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Treatment of Gunshot Wounds to Spine During Late 19th Century
Historical Vignette
Treatment of Gunshot Wounds to Spine During Late 19th Century Matthew Protas1, Maia Schumacher2, Joe Iwanaga2, Emre Yilmaz2-4, Rod J. Oskouian2,3, R. Shane Tubbs1,2
Key words American Civil War - Gunshot wounds - Neurosurgery - Spinal injury - Surgery -
From the 1Department of Anatomical Sciences, St. George’s University, Grenada, West Indies; 2Seattle Science Foundation and 3Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA; and 4Department of Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany To whom correspondence should be addressed: Maia Schumacher, B.S. [E-mail: [email protected]] Citation: World Neurosurg. (2018) 115:285-287. https://doi.org/10.1016/j.wneu.2018.04.198 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2018 Published by Elsevier Inc.
INTRODUCTION The mortality rate from gunshot wounds during the late 19th century was high due to the increased accuracy and destructive power of bullets. The advancement in weaponry in the 19th century changed the severity and types of wounds found on the battle field. During the American Civil War (1861e1865), inventions such as the Minié ball were created, leading to massive compound fractures in any area of the body injured.1 This was due to the increased velocity and accuracy of the Minié ball. This projectile was the first to be small enough to easily go down the barrel of a long gun. The Minié ball caused 87% fatalities when it penetrated the abdomen and 62% when it struck the chest.2 Major factors that limited care for gunshot wound victims on the battlefield were the dire lack of physicians, the long response time between injury and treatment, and the extremely unsanitary conditions.3 Most procedures were performed outside without gloves or disinfectant. In 1863, Middleton Goldsmith was one of the first neurosurgeons to address the risk of sepsis using bromine,
- BACKGROUND:
The demand for neurosurgical procedures increased drastically in the late 19th century owing to advances in ballistics during the American Civil War and Crimean War.
- METHODS
AND RESULTS: Surgical care for a gunshot wound to the spine relied on skilled identification and removal of the fractured bone. Hemorrhage control and infection prevention were also imperative for improving survival rates.
- CONCLUSIONS:
Although new techniques were implemented, the mortality rate from spinal injuries during this period was staggering. Nevertheless, those 19th century procedural methods provided the basis for present-day treatment for spinal injury patients.
bromide potassium, and water on surgical dressings during his procedures.4 Treatment of surgical gauze with carbolic acid and iodine was another major advance in preventing deaths from microbial infection.5 Despite the limitations, surgeons were able to perform complex surgical procedures during the 1800s. Spinal injuries were routine because of advances in ballistic technology.1,2 Although surgeons were heavily criticized at times for being too quick to operate, the foundations for modern neurosurgery were laid on the battlefields of the 19th century. Amputations were among the most common surgical procedures for serious injuries during wartime.6 Because the spine could not be amputated, new surgical techniques had to be developed and detailed procedures were designed to treat patients with ballistic injuries. The focus of treatment for ballistic injuries to the spine was on preventing further neurologic injuries, controlling bleeding, and minimizing the risk of meningoencephalitis. A comprehensive description of late 19th century treatments for cranial, head, and neck injuries has been described in The International Encyclopedia of Surgery, volume II.7 The following paper details the surgical treatments for gunshot wounds to the spine to improve understanding of neurosurgical procedures during the late 19th century.
WORLD NEUROSURGERY 115: 285-287, JULY 2018
GUNSHOT WOUNDS TO SPINE Prognosis The prognosis for gunshot wounds to the vertebrae (Figures 1 and 2) during the late 19th century was not bad unless the spinal processes were injured, in which case the mortality rate was high. Once the dura was punctured, the mortality rate skyrocketed. Unlike wounds to the cranium at this time, any break in the dura was not considered a serious risk for infection.8 Causes of death in these patients were typically due to infections such as meningitis, abscess, hemorrhage due to vascular injury, or direct injury to the cord. The mortality rate from vertebral gunshot wounds were high during the Crimean War at 88% and were worse in the French Army during this time at 94%.7 The mortality rate for the cervical region was the highest followed by the thoracic and lumbar regions. Quick death typically prevented most of these patients from even reaching a physician’s care. This was the case for most injuries during the 1800s because the lapse of time between injury and care was not optimal. Mortality was much more likely to occur in military service than in civil cases.7 Diagnosis A gunshot wound to the spine in the late 19th century was diagnosed by viewing the trajectory of the entrance wound, neurologic
www.WORLDNEUROSURGERY.org
285
HISTORICAL VIGNETTE MATTHEW PROTAS ET AL.
TREATING GUNSHOT WOUNDS TO SPINE IN LATE 1880S
symptoms, and palpation of the vertebral bodies. Surgeons were instructed to rely on palpation as the primary source of detection for the resting place of the bullet because trajectory and neurologic symptoms were not specific enough for diagnosis. The apparent trajectory of the bullet was frequently misleading because ricochets from vertebral injuries were common. The surgeons were taught to look for cerebrospinal fluid as this was 100% indicative of a spinal fracture. Except for injuries to the lumbar region, they were instructed to always presume injury to the spinal cord and confirm it by the neurologic symptoms.7
Figure 1. Lateral view of thoracic vertebrae 8e10 with fracture site and evidence of conoidal ball in vertebral canal.7
Figure 2. Lateral view of a round musket ball lodged in the vertebral body of L2.7
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Treatment Rest and immobilization was the key treatment for any spinal cord injury regardless of the cause. In the 19th century, the first-line treatment for vertebral body injuries due to a gunshot wound was to remove the bullet and bone fragments. Surgeons were taught to explore the wounds with their little finger, to avoid further spinal cord injury, to make sure that all foreign bodies had been completely removed. Special instruments were also developed to remove bullets (Figure 3).9 Bullets or bone fragments were left alone if they could not be removed without significant force or within a reasonable timeframe. If there was extensive hemorrhage on removal of the foreign body, ligation of the affected arteries was the treatment of choice to stop the bleeding. To avoided further injury to the patient, extensive cutting to find the bullet was avoided and antiseptic dressing was used to prevent infection.7 After the depressed spinous processes or laminae were elevated, trephining was suggested, but it showed little benefit at the time. This knowledge and improved understanding of these types of wounds would propel and shape current treatment paradigms. The use of trephining was first suggested by Larrey, who stated that use of a trephine was important to prevent further bone fragmentation.8 Wet-cupping was recommended in cases of meningitis, and dry-cupping was for patients who had suffered concussions. Further management of paralyzed patients relied on ensuring that the bowels and bladder were emptied. Prevention of bedsores was also found to be imperative. These treatments and recommendations are still in use today
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.04.198
HISTORICAL VIGNETTE MATTHEW PROTAS ET AL.
TREATING GUNSHOT WOUNDS TO SPINE IN LATE 1880S
2. Blaisdell FW. Medical advances during the Civil War. Arch Surg. 1988;123:1045-1050.
3. Kuz JE. The ABJS Presidential Lecture, June 2004: Our orthopaedic heritage: the American Civil War. Clin Orthop Relat Res. 2004;429:306-315.
4. Goldsmith M. A Report on Hospital Gangrene, Erysipelas and Pyaemia: As Observed in the Departments of the Ohio and the Cumberland, with Cases Appended. Louisville, KY: Bradley & Gilbert; 1863.
5. Allen JA. The Chicago Medical Journal. Vol XXVII. Chicago, IL: The Chicago Medical Journal; 1868.
6. Rutkow IM. Amputation vs. nonamputation: a Civil War surgical dilemma. Arch Surg. 1999;134:1284.
7. Connor PS. Gunshot wounds; head. In: Ashhurst J, ed. The International Encyclopedia of Surgery. Vol. II. New York, NY: William Wood Co; 1882:171-185.
Figure 3. Special instruments used during the 19th century to remove bullets.9 From left to right, Gomrig forceps, fenestrated forceps, bullet extractor, and Thomassin extractor.
in postespinal trauma care. Modern medicine has come a long way from 19th century battle fields. However, the basic practices of avoiding further injury and providing patient safety and comfort in patients with gunshot wounds to the spine are still practiced today.
was found important to close the wound with sutures. For deep penetrating wounds, removal of the foreign bodies was imperative for a good postsurgical prognosis. The methodology behind today’s spinal treatments is parallel to the late 19th century; the only differences lie in the tools and procedures used.
9. Gross SD. A system of surgery; pathological, diagnostic, therapeutic, and operative. 5th ed. Vol I. Philadelphia, PA: Henry C. Lea; 1872.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 9 March 2018; accepted 26 April 2018 Citation: World Neurosurg. (2018) 115:285-287. https://doi.org/10.1016/j.wneu.2018.04.198
CONCLUSION Treatment of gunshot wounds to the spine during the 19th century focused on removing the bullet followed by termination of bleeding. For superficial injuries, it
8. Roux FE, Reddy M. Neurosurgical work during the Napoleonic Wars: Baron Larrey’s experience. Clin Neurol Neurosurg. 2013;115:2438-2444.
REFERENCES 1. Adams GW. Doctors in Blue. The Medical History of the Union Army in the Civil War. New York, NY: H. Schuman Inc; 1952.
WORLD NEUROSURGERY 115: 285-287, JULY 2018
Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2018 Published by Elsevier Inc.
www.WORLDNEUROSURGERY.org
287
Treatment of Gunshot Wounds to Spine During Late 19th Century Matthew Protas1, Maia Schumacher2, Joe Iwanaga2, Emre Yilmaz2-4, Rod J. Oskouian2,3, R. Shane Tubbs1,2
Key words American Civil War - Gunshot wounds - Neurosurgery - Spinal injury - Surgery -
From the 1Department of Anatomical Sciences, St. George’s University, Grenada, West Indies; 2Seattle Science Foundation and 3Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA; and 4Department of Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany To whom correspondence should be addressed: Maia Schumacher, B.S. [E-mail: [email protected]] Citation: World Neurosurg. (2018) 115:285-287. https://doi.org/10.1016/j.wneu.2018.04.198 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2018 Published by Elsevier Inc.
INTRODUCTION The mortality rate from gunshot wounds during the late 19th century was high due to the increased accuracy and destructive power of bullets. The advancement in weaponry in the 19th century changed the severity and types of wounds found on the battle field. During the American Civil War (1861e1865), inventions such as the Minié ball were created, leading to massive compound fractures in any area of the body injured.1 This was due to the increased velocity and accuracy of the Minié ball. This projectile was the first to be small enough to easily go down the barrel of a long gun. The Minié ball caused 87% fatalities when it penetrated the abdomen and 62% when it struck the chest.2 Major factors that limited care for gunshot wound victims on the battlefield were the dire lack of physicians, the long response time between injury and treatment, and the extremely unsanitary conditions.3 Most procedures were performed outside without gloves or disinfectant. In 1863, Middleton Goldsmith was one of the first neurosurgeons to address the risk of sepsis using bromine,
- BACKGROUND:
The demand for neurosurgical procedures increased drastically in the late 19th century owing to advances in ballistics during the American Civil War and Crimean War.
- METHODS
AND RESULTS: Surgical care for a gunshot wound to the spine relied on skilled identification and removal of the fractured bone. Hemorrhage control and infection prevention were also imperative for improving survival rates.
- CONCLUSIONS:
Although new techniques were implemented, the mortality rate from spinal injuries during this period was staggering. Nevertheless, those 19th century procedural methods provided the basis for present-day treatment for spinal injury patients.
bromide potassium, and water on surgical dressings during his procedures.4 Treatment of surgical gauze with carbolic acid and iodine was another major advance in preventing deaths from microbial infection.5 Despite the limitations, surgeons were able to perform complex surgical procedures during the 1800s. Spinal injuries were routine because of advances in ballistic technology.1,2 Although surgeons were heavily criticized at times for being too quick to operate, the foundations for modern neurosurgery were laid on the battlefields of the 19th century. Amputations were among the most common surgical procedures for serious injuries during wartime.6 Because the spine could not be amputated, new surgical techniques had to be developed and detailed procedures were designed to treat patients with ballistic injuries. The focus of treatment for ballistic injuries to the spine was on preventing further neurologic injuries, controlling bleeding, and minimizing the risk of meningoencephalitis. A comprehensive description of late 19th century treatments for cranial, head, and neck injuries has been described in The International Encyclopedia of Surgery, volume II.7 The following paper details the surgical treatments for gunshot wounds to the spine to improve understanding of neurosurgical procedures during the late 19th century.
WORLD NEUROSURGERY 115: 285-287, JULY 2018
GUNSHOT WOUNDS TO SPINE Prognosis The prognosis for gunshot wounds to the vertebrae (Figures 1 and 2) during the late 19th century was not bad unless the spinal processes were injured, in which case the mortality rate was high. Once the dura was punctured, the mortality rate skyrocketed. Unlike wounds to the cranium at this time, any break in the dura was not considered a serious risk for infection.8 Causes of death in these patients were typically due to infections such as meningitis, abscess, hemorrhage due to vascular injury, or direct injury to the cord. The mortality rate from vertebral gunshot wounds were high during the Crimean War at 88% and were worse in the French Army during this time at 94%.7 The mortality rate for the cervical region was the highest followed by the thoracic and lumbar regions. Quick death typically prevented most of these patients from even reaching a physician’s care. This was the case for most injuries during the 1800s because the lapse of time between injury and care was not optimal. Mortality was much more likely to occur in military service than in civil cases.7 Diagnosis A gunshot wound to the spine in the late 19th century was diagnosed by viewing the trajectory of the entrance wound, neurologic
www.WORLDNEUROSURGERY.org
285
HISTORICAL VIGNETTE MATTHEW PROTAS ET AL.
TREATING GUNSHOT WOUNDS TO SPINE IN LATE 1880S
symptoms, and palpation of the vertebral bodies. Surgeons were instructed to rely on palpation as the primary source of detection for the resting place of the bullet because trajectory and neurologic symptoms were not specific enough for diagnosis. The apparent trajectory of the bullet was frequently misleading because ricochets from vertebral injuries were common. The surgeons were taught to look for cerebrospinal fluid as this was 100% indicative of a spinal fracture. Except for injuries to the lumbar region, they were instructed to always presume injury to the spinal cord and confirm it by the neurologic symptoms.7
Figure 1. Lateral view of thoracic vertebrae 8e10 with fracture site and evidence of conoidal ball in vertebral canal.7
Figure 2. Lateral view of a round musket ball lodged in the vertebral body of L2.7
286
www.SCIENCEDIRECT.com
Treatment Rest and immobilization was the key treatment for any spinal cord injury regardless of the cause. In the 19th century, the first-line treatment for vertebral body injuries due to a gunshot wound was to remove the bullet and bone fragments. Surgeons were taught to explore the wounds with their little finger, to avoid further spinal cord injury, to make sure that all foreign bodies had been completely removed. Special instruments were also developed to remove bullets (Figure 3).9 Bullets or bone fragments were left alone if they could not be removed without significant force or within a reasonable timeframe. If there was extensive hemorrhage on removal of the foreign body, ligation of the affected arteries was the treatment of choice to stop the bleeding. To avoided further injury to the patient, extensive cutting to find the bullet was avoided and antiseptic dressing was used to prevent infection.7 After the depressed spinous processes or laminae were elevated, trephining was suggested, but it showed little benefit at the time. This knowledge and improved understanding of these types of wounds would propel and shape current treatment paradigms. The use of trephining was first suggested by Larrey, who stated that use of a trephine was important to prevent further bone fragmentation.8 Wet-cupping was recommended in cases of meningitis, and dry-cupping was for patients who had suffered concussions. Further management of paralyzed patients relied on ensuring that the bowels and bladder were emptied. Prevention of bedsores was also found to be imperative. These treatments and recommendations are still in use today
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.04.198
HISTORICAL VIGNETTE MATTHEW PROTAS ET AL.
TREATING GUNSHOT WOUNDS TO SPINE IN LATE 1880S
2. Blaisdell FW. Medical advances during the Civil War. Arch Surg. 1988;123:1045-1050.
3. Kuz JE. The ABJS Presidential Lecture, June 2004: Our orthopaedic heritage: the American Civil War. Clin Orthop Relat Res. 2004;429:306-315.
4. Goldsmith M. A Report on Hospital Gangrene, Erysipelas and Pyaemia: As Observed in the Departments of the Ohio and the Cumberland, with Cases Appended. Louisville, KY: Bradley & Gilbert; 1863.
5. Allen JA. The Chicago Medical Journal. Vol XXVII. Chicago, IL: The Chicago Medical Journal; 1868.
6. Rutkow IM. Amputation vs. nonamputation: a Civil War surgical dilemma. Arch Surg. 1999;134:1284.
7. Connor PS. Gunshot wounds; head. In: Ashhurst J, ed. The International Encyclopedia of Surgery. Vol. II. New York, NY: William Wood Co; 1882:171-185.
Figure 3. Special instruments used during the 19th century to remove bullets.9 From left to right, Gomrig forceps, fenestrated forceps, bullet extractor, and Thomassin extractor.
in postespinal trauma care. Modern medicine has come a long way from 19th century battle fields. However, the basic practices of avoiding further injury and providing patient safety and comfort in patients with gunshot wounds to the spine are still practiced today.
was found important to close the wound with sutures. For deep penetrating wounds, removal of the foreign bodies was imperative for a good postsurgical prognosis. The methodology behind today’s spinal treatments is parallel to the late 19th century; the only differences lie in the tools and procedures used.
9. Gross SD. A system of surgery; pathological, diagnostic, therapeutic, and operative. 5th ed. Vol I. Philadelphia, PA: Henry C. Lea; 1872.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 9 March 2018; accepted 26 April 2018 Citation: World Neurosurg. (2018) 115:285-287. https://doi.org/10.1016/j.wneu.2018.04.198
CONCLUSION Treatment of gunshot wounds to the spine during the 19th century focused on removing the bullet followed by termination of bleeding. For superficial injuries, it
8. Roux FE, Reddy M. Neurosurgical work during the Napoleonic Wars: Baron Larrey’s experience. Clin Neurol Neurosurg. 2013;115:2438-2444.
REFERENCES 1. Adams GW. Doctors in Blue. The Medical History of the Union Army in the Civil War. New York, NY: H. Schuman Inc; 1952.
WORLD NEUROSURGERY 115: 285-287, JULY 2018
Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2018 Published by Elsevier Inc.
www.WORLDNEUROSURGERY.org
287