Thursday, December 26, 2013

THE DOCTOR'S BAG




I THINK IT'S BUSTED, DOC!

By Keith Souter  aka CLAY MORE


It is a dangerous business being a character in a western novel. You can get shot at, tossed off a horse, hurled through a saloon window or be pushed over a ravine. You have seen it on the movies, read it in the novels or written about it yourself. Any of them can have fatal consequences, but more often than not in this fictional world that we love so much the result is a broken bone somewhere. And then the Doc comes along just in time to hear that speculative diagnosis - "I think it's busted, Doc!"


                                           A Dash for the Timber by Frederic Remington

And of course, an examination reveals all, a splint is manufactured, a dose or two of laudanum and "You'll be up and about in no time at all."

But in real life it is often more complex than that.

 
                                             The BroncoBuster by Frederic Remington

The birth of orthopaedics
We know that doctors have been setting bones since the days of the ancient Egyptians. We have surgical papyri outlining treatments and mummies have been found with splints made of bamboo, reeds, wood or bark, padded with linen.

The roman physician Galen (129-199 AD) treated gladiators and recorded his treatments in his medical and surgical encyclopaedias. His treatments were used as the basis for treatments all the way up the the Renaissance.

The name orthopaedics was first used  in 1741 in France, when Nicholas Andry, a professor of medicine at the University of Paris coined it from the Green words 'orthos,' meaning 'bone' and 'paideia' meaning 'rearing of children'. His book Orthop√©die was about the prevention and correction of musculoskeletal deformities in children. There was a real need for this since there were many diseases that could cause problems like scoliosis (curvature of the spine), abnormalities in the growth of bones (e.g., tuberculosis), various infections (osteomyelitis), vitamin disorders (e.g. vitamin D deficiency causing rickets or bowed legs), and conditions that could cause paralysis, such as poliomyelitis.


                                                     Professor Nicholas Andry (1658-1742)

So, the specialty of orthopaedics was originally all about treating children to prevent problems. The treatment of fractures became added along the way.

The frontispiece for his book showed a sapling supported by a staff. This has been taken as the logo of orthopaedic institutions and organisations across the world ever since.



In   Jean-Andre Venel established the first orthopaedic institute in 1781 for the treatment of children.

Splints and supports
As mentioned above, splints of various forms have been used from the times of antiquity. The purpose of them is simply to support the leg and prevent movement of the broken ends of the broken bone.

In medieval times surgeons knew that fractures bones had to be kept in place. One method of doing this was to soak bandages in horses' urine. As the bandage dried it would stiffen into a splint.

Plaster of Paris casts
This was a fantastic addition to the surgeon's armamentarium of treatments. It was the invention of Antonius Mathysen, a Dutch military surgeon in 1851. Essentially, a continuous bandage is wound round and round the limb then soaked in Plaster of Paris. It is called this because it was first used extensively in Paris in medicine and in building.



Essentially, it is made from gypsum, which is heated to produce anhydrous calcium sulphate. When water is added to this it forms gypsum again and hardens.  Hardening takes place very quickly, but it has to dry out. The larger the cast, the longer it takes. An arm cast will dry out in 3-6 hours and a leg cast may take up to 6 hours.Yet full drying may not be complete for 72 hours.

Diagnosis of fractures
Nowadays we are very dependent on x-rays, but in the old West there was no such thing. William Roentgen discovered them in 1895. Only a year later, Dr John Hall-Edwards in Birmingham, England started to use the so-called X-rays in medical diagnosis.

In the Old West doctors relied on physical examination to diagnose fractures. Then, and now fractures would be divided into two broad types:
  • Closed or simple fractures - when the skin is intact.
  • Open or compound or - when the broken bone protrudes through the skin.
The type of fracture can vary immensely. We talk about a 'clean break' meaning a simple transverse fracture. But it can also be oblique, as can happen with a torsion injury. Or it can be comminuted, meaning fragmented, It can be complicated by causing blood vessel or nerve damage. And it can be a 'greenstick' (as happens in youngsters, when a bone gets bent and only partially fractures).



The principles of treatment of fractures was relatively simple then. If moving the part of the body distal to (furthest away from the site of the pain) caused extreme pain or if  grating could be felt, then a fracture would be diagnosed. 

The bone had to be set. That is, the limb had to be stretched in order to make sure it was the same length as the other. This would give the best chance to get the two broken ends in position against one another to allow healing to take place.

Without the use of x-rays it is very likely that all manner of injuries would end up being diagnosed as a fracture. The treatment would involve immobilising the part and hopefully, the injured part would just 'knit together' and be whole again after a few weeks. Remember, that nature actually does the healing, not the doctor, surgeon or nurse. All that they do is create the best circumstances for nature to do its job.

And of course if the 'broken bone' healed up all right, it would bring nothing but kudos to the doctor, whether it actually had been a fracture or not.


Bone healing
What actually happens when the bone ends are back in opposition is that a large haematoma, or blood clot forms around the ends. This is rather like jelly. After a few days blood vessels grow into it and cells called phagocytes start digesting any debris and tissue that won't heal. Then other cells called fibroblasts start to lay down collagen, that forms a frameworks around the bone ends. This secures the  one ends and new bone is laid down. As a rule of thumb, most bones will have knitted in about 6 weeks.

Some fractures worth knowing about
There are lots of different fractures, many of which are named after the doctors or surgeons who first described them. Some of the ones which our western doctors would have known about are as follows:

Colles fracture
A fracture of the distal radius one inch (2.5 cm) above the wrist. It was described by Abraham Colles an Irish professor of anatomy in 1814. It is sustained by falling on the outstretched hand as when you try to break your fall. The problem is that the broken bone gets displaced and causes a dinner-form abnormality if it is not replaced in posit and immobilised. It takes 4- 6 weeks to heal.

Bennett's fracture 
This is one that could occur in saloon brawls, or whenever a really hard surface was punched. If you swing at someone and they duck, causing you to punch the wall, you may end up with a Bennett's fracture. It can also occur if someone punches someone else's skull! It is a fracture of the first metacarpal, the big bone at the base of the thumb. It is also common in people who have never learned how to punch correctly - which is most people! It was described by Edward Hallaran Bennett, professor of surgery at Trinity College Dublin in Ireland in 1882. It needs immobilisation of for 4-6 weeks.

Scaphoid fracture
This is not named after anyone, but is the name of one of the bones of the wrist. It also occurs when you try to break your fall. It causes pain in the 'anatomical snuffbox.'  This is an area at the base of the thumb. It is called this because in days of yore when folk took snuff, they placed a pinch in the lilt depression on the ice of the wrist formed when you elevate the thumb perpendicular to the hand. The problem with this fracture is that the scaphoid has a variable blood supply and in many people the blood supply comes distally. That is, blood vessels do a U-turn to supply the bone from its far end. If they do not also have a blood supply going directly into the base of the bone (that is, from the top and bottom) then non-union of the bone can occur and the piece without the blood supply can die.

Monteggia fracture
This is a fracture of the proximal third of the ulna (the larger bow in the forearm) with dislocation of the head of the radius (the smaller bone). It was named after Giovanni Monteggi, (1762-1815) an Italian professor of anatomy and surgery. It occurs with a fall and a twist. It is a difficult one to treat because the breaks and the two bones are hard to get in the right positions.  Nowadays it may necessitate operation.

Clavicle fracture
The collar bone is commonly injured in contact sports and fights. A direct blow to the upper chest can  fracture it, most usually at the junction between the middle and outer thirds. They heal up very well generally. We used to use figure of eight bandages and a sling, but really they generally just heal without any intervention.


Fracture of neck of femur
The femur is the thighbone. The two main parts are the neck of the femur, where it forms the hip joint and the shaft, the main part of the thigh.  This is the sort of fracture that happens in older people who may have osteoporosis, or thinning of the bone. This is nowadays treated by internal reduction and fixation. It is probably not going to occur to your hero or heroine in the western novel, but could to another character. It classically causes a great deal of pain after a fall or twist, and the leg will show external rotation due to the weight of the limb.


Fracture of the shaft of the femur
This can occur with any large trauma, either directly from a blow or from a fall. Depending upon which part of the shaft is affected the muscles will move the two parts ion different directions. The first aid treatment would be to strap the two legs together, so that the good leg acts as a splint.

Skull fracture
The big thing here is the possibility of a hemorrhage inside the skull or into the brain. In terms of the novel, the big question would be whether to trephine or not. That is, whether to make a hole in the skull to release blood.

This just happens to be one of the questions that Doc Logan Munro is forced to consider in Wolf Creek 8: Night of the Assassins. But you will find no spoilers here!

And it is also a question posed to Doc Marcus Quigley in Dead Man's Game.
______________________________________________________________________________
 Clay More's character of Dr Logan Munro, the town doctor is appearing in several of the Wolf Creek novels







And his other new character, Doc Marcus Quigley, dentist, gambler and occasional bounty hunter continues in his quest to bring a murderer to justice, in DEAD MAN'S GAME the last in his  ebook short stories THE ADVENTURES OF DOCTOR MARCUS QUIGLEY published by High Noon Press.



16 comments:

  1. That was really interesting. I love injuring my characters so this is a goldmine for me. Thanks. Jo

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  2. Fascinating. We do tend to gloss over the ramifications of such injuries when we write, slows down and takes away the super human attributes of the protagonist. (I do think your spell check was having problems on this one. *just a note)
    Thank you so much for taking the time to explain the ins and outs of pioneer medicine. Love it. Doris

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  3. Keith, I always love your posts so much--healing time is something that is important and has always been "a guess" for me with my characters, so this helps a lot. You always have such wonderful information!
    Cheryl

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  4. Keith,

    Ugh!

    Glad we have modern medicine. At least five times in my life, I would have been long gone---without it!

    Isn't it also true, that westerners had no doctor and set bones as best they could? I had an uncle with a hump after he fell from a table and another with a crooked leg and a limp after a fall. But that was many, many years ago---when I was a child.


    You're a better man than me, dealing with all of this...stuff.

    Charlie

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  5. Keith, so why does it take six times longer for an arm cast to dry? Also did the doctors back then have anything they used for plates for serious breaks? As always I really enjoyed this blog.

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  6. You are very welcome, Jo. Glad it is of some use.

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  7. Thanks, Doris! To tell you the truth I wrote it and saved it, meaning to come back and check it, but Christmas arrived before I was ready! I hope I have altered the errors and glitches.

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  8. Thanks, Cheryl. I think rules of thumb are useful to apply, as in this article.

    Nowadays people often do not take enough time to convalesce properly after illness of injury. I think that is a sign of the pressures that there are on people to get back to work as quickly as possible.

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  9. Hi Charlie, yes people would have had to do the best they could without medical care. The problem of trying to set a bone is suggested in the diagram which shows a vital structure, like an artery near broken bone ends. The process of over-vigorous 'setting' could easily rupture a vessel or damage a nerve.

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  10. Really good information, Keith. Thanks loads. Usable in many situation. Like use of the uninjured leg to steady the broken one. Would a cowboy know to do that, or a camp cook, experienced by lots of trail drives, etc.

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  11. Hi Livia, I am afraid that a hyphen was missing! The arm PoP casts would dry quicker and you need to allow longer for the legs.

    So weight being was discouraged until fully dry.

    Operative fixation was being started in the 19th century, but it really amounted to opening around the site and then getting the bones into position as best they could to allow healing. The problems were that infection would be possible (and likely), the bone healing would be delayed, there would be muscle damage and stiffness of joints would often occur. Also, the fracture may not be stable. Using screws and plates came later and the used of Kuntscher nails for internally fixing came in the 20th century.

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  12. Hi Charlie, thanks.

    Yes, I think that sort of thing would be picked up by folk. Blacksmiths were often the orthopaedic specialists of their day! Cooks as well probably dealt with all manner of things and kept a rudimentary medical kit.

    And of course, after the war there would have been lots of medical orderlies who would disseminate their knowledge.

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  13. Well phooey, I was hoping there was some weird reason it took longer for the cast to dry on the arm. I do appreciate the information. Dad broke his ankle a few years ago that required a plate. He was off that foot for 5 long months. I'm sure age and the plate had some to do with the slow recovery. He would have had real trouble in the nineteenth century.

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  14. Keith and Livia,

    Three years ago, the last day of the year, I slid down a long icy driveway, went up in the air and came down on my right ankle. Five bones broken and the right foot went totally backwards.

    At the emergency they reset the foot. They put me out, and when I woke up, the foot was in the right place.

    After many weeks of blood blisters and waiting for the swelling to go down, I had an operation, a long steel plate inserted and seven screws.

    There was lots of pain and lots of pain pills. After six weeks they took the cast off. I could walk on it, but therapy wouldn't work because my nerves were attacking my body. There is a name for this condition---but the short part of it, is, it required an insertion of a needle in the spine to block nerve pain. This process worked the first time and I was lucky.

    After weeks of therapy, the ankle began to move. I now walk with a slight limp, and the pain waxes and wanes, but never goes away.

    I forgot! Having broken bones like this back then would have meant infection and loss of life? Or---a foot that healed facing backwards?

    I can say with authority having such trauma with bones, was no fun at all.

    Charlie

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  15. You are right, Livia, ageing can slow the time needed for recovery. Also, if bones are osteopenic or osteoporotic then healing can be difficult.

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  16. Charlie, the thing is that just as nature grows plants in all manner of places, nature will allow bones to heal, even after horrific injuries. You get the best result if the bone ends are in opposition and they are stabilised, but healing will occur eventually if you leave bones slightly out of place. When I was in India, many moons ago, I saw cases of people who had fractured bones that had never been treated - including feet the wrong way round.

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