A HISTORY OF MEDICAL TECHNOLOGY c. 1993, 1995 Thomas Barnes TL 0: THE STONE AGE - First-Aid, Midwifery and Herbalism exist. Medicine is based on herbalism and shamanism. Doctors are very likely to be seen as "shamans" holding mystical powers. Trepanning and simple surgery exist, but aren't formalized. No operations to the chest or abdomen are possible. No operations on the head (except trepanning) are possible. All operations are at the default to Surgery from First Aid. First Aiders have no concept of CPR or other "high-tech" procedures. They can treat shock. At T.L. 0 Herbalism or First Aid is used to aid sick or wounded characters and Midwifery is used to deliver babies. Most human cultures, even "Stone Age" ones rapidly advance to T.L.1 in Medical Technology. TL 1: THE DAWN OF CIVILIZATION - Physician, Dentistry and Surgery skill are introduced. Medicine is still based on herbalism and shamanism. Surgeons can do all Low-Tech procedures, but can't do chest, abdominal or head surgery - knowledge of anatomy is still too crude. MIDWIFERY AND PRAGMATIC SURGERY - Midwifery and Pragmatic Surgery gradually lost status over the ages, beginning at T.L.1. They were considered "lower-class" and relegated to barber surgeons and "wise-women" in most cultures until TL 6. Practicioners of midwifery and pragmatic surgery were generally looked down upon by formally trained physicians. However, pragmatic surgery and midwifery last from antiquity to modern times, since praticioners of these traditions generally seemed more effective than physicians and many communities were too small or poor to attract a formally trained healer. HERBALISM - Herbalism is discovered at T.L. 1. Herbalism is the traditional "folk medicine" of peasants, folk-healers, and self-trained herbalists. It is not likely to be terribly effective at higher tech levels, since it really doesn't advance past TL 2, but is very unlikely to be hurtful either. At later levels Herbalism evolves into Homeopathic Medicine. It will never do more than 1 point of damage, unless the Herbalist or Homeopathic physician rolls a verified Critical Failure. TL 2: THE GREEKS AND ROMANS - This is the beginning of Scientific Medicine. Pragmatic observation and the beginnings of real surgery and preventive medicine occur about this time. Physicians spend a lot of time emphasizing preventative medicine - diet, clothing, and activity. There is a great deal of overlap with Occult and Theology skills with the Physician skill at this level. A successful Physician roll will allow a character to "prescribe" the "proper" lifestyle, medicine, or magic amulet for a patient, and generally impress the patient with the doctor's efficacy. Fast-talk skill is substituted for charlatans. Another important skill at this level is the skill of determining whether a patient will live or die because of an illness, and, if the patient dies, how long it will take him to die. This requires a Diagnosis roll (at a penalty for a subtle or strange malady). The better the roll, the more accurate the prognostication. A failure means the doctor's prediction is no better than random. A Critical Failure means that the doctor is humiliatingly wrong. The concepts of contagion and quarantine are known, but the science of epidemiology is poorly understood. The status of physicians was not particularly high, since many Greek and Roman physicians were slaves. Historically, surgeons were seen as tradesmen, and were a step below Physicians in social status. Surgery focuses on the treatment of battlefield injuries. All low-tech surgical procedures are possible, but there is no cure for open fractures. Amputation is the only solution. Surgery to the head, chest and abdomen can be attempted at - 4 to skill. Gross anatomy is fairly well known, but doctors have no clue about microbiology and endocrinology. Plastic surgeons can repair missing noses and ears. The Romans especially made inadvertant advances in public health by building sewers, water lines, and public baths in their cities and by organizing municipal trash removal and street cleaning services. This knowledge, while never lost, was never systematically applied to later European or Arabic cultures, until it was revived in Europe and the United States in the early 19th century. TL 3: THE MIDDLE AGES - Same as TL 2. At this level, Western medicine went into a period of decline from approximately 500 A.D. to 800 A.D. before being revived by Arabic translations of Greek works. Doctors based all maladies on the Aristotelean notion of "humors". Even then, much of the knowledge of public health gained by the Romans was lost. Disease was believed to be an "imbalance" of humors caused by some unfavorable element in the patient's enviornment, evidence of divine wrath, or the result of malign astronomical influences. It was treated with magical or astrological incantations, medicines designed for their rare ingredients and foul taste rather than efficacy, bleeding, caustic compresses, and purgatives. Medical research consisted of exigesis on the works of Aristotle and Galen. The most important contribution of medieval medicine was the creation of a number of medical schools which allowed physicians to undergo formal training. Also important was the formation of a number of formal hospitals for care of the dying. Historically, these were usually attached to churches or monasteries and catered only to the very poor. Conditions were extremely unsanitary and unpleasant, in spite of the best efforts of the attendants, and anyone who could afford it sought private care in their own home. Until modern times hospitals were seen as places where poor people went to die, not as places of healing. Surgeons lost even more social standing. They were often itinerant and were treated as members of the lower or middle class. In addition to surgery they also performed dentistry and barbering. Physicians kept or improved their social status. However, their function as advisors and diagnosticians was fundamentally unchanged from Ancient times. The only new medieval diagnostic technique was Uroscopy, or diagnosis based on the the color and odor of a patient's urine. A physician may do this with successful Diagnosis roll. Physicians also diagnosed illnesses and devised cures using astrology. In both cases, the better the Diagnosis roll, the more accurate the diagnosis. Due to the effects of the Black Death in the 14th century, there was some revival of public health measures, such as municipal trash removal and quarantine of the sick. Certain castles, monasteries, or cities might also have running water and sewers at any time in Period. Contrary to popular belief, medieval sanitation was not completely awful. People tried to keep themselves, their clothes, and their houses clean, and public and private baths were common. However, public baths rapidly gained a reputation for being little better than brothels. TL 4: THE RENAISSANCE - Same as TL 2. This is the beginning of scientific medicine. New advances in anatomy (due to the invention of the microscope and changes in artistic styles), drugs (the use of metallic compounds) and surgery occured along with a gradual rejection of the Galenic and Aristotlian medicine. In practice this had little effect on efficacy and safety. By the 17th century national scientific societies were formed to encourage scientific medicine, hospitals and medical schools were well established, and many important advances were made understanding of human physiology. The most important game effect is that Physiology/TL 4 is a different skill from Physiology/TL 1-3. A TL 4 surgeon can do chest, abdominal and head surgery at - 2 to skill in addition to other penalties. TL 5: THE ENLIGHTENMENT - Same as TL 4 until very late in the period. Advances in understanding of physiology (made in the 15th - 17th century) were slow to be applied to practical medicine. In early TL 5, in spite of the advances in basic research, the only effect of "scientific" medicine was to reject cures based on astrology and divine intervention, leaving only brutal cures based on restoring the balance of humors. Four common techniques were used: Bleeding - A patient could be treated by Bleeding. This involved making an incision in a vein with a scalpel-like instrument called a fleam and drawing off blood into a basin, sometimes in large quantities. Cupping - Cupping a patient meant applying hot glass "cupping glasses" over an incision to create a vaccuum. The vaccuum would suck blood out of the wound - which had same effect as bleeding. Cupping also had the side effect of leaving ring- shaped burns on the patient's body. Caustic Plasters - Compresses of caustic materials were placed on certain parts of the patients body. It was thought that the "hot", "dry" humors of the material in the compress would assist against conditions that caused an excess of "cold" or "moisture". This technique also burned the patient's skin. Purgatives - Certain illness were thought to be curable by administering strong emetics or laxatives. Of the later the most popular was either mercury or mercury salts (calomel). Mercury will pass harmlessly through the body, but mercury salts are poisonous! Physicians had very little sense of how blood is produced or regenerated, or its importance to the body, so it was common for physicians to sometimes bleed patients for, literally, quarts of blood. More than one famous patient was bled to death by his doctors! Understandably, many people assumed that all doctors were quacks and avoided them. The social roll of doctors until modern times was to accurately diagnose the duration and dangerousness of an illness, and come up with a possible cure, not to heal. Medicine improved in the 19th century due to medical advances initially made by the French during and after the Revolution. The trained physicians in France tended to be royalists, so they fled or were executed during the Revolution. This, along with the subsequent need for battlefield surgeons during the Napoleonic wars greatly speeded the pace of practical medical knowledge. In addition, discoveries in biology, physics, anatomy, and chemistry were finally applied to medicine. By 1820 a reasonably competent physician would have accurate knowledge of gross anatomy, understand that oxygen is vital to life, and would be less likely to use the harsh treatments of the early part of the period. In addition, vaccination was first discovered. By 1800 a knowledgable character might be innoculated against smallpox. Real medical progress accelerated in the middle of the 19th century. Anesthesia (c. 1850) and Antisepsis (c. 1860) were discovered. Several major epidemics coupled with the discovery of germ theory spurred huge advances in pubic health (c. 1840). For the first time since the Romans cities installed sewers and running water. At the same time, improved technology allowed more and better food to be produced, resulting in a better-fed, healthier populace. For the first time in history, physicians and surgeons to accurately diagnosis a disease and aid people, rather than comforting them while they died. There were huge advances in military medicine as well. The wars of the 18th century and the Napoleonic Wars produced the ultimate refinement in low-tech "pragmatic" surgery. More importantly, organized military hospitals and ambulance services were established. Prior to about 1850 wounded soldiers were expected to get themselves to shelter or rudimentary aid stations. If they survived their initial wound they to rely on themselves or their comrades for medical aid. The result was grossly inadequate, squalid hospital conditions. During the Crimean War in 1856 (between France and England vs. Russia), these dreadful conditions came to the attention of the British and American public. The result was an organized system of ambulances, military aid stations, and hospitals, staffed by either trained medical orderlies, or volunteer, civilian female nurses. (Prior to the Crimea and the the example of Clara Barton, nursing soldiers was not a fit occupation for a respectable woman.) Battle casualties still faced a slow and excruciating trip to the field surgery, but if they survived their wound and their treatment, they could be assured of some sort of organized care. Another important advance was the introduction of canning. This technique was invented by the French during the Napoleonic wars, but quickly became a European fad. In addition to making it easier to supply soldiers in the field, it also provided a safer and more nutritious source of food. At the end of this period medical schools in the U.S. and Europe underwent reform. Before medical school reform (c. 1880 in the U.S.) there were many competing schools of thought about the causes of disease and the best method of treating patients. Convincing doctors from another tradition that a new medical advance is efficacious was very hard. There was much acrimony between the adherants of different traditions - as well as many accusations of quackery! Since "modern" or "allopathic" medicine seemed excessively harsh many competing types of medicine evolved in the 19th century. The best known of these is Homeopathy. This school of medicine treats disease by giving a patient a very dilute dose of a medicine that produces the same symptoms of the disease the homeopathic physician is trying to treat. Since most of the homeopathic remedies are based on traditional herbs, it is, essentially, the final refinement of Herbalism. TL 6: MODERN MEDICINE - Any physician from this period will understand anesthetics, anesthesia, germ theory, public health, cell structure, and anatomy. Hospitals are clean, professional places. Doctors and surgeons use sterile techniques to prevent disease and infection. Better understanding of diet, nutrition, and public health results in sanitary public health conditions and improved diet. This improves overall public health. Blood transfusions are available about 1920. Use of oxygen in surgery (along with regualated anesthesia) occurs about 1900. Mass vaccinations occur about 1880-1920 depending on the disease. In the 1930's the first antibiotics (sulfa drugs) are available to treat infections. This makes abdominal surgery much easier. Battlefield surgery also improves with the invention of the automobile and the portable radio. Battle casualties were aided by trained medics, and were taken to aid stations by organized teams of stretcher bearers or motorized ambulances. Aid Stations will have a trained physician and medical equipment to stabilize casualties before they are taken to a field hospital for emergency surgery. This process is still slow but it is still faster than previous systems. TL 7: THE PRESENT DAY - In addition to a refinement of the discoveries of TL 5 and 6, there are numerous advances in medicine that improve life and help critically ill patients to recover. Organ transplant surgery becomes commonly available at the end of this period. In addition, scientists start to understand the workings of cells on the molecular level. Gene Therapy for genetic maladies is in its infancy at the end of the period. During the Korean War, battlefield surgery is revolutionized by the invention of the helicopter. Once a patient is under the care of the medics a helicopter can transport the patient to a field hospital for emergency surgery, literally within minutes of being wounded. TL 8: The Near Future - Presumably the pace of medical research at TL 7 will continue and experimental technologies first discovered at TL 7 will find practical applications. At this Tech Level it is very likely that gene therapy will provide cures for many genetically based diseases, including some forms of cancer. Organ transplant technology will be mated with advances in medical electronics to produce practical "bionic organs" to replace damaged or failing natural organs. Much more likely is a sort of physiologically activated "drug pump" that is implanted into the body and which is activated under certain circumstances. These will mostly be used for theraputic purposes, to administer drugs that normally would have to be injected, but they could be used for other purposes by adventurers. NEW MEDICAL SKILLS HERBALISM M/H IQ-5, Botany-5, Physician (TL1-3)-3, Appropriate Survival-5 Herbalism either as part of Physician (TL 0-1) or as a seperate skill consists of choosing, refining and administering plant-based concoctions that might have healing effects. Whether the ministrations of an herbalist have anything other than a placebo effect is up to the GM. After T.L. 1 it is supplanted by Physician and Surgery skills, until it becomes virtually discredited by TL 6. Homeopathic medicine is a variety of herbalism. LOW-TECH PHYSICIAN (TL 1-4) M/H IQ-5, First Aid-5, Low Tech Surgery-5, Fast Talk-5, Midwifery- 3, Occult-5, Theology-5 The Low Tech Physician skill allows the character to successfully perform as a professional healer in his culture. A doctor's ability to heal patients is limited at this tech level, and in Ancient and Medieval medicine most "cures" prescribed by doctors were ineffective or dangerous. Until modern times a physicians had three important functions - diagnose illness (in term of the medical theories of the day), determine whether or not a patient was going to die from an illness or wound, and suggest possible treatments for an illness (or health regimens to prevent illness). Diagnosing illness uses the Diagnosis skill. But a successful Low Tech Physician roll is required to make a prognosis of recovery or death, and to couch the diagnosis in impressive terms. A successful skill roll will also allow the doctor to prescribe and administer the "appropriate" preventative or palliative medicine for his culture. The exact details are up to the GM. LOW-TECH SURGERY (TL 1-4) M/H IQ-5, Low Tech Physician-5, First Aid-5, Veterinary-3 Low Tech surgery consists of removing foriegn bodies, minor surgery (lancing boils, pulling teeth), amputating limbs, trephaning the skull (for whatever reason, most probably suspect to modern medicine), staunching bleeding, and sewing up wounds. MIDWIFERY M/A IQ-5, Low Tech Physician-4, Physician (TL 5+)-0, Herbalism-5, Vet-2, Animal Handling-7, First Aid-5, Child Rearing- 5 This is the skill of assisting women before, during, and after childbirth. A skill roll gives +1 per 2 points the roll is made to the mother's HT roll to successfully deliver a baby. It the mother is unable to give birth (due to poor health or Fatigue) a successful roll will allow the Midwife to deliver the baby and to save the mother. Penalties to skill (and HT rolls) can be applied for odd birth presentations or multiple births. It comes into existance at TL 0, and persists virtually unchanged to the present day. It is more or less discredited by Physicians and Surgeons all through history. DENTISTRY M/H PREREQ: DX 10+ IQ-5, Physician-5, Surgery-3, First-Aid-7 This is the skill of pulling, repairing and cleaning teeth as well as producing dentures and dental appliances. Prior to to TL 4 it is part of the Low Tech Surgery skill. A successful roll is required to pull a tooth, fill a cavity or produce a comfortable dental appliance. No roll is required to clean teeth. Removal of impacted or badly damaged teeth is at a penalty. All modifiers for lack of anesthetic (-4 to skill, -6 if the dentist is doing something delicate) apply, as do the modifiers for a struggling or unwilling patient. Dentistry comes into existance at TL 1. Dentistry becomes distinct from Surgery at TL 5. PHARMACY M/H IQ-6, Biochemistry-3, Physician-2, Surgery-3, Herbalism-5, Diagnosis-4, Poisons-4, First-Aid-5, Nursing-3 This is the skill of identifying, using and prescribing drugs. For illegal drugs Streetwise-5 can be used. A successful roll vs. Pharmacy is required to prescribe the correct sort of drug for a given medical problem (after a successful Diagnosis roll). A roll vs. Pharmacy will also allow the character to know the correct tratment to combat an overdose of a drug, to identify a drug and to compound simple drugs. A Physician roll is required to successfully administer a drug that is injected. Filling perscriptions and administering drugs under the supervision of a more knowledgable person requires no roll. On a failure, the drug administered isn't effective for whatever reason. On a Critical Failure the patient reacts badly to the drug or the incorrect drug is administered (only on a verified CF will a trained pharmacist actually administer a lethal drug). Pharmacy becomes independent of Herbalism by TL 5. NURSING M/H IQ-5, Physician-2, Surgery-2, Diagnosis- 3, First-Aid-4 This is the skill of taking care of sick or wounded people after they have been treated by a Surgeon or Physician. A successful Nursing roll will allow the nurse to perform routine tasks, like changing bandages, taking care of critically ill or unconcious patients, or administering drugs prescribed by a physician. A competent nurse will also have a high First Aid and/or Physician skill, and Nursing defaults to these skills at Nursing-5 for Physician skill and First Aid for First Aid skill. A successful Nursing roll will allow the nurse to notice non-obivious changes in a patient's condition. Diagnosis skill is required to figure out exactly what is going on, but the nurse can report his observations to the physician. Successful nursing rolls give a bonus to a doctor's Physician skill equal to +1 per 3 points the Nursing roll was made by (to a maximum of +3), since nurses can observe a patient and quickly report problems to a physician Nursing first appears at TL 1. It is recognized as a "suitable" profession for "decent" women at TL 5. It becomes regularized and professionalized by TL 6.