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GUNSHOT WOUNDS OF THE SPINE; THEIR SURGICAL ASPECT.
770
If a
tin is put away with an unsatisfactory tap, eshein the incubator, the cultures may readily be killed or may become grossly contaminated with moulds. When the anaerobic state is maintained satisfactorily moulds never grow inside the vessel. cap.
GUNSHOT WOUNDS OF THE SPINE; THEIR SURGICAL ASPECT.1 BY DONALD ARMOUR, M.B.TOR., F.R.C.S.ENG.,
cially
Practical results obtained with the apparatus.We havenow had our apparatus in use for a number of months and we are able to obtain constantly satisfactory results. Our work has been directed almost entirely to the study of septic gunshot wounds, and we have isolated from these a large number of strains of bacteria, some of which we can identify while others are unknown to us. If one takes an ordinary sloped agar tube or, better, serum-agar and inoculates it with pus taken direct from a wound without any preliminary heating or other preparation either of the medium or pus, it is easy in 24 to 48 hours to grow isolated surface colonies of such bacteria as B. welchii or " malignant oedema," and then by subculture to isolate these strains pure. This isolation is easy, but at the same time it must be admitted that it is not so simple as is the case with most anaerobic organisms. It is not uncommon to find a contamination of a strain persisting through several subcultures from absolutely distinct colonies, and particularly is this the case with staphylococcus. Such cultures may, of course, be readily purified by heat, but we have avoided this method as far as possible owing to the impossibility of gauging at present the effect of heat upon the anaerobe. We have had little difficulty from contaminations with streptococci or colon bacilli; indeed, the conditions of the culture appear to reduce seriously the power of these bacteria to grow. We have been often struck by the inability of so-calle’d facultative anaerobes to develop in our apparatus. Having thus isolated a strain in pure culture it is very easy to study its behaviour upon the ordinary laboratory media, slope agar, agar stabs,
LIEUTENANT-COLONEL, R.A.M.C.; SURGEON-IN-CHIEF, THE CANADIAN MILITARY HOSPITAL; SURGEON TO THE KING GEORGE HOSPITAL, TO THE NATIONAL HOSPITAL FOR THE
HONORARY
QUEEN’S
PARALYSED AND
(1) Those in which the functions of the spinal cord are not interfered with; and (2) those in which there is more or less interference with the functions of the spinal cord, with or without obvious injury to the vertebral column. In the second group the damage to the spinal cord is usually immediate-i.e., occurs at the time of receipt of the primary wound. But it is of the very greatest importance to remember that in cases where the spinal cord has escaped immediate. damage, later or remote effects involving this structure may follow on the injury to the vertebral These later effects are produced by column. inflammatory products giving rise to thickening of the meninges ; adhesions between the dura and bony wall, the dura, pia-arachnoid, and cord, with subsequent pressure due to the formation of a simple serous cyst of the meninges ; by narrowing of the spinal canal through excess or misplaced callus ; by blood clot, intra- or extra-dural ; or as the result of continued suppuration. If the injury to the cord be immediate it may be caused buy :-1. The missile itself passing through the spinal canal, in which case the cord is wholly or partially divided. 2. Fractured portions of bone driven in against the cord, causing compression, contusion, laceration, or complete division. This would appear to be the most frequent cause of the cord injury. 3. Concussion. Under this head are included those cases in which, though neither of the preceding causes is operative, yet as a result of the vertebral column being struck certain structural changes are set up in the cord which are due to the jarring or commotion effects of the blow. Spiller has described this condition as The cord may show no " traumatic myelitis." external signs of injury either to inspection or palpation. Lieutenant-Colonel Gordon Holmes has recently described in his Goulstonian lectures the microscopical appearances found in such cases. He points out that the special character of these lesions is their diffuse and irregular distribution and their tendency to diminish gradually from the of maximal disturbance. He concludes: point " Whatever may be the exact mechanism of spinal it must be admitted that a sudden
strains.
Literature.-1. H. Buchner : Eine neue Methode zur Kultur anaerober Mikroorganismen, Centralbl. f. Bakter. u. Paras., Orig., 1888, Bd. iv., p. 149. 2. W. Bulloch : A Simple Apparatus for Obtaining Plate Cultures or Surface Growths of Obligate Anaerobes, Ibid., (Continued at foot of next column.)
ETC.
THOUGH injury to the spinal cord is not a necessary consequence of gunshot wounds of the spine, it is obvious that the chief interest of such wounds lies in the commonly associated injury to the spinal cord and nerve roots. From a clinical point of view, therefore, cases of gunshot wound of the spine may be divided into two main classes :-
broth, serum, gelatine, milk, and so on. Further, the action of the bacteria upon the various fermentable sugars or upon dye-stuffs may be determined and so valuable information obtained which may bear upon a more satisfactory classification of such It is well known that many anaerobes are affected in their morphology and biological characters-for instance, in the production of toxin-by the presence of sugar in the medium, and it is one of the advantages of the present method that dextrose is quite We unnecessary for the furtherance of growth. have thus been able to study these bacteria in a more stable condition than is usual. Advantages of the 97tethod.-l. The method is clean. 2. It is rapid, the whole process being complete in about a quarter of an hour. 3. It is available immediately without any preliminary preparation or reagent other than hydrogen. 4. It is suitable for use with any laboratory medium without preliminary preparation of the medium. 5. It will grow the strictest anaerobes with great rapidity upon the surface of a solid medium. For instance, colonies of B. tetani in subculture upon serum-agar are visible in 24 hours. We desire to express our thanks to Professor Bulloch for his kindly interest and advice on many points, and to Captain W. E. Bullock, R.A.M.C., for assistance and advice in the details of the method.
EPILEPTIC,
concussion
of ’
1
Being
London
the on
opening
remarks at a discussion at the Medical Society
March 20th.
(Continued from preceding column.) Orig., 1900, Bd. xxvii., p 139. 3. P. P. Laidlaw: Some Simple Anaerobic Methods, Brit. Med. Jour., 1915, vol. i., p. 497. 4. E. Pfuhl: Die Züchtung anaerober Bakterien in Leberbouillon, sowie in Zuckerbouillon und in gewohnlicher Bouillon, mit einem Zusatz von Platinschwamm oder Hepin unter Luftzutritt, Centralbl. f. Bakter. u. Paras., Orig., 1907, Bd. xliv., p. 379. 5. Th. Smith: Some Devices for the Cultivation of Anaerobic Bacteria in Fluid Media without the Use of Inert Gases, Journ. of Boston Soc. of Med. Sciences, 1899. vol. iii., p. 340. 6. G. Tarozzi: Ueber ein leicht in aerober Weise ausführbares Kulturmittel von einigen bis jetzt für strenge Anaerobien gehaltenen Keimen, Centralbl. f. Bakter. u. Paras., Orig., 1906, Bd. xxxviii., p.619.
771 on the vertebral column can produce diffuse, irregular, and severe structural changes within the spinal cord. The factors which determine the severity of these lesions must be the momentum of the projectile, the part and surface area of the vertebra which it strikes, and the region of the spine which is wounded." Now, is it possible to recognise clinically these three different results of gunshot wounds of the spine ? For were it so, the question of operative interference would be made very simple, inasmuch as the first and third groups obviously would be excluded as beyond surgical relief. Naturally, we turn to X rays as likely to be the most helpful agent in determining the nature of the injury. But, unfortunately, it is in gunshot wounds of the spine that, in my experience, X rays are most unreliable. This is not to be construed in any way into a criticism of the skill of radiographers. It is simply a statement of the limitations of the X rays
violent impact
themselves. in the first
place they may
not reveal any
bony
when present. This is particularly true of the single flat plate. In all such cases it is necessary to have stereoscopic plates taken. I have had two or three such experiences. Again, the X ray plate never reveals the full extent of the bony injury within the spinal canal-i.e., where the damage to the cord is being produced. This is not to be wondered at when we consider how small a piece of bone may be the traumatic agent and how much it is overlain and overshadowed by the vertebra surrounding it. Therefore, in my opinion, the X ray plate should only be regarded as confirmatory evidence, or used to assist in the localisation of foreign bodies or for the purposes of bony localisation. In considering operative intervention, the questions that will arise are in order of importance :1. Will any benefit to the patient result from the operation ? 2. Will his life be endangered by the operation ? 3. Will he be made worse by the
injury
even
operation ? The condition should
certainly not be made worse it is undertaken by a operation, provided by competent surgeon accustomed to operate, frequently upon the spinal cord. Unless the operator has had considerable experience in spinal surgery, the
it is very easy to overlook the site and cause of the compression. In these cases there are two levels to be considered, the neurological and the bony. The level of the lesion as indicated by the clinical symptoms usually does not correspond with the level of maximal damage. This is explained by the secondary changes which take place above and below the site of the injury in the cord. It is essential, in order that an operation should be perfectly successful, that all pressure on the cord from whatever cause be removed. Hence the necessity for a wide exploration both vertically
The
operation
is ended
quite
oblivious of the fact
that the pressure on the cord has in no way been relieved by this " plumbic " manoeuvre. In septic cases care should be taken not to open the dura if still intact. If already opened care should be taken not to break down any adhesions of a protective nature lest a septic meningitis be set up. Drainage along the usual surgical lines must be employed in septic cases. In those cases free from sepsis the dura should be opened for inspection of the cord. The patient’s life will not be endangered by the operation if a proper estimate has been made of his general condition beforehand. The chief and most frequent contra-indication is a general septic condition arising from the state of the kidneys and bladder, with persistent high temperature and perhaps rigors and a weak and irregular pulse. There is an added danger where the intercostals are paralysed, but with a skilled anæsthetist this may be obviated. Will any benefit result from the operation ? Let us consider what the operation may be expected to do. Briefly, it will relieve pressure, or, at any rate, remove any doubt as to whether continued pressure exists. If the spinal cord be not totally destroyed continued pressure may succeed in completing its Therefore operation is indicated: destruction. (1) To relieve pressure from depressed or displaced fragments of bone; (2) to relieve pressure from blood-clot or from extensive haemorrhage, either extra- or intra-dural ; (3) to relieve pressure and prevent further destruction from oedema by enlarging the constricted bony canal ; (4) to remove the future danger of pressure from exudate and inflammatory thickening. No operation will restore a cord in which complete transverse section has taken place. Nor will an operation benefit cases of concussion. Therefore we are brought back to the question upon the answer to which hangs the whole subject of operation : Are there any symptoms by which we can in a reasonable time determine beyond a doubt that we are dealing with a case either of complete transverse section or of pure concussion’? In short, is there any symptom-complex which establishes beyond a doubt that the injury to the cord is irremediable ? If there -is not, then should not. such a conclusion urge us to give our patient the benefit of an operation which experience shows neither materially endangers his life nor adds to his discomfort, but actually lessens his pain ? It will at least allow us to determine the exact nature and extent of the lesion and to place the cord under the most favourable conditions for recovery of function, if recovery be possible. I have said a reasonable time. It is unfair to the patient and unfair to surgery to wait on and on till hope gives place to despair and then to call in a surgeon as a last resource to perform the impossible.
Harley-street, W. and laterally. It is not only not necessary, but it is bad surgery to waste time in searching for a LITERARY INTELLIGENCE. -The American Journal missile which has ceased to do damage and has of Gastroenterology has combined with the Proctologist and passage beyond the immediate area of operation. hereafter will be published as the Proctologist and GastroYet one sees too frequently a sort of surgical from St. Louis. Dr. Rollin H. Barnes, St. Louis, enterologist, hypnosis produced by an X ray plate which shows will be managing editor and publisher. a bullet or piece of shell still in the human FINSBURY DISPENSARY.-Owing to the body, though perfectly innocuous at the time. warTHE the customary biennial festival of this institution has This hypnotic state is apparently only recovered been abandoned, and the Lord Mayor of London, as vicefrom when the operator is able to produce makes an earnest appeal for funds to carry on to the admiring onlookers the piece of lead, president, the work. Contributions may be sent to him at the Mansion while his own satisfaction reminds one of a certain House, or to the secretary, Finsbury Dispensary, Brewer-nursery rhyme connected with one Jack Horner. street, Goswell-road, E.C.
’
If a
tin is put away with an unsatisfactory tap, eshein the incubator, the cultures may readily be killed or may become grossly contaminated with moulds. When the anaerobic state is maintained satisfactorily moulds never grow inside the vessel. cap.
GUNSHOT WOUNDS OF THE SPINE; THEIR SURGICAL ASPECT.1 BY DONALD ARMOUR, M.B.TOR., F.R.C.S.ENG.,
cially
Practical results obtained with the apparatus.We havenow had our apparatus in use for a number of months and we are able to obtain constantly satisfactory results. Our work has been directed almost entirely to the study of septic gunshot wounds, and we have isolated from these a large number of strains of bacteria, some of which we can identify while others are unknown to us. If one takes an ordinary sloped agar tube or, better, serum-agar and inoculates it with pus taken direct from a wound without any preliminary heating or other preparation either of the medium or pus, it is easy in 24 to 48 hours to grow isolated surface colonies of such bacteria as B. welchii or " malignant oedema," and then by subculture to isolate these strains pure. This isolation is easy, but at the same time it must be admitted that it is not so simple as is the case with most anaerobic organisms. It is not uncommon to find a contamination of a strain persisting through several subcultures from absolutely distinct colonies, and particularly is this the case with staphylococcus. Such cultures may, of course, be readily purified by heat, but we have avoided this method as far as possible owing to the impossibility of gauging at present the effect of heat upon the anaerobe. We have had little difficulty from contaminations with streptococci or colon bacilli; indeed, the conditions of the culture appear to reduce seriously the power of these bacteria to grow. We have been often struck by the inability of so-calle’d facultative anaerobes to develop in our apparatus. Having thus isolated a strain in pure culture it is very easy to study its behaviour upon the ordinary laboratory media, slope agar, agar stabs,
LIEUTENANT-COLONEL, R.A.M.C.; SURGEON-IN-CHIEF, THE CANADIAN MILITARY HOSPITAL; SURGEON TO THE KING GEORGE HOSPITAL, TO THE NATIONAL HOSPITAL FOR THE
HONORARY
QUEEN’S
PARALYSED AND
(1) Those in which the functions of the spinal cord are not interfered with; and (2) those in which there is more or less interference with the functions of the spinal cord, with or without obvious injury to the vertebral column. In the second group the damage to the spinal cord is usually immediate-i.e., occurs at the time of receipt of the primary wound. But it is of the very greatest importance to remember that in cases where the spinal cord has escaped immediate. damage, later or remote effects involving this structure may follow on the injury to the vertebral These later effects are produced by column. inflammatory products giving rise to thickening of the meninges ; adhesions between the dura and bony wall, the dura, pia-arachnoid, and cord, with subsequent pressure due to the formation of a simple serous cyst of the meninges ; by narrowing of the spinal canal through excess or misplaced callus ; by blood clot, intra- or extra-dural ; or as the result of continued suppuration. If the injury to the cord be immediate it may be caused buy :-1. The missile itself passing through the spinal canal, in which case the cord is wholly or partially divided. 2. Fractured portions of bone driven in against the cord, causing compression, contusion, laceration, or complete division. This would appear to be the most frequent cause of the cord injury. 3. Concussion. Under this head are included those cases in which, though neither of the preceding causes is operative, yet as a result of the vertebral column being struck certain structural changes are set up in the cord which are due to the jarring or commotion effects of the blow. Spiller has described this condition as The cord may show no " traumatic myelitis." external signs of injury either to inspection or palpation. Lieutenant-Colonel Gordon Holmes has recently described in his Goulstonian lectures the microscopical appearances found in such cases. He points out that the special character of these lesions is their diffuse and irregular distribution and their tendency to diminish gradually from the of maximal disturbance. He concludes: point " Whatever may be the exact mechanism of spinal it must be admitted that a sudden
strains.
Literature.-1. H. Buchner : Eine neue Methode zur Kultur anaerober Mikroorganismen, Centralbl. f. Bakter. u. Paras., Orig., 1888, Bd. iv., p. 149. 2. W. Bulloch : A Simple Apparatus for Obtaining Plate Cultures or Surface Growths of Obligate Anaerobes, Ibid., (Continued at foot of next column.)
ETC.
THOUGH injury to the spinal cord is not a necessary consequence of gunshot wounds of the spine, it is obvious that the chief interest of such wounds lies in the commonly associated injury to the spinal cord and nerve roots. From a clinical point of view, therefore, cases of gunshot wound of the spine may be divided into two main classes :-
broth, serum, gelatine, milk, and so on. Further, the action of the bacteria upon the various fermentable sugars or upon dye-stuffs may be determined and so valuable information obtained which may bear upon a more satisfactory classification of such It is well known that many anaerobes are affected in their morphology and biological characters-for instance, in the production of toxin-by the presence of sugar in the medium, and it is one of the advantages of the present method that dextrose is quite We unnecessary for the furtherance of growth. have thus been able to study these bacteria in a more stable condition than is usual. Advantages of the 97tethod.-l. The method is clean. 2. It is rapid, the whole process being complete in about a quarter of an hour. 3. It is available immediately without any preliminary preparation or reagent other than hydrogen. 4. It is suitable for use with any laboratory medium without preliminary preparation of the medium. 5. It will grow the strictest anaerobes with great rapidity upon the surface of a solid medium. For instance, colonies of B. tetani in subculture upon serum-agar are visible in 24 hours. We desire to express our thanks to Professor Bulloch for his kindly interest and advice on many points, and to Captain W. E. Bullock, R.A.M.C., for assistance and advice in the details of the method.
EPILEPTIC,
concussion
of ’
1
Being
London
the on
opening
remarks at a discussion at the Medical Society
March 20th.
(Continued from preceding column.) Orig., 1900, Bd. xxvii., p 139. 3. P. P. Laidlaw: Some Simple Anaerobic Methods, Brit. Med. Jour., 1915, vol. i., p. 497. 4. E. Pfuhl: Die Züchtung anaerober Bakterien in Leberbouillon, sowie in Zuckerbouillon und in gewohnlicher Bouillon, mit einem Zusatz von Platinschwamm oder Hepin unter Luftzutritt, Centralbl. f. Bakter. u. Paras., Orig., 1907, Bd. xliv., p. 379. 5. Th. Smith: Some Devices for the Cultivation of Anaerobic Bacteria in Fluid Media without the Use of Inert Gases, Journ. of Boston Soc. of Med. Sciences, 1899. vol. iii., p. 340. 6. G. Tarozzi: Ueber ein leicht in aerober Weise ausführbares Kulturmittel von einigen bis jetzt für strenge Anaerobien gehaltenen Keimen, Centralbl. f. Bakter. u. Paras., Orig., 1906, Bd. xxxviii., p.619.
771 on the vertebral column can produce diffuse, irregular, and severe structural changes within the spinal cord. The factors which determine the severity of these lesions must be the momentum of the projectile, the part and surface area of the vertebra which it strikes, and the region of the spine which is wounded." Now, is it possible to recognise clinically these three different results of gunshot wounds of the spine ? For were it so, the question of operative interference would be made very simple, inasmuch as the first and third groups obviously would be excluded as beyond surgical relief. Naturally, we turn to X rays as likely to be the most helpful agent in determining the nature of the injury. But, unfortunately, it is in gunshot wounds of the spine that, in my experience, X rays are most unreliable. This is not to be construed in any way into a criticism of the skill of radiographers. It is simply a statement of the limitations of the X rays
violent impact
themselves. in the first
place they may
not reveal any
bony
when present. This is particularly true of the single flat plate. In all such cases it is necessary to have stereoscopic plates taken. I have had two or three such experiences. Again, the X ray plate never reveals the full extent of the bony injury within the spinal canal-i.e., where the damage to the cord is being produced. This is not to be wondered at when we consider how small a piece of bone may be the traumatic agent and how much it is overlain and overshadowed by the vertebra surrounding it. Therefore, in my opinion, the X ray plate should only be regarded as confirmatory evidence, or used to assist in the localisation of foreign bodies or for the purposes of bony localisation. In considering operative intervention, the questions that will arise are in order of importance :1. Will any benefit to the patient result from the operation ? 2. Will his life be endangered by the operation ? 3. Will he be made worse by the
injury
even
operation ? The condition should
certainly not be made worse it is undertaken by a operation, provided by competent surgeon accustomed to operate, frequently upon the spinal cord. Unless the operator has had considerable experience in spinal surgery, the
it is very easy to overlook the site and cause of the compression. In these cases there are two levels to be considered, the neurological and the bony. The level of the lesion as indicated by the clinical symptoms usually does not correspond with the level of maximal damage. This is explained by the secondary changes which take place above and below the site of the injury in the cord. It is essential, in order that an operation should be perfectly successful, that all pressure on the cord from whatever cause be removed. Hence the necessity for a wide exploration both vertically
The
operation
is ended
quite
oblivious of the fact
that the pressure on the cord has in no way been relieved by this " plumbic " manoeuvre. In septic cases care should be taken not to open the dura if still intact. If already opened care should be taken not to break down any adhesions of a protective nature lest a septic meningitis be set up. Drainage along the usual surgical lines must be employed in septic cases. In those cases free from sepsis the dura should be opened for inspection of the cord. The patient’s life will not be endangered by the operation if a proper estimate has been made of his general condition beforehand. The chief and most frequent contra-indication is a general septic condition arising from the state of the kidneys and bladder, with persistent high temperature and perhaps rigors and a weak and irregular pulse. There is an added danger where the intercostals are paralysed, but with a skilled anæsthetist this may be obviated. Will any benefit result from the operation ? Let us consider what the operation may be expected to do. Briefly, it will relieve pressure, or, at any rate, remove any doubt as to whether continued pressure exists. If the spinal cord be not totally destroyed continued pressure may succeed in completing its Therefore operation is indicated: destruction. (1) To relieve pressure from depressed or displaced fragments of bone; (2) to relieve pressure from blood-clot or from extensive haemorrhage, either extra- or intra-dural ; (3) to relieve pressure and prevent further destruction from oedema by enlarging the constricted bony canal ; (4) to remove the future danger of pressure from exudate and inflammatory thickening. No operation will restore a cord in which complete transverse section has taken place. Nor will an operation benefit cases of concussion. Therefore we are brought back to the question upon the answer to which hangs the whole subject of operation : Are there any symptoms by which we can in a reasonable time determine beyond a doubt that we are dealing with a case either of complete transverse section or of pure concussion’? In short, is there any symptom-complex which establishes beyond a doubt that the injury to the cord is irremediable ? If there -is not, then should not. such a conclusion urge us to give our patient the benefit of an operation which experience shows neither materially endangers his life nor adds to his discomfort, but actually lessens his pain ? It will at least allow us to determine the exact nature and extent of the lesion and to place the cord under the most favourable conditions for recovery of function, if recovery be possible. I have said a reasonable time. It is unfair to the patient and unfair to surgery to wait on and on till hope gives place to despair and then to call in a surgeon as a last resource to perform the impossible.
Harley-street, W. and laterally. It is not only not necessary, but it is bad surgery to waste time in searching for a LITERARY INTELLIGENCE. -The American Journal missile which has ceased to do damage and has of Gastroenterology has combined with the Proctologist and passage beyond the immediate area of operation. hereafter will be published as the Proctologist and GastroYet one sees too frequently a sort of surgical from St. Louis. Dr. Rollin H. Barnes, St. Louis, enterologist, hypnosis produced by an X ray plate which shows will be managing editor and publisher. a bullet or piece of shell still in the human FINSBURY DISPENSARY.-Owing to the body, though perfectly innocuous at the time. warTHE the customary biennial festival of this institution has This hypnotic state is apparently only recovered been abandoned, and the Lord Mayor of London, as vicefrom when the operator is able to produce makes an earnest appeal for funds to carry on to the admiring onlookers the piece of lead, president, the work. Contributions may be sent to him at the Mansion while his own satisfaction reminds one of a certain House, or to the secretary, Finsbury Dispensary, Brewer-nursery rhyme connected with one Jack Horner. street, Goswell-road, E.C.
’