One of the greatest limitations on population growth in the 1630s (both OTL and NTL), and in the Third World today, is the number of children who die before their tenth birthday. The emotional and physical toll on the parents (especially the mothers) was literally incalculable, and was part of the reason used to “justify” treating women as the “weaker sex.”
A surprising number of these deaths are preventable with up-time technology that is easily adapted to down-time situations. This includes improved food and water sanitation; improved food sources and nutrition; appropriate waste disposal; and appropriate immunizations, which may be active (relatively easy), or passive (which requires a bit higher technology). Some of the diseases, including smallpox and polio, have no known reservoirs outside of man, and might be eventually eliminated in the NTL.
Additionally, the down-time authorities have experience in limitations of travel, the use of isolation wards (lazarettes) and traveler quarantines as a method of reducing the spread of disease. Information on the germ theory, Koch’s postulates and up-time hygiene will put these methods on a rational basis, and improve the effectiveness of the techniques. This improvement alone will limit the spread of many of the pestilences “scheduled” to appear between 1634 and 1700. This is the main reason why Mike Stearns, James Nichols, Beulah McDonald and Mary Pat Flanagan are determined to spread this information as widely as possible.
In April 1634, Anna Krause did a report on childhood diseases in the area around Grantville. She received a blue ribbon for her efforts, and was pushed toward a career in nursing/medicine by Hennie DeVries, RN. Fraulein Krause is the first known down-timer to study what we know now as Epidemiology.
Rashes with Fevers
Down-time physicians would not have been able to differentiate many of these diseases before the arrival of up-time information. The “Six Diseases” were finally separated in the late 1800s, and named as such in the early 1900s. All of them start with fevers and muscle aches, loss of appetite, nausea, and sometimes diarrhea. Often sore throats and headaches are common with all of these infections.
Scarlet Fever/Scarletina, known as the Second Disease, as it was the second rash described as a separate entity. Normally associated with a high fever (103 F is common, and 105 F is not unusual), and a bright red rash that may be patchy, all over the body or just confined to the tongue (the so called “Strawberry Tongue”). The rash on the body is peculiar, in that it feels as rough as sand paper. This is the only rash in this group that is not caused by a virus, but by toxins produced by Streptococcal throat infections. The tonsils at the back of the throat are usually swollen and covered with pus. Lymph nodes in the neck, usually along the front side, are swollen and tender. Without antibiotic treatment, these throat infections will eventually lead to many problems with the heart, kidneys, ears or lungs.
Viral Flat Rashes
The Arab Physician/Philosopher Abu Bakr Muhammad ibn Zakariyā Rāzī (Zakariā-ye Rāzi: Persian: زكريای رازی), better known in Europe by his Latinized name, Rhazes, first described measles (First Disease) as compared to smallpox in the 9th Century (CE). Despite this, there was enough overlap between measles and other viral rashes to prevent clear delineation for another 900 years. The “three C’s” (cough, coryza (runny nose and sore throat) and conjunctivitis) are some of the initial symptoms, but these are also common to influenza. Koplick’s spots, blue white dots on red rings inside the mouth are present from about 24 hours before the rash starts to 48 hours afterwards, and are diagnostic for the measles. Two to four days after the onset of the fever, a flat red rash spreads from hairline down the body, turning from red to brown over the course of several days, and resolves in the same head-to-toe pattern, commonly with dandruff-like flaking of the skin as the rash resolves. The rash is typically most prominent along the shoulders, back of the neck and upper arms, but the rest of the body, including the palms and soles, may be involved. The dandruff-like flaking skin will not extend to the palms and soles.
The virus can be transmitted from person to person starting with the first appearance of the “three C’s” (up to 5 days before the rash is noticeable) and extending for around five days after the rash appears. As the disease is highly infectious, upwards of 90% of non-immune people will catch the infection from even brief contact with an active case. Major complications of measles infections include ulcers of the delicate membranes of the eye, which can lead to scarring and blindness, and weakening the body’s immune system for some time after the infection, making a secondary, bacterial, infection more likely. These infections often include severe ear infections that may lead to deafness and pneumonia, which can be fatal. Other problems which can occur include an aseptic meningitis (a cause of seizures), viral pneumonitis (which again sets the stage for pneumonia) and even an inflammation of the liver. A significant diarrhea may also occur. Malnourished children, especially those suffering from Vitamin A deficiency, are ten times as likely to die from the infection.
Care is almost completely supportive, even in OTL. There are some antiviral agents which help shorten the period of illness, but they are rarely used. Fever control, oral hydration, and relief of the itching as the rash starts to resolve will be the main treatment for simple cases. Cases that are more complex will require intravenous fluids for severe dehydration, possibly antibiotic treatment for the secondary infections, or medications to control seizures associated with the high fever or from the inflammation of the tissues surrounding the brain (meningitis). Based on Iver Cooper’s chemical time lines, I believe that the drug paraldehyde will be the first available medication to control acute seizures some time in 1633 or early 1634, as it is a cyclic form of formaldehyde. Barbiturates are more complex, having a substituted ring structure (2 nitrogen and four carbon atoms, but they will most likely be the second group of drugs in this classification, as they were in OTL, as they are much simpler than the other drugs. Vitamin A supplementation alone has been shown to reduce the risk of death by 50% even in the face of significant protein calorie malnutrition or young age. High dose carrot juice will probably be among the safest ways to deliver the vitamin in the 1630s, as the vitamin itself is potentially toxic.
Prevention will be a matter of case tracking and isolation of contacts, until the development of virus culturing techniques capable of producing live virus vaccines, probably in the late 1640s or early 1650s.
Koplick’s spots (small blue white dots on inside of cheek) (photo courtesy of the WHO website)
Rubella, also known as “German” or “Three Day Measles,” was the Third Disease to be differentiated by physicians in OTL. Generally milder, up to one half of all the patients may be almost without symptoms. The fever is generally lower, the rash is very mild, and the amount of discomfort is lower with the “Three C’s” being almost absent in many cases. The great tragedies occur when a young woman in the first months of her pregnancy contracts the disease. This prenatal rubella exposure results in marked congenital growth and mental retardation, hearing loss, heart disease, and eye problems. An interesting point that will make an excellent story line is that some cases of congenital rubella may remain infectious until the child’s first birthday.
Treatment is again supportive, with oral hydration and fever control. The rash is generally not as “itchy” as that of true measles.
Prevention again consists of case tracking and contact isolation. With rubella, there will be the development of “rubella parties,” where nubile young females who are not known to have had the disease will be exposed to a known case of rubella and isolated together for several days. This will be the best method of preventing the complications of congenital rubella until the development of advanced live virus vaccines.
The term “Fourth Disease” is no longer recognized, as it was actually several different, similar rashes, all of which were mild and require no further discussion here.
The Fifth Disease to be isolated is characterized by a high fever, malaise and a loss of appetite for two or three days, followed by the development of the classic “slapped cheek” rash, a solid, bright red rash limited to the cheeks. A peculiar, more generalized rash will often develop over the body in the following days, which has been described as looking like a fishing net dipped in red paint was applied to the body. Usually a mild disease, limited to children under age six, it requires only supportive care. Barring problems from the high fever (which is controllable), there are no long-term problems.
The Sixth Disease is another disease of early childhood, usually occurring before the second birthday. Again, it is characterized by a high fever (up to 104F/40C), the possibility of seizures associated with the fever, and followed by a rash on the body a day or so after the fever subsides. This is a more generalized rash than that of Fifth Disease, and again, does not cause problems with itching.
Viral pustular rashes:
Small Pox is well known to down-time physicians, who have survived and then treated waves of this disease for their entire lives. The infection starts with a fever with prostration, headaches or backaches several days before the rash appears. The rash starts in the mouth (enanthem) and then spreads to the face around the mouth and nose after a day or so. Over the next several days, the rash spreads to the extremities especially the distal limbs, including the palms and soles, but rarely affects the trunk or abdomen. There is only one crop of lesions, which initially appear dimpled, but later extend deep into the skin, resulting in healing with scarring in survivors. Saliva, fluid from the skin lesions and scabs are very infectious. Fatality rates in naïve populations were up to 30%, with younger children and infants being more likely to die. Some varieties, including flat and hemorrhagic forms, have higher (90+%) fatality rates. Survivors will have life long immunity to the disease.
Chicken Pox, on the other hand, is a milder disease with a much lower fever, much less prostration and a more variable course. Patients will show multiple crops of lesions, which are superficial (“dew on rose petal”), and which are more on the body than the face and limbs, and very rarely on the palms and soles. These pox usually heal without scarring because of the more superficial nature of the infection. Fatalities are uncommon, but possible when the disease is contracted by older persons who were not exposed as children, as lung infections may result. The name “chicken pox” is not related to an infection of fowl, but from the idea that the disease was a weaker, or “chicken,” form of small pox.
Both diseases are highly infectious by airborne spread from early in the disease, and teens or adults who are exposed to the infection but do not get the infection have probably been exposed as young children even if no history (or typical scarring) is present.
There are several infections in this classification, including Typhus and the various Spotted Fevers. None of them are directly transmissible from person to person, instead being passed by an arthropod vector, usually body lice or ticks. The problems with Typhus are already in canon in several stories, and the spotted fevers will be discussed in another article.
Making the Diagnosis Clinically
These diseases are mostly easy to diagnose once they are in the acute stage, as each one has a consistent pattern. The trick is to make the diagnosis early enough to help quarantine patients to prevent the spread of the disease. All of the diseases tend to follow several stages of infection:
Asymptomatic or Latent stage: these infections usually take between 5 and 20 days from exposure to the first symptoms, which usually consist of fever, aches, pains and general discomfort.
Prodrome stage: starting with the first, usually non-specific symptoms noted above, the patient is now infectious. Generalized discomfort quickly progresses, with nausea, vomiting or diarrhea and loss of appetite and energy commonly occurring.
Active infection stage: This is usually where the characteristic rashes start to become obvious. With the notable exceptions of small pox and chicken pox (which remain infectious until the last of the scabs are gone), most of these diseases are infectious for only a few days after the rash becomes apparent. Very young, malnourished or otherwise debilitated children can become frighteningly ill in a very short time at this point, mostly due to dehydration associated with the fevers and diarrhea. Care consists of reducing the fevers, maintaining hydration and nutrition, and preventing secondary infections (most often pneumonia) by encouraging deep breathing and coughing to prevent excessive mucus from clogging the airways. Antibiotics will help with the secondary infections if they are caught in time.
Resolution stage: The patient is no longer miserable from a fever, the rash is starting to resolve, and the appetite is coming back. As previously noted, small pox and chicken pox are both still infectious at this time, until the “pox” are fully resolved. The other infections are no longer infectious after the fever drops and the rash starts to resolve.
Meningitis is an inflammation of the membranes that cover the brain. There are two basic types: “aseptic” (because nothing grows when the spinal fluid is cultured), caused by one of several viri, which is usually mild, or “purulent,” (caused by bacteria or fungi) which is more often severe, and may result in disability or death. Both the bacterial and fungal types may result from the spread of an infection from an infection of the sinuses, blood, facial skin or scalp. An interesting point is that “encapsulated” organisms such as pneumococcus and meningiococcus, or fungi such as Cryptococcus cause many cases of purulent meningitis. These capsules contain sugar groups that generally act to protect the bacteria from attack by the body’s defenses. These same sugar groups can be processed (when the technology is available) into vaccines to provide significant protection from these infections.
Encephalitis is usually viral, but may be from syphilis or brain abscesses. Biting insects, usually mosquitoes, most often transmit the viral forms except for rabies. Cases range from mild to devastating, with a modest but high percentage of victims needing life long care.
Poliomyelitis (Polio) is a viral inflammation of the spinal cord and brain that develops after infection by a water borne virus. The initial infection is actually in the gut, and only progresses to the more serious form if the body’s defenses do not suppress the disease early on. There is evidence that the disease is mild very early in life, with immunity developing from the mild disease (similar to the Sabin oral polio vaccine, see below). Seasonal pandemics of paralytic polio were noted in OTL as cities became larger and improved sanitation, until the development of first the Salk and later the Sabin vaccines in the 1950s (see below).
There was a correlation between polio pandemics and improved municipal hygiene, and polio in the 1890-1954 timeframe did hit the middle and upper classes in the cities much harder than the lower, and more rural classes. This being said, there is no direct evidence that I know of that might show that a new, more aggressive strain of the polio virus developed along with the improvement of central sanitation, but it is certainly a consideration. I can not excessively stress how feared this disease was at the time. The apparent randomness of many of the cases (due to variations in previous exposure giving partial immunity, as well as the wide variation of pathogenicity of the virus strains) caused a level of terror not seen since the terrors of syphilis in the 1500s and not seen again until the first cases of AIDS were diagnosed in the 1980s. A similar pattern can be expected in the NTL, and I expect that the Daisy Matheny Memorial Biolab will be in the forefront of redeveloping polio immunizations. Polio vaccines will be some of the more difficult to reproduce, as they need live primate cells in culture for mass production. In OTL, this took until the late 1940s to get started and into the late 1950s to perfect.
As with small pox, measles and most other viral diseases, there will be no cure, only prevention, supportive care in the acute disease, and rehabilitation after recovery. Iron lungs are well within the tech level of the 1630s. With Torricelli and Guericke around, there might even be some improvements leading to the more portable cuirass types much sooner than in OTL. Limb bracing and crutches will be well within 1630s tech, especially with up-time knowledge to help reduce some of the “clunkiness” of early efforts.
The complications of these diseases span many organ systems and can be temporary, life long or even life threatening. Strep throat and Scarlet Fever lead to the heart problems associated with Rheumatic Fever and Bright’s Disease which may lead to kidney failure. Rubella is another one of the congenital infections that lead to TORCHES syndrome, the other relatively common ones including Toxoplasmosis, Cytomegalovirus, Herpes virus, Hepatitis B, and Syphilis. Syphilis has been covered in detail in an earlier article, and the others will be covered in the future. These all may lead to an assortment of birth defects, preterm labor and even miscarriage. The chicken pox virus resurfaces later in life as Herpes Zoster, or Shingles, a rash that can be debilitatingly painful.
Laboratory Tests Available
In the first year or so after the Ring of Fire, there will be a limited amount of up-time testing equipment available, mostly test strips from the nursing homes, but these will quickly run out. There are enough old hands around who remember the manual methods that were in use prior to the 1980s in OTL, and which are still in use in many field situations even today in 2010, simply because these testing methods are simple and robust.
Manual blood counts require a couple of different, but simple, dilution solutions which can be reproduced down-time with little problem, along with a decent microscope (with a magnification level low enough to be reproduced down-time, roughly two to four hundred power), and a specially calibrated grid etched on a microscope slide, which is again reproducible down-time (with the help of similar microscopes and a device called a reducing pantograph.) Differential counts of white blood cells use the same microscope, and the dried blood film is stained with a simple mix of stains that should be available from the high school lab stocks until Lothlorien Farbenwerk starts reproducing the dyes from coal tar.
Urine testing starts with simple chemical tests for sugars, proteins and ketones to start, all of which an alchemist of Dr. Gribbleflotz’ stature will be able to reproduce with up-time guidance. The microscopic examination again uses a medium power microscope, some simple stains, and a hand powered (ultimately electric) centrifuge, again simple enough for easy reproduction down-time.
Microbiological cultures will be one of the more complex up-time techniques to reproduce, at least until the Agar supply is reproduced. After that, it will be a matter of finding the correct combinations of nutrients and inhibitors to promote the growth of the species that you are interested in, while preventing the overgrowth of unwanted bacteria or molds.
Lumbar puncture is actually a diagnostic technique of inserting a thin needle into the spinal canal and removing a small amount of spinal fluid for testing. There is a possibility that a few pre-packaged equipment trays will have come back with the Ring of Fire, but not many at all. These will be difficult to reproduce down-time, due to the need for stainless steel for the spinal needles and the need to redevelop local anesthetics (at least to the level of cocaine) to ease the discomfort of the procedure. I’ve done enough of them over the years to know how difficult they are under the best of circumstances. I’d hate to do one without the anesthetic available. Additionally, the needles need to be relatively—up to four inches—long, and have a hair fine removable obturator wire running through the center of the needle, which may be the most difficult item to reproduce consistently.
Microscopic Evaluation of Microbial Organisms
These tests will be more limited than the microscopic tests previously described, as there will be a more limited supply of instruments suitable for this purpose. These tests need the more sophisticated up-time instruments which are capable of both higher magnification (up to one thousand times normal) and finer resolution (being able to distinguish two small objects closer together) than down-time instrument makers will be able to accomplish for a number of years.
Gram’s technique will continue to be the mainstay of microbiology, because it is simple and easily reproducible. Again, the high school stocks should last until the Dye Works have started producing.
Acid-fast staining techniques are similar to Gram’s technique, but involve different dyes, and the use of an acid-acetone solution instead of an alcohol solution to remove unwanted stain from the specimen. This is used to make the diagnosis of tuberculosis and similar infections.
India Ink (a suspension of fine carbon black particles in water or alcohol) can be used as a “negative stain,” in particular for examining spinal fluid or urine, looking for encapsulated organisms. The capsules form a noticeable clear zone in the midst of the fine black particles.
Many of the diseases discussed here result in long term, often life long, protection from reinfections. Smallpox and pertussis in particular were known in the 1630s to confer immunity to survivors after recovery, allowing them to work with relative impunity in the face of new cases.
Rubella parties—and similar parties for chickenpox and measles—have already been mentioned, and should be considered for children in the 10-13 year age range who have not had a documented case of the wild disease yet, at least until the development of effective and relatively safer vaccines
Live, attenuated virus vaccines, when developed, should not be given to pregnant women or those with severe immune problems (which, in the NTL, would be fairly rare). Certain of the live virus vaccines, in particular rubella, have the same capacity to cause birth defects in early pregnancy as the wild disease.
Smallpox immunizations were initially “variolation,” where fluid or pus from a mild case of smallpox was used to induce a (hopefully) mild case of smallpox in another person. As practiced in some areas of Europe in the 1630s, this was associated with purging, bleeding, and large doses of pus rubbed into large wounds, resulting in erratic outcomes, including severe life threatening disease. With up-time information, better hygiene and nutrition, and small doses of pus, this is a relatively safe way to prevent severe disease, but is not a good way to isolate active cases. True vaccination, where the vaccina virus from cowpox, cat pox, or “grease” (horse pox), is much safer, and can be used to isolate cases of true smallpox by immunizing contacts of active cases in a “ring” fashion. This technique resulted in the elimination of small pox as a disease in the wild in OTL.
However, even vaccina use is not without danger, especially with infants and small children when they are receiving their first dose. Fevers are common, and “inadvertent inoculation” (spread of the infection to other areas on the body by transfer of material from the desired site) is more common in younger children who pick or scratch at the healing lesion. More rarely, more generalized vaccinia or immune complications can also occur. These are generally mild and self limited, but are more common if the patient is debilitated, has problems including eczema or psoriasis, or has a lowered immune system, and persons with these problems are likely to have problems with inadvertent inoculation by exposure to a person with an active vaccination site. The chances of death or serious complications in healthy persons in OTL are on the order of one in one hundred thousand to one in one million.
Vaccination is known to provide substantial protection for at least ten years, and even the waning protection after fifteen or twenty years is enough to usually prevent death if not scarring. It is already canon that the thirty-year-old vaccinations of most of the older folks in Grantville will not provide full protection, and immune serum from recent survivors may need to be used to help extend the protection. The last vaccinations for general US citizens were in the 1970s and the last general vaccination for the US military was done in the mid to late 1980s. Except for certain researchers, no further smallpox vaccinations were offered in the US until 2002.
The Salk polio vaccine is an injectable, killed virus vaccine and only confers humoral (blood borne) immunity that prevents the spread of the poliovirus from the gut through the blood stream and then to the spinal cord, preventing the development of full blown poliomyelitis with the resulting complications of frequent paralysis or long term weakness. Current recommendations in OTL are for the Salk vaccine as the primary immunization against polio, due to the now rare nature of this disease. The development of the Salk vaccine in the early 1950s freed many parents from the worry of a devastating illness that seemed to strike frequently, but randomly, among children.
The Sabin polio vaccine, which was developed in the mid to late 1950s, is the oral form of the immunization that causes a mild case of the infection in the gut. It induces immunity both in the blood (humoral) and in the gut, which prevents the spread of the infection both in the body and from person to person. Now that the risk of polio is so diminished in OTL, current recommendations are for more use of the Salk type vaccines due to the small but significant chance that the live virus can revert to the wild (paralytic) type and spread in close contacts. I expect that the Sabin vaccine, once developed, will be the preferred form for prevention of polio for a long time in the NTL, until the development of the substantial level of herd immunity to this disease that we now enjoy.
Influenza vaccine, whether a killed whole virus, killed split virus, or live, attenuated virus vaccine, will be lower on the list of vaccines to develop, simply because of the generally lower mortality from the disease and the known problems with variability in each year’s spread of disease. The one advantage of influenza virus is that it does grow in fertilized eggs, so complex methods of cell culture are not needed. The disadvantage is that a large number of eggs are needed to produce significant amounts of the virus to process into the vaccine, and purification is not trivial.
Bacterial vaccines are under development in canon at the Matheny BioLabs. Already documented are the killed whole cell vaccines for Pertussis (whooping cough) as a dual vaccine with typhoid by late 1634. Tetanus toxoid is also being developed by summer 1634. Diphtheria toxoid will probably be close behind, as it is no more complex.
Louis Pasteur’s famous rabies vaccine will likely be among the next to be reproduced, as there is a ready source of rabbits already in canon, and rabies is one of the more feared (and fatal, even today) viral infections around. The treatment will involve a long series of painful shots in the abdomen, again, until the development of cell culture techniques, but will prove life saving to patients ravaged by rabid canines.
As the BioLabs become more sophisticated and competition emerges, the capsule antigens of many organisms that cause pneumonia or meningitis will be the next rich source for immunizations. These will include up to 23 forms of pneumococcus, three forms of meningiococcus, and Hemophilus influenzae type B (or HiB). I do not expect this to happen until the 1650s at the earliest, as the purification techniques needed are about as complex as those needed for the growth of pure cell cultures.
Immune serum (more commonly known as antiserum) from survivors of recent infections is used as early as 1632, and the purification of concentrated gamma globulin fraction is simple enough that it should be available by 1635 or 1636. For infections such as tetanus (which are usually fatal in humans), the use of hyper immunizations (where fairly massive doses of the appropriate toxoid are given to the subject animals) to produce immune serum, first from horses and sheep and later humans, will help slow the progression of those diseases and allow the body to recover.
Crude Penicillin is available early on, thanks to the serendipitous discovery of a high producing strain of the mold at the back of the high school laboratory freezer. Cologne Medical develops pea juice with borax as an inhibitor of unwanted overgrowth by Jan 1635. Both Diphtheria and most Streptococci (species of this bacteria are responsible for strep throat, many cases of pneumonia and meningitis, and a particular infection of new born babies) are sensitive to topical (and later injected or oral) penicillin, so even the crude broth cultures can be used as gargles to treat urgent cases of diphtheria and strep throat.
Chloramphenicol and the sulfa drugs are also useful in the treatment of the secondary infections associated with these (mostly) viral infections.
For further reading:
http://www.cdc.gov/vaccines/pubs/surv-manual/default.htm this link leads to the current US CDC recommendations for surveillance of vaccine preventable diseases and is available to the public.
These are some of the books that should have been available in Grantville at the time of the Ring of Fire:
Control of Communicable Diseases in Man, 14th edition 1985, US CDC
The Travel and Tropical Medicine Manual, 2nd Edition 1995 W B Saunders
Scientific American Medicine (in a loose leaf binder format, updated monthly)