The Outlandish Companion

by Diana Gabaldon

  I would also note that a _single_ (massive) PE causes death by sudden occlusion of major pulmonary arterial supply, resulting in the dramatic onset of anoxia. A strong victim fights violently for a few moments, flailing and gasping desperately for air, before succumbing, a weak patient merely ceases to live. (The problem with pulmonary embolic phenomena is that, however well the patient can move air, it just doesn’t do any good. The blood won’t be oxygenated because pulmonary circulation has ceased due to the blockage. No heroic measures of any kind can save the victim from massive PE.) A less sudden death from pulmonary embolic phenomena results when there is a more gradual showering of many micro-emboli into the lung-bed capillaries, causing a more gradual reduction in pulmonary circulation. So you might want to refer to pulmonary emboli instead of pulmonary embolus if this is to be the possible cause of a death that doesn’t occur suddenly.

  Is any of this helpful? I hope I’m expressing my ideas clearly here, and that they may be constructive for you. Ellen and others may have more useful suggestions.

  I’m sorry to hear about the migraine. One of my problems in recent months, too. Matter of fact, I had one yesterday—all day. It’s a terrible thing when a man feels so bad he can’t even whine!!!

  Sincerely, and with best regards, Alan Smithee

  Fm: Diana Gabaldon 76530,523

  To: Alan Smithee 110165,3374 (X)

  Dear Alan—

  Thank you! Re your comments, let’s see if I can disentangle enough to answer coherently.

  Okay. Rosamund is suffering from fever _before_ administration of penicillin (I’d figure anybody who’d had a major wound infection for three days would have some degree of fever, don’t you?). So we can probably assume that the septicemia is systemic, thus providing a stronger motive for trying the experimental penicillin. Likewise, we can safely assume that the fever is not caused by the injection. (Claire does write, “Patient presented with high fever…” right? Doesn’t this mean the patient had a high fever when first seen?)

  Rosamund does expire very quickly following the second injection—maybe ten to fifteen minutes? (given that Claire is trying various resuscitory [goodness, is that a word?] techniques, like cricothyrotomy). You (the reader) might not have much idea of the time frame from the original description—which is the result of Claire’s caution in writing down a detailed description. If that seems a necessary piece of information, it would be easy to add a line regarding the timing.

  If she’s writing this purely as her own case notes, it wouldn’t be necessary to record a lot of stuff—like the time between injection and expiration, or the failure of resuscitation—because she (Claire) would be unlikely either to forget those details, or to need them later.

  On the other hand, if she’s writing at least in part for the information of an unknown person who may have nothing to go on _save_ the case notes, she’d better put down every single thing she can, including things like a very detailed description of the anaphylaxis and the steps taken to combat it (ineffective though they might be); an illustrated account of how to perform a cricothyrotomy (with notes on the circumstances in which to employ this procedure); possible causes of complication (including pulmonary emboli, abscess-spilling, etc.), and so on.

  However, she hasn’t gotten to the point of deciding how much to put down; when the scene opens, she’s still in the process of writing. (One thing to consider from a purely novelistic point of view is how much detail will lend hat sense of reality to a reader, and how much is overkill . Consequently, I started with the minimum, and let other details—like Rosamund’s respiratory distress—emerge less directly, during the course of Claire’s introspection.)

  Yes, OK; she should administer the first injection before doing the mechanical intervention—a good point.

  Re the pigeon poultice; that’s done mostly for the psychological benefit of the patient—that’s what the patient is convinced will help. From the description, a thick layer of antibacterial dressing is applied to the wound (which is probably also bandaged—perhaps I should mention that step, too), and then the split pigeon bound over that. As described, the raw pigeon wouldn’t actually be in physical contact with the open wound, and while it might be cumbersome, probably_ wouldn’t_ do any actual harm.

  Many thanks—your comments are _very_ helpful!—Diana

  Fm: Alan Smithee 110165,3374

  To: Diana Gabaldon 76530,523

  Dear Diana,

  Yes, I understood that Rosamund presented with high fever. I just wanted to explain that, to me, this sign made it seem less likely that her death was due primarily to anaphylaxis, particularly because death ensued some time later after the second injection. This sequence would make me suspicious that the drug had been ineffective, rather than that it had elicited a fatal reaction in the patient. Normally, to set up anaphylactic reaction with a drug, the patient would have to be exposed to it a week or more before the dose which precipitates the reaction. I’ve been assuming that the patient has been sensitized to something besides the penicillin which is present in her environment _and_ in the drug (as an impurity). I believe this to be the most likely scenario for anaphylaxis, given the circumstances. What I’m trying to get at is that, if you wish to appear (medically) certain that the death is from anaphylactic shock, there has to be a sudden change in the patient’s condition as soon as the penicillin is introduced. As stated before, the best time to administer the drug would be before invasive treatment of the wound. Given the nature of severe anaphylactic shock, I doubt that Claire would have the opportunity to do anything but life support following onset of the reaction.

  With a longer time span, the idea that the penicillin engendered a fatal reaction in Rosamund becomes less supportable, I think, though not out of the question. That’s what I was getting at. If you want there to be a question of cause, the scene’s timing is good as is—with the exception that the first penicillin injection should have come before the wound care. I do think it’s important for her to explain her reasoning in her notes, to justify her unorthodox choices. I don’t know if it’s necessary to be explicit. There might be an artful way to allude to it without shoveling medical concepts by the bucketload at the reader.

  I think that the scene stands well as is, as long as you intend for there to be a question about cause of death. And the way you use the words really fixes the scene in my mind. I feel like I’m looking out through Claire’s eyes part of the time, and I can feel the warmth of the communion with her daughter on my skin.

  I’m having to fight my wife for OUT-LANDER. Shouldn’t have said anything about it until I had finished it. Ha!

  Have a good one! Alan

  Fm: Ellen Mandell 76764,2512

  To: Diana Gabaldon 76530,523

  Dear Diana,

  Made me cry. More later. Ellen

  Fm: Jo C. Harmon 103151,655

  To: Diana Gabaldon 76530,523

  Dear Diana,

  I’ve read your excerpt from THE FIERY CROSS. I’m an RN who worked in the area of internal medicine for a few years. For me, what interrupted the flow of the narrative were the following questions:

  Just how is Claire purifying and/or extracting the penicillin from rotted casaba rind?

  Where is she getting needles to administer the medication IV?

  (My guess is that you’ve addressed these issues earlier in the book.)

  With the patient’s manifestations of symptoms which could be indicative of hypersensitivity, why did Claire choose to administer the second dose of the drug… given that the state of the patient’s illness was, for that time, most assuredly fatal?

  Was she gambling that she could knock out the infection before hypersensitivity became life-threatening?

  I know she’s feeling guilty, but there are other possibilities as to why the patient developed these symptoms, aren’t there? Do these other possibilities cross her mind at some point?

  Hope this helps.

  Jo

  Fm:
Diana Gabaldon 76530,523

  To: Jo C. Harmon 103151,655

  Dear Jo—

  Thanks! Re your questions:

  1. Damned if I know. It ain’t going to be _very_ purified, which is of course one of the difficulties with do-it-yourself penicillin. However, all the trouble in getting hold of enough of the stuff, and how, and whether it’s effective—i.e., her experimental methods—is dealt with elsewhere. With luck, by the time I write that part, I’ll have figured out how (sort of) to do it. _Penicillium_ does _grow_ on rotted melon rind, though, since one of my sources cited a picture of same.

  2. Needles are no problem (unless I want them to be )—she had six of them at the end of VOYAGER, and no doubt at least a couple have survived thus far (getting more is going to be one of the later issues to be dealt with; eighteenth century technology would have been adequate; it’s just a matter of finding the proper craftsman ). Anyway, one of my earlier medical consultants informed me that to do a proper anaphylaxis, it would have to be an IV administration, because penicillin by mouth doesn’t do that.

  3. Given that the patient’s illness was most assuredly fatal anyway—what did she have to lose by trying the penicillin? The urticaria, etc., might _not_ have been symptomatic of hypersensitivity; my earlier consultant tells me they could as easily be symptoms of the septicemia. Or, even if the patient did have a hypersensitivity, there would be at least a chance that a further dose would be survivable—while the infection wasn’t.

  4. Yes, the other possibilities cross her mind—in this scene, in fact—pulmonary embolism, for one. However—not being a doctor, etc., myself, I’m guessing on this one—I _think_ that a doctor with a good deal of clinical experience (which Claire is, by this time) and a reputation as a diagnostician (which she has; established in earlier books) would have a very good gut feel for what was happening or had happened, even if he or she couldn’t foresee it. I.e., having seen this woman die in front of her, Claire is pretty sure that it was anaphylaxis, even though the dry recital of symptoms might fit other diagnostic scenarios.

  Sound plausible?—Diana

  Fm: Jo C. Harmon 103151,655

  To: Diana Gabaldon 76530,523

  Diana:

  << she had six of them at the end of VOYAGER, and no doubt at least a couple have survived thus far >>

  Oh. My memory fails me… I’d thought she’d lost all of them in the shipwreck. I don’t recall her using or mentioning them in DRUMS… did she? (Guess I’d better go back and read it one more time—shucks.)

  <>

  I certainly defer to those who likely have more knowledge and experience than I (and there are plenty); however, my mother had anaphylaxis after IM injection of penicillin. Fortunately, epinephrine was available and on hand. I suspect that the severeness of a reaction would also depend upon the degree of hypersensitivity. (But, I digress.)

  As a reader with some medical background, I’d expect if Claire’s patient developed anaphylaxis after IV push administration of penicillin, one of the most outstanding symptoms would be respiratory distress… in addition to the others that were mentioned.

  << Given that the patient’s illness was most assuredly fatal anyway—what did she have to lose by trying the penicillin? >> That’s what I suspected.

  <<—I _think_ that a doctor with a good deal of clinical experience (which Claire is, by this time) and a reputation as a diagnostician (which she has; established in earlier books) would have a very good gut feel for what was happening or had happened, even if he or she couldn’t foresee it. >>

  I agree. As in every part of life—that gut feel is usually truth.

  <>

  <>

  Yes, it does. I do feel, though, that the symptom of respiratory distress would be present… but, again, defer to those who have more knowledge than I. Jo

  Fm: Diana Gabaldon 76530,523

  To: Jo C. Harmon 103151,655

  Dear Jo—

  Well, I thought she’d lost them in the shipwreck, too, but small matters like that are easily adjustable . As long as I didn’t flat out _say_ she lost them somewhere, I can always explain them _ex post facto_, one way or the other (ah, what it is to be a godlike Author!).

  I’m sorry, I wasn’t precise. My informant said it would need to be _injectable_, not necessarily IV. Just my guess that if you had what looked like a systemic septicemia, you’d do IV push.

  Hm. You mean, you would expect respiratory distress following the _first_ administration of penicillin? Because Rosamund definitely had respiratory distress following the second.

  Do hypersensitive individuals normally show symptoms of allergy following a first exposure, though? I know very little about it, but had the impression that a first exposure might be symptomless, but—having had the effect of sensitizing the patient—the second exposure might have dramatic effects. Very easy to include respiratory distress following the first injection, if it should be there, of course.

  Thanks for the help!—Diana

  Fm: Jo C. Harmon 103151,655

  To: Diana Gabaldon 76530,523

  Dear Diana:

  << Do hypersensitive individuals normally show symptoms of allergy following a first exposure, though? I know very little about it, but had the impression that a first exposure might be symptomless, but—having had the effect of sensitizing the patient—the second exposure might have dramatic effects.>>

  I think you’re right about the probable lack of reaction to the first exposure, of course. Didn’t think that one through before my fingers flew across the keys!

  <>

  So true—don’t know about you, but I have to avoid mushrooms, cheese, and wines or else I get a whopping migraine. (Can’t eat too much chocolate, either.) Jo

  Fm: Arlene McCrea 73051,2517

  To: Diana Gabaldon 76530,523

  Diana,

  Thought your section PENICILLIN was terrific! Did, however, have something you might consider.

  Since the funeral repast was being laid out in the same room as the corpse, I wondered how soon after death did this occur? If the corpse had such a virulent infection, I would think that without embalming, the odor of death would be pervasive.

  I wanted to be certain about this before I wrote you, so I phoned my daughter Lisa (who has been a nurse for twenty years) and she agreed with me. Her comment was “You’d better put the corpse in the root cellar right away if you expect to eat in that room!” Even more so since she had the open wound! With the kind of a wound you described the odor would get bad very quickly!

  Lisa said in reading the passage she would notice that right away!

  Just trying to be helpful! Arlene

  Fm: Ellen Mandell 76764,2512

  To: Diana Gabaldon 76530,523

  Dear Diana,

  Let’s see, where should I begin? Penicillin, which is what Alex Fleming named the liquid secreted by his mold, isn’t toxic. Neither is the mold. Fleming showed this by injecting his mold—full strength—into mice and rabbits without harm. Although large doses of penicillin may cause nausea or diarrhea, you (Claire, rather ) won’t be able to kill your patient with an overdose.

  The big problem in penicillin production was getting a high enough yield of the liquid—I read somewhere that adding brewer’s yeast improved the yield—and the key step in purification was freeze-drying. Not much help, I’m afraid.

  Certainly exposure to the molds can be sensitizing. I had a positive scratch test to the _Penicillium spp._ mixture, because I’m sensitized to one or more of the molds in the mixture. But if I inhaled raw _Penicillium_, without first snorting some Nasalcrom, I expect that I’d get a runny nose at worst, and I eat Roquefort and other blue cheeses with allerg
enic impunity.

  Molds aren’t on the list of substances—mostly proteins—that cause anaphylaxis. And while penicillin most definitely is, the manifestation of human drug allergies depends on the route of administration as well as genetic predisposition and the extent of prior exposure. So while Claire’s patient could have an idiosyncratic reaction, I think the chance of allergic anaphylaxis is vanishingly small, unless the stuff was injected, and even then it’s hardly likely.

  In the big surveillance studies, the rate of anaphylactoid reactions to injected penicillins is less than 1 in 3,000, the vast majority being to semisynthetic penicillins, which are more allergenic than penicillin G. It’s estimated there are fewer than 100 annual fatalities attributable to penicillin injections in the U.S., and none to oral penicillins.