ON COMPOUND FRACTURES._Commentaries on the Surgery of the War in Portugal, Spain, France, and the Netherlands from the battle of Roliça, in 1808, to that of Waterloo, in 1815; with additions relating to those in the Crimea in 1854-55, showing the improvements made during and since that period in the great art and science of surgery on all the subjects to which they relate.

141. 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.

[Footnote 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.]

[Illustration]

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._

+-----------------+--------+-----+--------+-----------+----------------+

+-----------------+--------+-----+--------+-----------+----------------+

|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 |

| | | | | | |

| | | | | | |

|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.

+-----------------+---------+------------+---------+-----+----------+

+-----------------+---------+------------+---------+-----+----------+

|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._

+---------+-----------+--------+-----+-------+-------+------------+

+---------+-----------+--------+-----+-------+-------+------------+

| |joint | 13| 10 | 2 | 1 | |

| |extremities| 108| 58 | 40 | 10 | |

| |Lower ditto| 148| 95 | 38 | 15 | |

| |Trepan | 3| 3 | | | |

| | | | | | | |

| |extremities| 22| 5 | 8 | 9 | |

| |Lower ditto| 23| 9 | 6 | 8 | |

| | | | | | | |

|Bilbao |Shoulder- | | | | |{The great |

| |joint | 5| 5 | | |{number of |

| |Upper | | | | |{amputations|

| |extremities| 146| 48 | 46 | 52 |{at this |

| |Lower ditto| 68| 36 | 16 | 16 |{station was|

| |Aneurism | 1| 1 | | |{in part |

| | | | | | |{occasioned |

| | | | | | |{by hospital|

| | | | | | |{gangrene. |

| | | | | | | |

| |joint | 1| ... | ... | 1 | |

| |extremities| 11| 1 | 3 | 7 | |

| |Lower ditto| 14| 6 | 3 | 5 | |

| |Trepan | 3| 2 | 1 | | |

| |Aneurism | 1| 1 | | | |

| | | | | | | |

| |extremities| 12| 4 | 8 | | |

| |Lower ditto| 5| 3 | 2 | | |

| | +--------+-----+-------+-------+ |

| |Total | 584| 287 | 173 | 124 | |

| +-----------+--------+-----+-------+-------+ |

| joint | 19| 15 | 2 | 2 | |

| 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.

No. 4.--CAPITAL OPERATIONS _performed in the Field with Divisions of

the Army during the same period_.

|DIVISIONS.

| |OPERATIONS.

| | |Number operated upon.

| | | |Died.

+--------+--------------+-----+-----+-----+-----+-----+--------------+

| |extremities | 3 | 1 | 2 | | | |

| |Lower ditto | 3 | 2 | 1 | | | |

|First |Shoulder-joint| 3 | ... | 2 | ... | ... | 1}Sent |

|division|Upper | | | | | | }to |

| |extremities | 14 | 1 | 3 | 5 | ... | 5}General |

| |Lower ditto | 10 | 2 | ... | 1 | 1 | 6}Hospital. |

| |Trepan | 2 | 2 | | | | |

|Second |Shoulder-joint| 1 | ... | 1 | | | |

| |Upper | | | | | | 5}Sent to |

| |extremities | 16 | ... | 5 | 6 | ... | }General |

| |Lower ditto | 21 | 3 | 6 | 7 | ... | 5}Hospital. |

| |Aneurism | 1 | ... | ... | 1 | | |

|Third |Shoulder-joint| 1 | ... | ... | 1 | | |

| |extremities | 17 | 2 | ... | 15 | | |

| |Lower ditto | 10 | ... | 2 | 8 | | |

| |extremities | 10 | ... | 10 | | | |

| |Lower ditto | 20 | ... | 20 | | | |

|Fifth |Shoulder-joint| 12 | ... | 8 | 2 | ... | 2}Sent |

| |Upper | | | | | | }to |

| |extremities | 57 | 1 | 36 | 2 | ... |18}General |

| |Lower ditto | 41 | 10 | 13 | 2 | ... |16} Hospital. |

|Sixth |Shoulder-joint| 1 | 1 | | | | |

| |Upper | | | | | | 2}Sent to |

| |extremities | 7 | ... | 5 | ... | ... | }General |

| |Lower ditto | 6 | 1 | 1 | 3 | ... | 1}Hospital. |

|Seventh |Upper | | | | | |14}Sent to |

| |extremities | 18 | ... | 3 | 1 | ... | }General |

| |Lower ditto | 9 | 1 | ... | 1 | ... | 7}Hospital. |

| | | | | | | |}The whole |

|Light |Shoulder-joint| 1 | ... | ... | ... | ... |}of these |

|division|Upper | 21 | ... | ... | ... | ... |}cases sent to|

| |extremities | | | | | |}the General |

| |Lower ditto | 8 | ... | ... | ... | ... |}Hospital; |

| |Trepan | 4 | ... | ... | ... | ... |}results not |

| | | | | | | |}known at |

| | | | | | | |}the division.|

| | +-----+-----+-----+-----+-----+ |

| | Total | 317 | 27 | 118 | 55 | 1 | |

| +--------------+-----+-----+-----+-----+-----+ |

| Shoulder-joint| 19 | 1 | 11 | 3 | ... | 4}Sent |

| Upper | | | | | | }to |

| extremities | 163 | 5 | 64 | 29 | ... |65}General |

| Lower ditto | 128 | 19 | 43 | 22 | ... |44}Hospital. |

| Trepan | 6 | 2 | ... | ... | ... | 4} |

| Aneurism | 1 | ... | ... | 1 | ... | |

+-----------------------+-----+-----+-----+-----+-----+--------------+

Of 310 amputations 25 died, 172 recovered in the field, and 113 were

sent to the rear, of whom one-sixth may be considered to have died,

making a total of 45 deaths in 310 cases--the proportion of upper

extremities to lower in the 310 being as 182 to 128, thus greatly

influencing the result, which is consequently much more favorable

than if the numbers had been reversed. The proportion of upper to

lower extremities in the secondary amputations, as by return No. 3,

is equally in favor of the upper, and can only be accounted for, when

compared with Return No. 4, by the army being constantly in motion and

the hospitals at a distance. The difference of results at the several

stations is also remarkable; it is so with the divisions in the field.

The 3d and 4th divisions, under Staff-Surgeons Lindsey and Boutflower,

kept their amputations with them in bivouac, and their success is

remarkable; that of the 4th division has no parallel. The light

division, on outpost duty, could not keep their amputations. These two

returns include 886 amputations.

The labors of the surgeons of the army may be judged of by the fact

that, during the last three months of the year to which these returns

refer--viz., from September 25th to December 24th, 1813--the number of

sick and wounded amounted to 37,144, a number nearly equal to that of

the whole army.

No. 5.--RETURN _of_ CAPITAL OPERATIONS, _Primary and Secondary,

performed in the British General Hospitals, Brussels, or brought in

from the Field between 16th June and 31st July, 1815_.

|OPERATIONS.

| |General total.

| | |Primary operations.

| | | |Died.

+---------+---+---+---+---+-------+---+---+---+------+---+--+--+--------+

| joint | 8| 6| 1| 5|1 to 6| 12| 6| 6|1 to 2| 11| | | |

|Hip-joint| 1|...|...|...|... ...| 1|...| 1|......| 1|..|..|A French|

| | | | | | | | | | | | | |who |

| | | | | | | | | | | | | | ed. |

|Thigh |148| 54| 19| 35|1 to 3| 94| 43| 51|1 to 2| 86| 9| 4| |

|Leg | 93| 43| 7| 26|1 to 6| 50| 16| 34|1 to 3| 60|..| 4| |

|Arm | 72| 21| 4| 17|1 to 5| 51| 13| 38|1 to 4| 55|..| 6| |

|Forearm | 39| 22| 1| 21|1 to 22| 17| 5| 12|1 to 3| 33|..| 3| |

| tied | 1|...|...|...|... ...| 1|...| 1|......| 1|..|..| |

|Trephine | 2|...|...|...|... ...| 2| 1| 1|1 to 2| 1|..| 1| |

| +---+---+---+---+-------+---+---+---+------+---+--+--+ |

|Total |374|146| 32|104|... ...|228| 84|144|......|248| 9|18| |

+---------+---+---+---+---+-------+---+---+---+------+---+--+--+--------+

Commentaries on the Surgery of the War in Portugal, Spain, France, and the Netherlands from the battle of Roliça, in 1808, to that of Waterloo, in 1815; with additions relating to those in the Crimea in 1854-55, showing the improvements made during and since that period in the great art and science of surgery on all the subjects to which they relate. · 第 64 / 129 题