A chainsaw to the spine

injuries of the spineIn the early nineteenth century surgery was a primitive affair, generally limited to a few commonly performed operations. Most people know about agonising amputations, or the (possibly even more agonising) operations for bladder stones and mastectomy; others in the surgeon’s repertoire included basic procedures to remove cataracts or to release pressure in the skull. But here’s a truly astonishing case of complex spinal surgery, performed without anaesthesia, which I found in The Lectures of Sir Astley Cooper, a two-volume work published in 1831. Cooper was one of the most celebrated surgeons of the age, notable for a series of pioneering operations. In a lecture devoted to injuries of the spine he alludes to a procedure reported by his nephew Frederick Tyrrell.  It was Tyrrell who prepared his uncle’s lectures for publication, and he took this opportunity to insert (in an extended footnote) his own account of this courageous operation:

John Buckley, aged twenty-five, a labouring man, about the middle size, and of rather spare habit, was brought into St Thomas’s Hospital, on the evening of Tuesday, the 15th of October 1822, having received some injury to the spine, which was occasioned by his slipping at the time he was carrying a heavy load of cast metal: he fell about five feet, but was not aware that the metal struck him. The accident had happened early in the morning of the 13th, since which time his urine and faces had passed off involuntarily.

It was not necessary for the metal to hit him; falling awkwardly while carrying a heavy load could easily result in a spinal injury.

I saw him a few hours after his admission into the Hospital, and, on examination, found that he had lost all sensation and power of motion, below Poupart’s ligament anteriorly, and the lumbar vertebrae posteriorly; in fact, the superior edge of the pelvis marked accurately the line between the sensitive and the non-sensitive parts.

He had lost all sensation below the top of the pelvis; today this might be termed paraplegia.

vertebra
Diagram of a typical thoracic vertebra, from Gray’s Anatomy

The spinous process of the twelfth dorsal vertebra was depressed, and he complained of acute pain when this part was touched.

Known as T12 (12th thoracic vertebra), this is one of the strongest and most substantial bones of the spine.

He had not passed any urine since his admission, but at night he complained of its accumulation giving him inconvenience, when it was drawn off. 16th. He was much the same in every respect; in the afternoon, my colleague (Mr Green) was kind enough to see him with me; when we decided that an operation…might probably be beneficial; but as our consultation was late in the day, and the operation likely to be very tedious, l deferred it until the next morning.

The following day Tyrrell examined him again; since there were no signs of improvement, surgery was the only option.

At half past ten o’clock he was taken into the operating theatre on his bed, being placed with his face downwards, and some pillows under the lower part of the abdomen, in order to elevate that portion of the spinal column which had been injured. My colleagues (Messrs Travers and Green) being present, I performed the following operation.

There was no anaesthesia at this date, of course, but in his thorough notes of the operation Tyrrell makes no mention of pain relief for the patient until after the procedure had been completed. Opium or alcohol were often employed as analgesics, but it seems that neither was used on this occasion. One possible reason is that it was a spinal operation, and the surgeon needed his patient to be fully conscious and able to describe any return of sensation to his legs.

An incision, about six inches in length, was made through the integuments, in the direction of the spinous processes, having that of the last dorsal vertebra in the middle, over the point of which was observed some slight extravasation of blood.

The ‘integuments’ are the tough outer layers – the muscle and skin. The ‘processes’ are the lumps that project from the side of each bone of the spine. The surgeon observed some bleeding from the vertebra which he believed to have been injured.

The muscles were then separated by the scalpel, from the sides of the spinous processes, and from the arches of the twelfth dorsal and first lumbar vertebrae, as far as the transverse processes, also partially from those above and below. During this separation some arterial haemorrhage occurred, which was very troublesome in obstructing my view of the parts; but it was not very copious. An assistant then held aside the integuments and muscles with a broad bent piece of iron, so as to allow of the application of a small trephine on the arch of the first lumbar vertebra.

A trephine is a sharp instrument in the shape of a cylinder, used to made a circular hole in bone or other tissue. They have been used since antiquity in the operation known as trepanning, to relieve pressure on the brain, most often caused by haemorrhage. In this case Tyrrell was hoping to release the blood and bone fragments presumed to be compressing the spinal cord.

After using the trephine for some time ineffectually, 1 cut away the spinous process of the vertebra: with a chain-saw, which enabled me to see much better the operation of the trephine; and finding that I made very little progress with it, I took, instead of it, one of Hey’s small saws, with which I sawed nearly through the arch, close to the transverse process; and after having done the same on the other side, I soon succeeded in removing the larger part of the arch with a pair of strong tooth forceps, leaving but a thin portion, covering the canal.

Just imagine lying wide awake while a surgeon uses a chainsaw in an unsuccessful attempt to cut through part of your spine! Hey’s saw was more often used on the skull, particularly in trepanning.

The arch of the twelfth dorsal (over which the extravasation [bleeding] had been observed) was distinctly found to be loose: I then proceeded to remove it, as I had done the former, which I soon effected completely, so as to expose the ligamentum subflavum: this was found divided: on elevating it, the dura matral covering of the cord was seen quite perfect, and apparently free from injury. I then removed the portion of the arch of the first lumbar, which I mentioned as having left, together with the ligament, exposing near two inches of the sheath of the cord, which appeared healthy; and under which the pulsations of the cord could be seen.

To clarify: Tyrrell succeeded in removing a substantial part of two vertebrae. This was not ideal, since it left a short section of the spinal cord unprotected from further injury; on the other hand, it removed the structures which had compressed of the cord and which threatened to damage it further. With the main part of the procedure complete, the surgeon was now anxious to find out whether it had made any difference. And it had:

The patient could now feel distinctly, on being pinched inside the thigh; which immediate return of sensation was beyond my most sanguine expectations. The edges of the wound were brought together by two sutures, dressed lightly with strips of adhesive plaster, and the patient removed to his ward, on the same bed, and in the same position. The operation occupied nearly an hour and an half, during which time the patient scarcely uttered a complaint.

He must have had the patience of a saint and the pain threshold of a woman in childbirth. Only now did he receive any pain relief:

Soon after being placed in his ward, he took thirty drops of the tincture of opium, as he expressed a wish for something to make him sleep. I saw him again at three o’clock, when he said he felt very comfortable; but did not appear to have more sensation than when removed to his ward after the operation; he had not slept, in consequence of which the tincture of opium was to be repeated in the evening.

‘More patience is required in the performance of this operation than skill,’ remarks Mr Tyrrell, ‘as it is extremely tedious, and requires much care in using the saw’.  He did not see his patient again until the early hours of the following morning, when he

was perfectly easy; had slept, and felt me pinch his toes: a very considerable oozing had taken place from the wound, more of a serous than sanguineous nature; his pulse was feeble; in consequence of which I directed him to take weak wine and water, when thirsty.

The ‘oozing’ was clear rather than bloody, generally seen as a good sign which indicated normal healing.

The signs were at first promising: sensation had apparently returned to his lower extremities, and the wound was apparently beginning to heal without any sign of infection.  But it soon became clear that he had no control over his bladder or bowels, which necessitated regular use of a catheter to drain urine. It was, in the end, this problem which killed him. After a week or so he reported severe pain in the lower abdomen, and it soon became clear that he had a bladder infection.  His condition deteriorated and after the infection spread he was unable to retain food or drink for any length of time. Opium, leeches and various medicines failed to improve his symptoms. A fortnight after the operation, Mr Tyrrell visited him and found him uncomfortable and suffering from a fever:

In the night he was very restless; and on one occasion, when the nurse quitted his bedside for a few moments, be nearly got out of bed, and was only prevented by her return; towards morning he became more quiet, but was evidently sinking, and he died about six o’clock on the 30th, having been perfectly sensible until within a short time of his death.

A post mortem revealed signs of extensive infection which had apparently begun in the bladder and spread to the surrounding organs, including the intestines. Although Tyrrell did not use the word, this was probably peritonitis, a potentially catastrophic infection which can rapidly spread through adjacent organs of the abdomen. The site of the operation, on the other hand, remained healthy, and Mr Tyrrell concludes his report with this upbeat observation:

The immediate, although partial, return of sensation in my patient, and the after gradual increase of feeling, are proofs that the operation was in a degree serviceable. The patient also lived long enough to show that the effects of the operation upon the parts immediately concerned in it, are not sufficient to afford any ground for objection to its performance.

Today it is well known that paralysed patients who cannot evacuate the bladder voluntarily require careful management to prevent infection. Frederick Tyrrell himself felt that regular use of the catheter might have saved the man’s life.  Of course it is impossible to know what would have happened if infection had been avoided, but from a distance of almost two centuries it appears that he came agonisingly close to a remarkable surgical triumph.

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