http://en.wikipedia.org/wiki/William_Fraser_Tolmie
Warning to Reader.
These notes include the details of a fairly descriptive event that took place in Oregon in 1834. It is the story of a Frenchman who nearly lost his limb and life due to an ax-related foot injury. Dr. Tolmie is very detailed in his description of the problems he had to face with this patient, in particular the blood loss, arterial wound and infection of the decaying parts. The patient survives in the end and fortunately doesn’t even lose his limb. But based on Tolmie’s description of the case, this very fortunate outcome is quite a surprise.
Introduction to Fort Medicine– A Case of Surgery
WILLIAM FRASER TOLMIE, ca. 1831, 1834
NOTE: Olof Larsell’s The Doctor in Oregon (pp.72-80) has an extensive writing on William Fraser Tolmie with quotes from his writings, from which these notes on the medical history of Fort Vancouver were taken.
This particular story is unique due to the details of the events that took place and the anatomy and physiology of an operation that took place and nearly failed in 1833 in Oregon Territory.
At the age of just 23 years of age, WILLIAM FRASER TOLMIE, was appointed surgeon and clerk for HUDSON’S BAY COMPANY. This position was granted to Tolmie under the recommendation of his botany professor at the University of Glasgow, Scotland, DR. WILLIAM J. HOOKER. Tolmie learned medicine at the University of Glasgow, and graduated from there in August, 1831. He did his clinical training at a local Glasgow Hospital for a year following his graduation, and then initiated his service for Hudson’s Bay Company on September 21, 1832. Once he arrived at the fort, Tolmie performed his medical services alongside Dr. Gairdner.
The following Spring, in May of 1833, Tolmie was travelling about the region trying to acquaint himself more with the region he was in charge of. One thing he would have noted was the unique cultural background of many of the local inhabitants. There were more than likely still a number of French-Canadian trappers passing through every now and then, connecting with agents stationed at the fort for their regular supplies of wares and such. An unusual number of ships could be seen along the western shores as well, some of these ships cayying the most unique people. An international route was well established with Russian and of all places in Europe, Denmark. Quite often, these ships would come into the region at an unexpectedly frequent pace. Although only a few times per year, this suggested the Danes had some interest in the unclaimed Pacific Northwest Territory. In just a few years this interst would be well proven once these Danes set up an orphanage, mostly of boys, just a little south of the Columbia River on down the Willamette River. These young Danes resided in an orphanage.
Another unsual character Tolmie met us with was his gardener, who clalimed he was celtic (Sat. May 4, 1833, Larsell, p. 72). Tolmie also makes mention that day of the apothecary hall that had been set up for the area, and a case of subacute pleuritis that he had to attend to. The next day, Tolmie got into some of his favorite past time, botanizing. In his Sunday May 5th, 1833 this led him to write about the Devil’s Wood he had heard about from locals and was now searching for. [Note: this plant is identified by Larsell as Dogwood, Cornus nuttallii, which could be an error. Lyon’s Plant Names Scientific and Popular, identifies Devil-Wood as Osmanthus americanus (L.) B. & H., but this too is probably also in error. The more likely candidate is the Devil’s Club, of the Ginseng Family, or Opopanax sp.] On his notes on this new species, Tolmie writes “Having been informed that the root was employed in the U.S. for the care of intermittents. Mr. McL. used it here last season in doses of …dryed root powder and [had] success in subduing disease with cinchona too…”
This use of Devil’s Wood by Dr. McLaughlin led Tolmie to try it on some of his own patients. On May 3, 1833, Wednesday, he “Collected a specimen if the Devil’s tree used as a purge in the U.S. and tried it in a few instances.” [Wed. May 8, 1833, p. 73.] The following day, Thursday, May 9th, he continues his entry on this local species: “Examined plants procured last night. It is I think Cornus Florida. which, in the U.S. is sometimes substituted for cinchona in a dose of [ ] or [ ] powdered bark; its composition is Cinquonanie Quinine and [Opium] Gum.” ([Thurs. May 9, 1833] Larsell, p. 73)
This work on the Devil’s Wood could not have come at a better time. One week later, on Thurs. May 16, 1833, Tolmie made notes in his journal about some cases of Intermittent fever that recently developed and devastated the population of the local tribes. [Larsell, p. 74] The most likely intermittent fever to occur in this region was malaria, although the reason it infected only the local tribe remains uncertain. This disease is typically carried in by ships from the tropics down south. At the time, shipping between Chili and the western shores of Mexico were common, most often for food supplies and such. It is therefore very likely that this was one of the first malaria epidemics in local history to come to the shores and migrate inland.
That same day, Tolmie enters some details about the quarters he is to stay in within the headquarters building [p. 74]. At this time he also notes the following about his surgical tools:
“There is an excellent supply of surgical instruments for amputation, 2 trephinning, 2 eye instruments, a lithotomy, a cupping case, besides 2 midwivery forceps and a multitude of catheters, sounds, bandages, probings, 2 forceps, etc. not put in order.”
May 30, 1833
Two weeks later, Tolmie has to take a trip to Nisqually. On May 30th, 1833, he lands at the docking site here and makes his way onshore to attend to his first major medical emergency. A local Frenchman, Pierre Charles, had “cloven his foot with an axe” a day or two ago and was being treated for “a terrible wound extending from ankle to second toe, bones being properly sliced.” Apparently, the point of the axe had passed through the foot, leaving a gaping wound one inch in size in the sole.
After submersing Pierre’s foot in cold water, Tolmie prepared it a removal of the bandage and its viewing for the first time since the injury. After removing the bandage, Tolmie applied “three strips of adhesive plaster and above these lime sip’t in cold water over all the canvass bandage.” In short time this resulted in the oozing of arterial blood from the wound, not a good sign. Soon the flow of this arterial blood to the point where Tolmie had to try to subdue the bleeding or risk losing the life of his first major case. According to his notes he first applied pressure to the injury and vessel where the blood was gushing out, which was to no avail. So he then clamped the artery with a tenaculum. This only worked for a few seconds. As pressure builtg up behind the clamp, the ttwo neighboring branches of this artery began to take on this increased flow pressure and soon the clot that blocked each of them cleared and both arteries began spewing out blood. This forced Tolmie to apply a tourniquet to the femoral artery deep in the thigh, and to tie a handerkerchief tied tightly around the lower leg just above the ankle joint. In spite of this, the bleeding from the arteries continued. This led Tolmie to do the worst, apply button forceps directly to the bleeding vessel (such a maneuver can make the cut end of the artery worse and unrepairable). This was effective at reducing the bleeding to a trickle, leaving Tolmie, his patient and the team equally in a state of shock:
“The patients and attendents were greatly alarmed and I returned heart felt thanks to the Almighty when after two vessels were secured by torsion and the bleeding quickly diminished. He lost at least [ ] of blood, trembled violently, and repeating his prayers and believe gave himself up for lost, but the comparative goings of the pulse always inspired me with hope.”
Tolmie next applied wet handkerchiefs loosely to the site, with large pieces of lint coated with tincture of calamine (“Caldimin.”). He followed this with an administration of “a powerful dose of sulph. Soda” and an order for a “spare diet” for the patient.
Nearly two weeks after this operation, about the 12th of June, Pierre’s foot had improved, although minimally. Much of the surgical site where the necessary repairs were made by Tolmie had begun to scar over and were closing off by forming adhesions. The next day, Tolmie placed a new adhesive plaster over the wound “to bring the lips of the wound in opposition [together].” This was followed by the application of another loose bandage.
Later that day the wound was giving Pierre more pain in the foot area. Tolmie noted the healing edges had turned inward into the wound. This meant theyy were not growing together to form an adhesion. This led Tolmie to administer a fomentation to the surgical site and apply a poultice, which he changed a few hours later.
By this time it had also become clear to Tolmie that Pierre was developing a fever, perhaps from the infection, or as a consequence of a continuing traumatic shock. To treat this fever, Tolmie administered “GR X P. Ipecac:C., which is to be repeated.” [translation: “Grains 10 Pulvis (Powdered) Ipecacuanha Cinchona?” or “Grains 10 Powdered Ipecacuanha C.”]
Later on Friday, June 14th, Pierre “perspired copiously,” and so was adminstered the medicine Calet Jalep (Jalap–a laxative), which “operated twice” on his bowels. By now, the wound had developed quite a swelling, and for the first time was discharging serous matter (a clear thick fluid) from the wound. According to his diary entries, this led Tolmie to think the joint capsule had been penetrated by the infection taking place.
Later that afternoon, this region has hemorrhaged. So, Tolmie once again removed the poultice, replacing it with “a dripping of calamine cruste,” followed by a packing of the entire foot by a cotton handkerchief, and a repeated wettening of the healing ankle with cold water. Tolmie was by now feeling the poultices were causing the tissue to further separate from each other, rather than assist in the binding, scabbing and ultimately granulation process. So, on Sat. June 15th, he planned to apply a cold lotion to Pierre’s healing foot, only to stop this procedure due to the pain Pierre claimed he was suffering from due to his ankle. Consequently, another poultice was applied to the area, and later that day, Pierre began to again show his first signs of shock such as trembling and sensing chills. At 4 PM he was again administered a grain of Ipecac C., which was repeated again at 8 PM, each followed by a glass or more of warm water each time.
Sunday, June 16, 1833
It is now just two weeks past the cleaning and repair Tolmie did on Pierre’s foot. Tumefaction has developed around the ankle, which “did not pit on pressure.” In his journal, Tolmie then gives a fairly vivid description of the area surrounding the exposed bones, noting the unhealing left lip of the wound, and the “healthy discharge” of pus coming from this site along with decaying skin. Pierre continued to sweat that day, and passed no stools.
At one point in this process, Tolmie feared the onset of what he called phlegmatous erisyp. [erysipelas] from the ailing foot. This would be a severe reddening of the foot, with possible blistering, indicating the foot was going to have to be amputated. This led Tolmie to incise the foot at the reddened site, enabling more serum to escape; this unfortunately was complicated by a short hemorrhage that also followed due to a small artery he had cut. After ceasing the bleeding, Tolmie inserted a rag between the lips of the wound, and applied a cataplasm consisting of 3 1/2 [pounds] flour. This caused the pain from this site to continue throughout the day, receding by nighttime but with Pierre’s pulse quickening. To prevent further bleeding and swelling, Pierre’s foot had to be laid on a support while he slept.
[Note: Tolmie’s use of ‘phlegmatous erisyp.” reveals an important part of his medical reasoning about this condition. Erysipelas is an infectious process due to a bacterium, most commonly group A beta-hemolytic Streptococcus pyogenes. This term is also sometimes associated with the effects of eating food made with flour that has been contaminated with a fungus, causing the skin to redden and the person to feel very hot. Erysipelas itself is just a red-hot condition of the skin. It often precedes gangrene-prone conditions, and is an indicator that some sort of systemic infection is setting in. Usually this also precedes the events of a patient going into septic shock.]
The next day, on Monday, June 17th, 1833, Tolmie began his notations with “Pierre slept well until 11 last night when his foot slipped off the supports on which it lay and he has since this morning been in great suffering.” Tolmie removed the cataplasm about 8 in the morning, which had unfortunately adhered a bit too much to the ailing limb, making its removal painful. By now he could see that the tumefaction had spread around the ankle and above and below it by four inches. Some of the parts appeared reddenen and inflamed and the wound was discharging ample amounts of pus “of good color but rather thin.” So Tolmie removed a layer of the coagulated blood lying over this injury, noting the underlying tendon was also decaying and nearly detached from the bone. Tolmie then applied another cataplasm to the lower surface of the foot and covered it with warm-wetted flannel.
By afternoon, Pierre’s pains were shooting upwards into the thigh, and from there spread “along left side of his heart which palpitated violently.” This led Tolmie to prescribe to Pierre “a grain of opium with calomel.” Later that morning Pierre was given a dose of sulphated Soda “to relieve irritation.” By mid-afternoon (3 PM) he was fed rice soup for dinner, and at suppertime he was given about a pint of elk soup.
Since mid-afternoon Pierre had been feeling an urge to pass stools, which was a good sign. But his efforts to clear were unsuccessful. Later that night, Tolmie gave him an injection by clyster (enema). Meanwhile, the dressing was once again removed, and the cataplasm replaced. This site was then fomented once again with a cloth pack applied to the site. After removing “a large portion of coagulation,” Tolmie applied a piece of cloth dipped in a “watery infusion of opium” to the site and immersed the foot in it. [pp. 76-77]
Tuesday, June 18, 1833
Several stool passages in the morning and the fomentations were continued. Tolmie notes “a copious discharge of healthy puss.” He then gave Pierre a diet made of tea and cakes made from plain flour. The poultices were omitted this time due to their binding to the healing tissues as a result of the last attempt. So a blanket was then made damp with hot water and laid on the site. As the pain in the foot got more intense, and the pulse quickened but feeling much feebler, Tolmie writes: “Thinks the cold air entering the door affected limb while bed was being made.” He then prescribed G. opium [Gum Opium], and turned to Copper’s book on medicine to review mortification and lock-jaw. [p. 77]
The night from Tuesday to Wednesday, June 19, 1833 was a restless, diaphoretic night. When Tolmie removed the flannels upon Pierre’s awakening, he once again observed a copius discharge of pus. Pierre’s pulse was strong and soft. He treated the site, repacked it, and at 5 PM, removed the dressing again. These same steps were repeated, and the fomentations continued. Pierre is continuing to heavily perspire.
A few days later, on Sunday, June 23rd, the wound looks better and after the examination gets redressed with an adhesive strap. A few more days later, Tuesday, June 25th, Tolmie claims that the granulation process has been continuous over the past few days. He plans to continue applying new bandages and adhesive plasters, so long as the supply does not run out. He writes: “if the limb is properly bandaged any careful person might take charge in a day or two as the man’s health is now good and nature active in the way of granulation and insipient cicratization.”
Finally on Friday, June 28, 1833, Tolmie determines that he is about aweek away from the recovery state needed for Tolmie to depart and to begin to carry out his regular business once again as before. It is now nearly one month into this process.
The weekend marks the end of this nearly tragic case involving Pierre Charles. On the next day, Saturday, June 29th, the palce where Tolmie is staying suffers an earthquake. One day later he writes the following letter:
“F. Heron, Esq., Sir, You have decided on my remaining in this quarter until Pierre Charles can be reported safe and sound and requested me to state when that desirable event is likely to happen. I have to inform you that if the wound on his foot continues to heal as it has for the past week it will in three or four weeks be completely cicratized and no further requiring application. W.F.T.”
July 1, 1833
On Monday July 1st, Pierre had a sudden attack of vertigo. Tolmie notes however that his foot is cicratizing well. On Wednesday July 10th Pierre complains of some ankle joint pain. Two days alter, July 12th, he complains of pain in the tibia. Still, the wound looks well but is not healing as rapidly as Tolmie would like. This leads him to switch the use of strap types being applied, replacing the adhesive strap that involves grease, with one that uses a different type of unguents.
This is Tolmie’s last entry for this case involving Pierre. On Monday, August 5th, Tolmie places an order for recharging his stock in the medicine chest. This order requests “Jalap. Potass. Supert. Emplast Adhes: 1 yard cal: acid citric,” some cupping glasses, “2 aneurism needles, 1 for the carotid, the other size for the radial”
According to a December 10, 1833 communication, Tolmie learned that as of late November, Pierre Charles was fully recovered, and on board a ship.
Tolmie remained at the fort until February 1836.
Fort Vancouver, 1824 (wikipedia)
OTHER NOTES
Tolmie makes use of another Oregon plant just one more time. This is Salal, in which the berries are pounded into a mash, for use as a poultice for treating an abscess (see August 18, 1833 entry below).
The following entries are added for completeness of this review.
Fri. June 14, 1833.
Mr Laderitch. “whose stomach and bowels are disordered” was prescribed “an emetic instanter and a purge.” His subsequent complaint of bowel pain led Tolmie to apply a sinapsis to the abdomen and then prescribe a “gut. XXX Ip. opie.” [30 drops [guttae] of Ipecac Opium.]
August 18, 1833
Treating an abcess experienced by an Indian in old Kasket: “a large suppurated tumor immediately under angle of jaw on left side.” Tolmie opened the abcess and placed a poultice made of the berries of Salal/Shallon (Gaultheria shallon) on it. [p. 79-80]
November, 1834
treated chief Quanachanott of Kokwatoch village with dysuria by prescribing “essence of PPt” [essence of Peppermint].
Dec, 10, 1833 Tolmie ordered some hernia trusses.
Tolmie Left Fort Vancouver in February 1836.
Fort Vancouver, 1859 (wikipedia)
ADDITIONAL REFERENCES
W.F. Tolmie’s Journal [OHS], p. 230.
A.S. Munro. “History of Medicine in British Columbia.” Canadian Medical Journal (1931), 37:293.
Burt Brown Barker. “McLoughlin Proprietary Account wtih Hudson’s Bay Company, Quarterly (1944), 45: 1-14.
S.F. Tolmie. “My Father: William Fraser Tolmie.” British Columbia Historical Quarterly. 1937, 1:232.
A.G. Harvey. “Meredith Gairdner: Doctor of Medicine.” British Columbia Historical Quarterly. 1945, 9:89-111.
M. Gairdner. Essay on the natural history, origin, composition and medicinal effects of mineral and thermal springs. (Edinburgh, 1832).
Brian Altonen, MPH, MS 