Henry Ford Hospital Medical Journal

Volume 25 Number 3 Article 2

9-1977

Milestones leading to the development of spinal surgery in the late 19th century

D. J. Canale

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Recommended Citation Canale, D. J. (1977) "Milestones leading to the development of spinal surgery in the late 19th century," Henry Ford Hospital Medical Journal : Vol. 25 : No. 3 , 131-144. Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol25/iss3/2

This Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Henry Ford Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons. Henry Ford Hosp Med Journal Vol 25, No 3, 1977

Milestones leading to the development of spinal surgery in the late 19th century

D.J. Canale, MD*

The significant amountof spinal surgery in neurological practice today prompts a sur­ vey of the historical development of surgical treatment of disorders of the spine. Any discussion tracing the events leading to modern surgical practice must necessarily contain the contributions of men of medi­ cine through the centuries; therefore, neu­ rosurgery as practiced today is greatly indebted to the efforts of courageous and dedicated men in world history extending to the ear/y Egyptians. Overcoming seemingly insurmountable barriers of prejudice bred of ignorance, societal customs, and religious tradition, these fathers of medicine have contributed the knowledge and experimen­ tal evidence which form the cornerstone of modern medical practice. From the papyrus records of a surgeon of 2500 B.C. to Lister's paper on asepsis and Morton's use of anesthesia, the advance of surgery as an integral part of medical prac­ tice may be observed through the detailed records describing diagnostic procedures and treatment methods. Also viewed are surgical techniques employing remedies and instruments which bear little re­ semblance to those in use today. Historical precedent is a well-known * Clinical assistant professor, Department of neu­ motivator, prompting understanding and rosurgery, The University of Tennessee Center for inspiring progress. Building on these the Health Sciences, Memphis, Tennessee. milestones of the past, modern men of medi­ Address reprint requests to Dr. Canale at 1314 cine may further advance the practice of Peabody Avenue, Memphis, Tennessee 38104 spinal surgery.

131 Canale

OINCE spinal surgery comprises such a however, as the chronological order in Fig­ ure 1 shows. significant part of neurosurgical practice to­ day, an account of the historical develop­ ment of surgery of the spine seems Ancient Egyptian particularly appropriate. This paper will re­ count and exam ine d iscoveries and events in The first references in recorded history to medical history that have contributed to the treatmentof disorders of the spine are found advancement of knowledge of the nervous in an ancient Egyptian writing, the Edwin system and the science of surgery and, more Smith Surgical Papyrus^ dated about 1700 particularly surgery of the spine and spinal B.C. The document is a copy of an earlier cord. writing dated about 2500 B.C., possibly written by Imhotep, the earliest known phys­ Successful surgical treatment of disorders ician and architect, with commentaries add­ of the spine and spinal cord was first accom­ ed by a later surgeon. This ancient record is plished in the latter part of the nineteenth concerned largely with surgical problems in century when William Macewen of that, of the 48 cases described, 27 are of Glasgow performed the first successful lami- trauma to the head and 6 of injury to the nectomyin 1883. Shortly thereafter, in 1887, spine. An idea of the treatment rendered by Victor Horsley of London successfully re­ the ancient surgeon can be shown in two moved an intraspinal tumorwhich had been examples. In case 29 of the papyrus, the diagnosed and localized preoperatively by ancient surgeon describes a gaping wound Sir William Gowers. in a cervical vertebra with no apparent neurological deficit. Treatment consisted of Their efforts had been preceded by two binding it with fresh meat on the first day and momentous events in medical history. In afterwards to "moor him at his mooring 1846 Dr. W. T. Morton first demonstrated the states" until the period of injury passed. practical use of ether anesthesia at Massa­ This, perhaps, was a method of splinting the chusetts General Hospital, a procedure wound. Case 31 is an example of a more which precipitated a remarkable increase in serious injury in which the ancient surgeon surgical procedures. Surgery of the nervous describes a dislocation of the cervical ver­ system, however, proved yet too hazardous tebra with paralysis of both arms and legs, since the problem of sepsis had not been incontinence of urine, priapism, and spon­ overcome. taneous ejaculation. The ancient surgeon declares the verdict to be unfavorable, and The publication in 1867 of Joseph Lister's no treatment is suggested. In this case one famous paper,^ On a New Method of Treat­ can assume that the surgeon recognized the ing Compound Fractures, Abscesses, etc. futility of treatment and, perhaps, declined with Observations on the Conditions of Sup­ to treat the patient because of fear of being puration, introduced aseptic or antiseptic accused of contributingto the fatal outcome. surgery, and helped initiate surgery of the From the writings of other civilizations in nervous system. The importance of Lister's existence during this period, such as the work cannot be overestimated. Horsley re­ Babylonian and Assyrian in Mesopotamia, ferred to surgery done prior to Lister as the as well as the Hebrew, Hindu, and Chinese, "pre-scientific epoch of surgery," Surgery, as there are not found any specific references to a definitive treatment for certain disorders of injuries or disorders of the spine. the spine, was then establ ished by Macewen and Horsley in the last quarter of the nine­ teenth century following the contribution of Classical Greek period Morton and Lister. The first attempts at spinal The rise of Greek medicine is recorded in surgery occurred much earlier in history, the writings of Hippocrates, the "father of

132 Milestones of spinal surgery

MIL£STO^ES IN THE HISTORY OF SPINAL SURGERY

yiN SMITH wiCAL PAPYRUS

HIPPOCRATES. 5TH CEriruRY^ B.C.

6AL£N 164 A.D.

PAUL OF AEGENA, 7TH CENTURY

VESALIUS m5 HlUMNUS

WHYTT CONTUGNO HEISTER POTT

CLINE COOPER

/VJESTHESIA k>W-SEQUARD. 1850 jviL WAR 1861 -ISTER 186/ CLINICAL NEUROLOGY

Figure 1 In addition to the dates shown, othermilestones in spinal surgery were reached in the late 19th century by Macewen in 1883 and Horsley in 1887.

133 Canale

medicine," during the classical period of the probably following closely the methods of fifth century B.C. He did much to advance Hippocrates. Galen was the first to section the science of medicine by separating medi­ experimentally the spinal cord at various cine from religion and by accurately describ­ levels in animals and to study the effects ing diseases. Although he does not describe thereof. For this reason, he may be called the any actual surgery of the spine, he describes first experimental neurologist. His influence a gibbous deformity of the spine in which the was profound, and his writings have been spine is "contracted to a hump" from dis­ followed for centuries. Unfortunately his ease, most likely tuberculosis. He also de­ idea that suppuration was an essential part of scribes scoliosis of the spine which he notes heal ing retarded the development of surgery occurs in persons in good health. In these and was not entirely overthrown until the cases he describes treatment which included time of Lister. extension and pressure on the deformity. He notes that fractures of the spinous processes may occur without other serious injuryto the Middle Ages spine and that these will heal rapidly In The work of Paul of Aegina, the last of the addition to his observations regarding the great Byzantine physicians, provides the spine, he gives detailed descriptions for trep­ next milestone in surgical history of the spine hining the skull for head injuries. Regarding during the early part of the Middle Ages. dislocations of the vertebrae, he describes Paul, practicing in Alexandria, is said to have two types. The first is that in which the been the first surgeon to operate on the vertebrae are displaced forward, compress- spine. He recognized that the bodies of the ingthe spinal marrow and resulting in insen­ vertebrae may be fractured, with resulting sibility, paralysis, and retention of urine and compression of the spinal marrow. Regard­ feces. For these cases he declares there is no ing treatment he says: satisfactory treatment and deplores the use of cupping and extension as methods of Wherefore having first given warn­ treatment for forward displacement which ing of the danger, we must, if possi­ ble, attempt to extract by incision he declares to be usually fatal. The second the compressing bone, or, if not, we type of dislocation is that of backward dis­ must soothe the part by the anti­ placement of the vertebrae which he notes is inflammatory treatment.'* rare but carries a better prognosis and is usually not associated with paralysis but This may be also one of the first examples may be confused with simple fracture of the of informed consent for surgery of the spine. spinous processes. He states that one rarely It is doubtful that the surgery which he succeeds in straightening the dislocation, recommended could be compared with a and inthisparticularcase,condemnsthe use true laminectomy as we know it today of succussion on a ladder.^ In general, medicine and surgery declined duringthe medieval period, with surgery, for Graeco-Roman the most part, being divorced from medicine and held in disrepute. With the rise of the Garrison tells us that with the destruction universities in the latter part of the Middle of Corinth in 146 B.C., Greek medicine Ages, beginning with Salerno in the eleventh migrated to Rome where Galen, the greatest century, there was a rebirth of interest in the Greek physician after Hippocrates, prac­ study of anatomy; and human dissection was ticed about 164 A.D." Prior to this, after again permitted. Mondino's revival of ana­ having studied in Alexandria, Galen had tomic dissection at the University of Bologna been appointed surgeon to the gladiatorial in 1315 was to have added significance two amphitheater, and undoubtedly had the op­ hundred years later in the anatomy of Ves­ portunity to treat a number of spinal injuries, alius. Guy de Chauliac, the greatest surgeon

134 Milestones of spinal surgery of the Middle Ages, writing in the fourteenth the same as those of Hippocrates. He gives century, recognized the symptoms of spinal clear instructions about the reduction of cord injury but felt the prognosis was hope­ dislocations in the cervical area, as well as less and recommended no surgery dislocations in the thoracic and lumbar re­ gions, using a traction and counteraction technique, with the patient lying face down The Renaissance period on a table. (See Figure 2.)

The advent of the Renaissance Period brought many advances in surgery, largely Considering the kinds of instruments because Andreas Vesalius, whose monu­ available at the time and the probable out­ mental work De Fabrica Human/ Corporis come of most injuries to the spine, it is published in 1543 provided for the first time doubtful that a formal operation on the spine a correct understanding of the human body with removal of lamina was often per­ with a reasonably accurate anatomical de­ formed. In his Apology, Pare records his scription of the spine and spinal cord. Ves­ treatment of the Constable Anne de Mon- alius also repeated Galen's experiments of morenci, the leader of the Royalists in the sectioning of the spinal cord. Battle of St. Denis in 1567. Monsieur le Connestable had been suddenly rendered The influence of Vesalius on Renaissance paraplegic from a gunshot in the middle of surgery is best noted in the works of Ambrose the spine. Pare went to Monsieur le Con- Pare, the famous sixteenth century French nestable's house and dressed his wound but surgeon. Pare wrote an epitome of the Fab­ did not operate, reasoning that the spinal rica in the vernacular which became popu­ cord was crushed. He stated that the patient lar with surgeons of that time. His most well- became confused and in a few days died. known contributions are his use of the liga­ Pare, no doubt, recognized the futility of ture, instead of the cautery, for bleeding attempting to operate on this type of vessels in amputation stumps and his advice wound.' There were, during the Renais­ againstthe use of boil ing oil in the treatment sance, very few outstanding surgeons, so of gunshot wounds. Pare gives rather explicit that operations on the spine were very rare. instructions regarding spinal injuries. He noted that the vertebrae may be fractured with the resulting compression of the spinal marrow. Regarding treatment, he says: Seventeenth century

Amongst these symptoms, are the Surgery, progressing little in the seven­ stupidity or numnesse and palsie, of the armes, legges, fundament and teenth century, was performed for the most bladder, which diminish, or else part by barbers and was not held in high take away from them the facultie of sense and motion; so that their regard. Fabricius Hildanus, often called the urine and excrements come from father of German surgery, during this period them against their wils and knowl­ described a unique method of reducing cer­ edge, or else are wholly supprest. Which when they happen (saith vical dislocations by traction on a metal awl Hippocrates) you may fore-tell that passing through the ligamentum muchae." death is at hand, by reason that the This failing, he recommended early opera­ spinal marrow is hurt. Having made such a prognosticke, you may make tion with the incision down to the spinous an incision, to take forth the splin­ processes and dissection to expose the lam­ ters of the broken vertebrae, which, ina on both sides with open reduction of the driven in, presse the spinal marrow, and the nerves thereof.^ luxation with the aid of simultaneous exten­ sion and traction. Armour notes that his His description of the different kinds of operative description closely resembles the dislocation of the vertebrae are essentially modern operative approach to the laminae.'

135 Canale

Figure 2 Illustration taken from "The Works of that Famous Chirurgion, Ambrose Parey", 1634, shows a method of reduction of dislocation of vertebra using traction and counter traction with pressure over the site of dislocation.

Eighteenth century to the hip, which he calls "arthritic" sciatica, and another which "runs" down the leg to The eighteenth century brought several the foot, which he calls "nervous" sciatica. discoveries historically important to spinal His recommended treatment included surgery. Some of these, while not of immedi­ bloodletting, purging and opium. In more ate importance, were quite significant in protracted cases, he applied a cautery over later developments in neurology and neu­ the course of the nerve to produce a bl ister of rophysiology.'" Robert Whytt, professor of the skin. A preferred area was in the region of the Institutes of Medicine at Edinburgh, re­ the head of the fibula where the common peated the experiments that had been per­ peroneal nerve is quite superficial. In pursu­ formed on the spinal cord section by ing the site of nervous irritation in sciatica, Stephen Hales, an English country parson. he was led to the spinal cord, where he Whytt firmly established the nature of reflex encountered cerebrospinal fluid. Cotugno action in the decapitated frog and experi­ gave the first accurate description of the mentally demonstrated for the first time that fluid. The presence of cerebrospinal fluid in only a small segment of spinal cord was cases of hydrocephalus was known to the sufficient to allow reflex action. early Greeks. Until Cotugno's time it was thoughtthatduring lifea vapor occupied the Domenico Cotugno, professor of surgery ventricles and subarachnoid space. Cotugno and anatomy at the University of Naples, attributed the fact that the fluid had not been made other significant discoveries during observed by earlier anatomists to the com­ this century. In 1764, Cotugno published his mon practice of decapitating the cadaver "De Ischiade Nervosa Commentarius."^^' prior to dissecting either the brain or spinal This work contains astute clinical observa­ cord. This caused all the fluid around the tions on sciatica in which he distinguishes brain and spinal cord to flow out and to be two types, one in which the pain is limited lost. In20casesofdissection without remov-

136 Milestones of spinal surgery

ing the head, he collected between four and kind of sling traction for which he gives five ounces of spinal fluid in each one. To cred it to Jean-Louis-Petit of Paris, the leading prove that this fluid was also present during French surgeon of the first half of the eigh­ life, he dissected living animals and found teenth century. This method of placing the cerebrospinal fluid to be present.''' traction apparatus under the chin and oc­ ciput is essentially the same as we use today By the middle of the eighteenth century (See Figure 3). the status of surgery had improved in Eng­ land as well as on the continent. One must Perhaps the most significant advance in doubt, however, that operative intervention surgery of the spine in the late eighteenth was often successful, judging from the writ­ century was a new operation described by ings of Lorenz Heister, a leading German Percival Pott. Pott was surgeon to SL Bar­ surgeon whom Horsley credits with first tholomew's Hospital, London, when he describing trephining of the spine. Heister published in 1779 his pamphlet, Remarks on states: That Kind of Palsy of the Lower Limbs Which Is Frequently Found To Accompany a Curva­ If in any case the spinal marrow should be divided, death will be ture of the Spine and Is Supposed to Be generally an inevitable conse­ Caused by It; Together With its Method of quence; but to offer the patient no Cure; etc.'*" Considering the state of knowl­ assistance because we despair would seem cruel and uncharita­ edge of surgery at this time, Pott's discovery ble; therefore, we must try our skill, was of particular importance because he though our attempt should be in introduced a relatively easy method of treat­ vain; in order to which, the surgeon must bare the fractured vertebrae ing and frequently curing paraplegia due to with the scalpel, and replace orelse tuberculosis of the spine, which was not remove such fragments as injure the spinal marrow; the wound is to be uncommon at this time. Percival Pott noted afterwards gently cleansed as usual that this disease or distemper was called and dressed with Balsams, clapping "palsy" and was supposed to be due to over them a compress dipped in warm spirit of wine, or lime water, curvature of the spine. He reasoned that the and spirit of wine camphorated, to commonly held theory of injury being the be held on with the napkin and cause of the curvature was not correct even scapulary, until the wound shall terminate either in a perfectcure or though he did not recognize the tuberculous death." nature of the disorder. He studied thiscondi- tion carefully, performing postmortem ex­ Heister also clearly described his method of aminations in which he noted that the manual traction and manipulation for reduc­ intervertebral cartilage (discs) was de­ tion of cervical spine fractures. In his book, A stroyed, and that a quantity of sanies (pus) General System of Surgery, he illustrates a lodged between the "rotten bones" and the

Figure 3 illustration taken from Page 192 of "a General System of Surgery, in three parts," by Dr. Lawrence Heister, 1768. The figure on the left illustrates a sling placed over the head. On the right is another sling used to retain the patient's body and pull down on the shoulders. This sling method was used to treat subluxation of the cervical vertebra.

137 Canale

dura. In describing the treatment he stated: were sensory." Francois Magendie of France "The remedy for this most dreadful disease demonstrated the sensory function of the consists merely in procuring a large dis­ posterior spinal nerve roots in 1822 after charge of matter, by suppuration, from un­ hearing of Bell's work. Magendie cut the derneath the membrana adiposa on each posterior roots of the lumbar and sacral sideof thecurvatureand in maintainingsuch nerves on one side and demonstrated that discharge until the patient shall have per­ the ipsilateral hind limb became totally in­ fectly recovered the use of his legs." This sensible to pain but was still able to move. recovery, he noted, would occur even The Bell-Magendie law, showing the func­ though the curvature of the spine remained. tion of the spinal nerve roots, has been compared in importance to Harvey's dem­ His technique consisted of incision and onstration of the circulation of the blood. drainage of the paraspinous mass. He pre­ ferred placing a large kidney bean in the The nineteenth century opened with the bottom of the incision and sprinkling in controversy over operating on the spine for powdered cantharides (Spanish Fly) to act as fractures. Injuries to the spine with fracture an irritantin keepingthewoundfromclosing and compression of the spinal cord caused over. His experience with the use of setons by falls, blows or gunshot wounds were the (linen drains) was not satisfactory because onlyconditions for which spinal surgery was patientsdid not take proper careof the drain. considered at this time. Benjamin Bell of Three years later in 1782, Pott elaborated Edinburgh, writing in 1801, recommended further on this condition with another pub­ surgery where there was reason to believe lication in which he states his belief that the that the cord was compressed by depressed cause of the paralysis was erosion of the bone fragments, citing a case of recovery vertebrae and that consolidation and union from paralysis after the removal of a musket of the vertebrae which had been carious was ball lodged in a vertebra.^' essential for cure. At this time suppuration was still considered an essential part of Charles Bell of London was, undoubtedly healing, and Pottdid not associate the drain­ a very talented surgeon as well as an ana­ age of the purulent abscess and its conse­ tomist and experimental neurologist. This is quent relief of pressure on the dura and perhaps best demonstrated in his recom­ spinal cord with recovery of paralysis. This mendations regardingthe treatmentof spinal does not, however, detract in any way from injuries. His clear advice on the handling of his accomplishment" a patient with an acute spinal cord injury would hold true even today He states: "In whatever way the vertebrae are broken, the Nineteenth Century danger of moving the body must be appar­ Two important physiological discoveries ent, since in every change of posture, or turn relating to the functions of the spinal nerve of the body, broken bones may be thrust roots were made in the early nineteenth against the spinal marrow." Further, he ad­ century and had a profound effect in later vises the surgeon to carry a catheter with him years on the diagnosis and treatment of when called to see his patient with a spinal disorders of the spine. The first of these injury. His description of the patient with a important contributions to neurophysiology distended bladder and ileus in this period of was made by Sir Charles Bell in 1811 in a "the first shock," as he calls it, is essentially privately printed pamphlet. Idea of a New the same as we view a spinal-cord-injured Anatomy of the Brain,'" in which he demon­ patient today with "spinal shock." strated that stimulation of the anterior spinal nerve roots caused the muscles to contract, Bell explains that, "looking into the anat­ disproving the theory that all spinal nerves omy as our only guide," there is good reason

138 Milestones of spinal surgery to surgically decompress the spinal cord; same circumstances that one would de­ however, the "real circumstances" are such compress the brain in a case of depressed that removing the bone doesn't correct the skull fracture. Cline's operation and par­ injuryto the spinal marrow. Moreover, "the ticularly his lectures attracted wide atten­ little probability that the operation would do tion, and the case was even the subject of a good with the chance of doing much mis­ report in the lead article of the Januar/, 1815, chief deters us from laying open the edition of the New England journal of Medi­ canal."^^ (See Figure 4.) One can't help but cine and Surgery.^" Considerable contro­ conclude that the "state of the art" of spinal versy overCline's position went on for years. surgery at this time was not very high. Bell's Astley Cooper, a pupil of John Hunter and a conservative philosophy regardingthe man­ popular surgeon at Guy's Hospital in Lon­ agement of these patients, expressed in his don, supported Cline. Cooper's position on operative surgery of 1810, however, was not Cline's operation was: "1 am certain that shared by all. such an attempt was laudable... and if it saves only one life in a hundred, it is more In 1814 the younger Henry Cline, surgeon than I have yet seen accomplished by surg­ to St. Thomas Hospital of London, per­ ery." Cooper noted these spinal-cord-in­ formed a formal operation for removal of a jured patients were without hope though depressed vertebral arch." The patient, who there were differences in survival. Those was paraplegic, died following surgery. In a cases of fracture above the third cervical clinical lecture afterwards, Cline neverthe­ vertebrae were immediately fatal. Patients less justified the operation on the basis of the with fractures of the lumbar vertebrae usu-

Figure 4 Taken from "A System of Operative Surgery Founded on the Basis of Anatomy," by Charles Bell, this illustration shows Bell's knowledge of pathological anatomy in fractures and dislocation of the spine, and the consequent injury to the spinal cord. Page 225, 1814 London edition.

139 Canale

ally diewithin sixweeks of injury; those with internally galvanism to the legs, iodine of similar injuriesof the dorsal vertebral survive potassium for syphilitic tumors, and, if a no more than a fortnight or three weeks; and tubercle is suspected, cod liver oil. The death ensues in three to seven days follow­ patient is also advised to have a most nour­ ing fractures of the cervical vertebrae." With ishing diet and a little wine. In no place is his conservative views Charles Bell vehe­ surgery mentioned for treatment of a spinal mently opposed both Cline and Cooper on cord tumor at what was literally the "mecca this matter. Commenting on this controversy of neurology" a scant 26 years before Victor Donald Armour stated that because of Bell's Horsley was successfully to remove a spinal great influence as a leading neurologist of cord tumor at the same institution. By 1870, the day he helped retard the development of however, Brown-Sequard did express the spinal surgery" 1 would disagree with Ar­ view that trephining the spine might be mour on this matter as 1 think that Bell, useful, at least in cases of fracture of the recognizing the problems of sepsis and the spine with injury. limitations of the "free use of the chisel," realized the futility of surgery of the spine at this period. Following Cline's report, there The Civil War (1861-1865) in this country were occasional reports of operations on the provides another record for the study of spine, almost always unsuccessful, as late as surgery of the spine in the mid-nineteenth the mid-nineteenth century century Results of 642 cases of gunshot injuries to the vertebrae are reported in the Medical and Surgical hiistory of the War of A very i m portant f igu re i n med ic i ne i n the the Rebellion.^'' Of these 642 cases, 349 mid-nineteenth century was Charles Edward were fatal, a mortality rate of 55.5%. There Brown-Sequard whose experiments on the were 62 cases operated on, and of these 27 spinal cord made a significant contribution died. The majority of the operations (34 to the clinical diagnosis of lesions of the cases) consisted of removal of the musket spinal cord. He was widely travelled, and it ball. Bone spicules were removed in 24 is significant that he was appointed to the cases, and in four cases ligation of bleeding National Hospital for the Paralyzed and vessels was carried out The author notes that Epileptic, Queen Square, London, when it the successful operations resemble the one opened in 1860. He was the first to point out described by the famous French surgeon, the clinical significance of experimental Louis, one hundred years earlier, in which hemisection of the spinal cord. This really the operation consisted of an incision with laid the foundation for anatomy and function removal of a musket ball and loose bone of the spinal cord. His original papers on this fragments felt bythe examiningfinger. It was subject were published in 1850 and 1855. the conclusion of the surgeon general, when The essence of his experiments is described this volume was published in 1870, that in his statement: "So that wherever the "formal trephining of the spine has hitherto lesion, in a lateral half of the cerebrospinal given such unfortunate results that without axis may be — below, above or at the level of much more positive favorable evidence it the crossing pyramids — if it produces anes­ cannot be accepted as an established thesia, it is on the opposite side; while operation." paralysis in these cases is either on the same or on the opposite or both sides."" The final impetus for surgery of the spine came in the last quarter of the nineteenth In his text on paraplegia," published in century from a not unexpected source, the 1861, the treatment of paraplegia due to medical neurologist. The feel ing about surg­ tumors of the spinal cord is described. He ery of the spine at this time, however, had recommends the application of a large bell­ notchanged much, as evidenced by Herbert adonna plaster to the back, ergot of rye Page writing in 1881 in Heath'sD/ct/onary of

140 Milestones of spinal surgery

Surgery. He stated: "The operation of trep­ clinical level at D-6 of two years' duration. hining the spine ... is an operation not Macewen removed the 5th, 6th, and 7th within the range of practical surgery"^" The dorsal laminae and dissected a "fibrous medical neurologist atthe time undoubtedly neoplasm" off the dura. The patient began to was seeing most, if not all neurologic cases, improve almost immediately and eventually and recognized the possibilities for surgical made a complete recovery. Macewen did treatment of tumors in particular, now that not report the microscopic examjnation of the surgeons were operating under aseptic the "neoplasm," and it was presumed by and scientific techniques, following the in­ later writers to have been due to tuber­ fluence of Joseph Lister. culosis. He operated on a similar case in 1884 and by 1888 reported his experiences with six cases in which he had performed William Hammon, author of the first laminectomies. Two of these cases ended American text book of neurology and, with fatally but both had active tuberculosis." Weir Mitchell, a founder of American neu­ rology, raised the question in 1881 of who would be the first to attemptan operation on The distinction of successfully removing the spine for an intraspinal tumor. Ham­ the first spinal cord tumor was to go to Victor mond, like others in his day recommended Horsley He was a superbly qualified young anti-syphilitic treatment with iodine of po­ surgeon when, at the age of 29, he was tassium and mercury when a tumor of the appointed surgeon to the National Hospital spinal cord was suspected. If this measure for the Paralyzed and Epileptic, Queen was ineffective, he recognized that perhaps Square, London, in 1886. A year later in nothing else could be offered except "extir­ June, 1887, the historic operation took pation by trephining the vertebral place. A 42-year-old Army captain was ad­ column."^' mitted to the hospital on Sir William Gowers' service. He complained of intermit­ tent back pain, increasing in frequency and Byron Bramwell, the leading neurologist severity for three years, with weakness in the of Edinburgh, speaking on the treatment of lower extremities beginning four months extramedullary tumors in 1886, noted that priorto admission and progressingto spastic the operation was not yet a recognized plan paraplegia and incontinence. He had a sen­ of treatment. He added, however, that with sory level at D-5 to D-6. Sir William Gowers the advent of antiseptic surgery he would made the diagnosis of a benign intraspinal advise an operation if the growth could be tumor. Diagnoses prior to admission in­ local ized and if vigorous anti-syphilitic treat­ cluded intercostal neuralgia, syphilis, ment had failed to rel ieve the symptoms." In aneurysm, and hysteria. Horsley was asked the same year, Sir William Gowers of Lon­ to see the patient on the 9th of June and don commented that surgery "may ul­ examined him about 1:00 p.m. At 3:30 p.m. timately be able to cope in some degree with the same day, Horsley took the patient to meningeal tumors."" surgery Ether was employed as the anes­ thetic. The patient was placed in the semi- The real modern pioneer in spinal surgery prone position and "prepped" with carbol ic must be recognized as William Macewen, acid solution. The spray was used surgeon to the Glasgow Royal Infirmary throughout the operation in the typical List- With the encouragement of the neurologist, erian manner. Muscle bleeding was control­ Alexander Robertson, Macewen had already led with Wells forceps and sponge packing. begun operating on the spine, performing The 4th, 5th, and 6th dorsal spine were his first successful laminectomy in 1883. He removed. A %-inch trephine opening was operated on a nine-year-old boy who had an made in the 5th thoracic lamina, and the angularcurvatureof the spine with complete laminectomy was completed by removing spastic paraplegia and incontinence with a

141 Canale

the laminae of the 4th, 5th, and 6th dorsal about two months postoperatively He had vertebrae with bone forceps. After exposing little pain and was ambulatory At the end of the D-5 root at the upper end of the wound the year he was essentially asymptomatic. and not locating a tumor, Horsley feel ing the pressure, was unwilling to "leave the matter Horsley reviewed 58 cases of spinal cord undecided." His assistant, Charles Ballance, tumor, one of which was his own. Only in urged him to look higher, and, following one other case was surgery performed — a removal of an additional lamina, a bluish- lipoma in a 10-month-old child who sur­ red tumor was seen on the left side near the vived only six months. Al 1 other cases ended attachment of the dentate ligament and at­ fatally after treatment which included cau­ tached to the highest root of T-4. The tumor tery moxas, blister, iodine, mercury, po­ was dissected away from the cord without tassium, baths, etc. difficulty bleeding being controlled by gen­ tle pressure with sponges. The tumor bed Gowers and Horsley's case report^= re­ was irrigated with a 5% carbolic acid solu­ ceived worldwide attention and demon­ tion. The dura was not closed, and the strated conclusively that certain lesions of wound was drained and closed in layers. the spine and spinal cord are amenable to Under microscopic examination the tumor surgical treatment. In the succeeding years was described as a "fibromyxoma." Horsley surgeons on the continent of Europe and in states that "enormous quantities" of cere­ the United States began to operate on the brospinal fluid drained initially butthis grad­ spine with success — in virtually every in­ ually subsided over six weeks. After this stance acknowledging Horsley foropeninga experience, Horsley recommended remov­ new chapter in the history of surgery of the ing the drain within two days following spine. surgery rather than six, but did not mention closingthe dura. The patient was discharged

142 Milestones of spinal surgery

References

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143 Canale

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