J Royal Naval Medical Service 2009, 95.1 23-27

General Lord Nelson’s trans-humeral amputation – a case report

Sameer K Khan, Iram Saeed, Mark D Brinsden

Key words: Trans-humeral amputation, Neurostenalgia, Phantom pain

Introduction The operation Admiral Horatio Nelson is the ultimate hero of Nelson was taken down to the cockpit which British naval history. The amputation of his was cold, dimly lit and unsteady as the ship right arm in July 1797 off the shore of Santa tossed on the waves. A Petit type of screw Cruz, Tenerife, is one of the most famous (1) tourniquet (Figure 1) was applied to his arm. operations ever performed. Naturally British The ship’s standard scale of stores, at the medical authors (2), (3), (4) have published time of the engagement, included six concise accounts of the circumstances of this tourniquets(9). Each tourniquet comprised a life-saving surgery. It has also attracted cloth strap that was thrown around the limb comment internationally in non-English and the screw tightened, compressing the medical journals (5), (6), (7). This article aims limb between the two leather and cloth pads. to revisit this epic surgery in detail, including The amputation instruments were cold and post-op recovery and complications; and his their action on his non-anaesthetised limb psychological and physical rehabilitation. caused him much distress.

Nelson’s injury Nelson led the charge on the harbour mole just after midnight on 25th July. The Spaniards greeted this landing group with a hail of cannon and musket fire. Nelson was one of the first casualties, being struck in his right arm by grape shot fired from the canon El Tigre. His stepson Josiah Nisbett stemmed the haemorrhage with a tourniquet and returned him to the Theseus.

The surgeon The amputation was performed by Thomas Eshelby (8). He was a 28 year-old Yorkshireman with three years experience as a qualified surgeon. His usual assistant George Henderson had not returned from the failed invasion that night. He therefore turned to Louis Remonier, a French royalist, who had Fig 1: The tourniquet used on Nelson, and his been allowed to serve as surgeon’s mate. spy-glass. Courtesy of the Wellcome Trust.

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The median nerve crosses the brachial artery Constipation antero-medially in the arm close to the distal Nelson received opium every night. This made attachment of the coracobrachialis (10). The him constipated (July 29th entry), which was trans-humeral amputation was probably apparently relieved by Senna and Jalap. undertaken at this level. The evidence suggests that Eshelby inadvertently Dressing Changes incorporated the nerve into the second reef- Eshelby changed the first dressing himself on knotted ligature on the artery. He used silk July 27th, the 3rd post-op day, and was instead of waxed thread which was the more satisfied with the wound. One of the two common British practice. The ligatures were ligatures separated with the next dressing left long, to protrude beyond the level of the change – approximately 5 days after the stump, so that they may eventually be amputation. The second ligature was two removed by gentle traction at subsequent inches proximal to the wound edge, in a rather dressing changes. The team then attended to short stump, and was therefore not “teased” at the other casualties, including a further trans- that point for fear of causing secondary humeral amputation on a seaman named haemorrhage. Holding (11). Neurostenalgia (12) Post-operative recovery Nelson returned to Bath, England in Nelson received a pill of two grams of opium September. His wound was initially dressed by as immediate post-op analgesic and recovered the local doctor and then by his wife. His satisfactorily from his surgery (Figure 2). stump pain persisted which required nocturnal Eshelby’s daily progress notes are reproduced laudanum (3) The Bath physicians theorised it in (Figure 3). He subsequently received £36, was due to nerve(s) assimilated within the while his assistant was paid 24 guineas for arterial ligature. A letter from his brother their care. alludes to this: ‘I did this day meet Bayly a

Fig 2: Eshelby’s operation note from the Theseus’ Medical Journal. Courtesy of the National Archives. ‘Compound fracture of the right Arm by a musket ball passing tho’ a little above the Elbow ; an Artery divided ‘ the Arm was immediately Amputated, and the following give [sic] him. Rx; Opii gr. ij. f. Pil. statim s. Rep. Pil. Opii gr j-. Rep. Pil. Opii gr ij hora s.s. Lord Nelson’s trans-humeral amputation – a case report 25

Figure 3. Reproduction of the sections relevant to Admiral Nelson, from the Medical Journal of the Theseus 1797. Courtesy of the National Archives. 26 J Royal Naval Medical Service 2009, Vol 95.1

Swaffham surgeon, and esteemed a good the brave fellow that was killed beside me’ one. I mentioned particularly the apparent (16). pain in your right hand. He said it was a true Depression and recovery sign of a nerve being taken up with the artery, The simultaneous realities of his military defeat indeed he says it is hardly possible to avoid it and personal loss, began to sink in afterwards. as there are so many and such small ones: Despondency made him scribble with his that you must now have patience and all will reacquainted left hand ‘I am become a burthen do well, but he thinks the ligature had better to my friends and useless to my Country’ (13). not be forced too much…’ (13) However he felt a bit better when he boarded the Seahorse, and on his return journey home. Stump infection His peers and friends were encouraging and The Nelsons were perturbed by this additional supportive, as was a royal audience and problem and travelled to London to seek financial recompense. Events later in life expert opinion. The Vice-Admiral consulted helped him recover psychologically and cope Dr Benjamin Moseley (Physician at the Royal with his disability. His return to active Chelsea Hospital), William Cruikshank command in December, subsequent maritime (Anatomist-Surgeon) and Thomas Keate victories, and the companionship of Lady (Surgeon-General to the Army). At the same Hamilton were the more significant of these. time a fistula appeared along the tract of the Indeed he grew fond of his stump. He persisting silk ligature. The stump became hot nicknamed it as his ‘fin’ and would use it and swollen and had to be poulticed. The humorously to identify himself to strangers (17). collective opinion however, was to avoid rushing into a debridement or stump revision. Phantom pains There are allusions to occasional phantom limb Miraculous recovery pain later on in Nelson’s life, possibly related to The recalcitrant ligature gave way suddenly on changes in the weather. The stump also 3rd December 1797 and came away with the helped his subordinates in ascertaining his dressings. The stump healed rapidly thereafter mood, as it twitched when he was angry: and five days later Nelson sent a note to St ‘The admiral is working his fin,’ they would George’s Church in Hanover Square bearing say. ‘do not cross his hawse, I advise you!’ . this statement ‘ An officer desires to return Thanks to Almighty God for his perfect Physical rehabilitation recovery from a severe wound, and also for Nelson had written a letter left-handedly to his the many mercies bestowed upon him .’ commanding officer, Earl St Vincent, within 48 hours of his amputation. He added the Mental strength following post-script ‘ you will excuse my Nelson had displayed extreme courage and scrawl considering it is my first attempt’ (13). resilience in both the heat and aftermath of His spidery script however improved battle. He refused to be helped aboard the considerably over the coming years, becoming Theseus saying ‘I have got my legs left and characteristically horizontal and evenly spaced one arm’. Midshipman Hoste (14) recalled (18). seeing the admiral climbing into the ship with Nelson began using a combined knife and his left hand, right arm dangling by his side. fork. At least three of these implements are His subordinates saluted him when he arrived preserved to date, all engraved with the initial on deck, to which he promptly replied left- ‘N’. The National Maritime Museum exhibits a handed (15). He had intuitively realised that an silver three-pronged fork set in an ivory handle. amputation was the only option, so he asked A steel blade is attached to the lower prong by Eshelby to prepare for immediate surgery. a screw, as shown in Figure 4. Asked how to dispose of his amputated arm, A similar utensil was possessed by the he retorted ‘throw it into the hammock, with descendents of Nelson’s sister - Catherine Lord Nelson’s trans-humeral amputation – a case report 27

Med. 2007 Nov;68(11):623. 5. Rüttimann B. Nelsons Oberarm-amputation . Z Orthop Ihre Grenzgeb. 1982 Feb;120(1):86-8. 6. Buzzi A. La clinical quirurgica del Amirante Nelson. Medicos y Medicina en la Historia. 2001;1(1):5-9. 7. Ahlberg A. När »tigern« från Teneriffa krossade amiral Nelsons arm . Lakartidningen. 2001 Jun 20;98(25):3046. 8. Pugh G. Nelson and his surgeons . London: Livingstone Ltd; 1968. 9. Goddard JC. The navy surgeon's chest: surgical Figure 4. Nelson’s combined knife and fork. Courtesy of National Maritime Museum instruments of the Royal Navy during the Napoleonic War. J R Soc Med. 2004 Matcham. This seven inch long three-pronged Apr;97(4):191-7. fork has a worn out blade affixed by a slightly 10. Standring S, Wigley C, Collins P, Williams A. different screw assembly and was auctioned Upper Arm. In: Gray’s Anatomy. The Anatomical by Sotheby’s in October 2005 for £52,800 (19). Basis of Clinical Practice. 39th ed. Elsevier The Nelson Collection at Lloyds of London Churchill Livingstone, 2006: 856. includes a high carat gold example of fiddle 11. Medical Journal of the Theseus 1797. Admiralty and thread pattern, with a steel blade set into papers (Reference: ADM 101/123/2). The the fourth tine of the fork (20). There is National Archives. evidence that similar adjustments were made 12. Birch R, Bonney G, Wynn Parry CB, eds. Surgical in personal items of clothing and furniture in disorders of peripheral nerves . London: Churchill order to facilitate his rehabilitation. Livingstone; 1998. This case report illustrates Nelson’s 13. Nicolas NH. The Dispatches and Letters of Vice characteristic resolve and courage, and how Admiral Lord Viscount Nelson . London; 1844-6 these attributes influenced his recovery and (7 vols) rehabilitation against a background of immense 14. Hoste H. Memoirs and Letters of Captain Sir personal loss and complicated surgery. William Hoste. London; 1833 (2 vols) 15. Naish GPB. Nelson’s Letters to his Wife and References Other Documents, 1785-1831 . London; 1958. 1. Ellis H. Famous operations . Media, PA: Harwal 16. Oman C. Nelson . London; 1947. Publishing Co; 1984. p 85-91. 17. Coleman T. Nelson . London: Bloomsbury; 2002. 2. Power D. Some bygone operations in surgery . 18. Alberge D. Handwriting shows ‘transformation’ Br J Surg. 1932 Jan;19(75):351-55. in older Nelson. The Times 1995 Jul 24. 3. Gooddy W. Admiral Nelson’s neurological 19. URL http://www.sothebys.com/app/live/ illnesses . Proc Roy Soc Med. 1970 Mar;63:299- lot/LotDetail.jsp?live_lot_id=1&go.x=0&go.y=0&s 306. ale_number=L05132 4. Ellis H. Admiral Nelson's amputation . Br J Hosp 20. URL http://www.lloyds.com/NR/rdonlyres/

Sameer K Khan MRCS, Specialty Trainee in Trauma & Orthopaedics, Derriford Hospital, Plymouth PL6 8DH, UK

Iram Saeed FCPS, Medical Officer in Internal Medicine, North Medical Ward, Mayo Hospital Lahore, Pakistan

Mark D Brinsden FRCS(Tr&Orth), Consultant in Trauma & Orthopaedics, MDHU Derriford, Plymouth PL6 5YE

Correponding author: Mr Sameer K Khan, 103 College Dean Close, Plymouth PL6 8BP [email protected] 01752779245 07894809740