I took a look at one of my and @KaTrian's old WIPs set in a medieval fantasy world and realized the medicine in that world is far too advanced for the tone we were originally going for, so we'd like to make that aspect of the story more realistic. What I've gathered so far has been that letting blood and enemas were generally considered the be all end all to most common ailments and that people didn't understand that it was a good idea to keep wounds clean. What I'm wondering is are there any "home remedy versions" of antibiotics they might have used back then? Can any sources of antibiotics (or any equivalents that might help with infections) be found in nature? Or can antibiotics of any kind be produced with the tech they had in, say, 1300A.D? I'd also need any kind of estimates (I don't mind rough) as to the survival rates for the following injuries in the following conditions: the injured character is a strong, healthy 17yo and these injuries go untreated for a few hours or so. If necessary, I could provide some first-aid (like applying bandages), but if it's not necessary, I'd rather take the character as close to death as possible while still steering well clear from the realm of miracle healings. The injuries: -bicep pierced by a sharpened wooden stick (about 2cm or 3/4" in diameter) at the bottom of a trap -a cut on the forearm (about 10cm / 4" long and roughly 0,5cm / 0,2" deep) -dozens of welts / lacerations (not all of them open wounds) on the back from lashes from the buckle end of a belt There's one more injury, but I got a few more questions about that: During a tussle, while the character is on horseback, a footsoldier uses a dagger to stab the character between the thigh and groin (is there an English name for the bend between the two? I mean where the thigh starts. Inguen?), roughly around the inguinal ligament, somewhere between the pectineus and adductor (or thereabouts). How deep can a stab wound in that general area (give or take a few inches downwards or to either side, but not up towards the torso) be without being fatal? I know the femoral artery and vein pass through that general area, and I'd really rather the blade didn't cut those as I want the character to survive (but I don't mind keeping them bed-ridden for a week or two). What are the chances that such a wound, if it wasn't treated immediately, would be fatal? For instance, if it was an inch deep? Two inches? If the artery (or any other major blood vessels) hasn't been damaged, would it bleed a lot? Enough to cause the character to pass out and eventually bleed to death within a few hours? What are the chances of survival (again, ballpark estimate is more than enough) with all the aforementioned injuries combined? Also, any idea how large the usual enemas were back in those days? I think they used clysters, but I'm not sure if there was any standard as to the sizes of the syringes. I'd also like to ask about medieval treatments of urinary tract infection and urinary retention (caused by said infection). I believe they used long, thin metal tubes to get the urine going again, but how high (approximately) was the survival rate of those procedures? Does it matter if the patient is male or female? From what I've gathered, it's a bit trickier to perform the procedure on a female, but correct me if I'm wrong. Would the catheter be removed as soon as no more urine comes out? Is it likely that the catheter itself will cause scrapes and cuts that'll cause bloody urine? How common is it for such an infection to cause urinary retention and at which point since the onset of the infection would it take place? If they managed to drain the urine, how would they then proceed to treat the infection itself? Can cold alone cause an UTI? For instance, if the character lays in deep snow for several minutes (e.g. in -10C / 14F). How big of a difference would it make if their clothes or at least pants were wet? I've heard that sometimes when you choke out a person, they may wet or soil themselves. Does this apply only to choking (unconsciousness brought on by lack of bloodflow to the brain) or can it also happen if the person was knocked unconscious? I'm talking of a fairly severe concussion where the victim is unconscious / borderline unconscious (to the point of being incapacitated) for several minutes, veering close to the time limit when it starts to resemble a coma (but not quite that long). Sorry about the avalanche of questions. I'll keep googling and asking around and I'll retract the questions to which I find reliable answers, but it'd be much appreciated if you folks could answer even some of the questions. Thanks in advance!
I'll get to some other specifics later, but keep in mind, different forms of medicine developed in different parts of the world, most all of it based on superstition. Are you aiming for Europe in the Middle Ages? Antibiotic use didn't start until the germ theory came into being.
Wowsie, T. that is a big list I'll chime in quickly with one answer, will try to tackle the rest later. Penicillin, as produced by Penicillium mould (such as the green-grey mould that can grow on a lemon or bread) has allegedly been used in remedies since ancient times. It was used in dressings and even swallowed in warm tea or soup (if the mould was grown on bread). Honey, also, has been used since antiquity, especially for wound dressings, but generally, as bacteriostatic (prevents bacteria from multiplying). Hope that helps!
Look up sepsis, but it doesn't look survivable without antibiotics. Maybe have them be superstitious about washing a wound with vinegar even if they don't know why it works. Patient co uk helped me. They actually believed I was a fiction writer.
Molds may have been used, that's not the same as saying penicillin, a purified substance derived from a specific penicillium species of mold was used. If you write they used penicillin instead of, they used something like the mold of bread, your readers will balk. From page 2: It's important to keep in mind these remedies were hit and mostly miss. People were not carrying out any kind of systematic studies testing their superstitions. If something appeared to work, it was passed on. But finding something that actually worked was luck of the draw.
Much appreciated. And yeah, roughly in and between where Germany, France, Austria, and Italy stand nowadays. We aren't set on any one of those areas, so we can do some mixing and matching. It does, thanks a lot. I did read about the bread mold -thing, but wasn't sure if the source was reliable. Sooo... they could put honey in the wounds (and then dress them? Stitch them? Or leave them open for a while, wash off the honey, and then dress and / or stitch the wounds?) and make tea or soup with bread mold? We haven't ruled out that option either: they could have one or a few things that were discovered later (e.g. they might know that they need to clean wounds before dressing / stitching them or that they need to take certain plant extracts when they get certain infections, whether they understand why or not, e.g. if it's, like you suggested, a superstitious practice) if that's what it takes to keep the character alive. To all those who are better at biology than me: is it even borderline credible that they'd have some effective natural source of antibiotics? Like e.g. some plant they'd use to create an extract or some such? They might not know why or how the plant affects the patients except that they get cured of certain kinds of infections when they take that plant's extract. I've found a couple of sources (incl. Early History of Wound Treatment by R. D. Forrest) where it's mentioned that in ancient Egypt and Greece they used some molds and plants to make extracts to treat infections with, but I haven't yet found out whether the treatments were successful or not. Anyone know enough to say yay or nay?
One thing I encountered while trying to kill my character... during the Civil War, amputation had a one in five chance of saving someone's life. I also remember a Connections episode where a whole batch of soldiers died while someone was trying to think of a substitute for dipping the limbs in hot oil. I would love to read a story where they encountered a hyper-competent midwife. I heard that one of the inquisitions reset that progress because encouraging the most comfortable birthing positions went against believing in the original sin. (Ate the apple, one of the punishments was that reproduction hurt.)
OK, let's see. First, are you going for realism or do you want to connect the fantasy to threads of realism but end up with fantasy? People didn't know to keep wounds clean until Florence Nightingale began researching wound care in the 1800s Crimean War. And as far as I know that is universally true. But if someone knows or finds out differently, I would love to hear about it. I'm still researching whether Semmelweis got the idea of hand washing because the nurse midwives washed their hands or if it was strictly because he noticed the births they attended had a low mortality rate compared to the male physicians who attended autopsies. I've read a couple different sources on how much attention midwives paid to hygiene. When I'm done with my fiction duology, I plan to write a nonfiction book on the history of nursing that focuses on the accomplishments of nurses that history has typically overlooked. But accuracy matters and what I first thought about Semmelweis' discoveries I've found I need to look further. None of that matters to your WIP except to keep in mind just how recent our knowledge is of the role microorganisms play in disease. Even if practitioners noticed healing powers of locally applied mold, they would have had no idea why they were observing what it was they were observing. To be continued....
I've seen several times the idea of urine used to disinfect a wound and moss off trees or algae used on wounds. This discussion reminds me of a story I once saw on television of a berserker viking that was killed in an odd way. http://en.wikipedia.org/wiki/Sigurd_Eysteinsson
You can't 'disinfect' a wound until you know there are such things as microorganisms. Probably comes from my infectious disease background but I notice when people think we knew about disinfecting before anyone knew germs existed.
I guess I should probably expound on my answer a bit. The purpose of the moss and algae isn't to disinfect, but rather different. The moss and algae have a vascular property that allows them to draw impurities and infection out of the wound to the surface so that it can be regularly cleaned, and to keep the infection from getting into the bloodstream where it can spread and do the most damage. It also helps to draw nutrients out of the body to the surface of the wound so the wound can heal. I learned about this from my grandmother when she used chewing tobacco on a callous on my foot that had become infected. It's pretty amazing really.
You apply a layer of honey, or mould, or some other antimicrobial substance, directly on top of an open wound, and then cover it, either with a dressing or a bandage. Generally, we don't leave things in and then stitch up, unless it's a suture or a supportive mesh in case of hernia repairs etc. I imagine they might have also packed deeper wounds (saturate a gauze, or even some clean fresh leaves, in the remedy,whatever it is, and pack the cavity of the wound. This encourages healing by secondary intention, which means from the bottom up. So you don't stitch this type of wound, but bandage it, and every time you change the dressing, you take the pack out, clean the wound with saline, gently debride it (scrape off gently any slough - dead tissue, pus etc), pack it with fresh dressings, bandage. This can take weeks, but over time, wound gets smaller and smaller, until it's just a shallow ulcer, which you keep dressing until it's safe to leave it out to dry and form a scab. If you want to stitch a wound, say a bullet hole or deep laceration, you first need to stop the bleeding. This is done by applying direct pressure, sometimes for as long as 20-30 minutes. Remove foreign bodies, if there are any, clean and debride, and then stitch, leaving spaces between the stitches so that fluid can drain from it. Cover and leave. This encourages healing by primary intention or closure, the edges of the wound will stick together and after some time, usually a couple of weeks, the stitches can be removed. In this case, they might need mouldy bread, tea or what have you, taken orally, in order to fight infection. There's a long list of natural antibiotic substances, you could have a healer with a recipe for super potent antibiotic tonic or similar. It's definitely credible to have them use natural antibiotic substances, medicine and surgery were very well developed since Ancient Egypt. Perhaps they won't be as effective as intravenous or even oral antibiotics we have today, but it will be better than nothing. People differ individually, infections and injuries differ too. People have been known to recover from just about anything, including having a spear right through their brain. They had to saw the ends of the spear off, and the person lived with the wood in their head, but they lived. In medicine, anything is possible, so since you are writing a fantasy story, you can comfortably push the edge, even if it's unlikely, it probably won't be impossible. Maybe better than asking the questions, because the answers to each are many, tell us the scenarios you imagined, and I'll tell you whether they are plausible or not
If I Google, I see at least one website saying that the ancient Romans noticed that wool dipped in wine, or vinegar, helped in healing, and that applying honey to wounds also helped. The Romans also cared about piping fresh water in and piping sewage away. So while they no doubt lacked a germ theory, they still had some practices that worked.
In medieval times Myrrh was used to treat battle wounds. It has both analgesic and antibiotic properties. Yarrow was another commonly used treatment for battle wounds and was known as "staunchweed" and "soldier's woundwort."
@T.Trian - Here's one you might not have thought of ...and it's been proven recently to work really well at fighting infection. And I imagine you could make story meat out of this: http://news.sciencemag.org/2012/12/how-maggots-heal-wounds
But surely your grandmother knew about the germ theory. However, drawing the bad humors out is a good conceptualization for the Middle Ages.
Maggots are used to debride wounds, leeches are used to establish and improve blood flow to reattached limps and trauma where the blood supply is compromised. The maggots only eat the dead tissue (debridement). The leeches inject anticoagulants to keep blood flowing. I can't recall if they inject any vasodilators. The ick factor is pretty high but the medical principles are sound. I have no knowledge when these practices where first used. But maggots have been described historically as growing in wounds naturally. And leeches go along with blood letting. I could see an ancient healer saying to leave the maggots undisturbed without really knowing why it helped a wound. And even if they wouldn't be reattaching a severed part, putting a leech near a wound could inadvertently improve circulation to the wound. There's a lot of story potential there.
"The vapors" or "Miasma" was believed to be the cause of disease well back into the middle ages. Cholera was believed to have been spread on the Trade Winds when it was really spreading via the sailors. The lower part of London was where the slums were because all the sewage was flushed down the Thames and the smell was overwhelming given the size of the population. If you had money you lived up hill or away from the river. If you were poor you lived where the smells were the worst. It would have been the smell the Romans were escaping, and mythical causes of disease but by coincidence perhaps they also had less waterborne disease. Again I think there is great story potential there. The effect on disease would have been mostly to prevent waterborne epidemics like Cholera. It doesn't take much to contaminate a clean source of water but certainly it would be better than the outbreaks of disease where people get water from contaminated wells and rivers.
I think there were folk beliefs (as today) that were probably fanciful and didn't work very well, as regards healing. Bleeding, for example, to relieve 'apoplexy' and whatever. And you still hear people telling you not to go out in bad weather because you'll catch a cold. But true healers, who have existed as far back as history goes, and in many different cultures, would have done trial and error until they hit upon remedies that worked. They didn't know WHY they worked, only that they did. The use of honey to keep wounds clear of infection, for example. And other such things. They would have passed this knowledge on to apprentices, who would have kept the chain going. It would make sense to read up on herbal remedies, and if the plants used are indigenous to the area where your story is laid, it's reasonable to assume healers would have used them. If you're writing either fantasy or historical fiction from far back there is no reason to exclude natural remedies, coupled with common sense. Just like today, some 'doctors' would have been better than others. I just consulted my book by Ian Mortimer, The Time Traveller's Guide to Medieval England, which is available on Amazon.uk Kindle as well as paperback, and contains a LOT of information you might find useful, including the fact that enemas were administered using a pig's bladder!
Oh, definitely realism in the sense that I want everything to be... how should I put it, physiologically realistic? I.e. nobody gets cured from cancer because they eat sand. But I don't mind making it into fantasy in the respect that I'm willing to differentiate our story's world from the real medieval Europe in regards to when medical discoveries happened. I'm leaning towards giving them knowledge that methods A, B, and C work for ailments X, Y, and Z, but that they wouldn't know why they work, just that they do through trial and error that they or their predecessors have done even though the methods (A, B, C) would have been discovered later in our world. In the story, there's one character (a monk) who's heavily into medical experimentation and since he's hung around a lot of war zones, he has had plenty of chances to learn and test his theories in practice to see what works and what doesn't as well as to learn from other doctors working on the wounded soldiers. Okay, this'll take a moment, but here goes: As I mentioned, the character is 17, strong, and healthy (5'10 / 145lbs if that matters). It's a girl dressed up as a guy, so when she ends up in a fight against a few men, they don't go easy, thinking they're fighting another guy (she's actually trained fencing, she's fit, and has a sword, so that's why she doesn't get slaughtered in the first two seconds). In that scene she sustains the cut on her forearm, the stabwound in that as-of-yet unnamed bend between the thigh and groin, gets kicked in the knee by a horse (at this time I just made it swell up bad, but it didn't break or dislocate). Add to that a few knocks to the head and around the body. When she gets away from the guys (a friend of hers joins the party and draws the men's attention away from her, so she manages to limp away from the fight), she escapes into a forest, but the area is the hunting grounds of a local group, so they've set all sorts of traps. The character has lost enough blood and has exerted herself to such a degree that she starts passing out on her feet (kinda like you do when you push yourself too far in training), i.e. first her vision fills up with stars and then starts going dark, but she's still upright and conscious at that point. Because she can't see, she walks into a trap, a pit with spikes in it, but since it's an old trap the group hasn't reset yet, most of the spikes are broken or bent after the last larger animal fell into it, so only one spike injures her, piercing her bicep. As it stands now, she passes out at that point from bloodloss and 'cause she already had a concussion and, to add to that, hit her head in the bottom of the trap as she fell. I haven't and won't specify how long she's unconscious, but the group finds her in the trap and drags her along. They bandage the worst wounds (and perhaps use honey or some such to ward off infection, but not necessarily... if she can survive without, I'd rather they did shoddier work on her), but 'cause it turns out they're on different sides of a dispute, they choose to leave her in the forest to die. In the current version, her friends come looking for her the next day (around late noon, early evening) since the friend who could fight, also got injured and couldn't go after her straight away. Anyway, they carry her to a house and send for the aforementioned monk to help patch her up. How does it sound? Right now, she's bed-ridden for roughly a week and isn't back to full health until after something like.. 5-6 weeks, but the way I've written it so far, the stab wound between the thigh and groin never heals properly (it opens a few times before it's fully healed and often aches when she trains too hard or when they move to an area with a cold, snowy climate). In the snow setting, it's the same character who gets busted up again. Her group fights a bigger one, but their opponents are already wounded from a previous tussle, so that's why her group pulls through, albeit all with various injuries. Anyway, in that fight, she ends up grappling with a bigger guy who wrestles her to the ground (into knee-deep snow) and proceeds to pound her into unconsciousness (after he sits on her and starts hitting her head, she turns her back to him, so several punches land on the back of her head and neck). I'd estimate she receives about 10-20 punches to the face (not nearly all of them land cleanly or to the same spot because at that point she's still fighting back, trying to block the punches etc) and around 20 to the back of the head, around half of them after she's already fallen unconscious, but the guy is wearing only leather gloves instead of gauntlets. That happens fairly early into the fight, so after the guy leaves her in the snow, it takes around 5-10 minutes before anyone checks on her. She wakes up pretty soon, but is kinda like someone waking up from an opiate OD: can't really move, doesn't know where they are, what day it is, don't make any sense (and she has trouble talking anyway 'cause of the bruised, cracked, swelling lips) etc. The healer monk is among the first to get to her, and they're a couple of hours from the closest village where they rent a room and he starts patching up their fighters. That's the scene after which I figured she might've gotten the UTI and the consequent urinary retention which they would've fixed with a catheter and, to treat the UTI, some "natural" antibiotics. Any thoughts on that? I realize this is a lot, but any help would be really appreciated. Thanks, Jan! I actually saw a mention of that on the headlines of a local newspaper a week or so ago, but I didn't read the article. Maggots might definitely be a part of our fantasy world's medicine.
For what it's worth, I always assume that there's a chance that the ancient Romans were more, rather than less, advanced than the people of the Middle Ages on any given topic. That doesn't necessarily mean that the Romans had a germ theory or anything similar ("anything similar" probably being a respect for cleanliness even without a modern theory for its value), I'm just saying that the fact that it didn't exist in the Middle Ages doesn't necessarily mean, to me, that it didn't exist for the ancient Greeks and Romans.
@T.Trian : The bend you are referring to is called 'inguinal region' but 'groin' is the layman term everyone will understand. Ok, the rest sounds plausible. I've seen many a deep groin knife wound, in A&E, presented to me a week later, quite deep as well. They stopped the bleeding but the infection and movement kept opening it. The only thing that isn't very realistic is that it 'never heals properly'. That would be painful, she'd end up septic, her strength would be sapped. She could have a chronic abscess in there, but that's bad news. I'd sooner believed someone had super powers of immunity, then that they carried on fighting with non-healing groin wound. I say, stitch it up, load her up with medicinal herbs, and she will be ok in say 2-3 weeks? If she ends up with an ulcer, that either needs draining straight away, or it can drain by itself, weeks later (thus explaining her ongoing symptoms) by erupting through the skin. Once it does, wash it, debride it, pack it with dressings soaked in antibiotic ointment, heck even throw some maggots in there for a bit, and let it heal with secondary intention over the period of couple of months. Ok 6 weeks is good too. So you have a few options there. Must go have dinner, be back later for the rest
Thanks, @jazzabel, that gives me some ideas. Is any of those injuries something that might bug her for a longer time / the rest of her life? I don't mean anything debilitating, more like a slight, annoying ache now and then. I could always break something...? That came off more malicious than it sounded in my head. Btw, where did you come up with the ulcer? Would it be the sepsis that causes it? Maybe I'm misunderstanding 'ulcer' here. I feel like such a layman... How about the whole catheter-business? Can anyone die of the medieval version of the procedure? Are there any common complications, like a bit of blood in the urine from the catheter itself? Bon apétit!
@T.Trian : I didn't get the connection between the UTI and head injury, but UTI doesn't cause urinary retention in young, healthy people. It causes urgency to urinate even if bladder is empty, pain when passing urine, pain in bladder area, nausea, feeling dreadful, temperature and in the elderly even delirium. Urinary retention happens either due to neurological damage, in which case it's probably progressive or irreversible (like in MS or paraplegia) or a blood clot in the bladder, or a stone, or in men, enlarged prostate and other things that can cause obstruction. So if she has ordinary UTI, that can definitely be treated with herbs. No catheter is needed. Vitamin C acts as bacteriostatic, so taking lots of it will acidify the urine and help fight urinary infection. Alkaline things like baking soda will alkalinise the urine and alleviate some symptoms of the UTI, whilst the antibiotics take effect. Cranberry juice can help, but really, flushing the bladder with water would also help. The head injury wise, it's a lot of punches to the head abut importantly, she sounds like she has a concussion, but I'd be worried about skull fracture or more serious trauma to the brain, such as subarachnoid haemorrhage. You don't want her to have that, so better stick with a concussion. Her zygomatic (cheek) bone, maxilla, mandible, nose or orbital ridge could be fractured, giving her deformity, swelling and difficulty talking. In the old times healers knew how to 'set bones', in fact the tradition still persists in many Eastern European countries, so that can be dealt with. Following the concussion, she can be sleepy, but needs to be monitored (observed) for at least 24 hours. She can throw up a few times, but shouldn't be vomiting profusely, her headache shouldn't be so bad that it can't be alleviated with painkillers, and she should not be having episodes of fluctuating consciousness (usually sign of more severe cerebral damage). She might have some patchy amnesia involving the time around injury, and also, all her neurological functions should be intact (equal pupils, no weakness or seizures, no vertigo, no blindness, no bloody or clear discharge from ears or nose, no problems controlling her bladder or bowels, well oriented in time, place and person, intact cognition etc).
@T.Trian : Definitely, after some years of heavy fighting, she can develop chronic subdural haematoma like boxers do. She might have some mild cognitive damage and soft neurological signs (think pro boxers). Any significant musculo-skeletal trauma, broken or dislocated shoulder for example, even a bad bruise or a sprain, can ache in colder weather. She can also have repetitive strain injury, wielding a heavy sword can give her chronic elbow, wrist or even shoulder pain, so she'd need to rest it, or rub anti inflammatory ointments or even get some old school acupuncture once in a while. Ulcer-wise. Imagine having a deep cavity, say an infected knife wound in your thigh 8x10 cm in width and depth. You have to heal it up like I described above, with secondary intention method. The way it heals is from bottom up, so the base of the wound recovers first and over time, as you keep cleaning and debriding and packing it, the cavity gets smaller and shallower. Until one day, it's say 2cm wide and 0.3 cm deep. It hasn't healed yet, you still can't bring the edges together, it still has a bit if debris on top, which makes it an ulcer. If it's shallow enough, and infection is under control, you can leave it to scab over. You couldn't do this with an 8x10 deep infected wound, but you can now, when everyone beneath that shallow ulcer has healed from the bottom up.
