CAN YOU GIVE ME SOME MEDICINE, DOC?

THE DOCTOR'S BAG

- the blog about Medicine in the 19th Century 

A PRIMER ABOUT SOME OF THE DRUG THAT DOCTORS COULD MAKE UP

Keith Souter

In he Doctor's Bag this month we shall look at some of the drugs that the town doctor in the Old west could dispense to his or her patients.

In how many movies have you heard a character ask the town doctor for some medicine to cure some complaint or another. Very often  it is a request for  a painkilling drug and more often than not the doctor just happens to have a bottle of laudanum all ready in his bag. When you write a Western novel and have such a scene intended, you may want to stretch the request beyond a need for laudanum. Having your town doctor treat other conditions may make the doctor-patient interaction more realistic.

Doc Adams in Gunsmoke could always make and dispense a remedy. At a recent visit to the National Cowboy Museum in Oklahoma City I sought out Doc Adams and found him with some of the accoutrements of his trade. As I am sure you all know, he was played beautifully by Milburn Stone.

The G stood for Galen. Interestingly, this was a name chosen by Milburn Stone when the show transferred from radio to television.  It was a great choice, since Galen of Pergamum  131-201 AD) was an ancient Greek physician whose teachings dominated medical thought for well over a thousand years. He moved around a lot and at one time was the physician to a gladiator school.

A group of medicines were referred to as Galenicals, after him. Essentially, these were drugs that were used to balance the four vital fluids of the body, or humours as they were referred to. This was an archaic belief that the  body contained these four fluids - blood, black and yellow bile and phlegm - an that imbalance resulted in disease associated with the excess or deficiency of one or other of them. various herbs and minerals were known to have particular effects, so they were given to correct perceived imbalances. The cucumber, for example was used in medicines as a cooling galenical - hence, as cool as a cucumber. There is some rational, actually, since it is rich in natural salicylates, which like aspirin the modern day wonder drug, has anti-inflammatory effect and reduces abnormal temperature. Doctors in the 19th century were still practising the art of medicine rather than the science. It was a mixture of theories, empirical observation and peddling of treatments passed on from one generation to the other.

Just look at the bottom of the picture of Doc Adams and you will see his pestle and mortar. This is something that most doctors would have, for pounding ingredients when making medicines.

Mortar and pestle from author's collection

The mortar is the bowl and the pestle is the club-like implement used to grind and pulverise. They are tools that have been used to compound medicines for millennia.

A brief history of the pill
It probably comes as no surprise to learn that the ancient Egyptians invented the pill as a means of taking medicine. The Ebers papyrus of about 1550 BC outlines different ways of taking medicines, by enema, lozenges or pills. The pills were made of clay reread with the medication mixed through. Often they used the feces of animals as a binder and as a medicine.

The Persian physician Rhazes (865-925 AD) improved it by using a psyllium-seed mucilage that made the pills less bitter and nauseating.

A century later, the Persian polymath Avicenna (980-1037 AD) improved it further by using a fine coating of gold or silver foil.

Over the following centuries, other coatings were used, but they all had a disadvantage in that they allowed for only partial absorption of the active ingredient into the body. The problem was that many coatings were too difficult for the body to digest and much of the medication could simply pass straight through. On the other hand, sometimes too much would be released and absorbed, producing side effects from too much. We refer to a drug's bioavailability. That means the readiness with which it is made available to the body.

In 1834 the French pharmacist Mohes invented the gelatine capsule, which is rapidly digested allowing  good bioavailability. We still use these today, of course.

One of the greatest advances came in 1884 when Dr William Upjohn (1853-1932) patented a 'friable pill,' which was made by compressing powder into a pill shape. This would then dissolve in the stomach and be absorbed quickly. It had good bioavailability. 

Dr Upjohn lived, qualified and practiced in Michigan. He knew that his invention was a winner, the problem being to persuade other doctors to use his friable pills rather than their own hard pellets. He did it by sending thousands of pine boards along with traditionally made pills and his own friable pills to doctors all over the country, inviting them to  try to hammer the traditional pills into the board. They often did so without breaking, showing how hard it was for the body to absorb. In comparison, one of his friable pills could be turned into powder, ready to be absorbed, merely with the pressure of the thumb. It was a brilliant and persuasive image which became the logo of The Upjohn  Pill and Granule Company that he and his brother formed in Kalamazoo in 1886. It was to become one of the pharmaceutical giants of the 20th Century.

It changed the face of medicine.

The town doctor of the Old West had some effective medicines

Nowadays with our modern drugs is is easy to be smug and think that the town doctor on the frontier would have little to offer the patients under his or her care. That actually is not quite true. In fact, there were quite  number of medicines that he was able to obtain or manufacture. Your town doctor in some future novel may lie to use one or two of these.

In preparing drugs he would probably have a copy of the Pharmacopoeia of the United States of America. A Pharmacopoeia is a book of drugs with all their ingredients, actions and side effects.The first London Pharmacopoeia of 1618 contained recipes for 38 pills. In the early 19th century doctors in the USA used the European ones, until the first American one was published by the Massachusetts Medical Society in 1808. Another was published by the New York Hospital in 1816. Then in 1817 it was decided to produce a national one. This went through a lengthy production and was finally published in English and Latin in 1820.The fifth edition was produced in 1873. I use the sixth edition (in writing Western novels) of 1880.

A frontier town doctor could compound his medicines using some rudimentary equipment, a mortar and pestle, some pipettes, flasks etc. He would need a set of balance scales and various measuring devices. And he would need various reagents. All are listed in the Pharmacopoeia.

Apothecaries’ measurement

Weighing out ingredients for remedies was a complex business and a whole system of Apothecaries measures were used.

One pound or one grain

One pound = 12 ounces

One ounce = 8 drachms

One drachm – 3 scruples or 60 grain

An apothecary’s teaspoon was used to measure one fluid drachm.  This was equivalent to a quarter of a tablespoon.

           

When the household teaspoon size increased it became the equivalent of a third of a tablespoon, which it remains to this day. The Apothecary’s teaspoon, however, remained the same measure.

One could imagine the potential dangers that could ensue with drugs, many of which were extremely toxic, if the wrong spoon was used.

Digitalis

 This is one of the most effective drugs that the doctor would have had. It was used to treat dropsy, or heart failure. We still use it as digoxin. It is one of our oldest effective drugs in cardiology. It is a type of drug called a cardiac glycoside. 

It is  a purified drug that was first extracted from the foxglove plant, Digitalis lanata. It was discovered by William Withering (1741-1799), an English physician in 1785. He had noted that an old woman who practiced herbal medicine used a concoction for treating dropsy, which was the archaic name for heart failure. She achieved dramatic results and he analysed her concoction of twenty ingredients and worked out that the digitalis was the active beneficial agent. Digoxin increases the strength of the heart contractions and slows down the heart. Its effect would have been almost miraculous. 

Dover's Powder

This is a mixture of opium, ipecacuanha and sugar of milk. It was sedative in action, so could calm folk down. It also induces a perspiration reaction. We call these diaphoretic drugs. Back then it was believed that you could sweat an illness out. It was commonly used.

Arnica

This was made from the fried flowers of the plant, a native of the Old west. Made into a tincture, it dealt with strains and bruises.

Tartar emetic
Rather like giving a diaphoretic to induce sweating, it was thought that making someone sick could get poison out of their system. We cal these drugs emetics. This one was made from crystals of antimony and potassium tartrate. The antimony is emetic and also a diaphoretic.

Ipecacuanha emetic
This is another general purpose emetic. We used it a lot in casualty departments (Emergency Rooms in the USA) in hospital, after someone was brought in having taken a drug overdose or poison.

Laudanum
Of course, this is tincture of opium. It contains about ten per cent opium and it is reddish-brown. It was very bitter. It was an analgesic and sedative. In small doses it is also a cough suppressant. Indeed, the doctor could make up various types of cough remedy, often incorporating this.

Carrying case from the author's collection. It has a spring inside the bottom of the cylinder to cushion the medicine bottle inside. A good idea if it was in the doctor's bag being jostled in a buggy or a special medical saddlebag

Calomel 
This is an extremely old medicine. It was a white powder of mercuric chloride. It had profound laxative qualities and was a mainstay of treatment for infective conditions and syphilis.

Nux vomica
This was another of the multi-use medicines. It is prepared from the beans of an east Indian tree. It contains strychnine, which of course, is a highly poisonous agent. It was used as a stimulant, as indeed other poisonous substances like arsenic were used throughout the 19th century. It was used for digestive problems, heart disorders, depression (referred to as melancholy then), and erectile dysfunction in men.

Here are the Pharmacopeia of the United States of America, 1880 instructions:

ABSTRACTUM NUCIS VOMICJE.  ABSTRACT OF NUX VOMICA.  Nu x Vomica, in No. 60 powder, two hundred parts...., 200  •Sugar of Milk, recently dried and in fine powder,  Alcohol,  Water , each, a sufficient quantity,  To make one hundred parts.... 100  Mix Alcohol and Water in the proportion of eight (8) parts of Alcohol to>  one (1) part of Water, and, having moistened the Kux Vomica with one  hundred (100) parts of the menstruum, pack firmly in a cylindrical perco lator ; then add enough of the menstruum to saturate the powder and  leave a stratum above it. When the liquid begins to drop from the per colator, close the lower orifice, and, having, closely covered the percolator,,  macerate for forfcy-eight hours. Then allow the percolation to proceed,  gradually adding menstruum, until the Nux Vomica is exhausted. Be- serve the first one hundred and seventy (170) parts of the percolate, distil  off the alcohol from the remainder, and mix the residue with the reserved  portion. Place the mixture in an evaporating dish, and, having added  fifty (50) parts of Sugar of Milk, cover it with a piece of thin muslin gauze,  and set aside in a warm place, where the temperature will not rise above  50° C. (122° IT.), until the mixture is dry. Lastly, having added enough  Sugar of Milk to make the mixture weigh one hundred (100) parts, reduce  it to a fine, uniform powder.  Preserve the powder in a well-stopped bottle.

Seidlitz Powder

This was an effective antacid for stomach acidity. It was effervescent when added to water, because it contained an acid and an alkali. They react to produce carbon dioxide.

PULVIS EFFERVESCENS CQMPOSITUS,  COMPOUND EFFERVESCING POWDER.  [PULVERES EFFERVESCENTES APERIENTES, Pharm., 1870.—SEIDLITZ POWDER.] Grains.

  

Bicarbonate of Sodium, infine powder,

  

four hundred and eighty grains   480  grains

  

Tartrate of Potassium and Sodium, infine powder,

  

fourteen hundred and forty grains   1440 grains

  

Tartari c Acid, in fine powder,

  

four hundred and twenty grains   420 grains

Herbal preparations

In addition to the formal medicines of the day, many doctors would also use herbal preparations. remember that frontier doctors were a disparate group, many having had no formal training, or perhaps having simply served as an assistant to a doctor until they acquired sufficient experience and training to go it alone. Some, of course, merely bought a qualification from one of the many diploma mills. If you are interested in what types of doctor practiced back then, you can refer back to my very first Doctor's Bag blog.

Herbal medicines have been used for centuries and there were many such preparations used by Native American medicine men. We shall have a look at some of the herbal remedies used in a later blog.

 Samuel Thomson (1769-1843) the founder of Thomsonian Medicine

My alter ego Clay More has a couple of recent releases.  

The Doctor published by Western Fictioneers in the  West of the Big River series

- my novel based on events in the life of Dr George E. Goodfellow

THE DOCTOR by CLAY MORE

Redemption Trail published by Western Trail Blazer
- a novelette- novella

Sam Gibson used to be a lawman, until the day he made a terrible mistake that could never be taken back. Since then, he has alternated between wishing there were a way he could redeem himself and believing he deserved punishment. 


He’s about to get both… 

REDEMPTION TRAIL by CLAY MORE

And coming soon from Hale

Fate handed Hank Hawkins the opportunity of achieving his ambition of buying a ranch, and all he has to do to make it happen is to make it easy for a gang to rob the stage in Devil's Bones Canyon. Hank soon realizes, however, that the robbers never had any intention of leaving anyone alive and had planned a dry gulching. He survives but regains consciousness back in Hastings Fork, he vows to track down the murderers who betrayed him and have his revenge. But, when he sets off, he finds he has a companion - Helen Curtis, the fiancee of the messenger whose death lies on his conscience. Hank has many things to figure out, such as why there was one body missing and things are about to get even more complicated with the threat of death for both of them never far away.

DRY GULCH REVENGE BY CLAY MORE

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 Minié, 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."


*******************************************************************************

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.