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 Paré'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.
****
Notes:
[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&ie=UTF8&qid=1297729088&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.
The White Plague
by Brad Banner
Run! Yes, run, do not walk . . . to the nearest doctor's office and demand that they write a prescription for a twelve-month supply of isoniazid for every member of your family.
Unfortunately, even if the pharmacy has any of the drug, he is going to tell you "Hell, no." He knows just as well as you do that in 1631 you have been dropped in the middle of an epidemic that will last another 250 years. No, it's not the black plague. It's not smallpox, and it's not any of the sexy, fast-burning epidemics.
It is the white plague—tuberculosis.
Every person in Grantville is very likely to be infected with tuberculosis mycobacterium within the first year. One-third of them will get sick. Without modern medical treatment, probably half of those who get sick will die in the next five years. About one-fifth will be chronically sick and eventually die from the disease, and one-third will recover.
How do "they" prevent that from happening? I'm sorry, but "they" includes you and you have an important role to play. How? First you have to learn everything you can about tuberculosis.
Mycobacterium tuberculosis and Mycobacterium bovis, the main two causative agents of tuberculosis(TB), have preyed on their human and animal hosts for thousands of years. Tuberculi and tubercular lesions were found in mummies from Egypt that are thousands of years old. They were found in pre-Columbian mummies and skeletons in Peru. On most continents, there is evidence of TB as soon as people gathered in agricultural communities. M. tuberculosis causes most human TB. M. bovis, which also infects cattle, sheep and goats, is responsible for 5-25% of human infections depending on time period, geographic area, and control measures.
The common names for tuberculosis disease include TB, consumption, scrofula, phthisis, Pott's disease, and white plague. Phthisis is the ancient Greek and Roman name for TB and was the name used by doctors until the 1800s. Consumption, the common name for TB for centuries, was so ubiquitous in the 1800s that the pale skin and wasted appearance of its upper-class victims became fashionable. That fashion has persisted to this day. Think of the heroin addict appearance of many top models or the pale-skinned, razor-thin vampires of contemporary fiction. Consumption was associated with vampirism in some superstitious cultures of the Early Modern Era.
The fashionable consumptive appearance of TB is not the only aspect of the disease that has persisted into the present. Up to one-third of the world's population today is or has been infected with TB. One-tenth of those infected with TB develop disease. Of those that develop disease, over half die within five years if not treated. Between one and two million people die each year from tuberculosis. It is the most common infectious disease on Earth . . . just as it has been since antiquity. Most of today's TB infections and disease occur in Asia and Africa, where the same poor living conditions that were common in 1600-1900 Europe predominate. The sub-optimal living conditions include overcrowding (even in rural villages), poor workplace and home ventilation, malnutrition, poor hygiene, other common diseases, and lack of basic healthcare.
TB can affect nearly all of the body's organs. The most common and well known symptoms are related to the respiratory system. Small and large pulmonary granulomatous (cheesy) abscesses, known as tubercles, form and destroy normal lung tissue and rupture blood vessels in the lung. The disease can spread to other organs from the lungs.
The bovine strain of TB is usually acquired by ingesting infected milk (especially) and meat. It most commonly attacks the digestive system forming tubercles in the lining of the intestines. Tubercular meningitis is common in infants exposed to the bacteria. Scrofula refers to the form of the disease in which the lymph nodes of the throat are visibly swollen. In Pott's disease, the bacteria attacks the bones and connective tissue. The skin form of TB is known as lupus vulgaris. It causes terrible ulcerous disfigurations of the face that resemble leprosy.