You’ve Got a Little Something in Your Eye…

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A Dram of Outlander Voyager Read-Along  Chapter 60 (LISTEN HERE)

Outlander Science Club

You’ve Got a Little Something in Your Eye… (Listen to the podcast HERE!)

 

Jesus H. Roosevelt Christ,” I said.  “What was that?”

What was that, indeed!  In the search for Young Ian, Claire finds herself doctoring a young man in his twenties who is enslaved at Rose Hall. Lying quietly on a pallet in a dark corner of a kitchen pantry, he doesn’t seem to have a fever nor much distress. In fact, he appears rather well.  Until…

As though in answer to my question, the slave suddenly wrenched himself away from my hand, let out a piercing scream, and rolled up into a ball.  Rolling and unrolling himself like a yo-yo, he reached the wall and began to bang his head against it, still screaming.  Then, as suddenly as the fit had come on, it passed off, and the young man sank back onto the pallet, panting heavily and soaked with sweat.

From Voyager by Diana Gabaldon, Chapter 60

Claire indeed finds a small worm moving underneath the surface of her patient’s eye.

The Loa loa worm and Loa loa filariasis

Nope, this isn’t one of Geillis’ hexes or the product of Diana Gabaldon’s imagination. This is a real disease and Loa loa, with its predilection for swimming under the surface of its victims’ eyes is the stuff of itchy nightmares, my friends!

Loa loa, AKA African eye worm, is a parasitic worm that is passed to humans by the bite of a deerfly. Endemic only to parts of West and Central Africa, Loa loa can only be spread by the bite of the deer fly and cannot be spread person to person.  Claire’s patient at Rose Hall no doubt contracted the illness in Africa before he was enslaved and transported to the West Indies.

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.

UtIRaAp.gif
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.

 

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211: Trauma, of Both the Minor and Major Varieties

211: Vengeance is Mine

211 titlecard

This was a fun one! There were so many great medical moments and hilarious lines that it is no coincidence that this episode was written by Herself, Diana Gabaldon.

written by DG

Vengeance is Mine opens on Claire operating a makeshift dental clinic. With the resources available to healers of the time, most dental problems were treated by extracting the offending tooth. Aside from perhaps a shot or two of whiskey, teeth were pulled without anesthetics, sedatives or pain relievers. No novocaine, no nitrous oxide (laughing gas), no gentle topical anesthetic gel applied before the novocaine to avoid even the pain of the needle. Nope, these folks of the 18th century with dental ailments are desperate for help and tough as nails, knowing that if they can just tolerate the excruciating tooth extraction, relief will be forthcoming.

pulling tooth open mouth rupert watch
No matter the temperature, those wristlets have gotta go during the dirty work!  / STARZ

This is in stark contrast to dental clinics of today which advertise painless dentistry with the aid of topical and local anesthetics, post-procedure pain relievers and even the option of sedation. The feared drill isn’t even always necessary any more as some cavities can be “drilled” with a rather painless laser. As lovely as that is, it doesn’t quite carry the same motivating weight when convincing children to brush their teeth!

“Brush your teeth well so you don’t end up with a cavity that needs to be drilled!”
is now
“Brush your teeth well so you don’t end up sitting for a half hour in the dentist’s chair while your cavity is painlessly fixed!”

All joking aside, anesthesia really is an amazing advance and we are fortunate to live in this time in that regard!

plate of teeth
What do we suppose Claire does with all of the teeth she has extracted?  / STARZ

As Jamie and his men march toward Inverness, they camp along a river where Ross has the misfortune of impaling his own finger with a fish hook.

good shot hook in finger
Steady hands / STARZ

We see Claire back the hook out of the skin along its path of entry, a method called the Retrograde technique. This works because this hook is smooth and lacks barbs that would otherwise catch and prevent it backing out easily.

Rupert: Ah ye big baby, Angus’d bite it off wi’ his teeth.
Fergus: Angus didn’t have front teeth.
Rupert: He’d use his gums then.

Most fishing hooks made today have one or more barbs which prohibit simply pulling the hook smoothly out the way it came.

Anatomyofafishhook
Anatomy of a Fish Hook / source

There are a number of techniques one can employ to remove a barbed hook depending on the type of hook.  It can be very helpful to know the type of hook one is dealing with to better plan the removal.

typesFishhookanatomy
Fish Hook Types / source

Various methods allow the backing out of a barbed hook avoiding further trauma, though at times the location and type of fishhook will require advancing it through the skin, cutting the end of the hook, including the barb(s), and then allowing the hook to be backed out the way it came.

hook removal two
image: Shutterstock

For multi-barbed hooks, it may be necessary to advance the hook past all of the barbs, cut off the eye of the hook, and continue advancing the hook out.

I learned quickly to add a small pair of wire cutters to my first aid bag after my son hooked his uncle’s arm on his first try at fishing! Oftentimes, hooks can be removed in the field, though some embedded fishhooks cannot be easily removed or are in areas in which removal should not be attempted (in or near the eye!) and medical care should be sought.

Claire: I do wish I could give you a tetanus shot…
Ross: Tetanus. Never heard of it, but I’d take a shot of anything just now.
Rupert: Sounds Spanish. Must be gin.

Indeed, this is a risk she is all too well aware of and, as discussed when the tanner’s lad had his ear nailed to the pillory, there isn’t much to be done in the era before tetanus vaccination but cross your fingers and hope the odds are in your favor.

Moments later, the Redcoats show up. That’s never good news.

shooting at rupert
He’s got his eye on Rupert!  / STARZ

Oh Rupert, this guy just can’t catch a break. His dearest friend died in combat just days ago and now this!

claire holding rupert
Amazing makeup and prosthetic work!  / STARZ

Rupert has sustained a gun shot wound to the eye. Fortunately, it seems that the bullet has remained in the eye socket or perhaps lodged in the bones of the orbit, but has not penetrated into the brain.  A devastating injury, yes, but one that he will likely survive, so long as he avoids infection.

 

Gray190
Shown here are the bones of the skull and the bony structure of the orbit, or eye socket (source)

Claire works to remove the bullet from Rupert’s eye socket and debride the area, or clean by removing dead or devitalized tissue and foreign matter, to allow it to heal.  Rupert lies quite still throughout, despite the unimaginable pain involved.  Again, the people of that time seem to have incredibly impressive pain tolerance!  She sutures shut his now-empty eye socket and places a dressing over the wound.

tying on eye patch
Are we ready for a crossover with Black Sails yet? / STARZ

Rupert: I suppose one eye is better than none…
Claire: We’ll get you a black eyepatch and you’ll look a proper pirate.
Rupert: Pirates have eyepatches?
Claire: Along with peg-legs and parrots.

Adventures in Medicine continue in this episode with one Miss Mary Hawkins, in the kitchen, with a knife.  Having identified Danton, one of her attackers in Paris, she takes vengeance of her own.

stab wound
Angus the knife skills instructor would be proud / STARZ

Danton is stabbed in the abdomen and collapses to the floor.  Mary may not have had the same benefit as Claire in a crash course in the proper use of a sgian-dubh (RIP, Angus Mohr!), but has success, aiming in the mid-abdomen, slightly to the left, possibly lacerating the aorta and other abdominal vasculature in addition to some of the bowel.  We don’t see Danton in the aftermath of this injury, though we may assume he has sustained a fatal injury. The action quickly moves to another case of significant trauma…

beheaded2
Ah, the foreshadowed fate of a bewigged Duke of Sandringham!  / STARZ

This one, though, is rather self-explanatory and doesn’t require much in the way of medical commentary!

 

There was so much to enjoy in this episode – the development of Mary’s character, the reappearance of Hugh Munro, fun medical snapshots, humorous lines so reminiscent of the books, and Murtagh’s delivery of vengeance to the feet of Mary and Claire.  I’ve read that Ms Gabaldon will not be writing a script for season 3 because it would take too much time away from writing book 9. This episode was truly a joy and hopefully we’ll see more scripts from her someday!

Will the release of book 9 coincide with the premier of season 3?  2017 is promising to be a pretty epic year for Outlander fans!

 

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