1632

by Eric Flint

  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 alcohol and 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 wr
ap 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 Paré, 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!