[From Fernelius’ Universa Medicina, Geneva, 1679.1

BOOKSHELF BROWSING SURGERY AMONG THE NORTH AMERICAN INDIANS*

ERIC STONE, M.D., F.A.c.s.

PROVIDENCE, R. I.

I F questioned about the medica prac- tices of the American Indians most physicians wouId exceed their knowI-

edge by murmuring something about bizarre ceremonies, incantations and mum- bojumbo. These certainIy were phases of American medicine but a study of the subject reveaIs a surprising amount of reaIistic treatment for those conditions with which the Indian was famiIiar. The Indians’ tota inabiIity to grappIe with the probIem of epidemic infection, their terror and the absurdities to which they resorted created the popuIar opinion a hundred years ago that Indian medicine was non-existent. OnIy recentIy are arch- eoIogists and ethnoIogists bringing to Iight not onIy the pageantry but also the rationaIity of aborigina1 medica practices. The picturesque ceremonies were used either as a psychotherapeutic adjunct to Iegitimate therapeutics or were em- pIoyed in the face of grave disorders, usuaIIy those in the reaIm of interna medicine, where the pathoIogica1 process was beyond the reach of their diagnostic powers. The Indians’ crowning achieve- ments, medicaIIy, Iay in the fieId of sur- gery; especiaIIy if we consider surgery to incIude the care of wounds, fractures and

disIocations. This is not remarkabIe as it was just such disturbances to which they were most subject as the chase and war- fare were important eIements in their Iife.

WhiIe the average Indian knew infiniteIy more anatomy than the average white man the Indian medicine-man knew much Iess than his European brother. But it was not the Iack of anatomica knowIedge which Iimited to a marked degree the genera1 surgery of the Indian. Nor was it the ignorance of theories of sepsis and antisepsis for the invaders were just as ignorant. The uItimate reason for retarda- tion of surgica1 deveIopment Iay in the dependence of the Indian on impIements provided in the natura1 state by their environment. AI1 their tools for any occupa- tion consisted of stone, sheI1, horn, wood, bone, reeds or grasses and anima1 parts. The deveIopment of surgery to an unappre- ciated extent was due to the deveIopment of tooIs, especiaIIy those with cutting edges. The keenest cutting edges the Indian couId produce were those made by abrasion and grinding of ffint chips. This set a definite Iimit to the possibilities of their surgery. This, I beIieve, was even more important than the absence of the inductive method of thinking.‘,**

* Submitted for publication Aug. 10, 1931.

$79

580 A merican Journal of Surgery Stone-Surgery among the Indians SEPTEMBER, 1931

The Indians’ materia1 cuIture was that of the Stone Age, in curious contrast to their high artistic and ideationa deveIop- ment. They Iacked forceps, hemostats, indeed a11 essentia1 surgica1 impIements. However, with their crude instruments, the flint, the thorn and sinew, the cautery of gIowing coaIs, sticks and thongs they achieved noteworthy resuIts.

During the three centuries of contact with the invaders the Indians assimiIated but IittIe of the foreign culture, that IittIe consisted in borrowing or steaIing the white man’s weapons of offence. Indeed as one reviews the reIations of the two races there was IittIe in the contact which wouId invite the Indian to covet or admire the other’s cuIture. At present the Euro- pean cuIture is being shoved down the throats of the resistant remnants; but even today in many phases of Iife they cIing to their traditions. Although there are a reIativeIy Iarge number of Indians practicing orthodox medicine in the United States at present, some 600 having been graduated from recognized schooIs of medicine, the majority of medicine-men are practicing preciseIy as did their arche- type of 300 years ago.

In pre-CoIumb ian days certain tribes of the Southwest, under the influence of the advanced Mexican and CentraI Ameri- can CiviIizations, practiced trephining. The indications for the operation were probably not those of today for as far as can be Iearned the procedure was carried out on those possessed by evi1 spirits and the object of the decompression was to aIIow these spirits to escape. But that practicaIIy the procedure was good therapeutics in some cases was not to be doubted as many persons suffering from intercrania pressure present symptoms which wouId have appeared to the Indians to denote demoniaca possession. The degree of bone repair found in many trephined skuIIs indicates that there was a reIativeIy high surviva1 rate. It is further known that those who survived the operation were considered sacred and became part

of the priesthood. But this art had dis- appeared by the time of the Spanish conquests and nothing is known of the technique or of the instruments used in the 0peration.l”

Perhaps the most interesting operation performed on the continent at the time of its discovery was the incision and drainage of the chest in cases of empyema. This was not infrequently carried out by the Indians of the Great Lakes area as they were pecuIiarIy subject to Iung affections. The ribs were not resected; but very decent drainage and a high percentage of cures were attained by this method of treatment at a time when it was seIdom or never empIoyed in European practice.15

For the rest of the more formal phases of surgery Iittle can be said. AI1 Indians couId amputate digits; but not arms or Iegs. BoiIs and abscesses were opened, and drained by wicks of shredded bark or reeds. The indications for phIebotomy were understood and the operation was wideIy used.10~13~18

The North CaroIina Indians were the onIy ones who understood the use of the Iigature. This knowIedge permitted an interesting operation which they empIoyed on their slaves. To prevent the unfortunate prisoners’ escape they mutiIated their victims’ feet. An incision was made aIong the dorsum of the foot at the base of the toes and carried back to the head of the metatarsa1 bones at which point amputa- tion was compIeted. BIeeding vesseIs were tied with Iigatures of sinew (an improve- ment over the thread or wire Iigature in vogue at the time in Europe). The skin ffap was roIIed down over the exposed joint surfaces and restored by sinew threads to the soIe. This was quite an operation especiaIIy from the point of view of the sIave as the instruments con- sisted of scaIpeIs of sharpened flint and needIes made of thorns.l*

A more modern instance is interesting in that it demonstrates the Indians’ knowl- edge of hypnotics and presents surgery as it had been practiced by them through-

NEW SERIES VOL. XIII, No. 3 Stone -Surgery among the Indians American Journal of Surgery 58 I

out the ages. In rgo2 Naiuchi, a famous Zuni medicine man of the oId schoo1, opened a breast abscess. The patient

FIG. I. Trephined skuII.11

was given a bow1 of infusion of jimson-weed (Datura stramonium) to drink and in a few minutes seemed to be in a deep and peacefu1 sIeep. The abscess was wideIy incised with a fragment of flint and as the operator broke up the IocuIi with his unwashed and ungIoved finger a Iarge amount of pus was evacuated. Yucca wicks were pIaced and the wound dressed with a ground squash seed pouhice. During the entire procedure the patient sIept soundIy, making no move, not even a grimace.”

In the treatment of wounds the Indians were on famiIiar ground and might justIy be proud of their work in this fieId. The principIes which guided them bespeak keen observation and a cIear understand- ing of the probIems invoIved. They under- stood the importance of debridement, immobiIization, drainage, wound suture, the difference between heaIing by first intention and that after suppuration and

in the presence of the Iatter knew the efhcacy of cure by granuIation in a widely open wound.7*10*14

The Tuscarora, Dakota and Winnebago Indians sutured Iarger wounds with sinew threaded on bone needles, removing the suture in from six to eight days. They insisted that their wounds shouId heal from the bottom, which they accomplished when using sutures by pIacing a thin membrane of bark between the cut surfaces before pIacing their stitches. Some Indians, notabIy the MescaIero-Apache, used twists of fiber or cIoth as wicks for drainage. Most tribes contented themseIves by removing onIy the more superficia1 foreign bodies or comminuted bone fragments; but the Tuscarora showed a ski11 in de- bridement and the remova of even deep seated arrowheads or shot that wouId have been creditabre in Ig18.7,10,14

They dressed their wounds daiIy and used as medicaments onIy those things which promoted drainage or by osmotic action caused externa1 ffow of serum and other fluids. UntiI the wound heaIed they never appIied saIves which tend to sea1 the wound. They used washes, pow- ders, pouItices and packs; a few of their applications we know actuaIIy had anti- septic properties and others were stimuli for granuIating tissue.7B10J4

The use of nicotine was extensive, tobacco being chewed and tamped in the wound as a pIug or ground and dusted into it. Nicotine is wideIy antiseptic and draws fluid from raw surfaces. In 1912 a friend of mine took a canoe trip with an Indian guide. One day when bathing he tore his right thigh from just above the knee to within 2 in. of Scarpa’s triangIe and to a depth sufhcient to expose the saphenous vesseIs. The guide daiIy packed this wound with tobacco and the wound heaIed by first intention and in two weeks was functioning freeIy. A month Iater the wound was a fine hairIine of scar.

Another widespread practice, especiaIIy in compound fractures, was an aImost constant irrigation of the wound with coId

382 A mericsn Journal of Surgery Stone-Surgery among the Indians SEPTEMBER, 1031

water. The New EngIand tribes used the gum tree. Danderion greens were ground turpentine boiled from the wood of white fine and powdered on wounds and the pine in a simiIar way, or apphed the bark, whole Ieaf Iaid on as a top dressing. The

E

FIG. 2. A. FIint knife.4 B. Phlebotomy flints and scarifiers.lg c. Bone needle.8 D. Bone tube for ritualistic sucking and bIowing powders on wounds.19 E. Tamponer of carbonate of 1ime.l

beaten to a pulp, as a pouItice. They also used the bark of the aider as a pouI- tice, and decoctions of the bark of sarsa- pariIIa or infusions of heIIebore were appIied as wet dressings. Scrapings of the root of the water-IiIy were pIaced on granuIating wounds to speed a11 regenera- tion. In the middIe AtIantic area kerosene, which they skimmed from marshes, was used as wet dressings. In the Southwest hot pouhices of crushed watermeIon or squash seeds were common. The Southern Indians made wet dressings of decoctions of the root of pennywort, sometimes mixing with it an antiseptic and astringent gum obtained by boiIing the root of the sweet

Indians of the Great Lakes region and the Missouri River made tents or pouItices of the barks of sIippery eIm or common eider. A growth from the bark of the wiId rose was scraped off, charred and powdered on open wounds. In short the Indian not onIy knew what effects he desired of his treatment but had discovered what IocaI herbs would bring about these resuIts.2*G~S~”

As described previousIy, one tribe at Ieast knew the use of the Iigature in con- troIIing hemorrhage in wounds. Most of the tribes understood the use of the cautery to stop bIeeding and used Iive coaIs or burning brands for this purpose. For oozing the MescaIero for instance packed

NEW SERIES VOL. XIII, No. 3 Stone-Surgery among the Indians American JOU~WJ of Surgery 583

the wound with eagIe’s down. The Haidah used spiders’ webbs and the Missouri River Indians empIoyed puff baIIs, a11 acting as effective coaguIants. Where smooth sumach was indigenous its hemo- static property was we11 known. AI1 tribes couId appIy the tourniquet.*

This sounds Iike reIativeIy modern medicine and becomes even more impres- sive when compared with the practices of contemporaneous whites. The Indians were carrying out these rationa procedures in the care of wounds even as far back as the time when European doctors were despairing of the use of the cautery and boiIing oi1 and had swung to such ex- tremes as the puppy fat dressings of Pa& and the “weapon saIve” which ParaceIsus was endeavoring to repopuIarize.‘j

That the Indians had pecuIiar success with wounds is abundantIy attested by a host of witnesses as a11 observers, medica and military, noted the beautifu1 resuIts of the aborigines’ methods of treatment as compared with those of the whites. Indians seemed to have recovered from injuries which wouId have been fata to a white man. At a time when gunshot wounds of the bIadder were invariabIy fata to the pioneer these injuries were we11 borne by the Indians. LoskieI examined a man whose face had been torn in a fracas with a bear, the Iimbs Iacerated, the rib cage crushed, and the abdomen disemboweIed. The man had crawIed four miIes to his viIIage and in six months had com- pIeteIy recovered, except for hideous scar- ring. Bourke reports the cases of two severeIy wounded Indians who had been discharged from a miIitary hospita1, in extremis, that they might die among their peopIe. But a month Iater it was found that they had compIeteIy recovered under the care of their own medicine-men. Such records couId be continued indefi- niteIy as white men were so impressed by the abiIity of the Indian to survive terrific wounds that hundreds of cases have been described.5*16

*References 2, 7, IO, 14, 18.

The Indians were as famiIiar with fractures and disIocations as they were with wounds, and were just as successfu1 in their treatment. The knowIedge was not confined to the medicine-man for the Iay Indian was aImost as adept as his professiona brother. As a resuIt it was rare to find a deformity after a fracture.

In most tribes broken bones were imme- diateIy set and spIints appIied. The spIints were usuaIIy made of sIats, Iengths of sapIing or stout reeds cut Iong enough to immobilize neighboring joints. Near their two ends the sIats were fastened to one another by running thongs in such a way that when appIied they were about 2 in. apart. When such an arrangement was put in pIace it gave very efficient support, couId be easiIy readjusted and gave ampIe space for the appIication of soothing Iotions or pouItices or for the treatment of the wounds in compound fractures.3~‘2~13,18

Some of the tribes devised very perfect spIints. The Shoshone made a cast of raw hide saturated tiI1 pIiabIe with water. This was mouIded about the Iimb after the reduction of the fracture. When dried they resuIted in a rigid cast as perfect as any now produced by pIaster of Paris. The Winnebago and Dakota hit on the same device, except that they empIoyed sheets of bark. In both types windows were cut where wounds existed.2,6B’5

After union the Iimbs were skiIIfuIIy massaged, exposed to the sun or treated with heated stones, and passive and active motion used to restore function.

In regard to disIocations their treat- ment was equaIIy good. A few of the tribes did not understand the reduction of the hip; but a11 knew how to reduce disIocated shouIders or digits. The Ottawa and Chippewa reaIized the importance of mus- cuIar reIaxation, and having noted the reIaxation of the muscIes in the presence of nausea, brought this on by administering emetics before attempting reduction. Los- kiel happened on a Ione hunter just after he had reduced a disIocation of the hip. The Indian had strapped the foot of his

584 * merican Journal or Surgery Stone-Surgery

injured Ieg to a tree and then pushed him- self away from it using his arms and uninjured Ieg and with appropriate rota- tions of his peIvis had snapped the head of the femur into pIace.gs’6

The reaIIy remarkabIe recoveries from wounds and injuries may not have been entireIy due to skiIIfu1 case management. The Indian may have deveIoped bioIogica1 aids through centuries of exposure to such accidents which miIitated against shock, hemorrhage and suppuration; just as the civilized man had deveIoped a reIative racia1 immunity to many infectious diseases. One immediateIy thinks of the possibilities of more effective adrena

among the Indians SEPILMBER. ,931

activity or some such other endocrine adaptation. Furthermore each patient was treated separateIy in his own Iodge or tepee and so was not subject to hospita1 gangrene which in the 18th and 19th centuries wrought so much havoc among the soIdiers who were being wounded in the same way, at the same time.

But given these advantages on the one hand and the Iimitation of his physica equipment on the other, it must be con- ceded that the American, even at the time of his discovery, had brought certain phases of the art of surgery to a remarkabIe degree of perfection.

1. ANDREWS, E. Chicago M. Examiner, IO: 599, 1869. 2. ANDROS, F. J. A. M. A., I: 116, 1883. 3. BENEDICT, A. L. Med. Age, Ig: 767, 1901. 4. BOLTON, R. P. Indians Notes and Monographs.

M. Am. Ind. (Heye Foundation), 7: 57, 1930. 5. BOURKE, J. A. Medicine Men of the Apache.

Bureau American Ethnology, 1891. 6. BROWN, A. Surg. Gynec. Oh., 50: 647, Ig3o. 7. BUCHANAN, C. M. St. Louis Cow. Med., 21: 290,

1899. 8. CHAPIN, H. M. Indian ImpIements Found in Rhode

Island. Rhode Island Historical Society, 1924. 9. DARLING and WINDER. Boston M. & S. J., 34: g,

1846. IO. DENIG, E. T. St. Louis M. Ed S. J., 13: 312, 1855. II. FLETCHER, R. Contributions to N. Am. Ethn.,

12.

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IS.

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H&MAN; W. J. Med. @ Surg. Rep., 40: 157, 1879. HRDLICKA, A. Annual Report, Bureau American

Ethnology. No. 34, Igo6-07. JOSSELYN, J. New EngIand Rarities (1636), Boston,

WiIIiam Veazie, 1865. KUYKENDALL, G. B. Med. TV Surg. Rep., 33: 181,

1875. LO&X, G. H. History of the Mission of the United

Bretheren among the North American Indians. Tr. by C. I. La Trobe, London, 1794.

STEVENSON, M. C. AnnuaI Report, Bureau of Amer- ican EthnoIogy. No. 23: IgoI-Igo (1904).

TONER, J. M. Virginia Med. Monthly, 4: 334, 1877. WHITEBREAD, J. C. Proc. U. S. Nat. Museum, 67:

1923, Art. IO.