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                       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.




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   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. Italics are shown as _text_ and bold as =text=.