This is an historic image.
On January 1st, 1896, Wilhelm Roentgen presented the first ever xray, an image of his wife Anna’s left hand. Later that year, a young doctor by the name of Harvey Cushing—who would go on to become one of the most prolific surgeons in history and the father of modern neurosurgery, produced this image, the first clinical x-ray (they called them roentgenograms back then)—a gunshot wound to the neck and spine.
There are actually two images here, one from the front and one from the side. Each image took an incredible thirty-five minutes to expose.
The xrays show the bullet fragament (the dark blob) either within or overlying the C6 vertebra. So which is it—within the bone or in front of it?
It’s worth recalling that x-rays are 2-D representations of 3-D space. Consider a regular photograph. Everything visible in the frame of a regular photo will be condensed to a single plane, with only the items in the forefront visible. Everything behind will be hidden. With an x- ray however, everything in the frame will be condensed to a single plane including the items in the background. What?
If I take a picture of my hand over my face, my face is hidden by my hand. You can’t see how big my nose is or how many teeth are missing, because they are hidden by my hand. But if I take an xray of my hand over my face, you’ll see not only my hand bones, but all the bones, teeth, and various soft tissues of both my hand and face. In fact, that’s the hallmark of an xray—it looks through what’s on top to show what’s behind.
Put another way, in a photo only the visible foreground information is used to generate the image. By contrast, in an x-ray, all of the information in the frame (hidden or not to the naked eye) is used to generate the image.
So how do we know if the bullet is in the bone or in front of it? The answer, of course, is we have to have two images in different orientations. Fortunately, Harvey Cushing intuited this even back in 1896. The image on top is an AP image—an exposure taken from the front. The dark spot overlying the C6 vertebra is the bullet. C is the skull and D the ribs and lungs. The image is severely underexposed, so the soft tissue does not show well (including the lungs). Of course, since it was the first x-ray of its kind, we can forgive the underexposure.
The lower image is a side view. It shows the bullet overlying the C6 vertebral body as well. Since both the AP and side (lateral) xrays show the bullet overlying the bone, it must in fact be within the C6 vertebral bone itself—and not just in the soft tissue in front of or alongside the bone.
On the lateral image (bottom), A is the spinal canal (where the spinal cord itself lives, here it has been colored in for clarity). B is the so-called pre-vertebral space, the soft tissue in front of the spinal column. There isn’t much detail here compared to today’s imaging, but there’s enough for us to say there is no fracture of the bones despite the presence of the bullet in the body of the C6 vertebra. The body of any vertebrae lies in front of the spinal cord, and very often a bullet may be lodged there without damage to the cord itself (especially if it is a low velocity missile, as it likely was here).
At other times, severe spinal cord injury (paralysis) may result from a gunshot wound to the spine, even one that completely missed the spinal cord itself. This is caused by blast effect, a sort of shock wave that goes through the tissue as a result of the kinetic energy of the gunshot wound as it passes through and disrupts the anatomy. Think of it as the ripples emanating from a pebble thrown into a quiet pond of water.
Of course, it’s possible the bullet passed through the spinal cord before it came to rest in the C6 body. That’s doubtful here though, since there’s no apparent bony fracture and such a path would very likely have disrupted bone. More likely, this bullet entered the front or side of the neck and came to rest just in front of the spinal cord, within the C6 vertebral body. From a stability standpoint, such an injury is very stable (that is, it does not compromise the spine’s ability to hold the head up—the patient would not need to be externally braced). We would not operate to remove such a bullet today, unless CT showed a blood clot compressing the spinal cord. Even then, the primary goal would be to remove the blood clot; retrieving the bullet would be secondary. Of course, there might be a non-neurosurgical reason to operate, such as damage to the trachea, etc.
Occasionally, serial imaging will show the bullet’s position is not stable, that is, that the bullet is migrating around. In such a case, removal may become necessary. There is a famous case in the neurosurgical literature of a very heavy bullet migrating through brain tissue as seen on various images taken over time. Imagine the damage that could cause!
Was this patient paralyzed? No way to tell from the images and his or her clinical fate is lost to us.
What about Harvey Cushing, the enterprising young doctor who made the x-rays? As noted, he went on to become the father of modern brain surgery. Almost single handedly he reduced mortality in brain surgery from a wopping 70-90% to a much more tolerable though still astounding 10% (today it’s well, well below 1%).
Harvey Cushing operated on over 2,000 brain tumors. After he lost a patient in surgery as a medical student (he was responsible for anesthetizing the patient while the professor repaired a hernia during a lecture—when the patient died, the operation proceeded anyway!), he developed the anesthetic record, being the first to use serial recordings of heart rate and breathing. Blood pressure was added later after he discovered the BP cuff on a trip to Italy and brought it back to the United States with him (standard of care is to record all of these vitals and much more in modern day surgical anesthesia).
He made numerous advances in our understanding of the pituitary gland (Cushing’s disease, a dysfunction of the pituitary gland, is named after him).
Along with William Bovie, he developed electrocautery, which is used in 99% of operations today to minimize bleeding. Without it, modern surgery would not be possible. This cautery device is simply referred to as the “bovie” by operating surgeons today, as in holding out a hand and saying “bovie” and expecting the scrub tech to put the item in his or her palm.
Cushing was also an accomplished writer (though no fiction so far as I am aware). He won the 1926 Pulitzer Prize for his biography of Sir William Osler (considered by many the father of modern medicine, and one of the founders of Johns Hopkins Hospital). By the way, Cushing, who manned a military hospital in France during the last year of WWI and made many contributions to military medicine and surgery as well, was present when Osler’s son Revere died of his war wounds in France.
Cushing, a chain smoker, died of heart disease in 1939 at age 70. An autopsy showed he had a benign form of brain growth called a colloid cyst—which might well have been operated on using today’s standards but would have been considered inoperable by the standards of that time period. Indeed, it would have been difficult to diagnose it in life. That said, colloid cysts are often asymptomatic and by all accounts Cushing’s certainly was not an issue during his life.
For a tale of tense medical fiction set in the operating room, try my story THE CRUCIBLE, and enter the mind of a brain surgeon.
Edison McDaniels is a graduate of Stanford, a brain surgeon, and writes intense medical fiction and supernatural medical thrillers. Visit him on the web at SurgicalFiction.com, check out THE SURGICAL FICTION PODCAST on your favorite podcast app, or contact him with a question about writing medical fiction through the contact page.