Introduction and background
It has been estimated that the arrow has killed more individuals than any other weapon in history. However, many physicians and surgeons today regard this weapon as extinct as a cause of traumatic injuries [1]. Nonetheless, the historical significance of the bow and arrow has been cited by many as a turning point in medicine. The arrow was a deadly weapon in its most basic form; however, ancient civilizations developed multiple additions to enhance its effectiveness [2]. Barbs, metal fragments, and even crescent-shaped arrowheads have been recorded throughout history [2]. These variations proved difficult to manage, eventually leading to the development of certain tools specific to the extraction of arrows. Karger et al. argued that it was the advancements in developing tools and approaches for the extraction of arrows that served as a major stimulus for modern surgery [1].
In their report, Karger et al. cited the ancient Greek, Celsus, as the first to devote an entire chapter to arrow wounds and treatment of these wounds with surgical techniques [2]. These authors went on to note that, even at this early stage, Celsus understood the importance of pushing an arrow through emergence as opposed to pulling with traction. Celsus would eventually develop a surgical instrument, which he called the spoon of Diocles, to aid in this endeavor [2]. The story of Machaon, wounded by an arrow of Paris, was discussed at length in the Iliad by Homer [2]. Homer even goes on to describe the poor surgical approaches that were suffered by Machaon in attempts to remove these arrows [2]. Since then, many cultures have documented a great amount of knowledge about arrow wounds and their treatment.
At the turn of the 20th century, the occurrence of arrowhead injuries declined, and with it, so too did the literature concerning their management [2-3]. Recently, however, there has been a resurgence of documented cases concerning the difficulty in managing such traumatic injuries [3]. In 2010, a case report was published by Paramhans et al. describing a 35-year old male who presented with an impacted metallic arrowhead in his brainstem [3]. Their report concluded with an improvement of the patient’s neurological deficits after removal of the arrowhead. However, Paramhans et al. noted that one of the most difficult aspects of the penetrating injury was the removal of the arrow. The base of the arrow was located outside of the skull, disabling approaches via craniotomy. The tip was located near the brainstem, making extraction even more dangerous [3]. Paramhans et al. went on to note that while a fair amount of literature exists on trauma wounds involving guns and knives, there is very little research with respect to penetrating, non-gunshot projectile injuries [3]. In addition, a recent poll by Responsive Management for the Archery Trade Association conducted in 2014 revealed an increase in the participation in archery recreational events amongst United States (US) adults [4]. A more recent experiment conducted by forensic pathologists demonstrated how modern arrowheads can mimic both stab and gunshot wounds [5]. This experiment also noted that studies on arrow injuries were limited, and while they supplied a detailed report for classification of morphologic variations, they failed to mention management or treatment options for an arrow wound [5].
One of the last extensive works concerning the management of arrow wounds was an article published in the 19th century by JH Bill, who served as the Surgeon and Brevet Lieutenant-Colonel in the United States Army. His research concerning traumatic injuries inflicted by arrows is a comprehensive account, which has been included as a focus in this review.
