Nelson's Wound: Treatment of Spinal Cord Injury in 19th and Early 20th Century Military Conflicts

William C. Hanigan, M.D., Ph.D.; Chris Sloffer, M.D.

Disclosures

Neurosurg Focus. 2004;16(1) 

In This Article

Abstract and Introduction

During the first half of the 19th century, warfare did not provide a background for a systematic analysis of spinal cord injury (SCI). Medical officers participating in the Peninsular and Crimean Wars emphasized the dismal prognosis of this injury, although authors of sketchy civil reports persuaded a few surgeons to operate on closed fractures. The American Medical and Surgical History of the War of the Rebellion was the first text to provide summary of results in 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 the latter half of the century enabled Sir G. H. Makins, during the Boer War, to recommend delayed intervention to remove bone or bullet fragments in incomplete injuries. The civil experiences of Elsberg and Frazier in the early 20th century promoted a meticulous approach to treatments, whereas efficient transport of injured soldiers during World War I increased the numbers of survivors. Open large wounds or cerebrospinal fluid leakage, signs of cord compression in recovering patients, delayed clinical deterioration, or intractable pain required surgical exploration. Wartime recommendations for urological and skin care prevented sepsis, and burgeoning pension systems provided specialized longterm rehabilitation. By the Armistice, the effective surgical treatment and postoperative care that had developed through decades of interaction between civil and military medicine helped reduce incidences of morbidity and dispel the hopelessness surrounding the combatant with an SCI.

. . . A ball fired from her mizzen-top, which, in the then situation of the two vessels, was not more than fifteen yards from that part of the deck where he was standing, struck the epaulette on his left shoulder, about a quarter after one, just in the heat of the action. . . . Hardy, who was a few steps from him, turning round, saw three men raising him up. - "They have done 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 and laid upon a palate in the midshipmen's berth. It was soon perceived, upon examination, that the wound was mortal. . . . Hardy observed that he hoped Mr. Beatty could yet hold out some 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, Vice Admiral Nelson "crossed the T" and won a resounding victory over Napoleon's Combined Fleet. Three hours into the engagement, the Admiral was fatally shot by a French marksman who was aboard the Redoubtable. In the aftermath, it was readily acknowledged that neither Thomas Masterman Hardy, one of Nelson's "Band of Brothers" and Captain of the HMS Victory nor William Beatty, the ship's surgeon, could have saved him. The musket ball had entered from above Nelson's left shoulder and crossed through the midline, probably injuring the lower cervical or upper thoracic cord, ribs, lung, and major vessels. Beatty knew that combatants with SCIs either died quickly from associated injuries or slowly and cruelly from intervening infections.

The gradual improvement in the management of wounds such as Nelson's required longer than 100 years of active interplay between civil and military medicine and changes in clinical neuroscience and societal perspectives. In this report we will describe the development of the diagnosis and treatment of SCI from the naval encounter off the coast of Spain to the Meuse-Argonne offensive on the Western Front.

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