THREE AMPUTATIONS OF THE THIGH. 
TWO IN THE UPPER THIRD, ONE AT 
THE MIDDLE. 
BY 
JOHN W. ROSS, M.D., 
SURGEON, U. S. N. 
. FROM 
THE MEDICAL NEWS, 
August ii, 1894. [Reprinted from The Medical News, August 11, 1894] 
THREE AMPUTATIONS OF THE T H / G H —T W 0 
IN THE UPPER THIRD, ONE AT 
THE MIDDLE. 
By JOHN W. ROSS, M.D., 
surgeon, u. s. n. 
Case I.—Lewis Hart, a negro, seventeen years old, ot 
Yellow River, Santa Rosa County, Fla., was brought to 
me March 24, 1888, with the right knee and ankle dis- 
organized by suppurative tuberculous disease of seven 
years’ standing. All the structures concerned in these 
joints were involved ; the knee was dislocated outward; 
pus was escaping by seven or eight fistulse in the thigh 
and leg; the lower end_of the femur was softened and 
breaking down. There was great emaciation, profound 
anemia, extreme debility, difficulty in deglutition, loud 
anemic cardiac murmurs, but no organic disease of 
vital organs. 
I decided to amputate as soon as the patient could be 
built up sufficiently to stand the operation. 
On March 28th, the patient, showing no signs of 
improvement, but rather the reverse, I concluded to 
operate at once. Captain M. C. Wyeth, U. S. A., 
Post-Surgeon at Fort Barrancas, willingly consented to 
help me, although he thought that the patient would die 
from the anesthetic, as his heart was acting badly. He 
administered the ether, preceding it by a small drink of 
whiskey, and the operation was quickly done, Apothe- 
caries Purden and Waggener, U. S. N., and Nurse John 
Kelly assisting us. On account of the unhealthy state 2 
of the soft parts, an irregular flap-operation, approach- 
ing the circular, was done, two fistulous openings being 
unavoidably included in the longer anterior flap. The 
femur at the point of section, at about its center, was 
hardly more than a circular shell of bone, with a large 
medullary cavity. 
The patient emerged from the anesthesia with very 
little life in him, but was kept alive for a few days by 
frequent small quantities of liquid food, digitalis, and 
stimulants. A fter that he began to gain strength, and 
continued to do so, though very slowly. The vitality of 
the tissues was so low that it was impossible to get even an 
attempt at primary union of the flaps, and the stump 
had to be treated as an open wound. Whenever it 
was closed pain would come on and the temperature 
would rise. The flaps were kept as aseptic and in as 
good a position as possible, and at the end of about three 
months the patient went home with a good stump and 
in fair general health. 
After reaching home he grew fat and hearty, and being 
unusually intelligent acquired a fair education, writing 
me occasionally very creditable letters. 
Subsequently the same trouble that had destroyed the 
knee and ankle unfortunately reappeared in some of the 
lower costo-vertebral articulations, and the patient re- 
turned to me with an abscess to the right of the spine in 
the lower dorsal region. This was opened and cleaned 
out, and for about two years since there has been no 
advance of the trouble and the general health has been 
good. 
Case II.—Captain W. C. Gorgas, U. S. Army, Post- 
Surgeon at Fort Barrancas, who took a prominent part in 
the operation and after-treatment, has kindly given me a 
copy of his record of the following case: 
“Thor Christiansen, a Swedish sailor, eighteen years 
old, in February, 1890, fell, in Pensacola Harbor, from 
the mast of his ship to the deck, striking on the head of 3 
a belaying-pin, driving it through the upper third of his 
left thigh and breaking the femur at this point. 
“ He was taken to the Marine Hospital at Pensacola, 
and attempts were made to save the limb, but suppura- 
tion set in and the patient went from bad to worse. 
“ I first saw the patient July 13, 1890, in consultation 
with Dr. J. W. Ross, U. S. N., and Dr. Anderson. The 
lower fragment at this time protruded through the skin, 
and the upper one was about to come through, both 
communicating with a pus-cavity that held about a pint. 
The man suffered great pain, any movement causing 
him to cry out. The emaciation and debility were greater 
than I have ever seen in a person who recovered. In- 
deed, I thought it probable that he would not survive 
the night. I estimated at the time that he had about 
three square feet of bedsores, the largest, that over the 
sacrum, covering fully a square foot, and laying the bone 
bare. Every point of pressure was bare, elbows, scapulae, 
ribs, iliac bones, etc., and the pressing bone was bare in 
many of these places. There was no albumin in the 
urine, and all other organs were healthy. I was inclined 
to think that the patient would die in the course of the 
next twenty-four hours ; I was quite sure that he would 
not survive operation. This was the opinion of all who 
had seen him. 
“ Dr. Ross, having had a somewhat similar case before, 
urged immediate amputation, in which I supported him 
with many misgivings. Dr. Ross amputated at the 
point of fracture, making a circular skin-flap, and 
slitting up the flap to get out the dead bone. A short 
piece of femur was left in situ, the idea being to subject 
the man to as little shock as possible, and to disarticu- 
late at the hip-joint a few days later, after he had some- 
what recovered. Great care was given to asepsis dur- 
ing the operation. The patient suffered profoundly 
from shock for several hours, and it was only by steady 
care and stimulation that he survived. He began to 4 
gain from the day after the operation, and we kept de- 
ferring the second operation till we saw that it was not 
needed. He was moved to the military hospital at Fort 
Barrancas on the 21st. 
“ Improvement was rapid and steady, and by Septem- 
ber 22d he was walking about on crutches. He left the 
hospital in December, with all of the bedsores healed 
and the stump in good condition. 
“ What so impressed me in this case was the fact that a 
patient so weak and debilitated could recover from any 
operation. In future I shall not hesitate to operate on a 
patient, with otherwise healthy organs, on account ot 
debility, unless he is actually in articulo mortis. After 
this case it seems to me that it can never be too late to 
operate on such a patient.” 
Having been called in consultation by the surgeon of 
the hospital, I saw Christiansen first on July ioth, three 
days before the operation and about five months after 
the reception of the injury. He was a mere shadow and 
was expected to die at any hour. The lower end of the 
upper and the upper end of the lower fragment were 
widely separated, with several pieces of dead bone and 
a large pus-cavity intervening. The surgeon, after hav- 
ing tried many ingenious contrivances for keeping the 
bones in juxtaposition, had abandoned all hope of union, 
and was doing what he could to diminish suffering. As 
there was no other earthly hope, and as I had seen a 
very similar case saved by it, I advised immediate 
operation. 
On July 12th the patient collapsed, and it was thought 
that the end had come. After he had reacted the sur- 
geon telegraphed me to come up and amputate. 
On the next morning, July 13th, Dr. Gorgas, Dr. Ander- 
son, and I, assisted by our apothecaries and stewards, 
operated in the manner described. 
Once during the operation and once immediately 
afterward life appeared about extinct, but with external 5 
heat, stimulants hypodermatically and internally, and 
his wonderful vital tenacity, the patient survived. 
Apothecary (now Dr.) Richard Waggener staid by him 
until the next day, keeping him warm, nourishing him, 
and stimulating him per os and hypodermatically with 
whiskey, digitalis, and atropin. On the following morning 
Dr. Anderson told me that the patient would surely have 
died during the night but for Waggener’s faithful and 
skilful care. As the attendants in the hospital were 
overworked with other patients, one of the navy or 
army attendants nursed Christiansen night and day for 
nearly a week, at the end of which time he had gained a 
little strength and was comparatively comfortable. On 
July 2 ist Dr. Gorgas, in great kindness, sent an ambu- 
lance and took the patient to the army hospital, where 
there was a full corps of attendants and few patients. 
There he was nursed like a child back to health, the 
great difficulties being to heal the bedsores and teach 
him how to walk, as the muscles had atrophied and 
apparently disappeared. 
Finally, by December, being perfectly well and sound, 
he went back to his home in Wexio, Sweden. 
Some months later he sent me a grateful letter, telling 
me that he was strong and robust, asking advice regard- 
ing an artificial leg, and sending his photograph, which 
showed him to be in perfect health. 
In the following case the operation was not done by 
me. I am responsible for it, however, as but for my 
persistency it would not have been performed. It is 
reported here, because it conveys the same lesson, 
nil desperandum, as the two foregoing, and because of 
its striking resemblance to one of them. But for my 
experience with this case I should not have advocated 
or done the operation in Case II. 
Case III.—George William Ritchie, an ordinary sea- 
man-apprentice on the U. S. Flagship Hartford about 
nineteen years old, on October 24, 1884, fell from 6 
aloft on the Hartford in the bay of Callao, Peru, strik- 
ing the ratlines and landing on the grating of the 
Hotchkiss gun, sustaining a compound, comminuted 
fracture of the upper third of the left femur, a fragment 
of bone projecting through the external wound. 
On October 28th he was transferred ashore to the Gua- 
dalupe Hospital, Callao, where he passed out of the 
hands of the U. S. Surgeons. 
The Hartford sailed away not long afterward, and 
I being attached to the U. S. S. Onward, at Callao, 
was requested to look out for the boy. He seemed never 
to have recovered fully from the shock of the injury, and 
had gone along pretty rapidly from bad to worse. At the 
end of about three weeks he was in very much the same 
condition as was the boy Christiansen (whose case has 
been described) when first seen by me, except that he was 
less emaciated and the bedsores were not so bad. The 
wound was bathed in pus, and the broken ends of the 
upper and lower fragments movable and overlapping 
for several inches, with two or three pieces of broken 
bone hanging to them. There was high fever (appar- 
ently hectic), profound prostration, delirium, and intense 
suffering. A skilful diagnostician who examined him 
carefully, thought that pyemia had set in, involving 
especially the lungs. 
As death was certain and imminent without it, I 
endeavored to get the visiting surgeon of the hospital, 
Dr. Tavara, to remove the limb. He declined on the 
ground that it would be entirely useless, that the boy 
would die whether he amputated or not, and that it 
would injure his private practice to have the patient die 
during or immediately after operating upon him. 
At about this time the U. S. Steamship Wachusett 
came to Callao, with Surgeons W. H. Jones and W. R. 
DuBose, U. S. Navy, on board. These gentlemen went 
with me to see Ritchie, and agreed that death was 
inevitable without amputation. I also got Dr. Campion, 7 
a very able English surgeon of the Pacific Navigation 
Company, in charge of their hospital at Callao, to see 
Ritchie, and he shared the same opinion. I then 
brought about a meeting of these surgeons, Drs. Jones, 
DuBose, Campion, and Tavara, for a careful considera- 
tion of the case. Dr. Campion thought that amputation 
could do no harm and would greatly diminish the 
patient’s suffering. Dr. Jones had slight hope that it 
might save the patient’s life, and remarked that anyhow 
we might just as well kill him as to let him die by inches. 
Dr. DuBose thought that the only shadow of a chance 
for the patient’s life lay in amputation. Dr. Tavara 
considered that amputation would shorten the patient’s 
life, that he did not like to operate in such hopeless 
cases, and that it would injure his reputation as a sur- 
geon for Ritchie to die during or as the result of the 
operation. I said that the patient was a red-headed 
Scotch lad, with lots of vitality, and that if we would rid 
him of that thigh, with its terrible pain and discharge, I 
believed he would get well. I proposed that if Dr. 
Tavara would go ahead and cut the limb off we would 
all assist him in the operation and take the whole 
responsibility. The other surgeons supported me in 
this, and Dr. Tavara yielded. 
On November 9th, the day following our conference, 
I believe, we met at the Guadalupe Hospital, and 
assisted Dr. Tavara in amputating in the upper third of 
the left thigh. 
The very next day the patient was decidedly improved 
in every way, and from that time went straight along to 
recovery. 
During the following year I met Ritchie in New York 
City, getting fitted with an artificial limb. He was in 
fine health, and seemed almost as active on his one leg 
and crutch as the average man is on two legs. 
In these three cases, all of the kind that have entered 
into my experience during the past ten years, three lives 8 
were saved, but had only one been saved the amputa- 
tions, with all their trouble, responsibility, etc., would 
have been amply justified. They are reported with the 
hope that the results may cause other surgeons to operate 
under similar circumstances when they would not other- 
wise do so. Obviously the lesson they convey is of 
much wider application than to amputations, and covers 
all cases in which without operation death is certain, 
and when with it the slightest chance for life is afforded. 
It is not an agreeable thing to have a patient die upon 
the table, or to feel that an operation has been the imme- 
diate cause of death, and that the surgeon’s reputation 
may temporarily suffer thereby, but it is the surgeon’s 
duty to put himself in the patient’s place, and do unto 
him as he would wish to be done by. Human life is too 
sacred for any chance, however small, of saving it to be 
thrown away. In such cases, even when the patient 
does not survive, he is almost certainly delivered from 
much suffering. 
I remember seeing in Bellevue Hospital, New York, 
about twenty years ago, a woman who for some iniury 
of the leg had been urged to submit to amputation above 
the knee. She refused operation until she saw that she 
was about to die, and then begged with tears to have it 
done. Then the surgeons would not amputate, believ- 
ing that it was too late, and within a day or two the 
woman died. I have often thought since that had they 
operated promptly as soon as she gave her consent her 
life might possibly have been saved. 
In the foregoing cases no unusual operative skill was 
employed, nothing more than any well-equipped sur- 
geon of moderate experience might command. 
A study of these three cases has strengthened an 
opinion long held by me, that the danger of shock in 
modern operative surgery is overestimated. May not 
much of the dread of it have come down to us from the 
pre-anesthesia days when there was so much suffering 9 
from pain and fear ? May not much that we attribute 
nowadays to shock be due to loss of blood or to too 
energetic, administration of anesthetics? I can testify 
from personal subjective experience that the shock of 
being knocked down by an anesthetic, as it is frequently 
administered, is very great indeed, extremely like that 
of a heavy blow on the top of the head. 
Our plan here (the Government Reservation, near 
Pensacola, Fla.) is in the great majority of cases, both 
obstetric and surgical, to begin with chloroform given in 
small quantities very gradually until the patient sinks 
into an apparently natural sleep, and then the sensibility 
of the respiratory mucous membrane being obtunded, 
substituting the more irritating but less dangerous ether, 
to maintain the anesthesia with the latter. This method 
costs a little more time and trouble, but we are satis- 
fied that it pays well. In our work here we have 
given chloroform and ether to several hundred patients 
without any approach to an accident from the anesthetic. 
As Dr. Gorgas expresses it, “We chloroform the patients 
in order to give them ether.” The Medical News. 
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