Another in a continuing (if random) series of classic Word Wenches blogs: the first time Dr. Josh visited Word Wenches to answer a few questions about historical medicine.
Without further ado -- heeeeeere's Dr. Josh!
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The Wenches are delighted to welcome Dr. Josh King!
Dr. King graduated summa cum laude from University of Maryland, earned his M.D. from Penn State College of Medicine, and is now a 3rd year resident physician in internal medicine -- soon to be Chief Resident in Internal Medicine -- at University of Virginia.
He has lots of experience answering medical questions for writers, since he's the eldest son of Wench Susan Sarah, who regularly asks him how to get rid of villains, or how to strategically afflict and then treat heroines and heroes. He has also come up with some creative ways to poison and dose a few eleventh-century characters....
A word of warning, if you have a squeamish tummy for medical stuff, or are just about to eat a meal, you may want to proceed with care as you read his answers....
Dear Dr. Josh,
I am desperately curious about how people dealt with gonorrhea, how long they might have lived with it, and whether there was anything they might have done to alleviate symptoms (and imagine themselves cured) in days before antibiotics. Circa 1817, Lord Byron talks about getting the clap from this one and that one, which made me wonder. My 1887 edition of the Encyclopedia Britannica has some fascinatingly insane stuff about syphilis (like how it eventually goes away by itself or how one should give mercury to a syphilitic pregnant woman) but very little about gonorrhea.
-- Loretta
Dr. Josh: Gonorrhea's been around for a while... Galen named it way back in the 2nd century. Essentially, before antibiotics, it was treated the same as syphilis - with mercury! Actually, the two were often confused back then, and people were often coinfected. Since the symptoms of gonorrhea (burning on urination) often went away after a few weeks, it was often thought to have disappeared (although reinfection / reactivation of symptoms was common). Sulfa antibiotics came around in the 1930s, becoming the first treatment with any degree of reliability. Basically, my impression is that people just got used to it burning when they urinated. That's not all that uncommon, even today, as I've had patients who tolerate the symptoms for a long time before finally coming in for treatment.
Another note on syphilis - as far as the Great Pox (or, as the medical profession occasionally calls syphilis, the Great Imitator - so-called because its manifestations may be more protean than any other disease), there were quite a few treatments. Many of them were used for other sexually transmitted infections 'cause they couldn't tell which one was bothering them. Mercury was often used to treat venereal disease, as was guaiacum, the prepared sap of the guaiacum tree, since as early as the 15th-16th c. The final stage of syphilis is neurological involvement leading to madness; mercury toxicity can result in, you guessed it, madness (mercury also being the cause of 18th-19th c. mad hatter's disease, or erethism, as mercury was used in the preparation of felt).... So a lot of people went crazy for one of the two reasons.
(Johnny Depp in The Libertine, as the Earl of Rochester-- before The Syph got him)
Dear Dr. Josh,
This is of interest to me, too, since all of my present group of characters seem to die one way or another from venereal disease. Dr. Josh has helped my research with this matter before, but I'd be curious about what kind of hereditary effects (if any) "poxed" parents would transmit to their offspring. -- Susan Holloway Scott
Dr. Josh: Quite a few. To use the vernacular medicalese, vertically translated (meaning from mother to child at birth) syphilis is associated with significant badness. The symptoms can be severe enough to cause stillbirth and early infant death. At first, the new baby has a runny nose, which is often followed by a severe, peeling rash over the entire body. If you cultured these lesions, you'd find them teeming with the bacterium that causes syphilis. The infection can then involve any organ in the body, including liver, kidneys, and lungs. If the infant survives without treatment, they then enter a latent period, where they may slowly develop bony and tooth deformities, eye problems, and neurosyphilis leading to psychiatric problems including psychosis and dementia. Not so good. Usually, mothers who acquire the disease during pregnancy are at greater risk to transmit it to their baby, as the organism is more active early on.
Dr. Josh, I've heard that maggots were used to clean infection from wounds, which was gross but effective. Any comments on that? -- Mary Jo Putney
Josh, I'd also like to hear more about the treatment of wounds. I was very surprised to
read that stitching wounds wasn't done before antibiotics because they had to drain. Greater depth on that would be useful. Also, could you give us a guess on what sword and gunshot wounds were probably survivable in the past, and which probably weren't?
-- Jo Beverly
Dr. Josh: I combined these two questions ... The problem with stitching infected wounds is that doing so basically gives the bacteria a nice warm pocket to form abscesses. In fact, we often don't stitch together traumatic wounds if they're really dirty - we approximate the skin, slap some bandages over them and let them heal over weeks to months on their own, while giving them antibiotics. Wounds created in the operating room are sterile, so it's OK to stitch them up.
In terms of wound treatment, cautery was not always done because it caused death from tissue damage, later infection, and fluid loss. Of course, it was often done because not doing it often caused death from immediate blood loss. Maggots have several beneficial attributes - they disinfect wounds by killing bacteria, largely remove necrotic (dead) tissue, which stands the highest chance of getting infected, and stimulate wound healing through partially understood mechanisms. Nowadays, they are uncommonly used for patients with chronic wounds resistant to other forms of healing - I've only heard of them being used once or twice in my experience, and each time in a patient who was riddled with skin infections. I don't know much about herbal poultices and such, but my gut feeling is that the most important purpose they served was to avoid dehydration through open wounds - we often use wet gauze for the same purpose today, depending on the type of wound/burn.
Survivable wounds... basically, any gun wound that ruptures a major blood vessel, the heart, or perhaps the spleen would be likely to cause a fatal internal hemorrhage. Rupturing the intestines would be fatal, as they'd cause infection. Actually, a shot to the head (if it didn't rupture a blood vessel) might be one of the more survivable. Shoulder, arm, leg oughta be possible to survive. Chest wound that punctured a single lung might be survivable, often not - you'd have to get lucky and miss the aorta, its large branches, and the heart. Basically, internal bleeding kills you in a very short period, infection within hours to a few days. Same principles for sword wounds, but figure that a sword wound is more likely to cause severe tissue damage, bleeding, and infection in any area - so a shot to the leg might be survivable, but a deep cut to a muscular area of the leg would stand a greater chance of killing you from deep tissue infection (gangrene-like) or blood loss.
Could you also talk about how midwifery was more a woman's affair? -- Mary Jo
Dr. Josh: Midwivery...well, I don't know much about it, though I did my share in OB/Gyn rotations. I know that historically, men typically stayed away, including doctors (unless cases were complex), since it was considered a "woman's affair" as Mary Jo says.
In fact, this changed only in the 20th century, with (largely male) doctors getting in on the action.
However, history is coming full circle in the 21st century, with women being far more likely to go into OB/Gyn than men - my experience with current OB residency programs is that they're comprised of 80-90% (or higher) women. I'll just conclude with a brief suggestion that anyone considering the use of a midwife today is best advised to seek the services of a nurse midwife in a hospital in case a cesarean is necessary - there's a reason infant mortality is far lower today than in ages past, and it's not related to skill in delivering a baby (although nowadays we do have salad spoons, as Bill Cosby calls them).
Dear Dr. Josh,
Could you comment on plot-amnesia? I know novelists use amnesia shamelessly (I certainly have), and I've read some really interesting stuff about fugue states that aren't really organic in nature, but it could be interesting to hear him on the subject.
-- Mary Jo
Dr. Josh: Ah, amnesia! A concept far more common in fiction than reality. The only time I've ever encountered classic amnesia is in books, and I'm not talking about medical texts. The novelists' version of amnesia does occur, albeit very rarely; far more common is a selective memory loss of recent events associated with aging and dementia (not too useful to most novelists) and substance abuse (also not too useful to most novelists, although there's a certain subset).
There is a condition known as transient global amnesia where people lose their memory of recent events, but still tend to retain distant memories (the thought being that they are more 'hard-wired' into the brain). Frankly, no one really knows why it occurs, although there's some thought that it's somewhat stroke-like, and no one knows why it gets better. Because of this uncertainty, feel free to exploit at will - no one can fault you scientifically.
Dear Dr. Josh,
My question has to do with comas. I've been told that people in comas sometimes hear, but cannot respond. My ex-husband went into a diabetic coma when he was 13, and though he was immobile and couldn't open his eyes or speak, he remembered hearing the doctor telling his mother he was going to die, and his mother crying.
Is it possible to bring a person out of a coma (or speed their recovery) by external stimulation, such as reading or talking to them, or playing music, or by touching them? If not, then is it possible for a person who comes out of a coma on their own (whatever that is!) to remember things that were said to them while they were in a coma?
-- Sherrie Holmes
Dr. Josh: Well, coma is a tricky word... it basically refers to a level of unconsciousness, which can be due to a number of different conditions. Novelists' comas are like novelists' amnesia - useful in a plot sense, but not very realistic.
Coma states vary in the level to which they alter someone's level of consciousness - we have multiple scoring systems used to evaluate them. They can be short-lived, often seen with severe infections requiring hospitalization, shock from blood loss, metabolic disturbances (as your husband had), or drug-induced (e.g., modern anesthesia intentially induces a comatose state with short-acting drugs continuously infused). These are usually completely or nearly completely reversible, depending on the amount of permanent brain damage.
Longer comas usually result from a neurological insult - stroke, bleeding inside the head, brain damage from shock, or, as we commonly see, brain damage after cardiac resuscitation (loss of blood flow for minutes can cause very profound levels of brain damage. Those are usually reversible to a certain extent, but with increasing severity of the coma, the likelihood of a person emerging decreases. However, people can come out of them after either months or decades; the bad news is that they often have persistent neurological deficits.
As for your question, well, it depends on what caused the coma, and I assume you mean a longer coma (though I could be wrong). Modern medical science doesn't really have a good answer as to whether external stimulation can bring someone out of a coma. But since people rarely accept this as an answer, why should you? Many friends & family members of patients say they feel that stimulation helps their loved one to be more aware. I honestly haven't seen it myself as yet, but stimulation is unlikely to make matters worse.
Dr. King returns now and then to address topics in historical medicine, especially maladies and injuries that may afflict fictional characters ... be sure to watch Word Wenches for the next "Dear Dr. Josh" column!
Meanwhile, if you're curious about historical and medieval medicine, you may want to check out this link to an informative video clip featuring "Theodoric of York, Medieval Barber" ....