Contents

SECTION II

ORTHOPEDIC SURGERY

CHAPTER VI

AMPUTATION SERVICE,  A.E.F.

ORGANIZATION AND DEVELOPMENT

It was recognized at an early date by the chief surgeon, A. E. F., that the proper management of amputation cases constituted a problem for which special provision ought to be made. This was in conformity with the advice of the senior consultant in orthopedic surgery, A. E. F., who had had special opportunities for acquiring knowledge of the various orthopedic problems encountered in France and Great Britain, prior to our entrance into the war. The first step toward meeting this problem was taken in August, 1918, when, in an order which defined the responsibilities of the general and special professional services, the supervision of amputation cases was assigned to the division of orthopedic surgery.¹ Foreseeing the need of a special amputation service, the senior consultant, orthopedic surgery, immediately set machinery in motion, looking toward the training of a medical officer for this special type of work. Facilities for study were available in the bureau of artificial limbs of the American Red Cross in Paris and through the cooperation of the Allied Governments these facilities were extended to the chief amputation centers in England, Belgium, France, and Italy. Ample opportunity thus was provided for the acquisition of familiarity with all aspects of the amputation problem.

It soon proved that the chief difficulty in the way of providing proper treatment for this important group of cases was the general lack of understanding among military surgeons of the functional requirements in amputation cases. An amputation stump is useful only in the light of the prosthetic appliance which can be worn and of the degree of functional restoration obtained by its aid. Therefore, it is evident that the entire treatment, from the amputation itself, up to and including the fitting of the artificial limb, must be planned with a clear vision of the end result which may be obtained, and with knowledge of each and every danger which must be avoided in order to achieve this ideal. Familiarity with the functional value of amputations at different levels, with the physical requirements of a good stump, and with the different types of prosthetic appliances, is essential to the attainment of this goal.

The opportunities for acquiring this knowledge prior to the war were few and what there were had generally been neglected. Both in England and in France, the need for improvement in the treatment of amputation cases was forcibly brought home, early in 1915, when end results in the early war amputation cases began to be viewed. Many of these cases were in lamentable condition. The vast majority presented fat, congested stumps, with powerless muscles and serious joint contractures. Many had lost important segments of their limbs, due to the mistaken notion that a longer stump would be an incumbrance; and many others had to undergo reamputation and to lose

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valuable segments which might otherwise have been saved had suitable treatment been applied. A large number had to go back to the hospitals for long periods of treatment before artificial limbs could be fitted. All made very slow progress and some never succeeded in learning to walk.

It was in order to avoid similar results in the American Expeditionary Forces that the senior consultant, orthopedic surgery, planned to organize a special amputation service through which all amputation cases would pass before being evacuated to the United States.²

It was not until April, 1918, that American battle casualties occurred in sufficient numbers to justify the organization of an amputation service. At this time a small beginning was made at Base Hospital No. 9, Chateauroux, France. ³ All amputation cases were segregated in special wards, a gymnasium was established and a prosthesis shop organized. By July the service had expanded to 120 beds.

It had been the intention to have all amputation cases pass through this center. This plan proved impractical, however, when casualties began to occur in large numbers. Following the American battle activities along the Marne there was a sudden great influx of wounded into the base hospitals, American Expeditionary Forces, and some of the amputation cases were evacuated to the United States without receiving special care. To prevent a similar happening in the future the amputation service was transferred, in July, 1918, to Base Hospital No. 8, at Savenay.²

This location was selected because of its designation as the main distributing point for the evacuation of the wounded to the United States. From August,1918, until the signing of the armistice, no cases were evacuated without going through the hospital center at Savenay. All cases of amputation, therefore, could be seen and special treatment instituted when necessary. Early in 1919, the hospital centers at Bordeaux and at Brest also were designated as points of evacuation,⁴ and in order to meet this situation it was necessary to organizes special amputation services at these points. Medical officers who had received training at Savenay were available for duty elsewhere and little difficulty was experienced in supplying an experienced personnel. Prothesis shops also were organized and equipped at these points.

FUNCTIONS

The basic idea underlying the organization of an amputation service was to provide a center where the special problems encountered in the treatment of war amputations would be understood and where all facilities would be available to solve these problems with a view to the ultimate recovery of the maximum degree of function. Since it was the general policy that reconstructive surgery in totally disabled cases would be deferred until arrival in the United States, the functions of the amputation service consisted essentially of the following: First, to provide proper surgical, physiotherapeutic. and prosthetic treatment for amputation cases. Second, to gather information as to proper methods of treatment, and to spread this knowledge among the surgeons of the American Expeditionary Forces. Third, to prepare cases for evacuation to the United States, and to insure their arrival there in the best possible condition.

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The first function had to do with the actual treatment of the patient, provision for which was made by the organization of three departments--surgical. phvsio-therapeutic, and prosthetic. The surgical department naturally was the most important: its work was essentially the same as that of any other surgical organization, including operating, ward dressing, and records. Physiotherapy was under the direction of an athletic instructor of great ingenuity who conducted daily classes for the ambulatory cases. The men were put through stump drills, which were exceedingly valuable both for strengthening weak muscles and for teaching balance. This instructor also conducted classes for the men who had been fitted with provisional legs, and much of the success attained here was the result of the training in walking which he gave these patients. In addition, a certain number of reconstruction aides attached to the service administered massage and exercise to the bed cases. The prosthesis shop was under the direction of a sergeant, first-class, Medical Department, who was an artificial limb maker by trade. He quickly learned to make the plaster of Paris sockets for the provisional legs, and as the demand for appliances increased, trained others of the hospital detachment in the work so that there was never any delay in supplying apparatus. The skeleton legs. complete in every detail except for the socket were supplied by the American Red Cross.

The second function, that of disseminating knowledge of proper methods of treatment and of the common mistakes that were being made, was taken care of in two ways: By written reports to the senior orthopedic consultant; by personal visits to most of the hospital centers in France where opportunity to talk with the officers actually engaged in treating the cases proved most helpful. All amputation cases received at the hospital center, Savenay, were inspected upon arrival and careful note made of their condition.² When there was evidence of improper treatment, this was checked against the hospitals from which such cases had come, and thus it was possible at the end of every month to send full reports to the senior consultant who could make such use of the information as he deemed proper.

The third function of the amputation service was to prepare cases for evacuation to the United States and to insure arrival there in good condition. This was chiefly a matter of judgment and policy in selecting cases for evacuation, since by virtue of authority vested in the local orthopedic consultant nonorthopedic patient could be evacuated without his approval. Such a super-abundance of transportable patients was always available that it was necessary merely to make a systematic effort to keep them listed in order to be able to hold the nonevacuable cases for treatment.
TECHNIQUE OF AMPUTATIONS

In order to understand the special problems encountered in the treatment of amputation cases in the American Expeditionary Forces and the work of the amputation service, it is necessary to review the surgery of military amputations from the time when the limb was removed to the period of convalescence when it was possible to evacuate the patient to the United States.

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IN THE ZONE OF THE ADVANCE

In considering the technique of amputations when performed in the zone of the advance, it is important, first of all, to stress the subordinate role which military surgery necessarily occupied in relation to military tactics. Primarily military surgery had to be adapted to the varying conditions of military activity. With stable trench warfare the casualties were not numerous, and aside from raids and local actions the facilities of the evacuation hospitals were not strained. During such periods it was possible to give each case individual attention and careful after treatment, and special cases could be kept for considerable periods without evacuation. In periods of battle activity conditions were quite the reverse. The influx of casualties was enormous, the demand for beds quite in excess of the possibility of supply, and all hospital facilities were strained to the utmost. Each case had to be treated with a view to immediate evacuation, and the surgical procedures had to be adapted to meet this need. Further, because of the difficulty of evacuating the wounded from the field of battle under intense fire, the time between receipt of injury and of reaching evacuation hospitals in given instances was usually much greater than in quiet times. Contaminated wounds often became infected wounds before they reached the hands of the surgeon, therefore different operative procedures had to be employed. In such cases the prime endeavor was to obtain adequate drainage.

In respect to amputations, this fundamental rule of military surgery was strikingly illustrated. During the periods of quiet in the interval between February 5, 1918, and June 1, 1918, along sectors of the front occupied by American troops, the surgeons of the evacuation hospitals worked under almost ideal conditions. Postoperative cases could be followed for as long a period as was necessary before evacuation. Débridement, with closure by primary. delayed primary, or secondary suture, applied even to amputations. The amputation usually was performed at the level of the wound or immediately above it, with careful excision of all soiled, damaged, or devitalized tissue. Flaps were formed, not according to the classic modes of amputation, but in the way they could best be obtained from the sound tissues of the limb, with the view to conserving the greatest length of stump. If the time since injury was short and the amount of soft-part damage was well localized, it was occasionally possible to close the wound by primary suture. The more common procedure was to fix the flaps in eversion, leave the wound open, and await developments for 24 to 48 hours. At the end of this time the wound was care-fully dressed and bacterial examination made. If the condition of the wound appeared favorable, the flaps were then drawn together and sutured (delayed primary suture). If, instead, there was suggestion of infection, the wound was left open and Carrel-Dakin treatment instituted. At certain percentage of stumps treated by the latter method were closed at the end of 12 to 21 days by secondary suture; the remainder were evacuated and went on to cicatrization, later requiring some type of reconstruction operation.

In periods of battle activity the operative procedure was quite different: amputation cases had to be evacuated almost immediately. It had been shown that this immediate secondary evacuation could be done with little risk to the

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patient if the wound was left open. The great danger was infection, especially of the anaerobic type. Cases could not be watched carefully when being transported on a train, and in the case of at partially sutured stump or of one with flaps even though these were not closed, infection might develop and assume fatal proportions before the patient reached a hospital where proper treatment could be instituted.

It was to meet such a situation that the flapless amputation, unfortunately misnamed the guillotine amputation, had been devised by the surgeons of the Allied Armies early in the war. The skin was divided by a circular incision at the lowest possible level, taking into consideration the condition for which the amputation was performed. The skin was allowed to retract and then the fascia and outer layer of muscles were sectioned at this level and in turn allowed to retract. The inner layer of muscles was then cut and the bone was in turn divided at a still slightly higher level. When the amputation was completed the cut surface was in the shape of a slightly inverted cone or if the retraction had been great, a flat surface.

The reproach which has been directed against this operation is not so much against the flapless amputation itself as against the surgeons who misunderstood it and performed it as a guillotine division of the limb. By the latter method no allowance was made for retraction and upon the completion of the operation the wound appeared as a conical surface with the bone protruding at the apex and the skin margin representing the base. By this method there was an unnecessary sacrifice of soft parts. Undoubtedly better results might have been obtained if more heed had been given to the conclusions reached by the Interallied Surgical Congress at its meeting in 1917 which, inso far as concerns amputations, are as follows: ⁵

Primary amputations or those delayed 24 to 48 hours will be made as nearly as possible at the site of fracture by simple section of the soft parts or with slight trimming of the bone; in less grave cases the amputation will be made as near as possible to the level of the fracture.

Amputation for infection will be done by simple cross section or with very short flaps fixed in eversion. The stump will be regularized, if this is necessary, when the wound is disinfected and when all possible extension of the soft parts has been obtained.

A study of the end results justifies the conclusion that the flapless type of amputation had a definite place in military surgery. It possessed the advantages of preserving the maximum length of stump, of providing wide drainage and of requiring a minimum of time for its performance. It had the disadvantages of requiring a protracted period of after-treatment and of necessitating in most instances secondary reconstruction operations to prepare the stump for prosthesis. Cases operated by this method at the front usually were kept under observation for 48 hours, at the end of which time they could be evacuated in safety. If necessary they could be evacuated immediately with only slight risk. Their after-treatment was exclusively a matter for the base hospitals to which they had been evacuated.

IN THE BASE HOSPITALS

Nearly as many amputations were performed in the base hospitals at the rear as in the evacuation hospitals at the front. The great majority of these amputations were performed for sepsis and were of the open or flapless type.

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The procedure here was similar to that of the front, but with the difference that the patient who was usually very ill did not have to be evacuated. The after-treatment was under the control of the surgeon who performed the operation.

In the case of infection involving the upper end of the tibia or the knee joint, disarticulation of the knee by the flapless method proved a useful procedure. The operative risk was much less than with amputation of the thigh and it also possessed the advantages of opening up a smaller amount of fresh tissue to infection and of not giving rise to troublesome retraction of the soft parts. Later, when disinfection was obtained, reamputation for the purpose of regularizing the stump could be performed under ideal conditions.

FIG. 129.-  Use of Thomas splint in application of fixed extension to an amputation stump to overcome soft part retraction

A good many amputations were necessitated by secondary hemorrhage. Such hemorrhage was always caused by burrowing sepsis, and it was in order to control the latter rather than to stop the hemorrhage that amputation was indicated in most instances. In a certain number of cases amputations were performed, not for sepsis alone, but because of the presence of hopelessly mutilating injuries or of chronic sepsis in which it was apparent that a better functional result would be obtained with an artificial limb than with the injured member even if the treatment of the latter should prove unexpectedly successful. In practically all amputations of this latter group the part involved was the foot, ankle, or lower leg. It was well recognized that the possibility of saving any part of a hand justified a long uphill fight, whereas, with the leg, the functional result with-mar-artificial limb was in many cases better than if a badly damaged foot or ankle had been preserved.

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TREATMENT IMMEDIATELY FOLLOWING AMPUTATION

The chief problem of after-treatment was the large number of open amputation wounds. Very little difficulty was experienced in the case of amputations treated by either primary or delayed closure. Unfortunately, the number of these, from the nature of the military situation, was extremely small. This is shown by the following figures obtained from a group of 550 cases treated at the Hospital Center, Savenay. ² Of these, 323, or 58 percent, were either flapless or guillotine amputations; 170, or 30 percent, were amputations with flaps but without closure, and only 62, or 11 percent, were amputations with closure. Of the 550 cases, 493, or 88 percent, were open amputations as against 11 percent closed. It is also interesting to note that of the 62 cases with primary or delayed primary suture, only 75 percent remained closed.

FIG. 130.- Use of a spreader in sliding extension applied to an amputation stump to overcome soft part retraction

SOFT-PART RETRACTION

With an open stump, the chief danger in respect to future function was that of retraction due to the contraction of the severed muscles. Thus, in an amputation of the thigh by the flapless method, if the stump was examined a few days after operation it would be found that the skin had retracted considerably above the level of the bone and that the surface of the wound instead of remaining a plane had become frankly conical. If the process was allowed to continue, at the end of two to three weeks the end of the stump would have

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become a long tapering cone with the bone protruding a distance of 2 to 3 inches. and the distance between the bone tip and the retracted skin margin 5 to 6 inches. If nature was permitted to pursue her course, the marginal cicatrix contracted, shutting off the blood supply to the distal part, and after 8 to 10 weeks there remained only a protruding length of bare bone which in the course of time was sloughed away.

The process of retraction and natural reamputation was seen in its most extreme degree in the thigh but it could also be observed in amputations of the upper arm, forearm, or lower leg. It always led to a considerable diminution in the length of the stump, and in the case of the thigh this often amounted to as much as 5 or 6 inches. In addition it rendered the

FIG. 131.- This and Figures 132 and 133 show amputation of the thigh by the flapless method in various stages of healing under the influence of continuous extension. In this figure, the first stage, all possible extention of the skin flaps has been obtained with the result that the skin has turned in over the end of the stump.

stump conical and less suitable for prostesis while at the same time decreasing its power. Usually a broad, skin flaps has been obtained with the result that the thin terminal scar resulted which was Akin has turned in over the end of the stump adherent to the bone, and a secondary operation usually Was required before an artificial limb could be worn. But a stump is, above all things, a lever and, except in certain special regions which are mentioned elsewhere, its most important tissue is length. Therefore the importance of counteracting this process at its inception was obvious.

Soft-part retraction could be prevented or, if already present, could be overcome in large part by the proper use of extension. Extension was obtained by the application to the skin of adhesive plaster strips which extended from as close to the skin margin as possible, well up to

FIG. 132.- Second stage. The scar is contracting, but a fairly large open area with indolent skin margin remains

the base of the, stump. The free ends of the strips were attached to tapes and these were fixed by buckles to a spreader of suitable size and shape to which the extension cord was fixed. Traction was obtained either by leading the cord over a pulley at the end of the

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bed and fastening it to a weight (sliding extension), or1 by applying a short Thomas splint and the cord fastened to its end under tension (fixed extension).Sliding extension usually was best for hospital treatment, but the fixed extension with the Thomas splint was required for transportation. The adhesive strips did not interfere with the application of the dressings, and the strips were unbuckled from the spreader when complete exposure of the wound was required. The wound treatment could be carried on as adequately with the extension as without.

Under the influence of extension retraction was prevented and healing proceded rapidly. With the circular, flapless type of amputation, the end result was a thin round cicatrix at the end of the stump with or without sinuses, depending upon the degree of bone infection. In open amputations with short flaps the result was often a linear scar, and such stumps were quite suitable for prosthesis without other intervention.

FIG. 133.- The end result which may be expected in the absence of the stump with or without bone infection. The scar has shut down, pulling the skin with it, and there now remains a thin, adherent puckered sear sinuses, depending upon the degree of bone infection. In open amputations with short flaps the result was often a linear scar, and such stumps were quite suitable for prosthesis without other intervention.

The great majority of the open amputations, even when treated with extension, required secondary operations to get rid of the sear and the infected tip of bone. Most of these operations were of a single nature however, and did not constitute formal reamputations.

SEPSIS

Septic stumps constituted an important part of the amputation problem. Infection was usually only the continuation of the process for which the amputation itself had been performed. It is safe to say that all open amputations were infected. All types and degrees of infection were seen and all of the possible septic complicateions were encountered at different times.

FIG. 134.- Amputation of the thigh by the flapless method with oblique section in order to save the maximum amount fected. All types and degrees of of soft tissues. The stump has healed under extension, but infection were seen and all of the there remains a chronic osteomyelitis with multiple sinuses possible septic complications were encountered at different times.

Such complications were treated according to the usual surgical principles and require no special mention. In respect to the special manifestations of infection as seen in amputation stumps the most important feature noted was the little difficulty experienced with the flapless type of amputation and the endless trouble encountered when a partial closure had been attempted or when flaps bad been formed which tended to fall together.

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Many of the infections terminated by the formation in the stumps of residual abscesses which required drainage: occasionally the infection extended to the neighboring joint with the production of a septic arthritis.  In a below-the-knee amputation, with secondary infection of the knee joint, if the septic arthritis

FIG. 135.- Short amputation of the thigh. There has been considerable retraction of soft parts, but the stump has been treated by extension, with considerable gain.

FIG. 136.- Short amputation of the thigh, with marked considerable retraction of soft parts, but the stump has retraction of the soft parts and protrusion of the end of the bone covered by granulation tissue.

did not respond rapidly to drainage, the chance of procuring a useful joint was not great enough to justify a protracted fight, consequently reamputation above the knee was resorted to much earlier than if there had been a normal limb.

The best method of treating wound infection in an amputation stump was found to be the Darrel-Dakin method. Most of the wounds responded well to this treatment: some were disinfected entirely and in them secondary suture was sucessfully performed. A troublesome feature with the Carrel-Dakin method in amputation wounds was the tendency for the Carrel tubes to become displaced. This was obviated by stitching them, at intervals of about 1 inch, to a

FIG. 137.- This and Figure 138 show plastic closure of an open amputation stump, with marked retraction of the soft parts. In this pad with its attached tubes to the figure the retraction of the skin margins is noticeable, and there are bad scars.

piece of gauze and applying the pad with its attached tubes to the wound. Thse batteries of tubes had were made up beforehand, sterilized, and kept ready for use. For the thigh about eight tubes were required, for the arm or lower leg, about four. They could be used quite readily even when the stump was being treated with extension: thus effective contact of the solution with all parts of the wound was assured.

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After the acute infection had cleared up, a focus of chronic osteomyelitis in the terminal portion of the severed bone usually remained. Almost invariably multiple short sinuses existed, and as long as these remained open no difficulty was experienced. Wound healing progressed satisfactorily in such cases until only a central ulcer remained, then the sinuses would begin to close, the discharge would back up, and abscesses form. At this stage it was necessary either to remove the sequestrum, if this could be found, or to excise the terminal portion of the bone. It was always better to perform these operations in separate

FIG. 138.- The same stump as that shown Figure 137, after closure. The wound was excised, with a cone of tissue and the tip of the bone. The skin flaps were mobilized and draw together

steps, preliminary to the later reconstructive operation, rather than to

FIG.139.- Double amputation of both legs. The flapless method has been used in the right and there is an extensive terminal osteomyelitis

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attempt to combine the two in one sitting. In the combined operation the wound almost invariably became infected, causing its breakdown and a repeated operation.

HEMORRHAGE

Secondary hemorrhage was an infrequent complication of amputation, this experience being in marked contrast to that of the Civil War.⁷ Hemorrhages occurring 24 to 48 hours after amputation were due generally to an improperly placed ligature, or to one insecurely tied. Subsequent to this time it was usually the result of sepsis. Hemorrhage was a rare complication of the flapless type of amputation, even when the stump was badly infected, but was encountered more frequently in the amputation with flaps, loosely sutured, in which drainage was not so adequate.

JOINT DEFORMITY

Limitation of movement in the proximal joint of the stump was another complication to be feared in amputation cases. When it occurred limitation of movement was usually the result of fixation of the stump for a considerable period in improper position. The patient with a sensitive amputation stump always tried to get it into a position of muscular relaxation and to avoid movement. After a time adaptive shortening of the muscles occurred, the capsule contracted, and limitation of movement resulted. This tendency to contracture was increased still further by the presence of infection and periarticular inflammation. Generally joint deformity was found when treatment had been neglected, and in the case of a thigh amputation was furthered by the baneful practice of propping the stump in flexion on a cushion. It was more apt to develop in short stumps where its presence was most harmful. The usual deformities were: In amputation of the lower leg, incomplete extension of the knee; in amputation of the thigh, flexion of the hip; in amputation of the forearm, flexion of the elbow and limited rotary movement of the forearm; in amputation of the upper arm, abduction of the shoulder. The movements impaired were precisely those which are most essential in order to obtain the best function with a prosthetic appliance. Moreover, such joint deformities. in most instances, were avoidable. When splinting was indicated it was necessary only to fix the joint in the optimum position and to require that the joint be moved through its normal range of motion a few times each day. Continuous extension, in addition to preventing retraction, was also an excellent method of preventing joint contractures. With amputations of the lower leg and thigh it maintained the knee and hip in the extended positions and in the case of the upper arm it was applied usually in such a way as to hold the shoulder abducted, these positions being, in each case, the best for the recovery of function.

TERMINAL CONDITIONS

As outlined above, such were the chief problems of treatment in the period immediately following amputation; however, many conditions were encountered which constituted the problems of the more remote periods of treatment. These were the so-called terminal conditions.

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At no time was it the policy of the division of orthopedic surgery, A. E. F., to undertake reconstructive surgery in France unless thereby the patient could be restored to duty. In amputations the main object was to conserve function in every possible way and to prepare the patient for evacuation to the United States. However, the matter of so evacuating the wounded proved a very uncertain thing, especially for recumbent cases. Delays were numerous. In the principal evacuating centers, such as the hospital center at Savenay, there were always on hand really for evacuation several times as many patients as could be accommodated in the convoys. While awaiting transportation many of the amputation cases went on to the terminal stage of convalescence, and incertain instances advantage was taken of this delay to perform secondary reconstructive operations. These were done chiefly in an effort either to render the long sea trip a safer procedure than it otherwise would have been or to shorten the period of convalescence.

Among the conditions thus treated were: Protruding bone; localized terminal osteomyelitis; terminal ulcers; painful neuromata; painful osteophytes; intractable joint deformities; stumps unsuitable for prothesis, either by reason of amputation at an unfavorable level or because of insufficient covering of soft parts.

PROTRUDING BONE

Amputation cases were encountered with a variable length of bare bone protruding from an otherwise fairly well-healed wound. This condition, as noted above, was mainly the result of failure to employ extension and of consequents of part retraction. Occasionally it was due to the hurried amputation of an infected compound fracture where the soft parts had been simply divided near the seat of fracture without rectification of the bone. It was always move the protruding bone by sectioning it at a level below the soft parts without disturbing the rest of the wound. The incision was left open, tie cavity rapidly filled in with granulation tissue, and complete cicatrization was usually obtained. Thus the patient was made ambulatory and provisional prosthesis could be applied.

LOCALIZED TERMINAL OSTEOMYELITIS

As stated above, terminal localized osteomyelitis was the usual end

FIG. 140.- Short amputation of the lower leg, with marked flexion contraction of the knee. Open wound, with chronic osteomyelitis

result in infected amputation stumps. When such cases had progressed to the chronic stage it was necessary to get rid of the septic focus. In some, sequestrectomy was sufficient; in others, the infected part had to be excised. These operations, in the majority of instances, were of a simple nature and were done

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to allow the stump to become aseptic, so that the necessary reconstructive operations, which would be required later, might be performed under the most favorable conditions.

TERMINAL ULCERS

A common result in the flapless type of amputation was an intolerent ulcer, situated in the center of the scar, directly over the end of the bone. This was caused practically always by cicatricial interference with the blood supply to the central part of the wound. In such cases complete healing could not be obtained. The end of the bone was in close relation to the base of the ulcer and there was frequently an associated osteomyelitis. To close such a stump it was necessary to excise the scar with the tip of the bone and perform a plastic skin operation. If the stump was short and the amputation situated at the so-called critical level, it was sometimes advisable to transplant a pedicle skin flap from the opposite limb in a two-step procedure.

Some of these operations were performed in the American Expeditionary Forces, but usually only because of exceptional circumstances. There was a considerable hazard in respect to the results on account of the danger of stirring up a latent infection, and if all did not go well, evacuation might be considerably delayed. On the other hand, these cases were ambulatory and could be evacuated in safety, without operation. Treatment, therefore, was usually deferred until arrival in the United States.

PAINFUL NEUROMATA

Many stumps were painful, but in only a few were the symptoms due to neuromata. In the majority the causes were to be found either in infection and its sequelae or in circulatory disturbances. When definite evidence indicated a neuroma as the cause of the symptoms it was always sought to relieve the condition by operation. Such procedures were simple, gave immediate relief, and did not delay evacuation.

PAINFUL OSTEOPHYTES

Painful osteophytes constituted a very minor part of the amputation problem in the American Expeditionary Forces, although bony spurs were present in many of the cases, sometimes in extreme osteophytes. Much remains to be learned concerning the cause of these osteophytes. In many of the war cases infection undoubtedly played an important ro le in their production, but, they were also encountered in clean cases. Certain of these were probably caused by unnecessary fraying and shredding of the periosteum at the time of amputation. They might have been avoided in many instances if the a periosteam method of sectioning the bone, advocated by Bunge,⁷ could have been employed more widely. This procedure, however, was not advisable in potentially infected cases such as these. When it was used and infection developed. separation of a ring-like sequestrum from the end of the bone resulted.

Fortunately, osteophytes rarely caused trouble if the stumps were satisfactory in other respects. Occasionally a very large spur was found which seemed likely to interfere mechanically with the application of a prosthetic appliance, and in such a case it was usu ally excised.

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INTRACTABLE JOINT DEFORMITIES

Correction of joint deformity, when present, was considered a very necessary therapeutic measure before evacuation of the patient to the United States. The majority of such deformities yielded to massage and exercise. Intractable deformities were occasionally encountered; they occurred most, commonly in short amputations of the lower leg, and thigh. The application of provisional prosthetic appliances, when this was possible. with the active

FIG. 141.- This and Figure 142 show the provisional appliance used in the Amencan Expeditionary Forces for above-the-knee amputation. Lateral view with the peg flexed. The frame can be adjusted to the length of the stump

voluntary movement which their use stimulated, proved the most valuable single measure in counteracting these contractures. Unfortunately there were some very bad deformities in which prosthetic appliances could not be used, either on account of the presence in the stump of open wounds or because the amputatioin was associated with an injury to another part of the body which necessitated recumbent treatment. In such cases the best treatment was either continuous extension or corrective splinting.

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STUMPS UNSUITABLE FOR PROSTHESIS

Many healed amputation stumps were unsuitable for prosthesis, either by reason of amputation at an unfavorable level or because of insufficient covering of soft parts. Such cases usually required formal reamputation. It was against the general policy to perform these operations in the American Expeditionary Forces as they needlessly delayed evacuation to the United States. Occasionally, when considerable delay in evacuation obtained, and

FIG. 142.- Front view. The peg is extended and locked

when there was assurance of being able to perform the reamputation cleanly, these operations were done, but in general they were deferred until after arrival in the hospitals at home.

PROVISIONAL PROSTHESIS

The pioneer work of Martin ⁸ and of Hendricks, both of the Belgian Medical Corps, in the early years of the war had demonstrated in striking

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manner the beneficial effects of early weight bearing in the treatment of amputations of the lower limb. It was considered highly desirable to utilize this principle to as large an extent as possible in treating the amputation cases of the American Expeditionary Forces. Prosthetic appliances of suitable design for amputations of the lower leg and thigh and of sufficient simplicity to lend themselves to the purpose were therefore worked out and arrangements for their manufacture made with the American Red Cross in France.⁹

The appliance for thigh amputation consisted of a light steel frame to hold the socket which in the region of the knee was joined to a wooden block. This supported a strong wooden peg with rubber tip by which the weight was transmitted to the ground. There was a joint mechanism at the knee with lock, by means of which the peg could be flexed when sitting and locked in extension when standing. The appliance for amputation of the lower leg consisted of a light steel frame which terminated below in a simple type of articulated wooden foot. It was equipped with a laced leather corset for the thigh which was joined to the leg portion by steel side pieces, jointed at the knee. The sockets, in every instance, were of plaster of Paris, modeled directly to the patient's stump. The prosthetic appliance was fixed to the socket by a few turns of plaster bandage.

FIG. 143.- Type of temporary appliance used for hip-joint amputations

The same bearing points were utilized as in the case of the permanent artificial limbs. These were chiefly the bony prominences, the tuberosity of the ischium for thigh amputations and

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the shelving under surface of the upper end of the tibia for amputations of the lower leg. Secondarily the weight was taken by the soft parts, but always in a manner to relieve the wound of pressure, the lower end of the socket being left open for this purpose.

With temporary legs of this type it was possible to get patients out of bed and walking without other support very shortly after amputation. In

FIG. 144.- Patients with above-the-knee amputation fitted with the temporary peg leg with plaster socket

the case of clean sutured stumps weight bearing could be begun in two to three weeks. With open stumps it was necessary to wait considerably longer, until healing had progressed to a point where only a small wound remained. In such cases it was necessary to take steps to prevent the soft parts from being pushed upward by the pressure of the socket, a condition which might cause separation of the flaps in a recently healed stump, or retraction of the soft parts and protrusion of the bone in a stump with an open wound. Protection

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FIG. 145.- Mechanical drawing of the provisional aplliance for below-the-knee amputation used in the American Expeditionary Forces

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FIG. 146.- Application of the provisional appliance for below-the-leg amputation. The skeleton leg is fitted to the stump and the side irons are bent to conform to its shape

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was always provided in such cases by the application of traction. Broad adhesive strips with tapes were applied to the skin surface above the wound and the tapes passed down through the open end of the socket and fastened under tension to the lower portion of the apparatus. These traction strips served also to fix the leg to the stump and were used sometimes in lieu of suspenders.

While it was realized from the beginning that the percentage of amputation cases in the American Expeditionary Forces to whom this method of treatment could be adapted would be small, it was felt that the advantages

FIG. 147.- Application of the provisional appliance for below-the-leg amputation. The stump is covered with stockinette and the end protected with a cardboard cuff

to be obtained from it when it could be used would be so definite as to more than justify the effort. The results achieved more than sustained this prediction. Legs were applied in about 500 cases or in approximately 20 percent of all amputations of the lower extremity.¹⁰ Early weight bearing was shown to be of benefit in several different ways. It promoted wound healing by improving the circulation, and in cases with terminal localized osteomyelitis it favored the separation and spontaneous discharge of sequestra. It hastened stump shrinkage and prevented muscle atrophy and the development of joint contractures. In this respect it was far more valuable than any form of

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FIG. 148.- Application of the provisional appliance for below-the-leg amputation Two plaster bandages applied and modeled carefully to the contour of the stump to form the socket

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FIG. 149.- Application of the provisional appliance for below-the-leg amputation. The provisional appliance is then applied, the joint centered carefully in relation to the knee, and the frame incorporated In the plaster socket by additional turns of plaster bandage

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physiotherapy. It had an important psychological effect in counteracting despondency and in improving the patient's morale. In the healed cases it

FIG. 150.- Application of the provisional appliance for below-the-leg amputation. The upper margin of the socket is carefully lined with pencil, passing front just below the patella and being hollowed out behind to allow flexion of the knee

greatly reduced the intervening time until the permanent artificial limb could be fitted, and thus shortened the period of convalescence.

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FIG. 151.- The temporary leg completed, ready to apply

FIG. 152.- Group of soldiers fitted with temporary peg legs. These were the appliances used before the development of the articulated foot appliance

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REFERENCES

(1) Circular No. 46, Office of the Chief Surgeon, A. E. F., August 16, 1918.
(2) History of the Hospital Center, Savenay. On file, Historical Division, S. G. O., Part Two, 98-146.
(3) History of Base Hospital No. 9. On file, Historical Division, S. G. O.
(4) History of Hospital Center, Beau Desert. On file, Historical Division, S. G. O. History of Hospital Center, Kerhuon. On file, Historical Division, S. G. O.
(5) Conclusions sur les amputations adoptées par la conférence chirurgicale interalliée, 2d session, 14th to 19th May, 1917. Archives de médecine et de pharmacie militaires, Paris, 1917, lxviii, 272.
(6) U. S. War Department. Surgeon General's Office. Medical and Surgical History of the War of the Rebellion. Surgical Volume, Part III, 809. Government Printing Office, Washington, 1883.
(7) Bunge.: Zur Technik der Erzielung tragfähiger Diaphysensttüpfe ohne Osteoplastik. Beiträdge zur klinischen Chirurgie, Tülibingen, 1905, xlvii, No. 3, 808.
(8) Martin: In "Interallied Conference on the Care of Disabled Sailors and Soldiers. Lancet, London, June 22, 1918, i, 881.
(9) The Military History of the American Red Cross in France, by Lieut. Col. C. C. Burlingame, M. C. Copy on file, Historical Division, S. G. O.
(10) Annual Report of the Surgeon General, U. S. Army, 1919, ii, 1106.