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 th
e 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.
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