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 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 vitaclass="underline" 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.