The Case of the Fearless Mariner With a Mortal Chest Wound

Albert B. Lowenfels, MD; William A. Liston MD; David Burris, MD

Disclosures

November 21, 2008

How Would the Patient Be Treated Today?

Immediately after his death, Nelson's ship, the Victory, was towed to Gibraltar, where his body was preserved for the voyage to England in a cask of wine. The fleet surgeon, William Beatty, performed an autopsy and issued a full report.[1]

"The bullet entered the left shoulder near the acromion process, then followed a downward trajectory fracturing the second and third ribs, passing through the left lung, and dividing in its passage a large branch of the pulmonary artery. It entered the left side of the spine between the sixth and seventh dorsal vertebrae...made its way from the right side of the spine...lodged below the right scapula.

The rest of the body showed no abnormalities. The heart and lungs were sound...[the body] resembled ...a youth...giving every evidence that HIS LORDSHIP might have lived to a great age."

Despite the autopsy report, it is unlikely that the fatal bullet severed the pulmonary artery because, in such a case, it is doubtful that Nelson would have lived for longer than 2 hours. In view of the multiple rib fractures, the source of bleeding could have been a torn intercostal artery or vein or a lung laceration. Life-threatening respiratory insufficiency is unlikely because Nelson continued to talk to his surgeon and to other officers until his death.[2]

Nelson sustained injuries to both scapulae, the left chest wall, the second and third ribs, left lung, along with a pneumothorax, a pulmonary vascular injury, and a T6-T7 spinal cord injury. The initial description of his condition implies that his airway was intact, but that his breathing was labored. Signs of significant shock developed and progressed slowly over the course of a few hours. The cause of his death could have been due to hypovolemic shock and/or an increasing left hemopneumothorax.

Initial Treatment Today

In today's navy Nelson would command his fleet from an aircraft carrier or another major vessel of a carrier battle group. An aircraft carrier is equipped with the personnel and equipment for surgical emergencies at sea, including all types of major trauma. With a fully staffed trauma area, an operating room, a capable general surgeon assisted by flight surgeons and medical officers, corpsmen, as well as laboratory and radiological capability, Nelson's wounds, although serious, would have received prompt, effective treatment.

Current treatment would begin with transportation on a padded back board to the triage area aboard a modern-day aircraft carrier, followed by assessment by a competent trauma team trained to provide urgent interventions. Since Nelson's airway was intact, he would be given oxygen by mask while 2 large-bore peripheral IVs were inserted for rapid resuscitation. Presumably breath sounds would be decreased on the left side, so the next maneuver would be to insert a chest tube: if drainage was > 1500 cc of blood, he would be moved directly to the adjacent operating room where, if necessary, he could receive airway support.

While observing the chest tube output, the trauma primary survey would be completed, labs drawn, and chest radiography performed. A FAST examination (Focused Abdominal Sonogram for Trauma) would not have revealed abdominal bleeding. After a rectal examination, a Foley catheter would be inserted. When his condition stabilized, then arrangements would be made for medivac off the ship. Antibiotics and more fluid would be given. During his evacuation, the patient would be wrapped securely to a padded back board to prevent hypothermia, further spinal injury, and decubitus ulcer formation.

If the chest tube output indicated more severe or significant hemorrhage, then he would be moved to the operating room and prepared for a thoracotomy performed by a full surgical team. A "walking blood bank" would quickly provide large quantities of fresh blood. His heart rate, blood pressure, and pulse oximetry would be monitored continuously. Postoperatively, Nelson would be transferred to the ship's recovery room where he would be stabilized before transfer to a land-based hospital.

If injured today, Admiral Nelson would receive competent initial surgical care aboard a modern-day aircraft carrier. He would have survived, but unfortunately, would have remained a paraplegic.

Managing His Spinal Cord Injury Today

Today, gunshot wounds are the second most common cause of spinal cord injury, but advances in the treatment of traumatic paraplegia have been limited.[3] Nelson's spinal injury would have been quickly apparent because he was unable to move his lower limbs. Neurologic examination and a computed tomography scan would reveal the exact level of spinal injury. If the bullet had transected the spinal cord at the level of C6 or C7 there would be normal respiratory function but limited residual upper extremity function. After his recovery from the bullet wound, Nelson would be transferred to a large mainland military hospital and eventually to a center equipped to rehabilitate paraplegics.

Currently, no methods exist for repairing a transected spinal cord, although injured patients are able to function, either using crutches or a wheelchair.[4] Nelson's life expectancy would be about another 28 years -- 10 years less than a person without a spinal cord injury. He would join the list of other famous paralyzed persons including the accomplished violinist Yitzhak Perlman and President Franklin D. Roosevelt, both paralyzed because of poliomyelitis; President Garfield who became paralyzed after being shot; and the recently deceased quadriplegic actor Christopher Reeves.

How Nelson's Earlier Nonfatal Injuries Would Have Been Treated

Vision loss. Flying sand and gravel caused Nelson's first injury to his right eye leading to eventual loss of vision except for the ability to detect light. We do not have an accurate description of the extent of injury, but since the eye gave the appearance of being normal in later life, perhaps the damage was restricted to the cornea. If so, he might have benefited from a corneal transplant. However if the macula had been destroyed, then his visual loss would have been permanent.

Loss of his right arm. Nelson's second injury was a compound fracture of the right arm caused by a bullet wound, which severed the brachial artery, producing brisk hemorrhage, and caused extensive soft tissue damage. He endured amputation without anesthesia in an operation lasting about half an hour. Nelson suffered from phantom pain in the right hand for many months, perhaps because the median nerve had been ligated along with the brachial artery. He was right-handed, but learned to write with his left hand. Because of the risk of infection in pre-Listerian times, amputation for wounds of this sort was the accepted treatment: today it is highly unlikely that amputation would be necessary.

Famous One-armed Persons

Nelson is one of several famous persons who achieved success despite the loss of or serious disability of an upper extremity. This group includes:

  • Miguel de Cervantes, author of Don Quixote, who lost the use of his left hand in 1571 at the naval battle of Lepanto;

  • Kaiser Wilhelm II of Germany, whose left arm was paralyzed from a birth injury;

  • Two United States senators, Bob Dole and Dan Inouye, who both were injured during World War II;

  • Janek Mela, a double amputee who reached both the north and south poles;

  • John Wesley Powell, Colorado River explorer, who lost most of 1 arm at the Battle of Shiloh; and

  • Two baseball players -- Jim Abbot, 1-handed pitcher for the New York Yankees; and Peter Gray, an outfielder for the St. Louis Browns, who lost his right arm in a childhood accident.

In fiction and film, there are other examples: In JM Barrie's novel Peter Pan, Captain Hook's right hand, which Peter had cut off, was replaced by an iron hook. Shakespeare based his tragedy "Richard the Third," upon Richard, a Plantagenet king thought to have had a deformed arm or shoulder. In the 1955 film Bad Day at Black Rock, Spencer Tracy plays the part of John MacReedy, an avenging 1-armed World War II war veteran.

Summary

After the French defeat at Trafalgar, Napoleon never achieved his ultimate objective -- an invasion of the British isles. Given Nelson's victory and subsequent death, his reputation continued to grow. His flagship, Victory, can still be visited at its permanent birth in Portsmouth, England. Nelson's column with its statue of Lord Nelson dominates Trafalgar square, and is on the "must see" list for every London visitor. His epic victory has been recorded and interpreted in numerous paintings (Figure 3).

Figure 3.

HMS Victory, Admiral Lord Nelson's flagship at the time of the battle of Trafalgar. Permanently birthed at the Portsmouth Naval Base in the United Kingdom. The painting combines events from several times during the battle. Nelson's famous signal "England expects..." flies from the Victory (11:50); the top-mizzenmast falls (13:00); the Achille is on fire in the background (late afternoon); and the Redoutable sinks in the foreground (following day). Turner shows the Victory flying her signal flags from the main-mast, although in actuality they would have been flown from the en:mizzen-mast and were replaced with the signal for "engage the enemy more closely" once the battle commenced." Painting by J. M. W. Turner (oil on canvas, 1822-1824).

Nelson's role as savior of Britain during a critical time has been compared to Churchill's similar role in the 20th century. Nelson gave his life fulfilling the message in the signal he sent to his sailors prior to the battle of Trafalgar: "England expects every man to do his duty."

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