Hospital. He was then quite convalescent. On the 28th of the following October, I saw him in Tien-tsin, on my return from Pekin, at which time he looked pale, but was in good spirits; his digestion was good, his tongue clean, and his bladder acted perfectly. The wound in the back was covered by a small scab; that in the abdomen had quite healed, and left a small triangular cicatrix. He complained that he sometimes had "a drag in his belly," when he straightened himself up, and also when his bowels were costive, but that generally they were rather free." In other respects he was quite well.

66

In this case it is clear that the weapon passed through the abdomen without injuring the intestines, or any other important part, except the peritoneum.

In the "Medical Times and Gazette," of the 6th of May, 1854, there is a somewhat similar case recorded by Mr. Gallwey, of the Artillery.

CASE OE EXCISION OF THE KNEE JOINT FOR SCROFULOUS DISEASE OF THE BONES.

By Staff Surgeon T. W. Fox, M.B., Army Medical Department.

HENRY FLAVIN, aged 5 years 10 months, the son of a soldier in the Royal Canadian Rifles, at Quebec, had suffered for about fifteen months with scrofulous disease of the right knee joint, which gained ground in spite of every constitutional and local remedy, and eventually threatened both the child's limb and life. Constant pain and restlessness impaired the general health; the face was thin and anxious, and the body very weak and emaciated; the leg was flexed back on the thigh, the hamstring muscles firmly co eted; any movement of the knee caused extreme pain, the joint was swollen and painful, and numerous sinuses existed, and discharged thin seropurulent matter. The probe, when introduced through these, grated against carious bone. Amputation, or resection, was the only alternative. I performed the latter on February 3rd, 1861. Chloroform having been administered, a slightly curved incision was made across the front of the joint, from condyle to condyle, just below the patella; the joint was laid open, the crucial ligaments were carefully divided on a director, to avoid the popliteal vessels, which are extremely near in a young child. It was found necessary to saw a slice nearly an inch thick off the femur, which was done from behind forwards, by a butcher's saw; a thin slice was next taken off the tibia, but the caries having eaten more deeply into the structure of that bone, another portion had to be sawn off-in all about an inch in depth. The whole of the patella, although healthy, was next removed, as recommended by Fergusson and others.

The cut surfaces of both bones were approximated as soon as the hæmorrhage, which was profuse, had been checked. The soft parts were brought together by fine sutures, and the limb, loosely bandaged, was placed in a nearly straight position, on a padded splint. The patient was then removed to bed, and ordered five drops of laudanum, and a little port wine occasionally. On the fourth day after the operation it was necessary, to keep the limb in a straight position laterally, to use a box with moveable sides. The box was well padded, especially under the upper end of tibia, which was inclined to sink below the level of the femur. The patient, still very weak, was ordered cod-liver oil, citrate of iron and quinine, and milk diet, with mutton chops and port wine. On the 29th February the wound had nearly healed, although a small sinus near the upper and inner part of tibia discharged a large quantity of pus. The health was much better, and sleep and appetite improved. On the 4th March the limb was put up in pasteboard, with starch bandage outside, with opening at knee through which to dress the sores, which were still open.

March 15th-Great difficulty in keeping the limb in proper position, owing chiefly to the open sores; a narrow splint is now applied behind the knee, and also a long straight splint from axilla to heel.

March 23rd.-Owing to fresh sores round the joint the long splint had to be removed; the limb is now supported by the narrow back splint only. In April and May the progress of the case was slow, owing to the amount of strumous cachexia, and periosteal abscesses above and below; and the necessary changes of appliances for keeping the limb in position consequent thereon. In June and July the health had so far improved, that although two small sores were still open, the child had become strong, plump, rosy and cheerful, and in the latter month was able, with a high heel to his boot, to walk about firmly without a stick, the limb being nearly straight, and the joint, or rather the bones at the knee, firmly consolidated.

March 24th, 1862.-The child is now in excellent health, and actually running about with the other boys, as happy and ruddy as any of them, and without even a very thick shoe, and the (formerly unsound) leg is only two inches, or less, shorter than the other. This appears to me of some importance, as it has been stated in medical writings, that in cases of resection of the knee in childhood, the growth of the limb is checked, and the shortening so great, as to render the leg useless, or nearly so.*

CASE OF UNUNITED FRACTURE OF TIBIA AND FIBULA.

By Surgeon J. M. S. FoGo, R.A.

A STRONG healthy-looking soldier, aged 25; of three years' service; an agricultural labourer before he enlisted.

On the 25th of July, 1859, at Norwich, while at gun-drill, and seated on a limber-box, the gun-carriage and limber were overturned, and he suffered fracture of the left leg. The tibia was broken transversely at the junction of the middle with the lower third, and the fibula three inches lower down, about three inches from the ankle-joint. The limb was put up in the usual way on Liston's double-inclined plane splint, where it was kept for ten weeks.

On the removal of the splint, it was discovered that the tibia had not united firmly; but that perfect union by bone had taken place between the broken ends of the fibula. There was a trace of syphilitic skin disease, and syphilis was conjectured as the cause of non-union.

He was ordered to Woolwich, and arrived on the 16th of February, 1860. The leg was encased in pasteboard splints, and a mixture of the iodide of potassium and syrup of the iodide of iron was ordered, with nutritious diet and plenty of green vegetables.

4th April, 1860.—The pasteboard splints were removed. Noted, that there was no attempt at union of the tibia, and the splints were replaced to allow his health to improve farther.

2nd May, 1860.-Starched bandages were carefully and strongly applied instead of the pasteboard splints.

"The lower extremity of the thigh-bone continues to grow towards the kneejoint long after the bone has ceased to grow towards the hip-joint; while the upper ends of the principal pieces of the leg bones continue to grow towards the knee-joint for a considerable time after growth has ceased towards the ankle-joint." "Excision of the knee-joint

is more often followed by decided shortening of the limb, because at the knee-joint growth chiefly advances." Aitken "On the Growth of the Recruit." London, 1862. Page 40.

1st June, 1860.-The starched bandages fitted well, and he was desired to walk about on the leg a little. The eruption was gone, and there was no trace of syphilis.

19th July, 1860.-The bandages were again removed, and it was discovered that no more union by bone had taken place, but that the fractured ends of the tibia did not admit of the same extent of motion as before; probably from the formation of fibrous tissue.

1st August, 1860. No real good having resulted from the prolonged application of the starched bandage, the medical officers of the garrison determined, in consultation, that an operation of a less severe character than sawing off the ends of the bone (as recommended by Mr. Syme for false joint) should be performed; more particularly as Mr. Syme's operation was considered unjustifiable in the present instance, in consequence of the fibula being sound.

3rd August, 1860.-The operation was performed, and consisted in introducing a long strong subcutaneous cutting knife (made for the purpose) under the integument, an inch from the seat of fracture, getting it between the ends of the bone, cutting through any fibrous tissue that had formed, and incising the ends of the bone so severely as to induce inflammation. The leg was afterwards put on a double-inclined splint, which was kept applied for six weeks.

Ten days after the operation, abscess formed about the seat of the inflammation that was set up. The pus found an easy means of exit by the recently before made wound on the introduction of the knife. The abscess was emptied twice or three times by pressure with the hand, and closed satisfactorily. From some cause phlegmonous erysipelas attacked the limb below the seat of fracture, and gave rise to great constitutional disturbance. Before discovered, as it was hidden by the bandages, it led to the supposition of the existence of pyæmia. Free incisions were made, he was put on brandy and beef-tea, and this complication terminated satisfactorily.

15th September, 1860.-The splint was removed, and the bone was discovered to have united; he described it himself to be "quite firm," and he could now rest his weight on the leg, although the muscles were much reduced. 31st October, 1860.-He was discharged from hospital to convalescent duty, to recruit his strength.

The case was most gratifying, as the bone seemed to have completely united by bone, although it was not quite straight. The knee and ankle were recovering from the stiffness produced by the lengthened application of splints and bandages, and it was expected that he would have a useful and strong leg when the muscles had again become well developed.

19th February, 1861.-As the leg is not quite straight, and he complains of it giving under him sometimes in walking over the rough pavement of the stables; also, as he can always make it the means of evading any duty; he was brought before a Medical Board, and discharged from the service.

14th July, 1862. --After his discharge from the service, he obtained a situation on a railway, and now writes to his old comrades that he is a luggage porter, and is quite strong on the leg.

REPORT ON FEVER (MALTA).

By Assistant-Surgeon J. A. MARSTON, M.D., Royal Artillery.

This Paper was written during the winter of 1860, and forwarded to the Army Medical Department the following summer. Revised 1863.]

During the year 1859, the garrison of Malta suffered severely from the epidemic prevalence of typhoïd or enteric fever. It is proposed to devote the present Paper to the subject of Fever generally, as an army disease, and to the forms of fever incidental to troops serving in the Mediterranean, using the records of the Royal Artillery Hospital, as a text only, on which to base the whole amount of my experience and observation.*

I have been led to this subject from several considerations; viz., the experience I have had of this class of diseases in Great Britain and abroad; the special attention I have been obliged to give to fever, as a disease of this station; the importance of fever (in its generic sense) as an army disease+; the causes affecting its prevalence; the relations which fevers of this climate bear to those observed at home; and the modification of the symptoms induced by climateric influences.

From inquiries that I have instituted, it appears that fever generally--and the enteric form in particular-prevails more amid the troops than the natives of the Island.

Table of Fever for the Half Year ending December 31st, shewing the Strength of the Garrison, Admissions, and Mortality, during different Years.

The increased mortality of 1859 was entirely due to Typhoid fever. In the total number of fever cases (1,196) for the half year 1859, are included the trivial febriculæ as well as the typhoid form. The former must always predominate; say two-thirds of the total cases treated were not typhoïd in character.

* Typhoid fever alone is the cause of a larger number of deaths than any other acute malady, perhaps, in the civil as well as military population.

As far as possible, I made & point of seeing all the cas:s of fever-whether occurring among the troops or inhabitants--and of being present at the post-mortem examinations.

In the last Army Medical Blue Book (1859), I find, that the strength was 5,310 (excluding the Malta Fencibles), and the mortality was 19:02 per 1,000. Of 101 deaths, 59 were from miasmatic disease. Contrasted with other years, there was a marked increase in miasmatic, and a decrease in tubercular disease, as regards mortality.

Table of Cases of Fever treated in Royal Artillery during the Half Year ending December 31st, 1859.

Hence the mortality from fever during the half year has been 7 per 1,000 living; and, of the Typhoid fever cases treated, the mortality has been about 18 per cent.

The term "Continued Fever" has, unfortunately, hitherto been made to embrace all the varieties of fever, while typhoid has been used to indicate not only fevers, having symptoms denominated "low," but that stage or state also of any disease, in which great prostration of the nervous and vascular systems existed.

It seems to be tolerably certain that four forms are seen in Great Britain. 1. Febricula, or Ephemeral Fevers. 2. Relapsing. 3. Typhus. 4. Typhoïd, Enteric, or Pythogenic; to which I would add, 5th, Gastric Remittent Fever -very prevalent in the Mediterranean, — and, 6, Bilious Fevers-far less

common.

The non-identity of the Typhus and Typhoïd forms of fever seems to me to be a question definitively set at rest. The geographical distribution of the two diseases differs; for typhoid is found in tropical zones, while typhus is not. Parallel with this is the fact, that typhus prevails in winter, typhoid or enteric fever in autumn. It would be needless to enlarge tediously upon the marked differences between the two fevers as regards exanthem, symptoms, etiology, and pathology, as they have been so fully set forth in Dr. Jenner's philosophical treatise upon Fever.

In the winter of 1855-6, a typhus fever patient was admitted into the Military Hospital from a transport from the Crimea. Of that disease he died, and two attendants upon him took the fever, one of whom died. The symptoms, exanthem, and the post-mortem appearances, removed all doubt as to the nature of the disease. Quite recently (April 1861), we have had other cases of imported typhus. An Egyptian vessel ("Schah Gehald ") landed its crew at Liverpool, in February last, and they apparently carried typhus wherever they went. The medical attendants and sick at the Liverpool Southern Hospital, the attendants at the public baths, and the pilot who brought the vessel into the port, were all attacked with the disease, many of them dying. The remainder of the Egyptian crew and passengers were shipped on board a French vessel, the "Voyageur de la Mer," for Alexandria. During the voyage several of the Egyptians died. The vessel put into Malta, and there landed eight of the English crew that manned the ship, suffering from typhus fever. Two of these cases proved fatal. An engineer resident in Malta, who went on board the ship to superintend some repairs required by the engines, took typhus, of which he died. The plague-stricken vessel at last reached her destination (Alexandria), carrying typhus cases with her. I personally examined the cases landed at Malta, and heard the result of one post-mortem examination, and there could be no doubt that the disease was typhus.* Whether the

*The asserted spontaneous origin of typhus on board the "Schah Gehald "is not quite substantiated to my mind. There is an absence of positive proof that none of the passengers or crew were affected on first embarkation.