By Thomas A. Lazzarini; Alfredo A. Sadun, MD, PhD; and Arthur Vallejo, MD
Admiral Horatio Nelson is remembered as one of Britain’s greatest war heroes for his pivotal role in the Battle of Trafalgar, which led to his death and turned the tide of the Napoleonic Wars. The famed naval victory in essence established Britain’s role as the greatest power in Western Europe in the early 19th century, ushering in the era of Pax Britannica that lasted until the beginning of World War I in 1914.
Admiral Nelson was admired for his tactical mastery and his penchant for leading from the front and boarding enemy vessels to directly engage the opponent, something remarkable for a British naval officer. This undoubtedly contributed to his extensive war injuries and earned him his towering statue in Trafalgar Square, London. Prior to his death, Admiral Nelson catalogued his injuries in a list that he sent to his close friend, Admiral Sir Robert Kingsmill.
Wounds received by Lord Nelson (which he deemed "tolerable for one war"):
- His eye in Corsica;
- His belly, off Cape St. Vincent;
- His arm at Teneriffe;
- His head in Egypt.
While being transported by his British captors to his final exile on the island of Saint Helena, Napoleon Bonaparte himself remarked that it was Admiral Horatio Nelson, above all, who had frustrated his dream of global domination. Napoleon’s statement was compelling in light of Nelson’s spectacular victories at the Battle of the Nile in 1798 and the Battle of Trafalgar in 1805. Their devastating effect added to years of British naval blockades of French ports by Nelson during the French Revolutionary Wars.
Admiral Nelson had been a bold risk taker since his youth, but it is arguable that his tolerance for risk-taking increased to the point of recklessness during the last seven years of his life. A previously unrecognized possibility is that this resulted from his penetrating ocular trauma suffered at Calvi, in Corsica, during the spring of 1794, Admiral Nelson may have subsequently developed sympathetic ophthalmia, which may have had a profound effect on his late-life vision and overall health. The impending loss of his eyesight may be in part responsible for his notoriously reckless behavior toward the end of his military career, as he also sought ship bounties to afford his divorce and fund the lavish lifestyle of his mistress, Lady Hamilton.
Decades before, sympathetic ophthalmia was first characterized by Edinburgh’s William Mackenzie in 1840.
In June of 1794, Nelson initiated an amphibious assault on Calvi by strategically mounting guns on hilltops surrounding the town and bombarding enemy positions. On July 12y, in the midst of ongoing fire, Nelson was positioned at a forward battery when an enemy shell struck nearby, spraying sand and stone splinters into his right eye. Nelson returned quickly to action and claimed victory in August; however, his eye had been irreparably damaged by the injury. In a letter to his uncle, Captain Suckling, he wrote, “I can distinguish light from dark but no object.” To his wife, Fanny, he divulged that he, “most fortunately escaped only having my right eye nearly deprived of its sight” and that his right “pupil is nearly the size of the blue part [iris].”
Today, ophthalmologists are aware that sympathetic ophthalmia, also known as sympathetic uveitis, is a rare, bilateral granulomatous panuveitis that occurs after ocular trauma or, less commonly, ocular surgery. Mackenzie first coined the disease “sympathetic ophthalmia.” In 1910, Elschnig initially proposed it to be an autoimmune inflammatory disease, positing that the inflammation occurred in response to systemic exposure to uveal antigens following breakdown of the blood-ocular barrier. After an inciting ocular trauma, there is a variable latency period, after which sight-threatening inflammation occurs in both the exciting (injured) and sympathetic (contralateral) eye.
Sympathetic ophthalmia is hypothesized to result from a T-cell mediated autoimmune inflammatory response to choroidal melanocytes after disruption of the blood-ocular barrier. The established preventative measure is enucleation of the injured eye within two weeks of the traumatic event, a treatment that Prichard first introduced in 1851. Enucleation became established best practice by 1863.
With proper management, modern rates of sympathetic ophthalmia are quite low, with an incidence of 0.3-1.9 percent following open globe injuries. There is, however, no known estimate for the rate of sympathetic ophthalmia after penetrating ocular injuries without subsequent and timely enucleation.
The likelihood, however, of developing the devastating autoimmune complication is undoubtedly much higher after ocular trauma with retained foreign bodies and without early enucleation, as was the case for Admiral Nelson. If untreated, sympathetic ophthalmia generally has a long course, remarkable for intermittent periods of acute inflammation with quiescent intervals ranging from months to years in between flares.
There is considerable inconsistency of opinion regarding the state of Nelson’s eyesight in either eye in his later years. A frequently quoted article from The Times in October 1804 claimed that, despite the general understanding that Nelson had lost an eye, according to the “very best authority […] he could see best with (what people called) his worst eye.” Hence there was at least confusion as to whether Nelson’s worse eye was that originally injured.
In the same year, Nelson wrote: “[M]y eyesight fails me dreadfully; I firmly believe that in a very few years I shall be stone blind.” According to an official filing by the Court of Examiners in 1797, his eye injury was “fully equal to the loss of a limb.”
The theory that Admiral Nelson suffered from sympathetic ophthalmia is further strengthened by an ophthalmic exam documented by naval physician Dr. Thomas Trotter in 1801, who attended to Nelson when he developed a “violent ophthalmia in his only eye with a membranous substance seemingly spreading fast over the pupil.” After three days of hourly bathing and ocular rest, the inflammation dissipated. The “membrane” noted by Dr. Trotter is unlikely to reflect his known bilateral pterygia, as it was localized to his left (uninjured) eye and was observed to subsequently recede, a pattern consistent with an acute flare of anterior uveitis involving immune cells in the anterior chamber and fibrin deposition over the lens capsule.
Furthermore, Nelson complained of photophobia, requesting green eye shields for both eyes, which he hung from the brim of his hat. Another example, from a letter Admiral Nelson wrote to Emma Hamilton in 1801, states that, “Nelson’s left (uninjured) eye became inflamed as it did in periods of stress, and he begged Emma (Hamilton) to sew him some green shades to shield it from the light.” Finally, we find an excerpt from the same book dating to 1801, “Suffering from stress and searing eye pain which he could only dull with opium.”
The theory that Admiral Nelson may have in fact suffered from sympathetic ophthalmia can help explain some of the legends involving this war hero. One such myth takes place during the Battle of Copenhagen, in which Nelson famously claimed not to see his commander-in-chief’s flags signaling retreat. Legend has it that Nelson held a telescope up to his right (first injured) eye and stated: “I have only one eye -- I have a right to be blind sometimes,” before leading a victorious offensive.
This incident gave birth to the English phrase: “Turn a blind eye,” which means to willfully ignore undesirable information; however, in the context of wartime, stress and excitement may represent evidence of decreased vision caused by uveitis related to a sympathetic ophthalmia flare. In the time before his death, Nelson sought every opportunity to take an enemy ship, frequently assuming significant risk. This was during the same period in which he went through a costly divorce and assumed financial responsibility for Lady Hamilton’s extravagant taste.
Perhaps, as the years passed and repetitive bouts of ocular inflammation took a toll on his vision, Admiral Nelson saw the end of his career fast approaching and his opportunities for creating an estate closing. Clearly, he seized every opportunity to claim the prize and acclaim that accompanied taking enemy ships and not just beating, but demolishing, the enemy fleet.
This last battle showed Nelson at his most courageous. Though it ended in a great victory, Nelson was killed by a musket ball from close range that severed his spine. His legacy included fame though not fortune. His objective at Trafalgar, and in previous naval battles, was to totally destroy a numerically superior fleet. This tactic demoralized the enemy, rendered Britain master of the seas and turned Napoleon to the east, where he lost his Grand Armee on the Steppes of Russia. Ultimately, Nelson set the stage for Napoleon’s defeat and, perhaps, sympathetic ophthalmia set the stage for Nelson’s actions.
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