Monday, 25 August 2014

Infection: the Car Crash Killer of the Past

One of the aspects of writing historical fiction is showing how things have changed and how some things never do.  This month I planned to write purely about infection in a world without antibiotics and a full understanding of how infection spreads; i.e. the past.  As I composed this blog it expanded as I thought more about what was the biggest killer in the past and how it affected people.

I try to get things right when writing historical fiction, though I always focus on story first.  Clothes, tools and the environment are a starting point.  I'll admit, I tend to abandon the language because if the reader was experiencing the time and place like a native, it wouldn't feel strange or out of place, though I do try to avoid modern idioms.  Attitudes I keep, and that had me thinking:  what was the common killer and how does it affect people's thinking?

Antibiotics have been around for approximately a century.  That's almost three generations where infections, on the whole, have gone from stalking death to something a handful of pills can deal with - most of the time.

Today in the UK about 37,000 people a year die of sepsis.  That's in a population of roughly 60 million.  In the USA it's 700,000 infected with up to half dying in a population of approximately 300 million.  Until antibiotics came along the proportion of deaths was much larger.  Infection, coupled with diseases like cholera, was the biggest killer unlike today, where in the 'West' it is cancer and heart disease.

Until World War Two and the arrival of antibiotics, in almost all conflicts, more soldiers died of infection than from direct action.  There is a lot of concern about the reduction in antibiotic effectiveness and what would happen in our modern world without them; however, it mustn't be forgotten today there is a much better understanding of what infections are.  It gives us possible methods to beat them if this powerful tool is lost.  And of course, there is a massive pharmaceutical industry busying itself on solving the problem, for profit, but solving the problem all the same.

Our ancestors chance of surviving what we arrogantly call simple infections was much reduced.  Their understanding was limited, their weapons against the danger even more so.

I wanted to flag up death through infection as an effect on people and their attitudes.  Common causes of death over time change. Today the motor car kills more than war and terrorists combined, yet international murder gets the headlines.  Throw in all gun-crime and the car is still ahead in the life-ending.  Before the car, it was infection, grinding away at our numbers.

Think about infection and then think about your attitude toward cancer, heart attacks and road accidents.

Infection and Disease

Antibiotics are fantastic, they have saved millions of lives, but before them a simple scratch, a throat infection or an insect bite could kill  and people knew it.  Here's two famous people who died that way:

In 1799 George Washington had a sore throat aggravated by cold weather and getting soaked while out working.  That's another historical thing to note:  poor wet weather gear.  The infection, with no effective treatment, grew worse until taking the life of the great man.

In 1923 The Fifth Earl of Carnarvon, sponsor of the expedition that discovered Tutankhamen's Tomb, died from an infected insect bite.  Forget about the curse cobblers, with nothing to halt an infected wound,  he hadn't a hope.

What killed them we would hardly worry about in the modern world.

There used to be sepsis wards where the infected were kept isolated, tended to as best the medical staff could, but it was up to the poor sufferer's body to win or lose the battle for life.


When you think of King Henry VIII of England, which wife do you think of?  Is it Jane Seymour?  She was dead at twenty-eight years old, not by her husband's hand, but weeks after her first child was born.

It fits with the misconception that childbirth was the biggest killer of women until modern medicine started to turn the tide.  It's not that simple.  It's obvious many of the crises and traumas of childbirth were beyond the medicos of history; however, statistically it wasn't the biggest killer, infection was, but it played on the mind of every woman, probably many fathers-to-be too.

In The Tudor Housewife by Alison Sim there is an extract of a letter from a Lady Cornwallis to a friend.  She is expecting a baby and is terrified.  It's her fourth child; so it's no new mother-to-be's fear.  She's like a soldier going back to the front line.  She knows the risks and there is nothing she can do, but face them.  If you're writing a story of a happy couple expecting their first child it should be twinged with more anxiety than today.

Infection and diseases were big killers and even poor Jane Seymour probably died from an infection than the giving birth itself.  Childbirth made the mother more vulnerable to the risks about at the time.  Compared with everything else that could kill, childbirth was relatively rare even in the past - or there wouldn't be so many of us about now - though it was at the forefront of women's minds.  Ms Sim has a good theory, that since all the women of a household would attend a woman in labour it meant one terrible death would be witnessed by many.  This plays out for infection in general, there were few hospitals, at least that the ordinary soul could afford, and so death would be in the home, witnessed by all.

I like to think about attitudes, a good example is the midwife.  Sometimes a professional, sometimes a woman with a reputation for success.  In most past cultures where women received little respect or power, a midwife would be different.  Imagine a pompous male physician, with little time for folk remedies or amateur meddlers, especially women.  When it's his wife that is expecting, no matter what her social status, the best midwife in the area will be with her when the time comes.  Imagine the irony of a supposedly educated man deferring to Old Mother whoever, who can barely make her mark.

One of my great grandmothers was such a woman.  Without a medical certificate to her name,  her reputation was all she needed.  She turned down an offer of employment from the local doctor because of a fear she would have to charge for her services and thus price the poor out of the help they needed.

In middle ages Europe midwives were allowed to baptise children if they thought they wouldn't survive, so as not to suffer a death outside the Church.  Now there's power to the notionally powerless especially if you think about how many organised religions of the time liked to keep its power in male hands.

Flesh Wounds

There is no such thing as a 'flesh wound'.  Think about this the next time you get a paper cut and how much it hurts.  Then imagine the savage slash of a blade opening muscle or a bullet doing the same.

I love action movies, especially the 1980's and 1990's ones.  The heroes getting progressively cut, battered and bruised as he - and it is nearly always a he - battles apparently insurmountable odds.  Trouble is, I've seen historical versions and there's the catch.  One scratch could kill you, a bit of fabric trapped in a wound would go septic.  Your square-jawed hero could save the day, only to die a week later in a fever with puss pouring from what had been a simple cut.

If you are writing a historical tale, it's worth studying a bit of medicine and the medical theory of the time.  for poor George Washington, the physicians thought bleeding would remove the poison, where of course it weakened him further.


Our ancestors didn't die with every paper cut, wood splinter or sword blow.  Alexander the Great received eight notable injuries.  Lapham's Quarterly has a good diagram here of the locations of the wounds.  These didn't kill him.  I once read (sorry, can't remember the book) about a soldier from the War of the Roses who took a sword blow to the face.  He survived and someone rebuilt his features as best they could.  That is re-constructive surgery from five hundred years ago.  

Folk remedies too,  based on generations of experience saved lives; for example:  the importance of a clean wound and the efficacy of salt, were well known.

In Ian Mortimer's book The Time Traveller's Guide to Medieval England: A Handbook for Visitors to the Fourteenth Century, he reminds us that as time travellers we'd meet many people with limps, deformed arms or other disfigurements.  People did get injured, but they got better too.  Elizabeth the First of England was scared with smallpox.  That was a big killer of the time, but she survived, as many did.

When writing about the past remember the car crash killer is infection grinding away, poorly understood, but battled all the same.  It would be thought about like cancer and heart attacks are today and finally the power to heal can give rights to those who often have none.

Useful Books
The Tudor Housewife by Alison Sim.

The Time Traveller's Guide to Medieval England: A Handbook for Visitors to the Fourteenth Century by Ian Mortimer

Useful Links

Eye Witness to the Death of George Washington - An eye witness account of the First US Presidents final days.

The 5th Earl of Carnarvon's Death - A letter in the Lancet giving the details of the Earl's infection and death.

Sepsis: Antibiotics 'not working'  - A recent article about the current state of sepsis in health care.

A Historical Perspective on Sepsis - this paper says over 700,000 people in the USA get sepsis annually, up to half die.

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