Medicine: Wounds: 1. Medicine:Wounds

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1. Medicine:Wounds

This article is meant to give some pointers to authors. It is not intended to be comprehensive, and it simplifies many complicated issues. In other words, unless you are trained to do this, don't try this at home!
If you find something inaccurate, please email me. If you have questions that are not addressed, I'd be glad to add information to address them.

Warning! Some of this is moderately graphic in a fairly clinical way. Not for the very squeamish.


Basic Healers kit:

Dressings: Clean cloth to dress wounds. Bandages, which are actually what goes on top of the dressing to hold it in place.

Knives or scalpels: Very sharp blades, and the means to keep them sharp. A traveling healer might have only a few sizes; someone traveling light might use their everyday belt knife. A healer at home would have several.

Cleanser: Soap of some sort would be a nice touch, to wash the healer's hands and the body part needing work. Alcohol, the purer the better, for sterilization. A pot or container to boil water for sterilization.

Herbs: Any medicinal herbs you decide to include. I certainly would have willow bark which contains salicylic acid, as in aspirin. I assume most will want athelas, even though its properties are unknown. (More on herbs in the future.)

Suture material: Horsehair, linen, cotton, silk, and silver wire have all been used as suture. The natural materials most recently used are silk, and what is called 'catgut', but is actually made from sheep intestine. These two sutures can still be found today, although catgut is rapidly, and silk more slowly, disappearing in favor of synthetics. Human hair was another suture material used in ancient India, and a recent small study in India found human hair which was first washed and then sterilized in 'spirit' (alcohol, I assume) made a successful suture for small external wounds.
Sutures are classified as absorbable or nonabsorbable. Absorbable sutures are used anywhere the persistence of the suture will increase infection risk, which means internal sutures. The main natural absorbable suture is catgut, dissolving in 5 to 10 days, or if treated with chromic salts, 2 to 3 weeks. Nonabsorbable sutures are used where they can be removed, or where continued tensile strength is important.

Needles: Curved needles are today's standard, and a whole lot easier to sew with, but require needle holders to use. The ancient Romans did have needle holders, and any society that can make some of the artifacts known to Middle-earth can probably make needle holders. Curved needles were known in medieval times for leather work, so they should be available at this level of technology. Middle-earth needles, unlike modern needles, will need to have an eye and to be manually threaded before use.

Other instruments: Scissors for cutting dressings and bandages, fine scissors for suture, slightly larger ones for skin and tissue. Note that scalpels or knives can substitute for scissors. Tweezers, which are a type of forceps for those who want the medical word. These will be used to pick up and hold skin or the tissue under it when examining or suturing a wound. Clamps for holding tissue, grabbing objects you want to remove, and clamping off bleeding blood vessels. Retractors, which in Middle-earth will likely be of the 'hook' or 'rake' type, used to pull aside the edges of the wound so the healer can better see what is happening inside it. Since these are known in collections of antique Roman and British instruments, they are reasonable for Middle-earth.

Maggots: Maggots are useful in wounds where there is dead tissue and/or infection. The correct type of maggots will digest the dead tissue and leave the healthy tissue, and also produce antibacterial compounds.

"Historically, maggots have been known for centuries to help heal wounds. Many military surgeons noted that soldiers whose wounds became infested with maggots did better --- and had a much lower mortality rate --- than did soldiers with similar wounds not infested. William Baer, at Johns Hopkins University in Baltimore, Maryland, was the first physician (an orthopedic surgeon, actually) in the U.S. to actively promote maggot therapy; his results were published posthumously by his colleagues in 1932. MDT was successfully and routinely performed by thousands of physicians until the mid-1940's, when its use was supplanted by the new antibiotics and surgical techniques that came out of World War II. Maggot therapy was occasionally used during the 1970's and 1980's, when antibiotics, surgery, and other modalities of modern medicine failed." This information is taken from a page about current clinical use of Phaenicia sericata (green blow fly), found here
(Thanks to Stulti for bringing up the question of maggots.)


Wounds

Stab wounds can be more like punctures or more like slices. Punctures are more likely than slice type wounds to get infected, less likely to cut through deeper structures, although it can still happen. The thinner the blade, the more like a puncture.

Any wound that is more than just barely through skin can damage deeper structures; muscle, tendon, ligament, blood vessel, or internal organs. Correct assessment involves checking the function of underlying structures for muscle, tendon, and nerve; and actual exploration to see the damage directly. This may not be practical for some punctures with a very thin blade, such as would be seen on a screwdriver.

Repair: Wounds are closed three ways: Primary closure or 'primary intention' which is immediate wound closure, Delayed primary or 'third intention' which is surgical closure delayed 3 to 5 days in order to miss the period of greatest infection risk, and 'secondary intention' which means leaving the wound open and allowing it to heal by scarring and contraction. Each of these has its place. If the healer can sufficiently debride and wash out a wound within 6 to 8 hours, it can be sutured immediately. If it is too contaminated, or older than 8 hours, one of the other two methods should be used, as the risk of infection is high. There are exceptions to all this, but you don't want to learn medicine, just sound correct in your writing.

Skin wounds are often deep enough to be repaired in two layers. The lower layer is the bottom or 'underside' of the skin, just above a layer of fat which is usually not very thick in your average person. Repair this lower layer with catgut. Don't sew the fat layer itself. The top layer is the skin you see from the outside. Repair this with a nonabsorbable suture such as silk.

Tendons could be repaired with the tech level of Middle-earth, although there is a substantial risk of infection. Use silk for this, as catgut will dissolve too soon. Tendons on the back of the hand are much easier to repair than those on the front of the hand.

Muscles can be repaired without too much trouble, use catgut for this. Forget nerve repairs, it takes microsurgery to do a good job.


Arrow wounds: Don't pull out that arrow!

This is one of the major medical myths perpetrated by Hollywood. You don't have to take out the bullet most of the time. And although you do have to take out the arrow, don't just grab it and pull. Firstly, you probably won't be able to if it's really embedded, secondly you may do a lot more damage pulling it out than it did going in. If you think of it as a barb, you'll realize that like a fishhook, it will tear a lot more tissue coming out broad end first than it did penetrating sharp end first. The rules from an article in The International Encyclopedia of Surgery in 1882 are still pretty applicable:

1. An arrowhead must be removed as soon as found.
2. In the search for the arrow, extensive incisions are justifiable.
3. An arrow may be pushed out as well as plucked out.
4. The finger should be used for exploration in preference to a probe.
5. Great care must be taken to avoid detachment of the shaft.
6. Healing by first intention should be encouraged.
7. The surgeon should strive to comfort the patient. Although arrow wounds are not attended with much shock, they are usually the cause of great depression of spirits.
(Thanks to Dwimmer laik for this reference.)
What this means is that the healer should make an incision, free up the head by cutting it out of the tissue, and remove it. If it is an area where it can be pushed through, such as the calf muscle of a leg, that is also a good way to remove it. Have the healer push the point through, then either cut the feathered back end at the skin line and pull on the head to remove it; or cut the barbed head off and pull on the back end to remove it. Care of arrow wounds once the arrow is removed is similar to stab wounds.

Facial wounds The key thing here is that the wound not interfere with breathing. Some large wounds to the mouth/nose area can produce so much bleeding that the patient literally drowns in his/her own blood. Any character with this sort of wound should be sitting up and leaning forward so that the blood will drain outward instead of down the throat. Large penetrating wounds of the throat almost always resulted in death due to infection in the preantibiotic era.

Neck wounds Any real sword wound to the neck is likely to kill. It will kill rapidly if it cuts one of the carotid arteries, and rapidly or slowly if the trachea is cut. Cut the esophagus and the character will die more slowly, of infection. Someone would have to work very hard to deliver a nonfatal sword thrust to the neck, perhaps a glancing and shallow slice would do this.

Chest wounds Any wound that enters the chest cavity will result in partial-to-total collapse of the lung, and possible/probable blood in the lung, varying amounts. If you want your character to survive, make the injury a fairly clean in and out, one side only, and with a clean sword or knife. Have someone put an airtight dressing over it. If you make it a "sucking" chest wound, which means you can hear air drawn into the wound with every breath, it will be worse. In this case the airtight dressing must be open on one of the four sides only, in order to create a flap to allow air to be forced out.

While washing out wounds is good infection control in general, this is one case where you don't want water making its way into the chest cavity, unless someone is doing open chest surgery. I wouldn't expect this in Middle-earth.

If the amount of collapse is small, the air would get reabsorbed and the lung reexpanded; over a week or two is a good guess for a small collapse. Blood is a problem only if the loss is fairly large; say over 500 cc or 17 oz. It starts to become a problem at that point because it takes up space that the lungs need for air. If you have someone become slightly to moderately short of breath, recovery is a reasonable thought. If they are bringing up frothy bloody sputum, (like Boromir) forget it.

Wounds to the chest can also cut the aorta and vena cava, called the 'great vessels', in which case your character will bleed to death fairly fast. A stab wound to the heart is also very likely to kill.

Abdominal wounds If you want to scare your character or readers, have an abdominal wound that just penetrates the skin and muscle layer (known as the abdominal wall) but doesn't pierce the intestine or other organs. This will not differ much from wounds anyplace else. If you pierce the intestine you run a huge risk of infection and a slow death over a few days to a few weeks, usually on the shorter side. If you cut the liver, spleen or kidneys you have a good chance of bleeding to death without extensive surgery, usually over hours to a few days. The surgery needed to repair this would be almost impossible outside a well-equipped medical facility, say the Houses of Healing. If Middle-earth armies have MASH units, they could tackle something on this order. The same applies to any major blood vessel in the abdomen; the character would likely die outside a major medical facility.

Blood loss: The amount of blood loss people can tolerate varies with their weight. It will be different for a man weighing 80 kilos (or 176 pounds) and a hobbit who weighs, say 30 kilos (66 pounds). A person's blood volume is about 70 cc per kilo, say about 30 cc per pound. I will give typical symptoms of blood loss in terms of percentage of total blood volume lost, with some representative numbers for hobbits and men. If someone figures out how much an elf or dwarf weighs, tell me and I'll add the numbers for those races. I'm assuming that Boromir and Aragorn are fairly tall and muscular, and weigh about 80 kilos (or 176 pounds). If anyone has better guesses, I'd love to have them.

Effects of blood loss:

Class 1: 10% blood loss
Man: 500 cc or 16 oz, Hobbit: 210 cc or 7 oz - Healer sees no real effect.
Class 2: 15-25 % blood loss
Man: 840 to 1400 cc or 28 to 46 oz, Hobbit: 315 to 525 cc or 10 to 17 oz - Healer sees pulse increase slightly, cool hands and feet.
Class 3: 25-35 % blood loss
Man: 1400 to 1950 cc or 46 to 65 oz, Hobbit: 525 to 735 cc or 17 to 24 oz - Healer sees rapid pulse, patient pale, restless, sweaty.
Class 4: 35-50 % blood loss
Man: 1950 to 2800 cc or 65 to 93 oz, Hobbit: 735 to 1050 cc or 24 to 35 oz - Healer sees very rapid, weak pulse, patient very pale, cold, and confused.



Infected wounds
Any wound can become infected, as bacteria are all over, on the skin, on the sword or arrow. Pieces of things left in wounds up the risk of infection. Organic objects in wounds up it even more, so bits of steel are less likely to be a problem than bits of wood (which is one of the reasons why bullets don't have to be removed but arrows do.)

Correct care by modern standards using Middle-earth equivalents: Wash out wounds- the more, the better. Remove foreign objects, such as grit, leaves, etc. from wounds. If there is dead skin or tissue underneath the skin, it must be removed by cutting it away. Your character will know it's dead because instead of a nice pink or red it will be black or grey. If your character is cutting away dead tissue (debriding) and you want to be descriptive, he or she should cut down to where it bleeds, or where the patient can feel it, in order to be sure you have live tissue. Purple can be blood in the tissue -think a big bruise, or it can be on the way to black. It's hard to describe the difference.

Bite wounds are likely to get infected. Human bites are among the worst. Cat bites less so, and dog bites least of the three. Wolf or warg bites might be similar to dogs. One could argue that since elves don't get diseases, an elf bite might not get infected. On the other hand, they probably have 'good' bacteria in their mouth, and so might have some of the nastier types that just don't affect them. I don't know about orc bites, but looking at their teeth, I'd worry. If your character punches someone in the mouth and the victim's teeth break the skin- you have a human bite.

Worst places to get infected: Face, because it can get into areas close to the brain. Hands, because the infection destroys or scars the small compartments in the hand and causes loss of function. Anything internal.

If it gets infected, immobilize the part (i.e. splint a hand) if possible. Hot soaks or compresses, if possible. If the area swells up and feels squishy like a water balloon, or leaks pus, it must be opened and cleaned out. No poking with a needle or tiny little cuts; the incision in an abscess, also called a boil, should be at least half the diameter of the abscess. After the healer opens the abscess it should be washed out. I cringe every time this is described as being done in a river or stream, since I think of the bacteria for the people and animals downstream. After washing it should have a dressing placed on it. Expect the wound to drain for at least a few days afterward, the bigger the abscess, the longer it will drain. Once opened, it will feel better anywhere from immediately for an abscess under great pressure, to several hours. It will stay sore for a few days at least. If your character doesn't have the abscess opened it may burst on its own, accomplishing the same purpose. Or the infection may spread throughout the area, resulting in bigger trouble. The infamous red streaks going up leg or arm from the infected area towards the heart means that the infection has gotten into the lymph channels. This is not a good sign, especially in a world without antibiotics. The character will have swollen glands in that area also.

There is no real life equivalent to athelas, but I'll assume it has some antibacterial properties. Use it on infected areas.

This is a work of fan fiction, written because the author has an abiding love for the works of J R R Tolkien. The characters, settings, places, and languages used in this work are the property of the Tolkien Estate, Tolkien Enterprises, and possibly New Line Cinema, except for certain original characters who belong to the author of the said work. The author will not receive any money or other remuneration for presenting the work on this archive site. The work is the intellectual property of the author, is available solely for the enjoyment of Henneth Annûn Story Archive readers, and may not be copied or redistributed by any means without the explicit written consent of the author.

Story Information

Author: Lyllyn

Status: General

Completion: Complete

Era: Other

Genre: Research Article

Rating: General

Last Updated: 04/14/03

Original Post: 10/16/02

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