Grantville Gazette 35

The Progression of Trauma Care and Surgery after the Ring of Fire, Part 2

As in Part 1, I'll include a number of references in this article. Most will be to either canon or Wiki articles giving more detail on some topics than I can include here. I also wish to thank Panteleimon Roberts, Danita and Nimitz Lover for their off Bar input.

For some things, there are no good substitutions.

As I noted at the end of Part 1, only a limited amount of suture material came through the Ring of Fire (RoF). Some is at the physicians' offices, some at the veterinarians' offices, and possibly some at the nursing home. Dr. Ellis or Dr. McDonnell might have a couple of spools of black surgical silk stashed with old office equipment. Because of the war and the change in medical conditions, this small supply will rapidly be used up. I don't know what stocks of plain (unflavored, unwaxed) dental floss will be available at the RoF, but the floss is fine enough and limp enough to thread through eyed needles, as well as strong enough and has a good enough "hand" (the ability to be securely knotted) to act as an impromptu suture material once sterilized.

Up-time, we have a wide variety of suture materials,[i] but down-time the Grantville medical community's options will be limited, at least until material sciences catch up. It's interesting to remember that thread sizes were standardized before specific sutures were in regular use, with size 0 being the smallest thread that could be spun with early-nineteenth century technology. As suture materials advanced, smaller and smaller threads and filaments were made, requiring more and more zeros to indicate the sizes. While up-time sutures are available down to 11-0 size (used for corneal surgery and requiring the use of an operating microscope), the most common sizes used range from 3-0 to 6-0, which is as fine as most human hairs. Size 0 and even #1 sutures are most often used to hold chest tubes in place, or provide closure (when passed through buttons) in very obese abdomens. The use of smaller sutures, along with earlier removal, leads to less scarring, especially on the face.

The first absorbable sutures available down time will be processed from sheep gut. This material was used in Our Time Line (OTL) through the 1990s and is similar to the strings used for violins, violas and tennis racquets. In OTL, two forms were used, plain and chromic. The difference between the two was a treatment with chromic salts that makes the chromic-treated (essentially tanned) material last about twice as long as the plain, at an increased risk of serious inflammation. Gut is best sterilized with iodine solutions, a technique developed in 1906 in OTL. The synthetic absorbable suture materials (polyglycolic acid derivatives)[ii]will probably appear around the same time as nylon and polyethylene sutures do, as the same kind of advancements of the organic chemical industry is needed, and sutures done with the synthetics heal much better than those done with gut. This is especially true in plastic surgery and where absorbable sutures are needed near vascular repairs.

Early down-time non-absorbable sutures will include braided silk, spun cotton, and silver wire. Linen thread may also be used, although it is stiffer than cotton, and causes substantial inflammation[iii]. Both cotton and linen are more flexible and actually stronger when wet, which helps make them useful for suturing. Point of use sterilization will consist of wrapping the suture material around a soft core like a rubber tube and boiling it for twenty minutes. A sample should be weight tested for tensile strength before use.[iv] Braided polyester will probably be the first up-time suture material redeveloped, as it will be usable with the same kind of eyed needles as the silk and cotton.

A fair chance exists that some of the thinnest suture material for a few years will actually be iodine treated horsehair. This is the closest thing available to fine monofilament sutures and is soft enough to thread through the eye of the smallest needles.

Up until the early 1950s in OTL, all surgical needles had eyes to hold the thread, just like the common sewing needles from which they were derived. Despite modifications of the eyes to allow the suture material to lay flat along the tail of the needle, the bulk of the doubled thread causes more trauma to the patient's tissues than the simple passage of the curved needle.

In the early 1950s, a technique to swage the hollow butt end of the needle around the bitter end of the suture material was developed. This resulted in an "atraumatic" needle/suture set, which is much gentler to the tissues than the older method.

One reason for developing the swaged-on units was that monofilament suture materials were too stiff to lay properly in the grooves of an eyed needle. Fine (5-0 or smaller) monofilament suture material, needle drivers, and small swaged-on needles are all necessary preconditions for the development of vascular and cardiac surgery, as was noted in Part 1 of this series. Monofilament suture materials' stiffness does mean that it is more difficult to tie those materials securely. Despite their extra stiffness, monofilament sutures have advantages over the braided forms, both in reduction of tissue damage, reduction of tissue irritation, and reduction in the chances of post-operative infections. Over time, the braided or spun materials allow bacteria to follow the suture track deep into the tissues. Monofilament sutures decrease the risk of this effect. Both nylon and polypropylene may be available before 1640, and but probably not by the time stainless steel needles should be available-around 1636-37. These polymers are easily drawn out to fine monofilaments, especially with the expected down-time technological advances between 1631 and 1640. Thus, braided polyester and silk will probably be the first suture materials to benefit from swaged on needles as a result.

Up-time, swaged-on suture materials come in a variety of precut lengths, generally from 18 inches (45 cm) to 36 inches (90 cm). They are normally double wrapped and sterilized by radiation from Cobalt 60 or other high gamma radiation source. Steam sterilization will work for all of the natural materials except gut, and most of the synthetic materials. A caveat is that heating the monofilament materials while they are coiled may cause a "set," which makes the suture material much more difficult to deal with.

Needles in a Needle Stack[v]

Suture needles themselves come in a bewildering variety of sizes, shapes, and points, many of which are more or less interchangeable. The vast majority of needles up-time have a curve because this allows the needle to pierce flesh with a simple twist of the hand holding the needle driver. This also allows the tissues to meet together in a more natural position. While simple, tapered (conical) pointed needles will have some utility, most often there will be a triangular point with a cutting edge stretching along the inside (cutting) or outside (reverse cutting) of the curve. Straight needles are rarely used, being generally much larger (employed with the hand and not a needle driver), and reserved for situations where that is a feature and not a drawback. One example is closing the wound around a chest tube and securing that tube in place.

Stainless steel has already been mentioned as being the critical material for the development of instruments, suture needles, and orthopedic fixation wires. These three items will be the major driver for the first "laboratory" amounts of stainless steel, as even these small quantities of stainless will be useful. As other material sciences develop, it will be useful for hypodermic and intravenous (IV) injection needles and as supporting needles when intravenous catheters are re-introduced. As supplies increase in quality and quantity, other uses, including as staples for closing the skin (usually done one staple at a time) and for automatic stapling devices for bowel resections[vi] which place up to seventy small staples at a time, and for use in orthopedic plates, screws, intramedullary rods and prosthetic devices to replace hips and knees. Stainless steel will replace silver for closing traumatic gaps in the skull, and stainless steel wire will provide the extra strength needed to reinforce bones that have been cut or splintered, including the sternum (breastbone) after chest surgery. Eventually, exotic alloys and titanium will replace stainless steel for most of the prosthetic devices, but this will probably not happen until the 1650s at the earliest.

Where will it all come from?

Supply sources for all of these developments will end up spread across the USE and into the Union of Kalmar. Secondary sources will develop in the Lowlands, Padua and Venice, and France. In canon, we already have Lothlorien Farbenwerks (initially cannabis[vii], but later dyes and their derivatives); Manning's Medical Manufacturing (3M)[viii] (the providers of insulin among other medications); Daisy Matheny BioLabs (the re-developers of tetanus toxiod[ix], as well as other immunizations); Essen Chemical, (one of the first producers of chloramphenicol, HTH (calcium hypochlorite-used for water purification); gamma hexane hexachloride (one of the safest effective synthetic insecticides), and sulfanilamide[x] outside of Grantville). Other sources include The Antonites, a Franciscan monastery, (producers of decent crude penicillin from a mashed pea soup with a trace of borax[xi] after obtaining their initial culture material from Grantville); and several steel makers. One of the more important people working to provide steel will be Louis de Geer (1587-1652), who controlled much of the Swedish steel production[xii] and who is working closely with Essen Steel. The first imports of chromium could not arrive before the fall of 1635, and more likely sometime in mid to late 1636, from the mines in Maryland. Despite the amazing amount of down-time brainpower that can be brought to bear on the problem, it will be decades before some of the more exotic alloys, including titanium, will be available.

The various orthopedic pins and wires will be easy once high-quality stainless steel is available, as they are pulled in wire mills, and then threaded if needed. It will take some experimentation for the blacksmiths and instrument makers to get the surgical instruments correct. They will probably start with the scalpel handles, then larger clamps, then scissors, and finally the smaller clamps as their techniques improve. Most of the clamps use "box" hinges, where one part fits inside a "box" formed in the middle of another. This is the reason I expect master instrument-makers being associated with each of the New Model medical schools and with the larger New Model teaching hospitals.

As I recall, carbon steel needles in the early modern era were some of the more expensive items that a woman or tailor could own prior to the RoF; and those needles were rather larger than most of the ones used in surgery[xiii]. Add in that the swaged-on models can't be reused, and the cost of needle making will have to drop substantiallybefore the swaged-on models become practical.

It does help that some form of needle making (to support the growing sewing machine industry) is effectively in canon, even if I can't recall it being directly mentioned.

Duct tape but not bailing wire.

Another item that will be in short supply will be sticky tape, especially tape safe to use on human skin. While there are many field expedients (ripped petticoats come to mind) to bind dressings[xiv] to the victims, and many other type of non-adhesive bandages (in addition to rolls of gauze, and triangles of linen called cravats, Dr. Scultetus was credited with the development of the "many tailed abdominal bandage" that bears his name to this day) in OTL, surgical tape was not developed until the late 1800s, after the development of rubber-based adhesives. Adhesive bandages (Band Aid ™ brand bandages or British "sticking plasters"), with the dressing (a sterile gauze pad) already attached to a strip of tape, were not developed until the 1920s. By CE 2000, there were a wide variety of tapes, including many that could be directly applied to wounds as a form of closure (SteriStrips ™ were commonly used to replace sutures or staples after the first stages of healing have completed, reducing scarring). There is also a technique called "butterflying[xv]," where a strip of tape is cut one-third in from both sides, the edges folded back on themselves, and the central portion passed through a candle flame to sterilize it before the strip is applied to close the wound.

Once rubber-based adhesives are available, basic white surgical tape is a matter of mixing the adhesive with zinc oxide to reduce the growth of bacteria and modify the "tackiness." The mixture is then spread along a length of tightly woven, light- weight canvas duck material, and allowed to dry slightly, before being rolled on a wooden or cardboard form. This produces the familiar "sticky tape" that was the standard for securing dressing until the mid 1970s, when more advanced forms (with improved adhesives and lighter, sometimes even non-woven, fabrics became available. This old-fashioned adhesive tape is now mostly relegated to protective taping of athletes, and to improve grips on tools and sporting goods.

How will Grantville influence the development of trauma care and surgery in the New Time Line (NTL)?

The three most important contributions to surgical care that Grantville brings back are the "Germ Theory of Disease," the idea of controlled anesthesia, and 350 years of surgical history. The first leads to propagating aseptic (without infection) surgery methods, which is the first and most important method of preventing needless postoperative complications and death. The second allows the surgeon to operate meticulously when needed, rather than concentrating on speed. By the 1630s, there are already skilled surgeons who can remove a leg above the knee in less than five minutes, but the survival rate of their patients is dismal. Those same surgeons, operating aseptically, and with the advantages of controlled anesthesia, will probably take more than four times as long to remove a leg, but most of their patients will survive the surgery and potentially even thrive. Add in the descriptions of the most important of the 350 years of up-time developments and the open abdominal surgeries already in canon, and the science of surgery will take off in the late 1630s as it did in the 1920s in OTL. The major limitation to surgical advances between 1631 and the late 1630s will be the need to develop the supporting infrastructure, including building hospitals with aseptic operating rooms, creating and producing the needed instruments and redeveloping other materials, including sutures, antiseptics and anesthetics.

Those novel (to the down-timers) techniques will include such procedures as the development of a skin and muscle flap to close the stump of an amputation, bowel resections and colostomies for trauma and cancer, and tracheotomies and the use of chest tubes for the relief of ventilation problems in trauma, cancers or certain diseases. As the technology catches up, there will be a second expansion of surgical techniques, including cardiac and brain surgery, in the late 1640s and 50s, much like that seen in the 1950s and 1960s in OTL.

Aseptic Techniques developed out of the Germ Theory.

Prior to the medical establishment's understanding that there were organisms that caused disease, and those miniscule organisms could be transmitted between the sick and well by instruments, contaminated dressings, and even the very clothing and hands of the physicians and nurses, infections were commonplace consequences of medical care. Before the development of aseptic techniques, any surgery or even much of basic medical care, created almost as much a chance of a nasty death as a wound in combat. Aseptic techniques will cover the operations themselves, the care of the patient afterwards, and just as importantly, the care of the operating instruments themselves.

In OTL, there were several champions of cleanliness in health care. Beginning with Ignaz Philipp Semmelweis in Vienna, and Florence Nightingale in Great Britain, both in the middle of the 1800s, devotees of medicinal cleanliness included Joseph, Baron Lister in Great Britain, Louis Pasteur in France, and Robert Koch and Friedrich Loeffler in Germany in the later years of that century.

One interesting point is that the efforts of Ambroise Pare in the mid-1500s should be remembered in 1630, while they were largely forgotten by the 1800s. Mr. Pare, a barber-surgeon, was instrumental in developing techniques that allowed the French army to reduce the complications from field amputations by a large degree, mostly by avoiding the use of large-scale hot cautery to stop the bleeding of the stump, and an advanced understanding for his time of the value of cleanliness in wound healing. Add in the extra operating time allowed by the anesthesia to the benefits of aseptic technique, and Mr. Pare would have been ecstatic over up-time style care. Dr. Scultetus is in canon as having traveled to Jena and Grantville to learn these very techniques, and he was as honored in his time as Drs. Crile, Halsted, and Oschner are in OTL.

Baron Lister's ideas of "antiseptic surgery" included developing mechanisms to provide a fine mist of an antiseptic solution of carbolic acid (phenol) before and during the operation, ceasing the sprayers when the wound was finally dressed. Building on ideas put forth by Florence Nightingale on the need for clean, fresh air circulation to prevent disease, other physicians discovered that the baron's ideas, while good, caused problems for the patient and the operating team. A modified version of antiseptic surgery arose, where dust-catching filters and germ-killing ultraviolet lights were placed in the air ducts leading to the operating room. Air in surgical suites is constantly cycled through those ducts, preventing the airborne transmission of disease without exposing the operating team to the toxic germicide. Ultraviolet lights of this nature require a special type of glass that passes a higher percentage of those frequencies, but that is one of the few problems with reproducing them in the NTL.

Another place the ideas of Baron Lister and Florence Nightingale are likely to cross is in the construction the Operating Rooms and the insistence on thoroughly cleaning them after each use. Walls and floors of operating suites can be covered with closely set, well-glazed tile as was done in OTL from the 1920s to the early 1970s. Floor tiles may have a slightly roughened surface for the sake of better footing, or terrazzo floors may be used, with some of the up-time tricks making this application easier. Ceilings will probably be enamel-coated "tin" (galvanized steel), as these surfaces can better resist most common cleaning and disinfecting solutions. The tin ceilings will probably be very plain, with only enough embossing to increase the strength and help reduce some of the sound reflection, rather than the almost baroque pressed tin ceilings remaining from the Gilded Age here in the US. There will be one or more drains with "U" traps set in the floor, leading to a separate septic system, allowing for easy disposal of blood or other contaminated body fluids that might spill on the floor, as well as other spilled liquids.

The walls would be sprayed down using a pressure-pumped sprayer, similar to those that have been used by gardeners for fifty or more years before the RoF, and then wiped down with cloth pads on poles long enough to reach the ceiling. This same solution, probably a mixture of formaldehyde in alcohol and water (Formalin, also used as a preservative for tissues preparation) initially, later, one of several others as safer but still effective chemicals come out of the various laboratories, will be used on all environmental surfaces, not just the floor, walls and ceilings. Calcium hypochlorite solutions are another possibility, but this carries more risk of corrosion of various metal parts if not completely rinsed off. While the rooms will need to be completely aired out after the use of the Formalin protocol, the chances of corrosion are much lower.

As noted in Part 1, mild steel tends to rust if left wet. Salty solutions like blood and body fluids just accelerate that problem. Prompt cleaning with mild soap and water using a scrub brush, an initial acidic rinse to remove the last of the salts, followed by a clear distilled-water rinse and air-drying will reduce the chances of corrosion to an absolute minimum. Once dry, the instrument sets are re assembled according to standardized packing lists, wrapped with linen cover wraps, and then steam sterilized. This is again followed by adequate drying time to prevent corrosion. This means that the scrub nurse or technician in the OR will need to stop and lubricate the various hinges with sterilized mineral oil during set-up for the operation, but that is a relatively short procedure. As has been discussed on Baen's Bar, large amounts of high-chromium stainless steels are years, and the exotic alloys probably decades, down the road from the RoF. Doctors Nichols, Scultetus and their colleagues are stuck with mild steel for their new instruments at least through the end of 1636.

Baked, marinated, boiled or steamed: Instrument sterilization in the 1630s

The most common methods of sterilization after the Ring of Fire will include baking at 400°F for at least sixty minutes, the use of formaldehyde or glutaraldehyde[xvi] as cold sterilizing agents, or the use of small-scale steam sterilization. A twenty- to thirty-minute rolling boil in clean water will be a field expedient sterilization method, when a pressure cooker for steam sterilization is not available. I would expect that at least some of the medium sized (sixteen- to twenty-quart) pressure cookers that were to be found in many of the households of Grantville were purchased for use by the medical teams sent out from Grantville, but I did not find any mention of this in canon.

Of these methods, steam sterilization is the preferred method, due to its effectiveness and relative simplicity. It involves fifteen pounds of gauge pressure of steam for thirty minutes, followed by at least an hour to dry in the residual heat after the water and steam have been removed. This may be accomplished in a home pressure canning unit, as noted above, or in a small (six- to fifteen-inch diameter) commercial autoclave unit. Each of the physicians' and dentists' offices should have one of the smaller (six- to ten-inch diameter), and the veterinarians' office should have a larger (twelve- to fifteen-inch) model to handle the larger instruments used in large animal surgeries. Industrial-sized autoclaves (large enough to walk in, and capable of handling cart loads of instrument packs) will be developed by the time the Leahy Medical Center (LMC)is ready to use them, as they are a simple, relatively low pressure, extension of boiler technology. The only tricky part is designing and sealing a pressure tight door measuring up to six feet on a side. Smaller versions of the industrial model, measuring two to three feet on a side, will be commonly used in microbiology laboratories to prevent the spread of contamination from the used Petri dishes as the glassware is sterilized before cleaning and reuse. Almost as tricky will be reproducing the treated paper strips used to confirm that the steam (and therefore the heat) has penetrated to the center of the instrument packages. This will probably be a matter of the analysis of samples from existing stocks of those indicators at the RoF.

A positive demonstration of the sterilization will involve placing a paper packet of bacterial spores, most commonly one of the highly heat-resistant Bacillus species, in the middle of the autoclave load, and putting the spores on culture media (in the microbiology lab) to see if they will grow. If the sterilization is satisfactory, the spores will not show growth in the twenty-four hours after plating, and the load can safely be used. This does presuppose that the LMC will have enough equipment by that time to allow a load to sit for the needed day without being used. This was the industrial best practice when I was working in the sterile instrument department of St. Joseph's Hospital between the time I completed college, and went to basic training. Not much had changed by the late 1990s when I used similar but much smaller-scale techniques in my small town office.

A major problem with the reuse of the items designed to be "single patient use" is that many of them contain heat sensitive plastics. These will not stand the rigors of steam sterilization. It will be several years before ethylene oxide (mid-1630s?) or decades before Cobalt-60 (probably 1650s) radiation sterilization techniques will be practical. Careful cleaning and rinsing, followed by immersion in various solutions of formaldehyde and methanol, will most likely be used in the first years of the 1630s. The more stable, but still toxic, glutaraldehyde solutions should replace the others when it is available, probably around 1635. Because of the toxic nature of these disinfectants, a prolonged period of aeration will be needed to prevent the next patient from being exposed to any residual chemical fumes. Done properly, this "cold process" provides acceptable (even by up-time) standards levels of sterilization, leaving many opportunities for someone to write a story where something happens because it wasn't done correctly.

Cleanliness is next . . .

One thing that carried over from Baron Lister's "antiseptic" surgical ideals was the need for a full skin-scrub for both the patient and the operating team. While the operating team only needs to scrub their arms to the elbows, the Lister's carbolic acid (phenol) solutions were replaced in OTL with first dedicated surgical cleanser: Tincture of Green Soap[xvii], which contains liquid Castile soap along with 15% by volume alcohol and a small amount of glycerin. This is not the best antiseptic solution to use, but, given adequate contact time, it is effective. While iodine is in canon by 1634, derived from seaweed, the iodophor compounds are not going to be available early on. Tincture of iodine is not a good wound treatment due to the cellular toxicity of both the alcoholand the iodine, so it is less effective in the surgical suite. With DDT and gamma hexane hexachloride[xviii] in canon early on, hexachlorophene[xix] will probably be the first relatively safe, highly effective skin germicide to be reinvented.

Precautions will be needed when using the hexachlorophene with infants, small children and patients with significant skin problems, and in uses creating contact with internal body tissues. It is very effective for most other situations, including the ten-minute preoperative scrub that both the patient and surgical team undergo. As iodine becomes more available, various iodophor[xx] compounds will be developed, culminating with the development of something similar to povidone[xxi], which is the most commonly used carrier of iodine in OTL.

Chlorhexidine[xxii] type compounds will come later, as the organic chemical industry develops. Chlorhexidine also requires similar precautions to hexachlorophene, but is less absorbed through the skin. An interesting side effect of the use of chlorhexidine is that the surgical linens will need to be washed with soap and water before chlorine disinfectants are added, or a permanent dark stain will result.

What the well-dressed are wearing for surgery.

The idea of aseptic surgery requires that the patient be protected from outside sources of infection. This developed into elaborate drapes over the patient, and the practice of gowning and gloving the surgeon and operating assistants before the operation begins. In the early years of surgery, these drapes and gowns were made of white cotton or linen, which tolerate hot water, bleach and hot drying methods quite well. Similar cloth is used to double wrap the instrument sets before they are processed in the autoclave. The tight weave passes water vapor easily while remaining relatively waterproof, allowing both a modicum of comfort and protection for the operating team. Masks made of several layers of soft gauze will provide protection against germs being spread by sneezing, coughing or even breathing. Head coverings will be made from lighter material, and will probably resemble "mob caps" for both the nurses and long-haired surgeons. Some sort of beard covering will be needed for those with full beards, although most moustaches and Van Dyke/goatee facial hair will be adequately covered by the masks. The blue, green or gray scrubs and drapes did not come into common use in OTL until the development of closed-circuit TV removed the need for the operating amphitheater, reducing the chance of contamination from massed students trying to watch the operation. The reflection of the operating lights from the white drapes blinded the cameras.

Latex condoms are in canon by late 1634, and the manufacturing technology for surgical gloves is similar. These gloves can be sterilized by a modification of the autoclave technique, albeit with the need to use somewhat heavier latex than the up-time gloves needed. Because of this, the up-time gloves will be washed, tested for leaks, and re-sterilized for as long as possible. Under truly austere conditions, especially in extremely hot weather, the minimum kit for surgical dress will include the hat, mask, long sterile gloves, a light shirt and pants, low waterproof boots and a high-necked apron. The team will need to scrub higher on the arms, and for a longer period, when possible, between cases. If there is a truly massive mass casualty event, such as almost happened during the Croat Raid, then even this step is often abbreviated. Just as the gowns, caps and masks are changed between cases, the boots will need to be disinfected from case to case and at the end of the day. This will be interesting until the stocks of vulcanizable rubber are large enough to make the boots. The boots will also need to remain in the Operating Suite, to help prevent cross-contamination from the rest of the hospital from reaching into the surgical theater or vice versa. Additionally, military field hospitals, especially those operating in extremely hot areas and under mass casualty conditions, will tend toward the operating garb adopted by MASH-type surgeons: caps, masks, aprons and long gloves, with the gloves changed with each case and the aprons changed as available or needed.

Let there be light!

As I noted in Part 1, getting light into the recesses of the body is needed to do many procedures. In 1634:The Galileo Affair, a field expedient operating room is set up to take advantage of the early morning light, supplemented by water-filled clear glass bowls and reflectors to spread the light around the operating area. Panteleimon reports that one of his first posts to the Bar was in regards to this matter, as usually the use of glass globes tends to concentrate light like a burning glass, rather than diffusing it into the needed area.

The high-powered electric lights currently used in the ORs won't be available until decent amounts of tungsten are available, but my first thought was that the use of gas mantle lamps with good reflectors will be a decent substitute after the equipment is available for closed-circuit anesthesia is available and flammable anesthetic gases are no longer common.On further investigation, it turns out that, based on the experience of many anesthetists in austere areas of Africa and South America, the flammability problems (but not the storage problems) of ether have probably been overstated. This means that it would be safer to use the better light sources than to struggle on having to depend on natural light, as the gas mantles would be easier to put inside Davy Lamp screens (something that the miners should be using in any case), and operations can proceed at need into the night or start in the early mornings. Additionally, ether vapors are between two and three times as heavy as air, so mounting the gas mantle lights well above the operating field provides an additional margin of safety. I'll cover the safe use of ether and other flammable anesthetics in the next article. Panteleimon also pointed out that a properly designed down-time operating room will be set up to use the natural north light and indirect light from the other directions, as that is both more consistent through the day and avoids the hazards of direct sunlight which tends to be drying to the tissues. An assistant with a mirror can be used to direct stronger light into the field at need. Another point he made was very vital: while up-timers are used to having bright lights available 24/7/52, they will quickly adapt to the lower lighting levels available down-time out of sheer necessity. I also recall being able to adapt to those needs back in the days when I was doing field medicine in the army, even before decent individual night vision devices were available.

Morpheus and Lethe: The way to make speed less important to a surgeon.

It is already in canon that Dottore Thomas Stone used open-mask ether anesthesia to make it possible for Dottoressa Sharon Nichols to save "Feelthy" Sanchez' life.[xxiii] This was one of the most impressive demonstrations of up-time technology possible for the dignitaries present. Panteleimon was gracious enough to provide two anesthesia textbooks published before the RoF, and produced for the training of anesthetists working in austere circumstances-which turns out to be just as effective and much simpler than my training in a medium-sized community hospital in the 1980s indicated. I believe that even more effective forms of analgesia and anesthesia are possible before 1634, but most likely got put on the back burner due to lack of personnel to produce the more advanced modules. I have taken the anesthesia section out of this article as it now makes more sense to do an entire article the subject.

Needles, needles and more needles.

A question was raised as to the possibility acupuncture as a pain reliever or anesthetic. The general techniques were known, but there are only a few people who might have taken any classes in this subject. The most likely candidates would include Mr. Daoud, who had some training as a chiropractor, the physical therapists, and possibly the two folks with advanced degrees in physical education. This will remain true until someone down-time, perhaps excited by the descriptions in the library, acts as a medical Marco Polo and brings the information (and maybe a fully-qualified practitioner) back from the Celestial Court. One possibility here would be the Jesuit Michal Piotr Boym, ordained in 1631, who was part of a mission to China in the 1640s in OTL. Some of his best-known works in OTL cover the Chinese materia medica and herbals.

Physicians only see the patient once a day, nurses are with them all day.

Patient care aspects of postoperative care will play a large part in the up-time teaching. Outside of the towns large enough to support a hospital, the family will still do most care in the home, with the various traveling nurses and Sanitation Commission folks acting in a support and teaching role. In the hospitals, nurses will provide extensive care, especially in the Pre-Operative and Post Operative (Recovery) suites and the Intensive Care Units. This will be even more important in mass casualty situations, especially those under austere circumstances.

Student EMTs and nurses will probably provide much of the care on the wards as the patients progress toward being discharged. This will be done under the supervision of both their instructors and experienced nurses assigned to those wards. A vital part of this teaching will include the Germ Theory and its impact on standards of cleanliness.

Certain general principles will pertain to nursing care in the 1630s: keep the patient clean and dry, change dressings no more often than needed, maintain adequate fluid hydration and nutrition by any means possible, make sure the patients get their medications on time, and mobilize the patient as soon as practical. A collaboration with Danita for a further article on this subject is in the works, as much of my experience in this area was thirty years ago.

To Cut is to Cure.

Overall, trauma surgery will fall into several broad categories: Lifesaving, Limb salvaging, and Rehabilitating. Lifesaving surgery techniques were nicely described in the book M*A*S*H,based on the experiences of H. Richard Hornberger (writing as Richard Hooker) in a Mobile Army Surgical Hospital during the Korean War[xxiv]. His term was "Meatball Surgery": get in, stop the bleeding, control contamination from leaking bowels, and get out as fast as possible. This technique, more formally known as Damage Control Surgery, is still in use today for the most seriously injured patients. Sharon Nichols has clearly been trained in these techniques, even as she takes the time to do some teaching during the procedure. Similar techniques existed in the 1990s for the immediate care of life threatening chest wounds, and these should be known to Dr. Nichols or will be available through a combination of book and lab animal research.

Limb salvaging techniques will build on Dr. Nichols' knowledge, that of down-time surgeons such as Scultetus and Tulp, and the ideas of the barber-surgeon Pare, and Drs. Trueta and Halsted. Aseptic and anesthetic techniques will reduce the number of needed amputations, and the prolonged cast techniques will allow for more tissue salvage over all. Along with the idea of tissue flaps prepared with meticulous dissection, hemostasis[xxv] and approximation to close amputation stumps, the patients will be in much better shape to start with when they get into the hands of the Physical Therapists. This will turn people who might have been housebound into active members of the community.

Lastly, rehabilitating surgeries will correct problems from congenital defects, surgeries before the RoF, and problems that occur because someone did not have a chance to benefit from the up-time teachings. Stump reconstructions will be common, as will tendon-lengthening surgeries (because of limb contractures) due to both old injuries and the pre-RoF state of surgery. Some surgeries will also be performed on patients who are too old to benefit from the non-surgical techniques such as the Ponseti method of treatment of clubfoot.

To Close or Not To Close, that is the question!

Basic wound care in the 1630s, like that under austere circumstances in OTL, follows several basic principles. First, stop the bleeding. Second, cleanse the wound and remove all dead tissue or foreign material from the wound. Third, decide on the method and timing of closure. Finally, apply a dressing and leave the wound alone for at least forty-eight hours. One of the advances made in the mid 1700s by John Knox (an expert anatomist working as a British Army surgeon during the Seven Years War with France) was to limit the treatment of wounds in the field, where contamination by soil and manure was almost assured. Knox also advocated limited manipulation of the wound and the broad use of tincture of time to allow healing.[xxvi] This was an extension of Pare's work two centuries earlier, and was one of the major contributions of Mr. Knox to scientific practice of surgery.

The first step will be direct pressure to the wound for at least five, and preferably, ten minutes. This will allow the minute blood vessels and muscle tissue to form clots to stop much of the bleeding. Small blood vessels, mostly arteries between 1 and 3 mm in diameter, but some veins in the same size range, will need to be clamped and tied to prevent significant blood loss, along with swelling (hematoma) that will interfere with healing. Larger blood vessels are often re-connected in OTL, but this will again have to wait for the development of the appropriate suture material. Down-time, these blood vessels will be tied off, hopefully avoiding a loss of blood supply that will require an eventual amputation.

The second step can be carried out with clean, potable water (and mild soap if it is available), followed by careful investigation of the wound then trimming away any dead tissue. It includes removal of leaves, bullets, cloth and other debris. In the case of impaled objects such as arrows or branches, this may require enlarging the wound so that the surgeon can "get to the bottom"of the wound and make sure that no foreign material is left behind. If there is any question about contamination being left behind, then the treatment should include a modification of the method of Dakin and Carrel.[xxvii] Intermittent irrigations with a weak solution of sodium hypochlorite ( this is in canon in sufficient quality and quantity as of late 1632 or early 1633-the addition of boric acid increases the effectiveness but won't be available until 1634 or 1635) are used to flush the wound for several days. This should not be needed unless there is gross contamination of a deep wound with material such as manure. Alternatively, for wide, shallow wounds, the use of unpasteurized honey is now known to improve wound healing and prevent infections. Manuka Honey from New Zealand is the best known in OTL, but was not widely known in 1999.[xxviii] Granulated sugar was used with good success through the 1980s before being superseded by more advanced dressings. Obviously, the expense of sugar will make it prohibitively expensive, leaving the honey as one of the best alternatives.

The last step is wound closure. In OTL as of 2000, we generally worked with primary closure of almost all wounds if there was enough tissue left to cover the wound, and the wound did not involve an animal bite. Under austere conditions, this is often not the best choice of treatment. Areas with an extremely good blood supply (generally the head, face and neck) will do well with primary closure under most circumstances, thus limiting scarring in cosmetically-sensitive locations. Other areas of the body are best treated with delayed primary closure, where the wound is either packed with a non-stick material (gauze impregnated with petrolatum jelly in the NTL) or the deep spaces are closed loosely with the skin and subcutaneous tissues left open, and the whole wound covered with a bulky, sterile, absorbent dressing. The dressing and wound is then left alone for at least forty-eight hours to allow healing to start.

This is a dramatic change from the care that most medical personnel learned from 1960 to 2000 or so in the industrial world. As a resident physician covering the surgical service in 1987-89, it was common for me to personally have to change dressings and examine surgical and traumatic wounds twice a day. The lessons first taught during WWI and later relearned in the Spanish Civil War and WWII have come back around in these days of "super germs" that jump from patient to patient, to wit: dressing changes expose the tissues to new infection and slow the healing.

After the first forty-eight hours, delayed primary closure can be considered if there are no signs of infection. Otherwise, clean things up again, and apply a dressing that will stay on for one to several weeks while the wound heals by the natural process of granulation. This technique is called "healing by secondary intent," and can leave rather large scars. Dr. Trueta's advance was that he used a plaster of Paris cast to form the outer dressing, thereby keeping the fingers and instruments of well-meaning nurses and physicians out of the wound.[xxix] This was an advantage in treating open fractures of the limbs, as the limb had to be casted to prevent the movement of the bone ends.

Orthopedics

The use of plaster of Paris impregnated gauze cloth to form casts[xxx] to keep broken bones immobilized will be a significant advance over the rag-padded splints used by most bone-setters in the NTL. In OTL, the traditional padding and plaster gauze are made from cotton. Newer fiberglass casting materials used a synthetic padding. Linen gauze will do for the casting material, but the padding needs to be made from a lightly felted or flannel-type material. I'm not sure that the longer, stiffer fibers of linen will work for this. Possibly, Tom Stone had some Cannabis sativa, which produces higher quality fiber, stashed among the C. indica, which produces the higher quality resin so beloved of ladies with menstrual cramps. I believe that the hemp fibers have a soft enough "hand" to be woven into flannel (or made into the soft felt) that can be used for the padding. Cotton should be available in sufficient quantities for medical uses by 1634, based on imports from the Middle and Far East.

Among the simplest of orthopedic techniques, the bone-setters of the NTL already understand the closed reduction and splinting of simple long bone fractures. What the up-timers will bring will be the casting material and techniques, along with the use of radiographs to confirm that the bones have been brought back into natural alignment, and the aseptic techniques needed to care for fractures with wounds. As previously noted, once the injectable local anesthetic agents are again available, hematoma blocks will make bone setting more comfortable for the patient.

The bone-setters will probably also know that the joint above and below the fracture needs to be immobilized by the splint. Similarly, in cases of joint injury, the bone above and below the joint needs to be immobilized for treatment. Most fractures can be handled by these methods, although more complex fractures will take much longer to heal. Femoral neck ("hip") fractures and some femoral shaft fractures will not respond quickly to this level of treatment, and will be a major source of post trauma mortality for a long time after the RoF.

The next step in the management of more complex fractures will have to wait until stainless steel pins and rods are reintroduced. Known as skeletal traction, these pins act to transfer the force needed to maintain alignment directly to the bones. The pins are inserted through the skin to pierce the bone and come out the other side of the limb. Once inserted, traction is used to align all of the bone fragments into some close approximation of the natural bone. The pins are already in canon as of May 1634[xxxi], with the repair of a young boy's hand after he caught his fingers in a moving belt. I do not know if the pin used was from "old new stock" (left over from before the RoF), new stock (doubtful, as this is very early for even the smallest amounts of chromite to be returned to Grantville and appropriately refined to add to a batch of stainless steel) or a pin that was removed from another patient, cleaned and resterilized for reuse. This also argues that plain film radiographs are available at this point, as I doubt that Dr. Nichols would allow the use of this technique in a child this young without them[xxxii].

The traction will initially be provided by the hands of the surgeon's assistant and later continued by a system of pulleys, cords and weights, easily reproduced in the NTL, until the plaster hardens. Hip and femoral fractures will respond to this treatment, but may require three or more months in bed while the traction keeps things in line. "Spica" type casts, where not only one limb, but the pelvic or shoulder girdle is involved, with a strut passed between the limb cast and the body cast, can also be used for some hip and femoral fractures, but has the trade-off of weight versus freedom from traction. The pins can stabilize multiple bone fragments while the plaster cast holds the pins and the whole limb immobilized as the fracture heals. A somewhat more advanced system would use metal (even brass) rings and rods to form a system to provide the support needed to keep the pins in position, but this system will work best when the skin is left intact except for where the pins enter. Balancing the advantages and disadvantages of the systems is something that will have to be learned as the techniques develop.

To deal with fractures that are too complex or angulated to be reduced by traditional closed methods, or fractures that are already open due to wounds or the penetration of the sharp edge of bone through muscle, fat and skin, aseptic techniques allow the surgeon to clean and debride the tissues and to bring the bones back into alignment. Pins and traction are used to align the bones, the wounds are partially closed, and a plaster cast is again used to maintain the alignment of the pins (and therefore the bones) and immobilize the limb.

A surgeon experienced in this technique, with a good anesthetist and a good surgical team would be able to save the life and perhaps even the leg of someone as badly injured as King Charles I of England after his accident on icy roads.

One of the few situations where an open reduction will be needed for an otherwise closed injury will involve a fracture/dislocation of the elbow. Simple closed reduction of this injury often results in entrapment or damage of the ulnar nerve in a high percentage of the cases, while doing the open procedure, followed by pinning and casting, yields good results in the vast majority of the cases. These techniques will improve the lives of folks who suffer fractures, and markedly reduce both the number of amputations and the number of people who die from amputations.

More advanced orthopedic techniques are known to the up-time physicians and recorded in many books and periodicals in Grantville. These techniques, such as several types of open reduction and internal fixation (ORIF) and prosthetic joints, will be redeveloped as materials science produces the exotic alloys combining the needed strength with corrosion resistance and low weight. I would expect this to happen while Dr. Nichols is still around to provide guidance to the development teams.

The spread of the up-time techniques of amputation will only be limited by the spread of the controlled anesthetic and aseptic surgery techniques needed to support them. While few surgeons down time were experienced in abdominal or chest surgery, most of them were quite good at leg and arm amputations already, and many of them are well-practiced anatomists. With the development of appropriate tourniquets, the use of tourniquets to reduce blood loss will spread. Taken together, these techniques allow for meticulous stump preparation. Other up-time ideas that will be quickly adopted include the use of rasps and rongeurs to shape and smooth bone ends, sterile bone wax to plug the marrow cavity of the long bones, and the development of muscle and skin flaps that allow simpler healing and earlier use of prosthetics.

Additional improvements in physical therapy, orthotics, and rehabilitation will improve the number of amputation patients who return to an active lifestyle. These and other topics will be covered in Part 3.

****

[i]http://en.wikipedia.org/wiki/Surgical_suture

[ii] http://en.wikipedia.org/wiki/Polyglycolic_acid

[iii]Meade, Jackson, Ochsner. The Relative Value of Catgut, Silk, Linen, and

Cotton as Suture Materials. Surgery, 7(4), 485-514, 1940

[iv] Personal communication with Stanchem, 20101210

[v] Attributed to Ziva David "Why would you look for needles in a haystack?"

[vi] A bowel resection is the operation where a portion of the bowel is removed and the remaining ends are sewn back together.

[vii]1632

[viii]Grantville Gazette Volume 15: "Dog Days" insulin in quantity production by 1634

[ix]Grantville Gazette Volume 10: "Little Angel"January 1634

[x]Grantville Gazette Volume 5: "Ounces of Prevention"

[xi]Grantville Gazette Volume 10: "The Prepared Mind" April 1634

[xii]http://en.wikipedia.org/wiki/Louis_De_Geer_%281587-1652%29

[xiii]Grantville Gazette Volume 19: "First Impressions" Schwabach as "The 'chief seat of needle manufacture in Bavaria.'"

[xiv] Dressings are at least clean, and preferably sterile, and go against the wound. Bandages are clean but not necessarily sterile, and bind the dressings to the body.

[xv] Pictures of these items are included in the material to be posted at the 1632.org site

[xvi]http://en.wikipedia.org/wiki/Glutaraldehyde

[xvii][xvii]https://www.sciencelab.com/page/S/PVAR/10414/SLG1573

[xviii]"Ounce of Prevention" ibid: Lindane (gamma hexane hexachloride) is being produced by Essen Chemical by the summer of 1632

[xix]http://en.wikipedia.org/wiki/Hexachlorophene

[xx] Literally "Iodine carrying" compounds- organic molecules that allow iodine to remain in a watery solution

[xxi]http://en.wikipedia.org/wiki/Povidone

[xxii]http://en.wikipedia.org/wiki/Chlorhexidine

[xxiii]1634:The Galileo Affair

[xxiv] http://www.amazon.com/M-S-H-Cassell-Military-Paperbacks/dp/0304366617/ref=sr_1_9?s=books amp;ie=UTF8 amp;qid=1297729088 amp;sr=1-9

[xxv] Hemo (blood) stasis (stoppage)- the act of controlling bleeding.

[xxvi]Knife Man

[xxvii]http://en.wikipedia.org/wiki/Henry_Drysdale_Dakin

[xxviii]http://www.physorg.com/news171523022.html

[xxix] Personal communication with Christos Gianou, MD, former Chief Surgeon of the ICRC, and editor of the 2009 ICRC textbook on War Surgery (link to the textbook: http://www.icrc.org/Web/Eng/siteeng0.nsf/html/p0516)

[xxx]http://en.wikipedia.org/wiki/Orthopedic_cast

[xxxi]Grantville Gazette, Volume 15: "Breakthroughs"

[xxxii] Especially since it is noted that Dr. Nichols has limited experience in small bone orthopedics. Grantville Gazette Volume 4 "Heavy Metal Music" March 1633.