THE DOCTOR'S BAG

The blog about medical and surgical practice in the Old West

by Keith Souter 

aka CLAY MORE

MORE NOTES ON ARROW WOUNDS

Welcome back to the days of digging out arrows, bullets, mending busted bones and removing tonsils on a well-scrubbed kitchen table. After I complied two years or so of blogs into the book The Doctor's Bag, published by the good folk at Sundown Press, I thought that I had probably said as much as I needed to on the subject. Yet on looking back at some of those articles and the sources I used, I think there is quite a lot more information that writers of westerns and historical novels might find useful.

This month I am revisiting one of the earliest articles that I wrote for The Doctor's Bag. It was entitled Dig It Out, Doc! Part one - Arrow wounds.  It covers the history of arrow wounds from antiquity until the work of Doctor Joseph H. Bill. Of necessity, it merely covered the basics about the treatment of arrow wounds. There is certainly all that the writer needs in the chapter in the book if  he or she needs to deal with such a scene in their novel or story.  In this article I thought I'd look at one or two cases that Joseph Bill used to illustrate his work and also give some of his views about prognosis. 

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

Doctor Bill was an Assistant Surgeon in the US Army and had great practical experience in the treatment of arrow wounds. He wrote a short treatise entitled Notes on Arrow Wounds published in the American Journal of Medical Sciences, October, 1862.

The writing of such texts has changed considerably over the years. Doctor Bill would give his opinions  about the dangers posed by the different tribes, when discussing the different types of arrows. He writes:

"Before long these wounds will become of unfrequent occurrence, for our Indian tribes are fast being exterminated. We propose, in the first place, as a matter of historical interest, to state in this article that we know of arrow wounds. The subject still presents much of practical interest to the surgeon, and must continue so to do, in a greater or less degree, for the future."

Don't just pull it out!

He gives an account of the way that arrows are made, which he indicates is crucial to understanding the aims of treatment.  He gives this scenario:

"Let us suppose a case to illustrate and explain our meaning. An arrow is shot at a man at a distance of fifty yards. It penetrates his abdomen, and without wounding an intestine or a great vessel, lodges in the body of one of the vertebrae. The arrow is grasped by the shaft by some officious friends, and after a little tagging is pulled out. We said the arrow is pulled out. That was a mistake, it is the shaft only of an arrow that is pulled out. The angular and jagged head has been left buried in the bone to kill - for so it surely will - the victim. The explanation of such mishaps isthmus: the ribbon of tendon which compressed together the slit ends of the end of the arrow, and so clamped the head and the shaft together, had become wetted with the fluids effused in the course of the wound. When wetted, it was, of course, lengthened, and, if lengthened, loosened. It ceased longer to bind together the split sides of the shaft; this and the head were, consequently, very feebly united and readily detached. Experience has abundantly shown, and none know the fact better than the Indians themselves, that any arrow wound of chest or abdomen in which the arrow -head is detached from the shaft and lodged, is mortal. 

From this we conclude that the danger peculiar to all arrow wounds is, that the shaft becoming detached from the head of an implanted arrow, leaves this so deeply embedded a bone that it cannot be withdrawn, and that, remaining, it kills."

So there you have the stark fact. All those novels and movies where the arrow was plucked out and cast aside, had actually consigned the person to death, rather than a short convalescence after whiskey was poured over the wound and it was covered with a pad and bandage.

Laudable pus 

Pus is the white or yellow inflammatory fluid that forms when infection is present. Its colour depends upon its constituents, or which bacteria are present. Surgeons from the days of antiquity talked about 'laudable pus.' They thought that pus was a natural part of the healing process and that it was a necessary nuisance. It was not until the Germ theory  that they realized it was as sign of infection.

One of the oldest surgical maxims is 'Ubi pus, ubi evacuation,' which is Latin for 'where there is pus, let it out.'

Doctor Bill was working in the days before the Germ Theory, but he was aware of the special problems that arrow wounds caused, even after the whole arrow was removed.  He noted that the muscular tissue would contract after removal, distorting the tract of the arrow. Thus, when pus formed, it would lose its natural channel and collect in a pocket within the wound. Effectively it would become an abscess. The next stage was often sepsis, or spread of the infection to the bloodstream, often producing death in days or weeks. 

Poison arrows

Despite the problem of infection, Bill said that some tribes deliberately poisoned their arrows. 

"It is occasionally the practice of some of our Indian tribes to poison their arrows. The plan pursued is this (on the testimony of a Moquis Indian). The liver of some animal is exposed, and a rattlesnake compelled to insert his fang into it. The animal is at once killed, the liver removed, and wrapped up in the skin and buried. After seven or eight days the bundle is dug up, and the arrow-heads dipped in the pulpy and putrescent mass inclosed in the skin. After they are dry they are dipped in blood, again dried, and preserved for us."

Sometimes people did survive chest wounds

This is recorded as CASE V:

A Mexican, name unknown, whilst travelling the road near Fort Defiance, was shot by Navajoes with five arrows, all the arrows injuring the lung, and one of them passing through the upper border of the liver. I saw the man twenty minutes after the accident. The bleeding was most profuse, and the man fainted. Both lungs were wounded, I made the worst possible prognosis, but proceeded to extract the arrows, all of which I  safely removed. After the haemorrhage had ceased, I applied muslin soaked in collodion to each of the wounds, eight in number (some had penetrated right through the chest) and had the patient put to bed, and given  gram of morphia.

The next morning the patient was more comfortable than I had expected. He had been vomiting, and I gave him some acetum spit and acetate of lead, to quiet this and restrain secretion. In the afternoon the man complained of pain the right side, and difficulty in breathing. I removed the dressing from the wound, involving the liver and lung, and broke up some clots whereupon a considerably quantity of mixed fluids were discharged from the wound. These contained bile as I discovered by Pettenkofer's test (a standard test for bile)  . This procedure greatly relieved him, and he expressed himself much better. I ordered the prescriptions of the morning to be repeated.

The next day the patient vomited a considerable quantity of black, decomposed blood, and complained if the frequency of his urination. Urine very dark coloured, sp gravity 1036; urine contained chalice acid and sugar. All medicines ordered to be discontinued. 

After this the patient gradually recovered, all the wounds healing by first intention, except that implicating the liver, and that ceased discharging on the sixth day. In two weeks the man left the hospital, his urine still containing sugar, but no bile. In a few days the lat traces of sugar disappeared from his urine. He recovered completely.

Protection advocated

Doctor Bill felt that more should be done to protect soldiers from arrow wounds. 

"We wish in conclusion to recommend to those in authority the plan for protecting soldiers and others exposed arrow wounds with a slight curios. The Indians have a method of dressing bulls' hide for shields for themselves which renders it arrow proof. A cuirass made of such material, protecting the whole trunk from  before and behind, need not weigh more than eight or ten pounds, and by means of it a soldier could enter an Indian fight with fair chance of escaping death."

___________________

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.