Shoulder: Arms & Armour
But what are men, but leaves that drop from their branches to the earth?
Apollo’s speech, The Iliad, Book XXI, v 540
TRAINING IN EMERGENCY MEDICINE often felt like being awash in a sea of humanity; my pocket textbook a pilot-book for mariners. The departments themselves were often windowless as the engine room of a ship, and the staff moved in shifts just like deck officers on watch. Signing up for the training was a bit like enlisting in the Marines: the strict hierarchy of the medical staff, their bleached uniforms, their codes of behaviour, the alcoholic blowouts after hours.
On one afternoon shift it was sunny outside, but deep in the department there was only artificial light. A radio screamed an alert that an injured motorcyclist was on his way in by ambulance. The ambulance paramedic, Harry, let us know that although the biker was breathing and conscious his shoulder and chest had been badly injured. Harry was someone I’d come to know well in that department: battle-hardened, cynical but tremendously skilled at trauma life support.
A few minutes after the radio call, Harry hurried into the room pushing the patient ahead of him. The biker had a moonish pallor to his face, and crew-cut black hair. I noticed first his rigid plastic collar, then his oxygen mask, then, with relief, that he was breathing for himself. Harry had slashed open the left sleeve of his leather jacket to fit a blood pressure cuff and an IV drip. He’d splinted the right arm because its position looked wrong – the right hand hung limply at an angle, like a snapped lance.
‘Chris McTullom,’ Harry said, ‘twenty-five years old. He lost it on a bend, going forty or fifty I’d say. Hit the siding and went over the handlebars. There was a pillar by the side of the road – I reckon he went onto it with his shoulder.’
‘How long did he lie?’ I asked.
‘Just ten or fifteen minutes.’
‘Any sign he’s lost blood?’
He shook his head. ‘None. He’s had a litre of fluid IV, blood pressure is a hundred over sixty, pulse is a hundred and ten – no wounds. He’s a lucky lad.’
‘Has he said anything yet?’
‘Not much. Coma Scale is 11, pupils fine.’
I looked down at Chris and began to check him over: neck immobilised, breathing well and plenty of oxygen getting into his lungs. His pulse was fast but with good volume and there was no blood leaking onto the sheets.1 His fingertips on the left were pink and warm. I yelled in his ear, ‘CHRIS!’, and his eyes opened, but then closed again. ‘How is the bike?’ he moaned suddenly, ‘My bike …’ He wouldn’t squeeze my fingers when I asked him to, but when I pushed a pen hard down on his nail bed to check his responsiveness he pulled his hand away, swore and tried to punch me with his good arm. From being pale and expressionless his face began to boil with violence.
‘GCS is 12 or 13 now – he seems to be coming round.’
McTullom was straining with anger now, trying to get up and off the table, but unable to for the pain in his arm and the restraints on his head and neck. With Harry’s help I held him down and gave him an injection of morphine. He fell back into a doze, and we were able to cut through the protective armour of his jacket’s right sleeve. There was no blood on his T-shirt, but his right shoulder looked distorted – instead of being muscled and square as it was on the left, it was a pulpy, swollen diagonal. Harry was right: he must have hit the pillar with his shoulder, slamming his weight onto the collarbone. Once he had been tranquillised by morphine we rolled him carefully on his left side while maintaining the straightness of his spine, to see if he had any other injuries of his vertebral column. All normal.
‘Can you feel me touching your hand?’ – I began stroking the fingers of his left hand. His teeth were gritted, but he tried to nod – an impossibility in a hard collar. ‘Don’t nod, just say uh-huh if you can feel me.’
‘Uh-huh.’
‘What about here?’ I began to touch his fingers on the right. Nothing.
‘And here?’ I began to touch his arm higher up, towards the elbow, then the swollen shoulder. Nothing – he couldn’t feel me touching the skin. ‘Can you bend your fingers?’ I asked, putting my own fingers into his right palm. There was a slight flicker as he tried to make a fist. ‘Good. And bend your arm?’ Nothing. The rage he’d shown just a few minutes before was starting to give way to a drowsy, drug-addled fear.
‘What do you do for a living?’ I asked him.
‘Soldier,’ he said. ‘A gunner …’
When the X-rays came they showed that his right collarbone was smashed into pieces. There’s a fine network of nerves behind the collarbone, emerging from the neck and controlling movement and giving sensation to the arm. He hadn’t just broken up his shoulder in the crash; he’d paralysed his right arm.
HUMAN CULTURE EVOLVES with the drama of history, but our anatomy, and the limitations it imposes on us, remains the same. Homer’s Iliad was first written down almost three thousand years ago, describing a Greek siege of the city of Troy that may have taken place several centuries earlier than that. In Book VIII there’s a scene of heavy fighting – Teucer the master-archer is bringing down a slew of Trojans, and being cheered on by his king, Agamemnon. ‘I’ve shot eight arrows, and killed eight young warriors so far,’ says Teucer, ‘but there is one mad dog I cannot hit.’ The ‘mad dog’ is Hector, a prince of the Trojans. The next passage is worth quoting in full:
Hector jumped down from his chariot with a loud cry, picked up a great stone, and ran straight for Teucer in fury. Teucer took an arrow from his quiver and laid it upon his bow, but before he could take aim and fire Hector struck him with the mighty stone; he hit him on the collarbone, where it divides the neck from the chest – a deadly place. His hand and wrist were numbed by the blow, and as he fell forward onto his knees, the bow fell from his hand.
Teucer’s brother Ajax ran forward and stood over the fallen man, shield aloft, to protect him from a rain of arrows. Two more of his comrades ran over and lifted him, ‘groaning in pain’ back to the safety of the Greek ships.
The author of The Iliad was a surprisingly accurate observer of anatomy. The battlefields of antiquity must have been chaotic places, sprawling with bodies and mired in blood. The warriors and camp-following poets were familiar with what is now called ‘major trauma’, and may have developed their own trauma care. There are some medically qualified Homer enthusiasts who have gone so far as to propose him as an early battlefield medic. Repeated through The Iliad are careful accounts of spear wounds, arrow strikes and sword blows, which take care not just to describe the part of the body that has been wounded, but the physiological effects of those wounds and, on occasion, specific treatments.2
When Hector paralyses Teucer’s arm by hitting him ‘where the collarbone divides the neck from the chest’ it’s an accurate description of a trick still used by martial arts experts today – ‘The Brachial Stun’. A blow to this area may not just temporarily paralyse the arm: if it causes pressure on part of the carotid artery it can trigger a reflex slowing of the heart. In sensitive individuals the heart can slow to such a degree that the victim falls unconscious. There are innumerable ‘brachial stuns’ available to view on the Internet – home videos of US Marines practising on one another in their barracks, black belts filmed in the ring, even police officers attacking their suspects. Watching them, I thought of Teucer crumpling to the ground with his numb, lifeless arm.
THE NAME GIVEN to the spaghetti junction of nerves behind the collarbone is the ‘brachial plexus’, and when anatomy took a greater part in medical training every student had to memorise its arrangement:
Five nerve roots from five vertebrae in the neck unite to form three ‘trunks’, which divide into anterior and posterior divisions. Those divisions perform an elegant interleaving with one another before braiding into three ‘cords’: ‘medial’, ‘lateral’ and ‘posterior’. The posterior cord supplies those muscles which straighten the arm and wrist, as well as supply sensation to the back of the hand and forearm, while the medial and lateral cords activate those muscles which flex the biceps and wrist, and operate the small muscles of the hand.
The arrangement seems overly complicated, but arises from the way the arm forms in the womb. Brachium in Latin has the same root as our word branch – it starts as a bud, sprouting straight out from the trunk the way a branch grows from a tree. It begins to bud at just four weeks’ gestation, and over three subsequent weeks divides into a rudimentary hand, forearm and upper arm, then rotates through ninety degrees. It’s the movement of those muscles as the arm grows and rotates, and the fixed origin of the nerves in the neck, which provide the warp and weave of the brachial plexus. Homer didn’t know of the origin of the plexus but he was acutely aware of its anatomy, and the martial advantage that knowledge could give.
BETWEEN TRAINING in emergency medicine and as a general practitioner I took a job as a medical officer in Antarctica. The British Antarctic Survey sent me as a ship’s doctor to sail the length of the Atlantic Ocean and finish up at one of the most remote research stations in the world: Halley Base. The station would be isolated for ten months of the year in which I was to stay as base doctor. The evacuation of medical casualties was almost impossible for those ten months, so before taking up the post I was sent to a mixed military and civilian hospital for extra training.
The military doctors taught me how to give my own anaesthetics, drill out rotten teeth, and perform simple, single-handed trauma surgery. I’d always been suspicious of military medicine: to join a troop of soldiers intent on killing and maiming their enemies seemed to contradict every principle of ethical practice. Hippocrates said ‘first, do no harm’, but a close reading of his works also turns up ‘he who would become a surgeon must first go to war’. From antiquity until today, war has provided an abundance of casualties to learn from: in medicine, as in other fields of expertise, practise makes perfect.
The military doctors taught me how to take my own X-rays with a portable unit designed for the battlefield, reset broken bones and drill holes in the skull in case of coma following head injury – all skills they applied in war, but which they thought I might need in Antarctica. I was sent to traditional military establishments: dental anaesthesia at an air-force base, logistics at an infantry barracks. I took a course called ‘Disaster Relief Operations’ and sat in a room with thirty doctors, paramedics and nurses, all recently returned from battle zones. We learned how to build dressing stations near a front line, dig cholera-busting latrines, and other things that might be more useful on polar expeditions: satellite communications, improvised life support, and how to protect fragile drugs and equipment in transit. I developed an unanticipated respect for the military medics, and realised how much their predecessors had advanced our understanding of the body. Antiseptic surgery revolutionised the survival rates of soldiers during the Boer and First World wars, while the advent of antibiotics had a similar effect in the Second World War. Charles Bell had learned much attending the soldiers of Waterloo; the Roman surgeon Galen had been physician to the gladiators. Perhaps the anatomical knowledge shown in The Iliad was part of this long, often unacknowledged tradition.
THE WORD ‘ARMS’ is dual-use: parts of our bodies and weapons of war. ‘Armed’, ‘armour’, ‘army’ – our vocabulary bears witness to bodily violence, and humanity’s attitude to killing is written into our figures of speech. Someone skilled in violence is often known as ‘a strong arm’, and soldiers with a common cause ‘brothers in arms’. In Latin, armus means simply ‘shoulder’, while arma can mean any weapon, from a root meaning ‘that which is fitted together’.
A historian of military medicine, P. B. Adamson, once read The Iliad with more care and attention than most surgeons bring to the closing of wounds. While acknowledging that it is an epic poem and not a historical record he noted every cut, together with the weapon that had dealt it and whether the wound turned out to be a fatal one. He then compared the results with a similar exercise on Virgil’s Aeneid and concluded that at the time of the Trojan War spears were the most fatal weapons, but by the Roman period, which Virgil was describing, swords had the advantage. Stones were the least successful weapons in terms of killing people – 41 per cent of those hit by a stone end up dead (Teucer’s life wasn’t in danger when his arm was paralysed – after Hector disables him in Book VIII he pops up to fight again in Book XII). To be an archer like Paris or even Teucer, is, according to the subtext of The Iliad, to be slightly cowardly – archery delivers death from a distance as well as poorer accuracy: 74 per cent mortality as opposed to 100 per cent for swords and 97 per cent for spear thrusts. Adamson makes the point that in antiquity as today, armour encourages fierce engagement because it is reinforced towards the front but pitifully weak on the back. To turn on the battlefield and run has always been a mortally dangerous choice.
Adamson noticed that the legs are rarely injured in The Iliad, perhaps because the men often fought thigh-deep in the bodies of their fallen comrades, from the back of a waist-high chariot or even from within the protection of the hulls of their ships. He also notes that the head, neck and trunk are the parts of the body aimed for. When upper limbs are damaged in The Iliad it’s usually because those arms are being raised in defence, or injured while they are themselves raised in violence. These Homeric patterns of injuries are still encountered every day in emergency departments: doctors assessing victims of domestic abuse often check women’s forearms, as it is these that bear the brunt of warding off an attacker. A mid-shaft fracture of the ulna, the long bone of the forearm, is still known as a ‘nightstick fracture’ because it’s most commonly encountered in those who’ve been beaten with a policeman’s nightstick.
The pattern of wounds described by Homer remained broadly similar for almost three millennia after the siege of Troy – it was only after the widespread adoption of gunpowder, and the increasing distance between belligerents that it facilitated, that the pattern began to change. As weapons became more powerful, mortality figures paradoxically began to fall. Adamson compares the mortality and injury rates described in ancient texts with those that have been gathered from some of the most awful wars of the nineteenth and twentieth centuries.
Despite the appalling squalor and brutality of the Crimean War, the mortality rate from injuries was just 26 per cent – five and a half thousand deaths among twenty-one thousand British combatants. Proportions were similar for British troops in the First World War: of two and a quarter million soldiers, just under six hundred thousand died as a result of their injuries. Adamson shows that at their worst, shells and bombs turn up a mortality rate of 29 per cent (First World War), which is less than the rate for thrown stones described in The Iliad. The proportion of injuries sustained to the limbs versus those of trunk and head had entirely reversed: only 20 per cent of injuries in the ancient epics were to the limbs, but in the last century, injuries to the limbs make up 70 to 80 per cent of all those sustained in combat. As weapons grow more sophisticated, and kill at ever-greater distances, limbs started to become mutilated more often than soldiers were killed.
THERE ARE VARIOUS DEGREES of nerve injury. If the nerves behind the collarbone have been wrenched out of the spinal cord itself, there is almost no chance of recovery. If they’ve been ruptured there’s a small chance that some may heal, and nerve transplants sometimes help regain some weaker function. Nerves are in some respects similar to copper wiring surrounded by plastic insulation sheathing: a nerve that has been severely stretched may regrow if its outer sheath has remained intact and only the inner ‘axon’, corresponding to the copper of the wire, has split.
Two months after his motorbike crash I saw Chris McTullom waiting in line for the neurosurgical review clinic. He still carried his right arm in a sling. The muscles of his upper arm that had been so pulpy and swollen were now withered and limp, but he had regained some movement in them.
‘How are you getting on?’ I asked him.
He took his arm from the sling, and slowly flexed his biceps. ‘It’s coming back,’ he said. ‘I’m not fit for duty yet, but perhaps in another couple of months.’
‘And what then?’ I asked him.
‘Back to my unit,’ he said. ‘Afghanistan, probably.’ He slowly curled the fingers of his right hand, stiff with disuse, as if to take hold of a trigger.
THE WORD ‘ARM’ might be embedded in our terms for weaponry and violence, but is also at the root of the language we use for friendship and affection. ‘Embrace’ means ‘in arms’.
When the Greek and Trojan armies meet in Book VI of The Iliad, the Greek warrior Diomedes finds himself facing up to a Trojan named Glaucus, dressed in such magnificent armour that Diomedes thinks he must be one of the gods. ‘What great man are you, among us mortals?’ he shouts across the battlefield. ‘At the threat of my long-shadowed spear you show yourself braver than the rest.’
‘Why ask about my parentage?’ Glaucus shouts back. ‘Men are like leaves, they fall to the ground when their season ends, and spring brings new buds on the trees. So the generations of men die but new generations come to take their place.’
But after having initially refused to name his parents, Glaucus goes on to describe his ancestry: he is of Greek lineage; his grandfather was driven from Greece many years ago and settled in the lands of the Trojans. Diomedes realises that his own grandfather and Glaucus’ grandfather had been friends, and because of that friendship he resolves to make peace: ‘Let’s stay away from one another’s spears in the battle – there are many more Trojans for me to slaughter if the gods let me outrun them, and many Greeks for you to slay if you can.’
Standing apart from the hell of death that surrounded them, the two men leapt down from their chariots and clasped arms.
Footnotes
1 You can bleed to death internally without a drop spilling onto the floor: pelvic fractures, femoral fractures or bleeding into the chest or abdomen can all cause enough internal blood loss to threaten life.
2 But as the classicist K. B. Saunders noted dryly, ‘I do not expect every wound described by Homer to be realistically explicable. One should try to come to some physical explanation of events if possible. But miraculous things do happen in The Iliad … miraculous wounds should not be a surprise to us’; Classical Quarterly 49(2) (1999), 345–63.