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.

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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.

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(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.

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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.
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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!

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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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Learn More:

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

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Lallybroch: The Dunbonnet

A Dram of Outlander Voyager Read-Along 

Outlander Science Club

Voyager Chapters 4-6: Lallybroch

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Listen to this week’s Voyager Read-Along with A Dram of Outlander here, including this week’s installment of Outlander Science Club (by yours truly)!

The Outlander Science Club topic for this week was inspired by Jamie’s time in the cave and the psychological and physical effects that may result.

The Dunbonnet – The Effects of Living For Seven Years in a Cave

Following the Battle of Culloden, Jamie’s life is spared thanks to Lord John Grey and his bother Hal. He is brought back to Lallybroch where he is nursed back to health by Jenny, and spends the next seven years of his life living in a cave where he cannot be found by the Red Coats.

Hunting at night to feed himself and to occasionally provide for the family, Jamie spends his days alone in the cave with only some books and his thoughts.  Only once a month, at night, does he creep down to Lallybroch to shave, share a meal, and spend time with Jenny, Ian and the children.

Certainly, this will impact his health, spending his life in darkness and isolated for the most part from any human interaction.  What are the likely effects?

In addition to the uncomfortable conditions he endures with the incessant exposure to the elements and fear of discovery by the Red Coats who would no doubt mean violent punishment for both himself and his family who harbored him, Jamie also faces the effects of darkness and isolation on his health.

Prolonged exposure to darkness results in depression.  Studies in rats have shown that after only six weeks of limited sunlight exposure, the neurons in the brain responsible for producing norepinephrine, dopamine and serotonin already are in the process of dying.  These substances are the same neurotransmitters that are found to be decreased in humans with depression.

Chronic isolation from the company of other people can lead to a number of negative health effects.  Chronically lonely people have elevated blood pressure.  They are more vulnerable to infection and have higher incidence of dementia and Alzheimer’s disease.

A significant problem with chronic sunlight deprivation is a lack of vitamin D. Vitamin D is a fat soluble vitamin that plays an important role promoting the absorption of calcium in the gastrointestinal system and maintaining normal calcium and phosphate levels in the body.  Bone growth and remodeling depends on vitamin D.  Without it, bones can become thin, brittle, or misshapen.  In addition, vitamin D plays a role in cell growth, neuromuscular and immune function, and reduction of inflammation.

This vital nutrient is naturally present in very few foods. Though not available, of course, in the 17th century, vitamin D enriched foods and dietary supplements help to meet this need now.

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Selected food sources of Vitamin D, from the National Institutes of Health Office of Dietary Supplements (public domain)

Foods naturally containing vitamin D include mushrooms, alfalfa, lichen, fish liver oils, fatty fish species, cooked egg yolk, and beef liver.  In the Highlands, in the lean years following Culloden, it was unlikely many would have had access to beef.  While we do know that Jamie hunted deer, it seems that venison liver is not the good source of vitamin D that beef liver is.  Eggs were likely a rare luxury on his monthly visits to Lallybroch, if at all.  Not located in close proximity to the coast, it is doubtful he would have had any regular access to fatty fish while living in the cave. Scavenging for mushrooms and lichen were likely available to him, though only when in season.  Jamie’s diet definitely would not have met all of his vitamin D needs.

While even a modern diet with vitamin D enriched foods does not meet the typical daily requirement of vitamin D, exposure to sunlight makes up the difference.  Exposure to UVB rays from sunlight is a significant source of vitamin D. Vitamin D is produced in the skin when UVB rays from sunlight strike bare skin.  Unfortunately, Jamie likely had very little exposure to the sun during his years as the Dunbonnet, only leaving the cave under the protection of night.  Even if he had a few minutes of direct sun exposure at midday regularly, this still wouldn’t have met his vitamin D need year round. At latitudes north of 40°, as is the Highland region, sunlight is not strong enough to trigger the synthesis of vitamin D in the skin from October to March. With his limited diet and limited sun exposure, Jamie no doubt suffered from vitamin D deficiency.

Interestingly, birds and fur-bearing mammals also require vitamin D but clearly cannot absorb it through their feathered and fur covered skin.  They have adapted such that vitamin D is generated from the oily secretions of their skin and then deposited onto the feathers and fur and obtained orally during grooming.

What effect would inadequate vitamin D have had for The Dunbonnet?

Vitamin D deficiency classically causes skeletal problems.  With severe deficiency, children can develop rickets, a disease in which bone fails to properly mineralize, causing softening of the bones and skeletal deformities.  In adults, vitamin D deficiency can lead to osteomalacia, in which inadequate mineralization of the bone leads to bone and joint pain, muscle weakness particularly in those used to stand up from a seated position or walk up the stairs, and easy fracturing of bones, even from simple weight bearing.

Vitamin D deficiency puts adults at risk for osteoporosis, a condition of decreased bone mass leading to bone fragility and significantly increased risk of fractures.  Adequate levels of vitamin D can reduce the risk of developing a number of cancers as well as multiple sclerosis and rheumatoid arthritis.

With seven years of low vitamin D levels due to inadequate diet and rare exposure to sunlight, Jamie likely suffered from some degree of thinning of the bones.

Even today with vitamin enriched foods and supplements, vitamin D deficiency is widespread.  In the US, 41% of people have insufficient vitamin D.  Rates in South America and Europe are no better.

Are you consuming the recommended about of vitamin D on a regular basis?

recommended intake of vitamin d
Recommended Dietary Allowance for Vitamin D, from the National Institutes of Health Office of Dietary Supplements (public domain)

Just as Claire insists that the Highlanders eat their greens to avoid scurvy, no doubt she wouldn’t hesitate to line them all up and dose each with a spoonful of cod liver oil to keep their vitamin D levels up!

Stay tuned for more about scurvy!

 

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Further Reading:

Chinese Woman who has lived two years in a cave not unlike Jamie’s

Vitamin D Information from the National Institutes of Health