Nelson’s wound: treatment of spinal cord injury in 19th ......cervical injury, which is recounted in the Edwin Smith papyrus. Although the structural role of the spinal cord was

. . . A ball fired from her mizzen-top, which, in the then sit-uation of the two vessels, was not more than fifteen yards fromthat part of the deck where he was standing, struck theepaulette on his left shoulder, about a quarter after one, just inthe heat of the action. . . . Hardy, who was a few steps fromhim, turning round, saw three men raising him up. - “They havedone for me at last, Hardy” said he. - “I hope not,” cried Hardy.- “Yes!” he replied, “my back-bone is shot through.”

The cockpit was crowded with wounded and dying men,over whose bodies he was with some difficulty conveyed andlaid upon a palate in the midshipmen’s berth. It was soon per-ceived, upon examination, that the wound was mortal. . . .Hardy observed that he hoped Mr. Beatty could yet hold outsome prospect of life. “Oh, no!” he replied, “it is impossible.My back is shot through. Beatty will tell you so.”78

On October 21, 1805, 12 miles off Cape Trafalgar, ViceAdmiral Nelson “crossed the T” and won a resoundingvictory over Napoleon’s Combined Fleet. Three hoursinto the engagement, the Admiral was fatally shot by aFrench marksman who was aboard the Redoubtable. Inthe aftermath, it was readily acknowledged that neitherThomas Masterman Hardy, one of Nelson’s “Band ofBrothers” and Captain of the HMS Victory nor WilliamBeatty, the ship’s surgeon, could have saved him. Themusket ball had entered from above Nelson’s left shoulder

and crossed through the midline, probably injuring thelower cervical or upper thoracic cord, ribs, lung, and ma-jor vessels. Beatty knew that combatants with SCIs eitherdied quickly from associated injuries or slowly and cruel-ly from intervening infections.

The gradual improvement in the management ofwounds such as Nelson’s required longer than 100 yearsof active interplay between civil and military medicineand changes in clinical neuroscience and societal perspec-tives. In this report we will describe the development ofthe diagnosis and treatment of SCI from the naval en-counter off the coast of Spain to the Meuse-Argonne of-fensive on the Western Front.

DESCRIPTIONS AND DEBATES CONCERNINGSCIS

The association of paralysis with vertebral fractures ordislocations was recognized as early as 5000 BC, whenImhotep, the physician to Pharaoh Zoser III, described acervical injury, which is recounted in the Edwin Smithpapyrus. Although the structural role of the spinal cordwas not identified until Galen, rational but often spectac-ular treatment developed early. The diagnosis was not dif-ficult—varying degrees of weakness and incontinenceassociated with local pain and an area of deformity or lat-

Neurosurg Focus 16 (1):Article 4, 2004, Click here to return to Table of Contents

Nelson’s wound: treatment of spinal cord injury in 19th andearly 20th century military conflicts

WILLIAM C. HANIGAN, M.D., PH.D., AND CHRIS SLOFFER, M.D.

Department of Neurosurgery, University of Illinois College of Medicine, Peoria, Illinois

During the first half of the 19th century, warfare did not provide a background for a systematic analysis of spinalcord injury (SCI). Medical officers participating in the Peninsular and Crimean Wars emphasized the dismal progno-sis of this injury, although authors of sketchy civil reports persuaded a few surgeons to operate on closed fractures. TheAmerican Medical and Surgical History of the War of the Rebellion was the first text to provide summary of resultsin 642 cases of gunshot wounds of the spine. The low incidence of this injury (0.26%) and the high mortality rate (55%)discouraged the use of surgery in these cases. Improvements in diagnoses and the introduction of x-ray studies in thelatter half of the century enabled Sir G. H. Makins, during the Boer War, to recommend delayed intervention to removebone or bullet fragments in incomplete injuries. The civil experiences of Elsberg and Frazier in the early 20th centurypromoted a meticulous approach to treatments, whereas efficient transport of injured soldiers during World War Iincreased the numbers of survivors. Open large wounds or cerebrospinal fluid leakage, signs of cord compression inrecovering patients, delayed clinical deterioration, or intractable pain required surgical exploration. Wartime recom-mendations for urological and skin care prevented sepsis, and burgeoning pension systems provided specialized long-term rehabilitation. By the Armistice, the effective surgical treatment and postoperative care that had developedthrough decades of interaction between civil and military medicine helped reduce incidences of morbidity and dispelthe hopelessness surrounding the combatant with an SCI.

KEY WORDS • military • neurosurgery • spinal cord injury

Neurosurg. Focus / Volume 16 / January, 2004 1

Abbreviation used in this paper: SCI = spinal cord injury.

eral mobility of the bone on the back or neck. The prog-nosis in forward dislocations was hopeless. Posterior dis-placements could be treated with extension and pressure,principles of closed reduction that were followed for cen-turies (Fig. 1). Hippocrates’ method left nothing to the im-agination:

But the physicians, or some person who is strong, and notuninstructed, should apply the palm of one hand to the hump,and then, having laid the other hand upon the former, he shouldmake pressure, attending whether this force should be applieddirectly downward, or toward the head, or toward the hips. Thismethod of applying force is particularly safe; and it is also safefor a person to sit upon the hump while extension is made, andraising himself up, to let himself fall again upon the patient.And there is nothing to prevent a person from placing a foot onthe hump, and supporting his weight on it, and making gentlepressure. . . .42

Fracture management was similar for civil or battlecasualties. Albucasis, Oribasius, Celsus, Scultetus, andothers devised their own platforms or traction devices.Benjamin Bell stretched his patients over a wine cask.Fabricius Hildanus used pillows, or if that failed, an awlpassed through the spinous processes and connected usinga curved forceps. A rope tied to the forceps was used todistract the “luxation” and the hapless patient. The mostextreme measure was one of the most ancient. “Suc-cussion” required strapping the patient to a ladder upsidedown and letting gravity do the rest. Even Hippocratesstruggled with this technical feat:

Wherefore succussion on a ladder has never straightenedanybody, as far as I know, but it is principally practiced by

those physicians who seek to astonish the mob-for to such per-sons these things appear wonderful, for example, if they see aman suspended or thrown down, or the like; and they alwaysextol such practices, and never give themselves any concernwhatever may result from the experiment, whether bad or good.But the physicians who follow such practices, as far as I haveknown them, are all stupid . . . indeed, for my own part, I havebeen ashamed to treat all cases in this way, because such modesof procedure are generally practiced by charlatans.41

Given the extreme measures of closed reduction, physi-cians turned to surgical intervention. The indications var-ied from cosmetic repair of the gibbus to removal of bonefragments to relieve cord compression. Perhaps the firstproponent was Paulus Aegineta who, after warning thepatient of the danger, incised bone fragments in patientswith vertebral fractures. The French military surgeon,Ambrose Paré, recommended removal of free bone frag-ments; bone chips attached to the periosteum were left inplace. Other physicians inserted various concoctions intoopen wounds, leaving “the rest to God and the goodnessof nature.” Treatment continued “until the wound hashealed or the patient dead.”5 Surgeons quickly appreciatedtwo clinical facts: forced reduction in patients withoutSCIs was dangerous and therapy was futile for patientswith complete paralysis.60

The introduction of large armies, rudimentary medicalservices, and gunpowder separated the experiences ofcivil and military surgeons. Although combatants occa-sionally fractured their vertebrae, particularly those in thecavalry, the majority of battle casualties with SCIs sus-tained penetrating injuries. The distinction, however, wasan artificial one, as reports of injured soldiers or sailorsmingled with cases of fractures in civilians. In 1753, thesurgeon Géraud performed an operation in an Irish soldierfrom a Dilon regiment, who had been wounded by a mus-ket ball at the Battle of Fontenoi. Géraud tried five timesto remove the ball and bone fragments at the level of thethird lumbar vertebra. The wound became infected, butthe soldier may have regained function in his legs.26 Louis,the permanent secretary of the French Royal Academy ofSurgery described 14 cases of vertebral fractures and lux-ations during a lecture in April 1774, which was eventual-ly published in 1836.54 The seventh case was that of Cap-tain Villedon from the regiment of Vaubecourt, who wasshot while at the Bridge of Aménébourg sur l’Horn in No-vember 1762. Duplessis, the Surgeon-Major of the army,treated the thoracic wound at a hospital near Marbourg.Captain Villedon remained paralyzed, but the ball wasremoved. The soldier was then transported to Rosdorff,where Duplessis conferred with Louis. Exploring thewound with his fingers, Louis managed to remove sever-al large bone fragments. On the following day, the surg-eons explored the wound again and removed more frag-ments, justifying their intervention with a directcomparison with exploration of a cranial fracture. Thewound developed “suppuration abondante et louable;”however, the captain recovered and 12 years later walkedaround his estate at Ploitou with the help of a cane.Although this was not the first example of surgical inter-vention, it was the first report containing data from adefinitive long-term follow-up review. Louis’ paperincluded several examples of battle casualties and unsuc-cessful surgical attempts at decompression or reduction.

W. C. Hanigan and C. Sloffer

2 Neurosurg. Focus / Volume 16 / January, 2004

Fig. 1. Upper: Extension, mechanical traction, and pressureexhibited by Joannis Scultetum in 1656. Reprint from Armamen-tarium Chirurgicum, Ulm, Tabula XXV, II, p 56. Lower: Exten-sion and manual traction exhibited by Charles Elsberg in 1916.Reprinted from Elsberg CA: Diagnosis and Treatment of Surgi-cal Diseases of the Spinal Cord and its Membranes. Philadel-phia: WB Saunders, 1916, Fig. 111, p 217.

The analogy between surgery on the head and spinalcord was fundamental to the early treatment of SCI. Bythe end of the 18th century, Chopart and Desault recom-mended trepanation of the spine, even in cases in whichthere was no evidence of fracture or dislocation, in an ef-fort to relieve compression by blood or scar.60 Ten yearsafter Vice Admiral Nelson sustained his fatal wound, a re-port by George Hayward described a surgical procedureperformed by Mr. Cline, Jr., at St. Thomas’ Hospital.37 Mr.Cline performed surgery 1 day after injury in a patient ren-dered paraplegic after a fall from a balcony. Cutting intothe spinous processes of the thoracic region, Cline re-moved bone fragments with a rongeur and sawed off thetransverse processes to reduce the dislocation. The patientfailed to improve and died 5 days later, but Hayward be-lieved that the spine could “bear very considerable vio-lence without any dangerous consequences.” He addedthat, in the next patient, Cline would use the chisel witheven less caution in an effort to reduce the dislocation.Cline never performed another laminectomy. Similar tothe contemporary treatment of head injuries, these mixedmessages resulted in two radical views concerning surgi-cal intervention. Some surgeons, such as Sir AstleyCooper, lectured that it would be “unmanly” to refuse toperform an operation, although in his one effort, Cooperterminated the procedure prematurely. Others, such asCharles Bell and Benjamin Brodie, condemned aggressivesurgeries and referred to inaccurate diagnoses, carelesstechniques, and incomplete follow ups usually based onhearsay.

Alban Smith’s widely disseminated report in 1829 wasa good example. A Shaker farmer had fallen and fracturedhis lower cervical spine. The despair of the patient ledSmith to operate several months after the injury by usinga Hey’s saw-and-tooth forceps to remove the lamina, pedi-cles, and transverse processes of the upper thoracic verte-brae. After an attempt to reduce the dislocation, Smithsutured the remaining fragments together. Somehow thepatient survived and Smith, who believed in the beneficialinfluence of the spinal cord on skin viability, reported:

I saw him in a week afterwards. The ulcers in his glutealmuscles, which were produced by lying on his back, werehealed up; and he had some additional sensation in his hands.Since then I have not seen him; but I entertain considerablehopes.77

Medical officers either advocated conservative treat-ment or failed to address the problem. Surgeons in thePeninsular War did not mention SCI57 nor did Gross32 inhis manual published in 1862, Williamson87 during themutiny in India, or Hennen39 or Guthrie33 in their text-books. Sir George Ballingall7 wrote that Mr. Blair, a for-mer surgeon in the Royal Navy, had trephined the spine ofa lower deck man, but Ballingall condemned the proce-dure as did the French Medical Service.14 Lidell52 reported10 cases of gunshot wounds of the vertebrae without SCIsduring the Crimean War. Four of the patients survived,whereas all 22 military personnel with SCIs died. Theofficial medical history of the British Army during theCrimean War noted that infection of the “spinal marrow”resulted in death, even in casualties with fractures thatonly involve the spinous or transverse processes.30 Theexperiences of several medical departments corroborated

reports in the civil practice of cord “concussion.” In anoth-er comparison to the brain, the spinal cord could be con-cussed without evidence of external trauma or surgicalconfirmation of a fracture or SCI. The paralysis, like un-consciousness, either improved or remained unchanged.52

By the middle of the 19th century, infrequent and turgidcase reports offered a pale glimmer of success in a formi-dable surgical arena, but resulted in contentious debates.For the most part, treatment was limited to the ancientmethods of closed reduction and bedrest, or the occasion-al exploration and removal of a musket ball or bone frag-ments. Civil and military surgeons had little time to dealwith an infrequent problem that promised few clinical re-wards. A physiologist and another war would alter thispoint of view.

Defining the Problem

Charles Edward Brown-Séquard was 41 years old whenhe summarized his research into the function of the cen-tral nervous system in a series of lectures delivered to theRoyal College of Surgeons in 1858. The talks, publishedin book form 2 years later, were successful and strength-ened an already considerable reputation that originatedfrom his earlier description of the sensory decussation inthe spinal cord. The book included 12 lectures in whichBrown-Séquard lucidly described cerebellar, brainstem,and spinal cord functions with animal experiments andclinical examples. At the end he addressed surgical inter-vention for fractures and SCI. First he showed that open-ing the spinal canal and exposing the meninges or cord tothe air was in and of itself not dangerous, as he had donethis many times during his animal research. Second, heclaimed that death following spine fractures was due topressure or “excitation” of the cord and was not due todirect injury. Here he stepped on unfamiliar ground as hespeculated that skin sloughs or urinary infections were aresult of this irritation, rather than local ischemia or blad-der dysfunction. Most fractures contained bone splintersthat irritated the cord and, hence, removal of the bonecould improve the skin condition and bladder function.Third, reports of trepanation on the cord proved the use-fulness of surgery. Brown-Séquard admitted that manydescriptions, including that of Smith, were incomplete butat least some patients survived and showed improvement.He went on to observe that many experimental animalsimproved after section of the cord, suggesting a “reunion”and, finally, bone regenerated after removal, arguingagainst the potential hazards of spinal instability. Theselectures presented a skilled blend of neurophysiology andclinical observation. Brown-Séquard was well known inthe US, England, and France because he had various aca-demic appointments in all three countries. His strong ad-vocacy for surgical intervention was difficult to refute atany level.9

By the time of the publication of Brown-Séquard’sbook, America was involved in a war complicated by fire-arms, projectiles, and tactics that produced casualties bythe thousands. The authors of the massive official Ameri-can medical history obtained data from 20 military opera-tions ranging from the Revolution in Paris in 1830 to theRusso–Turkish War ending in 1877. Excluding the CivilWar, there were a total of 216,000 shot wounds (the Civil

Neurosurg. Focus / Volume 16 / January, 2004

Treatment of spinal cord injury in 19th and early 20th century

3

War resulted in almost 246,000 shot wounds on the Unionside alone).73 The introduction of the rifle Minié projectileincreased the range and accuracy: round, grape, cannister,or shrapnel shot achieved projectile velocities greater than1500 feet per second with ranges up to 5 miles.72 Thetactics of advancing troops over open ground in front offortified defensive positions led to huge numbers of casu-alties. Later in the war, entrenchment resulted in the pro-tection of the soldiers’ backs, but increased the number ofinjuries to the head and neck. Improvements in evacuationmeant that at least some casualties with SCIs were trans-ferred to larger general hospitals in the cities, and accuraterecords outlined specific wounds, clinical courses, andoutcomes. Autopsies provided the ultimate answers.

American medical officers described their own exten-sive experiences before compiling the official history. In1864, the surgeon John Lidell, who was in charge of theStanton General Hospital in Washington, DC, publishedan article in which he described a series of casualties withSCIs. He divided patients with closed fractures into thosewith immediate cord compression by bone and those witha gradual onset of symptoms that were due to compressionby blood from damage to the “meningo-rachidian” arter-ies. Dislocation without fracture was infrequent and usu-ally occurred in the cervical region with complete disrup-tion of ligaments and muscles. Gunshot wounds causedsimple fractures or fractures with direct damage to thecord and leakage of CSF. Digital exploration of thesewound was mandatory: “for in them the highest interest ofthe patient and the reputation of the surgeon are deeplyinvolved in the prognosis which he may give.”52 Lidell didnot favor reduction of fractures, however, and recom-mended trepanation only in unusual circumstances. Hisprescient advice for the transportation and medical care inpatients with SCIs is quoted at length:

Care should be taken at every step that the injury of thespinal cord be not increased by the employment of any unnec-essary violence in handling or moving the patient. After thereceipt of the injury, the coat, waistcoat, and shirt should not beremoved by pulling them off over his head, as generally prac-tised; for, by taking them off in this way, there is a great risk ofincreasing the displacement of the fragments, thereby increas-ing the lesion of the cord; but the clothing should be carefullycut off from him with a scissors or a sharp knife. In all case, ofparaplegia produced by violence, the safest way will be to con-duct the treatment on the hypothesis that the spine is fractured,until a contrary diagnosis is clearly established. For the purposeof removing the patient to his home or to the hospital, heshould be carefully placed in a recumbent position upon a litter,or a door removed from its hinges. If the fracture be located inthe cervical or superior dorsal region, his head should at thesame time be carefully steadied by pillows or cushions placedon each side of it. At the hospital, he should be placed upon awater-bed, or, in its absence, upon a soft mattress, for treat-ment, with a view to lessen the tendency to the formation ofbed-sores over the sacrum and the hips, a very strong tendencyto which will be present on account of the diminished vitalityof the paralyzed tissues. Bed-sores in such patients do not heal,and generally expedite the fatal result considerably. Specialattention should always be paid to the bladder. From paralysisof that organ, the patient cannot pass any urine of his own voli-tion. The catheter should therefore be regularly introduced atsuitable intervals twice a day, and the urine drawn off. . . .Particular attention should be paid to cleanliness. The surgeonshould every day see for himself that the genital organs, the

nates, the hips, and the sacral region are perfectly clean anddry, and that there are no dark-red spots indicative of the begin-ning of bed-sores. . . . 52

John Ashhurst, who was a surgeon at the Cuyler Gen-eral Hospital, approached the problem in a different man-ner. In 1867, he published what can only be described asan outcome analysis of cases culled from the previous lit-erature. Beginning with Hildanus in 1646, Ashhurst in-cluded only those reports that contained accurate descrip-tions of injuries, treatments, and outcomes. In this fashion,he analyzed 394 cases of SCI from a variety of causes,although only 16 were due to gunshot wounds.4 In 208cases the injuries involved the cervical region, in 106cases they involved the thoracic spine, and in 37 casesthey involved the lumbar region; the remaining cases in-volved mixed injuries. The incidence of mortality washighest in the cervical region (77%), followed by the tho-racic region (63%), and, finally, the lumbar spine (59%).Lumbar injuries displayed the greatest tendency to im-prove. Ashhurst took particular care to write that 15% ofpatients with SCIs lived for longer than a month, but lessthan 1 year, whereas 4% of all of these patients lived lon-ger than a year. He found that extension (with rotation orpressure) resulted in recovery in 30 of 44 cases, whereasgeneral treatment (bedrest) resulted in only 13 recoveriesin 117 patients. Resection failed to produce any recoveriesin 24 patients, leaving a mortality rate of 75%, and thuscould not be recommended.6

Although valuable, these reports were overshadowedby the publication of the first volume of The Medical andSurgical History of the War of the Rebellion in 1870. TheAmerican Army Medical Department used their newly or-ganized Army Medical Museum and the Surgeon Gener-al’s Library to supplement this monumental work of sixvolumes, each of which comprised more than 700 pagesand was edited entirely by medical officers. Daily regi-mental and hospital reports, which had been mandated by1863, along with surgical reports and detailed illustrationsproduced an accuracy that was applauded immediately inthe US and Europe.27,67

The history offered reports on 642 shot wounds of thespine; these represented 0.26% of all shot wounds and amortality rate of 55% (Fig. 2). The chapter edited by As-sistant Surgeon George Otis, who was the director of Sur-gical Records and worked in the Army Medical Museum,contained detailed descriptions of 133 cases, identifyingthe surgeon who contributed to each report. Otis includedan additional 62 operations on the spine.68 There was anoperative mortality rate of 43%; in 27 procedures per-formed to remove the ball, nine patients died and four re-turned to duty, whereas in 24 operations performed toremove bone, 10 patients died and seven returned to duty.All four patients who underwent arterial ligation in thecervical region died as a result of the surgery. The mortal-ity rate dropped from 70% in cervical injuries to 46% inlumbar injuries; wounds through the chest and abdomenwere fatal.71 The Surgeon General’s Library enabled theeditors to include several long bibliographies on SCI andthe Museum provided specimens on which to base en-gravings throughout the text (Fig. 3). Although the Con-federacy was not allowed to have its own medical history,Otis readily acknowledged the contributions of his rebel



colleagues, particularly with regard to spinal concussion. Some of the clinical reports and their young surgeon-

reporters were surprising. Many survivors with SCIswere transferred to Turner’s Lane Hospital in Philadelphiaand were treated there by Assistant Surgeon William W.Keen. He described the case of Private Charles Cleland,

from the 7th Wisconsin Volunteers, who was shot in themouth through to the third cervical vertebra. The trooperwas paralyzed in all four extremities, but the ball wasremoved with a Nelaton probe 1 week later and the patientimproved enough to stay on as a hospital attendant. Whileat Turner’s Lane, Private Cleland kept spitting up bonefragments:

. . . nearly the entire body of the third cervical vertebrae hascome away including the anterior half of the transverse processand the vertebral foramen. No injury to the vertebral artery hasbeen disclosed. What supports his head, anteriorly, I can’t con-ceive.69

Assistant Surgeon John Shaw Billings performed sur-gery in a Confederate prisoner, Corporal W. A. Freeman,of Company B, of the 13th North Carolina regiment, at theCliffburn Hospital in Washington. The wound, which waslocated in the upper dorsal region, was infected; Shaw ex-plored the wound with his fingers and then made a trans-verse incision to remove pus and large bone fragments.The wound was left open and packed with lint that hadbeen soaked in laudanum. Corporal Freeman did well andwas eventually transferred to the Old Capital Prison.70

Both assistant surgeons moved on to successful careers,each in his own fashion.

Several obstacles had been overcome by the end of theAmerican Civil War. Experience with SCIs expanded andimproved; operative intervention was no longer a rarity.The expertise of military surgeons now superseded theircivil colleagues, as army records testified to their accuratenotes and follow-up reviews. Older reports had been sum-marized and a new more reliable literature outlined in-juries and treatments. On the other hand, although it wastrue that both acute and chronic care improved, surgicalintervention was still haphazard. Despite the influenceof Brown-Séquard and dependable clinical observations,such as the negative prognostic signs of hypothermia and



5

Fig. 2. Table indicating Percentage of Fatality and Relative Frequency of Shot Wounds recorded during the War ofthe Rebellion. From Otis GA, Huntington DL: The Medical and Surgical History of the War of the Rebellion Sur-gical History, Part III, Volume II. Washington, DC: GPO, 1883, Table CXIX, p 691.

Fig. 3. “Lumbar vertebrae, with a cast-iron shot lodged in thecanal.” From Otis GA, Huntington DL: The Medical and Sur-gical History of the War of the Rebellion Surgical History, PartI, Volume II. Washington, DC: GPO, 1870, Fig. 195, p 443.

priapism, most neurological examinations were primitiveand incomplete. Nevertheless, it was obvious that for na-tional armies in very large conflicts, casualties with SCIscould no longer be ignored, left in bed, and allowed to die.

NEUROSCIENCE, ACCIDENTS, AND WEAPONS

Innovations in basic and clinical neuroscience duringthe next half century resulted in significant changes inthe treatment of patients with SCIs. Anatomists and neu-rophysiologists outlined nerve tracts and reflex arcs,demonstrating that the spinal cord showed distinctive re-flex activity following disease and injury. The emergenceof neurology as a specialty, although not regulated, pro-vided a cadre of well-trained observers. New instruments,such as the esthesiometer, and techniques, such as lumbarpuncture, added measurable data to the clinical examina-tion as well as to the cache of scientific apparatuses andtechniques by the bedside. Faradic or galvanic electricalstimulation determined the reaction of degeneration indamaged muscles and restored “trophic” influences on theskin that had been interrupted by SCI. By 1901, the inner-vation and various patterns of denervation had beendescribed for the bladder and rectum.23,28

Discoveries by Lord Lister, von Bergman, G. W. Crile,and many other civil surgeons broadened the range ofexpertise in the operating amphitheater. In an article pub-lished in 1884, William Thorburn,81 a surgeon in Man-chester, England, described the clinical picture of SCIs atvarious levels (Fig. 4). His recommendations for aggres-sive surgery in patients with compound fractures or com-pressive lesions stemmed from a large experience of 9000patients with accidental injuries who were admitted everyyear to the Manchester Royal Infirmary. Thorburn pre-ferred the new term, “laminectomy” rather than the olderphrase, “trephining the spine” with its remote analogy tocranial surgery.16,81 In 1905, at the University of Pennsyl-vania Harte36 analyzed the cases of 95 patients who under-went operations for spinal tumors. Most of the neoplasmswere “sarcomas,” although there were a variety of other

lesions such as Echinococcus species, cysts, adhesions, or“fibromas.” The mortality rate was a foreboding 47%, butHarte allowed some leeway concerning this statistic be-cause almost half the patients died weeks or months aftersurgery. By this time, osteoplastic laminectomies, whichhad been pioneered by Dawbarn and Urban in the late1880s, lost favor.60 Harte recommended a simple midlineincision and bilateral laminectomy, with careful preopera-tive localization so as not “to search for the growth toolow down in the spinal canal.”36 Harte used whatever in-struments were handy, including chisels and saws. Heclosed the dura mater “loosely” and drained all thewounds.

A decade after Harte’s paper, Charles A. Elsberg andCharles H. Frazier published their influential textbooks onspinal surgery. These surgeons devoted a great deal ofspace to SCIs. They recommended closed reduction forfractures, but if this failed, an open reduction was consid-ered. Penetrating wounds of the spine with retained frag-ments of bullets or knives were explored, particularly ifCSF continued to leak from the wound. Frazier notedfrom the literature that deaths more frequently occurred inpatients who did not undergo surgery, whereas the inci-dence of surgical intervention was almost three timeshigher in the 38% of survivors who showed improvement.In his own cases that were managed prior to 1911, the rateof operative mortality was 20%; this figure dropped to lessthan 7% between 1911 and 1915.

Both surgeons used meticulous techniques and discard-ed chisels, saws, and osteoplastic laminectomies. Elsbergused a straight midline incision and Frazier made a semi-lunar incision and reflected a flap over the spinous pro-cesses. The dura mater was opened gently after a laminec-tomy and the cord was split in the midline to remove clotswhen appropriate. Following exploration, the dura wasclosed and the wound drained. The authors downplayedthe innovation of spinal cord suture or myelorrhaphy. Fra-zier reported a summary of seven cases since Estes in1889 and attributed the poorly documented recovery rateto a failure to recognize uninjured portions of the cord orsegmental recovery of nerve roots above the lesion. “Theburden of proof” he wrote,

is so overwhelmingly on the operator that any such state-ments may be well set aside unless there be a detailed descrip-tion of his technique and findings in the examination. . . ..25

The plight of the patient with an SCI or a putativeSCI influenced public opinion during this period. In 1866,John E. Erichsen, a prominent London surgeon laterknighted, examined the disabilities of workers and pas-sengers involved in railway accidents and developed theconcept of “railway spine.”11,48,73 These patients demon-strated symptoms following their injuries that were simi-lar to the spinal cord “concussion” described during theCivil War. The importance of this condition did not lie inthe clinical phenomena—both Thorburn and Frazier con-demned the lack of clinical signs and Erichsen’s specula-tion of a “molecular disturbance” in the spinal cord—butinstead in the fact that the occurrence of symptoms wasassociated with litigation following the introduction ofworker’s compensation laws. Whatever the motives andlegal outcomes (courts generally ruled in favor of thedefendants), the accidents galvanized public support for



Fig. 4. “Figure of the upper extremities of a patient with a com-plete transverse lesion of the cord at the level of the sixth cervicalsegment.” Picture adapted from Frazier CH, Allen AR: Surgery ofthe Spine and Spinal Cord. New York: Appleton, 1918, Fig. 193,p 410.

medical care. Labor organizations lobbied, sometimesviolently, for government regulations and subsidies. By1914, legislation was introduced for most European coun-tries and the US as accident victims became a public con-cern, rather than an individual tragedy.15

Military medicine had its own problems and surgicalinnovation was not one of them. Huge numbers of non-battle casualties during the Spanish–American and BoerWars highlighted gross deficiencies in medical authorityand sanitary regulation. The wars of the late 19th and early20th centuries offered partial solutions to these concerns.The Franco–Prussian War demonstrated the effectivenessof an inclusive coordinated General Staff and the Rus-so–Japanese War reinforced the value of strict and prag-matic hygiene to dozens of military medical observers.Meanwhile, regular and reserve armies grew at exponen-tial rates while the ascendancy of machine guns and ar-tillery eluded military planners.40

The medical services managed to collect their statisticsand officers published their memoirs. Surgeon-GeneralLongmore, in a comprehensive text published in 1877,counted 2586 spinal injuries among various armies fromconflicts ranging from the Crimean War to the BritishConflict in the Sudan in 1871. The average mortality ratewas 32%, but ranged from 10 to 75%.53 Longmore waspessimistic about SCIs, but devoted little space to theirtreatment. Thomas Evans, in his experience with the Am-erican Ambulance corps during the siege of Paris fromSeptember 1870 to February 1871, recorded 247 admis-sions with a mortality rate of only 19%. There were fivesoldiers with spine injuries, four of whom died.21 TheBritish experienced a 58% mortality rate among patientswith SCIs during the Boer War. The War Office had hirednine civil consultants to inspect hospital facilities andinstitute standardized surgical care. One of these consul-tants, George H. Makins, who was later knighted, was asurgeon at St. Thomas’ Hospital in London and eventual-ly became president of the Royal College of Surgeons. Inhis memoir, Makins wrote of SCIs that “these cases formone of the most painful and distressing features of thesurgery of the campaign.”59,80 Fractures from falls or fromhard-mantle small-caliber bullets were infrequent. Func-tional paralysis or “concussion” was not uncommon. Ma-kins recommended surgery if one of the following threeconditions was present: 1) if the patient was suffering se-vere pain in the region above the wounded segment; 2) ifthe patient showed some improvement following evidenceof compression by bone fragments; or 3) if the patientshowed improvement followed by evidence of compres-sion by bullets or fragments in the spinal canal. Surgicaltreatment was delayed until the patient reached a gener-al hospital, which sometimes was hundreds of milesaway.13,64 None of the medical observers during the Rus-so–Japanese War (1904–1905) mentioned the treatment ofSCI. Statistics on specific injuries were hard to come byand most observers were more concerned with the com-batants’ integration of voluntary aid and sanitary proce-dures.31,56,79 The Balkan Wars (1912–1913) gave some hintof what was to come. Frazier reported a mortality rate of94%. Surgeons remarked on the frequency of wounds pro-duced by shells and the high incidence of infections.Casualties with SCIs were transported immediately to pre-

vent the onset of decubiti or bladder infection due to thelack of nursing care at hospitals near the front.51

Statistics showed the medical services that the mortali-ty rate for SCIs had increased during this period. Pre-ventative medicine was a priority, but the authorities couldnot ignore the widening gulf between the expertise of civiland military surgeons. To some extent the introduction ofconsultants and contract surgeons narrowed the gap andallowed for greater wartime flexibility and improvementsin care, but these were temporary fixes. The establishmentof army medical schools, increases in pay and rank,and specialists’ appointments partially relieved a dismalrecruitment; the development of a reserve componenthelped as well.

Both consultants and regular army officers knew thatmilitary medicine faced additional constraints such aseffective evacuation during battle. Consequently, medicaldepartments modified their tactics to adjust to the changesin war that occurred during the early 20th century. Zonesof collection, distribution, and evacuation containedspecific personnel, transport, and hospital facilities toensure that wounded personnel would pass through theline rapidly and reach appropriate care. Efficient transportmeant that increased numbers of severely wounded pa-tients reached hospitals before dying on the battlefield.This, in turn, indicated that the mortality rate for soldiersadmitted to the hospital would rise unless medical equip-ment and personnel improved and increased.

One innovation occurred quickly. Five months afterWilliam Roentgen’s submission to the Würzburg PhysicalMedical Society in December 1895, Lt. Col. Alvaro atthe Italian Military Hospital in Naples obtained x-rayfilms in two soldiers wounded at the Battle of Adowa.One year later, skiagrams were used during the Gre-co–Turkish War on a routine basis, or at least as routinelyas possible given the confusing collection of interruptors,commutators, coils, and fragile Crookes tubes. Tenaciousmedical officers (or quartermasters) lugged portable unitsthrough the Kyber Pass, Sudan, and Cuba. Lt. BruceSmith, who would later become chief radiographer for theRoyal Army Medical Corps, jerry-rigged an x-ray unitduring the siege of Ladysmith in 1899. Although it wasnot easy, he managed to develop 200 x-ray films. Within10 years, the use of x-ray studies became mandatory fortrauma care.1,8,10,74

There remained a fundamental clinical issue specific tothe patient with an SCI. Civil and military surgeons stillagreed that surgery was useless in patients with completeinjuries. The question was whether surgery was effectivefor patients with incomplete lesions and, if so, how to de-termine if an injury was incomplete. For punctilious neu-rologists, the appearance of any reflex, particularly theBabinski phenomena, indicated a partial lesion. Improve-ment in sensation no matter how vague or poorly lo-calized, or bladder evacuation associated with any volun-tary effort were positive signs.24 As a result, there was apotentially large population of patients with incompleteSCIs in whom surgical intervention was necessary if thespinal cord had been compromised by a bone or bullet.Another conflict would test this clinical assertion as wellas the value of civil expertise, public awareness, and mil-itary medical preparations.



7

SURGERY AND DISABILITY DURING THEGREAT WAR

There was no shortage of human material during WorldWar I. Wartime medical advertisements were constantreminders of casualties and disabling wounds (Fig. 5).Statistics were often incomplete, but American data wereaccurate for that country’s brief 4 months of active oper-ations. There were 147,651 hospital admissions for mis-sile injures. A total of 12,192 patients died, providing amortality rate of 8.2%. Five hundred ninety-eight (0.4%)of these patients sustained wounds to the spine, and 334(55.9%) of them died. Three hundred thirty-one patientsdied of “unspecified” injuries, whereas 267 died of in-juries caused by shells or shrapnel.55 The Ministry of Pen-sions in the UK published data on long-term care. In April1919, there were 3531 military patients with “paraplegia;”this was 0.3% of the disabled military personnel who re-quired either inpatient or outpatient treatment. By 1923,2481 (70%) of these patients died or were discharged frommilitary care.63 (In 1919, the totally disabled British sol-dier received £8 or the equivalent of $32/month in pen-sion. The American soldier received $30/month, whichrose to $95/month for soldiers with more than four depen-dents. This pension converts to approximately $1,200 to$3,800 a month in 2003 dollars.35)

The numbers, bad as they were, softened the reality.Spinal cord injuries were frequent occurrences in late1914 and in 1918, during the periods of mobile war. Thehigher incidence in 1914 was attributed to enfilade fireinto the flanks of advancing troops. Casualties in 1918were caused presumably by a lack of cover, the use ofrifles by German stormtroopers, and inaccurate indirectartillery fire. During the middle years of the war, trenchstalemate and the development of sophisticated surgicalcare near the front line complicated the analyses of SCIs.Surgical perspectives differed between personnel at fieldhospitals and base hospitals along the Atlantic andChannel coasts, and the constant shifting of patients andstaff hindered adequate follow-up review in these patients.

Many clinical observations occurred in the face of dra-matic obstacles. Two regimental medical officers triedtheir best:

Case B.-Pte.-was completely cut across at the level of thesecond or third dorsal vertebra by a large piece of high explo-sive shell shaped like a knife-blade (longer than the blade of anordinary bread knife and much heavier). . . . Examination of thetrunk showed the knee-jerks to be present and distinctly brisk.

Pinching the inner side of the thigh caused the correspondingleg to be drawn up, and both urine and fæces were voided . . .we regret that circumstances did not permit of investigation ofthe plantar response and ankle clonus.44

(The reader may forgive the officers for their failure tocomplete the neurological examination.) It was not sur-prising that the fog of war produced marked differences insurgical attitudes; consensus was difficult to achieve.

Early in the war, survivors with SCIs were transportedto hospitals in the UK and prompted a flurry of clinicalstudies. At Queen Square F. M. R. Walshe reported sever-al unusual findings. The presence of reflexes, includingthe Babinski phenomenon, were not associated with re-covery, but part of a “paraplegia in flexion” that origi-nated in the cord and was not dependent on efferent path-ways from the cortex.83 Later, Henry Head (who was laterknighted) and George Riddoch at the Empire Hospitaldemonstrated that intermittent bladder function was due tothe increased reflex activity seen in some patients withcord transection.38 Thorburn summarized these findings inhis chapter on SCI for the official British medical history:

These observations show clearly then that the return ofreflexes below the lesion is no evidence of returning function,and they incidentally remove the false premise upon which anestimate of recovery has often been based. . . . One is thus inthe majority of cases faced by the impossibility of determininghow far recovery is possible, and time alone will answer thisquestion.82

Gordon Holmes, the most scientifically prolific neurol-ogist during the war, rarely agreed with Riddoch22,75 andrelied on the Babinski reflex as early evidence of a partiallesion. Following his work with Percy Sargent, a surgeonat Boulogne, Holmes delivered the Goulstonian lecturesto the Royal College of Physicians of London in 1915.43

Using handwritten notes made on more than 300 patientswith SCIs, Holmes described clinical signs of injury to thesympathetic chain, hypothermia, and the unusual occur-rence of posttraumatic herpes in the upper margin ofthe sensory loss. He also described an incomplete lesionof the cervical region that presented with paralysis of thearms but spared the legs. He attributed this to cervical“softening,” with damage to the gray matter of the cord.Most importantly, he outlined a series of neuropathologi-cal changes that developed after the injury and demon-strated axonal swelling several segments away from theprimary lesion (Fig. 6 upper). These distant lesions withsmall areas of necrosis and hemorrhage resulted in necrot-ic cavities in the central cord that were filled with cellulardebris and degenerating axons (Fig. 6 lower).

Holmes made two points about these cases. The firstwas that spinal “concussion” was not always functionaland that tissue changes occurred in causalties withoutexternal evidence of trauma such as troops buried by shellexplosions. The diagnosis had to be confirmed by clinicalevidence of cord damage. Second, the distant lesions ac-counted for clinical deterioration several days or weeksafter injury. His data also indicated, although Holmes didnot agree, that the neurological examination was not areliable indicator of the extent of the injury. This meantthat military surgeons had to rely on their own expertiseand, during the war, their judgments varied a great deal.Marburg and Ramzi at the von Eiselsberg Clinic in Vienna



Fig. 5. Advertisement reprinted from the British Medical Jour-nal, December 23, 1915, p 27.

waited at least 4 or 5 weeks before laminectomy, whereasGuillain and Barré in the French Fifth Army advocatedimmediate surgery on all SCIs.65 Donald Armour, an offi-cer with the Canadian Army Medical Corps, wrote: “It isunfair to the patient and unfair to surgery to wait on andon till hope gives place to despair and then call in a sur-geon as a last resource to perform the impossible.”3

These opinions were generated from personal experi-ences at base hospitals. By 1917, the casualty clearing sta-tion had developed into a well-staffed and equipped,1000-bed trauma hospital located 5 to 7 miles from thestationary trench line. During a rush, casualties arrived inthe hundreds, between approximately 8 and 12 hours afterinjury. One of the most experienced medical officers inFrance was Colonel (Temporary) Henry Gray, anotherprominent London surgeon and consultant to the BritishThird Army. In July he summarized his pragmatic recom-mendations for field surgery in patients with SCIs. Hebelieved that if a casualty had an obviously incompletelesion with positive findings on x-ray films, then surgeryshould be performed before the patient was transported toanother facility. Other indications for immediate surgeryincluded severe radicular pain, increasing deficit afterinjury, or large, open wounds that could turn septic. Allother patients were sent back to the base by hospital train.Gray disliked set operations, preferring to open the woundif it was near the midline or creating a counter incision ifthe wound lay to one side. The surgeon could debride thebone or bullet without a complete laminectomy. Local

anesthesia with adrenaline supplemented by ether gavegood results. Drains were common and the dura matershould be closed if possible.29 By the Armistice, many sur-geons agreed with Gray, including American medical offi-cers, although their experiences in field surgery were notas comprehensive. (Harvey Cushing, the NeurosurgicalConsultant to the American Expeditionary Forces, fo-cused his effort on head injuries and had very little to writeabout SCIs.)34,45

Several changes went along well. To avoid false local-ization, x-ray films had to be obtained in two planes atright angles to the spine. The neurologists Pierre Marieand Gustav Roussy refuted the older principle that theabsence of a “trophic” influence of the spinal cord result-ed in cystitis, bedsores, and decubiti. They wrote that pro-longed compression and ischemia, skin abrasion, and con-stant urinary or rectal incontinence produced thesepotentially lethal complications, and recommended sim-ple measures similar to those described by Lidell duringthe American Civil War.2,66 Urologists such as Frank Kiddat the London Hospital developed aseptic techniques forintermittent or continuous bladder drainage. Mechani-cal bladder compression was used occasionally, whereasmany surgeons at casualty clearing stations advocated su-prapubic cystotomies. Kidd believed that it was importantto begin drainage soon after injury to avoid stretching ofthe muscle fibers and potential loss of reflex activity,which could be used later to empty the bladder.49

One discarded technique resurfaced and caused contro-versy. In late 1917, Colonel A. W. Mayo-Robson visited aCanadian hospital at Clivedon in his duties as consultantto the Southern Command in the UK. He learned that themedical officers had performed surgery in a paraplegicsoldier a few weeks after injury. They had removed a bul-let from a partially divided cord and had transplanted thespinal cord of a rabbit into the separated ends. Mayo-Robson approved of this procedure, as he had performeda similar procedure before and planned to use the tech-nique in another patient. He wrote in the British MedicalJournal that the procedure worked; the paraplegia was“passing off” and the result, “promises to be a brilliantsuccess.”62 Percy Sargent, the urbane and successful sur-gical partner of Gordon Holmes, took less than 1 week tocastigate Mayo-Robson in a letter to the editor. ColonelSargent reminded Colonel Mayo-Robson that his originaltransplantations were performed on peripheral nerves; theCanadian soldier had a partial injury and it was too earlyto tell if the injury was complete. Sargent summarized hisopinion as follows:

At the present time there exists neither experimental norclinical evidence that an operation of grafting upon the spinalcord does offer even the remotest possibility of success, and itseems cruel to hold out to these unfortunate patients any hopewhatever that, by submitting to a severe operation, by no meansintrinsically devoid of danger, their condition may be benefit-ted.76

One week later, the by now angry Colonel Mayo-Rob-son responded only by reiterating Sargent’s criticisms andlimiting the operation to “incurable” cases-without defin-ing the adjective.61

After the war, the survivors required additional surgicalattention. By 1919, Elsberg and others20,84 outlined opera-



9

Fig. 6. Upper: “A cross section of swollen axis cylindersin one lateral column two and a half segments above the level ofthe maximal damage produced by concussion.” Reprinted fromHolmes G: The Goulstonian lectures on spinal injuries of war.BMJ November 27, 1915, Fig. C, p 770. Lower: “A cavity inthe left dorsal column three segments above a direct injury to thecord. It contains only necrotic detritus.” Reprinted from Holmes G:The Goulstonian lectures on spinal injuries of war. BMJ Novem-ber 27, 1915, Fig. L, p 771.

tive indications for chronic traumatic lesions. Divisionof the posterior nerve roots was effective for intracta-ble spasticity or radicular pain. Late deterioration of func-tion could be prevented by exploration and lysis of adhe-sions, removal of new bone formation, or aspiration of oldintraspinal blood clots or intermedullary cysts. Elsbergalso entertained the possibility of nerve suture of thecauda equina and autotransplantation for bladder dysfunc-tion.50 Although these indications were not new, the patho-logical findings made by Holmes and later by Thorburn82

added impetus to the expansion of surgical therapy. Three years after the Armistice, Sir Robert Jones pub-

lished his textbook, Orthopaedic Surgery of Injuries.47

Jones, who had apprenticed under his uncle, Hugh OwenThomas, and practiced with Thorburn at the ManchesterRoyal Infirmary, was a leader in the effort to separate or-thopedic surgeons from their 19th century reputation ofbone setters and manipulators. In 1916, the British gov-ernment established the Ministry of Pensions to deal withthe massive number of casualties and the growing recog-nition of entitlements for conscripted soldiers. Jones sawhis opportunity and developed the concept of a compre-hensive military orthopedic hospital with physical “re-construction” and “creative workshops” to rehabilitate thethousands of casualties with fractures and amputations.These large specialized hospitals contained separate facil-ities for surgery, electrical therapy, baths, exercise rooms,and training programs. Orthopedists controlled the staff ofphysical therapists, massage therapists, and various con-sultants. In the second volume of his book, Jones includ-ed chapters on head and peripheral nerve injuries as wellas a chapter on SCI written by the omnipresent Percy Sar-gent and E. Farquhar Buzzard. Although the chapter wasnot particularly assertive, it was clear that injuries of thecentral nervous system fit into the grand scheme.17,86 Joneswas successful during the war with the establishment ofseveral dozen impressive demonstration hospitals aroundthe UK, but his postwar plans languished as political andfinancial constraints forced hospitals into other functions.

The treatment of patients with SCIs in the UK neverapproached the ideal. Eventually their care was decentral-ized into smaller hospitals or homes funded by voluntaryaid societies or the British Red Cross. One such domicilewas the Star and Garter, an old hotel in Richmond thatwas converted to become a “Hampton Court Palace” forthe totally disabled. The care was excellent, but rehabili-tation was negligible. The Star and Garter was meant to bethe soldiers’ “last home.” Sixty-three beds were kept filledduring 1919. Ten pensioners died, 19 were discharged toother facilities, and 28 were admitted to their final bil-lets.12,46

In the US, Jones’ concept of a unified comprehensiveprogram for the treatment, rehabilitation, and reeducationof injured military personnel took hold, but the orthopedicsurgeons, many of whom had trained under Jones in theUK during the war, failed to secure their clinical authori-ty. Casualties with SCIs were sent to various general hos-pitals around the country close to their homes. Their treat-ment relied on neurosurgical or medical expertise. In1921, the Veterans’ Bureau was created to reduce admin-istration and consolidate various government agencies.Wartime obligations and progressive reform mandated re-

habilitation and vocational training throughout hospital-ization and aftercare18 (Fig. 7). The public commitmentwould continue into another war.

OUTCOMES

The treatment of SCI was never a priority for militarymedicine. Most military personnel with these injuries,such as Vice Admiral Nelson, were killed in action by in-juries to other organs. The plight of the survivors, how-ever, compelled civil and military surgeons to develop ra-tional care, even in the face of permanent disability.Although the treatment for closed fractures changed verylittle, by World War I, a large number of casualties withpenetrating SCIs who managed to reach sophisticated sur-gical care during battle, underwent increasingly aggres-sive intervention.

The new surgical outlook was the result of many fac-tors. Reinforced by the experiences of military surgeonsduring major conflicts in the middle and late 19th century,the rapid development of neurology and civil surgery pro-vided a clinical framework that matured during WorldWar I. The integration of civil surgeons into the medicalservices brought expertise and surgical flexibility. Opin-ions on the treatment of SCI varied considerably but theapproach was similar. Penetrating SCIs required activetreatment that needed to be adapted to the requirements ofthe wounded and the conditions of war. Along with thischange in attitude, there were adjustments in medical ser-vices leading to more efficient evacuation, improvementsin x-ray studies and hospital facilities, and the ability todisseminate accurate (as much as possible) statistics andunfamiliar surgical techniques. The result was pragmaticand frequently successful operative care. Colonel Gray’sindications and techniques are, arguably, as relevant todayas they were in 1917.19

Improvements in long-term care paralleled those foracute treatment. Decubiti and bladder infections were no



Fig. 7. “Bergonie chair for giving general electrical treatmentsfor the psychological effect.” Reprinted from Crane AG: TheMedical Department of the United States Army in the WorldWar. Volume XIII, Part One, Physical Reconstruction and Vo-cational Education. Washington, DC: GPO, 1927, Fig. 70, p 155.

longer thought to be the pathophysiological results ofSCIs. Intermittent or continuous bladder drainage andstrict attention to skin care reduced sepsis and increasedsurvival in patients with SCIs. Government funding as afinancial base for physical rehabilitation, occupationaltherapy, and vocational reeducation became a viable alter-native to condescending charity and the inevitable result.To some extent, the early political developments arosefrom mixed motives, but changed the social landscape forcasualties with serious disabilities. In the US the mobi-lization of rehabilitation personnel resulted in the estab-lishment of organizations for physical and occupationaltherapists soon after the war. During the 1920s, profes-sional societies promoted the recognition of neurosurgeryas a specialty in the US and the UK. Put into perspective,these outcomes suggest that the evolution in the treatmentof patients with SCIs owes a great deal to military con-flicts in the 19th and early 20th centuries.

EPILOGUE

Paralyzed and bleeding internally, Nelson laid incramped midshipmen’s quarters in the after part of theship below the waterline. The attendants gave him lemon-ade as he watched Beatty work on the wounded, while thelower deck men cheered after each French ship wasstruck. Aware of his fatal injury, Nelson gave Hardyinstructions for the care of his family and requested thathis body not be thrown overboard. Hardy agreed and, afterthe engagement, interred the corpse in a leaguer, thelargest shipboard cask, which was filled with brandy. Thusembalmed, Horatio Lord Nelson returned to England anda hero’s burial. A midshipman, John Pollard, killed theFrench marksman and Surgeon Beatty returned to thecockpit.85

References

1. Abbott FC: Surgery in the Graeco-Turkish war. Lancet Jan-uary 14:80–83, January 21:151–156, 1899

2. Anonymous: The prevention of bedsores after injuries of thespinal cord in the war. Lancet July 10:84, 1915

3. Armour D: Gunshot wounds of the spine: their surgical aspect.Lancet April 8:771, 1916

4. Ashhurst J: Injuries of the Spine with an Analysis of NearlyFour Hundred Cases. Philadelphia: JB Lippincott, 1867

5. Ashhurst J: Injuries of the Spine with an Analysis of NearlyFour Hundred Cases. Philadelphia: JB Lippincott, 1867, pp52–53

6. Ashhurst J: Injuries of the Spine with an Analysis of NearlyFour Hundred Cases. Philadelphia: JB Lippincott, 1867, pp72–127

7. Ballingall G: Outlines of Military Surgery, ed 5. London:Longman, 1855, p 321

8. Borden WC: The Use of the Röntgen Ray by the MedicalDepartment of the United States Army in the War withSpain, 1898. Washington, DC: GPO, 1900

9. Brown-Séquard CE: Lectures on the Central Nervous Sys-tem. Classics of Medicine Library. New York: Gryphon,1995, Appendix, Part II, pp 244–260

10. Bruce F: Experiences of x-ray work during the siege of Lady-smith. JRAMC I:92–100, 1903

11. Caplan EM: Trains, brains, and sprains: railway spine and theorigins of psychoneuroses. Bull Hist Med 69:387–419, 1995

12. Charnwood L (ed): Recall to Life. A Journal Devoted to theCare, Re-education, and Return to Civil Life of DisabledSailors and Soldiers. London: John Bale, Sons & Danielsson,1918, pp 75–79

13. Cheatle GL: Four cases of gunshot injury to the spinal column.JRAMC I:271–276, 1903

14. Chenu JC: De la mortalité dans l’armée et des moyens d’é-conomiser la vie humaine; extraits des statistiques médico-chirurgicales des campagnes de Crimée en 1854–1856 etd’Italie en 1859. Paris: Hachette, 1870

15. Clevenger SV: Spinal Concussion: Surgically Considered asa Cause of Spinal Injury, and Neurologically Restricted toa Certain Symptom Group, for Which is Suggested the De-signation Erichsen’s Disease, or One Form of the Trauma-tic Neuroses. Philadelphia: FA Davis, 1889

16. Cooter R: Surgery and Society in Peace and War Ortho-paedics and the Organization of Modern Medicine, 1880–1948. London: Macmillan, 1993, pp 100–104

17. Cooter R: Surgery and Society in Peace and War Ortho-paedics and the Organization of Modern Medicine, 1880–1948. London: Macmillan, 1993, pp 105–136

18. Crane AG: The Medical Department of the United StatesArmy in the World War. Volume XIII, Part One, PhysicalReconstruction and Vocational Education. Washington, DC:GPO, 1927, pp 138–160, 247–255

19. David CA, Landy HJ, Green BA: Penetrating wounds of thespine, in Wilkins RH, Rengachary SS (eds): Neurosurgery, ed2. New York: McGraw-Hill, 1996, Vol II, pp 3055–3061

20. Elsberg CA: Some lessons observed in operations for old in-juries to the spinal cord, with remarks as to treatment. AnnSurg 69:239–244, 1919

21. Evans TW: History of the American Ambulance Establishedin Paris During the Siege of 1870–71; Together with the De-tails of Its Methods and Its Work. London: Low, Marston,Low, and Searle, 1873, pp 670–679

22. Fishman RS: Gordon Holmes, the cortical retina, and thewounds of war. Doc Ophthalmol 93:9–28, 1997

23. Frazier CH, Allen AR: Surgery of the Spine and Spinal Cord.New York: Appleton, 1918, pp 98–138



26. Geraud O: Sur un coup de feu à l’épine. Mem Acad Roy Chir2:515–517, 1753

27. Gillett MC: The Army Medical Department 1865–1917.Washington, DC: Center of Military History, US Army,USGPO, 1994, pp 25–31

28. Goetz CG, Chmura TA, Lanska D: Part I: the history of 19thcentury neurology and the American Neurological Association.Ann Neurol 53 (Suppl 4):S2–S26, 2003

29. Gray HMW: Early treatment of gunshot injuries of the spinalcord. BMJ July 12:44–45, 1917

30. Great Britain Army Medical Department: A Medical and sur-gical history of the British army which served in Turkeyand the Crimea during the war against Russia in the years1854–55–56. London: Harrison, 1858, Vol II, pp 336–338

31. Great Britain War Office, McPherson WG: The Russo-Japan-ese War. Medical and Sanitary Reports From Officers At-tached to the Japanese and Russian Forces in the Field.London: HMSO, 1908

32. Gross SD: A Manual of Military Surgery; or, Hints on theEmergencies of Field, Camp, and Hospital Practice. Phila-delphia: JB Lippincott, 1862

33. Guthrie GJ: Commentaries on the Surgery of the War inPortugal, Spain, France, and the Netherlands, From theBattle of Roliça, in 1808, to That of Waterloo, in 1815; WithAdditions Relating to Those in the Crimea in 1854–55,Showing the Improvements Made During and Since That



11

Period in the Great Art and Science of Surgery on all theSubjects to Which They Relate, ed 6. London: H Reshaw,1855

34. Hanson AM: The Medical Department of the United StatesArmy in the World War. Volume XI. Surgery: Manage-ment of Gunshot Wounds of the Head and Spine in For-ward Hospitals, A.E.F. Washington, DC: GPO, 1927, pp789–793

35. Harris G: The Redemption of the Disabled; a Study of Pro-grammes of Rehabilitation for the Disabled of War and In-dustry. New York: Appleton, 1919, pp 186–189

36. Harte RH: The surgical treatment of intraspinal tumors. AnnSurg 42:524–542, 1905

37. Hayward G: An account of a case of fracture and dislocation ofthe spine. N Engl J Med Surg IV:1–3, 1815

38. Head H, Riddoch G: The automatic bladder, excessive sweatingand some other reflex conditions, in gross injuries of the spinalcord. Brain 40:188–263, 1917

39. Hennen J: Principles of Military Surgery, Comprising Ob-servations on the Arrangement, Police, and Practice of Hos-pitals, and on the History, Treatment, and Anomalies ofVariola and Syphilis. London: Wilson, 1829

40. Herrmann DG: The Arming of Europe and Making of theFirst World War. Princeton: Princeton University Press, 1996

41. Hippocrates: The Genuine Works of Hippocrates (translatedby Adams F). Huntington, NY: Krieger, 1972, pp 232–233

42. Hippocrates: The Genuine Works of Hippocrates (translatedby Adams F). Huntington, NY: Krieger, 1972, p 238

43. Holmes G: The Goulstonian lectures on spinal injuries of war.BMJ November 27:769–774, December 4: 815–821, Decem-ber 11:855–861, 1915

44. Hughes B, Banks HS: War Surgery From Firing-Line toBase. London: Baillière, Tindall, & Cox, 1918, pp 604–605

45. Hull AJ: The treatment of gunshot wounds of the spine.JRAMC XXVIII:66–77, 1917

46. Joint War Committee of the British Red Cross Society and theOrder of St. John of Jerusalem in England: Reports by theJoint War Committee and the Joint War Finance Com-mittee of the British Red Cross Society and the Order of St.John of Jerusalem in England on Voluntary Aid Renderedto the Sick and Wounded at Home and Abroad and to Brit-ish Prisoners of War, 1914–1919. London: HMSO, 1921, pp698–700

47. Jones R (ed): Orthopaedic Surgery of Injuries. London:Frowde, 1921, pp 337–360

48. Keller T: Railway spine revisited: traumatic neurosis or neuro-trauma? J Hist Med Allied Sci 50:507–524, 1995

49. Kidd F: The treatment of the bladder in gunshot injuries of thespinal cord. BMJ April 5:397–399, 1919

50. Kilvington B: An investigation on the regeneration of nerves,with regard to surgical treatment of certain paralyses. BMJApril 27:988–990, 1907

51. Kondoleon EMM: The transport of the wounded in war. LancetOctober 14:892–894, 1914

52. Lidell JA: On injuries of the spine, including concussion of thespinal cord. Am J Med Sci XXXVIII:305–328, 1864

53. Longmore T: Gunshot Injuries: Their History, Characteris-tic Features, Complications, and General Treatment: WithStatistics Concerning Them as They are Met in Warfare.London: Longmans & Green, 1877, pp 289, 606–611

54. Louis: Remarques et observations sur le fracture et la luxationreports of medical observers attached to the armies in manchur-iades vertebres; Mémoire lu à la séance publique de l’Académieroyale de chirurgie, le 18 avril 1774, par Louis, secrétaire-per-pétuel de cette Societé. Arch Gén Méd (S.2) 11:397–429, 1836

55. Love AG: The Medical Department of the United StatesArmy in the World War. Volume XV, Part Two, Medicaland Casualty Statistics Based on the Medical Records of theUnited States Army, April 1, 1917, to December 31, 1919,

Inclusive. Washington, DC: GPO, 1925, Table 114, p 1023,Table 115, p 1024

56. Lynch C: Reports of Military Observers Attached to theArmies in Manchuria During the Russo-Japanese War.Part IV. Washington, DC: GPO, 1907

57. Macleod GHB: Notes on the Surgery of the War in the Cri-mea with Remarks on the Treatment of Gunshot Wounds.Philadelphia: JB Lippincott, 1862

58. Macpherson WG, Bowlby AA, Wallace CW, et al (eds): His-tory of the Great War, Based on Official Documents. Med-ical Services. Surgery of the War. London: HMSO, 1922, VolII, pp 130–131

59. Makins GH: Surgical Experiences in South Africa 1899–1900; Being Mainly a Clinical Study of the Nature and Ef-fects of Injuries Produced by Bullets of Small Calibre. Ox-ford: Frowde, 1913, pp 320–350

60. Markham JW: Surgery of the spinal cord and vertebral column,in Walker AE (ed): A History of Neurological Surgery. Balti-more: Williams & Wilkins, 1951, pp 364–372

61. Mayo-Robson AW: Correspondence: treatment of traumaticparaplegia. BMJ January 12:69, 1918

62. Mayo-Robson AW: The treatment of paraplegia from gunshotor other injuries of the spinal cord. BMJ December 29:853–854, 1917

63. Mitchell TJ, Smith GM: History of the Great War, Based onOfficial Documents. Medical Services, Casualties and Med-ical Statistics of the Great War. London: HMSO, 1931, Table20, p 335, Table 21, p 336

64. Morris CA: Presidential address on some war sequelae. LancetDecember 7:1559–1564, 1901

65. Office of the Surgeon General: War Surgery of the NervousSystem; a Digest of the Important Medical Journals andBooks Published During the European War. Compiled bythe Division of Brain Surgery, Section of Surgery of theHead. Office of the Surgeon General, War Department,Washington, D. C., 1917. Washington, DC: GPO, 1917, pp247–300

66. Office of the Surgeon General: War Surgery of the NervousSystem; a Digest of the Important Medical Journals andBooks Published During the European War. Compiled bythe Division of Brain Surgery, Section of Surgery of theHead. Office of the Surgeon General, War Department,Washington, D.C., 1917. Washington, DC: GPO, 1917, p 296

67. Otis GA: The Medical and Surgical History of the War ofthe Rebellion (1861–65). Surgical History, Volume II. Wash-ington, DC: GPO, 1870, pp iii–ix, xiii–xxii

68. Otis GA: The Medical and Surgical History of the War ofthe Rebellion (1861–65). Surgical History, Volume II. Wash-ington, DC: GPO, 1870, pp 425–465

69. Otis GA: The Medical and Surgical History of the War ofthe Rebellion (1861–65). Surgical History, Volume II. Wash-ington, DC: GPO, 1870, p 430

70. Otis GA: The Medical and Surgical History of the War ofthe Rebellion (1861–65). Surgical History, Volume II. Wash-ington, DC: GPO, 1870, p 433–434

71. Otis GA: The Medical and Surgical History of the War ofthe Rebellion (1861–65). Surgical History, Volume II. Wash-ington, DC: GPO, 1870, Table XX, p 455

72. Otis GA, Huntington DL: The Medical and Surgical Historyof the War of the Rebellion Surgical History, Volume II.Washington, DC: GPO, 1883, Table CXX, p 693

73. Otis GA, Huntington DL: The Medical and Surgical Historyof the War of the Rebellion Surgical History, Volume II.Washington, DC: GPO, 1883, pp 694–695

74. Reynolds L: The history of the use of the Roentgen ray in war-fare. AJR 54:649–672, 1945

75. Riddoch G: On the relative perceptions of movement and a sta-tionary object in certain visual disturbances due to occipitalinjuries. Proc Roy Soc Med 10:13–34, 1916



76. Sargent P: Correspondence: the treatment of traumatic paraple-gia. BMJ January 5:35–36, 1918

77. Smith AG: Account of a case in which portions of three dorsalvertebrae were removed for the relief of paralysis from fracture,with partial success. N Am Med Surg J 8:94–97, 1829

78. Southey R: The Life of Horatio Lord Nelson. London: JMDent & Sons, 1915, pp 259–262

79. Spear R: Report on the Russian Medical and Sanitary Fea-tures of the Russo-Japanese War to the Surgeon-General,U.S. Navy. Washington, DC: GPO, 1906

80. Stone MS: The Victorian Army: Health, Hospitals and SocialConditions as Encountered by British Troops during theSouth African War, 1899–1902. Dissertation. London: Uni-versity of London, 1992, pp 265–291

81. Thorburn W: Lectures on the surgery of the spinal cord, and itsappendages. BMJ June 23:1345–1348, 1884

82. Thorburn W: The pathology of gunshot wounds of the spinalcord. Br J Surg VIII:201–218, 1920–1921

83. Walshe FMR: The physiological significance of the reflex phe-nomena in spastic paralysis of the lower limbs. Brain 37:269–335, 1914–1915

84. Walton AJ: Hunterian lecture on the surgery of the spinal cord inpeace and war. Lancet February 15:244–250, 1919

85. Warner O: Nelson’s Battles. Yorkshire, UK: Pen & Sword,2003, pp 186–240

86. Watson F: The Life of Sir Robert Jones. Baltimore: Wood,1934

87. Williamson G: Notes on the Wounded from the Mutiny inIndia: With a Description of the Preparations of GunshotInjuries Contained in the Museum at Fort Pitt. London:Churchill & Sons, 1859

Manuscript receivedAccepted in final formAddress reprint requests to: William C. Hanigan, M.D., Depart-

ment of Neurosurgery, University of Illinois College of Medicine,Peoria P.O. Box 1649, Peoria, Illinois 61656. email: [email protected].



13