Classic Descriptions of Disease (Major, 1932, 1994).
There were also books by or about Percival Potts, Osler, Lister, the Mayos, Crile, Halsted, and many others, covering much of the development of medicine and surgery from the 1630s to the 1940s.
Thanks to the assistance of my antique-hunting aunt, I was also able to acquire books from several different rural Kansas physicians, including Modern Medical Therapy in General Practice (3 volumes, Barr, 1940), which was one of the premier texts of its day. While not covering surgeries directly, these tomes cover physiotherapy of the day in detail, as well as "low tech" diagnostic techniques for some of the more operable cancers. This is the sort of book I would expect in the libraries of the older physicians. They also would have various surgical textbooks dating back to their student and internship days.
A number of textbooks were available from the International Commission for the Red Cross/Red Crescent Societies in Geneva, Switzerland. Among those that were current in 1999 were Surgery for Victims of War (1999) [xxxiii] and Amputation for War Wounds (1992) [xxxiv] .
One or more of the ICRC books might have found their way home with one of the folks who had been on a mission trip, or could have been in Mary Pat’s traveling library. At least one copy of any of several editions of NATO War Surgery will probably be in the doctors’ personal libraries. I owned the 2ndUS (1988) edition of the NATO book, and had access to Amputations through my local hospital, so I’ll have to defer to the Editorial Board the chances that one of them might have come back.
“Modern” nursing textbooks available would have included:
Mosby’s Textbook of Nursing,
Brady’s Textbook of Medical-Surgical Nursing
Taber’s or Dorland's medical dictionary,
The Anatomy Coloring Book (which many medical students also used!)
The Lippencott Manual of Nursing Practice
The older nurses might have had copies of Cunningham’s Anatomy, DeLee’s Obstetrics and one of the older editions of The Merck Manual. This is based on the books that my mother still had in her library well into the 1990s, when my sister (a high risk OB doc) received them for her library.
Mary Pat is almost certain to have had an up-to-date Merck Manual, probably Stanhope & Lancaster’s textbook [xxxv] on public health, and her NCLEX (the US national nursing exam) review book. She’ll also probably have the current version of The Control of Communicable Diseases in Man, a publication of the US Centers of Disease Control. She’s interested in emergency nursing, so she may also have a copy of the Trauma Nurse Core Curriculum course with her. She may have had a number of other textbooks (including various military manuals) with her, but none have made it into canon yet.
The paramedics, basic emergency medical technicians, and anyone who took a medical course in the military should have a variety of medical resources in their libraries. In addition to the medical and nursing textbooks already mentioned:
Nancy Caroline’s Emergency Care in the Streets,
The American Academy of Orthopedic Surgeons’ EMT book, (The Orange Book),
Paramedic Emergency Care (Bryan Bledsoe, DO; Brady)
will all be popular. In addition to these, the military medics should have copies of
FM 8-230, Basic Nursing Care
FM 21-10, Field Hygiene
FM 21-11 First Aid for Soldiers
FM 8-36 The Aidman’s Handbook
and various others. The military manuals will have great (if not yet canonized) importance, as they will provide much information directly related to field medical care under austere circumstances. David Dorrman probably has copies of the USN versions of some of these books in his library.
Besides Chief Dorrman, we do have more up-time military medics [xxxvi] in canon, but few with recent experience. It was a very common secondary MOS in infantry units, and especially in the Special Forces. I’ll have to research to find which of the Combat Lifesaver programs was in effect between 1993 and 1999, as there were several changes in that time, but that will wait until Part 4.
Nimitz Lover also pointed out that there would have been other resources in the libraries of various fire fighters, including at least Hazardous Material Emergency Response Guides, and Civil Defense First Aid manuals, as well as more copies of books such as TheMerck Manual and various editions of Grey’s Anatomy. It is also probable that the safety office at the mine will have a library covering occupational health and advanced first aid, as well as equipment that will prove valuable to the rescue teams. She also pointed out that the families of chronically ill folks would likely have acquired a variety of useful popular medical books (ranging from Grey’s Anatomy to TheMerck Manual and on to herbal and other alternative therapies) before the RoF.
By 1999, a wide variety of medical resources and continuing medical education material were available in downloadable and CD-ROM formats. In addition to the previously mentioned Scientific American Medicine program, Novartis (a large pharmaceutical corporation) was a leader in this field, and I have several different items from them that were distributed by 1999. Most of mine covered drug therapies, but there were others aimed at surgeons (to get them to use the expensive drugs as an adjunct to the operations), that might prove valuable as materials technology catches up with the needs of the surgeons.
There were a few textbooks on CD available by 1999, and I would expect that Drs. Shipley and Adams would have owned them. Two that I can lay my hands on right now are:
The Color Atlas and Synopsis of Clinical Dermatology (a companion CD to the book Clinical Dermatology by Fitzgerald, and was available in 1997).
The Interactive Atlas of Human Anatomy, (Ciba-Geigy 1995), featured the brilliant works of Frank Netter. The etchings and drawings of Grey’s Anatomy pale by comparison. This one contains a feature that the instructors will love even more: the ability to create test material based on the illustrations. This CD was based on the hard back version noted above.
Some things will last . . .
Durable medical equipment available after the RoF will include items from the professional offices, ambulances, and mine safety group, as well as items that are out in the community for home health care. These will include respiratory equipment such as demand valves, Intermittent Positive Pressure Breathing (IPPB) treatment machines and Continuous Positive Airway Pressure (CPAP) equipment, and home nebulizer sets with associated air pumps. Other pieces of equipment will include laryngoscopes, a flexible endoscope or two, one to three electric cast-cutters, several portable electronic monitors and simple electric coagulation devices. As will be noted repeatedly, at least some of this equipment may come from the veterinarian’s office, as this office is likely to have been equipped for animal surgery, which does translate well to the capabilities down-time. A consideration is that many of the items that we currently take for granted as “single patient use/disposable,” can be cleaned, re-sterilized and then reused for other patients. We will examine the needs of sterilization in Part 2 of this article.
Considerations for how long the up-time equipment will last will be mostly due to battery life or the need for small, high intensity lamps. Any flexible, fiber optic endoscopes [xxxvii] would also have a life limitation due to breakages in the fiber optic bundles, although with care, those should last long enough for the technology to catch up with the need for a high intensity lamp for the light source. Drs. Adams and Shipley may have one flexible sigmoidoscope in their office; the veterinarians may have a flexible colonoscope or long gastroscope, and possibly the equivalent of a flexible bronchoscope to facilitate the intubation of large animals.
Rigid endoscopes, including bronchoscopes, gastroscopes, proctoscopes, and laryngoscopes will remain useful after their bulbs burn out. These instruments can be used with a coaxial mirror (that’s the one that fits over the doctor’s eye in many Norman Rockwell paintings) and an acetylene or “town gas” mantle (Coleman or Aladdin style) lamp as a light source. The rigid versions of the instruments are also wi
thin the capabilities of down-time technology to reproduce.
Women will not be neglected. Their special examination needs are relatively easy to manage, as the appropriate specula will be readily duplicated down-time by journeyman whitesmiths, using up-time recipes for pewter for the metal, to reduce the lead content, and make the equipment stronger. Again, the coaxial mirror will provide decent lighting into the recesses of the body.
Drs. Adams and Shipley should have been familiar with a couple of low technology tricks to help identify women at high risk for problems [xxxviii] , and one of them might have even owned a culposcope [xxxix] , which can double as an operating microscope in Dr. Nichols’ hands. These were techniques that I picked up in my residency and an item that I owned and used in private practice.
“Pap” smears won’t be a high priority for various reasons, but will be readily reproduced as the first down-time pathologists and pathology technicians come out of the system.
Otoscopes (ears) and opthalmascopes (eyes) will also be limited to the useful lives of their bulbs, but this will be measured in years for the wall mounted, line powered versions, due to the habit of most physicians of stocking a dozen or more bulbs for each type of instrument. The portable versions of these instruments usually had rechargeable batteries, which also last a long time. Again, coaxial mirrors will make a comeback for the examination of various cavities of the body, where the portable units are no longer usable due to battery or lamp failure.
Electric cast-cutters are heavy-duty vibrating saws, used to trim, modify or remove heavy plaster or plastic casts. We can expect at least two, possibly four, of these in Grantville. I’m sure that one will be turned over to the medical school or the medical examiner’s office, as they are also used to remove the top of the skull during an autopsy (or in the teaching of head and neck anatomy). Duplicating these items will be within the capabilities of any facility able to make fractional horsepower electric motors.
A few electric coagulation devices, such as Bovie [xl] and Hyfrecator [xli] devices, will also be available after the RoF, again, mostly in the veterinarian’s office. There will most likely be at least one Hyfrecator in each of the doctors’ offices, as those are cheaper, lower power and simpler than the Bovie devices, and don’t require the expensive grounding pads needed to use the more comprehensive devices safely. Bovie devices do have the advantage of being able to cut flesh and coagulate the minuscule blood vessels that otherwise make for a messy operating field. Hyfrecators provide point coagulation of bleeding vessels, and can be used to treat skin lesions by electrically desiccating them. Both devices use radiofrequency electric currents instead of heat to do the job, allowing the surgeon better control over the amount of damage that is caused. As more down-time electronics engineers are trained, these devices will be as simple to make as the first low-powered transmitters.
These should not be confused with the diathermy machines used in physical therapy to provide local heating with the use of microwaves to relieve sore muscles [xlii] . I would expect that at least one of the three older physicians would have a diathermy machine in his office, as the method was commonly used in office practice in the 1950s and 60s. Again, I inherited such a machine (operating at 1250 megacycles per the nameplate, and with two extra final power tubes still in the box) from one of our older doctors when I started my office practice in 1993, and he would have been a younger contemporary of Dr. McDonnell. It will take a bit longer for the diathermy machines to be replicated, so the hot wet packs and paraffin baths will have to do for a long time.
Most of the electrocardiographic monitors will be in the ambulances, with possibly one in each of the physicians’ and veterinarians’ offices, one at the mine and at least one at the nursing home. From the same sources, perhaps a dozen vital sign monitors will also be transported in the RoF. The state of the art of monitors at the time is such that the batteries will wear out long before the monitors break from other reasons, given a modicum of care, and the presence of stable AC line power. Between the time the batteries wear out, and the time the electronics and chemical industries can reproduce the monitors and batteries, it is probable that those monitors will still be able to work on AC line power in the operating theater and intensive care units, providing valuable information in critical situations.
At least two x-ray machines should be available, along with the film cassettes from before the RoF. One of those machines should be in the vet's office. At least one more will be found in the physician’s offices (forty miles is a long way to go to get basic radiographs—we had a decent, if elderly, set in our office and we were only three miles from the hospital), and maybe even a mobile machine at the nursing home (for the same reason). A fourth machine may be mothballed at the mine. The film is simple fine-grained monochrome, and glass plates can be used if needed. Once roll film is again available in 1635 [xliii] , I would expect 17x20 films to be within reach. Basic x-ray units, gently cared for, are mature enough technology that I'd expect many thousands of uses before failure, and a portable unit could be converted to stationary unit with the addition of a (large, oil bath) capacitor when the batteries wear out. The developing and fixing solutions are well within Dr. Gribbleflotz’ capacity (or that of any other reasonably competent alchemist) and the folks over in the electro-refining operation should reclaim over 99% of the silver in the used solutions. We know that black and white film photography is widely practical by 1636, and I would expect that a critical application such as radiographs would have been available at least a year earlier. [xliv]
Some things won’t . . .
There is a significant amount of disposable medical equipment that must be saved as future reference, since having these items on hand will make reproducing them easier as down-time materials science benefits from up-time knowledge. These items include almost everything made of flexible polymers, such as endotracheal tubes, urinary catheters, chest tubes, IV catheters and assorted drains. Many of these can be made from latex, but most work better with clear, stiffer, polymers such as PVC. Bag-Valve-Mask breathing assistance systems are reproducible with a formed, flexible latex membrane for the valve, machined brass or pressed glass for the valve body, and firm rubber for the mask. Making the bag is trickier, but can be done with a flexible rubber bag and a bit of spring steel, but better ones will come along as soon as PVC is available. I have included some illustrative diagrams adapted from the World Health Organization’s book, Anesthesia in the District Hospital, kindly provided to me by Stanchem, in the supplemental information to be posted on 1632.org.
Boys (and girls) and their toys.
Most of the basic surgical instruments [xlv] we use today date back hundreds of years, and many have roots in the Roman era. They fall into several broad classes, including cutting instruments, hemostatic clamps and holding instruments. While most instruments in 2000 were made of stainless steel with some inserts made of tungsten carbide, there were a few being made of the lighter titanium. We can expect a few odds and ends of instruments to have been in the nursing homes and more from the younger doctors’ offices [xlvi] , but many, if not most of them, will be low quality "single use/disposable" instruments.
Drs. McDonnell and Simms probably had a better selection of instruments stashed, and Dr. Ellis might have some made out of mild carbon steel as well. While carbon steels rust under adverse conditions, this is not a problem if the instruments are properly cleaned, lubricated, sterilized, dried and stored between cases [xlvii] .
Almost all of the instruments needed before 1640 can be reproduced from examples found in Grantville or from the illustrations and descriptions that can be found in some of the catalogs and books found in the doctors’ libraries, or in the State Library. Instrument makers working with the doctors will redevelop the ones that cannot be directly duplicated, through trial and error. Each hospital will probably have at least a journeyman instrument maker working as part of the central supply department as a matter of course, since carbon steel instruments need
far more care than stainless steel. This is especially true of scissors and needle drivers, both of which have the harder carbide inserts in OTL, but which will need regular adjustment, sharpening or re-facing in the NTL.
I would expect a master instrument maker to be on the staff of the Department of Surgery of any medical school that adopts the up-time techniques, to work with the surgeons and operating technicians to produce new instruments at need. Uberzeit Metall Werks [xlviii] , established in September 1633, was planning to offer "medical instruments, and different types of shears or scissors," along with the Ka-Bar and Swiss Army style knives. Mr. Farha reportedly had a number of type patterns available for his smiths to work from. One nice item in canon already is the development of replaceable razor blades [xlix] as this is the same technology needed to make replaceable scalpel blades. While fixed blade scalpels are still occasionally used even as late as 2000, they require regular and careful sharpening, while the replaceable blades are changed with each case.
The scalpel handles will come in about five different styles, depending on where and how they are being used, and there will initially be about five different styles of blades compared to the many currently in the inventory. Wiki [l] gives a decent rundown on the various handle and blade combinations available in OTL. Handles type 1, 2, 3, 4 and 7 are the most common, with the #2 and #4 being heavy-duty models. Type #7 is a longer, slimmer handle that is often used for delicate work such as plastic surgery. Blades 10, 11, 12, 15 and 22 will probably be the first ones made using disposable technology, but others will be made as the need occurs. [li]
Scissors cover several different, sometimes overlapping areas. It is possible to use them "across" the categories, but this may damage the scissors or the tissue. Paramedics and nurses carry some form of Lister or bandage scissors, which have a blunt lip (shovel tip) on the bottom blade and a rounded tip on the top blade. They also have an angle at the pivot, so that the bottom blade can be held flat against the skin, sliding under the bandages so that the bandages can be cut and removed without having to try to unwrap the dressing. The heavier forms usually carried by the paramedics, known as trauma or combat shears, have slightly serrated blades to prevent slippage and were developed in OTL to cut through a soldier’s heavy web gear on the battlefield. These shears will cut soft metal the thickness of up-time pennies easily, so will also handle the heavy leather jacks and buff coats common to downtime soldiers.