to your baby to a minimum. Drinking in pregnancy can lead to long-term harm to the baby, with the more you drink the grater the risk. […] The risk of harm to the baby is likely to be low if a woman has drunk only small amounts of alcohol before she knew she was pregnant or during pregnancy.”

Pregnancy in the 18th century was a scary proposition indeed. Reliable records of maternal death in the time are difficult to come by but studies of death records in the UK in the time suggest about 2.5-3% maternal death rate per baptism recorded.  Given an average of 5-6 pregnancies per woman, this would result in 11-16% risk for the average 18th century mother to die in childbirth or shortly after in her lifetime, and perhaps even higher given that the risk subsequent births are not necessarily independent of previous births.  Maybe we can understand why the women of the time (and their concerned partners) would encourage alcohol to help them relax and briefly forget about the fact they may not survive childbirth, especially without knowledge the alcohol would be doing any harm.  Compare this to the current risk of maternal mortality today in the US of 0.019%.

Even with her medical knowledge, Claire is coming from the reference point of the 1940’s when the medical community was of the opinion that alcohol was not hazardous to pregnancy, and actually was considered beneficial.  Seeing these huge shifts in the medical community’s understanding of the risk of alcohol, it makes one wonder what we will come to know in the future as an undeniable risk we assume is healthy today!

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Questions, comments, concerns, or suggestions for future Outlander medicine topics?  I’d love to hear from you!  Leave a comment here or find me on twitter @SassenachDoctor.