INSIDE THE REAL GRAY'S ANATOMY

The Doctor's Bag

The blog about Medicine and Surgery in the Old West 

By Keith Souter aka CLAY MORE

         

I am sure you will have heard of Gray’s Anatomy. It is the title of one of the most famous medical textbooks in the world. It is probably because of this that the eight longest television medical drama has benefitted from this, albeit in  Grey’s Anatomy, it is spelled with an ‘e’. 

Generations of medical students and aspiring surgeons have poured over its pages since it was written in 1858. It covers in immense detail every structure of the human body, all in glorious medical Latin (which happened to be the topic for last month's blog). I myself have a copy of the 30th edition, published in 1949, which I obtained when I was studying Medicine at the University of Dundee in Scotland in 1971. It is an impressive tome,  of 1533 pages, with 1285 coloured figures, weighing in at an impressive 5lb 5 ounces, or 2.4 kilos.

            

Henry Gray FRS, FRCS (1827-1861)

Henry Gray the author of the book trained at St George’s Hospital in London and at the early age of twenty-five was elected as a Fellow of the Royal Society. A talented anatomy demonstrator he wrote his famous book at the age of thirty-one. Sadly, at the age of thirty-four, while looking after a nephew who had smallpox, he contracted confluent smallpox, the most severe form of the disease where there are so many lesions that they become one confluence and inevitably, he died shortly afterward. It is ironic that at the time he was studying the anatomical effects of infectious diseases on various organs of the body.

        

One of his other great works was a dissertation ‘On the Structure and Use of the Spleen.’ This was an extremely useful paper, since the function of the spleen had been a mystery to doctors. In medieval times it had been thought that the spleen concentrated certain vital body fluids or humours, and that an excess of them could result in various types of mental aberration. Anger was one such emotion, hence the expression ‘to vent one’s spleen.’ It was also thought that it could be associated with depression. 

            

Of course, nowadays we know that the spleen has nothing whatever to do with the emotions. It is an extremely important organ of the reticulo-endothelial system. This system is part of the body’s immune system. It is called this because it consists of the reticular connective tissue, which contain cells called monocytes and macrophages. These accumulate i.n lymph nodes and in the spleen. The liver is also part of this system. 

            

The spleen is an organ about the size of a large fist, located in the upper left quadrant of the abdomen, although it cannot usually be felt, since it is just under the rib cage. It removes old red blood cells from the circulation and also produces and keeps a reserve of these precious red cells in case the body suddenly needs them. 

            

Glandular fever usually causes a reversible enlargement of the spleen. Malaria can enlarge it incredibly, to as much as nine kilos! (that's twice the weight of my Gray's Anatomy). 

 Surprisingly, the spleen is not essential to life, but if one has had a splenectomy, there is a potential risk of pneumonia. For this reason, people who have had their spleen removed may be offered a vaccine. 

The story behind Gray's Anatomy

This famous book, which generations of medical students and surgeons in training have studied as they have sought to learn about every organ, nerve, blood vessel and tissue in the body, has now gone through 40 editions.  The newest version has 1600 pages, 2,260 illustrations and weighs about eleven pounds, almost twice as heavy as my old copy. Like most medical texts it has changed dramatically over the years and been redesigned, restructured, rewritten and re-illustrated with modern techniques.  This mirrors the way that anatomy is taught in most medical schools throughout the world. Whereas in my day we spent  two years in the anatomy dissecting rooms, nowadays many schools teach anatomy with a mixture of  dissection, prosection (demonstrations by anatomists in front of students), computerised  demonstrations. Indeed, today if you do not wish to carry an eleven pound textbook around with you it is available  on-line. 

Yet there is a side to Gray's Anatomy that is not so well known. Whilst Henry Gray wrote the text, he collaborated on the dissections over eighteen months with an anatomy demonstrator and fellow surgeon  Henry Vandyke Carter. It was Carter who did the famous illustrations. 

Henry Vandyke Carter - self portrait

(1831-1897)

Upon completing the book Carter sailed to India to begin a career in tropical medicine and anatomy. Gray stayed behind, published the book and accumulated several accolades. This is not to say he did not deserve them, he unquestionably did, but somehow Carter did not receive due recognition. When the book was published in 1858 it was titled Anatomy, Descriptive and Surgical. Henry' Gray's name was on the cover and on the frontispiece Carter's name also appeared, but in smaller print and without his qualifications. It looked as though he had been reduced to role of the mere illustrator, not an equal. Gray received significant royalties, while Carter received none.

Carter worked for the Indian Medical Services for the rest of his career and became professor of anatomy at Grant Medical College in Bombay (modern day Mumbai). In 1888 he returned to England and became Deputy Surgeon to her Majesty, Queen Victoria.  He married and had a family, before dying from tuberculosis at the age of 66.

Undoubtedly, Carter should have received more credit for his work. This happens a lot in science and medicine, some get all the glory and go down in history, while others are slighted, passed over  and forgotten.

And finally, for you Western writers.....
A perusal of Gray's Anatomy will make you wary of those abdominal wounds. The fact is there is no good place to be wounded, since there is bound to be damage and surgical treatment has to be incredibly skillful.

The arterial blood supply of the bowel

The small intestine has been rolled aside to show the arteries 

....and if you look behind that!

There may be  some parts that are 'less bad' to be wounded, but luck will always play a huge part. You might say it's a Gray area!

***

If you are intrigued by medical Latin, then you might like to dip into this book, which you can pick up for a cent or two!

Doctor's Latin

If you are interested in reading more about medicine and surgery in the frontier days,  then you may find The Doctor's bag useful. It is a collection of my past blog posts, published by Sundown Press.

Buy The Doctor's bag

The novel about Dr George Goodfellow, the Tombstone surgeon to the gunfighters

Buy The Doctor

The novel about Ned Buntline, the King of the Dime Novelists

Buy The Dime Novelist

WESTERN WOUNDS -- HOW ACCURATE IS THAT?

I've been mulling over all month about a topic. Western weather, and how brutal cattle drives and prairie farming must have been. Another real life western hero, or heroine... or a plug about my re-release of the Spur-Award winning Double Crossing (trust me, it's at the end of this post.) But then I thought about one of the most popular Western Fictioneer members, Dr. Keith Souter (w/a Clay More) and thought, "hey, he's a doctor. I have some questions about stuff I see in movies or books."

So that's what we're chatting about today, western wounds. The image to the left is an antique medical bag. Cool, huh? I love including photos on my blog posts. Okay, back to three types of common western wounds. Recovering, surviving, should-this-be-used-in-your-next-book kind of thing, which is called a genre trope. I call it a "how come they did that instead of ... " type of thing. I have a few beefs (or is that beeves?) about what I've read or seen in westerns.

We'll start with something simple and work our way up.

MEG:  Hey, howdy, Dr. Keith! Many thanks for agreeing to participate in "Ask the Expert" today. I've seen a few movies where either the western hero or an Indian *cuts palm* and then waits for the other guy to do the same so they can make a blood bond ... another friend HATES that and claims that injury is too severe, especially in a medieval when they'd pick up their sword or bow and arrow and try to use the weapon. So, maybe they should use their thumb instead?

Dr. Keith Souter:  Cutting the palm will produce a lot of blood, as anyone will know if they have cut themselves with a knife. A very superficial cut would be enough to allow for symbolic mixing of the blood. Of course, with our knowledge about communicable blood-borne diseases nowadays, one would realize that to become a blood-brother in such a ceremony, where severed surface was placed against severed surface, would have a very good chance of transmitting infection. But back then HIV had not developed.

A deep cut would endanger the superficial palmar arch, a ring of arteries formed from branches of the radial artery and the ulnar artery. I have attached a plate from Gray's Anatomy, which has been one the main textbooks of anatomy used by medical students and doctors since it was first published in 1859, by Henry Gray, of St George's Hospital in London. (There is a TV show called Grey's Anatomy, that is a play on the name - note the different spelling). A deep cut would risk arterial damage, which would cause spurting of blood. That would be a significant wound. There would also be significant danger of nerve damage. A superficial hand wound takes a week or so to heal. Deep wound could take weeks and even months, if there was a lot of damage.

However, nature is not so dumb, and we have a protective tissue called the palmar aponeurosis, which protects those deeper structures. That is important considering all the potential trauma that could happen to the palm. It is an extension of the palmaris longus muscle. It can be seen when you flex your hand, as the single tendon in the middle of the wrist. 

14 % of people do not have that single tendon, but they will still have an aponeurosis. I have attached another of Gray's illustrations of the palmar aponeurosis and you can see how it protects the arterial ring.

So, although nicking the thumb would seem adequate for the purpose, cutting the palm superficially would work. The depth of the palm wound would determine whether it could be used. For a simple superficial one, then yes you could use a sword, fire a gun and hold a bow. Wrap it up and grip. It would hurt, but it could be used. A deep wound with a sword or dagger could damage an artery or a nerve. That would not be so usable. And of course, if you breach the palmar aponeurosis and you cut through the muscles that operate the fingers and thumb, the hand will be useless.

Meg:  Wow, this is fabulous. Okay, question number two. In Hell on Wheels, the widowed wife of the surveyor is shot in the shoulder with an arrow. I've read tons of books where heroes are shot in the shoulder, too. I have a problem with them using that arm afterward, or staunching the bleeding and going on about their business. Just how credible is that?

Dr. Keith Souter:  You are quite correct. A shoulder wound is an awful thing to receive. You would have a large chance of smashing the humerus, or worse, damaging the joint itself. And then there is a huge chance of catastrophic bleeding and nerve damage. I have attached another of Gray's illustrations of the arteries and the nerves in the shoulder. This does not include the veins, of course, but they are in close proximity. The artery is in red and the nerves are in yellow. 

The nerve supply is called the brachial plexus. It is the M shaped grouping that you see. Essentially, nerve roots from the cervical part of the spine amalgamate to form the brachial plexus. The three branches of the M are respectively, the radial nerve, the median nerve and the ulnar nerve. Hit or damage any of them and you will produce paralysis of those parts of the arm and hand that they supply.  

Shoulder gunshot wounds are horrific and if you want  a wound that you can carry on with, it should be a flesh wound to the upper arm. Even that will be incapacitating, but it is more plausible.

Having said that, human beings are capable of amazing feats of endurance when they are in danger. But as for fighting with a shoulder wound? Not easy!

Now an arrowhead is a filthy thing. The arrowhead must be removed, but the yanking out that you see and read about will not work. It simply leaves the arrowhead in where it will fester. That could then develop into septicaemia and result in death. I have researched this and will quote Dr J.H. Bill from the American Journal of the Medical Sciences, 1862, a surgeon with real and extensive experience of treating arrow wounds. "An arrow is designed so that its head will detach. Generally, when an arrow is fired it is designed to kill, not to maim." Read my April blog post, The Doctor's Bag, along with a few comments about poisoned arrow tips and how they made the poison.

Pistol balls would not travel as fast and made less of a mess than the Minie ball/bullet, which was used in the Civil War. It expanded and traveled faster and made more mess. But the thing about bullets is that they travel and get so hot they burn off microbes, so they are less liable to get infected than are arrow wounds. Shoulder gunshot depends on weapon caliber and if anatomical structures are damaged. If the bone is injured or nerves are damaged then it is useless and can't be used for a month or more and gradual recovery.

MEG:  Thanks for verifying, wow. I'll just grit my teeth if I see or read that kind of thing again. Since I'm fairly new to the western genre, I've been reading a lot of books where a character is "gut shot." I did not want to include a gut wound picture, because they are SOO GROSS! This will have to do, LOL. So does that mean - "you're dead?" How bad is being gut-shot? Can anyone survive or walk around with a wound in the gut?

Dr. Keith Souter:  Gut shots were always regarded as potentially fatal, but Dr George Goodfellow became the gunshot expert. I have talked about bullet wounds in my last blog. You had a chance of survival if it was a lower calibre weapon .32 or less, in the lower abdomen (below the umbilicus). Upper abdomen, or high calibre, very little chance. Check out the blog, Dig it Out, Doc - Part 2, Bullets, by clicking the link. Abdominal gunshots again depend on weapon caliber and site plus how much internal damage, depending on its direction - you could hit several vital organs, which could prove fatal. You would not be capable of fighting. Recovery would necessitate surgery and several months of healing. 

MEG:  Got it. Think LOWER when writing gunshot battles. Too much stuff in the upper area, I suppose, with the stomach, liver, spleen, etc...  Here's an encore question -- just because it's one of my favorite Clint Eastwood movies: How did good ole Clint survive the hanging in Hang 'Em High? I mean, he did survive and I believed it and figured it was accurate. But why? Just curious as to anatomy.

Dr. Keith Souter:  Hanging produces death either from breaking the neck, such as occurs on a gallows and there is a sudden drop, or from blockage of the airways, obstruction of the venous drainage in the brain by pressure on the jugular veins in the neck, or by obstruction of the arterial flow to the brain by pressure on the carotid arteries. It is also likely that the heart can suddenly stop as the result of vasovagal inhibition. 

In judicial hangings with a drop of six feet there is likely to be fracture dislocation at the level of the 2nd and 3rd cervical vertebrae or the 3rd and 4th vertebrae. This would tear the cord from the medulla of the brain. 

If someone is hoisted up from the ground, then the cervical fracture and dislocation and sudden death is less likely. The other causes mentioned above are likely eventually. In England in medieval days, the crime of treason was death by being hanged, drawn and quartered. The victim was hanged until he passed out, then he was cut down, revived and then the rest of the execution proceeded. Horrifically grisly, but they developed torture and execution into a fine art.

When people commit suicide by standing on a chair and then toppling it over, they usually do not break their neck (because the drop is not long enough) but will succumb by the other methods mentioned.

In a matter of life or death, people are able to do remarkable things - drag themselves around, stagger to safety. The fight or flight reaction comes into action and you pump up so much adrenaline that you can get extra strength to override the pain matrix. In addition, in battle - from studies in world War II - wounded soldiers often felt remarkably little pain even in the face of quite major trauma. According to the Gate Control theory of Melzack and Wall, put forward in 1965,  it is possible to close one or more of the gates in the transmission of pain from the site up to the brain. 

Meg: Interesting! Odd how that illustration shows the men with their mouths closed and eyes shut, where I would think they'd be gasping for breath. Hm. I'm so grateful to you, Doc, for chatting about such great western stuff! Thanks again. Readers can find Clay More's books here.

Meg Mims is an Award-winning author and artist -- her first published book, DOUBLE CROSSING, won the WWA Spur Award for Best First Novel in 2012. A blend of True Grit and Murder on the Orient Express, it has over 30 five-star reviews on Amazon. The sequel, DOUBLE or NOTHING, is also available and continues the story of heroine Lily Granville and hero Ace Diamond.