by Eric Flint
Prevention
Latex condoms are effective in preventing transmission, as is advising patients to abstain from sexual activity for at least seven days after treatment of both/all parties involved. The reported price of rubber in the 1630s will be on the order of a gram of rubber for a gram of silver, so condoms will not be cheap. If I understand the time line correctly, condoms will be available on at least a limited basis, by the end of 1634. This is at least partially due to the efforts of the military (which has uses of condoms beyond that of the common prophylactic practices).
Sequale of untreated disease
Untreated, gonococcal infection can spread throughout the body. This is more common in women than in men because of the ease that the infection can spread inside the body cavity. In a small, but significant, segment of the infected female population, Fitz-Hugh Curtis syndrome, typified by inflammation of the capsule around the liver, right upper abdominal pain radiating to the right shoulder, abdominal tenderness, and intra abdominal scarring (adhesions) occurs. While painful, Fitz-Hugh Curtis syndrome is more important as a marker for an occult pelvic infection that may become PID (see below).
Septic Arthritis is also a rare problem, seen mostly in young, active and sexually active patients, most often attacking one major joint (most commonly a knee). Diagnosis is made by using a needle to drain pus from the affected joint, and then the bacterial is identified by a combination of Gram staining and culture. High dose antibiotics, probably intravenously, will be needed. In severe cases, the joint will need to be surgically opened, and washed out, possibly repeatedly.
Urethral scarring producing strictures was a common problem in the 1630s, mostly in males, requiring the passage of smooth, tapered metal probes called "sounds" on a repeated basis to allow the afflicted male to empty his bladder. Similar scarring of the epididymus may cause sterility.
PID is a serious enough complication of gonorrhea and Chlamydia, to warrant a separate discussion below.
Infected adults who do not practice good personal and hand hygiene can contract a rather nasty eye infection from gonorrhea. Similarly, a baby born to a woman with an active infection is at risk for serious eye infections. Both cases can be treated with several days of antibiotic eye drops, usually of chloramphenicol or tetracycline. At least early in the 1630s, silver nitrate drops will be more useful for treating newborns, as it is more stable and easier to keep sterile and fresh in field situations.
Chlamydia Infections
This infection is caused by an obligate intracellular bacteria known as Chlamydia trachomatis. In this time line, chlamydial infections were differentiated from gonorrhea only after reliable culture methods for the gonococcus were developed. Chlamydia only infects specific types of cells, but can enter the body either through the mucus membranes or through breaks elsewhere in the skin. Several types of chlamydial infections are known, depending on the area of the body that is afflicted.
Urethritis is perhaps the most common form and, like gonorrhea, is somewhat more commonly diagnosed in the male partners in the absence of up-time testing. Again, males tend to display problems, in this case with a mild discharge and occasionally painful urination. Tragically, women rarely show significant signs or symptoms until much damage has been done in the form of PID. As with gonorrhea, the best way to determine if a woman needs treatment is to check her male partners and treat all of them. When the technology levels allow a resumption of "routine pap and pelvic" exams, screening for both gonorrhea and chlamydia will produce a surprising number of cases.
The second most common form is trachoma, an infection of one or both eyes that is still a leading cause of blindness in Third World countries, accounting for some 15% of world wide blindness in 1995. This can occur as a neonatal infection, may be sexually transmitted, or may be associated with poor hygiene, either from a lack of hand washing or from flies that carry the infective organisms.
Perhaps the most serious form in men is Lympho Granuloma Venereum, or LGV. (The most serious form in women is PID, see below) In the US and Europe in OTL, the type of Chlamydia that causes this infection is much more rare than the form that causes urethritis. It is more commonly seen in the Third World, and as a result, may be expected to be more common in the 1630s. As an acute disease, LGV is easily confused with several other infections, including plague.
The first stage of LGV is a painless ulcer that may be mistaken for chancre if it is noticed, but the sore is only seen in 1/3 of men, and even fewer women. In the second stage of LGV, in most males but only in 25% of females, swollen inguinal lymph nodes occur that may be mistaken for plague buboes, especially if they become abscesses. Female cases usually (75%) have the swollen nodes in the intra-abdominal node chains, which do not tend to become abscesses. Other signs and symptoms of advancing disease include rectal inflammation and often abdominal masses and pain.
Diagnosis
There will probably be no definite diagnosis available until the 1640s or 1650s, as culture is difficult and serology testing moderately complex even by current standards. This means that the diagnosis is one of exclusion, or you must treat on history and suspicion. Exclusion points for LGV include lack of treponemal forms in scrapings of the ulcers, "sterile" aspirates from the swollen lymph nodes (no bacterial seen on Gram's staining, nor do any bacteria grow when the pus is cultured), and that this disease, untreated, rarely results in death as compared to bubonic plague.
Treatment
A large percentage of cases will show spontaneous resolution without treatment, and with only a small chance of future recurrence. Cases that are more serious may need drainage of abscesses, which may also lead to spontaneous resolution. This drainage is best done by inserting a needle into the abscess, rather than cutting it open, which may lead to severe scarring. Medications including chloramphenicol, sulfas, and when available, tetracycline class drugs, are all effective in treating this disease; however, the course of therapy may extend to as much as three weeks. Currently, tetracycline class antibiotics are considered the drug of choice, due to the potential side effects of the others.
Ocular forms
Unlike ocular gonorrhea, silver nitrate drops are not effective for the treatment of chlamydia. The use of chloramphenicol or sulfa eye drops is effective and quite safe even in small children and infants
Prevention
Latex condoms are somewhat effective in preventing the transmission of chlamydial infections. However, as with syphilis, the infection can enter the body through small cuts or abrasions in the skin as well as through mucus membranes.
Sequale
See PID in the next section. The relatively mild chlamydial urethritis can result in epididymitis in males and reactive arthritis in both men and women. Reactive arthritis is more common in men than women, and involves a low grade fever, inflammation of the eyes, and one or more joints, more commonly of the lower body. Unlike the gonococcal arthritis, aspiration of joint fluid shows only white blood cells, and no evidence of infection. In this time line, Fitz-Hugh Curtis syndrome is now more often associated with a chlamydial infection than with gonorrhea, but this may be true due to missed co-infections. Up to 5% of patients with LGV may suffer from urethral or rectal strictures or peri-rectal fistulas. Neonatal infections may include a nasty pneumonia as well as eye infections. This is one of the few reasons to use silver nitrate drops for the prevention of eye infections in newborn infants, as any silver nitrate treated infant with an eye infection that persists for more than 48 hours after birth should also be treated with systemic antibiotics for a chlamydial infection. This is to prevent the chlamydial pneumonia that might otherwise show up one to three months after delivery.
Pelvic Inflammatory Disease (PID)
Pelvic Inflammatory Disease is a serious and potentially life-threatening infection of women, usually associated with un- or under-treated Gonorrhea or Chlamydia.
Diagnosis
In this time line, any female with a history of exposure to any previous e
pisode of STI, especially with a long and/or varied history of sexual activity, and no good evidence of cure after appropriate treatment is at risk for PID. Even without this history, any non-virgin female with the typical physical exam findings of: the shuffle (where the patient takes small shuffling steps to decrease the pain of movement), fever, lower abdominal or back pain, pain on "intimate" examination, and a lower abdominal mass is considered highly likely to have PID. The diagnosis is not absolute, as similar findings occur in appendicitis, tubal pregnancy, and even severe ovarian cysts. Since three of the four primary diagnoses can become life threatening in a frighteningly short time, appropriate care needs to be started rapidly. This will include consultation with Dr. Nichols or one of the other surgeons.
Lab results
Cultures of abscesses will probably show many types of bacteria, and anaerobic cultures are needed as well. White blood counts will be elevated, sometimes to very high levels (normals are 4,000 to 10,000 cells per cubic millimeter; PID can show between 15,000 and 30,000).
Treatment
Initial treatment is with high doses of intravenous antibiotics, probably starting with a combination of chloramphenicol and penicillin in the 1632 timeline. Metronidazole (a deceptively simple synthetic antibiotic that probably will not be available until the late 1630s or early 1640s) is also helpful. Cephalosporins, when available, will have good effects. However, any moderate to severe cases will probably require surgical drainage of abscess and for the removal of scar tissue. As there are three major and one minor conditions that have many of the same signs, surgery is also the only way to make the definite diagnosis. Exploratory surgery also treats the other two life-threatening conditions if one of them is found instead.
Sequale
Mild cases of PID will often result in tubal scarring with the attendant problems of sterility and a marked increase in the chances of tubal pregnancy. There is also a chance of Fitz-Hugh Curtis syndrome. The scars can also result in problems with twisted ovaries, uncomfortable as a minimum, and the source of future problems as well. More serious cases, as noted above, can result in tubal/ovarian abscesses, and even death from an associated ruptured tubal pregnancy.
Non-Gonococcal Urethritis
Several different bacteria in the mycoplasma/ureaplasma group can also cause mild urinary tract infections in both men and women. Diagnosis is similar to that for Chlamydia, as is the treatment. Many cases resolve spontaneously. Generally, there is no sequale to untreated infection, just misery. NGU is mentioned because it can sometimes mimic the more serious infections.
Parasites
Ectoparasites include crab or pubic lice, body lice, and head lice, all of which should be well known in the 1630s. Probably less well known would be the intradermal parasite known as scabies in our time line. The diagnosis is made by finding unexpected livestock on body or in clothing, by finding typical bite marks in areas of the body, by finding the burrows of scabies, or by finding the eggs (nits) attached to the hair.
Treatment in the 1630s will be initially with DDT dusting of sleeping quarters, disinfecting clothing with the use of DDT or steam laundry, and the use of fine-toothed nit combs on hairy areas of the body. Some groups will prefer to shave those areas to help reduce the chance of passing the infestation around. Oddly enough, the Roman technique of using olive oil as a precursor to bathing might have helped control lice, as medium weight oils (vegetable oil, light mineral oils) can be effective at killing the adult lice by smothering the critters.
Gamma Hexane (formerly Benzene) Hexachloride (GHH or Lindane) is cheap and relatively simple to make once the coal plants are turning out benzene. Like DDT and Chloramphenicol, it can be used with relative safety, at least by 1630's standards, although there are waste compounds associated with the production of GHH that are much more toxic to mammals, and much less toxic to insects. Canon has it starting in the winter of 1633-34 by the Essen Chemical Company. As with DDT and chloramphenicol, its use in this time line has been restricted because we have safer, less persistent alternatives. GHH is effective when used as shampoo for hairy areas in the treatment of lice or as a lotion for non-hairy areas in the treatment of scabies, but has age limitations and should only be used on intact skin.
The use of pyrethrum derivatives (from chrysanthemums) along with piperonyl butoxide can be expected in the mid-1630s time frame as a safer treatment for most forms of arthropod infestation. The exact timeframe will depend on the growth of sufficient chrysanthemum plants and sassafras trees to supply the needed precursors. This combination is most effective in the form of shampoos and lotions similar to Lindane, but is safe enough to use on infants and on irritated skin. Additionally, the flowers, dried and powdered, make a decent pediculcidal powder for use in linens, clothing presses, and on clothing itself. This is well within the capabilities of most of the herb wives once the flowers are grown in sufficient quantities.
Sequale
Body lice are known to carry a number of different diseases that have been touched on elsewhere. The others are more benign.
Other infections
There are a number of other sexually transmitted infections which exist in this time line. Among them are the bacterial infections of Donovanosis, and chancroid, the viral infections of herpes (two types, as well as other, related infections), warts, and hepatitis (five types, three of which also affect the blood bank), and assorted fungal skin infections. There are also several infections associated with pregnancy and childbirth that have significant effects on both the mother and baby. I’ll cover these in a separate article, as the impact most of them have is less than the ones I have already discussed. The impact of aseptic technique on childbirth is worth an article on its own.
There was one known case of HIV in Grantville at the time of the Ring of Fire, who deceased shortly thereafter without transmission. (Venus and Mercury, Grantville Gazette 24) By authorial fiat, there will be no transmission of the T-cell Lymphocytic virus from African monkeys to humans in the 1632 universe.
Any other common infections (such as influenza, the common cold, strep throat, and various skin infections) are more easily transmitted by the close, intimate contact involved in sexual intercourse.
Diseases of childhood will be discussed in another article.
Public Health Procedures
Guiding principle 1: The most important risk factor for any particular sexually transmitted infection is the presence of any other sexually transmitted infection, especially in patients who do not fit the typical "rakehell" profile. Patients who fit the "rakehell" profile should be considered to have AT LEAST ONE sexually transmitted infection any time they are evaluated. (Sorry, Captain Lefferts!)
Guiding principle 2: Intimate contacts of a known case must be tracked and treated, and all of their contacts must be tracked and treated as well. In this time line, there have been many studies showing that one missed contact can start the whole process all over again, and that there is often more to a "social circle" than just crumpets for high tea.
Guiding principle 3: Even without the hazard of HIV, any sexually transmitted infection that produces open sores markedly increases the chances of transmitting or catching any other sexually transmitted infection. Patients with known chronic, untreated or incurable sores must be followed closely. (See GP 4 below)
Guiding principle 4: Dr. Abrabanel takes the lessons from And the Band Played On VERY seriously. Public Health measures do not need to include demonization of particular life style choices, but rather education on choices that improve disease prevention. However, persons with known active disease who are not curable and who will not cooperate with appropriate measures to prevent transmission to other persons should be dealt with appropriately. Certainly some authorities prior to 1631 are already proven (with the Scots Grandgore Act of 1497 as an example) to be willing to forcibly isolate syphilis patients who were incurable at that time.
Public health measures contributed to a reduction in the spread of venereal infections
starting in the mid to late 1800s, and made significant inroads into the infectious problem after the development of the germ theory and definitive testing in the 1870-1910 era. Note that period is well before effective treatments for most of these infections existed. These measures include, but are not limited to:
Prenuptial and prenatal testing for syphilis (and later Hepatitis B) in particular
Testing of the blood supplies for syphilis and Hepatitis B as the blood banks come on line and then tracking infected donors.
Contact tracking for treatment.
Physical quarantine of flagrant re-offenders to prevent further spread of disease.
Water purification/pasteurization to help break the waterborne cycle of infections including Hepatitis A, Giardia, and many other diseases.
Public Health effects of Circumcision
Uncircumcised males are known in this time line to be at significantly more risk for both contracting and passing many of these infections, due to the more sensitive nature of the anatomy involved. Good hygiene (including washing under the foreskin) will help with this problem if circumcision is not an option. As this point was first noted in OTL in the 1930s, it will be interesting to see if circumcision penetrates the culture by the 1650s as it did in this time line in the 1950s.
Antibiotic time line
I am indebted to Iver Cooper's work for this section. Iver saved me major amounts of time with the posting of Industrial Alchemy Parts III and IV to the Slush Pile.
Penicillin in and of itself is being produced in small amounts in the USE by 1634, and a small but apparently viable sample of a "high producing" strain has been passed on to a manufacturer in Cologne for further development. I expect that at least three forms will be developed. In OTL, they are known as Benzathine Penicillin, a long-acting, intramuscular form; Penicillin Potassium (Crystal Pen), a fast-acting form that is generally given intravenously; and Penicillin VK, a fast-acting form that is suitable for oral administration. While penicillin allergies are among the most common allergies reported (totaling about 10% of all allergies), true penicillin allergies are relatively rare, and there are techniques available in the up-time information for overcoming this problem if penicillin is needed to treat a particular infection.