According to the velocity and ruggedness of the missile, will an artery bleed immediately, or at some more remote period; but in the majority of instances, the hemorrhage is primary, and if it be the principal artery of a limb, so much is instanta neously lost as to produce syncope; if the surgeon is on the spot at the time, a tourniquet should be loosely applied, the artery cut down upon, and secured above and below the wound, but at a little distance from it, to avoid its being involved in the inflammatory action of the wound, which must fol low. But if the surgeon is not at hand, and inflam mation has begun, a tourniquet must be loosely applied, and an assistant appointed to watch until sloughing and suppuration have taken place; and if then secondary hemorrhage ensues, the artery must be secured; but secondary hemorrhage is so rare, that not above four in the 1000 are attacked with it.
In musket-bullet wounds of the hand or foot, the bones of these are generally fractured, and in the treatment, we must always keep in view, that gun shot wounds are more contused than others. The other bones of the extremities when struck with musket-bullets, are also very often fractured, and commonly splintered, and require the same treat ment as decribed under fractures, bearing in mind that immediate amputation is more necessary in compound fractures from gunshot, than front any other causes. When a musket-bullet runs close beneath or centrad of the fascia of the arm or leg, it not unfrequently produces erysipelas phlegmo nodes, which, besides the treatment already recom mended for such, often requires the orifices of the wound to be enlarged. Wounds of the joints generally demand immediate amputation, for such a degree of inflammation and fever with suppuration follow, that the individual sinks under it, and there is no opportunity for secondary amputation.
When a musket-bullet is arrested in the body, and not situated in the contiguity of a vital or im portant organ, it ought to be abstracted wherever that is practicable, even if lodged in a bone, and as it generally prevents the wound healing, and produces inflammation, suppuration, and sinuses, and may prove an annoyance to the patient in after life, sometimes causing lameness if situated in the leg. All the bullet forceps and probes invented are of little or no avail, the finger in many cases being only admissible: the limb of the patient should be laid in the attitude in which it was wounded, and the left hand placed opposite the wound, into which the fore-finger of the right hand is to be inserted. If this fails, the patient should be requested to move gently the limb in various ways, and the seat of the bullet may by this means be as certained, and removed, due attention being paid to important objects, for when situated near a large blood-vessel, it ought to be allowed to remain. If the bullet which continues in the body is lodged in cellular or muscular substance, and produces no immediate irritation, a membranous cyst is gra dually formed around it, which adheres so close as to be with difficulty detached in a few months afterwards; and when situated close to a bone, the periosteum forms an osseous pouch. Sometimes they gravitate down a limb before becoming thus imbedded, and occasionally excite the formation of abscesses at a later period; at other times they excite so severe a pain that they compel the patient to have them extracted. From the earliest records of surgery there have existed much diversity of opinion and discussion, upon the propriety and manner of extracting bullets and other foreign bodies on the receipt of a wound. With respect to dilatation, it is now an axiom in British military surgery, never to dilate, unless necessity requires it.
Wounds inflicted by large shot, named large round, double-headed or bar-shot, grape, cannister, langrel, langrage, and shells, only differ from those caused by musket-shot, in the greater destruction of the part, and the more violent constitutional de rangement; for in musket-bullet wounds, unless the head, knee-joint or some important organ be in jured, there is trifling constitutional derangement on receipt of the wound. In severe wounds from cannon-shot, there is a dreadful concussion of the nervous and circulating systems, the patient has a pallid anxious countenance, a cold clammy skin, a feeble pulse, and most acute pain. In such a
condition of the constitution, and supposing the knee-joint the seat of the injury, amputation cannot be performed any more here than in compound fractures of the bones forming this joint; and if the patient has lost much blood, there will be probably convulsive motions of the limb, and even of the whole body, together with irritability of the stomach, hiccup, wavering of the intellect, and extremely feeble voice, and a pulse scarcely perceptible. These constitutional symptoms, however, are said by Dr. Quarrier not to be always present. When the patient rallies, which will be after a longer or shorter time, according to the extent and nature of the injury, and the idiosyncracy of his consti tution, for no precise period can be mentioned as described by authors on this subject, amputation should be performed. The rallying of the patient is characterized by pain, and a sensation of heat in the wound, a warmth of the skin, a quickness of the pulse, and thirst. There is another reason against immediate amputation, when the patient has been exposed to external cold after the receipt of the wound, for he then becomes in a measure frost-bitten, and requires to be thawed. On the propriety of immediate amputation, according to the hitherto received idea of this expression, there has existed much diversity of opinion from the early part of the sixteenth century. Dr. Quarrier and the other medical staff who were at the battle of Algiers, consider the expression " immediate" to apply to amputation performed as soon after the receipt of a wound as possible; while it had been formerly applied to the operation, whenever the system had rallied from the shock received by the wound, and contradistinguished from amputation performed when suppuration had taken place. The advocates for primary amputation, or when the constitution has rallied from the shock of the wound, are Du Chesne, Wiseman, Dionis, Le Dran, Ranby, Faure, De la Martiniere, Morand, Van Geseher, Pott, Schmucker, Boy, J. Bell, Dupuytren, Sanson, Begin, Larrey, Graefe, Guthrie, Thomson and Hennen. The advocates for secondary ampu tation, or when suppuration has taken place, are, Le Conte, Boucher, Bagieu, Bilguer, Percy, Sahatier, Mehee, and J. Hunter. Drs. Dewar and Quarrier, and Mr. C. Hutchison, recommend am putation instantaneously after the receipt of the wound, and contend that constitutional symptoms do not take place immediately; indeed the latter surgeon treats with contempt nervous commotion occurring to British seamen or soldiers: so that the only way of reconciling the opposite sentiments of Drs. Dewar, Quarrier, and C. Hutchison, with those of Drs. Hennen and Guthrie, is, that in the navy a man is brought instantaneously after being wounded to the surgeon, before constitutional symp toms have had time to appear, which, says Dr. Hennen, is a much earlier opportunity than any army surgeon can possibly enjoy; whereas a few minutes at least must elapse before the army sur geon can arrive at the wounded soldier, however fleet or active his ambulance may be. It is to be feared this instantaneous amputation was per formed indiscriminately in the reign of Louis the XIV., which from its fatality alarmed him and all France. There appears two conditions of the constitution after gunshot wounds, the one wherein no commotion follows, as in the seamen at the battle of Algiers; and the other wherein nervous agitation exists, as occurred to the duke of Monte bello, narrated by Larrey: that in the former, amputation may be instantaneously performed; while in the latter, some time must be allowed to elapse; and even both Mr. Guthrie and Mr. C. Hutchison recommend these methods of practice. In amputation of the upper or proximal third of the thigh, the operation is allowed by all writers on this,, subject to be seldom cr ever successful; and many cases are on record of those wounded in this region dying in a few minutes, before ampu tation could be performed.