to lie up for a short period, but never, until nine months ago, had he been sufficiently unwell to be obliged to give up his usual avocations. More lately his attention had been attracted by a decided swelling beginning to manifest itself upon the front of his thigh. This had gone on increasing for several weeks, until it had attained its present volume. There was also a disposition, lately, for the thigh to become flexed upon the pelvis, and now the limb could not be entirely straightened. Upon examination of the patient, who was emaciated and presented a marked scrofulous appearance, I found a large fluctuating swelling, evidently sub-fascial, occupying nearly the whole anterior part of the middle third of the right thigh. The thigh was slightly flexed upon the pelvis, and the knee and foot turned a little in; the limb, generally, was emaciated. There was likewise a small swelling over the nates, behind and lower than the trochanter; this, like the larger swelling, did not in any way disappear on pressure. The swelling upon the thigh was what had given the patient most anxiety, and induced him to come to the hospital. He only wanted something done for this, as he felt well enough, as yet, to go about, and for aught else would not have been disposed to lie up. The diagnosis was at once made out as morbus coxarius. The swellings were considered to be chronic abscesses, but at first I could not determine if they communicated with the joint. The disease of the joint did not seem to have progressed very far, as the patient walked readily, and the joint functioned very well; no grating could be discovered on manipulation, nor did extensive movement give much pain. I delayed opening the abscesses for several days, in order to watch a little the constitutional power of my patient, and further, too, to have my diagnosis more certain. I prescribed for him cod-liver oil 3ss, with wine 3ij, three times a day, and an anodyne at night.

April 10th.-The abscess of the thigh having materially increased in size, and the patient complaining of the feeling of tension, I made a kind of valvular opening at the dependent part, on the outer side of the sartorious muscle, and evacuated a large quantity of thin pus.

22d. I punctured the abscess over the nates, and, subsequently to this, both abscesses, having refilled, were again opened on several occasions.

May 4th.-Distinct fluctuation was discoverable higher up, behind the trochanter. A puncture was made here, and considerable pus flowed away, mixed, it appeared, with synovial fluid. Consequent upon this there supervened considerable irritative fever, with gastric disturbance and great restlessness. The oil was now discontinued, and P. gum opii, gr. j, with a glass of wine, given every three hours. The distressing symptoms were modified after a couple of days, and the opium was then only given at bedtime. The discharge from the last abscess was now very copious and offensive.

I had expressed a gloomy prognosis to some friends of the patient, and on this account I was applied to, on May 10th, to give him a discharge from the hospital, his friends preferring that he should die at home. At their earnest solicitation, a few days after, I consented to visit him privately. At the expiration of a few days I was much pleased to notice that a decided improvement had taken place under a free allowance of good wine, with nourishing diet, and opiates given when required. The discharge, though, continued profuse, and there were many evidences of extensive disease of the joint. Once or twice, when at the hospital, he heard me say something about dead bene and the persistence of the discharge. He now wanted to know if I could not in any way take out the dead bone, saying that he would submit to any operation that promised success. Eight or ten days elapsed, and finding that the discharge was as profuse as ever, moreover that ugly bed-sores were about appearing, I began to think that excision of the joint might offer a little chance. He seemed strong enough to stand an operation quickly performed, and this appeared the only alternative left. I then fairly stated to him my opinion, and told him how slight a chance the operation afforded; that it might hasten his end. He decided that the attempt should be made. I assumed the responsibility; but I determined that first I would explore the condition of the joint by making a free opening upon it through the cavity of a large abscess, just above the trochanter, and over the head of the femur. To open this abscess freely I con

ceived to be proper practice, even though I did not intend to resect the joint. It would be but carrying out the improved plan of Mr. Gay for treating suppurating joints. If the capsule of the joint was found open, and the head of the bone caried, then I would proceed to resect. Previous to commencing my incision, I had decided, by the test of Nélaton, that the head of the femur was still in the acetabulum.

On the 31st of May, 1856, my patient having been brought under the influence of ether (I used ether then instead of chloroform for the first and last time, at the suggestion of a friend; the patient took fully a pound before he became affected), was turned slightly upon the left side, and held in that position by assistants. I then thrust the point of a small amputating knife a little in front of the base of the trochanter, and carrying it upward and outward, and then downward and backward, formed a semilunar incision encircling the trochanter, and consequently had a sort of semilunar flap with the convexity upward. The knife went easily through the walls of the abscess alluded to above, and exposed its entire cavity. The finger passed in, and to the bottom of the wound, discovered plainly considerable destruction of the capsule of the joint, and also the head of the bone, still in the acetabulum, but quite rough, and partially destroyed by caries; the brim of the acetabulum, too, could be felt considerably diseased. Under these circumstances, I conceived it best to proceed and resect the head of the femur. The point of the knife was accordingly passed across the portions of the capsule yet entire. My assistant then flexed, and adducted the thigh, and, the round ligament not holding, the head was thrown out of the cavity, and then forced as much as possible through the external wound. I next passed the chain-saw behind the head and neck, and quickly divided the bone above the trochanters. Proceeding to examine the acetabulum, I was shocked at the extent of the disease. The brim was rough and crumbling, and there was an extensive perforation of the floor. With the gouge forceps I took away some portion of the brim, but soon desisted, as I felt it impossible to take away anything like the whole of the diseased structures. The wound was brought together by a few sutures, the lower end only kept open by a little lint to facilitate the exit of the discharge, the patient removed to bed, and the limb extended and kept steady by pillows. Not reacting as well as I desired, I ordered brandy freely until my afternoon visit, also a full dose of opium. In the afternoon his condition seemed better; he had warmth of skin, and a fair pulse. The brandy was continued, according to the indication, during the night, but upon my morning visit I was sorry to discover a greater disposition to collapse.

From this time he refused to respond to the most active internal and external stimulation, but sank and died, not quite thirty hours after the operation. I was not able to examine the body after death.

Appended to this case is a table, in which we have a summary account of all cases of the same kind which have been recorded up to the present time. This account shows very clearly that this operation is much less fatal than that of amputation at the joint, and that a very serviceable limb may at times be saved by it.

Table of Cases in which the Hip-Joint has been resected for Disease.

15 Simon
16 French
17 Fergusson

M. 162 years Caries; severe pain; sinuses with 1848. Removed four inches of fe- Pain ceased; health rapidly improved ;] discharge; some disease of aceta- mur, and portions of acetabulum. wound healed well.

18 Walton

25 Skey

F. 133 years Emaciated and nearly worn out; 1850. Head found absorbed; por

M. 14 Several Greatly reduced; bone dislocated.

1853. Neck and great trochanter Rapid improvement; suppuration profuse; removed. died some months after.

1853. Head and part of neck re- Three months after, progress very satisfacmoved.

tory.

Table of Cases in which the Hip-Joint has been resected for Disease-Continued.

Condition of patient, and state of parts
at time of operation.

Duration
of disease.

Head dislocated; abscess.