[Reprinted from The Medical News, February 24, 1894.] 
SOME INDICATIONS FOR AMPUTATION OF 
THE LEG. s' 
By F. F. BUNTS. M.D., 
PROFESSOR OF THE PRINCIPLES OF SURGERY AND CLINICAL SURGERY, 
MEDICAL DEPARTMENT OF WOOSTER UNIVERSITY, CLEVELAND. OHIO. 
In presenting the subject of amputation of the 
leg, I do not desire to convey the impression that I 
consider what I am about to say as in any degree 
essentially new, but rather to emphasize certain indi- 
cations that seem to call for amputations of the leg 
other than those most commonly found in works on 
surgery. 
1. I consider any injury to the foot, so severe as 
to permit only of a Pirogoff, a Symes, or a Chopart 
amputation, to be an indication for amputation of 
the leg in the lower third. 
2. Tuberculosis of the tarsal bones, except in child- 
ren, should, with few exceptions, be regarded as an 
indication for amputation of the leg in the lower 
or middle third. 
3. Those extensive wounds and burns of the soft 
parts in which large portions of the integument and 
soft parts are destroyed, leaving the bone covered 
only by an extensive and tender cicatrix, demand 
amputation. 
4. Senile gangrene of the toe or foot demands 
amputation of the leg or thigh above the bifurcation 
of the popliteal artery. 2 
5. Shock, dependent upon a severe injury to the 
leg, when it is obviously impossible to save the 
limb, should, if reaction do not take place in a short 
time, be an indication for immediate amputation. 
The first indication, that in which a Pirogoff, a 
Symes, or a Chopart amputation might be per- 
formed, is one which has been forcing itself upon the 
profession with increasing strength from year to 
year. 
The destruction of the arch of the foot, the un- 
certainty of obtaining useful stumps, the inability 
satisfactorily to adjust mechanical substitutes for the 
portion lost after either of these operations, seem 
to me to justify our recommending an amputation 
at this time, rather than to be obliged to see our 
patient forced to rely upon crutches, unsatisfactory 
and awkward substitutes for the foot, and most likely 
to undergo an amputation before he can have fitted 
a limb at all useful or comfortable. 
That amputation for suppurating tuberculous dis- 
ease of the tarsal bones in adults will not be accepted 
by a great many as an indication for amputation of 
the leg, I am well aware, and yet the treatment of 
this disease has been so uniformly unsatisfactory that 
I believe it should be considered an indication in 
most cases for amputation, rather than to allow the 
patient to continue with a practically useless foot, 
or to run the well-established risk of general tuber- 
culous infection. 
We have all, perhaps, seen those extensive wounds 
of the soft parts of the leg and foot in which cicatriza- 
tion has been eventually complete, and yet in which, 
owing to extreme sensitiveness, or to the repeated 3 
occurrence of large and intractable ulcerative pro- 
cesses, amputation has been rendered necessary after 
years of suffering, or of disability. In those cases in 
which we can foresee such a result, we should not 
let the importunities of the patient to save his leg 
blind us to the ultimate consequences, or to the 
propriety of advising amputation, and then allowing 
the patient to take upon himself the responsibility 
of the future. I am well aware that I am trespassing 
upon debatable ground when I advocate amputa- 
tion of the leg above the bifurcation of the popliteal 
artery in senile gangrene below that point, but I 
feel sure that by its early performance the patient has 
a better chance for life and usefulness, suffers less 
pain, and runs less risk of septic poisoning than by 
that method that tells us to fold our hands and wait 
for the line of demarcation to form. 
It is doubtful whether my last indication for 
amputation should technically be enumerated here, 
but what I wished particularly to call attention to 
was, that a patient suffering from severe shock as 
the result of a crush of the foot or leg, and who fails 
to react satisfactorily after not to exceed half an 
hour of intelligent efforts directed toward restoring 
the circulation and body-heat, will, if he be not in a 
moribund condition, stand a better chance of re- 
covery with an immediate amputation than by delay. 
Reaction will not be delayed by the operation, but 
the continued presence of a crushed and mangled 
limb will rather tend to perpetuate shock and render 
sapremia and septicemia more probable than a 
prompt and bloodless removal of the part. 
In presenting for consideration these indications 4 
for amputation, I have, for various reasons, pur- 
posely avoided referring to statistical evidence. 
Statistics, especially medical and surgical statistics, 
are capable of so many opposite interpretations, that 
they are often not only capable of carrying errone- 
ous impressions, but may be absolutely dangerous. 
Nor have I related cases illustrative of the various 
propositions stated, though I have considerable 
material for such illustration. I have rather preferred 
to state them briefly as the result of my clinical 
experience, satisfied that had I appreciated them 
fully at an earlier date I might have saved much suf- 
fering, and I believe a few lives. 
I trust that if any feel called upon to criticise these 
indications they will do so, using as a base their 
clinical experience, and not statistical compila- 
tions.