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by Murder

  cause it to leak or break. In this circumstance death from absorption of the huge dose of cocaine, heroin, or other drug is typically quick and dramatic. Cocaine and methamphetamine cause seizures, cardiac arrhythmias, heart attacks, and death. Heroin causes a dramatic drop in blood pressure, suppression of respiration to the point of apnea (no breathing), and death.

  Can Opium Addiction Make Someone Violent?

  Q: I need help. One of my characters has found a hundred-year-old suicide letter. The writer says he has become addicted to opium, his personality has changed, he's become violent and nasty, and he intends to kill himself to keep from burdening his family. My writers' group questioned whether opium would make someone violent. If someone did become addicted to a substance in the late 1800s and had a personality change for the worse, what drug would it have been if not opium?

  A: Opium, which is a gummy substance obtained from the opium poppy (Papaver somniferium), is a central nervous system depressant. It's the basis for morphine and heroin, and is a "downer." It causes lethargy and sleepiness, slow movements, depression, and in larger doses, coma and death. It is unlikely to stimulate violent or nasty behavior. That said, an opium addict who is undergoing withdrawal, either voluntary or forced, either jailed or unable to resup-ply himself, can become angry, aggressive, and even homicidal. So, yes, opium can indirectly cause the effects you want.

  One other thought: In your scenario it is the letter writer who states that his own behavior has changed. Is that real or imagined? Is there corroboration of this statement from a more reliable source? He's an addict, so his assessment may not be accurate. Maybe he is having violent dreams or hallucinations that he

  believes are true when in fact he is as gentle as a lamb—and depressed and suicidal. Opium can easily cause these types of delusions.

  Another drug choice might be cocaine, which was available during the nineteenth century. Users often become aggressive, short-tempered, and violent. Chronic use can cause paranoia, which can feed the underlying aggressive behavior. This is probably a better choice if it fits your story.

  Of course, he could have been addicted to both drugs. For a brief period of time during the nineteenth century, Sigmund Freud and others advocated cocaine as a treatment for opium addiction. Its stimulatory effects were seen as beneficial. After it became apparent that those treated in this manner became addicted to the cocaine, this treatment modality fell from favor. Perhaps the suicide letter or others found with it could mention that he had sought treatment for his addiction but was now despondent that the cure became its own curse.

  Another possibility is alcohol, which is common and easily available. Alcoholics often become aggressive, nasty, and even homicidal. And suicidal.

  Suicide is common among opium, cocaine, and alcohol abusers, as are accidental deaths from taking too much or combining drugs such as an opiate and alcohol. An interesting twist might be that the letter finder later acquires other evidence that indicate the suicide was perhaps not a serious attempt by the writer to take his own life but rather a gesture or cry for help that went too far. All too often addicts don't know how to ask for help, especially a hundred years ago, and believe that a suicide attempt will get them the attention they need.

  Is Ritalin Useful in the Treatment of Attention Deficit Disorder; and How Can It Be Abused?

  Q: My character's twelve-year-old son is put on Ritalin for attention deficit disorder. What would be the usual dose? How effective is it likely to be, and are there any side effects? Also, I read that this drug is commonly abused. How? By whom?

  A: Attention deficit disorder (ADD) is not uncommon. It goes by several other names, such as hyperactive or hyperkinetic child syndrome and minimal brain dysfunction syndrome. The characteristic symptoms of this disorder are short attention span, distractibility, emotional lability, impulsive actions, and hyperactivity. Learning may or may not be impaired. The diagnosis of ADD is not straightforward and depends more on the presence of several of these symptoms rather than the results of any specific test. Neurologic exams, such as electroencephalograms (EEGs), MRIs, and CT brain scans, are most often normal.

  Ritalin (methylphenidate hydrochloride) is effective for many sufferers of ADD. It is given orally twice per day, typically before breakfast and lunch. The typically recommended starting dose is 5 milligrams (mg) twice a day, which is increased by 5 to 10 mg every week until the desired effect is attained. The maximum dose should not exceed 60 mg per day. Ritalin comes in small round tablets of 5 mg (yellow), 10 mg (pale green), and 20 mg (pale yellow). There is also Ritalin SR (white), a 20-milligram sustained release tablet that is taken only once a day in the morning.

  Ritalin may lessen or eliminate the symptoms of ADD. Alternatively, one of its many side effects may occur; these include rashes, loss of appetite, nausea, headache, drowsiness, an increase or decrease in blood pressure and pulse rate, palpitations, and even a toxic psychosis, in which delusions and hallucinations may occur.

  Yes, Ritalin is a newcomer to the drug abuse crowd. It is ground and snorted and tends to give a rush similar to cocaine or metham-phetamine. Many primary schools have policies, stating that any medications taken by students during school hours must be given by the school nurse. The school bullies know this and watch to see which kids visit the nurse each morning to get their daily medications. Then they force the kids to hand them over and use the pills themselves or sell them to someone—kind of like a primary school Mafia.

  It is also found in high schools and on college campuses. An unscrupulous doctor or pharmacist can often be found who will prescribe or dispense the drug. In addition, Ritalin is an overpre-scribed medication (meaning it is given to patients who don't really need it, much as Valium was in the past), and thus there is a lot of it out there on the streets. A ready supply and a growing demand means escalating abuse.

  What Is Seasickness?

  Q: My novel is set in Victorian Boston. One of my characters, a middle-aged woman, must sail to England. She has severe seasickness every time she gets on a boat. What treatment might her physician suggest to get her through the trip?

  A: There were many treatments for seasickness at that time, but none of them worked very well. One reason was that little was known of the physiology of this disorder. One popular theory postulated that it was caused by disturbances in the circulation of blood to the brain, which caused it to become anemic and thus produced nausea, vomiting, and dizziness, the major symptoms of motion sickness.

  We now know that seasickness, motion sickness, and space sickness (due to weightlessness) are caused by scrambled signals received by the vestibular system (balance center) of the inner ear. As part of this elaborate system, the semicircular canals are the primary sensors of position and motion. They consist of three canals, each in a 90-degree plane to the other two, similar to the XYZ planes of solid geometry. One loops front and back, one right and left, and the last up and down. The canals are filled with fluid, and the action of gravity on this fluid lets the brain know if it is right side up, upside down, moving in a circle, and so forth.

  In a weightless environment these signals are lost because there is no gravity and therefore the fluid is weightless, and no signals are sent. Yet the brain needs these signals for orientation. Without them, vertigo and the other symptoms of motion sickness occur. In moving cars and ships, the fluids slosh around so that the brain receives chaotic and confusing signals, resulting in the same symptoms.

  In a report in the March 16, 1901, issue of the Journal of the American Medical Association, Dr. Daniel R. Brower offered the following treatment plan: Before the trip one should "avoid excessive fatigue and mental worry," eat lightly, and produce a "free catharsis by means of a full dose of massa hydrargyri, followed at the proper time by a saline purgative." (What he meant by "full dose" and "proper time" was not explained.)

  Once this cleansing of the bowels had been accomplished, he suggested adding one teaspoon each of "Potassii Bromidi" (potassium bromide
) and "Aq. Menthae Piperitae" (mint or peppermint oil) to water and drinking it three times a day until boarding the ship. Once on board, one should then take 10 to 15 grains (1 grain equals approximately 65 milligrams) of "Chloralamid," lie down, and remain horizontal until the ship was at sea and the effects of the medication had worn off. (He did not comment on what these effects might be.) Then one should "move around on deck to ascertain whether he has obtained his 'sea legs.' " If the seasickness returns, the Chloralamid should be repeated. His last and probably best advice was to "remain on deck as much as possible."

  This may be a case of the cure being worse than the disease.

  Fortunately for your lady, seasickness tends to resolve over a few days. Of course, "land sickness" can occur with the cessation of the sloshing of the fluids in the canals when the victim steps onto shore. Just when the canals become accustomed to the erratic signals, things return to normal, and once again the system is thrown off. Go figure.

  DISEASES AND THEIR TREATMENT

  How Do Heart Disease and Angina Limit My Hero's Activities?

  Q: My protagonist is a sixty-seven-year-old man who has heart disease. He has frequent minor heart attacks for which he uses nitroglycerin. He suffers one of his attacks when another man dies at his dinner party. He takes a pill and goes to bed. In the morning I have him resuming his regular activities. Is that feasible?

  A: The mistake you're making in terminology is extremely common. Don't feel bad: I see it all the time. Books, newspapers, patients, and TV reporters make the same mistake.

  The coronary arteries course over the surface of the heart and supply blood to the heart muscle. A heart attack (myocardial infarction, or MI) occurs when a portion of the heart muscle dies due to complete blockage of one of these arteries (Figure 8). This is a potentially lethal and emergent situation, and requires immediate hospitalization and treatment. Some MIs are silent, meaning there is no pain, while others are associated with mild and brief pain as you describe. However, most often the pain is severe and lasts for hours unless treatment is given. Yes, some people have heart attacks and go on about their business, but this is not the norm.

  What you are describing is angina pectoris, "angina" for short. This is pain coming from the heart muscle due to poor blood supply because of a partially blocked coronary artery (Figure 8). Angina does not lead to damage or death of the heart muscle itself.

  As you noted, the pill taken for this is nitroglycerin (nitro for short). It is placed under the tongue (not swallowed), dissolves quickly, and is absorbed directly into the bloodstream through the lining of the mouth. Nitro dilates (opens up) the coronary arteries, which increases the supply of blood and oxygen to the heart muscle and lowers the blood pressure (BP). This, in turn, lessens the work that the heart must do to move the blood around the body. The workload that the heart must carry is directly related to the blood pressure. The higher the BP, the more work—like weight lifting. Nitro increases supply and lessens demand, thus relieving the angina pain.

  Angina pain is typically a pressure-like heaviness in the middle of the chest, possibly with the spread of the discomfort into the left arm or jaw Other associated symptoms might include shortness of breath, sweatiness, a cold and clammy feeling, nausea, weakness, and mild dizziness. Anyone who sees your protagonist would know something is wrong. He would likely appear scared, sweaty, and perhaps pale.

  An episode of angina typically lasts one to five minutes if untreated. Nitro will resolve it in one or two minutes. After a bout of angina the person may feel tired or fatigued, but in a matter of five to ten minutes he would likely feel okay and be able to go ahead with normal activities.

  Obviously, people with angina are at risk for a true MI since any one of the pain episodes can evolve into a full-blown MI. The nitroglycerin would lessen this probability if taken immediately. That is why we tell patients with angina to keep their nitro with them at all times—not in the glove box or a desk drawer or the medicine cabinet but in their pocket or purse so that it is available at a moment's notice.

  A diagnosis of coronary artery disease with angina would fit your character's situation well. Throughout your story you could add a note of menace by having him suffer angina attacks whenever he is in a physically or emotionally stressful situation. An uphill walk, an argument, a fight, an emotional reunion or separation, or, as you suggested, the death of a friend or loved one could trigger an attack. Maybe he could have an angina episode and not have his nitroglycerin in his pocket and have to ride it out. This is a situation that would produce great fear. He might later feel foolish for not having his medication with him.

  How Would an Allergy to Bee Stings Affect My Character's Lifestyle?

  Q: I have a character with a potentially lethal allergy to bees. How would she live her life? Would she have a Medic-Alert bracelet or an antidote in the fridge? Would bees be attracted to her any more than they would be to a non-allergic person? Would she wear an insect repellent?

  A: Bee stings can result in several reactions. In a nonallergic person the sting site would burn and swell, but the reaction remains localized and fades in a couple of days. In allergic persons more severe and painful swelling of the area, which could involve the entire leg or arm, is likely to occur. It would swell like a sausage and be fiery red, painful, and itchy. A worse allergic reaction would involve breathing problems that result from spasm (narrowing) of the bronchial tubes—like a severe asthmatic attack. The victim could die from this without prompt treatment. The worst reaction is full-blown anaphylaxis. Here the swelling and bronchospasm are joined by cardiovascular collapse, which means the blood pressure drops into the basement. Shock and death follow quickly.

  Bee sting kits are available. These contain a small syringe of injectable epinephrine (adrenaline), which reverses the allergic effects quickly. The person would then go to an ER for more definitive treatment that would include more epinephrine, if needed, along with an antihistamine (such as Benadryl) and steroids.

  The kits can be kept in a purse or pocket. When needed, they are needed "right now," so it's best for allergic people to keep a kit with them at all times, just as heart patients should keep nitroglycerin with them at all times.

  The person would live a normal life but would be wise to avoid bees. A walk in the park would require extra vigilance but could be

  done without much danger. Insect repellent would be useful. It is believed that some perfumes, soaps, deodorants, and other good-smelling products may attract bees, but this is controversial.

  I know of no evidence that allergic persons are more likely to attract bees. Clothing color seems to be an issue, but it's not straightforward. Many people believe that bright colors—reds and yellows—might attract bees, but I recently read of one study that showed black and other dark clothing attracted them, too. Go figure.

  What Types of Malaria Exist?

  Q: My story is set in Louisiana in the late 1800s and the protagonist suffers from malaria. I understand there are different types of malaria and picture my character having the variety that never completely goes away but causes slow degeneration (anemia? gradual weakening? eventual death?). What type would that be? Also, do the chills always precede the fever? If the protagonist is given watered-down quinine, would the medicine suppress the symptoms, and would he then have milder chills and fever? I've also heard of a fever remedy called boneset. Would that be effective against malaria?

  A: Malaria was and is one of the world's leading killers. Currently, at least 300 million people become infected each year, and as many as three thousand die each day. Though it is now rare in the United States, it was not uncommon in the swampy areas of Louisiana in the nineteenth century.

  Malaria is what we call a protozoan disease. Protozoa are tiny single-celled organisms at the very lowest level of the animal kingdom. Protozoa of the Plasmodium family cause malaria. There are four types: Plasmodium vivax, or P. vivax; P. falciparum; P. malariae; and P. ovale. The most common type in the sout
heast United States

  and South America is P vivax. P. falciparum is the most deadly and even with treatment has a mortality rate of 20 percent. For your scenario, P. vivax is the best choice.

  The life cycle and the infection cycle of malaria are very complex and vary from species to species. I'll focus on what happens in the case of P. vivax and try to simplify it.

  Malaria and many other diseases are transmitted to humans via a "vector," or carrier. In the case of malaria the vector is the anopheles mosquito. The mosquito itself becomes infected when it bites an infected person. The malarial organisms enter the mosquito with the blood it extracts. They then reproduce and concentrate in the mosquito's saliva. When the mosquito bites someone else, the organisms are injected into the person's bloodstream. From here two developmental cycles occur.

  The first is the hepatic (liver) cycle, and the second is the erythrocytic (red blood cell, or RBC) cycle. In the hepatic cycle the malarial organisms injected into the bloodstream make their way to the liver and set up housekeeping in the liver cells, where they reproduce. This is the incubation period, and the victim usually has no symptoms. This typically last for about eight days, but the organisms may remain dormant in the liver cells for months or years. Sooner or later they reproduce, rupture the liver cells, and reenter the bloodstream. Symptoms begin at this stage.

  The organisms then enter the RBCs and the erythrocytic cycle begins. They reproduce in the red blood cells and eventually rupture them, return to the bloodstream, infect more RBCs, and this cycle continues. In P vivax this erythrocytic cycle occurs every forty-eight hours, although early in the infection this may be erratic. Eventually, they all seem to get on the same schedule.

  Interestingly, the presence of sickle-cell anemia tends to protect those individuals from malarial infection. It may be that the parasite can't reproduce properly in sickled cells. Since malaria is common in many areas of Africa, it is possible that people of African extraction, where most sickle-cell anemia is found, developed this mutation as a survival benefit.