Grantville Gazette 35 gg-35

by Paula Goodlett (Ed)

  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 gener
al 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.