Читать книгу Commentaries on the Surgery of the Npoleonic War in Portugal, Spain, France, - G. J. Guthrie - Страница 16
ON COMPOUND FRACTURES.
Оглавление141. A fracture of a bone, however simple it may be in its nature, is said to be compound when accompanied by an external opening in, or a wound of, the soft parts, communicating with the broken bone—a complication which usually gives rise to ulcerative inflammation and suppuration throughout the whole extent of the injury, preventing thereby those milder processes being effected which, under the more favorable circumstances of the skin being unbroken, lead to a speedy union of the broken parts; whence the desire manifested by the surgeon, in ordinary cases of compound fracture, to close the external wound, if possible, but which, from the nature of a gunshot wound, it is useless to attempt. A fracture is said to be comminuted when the bone is crushed, as by a heavy wheel passing over it. It may still, however, be a simple fracture, that is, without an external wound; and in that state it is much less dangerous than a similar injury accompanied by an external opening, however small, the edges of which cannot be immediately and permanently reunited.
142. An arm or a leg, as a general rule, is not to be amputated in the first instance for a compound fracture caused by a musket-ball, unless the ball be of large size, and the bone much shattered. An effort should always be made to save it; and, under reasonable circumstances with regard to the extent of injury, the comfort, climate, and ordinary good health of the sufferer, the object will frequently be obtained under good surgical treatment.
143. It is not so with the thigh. After the battle of Toulouse, forty-three of the best of the fractures of the thigh were attempted to be saved under my direction, and even selection. Of this number thirteen died; twelve were amputated at the secondary period, of whom seven died; and eighteen retained their limbs. Of these eighteen, the state three months after the battle was: five only could be considered well, or as using their limbs; two more thought their limbs more valuable, although not very serviceable, than a wooden leg; and the remaining eleven wished they had suffered amputation at first. Of the officers with fracture of the femur, one (having been taken prisoner during the action) died under the care of the French surgeons, by whom he was skillfully treated; the other has preserved a limb, which he rather wishes had been exchanged for a wooden leg.
In the five successful cases, the injury was in all at or below the middle of the thigh. In the thirteen others who retained their limbs, the injury was not above the middle third; and of those who died unamputated, several were near or in the upper third, and either died before the proper period for secondary amputation, or were not ultimately in a state to undergo that operation. Of the seven amputations which died, two were at the little trochanter, by the flap operation; and the others were for the most part unfavorable cases. In one case only was the head or neck of the bone fractured. The man lived for two months, and, from the dreadful sufferings he endured, it was much regretted that he had not lost his limb at the hip-joint at first. The operation ought, however, to have been the removal of the head and neck of the bone; but he was not seen in time by those who could or would have done this operation, which was then, however, only contemplated for the first time.
Nearly all the wounded, after this battle, had every possible assistance and comfort, from the second day after the action. The hospitals were well supplied with bedsteads—no inconsiderable point in the treatment of fractures—and several of the surgeons had been in almost every battle from the commencement of the war. The medicines and materials for their treatment were in profusion. The sick and wounded (1359 in number, including 117 officers) were in charge of two deputy inspectors-general, ten staff-surgeons, six apothecaries, and fifty-one assistant-surgeons; and the whole worked from morning until evening with the greatest assiduity. The surgery of the British army was then at the highest point of perfection it attained during the war; and this enumeration is given to show the number of medical men required under the most favorable circumstances for 1500 wounded men, if they are to have all the aid surgery can give them. Doctors are not the most ornamental part of an army perhaps, but there are days in a campaign when many poor fellows find them to be the most useful.
Every broken thigh or leg was in the straight position, and the success was greater than on any previous occasion. Nevertheless, with all these advantages, there can be little doubt that if amputation had been performed in the first instance, on the thirty-six out of the forty-three who died or only partially recovered, some twenty would have survived, able, for the most part, to support themselves with a moderate pension, instead of there being perhaps five, or at most ten, nearly unable to do anything for themselves. Baron Larrey, with the élite of the military surgeons of France, as well as of those of Germany, have maintained this opinion; and the result of the practice as yet observed in the Crimea essentially confirms it, partly from the greater extent of mischief done to the bone by the large needle two-ounce rifle bullets of the Russians, and partly perhaps from the want of the accommodation and appliances which the circumstances of the siege of Sebastopol did not admit of. In the present state of our knowledge, it is perhaps the safest practice, particularly under doubtful circumstances, in which it cannot be ascertained whether rest, the best surgical care, and comfort may not be wanting; without all which a favorable result cannot be expected.
144. War is an agreeable occupation, trade, or professional employment for the few only, not for the many; and particularly not for the poor, when they have the misfortune to have their limbs broken by musket-shot. There are very few men in England who know what are the first principles of a medico-military movement with an army in the field; and it will not materially signify whether there should be even one so instructed, until the nation at large shall be impressed with the idea that no expense, no trouble, ought to be spared to obtain for their soldiers so unhappily injured the utmost comfort and accommodation that can be procured for them, as well as the best surgical assistance. The first was little attended to in England during three-fourths of the Peninsular war; and the latter was supposed to be obtained, when the demand was urgent, by giving a warrant to kill or cure to persons as dressers who were unable to undergo an examination with any prospect of success, and prove themselves worthy a commission. Many a gallant soldier lost his life from the want of that proper attendance and care alluded to; many a desolate and unhappy mother mourned the loss of a son she need not have mourned for under happier circumstances, and who might have been the support, the happiness, of her declining years. Yet England calls herself the most humane, as well as the greatest, nation upon earth; she claims to be the most civilized, and she may be so; but certainly, in the case of those who have hitherto fallen in her defense, she could not on many occasions have been more careless or less compassionate. I have endeavored to impress on the directors of the East India Company in particular the injustice, the carelessness, of their treatment of the wounded soldiers of the royal army of Great Britain. My remonstrances have hitherto been in great part useless. It is to be hoped, however, that the present War Minister will cause an official public inquiry to be made into this matter, for that alone can cause this grievance to be redressed. Old habits are not to be overcome but by public opinion.
145. The peculiar difficulty in treating a gunshot fracture takes place when the bone is splintered for some distance, as well as broken. In these cases, inflammation occurs internally in the membranous covering of the cancellated structure of the bone, ending in the death of the parts affected; while the periosteum takes on that peculiar action externally which ends in the deposition of ossific matter around the splinters which have lost their life, and are enveloped by it. The bony matter, at first small in quantity, is gradually augmented, and deposited for some distance in the surrounding parts, so that it has been known to include the neighboring vessels and nerves in less than twenty days; at the end of a few weeks the quantity of ossific deposit is often very remarkable. Each splinter of bone becomes the sequestrum of a necrosis, in a similar manner as it is known to occur in the bones of young persons spontaneously affected by that disease, with this essential difference, that in the idiopathic disease there is only one, as if worm eaten, sequestrum, perhaps the length of the shaft of the bone, easily removable by one operation, while there may be in the traumatic disease several dead centers of ossific deposit, each of which requires to be removed by an operation to effect a cure. This new bony deposit will often be half an inch and more in thickness, and at a late period is as hard as the old bone. The repetition of operations required in such cases is very distressing, particularly in the thigh, in which the disease often continues for months, and even for years.
The following case, related by Colonel Wilton, is instructive: “Lieutenant Timbrell, late of my old regiment, the 31st, had both his thighs broken at the battle of Sobraon; he would not allow amputation, so the doctor put him in a boarded ‘dooley,’ and his legs in a kind of trough. As I was also wounded, I used to see him almost daily, and I never heard him complain except the days when the doctor tried to extend his legs. Some time after our return to England (perhaps seven or eight months) I went to visit him, and found him quite recovered, and able to enjoy a day’s shooting as well as most people. He showed me many pieces of bone which had come away from his wounds, and appeared to have lost about three inches of his height; his limbs were rather bowed. He is now paymaster of the 6th Foot; and when I saw him, a few days before he embarked for the Cape, he was as active as ever, although I do not think he could either run or jump.”
146. A musket-ball will often lodge in the less dense parts of bones, such as the great trochanter or the condyles of the femur, without fracturing the bone; it will sometimes even pass through the femur above and between the condyles, merely splitting, but without separating the bone in parts or pieces. Balls sometimes lodge in the shaft of the femur without breaking it, and frequently do so in the tibia, the humerus, the bones of the cranium, and even in others of less size. Balls thus lodged will sometimes remain for years—nay, during a long life—without causing much inconvenience. It is, however, generally the reverse, and they are often the cause of so much irritation and distress that the sufferers are willing to have them, and even their limbs, removed at last at any risk. Whenever, then, a ball can be felt sticking in a bone, although it cannot be brought into view, it should, if possible, be dislodged and removed by the trephine, by small chisels, by small, strong-pointed curved elevators, or by any of the screws invented for the purpose, which have sometimes been found efficient. An apparently useful instrument of this kind is attached to the forceps for extracting balls; it is more frequently used in France than in England. When the ball can be seen as well as felt, the surgeon must be guided by his own experience and judgment with respect to the most fitting instruments. It is to be removed if possible, whatever may be the means used for its abduction, after the wound has been properly enlarged for the purpose.
147. When a ball merely grazes a bone without breaking it, and passes through the limb, and no splinters can be felt by the finger, dilatation is unnecessary in the first instance; although some small splinters may be cast off subsequently, or a layer of bone may exfoliate, requiring assistance for their removal.
The bone may be fractured in a case of this kind transversely, and will require only the simplest treatment in an almost similar manner.
148. If the ball should enter and be flattened against the bone without breaking it, and lodge against it or in the soft parts, it should be sought for and removed. When the ball is flattened and the bone broken, it may lie between the broken extremities, and even lodge in one of them, rendering the case more complicated, and the necessity for close investigation more urgent. A leaden ball when striking on the sharp edge of a long bone, such as the spine of the tibia, has been known to be divided on it, without the bone being broken. This has happened in the arm.
149. When a ball strikes the shaft of a bone, such as the femur, directly and with force, it shatters it often in large, long, and pointed pieces, retaining their attachment to the muscles inserted into them. A fracture of this nature in the middle of the thigh will often extend downward into the condyles, and as high as, although rarely into, the trochanters. These are cases for immediate amputation.
150. Gunshot fractures of the head and neck of the femur have hitherto been fatal injuries, unless the whole extremity has been removed. It is hoped death may be prevented without this most formidable operation, by the removal of the head and neck of the bone, according to aphorism 85. If the upper third of the femur below the trochanter be badly fractured, and an attempt be made to save the limb, death generally occurs after several weeks of intense suffering, more particularly when the bone is broken by the large two-ounce balls now used by the Russians in the Crimea.
The least dangerous and the most likely to be saved are fractures of the lower third, or at most of the lower half, of the thigh-bone. When they do not communicate with the knee-joint, an attempt ought always to be made to save the limb.
151. The preservation of a femur fractured by a musket-ball, when splintered to any extent, ought only to be attempted if the principal splinters can be removed. When the splinters of the femur are long and large, it has been supposed that if they retain their attachment to the soft parts, they may be placed in apposition and preserved. This may be doubted. It ought, however, only to be attempted under the most favorable circumstances, and will not often succeed even then. In the humerus it is different. An examination by the finger in the first instance is necessary to ascertain the extent of the injury to the bone, and to enable the surgeon to remove the broken portions, as well as the ball or any extraneous substances which may be in the wound. The incisions necessarily required for this purpose in the thigh are sometimes neglected, or the surgeon refrains from making them from the great thickness of the muscular parts, and from the wound having taken place on the inside, near the great vessels, so as to render incisions of sufficient size or extent in some degree dangerous. The thickness of the muscular parts is not a sufficient reason for avoiding an incision, neither is the vicinity of the great vessels and nerves, although they may not be divided; if the situation of the bone on the outside of the thigh be attended to, the broken portions may sometimes be got at at that part, if not on the inside. If this cannot be done, amputation had better be had recourse to. The object of the examination of such a wound being to ascertain the state of the fracture, and to remove the splinters and any extraneous substances, the extent and number of the incisions must depend on them; the true principle of what has been called dilatation of wounds. If the ball should have merely struck and grazed the bone, and passed out, causing a transverse fracture only, there is no necessity for making incisions at the moment, although one or more may be subsequently required to aid in the discharge of an exfoliated piece of bone, or of a splinter which may have been overlooked. If the ball lodge deeply in the soft parts, after breaking the bone, it should be removed, if practicable, by a second or counter-opening, and a free vent should always be made for the discharge. It may, however, be laid down as a general rule, that whatever is likely to be required during the first few days had better be done on the first than on the second or third; for after inflammation has commenced, any handling or examination of the limb, however gently made, gives great pain.
152. After the first incisions have been made, and the larger splinters, which can be felt, have been removed, a secondary danger occurs from those which are smaller, and may have been overlooked, or not been discovered. This arises from the enveloping of these splinters in the new ossific matter described as being formed by the inflamed periosteum. This evil must be prevented by a careful examination of the wound when suppuration has been fully established, and the sensibility of the parts is in some degree diminished; when, if loose splinters of bone can be felt, they ought to be removed by incisions carefully and gently made to the extent which may be required. If this be not done early, the ossific deposit will take place around, and shut them in, even if the wound should close, which it usually will not. Their retention is accompanied by a firm thickening of the part, and in due course of time a spot of inflammation implies the formation of an abscess, and an ulcerated opening through the new bony deposit. When this abscess breaks externally, the probe will pass through the hole in the new bone, and rest on the rough, dead, and now perhaps movable splinter, the extraction of which can alone afford permanent relief. The earlier this is done the softer the ossific matter will be; at an early period, it will cut like Parmesan cheese intermixed with lime. If deferred until the bony matter is quite hard, it must be cut through with the chisel, or bone scissors or forceps, the application of which sometimes requires great force.
153. The successful treatment of a gunshot fracture of the thigh cannot be effected while the patient is lying on a little straw or a mat on the ground, and proper bedsteads should always form a part of the hospital stores of an army in the field. There is one in use at the Westminster Hospital, and another at the Royal Westminster Ophthalmic Hospital, which may be taken as models. Each, when complete, with mattress, etc., costs ten pounds, and, with a second inclined plane and mattress, might answer for two fractures; six may be easily carried in any common or spring cart wherever they are wanted. They would alleviate the sufferings, the horrible torments, many suffer unnecessarily. There is a very good and even cheaper one in use in the London Hospital, well worthy attention. An instrument or iron machine, movable from bed to bed, has been invented by Dr. Thomson, of Stratford-on-Avon, which lifts a man readily from his bed, and, after he has been dressed, lays him down again with ease in a similar manner to the bedstead alluded to. It has, however, the advantage of being movable, while the apparatus in the bedstead is fixed. Lord Strafford has sent one to his regiment, the Coldstream Guards, and Dr. Thomson has sent another. Young backs and young knees only can bend for consecutive hours over men lying on the ground. Doctors of fifty years of age cannot do it; they are physically unequal to the labor. A staff-surgeon half a century old on a field of battle is almost an absurdity in the art, if not in the science of surgery: he ought to be promoted to the rank of inspector. The custom of the present day is to promote men more on account of the length of their services than because of their value: whereas, to make good physicians and surgeons, it should be from their value, combined with a due regard to a moderate yet sufficient length of service, which certainly should never exceed, even if it amounted to, twenty years; ten or twelve, in time of war, would be better,—a matter of expense against life and human misery.
154. The position of the patient in a gunshot fracture of the thigh or leg is of the utmost importance. He should lie on his back, and the limb should be straight. It is almost impossible to keep a man’s thigh in the bent position, or on its side, without his turning on his back, and the union of the bone, if it take place at all, must then be at an angle. The bent position forward, or on an inclined plane, is defective, inasmuch as the matter, which must necessarily be secreted in great quantity, will gravitate backward in spite of every care to prevent it. When a proper bedstead is used, a slightly inclined plane will sometimes be advantageous at a later period, when the body may also be raised, even to the erect position, the principal object being to take off the action of the two muscles inserted into the smaller trochanter, which, with the rotators behind, raise and evert the upper end of the broken bone. This direction outward should be met by a similar direction of the lower part of the bone, and by the application, from time to time, of a proper splint, compress, and bandage on the elevated bone, if they can be borne with perfect ease.
155. Splints are of various kinds, and made of different substances. The discovery of gutta-percha has enabled some to be made of that substance, which, when moulded into sheets, of from one to two or three eighths of an inch in thickness, can be rendered soft and pliable by the application of hot water, regaining its firmness as it dries. Splints can thus be made of any size or length, and of any form, with apertures, if necessary, for the passage of the discharge from the wounds. Leather tanned without oil, and called splint-leather, is equally useful; if, when dried, the splints thus made become too hard, and press unequally, they can be softened by hot water, and removed and replaced with little comparative inconvenience.
One wooden splint of more than the length of the limb, somewhat similar to that called Desault’s, is absolutely necessary for the thigh, if it can be borne, which it rarely can, as a means of extension, or rather of preserving length. A shorter one on the inside, and one behind, will sometimes be required to complete the set A short one may be wanting for occasional use in front.
156. The bones of the leg being more exposed, admit of greater liberties being taken with them, and of larger portions, or even parts, being taken away successfully, than ought to be attempted in the thigh. A leg should, therefore, be seldom amputated for a fracture from a musket-ball. The splinters should be removed to almost any extent and number, and irregular portions sawn off from both ends, if they should be thus implicated. If one bone of the leg remain uninjured, the case becomes comparatively simple. The position should be straight on the heel, as a general rule, admitting of few exceptions.
157. The best apparatus for a compound fracture of the leg in either civil or military surgery, particularly in the latter, is that contrived by Mr. Luke, which may be seen in use at the London Hospital, and is supplied by Mr. M’Lellan, 3 Turner Street, Whitechapel Road. It is a simple iron cradle of small size, such as is used to guard a limb from the weight of the bedclothes, composed of three bars or large segments of a circle, united at their middles and ends or sides, as all cradles are, by a bar of iron of equal thickness. This is placed on a board a little wider than itself, with a ledge or bar at each side to prevent the cradle from moving, aided by two buttons or little pieces of wood on each side, which, being movable, turn over the iron bars, and thus render the board and cradle one firm piece. In this the leg is to be slung, to the center bar above, by ordinary tapes. A splint made of copper, to prevent rust or injury, hollowed to receive the leg, extending beyond the foot with a footboard, and beyond the condyles of the femur above, enables the tapes to be passed under the limb for slinging it; while from the extension of the splint beyond the condyles, it causes the leg and thigh to move together, in a manner which will often prevent the pain which follows a sudden motion of the patient. Solid wooden side splints are still wanting, and these should have holes cut in them to allow a vent for the discharge and for the application of dressings; or if a portion of the splint, say the middle, should require removal altogether for this purpose, the upper and lower parts may be united by a semicircular bar of iron, at the pleasure of the surgeon; within this the dressings may be applied, and by it the splint will be rendered firm.[3] When the leg is thus slung, the knee will be somewhat bent, the thigh raised, the muscles of the leg behind relaxed, and the patient can be moved with much greater facility than with any other apparatus; one great advantage of this apparatus is, that it can be used with effect even if the patient be obliged to lie on the ground. It admits of being slung as a whole in a spring-cart, by additional but strong, elastic straps fastened to or applied on the under part of the board, and thus a double slinging motion may be obtained when the sufferer is obliged to be moved.
[3] This apparatus has, I think, been improved upon at the Bristol Hospital by the addition of a bar on each side of the center one.
These splints are so portable that they may be carried into the field or upon the deck of a ship, to bring the patient to the surgeon.
In using the apparatus, the back of the leg and lower end of the thigh are to be evenly supported on a pad placed on the leg-rest; a splint is to be placed on each side of the leg, and the whole secured by straps carried around near the knee and ankle. The leg is then to be suspended by two straps from the bar of the cradle placed over the leg as represented, so as to swing without touching the folding board on which the cradle is placed. The foot should be secured to the foot-piece by a bandage.
Solid splints, and a firmly-fixed cradle, under which the leg may hang, may be said to be the sine qua non of the treatment of a gunshot fracture of the leg. The French in the Crimea have an apparatus called a GOUTTIÈRE, to be hereafter noticed.
158. Half-a-dozen pairs of long poles made light and of tough wood, which might always be replaced without difficulty, and a good thick ticking for each pair, having a case or pipe on each side in which the poles might run, ought to be a part of the surgical stores of every regiment on service in time of war. Two short irons, having at each end a ring through which the poles may run, will keep the ticking or sacking extended, and the patient flat and immovable unless shaken by accident. The sacking will roll up into little compass, if the poles should not be forthcoming or are not wanted, and, when the ground is damp, will make an excellent bedstead as well as a covering for the doctor. If four legs be added to each bearer, a great facility will be obtained on halting when the carriers are tired, the sufferer being raised from the ground, which in muddy or boggy places is very desirable.
159. The arm, when fractured by musket-shot, admits even of more strenuous efforts being made to save it; from its smaller size, and the more ready exposure of the bone or bones when badly broken, the danger is less. If an artery should yield by ulceration, it should be laid bare by operation, and a ligature placed on each bleeding end. An additional or second wound in the forearm only complicates the case, and the loss of a finger or two does not augment the danger. In fact, amputation should rarely take place in the first instance, and only in the second when mortification has commenced, or the strength and health of the patient will no longer bear the drain upon them. The head of the bone should be removed, with as much of the shaft as may be injured; the elbow-joint should be excised, if the condyles are destroyed and the joint injured; if the middle of the bone should be destroyed, the upper and lower ends of it should be approximated. A great advantage is derived from the facility with which the upper extremity can be supported as compared with the lower, and the aid to the general health which may be obtained from the locomotion sufferers with broken arms are capable of undergoing.
160. In making incisions for the removal of splinters of bone, both at an early and at a late period, particularly in the latter, when the soft parts are all impacted together, and nothing is gained beyond what is cut, the course of the trunks of nerves, as well as of the great arteries, should be carefully attended to, and those parts avoided; for a successful cure of the fracture will be much deteriorated in value, if accompanied by a loss of motion or of sensation in the hand or fingers.
161. Splints for the arm should be made of solid materials, although light; some a little hollowed, and at a right angle, to correspond with the bend of the arm, and to admit of a little motion of the radius and of the forearm and hand, which relieves the position, is more comfortable for the sufferer, and tends to prevent stiffness of the elbow. The pads of lining for the splints should be made of cleaned or carded wool, rather than of tow or old linen, protected by some one or other of the modern modifications of caoutchouc or gutta-percha.
162. The medical treatment of compound fractures should be directed to allay pain and to prevent as far as possible any excess of general irritation and fever; to sustain, at a subsequent period, the strength of the sufferer by appropriate medicines, good and sufficient diet, and a free circulation of air, without all which little can be expected, to say nothing of absolute rest and those ordinary attentions and comforts so necessary for the restoration of health.
163. The following returns are illustrative of the principles recommended with reference to primary and secondary amputations. The first two show the seats of injury in 1359 persons wounded and admitted into hospital after the battle of Toulouse. The fifth return should be considered rather as an approximation to the truth than as the exact truth, as it does not include those who died on the field of Waterloo, but those only who reached Brussels, and does not include those who were sent to Antwerp.
No. 1.—Return of Surgical Cases treated and Capital Operations performed in the General Hospital at Toulouse, from April 10th to June 28th, 1814.
| DISEASES AND STATE OF WOUNDS. | Total treated. | Died. | Dis- charged to duty. | Transferred to Bourdeaux. | Proportion of death to the number treated. |
| Head | 95 | 17 | 25 | 53 | 1 in 5-10/17 |
| Chest | 96 | 35 | 14 | 47 | 1 in 2-35/96 |
| Abdomen | 104 | 24 | 21 | 59 | 1 in 4-1/3 |
| Super’r extrem’s | 304 | 3 | 96 | 205 | 1 in 101 |
| Inferior ditto | 498 | 21 | 150 | 327 | 1 in 23-5/7 |
| Comp’d fractures | 78 | 29 | ... | 49 | 1 in 2-20/29 |
| Wounds of spine | 3 | 3 | ... | ... | 1 in 1 |
| Wounds of joints | 16 | 4 | ... | 12 | 1 in 4 |
| Amputations— | |||||
| Arm 7} Leg and thigh 41} | 48 | 10 | ... | 38 | 1 in 5-1/3 |
| Total | 1242 | 146 | 306 | 790 | 1 in 8-128/145 |
Wounded officers 117, not included, making a total of 1359, among whom thirteen cases of tetanus occurred, all of which proved fatal.
No. 2.—Officers.
| NATURE Of WOUNDS. | Admitted. | Dis- charged. | Sent to Bordeaux. | Died. | Remaining. |
| Head | 6 | 4 | 1 | ... | 1 |
| Chest | 10 | 2 | 2 | ... | 6 |
| Abdomen | 1 | ... | ... | ... | 1 |
| Sup’r extremities | 33 | 9 | 15 | ... | 9 |
| Inferior ditto | 49 | 12 | 21 | 1 | 15 |
| Comp’d fractures | 7 | ... | 1 | 2 | 4 |
| Slight wounds | 11 | 7 | 2 | ... | 2 |
| Total | 117 | 34 | 42 | 3 | 38 |
One secondary amputation of the arm occurred, and recovered; four of the inferior extremities, of which one died from tetanus. The thirty-eight remaining eventually went to Bordeaux, and thence to England.
No. 3.—Return of Capital Operations performed at the Hospital Stations of the Army in Spain, between the 21st of June and 24th of December, 1813, including the battles of Vittoria, the Pyrenees, and San Sebastian, to the entrance into France.
| STATIONS. | OPERATIONS. | No. operated upon. | Died. | Dis- charged cured. | Under treat- ment. | REMARKS. |
| Vittoria | Shoulder- joint | 13 | 10 | 2 | 1 | |
| Upper extremities | 108 | 58 | 40 | 10 | ||
| Lower ditto | 148 | 95 | 38 | 15 | ||
| Trepan | 3 | 3 | ||||
| Santander | Upper extremities | 22 | 5 | 8 | 9 | |
| Lower ditto | 23 | 9 | 6 | 8 | ||
| Bilbao | Shoulder- joint | 5 | 5 | {The great {number {of amputations at {this station {was in part {occasioned by {hospital {gangrene. | ||
| Upper extremities | 146 | 48 | 46 | 52 | ||
| Lower ditto | 68 | 36 | 16 | 16 | ||
| Aneurism | 1 | 1 | ||||
| Passages | Shoulder- joint | 1 | ... | ... | 1 | |
| Upper extremities | 11 | 1 | 3 | 7 | ||
| Lower ditto | 14 | 6 | 3 | 5 | ||
| Trepan | 3 | 2 | 1 | |||
| Aneurism | 1 | 1 | ||||
| Vera | Upper extremities | 12 | 4 | 8 | ||
| Lower ditto | 5 | 3 | 2 | |||
| Total | 584 | 287 | 173 | 124 | ||
| Recapitulation:— | ||||||
| Shoulder- joint | 19 | 15 | 2 | 2 | ||
| Upper extremities | 299 | 116 | 105 | 78 | ||
| Lower ditto | 258 | 149 | 65 | 44 | ||
| Trepan | 6 | 5 | 1 | |||
| Aneurism | 2 | 2 |
If one-sixth of the number remaining under treatment be considered to have died, which is a low calculation, the deaths will stand to the recoveries as 300 dead to 276 recovered, or a loss of more than one-half of the secondary operations.
