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.

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.

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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.
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!

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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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107: Gueule de bois (The Hangover)

The end of The Garrison Commander left us with Claire drinking large amounts of whisky and coming to terms with the fact she would tomorrow be marrying a Scot.

wedding contract
source: Starz

One James Alexander Malcolm MacKenzie Fraser, to be exact.

One of my few criticisms of the TV adaptation of the Outlander story was Claire telling Jamie on their wedding day that she couldn’t marry him because she didn’t even know his name. As we just saw above, at the end of The Garrison Commander, Claire is reading the marriage contract which we can see lists Jamie’s full name. However, let us assume perhaps she forgot because of all the whisky.

claire takes the bottle from dougal
source:  Starz

And how about all that whisky?

The next morning, Murtagh wakes a very hungover Claire.  It is time to dress for the wedding in the absolutely breathtaking gown which Ned Gowan has obtained (and hopefully he hasn’t obtained any other lasting gifts from his new friends that night – more on that in a future post!)

hangover claire
source:  Starz

The symptoms of hangover are universally known but scientists are still working to determine what exactly causes it. Some theories include:

1. The effect of the byproducts of ethanol as the body digests it.
After ingestion, ethanol is converted to acetaldehyde by the enzyme alcohol dehydrogenase. It is then converted to acetic acid. Acetaldehyde is more toxic than alcohol itself and remains at elevated levels for many hours after ethanol is ingested.

2. The effect of other substances in the beverage, known as congeners
Many alcohol drinks also contain other substances, either as flavoring or as a byproduct of the fermentation or aging process. These can include amines, amides, acetones, polyphenols, methanol, histamines, esters and tannins, many of which are toxic.

Different types of alcoholic beverages have differing amounts of congeners and in general, the darker the liquor, the higher the concentration. The amount found in bourbon is 37 times higher than that found in vodka.  This doesn’t bode well for our whisky drinking Scots!

3. Dehydration
Ethanol increases urine production (diuresis) and dehydration may be responsible for some of the symptoms of a hangover – thirst, dizziness and lightheadedness. Initially thought to be contributory, studies show that electrolyte changes are minimal after drinking, though.

4. Stomach acid
Nausea and vomiting may be due to the effect alcohol has on the stomach by stimulating the production of hydrochloric acid and delaying stomach emptying.

5. Low blood sugar
Alcohol can cause blood sugar to fall, causing fatigue, weakness and shakiness

6. Effect on blood vessels
Alcohol causes blood vessels to expand, leading to headaches

7. Immune response
Alcohol can cause an inflammatory response, causing the concentration of several cytokines (immune system communication signals) to be significantly increased. In fact, researchers have found if healthy subjects are injected with cytokines, the persons will have the symptoms of hangover such as nausea, headache, chills and fatigue!

8. Genetics
Some ethnic groups have a mutation in the alcohol dehydrogenase gene making the conversion from ethanol to acetaldehyde very fast. Others convert acetaldehyde to acetic acid more slowly and see a larger buildup of the more toxic acetaldehyde than other groups. Accumulation of acetaldehyde causes an alcohol flush reaction – redness to the face, neck and shoulders, or even the entire body, nausea and tachycardia (rapid heart rate).

Remember Henri de Toulouse-Lautrec from our discussion of Colum’s deformed legs?  He was an artist in France at the end of the 19th century who suffered from the condition and for whom it was named.  Below is one of his works depicting a hangover.

lautrec painting hangover
“Gueule de bois” (The Hangover), 1888 by Henri de Toulouse-Lautrec (1846-1901) / (source)

What to do?
1. Hydrate!  
2. Anti-inflammatories! If the mechanism of hangover is an inflammatory response, then anti-inflammatory medications may be the key. In fact, we already saw Claire thinking ahead and stockpiling willow bark for hangovers in preparation for The Gathering!
3. Eat! Get that blood sugar up and eat some carbs. Hopefully Murtagh has brought something for Claire when he came to wake her.
4. Caffeine! If the headache in a hangover is due to dilated blood vessels, then caffeine may counteract this with its action to constrict the blood vessels in the brain.

And if you are in modern day Scotland, packing fluids, caffeine and carbs in the form of  Irn-Bru is the thing to try!
irnbru

An older Scottish cure was the “Highland Fling” –  mix a tablespoon of cornflower into a pint of buttermilk.  Add salt and pepper and drink!

Cornflower has anti-inflammatory properties, so between that, the hydration and fats/carbs it provides, this remedy may be helpful!

cornflower
Cornflower / (source)

Throughout the course of the wedding night, Claire drank no less than eight glasses of whisky by my count.

what claire did all day
source:  Starz

Perhaps someone will be nice enough to prepare a Highland Fling for her!

 

Resources:

Top 10 Hangover Cures from around the World

Hangovers, Why?

A Few Too Many – is there any hope the hungover?

 

 

102: Herbs, Mushrooms and Leeches

Episode 102:  Castle Leoch

leoch
source:  Starz

Claire and the Highlanders arrive at Castle Leoch to a warm welcome.

Does anyone else see a bit of Mrs. Patmore in Mrs. FitzGibbons?

happy fitz
source:  Starz
patmore smile
source:  PBS

After giving Claire the once over, Mrs. Fitz guides Claire inside and allows her to tend to Jamie’s wound.  In addition to the shoulder dislocation, Jamie has suffered a gunshot wound to the shoulder which Claire tells Mrs. Fitz has not been cleaned or dressed properly.

 

Mrs. Fitz brings supplies to Claire including rags, garlic and witch hazel with which to boil the rags, and comfrey and cherry bark as what seems to be a compress for the wound.

Garlic has anti-inflammatory properties, as well as antibiotic, anti fungal and antiviral properties, which make it a good choice for the treatment of a wound.  Witch hazel is used as a remedy for skin sores, bruising and swelling.  Comfrey contains allantoin which is a substance thought to aid in wound repair and possess anti-inflammatory activity.  Cherry bark as well is used to soothe rashes and skin ailments.  Mrs Fitz is a wise woman and healer in her own right!

Claire examines Jamie’s wound and begins to clean it.

cleaning wounds
source:  Starz

Claire dresses the wound and puts Jamie’s injured arm in a swathe, wrapping fabric around Jamie to hold his arm against his body to immobilize it.

swathe
source:  Starz

 

A very travel weary Claire (travel weary may be an understatement after where she has been!), Mrs. Fitz dresses Claire.  It is time to meet The MacKenzie.

Claire is brought to Colum’s chamber where she meets him for the first time. She sees the deformity of his legs and identifies that he likely suffers from Toulouse-Lautrec Syndrome.  Despite years of medical school, residency and medical practice, I had some learning to do myself regarding this disease!  It is impressive that Claire is able to retrieve from her mind the name and characteristics of the disease.  My guess is she must have had a reason to remember it, perhaps from caring for a patient with it during her years as a nurse.

centered colum legs back
source:  Starz

Toulouse-Lautrec Syndrome is a disease which causes abnormality in the process of breaking down and rebuilding bones.  Throughout our lives, bones are continuously undergoing remodeling, with osteoblast cells forming new bone and osteoclast cells breaking down bones in a process to maintain bone mass.  In adults, approximately 10% of bone mass is replaced each year.

Also called Pycnodysostosis (sometimes spelled Pyknodysostosis), this disease is caused by an abnormal gene responsible for an enzyme called cathepsin K. Cathepsin K is important in the cells of normal bone that are responsible for bone reabsorption.  Without the normal function of this enzyme, bones do not undergo their normal process of bone reabsorption and they become dense and brittle.  This leads to fragile bones and frequent fractures with poor healing, as well as other hallmark findings such as large skull, short stubby fingers, dental abnormalities, small chin, hooked nose and an open fontanelle (or soft spot as we are familiar with in infants) in the skull.

The disease is named for one of the most famous patients to suffer of it, artist Henri de Toulouse-Lautrec.

Photolautrec
source

 

Shortly thereafter, Claire meets Geillis Duncan, who seems to share Claire’s love of botany and medicinal plants.

“Those kind are poison,” Geillis notes of the mushrooms Claire is examining.

poison mushroom
source:  Starz

As I am not a mycologist, I haven’t positively identified the mushroom which Claire is holding in this shot.  And in fact, she is not holding a mushroom of the same variety  described in the book, this one being whitish in color and the book referring to the bright red Ascaria variety.

It was on one of the fruit-picking expeditions to the orchard that I first met Geillis Duncan. Finding a small patch of Ascaria beneath the roots of an alder, I was hunting for more. The scarlet caps grew in tiny clumps, only four or five mushrooms in a group, but there were several clumps scattered through the long grass in this part of the orchard.
[…]
“Those kind are poison,” said a voice from behind me.  I straightened up from the patch of Ascaria I had been bending over, thumping my head smartly on a branch of the pine they were growing under.
As my vision cleared, I could see that the peals of laughter were coming from a tall young woman, perhaps a few years older than myself, fair of hair and skin, with the loveliest green eyes I had ever seen.
“I am sorry to be laughing at you,” she said, dimpling as she stepped down into the hollow where I stood. “I could not help it.”
“I imagine I looked funny,” I said rather ungraciously, rubbing the sore spot on top of my head. “And thank you for the warning, but I know the mushrooms are poisonous.”
“Ooh, you know? And who is it you’re planning to do away with, then? Your husband, perhaps?  Tell me if it works, and I’ll try it on mine.” Her smile was infectious, and I found myself smiling back.
I explained that though the raw mushroom caps were indeed poisonous, you could prepare a powdered preparation from the dried fungi that was very efficacious in stopping bleeding when applied topically. Or so Mrs. Fitz said;  I was more inclined to trust her than Davie Beaton’s Physician’s Guide.

From Outlander by Diana Gabaldon, Chapter 9

I’m unable to identify the Ascaria mushroom in my research and I wonder if it was indeed the Amarita muscaria mushroom which is a poisonous mushroom of bright red color.

Fly_Agaric_mushroom_05
source

The A. muscaria mushroom contains the toxins muscimol and ibotenic acid.  Both compounds mimic neurotransmitters in the brain, and ingestion of them causes nausea, low blood pressure, sweating, auditory and visual hallucinations, mood changes and loss of equilibrium.  Severe poisonings can cause coma and seizures.

There is no antidote for A. muscaria poisoning.  These patents are treated with supportive care, meaning supporting the function of the body until the effects have worn off.  Today, this may include activated charcoal and gastric lavage (“pumping the stomach”) to prevent absorption of the toxins, if presenting for emergency care early in the course of illness. Benzodiazepines like Ativan or Valium may be given for agitation or seizures.  Intravenous fluids and electrolyte replacement are generally needed.  With good supportive care, the outcome is often good.

 

The end of this episode once again finds Claire tending to a wounded Jamie. This poor man.  After taking the beating in the hall for Laoghaire, Jamie has sustained lacerations and contusions to his face.

tending jamies face
source:  Starz

Again, Mrs. Fitz has arrived with useful medicines for our injured Jamie.  Willow bark tea would be the 18th century version of aspirin.  Willow bark tea contains salicin which is a chemical very similar to acetylsalicylic acid, the active ingredient in aspirin. These wise Highlanders recognized the ability of salicilates to reduce inflammation and relieve pain.

Those who have seen the deleted scenes from episode 102 on the Season 1 DVD may remember an extended scene in which Mrs. Fitz applies leaches to Jamie’s swollen face.

She examines his eye and says, “Still bleedin’ under the skin. Leeches will help. Too many folk misuses leeches. Very helpful sometimes but you must understand how. When you use them on an old bruise, they just take healthy blood and it does the bruise no good.” She allows the leeches to remain on Jamie’s face for a bit and upon removing them, the swelling is markedly improved.

 

leeches
© Can Stock Photo Inc. / szefei

While modern medicine has moved past blood letting as a method of balancing the humours, leeches are indeed still used in healthcare!  Hirudotherapy, or the application of leeches, is used in reconstructive plastic surgery to aid in situations of venous congestion postoperatively to clear excess blood until normal blood flow is restored in the venous capillaries of the surgical site, generally over 2-6 days.  It would seem that Mrs. Fitz’s use of the leeches here to clear the excess blood in the contusions on Jamie’s face would be a very reasonable approach and will allow him, as she says, to see out of that eye tomorrow, rather than have it swollen shut!  I’m foreseeing potential applications for this technique on victims of bar room brawls that end up in the ER!

 

The episode closes with Colum informing Claire that she will not be transported back to Inverness but instead will remain at Castle Leoch.  The previous healer in residence has died and Leoch is in need of a healer.  Or so he says.  Claire finds herself more or less a prisoner now of the MacKenzie. A prisoner in the surgery. A victim of her own success?

prisoner in sugery
source:  Starz

 

Resources:
http://www.doctorsreview.com/history/picture-imperfect/
http://www.medicinenet.com/pycnodysostosis/article.htmAdams C. Herbal Medicine: 100 Key Herbs with All Their Uses as Herbal Remedies for Health and Healing, 2014.
Fauci, AS, Braunwald E, Isselbacher KJ, Wilson JD, Martin JB, Kasper DL, Hauser SL, Longo DL. (Eds.). (1998). Harrison’s Principles of Internal Medicine (14th ed.). New York, NY: McGraw-Hill.
Mumcuoglu KY. (2014). Recommendations for the use of leeches in reconstructive plastic surgery. Evidence-Based Complementary and Alternative Medicine. Volume 2014.
Porshinsky BS, Saha S, Grossman MD, Beery PR, Stawicki SP. (2011). Clinical uses of the medicinal leech: a practical review. J Postgrad Med. 57, 65-71.
Xue Y, Cai T, Wang W, Zhang Y, Mao T, Duan X. (2011). Clinical and animal research findings in pycnodysostosis and gene mutations of cathepsin K from 1996 to 2001. Orphanet Rare Dis. 6, 20.
Zaftig P, Hunziker E, Wehmeyer O, Jones S, Boyde A, Rommerskirch W, Mortiz JD, Schu P, Von Figura K. (1998). Impaired osteoclastic bone resorption leads to osteopetrosis in cathepsin-K deficient mice. Proc. Natl. Acad Sci. USA. 95, 13453-13458.