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 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.