Thursday, April 25, 2013

THE DOCTOR'S BAG



 DIG IT OUT, DOC!

Part 1    ARROWS

Keith Souter aka Clay More



Out on the frontier a doctor would have to be prepared to deliver babies, splint and fix broken bones, and dig out arrows and bullets. Tough work, if you then had to go and play poker and drink a little whiskey.
            In many a western a doctor is either called upon to dig out a bullet or arrow. He usually does so with some ease, depositing the missile in a tin bowl with a resounding clunk, a wipe of his brow and the message that “he’ll be all right now, once I patch up the wound.”
            But of course, in real life things are not quite as simple, so in this post I’m going to look at digging out arrows. In a later post we’ll talk about digging out bullets.

An ancient weapon
 I often mention that I live within arrowshot of the ruins of a medieval castle.  The castle is a Norman motte-and-bailey, one of many built all over England after the Norman Conquest by William the Conqueror in 1066. It is called Sandal Castle and although it is very much a ruin now, it was once of of the two most important castles in the north of England. Along with Sheriff Hutton near York, it was the base for the Council of the North, effectively the government for the North of England as established by King Richard III.  You may know him from William Shakespeare’s portrayal of him as the villainous uncle who had his two nephews murdered in the Tower of London. King Richard had started a rebuilding schedule a couple of years before his death.
            
The farmland around the castle was the site of the Battle of Wakefield in 1460, when King Richard’s father, The Duke of York was killed and beheaded. It was a brutal battle fought with longbow, pikes, swords and battle-axes.
            
I am a member of the Friends of Sandal Castle, a group who try to maintain the castle’s image and its place in history. Among other things, I have an interest in the longbow, since it played such a part in English history. And of course, the bow and arrow is one of the most ancient weapons. Indeed,  the invention of a weapon that fires projectiles a good distance enabled man to make hunting safer and more effective in the days of our earliest ancestors. Inevitably, as a swift weapon against other men it had no equal for many millennia. In a paper written in 2001 in World Journal of Surgery, Karger estimates that in the history of warfare, arrows have killed more people than any other weapon, including firearms.

The ruins of the Great Hall at Sandal Castle. The moat is beyond the far wall and archers would have defended the battlemented walls. 

Surgery advances in  times of war
It is an old maxim that surgeons adapt their techniques to the injuries of their times. The more trauma that is seen, the worse the injuries, then surgeons develop operations and methods  to deal with them.
            
There is a misconception that surgeons were an ill-trained lot of butchers in days gone by. In fact, in medieval times surgeons were often highly skilled and ingenious people. Having good surgeons in your army or navy was reckoned to be utterly essential, for people suffered horrific injures and needed to be treated. Arrow wounds were a major cause of death and morbidity.
            
At the Battle of Shrewsbury in 1403 Prince Henry , who would later become King Henry V (all this is recounted in Shakespeare’s Henry IV Parts I and 2) was wounded in the face by an arrow.  It apparently entered at the side of his nose, and according to the prince’s own surgeon, John Bradmore, it went in to a depth of almost six inches. Impossible, you might say. And again, how could he survive? Well, it is possible. This could well have been a penetrating injury that went in below the brain. He was undoubtedly lucky to survive, yet the skill of his surgeon is incredible.
            
John Badmore treated the wound with honey, crafted a surgical instrument to screw into the wooden shaft so that he could extract it.  Then he washed t out with alcohol. The patient was left with his battle scar, but also with great credibility as a warrior. He went on to become the hero of the Battle of Agincourt. A large part of his success at the battle was his deployment of English longbowmen.


A contemporary drawing of Bradmore's arrow extractor, from the book Fair Book of Surgery, c 1450

Ambroise Paré (1510-1590)
At the Battle of  Milan in 1536 a young barber-surgeon came across two badly wounded soldiers. A comrade asked f there was anything that he could do for them. Upon answering that he could not, the soldier slit their throats to put them out of their misery. Ambrose Pare was the surgeon. He was horrified and he vowed that in the future he would do all that he could to help even the most badly injured person. He famously said:
The art of medicine is to cure sometimes, relieve often and comfort always.

Ambroise Paré operating

Ambroise Paré was true to his words. He became one of  most influential anatomists and is regarded as one of the fathers of modern surgery. He devised means of treating wounds, invented prosthetic limbs and he introduced the technique of ligating arteries, rather than cauterizing them. Significantly, he established battlefield surgical techniques that greatly improved the chances of a casualty's survival. 


                                      Various prostheses invented by Ambroise Paré. 


Arrow wounds were, of course, common and  Paré  developed a pair of forceps for removing detached arrowheads. The uppermost of the two drawings below shows the forceps and the lowermost shows them being inserted into the arrowhead to remove it. 


Of course, there were many different types of arrowheads,several of which barbed. Removing them would cause further damage, if they were simply drawn out. That demanded greater ingenuity on the part of the surgeons, who developed dilators and other instruments in order to protect the tissues as well as they could and allowed them to retrieve the arrowheads. 

Dig it out, Doc!
One of the best sources of information about arrow wounds in the modern era comes from a paper by Dr J H Bill, an MD and Assistant Surgeon, published in the American Journal of the Medical Sciences, published in 1862. He wrote this paper from his own experience as a surgeon on the frontier. 
                  
He begins by describing how arrows are made, which is really crucial to the understanding of the problems involved with arrow wounds. Basically, the arrow has a shaft and a head. The shaft would vary in size from two to three feet, generally being made from dogwood. The head would be inserted into a slit and lashed to the shaft. The head would be made of iron, varying in size from half an inch to two and a half inches n length, and about half an inch to three-quarters of an inch in width at the base.

The lashing was done with tendons, which were tied tightly and allowed  to dry to tighten them further. This is also of importance to our understanding, because once an arrow penetrates the body the tissue fluids and blood would cause the lashing tendon to swell and come loose. Any attempt to pull the arrow out, as people were wont to do, would simply cause the shaft to come out, leaving the potentially lethal arrow-head inside the body. 

Dr Bill describes the relative frequency of arrow wounds. Wounds to the upper limbs were the commonest, because you could see an arrow coming and attempt to fend it off, only to sustain a wound, probably hitting and lodging in bone. Then came abdominal wounds, then chest, then lower limbs, then head, and lastly neck. Multiple arrow wounds were common, since a bowman could fire off six arrows per minute and once a person was hit once, they would be easy targets for the second and third.

The following are his recommendations for wounds to non-vital parts of the body.

1. An arrow passing through a limb makes a clean half-punctured, half-incised wound, which will generally heal by first intention, if proper treatment be instituted (That means the wound heals well as the two sides of the wound contact one another. This is as opposed to healing by second intention, as when a cavity heals from the bottom outwards. the second takes longer.)

2. An arrow lodging in bone requires some force, much tact, strong forceps, and an ample incision for its removal. (That means the wound needs to be made larger)

3. This removal should always be effected as soon as possible after the receipt of the injury, and the greatest care taken in doing so not to detach the shaft from the head of the arrow.

4. Always use the finger to explore the lodgement of an arrow-head and to determine if it is bent or straight.

5. If we fail to detect or to extract an arrow-head lodged in bone, we wait a few days, trusting to suppuration, tents, position, etc, and then search again and again for it.

6. If we fail in removing the foreign body by these means, we operate, making large incisions and compressing the artery of the limb. 

He also advocated using a magnet to attempt to detect the arrow-head. 

To remove arrows lodged in the chest or the abdomen he stated that it was vital to get the arrow-head out, otherwise it would be fatal. To do so he advised using a Coghill's suture twister, a long probe, basically, which could be used to pass along the length of the arrow shaft, bearing with it a loop of wire suture. This would be done after making a large incision to permit space and subsequently ease the extraction.  The  loop would be passed over the tip of the arrow-head and then drawn tight. It would then be twisted around the shaft, thereby ensuring that traction on the shaft would not cause the head to separate. And out it would come!

Then, clunk! Into the bowl. 

29 comments:

  1. Taking an arrow would be unpleasant, but having the thing removed sounds far worse. I didn't quite understand what they did when an arrow was stuck in a bone. Wouldn't removing the arrow break the bone, making another injury to deal with?

    ReplyDelete
  2. Clunk into the bowl indeed. Thanks, Keith. Very interesting.

    ReplyDelete
  3. Timing. I just stopped editing a book as an arrow was being removed to check out your blog. Now I can go back and see how the author handled it. Thanks for another informative blog Keith.

    ReplyDelete
  4. Yes, an arrow in a bone would be bad news. And very difficult to remove. Dr Bill describes having to bear down with all his weight on the limb in order to get purchase and then pulling with all his strength. The bone would effectively already be broken, but the foreign body would have to come out or abscess formation and osteomyelitis would result. That means infection of the bone. Septicaemia would also be possible, which means dangerous spread of infection to the blood.

    And of course, the arrow-head itself would probably introduce infection. Add to that, the surgeon shoving fingers into wounds and prodding around and it is surprising that anyone survived.

    Note also that arrows travel fast, but nowhere near as fast as the bullet from a gun. A bullet would attain a high temperature as it left the barrel and be almost sterilised at entry to the body.

    But of course, Dr Bill was writing in 1862, when doctors had no idea about germ theory.

    ReplyDelete
  5. WOW. Keith, I always enjoy your posts--I learn so much with each and every one! This is some fascinating information. I wrote a short story, Meant To Be, where the hero is shot with an arrow and the heroine (of course!) must remove it. The only thing she could do was widen the opening where the arrow went in to be able to get it out. Mercifully, the hero passed out. I shudder to think that I might have made a mess of the procedure, but in my defense, they WERE in a cave hiding with very little in the way of medical implements. LOL Love this post! Thanks so much for all your work on putting these together for us.
    Cheryl

    ReplyDelete
  6. Keith, I seriously think that after you've done a year or two's worth of these monthly blogs, you should put 'em all together and publish 'em as a reference guide for historical novelists.

    ReplyDelete
  7. I bet people were tempted to just leave the arrowhead in there. What an interesting blog.

    ReplyDelete
  8. I am amazed at how advanced these surgeons so many centuries ago. Also, I didn't realize that arrows have killed more people than any other weapon in the history of warfare. Great post, Keith. And, I think Troy has a great idea. You do need something else to write, don't you?

    ReplyDelete
  9. Cheryl, widening the entry wound would certainly have been the best thing to do. the tissues would spasm around it and swell, so that they would hold onto it. That would also tend to make the head separate from the shaft.

    ReplyDelete
  10. Troy and tom, kind of you to say.

    ReplyDelete
  11. Thank you, Charlene. Yes, it would have been tempting, but leaving an arrow-head would have been more dangerous than leaving a musket ball or a bullet, mainly because of the infection risk.

    ReplyDelete
  12. I am so glad for Modern Medicine. I can't imagine having to go through this trauma to get an arrow or bullet removed..

    ReplyDelete
  13. Fascinating post. Loved it!
    Jerry

    ReplyDelete
  14. Keith, I'd be the first to BUY that book -- so get cracking! LOL Amazing that arrows killed more people than bullets. Guess that makes sense. So does the number of Civil War soldiers dying from disease more than bullets, unless I'm wrong on that fact. Thought I heard that somewhere.

    ReplyDelete
  15. Absolutely, Kathleen! Thank heavens for the three 'a's - anaesthesia, analgesia and antibiotics.

    ReplyDelete
  16. Thanks, Livia, Frank and Jerry.

    ReplyDelete
  17. Dr. Keith Souter,

    Great information, great post! Makes the past a tad bit less romantic. Unless of course, if you had a great surgeon. The surgeon does his magic, the wound is doctored and bandaged, and the patient is saved---then the infection sets in and no antibiotics. Yup, makes those days a lot less romantic.

    Charlie Steel

    ReplyDelete
  18. Thanks, Meg. I believe you heard correctly

    According to Medicine of the Civil War, deaths:

    Union - in battle 110,070
    disease 224,586

    Confederacy
    - in batte 94,000
    disease 164,000

    ReplyDelete
  19. Thanks, Charlie. When it comes down to it Nature does the curing, All the physician and surgeon do is clear the mess to give the individual's constitution the best shot at recovering.

    Napoleon did not have a high regard for his doctors. He said, 'Doctors will have more lives to answer for in the next world than even we generals.'

    ReplyDelete
  20. I vote yes on collecting these articles and publishing them. Maybe through WF. :)

    ReplyDelete
  21. Fascinating post, Keith. And in the Civil War: horses and mules that died...approximately 1,500,000!!! I feel more sorry for the horses and mules than any of the soldiers. After all, they had no choice. The soldiers did. Also, could you email me? Been trying to reach you re:Wolf Creek Book 8 but my messages keep getting returned.

    Thanks,

    Jim Griffin

    ReplyDelete
  22. As usual a very educational post. I enjoy and learn so much when you post. Thank you so very much for taking the time to share your knowledge. I would buy you collection of medical posts. Doris

    ReplyDelete
  23. Thank you Jacquie and Doris. I hasten to add, of course, that I have no practical experience of removing arrows!
    But I have had to use the techniques with other foreign bodies.

    ReplyDelete
  24. Thank you, Jim. I'll email you off-line.

    ReplyDelete
  25. Dr. Keith,
    Great post. Informative down to the bone.
    I agree with those that said you should compile these posts into book.
    I've never seen a human shot with an arrow, but I've seen quite a bit of wild game taken by bow hunters. I'm pretty sure I'd rather be shot with a bullet than an arrow. Nasty wounds.
    Thanks for the info.
    M

    ReplyDelete
  26. Wonder what the difference would be if the arrowhead were flint?

    Have you read any of Bernard Cornwell's books? He has an "archer" series and wrote a novel about Azincourt, too. I think he's good. Would like to know your assessment.

    ReplyDelete
  27. Thanks, Marc. And when you get into the different arrow-head designs you can see how much damage people meant to inflict.

    ReplyDelete
  28. Hi Charlie,

    The most famous flint arrow victim was Oetzi, a prehistoric shaman-hunter who was found preserved in the Italian Alps in 1991. He had a flint arrow-head embedded in his left shoulder, not far from his lung.

    Dr Prunikres, a French nineteenth century surgeon had a collection of prehistoric bones with flint arrow-heads embedded in them. They had pathological changes of suppuration, which means that they were not all immediately fatal. They all seemed intact and did not fragment. Hard as flint!

    One thing I didn't put in the post, was the topic of poisoned arrows, an additional complication! Dr Bill recounts the testimony of a Moquis Indian who described how they poisoned arrows - they induced a rattlesnake to insert its fangs into the exposed liver of an animal. The liver was then removed, buried in skin for 7-8 days until it putrified and then retrieved. Arrow-heads were dipped in the goo that resulted and allowed to dry. Then they were dipped in blood and dried again.

    Other cultures have used arrow-poisons, mainly based on plant toxins.

    Squire Charles Waterton, a 19th century naturalist and explorer brought curare back from the Amazon. It was used as an arrow-poison. It is a powerful neurotoxin that caused paralysis. It was used on arrows or on darts blown from a blowpipe. It became one of the most important drugs that we have, the first of the muscle relaxants that are used in anaesthetics.

    I haven't read Bernard Cornwell, which is an omission that I must correct.

    Sorry to ramble on!

    ReplyDelete
  29. Thanks, Keith. Most informative. Sometimes in western movies, an arrow is removed from a limb by pushing it on through. After reading your comments, that makes some sense. Often arrows are simply pulled out (the victim grimacing dramatically), but now we know that would't have removed the fatal arrowhead.

    ReplyDelete