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If you are not located in the United States, you'll have -to check the laws of the country where you are located before using this ebook. - - - -Title: Artificial Limbs - -Author: Auguste Broca - Charles Ducroquet - -Editor: Reginald Cheyne Elmslie - -Translator: Reginald Cheyne Elmslie - -Release Date: October 13, 2017 [EBook #55739] - -Language: English - -Character set encoding: UTF-8 - -*** START OF THIS PROJECT GUTENBERG EBOOK ARTIFICIAL LIMBS *** - - - - -Produced by deaurider, Karin Spence and the Online -Distributed Proofreading Team at http://www.pgdp.net (This -file was produced from images generously made available -by The Internet Archive) - - - - - - - - - - MILITARY MEDICAL MANUALS - - GENERAL EDITOR: - - SIR ALFRED KEOGH, G.C.B., M.D., F.R.C.P. - - - ARTIFICIAL LIMBS - - - - - ARTIFICIAL LIMBS - - - BY - - A. BROCA - - _Professor of Topographical Anatomy - to the Faculty of Paris_ - - _AND_ - - DUCROQUET - - _Orthopædic Surgeon to the - Rothschild Hospital_ - - - TRANSLATED AND EDITED BY - - R. C. ELMSLIE, M.S., F.R.C.S. - - _Major R.A.M.C.(T.F.) - Orthopædic Surgeon to St. Bartholomew's Hospital, Surgeon to - Queen Mary's Hospital, Roehampton_ - - - _WITH 208 ILLUSTRATIONS_ - - - UNIVERSITY OF LONDON PRESS, LTD. - 18 WARWICK SQUARE, LONDON, E.C. 4. - - PARIS: MASSON ET CIE - 120 BOULEVARD SAINT-GERMAIN - - 1918 - - - - - GENERAL INTRODUCTION - - -The infinite variety of injuries which any war presents to the surgeon -gives to military surgery a special interest and importance. The -special interest and importance, in a surgical sense, of the great -European War lies not so much in the fact that examples of every form -of gross lesion of organs and limbs have been seen, for if we read -the older writers we find little in the moderns that is new in this -respect, but is to be found in the enormous mass of clinical material -which has been presented to us and in the production of evidence -sufficient to eliminate sources of error in determining important -conclusions. For the first time also in any campaign the labours of -the surgeon and the physician have had the aid of the bacteriologist, -the pathologist, the physiologist and indeed of every form of -scientific assistance in the solution of their respective problems. -The clinician entered upon the great war armed with all the resources -which the advances of fifty years had made available. If the surgical -problems of modern war can be said not to differ sensibly from the -campaigns of the past, the form in which they have been presented -is certainly as different as are the methods of their solution. The -achievements in the field of discovery of the chemist, the physicist -and the biologist have given the military surgeon an advantage in -diagnosis and treatment which was denied to his predecessors, and we -are able to measure the effects of these advantages when we come to -appraise the results which have been attained. - -But although we may admit the general truth of these statements it -would be wrong to assume that modern scientific knowledge was, on the -outbreak of the war, immediately useful to those to whom the wounded -were to be confided. Fixed principles existed in all the sciences -auxiliary to the work of the surgeon, but our scientific resources -were not immediately available at the outset of the great campaign; -scientific work bearing on wound problems had not been arranged in a -manner adapted to the requirements, indeed the requirements were not -fully foreseen; the workers in the various fields were isolated, or -isolated themselves pursuing new researches rather than concentrating -their powerful forces upon the one great quest. - -However brilliant the triumphs of surgery may be, and that they have -been of surpassing splendour no one will be found to deny, experiences -of the war have already produced a mass of facts sufficient to suggest -the complete remodelling of our methods of education and research. - -The series of manuals, which it is my pleasant duty to introduce to -English readers, consists of translations of the principal volumes of -the "Horizon" Collection which has been appropriately named after the -uniform of the French soldier. - -The authors, who are well-known specialists in the subjects which they -represent, have given a concise but eminently readable account of -the recent acquisitions to the medicine and surgery of war which had -hitherto been disseminated in periodical literature. - -No higher praise can be given to the Editors than to say that the -clearness of exposition characteristic of the French original has not -been lost in the rendering into English. - - - MEDICAL SERIES - -The medical volumes which have been translated for this series may be -divided into two main groups, the first dealing with certain epidemic -diseases including syphilis, which are most liable to attack soldiers, -and the second with various aspects of the neurology of war. The last -word on _Typhoid Fever_, hitherto "the greatest scourge of armies -in time of war," as it has been truly called, will be found in the -monograph by MM. Vincent and Muratet which contains a full account -of recent progress in bacteriology and epidemiology as well as the -clinical features of typhoid and paratyphoid fevers. The writers -combat a belief in the comparatively harmless nature of paratyphoid -and state that in the present war hæmorrhage and perforation have been -as frequent in paratyphoid as in typhoid fever. In their chapter on -diagnosis they show that the serum test is of no value in the case of -those who have undergone anti-typhoid or anti-paratyphoid vaccination -and that precise information can be gained by blood cultures only. The -relative advantages of a restricted and liberal diet are discussed -in the chapter on treatment, which also contains a description of -serum-therapy and vaccine-therapy and the general management of the -patient. - -Considerable space is devoted to the important question of the -carrier of infection. A special chapter is devoted to the prophylaxis -of typhoid fever in the army. The work concludes with a chapter on -preventive inoculation in which its value is conclusively proved by -the statistics of all countries in which it has been employed. - -MM. Vincent and Muratet have also contributed to the series a work -on _Dysentery, Cholera and Typhus_ which will be of special interest -to those whose duties take them to the Eastern Mediterranean or -Mesopotamia. The carrier problem in relation to dysentery and cholera -is fully discussed, and special stress is laid on the epidemiological -importance of mild or abortive cases of these two diseases. - -In their monograph on _The Abnormal Forms of Tetanus_, MM. -Courtois-Suffit and Giroux treat of those varieties of the disease in -which the spasm is confined to a limited group of muscles, _e. g._ -those of the head, or one or more limbs, or of the abdomino-thoracic -muscles. The constitutional symptoms are less severe than in the -generalised form of the disease, and the prognosis is more favourable. - -The volume by Dr. G. Thilbierge on _Syphilis in the Army_ is intended -as a _vade-mecum_ for medical officers in the army. - -Turning now to works of neurological interest we have two volumes -dealing with lesions of the peripheral nerves by Mme. Atanassio -Benisty, who has been for several years assistant to Professor Pierre -Marie at La Salpêtrière. The first volume contains an account of the -anatomy and physiology of the peripheral nerves, together with the -symptomatology of their lesions. The second volume is devoted to the -prognosis and treatment of nerve lesions. - -The monograph of MM. Babinski and Froment on _Hysteria or Pithiatism -and Nervous Disorders of a Reflex Character_ next claims attention. In -the first part the old conception of hysteria, especially as it was -built up by Charcot, is set forth, and is followed by a description of -the modern conception of hysteria due to Babinski, who has suggested -the substitution of the term "Pithiatism," _i. e._ a state curable -by persuasion, for the old name hysteria. The second part deals with -nervous disorders of a reflex character, consisting of contractures -or paralysis following traumatism, which are frequently found in the -neurology of war, and a variety of minor symptoms, such as muscular -atrophy, exaggeration of the tendon reflexes, vasomotor, thermal and -secretory changes, etc. An important section discusses the future of -such men, especially as regards their disposal by medical boards. - -An instructive companion volume to the above is to be found in the -monograph of MM. Roussy and Lhermitte, which embodies a description of -the psychoneuroses met with in war, starting with elementary motor -disorders and concluding with the most complex represented by pure -psychoses. - - - SURGICAL SERIES - -When the present war began, surgeons, under the influence of the -immortal work of Lister, had for more than a quarter of a century -concerned themselves almost exclusively with elaborations of -technique designed to shorten the time occupied in or to improve the -results obtained by the many complex operations that the genius of -Lister had rendered possible. The good behaviour of the wound was -taken for granted whenever it was made, as it nearly always was, -through unbroken skin, and hence the study of the treatment of wounds -had become largely restricted to the study of the aseptic variety. -Septic wounds were rarely seen, and antiseptic surgery had been -almost forgotten. Very few of those who were called upon to treat the -wounded in the early autumn of 1914 were familiar with the treatment -of grossly septic compound fractures and wounded joints, and none had -any wide experience. To these men the conditions of the wounds came as -a sinister and disheartening revelation. They were suddenly confronted -with a state of affairs, as far as the physical conditions in the -wounds were concerned, for which it was necessary to go back a hundred -years or more to find a parallel. - -Hence the early period of the war was one of earnest search after -the correct principles that should be applied to the removal of the -unusual difficulties with which surgeons and physicians were faced. It -was necessary to discover where and why the treatment that sufficed -for affections among the civil population failed when it was applied -to military casualties, and then to originate adequate measures -for the relief of the latter. For many reasons this was a slow and -laborious process, in spite of the multitude of workers and the wealth -of scientific resources at their disposal. The ruthlessness of war -must necessarily hamper the work of the medical scientist in almost -every direction except in that of providing him with an abundance of -material upon which to work. It limits the opportunity for deliberate -critical observation and comparison that is so essential to the -formation of an accurate estimation of values; it often compels -work to be done under such high pressure and such unfavourable -conditions that it becomes of little value for educative purposes. -In all the armies, and on all the fronts, the pressure caused by the -unprecedented number of casualties has necessitated rapid evacuation -from the front along lines of communication, often of enormous -length, and this means the transfer of cases through many hands, with -its consequent division of responsibility, loss of continuity of -treatment, and absence of prolonged observation by any one individual. - -In addition to all this, it must be remembered that in this war the -early conditions at the front were so uncertain that it was impossible -to establish there the completely equipped scientific institutions for -the treatment of the wounded that are now available under more assured -circumstances, and that progress was thereby much hampered until -definitive treatment could be undertaken at the early stage that is -now possible. - -But order has been steadily evolved out of chaos and many things are -now being done at the front that would have been deemed impossible not -many months ago. As general principles of treatment are established -it is found practicable to give effect to them to their full logical -extent, and though there are still many obscure points to be -elucidated and many methods in use that still call for improvements, -it is now safe to say that the position of the art of military -medicine and surgery stands upon a sound foundation, and that its -future may be regarded with confidence and sanguine expectation. - -The views of great authorities who derive their knowledge from -extensive first-hand practical experience gained in the field, cannot -fail to serve as a most valuable asset to the less experienced, and -must do much to enable them to derive the utmost value from the -experience which will, in time, be theirs. The series covers the whole -field of war surgery and medicine, and its predominating note is the -exhaustive, practical and up-to-date manner in which it is handled. It -is marked throughout not only by a wealth of detail, but by clearness -of view and logical sequence of thought. Its study will convince the -reader that, great as have been the advances in all departments in -the services during this war, the progress made in the medical branch -may fairly challenge comparison with that in any other, and that not -the least among the services rendered by our great Ally, France, to -the common cause is this brilliant contribution to our professional -knowledge. - -A glance at the list of surgical works in the series will show how -completely the ground has been covered. Appropriately enough, the -series opens with the volume on _The Treatment of Infected Wounds_, -by A. Carrel and G. Dehelly. This is a direct product of the war -which, in the opinion of many, bids fair to become epoch-making -in the treatment of septic wounds. It is peculiar to the war and -derived directly from it, and the work upon which it is based is as -fine an example of correlated work on the part of the chemist, the -bacteriologist and the clinician as could well be wished for. This -volume will show many for the first time what a precise and scientific -method the "Carrel treatment" really is. - -The two volumes by Prof. Leriche on _Fractures_ contain the practical -application of the views of the great Lyons school of surgeons with -regard to the treatment of injuries of bones and joints. Supported -as they are by an appeal to an abundant clinical experience, they -cannot fail to interest English surgeons, and to prove of the greatest -value. It is only necessary to say the _Wounds of the Abdomen_ are -dealt with by Dr. Abadie, _Wounds of the Vessels_ by Prof. Sencert, -_Wounds of the Skull and Brain_ by MM. Chatelin and De Martel, and -_Localisation and Extraction of Projectiles_ by Prof. Ombredanné and -R. Ledoux-Lebard, to prove that the subjects have been allotted to -very able and experienced exponents. - - ALFRED KEOGH. - - - - - PREFACE - - -No attempt is made in this little book to describe all the artificial -limbs and appliances that have been invented. Before the war these -were very numerous, since then their number has become countless, and -not a day passes without the appearance of some new model of greater -or less ingenuity. - -But all these special inventions, the utility of which we should not -think of denying, are only of real practical value if the makers have -followed out certain general principles in their manufacture. In the -following pages we have attempted to indicate what these principles -are. - -Our experience has been gained in connection with the _Fédération -des Mutilés_, where hundreds of disabled men have been examined and -fitted, and where we have always tried to give to each that appliance -which is best suited to his work. - -For this indeed is the vital principle, and great disappointments -will result if, for æsthetic reasons, every patient is given the same -appliance, whether it be the leg known as the American leg or an -elaborate artificial arm. More often than might be believed accurate -imitation of the external form of the natural limb is incompatible -with good functional use. This is particularly so in the upper limb. - -Perhaps the readers of these pages will gain a clear understanding of -these principles; and we shall have attained our object if by enabling -them to understand certain typical appliances we make it possible for -them to devise others which are at the same time strong, shapely and -practical. - -Throughout the volume it will be found that we express a preference -for the construction of artificial limbs for the lower limb out of -wood, the method adopted by the Americans. This procedure, because -strength and durability are so necessary, seems to us to constitute -a very real advance; these considerations are, however, of much -less importance in the case of the upper limb. It is a matter for -regret that the French official instructions have not compelled our -manufacturers to adopt this technique, too often the latter are -inclined to keep to their old routine, but they can be induced to -alter it, as we have proved by our success at the _Fédération des -Mutilés_. - -There is nothing revolutionary in such a suggestion. It has been -adopted by the Belgian Government in the fitting centres which they -have established; this is also the case with the English authorities, -who, we understand, have even attracted from America special fitters -for this work. We should have thought that we, in France, might -have developed our national supply of artificial limbs in the same -direction. - - - - - INTRODUCTION TO THE ENGLISH EDITION - - -The details of the manufacture of artificial limbs naturally differ -greatly in different countries. So much so that at first sight it -might appear useless to introduce into England and America the -account given in this work of the methods adopted in France. But, -as the authors state in their preface, the principles remain the -same whatever the details of the methods used. In the lower limb the -essentials to be studied are the points upon which weight can be -taken, the "Bearing Points," the proper method of fitting the stump, -the principles of securing stability and the mechanism of the knee and -ankle joints. These remain unalterable whatever be the material used -and whatever be the details of manufacture. - -In England it has for a long time been understood that every sailor -or soldier who has lost a limb has the right to expect that he will -be supplied with a good artificial substitute. And, further, it has -been taken for granted that this will, in the case of the lower limb, -be a full artificial leg and not a peg leg. Therefore the standard -pattern has in England been a full limb, and the peg has only been -supplied as a temporary appliance, and as an alternative appliance to -be used when the other limb requires alteration or repair. For this -reason the possibilities of the peg leg, except in its simplest form, -have perhaps been neglected in this country, and a study of the French -methods of making these peg legs, particularly the convertible peg -leg, is well worth while. - -The introduction of American artificial legs into this country has -not been so revolutionary in its results as it is apparently in -France, for we have been accustomed for many years to make the bucket -out of a single piece of willow. The alterations in our methods -introduced recently from America are essentially the following-- - -1. The use of a sling which passing over the shoulders is attached -to the leg below the knee in such a way as to act as a mechanism for -extending the knee. - -2. The manufacture of the leg portion out of a single piece of wood. - -3. The abolition of the old tendon action for the ankle joint (which -resembled the mechanism described on page 57) and its replacement by -the ankle with movement limited by indiarubber buffers. - -4. Covering the wooden part of the limb with a layer of raw hide or -parchment, which certainly adds to the strength. - -The sole remaining problem in the design of artificial legs appears -to be the invention of a knee mechanism which will lock in any degree -of flexion when a strain is put upon it, so that the wearer does not -necessarily fall when his weight comes upon the limb with the knee -flexed. A recent invention, still on its trial, seems to indicate that -this problem is not incapable of solution. - -In artificial arms the differences between the French and English -patterns are greater than in artificial legs. But here again the -principles remain the same. In England, also, we have _worker's arms_ -and _show arms_, but the latter tend to be more elaborate than the -French patterns, mechanical movements being more developed. For this -reason this pattern is usually called, in England, the _mechanical -arm_. Instead of the single cord, looped round the opposite shoulder, -and used to open the spring thumb (see p. 101), at least three such -cords are used, actuated (1) by rounding the back; (2) by expanding -the upper part of the chest, and (3) by raising or lowering the -shoulder on the side of the amputation. These may be used for various -purposes, of which the chief are (1) flexing the artificial elbow; -(2) working the elbow lock, and (3) actuating the thumb, fingers or -appliances used instead of the hand. The chief other differences in -the methods adopted in England are-- - -1. A smaller enclosure of the shoulder region for purposes of -suspension, the limb being held on by a harness of straps. We, in -fact, value mobility of the shoulder, and gain it at the expense of -stability. - -2. The use of various alternative patterns of elbow locks. - -3. The appliances used instead of the hand are very different in -pattern, although the principles for their construction remain as -described here by the authors. - -Much ingenuity has been expended on the design of mechanical -artificial hands, with results which are satisfactory so far as they -go, but which require much further development before the hand can -possibly replace even a few of the appliances which can be substituted -for it. For this reason it should be made an invariable rule that the -artificial hand, however ingenious and however apparently perfect it -may be, should be detachable, so that it may be replaced by other -appliances. - - R. C. E. - - - - - CONTENTS - - - PAGE - - GENERAL INTRODUCTION v - - PREFACE xiii - - INTRODUCTION TO THE ENGLISH EDITION xv - - - CHAPTER I - - GENERAL CONSTRUCTION OF AN ARTIFICIAL LIMB 1 - - - CHAPTER II - - GENERAL PRINCIPLES OF FITTING FOR THE LOWER LIMB 6 - - - CHAPTER III - - ARTIFICIAL LIMBS FOR AMPUTATIONS THROUGH THE THIGH 12 - I. Apparatus with bearing upon the ischium 12 - 1. The shape of the top of the bucket 13 - 2. Mode of suspension 21 - 3. Walking on a peg leg and similar appliances 28 - 4. Walking with free flexion of the knee 33 - II. Limbs without bearing upon the ischium 60 - - - CHAPTER IV - - ARTIFICIAL LIMB FOR DISARTICULATION AT THE HIP JOINT 64 - - - CHAPTER V - - ARTIFICIAL LIMBS WITH FREE KNEE JOINT FOR AMPUTATION THROUGH - THE LEG 66 - I. Appliances with bearing upon the tuberosities of the - tibia 67 - II. Appliances with end bearing only 77 - - - CHAPTER VI - - PARTIAL AMPUTATIONS OF THE FOOT 81 - - - CHAPTER VII - - ARTIFICIAL LIMBS FOR AMPUTATION THROUGH THE FOREARM 84 - I. Points of attachment 85 - II. Elbow joint 90 - III. The artificial hand and appliances 96 - A. The artificial hand 97 - B. Appliances for use in place of the hand 108 - - - CHAPTER VIII - - ARTIFICIAL LIMBS FOR AMPUTATION THROUGH THE ARM 129 - I. Artificial arm 132 - II. Worker's arm 138 - - - CHAPTER IX - - ARTIFICIAL LIMBS FOR DISARTICULATION THROUGH THE SHOULDER - JOINT AND AMPUTATION THROUGH THE DELTOID MUSCLE 143 - - - CHAPTER X - - SOME GENERAL PRINCIPLES IN THE RE-EDUCATION OF THE DISABLED 145 - - - INDEX 159 - - - - - ARTIFICIAL LIMBS - - - - - _CHAPTER I_ - - GENERAL CONSTRUCTION OF AN ARTIFICIAL LIMB - - -A prosthetic apparatus for any amputation is composed of two parts: - -1. The artificial limb. - -2. The attachment of this limb to the trunk. - -The artificial limb itself is divided into two parts: - -1. A conical socket. - -2. A part which replaces the missing limb and is in fact a terminal -functional appliance. - -Two conditions must be considered, whether or not there remains -attached to the trunk a segment of the limb capable of being fitted -into the base of the artificial limb, to which it gives support, and -to which, in addition, it can communicate movement. Accordingly the -artificial limb differs essentially for: - -1. Disarticulation of the shoulder and of the hip. - -2. Amputation of the arm and of the thigh. - -In the first case we attach to the trunk an instrument which is -entirely passive. - -In the second we attempt to turn to account the active movements of -the stump. - -These various parts do not lend themselves to a general description -applicable at once to the upper and lower limbs. Not only are -the modes of attachment and the functional artificial limb quite -different, but the bucket does not serve the same purposes. - -_The position of the scar._--The stump, which fits the bucket exactly, -transmits to it two kinds of force: - -1. The force of vertical pressure. - -2. Lateral force corresponding to the angular movements of the joint -above. - -The lateral force is transmitted by the whole of one surface of the -stump to the corresponding lateral surface of the bucket: by the -anterior and posterior surfaces only in the case of hinge joints such -as the elbow and the knee: by all surfaces in the case of joints with -movements of circumduction such as the shoulder and the hip. - -Vertical pressure exercised upwards or downwards may cause the limb to -press upon the bucket at two points: (1) on the summit of the cone, -_i.e._ on the extremity of the stump; (2) on the base of the cone, -_i.e._ on the bony prominences around the last remaining joint. The -adjustment is never sufficiently accurate for the relief due to the -fitting of the stump in the bucket to be of much importance. - -We should take it as a general rule that a scar cannot stand pressure -or friction; and that in consequence, when we amputate under -favourable conditions, we should arrange to place the scar in such a -position that from our knowledge of the suitable prosthetic apparatus -these two evils will be avoided. It should be added, however, that -after perfect primary union, the narrow and mobile scar is very -tolerant, but it must also be remembered--especially as will be -seen in the lower limb--that this condition is rarely realised in war -surgery. - -The length of the stump is often estimated by reference to that of the -other limb; amputation at the upper, middle, or lower third of the -thigh, of the leg, of the arm, or of the forearm. This is convenient, -starting from a certain minimum length, but there is an _absolute -minimum length_ below which the stump has insufficient leverage and -tends moreover to escape from the bucket. - -_Temporary and permanent apparatus._--For the irregular amputations -of war surgery which have suppurated, more often than for those of -civil practice, it is generally advisable, particularly in the lower -limb, to use a temporary apparatus, of fairly good fit, for several -weeks or even months before the permanent apparatus of more precise -fit. The stump has to soften and shrink gradually; only when this has -occurred can we make an accurately fitting bucket, by means of a cast -if necessary. - -_Materials for making the bucket._--The first method of construction -is that of _leather reinforced with metal_; a sheath strengthened -with metal supports, is laced around the stump; the supports further -give attachment, if there is room, to the artificial joints. This -is an excellent principle, either for stumps which are still likely -to diminish in size, or for the upper limb where exact fit is of -secondary importance. - -For buckets accurately fitted on a cast we employ: - -_Blocked leather_, which loses shape and ought to be abandoned for -artificial limbs for the lower extremity.[1] - -[1] This we have attained at the _Fédération des Mutilés_, having -forced the makers to abandon their routine. It seems to us therefore -that the same result might be attained for the appliances furnished by -the State, which are still made of leather. - -_Celluloid_ is the material of choice, but it has the defect of -requiring the hand of an artist; commercial attempts on a large scale -have so far yielded mediocre results. - -_Metal_ (zinc, sheet steel, aluminium), the defect of which is that -the apparatus, particularly for the lower limb, is noisy. This is also -an inconvenience in the metal joints of lateral steels of leather -appliances and of the spiral springs in certain wooden apparatus, -for this reason indiarubber is more often relied on for springs and -accumulators. - -_Wood_, for many years used for the commoner types of limbs for the -lower extremity, is now, as the result of American influence, utilised -for the making of apparatus hitherto termed "de luxe," but to-day -serviceable, thanks to this technique.[2] - -[2] Working in wood, to hollow out of a log of wood a bucket which -fits the stump accurately, is no novelty. Some sixty years ago two -Frenchman, Bailly, then Xavier, succeeded in such construction. But -these appliances, like the common, cheap unshaped peg leg, split -easily and were only made strong when the Americans conceived the -idea of covering the outer surface with a layer of raw hide: strong, -and therefore practical, for though we may resign ourselves to the -frequent renewal of a peg leg at 25 francs, it is another matter with -an appliance costing 300 to 400 francs. (Prices in peace time.) - -(In England the standard patterns of artificial legs have for many -years been made out of wood.--ED.) - -The adjustment to the stump is very exact; the contact with the -surface where there is friction is soft and comfortable without -padding; the appliance is light, strong and silent. The best woods -appear to be English willow and lime. The bucket should not present -any flaw or knot, this can be seen on the inner uncovered surface. - -But we must emphasise the general fact that _standardisation is -impossible when the bucket is made of wood_. For the other parts it -is possible but not for the bucket, which must be made specially for -each patient, hollows being made for each bony point, which must be -marked out and felt for with the fingers. A plaster cast would appear -more exact: but by this means we do not mark out the bony points. Good -results cannot be obtained, if, as certain people have tried, linear -measurements are sent to a workshop whence an apparatus is forthwith -despatched to a patient whom the maker has never seen. - - - - - _CHAPTER II_ - - GENERAL PRINCIPLES OF FITTING FOR THE LOWER LIMB - - -Whether we are dealing with an amputation of the leg or an amputation -of the thigh, the principle function of the artificial limb is to -support the weight of the body. The bucket must therefore give support -to this weight. Three bearing points are thus possible: at the base, -upon the surface and upon the end of the stump. - -1. _Bearing upon the base._--The principal bearing is that which -is taken by fitting the upper edge of the bucket under the bony -prominences situated around the last joint preserved, i.e. the -tuberosity of the ischium for the thigh, the head of the tibia for the -leg. - -2. _Bearing upon the surface of the stump._--Certain makers attribute -to this an importance which we believe to be imaginary, but which -leads them to erroneous conclusions. - -It is evident that if a conical stump which is jointless and which -transmits the weight is fitted exactly, point downwards, into a -conical bucket, supported below by a vertical pillar, the weight is -transmitted by the friction of the part enclosed against the bucket, -without any pressure upon the free end. Whence it may be concluded -that, as the end of the stump should not serve as a bearing point, we -should prefer a terminal scar to lateral scars which might be rendered -painful or even ulcerated by friction against the bucket. - -But experience shows us that if the pressure of the bucket at this -point is harmful to the lateral scars, it is not less so for most -terminal scars. - -The stump in its bucket is in fact a bone, furnished with soft parts -upon which we cannot exert vertical pressure, without squeezing them -back towards the base of the stump, thus exerting an upward tension -of the terminal soft parts over the end of the bone. This is bound to -occur unless there is a considerable length of soft parts beyond the -end of the bone, that is unless more bone has been sacrificed than was -necessary. In this way we get all the disadvantages of an end bearing -without its advantages. - -3. _Direct end bearing._--This is only the principal bearing in -certain special stumps which we shall indicate in due course; in some -of these it is the sole bearing. In the case of apparatus for the -usual amputations, above the epiphyseal enlargements, it is never more -than a complementary or accessory bearing, although a very useful one. - -To take pressure upon the end of the stump it is only necessary to -stretch across the bucket at the right height a piece of material -covered with felt. If the apparatus is made of leather, the support is -taken upon a circular band of metal fixed to the lateral steels. - -In order that direct pressure upon the stump may be possible, two -conditions are indispensable: that there is no terminal scar; and -that the extremity of the bone is well covered with a thick and -nonadherent flap. Actually walking directly on the stump does not -involve simply support by pressure, but also inevitable friction, -of greater or less importance, caused by the backward and forward -movement. This is only realised under the most perfect conditions if -the skin is adapted by its structure to this movement. This is the -case with the sole of the foot: where the epidermis and dermis are -thick and the subcutaneous areolar tissue and deep fascia, continuous -with it, enclose little cavities filled with globules of fat; these -form a cushion, like little globules of liquid gliding over each -other. The skin of the point and of the posterior surface of the heel -is less suitable anatomically than that of the sole: it is, however, -good, and it is for this reason that after amputation above the -malleoli, it is possible to walk directly upon the cut surface of the -tibia. - -Nevertheless skin which is not prepared in this way by its normal -structure can adapt itself to pressure and friction, provided that -it is padded by a thick muscular layer, sheathed whenever possible -with fibrous tissue. A skin which is not so lined, especially in -fair and stout people, with thin and delicate skin, ulcerates easily -as the result of friction or even of simple pressure, and bursæ and -callosities form. See what happens to the skin on the dorsum and outer -side of the foot in the case of talipes equino varus. The muscles of -the flap will not remain over the bone in the condition of muscular -tissue, they become fibrous--but they are useful because: - -1. They interpose a fibrous layer of greater or less thickness between -the bone and the skin, so that the latter remains movable over the end -of the bone and is not directly compressed; - -2. They adhere to the cut section of the bone forming a tendinous -insertion, which renders their action on the bony lever more powerful. - -A flap bears weight badly when the muscles have retracted around the -bone, over which there is then nothing but skin. It is the same when -the flap is stretched tightly across the end of the bone, _the soft -parts must remain soft and free_. - -Among the hundreds of cases of amputation of the leg or thigh that -have passed before us in being fitted at the _Fédération des Mutilés_, -there were many in which the presence of a terminal scar rendered the -fitting of an apparatus difficult; we have never found this the case -with a lateral scar; we have never seen the latter ulcerate rapidly as -the result of pressure or friction in a properly made wooden bucket. -So that it cannot be admitted that the proper covering of a stump is -ever a matter of secondary importance. - -Consequently we should consider, as a matter of principle, the -circular method of amputating only as a last resort, and we ought to -arrange the section of the soft parts so as to cover the end of bone -as adequately as possible, and to bring the scars to one side. - -We realise that in practice war surgery often necessitates deviations -from the ideal. We often find ourselves in a dilemma--either the stump -must be good but too short; or, being long, must be poor or even bad. - -In the special case of the thigh, circular amputation in the lower -third when it is carried out through healthy tissue and has not -suppurated can be trimmed and sutured in such a way as to give an -excellent scar, which is transverse and slightly posterior. In this -situation after these routine amputations, a linear scar which is -supple and has healed by first intention, separated from the bone -by a good cushion of muscular and fibrous tissue, causes little -embarrassment, whatever its position; at the end of a few months it -stands pressure and friction without harm. But we are considering -war surgery and consequently we are often called upon to fit stumps -in which the cicatrix is large, hard, and more or less irregular, in -which the bone has suppurated and in which the neighbouring soft parts -are indurated and scarred. These stumps are not, however, the results -of the work of the worst surgeon. - -Amputating through infected parts, resigning himself to healing by -granulation and subsequent trimming by operation, he must take time -and trouble to attain in the end a result which is good functionally, -although at first sight unsightly. But it is this surgeon who is on -the right road, rather than he who sends us good stumps which have not -suppurated, because he has amputated through the thigh for a wound of -the middle of the leg, or through the leg for a wound of the foot or -even of the front of the foot. - -It is clear, that for the stump effectually to play its part of a -lever in its bucket, a certain definite length is necessary; and we -ought to do everything possible to secure a length of at least 15 to -20 centimetres in a thigh stump, or 10 to 12 centimetres in a leg -stump. But when this length is secured, there is no great functional -difference between, for example, an amputation of the leg in the -lower third or in the lower quarter, particularly if the fitter -understands how to utilise direct end bearing. The knowledge of this -is of capital importance to the surgeon called upon to carry out -secondary operations upon imperfect stumps, in determining whether -it is possible to put an immediate stop to suppuration by drastic -shortening, or whether he must preserve length and lose time by -curretting the foci of inflammation in the bone. - - - - - _CHAPTER III_ - - ARTIFICIAL LIMBS FOR AMPUTATIONS THROUGH THE THIGH - - -There are two entirely different modes of fitting: - -I. For amputations above the condyles, in which weight must always be -borne upon the tuberosity of the ischium through the top of the bucket. - -II. For amputations through the condyles (or for disarticulation of -the knee) in which a direct end bearing may suffice. - - - I. Apparatus with Bearing upon the Ischium - - (_Amputation above the condyles._) - -In the construction of an artificial limb for amputation through the -thigh two entirely different principles may be used, according as it -is desired to make the patient walk upon a rigid shaft, that is to say -upon a peg, or upon an artificial leg proper, in which the knee bends -in walking (known as the American leg). - -But whichever principle is adopted, whatever material is chosen, wood -or leather, and however exact the fit in the bucket may be, certain -common rules govern:-- - -1. The shape of the top of the bucket by which it is fitted to the -top of the thigh and its bearing upon the ischium. - -2. The attachment of the limb to the trunk. - -To begin with we shall consider these two questions, and then -temporary and permanent apparatus, the peg leg and the full artificial -limb, will be described. - - - I. THE SHAPE OF THE TOP OF THE BUCKET - -The tuberosity of the ischium is the sole bony point which can prevent -the ascent of the limb when weight is applied. This tuberosity is -situated in the posterior part of the perineum (Fig. 1), the anterior -part of which is unable to stand pressure. It is necessary, therefore, -to clear this part by cutting down the inner border in its anterior -part, forming a _perineal concavity_, which rises posteriorly against -the ischium (Fig. 3). - -It is essential that the ischium should not be able to slip inside -the bucket, otherwise the inner border will come in contact with the -perineum: therefore the diameter of the bucket must be less than that -of the limb, so that the ischium may rest upon its upper edge. - -If the bucket is too large, the patient abducts the stump, so as -to lower the inner border and prevent pressure on the perineum; he -carries the leg away from the side as he walks, and this is both -unsightly and fatiguing. - -When an apparatus is completed, it is very easy to ascertain the site -of the pressure on the ischium. The limb being put on, the ischium -is fixed between the thumb and first finger, and it can then be -ascertained whether it rests on the edge of the bucket or lies within -it. This can be determined more exactly, if whilst the fingers which -mark the position of the ischium are kept within the bucket, the -patient is told to raise his stump. - -If the bucket is sufficiently narrow, it may be circular without the -excavation for the perineum (Fig. 2). But this shape is unsatisfactory -for another reason, because it results in a tendency for the limb to -rotate inwards. - -At the moment when the artificial limb is coming in contact with the -ground as it takes a step, the pelvis is oblique (the iliac spine of -the sound side lying posterior to that of the amputated side). The -sound limb as it executes its step is carried forwards, and the pelvis -which was oblique in one direction now becomes oblique in the opposite -direction. This movement is transmitted to the femur in the stump, so -that the artificial limb turns inwards relatively to the stump. With -each step this rotation becomes little by little more perceptible, -and after a time the patient is obliged to correct it by turning the -artificial limb with his hand. - -If, on the other hand, the front of the upper border of the bucket -slopes downwards and inwards at an angle of about 45 degrees, when as -a result of its weight the bucket turns inwards as the limb is swung, -the base of the stump will come against a higher part of bucket; but -when the pressure of the weight of the body returns, the stump, being -forced into the bucket, will descend again along this slope, that -is to say a passive external rotation of the artificial limb will -be brought about, correcting at every step the tendency to internal -rotation. - - [Illustration: AMPUTATIONS THROUGH THE THIGH - - FIG. 1. - - FIG. 2. - - FIG. 3. - - In the upright position the rami of the pubis and ischium, between - which stretches the perineum, slope downwards and backwards at an - angle of about 45° with the horizontal. The tuberosity of the ischium - bounds the perineum posteriorly, and is its lowest point. The rami - of the pubis and ischium, corresponding to the genito-crural fold, - mark the boundary between the thigh and the perineum. These bones are - unable to stand the pressure of an artificial limb. - - If the top of the bucket is narrower than the circumference of the - top of the limb, measured below the ischium, it may be circular and - still give support to the ischium, which will not slip into it. If - the ischium does slip into the bucket, the result will be that it no - longer serves as the support, the pressure coming instead upon the - rami of the pubis and ischium and upon the perineum. - - The constriction thus exerted upon the top of the stump may easily - become insupportable. The correct solution of the problem is to cut - down the upper border of the bucket opposite the perineum, letting it - rise again posteriorly beneath the tuberosity of the ischium, and - gain a good support there.] - -The same slope may be given to both edges of the bucket (Fig. 5). -This obliquity in the posterior part serves no useful purpose: it is -better on the contrary to lower the posterior border combining this -semioblique fitting with a rise beneath the ischium and a depression -under the perineum (Fig. 6). - -These conditions are easily carried out in a well-made wooden bucket, -represented in figures 8 and 9, in which it may further be seen that -from the front it is convex outwards; from the side, convex forwards -(Fig. 9). This form, which is that of some good American appliances, -ought to be generally used. - -_The curve outwards_, by drawing away the soft parts from it, frees -the region of the ischium and allows the tuberosity of the ischium to -press upon the bucket (Fig. 8). - -_If the thigh piece is curved forwards_, and particularly if the limb -is built with a very slight flexion of the knee, the stump remains -slightly flexed at the hip and the patient feels as if he is sitting -in the apparatus. - -When the thigh piece is straight, an uncomfortable pressure is -produced by the edge of the bucket against the ischium. It may be -added that extension of the hip is very often impaired, particularly -in patients with a short stump: The extensor muscles being divided, -the flexors cause contraction into a flexed position, the more so the -shorter the stump is. If the thigh piece is straight, the short stump -cannot follow the movement of extension necessary in walking; it slips -out of the bucket if the anterior lip of the latter is too low. - -The principles are the same for the leather bucket, known as the -_French pattern_. - - [Illustration: FIG. 4. - - FIG. 5. - - FIG. 6. - - FIG. 7. - - FIG. 8. - - FIG. 9. - - Figure 4 shows the circular bucket (almost always too large) of the - poor man's peg leg, attached to the body by a belt which is fastened - to a projection upwards from the outer side of the bucket. - - Figure 5 shows the oblique bucket, with symmetrical anterior and - posterior borders. Figure 6 one with the anterior border oblique, the - posterior border being cut away. Figure 7 shows the double obliquity, - downwards and backwards, of the bucket. The convexities of the bucket - and thigh piece, in the type which we consider to be the best, are - shown in figure 8 (convexity outwards), and figure 9 (convexity - forwards).] - -In this the thigh piece is strengthened by two lateral steels (to the -lower end of which is fixed the leg piece) joined posteriorly by a -semicircular cross piece on which the ischium should rest (Fig. 13). - - [Illustration: FIG. 10.] - - [Illustration: FIG. 11.] - -The usual form hitherto has been that shown in figure 10. The cross -piece was horizontal and formed simply a posterior semicircle; the -lateral steels were straight. Consequently in this pattern these -steels form a cone, in which the soft parts are not compressed on -the inner side, nor drawn outwards, as in the apparatus previously -described. Further, as long as the stump is not shrunken, the ischium -covered on its inner side by soft parts sinks into the bucket, and it -is the perineum which becomes the point of pressure (Fig. 11). Made -of leather, the perineal concavity soon loses its shape and really -no longer exists. Finally the bucket is circular, with the faults -inseparable from that shape (Fig. 12). - -In cases where it is felt necessary to employ leather, all these -faults are easily corrected, by giving the cross piece the shape -which we have described for the wooden bucket, and by prolonging it -forwards through two-thirds of the corresponding circumference, in -the shape of an oblique bucket. (Dotted line in Fig. 12.) - -If it is not strengthened, an oblique border of leather gives way, and -after a few months' use allows rotation. The leather which extends -from the termination of the metal ascends very steeply towards the -trochanter, whilst the posterior border of the bucket, which is -horizontal, curves downwards on the inner side to form the perineal -concavity. - - [Illustration: FIG. 12. - - FIG. 13. - - FIG. 14. - - The ordinary leather bucket is mounted upon two lateral steels, which - are joined by a posterior cross piece (Fig. 13). This framework is - shown in figure 10, and covered with leather in figure 12. If the - lateral steels are straight and divergent, this has all the defects - of the straight circular bucket. The concavity for the perineum, cut - out of the leather, soon loses its shape. It is, however, easy to - shape the cross piece as shown in figure 14, with a perineal concavity - and the anterior border oblique, following the dotted line in figure - 12. By doing this and curving the steel uprights appropriately, the - correct form of the wooden bucket can be copied exactly in a leather - and steel apparatus. Such a correct apparatus is shown in figures 15 - to 18.] - -In figure 14 is seen the metal framework; in figures 15 and 16 that -of the apparatus covered with leather; in figure 17 the support upon -the ischium; and the possibility of making this appliance identical -with the wooden bucket will be observed (Fig. 18). - - [Illustration: FIG. 15.] - - [Illustration: FIG. 16.] - - [Illustration: FIG. 17.] - - [Illustration: FIG. 18.] - - - II. MODE OF SUSPENSION - -_Suspension of the thigh piece_ is essential, and is all the more -important when the stump is short and consequently more liable to -slip out of the bucket. For this purpose support may be taken either -from the waist, upon the _prominence of the iliac crests_, or from -the _shoulders_ by means of braces. In the case of a long stump -(amputation below the middle of the thigh) only one of these methods -is necessary, we shall describe the usual methods: - -_The waist belt_ (French system) for leather appliances. - -_Braces_ (American system) for appliances of wood. - -If the stump is short a combination of the two methods is best. - - [Illustration: FIGS. 19 and 20.--Simple pelvic suspension, - with details of the joint at the hip.] - -A. SUSPENSION BY MEANS OF A WAIST BELT.--_For the peg leg -made of leather_ the best method consists in placing a pelvic plate, -which is attached to the hip steel, below the iliac crest (Figs. 20 to -24). A belt attached to the extremities of this plate surrounds the -pelvis and passes above the iliac crest on the other side. The thigh -piece is attached to this support, on the outer side, by articulation -of the outer femoral steel with the hip steel; on the inner side, by -a perineal strap. Braces complete the method of suspension of the -apparatus (Fig. 21). - - [Illustration: FIG. 21.] - -The axis of the metal joint between the outer femoral steel and the -lower end of the T piece should be directly above the great trochanter -(Fig. 20). - -The femoral steel often breaks in the neighbourhood of this joint -(Fig. 23); we have got over this difficulty by adding immediately -beneath it a joint which allows of abduction (Fig. 19). A perineal -strap limits this movement. - - [Illustration: FIG. 22. - - FIG. 23. - - _Suspension from the pelvis._ - - A metal hip piece is fixed below the iliac crest and held in place - by a belt which passes above the iliac crest of the opposite side - (Figs. 20 to 24). This piece is attached to the thigh bucket by a - joint shown in figure 19 (see also Fig. 22), which allows both flexion - and abduction of the hip, and which forms the suspension of the - outer side of the limb. The inner border is suspended by means of a - perineal strap, shown in figures 21 and 22. In figure 21 is shown how - a suspending brace may be easily added. Figure 23 shows the action of - a single hinge joint, allowing only flexion and extension at the hip - joint. On page 27 will be seen similar joints which, however, move on - the pelvic attachment as well as on the thigh piece. The object of - this is to prevent the pinching of the abdominal wall by the top of - the thigh bucket when the patient sits. It is indispensable in short - stumps. On page 21 will be seen a joint which allows abduction of the - hip, and thus relieves the strain upon the hinge joint; without it the - latter is easily broken.] - -B. SUSPENSION BY MEANS OF BRACES (American method).--The -American method of suspension has the advantage of leaving the pelvis -free; the patient does not feel the pull of the hip piece. Besides, -when the belt is used, if the patient sits down, the buttock on -the side of the stump is raised, to an extent corresponding to the -thickness of the bucket, an obliquity of the pelvis, which is both -uncomfortable and unsightly, being produced. The braces being relaxed -in the sitting posture, the patient can avoid this inconvenience; for -the stump may be slipped partly out of its bucket, the upper extremity -of which is then beyond the level of the edge of the chair. This -position is very comfortable, because it is normal, but the patient -must replace his stump in the bucket whenever he stands up. - - [Illustration: FIG. 24. - - FIG. 25. - - Braces composed of straps passing over the shoulders and down the - front, attached to the bucket by buckles. Posteriorly they are joined - together by a cross strap between the scapulæ, and beyond this are - continued in the form of elastic straps.] - -This form of suspension is essential for those artificial limbs with a -free knee-joint, in which, as we shall see, the braces serve to extend -the joint. - -We illustrate here two methods of attaching the braces to the thigh -piece, that which we use in the limb supplied by the Fédération (Figs. -24 and 25) and that which is used in the American limb of Marks -(Figs. 26 and 27). - - [Illustration: FIG. 26. - - FIG. 27. - - FIG. 26.--Braces which end below in looped thongs of leather. - - FIG. 27.--These loops, held in to the thigh piece by passing - beneath a loop of leather, pass over two pulleys about the middle of - the inner and outer sides of the thigh piece respectively. The outer - brace tends to abduct the limb if it is tightened.] - -C. COMBINED METHOD OF SUSPENSION.--_If the stump is short_ -the artificial limb must be attached both by a belt and by braces; the -latter should be 5 to 6 centimetres wide. - - [Illustration: FIG. 28. - - _Combined suspension for short stumps._ - - FIG. 28.--Complete appliance. - - FIG. 29 and 30 show the value of a flexion pivot between the - hip piece and the pelvic plate. If there is no such pivot, the T piece - undoubtedly rotates upon the belt, but not to a sufficient extent to - prevent the thigh piece in rising and pinching the abdominal wall - (Fig. 29). If there is a double joint the hip piece becomes oblique, - thrusting the thigh piece forward and allowing the patient to sit - erect (Fig. 30).] - -In these cases also, to prevent the stump escaping from the bucket -when the hip is flexed, the front of the thigh piece is carried as -high as possible; but if the appliance is furnished with a metal T -piece, such as has been described (Fig. 29, see also Fig. 23), then -this raised border prevents flexion of the hip by coming in contact -with the abdominal wall when the patient sits down. This difficulty -can be got over by making the top of the T piece movable; when the -patient sits down the vertical piece of the T becomes oblique, the -thigh piece comes forward, allows the stump to escape a little way and -no longer presses against the abdominal wall (Fig. 30). - -The belt may also be replaced by a leather corselet, having fixed to -it the hip piece that we have just described. - - [Illustration: FIG. 29.] - -The braces by themselves are a poor method of attachment for a short -stump. - - [Illustration: FIG. 30.] - -In the sitting position the stump easily escapes from the bucket. - -When the patient is standing the stump remains abducted, whilst the -apparatus, as the result of its own weight hangs vertically, in this -swaying position the lower extremity of the stump presses against the -outer side of the bucket, whilst the inner edge of the bucket cuts -into the flesh at the top of the thigh. - - - III. WALKING ON A PEG LEG AND SIMILAR APPLIANCES - -_The rigid peg and the jointed peg._--The peg leg is a rigid rod, -ending in a slight enlargement, which transmits the weight of the -body, resting by means of the ischium upon the top of the bucket, -directly to the ground. - -The erect position is thus very secure, and stability in walking is -also very good throughout the time when the artificial limb bears the -weight. - -To raise the limb from the ground and carry it forwards, the patient -uses at the same time both flexion of the stump at the hip and -movements of the pelvis (elevation, then rotation inwards) varying to -some extent with his proficiency and with the length of the stump. - -_The old-fashioned peg leg_, called the "poor man's peg," consists -of a bucket continued into a rigid peg. If the support beneath the -ischium is well made according to the principles described above, -it is an excellent temporary limb.[3] This bucket of common wood, -which is not specially shaped to the stump, is very economical; its -imperfect fit is an advantage in that the stump, which is still -enlarged, cannot bear friction; as the stump assumes its true shape -and diminishes in size, the bucket is packed. We would add that every -patient, who is not rich enough to possess two complete artificial -limbs should have in reserve an emergency peg leg, for occasions when -the artificial limb requires repair. - -[3] A number of temporary limbs have been designed, with buckets -of lattice work or of plaster. The old-fashioned wooden peg, which -is easily obtained, avoids all this additional work without any -disadvantage. - -As a permanent apparatus, with accurately fitted bucket, the rigid -peg leg has two defects: it has not the appearance of a leg and -foot, and when the patient is sitting the rigid peg is unsightly and -inconvenient to him and to his neighbours. We have therefore designed -and completed a _jointed peg leg_, the principle of which is as -follows: - -Below the thigh piece the peg is attached by a transverse joint, -this joint being locked in the extended position when the patient is -upright. The patient sets it free by manipulating the lock through the -trousers, when he sits down; when he gets up again the locking in the -extended position is automatic. - -The fitting of this transverse joint may be carried out in two ways. - -1. The upper end of the peg ends in a stirrup-shaped fork and the bolt -passes through the two ends of this fork and through the lower end of -the thigh piece (Figs. 31 to 33). - -2. The lower extremity of the thigh piece has cut in it a central -mortise into which fits a vertical plate, prolonged upwards from the -middle of the leg piece. The bolt passes through this artificial -tibial spine and through the two sides of the mortise in the thigh -piece. If the hole in the tibial spine through which this bolt passes -is square the hinge works securely (Figs. 34 to 36). - -In this form the axle turns with the leg, in the first form this is -also possible. But most often when the forked attachment is used it is -fixed to a leather thigh piece, and each end of the fork is jointed -independently to the corresponding end of the lateral steels of the -thigh piece, without any complete transverse bolt. It is then the fork -that revolves around these two joints. - - [Illustration: - - FIGS. 31 to 33.--Fixation of the stirrup of the leg (Fig. 31) - by a transverse bolt (Fig. 33), the aperture for which in the thigh - piece is seen in Fig. 32. Double lock (Fig. 32).] - - [Illustration: - - FIGS. 34 to 36.--Attachment by mortise and tenon, with a - bolt, square in section, passing through the knee. Single lock on the - outer side.] - -If there is a complete transverse bolt, the joint can be securely -locked by a single lock at one of its extremities (at the outer -extremity) (Figs. 36 to 39). - -If there are two lateral joints the single lock is insufficient, both -joints must be fixed at once; unless this is done, that which is not -fixed has a certain amount of play and is strained. - -It is, however, simple, by means of a posterior semicircle, to joint -the two locks and to work them together by a single movement (Fig. 32). - -For æsthetic reasons the wooden leg piece may be made in the shape of -a leg and foot. But if the principle of the peg leg has been adopted, -for an agricultural labourer for example, on account of its stability, -it is better to use an appliance in which a "show leg" is fitted -around the simple peg on days when appearance is more important than -work (Figs. 37 to 45). The limb is thus rendered lighter, for the -false calf consists of a simple layer of felt and it is very easy to -replace the enlarged lower end of the peg by a foot. - - [Illustration: FIGS. 37 to 40.--Attachment by a mortise, and - show foot.] - -We show later two models of this sort, one with an American thigh -piece of wood and a single lock upon a transverse axle, the other with -a leather thigh piece and a double lock. The first (Figs. 37 to 40) is -shown with an attachment by braces, and the second (Figs. 41 to 47) -with an attachment by means of a waist belt; we have already explained -when these two must be combined. - - [Illustration: FIG. 41. FIGS. 42 to 47. - - _Leather and steel peg leg, with show foot._ - - Figures 41 to 47 (leather appliance) should be compared with figures - 37 to 40 (wooden appliance) which complete them in certain points. It - is unnecessary to refer further to the method of fitting the bucket to - the suspension, or to the method of attaching and locking the knee. - - The peg--attached above by a stirrup or by a mortise, it does not - matter which--ends below in a rectangular tenon which fits into a - corresponding excavation in the upper surface of the terminal piece, - whether peg or foot (Figs. 38 and 44). A transverse bolt, square in - section, with a head at one end and a thread at the other, fixes these - two parts together. By taking out this bolt the peg can be replaced by - the foot or _vice versâ_. - - If the attachment of the foot is made in the heel, a fixed foot is - used (Figs. 43 and 45), but it is easy, by making the attachment - higher, to use a foot with movable ankle joint (Fig. 40). - - The attachment of the show calf piece around the peg is shown in - figures 43 and 45.] - -Most often the wooden thigh piece is to be preferred; the limb is -lighter and may last four or five years instead of about two years. - -We may add that leather loses its shape and the bucket becomes -enlarged, producing inconveniences already described on page 18. - -But _leather_--indespensable for certain stumps which cannot stand -a wooden bucket--has the advantage that it can be employed as a -_temporary fitting_. During the first weeks, sometimes even for the -first months, the shrinking of the stump can be accommodated by lacing -up the bucket, and, when shrinkage is complete, the leg part of this -first apparatus can be attached to a wooden bucket which the improved -condition of the stump now renders possible. - -This form is a little more expensive (80 frs.) than "the poor man's -leg," but I believe a great deal more comfortable. It may be added, -that it is easy when the foot is fitted at the end of the apparatus -to render flexion of the knee free and to attain the "American walk," -of which we shall speak later. All that is necessary is to attach in -front an artificial muscle of indiarubber, reaching from the thigh to -the leg and an extending sling like that in the American limbs (see -page 47). - -This appliance which we call the "Fédération Leg," because we designed -it at the _Fédération des Mutilés_, has already been imitated without -its origin being acknowledged. - - - IV. WALKING WITH FREE FLEXION OF THE KNEE - -A. _Design._--The oldest type, which will suffice for studying the -general conditions of stability, is that of Marks, with a fixed -foot shaped out of the same piece of wood as the leg: the ankle -joint--several types of which we shall describe later--does not affect -the question of stability. - -The appliance is made entirely of wood; it is strong and light. - -Nothing need be added to the description already given of the fitting -and method of attachment of the thigh piece, which ends below in a -curved "condyle,"[4] which fits into the top of the leg piece. It -is transfixed by a metal bolt, from each end of which a metal plate -descends and is riveted into a corresponding groove in the leg.[5] -This forms the axle which rotates in the thigh piece when the knee -flexes or extends. Flexion of the knee is free. Extension is stopped -just short of the straight line (see p. 16). - -[4] The bucket and the condylar portion are made of two separate -pieces of wood. - -[5] The hole through which the bolt passes being cut in soft wood -(willow or lime), must be strengthened by a cylinder of metal, of -leather, or of harder wood (beech or service tree) in which the axle -revolves. - - [Illustration: FIG. 48.--Marks leg with fixed foot.] - - [Illustration: FIG. 49.--Construction of the foot.] - -The foot is in equinus at an angle of 25° to 30° so that the heel -is 2 or 3 centimetres from the ground (the usual height of the heel -of a boot). The piece of wood which forms the instep and which is -continuous with the leg stops at a point corresponding to the middle -of the metatarsus, and is only half the thickness of the foot. The -rest of the foot is shaped of indiarubber stuck on to the instep -piece; the wood and rubber being enclosed in a sheath of leather. - -The foot should also point slightly outwards, as in the normal -standing position. - -_To ascertain whether the limb is built so as to ensure equilibrium_, -a thread is stretched against its side so as to pass through the axes -of the knee and ankle joints, if this cuts the ischial bearing point -at its centre the equilibrium of the patient is assured. Equilibrium -will be better still if the cord lies entirely behind the ischial -bearing point, leaving in front of it the greater part of the thigh -piece. The best method of ascertaining if the foot is properly mounted -is to hold the limb in front of one by the thigh piece, with the knee -bent at a right angle; it can then be seen whether the foot turns -outwards at the correct angle. - -It is not necessary to say anything more about the shape of the thigh -piece (page 17). - -The metal bolt which transfixes the knee must not allow any play; the -hole through which it passes must be lined with hard wood or leather. - -The indiarubber sole should be reinforced with several layers of -canvas incorporated in the rubber, as the latter if not so reinforced -perishes and cracks. - -The appliance must further be examined after it is applied. The level -of the iliac spines must be compared: the spine on the side of the -amputation should be 2 cm. below that of the sound side. - -Examine the position of the point of the foot. Make the patient sit -down, see if the knees are on the same horizontal plane; if the -sound knee is the higher the leg piece is too short. The foot being -fixed in the equinus position the patient must wear boots while the -examination is being carried out. - -B. _Mechanism of walking._--In walking, a step being taken with the -artificial leg, the toe of the foot is the last to leave the ground, -the heel being raised and the knee straight. The limb is swung forward -and raised by flexion of the hip: active flexion of the knee is -impossible, but passive flexion occurs, owing to the weight of the leg -piece, as the thigh is raised. - -At this moment the leg piece is vertical, forming an angle with the -thigh, from this position it must pass into one in which it is oblique -forwards and downwards, in a straight line with the thigh, _so that -the knee may be fully extended when weight is again borne by the limb_ -as the foot meets the ground. If at this moment the knee is flexed the -limb will double up under the weight of the body. - -The first contact of the limb with the ground should be at the heel -with, as we have already said, the knee extended. Afterwards as the -limb, which at first points obliquely forward and downwards, passes -into the vertical position in which it must be at the period when it -bears the whole of the weight, this complete extension becomes locked -and transforms the limb into a rigid column. - -This is brought about as explained on page 48 by mounting the foot -in equinus, and we must here describe the methods by which the -commencement of the movement of extension may be communicated to the -leg so that the heel may be the first part of the foot to touch the -ground. - -These methods may be termed _knee extending mechanisms_. They assist -the passive action of the weight of the leg. - -In fact the recurrence of extension is brought about by a pendulum -movement of the leg, which, at first oblique downwards and backwards, -swings into a downward and forward obliquity. But this movement -is slow (the pendulum which marks one second is one metre long) -and incomplete. The patient can make it complete with a little -instruction, by extending the thigh slightly as soon as the foot -touches the ground. - -This may be sufficient if the stump is long; the leverage is good, and -while the hip is being flexed a swing can be given to the thigh piece -which accentuates the pendulum movement of the leg. - -But with a short stump some special mechanism is essential to make -sure that extension will be complete, otherwise the patient will be -obliged to walk with short and calculated steps, to wait whilst the -pendulum action produces extension of his knee and allows him to put -weight upon his foot. - -C. _Mechanism for starting extension of the knee during the time the -leg is swinging._--There are two methods which are generally combined: - -1. Elastic traction by an artificial muscle. - -2. The extending sling. - -1. _Artificial muscle._--The action of an artificial muscle made of -elastic (noiseless) or of a coiled steel spring, is easily understood. - -(a) The simplest method (that which is commonly used for infantile -paralysis affecting the quadriceps) consists in fixing an elastic band -divided into two slips, one on either side of the patella between the -front of the thigh and of the leg, about the middle of each. (This is -represented in figure 98 in our convertable leg.) - -(b) When the apparatus includes the regular artificial knee the makers -generally place this mechanism in the interior of the thigh and leg -pieces, using methods which are often very ingenious. Of these we -illustrate some on pages 40 onwards, with an explanatory description. - -In describing these mechanisms, which may be called intra-condylar, -it is necessary to speak at the same time of the _stop to limit -extension_ because, as will be seen, it is combined with the extending -spring. - -We have already said that rigidity in extension when the limb is -vertical is essential, but whilst it is necessary for extension to be -_complete_ at this moment it is also necessary to prevent the knee -being forced into the _hyperextended position_, as this would quickly -strain the joint and render the limb useless. - -This limitation of extension can be effected quite easily by the -tension of a popliteal cord (see page 41. The knee in Marks leg), or -by carrying the anterior border of the leg piece upwards in front of -the thigh piece so that it impinges against the latter. - -This method is not very good because it is noisy. - -Moreover, the repeated impact against the leg piece may split the -wood, so that if this method is adopted the stop must be reinforced by -a binding of several layers of parchment. - -We will first describe a mechanism the association of which with the -extending sling will be seen on page 48. - -α. _To limit extension of the knee_ all that is necessary is -to prolong the antero-posterior diameter of the knee bolt (which -turns with the leg) by a horizontal wing, which engages with a -corresponding notch in the femoral condyle. We show here (Figs. 50 -and 51) a rather more complicated but still simple mechanism which -is interesting because it can be combined with the action of the -extending sling (see page 48). - -It consists of a piece of metal curved on the flat, ending above in a -cylinder through which the knee bolt passes, continued below into a -cylindrical tail piece, which fits into a ring which is fixed inside -the top of the calf. During flexion this plate moves in a median -posterior window in the femoral condyle, becoming oblique at the same -time as the tail piece sinks into the ring; during extension the tail -piece rises in the ring and the interior flat surface engages against -a corresponding groove in the femoral condyle (covered with leather to -secure silence). - - [Illustration: FIGS. 50 and 51.--Internal mechanism to limit - extension of the knee.] - -β. In the Marks knee an internal system of cords and springs -serves at the same time both to limit extension and to produce an -elastic extending force. It is a system which is fairly simple and -much used. - -1. _Limitation of extension_ is secured by a U-shaped cord, the -extremities of which are fixed to a wooden cross piece (T), fixed in -the thigh piece three centimetres above the axis of the joint. The -cords leave the thigh through two lateral openings in the back of the -thigh piece, and the loop passes through a ring halfway down the calf. - -2. _The extending force_ consists in a coiled steel spring the -mechanism of which is combined with that of this cord. The lower half -of the spring is enclosed in a copper tube lined with chamois leather -to secure silence; its upper half or rather more is coiled around a -wooden pin, which terminates above in a head which is cup shaped: -it will be seen (Fig. 57) that if pressure is made on this head the -spring is shortened and under compression. - -This spring is fixed below (by means of a tenon which allows -antero-posterior movement) upon a bracket in the calf which is -continuous with the ring through which passes the check cord. The -cup-shaped upper end is in contact with a ball which projects from -the upper surface of the thigh piece between the two openings for the -check cord (Fig. 53). It will be seen that when the knee is flexed -the spring, the head of which lies below the axis of the joint, will -be compressed at the same time as the check cord is relaxed so that -there is an elastic recoil tending to reproduce extension. The ball -which rests on the top of the spring is fixed in such a manner as to -be in the same horizontal plane as the axis of the knee: that is to -say, it is in the same vertical plane as this axis when the knee is -flexed to a right angle (Fig. 52). Therefore in this position the -spring has no tendency to produce either extension or flexion, that -is to say the mechanism is now at dead point, and when the patient is -sitting flexion to the right angle is maintained without any effort. - - [Illustration: _The Marks knee._ - - FIG. 52. - - FIG. 53. - - FIGS. 54 to 57. - - FIGS. 52 and 53.--O, knee bolt. T, cross piece of wood, - situated in the extended position above the knee bolt, in the flexed - position behind it. C, bracket fixed halfway up the interior of the - calf. - - A U-shaped cord _a_ passes through a hole in the bracket C and is - attached at each end to the cross piece T; it limits extension. The - two ends of the word enter the thigh piece by two apertures in the - posterior surface, between which is fixed a metal ball which projects - 2 cms. The extending spring is the rod _b_ which is fixed to this ball - and to a socket in the upper surface of the bracket. Figs. 54 to 57 - show the parts of this spring: a tube, a spiral spring, and a rod with - cup-shaped head. When the spring is in the tube and the rod in the - spring (Fig. 57), it will be seen that pressure upon the head of the - rod increases the tension of the spring.] - -In the knee shown in figures 58 and 59 the _extending mechanism_ is as -follows. Directly behind the axis of the joint is a metal crossbar, -upon which fits the grooved upper extremity of a piece of wood, the -other end of which rests (like a lance) in a pocket which is suspended -in the leg piece by an elastic band (the latter being kept stretched -to a greater or less extent by a lace which emerges from the calf). - - [Illustration: FIGS. 58 and 59.--Elastic spring for extending - the knee.] - -The elastic being slightly stretched when the knee is extended, it -will be seen that the crossbar turning round the axis of the knee -becomes lowered as the knee flexes, so that the elastic is stretched -and consequently opposes flexion; but when the knee is bent to a -right angle the axis of the joint, the crossbar and the wooden rod -are in the same vertical line; the mechanism is at a dead point just -as we have already seen in the Marks knee, and the tension on the -elastic presses the leg directly downwards without tending either to -flex or to extend it. - -Leather pads deaden the noise of the impact. - -Extension is limited, as will be seen by comparing figures 58 and 59, -by the vertical wooden rod meeting flat surfaces in the thigh and leg -pieces simultaneously. - -3. _Extending slings._[6]--To the sling which passes over the shoulder -on the side of the artificial limb, is attached a strap which passes -down in front of the thigh piece and is attached to the upper third of -the leg. - -[6] This is an old French method used in Fouilloy's appliance, which -has, however, only become generally used in the suspending braces of -the American appliance. - -When the patient raises the leg from the ground, the weight of the -appliance makes it slip down the stump, tension is thus produced upon -this strap and as a result the knee is extended. By an adroit movement -of the shoulder this extension can be carried out actively. - -When the limb rests upon the ground the weight of the body presses the -stump down into the bucket, the tension on the strap is released and -consequently the knee is free to flex. - -On pages 44 to 48 will be found figures showing the principal points -in this extending brace. - -The braces, whether they have or have not an extending strap, may be -constructed in three ways: - -_a_. To ease the constant pressure exerted on the shoulders by the -strap which is stretched by the weight of the artificial limb, the -brace may be made of elastic like the ordinary trousers brace. But the -limb they carry is heavy, so they rapidly become overstretched and it -is difficult to keep them properly adjusted. - -_b._ The stretching is naturally diminished if the upper part of the -brace is not elastic but an elastic section is inserted in its lower -third, in front and behind. - -_c._ But the patients almost always say that better command of the -limb is obtained with inelastic braces. If the strap is wide on the -shoulder, the pressure is well borne, and the lower attachment may be -made narrower, consisting of a leather thong (Fig. 64). - - [Illustration: Fig. 60. - - Fig. 61. - - Fig. 62. - - Fig. 63. - - Fig. 60.--Fouilloy's Braces. Figs. 61 to 65.--Marks' braces. - Fig. 61.--General construction of the braces. Figures 62 and - 63.--Attachment at the sides of the thigh piece. Figures 64 and - 65.--General view of the apparatus as worn.] - -To attach extension braces to the front of the leg piece the old -and simple method adopted by Fouilloy may be used. It consists in -attaching an elastic strap to the brace which passes over the shoulder -on the side of the amputation (and which is fixed to the top of the -thigh piece alongside of the other brace). The elastic strap ends in a -bifurcated leather thong each branch of which (held in place by a loop -of leather) descends obliquely alongside of the patella surface to be -attached to the corresponding side of the leg in its upper third (Fig. -60). - -In Marks' method the braces end below in loops made of a leather thong -(Fig. 61). These are held against the thigh piece by passing under -leather bands; they reach as far down as the upper third on the inner -and outer sides of the thigh (Figs. 62 to 65). - -To each of the loops, gliding on them by means of a pulley, is -attached a leather strap which descends vertically to the upper third -of the corresponding surface of the leg, being held in place by -passing under a leather band. These two straps are attached to each -other in front by a lace, which draws them towards the middle line, -and in this way brings their line of action forwards. The tighter the -lace is drawn the more powerful will be the extending force. - - [Illustration: FIG. 64. FIG. 65.] - -Instead of attaching the extension brace to the leg piece it may be -made to pass under a pulley in the interior of the knee. What actually -happens is that the thigh piece drops, owing to its weight, when -the limb is swung free; this throws a strain on the brace which is -transmitted to the leg piece by the following mechanism. The metal -stop described on page 39 which limits extension of the knee during -the period of weight bearing, is prolonged upwards and forwards -beyond the hole through which the axis of the knee passes, this -prolongation being furnished with two wooden pulleys (Fig. 69). The -loops attached to the braces enter the front of the thigh piece, each -by a separate opening, turn under the corresponding pulley and emerge -again posteriorly (Figs. 66 to 68). - - [Illustration: Fig. 66. Fig. 67. Fig. 68.] - -This mode of attachment has the advantage that when the limb is swung -the movement does not take place upon the shoulders--which easily -become chafed by the ordinary suspenders--but upon the pulleys upon -which the leather thongs work. - -The mechanism shown in figures 69 to 71 is interesting. When the metal -lever moves around the axis of the knee joint, its lower end and the -pulleys at the upper end travel in opposite directions: in flexion -the pulleys move downwards and forwards, the lower end upwards and -backwards; in extension they move in the opposite direction. Therefore -when the limb is swung and the knee bends (Fig. 71), the thigh piece -drops of its own weight, the braces tighten, raise the pulley and -consequently make the lower end of the lever move downwards and -forwards, thus extending the knee joint. - - [Illustration: Fig. 69. Fig. 70. Fig. 71.] - -D. _Mechanism to secure rigidity of the knee during weight -hearing._--During the time that the healthy limb is raised from the -ground and carried forwards there must be complete rigidity of the -artificial limb in the extended position. This is secured by mounting -the foot in the equinus position. When it has been swung forwards, in -taking a step, the limb comes in contact with the ground heel first; -then, as the leg becomes vertical the entire sole lies flat on the -ground; if the foot is in equinus this position is only possible with -the knee hyperextended, or with full extension it may be possible -for a very short period. So that it is the weight of the body that -locks the limb in the extended position, the sole of the foot sloping -obliquely downwards and forwards; and the weight being taken on the -toe. There is always a tendency to hyperextension, and to avoid -straining the limb in this direction (as occurs in a living knee which -is forced into the position of genu recurvatum by a talipes equinus) -it is as well, as we have already said, to oppose it by some passive -resistance, either in the form of a simple popliteal check cord or by -a stop fixed to the front of the leg. - - [Illustration: Fig. 72. - - Fig. 73. - - Fig. 74. - - Fig. 75. - - In Figure 72 the foot is fixed, the weight comes upon the point of the - foot, and pressure upon the axis AB tends to close the angle ABC, i.e. - to produce a genu recurvatum, and so to lock the knee in extension. - If the foot is articulated, equilibrium is secured in the same way. - Figures 73 to 75 are intended to show that in order that the axis ABC - may not be vertical (Fig. 73) the axis B of the knee must be behind - the perineal concavity in the bucket, and it is better if at the same - time the axis of the ankle joint C is carried forward.] - -This extension is unlocked automatically at the moment when the weight -is thrown forward on the healthy limb, the artificial limb rising on -its toe and the knee commencing to bend because the braces are relaxed. - -E. _Movable ankle._--We have taken as our type a limb with a fixed -foot. There are, however, a number of methods of attaching a foot with -a _movable ankle joint_. The general principles and the mechanism for -securing stability are those which we have already studied, but the -gait is more supple, at the price it is true of somewhat delicate -articulations and therefore of simplicity. - -The foot is made of a single piece of wood; it is divided transversely -at the level of the middle of the metatarsal bones, and the anterior -part (shaped like toes) is attached by two pieces of leather, dorsal -and plantar, between which are two indiarubber cylinders which keep -the toe piece extended 15° to 20° when at rest, and which allow, when -the foot is pressed on the ground, an extension to 45°. - -This foot is mounted on the leg at an angle of 45° beyond the right -angle, with an interposed rubber cylinder, which allows of the -diminution of the angle to 25° or 30° but no further. It is important -that flexion to a right angle should not be possible. In fact, a -slight degree of equinus is essential in order to secure the locking -of the knee in extension, exactly as with the fixed foot (compare -figures 73, 74 and 75 with figure 72), and as on the shoe there is -always a heel which makes us walk normally in slight equinus, the -two feet will be similar in appearance, the slight movement of the -artificial foot being sufficient to allow a rolling movement of the -sole upon the ground (Figs. 77 to 86). - - [Illustration: FIG. 76.] - - [Illustration: FIG. 76A.] - -The figures 76 and 76A show the simplest and best known mechanism. On -the upper surface of the foot two cavities are hollowed, one in front -and one behind the bolt of the ankle joint, in each of these is placed -a cylinder of rubber; the posterior cylinder is about twice as thick -as the anterior. Above them the leg piece is fixed, it ends in front -in a short instep which lies within the cavity hollowed out in the -foot. - -The foot is attached to the leg piece by a bolt made as follows: a -steel tube fitting into two corresponding grooves in the leg and foot, -is attached to the leg by being prolonged upward into a vertical rod, -which is secured by a nut inside the leg piece. - -Upon the steel tube moves a brass rod shaped like an inverted U, the -two ends of which pass through the foot and fasten beneath it by two -nuts (Fig. 82). - -Raising the point of the foot further compresses the anterior piece -of rubber, lowering it relieves the pressure upon this piece and -compresses the posterior piece. But the tension and the size of the -pieces of rubber are such that they are under slight compression in -the position of rest, the foot being in 30° of equinus. So that this -foot is never loose. When pressure is made on the point of the foot it -may come to within 15° or 20° of a right angle, but it returns to its -angle of 30° as soon as the pressure ceases. - - [Illustration: Figs. 77 to 81. - - Contact of the sole with the ground in normal walking. Heel first then - toe, with progressive dorsiflexion of the ankle joint. Compare with - the contact of the artificial foot in figures 82 to 86.] - -With boots on, with heels of 2·5 centimetres the two feet are in the -same position when the soles are flat on the ground. - -The forepart of the foot (representing the toes and the anterior part -of the metatarsals) is kept in this position (Fig. 76) in slight -extension by a piece of rubber, compression of which allows an -increase of extension of 15° to 20°. - -When a step is taken, the heel of the foot first meets the ground, -the leg pointing downwards and forwards. Then the whole sole comes -to lie flat on the ground, the degree of equinus being increased, -the posterior rubber compressed and the anterior relaxed (Figs. 82 -and 83), but when the limb is vertical the sole still being flat on -the ground, compression of the posterior diminishes and that on the -anterior increases (Fig. 84). This remains unchanged up to the moment -when the foot leaves the ground, whilst the heel rises and the weight -is borne on the toe piece of the foot, which is forced into extension -(Figs. 85 and 86). - - [Illustration: FIG. 82. - - FIG. 83. - - FIG. 84. - - FIG. 85. - - FIG. 86.] - -This method of using rubber cylinders is the simplest. Another -method, good but more delicate, is shown in figures 87 and 88. In the -leg below the calf are two cross pieces of wood; the lower placed -transversely supports the upper which is antero-posterior and so -increases its resistance to the cords which are attached to it. - -The shape of these pieces of wood can be seen in the figures and -require no further explanation. The bolt of the ankle joint is the -same as in the foot last described. To the antero-posterior cross -piece are attached two cords, which pass through the foot and are -attached beneath it, one under the heel, and the other about the -level of the midtarsal joint. The posterior cord is inelastic and -stops dorsiflexion of the foot. The anterior has a section of elastic -in it; it prevents the dropping of the foot whilst the limb is being -swung. A small pad of rubber placed in front beneath the anterior part -of the leg piece allows, by its compression, the partial correction of -the equinus when the sole is pressed flat on the ground. - - [Illustration: FIG. 87.] - - [Illustration: FIG. 88.] - -Some appliances allow the foot a little _lateral mobility_, by -rotation around an antero-posterior axis, so that it may adapt itself -to irregularities of the ground. We here illustrate the "Duplex -foot," which is very ingenious but which has the defect that after -a time the mechanism grates. The ankle attachment is carried out in -the same way as in the limbs last described (in this particular limb -it is attached by cords), but the foot piece is divided as in a -sub-astragaloid amputation; the lower surface of the astragaloid piece -bears a median antero-posterior projection, tapering posteriorly and -enlarged into a knob anteriorly, this lies in a corresponding groove -in the heel piece; alongside this are two rubber cushions which are -alternately compressed and relaxed as the foot inclines to one or -other side. - - [Illustration: FIG. 89.--Duplex Foot.] - - - _Combined mechanism for knee and ankle joints._ - -This very ingenious combination, which, however, necessitates a rather -complex mechanism, was devised by Palmer in 1850. It is carried out -in the limb made by Frees, the mechanism of which will be seen to -resemble that of the articulated foot shown on page 54 in figures 87 -and 88. - -Above the axis of the knee joint and at right angles to it is a wooden -cross piece, to which are attached three cords, two behind the joint, -one in front; these cords emerge from the thigh piece through an -opening in its lower end (Figs. 90 to 92). - -The posterior of these cords, made of hemp, ends inside the upper -third of the leg. It limits the extension of the knee, exactly as -described in the Marks leg. - -The other two cords extend down to the foot, which is attached in a -manner very similar to that shown on page 54, but with a single rubber -cylinder behind, and with the instep cut obliquely so that when the -joint is in the resting position of equinus there is an opening in -front amounting to an angle of 15° to 20°. The posterior cord, of -hemp, is attached in the heel; the anterior, made of catgut with an -indiarubber section, enters the foot obliquely and is fixed a little -in front of the middle of the sole. - -When the knee flexes, the wooden cross piece tilts, its posterior end -becoming lower, its anterior higher (Figs. 91 and 92), the elastic of -the anterior cord is tightened, thus raising the front of the foot, -whilst at the same time the heel cord is relaxed. Thus the mechanism -which produces extension of the knee acts at the same time upon -the foot; when the knee is straight the foot is plantar flexed to -20°, when the knee flexes the foot comes to a right angle. Thus the -foot becomes dorsiflexed at the same time as the knee flexes, as in -ordinary walking. - -If the action in walking is watched, it will be seen that as the limb -is swung forward, the toe is raised so as to clear the ground.[7] - -[7] The mechanism of this artificial leg resembles that of the "tendon -leg," which was in such common use in England before the present war -that it is often called the English pattern.--(ED.) - - [Illustration: FIG. 90. - - FIG. 91. - - FIG. 92.--(FIGS. 90 to 92. Foot and Knee of Frees.)] - -In the sitting position the anterior cord is not relaxed, there is no -dead point, so that the knee always tends to extend. This is somewhat -inconvenient. - - - _Conversion of the articulated peg leg into the leg with free knee - movement and vice versâ._ - -Whatever advantage it may be thought to possess, in our opinion the -artificial leg with free knee joint is only suitable for sedentary -occupations; it is not suitable for manual labourers and particularly -for agricultural labourers who are obliged to get about on rough -ground. Hence it is not uncommon for a patient who has been provided -with an American leg to come and ask for a peg leg. In figures 93 -to 95 it will be seen that it is a simple matter to transform the -limb into an articulated peg. It is only necessary to attach the -stirrup-shaped fork of the peg to the thigh piece by the knee bolt, -and to add the double lock. To this peg may be added, if desired, the -show calf and foot described on page 32. The full artificial leg can -be rebuilt whenever it is wished. - - [Illustration: FIGS. 93 to 95.] - -On the other hand, an articulated wooden peg leg, such as we have -described under the name of the Federation leg, can be easily adapted -for walking with a free knee. It is only necessary to unlock the knee -joint and to add the artificial muscle or accumulator of elastic shown -in figure 98. This supplies the extending force, the value of which we -have shown on page 36. We consider that this appliance is excellent -and we know patients who almost always walk upon the peg, but who -sometimes use a free knee for short walks. The conversion is simple -and requires no special care. Under these conditions the fixed foot -is almost always used; there is nothing to prevent the fitting of an -articulated foot, but we have already seen that there is no great -difference in walking between the old-fashioned fixed foot of the -Marks leg and the more or less complicated articulated feet of more -recent design. - - [Illustration: FIG. 96. - - FIG. 97. - - FIG. 98.] - - - II. Limbs without bearing upon the Ischium - - _For amputations through the condyles of the femur, and similar -amputations_ (_disarticulation of the knee and very short stumps below - the knee_). - -Certain orthopædists do not know how to fit an artificial limb to an -amputation through the condyles of the femur; they come therefore to -the conclusion that this is a bad operation, and ought to be replaced -by an amputation above the condyles. - -The two objections raised to this amputation are:-- - -1. That it is impossible to fit a wooden bucket because the bone at -the lower end of the stump is larger than it is at a higher level. - -2. That it does not leave enough room to fit an artificial knee joint -at the right level. - -These two objections are not valid, and, on the other hand, this -amputation allows us to fit an artificial limb with complete end -bearing, and this is a great advantage. - -1. _Fitting of the bucket._--The first difficulty is easily got over. -All that is necessary is to cut away the front of the lower half -of the bucket, and to cover in this opening with a lacing piece of -leather. The stump passes into the top of the bucket, comes out of -this opening and then falls back into the enlarged lower end where it -takes a direct bearing (Fig. 99). - - [Illustration: FIG. 99.--Limb with end bearing for amputation - in the region of the condyles of the femur. Anterior part of the thigh - bucket cut away to allow the insertion of the enlarged lower end of - the stump.] - -2. _Level of the knee joint._--It is clear that if the stump is too -long it is impossible to fit a knee joint with a bolt right through at -the same level as the opposite knee. The thigh piece would have to be -prolonged downwards in order to allow of the insertion of this bolt. - -This arrangement would not affect walking, but would be unsightly in -sitting because of the inequality in the length of the thighs. - -It is easy to overcome the difficulty by attaching the leg by two -independent lateral hinge joints, without a bolt right through, using -the stirrup-shaped fork and the double lock, if a peg is used. This -method, as we have already stated, is not so strong, but this is to a -large extent compensated for by the possibility of getting a direct -end bearing. - -3. _Direct end bearing and suspension._--If the stump is well covered -with a good anterior flap and if the lower end of the bucket is -accurately moulded upon it with an interposed layer of felt, the -patient can walk directly upon the end of the stump, without it being -necessary to carry the bucket up against the ischium, simple braces -being used as the means of suspension. - -4. There is nothing special about the braces or about the extending -strap if the knee is free, nor about the method of attaching the foot. - -These limbs for long stumps do not require any spring to extend the -knee, if one is wanted an artificial muscle is quite easily fitted. - -We have taken as our type an amputation through the femoral condyles. - -The covering of the stump is excellent, and pressure is taken upon -tissues which are naturally adapted to it (the thick skin and fibrous -tissue over the patella), specially if it has been possible to keep -the patella in the flap and fix it across the cut surface of the femur -(Gritti's operation). - -The mechanical points in the fitting of an artificial limb for an -amputation through the knee joint are the same. But this amputation -seems to us to be inferior to that through the condyles. The -sacrifice of three centimetres in length is of no importance in -an appliance with direct end bearing; and, on the other hand, -disarticulation has several disadvantages:-- - -1. The enlargement of the femoral condyles, without any compensating -advantage. - -2. The bearing upon the two condyles, separated by a groove. - -3. The insufficient covering of the condyles by the thin skin of the -front of the leg. - -The principles of fitting a limb are the same in amputations of -the leg in which we are obliged to make the patient walk upon the -bent knee (too short a stump, the position of the scars, persistent -osteitis, the impossibility of straightening the knee when it is -ankylosed or stiff in a flexed position), as in the old-fashioned -kneeling pin leg. - -A posterior transverse band, passing over the bent stump helps to hold -the limb on. - - - - - _CHAPTER IV_ - - ARTIFICIAL LIMB FOR DISARTICULATION AT THE HIP JOINT - - -Attempts have been made to attach to the pelvis, by means of a waist -belt or braces, a wooden artificial limb whose upper end is fitted -directly on to the tuberosity of the ischium. So far these have met -with little success. In our opinion, the only really practical method -is to enclose the whole stump and pelvis in a regular corset, and to -attach the artificial limb to this corset.[8] - -[8] Amongst English limb makers this moulded corset with the steel hip -attachments is usually known as the "tilting table."--(ED.) - -The moulding of this corset upon the stump must be accurate. - -The tuberosity of the ischium is the only bony point in the stump upon -which pressure can be taken. The corset may be made of leather, but, -until a new order is issued, the material of choice is celluloid, -moulded upon a plaster of Paris cast, in spite of the disadvantage -mentioned on page 4. - -The limb is an articulated peg leg, with convertible knee joint and -double lock, exactly the same as in the limb for amputation through -the thigh. - -It is attached to the pelvis (_i.e._ to the tilting table), as shown -in figures 100 and 101, by a joint with a double anterior lock, which -allows the patient to sit down by flexing the hip. - - [Illustration: FIG. 100. - - FIG. 101.] - -This general description and an examination of figures 100 and 101 -will suffice to explain this appliance. It is comparatively rarely -required, and its construction is difficult; we consider that the -forms shown in the illustrations are the best. It is only possible -to fit such an appliance when the conditions are good, when the scar -is above and in front of the ischium, and when the latter is well -covered. - - - - - _CHAPTER V_ - - ARTIFICIAL LIMBS WITH FREE KNEE JOINT FOR AMPUTATION THROUGH THE LEG - - -If the leg stump is ten centimetres long, if the knee joint is freely -mobile and capable of complete, or almost complete, active extension, -and if there are no adherent scars around the tuberosities of the -tibia, the American apparatus with free knee joint should be adopted. - -_Walking on the bent knee_ (as stated on page 63) with the "poor man's -peg" may be allowed as a temporary measure, but the patient must be -advised to give his knee a rest frequently in order to lessen the risk -of stiffness in a flexed position. - -There are two methods of fitting, corresponding with those we have -described for the thigh. - -1. For the ordinary amputations with bearing upon the top of the leg. - - [Illustration: - - FIG. 102.--Limb fitted upon the patient. Note that he - stands upon the toe, and that the knee is flexed. ] - - [Illustration: - - FIG. 103.--Posterior view of the same limb.] - - [Illustration: - - FIG. 104.--Anterior view of the same limb.] - -2. For amputation very low down with end bearing upon the extremity -of the stump. - - - I. APPLIANCES WITH BEARING UPON THE TUBEROSITIES OF THE TIBIA - -An artificial limb for amputation through the leg with a free knee -joint is composed of two parts: a leg piece (with foot) which is -fitted to the bony prominences around the top of the stump and -supports them; and a suspensory apparatus which consists of a lacing -thigh corset. - -A. LEG BUCKET.--The points on which the top of the bucket -must be fitted are the internal tuberosity and the anterior -tubercle of the tibia, and the head of the fibula, so that hollows -corresponding to these must be carved out. - -Pressure upon the head of the fibula is often painful, and a deep -concavity is therefore carved out for it. The pressure then comes upon -the external tuberosity of the tibia which, however, ordinarily bears -little weight. - -Whenever possible direct end bearing upon the termination of the -stump should be used as an accessory to relieve the weight upon the -tuberosities of the tibia; this is obtained as described on page 7. -It is only possible if the scar is lateral and if there is a good -thick posterior or external flap (in the upper third of the leg). An -anterior flap is the least satisfactory. - -It is also advisable-- - -That the inner surface and the anterior border of the tibia be divided -obliquely, and that the fibula be divided at a higher level than the -tibia. - -The fibula must not take weight, it is too slender. In high -amputations it has a tendency to tilt outwards, causing the double -inconvenience of widening the stump and of projecting through the -skin. If only 4 or 5 cms. of the fibula remain it is perhaps best to -disarticulate and remove it. - -With a fitting arranged in this way, we consider that the convenience -of walking with a free knee can be assured to patients whose stumps -measure only 10 cms. from the lower border of the patella. - -These principles can be applied to a limb constructed either of wood -or of leather. - -_The leather appliance_ (French method) is formed of a leather -cylinder, strengthened by two laternal steels which articulate at the -level of the knee joint with two similar steels in the thigh corset. -Its upper edge may be strengthened anteriorly by a metal plate, but -in practice the latter cannot be made to fit with precision the bony -prominences enumerated above. It is actually the edge of the leather, -adjusted by lacing, which supports tibial tuberosities, and therefore -the precision of the fit is soon lost. - -For this reason, for amputation below the knee, the American method of -construction with a wooden bucket is demonstrably superior. - -These limbs are infinitely more durable than the French. They may -last three years, whereas the French limb used by a young and active -patient is worn out at the end of the first year, and it was for this -reason that a limb with a free knee joint used to be considered a -luxury.[9] - -[9] That is the reason that amputation at four fingers' breadth below -the knee used to be called for the working class, amputation at "the -seat of election," a name which is no longer applicable and which is -liable to mislead the operator. - -This wooden bucket is shaped very accurately to the bony prominences, -and by passing the fingers over its inner surface the three hollows -corresponding to the points of pressure enumerated above can be -distinctly felt. - -It is important to describe the shape of the upper edge of the bucket -in order to guard against two points which may interfere with flexion-- - - I. Pinching of the tissues behind the knee. - - II. The tendency of the stump, when it is short, to tilt forward - in the bucket (Fig. 108). - -_Pinching of the flesh behind the knee_ in flexion takes place between -the edge of the leg piece and that of the thigh corset. - -If the top of the bucket is horizontal, it must inevitably occur, even -if the edge of the thigh corset is well cut away (Fig. 106). - -It can be avoided by cutting away these two edges into concavities -opposite each other. - - [Illustration: - - FIGS. 105 and 106.--Limb in which the upper edge of the leg - bucket is almost horizontal; in the sitting position (Fig. 106) the - flesh at the back of the thigh is pinched even if the lower end of the - thigh corset is well cut away.] - -In the French limbs made of leather it is usual to make the leg piece -very high in front, _i.e._ as high as the middle of the patella. -This is quite useless. The posterior border is cut down to a depth -of two fingers' breadth below the axis of the joint. Pinching is -thus avoided, but the posterior support is insufficient, the stump -tilts forward as described above and the bucket gapes in front (Fig. -108). If the top of the bucket is horizontal--as in certain American -limbs--there is, as we have already said, pinching of the popliteal -tissues and compression of the popliteal vessels and nerves (Fig. -106). A concavity is therefore necessary, but one reaching to one -finger's breadth below the axis of the joint is sufficient. In front -the edge of the bucket reaches up to the joint line, this is quite -sufficient to enclose the bony prominences (Fig. 109). - -The posterior concavity of the leg piece is combined with a concavity -in the thigh piece varied in accordance with the thickness of the -popliteal soft parts. - - [Illustration: - - FIGS. 107 and 108.--If the leg bucket is hollowed out too - much at the back, the stump is tilted obliquely forward (Fig. 108), - the knee loses contact with the bucket, and the flesh at the back of - the thigh is pinched.] - -To diminish further the tendency of the stump to tilt forward the -posterior edge of the bucket is flattened so that the shape of the top -of the bucket is triangular with curved sides and angles much rounded -(the anterior angle over the tuberosity of the tibia being obtuse). -This is the natural shape of a section of the top of the calf. In this -way the posterior muscles are flattened and no longer tend to escape -from the bucket when the knee is flexed. In figures 110 and 111 are -shown two ways in which this flattened posterior margin may be shaped. - - [Illustration: FIG. 109.] - - [Illustration: FIG. 110. FIG. 111.] - -B. SUSPENSION APPARATUS.--The leg is attached (_a_) by a -thigh corset taking its hold on the femoral condyles, and (_b_) by -braces over the shoulders. - -(_a_) _The thigh corset_ is made of leather laced in front. Two -lateral steels curving in sharply against the upper part of the -condyles (Fig. 112) form the most effective part of the support. At -their lower ends they are articulated with two steels passing up from -the top of the leg to which they are attached. The joint (Fig. 113) -is composed of a nut, A, into which fits a screw. Around the nut -is a copper ring made to move with the femoral steel by means of a -stop-notch. When the knee flexes and extends the wear comes upon this -copper ring. The steels remain intact. If the joint works loose it is -sufficient to renew the ring. - - [Illustration: FIG. 112. - - FIG. 113. - - FIG. 112.--The thigh steels, curved in above the condyles, - hold the limb on very securely.[10] - - FIG. 113.--Details of the joint at the knee.] - -[10] In this illustration the joints are placed too low. They should -be opposite the centre of rotation of the knee joint, _i.e._ a -transverse line passing through the femoral condyles. (ED.) - -(_b_) _The braces_ are a very useful addition which French -orthopædists should employ systematically. - -They increase the stability of the limb and allow the thigh piece to -be laced less tightly, so that contraction of the thigh muscles is -facilitated. - - [Illustration: FIG. 114.] - - [Illustration: FIG. 115.] - -Support may be given by a strap from a waist belt as shown in figure -117, but proper braces are better. These braces pass over the shoulder -of the sound side and are attached either to the thigh corset or to -the leg piece of the artificial limb. Attachment to the thigh corset -is made by a single strap either in front and behind (Fig. 114) or on -either side of the front lacing, the ends of the strap crossing in -front of the groin (Fig. 115). It is a simple matter to add to the -brace an extending strap, such as we have described for the artificial -limb for amputation through the thigh (page 44). It is only necessary -to terminate the brace in a strap from which two branches pass down -in an inverted V and are fixed to the sides of the front of the leg -piece (Figs. 116 and 117). This is unnecessary if the stump is long, -for its leverage will then be good. It is, however, very useful for -short stumps which give little power to the action of the quadriceps. -In the case of patients with a long stump an attempt has been made to -abolish the thigh piece and suspend the limb exclusively by braces. -This method, we believe, is inadequate even if it is completed by a -transverse band above the knee (Figs. 118 and 119). - - [Illustration: FIG. 116.] - - [Illustration: FIG. 117.] - - [Illustration: FIG. 118.] - - [Illustration: FIG. 119.] - -C. THE FOOT.--The foot, usually articulated, is fixed in -exactly the same way as in a limb for an amputation through the thigh, -_i.e._ it is mounted in the equinus position. But in this case, -however, precautions must be taken against stretching of the posterior -ligaments of the knee joint, because the equinus mechanically produces -hyperextension of the knee, and a genu recurvatum may result. For this -reason a strap must be fixed posteriorly between the thigh corset and -the leg piece to prevent full extension of the knee (popliteal check -cord). This means that we make the patient stand and walk with slight -flexion of the knee and with a corresponding elevation of the heel of -the shoe (2-3 centimetres). - - - II. APPLIANCES WITH END BEARING ONLY - -These appliances are suitable for certain amputations very low down in -the leg which we must first define. - -The orthopædist should consider the following operations as very low -amputations of the leg, allowing of walking with end bearing only, and -suitable for the same type of appliance:-- - - Supra-malleolar amputation.[11] - - Disarticulation at the ankle joint. - - Sub-astragaloid amputation. - - Osteoplastic amputations through the os calcis (or amputation - in which the os calcis is retained entire after removal of the - astragalus). - -[11] In England, of course, this is always called Syme's amputation. -It constitutes the type _par excellence_ of the end-bearing stump. -Upon a good Syme stump a patient may be able to walk ten miles without -an artificial foot, wearing simply an "elephant boot." Amputations -above the Syme level are not end bearing, however long the stump may -be. The other amputations in this region seen in English war surgery -are the various types of osteoplastic amputations in which a part of -the os calcis is retained (Pirogoff's amputation, etc.). These have -the following defects:-- - -(1) There is often sepsis between the tibia and the os calcis, -necessitating re-amputation. Osteoplastic amputations are unsuitable -for septic surgery. - -(2) Ankylosis between the os calcis and the tibia is often imperfect -so that the bulbous end of the stump is unstable. - -(3) The stump is too long to allow of the fixation of a good -artificial ankle joint beneath it. A Syme's amputation leaves two to -two and a half inches clearance between it and the ground. - -I have not yet seen a sub-astragaloid amputation in war surgery, and -only once a disarticulation through the ankle joint, the latter could -not bear pressure and it was necessary to convert it into a Syme's -amputation. In fact, in this region there is Syme's amputation and -a number of other far inferior amputations which should never be -considered when a Syme's amputation is possible. (Ed.) - -Certain limb makers consider these operations are bad for the same two -reasons that we have already refuted in connection with amputation -through the condyles of the femur, viz.-- - -(1) The stump being enlarged at its lower end will not fit into a -wooden bucket. - -(2) The stump is too long to allow an artificial foot to be fixed -below it. - -From this it simply follows: 1. That complete enclosure of the stump -in a wooden bucket is impossible; 2. That pressure must be placed -directly and exclusively upon the end of the stump. - -The latter condition is only possible if the state of the soft parts -allows the cutting of a thick plantar flap to cover the cut surface of -the bone and if care be taken to resect the posterior tibial nerve in -the flap. - -We therefore draw special attention to the excellent elliptical -supra-malleolar amputation with posterior flap (Guyon's method) in -which it is sufficient to retain a bare finger's breadth of skin from -the plantar surface in front of the point of the heel. It bears direct -pressure well, perfectly if a layer of the os calcis is cut with the -scissors from the area adjacent to the tendo-Achillis and applied -under the cut end of the tibia. - -For all these amputations the anterior flap is bad. The thin dorsal -skin of the foot is incapable of withstanding the direct pressure -which is indispensable for this method of fitting. - -Even if it were true that under these long stumps it is impossible to -insert an artificial foot for lack of space, the operations which we -have enumerated above should be recommended if the flap can be cut in -the way we have indicated. - - [Illustration: FIGS. 120 and 121.] - -Their great advantage--and the reason for retaining as much length of -bone as possible--is that they allow walking directly on the stump -without an apparatus. It is sufficient to have a circular shoe made by -any shoemaker consisting of a heel more or less thickened surmounted -by a lacing gaiter reaching halfway up the leg. Guyon's amputation -constitutes the limit up to which this "elephant boot" is possible. - -It is an unsightly apparatus, but its simplicity and cheapness should -be taken into consideration, for it is quite possible that a manual -labourer, especially a countryman, to whom an artificial foot and an -"elephant boot" are given, will reserve the former for Sunday and use -the other for his daily work. - -APPLIANCES WITH ARTIFICIAL FOOT.--The wooden piece which -partly encloses the stump consists of a block carved to the shape of -the stump and padded with felt, it is prolonged in front by an instep -reaching to the level of the middle of the metatarsus, and above by -a grooved piece which reaches halfway up the leg and encloses the -anterior half of the latter. A leather gaiter is fixed at the sides -and back and extends up the leg, being laced in front over the wooden -piece as a field boot is laced over the leather tongue. The foot -may be mounted at right angles to the leg, but it is better mounted -slightly in equinus. - -The sole and toes are of rubber as described on page 35. - -In studying figures 120 and 121 the following should be noted:-- - -1. The shape of the leg bucket in which an aperture behind permits the -introduction of the stump which is enlarged at its lower end. - -2. The mechanism by which the posterior gaiter laced in front fixes -this leg bucket. - -3. The articulation of the foot on a transverse axis. - - - - - _CHAPTER VI_ - - PARTIAL AMPUTATIONS OF THE FOOT - - -This name should be applied to amputations in which the mobility -of the ankle joint is retained, _i.e._ Chopart's amputation -(midtarsal disarticulation), Lisfranc's amputation (tarso metatarsal -disarticulation), amputation of several toes with their metatarsal -bones, or amputation of all five toes. - -1. _The amputations of Chopart and Lisfranc._--Chopart's amputation -has a grave defect: the anterior muscles have not sufficient leverage -to oppose this gastrocnemius and soleus, and the posterior tarsal -bones tilt forward so that the patient walks, not on the lower -surface of the os calcis and the plantar skin, but on the head of the -astragalus and of the os calcis and on a painful cicatrix. If certain -precautions are taken (careful preservation of the fibrous plantar -flap and suture to it of the anterior tendons) this defect is not -invariably present, and it is an exaggeration to say that Chopart's -amputation "has never given anything but disappointment." It should, -however, only be practised if the technique is well understood, and -even then it is rarely indicated, because it demands almost as much -plantar skin as Lisfranc's amputation. - -Nevertheless I have seen some good Chopart stumps the result of -operations by myself or by other surgeons; they should be fitted like -the stumps resulting from Lisfranc's operation. - -With regard to the latter, they can be easily and comfortably fitted, -provided that the scar is dorsal and is not stretched over prominent -bones. - -If the first cuneiform is not well covered it can simply be removed, -no functional disability results. It is mainly upon the plantar -surface of the stump that pressure is borne, but pressure comes also -upon the anterior surface when the foot is tilted downwards. - - [Illustration: FIG. 122.] - -The fore part of the foot which constitutes the prosthetic apparatus -consists of a block of wood, which reaches forward as far as the -middle of the metatarsus and ends in a vertical plate in front of the -stump. This block of wood is carved to the shape of the stump and -lined with felt. It is attached to the leg by a leather gaiter which -laces in front. - -Anteriorly it is prolonged into an artificial toe piece similar to -that already described for the artificial limb for amputation through -the thigh. - -This appliance is not indispensable. It is sufficient to use a piece -of cork shaped to the anterior surface of the stump and filling up the -anterior part of the boot, its advantage, however, is that once the -patient is fitted with this appliance he can wear an ordinary boot. - -2. _Partial Amputation of the Fore Part of the Foot._--These are-- - -Transverse amputation through the metatarsal bones. - -Disarticulation of one or more toes with their metatarsal bones. - -Disarticulation of one or more toes. - -For any of these amputations all that is required is an ordinary boot, -fitted with a cork, which is shaped to fit the stump and which fills -up the space left by the amputation. - -In order that the patient may walk well the scar should be dorsal and -should not be tense. - -We consider that the difficulty of maintaining equilibrium after -removal of the head of the first metatarsal, or even of the whole of -this metatarsal bone, has been much exaggerated. - -Removal of a marginal metatarsal bone (either alone or with its -neighbour), tends to make the foot tilt into varus or valgus; so that -the boot needs to be stiffened and the sole thickened to avoid this. - - - - - _CHAPTER VII_ - - ARTIFICIAL LIMBS FOR AMPUTATION THROUGH THE FOREARM - - -The constituent parts of an artificial arm are the same in principle -as for those of an artificial leg, they are-- - -1. A means of attachment preventing the appliance from dropping as the -result of its weight. - -2. A socket, fitted to the stump and articulated with the last named -at the elbow. - -3. The terminal appliance, intended to replace as far as possible the -amputated hand and, if possible, resembling it in appearance. In the -case of the upper limb the advantages that wood possesses in giving -strength and accuracy of fit do not apply, and the arm and the forearm -pieces are made of leather, with lateral steels articulated at the -elbow: this joint is active in the case of amputations of the forearm -but purely passive in amputations of the arm. - -We will commence by describing the appliance for amputation through -the forearm, taking as our type amputation in the lower half. This -will furnish an example which illustrates all the principles that -should guide us, the ends we should have in view, and the means by -which we can attain them. - -When once we have studied the apparatus by means of which the -functions of the hand can as far as possible be replaced, a short -description will suffice to explain what can be done when the loss -of movement of the elbow and then a shorter and shorter stump in the -upper arm oblige us to diminish the utility of the appliance. - -We must study in turn: (1) The attachment of the upper arm socket; (2) -the joint between this and the forearm socket; and (3) the appliances -attached to the extremity of the forearm whether these take the shape -of a hand or not. - - - 1. POINTS OF ATTACHMENT - -1. SUSPENSION.--In the exceptional amputation very low down, -in which the roots of the thenar and hyperthenar eminences remain, -the enlargement thus formed at the extremity of the forearm may be -used for the attachment of a wristlet which may suffice to support the -artificial appliance, provided that the latter is not intended for -heavy work. In the latter case an attachment from the elbow at least -must be added. - -This method would evidently be out of the question in the usual class -of case, viz. ordinary amputations through the forearm. - -In these the attachment may be made in two ways:-- - -(1) To the humerus above the condylar enlargements, the epicondyle and -the epitrochlea, the latter being much the more prominent. - -(2) To the top of the shoulder, _i.e._ to the surface over the -acromion and clavicle. - -A. _Attachment to the Elbow._--The simplest method of attachment is -that in which pressure is exerted upon the condyles of the humerus -(Fig. 124). A leather armlet laced in front is furnished with two -lateral steels, curved in above the condyles and articulated at the -level of the centre of rotation of the elbow joint with two similar -steels in the forearm piece (the socket). - - [Illustration: - - FIG. 123.--The three regions used as points of support, the - shoulder, the elbow and the wrist.] - - [Illustration: - - FIG. 124.--Suspension from the elbow. The side steels of - the arm piece are curved in to fit upon the supra-condylar ridges of - the humerus. A good method of suspension for long stumps, when the - appliance is not to be used for heavy work. It should be supplemented - in other cases by direct suspension from the shoulder.] - -This direct method of attachment is sufficient for a low amputation, -in cases where the patient does not do hard work. But if the stump -is short and if the patient has to carry fairly heavy weights -the appliance is only prevented from slipping by a considerable -constriction of the arm, which results in a serious interference with -muscular action. - -B. _Attachment to the Shoulder._--For this reason it is usually -advisable to supplement this by an indirect attachment to the acromion -and clavicle by means of a shoulder cap. - - [Illustration: FIG. 125.] - -The firmest and strongest pattern consists of a piece of blocked -leather, moulded to the shoulder, including the pectoral, -supra-clavicular and scapular regions. This is kept in place by a -strap which passes under the opposite axilla. It is cut away on the -outer side of the acromion, the anterior and posterior borders being -continued downwards on either side of the deltoid as two tapering -straps to which the armlet is attached. In this way full liberty of -movement is allowed to the shoulder (Fig. 125). - -This pattern is strong, but cumbersome and heavy. It can be lightened -by reducing it to an antero-posterior strap, 6 or 7 centimetres wide, -over the clavicle and spine of the scapula, ending in front and behind -at the level of the axillary folds in triangular enlargements. In the -upper and inner angles of these are attached the ends of the axillary -strap, to the lower and outer angles, prolongations from the armlet -(Figs. 126 and 127). - - [Illustration: FIGS. 126 and 127.] - -The lightest method, but obviously also the least secure, consists in -suspending the armlet by two straps, anterior and posterior, which -cross above the clavicle and then pass in the form of a loop under the -opposite axilla (Fig. 128). - - [Illustration: FIG. 128.] - -The choice between these three methods of attachment depends upon the -profession of the patient and the strength required by it. - -2. RESISTANCE TO UPWARD PRESSURE.--The artificial limb should -be capable of resisting upward pressure, when a thrusting force is -exerted by the hand. This is secured in the following three ways, the -hand being presumed to hang vertically with the elbow straight:-- - -(1) By pressure of the end of the stump in the socket (in amputations -low down with a palmar flap--for example, in disarticulation at the -wrist joint). - -(2) By pressure of the top of the forearm socket on the enlargement of -the forearm below the elbow. - -(3) By pressure of the inner side of the upper edge of the armlet -against the axilla. - -But, in actual work, thrusting movements are nearly always made with -the elbow bent to a right angle or almost so, then the pressure -transmitted through the forearm piece is borne almost entirely by the -steels of the armlet. - -3. RESISTANCE TO ROTATION.--A well-adjusted artificial arm -cannot rotate on the limb because-- - -(1) The forearm is elliptical in section and not circular, this is -specially so in the lower third. - -(2) Flexion of the elbow is only possible if the artificial joint -is in the same plane as the axis of the elbow joint--that is, the -sagittal plane. - -(3) The axillary strap of the shoulder attachment prevents rotation. - - [Illustration: - - FIG. 129.--The three regions used as points of resistance to - upward pressure.] - - [Illustration: - - FIG. 130.--The three regions at which rotation of the - apparatus may be prevented. ] - - - 2. ELBOW JOINT - -1. _The Concavity of the Armlet._--At the elbow joint the pinching of -the anterior soft parts on flexion is liable to take place in just the -same way as occurs at the back of the knee in amputations through the -leg. To avoid this it is necessary-- - -(1) That the axis of the joint should lie in a prolongation of a line -passing through the epicondyle and the epitrochlea. - -(2) That the armlet and the forearm socket should be cut away in front -in crescent-shaped concavities. - - [Illustration: FIG. 131.--Limb for amputation in the middle - third of the forearm.] - -The depth of these concavities is estimated when the limb is fitted. -Both the arm and the forearm may be cut away freely without any -resulting inconvenience, provided that the stump is long; but if the -stump is short and includes only the upper third of the forearm, it -is impossible to cut away the forearm socket sufficiently without -depriving the stump of a proper hold in the socket, so that movements -are not transmitted to the forearm lever with their proper force. -Consequently the socket for the forearm must be cut away very little, -and must be carried up to the level of the fold of the elbow when the -joint is flexed. The flesh in front of the elbow will not be pinched -if, the forearm being fitted very accurately, the muscles of the -upper arm are allowed free play, by cutting away the front of the -armlet to half its height, but in this case an indirect attachment to -the shoulder is essential.[12] - -[12] Another difficulty in fitting a short forearm stump arises -from the fact that the antero-posterior diameter of the forearm -immediately below the elbow increases considerably when the joint is -flexed, because of the contraction of the muscles arising from the -condyles. If the forearm socket is made to fit closely when the elbow -is extended it will be too small when the joint is flexed and will -prevent full flexion. If it was made to fit with the elbow flexed, -there is risk of the stump slipping out of the socket when the joint -is extended. (Ed.) - - [Illustration: - - FIG. 132.--Bad apparatus for amputation in the upper third of - the forearm. The front of the arm piece is insufficiently cut away.] - - [Illustration: - - FIG. 133.--Good apparatus. The arm piece is well cut away, - consequently the flesh does not bulge out.] - -2. _Construction of the Joint._--In most cases this is a simple -articulation between the steels of the arm and the forearm pieces by -two hinge joints. - - [Illustration: FIG. 134. - - FIG. 135. - - FIG. 134.--Limb for amputation through the lower third of the - forearm, with elbow joint of strong leather. - - FIG. 135.--Details of the joint.] - -The objection to this is that the movements of pronation and -supination, if these are present in the stump, are abolished. - -(_a_) _Long Stump._--When the stump is long (amputation in the lower -quarter) the following may be used: The steels of the forearm socket -are attached to the armlet, which is not furnished with steels, by two -straight strips of hard leather jointed at each end with rivets to -the corresponding piece of the limb. This allows a certain amount of -torsion so that pronation and supination are to some extent possible. -It is necessary to add an indirect attachment to the shoulder. Not -only must the armlet, not being closely moulded over the condyles, be -even when new laced so tightly as to be unbearable, but in addition -the inevitable loss of shape of the unsupported leather will in every -case soon interfere with proper support direct from the armlet (Figs. -134 and 135). - - [Illustration: FIGS. 136 and 137.--Amputation through the - forearm above the upper third. The elbow joint does not flex beyond - the right angle.] - - [Illustration: FIG. 138.--Limb for amputation through the - upper third of the forearm. (For a description of the ratchet see page - 135.)] - -This method is, moreover, scarcely applicable to patients who will -have to carry out heavy work. - -(_b_) _Short Stump._--The stump of an amputation in the upper third of -the forearm is too short to be securely held in the forearm bucket. -There is consequently a loss of power in the movements communicated, -particularly in flexion, the arm of the lever being too short; in -addition, the elbow joint in these cases is often a little stiff, so -that flexion beyond a right angle is impossible (Figs. 136 to 138). - -The chief functional difficulty depends upon the fact that, with the -elbow at a right angle, the anterior surface of the forearm stump -is too short to support a weight; for example, a basket held by the -handle. The stump escapes partly from the bucket when the forearm -extends. It is therefore well in such cases to fix the elbow at a -right angle by means of a ratchet identical with that used in the -artificial arm for amputation above the elbow (Fig. 138). - - - 3. THE ARTIFICIAL HAND AND APPLIANCES - -At the extremity of their forearm almost all patients wish in the -first place to wear something that is shaped like a hand. Many -people--and even many medical men--consider that this "artificial -hand" is really useful. In actual fact, by means of fairly simple -contrivances, it can be used to enable the patient to eat, to write, -to put on and take off his hat, but it is out of the question for it -to do real work. For that an appliance, a tool in fact, adapted for -use and not for appearance is necessary. - -The limb, therefore, will, as a rule, end in a hand, but for workmen -this hand will be capable of being unscrewed and replaced easily by -one or more appliances. - -Attempts have been made to construct so called universal hands and -forceps which will serve for any sort of work, but up to the present -none of these inventions have given satisfaction. And the practical -solution of the problem in the present state of affairs consists -in devising a special appliance for a particular trade, studying -carefully the movements necessary in this trade. - -A workman who in the course of his occupation carries out a number of -different movements may thus have several appliances, which he selects -as he requires them. For example, a locksmith must be able to hammer, -to file, and to drill holes in succession. - -We will describe first the hand properly so called, then the -appliances. The former is suitable for clerks, and it is for them that -the various improved patterns that we shall describe are made. The -latter are suitable for manual workers to whom should be given a hand -in which the mechanism is reduced to a spring thumb grip and one or -more special appliances. - -These appliances will almost always be constructed to carry out the -movements made by the left hand in the course of the work, because the -first step in the re-education of a patient who has lost the right -hand should always consist in training the remaining left hand to -carry out the work hitherto entrusted to the missing right hand. - - - A.--THE ARTIFICIAL HAND. - -The hand, which is screwed into the end of the forearm socket in such -a way that it is in semipronation when the arm hangs vertical, is -nearly always made of wood, but occasionally of aluminium.[13] - -[13] Hands are nearly always made of lime wood, which has the -advantage of lightness, but the fingers are fragile and easily break. -Instead of using hornbeam, which is hard but heavy, as the fragility -only affects the fingers, some makers have overcome this difficulty by -reinforcing the fingers by what they call a "philippeau." - -The finger is divided throughout its whole length by a mortise 1·5 -millimetres in width, in which are glued two layers of veneering wood -(mahogany, rosewood, etc., extremely hard woods, or else a layer of -hornbeam). - -It may be a simple show hand without any joint. This pattern is no -longer used. It may be jointed in one or in several fingers. We shall -first consider certain principles of construction which we can explain -by describing the chief mechanisms used. - -_Simple Spring Grip Thumb._--The simplest and most useful articulation -is that of the thumb, which when at rest is kept by means of a spring -in the flexed position, with the grip against the index finger which -is partly flexed (as are also the other fingers). - -In many cases the patient is content with this simple mechanism. He -opens the spring with the other hand and allows it to close on the -object he wishes to grip (Figs. 139-145). - - [Illustration: FIGS. 139 to 142.--_Mechanism of the passive - spring thumb._ - - The thumb turns on the axle D upon a piece which fits by a tapered - extremity C into a hollow cut out in the thenar eminence. The base of - the thumb is rounded. The spring AB flexes the thumb.] - - [Illustration: Figs. 143 to 145.--The Beaufort Thumb. - - The model shown on page 98 is more mobile than this, in which the - thumb turns on the axis AB, and is fitted directly into the thenar - eminence. But in this type it will be seen that the spring CD which - keeps the thumb flexed, reaches right up to the wrist, and is - therefore longer and more powerful. The thumb is much stronger, and - this is the mechanism usually adopted. It has the inconvenience that - it requires a deep excavation of the thenar eminence, encroaching - upon the root of the index finger, so that it is impossible to - mount the thumb in this way when it is desired to fit a movable - metacarpo-phalangeal joint to the index finger, either with a spring - (Fig. 155) or without (Fig. 148).] - -_The Automatic Thumb._--Active opening movement can be produced by the -mechanism shown in figure 146. A cord fixed behind the scapula of -the opposite side by a ring which passes over the clavicle and under -the axilla, extends down the posterior surface of the arm and forearm -pieces, running in pulleys which keep it in place. If the patient -bends the elbow and at the same time brings the arm and both shoulders -forward, rounding his back, the cord is tightened and pulls the thumb -into the position of abduction and extension. - -This narrow grip, between the tips of the thumb and index finger only, -is not always convenient. A commercial traveller or a foreman could -not easily hold with it the order book, in which he has to write. But -if the thumb, held by a powerful spring, is parallel to the palm of -the hand and grips against the other fingers, which are stretched out -and not semiflexed, the grip will be strong and convenient, especially -if a mechanism is introduced between the forearm and the hand, -allowing the latter to be rotated at will into any position (Fig. 148). - -As in the preceding case the thumb may have either a simple grip or an -automatic grip opened voluntarily by a cord from the shoulder. - -The following is a very interesting method which allows a fork or -pen to be held, the automatic thumb being used. The fingers are half -flexed, the index being separated from the middle finger, so that the -handle of a pen can be inserted between them. The grip of the thumb is -not against the tip of the index finger but against the outer side of -the last phalanx of the middle finger, against which in consequence -the handle of the object held will be pressed (Fig. 147). - - [Illustration: - - FIG. 146--Appliance with automatic thumb. The cord is fixed - to a loop which passes round the sound shoulder. Abduction and forward - movement of the shoulder and flexion of the elbow open the thumb.] - - [Illustration: - - FIG. 147.--Hand with space between the index and middle - fingers, wide enough to take the handle of a fork, which is held by - pressure of the thumb against the side of the middle finger.] - -The extended fingers are better placed for gripping than the -partially flexed fingers, although the latter are convenient to the -patient in certain ways. Ball and socket joints are inserted at the -interphalangeal joints. (Details are shown in figures 152 to 154.) -These are so stiff that they maintain the position in which they are -placed passively, as do the joints of an artist's lay figure. - - [Illustration: FIG. 148.--Articulated hand for commercial - travellers. The thumb, lying parallel to the palm of the hand, takes a - secure hold of such an article as a memorandum book. - - FIG. 149.--The usual pattern of hand. The grip is too small.] - - [Illustration: FIG. 150.--The index finger is the same length - as the middle finger. The thumb and index fingers are furnished with - nails. A small ball can be picked up. - - FIG. 151.--The middle finger being longer than the index, the - latter does not reach the surface of the table and the ball cannot be - picked up.] - -If the fingers are rigid and in semiflexion it is possible to -articulate all the metacarpo-phalangeal joints, fitting them with a -spring, which keeps them flexed, and arranging for active extension as -already described for the thumb. All that is necessary is to terminate -the cord by five separate strings instead of one. In certain special -cases this arrangement may be useful (Figs. 155 to 157). It seems to -us useless to render the interphalangeal joints automatic. - -As to the attempt which Beaufort appears to have made to give movement -to the wrist also, we do not believe that any practical result has as -yet been attained. - -For the relative length of the fingers and the utility of a nail on -the thumb and on the index finger see figures 150 and 151. - - - _Shape of the Hand._ - -In the usual pattern (Figs. 149 and 151) the fingers are semiflexed -and the thumb grips against the index finger, which is shorter than -the middle finger as in the natural hand. If it is desired to pick -up a ball, for example (Fig. 151), it will be seen that the middle -finger projects and gets in the way. For this reason it is advisable -that the index finger be longer than the middle, and in addition it is -useful to furnish the thumb and index finger with a little projection -representing the nail (Fig. 150). - -In figure 148 will be seen an arrangement which allows the thumb to -grip not by the tip, but by the whole length of its palmar surface (to -hold, for example, a notebook). The fingers of this hand have ball -and socket joints constructed in the way shown in figures 152 to 154. -The joints keep passively the position in which they are placed. -The attachment of the ball of the joint on an intermediate tenon is -similar to that of the thumb shown on page 98. The articulation of the -index finger prevents the sufficient excavation of the thenar eminence -for the insertion of the Beaufort thumb with its powerful spring. The -wrist rotates upon a bayonet joint. - - [Illustration: FIGS. 152 to 154.] - -The fingers shown in figures 155 to 157 are joined together into a -single piece, which articulates with the metacarpal part of the hand -upon a transverse axis. - -They are held in a position of flexion at the metacarpo-phalangeal -joints by four palmar springs and they are opened away from the thumb -by the action of a cord which bifurcates from the thumb cord on the -back of the hand. The pull of this cord is exerted upon the upper -angle of a triangle from the lower border of which four cords pass on -to the back of the phalanges. Figure 156 shows detail of a finger. We -know that attempts have been made to isolate by surgical means the -masses of the extensor and flexor muscles in the end of the stump, -making from them little prominences, perforated with a tunnel which is -lined with skin. The cords pass through the tunnels, and in this way -are worked voluntarily. We are not sure that this is practicable. - - [Illustration: FIGS. 155 to 157.--_Automatic fingers._ - - In figure 155 are seen the cavity in which the finger portion works - and the axis upon which movement takes place, also the four palmar - springs. In figure 157 the arrangement of the cords. In figure 158 the - attachment of the spring to the finger. This pattern, which we have - designed and which is not patented, seems to us to be simpler than - those in which the interphalangeal joints are also articulated and are - automatic. It gives a more accurate grip between the tips of the thumb - and index finger.] - -_The Brunet Grip._--The Brunet grip is described here because of its -resemblance to the automatic thumb, both being worked on the same -principles. - - [Illustration: FIGS. 158 and 159.] - - [Illustration: FIG. 160.] - - [Illustration: _Brunet's Grip._ - - Below the leather forearm piece, which laces up, the lateral steels - are continuous with each other in the form of an arch, to which the - grip is riveted. - - The latter consists of a strong semicircular piece of metal facing - downwards, ending in a pair of wide and thick jaws, like those of a - locksmith's pliers. When the apparatus is at rest, these are kept in - contact by the pressure of two powerful fixed springs, attached to the - semicircle on the forearm above and to the jaws below. The external - and dorsal spring is attached to the tip of its jaw, the internal and - palmar (the side on which the manipulating cord is attached) to the - base of it. - - The pliers are opened in the following way:-- - - Inside the semicircle to which the jaws are attached, lies a cylinder - with its ends cut obliquely; this rotates about a transverse axis, - and when at rest lies with its longer side upward. To the palmar edge - of the shorter side is attached a transverse eccentric, to which is - hooked a cord actuated as described in figure 146. When this is drawn - upward the cylinder rotates so that the wider side comes between - the jaws of the pliers and opens them; when the cord is relaxed the - springs turn the cylinder back again find the jaws close. Figures 158 - and 159 show the appliance at rest and with the jaws open. - - This appliance is patented and is made in one piece. We demonstrate in - figure 160 that it would be very easy to make the pliers detachable - from the forearm, with a screw connection, just as is done in the - various other appliances which will be described.] - -The grip of the automatic thumb always lacks power, for two reasons. -There is no room in the thenar eminence to fit a powerful spring and -the grip has always a very narrow hold. - -The Brunet grip is an actual pair of pliers, shaped like these and -furnished with a powerful spring. It is opened by a cord like that -of the automatic thumb. Figures 158 to 160 explain the mechanism. -It is an excellent appliance with which the wearer can carry out -the majority of the actions of everyday life. It has, however, the -disadvantage that it is not shaped like a hand--a point to which -patients attach much importance--and, moreover, it is a part of -a patented appliance, for which an interchangeable hand is not -manufactured. So that in order to have in addition an artificial hand, -which is capable of being removed and replaced by one or more of the -appliances which will be described later, it would be necessary for -the patient to possess two complete artificial limbs, and changing -from one to the other would evidently be inconvenient. - -We generally prescribe this appliance for patients who have lost both -arms, for one side and as a supplementary appliance. - -There are other similar models into details of which it is unnecessary -to enter. Those in which the grip is opened by movements of pronation -and supination are obviously only suitable for certain rare cases -(very long stumps, with free movement). - - - B.--APPLIANCES FOR USE IN PLACE OF THE HAND. - -The general principle is to fit to the end of the forearm piece an -attachment which can be screwed on or unscrewed at will and which -carries an appliance which is adapted to the various more or less -specialised movements of the patient's trade. - -Naturally the results thus attained must always be imperfect; but -however little perseverance and ingenuity he may possess, the patient -finds that he is able to educate the remaining arm, even when it -is the left, to replace the amputated one in a way that is often -remarkable. It is to this education that attention must be specially -directed in the workshops for the re-education of the maimed. - -1. _Knife and Fork._--The first necessity is to be able to eat, and by -certain very simple devices a fork, spoon or knife may be fixed to a -wooden hand, whether the thumb be mobile or not. - - [Illustration: FIG. 161.--Raynal's fork rest.] - -As a general rule if the patient has one arm intact, he uses the sound -hand only for this purpose, but when both forearms have been lost an -appliance is indispensable. - -We have already described how in the hand with an automatic thumb, -room can be left between the index and middle fingers for the handle -of a spoon or fork. A direct grip can also be obtained with the hand -shown in figure 147. - -The hand with five automatic digits (p. 105) is usually arranged in -such a way that it is possible to hold a tumbler for drinking; but a -patient with an amputation of one hand drinks with the other, and one -who has lost both hands can drink with a straw. - - [Illustration: FIG. 162.--The termination of the forearm is a - hemispherical piece of metal, furnished with a screw into which screw - at will the hand, the hook or the ring.] - -These appliances have replaced that in which the knife or fork is -attached to a block of wood which can be fitted into the palm of the -hand when required. It is inconvenient to be obliged to carry these -special implements about. - -Raynal's fork-rest has the advantage over the last mentioned that -it fits any fork. Figure 161 shows very clearly its construction and -the way in which it is used. The small special attachment, which is -screwed in place, is not cumbersome and can quite well be carried in -the pocket; it is, however, even more convenient to have an appliance -which is capable of gripping the fork directly like those described -previously. - - [Illustration: FIG. 163.--Vine dresser's hook. - (Gripouilleau).] - - [Illustration: FIG. 164.--The branch is held in the grip by a - leverage exerted by torsion.] - -2. _Appliances for Workmen._--All the appliances that are attached -to the arms in place of the artificial hand for performing various -kinds of work are elaborated from two simple forms: the hook and the -ring (for catching hold and carrying a parcel, for holding a handle, -etc.). A glance at figure 162 will show the nature of these and the -way in which they are used. But it will also be understood that if -the simple ring and hook are useful for equally simple purposes they -are altogether insufficient for skilled labourers whose work entails -a certain special adroitness, e.g. joiners, locksmiths, agricultural -labourers, etc. - -Many makers have realised this and have devised very ingenious -implements, some of which we reproduce, though we are obliged to limit -ourselves to certain types, for they can be varied in countless ways -according to the needs of particular cases. The same workman, as we -have already said, may have several appliances which he uses in turn -as he needs them in the course of his work. - -These appliances are constructed in two ways; some are fixed to the -end of the forearm and are immobile, some are attached by means of a -joint or joints and are capable of rotation in various directions. - -(_a_) _Fixed Appliances._--We illustrate here an appliance derived -from the simple hook, the _vine-dresser's claw_, devised some time ago -by Gripouilleau; branches of varying size can be held while the other -hand saws them or cuts them with the pruning shears (Figs. 163 and -164). - -This appliance of Gripouilleau, with a series of hooks, forms the -basis of almost all the "pincer hands" constructed by M. Boureau and -characterised by-- - -(1) The closure of the upper hook which is thus transformed into a -ring, the two appliances being combined in one; - -(2) The spring fixed to the straight side of the hook providing the -grip necessary for holding articles. If the free end of the spring is -turned up like the pointed toe of a mediæval shoe a sufficiently large -opening is left between it and the straight edge of the hook to enable -an object which is fixed mechanically or held by the other hand to be -pushed into and gripped by the spring. - -The simplest type of this mechanism is the _postman's hand_ (Figs. 165 -and 166). - - [Illustration: FIGS. 165 and 166. Postman's hand.] - -The left hand of the postman who sorts letters has for its work to -keep in the proper order the envelopes which are arranged in little -packets; the right hand has only to push the letter into place between -a flat spring, fixed to the wrist, and the back of the hook. If two -or three springs are supplied the postman can arrange two or three -packets of letters at the same time. He can also bind the packet with -string. - -The _vine-dresser's hand_ is provided with this spring to hold -small flat objects, but the second spring is wavy in outline, so -that semilunar spaces are left between it and the first. Into these -branches slip when the spring is pressed against them, and they are -thus held more firmly, whilst being sawn or pruned, than by the -twisting action of the old pattern hook of Gripouilleau (Figs. 167 and -168). - - [Illustration: FIG. 167.--Horticulturist's hand.] - - [Illustration: FIG. 168.--Method of holding a branch.] - -This thrust to seize the branch is somewhat rough, and is only -possible in holding hard wood which there is no fear of bruising. -For more delicate shoots (grafting vines indoors, preparation of -cuttings), a grip is necessary which can be opened before seizing -hold of the object. This is accomplished by prolonging the spring -towards the forearm as a handle, pressure upon which against the chest -(when standing), or against the knee (when sitting), opens the grip, -in which the graft, for example, is then placed in the opening of the -correct size. - -_The packer's hand_ is very ingenious (Fig. 169). It has the hook -pierced by an eye enabling a thread to be passed through a basket -as with a curved needle. The jaws of the pincers are smooth at the -tips, but further back they have a series of graduated notches in -which tacks of different sizes can be held whilst they are driven in -with the hammer. But of course a workman can only work quickly if he -can hold a number of tacks of the same size in the palm of his hand, -placing one under the hammer, relaxing his hold of it after the first -gentle blow has fixed it, and getting the next ready while he drives -it home. - - [Illustration: FIG. 169.--Packer's hand.] - -_The plumber's hand_ (Fig. 170) is made in the shape of a pair of gas -pliers, and ends in cutting edges with which wires can be cut. With -them a bolt can be held whilst the other hand screws on the nut. - - [Illustration: FIG. 170.--Plumber's hand.] - -_The leather-cutter's hand_ (Figs. 171 and 172) should be able to -hold the skin which the other hand cuts: it consists of a plate with -a rough surface fixed to a ball and socket joint which allows it to -turn in any direction, so that the other hand can follow the line to -be cut which is often sinuous. This appliance may also be used to hold -a drawing paper, a rule for cutting cardboard, or sheets of paper for -binding. - - [Illustration: FIG. 171.--Leather-cutter's hand.] - -The examples that we have chosen amongst Boureau's appliances for -craftsmen will, we believe, be sufficient to explain the principles -of their construction. These consist in studying the movements which -are normally carried out by the passive hand (usually the left hand, -but the right in left-handed people) and to devise an appliance -accordingly, the sound hand always becoming the active hand. - - [Illustration: FIG. 172.--Leather-cutter's hand.] - -We could have described many more examples, but we shall only say a -few words about the _mechanic's hand_, which is simply an adjustable -spanner which can be automatically closed, terminating in toothed -pliers to hold circular objects without the necessity for being -screwed up. As a matter of fact, in all the work of a mechanic -(sawing, filing, drilling, tightening screws, hammering, forging, and -grinding) the left hand is only used for picking up and steadying -the article to be manipulated. M. Boureau rightly considers that it -is better to entrust this rôle to the artificial hand rather than to -contrive to make the latter capable of sawing or of filing by means of -the devices which we shall describe further on (p. 121 and following), -ingenious and interesting though these may be. - -From these appliances, adapted to certain particular grips, others -have been devised for chair caning, soldering, and for enabling -factory hands to work starting levers and brakes. - -Thus each case must be studied separately and the workman furnished -with one or several appliances according to his needs, making the -necessary modifications from the existing patterns. - -Several of these appliances are attached by a ball-and-socket joint -like that described for the leather cutter: this is an intermediate -form between the fixed appliance and the jointed appliances which will -be described later. - -Boureau recommends that the length of the forearm should be such that -the artificial appliance reaches only as far as the level of the sound -wrist. The work will then gain in precision. We believe that this -principle holds good even for the true artificial hand, which should -be made 3 to 4 centimetres shorter than the sound hand. But it must be -realised that we shall be met with a difficulty, which we have already -experienced. Comments are made upon the appearance of the arm and the -wearer may sometimes be made to believe that this is due to faulty -construction. - -For certain special crafts the subject may be studied from another -standpoint and an actual tool constructed which carries out the -necessary actions like a machine worked by the forearm, so that in -these special cases the artificial hand is the active hand. - -At the Valentin Hauy Institute for the blind, where there has long -been a brushmaking workshop, we have seen in use a very ingenious -tool of this description with a combined action for carrying out the -entire manipulation of the thread which fixed the little bundles of -bristles into the holes perforating the back of the brush. Results are -so good that a blind and maimed worker using this apparatus works -more quickly than his comrades who have the use of both hands. It -consists of a two-pronged claw surmounted by a small thimble-shaped -projection and with a small hook, like a crochet hook projecting in -front (Fig. 173). The hook first passes through one of the holes in -the back of the brush, catches up the thread and draws it through -the hole (Figs. 174 and 175). The thread is then looped around the -thimble, whilst the sound hand binds the little bundle of bristles -into a twist of the loop (Fig. 176), and finally the bundle is fixed -into the hole, the claw being used to draw the brush towards the -worker (Fig. 177). - - [Illustration: FIG. 173.--Brushmaker's hook.] - - [Illustration: FIG. 174.--First movement. The string is - picked up by the hook.] - - [Illustration: FIG. 175.--Second movement. The string is - pulled through one of the holes perforated in the back of the brush.] - - [Illustration: FIG. 176.--Third Movement. Catching the bundle - of bristles.] - - [Illustration: FIG. 177.--Fourth Movement. The bundle is - fixed in the hole in the back of the brush.] - -(3) In place of an actual tool the detachable part may consist of a -clamp on the principle of a ring into which the tool is inserted by -the handle. The two principal methods are the screw and the American -chuck. A glance at figures 178 and 179 will explain how the large -handle of a tool intended for heavy work is controlled by means of a -screw and rings. - - [Illustration: FIGS. 178 and 179.--Nyrop's grip for hammer - and saw.] - -At Rouen we have seen the disabled Belgians who had been re-educated -wearing an ingenious T-shaped clamp by means of which the handle of a -tool may be held either in the line of the axis of the forearm or at -right angles to this. This method is specially useful for manipulating -a file which is worked with one hand while the other, in this case -the sound hand, presses upon the free end. Usually the filing is done -backwards and forwards, working from base to tip of the file, but -sometimes, specially for final polishing, the file is held with both -hands and worked from side to side. - -The American chuck consists of a pair of metal jaws fixed at their -base into a cylinder and appearing somewhat like the petals of a long -corolla. Another cylinder is screwed over the first to control the -opening and shutting of the jaws. When this cylinder is unscrewed -the jaws open and the handle of the tool can be inserted, when it is -screwed up it closes the jaws and makes them grip the handle. - - [Illustration: FIGS. 180 to 185.--_The American Chuck._ - - The pincers are composed of two jaws with vertical cylindrical grooves - (to fit upon a handle), joined above by a ring (Fig. 185) and coupled - by a spring C which keeps them apart. The pincers fit into a piece - B (Fig. 182) cut on the outer side with a screw thread (Figs. 182 - and 183) upon which the piece A is screwed up or down (Figs. 180 and - 181). When screwed towards the point of the pincers it presses on the - two jaws and closes them. When screwed in the opposite direction the - pincers open automatically.] - -If the jaws open widely, the wooden handle of a tool can be held, but -if the opening is small the unmounted tool must be fitted into them -(Figs. 186 and 187). This method is specially useful for files, as it -frequently happens that several files are required for the same piece -of work and they can be changed rapidly. - - [Illustration: FIGS. 186 and 187.--File fitted into the - American chuck.] - -It must, however, be insisted upon that the principle of giving a -passive rôle to the artificial hand is to be preferred. - -(_b_) _Appliances with Mobile Joints._--In the course of work the -direction of the wrist is changing at every instant, flexion, -extension, pronation, and supination occurring, sometimes in order -to move around the object, sometimes in order to maintain a suitable -position when the movements of the shoulder and elbow vary the -direction of the forearm. - -The consequence of this is that the worker learns to turn the piece of -work around with his sound hand. To get over this difficulty passive -joints are inserted at the wrist, which allow the appliance to move -when it is pressed against the piece of work and to take up the -direction which suits the inclination of the forearm. - - [Illustration: FIGS. 188 to 190.--Agricultural hook and ring. - (Gripouilleau.)] - - [Illustration: FIG. 191.--Combined hook and ring. (Boureau.)] - - [Illustration: - - FIGS. 192 to 194. 1. Tram driver's and chauffeur's bell. 2. - Method of use by a tram driver. 3. Management of a motor car lever. - Pressure at the extremity and traction.] - -One of the simplest mechanisms--and one of the oldest, because it was -designed by Gripouilleau--is that of the _agricultural labourer's -ring_, intended to grip and manipulate the handle of a wheelbarrow -or a plough. The ring is mounted on a transverse axis and moves in a -horseshoe which in its turn revolves on a shank which is screwed into -the forearm. The ring is provided with a screw, which may be tightened -upon the handle if desired, but which is, however, rarely used (Figs. -188 to 190). - -The _tram-driver's bell_, represented in figure 192, is devised on the -same principle. It moves on a transverse axis, and in figures 193 and -194 its utility in managing levers in driving a tram or a motor car -will be easily seen. The rotation of the horseshoe on the axis of the -forearm is not required. - -_The "cardan" joint_ also allows movement in every direction: it -consists of two semicircles of metal, placed at right angles, each -working around a transverse axis, these axes being united in the form -of a cross. The construction and working will probably be understood -without further explanation by a study of figures 195 to 198. The -first two represent a system with a ball in the centre, which is well -known commercially. The last two represent the simple universal joint -generally used in orthopædic surgery. It is somewhat more cumbersome -than the previous model. - - [Illustration: FIGS. 195 and 196.--Universal joint with ball.] - - [Illustration: FIGS. 197 and 198.--Simple universal joint.] - - [Illustration: FIG. 199.--Gardener's cylindrical spade - holder. A universal joint permits movements in every direction.] - -The spade holder used at the agricultural centre at Limonest is -mounted on a cardan (Fig. 199). - -The joint can be fixed by a compression screw which is easily and -quickly adjusted. - -Where several tools are necessary each should be complete with its own -universal joint. - -Other methods of terminal passive articulations are-- - -(1) Ball joints which have already been described in connection with -the fingers and which may be applied to the wrist. - -(2) Bayonet joints which are only applicable to certain artificial -hands which are not subjected to any great strain. - - [Illustration: FIG. 200.] - -Figure 200 explains this mechanism as it is applied to the artificial -hand represented in figure 148. - - - - - _CHAPTER VIII_ - - ARTIFICIAL LIMBS FOR AMPUTATION THROUGH THE ARM - - -In this chapter we shall deal only with amputation of the arm below -the upper third, _i.e._ with cases in which the stump is long enough -to transmit movements to the artificial limb. Amputation through the -deltoid muscle must be considered in association with disarticulation -of the shoulder. - -Below the arm socket is attached an artificial limb which represents -the elbow joint, forearm, and hand. - -There are two types to be described:-- - -1. The artificial arm proper, which has the external shape of the -natural limb. - -2. The worker's arm, a terminal appliance in which outward appearance -is not considered. - -The considerations as to the arm socket and its attachment by a -shoulder cap are the same for the two types of appliance. - -_Attachment and Arm Socket._--The surface over the acromion and -clavicle is the only point from which support can be given to an -appliance for an amputation through the arm; the attachment is made by -means of a shoulder cap. - -The general shape of this shoulder cap and its attachment by means -of a strap passed under the opposite axilla are similar to those -described for appliances for amputation through the forearm. - - [Illustration: FIG. 201.] - -The larger the shoulder cap the more it extends forwards over the -anterior wall of the axilla, upwards over the supra clavicular fossa, -and backwards over the scapula, the more secure will be the support. -The appliance is heavy and has no support other than the axillary -strap. The latter has a tendency to ride upwards against the axilla -where it exerts a pressure which may be uncomfortable. This may be -relieved by attaching a vertical strap which is buttoned to the -trouser belt. - - [Illustration: FIG. 202.] - -But although this extensive enclosure of the thoracic region may not -hinder the movements of the stump forwards and backwards, it must -obviously interfere with the movement of abduction. No doubt this -movement is the less important of the two, but we ought to try to -preserve it as far as possible. - -In short stumps we must abandon it. But if the stump is long and -consequently has no tendency to escape from the socket, even if this -slips down a little, movement may be retained by two methods. - -The first consists in separating the arm socket from a large shoulder -cap, and inserting a joint between (see page 87); but the appliance -is then heavy and cumbersome. Moreover, although abduction can thus -be easily attained, thrusting and pulling movements require a light -appliance, and finally it is impossible to secure rotation. - - [Illustration: FIGS. 203 and 204.--Shoulder fitting of small - extent allowing abduction.] - -It is possible, on the other hand, by means of the other method, which -consists in ending the shoulder cap at a line continued vertically -upwards from the thoracic margin of the axilla. If the straps are -strong and carefully adjusted the result is better than with the -fitting over the scapula, so that this appliance is preferable. We -here illustrate a method of fitting the straps which we consider a -good one. From the posterior part of the ordinary axillary strap, a -Y-shaped branch passes to the upper border of the shoulder cap above -and in front of the clavicle, this makes up for the small extent of -the enclosure of the shoulder. - -For the worker's arm a considerable enclosure without any joint is -essential, in order to secure stability. - -The arm bucket, usually continuous with the shoulder cap, is made of -leather strengthened with steels. - -The artificial arm is often abducted from the trunk, which constitutes -an inconvenience. This is sometimes due to a fault in the alignment, -the arm piece not being at right angles to the shoulder cap. It is, -however, more often due to the cylindrical shape given to the arm -bucket which forces it away from the trunk. The inner side of the -bucket should be flattened so that it may hang vertically close to the -thorax. - -The details of construction are different for the true artificial arm -and the worker's arm. - - - 1. ARTIFICIAL ARM - -The arm and forearm pieces are both made of leather. There is no -object in making them to lace, the stump is enclosed in a socket in -which it need not fit very tightly, because, as we shall explain, this -appliance is unsuitable for heavy work. - -These two parts are strengthened with steels, which are articulated by -hinge joints at the level of the elbow. We have to study-- - -1. The position of the steels and the direction of the axis of the -joint. - -2. The lock to fix the elbow joint in a flexed position. - -1. _Position of the Steels._--The stump can transmit to the arm socket -the various movements grouped under the name of circumduction, but its -hold does not enable it to transmit rotation. - -It is therefore undesirable--although usual--to attach the steels -on the arm and forearm to the inner and outer sides of the limb. If -this is done, as rotation is impossible, flexion of the forearm at -the elbow can only be carried out in the sagittal plane. But this -movement is only exceptionally required; the elbow being flexed to the -right angle and fixed in this position by a ratchet the limb forms a -hook upon which an object may be hung, provided that the forearm lies -transversely in contact with the abdomen and not antero-posteriorly. -Flexion should therefore be in a plane which is almost the frontal -plane (20° or 30° in front of this), and not in the sagittal plane. -As there is no active rotation of the arm therefore the steels must -be almost in the sagittal plane (the anterior a little external, the -posterior a little internal). - -In certain carefully constructed appliances the arm bucket is cut -transversely above the elbow and between the two parts a bayonet joint -is fixed where the arm can be rotated by the sound hand, so that the -direction of the elbow movement can be altered. - -2. _Ratchet to fix the Elbow Joint in the Flexed Position._--When at -rest the forearm should hang vertically. But the hand can only be used -when the elbow is flexed to an obtuse angle or a right angle, the -latter position being more often used. Therefore when the patient has -bent the joint to the required angle with his sound hand, he must be -able to fix it in this position. - -This fixation is effected by means of a ratchet attached to the outer -side of the elbow, which can be locked or unlocked at will. - -This ratchet consists of a flat metal plate with a prolongation -upwards shaped like the handle of a fork. The end of this prolongation -is attached to the arm steel by a pin joint about 3 centimetres above -the axis of the elbow joint. The plate is pierced by a rectangular -opening, one border of which is notched; it lies against the forearm -steel, a catch projecting from which fits into the opening, this -catch, situated 6 centimetres below the axis of the elbow, is of -the same diameter as the notches with which it engages. The higher -the notch with which engagement takes place the more nearly flexion -approaches the right angle. - -The width of the opening in the plate is twice the size of the catch, -so that the joint works freely when the catch glides on the smooth -edge and becomes fixed as soon as the catch engages in the notched -border. - -It is only necessary to arrange a lock, manipulated through the -sleeve, to bring the smooth or the notched border in contact with the -catch. - -Suppose that the handle of the ratchet is prolonged behind the point -at which it is hinged to the arm steel as a little lever furnished -with a button, and that an elastic cord or spring is stretched from -this button to a point on the postero-external border of the forearm, -then if the lever points upwards and the notches are on the upper edge -of the ratchet (as is the case in figure 205), the elastic, pulling -the lever forwards, will press the ratchet down and make the notches -engage with the catch on the forearm, if, on the other hand, the lever -points downwards the elastic traction will release the notches. The -reverse occurs if the notches are on the lower edge. - -It is then only necessary to arrange a mechanism by means of which -this little lever can turn, with a stop which arrests it above at the -vertical position, below at a point 45° beyond the horizontal. - - [Illustration: FIG. 205.--Elbow ratchet.] - -A simple mechanism of this sort is shown in figures 206 and 207. The -joint surfaces of the ratchet and of the little lever each bear a -shoulder, the former in front, the latter behind, extending over such -a proportion of their circumference as will make them act as stops in -the desired positions above and below. - -A lock is thus provided which can be manipulated with the other hand. - -In the particular pattern illustrated, traction is made by an elastic -cord fixed to the centre of the back of the wrist and ending above -in a leather strap pierced with holes which fix on the button of the -lever. This arrangement allows of the adjustment necessitated by the -gradual stretching of an elastic which is subjected to continuous -tension. - -A steel spring of this length (the whole length of the forearm) would -be too heavy if it were sufficiently powerful. If it is desired to use -this method the two ends of a powerful spring should be fixed, one to -the button on the lever, the other to the catch on the forearm with -which the ratchet engages. - - [Illustration: FIGS. 206 and 207.--The elbow ratchet and mode - of action of its lock.] - -The spring should always be in tension. As the distance between the -joint on the arm and any point on the forearm increases as the elbow -extends, it is better for the ratchet, with notches on its upper -edge, to be engaged when the button points upwards and free when it -points downwards. In the opposite arrangement, which is often used, -the tension is considerable without being useful when the forearm is -vertical, and the mechanism soon wears out. - -3. _Hand and Other Appliances._--The hand attached to the end of the -forearm has a spring thumb which may be passive or automatic. In -the latter case, if the stump is long enough to allow considerable -movements of the arm, the cord works in the way described on page 87, -for amputation of the forearm. If the stump is short, traction must be -exerted by movement of the shoulders, rounding the back. - -The hand with a mobile wrist is never used with these amputations -except in certain expensive appliances, in which in addition the four -fingers may be articulated, as described on page 101. For the ordinary -limb these delicate mechanisms are devoid of practical utility. - -It is easy to replace the hand with interchangeable appliances, but -when the patient has to do hard work this is not a satisfactory method. - -The arm with the ratchet at the elbow is in fact suitable for use -by a clerk. But it is not either strong enough or simple enough for -manual labour. In our opinion the functional and practical value of -an artificial arm, particularly for amputation above the elbow, is -often exaggerated, however it does exist, especially in many branches -of agricultural work. For the latter the slightness of the lateral -steels--and especially of the joints at the elbow--makes the appliance -insufficiently strong. The necessary delicacy of the ratchet and its -manipulation through the sleeve by the sound hand are additional -disadvantages. - - - 2. WORKER'S ARM - -If our object is to fit to an arm stump an appliance which will be at -the same time strong and flexible, capable of carrying out rough and -even vigorous work, we must abandon the attempt to imitate the natural -shape of the arm. - -The movements and strength of the stump must be transmitted to the -object held by means of a rigid rod at the extremity of which the -appliance for gripping is fixed. It is possible to fix around this -rod a show arm with a hand and a passive spring thumb for wearing on -special occasions, in exactly the same way as we fit the show leg -round the peg. Figures 208 and 210 will show at a glance how this is -done. - -But, as far as our present experience goes, this is only an accessory -added for æsthetic reasons. The true worker's arm consists of a strong -metal rod fixed to the arm socket in a way that we must now study. - -1. _The Arm Socket._--We have already said that this must be continued -into a shoulder cap of considerable extent, which may be perforated -in the region of the point of the shoulder in order to render the -appliance lighter. Abduction at the shoulder is thus sacrificed. - -The arm socket is made of leather, open down the front and laced. By -being laced it fits the stump more securely. It is strengthened by two -steels which may be fixed in the frontal plane because, as we shall -see, a passive rotation at the elbow joint is possible. - -These steels are directly continuous below with a hemispherical steel -cap, which is pierced in the axis of the limb by a hole into which is -bolted the connecting piece to which the rod which represents the -forearm is attached. - -2. _Articulation at the Elbow._--The forearm consists of simple metal -tube, attached beneath the arm socket by methods which depend upon the -following principles. - - [Illustration: FIGS. 208 and 209.--_Worker's arm and show - arm._ - - The worker's arm consists of a metal rod which swings backwards and - forwards at the elbow and also rotates upon the arm socket. To the - end of this rod an appliance can be screwed (a ring and hook are here - shown). Around the worker's arm a show arm with a hand (Fig. 209) can - be fixed. They are shown in place in Figure 210.] - -The only movements that the stump can transmit to the arm socket -are forward and backward movements hinging about the shoulder, and -abduction. The first of these movements is the only really useful one -for the workman. The downward pressure exerted by active extension of -the elbow no longer exists; in order to press upon an object the sound -hand must be used, for it is not practicable to make use of the weight -of the body thrown forward for this purpose. - - [Illustration: FIG. 210.--Show arm in position.] - -In backward and forward movements--considering, for example, the use -of the file--the angle at the elbow opens when the arm is thrust -forward and closes when it is pulled backwards. These passive -movements of the joint must not be impeded in any way, that is to say, -the forearm must swing freely below the arm upon a transverse axis and -it must also be able to rotate freely around a vertical axis. - -These movements are secured in the ploughman's hand which was designed -sixty years ago by Gripouilleau and in which the joint which we -have shown as a method of attaching the mobile ring to the wrist is -utilised. The forearm rod attached by a strong transverse pin swings -freely in a little stirrup-shaped cap, which itself rotates around a -bolt by which it is firmly fixed into the metal or wooden hemisphere -which terminates the arm socket.[14] - -[14] Wood, which was used by Gripouilleau, has been given up. - -It is clear that this complete liberty of action has its -disadvantages; the elbow joint can never be made to assume a fixed -position against any passive resistance; moreover, in actual practice -the useful range of either of these movements is small. For this -reason attempts have been made to devise methods by which they can be -limited in the various worker's arms which have been designed since -the beginning of the war. In all these arms the mechanism of the elbow -joint is derived from that of the ploughman's arm of Gripouilleau. -Unfortunately none of these mechanisms in which a pressure screw is -used for fixation possess any strength. At first sight, in a new -appliance they appear attractive and work well, but it is well known -to all mechanics that the thread of a screw which is in constant use -quickly wears and then it is impossible to tighten it. - -At the extremity of an artificial arm, whether it be an arm of natural -shape or a worker's arm simplified to the form of a jointed rod, any -of the appliances already described for forearm amputations can be -screwed on as required. - -It is by the use of these appliances that Gripouilleau's old -ploughman's arm, which ended in an interchangeable hook and ring, has -been improved. - -Apart from their actual economic value, results have been obtained by -use of these terminal appliances, in many different skilled trades, -which are of the greatest possible interest. - -For reasons that we have indicated in describing the attachment of the -elbow, the various attempts that have been made to give to the wrist -a mobility that is under control have not so far led to the invention -of an appliance that is both strong and durable. For this reason we -consider that until something new is designed it is better to make the -terminal appliance a fixed one. - - - - - _CHAPTER IX_ - - ARTIFICIAL LIMBS FOR DISARTICULATION THROUGH THE SHOULDER JOINT AND - AMPUTATION THROUGH THE DELTOID MUSCLE - - -So far as function is concerned these operations are identical; a -short arm stump is incapable of transmitting movements to the socket -of the artificial limb. - -That is to say, our appliance will be a purely passive one, and -at the present time it is useless to attempt to make any sort of -worker's arm. We must aim simply at supplying a limb which imitates -the external shape of the arm, with an elbow joint which can be locked -with a ratchet. At most it is possible by a movement of the opposite -shoulder to work an automatic thumb by means of a cord, as a rule, -however, a simple spring thumb is preferred. - -Nothing need be added to what has been said in the previous chapter -about the elbow joint or the hand. - -In the fitting of an attachment over the shoulder the amputation -through the deltoid presents an actual advantage. For in this case the -shape of the point of the shoulder is preserved, and the attachment -carried out as described on pages 87 and 130 fixes the appliance very -securely. - -If the entire humerus has been removed a very extensive enclosure of -the front and back of the chest is essential and in order that the -axilla may be in close contact with the top of the limb it is a good -thing to stretch across this space a layer of some firm material. - -These appliances can be used to steady a piece of paper upon which -the patient is writing, to carry a parcel which is not too heavy -with the elbow flexed, to grip an article with the thumb. A workman -who is being re-educated for some occupation which is possible -for a one-armed man, will usually--unless he is going out for -pleasure--leave his artificial arm at home in the cupboard. - - - - - _CHAPTER X_ - - SOME GENERAL PRINCIPLES IN THE RE-EDUCATION OF THE DISABLED - - -WHEN a disabled man has been fitted with an artificial -limb he has to learn a trade which will enable him to supplement -his pension and provide for himself and his family. In our opinion, -which we believe we have expressed more than once in this book, it is -nearly always advisable to determine what profession will ultimately -be possible before ordering the artificial limb. This principle is -perhaps not always thoroughly understood, although there are fitting -centres where it is fully recognised (a proof of this may be found in -a recent article by Nové-Josserand and Bouget). - -It is unnecessary to repeat that whilst every effort must be made to -associate form with function, the latter is bound to take precedence -of the former. It is, however, not always easy to impress upon -patients, and more especially upon their protectors, that _form_ is -for Sundays and holidays, and _function_ is for workdays. - -The grave problem of re-education of amputation cases, and in a more -general sense of all the maimed, now confronts us. We believe it to be -worth while to indicate the general principles so far as they are at -present understood. - - - I - -At the outbreak of war the idea of the disabled in general, and -particularly of those who had had a limb amputated, was often to give -up any really active trade and to seek a "situation" generally as an -official with no actual manual labour. It must be confessed that many -people, especially the nurses, encouraged them in this, and possibly -the latter would not deny having done so. - -It has rapidly become evident that there are too many maimed to -be supplied with situations as caretakers of public gardens or -doorkeepers, and that they will not be able to gain a living by making -tricoloured decanter-mats of string or raffia or artificial flowers, -when bazaars organised for their benefit by tender-hearted souls have -gone out of fashion. - -One of us was present a short while ago at the following little -scene:-- - -In a hospital where there were two amputation cases, one through the -lower fourth of the thigh, the other through the middle of the leg, -both agricultural labourers, a distinguished man of letters, actuated -by the best intentions, asked them what they counted on being able to -do after they had been fitted with artificial limbs. The first replied -that he hoped to return to agricultural work, the second that he would -never be able to do that but would look out for a "situation." Our -friend was much surprised to hear us say that he would be ill employed -in using his influence to obtain his desire for the second patient, -because a man with only one leg could work on the land with almost -no diminution of his ordinary capacity, even with the old-fashioned -kneeling peg leg. - -As Jean Camus has well said in a recent article in the _Paris -Médical_, "We are beginning to pass beyond the phase when re-education -of the maimed was left to chance. It is felt now that the frivolous -efforts of benefactresses who, acting with the best intentions but -without reflections, are delighted to be able to transform into a -shorthand typist an honest farm labourer who had a strong attachment -to the soil and could quite well return to it, must be avoided. Such -feats are both culpable and absurd." - -These fantastic ideas must be got rid of, and all our efforts must be -co-ordinated, the complexity of the conditions to be dealt with being -duly weighed. - -Given a maimed man the first care should be to educate to the maximum -all the uninjured and remaining parts. It is too often forgotten that -among the parts remaining the brain plays a leading rôle, even the -chief rôle, not only because it is the organ of "good will" without -which all attempts at re-education are fruitless, but also because -good will being given the intelligent man will succeed better and -will be able to adapt himself to more delicate work. "Physiotherapy -cannot be prescribed," says J. Camus, "as quinine is prescribed. The -malarial patient who takes the latter medicine benefits whether he -wishes to or not. The wounded man who submits each morning to his -mechanotherapeutic treatment does not recover unless he wishes." - -It is very difficult to make the layman understand this. He invariably -takes for granted the good will of the patient, with all of whose -complaints he sympathises, without for a moment realising that they -sometimes degenerate into jeremiads, often with an ulterior motive. -An examination by a doctor--and an experienced doctor--is therefore -necessary in order to determine under what physical and mental -conditions an amputation case can be re-educated; so that he may -understand that it is entirely to his interest to work as quickly and -as well as possible, that begging is degrading, and above all that -private charity is temporary and exhaustible; and that in consequence -he must as quickly as possible put himself into a condition to -supplement by a salary justly earned the pension or gratuity which is -certain to be insufficient for his maintenance. - -It can never be sufficiently insisted upon in dealing with the maimed -that by resuming work, and on account of the functional improvement -resulting from doing so, they need have no anxiety that their pension -will be reduced, because the amount of this is based on the extent of -the injury itself and on the man's rank, and not on his profession -before he became a soldier. In the same rank the pension is the same -for a surgeon or a lawyer, if both have lost a hand. - -It is a deep-seated notion, instilled into the minds of injured -workmen by the often suspicious folk who advise them, that if they -begin work before their case has been settled their pension will be -less. - -It must be acknowledged on the other hand that the civil expert -is often faced with a difficulty. As our law stands--and it is -unfair--work cannot be resumed partially with provisional half-pay -followed later by whole-time work with permanent salary. This -difference is important to our wounded soldiers, who have everything -to gain by a rapid and complete re-education and whose duty it is -to do whole or part-time work while their legal position is being -arranged and before the wound, in legal phraseology, has become -"consolidated," that is to say, before the completion of treatment. - -It is only fair to add that the patients are not alone to blame and -that the administration has for long been guilty of an error against -which reaction is growing, viz. delaying re-education until the time -when the local condition has become permanent and the patient has been -discharged and has received his prosthetic apparatus. - -This delay is deplorable, on both medical and social grounds. On -medical grounds because in very many cases before treatment is quite -complete the addition of carefully graduated and supervised work is -an important part of the treatment. On social grounds because it is -necessary to fight in every possible way against the common tendency -of the patient to fall into habits of laziness and intemperance. - -This is now understood, and almost everywhere to-day the wounded -soldier can resume work in workshops attached to the centres of -physiotherapy, and thus begin his re-education while continuing his -treatment. - -At a certain stage resumption of work becomes the best therapeutic -agent of all. - -It is obvious that this resumption of work cannot supply the place -of certain special treatments such as electrical treatment during -the regeneration of a nerve, balneotherapy, or graduated gymnastic -exercises; but is it not true that work with its continual active -movement is infinitely superior to passive mobilisation by means of -apparatus however ingeniously the latter may be contrived? Morover it -is surely a more efficacious course of mechanotherapy when the patient -works for half or all the day than is provided by the special course -occupying only an hour or two. - -The tendency to-day is in this direction, as, for example, at the -Grand Palais, thanks to the efforts of J. Camus, and also in the -agricultural centre of the XIIIth district under the direction of -Belot and Privat. At a given moment all treatment may be suspended and -the patient may devote himself exclusively to work with results the -excellence of which Nepper and Vallée have demonstrated. - -The workmen are then eligible for work in a town in private workshops, -but so far this freedom has more inconveniences than advantages. A -man whose working capacity is much reduced, and more especially a man -who requires re-education, has no place in an ordinary workshop where -neither the proprietor nor the foreman nor his fellow-workmen are in -truth much inclined to concern themselves about him. Where actual -education is necessary this is best supplied in special workshops -where the patient will be among comrades handicapped like himself, -whose progress he will be able to watch and whose efforts he will -imitate, rather than among able-bodied workmen, by comparing himself -with whom he is bound to be discouraged. - -The problem has been solved by the Belgians in a remarkable -establishment opened at Port-Villerz, and by the Austrians at Vienna -under the direction of Spitzy, as Nové-Josserand and Bouget inform -us, by delaying a maimed soldier's discharge from the army until his -re-education is as complete as possible. This method has proved to -be to the interest both of the individual and of the State, but we -do not seem to have considered this solution, and it is still to be -feared that it would accord ill with the independence of our national -character. The actual fact, though it has not been brought into -prominence, is that our usual system of "watertight compartments" has -been applied by adding to the centres of physiotherapy centres of -agricultural or industrial re-education, the results obtained in which -are dependent upon the efficiency of the director of physiotherapy. - -This matter seems to have received very little special attention in -connection with amputation cases. It is, however, of great utility to -develop the strength and agility of the remaining limbs by suitable -gymnastic exercises, to teach a man with only one leg, for example, -to jump without an artificial limb and to climb a slippery rope or a -ladder; or to train the left hand of a man who has lost his right; -to develop the greatest possible strength in the stump by training -it in movement combined with the exertion of force. In addition to -this, early and provisional equipment with artificial limbs must -become general. These temporary limbs are undoubtedly rudimentary -contrivances, but they are functionally good and are useful on account -of their mere weight. - -In this connection the temporary arms used by Nové-Josserand and -Bouget in their agricultural re-education centre are very interesting -models. The great advantage of using a temporary limb is that the -time required for the construction of the permanent apparatus, often -a considerable period, is not lost in idleness, the mother of all the -vices. - - - II - -It was said at the beginning of the last chapter that whenever -possible a disabled man should be given a real trade and not one of -those frivolous and trifling occupations which were at one time the -fashion. - -In the choice of a trade the ruling principle is that of aiming to -restore as nearly as possible the man's former occupation. This -principle should not, however, be carried to an extreme. - -As Camus has justly said, by his previous work a man has stored up -a mass of ideas, a fact which is too little realised, especially by -himself. These include the manner of choosing, holding, and attacking -the materials upon which he works, and of appreciating their qualities -and faults; knowledge of their market value, of the value of the -labour, etc. This should be utilised in his future work even though it -be realised, as M. Bourillon has remarked, that the resumption of his -trade in its entirety may be impossible. - -With the tools that have been described a man who has lost his forearm -may be able, for example, to undertake a locksmith's work and to -execute correctly all the movements required in plying the trade. -Granted; but how long will he take to make one piece, let us say, -as well as his neighbour? If he produces little he will not find an -employer to give him daily work, while if he does piecework, apart -from the fact that it is not in good repute among those who are the -actual leaders of the working classes, it will not be remunerative, -and to earn 3 frs. a day when a comrade earns 10 or 12 frs. is -practically an impossible solution. - -The case may be cited of a woman suffering from congenital deficiency -of the hand with a very short rudiment of the wrist which is only -slightly mobile. By means of contrivances which we need not describe, -and with no prosthetic apparatus, she threads her needle and sews as -quickly and as well as anybody. This is not an argument, for: (1) it -is a congenital lesion and the educability of a child is well known; -(2) the woman is extremely intelligent, and unhappily this favourable -factor cannot always be counted upon. It would be wrong to conclude -from this that a case of amputation at the wrist should be put to -sewing. - -It must never be forgotten that intelligence and will are factors of -the first importance, so that however little intellectual capacity -the disabled man may have, he is bound to profit by his passage -through the school of re-education in learning to read and write if -he is illiterate--this is more frequent than is usually believed--or -to improve his knowledge if he has already had some instruction. It -is, in fact, by brain work that many learn to replace their physical -defect. Let us take, for example, a disabled bricklayer. If he is -intelligent and is given a helping hand in the shape of the necessary -instruction, he may become a builder on his own account in a small way -when he knows how to make plans, work out estimates and keep accounts. - -This is not a Utopian fancy. In the small towns and villages there -are many owners of businesses such as masons, decorators, joiners, -etc., workmen who cannot spell, but who are intelligent, have business -minds and a gift for overseeing, who have given up the trowel and will -build you a house as well as, or often better than, many "architects." -It is with similar aims to these in view that a bricklayer should -be re-educated when it is judged that his intellectual capacity is -sufficiently great. - -Where there is no intelligence education can do little. There are in -civil life innumerable "casual labourers" with limbs intact who have -never been able to learn a regular trade and who earn a miserable -livelihood by doing what "turns up." Their situation becomes serious -when they lose some of their physical capacity. They can, however, -be rescued, particularly by encouraging them to become agricultural -labourers. It is indeed especially agricultural labourers who should -be urged to return to the land, and those mechanics who will be -unable to work in a factory for the future should also be encouraged -to take up this work. One reason for this is that the workman's -arm--especially if it has not been too much elaborated--is useful -for the execution of a considerable variety of work on the land. It -is unnecessary to speak of cases of amputation below the knee, since -their usefulness on the land may be taken for granted. - -In the country as a matter of fact a man never dies of hunger; and -this cannot be said of the town. Apart from actual cultivation of the -land, which is in part impossible for the maimed, there are numerous -and important occupations of which a town dweller would not think. It -is when he goes to the centre of re-education in agricultural work, -first of all to view it and then to work, that the disabled man takes -note of what he can or cannot do, and of the work in connection with -agriculture which is open to him, such as poultry rearing or bee -keeping. - -This applies to other employments than agriculture. - -Apart from his actual trade which the workman can no longer ply with a -sufficient return for his labour, he may be able to work at one or two -of the accessory employments which would not of themselves bring him -in a living but which would yield a satisfactory supplementary income. - -In certain re-education centres there seems to be a marked -predilection for crafts in which the apprenticeship is short -and the installation costs little, though these are in fact the -characteristics of those trades which give the labourer a poor return, -that is to say, time-work in a large or small workshop. - -At the beginning of the war an attempt was made to show that there -would never be enough tinkers, sabot makers, shoemakers, or saddlers -in the country. It is quite a false idea that a disabled man can -gain a living at one of these crafts in a village. It is true that -he can do so if, working as an agricultural labourer, he can act -as a barber in his spare time, and is capable of executing small -jobs, especially repairs, which the villagers would readily give to -him rather than have to go several miles to get them done. When the -disabled man has this additional work in his hands he will gradually -be able to ascertain whether the needs of the countryside and his own -personal capacity are compatible with its development. In that case, -however, he will be, in fact, a small proprietor buying his own tools -and materials and fixing a retail price. But the great majority of -workmen have no notion of such calculations and such organisation -as are indispensable when a man runs a business even if he is -alone. It follows, therefore, that the education of his mental, and -especially his commercial, faculties must be considered, and it must -be ascertained whether the man is likely to profit by such education. -It is useless to install in a hamlet a shoemaker who is incapable -of working except as an assistant, and in the town at the actual -factories the prospects are poor. - -Moreover, conditions of life in the disabled man's native place must -be considered as a matter of importance. A man from the Mediterranean -country has no idea beyond the cultivation of meadows, and one from -Picardy none beyond the making of cane baskets for packing flowers. - -Judgment is difficult, and in order that the choice may be exercised -as reasonably as possible, the careful collaboration of the patient, -the doctor and the managers of the workshops is essential. We repeat -that this is one of the principal objects for which the centres of -re-education are useful. There are some efficient men, we know, who -without asking anything of anybody find quickly and unerringly the -exact work that suits them. There is no need of anxiety in such cases. - -A certain metal worker from the invaded area suffering from -pseudarthrosis of the shoulder, whose wound we were treating, sent -for his wife, and they began to rear geese. We know two cases of -amputation of the right arm, an operative at an aeroplane works and -a worker in stucco, who during their stay at hospital and before -they had been supplied with artificial limbs, had taught themselves, -the one technical design the other ornamental design. Both of them, -as soon as they were discharged, have been taken on by their former -masters, who no doubt were fully conscious that they were thus -combining a good deed with good business. To come to a decision of any -value, however, cases of this sort must not be taken as a criterion, -for they are in fact exceptional. The majority of the men are in need -of guidance. - -The procedure employed at the Belgian centre of re-education at -Port-Villerz consists in allowing the patient to frequent the -workshops at will for a few days, during which time he sees what is -going on and is not slow to make his choice, which it appears rarely -needs to be amended. - -We have dealt chiefly with the conditions which are suitable for the -re-education of a man who has lost an upper limb, or, speaking more -generally, is disabled in one arm, for whom resumption of work in a -workshop will often be out of the question. The question is easier -of solution for the lower limb. Cases of amputation of the leg can -work standing, if supplied with an artificial limb, at practically -any trade. Cases of amputation of the thigh have numerous manual -occupations open to them in which they sit for at least part of -the time. It must be understood, however, that these professions -which require skill can, as a rule, only be learnt in well-equipped -workshops at the price of a fairly long apprenticeship. Two or three -years are necessary to make a good mechanic, a good watchmaker, -glass cutter, etc. This should not deter us in the case of fairly -young men. The difficulty is to organise special workshops, often with -a complicated equipment, where the maimed man can at least pick up -the rudiments of the work, for it is not to be thought of that he can -remain there during the whole time occupied in a complete training. - -In conclusion, we should like to draw attention to the law of 1831, -which regulates the distribution of pensions by means of groups -classified according as the loss is of two limbs or of one. No -distinction is made with regard to the seat of the amputation. But -a man who has lost both legs and has been suitably equipped with -artificial limbs can earn a fair wage, whereas a man who has lost -both arms is completely disabled so that he cannot even wash or -dress himself. Among the amputation cases the difference is also -considerable in the lower limb, between amputation through the leg -and through the thigh, and even more in the upper limb, between an -amputation retaining the movements of the elbow and one in which they -are lost. There is, moreover, a great difference in the quality of -stumps and the consequent utility of the artificial limb. It is of -course impossible to allow with mathematical precision for all degrees -of disablement, but the several general distinctions which we have -enumerated could be taken into consideration without difficulty. - - - - - INDEX - - American chuck, 122 - - Angle at which foot is set, 34, 49 - - Appliances for use instead of hand, 108 - with mobile joint, 123 - with universal joint, 126 - - Artificial hand, 96 - spring grip thumb, 97 - automatic thumb, 98 - Beaufort thumb, 99 - for commercial travellers, 102 - automatic fingers, 105 - - - Bearing points, 6 - upon ischium, 13 - upon condyles of femur, 62 - upon tuberosities of tibia, 67 - upon end of leg stump, 77 - - Bouget, 145, 151 - - Bonreau's appliances, 112 - function of the artificial hand, 117 - hook and ring, 124 - length of artificial forearm, 118 - - Braces for suspension of artificial leg, 24 - with extending sling, 43 - for amputation below knee, 73 - - Brunet's grip, 107 - - Brushmaker's hook, 119 - - - Camus, Jean, 147 - - Cardan joint, 126 - - Chauffeur's bell, 125 - - Combined mechanism for knee and ankle joints, 55 - - Combined suspension for artificial leg, 26 - - Condyles of femur, amputation through the, 60 - - Convertible peg leg, 58 - - - Deltoid muscle, amputation through the, 143 - - Duplex foot, 54 - - - Elbow joint, for above elbow amputations, 133 - for below elbow amputations, 91 - for below elbow amputations, short stumps, 95 - for worker's arm, 139 - - Elephant boot, 79 - - Equilibrium in an artificial leg, 35 - - - Federation leg, 33 - - Flexed knee, walking upon the, 66 - - Foot, construction, 35 - with movable ankle, 50 - with lateral mobility, 54 - - Foot, partial amputation of the, 81 - - Fork rest, Raynal's, 109 - - Frees' foot and knee, 57 - - - Gripouilleau, vine-dresser's hook, 112 - agricultural hook and ring, 124, 126 - ploughman's hand, 141 - - Guyon's amputation, 78 - - - Hip joint, disarticulation at the, 64 - - Hook and ring, agricultural, 124 - Boureau's, 124 - - - Index finger, length of, 102 - - - Knee extending mechanism, 37 - artificial muscle, 37 - extending sling, 43 - combined with ankle movement, 55 - - Knee joint, amputation through the, 60 - - Knee joint, for amputation through the leg, 73 - - - Leather-cutter's hand, 116 - - Leg bucket, shape of, 67 - material, 68 - - - Marks' leg, 34 - knee joint, 41 - braces, 45 - - Materials for bucket, 3 - for artificial arms, 84 - - - Nové Josserand, 145, 151 - - Nyrop's grip, 121 - - - Packer's hand, 115 - - Peg leg, 28 - with joint at knee, 29 - with show leg and foot, 31 - conversion into leg with free knee joint, 58 - - Perineal concavity, 15 - - Plumber's hand, 115 - - Postman's hand, 113 - - - Ratchet at elbow, 133 - - Re-education of amputation cases, 145 - - Rotation of artificial arm, prevention of, 89 - - - Shoulder joint, disarticulation at the, 143 - - Spade holder, 127 - - Stop to limit extension of knee, 38 - for amputation below knee, 76 - - Stump, length of, 3 - condition of allowing end bearing, 7 - Suspension of artificial arms, 85, 129 - to condyles of humerus, 85 - to shoulder, 87 - for worker's arm, 138 - - Syme's amputation, 77 - - - Thigh bucket, shape of, 13 - wooden, 17 - leather and steel, 20 - for amputation through knee joint or condyles, 60 - - Thigh corset, 73 - - Thumb, spring grip, 97 - automatic, 98 - Beaufort, 99 - - Tram driver's bell, 125 - - - Vine-dresser's hand, 113 - - - Waist belt, 22 - - Worker's arm, 138 - - Printed in Great Britain for the UNIVERSITY OF LONDON - PRESS, Ltd., by RICHARD CLAY & SONS, Ltd., London - and Bungay. - - - - - THE UNIVERSITY OF LONDON PRESS, LTD. - - have pleasure in announcing the publication of the following - series which covers the whole field of War Medicine and Surgery - - MILITARY MEDICAL MANUALS. - - A Series of handy and profusely illustrated manuals translated - from the French under the general Editorship of - - SIR ALFRED KEOGH, - G.C.B., LL.D., M.D., F.R.C.P., Hon. F.R.C.S. - _Late Director-General Army Medical Service_ - AND - Lt.-Gen. T. H. J. G. GOODWIN - C.B., C.M.G., D.S.O. - _Director-General Army Medical Service_ - - _Each translation has been made by a practised hand and is - edited by a specialist in the branch of surgery or medicine - covered by the volume._ It was felt to be a matter of urgent - necessity to place in the hands of the medical profession a - record of the new work and new discoveries which the war has - produced, and to provide for everyday use a series of brief and - handy monographs of a practical nature. The present series is - the result of this aim. Each monograph covers one of the many - questions at present of surpassing interest to the medical - world, is written by a specialist who has himself been in close - touch with the progress which he records in the medicine and - surgery of the war. Each volume of the series is complete in - itself, while the whole will form a comprehensive picture of the - medicine and surgery of the Great War. - - - _From the BRITISH MEDICAL JOURNAL: "The books are short and - practical, and are founded upon the most recent clinical and - laboratory experience."_ - - THE TREATMENT OF INFECTED WOUNDS. By A. Carrel and G. Dehelly. - Translated by Herbert Child, Capt. R.A.M.C., with Introduction by Sir - Anthony A. Bowlby, K.C.M.G., K.C.V.O., F.R.C.S., Surgeon-General Army - Medical Service. With 97 illustrations in the text and six plates. - Second Edition, with additions. Price 6/- net - - Is as fine an example of correlated work on the part of the - chemist, the bacteriologist, and the clinician as could well - be wished for, and bids fair to become epoch-making in the - treatment of septic wounds. - - - _The cost of postage per volume is: Inland 5d.; Abroad 8d._ - - LONDON: UNIVERSITY OF LONDON PRESS, LTD., - 18, WARWICK SQUARE, E.C.4 - - - - - MILITARY MEDICAL MANUALS - - THE SPECTATOR: "It would be hard to imagine a better set of - books; they are well written, well translated, well illustrated, - moderate in length, and moderate in price." - - - THE PSYCHONEUROSES OF WAR. By Dr. G. Roussy, Assistant Professor in - the Faculty of Medicine, Paris, and J. Lhermitte, sometime Laboratory - Director in the Faculty of Medicine, Paris. Edited by Colonel William - Aldren Turner, C.B., M.D., and Consulting Neurologist to the Forces in - England. Translated by Wilfred B. Christopherson. With 13 full-page - plates. Price 6/- net - - "The Psychoneuroses of War" being a book which is addressed - to the clinician, the authors have endeavoured, before all - else, to present an exact semeiology, and to give their work a - didactic character. After describing the general idea of the - psychoneuroses and the methods by which they are produced, the - authors survey the various clinical disorders which have been - observed during the war. - - - THE CLINICAL FORMS OF NERVE LESIONS (Vol. I). By Mme. Athanassio - Benisty, House Physician of the Hospitals of Paris (Salpêtrière), - with a Preface by Professor Pierre Marie. Edited with a Preface by E. - Farquhar Buzzard, M.D., F.R.C.P., Captain R.A.M.C.(T.), etc. With 81 - illustrations in the text, and seven full-page plates. Price 6/- net - - In this volume will be found described some of the most recent - acquisitions to our knowledge of the neurology of war. But - its principal aim is to initiate the medical man who is not - a specialist into the examination of nerve injuries. He will - quickly learn how to recognise the nervous territory affected, - and the development of the various clinical features; he will be - in a position to pronounce a precise diagnosis, and to foresee - the consequences of this or that lesion. - - - THE TREATMENT AND REPAIR OF NERVE LESIONS (Vol. II). By Mme. - Athanassio Benisty. Edited by E. Farquhar Buzzard, M.D., F.R.C.P., - Capt. R.A.M.C.(T.), etc. With 62 illustrations in the text and four - full-page plates. Price 6/- net - - This volume is the necessary complement of the first. It - explains the nature of the lesions, their mode of repair, - their prognosis, and above all their _treatment_. It provides - a series of particularly useful data as to the evolution of - nerve-wounds--the opportunities of intervention--and the - prognosis of immediate complications or late sequelae. - - _The cost of postage per volume is: Inland 5d.; Abroad 8d._ - - - LONDON: UNIVERSITY OF LONDON PRESS, LTD., - 18, WARWICK SQUARE, E.C.4 - - - - - MILITARY MEDICAL MANUALS - - "The importance of this comprehensive series can hardly be - exaggerated. The French genius in its application to scientific - medicine will be discovered here at its best and it will - be found to be a distinct gain to have had this method of - collaboration applied to so important an enterprise." - - - THE TREATMENT OF FRACTURES. By R. Leriche, Assistant Professor in the - Faculty of Medicine, Lyons. Edited by F. F. Burghard, C.B., M.S., - F.R.C.S., formerly Consulting Surgeon to the Forces in France. Vol. - I.--"Fractures Involving Joints." With 97 illustrations from original - and specially prepared drawings. Price 6/- net - - The author's primary object has been to produce a handbook of - _surgical therapeutics_. But surgical therapeutics does not mean - merely the technique of operation. Technique is, and should be, - only a part of surgery, especially at the present time. The - purely operative surgeon is a very incomplete surgeon in time - of peace; "in time of war he becomes a public disaster; for - operation is only the first act of the first dressing." - - - Vol. II.--"Fractures of the Shaft." With 156 illustrations from - original and specially prepared drawings. Price 6/- net - - Vol. I. of this work was devoted to _Fractures Involving - Joints_; Vol. II. (which completes the work) treats of - _Fractures of the Shaft_, and is conceived in the same - spirit--that is, with a view to the production of a work on - _conservative surgical therapeutics_. - - The author strives on every page to develop the idea - that anatomical conservation must not be confounded with - functional conservation. The two things are not so closely - allied as is supposed. There is no conservative surgery - save where the function is conserved. The essential point - of the treatment of diaphysial fractures consists in the - early operative disinfection, primary or secondary, by an - extensive sub-periosteal removal of fragments, based on exact - physiological knowledge, and in conformity with the general - method of treating wounds by excision. When this operation has - been carefully performed with the aid of the rugine, with the - object of separating and retaining the periosteum of all that - the surgeon considers should be removed, the fracture must be - correctly reduced and the limb immobilised. - - - FRACTURE OF THE LOWER JAW. By L. Imbert, National Correspondent of the - Société de Chirurgie, and Pierre Réal, Dentist to the Hospitals of - Paris. With a Preface by Medical Inspector-General Février. Edited by - J. F. Colyer, F.R.C.S., L.R.C.P., L.D.S. With 97 illustrations in the - text and five full-page plates. Price 6/- net - - Previous to the present war no stomatologist or surgeon - possessed any very extensive experience of this subject. Claude - Martin, of Lyons, who perhaps gave more attention to it than - anyone else, aimed particularly at the restoration of the - occlusion of teeth, even at the risk of obtaining only fibrous - union of the jaw. The authors of the present volume take the - contrary view, maintaining the consolidation of the fracture - is above all the result to be attained. The authors give a - clear account of the various displacements met with in gunshot - injuries of the jaw and of the methods of treatment adopted, the - latter being very fully illustrated. - - _The cost of postage per volume is: Inland 5d.; Abroad 8d._ - - - LONDON: UNIVERSITY OF LONDON PRESS, LTD., - 18, WARWICK SQUARE, E.C.4 - - - - - MILITARY MEDICAL MANUALS - - THE SPECTATOR: "For our physicians and surgeons on active - service abroad or in military hospitals at home these are the - very books for them to dip into, if not to read through." - - - FRACTURES OF THE ORBIT AND INJURIES OF THE EYE IN WAR. By Felix - Lagrange, Professor in the Faculty of Medicine, Bordeaux. Translated - by Herbert Child, Captain R.A.M.C. Edited by J. Herbert Parsons, - D.Sc., F.R.C.S., Temp. Captain R.A.M.C. With 77 illustrations in the - text and six full-page plates. Price 6/- net - - Grounding his remarks on a considerable number of observations, - Professor Lagrange arrives at certain conclusions which at - many points contradict or complete what we have hitherto - believed concerning the fractures of the orbit: for instance, - that traumatisms of the skull caused by fire-arms produce, on - the vault of the orbit, neither fractures by irradiation nor - independent fractures; that serious lesions of the eye may often - occur when the projectile has passed at some distance from it. - There are, moreover, between the seat of these lesions (due - to concussion or contact) on the one hand, and the course of - the projectile on the other hand, constant relations which are - veritable clinical _laws_, the exposition of which is a highly - original feature in this volume. - - - HYSTERIA OR PITHIATISM, AND REFLEX NERVOUS DISORDERS. By J. Babinski, - Member of the French Academy of Medicine, and J. Froment, Assistant - Professor and Physician to the Hospitals of Lyons. Edited with a - Preface by E. Farquhar Buzzard, M.D., F.R.C.P., Captain R.A.M.C.(T.), - etc. With 37 illustrations in the text and eight full-page plates. - Price 6/- net - - The number of soldiers affected by hysterical disorders is - great, and many of them have been immobilized for months - in hospital, in the absence of a correct diagnosis and the - application of a treatment appropriate to their case. A precise, - thoroughly documented work on hysteria, based on the numerous - cases observed during two years of war, was therefore a - necessity under present conditions. Moreover, it was desirable, - after the discussions and the polemics of which this question - has been the subject, to inquire whether we ought to return to - the old conception, or whether, on the other hand, we might not - finally adopt the modern conception which refers hysteria to - pithiatism. - - - WOUNDS OF THE SKULL AND THE BRAIN. Clinical forms and medico-surgical - treatment. By C. Chatelin and T. De Martel. With a Preface by the - Professor Pierre Marie. Edited by F. F. Burghard, C.B., M.S., - F.R.C.S., formerly Consulting Surgeon to the Forces in France. With 97 - illustrations in the text and two full-page plates. Price 7/6 net - - Of all the medical works which have appeared during the war, - this is certainly one of the most original, both in form and - in matter. It is, at all events, one of the most individual. - The authors have preferred to give only the results of their - own experience, and if their conclusions are not always in - conformity with those generally accepted, this, as Professor - Pierre Marie states in his preface, is because important - advances have been made during the last two years; and of this - the publication of this volume is the best evidence. - - _The cost of postage per volume is: Inland 5d.; Abroad 8d._ - - - LONDON: UNIVERSITY OF LONDON PRESS, LTD., - 18, WARWICK SQUARE, E.C.4 - - - - - MILITARY MEDICAL MANUALS - - From THE TIMES: "A series of really first-rate manuals of - medicine and surgery ... the translations are admirably made. - They give us in English that clearness of thought and that - purity of style which are so delightful in French medical - literature and are as good in form as in substance." - - - LOCALISATION AND EXTRACTION OF PROJECTILES. By Assistant Professor - Ombrédanne, of the Faculty of Medicine, Paris, and M. Ledoux-Lebard, - Director of the Laboratory of Radiology of the Hospitals of Paris. - Edited by A. D. Reid, C.M.G., M.R.C.S., L.R.C.P., Major (Temp.) - R.A.M.C. With a Preface on Extraction of the Globe of the Eye, by - Colonel W. T. Lister, C.M.G.. With 225 illustrations in the text and - 30 full-page photographs. Price 10/6 net - - This volume appeals to surgeons no less than to radiologists. - It is a summary and statement of all the progress effected by - surgery during the last two and a half years. MM. Ombrédanne and - Ledoux-Lebard have not, however, attempted to describe all the - methods in use, whether old or new. They have rightly preferred - to make a critical selection, and--after an exposition of all - the indispensable principles of radiological physics--they - examine, in detail, all those methods which are typical, - convenient, exact, rapid, or interesting by reason of their - originality: the technique of localisation, the compass, and - various adjustments and forms of apparatus. - - - WOUNDS OF THE ABDOMEN. By G. Abadie (of Oran), National Correspondent - of the Société de Chirurgie. With a Preface by Dr. J. L. Faure. Edited - by Sir Arbuthnot Lane, Bart., C.B., M.S., Colonel (Temp.), Consulting - Surgeon to the Forces in England. With 67 illustrations in the text - and four full-page plates. Price 7/6 net - - Dr. Abadie has been enabled, at all the stations of the - army service departments, to weigh the value of methods and - results, and considers the following problems in this volume: - (1) How to decide _what is the best treatment_ in the case - of penetrating wounds of the abdomen; (2) How to install the - _material organisation_ which permits of the application of this - treatment, and how to recognise those conditions which prevent - its application; (3) How to decide _exactly what to do in each - special_ case--whether one should perform a radical operation, - or a palliative operation, or whether one should resort to - medical treatment. - - - WOUNDS OF THE BLOOD-VESSELS. By L. Sencert, Assistant Professor in - the Faculty of Medicine, Nancy. Edited by F. F. Burghard, C.B., M.S., - F.R.C.S., formerly Consulting Surgeon to the Forces in France. With 68 - illustrations in the text and two full-page plates. Price 6/- net - - Hospital practice had long familiarised us with the vascular - wounds of civil practice, and the experiments of the - Val-de-Grâce School of Medicine had shown us what the wounds - of the blood-vessels caused by modern projectiles would be in - the next war. But in 1914 these data lacked the ratification - of extensive practice. Two years have elapsed, and we have - henceforth solid foundations on which to establish our - treatment. In a first part, Professor Sencert examines the - wounds of the great vessels in general; in a second part he - rapidly surveys the wounds of vascular trunks in particular, - insisting on the problems of operation to which they give rise. - - _The cost of postage per volume is: Inland 5d.; Abroad 8d._ - - - LONDON: UNIVERSITY OF LONDON PRESS, LTD., - 18, WARWICK SQUARE, E.C.4 - - - - - MILITARY MEDICAL MANUALS - - GLASGOW HERALD: "The whole series is heartily commended to the - attention and study of all who are interested in and responsible - for the treatment of the injuries and diseases of a modern war." - - - THE AFTER-EFFECTS OF WOUNDS OF THE BONES AND JOINTS. By Aug. Broca, - Professor of Topographical Anatomy in the Faculty of Medicine, - Paris. Translated by J. Renfrew White, M.B., F.R.C.S., Temp. Captain - R.A.M.C., and edited by R. C. Elmslie, M.S., F.R.C.S.; Orthopædic - Surgeon to St. Bartholomew's Hospital, and Surgeon to Queen Mary's - Auxiliary Hospital, Roehampton; Major R.A.M.C.(T.) With 112 - illustrations in the text. Price 6/- net - - This new work, like all books by the same author, is a vital and - personal work, conceived with a didactic intention. At a time - when all physicians are dealing, or will shortly have to deal, - with the after-effects of wounds received in war, the question - of sequelae presents itself, and will present itself more and - more. What has become--and what will become--of all those who, - in the hospitals at the front or in the rear, have hastily - received initial treatment, and what is to be done to complete a - treatment often inaugurated under difficult circumstances? - - - ARTIFICIAL LIMBS. By A. Broca, Professor in the Faculty of Medicine, - Paris, and Dr. Ducroquet, Surgeon at the Rothschild Hospital. Edited - and translated by R. C. Elmslie, M.S., F.R.C.S., etc.; Orthopædic - Surgeon to St. Bartholomew's Hospital, and Surgeon to Queen Mary's - Auxiliary Hospital, Roehampton; Major R.A.M.C.(T.). With 210 - illustrations. Price 6/- net - - The authors of this book have sought not to describe this or - that piece of apparatus--more or less "newfangled"--but to - explain the anatomical, physiological, practical and technical - conditions which an artificial arm or leg _should_ fulfil. - It is, if we may so call it, a manual of _applied mechanics_ - written by physicians, who have constantly kept in mind the - anatomical conditions and the professional requirements of the - artificial limb. - - - TYPHOID FEVERS AND PARATYPHOID FEVERS (Symptomatology, Etiology, - Prophylaxis). By H. Vincent, Medical Inspector of the Army, Member - of the Academy of Medicine, and L. Muratet, Superintendent of the - Laboratories at the Faculty of Medicine of Bordeaux. Second Edition. - Translated and Edited by J. D. Rolleston, M.D. With tables and - temperature charts. Price 6/-net - - This volume is divided into two parts, the first dealing with - the clinical features and the second with the epidemiology - and prophylaxis of typhoid fever and paratyphoid fevers A and - B. A full account is to be found of recent progress in the - bacteriology and epidemiology of these diseases, considerable - space being given to the important question of the carrier in - the dissemination of infection. - - _The cost of postage per volume is: Inland 5d.; Abroad 8d._ - - - LONDON: UNIVERSITY OF LONDON PRESS, LTD., - 18, WARWICK SQUARE, E.C.4 - - - - - MILITARY MEDICAL MANUALS - - From THE LANCET: "The names of the editors are sufficient - guarantee that the subject matter is treated with fairness and - discrimination." - - - DYSENTERIES, CHOLERA, AND EXANTHEMATIC TYPHUS. By H. Vincent, Medical - Inspector of the Army, Member of the Academy of Medicine, and L. - Muratet, Superintendent of the Laboratories at the Faculty of Medicine - of Bordeaux. With an Introduction by Andrew Balfour, C.B., C.M.G., - M.D., Lieut.-Col. R.A.M.C. Edited by George C. Low, M.A., M.D., Temp. - Capt. I.M.S. Price 6/- net - - This, the second of the volumes which Professor Vincent and - Dr. Muratet have written for this series, was planned, like - the first, in the laboratory of Val-de-Grâce, and has profited - both by the personal experience of the authors and by a mass - of recorded data which the latter years of warfare have very - greatly enriched. It will be all the more welcome, as hitherto - there has existed no comprehensive handbook treating these great - epidemic diseases from a didactic point of view. - - - ABNORMAL FORMS OF TETANUS. By MM. Courtois-Suffit, Physician of the - Hospitals of Paris, and R. Giroux, Resident Professor. With a Preface - by Professor F. Widal. Edited by Surgeon-General Sir David Bruce, - K.C.B., F.R.S., LL.D., F.R.C.P., etc., and Frederick Golla, M.B. - Price 6/- net - - Of all the infections which threaten our wounded men, tetanus is - that which, thanks to serotherapy, we are best able to prevent. - But serotherapy, when it is late and insufficient, may, on - the other hand, tend to create a special type of attenuated - and localised tetanus; in this form the contractions are as a - general rule confined to a single limb. This type, however, - does not always remain strictly monoplegic; and if examples - of such cases are rare this is doubtless because physicians - are not as yet very well aware of their existence. We owe to - MM. Courtois-Suffit and R. Giroux one of the first and most - important observations of this new type; so that no one was - better qualified to define its characteristics. This they - have done in a remarkable manner, supporting their remarks by - all the documents hitherto published, first expounding the - characteristics which individualise the other atypical and - partial types of tetanus, which have long been recognised. - - - WAR OTITIS AND WAR DEAFNESS. Diagnosis, Treatment, Medical Reports. - By Dr. H. Bourgeois, Oto-rhino-laryngologist to the Paris Hospitals, - and Dr. Sourdille, former interne of the Paris Hospitals. Edited by J. - Dundas Grant, M.D., F.R.C.S.(Eng.); Major R.A.M.C., President, Special - Aural Board (under Ministry of Pensions). With many illustrations in - the text and full-page plates. Price 6/- net - - This work presents the special aspects of inflammatory - affections of the ear and deafness, as they occur in active - military service. The instructions as to diagnosis and treatment - are intended primarily for the regimental medical officer. The - sections dealing with medical reports (_expertises_) on the - valuation of degrees of disablement and claims to discharge, - gratuity or pension, will be found of the greatest value to the - officers of invaliding boards. - - _The cost of postage per volume is: Inland 5d.; Abroad 8d._ - - - LONDON: UNIVERSITY OF LONDON PRESS, LTD., - 18, WARWICK SQUARE, E.C.4 - - - - - MILITARY MEDICAL MANUALS - - GUY'S HOSPITAL GAZETTE: "The series is a most valuable addition - to the medical literature of the war.... We deem it to be almost - indispensable to a medical officer, and have no hesitation in - unreservedly recommending it." - - - SYPHILIS AND THE ARMY. By G. Thibierge, Physician of the Hôpital - Saint-Louis. Edited by C. F. Marshall, F.R.C.S. Price 6/- net - - It seemed, with reason, to the editors of this series that - room should be found in it for a work dealing with syphilis - considered with reference to the army and the present war. The - frequency of this infection in the army, among the workers in - munition factories, and in the midst of the civil population - where this is in contact with soldiers and mobilised workers, - makes it, at the present time, a true epidemic disease, and one - of the most widespread of epidemic diseases. Dr. Thibierge, - whose previous labours guarantee his peculiar competence in - these difficult and important questions, has, in writing this - manual, very notably assisted in this work. But the treatment of - syphilis has, during the last six years, undergone considerable - modifications; the new methods are not yet very familiar to all - physicians; and certain details may no longer be present to - their minds. It was therefore opportune to survey the different - methods of treatment, to specify their indications, and their - occasionally difficult technique, which is always important if - complications are to be avoided. It was necessary before all - to state precisely and to retrace, for all those who have been - unable to follow the recent progress of the therapeutics of - venereal diseases, the characters and the diagnostic elements of - the manifestations of syphilis. - - - MALARIA IN MACEDONIA: Clinical and Hæmatological Features. Principles - of Treatment. By P. Armand-Delille, P. Abrami, G. Paisseau and Henri - Lemaire. Preface by Professor Lavern, Membre de l'Institut. Edited by - Sir Ronald Ross, K.C.B., F.R.S., LL.D., D.Sc., Lieut.-Col. R.A.M.C. - With illustrations and a coloured plate. Price 6/- net - - This work is based on the writers' observations on malaria in - Macedonia during the present war in the French Army of the - East. A special interest attaches to these observations, in - that a considerable portion of their patients had never had any - previous attack. The disease proved to be one of exceptional - gravity, owing to the exceptionally large numbers of the - Anopheles mosquitoes and the malignant nature of the parasite - (Plasmodium falciparum). Fortunately an ample supply of quinine - enabled the prophylactic and curative treatment to be better - organised than in previous colonial campaigns, with the result - that, though the incidence of malaria among the troops was high, - the mortality was exceptionally low. Professor Laveran, who - vouches for this book, states that it will be found to contain - excellent clinical descriptions and judicious advice as to - treatment. Chapters on parasitology and the laboratory diagnosis - of malaria are included. - - An early announcement will be made in regard to further volumes under - consideration. - - _The cost of postage per volume is: Inland 5d.; Abroad 8d._ - - - LONDON: UNIVERSITY OF LONDON PRESS, LTD., - 18, WARWICK SQUARE, E.C.4 - - -Transcriber's Note: - -1. All obvious spelling and punctuation errors have been corrected. - -2. 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You may copy it, give it away or re-use it under the terms of -the Project Gutenberg License included with this eBook or online at -www.gutenberg.org. If you are not located in the United States, you'll have -to check the laws of the country where you are located before using this ebook. - - - -Title: Artificial Limbs - -Author: Auguste Broca - Charles Ducroquet - -Editor: Reginald Cheyne Elmslie - -Translator: Reginald Cheyne Elmslie - -Release Date: October 13, 2017 [EBook #55739] - -Language: English - -Character set encoding: ISO-8859-1 - -*** START OF THIS PROJECT GUTENBERG EBOOK ARTIFICIAL LIMBS *** - - - - -Produced by deaurider, Karin Spence and the Online -Distributed Proofreading Team at http://www.pgdp.net (This -file was produced from images generously made available -by The Internet Archive) - - - - - - -</pre> - - - - -<p><span class="pagenum"><a name="Page_i" id="Page_i">[i]</a></span></p> - -<p class="center p6">MILITARY MEDICAL MANUALS</p> -<p class="center smcap sm p2">General Editor:</p> -<p class="center">SIR ALFRED KEOGH, G.C.B., M.D., F.R.C.P.</p> - - -<p id="half-title" class="center p4">ARTIFICIAL LIMBS</p> - -<div class="chapter"> - -<p><span class="pagenum"><a name="Page_iii" id="Page_iii">[iii]</a></span></p> - -<h1 class="p4">ARTIFICIAL LIMBS</h1></div> - -<p class="center p4 sm">BY</p> - -<table class="w50" summary=""> - <tr> - <td class="ctrlgleft">A. BROCA</td> - <td class="ctrsm1 xs"><i>AND</i></td> - <td class="ctrlgright">DUCROQUET</td> - </tr> - <tr> - <td class="ctrsm"><i>Professor of Topographical Anatomy</i></td> - <td></td> - <td class="ctrsm"><i>Orthopædic Surgeon to the</i></td> - </tr> - <tr> - <td class="ctrsm"><i>to the Faculty of Paris</i></td> - <td></td> - <td class="ctrsm"><i>Rothschild Hospital</i></td> - </tr> -</table> - -<p class="center p3 xs">TRANSLATED AND EDITED BY</p> - -<p class="center bold">R. C. ELMSLIE, M.S., F.R.C.S.</p> - -<p class="center xs"><i>Major R.A.M.C.(T.F.)<br /> -Orthopædic Surgeon to St. Bartholomew's Hospital, Surgeon to<br /> -Queen Mary's Hospital, Roehampton</i></p> - -<p class="center p4 sm"><i>WITH 208 ILLUSTRATIONS</i></p> - -<p class="center p4 bold">UNIVERSITY OF LONDON PRESS, <span class="smcap">Ltd.</span></p> -<p class="center sm bold">18 WARWICK SQUARE, LONDON, E.C. 4.</p> - -<p class="center p1 bold">PARIS: MASSON ET CIE</p> -<p class="center sm bold">120 BOULEVARD SAINT-GERMAIN</p> - -<p class="center p1 bold">1918</p> - -<div class="chapter"> - -<p><span class="pagenum"><a name="Page_v" id="Page_v">[v]</a></span></p> - -<h2 class="p4">GENERAL INTRODUCTION</h2></div> - -<p>The infinite variety of injuries which any war presents to the surgeon -gives to military surgery a special interest and importance. The -special interest and importance, in a surgical sense, of the great -European War lies not so much in the fact that examples of every form -of gross lesion of organs and limbs have been seen, for if we read -the older writers we find little in the moderns that is new in this -respect, but is to be found in the enormous mass of clinical material -which has been presented to us and in the production of evidence -sufficient to eliminate sources of error in determining important -conclusions. For the first time also in any campaign the labours of -the surgeon and the physician have had the aid of the bacteriologist, -the pathologist, the physiologist and indeed of every form of -scientific assistance in the solution of their respective problems. -The clinician entered upon the great war armed with all the resources -which the advances of fifty years had made available. If the surgical -problems of modern war can be said not to differ sensibly from the -campaigns of the past, the form in which they have been presented -is certainly as different as are the methods of their solution. The -achievements in the field of discovery of the chemist, the physicist -and the biologist have given the military surgeon an advantage in -diagnosis and treatment which was denied to his predecessors, and we -are able to measure the effects of these advantages when we come to -appraise the results which have been attained.</p> - -<p>But although we may admit the general truth of these statements it -would be wrong to assume that modern scientific knowledge was, on the -outbreak of the war, immediately useful to those to whom the<span class="pagenum"><a name="Page_vi" id="Page_vi">[vi]</a></span> wounded -were to be confided. Fixed principles existed in all the sciences -auxiliary to the work of the surgeon, but our scientific resources -were not immediately available at the outset of the great campaign; -scientific work bearing on wound problems had not been arranged in a -manner adapted to the requirements, indeed the requirements were not -fully foreseen; the workers in the various fields were isolated, or -isolated themselves pursuing new researches rather than concentrating -their powerful forces upon the one great quest.</p> - -<p>However brilliant the triumphs of surgery may be, and that they have -been of surpassing splendour no one will be found to deny, experiences -of the war have already produced a mass of facts sufficient to suggest -the complete remodelling of our methods of education and research.</p> - -<p>The series of manuals, which it is my pleasant duty to introduce to -English readers, consists of translations of the principal volumes of -the "Horizon" Collection which has been appropriately named after the -uniform of the French soldier.</p> - -<p>The authors, who are well-known specialists in the subjects which they -represent, have given a concise but eminently readable account of -the recent acquisitions to the medicine and surgery of war which had -hitherto been disseminated in periodical literature.</p> - -<p>No higher praise can be given to the Editors than to say that the -clearness of exposition characteristic of the French original has not -been lost in the rendering into English.</p> - - -<h3>MEDICAL SERIES</h3> - -<p>The medical volumes which have been translated for this series may be -divided into two main groups, the first dealing with certain epidemic -diseases including syphilis, which are most liable to attack soldiers, -and the second with various aspects of the neurology of war. The last -word on <i>Typhoid Fever</i>, hitherto "the greatest scourge of armies -in time of war," as<span class="pagenum"><a name="Page_vii" id="Page_vii">[vii]</a></span> it has been truly called, will be found in the -monograph by MM. Vincent and Muratet which contains a full account -of recent progress in bacteriology and epidemiology as well as the -clinical features of typhoid and paratyphoid fevers. The writers -combat a belief in the comparatively harmless nature of paratyphoid -and state that in the present war hæmorrhage and perforation have been -as frequent in paratyphoid as in typhoid fever. In their chapter on -diagnosis they show that the serum test is of no value in the case of -those who have undergone anti-typhoid or anti-paratyphoid vaccination -and that precise information can be gained by blood cultures only. The -relative advantages of a restricted and liberal diet are discussed -in the chapter on treatment, which also contains a description of -serum-therapy and vaccine-therapy and the general management of the -patient.</p> - -<p>Considerable space is devoted to the important question of the -carrier of infection. A special chapter is devoted to the prophylaxis -of typhoid fever in the army. The work concludes with a chapter on -preventive inoculation in which its value is conclusively proved by -the statistics of all countries in which it has been employed.</p> - -<p>MM. Vincent and Muratet have also contributed to the series a work -on <i>Dysentery, Cholera and Typhus</i> which will be of special interest -to those whose duties take them to the Eastern Mediterranean or -Mesopotamia. The carrier problem in relation to dysentery and cholera -is fully discussed, and special stress is laid on the epidemiological -importance of mild or abortive cases of these two diseases.</p> - -<p>In their monograph on <i>The Abnormal Forms of Tetanus</i>, MM. -Courtois-Suffit and Giroux treat of those varieties of the disease in -which the spasm is confined to a limited group of muscles, <i>e. g.</i> -those of the head, or one or more limbs, or of the abdomino-thoracic -muscles. The constitutional symptoms are less severe than in the -generalised form of the disease, and the prognosis is more favourable.</p> - -<p><span class="pagenum"><a name="Page_viii" id="Page_viii">[viii]</a></span></p> - -<p>The volume by Dr. G. Thilbierge on <i>Syphilis in the Army</i> is intended -as a <i>vade-mecum</i> for medical officers in the army.</p> - -<p>Turning now to works of neurological interest we have two volumes -dealing with lesions of the peripheral nerves by Mme. Atanassio -Benisty, who has been for several years assistant to Professor Pierre -Marie at La Salpêtrière. The first volume contains an account of the -anatomy and physiology of the peripheral nerves, together with the -symptomatology of their lesions. The second volume is devoted to the -prognosis and treatment of nerve lesions.</p> - -<p>The monograph of MM. Babinski and Froment on <i>Hysteria or Pithiatism -and Nervous Disorders of a Reflex Character</i> next claims attention. In -the first part the old conception of hysteria, especially as it was -built up by Charcot, is set forth, and is followed by a description of -the modern conception of hysteria due to Babinski, who has suggested -the substitution of the term "Pithiatism," <i>i. e.</i> a state curable -by persuasion, for the old name hysteria. The second part deals with -nervous disorders of a reflex character, consisting of contractures -or paralysis following traumatism, which are frequently found in the -neurology of war, and a variety of minor symptoms, such as muscular -atrophy, exaggeration of the tendon reflexes, vasomotor, thermal and -secretory changes, etc. An important section discusses the future of -such men, especially as regards their disposal by medical boards.</p> - -<p>An instructive companion volume to the above is to be found in the -monograph of MM. Roussy and Lhermitte, which embodies a description of -the psychoneuroses met with in war, starting with elementary motor -disorders and concluding with the most complex represented by pure -psychoses.</p> - - -<h3>SURGICAL SERIES</h3> - -<p>When the present war began, surgeons, under the influence of the -immortal work of Lister, had for more than a quarter of a century -concerned themselves<span class="pagenum"><a name="Page_ix" id="Page_ix">[ix]</a></span> almost exclusively with elaborations of -technique designed to shorten the time occupied in or to improve the -results obtained by the many complex operations that the genius of -Lister had rendered possible. The good behaviour of the wound was -taken for granted whenever it was made, as it nearly always was, -through unbroken skin, and hence the study of the treatment of wounds -had become largely restricted to the study of the aseptic variety. -Septic wounds were rarely seen, and antiseptic surgery had been -almost forgotten. Very few of those who were called upon to treat the -wounded in the early autumn of 1914 were familiar with the treatment -of grossly septic compound fractures and wounded joints, and none had -any wide experience. To these men the conditions of the wounds came as -a sinister and disheartening revelation. They were suddenly confronted -with a state of affairs, as far as the physical conditions in the -wounds were concerned, for which it was necessary to go back a hundred -years or more to find a parallel.</p> - -<p>Hence the early period of the war was one of earnest search after -the correct principles that should be applied to the removal of the -unusual difficulties with which surgeons and physicians were faced. It -was necessary to discover where and why the treatment that sufficed -for affections among the civil population failed when it was applied -to military casualties, and then to originate adequate measures -for the relief of the latter. For many reasons this was a slow and -laborious process, in spite of the multitude of workers and the wealth -of scientific resources at their disposal. The ruthlessness of war -must necessarily hamper the work of the medical scientist in almost -every direction except in that of providing him with an abundance of -material upon which to work. It limits the opportunity for deliberate -critical observation and comparison that is so essential to the -formation of an accurate estimation of values; it often compels -work to be done under such high pressure and such unfavourable -conditions that it becomes of little value for<span class="pagenum"><a name="Page_x" id="Page_x">[x]</a></span> educative purposes. -In all the armies, and on all the fronts, the pressure caused by the -unprecedented number of casualties has necessitated rapid evacuation -from the front along lines of communication, often of enormous -length, and this means the transfer of cases through many hands, with -its consequent division of responsibility, loss of continuity of -treatment, and absence of prolonged observation by any one individual.</p> - -<p>In addition to all this, it must be remembered that in this war the -early conditions at the front were so uncertain that it was impossible -to establish there the completely equipped scientific institutions for -the treatment of the wounded that are now available under more assured -circumstances, and that progress was thereby much hampered until -definitive treatment could be undertaken at the early stage that is -now possible.</p> - -<p>But order has been steadily evolved out of chaos and many things are -now being done at the front that would have been deemed impossible not -many months ago. As general principles of treatment are established -it is found practicable to give effect to them to their full logical -extent, and though there are still many obscure points to be -elucidated and many methods in use that still call for improvements, -it is now safe to say that the position of the art of military -medicine and surgery stands upon a sound foundation, and that its -future may be regarded with confidence and sanguine expectation.</p> - -<p>The views of great authorities who derive their knowledge from -extensive first-hand practical experience gained in the field, cannot -fail to serve as a most valuable asset to the less experienced, and -must do much to enable them to derive the utmost value from the -experience which will, in time, be theirs. The series covers the whole -field of war surgery and medicine, and its predominating note is the -exhaustive, practical and up-to-date manner in which it is handled. It -is marked throughout not only by a<span class="pagenum"><a name="Page_xi" id="Page_xi">[xi]</a></span> wealth of detail, but by clearness -of view and logical sequence of thought. Its study will convince the -reader that, great as have been the advances in all departments in -the services during this war, the progress made in the medical branch -may fairly challenge comparison with that in any other, and that not -the least among the services rendered by our great Ally, France, to -the common cause is this brilliant contribution to our professional -knowledge.</p> - -<p>A glance at the list of surgical works in the series will show how -completely the ground has been covered. Appropriately enough, the -series opens with the volume on <i>The Treatment of Infected Wounds</i>, -by A. Carrel and G. Dehelly. This is a direct product of the war -which, in the opinion of many, bids fair to become epoch-making -in the treatment of septic wounds. It is peculiar to the war and -derived directly from it, and the work upon which it is based is as -fine an example of correlated work on the part of the chemist, the -bacteriologist and the clinician as could well be wished for. This -volume will show many for the first time what a precise and scientific -method the "Carrel treatment" really is.</p> - -<p>The two volumes by Prof. Leriche on <i>Fractures</i> contain the practical -application of the views of the great Lyons school of surgeons with -regard to the treatment of injuries of bones and joints. Supported -as they are by an appeal to an abundant clinical experience, they -cannot fail to interest English surgeons, and to prove of the greatest -value. It is only necessary to say the <i>Wounds of the Abdomen</i> are -dealt with by Dr. Abadie, <i>Wounds of the Vessels</i> by Prof. Sencert, -<i>Wounds of the Skull and Brain</i> by MM. Chatelin and De Martel, and -<i>Localisation and Extraction of Projectiles</i> by Prof. Ombredanné and -R. Ledoux-Lebard, to prove that the subjects have been allotted to -very able and experienced exponents.</p> - -<p class="smcap r1">Alfred Keogh.</p> - -<hr class="chap" /> - -<div class="chapter"> - -<p><span class="pagenum"><a name="Page_xiii" id="Page_xiii">[xiii]</a></span></p> - -<h2>PREFACE</h2></div> - -<p>No attempt is made in this little book to describe all the artificial -limbs and appliances that have been invented. Before the war these -were very numerous, since then their number has become countless, and -not a day passes without the appearance of some new model of greater -or less ingenuity.</p> - -<p>But all these special inventions, the utility of which we should not -think of denying, are only of real practical value if the makers have -followed out certain general principles in their manufacture. In the -following pages we have attempted to indicate what these principles -are.</p> - -<p>Our experience has been gained in connection with the <i>Fédération -des Mutilés</i>, where hundreds of disabled men have been examined and -fitted, and where we have always tried to give to each that appliance -which is best suited to his work.</p> - -<p>For this indeed is the vital principle, and great disappointments -will result if, for æsthetic reasons, every patient is given the same -appliance, whether it be the leg known as the American leg or an -elaborate artificial arm. More often than might be believed accurate -imitation of the external form of the natural limb is incompatible -with good functional use. This is particularly so in the upper limb.</p> - -<p>Perhaps the readers of these pages will gain a clear understanding of -these principles; and we shall have attained our object if by enabling -them to understand certain typical appliances we make it possible for -them to devise others which are at the same time strong, shapely and -practical.</p> - -<p>Throughout the volume it will be found that we<span class="pagenum"><a name="Page_xiv" id="Page_xiv">[xiv]</a></span> express a preference -for the construction of artificial limbs for the lower limb out of -wood, the method adopted by the Americans. This procedure, because -strength and durability are so necessary, seems to us to constitute -a very real advance; these considerations are, however, of much -less importance in the case of the upper limb. It is a matter for -regret that the French official instructions have not compelled our -manufacturers to adopt this technique, too often the latter are -inclined to keep to their old routine, but they can be induced to -alter it, as we have proved by our success at the <i>Fédération des -Mutilés</i>.</p> - -<p>There is nothing revolutionary in such a suggestion. It has been -adopted by the Belgian Government in the fitting centres which they -have established; this is also the case with the English authorities, -who, we understand, have even attracted from America special fitters -for this work. We should have thought that we, in France, might -have developed our national supply of artificial limbs in the same -direction.</p> - -<hr class="chap" /> - -<div class="chapter"> - -<p><span class="pagenum"><a name="Page_xv" id="Page_xv">[xv]</a></span></p> - -<h2>INTRODUCTION TO THE ENGLISH EDITION</h2></div> - -<p>The details of the manufacture of artificial limbs naturally differ -greatly in different countries. So much so that at first sight it -might appear useless to introduce into England and America the -account given in this work of the methods adopted in France. But, -as the authors state in their preface, the principles remain the -same whatever the details of the methods used. In the lower limb the -essentials to be studied are the points upon which weight can be -taken, the "Bearing Points," the proper method of fitting the stump, -the principles of securing stability and the mechanism of the knee and -ankle joints. These remain unalterable whatever be the material used -and whatever be the details of manufacture.</p> - -<p>In England it has for a long time been understood that every sailor -or soldier who has lost a limb has the right to expect that he will -be supplied with a good artificial substitute. And, further, it has -been taken for granted that this will, in the case of the lower limb, -be a full artificial leg and not a peg leg. Therefore the standard -pattern has in England been a full limb, and the peg has only been -supplied as a temporary appliance, and as an alternative appliance to -be used when the other limb requires alteration or repair. For this -reason the possibilities of the peg leg, except in its simplest form, -have perhaps been neglected in this country, and a study of the French -methods of making these peg legs, particularly the convertible peg -leg, is well worth while.</p> - -<p>The introduction of American artificial legs into<span class="pagenum"><a name="Page_xvi" id="Page_xvi">[xvi]</a></span> this country has -not been so revolutionary in its results as it is apparently in -France, for we have been accustomed for many years to make the bucket -out of a single piece of willow. The alterations in our methods -introduced recently from America are essentially the following—</p> - -<p>1. The use of a sling which passing over the shoulders is attached -to the leg below the knee in such a way as to act as a mechanism for -extending the knee.</p> - -<p>2. The manufacture of the leg portion out of a single piece of wood.</p> - -<p>3. The abolition of the old tendon action for the ankle joint (which -resembled the mechanism described on <a href="#Page_57">page 57</a>) and its replacement by -the ankle with movement limited by indiarubber buffers.</p> - -<p>4. Covering the wooden part of the limb with a layer of raw hide or -parchment, which certainly adds to the strength.</p> - -<p>The sole remaining problem in the design of artificial legs appears -to be the invention of a knee mechanism which will lock in any degree -of flexion when a strain is put upon it, so that the wearer does not -necessarily fall when his weight comes upon the limb with the knee -flexed. A recent invention, still on its trial, seems to indicate that -this problem is not incapable of solution.</p> - -<p>In artificial arms the differences between the French and English -patterns are greater than in artificial legs. But here again the -principles remain the same. In England, also, we have <i>worker's arms</i> -and <i>show arms</i>, but the latter tend to be more elaborate than the -French patterns, mechanical movements being more developed. For this -reason this pattern is usually called, in England, the <i>mechanical -arm</i>. Instead of the single cord, looped round the opposite shoulder, -and used to open the spring thumb (see <a href="#Page_101">p. 101</a>), at least three such -cords are used, actuated (1) by rounding the back; (2) by expanding -the upper part of the chest, and (3) by raising or lowering the -shoulder<span class="pagenum"><a name="Page_xvii" id="Page_xvii">[xvii]</a></span> on the side of the amputation. These may be used for various -purposes, of which the chief are (1) flexing the artificial elbow; -(2) working the elbow lock, and (3) actuating the thumb, fingers or -appliances used instead of the hand. The chief other differences in -the methods adopted in England are—</p> - -<p>1. A smaller enclosure of the shoulder region for purposes of -suspension, the limb being held on by a harness of straps. We, in -fact, value mobility of the shoulder, and gain it at the expense of -stability.</p> - -<p>2. The use of various alternative patterns of elbow locks.</p> - -<p>3. The appliances used instead of the hand are very different in -pattern, although the principles for their construction remain as -described here by the authors.</p> - -<p>Much ingenuity has been expended on the design of mechanical -artificial hands, with results which are satisfactory so far as they -go, but which require much further development before the hand can -possibly replace even a few of the appliances which can be substituted -for it. For this reason it should be made an invariable rule that the -artificial hand, however ingenious and however apparently perfect it -may be, should be detachable, so that it may be replaced by other -appliances.</p> - -<p class="r1">R. C. E.</p> - -<hr class="chap" /> - -<div class="chapter"> - -<p><span class="pagenum"><a name="Page_xix" id="Page_xix">[xix]</a></span></p> - -<h2>CONTENTS</h2></div> - -<table class="toc" summary="Contents"> -<tr> - <th></th> - <th class="pag">PAGE</th> -</tr> -<tr> - <td class="cht">GENERAL INTRODUCTION</td> - <td class="pag"><a href="#Page_v">v</a></td> -</tr> -<tr> - <td class="chtsp">PREFACE</td> - <td class="pag"><a href="#Page_xiii">xiii</a></td> -</tr> -<tr> - <td class="chtsp">INTRODUCTION TO THE ENGLISH EDITION</td> - <td class="pag"><a href="#Page_xv">xv</a></td> -</tr> -<tr> - <td class="chap">CHAPTER I</td> -</tr> -<tr> - <td class="cht">GENERAL CONSTRUCTION OF AN ARTIFICIAL LIMB</td> - <td class="pag"><a href="#Page_1">1</a></td> -</tr> -<tr> - <td class="chap">CHAPTER II</td> -</tr> -<tr> - <td class="cht">GENERAL PRINCIPLES OF FITTING FOR THE LOWER LIMB</td> - <td class="pag"><a href="#Page_6">6</a></td> -</tr> -<tr> - <td class="chap">CHAPTER III</td> -</tr> -<tr> - <td class="cht">ARTIFICIAL LIMBS FOR AMPUTATIONS THROUGH THE THIGH</td> - <td class="pag"><a href="#Page_12">12</a></td> -</tr> -<tr> - <td class="cht1"> I. Apparatus with bearing upon the ischium</td> - <td class="pag"><a href="#Page_12">12</a></td> -</tr> -<tr> - <td class="cht2">1. The shape of the top of the bucket</td> - <td class="pag"><a href="#Page_13">13</a></td> -</tr> -<tr> - <td class="cht2">2. Mode of suspension</td> - <td class="pag"><a href="#Page_21">21</a></td> -</tr> -<tr> - <td class="cht2">3. Walking on a peg leg and similar appliances</td> - <td class="pag"><a href="#Page_28">28</a></td> -</tr> -<tr> - <td class="cht2">4. Walking with free flexion of the knee</td> - <td class="pag"><a href="#Page_33">33</a></td> -</tr> -<tr> - <td class="cht1">II. Limbs without bearing upon the ischium</td> - <td class="pag"><a href="#Page_60">60</a></td> -</tr> -<tr> - <td class="chap">CHAPTER IV</td> -</tr> -<tr> - <td class="cht">ARTIFICIAL LIMB FOR DISARTICULATION AT THE HIP JOINT</td> - <td class="pag"><a href="#Page_64">64</a></td> -</tr> -<tr> - <td class="chap">CHAPTER V</td> -</tr> -<tr> - <td class="cht">ARTIFICIAL LIMBS WITH FREE KNEE JOINT FOR AMPUTATION THROUGH THE LEG</td> - <td class="pag"><a href="#Page_66">66</a></td> -</tr> -<tr> - <td class="cht1"> I. Appliances with bearing upon the tuberosities of the tibia</td> - <td class="pag"><a href="#Page_67">67</a></td> -</tr> -<tr> - <td class="cht1">II. Appliances with end bearing only</td> - <td class="pag"><a href="#Page_77">77</a></td> -</tr> -<tr> - <td class="chap">CHAPTER VI<span class="pagenum"><a name="Page_xx" id="Page_xx">[xx]</a></span></td> -</tr> -<tr> - <td class="cht">PARTIAL AMPUTATIONS OF THE FOOT</td> - <td class="pag"><a href="#Page_81">81</a></td> -</tr> -<tr> - <td class="chap">CHAPTER VII</td> -</tr> -<tr> - <td class="cht">ARTIFICIAL LIMBS FOR AMPUTATION THROUGH THE FOREARM</td> - <td class="pag"><a href="#Page_84">84</a></td> -</tr> -<tr> - <td class="cht1"> I. Points of attachment</td> - <td class="pag"><a href="#Page_85">85</a></td> -</tr> -<tr> - <td class="cht1"> II. Elbow joint</td> - <td class="pag"><a href="#Page_90">90</a></td> -</tr> -<tr> - <td class="cht1">III. The artificial hand and appliances</td> - <td class="pag"><a href="#Page_96">96</a></td> -</tr> -<tr> - <td class="cht3">A. The artificial hand</td> - <td class="pag"><a href="#Page_97">97</a></td> -</tr> -<tr> - <td class="cht3">B. Appliances for use in place of the hand</td> - <td class="pag"><a href="#Page_108">108</a></td> -</tr> -<tr> - <td class="chap">CHAPTER VIII</td> -</tr> -<tr> - <td class="cht">ARTIFICIAL LIMBS FOR AMPUTATION THROUGH THE ARM</td> - <td class="pag"><a href="#Page_129">129</a></td> -</tr> -<tr> - <td class="cht1"> I. Artificial arm</td> - <td class="pag"><a href="#Page_132">132</a></td> -</tr> -<tr> - <td class="cht1">II. Worker's arm</td> - <td class="pag"><a href="#Page_138">138</a></td> -</tr> -<tr> - <td class="chap">CHAPTER IX</td> -</tr> -<tr> - <td class="cht">ARTIFICIAL LIMBS FOR DISARTICULATION THROUGH - THE SHOULDER JOINT AND AMPUTATION - THROUGH THE DELTOID MUSCLE</td> - <td class="pag"><a href="#Page_143">143</a></td> -</tr> -<tr> - <td class="chap">CHAPTER X</td> -</tr> -<tr> - <td class="cht">SOME GENERAL PRINCIPLES IN THE RE-EDUCATION OF THE DISABLED</td> - <td class="pag"><a href="#Page_145">145</a></td> -</tr> -<tr> - <td class="chtsp">INDEX</td> - <td class="pag"><a href="#Page_159">159</a></td> -</tr> -</table> - -<hr class="chap" /> - -<div class="chapter"> - -<p><span class="pagenum"><a name="Page_1" id="Page_1">[1]</a></span></p> - -<p class="center xxl">ARTIFICIAL LIMBS</p> - -<h2><i>CHAPTER I</i></h2></div> - -<h3>GENERAL CONSTRUCTION OF AN ARTIFICIAL LIMB</h3> - -<p>A prosthetic apparatus for any amputation is composed of two parts:</p> - -<p>1. The artificial limb.</p> - -<p>2. The attachment of this limb to the trunk.</p> - -<p>The artificial limb itself is divided into two parts:</p> - -<p>1. A conical socket.</p> - -<p>2. A part which replaces the missing limb and is in fact a terminal -functional appliance.</p> - -<p>Two conditions must be considered, whether or not there remains -attached to the trunk a segment of the limb capable of being fitted -into the base of the artificial limb, to which it gives support, and -to which, in addition, it can communicate movement. Accordingly the -artificial limb differs essentially for:</p> - -<p>1. Disarticulation of the shoulder and of the hip.</p> - -<p>2. Amputation of the arm and of the thigh.</p> - -<p>In the first case we attach to the trunk an instrument which is -entirely passive.</p> - -<p>In the second we attempt to turn to account the active movements of -the stump.</p> - -<p>These various parts do not lend themselves to<span class="pagenum"><a name="Page_2" id="Page_2">[2]</a></span> a general description -applicable at once to the upper and lower limbs. Not only are -the modes of attachment and the functional artificial limb quite -different, but the bucket does not serve the same purposes.</p> - -<p><i>The position of the scar.</i>—The stump, which fits the bucket exactly, -transmits to it two kinds of force:</p> - -<p>1. The force of vertical pressure.</p> - -<p>2. Lateral force corresponding to the angular movements of the joint -above.</p> - -<p>The lateral force is transmitted by the whole of one surface of the -stump to the corresponding lateral surface of the bucket: by the -anterior and posterior surfaces only in the case of hinge joints such -as the elbow and the knee: by all surfaces in the case of joints with -movements of circumduction such as the shoulder and the hip.</p> - -<p>Vertical pressure exercised upwards or downwards may cause the limb to -press upon the bucket at two points: (1) on the summit of the cone, -<i>i.e.</i> on the extremity of the stump; (2) on the base of the cone, -<i>i.e.</i> on the bony prominences around the last remaining joint. The -adjustment is never sufficiently accurate for the relief due to the -fitting of the stump in the bucket to be of much importance.</p> - -<p>We should take it as a general rule that a scar cannot stand pressure -or friction; and that in consequence, when we amputate under -favourable conditions, we should arrange to place the scar in such a -position that from our knowledge of the suitable prosthetic apparatus -these two evils will be avoided. It should be added, however, that -after perfect primary union, the narrow and mobile scar is very -tolerant, but it must also be remembered—<span class="pagenum"><a name="Page_3" id="Page_3">[3]</a></span>especially as will be -seen in the lower limb—that this condition is rarely realised in war -surgery.</p> - -<p>The length of the stump is often estimated by reference to that of the -other limb; amputation at the upper, middle, or lower third of the -thigh, of the leg, of the arm, or of the forearm. This is convenient, -starting from a certain minimum length, but there is an <i>absolute -minimum length</i> below which the stump has insufficient leverage and -tends moreover to escape from the bucket.</p> - -<p><i>Temporary and permanent apparatus.</i>—For the irregular amputations -of war surgery which have suppurated, more often than for those of -civil practice, it is generally advisable, particularly in the lower -limb, to use a temporary apparatus, of fairly good fit, for several -weeks or even months before the permanent apparatus of more precise -fit. The stump has to soften and shrink gradually; only when this has -occurred can we make an accurately fitting bucket, by means of a cast -if necessary.</p> - -<p><i>Materials for making the bucket.</i>—The first method of construction -is that of <i>leather reinforced with metal</i>; a sheath strengthened -with metal supports, is laced around the stump; the supports further -give attachment, if there is room, to the artificial joints. This -is an excellent principle, either for stumps which are still likely -to diminish in size, or for the upper limb where exact fit is of -secondary importance.</p> - -<p>For buckets accurately fitted on a cast we employ:</p> - -<p><i>Blocked leather</i>, which loses shape and ought to be abandoned for -artificial limbs for the lower extremity.<a name="FNanchor_1_1" id="FNanchor_1_1"></a><a href="#Footnote_1_1" class="fnanchor">[1]</a></p> - -<div class="footnote"> - -<p><a name="Footnote_1_1" id="Footnote_1_1"></a><a href="#FNanchor_1_1"><span class="label">[1]</span></a> This we have attained at the <i>Fédération des Mutilés</i>, -having forced the makers to abandon their routine. It seems to us -therefore that the same result might be attained for the appliances -furnished by the State, which are still made of leather.</p> - -<p><span class="pagenum"><a name="Page_4" id="Page_4">[4]</a></span></p></div> - -<p><i>Celluloid</i> is the material of choice, but it has the defect of -requiring the hand of an artist; commercial attempts on a large scale -have so far yielded mediocre results.</p> - -<p><i>Metal</i> (zinc, sheet steel, aluminium), the defect of which is that -the apparatus, particularly for the lower limb, is noisy. This is also -an inconvenience in the metal joints of lateral steels of leather -appliances and of the spiral springs in certain wooden apparatus, -for this reason indiarubber is more often relied on for springs and -accumulators.</p> - -<p><i>Wood</i>, for many years used for the commoner types of limbs for the -lower extremity, is now, as the result of American influence, utilised -for the making of apparatus hitherto termed "de luxe," but to-day -serviceable, thanks to this technique.<a name="FNanchor_2_2" id="FNanchor_2_2"></a><a href="#Footnote_2_2" class="fnanchor">[2]</a></p> - -<div class="footnote"> - -<p><a name="Footnote_2_2" id="Footnote_2_2"></a><a href="#FNanchor_2_2"><span class="label">[2]</span></a> Working in wood, to hollow out of a log of wood a bucket -which fits the stump accurately, is no novelty. Some sixty years ago -two Frenchman, Bailly, then Xavier, succeeded in such construction. -But these appliances, like the common, cheap unshaped peg leg, split -easily and were only made strong when the Americans conceived the -idea of covering the outer surface with a layer of raw hide: strong, -and therefore practical, for though we may resign ourselves to the -frequent renewal of a peg leg at 25 francs, it is another matter with -an appliance costing 300 to 400 francs. (Prices in peace time.) -</p> -<p> -(In England the standard patterns of artificial legs have for many -years been made out of wood.—<span class="smcap">Ed.</span>)</p></div> - -<p>The adjustment to the stump is very exact; the contact with the -surface where there is friction is soft and comfortable without -padding; the appliance is light, strong and silent. The best woods -appear to be English willow and lime. The bucket should not present -any flaw or knot, this can be seen on the inner uncovered surface.</p> - -<p>But we must emphasise the general fact that <i>standardisation is -impossible when the bucket is made of wood</i>.<span class="pagenum"><a name="Page_5" id="Page_5">[5]</a></span> For the other parts it -is possible but not for the bucket, which must be made specially for -each patient, hollows being made for each bony point, which must be -marked out and felt for with the fingers. A plaster cast would appear -more exact: but by this means we do not mark out the bony points. Good -results cannot be obtained, if, as certain people have tried, linear -measurements are sent to a workshop whence an apparatus is forthwith -despatched to a patient whom the maker has never seen.</p> - -<hr class="chap" /> - -<div class="chapter"> - -<p><span class="pagenum"><a name="Page_6" id="Page_6">[6]</a></span></p> - -<h2><i>CHAPTER II</i></h2></div> - -<h3>GENERAL PRINCIPLES OF FITTING FOR THE LOWER LIMB</h3> - -<p>Whether we are dealing with an amputation of the leg or an amputation -of the thigh, the principle function of the artificial limb is to -support the weight of the body. The bucket must therefore give support -to this weight. Three bearing points are thus possible: at the base, -upon the surface and upon the end of the stump.</p> - -<p>1. <i>Bearing upon the base.</i>—The principal bearing is that which -is taken by fitting the upper edge of the bucket under the bony -prominences situated around the last joint preserved, i.e. the -tuberosity of the ischium for the thigh, the head of the tibia for the -leg.</p> - -<p>2. <i>Bearing upon the surface of the stump.</i>—Certain makers attribute -to this an importance which we believe to be imaginary, but which -leads them to erroneous conclusions.</p> - -<p>It is evident that if a conical stump which is jointless and which -transmits the weight is fitted exactly, point downwards, into a -conical bucket, supported below by a vertical pillar, the weight is -transmitted by the friction of the part enclosed against the bucket, -without any pressure upon the free end.<span class="pagenum"><a name="Page_7" id="Page_7">[7]</a></span> Whence it may be concluded -that, as the end of the stump should not serve as a bearing point, we -should prefer a terminal scar to lateral scars which might be rendered -painful or even ulcerated by friction against the bucket.</p> - -<p>But experience shows us that if the pressure of the bucket at this -point is harmful to the lateral scars, it is not less so for most -terminal scars.</p> - -<p>The stump in its bucket is in fact a bone, furnished with soft parts -upon which we cannot exert vertical pressure, without squeezing them -back towards the base of the stump, thus exerting an upward tension -of the terminal soft parts over the end of the bone. This is bound to -occur unless there is a considerable length of soft parts beyond the -end of the bone, that is unless more bone has been sacrificed than was -necessary. In this way we get all the disadvantages of an end bearing -without its advantages.</p> - -<p>3. <i>Direct end bearing.</i>—This is only the principal bearing in -certain special stumps which we shall indicate in due course; in some -of these it is the sole bearing. In the case of apparatus for the -usual amputations, above the epiphyseal enlargements, it is never more -than a complementary or accessory bearing, although a very useful one.</p> - -<p>To take pressure upon the end of the stump it is only necessary to -stretch across the bucket at the right height a piece of material -covered with felt. If the apparatus is made of leather, the support is -taken upon a circular band of metal fixed to the lateral steels.</p> - -<p>In order that direct pressure upon the stump may be possible, two -conditions are indispensable: that there is no terminal scar; and -that the extremity of the bone is well covered with a thick and -non<span class="pagenum"><a name="Page_8" id="Page_8">[8]</a></span>adherent flap. Actually walking directly on the stump does not -involve simply support by pressure, but also inevitable friction, -of greater or less importance, caused by the backward and forward -movement. This is only realised under the most perfect conditions if -the skin is adapted by its structure to this movement. This is the -case with the sole of the foot: where the epidermis and dermis are -thick and the subcutaneous areolar tissue and deep fascia, continuous -with it, enclose little cavities filled with globules of fat; these -form a cushion, like little globules of liquid gliding over each -other. The skin of the point and of the posterior surface of the heel -is less suitable anatomically than that of the sole: it is, however, -good, and it is for this reason that after amputation above the -malleoli, it is possible to walk directly upon the cut surface of the -tibia.</p> - -<p>Nevertheless skin which is not prepared in this way by its normal -structure can adapt itself to pressure and friction, provided that -it is padded by a thick muscular layer, sheathed whenever possible -with fibrous tissue. A skin which is not so lined, especially in -fair and stout people, with thin and delicate skin, ulcerates easily -as the result of friction or even of simple pressure, and bursæ and -callosities form. See what happens to the skin on the dorsum and outer -side of the foot in the case of talipes equino varus. The muscles of -the flap will not remain over the bone in the condition of muscular -tissue, they become fibrous—but they are useful because:</p> - -<p>1. They interpose a fibrous layer of greater or less thickness between -the bone and the skin, so that the latter remains movable over the end -of the bone and is not directly compressed;</p> - -<p><span class="pagenum"><a name="Page_9" id="Page_9">[9]</a></span></p> - -<p>2. They adhere to the cut section of the bone forming a tendinous -insertion, which renders their action on the bony lever more powerful.</p> - -<p>A flap bears weight badly when the muscles have retracted around the -bone, over which there is then nothing but skin. It is the same when -the flap is stretched tightly across the end of the bone, <i>the soft -parts must remain soft and free</i>.</p> - -<p>Among the hundreds of cases of amputation of the leg or thigh that -have passed before us in being fitted at the <i>Fédération des Mutilés</i>, -there were many in which the presence of a terminal scar rendered the -fitting of an apparatus difficult; we have never found this the case -with a lateral scar; we have never seen the latter ulcerate rapidly as -the result of pressure or friction in a properly made wooden bucket. -So that it cannot be admitted that the proper covering of a stump is -ever a matter of secondary importance.</p> - -<p>Consequently we should consider, as a matter of principle, the -circular method of amputating only as a last resort, and we ought to -arrange the section of the soft parts so as to cover the end of bone -as adequately as possible, and to bring the scars to one side.</p> - -<p>We realise that in practice war surgery often necessitates deviations -from the ideal. We often find ourselves in a dilemma—either the stump -must be good but too short; or, being long, must be poor or even bad.</p> - -<p>In the special case of the thigh, circular amputation in the lower -third when it is carried out through healthy tissue and has not -suppurated can be trimmed and sutured in such a way as to give an -excellent scar, which is transverse and slightly posterior. In<span class="pagenum"><a name="Page_10" id="Page_10">[10]</a></span> this -situation after these routine amputations, a linear scar which is -supple and has healed by first intention, separated from the bone -by a good cushion of muscular and fibrous tissue, causes little -embarrassment, whatever its position; at the end of a few months it -stands pressure and friction without harm. But we are considering -war surgery and consequently we are often called upon to fit stumps -in which the cicatrix is large, hard, and more or less irregular, in -which the bone has suppurated and in which the neighbouring soft parts -are indurated and scarred. These stumps are not, however, the results -of the work of the worst surgeon.</p> - -<p>Amputating through infected parts, resigning himself to healing by -granulation and subsequent trimming by operation, he must take time -and trouble to attain in the end a result which is good functionally, -although at first sight unsightly. But it is this surgeon who is on -the right road, rather than he who sends us good stumps which have not -suppurated, because he has amputated through the thigh for a wound of -the middle of the leg, or through the leg for a wound of the foot or -even of the front of the foot.</p> - -<p>It is clear, that for the stump effectually to play its part of a -lever in its bucket, a certain definite length is necessary; and we -ought to do everything possible to secure a length of at least 15 to -20 centimetres in a thigh stump, or 10 to 12 centimetres in a leg -stump. But when this length is secured, there is no great functional -difference between, for example, an amputation of the leg in the -lower third or in the lower quarter, particularly if the fitter -understands how to utilise direct end bearing. The<span class="pagenum"><a name="Page_11" id="Page_11">[11]</a></span> knowledge of this -is of capital importance to the surgeon called upon to carry out -secondary operations upon imperfect stumps, in determining whether -it is possible to put an immediate stop to suppuration by drastic -shortening, or whether he must preserve length and lose time by -curretting the foci of inflammation in the bone.</p> - -<hr class="chap" /> - -<div class="chapter"> - -<p><span class="pagenum"><a name="Page_12" id="Page_12">[12]</a></span></p> - -<h2><i>CHAPTER III</i></h2></div> - -<h3>ARTIFICIAL LIMBS FOR AMPUTATIONS THROUGH THE THIGH</h3> - -<p>There are two entirely different modes of fitting:</p> - -<p>I. For amputations above the condyles, in which weight must always be -borne upon the tuberosity of the ischium through the top of the bucket.</p> - -<p>II. For amputations through the condyles (or for disarticulation of -the knee) in which a direct end bearing may suffice.</p> - -<h4>I. Apparatus with Bearing upon the Ischium</h4> - -<p class="center">(<i>Amputation above the condyles.</i>)</p> - -<p>In the construction of an artificial limb for amputation through the -thigh two entirely different principles may be used, according as it -is desired to make the patient walk upon a rigid shaft, that is to say -upon a peg, or upon an artificial leg proper, in which the knee bends -in walking (known as the American leg).</p> - -<p>But whichever principle is adopted, whatever material is chosen, wood -or leather, and however exact the fit in the bucket may be, certain -common rules govern:—</p> - -<p>1. The shape of the top of the bucket by which<span class="pagenum"><a name="Page_13" id="Page_13">[13]</a></span> it is fitted to the -top of the thigh and its bearing upon the ischium.</p> - -<p>2. The attachment of the limb to the trunk.</p> - -<p>To begin with we shall consider these two questions, and then -temporary and permanent apparatus, the peg leg and the full artificial -limb, will be described.</p> - - -<h5>I. The Shape of the Top of the Bucket</h5> - -<p>The tuberosity of the ischium is the sole bony point which can prevent -the ascent of the limb when weight is applied. This tuberosity is -situated in the posterior part of the perineum (<a href="#i_p015a">Fig. 1</a>), the anterior -part of which is unable to stand pressure. It is necessary, therefore, -to clear this part by cutting down the inner border in its anterior -part, forming a <i>perineal concavity</i>, which rises posteriorly against -the ischium (<a href="#i_p015b">Fig. 3</a>).</p> - -<p>It is essential that the ischium should not be able to slip inside -the bucket, otherwise the inner border will come in contact with the -perineum: therefore the diameter of the bucket must be less than that -of the limb, so that the ischium may rest upon its upper edge.</p> - -<p>If the bucket is too large, the patient abducts the stump, so as -to lower the inner border and prevent pressure on the perineum; he -carries the leg away from the side as he walks, and this is both -unsightly and fatiguing.</p> - -<p>When an apparatus is completed, it is very easy to ascertain the site -of the pressure on the ischium. The limb being put on, the ischium -is fixed between the thumb and first finger, and it can then be -ascertained whether it rests on the edge of the bucket or<span class="pagenum"><a name="Page_14" id="Page_14">[14]</a></span> lies within -it. This can be determined more exactly, if whilst the fingers which -mark the position of the ischium are kept within the bucket, the -patient is told to raise his stump.</p> - -<p>If the bucket is sufficiently narrow, it may be circular without the -excavation for the perineum (<a href="#i_p015a">Fig. 2</a>). But this shape is unsatisfactory -for another reason, because it results in a tendency for the limb to -rotate inwards.</p> - -<p>At the moment when the artificial limb is coming in contact with the -ground as it takes a step, the pelvis is oblique (the iliac spine of -the sound side lying posterior to that of the amputated side). The -sound limb as it executes its step is carried forwards, and the pelvis -which was oblique in one direction now becomes oblique in the opposite -direction. This movement is transmitted to the femur in the stump, so -that the artificial limb turns inwards relatively to the stump. With -each step this rotation becomes little by little more perceptible, -and after a time the patient is obliged to correct it by turning the -artificial limb with his hand.</p> - -<p>If, on the other hand, the front of the upper border of the bucket -slopes downwards and inwards at an angle of about 45 degrees, when as -a result of its weight the bucket turns inwards as the limb is swung, -the base of the stump will come against a higher part of bucket; but -when the pressure of the weight of the body returns, the stump, being -forced into the bucket, will descend again along this slope, that -is to say a passive external rotation of the artificial limb will -be brought about, correcting at every step the tendency to internal -rotation.</p> - -<p><span class="pagenum"><a name="Page_15" id="Page_15">[15]</a></span></p> - -<div class="figcenter" id="i_p015a" style="width:600px;"> - <img - class="p2" - src="images/i_p015a.png" - width="600" - height="462" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 1 and 2</p> - </div> - -<div class="figcenter" id="i_p015b" style="width:80%; margin: auto 10%;"> - <img - class="p2" - src="images/i_p015b.png" - width="315" - height="500" - alt="" /> - <p class="center"><span class="smcap">Fig. 3</span> </p> - <p class="sm">In the upright position the rami of the pubis and ischium, between -which stretches the perineum, slope downwards and backwards at an -angle of about 45° with the horizontal. The tuberosity of the ischium -bounds the perineum posteriorly, and is its lowest point. The rami -of the pubis and ischium, corresponding to the genito-crural fold, -mark the boundary between the thigh and the perineum. These bones are -unable to stand the pressure of an artificial limb.</p> - <p class="sm">If the top of the bucket is narrower than the circumference of the -top of the limb, measured below the ischium, it may be circular and -still give support to the ischium, which will not slip into it. If -the ischium does slip into the bucket, the result will be that it no -longer serves as the support, the pressure coming instead upon the -rami of the pubis and ischium and upon the perineum.</p> - <p class="sm">The constriction thus exerted upon the top of the stump may easily -become insupportable. The correct solution of the problem is to cut -down the upper border of the bucket opposite the perineum, letting it -rise again posteriorly beneath the tuberosity of the ischium, and gain -a good support there.</p> - </div> - -<p class="p2">The same slope may be given to both edges of the<span class="pagenum"><a name="Page_16" id="Page_16">[16]</a></span> bucket (<a href="#i_p017a">Fig. 5</a>). -This obliquity in the posterior part serves no useful purpose: it is -better on the contrary to lower the posterior border combining this -semioblique fitting with a rise beneath the ischium and a depression -under the perineum (<a href="#i_p017a">Fig. 6</a>).</p> - -<p>These conditions are easily carried out in a wellmade wooden bucket, -represented in <a href="#i_p017b">figures 8 and 9</a>, in which it may further be seen that -from the front it is convex outwards; from the side, convex forwards -(<a href="#i_p017b">Fig. 9</a>). This form, which is that of some good American appliances, -ought to be generally used.</p> - -<p><i>The curve outwards</i>, by drawing away the soft parts from it, frees -the region of the ischium and allows the tuberosity of the ischium to -press upon the bucket (<a href="#i_p017b">Fig. 8</a>).</p> - -<p><i>If the thigh piece is curved forwards</i>, and particularly if the limb -is built with a very slight flexion of the knee, the stump remains -slightly flexed at the hip and the patient feels as if he is sitting -in the apparatus.</p> - -<p>When the thigh piece is straight, an uncomfortable pressure is -produced by the edge of the bucket against the ischium. It may be -added that extension of the hip is very often impaired, particularly -in patients with a short stump: The extensor muscles being divided, -the flexors cause contraction into a flexed position, the more so the -shorter the stump is. If the thigh piece is straight, the short stump -cannot follow the movement of extension necessary in walking; it slips -out of the bucket if the anterior lip of the latter is too low.</p> - -<p>The principles are the same for the leather bucket, known as the -<i>French pattern</i>.</p> - -<p><span class="pagenum"><a name="Page_17" id="Page_17">[17]</a></span></p> - -<div class="figcenter" id="i_p017a" style="width:100%;"> - <img - class="p2" - src="images/i_p017a.png" - width="600" - height="299" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 4,5 and 6</p> - </div> - -<div class="figcenter" id="i_p017b" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p017b.png" - width="600" - height="415" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 7,8 and 9</p> - <p class="sm">Figure 4 shows the circular bucket (almost always too large) of the -poor man's peg leg, attached to the body by a belt which is fastened -to a projection upwards from the outer side of the bucket. Figure 5 shows the oblique bucket, with symmetrical anterior and -posterior borders. Figure 6 one with the anterior border oblique, the -posterior border being cut away. Figure 7 shows the double obliquity, -downwards and backwards, of the bucket. The convexities of the bucket -and thigh piece, in the type which we consider to be the best, are -shown in figure 8 (convexity outwards), and figure 9 (convexity -forwards).</p> - </div> - -<p class="p2">In this the thigh piece is strengthened by two lateral steels (to the -lower end of which is fixed the<span class="pagenum"><a name="Page_18" id="Page_18">[18]</a></span> leg piece) joined posteriorly by a -semicircular cross piece on which the ischium should rest (<a href="#i_p019">Fig. 13</a>).</p> - -<div class="figcenter" id="i_p018" style="width:550px;"> - <img - class="p2" - src="images/i_p018.png" - width="550" - height="385" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 10 and 11</p> - </div> - -<p class="p2">The usual form hitherto has been that shown in figure 10. The cross -piece was horizontal and formed simply a posterior semicircle; the -lateral steels were straight. Consequently in this pattern these -steels form a cone, in which the soft parts are not compressed on -the inner side, nor drawn outwards, as in the apparatus previously -described. Further, as long as the stump is not shrunken, the ischium -covered on its inner side by soft parts sinks into the bucket, and it -is the perineum which becomes the point of pressure (<a href="#i_p018">Fig. 11</a>). Made -of leather, the perineal concavity soon loses its shape and really -no longer exists. Finally the bucket is circular, with the faults -inseparable from that shape (<a href="#i_p019">Fig. 12</a>).</p> - -<p>In cases where it is felt necessary to employ leather, all these -faults are easily corrected, by giving the cross piece the shape -which we have described for the wooden bucket, and by prolonging it -forwards<span class="pagenum"><a name="Page_19" id="Page_19">[19]</a></span> through two-thirds of the corresponding circumference, in -the shape of an oblique bucket. (Dotted line in <a href="#i_p019">Fig. 12</a>.)</p> - -<p>If it is not strengthened, an oblique border of leather gives way, and -after a few months' use allows rotation. The leather which extends -from the termination of the metal ascends very steeply towards the -trochanter, whilst the posterior border of the bucket, which is -horizontal, curves downwards on the inner side to form the perineal -concavity.</p> - -<div class="figcenter" id="i_p019" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p019.png" - width="600" - height="397" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 12,13 and 14</p> - <p class="sm">The ordinary leather bucket is mounted upon two lateral steels, which -are joined by a posterior cross piece (Fig. 13). This framework is -shown in <a href="#i_p018">figure 10</a>, and covered with leather in figure 12. If the -lateral steels are straight and divergent, this has all the defects -of the straight circular bucket. The concavity for the perineum, cut -out of the leather, soon loses its shape. It is, however, easy to -shape the cross piece as shown in figure 14, with a perineal concavity -and the anterior border oblique, following the dotted line in figure -12. By doing this and curving the steel uprights appropriately, the -correct form of the wooden bucket can be copied exactly in a leather -and steel apparatus. Such a correct apparatus is shown in <a href="#i_p020a">figures 15 -to 18</a>.</p> - </div> - -<p class="p2">In <a href="#i_p019">figure 14</a> is seen the metal framework; in figures<span class="pagenum"><a name="Page_20" id="Page_20">[20]</a></span> 15 and 16 that -of the apparatus covered with leather; in figure 17 the support upon -the ischium; and the possibility of making this appliance identical -with the wooden bucket will be observed (<a href="#i_p020b">Fig. 18</a>).</p> - -<div class="figcenter" id="i_p020a" style="width:550px;"> - <img - class="p2" - src="images/i_p020a.png" - width="550" - height="371" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 15 and 16</p> - </div> - -<div class="figcenter" id="i_p020b" style="width:600px;"> - <img - class="p2" - src="images/i_p020b.png" - width="600" - height="431" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 17 and 18</p> - </div> - -<p><span class="pagenum"><a name="Page_21" id="Page_21">[21]</a></span></p> - -<h5>II. Mode of Suspension</h5> - -<p><i>Suspension of the thigh piece</i> is essential, and is all the more -important when the stump is short and consequently more liable to -slip out of the bucket. For this purpose support may be taken either -from the waist, upon the <i>prominence of the iliac crests</i>, or from -the <i>shoulders</i> by means of braces. In the case of a long stump -(amputation below the middle of the thigh) only one of these methods -is necessary, we shall describe the usual methods:</p> - -<p><i>The waist belt</i> (French system) for leather appliances.</p> - -<p><i>Braces</i> (American system) for appliances of wood.</p> - -<p><span class="pagenum"><a name="Page_22" id="Page_22">[22]</a></span></p> - -<p>If the stump is short a combination of the two methods is best.</p> - -<div class="figcenter" id="i_p021" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p021.png" - width="400" - height="446" - alt="" /> - <p class="center p0"><span class="smcap">Figs.</span> 19 and 20.—<span class="sm">Simple pelvic suspension, -with details of the joint at the hip.</span></p> - </div> - -<p class="p2">A. <span class="smcap">Suspension by means of a waist belt.</span>—<i>For the peg leg -made of leather</i> the best method consists in placing a pelvic plate, -which is attached to the hip steel, below the iliac crest (Figs. 20 to -24). A belt attached to the extremities of this plate surrounds the -pelvis and passes above the iliac crest on the other side. The thigh -piece is attached to this support, on the outer side, by articulation -of the outer femoral steel with the hip steel; on the inner side, by -a perineal strap. Braces complete the method of suspension of the -apparatus (Fig. 21).</p> - -<div class="figcenter" id="i_p022" style="width:311px;"> - <img - class="p2" - src="images/i_p022.png" - width="311" - height="450" - alt="" /> - <p class="smcap center p0">Fig. 21.</p> - </div> - -<p class="p2">The axis of the metal joint between the outer femoral steel and the -lower end of the T piece should be directly above the great trochanter -(<a href="#i_p021">Fig. 20</a>).</p> - -<p>The femoral steel often breaks in the neighbourhood of this joint -(<a href="#i_p023b">Fig. 23</a>); we have got over this difficulty by adding immediately -beneath it a joint which allows of abduction (<a href="#i_p021">Fig. 19</a>). A perineal -strap limits this movement.</p> - -<p><span class="pagenum"><a name="Page_23" id="Page_23">[23]</a></span></p> - -<div class="figcenter" id="i_p023a" style="width:323px;"> - <img - class="p2" - src="images/i_p023a.png" - width="323" - height="450" - alt="" /> - <p class="smcap center p0">Fig. 22.</p> - </div> - -<div class="figcenter" id="i_p023b" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p023b.png" - width="370" - height="350" - alt="" /> - <p class="center p0">Fig. 23.</p> - <p class="sm center"><i>Suspension from the pelvis.</i></p> - <p class="sm">A metal hip piece is fixed below the iliac crest and held in place -by a belt which passes above the iliac crest of the opposite side -(<a href="#i_p021">Figs. 20 to 24</a>). This piece is attached to the thigh bucket by a -joint shown in <a href="#i_p021">figure 19</a> (see also <a href="#i_p023a">Fig. 22</a>), which allows both flexion -and abduction of the hip, and which forms the suspension of the -outer side of the limb. The inner border is suspended by means of a -perineal strap, shown in <a href="#i_p022">figures 21 and 22</a>. In figure 21 is shown how -a suspending brace may be easily added. Figure 23 shows the action of -a single hinge joint, allowing only flexion and extension at the hip -joint. On <a href="#i_p027a">page 27</a> will be seen similar joints which, however, move on -the pelvic attachment as well as on the thigh piece. The object of -this is to prevent the pinching of the abdominal wall by the top of -the thigh bucket when the patient sits. It is indispensable in short -stumps. On <a href="#i_p021">page 21</a> will be seen a joint which allows abduction of the -hip, and thus relieves the strain upon the hinge joint; without it the -latter is easily broken.</p> - </div> - -<p><span class="pagenum"><a name="Page_24" id="Page_24">[24]</a></span></p> - -<p class="p2">B. <span class="smcap">Suspension by means of braces</span> (American method).—The -American method of suspension has the advantage of leaving the pelvis -free; the patient does not feel the pull of the hip piece. Besides, -when the belt is used, if the patient sits down, the buttock on -the side of the stump is raised, to an extent corresponding to the -thickness of the bucket, an obliquity of the pelvis, which is both -uncomfortable and unsightly, being produced. The braces being relaxed -in the sitting posture, the patient can avoid this inconvenience; for -the stump may be slipped partly out of its bucket, the upper extremity -of which is then beyond the level of the edge of the chair. This<span class="pagenum"><a name="Page_25" id="Page_25">[25]</a></span> -position is very comfortable, because it is normal, but the patient -must replace his stump in the bucket whenever he stands up.</p> - -<div class="figcenter" id="i_p024" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p024.png" - width="600" - height="525" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 24 and 25</p> - <p class="sm p0">Braces composed of straps passing over the shoulders and down the -front, attached to the bucket by buckles. Posteriorly they are joined -together by a cross strap between the scapulæ, and beyond this are -continued in the form of elastic straps.</p> - </div> - -<p class="p2">This form of suspension is essential for those artificial limbs with a -free knee-joint, in which, as we shall see, the braces serve to extend -the joint.</p> - -<p>We illustrate here two methods of attaching the braces to the thigh -piece, that which we use in the limb supplied by the Fédération (Figs. -24 and 25)<span class="pagenum"><a name="Page_26" id="Page_26">[26]</a></span> and that which is used in the American limb of Marks -(Figs. 26 and 27).</p> - -<div class="figcenter" id="i_p025" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p025.png" - width="385" - height="550" - alt="" /> - <p class="p0"><span class="smcap">Fig. 26.</span>—<span class="sm">Braces which end below in looped thongs of leather.</span></p> - <p class="p0"><span class="smcap">Fig. 27.</span>—<span class="sm">These loops, held in to the thigh piece by passing -beneath a loop of leather, pass over two pulleys about the middle of -the inner and outer sides of the thigh piece respectively. The outer -brace tends to abduct the limb if it is tightened.</span></p> -</div> - -<p class="p2">C. <span class="smcap">Combined method of suspension.</span>—<i>If the stump is short</i> -the artificial limb must be attached both by a belt and by braces; the -latter should be 5 to 6 centimetres wide.</p> - -<div class="figcenter" id="i_p026" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p026.png" - width="262" - height="450" - alt="" /> - <p class="smcap center">Fig. 28.</p> - </div> - -<div class="figcenter" id="i_p027a" style="width:400px;"> - <img - class="p2" - src="images/i_p027a.png" - width="400" - height="349" - alt="" /> - <p class="center smcap">Fig. 29.</p> - </div> - -<div class="figcenter" id="i_p027b" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p027b.png" - width="400" - height="332" - alt="" /> - <p class="center smcap">Fig. 30.</p> - <p class="center sm p0"><i>Combined suspension for short stumps.</i></p> - <p class=" sm p0"><span class="smcap">Fig. 28.</span>—Complete appliance.</p> - <p class=" sm p0"><span class="smcap">Fig.</span> 29 and 30 show the value of a flexion pivot between the -hip piece and the pelvic plate. If there is no such pivot, the T piece -undoubtedly rotates upon the belt, but not to a sufficient extent to -prevent the thigh piece in rising and pinching the abdominal wall -(Fig. 29). If there is a double joint the hip piece becomes oblique, -thrusting the thigh piece forward and allowing the patient to sit -erect (Fig. 30).</p> - </div> - -<p class="p2">In these cases also, to prevent the stump escaping from the bucket -when the hip is flexed, the front of the thigh piece is carried as -high as possible; but if the appliance is furnished with a metal T -piece, such as has been described (<a href="#i_p027a">Fig. 29</a>, see also <a href="#i_p023b">Fig. 23</a>), then -this raised border prevents flexion of the hip by coming in contact -with the abdominal wall when the patient sits down. This difficulty -can be got over by making the top of the T piece movable; when the -patient sits down the vertical piece of the T becomes oblique, the -thigh piece comes forward, allows the stump to escape a little way and -no longer presses against the abdominal wall (<a href="#i_p027b">Fig. 30</a>).</p> - -<p>The belt may also be replaced by a leather corselet,<span class="pagenum"><a name="Page_27" id="Page_27">[27]</a></span> having fixed to -it the hip piece that we have just described.</p> - -<p>The braces by themselves are a poor method of attachment for a short -stump.</p> - -<p>In the sitting position the stump easily escapes from the bucket.</p> - -<p><span class="pagenum"><a name="Page_28" id="Page_28">[28]</a></span></p> - -<p>When the patient is standing the stump remains abducted, whilst the -apparatus, as the result of its own weight hangs vertically, in this -swaying position the lower extremity of the stump presses against the -outer side of the bucket, whilst the inner edge of the bucket cuts -into the flesh at the top of the thigh.</p> - - -<h5>III. Walking on a peg leg and similar appliances</h5> - -<p><i>The rigid peg and the jointed peg.</i>—The peg leg is a rigid rod, -ending in a slight enlargement, which transmits the weight of the -body, resting by means of the ischium upon the top of the bucket, -directly to the ground.</p> - -<p>The erect position is thus very secure, and stability in walking is -also very good throughout the time when the artificial limb bears the -weight.</p> - -<p>To raise the limb from the ground and carry it forwards, the patient -uses at the same time both flexion of the stump at the hip and -movements of the pelvis (elevation, then rotation inwards) varying to -some extent with his proficiency and with the length of the stump.</p> - -<p><i>The old-fashioned peg leg</i>, called the "poor man's peg," consists -of a bucket continued into a rigid peg. If the support beneath the -ischium is well made according to the principles described above, -it is an excellent temporary limb.<a name="FNanchor_3_3" id="FNanchor_3_3"></a><a href="#Footnote_3_3" class="fnanchor">[3]</a> This bucket of common wood, -which is not specially shaped to the stump, is very economical; its -imperfect fit is an advantage<span class="pagenum"><a name="Page_29" id="Page_29">[29]</a></span> in that the stump, which is still -enlarged, cannot bear friction; as the stump assumes its true shape -and diminishes in size, the bucket is packed. We would add that every -patient, who is not rich enough to possess two complete artificial -limbs should have in reserve an emergency peg leg, for occasions when -the artificial limb requires repair.</p> - -<div class="footnote"> - -<p><a name="Footnote_3_3" id="Footnote_3_3"></a><a href="#FNanchor_3_3"><span class="label">[3]</span></a> A number of temporary limbs have been designed, with -buckets of lattice work or of plaster. The old-fashioned wooden peg, -which is easily obtained, avoids all this additional work without any -disadvantage.</p></div> - -<p>As a permanent apparatus, with accurately fitted bucket, the rigid -peg leg has two defects: it has not the appearance of a leg and -foot, and when the patient is sitting the rigid peg is unsightly and -inconvenient to him and to his neighbours. We have therefore designed -and completed a <i>jointed peg leg</i>, the principle of which is as -follows:</p> - -<p>Below the thigh piece the peg is attached by a transverse joint, -this joint being locked in the extended position when the patient is -upright. The patient sets it free by manipulating the lock through the -trousers, when he sits down; when he gets up again the locking in the -extended position is automatic.</p> - -<p>The fitting of this transverse joint may be carried out in two ways.</p> - -<p>1. The upper end of the peg ends in a stirrup-shaped fork and the bolt -passes through the two ends of this fork and through the lower end of -the thigh piece (<a href="#i_p030a">Figs. 31 to 33</a>).</p> - -<p>2. The lower extremity of the thigh piece has cut in it a central -mortise into which fits a vertical plate, prolonged upwards from the -middle of the leg piece. The bolt passes through this artificial -tibial spine and through the two sides of the mortise in the thigh -piece. If the hole in the tibial spine through which this bolt passes -is square the hinge works securely (<a href="#i_p030b">Figs. 34 to 36</a>).</p> - -<p><span class="pagenum"><a name="Page_30" id="Page_30">[30]</a></span></p> - -<p>In this form the axle turns with the leg, in the first form this is -also possible. But most often when the forked attachment is used it is -fixed to a leather thigh piece, and each end of the fork is jointed -independently to the corresponding end of the lateral steels of the -thigh piece, without any complete transverse bolt. It is then the fork -that revolves around these two joints.</p> - -<div class="figcenter" id="i_p030a" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p030a.png" - width="326" - height="400" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 31 to 33.—<span class="sm">Fixation of the stirrup of the leg (Fig. 31) -by a transverse bolt (Fig. 33), the aperture for which in the thigh -piece is seen in Fig. 32. Double lock (Fig. 32).</span></p> - </div> - -<div class="figcenter" id="i_p030b" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p030b.png" - width="223" - height="450" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 34 to 36.—<span class="sm">Attachment by mortise and tenon, with a -bolt, square in section, passing through the knee. Single lock on the -outer side.</span></p> - </div> - -<p class="p2">If there is a complete transverse bolt, the joint can be securely -locked by a single lock at one of its extremities (at the outer -extremity) (Figs. 36 to 39).</p> - -<p>If there are two lateral joints the single lock is insufficient, both -joints must be fixed at once; unless this is done, that which is not -fixed has a certain amount of play and is strained.</p> - -<p><span class="pagenum"><a name="Page_31" id="Page_31">[31]</a></span></p> - -<p>It is, however, simple, by means of a posterior semicircle, to joint -the two locks and to work them together by a single movement (<a href="#i_p030a">Fig 32</a>).</p> - -<p>For æsthetic reasons the wooden leg piece may be made in the shape of -a leg and foot. But if the principle of the peg leg has been adopted, -for an agricultural labourer for example, on account of its stability, -it is better to use an appliance in which a "show leg" is fitted -around the simple peg on days when appearance is more important than -work (Figs. 37 to 45). The limb is thus rendered lighter, for the -false calf consists of a simple layer of felt and it is very easy to -replace the enlarged lower end of the peg by a foot.</p> - -<div class="figcenter" id="i_p031" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p031.png" - width="344" - height="500" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 37 to 40.—<span class="sm">Attachment by a mortise, and -show foot.</span></p> - </div> - -<p class="p2">We show later two models of this sort, one with an American thigh -piece of wood and a single lock upon a transverse axle, the other with -a leather thigh piece and a double lock. The first (Figs. 37 to 40) is -shown with an attachment by braces, and the second (Figs. 41 to 47) -with an attachment by means of a waist belt; we have already explained -when these two must be combined.</p> - -<p><span class="pagenum"><a name="Page_32" id="Page_32">[32]</a></span></p> - -<div class="figcenter" id="i_p032" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p032.png" - width="594" - height="550" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 41 to 47</p> - <p class="sm center"><i>Leather and steel peg leg, with show foot.</i></p> - <p class="sm p0">Figures 41 to 47 (leather appliance) should be compared with <a href="#i_p031">figures -37 to 40</a> (wooden appliance) which complete them in certain points. It -is unnecessary to refer further to the method of fitting the bucket to -the suspension, or to the method of attaching and locking the knee.</p> - <p class="sm p0">The peg—attached above by a stirrup or by a mortise, it does not -matter which—ends below in a rectangular tenon which fits into a -corresponding excavation in the upper surface of the terminal piece, -whether peg or foot (Figs. 38 and 44). A transverse bolt, square in -section, with a head at one end and a thread at the other, fixes these -two parts together. By taking out this bolt the peg can be replaced by -the foot or <i>vice versâ</i>.</p> - <p class="sm p0">If the attachment of the foot is made in the heel, a fixed foot is -used (Figs. 43 and 45), but it is easy, by making the attachment -higher, to use a foot with movable ankle joint (Fig. 40).</p> - <p class="sm p0">The attachment of the show calf piece around the peg is shown in -figures 43 and 45.</p> - </div> - -<p class="p2">Most often the wooden thigh piece is to be preferred;<span class="pagenum"><a name="Page_33" id="Page_33">[33]</a></span> the limb is -lighter and may last four or five years instead of about two years.</p> - -<p>We may add that leather loses its shape and the bucket becomes -enlarged, producing inconveniences already described on <a href="#Page_18">page 18</a>.</p> - -<p>But <i>leather</i>—indespensable for certain stumps which cannot stand -a wooden bucket—has the advantage that it can be employed as a -<i>temporary fitting</i>. During the first weeks, sometimes even for the -first months, the shrinking of the stump can be accommodated by lacing -up the bucket, and, when shrinkage is complete, the leg part of this -first apparatus can be attached to a wooden bucket which the improved -condition of the stump now renders possible.</p> - -<p>This form is a little more expensive (80 frs.) than "the poor man's -leg," but I believe a great deal more comfortable. It may be added, -that it is easy when the foot is fitted at the end of the apparatus -to render flexion of the knee free and to attain the "American walk," -of which we shall speak later. All that is necessary is to attach in -front an artificial muscle of indiarubber, reaching from the thigh to -the leg and an extending sling like that in the American limbs (see <a href="#i_p047">page 47</a>).</p> - -<p>This appliance which we call the "Fédération Leg," because we designed -it at the <i>Fédération des Mutilés</i>, has already been imitated without -its origin being acknowledged.</p> - - -<h5>IV. Walking with free flexion of the knee</h5> - -<p>A. <i>Design.</i>—The oldest type, which will suffice for studying the -general conditions of stability, is that<span class="pagenum"><a name="Page_34" id="Page_34">[34]</a></span> of Marks, with a fixed -foot shaped out of the same piece of wood as the leg: the ankle -joint—several types of which we shall describe later—does not affect -the question of stability.</p> - -<p>The appliance is made entirely of wood; it is strong and light.</p> - -<p>Nothing need be added to the description already given of the fitting -and method of attachment of the thigh piece, which ends below in a -curved "condyle,"<a name="FNanchor_4_4" id="FNanchor_4_4"></a><a href="#Footnote_4_4" class="fnanchor">[4]</a> which fits into the top of the leg piece. It -is transfixed by a metal bolt, from each end of which a metal plate -descends and is riveted into a corresponding groove in the leg.<a name="FNanchor_5_5" id="FNanchor_5_5"></a><a href="#Footnote_5_5" class="fnanchor">[5]</a> -This forms the axle which rotates in the thigh piece when the knee -flexes or extends. Flexion of the knee is free. Extension is stopped -just short of the straight line (see <a href="#Page_16">p. 16</a>).</p> - -<div class="footnote"> - -<p><a name="Footnote_4_4" id="Footnote_4_4"></a><a href="#FNanchor_4_4"><span class="label">[4]</span></a> The bucket and the condylar portion are made of two -separate pieces of wood.</p></div> - -<div class="footnote"> - -<p><a name="Footnote_5_5" id="Footnote_5_5"></a><a href="#FNanchor_5_5"><span class="label">[5]</span></a> The hole through which the bolt passes being cut in soft -wood (willow or lime), must be strengthened by a cylinder of metal, of -leather, or of harder wood (beech or service tree) in which the axle -revolves.</p></div> - -<div class="figcenter" id="i_p034a" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p034a.png" - width="151" - height="550" - alt="" /> - <p class="center"><span class="smcap">Fig. 48.</span>—<span class="sm">Marks leg with fixed foot.</span></p> - </div> - -<div class="figcenter" id="i_p034b" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p034b.png" - width="150" - height="127" - alt="" /> - <p class="center"><span class="smcap">Fig. 49.</span>—<span class="sm">Construction of the foot.</span></p> - </div> - -<p class="p2">The foot is in equinus at an angle of 25° to 30° so that the heel -is 2 or 3 centimetres from the ground (the usual height of the heel -of a boot). The piece of wood which forms the instep and which is -continuous with the<span class="pagenum"><a name="Page_35" id="Page_35">[35]</a></span> leg stops at a point corresponding to the middle -of the metatarsus, and is only half the thickness of the foot. The -rest of the foot is shaped of indiarubber stuck on to the instep -piece; the wood and rubber being enclosed in a sheath of leather.</p> - -<p>The foot should also point slightly outwards, as in the normal -standing position.</p> - -<p><i>To ascertain whether the limb is built so as to ensure equilibrium</i>, -a thread is stretched against its side so as to pass through the axes -of the knee and ankle joints, if this cuts the ischial bearing point -at its centre the equilibrium of the patient is assured. Equilibrium -will be better still if the cord lies entirely behind the ischial -bearing point, leaving in front of it the greater part of the thigh -piece. The best method of ascertaining if the foot is properly mounted -is to hold the limb in front of one by the thigh piece, with the knee -bent at a right angle; it can then be seen whether the foot turns -outwards at the correct angle.</p> - -<p>It is not necessary to say anything more about the shape of the thigh -piece (<a href="#i_p017a">page 17</a>).</p> - -<p>The metal bolt which transfixes the knee must not allow any play; the -hole through which it passes must be lined with hard wood or leather.</p> - -<p>The indiarubber sole should be reinforced with several layers of -canvas incorporated in the rubber, as the latter if not so reinforced -perishes and cracks.</p> - -<p>The appliance must further be examined after it is applied. The level -of the iliac spines must be compared: the spine on the side of the -amputation should be 2 cm. below that of the sound side.</p> - -<p>Examine the position of the point of the foot. Make the patient sit -down, see if the knees are on the same horizontal plane; if the -sound knee is the higher<span class="pagenum"><a name="Page_36" id="Page_36">[36]</a></span> the leg piece is too short. The foot being -fixed in the equinus position the patient must wear boots while the -examination is being carried out.</p> - -<p>B. <i>Mechanism of walking.</i>—In walking, a step being taken with the -artificial leg, the toe of the foot is the last to leave the ground, -the heel being raised and the knee straight. The limb is swung forward -and raised by flexion of the hip: active flexion of the knee is -impossible, but passive flexion occurs, owing to the weight of the leg -piece, as the thigh is raised.</p> - -<p>At this moment the leg piece is vertical, forming an angle with the -thigh, from this position it must pass into one in which it is oblique -forwards and downwards, in a straight line with the thigh, <i>so that -the knee may be fully extended when weight is again borne by the limb</i> -as the foot meets the ground. If at this moment the knee is flexed the -limb will double up under the weight of the body.</p> - -<p>The first contact of the limb with the ground should be at the heel -with, as we have already said, the knee extended. Afterwards as the -limb, which at first points obliquely forward and downwards, passes -into the vertical position in which it must be at the period when it -bears the whole of the weight, this complete extension becomes locked -and transforms the limb into a rigid column.</p> - -<p>This is brought about as explained on <a href="#i_p048">page 48</a> by mounting the foot -in equinus, and we must here describe the methods by which the -commencement of the movement of extension may be communicated to the -leg so that the heel may be the first part of the foot to touch the -ground.</p> - -<p>These methods may be termed <i>knee extending mechanisms</i>. <span class="pagenum"><a name="Page_37" id="Page_37">[37]</a></span>They assist -the passive action of the weight of the leg.</p> - -<p>In fact the recurrence of extension is brought about by a pendulum -movement of the leg, which, at first oblique downwards and backwards, -swings into a downward and forward obliquity. But this movement -is slow (the pendulum which marks one second is one metre long) -and incomplete. The patient can make it complete with a little -instruction, by extending the thigh slightly as soon as the foot -touches the ground.</p> - -<p>This may be sufficient if the stump is long; the leverage is good, and -while the hip is being flexed a swing can be given to the thigh piece -which accentuates the pendulum movement of the leg.</p> - -<p>But with a short stump some special mechanism is essential to make -sure that extension will be complete, otherwise the patient will be -obliged to walk with short and calculated steps, to wait whilst the -pendulum action produces extension of his knee and allows him to put -weight upon his foot.</p> - -<p>C. <i>Mechanism for starting extension of the knee during the time the -leg is swinging.</i>—There are two methods which are generally combined:</p> - -<p>1. Elastic traction by an artificial muscle.</p> - -<p>2. The extending sling.</p> - -<p>1. <i>Artificial muscle.</i>—The action of an artificial muscle made of -elastic (noiseless) or of a coiled steel spring, is easily understood.</p> - -<p>(a) The simplest method (that which is commonly used for infantile -paralysis affecting the quadriceps) consists in fixing an elastic band -divided into two slips, one on either side of the patella) between the -front of the thigh and of the leg, about the middle of<span class="pagenum"><a name="Page_38" id="Page_38">[38]</a></span> each. (This is -represented in <a href="#i_p059">figure 98</a> in our convertable leg.)</p> - -<p>(b) When the apparatus includes the regular artificial knee the makers -generally place this mechanism in the interior of the thigh and leg -pieces, using methods which are often very ingenious. Of these we -illustrate some on pages 40 onwards, with an explanatory description.</p> - -<p>In describing these mechanisms, which may be called intra-condylar, -it is necessary to speak at the same time of the <i>stop to limit -extension</i> because, as will be seen, it is combined with the extending -spring.</p> - -<p>We have already said that rigidity in extension when the limb is -vertical is essential, but whilst it is necessary for extension to be -<i>complete</i> at this moment it is also necessary to prevent the knee -being forced into the <i>hyperextended position</i>, as this would quickly -strain the joint and render the limb useless.</p> - -<p>This limitation of extension can be effected quite easily by the -tension of a popliteal cord (see <a href="#i_p041a">page 41</a>. The knee in Marks leg), or -by carrying the anterior border of the leg piece upwards in front of -the thigh piece so that it impinges against the latter.</p> - -<p>This method is not very good because it is noisy.</p> - -<p>Moreover, the repeated impact against the leg piece may split the -wood, so that if this method is adopted the stop must be reinforced by -a binding of several layers of parchment.</p> - -<p>We will first describe a mechanism the association of which with the -extending sling will be seen on <a href="#i_p048">page 48</a>.</p> - -<p>α. <i>To limit extension of the knee</i> all that is necessary is -to prolong the antero-posterior diameter of the knee bolt (which -turns with the leg) by a horizontal wing,<span class="pagenum"><a name="Page_39" id="Page_39">[39]</a></span> which engages with a -corresponding notch in the femoral condyle. We show here <a href="#i_p039">Figs. 50 and 51</a>) -a rather more complicated but still simple mechanism which -is interesting because it can be combined with the action of the -extending sling (see <a href="#Page_48">page 48</a>).</p> - -<p>It consists of a piece of metal curved on the flat, ending above in a -cylinder through which the knee bolt passes, continued below into a -cylindrical tail piece, which fits into a ring which is fixed inside -the top of the calf. During flexion this plate moves in a median -posterior window in the femoral condyle, becoming oblique at the same -time as the tail piece sinks into the ring; during extension the tail -piece rises in the ring and the interior flat surface engages against -a corresponding groove in the femoral condyle (covered with leather to -secure silence).</p> - -<div class="figcenter" id="i_p039" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p039.png" - width="450" - height="375" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 50 and 51.—<span class="sm">Internal mechanism to limit -extension of the knee.</span></p> - </div> - -<p class="p2">β. In the Marks knee an internal system of cords and springs -serves at the same time both to limit<span class="pagenum"><a name="Page_40" id="Page_40">[40]</a></span> extension and to produce an -elastic extending force. It is a system which is fairly simple and -much used.</p> - -<p>1. <i>Limitation of extension</i> is secured by a U-shaped cord, the -extremities of which are fixed to a wooden cross piece (T), fixed in -the thigh piece three centimetres above the axis of the joint. The -cords leave the thigh through two lateral openings in the back of the -thigh piece, and the loop passes through a ring halfway down the calf.</p> - -<p>2. <i>The extending force</i> consists in a coiled steel spring the -mechanism of which is combined with that of this cord. The lower half -of the spring is enclosed in a copper tube lined with chamois leather -to secure silence; its upper half or rather more is coiled around a -wooden pin, which terminates above in a head which is cup shaped: -it will be seen (<a href="#i_p041c">Fig. 57</a>)that if pressure is made on this head the -spring is shortened and under compression.</p> - -<p>This spring is fixed below (by means of a tenon which allows -antero-posterior movement) upon a bracket in the calf which is -continuous with the ring through which passes the check cord. The -cup-shaped upper end is in contact with a ball which projects from -the upper surface of the thigh piece between the two openings for the -check cord (<a href="#i_p041b">Fig. 53</a>). It will be seen that when the knee is flexed -the spring, the head of which lies below the axis of the joint, will -be compressed at the same time as the check cord is relaxed) so that -there is an elastic recoil tending to reproduce extension. The ball -which rests on the top of the spring is fixed in such a manner as to -be in the same horizontal plane as the axis of the knee: that is to -say, it is in the same vertical plane as this axis when the knee is -flexed to a right<span class="pagenum"><a name="Page_41" id="Page_41">[41]</a></span><span class="pagenum"><a name="Page_42" id="Page_42"></a></span> -angle (<a href="#i_p041a">Fig. 52</a>). Therefore in this position the -spring has no tendency to produce either extension or flexion, that -is to say the mechanism is now at dead point, and when the patient is -sitting flexion to the right angle is maintained without any effort.</p> - -<div class="figcenter" id="i_p041a" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p041a.png" - width="345" - height="450" - alt="" /> - <p class="smcap center">Fig. 52.</p> - </div> - -<div class="figcenter" id="i_p041b" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p041b.png" - width="231" - height="450" - alt="" /> - <p class="smcap center">Fig. 53.</p> - </div> - -<div class="figcenter" id="i_p041c" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p041c.png" - width="288" - height="450" - alt="" /> - <p class=" center"><span class="smcap">Figs.</span> 54 to 57.</p> - <p class="sm center"><i>The Marks knee.</i></p> - <p class="sm p0"><span class="smcap">Figs.</span> 52 and 53.—O, knee bolt. T, cross piece of wood, -situated in the extended position above the knee bolt, in the flexed -position behind it. C, bracket fixed halfway up the interior of the -calf.</p> - <p class="sm p0">A U-shaped cord <i>a</i> passes through a hole in the bracket C and is -attached at each end to the cross piece T; it limits extension. The -two ends of the word enter the thigh piece by two apertures in the -posterior surface, between which is fixed a metal ball which projects -2 cms. The extending spring is the rod <i>b</i> which is fixed to this ball -and to a socket in the upper surface of the bracket. Figs. 54 to 57 -show the parts of this spring: a tube, a spiral spring, and a rod with -cup-shaped head. When the spring is in the tube and the rod in the -spring (<a href="#i_p041c">Fig. 57</a>), it will be seen that pressure upon the head of the -rod increases the tension of the spring.</p> - </div> - -<p class="p2">In the knee shown in <a href="#i_p042">figures 58 and 59</a> the <i>extending mechanism</i> is as -follows. Directly behind the axis of the joint is a metal crossbar, -upon which fits the grooved upper extremity of a piece of wood, the -other end of which rests (like a lance) in a pocket which is suspended -in the leg piece by an elastic band (the latter being kept stretched -to a greater or less extent by a lace which emerges from the calf).</p> - -<div class="figcenter" id="i_p042" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p042.png" - width="500" - height="388" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 58 and 59.—<span class="sm">Elastic spring for extending -the knee.</span></p> - </div> - -<p>The elastic being slightly stretched when the knee is extended, it -will be seen that the crossbar turning round the axis of the knee -becomes lowered as the knee flexes, so that the elastic is stretched -and<span class="pagenum"><a name="Page_43" id="Page_43">[43]</a></span> consequently opposes flexion; but when the knee is bent to a -right angle the axis of the joint, the crossbar and the wooden rod -are in the same vertical line; the mechanism is at a dead point just -as we have already seen in the Marks knee, and the tension on the -elastic presses the leg directly downwards without tending either to -flex or to extend it.</p> - -<p>Leather pads deaden the noise of the impact.</p> - -<p>Extension is limited, as will be seen by comparing <a href="#i_p042">figures 58 and 59</a>, -by the vertical wooden rod meeting flat surfaces in the thigh and leg -pieces simultaneously.</p> - -<p>3. <i>Extending slings.</i><a name="FNanchor_6_6" id="FNanchor_6_6"></a><a href="#Footnote_6_6" class="fnanchor">[6]</a>—To the sling which passes over the shoulder -on the side of the artificial limb, is attached a strap which passes -down in front of the thigh piece and is attached to the upper third of -the leg.</p> - -<div class="footnote"> - -<p><a name="Footnote_6_6" id="Footnote_6_6"></a><a href="#FNanchor_6_6"><span class="label">[6]</span></a> This is an old French method used in Fouilloy's -appliance, which has, however, only become generally used in the -suspending braces of the American appliance.</p></div> - -<p>When the patient raises the leg from the ground, the weight of the -appliance makes it slip down the stump, tension is thus produced upon -this strap and as a result the knee is extended. By an adroit movement -of the shoulder this extension can be carried out actively.</p> - -<p>When the limb rests upon the ground the weight of the body presses the -stump down into the bucket, the tension on the strap is released and -consequently the knee is free to flex.</p> - -<p>On <a href="#Page_44">pages 44 to 48</a> will be found figures showing the principal points -in this extending brace.</p> - -<p>The braces, whether they have or have not an extending strap, may be -constructed in three ways:</p> - -<p><i>a</i>. To ease the constant pressure exerted on the<span class="pagenum"><a name="Page_44" id="Page_44">[44]</a></span><span class="pagenum"><a name="Page_45" id="Page_45"></a></span> shoulders by the -strap which is stretched by the weight of the artificial limb, the -brace may be made of elastic like the ordinary trousers brace. But the -limb they carry is heavy, so they rapidly become overstretched and it -is difficult to keep them properly adjusted.</p> - -<p><i>b.</i> The stretching is naturally diminished if the upper part of the -brace is not elastic but an elastic section is inserted in its lower -third, in front and behind.</p> - -<p><i>c.</i> But the patients almost always say that better command of the -limb is obtained with inelastic braces. If the strap is wide on the -shoulder, the pressure is well borne, and the lower attachment may be -made narrower, consisting of a leather thong (<a href="#i_p046">Fig. 64</a>).</p> - -<div class="figcenter" id="i_p044a" style="width:386px"> - <img - class="p2" - src="images/i_p044a.png" - width="386" - height="550" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 60 and 61.</p> - </div> - -<div class="figcenter" id="i_p044b" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p044b.png" - width="500" - height="365" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 62 and 63.</p> - </div> - -<div class="figcenter" id="i_p046" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p046.png" - width="439" - height="550" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 64 and 65.</p> - <p class="sm">Fig. 60.—Fouilloy's Braces. Figs. 61 to 65.—Marks' braces. -Fig. 61.—General construction of the braces. Figures 62 and -63.—Attachment at the sides of the thigh piece. Figures 64 and -65.—General view of the apparatus as worn.</p> - </div> - -<p class="p2">To attach extension braces to the front of the leg piece the old -and simple method adopted by Fouilloy may be used. It consists in -attaching an elastic strap to the brace which passes over the shoulder -on the side of the amputation (and which is fixed to the top of the -thigh piece alongside of the other brace). The elastic strap ends in a -bifurcated leather thong each branch of which (held in place by a loop -of leather) descends obliquely alongside of the patella surface to be -attached to the corresponding side of the leg in its upper third (<a href="#i_p046">Fig. 60</a>.</p> - -<p>In Marks' method the braces end below in loops made of a leather thong -(<a href="#i_p046">Fig. 61</a>). These are held against the thigh piece by passing under -leather bands; they reach as far down as the upper third on the inner -and outer sides of the thigh (<a href="#i_p046">Figs. 62 to 65</a>).</p> - -<p>To each of the loops, gliding on them by means of a pulley, is -attached a leather strap which descends vertically to the upper third -of the corresponding surface of the leg, being held in place by -passing under<span class="pagenum"><a name="Page_46" id="Page_46">[46]</a></span> a leather band. These two straps are attached to each -other in front by a lace, which draws them towards the middle line, -and in this way brings their line of action forwards. The tighter the -lace is drawn the more powerful will be the extending force.</p> - -<p>Instead of attaching the extension brace to the leg piece it may be -made to pass under a pulley in the interior of the knee. What actually -happens is that the thigh piece drops, owing to its weight, when -the limb is swung free; this throws a strain on the brace which is -transmitted to the leg piece by the following mechanism. The metal -stop described on <a href="#Page_39">page 39</a> which limits extension of the knee during -the period of weight bearing, is prolonged upwards<span class="pagenum"><a name="Page_47" id="Page_47">[47]</a></span> and forwards -beyond the hole through which the axis of the knee passes, this -prolongation being furnished with two wooden pulleys (<a href="#i_p048">Fig. 69</a>). The -loops attached to the braces enter the front of the thigh piece, each -by a separate opening, turn under the corresponding pulley and emerge -again posteriorly (<a href="#i_p047">Figs. 66 to 68</a>).</p> - -<div class="figcenter" id="i_p047" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p047.png" - width="408" - height="550" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 66 to 68.</p> - </div> - -<p class="p2">This mode of attachment has the advantage that when the limb is swung -the movement does not take place upon the shoulders—which easily -become chafed by the ordinary suspenders—but upon the pulleys upon -which the leather thongs work.</p> - -<p><span class="pagenum"><a name="Page_48" id="Page_48">[48]</a></span></p> - -<p>The mechanism shown in <a href="#i_p048">figures 69 to 71</a> is interesting. When the metal -lever moves around the axis of the knee joint, its lower end and the -pulleys at the upper end travel in opposite directions: in flexion -the pulleys move downwards and forwards, the lower end upwards and -backwards; in extension they move in the opposite direction. Therefore -when the limb is swung and the knee bends (<a href="#i_p048">Fig. 71</a>), the thigh piece -drops of its own weight, the braces tighten, raise the pulley and -consequently make the lower end of the lever move downwards and -forwards, thus extending the knee joint.</p> - -<div class="figcenter" id="i_p048" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p048.png" - width="500" - height="392" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 69 to 71.</p> - </div> - -<p class="p2">D. <i>Mechanism to secure rigidity of the knee during weight -hearing.</i>—During the time that the healthy limb is raised from the -ground and carried forwards there must be complete rigidity of the -artificial limb in the extended position. This is<span class="pagenum"><a name="Page_49" id="Page_49">[49]</a></span> secured by mounting -the foot in the equinus position. When it has been swung forwards, in -taking a step, the limb comes in contact with the ground heel first; -then, as the leg becomes vertical the entire sole lies flat on the -ground; if the foot is in equinus this position is only possible with -the knee hyperextended, or with full extension it may be possible -for a very short period. So that it is the weight of the body that -locks the limb in the extended position, the sole of the foot sloping -obliquely downwards and forwards; and the weight being taken on the -toe. There is<span class="pagenum"><a name="Page_50" id="Page_50">[50]</a></span> always a tendency to hyperextension, and to avoid -straining the limb in this direction (as occurs in a living knee which -is forced into the position of genu recurvatum by a talipes equinus) -it is as well, as we have already said, to oppose it by some passive -resistance, either in the form of a simple popliteal check cord or by -a stop fixed to the front of the leg.</p> - -<div class="figcenter" id="i_p049" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p049.png" - width="550" - height="432" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 72 to 75.</p> - <p class="sm">In Figure 72 the foot is fixed, the weight comes upon the point of the -foot, and pressure upon the axis AB tends to close the angle ABC, i.e. -to produce a genu recurvatum, and so to lock the knee in extension. -If the foot is articulated, equilibrium is secured in the same way. -Figures 73 to 75 are intended to show that in order that the axis ABC -may not be vertical (Fig. 73) the axis B of the knee must be behind -the perineal concavity in the bucket, and it is better if at the same -time the axis of the ankle joint C is carried forward.</p> - </div> - -<p class="p2">This extension is unlocked automatically at the moment when the weight -is thrown forward on the healthy limb, the artificial limb rising on -its toe and the knee commencing to bend because the braces are relaxed.</p> - -<p>E. <i>Movable ankle.</i>—We have taken as our type a limb with a fixed -foot. There are, however, a number of methods of attaching a foot with -a <i>movable ankle joint</i>. The general principles and the mechanism for -securing stability are those which we have already studied, but the -gait is more supple, at the price it is true of somewhat delicate -articulations and therefore of simplicity.</p> - -<p>The foot is made of a single piece of wood; it is divided transversely -at the level of the middle of the metatarsal bones, and the anterior -part (shaped like toes) is attached by two pieces of leather, dorsal -and plantar, between which are two indiarubber cylinders which keep -the toe piece extended 15° to 20° when at rest, and which allow, when -the foot is pressed on the ground, an extension to 45°.</p> - -<p>This foot is mounted on the leg at an angle of 45° beyond the right -angle, with an interposed rubber cylinder, which allows of the -diminution of the angle to 25° or 30° but no further. It is important -that flexion to a right angle should not be possible. In fact, a -slight degree of equinus is essential in order to secure<span class="pagenum"><a name="Page_51" id="Page_51">[51]</a></span> the locking -of the knee in extension, exactly as with the fixed foot (compare -<a href="#i_p049">figures 73, 74 and 75</a> with <a href="#i_p049">figure 72</a>), and as on the shoe there is -always a heel which makes us walk normally in slight equinus, the -two feet will be similar in appearance, the slight movement of the -artificial foot being sufficient to allow a rolling movement of the -sole upon the ground (<a href="#i_p052">Figs. 77 to 86</a>).</p> - -<div class="figcenter" id="i_p051" style="width:70%;"> - <img - class="p2" - src="images/i_p051.png" - width="450" - height="208" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 76 to 76A.</p> - </div> - -<p class="p2">The figures 76 and 76A show the simplest and best known mechanism. On -the upper surface of the foot two cavities are hollowed, one in front -and one behind the bolt of the ankle joint, in each of these is placed -a cylinder of rubber; the posterior cylinder is about twice as thick -as the anterior. Above them the leg piece is fixed, it ends in front -in a short instep which lies within the cavity hollowed out in the -foot.</p> - -<p>The foot is attached to the leg piece by a bolt made as follows: a -steel tube fitting into two corresponding grooves in the leg and foot, -is attached to the leg by being prolonged upward into a vertical rod, -which is secured by a nut inside the leg piece.</p> - -<p>Upon the steel tube moves a brass rod shaped like an inverted U, the -two ends of which pass through the foot and fasten beneath it by two -nuts (<a href="#i_p053a">Fig. 82</a>).</p> - -<p>Raising the point of the foot further compresses<span class="pagenum"><a name="Page_52" id="Page_52">[52]</a></span> the anterior piece -of rubber, lowering it relieves the pressure upon this piece and -compresses the posterior piece. But the tension and the size of the -pieces of rubber are such that they are under slight compression in -the position of rest, the foot being in 30° of equinus. So that this -foot is never loose. When pressure is made on the point of the foot it -may come to within 15° or 20° of a right angle, but it returns to its -angle of 30° as soon as the pressure ceases.</p> - -<div class="figcenter" id="i_p052" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p052.png" - width="550" - height="117" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 77 to 81.</p> - <p class="sm">Contact of the sole with the ground in normal walking. Heel first then -toe, with progressive dorsiflexion of the ankle joint. Compare with -the contact of the artificial foot in <a href="#i_p053a">figures 82 to 86</a>.</p> - </div> - -<p>With boots on, with heels of 2·5 centimetres the two feet are in the -same position when the soles are flat on the ground.</p> - -<p>The forepart of the foot (representing the toes and the anterior part -of the metatarsals) is kept in this position (<a href="#i_p051">Fig. 76</a>) in slight -extension by a piece of rubber, compression of which allows an -increase of extension of 15° to 20°.</p> - -<p>When a step is taken, the heel of the foot first meets the ground, -the leg pointing downwards and forwards. Then the whole sole comes -to lie flat on the ground, the degree of equinus being increased, -the posterior rubber compressed and the anterior relaxed (Figs. 82 -and 83), but when the limb is vertical the sole still being flat on -the ground, compression of the posterior diminishes and that on the -anterior increases<span class="pagenum"><a name="Page_53" id="Page_53">[53]</a></span> (Fig. 84). This remains unchanged up to the moment -when the foot leaves the ground, whilst the heel rises and the weight -is borne on the toe piece of the foot, which is forced into extension -(Figs. 85 and 86).</p> - -<div class="figcenter" id="i_p053a" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p053a.png" - width="550" - height="194" - alt="" /> - </div> - -<div class="figcenter" id="i_p053b" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p053b.png" - width="350" - height="220" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 82 to 86.</p> - </div> - -<p class="p2">This method of using rubber cylinders is the simplest. Another -method, good but more delicate, is shown in <a href="#i_p054">figures 87 and 88</a>. In the -leg below the calf are two cross pieces of wood; the lower placed -transversely supports the upper which is antero-posterior and so -increases its resistance to the cords which are attached to it.</p> - -<div class="figcenter" id="i_p054" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p054.png" - width="450" - height="366" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 87 and 88.</p> - </div> - -<p class="p2">The shape of these pieces of wood can be seen in the figures and -require no further explanation. The bolt of the ankle joint is the -same as in the foot last described. To the antero-posterior cross -piece are attached two cords, which pass through the foot and are -attached beneath it, one under the heel, and the<span class="pagenum"><a name="Page_54" id="Page_54">[54]</a></span> other about the -level of the midtarsal joint. The posterior cord is inelastic and -stops dorsiflexion of the foot. The anterior has a section of elastic -in it; it prevents the dropping of the foot whilst the limb is being -swung. A small pad of rubber placed in front beneath the anterior part -of the leg piece allows, by its compression, the partial correction of -the equinus when the sole is pressed flat on the ground.</p> - -<p>Some appliances allow the foot a little <i>lateral mobility</i>, by -rotation around an antero-posterior axis, so that it may adapt itself -to irregularities of the ground. We here illustrate the "Duplex -foot," which is very ingenious but which has the defect that after -a time the mechanism grates. The ankle attachment is carried out in -the same way as in the limbs last described (in this particular limb -it is<span class="pagenum"><a name="Page_55" id="Page_55">[55]</a></span> attached by cords), but the foot piece is divided as in a -sub-astragaloid amputation; the lower surface of the astragaloid piece -bears a median antero-posterior projection, tapering posteriorly and -enlarged into a knob anteriorly, this lies in a corresponding groove -in the heel piece; alongside this are two rubber cushions which are -alternately compressed and relaxed as the foot inclines to one or -other side.</p> - -<div class="figcenter" id="i_p055" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p055.png" - width="264" - height="400" - alt="" /> - <p class="center"><span class="smcap">Fig. 89.</span>—<span class="sm">Duplex Foot.</span></p> - </div> - -<h6>Combined mechanism for knee and ankle joints.</h6> - -<p>This very ingenious combination, which, however, necessitates a rather -complex mechanism, was devised by Palmer in 1850. It is carried out -in the limb made by Frees, the mechanism of which will be seen to -resemble that of the articulated foot shown on page 54 in <a href="#i_p054">figures 87 -and 88.</a></p> - -<p><span class="pagenum"><a name="Page_56" id="Page_56">[56]</a></span></p> - -<p>Above the axis of the knee joint and at right angles to it is a wooden -cross piece, to which are attached three cords, two behind the joint, -one in front; these cords emerge from the thigh piece through an -opening in its lower end (<a href="#i_p057">Figs. 90 to 92</a>).</p> - -<p>The posterior of these cords, made of hemp, ends inside the upper -third of the leg. It limits the extension of the knee, exactly as -described in the Marks leg.</p> - -<p>The other two cords extend down to the foot, which is attached in a -manner very similar to that shown on <a href="#i_p054">page 54</a>, but with a single rubber -cylinder behind, and with the instep cut obliquely so that when the -joint is in the resting position of equinus there is an opening in -front amounting to an angle of 15° to 20°. The posterior cord, of -hemp, is attached in the heel; the anterior, made of catgut with an -indiarubber section, enters the foot obliquely and is fixed a little -in front of the middle of the sole.</p> - -<p>When the knee flexes, the wooden cross piece tilts, its posterior end -becoming lower, its anterior higher (<a href="#i_p057">Figs. 91 and 92</a>), the elastic of -the anterior cord is tightened, thus raising the front of the foot, -whilst at the same time the heel cord is relaxed. Thus the mechanism -which produces extension of the knee acts at the same time upon -the foot; when the knee is straight the foot is plantar flexed to -20°, when the knee flexes the foot comes to a right angle. Thus the -foot becomes dorsiflexed at the same time as the knee flexes, as in -ordinary walking.</p> - -<p>If the action in walking is watched, it will be seen that as the limb -is swung forward, the toe is raised so as to clear the ground.<a name="FNanchor_7_7" id="FNanchor_7_7"></a><a href="#Footnote_7_7" class="fnanchor">[7]</a></p> - -<div class="footnote"> - -<p><a name="Footnote_7_7" id="Footnote_7_7"></a><a href="#FNanchor_7_7"><span class="label">[7]</span></a> The mechanism of this artificial leg resembles that -of the "tendon leg," which was in such common use in England -before the present war that it is often called the English -pattern.—(<span class="smcap">Ed.</span>)</p> - -<p><span class="pagenum"><a name="Page_57" id="Page_57">[57]</a></span></p></div> - -<div class="figcenter" id="i_p057" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p057.png" - width="394" - height="600" - alt="" /> - <p class="center"><span class="smcap">Fig. 92.—</span>(<span class="smcap">Figs.</span> 90 to 92. <span class="sm">Foot and Knee of Frees.)</span></p> - </div> - -<p class="p2">In the sitting position the anterior cord is not relaxed, there is no -dead point, so that the knee always tends to extend. This is somewhat -inconvenient.</p> - -<p><span class="pagenum"><a name="Page_58" id="Page_58">[58]</a></span></p> - - -<p class="center p1 bold"><i>Conversion of the articulated peg leg into the leg with free knee -movement and vice versâ.</i></p> - -<p>Whatever advantage it may be thought to possess, in our opinion the -artificial leg with free knee joint is only suitable for sedentary -occupations; it is not suitable for manual labourers and particularly -for agricultural labourers who are obliged to get about on rough -ground. Hence it is not uncommon for a patient who has been provided -with an American leg to come and ask for a peg leg. In figures 93 -to 95 it will be seen that it is a simple matter to transform the -limb into an articulated peg. It is only necessary<span class="pagenum"><a name="Page_59" id="Page_59">[59]</a></span> to attach the -stirrup-shaped fork of the peg to the thigh piece by the knee bolt, -and to add the double lock. To this peg may be added, if desired, the -show calf and foot described on <a href="#Page_32">page 32</a>. The full artificial leg can -be rebuilt whenever it is wished.</p> - -<div class="figcenter" id="i_p058" style="width:380px"> - <img - class="p2" - src="images/i_p058.png" - width="380" - height="450" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 93 to 95.</p> - </div> - -<p class="p2">On the other hand, an articulated wooden peg leg, such as we have -described under the name of the Federation leg, can be easily adapted -for walking with a free knee. It is only necessary to unlock the knee -joint and to add the artificial muscle or accumulator of elastic shown -in <a href="#i_p059">figure 98</a>. This supplies the extending force, the value of which we -have shown on <a href="#Page_36">page 36</a>. We consider that this appliance is excellent -and we know patients who almost always<span class="pagenum"><a name="Page_60" id="Page_60">[60]</a></span> walk upon the peg, but who -sometimes use a free knee for short walks. The conversion is simple -and requires no special care. Under these conditions the fixed foot -is almost always used; there is nothing to prevent the fitting of an -articulated foot, but we have already seen that there is no great -difference in walking between the old-fashioned fixed foot of the -Marks leg and the more or less complicated articulated feet of more -recent design.</p> - -<div class="figcenter" id="i_p059" style="width:597px"> - <img - class="p2" - src="images/i_p059.png" - width="597" - height="550" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 96 to 98.</p> - </div> - - -<h4>II. Limbs without bearing upon the Ischium</h4> - -<p class="center"><i>For amputations through the condyles of the femur, and similar -amputations</i> (<i>disarticulation of the knee and very short stumps below -the knee</i>).</p> - -<p>Certain orthopædists do not know how to fit an artificial limb to an -amputation through the condyles of the femur; they come therefore to -the conclusion that this is a bad operation, and ought to be replaced -by an amputation above the condyles.</p> - -<p>The two objections raised to this amputation are:—</p> - -<p>1. That it is impossible to fit a wooden bucket because the bone at -the lower end of the stump is larger than it is at a higher level.</p> - -<p>2. That it does not leave enough room to fit an artificial knee joint -at the right level.</p> - -<p>These two objections are not valid, and, on the other hand, this -amputation allows us to fit an artificial limb with complete end -bearing, and this is a great advantage.</p> - -<p>1. <i>Fitting of the bucket.</i>—The first difficulty is easily got over. -All that is necessary is to cut away the front of the lower half -of the bucket, and to cover in this opening with a lacing piece of -leather. The<span class="pagenum"><a name="Page_61" id="Page_61">[61]</a></span> stump passes into the top of the bucket, comes out of -this opening and then falls back into the enlarged lower end where it -takes a direct bearing (Fig. 99).</p> - -<div class="figcenter" id="i_p061" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p061.png" - width="250" - height="550" - alt="" /> - <p class="center"><span class="smcap">Fig. 99.</span>—<span class="sm">Limb with end bearing for amputation -in the region of the condyles of the femur. Anterior part of the thigh -bucket cut away to allow the insertion of the enlarged lower end of -the stump.</span></p> - </div> - -<p class="p2">2. <i>Level of the knee joint.</i>—It is clear that if the stump is too -long it is impossible to fit a knee joint with a bolt right through at -the same level as the opposite knee. The thigh piece would have to be -prolonged downwards in order to allow of the insertion of this bolt.</p> - -<p><span class="pagenum"><a name="Page_62" id="Page_62">[62]</a></span></p> - -<p>This arrangement would not affect walking, but would be unsightly in -sitting because of the inequality in the length of the thighs.</p> - -<p>It is easy to overcome the difficulty by attaching the leg by two -independent lateral hinge joints, without a bolt right through, using -the stirrup-shaped fork and the double lock, if a peg is used. This -method, as we have already stated, is not so strong, but this is to a -large extent compensated for by the possibility of getting a direct -end bearing.</p> - -<p>3. <i>Direct end bearing and suspension.</i>—If the stump is well covered -with a good anterior flap and if the lower end of the bucket is -accurately moulded upon it with an interposed layer of felt, the -patient can walk directly upon the end of the stump, without it being -necessary to carry the bucket up against the ischium, simple braces -being used as the means of suspension.</p> - -<p>4. There is nothing special about the braces or about the extending -strap if the knee is free, nor about the method of attaching the foot.</p> - -<p>These limbs for long stumps do not require any spring to extend the -knee, if one is wanted an artificial muscle is quite easily fitted.</p> - -<p>We have taken as our type an amputation through the femoral condyles.</p> - -<p>The covering of the stump is excellent, and pressure is taken upon -tissues which are naturally adapted to it (the thick skin and fibrous -tissue over the patella), specially if it has been possible to keep -the patella in the flap and fix it across the cut surface of the femur -(Gritti's operation).</p> - -<p>The mechanical points in the fitting of an artificial limb for an -amputation through the knee joint are the same. But this amputation -seems to us to be inferior<span class="pagenum"><a name="Page_63" id="Page_63">[63]</a></span> to that through the condyles. The -sacrifice of three centimetres in length is of no importance in -an appliance with direct end bearing; and, on the other hand, -disarticulation has several disadvantages:—</p> - -<p>1. The enlargement of the femoral condyles, without any compensating -advantage.</p> - -<p>2. The bearing upon the two condyles, separated by a groove.</p> - -<p>3. The insufficient covering of the condyles by the thin skin of the -front of the leg.</p> - -<p>The principles of fitting a limb are the same in amputations of -the leg in which we are obliged to make the patient walk upon the -bent knee (too short a stump, the position of the scars, persistent -osteitis, the impossibility of straightening the knee when it is -ankylosed or stiff in a flexed position), as in the old-fashioned -kneeling pin leg.</p> - -<p>A posterior transverse band, passing over the bent stump helps to hold -the limb on.</p> - -<hr class="chap" /> - -<div class="chapter"> - -<p><span class="pagenum"><a name="Page_64" id="Page_64">[64]</a></span></p> - -<h2><i>CHAPTER IV</i></h2></div> - -<h3>ARTIFICIAL LIMB FOR DISARTICULATION AT THE HIP JOINT</h3> - -<p>Attempts have been made to attach to the pelvis, by means of a waist -belt or braces, a wooden artificial limb whose upper end is fitted -directly on to the tuberosity of the ischium. So far these have met -with little success. In our opinion, the only really practical method -is to enclose the whole stump and pelvis in a regular corset, and to -attach the artificial limb to this corset.<a name="FNanchor_8_8" id="FNanchor_8_8"></a><a href="#Footnote_8_8" class="fnanchor">[8]</a></p> - -<div class="footnote"> - -<p><a name="Footnote_8_8" id="Footnote_8_8"></a><a href="#FNanchor_8_8"><span class="label">[8]</span></a> Amongst English limb makers this moulded corset -with the steel hip attachments is usually known as the "tilting -table."—(<span class="smcap">Ed.</span>)</p></div> - -<p>The moulding of this corset upon the stump must be accurate.</p> - -<p>The tuberosity of the ischium is the only bony point in the stump upon -which pressure can be taken. The corset may be made of leather, but, -until a new order is issued, the material of choice is celluloid, -moulded upon a plaster of Paris cast, in spite of the disadvantage -mentioned on <a href="#Page_4">page 4</a>.</p> - -<p>The limb is an articulated peg leg, with convertible knee joint and -double lock, exactly the same as in the limb for amputation through -the thigh.</p> - -<p>It is attached to the pelvis (<i>i.e.</i> to the tilting table), as shown -in figures 100 and 101, by a joint with a double anterior lock, which -allows the patient to sit down by flexing the hip.</p> - -<p><span class="pagenum"><a name="Page_65" id="Page_65">[65]</a></span></p> - -<div class="figcenter" id="i_p065" style="width:437px"> - <img - class="p2" - src="images/i_p065.png" - width="437" - height="600" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 100 and 101.</p> - </div> - -<p class="p2">This general description and an examination of figures 100 and 101 -will suffice to explain this appliance. It is comparatively rarely -required, and its construction is difficult; we consider that the -forms shown in the illustrations are the best. It is only possible -to fit such an appliance when the conditions are good, when the scar -is above and in front of the ischium, and when the latter is well -covered.</p> - -<hr class="chap" /> - -<div class="chapter"> - -<p><span class="pagenum"><a name="Page_66" id="Page_66">[66]</a></span></p> - -<h2><i>CHAPTER V</i></h2></div> - -<h3>ARTIFICIAL LIMBS WITH FREE KNEE JOINT FOR AMPUTATION THROUGH THE LEG</h3> - -<p>If the leg stump is ten centimetres long, if the knee joint is freely -mobile and capable of complete, or almost complete, active extension, -and if there are no adherent scars around the tuberosities of the -tibia, the American apparatus with free knee joint should be adopted.</p> - -<p><i>Walking on the bent knee</i> (as stated on <a href="#Page_63">page 63</a>) with the "poor man's -peg" may be allowed as a temporary measure, but the patient must be -advised to give his knee a rest frequently in order to lessen the risk -of stiffness in a flexed position.</p> - -<p>There are two methods of fitting, corresponding with those we have -described for the thigh.</p> - -<p>1. For the ordinary amputations with bearing upon the top of the leg.</p> - -<p>2. For amputation very low down with end bearing upon the extremity -of the stump.</p> - -<div class="figcenter" id="i_p066a1" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p066a1.png" - width="206" - height="550" - alt="" /> - <p class="center"><span class="smcap">Fig. 102.</span>—<span class="sm">Limb fitted upon the patient. Note that he - stands upon the toe, and that the knee is flexed.</span></p> - </div> - -<div class="figcenter" id="i_p066a2" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p066a2.png" - width="204" - height="550" - alt="" /> - <p class="center"><span class="smcap">Fig. 103.</span>—<span class="sm">Posterior view of the same limb.</span></p> - </div> - -<div class="figcenter" id="i_p066a3" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p066a3.png" - width="212" - height="550" - alt="" /> - <p class="center"><span class="smcap">Fig. 104.</span>—<span class="sm">Anterior view of the same limb.</span></p> - </div> - -<p><span class="pagenum"><a name="Page_67" id="Page_67">[67]</a></span></p> - - -<h5>I. Appliances with Bearing upon the Tuberosities of the Tibia</h5> - -<p>An artificial limb for amputation through the leg with a free knee -joint is composed of two parts: a leg piece (with foot) which is -fitted to the bony prominences around the top of the stump and -supports them; and a suspensory apparatus which consists of a lacing -thigh corset.</p> - -<p>A. <span class="smcap">Leg Bucket.</span>—The points on which the top of the bucket -must be fitted are the internal tuberosity and the anterior -tubercle of the tibia, and the head of the fibula, so that hollows -corresponding to these must be carved out.</p> - -<p>Pressure upon the head of the fibula is often painful, and a deep -concavity is therefore carved out for it. The pressure then comes upon -the external tuberosity of the tibia which, however, ordinarily bears -little weight.</p> - -<p>Whenever possible direct end bearing upon the termination of the -stump should be used as an accessory to relieve the weight upon the -tuberosities of the tibia; this is obtained as described on <a href="#Page_7">page 7</a>. -It is only possible if the scar is lateral and if there is a good -thick posterior or external flap (in the upper third of the leg). An -anterior flap is the least satisfactory.</p> - -<p><span class="pagenum"><a name="Page_68" id="Page_68">[68]</a></span></p> - -<p>It is also advisable—</p> - -<p>That the inner surface and the anterior border of the tibia be divided -obliquely, and that the fibula be divided at a higher level than the -tibia.</p> - -<p>The fibula must not take weight, it is too slender. In high -amputations it has a tendency to tilt outwards, causing the double -inconvenience of widening the stump and of projecting through the -skin. If only 4 or 5 cms. of the fibula remain it is perhaps best to -disarticulate and remove it.</p> - -<p>With a fitting arranged in this way, we consider that the convenience -of walking with a free knee can be assured to patients whose stumps -measure only 10 cms. from the lower border of the patella.</p> - -<p>These principles can be applied to a limb constructed either of wood -or of leather.</p> - -<p><i>The leather appliance</i> (French method) is formed of a leather -cylinder, strengthened by two laternal steels which articulate at the -level of the knee joint with two similar steels in the thigh corset. -Its upper edge may be strengthened anteriorly by a metal plate, but -in practice the latter cannot be made to fit with precision the bony -prominences enumerated above. It is actually the edge of the leather, -adjusted by lacing, which supports tibial tuberosities, and therefore -the precision of the fit is soon lost.</p> - -<p>For this reason, for amputation below the knee, the American method of -construction with a wooden bucket is demonstrably superior.</p> - -<p><span class="pagenum"><a name="Page_69" id="Page_69">[69]</a></span></p> - -<p>These limbs are infinitely more durable than the French. They may -last three years, whereas the French limb used by a young and active -patient is worn out at the end of the first year, and it was for this -reason that a limb with a free knee joint used to be considered a -luxury.<a name="FNanchor_9_9" id="FNanchor_9_9"></a><a href="#Footnote_9_9" class="fnanchor">[9]</a></p> - -<div class="footnote"> - -<p><a name="Footnote_9_9" id="Footnote_9_9"></a><a href="#FNanchor_9_9"><span class="label">[9]</span></a> That is the reason that amputation at four fingers' -breadth below the knee used to be called for the working class, -amputation at "the seat of election," a name which is no longer -applicable and which is liable to mislead the operator.</p></div> - -<p>This wooden bucket is shaped very accurately to the bony prominences, -and by passing the fingers over its inner surface the three hollows -corresponding to the points of pressure enumerated above can be -distinctly felt.</p> - -<p>It is important to describe the shape of the upper edge of the bucket -in order to guard against two points which may interfere with flexion—</p> - -<blockquote> - -<p>I. Pinching of the tissues behind the knee.</p> - -<p>II. The tendency of the stump, when it is short, to tilt forward -in the bucket (<a href="#i_p071">Fig. 108</a>).</p></blockquote> - -<p><i>Pinching of the flesh behind the knee</i> in flexion takes place between -the edge of the leg piece and that of the thigh corset.</p> - -<p>If the top of the bucket is horizontal, it must inevitably occur, even -if the edge of the thigh corset is well cut away (<a href="#i_p070">Fig. 106</a>).</p> - -<p>It can be avoided by cutting away these two edges into concavities -opposite each other.</p> - -<p><span class="pagenum"><a name="Page_70" id="Page_70">[70]</a></span></p> - -<div class="figcenter" id="i_p070" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p070.png" - width="450" - height="311" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 105 and 106.—<span class="sm">Limb in which the upper edge of the leg -bucket is almost horizontal; in the sitting position (Fig. 106) the -flesh at the back of the thigh is pinched even if the lower end of the -thigh corset is well cut away.</span></p> - </div> - -<p class="p2">In the French limbs made of leather it is usual to make the leg piece -very high in front, <i>i.e.</i> as high as the middle of the patella. -This is quite useless. The posterior border is cut down to a depth -of two fingers' breadth below the axis of the joint. Pinching is -thus avoided, but the posterior support is insufficient, the stump -tilts forward as described above and the bucket gapes in front (<a href="#i_p071">Fig. 108</a>). -If the top of the bucket is horizontal—as in certain American -limbs—there is, as we have already said, pinching of the popliteal -tissues and compression of the popliteal vessels and nerves (Fig. -106). A concavity is therefore necessary, but one reaching to one -finger's breadth below the axis of the joint is sufficient. In front -the<span class="pagenum"><a name="Page_71" id="Page_71">[71]</a></span> edge of the bucket reaches up to the joint line, this is quite -sufficient to enclose the bony prominences (<a href="#i_p072a">Fig. 109</a>).</p> - -<p>The posterior concavity of the leg piece is combined with a concavity -in the thigh piece varied in accordance with the thickness of the -popliteal soft parts.</p> - -<div class="figcenter" id="i_p071" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p071.png" - width="450" - height="315" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 107 and 108.—<span class="sm">If the leg bucket is hollowed out too -much at the back, the stump is tilted obliquely forward (Fig. 108), -the knee loses contact with the bucket, and the flesh at the back of -the thigh is pinched.</span></p> - </div> - -<p class="p2">To diminish further the tendency of the stump to tilt forward the -posterior edge of the bucket is flattened so that the shape of the top -of the bucket is triangular with curved sides and angles much rounded -(the anterior angle over the tuberosity of the tibia being obtuse). -This is the natural shape of a section of the top of the calf. In this -way the posterior muscles are flattened and no<span class="pagenum"><a name="Page_72" id="Page_72">[72]</a></span> longer tend to escape -from the bucket when the knee is flexed. In figures 110 and 111 are -shown two ways in which this flattened posterior margin may be shaped.</p> - -<div class="figcenter" id="i_p072a" style="width:238px"> - <img - class="p2" - src="images/i_p072a.png" - width="238" - height="315" - alt="" /> - <p class="center"><span class="smcap">Fig. 109.</span></p> - </div> - -<div class="figcenter" id="i_p072b" style="width:450px"> - <img - class="p2" - src="images/i_p072b.png" - width="450" - height="295" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 110 to 111.</p> - </div> - -<p class="p2">B. <span class="smcap">Suspension Apparatus.</span>—The leg is attached (<i>a</i>) by a -thigh corset taking its hold on the femoral condyles, and (<i>b</i>) by -braces over the shoulders.</p> - -<p><span class="pagenum"><a name="Page_73" id="Page_73">[73]</a></span></p> - -<p>(<i>a</i>) <i>The thigh corset</i> is made of leather laced in front. Two -lateral steels curving in sharply against the upper part of the -condyles (Fig. 112) form the most effective part of the support. At -their lower ends they are articulated with two steels passing up from -the top of the leg to which they are attached. The joint (Fig. 113) -is composed of a nut, A, into which fits a screw. Around the nut -is a copper ring made to move with the femoral steel by means of a -stop-notch. When the knee flexes and extends the wear comes upon this -copper ring. The steels remain intact. If the joint works loose it is -sufficient to renew the ring.</p> - -<div class="figcenter" id="i_p073" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p073.png" - width="550" - height="369" - alt="" /> - <p><span class="smcap">Fig. 112.</span>—<span class="sm">The thigh steels, curved in above the condyles, -hold the limb on very securely.</span><a name="FNanchor_10_10" id="FNanchor_10_10"></a><a href="#Footnote_10_10" class="fnanchor">[10]</a></p> - <p class="p0"><span class="smcap">Fig. 113.</span>—<span class="sm">Details of the joint at the knee.</span></p></div> - -<div class="footnote"> - -<p><a name="Footnote_10_10" id="Footnote_10_10"></a><a href="#FNanchor_10_10"><span class="label">[10]</span></a> In this illustration the joints are placed too low. They -should be opposite the centre of rotation of the knee joint, <i>i.e.</i> a -transverse line passing through the femoral condyles. (<span class="smcap">Ed.</span>)</p></div> - -<p class="p2">(<i>b</i>) <i>The braces</i> are a very useful addition which French -orthopædists should employ systematically.<span class="pagenum"><a name="Page_74" id="Page_74">[74]</a></span> -They increase the stability of the limb and allow the thigh piece to -be laced less tightly, so that contraction of the thigh muscles is -facilitated.</p> - -<div class="figcenter" id="i_p074" style="width:460px"> - <img - class="p2" - src="images/i_p074.png" - width="460" - height="550" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 114 and 115.</p> - </div> - -<p>Support may be given by a strap from a waist belt as shown in <a href="#i_p075">figure -117</a>, but proper braces are better. These braces pass over the shoulder -of the sound side and are attached either to the thigh corset or to -the leg piece of the artificial limb. Attachment to the thigh corset -is made by a single strap either in front and behind (<a href="#i_p074">Fig. 114</a>) or on -either side of the front lacing, the ends of the strap crossing in<span class="pagenum"><a name="Page_75" id="Page_75">[75]</a></span> -front of the groin (<a href="#i_p074">Fig. 115</a>). It is a simple matter to add to the -brace an extending strap, such as we have described for the artificial -limb for amputation through the thigh (<a href="#Page_44">page 44</a>). It is only necessary -to terminate the brace in a strap from which two branches pass down -in an inverted V and are fixed to the sides of the front of the leg -piece (<a href="#i_p075">Figs. 116 and 117</a>). This is unnecessary if the stump is long, -for its leverage will then be good. It is, however, very useful for -short stumps which give little power to<span class="pagenum"><a name="Page_76" id="Page_76">[76]</a></span> the action of the quadriceps. -In the case of patients with a long stump an attempt has been made to -abolish the thigh piece and suspend the limb exclusively by braces. -This method, we believe, is inadequate even if it is completed by a -transverse band above the knee (<a href="#i_p076">Figs. 118 and 119</a>).</p> - -<div class="figcenter" id="i_p075" style="width:451px"> - <img - class="p2" - src="images/i_p075.png" - width="451" - height="550" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 116 and 117.</p> - </div> - -<div class="figcenter" id="i_p076" style="width:460px"> - <img - class="p2" - src="images/i_p076.png" - width="505" - height="550" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 118 and 119.</p> - </div> - -<p class="p2">C. <span class="smcap">The Foot.</span>—The foot, usually articulated, is fixed in -exactly the same way as in a limb for an amputation through the thigh, -<i>i.e.</i> it is mounted in the equinus position. But in this case, -however, precautions must be taken against stretching of the posterior -ligaments of the knee joint, because the equinus mechanically produces -hyperextension of the knee, and a genu recurvatum may result. For this -reason a strap must be fixed posteriorly between the thigh corset and -the leg<span class="pagenum"><a name="Page_77" id="Page_77">[77]</a></span> piece to prevent full extension of the knee (popliteal check -cord). This means that we make the patient stand and walk with slight -flexion of the knee and with a corresponding elevation of the heel of -the shoe (2-3 centimetres).</p> - - -<h5>II. Appliances with End Bearing only</h5> - -<p>These appliances are suitable for certain amputations very low down in -the leg which we must first define.</p> - -<p>The orthopædist should consider the following operations as very low -amputations of the leg, allowing of walking with end bearing only, and -suitable for the same type of appliance:—</p> - -<blockquote> - -<p>Supra-malleolar amputation.<a name="FNanchor_11_11" id="FNanchor_11_11"></a><a href="#Footnote_11_11" class="fnanchor">[11]</a></p> - -<p>Disarticulation at the ankle joint.</p> - -<p>Sub-astragaloid amputation.</p> - -<p>Osteoplastic amputations through the os calcis<span class="pagenum"><a name="Page_78" id="Page_78">[78]</a></span> (or amputation -in which the os calcis is retained entire after removal of the -astragalus).</p></blockquote> - -<div class="footnote"> - -<p><a name="Footnote_11_11" id="Footnote_11_11"></a><a href="#FNanchor_11_11"><span class="label">[11]</span></a> In England, of course, this is always called Syme's -amputation. It constitutes the type <i>par excellence</i> of the -end-bearing stump. Upon a good Syme stump a patient may be able to -walk ten miles without an artificial foot, wearing simply an "elephant -boot." Amputations above the Syme level are not end bearing, however -long the stump may be. The other amputations in this region seen in -English war surgery are the various types of osteoplastic amputations -in which a part of the os calcis is retained (Pirogoff's amputation, -etc.). These have the following defects:— -</p> -<p> -(1) There is often sepsis between the tibia and the os calcis, -necessitating re-amputation. Osteoplastic amputations are unsuitable -for septic surgery. -</p> -<p> -(2) Ankylosis between the os calcis and the tibia is often imperfect -so that the bulbous end of the stump is unstable. -</p> -<p> -(3) The stump is too long to allow of the fixation of a good -artificial ankle joint beneath it. A Syme's amputation leaves two to -two and a half inches clearance between it and the ground. -</p> -<p> -I have not yet seen a sub-astragaloid amputation in war surgery, and -only once a disarticulation through the ankle joint, the latter could -not bear pressure and it was necessary to convert it into a Syme's -amputation. In fact, in this region there is Syme's amputation and -a number of other far inferior amputations which should never be -considered when a Syme's amputation is possible. (Ed.)</p></div> - -<p>Certain limb makers consider these operations are bad for the same two -reasons that we have already refuted in connection with amputation -through the condyles of the femur, viz.—</p> - -<p>(1) The stump being enlarged at its lower end will not fit into a -wooden bucket.</p> - -<p>(2) The stump is too long to allow an artificial foot to be fixed -below it.</p> - -<p>From this it simply follows: 1. That complete enclosure of the stump -in a wooden bucket is impossible; 2. That pressure must be placed -directly and exclusively upon the end of the stump.</p> - -<p>The latter condition is only possible if the state of the soft parts -allows the cutting of a thick plantar flap to cover the cut surface of -the bone and if care be taken to resect the posterior tibial nerve in -the flap.</p> - -<p>We therefore draw special attention to the excellent elliptical -supra-malleolar amputation with posterior flap (Guyon's method) in -which it is sufficient to retain a bare finger's breadth of skin from -the plantar surface in front of the point of the heel. It bears direct -pressure well, perfectly if a layer of the os calcis is cut with the -scissors from the area adjacent to the tendo-Achillis and applied -under the cut end of the tibia.</p> - -<p>For all these amputations the anterior flap is bad. The thin dorsal -skin of the foot is incapable of withstanding the direct pressure -which is indispensable for this method of fitting.</p> - -<p>Even if it were true that under these long stumps it is impossible to -insert an artificial foot for lack of space, the operations which we -have enumerated<span class="pagenum"><a name="Page_79" id="Page_79">[79]</a></span> above should be recommended if the flap can be cut in -the way we have indicated.</p> - -<div class="figcenter" id="i_p079" style="width:450px"> - <img - class="p2" - src="images/i_p079.png" - width="448" - height="338" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 120 and 121.</p> - </div> - -<p class="p2">Their great advantage—and the reason for retaining as much length of -bone as possible—is that they allow walking directly on the stump -without an apparatus. It is sufficient to have a circular shoe made by -any shoemaker consisting of a heel more or less thickened surmounted -by a lacing gaiter reaching halfway up the leg. Guyon's amputation -constitutes the limit up to which this "elephant boot" is possible.</p> - -<p>It is an unsightly apparatus, but its simplicity and cheapness should -be taken into consideration, for it is quite possible that a manual -labourer, especially a countryman, to whom an artificial foot and an -"elephant boot" are given, will reserve the former for Sunday and use -the other for his daily work.</p> - -<p><span class="pagenum"><a name="Page_80" id="Page_80">[80]</a></span></p> - -<p><span class="smcap">Appliances with Artificial Foot.</span>—The wooden piece which -partly encloses the stump consists of a block carved to the shape of -the stump and padded with felt, it is prolonged in front by an instep -reaching to the level of the middle of the metatarsus, and above by -a grooved piece which reaches halfway up the leg and encloses the -anterior half of the latter. A leather gaiter is fixed at the sides -and back and extends up the leg, being laced in front over the wooden -piece as a field boot is laced over the leather tongue. The foot -may be mounted at right angles to the leg, but it is better mounted -slightly in equinus.</p> - -<p>The sole and toes are of rubber as described on <a href="#Page_35">page 35</a>.</p> - -<p>In studying <a href="#i_p079">figures 120 and 121</a> the following should be noted:—</p> - -<p>1. The shape of the leg bucket in which an aperture behind permits the -introduction of the stump which is enlarged at its lower end.</p> - -<p>2. The mechanism by which the posterior gaiter laced in front fixes -this leg bucket.</p> - -<p>3. The articulation of the foot on a transverse axis.</p> - -<hr class="chap" /> - -<div class="chapter"> - -<p><span class="pagenum"><a name="Page_81" id="Page_81">[81]</a></span></p> - -<h2><i>CHAPTER VI</i></h2></div> - -<h3>PARTIAL AMPUTATIONS OF THE FOOT</h3> - -<p>This name should be applied to amputations in which the mobility -of the ankle joint is retained, <i>i.e.</i> Chopart's amputation -(midtarsal disarticulation), Lisfranc's amputation (tarso metatarsal -disarticulation), amputation of several toes with their metatarsal -bones, or amputation of all five toes.</p> - -<p>1. <i>The amputations of Chopart and Lisfranc.</i>—Chopart's amputation -has a grave defect: the anterior muscles have not sufficient leverage -to oppose this gastrocnemius and soleus, and the posterior tarsal -bones tilt forward so that the patient walks, not on the lower -surface of the os calcis and the plantar skin, but on the head of the -astragalus and of the os calcis and on a painful cicatrix. If certain -precautions are taken (careful preservation of the fibrous plantar -flap and suture to it of the anterior tendons) this defect is not -invariably present, and it is an exaggeration to say that Chopart's -amputation "has never given anything but disappointment." It should, -however, only be practised if the technique is well understood, and -even then it is rarely indicated, because it demands almost as much -plantar skin as Lisfranc's amputation.</p> - -<p>Nevertheless I have seen some good Chopart<span class="pagenum"><a name="Page_82" id="Page_82">[82]</a></span> stumps the result of -operations by myself or by other surgeons; they should be fitted like -the stumps resulting from Lisfranc's operation.</p> - -<p>With regard to the latter, they can be easily and comfortably fitted, -provided that the scar is dorsal and is not stretched over prominent -bones.</p> - -<p>If the first cuneiform is not well covered it can simply be removed, -no functional disability results. It is mainly upon the plantar -surface of the stump that pressure is borne, but pressure comes also -upon the anterior surface when the foot is tilted downwards.</p> - -<div class="figcenter" id="i_p082" style="width:292px"> - <img - class="p2" - src="images/i_p082.png" - width="292" - height="300" - alt="" /> - <p class="center"><span class="smcap">Fig. 122.</span></p> - </div> - -<p class="p2">The fore part of the foot which constitutes the prosthetic apparatus -consists of a block of wood, which reaches forward as far as the -middle of the metatarsus and ends in a vertical plate in front of the -stump. This block of wood is carved to the shape of the stump and -lined with felt. It is attached to the leg by a leather gaiter which -laces in front.</p> - -<p>Anteriorly it is prolonged into an artificial toe piece similar to -that already described for the artificial limb for amputation through -the thigh.</p> - -<p>This appliance is not indispensable. It is sufficient to use a piece -of cork shaped to the anterior surface of the stump and filling up the -anterior part of the boot, its advantage, however, is that once the -patient is fitted with this appliance he can wear an ordinary boot.</p> - -<p><span class="pagenum"><a name="Page_83" id="Page_83">[83]</a></span></p> - -<p>2. <i>Partial Amputation of the Fore Part of the Foot.</i>—These are—</p> - -<p>Transverse amputation through the metatarsal bones.</p> - -<p>Disarticulation of one or more toes with their metatarsal bones.</p> - -<p>Disarticulation of one or more toes.</p> - -<p>For any of these amputations all that is required is an ordinary boot, -fitted with a cork, which is shaped to fit the stump and which fills -up the space left by the amputation.</p> - -<p>In order that the patient may walk well the scar should be dorsal and -should not be tense.</p> - -<p>We consider that the difficulty of maintaining equilibrium after -removal of the head of the first metatarsal, or even of the whole of -this metatarsal bone, has been much exaggerated.</p> - -<p>Removal of a marginal metatarsal bone (either alone or with its -neighbour), tends to make the foot tilt into varus or valgus; so that -the boot needs to be stiffened and the sole thickened to avoid this.</p> - -<hr class="chap" /> - -<div class="chapter"> - -<p><span class="pagenum"><a name="Page_84" id="Page_84">[84]</a></span></p> - -<h2><i>CHAPTER VII</i></h2></div> - -<h3>ARTIFICIAL LIMBS FOR AMPUTATION THROUGH THE FOREARM</h3> - -<p>The constituent parts of an artificial arm are the same in principle -as for those of an artificial leg, they are—</p> - -<p>1. A means of attachment preventing the appliance from dropping as the -result of its weight.</p> - -<p>2. A socket, fitted to the stump and articulated with the last named -at the elbow.</p> - -<p>3. The terminal appliance, intended to replace as far as possible the -amputated hand and, if possible, resembling it in appearance. In the -case of the upper limb the advantages that wood possesses in giving -strength and accuracy of fit do not apply, and the arm and the forearm -pieces are made of leather, with lateral steels articulated at the -elbow: this joint is active in the case of amputations of the forearm -but purely passive in amputations of the arm.</p> - -<p>We will commence by describing the appliance for amputation through -the forearm, taking as our type amputation in the lower half. This -will furnish an example which illustrates all the principles that -should guide us, the ends we should have in view, and the means by -which we can attain them.</p> - -<p>When once we have studied the apparatus by<span class="pagenum"><a name="Page_85" id="Page_85">[85]</a></span> means of which the -functions of the hand can as far as possible be replaced, a short -description will suffice to explain what can be done when the loss -of movement of the elbow and then a shorter and shorter stump in the -upper arm oblige us to diminish the utility of the appliance.</p> - -<p>We must study in turn: (1) The attachment of the upper arm socket; (2) -the joint between this and the forearm socket; and (3) the appliances -attached to the extremity of the forearm whether these take the shape -of a hand or not.</p> - -<h5>1. Points of Attachment</h5> - -<p>1. <span class="smcap">Suspension.</span>—In the exceptional amputation very low down, -in which the roots of the thenar and hyperthenar eminences remain, -the enlargement thus formed at the extremity of the forearm may be -used for the attachment of a wristlet which may suffice to support the -artificial appliance, provided that the latter is not intended for -heavy work. In the latter case an attachment from the elbow at least -must be added.</p> - -<p>This method would evidently be out of the question in the usual class -of case, viz. ordinary amputations through the forearm.</p> - -<p>In these the attachment may be made in two ways:—</p> - -<p>(1) To the humerus above the condylar enlargements, the epicondyle and -the epitrochlea, the latter being much the more prominent.</p> - -<p>(2) To the top of the shoulder, <i>i.e.</i> to the surface over the -acromion and clavicle.</p> - -<p>A. <i>Attachment to the Elbow.</i>—The simplest method<span class="pagenum"><a name="Page_86" id="Page_86">[86]</a></span> of attachment is -that in which pressure is exerted upon the condyles of the humerus -(<a href="#i_p086b">Fig. 124</a>). A leather armlet laced in front is furnished with two -lateral steels, curved in above the condyles and articulated at the -level of the centre of rotation of the elbow joint with two similar -steels in the forearm piece (the socket).</p> - -<div class="figcenter" id="i_p086a" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p086a.png" - width="308" - height="450" - alt="" /> - <p class="center"><span class="smcap">Fig. 123.</span>—<span class="sm">The three regions used as points of support, the -shoulder, the elbow and the wrist.</span></p> - </div> - -<div class="figcenter" id="i_p086b" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p086b.png" - width="270" - height="350" - alt="" /> - <p><span class="smcap">Fig. 124.</span>—<span class="sm">Suspension from the elbow. The side steels of -the arm piece are curved in to fit upon the supra-condylar ridges of -the humerus. A good method of suspension for long stumps, when the -appliance is not to be used for heavy work. It should be supplemented -in other cases by direct suspension from the shoulder.</span></p> - </div> - -<p class="p2">This direct method of attachment is sufficient for a low amputation, -in cases where the patient does not do hard work. But if the stump -is short and if the patient has to carry fairly heavy weights -the appliance is only prevented from slipping by a consider<span class="pagenum"><a name="Page_87" id="Page_87">[87]</a></span>able -constriction of the arm, which results in a serious interference with -muscular action.</p> - -<p>B. <i>Attachment to the Shoulder.</i>—For this reason it is usually -advisable to supplement this by an indirect attachment to the acromion -and clavicle by means of a shoulder cap.</p> - -<div class="figcenter" id="i_p087" style="width:356px"> - <img - class="p2" - src="images/i_p087.png" - width="356" - height="400" - alt="" /> - <p class="center"><span class="smcap">Fig. 125.</span></p> - </div> - -<p class="p2">The firmest and strongest pattern consists of a piece of blocked -leather, moulded to the shoulder, including the pectoral, -supra-clavicular and scapular regions. This is kept in place by a -strap which passes under the opposite axilla. It is cut away on the -outer side of the acromion, the anterior and posterior borders being -continued downwards on either side of the deltoid as two tapering -straps to which the armlet is attached. In this way full liberty of -movement is allowed to the shoulder (Fig. 125).</p> - -<p><span class="pagenum"><a name="Page_88" id="Page_88">[88]</a></span></p> - -<p>This pattern is strong, but cumbersome and heavy. It can be lightened -by reducing it to an antero-posterior strap, 6 or 7 centimetres wide, -over the clavicle and spine of the scapula, ending in front and behind -at the level of the axillary folds in triangular enlargements. In the -upper and inner angles of these are attached the ends of the axillary -strap, to the lower and outer angles, prolongations from the armlet -(Figs. 126 and 127).</p> - -<div class="figcenter" id="i_p088" style="width:500px"> - <img - class="p2" - src="images/i_p088.png" - width="500" - height="340" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 126 and 127.</p> - </div> - -<p class="p2">The lightest method, but obviously also the least secure, consists in -suspending the armlet by two straps, anterior and posterior, which -cross above the clavicle and then pass in the form of a loop under the -opposite axilla (Fig. 128).</p> - -<div class="figcenter" id="i_p089" style="width:237px"> - <img - class="p2" - src="images/i_p089.png" - width="237" - height="450" - alt="" /> - <p class="center"><span class="smcap">Fig. 128.</span></p> - </div> - -<p class="p2">The choice between these three methods of attachment depends upon the -profession of the patient and the strength required by it.</p> - -<p><span class="pagenum"><a name="Page_89" id="Page_89">[89]</a></span></p> - -<p>2. <span class="smcap">Resistance to Upward Pressure.</span>—The artificial limb should -be capable of resisting upward pressure, when a thrusting force is -exerted by the hand. This is secured in the following three ways, the -hand being presumed to hang vertically with the elbow straight:—</p> - -<p>(1) By pressure of the end of the stump in the socket (in amputations -low down with a palmar flap—for example, in disarticulation at the -wrist joint).</p> - -<p>(2) By pressure of the top of the forearm socket on the enlargement of -the forearm below the elbow.</p> - -<p>(3) By pressure of the inner side of the upper edge of the armlet -against the axilla.</p> - -<p>But, in actual work, thrusting movements are nearly always made with -the elbow bent to a right angle or almost so, then the pressure -transmitted through the forearm piece is borne almost entirely by the -steels of the armlet.</p> - -<p>3. <span class="smcap">Resistance to Rotation.</span>—A well-adjusted artificial arm -cannot rotate on the limb because—</p> - -<p>(1) The forearm is elliptical in section and not circular, this is -specially so in the lower third.</p> - -<p>(2) Flexion of the elbow is only possible if the artificial joint -is in the same plane as the axis of the elbow joint—that is, the -sagittal plane.</p> - -<p><span class="pagenum"><a name="Page_90" id="Page_90">[90]</a></span></p> - -<p>(3) The axillary strap of the shoulder attachment prevents rotation.</p> - -<div class="figleft" id="i_p090a" style="width:237px;"> - <img - class="p2" - src="images/i_p090a.png" - width="175" - height="400" - alt="" /> - <p class="center"><span class="smcap">Fig. 129.</span>—<span class="sm">The three regions used as points of resistance to -upward pressure.</span></p> - </div> - -<div class="figright" id="i_p090b" style="width:237px;"> - <img - class="p2" - src="images/i_p090b.png" - width="177" - height="400" - alt="" /> - <p class="center"><span class="smcap">Fig. 130.</span>—<span class="sm">The three regions at which rotation of the -apparatus may be prevented.</span></p> - </div> - -<p class="p2" style="clear: both">1. <i>The Concavity of the Armlet.</i>—At the elbow joint the pinching of -the anterior soft parts on flexion is liable to take place in just the -same way as occurs at the back of the knee in amputations through the -leg. To avoid this it is necessary—</p> - -<p>(1) That the axis of the joint should lie in a<span class="pagenum"><a name="Page_91" id="Page_91">[91]</a></span> prolongation of a line -passing through the epicondyle and the epitrochlea.</p> - -<p>(2) That the armlet and the forearm socket should be cut away in front -in crescent-shaped concavities.</p> - -<div class="figcenter" id="i_p091" style="width:237px;"> - <img - class="p2" - src="images/i_p091.png" - width="395" - height="450" - alt="" /> - <p class="center"><span class="smcap">Fig. 131.</span>—<span class="sm">Limb for amputation in the middle -third of the forearm.</span></p> - </div> - -<p class="p2">The depth of these concavities is estimated when the limb is fitted. -Both the arm and the forearm may be cut away freely without any -resulting inconvenience, provided that the stump is long; but if the -stump is short and includes only the upper third of the forearm, it -is impossible to cut away the forearm socket sufficiently without -depriving the stump of a proper hold in the socket, so that movements -are not transmitted to the forearm lever with their proper force. -Consequently the socket for the forearm must be cut away very little, -and must be carried up to the level of the fold of the elbow when the -joint is flexed. The flesh in front of the elbow will not be pinched -if, the<span class="pagenum"><a name="Page_92" id="Page_92">[92]</a></span> forearm being fitted very accurately, the muscles of the -upper arm are allowed free play, by cutting away the front of the -armlet to half its height, but in this case an indirect attachment to -the shoulder is essential.<a name="FNanchor_12_12" id="FNanchor_12_12"></a><a href="#Footnote_12_12" class="fnanchor">[12]</a></p> - -<div class="footnote"> - -<p><a name="Footnote_12_12" id="Footnote_12_12"></a><a href="#FNanchor_12_12"><span class="label">[12]</span></a> Another difficulty in fitting a short forearm stump -arises from the fact that the antero-posterior diameter of the forearm -immediately below the elbow increases considerably when the joint is -flexed, because of the contraction of the muscles arising from the -condyles. If the forearm socket is made to fit closely when the elbow -is extended it will be too small when the joint is flexed and will -prevent full flexion. If it was made to fit with the elbow flexed, -there is risk of the stump slipping out of the socket when the joint -is extended. (Ed.)</p></div> - -<div class="figcenter" id="i_p092a" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p092a.png" - width="252" - height="450" - alt="" /> - <p class="center"><span class="smcap">Fig. 132.</span>—<span class="sm">Bad apparatus for amputation in the upper third of -the forearm. The front of the arm piece is insufficiently cut away.</span></p> - </div> - -<div class="figcenter" id="i_p092b" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p092b.png" - width="252" - height="450" - alt="" /> - <p class="center"><span class="smcap">Fig. 133.</span>—<span class="sm">Good apparatus. The arm piece is well cut away, -consequently the flesh does not bulge out.</span></p> - </div> - -<p><span class="pagenum"><a name="Page_93" id="Page_93">[93]</a></span></p> - -<p class="p2">2. <i>Construction of the Joint.</i>—In most cases this is a simple -articulation between the steels of the arm and the forearm pieces by -two hinge joints.</p> - -<div class="figcenter" id="i_p093" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p093.png" - width="404" - height="450" - alt="" /> - <p><span class="smcap">Fig. 134.</span>—<span class="sm">Limb for amputation through the lower third of the -forearm, with elbow joint of strong leather.</span></p> - <p><span class="smcap">Fig. 135.</span>—<span class="sm">Details of the joint.</span></p> - </div> - -<p class="p2">The objection to this is that the movements of pronation and -supination, if these are present in the stump, are abolished.</p> - -<p>(<i>a</i>) <i>Long Stump.</i>—When the stump is long (amputation in the lower -quarter) the following may be<span class="pagenum"><a name="Page_94" id="Page_94">[94]</a></span><span class="pagenum"><a name="Page_95" id="Page_95"></a></span> used: The steels of the forearm socket -are attached to the armlet, which is not furnished with steels, by two -straight strips of hard leather jointed at each end with rivets to -the corresponding piece of the limb. This allows a certain amount of -torsion so that pronation and supination are to some extent possible. -It is necessary to add an indirect attachment to the shoulder. Not -only must the armlet, not being closely moulded over the condyles, be -even when new laced so tightly as to be unbearable, but in addition -the inevitable loss of shape of the unsupported leather will in every -case soon interfere with proper support direct from the armlet (<a href="#i_p093">Figs. -134 and 135</a>).</p> - -<p>This method is, moreover, scarcely applicable to patients who will -have to carry out heavy work.</p> - -<p>(<i>b</i>) <i>Short Stump.</i>—The stump of an amputation in the upper third of -the forearm is too short to be securely held in the forearm bucket. -There is consequently a loss of power in the movements communicated, -particularly in flexion, the arm of the lever being too short; in -addition, the elbow joint in these cases is often a little stiff, so -that flexion beyond a right angle is impossible (Figs. 136 to 138).</p> - -<div class="figcenter" id="i_p094a" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p094a.png" - width="500" - height="376" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 136 and 137.—<span class="sm">Amputation through the -forearm above the upper third. The elbow joint does not flex beyond -the right angle.</span></p> - </div> - -<div class="figcenter" id="i_p094b" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p094b.png" - width="323" - height="376" - alt="" /> - <p class="center"><span class="smcap">Fig. 138.</span>—<span class="sm">Limb for amputation through the -upper third of the forearm. (For a description of the ratchet see <a href="#Page_135">page 135</a>.)</span></p> - </div> - -<p class="p2">The chief functional difficulty depends upon the fact that, with the -elbow at a right angle, the anterior surface of the forearm stump -is too short to support a weight; for example, a basket held by the -handle. The stump escapes partly from the bucket when the forearm -extends. It is therefore well in such cases to fix the elbow at a -right angle by means of a ratchet identical with that used in the -artificial arm for amputation above the elbow (Fig. 138).</p> - -<p><span class="pagenum"><a name="Page_96" id="Page_96">[96]</a></span></p> - -<h5>3. The Artificial Hand and Appliances</h5> - -<p>At the extremity of their forearm almost all patients wish in the -first place to wear something that is shaped like a hand. Many -people—and even many medical men—consider that this "artificial -hand" is really useful. In actual fact, by means of fairly simple -contrivances, it can be used to enable the patient to eat, to write, -to put on and take off his hat, but it is out of the question for it -to do real work. For that an appliance, a tool in fact, adapted for -use and not for appearance is necessary.</p> - -<p>The limb, therefore, will, as a rule, end in a hand, but for workmen -this hand will be capable of being unscrewed and replaced easily by -one or more appliances.</p> - -<p>Attempts have been made to construct so called universal hands and -forceps which will serve for any sort of work, but up to the present -none of these inventions have given satisfaction. And the practical -solution of the problem in the present state of affairs consists -in devising a special appliance for a particular trade, studying -carefully the movements necessary in this trade.</p> - -<p>A workman who in the course of his occupation carries out a number of -different movements may thus have several appliances, which he selects -as he requires them. For example, a locksmith must be able to hammer, -to file, and to drill holes in succession.</p> - -<p>We will describe first the hand properly so called, then the -appliances. The former is suitable for clerks, and it is for them that -the various improved patterns that we shall describe are made. The -latter are suitable for manual workers to whom should be given<span class="pagenum"><a name="Page_97" id="Page_97">[97]</a></span> a hand -in which the mechanism is reduced to a spring thumb grip and one or -more special appliances.</p> - -<p>These appliances will almost always be constructed to carry out the -movements made by the left hand in the course of the work, because the -first step in the re-education of a patient who has lost the right -hand should always consist in training the remaining left hand to -carry out the work hitherto entrusted to the missing right hand.</p> - - -<h5>A.—The Artificial Hand.</h5> - -<p>The hand, which is screwed into the end of the forearm socket in such -a way that it is in semipronation when the arm hangs vertical, is -nearly always made of wood, but occasionally of aluminium.<a name="FNanchor_13_13" id="FNanchor_13_13"></a><a href="#Footnote_13_13" class="fnanchor">[13]</a></p> - -<div class="footnote"> - -<p><a name="Footnote_13_13" id="Footnote_13_13"></a><a href="#FNanchor_13_13"><span class="label">[13]</span></a> Hands are nearly always made of lime wood, which has the -advantage of lightness, but the fingers are fragile and easily break. -Instead of using hornbeam, which is hard but heavy, as the fragility -only affects the fingers, some makers have overcome this difficulty by -reinforcing the fingers by what they call a "philippeau." -</p> -<p> -The finger is divided throughout its whole length by a mortise 1·5 -millimetres in width, in which are glued two layers of veneering wood -(mahogany, rosewood, etc., extremely hard woods, or else a layer of -hornbeam).</p></div> - -<p>It may be a simple show hand without any joint. This pattern is no -longer used. It may be jointed in one or in several fingers. We shall -first consider certain principles of construction which we can explain -by describing the chief mechanisms used.</p> - -<p><i>Simple Spring Grip Thumb.</i>—The simplest and most useful articulation -is that of the thumb, which when at rest is kept by means of a spring -in the flexed position, with the grip against the index finger which -is partly flexed (as are also the other fingers).</p> - -<p>In many cases the patient is content with this simple mechanism. He -opens the spring with the<span class="pagenum"><a name="Page_98" id="Page_98">[98]</a></span> other hand and allows it to close on the -object he wishes to grip (Figs. 139-145).</p> - -<div class="figcenter" id="i_p098" style="width:70%; margin: auto 15%;"> - <img - class="p0" - src="images/i_p098.png" - width="366" - height="590" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 139 to 142.—<span class="sm"><i>Mechanism of the passive -spring thumb.</i></span></p> -<p class="sm">The thumb turns on the axle D upon a piece which fits by a tapered -extremity C into a hollow cut out in the thenar eminence. The base of -the thumb is rounded. The spring AB flexes the thumb.</p> - </div> - -<div class="figcenter" id="i_p099" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p099.png" - width="467" - height="500" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 143 to 145.—<span class="sm">The Beaufort Thumb.</span></p> - <p class="sm">The model shown on <a href="#i_p098">page 98</a> is more mobile than this, in which the -thumb turns on the axis AB, and is fitted directly into the thenar -eminence. But in this type it will be seen that the spring CD which -keeps the thumb flexed, reaches right up to the wrist, and is -therefore longer and more powerful. The thumb is much stronger, and -this is the mechanism usually adopted. It has the inconvenience that -it requires a deep excavation of the thenar eminence, encroaching -upon the root of the index finger, so that it is impossible to -mount the thumb in this way when it is desired to fit a movable -metacarpo-phalangeal joint to the index finger, either with a spring -(<a href="#i_p105ab">Fig. 155</a>) or without (<a href="#i_p102a">Fig. 148</a>).</p> - </div> - -<p class="p2"><i>The Automatic Thumb.</i>—Active opening movement can be produced by the -mechanism shown in figure<span class="pagenum"><a name="Page_99" id="Page_99">[99]</a></span> 146. A cord fixed behind the scapula of -the opposite side by a ring which passes over the clavicle and under -the axilla, extends down the posterior surface of the arm and forearm -pieces, running in pulleys which keep<span class="pagenum"><a name="Page_100" id="Page_100">[100]</a></span> it in place. If the patient -bends the elbow and at the same time brings the arm and both shoulders -forward, rounding his back, the cord is tightened and pulls the thumb -into the position of abduction and extension.</p> - -<p>This narrow grip, between the tips of the thumb and index finger only, -is not always convenient. A commercial traveller or a foreman could -not easily hold with it the order book, in which he has to write. But -if the thumb, held by a powerful spring, is parallel to the palm of -the hand and grips against the other fingers, which are stretched out -and not semiflexed, the grip will be strong and convenient, especially -if a mechanism is introduced between the forearm and the hand, -allowing the latter to be rotated at will into any position (<a href="#i_p102a">Fig. 148</a>).</p> - -<p>As in the preceding case the thumb may have either a simple grip or an -automatic grip opened voluntarily by a cord from the shoulder.</p> - -<p>The following is a very interesting method which allows a fork or -pen to be held, the automatic thumb being used. The fingers are half -flexed, the index being separated from the middle finger, so that the -handle of a pen can be inserted between them. The grip of the thumb is -not against the tip of the index finger but against the outer side of -the last phalanx of the middle finger, against which in consequence -the handle of the object held will be pressed (Fig. 147).</p> - -<div class="figcenter" id="i_p101a" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p101a.png" - width="450" - height="338" - alt="" /> - <p class="center"><span class="smcap">Fig. 146</span>—<span class="sm">Appliance with automatic thumb. The cord is fixed -to a loop which passes round the sound shoulder. Abduction and forward -movement of the shoulder and flexion of the elbow open the thumb.</span></p> - </div> - -<div class="figcenter" id="i_p101b" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p101b.png" - width="400" - height="298" - alt="" /> - <p class="center"><span class="smcap">Fig. 147.</span>—<span class="sm">Hand with space between the index and middle -fingers, wide enough to take the handle of a fork, which is held by -pressure of the thumb against the side of the middle finger.</span></p> - </div> - -<p class="p2">The extended fingers are better placed for gripping than the -partially flexed fingers, although the latter are convenient to the -patient in certain ways. Ball and socket joints are inserted at the -interphalangeal joints. (Details are shown in figures <a href="#i_p104">152 to 154</a>.) -These are so stiff that they maintain the position<span class="pagenum"><a name="Page_101" id="Page_101">[101]</a></span><span class="pagenum"><a name="Page_102" id="Page_102"></a></span> in which they are -placed passively, as do the joints of an artist's lay figure.</p> - -<div class="figcenter" id="i_p102a" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p102a.png" - width="450" - height="294" - alt="" /> - <p><span class="smcap">Fig. 148.</span>—<span class="sm">Articulated hand for commercial -travellers. The thumb, lying parallel to the palm of the hand, takes a -secure hold of such an article as a memorandum book.</span></p> - <p><span class="smcap">Fig. 149.</span>—<span class="sm">The usual pattern of hand. The grip is too small.</span></p> - </div> - -<div class="figcenter" id="i_p102b" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p102b.png" - width="450" - height="241" - alt="" /> - <p><span class="smcap">Fig. 150.</span>—<span class="sm">The index finger is the same length -as the middle finger. The thumb and index fingers are furnished with -nails. A small ball can be picked up.</span></p> - <p><span class="smcap">Fig. 151.</span>—<span class="sm">The middle finger being longer than the index, the -latter does not reach the surface of the table and the ball cannot be -picked up.</span></p> - </div> - -<p class="p2">If the fingers are rigid and in semiflexion it is<span class="pagenum"><a name="Page_103" id="Page_103">[103]</a></span> possible to -articulate all the metacarpo-phalangeal joints, fitting them with a -spring, which keeps them flexed, and arranging for active extension as -already described for the thumb. All that is necessary is to terminate -the cord by five separate strings instead of one. In certain special -cases this arrangement may be useful (<a href="#i_p105ab">Figs. 155 to 157</a>). It seems to -us useless to render the interphalangeal joints automatic.</p> - -<p>As to the attempt which Beaufort appears to have made to give movement -to the wrist also, we do not believe that any practical result has as -yet been attained.</p> - -<p>For the relative length of the fingers and the utility of a nail on -the thumb and on the index finger see figures <a href="#i_p102b">150 and 151</a>.</p> - - -<h6>Shape of the Hand.</h6> - -<p>In the usual pattern (<a href="#i_p102a">Figs. 149 and 151</a>) the fingers are semiflexed -and the thumb grips against the index finger, which is shorter than -the middle finger as in the natural hand. If it is desired to pick -up a ball, for example (<a href="#i_p102a">Fig. 151</a>), it will be seen that the middle -finger projects and gets in the way. For this reason it is advisable -that the index finger be longer than the middle, and in addition it is -useful to furnish the thumb and index finger with a little projection -representing the nail (<a href="#i_p102b">Fig. 150</a>).</p> - -<p>In figure <a href="#i_p102a">148</a> will be seen an arrangement which allows the thumb to -grip not by the tip, but by the whole length of its palmar surface (to -hold, for example, a notebook). The fingers of this hand have ball -and socket joints constructed in the way shown in figures 152 to 154. -The joints keep passively the<span class="pagenum"><a name="Page_104" id="Page_104">[104]</a></span> position in which they are placed. -The attachment of the ball of the joint on an intermediate tenon is -similar to that of the thumb shown on <a href="#i_p098">page 98</a>. The articulation of the -index finger prevents the sufficient excavation of the thenar eminence -for the insertion of the Beaufort thumb with its powerful spring. The -wrist rotates upon a bayonet joint.</p> - -<div class="figcenter" id="i_p104" style="width:500px"> - <img - class="p2" - src="images/i_p104.png" - width="500" - height="325" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 152 to 154.</p> - </div> - -<p class="p2">The fingers shown in <a href="#i_p105ab">figures 155 to 157</a> are joined together into a -single piece, which articulates with the metacarpal part of the hand -upon a transverse axis.</p> - -<p>They are held in a position of flexion at the metacarpo-phalangeal -joints by four palmar springs and they are opened away from the thumb -by the action of a cord which bifurcates from the thumb cord on the -back of the hand. The pull of this cord is exerted upon the upper -angle of a triangle from the lower border of which four cords pass on -to the back of the phalanges. Figure 156 shows detail of a finger. We -know that attempts have been made to isolate<span class="pagenum"><a name="Page_105" id="Page_105">[105]</a></span> by surgical means the -masses of the extensor and flexor muscles in the end of the stump, -making from them little prominences, perforated with a tunnel which is -lined with skin. The cords pass through the tunnels, and in this way -are worked voluntarily. We are not sure that this is practicable.</p> - -<div class="figcenter" id="i_p105ab" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p105ab.png" - width="600" - height="319" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 155 to 157.—<span class="sm"><i>Automatic fingers.</i></span></p> - <p class="sm">In figure 155 are seen the cavity in which the finger portion works -and the axis upon which movement takes place, also the four palmar -springs. In figure 157 the arrangement of the cords. In figure 158 the -attachment of the spring to the finger. This pattern, which we have -designed and which is not patented, seems to us to be simpler than -those in which the interphalangeal joints are also articulated and are -automatic. It gives a more accurate grip between the tips of the thumb -and index finger.</p> - </div> - -<p><span class="pagenum"><a name="Page_106" id="Page_106">[106]</a></span></p> - -<p class="p2"><i>The Brunet Grip.</i>—The Brunet grip is described here because of its -resemblance to the automatic thumb, both being worked on the same -principles.</p> - -<div class="figcenter" id="i_p106a" style="width:302px"> - <img - class="p2" - src="images/i_p106a.png" - width="302" - height="500" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 158 and 159.</p> -</div> - -<div class="figcenter" id="i_p106b" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p106b.png" - width="400" - height="144" - alt="" /> - <p class="center"><span class="smcap">Fig. 160.</span></p> - <p class="sm center"><i>Brunet's Grip.</i><span class="pagenum"><a name="Page_107" id="Page_107">[107]</a></span></p> - <p class="sm">Below the leather forearm piece, which laces up, the lateral steels -are continuous with each other in the form of an arch, to which the -grip is riveted.</p> - <p class="sm">The latter consists of a strong semicircular piece of metal facing -downwards, ending in a pair of wide and thick jaws, like those of a -locksmith's pliers. When the apparatus is at rest, these are kept in -contact by the pressure of two powerful fixed springs, attached to the -semicircle on the forearm above and to the jaws below. The external -and dorsal spring is attached to the tip of its jaw, the internal and -palmar (the side on which the manipulating cord is attached) to the -base of it.</p> - <p class="sm">The pliers are opened in the following way:—</p> - <p class="sm">Inside the semicircle to which the jaws are attached, lies a cylinder -with its ends cut obliquely; this rotates about a transverse axis, -and when at rest lies with its longer side upward. To the palmar edge -of the shorter side is attached a transverse eccentric, to which is -hooked a cord actuated as described in <a href="#i_p101a">figure 146</a>. When this is drawn -upward the cylinder rotates so that the wider side comes between -the jaws of the pliers and opens them; when the cord is relaxed the -springs turn the cylinder back again find the jaws close. Figures 158 -and 159 show the appliance at rest and with the jaws open.</p> - <p class="sm">This appliance is patented and is made in one piece. We demonstrate in -<a href="#i_p106b">figure 160</a> that it would be very easy to make the pliers detachable -from the forearm, with a screw connection, just as is done in the -various other appliances which will be described.</p> -</div> - -<p class="p2">The grip of the automatic thumb always lacks power, for two reasons. -There is no room in the thenar eminence to fit a powerful spring and -the grip has always a very narrow hold.</p> - -<p><span class="pagenum"><a name="Page_108" id="Page_108">[108]</a></span></p> - -<p>The Brunet grip is an actual pair of pliers, shaped like these and -furnished with a powerful spring. It is opened by a cord like that -of the automatic thumb. Figures <a href="#i_p106a">158 to 160</a> explain the mechanism. -It is an excellent appliance with which the wearer can carry out -the majority of the actions of everyday life. It has, however, the -disadvantage that it is not shaped like a hand—a point to which -patients attach much importance—and, moreover, it is a part of -a patented appliance, for which an interchangeable hand is not -manufactured. So that in order to have in addition an artificial hand, -which is capable of being removed and replaced by one or more of the -appliances which will be described later, it would be necessary for -the patient to possess two complete artificial limbs, and changing -from one to the other would evidently be inconvenient.</p> - -<p>We generally prescribe this appliance for patients who have lost both -arms, for one side and as a supplementary appliance.</p> - -<p>There are other similar models into details of which it is unnecessary -to enter. Those in which the grip is opened by movements of pronation -and supination are obviously only suitable for certain rare cases -(very long stumps, with free movement).</p> - - -<h5>B.—Appliances for Use in Place of the Hand.</h5> - -<p>The general principle is to fit to the end of the forearm piece an -attachment which can be screwed on or unscrewed at will and which -carries an appliance which is adapted to the various more or less -specialised movements of the patient's trade.</p> - -<p><span class="pagenum"><a name="Page_109" id="Page_109">[109]</a></span></p> - -<p>Naturally the results thus attained must always be imperfect; but -however little perseverance and ingenuity he may possess, the patient -finds that he is able to educate the remaining arm, even when it -is the left, to replace the amputated one in a way that is often -remarkable. It is to this education that attention must be specially -directed in the workshops for the re-education of the maimed.</p> - -<p>1. <i>Knife and Fork.</i>—The first necessity is to be able to eat, and by -certain very simple devices a fork, spoon or knife may be fixed to a -wooden hand, whether the thumb be mobile or not.</p> - -<p>As a general rule if the patient has one arm intact, he uses the sound -hand only for this purpose, but when both forearms have been lost an -appliance is indispensable.</p> - -<p>We have already described how in the hand with an automatic thumb, -room can be left between the index and middle fingers for the handle -of a spoon or fork. A direct grip can also be obtained with the hand -shown in figure <a href="#i_p101b">147</a>.</p> - -<p>The hand with five automatic digits (p. <a href="#Page_105">105</a>) is usually arranged in -such a way that it is possible to<span class="pagenum"><a name="Page_110" id="Page_110">[110]</a></span> hold a tumbler for drinking; but a -patient with an amputation of one hand drinks with the other, and one -who has lost both hands can drink with a straw.</p> - -<p>These appliances have replaced that in which the knife or fork is -attached to a block of wood which can be fitted into the palm of the -hand when required. It is inconvenient to be obliged to carry these -special implements about.</p> - -<p>Raynal's fork-rest has the advantage over the last<span class="pagenum"><a name="Page_111" id="Page_111">[111]</a></span> mentioned that -it fits any fork. Figure <a href="#i_p109">161</a> shows very clearly its construction and -the way in which it is used. The small special attachment, which is -screwed in place, is not cumbersome and can quite well be carried in -the pocket; it is, however, even more convenient to have an appliance -which is capable of gripping the fork directly like those described -previously.</p> - -<div class="figcenter" id="i_p109" style="width:400px"> - <img - class="p2" - src="images/i_p109.png" - width="400" - height="272" - alt="" /> - <p class="center"><span class="smcap">Fig. 161.</span>—<span class="sm">Raynal's fork rest.</span></p> -</div> - -<div class="figcenter" id="i_p110" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p110.png" - width="288" - height="450" - alt="" /> - <p class="center"><span class="smcap">Fig. 162.</span>—<span class="sm">The termination of the forearm is a -hemispherical piece of metal, furnished with a screw into which screw -at will the hand, the hook or the ring.</span></p> -</div> - -<p class="p2">2. <i>Appliances for Workmen.</i>—All the appliances that are attached -to the arms in place of the artificial hand for performing various -kinds of work are elaborated from two simple forms: the hook and the -ring (for catching hold and carrying a parcel, for holding a handle, -etc.). A glance at figure <a href="#i_p110">162</a> will show the nature of these and the -way in which they are used. But it will also be understood that if -the simple ring and hook are useful for equally simple purposes they -are altogether insufficient for skilled labourers<span class="pagenum"><a name="Page_112" id="Page_112">[112]</a></span> whose work entails -a certain special adroitness, e.g. joiners, locksmiths, agricultural -labourers, etc.</p> - -<p>Many makers have realised this and have devised very ingenious -implements, some of which we reproduce, though we are obliged to limit -ourselves to certain types, for they can be varied in countless ways -according to the needs of particular cases. The same workman, as we -have already said, may have several appliances which he uses in turn -as he needs them in the course of his work.</p> - -<p>These appliances are constructed in two ways; some are fixed to the -end of the forearm and are immobile, some are attached by means of a -joint or joints and are capable of rotation in various directions.</p> - -<p>(<i>a</i>) <i>Fixed Appliances.</i>—We illustrate here an appliance derived -from the simple hook, the <i>vine-dresser's claw</i>, devised some time ago -by Gripouilleau; branches of varying size can be held while the other -hand saws them or cuts them with the pruning shears (Figs. 163 and -164).</p> - -<div class="figcenter" id="i_p111a" style="width:400px"> - <img - class="p2" - src="images/i_p111a.png" - width="130" - height="350" - alt="" /> - <p class="center"><span class="smcap">Fig. 163.</span>—<span class="sm">Vine dresser's hook. -(Gripouilleau).</span></p> -</div> - -<div class="figcenter" id="i_p111b" style="width:400px"> - <img - class="p2" - src="images/i_p111b.png" - width="400" - height="339" - alt="" /> - <p class="center"><span class="smcap">Fig. 164.</span>—<span class="sm">The branch is held in the grip by a -leverage exerted by torsion.</span></p> -</div> - -<p class="p2">This appliance of Gripouilleau, with a series of hooks, forms the -basis of almost all the "pincer hands" constructed by M. Boureau and -characterised by—</p> - -<p>(1) The closure of the upper hook which is thus transformed into a -ring, the two appliances being combined in one;</p> - -<p>(2) The spring fixed to the straight side of the hook providing the -grip necessary for holding articles. If the free end of the spring is -turned up like the pointed toe of a mediæval shoe a sufficiently large -opening is left between it and the straight edge of the hook to enable -an object which is fixed mechanically or held by the other hand to be -pushed into and gripped by the spring.</p> - -<p><span class="pagenum"><a name="Page_113" id="Page_113">[113]</a></span></p> - -<p>The simplest type of this mechanism is the <i>postman's hand</i> (Figs. 165 -and 166).</p> - -<div class="figcenter" id="i_p113" style="width:550px"> - <img - class="p2" - src="images/i_p113.png" - width="550" - height="424" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 165 and 166. <span class="sm">Postman's hand.</span></p> -</div> - -<p class="p2">The left hand of the postman who sorts letters has for its work to -keep in the proper order the envelopes which are arranged in little -packets; the right hand has only to push the letter into place between -a flat spring, fixed to the wrist, and the back of the hook. If two -or three springs are supplied the postman can arrange two or three -packets of letters at the same time. He can also bind the packet with -string.</p> - -<p>The <i>vine-dresser's hand</i> is provided with this spring to hold -small flat objects, but the second spring is wavy in outline, so -that semilunar spaces are left between it and the first. Into these -branches slip when the spring is pressed against them, and they are -thus held more firmly, whilst being sawn or pruned,<span class="pagenum"><a name="Page_114" id="Page_114">[114]</a></span> than by the -twisting action of the old pattern hook of Gripouilleau (Figs. 167 and -168).</p> - -<div class="figcenter" id="i_p114a" style="width:550px"> - <img - class="p2" - src="images/i_p114a.png" - width="550" - height="272" - alt="" /> - <p class="center"><span class="smcap">Fig. 167.</span>—<span class="sm">Horticulturist's hand.</span></p> -</div> - -<div class="figcenter" id="i_p114b" style="width:550px"> - <img - class="p2" - src="images/i_p114b.png" - width="400" - height="345" - alt="" /> - <p class="center"><span class="smcap"> Fig. 168.</span>—<span class="sm">Method of holding a branch.</span></p> -</div> - -<p class="p2">This thrust to seize the branch is somewhat rough, and is only -possible in holding hard wood which there is no fear of bruising. -For more delicate shoots (grafting vines indoors, preparation of -cuttings), a grip is necessary which can be opened before seizing<span class="pagenum"><a name="Page_115" id="Page_115">[115]</a></span> -hold of the object. This is accomplished by prolonging the spring -towards the forearm as a handle, pressure upon which against the chest -(when standing), or against the knee (when sitting), opens the grip, -in which the graft, for example, is then placed in the opening of the -correct size.</p> - -<p><i>The packer's hand</i> is very ingenious (Fig. 169). It has the hook -pierced by an eye enabling a thread to be passed through a basket -as with a curved needle. The jaws of the pincers are smooth at the -tips, but further back they have a series of graduated notches in -which tacks of different sizes can be held whilst they are driven in -with the hammer. But of course a workman can only work quickly if he -can hold a number of tacks of the same size in the palm of his hand, -placing one under the hammer, relaxing his hold of it after the first -gentle blow has fixed it, and getting the next ready while he drives -it home.</p> - -<div class="figcenter" id="i_p115" style="width:550px"> - <img - class="p2" - src="images/i_p115.png" - width="550" - height="286" - alt="" /> - <p class="center"><span class="smcap">Fig. 169.</span>—<span class="sm">Packer's hand.</span></p> -</div> - -<p class="p2"><i>The plumber's hand</i> (Fig. 170) is made in the shape of a pair of gas -pliers, and ends in cutting edges with which wires can be cut. With -them a bolt can be held whilst the other hand screws on the nut.</p> - -<div class="figcenter" id="i_p116a" style="width:550px"> - <img - class="p2" - src="images/i_p116a.png" - width="550" - height="261" - alt="" /> - <p class="center"><span class="smcap">Fig. 170.</span>—<span class="sm">Plumber's hand.</span></p> -</div> - -<p><span class="pagenum"><a name="Page_116" id="Page_116">[116]</a></span></p> - -<p class="p2"><i>The leather-cutter's hand</i> (Figs. 171 and 172) should be able to -hold the skin which the other hand cuts: it consists of a plate with -a rough surface fixed to a ball and socket joint which allows it to -turn in any direction, so that the other hand can follow the line to -be cut which is often sinuous. This appliance may also be used to hold -a drawing paper, a rule for cutting cardboard, or sheets of paper for -binding.</p> - -<div class="figcenter" id="i_p116b" style="width:391px"> - <img - class="p2" - src="images/i_p116b.png" - width="391" - height="450" - alt="" /> - <p class="center"><span class="smcap">Fig. 171.</span>—<span class="sm">Leather-cutter's hand.</span></p> -</div> - -<p class="p2">The examples that we have chosen amongst<span class="pagenum"><a name="Page_117" id="Page_117">[117]</a></span> Boureau's appliances for -craftsmen will, we believe, be sufficient to explain the principles -of their construction. These consist in studying the movements which -are normally carried out by the passive hand (usually the left hand, -but the right in left-handed people) and to devise an appliance -accordingly, the sound hand always becoming the active hand.</p> - -<div class="figcenter" id="i_p117" style="width:550px"> - <img - class="p2" - src="images/i_p117.png" - width="550" - height="288" - alt="" /> - <p class="center"><span class="smcap">Fig. 172.</span>—<span class="sm">Leather-cutter's hand.</span></p> -</div> - -<p class="p2">We could have described many more examples, but we shall only say a -few words about the <i>mechanic's hand</i>, which is simply an adjustable -spanner which can be automatically closed, terminating in toothed -pliers to hold circular objects without the necessity for being -screwed up. As a matter of fact, in all the work of a mechanic -(sawing, filing, drilling, tightening screws, hammering, forging, and -grinding) the left hand is only used for picking up and steadying -the article to be manipulated. M. Boureau rightly considers that it -is better to entrust this rôle to the artificial hand rather than to -contrive to make the latter capable of sawing or of filing by means of -the devices which we shall describe further on (<a href="#Page_121">p. 121</a> and following), -ingenious and interesting though these may be.</p> - -<p><span class="pagenum"><a name="Page_118" id="Page_118">[118]</a></span></p> - -<p>From these appliances, adapted to certain particular grips, others -have been devised for chair caning, soldering, and for enabling -factory hands to work starting levers and brakes.</p> - -<p>Thus each case must be studied separately and the workman furnished -with one or several appliances according to his needs, making the -necessary modifications from the existing patterns.</p> - -<p>Several of these appliances are attached by a ball-and-socket joint -like that described for the leather cutter: this is an intermediate -form between the fixed appliance and the jointed appliances which will -be described later.</p> - -<p>Boureau recommends that the length of the forearm should be such that -the artificial appliance reaches only as far as the level of the sound -wrist. The work will then gain in precision. We believe that this -principle holds good even for the true artificial hand, which should -be made 3 to 4 centimetres shorter than the sound hand. But it must be -realised that we shall be met with a difficulty, which we have already -experienced. Comments are made upon the appearance of the arm and the -wearer may sometimes be made to believe that this is due to faulty -construction.</p> - -<p>For certain special crafts the subject may be studied from another -standpoint and an actual tool constructed which carries out the -necessary actions like a machine worked by the forearm, so that in -these special cases the artificial hand is the active hand.</p> - -<p>At the Valentin Hauy Institute for the blind, where there has long -been a brushmaking workshop, we have seen in use a very ingenious -tool of this description<span class="pagenum"><a name="Page_119" id="Page_119">[119]</a></span> with a combined action for carrying out the -entire manipulation of the thread which fixed the little bundles of -bristles into the holes perforating the back of the brush. Results are -so good that a blind and<span class="pagenum"><a name="Page_120" id="Page_120">[120]</a></span> maimed worker using this apparatus works -more quickly than his comrades who have the use of both hands. It -consists of a two-pronged claw surmounted by a small thimble-shaped -projection and with a small hook, like a crochet hook projecting in -front (Fig. 173). The hook first passes through one of the holes in -the back of the brush, catches up the thread and draws it through -the hole (Figs. 174 and<span class="pagenum"><a name="Page_121" id="Page_121">[121]</a></span> 175). The thread is then looped around the -thimble, whilst the sound hand binds the little bundle of bristles -into a twist of the loop (Fig. 176), and finally the bundle is fixed -into the hole, the claw being used to draw the brush towards the -worker (Fig. 177).</p> - -<div class="figcenter" id="i_p119a" style="width:400px"> - <img - class="p2" - src="images/i_p119a.png" - width="400" - height="169" - alt="" /> - <p class="center"><span class="smcap">Fig. 173.</span>—<span class="sm">Brushmaker's hook.</span></p> -</div> - -<div class="figcenter" id="i_p119b" style="width:500px"> - <img - class="p2" - src="images/i_p119b.png" - width="500" - height="302" - alt="" /> - <p class="center"><span class="smcap">Fig. 174.</span>—<span class="sm">First movement. The string is -picked up by the hook.</span></p> -</div> - -<div class="figcenter" id="i_p119c" style="width:550px"> - <img - class="p2" - src="images/i_p119c.png" - width="550" - height="327" - alt="" /> - <p class="center"><span class="smcap">Fig. 175.</span>—<span class="sm">Second movement. The string is -pulled through one of the holes perforated in the back of the brush.</span></p> -</div> - -<div class="figcenter" id="i_p120a" style="width:550px"> - <img - class="p2" - src="images/i_p120a.png" - width="550" - height="352" - alt="" /> - <p class="center"><span class="smcap">Fig. 176.</span>—<span class="sm">Third Movement. Catching the bundle -of bristles.</span></p> -</div> - -<div class="figcenter" id="i_p120b" style="width:550px"> - <img - class="p2" - src="images/i_p120b.png" - width="550" - height="415" - alt="" /> - <p class="center"><span class="smcap">Fig. 177.</span>—<span class="sm">Fourth Movement. The bundle is -fixed in the hole in the back of the brush.</span></p> -</div> - -<p class="p2">(3) In place of an actual tool the detachable part may consist of a -clamp on the principle of a ring into which the tool is inserted by -the handle. The two principal methods are the screw and the American -chuck. A glance at figures <a href="#i_p121">178 and 179</a> will explain how the large -handle of a tool intended for heavy work is controlled by means of a -screw and rings.</p> - -<div class="figcenter" id="i_p121" style="width:600px"> - <img - class="p2" - src="images/i_p121.png" - width="600" - height="444" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 178 and 179.—<span class="sm">Nyrop's grip for hammer -and saw.</span></p> -</div> - -<p class="p2">At Rouen we have seen the disabled Belgians who had been re-educated -wearing an ingenious T-shaped clamp by means of which the handle of a -tool may be held either in the line of the axis of the forearm<span class="pagenum"><a name="Page_122" id="Page_122">[122]</a></span> or at -right angles to this. This method is specially useful for manipulating -a file which is worked with one hand while the other, in this case -the sound hand, presses upon the free end. Usually the filing is done -backwards and forwards, working from base to tip of the file, but -sometimes, specially for final polishing, the file is held with both -hands and worked from side to side.</p> - -<p>The American chuck consists of a pair of metal jaws fixed at their -base into a cylinder and appearing somewhat like the petals of a long -corolla. Another cylinder is screwed over the first to control the -opening<span class="pagenum"><a name="Page_123" id="Page_123">[123]</a></span> and shutting of the jaws. When this cylinder is unscrewed -the jaws open and the handle of the tool can be inserted, when it is -screwed up it closes the jaws and makes them grip the handle.</p> - -<div class="figcenter" id="i_p122" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p122.png" - width="600" - height="504" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 180 to 185.—<span class="sm"><i>The American Chuck.</i></span></p> - <p class="sm">The pincers are composed of two jaws with vertical cylindrical grooves -(to fit upon a handle), joined above by a ring (Fig. 185) and coupled -by a spring C which keeps them apart. The pincers fit into a piece -B (Fig. 182) cut on the outer side with a screw thread (Figs. 182 -and 183) upon which the piece A is screwed up or down (Figs. 180 and -181). When screwed towards the point of the pincers it presses on the -two jaws and closes them. When screwed in the opposite direction the -pincers open automatically.</p> -</div> - -<p class="p2">If the jaws open widely, the wooden handle of a tool can be held, but -if the opening is small the unmounted tool must be fitted into them -(Figs. 186 and 187). This method is specially useful for files, as it -frequently happens that several files are required for the same piece -of work and they can be changed rapidly.</p> - -<div class="figcenter" id="i_p123" style="width:650px"> - <img - class="p2" - src="images/i_p123.png" - width="650" - height="210" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 186 and 187.—<span class="sm">File fitted into the -American chuck.</span></p> -</div> - -<p class="p2">It must, however, be insisted upon that the principle of giving a -passive rôle to the artificial hand is to be preferred.</p> - -<p>(<i>b</i>) <i>Appliances with Mobile Joints.</i>—In the course of work the -direction of the wrist is changing at every instant, flexion, -extension, pronation, and supination occurring, sometimes in order -to move around the object, sometimes in order to maintain a suitable -position when the movements of the shoulder and elbow vary the -direction of the forearm.</p> - -<p>The consequence of this is that the worker learns to turn the piece of -work around with his sound hand. To get over this difficulty passive -joints are inserted<span class="pagenum"><a name="Page_124" id="Page_124">[124]</a></span> at the wrist, which allow the appliance to move -when it is pressed against the piece of work and to take up the -direction which suits the inclination of the forearm.</p> - -<p><span class="pagenum"><a name="Page_125" id="Page_125">[125]</a></span><span class="pagenum"><a name="Page_126" id="Page_126"></a></span></p> - -<p class="p2">One of the simplest mechanisms—and one of the oldest, because it was -designed by Gripouilleau—is that of the <i>agricultural labourer's -ring</i>, intended to grip and manipulate the handle of a wheelbarrow -or a plough. The ring is mounted on a transverse axis and moves in a -horseshoe which in its turn revolves on a shank which is screwed into -the forearm. The ring is provided with a screw, which may be tightened -upon the handle if desired, but which is, however, rarely used (Figs. -188 to 190).</p> - -<div class="figcenter" id="i_p124a" style="width:500px"> - <img - class="p2" - src="images/i_p124a.png" - width="500" - height="380" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 188 to 190.—<span class="sm">Agricultural hook and ring. -(Gripouilleau.)</span></p> -</div> - -<div class="figcenter" id="i_p124b" style="width:550px"> - <img - class="p2" - src="images/i_p124b.png" - width="550" - height="418" - alt="" /> - <p class="center"><span class="smcap">Fig. 191.</span>—<span class="sm">Combined hook and ring. (Boureau.)</span></p> -</div> - -<p>The <i>tram-driver's bell</i>, represented in figure <a href="#i_p125a">192</a>, is devised on the -same principle. It moves on a transverse axis, and in figures <a href="#i_p125b">193</a> and -<a href="#i_p125c">194</a> its utility in managing levers in driving a tram or a motor car -will be easily seen. The rotation of the horseshoe on the axis of the -forearm is not required.</p> - -<div class="figcenter" id="i_p125a" style="width:550px"> - <img - class="p2" - src="images/i_p125a.png" - width="550" - height="251" - alt="" /> -</div> - -<div class="figcenter" id="i_p125b" style="width:600px"> - <img - class="p0" - src="images/i_p125b.png" - width="600" - height="398" - alt="" /> -</div> - -<div class="figcenter" id="i_p125c" style="width:70%; margin: auto 15%;"> - <img - class="p0" - src="images/i_p125c.png" - width="450" - height="362" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 192 to 194. <span class="sm">1. Tram driver's and chauffeur's bell. 2. -Method of use by a tram driver. 3. Management of a motor car lever. -Pressure at the extremity and traction.</span></p> -</div> - -<p class="p2"><i>The "cardan" joint</i> also allows movement in every direction: it -consists of two semicircles of metal, placed at right angles, each -working around a transverse axis, these axes being united in the form -of a cross. The construction and working will<span class="pagenum"><a name="Page_127" id="Page_127">[127]</a></span> probably be understood -without further explanation by a study of figures <a href="#i_p126">195 to 198</a>. The -first two represent a system with a ball in the centre, which is well -known commercially. The last two represent the simple universal joint -generally used in orthopædic surgery. It is somewhat more cumbersome -than the previous model.</p> - -<div class="figcenter" id="i_p126" style="width:600px"> - <img - class="p2" - src="images/i_p126.png" - width="600" - height="411" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 195 and 196.—<span class="sm">Universal joint with ball.</span></p> -</div> - -<div class="figcenter" id="i_p127a" style="width:516px"> - <img - class="p2" - src="images/i_p127a.png" - width="516" - height="550" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 197 and 198.—<span class="sm">Simple universal joint.</span></p> -</div> - -<p class="p2">The spade holder used at the agricultural centre at Limonest is -mounted on a cardan (Fig. 199).</p> - -<div class="figcenter" id="i_p127b" style="width:600px"> - <img - class="p2" - src="images/i_p127b.png" - width="600" - height="227" - alt="" /> - <p class="center"><span class="smcap">Fig. 199.</span>—<span class="sm">Gardener's cylindrical spade -holder. A universal joint permits movements in every direction.</span></p> -</div> - -<p><span class="pagenum"><a name="Page_128" id="Page_128">[128]</a></span></p> - -<p class="p2">The joint can be fixed by a compression screw which is easily and -quickly adjusted.</p> - -<p>Where several tools are necessary each should be complete with its own -universal joint.</p> - -<p>Other methods of terminal passive articulations are—</p> - -<p>(1) Ball joints which have already been described in connection with -the fingers and which may be applied to the wrist.</p> - -<p>(2) Bayonet joints which are only applicable to certain artificial -hands which are not subjected to any great strain.</p> - -<p>Figure 200 explains this mechanism as it is applied to the artificial -hand represented in figure <a href="#i_p102a">148</a>.</p> - -<div class="figcenter" id="i_p128" style="width:600px"> - <img - class="p2" - src="images/i_p128.png" - width="600" - height="207" - alt="" /> - <p class="center"><span class="smcap"> Fig. 200.</span></p> -</div> - -<hr class="chap" /> - -<div class="chapter"> - -<p><span class="pagenum"><a name="Page_129" id="Page_129">[129]</a></span></p> - -<h2><i>CHAPTER VIII</i></h2></div> - -<h3>ARTIFICIAL LIMBS FOR AMPUTATION THROUGH THE ARM</h3> - -<p>In this chapter we shall deal only with amputation of the arm below -the upper third, <i>i.e.</i> with cases in which the stump is long enough -to transmit movements to the artificial limb. Amputation through the -deltoid muscle must be considered in association with disarticulation -of the shoulder.</p> - -<p>Below the arm socket is attached an artificial limb which represents -the elbow joint, forearm, and hand.</p> - -<p>There are two types to be described:—</p> - -<p>1. The artificial arm proper, which has the external shape of the -natural limb.</p> - -<p>2. The worker's arm, a terminal appliance in which outward appearance -is not considered.</p> - -<p>The considerations as to the arm socket and its attachment by a -shoulder cap are the same for the two types of appliance.</p> - -<p><i>Attachment and Arm Socket.</i>—The surface over the acromion and -clavicle is the only point from which support can be given to an -appliance for an amputation through the arm; the attachment is made by -means of a shoulder cap.</p> - -<p>The general shape of this shoulder cap and its<span class="pagenum"><a name="Page_130" id="Page_130">[130]</a></span> attachment by means -of a strap passed under the opposite axilla are similar to those -described for appliances for amputation through the forearm.</p> - -<div class="figcenter" id="i_p130a" style="width:441px"> - <img - class="p2" - src="images/i_p130a.png" - width="441" - height="450" - alt="" /> - <p class="center"><span class="smcap">Fig. 201.</span></p> -</div> - -<div class="figcenter" id="i_p130b" style="width:455px"> - <img - class="p2" - src="images/i_p130b.png" - width="455" - height="450" - alt="" /> - <p class="center"><span class="smcap">Fig. 202.</span></p> -</div> - -<p class="p2" style="clear: both">The larger the shoulder cap the more it extends forwards over the -anterior wall of the axilla, upwards over the supra clavicular fossa, -and backwards over the scapula, the more secure will be the support. -The appliance is heavy and has no support other than the axillary -strap. The latter has a tendency to ride upwards against the axilla -where it exerts a pressure which may be uncomfortable. This may be -relieved by attaching a vertical strap which is buttoned to the -trouser belt.</p> - -<p>But although this extensive enclosure of the thoracic region may not -hinder the movements of the stump forwards and backwards, it must -obviously interfere with the movement of abduction. No doubt this -movement is the less important of the two, but we ought to try to -preserve it as far as possible.</p> - -<p><span class="pagenum"><a name="Page_131" id="Page_131">[131]</a></span></p> - -<p>In short stumps we must abandon it. But if the stump is long and -consequently has no tendency to escape from the socket, even if this -slips down a little, movement may be retained by two methods.</p> - -<p>The first consists in separating the arm socket from a large shoulder -cap, and inserting a joint between (see <a href="#Page_87">page 87</a>); but the appliance -is then heavy and cumbersome. Moreover, although abduction can thus -be easily attained, thrusting and pulling movements require a light -appliance, and finally it is impossible to secure rotation.</p> - -<div class="figcenter" id="i_p131" style="width:750px"> - <img - class="p2" - src="images/i_p131.png" - width="750" - height="358" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 203 and 204.—<span class="sm">Shoulder fitting of small -extent allowing abduction.</span></p> -</div> - -<p class="p2">It is possible, on the other hand, by means of the other method, which -consists in ending the shoulder cap at a line continued vertically -upwards from the thoracic margin of the axilla. If the straps are -strong and carefully adjusted the result is better than with the -fitting over the scapula, so that this appliance is preferable. We -here illustrate a method of fitting the straps which we consider a -good one. From the posterior part of the ordinary axillary strap, a -Y-shaped branch passes to the upper border of the shoulder cap above -and in front of the clavicle, this<span class="pagenum"><a name="Page_132" id="Page_132">[132]</a></span> makes up for the small extent of -the enclosure of the shoulder.</p> - -<p>For the worker's arm a considerable enclosure without any joint is -essential, in order to secure stability.</p> - -<p>The arm bucket, usually continuous with the shoulder cap, is made of -leather strengthened with steels.</p> - -<p>The artificial arm is often abducted from the trunk, which constitutes -an inconvenience. This is sometimes due to a fault in the alignment, -the arm piece not being at right angles to the shoulder cap. It is, -however, more often due to the cylindrical shape given to the arm -bucket which forces it away from the trunk. The inner side of the -bucket should be flattened so that it may hang vertically close to the -thorax.</p> - -<p>The details of construction are different for the true artificial arm -and the worker's arm.</p> - - -<h5>1. Artificial Arm</h5> - -<p>The arm and forearm pieces are both made of leather. There is no -object in making them to lace, the stump is enclosed in a socket in -which it need not fit very tightly, because, as we shall explain, this -appliance is unsuitable for heavy work.</p> - -<p>These two parts are strengthened with steels, which are articulated by -hinge joints at the level of the elbow. We have to study—</p> - -<p>1. The position of the steels and the direction of the axis of the -joint.</p> - -<p>2. The lock to fix the elbow joint in a flexed position.</p> - -<p><span class="pagenum"><a name="Page_133" id="Page_133">[133]</a></span></p> - -<p>1. <i>Position of the Steels.</i>—The stump can transmit to the arm socket -the various movements grouped under the name of circumduction, but its -hold does not enable it to transmit rotation.</p> - -<p>It is therefore undesirable—although usual—to attach the steels -on the arm and forearm to the inner and outer sides of the limb. If -this is done, as rotation is impossible, flexion of the forearm at -the elbow can only be carried out in the sagittal plane. But this -movement is only exceptionally required; the elbow being flexed to the -right angle and fixed in this position by a ratchet the limb forms a -hook upon which an object may be hung, provided that the forearm lies -transversely in contact with the abdomen and not antero-posteriorly. -Flexion should therefore be in a plane which is almost the frontal -plane (20° or 30° in front of this), and not in the sagittal plane. -As there is no active rotation of the arm therefore the steels must -be almost in the sagittal plane (the anterior a little external, the -posterior a little internal).</p> - -<p>In certain carefully constructed appliances the arm bucket is cut -transversely above the elbow and between the two parts a bayonet joint -is fixed where the arm can be rotated by the sound hand, so that the -direction of the elbow movement can be altered.</p> - -<p>2. <i>Ratchet to fix the Elbow Joint in the Flexed Position.</i>—When at -rest the forearm should hang vertically. But the hand can only be used -when the elbow is flexed to an obtuse angle or a right angle, the -latter position being more often used. Therefore when the patient has -bent the joint to the required angle with his sound hand, he must be -able to fix it in this position.</p> - -<p>This fixation is effected by means of a ratchet<span class="pagenum"><a name="Page_134" id="Page_134">[134]</a></span> attached to the outer -side of the elbow, which can be locked or unlocked at will.</p> - -<p>This ratchet consists of a flat metal plate with a prolongation -upwards shaped like the handle of a fork. The end of this prolongation -is attached to the arm steel by a pin joint about 3 centimetres above -the axis of the elbow joint. The plate is pierced by a rectangular -opening, one border of which is notched; it lies against the forearm -steel, a catch projecting from which fits into the opening, this -catch, situated 6 centimetres below the axis of the elbow, is of -the same diameter as the notches with which it engages. The higher -the notch with which engagement takes place the more nearly flexion -approaches the right angle.</p> - -<p>The width of the opening in the plate is twice the size of the catch, -so that the joint works freely when the catch glides on the smooth -edge and becomes fixed as soon as the catch engages in the notched -border.</p> - -<p>It is only necessary to arrange a lock, manipulated through the -sleeve, to bring the smooth or the notched border in contact with the -catch.</p> - -<p>Suppose that the handle of the ratchet is prolonged behind the point -at which it is hinged to the arm steel as a little lever furnished -with a button, and that an elastic cord or spring is stretched from -this button to a point on the postero-external border of the forearm, -then if the lever points upwards and the notches are on the upper edge -of the ratchet (as is the case in figure <a href="#i_p135">205</a>), the elastic, pulling -the lever forwards, will press the ratchet down and make the notches -engage with the catch on the forearm, if, on the other hand, the lever -points downwards the elastic traction<span class="pagenum"><a name="Page_135" id="Page_135">[135]</a></span> will release the notches. The -reverse occurs if the notches are on the lower edge.</p> - -<p>It is then only necessary to arrange a mechanism by means of which -this little lever can turn, with a stop which arrests it above at the -vertical position, below at a point 45° beyond the horizontal.</p> - -<div class="figcenter" id="i_p135" style="width:397px"> - <img - class="p2" - src="images/i_p135.png" - width="397" - height="450" - alt="" /> - <p class="center"><span class="smcap">Fig. 205.</span>—<span class="sm">Elbow ratchet.</span></p> -</div> - -<p class="p2">A simple mechanism of this sort is shown in figures <a href="#i_p136">206 and 207</a>. The -joint surfaces of the ratchet and of the little lever each bear a -shoulder, the former in front, the latter behind, extending over such -a proportion of their circumference as will make them act as stops in -the desired positions above and below.</p> - -<div class="figcenter" id="i_p136" style="width:514px"> - <img - class="p2" - src="images/i_p136.png" - width="514" - height="600" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 206 and 207.—<span class="sm">The elbow ratchet and mode -of action of its lock.</span></p> -</div> - -<p class="p2">A lock is thus provided which can be manipulated with the other hand.</p> - -<p>In the particular pattern illustrated, traction is made by an elastic -cord fixed to the centre of the back of the wrist and ending above -in a leather strap pierced with holes which fix on the button of the -lever. This arrangement allows of the adjustment necessitated by the -gradual stretching of an elastic which is subjected to continuous -tension.</p> - -<p><span class="pagenum"><a name="Page_136" id="Page_136">[136]</a></span></p> - -<p>A steel spring of this length (the whole length of the forearm) would -be too heavy if it were sufficiently powerful. If it is desired to use -this method the two ends of a powerful spring should be fixed, one to -the button on the lever, the other to the catch on the forearm with -which the ratchet engages.</p> - -<p>The spring should always be in tension. As the distance between the -joint on the arm and any point on the forearm increases as the elbow -extends, it is better for the ratchet, with notches on its upper<span class="pagenum"><a name="Page_137" id="Page_137">[137]</a></span> -edge, to be engaged when the button points upwards and free when it -points downwards. In the opposite arrangement, which is often used, -the tension is considerable without being useful when the forearm is -vertical, and the mechanism soon wears out.</p> - -<p>3. <i>Hand and Other Appliances.</i>—The hand attached to the end of the -forearm has a spring thumb which may be passive or automatic. In -the latter case, if the stump is long enough to allow considerable -movements of the arm, the cord works in the way described on <a href="#i_p087">page 87</a>, -for amputation of the forearm. If the stump is short, traction must be -exerted by movement of the shoulders, rounding the back.</p> - -<p>The hand with a mobile wrist is never used with these amputations -except in certain expensive appliances, in which in addition the four -fingers may be articulated, as described on <a href="#i_p101a">page 101</a>. For the ordinary -limb these delicate mechanisms are devoid of practical utility.</p> - -<p>It is easy to replace the hand with interchangeable appliances, but -when the patient has to do hard work this is not a satisfactory method.</p> - -<p>The arm with the ratchet at the elbow is in fact suitable for use -by a clerk. But it is not either strong enough or simple enough for -manual labour. In our opinion the functional and practical value of -an artificial arm, particularly for amputation above the elbow, is -often exaggerated, however it does exist, especially in many branches -of agricultural work. For the latter the slightness of the lateral -steels—and especially of the joints at the elbow—makes the appliance -insufficiently strong. The necessary delicacy of the ratchet and its -manipulation through the sleeve by the sound hand are additional -disadvantages.</p> - -<p><span class="pagenum"><a name="Page_138" id="Page_138">[138]</a></span></p> - -<h5>2. Worker's Arm</h5> - -<p>If our object is to fit to an arm stump an appliance which will be at -the same time strong and flexible, capable of carrying out rough and -even vigorous work, we must abandon the attempt to imitate the natural -shape of the arm.</p> - -<p>The movements and strength of the stump must be transmitted to the -object held by means of a rigid rod at the extremity of which the -appliance for gripping is fixed. It is possible to fix around this -rod a show arm with a hand and a passive spring thumb for wearing on -special occasions, in exactly the same way as we fit the show leg -round the peg. Figures <a href="#i_p139">208</a> and <a href="#i_p139">210</a> will show at a glance how this is -done.</p> - -<p>But, as far as our present experience goes, this is only an accessory -added for æsthetic reasons. The true worker's arm consists of a strong -metal rod fixed to the arm socket in a way that we must now study.</p> - -<p>1. <i>The Arm Socket.</i>—We have already said that this must be continued -into a shoulder cap of considerable extent, which may be perforated -in the region of the point of the shoulder in order to render the -appliance lighter. Abduction at the shoulder is thus sacrificed.</p> - -<p>The arm socket is made of leather, open down the front and laced. By -being laced it fits the stump more securely. It is strengthened by two -steels which may be fixed in the frontal plane because, as we shall -see, a passive rotation at the elbow joint is possible.</p> - -<p>These steels are directly continuous below with a hemispherical steel -cap, which is pierced in the axis of the limb by a hole into which is -bolted the<span class="pagenum"><a name="Page_139" id="Page_139">[139]</a></span> connecting piece to which the rod which represents the -forearm is attached.</p> - -<p>2. <i>Articulation at the Elbow.</i>—The forearm consists of simple metal -tube, attached beneath the arm socket by methods which depend upon the -following principles.</p> - -<div class="figcenter" id="i_p139" style="width:70%; margin: auto 15%;"> - <img - class="p2" - src="images/i_p139.png" - width="413" - height="600" - alt="" /> - <p class="center"><span class="smcap">Figs.</span> 208 and 209.—<span class="sm"><i>Worker's arm and show -arm.</i></span></p> - <p class="sm">The worker's arm consists of a metal rod which swings backwards and -forwards at the elbow and also rotates upon the arm socket. To the -end of this rod an appliance can be screwed (a ring and hook are here -shown). Around the worker's arm a show arm with a hand (Fig. 209) can -be fixed. They are shown in place in Figure 210.</p> -</div> - -<p class="p2">The only movements that the stump can transmit<span class="pagenum"><a name="Page_140" id="Page_140">[140]</a></span> to the arm socket -are forward and backward movements hinging about the shoulder, and -abduction. The first of these movements is the only really useful one -for the workman. The downward pressure exerted by active extension of -the elbow no longer exists; in order to press upon an object the sound -hand must be used, for it is not practicable to make use of the weight -of the body thrown forward for this purpose.</p> - -<div class="figcenter" id="i_p140" style="width:375px"> - <img - class="p2" - src="images/i_p140.png" - width="375" - height="600" - alt="" /> - <p class="center"><span class="smcap">Fig. 210.</span>—<span class="sm">Show arm in position.</span></p> -</div> - -<p class="p2">In backward and forward movements—considering, for example, the use -of the file—the angle at the elbow opens when the arm is thrust -forward and closes when it is pulled backwards. These passive<span class="pagenum"><a name="Page_141" id="Page_141">[141]</a></span> -movements of the joint must not be impeded in any way, that is to say, -the forearm must swing freely below the arm upon a transverse axis and -it must also be able to rotate freely around a vertical axis.</p> - -<p>These movements are secured in the ploughman's hand which was designed -sixty years ago by Gripouilleau and in which the joint which we -have shown as a method of attaching the mobile ring to the wrist is -utilised. The forearm rod attached by a strong transverse pin swings -freely in a little stirrup-shaped cap, which itself rotates around a -bolt by which it is firmly fixed into the metal or wooden hemisphere -which terminates the arm socket.<a name="FNanchor_14_14" id="FNanchor_14_14"></a><a href="#Footnote_14_14" class="fnanchor">[14]</a></p> - -<div class="footnote"> - -<p><a name="Footnote_14_14" id="Footnote_14_14"></a><a href="#FNanchor_14_14"><span class="label">[14]</span></a> Wood, which was used by Gripouilleau, has been given up.</p></div> - -<p>It is clear that this complete liberty of action has its -disadvantages; the elbow joint can never be made to assume a fixed -position against any passive resistance; moreover, in actual practice -the useful range of either of these movements is small. For this -reason attempts have been made to devise methods by which they can be -limited in the various worker's arms which have been designed since -the beginning of the war. In all these arms the mechanism of the elbow -joint is derived from that of the ploughman's arm of Gripouilleau. -Unfortunately none of these mechanisms in which a pressure screw is -used for fixation possess any strength. At first sight, in a new -appliance they appear attractive and work well, but it is well known -to all mechanics that the thread of a screw which is in constant use -quickly wears and then it is impossible to tighten it.</p> - -<p>At the extremity of an artificial arm, whether it be an arm of natural -shape or a worker's arm simplified to the form of a jointed rod, any -of the appliances<span class="pagenum"><a name="Page_142" id="Page_142">[142]</a></span> already described for forearm amputations can be -screwed on as required.</p> - -<p>It is by the use of these appliances that Gripouilleau's old -ploughman's arm, which ended in an interchangeable hook and ring, has -been improved.</p> - -<p>Apart from their actual economic value, results have been obtained by -use of these terminal appliances, in many different skilled trades, -which are of the greatest possible interest.</p> - -<p>For reasons that we have indicated in describing the attachment of the -elbow, the various attempts that have been made to give to the wrist -a mobility that is under control have not so far led to the invention -of an appliance that is both strong and durable. For this reason we -consider that until something new is designed it is better to make the -terminal appliance a fixed one.</p> - -<hr class="chap" /> - -<div class="chapter"> - -<p><span class="pagenum"><a name="Page_143" id="Page_143">[143]</a></span></p> - -<h2><i>CHAPTER IX</i></h2></div> - -<h3>ARTIFICIAL LIMBS FOR DISARTICULATION THROUGH THE SHOULDER JOINT AND -AMPUTATION THROUGH THE DELTOID MUSCLE</h3> - - -<p>So far as function is concerned these operations are identical; a -short arm stump is incapable of transmitting movements to the socket -of the artificial limb.</p> - -<p>That is to say, our appliance will be a purely passive one, and -at the present time it is useless to attempt to make any sort of -worker's arm. We must aim simply at supplying a limb which imitates -the external shape of the arm, with an elbow joint which can be locked -with a ratchet. At most it is possible by a movement of the opposite -shoulder to work an automatic thumb by means of a cord, as a rule, -however, a simple spring thumb is preferred.</p> - -<p>Nothing need be added to what has been said in the previous chapter -about the elbow joint or the hand.</p> - -<p>In the fitting of an attachment over the shoulder the amputation -through the deltoid presents an actual advantage. For in this case the -shape of the point of the shoulder is preserved, and the attachment<span class="pagenum"><a name="Page_144" id="Page_144">[144]</a></span> -carried out as described on pages 87 and 130 fixes the appliance very -securely.</p> - -<p>If the entire humerus has been removed a very extensive enclosure of -the front and back of the chest is essential and in order that the -axilla may be in close contact with the top of the limb it is a good -thing to stretch across this space a layer of some firm material.</p> - -<p>These appliances can be used to steady a piece of paper upon which -the patient is writing, to carry a parcel which is not too heavy -with the elbow flexed, to grip an article with the thumb. A workman -who is being re-educated for some occupation which is possible -for a one-armed man, will usually—unless he is going out for -pleasure—leave his artificial arm at home in the cupboard.</p> - -<hr class="chap" /> - -<div class="chapter"> - -<p><span class="pagenum"><a name="Page_145" id="Page_145">[145]</a></span></p> - -<h2><i>CHAPTER X</i></h2></div> - -<h3>SOME GENERAL PRINCIPLES IN THE RE-EDUCATION OF THE DISABLED</h3> - -<p><span class="smcap">When</span> a disabled man has been fitted with an artificial -limb he has to learn a trade which will enable him to supplement -his pension and provide for himself and his family. In our opinion, -which we believe we have expressed more than once in this book, it is -nearly always advisable to determine what profession will ultimately -be possible before ordering the artificial limb. This principle is -perhaps not always thoroughly understood, although there are fitting -centres where it is fully recognised (a proof of this may be found in -a recent article by Nové-Josserand and Bouget).</p> - -<p>It is unnecessary to repeat that whilst every effort must be made to -associate form with function, the latter is bound to take precedence -of the former. It is, however, not always easy to impress upon -patients, and more especially upon their protectors, that <i>form</i> is -for Sundays and holidays, and <i>function</i> is for workdays.</p> - -<p>The grave problem of re-education of amputation cases, and in a more -general sense of all the maimed, now confronts us. We believe it to be -worth while to indicate the general principles so far as they are at -present understood.</p> - -<p><span class="pagenum"><a name="Page_146" id="Page_146">[146]</a></span></p> - - -<h3 class="roman">I</h3> - -<p>At the outbreak of war the idea of the disabled in general, and -particularly of those who had had a limb amputated, was often to give -up any really active trade and to seek a "situation" generally as an -official with no actual manual labour. It must be confessed that many -people, especially the nurses, encouraged them in this, and possibly -the latter would not deny having done so.</p> - -<p>It has rapidly become evident that there are too many maimed to -be supplied with situations as caretakers of public gardens or -doorkeepers, and that they will not be able to gain a living by making -tricoloured decanter-mats of string or raffia or artificial flowers, -when bazaars organised for their benefit by tender-hearted souls have -gone out of fashion.</p> - -<p>One of us was present a short while ago at the following little -scene:—</p> - -<p>In a hospital where there were two amputation cases, one through the -lower fourth of the thigh, the other through the middle of the leg, -both agricultural labourers, a distinguished man of letters, actuated -by the best intentions, asked them what they counted on being able to -do after they had been fitted with artificial limbs. The first replied -that he hoped to return to agricultural work, the second that he would -never be able to do that but would look out for a "situation." Our -friend was much surprised to hear us say that he would be ill employed -in using his influence to obtain his desire for the second patient, -because a man with only one leg could work on the land with almost -no diminution of his ordinary capacity, even with the old-fashioned -kneeling peg leg.</p> - -<p><span class="pagenum"><a name="Page_147" id="Page_147">[147]</a></span></p> - -<p>As Jean Camus has well said in a recent article in the <i>Paris -Médical</i>, "We are beginning to pass beyond the phase when re-education -of the maimed was left to chance. It is felt now that the frivolous -efforts of benefactresses who, acting with the best intentions but -without reflections, are delighted to be able to transform into a -shorthand typist an honest farm labourer who had a strong attachment -to the soil and could quite well return to it, must be avoided. Such -feats are both culpable and absurd."</p> - -<p>These fantastic ideas must be got rid of, and all our efforts must be -co-ordinated, the complexity of the conditions to be dealt with being -duly weighed.</p> - -<p>Given a maimed man the first care should be to educate to the maximum -all the uninjured and remaining parts. It is too often forgotten that -among the parts remaining the brain plays a leading rôle, even the -chief rôle, not only because it is the organ of "good will" without -which all attempts at re-education are fruitless, but also because -good will being given the intelligent man will succeed better and -will be able to adapt himself to more delicate work. "Physiotherapy -cannot be prescribed," says J. Camus, "as quinine is prescribed. The -malarial patient who takes the latter medicine benefits whether he -wishes to or not. The wounded man who submits each morning to his -mechanotherapeutic treatment does not recover unless he wishes."</p> - -<p>It is very difficult to make the layman understand this. He invariably -takes for granted the good will of the patient, with all of whose -complaints he sympathises, without for a moment realising that they -sometimes degenerate into jeremiads, often with an ulterior motive. -An examination by a doctor—<span class="pagenum"><a name="Page_148" id="Page_148">[148]</a></span>and an experienced doctor—is therefore -necessary in order to determine under what physical and mental -conditions an amputation case can be re-educated; so that he may -understand that it is entirely to his interest to work as quickly and -as well as possible, that begging is degrading, and above all that -private charity is temporary and exhaustible; and that in consequence -he must as quickly as possible put himself into a condition to -supplement by a salary justly earned the pension or gratuity which is -certain to be insufficient for his maintenance.</p> - -<p>It can never be sufficiently insisted upon in dealing with the maimed -that by resuming work, and on account of the functional improvement -resulting from doing so, they need have no anxiety that their pension -will be reduced, because the amount of this is based on the extent of -the injury itself and on the man's rank, and not on his profession -before he became a soldier. In the same rank the pension is the same -for a surgeon or a lawyer, if both have lost a hand.</p> - -<p>It is a deep-seated notion, instilled into the minds of injured -workmen by the often suspicious folk who advise them, that if they -begin work before their case has been settled their pension will be -less.</p> - -<p>It must be acknowledged on the other hand that the civil expert -is often faced with a difficulty. As our law stands—and it is -unfair—work cannot be resumed partially with provisional half-pay -followed later by whole-time work with permanent salary. This -difference is important to our wounded soldiers, who have everything -to gain by a rapid and complete re-education and whose duty it is -to do whole or part-time work while their legal position is being -arranged and before the wound, in legal phraseology,<span class="pagenum"><a name="Page_149" id="Page_149">[149]</a></span> has become -"consolidated," that is to say, before the completion of treatment.</p> - -<p>It is only fair to add that the patients are not alone to blame and -that the administration has for long been guilty of an error against -which reaction is growing, viz. delaying re-education until the time -when the local condition has become permanent and the patient has been -discharged and has received his prosthetic apparatus.</p> - -<p>This delay is deplorable, on both medical and social grounds. On -medical grounds because in very many cases before treatment is quite -complete the addition of carefully graduated and supervised work is -an important part of the treatment. On social grounds because it is -necessary to fight in every possible way against the common tendency -of the patient to fall into habits of laziness and intemperance.</p> - -<p>This is now understood, and almost everywhere to-day the wounded -soldier can resume work in workshops attached to the centres of -physiotherapy, and thus begin his re-education while continuing his -treatment.</p> - -<p>At a certain stage resumption of work becomes the best therapeutic -agent of all.</p> - -<p>It is obvious that this resumption of work cannot supply the place -of certain special treatments such as electrical treatment during -the regeneration of a nerve, balneotherapy, or graduated gymnastic -exercises; but is it not true that work with its continual active -movement is infinitely superior to passive mobilisation by means of -apparatus however ingeniously the latter may be contrived? Morover it -is surely a more efficacious course of mechanotherapy when the patient -works for half<span class="pagenum"><a name="Page_150" id="Page_150">[150]</a></span> or all the day than is provided by the special course -occupying only an hour or two.</p> - -<p>The tendency to-day is in this direction, as, for example, at the -Grand Palais, thanks to the efforts of J. Camus, and also in the -agricultural centre of the XIIIth district under the direction of -Belot and Privat. At a given moment all treatment may be suspended and -the patient may devote himself exclusively to work with results the -excellence of which Nepper and Vallée have demonstrated.</p> - -<p>The workmen are then eligible for work in a town in private workshops, -but so far this freedom has more inconveniences than advantages. A -man whose working capacity is much reduced, and more especially a man -who requires re-education, has no place in an ordinary workshop where -neither the proprietor nor the foreman nor his fellow-workmen are in -truth much inclined to concern themselves about him. Where actual -education is necessary this is best supplied in special workshops -where the patient will be among comrades handicapped like himself, -whose progress he will be able to watch and whose efforts he will -imitate, rather than among able-bodied workmen, by comparing himself -with whom he is bound to be discouraged.</p> - -<p>The problem has been solved by the Belgians in a remarkable -establishment opened at Port-Villerz, and by the Austrians at Vienna -under the direction of Spitzy, as Nové-Josserand and Bouget inform -us, by delaying a maimed soldier's discharge from the army until his -re-education is as complete as possible. This method has proved to -be to the interest both of the individual and of the State, but we -do not seem to have considered this solution, and it is still to be<span class="pagenum"><a name="Page_151" id="Page_151">[151]</a></span> -feared that it would accord ill with the independence of our national -character. The actual fact, though it has not been brought into -prominence, is that our usual system of "watertight compartments" has -been applied by adding to the centres of physiotherapy centres of -agricultural or industrial re-education, the results obtained in which -are dependent upon the efficiency of the director of physiotherapy.</p> - -<p>This matter seems to have received very little special attention in -connection with amputation cases. It is, however, of great utility to -develop the strength and agility of the remaining limbs by suitable -gymnastic exercises, to teach a man with only one leg, for example, -to jump without an artificial limb and to climb a slippery rope or a -ladder; or to train the left hand of a man who has lost his right; -to develop the greatest possible strength in the stump by training -it in movement combined with the exertion of force. In addition to -this, early and provisional equipment with artificial limbs must -become general. These temporary limbs are undoubtedly rudimentary -contrivances, but they are functionally good and are useful on account -of their mere weight.</p> - -<p>In this connection the temporary arms used by Nové-Josserand and -Bouget in their agricultural re-education centre are very interesting -models. The great advantage of using a temporary limb is that the -time required for the construction of the permanent apparatus, often -a considerable period, is not lost in idleness, the mother of all the -vices.</p> - - -<h3 class="roman">II</h3> - -<p>It was said at the beginning of the last chapter that whenever -possible a disabled man should be<span class="pagenum"><a name="Page_152" id="Page_152">[152]</a></span> given a real trade and not one of -those frivolous and trifling occupations which were at one time the -fashion.</p> - -<p>In the choice of a trade the ruling principle is that of aiming to -restore as nearly as possible the man's former occupation. This -principle should not, however, be carried to an extreme.</p> - -<p>As Camus has justly said, by his previous work a man has stored up -a mass of ideas, a fact which is too little realised, especially by -himself. These include the manner of choosing, holding, and attacking -the materials upon which he works, and of appreciating their qualities -and faults; knowledge of their market value, of the value of the -labour, etc. This should be utilised in his future work even though it -be realised, as M. Bourillon has remarked, that the resumption of his -trade in its entirety may be impossible.</p> - -<p>With the tools that have been described a man who has lost his forearm -may be able, for example, to undertake a locksmith's work and to -execute correctly all the movements required in plying the trade. -Granted; but how long will he take to make one piece, let us say, -as well as his neighbour? If he produces little he will not find an -employer to give him daily work, while if he does piecework, apart -from the fact that it is not in good repute among those who are the -actual leaders of the working classes, it will not be remunerative, -and to earn 3 frs. a day when a comrade earns 10 or 12 frs. is -practically an impossible solution.</p> - -<p>The case may be cited of a woman suffering from congenital deficiency -of the hand with a very short rudiment of the wrist which is only -slightly mobile.<span class="pagenum"><a name="Page_153" id="Page_153">[153]</a></span> By means of contrivances which we need not describe, -and with no prosthetic apparatus, she threads her needle and sews as -quickly and as well as anybody. This is not an argument, for: (1) it -is a congenital lesion and the educability of a child is well known; -(2) the woman is extremely intelligent, and unhappily this favourable -factor cannot always be counted upon. It would be wrong to conclude -from this that a case of amputation at the wrist should be put to -sewing.</p> - -<p>It must never be forgotten that intelligence and will are factors of -the first importance, so that however little intellectual capacity -the disabled man may have, he is bound to profit by his passage -through the school of re-education in learning to read and write if -he is illiterate—this is more frequent than is usually believed—or -to improve his knowledge if he has already had some instruction. It -is, in fact, by brain work that many learn to replace their physical -defect. Let us take, for example, a disabled bricklayer. If he is -intelligent and is given a helping hand in the shape of the necessary -instruction, he may become a builder on his own account in a small way -when he knows how to make plans, work out estimates and keep accounts.</p> - -<p>This is not a Utopian fancy. In the small towns and villages there -are many owners of businesses such as masons, decorators, joiners, -etc., workmen who cannot spell, but who are intelligent, have business -minds and a gift for overseeing, who have given up the trowel and will -build you a house as well as, or often better than, many "architects." -It is with similar aims to these in view that a bricklayer should -be re-educated when it is judged that his intellectual capacity is -sufficiently great.</p> - -<p><span class="pagenum"><a name="Page_154" id="Page_154">[154]</a></span></p> - -<p>Where there is no intelligence education can do little. There are in -civil life innumerable "casual labourers" with limbs intact who have -never been able to learn a regular trade and who earn a miserable -livelihood by doing what "turns up." Their situation becomes serious -when they lose some of their physical capacity. They can, however, -be rescued, particularly by encouraging them to become agricultural -labourers. It is indeed especially agricultural labourers who should -be urged to return to the land, and those mechanics who will be -unable to work in a factory for the future should also be encouraged -to take up this work. One reason for this is that the workman's -arm—especially if it has not been too much elaborated—is useful -for the execution of a considerable variety of work on the land. It -is unnecessary to speak of cases of amputation below the knee, since -their usefulness on the land may be taken for granted.</p> - -<p>In the country as a matter of fact a man never dies of hunger; and -this cannot be said of the town. Apart from actual cultivation of the -land, which is in part impossible for the maimed, there are numerous -and important occupations of which a town dweller would not think. It -is when he goes to the centre of re-education in agricultural work, -first of all to view it and then to work, that the disabled man takes -note of what he can or cannot do, and of the work in connection with -agriculture which is open to him, such as poultry rearing or bee -keeping.</p> - -<p>This applies to other employments than agriculture.</p> - -<p>Apart from his actual trade which the workman can no longer ply with a -sufficient return for his labour, he may be able to work at one or two -of the accessory employments which would not of themselves<span class="pagenum"><a name="Page_155" id="Page_155">[155]</a></span> bring him -in a living but which would yield a satisfactory supplementary income.</p> - -<p>In certain re-education centres there seems to be a marked -predilection for crafts in which the apprenticeship is short -and the installation costs little, though these are in fact the -characteristics of those trades which give the labourer a poor return, -that is to say, time-work in a large or small workshop.</p> - -<p>At the beginning of the war an attempt was made to show that there -would never be enough tinkers, sabot makers, shoemakers, or saddlers -in the country. It is quite a false idea that a disabled man can -gain a living at one of these crafts in a village. It is true that -he can do so if, working as an agricultural labourer, he can act -as a barber in his spare time, and is capable of executing small -jobs, especially repairs, which the villagers would readily give to -him rather than have to go several miles to get them done. When the -disabled man has this additional work in his hands he will gradually -be able to ascertain whether the needs of the countryside and his own -personal capacity are compatible with its development. In that case, -however, he will be, in fact, a small proprietor buying his own tools -and materials and fixing a retail price. But the great majority of -workmen have no notion of such calculations and such organisation -as are indispensable when a man runs a business even if he is -alone. It follows, therefore, that the education of his mental, and -especially his commercial, faculties must be considered, and it must -be ascertained whether the man is likely to profit by such education. -It is useless to install in a hamlet a shoemaker who is incapable -of working except as an assistant, and in the town at the actual -factories the prospects are poor.</p> - -<p><span class="pagenum"><a name="Page_156" id="Page_156">[156]</a></span></p> - -<p>Moreover, conditions of life in the disabled man's native place must -be considered as a matter of importance. A man from the Mediterranean -country has no idea beyond the cultivation of meadows, and one from -Picardy none beyond the making of cane baskets for packing flowers.</p> - -<p>Judgment is difficult, and in order that the choice may be exercised -as reasonably as possible, the careful collaboration of the patient, -the doctor and the managers of the workshops is essential. We repeat -that this is one of the principal objects for which the centres of -re-education are useful. There are some efficient men, we know, who -without asking anything of anybody find quickly and unerringly the -exact work that suits them. There is no need of anxiety in such cases.</p> - -<p>A certain metal worker from the invaded area suffering from -pseudarthrosis of the shoulder, whose wound we were treating, sent -for his wife, and they began to rear geese. We know two cases of -amputation of the right arm, an operative at an aeroplane works and -a worker in stucco, who during their stay at hospital and before -they had been supplied with artificial limbs, had taught themselves, -the one technical design the other ornamental design. Both of them, -as soon as they were discharged, have been taken on by their former -masters, who no doubt were fully conscious that they were thus -combining a good deed with good business. To come to a decision of any -value, however, cases of this sort must not be taken as a criterion, -for they are in fact exceptional. The majority of the men are in need -of guidance.</p> - -<p>The procedure employed at the Belgian centre of re-education at -Port-Villerz consists in allowing<span class="pagenum"><a name="Page_157" id="Page_157">[157]</a></span> the patient to frequent the -workshops at will for a few days, during which time he sees what is -going on and is not slow to make his choice, which it appears rarely -needs to be amended.</p> - -<p>We have dealt chiefly with the conditions which are suitable for the -re-education of a man who has lost an upper limb, or, speaking more -generally, is disabled in one arm, for whom resumption of work in a -workshop will often be out of the question. The question is easier -of solution for the lower limb. Cases of amputation of the leg can -work standing, if supplied with an artificial limb, at practically -any trade. Cases of amputation of the thigh have numerous manual -occupations open to them in which they sit for at least part of -the time. It must be understood, however, that these professions -which require skill can, as a rule, only be learnt in well-equipped -workshops at the price of a fairly long apprenticeship. Two or three -years are necessary to make a good mechanic, a good watchmaker, -glass cutter, etc. This should not deter us in the case of fairly -young men. The difficulty is to organise special workshops, often with -a complicated equipment, where the maimed man can at least pick up -the rudiments of the work, for it is not to be thought of that he can -remain there during the whole time occupied in a complete training.</p> - -<p>In conclusion, we should like to draw attention to the law of 1831, -which regulates the distribution of pensions by means of groups -classified according as the loss is of two limbs or of one. No -distinction is made with regard to the seat of the amputation. But -a man who has lost both legs and has been suitably equipped with -artificial limbs can earn a fair wage,<span class="pagenum"><a name="Page_158" id="Page_158">[158]</a></span> whereas a man who has lost -both arms is completely disabled so that he cannot even wash or -dress himself. Among the amputation cases the difference is also -considerable in the lower limb, between amputation through the leg -and through the thigh, and even more in the upper limb, between an -amputation retaining the movements of the elbow and one in which they -are lost. There is, moreover, a great difference in the quality of -stumps and the consequent utility of the artificial limb. It is of -course impossible to allow with mathematical precision for all degrees -of disablement, but the several general distinctions which we have -enumerated could be taken into consideration without difficulty.</p> - -<hr class="chap" /> - -<div class="chapter"> - -<p><span class="pagenum"><a name="Page_159" id="Page_159">[159]</a></span></p> - -<h2>INDEX</h2></div> - -<ul> - <li> - <span class="smcap">American</span> chuck, - <a href="#Page_122">122</a></li> - <li> - Angle at which foot is set, - <a href="#Page_34">34</a>, - <a href="#Page_49">49</a></li> - <li> - Appliances for use instead of hand, - <a href="#Page_108">108</a></li> - <li class="isub2"> - with mobile joint, - <a href="#Page_123">123</a></li> - <li class="isub2"> - with universal joint, - <a href="#Page_126">126</a></li> - <li> - Artificial hand, - <a href="#Page_96">96</a></li> - <li class="isub2"> - spring grip thumb, - <a href="#Page_97">97</a></li> - <li class="isub2"> - automatic thumb, - <a href="#Page_98">98</a></li> - <li class="isub2"> - Beaufort thumb, - <a href="#Page_99">99</a></li> - <li class="isub2"> - for commercial travellers, - <a href="#Page_102">102</a></li> - <li class="isub2"> - automatic fingers, - <a href="#Page_105">105</a></li> -</ul> - -<ul> - <li> - <span class="smcap">Bearing</span> points, - <a href="#Page_6">6</a></li> - <li class="isub2"> - upon ischium, - <a href="#Page_13">13</a></li> - <li class="isub2"> - upon condyles of femur, - <a href="#Page_62">62</a></li> - <li class="isub2"> - upon tuberosities of tibia, - <a href="#Page_67">67</a></li> - <li class="isub2"> - upon end of leg stump, - <a href="#Page_77">77</a></li> - <li> - Bouget, - <a href="#Page_145">145</a>, - <a href="#Page_151">151</a></li> - <li> - Bonreau's appliances, - <a href="#Page_112">112</a></li> - <li class="isub2"> - function of the artificial hand, - <a href="#Page_117">117</a></li> - <li class="isub2"> - hook and ring, - <a href="#Page_124">124</a></li> - <li class="isub2"> - length of artificial forearm, - <a href="#Page_118">118</a></li> - <li> - Braces for suspension of artificial leg, - <a href="#Page_24">24</a></li> - <li class="isub2"> - with extending sling, - <a href="#Page_43">43</a></li> - <li class="isub2"> - for amputation below knee, - <a href="#Page_73">73</a></li> - <li> - Brunet's grip, - <a href="#Page_107">107</a></li> - <li> - Brushmaker's hook, - <a href="#Page_119">119</a></li> -</ul> - -<ul> - <li> - <span class="smcap">Camus</span>, Jean, - <a href="#Page_147">147</a></li> - <li> - Cardan joint, - <a href="#Page_126">126</a></li> - <li> - Chauffeur's bell, - <a href="#Page_125">125</a></li> - <li> - Combined mechanism for knee and ankle joints, - <a href="#Page_55">55</a></li> - <li> - Combined suspension for artificial leg, - <a href="#Page_26">26</a></li> - <li> - Condyles of femur, amputation through the, - <a href="#Page_60">60</a></li> - <li> - Convertible peg leg, - <a href="#Page_58">58</a></li> -</ul> - -<ul> - <li> - <span class="smcap">Deltoid</span> muscle, amputation through the, - <a href="#Page_143">143</a></li> - <li> - Duplex foot, - <a href="#Page_54">54</a></li> -</ul> - -<ul> - <li> - <span class="smcap">Elbow</span> joint, for above elbow amputations, - <a href="#Page_133">133</a></li> - <li class="isub2"> - for below elbow amputations, - <a href="#Page_91">91</a></li> - <li class="isub2"> - for below elbow amputations, short stumps, - <a href="#Page_95">95</a></li> - <li class="isub2"> - for worker's arm, - <a href="#Page_139">139</a></li> - <li> - Elephant boot, - <a href="#Page_79">79</a></li> - <li> - Equilibrium in an artificial leg, - <a href="#Page_35">35</a></li> -</ul> - -<ul> - <li> - <span class="smcap">Federation</span> leg, - <a href="#Page_33">33</a></li> - <li> - Flexed knee, walking upon the, - <a href="#Page_66">66</a></li> - <li> - Foot, construction, - <a href="#Page_35">35</a></li> - <li class="isub2"> - with movable ankle, - <a href="#Page_50">50</a></li> - <li class="isub2"> - with lateral mobility, - <a href="#Page_54">54</a></li> - <li> - Foot, partial amputation of the, - <a href="#Page_81">81</a></li> - <li> - Fork rest, Raynal's, - <a href="#Page_109">109</a></li> - <li> - Frees' foot and knee, - <a href="#Page_57">57</a></li> -</ul> - -<ul> - <li> - <span class="smcap">Gripouilleau</span>, vine-dresser's hook, - <a href="#Page_112">112</a></li> - <li class="isub2"> - agricultural hook and ring, - <a href="#Page_124">124</a>, - <a href="#Page_126">126</a></li> - <li class="isub2"> - ploughman's hand, - <a href="#Page_141">141</a></li> - <li> - Guyon's amputation, - <a href="#Page_78">78</a></li> -</ul> - -<ul> - <li> - <span class="smcap">Hip</span> joint, disarticulation at the, - <a href="#Page_64">64</a></li> - <li> - Hook and ring, agricultural, - <a href="#Page_124">124</a></li> - <li class="isub2"> - Boureau's, - <a href="#Page_124">124</a></li> -</ul> - -<ul> - <li> - <span class="smcap">Index</span> finger, length of, - <a href="#Page_102">102</a></li> -</ul> - -<ul> - <li> - <span class="smcap">Knee</span> extending mechanism,<span class="pagenum"><a name="Page_160" id="Page_160">[160]</a></span> - <a href="#Page_37">37</a></li> - <li class="isub2"> - artificial muscle, - <a href="#Page_37">37</a></li> - <li class="isub2"> - extending sling, - <a href="#Page_43">43</a></li> - <li class="isub2"> - combined with ankle movement, - <a href="#Page_55">55</a></li> - <li> - Knee joint, amputation through the, - <a href="#Page_60">60</a></li> - <li> - Knee joint, for amputation through the leg, - <a href="#Page_73">73</a></li> -</ul> - -<ul> - <li> - <span class="smcap">Leather-cutter's</span> hand, - <a href="#Page_116">116</a></li> - <li> - Leg bucket, shape of, - <a href="#Page_67">67</a></li> - <li class="isub2"> - material, - <a href="#Page_68">68</a></li> -</ul> - -<ul> - <li> - <span class="smcap">Marks'</span> leg, - <a href="#Page_34">34</a></li> - <li class="isub2"> - knee joint, - <a href="#Page_41">41</a></li> - <li class="isub2"> - braces, - <a href="#Page_45">45</a></li> - <li> - Materials for bucket, - <a href="#Page_3">3</a></li> - <li class="isub2"> - for artificial arms, - <a href="#Page_84">84</a></li> -</ul> - -<ul> - <li> - <span class="smcap">Nové Josserand</span>, - <a href="#Page_145">145</a>, - <a href="#Page_151">151</a></li> - <li> - Nyrop's grip, - <a href="#Page_121">121</a></li> -</ul> - -<ul> - <li> - <span class="smcap">Packer's</span> hand, - <a href="#Page_115">115</a></li> - <li> - Peg leg, - <a href="#Page_28">28</a></li> - <li class="isub2"> - with joint at knee, - <a href="#Page_29">29</a></li> - <li class="isub2"> - with show leg and foot, - <a href="#Page_31">31</a></li> - <li class="isub2"> - conversion into leg with free knee joint, - <a href="#Page_58">58</a></li> - <li> - Perineal concavity, - <a href="#Page_15">15</a></li> - <li> - Plumber's hand, - <a href="#Page_115">115</a></li> - <li> - Postman's hand, - <a href="#Page_113">113</a></li> -</ul> - -<ul> - <li> - <span class="smcap">Ratchet</span> at elbow, - <a href="#Page_133">133</a></li> - <li> - Re-education of amputation cases, - <a href="#Page_145">145</a></li> - <li> - Rotation of artificial arm, prevention of, - <a href="#Page_89">89</a></li> -</ul> - -<ul> - <li> - <span class="smcap">Shoulder</span> joint, disarticulation at the, - <a href="#Page_143">143</a></li> - <li> - Spade holder, - <a href="#Page_127">127</a></li> - <li> - Stop to limit extension of knee, - <a href="#Page_38">38</a></li> - <li class="isub2"> - for amputation below knee, - <a href="#Page_76">76</a></li> - <li> - Stump, length of, - <a href="#Page_3">3</a></li> - <li class="isub2"> - condition of allowing end bearing, - <a href="#Page_7">7</a></li> - <li> - Suspension of artificial arms, - <a href="#Page_85">85</a>, - <a href="#Page_129">129</a></li> - <li class="isub2"> - to condyles of humerus, - <a href="#Page_85">85</a></li> - <li class="isub2"> - to shoulder, - <a href="#Page_87">87</a></li> - <li class="isub2"> - for worker's arm, - <a href="#Page_138">138</a></li> - <li> - Syme's amputation, - <a href="#Page_77">77</a></li> -</ul> - -<ul> - <li> - <span class="smcap">Thigh</span> bucket, shape of, - <a href="#Page_13">13</a></li> - <li class="isub2"> - wooden, - <a href="#Page_17">17</a></li> - <li class="isub2"> - leather and steel, - <a href="#Page_20">20</a></li> - <li class="isub2"> - for amputation through knee joint or condyles, - <a href="#Page_60">60</a></li> - <li> - Thigh corset, - <a href="#Page_73">73</a></li> - <li> - Thumb, spring grip, - <a href="#Page_97">97</a></li> - <li class="isub2"> - automatic, - <a href="#Page_98">98</a></li> - <li class="isub2"> - Beaufort, - <a href="#Page_99">99</a></li> - <li> - Tram driver's bell, - <a href="#Page_125">125</a></li> -</ul> - -<ul> - <li> - <span class="smcap">Vine-dresser's</span> hand, - <a href="#Page_113">113</a></li> -</ul> - -<ul> - <li> - <span class="smcap">Waist</span> belt, - <a href="#Page_22">22</a></li> - <li> - Worker's arm, - <a href="#Page_138">138</a></li> -</ul> - -<hr class="full" /> - -<p class="center pq">Printed in Great Britain for the <span class="smcap">University of London -Press</span>, Ltd., by <span class="smcap">Richard Clay & Sons</span>, Ltd., London -and Bungay.</p> - -<div class="chapter"> - -<p><span class="pagenum"><a name="Page_161" id="Page_161">[161]</a></span></p> - -<div class="boxed p4"> - -<p class="center bold lg">THE UNIVERSITY OF LONDON PRESS, <span class="smcap">Ltd.</span></p></div> - -<p class="bold ctrblck p-left1">have pleasure in announcing the publication of the following -series which covers the whole field of War Medicine and Surgery</p> - -<hr class="r100" /> - -<p class="smcap xxl bold center">Military Medical Manuals.</p> - -<p class="center bold lg">A Series of handy and profusely illustrated manuals translated -from the French under the general Editorship of</p> - -<p class="center bold xl">SIR ALFRED KEOGH,</p> - -<p class="center bold">G.C.B., LL.D., M.D., F.R.C.P., Hon. F.R.C.S.</p> - -<p class="center bold sm"><i>Late Director-General Army Medical Service</i></p> - -<p class="center xs">AND</p> - -<p class="center bold xl"><span class="smcap">Lt.-Gen.</span> T. H. J. G. GOODWIN</p> - -<p class="center bold">C.B., C.M.G., D.S.O.</p> - -<p class="center bold sm"><i>Director-General Army Medical Service</i></p> - -<blockquote> - -<p class="sm p-left1"><span class="u">Each translation has been made by a practised hand and is -edited by a specialist in the branch of surgery or medicine -covered by the volume.</span> It was felt to be a matter of urgent -necessity to place in the hands of the medical profession a -record of the new work and new discoveries which the war has -produced, and to provide for everyday use a series of brief and -handy monographs of a practical nature. The present series is -the result of this aim. Each monograph covers one of the many -questions at present of surpassing interest to the medical -world, is written by a specialist who has himself been in close -touch with the progress which he records in the medicine and -surgery of the war. Each volume of the series is complete in -itself, while the whole will form a comprehensive picture of the -medicine and surgery of the Great War.</p></blockquote> - -<hr class="full1" /> - -<p class="bold u p-left1 ctrblck">From the BRITISH MEDICAL JOURNAL: "The books are short and practical, -and are founded upon the most recent clinical and laboratory -experience."</p> - -<blockquote> - -<p class="p-left1 bold lg">THE TREATMENT OF INFECTED WOUNDS. By A. Carrel and G. Dehelly. -Translated by Herbert Child, Capt. R.A.M.C., with Introduction by Sir -Anthony A. Bowlby, K.C.M.G., K.C.V.O., F.R.C.S., Surgeon-General Army -Medical Service. With 97 illustrations in the text and six plates. -Second Edition, with additions.</p> - -<p class="right bold lg">Price 6/- net</p></blockquote> - -<blockquote> - -<p class="sm p-left1">Is as fine an example of correlated work on the part of the -chemist, the bacteriologist, and the clinician as could well -be wished for, and bids fair to become epoch-making in the -treatment of septic wounds.</p></blockquote> - -<p class="center"><i>The cost of postage per volume is: Inland 5d.; Abroad 8d.</i></p> - -<hr class="r100" /> - -<p class="center">LONDON: UNIVERSITY OF LONDON PRESS, LTD.,</p> - -<p class="center"> 18, <span class="smcap">Warwick Square</span>, E.C.4</p> - -</div> - -<p><span class="pagenum"><a name="Page_162" id="Page_162">[162]</a></span></p> - -<div class="boxed p4"> - -<p class="xl bold center">MILITARY MEDICAL MANUALS</p> - -<p class="bold ctrblck p-left1">THE SPECTATOR: "It would be hard to imagine a better set of -books; they are well written, well translated, well illustrated, -moderate in length, and moderate in price."</p> - -<hr class="r100" /> - -<blockquote> - -<p class="bold p-left1">THE PSYCHONEUROSES OF WAR. By Dr. G. Roussy, Assistant Professor in -the Faculty of Medicine, Paris, and J. Lhermitte, sometime Laboratory -Director in the Faculty of Medicine, Paris. Edited by Colonel William -Aldren Turner, C.B., M.D., and Consulting Neurologist to the Forces in -England. Translated by Wilfred B. Christopherson. With 13 full-page -plates.</p> - -<p class="right bold pq">Price 6/- net</p> - -<p class="sm p-left1">"The Psychoneuroses of War" being a book which is addressed -to the clinician, the authors have endeavoured, before all -else, to present an exact semeiology, and to give their work a -didactic character. After describing the general idea of the -psychoneuroses and the methods by which they are produced, the -authors survey the various clinical disorders which have been -observed during the war.</p> - - -<p class="bold p-left1">THE CLINICAL FORMS OF NERVE LESIONS (Vol. I). By Mme. Athanassio -Benisty, House Physician of the Hospitals of Paris (Salpêtrière), -with a Preface by Professor Pierre Marie. Edited with a Preface by E. -Farquhar Buzzard, M.D., F.R.C.P., Captain R.A.M.C.(T.), etc. With 81 -illustrations in the text, and seven full-page plates.</p> - -<p class="right bold pq">Price 6/- net</p> - -<p class="sm p-left1">In this volume will be found described some of the most recent -acquisitions to our knowledge of the neurology of war. But -its principal aim is to initiate the medical man who is not -a specialist into the examination of nerve injuries. He will -quickly learn how to recognise the nervous territory affected, -and the development of the various clinical features; he will be -in a position to pronounce a precise diagnosis, and to foresee -the consequences of this or that lesion.</p> - -<p class="bold p-left1">THE TREATMENT AND REPAIR OF NERVE LESIONS (Vol. II). By Mme. -Athanassio Benisty. Edited by E. Farquhar Buzzard, M.D., F.R.C.P., -Capt. R.A.M.C.(T.), etc. With 62 illustrations in the text and four -full-page plates.</p> - -<p class="right bold pq">Price 6/- net</p> - -<p class="sm p-left1">This volume is the necessary complement of the first. It -explains the nature of the lesions, their mode of repair, -their prognosis, and above all their <i>treatment</i>. It provides -a series of particularly useful data as to the evolution of -nerve-wounds—the opportunities of intervention—and the -prognosis of immediate complications or late sequelae.</p></blockquote> - -<p class="center"><i>The cost of postage per volume is: Inland 5d.; Abroad 8d.</i></p> - -<hr class="r100" /> - -<p class="center">LONDON: UNIVERSITY OF LONDON PRESS, LTD.,</p> - -<p class="center"> 18, <span class="smcap">Warwick Square</span>, E.C.4</p> - -</div> - -<p><span class="pagenum"><a name="Page_163" id="Page_163">[163]</a></span></p> - -<div class="boxed p4"> - -<p class="xl bold center">MILITARY MEDICAL MANUALS</p> - -<p class="bold ctrblck p-left1">"The importance of this comprehensive series can hardly be -exaggerated. The French genius in its application to scientific -medicine will be discovered here at its best and it will -be found to be a distinct gain to have had this method of -collaboration applied to so important an enterprise."</p> - -<hr class="r100" /> - -<blockquote> - -<p class="bold p-left1">THE TREATMENT OF FRACTURES. By R. Leriche, Assistant Professor in the -Faculty of Medicine, Lyons. Edited by F. F. Burghard, C.B., M.S., -F.R.C.S., formerly Consulting Surgeon to the Forces in France. Vol. -I.—"Fractures Involving Joints." With 97 illustrations from original -and specially prepared drawings.</p> - -<p class="right bold pq">Price 6/- net</p> - -<p class="sm p-left1">The author's primary object has been to produce a handbook of -<i>surgical therapeutics</i>. But surgical therapeutics does not mean -merely the technique of operation. Technique is, and should be, -only a part of surgery, especially at the present time. The -purely operative surgeon is a very incomplete surgeon in time -of peace; "in time of war he becomes a public disaster; for -operation is only the first act of the first dressing."</p> - -<p class="bold p-left1">Vol. II.—"Fractures of the Shaft." With 156 illustrations from -original and specially prepared drawings.</p> - -<p class="right bold pq">Price 6/- net</p> - -<p class="sm p-left1">Vol. I. of this work was devoted to <i>Fractures Involving -Joints</i>; Vol. II. (which completes the work) treats of -<i>Fractures of the Shaft</i>, and is conceived in the same -spirit—that is, with a view to the production of a work on -<i>conservative surgical therapeutics</i>.</p> - -<p class="sm p-left1">The author strives on every page to develop the idea -that anatomical conservation must not be confounded with -functional conservation. The two things are not so closely -allied as is supposed. There is no conservative surgery -save where the function is conserved. The essential point -of the treatment of diaphysial fractures consists in the -early operative disinfection, primary or secondary, by an -extensive sub-periosteal removal of fragments, based on exact -physiological knowledge, and in conformity with the general -method of treating wounds by excision. When this operation has -been carefully performed with the aid of the rugine, with the -object of separating and retaining the periosteum of all that -the surgeon considers should be removed, the fracture must be -correctly reduced and the limb immobilised.</p> - -<p class="bold p-left1">FRACTURE OF THE LOWER JAW. By L. Imbert, National Correspondent of the -Société de Chirurgie, and Pierre Réal, Dentist to the Hospitals of -Paris. With a Preface by Medical Inspector-General Février. Edited by -J. F. Colyer, F.R.C.S., L.R.C.P., L.D.S. With 97 illustrations in the -text and five full-page plates.</p> - -<p class="right bold pq">Price 6/- net</p> - -<p class="sm p-left1">Previous to the present war no stomatologist or surgeon -possessed any very extensive experience of this subject. Claude -Martin, of Lyons, who perhaps gave more attention to it than -anyone else, aimed particularly at the restoration of the -occlusion of teeth, even at the risk of obtaining only fibrous -union of the jaw. The authors of the present volume take the -contrary view, maintaining the consolidation of the fracture -is above all the result to be attained. The authors give a -clear account of the various displacements met with in gunshot -injuries of the jaw and of the methods of treatment adopted, the -latter being very fully illustrated.</p></blockquote> - -<p class="center"><i>The cost of postage per volume is: Inland 5d.; Abroad 8d.</i></p> - -<hr class="r100" /> - -<p class="center">LONDON: UNIVERSITY OF LONDON PRESS, LTD.,</p> - -<p class="center"> 18, <span class="smcap">Warwick Square</span>, E.C.4</p> - -</div> - -<p><span class="pagenum"><a name="Page_164" id="Page_164">[164]</a></span></p> - -<div class="boxed p4"> - -<p class="xl bold center">MILITARY MEDICAL MANUALS</p> - -<p class="bold ctrblck p-left1">THE SPECTATOR: "For our physicians and surgeons on active -service abroad or in military hospitals at home these are the -very books for them to dip into, if not to read through."</p> - -<hr class="r100" /> - -<blockquote> - -<p class="bold p-left1">FRACTURES OF THE ORBIT AND INJURIES OF THE EYE IN WAR. By Felix -Lagrange, Professor in the Faculty of Medicine, Bordeaux. Translated -by Herbert Child, Captain R.A.M.C. Edited by J. Herbert Parsons, -D.Sc., F.R.C.S., Temp. Captain R.A.M.C. With 77 illustrations in the -text and six full-page plates.</p> - -<p class="right bold pq">Price 6/- net</p> - -<p class="sm p-left1">Grounding his remarks on a considerable number of observations, -Professor Lagrange arrives at certain conclusions which at -many points contradict or complete what we have hitherto -believed concerning the fractures of the orbit: for instance, -that traumatisms of the skull caused by fire-arms produce, on -the vault of the orbit, neither fractures by irradiation nor -independent fractures; that serious lesions of the eye may often -occur when the projectile has passed at some distance from it. -There are, moreover, between the seat of these lesions (due -to concussion or contact) on the one hand, and the course of -the projectile on the other hand, constant relations which are -veritable clinical <i>laws</i>, the exposition of which is a highly -original feature in this volume.</p> - -<p class="bold p-left1">HYSTERIA OR PITHIATISM, AND REFLEX NERVOUS DISORDERS. By J. Babinski, -Member of the French Academy of Medicine, and J. Froment, Assistant -Professor and Physician to the Hospitals of Lyons. Edited with a -Preface by E. Farquhar Buzzard, M.D., F.R.C.P., Captain R.A.M.C.(T.), -etc. With 37 illustrations in the text and eight full-page plates.</p> - -<p class="right bold pq">Price 6/- net</p> - -<p class="sm p-left1">The number of soldiers affected by hysterical disorders is -great, and many of them have been immobilized for months -in hospital, in the absence of a correct diagnosis and the -application of a treatment appropriate to their case. A precise, -thoroughly documented work on hysteria, based on the numerous -cases observed during two years of war, was therefore a -necessity under present conditions. Moreover, it was desirable, -after the discussions and the polemics of which this question -has been the subject, to inquire whether we ought to return to -the old conception, or whether, on the other hand, we might not -finally adopt the modern conception which refers hysteria to -pithiatism.</p> - -<p class="bold p-left1">WOUNDS OF THE SKULL AND THE BRAIN. Clinical forms and medico-surgical -treatment. By C. Chatelin and T. De Martel. With a Preface by the -Professor Pierre Marie. Edited by F. F. Burghard, C.B., M.S., -F.R.C.S., formerly Consulting Surgeon to the Forces in France. With 97 -illustrations in the text and two full-page plates.</p> - -<p class="right bold pq">Price 7/6 net</p> - -<p class="sm p-left1">Of all the medical works which have appeared during the war, -this is certainly one of the most original, both in form and -in matter. It is, at all events, one of the most individual. -The authors have preferred to give only the results of their -own experience, and if their conclusions are not always in -conformity with those generally accepted, this, as Professor -Pierre Marie states in his preface, is because important -advances have been made during the last two years; and of this -the publication of this volume is the best evidence.</p></blockquote> - -<p class="center"><i>The cost of postage per volume is: Inland 5d.; Abroad 8d.</i></p> - -<hr class="r100" /> - -<p class="center">LONDON: UNIVERSITY OF LONDON PRESS, LTD.,</p> - -<p class="center"> 18, <span class="smcap">Warwick Square</span>, E.C.4</p> - -</div> - -<p><span class="pagenum"><a name="Page_165" id="Page_165">[165]</a></span></p> - -<div class="boxed p4"> - -<p class="xl bold center">MILITARY MEDICAL MANUALS</p> - -<p class="bold ctrblck p-left1">From THE TIMES: "A series of really first-rate manuals of -medicine and surgery ... the translations are admirably made. -They give us in English that clearness of thought and that -purity of style which are so delightful in French medical -literature and are as good in form as in substance."</p> - -<hr class="r100" /> - -<blockquote> - -<p class="bold p-left1">LOCALISATION AND EXTRACTION OF PROJECTILES. By Assistant Professor -Ombrédanne, of the Faculty of Medicine, Paris, and M. Ledoux-Lebard, -Director of the Laboratory of Radiology of the Hospitals of Paris. -Edited by A. D. Reid, C.M.G., M.R.C.S., L.R.C.P., Major (Temp.) -R.A.M.C. With a Preface on Extraction of the Globe of the Eye, by -Colonel W. T. Lister, C.M.G.. With 225 illustrations in the text and -30 full-page photographs.</p> - -<p class="right bold pq">Price 10/6 net</p> - -<p class="sm p-left1">This volume appeals to surgeons no less than to radiologists. -It is a summary and statement of all the progress effected by -surgery during the last two and a half years. MM. Ombrédanne and -Ledoux-Lebard have not, however, attempted to describe all the -methods in use, whether old or new. They have rightly preferred -to make a critical selection, and—after an exposition of all -the indispensable principles of radiological physics—they -examine, in detail, all those methods which are typical, -convenient, exact, rapid, or interesting by reason of their -originality: the technique of localisation, the compass, and -various adjustments and forms of apparatus.</p> - -<p class="bold p-left1">WOUNDS OF THE ABDOMEN. By G. Abadie (of Oran), National Correspondent -of the Société de Chirurgie. With a Preface by Dr. J. L. Faure. Edited -by Sir Arbuthnot Lane, Bart., C.B., M.S., Colonel (Temp.), Consulting -Surgeon to the Forces in England. With 67 illustrations in the text -and four full-page plates.</p> - -<p class="right bold pq">Price 7/6 net</p> - -<p class="sm p-left1">Dr. Abadie has been enabled, at all the stations of the -army service departments, to weigh the value of methods and -results, and considers the following problems in this volume: -(1) How to decide <i>what is the best treatment</i> in the case -of penetrating wounds of the abdomen; (2) How to install the -<i>material organisation</i> which permits of the application of this -treatment, and how to recognise those conditions which prevent -its application; (3) How to decide <i>exactly what to do in each -special</i> case—whether one should perform a radical operation, -or a palliative operation, or whether one should resort to -medical treatment.</p> - -<p class="bold p-left1">WOUNDS OF THE BLOOD-VESSELS. By L. Sencert, Assistant Professor in -the Faculty of Medicine, Nancy. Edited by F. F. Burghard, C.B., M.S., -F.R.C.S., formerly Consulting Surgeon to the Forces in France. With 68 -illustrations in the text and two full-page plates.</p> - -<p class="right bold pq">Price 6/- net</p> - -<p class="sm p-left1">Hospital practice had long familiarised us with the vascular -wounds of civil practice, and the experiments of the -Val-de-Grâce School of Medicine had shown us what the wounds -of the blood-vessels caused by modern projectiles would be in -the next war. But in 1914 these data lacked the ratification -of extensive practice. Two years have elapsed, and we have -henceforth solid foundations on which to establish our -treatment. In a first part, Professor Sencert examines the -wounds of the great vessels in general; in a second part he -rapidly surveys the wounds of vascular trunks in particular, -insisting on the problems of operation to which they give rise.</p></blockquote> - -<p class="center"><i>The cost of postage per volume is: Inland 5d.; Abroad 8d.</i></p> - -<hr class="r100" /> - -<p class="center">LONDON: UNIVERSITY OF LONDON PRESS, LTD.,</p> - -<p class="center"> 18, <span class="smcap">Warwick Square</span>, E.C.4</p> - -</div> - -<p><span class="pagenum"><a name="Page_166" id="Page_166">[166]</a></span></p> - -<div class="boxed p4"> - -<p class="xl bold center">MILITARY MEDICAL MANUALS</p> - -<p class="bold ctrblck p-left1">GLASGOW HERALD: "The whole series is heartily commended to the -attention and study of all who are interested in and responsible -for the treatment of the injuries and diseases of a modern war."</p> - -<hr class="r100" /> - -<blockquote> - -<p class="bold p-left1">THE AFTER-EFFECTS OF WOUNDS OF THE BONES AND JOINTS. By Aug. Broca, -Professor of Topographical Anatomy in the Faculty of Medicine, -Paris. Translated by J. Renfrew White, M.B., F.R.C.S., Temp. Captain -R.A.M.C., and edited by R. C. Elmslie, M.S., F.R.C.S.; Orthopædic -Surgeon to St. Bartholomew's Hospital, and Surgeon to Queen Mary's -Auxiliary Hospital, Roehampton; Major R.A.M.C.(T.) With 112 -illustrations in the text.</p> - -<p class="right bold pq">Price 6/- net</p> - -<p class="sm p-left1">This new work, like all books by the same author, is a vital and -personal work, conceived with a didactic intention. At a time -when all physicians are dealing, or will shortly have to deal, -with the after-effects of wounds received in war, the question -of sequelae presents itself, and will present itself more and -more. What has become—and what will become—of all those who, -in the hospitals at the front or in the rear, have hastily -received initial treatment, and what is to be done to complete a -treatment often inaugurated under difficult circumstances?</p> - -<p class="bold p-left1">ARTIFICIAL LIMBS. By A. Broca, Professor in the Faculty of Medicine, -Paris, and Dr. Ducroquet, Surgeon at the Rothschild Hospital. Edited -and translated by R. C. Elmslie, M.S., F.R.C.S., etc.; Orthopædic -Surgeon to St. Bartholomew's Hospital, and Surgeon to Queen Mary's -Auxiliary Hospital, Roehampton; Major R.A.M.C.(T.). With 210 -illustrations.</p> - -<p class="right bold pq">Price 6/- net</p> - -<p class="sm p-left1">The authors of this book have sought not to describe this or -that piece of apparatus—more or less "newfangled"—but to -explain the anatomical, physiological, practical and technical -conditions which an artificial arm or leg <i>should</i> fulfil. -It is, if we may so call it, a manual of <i>applied mechanics</i> -written by physicians, who have constantly kept in mind the -anatomical conditions and the professional requirements of the -artificial limb.</p> - -<p class="bold p-left1">TYPHOID FEVERS AND PARATYPHOID FEVERS (Symptomatology, Etiology, -Prophylaxis). By H. Vincent, Medical Inspector of the Army, Member -of the Academy of Medicine, and L. Muratet, Superintendent of the -Laboratories at the Faculty of Medicine of Bordeaux. Second Edition. -Translated and Edited by J. D. Rolleston, M.D. With tables and -temperature charts.</p> - -<p class="right bold pq">Price 6/-net</p> - -<p class="sm p-left1">This volume is divided into two parts, the first dealing with -the clinical features and the second with the epidemiology -and prophylaxis of typhoid fever and paratyphoid fevers A and -B. A full account is to be found of recent progress in the -bacteriology and epidemiology of these diseases, considerable -space being given to the important question of the carrier in -the dissemination of infection.</p></blockquote> - -<p class="center"><i>The cost of postage per volume is: Inland 5d.; Abroad 8d.</i></p> - -<hr class="r100" /> - -<p class="center">LONDON: UNIVERSITY OF LONDON PRESS, LTD.,</p> - -<p class="center"> 18, <span class="smcap">Warwick Square</span>, E.C.4</p> - -</div> - -<p><span class="pagenum"><a name="Page_167" id="Page_167">[167]</a></span></p> - -<div class="boxed p4"> - -<p class="xl bold center">MILITARY MEDICAL MANUALS</p> - -<p class="bold ctrblck p-left1">From THE LANCET: "The names of the editors are sufficient -guarantee that the subject matter is treated with fairness and -discrimination."</p> - -<hr class="r100" /> - -<blockquote> - -<p class="bold p-left1">DYSENTERIES, CHOLERA, AND EXANTHEMATIC TYPHUS. By H. Vincent, Medical -Inspector of the Army, Member of the Academy of Medicine, and L. -Muratet, Superintendent of the Laboratories at the Faculty of Medicine -of Bordeaux. With an Introduction by Andrew Balfour, C.B., C.M.G., -M.D., Lieut.-Col. R.A.M.C. Edited by George C. Low, M.A., M.D., Temp. -Capt. I.M.S.</p> - -<p class="right bold pq">Price 6/- net</p> - -<p class="sm p-left1">This, the second of the volumes which Professor Vincent and -Dr. Muratet have written for this series, was planned, like -the first, in the laboratory of Val-de-Grâce, and has profited -both by the personal experience of the authors and by a mass -of recorded data which the latter years of warfare have very -greatly enriched. It will be all the more welcome, as hitherto -there has existed no comprehensive handbook treating these great -epidemic diseases from a didactic point of view.</p> - -<p class="bold p-left1">ABNORMAL FORMS OF TETANUS. By MM. Courtois-Suffit, Physician of the -Hospitals of Paris, and R. Giroux, Resident Professor. With a Preface -by Professor F. Widal. Edited by Surgeon-General Sir David Bruce, -K.C.B., F.R.S., LL.D., F.R.C.P., etc., and Frederick Golla, M.B.</p> - -<p class="right bold pq">Price 6/- net</p> - -<p class="sm p-left1">Of all the infections which threaten our wounded men, tetanus is -that which, thanks to serotherapy, we are best able to prevent. -But serotherapy, when it is late and insufficient, may, on -the other hand, tend to create a special type of attenuated -and localised tetanus; in this form the contractions are as a -general rule confined to a single limb. This type, however, -does not always remain strictly monoplegic; and if examples -of such cases are rare this is doubtless because physicians -are not as yet very well aware of their existence. We owe to -MM. Courtois-Suffit and R. Giroux one of the first and most -important observations of this new type; so that no one was -better qualified to define its characteristics. This they -have done in a remarkable manner, supporting their remarks by -all the documents hitherto published, first expounding the -characteristics which individualise the other atypical and -partial types of tetanus, which have long been recognised.</p> - -<p class="bold p-left1">WAR OTITIS AND WAR DEAFNESS. Diagnosis, Treatment, Medical Reports. -By Dr. H. Bourgeois, Oto-rhino-laryngologist to the Paris Hospitals, -and Dr. Sourdille, former interne of the Paris Hospitals. Edited by J. -Dundas Grant, M.D., F.R.C.S.(Eng.); Major R.A.M.C., President, Special -Aural Board (under Ministry of Pensions). With many illustrations in -the text and full-page plates.</p> - -<p class="right bold pq">Price 6/- net</p> - -<p class="sm p-left1">This work presents the special aspects of inflammatory -affections of the ear and deafness, as they occur in active -military service. The instructions as to diagnosis and treatment -are intended primarily for the regimental medical officer. The -sections dealing with medical reports (<i>expertises</i>) on the -valuation of degrees of disablement and claims to discharge, -gratuity or pension, will be found of the greatest value to the -officers of invaliding boards.</p></blockquote> - -<p class="center"><i>The cost of postage per volume is: Inland 5d.; Abroad 8d.</i></p> - -<hr class="r100" /> - -<p class="center">LONDON: UNIVERSITY OF LONDON PRESS, LTD.,</p> - -<p class="center"> 18, <span class="smcap">Warwick Square</span>, E.C.4</p> - -</div> - -<p><span class="pagenum"><a name="Page_168" id="Page_168">[168]</a></span></p> - -<div class="boxed p4"> - -<p class="xl bold center">MILITARY MEDICAL MANUALS</p> - -<p class="bold ctrblck p-left1">GUY'S HOSPITAL GAZETTE: "The series is a most valuable addition -to the medical literature of the war.... We deem it to be almost -indispensable to a medical officer, and have no hesitation in -unreservedly recommending it."</p> - -<hr class="r100" /> - -<blockquote> - -<p class="bold p-left1">SYPHILIS AND THE ARMY. By G. Thibierge, Physician of the Hôpital -Saint-Louis. Edited by C. F. Marshall, F.R.C.S.</p> - -<p class="right bold pq">Price 6/- net</p> - -<p class="sm p-left1">It seemed, with reason, to the editors of this series that -room should be found in it for a work dealing with syphilis -considered with reference to the army and the present war. The -frequency of this infection in the army, among the workers in -munition factories, and in the midst of the civil population -where this is in contact with soldiers and mobilised workers, -makes it, at the present time, a true epidemic disease, and one -of the most widespread of epidemic diseases. Dr. Thibierge, -whose previous labours guarantee his peculiar competence in -these difficult and important questions, has, in writing this -manual, very notably assisted in this work. But the treatment of -syphilis has, during the last six years, undergone considerable -modifications; the new methods are not yet very familiar to all -physicians; and certain details may no longer be present to -their minds. It was therefore opportune to survey the different -methods of treatment, to specify their indications, and their -occasionally difficult technique, which is always important if -complications are to be avoided. It was necessary before all -to state precisely and to retrace, for all those who have been -unable to follow the recent progress of the therapeutics of -venereal diseases, the characters and the diagnostic elements of -the manifestations of syphilis.</p> - -<p class="bold p-left1">MALARIA IN MACEDONIA: Clinical and Hæmatological Features. Principles -of Treatment. By P. Armand-Delille, P. Abrami, G. Paisseau and Henri -Lemaire. Preface by Professor Lavern, Membre de l'Institut. Edited by -Sir Ronald Ross, K.C.B., F.R.S., LL.D., D.Sc., Lieut.-Col. R.A.M.C. -With illustrations and a coloured plate.</p> - -<p class="right bold pq">Price 6/- net</p> - -<p class="sm p-left1">This work is based on the writers' observations on malaria in -Macedonia during the present war in the French Army of the -East. A special interest attaches to these observations, in -that a considerable portion of their patients had never had any -previous attack. The disease proved to be one of exceptional -gravity, owing to the exceptionally large numbers of the -Anopheles mosquitoes and the malignant nature of the parasite -(Plasmodium falciparum). Fortunately an ample supply of quinine -enabled the prophylactic and curative treatment to be better -organised than in previous colonial campaigns, with the result -that, though the incidence of malaria among the troops was high, -the mortality was exceptionally low. Professor Laveran, who -vouches for this book, states that it will be found to contain -excellent clinical descriptions and judicious advice as to -treatment. Chapters on parasitology and the laboratory diagnosis -of malaria are included.</p></blockquote> - -<p class="center bold">An early announcement will be made in regard to further volumes under -consideration.</p> - -<p class="center"><i>The cost of postage per volume is: Inland 5d.; Abroad 8d.</i></p> - -<hr class="r100" /> - -<p class="center">LONDON: UNIVERSITY OF LONDON PRESS, LTD.,</p> - -<p class="center"> 18, <span class="smcap">Warwick Square</span>, E.C.4</p> - -</div> - -<p class="transnote p4"> Transcriber's Note: All obvious spelling and punctuation errors have been corrected.</p> - - - - - - - - -<pre> - - - - - -End of the Project Gutenberg EBook of Artificial Limbs, by -Auguste Broca and Charles Ducroquet - -*** END OF THIS PROJECT GUTENBERG EBOOK ARTIFICIAL LIMBS *** - -***** This file should be named 55739-h.htm or 55739-h.zip ***** -This and all associated files of various formats will be found in: - http://www.gutenberg.org/5/5/7/3/55739/ - -Produced by deaurider, Karin Spence and the Online -Distributed Proofreading Team at http://www.pgdp.net (This -file was produced from images generously made available -by The Internet Archive) - - -Updated editions will replace the previous one--the old editions will -be renamed. - -Creating the works from print editions not protected by U.S. copyright -law means that no one owns a United States copyright in these works, -so the Foundation (and you!) can copy and distribute it in the United -States without permission and without paying copyright -royalties. 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