Thursday, June 27, 2013

THE DOCTOR'S BAG


 DIG IT OUT, DOC!

Part 2    BULLETS

Keith Souter aka CLAY MORE


Doc Galen Adams was really adept at digging out bullets. With his spectacles perched on the end of his nose, his sleeves rolled up, a look of intense concentration and a bit of fiddling with a forceps he would deposit yet another slug into a metal tray. The same scenario has been played out in countless novels and movies over the decades. 

 Not all doctors are portrayed as benevolently as Doc Adams. Some are hardened drinkers, who either need to be revived with a bucket of water, or fortified with a good drink. Doc Willoughby (played by Ken Murray), in The Man Who Shot Liberty Valance is a doc of the latter school. He is called to see Liberty Valance after he has been shot. He calls out: "Whiskey, quick!"

A willing aid appears with a bottle, which the good doc puts to his lips and takes a hefty swig. Thus, restored and ready for action, he turns Valance's body over with his foot, then announces: "Dead!"

The Minie bullet
A few blogs ago, Matthew Pizzolato showed us some Minie bullets, found on the Civil War battlefields. What an advance that was on the type of balls that were used in earlier times. The Minie ball was the brainchild of Claude-Etienne MiniĆ©, a French Army officer. He invented the Minie ball in 1847 and soon it enhanced the accuracy and the ability to maim and kill. Essentially it is a muzzle-loaded, spin stabilised bullet. It was made slightly smaller than the bore of the weapon. Its hollow base would expand so that it would fit the spiral grooves of the bore. Its head was conical, so it cut through the air at higher velocity.


They made a mess when they hit a person. Inevitably, out of necessity, War service increased the surgical expertise of surgeons on both sides. And of course, after the War this meant that many doctors who went west would have considerable experience in removing the various types of bullets.

Digging it out
This description is in keeping with the stoical nature of the good folk that we see depicted in novels and movies. But actually, even in the days of the old west, surgeons tried to remove bullets in the most efficient and least painful way that they could. I will be dealing with pain and anaesthesia (that's how we spell it over this side of the Pond), so for now I'll simply talk about the surgical process. 
                            
Hippocrates, the father of Medicine advised doctors to 'first, do no harm.' He meant, don't make the patient worse off through bad or incompetent treatment. This is certainly the case in the treatment of bullet wounds. You don't dig, but you assess, then locate, then remove, having as clear an idea as possible of the anatomical structures in the vicinity, which may have been damaged by the bullet, or which could be damaged in its removal.


            Note the wooden handle on the scalpel. Pre-sterilisation days

The assessment took into account the clothing and the wound itself. Clothes or anything that was in the bullet's path could be lodged inside the body. Some materials caused more problem than others. Indeed, Dr George Goodfellow, whom we shall come to in a moment, studied materials and bullet wounds and considered that silk could be a potential material for making bullet-proof vests. He even wrote a paper on it, entitled 'Notes on the Impenetrability of Silk to Bullets.'

Bullets were felt for by inserting a finger into the hole and prodding. We shudder at this nowadays, but there was no concept of microbes until the end of the  century. Indeed, a bullet would be pretty well sterilised as it came out of a gun, thanks to the immense heat that was generated. The risk of infection was actually increased by the surgeon's probing fingers.

Surgeons used a variety of probes and  forceps to locate bullets and to retrieve them.

The Nelaton bullet probe  was a French design. It had a porcelain knob at the end. When it came in contact with a firm object, it was rotated against it and withdrawn. If it was a bullet it would leave a lead mark on the porcelain. If it did not then there was a strong likelihood that it was a fragment of bone and the search had to continue.  Remember there were no such things as x-rays and so the doctor had to build up a picture of what had happened as the bullet went through the body.

 
                           
              The Nelaton probe, invented by Auguste Nelaton (1807-1873)


Some extractors had a screw, so that they could be screwed into the soft lead to remove it. Others had a sort of spoon that could be passed beyond so that they could scoop the bullet as it was withdrawn. Others could be passed beyond the bullet and then rotated so that a hook-like end-piece could pull on the far end of the bullet, allowing it to be retrieved. And a whole variety of forceps were developed. In general they had long thin blades with serrated ends to grasp the end of the bullet. But of course, often other instruments could be adapted for the task, including dental or gynaecological forceps.

Dr George Goodfellow


The doctor who achieved greatest fame with regard to bullet wounds was Dr George Goodfellow (1855-1910). He was a remarkable character; a doctor, naturalist, writer and intellectual. He became the acknowledged expert on gunshot wounds, as well as a pioneer in other types of surgery. He was no shrinking violet, however, but a man of his times. He would gamble, drink and on occasion, fight. Indeed, he had been the boxing champion at the US Naval Academy (from which he was dismissed) before he took up the study and practice of medicine.

He is famous as the doctor who treated both Virgil and Morgan Earp after the Gunfight at The OK Corral. Some months later he had to operate on Virgil again, after another gunshot wound, this time removing three inches of his left humerus. And a few months after that he performed a post mortem examination on the body of Morgan Earp, who was fatally wounded in Tombstone.

Dr Goodfellow shared his expertise in papers that he published in the medical journals. His paper, Cases of Gunshot Wound of the Abdomen Treated by Operation, published in May 1889 in The Southern California Practitioner is an erudite account of several cases that he personally treated.

His descriptions are excellent and he describes the exact path of the bullet in each case, describing the anatomical structures that had been damaged, and outlining how he treated them. He details how he closes intestinal holes, mesenteric vessel damage, liver tears and liver holes. He even talks about repairing the rectum in one case

But by this time he had absorbed the scientific discoveries that had been made and he understood the need for sterility in the operation. He talks about this in one case.

"At the time of operating in '81-82 I used Lister's method in its entirety. The intestines were sutured with gut; and in my cases the continuous Glover suture was used. In Mathews' the silk interrupted."

He is referring to Lord Joseph Lister, the pioneer of aseptic surgery. He advocated using carbolic acid to sterilise instruments and to cleanse wounds. George Goodfellow was therefore at the forefront of aseptic surgery.

[A Glover's suture is a means of bringing together two surfaces of a wound by making a continuous suture, with each stitch passing through the loop of the preceding one. When he talks about Mathews, he is referring to a Dr Mathews who had operated on another case. Matthews used individual sutures or stitches. It is the surgeon's individual preferences]

Caliber of bullets
He talks at some length about the type of bullets and the damage that they do. He mentions that the caliber of weapons and the amount of powder behind the ball is greater in the West than the East.

"the 44 or 45-caliber Colt revolver, cut off or long, with the 45-60 and 44-40 Winchester rifles and carbines, are the toys with which our festive and obstreperous citizens delight themselves; and it may be stated as a truism that, given a gunshot wound of the abdominal cavity with one or other of the above caliber balls, if the cavity be not opened within an hour (I here put a very long limit on the time to be allowed) the patient by reason of hemorrhage is beyond any chance of recovery, and this without anything injured of greater moment than vessels of capillary size or a trifle larger, in either mesentery or intestines. With smaller caliber balls, 32 downward, there may be more propriety in waiting, and the smaller the ball, the more advisable it may be. Any ball from 32 up may be expected to inflict damage enough to necessitate immediate operation; at least such has been my experience."


A surgical rule of thumb
He also makes a broad distinction between upper and lower abdominal wounds.

"With wounds of the pelvic portion of the abdominal cavity more time is accorded the surgeon in which to make up his mind, and he can more justifiably act upon the laissez faire principle. Even here too much waiting proves disastrous in a majority of instances, and it is usually found when too late that surgical interference would have been advisable. Barring the cutting of a considerable vessel in the lower cavity there is no danger of immediate death from hemorrhage. The danger usually lies in the subsequent inflammatory action  caused by fecal or urinary extravasation from wounds of bowel or bladder. Even where these are wounded, death is by no means inevitable without surgical interference. In these cases, however, the nature of the wound and the gravity of the symptoms must be the surgeon's guide. The same may be said of wounds of the extreme upper portion of the abdominal cavity which chance to pass the hemorrhagic stage without interference. I can just now recall but one that I have ever seen do so; and she must have been bullet proof to have stopped a 45-caliber Colt pistol ball with her stomach.

"This is the exception. The rule is that wounds of the abdominal cavity produce death immediate or remote, generally immediate."

[In other words, you can delay perhaps with lower abdominal wounds, but never with upper ones. Surgery is needed]

And finally - the gunman's maxim
He  concludes his discussion with his emphatic view, based on his experience, about the need for surgery in abdominal gunshot wounds and mentions the gunman's maxim:

"I feel more than ever that a surgeon who delays longer than for necessary preparation is guilty of criminal neglect. A 44-40 or 45-35 Winchester pistol bullet through the abdomen gives no chance for life. Death is the inevitable result, usually within an hour. And the laity need no learned dicta upon this point, particularly those who live by the pistol and die by the pistol. Their maxim is "shoot for the guts", knowing that death is certain, yet sufficiently lingering and agonising to afford a plenary sense of gratification to the victor in the contest."


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Writing as Clay More, Keith Souter  is currently writing his series of ebooks about  The Adventures of Doctor Marcus Quigley, dentist, gambler and bounty hunter, published by High Noon Press.  The third in the series The Covered Trail is due today, June 27th.


He also writes the character of Dr Logan Munro in the Wolf Creek series and has a short story about Doc Munro in the forthcoming Wolf Creek 6,  Hell on the Prairie.

His latest project is a novel about Dr George Goodfellow, entitled The Doctor for the West of the Big River series, published by Western Fictioneers.

37 comments:

  1. Fascinating post, Keith. And it does indeed prove what so many don't realize.... a person in the frontier West who was gut-shot didn't always die. Usually, but not always.

    Jim Griffin

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  2. Your posts are always interesting, Keith. Glad you became one of WF's regular bloggers.

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  3. You know, much as I love Galen Adams, Logan Munro is giving him a serious run for his money in my book as my favorite Old West doctor... in part because of how much I learn from everything Keith writes.

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  4. Great information, Keith. I don't often mutter "ouch" or "ugh" when reading a blog post, but I made an exception in this case. In all seriousness, though, my take-away was that no matter how "minor" the wound, there is danger in not treating it within a certain time frame. I was interesting that the size of bullet often determined whether the wound had to be treated immediately, could be left to later. Thanks.

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  5. Keith, another fantastic blog post. I love this monthly Doctor's Bag post you do. I always learn something, and in most every one of my stories, the poor protagonist gets wounded somehow! LOL I am with Troy about your Logan Munro. Galen Adams has always been one of my favorite characters, but Dr Munro is closing in fast on him. I really loved your short story in the anthology, btw. Great action and what a surprise!
    Cheryl

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  6. Thanks, Jim. Dr Goodfellow was an amazing doctor. He was literally pushing back the frontiers of surgery. He performed the first laparotomy after a gunshot wound and repaired the damaged intestine.

    He was the man to see if you were shot.

    Keith

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  7. Thank you, Livia. I appreciate that.

    Keith

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  8. Thanks, Tom. I didn't go into the operative details in too much detail, but Dr Goodfellow gives great descriptions. That is good clinical practice, since even after a century and a quarter you can pick up his cases and see exactly what he did.

    It wasn't just gunshot wounds that he pioneered, however. He performed one of the first successful perineal prostatectomies.

    Keith

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  9. Than you, Cheryl. I am having great fun writing about Logan Munro. And I loved your story, too.

    Keith

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  10. I so enjoy learning how things were done in the past. Your own knowledge of the subject allows me the reader to understand what the professional did. If I were to read the good doctors writings it would take a long time to understand. Thank you for putting it into language I can relate to. Your contributions to knowledge are invaluable and you make good use of that knowledge in your writing. Doris

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  11. Thank you, Doris. I appreciate that.

    Interestingly, doctor is Latin for teacher. I see that as part of my job as a doctor, to facilitate understanding about health issues. And as a medical writer I try to explain things in ordinary language, rather than with the obscure terminology that the profession has prided itself upon for years.

    Yet the use of the title of doctor did not become associated with medicine until the Middle Ages. Indeed in Roman times a doctor was called a 'medicus'.

    Keith

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  12. I read once, quite some time back, that before the conical bullet was invented, it was better to be shot in the abdomen than the chest, the theory being the round ball would tend to push the softer organs of the abdomen aside, but would cause more damage to bone and therefore organs in the chest. Once the conical bullet was invented, the abdominal wounds became the more serious ones, as conical bullets would tend to penetrate abdominal organs, rather than push them aside, but would do less damage to bones. Any thoughts on that, Keith?

    Jim Griffin

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  13. Thanks for the interesting question, Jim.

    I think that was probably true. A penetrating wound to the chest could hit the heart and be fatal, of course, and if the lung was hit then a catastrophic haemorrhage could result. A ball passing through the abdominal wall could hit either the lesser or the greater omentum. These are two double folds of peritoneum (membrane that lines the abdominal cavity). The lesser omentum hangs down in front of upper abdominal structures and the greater omentum hangs down from the stomach and covers the intestines. The greater omentum accumulates fat. It could, therefore, act as an internal cushion to a slow moving ball (as your question refers to).

    If it was a hit from close range it would obviously have greater penetrating ability. Longer range (which would make for a lucky shot) the ball would be losing its momentum and have less penetrating ability.

    The Minie ball, a conical bullet proved to be so devastating because it expanded in the bore and with its conical shape achieved much greater velocity. It would indeed have greater penetrative ability and did so much damage.

    Then the increasing calibers with increasing powder really ramped the destructive ability up.

    Looking at my forensic texts, ballistics experts look at muzzle energy as a measure of potential wounding ability. For example, .177 air gun has muzzle energy of 6 foot pounds; a .38 S&W revolver has 173 and a .303 rifle has 2240 foot pounds!

    Going back to the round ball, you would again have a better chance of survival with a lower abdominal wound, as long as no major vessel was hit, than an upper one, where your major organs are located. Exactly as Dr Goodfellow tells us.

    Keith

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  14. First of all, I think I'd rather have a double-dose of laudanum than a shot of whiskey. :)

    What I'm wondering about is how they got the stitches out of the internal organs that they repaired. I'm sure they didn't have dissolvable sutures. ???

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  15. Ah, typos. But blogger doesn't let us edit. Sigh.

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  16. Thanks for another interesting question, Jacquie. In fact, catgut sutures have been used since Roman times. It was made from the intestines of sheep or cattle and was used in surgery and for the strings of musical instruments. On average it is absorbed by the body in about 3 months.

    Infection was a big problem, since these sutures were not sterilised. Joseph Lister used carbolic treated catgut, which Dr Goodfellow used and advocated.

    Keith

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  17. This is my first time reading one of your posts, but I assure you it won't be my lasst. I invite you to visit Cowboy Kisses, which is comprised of combination research information combined with promo as you've done. Excellent job.

    http://cowboykisses.blogspot.com

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  18. Thank you, Ginger. I just had a quick visit and was really impressed. It is late on my side of the Pond, but I shall return to have a good look tomorrow. A good mix of posts there and several have already caught my eye for further study.

    Thanks for stopping by.

    Keith

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  19. Dr. Goodfellow saved the life of a protagonist of mine, Matt Stryker, in the novel Road to Rimrock. I used him because I knew of his vaunted ability with gut wounds. However, Stryker was without medical help for a couple of days. I suppose he should have died.

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  20. Terrific post, Keith. I've avoided having any of my protags get shot because I didn't want to get into the details of how a bullet wound was treated. Now I know! Thanks for that. Like Ginger, this the first time I've read one of your posts. I'll definitely watch for more.

    Lyn Horner
    http://lynhorner.com

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  21. What a great post for information. I do write in the west in the mid 1800s and there are a lot of bullets that need removing. I appreciate learning all of this.

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  22. Lyn- Keith's "The Doctor's Bag" has been a monthly blog since the beginning of the year, I thnk. You should go back and check 'em all out.

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  23. Hi Charlie, thanks for stopping by.

    He could have survived, especially under Dr Goodfellow's care. Indeed, he gives a few examples of cases that he operated on, who did survive. One patient, Jack Smith, an Englishman was shot with a .32 caliber Colt revolver in a fight in the Huachuca mountais, five days before he was admitted to Dr Goodfellow's hospital. He was shot in the lower abdomen, just below the umbilicus, while he was leaning slightly forward. The course of the ball, he deduced was downward and to the left. Goodfellow operated four days after that! (All in keeping with his thoughts about lower abdominal wounds and lower calibers of .32 or less, giving the best prognosis). There were six holes in the intestine, which he closed. He did not find the ball. The patient survived and was discharged from his care after a little over one month.

    Recovery would depend upon good luck, a strong constitution and how well and how sterile the conditions at the time of operation were.

    Keith

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  24. Hi Lyn and Paisley, thanks for stopping by. This was part 1 of 'Dig it out, Doc.' Part 1, a couple of blogs ago was about removing arrows. You might find that of interest, both about the need to remove the arrowhead, and also in one of the last comments I added a little about poisoned arrows.

    Keith

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  25. That was a very interesting post, Keith. Makes us glad to live in times when we have more chances to survive surgery. And childbirth. What the injured parties suffered prior to anaesthetics and the knowledge of bacteria passes our modern imaginations.

    I have only one thought to add; prior to Lord Lister's experiments with cleanliness and carbolic, (you may know, of course), the pioneer in this area was a Hungarian obstetrician, Dr. Ignaz Semmelweiss. Women died in their thousands from childbed fever, for centuries, most of it caused by the fact that doctors & midwives didn't wash their hands.
    When Semmelweiss discovred this he was laughed out of his job and into insanity. An excellent novel was written about him by Evan Hunter, "The Cry And The Covenant."

    Keep up the good work.

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  26. Thanks, Monya. Yes, Semmelweiss's work had a huge impact on our understanding. He is one of the giants of medical science. I didn't know about this novel and will check it out.

    And we can look back even further. With the development of better microscopes people were able to see the microscopic world. Indeed, Antonie van Leewenhoek (1632-1723) was a Dutch draper and amateur scientist who has a good claim to be the ‘father of microbiology.’ This quite remarkable man made over four hundred microscopes of varying complexity in his life, of which only about nine have survived. He subjected everything that he could think of (including his own bodily fluids and scrapings from his teeth) to microscopic examinations and submitted his findings to the Royal Society in London. He was the first person to discover microbial organisms, which he called ‘animalcules’. He described protozoa (unicellular animals), bacteria, yeast cells, red blood cells and spermatozoa.

    But it was when Louis Pasteur came along and developed stains to distinguish different types of microbes, that the Germ Theory came about. Then Lister put his scientific findings into clinical practice.

    Keith

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  27. Terrific stuff, Keith. Your responses to comments are ever bit as good as the actual post. Not being pro-cat, myself, I was disappointed to learn cat gut sutures aren't actually made from cat guts (hey, all you cat people lighten up. I'm just kidding!)

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  28. Thanks, Phil. Why it is called catgut is open to debate. One idea is that it comes from cattle gut. Another is that it came from kit gut, which apparently related to a term for a fiddle. But it may even have come from catgut!

    Keith

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  29. Such an interesting post, Keith. Very useful knowledge for western writers, too.
    I've seen my share of gunshot wounds in the ER, but none of them treated as they did in your description of the old west. It's no wonder no one survived a gut wound then.
    Great post. Loved the different instruments used to fetch out the bullets.

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  30. Thanks, Sarah. And when you think that they had no IV fluids, no transfusions (only 2 were done in the Civil War, and only one survived, as you would imagine since there was no conception of blood incompatibility) only rudimentary anaesthesia, no muscle relaxants and no x-ray or imaging. Amazing what people like Dr Goodfellow achieved.

    Keith

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  31. Keith, I loved this post and the comments. What a boon to western writers! Thanks so much.

    P.S. What do you think of the new Lone Ranger movie? I plan to see if, but I'm skeptical. In my mind, Clayton Moore IS the Lone Ranger and Jay Silverheels is Tonto.

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  32. Thank you, Caroline. I appreciate that.

    I am looking forward to seeing The Lone Ranger when it comes out over here in July. Clayton Moore and Jay Silverheels are fixed in my mind, too. And of course, my pen-name is a homage to him. I read and enjoyed his autobiography and loved the fact that he kept The Creed of the Lone Ranger' in his wallet.

    I expect the movie to be a swashbuckler like some of Johnny Depp's latest. I enjoyed those, which are in the same tradition, I think, as the Errol Flynn swashbucklers. Who could fail to like Flynn's Robin Hood with Basil Rathbone as the Sheriff of Nottingham?

    I am approaching it in that frame of mind and I am hopeful that it will stir youngsters' imagination and give them an appetite for the western genre.

    Keith

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  33. Dr. Keith,

    A post every western writer can use.

    You are a fantastic asset to Western Fictioneers.

    How horrible to be sick, shot and wounded during this era. The Civil War and the aftermath of each battle must have been horrible indeed, for the surgeon and for the patient.

    Charlie S.

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  34. Hi Charlie, thank you do much for that. I hope these blogs are if some use to my flow writers.

    Yes, it must have been horrific. The surgeons did the best that they could. As Ambroise Pare, one of the fathers of surgery said in the 16th century, 'I bandaged him, God healed him.' That is still the case. All that the doctor or surgeon can do is to assist nature.

    Keith

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  35. Darned typos and auto-correct! I meant - of some use to
    my fellow writers.

    Keith

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