by Eric Flint
The Progression of Trauma Care and Surgery after the Ring of Fire, Part 2
by Gus Kritikos
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.
Whe
re 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 substantially before 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 Paré in the mid-1500s should be remembered in 1630, while they were largely forgotten by the 1800s. Mr. Paré, 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. Paré would have been ecstatic over up-time style care. Dr. Scultetus is in canon as having traveled to Jena and Gr
antville 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.