open fracture/sepsis without medical intervention

Setting: 40,000 years ago, late middle palaeolithic Neandertal culture. This is backstory, events that are discussed in the story, but they happened maybe a couple of years before.

One character, a young man, dies of complications of a hunting accident (thrown by a large animal, per the kinds of injuries found in the Neandertal fossil record). For story/characterisation reasons, his death is traumatic for the rest of the community, particularly for his (then) adolescent younger brother who witnesses the accident when he's first learning how to hunt. Their mother dies shortly afterwards, which also affects the younger brother.

I need to get the details right for both deaths.

The injury I have in mind for the young man is an open fracture of the radius and/or ulna which becomes infected and he dies of sepsis in the following days. I need to know the details of how the illness progresses and what happens to him before he dies. For example I've seen photos of people in hospital with sepsis that have blackened limbs that require amputation. How would this pan out with no medical intervention at all including no painkillers? The people in the story have only the most basic knowledge of first aid and herbal medicine and have no idea how to help him besides keeping him warm by the fire and sitting with him. So from the time they carry him back from the scene of the accident (he'd be carried on someone's shoulders, fireman style - they live in a cave that's dry and gets the sun around midday, with a well kept hearth, animal skins for warmth) until he dies, what's likely to happen? What are the timescales involved? And what actually would kill him - multiple organ failure? Or without medical intervention would he die of the sepsis before it gets to that stage? Presumably people did survive sepsis sometimes without medical intervention otherwise the body wouldn't have evolved to respond that way.

Are there any other fractures/injuries that he's likely to have also sustained from being thrown by a large animal if he's landed in such a way as to fracture the radius/ulna? Any other possible complications of the open fracture besides sepsis?

Regarding the mother's death, this doesn't have to be within an exact timescale as long as it's close enough after her son's death for the other people in the community to link the two deaths, i.e. they interpret it that she never got over seeing her son die like that and the heartbreak and shock of it killed her. I've heard that there's a thing where after a trauma/traumatic bereavement there's a higher risk of dying of a heart attack, but I'm not keen on the death being heart related as heart disease is rare in hunter-gatherer populations. I'd like to give some hint of what caused her death if possible, as opposed to just having her randomly drop dead, although it would be a hint as told by her people a couple of years later, e.g. she had (symptom or symptoms) then died. It'd probably work better story wise if it's something that makes her slowly get weaker and then die.

Thank you I typed out a reply and then lost it. I possibly didn't pass the "are you a human?" test, lol. I also blame my internet provider as the internet randomly drops and they refuse to acknowledge there's any problem.

Woollybear said:

I'm going to pop in, expecting Maeze and Roxxsmom to set any of this straight, but here's my thoughts, having taught Micro and being a microbiologist and also knowing a couple gals whose kids died of sepsis.

It can be quick. 24 hours from injury to death would be believable. <a href="https://www.cheatsheet.com/health-fitness/diseases-that-can-kill-in-one-day.html/" target="_blank">Here are some pathogens etc that kill quickly.</a> If you need the course to be slower, that's believable too--it depends when the sepsis sets in following the wound / infection. Depending on what specifically entered the wound (bacterially speaking), or how much blood was lost, it could be quicker yet.<br>
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I'd expect a fever as a sign of sepsis. I'd expect delirium and pain. System wide freak out. I'd expect these to onset within a few hours, and death to follow within a day. I wouldn't expect blackening (i associate that with localized infections like gangrene, i.e. an infection that has not gone 'septic' but could still do so) but would easily accept organ failure.<br>
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I'd expect broken ribs, in the fall, (opportunity to puncture a lung if you like) and a concussion is possible as well.

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Thank you That's really helpful Based off that, does the following sound plausible?


- accident happens in the morning, some distance away, he is carried back, fireman style. Has an open fracture to the right arm, cracked ribs and mild concussion (brief loss of consciousness and mild concussion symptoms, no brain bleeding)
- they arrive back at the cave around noon - he's put by the fire and they attempt to make him comfortable. He's in loads of pain and has difficulty breathing deeply (due to rib fractures), but can breathe enough to not be in respiratory distress. He's fully conscious and responds normally, albeit lots of pain, mainly the arm which he can't move at all, his chest and a headache from the concussion. Talking is hard due to the rib fractures so he doesn't manage to talk in whole sentences but what he says is coherent
- overnight the pain in his arm worsens as infection sets in, there's redness on the skin around the injury that's starting to spread (Northern European Neandertals had pale skin per DNA evidence) and he gets very little sleep due to the pain
- by morning he's feverish, flu-like symptoms, chills, shivering, in loads of pain and very distressed
- by the afternoon his fever is very high, with delirium and struggling to breathe - combination of sepsis and pain in his chest... not sure how things would pan out from this point until he dies. Would there be other symptoms, e.g. seizures, loss of consciousness, before he dies?


Is the above an appropriate timeline with the symptoms etc happening at the right times? Is there anything I've missed, or any other possible symptoms that could emerge? Things that the characters would notice.<br>

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If you are using furs and hides, you may be able to work in anthrax as a complicating factor, but it's probably not needed (or particularly wise) as the disease course for anthrax sounds like it is outside your window.

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I'm trying to keep away from recognisable modern infections, because bacteria etc evolve much more quickly than humans. I looked up rabies for another part of the story and its evolution is dated in thousands of years so is unlikely to have been around 40,000 years ago, so I had to scrap that idea. Sepsis is fine as it's the body's reaction to infection (and humans evolve slowly - Neandertals really weren't that different to us) but the bacterial infection that causes the sepsis needs to be generic.

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Not sure what you are asking re: the mom, but Carrie Fisher's mom died *the next day.* Immune system is suppressed by grief. Depression happens. Will to live declines. The mom could stop eating properly, sleep poorly, develop a death wish, die of a viral disease the following winter.

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This fits really well. The population is very small and already in decline so the loss of an experienced hunter has a big impact. They hunt co-operatively so need a certain number of hunters for it to work, so they have to throw two adolescent boys (the younger brother and his cousin) in the deep end; they have to learn to hunt very quickly. So in addition to grief and depression, the mother has the daily fear that her younger son will get killed hunting too. Due to the impact on the hunters, they are less successful - where previous they'd have eaten meat most days, they're now going for several days at a time without meat. The accident happens at the end of autumn/start of winter, so there's not a huge amount of plant foods to make up for the lack of meat. If due to depression the mother isn't always eating her share of the meat when they have meat - her community will insist she has her share but if she refuses to eat much of it, there are hungry people who will eat it instead. So she'd become gradually weaker. <br>

I've read that in elderly and immune compromised people, severe infections can sometimes have very few symptoms, because the symptoms of illness (e.g. fever) are often the body's way of fighting it. So would it be plausible that one day she has some very minor symptoms, e.g. headache, mild nausea, loss of appetite (even more than usual), then she goes to sleep and dies in the night?


All of this would work in making her people consider that she died because her son died in that horrible way and she never got over it.

Thanks again Please let me know if any of the details of either death are not plausible or if I've missed anything or got any timelines wrong.

Woollybear said:

1. Fireman style might be a problem with broken ribs. It'll depend how you handle it. Maybe the ribs are fractured and he screams from the pain but they have not other way to carry; IDK.

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Yeah there isn't really any other way they could bring him home, various two person carry techniques would put pressure on his broken arm. If his injuries are on the right side of his body they'd carry him in a way that put the pressure on the left side, for the fireman carry they'd have to hold on to his left arm and leg to avoid further injuring the right one.

2. I'd be curious what he fell onto. Lets say his buddy was gutting a mammoth and the entrails are in a messy pile. He gets thrown, breaks his arm in the middle of all those guts, then yeah the bacterial load to his wound is likely higher than if he lands on, say, a clean tarp they had just set out. And everything in between will have its own risk. This isn't a problem, I'm just curious where he falls to pick up the infection.

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He would've landed on the ground, probably uneven/somewhat rocky ground. I'd imagine given the way Neandertals hunted, they could handle some heavy knocks and being thrown. But if the ground is uneven and rocky, landing after a fall's a lot less predictable. Although I'm not worrying so much about the exact details of the accident as the POV character telling these events is the sister of the man's mother, so she only observes what happens from when he's already in the cave (when the women get back from gathering).

Given it's Northern Europe, the ground may be quite muddy. They'd be on land that's currently being grazed by large herbivores so there'd be animal dung on the ground. It's also possible the wound could be contaminated with the blood of the animal he was hunting, if he'd already speared it (or attempted to) and got the blood on his skin. Also, bacteria on his own skin and that of the others he's hunting with.

2b. I'm curious if they give him a field dressing. Depending on the water they use to clean the wound they might make things worse, etc. Or if they don't clean it, set it, etc. Again, I'm just curious.

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I'm still wondering about this. There's no hard evidence for Neandertals having any kind of medicine, however there's some evidence that points in that direction, while not being conclusive. Elsewhere in the story I've got them using yarrow to treat minor wounds. I'm inclined to think they'd just leave the injury alone and not want to do anything to it for fear of making the pain worse and because injuries like that are horrible to even look at. But their beliefs about the healing might lead them to try to put something on or near the wound. I tend to develop this kind of worldbuilding as I go along so I haven't 100% figured out all their beliefs.

MaeZe said:

Sepsis causes your blood pressure to drop: "septic shock", so he probably wouldn't have seizures. If you want him to for some reason, connect it to the head injury. Personally I'd leave the seizures out. With septic shock you simply get weaker and weaker until you lose consciousness and die soon after as your heart and lungs fail.

The black necrotic limb you asked about occurs when blood doesn't get to that part of the body, usually a limb. It takes a few days, doesn't happen all at once. For the timeline you are using (which is good by the way but benbenberi is right you can choose the time line) you would see a lot of swelling of the arm, eventually including the areas distal to the injury, AKA including the hand.

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Thanks There's no need for him to have seizures, it's just that the events are told by one of the characters, so if there are things like blackening of limbs and seizures, she'll remember them in vivid detail. But if they're not likely I'll stick to the other things.

I suggest you have the mother be ill, coughing, maybe a pneumonia, before the son has his injury. That would make it more plausible to the reader, while staying with the people in the story believing something else.

People can get depressed and die but that usually takes more than a single day and it is typically from not eating.

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frimble3 said:

I'm thinking that the shock for the mother would be worse because she watched her son die - it wasn't just reported back to her that he was killed on the hunt.
He was her eldest, if not firstborn, then eldest surviving son. If she was already unwell (pneumonia sounds good) then losing him would hit her hard.

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I'm thinking along the lines of a slowish decline in physical and mental health, including not eating properly and there not being meat as often due to them losing an experienced hunter, plus the added stress of seeing her younger son go out hunting each day when he's a bit too young, then dying of an illness that didn't look (to them) all that serious. Pneumonia sounds suitable for what she dies of and it's useful to know it doesn't have to be contagious.

Thanks again everyone for all your excellent help.

MaeZe said:

Worth mentioning: the lining of bones (periosteum) has a very rich blood supply. When you fracture a bone you tear the periosteum and a very large bruise always goes with it. It might take a day for that blood to get to the surface. So the arm might not become necrotic, but by the next day a very large bruise would appear.

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Thanks The POV character would definitely notice that.

It also explains the huge bruise I got when I cracked my ulna playing ice hockey, even though it was only cracked and not fully broken. The bruise went the entire length of my forearm (albeit I have short forearms - probably Neandertal genes lol)

Interesting discussion re bacteria species. They definitely would've had a lot of bacteria on the skin, some of which probably would've originated from animals they hunted and ate. Personal hygiene is quite difficult with middle palaeolithic technology. Also any skins/furs they laid him on or put over him to keep him warm would have its own bacteria.

ULTRAGOTHA said:

Is this because they're cut off from the rest of their group? Because Neanderthals did use herbs for medicine and pain control.

Also here.

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Thanks for the links. I've looked into this a fair bit. (Being as obsessed with Neandertals as I am, lol.) The evidence isn't as conclusive as the articles make it out to be* though IMO it's reasonable to suggest they had some kind of basic herbal medicine, which could include plants that contain natural painkillers. But that doesn't mean that all Neandertals everywhere had the same knowledge, or access to the same plants, fungus, etc. There'd be a lot of variation.

*finding traces of medicinal herbs or fungus in teeth or in graves isn't proof that they were definitely used as medicines, and not just eaten because they were food (or mouldy food) - the most suggestive thing is the frequency at which these things are found, for example in the Shanidar grave (the one that's usually taken as evidence for burial with flowers) most of the plants were medicinal in one way or another. Coincidence? Hard to say. Same with the teeth evidence. Personally, I think they most likely did have some kind of herbal medicine, also the ability to treat uncomplicated fractures, if for no other reason than the sheer number of Neandertal skeletons that have healed fractures.

I have them using basic herbal medicine and first aid elsewhere in the story. I've got them splinting a broken bone (not open or with any complications besides swelling/bruising) and using herbs including yarrow. But nothing that would be effective for an open fracture (a pretty nasty one, radius and ulna broken and forearm basically bent in the middle with the broken bits sticking out) or sepsis. Things like white willow bark that contain salicylic acid would be pretty much taking an aspirin for an open fracture. Probably it's bad phrasing on my part though (the bit you quoted), because I didn't mean they wouldn't attempt to treat his injury/illness in any way, just that they wouldn't have had any medicine that would be effective enough to change the outcome of the injury. Survival would be prolonged by being looked after and kept warm compared to being left to die where he fell, that's about it.

I've considered the idea that they try to treat the wound with herbs (i.e. putting them on the wound) as this would increase the risk and severity of the infection, but on balance I think the sight of such an injury would make people's instincts to not touch it kick in. At it reads currently they try to get him to eat some yarrow when he becomes feverish (yarrow can be helpful for mild fever) but he can't/won't eat it. In terms of sticking with the narrative voice and way the events are told in the story (1st person Neandertal POV, 2 years after the event) adding too many details wouldn't work from a creative point of view so I haven't had them try to put anything directly on the wound.