[Extracted from the American Journal of the Medical Sciences for January, 1873.] 
AMPUTATION AT THE HIP-JOINT. 
By A. E. CAROTHERS, M.D., 
OP SALTILLO, MEXICO, 
LATE ASSISTANT-SURGEON UNITED STATES VOLUNTEERS 
■a, 
WITH TWO WOOD-CUTS. £/} 
To determine the conditions which render amputation at the hip-joint 
necessary, and the propriety of its performance under any circumstances, are 
among the most difficult problems in military surgery. The proper treat- 
ment to be adopted in a case of gunshot fracture of the trochanters and 
neck of the femur is a grave question, especially if there be serious secondary 
lesions of the great vessels complicating it. The difficulty of its solution is 
little lessened by a consultation of authorities ; some whose opinions are of 
the greatest weight standing arrayed on each side of the question ; some 
regarding it only justifiable as a secondary operation, after a tolerance of 
suffering and suppuration has been established ; others advocating recourse 
to it after reaction from the original injury has been established and before 
the vital forces have been exhausted by a uselessly prolonged period of 
pain, confinement, and suppuration ; others again proposing to operate 
primarily, believing that the use of chloroform obviates the shock to such 
a degree as to render it safe, and not subjecting the patient twice to the 
shock of a grave injury; while many condemn it under all circumstances, 
trusting, in cases not suitable for resection, to the judiciously aided efforts 
of nature for a more favourable result than is predicted by the published 
statistics of the operation with their appalling list of deaths. 
The wonderful results obtained from carbolic acid and other antiseptics 
in the conservative field of surgery of late years will do much to strengthen 
this latter opinion, or at least to circumscribe the list of cases demanding 
this terrible mutilation of the human body. 
I was most forcibly impressed with these reflections after reading the 
two admirable papers on this and its associate operation, issued from the 
Surgeon-General’s Office U. S. Army; viz., Circular, No. 7, of July 1st, 
1867, on Amputation at the Hip-joint, and Circular, No. 2, of January 
2d, 1869, on Excision of the Head of the Femur, which are among the 
1 2 
most valuable contributions on this subject to surgical science that have 
ever been presented to the profession. 
The opinions expressed in these reports are those of the lending sur- 
geons of the U. S. Army in the late war, by whom the operation and the 
various substitutes for it were put into practice as extensively and under 
as fair conditions for determining their relative value, as by any other 
body of men in the history of surgery. As such, their opinions are entitled 
to the highest consideration ; but to what widely different conclusions 
these distinguished gentlemen have arrived, and how little they have 
settled these questions, can only be appreciated by a perusal of their 
letters as published in the works referred to. 
We are all aware of the fallacy of surgical statistics; but such is the 
practical spirit of the age that the world and the profession demand facts, 
not theories, and none will deny that by an intelligent analysis of a large 
number of cases practical deductions of great value may be arrived at. It 
is with the view of adding to the reliable statistics of this debatable opera- 
tion that I present the following account of a case which has recently 
occurred in my military practice in the late revolution in this country, 
leaving theoretical discussions of it to men of abler minds and greater 
leisure than I possess :— 
Juan Blanco, set. 14 years, a native of Guadalajara, Mexico, serving as 
orderly to Lieut. Itibera of the 21st Infantry of the Line, Mexican Army, 
was wounded by a conical musket-ball at the storming of the city of Sal- 
tillo, Mexico, on the morning of the 5th of December, 1871. He was 
carried the same day to the field hospital of the insurgent army, where 
he lay upon the ground with little or no attendance for several days. He 
was then removed to the military hospital of this city, where I first saw 
him on December 13th, he being pointed out to me by the surgeon in 
attendance as a hopeless case. On the night previous he had suffered a 
severe secondary hemorrhage, in which the blood ran off the bed and 
along the floor a distance of several yards, in consequence of which he 
was greatly debilitated and had fainted several times. 
Determined to make an attempt to save his life, I asked and obtained 
permission to remove him to my house, which was done the same day. 
Upon inquiry I learned that he had had no evacuation from the bowels 
for eight days, or since the reception of the wound, during which time he 
had eaten very little food. An enema was given, which operated well, 
and he was allowed to rest the next day, being fed with nourishing broths, 
no attempt being made to change the dressing of the wound for four of 
further hemorrhage. 
On the morning of December 15th a consultation was held, at which 
Drs. Smith, Lnckie, Barreda, and Fernandez were present. We found a 
gunshot wound in the upper portion of the left thigh, which was stuffed 
with lint, saturated with liquor ferri perehJoridi, firmly bound down by a 
compress and roller. Upon removing the lint the wound was observed to 
be in a sloughy condition and quite offensive. From the account of the 
ward surgeon, and the appearance of the wound, it was thought that the 
hemorrhage had arisen from the profunda femoris artery, and this opinion 
was subsequently verified. 3 
A most extensive fracture of the trochanters and upper 
half of the left femur was discovered, the ball having en- 
tered the thigh at the middle of the inner margin of Scarpa’s 
space behind the femoral artery, after having first nearly 
divided the penis; crushing the bone to fragments in its 
course, and making its exit just below the trochanter major. 
(See accompanying representation of the bone.) 
In view of the great extent of the injury to the bone, 
and of the secondary hemorrhage from so important an 
artery as the profunda femoris with the almost certainty of 
its recurrence, and the difficulty of the deligation of the vessel, 
it was decided to amputate through the trochanter or neck 
of the femur as the only reasonable chance of saving life, 
and I performed the operation by inserting a long knife 
through the track of the wound, and cutting outward, making 
a short anterior, or rather antero-exterior flap; reinserting 
the knife, and making a long and thick postero-interior one, 
being guided in my selection of the incision and flaps by 
the peculiarities of the wound, making them from the tissue 
least injured by spicula of bone, and inflammatory and sup- 
purative action. 
Upon examining the remaining fragment of bone, I found that the cap- 
sular ligament was detached from its adhesions along the upper margin 
of the posterior inter-trochanteric ridge, which had been almost entirely 
carried away by the ball, along with the lesser trochanter; and that the 
neck of the bone was becoming carious, being involved in the same dis- 
eased action which had divided the artery, and was manifest at the 
wound of entrance. 
Convinced now that the diseased action extended to within the joint, 
and of the worse than uselessness of leaving the head in situ to become 
a source of future irritation, I at once disarticulated and removed it, cut- 
ting away the capsular ligament close up to the acetabulum. Finding 
this latter in a healthy condition, I terminated the operation by slightly 
trimming the flaps to suit the altered operation, being careful to remove 
every fragment of tissue -showing the least sign of disease. The wound 
was then carefully washed with a solution of chloralum, one ounce to four 
ounces of water, and, as soon as all bleeding had ceased, it was closed 
with silver-wire sutures, leaving drainage outlets at upper and lower angles, 
and dressed with lint wet in the same solution. 
I was ably assisted in the operation by the gentlemen above named, and 
Messrs. Quintanilla, Elizondo, Cortesan, and Lozano, medical students 
from the school in Monterey. Chloroform was administered to complete 
anaesthesia by Dr. Smith, and was well borne. 
Thanks to the efficient aid of my assistants, less blood was lost than in 
an ordinary thigh operation. No torniquet was used, nor was compres- 
sion of the abdominal aorta attempted, Dr. Barreda compressing the 
femoral artery at the crural arch with the thumb of one hand, while with 
the fingers of the other he followed the knife as I made the anterior in- 
cision, grasping the artery as it was divided and retracting the flaps over 
the groin ; another assistant standing ready to do the same with the 
branches of the ischiatic, circumflex and gluteal, which were ligated on 
the moment, the femoral being tied last. 
When it is considered that the patient was a slim delicate boy, worn 
down by suffering, suppuration, and the neglect consequent upon the 4 
defeat of the troops to which he belonged, the occupation of the city by 
the hostile forces, and the lack of efficient hospital organization common 
to insurrectionary armies; it is not surprising that the shock of the ope- 
ration was great. His pulse, which had been about 130 before the ope- 
ration, disappeared entirely at the wrist for from twelve to sixteen hours; 
cold clammy sweat stood in bead-like drops on the skin, the breathing be- 
came sighing and hollow, and it was only by the use of the most vigorous 
measures that he was roused from this state of collapse. One ounce of 
brandy was ordered every two hours, or rather “ ad libitum” with two 
grains of musk and eight grains of carbonate of ammonia every two hours, 
and artificial heat applied to the extremities, under which treatment a slow 
but steady reaction was established by the morning of Dec. 16. 6 A.M. 
Pulse feeble, 160; tongue dry; great thirst, anxiety, restlessness, but no de- 
lirium. Gave an eggnog and ordered Leibig’s extract of beef ad libitum ; 
continued brandy, one ounce every three hours. Nothing of note occurred 
during the day, the reaction steadily improving, the pulse gaining in 
volume and diminishing in frequency. 9 P. M. Pulse 140, much fuller; 
tongue more moist; less thirst; less pain ; wound cool, and appears to Ihj 
glued together by adhesive inflammation. Some sanguineous discharge 
from angles of wound ; continue treatment. 
17//?, 9 A.M. Pulse varying from 135 to 145; temperature in axilla 
100.5; appetite good ; general condition improving. 9 P.M. Has eaten 
well and passed a very good day, but in the evening the young vagabond 
induced the servant to give him more than his allowance of brandy, and 
he is gloriously drunk. 
18//?, 9 A.M. Pulse 150; temperature 102; is clearly no better from 
last night’s indiscretion ; wound however cool ; looks well and appears to 
be adherent; ordered boiled chicken, extract of beef, eggnog, and brandy 
in greater moderation than yesterday. 9 P.M. Has passed a very com- 
fortable day ; ate half a boiled chicken at dinner with appetite. General 
condition much the same, but pulse rather weaker than in the morning. 
Wound discharging well; pus at both outlets. Has had a natural action 
of bowels spontaneously. Smokes cigarettes with great satisfaction. 
19//?, A.M. Pulse 150 ; temperature 101.5; good appetite; condition 
improving. Removed all of the sutures, and found union by first intention 
complete throughout the wound except at the angles, where bits of lint 
had been inserted to maintain outlets for sanguineous exudations, and the 
synovia, which I anticipated would be secreted from the acetabulum upon 
its being opened, but of which no appearance has existed in the discharges 
which now consist of laudable pus. Supported the wound with strips of 
adhesive plaster. Injected orifices at angles of wound with the solution 
of chloralum twice a day; continue treatment. 9 P.M. Has eaten 
during the day a large piece of beef-steak, part of a chicken, bread, rice, 
extract of beef, etc. Pulse 138. 
20th, 9 P.M. Has passed a good day, and is becoming very ill natured. 
Pulse 138. 
21s/, 9 A.M. Pulse 145; temperature 102.2; is slightly feverish, due 
to having no action of the bowels for several days. Ordered a simple 
anema, which did not act. Gave an ounce of castor oil, to be followed by 
another enema. 9 P.M. Has had a good action of purge, and is better. 
Pulse 140. 
22d, 9 A.M. Pulse 132; temperature 101.2; condition decidedly im- 
proved. Stopped brandy, and ordered two pints of ale daily, instead. 
23d, 9 A.M. Pulse 150 ; temperature 101.5. The wound does not look 5 
so well to-day, the granulations being somewhat pale and the pus scanty 
though well formed. The cicatrix opened for about an inch and a half at 
its outer end when I removed the adhesive strips. Upon investigation it 
was found that he has deceived me as to his food, taking much less than I 
supposed. Made no change except to personally superintend his meals. 
24th, 9 A.M. Pulse 138; temperature 101.5; the granulations in the 
wound a little more florid. Changed the chloralum dressing for R acid 
carbolic 5j> 01. olivae %j. Commenced giving elixr Calisayae, one ounce 
three times daily. The bowels act once in two days, the evacuations being 
consistent and show good digestion. The patient sat up in bed to-day, 
and amused himself by drawing pictures on a slate. 
25(h. Pulse 138 ;• temperature 102. Removed all the ligatures but 
two. Wound rather pale, dressed with carbolic acid 3j> resin cerate 3j. 
26th. No change. Pulse 136 ; temperature 101.8; continue treatment. 
27th. Pulse and temperature same as yesterday. Had considerable 
griping in the bowels. Gave tr. zingiberis and tr. opii camph. Appetite 
not so good as heretofore, but appearance of wound improved. Another 
ligature came away. 
28th. Pulse 134 ; temperature 101. The last ligature, that of the 
femoral artery, came away to-day. General condition improving, and 
granulations in wound becoming again florid and firm; appetite better; 
no griping ; bowels act once in twenty-four hours. 
29th. Pulse 126; temperature 100.8; steadily improving; wound 
rapidly filling up. The patient sat up in a chair to-day for first time. 
The boy continued improving, sitting up a few hours daily, and rapidly 
gaining strength until January 15th, one month from the date of opera- 
tion, when he, for the first time, left his bed on crutches, with the aid of 
which he soon learned to walk. 
The wound was firmly closed, except at the two angles, where a slight 
discharge was kept up for another month or so by a few small spicula of 
bone which had been buried among 
the tissues, escaping notice at the 
time of operating, and which made 
their way to the surface from time 
to time, and were extracted or dis- 
charged with the pus. 
On February 3d he walked from 
my house to the hospital, a distance 
of four squares, all the way up 
hill, without assistance, where he 
remained until July 20, 1872, 
when a photograph (represented in 
the accompanying cut) was taken, 
and on the day following he left 
for the city of Mexico with the 
cavalry brigade of Gen. Ribera, in 
perfect health and with his stump 
entirely healed, seven months and 
six days after the operation. 
During the time of his stay in 
the hospital nothing noteworthy 
occurred, except that in April he 
had an eruption of a herpetic 
character at the margin of the 6 
cicatrix, the outer end of which, in consequence, opened for about, an inch 
and a half, rendering it necessary to support it with adhesive straps, under 
which treatment, combined with an improvement in diet and ventilation, 
and frequent, baths in cold water, it soon firmly closed, and contracted to a 
surprisingly small line. 
At the risk of wearying the patience of my readers I have reported this 
in detail from the notes in my case book, and I only regret that I 
did not get the temperature of the first and second days, owing to not 
having my axillary thermometer at hand. 
I wish to direct attention to several points of treatment; and certain sur- 
rounding circumstances, which seem to me to have contributed to the favor- 
able result, and explain the remarkable rapidity of recovery, this boy being 
the first out of eight amputations of knee-joint and thigh, which I made 
at that time, who sat up on a chair or walked with crutches. 
The operation in itself was that calculated to cause the least loss of 
blood from the facility and rapidity of its ]>erformnnee, no attempt being 
made to control hemorrhage by mechanical appliances, always more or 
less imperfect, but dependence being placed upon the dexterity of the as- 
sistants in following the knife with their hands, grasping the flap as it 
was made, and stopping the orifices of the bleeding arteries with the tips 
of their fingers as soon as they were discovered. 
The liberal use of stimulants and nutrients on a scale and in view of 
symptoms, that would scarcely meet the approval of those unaccustomed 
to hazardous operations upon soldiers worn down by physical and moral 
causes, needs only to be referred to to receive its just share of credit in the 
result. 
The use of chloralum as a dressing, which in my hands has been of 
great service, and I think its use contributed largely to the success of this 
case, securing union by first intention, preventing diffuse suppuration, and 
destroying all septic influences. My experience has not yet been suffi- 
ciently great in its use to warrant my drawing a comparison between it 
and carbolic acid, but, so far as it goes, in hospital gangrene, erysipelas, 
and simple phagedena, it leans decidedly in favour of the chloralum. 
The extraordinary rapidity of recovery and the absence of all untoward 
symptoms in the progress of the case are attributable to the causes referred 
to, combined with the youth of the patient, the climate of the place in 
which the operation was performed, and the race to which the patient be- 
longed. The lower order of Mexicans, in whom the Indian blood predom- 
inates, or is almost pure, bear surgical operations better than any other 
people I have seen ; due, perhaps, to their simple and temperate life, 
mainly in the open air; their stoicism and complete resignation to the 
“ voluntad de Dios,” securing a tranquil state of mind. This place being 
over 5000 feet above the sea level, situated in a mountainous district noted 
for its salubrity, the climate is singularly favourable to surgical operations. 7 
As to the operation selected I desire to call attention to certain advan- 
tages derived from it, premising that I claim no credit for originality in it, 
as I was almost compelled by the peculiarities of the wound to adopt it 
as the best means of securing sound flaps. From the oblique character of 
the wound its outer angle is sufficiently low when the patient is on his 
back to admit of complete drainage of discharges from the deepest part 
of the wound, the acetabulum, while, at the same time, it is sufficiently in 
front to facilitate the dressing, leaving the cicatrix subsequently under the 
patient’s own control for washing, dressing, etc. 
The stump obtained by making the long flaps from the posterior and 
inner part of the thigh presents great advantages as affording a full round 
buttock to the patient, on which he can sit with ease and comfort undis- 
turbed by the cicatrix, which is entirely out of the way ; as will be seen 
by the photograph ; and in the event of the adaptation of an artificial 
limb it is sufficiently high to be out of the line of pressure of the weight 
of the body, at the same time being in the softest part of the stump; and 
not exposed to pressure over any bone. 
Although not prepared to go into a disquisition upon, or defence of, 
this operation, yet I will say that I can conceive of no other procedure 
which would offer a chance of life equal to it in a case like the one I have 
just reported; in which the bone was extensively fractured to within the 
capsular ligament; or at least to its very insertion, the neck of the bone 
carious to the epiphysis from an extension of the sloughing action in the 
soft parts, the joint unquestionably opened ; and where a secondary hem- 
orrhage from so important a vessel as the profunda femoris had been 
caused by sloughing of the wound. 
The deligation of the profunda is in itself a serious and difficult opera- 
tion, requiring a high order of operative skill, and in this case would have 
probably been useless, as will be admitted by all who have seen such cases 
die after repeated hemorrhages, from the diseased action involving the 
coats of the artery above the ligature. 
The ligature of the femoral artery at the crural arch, the nearest point 
of safety to the slough, would, in all probability, condemn the limb to 
gangrene. The excision of the head and nearly half of the shaft of the 
femur, is almost as formidable an operation as the amputation even, under 
favourable circumstances, and would have been useless in this case, as offer- 
ing no relief to the principal danger, that of a return of the hemorrhage. 
To expectation the same argument applies, so what can the surgeon do 
but amputate? That by so doing he will offer the unfortunate patient a 
fair chance of life is shown by this case. 
If any conclusions can be founded on the foregoing report and 
tions, they are, that where gunshot fracture of the trochanters, neck or 
head of the femur is complicated by wound of the great vessels of the 8 
thigh, or where they are included in a slough of the wound causing second- 
ary hemorrhage ; it is the duty of the surgeon to give the patient the 
chance for life that lies in amputation at the hip-joint. 
Saltillo, Mexico, August 6, 1872.