Contents

713

SECTION II

ORTHOPEDIC SURGERY

CHAPTER VII

CARE OF THE AMPUTATED IN THE UNITED STATES

ADMINISTRATION

The experience of the European nations at the time of our entrance intothe conflict was already sufficient to indicate clearly the possible magnitude of our amputation problem. The general use of high-explosive shells and the prevalence of gas gangrene had increased greatly the frequency of amputation and had counteracted the gain due to improved surgical methods; so that, in the face of an estimated total at that time for all the countries engaged of nearly 300,000 amputations, the artificial limb problem had naturally become a serious economic question abroad. While our own country was particularly fortunate in possessing a thriving artificial-limb industry, its usefulness was in great danger of being seriously curtailed both through the loss of its skilled workmen in the draft or by transfer to munition work and also through difficulty in securing supplies. It seemed wise, therefore, for our country to make provision for meeting the greatest possible demand under the most unfavorable conditions.

It is evident that the highest degree of functional use with the artificial limb can be assured only through an organization of the work which takes into account every phase of treatment. Hence provision must be made for systematic attention during each of the five stages into which treatment naturally divides itself: (1) The amputation itself; (2) the care of the stump; (3) provision of the artificial limb; (4) general functional training; (5) special vocational training. During these successive periods the amputated pass under the care of the surgeon, the artificial-limb maker, and the educational officer. Furthermore, success in training depends in no small degree on the attitude of the general public. To secure the effective cooperation of all these agencies called for a definite program of education.

EDUCATIONAL PROGRAM

On the part of the surgeon, considerable uncertainty still existed as to the preferable sites of amputation, little attention had been paid to systematic stump care. the use of temporary appliances with plaster-of-Paris sockets asa means of securing early functional use of the stump was practically untried in this country, and but little was known of the general principles of prosthesis. Moreover. the circular method of amputation, which had been found so necessarv and advantageous in counteracting the dangers of infection. required an entirely different character of after-treatment from the customary amputation of civil life. All these points were covered in articles relating to amputations, fitting artificial limbs, and the care of the stump,¹ and were distributed in reprint or other forms to Army surgeons. Further instruction in the subject was given to student officers by means of didactic and clinical lectures and practical demonstrations in the various courses of instruction in military

714

orthopedic surgery. In these courses the artificial-limb makers were frequently called upon to explain the design and construction of artificial limbs and the principles of fitting. Later, as the amputation center at Walter Reed General Hospital developed, medical officers were sent there for courses of instruction in the care of the stump, the principles of stump surgery, the technique of the construction of the temporary peg legs, and the general principles of artificial limbs.

To educational officers and reconstruction aides, talks, supplemented by the use of moving pictures, were given, covering particularly the details of the later stages of treatment.

For the amputated themselves this general educational work consisted of talks to all the men by those in charge of the service, and also practical demonstrations in which civilian amputated who had acquired especial skill showed what is possible with and without an appliance. Facts which every amputated individual should know were formulated and issued in pamphlet form.² To this was added later information concerning obtaining permanent artificial limbs. ³

The slight degree of incapacity for most occupations caused by the loss of a leg, provided a proper appliance be worn, was a matter of common knowledge on the part of the general public in our country, but the possibilities in loss of the upper extremity were not so generally known. Moreover, with rare exceptions, employers were prejudiced against the hiring of such men for manual occupations. It was imperative, therefore, that the public should be taught to what extent and in what occupations the amputated were able to carry on productive labor. The success of this part of the work, which was taken over by the division of physical reconstruction, Surgeon General's Office, as a part of its general campaign of education,⁴ was made possible largely through the generous assistance rendered by the many amputated men throughout the country who had attained positions of competence.

AMPUTATION CENTER

In planning for hospital accommodations, consideration of efficiency and economy indicated the desirability of segregating the amputated, as far as possible, in one center preferably reserved exclusively for such cases. This was in accord, too, with the experience of other countries. With such a unification of the work, the fitting of appliances would be greatly facilitated, training in all its forms more readily carried out, and the study of the various problems in the care of this type of case carried on under the most favorable conditions. Unfortunately, the size of our country offered too great an objection to this arrangement, since the distances involved in the majority of cases were so great as to make it impracticable for the returned soldier to be furloughed to his home or to be visited by his friends. The situation seemed to be best met, therefore, by arranging for a chief amputation center, near the ports of debarkation, with a limited number of subcenters in other parts of the country.⁵

Walter Reed General Hospital, Washington, was accordingly chosen by the Surgeon General as the chief amputation center, and Letterman General Hospital, San Francisco, General Hospital No. 26, Fort Des Moines, Iowa, and General Hospital, Fort McPherson, Ga., were designated as subcenters.

715

A little later, United States Army General Hospitals No. 29, Fort Snelling, Minn., No. 3 at Colonia, N. J., and No. 10, at Boston, were also designated as subcenters. Early in 1919, a change was made in this arrangement, No. 3 at Colonia being designated as the distributing center for all cases of amputation arriving at the port of New York ⁵ and Walter Reed General Hospital for all those arriving at Newport News.⁵ Since the port at New York was the one finally used, this resulted in making these services practically equal, each maintaining an average of between 600 and 700 cases during the late spring of 1919. The center at Fort Des Moines became third in importance. That at Letterman General Hospital proved to be the smallest in point of numbers. but it maintained a very high standard of work.

THE HOSPITAL SERVICE

The ward organization of a large amputation service proved to be an important factor in its success. It was found that not only could treatment be carried out more easily but that discipline was more readily enforced when the cases were divided according to the stage of treatment. A division into the following groups proved the best arrangement: The unhealed; the pre-operative and postoperative; the prefitting and postfitting; the training groups. In the unhealed group, the further separation, as far as possible, of the recumbent and ambulatory cases aided materially in the control of those who were recumbent.

An appliance shop for artificial-limb fitting was provided at each center except at Fort Snelling; here it seemed more expedient, owing to the proximity of one of the manufacturers of the provisional appliances, to have the fitting done at the factory. In arranging the shop facilities, it was not found necessary to install an extensive equipment, since parts whose construction called for unusual or expensive machinery could easily be secured from regular artificial-limb manufacturers. This greatly simplified the problem, the equipment thus required being no more than that needed for the ordinary orthopedic brace work. Considerable floor space was necessary, however, in order to take care of a large number of cases easily and rapidly; one of the regular one-story pavilions met the needs very well in the smaller centers while in the larger, one of the regular reconstruction shops proved most satisfactory.

The medical personnel of the amputation service consisted of its chief who had also professional supervision over the shop, one or, in the larger centers, usually two assistants, one or sometimes two officers in charge of the shop, and the usual number of ward surgeons. The assignment of an additional officer to both the postfitting wards and the shop was found most helpful in securing better supervision and fitting.

The task of securing the required skilled personnel, for surgical and for prosthetic work, proved more difficult than was anticipated. Lack of training in the care of the amputated was largely responsible for this in the case of the surgical personnel, but it was due also to the qualifications demanded by the work, a considerable mechanical ability in addition to the surgical knowledge being necessary. Furthermore, few men were anxious to confine themselves to such an apparently restricted field for the duration of the war. In the case of the personnel for prosthetic work. the artificial limb workmen accepted

716

under the draft were few in number and on account of their age naturally of only moderate experience. Moreover, owing to the regulations covering overseas duty, it was difficult or even impossible to reserve them for domestic service. The number secured was so small that it became necessary to train men for the various details of limb construction and fitting.

ARTIFICIAL LIMB LABORATORY

The Surgeon General recognized from the first the importance of making adequate provision for the study of the design and construction of prostheses, particularly from the standpoint of standardization, and for the proper testing of the many new appliances and devices which were being constantly presented, as well as for the carrying out of experimental work. He accordingly authorized the establishment of an artificial limb laboratory for this purpose.⁶ The equipment for this laboratory, which it seemed wisest at first to restrict to a comparatively simple character, was installed at the Army Medical School Washington, D. C., in January, 1918,⁷ but was moved to the Walter Reed General Hospital in March of the same year,⁷ in order to secure better coordination between the experimental and the clinical parts of the work. A certain amount of both experimental and routine prosthetic work was still carried on at the Army Medical School, however, throughout the war, in the shop of the orthopedic section.

SUPPLY OF ARTIFICIAL LIMBS

The artificial-limb situation in the United States was such as to put on the question of Government manufacture an entirely different aspect from that which obtained in other countries. The large number of amputations in the Civil War, with the enormous yearly addition from industrial accidents which occurred before the introduction of the "Safety first" movement, had tremendously stimulated endeavor in this field, so that our artificial-limb industry had become the best developed in the world. Not only was the industry a large and thriving one but in addition it was well distributed geographically, so that there was hardly a city of importance that did not have one or more artificial-limb concerns. While the output of some of these was small and the shop facilities far from modern, a number of our larger firms had been engaged since early in the World War in supplying limbs in very considerable numbers to our Allies, thus showing their ability to handle a large volume of business. Also it was learned by means of a questionnaire sent out by the Surgeon General that the industry as a whole, with its existing equipment, could produce a thousand limbs per month in addition to the number required for civilian needs.⁸ Furthermore, in order to be better prepared to handle the problem and to utilize to the fullest extent the resources of our country in this respect, the manufacturers, at the suggestion of the Council of National Defense, had formed The Association of the Artificial Limb Makers of the United States.⁹ In view of the ample facilities afforded by the established industry, therefore, it seemed unnecessary to attempt Government manufacture.

Our relation to the question of standardization also seemed to differ from that of other countries. Examination of the product of a large number of concerns showed a surprising uniformity in all essential points. While differing

717

in minor details, they were with few exceptions similar in design, substantial in construction, and excellent in workmanship. Since the established policy of bonding manufactures who desired to supply limbs to the Government furnished a means of eliminating the incompetent, it seemed unwise during the stress of war to subject approved manufacturers to the expense and inconvenience that would be caused by the insistence on the production of definitely standard-ized types. Moreover, while the needs of the Army might have been met in a very satisfactory manner by the arbitrary choice of any one of several established models as a standard, an actual standardization was clearly out of the question at that time. To be of any real value standardization can not be based on opinion but must rest on scientific study. It is an undertaking which is obviously not to be considered during war but which offers a very proper subject for the attention of the Government in times of peace.

Our artificial-limb problem was made somewhat more difficult by the enactment of the War Risk Act, October 6, 1917.¹⁰ Up to this time artificial limbs had been issued by the Medical Department, and hence under the authority of the War Department. In this act, however, Congress provided for their issue to discharged soldiers and sailors through the Bureau of War Risk Insurance, thus transferring the authority to the Treasury Department. The situation was thus complicated in that the case passed from the control of one branch of the Government to that of another at an important stage in treatment. For, to retain the amputated soldier in the service as a patient in an Army hospital during the long period necessary for the stump to attain its final form and so be in proper condition for the fitting of the permanent artificial limb, was obviously inadvisable from the standpoint of the Army and of the soldier himself. Yet it was just as obviously essential to provide for his proper training in the use of an appliance of the final type, such training being regarded as one of the most important parts of modern treatment.

To meet all these conditions the provision of prostheses of regular design, so as to fulfill the requirements of training, but constructed with the intention of meeting the demands of the wearer only during the first six months, or if necessary the first year, of stump life seemed most satisfactory. An artificial leg of this sort can be constructed on the "ready-made" plan. Fiber may be used in place of wood and sufficient parts carried in stock to fit individuals of different height and size of stump. The fiber socket can be adapted very satisfactorily to thigh amputations, while in below-knee amputations it can be used to hold the plaster-of-Paris socket. The artificial arm can be constructed on this plan more easily than the artificial leg. The advantages of such a method are many: (a) The minimum demand is made upon industry, since all the work of manufacture may be done in established plants and only such shop facilities have to be provided at the amputation center as are required for fitting and repairs. (b) Production in any quantity is possible, and hence in the event of the number of the amputated being so great as to overtax the established artificial-limb industry, a means is thus provided for meeting the need until such time as the permanent limb can be secured. (c) The maximum number of amputated can be cared for, the time required for fitting the ready-made appliance being much less than for the special one, and no more than

718

when the temporary leg is used. (d) The educational value of the provisional leg is an important feature, the wearer learning how an artificial leg should feel and act and how to care for it; this knowledge naturally makes easier the work of the skilled artificial-limb maker and is at the same time the most certain means at our command for eliminating the unskilled one. (e) The conditions imposed by the War Risk Act are met most satisfactorily. (f) An equitable distribution of the work of supplying the permanent appliance is favored, since it is not secured until the amputated have reached their homes; this not only makes possible the maximum output but is in accord with established Government policy.

TREATMENT OF AMPUTATION STUMPS

In order to record fully the results of experimental development and clinical observations of the surgical and prosthetic treatment of stumps in all centers, a questionnaire was prepared covering all the salient points. This was submitted to the former chiefs of amputation centers with a request that a detailed statement of their observations and experiences be given, using the outline as submitted in order to facilitate the study of comparative methods and results. The experiences herein related and the conclusions drawn constitute a review of the reports received from the former chiefs of amputation sections.¹²

AMPUTATION CASES RETURNED TO THE UNITED STATES

The following is a list of the total number of amputation cases which werereturned to the United States: ¹²

LOSS OF EXTREMITIES

Upper extremity:
    One arm above elbow ...........................................550
    One arm at elbow ...................................................41
    Both forearms............................................................3
    One forearm..........................................................212
    One hand at wrist....................................................26
    Both hands................................................................1
    One hand................................................................18
    Part of both hands.....................................................4
    Part of one hand.................................................1,481
    One arm and one forearm..........................................1
   One arm above elbow and part of hand.......................4
    One arm below elbow and part of hand......................1
    One forearm and one hand.........................................2
    One hand and part of hand ........................................2
    Total...................................................................2,346

Lower extremity:
    Both thighs................................................................11
    One thigh.............................................................1,137
    Both legs at knee.........................................................1
    One leg at knee.........................................................95
    Both legs below knee...................................................9
    One leg below knee.................................................327
    Both legs at ankle.........................................................3
    One leg at ankle.......................................................131
    Both feet......................................................................1
    One foot ...................................................................20

719

Lower extremity- Continued.
    Part of both feet............................................................3
    Part of one foot.........................................................280
    Thigh and leg at knee.....................................................2
    Thigh and leg below knee...............................................5
    Leg at knee and part of foot...........................................2
    Leg below knee and foot................................................2
    Leg below knee and part of foot.....................................3
    Total......................................................................2, 032

Upper and lower extremities:
    Arm above elbow and one thigh......................................3
    Arm above elbow and leg below knee.............................1
    Arm above elbow and one foot........................................1
    Arm above elbow and part of one foot.............................1
    Arm below elbow and one thigh.......................................2
    Arm below elbow and leg below knee..............................4
    One hip and part of hand.................................................1
    Leg at thigh and part of hand..........................................8
    Leg at knee and part of hand..........................................1
    Leg below knee and part of hand....................................3
    Total...............................................................................25
Grand total.....................................................................4,403

CONDITION OF STUMPS ON ARRIVAL IN THE UNITED STATES

In 1918, when the number of amputations was yet small, the majority of stumps were healed when they were received in base hospitals in this country,

FIG. 153.- This and Figures 154 to 157 show the average sagittal stumps from four to eight months after trauma

FIG. 154

and many of them were fitted with temporary appliances. Later, when thenumber of wounded rapidly increased, most of them were only partially healed.Contractures of adjacent joints were only occasionally seen, the most common

720

being short thigh stumps showing a varying degree of flexion and abduction deformity; flexion contracture of leg stumps less frequently; Chopart stumps in equinus; forearm stumps with limited supination and arm stumps with limited abduction. The vast majority of the amputations were of the sagittal

FIG. 155

FIG. 156

(guillotine) type, or the modified sagittal with irregular skin flaps. These stumps usually showed a terminal circular or an irregularly shaped granulating area with partial marginal epithelization, often unhealthy in appearance, and

FIG. 157

FIG. 158.-  Same as in Figure 157 after reamputation and healing

almost invariably giving positive cultures of staphylococcus and streptococcus, and occasionally diphtheria. A limited number showed visible sequestration of bone. Edema of the soft parts adjacent to the wound was the rule and its extent was dependent upon the degree and nature of the infection and upon the

721

site of the amputation, being more marked and more persistent in amputations below the middle third of the leg, and in the lower third of the forearm. It was evident in most cases in which primary aseptic amputations had been performed that the published official instructions regarding sites for amputation ^l3 had been adhered to. In spite of the fact that infection was the rule in stumps requiring secondary surgery, conditions were favorable when contrasted with those existent at the time of the primary amputation overseas. In the latter case the primary consideration was the eradication of a potential life-destroying pathological process with the minimum sacrifice of limb length, whereas under the comparatively favorable conditions existing at the time of the secondary stump surgery it was possible to give full consideration to the prosthetic and functional requirements of the stump.

FIG. 159.- Stump showing terminal edema and other evidences of latent infection

STUMP PATHOLOGY

REFERABLE TO BONE

In nearly every case it was evident that the bone as well as the soft parts had been exposed to infection with a resulting localized osteomyelitis of varying degree. The process of sequestration and involucratization, with associated low-grade infection of the adjacent soft parts, did not differ materially from osteomyelitis under other conditions; it was usually limited to the terminal portion of the bone on account of the fact that drainage was thorough. This terminal osteomyelitis was one of the chief causes of long delay in healing and required roentgenographic study and special treatment before secondary final plastic operations could be successfully done.

The most common type of sequestrum seen was ring-shaped, usually about1½ cm. in thickness. It was usually loose and partially visible or palpable; less frequently it was more or less concealed by excessive bone production extending down from the bone cortex. In some instances it was seen to be practically encapsulated by new bone formation with a small sinus leading through the latter.

Excessive terminal bone production in guillotined stumps was the rule. The most common form was an irregular mushrooming, with a tendency to spurs on the inner aspect of the femur. Occasionally sharp exostoses were seen. These often were sharp enough and long enough to cause sufficient pain to warrant their removal.

722

Interosseous bony union was seen in both the forearm and leg. In the former, operative interference was instituted only when the forearm stump was long enough to preserve the movements of pronation and supination. Treatment consisted in removing the connecting bony overgrowth and the interposition

FIG. 160.- Typical ring sequestrum

of muscle. Obviously in the leg this condition is helpful rather than detrimental, unless associated with terminal sharp exostoses.

Displacement of the patella in the Stokes-Gritti amputation and of the portion of the os calcis in the Pirogoff operation were seen. Nearly all amputations

723

of the types were unsatisfactory and required additional surgical treatment.

Comminuted fracture complicated by extensive osteomyelitis of the shaft was met with occasionally. Preliminary treatment of the osteomyelitis was of course instituted before stump surgery was attempted.

FIG. 161.- Complete ring sequestrurn surrounded by new bone formation. The stump is healed except for small sinus from the sequestrum

Inequality in the lengths of the bones in amputations of the forearm and of the leg occasionally demanded correction. In leg amputations the prosthetic requirement that the fibula be approximately 2 cm. shorter than the tibia, as a rule, had been met in primary amputation. In certain short leg stumps it had evidently been possible at the primary amputation to save several inches of fibula but a much smaller amount, of tibia. Such cases naturally form an exception to the general rule.

724

REFERABLE TO SOFT PARTS

Stumps with redundant soft parts were seldom found. When this condition did occur it was usually associated with late necrosis of bone or with

FIG. 162.-  Excessive terminal bone production, "mushrooming." Note that muscles are above this area

extensive comminution of bone without equal damage to the soft parts, in which case it was, of course, wise to save all viable soft parts available, as thereby greatly facilitating the late plastic surgery. The secondary removal

725

of soft parts for surgical or prosthetic reasons was not done until the necessity for and the possibility of utilizing them in connection with osteoplastic methods to increase the length of the stump had been considered.

FIG. 163.- Bony spur in below-knee amputation

Tender nerve ends occurred most frequently in amputations of the upper extremity. They seldom make themselves manifest until ain appliance has beef worn, so that in the treatment of unhealed stumps it was considered safest. to assume that every nerve which was palpable might give trouble, and

726

its treatment was indicated at the time of the secondary plastic procedure. Simple high division after crushing and ligature seemed to give results equally as good as those obtained after more elaborate neuroplastic methods.

FIG. 164.- Interosseous bony union in below-knee stump. Spurs

PREOPERATIVE AND NONOPERATIVE TREATMENT

In a preliminary report of experiences in treating the first 500 cases, published in 1919,¹⁴ a very conservative policy in the surgery of unhealed stumps was advocated. It seemed then that by the use of skin traction and other

727

nonoperative measures, healing could be obtained in a reasonable time and that secondary operative surgery of the stump could be dispensed with in the majority of cases. Subsequent experience showed that it was impossible to obtain complete healing in guillotined stumps, but that a very long time was required and that the resulting scar was not sufficiently tolerant of the usual traumas of an appliance to be practical. It was also found that many stumps either actually required reamputation at a higher level or that a limited amount of bone could be removed without damaging the stump from a functional viewpoint; so that finally plastic methods designed to obtain a firm closure, with freely movable skin, were employed usually before cicatrization was complete.

The importance of surgical rest and in most cases actual recumbency in the treatment of large infected wounds of the extremities was frequently observed and can not be too strongly emphasized. Nothing was gained by hastening prosthetic treatment to the point of applying temporary prosthesis before the stump was considered surgically sound. In the majority of cases it was found best to treat all cases judged to require secondary surgical procedures in recumbency until wounds were in the required condition for operation. It was noted repeatedly that wounds which had remained practically stationary under ambulatory treatment would promptly improve in recumbency.

Skin traction was used as a matter of routine both in recumbent and ambulatory treatment. In the former, direct extension was employed by means of adhesive strapping with pulley and weights and in the latter counter-extension with a modified Thomas splint. It is interesting to note that the former method is accurately described in "The Medical and Surgical History of the Rebellion." ¹⁵

Traction was, of course, most effective when applied immediately after the amputation. Its effect then was to actually reduce the extent of uncovered area. If it had not been applied early and the skin had been allowed to retract and to become adherent to the edges of the ulcer, traction did not tend to reduce the unhealed area materially, but it relieved tension at the edges, thus favoring healing, and was particularly helpful in subsequent plastic operations by rendering the skin more redundant. In a few cases in which there was wide retraction of the skin in short stumps, it seemed best to dissect the skin free and then apply traction for a time before attempting final plastic closure. The favorable influence of stump traction in the prevention of joint contractures was repeatedly observed.

WOUND ANTISEPSIS

The Carrel-Dakin routine treatment was used in all infected stumps as long as the unhealed area was large, concave, and discharging pus freely. Dichloramine-T was substituted when the wound became smaller in area, the granulations healthy and reasonably clean.

Massage of the terminal part of the stump was found to be beneficial in several ways. In healed stumps with small scar areas adherent to bone, massage was effective in loosening the scar and improving its circulation and thus increasing its tolerance to trauma. In unhealed stumps massage of the skin

728

adjacent to the scar area assisted in removing edema and generally improving the circulation, as well as rendering the skin free and more redundant preparatory to the final plastic procedures.

ATTENTION TO ADJACENT JOINTS

The following prophylactic measures against joint contractures were used: In so far as it was possible, the recumbent position of the patient and the adjustment of traction was such that the usual contractures would tend to be prevented. At each dressing the stump was moved to the full limit in the opposite direction to that in which a contracture was most likely to develop.

WHEN SECONDARY STUMP SURGERY SHOULD BE DONE

Attempts to perform early secondary closure of infected guillotine stumps resulted in a high percentage of failures. It seemed that the most important factors causing the failures were (1) the poor general condition of the patients following the more or less recent severe trauma on the battlefield in conjunction with the subsequent operative and postoperative treatment, and (2) absorption of toxins from latent infection of the stump, which is not only present in the terminal granulating area, and in many cases in the terminal portion of the bone, but, as has been conclusively shown by Huggins¹⁶ and others, also exists in the lymphatic channels for a considerable distance proximal to the unhealed area.

It was found that it was not justifiable to attempt plastic closures or reamputations adjacent to the unhealed area until at least five or six months had elapsed from the time of the original injury. An attempt was made to establish definite preoperative indications by bacterial counts from the wound surface, but it became apparent that this method of control was not reliable, as it gave no exact indication of the extent of latent infection in the lymphatic channels further up the limb. It was found better to depend upon observations referable to the clinical appearance of the stump and the general condition of the patient.

As long as the stump remained swollen, boggy, and edematous it was found that there was latent infection present which defeated attempts at plastic closure. The disappearance of the edema was usually coincident with the gradual improvement in the general condition of the patient and in the local appearance of the unhealed area. Final closure was deferred until (1) the skin and subcutaneous tissue was soft, dry, and wrinkled, freely movable and absolutely free from edema, (2) all sinuses leading to bone or other foreign bodies had been radically treated and cured, (3) cultures from the unhealed area were free from streptococcus and the field count was reasonably low (less than five to the field) for other less virulent pyogenic organisms.

OPERATIVE TREATMENT OF UNHEALED CASES

From the standpoint of treatment stumps could be conveniently and advantageously divided into three distinct groups, as follows: Group I.-Stumps in which a limited amount of bone may be removed without diminishing

729

the ultimate functional value of the stump. Group II.-Stumps which are already too short and which will, consequently, not permit of additional sacrifice of bone. Group III.-Those in which sagittal amputation has been done at a site considerably distal to the ultimate secondary site to be selected.

GROUP I

The question of bone length required careful consideration in every case. and there were times when it was justifiable to sacrifice ideal conditions regarding the soft parts in order to preserve it. On the other hand, in perhaps the majority of the sagittal amputations, little was lost in ultimate function by removing a limited amount of bone and much probably was gained by the additional freedom allowed to eradicate more thoroughly tissues subject to

FIG. 165.-  Long thigh stump requiring secondary plastic operation. Example of Group I

possible pathological changes in the terminal portion of the infected stump. The following are examples in this group: Sagittal amputations 9 inches or more below the knee-joint; infected sagittal knee-joint amputation. Before attempting final plastic closure of stumps in this group it was necessary that all indications previously pointed out regarding the proper time to operate be present, except that the actual size of the unhealed area could be safely disregarded.

The following method seemed to give the best results and was quite generally used: The unhealed area and the scar are completely covered with a gauze sponge which has been saturated with tincture of iodine. The incision is now made in healthy skin one-half cm. from the edge of the sear. It should follow the general contour of the scar area. No attempt should be made to form specially designed skin flaps. The distal skin is clipped to the iodined

730

gauze as the incision is being made, thus completely isolating the terminal infected area. The skin and scar are then dissected distally, separating them from the muscle, to the place where the latter are attached to the bone. It will usually be found that this is above the area of new bone production and well away from the unhealed area, usually 1 to 1½ inches. The periosteum is incised just within the area of fibrous tissue which extends somewhat distal to the muscle fibers. The bone is sawed at this point. If the preoperative treatment has been properly carried out and the scar area is not excessive, it will now be possible by careful disposition of the skin to cover the end completely. If it is found that the available skin is not sufficient, additional bone or muscle may be removed. It is better to avoid cutting through the muscles and deep vessels. The nerves are found usually by palpation and should be pulled down and severed through a small longitudinal incision in the muscles. The wound should be drained for 48 hours through a posterior stab wound This type of drainage was found to be preferable because it gave the best drainage, being dependent, and, in the event infection occurred, sufficient drainage was afforded to prevent the incision line from separating. Primary union in the incision line was often obtained and maintained in the presence of purulent discharge which was satisfactorily taken care of through the posterior drainage incision.

GROUP II

In this group it was found to be imperative that at least six to eight months should have elapsed since the initial injury and that in addition to the preoperative requirements already enumerated, it was preferable that the wound be completely cicatrized or that the unhealed area be very small and practically sterile.

The aim of operative procedures in this group was to remove intolerant scar and to replace it by freely movable healthy skin. The following methods were used and found successful.

In short below-the-knee stumps the presence of the fibula is usually not desirable; moreover, by its removal, sufficient skin can be mobilized to cover successfully a fair-sized scar area. In addition, muscular tissue of the calf may be removed quite extensively without injuring the stump in any way. In conjunction with these measures it was usually necessary to employ one of the following methods of skin mobilization: (1) Single or double pedicle swing, in which case flaps of skin and subcutaneous tissue of various shapes were swung from the lateral surface to the terminal surface of the stump, closure of the donor area being accomplished by diminishing the circumference of the stump. (2) Double pedicle transplant. A rectangular flap taken from the posterior was dissected free and moved to a terminal position with double pedicles, internal and external. This method was very successful in short leg stumps with a broad, smooth, bony surface. Total end bearing was usually made possible. (3) Distal pedicle transplant. This is a well- known method and requires no further mention here.

In short thigh stumps closure was usually made possible by using the single pedicle swing flap. Occasionally it was necessary to remove a limited amount

731

of muscles. It was found best to remove a triangular section with the base external. Muscles on the inner surface could be removed with the least damage.

Thiersch and Reverdin grafts were occasionally tried. Healing was of course hastened, but closure was not firm enough for practical purposes.

GROUP III

Amputation through the ankle joint may be cited as an example of this group. In this case the Syme amputation could not be considered, as sufficient soft parts are not available, so that the middle and lower third of the leg is the site to be selected. Another example is sagittal amputation one-half inch below the knee joint, requiring a formal amputation. In this group it was possible largely to disregard pathology referable to the terminal part of the stump and to proceed with the final amputation much earlier than in the other groups. In all cases, however, it was found advisable to adhere strictly to the rules regarding delay until the general condition was sufficiently improved to withstand a major surgical procedure, and to those regarding edema of the soft parts and associated lymphangitis and lymphadenitis. The treatment in this group was formal reamputation.

A reamputation is equivalent practically to a primary amputation under ideal conditions and necessarily involves careful consideration regarding the site of amputation and its influence upon the ultimate functional result. The value of a stump in terms of function can be correctly estimated only when the stump and its prosthesis are considered as a composite functioning unit. It follows then that in order to choose the proper site one must consider carefully the comparative value of prosthetized stumps.

SITE OF AMPUTATION OR REAMPUTATION WITH REFERENCE TO PROSTHETIC REQUIREMENTS

LOWER EXTREMITY

FOOT

Phalangeo-metatarsal amputations and transmetatarsal amputations.- These were infrequent, but it was noted that amputations anywhere in the metatarsal area gave good function. All the bone length possible should be saved. It is a mistake, however, to attempt to preserve bone length in the foot at the expense of perfect skin covering. A sear on the foot healed by granulation, directly overlying bone, inevitably will ulcerate and cause intermittent disability which eventually will lead to a reamputation. Every effort should be made to obtain a dorsal linear scar, the ends of the bones being well covered with a plantar flap. The use of the distal pedicle transplant will sometimes obviate the necessity for reamputation in these stumps.

Lisfranc's amputation.- Amputation at the transmetatarsal joint gives reasonably good function. Dorsal flexion of the foot is better preserved by anchoring the dorsal flexors to the ends of the bones. The same general surgical considerations apply here as described for metatarsal amputations. The

732

only appliance necessary for this, as well as the former, is a filler for the toe of the boot and a steel inset in the sole to prevent turning up of the toe.

Transtarsal amputations.-Transtarsal amputations distal to Chopart's joint seemed preferable to Chopart's amputation, as proper balance of the dorsal and plantar flexors of the foot is better preserved. However, the same prosthetic objections apply to this amputation as to the Chopart.

Chopart's' amputation.-Mediotarsal (Chopart's) amputation usually resulted in bad function for surgical as well as prosthetic reasons. The majority seen were sagittal amputations at this site, in no sense classical Chopart's amputations, but rather guillotine amputations at or near the mediotarsal joint. It was assumed that it was not the intention of the surgeons who performed the primary amputations that these should function as Chopart stumps. Most of them required reamputation. Attempts to improve them by plastic methods were usually not successful. The conclusion drawn from experiences in treating a limited number of classical Chopart stumps are as follows: (1) Surgical difficulties--(a) The type of injury requiring a Chopart stump seldom

FIG. 166.-  A typical sagittal Chopart stump

leaves sufficient plantar flap to permit the scar being well placed on the dorsal surface. (b) Equinus deformity of the stump eventually develops in spite of efforts to preserve foot balance by tenoplastic procedures. As equinus develops the scar which is usually terminal and poorly vascularized is pressed upon, and end bearing, the greatest asset of this stump, must be forfeited. (2) Prosthetic difficulties-The stump is too short to properly anchor the necessary"fill" in the fore foot, so that constant friction between the toe "fill" and the end of the stump takes place, usually resulting in ulceration and consequent disability. Lack of stability in the toe part of the appliance prevents the necessary forward thrust in walking so that slight limp is invariably present. In many Chopart stumps it is necessary to anchor the fore foot by extending a steel rod to the ankle joint and connecting this by a joint to a steel upright which is laced to the leg. This appliance requires a special shoe with a very unsightly ankle.

The percentage of surgical successes in Chopart is so low and the prosthetic difficulties so considerable that it is not a justifiable amputation unless it is intended that a simple elephant boot be worn continually instead of the

733

articulated appliance. This point is mentioned because there are undoubtedly cases in which occupational considerations should predominate over the esthetic.

Pirogoff's osteoplastic amputation.- Two cases are recorded which required reamputation on account of displacement of the remaining portion of the calcaneum. The added risk of an osteoplastic procedure is not compensated for in any way, as the percentage of total end-bearing stumps following the Syme amputation is quite as high as in the Pirogoff. The added length in the Pirogoff requires that the other shoe be raised at least an inch to make up for the space required for the ankle movement.

Syme amputation.-The chief advantages noted in the perfect Syme amputation were that it is total end bearing and that the length of the limb is approximately preserved, so that the patient can move around in the nude without his appliance, and that either the straight boot or the appliance with an articulated foot can be worn with reasonably good function.

Unfortunately, the percentage of perfect Syme stumps was not high. Failure was usually attributed to one or more of the following causes: Sloughing of the planter flap due to cutting the pedicle too narrow: lateral displacment of the flap; sawing the bones at right angle to the terminal axis of the tibia rather than to the long axis of the leg; making the bone section too near the joint to allow space for the mechanism of the artificial ankle.

Functionally, a perfect, total end-bearing Syme stump is a satisfactory stump. The choice between this amputation and one at the ideal site in the leg is one which involves an analysis of the occupation and habits of the patient. A laborer is better satisfied with the Syme amputation because he can wear astraight, nonarticulated boot during the working hours, and he is less likely to be dissatisfied with the bulky, unsightly ankle mechanism when "dressed up"than a professional man, for example, would be.

THE LEG

Amputations in the lower third.- The rare opportunity of observing a considerable number of amputations in the lower third of the leg was offered. All required reamputation mainly on account of poor vascularity and associated complications. Nothing is gained by the additional bone length in these stumps, as excessively long leg stumps interfere with proper shaping of the ankle portion of the artificial limb and may actually interfere with the ankle mechanism.

Amputation at the ideal site.- Amputation through the middle of the leg, or a little below, as recommended in an official publication,¹³ proved to be the preferable site. The essential points in the technique adopted were: (1) Long anterior and short posterior flaps, the scar line being posteroterminal; (2) circular division of muscles without suture or the use of a thin flap of muscle and facia sutured over the bone ends to prevent adherence of the skin to bone; (3) division of the fibula one-half inch higher than the tibia; (4) beveling of the tibial crest; (5) drainage when necessary through a small stab wound in the middle of the posterior flap.

The appliance for this amputation is simple, durable, and shapely. If the fitting is proper, disability is scarcely discernible. Stump tolerance to the appliance

734

 is quickly acquired and the functional result is very gratifying to all concerned.

In amputations of the leg above this level every effort was made to preserve all bone length possible. When the amount of bone length that can be preserved with good soft part coverings is 3 inches or less, it is justifiable to sacrifice ideal conditions as regards the soft parts, if bone length may thereby be increased It was generally considered early in the war that it was not justifiable to attempt to amputate below the knee if the amount of bone length possible to be saved was less than 3 inches. Subsequent surgical and prosthetic developments warrant a revision of this opinion. In these cases the leverage may be increased. to the point of utility by removing the fibula, cutting away practically all of the muscular tissue on the back of the stump and severing the inner hamstring. Special study and experimentation in the prosthetic treatment of short stumps carried out at various clinics gave promise of increasing the functional utility of stumps not less than 2 inches in length, so that it seems best to defer reamputation until surgical attempts to increase bone length or to increase leverage by other methods have failed.

FIG. 167.- Transcondylar reamputation. Total end bearer

THE THIGH

If it was not possible to amputate below a point 2 inches from the kneejoint (bone length), the next best site proved to be the high transcondylar amputation. This excludes knee-joint amputations, all osteoplastic amputations at or immediately above the knee joint, and low transcondylar amputations. All of these are too long to allow the use of the standard artificial knee action and require a cumbersome and faulty mechanism outside the clublike stump. Osteoplastie amputation (Stokes-Gritti) offers nothing in function above the high transcondylar to compensate for a rather high percentage of

735

surgical failures (in three seen by the writer at Walter Reed General Hospital all required reailputatioii) and the prosthetic difficulties already mentioned. In the high transcondylar amputation the bone section is made at the point where the condyles begin to merge with the shaft. It is important to keep within the spongy bone just below the beginning of the medullary cavity proper. A long anterior flap of skin and quadriceps tendon is used. The scar is placed well posteriorly, away from the end-bearing surface. Surgical failures are few. Practically all of them ipermit total end bearing. Ample space is left to place the standard artificial knee action in the proper place.

Above the site for the high transcondylar amputation every effort was made to save all bone length possible to a point 2 inches below the lesser trochanter. All stumps having bone length of from 2 to 4 inches below the lesser trochanter require a pelvic band. This is an objectionable feature. so that a special effort was always made to preserve more than 4 inches, if possible. A stump having bone length of less than 2 inches below the lesser trochanter does not have sufficient leverage to operate the thigh appliance. The only choice, then, is to give a stump suitable for the so-called hip-joint appliance.

From a prosthetic and functional viewpoint the classical disarticulation at the hip is not preferable to amputation through the neck, which is much more quickly and easily performed. In the latter the mortality is lower, and the resulting stump is better adapted for the fitting of and appliance. It was not, however, considered justifiable to reamputate a stump too short to operate the usual thigh appliance for prosthetic reasons solely.

UPPER EXTREMITY

The role of the appliance in the functional utility of stumps of the upper extremity is considerably less important than is time case in stumps of the lower extremity. In fact, it is debatable whether or not appliances in the case of single amputations of the upper extremity are of sufficient value to constitute a deciding factor in the selection of site. The young soldier who has lost an arm is eager for his appliance, because he is desirous of masking his disability and because lie hopes that it will be functionally useful. To his great disappointment, lie soon realizes that it is indeed a poor substitute for either purpose. It has been found that approximately 60 percent of individuals who have suffered the loss of a single arm do not find existing prostheses sufficiently useful to compensate for the inconvenience of wearing them, except occasionally for esthetic reasons. The following conclusions regarding sites are based upon the use and requirements of American prostheses existing at the time our amputation cases were being treated and do not involve a consideration of surgical and prosthetic experimental work being carried out in various foreign clinics during and after the World War, as opportunity for exhaustive study and practical applications of these appliances and methods was not possible in the short time offered.

THE HAND

In primary surgery immediately following the trauma nothing more should be lone than débridement, trimming the devitalized tissues, and establishing

736

thorough drainage, the question of site being totally disregarded. The prevention of contractures of the fingers following infection and of the formation of scar tissue demands special attention from the beginning. In the secondary surgery of the hand radical alteration in the site of amputation is seldom advisable. The usual conditions demanding treatment are, sluggish, unhealed areas associated with localized osteomyelitis, or tender and adherent scars with deforming tendency. The latter condition usually demands special plastic procedures, the aim of which is to displace the scar by freely movable tolerant skin. The distal pedicle transplant gave the best results where it was important that no bone should be sacrificed. Usually a portion of a phalanx of any of the fingers except the index and thumb can be sacrificed without serious functional damage in order to obtain good soft part covering. The loss of the thumb or any part of it constitutes a serious disability. A badly damaged thumb, with loss of muscular power or ankylosis, or both, is preferable to no thumb at all. Heroic efforts at reconstruction of the thumb are justifiable. One case in which a thumb stump was lengthened one-half inch, with gratifying functional improvement, has been reported. ¹⁷

Prostheses for amputations of individual or multiple digits are very useful but are usually inferior to even a severely mutilated stump. They are most useful if the thumb is amputated or if all except the thumb are gone, as apposition is made possible by their use. If sufficient of any of the fingers remain to make active apposition possible, prostheses are seldom worn except for esthetic reasons.

Transcarpal amputation is preferable to amputation at the wrist even though there may be an adherent terminal scar. The latter can be repaired by distal, pedicle skin transplant.

Wrist-joint amputation is distinctly preferable to any higher up, as pronation and supination are better preserved, and the fitting of an esthetic hand or a work appliance is facilitated by the more or less club-like end of the stump, which permits the elimination of much attachment apparatus.

THE FOREARM

Amputation in the forearm should be done as low down as possible. In the lower third circulation is often poor, but usually not troublesome enough to warrant amputation higher up solely on this account. Primary amputation should seldom be done higher up for this reason, and reamputation should not be considered unless all efforts to improve the circulation have failed. The importance of preserving pronation and supination warrants special attention to surgical details; i. e., careful treatment of the periosteum to avoid shredding and consequent overproduction of bone and the interposition of muscle to prevent bony bridging.

No matter how short a forearm stump may be, it should not be sacrificed, as in the majority of cases a forearm stump, no matter how short, is more useful without prosthesis than an upper-arm stump either with or without an appliance. They should never be shortened to correct inequality in the length of the bones. Tender scars or scars objectionable for any reason should not be corrected by the

737

sacrifice of bone, but by plastic methods involving the soft parts only. The presence of redundant soft parts in this region constitutes an indication for plastic methods to increase length rather than for their removal.

THE UPPER ARM

Transarticular and transcondylar amputations are generally considered objectionable from the standpoint of existing prosthesis, because the fitting is difficult and there is inconvenience to the patient in applying and removing the apparatus. Moreover, the artificial joint must be placed lower than normal. On the other hand, experience shows that in single amputations less than 20 percent of persons with amputation of the upper arm wear appliances. Of these it is reasonably safe to assume that the majority are wearing a practical (work) appliance rather than the dress-up type. The newer types of the former, are more securely fitted with less "harness " if the bony prominences of the condyles are present, so that before deciding upon the sacrifice of the condyles a careful analysis of the requirements in the individual case is necessary. The transcondylar is preferable to the transarticular amputation n any case. Above this all bone length possible should be saved.

It was found that short arm stumps could be improved as regards leverage by severing or raising the insertions of the pectoralis muscles, the latissimus dorsi and the teres major. The humeral head should always be saved if possible, as the shoulder contour is preserved thereby. In double amputation of the upper extremities the necessity for prosthesis is unquestionable, so that the rules regarding site for amputation as influenced by prosthesis and previously outlined 18 apply more forcibly here. The most successful cases of double amputation seen, however, were those using special, usually self-designed, appliances particularly adapted to their individual requirements. In the latter case the more conservative surgical methods would be most applicable.

CINEMATIZATION OF AMPUTATION STUMPS

Cinematization of stumps is accomplished by connecting at the end of the stump the antagonistic muscles, or by giving them artificial insertion into the prosthetic apparatus.

In July, 1918, the report of a special committee directed to investigate the question of cinematization was available for the information of those engaged in amputation work.¹⁹ Briefly the conclusions of this committee were that enematization was still in the experimental stage and that it could not be recommended except as an experimental procedure and that it should not be attempted unless adequate facilities were available for pursuing the experimental prosthetic work necessarily associated with it. No doubt the few who were interested felt that they were not adequately fortified with the requisite knowledge and experimental facilities to undertake this work on a really progressive scale. Three cases were done in the base hospitals in the United States and two cinematized stumps were returned from overseas.20 In only one of these cases was the final functional result a distinct improvement over that obtained with the usual methods. Two were failures and required excision of the tunnels. Lack of

738

success was due to failure of coordination in the surgical, physiotherapeutic, and prosthetic treatment, which resulted from the frequent transfer of patients and perhaps in a measure to the breaks in follow-up coincident with frequent changes in personnel after the beginning of the armistice.

POSTOPERATIVE TREATMENT

In all stumps in which there was even moderate tension, traction straps were applied in the operating room. It was found best not to apply weights in undrained cases until the following day, unless tension was marked. In the average case of this type, traction, if applied at once, seemed to favor oozing and the accumulation of clot. In addition to the advantages of traction previouslv mentioned, there seems to be no doubt that it adds to the comfort of the patient by preventing muscular spasm and that it is instrumental in preventing postoperative hemorrhage in the same way.

Blood drainage was removed in 48 hours. In case secondary hemorrhage occurred, with ballooning of the flaps, it was found best to remove the sutures, clean out the clot, and reapply traction. Secondary infection was the rule in all cases in which special attention had not been given to the elimination of dead spaces and in those in which secondary hemorrhage occurred.

After the wound was healed, massage of the muscles was begun. Adjacent joints were moved passively once daily through the full range of motion. After healing was firm, if the patient was able to be out of bed, he was sent to the shop for his provisional fitting. Daily baking and massage was continued after fitting, in order to remove edema and to generally improve the circulation. The stump was bandaged at all times when the appliance was not being used.

USE OF PROVISIONAL APPLIANCES IN AMPUTATIONS

LOWER EXTREMITY

In all stumps of the lower extremity, with the exception of partial amputation of the foot and the Syme amputation, a portion of the stump is called upon to function in a manner entirely new and for which it is poorly adapted, i. e.. weight, hearing. Radical physiological changes necessarily take place in the weight-bearing portion of the stump, pressure atrophy of the soft parts; increased tolerance of the skin to lateral pressure from the encasing socket of the appliance; development of balance and sense of position; tolerance to pressure on and adjacent to bony prominences. The other important task of the stump leg is propulsion of the limb and its appliance. In spite of the fact that the artificial limb is not as heavy as the amputated part, more power is required in swinging it on account of its comparative inertness. Increased difficulty in balancing undoubtedly adds to the demands made upon the muscular power of the proximal part of the stump leg. The preservation of normal muscular power, or better the development of increased muscular power in the proximal part of the stump leg, is of vital importance. Since certain definite physiological changes must take place both in the stump and the proximal part of the leg before a stump can be considered functionally fit fora permanent appliance, it is clearly the duty of the surgeon to use all methods

739

at his disposal to hasten these changes and to obtain a good functional as well as a good surgical stump before a permanent appliance is used.

PRINCIPLES OF FITTING

Weight bearing in the case of below-knee amputation is distributed as follows: Cone bearing (lateral surface bearing); bony prominence bearing (head of tibia, tuberosity of tibia, fibula below head) partial thigh-surface bearing (thigh cuff); and, in a certain percentage of cases, end bearing. In a finished appliance the stump is incased in a solid shell which is molded or carved to fit the stump in such a way that all the bearing points and surfaces are usedto a variable degree. The physiological changes in the stump will depend largely upon the predominating type or types of bearing chosen in a particular ease.

Cone and bony prominence bearing with slight partial thigh bearing are found to be applicable to most leg stumps except in the Syme amputation. Pressure atrophy is rapid and marked, consequently repeated remolding of the socket is imperative. End bearing diminishes pressure atrophy of the stump. In amputation of the thigh, bony prominence bearing (ischial tuberosity) cone hearing, and, in certain cases, end bearing, are utilized. Bony prominence bearing predominates so that pressure atrophy of the stump is slower and less marked than in leg stumps. End bearing has the same relative advantages, but to a lesser degree.

Undoubtedly end bearing is possible in a high percentage of stumps; success in obtaining it is largely dependent upon faithfulness and persistence in carrying out the necessary preliminary measures to increase the tolerance of the end of the stump. Experience has proven that a definite distinction must be made between total and partial end bearing, and that in certain instances end bearing may not be desirable, i. e., in long, below-the-knee stumps. Cone and bony prominence bearing have given nearly perfect function. If end bearing is attempted in these stumps it is found that there is a certain lack of adhesion between the appliance and the stump and that the gait is not as good as with cone bearing. In thigh stumps of moderate length total end bearing is not preferable to ischial and cone bearing for the same reasons. There is little doubt that partial end bearing is always an advantage.

The following stumps, in addition to partial foot amputations, were found to be especially well adapted for end bearing: (1) The Syme stump; (2) short below-knee stumps, and (3) that resulting from a transcondylar amputation. The bone section in each of these is through spongy bone, which seems to give a more tolerant end bearing surface. Each is clubbed more or less on the end, which favors proximal methods of attachment of the appliance, thus avoiding instability of the appliance mentioned above.

An ideal provisional appliance should possess, in the main, similar mechanical features to those found in permanent appliances. The socket should be of solid material and should be molded or carved in the same accurate manner, as in a permanent one. Excavations and additions which are customarily made to influence bearing on certain definite points, which are known to be adapted for this function, should be carefully made. A provisional appliance which

740

merely shrinks the soft tissues of the stump and does not develop the tolerance of the bearing points and surfaces, which will be called upon to function in a proper permanent appli- ance, is not an efficient provisional appliance. The provisional socket must be ne which can be remolded frequently and comparatively inexpensively. In addition to changing sha ne in a certain percentage of cases it is not only desirable, but necessary to change the position of the socket so that a complete change of socket rather than a reshaping is sometimes necessary. This feature is important in all cases in which there is more or less malposition of the stump, which is gradually being improved by the use of the appliance.  

Various types of temporary appliances were used in the different centers. In most of them the socket was made of plaster-of Paris and the framework of wood or metal. In one center a papier mâché socket was used and found to be very satisfactory.

The soldier with a recent amputation usually s most concerned in removing his physical deficiency as soon as possible from an esthetic rather than from a functional standpoint. Pegs and the cruder types of temporary appliances were strenuously objected to by a fair number of patients. After the provisional type of appliance was available in quantities, very few pegs were used. There seemed to be no advantage in delaying the fitting of the standard provisional appliance, inasmuch as it was even more versatile

FIG. 168.- Temporary appliance--plaster socket stock metal bars: wooden foot.  This was the best type of temporary applicance

as regards refitting than pegs and the cruder temporary applicances.  An attempt was made to utilize a provisional leg which in all respects looks like a finished leg. Of necessity it was adjustable as regards length, foot position, and socket. The

741

FIG. 169.- This and Figure 170 show original models of stock provisional appliances for thigh and leg amputation. An adjustable leather cuff was used to effect refitting

742

socket adjustment was accomplished by supplying a rather large number of stock sizes, and by means of a leather cuff which could be adjusted to the shrinking stump by lacing.

FIG. 170

In addition to meeting the esthetic requirements more satisfactorily than the temporary appliance, it offered the advantage of quantity production and quicker fitting. While this type of appliance was not applicable to as high a percentage of cases as anticipated, it was used in all centers except one, until supplemented by a more versatile type.

743

In thigh amputations this type of finished provisional leg was entirely satisfactory and in about 85 percent of cases where there was sufficient bone length to operate the ordinary thigh leg. Most of the remaining lo per center into the class of excessively long stumps. It was not possible to fit these on account of interference of the mechanism for the adjustment of length.

The greater part of the weight is taken on the tuberosity of the ischium and

FIG. 171.- Provisional appliance used at Letterman General Hospital

accurate cone bearing is relatively unimportant, consequently the cone fitting does not need to be very exact. In leg amputations the task of fitting this type of leg was much more difficult. Bony prominences are more numerous and less tolerant to weight bearing. Consequently, the bony prominence fitting must be more accurate and a greater amount of weight bearing must be
allotted to the cone fitting. For this reason the latter must be more precise.

744

In order to meet the requirements of the more difficult cases which it was not possible to fit with the original model of the stock appliance, a more versatile type was developed and the stock parts (framework) manufactured

FIG. 172.- Letterman General Hospital artificial leg, assembled and unassembled

in quantity, in a variety of sizes; the only essential difference from the original model being that, instead of making the necessary refitting, by means of a leather-laced cuff, a plaster-of-Paris refitting was substituted in leg amputations.

The plan generally adopted in all amputation centers was to fit the stump with a temporary appliance as soon as healing was complete, but not to hasten the prosthetic treatment at the expense of a good surgical result. The appliance was worn at first to the limit of tolerance,

FIG. 173.- The final model of provisional leg with a plaster of Paris inset

745

special care being taken not to damage the soft parts. The part of the appliance which incases the terminal part of the stump, commonly called the socket, was changed and refitted as pressure atrophy progressed. Three changes were usually required. Deformities and surgical defects of the stump, i. e., bony spurs, latent infection and tender nerves, will be readily discovered and should be treated during this preliminary prosthetic treatment. Stumps were not fitted with a permanent appliance until they were surgically sound, pressure atrophy of the weight-bearing portion well advanced and the propulsive musculature of the proximal part of the leg well developed. The stock provisional appliances used were found to be sufficiently durable to last from eight months to one year. Six months preliminary prosthetic treatment was usually found to be sufficient to prepare stumps for permanent appliance.

Partial amputations of the foot, Syme stumps, end-bearing knee-joint amputations, and disarticulations of the hip as a rule were not fitted with provisional appliances. During the earlier experimental period a few were fitted in the appliance shops largely for experimental reasons. In these stumps the fitting is difficult and there is so little change in the stump as compared with those in which cone and bony prominence bearing predominates that there seems to be no reason to delay the permanent fitting.

UPPER EXTREMITY

The use of provisional appliances in amputations of the upper extremity does not seem to be so essentially necessary from the standpoint of fitting as in those of the lower extremity. The physiological changes in the stump from the use of the appliance are not marked enough to necessitate frequent refittings and it is not necessary to have so exact a fitting as in lower extremity stumps. The chief advantages in provisional fitting are that (1) immediate fittings are possible, which would not be the case in the time of war if permanent appliances were supplied by the artificial limb industry; (2) an opportunity is given to coordinate the surgical, prosthetic, and physiotherapeutic treatment and to carry out a reeducational program which is often more helpful than the appliance, per se; (3) surgical defects of stumps become apparent while the patient is still under Army control and can be corrected at once; (4) the patient has an opportunity to learn something about appliances which enable him to make a more intelligent choice of a permanent appliance.

The first appliances used were of simple design and rather crudely made. The socket was of plaster of Paris. In the end of the socket was incorporated a metal clamp to hold various implements. Later an inexpensive arm with a universal end attachment plate in which a hand, tools, or any type of hook or other useful device could be used interchangeably was adopted. The metal parts were manufactured in quantity and issued to amputation centers. Sockets were made of leather, the work of fitting being done in appliance shops. No originality can be claimed for this appliance, as similar types were already being used abroad. Workmanship and exactness of fitting was probably

746

FIG. 174.- This and Figures 175 and 176 show the type of provisional arm used, and various attachments for work and play

FIG. 175

747

not equal to that obtainable in the open market, but it is believed that it served the purpose as a provisional appliance as well its could hove been expected from any single type of appliance obtainable.
                                        
FIG. 176
                                  
REFERENCES

(1) The Relation between the Amputation and the Fitting of the Artificial Limb. Military Surgeon, Washington, D. C., February, 1918, xlii, 154. The Temporary Artificial Limb. Ibid., April, 1918, xlii, 490. The Care of the Amputation Stump. Review of War Surgery and Medicine, Washington, D. C., 1919, ii, No. 2, 22.
(2) Information on Artificial Limbs and the Care of the Stump. In The Relation between the Amputation and the Fitting of the Artificial Limb. The Military Surgeon, Washington, D. C., February, 1918, xlii, 154.
(3) Circular No. 90, Surgeon General's Office, February 14, 1919.
(4) Letter from the Surgeon General to Major Edgar King, M. C., August 22, 1917. Subject: Assignment as Chief of Division of Special Hospitals and Physical Reconstruction. On file, Record Room, S. G. O., 115568 (Old Files). Memorandum from S. G. O., May 6, 1918. On file, Record Room, S. G. O., 0.024  (Division of Special Hospitals and Physical Reconstruction).
(5) Annual Report of the Surgeon General, t. S. Army, 1919, ii, 1106.
(6) Ibid., 1918, 399.
(7) Report from Division of Military Orthopedic Surgery to the Surgeon General, July 15, 1918. On file, Record Room, S. G. O.
(8) Correspondence. On File, Record Room, S. G. O., 442.3 (Artificial Limbs). Weekly Reports. On file, Record Room, S. G. O. (Weekly Report File).
(9) Letter from the Association of Artificial Limb Manufacturers of America, to the Surgeon General, October 19, 1917. Subject: Meeting in Washington. On file, Record Room, S. G. O., 442.3 (Artificial Limbs).
(10) Annual Report of the Surgeon General, U. S. Army, 1919, ii, 1105.
(11) Amputation Reports. On File, Record Room, S. G. O., 702.2.
(12) Based on Sick and Wounded Reports made to the Surgeon General.
(13) Relation between the Amputation and the Fitting of the Artificial Limb. The Military Surgeon, Washington, D. C., February, 1918, xlii, 154.
(14) The Care of the Amputation Stump. Review of War Surgery and Medicine, Washing- ton, D. C., 1919, ii, No. 2, 22.
(15) The Medical and Surgical History of the War of the Rebellion. Government Printing Office, Washington, Surgical Volume, Part III, 357.
(16) Huggins, G. M. The Surgery of Amputation Stumps. Lancet, London, April 28, 1917, I, 646.
(17) Lyle, H. H. M. The Formation of a New Thumb by Klapp's Method. Annals of Surgery, 1914, lix, No. 5, 767.
(18) "Amputations and Artificial Limbs" from Some Essentials in Military Surgery. Printed for the Surgeon General, United States Army. Press of the American Medical Association, Chicago, n. d., 39.
(19) A Report to the Chief Surgeon, A. E. F., by Major Williams S. Baer, M. R. C., and Capt. Philip D. Wilson, M. R. C. Subject: Cinematic Amputation in Italian Hospitals. War Medicine (Published by the American Red Cross), Paris, 1918-1919, ii, No. 1, 218