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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.
Complications
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.
Immunization
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.
Polio Vaccines
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.
Other Vaccines
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.
Other Treatments
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.
Antibiotics
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)
The Progression of Trauma Care and Surgery after the Ring of Fire, Part 1
by Gus Kritikos
From Wikipedia: From Greek τραῦμα = "wound" compare verb τιτρώσκω = "I injure"
A number of stories in canon depict serious injuries and deaths resulting from trauma, but I don't recall any specific articles, and few stories, covering the care of injuries either under austere conditions generally or in the New Time Line (NTL) specifically. In this article, I will include a number of references to stories in canon, to Wiki, and to professional articles and textbooks that cover some topics in more detail than practicality allows including here. I am also working on an addendum to be posted on the 1632.org site, with pictures and diagrams of various instruments as a resource for other authors.
I dedicate this series of articles to my first medical instructor: my mother, Darlene (a Diploma RN, 1951) who taught me how to give a bed bat
h and change the bed under the patient, even for patients in skeletal traction.
My thanks to Danita, Kerryn, Stanchem and Nimitz Lover for off bar advice, suggestions, and requests for clarification. Any errors of omission or commission remain mine.
The State of the Art in AD 2000
Here in the US, we’ve chosen to use a pyramid approach to treat trauma, where the doctors are usually centralized in hospitals, taking care of other patients when not working on a trauma patient. Other people, at various levels of training, occupy lower areas of the pyramid, seeing the cases earlier, usually in the field. Therefore, the first trained personnel to encounter most serious trauma patients in OTL are often among the lowest-paid and least-trained professionals (or volunteers) in the system, known as first responders. First responders open or maintain the trauma victim’s airway so they can breathe adequately. If the victim is not breathing, they provide breaths through any one of various methods of artificial ventilation. If the victim’s heart is not beating, first responders may perform compressions to promote circulation. They also control or stop bleeding and transport the patient to the hospital for definitive care. These steps are essential for the trauma victim’s survival because they preserve brain and organ function before arrival at the hospital. While there has been much discussion in Old Time Line (OTL) about "the Golden Hour" and the "platinum ten minutes," over the last thirty years, we've found that these are more guidelines for aggressive transportation, rather than hard limits on survivability. I will also point out that not all trauma requires an OR visit. For example, the casting of broken limbs, initial care of moderate or even some severe burn patients, and watchful waiting on many closed head injuries (CHI) all don’t require immediate OR time. That being said, severe trauma is a condition that can only be treated in the operating room, and only temporarily handled in the field or even the Emergency Department (the ED, also known as Accident and Emergency—A&E—in the British system). Other countries, particularly France, Germany, and to a lesser extent Spain, have physicians and nurses responding directly to the accident site in the ambulance. This is practical in Europe because of the much smaller distances generally involved. I know of no study that shows an advantage either way.