The Knowledge: How to Rebuild Our World From Scratch (17 page)

MEDICINE

The city was desolate. No remnant of this race hangs around the ruins, with traditions handed down from father to son and from generation to generation. . . . Here were the remains of a cultivated, polished, and peculiar people, who had passed through all the stages incident to the rise and fall of nations; reached their golden age, and perished. . . . In the romance of the world’s history nothing ever impressed me more forcibly than the spectacle of this once great and lovely city, overturned, desolate, and lost. . . . overgrown with trees for miles around, and without even a name to distinguish it.

J
OHN
L
LOYD
S
TEPHENS,
explorer who discovered the remains of the Mayan civilization
(ca. 1841)

AFTER THE COLLAPSE
of technological civilization, you would see the almost complete unraveling of modern medical capability. For people used to living in developed nations where an ambulance can be summoned with a phone call, the evaporation of health care, and the loss of the peace of mind that used to come with it, would be pretty terrifying. Every injury is now potentially fatal. A compound fracture of the leg, caused by tripping over some rubble in an abandoned city, is lethal if it doesn’t receive adequate medical attention. Even an utterly
trivial incident could end up being a death sentence: a pricked finger that becomes infected and poisons the blood. So in the immediate aftermath of the catastrophe you may find a continued decline in numbers, simply because the death rate from injury and disease exceeds the birthrate. Without access to antibiotics, surgical procedures, or medications for prolonging the deteriorating body in old age, survivors can anticipate their life expectancy to plummet from the 75–80 years reasonable in the developed world today. Even if plenty of nurses, doctors, and surgeons survive, their detailed knowledge and skills will become rapidly useless without access to diagnostic equipment and blood tests or the availability of modern pharmaceutical drugs. And what if this highly specialized medical learning is itself subsequently lost? How can you accelerate the recovery of centuries of know-how?

As with most of the other topics covered in this book, it would be impossible to meaningfully describe even a minute sliver of current medical knowledge: the complex system of organs, tissues, and molecular mechanisms running the healthy human body and how they are perturbed by particular diseases or injuries; the cornucopia of pharmaceuticals we use today and how to synthesize them; or the myriad intricate surgical procedures. But what we can hope to achieve is to explain the most fundamental knowledge that will give you a fighting chance in the immediate aftermath, and describe the tools and techniques that will be essential in accelerating the rediscovery of everything else from the ground up.

Today, most of us in the West will eventually succumb to chronic diseases such as heart disease or cancer as the body starts malfunctioning with age; but, as throughout our history and in developing nations to this day, in a post-apocalyptic world it is infectious contagions that will return as the scourge of humanity.

Indeed, many of these infectious diseases are a direct consequence of civilization itself. In particular, the domestication of animals, and
living with them in close proximity, allowed diseases to jump the species barrier and infect humans. Cattle transferred tuberculosis and smallpox into the human pathogen pool, horses gave us rhinovirus (the common cold), measles came from dogs and cattle, and pigs and poultry still pass us their influenzas. In addition, city living positively encourages disease: tightly packed populations allow rapid propagation of contact-based or airborne contagions, and poor sanitation and squalid conditions result in pandemics of waterborne disease. Until relatively recently, urban death rates were so high that the population of cities was maintained only by a constant influx of migrants from the countryside. But despite its risks, living together also promotes trade and the rapid transmission of far more important commodities: ideas. As the population recovers after the apocalypse, urbanization will once again foster collaboration and inspiration between people with different skill sets and specialties and will greatly accelerate the redevelopment of technological sophistication.

So let’s look first at how to keep the surviving society healthy and shielded from disease, as well as ensuring safe childbirth to help the post-apocalyptic population increase as quickly as possible.

It would be ironic if you were fortunate enough to survive the end of the world as we know it only to perish a few months later from an easily preventable infection. In a post-apocalyptic world without antibiotics or antivirals, you desperately want to avoid becoming infected. Contagions are caused by the overwhelming of the body’s defenses by microbial invaders, and understanding basic sanitation and hygiene will do more than any other single piece of information to save your life in the immediate aftermath.

We now understand well the mechanism of
cholera. The
Vibrio
bacterium multiplies rapidly in the nutrient-rich soup of the small intestine, hitting the intestinal wall with a targeted molecular toxin that triggers diarrhea and aids the organism’s spread to new hosts. Many enteric infections have a similar modus operandi and are spread readily by what doctors delightfully term fecal-oral transfer. The simple preventative trick is to break this cycle.

On an individual level, the single most effective thing you can do to protect yourself from potentially life-threatening disease and parasites is to regularly wash your hands (using the soap we’ve learned to make in Chapter 5). This isn’t some ritualistic hangover from modern civilization, a matter of good manners to keep your mitts looking nice, but a basic survival skill—do-it-yourself health care. Alongside this, as a society you need to ensure that your drinking water isn’t contaminated with your own or anyone else’s excrement. These are the central tenets of modern public health, and retaining the most basic principles of germ theory will keep the post-apocalyptic society healthier than that of our ancestors even as late as the 1850s.

If you do succumb to an enteric infection, the good news is that the condition is often entirely survivable. Even something as historically devastating as cholera is not actually directly lethal: you die from rapid dehydration resulting from the profuse diarrhea, losing as much as 20 liters of body fluid a day. The treatment, therefore, is astoundingly straightforward, even though it was not widely adopted until the 1970s.
Oral rehydration therapy (ORT) consists of no more than a liter of clean water with a tablespoon of salt and three tablespoons of sugar stirred in, to replace not only the water lost in the sickness, but also your body’s osmolytes. To survive cholera you don’t need advanced pharmaceuticals, just attentive nursing.

Without modern medical intervention, childbirth will once again become a dangerous time for both mother and child. Today, serious complications during birth are often resolved with a Cesarean section: the surgeon slicing through the muscular abdominal wall and into the womb to lift out the baby. Although this is now a routine occurrence, and even requested by mothers without any medical necessity, for centuries C-sections were only ever attempted as a last resort in an effort to save the child after the mother had already died or was beyond hope. The first known cases of the woman actually surviving the surgery did not occur until the 1790s, and the death rate in the 1860s was still over 80 percent. A C-section is still a very complicated and traumatic procedure today, and in the aftermath of the Fall will not soon offer any safe alternative to natural birth.

A nonsurgical way to help a baby through a difficult birth was developed sometime in the early 1600s. The birthing forceps represent a profound improvement in obstetrics, enabling the midwife or doctor to reach up the birth canal to firmly but carefully grip around the skull of the fetus and realign the head or gently pull the whole baby out.
*
An important improvement was for the two arms of the tool to be detachable off the pivot so they could be independently slid into position, and over time the design has gradually evolved for the arms of the forceps to follow the anatomical curvature of the mother’s pelvis (so that the instrument works in tandem with the muscular contractions) and the
clamp ends to be shaped around the baby’s skull.

BIRTHING FORCEPS.

Premature and low-birth-weight babies are likely to die if they are not kept warm in a hospital incubator until they are able to better regulate their own body temperature. Modern incubators are expensive and sophisticated machines, and like many other items of medical equipment, when donated to hospitals in the developing world today they often soon fall out of service due to power surges, unavailability of spare parts, or lack of specialist technicians to repair them; some studies find that up to 95 percent of medical equipment donated to some hospitals is inoperative within the first five years. A company called Design that Matters is attempting to address this issue, and their ingenious solution is a great example of the sort of appropriate technology that would need to emerge in a post-apocalyptic scenario. Their incubator design uses standard automobile parts: common sealed-beam headlights are used as the heating elements, a dashboard fan circulates filtered air, a door chime sounds alarms, and a motorcycle battery provides the backup electrical supply during power outages or when the incubator is being transported. All of these parts will be readily scavengeable in the aftermath and can be repaired with the know-how of local mechanics.

The key skill of a doctor is diagnosis—being able to identify the disease or condition that a patient is suffering from, and so to determine the
appropriate course of treatment or surgical procedure. The doctor asks patients to describe the details of the onset and background of their complaints and the sets of symptoms they experience. This information is then combined with the signs discovered during physical examination. The likely causes of a complaint suggested by this process help the clinician decide what follow-up investigations to request, such as blood tests, microscopic examination of samples taken from the body, or internal imaging techniques like X-rays or CT scans. The results from these investigative efforts provide the clues for reaching a diagnosis.

After the apocalypse not only will you lose the advanced tests and scanning equipment, but much of the medical expertise itself will also be lost. Medicine and surgery, more than many other areas covered in this book, rely heavily on implicit or tacit knowledge—something you have learned how to do but would find extremely difficult to successfully convey to someone else in just words or pictures. In Britain, it takes up to a decade of medical school and on-the-job learning in a hospital to achieve competency as a registrar doctor (the equivalent of a US fellow in a subspecialty), all of this with training and hands-on demonstrations provided by someone already proficient. If this cycle of knowledge transfer breaks with the collapse of civilization, it will be impossible to teach yourself the necessary practical skills and interpretative expertise from textbooks alone. So let’s look at the very fundamentals of medicine and surgery: if all of the specialist understanding and equipment have disappeared, how can you recover the essential knowledge and skills?

Informed diagnosis relies on a variety of investigations, but until the early nineteenth century the medical profession didn’t possess a single instrument that allowed doctors to assess the internal state of the body; they had to rely on visible external signs, prodding with their fingertips for enlarged organs or masses, or tapping the abdomen and thorax for the differing sounds of underlying air or fluid. (This percussive technique was invented by a physician who was the son of a
innkeeper; he is said to have gotten the idea from the method of judging the remaining level of wine in a cask.)

The tool that transformed medical diagnosis is astonishingly simple. The stethoscope need be no more than a hollow wooden tube held to the ear and pushed against the patient’s body, or even a rolled-up bundle of papers, which was how the tool was invented in 1816. René Laennec was uneasy about his ear and cheek touching the chest of a particularly buxom woman and so he improvised, realizing that the makeshift tube was not only perfectly adequate for transferring the sounds of the heart, but actually served to amplify them. A stethoscope can reveal the internal sounds of the body: not only anomalies in the sound of the heartbeat, but the wheeziness or crackling indicative of lung disease, the silence at the point of an obstructed bowel, or the faint heartbeat of a fetus.

Before the end of the nineteenth century, not only the stethoscope, but compact thermometers able to measure body temperature and inflatable cuffs linked to a gauge for measuring blood pressure, were standard items in a doctor’s kit bag. The clinical thermometer can reveal a fever indicative of infection, and the pattern shown by regular readings plotted on a temperature chart can even be suggestive of certain diseases. But the stethoscope will remain your key tool for assessing the internal condition of the human body until the post-apocalyptic civilization has relearned how to generate a very high-energy form of light. Here’s how.

In the closing decades of the nineteenth century, two curious emanations were discovered. The first of these was found to stream off the negative electrode when a high voltage was applied between two metal plates. These emissions were named cathode rays, and we now identify them as electrons: the agents of electric current in a wire that are accelerated away down the steep electric field created by the voltage. Flying electrons are rapidly absorbed by even tenuous matter like air, and
so these cathode rays can travel an appreciable distance only inside a container evacuated of gas. Cathode rays could be noticed, therefore, only once scientists were able to produce effective vacuum pumps to suck out practically all the air in sealed glass canisters.

The small amount of gas left inside these early vacuum tubes produced an eerie glow as it was struck by the fast-moving electrons (an effect exploited in neon lights). The German physicist Wilhelm Röntgen wanted to exclude this light so that he could study the cathode rays penetrating through the wall of the vacuum tube, so he wrapped the tube in black cardboard. It was at this point that he noticed a fluorescent screen on the other side of the lab bench glowing a faint green. This was far too distant for cathode rays to be reaching, and Röntgen nicknamed this invisible new radiation X-rays, after their mysterious nature. We now know these X-rays to be ultra-high-energy electromagnetic waves emitted when the accelerated electrons slam into the positive electrode in the vacuum tube.

To his utter astonishment, Röntgen realized that X-rays allow you to see right through solid objects, such as the contents of closed wooden boxes; most eerily of all, in 1895 he was able to use X-rays to take a photograph of the bones inside his wife’s hand. As X-rays are absorbed more easily by dense internal structures like bones than by soft tissues, the image essentially showed the shadow of her bones from energetic light shone straight through her body. X-rays are dangerous, as they are energetic enough to trigger mutations and cause cancer, and so patients should be exposed for only a short burst to capture a snapshot on photographic film, with the doctors shielded behind a lead screen. Despite these health risks, the opportunity offered by radiography to peer inside the living body in order to examine the vital organs, assess bone fractures, or locate tumors provides vastly greater capability for diagnosis than the first diagnostic tool, the stethoscope.

But being able to externally sense the interior condition of the body
is only half of the problem you’ll face after the Fall. It is absolutely crucial to be able to link patient examinations to an accurate understanding of how our body is actually built—to literally know ourselves inside out. So if this detailed knowledge of the intricacies of our own inner structure is lost, how could you rediscover it from scratch, and so recognize what is healthy and what is abnormal?

The internal construction of animals is familiar from butchery, but the human body has important structural differences. and so getting reacquainted with anatomy, gained through human dissection, will be imperative during the reboot. Anatomy and postmortem dissection will be crucial for the redevelopment of pathology—the understanding of the root causes of diseases. The practice of conducting a post-mortem is absolutely vital in correlating the external signs and symptoms of sickness in the patient while alive with internal anatomical faults or defects that can be assessed only after death. The recognition that a particular disease is often caused by a problem in a specific organ, rather than being a systemic issue—as suggested by the premodern belief in the imbalance of bodily humors: blood, phlegm, and black and yellow bile—is pivotal to pathology, and this realization is in turn crucial for our ability to address the underlying cause of a disease, rather than simply trying to treat the symptoms that are manifested.

Once the fundamental cause has been identified, the next step is the prescription of medication or the undertaking of surgical intervention.