13 20 371 https://staging.drfop.org/files/original/baa690570cdf9103498cc78a51072780.pdf efeb1aaeccfa288eeec9bc5ecd38a00c https://staging.drfop.org/files/original/02116dc22518c1eb39c68be56eeadcbe.jpg 8a184304fcba8cc4b1780900d847a8a3 https://staging.drfop.org/files/original/5d633c5174ca141632fa4a4f1e21747b.jpg 5e04ded931d40f7f74cd630cd3fa88fd https://staging.drfop.org/files/original/d54d587bc683285e12a948e28325014e.jpg 7ac002016da544b27b8905e5ce7e190c https://staging.drfop.org/files/original/2d411a366a5894b21122ede2a2d07a78.jpg c37bdd60e381a074882dba174d8ebb45 https://staging.drfop.org/files/original/b3276065c28d0d1acc9bd4fbbc1682bd.jpg 161db3ea42e5ab5ea0b8020149c71991 https://staging.drfop.org/files/original/634383156fceaec626e209462b0523ec.jpg 846701e1d084860d18e51ec6f7c5a191 https://staging.drfop.org/files/original/3534840b8b9014b939dcf553b7d798a6.jpg 4ccf1cb63eb1401e3b40b6c3e79e7463 https://staging.drfop.org/files/original/cd15263c33b6e8fe70f3974c54e1df63.jpg 0ea4cec660c63647ee6e63d27d767ee7 https://staging.drfop.org/files/original/5b000331efb05bcdc1dbbad2cfa91b16.jpg 3ca6176c57505618b576214526d5f2fd https://staging.drfop.org/files/original/721dba1469c7361d052d71dc63510353.jpg 45e5a147daaf98d9a8290c41165c37e9 https://staging.drfop.org/files/original/1693caaecd751197fb1a87e816bd59c1.jpg b812afdf152beffe304e924d2710b595 https://staging.drfop.org/files/original/7790ac1614e11c427aa22f45d0c2dd52.jpg 073ddc987fa51b9507a6a6c4ab2381e6 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_02_004.pdf Year 1955 Volume 2 Issue 2 Page Number(s) 4 - 21 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_02_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_02_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Anthropology and Social Significance of the Human Hand</h2> <h5>Ethel J. Alpenfels, D.Sc. <a style="text-decoration:none;">*</a><br /></h5> <p>A definitive study of the anthropology of the human hand has yet to be written. Certain investigators, notably Krogman<a></a>, Schultz<a></a>, Ashley-Montagu<a></a>, Clark<a></a>, and Huxley<a></a>, have done intensive work on specific aspects of the morphology of the human hand. Nevertheless, the paucity of published studies, the fragmentary nature of the research, and the failure to attempt any but the most general conclusions make it difficult to summarize in a short article the present status of the hand in human evolution. Authorities differ both in opinion and in practice as to the value of anthropometric measurements in tracing the lines along which specialization has moved in the evolution of the hand. Published materials on the social significance of the hand are, however, numerous, and the importance of the hand as an organ both of performance and of perception has been recognized in all fields of the social sciences.</p> <p>Man alone has a hand. He uses it as a tool, as a symbol, and as a weapon. A whole literature of legend, folklore, superstition, and myth has been built up around the human hand. As an organ of performance it serves as eyes for the blind, the mute talk with it, and it has become a symbol of salutation, supplication, and condemnation. The hand has played a part in the creative life of every known society, and it has come to be symbolic or representative of the <i>whole </i>person in art, in drama, and in the dance. Students of constitutional types have used the hand as a means of classification, and the correlation between mental ability and manual dexterity has been the subject of much research. At the University of Pennsylvania, Krogman, using x-rays of the hand, currently is demonstrating new and important aspects of the interrelation of a child's growth and mental age. Thus the hand, perhaps because it is also dominant in the world of action, has come to be interpreted and understood best in its social aspects.</p> <p>But in a sense the human hand is a paradox. Although it is said to be the highest achievement of primate evolution, research to date shows it to be no more than a variation of a primitive vertebrate plan. The successive stages of evolution give proof, if proof be needed, that our sensitive and mobile hands, with their opposable thumbs, are part of man's vertebrate ancestry.</p> <p>In the suborder Lemuroidea, both recent and extinct, are found pawlike hands. The fourth digit<a style="text-decoration:none;">*</a> is elongated and, together with the first digit, acts like a pair of pincers to grasp a bough. Hooten<a></a> has pointed out that this is an adaptation found in all the lemurs, enabling them to maintain a more secure hold on boughs of large diameter. In lemurs, all of the digits are flat-nailed (except in the aye-aye, which has kept a number of primitive anatomical features), and several modifications appear in the carpal pattern. <b>(Fig. 1)</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. One conventional method of identifying the digits of the hand. Some authorities prefer to think of the hand as possessing a thumb and four fingers. Both methods of nomenclature occur throughout this issue of Artificial Limbs. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the suborder Tarsioidea, entirely arboreal, specialization of the hind limbs for hopping frees the hands not only for grasping but for feeding as well. The hind limb is longer than the forelimb, all of the terminal phalanges are flat-nailed, and the terminal digital pads have curious discs, almost like suction cups, enabling the tarsier to support himself on a smooth surface.</p> <p>These and other adaptations foreshadow higher primate development (<b>Fig. 2</b>), but we must look further to find man's place in the primate scheme. The suborder Anthropoidea, the third and highest of the primate group, includes larger arboreal forms. Longer fore limbs, together with a relatively shorter thumb (approaching atrophy in some forms), provide a means of brachiation. It has been suggested that the short thumb is related to the specialization of the hand as a grasping mechanism, permitting a quick release of the hand in swinging from one branch to another. But in this suborder the hands still retain their primitive features, and only in certain of the Old World Monkeys do the proportions of the digits approach those of man. The emancipated hands of the anthropoids, with thumbs that rotate and oppose the other finger tips, are directed by a more complex nervous system and a larger and better developed brain. Liberation of the hand may have been one of the decisive forces in the descent of certain anthropoids to the ground.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Comparative proportions (not relative size) of the hands of man and of certain related ancestral forms. Top row, left to right, hands of a tarsier, of a lemur, and of a Rhesus monkey. Bottom row, left to right, hands of a chimpanzee, of a human with atypical simian characteristics, and of normal man. In all cases except that of the lemur, the digital formula is 3 &gt; 4 &gt; 2 &gt; 5 &gt; 1. From Jones<a></a>, by permission of Bailliere, Tindall, and Cox, Ltd. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The Evolution of the Hand</h3> <h4>Links with the Past</h4> <p>Man's hand retains the ancient pentadactyl pattern found in early vertebrates. Geological records show that, during the Devonian period of Silurian times, primitive sharks appeared having typical paired fins corresponding to the paired limbs in man, and these organs were destined to give rise to later and higher forms. But there is a great difference belween the paired limbs of the early forerunners of present-day fishes and the pentadactyl limbs of other vertebrates. All of the steps are not yet clear, and the gap between the ancient fishes and the amphibians has not yet been bridged, but it appears that in the early amphibians the migration from water to land led to adaptations and modifications, especially in the area of the shoulder and pelvic girdles.</p> <p>These early ancestors of the primates had short legs, which grew progressively longer in the mammalian stage<a></a> and they walked flat-footed. The ability of the limbs to rotate brought about changes in the entire body. Striking homologies can be found in the hand and arm of man, the wing of a bat, and the foreleg of the frog. Where there are fewer digits, as in the hoof of the horse or the wing of the bird, the reduction has been due to adaptation to special environmental conditions.<a></a> Such reductions make for greater speed in the specialized limbs of the horse.</p> <h4>Upright Posture and Differentiation</h4> <p>The release of the hand from the requirements of locomotion, accompanied by the specialization of the foot and hind limbs for that purpose, led to upright posture (<b>Fig. 3</b>). Evidences of divergent evolutionary trends in the primate order are clearly distinguishable in the primate hand, especially those relating to limb length and trunk length (<b>Fig. 4</b>). Only the mountain gorilla has a hand shorter than that of man, not only with respect to limb length but in relation to trunk length. The longest hands among the great apes are those of the gibbon, the orangutan, and the chimpanzee. Specialists in the evolution of the hand have attributed the long, slender hands of these genera to brachiation and suspension, behavior that elongates not only the arms but, the hands as well, especially the fingers and the metacarpal bones.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The evolution of the hand (top row) and foot (bottom row), as revealed in skeletal structure. A, a primitive reptile; B, C, mammal-like reptiles; D, a lemur, representing a primitive mammalian type; E, man. Note the reduction in the number of joints in the toes, the specialization of the proximal ankle bones in mammals, some reduction in the number of wrist and ankle bones, and the variations in the thumb and great toe From Romer<a></a>, by permission of The University of Chicago Press </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 4. Exact diagrammatic front views of the four largest primates at fully adult age, drawn from detailed measurements on actual specimens, hair omitted, and all reduced to the same trunk height. From Romer<a></a>, by permission of The University of Chicago Press. Originally constructed by A. H. Schultz. Note that, from orang to chimp to gorilla to man, both limb length and hand length generally decrease with respect to trunk height. Only the gorilla has a hand shorter than that of man. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As for the length of the thumb, man andthe other great apes show sharp divergence, especially when the thumb is considered with respect to hand length. As contrasted with the short thumb of the anthropoid apes, man's thumb is long and well developed. Attempts to explain this difference have led to an either-or position. Either the thumbs of the apes have atrophied as a result of their arboreal life or man's thumbs have lengthened in the evolutionary process.</p> <h4>The Shoulder and Upper Arm</h4> <p>In man the shoulder and upper arm are adapted for strength. As for the other portions of the arm down to and including the hand, the more distal the part the more it is adapted for complex and delicate functions and the less for strength. The pectoral girdle in man consists of three bones. The scapula is directed dorsally, the coracoid process extends forward and downward to meet the sternum, and, anterior to the coracoid, the clavicle connects scapula and sternum. Because the pectoral girdle is not joined directly to the spine, though it may articulate with the sternum, the structure permits great freedom of motion in the shoulder area. Briefly, the human arm, supported and controled by a large number of muscles, together with the elbow and wrist joints, gives freedom to a hand that has become the willing servant of the human intellect.</p> <h4>Man's Opposable Thumb</h4> <p>The powerful and well-developed thumb of man is one of his few uniquely human characteristics. Through successive stages of vertebrate evolution, the thumb has separated from the other fingers and developed specialized musculature. In the Anthropoidea, the feature of opposability led to greater tactile and exploratory facility. Man's thumb, comparatively twice as long as that of some of the anthropoids, reveals a steady increase in absolute and relative length (<b>Fig. 2</b> and <b>Fig. 4</b>) and, at the same time, the steady development of opposability, extensibility, and flexibility. When the "hand" of the ape is compared with the hand of man it becomes, in the words of Krogman<a></a> a "misnomer." In the ape, hands are hands by definition only. Although man's hand, the end-product of our evolutionary development, retains the basic, primitive, pentadactyl pattern common to all land vertebrates, it nevertheless is uniquely human. The earliest animal footprint known (from the Permian of the Tambach in Thuringia) is so similar in appearance to that of the human hand that the animal which left the fossil print was named "Cheirotherium," or the "handbeast" <a></a></p> <h4>Variations of the Human Hand</h4> <p>The morphological pattern of man's hand shows its affinity to the "hands" of other animals. But while man has kept the primitive pattern, other animals have specialized. In birds, for example, the hand has become a wing, in the horse a hoof, in the whale a flipper, in the dog a paw, and so on. According to Hooton<a></a>, Crawford has demonstrated the difference between tool-using, as in man, and tool-growing, as in most animals. Animals use no tools other than those developed out of the materials furnished by their own bodies. Man, however, was<a></a> "the first animal to grow a limb outside himself by making tools out of wood and stone." Furthermore, the limbs of animals are specialized for single purposes only. The horse can run, the mole can dig, but neither can climb; man makes instruments that are imitations of the body tools of other animals a digging stick, an awl, a scraper, or a dagger.<a></a> The power and versatility of the human hand rests, in part, upon its generalized pattern. But it is the human brain, with its intricate and elaborated nervous system, that coordinates man's eye and hand. Thus, man is born with a hand free to do the bidding of his expanded brain.</p> <h3>The Anthropometry of the Hand</h3> <h4>Early Studies</h4> <p>The past fifty years have seen a gradual increase in the literature devoted to the anthropometry of the human body. But until that time, individual investigators had gone their separate ways, and there was little concurrence on standardization of the measurements to be employed, on the way in which these measurements were to be taken, or on the instruments to be used. Furthermore, just as in the osteological studies conducted in anthropological museums, early research on living animals was devoted largely to the head and facial features, and only later was study extended to the remainder of the body. Hence the dearth of anthropometric studies on the hand is easy to understand. Lacking, also, are routine osteometric recordings and systematic measurements and indices that could provide the comparative anatomical data necessary for a definitive work on the evolution of the human hand.</p> <h4>The Lack of Data</h4> <p>Authorities appear to agree that no part of the human body has been as neglected as has the hand.<a></a> The reasons for this situation are many, but perhaps the most important one is the scarcity of fossilized primate hands, probably owing to the fact that these bones are small, fragile, and easily destroyed by the action of the forces of nature. Nor are the anthropological collections of complete hands of the modern anthropoids anywhere near adequate. During the past few years, individual investigators and museums have been attempting to increase the number of complete hands available for study, but the collections still are quite inadequate. Moreover, as was demonstrated at the University of Chicago, skeletons often turn out to be composites of many separate individuals and, therefore, of little use in anthropometric studies.<a></a> These handicaps, together with the complexity and the extreme variations found in the human hand, make it exceedingly difficult to get accurate results.</p> <h4>The New Focus</h4> <p>The early work in comparative anthropometry was devoted entirely lo race differentiation.<a></a> At the present time, however, that interest is lagging, and extensive growth studies of the epiphyseal closures of the metacarpals and the phalanges are being conducted at the University of Pennsylvania.<a></a> The x-ray technique, used for many years, has become the major tool by means of which the anthro-pometrist and anatomist can study living persons. It is dependable and important, especially in studying the highly differentiated parts of the human hand.</p> <h4>Classification</h4> <p>The morphology of the hand has proved useful in classifying hand types. Wechsler's system<a></a> is based upon four hand dimensions (<b>Fig. 5</b>). From all possible combinations of length and three breadths, he derives six index categories, as shown in <b>Table 1</b>. Thus, the long, narrow hand type in man would be, for example, 1-1-1-2-4-3, that of the short, broad hand 4-4-4-4-4-4.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Hand measurements according to Wechsler. From Krogman<a></a>, by permission of Ciba <i>Symposia</i>. </p><ol> <li><i>Stylion radiale, </i>at tip of radial styloid process.</li><li><i>Stylion idnare, </i>at tip of ulnar styloid process.</li><li><i>Interslylion, </i>mid-point of line connecting 1 and 2.</li><li><i>Daclylion III, </i>at tip of third finger.</li><li><i>Metacarpale radiale, </i>at metacarpophalangeal junction of index finger.</li><li><i>Metacarpale ulnare, </i>at metacarpophalangeal junction of little finger.</li><li><i>Proxindicion, </i>at proximal interphalangeal junction of index finger.</li><li><i>Ulnoquintion, </i>at intersection on ulnar side of little finger of line perpendicular <i>[sic] </i>to length dimension, drawn from 7.</li><li><i>Dislindicion, </i>at distal interphalangeal junction of index finger.</li><li><i>Ulnoquartion, </i>at intersection on ulnar side of ring finger of line perpendicular <i>[sic] </i>to length dimension, drawn from 9.</li></ol> <p></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1 </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Handedness in Man</h3> <h4>Right and Left - Good and Evil</h4> <p>The cultural world in which man lives, both in preliterate and in technologically advanced societies, tends to be a "right-handed" world. Cross cultural studies reveal that different sides of the body, the left or the right, are associated with different social activities. In India, the right side and the right hand perform tasks considered to be "clean," while the left side and the left hand perform tasks considered to be "unclean." The two types of activities are separated rigidly. The right hand, for example, is used for cooking and eating, whereas the left hand is used in bathing, elimination, or activities associated with sex. Indeed, it is common in many areas of the world to find food related to the right hand, while the left hand is associated with sex.<a></a></p> <p>The right and left hand have come to symbolize good as opposed to evil, gods as opposed to demons. Hence, they are considered as two forces constantly at war with one another. The shadow plays of the Balinese illustrate the widespread association of good and evil with the right and left side respectively. The mystic story teller takes the marionettes out one by one, placing the "good" and "noble" characters at his right side and, at the left, the "evil" and "sinister" characters. In the end, truth and goodness always win, which demonstrates the triumph of the magical powers of the right side. At all important life crisesbirth, death, marriage, initiation ceremoniesthis magic balance between left and right is maintained. Among the Tiv of Nigeria, the afterbirth of a boy child is always buried to the left of the door in order to propitiate the evil spirits residing there. In Bali, a boy's placenta is buried on the right and a girl's on the left side of the entrance to the house.<a></a></p> <h4>Caste and The Hand</h4> <p>The symbolism of the hands in ceremonial rites has, in various ways, come to indicate social class and caste. Among the Balinese, for example, it is a mark of social distinction to wear long nails, but only the priest may wear them on both hands. The giant-god of pre-Hindu times is believed to have carved out all of the caves with the fingernails of his left hand. The Indian caste system is noted for a unique feature in that many of the castes are divided into two sections called the "right-hand" (Balagai) and the "left-hand" (Yedagai) castes. Certain socially lower artisan castes, such as workers in leather, belong to the left-hand subgroup.<a></a> Among the Motu of Papua, the moieties are grouped by the left and right hand. Members of the right-hand moiety have senior status in matters of inheritance, while members of the left hand moiety have junior descent status.<a></a></p> <h4>Other Influences</h4> <p>Music for the piano usually is written in such a way that the melody is carried by the right hand. Threads in bolts, pipes, and even in glass jars are right-handed. Soup and gravy ladles, fish forks, and meat grindersin fact, the majority of our manufactured products are designed for the right-handed individual. Can the custom of men buttoning their coats on the right side and women on the left be a survival from our primitive past when the right was reserved for men because it was "good" and the left for women because it was "evil"? Our society is belatedly recognizing the right of sinistrodextral people to full participation in our culture. Banks are issuing left handed checkbooks, left-handed armchair desks have been introduced in schools, and left-handed scissors and other implements and tools now are available.</p> <h4>Handedness in Early Man</h4> <p>Whatever the reasons for associating right with "good" and left with "evil," the fact remains that man is predominantly right-handed, a fact that appears to have been true even in prehistoric times. Early writers explained the enigma of right-handedness in the Lamarckian sense of "use and disuse." They noted that, since the heart was located on the left side of the body, the warrior carried his shield in his left hand. The right hand was free and, through more frequent use, developed in both size and dexterity. This "acquired" characteristic was passed on to succeeding generations.</p> <p>During the nineteenth century, as the authenticity of plant and animal fossils was established, and with the growth of anthropology as a more exact science, numerous archaeological sites were excavated. By the beginning of the twentieth century, thousands of artifacts had been uncovered, more precise data were available, and the picture of life in prehistoric times began to emerge in greater detail. The oldest implement found in Europe was beveled for grasping between the right thumb and first finger. The implements of primitive Paleolithic sculptors were found to approximate in number and in form those of modern sculptors. All of the tools uncovered in a Spanish cave, said to have been inhabited during Solutrean times, are designed to fit the hand, and, from the almost perfect adaptation of these instruments, we may infer that these ancient artists were right-handed.<a></a> Based upon the frequency of left-handed flint tools found <i>in situ </i>in France, other authorities, Krogman<a></a> for example, note that the incidence of left-handedness increased during the New Stone Age.</p> <h4>Handedness in Apes</h4> <p>During the past three decades, handedness in the apes has been studied extensively in the United States. Yerkes <a></a>, in his classical work on the apes, found that handedness appears in chimpanzees. He points out that they use one hand consistently for certain purposes and the other hand for other activities. He says, however, that right-handed dominance has not been demonstrated and that the three types of motor activity found in man (right-and left-handedness and ambidexterity) occur with about equal frequency.</p> <h4>The Chick Embryo</h4> <p>The problem of left- and right-handedness in chickens has been reported. At about the 38th hour in the chick embryo, certain processes are initiated that result in what may be termed very loosely a "right-handed embryo." In certain chemicals, the molecular structure is "left-handed" in that it is of the nature of the mirror image of the "right-handed" counterpart. After a number of hours of incubation, fertile chicken eggs exposed to such "left-handed" chemicals evidence a "left-handed" type of flexure of the developing brain.</p> <h4>Asymmetry</h4> <p>Yerkes<a></a> holds with the current opinion that asymmetry of the left and right hand (<b>Fig. 6</b>) is related to a general asymmetry of the entire body. The right and left leg in man, for example, also differ in strength and in dexterity. Similarly, the right lung is slightly heavier, the abdominal viscera are heavier on the right side, both the spine and pelvic regions display asymmetry, and hence the center of gravity of the body is slightly to the right. Kahn<a></a> reports a number of experiments which demonstrate that, owing to this asymmetry, every blind wandering ends in a circle. Thus, man cannot write, nor walk, nor drive a car blindfolded without becoming a victim of his physical asymmetry.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Typical difference between the right and left hands of a single individual. The right has a shorter palm and longer fingers, and the long longitudinal line is more marked. From Wolff.<a></a> by permission of Methucn and Co., Ltd. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Endocranial casts of the brain cavities of fossil and of modern man support this evidence, and here too asymmetry appears. The left occipital portion of the brain predominates to produce right-handedness, a fact established by Smith.<a></a> One school of thought claims that this asymmetry of the brain represents a primitive character in the higher apes and man. According to Clark<a></a>, however, Keith maintains that, on the contrary, asymmetry represents an evolutionary advance.</p> <p>The general physical asymmetry of the body is associated with a social asymmetry in our human prejudice against the left side. The human preference for right-handed tools and artifacts has, somehow, invaded the social and moral life. There also is a <i>sinistra </i>and <i>dextera </i>view of the world now fixed in our vocabulary.</p> <h4>Handedness in Language</h4> <p>We speak of dexterity (from the Latin "dexter," connoting "right," "favorable") in referring to skill, and this idea has been traced back to Sanskrit, the ancient literary language of India. From the category of physical things, the right hand has reached out to influence many other areas of human life. To be "orthodox" is to follow the "right" or "true" opinion. The concept of legal justice comes from the French "droit," meaning "right" or "law." Contrariwise, the word "left" symbolizes "evil," "weak," "awkward." The word for "left" in French is "gauche," meaning "awkward." The Latin "sinister," meaning "left," rarely applies to that which threatens but, rather, to that which is known to act covertly or insidiously. The bar sinister is the heraldic symbol of bastardy. A man who marries below his social rank gives his left hand, not his right, to his bride. Thus, in our own culture today there survive in our language and customs the social implications that historically have characterized handedness in man.</p> <h3>The Hand as a Sensory Organ</h3> <h4>The Sensory Experience</h4> <p>Although prehension is the major function of the hand, the hand is, at the same time, one of man's primary sense organs. This tactile quality provides sensory experience that may be grouped into four general categories.<a></a> The first consists of "surface sensations" stimulation generated by touching tangible objects. The second is termed "space-filling" stimulation generated by pulling the hand through liquid substance. "Spacelike sensations," comprising the third category, relate to the touch of distinctively shaped objects felt through a heavy material. Finally, there are "penetrable-surface sensations," experienced, for example, by a physician as he palpates some part of the body to locate, through the outer layer of flesh, some abnormal condition in deeper tissue.</p> <p>Movement is indispensable in sensory experience, and experimentation demonstrates that even the "imaginary" touch sensations are located in the finger tips. According to Katz<a></a>, it is quite impossible to call up the image of touch without, in imagination, moving the hand. The moment we imagine our hands at rest, the image becomes uncertain or disappears.</p> <p>When body and ambient temperature are equalized, the hand may be used as an instrument for the perception of the relative levels of heat and cold. Preliminary determination of body temperature can be determined by placing the hand on the forehead. In folk society, for example, where accurate measures of determining fever temperature are not available, a normal hand placed upon the forehead is used to determine the presence of fever.</p> <h4>A Percussive Tool</h4> <p>The human hand can also be used as a percussion instrument. With an apparatus which he called "the percussion phantom,"<a style="text-decoration:none;">*</a> von Gotzen found that vibratory impulses generated by finger percussion can be felt even when the auditory sense is eliminated.</p> <h4>A Vibratory Tool</h4> <p>Vibratory sensations, as perceived by the hand, are of importance in teaching the deaf to speak. By placing one hand on the larynx of a speaker and the other hand on his own larynx, a deaf-mute learns the vibration patterns of speech sounds. When the patterns "heard" by his left and right hand are identical, the student has succeeded in imitating the sound. Helen Keller utilizes the vibratory phenomena when she "hears" music by placing her hand on the piano.</p> <h3>The Human Hand in Art</h3> <p>Through the ages the human hand has appeared in all of the creative arts of every culture.<a></a> A single line, a schematic portrayal, a simple gesture of the hand, and character and personality stand revealed as clearly as they are seen in the human face. Recently, in the Kefauver investigation of crime in New York City, the television camera focused on the hands of a witness, and millions in the television audience watched while hands expressed feelings that man has taught his face to disguise.</p> <p>In the creative arts, the hand speaks, and one senses the tremendous power of the hand to convey human emotions. The hands are the organs of the body which, except for the face, have been used most often in the various art forms to express human feeling. The hands point or lead or command; the hands cry out in agony or they lie quietly sleeping; the hands have moods, character, and, in a wider sense, their own particular beauty. From prehistoric times to our own day, in every society known to science, the hands symbolize cultural behaviors, values, and beliefs.</p> <h4>Painting and Sculpture</h4> <p>Many studies of the hand appear in the traditions of western art. From schematic and conventional hand portraits, the artists of the fifteenth century began to draw anatomically correct hands, and, slowly but surely, the hand was seen as having a personality and a culture of its own. Albrecht Durer (1471-1528) devoted a lifetime to the study of anatomy, and in his studies of hands the lines, the curves, the veins, the wrinkles delineate the complexity of the human hand (<b>Fig. 7</b>). In another medium, the French sculptor Auguste Rodin (1840-1917) deliberately used the hands to create unmatched works of art.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Famed "Hands of an Apostle Praying," by Albrecht Diirer (a.d. 1471-1528). Courtesy The Public Library, Washington, D. C. The original hangs in the Albertina Museum in Vienna. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Prehistoric Artist</h4> <p>Early man left records in shallow caves, in rock shelters, and, in the great period of art during late Paleolithic times, on the walls of the innermost recesses of caves in France and Spain In the ancient engravings and the wall paintings found in caves in eastern Spain, the arms and legs perform animated gestures in running, in drawing a bow, in gathering honey, and in the dance.</p> <p>The human hand appears in quasi magico-religious silhouettes of complete or partially mutilated hands outlined in color on the walls of the grotto of Gargas in the Pyrenees Mountains. The fingers appear to be cut off at the distal end of the first phalanx, with one or more digits missing entirely. Curiously, the thumb never is amputated. The same type of finger mutilation is found in wall paintings in the caves of central Australia. Apparently the practice was customary among the early Aurignacian people of Paleolithic times, and it also is reported in other preliterate tribes. According to Osborn <a></a>, Breuil believes that painting had its beginning in these stencilled contours produced by laying the hands against the limestone walls and spreading red and black paint on the surrounding area. In other examples, the hand was covered with pigment and pressed against the wall.</p> <h4>The Dance</h4> <p>The formal patterns and definite movements of the dance make it one of the greatest of the interpretative arts. It is, apparently, also one of the oldest arts. Whether viewed from a recreational, religious, or aesthetic standpoint, this expression of culture has attained meaning and intensity through movement of the hands. Joint dances between the sexes are rare among primitive tribes, and the hand thus has been liberated for gestures and symbolic movements. In India, the hands can tell an entire story. In Australia, among one of the most technologically simple tribes, the movements of the hands make the dance merge into drama. Indeed, it is difficult to separate the dance from music and from drama, but in each of these art forms it is the hand that gives meaning to words spoken. Perhaps the rhythm produced by the hands in clapping and in slapping the body originally led to music and to the dance.</p> <h3>The Hand in Culture and Society</h3> <h4>Language Abstractions</h4> <p>Because the human hand is an organ of performance, it is not surprising that the hand should "manipulate" ("to lead by the hand") the human vocabulary. The hand receives the "mandate" (from Latin "manus," for "hand," plus "dare," "to give") from the brain, and to "manage" is to govern, direct, or control. Thus, man "commends" (which originally meant "to place in one's hands") and "commands," both words related to "mandate" and, therefore, to the Latin "manus," for "hand."</p> <p>With its basic movements for grasping objects (page 33), the human hand also is "handy" ("dexterous," "to have two right hands") for grasping ideas. To "comprehend" is to "seize" (Latin, "capere," "to seize"), from which we derive such words as "perceive," "conceive," and "receive." Thus, by various shades of meaning, the human hand not only "hands down" information but "picks" it up. The human hand also is an organ of perception and thus lends itself to the most abstract concepts. "Handsome" originally meant "dexterous." "To feel" is connected somehow with the Greek word for hand, "palame." To say in Latin "dicere" means "to point." We touch, feel, handle, finger, thumb, paw, grope, palpate, and stroke objects.</p> <h4>One and One Are Two</h4> <p>Man's hand not only manipulates and grasps, and makes and points, but it counts as well. Counting is very different from what we loosely term "number sense," an attribute that man shares with other animals. In its real connotation, counting appears to be an exclusively human characteristic, and numbers, like so many abstractions, begin with the human body. The old Roman numerals I, II, III, and IIII<a style="text-decoration:none;">*</a> are thought to be representations of the fingers. In certain of the less well-known languages, the word for hand gives us the word for five. "Five" also has come to mean "hand," and in English the slang expression "give us five" once meant "to shake hands."</p> <p>One example of the use of hands in counting is that of the Mafulu mountain people, who do not use pebbles or sticks but instead use the hands and feet.<a></a> Here counting is accomplished by the use of two numerals, "one" and "two." In indicating "one," the hand first is stretched open to indicate "nothing," the thumb then is closed down meaning "one," the first digit closed down meaning "two," and so on, until all of the fingers of one hand are closed. The process is repeated with the other hand, and, to count to 20, the clenched fist points to the feet and to all of the right and left toes. If the count is above 20 (usually only when important occasions demand, such as counting pigs for a ceremony) another man is called to stand beside the first. If the number goes as high as 83, five men join. Four men go through the entire process, and the last man closes the first three digits.</p> <h4>Man the Measuree</h4> <p>Equally important has been the use of the hand as a unit of measurement. Tables showing the use of body organs as units of measure have been established for volume, surface. width, and length (<b>Fig. 8</b>). The earliest records show that the use of the index finger for indicating length was a widespread custom. In Europe the height of a man was estimated by a definite number of finger lengths based upon the measurement of the middle finger. In Latvia, the length of the middle finger was used to measure lengths for women's stockings or woolen socks (three times the length of one's middle finger). Sixteen times the length of the middle finger equals the normal human stride. The hand and thumb were used to measure width, 12 thumb widths being equal to one foot. Tools were made by the eldest member of the family and adjusted to the hand grasp. Thus, a scythe blade for an adult man was as long as nine or ten widths of the clenched hand, eight for an adult woman, and seven or eight for an adolescent (<b>Fig. 9</b>). The same pattern is found through much of eastern and northeastern Europe today.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Natural units of measure, still in use by Latvian and other European peasants. From Drillis.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. The method, common among Latvian and other European peasants even today, of arriving at the proper dimensions for farm tools using the hand as the unit of measurement. From Drillis.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Some Tribal Customs</h4> <p>In the Sun Dance of the Plains Indians of the United States, finger joints were occasionally pledged as a thank-offering for recovery from illness or to ensure revenge for a slain relative.<a></a> Cole<a></a> reports that individual warriors among the tribes of Mindanao carried home a hand as evidence of a successful fight and that at such times festivals were held to celebrate the event. Among the Tinguian tribes of the Philippine Islands, joints of the little fingers were added to ear lobes and brains to make a liquor that was served to the dancers. Here, as in most areas of the world, the brew was consumed not for nourishment but in order to secure that part of the enemies' bodies thought to house strength and valor.</p> <p>Such reports may throw light upon the presence of the mutilated hands found on the walls of the European caves and dating from late Paleolithic times. The scarcity of drawings of the human form in cave paintings may be related in some way to the belief, still found among certain of our "primitive" contemporaries, that realistic portraits might give an enemy magic power. Possibly, through some similar process of sympathetic magic, the hand has already become a symbol to be portrayed realistically in religious ritual.</p> <h4>The Fingerprint</h4> <p>Human hands have been used in various cultures as a means of positive identification. In ancient China, fingerprints were used to sign or to autograph paintings. They are doubly valuable as "signatures" because they cannot be altered or forged, and the intricate patterns of whorls, circular and folded loops, and arches differ from finger to finger and from individual to individual. As the person grows, his individual fingerprint patterns increase in size but do not change in geometric proportions. In 1882, Bertillon, a young French anthropologist, began to develop his famous system for identification of criminals by a physical description based upon eleven anthropometric measurements, deformities, and impressions of lines and markings of the finger tips. The Bertillon system of fingerprints has been used internationally and has proved valuable for physical identification.</p> <h3>Some Other Considerations</h3> <h4>Occultism, Symbolism, and Ritualism</h4> <p>In an anatomical sense, each hand is unique. Every hand betrays its possessor by characteristic mo/ement patterns, by peculiarities of gesture, or by occupational stigmata arising from physical and mechanical causes. From these characteristics, palmistry and a branch of occultism known as "chiromancy" have, for centuries, attempted to read the past, present, and future of individuals. Since early antiquity, numerous scholars of repute have concerned themselves with studies in palmistry. According to D'Arpentigny<a></a>, Plato, Aristotle, Galen, Albertus Magnus, the Ptolemies, Avicenna, Averroes, Antiochus Tibertus, Tricasso (<b>Fig. 10</b>), Taisnier, Belot, and others have handed down lengthy treatises on the subject, and the observations of these early writers still prevail in our own modern times (<b>Fig. 11</b>). Palmists are interested chiefly in the surface of the handlines, stars, crosses, islandsand have divided the life line into seventy parts, each part symbolic of one of man's allotted seventy years of life. Chirognomists study the shape and form of the entire hand, in addition to surface characteristics.<a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Principal lines and mounts of the hand as charted by Patritio Tricasso da Cerasari (Tricassus the Mantuan), a celebrated chiromancer of the sixteenth century. From Lenssen<a></a>, by permission of The Studio Publications, Inc., New York City. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. The mounts and principal lines of the hand and the interpretative functions traditionally assigned to the several areas. Authorities differ in detail, but all follow the same general pattern. In palmistry, which dates from antiquity and which has been the subject of serious discussion by numerous scholars, including Aristotle, the relative development of the mounts and lines is considered to show the comparative ability of the subject to implement the talents and qualities associated with the individual features. Generally the mounts are seven in number, the eighth (Mount of Neptune) occurring in a comparatively small number of cases. Reference to the sun, moon, and planets relates, of course, to the influence which, in early philosophy, these celestial bodies were thought to exercise upon the course of an individual's life. Modern astrology calls upon similar relationships. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>But it is in the realm of quasi magic and symbolism that the hand reaches its highest cultural significance. For the great majority of mankind who think in concrete rather than in abstract terms, graphic representations of superhumanity are related to the human body. The Hindu of India symbolizes this super-humanity by the multiplication of the most important parts of the body, which, to him, are the head, the arms, and the hands. Since arms and hands are extremely useful, a twelve-armed god demonstrates the power and the strength denied a two-armed god. Such thinking may appear grotesque to the Westerner, but the Hindu, accustomed to symbolic thinking, knows that man is not so constructed, nor does he wish that he were. He simply recognizes that power and wisdom and strength may be expressed quantitatively.<a></a>The Moslem often wears a small image of the hand around his neck to ward off the evil eye.</p> <p>Not only in the eastern world does the hand play an important part in the ritual usages but in western culture as well. The pentagram, the five-pointed star, is said to have been derived from an ancient custom of covering the face with the open fingers of the hand. That practice gradually was replaced by invoking the numeral "five," a convention that persists today in countries in central Europe. In Latvia, for example, the pentagram now appears on barns as a protective device.</p> <p>Finally, the hand has become symbolic of human sentiment. We bless and we salute by raising the hand in various ways. The gentle laying on of hands is at once a symbol of benediction and, as among certain religious sects, the means of curing the sick and of drawing out the evil spirits that reside within the body. In legal practice, oaths are taken in court by the simultaneous use of both hands, right hand up and the left hand on the Bible. We close a bargain by shaking hands, we raise our hands in salutation, and a man takes a woman's hand in marriage. Contrariwise, the hand may express condemnation, malediction, and final judgment. In cursing we point the hand at the enemy. In ancient Rome, thumbs down ("pollice verso") sentenced the gladiator to death. Thus, the hand has become an expository of human sentiment. It can express love, hate, doubt, questioning, hospitality, judgment, rejection, or acceptance.</p> <h4>The Hand and Good Health</h4> <p>The handshake may become an index to personality and representative of the <i>whole </i>person. The cold, limp hand, the strong, firm grasp, the moist palm, the dry palm, all help us to create a mental image of personality. To the trained hand of the physician, the cold, moist, flabby handshake often reveals clues relating to physical condition. Such a handshake often is a symbol of physical illness or an indication of an emotional disturbance. To the trained eye of the doctor the hand tells even more. The coloring, texture, lines, and creases sometimes reveal sickness or health. A trembling, warm, moist hand may mean overactivity of the thyroid, redness may indicate gout, a bluish appearance may indicate a certain kind of heart disease, and bad cases of malnutrition and diet deficiency frequently are reflected in the hand. There are many variations in the appearance of each hand, but the danger signals can be read only by the skilled hand and eye of a physician.</p> <h4>The Hand in Expression</h4> <p>The hand has also become associated with certain ethnic and nationality groups, for specific hand gestures have been associated with certain cultural types. Indeed, it has been said of the Italians that they never speak a language, that they caress it. Because movement of the hands serves to emphasize the spoken word, all of us find it difficult to speak while our hands remain perfectly still. A dramatic presentation of the use of the hand in conversation was portrayed through the medium of modern dance in a performance by a group at New York University involving an interpretation of an adolescent the telephone (<b>Fig. 11</b>). talking over No word was spoken, but the wide variety of gestures made clear to everyone what the performer was saying. The cult and the culture of the "teen-ager" in our country was delineated as sharply through the dance as it could have been through the medium of the written word.</p> <h3>Conclusion</h3> <p>From its basic use, prehension, which grew out of anatomical development, the human hand gradually has evolved until it is now also an effective instrument for symbolic and aesthetic interpretation. Man's capable and sentient hand not only serves as a tool but it wields tools as well, and it has in addition the ability to take the place of other body organs. Because of its remarkable adaptability to functional requirements, as compared with the specialization in the forelimb of other animals, the hand is largely responsible for the creative manifestations that characterize the human species and that distinguish it from all other known forms of life. The hands are, as Kant is reported to have said, "man's outer brain."</p> <h3>Acknowledgment</h3> <p>For valued help in obtaining the illustrations which accompany this article, the author is indebted to Marian Blumler, staff member of the Library, National Academy of Sciences National Research Council, who conducted a search of source material and arranged for loan of the necessary documents.</p> <p><b>References:</b></p> <ol> <li>Adam, Leonhard, <i>Primitive art</i>, Harmendsworth Middlesex, Penquin Books, Ltd., rev. ed., 1949.</li> <li>Ashley-Montagu, Francis M., <i>On the primatethumb</i>, Am. J. Phys. Anthropol., 16(2):291 (1931).</li> <li>Boas, Franz, <i>Primitive art</i>, H. Aschehoug, Oslo, 1927. pp. 344, 349.</li> <li>Boyd, William C, <i>Genetics and the races of man; an introduction to modern physical anthropology</i>, Heath, Boston, 1950. pp. 16-17.</li> <li>Clark, W. E. Le Gros, <i>Early forerunners of man; a morphological study of the evolutionary origin of the primates</i>, Bailliere, Tindall, and Cox, London, 1934. pp. 103-140.</li> <li>Cole, Fay-Cooper, <i>Lectures</i>, University of Chicago, 1940-41.</li> <li>D'Arpentigny, C. S., <i>The science of the hand</i>, translated from the French by Ed. Heron-Allen, Ward, Lock, and Bowden, London, 1895.</li> <li>Drillis, Rudolf J., <i>Darba riki [Tools]</i>, in <i>Lalviesu konversacijas vardnica [Latvian encyclopedia]</i>, A. Gulbis, Riga, 1928-29. Vol. 3, p. 4611.</li> <li>Drillis, Rudolf J., <i>Mcri [Units of measure]</i>, in <i>Latvieiu konversacijas vardnica [Latvian encyclopedia]</i>, A. Gulbis, Riga, 1928-29. Vol. 14, p. 26691.</li> <li>Flory, Charles D., <i>Osseous development in the hand as an index of skeletal development</i>, Society for Research in Child Development, Monographs, Vol. 1, No. 3, National Research Council, 1936.</li> <li>Hodges, Paul C, <i>An epiphyseal chart</i>, Am. J. Roentgenol., 30(6): 809 (1933).</li> <li>Hooton, Earnest A., <i>Up from the ape</i>, Macmillan, New York, 1931.</li> <li>Huxley, J., <i>From fin to fingers: the evolution of man's hand</i>, Illustrated London News, December 1930. pp. 1138-39.</li> <li>Jones, Frederic Wood, <i>The principles of anatomy as seen in the hand</i>, 2nd ed., Williams and Wilkins, Baltimore, 1942.</li> <li>Kahn, Fritz,<i> Man in structure and function</i>, Alfred A. Knopf, New York, 1943. Vol. 1, pp. 1515-16.</li> <li>Katz, David, <i>On the psychology of the human hand</i>,Bulletin Vol. 32, No. 10, University of Maine Studies, Second Series, No. 14, <i>The vibratory sense and other lectures</i>, The University Press, Orono, 1930. pp. 75-78.</li> <li>Krogman, Wilton M., <i>The anthropology of the hand</i>, Ciba Symposia, 4(4):1294 (1942). '</li> <li>Lenssen, Heidi, <i>Hands in nature and art</i>, Studio Publications, New York, 1949.</li> <li>Mead, Margaret, el al., <i>Cultural patterns and technical change</i>, World Federation for Mental Health, UNESCO, Igsel Press, Ltd., Deventer, Holland, 1953.</li> <li>Mierzecki, H., <i>Symbolism and palhognomy of the hand</i>, Ciba Symposia, 4(4):1319 (1942). '</li> <li>O'Malley, L. S. S., <i>Indian caste customs</i>, Macmilan, New York, 1932. pp. 21-22.</li> <li>Osborn, Henry F., <i>Men of the Old Stone Age, their environment, life, and art</i>, 3rd ed., Scribner, New York, 1919.</li> <li>Personal communication from Margaret Cormack, Brooklyn College.</li> <li>Reininger, W., <i>The hand in art</i>, Ciba Symposia, (4):1323 (1942).</li> <li>Romer, Alfred Sherwood, <i>Man and the vertebrates</i>, University of Chicago Press, Chicago, 1933.</li> <li>Romer, Alfred Sherwood, <i>Man and the vertebrates</i>, 2nd ed., University of Chicago Press, Chicago, 1937. Especially pp. 27-28, 41-42, 363-70.</li> <li>Rosenstiel, Annette, <i>The Motu of Papua-New Guinea: a study of successful acculturation</i>, Ph.D. thesis, Columbia University, 1953. Microfilm.</li> <li>Schultz, Adolph H., <i>Characters common to higher primates and characters specific for man</i>, Quart. Rev. Biol., ll(4):425-455; ll(3):259-283, 434-437 (1936).</li> <li>Schultz, Adolph H., <i>The skeleton of the trunk and limbs of higher primates</i>, Human Biol., 2(3):303 (1930).</li> <li>Smith, Grafton E., <i>The evolution of man</i>; essays, 2nd ed., Oxford University Press, 1927.</li> <li>Wilder, Harris H., <i>A laboratory manual of anthropometry</i>, Blakiston, Philadelphia, 1920. pp. 84-109.</li> <li>Wiser, Charlotte V., and William H. Wiser, <i>Behindmud walls</i>, Harper, New York, 1930.</li> <li>Wolff, Charlotte, <i>The human hand</i>, Methuen, London, 1942.</li> <li>Wright, W. B., <i>Tools and the man</i>, George Bell and Sons, Ltd., London, 1939.</li> <li>Yerkes, Robert M., <i>Chimpanzees; a laboratory colony</i>, Yale University Press, New Haven, 1943.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Personal communication from Margaret Cormack, Brooklyn College.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Lenssen, Heidi, Hands in nature and art, Studio Publications, New York, 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Mierzecki, H., Symbolism and palhognomy of the hand, Ciba Symposia, 4(4):1319 (1942). '</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">D'Arpentigny, C. S., The science of the hand, translated from the French by Ed. Heron-Allen, Ward, Lock, and Bowden, London, 1895.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Cole, Fay-Cooper, Lectures, University of Chicago, 1940-41.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Wiser, Charlotte V., and William H. Wiser, Behindmud walls, Harper, New York, 1930.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Drillis, Rudolf J., Darba riki [Tools], in Lalviesu konversacijas vardnica [Latvian encyclopedia], A. Gulbis, Riga, 1928-29. Vol. 3, p. 4611.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Drillis, Rudolf J., Mcri [Units of measure], in Latvieiu konversacijas vardnica [Latvian encyclopedia], A. Gulbis, Riga, 1928-29. Vol. 14, p. 26691.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Cole, Fay-Cooper, Lectures, University of Chicago, 1940-41.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">IV is a later development.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Osborn, Henry F., Men of the Old Stone Age, their environment, life, and art, 3rd ed., Scribner, New York, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Adam, Leonhard, Primitive art, Harmendsworth Middlesex, Penquin Books, Ltd., rev. ed., 1949.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Boas, Franz, Primitive art, H. Aschehoug, Oslo, 1927. pp. 344, 349.</td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Reininger, W., The hand in art, Ciba Symposia, (4):1323 (1942).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Katz (16) describes the apparatus as a square wooden box, about 60 centimeters long by 8 centimeters deep, and open at the top. Around the top edge a strip of felt is fitted, and over the whole a thick cardboard square is fastened; this side of the box is clamped on with metal clips. The cardboard is strong enough to resist considerable pressure without sagging. On the underside of the cardboard, i.e., inside the box, objects of different shapesfor example, round, elliptical, or heart-shaped objectsare pasted to substantial pieces of lead which appear either as matrices or as patrices, i.e., they are cut into or cut out of lead. The thickness of the plate is chosen according to the degree of difficulty of the percussion task to be presented to the student. In general, the thicker the plate, the easier the task. The plates are so arranged that the figure is located in the middle of ihe underside of the cardboard. Each cardboard is fitted with one figure (if necessary, composed of two parts), so that there are as many cardboards as there are figures required for the test. Students were asked to determine, through percussion alone, the form of figures cut into or out of the lead plates.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Katz, David, On the psychology of the human hand,Bulletin Vol. 32, No. 10, University of Maine Studies, Second Series, No. 14, The vibratory sense and other lectures, The University Press, Orono, 1930. pp. 75-78.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Katz, David, On the psychology of the human hand,Bulletin Vol. 32, No. 10, University of Maine Studies, Second Series, No. 14, The vibratory sense and other lectures, The University Press, Orono, 1930. pp. 75-78.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Clark, W. E. Le Gros, Early forerunners of man; a morphological study of the evolutionary origin of the primates, Bailliere, Tindall, and Cox, London, 1934. pp. 103-140.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Smith, Grafton E., The evolution of man; essays, 2nd ed., Oxford University Press, 1927.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>33.</b> </td><td class="clsTextSmall">Wolff, Charlotte, The human hand, Methuen, London, 1942.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Kahn, Fritz, Man in structure and function, Alfred A. Knopf, New York, 1943. Vol. 1, pp. 1515-16.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Yerkes, Robert M., Chimpanzees; a laboratory colony, Yale University Press, New Haven, 1943.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Yerkes, Robert M., Chimpanzees; a laboratory colony, Yale University Press, New Haven, 1943.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Krogman, Wilton M., The anthropology of the hand, Ciba Symposia, 4(4):1294 (1942). '</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Osborn, Henry F., Men of the Old Stone Age, their environment, life, and art, 3rd ed., Scribner, New York, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Rosenstiel, Annette, The Motu of Papua-New Guinea: a study of successful acculturation, Ph.D. thesis, Columbia University, 1953. Microfilm.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">O'Malley, L. S. S., Indian caste customs, Macmilan, New York, 1932. pp. 21-22.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Cole, Fay-Cooper, Lectures, University of Chicago, 1940-41.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Mead, Margaret, el al., Cultural patterns and technical change, World Federation for Mental Health, UNESCO, Igsel Press, Ltd., Deventer, Holland, 1953.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Hodges, Paul C, An epiphyseal chart, Am. J. Roentgenol., 30(6): 809 (1933).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Krogman, Wilton M., The anthropology of the hand, Ciba Symposia, 4(4):1294 (1942). '</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Hodges, Paul C, An epiphyseal chart, Am. J. Roentgenol., 30(6): 809 (1933).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Boyd, William C, Genetics and the races of man; an introduction to modern physical anthropology, Heath, Boston, 1950. pp. 16-17.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Flory, Charles D., Osseous development in the hand as an index of skeletal development, Society for Research in Child Development, Monographs, Vol. 1, No. 3, National Research Council, 1936.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Ashley-Montagu, Francis M., On the primatethumb, Am. J. Phys. Anthropol., 16(2):291 (1931).</td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Wilder, Harris H., A laboratory manual of anthropometry, Blakiston, Philadelphia, 1920. pp. 84-109.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">Wright, W. B., Tools and the man, George Bell and Sons, Ltd., London, 1939.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Hooton, Earnest A., Up from the ape, Macmillan, New York, 1931.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Hooton, Earnest A., Up from the ape, Macmillan, New York, 1931.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Ashley-Montagu, Francis M., On the primatethumb, Am. J. Phys. Anthropol., 16(2):291 (1931).</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Clark, W. E. Le Gros, Early forerunners of man; a morphological study of the evolutionary origin of the primates, Bailliere, Tindall, and Cox, London, 1934. pp. 103-140.</td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Hooton, Earnest A., Up from the ape, Macmillan, New York, 1931.</td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Krogman, Wilton M., The anthropology of the hand, Ciba Symposia, 4(4):1294 (1942). '</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Krogman, Wilton M., The anthropology of the hand, Ciba Symposia, 4(4):1294 (1942). '</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Romer, Alfred Sherwood, Man and the vertebrates, University of Chicago Press, Chicago, 1933.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Romer, Alfred Sherwood, Man and the vertebrates, University of Chicago Press, Chicago, 1933.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Clark, W. E. Le Gros, Early forerunners of man; a morphological study of the evolutionary origin of the primates, Bailliere, Tindall, and Cox, London, 1934. pp. 103-140.</td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Huxley, J., From fin to fingers: the evolution of man's hand, Illustrated London News, December 1930. pp. 1138-39.</td></tr><tr><td class="clsTextSmall"><b> 26.</b> </td><td class="clsTextSmall">Romer, Alfred Sherwood, Man and the vertebrates, 2nd ed., University of Chicago Press, Chicago, 1937. Especially pp. 27-28, 41-42, 363-70.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Romer, Alfred Sherwood, Man and the vertebrates, 2nd ed., University of Chicago Press, Chicago, 1937. Especially pp. 27-28, 41-42, 363-70.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Jones, Frederic Wood, The principles of anatomy as seen in the hand, 2nd ed., Williams and Wilkins, Baltimore, 1942.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Hooton, Earnest A., Up from the ape, Macmillan, New York, 1931.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Meaning that digit corresponding to the ring finger in man. Among anatomists generally, at least two systems for identifying hand digits are in accepted scientific usage, often interchangeably by the same writer. A common convention is to number the digits from I to V, beginning with the thumb as digit I and ending with the little finger as digit V (Fig. 1). But many competent writers, thinking of the hand as having a thumb and four fingers, label the fingers as first, second, third, and fourth, meaning the index finger, the middle finger, the ring finger, and the little finger or pinkie, respectively. Throughout this issue of Artificial Limbs, it is considered that the normal hand has five digits, one of which is a thumb, the other four being fingers. A digit is here referred to with the understanding that digit I is the thumb Fingers are referred to as being numbered beginning with the index finger as the first finger.-Ed.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Huxley, J., From fin to fingers: the evolution of man's hand, Illustrated London News, December 1930. pp. 1138-39.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Clark, W. E. Le Gros, Early forerunners of man; a morphological study of the evolutionary origin of the primates, Bailliere, Tindall, and Cox, London, 1934. pp. 103-140.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Ashley-Montagu, Francis M., On the primatethumb, Am. J. Phys. Anthropol., 16(2):291 (1931).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Schultz, Adolph H., Characters common to higher primates and characters specific for man, Quart. Rev. Biol., ll(4):425-455; ll(3):259-283, 434-437 (1936).</td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Schultz, Adolph H., The skeleton of the trunk and limbs of higher primates, Human Biol., 2(3):303 (1930).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Krogman, Wilton M., The anthropology of the hand, Ciba Symposia, 4(4):1294 (1942). '</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Ethel J. Alpenfels, D.Sc. </b></td></tr><tr><td class="clsTextSmall"> Professor of Anthropology, New York University, New York City.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1955_02_004/table1.jpg Figure 7 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-12.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Anthropology and Social Significance of the Human Hand Creator An entity primarily responsible for making the resource Ethel J. Alpenfels, D.Sc. * https://staging.drfop.org/files/original/fcf5e10ffc3bff3cb89b517eb63ea5a2.pdf 0b8215ed539490f64e8cf75633dbb151 https://staging.drfop.org/files/original/5df5af90029daa1b7947c5ee33d08bc8.jpg 949b68f099a2ded1f6d45b1a93835af6 https://staging.drfop.org/files/original/e885e588918c3f3ed5fed4be446f6515.jpg 9c9edb182b521a4f3c55907aac2c12c4 https://staging.drfop.org/files/original/8ae9ef1f9e51a1ffe5839ee578fde9ec.jpg 3e30a207b5d92d01eaba842dbb9ce17e https://staging.drfop.org/files/original/dc315daacc177135b612f6d9d75dac9f.jpg 80cbacdea646e05d40116aa522d6538c https://staging.drfop.org/files/original/d6a0e71d869fdf811919200fc92af175.jpg 8af7b934c360f7d8be36455e7d27b56d https://staging.drfop.org/files/original/dcd15d5b2cb3600bbb9a16ceee230a8a.jpg b4bee6b427deadb2481ef102215ea90d https://staging.drfop.org/files/original/fbab7c843102fc1a6a56f0387d6474e7.jpg eecb06f6a79e8bf93b309fd4571aa73e https://staging.drfop.org/files/original/a36d8df923391175c131cc2503b2ad4f.jpg f12d7502edc79a9815ea0effa5a61252 https://staging.drfop.org/files/original/65c39b075e4ed74821b311f1425e07fe.jpg 33cdcc9406cbfccab6083b95a496cd32 https://staging.drfop.org/files/original/7ad63a3c7138be2c4aeadf85e67c3352.jpg 7f4f5ea9d217ef6cb6424c830141f675 https://staging.drfop.org/files/original/2c83de4880188f302b29099589602a5f.jpg c8b1c39cf8255f9580c8abf663fd469e https://staging.drfop.org/files/original/ae139375a47c70c260990878a1f0ae09.jpg 9e529d7b3beb3edc4fb97f0b018934f9 https://staging.drfop.org/files/original/dddd1109e0786871b6890b901ad89193.jpg f0c7d156e4cf6e475c16a3ffd9013a96 https://staging.drfop.org/files/original/43b8b6068ae6129c2d30f9f07c50ffce.jpg a10cd2406b8ed3c261645d2669705d61 https://staging.drfop.org/files/original/6fc43a0cc84ce447ae02214678f3688f.jpg f11a6615dd5d7161c615453a358094c1 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_01_035.pdf Year 1955 Volume 2 Issue 1 Page Number(s) 35 - 60 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_01_035.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_01_035.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Functional Considerations in the Fitting of Above Knee Prostheses</h2> <h5>Charles W. Radcliffe, M.S., M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>In the fitting of any artificial limb, the goal of the prosthetist is simply to restore to the amputee the ability to perform everyday activities in an easy, natural, and comfortable manner. The basic requirements are therefore three in number-comfort, function, and appearance, the latter embracing both cosmetic appearance and appearance in use. Unless a prosthesis is reasonably comfortable, the amputee will be unable to wear it. Unless it performs the necessary functions with reasonable ease and dexterity, the amputee is not apt to find the device very useful. Unless it is reasonably acceptable cosmetically, and unless it can be operated in a natural manner, the limb is likely to be disagreeable both to the wearer and to his friends and associates. But this seemingly simple set of requirements is vastly complicated by the fact that the three are all mutually interrelated. That is to say, the degree of satisfaction attained in one condition is influenced greatly by the situation prevailing with respect to the other two. Cosmetic appearance, for example, is necessarily limited by details of mechanism, and vice versa. No matter how elaborate a prosthetic device may be, it cannot be made to function properly unless it can be manipulated with ease and without discomfort. And conversely, no device can be comfortable in use unless its functional characteristics are properly integrated with the residual biomechanics of the wearer. Any change aimed at improvement in one condition unavoidably affects the other two-sometimes favorably, sometimes unfavorably.</p> <p>In the lower extremity, cosmesis presents no serious problem. Since it is comparatively easy to fashion an artificial leg to an external shape and appearance more or less like that of its normal counterpart, and since in both sexes the lower extremity may be concealed beneath some sort of clothing, the actual cosmetic properties of a lower-extremity prosthesis amount to refinements to be added after all other requirements have been met. More critical in the lower extremity are comfort, function, and appearance in use. The leg prosthesis is in almost constant service, and it must provide both adequate support and a natural-appearing gait with as modest consumption of energy as possible. In fitting an above-knee limb, therefore, correct practices based on established biomechanical principles are mandatory if success is to be had.</p> <p> Because during all activities the suction-socket above-knee leg<a></a> is controlled by the amputee through the use of remaining hip musculature, every effort must be made to ensure that these muscles are used to the fullest possible extent without causing discomfort. The intent here<a style="text-decoration:none;">*</a> is to present the basic concepts that apply to the fitting of all above-knee prostheses, regardless of type of suspension, but which have particular application to the suction-socket above-knee leg. Although the details of fitting must necessarily be modified as dictated by the individual case, the basic features apply to all cases.</p> <h3>The Principles of Above-Knee Alignment</h3> <h4> Mediolateral Stability</h4> <p>When one watches the walk of a typical above-knee amputee, two characteristics of gait often are particularly apparent. First, sidesway, <i>i.e.,</i> lateral movement of the torso from side to side, is exaggerated. Second, the amputee usually walks with his feet farther apart than does a normal individual of similar build. The average individual walks in such a manner that the lateral distance between successive points of heel contact is from 2 to 4 in. In order for the gait of an amputee to appear as normal as possible, therefore, he must walk with a base equally narrow. The amputee with a walking base of from 6 to 12 in. never can achieve a normal gait appearance. If such an amputee is asked why he walks with a wide base, he usually gives as the reason that it is more comfortable or that he feels more secure with his feet farther apart. </p> <p>This circumstance is accounted for by the fact that, as an amputee attempts to walk with his feet closer together, certain functional requirements are placed upon the fit of the socket and upon orientation of the socket in space. In general, these requirements are not fulfilled in a prosthesis aligned for a wide-base gait. If an attempt is made to use such a prosthesis with a gait of narrow base, difficulties arise because certain forces come into play that cannot be accommodated by the stump in a comfortable manner. Although a poorly fitted prosthesis may be reasonably comfortable for many months provided the amputee walks so as to compensate for errors in fit and alignment, the same prosthesis may be very uncomfortable if the wearer attempts to change to a more normal-appearing gait. It is, however, possible to construct for the average above-knee amputee a prosthesis that allows a reasonably normal gait, that is comfortable in all normal activities, and that eliminates common points of stump irritation such as those in the crotch area and near the end of the femoral stump.</p> <h5> <i>The Weight-Bearing Line</i> </h5> <p>One of the most common terms used by the prosthetist in the fitting and alignment of an above-knee prosthesis is the "weight-bearing line." It serves as the guide for many phases of setting up the prosthesis, but its exact position is subject to considerable difference of opinion. One prosthetist may use a weight line drawn from the ischial tuberosity through the center of the ankle joint; a second may select a line falling along the medial side of the foot; and a third may advocate use of a line drawn from the geometric center of the socket at the ischial level to the center of the heel. It is possible to get many other definitions of the weight-bearing line. As a matter of fact, they probably are all equally helpful in the alignment of prostheses. In considering the manner in which the weight-bearing line is used, it becomes apparent immediately that such a line actually serves as a "reference line" or "construction line."</p> <p> In the discussion that follows, the term "weight line" is used to establish a mental picture of a theoretical line in space along which the force of the body weight acts. This concept differs from "weight-bearing line" in that "weight" is due to the gravitational attraction of the earth, whereas "weight-bearing" refers to the transmission of a force through the structural elements of the anatomy and the prosthesis. Although it would appear difficult to establish any one line which accounts for the net effect of the weight of the various and widely separated parts of the anatomy, that can be done in a theoretical, idealized way by defining a point within the body at which the effect of all body weight can be assumed to be concentrated. This point is usually designated as the "center of gravity" of the body as a whole. With all the weight assumed to be concentrated at the center of gravity, the body weight must then always be considered as acting directly downward from this point, as though it were a plumb bob suspended on a string hanging from the center of gravity. The string would represent the body weight line. A short definition of the weight line as shown in Figure <i>A</i> might read as follows: <i>The weight line of the body is a line through the center of gravity along which the body weight can be assumed to act vertically downward at all times.</i> </p> <h5> <i>Variations in Vertical Force</i> </h5> <p>Thus far we have considered only the effect of the body weight acting downward. For either an amputee or a person with two good legs, the body weight must be supported by the contact between foot and floor. For many reasons, the force of contact between foot and floor is very difficult to measure accurately because, for either foot, the contact force is extremely variable over the short time the foot is supporting weight. Shortly after the heel strikes the floor, the leg receives an initial load which, because of the slight reduction in the rate of progression of the body as a whole, quickly increases to a value greater than body weight. During the mid-portion of the stance phase, as the center of gravity of the body is reaching the lowest point in its path of motion, the load on the leg decreases to a value somewhat less than that of body weight. As the body is being elevated and propelled forward into the next step, the load builds up again to a value greater than that of body weight.</p> <h5> <i>Forces in Shear</i> </h5> <p>While all this is occurring, the person also is swaying from side to side and varying in speed slightly as he walks. This condition requires that the contact force must also provide some horizontal frictional forces along the floor, as everyone has realized after slipping on ice or when making a sharp turn. The forces acting on the foot during walking are, then, of two kinds-those acting perpendicular to the floor, which support the body weight, and those acting parallel to the floor, which are necessary to provide resistance to the impetus of the body moving forward, backward, or sideways.</p> <h5> <i>Floor Reaction and Load Line</i> </h5> <p> The total force exerted on the sole of the foot-the combination of all these effects-is known as the "floor reaction." It acts along the same line as does the total force exerted by the amputee on the socket of the prosthesis. The floor-reaction force is the load which the leg, whether normal or prosthetic, must transmit upward from the floor. In general, the line of these forces, known as the "load line" ( <b>Fig. 1</b> <i>B),</i> is not perpendicular to the floor but is directed upward, inward, and forward or backward with an inclination that varies continually during the time either foot is supporting the body. It is very definitely not a line drawn from the center of the hip joint through the knee and ankle joints. A line so drawn should, instead, be designated as the "mechanical axis of the lower extremity." </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 1. Definitions in alignment of the lower-extremity prosthesis. A, The "center of gravity" of the body is a point at which all body weight can be assumed to be concentrated. The effective body weight passes through the center of gravity and acts vertically downward along the "weight line." B, The "load line" is a line along which the force between the foot and the floor acts. In general, it is not perpendicular to the floor surface, since this force has two effects. First, it supports the body weight in a vertical direction, and second, it provides the horizontal forces necessary to cause motion of the body in the forward and medial directions. C, The "support line" is a vertical line along which the effective supporting force exerted between the rim of the socket and the stump of the amputee is assumed to act. In general, the support line does not pass through the center of gravity or through the center of foot pressure.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5> <i>The Support Line</i> </h5> <p> An additional necessary concept is that of the "support line" (<b>Fig. 1</b>). In order to define the support line, it is necessary first to identify a "support point," which may be defined as the center of action of all the vertical supporting forces at the top rim of the socket, including the ischial-bearing force, support in the gluteal region, and support in other weight-bearing areas around the socket rim. Where such a point lies is very difficult to establish, its actual location depending largely upon the individual prosthetist's methods of fitting. In a typical ischial-bearing socket, the support point is probably somewhere anterior and lateral to the point of contact of the socket with the ischial tuberosity. The support line is defined as a vertical or plumb line, passing through the support point, along which the effective supporting force between the socket rim and the stump can be assumed to act. In general, the support line coincides neither with the weight line nor with the load line. </p> <h5> <i>Use of the Hip Abductors</i> </h5> <p> <b>Fig. 2</b> presents a rear view of an above-knee amputee, walking with a narrow base, at an instant during the walking cycle when the full weight is carried on the prosthesis. During the stance phase, the amputee, like the normal individual<a></a>, keeps his pelvis horizontal primarily by action of the hip abductors on the supporting side, as shown by abductor tension in <b>Fig. 1</b>. If, for one reason or another, the hip abductors are unable to exert the necessary force, the pelvis has a tendency to drop toward the unsupported side. When, therefore, the above-knee amputee stands upon his prosthesis, his pelvis may tend to drop toward the normal side owing either to inadequate hip abductors or to inadequate support on the lateral side of the stump-support which is necessary to stabilize the femur and to form a firm base for action of the hip-abductor musculature. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 2. Use of the hill abductors for lateral stabilization of the pelvis.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Dropping of the pelvis toward the normal side generally results in an increase in pressure in the crotch area. It often allows the pubic ramus to come into contact with the medial wall of the socket and .an therefore be extremely uncomfortable. Anticipating this action, the amputee makes appropriate compensation. He maintains his balance either by leaning over the prosthesis, which results in the familiar amputee list, or by walking with a wide base and swaying from side to side. In the alignment of an above-knee prosthesis, then, one of the most important objectives is to construct the prosthesis in such a way that the hip abductors may be used in a normal and comfortable manner to prevent this tendency toward pelvic drop, torso list, or sidesway, and to allow a reasonably normal and comfortable gait.</p> <h5> <i>The Pelvic Lever</i> </h5> <p> As indicated in <b>Fig. 1</b> <i>A</i>, the center of gravity of the body is defined as the point at which the entire weight would have to be concentrated were it to have the same effect on the body as a whole as does the actual weight distribution. On the strength of this concept, the pelvis can be assumed to act as a lever in the stance phase while the amputee supports his weight on the prosthesis <b>Fig. 3</b>. Using the ischium as a supporting pivot or fulcrum, the pelvic lever supports the body weight (which acts vertically downward through the center of gravity and along the weight line) by the balancing action of the hip abductors, the process being similar to normal hip action in which vertical support is through the hip joint. If this lever action is to prevent dropping of the pelvis toward the unsupported side, the tension in the hip abductors must be sufficient to balance the body weight. The abductor muscle force can perform this function only if abduction of the stump is prevented by firm contact against the lateral wall of the socket. Otherwise the muscle action would simply cause abduction of the femoral stump inside the socket. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 3. Lever action of the pelvis in stabilization of the torso.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5> <i>Distribution of Lateral Pressure</i> </h5> <p> The necessary stabilization of the stump against the lateral wall of the socket can be accomplished comfortably if the stabilizing pressure is distributed widely over the lateral side. For a stump of average length, stabilization is achieved by fitting the lateral wall snugly over its entire length. A slight flattening of the lateral wall, with relief near the distal end of the femur, usually ensures that the stabilizing forces are not only comfortable but that they are directed medially as required <b>Fig. 2</b>. If, with the stump improperly supported against the lateral wall, an attempt is made to use the hip abductors for pelvic stabilization, the result may be a gap around the lateral brim and a painful concentration of pressure near the end of the stump. </p> <h5> <i>Considerations of Mechanical Advantage</i> </h5> <p> Two other factors enter into the lateral stabilization of the pelvis by the hip abductors. First, in balancing the body weight on the ischial fulcrum, the tension in the hip abductors has greatest mechanical advantage when the lever arm between the abductor tension and the support point is as long as possible. Support of a substantial portion of the body weight by the ischial seat and of a smaller amount by the gluteal musculature gives the abductor tension sufficient mechanical advantage to balance the body weight with little or no conscious effort on the part of the amputee. The characteristics of this lever system are shown in the schematic diagram of <b>Fig. 3</b> , where the required tension <i>T</i> is reduced by decreasing the distance <i>x</i> and increasing the distance <i>y.</i> </p> <h5> <i>Adduction of the Stump</i> </h5> <p> A second factor in making allowance for normal use of the hip abductors is the degree of stump adduction in the socket. The "rest-length" theory of muscle action<a></a> has shown that the muscles of the body act most efficiently when they are at approximately their normal rest length. To make the action of the hip abductors efficient, the stump, when fitted in the socket, must be adducted in such a manner that the outward movement of the femur within the muscle mass of the stump is anticipated and that the normal pelvic-femoral angle is maintained as closely as possible while the body weight is being supported on the prosthesis. For the average amputee, this requirement can be met in a practical way by aligning the medial wall of the socket perpendicular to the floor, the lateral wall being sloped definitely inward. Although exceptions are necessitated on the basis of stump length, the short stump being aligned with less adduction, every effort should be made to adduct the stump as much as conditions permit. </p> <p> An additional advantage of alignment in adduction becomes apparent immediately. As a result of the accompanying decrease in tension of the adductor musculature, pressure in the crotch area is decreased. As a result of this relaxation, the pressure in the crotch or medial area (<b>Fig. 2</b>) is then predominantly lateral rather than vertical and no longer causes painful pressure on stretched adductor tendons or in the region of the ramus. It should be emphasized here that a socket properly fitted and aligned carries little or no weight on the medial wall. </p> <h5> <i>Foot Position</i> </h5> <p> Alignment of the foot in a medial position, a fundamental consideration if the amputee is to walk without excessive sidesway or torso list, helps to ensure that the body weight will be borne chiefly on the ischial seat. The average amputee walks well with the centerline of the foot located directly below the ischium during the time the prosthesis is supporting the entire body weight. But this rule-of-thumb, illustrated by the reference line shown in <b>Fig. 2</b>, must vary depending upon the capacity of the amputee to use his hip abductors. If an amputee with a very short stump attempts to use it for lateral stabilization, he cannot tolerate the increased and usually localized pressure resulting from the short stump length and the concentration of force in a small area. He must, therefore, walk with more limited use of his hip abductors, and compensation is effected by leaning over the prosthesis to shift the weight line closer to the support line and by walking with a wider base, an expedient which increases lateral stability but leads to excessive sidesway. Because of these factors, and because of the probability in such cases of some degree of abduction contracture, the amputee with a very short stump should have his prosthesis aligned to accommodate a gait of wider base. </p> <h5> <i>Recapitulation</i> </h5> <p>In summary, mediolateral stabilization of the pelvis accompanied by a decrease in the amount of sidesway and list can be achieved by alignment of the foot in a medial position relative to the socket, by fitting the stump in an adducted position where possible, and by providing firm support for the stump against the lateral wall of the socket to allow efficient use of the remaining abductor musculature of the hip.</p> <h4>Knee Control</h4> <h5> <i>Involuntary Control</i> </h5> <p> Generally, the tendency of the articulated knee joint of the above-knee prosthesis to collapse under load is controlled involuntarily through alignment or by mechanical devices which lock or restrain flexion while the body weight is being transferred through the prosthesis.<a></a> Although involuntary control is desirable as an aid in achieving a smooth and natural-appearing gait, a proper balance must be obtained between the amount of involuntary and voluntary control of knee stability, taking into account the amputee's coordination and age and the condition of his stump. </p> <p>Involuntary control of knee stability during weight-bearing is made possible by so placing the knee axis that it is at all times posterior to the load line of the prosthesis<a></a>. A prosthesis with the socket placed well forward on the knee block or aligned in hyperextension and with the knee joint located posterior to the ankle joint is said to have a high degree of "alignment stability." That is to say, under load the knee joint is forced to extend until the extension stop makes contact and prevents further motion. This expedient often is necessary for amputees who have a fear of falling or when it is required because of age, insufficient stump power, excessive weight, or the prevailing terrain. But it has the disadvantage of making the prosthetic knee hard to flex under even a light load and thus results in poor gait and difficulty in negotiating stairs and slopes. </p> <h5> <i>Voluntary Control</i> </h5> <p> An attempt should therefore always be made to minimize the amount of involuntary alignment stability and to provide for a maximum of voluntary knee control by stump action because this type of functioning results in the smoothest and most effortless gait possible. The average above-knee amputee has a reasonable amount of strength remaining in his hip flexors and extensors and is able to extend and flex his stump throughout an appreciable range of motion, and it is important that the fullest use be made of this musculature in voluntary control of knee stability. That this control may be exercised in the most efficient manner possible, the stump should never approach the limits of its motion as the amputee performs normal activities. If, for example, the stump is able to extend a maximum of 20 deg. to the rear, then at push-off any forced extension in excess of the 20 deg. results in a forward rotation of the pelvis. To compensate for such a forward pelvic rotation, the amputee must arch his back, an expedient which leads to the development of lordosis. Alignment of the socket in a position of initial flexion, as shown in <b>Fig. 4</b>, eliminates much of this difficulty. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 4. Influence of alignment on control of knee stability, socket aligned in initial flexion to avoid exces. sive pelvic rotation.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5> <i>Initial Flexion</i> </h5> <p>When the socket is aligned with initial flexion, several other advantages become apparent. Since the length of the hip extensors is increased by the additional degree of hip flexion, the amputee has greater control of knee stability during the entire stance phase of the walking cycle. Since the extensor muscles are thus elongated slightly, they are able to develop the required tension easily. With much less conscious effort on the part of the amputee, therefore, the stump is able to exert the force necessary to keep the prosthetic knee back against its extension stop.</p> <p> Again, in an amputee with overdeveloped hamstring musculature there often is a tendency, as the stump extends at push-off, for the muscles to force the tuberosity of the ischium off the ischial seat, thereby causing pressure on the hamstring muscle and attachments and against the anterior brim of the socket. Initial flexion of the socket reduces this tendency and allows a portion of the body weight to be borne comfortably upon the hamstring attachments.<a style="text-decoration:none;">*</a> </p> <p>If the same degree of alignment stability is to be maintained, initial flexion of the socket must be accompanied by a shifting of the socket anterior to the knee axis. Merely changing the extension stop to decrease knee extension never can achieve the desired end-results. But less alignment stability is necessary under these conditions because of the increased voluntary control of the knee. Anterior positioning of the socket relative to the knee axis allows the prosthetic knee to be flexed a great deal more easily as weight is transferred from the prosthesis to the normal leg at the end of the stance phase. The result is a smoother gait. Although increased use of the hip extensors owing to their greater working length produces some decrease in the power available in the hip flexors, the loss is not serious since during ordinary activities the hip flexors never approach the limit of their range of flexion and since the force requirements are small as compared with those of the hip extensors.</p> <h5> <i>Ankle Position and Toe Break</i> </h5> <p> Another important factor in achieving the proper amount of knee stability is the fore-aft position of the ankle joint relative to the knee joint. For the active above-knee amputee, it usually is desirable to have the ankle joint directly below or slightly posterior to the knee joint, as shown in <b>Fig. 4</b>. Such an arrangement has several effects. First, as the foot is moved to the rear, the distance out to the toe break decreases to give the foot more of a "rocker" action and to allow the knee to flex easily at the end of the stance phase. Second, the major portion of the weight can be carried on the ball of the foot while standing. And third, the amount of toe clearance during walking is greater for a given angle of knee flexion. To move the ankle joint too far to the rear, however, results in instability at heel contact and excessive shortening of the stride. </p> <p> Many of these advantages can be achieved by use of a double toe break <i>(i.e.,</i> a flexible forefoot), which also gives the foot more of a rocker action and decreases the amount of vaulting over the prosthetic foot. But too much flexibility or too short a distance from ankle to toe break causes the leg to feel too short at the time of push-off. </p> <h3>Dynamic Alignment</h3> <p>For the major part of the time that the amputee is supporting himself on the prosthesis during the stance phase, the motions are relatively smooth, and the forces act on the prosthesis in essentially the same way as if the amputee were standing still with all weight carried on the artificial leg. During the swing phase, however, and during the times of transition from stance to swing and from swing to stance, the behavior of the prosthesis is influenced largely by dynamic forces varying rapidly with time. It is often relatively easy to fit an amputee so that he is comfortable in the stance phase, but in many cases it is more difficult to construct the prosthesis so that the amputee is able to walk with a smooth, natural-appearing, effortless swing-through. The first requirement for a smooth swing phase is a smooth transition from stance to swing, since, if the prosthesis is to swing properly, it must be given a good start.</p> <h5> <i>Knee Stability and Toe Break</i> </h5> <p>Of particular importance during these transition periods are knee stability, as affected by alignment and by the stiffness of dorsi-fiexion and plantar flexion at the ankle, and the combined effect of toe-out and orientation of the toe break in the foot. For security, the knee axis should be positioned far enough behind the hip-ankle line so that the amputee is conscious of a stable knee while standing. The amount of security desired depends upon the particular amputee. If, as the amputee attempts to walk, the knee feels insecure, the dorsiflexion position and stiffness in the ankle should be investigated as a possible additional cause of knee instability.</p> <p>In general, placing a stiff dorsiflexion bumper in the ankle and having the foot plantar-flexed in the neutral position, close to the point where the amputee has the sensation of "walking over a hill," produces the most desirable knee stability and allows smooth flexion of the knee at the start of the swing phase. The amount of toe-out usually is adjusted to the individual amputee. In all cases, however, the toe break should be at right angles to the line of progression to prevent insecurity resulting from the rapid shifting of the center of pressure during push-off.</p> <h5> <i>Whip in the Swing Phase</i> </h5> <p> One of the more obvious indications of poor dynamic alignment is the so-called "whip" of the prosthesis during the swing-through (<b>Fig. 5</b>). This lateral movement of the knee accompanied by medial movement of the foot, or vice versa, usually is caused by an incorrect amount of adduction for the particular socket being fitted, an improper angle of the knee axis with respect to the frontal plane, the natural tendency of the femoral stump to twist inward as it is brought forward, or a combination of these factors. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 5. Common indications of incorrect alignment. A, Whip of the prosthesis during the swing phase. B, Mediolateral instability. C, Rotation at heel contact. For specific causes of these difficulties, see Radcliffe (10).</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>An above-knee prosthesis often is "knocked" at the knee to position the foot laterally for greater stability while standing. Sufficient two-leg standing stability thus can be attained, but a stable, narrow-base gait is not then possible. The tendency of the prosthesis to whip also is aggravated because, as it swings like a pendulum, the leg has a natural tendency to swerve medially after toe-off and then to swerve out again just before heel contact. A prosthesis having the foot aligned medially for a narrow base during the stance phase need only move forward in a straight line from toe-off to heel contact.</p> <h5> <i>Rotation of Knee Axis</i> </h5> <p> Studies of normal human locomotion<a></a> show that the femur rotates an average of 3 to 4 deg. medially as the hip is flexed to bring the knee forward. Medial rotation of the femur causes a lateral displacement of the foot, as can be verified easily by observation of a person standing and flexing the hip while the shank hangs vertically. Accordingly, the knee axis in an above-knee prosthesis usually is rotated laterally to compensate for the tendency of the femur to rotate medially as the hip is flexed.<a style="text-decoration:none;">*</a> When the prosthetic knee axis is aligned in a position laterally rotated with respect to the socket, the foot moves somewhat medially with knee flexion, thus compensating for lateral movement of the foot caused by the medial rotation of the socket during the swing phase and allowing the foot to travel in a straight path. </p> <h5> <i>Ankle Stiffness</i> </h5> <p>The stiffness of plantar flexion at the ankle determines, to a large degree, the stability of the knee at heel contact. A stiff ankle does not allow the foot to rotate forward into the stable flat position and thus tends to cause the knee to buckle forward as the weight is transferred to the prosthesis. An ankle joint with insufficient plantar-flexion stiffness, however, allows the foot to slap at heel contact. A proper balance between these two effects must therefore be attained for the individual amputee. Proper swing-through is achieved by proper dynamic alignment, which, in turn, is effected by a comfortable, stable, and functional prosthesis in the stance phase; a smooth transition from stance to swing phase; proper ankle stiffness; and adjustment of the knee axis in lateral rotation to compensate for medial rotation of the stump during hip flexion.</p> <h4>Socket Shape and Orientation</h4> <p>Considered thus far are the means by which the amputee can make most efficient use of the remaining hip musculature to control body movements and to control the prosthetic knee during the stance and swing phases. There are, however, many functional details of socket shape and fit which make it possible for the amputee to derive these benefits comfortably.</p> <h5> <i>The Lateral Wall</i> </h5> <p>As already indicated, for the amputee having sufficient stump length and power, sidesway and leaning over the prosthesis during the stance phase can be eliminated almost entirely by making provision in the socket for full use of the remaining abductor muscles of the hip, primarily the gluteus medius. This can be achieved in two ways. First, the stump is adducted in the socket so that the lateral wall is sloped downward and inward, the medial wall remaining essentially vertical. Second, a slight flattening of the lateral wall, and undercutting for relief of pressure points where necessary, ensures a comfortable distribution of the pressure directed medially against the stump. The hip abductors then can develop tension as needed because the excursion of the femur is blocked comfortably against the lateral wall of the socket. If, after the fit of the lateral wall is considered satisfactory, the socket is too tight, relief should be provided along the medial wall of the socket to avoid disturbing the fit required to block excursion of the femur.</p> <h5> <i>The Anterior Wall</i> </h5> <p>The lateral pressures, acting with the horizontal counterpressures in the upper portion of the medial wall, tend to maintain the ischium on its seat medially. To hold the ischium in place still more firmly, it is necessary to provide stabilization at the front of the socket. Accordingly, the anterior wall of the socket should fit the stump firmly in the area of Scarpa's triangle, and a very accurate measurement should be made of the distance from the ischial tuberosity to the tendon of the adductor longus so that the anteromedial apex may be fitted snugly around the adductor tendons. The socket brim should be rounded and fitted high on the anterior side. If fitted properly, the anterior brim usually can be brought up to the level of the inguinal crease without producing discomfort when the wearer is seated. The actual height of the anterior brim varies with the individual and is limited by contact with bony prominences. It usually extends from 2 to 2-1/2 in. higher than the ischial seat, but it should extend at least high enough so that the brim will press into the abdominal muscles rather than pinch a roll of flesh near the top of the stump. Distributed over the upper portion of the entire anterior wall of the socket, such anterior counter-pressure easily can prevent the ischium from sliding into the socket and can prevent the discomfort that would result in the crotch area.</p> <h5> <i>The Adductor Region</i> </h5> <p>Incorporation of the proper distance from the adductor tendons to the ischial tuberosity, combined with a well-fitted, high, anterior brim, usually eliminates entirely any unwanted pressure in the crotch area. Some lateral counterstabilization by pressure in the crotch area is unavoidable, but it should be predominantly by lateral rather than by vertical pressure, and it can be tolerated comfortably if distributed over the widest possible area. Flattening the medial wall of the socket is one means of ensuring a comfortable distribution of pressure in the adductor region.</p> <h5> <i>The Anteroposterior Dimension</i> </h5> <p>Weight-bearing in the gluteal region makes it possible to reduce the size of the ischial seat. If the anteroposterior dimension is shortened, the socket may be widened in the mediolateral dimension, a feature having several advantages. First, it allows a greater area for gluteal weight-bearing on the posterior rim of the socket. Second, the ischium is moved laterally, allowing the ramus to be carried within the brim of the socket and thus easing a major source of irritation. Finally, because the ischium bears no weight in the posteromedial apex, there is less tendency for crowding of the adductor and hamstring musculature. Relaxation in this area owing to stump adduction also helps to relieve uncomfortable vertical pressures.</p> <h5> <i>Shape at Ischial Level</i> </h5> <p> As a result of these functional requirements, the socket shape shown in <b>Fig. 6</b> has evolved. When coupled with the proper alignment, it has proved to be extremely beneficial to the average amputee. As with any method of fitting, variations in shape must be made in accordance with the muscular development and condition of the individual stump. The influence of muscular development at the ischial level is shown in (<b>Fig. 7</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 6. Anatomical features of an above-knee stump in weight-bearing, shown in cross section 1/2 in. below schial level.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 7. Influence of stump muscular development on socket shape at ischial level.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Entrances of the adductor tendons in the anteromedial apex, shown as <i>A</i> in <b>Fig. 6</b>, can be made more comfortable by a slight flaring of the socket brim in this region. Flaring of the socket brim in the hamstring area <i>B</i> has no function while the amputee is walking, but it contributes remarkably to his comfort while sitting. Many amputees experience a burning sensation while sitting because the hamstring attachments attempt to stretch over an ischial seat located high or medially, especially when the ischial seat has been placed diagonally across the posteromedial apex. The socket shape shown in <b>Fig. 6</b>, however, allows the ischial seat to be placed laterally to provide relief in the hamstring region and does not disturb the functioning of the limb during walking. </p> <h3>Construction of the Socket</h3> <h4>Stump Examination and Measurements</h4> <p>Before construction of an above-knee prosthesis is started, it is essential that a very careful evaluation be made of the amputee and his stump. A prosthesis may thus be planned and constructed to take full advantage of the individual patient's capabilities. Of particular importance is a thorough examination of the stump with regard to its functional characteristics. Answers to the following questions are helpful in planning the prosthesis, and they should be included in the examination data:</p> <ol> <li> What degree of stump flexion contracture is present? </li><li> What degree of stump abduction contracture is present? </li><li> Is the stump musculature soft, average, or hard? </li><li> Is the hamstring group soft, average, hard, or prominent under tension? </li><li> Is the gluteal group soft, average, hard, or prominent with stump extension? </li><li> Is the stump contour along the lateral side convex, concave, or essentially flat? </li><li> Is the rectus femoris muscle prominent with stump flexion? </li><li> Is the adductor longus soft, average, or hard? </li><li> Is the ischium toughened, pressure sensitive, padded with muscle, or prominent? </li><li> Has the amputee been accustomed to ischial-bearing? </li><li> What is the amount and location of redundant tissue? </li><li> What is the extent, location, and adherence of scars? </li><li> Are there areas of prior irritation as shown by blisters, boils, pimples, scars, darkened skin areas, and so forth? </li><li> Are there areas which are sensitive because of bone spurs or other prominences? </li><li> Is there any prior history of edema? </li></ol> <p> In addition to this general information about the condition of the stump, which can be recorded on a form such as <b>Fig. 8</b> <i>8A,</i> the series of measurements indicated in <b>Fig. 8</b> <i>8B</i> should be recorded carefully. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 8A. Form used at the University of California for recording stump characteristics and measurements in above-knee fitting.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Planning the Socket Shape</h4> <p>After the information gathered during the examination is recorded, the limbfitter is ready to begin planning the prosthesis, a phase essential to proper fit. The socket contours and the over-all alignment to be incorporated into any lower-extremity prosthesis depend upon the interrelation of many factors. First, the amputee's general physical condition must be determined. Will the amputee be an active walker? Will ease of walking be more important than knee security, or vice versa? Has the amputee developed gait habits that require corrective training? Second, the stump must be evaluated on a functional basis. In terms of its potential usefulness in control of the prosthesis and of body movements, is it classed as short, medium, or long? Is there a normal range of motion in all directions? Are there any sensitive areas that restrict stump function? The answers to these questions affect the alignment of the prosthesis as well as the fit of the socket.</p> <p> It is important to plan for alignment before the socket contours are considered because the orientation of the socket on the stump and the alignment of the socket on the prosthesis may affect considerably the method of fitting the socket. Shown in <b>Fig. 8B</b> are some general features of alignment based upon the functional capacity of the stump-short, medium, and long. There are exceptions, of course, and these illustrations should serve only as a guide. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Figure 8B.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> After the general type of alignment has been decided upon, the necessary features can be incorporated into the orientation of the socket on the stump, a matter requiring a decision regarding the approximate amount of initial flexion and adduction to be anticipated in the final alignment. The socket contours are determined by reference to the information on stump muscle development recorded during the examination. <b>Fig. 7</b> shows a typical socket shape for an amputee of average musculature and indicates the variations possible with different types of stump muscle development. Undersize patterns for use in roughing out the socket contours are shown actual size in <b>Fig. 9</b> and <b>Fig. 10</b>. The dimensions shown along the medial side of the patterns are typical measurements of the distance from the ischial tuberosity to the anterior aspect of the adductor longus tendon. The perimeter measurements shown correspond to actual stump dimensions. But these patterns may require modification to provide for individual stump characteristics, an example of such a pattern modification being shown in <b>Fig. 11</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 9. Variations in alignment to accommodate stumps of different functional lengths. With the short stump, the slow or hesitant walker, having limited use of the hip abductors and extensors, needs considerable alignment stability. The moderate walker, with stump of medium functional length, has average use of the hip abductors and extensors. Alignment for the long stump is for an active walker having good use of the hip abductors and extensors.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 10. Undersize socket patterns (shown actual size) for stump with soft or average musculature,</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 11. Undersize socket patterns (shown actual size) for stump with firm musculature.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Materials</h4> <p>The primary features required of a material to be used in making a suction socket are ease in forming to the proper shape, adaptability to a surface finish which is nonirritating and easy to keep clean, and ease in making alterations as required by changes in the stump. Wood and plastic laminates have, so far, proved to be the most satisfactory. But major changes in the size of the stump often take place during the first several months of wear. Hence, wood is recommended for the first socket because it is relatively simple to shape and allows alterations to be made as required. After the stump size is stabilized, a socket can be made of plastic laminates, which seem better than wood because of their flexibility, their ability to stand cleansing with soap and hot water, and their greater resistance to the action of perspiration.</p> <h4>Shaping the Wooden Socket</h4> <p> The three stages in shaping a typical socket are shown in <b>Fig. 12</b>. In the first, the posteromedial shelf is cut after laying out the socket pattern on the top of the socket block. The ischiogluteal shelf is cut in such a way as to be horizontal when the socket is oriented vertically in space. For the average socket, the medial wall is parallel to the vertical reference line ( <b>Fig. 2</b> ), and therefore the horizontal ischiogluteal shelf is cut at right angles to the medial wall of the socket. After the ischiogluteal shelf is cut, the missing portion of the socket pattern line is transferred down to the ischial level. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 12. Modification of socket shape to accommodate individual stump characteristics.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The second construction stage shows the roughed-out socket, where considerable extra wood has been left above the ischial level to allow for the protrusion and flaring of the anterior brim in this area. The finished socket is shown in the third stage with all areas of the socket brim flared and rounded to prevent irritation of the stump, especially important in the anteromedial apex where the adductor longus tendon enters the socket.</p> <p> <b>Fig. 6</b> indicates the principle muscle groups and other anatomical features considered in preparing the patterns used as a guide in the preliminary layout of the socket outline. Because of the atrophy of certain muscle groups in the above-knee stump, and because the cross section shows the stump in the weight-bearing condition, the shape differs slightly from that of the normal. When the stump is bearing weight, it is necessarily compressed slightly in areas of relatively soft tissue which support load, such as the gluteal channel. </p> <h5> <i>The Lateral Wall</i> </h5> <p>The lateral side is always higher than the level of the ischial seat. In most cases, it is possible to extend it over the trochanter. To do so is especially important when the slump is short and when the height of the socket in this region may be required to maintain suction. If the muscular development requires it, the lateral side of the socket is, in some cases, undercut above the ischial level. Examination of the amputee determines the amount of undercut required, and, if it is necessary, it should be done with caution. The lateral wall should taper in acutely below the ischial level to provide adduction and lateral support for the femur upon weight-bearing above the distal end. Because the femur has been established as the body stabilizer during the stance phase, an undercut below the ischial level may distribute the pressure unevenly and thus allow most of the pressure to be taken at the top of the socket and near the distal end of the stump. The lateral wall should be shaped to fit the stump accurately and should, if necessary, be flattened to distribute the lateral-support pressure over a large area so that it can be tolerated comfortably.</p> <h5> <i>The Medial Wall</i> </h5> <p> The length of the crotch-line area that receives the adductor longus, gracilis, and adductor magnus muscles should be determined accurately by skeletal measurements. As indicated in <b>Fig. 11</b>, the measurement from the anterior aspect of the adductor longus tendon to the weight-bearing portion of the ischial tuberosity, less about half an inch, gives the approximate length of the medial side of the socket. In general, the upper third of the medial wall is flattened, and the superior brim is flared to prevent skin irritation. </p> <p>In almost every case, the crotch-line height varies with respect to the level of the ischial seat, but it should always be as high as is tolerable. In the typical socket, the crotch area is from 1/8 to 1/4 in. lower than the ischial seat. A pelvic tilt lowers the ramus of the ischium and may require a lowering of the medial side of the socket. In a properly fitted ischiogluteal weight-bearing socket, little or no weight should be borne on the medial side. From the ramus to the anteromedial apex, the medial brim can be raised as governed by comfort. If a medial adductor roll is present, the socket is enlarged slightly (never lowered) on the medial side to accommodate the excess tissue, which then is pulled into the socket and eventually diminishes.</p> <h5> <i>The Anteromedial Apex</i> </h5> <p> The socket shape at the anteromedial apex (<b>Fig. 6</b>) should conform to the contour of the adductor longus and gracilis muscles. The shape varies in each case, however, because these muscles form a cordlike tendon which must be fitted accurately. Tightness in this region, a common source of irritation in suction sockets, usually is caused by excessive length of the medial side of the socket. This condition allows the ischium to slide forward into the socket and to wedge the stump into the anteromedial apex. If tightness in the anteromedial apex persists, it is apt to be due to inadequate support of the stump across the anterior brim and down the anterior aspect of the adductor group. </p> <h5> <i>The Anterior Wall</i> </h5> <p>The primary function of the anterior brim of the socket is to maintain the ischium in place on the ischial seat so that ischial weight-bearing causes no discomfort. In many cases of amputees who are unable to tolerate ischial weight-bearing, the trouble can be traced to improper contact between ischium and socket. Ischial bearing on the edge of a flat ischial seat is especially uncomfortable. To maintain the ischium in place properly, considerable counterpressure from the front of the socket is required. Since, by and large, the portion of the stump in contact with the region of the anterior brim is soft tissue, some compression of the stump is necessary. This is accomplished by a flattening and inward protrusion of the anterior brim in the area of Scarpa's triangle.</p> <p>The upper portion of the anterior brim is fitted 2 to 2-1/2 in. higher than the ischial seat and with a generous flare along the superior brim. When the socket is fitted with such a "high front," the anterior brim can hold the ischium in place comfortably. The high front does not interfere with sitting or with the amputee's ability to bend over far enough to tie his shoes. As the stump is flexed, the higher brim of the socket is accommodated by the abdominal musculature and does not pinch a roll of flesh on the upper portion of the thigh. The brim should be lowered only as necessary to prevent contact with bony prominences such as the anterosuperior spine. A channel should be provided below the brim for the rectus femoris muscle, which usually becomes prominent with stump flexion.</p> <h5> <i>The Posterior Wall</i> </h5> <p>The back of an ischial-bearing socket deserves particular attention. Channelization for the gluteus maximus muscle depends on the individual, but, in most cases where there has been little atrophy or distortion, this region of the socket should be kept on the same level as the ischial seat with a gradual enlargement in the posterolateral apex. The gluteus muscle should carry a considerable amount of body weight on a flared socket brim.</p> <p>Relief for the adductor muscles or the crotch line often can be made by relieving the gluteus maximus. Too tight a fit over the gluteus maximus can cause crowding of the adductor muscles in the crotch section. If the space for the gluteus muscle is lowered and widened, the ischial tuberosity can be moved posteriorly and laterally on the ischial seat of the socket. Lowering this section, however, increases pressure on the ischial tuberosity and should, therefore, be avoided. Should additional room be needed within the socket, the lateral side of the gluteal region can be made wider. The gluteal area should be widened instead of cut deeper posteriorly because a deeper section forms a hump or radius on which the leg rotates during sitting and thus causes a burning sensation of the skin over the ischial tuberosity.</p> <p>The outside shape of the socket in the posterior region is important to sitting comfort, but no attempt should be made to complete its shaping until the inside has been made comfortable and until the leg has been aligned properly and tested by walking. After these things are done, the back then is flattened for comfort and alignment while sitting.</p> <h5> <i>The Ischial Seat</i> </h5> <p>The ischial seat cannot be overemphasized. It should be located accurately under the ischial tuberosity, and, in the determination of its location, individual variations in anatomy must be taken into account. The seat should be adequate but not so wide as to cause discomfort while sitting. Slipping of the ischial tuberosity either to the inside or to the outside of the seat, conditions which create a great deal of discomfort, can be prevented by shaping the bearing surface in such a way that the seat slopes slightly toward the inside of the socket to render it more comfortable. Sloping increases the radius of the edge of the ischial seat and lessens the burning sensation of the skin in this region.</p> <p>If the ischial seat is too prominent, or if the ischium rides on the edge of the seat, a jabbing sensation or a marked increase in pressure is felt near the end of the stance phase. Lowering the ischial seat allows more weight to be distributed to the gluteal region and, if the ischial tuberosity is located properly on the seat, results in less discomfort and a shorter break-in period.</p> <p>Amputees with highly developed stump muscles may not require a well-defined ischial seat. In some cases, the muscles may push the ischial seat away from the tuberosity of the ischium and cause the weight to be carried by the muscles around the top of the socket. Such a condition is not objectionable, provided that the socket is designed with proper modification of the ischial seat. Indeed, such a design may be necessary in unusual cases, as for example those with end-bearing stumps.</p> <h4>Special Considerations in the Suction Socket</h4> <h5> <i>Tightness of Fit</i> </h5> <p> In the case of the suction socket, better results are obtained by having proper contours than by having a tight fit .<a></a> If, in the course of donning the leg, much difficulty is encountered in removing the sock, the fit is too tight. The superior brim of the socket should fit the contour of the stump while the muscles are tensed, and the fit should be so accurate that the socket can be suspended for short periods by skin friction without the aid of negative pressure <i>(i.e.,</i> without a valve). </p> <h5> <i>Free Space Below the Stump End</i> </h5> <p>The volume of unoccupied space at the lower end of the suction socket is not critical in obtaining sufficient suction. In most cases, it is convenient to have approximately 2 in. of space below the end of the stump to provide room for installation of the valve and for elongation of the soft tissue. In general, the smaller the volume in the end of the socket the less the excursion, but in itself the amount of free volume has no significant effect on the magnitude of the negative pressure.</p> <h5> <i>End Bearing</i> </h5> <p>If it can be tolerated, end-bearing is recommended because it relieves the load on the ischium. Felt or foam-rubber padding placed in the bottom of the socket permits comfortable end-bearing, the thickness of the padding governing the amount of weight carried on the end of the stump. Although little free space remains in the socket, adequate suction and control are not affected. For example, Gritti-Stokes amputations, which are principally end-bearing, have been fitted successfully.</p> <h5> <i>Inside Finish</i> </h5> <p>No single recommendation is made regarding adequate nonirritating finishes. Industrial and perspiration-resistant lacquers common to the limb industry are being used routinely. Some subjects have reported slipping of the socket because of perspiration. In some cases, perspiration also has caused the lacquer finish to deteriorate and to produce a roughness resulting in skin irritation. In general, however, these industrial lacquers have proved satisfactory when applied according to manufacturers' specifications. In cases of excessive perspiration, the socket may have to be refinished every few months. Whenever perspiration creates a severe problem, the amputee should be referred to a dermatologist for possible treatment.</p> <h5> <i>Bottom Seal</i> </h5> <p>The bottom of the socket should be sealed with a piece of hard wood 1/8 in. thick or more, cut so that the surface goes along the grain, and sealed with a waterproof glue. The bottom may be given additional protection by applying a thin coating of one of the thermosetting plastics common to the limb industry.</p> <h5> <i>Control of Negative Pressure</i> </h5> <p>Several different types of valves have been used in suction sockets with good results. A simple type of plug valve with a manual suction release is satisfactory. Automatic expulsion valves permit some change of air in the socket, a beneficial feature during hot weather and at times when the amputee perspires. They have proved successful in all cases and are now in general use.</p> <p>The valve opening should be positioned for ease in removing the fitting sock when the leg is donned and for convenience in operating the manual control, and it should be placed where the distal end of the stump is least likely to touch the inner face of the valve. The optimum location is toward the front on the medial side below the stump end.</p> <p> The magnitude of the negative pressure or suction required to hold a suction socket in place is only slightly greater than the value given by dividing the weight of the prosthesis by the cross-sectional area of the stump near the distal end-in most cases about 1-1/2 lb. per sq. in. With the additional support given by contracting the stump muscles during each step, a negative pressure of 1-1/2 lb- Per sq. in. is sufficient. Some amputees prefer somewhat greater suction, with its accompanying feeling of security, but excessive suction may cause edema. A negative pressure greater than 1-1/2 lb. per sq. in. indicates the presence of forces tending to pull or push the leg off the stump. This action may occur when the stump muscles are contracted, or it may be caused by an improper fit resulting in constriction of the muscles. Use of a gauge for measuring the maximum negative pressure at the time of the rough and the final fittings serves as a check on the quality of fit and is essential to good and consistent results. </p> <p> Accurate records should be made of the variations in pressure inside the suction socket during normal walking. With the automatic expulsion valve now in general use, these records should show a small positive pressure during weight-bearing and a negative pressure when the leg is in the swing phase. ( <b>Fig. 13</b> ) is a record of the pressure variations in a suction socket during two complete walking steps, the valve used during this test permitting automatic exhaust starting at a positive pressure of 1/2 lb. per sq. in.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 13. Three stages in the construction of a wooden socket. A, Block cut to form posteromedial shelf. B, Roughed-out socket. C, Completed socket with inside finished and rawhide covering on outside.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The stiffness of the spring in the valve has, in itself, no direct effect on the magnitude of the maximum negative pressure. It does, however, allow a greater or lesser amount of air to be expelled with each step and thereby affects the amount of positive pressure developed during weight-bearing. Fairly high positive pressure within the socket during the stance phase generally is found desirable because it increases the pavex action of the socket on the stump, with consequent benefit to the circulation. High positive pressures help to control edema and to give the amputee a sense of "walking on air." But, as already mentioned, too great a positive pressure in the stance phase may tend to push the leg off or to increase the piston action of the stump in the socket. Springs permitting expulsion at a positive pressure of 1/2 <i>, 1-1/2</i> or 2 lb. per sq. in. now are commercially available. The choice should be based upon individual circumstances. Some leakage generally occurs either in the valve or between the socket wall and the stump. A regulated amount of leakage is, however, desirable because it relieves the suction during periods of inactivity. If the leak rate is too great, the leg may fall off or the piston action may be excessive and cause discomfort. If the leak rate is too small, however, edema may result. A good test for leak rate is to measure the time required for the negative pressure to drop to half its initial value while the prosthesis is suspended on the relaxed stump. If the time is 50 to 80 sec, the leak rate is satisfactory, but if it is greater than 100 sec, the manual release should be used during periods of inactivity. </p> <p>Conclusion In summary, then, it may be restated that, in the construction of an above-knee artificial leg, the objective of the prosthetist is to provide the wearer with optimum security in standing and walking, the best possible walking pattern, a minimum requirement for expenditure of energy in usual activities, and a generally comfortable leg that can be used more or less continuously without injuring the stump and without causing undesirable postural deformities. The above-knee prosthesis is called upon to replace as nearly as possible the functions of the normal leg, but it must do so under the influence of a residual motor mechanism deficient in power and sensory control. The necessary features are therefore to be obtained only by observance of certain functional rules established on the basis of anatomical, physiological, and mechanical considerations.</p> <p>Of first importance is that the prosthetist well understand the mutual interdependence of the details of alignment of the various components and of the fit and orientation of the socket. Since, unlike the normal limb, support in the above-knee prosthesis is not through the shaft of the femur but through some other axis, due cognizance needs to be taken of the new set of musculomechanical relationships and of the influence of these relationships on the static and dynamic characteristics of the artificial replacement. When proper compensation for these factors is made by the limbfitter, undesirable compensation by the amputee is avoided, while the requirements of comfort, function, and acceptable gait are satisfied. In no other way can so much satisfaction be afforded the above knee amputee.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 14. Typical pressure variation in an above-knee suction socket during level walking. Body weight: 145 lbs.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li> <p>Buchthal, Fritz, and E. Kaiser, Optimum mechanical conditions for work of skeletal muscle, Acta Psychiat. et Neurol., 24:333 (1949).</p> </li> <li> <p>Eberhart, Howard D., Verne T. Inman, and Boris Bresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</p> </li> <li> <p>Eberhart, Howard D., and Jim C. McKennon, Suction-socket suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</p> </li> <li> <p>Haddan, Chester C, and Atha Thomas, Status of the above-knee suction socket in the United Stales, Artificial Limbs, May 1954. p. 29.</p> </li> <li> <p>Inman, V. T., Functional aspects of the abductor muscles of the hip, J. Bone and Joint Surg., 29:607 (1947).</p> </li> <li> <p>Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</p> </li> <li> <p>Libet, B., H. J. Ralston, and B. Feinstein, Effect of stretch on action potentials in muscle, Biol. Bull., 101:194 (1951).</p> </li> <li> <p>Radcliffe, C. W., Use of the adjustable knee and alignment jig for the alignment of above knee prostheses, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, August 1951.</p> </li> <li> <p>Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954. p. 23ff.</p> </li> <li> <p>Radcliffe, Charles W., Alignment of the above-knee artificial leg, Chapter 21 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</p> </li> <li> <p>Ralston, H. J., Mechanics of voluntary muscle, Am. J. Phys. Med., 32:166 (1953).</p> </li> <li> <p>Ralston, H. J., H. D. Eberhart, V. T. Inman, and M. D. Shaffrath, Length-tension relationships in isolated human voluntary muscle, Proc. 17th Internat. Physiol. Cong., Oxford, 1947. p. 110.</p> </li> <li> <p>Ralston, H. J., V. T. Inman, L. A. Strait, and M. D. Shaffrath, Mechanics of human isolated voluntary muscle, Am. J. Physiol., 151:612 (1947).</p> </li> <li> <p>Ramsey, R. W., and S. F. Street, Isometric length-tension diagram of isolated skeletal muscle fibers of frog, J. Cell. and Comp. Physiol., 15:11 (1940).</p> </li> <li> <p>Schede, Franz, Theorelische Grundlagen fur den Bau von Kunstbeinen; insbesondere fur den Oberschenkelamputierten, Ztschr. f. orthopad. Chir., Supplement 39, Enke, Stuttgart, 1919.</p> </li> <li> <p>Schnur, Julius, Beinbelastungslinie und Schwerlinie, Medizinische-Technik, 5(3):54 (March 1951).</p> </li> <li> <p>Schnur, Julius, Die Aquilibral-Kontakt Prothese, Orthopadie-Technik, 4(2) :36 (February 1952).</p> </li> <li> <p>University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes.</p> </li> <li> <p>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, 3rd edition, April 1949.</p> </li> <li> <p>Wagner, Edmond M., and John G. Catranis, New</p> </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall"> Eberhart, Howard D., and Jim C. McKennon, Suction-socket suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The amount of medial rotation in the stump depends upon the inherent physiological characteristics of the hip joint and upon the loss of muscular function after amputation. Some amputees have even been observed to have lateral rotation of the stump upon hip flexion.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall"> Eberhart, Howard D., Verne T. Inman, and Boris Bresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall"> University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Too much initial flexion results in a decrease in stride length, which may be undesirable in some cases.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall"> Radcliffe, Charles W., Alignment of the above-knee artificial leg, Chapter 21 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall"> Wagner, Edmond M., and John G. Catranis, New </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall"> Buchthal, Fritz, and E. Kaiser, Optimum mechanical conditions for work of skeletal muscle, Acta Psychiat. et Neurol., 24:333 (1949). </td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall"> Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall"> Libet, B., H. J. Ralston, and B. Feinstein, Effect of stretch on action potentials in muscle, Biol. Bull., 101:194 (1951). </td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall"> Ralston, H. J., Mechanics of voluntary muscle, Am. J. Phys. Med., 32:166 (1953). </td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall"> Ralston, H. J., H. D. Eberhart, V. T. Inman, and M. D. Shaffrath, Length-tension relationships in isolated human voluntary muscle, Proc. 17th Internat. Physiol. Cong., Oxford, 1947. p. 110. </td></tr><tr><td class="clsTextSmall"><b> 13.</b> </td><td class="clsTextSmall"> Ralston, H. J., V. T. Inman, L. A. Strait, and M. D. Shaffrath, Mechanics of human isolated voluntary muscle, Am. J. Physiol., 151:612 (1947). </td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall"> Ramsey, R. W., and S. F. Street, Isometric length-tension diagram of isolated skeletal muscle fibers of frog, J. Cell. and Comp. Physiol., 15:11 (1940). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall"> Inman, V. T., Functional aspects of the abductor muscles of the hip, J. Bone and Joint Surg., 29:607 (1947). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">It should be understood that no new theory of alignment is intended, that the aim is simply to explain logically some of the problems facing prosthetists in the construction of above-knee legs and to provide rational solutions for those problems. The views presented are the combined result of experience gained at the University of California Prosthetic Devices Research Project during limbshop trials of the adjustable leg and alignment duplication jig(8,9,10) of a study of methods presently in use by the artificial-limb industry, and of a survey of information presented in the German literature.(15,16,17)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall"> Eberhart, Howard D., and Jim C. McKennon, Suction-socket suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall"> Haddan, Chester C, and Atha Thomas, Status of the above-knee suction socket in the United Stales, Artificial Limbs, May 1954. p. 29. </td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall"> University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, 3rd edition, April 1949. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Charles W. Radcliffe, M.S., M.E. </b></td></tr><tr><td class="clsTextSmall">Acting Assistant Professor of Engineering Design University of California, Berkeley; member, Technical Committee on Prosthetics, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-22.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-23.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-24.jpg Figure 4 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-25.jpg Figure 5 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-26.jpg Figure 6 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-27.jpg Figure 7 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-28.jpg Figure 8 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-29.jpg Figure 9 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-30.jpg Figure 10 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-31.jpg Figure 11 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-32.jpg Figure 12 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-33.jpg Figure 13 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-34.jpg Figure 14 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-35.jpg Figure 15 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-36.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Functional Considerations in the Fitting of Above Knee Prostheses Creator An entity primarily responsible for making the resource Charles W. Radcliffe, M.S., M.E. * https://staging.drfop.org/files/original/704be8285e9e81b00a548f4079273dd0.pdf 8d139ddf679c176348350d328a543afd https://staging.drfop.org/files/original/49cf18e648ecc82d654ec1eff2291631.jpg c1cfed36a05f0a2fc50153fd5c760913 https://staging.drfop.org/files/original/75674097e4e35c77fdec5a976ff86d62.jpg 9f31ccdf0294986d2aea9d550887f50f https://staging.drfop.org/files/original/6e8abc5344c8c89a34bb7bb7e58e2657.jpg 6093fff8491a17af6fc0bb951f2df011 https://staging.drfop.org/files/original/37d0211a1c3964d660b5475199ef272d.jpg e15ab0ecdc3c30f04f9a0f88d1e7f911 https://staging.drfop.org/files/original/074ff2c61033b2276ba9ba6b32d533dc.jpg 18833eb4185b3218e31d0f5a35889396 https://staging.drfop.org/files/original/25f6feb898b3105da3d22efedaad8b5f.jpg 14cd923437e363674f1305376f929c93 https://staging.drfop.org/files/original/98c6f90be1d6a610b1532fee234863eb.jpg 77448c6435f7e839884d481f8bb7c0bc https://staging.drfop.org/files/original/bf8014ecf9aef0436238851fa1474e8e.jpg a485adc4c47126a56ef395422b794cc0 https://staging.drfop.org/files/original/a3f8fed82c099bfaf63d22effee25dc9.jpg 3aafbd4368cc3968a6ed5d0bf3d576af https://staging.drfop.org/files/original/63989f61bdf02ae37100a3e5d28a3065.jpg 3b2ff7b083f358ef57a6a637a5333dc6 https://staging.drfop.org/files/original/6a514f0e2ba1bfd9ba93437672e576c3.jpg 17049ac032017d5b129e9629dd56a9f4 https://staging.drfop.org/files/original/dd2a27378293b40a365d988be7038823.jpg 487fe803ef2ffdf12201d3e066227729 https://staging.drfop.org/files/original/79421da1d5927a2f575339efaaae587a.jpg 7727b475ea61106ccba34b7e0a8fea80 https://staging.drfop.org/files/original/85780afcefa210b16b3180eb1a8a32c7.jpg 0929c4e5349737a970d707389cc7e591 https://staging.drfop.org/files/original/80b1690efe4254fee0a6b928f0221b73.jpg b35fcbb513359778fadce4c9655b88ac https://staging.drfop.org/files/original/a7b48775e41332452941b1805803de4f.jpg 2d1f4f535f9b9df473d2a83b9a61d6db https://staging.drfop.org/files/original/354cad5e63e3f2ee432a2a43b8af480f.jpg f54280fbcdcd946cade07b9a0e67cf76 https://staging.drfop.org/files/original/8932dd244d2f177f348642bab3474157.jpg a9162486c8f3c0b05d8e402bb14cb9cc https://staging.drfop.org/files/original/172fcac01d1f6b60da95c9da079d9b0c.jpg 29f465e6e6425c776b16326e64e5ec8a DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_01_004.pdf Year 1955 Volume 2 Issue 1 Page Number(s) 4 - 34 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_01_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_01_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Lower-Extremity Clinical Study-Its Background and Objectives</h2> <h5>VerneT. Inman, M.D., Ph.D., <a style="text-decoration:none;">*</a><br />Howard D. Eberhart, M.S. <a style="text-decoration:none;">*</a><br /></h5> <p> If it may be postulated correctly that the most satisfactory artificial leg is the one which most nearly simulates the static and dynamic behavior of the natural limb it replaces, the successful practice of lower-extremity prosthetics poses a twofold requirement. The first is an intimate and detailed knowledge of the characteristics of the normal leg in all common activities, and the second is the ability to reproduce as nearly as possible, by a combination of design and fit of the substitute limb, the kinetic and kinematic features essential to normal locomotion. In the Artificial Limb Program, principal responsibility for fundamental studies in normal and amputee gait and in lower-extremity prosthetics has, since 1945, resided in the Prosthetic Devices Research Project at the University of California, Berkeley Campus. </p> <p> But the problems facing the leg amputee are not wholly prosthetic. Many, indeed, are clearly medical. For the amputee, being no longer the whole normal individual, manifests gross structural and physiological changes to be dealt with successfully only by the physician. </p> <p> The Lower-Extremity Clinical Study being conducted jointly by the Department of Engineering, University of California, Berkeley, and the University of California Medical School, San Francisco, and in cooperation with the U. S. Naval Hospital, Oakland, has as its chief objectives the analysis of medical problems inherent in the amputated state and the application of fundamental knowledge to practical problems in the management of lower-extremity amputees. Current techniques and practices in the fitting of leg amputees still are so varied from place to place and from prosthetist to prosthetist that some orderly means has been wanting for establishing what is, everything considered, the best prosthetics practice in the lower extremity. Designed to close the gap between basic work in the laboratory and work in the field, the Clinical Study is an outgrowth of the fundamental research in locomotion conducted earlier by the Berkeley Project. </p> <h3>The Background </h3> <p> For a number of years during World War II a group at the University had been conducting research in the field of biomechanics and had published data relating to the behavior of the upper extremity. In the autumn of 1945, therefore, the University was approached by a representative of Northrop Aircraft, Inc., a company which at that time was already engaged in prosthetics research<a></a> under contract with the then Committee on Artificial Limbs of the National Academy of Sciences- National Research Council. It was requested that the University group undertake an investigation aimed at providing information that could be utilized in the design and construction of lower-extremity prostheses. </p> <p>The suggestion having been taken under advisement, the entire Committee on Artificial Limbs met at the University shortly thereafter to consider the proposal and to evolve details of contractual arrangement. Out of this meeting came two basic observations. One was that, inasmuch as the financial support for the work was to come from public funds, any information derived from the contract would have to be shared with all other contractors participating in the Artificial Limb Program as well as with the general public. The other was that, in the opinion of the conferees, between five and seven years of study would be required before sufficient detailed and quantitative information could be accumulated to effect substantial improvement in lower-extremity prostheses.<a></a> At the outset, the University group insisted that it be kept free of the task of developing prosthetic devices-that it simply be permitted to investigate normal human locomotion and to furnish the collected data for others to use. The original concept of the scope of the project-as a program of basic research in human locomotion-has been adhered to up to the present time, the only deviations having involved development of experimental devices<a></a> needed to assist in the locomotion studies. </p> <p> The early years, then, were spent in working out techniques suitable for recording objectively the motions and the forces involved in the gait of man.<a></a> Of course, the investigators took advantage of all the previous work in this field, not only that done by other contractors<a></a> participating in the Artificial Limb Program but also that contained in material, particularly that of Elftman<a></a> published in the United States and in foreign countries over a period of many years. By 1947, enough data had been accumulated to publish a comprehensive report<a></a> on the walking pattern of normals and of leg amputees.<a style="text-decoration:none;">*</a> </p> <p> Attempts to translate the results of basic research into criteria for the improvement of prosthetic devices led to the second phase of the project, that is, to developmental research, an area that involves engineering and prosthetics technology. During the last few years, this phase of the project has been conducted on a relatively small scale. As devices were prepared for trials by amputees, the problem of fit and alignment had to be attacked, and hence fundamental studies were undertaken in this area in order to establish a set of basic principles and techniques.<a></a> Because fitting and alignment contribute most to the comfort and therefore to the success of any artificial leg, the validation of these principles and techniques formed the basis for embarking on the third phase of the project, the Lower-Extremity Clinical Study, an activity that provides a laboratory where medical and prosthetic problems can be handled under controlled conditions. It offers an opportunity to see how individual solutions may be obtained by applying a set of general principles based on biomechanical considerations. Until recently, the study group has been concentrating on the problems of the above-knee amputee because that case appeared to offer neither the most difficult nor simplest set of circumstances. </p> <h4> The Locomotion Studies </h4> <h5> <i>Muscle Physiology</i> </h5> <p> When the Prosthetic Devices Research Project first was organized, man was viewed as a machine, the object being to measure the displacements, accelerations, and forces required in human locomotion.<a></a> But man is more than a single machine. He is powered by a complicated system of many internal engines served by muscles. Accordingly, the study was broadened to include the field of muscle physiology.<a></a> Investigation of the behavior of the musculature during normal locomotion (<b>Fig. 1</b>) revealed the basic action of the various muscles involved<a></a> It was shown that in locomotion each muscle acts when it is near its rest length but that it acts for a very short period of time in each walking cycle.<a></a> This action makes the contraction essentially isometric and limits the activity of each muscle fiber to a few twitches. Under these conditions the muscle works with minimal energy and maximum tension, which helps to explain why a person can walk considerable distances without tiring. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Typical electromyographic summary curves, in this case for the hamstring group. Ten subjects. Cadence: 95 steps per minute, level walking. Data from UC studies 102. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Upon working out the speed of contraction, it was found that, if muscles are halved, their contractile velocities likewise are halved (<b>Fig. 2</b>). Utilizing a profile electromyographic recording (electromyogram rectified and dampened to give a relatively smooth line), and taking the maximum amplitude in a given cycle as 100 percent, the average durations with an amplitude greater than 75, 50, or 25 percent are approximately 0.04, 0.1, and 0.2 second, respectively.<a></a> Since it seems probable that the profile electromyographic amplitude largely indicates relative numbers of active motor units, it would appear that most of the units participating in this phasic action are active during bursts of 0.1 to 0.2 second only. According to Weddell<a></a>, at a repetition rate of 20 per second or less most motor units would fire in each cycle one to four times only. In such a case, any temporal summation taking place at neuromuscular junctions would not be effective fully, and the action of a motor unit, at least in a normal phasic pattern like locomotion, would not have the character of a sustained tetanus. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Relation between the maximum speed with which a muscle can contract and the weight with which it is loaded. When the length of the muscle is halved, its speed of contraction is also halved. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> As a result of these investigations, in 1947 the group at Berkeley, noting the earlier work of Blix<a></a>, was first to call attention to the length-tension relationships existing in human muscles<a></a> and thus laid the basis for the decision to use certain muscles for the cineplastic technique.<a></a> The characteristics of the length-tension diagram have since proved to be of fundamental importance in devising prosthetic aids for upper-extremity amputees.<a></a> The cineplastic muscle tunnel, comprising a skin-lined tube placed through the distal end of a muscle, permits an amputee to utilize effectively his own muscle forces for activating an artificial arm or hand. But in order to operate a cineplastic prosthesis efficiently, it is necessary that the muscle be near its rest length, so that it can generate a force sufficiently large and so that it can shorten enough to carry out necessary movements.<a></a> Appearing in publications as early as 1949, the work conducted at the University of California has been recognized by Buchthal<a></a> of the University of Copenhagen as the best so far done on normal human muscle dynamics. </p> <h5> <i>Energy Requirements</i> </h5> <p> In another study, an investigation was made of the dissipation of energy (<b>Fig. 3</b>) in human locomotion.<a></a> Results showed that approximately 50 percent of the energy consumed in walking is used simply in bouncing up and down, that is, in vaulting over one leg and then the other. The other half is used in the oscillations of the legs. It is therefore apparent that, if the amputee is not to be subjected to unduly large energy demands, he must have a smooth pathway of displacement of the center of gravity of the body.<a></a> Any deviation from the smooth, natural locus of the center of gravity means excessive dissipation of energy and consequent degradation into heat.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 3. Typical moment-angle diagram for the leg of a normal subject during level walking. From Bressler [sic] and Berry (14). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Contrary to much popular belief, man not only pushes his way through space. He also <i>pulls </i>his way.<a></a> Indeed, deceleration of the swinging leg, not push-off from the other toe, provides the greater part of the energy for locomotion, the proportion attributable to deceleration of the swinging leg being about 4, that attributable to push-off only 3. Energy is absorbed by the knee to decelerate the leg and foot during the swing phase, but not all of the energy so absorbed is lost.<a></a> A considerable portion is stored and returned to the system in the later part of the swing phase to impart continued forward acceleration at the time when most of the body's potential energy is lost.<a></a> Thus locomotion is due not only to the push of the member in support but also to the pull of the deceleration in the swinging knee. </p> <p> Because the above-knee amputee has no calf group, and therefore cannot contribute the equivalent of this force at push-off, it was suggested that some conservation of energy might be effected in a prosthetic device without an ankle joint.<a></a> That this was a correct deduction has since been demonstrated (<b>Fig. 4</b>) in the Stewart-Vickers leg,<a></a> in which the ankle is locked at toe-off until 20 deg. of knee flexion has occurred.<a></a> It has the highest net output and the lowest total input of all legs tried to date (<b>Fig. 5</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 4. Cadence changes observed in above-knee amputees asked to walk at "normal" speed first with a conventional limb and then with the Stewart-Vickers (locked ankle) prosthesis 114. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Energy characteristics of the normal ankle compared with those of the conventional leg and the Stewart-Vickers leg. Top, total input, total output, and net output of both ankles per stride. Bottom, input and output of each ankle per step. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Amputee Pain </h4> <p> Intimate contact with amputees led to the early investigation of pain as related to the amputee patient.<a></a> In 1946 a team of interviewers set out to question amputees in various hospitals, particularly in the Veterans Administration Hospitals and in the Naval Hospital then at Mare Island. Over a period of a year and a half, detailed histories were obtained from 80 patients. As a result of this review, further funds were provided by ACAL to establish a Pain Clinic at the University of California, primarily to evaluate pain as found in the amputee. Established in August 1949, the clinic functioned until January 1953. </p> <p> In June 1952, an analysis of 218 amputees was reported.<a></a> In this study, which constitutes one of the largest series on record, the type and frequency of pain in the amputee were explored. Because it was thought that perhaps deficiencies in stump circulation might contribute to the pain experienced by the amputee, circulatory studies were undertaken. Concurrently, innervation of the deeper tissues was studied.<a></a> Sections of tissue were taken from periosteum, muscle, and skin, and the nerve supply to these tissues was demonstrated by a methylene blue technique. </p> <p> One of the most intriguing aspects of this investigation was the work with normal individuals in whom irritative lesions purposely were produced in the deeper tissues.<a></a> With the authors, some 75 medical students, and three laboratory assistants serving as subjects, 0.5 to 1.0 cc. of 6-percent saline solution was injected systematically into the paravertebral muscles at each intervertebral level from the atlanto-occipital area to the lower sacrum. Five subjects were used in the testing of each injection site, a total of 140 individual observations being made. Although the distribution of pain approximated a segmental plan, it also overlapped considerably and differed in location from the conventional dermatomes. It was found that, in any irritation of deep somatic tissues, pain did not restrict itself to the area of injection but tended to radiate distally into the extremities. Injection of 6-percent saline into any given interspinous level produced in the normal a characteristic pain distribution that was remarkably constant from subject to subject. The distribution of pain referral from deep structures in the normal suggested similar investigations in the amputee. To elicit the sensation of the phantom limb, it was necessary to inject the salt solution into the appropriate interspace. In the normal, radiation of pain into the lower limb was most marked when the interspinous tissue between L4 and L5 was affected, and in the above-knee amputee the L4-L5 interspace also gave the best response. The immediate reactions of amputees resembled those reported by normals-a rapid onset of pain close to the site of injection and then, in the case of L4-L5 injection, radiation into the buttocks and the posterolateral aspect of the thigh. In nearly all instances there occurred a rapid "filling" of the absent areas of the phantom limb, the subjects usually evidencing surprise at the sudden totality of a phantom limb even though the new portions were seldom, if ever, immediately painful. </p> <p> Severe pain was a frequent feature in the portion of the phantom present before injection. After injection the pain often spread into the newly "filled in" portion of the phantom limb. Transient pain following injection occurred in phantom limbs regardless of the existence of preinjection pain. But in many cases involving pre-existing phantom pain, a secondary decrease in the amount of pain followed the injection, in some but not in all instances the decrease being preceded by a transitory accentuation of the pre-existing pain. Occasionally, the decrease reached the point where no pain was felt, so that the amputee experienced the first complete relief in many months. </p> <p> The decrease in pain is even more remarkable when one considers that it is brought about by the application of a noxious stimulus to a tissue remote from the phantom itself. For example, in an above-knee amputee who had undergone amputation two months before the investigation, there was a phantom sensation of the "foot" only, the phantom being very painful with the sensation of severe constriction of the great "toe" (<b>Fig. 6</b>). When saline was injected into the L4-L5 interspace, much of the intervening phantom limb was filled in almost immediately, the anterior aspect of the "leg" becoming the most prominent part. Soon after the phantom was "completed," the preexisting pain in the "foot" increased in intensity and area. This state continued for five or six minutes, whereupon the pain began to decrease and continued to do so until, in another five minutes, it had disappeared completely. Numbness, but not pain, remained in the "foot" only. In some instances even phantom awareness disappeared after saline injection. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Effect of interspinous injection of saline on the painful phantom limb of one subject. A, Phantom before injection. B, Radiation of sensation induced by injection of 6-percent sodium chloride solution. C, Residual sensation following injection. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In general, the saline injections had greater effects on phantom limbs than on real ones, a peculiar susceptibility best illustrated by the effects of mid-line injections. An accurately placed mid-line injection in a normal subject produces very little radiation, the severe pain being confined to a rather small area in the immediate vicinity of the injection. In the case of the amputee, however, such minimal radiation in the trunk is accompanied by profound effects on the phantom extremity. Every conceivable change in phantom form and phantom pain can result from interspinous injection of an irritating hypertonic saline solution, the changes probably stemming from the sudden increase in the sensory inflow at the particular segmental level. </p> <p> Out of these observations came, then, one method of treating phantom pain, for when a small amount of hypertonic saline was injected into the appropriate segmental interspinous ligament, the phantom experience was changed and pain occasionally was relieved. This finding led to the use of hypertonic saline for the treatment of various painful conditions. Although permanent cures resulting from such techniques are not numerous, the method may prove to be a valuable addition to the modern medicine chest, which is by no means rich in effective pain palliatives.<a></a> </p> <p> It deserves to be noted that, in seeking the origin of the phantom experience, one must look not only for direct involvement of the nerves of major nerve trunks. The entire segment of the extremity must be investigated for any irritative skeletal lesions arising from the joints, the muscles, or the connective tissues of the stump or from portions proximal to the stump. </p> <h3> Evolution of Basic Data </h3> <p> From the basic studies now has come much information of value in prosthetics. As early as 1947 it was determined<a></a> that in normal walking the leg rotates in space internally and externally about 15 deg. on the average (<b>Fig. 7</b>). That this horizontal rotation of the extremity might be of some importance in human locomotion has since been known as the "Berkeley fetish," and as far as is known no one has yet taken cognizance of the fact in any successful limb design. In 1950 it was suggested<a></a> that it would be of considerable value if deceleration at the end of the swing phase could be incorporated through some sort of variable-cadence knee joint. This has been done in at least one device, the U.S. Navy above-knee leg,<a></a> now available commercially (see <i>Digest, </i>this issue, page 65). Several others currently are under development. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 7. Typical relative rotations of the pelvis, femur, and tibia in normal, level walking. Data from UC studies </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> At the same time it was suggested that, inasmuch as the above-knee amputee can obtain no forward propulsion by contraction of the calf group, the ankle joint is of little use- that, indeed, if an ankle joint with rubber bumpers is used, energy is lost by hysteresis of the bumpers. As already mentioned, the improved performance of the Stewart-Vickers leg, in which the ankle is locked at toe-off up to 20 deg. of knee flexion, proves the validity of the original observation. Similarly, it was pointed out that, because of the interrelationship between the ankle-foot function and the knee-joint function, greater stability would be required of the knee joint were the articulated ankle to be abandoned. </p> <p> In 1953, Saunders, Inman, and Eberhart<a></a>, summing up the results of all the basic studies, pointed out that there is an interrelationship between all displacement patterns of all segments of the lower extremity, that there are six major determinants in locomotion, that modification of one results in modification of the others, and that any changes in the knee or ankle, either in normal or in amputee, are necessarily accompanied by compensatory changes in the remaining joints. Basically, locomotion is the translation of the center of gravity through space along a pathway requiring the least expenditure of energy (<b>Fig. 8</b>). The six major determinants of the pathway are pelvic rotation, pelvic tilt, knee flexion, knee extension, knee and ankle interaction, and lateral displacement of the pelvis. Serial observations of irregularities in these determinants provide insight into individual variation and a dynamic assessment of pathological gait, which may be viewed as an attempt to preserve the lowest possible energy consumption by exaggerating motions at unaffected levels. Compensation is reasonably effective with the loss of one determinant, that at the knee being the most costly. Loss of two determinants makes effective compensation impossible, the cost of locomotion in terms of energy then being increased threefold, with an inevitable drain upon the body economy. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. The sum of the effects of the six determinants of gait. The pathway of the center of gravity is a smooth curve in both horizontal and vertical planes. From Saunders, Inman, and Eberhart<a></a>, by permission of The Journal of Bone and Joint Surgery. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> With regard to the surgery of amputation, the studies in muscle physiology suggested that considerable improvement might be effected in lower-extremity prosthetics were muscles fixed in the distal end of the stump so that they could not retract.<a></a> As previously pointed out, retraction of these muscles means shortening, and shortening means an inability to develop natural tensions. More recently the studies have suggested that, in order to retain normal weight-bearing through the shaft of the femur, more attention should be paid to the possibility of end-bearing rather than to the more conventional method of weight transmission through the ischial seat. All of these ideas, derived from the results of the early studies on locomotion, were offered to the limb industry by the University group in the hope that designers or manufacturers would incorporate the recommended features into new prostheses. </p> <h3> The Clinical Study </h3> <p> In the spring of 1953, after years of basic study, the question arose as to what might be done toward applying to the amputee problem some of the knowledge gained. After several months of discussion, the UC Prosthetic Devices Research Project accepted a proposal to institute the so-called "Clinical Study," the principal objective being to draw upon the pool of fundamental knowledge, to attempt to apply it toward the solution of practical problems, and to see whether or not there would emerge certain definite devices or methods which could be passed on to the artificial-limb industry and to prosthetists. Last year, then, the clinical program was established, and currently it is the center of attention. </p> <p> To organize such a clinical study obviously required a limbshop and examining rooms. Through the kindness of the Navy, space was afforded at the Navy Prosthetics Research Laboratory at the U.S. Naval Hospital at Oakland, California. There the setup includes a small limbshop where prosthetics work is done, a medical examination room, fitting and training rooms, an evaluation and photography room, and conference rooms, the entire operation being conducted in cooperation with the limb industry. Through the Industry Advisory Committee, amputees are selected on the basis of referral by limbshops, by physicians, by rehabilitation agencies, by the Veterans Administration, and by direct personal contact. After preliminary screening by the Clinical Study Group, an individual is selected only with the approval of the Industry Advisory Committee, and all of the work is done with the knowledge, assistance, and cooperation of the artificial limb industry. </p> <p> Because it is concerned primarily with research, the Clinical Study is not a commercial operation, and consequently production is not high and is not supposed to be. Thus far only 16 subjects have entered the clinic. Of these, 10 are unilateral above-knee amputees ranging in age from the teens to the seventies, two are bilateral above-knee cases, one is a bilateral above-knee/below-knee case, two are hip-disarticulation cases, and one is a unilateral below-knee case. Five are in the follow-up stage, six in the postfitting adjustment stage, three in the fitting stage, and two in the pre-prescription stage. All save one have been complicated cases, presenting difficult problems that nobody else wished to tackle. From particular cases such as these have come practical answers for other difficult cases. </p> <p> A thorough and complete study-from the medical, biomechanical, and prosthetic points of view-is made of each case, and individual problems are diagnosed and corrected. To find the best possible solution in any particular case requires a knowledge of what attempts have been unsuccessful and why they failed, for sometimes a great deal more is learned by determining why one proposed solution failed than by determining why another was successful. </p> <h4> The Clinic Team </h4> <p> The clinic team consists of an orthopedic surgeon, a prosthetist, a physical therapist or amputee instructor, and sometimes an engineer<a></a>. This group makes the initial evaluation and provides a prescription<a></a> based on complete data including a medical history, an analysis of existing condition of the stump and of the rest of the body, and an evaluation of the old prosthesis. The prescription is reviewed by the Clinic Study Panel, including several orthopedic surgeons, a psychiatrist, a prosthetist from industry, and an engineer familiar with prosthetic problems. Once the prescribed device is fitted, the results are viewed by the Panel, and the reasons for success or failure are documented fully so that the case may serve as an example for future reference. No experimental devices are used in the clinic program. Only those devices available commercially are fitted to the subjects. </p> <h4> Industry Participation </h4> <p> Active participation by individual members of the artificial-limb industry has not yet started, but plans are now being made for such activity in the immediate future. That part of the program will involve working with prosthetists, screened by the industry, who will visit the clinic for a period of orientation. They will follow cases through the clinic study and then be assigned a shop case on a cooperative basis. The clinic team will act initially as a review committee in preparing the prescription, but the individual prosthetist will fill the prescription in his own shop. After fitting, the amputee and the prosthetist will return to the clinic for evaluation. This procedure provides a twofold check. It evaluates the prosthetist's degree of efficiency and tests the validity of the clinic's method of prescription. </p> <h4> Prosthetic Problems </h4> <h5> <i>Crotch Pressure</i> </h5> <p> Because enough time has now elapsed to be sure that more than temporary success has been achieved, some general ideas can be discussed with a fair degree of confidence. The most common complaint heard by the group relates to crotch pressure. In every instance, however, the condition has been eliminated. Correcting for excessive crotch pressure involves two things-the right socket shape and correct alignment (page 35). Proper socket shape is ensured by providing for ischial-gluteal bearing (which prevents sinking into the socket), by controlling the anteroposterior dimension, and by raising the height of the socket brim. </p> <h5> <i>Localized Socket Pressure</i> </h5> <p> The next most common complaint relates to edema. Rarely has there been a case of the suction socket where edema could be traced to high negative pressure alone. Excessive crowding or tightness invariably were contributing factors. Edema may result principally from a high rate of pressure change at any point along the length of the stump. Because emphasis has been placed on socket shape near the top brim, not enough attention has been given to good fit throughout the length of the stump. Any constrictions or ridges, including those formed by muscle groups, cause pressure changes that interfere with venous return. The inside finish of the socket also may be a factor. In one instance, for example, a severe case of edema was alleviated by providing the socket with a smooth, high-gloss finish. </p> <h5> <i>Socket Brim</i> </h5> <p> Skin irritation around the socket brim also is a source of annoyance and discomfort. Accordingly, dermatologists are cooperating in the program. They examine amputees having skin problems and outline procedures for therapy, including the taking of biopsies of the skin. Pigmentation is evaluated to determine whether or not it is due to capillary hemorrhage caused by decreased suction or whether it is merely a pigmentation that often occurs in areas of friction. Out of this study should come a routine test and a new modality of skin care for the leg amputee. </p> <p> Again, the condition can be eliminated by controlling the shape and height of the anterior and lateral brim above the ischial seat. Medial width also is a controlling factor because it determines the total amount of pressure exerted by the front of the socket to maintain stability on the posterior weight-bearing surface. And, as in the case of edema, the inside finish is important in preventing skin damage. Sitting discomfort, a complaint often heard, usually is relieved by using a flat back, by not having the inside edge of the seat too sharp, and by ensuring that any channel for gluteal relief is not too large. </p> <h5> <i>Alignment</i> </h5> <p> Alignment is a continuing problem, and the development of guiding principles is most important. Although general principles are comparatively simple to state, to understand them fully and to apply them to individual cases is difficult. One of the objectives of the clinical program is to apply to typical problem cases the alignment principles developed through fundamental research and to develop examples showing how these principles can be applied, why they work, and the end-results that can be obtained. Naturally, the best results are obtained when the stump is so oriented as to take full advantage of the remaining hip musculature. There is a growing body of information relating to a number of common problems-problems associated with changing from a pelvic belt to a suction-socket leg; problems concerning the very muscular stump with prominent hamstrings or with some particularly firm muscle or muscle groups isolated in the stump; problems of the short and the long above-knee stump; problems caused by the flabby stump; and problems of inside finish. </p> <h4> Medical Problems </h4> <p> Often the problems of the amputee, both in the lower extremity and in the upper, stem not from an ill-fitting prosthesis. More often the problems can more properly be termed medical. Accordingly, the Clinical Study includes investigation of those aspects of amputee rehabilitation related to physiological changes associated with loss of limb. </p> <h5> <i>Pain</i>-<i>Phantom and Real</i> </h5> <p> As pointed out long ago<a></a>, loss of the normal limb so often is followed by the appearance of some form of phantom limb that, when a patient does not acknowledge one, it is suspected that he is withholding information or that the phantom has been repressed. Statistics show that the phantom is a normal phenomenon in the sense that most amputees have it. It is pathological, however, in the sense that the amputee perceives something that actually does not exist. </p> <p> In general, awareness is a matter of degree and, to some extent, a matter of verbal conventions. Some amputees say that the phantom has the same unobtrusive quality as does the material counterpart, that it appears only when called upon. Sometimes the amputee has difficulty in remembering that the phantom is unreal and that it does not serve in the capacities of its living predecessor. The normal person is not particularly aware of his limbs unless his attention is drawn to them in some way. Except under the impact of a sudden stimulus, or when a special effort is made, preferably together with a movement, our awareness is potential and shadowy in nature. With the eyes closed, and with the limb at complete rest, awareness is, in fact, not too far removed from mere imagination. To make certain that the limb exists, we move it, look at it, or rub some part of it. The amputee cannot conduct such an empirical test. </p> <p> Sometimes the patient can sense his lost limb as acutely as he can the remaining real one, and he often can imagine that he can "move" the phantom. More often, however, the phantom draws attention to itself by some "abnormal" sensation which makes the amputee more aware of it than he is of his real limb. Fortunately, only a small percentage of all phantoms habitually are painful. Some typical ones are shown in (<b>Fig. 9</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. The phantom limb, a phenomenon of almost universal occurrence among amputees. A, Phantom toes and ankle, reported more frequently than are other phantom parts of the amputated lower extremity. B, Mild "tingling," characteristic of the painless phantom, is often described in terms of "crawling ants." C, The "telescoping" phantom, in which the foot, over a period of time, gradually approaches the stump and finally disappears within it. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Frequently the "foot" seems to shorten and approach the end of the stump. The patient illustrated in Figure <i>9C </i>experienced "telescoping" of the phantom, a phenomenon which, contrary to the observations of most other writers on the subject, was found infrequently in the Berkeley series. It is true that relatively undifferentiated parts like the calf and the forearm commonly are not felt. Some phantoms of distal parts are, from their onset, situated at the normal distance from the trunk. Others always seem to be located closer to the stump than normal. A few patients experience a gradual shrinkage of intermediate phantom parts, as has occurred over a period of years in the subject illustrated in (<b>Fig. 10</b>). In this case, all that remains of the shrunken ghost are the "toes," and these have come to lie not in empty space, as is the rule, but inside the stump. Not infrequently a phantom which has shortened may, on application of a prosthesis, lengthen and actually become identified with the artificial limb. Thus, in one instance, a young above-knee amputee felt as though the shortened "foot" were appended to the stump. When he wore his prosthesis, however, the phantom foot felt as though it were in the position corresponding to that of the artificial foot. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. A rare and peculiar form of phantom experience. Here the two "toes" seem to reside within the stump itself. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Awareness of the missing member may or may not be described as basically unpleasant, but it is subject to intermittent unpleasant sensations-itching, tingling, or pain (<b>Fig. 11</b>). As pointed out by Livingston <i>, </i><a></a> the pattern of the painless phantom bears no resemblance to the areas of distribution of the major peripheral nerves. Thus the partial nature of the phantom cannot be ascribed to the affection of certain nerve lesions in the stump. Rather, the pattern of the phantom seems to relate to the most mobile parts and to those serving the highest degree of sensory function. But a substantial number of amputees experience, at one time or another, some sort of painful phantom of varying duration (<b>Table 1</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. The painful phantom, of fairly common occurrence among amputees at one time or another. Only some 30 percent experience no phantom pain at any time. Probably about 10 percent face persistent and sometimes incapacitating pain. A, Among the similes used to describe a phantom pain is "as if my toes are being crushed by a hammer." B, Pain experienced at the site of an injury leading to amputation, such as a fracture, often persists as a part of the phantom pattern. C, The "hot wire" sensation and involuntary cramping of phantom toes are among the other frequent manifestations. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> How many amputees have pain? Taking into consideration the inadequacies of follow-up information, the subjective character of the pain experience, and the semantic difficulties beclouding the term "pain," a conservative estimate would be that 80 percent of all amputees are substantially free of pain and are either being trained for useful work or else are already actually so engaged. It is likely that, of the remaining group, possibly half are faced with severe intermittent or persistent pain. Because of persistent, incapacitating pain, approximately 10 percent of all amputees never get into a limbshop, never get out of the doctor's office. They become narcotic addicts and often commit suicide. Where pain enters the phantom syndrome, it may assume large clinical importance. If it is excruciating and persists for long periods, it may take a devastating toll of the whole personality and physical well-being. </p> <p> In describing severe pain, we all use a vocabulary taken from common objects known to produce injury. Lesser pains are described in terms of cutaneous and deep sensations. Thus we speak of "pressure," of "pins and needles," of "sharp" pains and "dull" aches, of "stabbing" and "shooting" pains. It seems unlikely that man at his present stage of evolution ever will devise a specific terminology for pain because he has no special organ for observing his discomforts. No matter how introspective a person may be, his account of pain always is phrased in imagery taken from other fields of experience. Nothing could be more real than these sensations, but we say "as if" to give them intelligible expression. The vocabulary is metaphorical. </p> <p> It is not surprising, therefore, to find amputees using language akin to that of the torture chamber when they try to do justice to their agonies. They hardly go further than anyone else in telling about physical sufferin. Nor do they hallucinate when they talk about "ropes" and "vises," for they remain aware of the imaginary character of these similies. It is possible, however, that, as the tearing and squeezing sensations are felt in a part of the body known to be missing, the suffering is heightened and the imagery made more vivid by the ghostly character of the phantom. </p> <p> It has been argued that phantom sensations are hallucinations because they entail a belief in the reality of an absent object, or that they are illusions because irritations of the stump are being misinterpreted, or that they are normal sensations because the cerebral representation of the once-present member still is intact. Some workers have correlated the type of sensation with the "level" of its origin in the nervous system, painful sensations being ascribed to pathological conditions of the cut nerve end in the stump or to mental aberrations. But classifications of either the amputee's descriptions or of the presumptive causes bringing about the sensations have thus far been unsatisfactory. The various frames of reference used in the statistical survey at Berkeley do, in fact, overlap. Duration and frequency of pain have some influence on the complaint of severity. Tingling and burning seem to be more superficial and, however annoying, more tolerable than do tearing, stabbing, cramping, squeezing, and crushing. It should be understood, however, that there are degrees of each of these and that, as such, intensities may, to a point, be compared with each other. </p> <p> It is obvious that a patient's account of his painful feeling is colored by his personality. The way a person describes such experiences depends not only on the abnormal processes causing them but also on his imagination, his previous experience, his learning, his cultural inheritance, and his vocabulary. But any view which discounts the abnormal physiological processes and credits only their "mental" interpretation is probably in error. The complexity of the nervous system and its integration into one functioning whole does not favor the idea that there is one chief recipient and executive who sorts out the messages from the various parts of the body and, in the case of pain, edits them as writhings and groans or as sentences made up of more or less colorful language. It seems improbable that there is simply one stimulus arising somewhere in the organism and that the ego reacts to this stimulus in a more or less stoic way. A so-called "neurotic" or "imaginative" disposition is likely to pervade the most "bodily" of processes, while a steadfast person is apt to have a stomach and blood vessels no more stable than his emotional display. </p> <p> Regardless of individual personalities, however, there is a certain uniformity in the complaints of pain-stricken amputees. Although the matter has not been explored from the point of view of psychophysiological typing, it appears that pain phenomena cannot be predicted either from the age of the patient or from the age of his phantom. By the same token, racial or cultural background and physical or mental make-up cannot be used to predict pain phenomena. Nor have the local pathological factors before, during, and after amputation-the factors that might be held responsible for the appearance of pain-been elicited. </p> <p> Aside from the problem of the painful phantom is that relating to painful stumps (<b>Fig. 12</b>). Amputees may have spontaneous stump pain. Or they may have so-called "trigger points," certain areas which, on slight pressure, tend to produce a flash of pain persisting for various intervals of time. Patients have complained of circumscribed areas of pain in the stump even though palpation revealed no corresponding point of tenderness. These two conditions usually are found together. Nodularities in the stump often are palpable, as indeed they are, on a minor scale, in other subcutaneous parts of the body. Some of these are tender, some are not; some are and some are not connected with phantom pain. In fact, separate places in the same stump may represent exclusive triggers-one for stump pain, the other for phantom pain. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Types of stump pain. About a third of the clinical reports of pain refer to discomfort in the stump rather than in a phantom part. Stumps may be painful to the touch (A) or spontaneously (B). Frequently present are "trigger points," pressure upon which gives rise to pain over a larger area, either in the stump or in a phantom or both (C). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> But the conditions prevailing at the end of the stump, including such nodules as the famous "amputation neuroma," do not provide a basis for intelligent speculation. The mere fact that stimulation of a presumptive neuroma often produces pain in the phantom is no proof for the theory that the "cause" of this pain lies solely in the periphery. In order to be disabused of such a notion, one has only to look at certain cases of known diseases of the central nervous system or at. complete transections of the spinal cord. In the latter, the brain receives no communications from the stump. In cases of painful diseases of the central nervous system, stimulation of the normal peripheral tissues having their nervous connections with the diseased part of the central nervous system often produces an abnormal sensation, including pain. This phenomena always is referred to the periphery. Nobody sounds convincing when he says that he feels pain in the brain or spinal cord. The central nervous system has no conscious sensory representation of itself. The mere description of a painful sensation does not permit detection of its origin. The origin has to be deduced from circumstantial evidence which, in the case of amputees, is lacking. Even where sensations are "triggered off" from the periphery, they can be completed only by participation of the central nervous system, and disturbances may occur anywhere along the line. </p> <p> We are confronted with the anomaly that stimulation of a certain trigger point within the stump arouses not a distant, painful phantom but one incorporated in the flesh of its own trigger. The specificity of this trigger further is illustrated by the fact that, on the opposite side of the same stump, there may be another tender spot, stimulation of which sets up increased local stump pain. </p> <h5> <i>Circulatory Problems</i> </h5> <p> Investigation of circulation in the amputee reveals that the stump acts as though it were poikilothermic, that is, it has no ability to change its temperature. Rather, the temperature of the stump matches that of the surroundings, as occurs in a cold-blooded animal. </p> <p> Studies concerning the relationship of the vascular system to pain in amputees have been conducted along three general lines. First has been evaluation of the status of the circulatory system in amputation stumps, both in patients suffering from phantom or stump pain and in amputees free of pain. The second has involved clinical and laboratory studies of selected nonamputee patients suffering from pain syndromes possibly related in pathophysiology to phantom pain. And finally tests have been conducted with various sympatholytic drugs and blocking procedures, first with respect to their effects on phantom-limb pain and related pain syndromes and second in regard to their effects on the circulation of blood in stumps and in painful limbs. </p> <p> Studied in detail were 43 amputees, 31 without known vascular disease (Group A) and 12 suffering from vascular disease either as the underlying cause of amputation or as a concomitant to the amputation (Group B). Pain in the stump or phantom limb was an important problem for 15 of the patients in Group A and for 8 of those in Group B. The remainder described varying degrees of phantom awareness but denied that pain existed or, if it did exist, that it was disturbing. </p> <p> One method of investigation was simple clinical examination. In that survey, stumps appearing to have an adequate blood supply were found, when exposed to air at room temperature, to be almost uniformly cold to the touch as compared with the opposite extremities. In oscillometric tests, the pulse of arterial blood into the stump was found to be significantly smaller than that into the normal limb (<b>Fig. 13</b>). In skin tests with histamine, the appearance of normal flares and wheals indicated that local denervation could not account for the failure of the skin to warm during generalized body warming. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Pulsations recorded during generalized vasodilatation in a below-knee amputee. Oscillometric records show a smaller amplitude of pulsation in the blood vessels supplying the stump (A) than in those supplying the sound limb (B). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> (<b>Fig. 14</b> and <b>Fig. 15</b>) indicate graphically the results of surface-temperature measurements on the normal extremities and on the stumps of two amputees. <a></a> Skin temperature was measured after initial exposure of the body to cool air in a room with controlled atmosphere, the subject being exposed until finger and toe temperatures were stabilized. Recordings were made by means of thermocouples taped to the skin of the stump and to the contralateral extremities at multiple points along the length of the limb, the thermocouples being applied symmetrically so that points equidistant from the trunk could be compared. All such measurements were made with the subject in a basal state and exposed to room air between 17deg and 21deg C, conditions leading uniformly to constriction of the cutaneous vessels of the extremities in normal subjects. Under such circumstances, a temperature gradient exists between the proximal and distal portions of a normal arm or leg, so that the surface temperature of a finger or toe is several degrees lower than the temperature at points near the trunk. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Surface temperatures in the upper extremities of a below-elbow amputee during cooling and subsequent warming and vasodilatation. Above, time-temperature relations. Below, length-temperature relations. Points along the extremities indicate the locations of thermocouples. Relative humidity constant at 65 percent. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Surface temperatures in the lower extremities of an above-knee amputee during cooling and subsequent warming and vasodilatation. Above, time-temperature relations. Below, length-temperature relations. Points along the extremities indicate the locations of thermocouples. Relative humidity constant at 74 percent. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Temperatures then were recorded during maximal vasodilatation induced by oral administration of whiskey and wrapping the trunk in an electric blanket. After vasodilatation, the gradient is abolished or reversed in the normal limb, finger and toe temperatures rising to 30deg C or higher. </p> <p> At the end of the initial cooling period, when subjects had been exposed to cool room air for periods of from 30 to 150 minutes, the surface temperature at the distal end of the stump almost invariably was cooler than was the skin at a symmetrical point on the corresponding intact limb. Analysis of the temperature gradients found after cooling showed further that, in at least a third of the Group A amputees and in half of the Group B amputees, the stumps were cooler than were the opposite extremities, not merely at the distal ends but for distances of from 20 to 55 cm. from the ends. </p> <p> In one instance a patient was put in a room at 18deg C with nothing across his body except a towel. Over a period of two hours the body temperature was lowered to a point just above that at which shivering occurred. The temperature of the toe in the normal extremity dropped to a low level. When the patient suddenly was given 2 ounces of whiskey and warm water and had an electric blanket placed across his chest, the temperature of the normal extremity rose rapidly. But the temperature of the stump remained constant during the entire procedure, a phenomenon characteristic of all amputation stumps. </p> <p> A total of 40 amputees (28 Group A, 12 Group B) were subjected to one or more vasodilatation tests, and the responses of 45 stumps were observed. Of these, nearly two thirds failed to warm significantly at a time when the skin temperature of the normal extremities had risen to 30deg C as a result of indirect or "reflex" vasodilatation. Only occasionally did stumps show evidence of significant vasodilatation. It occurred with higher frequency in those patients with underlying or concomitant vascular disease than in amputees of Group A. Thus, of 11 stumps in which the temperature rose to the same level as the corresponding point on the contralateral limb, or even to levels reflecting "ceiling" blood flow for skin, only six were among the 32 stumps of Group A patients, and five were among the 13 stumps of Group B patients. In brief, a smaller proportion of stumps showed vasodilatation in Group A patients (one fifth) than in Group B patients (two fifths). </p> <p> In the majority of trials, experiments with other methods of inducing vascular relaxation were equally ineffective in causing a rise in stump temperature. In a total of eight intravenous injections of vasodilator drugs, the temperature of the stump increasedonlyslightly on two occasions (2.5deg C or less). A rise in temperature was effected once with Priscoline (2-benzylimidazoline hydrochloride) and once with tetraethylammonium chloride. Injections of prccaine in the region of the lumbar sympathetic ganglia produced a significant warming of the stump in one of two cases only. No correlation was found between the degree of phantom or stump pain experienced by these patients and the extent to which slump temperature fell during the initial period of exposure or the extent of stump warming during generalized vasodilatation. Amputees rarely complained of stump or phantom pain during these experiments, even though they were subjected to extremes of temperature requiring rapid vasomotor adjustments. </p> <p> The ease with which stumps become cool on exposure to a cold environment can be attributed to two factors. First, surface-volume relationships in stumps favor cooling. Second, less blood passes through the stump than through comparable portions of the intact limb because, in the stump, distal tissues are absent. Apparently the shunts between the arterial and the venous side, which permit an increased volume of blood to flow through the extremity, are located distal to the wrist joint and to the ankle joint. In amputations at or above the wrist or ankle, therefore, flow of blood to the extremity is impaired. Normally, body heat is lost chiefly through radiation from hands, head, and feet. When the body is deprived of one of these radiating "fins," the remaining stump cannot be warmed. Neither can excess heat be radiated away, and for that reason an amputee often finds intolerable an environmental temperature that is quite acceptable to the normal. The amputee is distressed in a heated room, while the normal subject suffers no discomfort. Since the radiating mechanism is lost with amputation of an extremity, and since the only other means of cooling is through evaporation of sweat, the amputee is more likely to be troubled with problems of perspiration. </p> <h5> <i>Skeletal Changes</i> </h5> <p> In addition to problems of pain and changes in circulation, the amputee sometimes is troubled by decalcification of the stump and adjacent portions of the pelvis, a change that occurs when the body weight no longer is borne along the axis of the major articulations but along the prosthetic weight line (page 36). Because in an osteoporotic extremity the covering of the bone is more sensitive than is that in the normal, a decalcified bone often becomes exceedingly tender and develops spontaneous pain. </p> <p> An interesting fact is that the joint itself, in (<b>Fig. 16</b>) the hip joint, begins to show early degenerative changes because it no longer transmits weight. In future studies it should be possible to evaluate more closely what changes are to be expected in the proximal articulations of an amputation stump, and more particularly in the joint cartilage covering the articulations, as a result of elimination of normal weighi-bearing through thesearticulations. Obviously, the only way la preveni osteoporosis and increased sensitivity is to resort to some type of end-bearing. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16 Roentgenogram of an above-knee amputee, showing skeletal changes that occur when the hip and the remainder of the leg on the amputated side are deprived of the normal stimulation of weight-bearing </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In the younger leg amputee, moreover, especially in growing children, other bony deformities develop (<b>Fig. 17</b>). Instead of the normal curvature of the neck of the femur, there develops a valgus deformity as is seen in polio and in dislocated hips. And finally, of course, because of loss of the mass of the limb, one must expect to find scoliosis and other abnormalities in the spine (<b>Fig. 18</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Complicating deformities in juvenile amputees. When amputation is necessitated in childhood, defects often occur in the subsequent growth of related bony structures. Here, for example, the pelvis is smaller, and the pelvic-femoral angle larger, on the amputated side than on the sound side. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Scoliosis, a postural defect often a sequel to amputation of the lower extremity. Loss of the weight of the amputated limb leads to habitual compensatory positioning of other body elements and thus complicates rehabilitation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3> Summary </h3> <p> In summary, it may be said that, first, amputation produces changes in musculature, not only the familiar contractures and atrophy <i>{50,88) </i>but other changes as well. If a muscle is cut in half, its ability to shorten is decreased. A mid-thigh amputation decreases the effective normal range of motion of the hamstring group. If the hamstring group is cut in half, the velocity of contraction is halved, and an amputee thus afflicted cannot therefore perform certain functions with any degree of facility. </p> <p> The mechanism of normal level walking requires the expenditure and distribution of considerable energy, for which the body depends largely upon the leg musculature. Thus, the handicap resulting from loss of any part of the leg is due not only to the loss of support but also to the loss of power available from the muscles. The skeletal structure of a normal limb can more or less easily be simulated in a prosthesis, but such a device has little value without simultaneous provision for the necessary power. Accordingly, an understanding of the energy characteristics of normal level walking is important in considering the design criteria for artificial legs. Judging from the results of the energy studies at Berkeley, at a given pace an above-knee amputee uses two and a half to three times as much energy as does the normal. The adverse effect of this overexertion is only further complicated by the fact that heat production is increased at a time when the radiating mechanism has been impaired. In the manufacture of any lower-extremity prosthesis, then, an important consideration, is to design the substitute limb for maximum energy conservation. </p> <p> Medical problems are common to all amputees. Some of them, for example those related to circulation, cannot be solved, but proper surgical procedures help to preserve the musculature and skeletal structures of adjacent joints. Moreover, many things can be done to relieve pain, both spontaneous phantom pain and the tender trigger points occurring in stumps. All amputees suffer some discomfort at one time or another. They are bothered by skin changes occurring over the bony prominences, by edema at the distal end of the stump, and by attritional lesions occurring in the folds of the groin (<b>Fig. 19</b>). A minor skin lesion can disable a leg amputee completely, especially when it means staying off the leg or going on crutches. Increased perspiration and poor ventilation of the stump in the prosthesis may close the sweat glands and make the skin susceptible to fungal diseases, and contact dermatitis may result if the patient is allergic to certain materials used in the manufacture of the prosthesis. Such problems must be solved by socket fit, by alignment, or by other procedures. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Problems of fit. Among them are irritation and swelling in the crotch area, edema at the stump end, and tenderness at pressure points. Because such problems are more or less readily corrected by proper fit and alignment, they are less medical than prosthetic, although chronic skin irritation may need the attention of a dermatologist. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> From the Clinical Study have come valid recommendations concerning fit, alignment, and functional characteristics. As already noted, some horizontal rotation (between 9 and 15 deg.) is desirable in an artificial leg. Further, increased stability in the knee joint increases the leg amputee's sense of security. Some conservation of energy can be effected by eliminating the articulated ankle joint. And finally, the matter of appearance deserves consideration. In this regard, attention must be given to the color, contour, and texture of the artificial leg. </p> <p> In the last analysis, the problem of the leg amputee is more than that of providing him with a prosthetic device. He has many medical problems, including pain, abnormalities in circulation, heat intolerance, and skeletal and muscular changes. The prosthetic device itself raises other problems-conservation of energy, proper alignment, comfort, and cosmetic appearance. The Lower-Extremity Clinical Study is concerned with the solution of all these problems. The manner in which solutions are sought is shown in (<b>Fig. 20</b>), where the central area represents the pool of fundamental knowledge accumulated over a period of nine years. As the amputee moves around the circle, each problem is studied and solved before he is allowed to move into the next phase of processing. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Functional organization of theLower-Extremity Clinical Study:. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> To date, pain and skin irritation have been the predominant problems, and study groups are being organized to investigate these areas in detail. Study groups also have been organized to investigate skeletal and muscular changes. At each step in the process, the panel itself often is faced with difficult problems. For example, the question of evaluation always is present, and it is not easy to determine whether or not the amputee actually has benefited from the time and effort devoted to his case. But as each difficulty is solved, the information derived is placed at the disposal of all those concerned, not only those within the Clinic Study Group but also all others whose interests lie in the field of amputee management. Seminars are held weekly to ensure that the information is brought to the attention of all interested persons. Eventually, all of the problem-solving data stemming from the investigations will appear in educational publications and will be available to members of the artificial-limb industry. </p> <p> Finally, it may be said that the University group has no intentions of producing prosthetic devices and, indeed, makes excursions into that field only when it is necessary to develop experimental models pertinent to the study. </p> <p> The only function is to produce sound ideas that can be used by the artificial-limb industry in the manufactuie and fitting of improved prostheses. The study must, however, continue to be active until the basic scientific information can be translated into useful guides for the professions involved in the rehabilitation of the amputee. </p> <h3> Acknowledgments </h3> <p> For the illustrations appearing in this article, the authors are indebted to two people in particular. Thomas Raubenheimer, of the Department of Medical Illustration, University of California Medical Center, San Francisco, prepared the charcoal halftones. With the exception of <b>Fig. 8</b>, all line drawings were worked up by George Rybczynski, free-lance illustrator of Washington, D. C. </p> <p><b>References:</b></p> <ol> <li>Adel Precision Products Corp., Burbank, Calif.,Subcontractor's Final Report [to the] Committee on Artificial Limbs, National Research Council, The development of a hydraulically operated artificial leg for above knee amputations, 1947. </li> <li>Alldredge, Rufus H., The cineplaslic method in upper-extremity amputations, J. Bone and; Joint Surg., 30A:359 (1948). </li> <li>Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasty, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. 4.</li> <li>'Bartholomew, S. H., Determination of knee moments during the swing phase of walking and physical constants of the human shank, University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, January 1952. </li> <li>Bechtol, Charles 0., The prosthetics clinic team, Artificial Limbs, January 1954. p. 9. </li> <li>Bechtol, Charles O., The principles of prosthetic prescription, Chapter 6 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </li> <li>Berry, F. R., Jr., Angle variation patterns of normal hip, knee and ankle in different operations, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 21, February 1952. </li> <li>Blaschke, A. C, General energy considerations and determination of muscle forces in the mechanics of human bodies, University of California (Los Angeles), Department of Engineering [Contractor's Memorandum Report No. 9 to the Advisory Committee on Artificial Limbs, National Research Council], September 1950.</li> <li>Blaschke, A. C, and C. L.Taylor, Biomechanical considerations in cineplasty, University of California (Los Angeles), Department of Engineering, Special Technical Report 18, 1951. </li> <li>Blaschke, Alfred C, and Craig L. Taylor, The mechanical design of muscle-operated arm prostheses, J. Franklin Inst., 266:435 (1953). </li> <li>Blix, Magnus, Die Lange und die Spannung des Muskels, Scandinav. Arch. f. Physiol., 6:150 (1894). </li> <li> Bradley, C. A, and Son, Inc., and Catranis, Inc., Syracuse, N. Y., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Artificial limb development for above-knee amputees including mechanical and hydraulic knee locks; suction socket and suction socket controls; knee lock controls operated by hip motion, stump muscles and foot position; toe pick up and foot providing lateral, plantar and dorsal flexion, July 1947. </li> <li>Bresler, B., Use of energy methods for evaluation of prostheses, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, September 1951. </li> <li>Bressler [sic], B., and F. R. Berry, Energy characteristics of normal and prosthetic ankle joints, University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, April 1950. </li> <li>Bresler, B,, and F. R. Berry, Energy and power in the leg during normal level walking, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, May 1951. </li> <li>Brown, E., and N. Foreman, Studies of skin temperature and of indirect vasodilatation in amputation stumps, Am. J. Med., 10:112 (1951). </li> <li>Buchthal, Fritz, and E. Kaiser, Optimum mechanical conditions for work of skeletal muscle, Acta Psychiat. et Neurol., 24:333 (1949). </li> <li>Close, J. R., and V. T. Inman, The action of the ankle joint, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1952. </li> <li>Close, J. R., and V T. Inman, The action of the subtalar joint, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 24, May 1953. </li> <li>Contini, Renato, Prosthetics research and the engineering profession, Artificial Limbs, 1(3):47 (September 1954). p. 58. </li> <li>Cunningham, D. M., Components oj floor reactions during walking, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, November 1950. </li> <li>Eberhart, Howard D., The objectives of the lower extremity prosthetics program, Artificial Limbs, May 1954. p. 4. </li> <li>Eberhart, Howard D., Herbert Elftman, and Verne T. Inman, The locomtor [sic] mechanism of the amputee, Chapter 16 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </li> <li>Eberhart, H. D., and V. T. Inman, An evaluation of experimental procedures used in a fundamental study of human locomotion, Ann. N. Y. Acad. Sci., 51:1213 (1951). </li> <li>Eberhart, Howard D., Verne T. Inman, and Boris Bresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </li> <li>Elftman, H., A cinematic study of the distribution of pressure in the human fool, Anat. Rec, 69:481 (1934). </li> <li>Elftman, H, The measurement of the external force in walking, Science, 88:152 (1938). </li> <li>Elftman, H., The rotation of the body in walking, Arbeitsphysiol., 10:219 (1938). </li> <li>Elftman, H., The force exerted by the ground in walking, Arbeitsphysiol., 10:485 (1938). </li> <li>Elftman, H., Forces and energy changes in the leg during walking, Am. J. Physiol., 125:339 (1939). </li> <li>Elftman, H., The function of muscles in locomotion, Am. J. Physiol., 125:357 (1939). </li> <li>Elftman, H., The function of the arms in walking, Human Biol., 11:529 (1939). </li> <li>Elftman, Herbert, The work done by muscles in running, Am. J. Physiol , 129:672 (1940). </li> <li>Elftman, H., The action of muscles in the body, Biol. Symposia, 3:191 (1941).</li> <li>Elftman, H., Experimental studies on the dynamics of human walking, Trans. N. Y. Acad. Sci., 11:1 (1943). </li> <li>Elftman, H., The bipedal walking of the chimpanzee, J. Mammalogy, 25:67 (1944). </li> <li>Elftman, H., The carrying angle of the human arm as a secondary sex character, Anat. Rec, 91:49 (1945). </li> <li>Elftman, H., The orientation of the joints of the lower extremity, Bull. Hosp. Joint Diseases, VI-.139 (1945). </li> <li>Elftman, H., Torsion of the lower extremity, Am. J. Phys. Anthropol., N.S. 3:255 (1945). </li> <li>Elftman, H., The basic pattern of human locomotion, Ann. N. Y. Acad. Sci., 51:1207 (1951). </li> <li>Elftman, Herbert, The functional structure of the lower limb, Chapter 14 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </li> <li>Elftman, Herbert, and John T. Manter, The axis of the human foot, Science, 80:484 (1934). </li> <li>Elftman, Herbert, and John Manter, Chimpanzee and human feel in bipedal walking, Am. J. Phys. Anthropol., 20:69 (1935). </li> <li>Elftman, H., and J. T. Manter, The evolution of the human fool, with especial reference to the joints, J. Anat., 70:56 (1935). </li> <li>Feinstein, Bertram, John N. K. Langton, R. M. Jameson, and Francis Schiller, Experiments on pain referred from deep somatic tissues, J. Bone and; Joint Surg!, 36A:981 (1954) </li> <li>Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs, Chapter 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </li> <li>Felkel, E. O., Determination of acceleration from displacement-time data, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 16, September 1951. </li> <li>Felkel, E. O., Determination of accelerations of the human leg during locomotion, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Winter 1951. </li> <li>Goodyear Tire and; Rubber Company, Akron, Ohio, Subcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], The development of a foot prosthesis incorporating a metal structure and a bonded rubber to metal ankle joint, 1947. </li> <li>Gordan, G. S., B. Feinstein, and H. J. Ralston, Effect of testosterone upon atrophy of denervated skeletal muscle, Exper. Med. and; Surg., 7:327 (1949). </li> <li>Hosmer Corp., A. J., Santa Monica, Calif., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Hydraulic weight bearing knee lock for knee dis-articidation amputations; work arms for wrist disarticulations, below and above elbow amputations; work tools and devices for vocational rehabilitation; hydraulic control to actuate hooks and hands used on work arms; improved design hook, 1947. </li> <li>Inman, V. T., Functional aspects of the abductor muscles of the hip, J. Bone and; Joint Surg., 29:607 (1947). </li> <li>Inman, V. T., Theoretical requirements of a lower-extremity prosthesis, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, December 22, 1950. </li> <li>Inman, V. T., Innervation of the extremities, 3rd Biennial Western Conference on Anesthesiology, The California Society of Anesthesiologists and the Northwestern Society of Anesthesiologists, Los Angeles, 1953. p. 22. </li> <li>Inman, V. T., B. Feinstein, and H. J. Ralston, Some observations on electromyography, Am. J. Physiol., 155:445 (1948). </li> <li>Inman, Verne T., H. J. Ralston, J. B. deC. M. Saunders, Bertram Feinstein, and Elwood W. Wright, Jr., Relation of human electromyogram lo muscular tension, University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Report to the Advisory Committee on Artificial Limbs, National Research Council, November 1951. </li> <li>Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </li> <li>Inman, V. T., H. J. Ralston, J. B. deC. M. Saunders, B. Feinstein, and E. W. Wright, Jr., Relation of human electromyogram lo muscular tension, Electroencephalog. and; Clin. Neuro-physiol., 4:187 (1952). </li> <li>Levens, A. S., V. T. Inman, and J. A. Blosser, Transverse rotation of the segments of the lower extremity in locomotion, J. Bone and; Joint Surg., 30A:859 (1948). </li> <li>Libet, B., Neuromuscular facilitation by stretch, and the duration of muscular activation in locomotion, Proc. 19th Internat. Physiol. Cong., Montreal, 1953. p. 563. </li> <li>Libet, B., and B. Feinstein, Analysis of changes in electromyogram (EMG) with changing muscle length, Am. J. Physiol., 167:805 (1951). </li> <li>Libet, Benjamin, and Bertram Feinstein, Human electromyogram, Surg. Forum, W. B. Saunders Co., Philadelphia, 1952. p. 415. </li> <li>Libet, Benjamin, H. J. Ralston, and Bertram Feinstein, The effect of stretch on action potential in muscle, Biol. Bull., 101:194 (1951). </li> <li>Libet, B., and E. W. Wright, Jr., Facilitation at neuromuscular functions by stretch of muscle, Fed. Proc, 11:94 (1952). </li> <li>Livingston, Kenneth E., The phantom limb syndrome: a discussion of the role of major peripheral nerve neuromas, J. Neurosurg., 2:251 (1945). </li> <li>Mitchell, S. Weir, Phantom limbs, Lippincott's Mag. Pop. Lit. So, 8:563 (1871). </li> <li>National Research and Manufacturing Company, San Diego, Calif., Subcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], An investigation of low pressure laminates for prosthetic devices; design and fabrication of above-knee and below-knee artificial legs; preparation of a production survey for manufacture of artificial plastic legs, 1947. </li> <li>New York University, Prosthetic Devices Study, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Shakedown lest of the Navy above-knee prosthesis, May 1951. </li> <li>New York University, Prosthetic Devices Study, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The functional and psychological suitability of an experimental hydraulic prosthesis for above-the-knee amputees, March 1953. </li> <li>Northrop Aircraft, Inc., Hawthorne, Calif., Subcontractor's Final Report [to the] Committee on Artificial Limbs, National Research Council (Contract VAm-21223), A report on prosthesis development, 1947. </li> <li>Northwestern Technological Institute, Evanston, III., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, A review of the literature, patents, and manufactured items concerned with artificial legs, arms, arm harnesses, hands, and hooks; mechanical testing of artificial legs, 1947. </li> <li>Pare, A., from T. Johnson, The works of that famous chirurgion, Ambrose Parey, translated out of the Latine and compared with the French, Richard Cotes and Willi: Du-gard, London, 1649. </li> <li>Polissar, M. J., Concentration and potential pattern within the membrane and its relation lo penetration of ions and lo time constants of electrolonus and accommodation, Fed. Proc, 11:124 (1952). </li> <li>Polissar, M. J., Physical chemistry of contractile process in muscle. I. A physiochemical model of contractile mechanism, Am. J. Physiol., 168:766 (1952). </li> <li>Polissar, M. J., Physical chemistry of contractile process in muscle. II. Analysis of other mechano-chemical properties of muscle, Am. J. Physiol., 168:782 (1952). </li> <li>Polissar, M. J., Physical chemistry of contractile process in muscle. III. Interpretation of thermal behavior of stimulated muscle, Am. J. Physiol.. 168:793 (1952). </li> <li>Polissar, M. J., Physical chemistry of contractile process in muscle. IV. Estimates of size of contractile unit, Am. J. Physiol., 168:805 (1952). </li> <li>Radcliffe, C. W., Flexion stiffness of prosthetic ankle joints, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, May 1949. </li> <li>Radcliffe, C. W., Information useful in the design of damping mechanisms for artificial knee joints, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1950. </li> <li>Radcliffe, C. W., Use of the adjustable knee and alignment jig for the alignment of above knee prostheses, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, August 1951. </li> <li>Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954. p. 23ff. </li> <li>Radcliffe, Charles W., Alignment of the above-knee artificial leg, Chapter 21 in Klopsteg and Wilson's Humanlimbs andtheirsubstitutes, McGraw-Hill, New York, 1954. Especially pp. 686-688. </li> <li>Ralston, H. J., Muscle dynamics, Surgical Forum (1951), American College of Surgeons, Clinical Congress, W. B. Saunders, Philadelphia, 1952. p. 418.</li> <li>Ralston, H J., Isometric tension in the intact human quadriceps, Proc. 19th Internat. Physiol. Cong., Montreal, 1953. p. 692. </li> <li>Ralston, H. J., Mechanics o] voluntary muscle, Am. J Phys. Med., 32:166 (1953). </li> <li>Ralston, H. J., J R Close, V T. Inman, and B. Feinstein, Dynamical and electrical features of human isolated voluntary muscle in isometric and isotonic contraction, Fed. Proc, 7:97 (1948). </li> <li>Ralston, H. J., H. D. Eberhart, V. T. Inman, and M. D. Shaffrath, Length-tension relationships in isolated human voluntary muscle, Proc. 17th Internat. Physiol. Cong., Oxford, 1947. p. 110. </li> <li>Ralston, H J., B. Feinstein, and V. T. Inman Rate of atrophy in muscles immobilized at different lengths, Fed. Proc, 11:127 (1952). </li> <li>Ralston, H. J., V. T. Inman, B. Feinstein, and B. Libet, Human electromyogram, Am. J. Physiol., 163:743 (1950). </li> <li>Ralston, H. J., V. T. Inman, L. A. Strait, and M. D. Shaffrath, Mechanics of human isolated voluntary muscle, Am. J. Physiol., 151:612 (1947). </li> <li>Ralston, H. J., B. Libet, and E. W. Wright, Jr., Effect of stretch on action potential of voluntary muscle, Am. J. Physiol., 173:449 (1953). </li> <li>Ralston, H. J., and B. Libet, The question of tonus in skeletal muscle, Am. J. Phys. Med., 32:85 (1953). </li> <li>Ralston, H. J., M. J. Polissar, V. T. Inman, J. R. Close, and B. Feinstein, Dynamic features of human isolated voluntary muscle in isometric and, free contractions, J, Appl Physiol., 1:526 (1949). </li> <li>Ralston, H. J., E. W. Wright, Jr., B. Feinstein, and V. T. Inman, Effect of stretch upon action potential of voluntary muscle, Am. J. Physiol., 159:586 (1949). </li> <li>Ryker, N. J., Jr , Glass walkway studies of normal subjects during normal level walking, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 20, January 1952. </li> <li>Ryker, N. J., and S. H. Bartholomew, Determination of acceleration by use of accelerometers, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, September 1951. </li> <li>Saunders, J. B. deC. M., Verne T. Inman, and Howard D. Eberhart, The major determinants in normal and pathological gait, J. Bone and; Joint Surg., 35A(3):543 (1953) </li> <li>Schiller, F., Pain-controlled and uncontrolled, Science, 118:755 (1953). </li> <li>Spittler, A. W., and I. E. Rosen, Cineplaslic muscle motors for prostheses of arm amputees, J. Bone and; Joint Surg , 33A:601 (1951). 100. Strait, L. A., V. T. Inman, and H. J. Ralston, </li> <li> Sample illustrations of physical principles selected from physiology and medicine, Am. J. Physics, 15:375 (1947). </li> <li>Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasty, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York. 1954. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, Preliminary Report [to the] Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, September 1947. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, |Report to the] Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, revised edition, April 1948. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, Supplementary Report 2, The forces and moments in the leg during level walking, revised August 10, 1948. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, 3rd edition, April 1949. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Biceps cineplasty and prosthesis for below-elbow amputations, April 1950. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Functional considerations in fitting and alignment of the suction socket prosthesis, March 1952. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, Functional considerations in fitting and alignment of the suction socket prosthesis, 2nd ed., August 1953. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, The pattern of muscular activity in the lower extremity during wilking, September 1953. </li> <li>Wagner, Edmpnd M., Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954. p. 8. </li> <li>Wagner, Edmond M., and John G. Catranis, New developments in lower-exlremity prostheses, Chapter 17 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. p. 482. </li> <li>Wagner and Catranis, op. cit., p. 511. </li> <li>Weddell, G., B. Feinstein, and R. E. Pattle, Electrical activity of voluntary muscle in man under normal and pathological conditions, Brain, 67:178 (1944). </li> <li>Wohlfart, G., B. Feinstein, and J. Fex, Uber die Bieziehung zwischen electromyographischen und anatomischen Befunden in normalen Muskeln und bei neuromuskularen Erkrankungen, Arch. f. Psychiat. u. Ztschr. Neurol., 191:478 (1954). </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Brown, E., and N. Foreman, Studies of skin temperature and of indirect vasodilatation in amputation stumps, Am. J. Med., 10:112 (1951). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>65.</b> </td><td class="clsTextSmall">Livingston, Kenneth E., The phantom limb syndrome: a discussion of the role of major peripheral nerve neuromas, J. Neurosurg., 2:251 (1945). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>66.</b> </td><td class="clsTextSmall">Mitchell, S. Weir, Phantom limbs, Lippincott's Mag. Pop. Lit. So, 8:563 (1871). </td></tr><tr><td class="clsTextSmall"><b>72.</b> </td><td class="clsTextSmall">Pare, A., from T. Johnson, The works of that famous chirurgion, Ambrose Parey, translated out of the Latine and compared with the French, Richard Cotes and Willi: Du-gard, London, 1649. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Bechtol, Charles O., The principles of prosthetic prescription, Chapter 6 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Bechtol, Charles 0., The prosthetics clinic team, Artificial Limbs, January 1954. p. 9. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>88.</b> </td><td class="clsTextSmall">Ralston, H J., B. Feinstein, and V. T. Inman Rate of atrophy in muscles immobilized at different lengths, Fed. Proc, 11:127 (1952). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>97.</b> </td><td class="clsTextSmall">Saunders, J. B. deC. M., Verne T. Inman, and Howard D. Eberhart, The major determinants in normal and pathological gait, J. Bone and; Joint Surg., 35A(3):543 (1953) </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>97.</b> </td><td class="clsTextSmall">Saunders, J. B. deC. M., Verne T. Inman, and Howard D. Eberhart, The major determinants in normal and pathological gait, J. Bone and; Joint Surg., 35A(3):543 (1953) </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>68.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Shakedown lest of the Navy above-knee prosthesis, May 1951. </td></tr><tr><td class="clsTextSmall"><b>112.</b> </td><td class="clsTextSmall">Wagner, Edmpnd M., Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954. p. 8. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>79.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Information useful in the design of damping mechanisms for artificial knee joints, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1950. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>59.</b> </td><td class="clsTextSmall">Levens, A. S., V. T. Inman, and J. A. Blosser, Transverse rotation of the segments of the lower extremity in locomotion, J. Bone and; Joint Surg., 30A:859 (1948). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>98.</b> </td><td class="clsTextSmall">Schiller, F., Pain-controlled and uncontrolled, Science, 118:755 (1953). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>45.</b> </td><td class="clsTextSmall">Feinstein, Bertram, John N. K. Langton, R. M. Jameson, and Francis Schiller, Experiments on pain referred from deep somatic tissues, J. Bone and; Joint Surg!, 36A:981 (1954) </td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs, Chapter 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>109.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>54.</b> </td><td class="clsTextSmall">Inman, V. T., Innervation of the extremities, 3rd Biennial Western Conference on Anesthesiology, The California Society of Anesthesiologists and the Northwestern Society of Anesthesiologists, Los Angeles, 1953. p. 22. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>109.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>65.</b> </td><td class="clsTextSmall">Livingston, Kenneth E., The phantom limb syndrome: a discussion of the role of major peripheral nerve neuromas, J. Neurosurg., 2:251 (1945). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>114.</b> </td><td class="clsTextSmall">Wagner and Catranis, op. cit., p. 511. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Contini, Renato, Prosthetics research and the engineering profession, Artificial Limbs, 1(3):47 (September 1954). p. 58. </td></tr><tr><td class="clsTextSmall"><b>69.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The functional and psychological suitability of an experimental hydraulic prosthesis for above-the-knee amputees, March 1953. </td></tr><tr><td class="clsTextSmall"><b>112.</b> </td><td class="clsTextSmall">Wagner, Edmpnd M., Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954. p. 8. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>78.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Flexion stiffness of prosthetic ankle joints, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, May 1949. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>48.</b> </td><td class="clsTextSmall">Felkel, E. O., Determination of accelerations of the human leg during locomotion, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Winter 1951. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">'Bartholomew, S. H., Determination of knee moments during the swing phase of walking and physical constants of the human shank, University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, January 1952. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Bresler, B,, and F. R. Berry, Energy and power in the leg during normal level walking, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, May 1951. </td></tr><tr><td class="clsTextSmall"><b>102.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes. </td></tr><tr><td class="clsTextSmall"><b>105.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Supplementary Report 2, The forces and moments in the leg during level walking, revised August 10, 1948. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Inman, V. T., Theoretical requirements of a lower-extremity prosthesis, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, December 22, 1950. </td></tr><tr><td class="clsTextSmall"><b>97.</b> </td><td class="clsTextSmall">Saunders, J. B. deC. M., Verne T. Inman, and Howard D. Eberhart, The major determinants in normal and pathological gait, J. Bone and; Joint Surg., 35A(3):543 (1953) </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Eberhart, Howard D., Herbert Elftman, and Verne T. Inman, The locomtor [sic] mechanism of the amputee, Chapter 16 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Elftman, H., The basic pattern of human locomotion, Ann. N. Y. Acad. Sci., 51:1207 (1951). </td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Elftman, Herbert, The functional structure of the lower limb, Chapter 14 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Bresler, B., Use of energy methods for evaluation of prostheses, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, September 1951. </td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Bressler [sic], B., and F. R. Berry, Energy characteristics of normal and prosthetic ankle joints, University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, April 1950. </td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Bresler, B,, and F. R. Berry, Energy and power in the leg during normal level walking, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, May 1951. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Buchthal, Fritz, and E. Kaiser, Optimum mechanical conditions for work of skeletal muscle, Acta Psychiat. et Neurol., 24:333 (1949). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Buchthal, Fritz, and E. Kaiser, Optimum mechanical conditions for work of skeletal muscle, Acta Psychiat. et Neurol., 24:333 (1949). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Blaschke, Alfred C, and Craig L. Taylor, The mechanical design of muscle-operated arm prostheses, J. Franklin Inst., 266:435 (1953). </td></tr><tr><td class="clsTextSmall"><b>101.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasty, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York. 1954. </td></tr><tr><td class="clsTextSmall"><b>107.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Biceps cineplasty and prosthesis for below-elbow amputations, April 1950. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., The cineplaslic method in upper-extremity amputations, J. Bone and; Joint Surg., 30A:359 (1948). </td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasty, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. 4.</td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Blaschke, A. C, and C. L.Taylor, Biomechanical considerations in cineplasty, University of California (Los Angeles), Department of Engineering, Special Technical Report 18, 1951. </td></tr><tr><td class="clsTextSmall"><b>99.</b> </td><td class="clsTextSmall">Spittler, A. W., and I. E. Rosen, Cineplaslic muscle motors for prostheses of arm amputees, J. Bone and; Joint Surg , 33A:601 (1951). 100. Strait, L. A., V. T. Inman, and H. J. Ralston, </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>57.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">Libet, Benjamin, H. J. Ralston, and Bertram Feinstein, The effect of stretch on action potential in muscle, Biol. Bull., 101:194 (1951). </td></tr><tr><td class="clsTextSmall"><b> 64.</b> </td><td class="clsTextSmall">Libet, B., and E. W. Wright, Jr., Facilitation at neuromuscular functions by stretch of muscle, Fed. Proc, 11:94 (1952). </td></tr><tr><td class="clsTextSmall"><b>83.</b> </td><td class="clsTextSmall">Ralston, H. J., Muscle dynamics, Surgical Forum (1951), American College of Surgeons, Clinical Congress, W. B. Saunders, Philadelphia, 1952. p. 418.</td></tr><tr><td class="clsTextSmall"><b>84.</b> </td><td class="clsTextSmall">Ralston, H J., Isometric tension in the intact human quadriceps, Proc. 19th Internat. Physiol. Cong., Montreal, 1953. p. 692. </td></tr><tr><td class="clsTextSmall"><b>85.</b> </td><td class="clsTextSmall">Ralston, H. J., Mechanics o] voluntary muscle, Am. J Phys. Med., 32:166 (1953). </td></tr><tr><td class="clsTextSmall"><b>86.</b> </td><td class="clsTextSmall">Ralston, H. J., J R Close, V T. Inman, and B. Feinstein, Dynamical and electrical features of human isolated voluntary muscle in isometric and isotonic contraction, Fed. Proc, 7:97 (1948). </td></tr><tr><td class="clsTextSmall"><b>87.</b> </td><td class="clsTextSmall">Ralston, H. J., H. D. Eberhart, V. T. Inman, and M. D. Shaffrath, Length-tension relationships in isolated human voluntary muscle, Proc. 17th Internat. Physiol. Cong., Oxford, 1947. p. 110. </td></tr><tr><td class="clsTextSmall"><b>90.</b> </td><td class="clsTextSmall">Ralston, H. J., V. T. Inman, L. A. Strait, and M. D. Shaffrath, Mechanics of human isolated voluntary muscle, Am. J. Physiol., 151:612 (1947). </td></tr><tr><td class="clsTextSmall"><b>91.</b> </td><td class="clsTextSmall">Ralston, H. J., B. Libet, and E. W. Wright, Jr., Effect of stretch on action potential of voluntary muscle, Am. J. Physiol., 173:449 (1953). </td></tr><tr><td class="clsTextSmall"><b>93.</b> </td><td class="clsTextSmall">Ralston, H. J., M. J. Polissar, V. T. Inman, J. R. Close, and B. Feinstein, Dynamic features of human isolated voluntary muscle in isometric and, free contractions, J, Appl Physiol., 1:526 (1949). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Blix, Magnus, Die Lange und die Spannung des Muskels, Scandinav. Arch. f. Physiol., 6:150 (1894). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>115.</b> </td><td class="clsTextSmall">Weddell, G., B. Feinstein, and R. E. Pattle, Electrical activity of voluntary muscle in man under normal and pathological conditions, Brain, 67:178 (1944). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>55.</b> </td><td class="clsTextSmall">Inman, V. T., B. Feinstein, and H. J. Ralston, Some observations on electromyography, Am. J. Physiol., 155:445 (1948). </td></tr><tr><td class="clsTextSmall"><b>56.</b> </td><td class="clsTextSmall">Inman, Verne T., H. J. Ralston, J. B. deC. M. Saunders, Bertram Feinstein, and Elwood W. Wright, Jr., Relation of human electromyogram lo muscular tension, University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Report to the Advisory Committee on Artificial Limbs, National Research Council, November 1951. </td></tr><tr><td class="clsTextSmall"><b>58.</b> </td><td class="clsTextSmall">Inman, V. T., H. J. Ralston, J. B. deC. M. Saunders, B. Feinstein, and E. W. Wright, Jr., Relation of human electromyogram lo muscular tension, Electroencephalog. and; Clin. Neuro-physiol., 4:187 (1952). </td></tr><tr><td class="clsTextSmall"><b>61.</b> </td><td class="clsTextSmall">Libet, B., and B. Feinstein, Analysis of changes in electromyogram (EMG) with changing muscle length, Am. J. Physiol., 167:805 (1951). </td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">Libet, Benjamin, and Bertram Feinstein, Human electromyogram, Surg. Forum, W. B. Saunders Co., Philadelphia, 1952. p. 415. </td></tr><tr><td class="clsTextSmall"><b>89.</b> </td><td class="clsTextSmall">Ralston, H. J., V. T. Inman, B. Feinstein, and B. Libet, Human electromyogram, Am. J. Physiol., 163:743 (1950). </td></tr><tr><td class="clsTextSmall"><b> 116.</b> </td><td class="clsTextSmall">Wohlfart, G., B. Feinstein, and J. Fex, Uber die Bieziehung zwischen electromyographischen und anatomischen Befunden in normalen Muskeln und bei neuromuskularen Erkrankungen, Arch. f. Psychiat. u. Ztschr. Neurol., 191:478 (1954). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>60.</b> </td><td class="clsTextSmall">Libet, B., Neuromuscular facilitation by stretch, and the duration of muscular activation in locomotion, Proc. 19th Internat. Physiol. Cong., Montreal, 1953. p. 563. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Blaschke, A. C, General energy considerations and determination of muscle forces in the mechanics of human bodies, University of California (Los Angeles), Department of Engineering [Contractor's Memorandum Report No. 9 to the Advisory Committee on Artificial Limbs, National Research Council], September 1950.</td></tr><tr><td class="clsTextSmall"><b>52.</b> </td><td class="clsTextSmall">Inman, V. T., Functional aspects of the abductor muscles of the hip, J. Bone and; Joint Surg., 29:607 (1947). </td></tr><tr><td class="clsTextSmall"><b>111.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, The pattern of muscular activity in the lower extremity during wilking, September 1953. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>73.</b> </td><td class="clsTextSmall">Polissar, M. J., Concentration and potential pattern within the membrane and its relation lo penetration of ions and lo time constants of electrolonus and accommodation, Fed. Proc, 11:124 (1952). </td></tr><tr><td class="clsTextSmall"><b>74.</b> </td><td class="clsTextSmall">Polissar, M. J., Physical chemistry of contractile process in muscle. I. A physiochemical model of contractile mechanism, Am. J. Physiol., 168:766 (1952). </td></tr><tr><td class="clsTextSmall"><b>75.</b> </td><td class="clsTextSmall">Polissar, M. J., Physical chemistry of contractile process in muscle. II. Analysis of other mechano-chemical properties of muscle, Am. J. Physiol., 168:782 (1952). </td></tr><tr><td class="clsTextSmall"><b>76.</b> </td><td class="clsTextSmall">Polissar, M. J., Physical chemistry of contractile process in muscle. III. Interpretation of thermal behavior of stimulated muscle, Am. J. Physiol.. 168:793 (1952). </td></tr><tr><td class="clsTextSmall"><b>77.</b> </td><td class="clsTextSmall">Polissar, M. J., Physical chemistry of contractile process in muscle. IV. Estimates of size of contractile unit, Am. J. Physiol., 168:805 (1952). </td></tr><tr><td class="clsTextSmall"><b>92.</b> </td><td class="clsTextSmall">Ralston, H. J., and B. Libet, The question of tonus in skeletal muscle, Am. J. Phys. Med., 32:85 (1953). </td></tr><tr><td class="clsTextSmall"><b>100.</b> </td><td class="clsTextSmall"> Sample illustrations of physical principles selected from physiology and medicine, Am. J. Physics, 15:375 (1947). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">'Bartholomew, S. H., Determination of knee moments during the swing phase of walking and physical constants of the human shank, University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, January 1952. </td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Berry, F. R., Jr., Angle variation patterns of normal hip, knee and ankle in different operations, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 21, February 1952. </td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Bressler [sic], B., and F. R. Berry, Energy characteristics of normal and prosthetic ankle joints, University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, April 1950. </td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Bresler, B,, and F. R. Berry, Energy and power in the leg during normal level walking, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, May 1951. </td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Close, J. R., and V. T. Inman, The action of the ankle joint, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1952. </td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Close, J. R., and V T. Inman, The action of the subtalar joint, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 24, May 1953. </td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Cunningham, D. M., Components oj floor reactions during walking, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, November 1950. </td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">Felkel, E. O., Determination of acceleration from displacement-time data, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 16, September 1951. </td></tr><tr><td class="clsTextSmall"><b>48.</b> </td><td class="clsTextSmall">Felkel, E. O., Determination of accelerations of the human leg during locomotion, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Winter 1951. </td></tr><tr><td class="clsTextSmall"><b>96.</b> </td><td class="clsTextSmall">Ryker, N. J., and S. H. Bartholomew, Determination of acceleration by use of accelerometers, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, September 1951. </td></tr><tr><td class="clsTextSmall"><b>105.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Supplementary Report 2, The forces and moments in the leg during level walking, revised August 10, 1948. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>103.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Preliminary Report [to the] Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, September 1947. </td></tr><tr><td class="clsTextSmall"><b>104.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, |Report to the] Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, revised edition, April 1948. </td></tr><tr><td class="clsTextSmall"><b>106.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, 3rd edition, April 1949. </td></tr><tr><td class="clsTextSmall"><b>108.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Functional considerations in fitting and alignment of the suction socket prosthesis, March 1952. </td></tr><tr><td class="clsTextSmall"><b>110.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, Functional considerations in fitting and alignment of the suction socket prosthesis, 2nd ed., August 1953. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The 1947 report contains an extensive bibliography of earlier work, mostly German, on the mechanism of human locomotion and on related matters. It is available, either in photostat form or on microfilm, from the U. S. Armed Forces Medical Library, 7th Street and Independence Ave., S. W., Washington 25, D. C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>102.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Elftman, H., A cinematic study of the distribution of pressure in the human fool, Anat. Rec, 69:481 (1934). </td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Elftman, H, The measurement of the external force in walking, Science, 88:152 (1938). </td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Elftman, H., The rotation of the body in walking, Arbeitsphysiol., 10:219 (1938). </td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Elftman, H., The force exerted by the ground in walking, Arbeitsphysiol., 10:485 (1938). </td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Elftman, H., Forces and energy changes in the leg during walking, Am. J. Physiol., 125:339 (1939). </td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Elftman, H., The function of muscles in locomotion, Am. J. Physiol., 125:357 (1939). </td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Elftman, H., The function of the arms in walking, Human Biol., 11:529 (1939). </td></tr><tr><td class="clsTextSmall"><b>33.</b> </td><td class="clsTextSmall">Elftman, Herbert, The work done by muscles in running, Am. J. Physiol , 129:672 (1940). </td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">Elftman, H., The action of muscles in the body, Biol. Symposia, 3:191 (1941).</td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Elftman, H., Experimental studies on the dynamics of human walking, Trans. N. Y. Acad. Sci., 11:1 (1943). </td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Elftman, H., The bipedal walking of the chimpanzee, J. Mammalogy, 25:67 (1944). </td></tr><tr><td class="clsTextSmall"><b>37.</b> </td><td class="clsTextSmall">Elftman, H., The carrying angle of the human arm as a secondary sex character, Anat. Rec, 91:49 (1945). </td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Elftman, H., The orientation of the joints of the lower extremity, Bull. Hosp. Joint Diseases, VI-.139 (1945). </td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Elftman, H., Torsion of the lower extremity, Am. J. Phys. Anthropol., N.S. 3:255 (1945). </td></tr><tr><td class="clsTextSmall"><b> 42.</b> </td><td class="clsTextSmall">Elftman, Herbert, and John T. Manter, The axis of the human foot, Science, 80:484 (1934). </td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Elftman, Herbert, and John Manter, Chimpanzee and human feel in bipedal walking, Am. J. Phys. Anthropol., 20:69 (1935). </td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Elftman, H., and J. T. Manter, The evolution of the human fool, with especial reference to the joints, J. Anat., 70:56 (1935). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Adel Precision Products Corp., Burbank, Calif.,Subcontractor's Final Report [to the] Committee on Artificial Limbs, National Research Council, The development of a hydraulically operated artificial leg for above knee amputations, 1947. </td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall"> Bradley, C. A, and Son, Inc., and Catranis, Inc., Syracuse, N. Y., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Artificial limb development for above-knee amputees including mechanical and hydraulic knee locks; suction socket and suction socket controls; knee lock controls operated by hip motion, stump muscles and foot position; toe pick up and foot providing lateral, plantar and dorsal flexion, July 1947. </td></tr><tr><td class="clsTextSmall"><b>49.</b> </td><td class="clsTextSmall">Goodyear Tire and; Rubber Company, Akron, Ohio, Subcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], The development of a foot prosthesis incorporating a metal structure and a bonded rubber to metal ankle joint, 1947. </td></tr><tr><td class="clsTextSmall"><b>51.</b> </td><td class="clsTextSmall">Hosmer Corp., A. J., Santa Monica, Calif., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Hydraulic weight bearing knee lock for knee dis-articidation amputations; work arms for wrist disarticulations, below and above elbow amputations; work tools and devices for vocational rehabilitation; hydraulic control to actuate hooks and hands used on work arms; improved design hook, 1947. </td></tr><tr><td class="clsTextSmall"><b>67.</b> </td><td class="clsTextSmall">National Research and Manufacturing Company, San Diego, Calif., Subcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], An investigation of low pressure laminates for prosthetic devices; design and fabrication of above-knee and below-knee artificial legs; preparation of a production survey for manufacture of artificial plastic legs, 1947. </td></tr><tr><td class="clsTextSmall"><b>71.</b> </td><td class="clsTextSmall">Northwestern Technological Institute, Evanston, III., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, A review of the literature, patents, and manufactured items concerned with artificial legs, arms, arm harnesses, hands, and hooks; mechanical testing of artificial legs, 1947. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Eberhart, Howard D., The objectives of the lower extremity prosthetics program, Artificial Limbs, May 1954. p. 4. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Eberhart, H. D., and V. T. Inman, An evaluation of experimental procedures used in a fundamental study of human locomotion, Ann. N. Y. Acad. Sci., 51:1213 (1951). </td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Eberhart, Howard D., Verne T. Inman, and Boris Bresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>80.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Use of the adjustable knee and alignment jig for the alignment of above knee prostheses, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, August 1951. </td></tr><tr><td class="clsTextSmall"><b>81.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954. p. 23ff. </td></tr><tr><td class="clsTextSmall"><b>82.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Alignment of the above-knee artificial leg, Chapter 21 in Klopsteg and Wilson's Humanlimbs andtheirsubstitutes, McGraw-Hill, New York, 1954. Especially pp. 686-688. </td></tr><tr><td class="clsTextSmall"><b>95.</b> </td><td class="clsTextSmall">Ryker, N. J., Jr , Glass walkway studies of normal subjects during normal level walking, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 20, January 1952. </td></tr><tr><td class="clsTextSmall"><b>102.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes. </td></tr><tr><td class="clsTextSmall"><b> 112.</b> </td><td class="clsTextSmall">Wagner, Edmpnd M., Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954. p. 8. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>113.</b> </td><td class="clsTextSmall">Wagner, Edmond M., and John G. Catranis, New developments in lower-exlremity prostheses, Chapter 17 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. p. 482. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>70.</b> </td><td class="clsTextSmall">Northrop Aircraft, Inc., Hawthorne, Calif., Subcontractor's Final Report [to the] Committee on Artificial Limbs, National Research Council (Contract VAm-21223), A report on prosthesis development, 1947. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Howard D. Eberhart, M.S. </b></td></tr><tr><td class="clsTextSmall">Professor of Civil Engineering, University of California, Berkeley; member, Advisory Committee on Artificial Limbs, National Research Council, and of the Technical Committee on Prosthetics, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>VerneT. Inman, M.D., Ph.D., </b></td></tr><tr><td class="clsTextSmall">Professor of Orthopedic Surgery, School of Medicine, University of California, San Francisco; Professional Associate, Advisory Committee on Artificial Limbs, National Research Council; member, Technical Committee on Prosthetics, ACAL, NRC. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-12.jpg Figure 12 http://www.oandplibrary.org/al/images/1955_01_004/table01.jpg Figure 13 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Lower-Extremity Clinical Study-Its Background and Objectives Creator An entity primarily responsible for making the resource VerneT. Inman, M.D., Ph.D., * Howard D. Eberhart, M.S. * https://staging.drfop.org/files/original/e35faf467e1ea9e763ac08ddcf0dbfd3.pdf 1f9fe1e89568efceb15d185fd6f39011 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_03_001.pdf Year 1955 Volume 2 Issue 3 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_03_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_03_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Harnessing- Here and Hereafter</h2> <h5>John Lyman, PhD <a style="text-decoration:none;">*</a><br /></h5> <p>However well designed the other parts of an artificial arm may be, the functional success of the upper-extremity prosthesis must ultimately depend upon the adequacy of the coupling between the human being and the inanimate mechanism. Since this man-machine linkage is intended to hold the arm on the stump and to secure from residual body sources the mechanical power necessary for operation and control of the prosthesis, the technique of constructing it has come to be known simply as "harnessing." Because body harness is such ah intimate piece of apparel, and because arm amputees exhibit the same kinds of individual differences as characterize the rest of the population, it seems likely that proper harnessing will long remain a tribute to the personal skill of the prosthetist, despite all advances in prefabricated components. Although the clinic team may prescribe the specifications for a prosthesis within the existing framework of medical and engineering knowledge, the final result depends largely upon the prosthetist's talent for constructing and fitting the harness in such a way as to meet anatomical, physiological, and functional requirements.</p> <p>Functionally, the harness may serve one or more of three purposes: it may hold the prosthesis in place; it may transmit power and excursion to produce force and movement in operating components; it may convey to the wearer the intelligence needed for arm control. In conventional construction of upper-extremity prostheses, it has been customary to rely upon the harness for the performance of all three of these services and, further, to obtain them all from a single harness system. Such an arrangement is of course grossly unlike that of the normal limb, where the control function, mediated by the nervous system, is clearly separated from the functions of suspension and of power transmission. Only in externally powered prostheses, as for examples the TBM Electric Arm and the Vaduz hand, has an attempt been made to separate the control function from the power and suspensory functions. Although to date such devices have not proved to be as useful or reliable as simpler ones, they are representative of an approach which may, in the long run, lead to far more refined limb substitutes than can be contemplated by further development of a harnessing philosophy which stresses the combining of suspension, power transmission, and control.</p> <p>The use of body power for operating an artificial arm forms an inherent control link between the neuromuscular system and the prosthesis. To the extent that a "closed loop" is effected via the sensory feedback available to the power-producing muscles, control of force and excursion through the power-transmission system is possible without the aid of external sensory-feedback loops such as vision and hearing. While the latter cues are generally present, they can at best serve only in an auxiliary capacity. The rich sensations of touch, pressure, pain, and temperature, which have been lost with the natural limb, have no substitute beyond their dim reflection in the signals from harness strap or cineplasty muscle pin of present-day prosthetics technology.</p> <p>One can argue, with considerable sustaining evidence, that the modern arm prosthesis is quite functionally adequate in most respects and that the addition of refinements in the form of further sensory cues for improved control would only complicate harnessing unnecessarily. But to take this viewpoint is paying tribute to the adaptability of the human mechanism rather than to the adequacy of today's prosthetics research and development. As facts currently stand, it appears that no clear-cut assessment has been made of the importance of sensory losses to the amputee. The effort has been to achieve prosthetic replacement of motor function, and it still is not generally recognized that this goal has been approached with the present degree of success only because sensory control loops are established incidentally in the course of harnessing for power transmission. The major inadequacies leading to failure in externally powered prostheses can be traced directly to shortcomings in the design of control loops-loops which are intrinsic even in the crudest of body-powered prostheses.</p> <p>Since in the present state of the art the optimum connection between the amputee and the operating mechanism is still so indispensable to the proper functioning of the upper-extremity prosthesis, this issue of Artificial Limbs is devoted to a summary of current harnessing technology as developed under the auspices of the Advisory Committee on Artificial Limbs. Although progress in the improvement of body harness has been substantial since World War II, even the latest techniques fall far short of duplicating the neuromuscular mechanism of the normal arm. And consequently there is still a great deal of forward-looking to be done in the research, development, and production phases of upper-extremity prosthetics.</p> <p>Where will the technology come from that may make possible "sensory prostheses" with attendant refinements in the present "motor prostheses"? Probably not directly from current trends in artificial-limb research. As is common knowledge, a very real and dynamic revolution is under way in the modern engineering sciences. It is accompanied by a plethora of popular terms like"cybernetics," "servomechanisms," "information theory," "digital and analogue computers," and "automation," to name a few. From the developments that are taking place, many new materials and processes are becoming available. Just as the aircraft industry, through the Northrop design studies, has contributed the present lightweight plastic artificial arm and the Bowden-cable transmission system, so it may be anticipated that within a relatively few years the electronics and missile industries may make even greater contributions. Compact, reliable, and lightweight items like the famed transistor may become as commonplace in the control systems for artificial arms as is presently the case in hearing aids. New products from metallurgy and chemistry may eventually make it possible to realize direct attachment of prosthetic devices to remaining skeletal members of the body through the skin and surrounding tissue, with consequent elimination of the socket and of the suspensory elements of harness. Much of the theory and much of the methodology for accomplishing the direct coupling of man to mechanism, including the all-important link to the nervous system for control, are either available already or else are promised within the foreseeable future.</p> <p>Because in the field of amputee rehabilitation there are never apt to be available the amounts of research money now characteristic of other fields of science and invention, it is fortunate that a systematic plan for the advancement of limb prosthetics has become so well established in the decade since World War II. The Artificial Limb Program furnishes an organized means of following progress in other areas and of adapting to limb substitutes new approaches and new techniques that would otherwise lie far beyond the purse of prosthetics research itself. The future in design of limb replacements is thus perhaps now greater than ever before. Even so, no matter how sophisticated upper-extremity prostheses may become, the actual utility of any given artificial arm will continue to reside largely in the degree to which the fitter can attain the optimum sensory-motor association through accomplished harnessmaking. In no other known way can so much satisfaction be afforded the individual arm amputee.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>John Lyman, PhD </b></td></tr><tr><td class="clsTextSmall">Assistant Professor of Engineering, University of California, Los Angeles.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Harnessing- Here and Hereafter Creator An entity primarily responsible for making the resource John Lyman, PhD * https://staging.drfop.org/files/original/69dcd7caf7126245f67c576a23eed259.pdf b7b6157c3a00c22ce04eab5fcbcd9bd3 https://staging.drfop.org/files/original/cd52e34d44c4e57526a5fce138f7f698.jpg 7a198c7f047f773bbc6304cfba3cf5ca https://staging.drfop.org/files/original/5d7294a2a8e341f658d1da509204af9b.jpg 7bd95a76b3d734667480ec0dfa10627e https://staging.drfop.org/files/original/41aca07379059375c3292b724c20ad74.jpg 1d4152198663676bd39749aa3927f9a9 https://staging.drfop.org/files/original/67da595e2b69a4eddfa254d7f3e4af1b.jpg 37ef26f3aa707b94fe6ce8c247500085 https://staging.drfop.org/files/original/9b09d3285dd63986158fb6ad3ff17829.jpg 1834799a9a45cb6e9a6a14ebdaeaf347 https://staging.drfop.org/files/original/01becc70231689f01d3e23078ca3d426.jpg a30c1c89e6080e63e83f5a4d21259851 https://staging.drfop.org/files/original/c837aee0438447ad78993b03f0c6c200.jpg a8318e44f6a4c5f16bad1e856293ce4f https://staging.drfop.org/files/original/b42005d371ab6bcdfafd2938aebf111f.jpg e14968ee1a57f38cdb7f3d3f58869784 https://staging.drfop.org/files/original/6d838654a7a10c9c607154be00da4967.jpg 6487b2156f041d65856f1b7fbd7fce04 https://staging.drfop.org/files/original/c721165ea01198ee6aef4e31acd0fdac.jpg f2e09c1ac6e6f04fc5b0a5eb66bcbd18 https://staging.drfop.org/files/original/86e71ac88dc77c0fe807c5821fd82c2a.jpg c276be77977e747e8b61adff1578acb7 https://staging.drfop.org/files/original/594db7f923eba326a0a22d4a72240941.jpg 37b19234f934f0937579f96fc8254bfe https://staging.drfop.org/files/original/7911660ec28bd9831354b1be9725eb7d.jpg 83d75d5dd8bf9a0f175a066cfac8db09 https://staging.drfop.org/files/original/2ce46311925780543b5f166aae06734c.jpg 20250700f961fbca04d3a509217ae6f4 https://staging.drfop.org/files/original/51f64afd51e21f05fcb8be1cf6b566a6.jpg 78db7332d104e619ea0153d0faf72faa https://staging.drfop.org/files/original/67dbcbc2d6e97fce74975c8e5425df4d.jpg 9c9248069a2f1eeb39d500e952d2092d https://staging.drfop.org/files/original/d9cb0275b460dcb93313cf0a93e01dc4.jpg 1b87da727d718119cf9f5981c3028001 https://staging.drfop.org/files/original/bbe231086fad6f1a5604ed09094d496d.jpg 284ec9e3ade0dccb3ab0c62ed1ae442e https://staging.drfop.org/files/original/72335cd71fe5e3195663463b7ff672df.jpg 6e71c69d6cb6b4d01362c92378c81350 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_02_022.pdf Year 1955 Volume 2 Issue 2 Page Number(s) 22 - 35 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_02_022.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_02_022.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Anatomy and Mechanics of the Human Hand</h2> <h5>Craig L Taylor, Ph.D. <a style="text-decoration:none;">*</a><br />Robert J. Schwarz, M.D <a style="text-decoration:none;">*</a><br /></h5> <p>It is obvious to all that the human hand represents a mechanism of the most intricate fashioning and one of great complexity and utility. But beyond this it is intimately correlated with the brain, both in the evolution of the species and in the development of the individual. Hence, to a degree we "think" and "feel" with our hands, and, in turn, our hands contribute to the mental processes of thought and feeling.</p> <p>In any mechanism, animate or inanimate, functional capabilities relate both to structural characteristics and to the nature of the control system available for management of functions singly or in multiple combinations. Just so with the human hand. Analysis of normal hand characteristics therefore requires an understanding of both sensory and mechanical features. Of course whole volumes have been written on hand anatomy, and it is not possible in a short article to describe all elements in detail. It is helpful, however, to review the basic construction of bones and joints and of the neuromuscular apparatus for governing motions and forces. Twenty four muscle groups, controlled by the various motor and sensory nerve pathways, with their rich potentialities for central connection, and acting upon a bone and joint system of great mechanical possibilities, give to the hand its capacity for innumerable patterns of action.</p> <h3>The Functional Structure of the Hand</h3> <h4>The Bones</h4> <p>The bones of the hand, shown in (<b>Fig. 1</b>), naturally group themselves into the carpus, comprising eight bones which make up the wrist and root of the hand, and the digits, each composed of its metacarpal and phalangeal segments (<b>Table 1</b>). The carpal bones are arranged in two rows, those in the more proximal row articulating with radius and ulna. Between the two is the intercarpal articulation. The bony conformation and ligamentous attachments are such as to prevent both lateral and dorsal volar translations but to allow participation in the major wrist motions (<b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Bones and articulations of the hand, including the interosseus muscles. A, volar view; B, dorsal view. For nomencla ture, see Tables 1 and 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. Bones and Joints of the Hand and Wrist </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Angles of rotation about the wrist. A, extension (or dorsiflexion); B, flexion (or volar flexion); C, radial flexion; D, ulnar flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In each of the digits, the anatomical design is essentially the same, with exceptions in the thumb. Metacarpals II through V articulate so closely with the adjacent carpal bones of the distal row that, although they are capable of some flexion and extension, independence of motion is very limited. The metacarpal shafts are arched to form the palm, and the distal ends are almost hemispherical to receive the concave curvature of the proximal ends of the first phalanges.</p> <p>The metacarpophalangeal joint exhibits a pattern seen also in the interphalangeal joints. As shown schematically in (<b>Fig. 3</b>), the virtual center of rotation lies approximately at the center of curvature of the distal end of the proximal member. The lateral aspects of the joint surfaces are narrowed and closely bound with ligaments, so that lateral rotation is small in the metacarpophalangeal joints and lacking entirely in the phalangeal articulations. Hence, the latter are typical hinge joints. The thumb differs from the other digits first in that the second phalanx is missing and, second, in that there is greater mobility in the carpometacarpal articulation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Section through radius, lunate, capitate, and the bony structure of digit III, showing virtual centers of rotation of each segment upon the next more proximal one. When the fist is clenched, the prominence of the knuckles is formed by the head of the more proximal member of each articulation. For nomenclature, see Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Muscles and Tendons</h4> <p>Most of the muscles of hand and wrist (<b>Table 2</b>) lie in the forearm and, narrowing into tendons, traverse the wrist to reach insertions in the bony or ligamentous components of the hand. Generally, the flexors (<b>Fig. 4</b>) arise from the medial epicondyle of the humerus, or from adjacent and volar aspects of the radius and ulna, and then course down the inside of the forearm. They are, therefore, in part supinators of the forearm (<b>Fig. 5</b>).The extensors (<b>Fig. 6</b>) of wrist and digits originate from the lateral epicondyle and parts of the ulna, pass down the dorsal side of the forearm, and thus assist in pronation. The thumb shares in the general flexor extensor scheme, but its extensors and abductors originate from mid and distal parts of radius and ulna.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Flexors of wrist and digits. For nomenclature, see Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Forearm design as related to hand mobility. By virtue of this arrangement, the hand can be rotated through 180 deg., palm up to palm down, with the elbow flexed. With the arm fully extended, participation of shoulder and elbow allows the hand to be rotated through almost 360 deg., palm up to palm up. U, ulna; R, radius; P, pronation; S, supination. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Extensors of wrist and digits. For nomenclature, see Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The tendons of wrist and hand pass through bony and ligamentous guide systems, as shown schematically in (<b>Fig. 7</b>). Flexor tendons pass through a "tunnel" bounded dorsally by carpal bones, laterally by the greater multangular and the projection of the hamate, and volarly by the tough transverse carpal ligament. Similarly, the dorsal carpal ligament guides the extensor tendons, and a system of sheaths serves as a guide for flexor and extensor tendons through the metacarpal and phalangeal regions.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. The anatomy of prehension. Schematic sections through digits I and III show essential relations of muscles and bones. The letters LG indicate the presence of ligamentous guides which channel close to the wrist the tendons of muscles originating in the forearm. Guide line X—X indicates relative position of carpal bases of thumb and fingers. For rest of nomenclature, see Tables 1 and 2. From Taylor.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The intrinsic muscles of the hand, <i>i.e., </i>those with both origin and insertion confined to wrist and hand (<b>Fig. 8</b>), are, with the exception of the abductors of thumb and little finger, specialized for the adduction of the digits and for opposition patterns such as making a fist, spherical grasp, and so on.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Volar intrinsic muscles of the hand. For nomenclature, see Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Palmar and Digital Pads</h4> <p>The volar aspect of the palm and digits is covered with copious subcutaneous fat and a relatively thick skin so designed in a series of folds that it is capable of bending in prehension. The folds are disposed in such a way as to make for security of grasp, while the underlying fat furnishes padding for greater firmness in holding. Because, however, slipping of the skin over the subcutaneous fat would lead to insecure prehension, the folds are tightly bound down to the skeletal elements, much as mattresses and upholstered furniture are quilted or otherwise fastened to prevent slippage of the filler.</p> <p>In the hand, the volar skin is tied down by white fibrillar tissue connecting the sheaths of the flexor tendons to the deep layer of the dermis along the lateral and lower edges of the palmar fascia. The folds therefore vary with the relative lengths of the metacarpal bones and with the mutual relations of the sheaths of the tendons and the edge of the palmar fascia.</p> <p>The sulci, or furrows, are emphasized because the subcutaneous fat in any given area is restricted to the interval between the lines along which the skin is tied down. Thus pressure upon any individual montic ulus cannot displace the underlying soft tissue beyond the boundaries established by the fibrillar connections. The relative size of any particular eminence is an indication of the size of the muscle involved and of its relative development through usage, with the exception that the size of the hy pothenar eminence depends in part upon the prominence of the pisiform.</p> <h4>The Dorsal Integument</h4> <p>Unlike the volar surface, the dorsal side of the hand is covered with thin, soft, pliable skin and equally mobile subcutaneous tissue, both capable of yielding easily under tension. Because in flexion of the fingers and in making a fist the covering on the back of the hand must be able to stretch from wrist to fingernails, the dorsal skin is arranged in numerous minute redundancies, which, in the fiat of hand, are manifest in the typical transverse wrinkles, particularly over the phalangeal articulations. Special adaptations in the dorsal skin of the thumb accommodate the distinctive rotational planes of that digit about its carpometacarpal articulation. In the normal, healthy hand, the degree of redundancy in any given area is just such that all wrinkles are dispatched when the fist is clenched. Swelling in any area, dorsal or volar, inhibits flexion extension of the part affected.</p> <h4>Nerve and Blood Supply</h4> <p>Three principal nerves serve the muscles of the hand (<b>Fig. 9</b>). Nerve supply is indicated, except for minor variations and exceptions, in (<b>Table 3</b>). Each of these major nerve trunks diverges into countless smaller branches ending in the papillae of the palmar pads and dorsal skin, and the whole neuromuscular system is so coordinated in the brain that motor response to stimuli is ordinarily subconscious and reflex. Thus an object slipping from the grasp is automatically gripped more firmly, but not so firmly as to damage the hand itself. Noxious stimuli are rejected automatically, as when the fingers are withdrawn from an object uncomfortably hot.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Nerves supplying the hand. Top to bottom, ulnar nerve, median nerve, radial nerve. See Table 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The wrist and hand receive their blood supply from the radial and ulnar arteries, which run parallel with the bones concerned, enter the hand through the flexor "tunnel," and then join through a double arch system (<b>Fig. 10</b>). Small branches from the arches serve the digits. The major venous system comprises the basilic and cephalic veins superficially placed on the volar surface of the forearm.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Blood supply to the upper extremity. A, above, medial view of the elbow. A, bottom, dorsal veins of the hand. B, superficial veins of the arm. C, arteries of the arm. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The Resting Hand Pattern</h3> <p>The resting hand assumes a characteristic posture, a feature easily seen when the hand hangs loosely at the side. The resting wrist takes a mid position in which, with respect to the extended forearm axis, it is dorsiflexed 35 deg. (<b>Fig. 11</b>). It is worth noting that this is the position of greatest prehensile force (<b>Fig. 12</b>, bottom). The mid position for radial or ulnar flexion appears to be such that the metacarpophalangeal joint center of digit III lies in the extended sagittal plane of the wrist (<b>Fig. 11</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. The resting hand pattern. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12 Effect of forearm-hand angle upon wrist flexion and extension forces and upon prehension forces. Above, relationship between forearm-hand angle and maximum forces of wrist flexion and extension measured at the carpometacarpal joint. Heavy lines, flexion (volar flexion); light lines, extension (dorsal flexion). Solid lines, averages; dotted lines, standard deviations. Unpublished data, UCLA, 15 male subjects. Below, relationship between forearm-hand angle and maximum prehension force measured between thumb and opposing index and middle fingers grasping a 1/2-inch block. Right hand, eight normal male subjects. Solid line, average; dotted lines, standard deviations From a UC report.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Typically, the conformation of fingers and thumb is similar to that shown for palmar prehension (<b>Fig. 13</b>), the fingers being more and more flexed from index to little finger. The relations between thumb, palm, and fingers are such as to permit grasp of a 1.75 in. cylinder crossing the palm at about 45 deg. to the radioulnar axis. Bunnell<a></a> considers this "an ancestral position ready for grasping limbs, weapons, or other creatures."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Six basic types of prehension, as defined by Schlesinger.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Fixed Hand Adaptations</h3> <p>In thrusting or striking actions and the like, the hand may assume fixed and rigid postures while functioning with the arm in support. These represent nonspecialized functions in which the hand serves merely as an adapted "end of the arm." The various forms include the flat of hand, the clenched fist, the knuckle and digital support postures, and so on.</p> <h3>Wrist Mechanics</h3> <p>The wrist joint, composed of the radiocarpal and intercarpal articulations (<b>Fig. 1</b>), has an elliptical rotation field with the major axis in the dorsal volar excursion, the minor in the ulnar radial. No significant torsion occurs. Bunnell<a></a> gives the angular excursions about the radiocarpal and intercarpal articulation as shown in (<b>Table 4</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 4. Angular Extent of Wrist Flexions" </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The rotation within the carpal bones during these movements is too complicated for brief treatment. Not only do the rotations occur at several articulating surfaces, but the virtual axes of rotation lie distal to the contact surfaces owing to gliding motions in the convex concave structure of the joints. Idealization of the motions into those of a simple lever, rotating about a fixed center, as implied in diagrams such as <b>Fig. 2</b>, can be justified only as a convenient approximation.</p> <p>The muscles traversing the wrist include those inserting into the carpus and metacarpus and those mediating flexion and extension of the phalanges. The latter contribute to the wrist action, particularly under loads. In such cases, the finger muscles develop reaction against the object held (or within the hand itself if the fist is clenched) and add their forces to wrist action. The forces, action, and grouping of these muscles are given in <b>Table 5</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 5. <br /> ^a From Fick. <a></a> <br /> ^b The palmaris longus, absent in about 15 percent of cases, is omitted from the summed Fick forces of volar flexion.<br /> ^c Averages from measurements of maximum forces normal to the hand, applied at the metacarpophalangeal joint, on 15 young males at the University of California at Los Angeles (unpublished data). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Prehension Patterns</h3> <p>It is evident equally from a study of the muscle bone joint anatomy and from observation of the postures and motions of the hand that an infinite variety of prehension patterns is possible. For purposes of analysis, however, it suffices to describe the principal types. Seeking a logical basis for defining the major prehension patterns, Keller et al.<a></a> found that the object contact pattern furnishes a satisfactory basis for classification. From &gt;photographic observation of the prehension patterns naturally assumed by individuals when (a) picking up and <i>(b) </i>holding for use common objects used in everyday life, three types were selected from among those originally classified by Schlesinger.<a></a> These, appearing in (<b>Fig. 13</b>), are palmar, tip, and lateral prehension, respectively. The frequency with which each of these types occurred in the investigation cited is given in (<b>Table 6</b>). While the relative percentages differ in the two types of action, the order of frequency with which the prehension patterns occurred is the same.<a style="text-decoration:none;">*</a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 6. Frequency or Prehension Patterns </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Mechanical Anatomical Basis or Prehension Patterns</h3> <p>It is convenient to analyze digital mechanics in terms of flexion extension variations in the digits, thumb postures, and variations in the radioulnar axis.</p> <h4>Individuation of Digital Flexion Extension</h4> <p>Insertion of flexor and extensor muscle systems into several major segments along the proximal distal axis provides a variety of flexion extension patterns in the digits. In <b>Fig. 7</b>, the essential components are shown schematically for digits I and III. With these attachments, fixation of carpal and metacarpal segments by cocontraction of flexor and extensor carpi muscles provides a firm base for independent movements and fixations of the phalangeal segments. Individual flexions of the second and terminal phalanges stem from separate flexor muscle (<b>Fig. 13</b>). The counterbalancing digital extensor inserts into the two most distal phalanges and, on contraction, rigidly extends the entire finger. Coordinated action between extensor and flexor groups, however, permits fixed intermediate positions of each segment of the system.</p> <p>Two common postures of this system may be pictured. In palmar prehension (<b>Fig. 13</b>), the carpal and metacarpal segments commonly fix the wrist in moderate extension, while the digital configuration, mostly metacarpophalangeal flexion coupled with only slight phalangeal flexion, indicates action of the long flexors, strongly modified by the lumbricals and interossei, which are in position not only to contribute to the metacarpophalangeal flexion but also to maintain the phalangeal xtension. In tip prehension, the action of muscles upon carpal and metacarpal bones is similar, but distributed flexion in all phalangeal segments indicates predominant flexor activity.</p> <h4>Thumb Versatility Patterns</h4> <p>The versatility of the thumb lies, first, in the variety of its flexion extension patterns and, second, in the adjustable, rotatory plane in which flexion extension can take place. The first of these is directly analogous to the digital system for the other four fingers, in that for any given metacarpal position there are numerous possible positions of the phalanges. The second effect is due to the relative mobility of the carpometacarpal joint, which allows the thumb to act in any plane necessary to oppose the digits. The principal oppositions are semidirect, as seen in palmar, tip, and spherical prehensions. Actually, in these cases the plane of the thumb action is inclined 45 to 60 deg. to the palmar plane. In lateral prehension, the plane is approximately parallel to the palmar plane.</p> <h4>Variations in the Radioulnar Axis of the Hand</h4> <p>A third principal mode of variation concerns cross hand alignments. Thus the metacarpophalangeal joints may be drawn into line, and with abducted thumb a flat hand position is assumed. At the other extreme, the hand is cupped for spherical prehension (<b>Fig. 13</b>) as the opponens muscles of thumb and little finger, aided by other adductors and flexors, act to pull these digits toward each other. Similar alignment occurs when a fist is made.</p> <h3>Hand Movements</h3> <p>The large number of muscles and joints of the hand obviously provides the equipment for numerous and varied patterns of movement. Not so evident, but equally important in determining complexity and dexterity of motion, are the large areas of the cerebral cortex given over to the coordination of motion and sensation in the hand. Thus, in the motor cortex the area devoted to the hands approximately equals the total area devoted to arms, trunk, and legs.<a></a> This circumstance ensures great potentiality for coordinated movement and for learning new activities. Similarly, the sensory areas are large, so that they determine such advanced functions as stereognosis, the ability to recognize the shape of an object simply by holding it in the hand. The great tactile sensitivity of the hand is, of course, in large part due to the rich supply of sense organs in the hand surface itself. The threshold for touch in the finger tip, for example, is 2 gm. per sq. mm., as compared to <i>33 </i>and 26 for the forearm and abdomen respectively.<a></a></p> <p>The three major types of movement described by Stetson and McDill<a></a> are in part represented in the hand. They include fixation movements including cocontractions; movements ranging from slow to rapid with control of direction, intensity, and rate; and ballistic movements.</p> <h4>Fixation Movements</h4> <p>In all of the types of prehension described, the hand assumes a fixed position. If the prehended object is unyielding, reactions to the flexion forces are afforded by the object. If the object is fragile, or the hand empty, the hand is maintained in any required prehensile posture by cocontractions of the opposing muscle groups.<a style="text-decoration:none;">*</a></p> <p>The characteristics of balanced muscular action when supporting in the hand loads which produce moments at the wrist have been studied electromyographically by Dempster and Finerty.<a></a> In general, when average potential amplitudes are used to characterize the electrical activity of the muscle, the curves of load action potential are linear. Frequencies range from 35 to 65 per sec. but bear no clear cut relationship to load. Typically, each of the muscles traversing the wrist was found to function as agonist, lateral stabilizer, or antagonist as the moment load was shifted from direct opposition at zero deg. to the 90 deg. and then to the 180 deg. positions. The magnitude of the action potentials associated with each of these roles is approximately in the order 4:2:1.</p> <h4>Slow and Rapid Movements</h4> <p>In movements ranging from slow to rapid, with control of direction, intensity, and rate, there is always some degree of cocontraction to ensure control and to permit changes in force and velocity. A net force in the muscles causes motion. In this category is a long list of activities, such as writing, sewing, tying knots, and pressing the keys of musical instruments. Included are most actions involving differential or integrated motions of the digits.</p> <p>It is of interest to note that the full capacity for these motions is seldom developed by the average individual. With intensive practice, significant increases in the facility of manipulation, even with simple operations, may be achieved, although individuals differ markedly in the amount of training gain. The average individual has latent potential for development of skill, as shown by the feats of manipulation occasionally evidenced. Knot tying, cigarette rolling, and similar complex manipulations may be performed with one hand, as often demonstrated by accomplished unilateral arm amputees. According to Tiffin<a></a>, dexterity differences are correlated neither with mental ability nor with hand shape or dimensions, but Cox<a></a> points out that they have an important effect on the performance of industrial assembly operations.</p> <h4>Ballistic Movements</h4> <p>Ballistic movements are rapid motions, usually repetitive, in which active muscular contractions begin the movement, giving momentum to the member, but cease or diminish their activity throughout the latter part of the motion. It is unlikely that, of themselves, the fingers utilize this type of motion to any marked degree. Barnes<a></a> reviews evidence that in repetitive work finger motions are more fatiguing, less accurate, and slower than are motions of the forearm. Consequently, in repetitive finger activities in which there is a ballistic element, such as piano playing, typing, and operating a telegraph key, wrist and elbow motions predominate while the fingers merely position themselves to strike the proper key.</p> <h3>Hand Dynamics</h3> <p>The hand muscles, their actions, and contractile forces are given in (<b>Table 5</b>) taken from Fick.<a></a> The total Fick force equals the sum mated forces of the individual muscles participating in the action. For each muscle the force is equal to the physiological cross section <i>(i.e., </i>the total cross section of the muscle taken normal to its fibers) multiplied by the force factor of 10 kg. per sq. cm., estimated by Fick to hold for human muscle. These forces are produced along the axis of the muscle and its tendon, but since the effective moment arm upon any of the wrist or hand joints is small, the <i>measured </i>isometric forces are only about 10 percent of the total force.</p> <p>Among the wrist actions, total forces and measured isometric forces assume the same rank order. The variation,. with wrist angle, of both flexor extensor forces in the wrist and of prehensile forces in the hand is of practical importance as well as theoretical interest. The prehensile force reaches a maximum at a wrist angle of about 145 deg. (<b>Fig. 12</b>, bottom). This is approximately the angle at which the maximum forces of wrist flexion and extension occur (<b>Fig. 12</b>, top). It is common experience that the wrist assumes this angle when very strong prehension is required. The lessened forces at wrist angles toward the extreme positions of flexion or extension are attributable to the well known force reductions in the isometric length tension curve as a muscle is markedly stretched or slackened.<a></a> The exception to this rule, seen in the augmented force of flexion at wrist angle 85 deg., apparently means that this degree of wrist extension does not stretch the flexor muscles beyond their force maximum.</p> <h3>Conclusion</h3> <p>This, briefly, constitutes the anatomical basis of hand mechanics, from which it can be seen that normal hand function is the result not only of a highly complex and versatile structural arrangement but also of an equally elaborate and fully automatic system of controls. As will be seen later (page 78), such considerations lay down the principal requirements and limiting factors in the design of reasonably successful hand substitutes. When, in the normal hand, any functional feature, either mechanical or sensory motor, is impaired, manipulative characteristics are reduced correspondingly. In the arm amputee, hand structural elements have been wholly lost, and the most delicate neuromuscular features, those in the hand itself, have been destroyed. Although the lost bone and joint mechanism can be simulated, adequate replacement of the control system defies present ingenuity. Lacking control comparable to that in the natural hand, present day artificial hands are necessarily limited in the mechanical details that can be utilized, which accounts for the fact that the regain in function currently possible in hand prostheses falls far short of duplicating the natural mechanism.</p> <h3>Acknowledgment</h3> <p>The anatomical drawings which accompany this article are the work of John Cassone, medical illustrator at the University of California, Los Angeles.</p> <p><b>References:</b></p> <ol> <li>Barnes, R. M., <i>Motion and time study</i>, Wiley, New York, 1937.</li> <li>Best, C. H., and N. B. Taylor, <i>Physiological basis of medical practice</i>, Williams and Wilkins, Baltimore, 1937. p. 1256.</li> <li>Best and Taylor, op. cit., p. 1418.</li> <li>Bunnell, Sterling, <i>Surgery of the hand</i>, Lippincott, Philadelphia, 1944.</li> <li>Cox, J. W., <i>Manual skill</i>, Cambridge University Press, 1934.</li> <li>Dempster, W. T., and J. C. Finerty, <i>Relative activity of wrist moving muscles in static support of the wrist joint; an electromyographic study</i>, Am. J. Physiol., 150:596 (1947).</li> <li>Fick, Rudolf, Handbuch der Anatomic und Mechanik der Gelenke<i></i>, Dritter Teil, G. Fischer, Jena, 1911.</li> <li>Inman, Verne T., and H. J. Ralston, <i>The mechanics of voluntary muscle</i>, Chapter 11 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>Keller, A. D., C. L. Taylor, and V. Zahm, <i>Studies to determine the functional requirements for hand and arm prosthesis</i>, Department of Engineering, University of California at Los Angeles, 1947.</li> <li>Schlesinger, G., <i>Der mechanische Aufbau der kunstlichen Glieder in Ersatzglieder und Arbeitshilfen</i>, Springer, Berlin, 1919.</li> <li>Stetson, R. H, and J. A. McDill, <i>Mechanism of different types of movement</i>, Psych. Mono., 32(3): 18 (1923).</li> <li>Taylor, Craig L., <i>The biomechanics of the normal and of the amputated upper extremity</i>, Chapter 7 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>Tiffin, Joseph, <i>Industrial psychology</i>, Prentice-Hall, New York, 1947.</li> <li>University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Fundamental studies of human locomotion and other information relating to design of artificial limbs</i>, 1947. Vol. II.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Fick, Rudolf, Handbuch der Anatomic und Mechanik der Gelenke, Dritter Teil, G. Fischer, Jena, 1911.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Barnes, R. M., Motion and time study, Wiley, New York, 1937.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Cox, J. W., Manual skill, Cambridge University Press, 1934.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Tiffin, Joseph, Industrial psychology, Prentice-Hall, New York, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Dempster, W. T., and J. C. Finerty, Relative activity of wrist moving muscles in static support of the wrist joint; an electromyographic study, Am. J. Physiol., 150:596 (1947).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">There are many other examples of fixation stales, such as the open claw conformation of the fingers and the extended and rigid index finger for dialing a telephone.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Stetson, R. H, and J. A. McDill, Mechanism of different types of movement, Psych. Mono., 32(3): 18 (1923).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Best, C. H., and N. B. Taylor, Physiological basis of medical practice, Williams and Wilkins, Baltimore, 1937. p. 1256.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Best and Taylor, op. cit., p. 1418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Predominance of palmar prehension in both activities accounts for adoption of this pattern in the design of modern artificial hands (page 86).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Schlesinger, G., Der mechanische Aufbau der kunstlichen Glieder in Ersatzglieder und Arbeitshilfen, Springer, Berlin, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Keller, A. D., C. L. Taylor, and V. Zahm, Studies to determine the functional requirements for hand and arm prosthesis, Department of Engineering, University of California at Los Angeles, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Fick, Rudolf, Handbuch der Anatomic und Mechanik der Gelenke, Dritter Teil, G. Fischer, Jena, 1911.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Bunnell, Sterling, Surgery of the hand, Lippincott, Philadelphia, 1944.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Schlesinger, G., Der mechanische Aufbau der kunstlichen Glieder in Ersatzglieder und Arbeitshilfen, Springer, Berlin, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Bunnell, Sterling, Surgery of the hand, Lippincott, Philadelphia, 1944.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Vol. II.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Robert J. Schwarz, M.D </b></td></tr><tr><td class="clsTextSmall">Instructor in Otolaryngology, College of Medical Evangelists, Los Angeles; formerly Assistant in Engineering Research, University of California, l.os Angeles.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Craig L Taylor, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Professor of Engineering, University of California, Los Angeles; member, Advisory Committee on Artificial Limbs, National Research Council, and of the Technical Committee on Prosthetics, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-13.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_02_022/table01.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-14.jpg Figure 4 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-15.jpg Figure 5 http://www.oandplibrary.org/al/images/1955_02_022/table02.jpg Figure 6 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-17.jpg Figure 7 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-18.jpg Figure 8 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-20.jpg Figure 9 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-21.jpg Figure 10 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-22.jpg Figure 11 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-24.jpg Figure 12 http://www.oandplibrary.org/al/images/1955_02_022/table03.jpg Figure 13 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-25.jpg Figure 14 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-27.jpg Figure 15 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-29.jpg Figure 16 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-30.jpg Figure 17 http://www.oandplibrary.org/al/images/1955_02_022/table04.jpg Figure 18 http://www.oandplibrary.org/al/images/1955_02_022/table05.jpg Figure 19 http://www.oandplibrary.org/al/images/1955_02_022/table06.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Anatomy and Mechanics of the Human Hand Creator An entity primarily responsible for making the resource Craig L Taylor, Ph.D. * Robert J. Schwarz, M.D * https://staging.drfop.org/files/original/2af24d33498f903f19fea2c5675a74ef.pdf d4e6f2d65239910f25cf126d68e7c8dc https://staging.drfop.org/files/original/4d3ddcf7651fff9ec5dd9c3427c58e15.jpg 2749c27e2446e4f746ea4e1d8d08afea https://staging.drfop.org/files/original/eb71c2538c5e88109be6c357c40e60cd.jpg a33087cc766f88e31bed11c95885bb6e https://staging.drfop.org/files/original/92f0b57c8b3defb346a3497604e47f3f.jpg 603429119911e70056b4450ef18b92d0 https://staging.drfop.org/files/original/5f498a6651b7e9b8f1eec1ea73532e91.jpg 9fdf9004b81b54e8652950012ccb0165 https://staging.drfop.org/files/original/b041422d191f77298643b52ef852617e.jpg 17c5cb478f84c50ccb8cd4e0527884cd https://staging.drfop.org/files/original/7fe13473de8d4000ed8c8f18cd3c0b4d.jpg 2a4e79271e4ba7bbbe536c18ab728781 https://staging.drfop.org/files/original/2297ac77954f4047d113992c6d45458d.jpg 2cf1cf57dd83112d6fbeee8a32f2027e https://staging.drfop.org/files/original/e8e3e367a8c90615a071af926d0dcc43.jpg a5aa4351b6ee2371ba40f0cf38df6840 https://staging.drfop.org/files/original/aa16b41fd406f041938dd06c277015c2.jpg 649eaeff89a5184e2def9092077444fe https://staging.drfop.org/files/original/121e62ebcf3c71973c3482ab42e53c83.jpg 15b4270a6585a213d7aedf6a76d60520 https://staging.drfop.org/files/original/9a57f9be025587ccf0193133556036ad.jpg 168fdb2039020ed045f4a822c8e13c6b https://staging.drfop.org/files/original/d83a4fc2a02d05be889604c2340a00a2.jpg f4fc363ce2a8acfc59cc24e5042d33da https://staging.drfop.org/files/original/c60c52b30ad7a3259df529b2acf883a3.jpg 8ccb20f11781e2ba1dbbce79edefa8b0 https://staging.drfop.org/files/original/8a8b1b1c51d20c3232be371241d1e215.jpg 12ee4710b77effd0f0bd2c647a1b1aca https://staging.drfop.org/files/original/a876719fff8467e1a527e2a73d31a30b.jpg 2b985f3fea23eaa471be8fac044cb345 https://staging.drfop.org/files/original/6449892d298e50c73e338beea299bbc0.jpg ac35194aca22c469e31de504b9bed2b5 https://staging.drfop.org/files/original/5ed18cbfc520ac464095a32b721c6849.jpg 759e2b53115fae6bf241f4d450875a36 https://staging.drfop.org/files/original/076402ce0eaaee6760087a9c8a6b61a6.jpg 8100a1578a04f465b946f59287bb3d36 https://staging.drfop.org/files/original/ff64515284519fe251c8dd39ea00d384.jpg 74b1d12ca12689370d20ffc2f18789bd DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_03_004.pdf Year 1955 Volume 2 Issue 3 Page Number(s) 4 - 25 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_03_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_03_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Biomechanics of Control in Upper-Extremity Prostheses</h2> <h5>Craig L. Taylor, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>In the rehabilitation of the upper-extremity amputee, structural replacement by prosthetic arm and hand is an obvious requirement, and it poses a comparatively easy task; functional replacement by remote control and by substitute mechanical apparatus is more elusive and hence infinitely harder. For the purposes of functional utility, remaining movements of upper arm, shoulder, and torso must be harnessed, and use must be made of a variety of mechanical devices which amplify remaining resources by alternators, springs, locks, and switching arrangements. The facility of control attained through this apparatus is the key to its ultimate value.</p> <p>The future of upper-extremity prosthetics depends upon an ever-increasing understanding of the mechanics of the human body by all who minister to the amputee-prosthetist, surgeon, and therapist alike. It must always be stressed that the final goal is an amputee who can function. Too often there is a tendency to put undue faith in the marvels of mechanism alone, when in fact it is the man-machine combination that determines performance. It is in this broad frame of reference that the biomechanical basis of upper-extremity control must be approached.</p> <h3>Prosthetics Anthropometry</h3> <h4>Surface Landmarks</h4> <p>If successful control is to be obtained, the various components of the prosthesis must be positioned with a good degree of accuracy.</p> <p>To do so requires reference points on the body, of which the most satisfactory are certain bony landmarks. Most of these skeletal prominences protrude to such an extent that location is easily possible by eye. Others require palpation, and this method should be used to verify observation in every case. The bones most concerned in upper-extremity anthropometry are the clavicle, the scapula, the humerus, the ulna, and the seventh cervical vertebra. Surface indications of protuberances, angles, or other features of these bones constitute the landmarks, the locations and definitions being given in <b>Fig. 1</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Bones and external landmarks in the upper extremity. Definitions: <i>seventh cervical vertebra, </i>most prominent vertebra in the neck region; <i>acromion, </i>extreme lateral edge of the bony shelf of the shoulder; <i>inferior angle of scapula, </i>lowest point on shoulder blade; <i>epicondyles, </i>lateral and medial bony points at the pivot of the elbow; <i>ulnar styloid, </i>projecting point on little-finger side of the wrist. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Arm and Trunk Measurements</h4> <p>The typical male torso and upper extremity are shown in <b>Fig. 2</b>, which, together with <b>Table 1.</b>, was derived from average measurements on Army personnel.<a></a> Such an average form serves to establish harness patterns and control paths. The arm, forearm, and epicondyle-thumb lengths constitute the basis of sizing prostheses.<a></a> (In everyday language the word "arm" is of course taken to mean the entire upper extremity, or at least that portion between shoulder and wrist. In anatomical terms, "arm" is reserved specifically for the segment between shoulder and elbow, that between elbow and wrist being the "forearm." Although in the lower extremity the word "leg" commonly means the entire lower limb, whereas anatomically the "leg" is that segment between knee and ankle, confusion is easily avoided because we have the special word "shank." No such spare word is available to describe the humeral segment of the upper limb.-Ed). Arm length places the artificial elbow; forearm length locates the terminal device. The epicondyle-thumb length is an important over-all sizing reference because in the unilateral arm amputee it is customary to match hook length (and, in the case of the artificial hand, thumb length) to the length of the natural thumb <b>(Fig. 3)</b>.The bilateral arm amputee can be sized from body height by means of the Carlyle formulas<a></a>, which employ factors derived from average body proportions.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Basic anthropometry of the male torso and <b>upper extremity. </b>See Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Correct lengths for upper-extremity prostheses. In the unilateral case, hook length is made to coincide with normal thumb length, as is also the thumb length of the artificial hand. For bilateral arm amputees, <i>A = </i>0.19 X (body height); <i>B + C </i>= 0.21 X (body height). After Carlyle (J). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Functional Anatomy</h4> <p>The human torso, shoulder, and upper extremity are exceedingly complex structures. In any dealing with these elements of anatomy, therefore, it is desirable to sort out from the mass of detail those features important to the particular area of study and application. Where prosthetic controls are concerned, the mechanism of movement is the central subject of consideration. This functional anatomy treats of the aspects of bone, joint, and muscle structure that together determine the modes and ranges of motion of the parts. It is a descriptive science, and while to escape dependence upon nomenclature is therefore impossible, the purpose here is to convey a basic understanding of the operation of the upper-extremity mechanisms without undue use of specialized terminology. In any case, the reader should have available basic anatomical references such as <i>Gray's Anatomy</i><a></a> or kinesiology texts such as those of Steindler<a></a> and of Hollinshead. <a></a></p> <h4>Elementary Motions of the Upper Extremity</h4> <p>The geometry of each joint is complex, and most movements involve an interaction of two or more joints. Consequently, a motion nomenclature based on joint movements would be unnecessarily complicated. More simply, the motion of each part upon its proximal joint may be described with respect to the principal planes which intersect at that joint. In this system, moreover, one may define a standard position in which the trunk is erect, the arms hang with their axes vertical, the elbows are flexed to 90 deg., and the wrist planes are vertical to assume the "shake-hands" position. <b>Fig. 4</b> presents the angular movements possible in the three planes of space. The shoulder-on-chest, arm-on-shoulder, and hand-on-wrist actions take place through two angles, as if moving about a universal joint. Geometrically, the arm motions are more precisely defined by a spherical coordinate system where the segment position is given by longitude and colatitude angles. For descriptive purposes, however, the anatomical nomenclature is commonly used. It should be recognized that, for multiaxial joints, flexion-extension and elevation-depression angles describe motions in the major orthogonal planes only, and intermediate angular excursions must be thought of as combinations of these motions.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Simplified movement system in the upper extremity. Wrist flexion is omitted since ordinarily it is not involved in upper-extremity controls. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The simplified movement system depicted in <b>Fig. 4</b> is incomplete in many ways. Not included are such movements as twisting of the shoulder due to various scapular movements, anterior-posterior swings of the arm in positions of partial elevation, and the slightly conical surface of revolution of forearm flexion.(It deserves to be noted here that, taken literally, expressions such as "forearm flexion-extension," "arm flexion-extension," and "humeral flexion-extension" represent questionable nomenclature. To "flex" means to "bend." Limb segments do not bend very readily without breaking. Joints are <i>designed </i>for flexion. In the lower extremity, for example, one speaks not of "shank flexion" but of "knee flexion," not of "thigh flexion" but of "hip flexion." That is, one uses "flexion" or "extension" not with reference to motion of the distal segment but with reference to the more proximal joint. Although Webster accepts the expression "to flex the arm," he obviously uses the word "arm" in the everyday sense of meaning the entire upper extremity, or at least that portion between shoulder and wrist. Because this loose terminology in the upper extremity is so widely established, not only among workers in prosthetics, it is used throughout this issue of Artificial Limbs, with the understanding that "forearm flexion" means "elbow flexion," "arm flexion" and "humeral flexion" mean "flexion of the glenohumeral joint (and associated structures) " See page 9 <i>et seq.</i>-Ed.). These details may, however, be ignored in the interest of the simplicity of description that is adequate for the purposes of upper-extremity prosthetics.</p> <h4>The Shoulder Girdle</h4> <p><i>Skeletal Members and Joints</i></p> <p>The scapula and clavicle are the chief bones making up the shoulder girdle. Secondarily, the proximal portion of the humerus may be included, since the close interarticulation of all three bones at the shoulder joint gives a considerable degree of coordinated activity among them and also extends to the complex as a whole the actions of many of the muscles inserting on the individual members.</p> <p>Details of the skeletal anatomy involved are shown in <b>Fig. 5</b>. There are in the system two joints and one pseudo joint. In the sternoclavicular joint, the clavicle articulates with the sternum in a somewhat saddle-shaped juncture recessed in a concavity within the sternum. The biaxial surfaces permit movements in two planes. Ligaments crossing the joint prevent displacement of the clavicle anteriorly and laterally. The elevation-depression range is 50 to 60 deg., the flexion-extension range from 25 to 35 deg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Skeletal anatomy of the shoulder region, <i>a, </i>Anterior view. <i>b, </i>Posterior view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the acromioclavicular joint, the distal end of the clavicle articulates with the scapula in an elliptical juncture which permits a ball-and-socket type of action. The acromioclavicular ligaments bind the joint directly. Strong ligaments from the clavicle to the coracoid process give important additional stabilization. The range of movement is small, being only about 10 deg. in the frontal and sagittal planes.</p> <p>The pseudo joint, the scapulothoracic, is a muscular suspension which holds the scapula against the thoracic wall but which at the same time permits translatory and rotatory movements. A large factor in maintaining this joint in position is barometric pressure, which is estimated to act upon it with a force of 170 lb.</p> <p><i>Muscles and Movements</i></p> <p>The complex arrangement of bony elements is rivaled by the involved nature of the muscles of the shoulder girdle and by the intricate ways in which they act upon it. The schematic view of <b>Fig. 6</b> presents the fundamentals. Elevation of the shoulder is seen to be brought about principally by elevators and downward rotators of the scapula, such as the upper trapezius, the levator scapulae, and the rhomboids. Although the rhomboids assist in elevation, they do not contribute to upward rotation. Depression of the shoulder is mediated by muscles inserted on the scapula, the clavicle, and the proximal end of the humerus. Anteriorly the lower fibers of the pectoralis major, the pectoralis minor, and the sub-clavius, and posteriorly the lower trapezius and latissimus, act as depressors.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Schematic kinesiology of the shoulder girdle. <i>L, </i>latissimus; <i>LS, </i>levator scapulae; <i>LT, </i>lower trapezius; <i>MT, </i>medial trapezius; <i>PM, </i>pectoralis major; <i>Pm, </i>pectoralis minor; <i>RM, </i>rhomboid major; <i>Rm, </i>rhomboid minor; <i>SA, </i>serratus anterior; <i>SC, </i>subclavius; <i>UT, </i>upper trapezius. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Rotation of the scapula upward <i>(i.e., </i>right scapula, viewed from the rear, rotates counterclockwise) or downward <i>(i.e., </i>right scapula, viewed from the rear, rotates clockwise) is brought about by a special combination of the elevators and depressors. As shown in <b>Fig. 6</b>, two portions of the trapezius, together with the serratus, cause upward rotation. Conversely, the pectorals, the latissimus, and the rhomboids cooperate to cause downward rotation. As will be seen later (page 13), the mechanical principle of the couple applies in these rotatory actions upon the scapula.</p> <p>Flexion and extension of the shoulder involve as principal elements the abduction and adduction, respectively, of the scapula. The flexor muscles acting on the shoulder complex are the pectoralis major and minor, which swing the clavicle and acromion forward. The serratus anterior aids strongly by abducting the scapula. The extensors, placed posteriorly, include the latissimus, which pulls posteriorly and medially on the humerus, and the trapezius and rhomboids, which pull medially on the scapula.</p> <p>The forward and backward shrugging of the shoulders with abduction and adduction, together with some upward and downward rotation of the scapulae, constitutes a major control source. Even in above-elbow amputees who use humeral flexion for forearm lift and for terminal-device operation at low elbow angles (page 22), scapular abduction is utilized for terminal-device operation at large angles of elbow flexion <i>(e.g., </i>when the terminal device is near the mouth). In shoulder amputees, both these operations depend wholly upon scapular abduction augmented by upward rotation.</p> <h4>The Arm</h4> <p><i>The Humerus and the Glenohumeral Joint</i></p> <p>The humerus, together with its joint at the shoulder, comprises the skeletal machinery of the arm. As noted in <b>Fig. 4</b>, it is capable of flexion-extension, elevation-depression, and rotation upon its proximal joint. The glenoid cavity, a lateral process on the scapula, receives the spherical surface of the humeral head. The glenohumeral articulation is therefore of true ball-and-socket character. The fibrous joint capsule is remarkable in that it envelops the humeral head and the glenoid margins in complete but rather loose fashion, so that a wide range of movement is possible. To some extent barometric pressure, but to larger extent the musculature spanning the joint, is responsible for keeping the articular surfaces together in all angular positions. A group of muscles including the subscapularis, the supraspinatus, and the infraspinatus function principally in this holding action.</p> <p><i>Muscles and Movements</i></p> <p>The kinesiology of the arm is closely associated with that of the shoulder girdle, nearly all natural movements involving a coordinated movement between arm and shoulder. It is helpful, however, first to describe the pure movements of the arm. Schematics of the muscles acting upon the arm are presented in <b>Fig. 7</b>. Elevation is effected by the lateral deltoid and the supraspinatus, depression by the latissimus, the pectoralis major, the long head of the triceps, and the teres major. In both actions, the contributions of individual muscles differ according to the angle of the arm. And it should be noted that, with insertions near the pivot point of the humeral head, the rotatory moments are proportionately small, thus accounting for the large number of muscles necessary to give adequate joint torques. Arm flexion and extension are brought about by two groups of muscles. The biceps, the coraco-brachialis, the anterior deltoid, and the clavicular fibers of the pectoralis major mediate flexion, while the posterior deltoid, the long head of the triceps, the latissimus, and the teres major effect extension. Rotation of the arm depends upon muscles that insert on the surface of the humerus and then pass anteriorly or posteriorly around it to impart medial or lateral torsion. As would be expected, rotational forces are greatest when the arm hangs at the side; torque is reduced drastically when the arm is elevated over the head and the twisting angles of the muscles tend to disappear.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Schematic kinesiology of the arm. <i>AD, </i>anterior deltoid; <i>B, </i>biceps; <i>CB, </i>coracobrachialis; <i>IS, </i>infraspinatus; <i>L, </i>latissimus; <i>LD, </i>lateral deltoid; <i>PD, </i>posterior deltoid; <i>PM, </i>pectoralis major; <i>S, </i>subscapularis; <i>SS</i>, supra-spinatus; <i>T, </i>triceps; <i>TM, </i>teres major; <i>Tm, </i>teres minor. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Combined Arm and Shoulder Movements</i></p> <p>In most natural arm movements, such as arm elevation, arm flexion, forward reaching, and to-and-fro swings of the partially elevated arm, both arm and shoulder girdle participate. In full arm elevation of 180 deg., for example, 120 deg. are contributed by rotation of the arm on the glenohumeral joint, 60 deg. are contributed by upward rotation of the scapula.<a></a>In forward reaching, involving partial arm flexion, the shoulder flexes and the scapula abducts and rotates slightly. Properly managed, this motion, the common flexion control motion of both the above- and the below-elbow amputee (pages 19-22) can give marked gracefulness to prosthetic operation.</p> <h4>The Forearm</h4> <p><i>Skeletal Members</i></p> <p>The radius and ulna together constitute a forearm lever which can rotate about the elbow axis. By virtue of the arrangement at the proximal head of the radius and at the distal end of the ulna, the forearm can also carry out torsion about its longitudinal axis to produce wrist rotation. With the aid of the mobility at the shoulder and at the wrist, it is possible to place the hand in space in an almost unlimited number of positions. The skeletal anatomy of the elbow is shown in <b>Fig. 8</b>, the articulations being the ulno-humeral and the radiohumeral. Participating in forearm rotation is the radioulnar joint at the wrist.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. The right elbow joint, viewed from in front. The thin capsular ligament is not shown. Note that the ulna, with its posteriorly projecting olecranon, forms a hinge joint with the humerus, while the head of the radius is free to rotate within the annular ligament. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The ulnohumeral joint has an unusual structure. The complex surfaces of articulation between ulna and humerus are such that the axis of rotation of the forearm is not normal to the long axis of the humerus. As the elbow is flexed or extended, therefore, the forearm does not describe a plane. Instead, the ulna swings laterally as the elbow is extended, until at full extension the cubital angle is about 170 deg. Xevertheless, only small error is involved in considering the motion to be essentially that of a simple hinge with an axis of rotation perpendicular to ulna and humerus and allowing the ulna to swing through about 140 deg. of flexion.</p> <p>In the radiohumeral joint, the slightly concave proximal end of the radius articulates with the hemispherical capitulum placed somewhat laterally on the anterior surface of the distal end of the humerus. The radius is free to move with the ulna through the complete range of flexion and, in addition, to rotate with forearm pronation and supination. In the radioulnar joint, the distal end of the ulna forms a curved surface against which the radius opposes an articulating concavity. As the forearm goes through a pronation-supination range of about 170 deg., the radius "swings like a gate" about the distal end of the ulna.</p> <p><i>Muscles and Movements</i></p> <p>As shown in <b>Fig. 9</b>, the musculature for providing forearm flexion and extension is comparatively simple, while that for pronation-supination is somewhat more involved. Flexion of the forearm is effected principally by the biceps, originating on the scapula and inserting on the radius, and by the brachialis, spanning the elbow from humerus to ulna. Secondarily, the brachioradialis and other muscles, originating distally on the humerus and coursing down the forearm, contribute to flexion. Extension is largely the function of the triceps, originating on both the scapula and humerus and inserting on the leverlike olecranon process of the ulna. A small extensor action is added by the anconeus.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Schematic kinesiology of the forearm. <i>A, </i>anconeus; <i>B, </i>biceps; <i>BR, </i>brachialis; <i>BrR, </i>brachioradialis; <i>PT, </i>pronator teres; <i>PQ, </i>pronator quadratus; <i>Su, </i>supinator; <i>T, </i>triceps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Rotation of the forearm is a function of many muscles. Some, such as the supinator, evidently are designed for the purpose, while others, as for example the finger flexors, have different principal functions, the contribution to forearm rotation being only incidental. <b>Fig. 9</b> presents the major rotatory muscles only. Supination is mediated by the brachioradialis, the supinator brevis, and the biceps, pronation by the pronators quadratus and teres. Of great importance to upper-extremity prosthetics is the fact that rotation of the forearm is a function of total forearm length. With successively shorter stumps, not only are the rotation limits of the radius and ulna reduced, but also the contributions of muscles are eliminated as their insertions are sectioned.</p> <h4>Musculoskeletal Mechanisms</h4> <p>The upper extremity having been considered from the standpoint of functional and descriptive anatomy, attention may now be turned to a more mechanical view of its operations. Typical elements of mechanism in the upper extremity include joints (bearing surfaces), joint-lining secretions (lubricants), bones (levers and couple members), tendons (transmission cables), and muscles (motors). The arrangement of these elements makes up a complex machinery capable of such diverse activities as precise orientation in space, performance of external work, fine digital manipulations, and so on.</p> <h4>Typical Joint Mechanics</h4> <p>The elbow joint embodies the essential structures of diarthrodial joints. The bearing surfaces are covered with a thin layer of articular cartilage that is continuous with the synovial membrane lining the whole joint capsule. Subsynovial pads of fat serve to fill up the changing spaces that occur during movement of the joint (<b>Fig. 10</b>). It is believed that these fatty deposits serve as "pad oilers" to maintain the continuous film of synovial fluid over the articular surfaces.<a></a> This fluid contains mucin (a glycoprotein which serves as a lubricant for the joint) and other material constituting a nutritional medium for the articular cartilage. Considerable uncertainty exists concerning the method of formation and distribution of the fluid to the joint, but its mechanical function is clear and the normal joint performs as a well-oiled bearing.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Typical change in joint spaces with flexion-extension, as revealed by the elbow. Redrawn from Steindler <i>(17), </i>after Fick. <i>A, </i>Gap of the medial border of the olecranon surface with elbow in extreme extension. <i>B, </i>Gap of the lateral border of the olecranon in extreme flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Bones and Their Mechanical Function</h4> <p>The bones of the upper extremity, besides forming a support for soft tissue, provide a system of levers which makes the arm an important mechanism for the performance of gross work, such as lifting, slinging, and thrusting. The arm bones serve further as positioners of the hand, in which other, finer bones constitute the intricate articulated framework of the manipulative mechanism. Two main features of bones merit discussion here-their internal composition and construction and their external shape and adaptations that permit them to serve as members of mechanical systems.</p> <p><i>Internal Structure</i></p> <p>There is much evidence that the gross internal structure of bone is eminently suited to withstand the mechanical stresses placed upon it by the compressive loads of weight-bearing, by the tensions of tendons and ligaments, and by the lateral pressures of adjacent tissues.<a></a>The nature and orientation of the trabeculae in cancellous bone have, for example, long been held, in theory, to provide the maximum strength along the lines of major stresses. This idea, originally suggested by von Meyer, has been championed by many, including Koch, who carried out a stress analysis on the femur.<a></a> Objections to the von Meyer theory have dealt largely with the frequent and incautious extension of the concept. It is now believed that genetic and growth factors determine the essential form and dimensions of bone. Mechanical stresses serve secondarily to mold and modify it to give added strength where stresses are greatest. One must grant from even a superficial examination of the internal structure of bone that Nature has done an admirable job of designing for maximum strength with minimum weight.</p> <p><i>Members of Mechanical Systems</i></p> <p>The second principal feature of bones, that of serving as rigid members in a complex of mechanical systems, is the one that has engaged the most attention. It is surprising that the simple lever concepts of Archimedes have persisted in anatomy and kinesiology texts to the present day. Thus, the forearm-flexor system is said to act as a third-class lever, the extensor system as a first-class lever. Although these assertions are of course true, both of these systems are, in the more complete language of Newtonian mechanics, parts of force-couple systems in which equal and opposite components of force are transmitted through the bones and joints (<b>Fig. 11</b>). Elft-man<a></a> has emphasized this view. The magnitude of the couple is given by the product of the force (either of the equal but opposite forces) and the distance between them, which also is numerically equal to the torque of the muscle force. The concept of the couple calls attention to the existence of the equal and opposite forces in joints and emphasizes the loads placed upon them by muscular work. Another and more complicated application of the couple is seen in scapular rotation. Here, as described by Inman <i>el al.</i><a></a> and as shown in <b>Fig. 12</b>, the pull of the lower fibers of the serratus anterior upon the scapula is such as to give it upward rotation, while the thrust of the clavicle, acting through the acromioclavicular joint, holds a pivot for the rotation. Simultaneously, the pull of the upper trapezius fibers causes the clavicle to undergo angular rotation about the sternoclavicular joint. The result is that, at least through the first 90 deg. of arm elevation, the motion is shared by coordinated angular rotations of scapula, clavicle, and humerus. As a basic part of this rotatory action, the scapula acts as the moment arm of a force couple, the trapezius and serratus providing components of force which are equal and opposite.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Force couples at the elbow. Tensile forces in biceps and brahialis are associated with equal, opposite, and parallel forces through the joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Muscle forces acting on the shoulder, anterior view. The trapezius, acting diagonally, gives a supportive component. <i>Fy</i>,<i>, </i>and a horizontal component, <i>Fx, </i>which together with the opposite force from the serratus, 5, comprise an upward rotatory force couple on the scapula. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Tendons and Muscles</h4> <p>The specific functions of tendons are to concentrate the pull of a muscle within a small transverse area, to allow muscles to act from a distance, and in some instances to transmit the pull of a muscle through a changed pathway. The mechanical importance of this tissue is nowhere more evident than in the arm, where a large degree of versatility of motion in the segment distal to each joint is preserved by "remoting" the action of muscles through slender, cablelike tendons over joints. By this means lines of pull are brought near the joint axes, thus providing a lever arm consistent with the tensile force of the muscle at all joint angles and also giving at low joint angles an increased angular motion for a given linear contraction. Other advantages of remoting the muscles are seen in the forearm and hand. In order to afford the variety and complexity of interdigital movements, many independent muscle units are necessary, and critical space problems are avoided because muscles such as the common flexors and extensors of the fingers are placed at some distance up the forearm.</p> <p>The predominant function of tendon as a tension member in series with muscle, which is a tension motor, is seen in early growth stages. An undifferentiated cellular reticulum of connective tissue is everywhere found in embryonic tissue. The parent cells are fibroblasts; they elaborate and extrude the collagenous material of which white fibers are made. <a></a> At this point the presence of mechanical tensions in the tissue influences the rate, amount, and direction of the resultant fiber formation. At maturity the tendon is composed almost entirely of white collagen fibers, closely packed in parallel bundles, to form a cablelike strand. It is contained within a sheath which forms a loose covering lubricated continuously by a mucinous fluid to reduce friction with surrounding tissues.</p> <p>Mutual adjustment of the characteristics of muscle and tendon is shown in many respects. The musculotendinous juncture varies with the arrangement of the muscle fiber. It shows a simple series arrangement for fusiform muscles like the biceps, or it comprises a distributed attachment zone by continuation of the tendon into intramuscular septa where pinni-form fibers may insert (<b>Fig. 13</b>). In some unexplained way the relative lengths of muscle and associated tendon are so composed that the shortening range of the muscle is that necessary to move the segment distal to the joint through its maximum range.<a></a> The capacity to adapt the ratio of muscle length to tendon length has been demonstrated in an experiment in which the pathway of the tibialis anterior tendon in the rabbit was shortened. The result was that the tendon shortened while the muscle lengthened to regain the normal joint range.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Muscle fiber patterns. <i>A, </i>Fusiform. <i>B, </i>Bipinniform. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The relative strengths of muscle and of tendon also show an approximate compatibility, the tensile strength of tendon, measured at from 8700 to 18,000 lb. per sq. in.<a></a>, being greater than that for muscle. Strength tests of excised muscle-tendon systems show that failure commonly occurs in the belly of the muscle, or at the musculotendinous juncture, or at the bone-tendon juncture, but never exclusively in the tendon itself. Analysis of clinical cases indicates that muscle is still the site of failure even when it is maximally tensed.<a></a> It is clear, then, that of the muscle-tendon combination the tendon is normally always the stronger.</p> <h4>Forearm-Fexor Mechanics</h4> <p>The forearm-flexor system is well suited to serve as an example of biomechanics because the bone-joint system comprises a simple uniaxial hinge while the flexor muscles, though five in number, can be reduced to a single equivalent muscle whose geometry and dynamics can be specified from measurement data. <b>Fig. 14</b> illustrates the lever system on which the equivalent muscle acts. The angle between the axis of the muscle and that of the forearm bones, <i>i.e., </i>the "angle of pull," theoretically ranges from 0 deg. at full extension to 90 deg. at 100 deg. of elbow angle, and since the moment arm is continuously proportional to the sine of the angle of pull the mechanical advantage of the lever also is proportional to it.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Forearm-flexor mechanics. Insert gives the geometry of the idealized flexor system. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>There are of course departures from this idealized geometry. For one thing, the angle of pull and the elbow angle are not exactly equal. Moreover, at small elbow angles the torque component does not actually drop to zero because the muscles must always pass over the elbow joint at some finite distance from its center. Finally, the force-length curve<a></a> of the equivalent muscle must also be taken intoaccount in expressing the effective torque. For these and other reasons, actual torque measurements take precedence over theoretical calculations, and the composite curve of <b>Fig. 14</b> has been plotted from the results of a number of investigators. Whereas the moment arm peaks at an elbow angle of 100 deg., the muscle force is declining throughout the elbow-flexion range, and the net effect, as reported by Miller ,<a></a> is a maximum torque of about 625 lb.-in. at from 80 to 90 deg. Clarke and Bailey<a></a> found a peak of about 400 lb.-in. at between 70 and 80 deg., and the author has obtained 550 lb.-in. just under 90 deg. in a group of subjects. Wilkie's data give a value of about 525 lb.-in. at 80 deg., measured on himself.<a></a> These variations can be explained as resulting from the effect of a limited sampling of an inherently variable characteristic. Greater consistency probably could be obtained in a larger series of measurements.</p> <h4>Maximum Torques in Major Aactions</h4> <p>Because they express the fundamental output characteristics, and because they are most easily measured, the muscle torques about the major joints represent the most significant and practical aspects of the statics and dynamics of the musculoskeletal system. Not only is muscular power a concept of uncertain validity but also it is very difficult to measure. The combined effect of muscle and lever, however, can easily be measured in many subjects, so that statistical stability can be achieved in the results. Because muscle agonists change length with joint angle, and because they are thus caused to work on different parts of their length-tension diagrams, joint torques vary as a function of joint angle. As demonstrated by Clarke<a></a>, this phenomenon, shown in <b>Fig. 14</b> for the forearm-flexor system, holds more or less for all major actions about the joints. But these details may be neglected in summarizing the maximum torques throughout the upper-extremity system (<b>Table. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Functional Role of Sockets</h4> <p>The socket is the foundation of the upper-extremity prosthesis. It obtains purchase upon the most distal segment of the remaining member and should be stable, though comfortable, in its fit with this member. The socket must bear weight both axially and in all lateral directions. It is the attachment member for mechanical components and for control guides and retainer points. Hence the socket must be a sound structural member as well as a custom-fit, body-mating part. Finally, the socket extends the control function of the member to which it is fitted, giving movement and direction to the prosthesis. In any discussion of prosthetic controls, therefore, the starting point is the socket.</p> <p>The requirement of formability and strength in sockets has been met satisfactorily by the introduction of polyester laminates.<a></a> These materials permit close matching of the stump impression, and variations in strength can be introduced by increasing the number of laminate layers. The double-wall construction<a></a> provides a stump-fitted inner wall, with an outer wall that can be designed to structural uniformity and cosmetic requirement. Sizing to achieve this aim has now been reduced to standard practice. <a></a> Finally, the texture and coloring of the plastic laminate can be controlled to achieve satisfactory cosmetic results.</p> <h4>The Below-Elbow Socket</h4> <p>The peculiar feature of the forearm, that pronation-supination is a function of the whole forearm length, places a special limitation on the below-elbow socket. Although for stability in flexion the whole remaining forearm stump is best sheathed in the socket, to do so prohibits forearm rotation. In the case of the longer below-elbow stumps, therefore, some sacrifice in stability can be afforded in the interest of retaining forearm rotation. The proximal portion of the socket is fitted loosely to give freedom for forearm rotation while the distal portion is fitted snugly to provide a stable grip. <b>Fig. 15</b> shows the amount of forearm rotation available at various levels of the natural forearm and that remaining in below-elbow amputees of various types. Because of torsion of the flesh, however, and because of slippage between the skin and the socket, effective socket rotation is lost in stumps which are only 50 percent of forearm length. The effective socket rotation remaining in the wrist-disarticulation case is only about 90 deg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Below-elbow amputee types, based on average forearm length, epicondyle to styloid. After Taylor <i>(18).</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Further adaptations of below-elbow sockets to suit the functional requirements at the various levels are shown in <b>Fig. 16</b>. In the long below-elbow stump, the elliptical cross-section of the forearm near the wrist permits a "screw-driver" fit of the socket to yield the maximum in rotational stability. With the shorter stumps, the possibility of effective rotation is reduced and is lost completely at about 50 percent of forearm length. At this level, the problem of forearm rotation is outweighed by that of providing flexion stability. Dependence upon a rigid or semirigid hinge system is necessary in the short below-elbow stump, and finally, in the very short stump, effective forearm flexion is so reduced that a split socket with step-up hinge becomes a necessity.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Schematics of below-elbow prostheses. For each type, an insert gives the cross-sectional anatomy 1 in. from the end of the stump. Sections are taken from the normal anatomy of the forearm. Sockets, hinges, cuffs, and suspensions are for <i>a, </i>single socket; <i>b, </i>rotation type; <i>c, </i>double-wall socket; and <i>d, </i>split socket. After Taylor <i>(18).</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The goal of below-elbow socket design is to regain as completely as possible the control function of the forearm, which includes <i>(a) </i>positioning of the hand by forearm flexion and <i>(b) </i>hand rotation by means of pronation-supination. In the below-elbow prosthesis, adequate forearm flexion is obtained rather easily; rotation is limited to the potential available in the longer stumps. Manual wrist rotation, of course, supplements the remaining natural rotation. In the below-elbow prosthesis, then, control of the terminal device in space depends in fair measure upon the role of the socket in preserving the residual flexion and rotation of the below-elbow stump.</p> <h4>The Above-Elbow Socket</h4> <p>Unlike the below-elbow case, the above-elbow stump presents no problem of diminishing rotation with diminishing stump length because arm rotation is confined wholly to the gleno-humeral joint. Socket design for the above-elbow case is therefore related principally to the requirement of fitting the stump closely so that the humeral lever can be fully effective in controlling the prosthesis. <b>Fig. 17</b> shows the minor variations corresponding to above-elbow type, including the elbow disarticulation. Sockets for the latter must take account of the bulbous end of the stump. They must provide snug fit around the epicondyle projections but maintain sufficient room in the region just above, where the stump cross-section is reduced, to permit insertion of the stump in the socket. In both the elbow-disarticulation and the standard above-elbow cases, the upper margin of the socket is terminated below the acromion for freedom of movement at the shoulder. In the short above-elbow case, the socket is carried up over the acromion to obtain additional stabilization and suspension from the shoulder, as required by the very limited stump area. The control function of the above-elbow socket is twofold. As in the below-elbow case, the socket extends the slump to the next more distal joint and thus gives range and direction to this component upon which the positioning of the still more distal segments depends. But in addition to this feature, the above-elbow socket also has a power function. Through its attachments to shoulders and torso, it provides the forces and displacements needed to produce forearm flexion, terminal-device operation, and elbow lock. To fulfill these functions, the socket must have stable purchase on the stump in both flexion and extension. Hence, for elbow-disarticulation and above-elbow types, the socket should continue to the axillary level; for short-above-elbow amputees, it should come up over the acromion (<b>Fig. 17</b>). Finally, medial and lateral rotation of the socket are necessary for further functional positioning. Close fit and good suspension are required to give stability in these actions.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Schematics of above-elbow sockets, including elbow disarticulation. For each type, an insert gives the cross-sectional anatomy at the indicated level. Dashed lines show stump contour and inner wall of the socket. Standard and short above-elbow cases have a double-wall socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Shoulder Socket</h4> <p>In the range of amputation sites from transection of the humeral neck to complete removal of the shoulder girdle, the socket form changes from shoulder cap to thoracic saddle. As displayed in <b>Fig. 18</b>, the bearing area increases as the remaining shoulder elements are reduced; similarly, the amount of "build-out" needed to preserve shoulder outline increases with increasing amputation loss. With disarticulations and all more extreme losses, sectional plates may be introduced at the axillary parasagittal plane. This arrangement makes it possible to fabricate the prosthesis in two sections, a matter of considerable advantage to the limbmaker, and it also affords the functional advantage of a preposition swivel of the humeral section upon the saddle section to simulate flexion-extension of the arm.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Schematics of shoulder sockets. Solid lines show residual bony structure, dashed lines the body contour and inner wall of the socket. Disarticulation and forequarter sockets may be two-piece with sectional plates at <i>a.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The functional aspects of the shoulder socket are to some extent secondary to the structural; yet there are certain definite functional ends to be served. Shoulder and scapular mobility in elevation, flexion, and extension should be preserved to the highest possible degree. In humeral-neck and shoulder-disarticulation cases, aid can be given to the shrug control (biscapular abduction), and at least a small range of motion can be given to the elbow, but of course no such function can be expected in forequarter or partial-forequarter amputees.</p> <h4>Major Arm and Shoulder Controls</h4> <p>The common method of operation of upper-extremity prostheses is by means of shoulder harness which provides suspension and which also transmits force and excursion for control motions. In this manner such operations as forearm flexion-extension, terminal-device operation, and elbow lock are managed. <b>Fig. 19</b> presents the essential features of the major harness controls. In principle, each effective control must begin with a point stabilized on shoulder or torso, pass over a voluntarily movable shoulder or arm part, and thus provide relative motions with respect to the origin. At the movable point, the control cable enters the Bowden-type housing, which transmits the relative motion independent of movements of the distal segments. Controls may be used singly or in combination, depending upon the level of amputation, amputee preference, and other practical considerations.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Major harness controls. The points stabilized by harness (x) are beginning points for the control cable, which passes into a Bowden-type housing at movable points (¦). The relative motion is transmitted via the Bowden cable to distal points on the prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Besides the relative motions between various segments of the human body, still another source of energy for operation of upper-extremity prostheses can be made available by the surgical procedure known as cineplasty, <a></a> in which a skin-lined tunnel is fashioned in the belly of a muscle group. In various experimental programs conducted both here and abroad, muscle tunnels have been made in the forearm flexors, the forearm extensors, the biceps, the triceps, and the pectoralis major.</p> <p>Of all the various combinations tried, the biceps tunnel in below-elbow amputees has proved to be the most successful. Failure of other cineplasty systems has been due in some cases to inability of designers to overcome the mechanical problems involved in harnessing the energy thus provided and in other cases to the inherent properties of the particular muscle group concerned. In the below-elbow case, use of the biceps tunnel eliminates the need for shoulder harness and permits operation of the prosthesis with the stump in any position. It has given excellent results in many instances and has been made available to those beneficiaries of the Veterans Administration who can make effective use of the procedure.<b>Fig. 21</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Coordinated control motions for elbow lock. Simultaneously the humerus is both extended <i>(a) </i>and abducted <i>(b) </i>while the shoulder is depressed (c) and the trapezius is bulged <i>(d) </i>by downward rotation of the scapula. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The cineplasty tunnel in the biceps of the average male will provide sufficient force and excursion to operate modern terminal devices-an average maximum force of 50 lb. and 1 1/2 in. of useful excursion. It is not unusual for some individuals to be able to build up the force available to a value in excess of 100 lb., but such a high force normally is not required.</p> <h4>The Nature and Operation of Ccontrol Systems</h4> <p><i>The Below-Elbow Single-Control System</i></p> <p>The single control for the below-elbow amputee is powered by arm flexion to provide terminal-device operation. This control motion, used by the above-elbow amputee also, depends upon a coordinated flexion of the humerus and abduction of the scapula on the amputated side; little shoulder activity is required on the sound side. It is substantially the same motion as that used in normal unilateral reaching. The displacements of humerus and scapula are additive, so that the resulting motion is quite natural. With full Bowden-cable transmissions of power from arm cuff to forearm socket, there is no influence of elbow angle, and the operation is mastered easily by all amputees with stumps of 35 percent or more of normal forearm length.</p> <p><i>The Below-Elbow Dual-Control System</i></p> <p>(Although the terminology commonly used to describe the several control systems could well afford to be better systematized, it is adopted here because it is now so well established throughout the field of prosthetics. One <i>may </i>think of "dual control" as meaning that two control sources are involved in the provision of all necessary functions, but according to convention it means that two functions, specifically elbow flexion and terminal-device operation, are provided by a single control source, the third function, elbow lock, if needed, being managed by an additional control source. Yet "triple control" (page 22) in the accepted sense means not that three functions are furnished by a single control source but that three control sources are used to provide three functions, one for each.-Ed.)</p> <p>In harnessing below-elbow stumps shorter than 35 percent of normal forearm length, it generally is necessary to use an auxiliary type of lift to help the amputee flex the forearm. This procedure is applicable to a split-socket type of prosthesis. It merely is an adaptation of the above-elbow dual-control system (page 22) using a lever loop positioned on the forearm section so that arm flexion may be utilized to assist in forearm lift. The cable housing is split and assembled so that when the arm is flexed the elbow will flex. The elbow hinge has no locking mechanism, the short below-elbow stump being used to stabilize the forearm. Normally, sufficient torque is available about the elbow axis to give adequate stability in all usable ranges.</p> <p>In prescribing for a new amputee with this level of amputation, it might be advisable first to have the amputee try a split-type prosthesis without the below-elbow dual-control system. If, at time of initial checkout, the amputee cannot lift his forearm, or if he complains of painful contact with his stump, then of course the dual system is indicated. After the assist lift has been worn for some time, the remaining muscles of the stump may have hypertrophied, in which case the amputee might be able to discard the dual system and convert to the below-elbow single control.</p> <p><i>The Below-Elbow Biceps-Cineplasty System</i></p> <p>Force and excursion provided by the biceps muscle tunnel are harnessed by inserting into the tunnel a cylindrical pin of a nontoxic material and attaching a cable to each end of the pin. As in the other types of control systems, the Bowden-cable principle is employed to maintain a constant effective distance between the source of energy and the mechanism to be operated, regardless of relative motions occurring between body segments. In order that conventional terminal devices may be employed, it is necessary to join the two cables before attachment to the mechanism. Several devices for making this coupling are available commercially.</p> <p>Suspension of the socket is provided by an arm cuff, which is attached to the socket by any of the various hinges normally used in fabrication of below-elbow prostheses. The arm cuff is fashioned in such a manner that forces tending to pull the prosthesis from the stump are absorbed by the condyles of the elbow rather than by the muscle tunnel.</p> <p><i>The Above-Elbow Dual-Control System</i></p> <p>In above-elbow amputees, the humeral stump furnishes the motive power for the three operations of the prosthesis-flexion of the forearm, operation of the terminal device, and management of the elbow lock. The first two operations are so linked mechanically that a single control motion, arm flexion, produces either terminal-device operation or forearm flexion, depending on whether the elbow is locked or unlocked (<b>Fig. 20</b>). Although the control motion by arm flexion in the above-elbow case is similar to that described for the below-elbow amputee, there are several differences. Because the cable passes through a lever loop on the forearm to give torque about the elbow, it is affected by elbow position. As the forearm is flexed, arm-flexion excursion is used up, and the excursion needed to operate the terminal device must come from scapular abduction (shrug), as in shoulder cases. Typically, the above-elbow amputee manages a full range of free forearm flexion by a normal arm-flexion movement. But in the elbow-angle range of from 90 to 135 deg., with elbow locked for terminal-device operation, he must call upon supplementary excursions from biscapular abduction. With the terminal device at the mouth, practically all operation depends upon shoulder shrug.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Operation of above-elbow and shoulder dual controls. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the above-elbow dual-control system, operation of the elbow lock depends upon humeral extension and associated coordinations. When the forearm has been flexed to the position desired, the elbow lock is engaged by the arm-extension movement. Skill is needed to maintain tension on the arm-flexion cable so that the arm does not drop during the locking control motion. Well-trained amputees elevate the arm moderately to compensate for the humeral extension and thus maintain the elbow angle. The extension control motion is complex. The humerus is simultaneously extended and elevated so that it moves obliquely to the side. During this phase, the point of the shoulder must be stabilized, or even moved forward, and the trapezius is bulged by downward rotation of the scapula (<b>Fig. 21</b>).<b>Fig. 22</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Location of the proximal retainer for both above- and below-elbow cases. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>The Above-Elbow Triple-Control System</i></p> <p>The triple-control system has been devised to separate terminal-device operation from forearm lift. When the dual-control system is used, the amputee must select, by the use of the elbow lock, either terminal-device operation or forearm lifting. By separating forearm flexion and terminal-device operation, the triple control makes it possible for the terminal device to be controlled by an independent body motion. Although in general an above-elbow amputee fitted with triple control has an elbow lock, a few such cases are able to separate prehension from forearm flexion without use of the lock.</p> <p>A control cable from the terminal device is so attached and positioned that biscapular abduction or merely shoulder shrug will operate the terminal device through its full range of prehension. To lift the forearm the amputee uses arm flexion. Elbow-lock operation is accomplished in the same manner as in the dual-control system, that is, by arm extension.</p> <p>It is apparent that this arrangement will work best with a comparatively stable socket and a relatively long above-elbow stump. The chief advantage of the triple-control system is that at full forearm flexion the terminal device may still be operated through its complete range.</p> <p><i>The Shoulder Dual-Control System</i></p> <p>In the absence of the humeral lever, the shoulder becomes the major power source, biscapular abduction controlling both forearm and terminal device in the dual-control system. The control path courses horizontally across the scapulae, and either opposite-axilla loop or basic chest-strap harness (page 46) captures the action satisfactorily. The combination afforded by the dual principle also is illustrated in <b>Fig. 20</b>.</p> <p>The shoulder amputee has a special difficulty in obtaining the combination of full forearm flexion and terminal-device operation because, unlike the above-elbow amputee, who can add the excursions of humeral flexion and scapular abduction, he must obtain all movement from biscapular abduction. Shoulder amputees with broad shoulders and wide chests usually achieve this action satisfactorily; others must accept the limitation of partial terminal-device operation at full forearm flexion. Partial-shoulder and fore-quarter amputees must depend upon the sound shoulder entirely, and in this case the action range of the terminal device typically is limited to not more than 90 deg. of forearm flexion.</p> <p>In shoulder amputees, operation of the elbow lock must be managed by various special arrangements. The waist control, utilizing shoulder elevation; the perineal strap, based on relative motion between shoulders and pelvis; the nudge control, requiring either manual or chin operation; extreme shoulder flexion on the sound side; and extension of the shoulder on the amputated side complete the array of known feasible possibilities. It is evident that with this class of amputees control motions will be slower and deliberately sequential. They are therefore necessarily more noticeable and awkward.</p> <p><i>The Shoulder Triple-Control System</i></p> <p>The harness required for the triple-control shoulder-disarticulation system consists of a chest strap for forearm flexion, a waist strap to operate the elbow lock, and an opposite-shoulder loop for prehension. The amputee must have excellent scapular abduction and must be able to separate it from extreme opposite-shoulder shrug, and he must have available good shoulder elevation on the amputated side. The chief advantage of the triple control in the shoulder-disarticulation case is identical to that of the triple control in the above-elbow case, namely, that the terminal device may be operated fully in the vicinity of the mouth. To operate the prosthesis from an extended position, the amputee first produces biscapular abduction, thus raising the forearm. Then, with the forearm held in place, he elevates the shoulder on the amputated side to lock the elbow. To operate the terminal device, he then flexes the sound shoulder. Excursion for terminal-device operation is thus unaffected by forearm flexion.</p> <p>Unfortunately this system must be restricted to humeral-neck and shoulder-disarticulation cases. For lack of sufficient excursion on the amputated side, it is unlikely that a forequarter amputee would be able to use triple control.</p> <h4>Mechanical Application of the Major Controls</h4> <p>To elucidate practical amputee biomechanics, it is necessary to refer to several aspects of the connecting mechanism between amputee and prosthesis in the power-transmission system. Of first importance are the proximal retainers, which are located at the point where the cable from the shoulder harness enters the cable housing. These retainers are the beginning points of the transmission systems indicated in <b>Fig. 19</b>. In both below- and above-elbow cases, the proximal retainer is positioned in accordance with the ratios shown in <b>Fig. 22</b>. For all above-elbow stumps of greater than 50 percent of acromion-to-epicondyle length, the proximal retainer point is placed slightly lower than half way down the arm, the reason being that the control passes naturally through this point in its course from opposite shoulder, across the scapula, and thence to the lever loop on the forearm shell. The humeral lever power is quite adequate at this point (<b>Table 3</b>), and no practical advantage is gained by a lower placement. With above-elbow stumps less than 50 percent as long as the normal arm length, acromion to epicondyle, the proximal retainers must be placed at the level of the stump end in order to prevent undue tipping of the socket, as would occur if forces developed beyond the end of the stump.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In shoulder cases, the control path is directed horizontally at approximately the midscapular level and brought to the arm section at the axilla. The control motion is purely biscapular abduction, and consequently the proximal retainer is placed on the prosthesis at the midscapular level. The resulting force and excursion are given in <b>Table 3</b>.</p> <p>Arm-extension forces are potentially quite high, as also shown in <b>Table 3</b>. Because only 2 to 6 lb. of force and 1/2 in. of excursion are required to operate an elbow lock, normally there is a generous power excess. The principal concern in harnessing arm-extension control is to obtain operation with minimal movement and thus to avoid awkwardness.</p> <h3>Conclusion</h3> <p>The central purpose of this article has been to outline the biomechanical basis of control in upper-extremity prostheses. Consequently, emphasis has been placed upon the normal and residual functional anatomy and kinesiology underlying this service. The particularized biomechanics of prosthesis control has been defined, and the limitations incurred in amputations at high levels have been stressed. The major message is that a thorough understanding of the motions of control available to each type of patient is necessary to the proper prescription, fitting, and training of the upper-extremity amputee. Thus only can full advantage be taken of the improved functional features to be found in modern arm components.</p> <p><b>References:</b></p> <ol> <li>Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, <i>The techniques of cineplasly, </i>Chapter 3 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Carlyle, L. C, <i>Using body measurements to determine proper lengths of artificial arms, </i>Memorandum Report No. 15, Department of Engineering, University of California (Los Angeles), 1951.</li> <li>Carlyle, Lester, <i>Fitting the artificial arm, </i>Chapter 19 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Clark, W. E. Le Gros, <i>The tissues of the body; an introduction to the study of anatomy, </i>3rd ed., Clarendon Press, Oxford, 1952.</li> <li>Clarke, H. Harrison, and Theodore L. Bailey,<i>Strength curves for fourteen joint movements, </i>J. Assoc. Phys. &amp; Ment. Rehab., 4(2):12 (1950).</li> <li>Cronkite, Alfred Eugene, <i>The tensile strength of human tendons, </i>Anat. Rec, 64:173 (1936).</li> <li>Elftman, H , <i>Skeletal and muscular systems: structure and function, </i>in <i>Medical Physics, </i>O. Glasser <i>el al., </i>eds., Vol. I, p. 1420, Year Book Publishers, Inc., Chicago, 1944.</li> <li>Haines, R. W., <i>On muscles of full and of short action,</i> J. Anat., 69:20 (1934).</li> <li>Hollinshead, W. H., <i>Functional anatomy of the limbs and back; a text for students of physical therapy and others interested in the locomotor apparatus, </i>Saunders, Philadelphia, 1951.</li> <li>Inman, Verne T., and H. J. Ralston, <i>The mechanics of voluntary muscle, </i>Chapter 11 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Inman, V. T , J. B. deC M. Saunders, and L. C. Abbott, <i>Observations on the function of the shoulder joint, </i>J. Bone &amp; Joint Surg., 26:1 (1944).</li> <li>Koch, John C, <i>The laws of bone architecture, </i>Am. J. Anat., 21:177 (1917).</li> <li>Lewis, Warren H., ed., <i>Gray's anatomy of the human body, </i>24th ed. revised, Lea and Febiger, Philadelphia, 1942.</li> <li>McMaster, Paul E., <i>Tendon and muscle ruptures; clinical and experimental studies on the causes and location of subcutaneous ruptures, </i>J. Bone &amp; Joint Surg., 15:705 (1933).</li> <li>Miller, D. P., <i>A mechanical analysis of certain lever muscles in man, </i>Ph.D. dissertation, Graduate School, Yale University, New Haven, Conn., 1942.</li> <li>Newman, R. W., and R. M White, <i>Reference anthropometry of Army men, </i>Report No. 180, Quartermaster Climatic Research Laboratory, Lawrence, Mass., 1951.</li> <li>Steindler, Arthur, <i>Kinesiology of the human body tinder normal and pathological conditions, </i>Charles C Thomas, Springfield, Ill., 1955.</li> <li>Taylor, Craig L., <i>The biomechanics of the normal and of the amputated upper extremity, </i>Chapter 7 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Taylor, Craig L., <i>Control design and prosthetic adaptations to biceps and pectoral cineplasly, </i>Chapter 12 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>University of California (Los Angeles), Department of Engineering, <i>Manual of upper extremity prosthetics, </i>R. Deane Aylesworth, ed., 1952.</li> <li>Unpublished data, UCLA.</li> <li>Wilkie, D. R., <i>The relation between force and velocity in human muscle, </i>J. Physiol., 110:249 (1949).</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasly, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b> 19.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasly, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Carlyle, Lester, Fitting the artificial arm, Chapter 19 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Carlyle, Lester, Fitting the artificial arm, Chapter 19 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Clarke, H. Harrison, and Theodore L. Bailey,Strength curves for fourteen joint movements, J. Assoc. Phys. &amp;Ment. Rehab., 4(2):12 (1950).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Wilkie, D. R., The relation between force and velocity in human muscle, J. Physiol., 110:249 (1949).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Clarke, H. Harrison, and Theodore L. Bailey,Strength curves for fourteen joint movements, J. Assoc. Phys. &amp;Ment. Rehab., 4(2):12 (1950).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Miller, D. P., A mechanical analysis of certain lever muscles in man, Ph.D. dissertation, Graduate School, Yale University, New Haven, Conn., 1942.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">McMaster, Paul E., Tendon and muscle ruptures; clinical and experimental studies on the causes and location of subcutaneous ruptures, J. Bone &amp;Joint Surg., 15:705 (1933).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Cronkite, Alfred Eugene, The tensile strength of human tendons, Anat. Rec, 64:173 (1936).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Clark, W. E. Le Gros, The tissues of the body; an introduction to the study of anatomy, 3rd ed., Clarendon Press, Oxford, 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Haines, R. W., On muscles of full and of short action, J. Anat., 69:20 (1934).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Clark, W. E. Le Gros, The tissues of the body; an introduction to the study of anatomy, 3rd ed., Clarendon Press, Oxford, 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Inman, V. T , J. B. deC M. Saunders, and L. C. Abbott, Observations on the function of the shoulder joint, J. Bone &amp;Joint Surg., 26:1 (1944).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Elftman, H , Skeletal and muscular systems: structure and function, in Medical Physics, O. Glasser el al., eds., Vol. I, p. 1420, Year Book Publishers, Inc., Chicago, 1944.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Koch, John C, The laws of bone architecture, Am. J. Anat., 21:177 (1917).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Clark, W. E. Le Gros, The tissues of the body; an introduction to the study of anatomy, 3rd ed., Clarendon Press, Oxford, 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Clark, W. E. Le Gros, The tissues of the body; an introduction to the study of anatomy, 3rd ed., Clarendon Press, Oxford, 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Steindler, Arthur, Kinesiology of the human body tinder normal and pathological conditions, Charles C Thomas, Springfield, Ill., 1955.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Hollinshead, W. H., Functional anatomy of the limbs and back; a text for students of physical therapy and others interested in the locomotor apparatus, Saunders, Philadelphia, 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Steindler, Arthur, Kinesiology of the human body tinder normal and pathological conditions, Charles C Thomas, Springfield, Ill., 1955.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Lewis, Warren H., ed., Gray's anatomy of the human body, 24th ed. revised, Lea and Febiger, Philadelphia, 1942.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Carlyle, Lester, Fitting the artificial arm, Chapter 19 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Carlyle, L. C, Using body measurements to determine proper lengths of artificial arms, Memorandum Report No. 15, Department of Engineering, University of California (Los Angeles), 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Newman, R. W., and R. M White, Reference anthropometry of Army men, Report No. 180, Quartermaster Climatic Research Laboratory, Lawrence, Mass., 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Craig L. Taylor, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Professor of Engineering, University of California, Los Angeles; member, Advisory Committee on Artificial Limbs, National Research Council, and of the Technical Committee on Prosthetics, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-3.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-2.jpg Figure 4 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Biomechanics of Control in Upper-Extremity Prostheses Creator An entity primarily responsible for making the resource Craig L. Taylor, Ph.D. * https://staging.drfop.org/files/original/58b9ac3acbd103e06a1b89d3952822dc.pdf 0a1ffc6373173388efb41ba207d3695b https://staging.drfop.org/files/original/484b8daccf6ce6c0aece26201505c00e.jpg 0b54c5978606817a280da5a93803beba https://staging.drfop.org/files/original/c48afbc6a0c4b0e08fe65bc1293586dc.jpg 5610616274d318d4c61c5f823dccceb4 https://staging.drfop.org/files/original/7ad84a93475df636cf432dd2ed54559a.jpg 98eb6b4ed650868e68250eae91be6158 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_02_036.pdf Year 1955 Volume 2 Issue 2 Page Number(s) 36 - 46 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_02_036.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_02_036.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Some Problems in the Management of Upper Extremity Amputees</h2> <h5>Frederick E. Vultee, Capt., USA (MC) <a style="text-decoration:none;">*</a><br /></h5> <p>Experience in the rehabilitation of upper extremity amputees in recent years has highlighted the advantages of many concepts not previously considered or else heretofore noted only superficially. Not only has the development of prosthetic devices assured a greater degree of rehabilitation of many more amputees, but consideration of the amputee as a whole also has played a major role. It is now well recognized that, in times past, attention was too often directed only to the amputation stump. After the wound had healed, the patient was referred to a prosthetist without benefit of a physician's final evaluation. The development of the clinic team approach<a></a> foreshadowed the end of such practices, and with the growth of the clinic team has come the all important factor of considering the patient as a whole.</p> <p>Implicit in such an approach is the concept that complete upper extremity rehabilitation can rightly be expected only when the amputee has been afforded adequate training in efficient utilization of the prosthesis with which he has been fitted. Incomplete or unsystematic training is, at best, responsible for improper habits in prosthetic usage and hence for awkwardness and inefficiency. In the extreme case, it may lead to discard of the prosthesis entirely even though the components involved may themselves be of the greatest utility to an accomplished amputee wearer. The therapist has thus come to be looked upon as an important member of every prosthetics clinic team.</p> <p>The importance of good health also has come to be realized. The patient who suffers from complicating injuries or diseases may not be able to cooperate fully, and when cooperation is limited, interest and motivation die rapidly. For example, the obese patient will profit by guided weight reduction and proper weight stabilization, and the anemic and allergic will benefit by proper corrective measures. Dermatological problems frequently are a serious complication for the amputee, especially when involvement of the stump is threatened or when harnessing excoriates areas of existing dermatitis. Here proper therapeutic measures may permit continued use of the prosthesis or ensure only a temporary suspension of its use. If, however, such conditions are allowed to continue unchecked, they may result in a prolonged period of inactivity.</p> <p>Equal in importance to good physical condition is a healthy mental attitude. Unless rehabilitation therapy includes consideration of the patient's mental outlook, the entire process of recovery may result in complete failure. Accordingly, some cases may require the assistance of specialists in psychiatry and related fields.</p> <p>With respect to the patient's mental condition, an important factor relates to vocational and avocational pursuits. Whether an amputee can engage successfully in work and recreation to his own liking, and whether he has a taste for such activities as are possible to him, may together spell the difference between success and failure in any given case. Proper attention by a qualified occupational therapist is therefore essential.</p> <p>Functional loss aside, a number of other problems arise from hand loss. In addition to the functions of grasp and tactile sense, the hand is used in many symbolic patterns in benediction, in supplication, in the salute, in the handshake. These are ancient and time honored functions denied the person who has suffered loss of the hand. In the rehabilitation of the upper extremity amputee, too much stress often is laid upon the restoration of functional losses relating to prehension, often forgetting the extraprehensile activities essential to the amputee's existence.</p> <p>In addition to these matters are the problems associated with the importance of early fitting and those involved in the special cases of multiple amputation. And finally, mention deserves to be made of the largely faulty but widespread notion that people are inherently right handed or left handed. In the rehabilitation of the upper extremity amputee, the popular concept of hand dominance leads to one of the most difficult problems to be overcome.</p> <p>Since each of these individual problems is closely interrelated with all the others, the order in which they are considered by the clinic team is of no particular significance. Of greatest importance is that they all <i>be </i>considered and that over all evaluation of the amputee's status take into account all the individual factors that, together, constitute total rehabilitation.</p> <h3>The Problem of Hand Dominance</h3> <p>Most people define handedness solely on the basis of whether the right or the left hand is used in writing, or in throwing a baseball, or the like. The less specific definition of a medical dictionary, which describes handedness as the preferential use of one hand over the other, is perhaps more acceptable, for handedness does not appear to be a flat case of one "necessary" and one "nice to have" hand but rather a case of two cooperating members either one of which could be trained as the leader. Nevertheless, the concept of dominance is so widely established that loss of the writing hand is considered by most compensation authorities to constitute severe disability, whereas loss of the other often is viewed lightly. Similarly, loss of one hand in the ambidexterous generally is considered to present no great rehabilitation problem.</p> <p>How do we determine whether an individual is right or left handed? When the average person is asked which is his dominant hand, he usually selects the writing hand. In the upper extremity amputee, we seemingly are presented with a case of "dominance" or "sub dominance." Simply to ask the patient whether he is, or was, right or left handed is, in most cases, a wholly inadequate method of determining the degree of dominant handedness. It produces premature evaluations of disability and of future rehabilitation problems, both of which may need complete revision before the patient is discharged from the care of the clinic team. The problem of handedness is of primary interest to those directly responsible for all phases of training the upper extremity amputee. It is during the preprosthetic stage that the real aspects of dominance present themselves, for during this period the patient is a one handed individual.</p> <h4>The Dictates of Convention</h4> <p>Judging from the design of many of the articles we use daily, it appears that society already has dictated that ours shall be a colony of right handed individuals. From the position of the knife and fork at the table to the placement of the gearshift lever on the modern automobile, we are reminded constantly that we are expected to use our right hand much more than our left. This decision of engineers and of authorities in etiquette causes no small concern to the parents of children who seem to use the left hand more than the right. Parents recall other left handed individualsindividuals who always find themselves crowded when seated at the dinner table (<b>Fig. 1</b>), or whose bodies assume the position of an animated corkscrew when attempting to write at a desk. For these and other reasons, parents try subtly to encourage the use of the right hand in the young child, despite some of the beliefs of medical science. Even the garmentmakers have conspired against the man who uses his left hand for some tasks. Commonly, a button is placed over the left hip pocket, where it seems understood the wallet will be placed, while the right hip pocket is free for easy withdrawal of the handkerchief. The man who uses the left hip pocket for the handkerchief has no protection for the wallet when it is kept on the right.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. The southpaw at dinner. Convention dictates the norm; habits in conflict with the established pattern usually lead to trouble. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Popular Fallacy</h4> <p>These elementary observations indicate that hand usage is dictated by habit patterns, possibly as a means of conforming to the norms of the society in which we live (page 9). It is important, however, to consider whether or not truly right or left handed individuals exist and, if so, to consider what is meant by the terms. As has been noted, when the arm amputee first is questioned about handedness, writing is apt to be the first thing considered, and the answer is likely to be made on that basis. Additional questioning usually reveals that, although the patient may have used the right hand for writing, many other tasks requiring delicate, coordinated movements might have been done with the left hand, or vice versa.</p> <p>Too many persons believe that the writing hand also is the only hand capable of performing all other smoothly coordinated tasks. As more probing questions are asked of the patient, it may be evident that the opposite hand also performs many functions. If the keys or small change are carried in the pocket opposite from the hand used in writing, bilaterality rather than simple dominance may well be indicated. Information in this connection can be elicited more readily with male patients by asking which pocket carries the handkerchief, which pocket holds the wallet, which hand holds the pipe or cigarette, and which hand is used to strike a match.</p> <p>It often is surprising to find that, with the exception of writing, almost all daily activities involve equal participation of both hands, one serving as a helper to the other with interchangeable ease. When loss of the use of a hand occurs, either temporarily or permanently, the most frequent problem stems not from the inability to write but rather from the inability to perform the tasks requiring use of both handstying shoes, buttoning clothes, cutting food, and so on. Hence, it is important that a prosthesis be designed to restore bilateral activity rather than dominance or the ability to write. When a patient loses a so called "subdominant" hand, he soon expresses some degree of surprise at the number of jobs formerly done by the missing member. He also notes, with as much surprise, that many tasks are quite difficult for the remaining hand alone, even though it be the dominant or leading hand. But the amount of time required to relearn all these tasks, including writing, with some degree of agility is quite short. Except in bilateral cases, the patient soon becomes reasonably independent. If allowed to continue as a one handed individual, the unilateral arm amputee soon learns short cuts that permit him to be more independent and ultimately to feel that he has no need for a functional replacement of the missing hand.</p> <p>Such a patient gives the greatest cause for concern. Perhaps the inability of some to recognize the absence of a true dominance or to understand the rapidity with which a one handed individual can adjust and become reasonably independent may, in some measure, account for a number of failures in upper extremity rehabilitation. Certainly there are other causesinadequate surgery, poor prosthetic replacement, inadequate training contributing to these failures. But only when all of these factors are considered and eliminated can full utilization of the prosthesis be expected.</p> <p>The patient who has learned to do reasonably well with one hand is the very patient most likely to be a failure when fitted with a prosthesis. His training will be most difficult and frustrating for all concerned simply because he cannot recognize the need for a prosthesis. Training for such a patient comprises largely a program of unlearning all of the grotesque contortions to which he has become accustomed. Because here the individual, having been pleased with his one handed accomplishments, must learn to be a two handed person again somewhat against his "better judgment," frustration becomes an important consideration. The more complicated the prosthesis, the lower is the frustration tolerance of the patient because he cannot accept the need for a device which seems to complicate rather than to simplify his life.</p> <h4>A Two-Handed World</h4> <p>One might now properly ask why so much concern should be shown for such a patient. Would it not be easier to permit his unilateral activities to continue and thereby eliminate all problems of fitting, training, and further care? Unfortunately, the solution is not so simple. We live in a two handed world. To maintain our place in society, two hands are needed, or at least substitutes for them. One need only consider the obvious difficulties encountered by the one handed individual when carrying a loaded cafeteria tray, serving himself at the table, or attempting to tie up a parcel (<b>Fig. 2</b>). In the effort to prevent similarly embarrassing situations, the one handed person may gradually seek less and less public contact, social and vocational, and with this self inflicted isolationism ultimate loss of his own security may develop. Despite all short cuts and self helps, the amputee who remains without a prosthesis must still require a degree of additional assistance for many tasks. A functional prosthesis offers independence. An unfitted stump usually leads only to a gradual but ultimate deterioration of self pride in all tasks, public or private.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. The empty sleeve versus the upper extremity prosthesissome examples. Although the unilateral arm amputee may learn to perform well with the remaining sound hand many activities formerly conducted with the amputated member, and although the stump and other parts of the anatomy may be called upon to substitute in "two handed" activities, a great many essential functions are carried out awkwardly, if at all, by the arm amputee who remains unfitted. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Psychological Problems</h3> <p>When it appears that a patient has emotional complications that are not responding to treatment, he should be referred to other medical specialists. Such emotional problems may occur at any phase of the patient's course, and the use of proper specialists will, in many instances, permit the rehabilitation team to continue its work while the patient receives the indicated treatment. Prompt recognition and treatment of such unfortunate situations often will salvage the patient, where otherwise he might drift aimlessly through prosthetic fitting and training until the symptoms are so pronounced as to be recognized by everyone on the street.</p> <p>Initial interviews rarely, if ever, disclose an amputee's underlying feelings about his loss. As he advances through the rehabilitation processes, the amputee may feel that it is too late to open questions of fear and misgiving, in which case his feelings of insecurity are only perpetuated. Hence, it is wise for the physician to suggest possible questions and answers when the amputee is first interviewed. To focus attention upon likely questions may offer an opportunity for the patient to talk about his family's acceptance of his amputation, to discuss social problems resulting from his physical and mental condition, and to air any other problems peculiar to the individual. Unfortunately, no hard and fast rule can be applied; for no two amputees are alike, either in physical or mental make up or in social and economic status. In any given case, each question should be answered as frankly as possible, and, if the answer is not known, every effort should be made to provide one as quickly as possible. Although left to themselves most amputees ultimately find the answers to their own questions, the answers thus obtained usually come only after many frustrations and sometimes after severe emotional stress.<a></a></p> <h3>Medical Problems</h3> <p>The problems of pain, real and phantom, and of phantom sensation, sometimes are so difficult as to postpone actual fitting and training or even to suspend use of the prosthesis after it has been fitted. Recently, phantom pain and phantom sensation have been explored at length<a></a> and more complete concepts of etiology and treatment now are evident. When it is caused by thin or densely adherent scar tissue, neuromata, or bony spurs, stump pain is one of the most common causes for delayed initial fitting or for abandonment of the fitted prosthesis.</p> <p>In such cases it is futile to delay treatment in the hope that actual fitting, continued use of the prosthesis, exercise, or physical therapy may render a neuroma painless or reduce a spur so that it no longer is troublesome. As time passes and the pain or tenderness persists, the patient is entirely justified in questioning whether or not he ever will be able to wear a prosthesis. Specific difficulties that do not respond to conservative measures should be corrected surgically and with the least possible delay. When it seems wise to attempt a conservative approach to minor stump difficulties, an explanation will ensure the patient's continued confidence in the physician. During such a period, the patient's progress must be evaluated regularly. When and if the conservative treatment fails, more radical measures are in order.</p> <h3>Vocational Problems</h3> <p>All amputeesthose, like the housewife, engaged in the home as well as those employed in business and industryhave vocational problems at one time or another. Again, the patient requires much honest and factual reassurance. Although the trend in employment of the physically handicapped is much more gratifying now than it has been in previous years, rose colored pictures of industries seeking amputees for all types of employment lead only to false comfort and to eventual disillusionment of the patient. Although true vocational counseling has become a specialty in itself, the physician must never lose sight of the fact that the job of restoring the patient to useful function is his, the physician's, personal responsibility. Even though the patient may at some time be evaluated by a vocational counselor, the physician must regard the evaluation as a type of referral with continued follow up to ascertain the progress being made.</p> <p>Proper use of the social worker may prove invaluable in maintaining close liaison with the employer and the rehabilitation team.<a></a> The employer should be encouraged not to discharge the amputee patient until the possibilities of further employment have been fully explored. To the new amputee still in the hospital, nothing can be more devastating than a notice to the effect that he has lost his employment as a result of his newly acquired handicap (<b>Fig. 3</b>). Assurance that there is a reasonable chance of continued employment, or that efforts are being made to place the patient in some similar position, will do much to speed his total recovery and to provide motivation, the one factor without which there can be no genuine rehabilitation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The pink slip versus the helpful proprietor. In total amputee rehabilitation, morale is important. Full cooperation of the employer is essential to the success of the prosthetics clinic team. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is fortunate that current trends in aiding the physically handicapped are toward providing vocational training and placement rather than monetary compensation and the subsequent opportunity to sit in the park and collect the pitying, sideward glances of the passers by. The amputee who formerly held a job requiring bilateral hand use very early recognizes the need for a prosthesis, accepts it readily, and receives training as quickly as possible. With the younger, inexperienced person, who perhaps has drifted aimlessly through several more or less unproductive jobs, the problem of prosthetic acceptance and use is more complicated. Such a person has yet to learn the true value of two hands.</p> <p>Unfortunately, some of the veterans of World War II and of the Korean conflict have been victims of such an experience. These men, many coming directly from high school or from odd jobs, had no opportunity to learn vocations or skills requiring use of two hands. Consequently, many of them accept a prosthesis, cooperate halfheartedly in training and follow up, and then discard the prosthesis to look the country over for a job they can do with one hand and sympathy. When an effort is made to offer these people vocational guidance, many indicate they are "going to school," apparently in the belief that one can get through school with one hand. But as a matter of fact the process of education more often than not demands bilaterality, and the inability to recognize the value of a prosthesis constitutes the principal reason why many amputees eventually withdraw from schools.</p> <h3>Training Problems</h3> <p>Although there can now be no doubt of the value of prosthetics training, it is interesting to note that many amputees, usually those who have worn a prosthetic device for many years, indicate that they see no need for training. The patient and prosthesis become one, and little tricks of operation and short cuts, all of which lead to increased efficiency, become second nature. From such a peak of efficiency it is difficult to remember the basic training required to perfect every motion, In the past, moreover, training rarely was conducted as intensively as it is today. Simple instruction in the use of the terminal device, usually by the prosthetist, was about all the patient could expect, and he depended on trial and error and the passage of time for the remainder of his training.</p> <p>A patient who has gone through such a procedure may scoff at the prolonged period of time now thought necessary to assure adequate training in prosthetic control. But the time thus spent really is immeasurably short because it saves the patient much false motion and wasted effort and prepares him to resume his place in society more quickly than the patient with no training. Of course, training must not be confined to the period of prosthetic wear; rather, it must start as soon as the condition of the stump permits.<a></a> Prepros thetic training includes maintenance of joint mobility and muscle strength as well as maintenance of cerebral patterns of motion.</p> <h3>The Problems of Multiple Amputation</h3> <p>The bilateral hand amputee presents both to the patient and to the medical staff a problem of the greatest difficulty. The patient who has lost both hands still possesses two stumps which afford some means of gross prehension. A pencil can be grasped for crude writing, an eating utensil can be held between the stumps for clumsy eating, and the stumps fill out the sleeves. But all delicate prehension, all discrete tactile senses, are lost. Initially, the bilateral amputee is apt to be deeply depressed, and he therefore usually responds poorly to the first rehabilitation contacts. He requires as rapid a fitting as possible, because otherwise he remains almost completely dependent for all necessities, not only economically but, more important, socially and in the home. The latter situation is the one usually most devastating and the one which unfortunately most often is brushed over when the patient first is met. He must have assistance not only in eating but in all toilet activities as well and finds himself relegated to a crude and almost infantile existence.</p> <p>Prosthetic training is much more detailed and prolonged for the bilateral amputee than for the unilateral because the patient has no remaining natural hand for a prosthesis to assist. All acts of dexterity must be accomplished by one or the other terminal device. The therapist cannot consider training complete when the patient meets the requirements of the unilateral amputee but must, in addition, cover use of the prostheses in all acts of everyday lifefeeding, toilet care, and dressing. It is fortunate that such activities are well within the realm of accomplishment for the bilateral hand amputee, especially when the stumps are comparatively long and the natural elbows are intact.</p> <p>An additional complication, usually resulting from trauma, involves amputation of part of a leg in addition to loss of an arm. In the light of present experience, neither amputation truly can be said to take priority over the other, and each case must be considered on an individual basis. In every case, body mechanics and sense of balance are impaired seriously. Gait training becomes more difficult when a part of an arm has been lost. Similarly, upper extremity training is made more difficult without the use of both normal lower extremities. The patient is necessarily confined to bed or uses a wheel chair or crutches for support. If one of the arms is artificial, crutches are used only with difficulty and often in a manner potentially dangerous. The patient may find his arm prosthesis so attached to the crutch that, in the event of a fall, he is unable to free himself rapidly and to discard the crutch. There is thus always the possibility of damage to the stumps or other parts of the body. Considering these potentials, it would seem best to undertake gait training first. When it can be instituted safely, this practice seems to present fewer problems to all concerned.</p> <h3>The Problems of Early Fitting</h3> <p>Early fitting of the prosthesis has come to occupy a major place in present day concepts of amputee management. To postpone fitting until maximum stump shrinkage has occurred often gives the patient those few extra weeks of one handed experience that lead him to believe he does not need a prosthesis. Although there is no known criteria for determining exactly when a stump has stopped shrinking, it now appears that the greatest incentive to maximum shrinkage is actual wear and use of a prosthesis. Once the patient is shown that early fitting and constant practice are the shortest roads to recovery, he usually cooperates willingly.</p> <p>With early fitting naturally comes the problem of continued stump shrinkage, which usually results in a loose socket. It is entirely possible that fabrication of a second socket may be necessary before complete adjustment has taken place. The patient should be made aware of this possible complication, and, when it appears that a second socket may be required, the added cost might be included in the price of the prosthesis. In a patient's decision to abandon a device, repeated expenditures for prosthetic adjustments often play as important a role as does a loose socket. But if initially the patient is told the reasons for possible additional expenditures, more than likely he will accept the conditions without protest and without discouragement.</p> <h3>Some Solutions</h3> <p>What can be done to solve some of the problems that are potential sources of failure in the proper utilization of an arm prosthesis? First, it must be realized by all concerned with the management of upper extremity amputees that the present concept of dominance is a relative one. The person who loses the so called subdominant hand is just as seriously disabled as is the one who loses the dominant hand, and he stands just as much chance of becoming a nonwearer. The remaining member often can be taught to perform many of the functions of the missing hand. If this situation is allowed to persist for long, the amputee begins to feel that prosthetic replacement is unnecessary.</p> <h4>The Education of The Physician</h4> <p>To the end that all upper extremity amputees shall be properly fitted and trained, it is imperative that the education of all physicians and ancillary medical personnel be continued and expanded. Current knowledge and new techniques must be passed on not only to those physicians and technicians who, because they are specialists, see amputees regularly but also to all general practitioners, especially to the family doctors who usually are first to see the amputee. The general practitioner must be brought to realize that new skills and devices are available to help his patients, and he also must be made aware of the fact that the longer assistance is delayed the more unlikely is the amputee to wear and use a prosthesis. Education must be carried to every level, ideally down to the county medical society, which in many instances is the only group in which the general practitioner can participate regularly. Information relating to amputee management should appear in <i>all </i>medical literature, for technical assistants also are responsible for extending any educational program devoted to the amputee. If complete success in total rehabilitation is to be expected, an amputee must be presented to the various specialized centers or clinics with the least possible delay after amputation.</p> <h4>The Education of the Amputee</h4> <p>Equal stress must be placed upon educating the amputee. If, for example, he has a short stump or some other problem requiring that he be fitted with a more complicated and hence less efficient device, the limitations of the prosthesis must be explained in detail. Too many patients are given the benefit of excellent surgery and fit but are not prepared for the shock that comes when they discover that the prosthesis is, at best, only a device to assist the remaining hand. Such a disappointment often produces discouraging results and sometimes complete failure. Many specialists and technicians are prone to be overenthusi astic about a particular prosthesis. What to them appears to be an excellent prosthesis well may be to the patient a hideous collection of bolts and ropes. As a result of some specialists' enthusiasm, many amputees envision a prosthetic device far more functional than actually is possible.</p> <p>When a patient is counseled for the first time, therefore, every effort should be made to point out all the factors involved in total rehabilitation. The limitations of the prosthesis should be explained at once, so that no false concepts or hopes are allowed to exist or to be perpetuated. Even if nothing more than a photograph is available, the patient should be shown a prosthesis similar to the one he eventually will use, and the necessity for training must be outlined so that the patient realizes that wearing the prosthesis and using it efficiently are two distinct functions. Many patients are astonished to find that training is necessary, and many look upon it as just one more stumbling block in an already confused amputee existence. Each step in the program must be explained fully, and the possible complications also must be outlined. Only in this way can the amputee be spared the bitter disappointments that often attend rehabilitation.</p> <h4>Training and Checkout</h4> <p>Adequate checkout procedures should assure efficient mechanical function as well as correct fit.<a></a> An inefficient cable system may, for example, render an otherwise satisfactory prosthesis so difficult or clumsy to operate that even the patient with a great desire to learn may find it impossible to use the device. The disinterested patient who does not appreciate the true value of prosthetic replacement may seize upon such a situation as the final excuse to give up training completely.</p> <p>Prosthetic training and final checkout complete the patient's initial steps toward rehabilitation, but unfortunately training can be responsible for failure. Therapists must be sympathetic with the patient's initial efforts, but they also must be firm in developing adequate control before actual use of the prosthesis is attempted. The patient's first desire after receiving the prosthesis is "to do something with it," and time spent in learning control techniques may seem worthless to him. Here again explanation of the reasons for the training steps is essential.</p> <p>If the patient is unable to demonstrate adequate control skill in a reasonable time, it often is wise to postpone or slow the training process rather than to provoke marked frustration in both patient and therapist. In such instances it is important that the therapist keep the prosthesis until sufficient basic skills are developed by the patient. If the amputee is permitted to wear the device immediately, he is likely to develop inefficient and sometimes weird methods of operation, thus negating all of the valuable time expended in fabrication and fitting. It is essential, however, that the patient understand the reasons for his sometimes difficult and slow progress in training and why it is necessary for the therapist to retain the prosthesis until basic skills are achieved.</p> <p>In some clinics there are to be found a standard below elbow and a standard above elbow prosthesis with split and laced sockets to permit adaptation to many different kinds of stumps. These so called "standard" prostheses are used in early training to prepare the patient for efficient operation of his prescribed prosthesis. When used with proper care and reasonable patient selection, they serve a valuable purpose, but such a procedure may be unwise if the training arm cannot be adjusted readily to the individual patient or if it contains undesirable components. Attempts to use an ill fitting training arm may be so difficult that the patient becomes discouraged and anticipates the permanent prosthesis with misgivings. Accordingly, training arms should be used only on the advice of the clinic team. Too much training can be as harmful as too little. The higher the level of amputation the less functional usefulness can be derived even from the best prosthesis. Realization of this circumstance can prevent the hypertensive episodes that occur in patient and therapist alike when too much is demanded of the amputee prosthesis combination. There is no personal defeat when, as is often the case, it must be admitted that the prosthesis can serve only as a "helper" hand. Under such circumstances, training, to be effective, must be guided appropriately. Overtraining only discourages the patient whose level of amputation is a basic factor in determining the degree of prosthetic function. Achievement tests should be used to measure and record the patient's progress and final skills, but such tests vary from level to level and from patient to patient and can serve only as a crude measuring stick, not as the final criterion as to whether or not a patient has achieved the maximum benefit of training. The answer to that broad question can come only with careful observation of the patient during activities of daily living and of vocational pursuits.</p> <h3>Conclusion</h3> <p>From these considerations, it is possible to formulate certain basic rules for the management of the upper extremity amputee. It is important first to know as much as possible about the patient besides the fact that he is missing a hand. It is necessary to understand him and to understand his disability. Too much faith must not be placed in the absence of either a so called "dominant" or "subdomi nant" hand as the sole measure of disability. In addition, the patient must be made to understand what is in store for him. Above all, no questions about any phase of his problem should be left unanswered. In some instances the amputee is reluctant to discuss problems not relating directly to his amputation, and the physician should be certain that, aside from the amputation, there are no other physical or mental problems that may affect total rehabilitation.</p> <p>For psychological as well as physical reasons, the patient should be fitted as rapidly as possible. Early fitting allows the amputee to realize the advantages and limitations of his prosthesis. Moreover, early fitting often eliminates the danger of the patient's coming to think that he can get along with one hand a situation which can complicate and prolong total rehabilitation. Finally, because overtraining can be just as harmful as are all the other "don'ts" of amputee management, no attempt should be made to train the patient to do more things than the level of his amputation and the nature of his prosthesis permit.</p> <p>When all of these individual problems are considered systematically by the respective members of the clinic team, over all management of the upper extremity amputee becomes a synthesis of cooperative effort. In no other way can so much success and satisfaction be afforded both the patient and those charged with his care.</p> <p><b>References:</b></p> <ol> <li>Abt, Lawrence Edwin, <i>Psychological adjustment of the amputee</i>, Chapter 5 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw Hill, New York, 1954.</li> <li>Bechtol, Charles O., <i>The principles of prosthetic prescription</i>, Chapter 6 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw Hill, New York, 1954.</li> <li>Bechtol, Charles O., <i>The prosthetics clinic team</i>, Artificial Limbs, January 1954. p. 9.</li> <li>Carlyle, Lester,<i> Artificial arm checkout procedures</i>, Artificial Limbs, January 1954. p. 25.</li> <li>Feinstein, Bertram, John N. K. Langton, R. M. Jameson, and Francis Schiller, <i>Experiments on pain referred from deep somatic tissues</i>, J. Bone and Joint Surg., 36A:981 (1954).</li> <li>Feinstein, Bertram, James C. Luce, and John N. K. Langton, <i>The influence of phantom limbs</i>,Chapter 4 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw Hill, New York, 1954.</li> <li>Jampol, Hyman, and Jerry Leavy, <i>Training the upper extremity amputee</i>, Chapter 23 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw Hill, New York, 1954.</li> <li>Kuitert, J. H., and F. E. Vultee, <i>Prosthetic training for the upper extremity amputee with cineplasty</i>, Arch. Phys. Med. and Rehab., 34:367 (1953). </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Studies relating to pain in the amputee</i>, June 1952.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Carlyle, Lester, Artificial arm checkout procedures, Artificial Limbs, January 1954. p. 25.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Jampol, Hyman, and Jerry Leavy, Training the upper extremity amputee, Chapter 23 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Kuitert, J. H., and F. E. Vultee, Prosthetic training for the upper extremity amputee with cineplasty, Arch. Phys. Med. and Rehab., 34:367 (1953). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Bechtol, Charles O., The principles of prosthetic prescription, Chapter 6 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Bechtol, Charles O., The prosthetics clinic team, Artificial Limbs, January 1954. p. 9.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Feinstein, Bertram, John N. K. Langton, R. M. Jameson, and Francis Schiller, Experiments on pain referred from deep somatic tissues, J. Bone and Joint Surg., 36A:981 (1954).</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs,Chapter 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Abt, Lawrence Edwin, Psychological adjustment of the amputee, Chapter 5 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Bechtol, Charles O., The prosthetics clinic team, Artificial Limbs, January 1954. p. 9.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Frederick E. Vultee, Capt., USA (MC) </b></td></tr><tr><td class="clsTextSmall">Physical Medicine Service, Walter Reed Army Hospital, Washington, D. C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_02_036/1955-MayOCRBatch-31.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_02_036/1955-MayOCRBatch-32.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_02_036/1955-MayOCRBatch-33.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Some Problems in the Management of Upper Extremity Amputees Creator An entity primarily responsible for making the resource Frederick E. Vultee, Capt., USA (MC) * https://staging.drfop.org/files/original/2dea17a3a5a3c752d1ee37559bbaa825.pdf 7a4435086ff3850c01c2ef893fa48eac https://staging.drfop.org/files/original/43d8a129940cb8511733726caf27bf79.jpg 5b81f8134177bd4ec394e1f9f2c7aa76 https://staging.drfop.org/files/original/39e08fec5517e38ce66dbeac92235181.jpg 69fe78cabce5d19c388bd5c6790f61fa https://staging.drfop.org/files/original/3a2aea30bf763bcff465c69a91b543c6.jpg 50d23a5eff289ab00376b2787b04b7a4 https://staging.drfop.org/files/original/a8157ca13387fd20c5b413875668ef69.jpg 0ae08cbaf0551506dc3f01cef5e2c987 https://staging.drfop.org/files/original/0b36336724f1ed95ee0fdecea4e24704.jpg 72776be8ad19dce1b202d29195559889 https://staging.drfop.org/files/original/9f72cc18e382ab675a87069c72e62cd2.jpg b62295fcb70277ba0a60bef4591a702f https://staging.drfop.org/files/original/58911f3f64dd71a25a20575b8272b859.jpg b996ee7ff9c38a927feb2bb4ca0678f1 https://staging.drfop.org/files/original/900709fd561acd10c0f47effcf1360ef.jpg b85e77771aac862aba66ec7c33585be5 https://staging.drfop.org/files/original/073bad9839c0df598f8e71002a2f42be.gif 4535091be1c2df849d6a024ab57da422 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_02_047.pdf Year 1955 Volume 2 Issue 2 Page Number(s) 47 - 56 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_02_047.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_02_047.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Noticeability of the Cosmetic Glove</h2> <h5>Tamara Dembo, Ph.D. <a style="text-decoration:none;">*</a><br />Esther Tane Baskin, M.A. <a style="text-decoration:none;">*</a><br /></h5> <p>Ahand prosthesis can be useful in more than one way. It can be helpful in dealing with objects, and it can be helpful in interpersonal relations. The latter aspect is the one with which we are here concerned. The usefulness of a prosthesis in human relations is termed "social usefulness." To a wearer who considers his hand amputation a private matter, for example, and to one who does not wish to be recognized as an amputee, a prosthesis is socially useful if it cannot be recognized as an artificial device. Moreover, the amputee may be concerned that another person looking at the prosthesis should feel comfortable. In such a case, that prosthesis is most useful which does not repulse or embarrass another person but is "good to look at."<a style="text-decoration:none;">*</a></p> <p>In 1949 a cosmetic glove, produced at the Army Prosthetics Research Laboratory, was sent for testing to the Research Division of the College of Engineering, New York University. Investigation of the cosmetic glove led to formulation of the problem of the social usefulness of prosthetic devices in general. The methods developed during the study of the glove are, furthermore, generally applicable to the investigation of the social usefulness of other prostheses. This article deals only with the problem of the noticeability of the cosmetic glove. The question of its appearance, <i>i.e., </i>the desirable and undesirable characteristics of the sight of the cosmetic hand, is not discussed.</p> <h3>Experiments and Results</h3> <p>On cursory examination, the experimental prosthesis looked like a normal hand, but on closer scrutiny it could easily be recognized as a cosmetic device. Further, it did not match the normal hand of the particular wearer, although it was, at that time, the best match among several available cosmetic gloves (<b>Fig. 1</b>, <b>Fig. 2</b>, <b>Fig. 3</b>, and <b>Fig. 4</b>). Moreover, the glove simply was filled with vinyl foam, and the hand was thus nonfunctional except insofar as the amputee might wedge light objects between the springy fingers.<a style="text-decoration:none;">*</a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Winthrop Sullivan wearing the cosmetic glove on his left (to the reader's right). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Mr. Sullivan's hands. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Brennan C. Wood wearing the cosmetic glove on his right (to the reader's left). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Mr. Wood's hands. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The problem was to determine whether such a glove is realistic enough not to be noticed as a prosthesis, or, rather, how frequently the wearer of such a glove goes unrecognized as an amputee. Four different experiments were conducted.</p> <h4>Experiment I</h4> <p>In the first experiment, 30 separate tests were performed. Each required a wearer,<a style="text-decoration:none;">*</a> an experimenter, an observer, and a stranger. The stranger was the "subject" because his reaction, <i>i.e., </i>whether he did or did not recognize the cosmetic hand as a prosthesis, was of prime importance. The wearer went, as a cus tomer, to various stores and shops in New York City and engaged salemen (subjects) in conversation. In each instance, he put his arms on the counter and, to make sure that the cosmetic glove was in sight of the salesman, gestured, pointed, scratched his hand or face, indicated size or shape of objects, held a newspaper, smoked, soiled the cosmetic hand and wiped it off, or supported objects <i>(e.g., </i>held a wallet against his body with the artificial hand), all the while acting in a leisurely manner in order to prolong the contact, usually for from five to twenty minutes. Experimenter and observer entered the store with the wearer but as a separate party. While the wearer talked to the subject, experimenter and observer stood aside as if engaged in conversation, the observer pretending to listen to the experimenter but actually taking notes on the behavior of the wearer and the salesman. The latter, of course, did not know that he was the "subject" of a psychological experiment.</p> <p>When the wearer left the store, the experimenter approached the salesman and asked some questions about the man who had just left. The observer continued to stand aside and recorded the discussion (interview) between the experimenter and the subject. An example of an interview follows:</p> <blockquote><p><i>Experimenter: </i>Did you notice anythingabout the man who was just in here? <br /> <i>Salesman: </i>In what respect? <i>Experimenter: </i>Well, did you notice anything unusualabout him? <br /> <i>Salesman: </i>About his hand. <br /> <i>Experimenter: </i>What was there about it you noticed?<br /> <i>Salesman: </i>There was no action in it. <br /> <i>Experimenter: </i>When did you notice it? <br /> <i>Salesman: </i>When he had his hand at his side. When helighted a cigarette. He held his hand like this[shows stiff position].<br /> <i>Experimenter: </i>Do you think it could have been an artificial hand? <br /> <i>Salesman: </i>No, it was not an artificial hand. It was his hand. He held it close to his side. Maybe he had no action in the shoulder. He did not use that hand. Used one hand at mirror. Held it. Just turned it.</p> </blockquote> <p>After being informed that the hand was a prosthesis, the salesman said he had not recognized it as such.</p> <h4>Experiment II</h4> <p>In the second experiment, three or four people (college students and their friends) were asked to take part as subjects of a psychological group experiment on "impressions of personality." On their arrival, the subjects found the wearer, who was introduced as one of the group members. Everyone was asked to sit around a table and to wait for another group member supposedly delayed and, in the meantime, to get acquainted with each other. The wearer, holding his hands in plain view on the table, conversed with the group members. After about 10 minutes he left the room, ostensibly to make a phone call. Then each member of the group was asked to accompany an experimenter to another room, where the participant was asked to give his impression about the person who went to make the phone call. If, during the interview, it became clear to the experimenter that the subject had not noticed the hand, the subject was given another opportunity to observe the wearer, and then a second interview took place. Sometimes the procedure was repeated a third time. In all, 29 subjects were used.</p> <p>An example of an interview performed in Experiment II follows:</p> <blockquote><p><i>Experimenter: </i>As you know, we are studying quick impressions of personality. Mr. X is part of the experiment. Could you give your first impressions of him? What struck you about him, mainly?<br /> <i>Subject: </i>He seemed intelligent, friendly, sociable. It seemed as though he could talk on other than his major field of interest.<br /> <i>Experimenter: </i>How would you describe him physically?<br /> <i>Subject: </i>Physical impressions are a pretty personal matter, I think. Would say he was more positive than negative, from the point of view of attractiveness. Genial.<br /> <i>Experimenter: </i>Could you give the outstanding characteristics of his face?<br /> <i>Subject: </i>He had a fairly easy smile, seemingly accompanying a sense of humor and a desire to please.<br /> <i>Experimenter: </i>Could you describe his hands?<br /> <i>Subject: </i>Yes, I noticed his hands. I usually do notice hands.<br /> <i>Experimenter: </i>Could I interrupt to ask why you always notice hands?<br /> <i>Subject: </i>I just always have. It dates from the fact that when I was young I thought I couldn't be beautiful, but I could have nice hands and fingernails, so I always notice other people's. I guess I can visualize the hands of every friend I have ever had. I think his were in between, no particular character.<br /> <i>Experimenter: </i>Anything else?<br /> <i>Subject: </i>He had nice hair, a little wavy. A kind of flushed face, more healthy than not.<br /> <i>Experimenter: </i>Were there any gestures on Mr. X's part that you remember?<br /> <i>Subject: </i>No. He had his hands out on the table most of the time, but I don't remember his gestures particularly.</p> </blockquote> <p>The subject who stated that she usually notices hands did not notice the cosmetic hand or any signs of difference about the hand. The experimenter and the subject returned to the group. After about ten minutes more the wearer left, and the second interview took place:</p> <blockquote><p> <i>Experimenter: </i>Now can you give some further impressions of Mr. X?<br /> <i>Subject: </i>I noticed his eyes more this time, a little different than most people's but difficult to describe, noticeable. I noticed his nose tips up a little, like Sonja Henie's. I noticed his hands more because you called them to my attention, but I don't think these physical impressions mean too much.<br /> <i>Experimenter: </i>Was there anything outstanding about his hands?<br /> <i>Subject: </i>His nails were not particularly graceful, they were a little short, but clean looking. I confirmed the fact that his hair was curly and his face ruddy. He seemed very well balanced, not neurotic, in that he seemed willing to go along on other people's fun. He certainly didn't show any compulsion to take the spotlight or to resent it when somebody else took it.<br /> <i>Experimenter: </i>We'll all go back together again, and then<br /> there will be a third interview. I want you to notice his hands again particularly, and in detail. Notice the movement or lack of it. The subject was interviewed again after she saw the wearer for the third time:<br /> <i>Subject: </i>I did notice his hands, the shape, and the rather short fingernails. They looked clean and healthy, but I like tapering fingernails.</p> </blockquote> <p>Even during the third period of contact with the wearer, the subject did not notice any difference between the wearer's two hands, although she was able to describe them. The results of Experiments I and II are given in (<b>Table 1</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1 </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Of 30 subjects in Experiment I, 24 (80%) did not recognize the cosmetic hand as a prosthesis. In fact, they did not even notice any difference between the two hands of the wearer.<a style="text-decoration:none;">*</a> The remaining 6 subjects (20%) commented that the arm or hand was in some way injured, but they too did not notice that the hand was artificial.<a style="text-decoration:none;">*</a> Thus, in an everyday situation of a salesman dealing with a customer, <i>not one </i>salesman in Experiment I noticed the cosmetic glove <i>as a prosthesis.</i></p> <p>The question arises as to why the prosthesis was not noticed by the salesmen. One could ask whether the unnoticeability may not be accounted for by the "fact" that the busy New York salesman does not have enough time to pay attention to the appearance of his customers. This, however, was not borne out by the data. When asked to describe the customer (the wearer), the salesman was well able to describe how the wearer looked, what he did, and what he said. Yet the saleman had not noticed the cosmetic glove.</p> <p>In Experiment II, 29 subjects took part.<a style="text-decoration:none;">*</a>Within the framework of "description of personality," 23 (80%) did not notice any difference between the two hands, 3 (10%) noticed that one hand looked different from the other but did not recognize it to be an artificial hand, and 3 (10%) noticed that it was a prosthesis.</p> <p>That the cosmetic hand was not recognized by any of the salesmen as a prosthesis and rarely as such by the students and their friends, one may argue, is due to the "fact" that people do not pay attention to the properties of another person's hands. To test this "hypothesis," Experiment III was carried out.</p> <h4>Experiment III</h4> <p>In Experiment III, with a setup essentially the same as in Experiment II, the wearer used a hook instead of the cosmetic hand. Here, 11 out of 12 people (92%) noticed that the amputee was wearing a prosthesis. It appears, then, that the cosmetic hand goes unnoticed not because people are negligent in their observations but rather because it does not deviate sufficiently from the appearance of the natural hand. The hook, however, which deviates radically in appearance the normal is noticed readily (<b>Table 2</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2 </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Experiment IV</h4> <p>In the first three experiments, untrained observers were used. The question arose as to whether different results would be obtained in experiments with people especially trained to notice bodily characteristics. One could expect that art students, for example, would be especially apt to notice the cosmetic hand. Accordingly, in Experiment IV, six art students participated as subjects, all members of a drawing class for which the wearer served as a model. Six to eight feet separated the wearer from the students. They were told that, after having made the drawing, they would be asked how the model impressed them as a person.</p> <p>During the first part of the experiment, the wearer posed with his cosmetic left hand supporting his chin (<b>Fig. 5</b>). Ten minutes were allotted for the drawing. Then the wearer left, and the art students were questioned individually, the interviews being conducted in terms of what impression the art student had of the model's personality. Results showed that not one of the six art students was aware that he had been drawing an artificial hand, although some reference was made to the difference between the two hands, or it was felt that the hand somehow did not fit the person.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Mr. Sullivan as sketched by an art student. The hand held to the face is the cosmetic one. While drawing this picture, the art student did not notice a difference between the two hands (Experiment IV, Part 1). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The second part of the experiment offered even greater opportunity for direct comparison of the two hands. Here, the subjects were told that the model (wearer) would return for a second pose and that later the subjects would be asked "how his <i>hands </i>expressed personality." During the second drawing period, the wearer sat with his two hands covering his face (<b>Fig. 6</b>). But even under these conditions, only two of the six subjects noticed that one of the hands was artificial. The remaining four did not realize that they were drawing a cosmetic hand.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Second drawing of Mr. Sullivan by the same art student who drew the picture shown in Figure 5. The notation listing the differences between the two hands is that made by the student at the time of the drawing (Experiment IV, Part 2). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To illustrate how, in spite of differences noticed between the two hands in Experiment IV, it did not occur to the subjects that one hand was artificial, excerpts from two interviews conducted after the second drawing (<b>Fig. 7</b>) follow:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Drawing made by an art student during Experiment IV, Part 2. The left hand (on the reader's right) is the cosmetic one. The student saw the hands as different owing to the occupation he ascribed to the wearer. He thought the wearer was a violinist. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <blockquote><p><i>Experimenter: </i>What gives now?<br /> <i>Subject: </i>Interesting things, real interesting. Makes a difference when you know you're supposed to look at hands. About his hands, there is a basic difference in his two hands. The right hand is more used, I would say [left hand is the cosmetic one]. There are several interesting things about them. First of all, the fingernails were fairly short. Gives me an idea that he may play a stringed instrument. The button of his cuff was open, couldn't tell if broken off. I thought of a violinist who would open his cuff so he could handle it. I think he is right handed because that would be the bow hand, and all the movement would have opened the cuff. I don't think this particularly jibes with the feeling that the hand that would do the fingering would be the most wrinkled, worn hand. For this was not the case. Yet had the feeling that he does do something special that involves t h specialized use of one of his hands.<br /> <i>Experimenter: </i>Why do you think this?<br /> <i>Subject: </i>Well, there is a basic difference in structure. 1 couldn't see the right hand before when he was posing [subject refers to <b>Fig. 5</b>], I drew the right hand first. It was thinner. I felt there was more structure visible, it was more wrinkled, I could think of some special occupation. Another interesting thing, the watch was worn inside the wrist on the right hand, which made me think it indicates a little about the personality.</p> </blockquote> <p>Another interview in Experiment IV went as follows:</p> <blockquote><p><i>Experimenter: </i>And what did the hands express?<br /> <i>Subject: </i>Well, it looked to me as if [the hands express] the character of a person in very serious thought.Some trouble, wrestling with some problem, rather unhappy.<br /> <i>Experimenter: </i>Was this because of the hands, or the pose, or both? <i>Subject: </i>Both together. The hands were very tense and tight, not relaxed. Indicated that there was a conflict. <br /> <i>Experimenter: </i>This was the physical appearance?<br /> <i>Subject: </i>Yes, the tense position of the hand and fingers, the fingers close together and tight, not relaxed and easy. They show what's inside the person. He unconsciously clenched his fist and you noticed something.</p> </blockquote> <h3>Discussion</h3> <p>In the first experiment in which the cosmetic glove was worn, not once was the cosmetic hand recognized as a prosthesis. In Experiment II, the glove was seen as a prosthesis by only three (10%) of the subjects. In both experiments, a difference between the two hands was noticed only rarely. In Experiment III, the hook was recognized as a prosthesis in all cases save one. If one wishes to "explain" the unnoticeability of the cosmetic hand during relatively short contacts, one may say that the appearance of the cosmetic hand is similar enough to that of the normal to remain unnoticed. We know, however, that the differences between the glove and the normal hand are pronounced enough to be seen by almost anyone. What, then, are the conditions under which the <i>similarity, </i>rather than the <i>dissimilarity, </i>is decisive? To understand what is involved requires a brief discussion of a few general problems of visual perception.</p> <p>It is a well known fact that objects on which we focus are seen much more clearly than are those seen within the area of our peripheral vision. Distinguished from these two areas in the visual field should be two others, namely, "area of concern" and "area of mere presence." An object is in the "area of concern" if we inspect it, that is, if we concern ourselves with it. If, however, we perceive an object "as just being there," if it is not being examined by us and we do not concern ourselves with it, it is in the "area of mere presence."</p> <p>The area of presence and the area of concern of a visual field do not necessarily coincide with the central (focal) and peripheral parts of the field of vision. Each of the areas, that of concern or that of mere presence, can be either central or peripheral. We can, for example, stare at an object, focus on it, and yet not be concerned with it but with something going on elsewhere in our field of vision. Such is the case, for example, when one is looking at an object but wishes to watch another person unobtrusively. Here, the object focused upon is central and at the same time is in the area of mere presence. The person being watched is in the peripheral field of vision but at the same time is in the area of concern. Centrality and peripherality thus are distinguished by whether we do or do not look at an object directly, areas of presence or concern by whether or not we attend to (examine) the object.<a style="text-decoration:none;">*</a></p> <p>Often there is a tendency on the part of an observer to make the area of concern coincide with the center of his field of vision, while objects that do not concern him are shifted to the periphery. The separation of the field of vision into central and peripheral areas is, however, essentially different from the separation into areas of concern and of mere presence. With regard to the noticeability of the cosmetic hand, the most important fact is that objects in the area of concern differ in appearance from those in the area of presence. Some differences in details perceived when two objects are in the area of concern are not perceived when two objects are in the area of mere presence. Thus, two objects in the area of concern may look different, whereas the same two objects may look alike when in the area of mere presence.</p> <p>In meeting people, we usually do not concern ourselves with their hands, <i>i.e., </i>hands are in the area of mere presence. Because the observer perceives fewer details in this area, hands which on examination look different can appear alike to the stranger and thus may not provoke attention during casual contacts. This would account for the infrequency with which the cosmetic hand was recognized in Experiments I and II. Since looking directly at or focusing on an object does not necessarily mean that the object is examined, glancing and looking at the hands directly, as did some of our subjects, failed to result in observation of significant differences.</p> <p>When something unusual happens, the hands shift from the area of mere presence to that of concern or, to put it in another way, the observer changes the position of the hand from the area of mere presence to that of concern. If, for instance, the subject expects the wearer to use a given hand, and if this hand is not used as expected, or if the action is interrupted (Experiment I), the observer becomes concerned with the hand, examines it, and becomes aware of its deviation from an ordinary hand. Again, if examination of the hands is suggested to a subject, the area in which they are seen becomes one of concern. Moreover, if the subject is told that the hand is artificial, an incentive is provided to examine it. In this case, too, the hand is perceived in the area of concern.</p> <p>The physical properties of the cosmetic hand are such that, on examination, they are seen not to match those of an ordinary hand. Yet the handlike prosthesis is sufficiently similar to a normal hand that, in the area of mere presence, it may be seen as an ordinary hand. A hook, however, differs to such an extent in physical properties that, even in the area of mere presence, it can hardly be mistaken for a hand. This accounts for the results of Experiment III, in which the hook was noticed by all but one subject.</p> <p>In comparatively few instances (Experiments I and II), the cosmetic hand was seen as "different" from the other hand but was not recognized as artificial. The existence of cases in which differences are recognized, but in which the hand is not recognized as a prosthesis, may be due to the fact that, as a rule, people are not aware that a realistic hand prosthesis exists. Were that fact commonly known, the 20 percent who noticed the hand as "injured" in the first experiment, and the 10 percent who noticed it as "different" in the second experiment, might have seen it as a prosthesis. But knowledge of the existence of such a prosthesis would not affect the proportion of those who saw <i>no </i>difference (80 percent in both the first and second experiments). Since they did not notice any difference, these subjects would not even begin to concern themselves with the hand. As long as the hands match in the area of presence, knowledge that artificial hands exist would not in itself lead to an examination of hands.</p> <h3>Future Work</h3> <p>Briefly stated, the results show that strangers in everyday contacts with the wearer rarely notice a difference between the two hands. Yet noticeability is only one aspect of the larger problem of social usefulness of the cosmetic hand. Recognition of the cosmetic hand as a prosthesis is bound to occur in repeated contacts with the wearer. Furthermore, friends and relatives know that a wearer is an amputee. When the hand is recognized as artificial, a new problem arises. The appearance of the hand in the area of concern becomes important. Preliminary investigations indicate that, when the cosmetic glove is recognized as such, its appearance evokes in some people very unpleasant feelings. The study of the appearance of the cosmetic glove thus is necessary in order to determine the emotional impact relative to that of other prostheses and to ascertain which properties of the hand provoke negative feelings.</p> <p>Some people perceive a cosmetic hand as having a yellowish greenish shade. This circumstance might evoke toward the prosthesis feelings as toward a dead hand. Such feelings might be alleviated if the color of the cosmetic hand approached more closely that of an ordinary hand (page 57). It might even be shown that, to appear as real as possible, the cosmetic hand should have a definitely less yellowish tinge than does an ordinary hand. For such determinations, the subjects chosen should have strong negative feelings toward the hand available now, and observations should be made when the hand is worn.</p> <p>In conclusion, it should be stressed again that the problem of noticeability is only one aspect of the larger problem of the social usefulness of prostheses. Further studies are required to uncover those psychological properties of the observer which have to be taken into account in order to develop not only "functionally" but also "socially" (or rather "socio psychologically") useful prostheses.</p> <br /> Figure 1 http://www.oandplibrary.org/al/images/1955_02_047/1955-MayOCRBatch-34.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_02_047/1955-MayOCRBatch-35.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_02_047/1955-MayOCRBatch-36.jpg Figure 4 http://www.oandplibrary.org/al/images/1955_02_047/1955-MayOCRBatch-37.jpg Figure 5 http://www.oandplibrary.org/al/images/1955_02_047/table01.jpg Figure 6 http://www.oandplibrary.org/al/images/1955_02_047/table02.jpg Figure 7 http://www.oandplibrary.org/al/images/1955_02_047/1955-MayOCRBatch-40.jpg Figure 8 http://www.oandplibrary.org/al/images/1955_02_047/1955-MayOCRBatch-41.jpg Figure 9 http://www.oandplibrary.org/al/images/1955_02_047/1955-MayOCRBatch-42.gif Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Noticeability of the Cosmetic Glove Creator An entity primarily responsible for making the resource Tamara Dembo, Ph.D. * Esther Tane Baskin, M.A. * https://staging.drfop.org/files/original/d3e07ca0af0348fd4c2e920c106b4c65.pdf 809d9e3993c31bb21b2a8dc9b7031253 https://staging.drfop.org/files/original/222baa00904d46e2a3f74ce88ede3447.jpg c7b121f400393dc467ed647aeacdac4e DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_03_061.pdf Year 1955 Volume 2 Issue 3 Page Number(s) 61 - 63 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_03_061.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_03_061.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Some Experience in Harnessing Extreme Arm Cases</h2> <h5>Craig L. Taylor, Ph. D. <a style="text-decoration:none;">*</a><br /></h5> <p>With recent developments in shoulder prostheses, including that for complete removal of the shoulder girdle, it is possible to fit all upper-extremity amputees with useful arm substitutes. But of course it does not follow that all patients with high amputations can obtain from the available harnessing resources a uniformly good level of prosthetic function. It is appropriate to review present experience with such cases in order to establish realistic guides for the fitter. Although there is only a limited number of upper-extremity amputees with multiple amputations or with amputations at very high levels, the UCLA Case Study<a></a> has accumulated a sufficient number to make tentative conclusions possible.</p> <p>Limitation in the potentialities of shoulder harness begins with the unilateral shoulder case of the disarticulation type. Unilateral humeral-neck amputees with an intact shoulder girdle have, in every case known, been able to manage the shoulder dual control, and with any of several elbow-lock arrangements they have been able to carry out all of the operations of the prosthesis. Further unilateral shoulder losses, or losses of both shoulders at various levels, entail such impairment of harnessable shoulder mobility that it is impossible to attain the operating effectiveness ordinarily to be expected from the major prosthetic controls. A review of several types of fittings and the results obtained indicates the nature of these limitations.</p> <h4>Unilateral Shoulder Amputees</h4> <p> In the unilateral shoulder amputee, limitation begins with the disarticulation because the leverage on the amputated side is then so reduced that biscapular shrug no longer gives the necessary excursion. With most men of average to large build, however, the results usually are satisfactory (<b>Table 1</b>). In the case of M.W., pelvic control was required. T.M., a large and broad-shouldered man, obtained good function despite large, but not complete, clavicle and scapula losses. With the fore-quarter case, P.H., the sound shoulder could not manage the full control, and the functional regain was decidedly marginal.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Bilateral Above-Elbow/Shoulder Combinations</h4> <p> No case of bilateral humeral-neck amputation has thus far come to notice, but the bilateral above-elbow/shoulder combination is comparatively frequent. Five cases of this type can be cited. All save one are at least moderately successful. The unsuccessful case, C.B., has a number of stump complications that have prevented a satisfactory result. Otherwise, good operation, one prosthesis at a time, is provided by harnessing modifications in which the elements of the shoulder-disarticulation harness from one side and of the figure-eight from the other are combined. It should be noted that in all these cases both shoulder girdles are intact, and there is in addition one humeral stump. Hence, shrug and arm-flexion controls can be managed normally.</p> <p>The first case of this type, L.S., is a young man, age 29, with a right above-elbow stump of 10 in. and a humeral-neck amputation on the left side. The musculature and mobility of both shoulders and of the right stump are good. Amputee L.S. is tall and slender but of moderately broad-shouldered build. He is fitted on the right with an above-elbow dual control, on the left with a modified shoulder-disarticulation harness with nudge control for elbow lock. He is rated as a good wearer and is independent in nearly all activities.</p> <p>The second case, C.B., is an elderly man, age 60. He has a right shoulder disarticulation and a left short humeral stump supplemented with a tibial graft. Neuromata in the shoulder area and tenderness about the tibial graft have made fitting difficult; trial fittings with numerous types of harness have not been successful. The age of the subject, recurrent shoulder pain, and habits of dependence have together prevented satisfactory results.</p> <p>Another case, M.C., is a young woman, age 36, with a right short above-elbow and a left humeral-neck stump, the latter supplemented with a tibial graft not yet ready for fitting. Meanwhile, amputee M.C. is operating well with the right prosthesis only. She has acquired skill in eating, drives a car, does housework, and is rated a good wearer generally. Future addition of the left prosthesis is uncertain.</p> <p>Amputee R.G. is a young man, age 31, with a right short above-elbow and a left humeralneck amputation. He is tall and rangy with broad shoulders. Bilateral pectoral muscle tunnels had been constructed, but they were eventually closed at the amputee's request. When last seen he was fitted with short above-elbow dual control on the right side and shoul-der-disarticulation dual control on the left. For a while the left elbow lock was operated by the pectoral tunnel, but the method of elbow-lock operation after removal of the tunnel is unknown. Over several years of observation this amputee was rated as a moderately good wearer and was independent in most personal activities.</p> <p>Finally, J.L. is a man, age 40, with a right above-elbow stump 9 in. long and a left amputation at the humeral neck. Of fairly tall and rangy body build with good shoulder and stump mobility, he was fitted with a right above-elbow dual control and a left basic shoulder-disarticulation harness, the left elbow lock being operated by a nudge control After fitting and training he attained a good level of performance and as far as is known continues to be a good wearer.</p> <h4>Bilateral Shoulder Disarticulation</h4> <p> The reduced shoulder width associated with the bilateral shoulder-disarticulation case so impairs scapular abduction and shoulder flexion that complete control of the prostheses is not possible. Full operation of the terminal device at elbow angles above 90 deg. cannot be managed with the dual control, and a lower level of operation must be accepted. The pelvic control remains a possibility, but this expedient has so many disadvantages of inconvenience, awkwardness, and discomfort that few if any amputees accept it for continuous use. Shoulder control can at best be unilateral only.</p> <p>Nevertheless, an acceptable level of function may result. For example, J.G. is an elderly man, age 63, with bilateral shoulder disarticulations. Of medium build and with rounded chest, he has to date been completely dependent on help from others. Fitting and care have been sporadic because of infrequent visits to the laboratory. He last was fitted unilaterally with a right prosthesis and a reaction cap on the left shoulder. Thus far the fit has been promising. At the last visit he had managed eating and other activities.</p> <p>With the congenital anomalies, amelia and phocomelia, control functions usually are considered as being the same as those for the shoulder-disarticulation case. Shoulder girdles are narrow because of the absence of humeral heads or owing to loose and nonarticulated rudimentary elements, so that basic shoulder control may not be adequate for bilateral function. In phocomelia, with both forearm and hand or only hand elements, additional help may often be obtained for secondary controls such as elbow-lock operation. In any event, these congenitals early develop "manipulation" with the feet, and these capabilities have not been matched, so far as is known, by any upper-extremity prosthesis.</p> <p><b>References:</b></p> <ol> <li>Gottlieb, M. S., <i>Final report of the UCLA upper extremity amputee case study, </i>Department of Engineering, University of California (Los Angeles), in preparation 1955.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Gottlieb, M. S., Final report of the UCLA upper extremity amputee case study, Department of Engineering, University of California (Los Angeles), in preparation 1955.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Craig L. Taylor, Ph. D. </b></td></tr><tr><td class="clsTextSmall">Professor of Engineering, University of California, Los Angeles; member, Advisory Committee on Artificial Limbs, National Research Council, and of the Technical Committee on Prosthetics, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_03_061/tmp48F-1.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Some Experience in Harnessing Extreme Arm Cases Creator An entity primarily responsible for making the resource Craig L. Taylor, Ph. D. * https://staging.drfop.org/files/original/4466dc9f88049d40488d6be216fd66d6.pdf df7dcc4340714709da0ed7b7c1699d85 https://staging.drfop.org/files/original/53b5a7a21d9da4b70e22698b5a760aaa.jpg 580a52b9ef39dda90026098898a6a1ce https://staging.drfop.org/files/original/a0eb985726680bed7cd45922e2034e1d.jpg c4a800fceb94238c2677ac1353245ed1 https://staging.drfop.org/files/original/67e644fd9e00ecd25e6e49a71794f407.jpg 60eaf7d0437847d9e266dcd9fbc1c939 https://staging.drfop.org/files/original/589ba45ffbb62595ca1df05cfeb159c0.jpg 8566b117423ddacb7a5d4153e234f8a8 https://staging.drfop.org/files/original/36ba8f4a7fa3b03421d6f86028269823.jpg 1abb24b7a318ac3b59305fe354af6d54 https://staging.drfop.org/files/original/073598b3381e4a6ac1c6962280a87675.jpg 5b5ae92ad35825fadc4a43eca508978b https://staging.drfop.org/files/original/720a349f49e9cd4af439cb42bebb620b.jpg 10091d4c9cdda7e591209ada36971ae1 https://staging.drfop.org/files/original/f376141812a404af3010dfdf6dbedf29.jpg da6eec89495628a12e65102fc753e2b6 https://staging.drfop.org/files/original/206ae750fa9a0a06275a4a9cc9a4dce8.jpg 724c967272fa84216d1830d4dd4d9548 https://staging.drfop.org/files/original/73d9f7175d3a09f5fd09ba00e95cca0e.jpg 394abd72058740013c9e1f4ea0d5011f https://staging.drfop.org/files/original/a44144b9c6d5a256cd7da054cf8621d2.jpg 418b6d99ee67aedca58cceff52f4205e https://staging.drfop.org/files/original/a716afbeccd1b0841e1ff0e4c66fc23d.jpg e9abb6131a86c67ffdd79c69428ff2a8 https://staging.drfop.org/files/original/eb429fccd53602c04c0a0d04864cad6f.jpg 99826548df6f19c657326b20ba9434f3 https://staging.drfop.org/files/original/16212ba76062ab46774d405e1c0d6dbb.jpg 10231e0bc58bc0d853c27072bd4f19fd https://staging.drfop.org/files/original/8eb0c9a2760981415e2d2ac1a225b498.jpg 1078787fef23aa145c6f4ba544fa286b https://staging.drfop.org/files/original/c7712445845a41b936dc9aeb5cf902d3.jpg 18d9adab9f4fb258d754543b62f65721 https://staging.drfop.org/files/original/067afcb3523416f2f0455fb4e8973fd5.jpg 6b11e8017d8bf6ffd5e528d796afc842 https://staging.drfop.org/files/original/05def91a2bbdd073ada3f01fe3651289.jpg e36c49e73001acd8cb53a05c873baf00 https://staging.drfop.org/files/original/30f0645250433050bcfeab5015060e2d.jpg e054259f8d752d7f0859d67bd239c669 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_03_026.pdf Year 1955 Volume 2 Issue 3 Page Number(s) 26 - 60 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_03_026.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_03_026.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Harness Patterns for Upper-Extremity Prostheses</h2> <h5>Robert J. Pursley, Lt., USA (MSC) <a style="text-decoration:none;">*</a><br /></h5> <p>The comparatively recent development of more functional components for artificial arms has made it necessary to analyze in greater detail the requirements of harnessing the power needed for effective operation. Just as an automobile is helpless without a well-designed and well-built engine and transmission system, so an arm prosthesis is helpless without a well-designed and well-constructed harness. To build a successful harness system requires not a knowledge of some long-lost art but, instead, a careful appraisal of the wearer, of the device to be worn, and of the available tools to be put to work. Since the modern body harness constitutes a dynamic coupling between a human being and a mechanism designed to replace a living extremity, the problem of devising it is also one of dynamics and of what some call "human engineering."</p> <p>Many illustrations of typical harness patterns are presented later in this article. But it is not enough for the harnessmaker simply to reproduce what is shown in these drawings of typical patterns or to superimpose on an individual amputee a generalized harness pattern of any particular type. He must first understand the purpose of the harness, the requirements of the particular prosthesis involved, and the body motions available, and he must then apply his own skill and judgment in making appropriate modifications to suit the individual case. It is, of course, far more important to produce a harness that will give the desired functional results than it is to produce one that looks exactly like any one of the drawings. The illustrations are therefore intended as general guides only, not as a detailed description applicable to every case of amputation at the indicated level. When planning and making any harness, the prosthe-tist should examine the location of each element to ensure proper function with the expenditure of minimum effort on the part of the particular wearer concerned.</p> <p>The first and most simple requirement of any harness is that it must hold the prosthesis securely on the stump. The second is that it must be comfortable to the amputee. Generally, suspension, as such, is easily obtained, but to suspend the prosthesis properly and at the same time to assure maximum comfort for its wearer is more difficult. If either of these requirements becomes a matter of choice, then comfort must be the more important consideration. If the harness is not comfortable, or at least tolerable, the person for whom it was intended will soon hang it politely on a suitable nail. Since almost no harness can be constructed satisfactorily without a few compromises at first, it is unwise to promise complete success on the first try.</p> <p>The third and all-important requirement of functional body harness is that it must supply a source of power for the operating components of the prosthesis. This means simply that residual body motions must be harnessed to replace lost functions of the natural member, but to provide controls that are operable in an effective and yet inconspicuous manner poses a complex problem. It requires an examination of the body motions that can be utilized by the harness without detracting from the usefulness of the remaining normal hand and without introducing unduly awkward gyrations of parts of the anatomy not ordinarily involved in arm activity. The higher the level of amputation, the greater the control requirements but the fewer the sources of control. The problem is further complicated by the need to maintain the proper balance between adequate suspension, acceptable comfort, and worthwhile function, for each of these needs is often satisfied only at the expense of the other two. A look at the background of harnessing for upper-extremity prostheses <a></a> reveals that, when devices were generally passive in nature, so was the harness. As devices have increased in function, so has the harness also. Today the development of devices has in general surpassed the art of harnessing them. With the proper approach, however, and using a common-sense analysis both of the amputee's capabilities and of the requirements of the prosthesis, an accomplished limbfitter can in almost every case turn out a very acceptable harness that will meet functional needs to a surprising degree.</p> <h4>Harnessing for the Below-Elbow Cases</h4> <p>The prosthesis for the unilateral below-elbow case is unquestionably the simplest to harness. For the reason that the below-elbow amputee retains his own elbow, and therefore usually requires replacement of prehension only, he can almost without exception be harnessed successfully. At least three feasible control motions are to be had. In order of decreasing usefulness, they are arm flexion on the amputated side, shoulder depression on the amputated side, and scapular abduction. The choice and extent of use of these three motions, singly or in combination, is largely a matter of personal preference depending on the area in which the terminal device is required to operate. With the elbow flexed to 90 deg. and with the terminal device located slightly above the level of the head, for example, arm flexion is almost completely spent. Using scapular abduction under the same circumstances, however, the below-elbow amputee can still operate the terminal device satisfactorily. Successful wearers of below-elbow prostheses develop their own individual patterns of operation and subconsciously learn to operate the device in all areas in which it is called upon.</p> <p>The problem of transmitting the force and excursion of body motions from the source to the point of use has in the past involved a wide variety of materials. Rawhide thongs and leather laces are only two of many that have been used, even as late as only a decade ago.<a></a> The flexible metal cable and wrapped-wire housing adopted from the aircraft industry is currently the most widely used and is the most satisfactory available today. It is based on the Bowden principle (<b>Fig. 1</b>), which makes it possible to transmit force and excursion from the body to the terminal device regardless of elbow angle.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. The principle of the Bowden cable for transmitting tension forces applied at one end. Although point <i>C </i>is brought closer to point <i>A </i>when rotation occurs about <i>B, </i>the housing <i>D </i>prevents slack in cable <i>E </i>by preserving the <i>effective </i>path length <i>A </i>to C. A counter-force is required at the opposite end to return the flexible cable to its original position. Other types of Bowden cables are based on the torque principle, as used in speedometer cables, or the push-pull principle, as used in the temperature controls of the automobile heater. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Utilizing any or all of the three useful body motions, together with the Bowden-cable transmission system in every case, two alternate harness patterns are available for the below-elbow amputee with a stump of medium length. The first is known as the "figure-eight" harness, the second as the "chest-strap" harness. In addition, there are two special modifications, one for the very long and another for the very short below-elbow stump. These are, respectively, the "double-axilla-loop" harness and the "dual-control" harness. Finally, there is the special harnessing arrangement using the biceps cineplastic muscle tunnel to provide force and excursion.</p> <h4>The Below-Elbow Figure-Eight Harness</h4> <p><i>The Harness Pattern</i></p> <p>The figure-eight pattern, of which <b>Fig. 2</b> presents a typical example, is the harness most commonly used in the unilateral below-elbow case, the axilla on the sound side being the site of anchor for capturing the relative motion. The front view of <b>Fig. 2</b> shows the suspension portion of the harness. The front harness strap, passing over the shoulder at the pectoral interval on the amputated side, buckles to the inverted Y-strap supporting the leather triceps pad, which in turn supports the socket through the flexible elbow hinges. The back view shows the transmission system from harness to terminal device. The general path of the control cable is such that sharp bends and curves of small radius are avoided as much as possible.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. The below-elbow figure-eight harness. A simple webbing loop passes around the sound shoulder, the front portion being used for suspension, the back for attachment of the control cable. The inverted Y-suspensor. triceps pad, and flexible elbow hinges are constructed of 4 to 6-oz. strap leather and lined with 4-oz. pearl horse-hide or equivalent. The proximal retainer on the triceps pad is of the flexible leather type to improve cable life. The three circled inserts show possible variations in individual cases. Circle <i>A </i>illustrates the leather half-cuff as used in combination with rigid elbow hinges and a single billet. Circle <i>B </i>shows a hall-cuff with two billets, again in combination with rigid elbow hinges. Circle <i>C </i>shows the inverted Y-strap as made from fabric instead of leather. Any of the combinations shown may be used as required to furnish the necessary stability depending upon occupational needs, level of amputation, and other factors. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The chief purpose of the control system is to transmit force and excursion to the terminal device. When, however, the amputee must pick up loads with forearm extended, the cable is expected to assist in support whenever the load is of any appreciable magnitude. This, then, is an example of what is meant by the proper balance of forces that is needed to meet amputee requirements. Both suspension and control system should be so constructed and adjusted as to be comfortable and yet be able to meet a reasonable load-support requirement without unnecessary displacement of the prosthesis. Tests for determining allowable displacements and other important factors have been set forth by Carlyle.<a></a></p> <p>As shown in <b>Fig. 2</b>, the harness is padded and protected under the axilla, and the control cable is so adjusted that it cannot come into contact with the amputee's back. For maximum excursion, the cross of the harness should be below the cervical vertebrae and not more than 1 in. toward the sound side of the vertebral spine. The control attachment strap <i>(i.e., </i>the strap attached to the flexible control cable) should lie at the midscapular level. In the course of constructing the harness, visual observations of all these details should be made while the wearer goes through the movements to be expected in normal use.</p> <p>Because of the simplicity of the figure-eight harness, minor deviations usually are not serious. Occasionally, indeed, exceptions to the normal placement of the harness cross are necessary and desirable to improve comfort. The figure-eight harness can be worn successfully by the majority of below-elbow amputees with ordinary duties, it is easy to construct and there is little chance for error, and it is functional and comfortable in most cases. Together these advantages generally represent the reason why it is so widely used. It readily adapts itself to vocations that are clerical in nature and to individuals requiring medium duty, such, for example, as the lifting that might be required of a stockroom worker.</p> <p><i>Below-Elbow Cliffs, Pads, and Hinges</i></p> <p>To furnish suspension and socket stability, three types of cuffs and pads, with and without fillers, are available, and any of several types of hinges, some flexible and some rigid, may be used. The circled inserts <i>A </i>and <i>B </i>of <b>Fig. 2</b> show some of the variations giving greater and greater stability as needed in the individual case. The choice of cuff and hinge combination is strictly a consideration for the prescription team, the rule being to provide maximum stability with the absolute minimum of harness. Prescription criteria and suitable templates for cuffs are described in considerable detail in Section 5.6 of the <i>Manual of Upper Extremity Prosthetics.</i><a></a> It should be remembered that many combinations of hinges and cuffs are available and that no one cuff must necessarily be accompanied by any particular type of hinge. Moreover, the prescription for any given amputee should take into account his own individual requirements and personal preferences.</p> <p>There are at least two ways of making cuff suspension systems, material selection being the principal distinguishing factor. The preference of the limbmaker may enter into the choice of technique largely because of the fabrication facilities that happen to be available. Leather has long been used in the limb industry, and it is readily adaptable because of its molding characteristics. Although the ability of leather to conform readily to the shape of the arm represents something of an advantage over webbing straps (circled insert <i>C </i>of <b>Fig. 2</b>), its tendency to absorb perspiration and thus to deteriorate, as well as to acquire unpleasant odors, is considered by many to be a distinct argument against its use in arm cuffs. The webbing strap, while perhaps less stable, offers the advantage of being easily washed and quickly replaced. Modern synthetic fabrics now available commercially can be laundered without undue shrinkage and may be reapplied without stretching under load.</p> <p>The below-elbow cuffs and pads usually are made of 4- to 6-oz. strap leather and are lined with horsehide or similar material. The fabrication of this component calls for the cutting, sewing, and fitting skills of the limbmaker. To make the Y-shaped leather suspension strap, a paper pattern is first cut to conform to the amputee's arm. When the template lies smoothly against the arm above the bulge of the biceps and will reach properly from the triceps pad or cuff to the webbing suspension strap passing over the shoulder at the pectoral interval, its shape is reproduced in 4- to 6-oz. strap leather or equivalent. The lower legs of the leather suspension strap are then riveted to the cuff or pad in such a position that the "V" lies smoothly against the arm and will support axial loads.</p> <p>The webbing inverted Y-suspensor is prepared by folding a piece of 1/2-in. webbing back on itself in such a way as to form a "V." The apex of the "V" is then sewed directly to the front suspensor strap of the harness at such a level as to give a smooth transition from the harness to the cuff or pad. The lower attachments to the cuff or pad are made by means of 1/2-in. buckles.</p> <p>Again, material selection is the chief factor determining technique. When leather is used, it is hard to determine the proper length of the legs of the "V" and to assure proper alignment without later adjustments. Moreover, unless leather components are coated with nylon <a></a> or similar material, the effects of perspiration will soon become apparent. Conversely, the webbing Y-suspensor offers easy adjustment of alignment and also resistance to perspiration by virtue of its washability. When fitted properly, both systems are acceptable, and hence personal preference is an influencing factor.</p> <h4>The Below-Elbow Chest-Strap Harness</h4> <p>Although the figure-eight harness is suitable for most below-elbow cases, it does not meet all vocational requirements. Heavy-duty activities, such as those of a farmer, requiring frequent lifting of loads greater than 50 lb., can best be accommodated by a below-elbow chest-strap harness. <b>Fig. 3</b> shows a typical example. By the addition of the shoulder saddle to reduce unit stresses on the shoulder and opposite axilla, the load-supporting capabilities and amputee comfort can be greatly improved, but to obtain a satisfactory result with the chest-type harness presents a greater challenge to the harnessmaker.<a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The below-elbow chest-strap harness The two suspensor straps running through D-rings are attached to a leather shoulder saddle Improved stability and reduced unit stresses over the shoulder offer greater ability to lift axial loads. Normally, the below-elbow chest-strap harness, used on amputees requiring heavy-duty service. is constructed in combination with half-cuff and rigid elbow hinges. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><a></a> It has been said that some limbmakers construct the chest-strap harness simply because they do not know how to make the figure-eight design. There ap pears to be no real evidence to prove which type really is the older, but it is generally accepted that the chest strap was the forerunner of the figure-eight. Regardless of priority, both patterns are acceptable, and each offers advantages and disadvantages.</p> <p>As shown in <b>Fig. 3</b>, there are basically three elements in the below-elbow chest-strap harnessâ€"the chest strap to hold the harness on, the shoulder saddle to serve as an anchor for suspending the prosthesis, and the control attachment strap for operating the terminal device. To connect the shoulder saddle and to suspend the prosthesis, two lengths of 1/2-in. leather or webbing are used. They originate on the back of the shoulder saddle, thread through D-rings on the cuff, and then buckle to the front of the saddle. This arrangement distributes the load on four points of the saddle and two points of the cuff and offers the inherent self-equalizing effect by virtue of the D-rings.</p> <p>The control attachment strap is connected to the chest strap and utilizes arm flexion and scapular abduction on the amputated side. Since no definite anchor is involved, neither scapular abduction nor shoulder flexion on the sound side can be harnessed, so that, unlike the case with the figure-eight harness, in the chest-strap design these body motions cannot be used as a source of reserve excursion. Although this basic difference is responsible for the improved comfort of the chest-strap harness, lack of a positive anchor not only robs the amputee of a third control motion but actually permits the harness to rotate upon the chest when excessive forces are applied to the control cable.</p> <p>The indications for and advantages of the chest-strap harness lie in its improved comfort and greater lifting capacity. The chief reasons for its selection over the figure-eight arrangement are concerned with vocational considerations, relief of unavoidable discomfort in the opposite axilla, and amputee preference based on his past experience. Both the figure-eight and the chest-strap harness may be used with almost any combination of hinges and cuffs. It may not be desirable to use a triceps pad and a shoulder saddle in combination, but there is no law against this possibility. The rule, as always, is to try for maximum stability with a minimum amount of harness. This being the case, the figure-eight harness should be tried first.<a style="text-decoration:none;">*</a> If it is not satisfactory, then the more complicated chest-strap harness may be resorted to. For detailed discussions of fabrication techniques for both harnesses, reference may be had to Section 5.0 of the <i>Manual of Upper Extremity Prosthetics .</i><a></a> </p> <h4>The Double-Axilla-Loop Harness</h4> <p>The increased frequency of successfully fitted wrist-disarticulation cases has led in such instances to a departure from the typical below-elbow harness pattern. A very simple and useful harness has been reported by the Naval Prosthetics Research Laboratory<a></a> for use with transcarpometacarpal cases, and the technique is also adaptable to wrist-disarticulation cases. As shown in <b>Fig. 4</b>, a double axilla loop originates the initial body motion on the sound side and provides its own reaction point on the amputated side. A solid piece of Bowden cable extends from the proximal reaction point located on the axilla loop on the amputated side to the distal reaction point located on the arm socket. The cable housing is covered with a piece of plastic tubing to prevent pinching of flesh and pulling of hair on the subject's arm.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. The double-axilla-loop harness for wrist disarticulations and transcarpometacarpal amputations. The loop on the amputated side serves as the reaction point, relative motion being produced when the sound shoulder is flexed. The control cable continues to the distal reaction point on the arm socket ([link5]) The auxiliary elastic strap indicated by dotted lines may or may not be needed. <i>Courtesy U S Naval Hospital, Oakland, Calif. .</i><a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It should be pointed out that the double-axilla-loop harness is only a means of supplying terminal-device operation. Suspension must be inherent in a well-fitted socket, which usually must be split to facilitate donning, the condyles of the wrist being the principal means of retaining the socket on the stump (<b>Fig. 5</b>). Wrist disarticulations can be fitted by this technique at first. If it proves to be unsuccessful for any reason, the harness may easily be replaced with a conventional below-elbow figure-eight harness.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Wrist-disarticulation socket for use with the double-axilla-loop harness. Control cable extends to the proximal reaction point located on the axilla loop on the amputated side ([link4]). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Below-Elbow Dual-Control System</h4> <p>As opposed to the problem of fitting the wrist disarticulation and other long below-elbow stumps, there is the one involving the fitting and harnessing of the very short below-elbow slump. Use of the split-socket type of prosthesis furnishes a means of increasing the range of elbow flexion through a mechanical step-up. Thia expedient greatly improves the versatility of the below-elbow prosthesis and in the majority of cases proves to be very satisfactory when using the below-elbow figure-eight harness based on the single-control principle.</p> <p>For marginal cases with insufficient torque about the elbow to lift the prosthetic forearm, another departure has been made from the usual pattern of control. The below-elbow dual-control system, shown in <b>Fig. 6</b>, uses a forearm lever loop and a split-housing cable system. Since in this case the cable housing is in two separate pieces, the effective distance between the reaction point on the arm cuff and that constituted by the lever loop on the forearm shell is no longer independent of elbow angle, so that arm flexion produces forearm flexion. When used with the very short below-elbow stump, the dual-control system thus provides an assistive lift for forearm flexion, sometimes especially needed when forearm flexion is begun from full forearm extension. Ordinarily the short below-elbow case has enough torque about the elbow to stabilize the forearm, so that no elbow lock is required. When the forearm socket is stabilized by the stump, the force from the harness is transmitted to the terminal device.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. The below-elbow dual control using the split-socket type of prosthesis for the short below-elbow case. Since the cable housing is in two pieces, arm flexion assists in lifting the prosthetic forearm. The stump is then used to stabilize the elbow for terminal-device operation, no elbow lock being needed. The design of the step-up elbow hinges has been discussed in detail by Alldredge and Murphy (<i>1</i>). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The familiar rule of first trying the less complicated harness should be applied at this level also. If the forearm cannot be flexed by the stump without unnecessary fatigue, or if forearm flexion is painful, then the dual system is indicated. Amputees fitted with the dual control should be checked periodically to see whether the residual muscles have hy-pertrophied enough to be adequate for unassisted forearm flexion, in which event the single control may be substituted. No harm is done by using the below-elbow dual-control harness when its necessity is questionable, but again the usual desirability of simplicity of harness would suggest discard of the assist lift when adequate function can be obtained without it.</p> <h4>The Below-Elbow Biceps-Cineplasty System</h4> <p><i>The Case for Cineplasty in General</i></p> <p>Since World War II, there has been, especially in the United States, a considerable revival of cineplastic surgery <a></a> to produce muscle tunnels capable of harnessing for the operation of artificial arms. Practically all available muscles of the arm and two major muscles of the chest (the pectoralis major and minor) have been harnessed by various means to operate arm prostheses. Two basic philosophies have developed in the use of the cineplastic muscle tunnel. First established was the idea of using the muscle motor to power the terminal device. The advantages of this means of independent terminal-device operation, without relying upon body motions, were readily apparent, to say nothing of the possibility of eliminating body harness completely in some cases.</p> <p>Some authors, for example Mount and Bernberg,<a></a> discuss the advantages of an increased sense of pressure and generally improved sense of perception when a muscle motor is harnessed to a terminal device. Mount and Bernberg say "The results generally indicate that the two Ss [subjects] using cine-plastic prosthesis distinguished, compared and recognized given objects with greater skill and precision than the Ss [subjects] using prosthesis of the harness type." Although further scientific tests to support this observation have not been conducted, subjects successfully fitted with both a conventional and a cineplastic prosthesis indicate that they have a better sense of pressure or feel with the latter.</p> <p>In the second philosophy developed, the pectoral tunnel is used to operate the elbow lock in the shoulder-disarticulation case. Obviously, the advantage in this case lies in the provision of the additional source of control.</p> <p>It may be stated, without reservation, that of all the possible arrangements involving cineplasty, the greatest degree of success has been obtained using the biceps muscle tunnel to power terminal-device operation in the below-elbow case. This does not mean that the combination of other muscle tunnels and other levels of amputation may not be successful in individual cases. Spittler and Fletcher,<a></a> Kessler , <a></a> Alldredge <i>et al., </i><a></a> and Taylor<a></a> report other muscles and other levels of amputation successfully fitted with cineplastic prostheses. Because, however, the other cases have not yet been proven clinically in the general sense, the discussion of the fitting of cineplasty is here restricted to the below-elbow biceps system.</p> <p>In the below-elbow biceps case, fitting is greatly simplified because the muscle tunnel is above the first sound joint in the amputated stump. The socket may thus be made to harness residual pronation and supination, and it does not require window-type construction <a></a> since the tunnel is once removed in the upper arm.</p> <p>Because the biceps tunnel in the below-elbow case is able to avail itself of the physiological characteristics of muscle, <a></a> adequate force and excursion are to be had. Since normally muscles are contracted to produce prehension, contraction of the biceps muscle tunnel should effect closing of the terminal device. For this reason it is generally accepted that a voluntary-closing device is most desirable for use with cineplastic amputees. Of course if the improved sense of pressure is to be had, then it may be best to use the voluntary-closing terminal device. Regardless of all data presented here and elsewhere, however, many biceps tunnels have been successfully harnessed in the below-elbow case with the voluntary-opening terminal device.<a style="text-decoration:none;">*</a> This circumstance can only suggest that the prescription of the terminal device in cineplasty is largely in the same area as is the prescription of the terminal device in the conventional case using body harness.</p> <p>The back-and-forth discussion of these factors is endless. It is therefore useful to have a look at the indications for cineplasty as seen from the point of view of the amputee. Needless to say that, in the growth of prosthetics clinic teams, new amputees are seeing more and more the types of prostheses worn by other amputees. Usually when the wearer of a conventional arm prosthesis sees a cineplastic type he feels that a "Cadillac" version of an artificial arm is available for him. No doubt personal choice, or the individual desire for a cineplastic type of prosthesis, is the major consideration. Amputees who were not too favorable at the time of discussing the cineplasty procedure have not obtained the same degree of success and training as have those who indicated their preference for cineplasty from the beginning.</p> <p>Another important factor relates to vocation. If a below-elbow amputee desires to do, for example, mechanical work on an automobile, he often finds himself lying on his back on a dolly. In this position, he is quite restricted in body motions for using a shoulder-harness prosthesis. For the wearer of a conventional prosthesis to operate his terminal device in this position involves the use of many body motions other than those ordinarily involved.</p> <p>Although no real criterion has yet been developed for the selection of individuals for the cineplasty type of prosthesis, it can be stated categorically that the personal preference of the individual and the vocational considerations are of prime importance and should therefore be discussed thoroughly with the patient before reaching a decision.</p> <p><i>The Two Established Systems</i></p> <p>Prosthetic fitting and socket construction for a biceps-cineplasty below-elbow prosthesis are very similar to the conventional techniques. The socket must provide stability and a means of attaching a terminal device. Suspension of the prosthesis may be handled in various ways. Two power-transmission systems have been developed, one at the University of California at Los Angeles and the other at the Army Prosthetics Research Laboratory. A comparison of the efficiencies of the two systems has revealed that they have quite similar characteristics.<a></a></p> <p><i>The UCLA Below-Elbow Biceps-Cineplasly System. </i></p> <p>The power-transmission system of UCLA consists of a muscle-tunnel pin, a dual-cable power-transmission system, and a twin cable mounting harnessed to the terminal device. All parts of this system, shown in <b>Fig. 7</b>, have been available commercially for some time, and the arrangement has received wide use in the field. Three types of cuffs are available for suspension in the UCLA system. The epicondyle cuff (<b>Fig. 8</b> and <b>Fig. 9</b>), the epicondyle clip (<b>Fig. 10</b>), and the epicondyle strap (<b>Fig. 11</b>) may be used with any selection of either flexible or metal double- or single-axis elbow hinges. The method of installing the UCLA system is described in detail in Section 10.0 of the <i>Manual of Upper Extremity Prosthetics.</i><a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. The UCLA below-elbow biceps-cineplasty system with epicondyle cuff and rigid elbow hinges. The twin cable mounting is connected to the yoke to allow positioning for adequate operating excursion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Pattern for the UCLA epicondyle cuff. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Alternative design of the UCLA epicondyle cuff, constructed of stainless steel and covered with horsehide, the rigid hinges being attached to the cuff before covering. The cross strap at the top helps to stabilize the cuff on the arm. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. The UCLA epicondyle clip, constructed of stainless steel and covered with horsehide. Conventional baseplates are attached to be used as the proximal retainers for the dual cable system. The clip can be used with or without the auxiliary elastic strap as needed to maintain the clip in position when the arm is flexed. The epicondyle clip has also been constructed of a semirigid plastic such as Royalite. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Typical pattern for the APRL epicondyle strap, reduced to exactly half the size needed to produce a strap for an arm with a circumference of 10 1/2 in. Placed as drawn on the grain side of the selected leather, this template makes a left or a right strap depending on whether the amputee prefers to have the strap buckle toward the medial or toward the lateral side of the arm. To produce a strap buckling in the reverse directions, the template is turned over and placed on the grain side of the leather. The dotted lines indicate a modification to accommodate a biceps tunnel located low on the upper arm when it is desirable to save space in the anterior fold of the elbow. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The UCLA system is quite adequate and very simple to harness and provides easy pre-positioning and ready adjustment of effective cable length. It has met with a very large degree of success throughout. Compared to the APRL system,<a></a> it offers the advantage of being applicable to a wider selection of terminal devices inasmuch as the control system may be mounted either on the top or on the bottom of the arm socket (<b>Fig. 12</b>). It offers also the advantage of allowing pre-positioning of terminal devices with less friction throughout the cable system.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Alternate locations of the twin cable mounting for various terminal devices in the UCLA below-elbow biceps-cineplasty system. If it is desirable to interchange between the voluntary-opening hook and the voluntary-closing hand, two snap portions of the twin cable mounting may be used, one toward the lower side and another on the top side of the socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>The APRL Below-Elbow Biceps-Cineplasty System. </i>The APRL system, as it appears in the <i>Manual of Upper Extremity Prosthetics</i><a></a>has been revised to improve function. The principal modifications (<b>Fig. 13</b>) have been to adopt flexible leather hinges and to discard the so-called "transit elbow hinges." Since these changes,<a></a> indications have pointed to a greater degree of success when the biceps tunnel is used with a voluntary-closing terminal device.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Completed installation of the APRL below-elbow biceps-cineplasty system. The epicondyle strap is used in conjunction with flexible leather hinges, the hinges being adjustable by means of strap-type buckles placed at the points of attachment on the arm socket. The ox-bow tunnel pin, fitted with "Dot Fasteners" for joining to the sheave-type cable equalizer, is recommended for use with the APRL system. A flat cable-extensor mechanism is used to allow cable adjustment within the system and to permit interchangeability of terminal devices. Insert shows a variation in pin design that is available commercially. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although both the voluntary-closing and voluntary-opening hands and hooks are recommended routinely for use with biceps tunnels in below-elbow amputees, experience has shown that voluntary-closing devices have offered a number of special advantages. The available excursion can be increased by utilizing spring forces in the terminal device to recover excursion, thereby stretching the biceps tunnel into pre-tension beyond the rest length of the muscle.<a></a> Moreover, the improved ability to select prehensile forces at the finger tips makes it possible for amputees to handle, say, an ice-cream cone without crushing it or to wield a hammer or other heavy object without dropping it. Expressed amputee reaction seems to indicate, furthermore, that a considerable amount of pressure appreciation is realized through the use of the voluntary-closing terminal device, where the biceps is contracted for gripping an object. Of course, some pressure appreciation is lost when the voluntary-opening device is used, for then the biceps is contracted to open the device against the tension of the spring or rubber band, and the grasping force is exerted by the spring or rubber band upon relaxation of the muscle. Although no published data are available to support the claim of improved pressure appreciation with the voluntary-closing device, there are sound indications from active users that such a cue to the pressure exerted is of definite advantage.</p> <p>Since no published instructions for installing the APRL below-elbow biceps-cineplasty system are available, a simplified set is included here. The first step is to cut and check a paper template for the epicondyle strap in order to assure proper size and shape before proceeding to make the finished strap. The typical size and shape are indicated in <b>Fig. 11</b>. The pattern should be placed around the arm and examined for comfort, both with the patient's elbow extended and in maximum flexion (<b>Fig. 14</b>). If the biceps tunnel is located low on the arm, the template should be shaped as indicated by the dotted lines in <b>Fig. 11</b> to allow for maximum passive stretch. By thus lowering the front portion of the epicondyle strap, comfort, as well as excursion, is improved.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Procedure for checking the paper template when making the epicondyle strap. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>With the epicondyle strap fastened in place, the normal elbow center is marked on the projecting hinge tabs. Standard baseplates are located as close to these points as possible and are held in place with a clamp on the upper edge (<b>Fig. 15</b>). They are then so aligned that the cable housings will follow smooth curves from the tunnel pin through the elbow center to the two distal retainers on the arm socket. Notation should be made of the approximate angles shown in <b>Fig. 11</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Placement of the baseplates on the epicondyle strap. They should be so positioned that the cable housings pass through gentle curves from the muscle tunnel to the distal baseplates on the arm socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The extending ears adjacent to the rivet holes on the two proximal baseplates should now be bent, as shown in <b>Fig. 16</b>, to follow the contour of the epicondyles, thus giving greatly improved comfort as well as added stability in supporting axial loads. The baseplates are then riveted to the epicondyle strap by means of the top rivets only.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Bending the ears of the proximal baseplates to conform to the contour of the epicondyles. This detail gives added stability in supporting axial loads and improves amputee comfort. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Two pieces of 4-oz. strap leather 5/8 in. wide are now cut long enough to connect the epicondyle strap to the arm socket. A piece of nylon or vinyon strap is attached by rubber cement to the inside of the leather straps, and the whole is stitched along each side. One end of each of these two flexible hinges is then laid under one of the lower ears of the proximal baseplates and the lower rivets are driven in.</p> <p>With the epicondyle strap fastened in position, the arm socket is placed on the patient, and the proper length of the flexible hinges is determined. Finally, the positions of the distal hinge attachments are marked, and the hinges are riveted to the socket, adjustment being provided for by the two buckles.</p> <p>The arm socket and epicondyle strap are now put in place, the cable-housing retainers are attached to the baseplates on the epicondyle strap, and the cable housings are continued through the elbow center in such a way as to maintain a gentle wave to a point approximately 2 in. below the top of the arm socket (<b>Fig. 13</b>). The arm is then removed from the patient, and the baseplates are riveted in position on the socket. The male end of the cable lengthener is now attached to the terminal device, the lengthener is extended to the full-open position, and the other end of the lengthener is attached to the sheave equalizer.</p> <p>Next the cable housings are installed and adjusted to obtain maximum elbow flexion and extension without compression or stretch of the housings. The ends of the housings are trimmed so that, when the ferrules are installed, the housings will terminate flush with the rivets on the baseplates. The ferrules are then pinched slightly with a diagonal cutter.</p> <p>A female snap-on attachment is now fastened to one end of a length of cable, and the attachment is snapped to the pin. The free end of the cable is fed through one cable housing, down through and around the sheave, and back up through the other cable housing. The terminal device is opened, the muscle tunnel is pulled into passive stretch, and the cable length is measured. The cap fitting is installed according to manufacturer's instructions. Normally, the cable will be a little too long. Adjustment may be made by taking up on the cable-length adjuster.</p> <p>After a period of use of the prosthesis, the amputee may find that the adjuster can no longer remove slack from the system. This development can be expected in some cases. It is only an indication that the tunnel has stretched with use. In this event, the control cable should be detached, shortened, and reattached as in initial cable installation.</p> <p>The APRL system as described here has been used experimentally with a great deal of success, but the lack of commercial availability of components in the past has limited its use in the field. It is designed primarily to be used with the voluntary-closing type of terminal device. Furthermore, the frictional losses in pre-positioning are greater than in the UCLA system, and unless the sheave equalizer is placed on the top of the socket use is limited to voluntary-closing terminal devices. This circumstance makes interchange-ability of a voluntary-closing hand and a voluntary-opening hook quite impractical. The APRL system is primarily recommended for use with the epicondyle strap, which normally gives ample support for axial loads without appreciable displacement of the socket.</p> <p>A distinct advantage of the APRL system over that of UCLA is that the effective cable links between the equalizer and the muscle tunnel may be adjusted while at the same time maintaining equalized forces. To adjust the effective cable links between the twin cable mounting and the muscle tunnel in the UCLA system requires a turnbuckle, which in effect changes the links of the cable housing, thus increasing frictionai losses within the system.</p> <h4>Harnessing for the Above-Elbow Cases</h4> <p>Basically, two functional requirements must be met in above-elbow cases. Not only must prehension be provided for but it must be usable at various degrees of forearm flexion. Experience has shown that satisfactory prehension can best be obtained through a normal range of forearm flexion when provision is made for stabilizing the forearm at the selected level of operation. Thus, to the two basic functions there must be added the requirement of elbow lock. The body motions easily accessible and available for controlling these three functions in the above-elbow prosthesis are arm flexion, arm extension, and scapular abduction.<a style="text-decoration:none;">*</a></p> <p>At present there are three satisfactory harness patterns for the above-elbow case, two based on the so-called "dual control" and the third based on "triple control." The two dual-control systemsâ€"the above-elbow figure-eight harness and the above-elbow chest-strap harnessâ€"utilize arm flexion for forearm flexion and terminal-device operation, elbow lock being effected by arm extension. In the triple-control harness, arm flexion is used to produce forearm flexion, arm extension gives elbow lock, and terminal-device operation is obtained by shrug of the sound shoulder. Each of the three systems has its own advantages and disadvantages, and each therefore has indications and contraindications in individual cases.</p> <h4>The Above-Elbow Figure-Eight Harness</h4> <p>From the wearer's point of view, the above-elbow figure-eight harness (<b>Fig. 17</b>) constitutes the easiest way of meeting the requirements of the above-elbow case. It is simply a modified below-elbow figure-eight design with provisions for the added functional requirements. Although in the below-elbow case it is essential mechanically to maintain a constant effective distance between the proximal and distal reaction points of the terminal-device control cable (Bowden principle), in the above-elbow case two functions may be obtained from a single cable by splitting the cable housing and substituting for the distal reaction point a lift lever on the forearm shell.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. The above-elbow figure-eight harness. The basic structure consists of a loop about the opposite axilla, the front portion supporting the arm and the rear portion attaching to the control cable so that arm flexion gives forearm flexion and terminal-device operation. The piece of elastic inserted in the front portion provides for relative motion for elbow locking by arm extension, the elbow-lock control being attached to the nonelastic portion. Suspension is improved by the lateral support strap and indicated auxiliary straps when necessary. As in the below-elbow dual control ([link6]), the cable housing is split so that arm flexion gives forearm lift when the elbow is unlocked, the leather lift loop on the forearm shell serving as the distal reaction point. If it is difficult to start the forearm into initial flexion, two baseplates may be used on the arm socket. The length of the leather lift loop on the forearm shell should be such that, when the forearm is extended, the distance from the center of the cable to the center of the elbow is equal to the distance from the center ot the forearm to the center of the cable housing. This arrangement reduces the amount of force needed to start the forearm into initial flexion without increasing the excursion required for full forearm flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This arrangement couples forearm flexion and terminal-device operation to produce the dual control as used in the case of the very short below-elbow stump. Motion in the control source elicits terminal-device operation or forearm flexion depending on whether the elbow is locked or unlocked.</p> <p>In the dual-control system, arm flexion is used as the source of control for forearm flexion and terminal-device operation, sometimes augmented by scapular abduction at large elbow angles, such as when the terminal device is near the mouth. A piece of elastic-webbing is substituted for the nonelastic front attachment strap of the below-elbow figure-eight harness. It is attached at the level of the clavicle and extends to the adjustable buckle on the arm socket, a minimum of 6 in. being desirable for easy operation of the elbow lock. The elbow-lock control cable is attached to</p> <p>the nonelastic portion of (he front attachment strap by means of a piece of 1/2-in. webbing bearing a 1/2-in. adjustment buckle. Arm extension thus produces relative motion between the elastic webbing and the nonelastic control strap in such a way as to induce elbow locking. Thereafter arm flexion controls terminal-device operation. With proper training and practice the amputee can become very adept in effecting smooth operation of all three prosthetic controls.</p> <p>Suspension is improved by adding a connecting strap, known as the "lateral support strap," above the cross on the amputee's back. It extends laterally across the shoulder to a buckle on the lateral side of the arm socket. Proper adjustment of the lateral support strap controls alignment in the abduction-adduction plane. With these modifications, the below-elbow figure-eight harness is adapted to become the figure-eight for the above-elbow case. In summary, the alterations include insertion of the elastic webbing in the front to help suspend the socket and to provide for relative motion for elbow-lock control, addition of the lateral support strap over the shoulder to contribute to socket stability, and the use of the two-piece cable housing to give forearm flexion when the elbow is unlocked.</p> <p>The two optional straps indicated in <b>Fig. 17</b> together improve suspension, increase the available excursion, and assist in maintaining the control attachment strap on the shoulder when the arm is raised. The over-the-shoulder strap forms a webbing network to support axial loads and to stabilize the lateral support strap and front attachment strap on the shoulder. The cross-back elastic strap not only gives greater excursion both in scapular abduction and in arm flexion but it helps to prevent the control attachment strap from riding over the shoulder during extreme arm flexion, such as when the amputee is working in areas over his head. But again, following the rule of simplicity whenever possible, the above-elbow figure-eight harness should be tried first without the two optional straps. If that proves unsatisfactory, then the extra straps may be added.</p> <p>For a detailed description of the technique of fabricating the above-elbow figure-eight harness, reference may be had to Section 6.7 of the <i>Manual of Upper Extremity Prosthetics </i><a></a> or to the report of the NYU Committee on Above-Elbow Harness.<a></a> It will suffice here to describe some of the common errors often leading to difficulties. Careful observation should always be made to be certain that the elastic straps are not too short and that the proximal end and distal buckle of the front suspensor strap are properly positioned. A minimum of 6 in. of elastic is required to give sufficient excursion for operation of the elbow lock and to provide adequate length for adjustment of tension in the strap.</p> <p>Placement of the proximal end of the elastic suspensor not lower than the clavicle enables the amputee to feel the elastic stretching over the deltopectoral interval during the elbow-lock operation, thus furnishing an additional cue to ensure reliable elbow function, and it permits the minimum of 6 in. of elastic to be used without bringing the attachment too far down on the socket. Normally the harness cross should lie approximately 1 in. toward the sound side of the vertebral spine. Crossing the harness at this point usually brings the control attachment strap over the lower third of the scapula, where maximum excursion may be utilized. The cross should be below the seventh cervical vertebra, thus avoiding the discomfort caused when the harness rides up. If the cross is more than 1 in. toward the sound side, the axilla loop is unduly decreased in size, with consequent increase in discomfort at the axilla.</p> <p>The control attachment strap should not fall so low as to prevent arm abduction, and the lateral support strap should not ride too high on the neck. If the cross is farther to the amputated side, the control attachment strap may ride too high. Placement of the lateral support strap 1/2 in. forward of the acromion is found to result in optimal stabilization of the prosthesis on the stump without causing rotation. Attachment of the lateral support strap should be 2 in. below the acromion. When it is attached at a lower point, the strap rolls back and forth over the shoulder, and higher attachment results in poor cosmesis because of the interference of the buckle with the shoulder pad of clothing. Placement of an adjustable buckle at the junction of the front support strap and elastic suspensor provides optimal position for adjustment of the elbow-lock control cable.</p> <p>The placement of the elastic suspensor strap markedly influences the effectiveness of the elbow-lock control motion. If excess slack is left in the elbow control cable, it must be taken up by the control motion before the lock will operate, and consequently the total excursion will then be greater than necessary. At the same time, there must be sufficient slack in the cable to permit relaxation of tension for resetting the elbow-lock mechanism.</p> <h4>The Above-Elbow Chest-Strap Harness</h4> <p>The chief advantages of the above-elbow figure-eight harness are that it is functional and simple and will satisfy the needs of most vocational activities. As in the below-elbow case, however, if there is a requirement for the harness to lift heavy loads, then another type is indicated. Again as in the below-elbow case, the chest-strap harness (<b>Fig. 18</b>) is recommended for the above-elbow amputee whose activities commonly involve heavy-duty work. By supplying a shoulder saddle and thus reducing the unit stresses over the shoulder, the above-elbow chest-strap harness provides greater comfort, and hence greater loads can be accommodated.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. The above-elbow chest-strap harness using for suspension a leather strap threaded through a D-ring on the lateral wall of the socket and attached to a leather shoulder saddle at two points, The strap for the control cable may be attached either to the shoulder saddle, as shown, or to the chest strap at the midspine position. As in the below-elbow case, this type of harness improves lifting ability and reduces unit stresses over the shoulder on the amputated side. The elbow-lock control cable is attached to the front of the shoulder saddle, and again a piece of elastic is used as the front suspensor between shoulder saddle and arm socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The shoulder saddle has taken two forms, the leather type and the webbing type. The leather type is precisely like that used in the below-elbow chest-strap harness. <b>Fig. 19</b> and <b>Fig. 20</b> illustrate webbing-type shoulder saddles that furnish adequate suspension on the lateral side of the arm socket and provide for the relative motion needed for elbow lock and for dual control. The operational pattern of body motions is identical to that used with the above-elbow figure-eight pattern. Arm flexion manages dual control <i>(i.e., </i>forearm flexion and terminal-device operation), and arm extension controls the elbow lock.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. The above-elbow chest-strap harness with webbing shoulder saddle. The functional arrangement is identical to that in the above-elbow chest-strap harness with leather shoulder saddle ([link18]). The leather has simply been replaced with a webbing saddle designed to give the same function. The technique is best used on individuals who perspire freely but who nevertheless need the chest-strap type of harness for heavy lifting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. An alternative construction of the webbing shoulder saddle for use with the above-elbow chest-strap harness. Beginning at the point of attachment on the front of the arm socket, the principal strap passes over the shoulder on the amputated side, continues across the amputees back, goes under the opposite arm, crosses the chest, again passes over the shoulder on the amputated side, and buckles to the rear portion of the socket. This arrangement equalizes the forces when axial loads are encountered. A Y-type construction is used to connect the control cable to the chest strap at the midspine position and at the point where the chest strap crosses the shoulder. A similar construction is used in front, the lower leg of the Y" being made of elastic to permit the relative motion needed for elbow-lock control. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The above-elbow chest-strap harness has as its chief advantage the ability to lift axial loads with lower unit stresses over the shoulder. Its primary disadvantage lies in its characteristic tendency to rotate about the chest owing to lack of a positive anchor. Again as in the below-elbow case, the simpler figure-eight design should be applied to the above-elbow case whenever it can be made to serve the amputee satisfactorily. The above-elbow chest-strap harness should be adopted only when the simpler figure-eight harness proves to be inadequate in any given case.</p> <h4>The Above-Elbow Triple Ccontrol</h4> <p>In the above-elbow triple-control harness (<b>Fig. 21</b>), arm flexion produces flexion of the forearm, arm extension provides elbow-lock control, and extreme flexion of the sound shoulder (shrug) gives terminal-device operation. Although the control system is quite simple, it requires the amputee to distinguish between arm flexion on the amputated side and extreme flexion of the shoulder on the opposite side to yield two separate controls. Above-elbow amputees with long stumps can usually make this distinction readily enough; those with medium to short stumps find it very difficult.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. The above-elbow triple-control harness. It differs from the dual-control pattern in that three body motions are required. The axilla loop uses shrug of the opposite shoulder to operate the terminal device, so that in this case the chest strap is separated at approximately the midspine position. Relative motion takes place between the axilla loop on the sound side and the reaction point located on the portion of the harness on the amputated side. A supporting shoulder saddle is constructed of a webbing network, and the control attachment strap for forearm flexion is attached at a point over the superior spine of the scapula on the amputated side. Arm flexion then lifts the forearm. Arm extension is harnessed as usual, a piece of elastic being used as the front suspensor strap to provide for the necessary relative motion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The advantage of triple control lies in the possibility of operating the terminal device without first locking the elbow. But the complexity of fabricating the triple-control system has been a major disadvantage and has discouraged its use. It is recommended for amputees requiring versatility in the use of the prosthesis, but it should be approached cautiously by the harnessmaker.</p> <h4>Harnessing for the Shoulder-Disarticulation Cases</h4> <p>To provide adequate functional harness for the shoulder-disarticulation amputee has always been especially difficult because of the lack of the control source otherwise available from humeral motion. In the absence of an arm stump, it has been to date, for all practical purposes, impossible to provide any satisfactory voluntary motion of the prosthetic arm about the shoulder, and consequently a substitute must be sought for arm extension, the control source commonly used by the above-elbow amputee for operation of the elbow lock. The alternatives are to use manual operation of the lock by the sound hand or else to harness some residual control source ordinarily remote from arm function.</p> <p>Since in any case manual control is undesirable because it interrupts two-handed activities, the trend has been to utilize other body motions such as those of the head or shoulders. The nudge control,<a></a> with the operating button located on the shoulder cap of the prosthesis, was designed to be operated by pressure from the chin. But this system leads to such awkward appearance in use that it has since been more or less superseded by harness designs utilizing shoulder motions. The perineal strap, with function based on relative displacement between shoulders and pelvis, is disliked by most amputees and therefore has been used less and less except where special complications prohibit other arrangements. The most practical system worked out to date involves use of a waist band or equivalent. At the present time, there are four satisfactory harness patterns for the male shoulder-disarticulation case and two suitable for the female. For the male, there are three dual-control systems, all operated by scapular abduction, elbow lock being accomplished in the first case by shoulder elevation on the amputated side, in the second by flexion of the opposite shoulder, and in the third by shoulder extension on the amputated side. The fourth system for the male utilizes the triple-control principleâ€"scapular abduction to provide forearm flexion, elevation of the shoulder on the amputated side to give elbow lock, and shrug of the opposite shoulder to operate the terminal device. Since all four of these systems involve a chest strap unsuited to the female, two special arrangements have been worked out for women. Both are built around a brassiere, and both utilize dual control, in the one case operated by scapular abduction, in the other by motion of the opposite shoulder. In both cases, elbow lock is effected by elevation of the shoulder on the amputated side.</p> <h4>Harness Patterns for Men</h4> <p><i>Dual Control with Shoulder-Elevation Elbow Lock</i></p> <p>Of the four shoulder-disarticulation harness systems for males, the one most often used with the least trouble involves scapular abduction for dual control of forearm flexion and terminal-device operation, elbow lock being managed by elevation of the shoulder on the amputated side. As in all dual-control systems, excursion of the control source, in this case bilateral abduction of the scapulae, produces either terminal-device operation or forearm flexion depending on whether the elbow is locked or unlocked.</p> <p><b>Fig. 22</b> presents the basic details of this harness pattern. A webbing chest strap attaches to the front of the shoulder cap, passes under the axilla on the sound side, crosses the back at the midscapular level so as to utilize the maximum available excursion, and attaches to the control cable positioned on the back of the shoulder cap. An elastic suspensor strap extends from the top of the shoulder cap, diagonally across the back, and attaches to the chest strap at a point just toward the sound side of the vertebral spine. The length of the chest strap is so adjusted as to permit full terminal-device operation without bringing the cable into contact with the skin.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Shoulder-disarticulation harness using scapular abduction for dual control, elbow lock being operated by shoulder elevation on the amputated side. After Pursley <i>, </i><a></a> by permission of <i>Orthopedic and Prosthetic Appliance Journal.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Elbow-lock operation by shoulder elevation is provided for by linking the elbow control cable to a waist strap encircling the trunk below the thoracic cage, thus establishing an anchor to oppose shoulder elevation. Although adequate force for elbow locking is usually available, care is taken to position the cable reaction points in such a way as to eliminate as much frictional resistance as possible.</p> <p>This system offers several distinct advantages over other methods of harnessing the shoulder-disarticulation case. It involves the minimum amount of harness needed to operate the three basic controls, and it has the inherent advantage of avoiding any possibility of interference between elbow locking and the other two functions. Thus training is simplified considerably, and the success of the individual harness may be determined at the time of fitting.</p> <p><i>Dual Control with Opposite-Shoulder Elbow Lock</i></p> <p>A second shoulder-disarticulation harness system seen frequently also uses scapular abduction for dual control of forearm flexion and terminal-device operation, but elbow lock is effected by a forward rotation of the sound shoulder. The arrangement for dual control is precisely like that just described, the difference in the harness as a whole being concerned with the method of elbow locking (<b>Fig. 23</b>). In addition to the chest strap and the elastic suspensor strap, there is provided for the sound shoulder a webbing saddle, the cross-back extension being attached to the elbow control cable near the point of stabilization on the back of the shoulder cap. Again the lengths of the straps are so adjusted as to permit adequate excursion without the cables touching the flesh.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Shoulder-disarticulation harness using scapular abduction for dual control, elbow lock being operated by flexion of the shoulder on the sound side. After Pursley,<a></a> by permission of <i>Orthopedic and Prosthetic Appli~ ance Journal.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although this system eliminates the need for the waist strap, it obviously introduces more complicated harness about the shoulders, and it offers the inherent disadvantage of the possibility of inadvertent locking or unlocking of the elbow in the course of forearm flexion or terminal-device operation. If, however, care is taken to keep the chest strap at the mid-scapular level while making the opposite-shoulder loop as high as possible, and if the amputee is thoroughly trained, the two operating body motions can usually be separated satisfactorily.</p> <p>Because in this system the elbow-lock control cable traverses a comparatively long path, and also because the associated harness moves across the entire surface of the back, the frictional forces involved are sometimes such that the alternator spring in the elbow is not strong enough to return the control cable to the relaxed position. When this is the case, an additional spring may be added on the inside of the arm section (<b>Fig. 24</b>). Since this extra spring force makes the elbow lock more difficult to operate, it has the incidental advantage of making it easier for the amputee to separate opposite-shoulder shrug from scapular abduction, thus helping to avoid inadvertent elbow action. If difficulty is still encountered, separation of controls is sometimes made easier if the opposite-shoulder loop is adjusted to require an extreme flexion of the sound shoulder before elbow locking is induced.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Installation of the elbow-lock cable, showing arrangement when auxiliary spring is needed to return cable to relaxed position. The additional spring force makes it easier to separate the elbow-lock control motion from scapular abduction. After Pursley,<a></a> by permission of <i>Orthopedic and Prosthetic Appliance Journal.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In any event, a considerable period of practice is usually required before the average amputee can manage separation of controls systematically and with the necessary confidence. Training is thus more prolonged than is the case with the shoulder-elevation elbow lock, and consequently the dual-control harness using opposite-shoulder lock offers the further disadvantage that the ultimate success in any given case is difficult to determine at the time of initial fitting.</p> <p><i>Dual Control with Shoulder-Extension Elbow Lock</i></p> <p><b>Fig. 25</b> presents the dual-control shoulder-disarticulation harness utilizing shoulder extension to lock and unlock the elbow. The lower leg of the front attachment strap contains a piece of 1-in. elastic, the front elbow-lock control being connected to the nonelastic part of the chest strap. Thus shoulder extension produces a relative motion for elbow locking.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Shoulder-disarticulalion harness using scapular-abduction dual control, elbow lock being operated by extension of the shoulder on the amputated side The chest strap terminates in front in a forked arrangement for attachment to the socket. A piece of 1-in. elastic is inserted in the lower leg of the fork, and the elbow-lock control cable is attached to the base portion of the chest strap just beyond the elastic, thus providing for relative motion upon extension of the shoulder on the amputated side. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To operate the prosthesis starting with forearm extended, scapular abduction is used to produce forearm flexion. While maintaining enough force on the lift cable to hold the forearm in the desired position, the amputee extends his shoulder on the amputated side to lock the elbow. Thereafter scapular abduction operates the terminal device.</p> <p>Although this system may be used on any shoulder-disarticulation case, amputees retaining the humeral neck are the most successful. Patients without the humeral neck experience difficulty in coordinating the two body motions. In any event, the length of the elastic and the position of the wide attachment are both critical. Normally a piece of 1-in. elastic 1 1/2 in. long is used as a start. If the elbow is difficult to operate, the elastic portion is made longer. If the elbow operates inadvertently, the elastic is shortened so as to require more definite shoulder extension to lock and unlock. Although this type of shoulder harness is quite new, experience to date would suggest consideration of new elbow mechanisms especially designed for use with it. An obvious advantage is elimination of the waist band and opposite-shoulder loop used respectively in the other two dual-control systems.</p> <p><i>Triple Control</i></p> <p>In the triple-control system for shoulder disarticulation, as in the triple control for above-elbow cases, the three necessary functions are provided by three control sources, one for each. The usual and generally most successful pattern utilizes scapular abduction for forearm flexion, shrug of the sound shoulder for terminal-device operation, and elevation of the shoulder on the amputated side for control of the elbow lock. The basic pattern (<b>Fig. 26</b>) involves a minor modification of the chest strap seen in <b>Fig. 22</b> and <b>Fig. 23</b>, an elastic suspensor strap also similar to that seen in <b>Fig. 22</b> and <b>Fig. 23</b>, an opposite-shoulder loop with an extension passing over the seventh cervical vertebra or slightly below it, and a linkage between elbow control cable and waist band.<a style="text-decoration:none;">*</a>Although the triple control requires more harness than do the other three patterns for shoulder disarticulation, it offers certain advantages not to be had from dual control. Separation of terminal-device operation from forearm flexion offers improved control over prehension, since during forearm flexion no force or excursion is introduced affecting the terminal device. Likewise, as in the case of the dual control with shoulder-elevation elbow lock, the triple-control system overcomes the difficulty of separating elbow lock from the other two functions, so that inadvertent elbow locking or unlocking is avoided. The result is, again, simplified training and the possibility of determining the success of the harness at the time of initial fitting.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Shoulder-disarticulation harness utilizing triple control. Scapular abduction provides forearm flexion; shoulder on sound side operates terminal device; elbow lock is operated by shoulder elevation on the amputated side. After Pursley,<a></a> by permission of <i>Orthopedic and Prosthetic Appliance Journal.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Harness Patterns For Women</h4> <p>Since the chest strap, common to all four harness patterns for male shoulder-disarticulation cases, is unsuited for most women, harness designs for female shoulder-disarticu-lation amputees are best based on some other principle. The most satisfactory method found to date for eliminating the chest strap is to utilize as part of the harness a brassiere made of sturdy material.<a style="text-decoration:none;">*</a> As shown in <b>Fig. 27</b>, a strip of 1-in. webbing is sewed around the lower edge of the brassiere known to bra designers as the "diaphragm band." The shoulder cap is so designed as to project in front below the breast on the amputated side to provide an anchor point <i>(B) </i>to which the diaphragm band is attached. An elastic sus-pensor strap attaches to the top of the shoulder cap at <i>A</i>, passes diagonally down the back, and is sewed to the diaphragm band at <i>C </i>somewhat toward the sound side of the vertebral spine. For ease in adjustment and to provide for ready laundering, a buckle is used at <i>D, </i>a clip-type disconnect is installed at <i>E, </i>and attachments at <i>B </i>and <i>A </i>are made with snap fasteners. The arrangement for control of the elbow lock utilizes the waist band<a style="text-decoration:none;">*</a> in the same way as in the corresponding pattern for the male (<b>Fig. 22</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Harness for female shoulder-disarticulation cases, made integral with bra but detachable from arm socket for laundering. Scapular abduction provides dual control of forearm lift and terminal-device operation, while elbow lock is effected by shoulder elevation on the amputated side. After Pursley, <a></a> by permission of <i>Orthopedic and Prosthetic Appliance Journal.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although in this harness design the diaphragm band crosses the back somewhat lower than the midscapular level desired with the chest strap, adequate excursion is usually available from biscapular abduction, which, as in the male patterns of <b>Fig. 22</b>, <b>Fig. 23</b> and <b>Fig. 25</b>, provides dual control of forearm flexion and terminal-device operation. Shoulder elevation provides control of elbow locking.</p> <p>A problem encountered with the design shown in <b>Fig. 27</b> is that in flat-chested persons or in those with comparatively small breasts it is sometimes difficult to get adequate stability, so that operation of the dual control causes the brassiere to rotate upon the chest. When such a situation prevails, use may be made of the modification shown in <b>Fig. 28</b>, where the brassiere is called upon to provide suspension only, the loop about the sound shoulder furnishing the dual control. Here, as in Figure 27, attachments <i>A, B, </i>and <i>D </i>are made with snap fasteners so that the entire harness can be removed from the arm socket for laundering, the elastic suspensor being sewed to the diaphragm band at <i>C.</i></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Alternative harness for female shoulder-disarticulation cases in which the simpler arrangement of Figure 27 proves too unstable. Here the bra is used for suspension only. The loop over the sound shoulder provides dual control of forearm lift and terminal-device operation, while elbow lock is effected by shoulder elevation on the amputated side After Pursley,<a></a> by permission of <i>Orthopedic and Prosthetic A ppliance Journal</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Some Special Cconsiderations</h4> <p>A distinguishing characteristic of the shoulder-disarticulation amputee is that the available control sources are for the most part of comparatively high force but of low excursion. Most commercially available terminal devices require an average of 1 3/4 in. of excursion for full operation, and normally 2 to 3 in. of excursion are needed to produce full forearm flexion of 135 deg. Generally, the total exceeds the excursion available from scapular abduction. This means that if, in a dual-control system with a voluntary-opening hook, where the excursions for forearm flexion and for terminal-device operation are additive, the amputee is to be able to open the hook at the mouth, some means must be found for obtaining the extra excursion. The only other alternatives are to use a voluntary-closing hook, in which case the excursion used in forearm flexion is regained for hook operation, or to use triple control, in which case forearm flexion and terminal-device operation are obtained from two separate sources. But many shoulder-disarticulation amputees do not care for voluntary-closing terminal devices, and others, for this reason or that, are not always able to manage the triple control. Since in general the force available from scapular abduction far exceeds that needed for forearm lift and prehension, some of the force may be sacrificed in the interest of obtaining an increase in excursion. The "block-and-tackle" cable system shown in <b>Fig. 29</b> and <b>Fig. 30</b> provides a two-to-one step-up in excursion at the expense of surplus force. It may be used with any of the six harness systems whenever added excursion is needed either for forearm flexion or for terminal-device operation. In <b>Fig. 23</b>, for example, it is applied to the dual control. In [link26], it is used to step up forearm flexion in the triple control. It could equally well be installed in the system of <b>Fig. 22</b>, should that prove to be necessary in any given case. Conversely, when excursion step-up is not required for the patterns of <b>Fig. 23</b> and [link26], an external cable routing may be used, as in <b>Fig. 22</b>. In any case, careful analysis of the excursion available and of that required for the terminal device prescribed forms the basis of judgment as to whether the step-up system is indicated or not.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Cable system for reducing the amount of excursion needed in the shoulder-disarticula-tion dual control. After Pursley,<a></a> by permission of <i>Orthopedic and Prosthetic Appliance Journal.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Installation of the excursion-reducing cable system shown in Figure 29. After Pursley <a></a>, by permission of <i>Orthopedic and Prosthetic Appliance Journal.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although the six harness patterns described here represent the most generally successful designs now in common use for the shoulder-disarticulation case, no one of them provides a voluntary control source for motion of the upper arm about the shoulder. This deficiency, of course, imposes upon the shoulder-dis-articulation amputee a rather serious limitation not characteristic of the normal arm. Some provision for arm flexion-extension is possible by making the arm socket in two pieces, a humeral section and a shoulder cap, and using the so-called "sectional plates" .<a></a> But this arrangement is intended for manual pre-position only. Recently<a></a> a shoulder-disarticulation arm has been designed with a shoulder joint giving a combination of flexion and abduction to permit comfortable sitting at a table or desk, but again arm lift is manual, there being no satisfactory control source for voluntary flexion-abduction about the shoulder cap. Development of an additional voluntary control source to simulate the motion of the normal glenohumeral joint is now perhaps the most pressing need of the shoulder-disartic-ulation amputee.</p> <h4>Harnessing for Bilateral Arm Amputees</h4> <p>As compared to the unilateral case, the prosthetic requirements of bilateral arm amputees are magnified many fold. Experience shows that the unilateral subject uses his prosthesis chiefly to hold, carry, or assist in activities requiring two hands. Bilat-erals, on the contrary, are required to rely wholly on their arm substitutes for both one-handed and two-handed activities. The prescription criteria and techniques of fitting are therefore modified for the bilateral in an attempt to provide general operation in areas where the unilateral uses his normal hand. Bilateral arm amputees must, for example, have access to the pockets, both shirt pockets and side and hip trouser pockets if possible. They must be able to brush the teeth, comb the hair, use a buttonhook to manage button closures, and perform a great variety of other essential activities in the course of daily living. In general, all of these functions require action close to the body, behind the back at waist level, or at face, neck, or above the head. The prescription criteria for bilaterals therefore require special attention to personal as well as vocational needs, and consideration must be given to such special items as easily operable wrist disconnects and wrist-flexion units. Fabrication techniques are altered to provide for greater strength, and socket margins must be carefully determined in order to assure maximum socket stability for improved control.</p> <p>In below-elbow cases, residual pronation and supination is, of course, priceless. In every step of amputee care, every effort should be made to maintain forearm rotation. Attention should be paid this matter from the time of the original amputation and should continue through prescription, socket fitting, and fabrication of the harness.</p> <p>A matter of the greatest importance to the bilateral arm amputee is that of being able to get the harness and prostheses on and off without help from others. Bilateral above-elbow and shoulder-disarticulation amputees can almost always manage to get their prostheses off without help, but they sometimes require assistance in putting the arms on. Special brackets mounted on a wall in a bedroom are often needed to help amputees otherwise unable to perform independent donning. If, for example, a bilateral with short above-elbow stumps cannot control his prostheses while reaching for the harness cross on his back to remove the harness by pulling it over his head ("skinning-the-cat"), he hangs the cross over the wall hook by simply backing up to it. He then bends his knees to lift the straps over his head. Leaving the harness cross on the hook, he then removes the prostheses by holding the terminal devices, one at a time, each with the opposite foot. Thus the arms are left hanging in such position that the stumps can again be inserted into the sockets and the harness slipped back over the head.</p> <p>Control in the bilateral amputee is at best difficult. Because the number of controls required is doubled, less effective control motions must be brought into use, and independence of control becomes a problem. At present, six control functions, three for each arm, are about all that can be manipulated conveniently and efficiently. Even so, interaction between controls is noticeable.</p> <h4>The Bilateral Below-Elbow Harness</h4> <p>The easiest way to describe a bilateral below-elbow harness (<b>Fig. 31</b>) is to start by supposing that a unilateral below-elbow amputee has lost his remaining good arm below the elbow and has asked that his old figure-eight harness be used to make the new bilateral harness. The first step would be to cut the axilla loop on what was formerly the sound side. The front portion of the cut strap would then be attached to the inverted Y-suspensor of the new prosthesis. The back portion of the cut strap would be turned back upon itself and attached to a buckle. It thus would become the control attachment strap for the new prosthesis.<a style="text-decoration:none;">*</a> Arm flexion on either side then gives terminal-device operation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. The bilateral below-elbow figure-eight harness. A webbing inverted Y-suspcnsor with triceps pad and flexible leather hinges is shown on the right side, while a leather inverted Y-suspensor with full cuff and rigid hinges is shown on the left. Similarly, one type of hook is shown on one side and another type on the other. In the bilateral case, prescriptions should be written independently for the two sides with a view toward providing as much utility as possible. As in the corresponding unilateral cases, the choice of cuffs, pads, hinges, terminal devices, and other details is made on the basis of the individual characteristics of the stump for which the prosthesis is intended. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The cross on the back may be lowered by loosening the inverted Y-straps in front and taking up the slack in the control attachment straps. The reverse procedure moves the cross up. Should the cross be too far to one side, it may be moved horizontally by loosening the inverted Y-strap and control attachment strap on that side and taking up the slack on the opposite side.</p> <p>An important consideration is the choice of materials best suited to the individual case. In <b>Fig. 31</b>, the right Y-suspensor is made of vinyon, while the left is made of leather. If the amputee finds that getting the harness on and off is a major problem, then the tendency of leather to maintain its shape makes it easier to slip the stumps through the suspensors. If excessive perspiration is a problem, then vinyon tape may be more suitable.</p> <p>Although the combination of one leather and one vinyon Y-suspensor is shown in <b>Fig. 31</b> primarily to suggest the two possibilities, it is not inconceivable to consider the arrangement for actual use. In the bilateral below-elbow cases, the choice of cuffs and hinges is made independently for each side on the basis of such factors as stump length, muscular tone, and elbow mobility. In some cases, it might be well to consider using flexible hinges on one side to encourage the use of residual pronation-supination while applying full cuff and rigid hinges on the other to provide stability. A bilateral so fitted would thus have the added versatility provided by an enhanced function of one kind in one arm and an enhanced function of a different kind in the other.</p> <p>In <b>Fig. 31</b>, a wrist-flexion unit is installed on the left prosthesis. Although in exceptional cases the bilateral fitting of wrist-flexion units might be desirable, ordinarily only one flexion device is necessary. When only one wrist-flexion unit is used, amputee preference, or simply prosthetic dominance of one extremity over the other, is probably the best criterion for determining the side to which wrist flexion should be applied.</p> <h4>The Bilateral Above-Elbow Harness</h4> <p>The unilateral below-elbow figure-eight harness has been adapted for bilateral above-elbow cases as well as for the bilateral belowelbow amputee. It is essentially the same as for the below-elbow cases but with added suspensory harness and means of operating the elbow locks. A typical pattern is illustrated in <b>Fig. 32</b>. If allowance is made for the increased need for function in the bilateral case, then fabrication of the bilateral above-elbow harness is similar to that of the unilateral above-elbow figure-eight pattern. Use is made of the same methods of harness adjustment as in adjusting the harness for the below-elbow bilateral.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. The bilateral above-elbow figure-eight harness. As in the bilateral below-elbow case, here too the choice of components for the two sides is made independently with regard for individual stump characteristics and with the intention of providing as much useful function as possible. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Before attempting the fabrication of the bilateral above-elbow harness, the harness-maker must understand the above-elbow figure-eight harness for unilaterals. He should then discuss with his patient any special vocational or personal activities requiring modification of harness design. When the harness is completed, the prosthetist should make it a point to follow up progress in training to make sure that the bilateral amputee can soon become self-sufficient in all necessary activities. If attention is paid to these few details, and if each bilateral amputee is treated as an individual problem, surprisingly good results may be obtained in practically all bilateral cases.</p> <h4>The Bilateral Shoulder-Disarticulation Harness</h4> <p>Because the bilateral shoulder disarticulation and the bilateral above-elbow/shoulder combination represent comparatively rare and highly specialized instances of upper-extremity amputation, it has thus far not been possible to establish any set harness pattern for these cases. Although in general the bilateral shoulder-disarticulation harness is a sort of combination of two shoulder-disarticulation harnesses for the unilateral, every amputee requiring such harness must have meticulous attention to details in the individual case. In any event, it is obvious that, in the bilateral shoulder-disarticulation amputee, the goal of the prosthetist is to obtain as much function as possible regardless of necessary deviations from ordinary practice. Although experience with extreme cases of this kind has to date been limited, the Case Study at the University of California at Los Angeles (page 61) has accumulated some useful information. At present, the knowledge gained at UCLA probably offers the most important guide for management of the individual bilateral shoulder-disarticulation case.</p> <h3>Conclusion</h3> <p>To the student of the art of harnessing upper-extremity prostheses, it will now have become perfectly plain that here, as in almost every other published source, the harness designs presented are principally those applicable to the comparatively young, healthy, adult male amputee. Included, furthermore, are only those systems for which there has been accumulated enough clinical evidence to prove their validity for use with presently available arm components. Noticeably missing are special patterns and fabrication techniques for the very young, for the very old, for the debilitated, for the special cases involving other complicating handicaps, and, with two exceptions, for the female.</p> <p>The reason for this situation lies in the fact that, inspired as it was by the desire to aid the veteran returning from the wars, the Artificial Limb Program, sponsored by the Veterans Administration and the Department of Defense, has quite naturally placed emphasis upon the type of amputee to be expected from the battlefield. But it is not fully appreciated by the general public that there are produced annually from disease or accidentsâ€"in the home, on the highway, in the factoryâ€"many, many more amputees than are ever produced in military campaigns. Such causes of amputation play no favorites with age or sex.</p> <p>Fortunately, the basic principles involved in the harnessing of the adult male are more or less fully applicable to the juvenile amputee. Recently, for example, an armamentarium chart defining child amputee types and offering suggestions for prescription for children of age three and a half to ten years has been prepared under the auspices of the Michigan Crippled Children Commission.<a></a> Two columns of this reference document are devoted to "harness type" and "control type" respectively. Except for the omission of the below-elbow dual control and of the above-elbow and shoul-der-disarticulation triple controls, at every level of arm amputation in the child the recommended harness and control systems are identical with those used for the corresponding level in the adult male. The only significant modifications are concerned with the use of 1/2-in. instead of 1-in. webbing, according to the size of the child, and with the twofold recommendation that the harness be worn over a T-shirt and that the younger children be provided with two harnesses, one to be worn while the other is laundered. Since in general young children do not possess harnessable forces as large as are usually to be had in the adult, the unit stresses produced by the narrower webbing are acceptable to the small child, and hence, following the rule of minimum permissible harness in all cases, it is obviously advisable to use the 1/2-in. material whenever it can serve the small fry satisfactorily. The need of children generally for a frequent change of clothing deserves no further comment here.</p> <p>In any event, it will be recalled that some twelve-year-olds are actually larger and stronger than some adults, and consequently the determining factor in any given child is his own particular size, which in turn determines whether 1/2-in. or 1-in. material will provide the more comfort. Other features of harness fabrication for children are essentially the same as for adult harnessing.</p> <p>As for the adult female, generally the harness for the adult male is applicable, with the exceptions that the chest-strap designs usually are not desirable and that commonly more emphasis is placed on cosmesis. Most women, for example, prefer to have a choice of wearing "V" necklines instead of being restricted to Peter Pan collars or other high necklines. The figure-eight harness pattern is adequate for both above- and below-elbow female amputees. In high-above-elbow cases and shoulder disarticulations, the patterns of <b>Fig. 27</b> and <b>Fig. 28</b> usually serve satisfactorily.</p> <p>Elderly amputees, amputees with multiple limb losses, and those with additional complications such as blindness or deafness all present such highly specialized problems that no single harness pattern can be more than partially satisfactory in all cases. Some evidence seems to indicate that there may even be an age limit beyond which most individuals begin to feel that bothering with an artificial arm at all is no longer worth the effort. But no really scientific evaluation has yet been made of the needs of the aged amputee. Circumstances in the individual case must therefore dictate the course to be taken. As in the case of children, some geriatric patients are healthy, strong. and dynamic; others are ailing, feeble, or lethargic. In the elderly amputee, therefore, as in all special cases, personal factors prevent the recommendation of any generalized harnessing system.</p> <p>In the two illustrations of typical harnessing for bilateral arm amputees (<b>Fig. 31</b> and <b>Fig. 32</b>), the subjects are shown as having amputations at approximately the same level on the two sides. In actual clinical practice, of course, bilateral arm cases present all possible combinations of above- and below-elbow amputations. In all such cases, the problem of devising suitable harnessing combinations presents a special challenge to the prosthetics clinic team. Similarly, in the case of amputations complicated by other mental or physical handicaps, special assessment of the individual patient must be made to determine, first of all, whether use of a prosthesis is actually feasible and, if so, what if any departures from conventional harness patterns are indicated. In all such unusual instances, the considered judgment of the clinic team is indispensable in the development of a specialized harness pattern suited to the needs and abilities of the individual concerned,</p> <p>It may now be reiterated that, even in the so-called "standard" cases, it does not suffice to supply a "standard" harness. The reference chart of <b>Table 1</b> is appended here only for the convenience of the clinic team in selecting the basic kind of harness applicable to any given case. It is, in the end, the responsibility of the prosthetist to see that the details are properly custom-matched to the wearer and that, after adequate amputee training, the harness chosen actually fulfills satisfactorily the needs of the wearer for whom it was intended. Less meticulous avenues of approach lead ultimately to failure.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. (For a larger image of this table, please refer to the PDF link at the top of the page.) </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Finally, cognizance should be taken of the understandable circumstance that the harness patterns presented here have all been developed specifically for use with existing mechanical devices. The above-elbow and shoulder-disarticulation systemsâ€"the dual-control figure-eight, the dual-control chest-strap, and the triple-control patternsâ€"have, for example, all been designed around existing elbows. Because heretofore the art of harnessing has lagged behind the development of arm components, it has been necessary in recent years to design the harness systems to fit the mechanical parts rather than vice versa. A more logical arrangement would have been first to analyze the available body control motions, to design the harness for maximum utilization of these motions in the least awkward way, and then to design the other parts of the prosthesis in such a manner as to be operable by control patterns best suited to amputee characteristics. Future research in harnessing can be expected to influence redesign of desirable operational characteristics of the mechanical devices now available and to encourage the development of wholly new and improved arm components.</p> <h4>Acknowledgment</h4> <p>With the exception of the photographs and of <b>Fig. 12</b>, the illustrations appearing in this article are the work of George Rybczynski, free-lance artist of Washington, D. C.</p> <p><b>References:</b></p> <ol> <li>Alldredge, Rufus H., and Eugene F. Murphy,<i>Prosthetics research and the amputation surgeon, </i>Artificial Limbs, 1(3):4 (September 1954).</li> <li>Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, <i>The techniques of cineplasty,</i>, Chapter 3 in Klopsteg and Wilson's <i>Human limbs and their substitutes. </i>McGraw-Hill, New York, 1954.</li> <li>Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Technical Report 5424, <i>Comparison of UCLA and APRL cable transmission systems for B.E. biceps cineplasty arm, </i>21 June 1954.</li> <li>Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Technical Report 5526, <i>Shop instructions for cable and sheave equalizer systems (below-elbow cineplasty APRL), </i>8 August 1955.</li> <li>Carlyle, Lester, <i>Artificial arm checkout procedures,</i>Artificial Limbs, January 1954. p. 25.</li> <li>Carlyle, Lester, <i>Fitting the artificial arm, </i>Chapter 19 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Carnes, W. T., U. S. Patent 1,046,966, December, 1912.</li> <li>Carnes, W. T., U. S. Patent 1,046,967, December, 1912.</li> <li>Carnes, W. T, U. S. Patent 1,402,476, January, 1922.</li> <li>DeFries, Myron G., and Fred Leonard, <i>Bacterio-static nylon films, </i>Applied Microbiology, 3(4):238 (1955).</li> <li>Fletcher, Maurice J., and A. Bennett Wilson, Jr.,<i>New developments in artificial arms, </i>Chapter 10 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Hitchcock, William E., <i>Abduction for shoulder disarticulation prosthesis, </i>Orthop, Pros. Appl. J., September 1955. p. 23.</li> <li>Inman, Verne T., and H. J. Ralston, <i>The mechanics of voluntary miscle, </i>Chapter 11 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Kessler, Henry H., <i>Cineplasty, </i>Charles C Thomas,Springfield, Ill., 1947.</li> <li>Langdale-Kelham, R D., and George Perkins,<i>Amputations and artificial limbs, </i>Oxford University Press, London: Humphrey Milford, 1944.</li> <li>Leonard, Fred, T. B. Blevins, W S. Wright, and M. G. DeFries, <i>Nylon-coated leather, </i>Ind Eng. Chem., 45:773 (1953).</li> <li>Marks, George E., <i>A treatise on Marks' patent artificial limbs with rubber hands and feet, </i>A. A. Marks, New York, 1889.</li> <li>Mary Free Bed Children's Hospital and Orthopedic Center, Grand Rapids, Mich., <i>Child amputee types and suggestions for prosthetic prescription, 3 1/2 years to 10 years </i>(a chart), 1955.</li> <li>Mount, George E., and Raymond E. Bernberg,<i>A preliminary comparison of perception undet cineplastic and harness prostheses, </i>Am. J. Psychol., LXII(1):106(1949).</li> <li>New York University, Prosthetic Devices Study, Committee on Above-Elbow Harness [Hector Kay, Chairman], Report of conference, <i>The above-elbow figure-eight harness a guide to procedures and principles, </i>September 23, 1954.</li> <li>Northrop Aircraft, Inc., Hawthorne, Calif., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Artificial arm and leg research and development, </i>February 1951. Sections 1.6.1 and 1.6.1.1, p. 92.</li> <li>Northwestern Technological Institute, Evanston,Ill., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>A review of the literature, patents, and manufactured items concerned with artificial legs, arm harnesses, hand, and hook; mechanical testing of artificial legs, </i>1947.</li> <li>Pursley, Robert J., <i>Harness for shoulder disarticulation amputees, </i>Orthop. &amp; Pros. Appl. J., March 1955. p. 15.</li> <li>Spittler, August W., and Maurice J. Fletcher,<i>Technique of cineplastic surgery and prosthetic appliances for cineplasty, </i>Am. Acad. Orthopaedic Surgeons Instructional Course Lectures, Volume X, Edwards, Ann Arbor, Mich., 1953.</li> <li>Taylor, Craig L., <i>The biomechanics of the normal and of the amputated upper extremity, </i>Chapter 7 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Taylor, Craig L., <i>Control design and prosthetic adaptations to biceps and pectoral cineplasty, </i>Chapter 12 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>University of California (Los Angeles), Department of Engineering, <i>Manual of upper extremity prosthetics, </i>R. Deane Aylesworth, ed., 1952.</li> <li>U. S. Naval Hospital, Oakland, Calif., Artificial Limb Department, Blueprint 811, <i>Carpometacarpal {harness controlled) prosthesis, </i>September 22, 1952.</li> <li>Wilson, A. Bennett, Jr., and Robert J. Pursley,<i>Fitting the wrist disarticulation case, </i>Orthop. &amp; Pros. Appl. J., September 1952. p. 17.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Mary Free Bed Children's Hospital and Orthopedic Center, Grand Rapids, Mich., Child amputee types and suggestions for prosthetic prescription, 3 1/2 years to 10 years (a chart), 1955.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">While this hypothetical case suffices to describe the harness, it carries the faulty implication that the bilateral harness is simply two unilateral harnesses. No such implication is justified, for, as already pointed out, the functional requirement is magnified many fold, there is the complication of effecting separation of controls, and in addition there is the problem of getting into and out of the harness.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Hitchcock, William E., Abduction for shoulder disarticulation prosthesis, Orthop, Pros. Appl. J., September 1955. p. 23.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness for shoulder disarticulation amputees, Orthop. &amp;Pros. Appl. J., March 1955. p. 15.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness for shoulder disarticulation amputees, Orthop. &amp;Pros. Appl. J., March 1955. p. 15.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness for shoulder disarticulation amputees, Orthop. &amp;Pros. Appl. J., March 1955. p. 15.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness for shoulder disarticulation amputees, Orthop. &amp;Pros. Appl. J., March 1955. p. 15.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">When the waist band is disliked by the female amputee, the elbow control strap may be anchored to a girdle or pantie girdle, just as it may be anchored to the trousers in the male.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Not chiffon or lace!</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness for shoulder disarticulation amputees, Orthop. &amp;Pros. Appl. J., March 1955. p. 15.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Use of the waist band, as in Figure 22, is largely a matter of personal preference. Some amputees like it, some do not. When the amputee wishes to dispense with the extra waist strap, the elbow control may be anchored to an item of clothing such as a button at the top of the trousers near the fly, as in Figure 26. The control strap then passes out of the shirt between buttons, so that no special opening is needed. But of course when this arrangement is used, the prosthesis is inoperable when the wearer is unclothed.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness for shoulder disarticulation amputees, Orthop. &amp;Pros. Appl. J., March 1955. p. 15.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness for shoulder disarticulation amputees, Orthop. &amp;Pros. Appl. J., March 1955. p. 15.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness for shoulder disarticulation amputees, Orthop. &amp;Pros. Appl. J., March 1955. p. 15.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., and A. Bennett Wilson, Jr.,New developments in artificial arms, Chapter 10 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b> 25.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b> 27.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study, Committee on Above-Elbow Harness [Hector Kay, Chairman], Report of conference, The above-elbow figure-eight harness a guide to procedures and principles, September 23, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">It may be noted that the techniques for harnessing the above-elbow amputee can be applied equally well to articulated braces for flail arms.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary miscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Technical Report 5526, Shop instructions for cable and sheave equalizer systems (below-elbow cineplasty APRL), 8 August 1955.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Technical Report 5424, Comparison of UCLA and APRL cable transmission systems for B.E. biceps cineplasty arm, 21 June 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Technical Report 5424, Comparison of UCLA and APRL cable transmission systems for B.E. biceps cineplasty arm, 21 June 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Although common-sense logic might lead one to suppose that improvement in pressure appreciation would be obtainable only were the terminal device voluntary-closing, it turns out that considerable improvement is to be had also from muscle tunnels harnessed to voluntary-opening devices. The tests conducted by Mount and Bernberg were, for example, all made with amputees wearing voluntary-opening hooks. How does the amputee so fitted estimate the amount of force being exerted at the hook fingers? He measures holdback and subtracts it mentally from the known total force exerted by the hook when no restraint is applied. (Ed)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary miscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasty, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasty, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasty,, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes. McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Kessler, Henry H., Cineplasty, Charles C Thomas,Springfield, Ill., 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Spittler, August W., and Maurice J. Fletcher,Technique of cineplastic surgery and prosthetic appliances for cineplasty, Am. Acad. Orthopaedic Surgeons Instructional Course Lectures, Volume X, Edwards, Ann Arbor, Mich., 1953.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Mount, George E., and Raymond E. Bernberg,A preliminary comparison of perception undet cineplastic and harness prostheses, Am. J. Psychol., LXII(1):106(1949).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasty,, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes. McGraw-Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Kessler, Henry H., Cineplasty, Charles C Thomas,Springfield, Ill., 1947.</td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Spittler, August W., and Maurice J. Fletcher,Technique of cineplastic surgery and prosthetic appliances for cineplasty, Am. Acad. Orthopaedic Surgeons Instructional Course Lectures, Volume X, Edwards, Ann Arbor, Mich., 1953.</td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasty, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., and Robert J. Pursley,Fitting the wrist disarticulation case, Orthop. &amp;Pros. Appl. J., September 1952. p. 17.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">U. S. Naval Hospital, Oakland, Calif., Artificial Limb Department, Blueprint 811, Carpometacarpal {harness controlled) prosthesis, September 22, 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">U. S. Naval Hospital, Oakland, Calif., Artificial Limb Department, Blueprint 811, Carpometacarpal {harness controlled) prosthesis, September 22, 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Except, of course, in those cases where extremely heavy duty is a requirement from the beginning.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasty,, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes. McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasty,, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes. McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">DeFries, Myron G., and Fred Leonard, Bacterio-static nylon films, Applied Microbiology, 3(4):238 (1955).</td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Leonard, Fred, T. B. Blevins, W S. Wright, and M. G. DeFries, Nylon-coated leather, Ind Eng. Chem., 45:773 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Carlyle, Lester, Artificial arm checkout procedures,Artificial Limbs, January 1954. p. 25.</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Carlyle, Lester, Fitting the artificial arm, Chapter 19 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Northrop Aircraft, Inc., Hawthorne, Calif., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Artificial arm and leg research and development, February 1951. Sections 1.6.1 and 1.6.1.1, p. 92.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and Eugene F. Murphy,Prosthetics research and the amputation surgeon, Artificial Limbs, 1(3):4 (September 1954).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Carnes, W. T., U. S. Patent 1,046,966, December, 1912.</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Carnes, W. T., U. S. Patent 1,046,967, December, 1912.</td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Carnes, W. T, U. S. Patent 1,402,476, January, 1922.</td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Langdale-Kelham, R D., and George Perkins,Amputations and artificial limbs, Oxford University Press, London: Humphrey Milford, 1944.</td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Marks, George E., A treatise on Marks' patent artificial limbs with rubber hands and feet, A. A. Marks, New York, 1889.</td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Northwestern Technological Institute, Evanston,Ill., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, A review of the literature, patents, and manufactured items concerned with artificial legs, arm harnesses, hand, and hook; mechanical testing of artificial legs, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Robert J. Pursley, Lt., USA (MSC) </b></td></tr><tr><td class="clsTextSmall">Chief, Research Limb Section, Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Washington, D. C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Harness Patterns for Upper-Extremity Prostheses Creator An entity primarily responsible for making the resource Robert J. Pursley, Lt., USA (MSC) * https://staging.drfop.org/files/original/e678471a88e3fafdcc78502486bb9378.pdf 0c896873793ae2afd1dd418dddff6f7d DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1956_01_001.pdf Year 1956 Volume 3 Issue 1 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1956_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1956_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Lesson In Lesions</h2> <h5>C. Leslie Mitchell, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The human integument, with its complex structural and functional organization, is one of the most remarkable packaging materials in the world. Unlike inanimate wrappers however elaborate, it has under ordinary circumstances the extraordinary facility of regenerating itself, of adapting to the local environment, and of resisting attack by all kinds of agents-chemical, physical, and biological. The reason for this situation lies in the fact that living skin, as is the case with other living tissues, undergoes continuous metabolism, with consequent growth and decay.</p> <p>But in addition to its mechanical function-that of providing a tough, protective outer covering for the body-the skin has many important but little-recognized physiological properties, among these being its ability to function as a respirator in the exchange of oxygen and carbon dioxide; as a regulator of body temperature by means of sweat glands under control of the sympathetic nervous system; as an agent in the conservation of water and electrolytes; as a sensory organ to record heat, cold, pain, and touch; as a corridor for the reception of vitamins and hormones; and as a barrier against infection. Despite all these indispensable services, the integrity of the skin is so much taken for granted by almost everybody that usually no attention is directed to it until some deviation from the normal develops. Its numerous functions are poorly understood by most laymen, if not indeed by many physicians. Yet neglect of its proper care can result in serious consequences.</p> <p>Proper functioning of the skin is dependent on many factors, such for example as freedom from constriction and irritation, adequate exposure to air, prompt removal of waste products from its surface, and avoidance of extremes of heat and cold. Whenever the skin is subjected to abnormal insults, the problem of skin care is multiplied many times. Since the wearing of a prosthesis, particularly on the weight-bearing lower extremity, unavoidably creates most of the conditions-constriction, excessive moisture, increased heat, mechanical irritation, and undue pressure-conducive to poor skin health, it quite naturally places upon the skin of the stump a set of demands far in excess of the normal. And not only that. Having lost one of his principal heat-radiating "fins," and being at the same time required to exert in locomotion more energy than does the normal person, the leg amputee commonly perspires more freely than normal, and hence his needs for skin hygiene are more acute than are those for one who walks on two natural legs.</p> <p>The basic requirements of a lower-extremity prosthesis are to provide comfort, function, and appearance. Of these, comfort is unquestionably of chief importance, for without comfort the amputee will fail to obtain satisfactory function, or appearance, or both, and will ultimately either limit use of the prosthesis or else find it impossible to wear it at all. In a large percentage of cases of difficulty or failure, skin lesions of one type or another involving the stump are found to be the cause of discomfort, thus preventing the amputee from wearing the limb. Prophylaxis is, therefore, a <i>sine qua non </i>in this regard, and only through adequate knowledge of skin physiology can these disorders be anticipated and thus prevented.</p> <p>Although disabling skin lesions on the stump of the leg amputee have constituted a serious complication ever since prostheses were first used for the lower extremity, full appreciation of the problem and suggestions for solution have not been forthcoming until recently. As has been typical with most problems in medicine, little was accomplished until a concerted effort was made to understand normal function and to investigate reaction to the abnormal. It is encouraging to note that there is now well under way, with the sponsorship of the Prosthetics Research Board of the National Academy of Sciences-National Research Council, a systematic attack aimed at solution of the cutaneous problems of the leg amputee.</p> <p>Because even the most satisfactory lower-extremity prosthesis is of no avail if the amputee is deprived of wearing it, and because painful skin lesions in a leg stump have so frequently been the cause of inability to use an artificial leg properly, the then Prosthetic Devices Research Project at the University of California, Berkeley (now the Lower-Extremity Amputee Research Project), in conjunction with the Department of Dermatology at the University of California Medical School in San Francisco, organized in the autumn of 1954 a skin-study group to investigate the cutaneous difficulties of the lower-extremity amputee. In the course of the succeeding two years there has been accumulated a considerable body of new knowledge, not only on the nature and physiology of healthy skin but also on some of the specific clinical manifestations of skin disorders in amputees. Since the proper management of cutaneous disturbances is so essential to lower-extremity function, this issue of Artificial Limbs is devoted to a presentation of some of the information gathered thus far. In the first of two articles, a dermatologist discusses the anatomy and physiology of normal skin and what is to be expected when healthy skin is subjected to unfavorable conditions. In the second, another dermatologist characterizes the common skin maladies of leg amputees and offers suggestions for prevention and treatment.</p> <p>An interesting observation is that proper care of the stump skin is found to be the responsibility not only of the attending physician and the prosthetist but, and even more important, of the amputee himself. Nevertheless, simple attention to good practices of daily hygiene is not enough. A considerable number of skin disorders peculiar to the lower-extremity stump present themselves despite all precautions. Some are common to all leg amputees. Many are the result of individual skin idiosyncrasies or of climatic conditions. Some are so intractable as to be amenable to cure only by total excision.</p> <p>While the newer understanding has in recent years appreciably decreased the incidence of serious skin lesions in leg amputees and has made it more readily possible to deal successfully with some of those that do occur, it is obvious that much work remains to be done. For the complete etiology of many of the characteristic disease states yet remains to be elucidated. It is to be hoped that the initiative taken by the pilot study group at the University of California may prove to be a stimulus for similar investigative work at other centers of medical research throughout the world. The lesson is here for us to learn. Unless skin problems can be eliminated once and for all, there can be no true rehabilitation of the lower-extremity amputee.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>C. Leslie Mitchell, M.D. </b></td></tr><tr><td class="clsTextSmall">Surgeon-in-Charge, Division of Orthopaedic Surgery, Henry Ford Hospital, Detroit; member, Prosthetics Research Board, NAS-NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Lesson In Lesions Creator An entity primarily responsible for making the resource C. Leslie Mitchell, M.D. * https://staging.drfop.org/files/original/bca9b91aef7e3781b29df6181fc9502d.pdf 5d1adb8f6a4a251bfae87557108dcb7b https://staging.drfop.org/files/original/eba4db041582a948e7b8573f8171e55d.jpg d2d2b8d66e11f8576a2669c92ca431c9 https://staging.drfop.org/files/original/fd1e1b1fed23a83e0b989fbdbee7731c.jpg f2cfcea12c8494514b518ab14dc364a4 https://staging.drfop.org/files/original/02e3a3d141fd7f689df0f060da69142d.jpg 9b11833db8cba18b2e267287fd0b4381 https://staging.drfop.org/files/original/a5f74e0c94bba45447600513cce141f8.jpg 018efbb47c12a9ec5dd55890d76452de https://staging.drfop.org/files/original/cafd284bedbe85e23e4580df59846ea7.jpg 171443759e0f481de14918280826908f https://staging.drfop.org/files/original/98bb321dbfa2d34e578725fb1144ba2f.jpg 1b3540601d776f662c1f47f391614aec https://staging.drfop.org/files/original/eca5fce7b392bd0df7651f5c56ae05c4.jpg 85962872df45d132db9f927a8516721c https://staging.drfop.org/files/original/ab2922020f921ea9dc3260155c6b9855.jpg 4734cb468510d0554f5b80d449a9e507 https://staging.drfop.org/files/original/5efb5f8b47d417ecc3fb56b4e116ff85.jpg 8c2f5c4fa3b6df3b4341c0ec47f5af9b https://staging.drfop.org/files/original/0ff459c59890e9e3a392d35fd4d1a0bb.jpg ec9505e7eff0bdb1e3aad92c00d7e0b4 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1956_01_004.pdf Year 1956 Volume 3 Issue 1 Page Number(s) 4 - 19 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1956_01_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1956_01_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Skin Health and Stump Hygiene</h2> <h5>Gilbert H. Barnes, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Literally the word "hygiene" connotes a state or condition of health. But adequate hygiene, or good health, of the human skin presents a complex problem involving much more than a casual acquaintance with soap and water, the concept which usually comes to mind when hygiene is mentioned. The functional state of our human integument is pretty much taken for granted by most of us. We know that this two-square-yard covering will, in most cases, repair itself in event of local injury, provided infection is avoided. Cheerfully we dissolve it in strong chemical solutions. We broil it in the summer sun until it peels off like old birch bark. We allow it to be rubbed and blistered in tight shoes for vanity's sake. As a nation, we spend millions of dollars on elaborate sun-tan lotions guaranteed to produce in it the beautiful brown of the aborigine and at the same time an equal fortune on lotions and creams which promise to bleach it out to the shade of a sheltered lily.</p> <p>Even though the skin has remarkable powers of restoration, the conditions of use are occasionally too damaging, or the opportunities for healing between periods of use are too brief for repair and maintenance. In such instances, there may be an acute breakdown of the skin with a severe inflammatory reaction, or the process may be a gradual one, with a progressive deterioration of the skin and a loss of its protective properties. Among individuals in certain occupations, we frequently see both manifestations of such skin reaction. Housewives, mechanics, laboratory workers, and others whose work exposes certain areas of the body, particularly the hands and arms, to prolonged soaking in solutions and solvents, or even in plain water, are prone to recurrent skin irritation and breakdown. In such cases, the chemical and physiological properties of the skin are altered to such a degree that the skin's built-in protective functions are no longer effective. Even in the absence of prolonged soaking, the skin may be injured locally by contact with an irritant, such as a strong acid, or with a sensitizing agent, such as poison ivy.</p> <p>All of these considerations similarly pertain to amputees who wear some type of prosthesis (<b>Fig. 1</b>), most of which are attached to the stump by means of a snugly fitted socket which excludes circulating air and traps the accumulated sweat against the skin. In the lower-extremity amputee, the effect is aggravated by the added factor of weight-bearing and uneven loading on localized areas of the stump skin, especially in the adductor region of the stump and at other points of contact with the socket rim. Weight-bearing is attended by other mechanical stresses, especially intermittent stretching of the skin and friction from rubbing against the socket edge and interior surface. The latter results in two important and harmful effects on the skin- heat, and abrasion of the skin surface, which in time can, by steady attrition, become highly destructive. Over a long period of time, heat alone may be capable of causing profound changes in the metabolism of living tissues. The stump skin of the amputee is especially vulnerable to the possible irritant or allergic action of various materials that compose the socket of the artificial leg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Injury to the stump skin. The gremlins symbolize some of the common types of damage that may be inflicted upon the stump skin inside the socket of a prosthesis. Injury may be incurred mechanically when parts of the socket abrade the skin or burrow into it. The materials of the socket, coming in intimate contact with the skin, sometimes act as irritants or as sensitizing agents to create a local dermatitis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In this situation, then, the state of health of the stump skin is of the utmost importance in determining whether or not the prosthesis can be tolerated. If the skin cannot be maintained in a good functional condition in spite of daily wear and tear, then the weight-bearing prosthesis cannot be worn, no matter how accurate the fit of the socket may be.</p> <p>It is the purpose of this article to review some of the basic principles of skin biochemistry and physiology concerned in the maintenance of good hygiene in the stump area. Included are some remarks relative to the use of certain disinfectant agents in skin cleansing, and to some of the natural skin defenses against bacterial invasion, because these topics also are germane to the principal subject with which this article is concerned.</p> <h3>The Skin as a Vital Organ</h3> <p>Man cannot live without his envelope of skin any more than he can exist without his heart or his liver. It might seem at first thought that the cutaneous covering of the body performs about the same function as the leather cover of a baseball -and very little more. Actually, the biochemical and physiological activities of the skin are every bit as complex as are those of the liver. The respiratory rate of the main cellular portion of the epidermis, based on oxygen-uptake studies and glycolysis measurements, has been computed to be from two to ten times as high as the rates of other body tissues.</p> <p>The skin possesses many properties vital to health and life itself. Of particular interest to us from the standpoint of prosthetic design and use is the part it plays in mechanical support of the soft tissues of the stump. It provides a tough, elastic outer covering with a tensile strength of up to 2 kg. per sq. mm. Furthermore, this covering has a tremendous capacity for repairing itself after injury and for strengthening itself at points of mechanical stress, such as those occurring on the lower-extremity stump in association with the wearing of an artificial limb. A familiar example of this is the "lichenification," or leatherlike thickening of the skin over the ischial tuberosity and in the adductor region of the thigh. We know that "calluses," or localized thickenings of the horny outermost layer of the skin, will form at points of repeated pressure. Sometimes a BB-shotlike condensation of horny material will develop over a pressure point, producing the well-known "corn." All of these thickening processes illustrate the defensive reaction of the skin to abnormal mechanical stress by elaborating a natural cushion from its cellular elements.</p> <p>Mechanical protection, however, is only one of many important services which the skin performs. Its function in the conservation of water and electrolytes, those ionized salts which constitute an essential part of the body fluids, is nearly as indispensable as is the function of the kidneys. The skin is extremely important in the regulation of the body temperature within relatively narrow limits. It possesses certain important electrical and chemical properties. It is also the first barrier, and one of the chief defenses of the body, against infectious diseases.</p> <p>Many other properties of the skin that are of less immediate importance to the problem of stump hygiene nevertheless have a bearing on human health and welfare. For example, we rely on the sensory organs of the skin for a good part of our information about the world around us. Through nerve endings at or near the surface, the body receives the outside environmental stimuli of heat, cold, pain, and touch. Also important to health is the role of the skin in maintaining a highly complex system of pigment metabolism and in providing a source of vitamins important for growth and nutrition.</p> <p>Although there are other vital functions of the skin, those cited serve to illustrate the importance and variety of the services the normal skin performs. Some of these are described at greater length in the following portions of this paper.</p> <h3>The Anatomy of the Skin</h3> <p><b>Plate I</b> shows in semidiagrammatic form the principal structures of the skin concerned in stump hygiene. The skin is seen to consist of two distinct layers-the epidermis and the dermis, or true skin. These two layers are joined by a system of fingerlike projections, the rete pegs, which protrude down from the epidermis and interlock with the papillae, which project up from the dermis. This device furnishes a relatively large surface area at the dermal-epidermal junction, thus providing a strong bond between the two layers.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Plate I. A section of normal human skin. 1, Epidermis; 2, true skin; 3, subcutaneous tissue; 4, horny layer; 5. clear layer; 6, granular layer; 7, germinativc layer; 8, capillary network; 9. artery; 10. vein; 11. lobules of fat; 12. nerve; 13, corpuscle of Vater; 14. sweat gland; 15, duct of sweat gland; 16, pore of sweat gland; 17, hair follicle; 18, hair shaft; 19, bulb of a hair; 20, arrcctor muscle; 21, sebaceous gland; 22, duct of sebaceous gland. Courtesy White Laboratories, Inc., KenilKorth, .V. J. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The most superficial layer of the epidermis is the so-called "horny layer," consisting of a material called "keratin," which is very similar to animal horn. Scattered over the surface of the skin are numerous deep pockets, called "follicles," into which sebaceous, or oil, glands discharge their contents. From the follicles protrude the hairs of the skin.</p> <p>Two other types of glands in the skin have an important bearing on the subject of stump hygiene. They are the eccrine, or small sweat glands, which lie in coils near the base of the dermis, and the apocrine, or large sweat glands (not shown in Plate I), which are similarly situated but are more localized in distribution than are the eccrine glands. The watery sweat secretions pass to the surface of the skin by way of the sweat ducts, discharging on the surface through the sweat-duct opening, or pore.</p> <p>Deep to the dermis lies the subcutaneous zone. Here, cushioned in masses of fat cells, are the large blood vessels which serve the skin. From the arteries, smaller vessels rise, becoming narrower as they branch, until they terminate in fine capillary nets in the papillae of the dermis. Blood from the papillary nets returns again by a venous collecting system to the large veins in the subcutaneous tissue.</p> <h4>Relation of Skin Structures to Disease</h4> <p>All of these structures are vulnerable to damage from prolonged wear of a prosthesis. Injury to each different anatomical site results in a specific disease complex of the skin. For example, excessive heat and moisture may result in a local blocking of the sweat-duct pores. We are familiar with this condition in the form of what is known popularly as "prickly heat," a common malady in warm, humid climates; and the same disorder can occur over stump skin under similar environmental conditions.</p> <p>Prolonged use of negative-pressure sockets, and to a lesser degree of conventional sockets, may lead to engorgement of the small blood vessels of the skin, resulting in local areas of rupture and extravasation of blood into the surrounding tissues. The dark pigmentation often seen on the terminal end of the stump is the result of this bleeding under the skin. It is usually accompanied by some degree of edema, a state in which there is an abnormal collection of watery fluid in the soft tissues. Thus the skin disorder here is essentially focused in the circulatory system, whereas the previously cited condition of sweat-duct blockage affects primarily one of the glandular systems of the skin. It follows, then, that the over-all hygiene or good health of the stump skin reflects, among other things, the functional state of each of the anatomical components of the skin.</p> <h4>Skin Glands and Stump Hygiene</h4> <p>In the skin of the lower extremity, three different types of glands produce secretions that are discharged on the surface of the skin. These are the eccrine glands, the apocrine glands, and the sebaceous glands (Plate I). During daily use of a prosthesis, their secretions accumulate inside the socket, where they may become a serious hazard to local stump hygiene.</p> <p><i>The Eccrine Glands</i></p> <p>The eccrine glands, or small sweat glands, are distributed over the entire surface of the body. They are accessory structures that develop from the epidermis. They are true secretory glands, producing a clear, aqueous fluid, and their functioning is vital to the heat regulation of the body, since these glands are the principal source of sweat. It has been estimated that there are over two million of these glands in the skin of a normal adult and from 500 to 600 per sq. in. over the skin of the thigh and lower leg. It has been reported that the capacity for sweating is considerably less for females than for males. According to Weiner <i>{23), </i>roughly 50 percent of heat sweat comes from the trunk, 25 percent from the head and upper limbs, and 25 percent from the lower limbs.</p> <p><i>Sweat Deposits. </i>Eccrine sweat is a clear, watery solution containing 0.5 to 1.0 percent of solids. These solids play an important role in stump hygiene because, in the absence of adequate daily cleansing, their accumulation on the surface of the stump and in the socket interior may serve as a source of irritation and to some extent as a culture medium for the growth of harmful organisms. The eccrine sweat solids include urea (in at least twice the concentration found in blood plasma); creatine and creatinine in minute quantities; uric acid; a variety of different amino acids; ammonia; free choline; occasional traces of glucose; lactic acid and lactate (to the extent of more than 2 grams in 90 minutes of heavy physical labor); many of the water-soluble B-vitamins; traces of dehydroascorbic acid; and the minerals sodium, potassium, calcium, magnesium, sulfates, phosphates, and iron. In addition to the sweat solids, there are the secretions of local oil or sebaceous glands, plus a quantity of nitrogenous material made up of keratin shreds and other cellular debris which has been desquamated from the surface of the skin.</p> <p>This is the residue which collects on the skin and in the socket under normal conditions. If the skin has been damaged by abrasion against the socket wall, or if an eczematous skin condition is present, there may be "weeping" or oozing of serum over the surface, where it mixes with the sweat, oil, and skin debris. This serous material is deposited on the interior wall of the socket, where it dries and sets almost like glue. Successive laminations are added from each day's accumulation, until a considerable thickness may be attained (<b>Fig. 2</b>). Constant wearing and rubbing against the skin may produce a polished, glassy finish on the surface. In the interests of good hygiene, this deposit should be cleaned out of the socket interior regularly.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Debris in the socket. Accumulation of waste in the socket is not favorable to good stump hygiene. Daily waste, consisting of sweat solids, oily secretions, and cellular debris, often combined with serous ooze, is deposited in successive layers that should be cleaned from the socket regularly. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The innervation of eccrine sweat glands, pharmacologically speaking, is parasympathetic or cholinergic. Dale and Feldberg<a></a> demonstrated that the postganglionic nerve fibers liberate acetylcholine at their endings on the receptor cells of the sweat glands. Where excessive perspiration, or hyperidrosis, has been a serious problem, clinical application of this finding has been made by treatment of the patient with an anticholinergic blocking agent to diminish sweating. Drugs like methantheline bromide (Banthine) and diphemanil methyl sulfate (Prantal), which are anticholinergic, have been tried.</p> <p>Such treatment has proved sometimes very helpful, sometimes of slight benefit, and often discouraging. Even though excess perspiration may be reduced, there are not infrequently unpleasant side-effects, such as a sensation oi heat, dryness of the mouth and throat, headache, and urinary retention. In the amputee, who often has an overheating problem in the first place, any further impairment of his cooling mechanism may not be tolerated. In some cases, however, an effort to control excessive sweating may be worth a try; certainly any drying effect that such drug therapy may exercise in the stump area will contribute to the hygienic state of the stump skin.</p> <p><i>Eccrine Sweat Retention.</i> In profuse sweating, the sweat is expelled from the eccrine glands onto the surface of the skin at intraductal pressures ranging as high as 250 mm. of mercury. If the outlet at the surface of the skin becomes blocked by masses of keratin, local inflammation, or other obstruction, this pressure may be sufficient to cause rupture of the duct (<b>Fig. 3</b>). If the rupture takes place near the surface at the level of the horny, or keratin layer, the sweat collects in this layer in a raindroplike configuration of little blisters. If the rupture is deeper in the skin, there may be local inflammation, characteristic of "prickly heat." Where the duct is ruptured still more deeply, symptoms are few or none, and the only surface sign consists of small, noninflammatory elevations, or "papules."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Pressure in eccrine sweat glands. When an eccrine gland is actively secreting sweat onto the surface of the skin, the pressure in the sweat duct may rise to 250 mm. of mercury. If the opening of the gland becomes blocked, as symbolized by the gremlin, this pressure may be sufficient to rupture the gland duct and allow the sweat to escape into the skin. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Sweat retention may involve most of the skin surface of the body and may be accompanied by pronounced generalized symptoms of fever, headache, and exhaustion, a condition usually confined to tropical climates. More commonly it affects only a localized part of the body. It has been reported in many different types of eczema and in a variety of healing inflammatory lesions. Preliminary investigations of eczematous eruptions of the stump suggest that sweat retention occurs in this area also. The heat and humidity which prevail over the stump skin during use of a prosthesis are factors which encourage the development of sweat-duct blockage and localized sweat retention.</p> <p><i>The Apocrine Glands</i></p> <p>The apocrine glands, unlike the eccrine glands, develop from the follicular epithelium of the hair, as do the sebaceous glands. Apocrine glands are much larger than eccrine glands, and they are limited in their distribution to the underarm area, the breasts, the midline of the abdomen, and the anal and genital areas. Modified apocrine glands are also found in the external canal of the ear and in the vestibule of the nose.</p> <p>The apocrine secretion is a turbid, whitish-to-yellowish fluid which dries like glue to form a light-colored plastic. The total number of apocrine glands is greater in women than in men, and axillary sweating starts earlier in adolescent girls than in adolescent boys.</p> <p>The apocrine glands in the groin and axilla are occasionally the site of a chronic, extremely stubborn disease of the skin called "hidraden-itis suppurativa." This disease is characterized by large, burrowing, painful cysts which are filled with a foul discharge. These periodically break down and drain, then heal with scarring, and the process may be repeated indefinitely. Frequently the condition is so severe that surgical extirpation, followed by skin-grafting, affords the only means of controlling it. Rarely, hidradenitis suppurativa is encountered in amputees. In such cases it can cause a really serious handicap, making the use of a prosthesis or crutches impossible.</p> <p>Innervation of the apocrine glands is exclusively adrenergic, as compared with the cholinergic innervation of the eccrine glands. The apocrine system responds sluggishly or not at all to heat. However, it does respond promptly to emotional or painful stimuli. In the management of this aspect of the amputee's hygiene, therefore, it is important to bear in mind that pain or tenderness in the stump, or an emotional disturbance, may aggravate any existing skin disorders in the groin or underarm regions through stimulation of this specialized glandular system.</p> <p>Unfortunately, the apocrine glands occur in the areas upon which the amputee must depend for support in the use of a crutch or an above-knee prosthesis. The apocrine glands can be a source of considerable grief, if, through poor hygiene, infection, or other cause, these areas are allowed to become unserviceable for weight-bearing.</p> <p><i>The Sebaceous Glands</i></p> <p>The sebaceous glands occur wherever there are hair follicles. In addition, there are scattered, free sebaceous glands which are independent of the follicles. Their secretion is an oily liquid composed of fatty acids, alcohols, hydrocarbons, and certain vitamin precursors. This material, called "sebum," becomes solid at about 30 degrees C (86 degrees F), the prevailing skin-surface temperature.</p> <p>A unique feature of sebaceous-gland secretion is the capacity of the glands to secrete very rapidly onto a defatted skin surface, but at a rate which gradually declines until the new fat layer of the surface reaches a certain critical thickness. When this occurs, sebum production stops or falls to a minimum. If, however, the fat layer is removed, rapid secretion starts again. The more viscous the sebum becomes, the earlier the sebum expulsion is stopped. As a result, more oil is secreted per unit time at a high environmental temperature than at a low temperature.</p> <p>Presumably, the counterpressure of the oil film on the surface prevents further production by back-pressure in the gland. There is an interesting fact, however, which is not entirely explained by the back-pressure theory: if the duct of the gland is blocked by sebum only, no pathologic change takes place in the secretory cells of the sebaceous glands, but if the obstruction is caused by masses of keratin or other foreign matter, as in the case of comedones ("blackheads") and various types of follicular keratoses, degenerative changes in the gland set in relatively early.</p> <p>This phenomenon of controlled oil production is one in which a normal physiologic process appears to work with the amputee rather than against him in the wearing of a prosthesis. Here, the accumulating lipid film under the socket will serve as its own shut-off valve for further secretion, without damage to the sebaceous glands in the stump skin.</p> <p>Heat Control and the Healthy Skin Healthy skin exercises a vital role in the thermoregulation of the body, a function in which the skin of the lower extremities normally has an important share. This surface control supplements the central heat-regulatory center in the hypothalamus of the brain. At basal conditions, the heat balance of the normal body is maintained by cutaneous vasomotor adjustment through an environmental temperature range of 25 degrees to 31 degrees C (77 degrees to 88 degrees F), the so-called "zone of vasomotor control." Above this range, at 31 degrees to 32 degrees C (88 degrees to 90 degrees F), when cutaneous blood flow has reached its maximum, sweating sets in-the "zone of evaporative regulation." Between 31 degrees and 36 degrees C (88 degrees and 97 degrees F) and at low humidity, evaporative heat loss easily maintains normal temperature. Below the zone of vasomotor control, the skin temperature falls, and body temperature is maintained chiefly by chills (the "zone of cooling"). If environmental temperature is maintained below a critical level of 31 degrees to 32 degrees C, there is generalized, but grossly invisible, periodic sweating known as "insensible sweating." Consequently, although the principal thermoregulation in this temperature range is vasomotor, there is still an assist from the sweat glands in cooling the skin surface.</p> <p>The values cited are those reported for the normal. In the amputee, significant areas of cooling surface, along with the component sweat glands, have been subtracted from the total reserve of functional skin surface. In addition, the complex and important system of vascular shunts and arterioles in the amputated limb or limbs has also been lost from the total heat-regulatory mechanism. As a result, a number of characteristic and troublesome disturbances of temperature and heat control are associated with amputation.</p> <p>Among these is the phenomenon of the poikilothermic stump, which has been studied by staff members of the University of California Medical School <i>. </i><a></a> In this condition, the surface temperature over the distal part of the stump, and over a considerable portion of the stump proximally as well, tends to become stabilized at the temperature of the surrounding air, more or less independently of any vasomotor control. Thus it is seen that, in a lower-extremity amputation, not only is part of the original heat-control surface permanently lost but the remaining stump surface is no longer normally effective as part of the heat-control mechanism. Nevertheless, it is important to maintain the hygiene, or good health, of this remaining skin area in order to preserve whatever function it may still possess for heat regulating, and particularly for cooling.</p> <h4>Mechanisms of Heat Loss</h4> <p>Heat loss from the normal skin takes place by radiation, convection, conduction, and evaporation. All of these mechanisms are interfered with, if not entirely abolished, over the stump area when a tightly fitted socket is worn, Excessive local heating of the stump can result (<b>Fig. 4</b>), particularly during warm, humid weather, and a major hygienic problem can arise under such conditions.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Overheating of the stump. Since air cannot circulate inside a snugly fitted socket, the stump is usually bathed in sweat. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Heat loss from the skin by radiation takes place in the form of infrared rays in the range of 5 to 20 m/u. Under normal conditions, radiation accounts for about 60 percent of total heat lost from the body. In the amputee, it seems probable that loss of heat from the stump area by this mechanism is greatly restricted by the socket of the prosthesis. We do not at present, however, have any data to confirm this supposition.</p> <p>Convection depends upon the transfer of energy by means of moving air and thus is negligible as a means of heat loss from the stump when a prosthesis is worn.</p> <p>Conduction, the transfer of heat between two media in direct contact, is of great importance to the amputee. As the socket becomes warmed to skin temperature, it acts as an insulator against further dissemination of heat from the surface of the stump. It appears probable also that in the vicinity of principal loading, especially along the medial, anterior, and posterior segments of the socket rim, heat is generated by the friction resulting from shearing action between the skin and the socket rim. The insulating effect of the socket would, of course, tend to maintain any such local elevation of temperature. We are initiating a clinical study of this question, employing thermistors for the direct reading of skin temperatures while the prosthesis is being worn under various conditions of normal use.</p> <p>Just how significant increased local heating of the skin may be in adversely affecting skin hygiene and metabolism over a long period of time we cannot say at present. It is known that an increase in environmental temperature elevates the oxygen and nutritional requirements of most tissues. At the same time, the blood supply to the skin of a lower-extremity stump, if changed at all by the active use of a prosthesis, is probably reduced. One might speculate here whether the predilection of these weight-bearing sites for the development of recurrent "pressure sores" may not be related to increased local heat plus diminished nutrition, as well as to mechanical damage and to maceration from sweat. Certainly this area of stump hygiene merits further investigation.</p> <h4>Reflex Sweating</h4> <p>If, in the normal person, the environmental temperature is raised above a critical level between 31 degrees and 32 degrees C (88 degrees and 90 degrees F), there is a sudden, visible outbreak of sweating over the whole body. A similar response, termed "reflex sweating," may be observed when only a portion of the body surface is heated. Whenever there is excessive heating of the stump, the conditions favor reflex sweating, even though the environmental temperature of the rest of the body is below the critical level necessary for visible sweating. Certainly a valuable contribution, both to the comfort of the amputee and to the improvement of his stump hygiene, would be the development of new socket materials and designs which would provide for more rapid heat transfer by conduction and radiation to the outside air.</p> <p>Loss of heat by evaporation from the stump is negligible in the case of the suction socket. Where the conventional socket is worn with a wool stump sock, however, the wicking action of the sock may well provide an avenue for evaporation and consequent cooling. A light stump sock for use with the suction socket may prove feasible. If so, the cooling effect, as well as the added support and protection afforded the stump skin, would be of benefit in maintaining a healthy stump.</p> <p>According to Rothman,<a></a> sweating which is elicited by exercise begins at a lower skin temperature than does sweating produced by external heat. Bazett<a></a> suggested that there may be, deeply situated near vascular plexuses, thermal receptors which are warmed by the working muscles. These receptors may in turn activate the sweat glands of the skin. Whatever the true explanation may be, the combination of excessive sweating (<b>Fig. 5</b>) and increased energy requirements for locomotion is all too familiar to the lower-extremity amputee.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Excessive sweating. An amputee using an artificial leg may complain more of general bodily discomfort from heat and excessive sweating than would a normal individual undergoing similar exertion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Visible sweat secretion and heat loss can also occur independent of thermoregulatory needs. For example, sweating can be elicited with ease at air temperature below 31 degrees C (88 degrees F) by the ingestion of hot drinks, probably through a viscerocutaneous reflex. A variety of other nervous impulses unrelated to heat control may produce sweating. One of the most important of these is "emotional sweating," which may at times affect most of us to some degree. In dermatologic practice, we sometimes see patients in whom this condition has become so severe as to be almost incapacitating. Serious limitations affecting social contacts and employability result. The same disturbance of sweat mechanism may be experienced by amputees. Although the emotional factor may be important in some amputees who have a troublesome hyperidrosis, it is apparent from some of the known physiologic mechanisms for sweating that there may be other reasons for such an increase.</p> <h3>Stump Hygiene and Germs</h3> <p>It has been a matter of frequent observation that the normal skin is not a sterile skin. Such a condition simply does not exist. Normal skin teems with immense numbers of unseen organisms, some harmless and some pathogenic, that is, capable, under the right combination of circumstances, of causing an infection of the skin. Normally, the harmful bacteria and fungi are held in check by a number of different forces. Most of the time we live in some measure of harmony with this enveloping horde. But when resistance to infection is lowered by local skin damage, the presence of some generalized disease, a metabolic disturbance such as diabetes, or any one of numerous other causes, then this harmonious balance is destroyed and the avenue of invasion is opened. Two different classes of bacteria exist on normal skin under average conditions-the resident bacteria, which remain fairly constant, and the transients, which may be almost anything (<b>Fig. 6</b>). In addition, a variety of fungi come and go, chiefly members of the yeasts and molds, although other types, such as those which cause ringworm of the feet and body, may be present.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Flora of the skin. Of the teeming numbers of microorganisms on the normal human skin, some are resident bacteria, which are found on the skin more or less constantly, while others are transient bacteria-only temporary visitors. Common among the residents are Corynebacterium acnes, the so-called "acne bacillus"; Micrococcus epidermidis; and Micrococcus pyogenes, a skin pathogen. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Evans <i>et al. </i><a></a> have studied the resident bacterial flora in 146 sample scrapings from the skin of 17 adults over an eight-month period. They found that the anaerobic bacteria (those which grow in the absence of free oxygen) outnumbered the aerobic bacteria (those which require free oxygen) by a ratio that ranged between 10:1 and 100:1. In most of the cases, one species of anaerobic bacteria predominated, the so-called "acne bacillus," <i>Propionibacterium acnes (Corynebacterium acnes). </i>Of the aerobic bacteria, two species were observed regularly: <i>Micrococcus epidermidis </i>and <i>Staphylococcus albus {Micrococcus pyogenes), </i>the latter a skin pathogen The observation was made that, at least in cultures, some types of bacteria inhibited the growth of others. This finding might constitute one explanation for the overgrowth of certain bacteria, especially the acne bacillus, at the expense of the others. It was also found that the sebaceous glands were the major site of growth of bacteria on the skin and that exercise with sweating caused a transient minor increase in skin flora.</p> <p>What effect might the wearing of an occlusive prosthesis be expected to have on common skin pathogens trapped under the socket? How might the normal defenses of the skin be affected by the conditions attendant upon the use of a prosthesis? To answer these questions, let us consider four common groups of organisms which are likely to cause skin infections in the region of the amputee's stump-the gram-negative organisms like <i>Escherichia coli,</i> the staphylococci, the beta hemolytic streptococci, and <i>Proteus, </i>some strains of which are secondary wound invaders.</p> <p>We know that the normal skin surface has two important natural defenses against bacterial invasion-first, the ordinary drying action on the surface, facilitated, where the skin is uncovered, by the movement of air currents; second, the presence of unsaturated fatty acids (particularly oleic acid), which are components of the sebum, or oily secretion from skin oil glands.</p> <p>Gram-negative organisms, that is, those organisms which do not retain the selective blue dye used in the Gram staining technique, are particularly sensitive to drying. This alone is effective in killing or inhibiting their growth. Unfortunately, the dry state never exists for any length of time over the stump skin during the use of a prosthesis.</p> <p>Both the drying and the action of the fatty acids are slightly to moderately inhibitory against the staphylococcal organisms. In other words, neither factor offers sure protection against invasion by this group of germs, but both have deterrent value in the normal skin. Again, the moist state which usually exists under the socket tends to encourage the growth of staphylococci.</p> <p>Although the beta hemolytic streptococcus is unaffected by drying, it is destroyed by oleic acid. But streptococci will grow in serous exudate, such as may be seen in a weeping eczematoid dermatitis of the stump, because the albumin in the exuded serum neutralizes the oleic acid, the chief natural antagonist of the streptococci. This relation of exudative lesions of the skin to secondary infection underlines the importance of adequate hygienic care in routine management of minor abrasions and irritations of the stump area. Furthermore, it should be apparent that there are times when the continued use of a prosthesis on a stump which is the site of a dermatitis, especially where a serous discharge is present, will prevent healing and is almost certain to invite a secondary infection.</p> <p>The <i>Proteus </i>strains-the fourth group of organisms mentioned-multiply rapidly in a moist environment. Any occlusive dressing or cover, such as the socket, which tends to increase local moisture on the skin will favor a heavy overgrowth of <i>Proteus.</i></p> <p>Thus we see that, in all four of the examples cited, the use of a prosthesis may be expected in some measure to interfere with the defensive mechanisms of normal skin in its resistance to disease. This interference is augmented by prolonged or strenuous use of the prosthesis and by the presence of any pre-existing lesions, however minor they may seem to the amputee.</p> <h3>Electricity and the Skin</h3> <p>The electrical behavior of the skin plays an important part in the preservation of good health. Normally, there is a negative electrical charge in the superficial layers of the skin. When an alkaline condition prevails, this electrical negativity is increased owing to adsorption of negatively charged hydroxyl ions. An acid condition of the skin, however, causes a discharge of this normal negativity, which is complete between pH 3 and pH 4. As the relative acidity of the skin increases, there is eventually a reversal of the charge, the skin surface becoming electrically positive. Furthermore, investigators have reported that scarring of the epidermis<a></a> and prolonged soaking in water or concentrated salt solutions<a></a> tend to cause a discharge of the normally negative charge of the skin. Both of these abnormal conditions may develop over the stump as the result of use of a prosthesis.</p> <p>Just what effect socket wear has on the normal electrical behavior of the stump skin, or how significant this may be in maintaining a healthy condition in the stump area, we do not know at the present time. This is, however, another problem that should receive further investigation. We do know that the negativity of normal skin can be a factor in the defense of the body against pathogenic organisms, which are also negatively charged and which tend to be repelled from, or bound to, the surface of the skin according to variations in the electrical charge on the latter (<b>Fig. 7</b>). It is of interest, incidentally, to note here that in muscle the relationship of negative-positive electrical charges to normal and damaged tissue, as here described for the skin, is just reversed.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Electrical charge on the skin as a defense against germ invasion. Germs, which are negatively charged, tend to be repelled from the normally negative surface of the skin but are attracted to the skin when this charge is reversed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Stump Hygiene and Local pH or the Skin</h4> <p>Blank<a></a> has confirmed earlier observations that the pH of healthy skin is always on the acid side, falling usually between 4.2 and 5.6. Furthermore, both eccrine sweat and apocrine sweat are normally acid. These facts have given rise to the concept of the so-called "acid mantle" of the skin, which is cited by some investigators as one of the body's natural defenses against disease. Schmid<a></a> found a significant shift toward the alkaline side in the surface pH of the skin in cases of eczema and in seborrheic dermatitis, an inflammatory disorder involving especially the hairy and more oily regions of the skin. In general, an even greater shift toward the alkaline side takes place in these inflammatory diseases if the intact skin is broken and neutral in charge or if alkaline extracellular fluid diffuses through, as in any acute, weeping dermatitis of the stump. With healing, the original acid pH returns.</p> <h4>Buffering Action of Normal Skin</h4> <p>Another important property of the skin is its buffering action. If the skin surface is exposed to dilute acids or alkalies, there is normally a corresponding shift of the pH locally; but this is temporary, and the former acid pH is rapidly restored. This behavior represents the neutralizing capacity of the skin. Probably the most important agents in this neutralizing property are the sweat constituents, especially the lactic acid-lactate system and the amphoteric amino acids. Any local damage to the sweat mechanism, such as might be caused by socket irritation, could conceivably impair this important function of the skin in the involved areas. Burckhardt <i>{7,8) </i>and others have established that there is a definite correlation between the acid and alkali neutralizing capacity of the skin and its tolerance for acids and alkalies.</p> <p>Pursuing a discussion of acid-base balance brings to mind several unanswered questions with regard to the amputee's problem of stump hygiene. We would like to know, for example, what happens to the normally acid pH of stump skin during the daily wearing of an airtight socket. Does stump skin possess the same pH and buffering properties as the skin of an intact limb? What effect do different socket materials have on the pH of stump skin? Does an interior finish which gives an alkaline reaction necessarily cause more damage to the skin than does one with an acid reaction? These are questions which should receive further investigation in the light of their vital relationship to stump hygiene.</p> <p>It might seem from the foregoing that the cutaneous surface which gives an acid reaction denotes a healthy skin, resistant to invasion and disease, while an alkaline-reacting skin surface denotes the presence of some disease state. Unfortunately it is not quite so simple. Some organisms grow readily on an acid medium. Pathogenic fungi, for example, flourish on certain media at pH 4.9. Nonetheless, in general, it is desirable to maintain the surface of the skin at least slightly on the acid side.</p> <p>Washing, even with plain water, causes moderate hydration of the horny layer, with a drop, according to Szakall ,<a></a> from pH 6.3 to pH 5.3 in 30 minutes. This information may also have some application to lower-extremity prosthetics, since the stump skin becomes soaked with sweat in most cases shortly after the prosthesis is put on. Furthermore, a single washing with soap removes about 50 percent of the surface lipid film, thereby facilitating the outward diffusion of carbon dioxide, the acid reaction of which helps to neutralize an alkaline state on the surface of the skin.</p> <h4>Surface pH and Degerming of the Skin</h4> <p>Control of surface pH is also important in degerming the skin. Blank, Coolidge, and others,<a></a> in an extensive study of the surgical scrub, have investigated many different germicidal agents and techniques of cleansing. Among the agents studied were the quaternary ammonium compounds, like Ceep-ryn and Zephiran, which are widely used in surgical cleansing of the skin. While these compounds do exert a bacteriostatic or bacteriocidal effect, Blank<i>et al.</i><a></a> found that they also have the property of binding the bacteria to the skin. It was demonstrated that, at a pH a little higher than the isoelectric point of keratin, the quaternary ammonium compounds change the normally negative charge on the surface of the skin to positive. Since the bacteria are negatively charged, they are attracted to the skin. If the pH is then increased considerably, for example by rinsing with an alkaline soap, the charge on the skin will revert to negative and the bacteria will be released from the skin, as has been confirmed experimentally by analysis and culture of the rinse water.</p> <p>Another germicidal agent commonly used in disinfecting the skin is G-ll, or hexa-chlorophene. Chemically it is 2,2'-methyl-enebis (3,4,6-trichlorophenol): [pic1]</p> <p>This compound has the double advantage of accumulating on the skin when used daily and of not being inactivated, as most germicides are, when combined with a detergent. If used only at infrequent intervals, G-ll is no more effective as a disinfectant than any nonmedi-cated soap. If used regularly, however, within five to seven days there will develop in the skin a concentration sufficient to cause a definite reduction in the bacterial flora. One contraindication to the use of this agent is the presence of a serous ooze, such as we see not infrequently on the stump in various types of eczematous skin conditions. Seastone<a></a> has reported that as little as 1.0 percent of sterile serum will reduce the bacteriostatic effect of this agent.</p> <p>Hexachlorophene is available commercially in combination with various soaps and liquid detergents, in strengths varying from 0.75 to 3.0 percent. These include such brand names as Dial soap, Gammaphen soap, pHisoHex, and Septisol. Another useful preparation of G-ll is an alcoholic solution containing 0.1 percent of G-ll, with 0.5 percent of cetyl alcohol added as an emollient. This solution may be used as a two-minute rinse following soap-and-water cleansing of the stump.</p> <p>A useful cleansing agent for stump skin has been found to be pHisoHex, especially where superficial infection is a problem. It consists of an emulsifying agent known as pHisoderm, to which 3 percent of G-ll has been added. Chemically, pHisoderm is sodium octylphenoxyethoxyethyl ether sulfonate, plus lanolin cholesterols, lactic acid, and petrolatum. Its pH is 5.5, approximately that of normal skin. It lowers the surface tension of water and is an active emulsifier.</p> <p>There are many other agents for degerming the skin, many of which are too irritating for the type of regular use necessary to routine stump care. One of the more readily available of these is alcohol, which remains a useful bacteriocidal preparation. Isopropyl alcohol, for example, is germicidal up to 50-percent dilution. Too-frequent use of such solvents, however, will dry the skin excessively and may do more harm than good. Furthermore, any marked depression of bacterial flora over the stump skin cannot be maintained for long during use of the prosthesis.</p> <h3>Selective Absorption as a Protective Barrier</h3> <p>The healthy cutaneous envelope of the body is constantly active as a physicochemical barrier against the outside world, retaining some substances and passing others through (<b>Fig. 8</b>). As early as 1904, Schwenkenbecher<a></a> showed that the intact skin is permeable to fat-soluble substances and to certain gases but is practically impermeable to water and most electrolytes. Most substances which are soluble in both water and lipids penetrate the skin and pass into the general circulation at rates comparable even to gastrointestinal or subcutaneous absorption. Phenolic compounds, lipid-soluble vitamins, and hormones penetrate rapidly. This property of the skin conceivably could be of serious import in the indiscriminate use of socket materials or finishes capable of liberating absorbable toxic fractions which could be taken up by the stump skin.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. The skin as a protective physicochemical barrier. The skin conserves in the body some substances like water and electrolytes by selectively barring their outward passage. Other substances, for example the gases carbon dioxide and oxygen, are passed freely through the skin. Lipid-soluble vitamins and hormones likewise readily penetrate the skin barrier. Unfortunately, certain materials which are potentially toxic, such as the phenolic compounds, may also be freely absorbed by the skin. Care should therefore be taken to avoid prolonged intimate contact with such materials. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In rare instances, individuals have demonstrated a peculiar sensitivity, known as an "idiosyncrasy," on first exposure to certain drugs and chemicals applied to the skin. Alexander<a></a> described a case of iododerma, a form of iodine reaction, resulting in the death of a 37-year-old woman following routine preoperative cleansing of the surface of the skin over the abdomen with iodine. This is not intended to suggest that any similar hazard exists in the use of present-day, conventional socket materials. It does, however, emphasize the fact that the skin may be, in certain rare cases, an open portal to the systemic circulation.</p> <p>Transfer of gases across the skin barrier may take place with ease in either direction. The biological significance of the movement of oxygen and carbon dioxide through the skin, which was once thought negligible, is given more importance now. Shaw and others<a></a> found that oxygen was given off through the skin when the oxygen content of the ambient air was reduced to about 2 percent and that it was absorbed more rapidly when the skin was surrounded by a gaseous mixture containing about 37 percent of oxygen than when surrounded by air. According to Chambers and Goldschmidt,<a></a> if the total skin surface is surrounded by nitrogen gas instead of air, there may be a compensatory, increased uptake of oxygen by the lungs.</p> <p>Hediger<a></a> reported that, from a water chamber containing the dissolved gas, carbon dioxide passed into the skin as long as the water contained more than 4 percent of carbon dioxide. When the concentration dropped below 4 percent, carbon dioxide diffused outward through the skin, as it does constantly under physiological conditions. Measurements cited by Rothman and Schaaf<a></a> showed that over a 24-hour period 7 to 9 grams of carbon dioxide escaped from the total skin surface, less that of the head, of an adult male. The amount suddenly increased when the temperature was raised to the critical temperature of visible sweat secretion.</p> <p>Cleansing of the skin with organic solvents such as ether, benzene, and, to a lesser degree, alcohol, enhances percutaneous absorption, that is, absorption across the skin barrier. Since such solvents are used frequently in the cleansing of the stump, as well as of the interior of the prosthetic socket, this effect upon the skin's absorption should be borne in mind. Moisture, almost constantly present in the wearing of a prosthesis, also promotes trans-epidermal absorption by an unexplained mechanism.</p> <h3>Summary</h3> <p>Through the use of improved prostheses, many amputees have been able to return to relatively normal physical activity and to take again their rightful place in business and social life. It must be remembered, however, that the use of a prosthesis places upon the leg amputee new and heavy demands, including not only muscular and emotional readjustments but also the infliction of unaccustomed wear and tear upon his stump skin. Daily, for the rest of the amputee's life, his stump will be subjected to an abnormal environment that combines heat, moisture, and darkness with chemical and mechanical irritation. It becomes imperative then, in restoring the amputee to full activity, to make certain that he understands the importance of systematic skin care. An adequate appreciation of the necessary requirements for good stump hygiene must be based on a knowledge of the functions and limitations of normal skin.</p> <p>The skin provides for the other tissues a highly effective, tough and elastic outer covering, which has a great capacity for strengthening itself at points of stress and for repairing itself after injury. But this capacity of the skin for mechanical protection, the limits of which are of special interest in prosthetics design, is only one of its many important functions. The skin possesses, in addition, a variety of anatomical structures, including the eccrine, apocrine, and sebaceous glands, the normal function of which is necessary for the preservation of good skin hygiene. The eccrine glands are indispensable in the heat control of the body. All of the glands produce secretions, some of which are exceptionally copious. This normal function poses an important sanitary problem for the amputee and makes routine cleansing of both the skin and the prosthesis essential.</p> <p>The natural defenses of the skin against germs depend upon good hygiene. Conditions inside the socket tend to impair the resistance of the skin to infection, but through adequate cleansing, frequent airing, and intelligent care of early lesions, serious infection may be avoided.</p> <p>Knowledge is increasing concerning the electrical and chemical buffering properties of the skin and their role in the maintenance of skin health. There is usually a negative charge in the superficial layers of normal skin. It is, however, discharged by injury or by prolonged soaking in water or salt solution. Similarly, normal skin is slightly acid, but in the presence of inflammation of the skin a shift to the alkaline side usually occurs. The sweat constituents contribute largely to the capacity of the skin to neutralize or buffer dilute acids and alkalies to which it is exposed. Whether or not these properties are retained intact by the stump skin of amputees and, if so, how they are affected by the conditions of use of a prosthesis are important areas for further research.</p> <p>Although the skin serves as a protective barrier, it is readily penetrated by certain substances. For this reason the stump should be protected from contact with materials potentially toxic. Similarly, the stump skin may be subject to a variety of local injuries- mechanical, chemical, or allergic in origin. Again the importance of early and close attention to minor lesions and to good preventive hygiene must be emphasized.</p> <p>There have been two chief aims in this discussion of basic principles. The first was to impart an awareness of the complex nature of the problem of stump hygiene and the second to emphasize that good stump hygiene, far from being an academic matter, is one of the utmost importance to the amputee. Like the proverbial dispatch rider whose horse was crippled for want of a horseshoe nail, the amputee may suffer discomfort and serious disability because of neglect of a seemingly insignificant lesion or failure to follow a simple cleansing routine.</p> <h3>Acknowledgments</h3> <p>A special acknowledgment is due Rothman's excellent sourcebook of dermatologic research, <i>Physiology and Biochemistry of the Skin , </i><a></a> which the author found to be a useful guide in the preparation of this article. The cartoons are the work of Tom Raubenheimer, medical illustrator at the University of California Medical Center, San Francisco.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Alexander, R. C, Fatal dermatitis following the use of iodine spirit solution, Brit. Med. J., 2:100 (1930).</li> <li>Bazett, H. C, Theory of reflex controls to explain regulation of body temperature at rest and during exercise, J. Appl. Physiol., 4:245 (1951).</li> <li>Blank, I. H., Measurement of pH of the skin surface. II. pH of the exposed surfaces of adults with no apparent skin lesions, J. Invest. Dermat., 2:75 (1939)</li> <li>Blank, I. H , and M. H. Coolidge, Degerming the cutaneous surface. I. Quaternary ammonium compounds, J. Invest. Dermat., 16:249 (1950).</li> <li>Blank, I. H., and M. H. Coolidge, Degerming the cutaneous surface. II. Hexachlorophene (G-ll), J. Invest. Dermat., 15:257 (1950).</li> <li>Blank, I. H., M. H. Coolidge, L. Soutter, and G. V. Rodkey, A study of the surgical scrub, Surg., Gyn., and Obstet., 91:577 (1950).</li> <li>Burckhardt, W., Beilrage zur Ekzemfrage. II. Die Rolle des Alkali in der Pathogenese des Ekzems speziell des Gewerbeekzems, Arch. f. Dermat. u. Syphilol., 173:155 (1935).</li> <li>Burckhardt, W., and W. Baumle, Die Beziehung der Saureempfindlichkeit zur Alkaliempfindlichkeit der Haul, Dermatologica, 102:294 (1951).</li> <li>Chambers, A. H., and S. Goldschmidt, The influence of cutaneous atmospheric oxygen absorption upon the apparent total oxygen utilization of the body, Am. J. Physiol., 129:P331 (1940).</li> <li>Dale, H. H , and W. Feldberg, The chemical trans- mission of secretory impulses to the sweat glands of the cat, J. Physiol., 82:121 (1934).</li> <li>Evans, C. A., W. M. Smith, E. A. Johnston, and E. R. Giblett, Bacterial flora of the normal human skin, J. Invest. Dermat., 15:305 (1950).</li> <li>Hediger, Stephan, Experimentelle Untersuchungen iiber die Resorption der Kohlensaure durch die Haut, Klin. Wchnschr., 7:1553 (1928).</li> <li>Keller, Phillip, Die biologishen Grundlagen fur die elektrischen Potentiate der Haul, Arch. f. Dermat. u. Syphilol, 160:136 (1930).</li> <li>Rein, Hermann, Die Elektrophysiologie der Haut, in Jadassohn's Handbuch der Haut- und Ge-schlechtskrankheiten, 1:43 (1929).</li> <li>Rothman, Stephen, Physiology and biochemistry of the skin, University of Chicago Press, Chicago, 1954.</li> <li>Rothman, S., and F. Schaaf, Chemie der Haut, in Jadassohn's Handbuch der Haut- und Ge-schlechtskrankheiten, 1:161 (1929).</li> <li>Schmid, Martin, Vergleichende Unlersungen iiber die Sdure-Basen-Verhaltnisse auf der Haul, Dermatologica, 104:367 (1951).'</li> <li>Schwenkenbecher, [A.], Das Absorptionsvermbgen der Haut, Arch. f. Anat. u. Physiol. (Physiol. Abt), p. 121 (1904).</li> <li>Seastone, C. V., Observations on the use of G-ll in the surgical scrub, Surg., Gyn., and Obstet., 84: 355 (1947).</li> <li>Shaw, L. A., A. C. Messer, and S. Weiss, Cutaneous respiration in man. I. Factors affecting the rale of carbon dioxide elimination and oxygen absorption, Am. J. Physiol., 90:107 (1929).</li> <li>Szakall, Alexander, Uber die Physiologie der obersten Hautschichten und ihre Bedeutung fur die Alka-liresislenz, Arbeitsphysiol., 11:436 (1941).</li> <li>University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952.</li> <li>Weiner, J. S., The regional distribution of sweating, J. Physiol., 104:32 (1945).</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Rothman, Stephen, Physiology and biochemistry of the skin, University of Chicago Press, Chicago, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Rothman, S., and F. Schaaf, Chemie der Haut, in Jadassohn's Handbuch der Haut- und Ge-schlechtskrankheiten, 1:161 (1929).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Hediger, Stephan, Experimentelle Untersuchungen iiber die Resorption der Kohlensaure durch die Haut, Klin. Wchnschr., 7:1553 (1928).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Chambers, A. H., and S. Goldschmidt, The influence of cutaneous atmospheric oxygen absorption upon the apparent total oxygen utilization of the body, Am. J. Physiol., 129:P331 (1940).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Shaw, L. A., A. C. Messer, and S. Weiss, Cutaneous respiration in man. I. Factors affecting the rale of carbon dioxide elimination and oxygen absorption, Am. J. Physiol., 90:107 (1929).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alexander, R. C, Fatal dermatitis following the use of iodine spirit solution, Brit. Med. J., 2:100 (1930).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Schwenkenbecher, [A.], Das Absorptionsvermbgen der Haut, Arch. f. Anat. u. Physiol. (Physiol. Abt), p. 121 (1904).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Seastone, C. V., Observations on the use of G-ll in the surgical scrub, Surg., Gyn., and Obstet., 84: 355 (1947).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Blank, I. H., M. H. Coolidge, L. Soutter, and G. V. Rodkey, A study of the surgical scrub, Surg., Gyn., and Obstet., 91:577 (1950).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Blank, I. H , and M. H. Coolidge, Degerming the cutaneous surface. I. Quaternary ammonium compounds, J. Invest. Dermat., 16:249 (1950).</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blank, I. H., and M. H. Coolidge, Degerming the cutaneous surface. II. Hexachlorophene (G-ll), J. Invest. Dermat., 15:257 (1950).</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Blank, I. H., M. H. Coolidge, L. Soutter, and G. V. Rodkey, A study of the surgical scrub, Surg., Gyn., and Obstet., 91:577 (1950).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Szakall, Alexander, Uber die Physiologie der obersten Hautschichten und ihre Bedeutung fur die Alka-liresislenz, Arbeitsphysiol., 11:436 (1941).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Schmid, Martin, Vergleichende Unlersungen iiber die Sdure-Basen-Verhaltnisse auf der Haul, Dermatologica, 104:367 (1951).'</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Blank, I. H., Measurement of pH of the skin surface. II. pH of the exposed surfaces of adults with no apparent skin lesions, J. Invest. Dermat., 2:75 (1939)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Keller, Phillip, Die biologishen Grundlagen fur die elektrischen Potentiate der Haul, Arch. f. Dermat. u. Syphilol, 160:136 (1930).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Rein, Hermann, Die Elektrophysiologie der Haut, in Jadassohn's Handbuch der Haut- und Ge-schlechtskrankheiten, 1:43 (1929).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Evans, C. A., W. M. Smith, E. A. Johnston, and E. R. Giblett, Bacterial flora of the normal human skin, J. Invest. Dermat., 15:305 (1950).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Bazett, H. C, Theory of reflex controls to explain regulation of body temperature at rest and during exercise, J. Appl. Physiol., 4:245 (1951).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Rothman, Stephen, Physiology and biochemistry of the skin, University of Chicago Press, Chicago, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Dale, H. H , and W. Feldberg, The chemical trans- mission of secretory impulses to the sweat glands of the cat, J. Physiol., 82:121 (1934).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Gilbert H. Barnes, M.D. </b></td></tr><tr><td class="clsTextSmall">Clinical Instructor in Dermatology, School of Medicine, University of California Medical Center, San Francisco, and member of the Study Group on Dermatology, Lower-Extremity Amputee Research Project, University of California, Berkeley and San Francisco. Based on a lecture presented before the University of California Pilot School in Lower-Extremity Prosthetics, August 25, 1955, at the U.S. Naval Hospital, Oakland, California.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1956_01_004/spring56-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1956_01_004/spring56-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1956_01_004/spring56-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1956_01_004/spring56-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1956_01_004/spring56-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1956_01_004/spring56-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1956_01_004/spring56-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1956_01_004/spring56-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1956_01_004/spring56-10.jpg Figure 10 http://www.oandplibrary.org/al/images/1956_01_004/spring56-09.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Skin Health and Stump Hygiene Creator An entity primarily responsible for making the resource Gilbert H. Barnes, M.D. * https://staging.drfop.org/files/original/2579b493cff96641963df1959617da9c.pdf 7a040dc0c6d8940381d830ff94df216c https://staging.drfop.org/files/original/9b5a594f58f0c51923251fd92a135602.jpg 57b06d3b863d2d96e319e45c7e311ec2 https://staging.drfop.org/files/original/b27d9746413c7245b9c9d57b6c78296c.jpg c3f708f42d9205528c3d92eaa69c5f8d https://staging.drfop.org/files/original/489333ee5663a0918fc1188cd04de355.jpg 6246ddbb7c073c52f3680d9cc2e692d5 https://staging.drfop.org/files/original/0f1a2c0ffe09ce58f56c671508caf8d0.jpg 9ace1443273e65a96546085fac38ccff https://staging.drfop.org/files/original/b757babe164755ddc45d09d746d12a25.jpg bb43beeaee57a9d23d027255cfe57a90 https://staging.drfop.org/files/original/28098c9ae09a1b29b5e2746fbf9dae57.jpg 146ed72dacbc879d115802dfe7b040ec https://staging.drfop.org/files/original/101b4a63eb00b02f48dd5cceb047df08.jpg a8b81c922b4a290b5521ca6debc85bc1 https://staging.drfop.org/files/original/72a60b523a40a4d235c1d18c8b9b7261.jpg c8c5932ddfd82c4f9b5bb9c021a4057c https://staging.drfop.org/files/original/dca53dfdadc820d9695f082cef6c3cc6.jpg 6844b1ba2d83cec4968a44656a93d8c4 https://staging.drfop.org/files/original/4a2c27c0bdc553dc08831ffd607191a8.jpg 28ad5e1095f6eea7da754bc99dddcfd2 https://staging.drfop.org/files/original/895503c909a9093928949c6025df2493.jpg b6dcdac7b597f6d539a04096e67f49a8 https://staging.drfop.org/files/original/ce093d59e2f69e93fb1e12645cdaa70c.jpg 4d30dc7c5aaece3d4f6ec528523d2cc3 https://staging.drfop.org/files/original/85aef58e9738f2b66ee033e80c6a23e1.jpg 8d5b678b30f6204ae837a9fe4db7cd24 https://staging.drfop.org/files/original/03c3b38192c1044ec4565bd3d585f5d9.jpg a1b1b398e8264b9b4130b912c592a94d DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1956_01_020.pdf Year 1956 Volume 3 Issue 1 Page Number(s) 20 - 35 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1956_01_020.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1956_01_020.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Skin Problems of the Lower-Extremity Amputee</h2> <h5>S. William Levy, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Since the establishment, in the autumn of 1954, of the skin-study group of the Lower-Extremity Amputee Research Project at the University of California, other physicians within the Project have referred to us for observation and treatment those amputees having cutaneous problems associated with the wearing of a prosthesis. Out of this nidus, specific information regarding the various clinical problems has been assembled and correlated in an effort to benefit the individual amputee. Some of the clinical problems have aroused interest in basic dermatologic research, so that investigation has not been of a purely clinical nature.</p> <p>The cutaneous difficulties associated with the wearing of a leg prosthesis have been evaluated in more than 200 patient-visits, and every effort has been made to classify cutaneous disorders specifically. Approximately the same number of above- and below-knee amputees have been carefully screened and examined. Complete histories have been taken, and physical examinations of the skin have been performed. Skin biopsies have been obtained in many instances, and histopathologic sections have been examined carefully in an effort to determine the course of a specific disorder.</p> <p>Other laboratory aids, such as skin scrapings for fungi or patch tests for contact dermatitis, have been utilized. Stump hygiene is important in relation to many clinical disorders of the skin, and accordingly a specific hygienic program for the care of the stump is being developed.</p> <p>Skin lesions, however minute they may appear, are nevertheless of great importance since they may be the beginning of an extensive cutaneous disorder that may be mentally, socially, and economically disastrous to a given individual. It is best to view any minor irritation as a potentially dangerous symptom and to deal with it as early as possible. Once the skin problem has begun, it should not be ignored in the hope that it will heal of its own accord. Nothing can be more frustrating to the lower-extremity amputee than to be told to remain off his prosthesis or to go on crutches because he has neglected a minor skin eruption.</p> <p>This article is devoted to the common skin problems and danger signals associated with the wearing of a lower-extremity prosthesis. Most of our experience has been gained with the above-knee amputee using the suction-socket suspension, but it is believed that the same or similar problems arise in patients using the more conventional types of suspension.</p> <h4>Stump Hygiene</h4> <p>Hygienic measures are of the utmost importance in the daily care of amputation stumps and in the use of prostheses. A neglect of cleanliness can easily result in damage to the skin and thus open the door to a number of cutaneous disorders which can require temporary removal of the prosthesis. There is no unanimity of opinion on exactly what measures should be employed routinely. Amputees have come to us with many varied and weird ideas. Some have used strong soaps and alkalies on their stumps, some alcohol, and others formaldehyde. These hygienic measures have been handed down from one person to another and frequently without reason or logical explanation. Some patients fail to wash either the stump or the socket, thereby giving rise to maceration and malodor.</p> <p>A simple hygienic program using a sudsing detergent has in many instances prevented or eliminated a cutaneous disorder, and hence we frequently request an amputee to follow a given routine. He is advised against the use of any preparation which would leave a deposit in the socket or any solvent which might affect the interior finish. A simple procedure for cleaning the socket is to wash the inner surface with a lukewarm, soapy cloth or one containing a detergent, remove the soapy residue with a clean wet cloth, and then dry out the socket with a towel. The prosthesis should not be put on for several minutes so that it may have an opportunity to dry completely.</p> <p>For the stumps of most individuals, a bland soap or liquid detergent provides a good cleansing without irritating the skin. Soaps or detergents containing hexachlorophene provide a bacteriostatic action, in addition to cleansing, and may aid in reducing the danger of infection. An amputee is frequently advised to purchase a plastic squeeze bottle of pHisoHex,® an item available in every drugstore, relatively inexpensive, and to be had without a prescription. He is instructed to spread over the amputation stump a small amount of this antibacterial sudsing detergent containing hexachlorophene. A little water is added and the material worked into a lather. More and more water is added to increase the amount of sudsing. He is told to avoid washing off the suds until ready for thorough rinsing. When well cleansed, the site is then rinsed off with lukewarm water, and the stump is dried by patting rather than by vigorous rubbing. This simple routine should be followed nightly, or every other night, depending upon the rate of perspiration, the degree of malodor, and the bathing habits of the individual. In the treatment of some persistent eczemas of the stump, this simple hygienic program was found to be curative.</p> <h4>Clinical Problems</h4> <p>Some amputees go along for months or years without difficulty or irritation of the stump skin. In others, the skin is a weak tissue, and frequent difficulties arise. Persons concerned with amputees should be aware of certain pathologic conditions-certain danger signals-which are frequently the forerunners of seriously incapacitating cutaneous disorders. Early recognition and treatment of these conditions can avert much mental anguish and loss of social or economic activity. It should be remembered that, once on a prosthesis, the amputee desires to stay on, and it is of vital concern to the physician and prosthetist to prevent any disorder which may return him to crutches or bed rest. What, then, are some of these danger signals?</p> <h4>Stump Edema Syndrome</h4> <p>When an amputee first starts wearing a suction-socket prosthesis, he can expect to see edema or swelling and reddish-brown pigmentation, roughening, and drying of the skin of the terminal portion of the stump (<b>Fig. 1</b>). These changes are the almost inevitable result of the altered conditions forced upon the skin and subcutaneous tissues. They are relatively innocent, do not usually require therapy, and are partially prevented by gradually compressing the stump tissues with an elastic bandage prior to use of the prosthesis. An incorrectly fitted socket may predispose a leg amputee to this disorder.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Stump edema syndrome. <i>A, </i>In a 33-year-old male above-knee amputee wearing a suction-socket prosthesis. Note the swelling of the <i>end </i>of the stump, with pigmentation and hemorrhage into the skin. <i>B, </i>Enlarged view of <i>A. </i>showing hemorrhagic nodules with superficial erosion. <i>C, </i>In a 38-year-old male above-knee ampulee wearing a suction-socket prosthesis, with swelling and hemorrhagic plaque. No erosion or ulceration has occurred. <i>D, </i>Same patient as in C, showing socket-rim pigmentation and irritation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In several of our patients the edema has been massive, and distal pigmentation has followed, with the formation of hemorrhagic papules and nodules. Superficial erosion of the skin in these regions is not uncommon, and, in rare instances, deep ulcers can result from the poor cutaneous nutrition (<b>Fig. 2</b>). Multiple biopsies have been taken in order to determine the pathogenesis of this disorder. Special staining of the sections revealed that the pigmentary changes were due to the blood pigment, hemosiderin, within the tissue (<b>Fig. 3</b>). The collagen of the dermis was thickened by newly formed fibrous connective tissue, and there was an abnormal proliferation and dilatation of blood vessels. It may be that this kind of disorder is vascular in origin and that a venous and lymphatic congestion is productive of the edema and hemorrhage. It is hoped that the basic pathogenesis will be clarified as more patients with this syndrome are studied.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Chronic ischemic ulcer, in a 43-year-okl male below-knee amputee. Poor prosthetic fit with venous obstruction was productive of this lesion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Pigmentation following stump edema syndrome. <i>A, </i>Brown pigmentation of the skin of the distal portion of the stump. <i>B, </i>Microscopic section of A, showing a marked increase in the thickness of the epidermis, with sclerosis of collagen and infiltration of pigment-laden cells. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Edematous portions of the skin of the distal part of the stump may become pinched and strangulated within the socket (<b>Fig. 4</b>). Such areas may ulcerate or become gangrenous owing to impaired blood supply.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Strangulated skin. Unusual view, showing the distal stump skin resting on the foam-rubber cushion, as seen through the valve opening of a suction-socket prosthesis. A portion of the skin has become partially strangulated, resulting in stasis, edema, and pain. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Contact Dermatitis</h4> <p>Contact dermatitis (<b>Fig. 5</b>) is caused by contact of the skin with a chemical that acts either as a primary irritant or as a specific allergic sensitizer. As defined by Schwartz,<a></a> "A Primary Cutaneous Irritant is an agent which will cause dermatitis by direct action on the normal skin at the site of contact if it is permitted to act in sufficient intensity or quantity for a sufficient length of time." Again using Schwartz' definition <a></a>, "A Cutaneous Sensitizer is an agent which does not necessarily cause demonstrable cutaneous changes on first contact but may effect such specific changes in the skin that, after five to seven days or more, further contact on the same or other parts of the body will cause dermatitis." Contact dermatitis may be acute, subacute, or chronic, and moderately severe to severe itching is present in most forms. In the acute and subacute types, diffuse erythema, edema, oozing, and crusting predominate. In addition, vesicles are often present if a specific allergic sensitizer is the cause. In chronic forms, erythema, scaling, and lichenification (thickening) prevail.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Contact dermatitis. <i>A, </i>Chronic, of the distal stump skin, due to contact with a plastic-covered cushion on the bottom of a suction socket. Removal of the cushion provided complete clearing in one week. Patch tests were positive for allergic sensitivity to the plastic <i>B, </i>Of the distal stum]) skin, due to contact with a foam-rubber pad on the bottom of a prosthetic socket. Note the circular zone of erythema and edema. Rapid clearing and disappearance of itching followed removal of the pad C, Left, the foam-rubber pad removed from the socket of the patient in <i>B; </i>right, the small piece of the material (4 mm in diameter) used in patch-testing <i>D, </i>Skin of the upper arm of the same patient as in <i>B, </i>showing a positive reaction to foam rubber. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>We have seen a number of patients with contact dermatitis of the amputation stump. In order to understand the problem, we have had to learn about the plastics and resins used in the external and internal finishes of the different types of prostheses. In some instances, we found only by carefully taken history that the use of a new cream, lubricant, or cleansing agent coincided with the onset of the dermatitis. Some amputees use a foam-rubber cushion, others a plastic-covered pad on the bottom of their socket. These are also capable of producing a contact dermatitis of the skin weeks, months, or even years after use (<b>Fig. 5</b>, <i>A </i>and <i>B).</i></p> <p>On patients exhibiting the clinical manifestations of contact dermatitis, every attempt has been made to determine the exact contactant. Patch tests (<b>Fig. 5</b>, <i>C </i>and <i>D) </i>have been most informative with respect to specific substances as the cause of the dermatitis. In diagnostic patch-testing, a small amount of the suspected substance is applied to a site of normal skin on the patient. It is covered with an innocuous, impermeable material such as cellophane, which is then sealed to the skin by adhesive plaster. It is usually sufficient to leave the patch on for 24 to 48 hours. Upon removal of the patch, a positive reaction is signified by erythema, vesiculation, or blister formation at the site of application.</p> <p>Because patch-testing with strong concentrations of known primary irritants will result in reactions on any skin, solutions of such substances are first diluted according to published lists<a></a> in order to prevent a false positive reaction and possible injury to the skin. A generalized eruption following the patch test indicates a high degree of sensitivity, but fortunately such eruptions are rare. Experience and good clinical judgment are necessary in choosing the correct chemical concentration of the irritant and the proper time for performing the patch test.</p> <p>The sockets of leg prostheses are commonly finished on the inside by the application of a varnish or lacquer and on the outside by coating with plastics and resins. These complex organic substances are capable of causing a contact dermatitis in a given individual who has become sensitized. This sensitization is similar to that produced by poison oak or poison ivy, and the intensity of reaction may vary under different conditions of heat, humidity, and friction. The epoxy resins,<a></a> if incompletely cured in their manufacture, may, in addition to being a specific allergic sensitizer, produce a primary-irritant dermatitis. These resins are frequently used to improve the appearance of a socket and to render it impervious to external agents. In the uncured state at room temperature they are viscous, amber-colored liquids. Curing agents, known as catalysts or hardeners, are added to solidify the plastic material. These agents are organic amines of various types and, when left in excess by incomplete baking or curing at high temperatures, are able to produce a primary-irritant dermatitis.</p> <p>We have had several patients with proven contact dermatitis to Ambroid,® C-8 epoxy resin, polyethylene, foam-rubber pads, and plastic-covered cushions. Removal of the suspicious contactant resulted in a cure, and subsequent patch-testing proved the diagnosis.</p> <p>In those instances of contact dermatitis where the irritant has not been obvious and the patch tests have been inconclusive, temporary therapy has alleviated the symptoms. Cool compresses, bland antipruritic lotions, and the topical use of hydrocortisone or fluorohydro-cortisone preparations have been most beneficial.</p> <h4>Post-Traumatic Epidermoid Cysts</h4> <p>Young, <a></a> in 1951, described the appearance of multiple cysts in the skin of an amputee's thigh in association with the wearing of an artificial limb. Other authors<a></a> have described similar nodules in the skin under the rim of the socket. In the typical case (<b>Fig. 6</b>), the cysts do not appear until the patient has worn an artificial limb for months or possibly years. They occur most frequently in above-knee amputees in the areas covered by the upper medial margin of the prosthesis but have also been described in below-knee amputees.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Post-traumatic epidermoid cysts. <i>A, </i>Early phase, in a Negro patient. Tiny follicular keratin plugs have developed in the skin of the adductor region. Some have enlarged to form tender nodules. <i>B, </i>Slightly later phase, in a 15-year-old white female. <i>C, </i>Still later phase, in the adductor region of a white male, where the nodules are larger and have become firm, tender, and cystic. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Characteristically, in the above-knee amputee small follicular keratin plugs develop in the skin of the adductor region of the thigh along the upper edge of the prosthesis. In the beginning they appear as small lumps or nodules and will, at times, disappear when the prosthesis is removed temporarily. Under the constant friction and pressure of the prosthesis, they become larger and more numerous. Some become pea-sized, round, or oval swellings deep within the skin. Gradually, with enlargement, they become sensitive and tender to the touch. The skin may break down and erode or ulcerate. With continued irritation by the prosthesis, the nodular swelling may suddenly burst and discharge an opaque, purulent fluid. The discharging sinus may become chronic and thus make it impossible for the patient to use his prosthesis. In other instances, the break may take place within the deeper portion of the skin, and subcutaneous intercommunicating sinuses may develop.</p> <p>The larger nodules become especially tender and necessitate removal of the prosthesis. These should not be confused with ordinary furuncles or boils (<b>Fig. 7</b>), which may occur on any portion of the stump. Surgical excision of the chronic, isolated, noninfected nodule may give relief, but no completely satisfactory method of treatment is known. In the acutely infected phase, hot compresses and antibiotics are indicated. As the process localizes, incision and drainage may be beneficial temporarily. <i>Micrococcus pyogenes (Staphylococcus aureus) </i>is frequently a secondary bacterial invader and at times resistant to many antibacterial agents. In some of the cystic lesions, the contained fluid is sterile.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Furuncle, or boil. Subsiding, on the distal stump skin of a below-knee amputee. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The cysts range in size from microscopic papules to large nodules that can be palpated with the fingers. The microscopic picture, therefore, is variable, depending upon the size of the lesion and the extent of secondary irritation or infection. In the earliest phase, a keratin plug is seen to form. Later this plug invaginates the epidermis, and pockets of keratin appear in the subepidermal region of the skin. The invaginated epidermis containing keratin may be superficial or deep within the corium. As the keratin cyst enlarges and becomes secondarily infected, acute, subacute, and chronic inflammatory cells are seen. Foreign-body giant cells and newly formed capillaries and fibroblasts are not uncommon about the disintegrating cyst wall.</p> <p>Many authors have written extensively on the cause of these so-called "prosthetic nodules and abscesses," so frequently the concern of the physician, the limbfitter, and the amputee. Their occurrence is not restricted to wearers of the suction-socket prosthesis, since amputees complained of these inflamed swellings long before the suction socket came into widespread use. In the first third of this century, German investigators<a></a> ascribed the lesions to foreign bodies and wrote of finding "chamois-leather" particles, fine hairs, talc, and amorphous substances in the giant cells of the fully developed cyst. Other writers <i>{2,3,15) </i>disputed these foreign bodies as the cause and attributed the formation of the nodules to pressure and irritation from the socket and to epidermal keratin forced inward by this pressure. Some present-day investigators<a></a> regard the cysts as sebaceous adenomata and speak of sebaceous adenitis as being of frequent occurrence in the adductor region of the thigh stump. These and similar lesions have also been described in the hands and fingers following trauma.<a></a></p> <p>Although our studies have been limited, and although we are only now beginning to see these nodules in various stages of development, it appears that the condition is one in which the surface keratin and epidermis becomes invaginated, acting as a "foreign body." Under the influence of friction and pressure from the prosthesis, the keratin plug and its underlying epidermis are displaced into the corium. The result is the production of nonspecific inflammatory tissue and implanted epidermoid cysts. These can remain quiescent for a long period of time or can, with secondary bacterial invasion, become abscessed and produce the characteristic clinical and pathologic picture previously described.</p> <p>Recurrent and secondarily infected nodules may require the attention of a dermatologist or a surgeon. Some lesions necessitate incision and drainage. For others, total excision of the cyst under local anesthesia is the treatment of choice. These methods, however, do not solve the entire problem and may only succeed in alleviating an acute phase. The chronic problem can, in some instances, be mitigated or successfully eliminated by proper fit and alignment of the prosthesis.</p> <p>At the present time we are attempting the clinical trial of topical agents in an effort to prevent or retard the formation of the keratin plug, which may be the precursor of the epidermoid cyst. We are endeavoring to develop a stump sock or adductor rim sock for use with the suction-socket prosthesis to prevent cyst formation, but to date this effort has been of an experimental nature only. In our experience, there is no completely satisfactory method of treatment, and each amputee with the problem offers a therapeutic challenge.</p> <h4>Folliculitis and Furuncles</h4> <p>Folliculitis, usually caused by staphylococci, is a superficial bacterial infection of the hair follicle in which the primary lesion is an inflammatory papule or pustule. In contrast, a furuncle (<b>Fig. 7</b>) is a larger, more deep-seated, painful, bacterial infection of the pilosebaceous apparatus and is invariably caused by a staphylococcus or a streptococcus. Whereas folliculitis typically consists of multiple, small. itching, red papules, the furuncle, or "boil," is usually a tender, deep-red nodule which eventually rises to the surface of the skin and discharges its necrotic core.</p> <p>Folliculitis is a commonly encountered problem in the amputee, particularly in dark-complexioned, hairy persons with an oily skin. The condition is aggravated by the use of an artificial leg (<b>Fig. 8</b>). It is usually worse in summer, when increased warmth and moisture from perspiration promotes maceration of the skin, which, in turn, favors invasion of the hair follicle by bacteria. Ordinarily this process is not serious, but sometimes it progresses to boil formation, cellulitis, or an eczem-atous, weeping and crusted, superficial pyoderma.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Skin changes acompanying the early use of prosthesis <i>A. B, </i>and <i>C </i>show the skin of the same below-knee amputee. .1, Normal stump skin before the prosthesis was worn. <i>B, </i>Reactive hyperemia with itching and tingling, shortly after the prosthesis was used for the first time. Compare the flush with the normal skin color, which returns under pressure by the glass slide <i>C. </i>Small areas of folliculitis on the skin, which began to develop after wearing of the prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Folliculitis and boils may follow upon poor hygiene of the stump or the socket or both. In several patients, chronic recurrent folliculitis was essentially cured by having the amputee adhere to the routine hygienic program using pHisoHex.® The hexachlorophene in this product is a hundred times more effective than is soap in eliminating skin bacteria, and that circumstance possibly accounts for the effectiveness of this program. In other instances, therapy may require the use of wet dressings, the incision and drainage of boils after localization, the oral or parenteral use of antibacterial substances, and the application of local bactericides, but we do not subscribe to the use of epilating doses of roentgen-ray therapy, which has been reported by Heller.<a></a> Since these conditions of the stump are frequently chronic or recurring, it is best to choose relatively nonsensitizing substances for topical application.</p> <h4>Additional Cutaneous Problems</h4> <p><i>Fungous Infections</i></p> <p>Superficial fungous infections of the stump may be difficult to eradicate completely because of continued moisture, warmth, and maceration of the skin within the enclosed socket of the artificial leg. Tinea corporis<a></a> , or ringworm of the nonhairy portions of the skin, is characterized by oval to round, scaly, erythematous, itching lesions, usually appearing only on the part of the stump enclosed by the socket. The diagnosis is confirmed by microscopic demonstration of the fungal filaments in scales or vesicles removed from a lesion. Therapy consists of the application of fungistatic creams and powders over an extended period.</p> <p><i>Nonspecific Eczematization</i></p> <p>Nonspecific eczematization of the stump skin has been seen in a number of instances (<b>Fig. 9</b> and <b>Fig. 10</b>). Here the amputee presents a weeping, itching, nonhealing plaque of dermatitis over the distal portion of the stump. The lesion is dry and scaly and then suddenly becomes moist without reason. It waxes and wanes over a period of months to years and may be a major source of mental anxiety.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Erosion and eczematization ot the stump skin from poor prosthetic fit and alignment. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Nonspecific eczematization. <i>A, </i>Of three months' duration on the stump skin of a 32-year-old above-knee amputee who presented unusually poor stump cleanliness. <i>B, </i>Enlarged view of <i>A, </i>showing erythema, edema, and vesiculation. After a simple hygienic program with a sudsing detergent containing hexachlorophene, the eczematous process disappeared completely. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>We have tried to find the cause through either history, physical examination, or laboratory tests, or through studying the clinical course of the eczematous process. At times we have been able to elicit a significant history of recurrent allergic eczema or to demonstrate active eczematous lesions on other portions of the body to account for the eruption on the stump. In other instances, the eczema was secondary to edema and congestion of the terminal portion of the stump, so that only with the alleviation of these problems did the condition clear. Drug sensitivities from the internal use of an agent such as penicillin may present themselves on the amputation stump. Ideally, whenever possible, the cause of the eczema should be found and removed. Temporary symptomatic treatment with topical hydrocortisone or fluorohydrocortisone preparations is effective, but the condition will frequently recur unless the cause is eliminated.</p> <p><i>Generalized Disorders</i></p> <p>The localization of other skin disorders on the amputee's stump is not an uncommon occurrence. We have seen patients with acne vulgaris of the face and back develop acne lesions of the stump. We have seen similar localizations in patients with seborrheic dermatitis, folliculitis, and eczema. There are recorded instances of psoriasis and lichen planus developing on the stump skin with few lesions present elsewhere on the body <i>{9). </i>Here again, it is important to diagnose the generalized cutaneous disorder and to treat it der-matologically in order to improve the stump condition.</p> <p><i>Intertriginous Dermatitis</i></p> <p>An intertriginous dermatitis is an irritative condition of those skin surfaces which are in constant apposition and between which there is a hypersecretion and a retention of sweat. This situation usually occurs in the crotch (<b>Fig. 11</b>), but on occasion it occurs in the folds at the end of the stump where two regions of skin rub each other and where the protective layer of keratin is removed by the friction. A chronic disorder may develop, with deep, painful fissures and with infection and eczematization. Hygienic measures to cleanse the apposing folds and the use of drying powders are beneficial. At times, it may be necessary to re-excise the bulky, infolded stump skin in an effort to provide a linear scar which would preclude this form of disorder.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Skin irritation in the crotch area. <i>A, </i>Chronic, resulting from continued friction and pressure from the socket. <i>B, </i>Enlarged view of <i>A</i>, showing thickened (lichenified) and pigmented skin containing the early phase of post-traumatic epidermoid cysts. The skin of this area may become eroded or ulcerated. In some instances, these problems may be corrected by proper prosthetic fit and alignment. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Adherent Scars</i></p> <p>With repeated infection and ulceration of the skin, the scar may become adherent to the underlying subcutaneous tissues (<b>Fig. 12</b>), a condition which invites further erosion and ulceration. Long wear and tear from the use of a prosthesis may necessitate surgical revision in order to free the scar in the bound area.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Scar tissue of several years' duration on the distal stump skin. Through repeated years of wear and tear from using a prosthesis, the skin has become adherent to the underlying tissue. Such abnormalities are capable of causing repeated infection, erosion, and ulceration. This below-knee amputee .was treated by surgical revision of the scarred area. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Chronic Ulcers</i></p> <p>Chronic ulcers (<b>Fig. 2</b>) of the stump may result from bacterial infection or from poor cutaneous nutrition secondary to an underlying vascular disorder. In every instance, the underlying cause should be investigated and appropriate treatment provided. Malignant ulcers have developed within old, persistent stump ulcerations, and hence every effort should be made to diagnose the condition before it becomes chronic.</p> <p><i>Tumors</i></p> <p>Tumors of the stump may be malignant or benign. We have seen innocent hyperkeratosis, or callus formation, and have removed verru-cae, or viral warts, from the stump skin. Simple "skin tags," or cutaneous papillomas, are easily removed dermatologically under local anesthesia. A cutaneous horn (<b>Fig. 13</b>) on an amputation stump has been recorded<a></a>, and we have removed one from a below-knee amputee wearing a conventional prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Cutaneous horn of several years' duration in a below-knee amputee. Local excision of the lesion was curative. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Extensive verrucous hyperplasia (<b>Fig. 14</b>) of the entire terminal stump skin has been seen in one instance. A surgical biopsy failed to reveal the pathologic picture of viral verrucae. This hyperplastic condition was felt to be secondary to an underlying vascular disorder, bacterial infection, and poor prosthetic fit and alignment. Treatment to date has consisted of adequate control of the bacterial process and gradual end-bearing maneuvers to improve the vascular stasis. A new prosthesis is being manufactured to correct the fit and alignment. Here is an example of the need for the services of the entire clinic team to provide the maximum benefit to the individual amputee.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Verrucous hyperplasia of the distal stump skin. <i>A, </i>Distal view, showing the warty nature of the skin. This hyperplastic condition was felt to be secondary to an underlying vascular disorder, bacterial infection, and poor prosthetic fit and alignment. <i>B, </i>Microscopic section of a warty nodule in <i>A. </i>Note the hyperplasia of the epidermis, with sclerosis of the collagen and chronic inflammation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Malignant tumors of the stump skin have been recorded by others, but we have not as yet encountered any primary cancers in our series of patients.</p> <h4>Summary</h4> <p>The cutaneous problems of the lower-extremity amputee are many and varied. They are real problems, which can begin insidiously without creating additional disability and then, through neglect and mistreatment, seriously threaten the social and economic rehabilitation of the amputee. A variety of skin disorders are found to localize on the skin of the lower-extremity stump because of the many new insults to which it is subjected when a prosthesis is worn. These disorders may require dermatologic consultation for either diagnosis or treatment.</p> <p>In the past year, the cutaneous difficulties associated with the wearing of a leg prosthesis have been evaluated during more than 200 patient-visits to the Lower-Extremity Amputee Research Project at the University of California Medical Center in San Francisco. Hygiene is important in relation to many skin disorders of the stump, and consequently a specific hygienic program is being developed, The danger signals and the clinical problems which have been found to require medical attention include the stump edema syndrome, contact dermatitis, post-traumatic epidermoid cysts, folliculitis and furuncles, superficial fungous infections, nonspecific eczematization, intertriginous dermatitis, chronic ulcers, and tumors of the stump.</p> <p>The skin-study group is a comparatively recent addition to the Lower-Extremity Amputee Research Project of the University of California. It is hoped that, through this study group, the varied cutaneous disorders associated with the lower-extremity amputee will, over a period of time, be fully classified and thereby be prevented.</p> <h4>Acknowledgments</h4> <p>The author is indebted to Mrs. Ellen Brennan for her coverage of the literature and to Mr. Leo Sakovich for his help with the photographs. Sincere appreciation is expressed to these laboratory technicians and to the other personnel of the University of California Medical Center in San Francisco for their aid in the completion of this paper.</p> <p><b>References:</b></p> <ol> <li>Conn, H. R., <i>Amputation stumps of lower ex- tremities: the causes and treatment of prolonged disability, </i>Surg., Gyn., &amp; Obstet., 43:524 (1926).</li> <li>Gillis, Leon, <i>Amputations, </i>William Heinemann Medical Books, Ltd., London, 1954.</li> <li>Gillis, Leon, <i>Infected traumatic epidermoid cysts, the result of rubbing by an artificial limb, </i>Proc. Roy. Soc. Med., 47:9 (1954).</li> <li>Heller, W., <i>Zur Behandlung von Furunkeln und Follikuliliden, am Amputationsstumpf, </i>Deutsche med. Wchnschr., 69:812 (1943).</li> <li>King, E. S. J., <i>Post-traumatic epidermoid cysts of hands and fingers, </i>Brit. J. Surg., 21:29 (1933).</li> <li>Makai, Endre, <i>Lipogranulomatosis subcutanea am A mputationssliimpfe (Prolhesenrandknoten)</i>, Zent-ralbl. f. Chir., 57:590 (1930).</li> <li>Mayne, F. E., and L. O'Shaughnessy, <i>Cutaneous horn on an amputation stump, </i>Brit. Med. J., 1: 624 (1931).</li> <li>Savitt, Leonard E., <i>Contact dermatitis encountered in the production of epoxy resins, </i>A. M. A. Arch. Dermat. &amp; Syphilol., 71:212 (1955).</li> <li>Schamberg, I. L., <i>Dermatitis of lower limb amputa- tion slump, </i>J. Am. Med. Assoc, 150:1653 (1952).</li> <li>Schwartz, Louis, <i>Allergic occupational dermatitis in our war industries, </i>Ann. Allergy, 2:387 (1944).</li> <li>Schwartz, L., L. Tulipan, and S. M. Peck, <i>Occupa- tional diseases of the skin, </i>2nd ed., Lea &amp; Febiger, Philadelphia, 1947.</li> <li>Slocum, Donald B., <i>An atlas of amputations,</i> Mosby, St. Louis, 1949. pp. 254-288.</li> <li>Thomas, A., and C. C. Haddan, <i>Amputation prosthesis, </i>Lippincott, Philadelphia, 1945. pp. 54-67.</li> <li>Wohlvill, Fr., <i>Über "Prothesenrandknoten," </i>Virchows Arch. f. path, Anat.. 288:576 (1933).</li> <li>Young, Freida, <i>Post-traumatic epidermoid cysts,</i> Lancet, 1:716 (1951).</li> <li>zur Verth, [M.], <i>Prothesenrandknoten und Pro- thesenrandabszesse, </i>Zentralbl. f. Chir., 63:322 (1926).</li> <li>zur Verth, [M.], <i>Prothesenrandknoten und ihre Entstehung, </i>Dermat. Wchnschr., 88:45 (1929).</li> <li>zur Verth, M., and K. H. Vohwinkel, <i>Prothesen- randknoten, </i>Deutsche Ztschr. f. Chir., 205:302 (1927).</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Mayne, F. E., and L. O'Shaughnessy, Cutaneous horn on an amputation stump, Brit. Med. J., 1: 624 (1931).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Schamberg, I. L., Dermatitis of lower limb amputa- tion slump, J. Am. Med. Assoc, 150:1653 (1952).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Heller, W., Zur Behandlung von Furunkeln und Follikuliliden, am Amputationsstumpf, Deutsche med. Wchnschr., 69:812 (1943).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Conn, H. R., Amputation stumps of lower ex- tremities: the causes and treatment of prolonged disability, Surg., Gyn., &amp;Obstet., 43:524 (1926).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">King, E. S. J., Post-traumatic epidermoid cysts of hands and fingers, Brit. J. Surg., 21:29 (1933).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Slocum, Donald B., An atlas of amputations, Mosby, St. Louis, 1949. pp. 254-288.</td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Thomas, A., and C. C. Haddan, Amputation prosthesis, Lippincott, Philadelphia, 1945. pp. 54-67.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Makai, Endre, Lipogranulomatosis subcutanea am A mputationssliimpfe (Prolhesenrandknoten), Zent-ralbl. f. Chir., 57:590 (1930).</td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Wohlvill, Fr., Über 'Prothesenrandknoten,' Virchows Arch. f. path, Anat.. 288:576 (1933).</td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">zur Verth, [M.], Prothesenrandknoten und Pro- thesenrandabszesse, Zentralbl. f. Chir., 63:322 (1926).</td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">zur Verth, [M.], Prothesenrandknoten und ihre Entstehung, Dermat. Wchnschr., 88:45 (1929).</td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">zur Verth, M., and K. H. Vohwinkel, Prothesen- randknoten, Deutsche Ztschr. f. Chir., 205:302 (1927).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Gillis, Leon, Amputations, William Heinemann Medical Books, Ltd., London, 1954.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Gillis, Leon, Infected traumatic epidermoid cysts, the result of rubbing by an artificial limb, Proc. Roy. Soc. Med., 47:9 (1954).</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Makai, Endre, Lipogranulomatosis subcutanea am A mputationssliimpfe (Prolhesenrandknoten), Zent-ralbl. f. Chir., 57:590 (1930).</td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Thomas, A., and C. C. Haddan, Amputation prosthesis, Lippincott, Philadelphia, 1945. pp. 54-67.</td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Wohlvill, Fr., Über 'Prothesenrandknoten,' Virchows Arch. f. path, Anat.. 288:576 (1933).</td></tr><tr><td class="clsTextSmall"><b> 16.</b> </td><td class="clsTextSmall">zur Verth, [M.], Prothesenrandknoten und Pro- thesenrandabszesse, Zentralbl. f. Chir., 63:322 (1926).</td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">zur Verth, [M.], Prothesenrandknoten und ihre Entstehung, Dermat. Wchnschr., 88:45 (1929).</td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">zur Verth, M., and K. H. Vohwinkel, Prothesen- randknoten, Deutsche Ztschr. f. Chir., 205:302 (1927).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Young, Freida, Post-traumatic epidermoid cysts, Lancet, 1:716 (1951).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Savitt, Leonard E., Contact dermatitis encountered in the production of epoxy resins, A. M. A. Arch. Dermat. &amp;Syphilol., 71:212 (1955).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Schwartz, L., L. Tulipan, and S. M. Peck, Occupa- tional diseases of the skin, 2nd ed., Lea &amp;Febiger, Philadelphia, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Schwartz, Louis, Allergic occupational dermatitis in our war industries, Ann. Allergy, 2:387 (1944).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Schwartz, Louis, Allergic occupational dermatitis in our war industries, Ann. Allergy, 2:387 (1944).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>S. William Levy, M.D. </b></td></tr><tr><td class="clsTextSmall">Clinical Instructor in Dermatology, School of Medicine, University of California Medical Center, San Francisco, and supervisor of the Study Group on Dermatology, Lower-Extremity Amputee Research Project, University of California, Berkeley and San Francisco.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b001.jpg Figure 2 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b002.jpg Figure 3 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b003.jpg Figure 4 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b004.jpg Figure 5 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b005.jpg Figure 6 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b006.jpg Figure 7 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b007.jpg Figure 8 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b008.jpg Figure 9 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b009.jpg Figure 10 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b010.jpg Figure 11 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b011.jpg Figure 12 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b012.jpg Figure 13 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b013.jpg Figure 14 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b014.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Skin Problems of the Lower-Extremity Amputee Creator An entity primarily responsible for making the resource S. William Levy, M.D. * https://staging.drfop.org/files/original/2af5e4a68353a2eed24a09786fdea090.pdf 90e8b0a379e8b9a8e9201fa5eefad784 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1956_02_001.pdf Year 1956 Volume 3 Issue 2 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1956_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1956_02_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Artificial Limbs - Their Human Owners</h2> <h5>David Shakow, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>In all areas of medicine and engineering where psychological factors are important, consideration of matters of the mind comes late. Physical problems are so obvious, urgent, and definable-mental problems so frequently cryptic, postponable, and unclear. But it usually develops that, soon after some control has been achieved over the immediate physical problems, the psychological problems obtrude themselves and call persistently for solution. Thus, in the field of amputations and artificial limbs, the primary effort has to date been directed quite naturally toward the achievement of physical restoration of function. Proportionately little thought has been directed toward the understanding and handling of the psychological problems which, in the amputee, the markedly altered adjustment situation creates. Although mechanics and the biomechanics of the amputee have many important identical principles, there is a whole area of needed activity of a quite different order.</p> <p>The psychological problems of the amputee are, of course, not merely problems of the physically disabled person himself. The new situations that are created with loss of limb are clearly social-psychological in character-situations where not only the manifold attitudes of the patient, both implicit and explicit, toward the loss and the replacement are important but also where the attitudes of family and associates toward him and his difficulty are equally significant. Hence, any full psychological study of the problem of physical handicap must involve three aspects: the attitudes of the disabled person toward the changes created in him by his new situation, as it affects his previous concepts of himself and the image he has of his body; the attitudes of others, especially significant others, toward his differentness; and, finally, the interaction of these two in the social context in which it occurs.</p> <p>In a recent evaluation of studies in this general area, Roger Barker and associates deplore the inadequacy and rarity of satisfactory investigations. Whatever the importance of adjustment problems, not only in the amputee but in all persons suffering a misfortune, it is only when problems become prominent and when social obligations are keenly felt that there appears a readiness to pay attention to what appear on the surface to be secondary aspects of problems. Just such a situation arose during World War II, when disabled veterans were returning from the battlefields in great numbers but when, although much thought was being given to physical rehabilitation, little had been done to face the problems associated with psychological readjustment.</p> <p>In response to this need, there was established at Stanford University on February 1, 1945, a study group to inquire into the social-emotional relationships between injured and noninjured people. Conducted partially under contract between Stanford and the wartime Office of Scientific Research and Development (recommended by the Committee on Medical Research), partially under a contract between the University and the Army Medical Research and Development Board of the Office of the Surgeon General, War Department, the work continued until April 1, 1948. By far the majority of the handicapped subjects studied were amputees.</p> <p>Despite the technical significance of the final report of the project, only a few mimeographed copies were distributed. It is only now-more than eight years later-that the results are seeing the light of print. Because it recognizes the basic nature of the contribution and its significance in the presentation of important problems in the psychology of handicap, the Prosthetics Research Board of the National Academy of Sciences-National Research Council has seen fit to devote an entire issue of ARTIFICIAL LIMBS to the reproduction of a single, exceptional monograph otherwise long since obscure and inaccessible. From one point of view, the departure reflects a considerable advance in the field of limb prosthetics-an acceptance of the importance of psychics as well as of the long-recognized importance of mechanics. For this major step forward, the Prosthetics Research Board merits the thanks of all.</p> <p>With regard to the unusual content of the monograph itself, a few remarks are in order. Barker and associates point out, for example, that physically deviant persons appear not to be a homogeneous group psychologically and that "so far as the somatopsychological relation is concerned there is no direct univocal link between physique and behavior." They state further that "lawful somatopsychological relations between physique and behavior are mediated by the psychological situation " These affirmations are especially pertinent to the report we are here studying. Indeed, the present material should properly be viewed in the context of these generalizations about the field as a whole. Although many questions are raised, and although many "I-wish-they-had's" remain unfulfilled, it is important to recognize the pioneering character of the study, the complexity of the field, and the reasons for the absence of more objective data and for the limited statistical treatment of the material. We should be grateful for the broad attack on the area, the commonsenseness and humanness of the molar approach used, its consistent emphasis on the total person, and the attempt to tackle the problems broadly in the context of a general theory of loss and maladjustment.</p> <p>We should perhaps not pass by the opportunity of calling attention to a few additional topics of especial interest that are dealt with in the monograph. For one thing, there is the emphasis on the emotional aspects of physical handicap rather than on the intellectual and the attempt to deal systematically with such difficult, though apparently commonplace, topics as misfortune and sympathy, seen from both the standpoint of the stricken person and of the outsider.</p> <p>There is, too, an important discussion on some of the methodological problems, particularly the place of measurement and the interview as a tool, in the present status of psychological study in the field. The presentation is made more effective by the liberal quotations from interviews and the inclusion of records of actual interviews in the appendices.</p> <p>The authors would, to be sure, be the last persons to claim any definitiveness for their study. Its major contribution lies in opening up questions and delineating areas clamoring for further psychological investigation both by more precise methods and with greater intensity. The authors' own attitudes in this respect may be gathered from the fact that they conclude the body of the monograph with a chapter headed Direction of Further Research.</p> <p>It is to be hoped that the recognition given at this time by the Prosthetics Research Board to this area of study will be the stimulus that the field needs for the multiplication of studies on this important aspect of the adjustment of the disabled person and of the noninjured people with whom he comes in contact.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>David Shakow, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Laboratory of Psychology, National Institute of Mental Health, National Institutes of Health, Bethesda, Md.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Artificial Limbs - Their Human Owners Creator An entity primarily responsible for making the resource David Shakow, Ph.D. * https://staging.drfop.org/files/original/181a62dbeea14fc8cb1883736bd6f417.pdf 090f8bf2b70b72c4c5b835bebc2ed0d7 https://staging.drfop.org/files/original/63ac87e98d222a1677b6e3631411fbe9.jpg 99dbf6e84f6a51a868181896f9e1847e https://staging.drfop.org/files/original/f51d49a6caadcd9ae0527929c1b793b2.jpg a5661d7829f929030e7b25e4be6e54ab https://staging.drfop.org/files/original/a9262bba31c61cb78e9c241a50d1da89.jpg 1bb3115c8ee83f1deee20edaf6dd73aa DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1956_02_004.pdf Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1956_02_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1956_02_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Adjustment to Misfortune-A Problem of Social-Psychological Rehabilitation</h2> <h5>Tamara Dembo, Ph.D., <a style="text-decoration:none;">*</a><br />Gloria Ladieu Leviton, Ph.D., <a style="text-decoration:none;">*</a><br />Beatrice A. Wright, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <blockquote><p><b>Dedicated to the memory of Kurt Lewin</b></p> </blockquote> <p>At particular times in the history of science, particular problems become ripe for investigation. A precipitating event brings them to the attention of a single person and sometimes to that of several at the same time. It is therefore understandable that during World War II the need was felt to investigate the problems of social psychological rehabilitation of the physically handicapped and that someone should look for a place and the means to set up a research project that would try to solve some of these problems. In pursuit of such a goal a research group was established at Stanford University on February 1, 1945. Conducted partially under a contract between Stanford University and the wartime Office of Scientific Research and Development (recommended by the Committee on Medical Research), partially under a contract between the University and the Army Medical Research and Development Board of the Office of the Surgeon General, War Department, the work continued until April 1, 1948. </p> <p> To investigate the personal and social problems of the physically handicapped, two groups of subjects were needed—people who were considered handicapped and people around them. Therefore, as subjects of the research both visibly injured and noninjured people were used. Interviews were employed as the primary method of investigation, the great majority of the 177 injured persons interviewed being servicemen or veterans of World War II. More than half the subjects had suffered amputations and almost one fourth facial disfigurements. The injured man was asked questions designed to elicit his expectations, experiences, and feelings in his dealings with people around him. Sixty five noninjured people also were interviewed in regard to their feelings toward the injured man. </p> <p> A first task in the research project was to determine the meaning of the relationship between the injured and the noninjured. Was it primarily that of the helper and the helped, of the curious onlooker and the one who is looked upon, of the independent and dependent person, the one who rejects and the one who is rejected, the person who pities and the one who is pitied? All these relationships exist between the injured and the noninjured. Some of them were described during the first period of the research program.<a></a> As the research proceeded, it was seen that one particular relationship between the injured and the noninjured was more "basic" than others—basic in the sense that it underlies and determines the character of other relationships. This underlying relationship is the one which exists when a person who regards himself as fortunate regards another as unfortunate. We learned that to understand this relationship one has to see "being unfortunate" as a value loss and, furthermore, that the adjustment of this relationship involves the problem of acceptance of loss—a case of value change. </p> <p> In current psychology, the problem of acceptance of loss is hardly investigated. Loss is usually seen as an end point of unsuccessful, goal directed behavior (failure) or else it is investigated in terms of the effect of failure on further goal directed behavior (such as on setting the next "level of aspiration"). But it is important to know what loss means to the person himself, how it affects the opinions and behavior of others toward him, and what acceptance of loss implies. Too often life is seen as a series of goal directed acts, whereas the <i>consumption of gains </i>and the <i>acceptance </i>(or nonacceptance) of losses which result from those acts are disregarded. </p> <p> Almost all people are at some time faced with the necessity of adjusting to loss. In investigating the problems of injured people, therefore, we are dealing not only with special problems of a special group but with problems important to all. If we state that the injured need psychological rehabilitation or adjustment, this in no way implies that they are not "normal." The impact of loss which they experience produces suffering and difficulties. The overcoming of psychological suffering, whether or not it threatens mental illness, is a problem of adjustment. </p> <p> This monograph is written as a scientific paper and no attempts at popularization are made. Popularization of our findings is a special task—a task which, if skillfully done, would indeed be useful for the information and education of the general public. Those who are not specially concerned with methodological and theoretical considerations may still find the less technical chapters (Chapters V through VII) of interest. The first four chapters and the last one will be of greater interest to the theoretical psychologist. </p> <p> Part I introduces the general field of social emotional relationships. It deals with our approach and viewpoints regarding problems, data, theory, and measurement. We tried to examine the appropriateness of scientific beliefs and attitudes for the new area investigated. Part II deals with the investigation of the visibly injured, a group which, in our culture, is frequently considered unfortunate. Chapter IV presents the procedures used and their rationale. Chapter V discusses devaluation, by the noninjured, of the injured as people who have experienced a misfortune a value loss. Chapter VI is concerned with the reactions of the noninjured to the suffering aspect of misfortune rather than to its value loss aspect. The structure or nature of the genuine, positive feelings of sympathy is outlined. Chapter VII deals with the problem of overcoming suffering through acceptance of loss. In Chapter VIII we attempt to point out the direction which future research may take. The appendices include sample interviews with injured and noninjured subjects and a brief summary of methods other than interviews that were tried out in our study.<a style="text-decoration:none;">*</a> </p> <p> Three years in a new and relatively unexplored field has to be considered a pilot period. After exploration the field is seen to be fruitful, both for the growth of ideas on the specific topics and also for the development of more general theoretical problems in psychology. But only a beginning has been made, and the material here presented is therefore properly viewed only in the light of its pioneer character. </p> <p> Many of our findings may from the theoretical standpoint be seen as more precise statements of problems awaiting further investigation. From the practical standpoint, the study may be useful to those who critically examine the findings, not with the orientation of translating them into rules of behavior but so that their understanding of the problems involved in loss may be broadened. The injured, we hope, will find this type of investigation promising in its attempts to lead people to feel that it is not the AMPUTATED LIMB and John Doe but John Doe, the person, who really exists. </p> <h3>Part I: Methodological and Theoretical Considerations Concerning Social Emotional Relationships </h3> <h4> Chapter I: Some Characteristics of Social Emotional Relationships </h4> <p> We shall present a list of pairs of words designating social emotional relationships. We ask you, the reader, to think about the feelings connoted. Specific points to consider may be seen in the first example, the idea of "abandonment." How does the abandoner feel? How does the abandoned feel? How do they feel toward each other? How do you, as a person not involved in the interaction, evaluate abandonment? As you proceed down the list, you should ask yourself these and any other questions you think of which bring out the emotional meanings of the interaction concerned. We ask you to work hard because in so doing we think that you will see the problems of the psychology of emotions in a very different way from the orientation given them traditionally. You will see this field not only as unexplored but also as full of psychological resources available to those who are ready to dig. Here is the list: </p> <ul> <li>To abandon — to be abandoned. </li> <li>To abhor — to be abhorred. </li> <li>To feel that someone is able — to feel that another considers you able.</li> <li>To consider someone abnormal — to be considered abnormal. </li> <li>To be abrupt — to be exposed to abruptness</li> <li>To consider someone absurd — to be considered absurd. </li> <li>To abuse — to be abused</li> <li>To accept another person — to be accepted. </li> <li>To feel in accord with someone — to feel that another person is in accord with you.</li> <li>To accuse — to be accused. </li> <li>To become accustomed to someone — to have someone become accustomed to you.</li> <li>To consider someone as an acquaintance — to be considered an acquaintance. </li> <li>To acquit someone — to be acquitted. </li> <li>To act in a given way, without actually feeling that way — to feel that someone is just acting. </li> <li>To adapt yourself to someone — to feel that another person is adapting himself to you. </li> <li>To help someone become adjusted — to have someone try to adjust you. </li> <li> To admire — to be admired. </li> <li> To admit to someone — to get an admission. </li> <li> To adopt — to be adopted. </li> <li> To adore — to be adored. </li> <li> To advise — to be advised. </li> <li> To feel affable — to feel that another person is affable. </li> <li> To give affection — to get affection. </li> <li> To affront — to be affronted. </li> <li> To be against someone — to feel that another person is against you. </li> <li> To aggravate someone — to be aggravated by someone. </li> <li> To be aggressive toward someone — to feel that another person is aggressive toward you. </li> <li> To agree with someone — to feel that another person agrees with you. </li> <li> To aid someone — to be aided. </li> <li> To alarm someone — to be alarmed by someone. </li> <li> To give an alibi — to get an alibi. </li> <li> To consider someone an alien — to be considered an alien. </li> <li> To allow someone — to do something to be allowed. </li> </ul> <p> Only a few of the diverse emotions or feelings are mentioned above. They were selected from the first 20 pages of <i>The Pocket Oxford Dictionary </i>(New York, 1927), which has 1010 pages. The list might have impressed you with the tremendous number of unexplored problems in the area of emotions. You might have wanted to take stock of the actual concern shown them in textbooks and courses and in current research in the field of emotions. The psychological structure and the functions of the majority of emotional relationships are unknown. Yet these problems practically do not exist as topics of systematic investigation. At the 1947 meeting of the American Psychological Association, only four of some 200 papers fell under the program headed <i>Emotions. </i>The program on <i>Emotions </i>was sponsored by the Division of Physiological and Comparative Psychology. </p> <p> We do not wish to imply that emotional problems are completely disregarded by psychologists. The psychology of personality, social psychology, and abnormal psychology <i>do </i>take them into account, but within these divisions other problems, particularly problems of needs and goal directed behavior, have been in the center of attention. </p> <h4>Evaluation by the Outsider </h4> <p> When you were asked to evaluate the emotional relationships given in the list, you may have felt uncomfortable because of a vague feeling indoctrinated into all of us that in science one should be nonevaluative. Whether a psychologist should or can be nonevaluative is not our present topic. Rather, we are concerned with emotional relationships which are considered by people at large, with or without the permission of the scientist, as desirable or undesirable, good or bad. It is simply an undeniable psychological phenomenon that evaluations are made, and as phenomena they cannot be disregarded. In fact, these evaluations, as shall be seen, are important for the understanding of the dynamics of emotional interpersonal relationships and the problem of adjustment of these relationships. </p> <p> If one considers the relationships in the list, it is noticed that, even though no specification is given of the conditions under which they exist, some of them connote undesirable feelings and states, others more desirable ones. Examples which fall into the negatively evaluated group are "to abuse," "to abhor," "to accuse," "to affront." Examples which fall into the positively evaluated group are "to accommodate," "to admire," "to allow." There are others which seem less definitely to belong to the negative or positive group. For example, "to get accustomed," "to admit." Such abstract evaluations are not made specifically in terms of the meaning of the relationship to either of the partners. They are given by a person who psychologically takes the position of an outsider. </p> <p> Evaluations of outsiders very often show a high level of agreement, as is easily demonstrated by a simple experiment. The list of words can be presented rapidly to a group of subjects who are asked to evaluate the relationship as positive or negative from the standpoint of an outsider to the relationship. In only a few instances will there be disagreement, and these disagreements will be due largely to what amounts to a violation of the instructions: for instance, the subject may "take sides" with one of the partners, or the subject may base his reply on the circumstances of particular situations. </p> <p> Evaluations of outsiders might be considered standards of cultural judgment. It may be the high agreement in the evaluations of outsiders which make them appear to have the role of common cultural standards. It might be interesting to investigate whether some of them are not, in fact, intercultural. The common cultural standards play a not unimportant role in the life of human beings. For example, they strongly determine reputations and the jury's verdict of life or death. </p> <h4>Evaluations by Donor and Recipient </h4> <p> In any relationship, the person who bestows the emotion may be called the "donor," and the person upon whom the emotion is bestowed may be called the "recipient." The difference in the meaning of the relationship for the donor and the recipient is frequently very great. To give an appreciation of this difference, the list was arranged in pairs. You were asked to feel the way the donor in the relationship might feel and the way the recipient might feel. "To abuse or to be abused, to accept or to be accepted" are emotionally far apart. Sometimes both donor and recipient will evaluate a given relationship in the same way. But since the meaning which the relationship has for one partner is not the same as that given to it by the other, their evaluations often differ, and this difference may produce difficulties in the relationship. Help, for example, is almost always seen as positive for the recipient as judged by the donor, but as judged by the recipient it often has both positive and negative aspects. It is important for adjustment of relationships to know the conditions under which the donor and the recipient give the same evaluations and, when they do not, to find ways of producing a change which will lead to agreement in evaluation. </p> <p> The donor and recipient not infrequently attempt to overcome the difficulties resulting from their different evaluations by urging each other to "be objective." But objectivity, in the sense of assuming the position of an outsider and giving abstract evaluations, is not what is really desired. What each <i>really </i>wants is that the partner should "understand" him, <i>i.e., </i>should understand the meanings the relationship has for him. He wants the other to take his (the first's) position and from this standpoint to think, evaluate, and act. </p> <h4>Scope of Meanings and Structure of Relationship </h4> <p> It is seen from the list that a great variety of social emotional relationships exist and that each is characterized not merely by pleasantness or unpleasantness but by a diversity of qualitative connotations. It might be agreed, for example, that one feels lost and hurt when abandoned or that one may feel free and at the same time guilty when abandoning someone. It may also be agreed that one will feel aversion for, and a desire to escape from, one abhorred and that one would feel rejected and resentful if a person abhorred him. Each connotation will be referred to as a "meaning" of an emotional relationship. The diverse, sometimes apparently contradictory meanings which an emotional relationship can have for different people under different circumstances build the "scope of meanings of a social emotional relationship." </p> <p> As an illustration, we present some of the meanings which "being helped" has for the injured: it means that a goal is made accessible; it means that another person is courteous and polite; it means that the injured person is in a position of lower status; it means dependence, burden, etc.<a></a>. We assume that these meanings are not merely a congeries of separate entities attached to the same word. Instead, we believe analysis will show that many of them hang together, that they may be integrated within one or more coherent structures.<a style="text-decoration:none;">*</a> When the structure of a relationship has been determined, it is sometimes found that some of the meanings which subjects give to the word do not belong to the relationship in question but to a different one. For instance, in the case of the sympathy relationship, the structure of which is described in Chapter VI (page 27), some of the subjects gave meanings which belong to the relationship of "pity," a relationship which has a different structure. </p> <p> The determination of the scope of meanings seems to us an essential problem because it is the first step toward determining structures of relationships. The structure is a better description of the social emotional relationship than is the scope of meanings. Even before the development of the structure of a relationship, however, the determination of the scope of meanings has practical value. It permits realization of possibly disturbing connotations and encourages precautions and safeguards against them. </p> <h4> Chapter II: Qualitative versus Quantitative Approaches in a New Field </h4> <p> In a new field, the formulation of meaningful problems is a task in itself—a task which often takes much time and effort. It is easy within an hour or two to state a hundred questions, in a few days to state many more. Yet only a few of these will prove to be fruitful. The selection of problems which are scientifically promising is an extensive qualitative research job. </p> <p> Essential questions are those which promise to become an integral part of an interrelated group of problems and to lead to the development of corresponding systems of concepts. In a new field neither the problems nor the systems are known. They have to be discovered by giving a "qualifying examination" to the problems and preconcepts which occur to us, since these include both promising and unpromising ones.<a style="text-decoration:none;">*</a> The qualifying examination consists of a test which shows whether a particular problem and preconcept with other "candidates" promise to form an interdependent team. When they not only develop but also add to the development of the emerging system, they acquire the position of fruitful essential problems and preconcepts. </p> <p> Consider an example of a problem which does not seem promising, in the sense that it is likely to remain an isolated problem. It is noted that some of the items in the list connote what may more frequently be called feelings <i>(e.g., </i>"to abhor," "admire," "adore"). Others have the character of emotional acts <i>(e.g., </i>"to accuse," "advise," "acquiesce," "admit"). Still others reflect social distance <i>(e.g., </i>"to consider someone an acquaintance or an alien"). These categorizations seem, however, not to lead to further understanding. They simply fix the different relationships into more or less neat cubbyholes, which are, as far as we can see at the present time, blind alleys. In this example, categories rather than preconcepts are relied upon to "order" the facts. Only an orderly catalog instead of a system of interrelated dynamic concepts can be built up in such a way. </p> <p> An example of a problem which we consider promising is the determination of value structures held by those people who are undergoing difficulties and by those who have overcome these difficulties. This, we believe, is one of the first steps in conceptualizing adjustive change (Chapters V, VII, VIII). </p> <p> Another example of what might be considered promising for future investigation relates to the "mutual" relationship. When discussing the relationships in the previous chapter, all of our examples were of "onesided relationships." Each involved one donor and one recipient. But partners may abuse each other, accept each other, or admire each other. Each may be in the position of donor and recipient at the same time. Mutual and one sided relationships are not merely convenient methods of classification. They bring into focus a number of questions important dynamically. </p> <p> It frequently happens that when a one sided relationship is unpleasant for the recipient, he will try to change it to a mutual one. For example, if he is being abused he may begin to abuse the other. What effect does this change produce? The question will be sharpened if we consider the following hypothetical statement: </p> <p> <i>R_p^rd </i>= <i>R_p^r </i>+ <i>R_P^d,</i> </p> <p> where <i>R_p </i>indicates the person <i>p</i>'s relationships, and <i>d </i>and <i>r </i>indicate the donor and recipient positions, respectively. In this statement, <i>p's </i>mutual relationship is a simple summation of his relationships as donor and recipient. Can this actually be the case? Are the <i>meanings </i>for <i>p </i>in the mutual relationships <i>(R_p^rd) </i>equal to the sum of meanings which the one sided relationship has for him when he is only a recipient <i>(R_p^r) </i>plus the meanings it has for him when he is a donor <i>(R_p^d)? </i>This question is important, for if the addition of the new meanings of the donor relationship does not change the old meanings of the recipient relationship, then the addition will not diminish the previously existing conflicts or difficulties.<a style="text-decoration:none;">*</a>Actually, the "adding" of new meanings may not be an addition at all but rather a re structurization of the first one sided relationship <i>(i.e., </i>a change in some of the meanings which the relationship originally had for the person). In the latter case we would have to study the type of change produced by the restructurization and the circumstances under which the change is adjustive. </p> <p> At different stages of research, the "candidate problems" must be subjected to further test. For a time they might drop out from the "team," and then later their participation may again become fruitful. Within this process they may change their character and gain a new role. </p> <p> The "candidate problems" are thoughts of the investigator, fed by qualitative observations and checked by them. For this type of work, an armchair and a pencil are more appropriate than a straight chair and a calculating machine. It might require self control on the part of the investigator to go on with conceptualization and qualitative analysis of data when he is constantly lured by more easily quantifiable, nonsystematic, isolated problems. </p> <h4>The Position of Measurement in Psychological Research </h4> <p> The attitude, "Investigate what you can measure," is not infrequently found in psychological research practice. But there is such a thing as primitive quantification. Quantification of data on systematically unimportant questions is primitive. And there is also such a thing as premature quantification. That quantification which is done before the laborious task of qualitative description of problems and concepts is sufficiently advanced is premature.<a style="text-decoration:none;">*</a></p> <p>The determination of statistically significant differences between two sets of data does not ensure that these data are important either practically or for further theoretical advance. Instead of regarding the statistical fact as an observation which needs anchoring in an explanatory system before its import can be judged, all too frequently such observations, by sheer virtue of their statistical nature, are held up as contributions in themselves. We do not declare that measurement should not be done without a well developed theoretical framework. But we do assert that such measurement often produces statistically significant differences on inessential details. And we further assert that where problems well grounded in theory have not as yet been formulated, data analyzed qualitatively may contribute far more to the understanding of important problems. </p> <p>Where there is a well defined theoretical system, however, measurement has a very important and different position. Measurement in this case, as we see it, means measurement of conceptually defined constructs and the determination of interrelationships among those constructs. Preliminary to such measurements, one has to determine whether the constructs used permit metrization or whether nonmetrical mathematical (topological) statements should be made. The particular problems involved in this type of mathematical determination in psychology were first realized by Kurt Lewin<a></a> in regard to problems of goal directed behavior. Such mathematical determination will have to be made in the field of emotions as in any other field, though it may take years before it is possible. In the meantime, sound investigation, systematic in nature, will have to be primarily qualitative.</p> <p>There also may be considerable practical value in qualitative investigation before quantification is possible. The knowledge of <i>what </i>affects a given social emotional relationship, even if we are unable to indicate the strength of that factor, is of value. For example, we may not be able to state the extent to which sympathy reminds an injured person of the negative implications of his injury. The fact that sympathy <i>may </i>remind, however, immediately calls for caution in conveying compassion to the injured.</p> <h4>Concerning Frequency Counts </h4> <p>At any stage in theoretical development, one may tally the number of times a given observation occurs in the sample studied. But the meaning of such frequencies needs to be examined. The sheer number of occurrences does not indicate the relative importance of the event. We do not consider more important the fact that a person dealt honestly with us ten times than that he once cheated us. Nor can we say, without further proof, that there is a one to one relation between the strength of a factor and the frequency of its occurrence. </p> <p> One function of frequency counts is to permit a more accurate prediction of the number of occurrences of like events in like populations. This function, however, is often limited by failure to define the research population in terms of systematically important factors. </p> <h4>Some Problems of Sampling </h4> <p> To "select" a population for research in a new field which lacks systematization is harmless but also meaningless and therefore to be rejected as impractical. The traditional parameters of age, IQ, socioeconomic status, and geographic location should not be thought of as automatic principles of selection. Their usefulness for the particular research has to be determined in each case. It may be, for example, that in research on the injured it would be more appropriate to define the sample in terms of preinjury attitudes toward the handicapped, relative evaluation of beauty and physical prowess as compared with other personality characteristics, and sensitivity to status position. A group which is homogeneous with regard to some arbitrarily selected factors will actually be heterogeneous with regard to those factors which prove to be of systematic importance. </p> <p> Heterogeneity is, however, not a disadvantage. In an unstructured, new field, where the first task is to determine fruitful problems and the concepts to be used in their solution, the danger lies in overlooking diversities which should be taken into account. Heterogeneous groups which yield a wide range of differences in behavior are therefore welcomed. To narrow down the range of subjects is permissible only for a good reason. This reason has to be specified. In the beginning stages of our research on the social emotional relationships between visibly injured and noninjured persons, it was legitimate to include a variety of subjects. To have limited the investigation to, say, leg amputation cases, for the sole reason that in the interests of homogeneity the type of disability should be uniform, would have been groundless. </p> <p> In later stages of research, the original sample might legitimately be narrowed down or enlarged, depending on the particular problem being pursued. For example, we have indications that a person's status values affect his attitudes toward such social emotional interactions as sympathy, help, curiosity, and so on. This suggested systematic relationship could be tested by narrowing down the sample so that but two groups would be included, one strongly status minded and the other not, according to certain criteria. Whether the expected differences are to be found could then be determined. As an example where an even more heterogeneous sample than the original one is indicated, we can present again an instance from our research. The understanding of problems of loss became clearer to us when the concept of misfortune was introduced. In light of this theoretical orientation, it undoubtedly would be fruitful for further research to enlarge the sample to include, in addition to the injured, other persons regarded as being in an unfortunate situation. In short, throughout research, the sample taken for study should be determined by the requirements of the problem being studied and not by applying sampling procedures which are either extraneous to the purpose of the research or else actually interfere with it. </p> <h4> Chapter III: The Interview as a Tool for Investigating Emotional Contents </h4> <p> The interview as an experimental tool is in disrepute with many present day investigators. Some investigators will go as far as to withdraw the honorable title of "real scientific endeavor" from a study which uses "just interviews" because interviews do not deal with how the person "actually behaves." In this chapter we shall examine the validity of this argument. </p> <h4>Reflection Units and Interaction Units </h4> <p> Consider this example: A young girl gets an invitation to a ball. She is full of anticipation perhaps she will be the belle. Perhaps a certain young man will dance often with her. She decides what gown she will wear and how to arrange her hair. She plans imaginary conversations with gallant partners. But she is anxious too. Maybe she will be a wallflower; maybe the young man will not even notice her. Finally, after a succession of alternating moods, the ball arrives. The social interaction which has occasioned so much thought and feeling actually takes place. </p> <p> If, in the investigation of social emotional relationships, only interaction units were studied, a large part of the course of events would be neglected. Periods of reflection which include planning, expectations, evaluations, struggle with one's feelings and moods, would be excluded from study. Similarly, if in the investigation of personal emotional events only action units were studied, periods of reflection would be overlooked. The interactions or actions themselves might not be fully understood without the consideration of reflection units. </p> <p> The high status position of interaction data as compared with the data of reflection units seems in part to be based upon a vague feeling that only interactions are "real facts." But the types of reflection units enumerated above are all <i>real in the sense that they exist as psychological phenomena. </i>Even if reflection units had a segregated existence and did not influence interaction units, they would still have to be studied as real psychological phenomena within the life of the person. The reflections themselves may produce pain and consequently require adjustment; for instance, a man with a scarred face believed that "no woman in her right mind could possibly accept me now." </p> <p> Is it meaningful to ask whether interaction units are <i>scientifically more real </i>than reflection units? The frequently stated criterion of scientific reality, "What is real is what has effects," concerns not observable facts but the reality of descriptive, explanatory concepts. The reality of the effects is not under discussion in the criterion; nothing is implied about them but their virtue of being available for observation. Scientifically, reflection units and interaction units are both legitimate observable facts. It is true that in the case of reflection units the content must be communicated to the interviewer. But this mediation should be no more disturbing than that of other instruments. The criterion cited does not specify that the observable facts must be observed directly.<a style="text-decoration:none;">*</a> </p> <p> What conclusions can be drawn as to the relative merits of the two types of units for study? Both interactions and reflections are real phenomena and legitimate observable facts; psychological difficulties requiring adjustment may exist in either case. They differ in that interactions can be observed directly, whereas the content of reflections must be communicated to the investigator by the subject. For an investigator, the difference between them is simply one of kind and not of value. </p> <h4> Interviews Versus Behavior Observations </h4> <p> We submit that the richness of emotional life can be more fully realized through the use of the interview than through observation of behavior. It is true that we can infer something about underlying emotions from behavioral observations, but the understanding gained in this way is usually more limited. If we could have observed the girl smiling over the invitation, taking from her wardrobe first one gown and then another, being absent minded about her everyday tasks, and so on, we might have been able to infer something about her feelings. But the complexity of her feelings, the content of her hopes and fears, remains largely unappreciated. On the other hand, for particular problems observation of behavior would be required, for example in order to study the effects of reflections on behavior, such as how fear of failure affects performance, or whether verbal attitudes correspond to behavior.<a style="text-decoration:none;">*</a> Only when a particular problem is specified may one method be judged better or worse than another. </p> <h4> Validity of Interviews Versus Validity of Behavior Observations </h4> <p> It is frequently stated that the subject willfully or otherwise does not tell the interviewer what he actually feels. But one cannot claim superiority for behavioral observations on these grounds. Hiding emotional contents is not limited to interviews. One can cover up one's real feelings with actions just as easily as with words. One can smile when he is sad just as easily as he can say he is well when he feels bad. Friendly acts may be due to bad intentions. They may be performed to cover up the real feelings behind them. One covers up if there is a <i>need </i>for it. </p> <p> The need to hide during an interview, it might be argued, may frequently be less strong than in interaction units. It might be considered whether hiding of feelings from a person with whom they are connected is not frequently more necessary than when discussing or reflecting about these feelings with a third person. It is likely that feelings of guilt or shame will be less strong in regard to statements than to acts. Especially if the third person takes a nonjudgmental position or the position of an ally will the true feelings as far as they are recognized by the subject be expressed more openly than in interaction units. Of course the need to hide particular emotions will exist during interviews, but the interaction units cannot be turned to as the better ones in this respect. </p> <h4> Knowledge of the Subject About His Own Emotions </h4> <p> Interviews are sometimes held in disrepute on grounds that people do not know their own feelings. Has not depth psychology taught that people fool themselves? Does not the subject need first to be analyzed and to be an experienced psychiatrist or to have special training in psychological matters in order to be able to make pertinent statements? Fortunately, people do not learn to cognize feelings in college only. Much of what one feels when someone nags him, for example, or helps him, or when he is jealous, can be perceived without special psychological training.<a style="text-decoration:none;">*</a> If the objection is raised that the conscious meanings which feelings have for the subject are less important and more superficial than those of which he is not aware, we would say that such a statement is premature. Explicit criteria of importance have first to be given. </p> <p> If important feelings are those which affect a person's behavior, we say that those consciously given share the same honors as the hidden. And if it is asserted that unconscious feelings are more important because they explain <i>more </i>of a person's behavior, one is called upon to compare counts. This has never been done, nor does it make sense to do so. For immediately the question arises as to what weights to assign to the individual behavior units. Are they more important because they are resisted? Then what is the rationale for considering the resisted more important? We suspect that all too often the hidden is identified with the important by sheer virtue of the fact of its covertness. Clearly missing is a link which must be supplied before such an evaluation can have scientific merit. </p> <p> As far as we can see, it is scientifically meaningless to argue about the importance or superficiality of perceived meanings of feelings before the criteria of such judgments are made clear. One criterion does exist. If important problems are those which are essential in the sense discussed on page 8, <i>i.e., </i>problems which attempt to relate observable facts to systems of concepts, then there is nothing which leads us to exclude feelings as perceived by the subject as "candidates." Criticisms regarding essentiality of problems are applicable to overt and covert meanings alike. </p> <h4> Feeling Level Versus Intellectual Level of Discussion </h4> <p> Emotional topics can be discussed with almost anyone who is willing to participate in an interview. The discussion, however, may take place on an intellectual level or on a feeling level. One can "just talk about" feelings, in an abstract, impersonal way (intellectual level), or one can analyze one's feelings in terms of the particular intimate meanings they have for the individual (feeling level). Psychotherapy, whether directive or non directive, strives for such a feeling analysis by the patient. It has been commonly recognized that, in order for feeling analysis to take place, the person must have a need to examine his feelings, and he must expect the interviewer to be tactful, understanding, trustworthy, etc. In the study of the meanings which social emotional relations have for the donor and for the recipient, however, a further important condition must be realized. To approach such meanings on the feeling level, the subject must <i>actually feel </i>the position of a partner in the relationship. He must feel something of the hurt involved in being stared at, for example; or in the case of the donor position, something of the curiosity. It is more advantageous to select subjects who in actual life are donors or recipients in the relationship investigated. Otherwise the subject tends to discuss on the intellectual level or evaluate as an outsider, and in neither case can he convey the emotional impact which the relationship has for a partner. </p> <h4>Analysis of Data in the Area of Emotions </h4> <p> The principles which guided us in choosing methods of collecting data apply no less to its handling after it has been gathered. The whole flavor of the emotional meanings which one was at such pains to obtain can be lost if the approach to the data is unwisely rigid. The investigator is forced to perceive and to feel emotional relationships from the point of view of the donor and recipient before he can understand the meanings and evaluations ascribed to them. Not being involved in the particular relationship, the investigator has to find equivalent relationships in his own experience. Frequently in our research we had to feel through relationships from our own personal histories in order to be able emotionally to understand the subject's comments. Though the occasion at which sympathy, for instance, was given to us differed from the occasion leading to sympathy relationships in our subjects, the tool of self analysis was useful. There is an obvious danger of analyzing superficially similar relationships instead of equivalent ones. Self analysis, therefore, should be used for the purpose of getting "hunches" which can be applied to the data obtained from the subjects. Such an approach leads to aspects of data which an investigator, viewing the data as an outsider, will overlook or misinterpret. </p> <p> There is nothing unscientific about being a subject and an investigator at the same time. In perception psychology, for example, the investigator frequently takes this double role. He can perceive and then cognize what he is perceiving. In the area of emotional problems, the investigator should try to feel the emotional situations being studied and then to examine what he is feeling. Physical, physiological, and psychological laws which hold for the object of the investigation hold for the investigator also. In investigating emotional relationships, to feel is at least as essential as to think. </p> <p> If we state that one has to do not only a thorough job of thinking but also of feeling we make a realistic statement concerning the method of studying emotional relationships. Our view on the necessity of emotional understanding is not as radical as it may seem. Frequently in psychology statements are made that we have to investigate contents as they "exist for the subject," "what it means to the subject," "to see with the eyes of the subject." The need for feeling "like the subject feels" was long felt by therapists. The requirement of psychoanalysis that they themselves be analyzed is partially for the purpose of facilitating emotional understanding. </p> <p> In attempting to find aspects under which the data may be fruitfully seen, complete freedom should be given to the investigator. He cannot be free enough and "wild" enough in looking for interpretations and possible implications of the raw data which might lead to hunches, hypotheses, and conceptual formulations. Hunches are freedom loving birds which do not hatch in supervised, restricted areas. This does not mean that the data will be distorted or that the results will be "only speculation" and not "facts." The test is whether, when a category has been well defined, independent observers will agree that given items of the raw data fit the category. If they do agree, then this aspect is indeed "an observable fact." If we are too "wild" in our interpretations, then we shall be caught by another observer. But if we are unwisely rigid we shall not be able to make a step in the direction of theoretical progress. </p> <h3><b>Part II: Study on the Visibly Injured</b> - A Group Considered Unfortunate</h3> <h4>Chapter IV: Research Procedures </h4> <p> Our approach to the problems of the social emotional relationships of the visibly injured was based on the theoretical and methodological considerations discussed in Part I. Because the task was that of determining essential problems in the new field of social emotional relationships, qualitative methods were chosen as the appropriate ones. Measurements at this time would have been premature. Frequencies of observations and statistical analysis are therefore not presented, since they would only be misleading. </p> <h4> Subjects </h4> <p> Heterogeneity of subjects, as has been seen, is an asset for such a study. The subjects (177 visibly injured and 65 noninjured persons) varied as to age, race, intelligence, socioeconomic background, occupational interests, marital status, and so on. The injuries varied. The relationship of the noninjured to the injured persons varied. To have narrowed the groups for the sole reason that they should be homogeneous would have given us a more limited picture of the emotional meanings of the relationships existing between the injured and the noninjured. </p> <p> If, at the beginning of our investigation rather than at the end of it, we had known that the relationship of misfortune was especially important to the understanding of the problems studied, we would have considered it profitable to have included persons who experienced misfortunes other than injuries. But our research was an outgrowth of interest in the problems of the injured, and thus misfortunes other than visible injuries were not studied. Orthopedic cases and cases involving plastic surgery were chosen because the visibility of the injury is important in relationships with noninjured who are not close to the injured. Blind and deaf persons were excluded as subjects since it was felt at the time that the specific additional problem of communication between them and the noninjured would have in the beginning of the research unnecessarily complicated the data. </p> <p> The ages of the injured subjects ranged from 19 to 58 years, the duration of their disabilities from two months to <i>33 </i>years. Of the 177 injured subjects, 121 were hospitalized servicemen of World War II and four were women. (<b>Table 1</b>) presents the distribution of the subjects according to type of disability; (<b>Table 2</b>) gives the distribution of the non injured according to relationship with injured persons. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Interview Procedures </h4> <p> After having tried out several techniques of investigation, a summary of which is given in Appendix I, we found that the scope of meanings of social emotional relationships could most adequately be determined by interviews. Prior to the interview much work was done on the selection and formulation of questions, the purpose being not to set up a questionnaire for the interviewer to follow rigidly but rather to prepare him for the interview. We wish first to point out why we think it unnecessary and often disadvantageous to follow a rigid order and formulation of questions; then we would like to explain what we mean by "preparing the interviewer for the interview." </p> <p> It was observed that, for at least three reasons, the actual course of events in an interview might require deviations from a prearranged interview. In the first place, identity of questions and order does not ensure that the psychological situation will be the same for different subjects. In many instances, a question will have the same meaning for each subject only when it is put in a different form. Thus, in our study, as well as in many investigations where comparisons among the subjects are made, rigid interview procedure is con traindicated. That we deny the necessity of maintaining a rigid formulation and order of questions does not imply that we disregard the influence of preceding events upon a given question. Rather, we assert that this kind of influence can be validly determined only when the analysis of data is made. A rigid order gives an "appearance" of the same conditions and illegitimately relieves the experimenter from investigating the effects of the actual psychological conditions upon the responses of the subject. </p> <p> Secondly, a rigid interview leads in many cases to a more superficial intellectual discussion than is the case when the interviewer follows the natural course of the discussion. If a subject is developing a topic in a given direction and the interviewer goes on to the next question on the list, the interruption might be emotionally disturbing. Such interruptions promote the feeling that the interviewer is not really interested in what the subject is saying but just has to complete the task of getting answers to "twenty questions." </p> <p> Finally, in a nonrigid interview the subject may introduce new topics which, in the exploratory stage of research, are often worthy of consideration. </p> <p> To "prepare" or train the interviewer, the design and redesign of questions that might be asked in the interview is of extreme value. First, the process of developing questions sharpens the sensitivity of the interviewer to the scope of meanings which may be implied in a question and in possible answers to it. It prepares him to listen for the shades of meanings which the subject may bring out. Secondly, the interviewer, when later analyzing the interviews, will also be more sensitive to the shades of meanings implied in the subjects' statements. Third, the attention given in the training to the problem of the logic of transitions from one question to another and to the possible negative effects implied in some transitions is also important. The interviewer is then better able, when the subject waits for him to take the lead, to introduce a new topic without disrupting the relationship. And finally, the training on design of questions makes the interviewer realize what questions may be seriously disturbing to the subjects, a matter especially important with the injured subjects and their sharers for whom the injury is a vital problem not limited to the interview situation. </p> <p> The design of questions to be used as guides for interviews in a new area is a serious and laborious task. During the research, changes in the original questions were made; some were dropped, others added. In successive interviews, the improved interview form served to suggest the areas to be brought up for discussion, but when and how they were to be introduced was left to the judgment of the trained interviewer. We present below one of the prearranged lists of questions which was developed during the training period and used as a guide in some interviews with injured subjects: </p> <ol> <li>How do people act? <ul> <li>How should they treat you?</li> </ul> </li><li>How about their asking questions? </li><li>How about help?</li><li>Do you think that noninjured people are uncomfortable when they are with you for instance are they at a loss for words? <ul> <li>Do you think they are afraid of hurting your feelings?</li> <li>Do you try to put them at ease? </li> </ul> </li><li>Do you think it wise for the uninjured to make light of the injury? <ul> <li>Do you think a person who is not injured should kid the man about the injury?</li> <li>Is it good for them to tell an injured man about all the things that another injured man can do? </li> <li>Is it good for them to tell a man that his injury is not noticeable? </li> </ul> </li><li>Do you like to hear it said that the injured man is courageous? </li><li>What do you think comes into a person's mind when he sees someone with an amputation? <ul> <li>Do you think many people would feel sorry for him?</li> <li>Would many people feel respect for him?</li> <li>Is the opposite ever true? Would anybody look down on him? </li> </ul> </li><li>Do other people react any differently from what you expected at first? </li><li>What percentage of people do you think act very well and really badly? How many in between? </li><li>How would you check whether a person has the right feeling toward injured people? Do you do anything like that? </li><li>Did you ever know anybody who was injured, before you were hurt? 11a. How did you feel about him? <ul> <li>Do you feel differently about them now? </li> </ul> </li><li>What would you be careful of now when you're with another injured person? </li><li>Do you ever feel sorry for anyone around here? </li><li>Is there a bad kind of sympathy and a good kind? <ul> <li>Is there a kind you can't help? </li> </ul> </li><li>Is pity different from feeling sorry? </li><li>Quite a number of things may be important for other people who are injured to know about the stages one goes through. It would help them to know they are not the only ones who have these feelings in the beginning. How was it at the beginning? What are the stages one has to go through and the things you have to get used to? </li><li>Do you think a person should try not to think about his injury? </li><li>Is it better if he thinks and talks about his injury in a matter of fact way, whenever there is any reason to think or talk about it? </li><li>What would you do if you saw a fellow patient who was feeling sorry for himself? </li><li>What kind of person will let his injury lick him, or get him down? </li><li>Do you think you would have been able to take it if it had been worse? </li><li>Does it help to know that another person was injured worse than you? <ul> <li>Is it because the other person is in a worse condition, or because even though he is in a worse condition he can still take it? </li> </ul> </li><li>What things have you learned to do since you were wounded? <ul> <li>What things do you still have to learn? </li> </ul> </li><li>Which is more important, the looks, or the things you can't do? <ul> <li>Does it matter much how it looks, either to other people, or to you? Do you have to get used to it? </li> </ul> </li><li>Is an injury easier to take for a woman or a man? 25a. Would you object to marrying an injured woman? </li><li>Do the men feel that their injuries will make a difference in their getting married? <ul> <li>Let's say that about 70 out of 100 men are married in the general population. What would you expect about wounded people, would there be more of them married, or less, or about the same? </li> </ul> </li><li>Are you satisfied with your stump? <ul> <li>Some people say that they get mad at the stump and try to hurt it. What do you think the reason might be? </li> <li>Have you ever felt that way? </li> </ul> </li><li>Are there some words you object to? <ul> <li>How about the word, stump? </li> </ul> </li><li>Do you think that after an injury a man gets more interested in new things that didn't interest him before that he looks on life differently or that things that were important before don't seem important now while new things do? <ul> <li>Do you have any new plans for a job? </li> <li>Do the same kind of people interest you? </li> </ul> </li><li>There are a good many things we haven't talked about that might be very important, and we'd be glad to have your suggestions. Is there anything else that occurs to you that would be good for us to talk about? <ul> <li>Anything you think the wounded man ought to know? </li> <li>Anything the public ought to know? </li> </ul> </li></ol> <p> The interview usually lasted about an hour and a half. In a few instances, there were repeated interviews with the same subject. About half of the interviews were recorded by the interviewer himself as verbatim as possible, the others by a stenographer or a trained recorder. A sample interview with a noninjured subject is given in Appendix II. Sample interviews with three injured subjects are given in Appendix III. </p> <p> The cooperation of the injured subjects was obtained by telling them that the purpose of the study was to determine difficulties existing in the relationships between injured and noninjured people and how these difficulties could be overcome. The subjects were asked to help in finding out "how people act" and "how they should act." The injured considered the endeavor a worthy one. Many of them challenged the usefulness of current magazine articles, and some felt that correct information might improve matters. The social emotional relationships discussed had a high potency for them. Many of the subjects were recently injured, but all of them had had contacts with the noninjured—contacts in which they were the recipients of help, of curiosity, of sympathy, of being considered an unfortunate person. For them, such relationships were real and vital. Because they mattered to them they discussed problems not only intellectually but also on the feeling level. </p> <p> In the interview the injured subjects were first asked "how the noninjured behave and how they should behave." This confirmed the feeling which we had attempted to convey when we first approached them that we valued their opinions and knowledge as they "are the ones who really know." This openended question was also a precaution against feelings in the subject of intrusion into his privacy. Later in the interview, when the subjects became involved and felt secure and free with the experimenter, they frequently shifted to their own personal feelings and were even willing to discuss private matters brought up by the interviewer. </p> <p>Since particularly during the war the feeling that something should be done to help the injured was strong, cooperation was also readily secured with the noninjured subjects when the purpose of the study was explained to them. At the beginning of the interview, however, it was a difficult task to achieve real emotional involvement on the part of those noninjured who were not close to injured persons. Noninjured persons who are in the position of sharers, wives and mothers of the injured for example, do feel that relationships between the injured and noninjured really concern them. But for other noninjured, the area of problems is not a vital one. Some time was therefore spent with subjects of this group at the beginning of the interview in discussion of injured persons they knew and how they felt about them in an attempt to bring the discussion to a more basic feeling level. In order to keep the subject on the feeling level, the interviewer also attempted to bring out the conflict in the noninjured between ethical demands and emotional feelings. Because it is considered "good" by the noninjured to believe that the injury does not matter to them, they may try to convince the interviewer and themselves that they do not have any "special feelings toward an injured person." When the interviewer responded to the underlying emotional feelings rather than to the overt ideological statements, the noninjured not infrequently became aware that the relationships involved important meanings for them and not merely intellectual or ideological ones. Discussion on the feeling level could then take place. </p> <h4>Analysis of Data</h4> <p> The analysis of data in a new field, where the aim is to discover essential problems, requires a great flexibility on the part of the investigator. Because the search is for "hunches" and connections among them and not for frequencies of occurrences, an attitude of a single subject in its ramifications requires much thought and understanding. For those who will work further in this field, we wish to mention some points which are well to keep in mind when analyzing interview material. </p> <p> The understanding of the emotional meanings implied in the statements of the subject requires taking into account the context of the discussion. It is important to consider the interplay between the responses of the subject and those of the interviewer. Sometimes contradictory statements made by the subject in different portions of the interview lead to understanding of basic feelings. Always it is necessary to try to put oneself in the position of the subject and to feel with him. Often, in order to appreciate the subject's subtle feelings, it helps to examine one's own feelings in situations similar to those evaluated by the subject. Frequently the impact of the subject's own feelings is further enhanced if the investigator assumes the position of the other partner in the relationship he was talking about. In our work this was especially true in analyzing the noninjured records. The covert meanings appeared most clearly if we tried to see the implications which a superficially innocuous statement might have if an injured person were to read it. </p> <p> A rigid scheme of analysis of interview material may lead to superficial conclusions; since in such a case one is obliged to cover the material in a technical, automatic way, the many meaningfulness of the single answer of the subjects is apt to be overlooked. Thus, for our purpose, the interview material was more fruitfully analyzed by developing categories as the analysis proceeded rather than by following a predetermined scheme. This meant categorizing, recategorizing, and again re categorizing. When a new category was added it sometimes required a re examination of parts of interviews in the light of the new insight gained. Not all of our theoretical statements, however, are based on category analysis of all the interviews. Sometimes the attitudes expressed in single cases gave us hunches which led to the development of hypotheses and theoretical understanding. In these ways we tried to determine the scopes of meanings and structures of social emotional relationships. </p> <h3> Chapter V: Misfortune </h3> <p>Many kinds of social-emotional relationships exist between injured and noninjured people. Which should be investigated as more essential? We began with those which were frequently pointed out by the injured themselves, namely, "to help—to be helped," "to question—to be questioned," "to stare—to be stared at," "to sympathize—to be sympathized with," "to accept—to be accepted."<a style="text-decoration:none;">*</a> During the analysis of data, a different relationship emerged as more basic for understanding the social psychological problems of the injured the relationship "to consider someone unfortunate to be considered unfortunate." This relationship enables us to tie together many of the phenomena observed and indicates the direction which further research should take. The finding and description of this essential relationship is a <i>result </i>rather than the historical beginning of our investigation. </p> <h4> An Experiment for the Reader </h4> <p> The line below represents a scale. The letter <i>F </i>designates the position of the most fortunate person and <i>U </i>the position of the most <i>un</i>fortunate. The sign in the middle of the scale designates the average position. Before reading the text further, quickly and going simply by feeling rather than on the basis of intellectual consideration indicate your own position on the line. (<b>Fig. 1</b>) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Figure 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> This experiment was performed with a group of 30 students at Stanford University but not in the context of a discussion about the injured. Only one of the group placed himself in the average position, none below this point. In a variation of the experiment with 10 other subjects, the instructions were changed so that the middle of the scale represented the average position for members of the subject's own social group. The "fortune phenomenon" still held in this case.<a style="text-decoration:none;">*</a> </p> <p> We expect that you too will have put yourself somewhere above the average position. It would seem that there must be a "terrible misfortune," and even this may not suffice, to lead one to put himself below the average. One feels also that should somebody judge him to be unfortunate and place him low on the scale he would resist accepting such a judgment. Yet very easily does the noninjured make such a judgment regarding the injured. </p> <p> It is our task to specify further the feelings of the person who considers himself fortunate toward the one whom he considers unfortunate and also the feelings of the person who is considered unfortunate when he knows that he is so considered. Though the relationship as it concerns the injured is in the focus of our attention, the discussion has implications for anyone who is judged unfortunate. </p> <h4> Misfortune As An Event </h4> <p> A painful event which does not have far reaching consequences may be called "a mishap." If the event produces prolonged and more inclusive suffering, if it affects a large part of the life space of the person, it is called "a misfortune." Other people will tend to shift the position of the sufferer downward on the fortune scale. The circumstances surrounding the event may themselves be important. They may affect the feelings of the person himself and the relationship between him and others. But this is a special problem, and fruitful investigation of it presupposes knowledge of the nature of the misfortune relationship. We shall, therefore, in this first study of misfortune, disregard such differences as whether an arm was lost in a car accident or because of shrapnel wounds. </p> <p> For an investigation of the effect of the circumstances surrounding the event upon the feelings of the person himself, simple grouping into war and accident casualties, for example, would be too superficial. The groupings have rather to be made in terms of the intimate psychological meanings which the circumstances have for the person. For example, in the case of the war wounded: I volunteered and therefore I caused my injury; I was not careful enough I handled explosives too automatically; I got shot when I went out to help my friend it just came; I wanted to be wounded in order to return to the mainland. Moreover, one would have to know whether after his injury the person believes that his loss was for a worthy cause, or whether he became disillusioned, and so on. Similarly, psychologically meaningful subgroups would have to be distinguished for the investigation of the effect of the circumstances upon the evaluation of the donor. We shall emphasize not the nature of the event which produced the change in position on the fortune scale but the consequences of the persisting difference in position between those who are considered fortunate and those who are considered unfortunate. </p> <h4> Misfortune and Suffering </h4> <p> That an unfortunate person suffers is the fact which is outstanding from the point of view of common sense observation. It is also the suffering aspect of misfortune to which people who are close to the sufferer and who share his difficulties predominantly react. We can then ask, "Is the judgment that a person is in an unfortunate position only a statement that he suffers and nothing more?" Are "unfortunate" and "suffering" equivalent? We shall see that there are instances in which the judgment of unfortunate is made in spite of the fact that the person does not suffer, at least not directly from the event itself, and that there are other instances in which suffering occurs and yet the judgment of unfortunate is withheld. </p> <p> Let us first consider the fact that when suffering is not perceived the person may still be considered unfortunate. This is true, for instance, in the case of a person having a facial disfigurement. It may be objected that, even if the suffering is not perceived, people "realize" that he suffers, and this may have something to do with considering him unfortunate. But, we ask in a provoking way, may it not be this "realization," the opinion of others that he is unfortunate, which makes him suffer, rather than anything independent of these opinions? </p> <p> It is also puzzling that not all people who experience suffering are considered unfortunate. Boxers, pioneers, members of an arctic expedition are not considered unfortunate. The argument that in such cases the suffering is of short duration does not always hold; the hardships of the pioneers lasted a lifetime. Nor does it help to point out that these sufferings are self imposed and are therefore not misfortunes. It is not strictly true that they are self imposed, especially when they are necessary to gain a livelihood. Moreover, someone who imposes an injury upon himself in attempting to commit suicide is still judged by many to be an unfortunate person. </p> <p> It should be clear from the foregoing that the statement, "One considers somebody unfortunate when one perceives that he suffers," is unprecise. We shall see in a subsequent section (p. 21) that a statement which is almost the reverse will, paradoxical as it seems, lead us further: "When one considers somebody unfortunate, one will not only expect him to suffer but may even feel that he <i>ought </i>to suffer!" </p> <h4> Misfortune As a Value Loss </h4> <p> In order to understand many of the social emotional relationships arising between the fortunate and the unfortunate we must make explicit one important aspect of misfortune: a misfortune involves, in the eyes of the judge, a loss or absence of something valuable. But the word "misfortune" is sometimes used when the person has experienced no unfortunate event, for example when the injury is congenital. In this case, the absence of a value may be felt psychologically as a loss. </p> <p> The judgment of misfortune is an expression of personal and social values which the donor holds high. In our culture, most persons do not consider an amputation, a facial scar, or other injuries simply neutral variations, like color of eyes or length of hair. Instead, these variations of "body whole," "body competent," and "body beautiful" are <i>considered </i>disfigurements and handicaps. That is, they are judged to be misfortunes value losses. </p> <h4> The Requirement of Mourning </h4> <p>Since a misfortune is, in the eyes of the judge, a loss of something valuable, the person who experiences a misfortune is generally expected to suffer and mourn his loss. An injured man described the expectations of his visitors in the hospital as follows: "They expected to see me in a worse mental state. I was pretty cheerful and cheered <i>them </i>up." Sometimes these expectations may even have the character of a judgment as to what is proper: it is <i>natural </i>and <i>normal </i>to mourn one's loss when struck by misfortune. It may therefore be disturbing and uncanny to the noninjured to find an injured person who is not distressed, who does not feel and act like an unfortunate person. The noninjured will tend to suspect that the injured person is putting on a good act, or they may conclude that he does not yet realize what has happened to him but "will in time." </p> <p> We venture to say that these feelings of the donor do not arise solely from the possible intellectual consideration that emotional acceptance of a loss is inconceivable. It is likely that they stem also from the need on the part of the fortunate to keep high those personal and social values which he possesses or cherishes. He therefore objects to the apparent disrespect shown these values as implied in the nonacceptance of the unfortunate position by the person who is deprived of them. When the recipient does not show that he feels unfortunate, the implication is that the loss is not so great, and therefore the donor requires that the recipient mourn. We are now ready to state the following hypothesis: When the fortunate person has a need to safeguard his values, he will either <i>(a) </i>insist that the person he considers unfortunate is suffering (even when he seems not to be suffering) and that he ought to suffer or <i>(b) </i>devaluate the unfortunate person because he ought to suffer and does not. </p> <p> We expect that the noninjured will resist the implications of this hypothesis. It implies that they <i>want </i>the unfortunate to suffer, which is in direct conflict with prevailing ethical codes. An analysis of several examples will, however, make the hypothesis more convincing. </p> <p> Consider a woman to whom "position is everything in life." She must consider as unfortunate those who are omitted from the social register. If she does not it would mean that her position is not so valuable after all. If they do not accept the fact that they are unfortunate, she must consider them either too stupid to know better, or insensitive, or shamming; otherwise her own position is threatened. </p> <p> Or take the attitude of a married woman toward her spinster sister. Perhaps the duties of a wife and mother make up her whole life. If these are not important, then what is she? Nothing. It would be an intolerable state. She must consider single women unfortunate and require that they recognize this position. Otherwise how can she escape insecurity, anxieties, conflicts, and the necessity for revaluation which might increase the importance of other value scales on which she has a low position? </p> <p> To one who is proud of her beauty, whose sole stock in trade it is, the ugly duckling who flirts and seems happy would be disturbing. The beauty may laugh at the plain one and comment on her appearance so that she will "know her place." If she accepts this place, then she supports and does not challenge the values of the beauty. </p> <p> For like reasons, it is considered scandalous if a widower remarries too soon. He should have observed a "decent" period of mourning. He is heartless and disrespectful. He threatens the value of strong interpersonal ties. He undermines the value of dependence upon each other in close relationships. </p> <p> The feelings of the judge which are implicit in the requirement of mourning will tend to be expressed, however, only in covert ways because of the conflict between these feelings and ethical demands. Thus in the following example, though the demand for suffering is not overt, the noninjured subject makes it clear that an injury is devaluating and that the injured should be ashamed of and hide the injury: </p> <blockquote><p> The last place I worked there was a girl there who had been born without an arm. It was about to here [indicates above elbow). And she had fingers on it. She didn't care. She used it to hold bobbie pins, etc. ... I didn't think it was very nice. Right in front of the other girls she would uncover it. Would you think that was all right? [Interviewer: What did you feel about it?] It was repulsive. If it had been an amputation it would have seemed cleaner. I thought at the time that I would have gone into the dressing room and do that and not be where so many people could see it. </p> </blockquote> <h4>Misfortune and Devaluation </h4> <p>It has been seen that if a person does not mourn his loss when the donor believes that he ought to he will be devaluated. Mourning his loss does not, however, insure the unfortunate against devaluation. He may be devaluated whether he mourns or not. There remains then the task of determining other conditions under which a person who experienced a misfortune is devaluated. </p> <p>Devaluation of a person implies comparison. The comparison may be made between two persons in respect to particular characteristics, or between the current state and a previously existing or predicted future state of the same person, or a person may be compared with some abstract norm. The standard of comparison has a position which is evaluated positively and below which any position is negative. Thus, when there is devaluation, the comparisons are not made in neutral terms indicating likeness or difference. Instead, there is always a judgment of better or worse. The position of the person being judged and the standard against which he is compared may be represented on a value scale. </p> <p> Summarizing, we may say that devaluation presupposes comparison on a value scale on which a person is judged to be in position <i>x, </i>the standard occupying position <i>y, </i>which is higher on the scale. Close consideration of this statement, which sounds so self evident, will show the problems actually involved. Several terms used require further specification. These specifications will help in the task of determining the conditions which lead to devaluation. The terms are "value," "person," "position of the person," and "standard." </p> <h4> <i>Value</i> </h4> <p> We raise the question: Does devaluation occur when a person has lost or lacks <i>any </i>value, or does it occur only when particular values are involved? It would seem that even when something is evaluated highly, the nonpossessor is not necessarily devaluated. Two kinds of values which preclude devaluation can be distinguished—possession values and asset values. </p> <p> <i>Possession Values. </i>If a value is seen only as a possession of a person and not as a personal characteristic, devaluation of the person cannot take place. Thus beautiful pictures may be evaluated highly, yet those whose homes do not boast of even one old master are not devaluated. Though this seems clear, the terms "personal characteristic" and "possession" are in themselves problematic. Psychologists are uncomfortable when they have to draw a boundary between the person and the environment. Whether something is seen as a part or characteristic of a person or as a possession seems to depend upon the judge. The person who has lost someone dear to him may feel that he has lost part of himself. Clothes may be thought of as a material possession and "being well dressed" as a personal characteristic. Where some judges would perceive a "man who owns a house," others would perceive a "home owner," a substantial and responsible member of the community. Even a part of the body may be thought of simply as a possession rather than as a characteristic of the person, as the following statement of an injured man would seem to imply: </p> <blockquote> <p>In other words, I kind of think now that the hands and legs are just merely tools. Where if you haven't got the right tool there are some jobs you cannot do. It is not the handicap that holds a man down. It is his head. In the beginning one does not see it— that they are tools. </p> </blockquote> <p> The general problem will have to be solved: What are the conditions under which a value will be seen as a personal characteristic or simply as a possession? </p> <p> <i>Asset Values. </i>Even when a value is seen as a personal characteristic, the nonpossessor is not devaluated if the value is regarded as an asset value. When asset values are involved, the person does not base his evaluation upon comparison with any standard. He may, for example, simply enjoy the musical performance of his acquaintance without comparing it with the performance of anyone else. Should the judge not be talented in this regard, he is not disturbed because he is inferior to another. Musical ability in others and himself is seen as an asset value. More generally, the existing state of a person may be felt to be satisfying (or disturbing) without comparing it with a standard. A woman, for example, who is forced because of family and children to give up a vocation which until then had made up a large part of her life will not feel inferior if a vocation represents to her an asset value which is a "fine thing to have" if circumstances permit. </p> <p> From the above, it is clear that it is not inherent in a value to be considered an asset value. Among other things, the needs of the judge will determine whether or not he is in a comparison frame of reference. Thus, though musical ability may be an asset value under certain circumstances, when the judge is in a comparison frame of reference because he has to select members of an orchestra it is not. In the latter case, we may speak of musical ability as a comparative value, a value used in making comparisons for the purpose of evaluating the person. </p> <p> We wish to make a sharp distinction between comparative values and the possibility of making comparisons when asset values are in question. In the latter case, comparisons which might be made are intellectual ones which do not affect the evaluation of the person. In the former case, the comparison is the main aspect; whether or not the person is meeting the standard with all its consequences is most important. </p> <h4><i>Person</i> </h4> <p>We have to distinguish between what we call "total person" and "characteristics of a person." By "total person" we mean all the characteristics which are taken into account by the judge at a given time whether they are clearly or only vaguely perceived. Devaluation can exist in regard to single characteristics and not in regard to others. If the characteristics on which the person is devaluated are "decisive" for the judgment of the total person, total devaluation will take place. But if these characteristics are seen as unimportant, then the person is not devaluated as a total person though he is devaluated on single scales. Moreover, when the single characteristics on which the person is devaluated are the only ones that enter the evaluation of the judge, then "total person" is equivalent to these characteristics and total devaluation takes place. </p> <p> Consider the example of the noninjured girl who said: </p> <blockquote> <p>He's correct in not proposing if he couldn't earn a living because of his handicap. </p> </blockquote> <p> This subject evaluated the injured person as a husband in terms of a single characteristic or scale on which she feels he has an inferior position. Because other characteristics of a good husband are not taken into account, he is necessarily devaluated as a husband. If other characteristics which are felt to be the decisive ones are considered, such as affection and understanding, he may be judged equal to whatever is taken as the standard. He will be devaluated only if the girl feels that earning a living is of primary importance. </p> <p> Examine similarly the self devaluation of an amputee who says: </p> <blockquote> <p>You feel like a heel lots of times when kids are playing on the street with their sleds. Other fathers can play with their kids.</p> </blockquote> <p>The subject devaluates himself because other characteristics which may be considered more important for a good father than those on which he falls short are not considered at the moment. </p> <p> Devaluation of the injured is not limited to bodily values only. When the injured person is devaluated because of physical performance, appearance, or aptitude for particular roles, a jump is not infrequently made so that he is also devaluated in regard to assumed mental characteristics. Some people directly indicate that abnormality of the body means abnormality of the psychological make up. Thus we have the following statements made by noninjured subjects: </p> <blockquote><p>You'd be very conscious of your own deformity; it would hurt you psychologically.</p> <p> Some have a disposition to arrogance. "You are going to accept me whether you like it or not" like a midget, you know, inferiority complex. Some overdo the matter of being congenial. [Note that even positive traits are seen as negative]</p> <p>After she [girl with short bowed legs] had been with us for a short while, we accepted her as normal, except for that handicap. [This implies that at first they didn't accept her as normal.] </p> </blockquote> <p> We should like also to point out that devaluation of the total person does not always occur by way of single characteristics. Sometimes there seems to be a direct, all inclusive judgment of devaluation of the total person. It seems that the broader the meaning of the word "person" the less clearly does the judge perceive how the single scales determine his evaluation of the person. He has a vague feeling, for example, that a "cripple" is somehow "an inferior person." </p> <p> In speaking about devaluation of a person, then, we must ask two questions. Is his devaluation limited to particular characteristics or is he devaluated as a total person? Is he devaluated because only those scales on which he has a low position are taken into account or because these scales are given considerable weight when the scope of values is enlarged to include other characteristics of the person. </p> <h4> <i>Position of the Person</i> </h4> <p> To a judge, the permanence of a person's position with respect to the standard is important in his evaluation of the person. We may expect that devaluation will be less severe if, when taking the "time perspective" into account, the position of the person is seen to shift in the direction of the standard.<a style="text-decoration:none;">*</a> The judge may expect the shift for different reasons. In some cases, he may feel that the loss can be replaced in whole or in part. Thus, even a person who considers "home owner" as a characteristic of the person, and a minimum requirement for the role of a responsible community member, may not devaluate someone who suffers the misfortune of having his house destroyed. The judge may expect that he will again be able to establish a home and thereby to regain his former position. The loss is only temporary. </p> <p> In other cases, the person may be expected to adjust to his loss even though the lost value cannot be regained. The position of the person, then, is felt to shift so that he can meet the standards in regard to such values as, for example, adequate personality, social usefulness, and the like. For problems of injuries, the shift due to perception of adjustability is of particular importance. Even in those instances in which physical improvement can be limited only, the recognition that one can adjust to the injured state will minimize de valuative feelings. A noninjured woman says: </p> <blockquote><p>When I thought of the courage it took to ignore those handicaps, I felt humble. I felt that anyone who overcomes a handicap like that wins an added amount of respect from everyone.</p> </blockquote> <p> For this subject, the fact that the injured men were able to adjust to their handicaps led her to evaluate them not as inferior but, on the contrary, as persons meriting respect. </p> <p> We believe further that the judgment of adjustability will depend upon the adjustment of the judge. A person who feels in essence "What a terrible misfortune to be injured, I could never stand it. I would rather die," we consider maladjusted with respect to injuries. The following comments were made by noninjured people: </p> <blockquote><p> It wouldn't be worth while to live. I'd develop a complex and go off in my little hole. I'd go into hiding and not show my face for the rest of my life.</p> </blockquote> <p>To such people it will seem impossible that one can adjust to injuries. </p> <h4> <i>Standard</i> </h4> <p> In connection with the term "standard," we have previously noted that the standard may be another person, the same person at a different time, or some abstract norm. Frequently the abstract norm has the character of the minimum requirement for a certain role. If the person does not meet the minimum requirement, he will be judged as an unacceptable candidate for whatever role is in question (for example, that of husband, employee, team member, etc.) or he will be devaluated as unfit to continue in the role. This is illustrated by the noninjured girl who said: </p> <blockquote><p> He's correct in not proposing if he couldn't earn a living because of his handicap. </p> </blockquote> <p> In the extreme case of devaluation of the total person, the person will be thought of as an outcast. He does not meet the minimum requirements on a value scale which, in the opinion of the judge, everyone "ought to possess" in order to be a normal human being. Though such extreme devaluation is not often directly expressed, we do find, in the records of the noninjured, statements such as the following when severe handicaps are being discussed: </p> <blockquote><p> If you have no limbs you are not a person really. With both arms and legs gone the person isn't of any use, a detriment to society. </p> </blockquote> <p> When a person is above the level of minimum requirements or "ought standard" (either for a particular role or for a "normal" human being), he may still be devaluated as inferior, for example in comparison with some other person, but the devaluation will not be as severe. </p> <p> There are individual differences in regard to where the ought standard is set. For some it is simply undeniable that a man ought to be able to support his family entirely by his own efforts. If he is disabled so that his wife must work, or if state assistance is required, he will be seen to fall short of this minimum requirement and will be judged unworthy to have a family. Some people may not see this as an ought standard at all; others may apply it to themselves and yet not require anyone else to meet it. </p> <p> We can now state that the most severe type of devaluation (devaluation as unworthy or unacceptable) will occur when the person, in the eyes of the judge, falls below the ought standard on a value scale. </p> <h4> <i>Conclusion</i> </h4> <p> It is obvious by now that the value structure of the judge is of utmost importance. Devaluation will depend upon whether the judge regards the values in question as possessions or as personal characteristics. It will depend upon whether the judge considers the values as comparative values or as asset values. It will depend upon whether the judge regards the person only in terms of single value scales on which he has a low position; whether the judge regards these values as decisive in the context of other characteristics of the person, that is, when the scope of values is enlarged; or whether in this context they are felt to be nonessential. It will depend upon whether or not the judge regards the state of the person as an unadjustable one. It is up to the judge how high the standards will be set, whether he considers a particular standard an ought standard for <i>his </i>concept of the role of husband, father, etc., or of a "normal" person, and whether the standards are flexible or rigid. It is not the objective loss but the values of the judge which determine devaluation. A remedy, therefore, is a change in the value system of the judge. The judge may be another person, or the person himself who experiences the loss. In the first case we speak of the devaluation of someone else, in the second case of self devaluation. </p> <h4> Conflict in the Noninjured </h4> <p> Devaluation of the injured, like the requirement of mourning, conflicts with ethical prescripts as well as with spontaneous, positive feelings toward the injured. The noninjured person does not want to hurt the injured. He tries to be tactful. He will not address the injured with an emotionally loaded word like "cripple." He will be reluctant to say that the injured man is inferior, to be pitied, etc. He will not point to the injured part of the body. He will hesitate to mention handicaps in the presence of the handicapped person. He might sometimes dare to mention handicapped people who "get along amazingly well" (almost as good as a noninjured person) or who, like Roosevelt, are as good as the best noninjured. He might dare to say that he "would never have noticed it" or that someone else has not noticed it. He might feel a strong positive tie with the injured person and feel genuinely sympathetic toward him. </p> <p> Because negative, devaluating attitudes conflict with positive feelings toward the injured which are ethically prompted or which are spontaneous and genuine, we can expect that devaluation will seldom be manifested simply and directly but will tend, instead, to be covered up. For example, a noninjured subject who showed concern and warmth toward the injured could not admit his attitude that a handicapped person is less acceptable. But this status discriminatory attitude is covertly expressed when he says: </p> <blockquote><p>I can readily understand how they [people with less severe handicaps] might resent being classed with those who are totally handicapped.</p> </blockquote> <p>Another subject is able to express his de valuative feelings when speaking about himself if he were injured: </p> <blockquote><p>Without doubt I would be tremendously depressed [if I had an arm or a leg off] at the thought that your usefulness is over now and that you will be nothing but a burden from now on. </p> </blockquote> <p> But he is unable to leave the discussion on this negative level. He hastens to right the situation, to pay deference to the other side of the conflict, and adds:</p> <blockquote><p>But I presume that that would pass and with a little bit of expert help one could return to a normal life.</p> </blockquote> <p> It is also often difficult to disentangle just when the favorable, verbalized attitudes correspond to the underlying feelings and when they do not. When our subjects speak of the courage of the injured, their cheerfulness, perseverance, etc., they are expressing attitudes which overtly are favorable. Sometimes these attitudes seem to be prompted by ethical demands and sometimes they seem to reflect genuine feelings. One suspects that the positive feelings expressed by the following subject are glib and superficial: </p> <blockquote><p> I have met one woman in particular with both legs gone and she had artificial limbs and she got along beautifully. She lost her legs about a year before I met her. And she was very happy. I have more sympathy, and I thought she was very brave.</p> </blockquote> <p>On the other hand, in the following account a noninjured subject reveals a feeling of warmth and respect for the injured: </p> <blockquote><p> I went to a dinner party the other night for the wounded Japanese soldiers at —— Hospital. There were about a dozen of them one completely blind, two with partial sight, another with a leg off, another without an arm. When I first arrived I thought, "I can't bear this. I have never been able to look at suffering." I wanted to go away. I stayed. I got acquainted with these boys. They not only had the physical handicap. They had the racial handicap which is a serious one in this country. I stayed until midnight. I felt each one could have been a friend of my son. They were so courageous, so gay, so sympathetic and generous with the blind boy. They helped him so unobtrusively. I felt I had learned a great deal. I felt there was nothing we could do for them. They were doing for us ... . The way I felt about those boys I felt inferior. </p> </blockquote> <p> The conflict in the noninjured may be evaded or diminished in different ways. We should like to mention two phenomena which might be less obvious than simple avoidance of the injured as a means of escaping the conflict. These phenomena are aversion and spread emotional reactions which make it easier for the noninjured to avoid the injured Aversions have the useful quality of enabling the non injured person to feel that he does not voluntarily avoid the injured but that he does so for reasons beyond his control.<a style="text-decoration:none;">*</a> Spread, or the exaggeration of negative effects of an injury, may provide the noninjured with an excellent reason for excluding the injured from participation in activities which might, for example, be somewhat strenuous. And if one exaggerates the injured person's sensitiveness and withdrawing tendencies, ethical demands will not be obviously violated, since one can assert that the injured person would feel uncomfortable in the group or decline the invitation anyway. </p> <p> In the following chapter we discuss in detail one type of genuine and spontaneous positive feeling toward the injured—that of sympathy. </p> <h3> Chapter VI: Sympathy </h3> <p> Sympathy is brought about in the donor by the suffering aspect of misfortune rather than by the value loss aspect. As stated on page 8, our approach to the study of the sympathy relationship was to consider the total scope of meanings assigned to the word "sympathy" and then to extract those which were tied together by a coherent underlying structure. Pity and other devaluative meanings which the subjects sometimes give to the word "sympathy" do not belong to the same structure. </p> <h4> Primacy of Needs and Emotions </h4> <p> In the older treatises, sympathy was considered an instinctive, or at least an immediate, response to the perception of emotion in another; the perception of pain would bring about discomfort in the observer, the perception of joy would give him satisfaction. We would have no great objection to such a "theory" as far as it goes, but there are difficulties in its incompleteness. For example, we would be reluctant to term "sympathetic" one who, because of his discomfort on perceiving the distress of another, tries to escape the situation. </p> <p> It is essential for the sympathy relationship that the donor set aside his own needs and feelings in favor of those of the suffering member. The recipient will then feel that his needs and emotions are given primacy, and only then will he feel that the donor is sympathetic. The conditions leading to the existence of primacy of needs and emotions of the other are not known to us and require further study. Most frequently it arises in what we call "we groups." The partners in a we group feel bound together by strong ties of friendship, family, etc. They like each other, enjoy being together, need each other. But relative contributions are not measured; comparison of values possessed is not in order; what is important is "we" rather than "you as compared with me." The group is characterized by the sharing of the feelings of one member by the other. The partner is pleased with the joy of the recipient; he is made sorry by the recipient's sorrow. As an injured man says: </p> <blockquote><p> Love for a certain person, that is why you feel sorry. I know my mother feels awfully sorry that I lost my arm. Every time something happened to me my father too felt awfully sorry for me. It was just that he loved me. You just can't get away from it I guess. </p> </blockquote> <p> Instead of putting one's own needs always first, primacy is given to those of the other when they are felt to be more urgent. Exceptional stress and exceptional happiness of the other take precedence over the everyday level of feelings of the donor. He sets them aside and participates in the intense joys and sorrows of the partner. </p> <p> Primacy of needs and emotions, however, does not arise in we groups only. It may exist between people who have no lasting relationship with each other, whose relationships are as tenuous as being fellow Americans in a foreign country or even passers by. What the forces are which keep the donor in the negative distress situation in these instances are not known. </p> <p> What primacy of needs and emotions implies in the sympathy relationship may be described under the headings <i>Congruence, Understanding, </i>and <i>Readiness to Help.</i><a style="text-decoration:none;">*</a> </p> <h4> <i>Congruence</i> </h4> <p> The injured sometimes slate that no one can ever really know what it is like to be injured unless he is himself injured. Those who would urge this against the possibility of real sympathy would probably subscribe to the "identity theory" of sympathy. This as usually stated is "seeing and feeling the distress as the other person sees and feels it." An injured person who rejects sympathy gave this as a reason: </p> <blockquote><p> It's very easy for a person to sympathize who hasn't had the experience himself. It would be a very shallow thing. It wouldn't mean anything to me ... . How can you sympathize with me if you haven't lost your father and I have? You wouldn't know what it is like. How can a fellow sympathize with you if he hasn't lost the leg or the arm? I don't think he could do it. </p> </blockquote> <p> It should be clear that primacy of needs and emotions does not imply identity of feeling. We doubt that the feelings of the donor and recipient can be identical. Nor would identity have advantages. The donor cannot <i>see </i>the situation as the recipient sees it. He cannot know all the emotional ramifications of being injured. And even if he were to understand much of what it means to be injured, he would not feel the suffering in the same way as the injured person does. He does not suffer the actual social deprivation nor the self devaluative feelings of the recipient. The recipient is distressed over the loss itself, the donor because the recipient suffers. The <i>content </i>of their distress is therefore different. Even in the case of a sharer (e.g., a wife or mother) who may himself experience loss, the content is still different. </p> <p> The donor need not approach the <i>mood </i>of the recipient in intensity, nor is it necessary that his mood be the same qualitatively, as long as it is not incongruous. If someone is depressed, a sympathizer need not also become depressed. There are other manifestations of concern sufficiently in harmony with the mood of the recipient to be considered sympathy. On the other hand, gay attempts to divert him will seem incongruous and may be considered an indication that the donor does not give primacy to the needs and emotions of the recipient. </p> <p> Moreover, were the donor to feel precisely the same way as the recipient, it is questionable whether any <i>action </i>he could take would be effective in diminishing the distress. The anxiety and fearfulness of the recipient, for example, would prevent him from realistically evaluating his situation. A similar anxiety and fearfulness in the donor would also act as a barrier to adjustive effort. </p> <p> Thus the donor and the recipient <i>perceive </i>differently, <i>feel </i>differently, and <i>act </i>differently. Congruence rather than identity is required in each of these instances. What makes for congruence is an important problem meriting special investigation. </p> <h4> <i>Understanding</i> </h4> <p> In a distress situation there are in the recipient two conflicting needs that must be taken into account by the donor. On the one hand the recipient wishes to remain in the area of preoccupation with his loss because of attachment to the object of loss, desire for clarification, etc. On the other hand, he wishes to leave the area because of the negative character of the situation (the unpleasantness of the state of depression, a feeling of unproductiveness, etc.). A clear example of both tendencies is found in a bereavement situation in which, in spite of the negative characteristics of grief, one wishes to continue to mourn as an expression of devotion to the person he loves. The first thing the donor must understand, then, is this conflict in the recipient. He must not only be concerned about the emotional state of the recipient in the sense of wishing to help him leave the negative area; he must also give sufficient weight or respect to the reasons which produced the distress and which keep the recipient in the area of preoccupation with the loss. When either of these attitudes is felt to be lacking, the recipient feels that he is not understood. For example, a mother may be genuinely concerned over the unhappiness of her adolescent daughter, but if she tries to soothe her by saying, "It's only puppy love. You'll soon forget all about him," the daughter, even when recognizing her mother's concern, will feel that she doesn't understand and thus that she is not really sympathetic. Similarly, if someone tries to "cheer up" an injured friend by saying, "Oh, you'll soon get a new leg," he may be felt to take lightly the feeling of loss which the injured man experiences. It is equivalent to saying to someone bereaved, "You'll soon get a new wife"! In the following instance an injured man defines sympathy entirely in terms of giving sufficient weight to the reasons for distress: </p> <blockquote><p> Sympathy is appreciating the difficulties you might have.</p> </blockquote> <p>The wish for respect to the cause of distress is seen in the following statements made by injured subjects:</p> <blockquote><p>[People say] "Now before long you'll be as good as new." That's a bunch of posies all for naught .... They don't know what they're talking about .... Though people say, "Oh you'll forget it in a few years," they're always the people who aren't injured. </p> <p> People would come in and tell me how lucky I was. It was just that they were trying to put a whole new set of values on my misfortune. If there is anything you feel about it, it is that it was not lucky. </p> </blockquote> <p>The sympathizer cannot take lightly any features of the situation which are of great moment to the injured even though, in his efforts to bring about emotional relief, he may try to emphasize certain positive aspects. </p> <p> It is important to point out that the word "understanding" is misleading when it is taken to imply only a conscious intellectual appreciation of the diverse meanings which the loss has for the injured. When the injured speak of a person who understands, they sometimes speak in these terms: </p> <blockquote><p> Probably that girl could not answer your questions but she just knew. Some people are like that. . . . There is a person that just has an instinctive good taste and quality in her.</p> </blockquote> <p>It seems as though there is such a thing as emotional understanding that is, grasping the emotions of the other person directly on the emotional level without the intermediate step of intellectual realization of these emotions. The distinction between intellectual and emotional understanding is clearly brought out in the following statement of a noninjured woman: </p> <blockquote><p> Every mother thinks about the possibility of her son coming back wounded or disabled. ... I don't know just how I would react. . . . You would have to feel your way along and learn every day. But if you really love and understand them, you would learn very quickly, by experimentation, and I think you would have to give it a great deal of deep thought, and you would have to have a lot of wisdom, but wisdom comes in an emergency of that sort. [Interviewer: When you said wisdom, that implied intellectual knowledge.] Not necessarily. I would say more a wisdom of the heart. </p> </blockquote> <p> There is nothing mystical in the fact that one may react before having time to understand intellectually. We spontaneously catch a ball suddenly thrown to us without intellectually deciding on a course of action. Similarly, in the case of emotional relationships we frequently react in an appropriate way which is called "intuitive." It seems necessary to assume that the speed of emotional processes is greater than the speed of intellectual ones and that, in communication, emotional grasping of the feelings of another person is faster than intellectual grasping.<a style="text-decoration:none;">*</a> Intellectual understanding may, however, enhance the relationship in which emotional understanding already exists. It may increase the effectiveness of the help offered because intellectual understanding may lead to useful suggestions which the recipient may be ready to accept. </p> <h4> <i>Readiness to Help</i> </h4> <p> It is not by chance that expressions of sympathy are usually followed by some such statement as, "If there is anything I can do, let me know." Such readiness to help should be considered as much a part of the structure of sympathy as congruence of feelings and understanding. This is demonstrated when the injured inveigh against the "so called sympathy which is nothing but words." For example: </p> <blockquote><p> The good kind you try to do what you can for them to help them out. The bad kind they just say they feel sorry and let it go at that. </p> <p>Oh, absolutely [there is a good and bad kind of sympathy]. But it can be expressed through actions rather than through words fidelity, sticking by you through thick and thin. </p> </blockquote> <p> The kind of physical help which is acceptable is elaborated elsewhere<a></a>. In the sympathy relationship, we are especially concerned with emotional help in overcoming feelings of distress. Whether or not this type of help will be acceptable will depend upon whether the donor continues to be guided by the recipient's wishes and also upon his knowlesdge of the relative strength of the momentary tendencies toward and away from the distress area. The donor should be passive or active depending on these wishes and tendencies. </p> <p> When the tendency to stay in the area of concern with loss is very strong, the recipient may want nothing more than assurance of concern, an understanding listener, or the comfort of bodily contact with a person with whom strong ties exist. The word "passive" should be taken very seriously. Expressions of concern which are uncontrolled and immoderate may be very disturbing. A few subjects give hints as to why demonstrative manifestations of sympathy are disturbing: </p> <ol> <li>The injured person may be so keyed up emotionally in regard to the whole injury situation that additional emotionality is difficult to bear: <em>Sympathy is disagreeable to the man because of the state of emotion he is already in.</em> </li><li>Any strong emotional expression may make the man feel that his situation is even more unfortunate than he thought it to be. It can easily lead to a feeling of futility of his attempts to adjust: <em>I don't want them to cry. It makes me feel sick I can do anything anybody else can but when they do that I would have to feel that I would have to give up trying to do things.</em> </li><li>The man does not know how to act when strong emotionality is shown. The situation tends to become unstructured. Embarrassment results: <em>Sometimes a motherly old gal embarrasses you with how sorry she feels for you.</em> </li><li>Strong emotionality may arouse feelings of guilt in the man at having caused so much distress: <em>I don't want anybody to feel sorry for me Sorrow isn't a thing to share.</em> </li></ol> <p> Further, there are other important reasons why the injured objects to excessive emotionality. The injured may doubt the sincerity of the feeling, and any demonstration may convey to the injured that the donor is trying to make sure that his "goodness" is appreciated by the injured (page 31). We wish especially to stress the fact that excessive emotionality has also the danger of making the donor imperceptive to the shifts in feelings and changes in needs of the sufferer. It is important to note that in the opinion of the injured a deep positive feeling on the part of the sympathizer can be conveyed to them without any emotional display. They object to shallow sympathy, but shallow sympathy is not, of course, equivalent to sympathy that is manifested simply and without elaboration. <i>Active </i>help requires that the donor be alert in watching for an occasion when he can strengthen the forces in the recipient in the direction of leaving the distress area without provoking resistance from the recipient. One injured subject identifies this as encouragement rather than sympathy, but the idea is essentially the same: </p> <blockquote><p> You can always take encouragement. More than sympathy, it is the cheerful look, not a sorrowful look a feeling of raring to go that kind of infects you not the idea that the world has gone wrong. </p> </blockquote> <p> Yet sudden or too strong or persistent urgings in the direction of leaving the area reflects on the genuineness of the donor's appreciation of the cause of distress. At the first sign that he has proceeded beyond the ability of the recipient to follow him, the donor must be ready to abandon any benevolent attempts. Because the emotions of the donor are not identical with those of the recipient, because he is not so depressed, he is already a step ahead in the struggle to overcome the distress. It is this discrepancy in feeling which gives the donor the possibility of shifting the recipient in positive directions. But the emotional change required of the recipient cannot be too great. Only small steps can be taken, the size of the allowable step being not infrequently smaller than the donor wishes would be possible. </p> <p> The meaning of size of step may be grasped more fully if we consider the parallel case in the intellectual realm. A teacher may explain too quickly or may omit necessary intermediate points. The student is then unable to follow because the size of the steps taken by the teacher has been too great. In the emotional realm, we may take the case of a noninjured person who, wishing to overcome the brooding of his injured friend, suggests a joyful interlude. Though the injured friend <i>also </i>wishes to overcome his brooding, merrymaking requires too great an emotional change for him. It is interesting that when someone is deeply distressed a sympathetic person may suggest a cup of tea. This may represent not only concern for needs which the sufferer himself might neglect; it is also a shift from preoccupation with loss to an activity which is neutral enough not to seem incongruous. It will also not be seen as too great an emotional step if the donor gradually aligns himself with and strengthens those positive aspects which the recipient might express, for example that he has the fortitude or stamina required, or the hope of an eventually successful outcome. </p> <h4> Spontaneous and Ethically Dictated Sympathy Sincerity </h4> <p> In the absence of spontaneous sympathetic feeling, there may still be strong social pressure to play the appropriate role. Thus, besides sympathy based on genuine primacy of need of another person there is simulated sympathy— sympathy for the purpose of adhering to the ethical ideal that one <i>ought </i>to be a good person, which sometimes implies self aggrandizement. Most people will be able to recall being at one time or another donors of both kinds of sympathy—that which is "ought inspired" and that which is prompted by genuine concern In some instances the former will be difficult to admit to oneself. </p> <p> It is important that the dynamics of interrelationship between the donor and recipient is different in the two cases. If the sympathy is ought inspired, the donor will do as much for the recipient as is required by the donor's need to be "good." We cannot help but suspect that he will be guided much more by what <i>he considers </i>good for the other than by the needs and wishes of the person he is sympathizing with. The recipient distinguishes between spontaneous and ought inspired feelings of sympathy in the donor and speaks of them as "sincere" or "insincere." This does not mean that he always correctly detects them. But when the underlying feelings are seen as spontaneous and genuine they will be evaluated as positive, even though the recipient may not for other reasons welcome the overt expression of sympathy <i>(e.g., </i>because of lack of knowledge or sensitivity in the donor or because of some conflict in himself; see page 32). Positive evaluations of the genuine feelings are expressed in these terms: </p> <blockquote><p> I don't mind [if old friends say they are sorry]. Being a friend I felt that his word was sincere, coming from the heart. <br /> Sincerity means a lot.</p> <p>Yes [there is a good kind of sympathy and a bad kind]. You can always tell the person who does actually have a feeling for you and is sincere. </p> </blockquote> <p> Ought inspired sympathy can be evaluated as proper when seen as a formal expression of politeness. The donor thereby conveys only a recognition of the seriousness of the event and his intention not to intrude further into the privacy of the recipient. A limited interaction of this sort is accepted, but it must be brief and does not bear repetition. The injured say: </p> <blockquote><p> I think it is all right [for someone to say he is sorry on first meeting]. I think I would say the same thing. If he would let it go with saying he was sorry and not rave on about it. </p> <p>I don't mind anybody saying that. It's just like a person saying, "I'm sorry you are sick." Not if he just said it once. It's the same if you have lost a wife or relative or something; people offer their condolences. That is the same thing. It is all right if you don't overdo it. That is just common politeness. </p> </blockquote> <p> While this type of sympathy is less valuable to the recipient than is genuine sympathy, it bears no great dangers. Perhaps the only additional caution required is that overt expression of this sort of feeling should emphasize the event and not the man. To say, "I'm sorry it happened," conveys what is needed. "I'm sorry for you," may connote devaluation: </p> <blockquote><p> A person can say he is sorry it happened, but I don't want him to say he's sorry for me. . . . It's in the time element. Sorry it happened refers to the past and it doesn't mean he keeps right on feeling sorry . . . and pity and being sorry <i>for </i>a person suggests looking down. </p> </blockquote> <p> Though interactions of this kind are accepted, they are by no means considered necessary by the injured. But the injured know also that their acquaintances may feel embarrassed if they make no comment on first meeting the man after the injury. Hence, in addition to the evaluation of "proper," the same behavior may be regarded as <i>neutral or unimportant:</i> </p> <blockquote><p> They don't really need to say it, but it's all right. If they say [casually], "It was hard luck," it's all right. I'd just as soon they wouldn't say it. If it's a friend of yours, you know anyway. </p> </blockquote> <p>The evaluations become negative when the basis for the expression of sympathy is felt entirely to be a matter of obligation:</p> <blockquote> <p>Some people who are not so close to you feel they <i>should </i>give sympathy and say they're sorry you lost your leg. </p> <p>This sentimental stuff. It seems to be partly an act. Old people seem to think they are obligated. </p> </blockquote> <p>The simulated sympathy which is feigned for self aggrandizement or to satisfy some other need of the donor is rejected: </p> <blockquote><p>Well, there's the crocodile type [of sympathizer]. . . . Cries, you know, like the crocodile. Then . . . the he man type. He comes up and claps you on the back. All the time patting himself on the back. </p> </blockquote> <p> Ought inspired sympathy, when mistaken by the recipient for genuine feelings, provokes positive feelings toward the donor in return. When the recipient does reciprocate and later finds no real concern for his needs, he feels cheated or fooled first because he was under false pretenses drawn into serving as a means of satisfaction of the needs of the other; second because he was ready to accept emotionally this person whom he now rejects as unworthy; and third because, believing himself secure with this person, he permitted himself to expose his private and sensitive feelings. Insincerity in such a case is therefore threatening; it is rejected and avoided. </p> <h4> Desire To Be Noninjured </h4> <p> Sympathy may be unwelcome not only because of some failing of the donor but because of the recipient's own attitude toward his injury. To welcome sympathy means that the injured man must admit that the injury has made a difference to him, even if it is only in particular and confined ways. He must not only see himself in the sympathetic situation as an injured person but must also be willing to have the sympathizer see him as such. This is not easy to do if the man has negative emotional feelings toward being considered an injured man. The resistance against being regarded as an injured person may be seen in the man's resentment of sympathy when he says: </p> <blockquote><p> Servicemen don't want their family to feel sorry for them. . . . Some people feel sorry but not around Utah. They see a lot of it. They treat you just as if you were another man. </p> </blockquote> <p> The persistent demand by the injured to be treated like anyone else may be indicative of healthy attitudes when it reflects their resistance to being devaluated. But when it is a sign that the injured person doesn't want to share injury connected matters because he is ashamed of them, that he wishes above all else to be considered a noninjured person, then he must of necessity remain troubled. When he reaches the point where he can face the fact of his injury, then he becomes able to receive the comfort which sympathy may bring. </p> <h4> Sympathy and Adjustment </h4> <p> The desire of the sympathizer is to help the sufferer to reach a happier state, to help him to adjust. The recipient, too, may wish sympathy not only because of the immediate comfort that it may give him but also because he hopes that the other will help him overcome emotional difficulties. But is there anything in the nature of the sympathy relationship as such which will assure better adjustment? Does it imply that the sympathizer will be better able to recognize intellectually or emotionally what leads to adjustment? Just as the recipient himself, the donor may err as to what is adjustive. He may lead in nonadjustive directions. One can say only that the sympathy relationship provides a favorable atmosphere for influencing the recipient, whether for better or for worse. </p> <p> There is, however, another point to be considered, namely, whether sympathy, as an expression of we group feelings, does not always have some adjustive value. Sympathy, as an expression of we group feelings, gives assurance that one is of worth to another person. We shall see that adjustment may imply the overcoming of the feeling of worthlessness of oneself and meaninglessness of the world around. </p> <h3> Chapter VII: Acceptance of Loss </h3> <p> In the preceding two chapters we spoke about the meaning which misfortune has for the noninjured and about his feelings toward the injured. We indicated that these feelings lead to difficulties <i>(Misfortune, </i>Chapter V) and to attempts on the part of the noninjured to lessen the suffering of the injured <i>(Sympathy, </i>Chapter VI). In his social relationship with the noninjured, the injured has to find a manner of living most satisfactory for him. He has also to overcome certain individual difficulties in addition to those produced by social relationships. He has to accept both personal loss and social loss. </p> <p> The content of personal loss as felt by the injured may be conveyed by the following statement ascribed by us to a leg amputee: </p> <blockquote><p> The leg which was a part of me and like the other is now detached from me. With it I felt free to move, to jump, to run, to play. I could move it, move with it; it moved me. I will be hampered. I will not be able to climb a mountain (even though I never climbed one before). I won't be able to dance or fight as well as before. I won't be able to take a job that requires standing for hours. The prosthesis can fail. I can slip and fall. I have to take care of the stump. When I look in a mirror I won't see a whole man; I will have to get used to seeing myself this way. I can't bound out of bed in an emergency. When I move I will think, "Is it worth the inconvenience and effort of getting up?" So much that I will do would have been so much easier; in a shorter time I could have done so much more. I will always be less able than I would have been. I was a better man when I had my leg and amounted to much more than now. I will never be what I wish I were, and ought to be had I the leg. </p> </blockquote> <p> In suffering from social loss, the individual suffers as a member of a group. He feels that he is not accepted as equally worthy. Other values which the group can offer, such as companionship, are made inaccessible. </p> <p> The content of social loss as felt by the injured may be conveyed by the following statement ascribed by us to a leg amputee: </p> <blockquote><p> I will be considered inferior by others. They feel that I can't contribute my fair share. I will be regarded as a burden. They won't want to associate with me. They might stand my presence but not accept me as they would a noninjured man. Girls won't want to go out with me. People will be repulsed by the sight of me. </p> </blockquote> <p> One could consider each of these difficulties and see how each in turn could be overcome. This obviously is an endless task, for one could continue to enumerate specific sufferings involved in personal and social loss. Instead, it is more meaningful to try to see whether there are not some conditions common to diverse difficulties. Understanding of these conditions is actually a first step toward solving problems of adjustment, for only when they are clearly specified can we tell what it is that must be changed, and only then are we able to get some insight regarding the state to which it would be desirable to change and how to produce the change. </p> <p> The desired state which we call "acceptance of loss" does not mean becoming reconciled to one's unfortunate situation. Instead, acceptance of loss is a process of value change. Before discussing value changes, however, we wish to describe those attempts at adjustment which seem promising to the injured, yet not only fail basically to overcome the difficulties but even create new ones. </p> <h4> Maintaining the Noninjured Standard </h4> <p> The way in which the injured person tries to overcome difficulties is determined by the fact that his values are those of a noninjured person. A blow which damages a part of his body does not at the same time lead to changes within his value system.<a style="text-decoration:none;">*</a> He may continue to maintain the noninjured position as <i>the </i>standard of comparison and direct his efforts toward reaching it. He may cling to the belief that the way to overcome his difficulties is to be, in his own eyes and in the eyes of others, a noninjured person. To achieve the end of being considered noninjured, he uses all means available, both realistic and unrealistic ones. </p> <h4> <i>Realistic Attempts to Achieve the Noninjured Standard</i> </h4> <p> The realistic means used by the injured to be like the noninjured are strenuous efforts to perform certain tasks independently and to equal or surpass the success of the noninjured in certain roles. These attempts can be considered realistic because in certain limited ways they are successful. The injured can equal or surpass the noninjured performance on particular scales or in particular roles. But <i>if the sheer fact of being an injured person is a difference which makes a difference to the injured man, that is, if the noninjured remains the wished for ideal, no matter how often he does as well or better than the noninjured he will still devaluate himself as an imperfect noninjured person.</i> </p> <p> In their efforts to be noninjured, the injured impose upon themselves unnecessary strain, Whereas the noninjured person often readily accepts help when it is more convenient to do so than to perform a task alone, the injured person tends to be reluctant to accept help if the help is not absolutely necessary<a></a>. Thus an injured man says: </p> <blockquote><p> I wouldn't accept help except where absolutely necessary. Offers of help get me down unless I were in a real jam. [Interviewer: What do you mean by absolutely necessary?] Oh, something like an earthquake out here where I couldn't get my hands on my crutches in time. </p> </blockquote> <p> <b>And another says: </b></p> <blockquote><p> You'd like to be a lot more independent than you were before. If somebody opened the door before, you never paid attention to it, but they do it now and you notice it. </p> </blockquote> <p> In order to explain why the injured, in striving to be and behave like a noninjured person, is led to impose greater hardships upon himself, we must take into account that "help is necessary" has a double connotation. It means "Without help I will not reach a desired goal," and "I am not able." The latter implies comparison of one's own ability with that of another. "You cannot do it, but I can," is, in our ability minded society, a most unwelcome comparison. For the injured person who wishes to be noninjured, the ability comparison aspect of help has a greater weight than for the noninjured, and he wishes to deny that he <i>needs </i>to be helped. The necessity of the goal, therefore, has to be greater for the injured in order to overcome the resistance against being helped. This, we suspect, could be shown by a simple experiment. </p> <p> A scale of the necessity of help is constructed. One end indicates "help is a pure matter of convenience" <i>{i.e., </i>no great effort needed to perform the activity alone, but someone willing to share the effort), the other "help is absolutely necessary" <i>{i.e., </i>an important goal completely inaccessible without the assistance of another). We can then determine the points at which help will be welcomed by injured and noninjured persons. Judging from the data we have, we would expect that the point of acceptance of help by those of the injured who wish to be as much like the non injured as possible will not in general coincide with that chosen by the average of the non injured subjects but will be nearer to the point of "help is absolutely necessary." Thus, when the injured person in speaking about help says, "Treat me like anyone else," he may not mean "Give me as much help as you would a non injured person for whom a task is inconvenient." Instead, he may mean "Do not help me; a noninjured person would not require help in this situation." </p> <h4> <i>Unrealistic Attempts to Achieve the Noninjured Standard</i> </h4> <p> The unrealistic means toward being considered noninjured are the attempts to deny that an injury makes any difference whatsoever, either to the person himself or to anyone else. The injured man should forget and others should forget; if both would forget there would be no difficulties: </p> <blockquote><p> [Interviewer: How should a person go about adjusting?] <br /> I think he should forget about it. People should just forget what happened. If he doesn't think of it, it won't bother him. </p> </blockquote> <p> Two reasons seem to support the belief in this literal kind of forgetting. First of all, in the highly emotional striving for adjustment, the aim and the means are not sharply distinguished. "I wish my injury would be forgotten," and "It can be done by actual forgetting," merge together in an emotional state which leads to primitivization in thinking. </p> <p> Secondly, the injured man does many things without feeling like an injured person. When he is in a bar, reading the comics, discussing political affairs, and so on, the thought that he is an injured person may not enter. In such situations he escapes the painful devaluative feelings associated with his loss. Temporary forgetting which the injured man does experience may make him believe that he can forget the injury most of the time. </p> <p> Temporary forgetting may not be altogether valueless in the process of adjustment. It may provide much needed emotional relief before one can again become involved with the problems brought about by other adjustment attempts. Consideration of problems connected with the injury goes on at the emotional level with such intensity that temporary escape may be welcomed as a psychological rest from too much strain on the organism.<a style="text-decoration:none;">*</a>But the injured person realizes in time that it is not only hard to forget what exists but that also so much happens which may "remind." Thus an injured man who said, "You can forget you are hurt if everybody ignores it," a few sentences later complained, "If you go out you can hardly go through a day without people asking you about it." And reminding is not due only to the incorrigibility of the non injured. A person who wears a prosthesis, for example, has to put it on and take it off. The injured often has to enter situations in which other people are handicapped, and again he is reminded. Thus even if one could willfully forget, one would constantly be reminded by new occurrences. The wish and the impossibility of forgetting are brought out clearly in this statement: </p> <blockquote><p> More or less forget about it is the best thing, but how are you going to forget when everybody keeps reminding you of it? I guess in time to come they won't be half as curious and will accept it. ... I don't think about it unless someone speaks about it, or if I think about something I want to do and then I think, "Hell, I can't do that." You shouldn't worry about it, but you can't forget that one moment when you got hit. But it's about the future that you think. </p> </blockquote> <p> The belief in the possibility of literal forgetting gives way, therefore, to the feeling that the injured and noninjured should behave toward each other <i>as if </i>the injury did not exist: </p> <blockquote> <p>I'd just act normal, as if nothing had happened. <br /> The happy and perfect thing is to have it ignored completely. <br /> [Forgetting?] That's hardly possible but we can all make believe. </p> </blockquote> <p> It is evident that such behavior does not really mean that the man will be considered noninjured. On the contrary, it is implicit in acting "as if" that he actually is not noninjured. </p> <p> As in the case of temporary forgetting, which has some positive aspects, so also "as if" behavior has its assets, though they be limited. The injury may be considered a personal matter, and "as if" behavior serves the purpose of keeping others from intrusion into privacy. Thus, under certain circumstances, "as if" behavior may be appropriate, especially where strangers are involved. But "as if" behavior, again as in the case of the attempt to forget, brings about difficulties in the relationships between the injured and the noninjured. When the participants in a relationship are closely associated, persistent role play has negative effects. First, if each feels that he can never relax his guard there will be a constant strain. But worse than that. It is characteristic of close relationships for the partners to share their feelings. If the formal surface behavior which is appropriate to stranger relationships persists, they will begin to feel like strangers to each other. Closeness, which is built upon easy communication, sharing of feelings, the warmth of sympathetic interactions, gives way to estrangement. Basic understanding between the persons cannot be reached. The injured person will continue to feel that he is not understood and cannot be understood.<a></a> Again, as in the case of help (page 34), the injured deviates from the actual behavior of the noninjured, for the noninjured does not ordinarily impose such restraint upon himself and does not in time of stress deprive himself of the comfort of sympathy. </p> <h4>Some Value Changes Involved in Acceptance of Loss </h4> <p> Denial that a difference exists, as we have seen, not only does not overcome difficulties; it may actually create new ones. But above all it hinders basic adjustment, for admission that a difference exists is a prerequisite for the further step of accepting the difference as non devaluating. Most important for the process which we have called "acceptance of loss" is a process of revaluation. Although this process is too complicated to permit us at present to make more than a few statements regarding either observed changes or possible ones, we can present, as an incentive to further study, the advances we have thus far made in understanding it. </p> <p> The first problem is why revaluation should be so difficult for the injured. Why, in the face of persistent difficulties, do they cling so strongly to those evaluations which hurt them? Two reasons may be mentioned. First, the injured seem to feel that, since abnormality of the body connotes psychological deviation or even mental abnormality to some people, they will only strengthen this impression should they maintain values which differ from the noninjured's viewpoints and ideals. Second, and most important, is the fact that to produce value changes on the emotional level is at least as difficult as to change the needs of the person. Though one may easily convince a person intellectually of the advantage of adhering to different values, their actual integration within the value system of the person is bound to meet resistance. This is understandable if we consider that single values are not independent from other values of the person, so that one change in the value system necessitates making changes in other values or giving them up. </p> <p> Some of the value changes which we believe would do much to overcome suffering from loss may be examined in the light of certain considerations brought out in the discussion of devaluating misfortune. First, devaluation will be diminished to the extent that the values lost are felt to be nonessential for the evaluation of the person when the scope of values is enlarged to include other personal characteristics. Second, devaluation will be overcome when the values lost are regarded as asset values rather than as comparative values. A third possibility, viewing the value lost as a possession value rather than as a personal characteristic (page 22), doubtless has ad justive significance, but this will not be further elaborated here. </p> <h4> <i>Enlargement of Scope of Values</i> </h4> <p> We may describe two examples in which enlargement of scope of values takes place.</p> <p><i>The State of All-Inclusive Suffering. </i></p> <p>For the injured person to see the lost values in a larger setting of other values is of special importance in the case where he feels he has nothing more for which to live. The problem then is to bring about the emotional realization of the existence of other values. Some injured subjects have admitted that in the initial stages their suffering was so acute, the experience of loss (of both personal and social values) so overpowering, that the idea of suicide presented itself. In such a state the loss seems to pervade all areas of the person's life. Whatever he thinks about, whatever he does, he is troubled, pained, and distressed. There is no differentiation between areas of the person which are and are not injury connected. All that matters are the values affected by the injury, and they are lost. No other values in life are important or even exist. </p> <p> There are two characteristics of such a state which make the thought of suicide likely. First, the perception of only a single area which is characterized by suffering means complete devaluation of one's life. Moreover, the suffering seems to be boundless, not only in extent but also in time. If no other area is seen, then there is nothing to which one can hope to change. The only hope of escaping suffering is to leave life altogether.<a style="text-decoration:none;">*</a> </p> <p> Fortunately, such black depression and despair does not persist in most of the injured who experience it. There is a gap in our knowledge as to just how it is overcome, but what is necessary is the perception of something besides suffering in life. It may be that, when the decision to commit suicide is made and when only execution of the plan remains, the injured may look back at what will be given up: suffering <i>and life. </i>When fighting against living further is no longer necessary, as it is before the decision is reached, life itself may be seen as a value. At such a moment this sudden experience of something else than suffering may be sufficient to give the first hold and with it the feeling of hope and strength which we have called the "stamina experience," so distinctive and easy to recognize when encountered, although difficult to convey, that it was named long before its place in problems of value change was seen. </p> <p> Those who have had the stamina experience know that life is worth living again. They feel that'' they have been all the way down to the last door and come back," that no other enemy will ever be so formidable. The realization that the essential value of life is regained means that the unbearability of the situation has been overcome. It means that the person is able to attend to what life holds for him, to begin to appreciate the fullness of meaning of having what he does have. As one very severely injured man put it: </p> <blockquote><p> You gradually see that there is more to life than you thought possible. . . . They all think at the beginning that they are no good. Why there was a fellow here the other night who had a couple of fingers missing, and you would think there was nothing worse under the sun. And I said to him, "Well, son, you still have a pair of arms, a good pair of legs, a good pair of eyes. Why just think of it! I would be glad to have a good pair of anything." </p> </blockquote> <p> Another injured man stated: </p> <blockquote><p> I have a sharper appreciation of things I valued before health, happiness, comfort, friendship. I am a hedonist. I feel lucky for just being here.</p> </blockquote> <p>And still another calls it a "conversion to life": </p> <blockquote><p> Before, when I would try to analyze myself, I would come against a blank wall. F'or seven months I don't think half the time I knew what was going on. . . . Some things have become more important that before seemed so unimportant, and consequently less important the other things that seemed so important before. ... I never had a clear conception of what it meant to live. In other words, I have come to the conclusion that most people go through life and never accomplish anything. They just live. They eat and sleep. . . .Cows I call them . . .They just grow and disintegrate. ... I feel that if I don't make a contribution what's the use of having come back alive. I don't want to waste my life now. . . . [Interviewer: It's almost a religious experience.] Well, it's a complete change. . . a conversion to life. Religion is another thing. . . . You have got to dance, to laugh, and have your fun, but also you can put your aims on a higher plane. </p> </blockquote> <p> The injured frequently maintain that "It is up to the man himself," to overcome the depression in the acute suffering stage. In other words, perception by an outsider that something other than suffering exists is felt to be unconvincing to one who is within the area which seems all pervading. Some injured therefore state that the depressed one should be left alone. Others, however, try to overcome what they call "self pity" in a friend by scolding and ridicule: </p> <blockquote><p> That's all within the man himself. I have seen them when they haven't anything to live for after the injury. [One guy] wasn't eating, feeling so sorry for himself. I called him everything but a gentleman. I called him everything I could think of. After that he started eating. </p> </blockquote> <p> The fact that the friend is hurt and feels these insults to his manliness means that he discovers at least pride as a remaining value. As different as the overcoming of depression by oneself or with this sort of "help" may be, they have in common the finding of a value at a time when every value is lost. </p> <p> The method of hurting the injured man during depression should not be given as a recommendation to the noninjured. Such behavior on the part of the noninjured would simply intensify the feeling of being devaluated. When the injured use this method it means "He is not devaluating me for being injured but for being unmanly." At the same time, the injured friend is there as an example that one can be injured without feeling that everything has been shattered. </p> <p> What the conditions are which give the values of manliness, of pride, the power to restructure the meaning of the lost values so that they no longer dominate the person's life needs further investigation. Though the lost values may retain their importance, the stamina experience brings with it the strength and hope which make the injured person feel that he is ready to live further <i>in spile </i>of difficulties. An important condition toward overcoming devaluation is thereby realized. The injured state is no longer regarded as an unadjustable one. At least in the sense of being able to make a go of it in spite of difficulties, the person feels he can adjust (page 24). But though the worst consequences of loss may be avoided through enlargement of scope of values, it does not mean that all suffering is overcome. It does mean, however, that the person has been faced with the necessity for revaluation. He has had to see the place of the lost values in his whole value system. In this way he is a step ahead, for adjustment, when the person is not in a depressed state, also entails value changes. </p> <p> <i>The Problem of Appearance. </i>A person may be bothered by his appearance because he feels that it discounts his attractiveness to others. The injured person may believe, for example, that when someone looks at him his scar is seen and nothing else matters. We propose that devaluation due to damaged appearance will be diminished to the extent that surface appearance is felt to be nonessential for the evaluation of the person when the scope of values is enlarged so that surface appearance is included within personality appearance. Actually, the perception of the appearance itself may then change so that it is seen in light of the personality. Thus, whatever the objective condition of the surface appearance may be, when one reacts positively to the person the appearance may be felt to be attractive. Of appearance, a man who was undergoing plastic surgery had this to say: </p> <blockquote><p> Some people who you can look at their picture and say that they are extremely homely and yet the people who know them will swear that they are good looking. I heard that people used to think that Lincoln was very handsome. A man could not grow an awful lot homelier than Lincoln. . . . There are certain things in a man's face that are an indication of his character, and if those things are what you like they make him good looking despite the fact that his features are a little irregular. </p> </blockquote> <p> In this case the attractiveness of a person is determined not primarily by a smooth, unblemished surface appearance but more decisively by his personality, from which scars may not detract. </p> <p> Many people quite naturally judge a person's attractiveness in terms of his personality. Under certain circumstances it seems that the influence of personality recedes to the background while that of surface appearance becomes the focus of attention. In the case of the injured, primacy of surface appearance leads to devaluation, so that the integration of surface appearance within the context of personality should diminish suffering. The conditions which determine the primacy of personality or surface appearance is a problem requiring special investigation. </p> <p> We present below an excerpt from an interview with a person who has a severe facial injury. During the interview, the evaluation of the appearance or attractiveness of a person is seen to change from surface appearance to personality appearance: </p> <blockquote><p> <i>Subject: </i>Undoubtedly at first it is a great shock to a person's family their loved ones when they see him with his features changed from what he was before. It is a great shock at first. They have to be around him for a while before they realize that fundamentally he is not changed. <br /> <i>Interviewer: </i>Do you think, actually, it is a big shock? I don't think so. I am speaking from my own experience, I am asking you, what do <i>you </i>see in a person you meet a new person what do <i>you </i>see? <br /> <i>Subject: </i>The first thing you see is his appearance. <br /> <i>Interviewer: </i>Why do you say that? The first person you saw here was John Hall. When he came in, what did you see? <br /> <i>Subject: </i>A fine looking young man a gentleman. <br /> <i>Interviewer: </i>Now, has gentleman anything to do with a scar? <br /> <i>Subject: </i>No. <br /> <i>Interviewer: </i>Now let us say there is a new doctor on the ward. He comes in. What do you see? <br /> <i>Subject: </i>It is hard to say. If he has a strong personality, the first thing you see is his personality. Is he capable? How he approaches you. <br /> <i>Interviewer: </i>That is it. Myself, I think is it a nice person? Do you see? It is the kind of person. What kind of a nose? Do you remember the kind of nose John Hall has? What kind of mouth he has? <br /> <i>Subject: </i>Not distinctly. But if there had been something outstanding, for instance a bad scar, you would remember, wouldn't you? <br /> <i>Interviewer: </i>Now, for instance, when you look at the patients in the hospital, what do you notice about them? <br /> <i>Subject: </i>The boys, when you first see them, you notice first their scars. <br /> <i>Interviewer: </i>The first moment? <br /> <i>Subject: </i>The first moment. That is the hard part. <br /> <i>Interviewer: </i>How long? <br /> <i>Subject: </i>Until he says something. Then you start getting an idea about his personality, and once you start thinking of him as he really is, you don't think of his scars. You don't remember them. <br /> <i>Interviewer: </i>You can see the nose of a person, but when you speak to a person you don't notice the nose. You notice the personality, because you see you looked at John Hall, and you only saw the personality. <br /> <i>Subject: </i>The way I was impressed that is the way I was impressed. That is new. I hadn't thought of that before. </p> </blockquote> <p> In the above example, the attractiveness of a person is seen primarily in terms of the more inclusive personality appearance rather than in terms of surface appearance. If this is a lasting change, then we can expect that for this subject devaluation of the injured due to damaged surface appearance will be diminished. </p> <h4> <i>Change from Comparative Values to Asset Values</i> </h4> <p> Two situations involving a change from comparative to asset values may be described. </p> <p> <i>The Problem of Mourning. </i>A person may mourn his loss because the personal satisfactions which the object of loss gave him in the past are now denied him. For example, the injured man may feel, "With the old leg I was free to move, to jump, to run, to play. I could move it, move with it; it moved me." Overcoming of mourning does not require a lowering of the level of aspiration (being satisfied with less), nor does it require depreciating the object of loss. What seems to be necessary to overcome mourning is a change in relationship to the object of loss. </p> <p> In the case of loss of a person, the one bereaved must recognize that, although further <i>interactions </i>with the person are impossible, a <i>relationship </i>nevertheless can still persist. Some of the values which they had formerly shared, and which, in his first grief, he may have seen as dependent upon the presence of the lost one, can be kept. He can do what the loved one would have done and wanted him to do. He can bring up his children to observe the traditions which his wife had begun. Then he can look back upon the past with tenderness rather than rejecting any painful reminders of it. </p> <p> Some similarities may be found in the change of relationship to the lost object which is necessary in the case of the injured. An amputee, for example, has to feel that the most essential functions which the limb had formerly enabled him to perform can be carried on by the stump and the prosthesis. He has to feel that he is still an intact organism, a whole man. A change of feeling has to take place from that expressed by one subject: </p> <blockquote><p>What does she see when she comes in? Half a man lying on the bed. . . .</p> </blockquote> <p>to that expressed by another:</p> <blockquote><p>I am a long way from worthless. I am still a good man without the leg.</p> </blockquote> <p> Such a viewpoint implies that one turns to the satisfactions existing in the present and does not derive essential satisfactions or dissatisfactions from comparison with the noninjured state in the past. It means that a leg as a value has changed from a comparative value (without which one is inferior) to an asset value (a good thing when it is present). If such a change takes place on the emotional level, the past can be remembered without pain but with tenderness with that tenderness which old people not infrequently feel toward the reminiscences of their youth. The two states of the person before and after the change can be described as, first, "I am nothing but an incomplete noninjured person who has always to mourn his loss," and, second, "I am as I am, and though I don't have all the possible values which can be <i>imagined, </i>my life is full." </p> <p> <i>The Problem of Disability. </i>The change from comparative to asset values is indicated not only when the person suffers because of personal loss as described above but also when he suffers because of loss which is socially evaluated. As an example, we shall consider the disability aspect of the injury. </p> <p> To call someone disabled implies that <i>performance </i>determines the evaluation of the person. In our society, people are frequently compared with each other on the basis of their achievements. Schools, for example, are predominantly influenced by the achievement or product ideology. High grades are given not to the one who worked hardest but to the one who performed best. Under certain circumstances, of two who reached the same performance level, the one who did so with greater ease is considered the better. He is seen as potentially a better producer than the one who had to work harder. Thus, effort is not always considered as a positive value but, paradoxically, sometimes as a liability. </p> <p> If one would follow the maxim which also exists in our society to the effect that, "All that is expected of you is that you do your best," it would mean that the person would not be compared with others in regard to ability; it would mean that his own state matters and thus that it does not matter whether he lost or lacks ability. Actually, one wishes to say, a person does not lack ability; he can only <i>have </i>it. In everyday life we do evaluate as equally good citizens those who pay taxes according to their financial state. The injured who applies himself with effort contributes the most that he can as a <i>person. </i>Though the unsatisfactory physical tools of his body may have limited his production, his personal contributions are at the maximum. As a <i>person </i>he is not different from the noninjured. </p> <p> Effort as a basis for evaluation is observed in the injured. A bilateral amputee stated: </p> <blockquote><p> Sorry is for someone who does his damnedest but still he is physically unable to accomplish what he does in the best way. Pity is for someone you feel like he isn't putting everything into it. Not up to standard, up to what you judge by. Maybe I am wrong but that's the way I think of it. </p> </blockquote> <p> This man expresses the thought that, in addition to the scale of achievement ("accomplishing what one does in the best way"), there is another scale, that of effort ("doing one's damnedest," "putting everything into it"), and that devaluation ("pity") should be reserved for those who are lower on the effort scale. Only those who do not put forth sufficient effort should be judged as "not up to standard." </p> <p> Why bring up the change from one comparative value (the product achievement value) to what appears to be just another comparative value (effort) when we are discussing the change of comparative values to asset values? It is true that effort, in this case, is seen as a comparative value, but when effort becomes the yardstick by which a person judges himself, then the <i>values lost </i>are changed from comparative to asset values. Greater ability or achievement becomes a good thing when it exists, but not a loss, or a lack, or a disturbance when it is absent. Such a change is but one among others that are required for the person to perceive his existing state as valuable rather than as a crippled, noninjured state. </p> <p> These differing evaluations of one's existing state have important consequences. The particular problem which we should like to discuss as an example is the effect of the two evaluations on the readiness of the person to improve wherever realistic improvements are possible and on his persistence in bettering his state. </p> <p> It would seem at first glance that maintaining the noninjured state as the standard would have the advantage of leading the injured to increase his efforts, for example in dealing with the physical environment. The injured would desire the best prosthesis, try to improve in using it, and learn as many skills as he could in order to be able to perform the physical tasks which the noninjured can perform. But the desire to be able to handle the physical world does not stem only from the wish to be as much like the noninjured as possible. We even doubt that the desire to be as good as the noninjured is helpful. The injured person who emotionally desires to be noninjured will see even objective improvement over previous performance as still falling short of the goal and hence failure. The same objective improvement can be seen as success (in comparison with recent performance) or failure (in comparison with the noninjured). The following two examples illustrate the different feelings resulting from the different evaluations of one's present state. In the first, "always wondering whether I could have done better" indicates feeling of failure, in the second, "enjoying learning over again" a feeling of success: </p> <blockquote><p> We'll be satisfied with less but there'll always be a little bit of doubt as to whether we could have done a little bit better without it. Maybe I'll be able again to play a good game of golf, but I'll always wonder whether I could have done better. ... In some part of your mind you just have to check off the fact that vou're missing something extremely valuable. </p> <p> The more you learn to use it the less it bothers you. If it's just hanging it will. . . . The more I learned the better off I was. ... I figured it was gone so I might as well see what to do about it. ... I enjoy learning to do things over again. It offers a challenge to you. I think, "What's the best way?" before I start fooling around. </p> </blockquote> <p> It seems reasonable to expect that, if a subject feels he is improving, he will hopefully continue. If he is constantly frustrated by unsuccessful attempts, forces away from the unreachable goal and disruptive emotional effects will appear.<a></a> </p> <p> Our discussion is of value for an important practical problem of the amputee. In trying out a new, technically improved prosthesis, some of the injured feel that it is an improvement and others do not. Besides the question of the physical fitness of the prosthesis for the individual, psychological conditions leading to the different reactions are important. It would be promising to study whether those injured who are dominated by the noninjured standard are more easily dissatisfied with the new prosthesis than are those who consider their postinjury state as valuable. We predict that the former group will more easily be disappointed because, in comparison with the noninjured standard, the results obtained with the prosthesis can be seen only as a failure. The latter group, however, will recognize any actual improvement and consequently will be encouraged to continue using the prosthesis. Those who maintain the noninjured as their standard require psychological adjustment before they will be able to accept an objective improvement as such rather than as a new indication of the unreachability of the noninjured state. We venture to say that only if the postinjury state is taken by the subject as a basis for comparison can he make valid judgments as to the advantages of the technically improved prosthesis.<a style="text-decoration:none;">*</a> </p> <h4> <i>Conclusion</i> </h4> <p> Acceptance of loss is seen as involving changes in the value structure of the person. We have pointed out only some of the changes which may lead to acceptance of loss. Clearly there are others. Our statements have to be taken as suggestions for further research rather than at their face value. We discussed four kinds of situations: <i>a, </i>overcoming all inclusive suffering; <i>b, </i>overcoming mourning; <i>c, </i>overcoming devaluation produced by damage to appearance; and <i>d, </i>overcoming devaluation produced by physical disability. </p> <p> The kinds of value changes that may alleviate the suffering in these situations are closely connected with those value preconstructs discussed under <i>Misfortune and Devaluation </i>(page 22). The value change involved in <i>a </i>and <i>c </i>can be seen as one in which enlargement of the scope of values takes place. In the case of all inclusive suffering, enlargement of the scope of values is the first step toward the possibility of acceptance of loss, since the main problem here is to regain, psychologically, values other than those lost. In the case of devaluating appearance, enlargement as such is not in itself an advantage unless with the enlarged scope of values the values lost are seen as relatively nonessential. In both cases, the person will maintain the noninjured standard and regard the values lost as comparative values. Thus, the person may still devaluate himself, for instance when a particular situation arises in which enlargement is made difficult. </p> <p> The value change involved in <i>b </i>and <i>d </i>can be seen as one in which the values lost are regarded as asset values rather than comparative values. In this case, the person feels that his own state is a worthy one. When, instead of selecting unreachable states as a standard, he turns to what he has and can reach, life can be seen to offer more than he can possibly avail himself of. He frees himself from devaluating comparisons with a ghost ideal of a different but actually not better person, the noninjured. Thus, acceptance of loss seems to be more fully realized through the second type of value change. </p> <h4> Acceptance of Personal Loss and Reaction to Social Loss </h4> <p> The injured person who has accepted his personal loss will feel one way about the discriminatory attitudes of the noninjured. He who has not accepted his loss feels another. The social loss of the injured person his feelings of nonacceptance as a group member has a basis in reality. Whether or not the person has adjusted to his loss, therefore, he will experience difficulties in his relationships with noninjured people. But the reaction in the two cases will be quite different. </p> <p> Where the person devaluates himself because of his loss, he will feel that his nonacceptance by others is largely justified. He will agree with the other group members that a noninjured person is more valuable, more likeable, more worthy. He will suffer keenly that he happens to be on the short end of this relationship, but he will see it as an unavoidable and natural fact, to be supported as morally valid. He will feel that no one can change this state of affairs that one can perhaps try to behave "as if" he were non injured but that emotional devaluation of him must prevail. </p> <p> If, however, the injured person has accepted his loss, he will not devaluate himself. He will consider himself an equally worthy member of the group and thus feel that he should be fully accepted by the group and have access to the values which the group can offer. He will see that it is the maladjustment of the noninjured toward injuries which leads them to devaluate and reject him, a fact which hinders him from having access to the values of the group. He will see that the locus of the difficulties is not in the injured who adjusted to his personal loss, not in the natural, lawfulness of devaluation of the injured, but in the noninjured. </p> <p> A considerable part of the suffering due to nonacceptance by others is thereby removed. Because the negative evaluations of others are seen as unwarranted, because the injured person does not blame himself, they hurt less. Instead, the person who holds them may in turn be devaluated and seen as ignorant or prejudiced. This counterdevaluation also may serve to diminish suffering from social loss.<a style="text-decoration:none;">*</a> </p> <p> Whereas the maladjusted injured person wishes to be accepted by the noninjured though he feels he ought not be accepted, the adjusted injured person will care less to associate with those whose values he does not share or respect. The adjusted injured person gains a considerable degree of emotional independence and freedom from the noninjured. This does not mean that the injured person does not and need not care about how the noninjured receive him. Even though he may not care to associate with a given person, he does wish to maintain close relationships with others. Moreover, in a world dominated by the noninjured, it is often the noninjured who determine whether the injured person can have access to important values such as jobs and group memberships of many kinds. Thus it is of vital interest to the injured that the noninjured become adjusted to injuries. </p> <h4> Acceptance of Loss By the Noninjured</h4> <p> Acceptance of loss is of great importance not only to the injured. Persons close to the injured (that is, those who are in the position of sharers), as well as the large number of non injured who have little to do with injured people, have much to gain from healthy attitudes toward injuries. The sharer suffers not only because the injured person suffers (sympathy) but also because he too experiences a loss (personal and social loss). A wife may feel the loss of her husband's leg just as personally, just as deeply, as the husband himself. The sharer has, therefore, to accept the loss just as does the injured person before suffering may be overcome. It is of extraordinary practical importance for an injured man to realize that his closest sharers his wife, mother, and so on cannot be expected to accept the loss immediately. Just as he has to go through the struggle to accept the loss, so does the sharer. </p> <p> For the nonsharer, adjusted attitudes toward injuries do much to free him from anxieties regarding bodily harm. He still will continue to regard body whole as a value, but as an asset value and not as a comparative value. The loss, then, is regarded as an adjustable state and not as a catastrophe. Consequently, in threatening situations, he would not become careless about his safety, but the anxiety would be reduced to realistic fear. </p> <p> Since acceptance of loss has adjustive significance for all persons, the question arises as to how the noninjured may be brought to face it as a problem. The need to attempt to accept the loss exists in noninjured sharers, for they also experience a loss. But what about nonsharers? In general, they do not feel the necessity of imposing upon themselves the problem of adjusting to injuries. They may feel uncomfortable in the presence of an injured person, they may devaluate the injured or wish to diminish his suffering, but they do not see the suffering as <i>their </i>problem. Not only do they feel that real acceptance of this kind of loss is extremely difficult; what is more important, they do not feel that they should try to accept it. The general attitude may be described as, "Problems of visible injuries are special problems. They do not actually concern me." </p> <p> At least two groups of people not in the position of sharing a loss with an injured person may consider more closely their feelings toward injuries. First, there are people who are bothered by social justice. When considering injured people, they may question their own attitudes, since negative feelings toward a suffering part of humanity are regarded as unjust and intolerable. As they puzzle, they may discover their own basic nonacceptance of injuries and struggle to see the loss as an adjustable and acceptable state. The second group consists of those people who have a general need for self adjustment in whatever area anxiety is felt. Just as a person who is frightened when climbing a mountain may wish to ascend again in order to overcome the fear, so may a person who feels uneasy about body welfare wish to meet the problem of non acceptance of loss. </p> <h3> Chapter VIII: Direction of Further Research </h3> <p> The study of adjustment of any kind, including acceptance of loss, requires the investigation of, first, the conditions C₁ and C₂underlying the nonadjusted and adjusted states, respectively, and, second, the conditions leading to change of condition C₁ to condition C₂, expressed as ch(C₁ --&gt; C₂). That is, two distinct tasks are involved: first, there must be determined <i>what </i>has to be changed to <i>what </i>and, second, <i>how </i>the change takes place. The study reported here deals only with the first task, that is, with the determination of conditions of nonacceptance (C₁) and acceptance (C₂) of loss. </p> <p> For the determination of what has to be changed to what, manifestations of the two conditions C₁ and C₂ have to be observed. These manifestations, or events, which in our case were the statements by injured persons concerning nonacceptance and acceptance of loss, were the raw data on the basis of which the underlying conditions C₁ and C₂ were specified. Conditions C₁ and C₂ are always specified in terms of constructs and their interrelationships; the underlying conditions in our case are value statements on the conceptual level. </p> <p> Once C₁ and C₂ have been determined, further research should take the direction of systematic search for and examination of the manifestations of ch(C₁ --&gt; C₂). As the result of our study, we know that conditions C₁ and C₂involve different value structures. The conditions of value change could then be studied by designing experiments which would promote value change and permit the observation of its manifestations. </p> <p> We will now suggest two examples of situations in which value change may be brought about. Both are designed to have the subject himself try to bring about the change. </p> <p> First example: The injured man is asked to try for one day to accept the role he usually resists taking, namely, the injured role. The injured role does not mean one of overde pendence and self pity. Rather, it means that the person does not go out of his way to appear noninjured. He is encouraged, for example, to take advantage of offers of special consideration by others which will make things easier for him. He may also be asked to discuss a personal matter related to his injury with someone to whom he feels close; this should be a matter which in the past he has refrained from bringing up. For that day he has to abandon the noninjured role as the ideal and accept the injured role as the one to strive for. He may succeed in changing, and report these changes, or he may fail and report the difficulties. In either case, a gateway is opened for analysis of the conditions of change. </p> <p> Second example: An injured man is asked to note events, situations, and interpersonal relationships occurring during the day which are and are not injury connected <i>(i.e., </i>whether the event included any aspect of the injury). He is asked to consider further whether the injury entered in a positive, negative, or neutral way. Finally, he is to examine, for alternative interpretations which give them a more positive character, those events which he characterized as negative. For example, the events noted may have included a lift on the way to work (injury connected, positive), staring by someone in the elevator (injury connected, negative), or dictating letters (not injury connected). Crucial for the study is the instruction given to the subject to search for a change in the character of the injury connected negative events. In the elevator example, the subject may come up with the statement that not all staring needs to be staring at an amputation; someone might stare when he is in deep thought about his own personal concerns. In searching for a substitute for the negative character of the event, the injured person thus restricts the all inclusive ness of the devaluating injury so that other values become available. As in the preceding hypothetical experiment, analysis of these attempts at changing values should lead us to the specifications of the general conditions of value change. </p> <p> In returning to our study here reported, we want to mention a number of value constructs related in pairs to C₁ and C₂. These are: comparative values <i>vs. </i>asset values, personal properties <i>vs. </i>posessions, and all inclusive value loss <i>vs. </i>partial value loss. The conditions of change from one member of a pair to the other, ch(C₁ --&gt;&gt; C₂), are yet to be determined. </p> <p> These changes, we believe, are only a few of the necessary changes involved in acceptance of loss. One can be sure that acceptance of loss does not imply only the value changes mentioned above, nor only value constructs. </p> <p> Although much further study of C₁ and C₂ is indicated, we feel enough is already known to encourage investigations of ch(C₁ <i> --&gt; </i>C₂). The knowledge to come from such investigations should provide a systematic basis for understanding and aiding the psychological adjustment of the injured. </p> <h3> Acknowledgments </h3> <p> The research project which gave rise to this article might never have started without the encouragement and advice of many people, and in particular of Gordon W. All port, Roger G. Barker, Karl M. Bowman, Albert A. Campbell, Dorwin Cartwright, Lawrence K. Frank, Kurt Lewin, Rensis Likert, Ronald Lippit, Jean W. Macfarlane, Donald G. Marquis, David Shakow, George D. Stoddard, and Donald Young. The active interest and hospitality of Roger G. Barker, Alvin C. Eurich, Paul R. Farnsworth, Ernest R. Hilgard, Quinn McNemar, Calvin P. Stone, Edward K. Strong, and Lewis M. Terman provided a home for the project at Stanford University. </p> <p> The Advisory Board included Ernest R. Hilgard (Chairman), Roger G. Barker, Paul R. Farnsworth, George S. Johnson, Donald E. King, Quinn McNemar, and Calvin P. Stone. Their interest and support helped us to complete this phase of the investigation. The research staff included Dan L. Adler, Tamara Dembo, Eugenia Hanfmann, Helen Jennings, Gloria Ladieu Leviton, Milton Rose, Ralph K. White, and Beatrice A. Wright. </p> <p> The findings are the result of a group endeavor. Some of the members were unable to continue for the whole period, however, and the three acknowledged authors take responsibility for whatever in this paper is subject to criticism. </p> <p> The investigation was furthered by the productive thinking and hard work of Donald Glad, Verda Heisler, Marguerite Q. McFate, and Alice Phillips Rose, all Research Assistants. The following students contributed not only their technical skills but also stimulating and fruitful ideas: Dorothy Groesbeck, Ruth Katz, J. Maurice Rogers, Heber C. Sharp, Nancy Starbuck, William L. Thompson, Helene Veltfort, George Gromeeko, and Marjorie Dwyer. Our secretaries, to whom we are much indebted, were Bertha Bull, Joan Glad, and Joyce James. </p> <p> We highly appreciate the cooperation of the staff and patients at Dibble and Bushnell General Hospitals. To all who served as subjects we are most grateful. </p> <p><b>References:</b></p> <ol> <li>Adler, D., G. Ladieu, and T. Dembo, Studies in adjustment to visible injuries: social acceptance of the injured, J. Soc. Issues, 4:55 (1948). </li> <li>Barker, R. G., B. A. Wright, L. Meyerson, and M. R. Gonick, Adjustment to physical handicap and illness: a survey of the social psychology of physique and disability, Social Science Research Council, New York, Revised 1953. </li> <li>Dembo, Tamara, Der Aerger als dynamisches Problem, Psychol. Forsch., 16:1 (1931). </li> <li>Frank, L. K., Time perspectives, J. Soc. Phil., 4:293 (1939). </li> <li>Ladieu, G., E. Hanfmann, and T. Dembo, Studies in adjustment to visible injuries: evaluation of help by the injured, J. Abnorm. and; Soc. Psychol., 42:169 (1947). </li> <li>Lewin, Kurt, Richtungsbegriff in der Psychologie, Psychol. Forsch., 19:244 (1934). </li> <li>Lewin, Kurt, The conceptual representation and the measurement of psychological forces, Duke University Press, Durham, N. C, 1938. </li> <li>White, R. K., B. A. Wright, and T. Dembo, Studies in adjustment to visible injuries: evaluation of curiosity by the injured, J. Abnorm. and; Soc. Psychol., 43:13 (1948). </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">This is a good example of how changing a onesided relationship to a mutual one changes the meanings which the relationship originally had for the person (page 9). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">A similar practical problem is raised in a much more general area. If ones own state is felt to be valuable, should not comparison with oneself in performing activities be a better incentive than comparison with others and, if so, should not this guide our educational procedures? </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Dembo, Tamara, Der Aerger als dynamisches Problem, Psychol. Forsch., 16:1 (1931). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">In the present state of knowledge, we are not able to state whether those who consider or commit suicide after acquisition of a physical injury have had pronounced neurotic trends which prevent them from standing the additional stress of the unfortunate position or whether an otherwise stable individual but with an extreme evaluation of the fortunate position may consider or commit it Also, we may ask whether the extreme evaluation of body whole and bodybeautiful is not itself an expression of instability or strong neurotic trends. There was a time, not so long ago, when little attention was paid to the problems of the good, quiet child; only the boisterous child was considered a problem. Similarly, high self esteem and satisfaction with ones appearance or any other fortunate position is considered healthy and only lack of self esteem is felt to be a problem. We think that extreme self esteem on the basis of comparison with the unfortunate position of others may be an unhealthy and dangerous state of unpreparedness to meet situations of loss or misfortune. From the standpoint of mental health, little attention is paid to preparedness for psychological suffering. Attitudes toward misfortune, as is the case with any other emotional attitudes, need educational and sometimes therapeutic guidance.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">White, R. K., B. A. Wright, and T. Dembo, Studies in adjustment to visible injuries: evaluation of curiosity by the injured, J. Abnorm. and; Soc. Psychol., 43:13 (1948). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Activities which separate one sufficiently from emotionally intense conflicting and frustrating contents seem to give one the possibility of recuperation. To shift at will to less emotionally intense situations, i.e., temporary forgetting, is a blessing and sign of psychological well being or health. When one is under strain, he seems to need it more, but frequently the shift is more difficult. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Ladieu, G., E. Hanfmann, and T. Dembo, Studies in adjustment to visible injuries: evaluation of help by the injured, J. Abnorm. and; Soc. Psychol., 42:169 (1947). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The study of congenital cases, or those injured in early childhood, would be important for understanding problems of acceptance of loss. Do these people differ in their value systems from those who are injured later in life? It would also be important to study the value structure of those who experienced gain after loss, who changed from a handicapped to a nonhandicapped position (e.g., cured cardiac cases and cases of arrested tuberculosis).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Ladieu, G., E. Hanfmann, and T. Dembo, Studies in adjustment to visible injuries: evaluation of help by the injured, J. Abnorm. and; Soc. Psychol., 42:169 (1947). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The postulate that the speed of emotional processes is greater than the speed of intellectual ones leads us to further statements. First, in a unit of communication in which a single intellectual thought is conveyed, we can expect to find several emotional meanings. Second, the speed of emotional processes is greater than the speed of intellectual control of them (if we assume that intellectual realization is a prerequisite for intellectual control). Thus, in communication we sometimes convey more than we intend since intellectual control cannot keep pace with feelings. The phenomena of the piling up of emotional meanings (first statement) and of covert meanings (second statement) can be shown if a record of communication is made and if we have enough time to analyze each emotional connotation separately. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">This study deals with loss, and therefore with distress situations. Omitted in the rest of this chapter are the modifications and extensions which would be necessary to take account of joy and other emotions that could be shared.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">We do not imply that the reason for aversions is a need to escape the conflict. Nor is the reason something inherent in humans which makes it natural for them to be filled with aversion at the sight of deviations from the normal human form. The ideal of beauty, the Venus de Milo, is a bilateral amputee. The stunted feet of Chinese women were considered beautiful. The heavily padded shoulders of a few years ago exceeded the normal body form. Aversions are visual allergies, symptoms of more general psychological maladjustment and not only of conflict between positive and negative feelings toward the injured.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">For a discussion of time perspective, see Frank.4</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">It would be worth while to study this phenomenon further and, in the search for those who might put themselves below the average, to take as subjects prisoners and different groups of mental patients. Interviews in connection with such experiments are indicated.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The findings concerning these relationships (except sympathy, which is discussed in the present monograph) have been reported by Ladieu, Hanfmann, and Dembo (5), by White, Wright, and Dembo (8), and by Adler, Ladieu, and Dembo (1).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">In no way do we believe that the subjects conscious perceptions of their feelings are the only data worthy of study Many other clues during an interview give us indications of hidden meanings which broaden the understanding of the persons feelings.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">One would wish that instead of imputing a lower quality to interview data, instead of stressing that how a person thinks he will act does not always correspondto how he will act, attention would be given to the specific conditions under which intentions and attitudes, given an action test, either are or are not carried out.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The validity of the interview as an instrument is a separate problem. See next column.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Lewin, Kurt, Richtungsbegriff in der Psychologie, Psychol. Forsch., 19:244 (1934). </td></tr><tr><td class="clsTextSmall"><b> 7.</b> </td><td class="clsTextSmall">Lewin, Kurt, The conceptual representation and the measurement of psychological forces, Duke University Press, Durham, N. C, 1938. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Though it may increase them.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Thous it may increase them.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall"> By preconcept we mean a term which lacks either a rigid conceptual definition or a precise operational definition. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">By structure of a social emotional relationship we mean those characteristics which, when interrelated, are necessary and sufficient to describe the nature of the relationship. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Ladieu, G., E. Hanfmann, and T. Dembo, Studies in adjustment to visible injuries: evaluation of help by the injured, J. Abnorm. and; Soc. Psychol., 42:169 (1947). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">For other methods used in the area of adjustment to physical handicaps, see the critical review of the literature by Barker, Wright, Myerson, and Gonick.2</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Adler, D., G. Ladieu, and T. Dembo, Studies in adjustment to visible injuries: social acceptance of the injured, J. Soc. Issues, 4:55 (1948). </td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Ladieu, G., E. Hanfmann, and T. Dembo, Studies in adjustment to visible injuries: evaluation of help by the injured, J. Abnorm. and; Soc. Psychol., 42:169 (1947). </td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">White, R. K., B. A. Wright, and T. Dembo, Studies in adjustment to visible injuries: evaluation of curiosity by the injured, J. Abnorm. and; Soc. Psychol., 43:13 (1948). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Beatrice A. Wright, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Research Fellow in Psychology, University of Kansas. Lawrence.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Gloria Ladieu Leviton, Ph.D., </b></td></tr><tr><td class="clsTextSmall">Psychologist, LaGrange, Illinois</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Tamara Dembo, Ph.D., </b></td></tr><tr><td class="clsTextSmall">Associate Professor in Psychology, Clark University, Worcester, Massachusetts.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1956_02_004/1956-Autumn-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1956_02_004/1956-Autumn-1b.jpg Figure 3 http://www.oandplibrary.org/al/images/1956_02_004/1956-Autumn-3.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Adjustment to Misfortune-A Problem of Social-Psychological Rehabilitation Creator An entity primarily responsible for making the resource Tamara Dembo, Ph.D., * Gloria Ladieu Leviton, Ph.D., * Beatrice A. Wright, Ph.D. * https://staging.drfop.org/files/original/8c59087dd5defe8f43e0fb7935616737.pdf 8ce43640135a5c2fa157eb5fa345410e DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1957_01_001.pdf Year 1957 Volume 4 Issue 1 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1957_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1957_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Getting Down to Cases</h2> <h5>Charles O. Bechtol, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>It is the common teaching of all experience that even the most carefully planned activities seldom follow the course originally laid out for them. Man tends to play himself through life by ear, as it were, in a series of false starts and fortunate recoveries. In all fields of endeavor, therefore, hindsight is more often than not the quality which, in the long run, keeps people going in the general direction of progress. That such is the way things are is perhaps nowhere more patent than in the evolution of the Artificial Limb Program.</p> <p>When, for example, in 1945, the Committee on Prosthetic Devices (now the Prosthetics Research Board) set out to improve the lot of the amputee population, it chose for itself the seemingly obvious, if also apparently simple, goal the design and development of new and improved artificial limb components. Because of the more or less widely held misconception, even among amputees themselves, that improved devices alone might well raise the level of the art of limb prosthetics to that existing in other fields of science and invention, the Committee established, through arrangements for contract research, a far flung program with principal emphasis on the fundamental investigation of human locomotion, on time and motion studies of the human arm and hand, and on what might by some be called professional gadgeteering.</p> <p>After a few years of organized effort on the part of engineers and prosthetists, with the consequent development of new and supposedly improved models and techniques, and after the application of experimental prostheses to amputees for initial tests of the new equipment, it became perfectly clear that, if genuine improvement in amputee service were to be had, something more would be needed. In retrospect came realization of the circumstance that no single design of prosthesis is ever apt to be superior for all amputees of a given type and, conversely, that every amputee presents in one way or another a special problem not amenable to mass treatment. Put in engineering language, the difficulty was seen to lie in the fact that dealing with the rehabilitation of amputees means dealing with a "nonstandard product," the human being. He comes in all sizes, shapes, and conditions. And his reaction to any given selection of equipment is almost always grossly influenced by his individual personal needs and characteristics—physical and mental—as well as by his activity requirements. Since most of the new devices and new methods were largely untried at the clinical level, there existed no valid criteria either for determining when components had been prescribed and fitted to best advantage in the individual case or for assessing the degree of utilization achieved by a given wearer. In the absence of demonstrable proof of successful application on a relatively broad scale, the limb industry was understandably reluctant to adopt the new ways and means with any ostensible enthusiasm. But at the beginning of the Artificial Limb Program in 1945 no one was in a position to predict such eventualities.</p> <p>Lacking, in brief, was the experience necessary for the construction of a general set of principles of amputee management. In recognition of this state of affairs, and in view of the especially challenging problems prevailing in the upper extremity, there was established in mid 1950, in the Department of Engineering at the University of California at Los Angeles, the so called "Case Study Program," with the purpose of investigating the application of prostheses to a wide variety of amputee types and of developing effective methods for evaluation of amputee service, not only with regard to the quality and applicability of the mechanical equipment but also with concern for the effect of training and of occupational, educational, recreational, and other personal factors on the final success of prescription and fitting. Intended to bridge the gap between fundamental work in the laboratory and practice in the field, and with excellent industry participation, the work continued until 1953. Analysis of the data thus accumulated continued until late in 1956.</p> <p>So fruitful was the case study work in upper extremities at UCLA that in the spring of 1953 there was organized at the University of California at Berkeley a similar investigation into the problems of the leg amputee, especially the above knee case, a matter that had already been the subject of fundamental research and engineering design at that institution since the beginning of the Artificial Limb Program eight years earlier. Again with the wholehearted cooperation of the limb industry, the so called "Clinical Study" in lower extremities has, like the UCLA Case Study, now garnered much valuable information on which to base some general principles.</p> <p>Because the experience gained at UCLA and at Berkeley represents the most reliable data available on what now constitutes good practice in limb prosthetics, the bulk of this issue of <i>Artificial Limbs</i> is devoted to a presentation of selected case histories, predominantly the histories of typical problem cases as contrasted with cases that responded readily and well to routine fitting. The balance is given over to a discussion, by one of the world's best known leaders in hand surgery, of the possibilities for surgical reconstruction of damaged hands and of the application of prostheses for the partial hand, an area which offers, if anything, even more highly specialized individual cases and which therefore has not yet been the subject of any major investigation within the Artificial Limb Program. Bunnell's contribution fills admirably what would otherwise be a noticeable gap in the coverage.</p> <p>As regards the broad implications of the case material, it is worth observing how many and diverse are the ways in which the problem of amputee rehabilitation must be attacked and how wide is the variety of skills necessarily brought to bear. In pursuit of clinical work it was found essential to enlist the participation of numerous specialists, each with his own particular interests and abilities. Functioning together, these people not only aided materially several hundred cooperating amputee subjects but at the same time contributed to their own self development and hence to the growth of techniques suitable for widespread dissemination to practicing clinic teams. Thus, in a larger sense, they laid the basis for the nationwide program of prosthetics education now so well under way. Because, in turn, the education program resulted in a vast increase in the number of available clinic teams, amputees in the United States are today reaping benefits that could scarcely have been visualized seven or eight years ago. Here then, in the results of the case studies, lies the key to continued advancement in the mastery of limb prosthetics.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Charles O. Bechtol, M.D. </b></td></tr><tr><td class="clsTextSmall">Associate Professor of Surgery and Chief of the Division of Orthopedic Surgery, Yale University; Orthopedic Consultant, Veterans Administration Hospital, West Haven, Conn.; formerly Assistant Clinical Professor of Orthopedic Surgery, University of California, and Western Area Consultant for Orthopedic and Prosthetic Appliance Clinic Teams, Veterans Administration; member, Committee on Prosthetics Research and Development, PRB, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Getting Down to Cases Creator An entity primarily responsible for making the resource Charles O. Bechtol, M.D. * https://staging.drfop.org/files/original/69040961fa14eb3de1832ed0d1d448a5.pdf df098d8f74c3d28303ceedffbfd1dcaf DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1957_02_001.pdf Year 1957 Volume 4 Issue 2 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1957_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1957_02_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Canadian Candidate</h2> <h5>C. A. BELL, B.A.Sc, O.B.E., M.C <a style="text-decoration:none;">*</a><br /></h5> <p>Throughout the 200-odd years since its inception, the surgical procedure known as disarticulation of the hip has been fraught with danger and disappointment both medically and prosthetically. On few persons has the operation been performed, and fewer still have survived for any gratifying period. Because hip disarticulation is so severe a measure, and because in recent years it has for the most part been carried out only in the attempt to forestall fatal disease, the level of medical success thus far attained has been disturbing. Because the hip-disarticulation amputee presents such a difficult problem in anatomical deficiency, his successful rehabilitation prosthetically has proved particularly evasive.</p> <p>Although even in modern times postoperative mortality from residual systemic disease has remained alarmingly high, recent advances in surgical techniques and in medicine as a whole have done much to encourage hip disarticulation where it might not otherwise have been attempted. This circumstance, together with a growing tendency toward the use of radical amputation surgery as a curative measure in cases of malignancy, has been responsible for an increasing incidence of hip-disarticulation amputees. Meanwhile, the problem of providing a reasonably satisfactory substitute for a lower extremity amputated at hip level has over a long period of years continued to be most difficult for the limbmaker and most exasperating for the patient.</p> <p>To satisfy functional requirements in amputations at or about the hip, the prosthetist has not only to furnish a limb with three simulated anatomical joints, all of which have to be stabilized in the stance phase of walking, but he must do so with only the torso and associated structures as a source of activation and control. In the absence of an adequate thigh stump, reliable management of an articulated lower-extremity prosthesis calls for the use of various locks, or equivalent, and for the coordinated action of pelvis, trunk, and remaining sound leg. The saving grace in this situation is that weight-bearing can still be provided on one of Nature's chosen seats of election, the ischium.</p> <p>The hip-disarticulation prosthesis to which this issue of <i>Artificial Limbs</i> is devoted is the culmination of many years of practical work, later combined with present-day methods of organized research and the application of new materials. Canada has had much experience in the provision of orthopedic and prosthetic appliances in the aftercare of her veterans. Early in 1916, the government of the day was confronted with the matter of supply for members and ex-members of the Canadian Expeditionary Force. After thorough investigation, it was found that existing facilities were extremely limited and unable to cope with the problem. Further, although standardization of appliances was deemed essential to provide ready maintenance or renewal accessible to the veteran's place of residence over the breadth of the country, no such standardization existed throughout the Dominion. Government proprietorship was considered the best means for keeping in touch with latest developments in prosthetics from other countries and also seemed to offer the most expeditious way of initiating a domestic program of experimental work that would be productive of results in keeping with the policy of standardization.</p> <p>The agency thus established, which today is known as the Prosthetic Services Branch of the Department of Veterans Affairs, now consists of some twelve operating centres and six visiting facilities situated in or adjacent to Departmental hospitals in the principal Canadian cities from coast to coast. The largest centre, located at Sunnybrook Hospital in Toronto, serves as the central manufacturing facility for the production of standard parts and stores for supply to all other centres. Here also is located a research section technically staffed for the investigation of new designs, materials, and techniques. Situated close to the medical and production facilities, and with patient personnel from the largest veteran area, this unit provides ample opportunity for field-testing and final approval for manufacture in other District facilities across the country. It was here that Colin McLaurin and James Foort were inducted into the field of prosthetics research and here also that, early in 1954, McLaurin brought into production the hip-disarticulation leg now generally known as the "Canadian type."</p> <p>To produce an improved prosthesis for the hip-disarticulation case was already one of the problems confronting the design section organized in 1916. At that time, the choice of willow setups, wood or leather sockets, and heavy joints did not provide for a light limb or for good control. Later, in 1926, the Department adopted the J. E. Hanger English metal limb, which included a design known as the "tilting-table leg." This limb, although of lightweight construction and representing a decided improvement over former designs, did not eliminate locks, and, moreover, the location of the hip joint directly under the ischial seat created, when the wearer sat, a pelvic tilt that was tiresome over any lengthy period. Further design work was carried out after World War II using a lateral hip joint and folding-latch mechanism. But this device, while solving the "tilt" problem, necessitated heavy construction and gave little improvement in control. Because of this discouraging state of affairs, many hip-disarticulation and short-stump above-knee amputees had long preferred crutch ambulation rather than bother with the best prosthesis available.</p> <p>The current design of the Canadian-type hip-disarticulation prosthesis was evolved by McLaurin after some three years of work in which the scope of investigation was broadened to explore more features than the height of the joint under the seat. Included were a mechanical design of the hip joint to promote walking with a free hip, an alignment that provides stability through all phases of the walking cycle, and, finally, a new concept of a plastic socket-waistband. This all-plastic member embraces the pelvis and incorporates a rather rigid band which encircles the waist. When well fitted, it provides comfortable weight-bearing, a suspension that requires only the tightening of the front restraining strap, and a degree of control which permits the amputee to move the limb freely and confidently.</p> <p>Performance on the new device by a test amputee exceeded all expectations, despite the fact that in addition to an amputation at the right hip he had suffered amputation of the right arm above the elbow. Shortly after trials, he reported his ability to walk forty city blocks with less effort than he had formerly expended in two blocks with the old-style metal limb. The ease of donning and removing the new leg with the simple yet secure suspension was impressive. Further field-testing on a larger number of hip-level amputees justified the acceptance of the design as a standard of production, and by September of 1954, through instruction and training of District fitters, it was made available on a Dominionwide basis. Some thirty-two cases have been fitted to date, and twenty-five of these have been classified as successful.</p> <p>Following the results attained at Sunnybrook, the Prosthetics Research Group at the University of California at Berkeley undertook to assess the new device and to work out improved procedures for construction and fitting, and in the spring of 1956 the Committee on Prosthetics Research and Development of the Prosthetics Research Board approved the issuance of the Canadian-type hip-disarticulation prosthesis to veteran beneficiaries throughout the United States. Here, then, is a Canadian candidate for utilization by clinic teams everywhere in dealing successfully with one of the most troublesome prosthetic problems of all.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>C. A. BELL, B.A.Sc, O.B.E., M.C </b></td></tr><tr><td class="clsTextSmall">Director of Prosthetic Services, Department of Veterans Affairs, Ottawa, Canada.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Canadian Candidate Creator An entity primarily responsible for making the resource C. A. BELL, B.A.Sc, O.B.E., M.C * https://staging.drfop.org/files/original/a7159063fb302b4a250573acb23abb85.pdf aa6c07bf41a25532666dc158ce0efc4b https://staging.drfop.org/files/original/c42f998e614f8cd33a557b45a09d067d.jpg 252589ddc51f2a80b7358f6974149b31 https://staging.drfop.org/files/original/8d6cfd7f8cac05cec1a7453dc79b69bd.jpg 4d64a6d4509dc6980e238a1a502d6547 https://staging.drfop.org/files/original/e6c5c23d894b219b103d507658c2b0ac.jpg 6e9ac58868a4f5e82d8a903c755fea21 https://staging.drfop.org/files/original/e91306e674a1c8947e9630148ddffd96.jpg ccb3e8403102657e330cce7186b530cc https://staging.drfop.org/files/original/68227ba109352f07e3866a1f452796c9.jpg 039bf222e5524b1352c7ab1b0ffd41a6 https://staging.drfop.org/files/original/19c1aad96069fabe0758187e646d1228.jpg e471fbdbef1ed11c58c71eff500781ba https://staging.drfop.org/files/original/2f07aa534dbd1584512f9c90809230d2.jpg 3570573c6cfd62aecaafbde8fbefc4ea https://staging.drfop.org/files/original/1a1fe4a37edcbe75d90b6ad73b8d0d4e.jpg c6ddc6b5a6d87db0bf2007ef5d8638b6 https://staging.drfop.org/files/original/75a33a9d6d5d0849ce7c12868685f1f9.jpg 1971a4230bd4ec28af875304f23a2cf6 https://staging.drfop.org/files/original/2617ce55fd29a20968da7d3e13766774.jpg 07a4a8a190d0f78932851483890b3b5d https://staging.drfop.org/files/original/c4d84385c58581f6533ec9d4e71f4fdc.jpg 30755fd905f1bc5e9d75566a928e222a https://staging.drfop.org/files/original/f6cffdc0a882bdda54350168a2222b6d.jpg a25624d88c7dadd9d6fa60f533badf24 https://staging.drfop.org/files/original/97eeaf86cf996280b7c14b0c5986553e.jpg 8268c26f3339dea97ccd44cdaba968a2 https://staging.drfop.org/files/original/015afe62ead49a74fb3a6f4162d7dc17.jpg cc0ba22ce6d1dbfee4a7d9bb8d429894 https://staging.drfop.org/files/original/9b82fe61ad066b08870be2171f256b77.jpg 36eccb8e1aac51332d921c634ede86be https://staging.drfop.org/files/original/e9359d5db4d7aafa657acee425a392c9.jpg 5b2005fd8445657c7504c01fe7a6773b https://staging.drfop.org/files/original/eec578b1c7b89a572f2f806882dda2fe.jpg ec67913ae1770d508da25e93c69258d2 https://staging.drfop.org/files/original/f69e7b05d484398ec53b97b665e4f948.jpg ac554dd86efbc1142de95f1fbca637b2 https://staging.drfop.org/files/original/fc43c4b25852b8cefa8ce6d8cccbb2cb.jpg 55676a5ab998ab1a06d8f6ea61c38fec DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1957_01_004.pdf Year 1957 Volume 4 Issue 1 Page Number(s) 4 - 40 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1957_01_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1957_01_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Some Experience with Prosthetic Problems of Upper Extremity Amputees</h2> <h5>Marvin S. Gottlieb, M.A. <a style="text-decoration:none;">*</a><br />Robert L. Mazet, JR., M.D. <a style="text-decoration:none;">*</a><br />Craig L. Taylor, Ph.D. <a style="text-decoration:none;">*</a><br />Marian P. Winston, B.A. <a style="text-decoration:none;">*</a><br /></h5> <p>The history of the upper extremity prosthetics program up to 1954 has been outlined in a previous article in this journal<a></a>. From 1950 to the present, the upper extremity research group established in the Department of Engineering, University of California at Los Angeles, has processed some 300 arm amputees: 72 during the Case Study Program<a></a>, an overlapping 250 during the 12 schools at the Prosthetics Training Center<a></a>, a small group of adult research amputees, and 104 children seen at the Child Amputee Prosthetics Project<a></a> prior to July 1, 1956. From the adult cases we have selected 23 of special interest to summarize in this article.</p> <p>First presented are five cases that responded well to standard methods, the purpose being to establish a baseline for comparison with the problem cases. Cases aided by the development of special equipment and by training in its use are grouped in one section because of the interrelationship between fitting, correct equipment, and amputee training. Under the heading of special equipment come the prototypes of several devices now standard in the armamentarium and also some modifications that remain unique to the individual wearer.<a style="text-decoration:none;">*</a> Cases aided by medical and biomechanical treatment are grouped together, again because of the interrelationship involved.</p> <p>Although some three fourths of all arm amputees encountered in the program have become consistent users of functional prostheses, we have chosen to present unsolved problems in nearly half of the case histories given here. The reason, obviously, is to draw attention to the areas of need. Apart from some unilateral wrist disarticulation and long below elbow amputees who operate easily and efficiently without prostheses (whom we do not consider to be problem cases), arm amputees who have the opportunity to be fitted properly, but who fail to use their prostheses, most often fall into one of three classes:</p> <ol> <li>Women of limited strength who object to the weight of forearm and terminal device.</li><li>Persons with severe biomechanical limitations, such as forequarter amputees.</li><li>Individuals suffering from disabling pain.</li></ol> <p>Just to show that arm amputees are no exception to the general orneriness of mankind, the closing section covers cases presenting unsolved psychosocial problems.</p> <p>It will be clear that several of the case histories might have been classified under some of the other headings. For example, in view of the drastic effects that the patient's postampu tation decrease in earnings had on his family life, Case 9, discussed from the viewpoint of special equipment, could as reasonably have been classified under psychosocial problems. Case 13, discussed under biomechanical treatment, represents also an achievement in equipment modification. And so forth.</p> <p>The expression "man machine combination" is a well worn phrase in contemporary bio technical research. In limb prosthetics, one might say, there is a "man equipment training combination" in which the man may be modified by medicine, by surgery, by physical or occupational therapy, by developments in the psychosocial realm, or by training in control and use of the prosthesis. The equipment must be compatible with all these and may have to be modified by redesign or special fitting to overcome the man's biomechanical limitations. Training may be either of negligible importance, as in Case 12, or crucial, as in Cases 7 and 11. Its usual importance tends to be somewhere between the two extremes.</p> <p>Finally, it may be noted that the standards, procedures, and techniques employed in fitting, fabrication, and training are all described in detail in the <i>Manual of Upper Extremity Prosthetics, </i>2nd Edition.<a></a> Similarly, all materials and most of the components mentioned are listed in the <i>Manual, </i>together with sources and characteristics. Of the components not otherwise referenced directly, all have already been described in previous issues of Artificial Limbs, in the collaboration by Klopsteg, Wilson, <i>et al. </i><a></a>, in manufacturers' catalogs, or in the general literature of the field. A number of the special components are described in recent reports of the Engineering Artificial Limbs Project at UCLA.</p> <h3>Cases Responding Well to Standard Methods</h3> <h4>Case 1, Forequarter</h4> <h5><i>History</i></h5> <p>Case 1, male, a 30 year old medical photographer, was first seen in the Case Study in February 1951, eight years postoperative. His left forequarter amputation, in which the left scapula and two thirds of the clavicle had been removed, followed injury in wartime Naval service. The Navy had provided him with a Navy Fitch<a></a> arm (double coupled flexion type with wooden forearm, leather socket, catgut cords, and double chest strap harness) but had not trained him to use it. Because of socket discomfort, he had worn no prosthesis for the preceding five years and was unable to operate his Navy Fitch arm at all for testing purposes. He was able to fulfill all his functional needs satisfactorily with one hand, did not believe that any functional prosthesis for his level of amputation was available, and sought only a cosmetic replacement.</p> <h5><i>Examination and Evaluation</i></h5> <p>The patient was 6 ft. 4 in. tall, weighed 195 lb., was well muscled, and had good posture considering the extent of his loss (<b>Fig. 1</b>). The operative scar on the left shoulder girdle was well healed and not tender, but the area of the axilla was hypersensitive to touch. The subject was able to move the end of the remaining third of the clavicle only very slightly in flexion extension but was judged to have a good range of motion in elevation depression.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Case 1. Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>The patient's unusually good conformation enabled him to be fitted with a modified shoul der disarticulation prosthesis rather than with the usual forequarter type. Accordingly, a sectional type of shoulder prosthesis was prescribed, with emphasis on the cosmetic shaping of the shoulder cap. It included (<b>Fig. 2</b>) a chest strap harness with four attachment points on the shoulder cap, an opposite shoulder loop for dual control of terminal device operation and forearm flexion, and nudge control of the elbow lock since the patient had no desire for an actively operated elbow. The nudge control failed mechanically several times, a circumstance which led to a satisfactory redesign. Originally provided with a Dorrance hook, the patient later requested and received an APRL hand and hook. The pressure control feature of the APRL hook proved "invaluable" in his darkroom work.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Case 1. Prosthesis provided at UCLA. The unusually good physical conformation and range of motion of this forequarter amputee enabled him to be fitted successfully with a modified shoulder disarticulation type of prosthesis rather than with the full forequarter socket. There was more functional regain than usual considering the patient's level of amputation. Compare with Cases 15 and 16. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Training in use of the prosthesis was aided by the patient's wife, who was an occupational therapist. After training, the amputee passed nine out of ten activity tests and was judged to perform with extreme smoothness and remarkable ease and dexterity considering his level of amputation. When followed up a year later, the subject reported that he wore his prosthesis during most of his waking hours, sometimes as much as 120 hours a week, using the hand for most of his picture taking and public contact work and the hook in developing negatives and making prints.</p> <h5><i>Summary</i></h5> <p>In this case, better results were obtained than might reasonably have been expected. A unilateral forequarter amputee, the patient was interested only in a cosmetic replacement, did not seek functional regain, and did not believe that it was possible. Yet by proper fitting, followed by good training, he became an excellent prosthesis user.</p> <h4>Case 2, Wrist Disarticulation</h4> <h5><i>History</i></h5> <p>Case 2, male, a 38 year old machine operator and assembler of tools and outdoor furniture, was first seen by the Case Study in June 1952, seven years after amputation. His left hand had been lost by a shrapnel injury to the wrist while he was serving in a Polish French tank combat crew in Berlin. He had been fitted with a plastic socket with interchangeable Dorrance No. 8 hook and Becker wooden hand but had not worn the prosthesis for the preceding five months because the socket was broken. Prior to the breakdown, the patient had used the wooden hand 10 hours a day.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed a screwdriver shaped stump with the styloids intact (<b>Fig. 3</b>). Physical condition was good, although forearm rotation was somewhat limited. The amputee had never received any physical therapy or prosthetic training.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Case 2. Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>There is available no wrist cap that matches the elliptical cross section of the human wrist, and the wrist disarticulation socket must therefore be faired out to meet the round wrist caps used. In this case, an attempt was made to develop a manually operated wrist unit of elliptical cross section using rubber O rings to supply the friction necessary for resistance to rotation. But the resulting appearance was not satisfactory, the added length (1.3 in.) was too great, and frictional characteristics were not as desired. Rather than devote the time and effort necessary to redesigning the unit, the practical solution was adopted of using a Sierra Model C wrist cap instead and fairing out the socket accordingly (<b>Fig. 4</b>). Use of the Model C wrist cap decreased the length by half an inch and improved the functional characteristics.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Case 2. Prosthesis provided at UCLA. Because of required weekly cleaning and relative breakability in heavy work, the APRL hook shown here was later given up in favor of a Dorrance No. 5. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In accordance with the patient's desire, he was supplied with an APRL hook. He preferred it because of the selective prehension and "better mechanism" and because he felt that exposed rubber bands, as in the Dorrance models, would accumulate grease in his work. But the hook required weekly servicing because of dirt accumulation, and when the patient ripped the stud off he requested a Dorrance No. 5 hook instead. After experience with the Dorrance hook, however, he reported that it tended to scratch the furniture he polished on the job. At the patient's insistence, an auxiliary prosthesis was constructed for use with the old Becker hand, which he considered ideal for the polishing operation. The patient's one remaining objection to his prosthetic equipment was that, with his limited pronation supination, the hook could not be positioned fast enough, but the length of his stump contraindicated use of a step up rotation prosthesis. At last report, the patient was wearing a prosthesis 10 hours a day, 70 hours a week.</p> <h5><i>Summary</i></h5> <p>Case 2 was a relatively uncomplicated case that responded well to standard methods of fitting and prescription. This particular case points up the unavailability of certain desirable equipment for the wrist disarticulation amputee and the importance of considering all the occupational requirements in prescribing a terminal device.</p> <h4>Case 3, Medium Below Elbow</h4> <h5><i>History</i></h5> <p>Case 3, male, a 48 year old butcher specializing in breaking and boning fore quarters of beef, was first seen in the Case Study in July 1951, nine months after amputation of his left arm below the elbow and one month after prosthetic fitting. He wore his new prosthesis at work but not otherwise, and he complained of stump soreness and pressure, a shoulder saddle that tended to slip under load, and awkward placement of the thumb of the Dorrance No. 1 hook. He had received no training in the use of his prosthesis.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed a screwdriver shaped stump, 7.8 in. from epicondyle to tip, exceptionally finn and well muscled, with the radius approximately half an inch longer than the ulna (<b>Fig. 5</b>). The forearm flexors were markedly hypertrophied, and forearm flexion was limited to 120 deg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Case 3. Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>Because of the patient's heavy work, a heavy duty short below elbow type of prosthesis was prescribed (<b>Fig. 6</b>). The amputee specified modification in harness which called for replacing the leather shoulder saddle by one of washable webbing. In view of the patient's desire for selective prehension force, an <b>APRL </b>hook was prescribed experimentally, but it was badly damaged in the course of the patient's work and was therefore replaced by a Dorrance No. 1 hook. An F-M disconnect was tried. But after the patient's hard use broke the gear teeth of the disconnect three times, a threaded type of disconnect was prescribed instead. The first three sockets fabricated proved unsatisfactory the first because it interfered with circulation, the next two because of rubbing against the distal end of the radius and the ulna when the patient rotated his forearm. The fourth socket proved satisfactory, but the cables continued to fray with use and had to be replaced every few weeks.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Case 3. Heavy duty prosthesis as prescribed for reason of occupation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Summary</i></h5> <p>This case emphasizes the importance of rugged equipment for heavy work in the manual trades and the shortcomings in this respect of many available components. The amputee made a contribution to limb prosthetics in initiating the washable webbing shoulder saddle. His experience with cable wear and frequent replacement indicates the problem which has since been very largely solved by swaged fittings and by the nylon cable housing liner.</p> <h4>Case 4, Below Elbow Biceps Cineplasty</h4> <h5><i>History</i></h5> <p>Case 4, male, a husky 18 year old student, first entered the Case Study in December 1951, six years after a right below elbow amputation that followed an explosion in a chemistry experiment in his home. About six months after the accident, he had been fitted with a laced leather socket and wooden hand, but he abandoned the device because he continued to break the fingers in the course of surf casting and other outdoor activities. About a year later, the patient obtained his second prosthesis, with a David work hook, and wore it daily until it became inoperable. He had received no prosthetic training.</p> <h5><i>Examination and Evaluation</i></h5> <p>The stump was 83 percent of forearm length, screwdriver shaped, and well muscled. The patient had a complete range of motion except for forearm rotation, which was limited to 30 deg. of pronation, no supination.</p> <h5><i>Treatment</i></h5> <p>Classified as a long below elbow type, the amputee was fitted with the standard prosthesis for his level of amputation, with an APRL hand and APRL hook. Operation of the voluntary closing device was learned readily, and the patient was judged an excellent user. In the trainer's judgment, the wearer's performance of test activities was as good as that of a normal person.</p> <p>Having heard of the increased range of motion and the freedom from shoulder harness made possible by the cineplastic procedure, the amputee returned to the clinic three months later as a candidate for biceps cineplasty under the experimental program. The operation was prescribed, and the biceps muscle tunnel was constructed in July 1952 without postoperative complications (<b>Fig. 7</b>). Six weeks after surgery, the patient returned to the clinic, where his below elbow biceps cineplasty prosthesis was completed (<b>Fig. 8</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Case 4. Patient after construction of biceps muscle tunnel. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Case 4. Patient wearing cineplastic prosthesis. Tunnel could develop 120 lb. of pull under 10 lb. of initial tension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After fitting and training, the patient was tested, and his performance was found to be nearly as good as it had been with the harness controlled prosthesis. At that time, he experienced pain when the load on the tunnel reached 15 lb., but when this problem was overcome he proved to have a tunnel that could develop 105 lb. of pull when under 1 lb. of initial tension and 120 lb. under 10 lb. of initial tension. Two or three years later, the amputee modified his epicondyle clip by cutting it down in size and padding it deeply with foam rubber. Vinyl plastic was tried as a covering material, but the patient proved sensitive to it and went back to leather.</p> <p>After almost five years, this patient was wearing his prosthesis with APRL hook all of his waking hours. He had no interest in a hand and would not consider a voluntary opening hook, although he complained of the relative susceptibility of the APRL device to breakage. After several years' experience, he no longer broke his hooks, but the rubber linings wore off the hook fingers and required replacement every few months.</p> <h5><i>Summary</i></h5> <p>This case is an example of successful application of the below elbow biceps cineplasty. Although the amputee was an excellent user of a satisfactory harness operated prosthesis, he thought the increased range of motion and freedom from shoulder harness worth the surgery. This case also shows the amputee's insistence on using his preferred terminal device, even for activities for which he knew it was unsuitable.</p> <h4>Case 5, Above Elbow/Humeral Neck Combination With Bilateral Pectoral Cineplasty</h4> <h5><i>History</i></h5> <p>Case 5, male, a 31 year old Air Force fighter pilot and former ail American football player, entered the project in November 1950 on special leave from a military hospital. He had been under medical treatment since 1947, when the fire that followed a jet crash landing severely burned his head, the left side of his body, and both arms, resulting in bilateral arm amputation. Both pectoral muscles had been tunneled. The patient had been fitted with Navy Fitch double coupled flexion arms, the cineplastic tunnels being used for prehension control.<a></a> He complained of poor socket fit, restrictive harnessing, rotation of the sockets on the stumps, and the absence of an elbow lock and expressed a desire to learn to perform essential services for himself independently. Except for a six month program of exercise to strengthen the muscle tunnels, he had never received any training in connection with his amputations.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed a right above elbow stump and a left humeral neck amputation, the two sides having the same pattern of scarring over the deltoid and the anterior and posteromedial aspects. There was limitation of humeral motion on the right side and no motion at all on the left. Exercises were prescribed. The patient appeared to be in excellent general condition, physically and psychologically. The right tunnel had a maximum excursion of 3 in. and a maximum force of 51 lb., the left 2.75 in. and 56 lb.</p> <h5><i>Treatment</i></h5> <p>To overcome the rotation of the sockets when the pectoral tunnels were contracted, to enable the amputee to don his prostheses independently, and to avoid the restriction of motion involved in force transmission through bilateral pectoral cineplasty, the right side (above elbow) was fitted and harnessed without use of the pectoral tunnel. The tunnel pin on the left side (humeral neck) was modified in an effort to improve efficiency of the power transmission system and to make it possible for the amputee to insert the pin either by means of the opposite prosthesis or by means of the mouth.</p> <p>Forearm flexion and prehension control were of the standard, harness operated dual type powered on the right side by humeral flexion and on the left by scapular abduction (<b>Fig. 9</b>), elbow lock on the left being operated by the left pectoral tunnel. After about three hours of training in the control and use of his new prostheses, the amputee was judged proficient.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Case 5. Prostheses provided at UCLA. Use of the pectoral tunnel for elbow lock on the left side was later given up. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The unused right pectoral tunnel was removed surgically, and about three years later the patient gave up use of the other tunnel but continued to use the prescribed arms without modification. He had had new prostheses made in 1953 but used them only for gardening and similar activities because he considered the upper portion of the right arm too long. In February 1957, more than six years after fitting, he was still wearing the prescribed arms and the same harness, although he had worn out four Northrop Sierra two load hooks and had been interchanging the two Northrop Model C elbows throughout the six years whenever service was required. He used the right prosthesis for most functions, with occasional help from the left. The patient did not bother with his own buttons or cutting his meat for himself, but he was active in the insurance business, took up hunting, and reported: "I write, drive, just like anyone else only thing, I ain't as pretty."</p> <h5><i>Summary</i></h5> <p>One of many cases in which pectoral tunnels did not work out as planned, this bilateral arm amputee was made independent through standard prosthetic fitting and training. He modified his bilateral prosthetic control system to emphasize unilateral function.</p> <h3>Cases Aided by Special Equipment and Training</h3> <h4>Case 6, Shoulder Disarticulation</h4> <h5><i>History</i></h5> <p>Case 6, male, a 23 year old office worker and preamputation bakery truck driver salesman, entered the clinic in September 1952, five months postoperative. His right arm had been disarticulated at the shoulder (<b>Fig. 10</b>) because of a malignant tumor.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Case 6. Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed no medical contraindications to prosthetic fitting. Exercises to increase the range of motion of the shoulder girdle were prescribed.</p> <h5><i>Treatment</i></h5> <p>At first, a standard, sectional type of shoulder disarticulation prosthesis was prescribed and fitted, with dual control for forearm flexion and prehension and with nudge control of the elbow lock, a Dorrance No. 555 hook being used to keep weight to a minimum (<b>Fig. 11</b>). Later the patient was given a Northrop Sierra two load hook to evaluate; he adopted it enthusiastically.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Case 6. Pioneer fitting of a shoulder disarticulation, including prototype of the UCLA manually controlled, friction type shoulder joint The amputee refused to give up the prosthesis even when bodily changes due to illness made it irritating. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since the amputee experienced difficulty in putting on a shirt or coat, he asked for a movable shoulder joint which would allow him to flex his prosthesis in the parasagittal plane. Designed to his satisfaction, this device proved to be the prototype of the UCLA manually controlled, friction type shoulder joint. At the patient's suggestion also, the nudge control was redesigned to cut down its protrusion and prevent clothing from catching in it. A month later, the subject reported that he wore his prosthesis 12 to 15 hours a day, that it was adequate for the needs of daily living, but that he would prefer a cosmetic hand of some kind for social occasions.</p> <p>In May 1955, the patient underwent surgery for removal of a large metastatic tumor mass in the right lung, and beginning in September 1956 he received x ray therapy for an inoperable lesion of the left lung. Loss of weight and atrophy of the shoulder girdle impaired the fit of the prosthesis, but the subject rejected medical advice that he wear only a shoulder cap to decrease the weight. He continued to wear the prosthesis until irritation of the bony prominences of clavicle and scapula necessitated prescription of a new soft socket liner in February 1957. At that time he was in good general health and working regularly.</p> <h5><i>Summary</i></h5> <p>This pioneer fitting of a shoulder disarticulation case resulted in devices now standard in the armamentarium. The satisfaction gained by the patient from his prosthesis is indicated by the fact that he insisted on wearing it even when bodily changes made it irritating physically.</p> <h4>Case 7, Bilateral Shoulder Disarticulation</h4> <h5><i>History</i></h5> <p>Case 7, male, a 63 year old bridge and building construction foreman with bilateral shoulder disarticulations (<b>Fig. 12</b>), entered the clinic in November 1953, three months after the amputation of his right arm because of osteomyelitis. The left arm had been amputated 15 years earlier as an ultimate aftereffect of trauma in 1923. The patient had never worn a prosthesis. In addition to independence in self care, he particularly needed to be able to sign his name the one manual function required in his job.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Case 7. Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed a well healed scar in the left shoulder region but on the right some postoperative edema, encrustation, and weeping. Shoulder motion was limited, and strength was poor.</p> <h5><i>Treatment</i></h5> <p>After an interruption due to an unrelated operation (splenectomy), the amputee was fitted at the Prosthetics Training Center bilaterally and also unilaterally with a right shoulder disarticulation prosthesis. A year later, in 1955, he reported that he wore either the bilateral set or the unilateral prosthesis all his waking hours, usually the unilateral prosthesis, which had greater force and excursion and did not present the problem of interaction of controls. But he used this prosthesis only for picking up and carrying light objects and for nonprehension activities, such as pushing, pulling, striking, and hooking.</p> <p>In May and June of 1955, the patient spent seven days at the Prosthetics Laboratory for alterations, experimentation, and training. His shoulder turntable was modified by addition of a Belleville washer in order to maintain constant friction, and nylon cable housing liners were installed. Several experimental modifications of the elbow unit were tried in an attempt to secure smooth, reliable operation, but the final solution consisted of generous lubrication of the cable with paraffin, plus replacement of the housing by another long enough to allow an in line entry of the cable into the locking unit.</p> <p>The amputee's difficulties with the other components of his prosthesis resulted from lack of understanding of the mode of function, and he was therefore given intensive training. Patterns of activity feasible for this particular patient were worked out, and practice was supervised. Under this guidance, he learned to eat "all shapes and consistencies of food" with a fork, to write legibly, to unzip and zip his trousers (with a 3 in. elkhide thong attached to the zipper pull) for independent urination, to put on and take off a shirt or coat, to turn book and magazine pages, and to perform other activities. The therapist devised special equipment for his use, including a stand for his electric shaver and a simple trouser belt with a D ring buckle that he could tighten or loosen with one prosthesis.</p> <p>In January 1956, it was found that the patient had not been employing these techniques at home because it upset his wife to see him struggle and she preferred to do things for him. In March 1956, he was fitted with a unilateral prosthesis employing the UCLA manually controlled, friction type shoulder joint, modified arm rotation turntable, nylon cable housing liners, and a cable excursion multiplier (<b>Fig. 13</b>). He was the first of the amputees fitted with this system. Two months later, he wrote that he had leveled a building lot by hand and prepared it for planting, performed household chores, and worked in an office answering the phone, writing down messages, and checking workmen in and out with equipment. In December 1956, the amputee wrote, in his own shaky but legible penmanship, to report the prolonged illness of his wife, during which he had taken care of himself after years of dependence.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Case 7. Successful unilateral fitting of the bilateral shoulder disarticulation case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Summary</i></h5> <p>This complex case has been given in some detail because it highlights several different aspects of the problem of the severely handicapped amputee. The interrelationship of equipment and training is pointed up. When the patient was unable to operate his components, the solution resided in modification of some, realignment in one case, and better training in use of the others. The effect of oversolicitous family members in keeping the handicapped person dependent is shown. Given usable prosthetic equipment and training, this elderly bilateral shoulder disarticula tion amputee was able to operate independently when his wife was no longer able to help him. The case meets one of the prevailing standards of rehabilitation gainful employment at an appropriate task.</p> <h4>Case 8, Very Short Below Elbow</h4> <h5><i>History</i></h5> <p>Case 8, male, a 32 year old clerk, was first seen in the Case Study in November 1950. His very short below elbow amputation had resulted from machine gun fire during service as an Army rifleman in France in September 1944. Except for the insertion of the biceps, the forearm musculature had been lost. Several unsuccessful efforts at prosthetic fitting unsuccessful because of the limited stump motion had convinced him that he would have to undergo reamputation above the elbow in order to be fitted with a useful prosthesis. He came to the Case Study as a last resort before reamputation.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination revealed a 3.8 in. below elbow stump. A bony block in the elbow limited forearm motion to between 150 and 165 deg. of extension.</p> <h5><i>Treatment</i></h5> <p>A very short below elbow split socket prosthesis was prescribed, with an above elbow type of dual control for forearm flexion and prehension and with a special device which enabled the 15 deg. of stump motion to operate the elbow lock (<b>Fig. 14</b>). This was the prototype of the stump actuated elbow lock now standard in the armamentarium.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Case 8. Amputee with very short (3.8 in.) below elbow amputation fitted with the stump actuated elbow lock. Reamputation previously considered, was avoided. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although the patient rated the prosthesis as excellent, he felt that more practice was needed in learning to operate the elbow lock with his stump and was found not to be wearing the prosthesis as many hours a week as he had reported. Three years later, however, he was wearing the limb constantly.</p> <h5><i>Summary</i></h5> <p>In this clear cut case, the design of a special device to meet a special situation solved the amputee's problem. The patient was saved from reamputation by the development of a device that is now standard. The history suggests, however, that the solution would have been still more successful, in terms of prosthesis use, had the amputee received more training and perhaps psychological counseling.</p> <h4>Case 9,Very Short Below Elbow With Biceps Cineplasty</h4> <h5><i>History</i></h5> <p>Case 9, male, age 40, was seen as an industry counseling case in October 1951, two and a half years after an amputation which resulted from an industrial accident while he was working as an elevator and control system installer. On the patient's return to work, after nearly two years' disability, the elevator company had transferred him to office work at slightly more than half his former salary. On the reduced income, he had been forced to give up his home. his wife suffered a nervous breakdown, and the two children had to live with relatives during a long period of readjustment. He had been provided in 1949 with a cosmetic arm and "Realastic" hand but had never had a functional prosthesis.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed a left very short below elbow stump, badly scarred, with flexion limited to 90 deg. by a bony block in the elbow. Shoulder motion also was limited.</p> <h5><i>Treatment</i></h5> <p>The amputee was given a short below elbow prosthesis with an APRL hand and with the forearm set in 20 deg. of initial flexion. Five months later he reported himself satisfied with this limb and, although he said he was wearing it 12 hours every day, he desired a step up hinge to increase forearm flexion. In September 1953, a split socket prosthesis with variable ratio step up hinge was fitted, with both hook and hand as terminal devices. The new prosthesis increased the patient's maximum forearm flexion to 120 deg., and he was judged as being "very adept" with both hand and hook. After acquiring a functional prosthesis, the amputee was able to return to his skilled trade with another employer, although he had to start as an elevator mechanic's helper.</p> <p>Learning that still greater functional regain (ability to operate the prosthesis above shoulder level) was possible with biceps cineplasty control, the patient had his left biceps muscle tunneled in August 1954 as an experimental subject in the below elbow biceps cineplasly program (<b>Fig. 15</b>). Shortly after the surgerv, he was fitted with a below elbow biceps cineplasty prosthesis with split socket, variable ratio step up hinge, and UCLA control system. In March 1956, an experimental prosthesis was fabricated for him using the new UCLA 1.5 ratio step up elbow hinge (<b>Fig. 16</b>). With this limb he was able to lift 11 lb., nearly twice his previous maximum. It should be remembered that in this case slump flexion was not aided by the biceps because the biceps tendon had, of course, been severed The 1.5 ratio hinge gave 5 deg. more forearm flexion than did the variable ratio hinge. Although this increase in forearm flexion was of no importance to the patient, who had fell that the variable ratio hinge gave all the forearm flexion he needed in his left arm, he greatly appreciated the ease and smoothness of action of the 1.5 ratio hinge. By 1957 he had advanced to the position of elevator inspector.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Case 9. Patient after construction of biceps muscle tunnel. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Case <i>9 </i>Patient fitted with UCLA below elbow biceps cineplasty system using split socket and the 1.5 ratio step up elbow hinge. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Summary</i></h5> <p>This case highlights the contribution of new devices to the welfare of the amputee with a very short below elbow stump.. It also points up the socioeconomic value of a functional prosthesis in the manual trades. When this amputee was prevented from working at his highest level of skill, severe dislocation was experienced by an entire family. Fitting of a suitable prosthesis enabled him to return to gainful employment.</p> <h4>Case 10, Congentinal Below Elbow.</h4> <h5><i>History</i></h5> <p>Case 10, female, a 37 year old teaching nun, entered the clinic in January 1955. A congenital left below elbow amputee, she had worn cosmetic arms since the age of four She was wearing a cosmetic appliance 6 hours a day, 5 days a week, but desired more prosthetic function. Her particular desire was to be able to hold an open book while writing at the blackboard.</p> <h5><i>Examination and Evaluation</i></h5> <p>The patient was of slight build (<b>Fig. 17</b>). Stump length was on the borderline of the very short below elbow type (3 in. below the epi condyles). Forearm flexion was limited to 90 deg., and strength was also limited. There was pain on pressure at the tip of the stump and along the anterior surface; x rays showed two bony spurs on the anterior surface of the ulna.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Case 10 Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>The patient was first fitted with a short below elbow prosthesis with Hosmer PC 100 hinges, flexion range being sacrificed for simplicity. Three months later, another prosthesis was made, with outside locking elbow hinges as commonly used with the elbow disarticula tion type of prosthesis. For greater gripping surface, the Dorrance No. 555 hook was replaced by a Dorrance No. 5X. To help relieve pressure on the stump during forearm flexion, the therapist suggested use of humeral abduction, and the patient found this technique made many activities more comfortable and less awkward.</p> <p>For further relief from pressure, a polyure thane foam socket liner was made the following July. The seam coincided with a bony prominence, however, so that a new liner was necessary. At the same time, the socket was cut out to free the medial epicondyle.</p> <p>When nylon cable housing liner was installed in February 1956, the patient reported that:, although it afforded great mechanical advantage, it deprived her of the "vibration feedback" on which she had previously relied for information as to her cable tension and amount of hook opening. The final modification (<b>Fig. 18</b>) was made in July 1956, when a chest strap was added to the harness to prevent it from slipping off the shoulder when the arm was raised in upward and backward motions. Over the period covered, the patient tried several hooks, alternating between her needs for greater gripping surface and for lighter weight. Her final choice was the Dorrance No. 5XA. In February 1957 she was provided with three interchangeable socket liners for purposes of cleanliness.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18, Case 10 Present prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This patient's desire to pass out papers to her classes was met by the technique of holding the stack of papers upright with the right hand and picking off copies with the hook.</p> <h5><i>Summary</i></h5> <p>This case indicates the experimental approach that must be adopted to meet the needs of an amputee with special physical limitations. It also suggests the use of the custom fitted soft socket liner when the amputee's stump configuration is too complex and painful to be made comfortable in the conventional plastic socket. The outside locking elbow hinge provided the needed stability for this short below elbow amputee with limited strength.</p> <h4>Case 11, Short Above Eelbow/Humeral Neck Combination</h4> <h5><i>History</i></h5> <p>Case 11, female, a 35 year old health educator and graduate dentist, entered the program in March 1953, 11 years after amputation. With right short above elbow and left humeral neck stumps, she had lost her arms as a result of electrical burns in a sailing accident. Before her marriage, she was self supporting as a teacher and lecturer. After marriage, she was an active housewife and mother of two small sons. She had been fitted with bilateral prostheses of modern type in 1947. Her second and third prostheses were for the above elbow side only, and the third, fitted in November 1952, was the first to incorporate an elbow lock. The family moved from Michigan to Los Angeles so that the patient could enter the UCLA program. They remained for two and a half years, during which various combinations of prosthetic equipment were tried.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed a right stump extending 5.3 in. below the acromion, a left stump 3 in. below the acromion (<b>Fig. 19</b>). The patient was tall and broad shouldered, with excellent mobility of the shoulder girdles. The right stump required shrinkage, however, and in September 1954 the subject underwent surgery for excision of a neuroma, a spur, and a bursa. Simultaneously, excess fat and skin were trimmed off. About six months later, a fibular bone graft into the left humeral head was performed, but the stump thus produced was not functional, it projected at an awkward angle, and it proved sensitive to socket pressure.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 19. Case 11, Patient as seen on referal. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>Before the bone graft, the amputee was fitted bilaterally (<b>Fig. 20</b>). She was trained to use each arm effectively, but because of interaction of controls she had great difficulty in coordinated activities and she found that the left arm was in the way in many functions. She was taught to drive an automobile (for the first time) using the driving ring, obtained her driver's license, and from that time continued to drive for herself and to take her turn at the wheel on long trips. She prepared the family meals and washed the dishes but did not feed herself because of limited forearm ilexion. Later, with the addition of a wrist flexion unit and with intensive training, she learned to use a fork effectively but found it an activity too fatiguing for everyday use.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Case 11. Patient as fitted bilaterally. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In June 1955, before the grafted slump was ready for fitting, the patient was fitted with a right prosthesis, with only a shoulder reaction cap on the left side (<b>Fig. 21</b>). Function was much better without cross controlling, <b>but </b>she stated that bilateral fitting was worth some sacrifices for the sake of body balance and prevention of spasm of the neck and back muscles.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Case 11. Patient as fitted unilaterally with opposite shoulder reaction cap. Properly aligned unilateral prosthesis gave body balance without counterweigh ting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The disadvantages mentioned were found to be due to subtle misalignment of the single arm and were corrected by fabrication of a unilateral prosthesis correctly aligned.</p> <p>In a final attempt to achieve successful bilateral fitting, the patient suggested a perineal strap. This change in harnessing, tried in January 1956, succeeded in separating the control motions but at the cost of limiting motion and preventing the wearer from putting on her prostheses independently. After this, the subject concluded that unilateral fitting without perineal harnessing gave her the maximum of function, especially with the aluminum Dorrance 5XA hook and a slightly shortened forearm. Several months after the family moved away, the amputee sent word that her final prosthesis was the lightest and most comfortable of all and reported that she fed herself quite nicely with the swivel "spork" (combination of spoon and fork).</p> <h5><i>Summary</i></h5> <p>The maximum comfort and function attained by this bilateral high level amputee was obtained with unilateral equipment. Even body balance was restored by careful alignment without further counterweighting of the opposite side. Intensive training, plus high motivation on the amputee's part, resulted in regain of many functions and the learning of some new ones <i>(e.g., </i>driving a car). The attempt to lengthen the humeral neck stump by a bone graft, while successful from a surgical viewpoint, was of no prosthetic value because of the angle of the resulting stump.</p> <h3>Cases Aided by Medical and biomechanical treatment</h3> <h4>Case 12, Shoulder Disarticulation With Weak Pectoral Tunnel</h4> <h5><i>History</i></h5> <p>Case 12, male, a 22 year old beekeeper, entered the program as an industry counseling case in February 1952, 18 months after the loss of his right arm in a mortar barrage during the Korean War. The small cineplastic pectoral tunnel that had been constructed was intended to operate the elbow lock of the shoulder disarticulation prosthesis with which he had been fitted. But when the patient was seen at UCLA, he was operating the elbow lock manually with the opposite hand because the tunnel pin excoriated his muscle tunnel and also because operation of the elbow required more excursion than he could produce (because of stretching of the nylon control cord).</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed the pectoral tunnel to be unusually narrow and superficially placed (<b>Fig. 22</b>). The maximum force developed during testing was 8 lb., less than one sixth the force normally available from a pectoral tunnel. Although the two shoulders were at the same height, the patient had developed a thoracic curve with compensating lumbar curve.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Case 12. Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>Prescribed physical therapy included posture instruction and practice, exercises to develop the left arm and right shoulder girdle, and DeLorme progressive pulley exercises for the muscle tunnel. After 20 half hours of supervised practice and eight hours of massage and irradiation, the maximum force available from the pectoral tunnel had more than doubled to 19 lb., still about a third of the normal amount but more than enough to operate the prescribed elbow lock. The tremor which had been evident on contraction had disappeared.</p> <p>A question mark muscle pin was prescribed to overcome the rubbing and pressure pain experienced with the straight muscle pin, and an adjustment turnbuckle was included. A larger shoulder cap (with circular cut out for the muscle tunnel) provided stability, and the modern cable transmission system lessened friction and increased efficiency (<b>Fig. 23</b>). Instead of the hinge joint which had allowed the patient to abduct his prosthesis by bending his body to the right, the prescribed prosthesis included the new UCLA manually controlled friction type shoulder joint, which allowed him to flex the humeral section.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Case 12. Present prosthesis. By physical therapy and suitable adaptation of equipment, a weak, superficial pectoral tunnel was reclaimed for elbow lock operation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Training results cannot be reported because the subject left for his home state as soon as his new prosthesis was checked out. The physical therapist, however, reported that the patient was "quite adept without instruction."</p> <h5><i>Summary</i></h5> <p>This amputee represents a case of a surgically inadequate pectoral tunnel which, by physical therapy and proper adaptation of equipment, was reclaimed for elbow lock operation.</p> <h4>Case 13, Female Congenital Below Elbow With Weak Biceps Tunnel</h4> <h5><i>History</i></h5> <p>Case 13, a 25 year old office worker first seen in March 1951, is the only female cineplasty case in the UCLA experience. A congenital left below elbow amputee, she had been fitted with her first prosthesis in October 1949 after biceps cineplasty and had never received any training. The patient reported that since graduation from high school she had been employed in secretarial work, bookkeeping, filing, sorting, operating "Mimeograph," running an "Addressograph," manning a PBX switchboard, and typing and that her amputation had not affected her earning power. She stated that her cineplastic Huffner prosthesis with magnesium forearm and metal hand was too heavy, fitted poorly, rubbed at the elbow joint, and caused damage to clothing. The tunnel pin was observed to slip to one side during operation, and the prosthesis rotated accordingly so as to require readjustment every 15 minutes.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed a firm stump with a full range of forearm flexion. Curvature of the bones limited extension of the forearm to about 150 deg. The muscle tunnel showed a usable excursion of approximately 2.5 in. and a rest length force of 13 lb.</p> <h5><i>Treatment</i></h5> <p>Resistive exercises were prescribed to be performed at home, and tunnel exercise pins of increasing diameter up to 1/3 in. were given successively. Work on the prescribed prosthesis was started during the fifth week of exercise. Although there was a temporary gain of 1 in., tunnel excursion did not increase permanently as a result of exercise, but the force more than doubled to approximately 30 lb. While this value is markedly less than normal biceps cineplasty tunnel force in a male amputee, lack of comparative data on female cases prevents a judgment as to whether this relative weakness of the biceps is normal for the patient's sex.</p> <p>In any event, the tunnel was not adequate to operate the desired terminal device, the APRL hand. Accordingly the mechanical advantage of the lexer system of an APRL hand was doubled, thereby reducing the force requirements by one half but doubling the excursion requirements. The problem of slipping of the tunnel pin was eliminated by the development of the UCLA equalizing yoke, which also increased the available force by maintaining the tunnel ina slightly prestretched position (now the standard procedure). The new prosthesis (<b>Fig. 24</b>) enabled the patient to obtain 5 lb. of prehension force at 1 in. of opening, as contrasted to the 1 lb she was able to obtain with her old equipment.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Case 1.3, Patient with new prosthesis Physical therapy, modification of equipment, and special training made useful an otherwise surgically inadequate biceps tunnel. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Unfortunately, family reasons required the patient's return to Chicago immediately after checkout, without any training. During the next two years she wore the prosthesis little. After two years, referral to Dr. Clinton L. Compere in Chicago resulted in the fitting of a new prosthesis, with proper training in its use, after which the amputee became a satisfied and consistent user When followed up three vears later, she continued to express satisfaction with her prosthesis and recommended cineplasty to other female amputees.</p> <h5><i>Summary</i></h5> <p>This case points up the interrelationship between considerations of surgery, physical therapy, engineering, and training. An essentially inadequate muscle tunnel (a surgical problem) was rendered useful by exercise, special individual modifications of equipment, and development of components which benefit all below elbow biceps cineplasty amputees. The results of physical therapy and engineering design were negated by lack of prosthetic training. When training became available, the amputee was changed from a virtual non wearer to an enthusiastic user.</p> <h4>Case 14, Shoulder Disarticulation</h4> <h5><i>History</i></h5> <p>Case 14, male, a 27 year old purchasing liaison representative with a paralyzed right arm, first appeared at the project in June 1952. A brachial plexus traction injury six years earlier had resulted in loss of arm control and virtual loss of forearm control.</p> <h5><i>Examination and Evaluation</i></h5> <p>A few intrinsic muscles remained in the hand, the forearm could be flexed very slightly, and a low level of sensation remained, but all the major arm and scapular musculature had atrophied. The patient was exceedingly anxious to have the flail arm removed so that he could wear a functional prosthesis. He said that the flail arm was useless and in the way. He was experiencing marital difficulties during this period, and the clinic psychologist suspected that the desire for amputation might be an emotional reaction to the home situation. The clinic strongly recommended against amputation until functional bracing had been tried. It prescribed such bracing. But this advice was not followed, and the arm was amputated.</p> <h5><i>Treatment</i></h5> <p>In August 1952, the patient reappeared at the clinic, a month postoperative, for fitting as a shoulder disarticulation amputee (<b>Fig. 25</b>). He was instructed in how to correct posture and was given shoulder exercises to do. Fitting and training in the use of a standard shoulder disarticulation prosthesis resulted in excellent use (<b>Fig. 26</b>). The amputee continued to serve the schools of the Prosthetics Training Center and the UCLA research program as an amputee subject, was considered an excellent user of his prosthesis, and stated three years after amputation that he had never regretted his decision. As far as the staff can judge, his emotional difficulties appear to have been resolved by the amputation and successful prosthetic fitting.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Case 14. Patient as seen one month after voluntary disarticulation of a flail arm against clinic advice. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Case 14. Successful shoulder disarticulation prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Summary</i></h5> <p>It is difficult to prescribe the removal of an extremity that retains some sensation and some function, with a view toward replacing it with a mechanism. This patient knew what he wanted, obtained it against the advice of the clinic, and is apparently well satisfied with the results.</p> <h3>Cases Presenting Unsolved Problems of Biomechanical Limitation</h3> <p>The chief unsolved problem of biomechanical limitation in upper extremity prosthetics is the case of the forequarter (interscapulo thoracic) amputee, whose entire scapula and clavicle have been removed. In the UCLA experience to date, there has been no congenital forequarter amputee and only one caused by injury.<a style="text-decoration:none;">*</a> All the rest had undergone amputation because of malignancies. With the possible exception of one traumatic child case, which is still in question, within the knowledge of the staff no true forequarter amputee has become a successful user of a prosthesis.</p> <p>In forequarter cases, any functional regain is achieved at the cost of great effort because so little excursion is available by way of body control motions and because so much area must be covered by the socket for stability virtually the entire thorax and back to the mid line on the side of amputation plus a curved lobe that hooks around the neck onto the opposite shoulder. So far, none of our forequarter cases have considered the effort and discomfort worthwhile. Their attitudes may be influenced by a conscious or unconscious fear of stirring up malignancies, for the mortality rate among these cases has been high.</p> <h4>Case 15, Forequarter</h4> <p>Case 15, a 30 year old housewife, entered the project in June 1955, seven months after amputation for a recurrence of rhabdomyosarcoma. She was intelligent and anxious to cooperate. After a three month period of training and practice in use of the prescribed prosthesis, she doubted whether the functional regain was worth the effort and discomfort. Later, word of her death reached the clinic.</p> <h4>Case 16, Forequarter</h4> <p>Case 16, a 31 year old housewife, was seen in July 1955, about four months after amputation for a malignant synovial tumor. After prescription, fitting. and instruction, she was unable to operate the prosthesis enough to check it out for mechanical functioning. Because she was able to manage adequately with one hand all of her activities except sewing and knitting, and because she found the prosthesis hot, heavy, uncomfortable, and difficult to operate, she withdrew from the program and was referred to a maker of cosmetic restorations.</p> <h4>Case 17, Congenital Quadrilateral</h4> <h5><i>History</i></h5> <p>Case 17, male, a 27 year old congenital quadrilateral amputee 29 in. tall, entered the clinic early in 1951. Born without legs (bilateral hip disarticulations), he managed locomotion at home by hopping on his pelvic musculature. Away from home he was dependent on others for transportation; he could maneuver his wheelchair into the street but not across curbs. On the right was a below elbow stump, while the left stump was above elbow.(<b>Fig. 27</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Case 17. Upper extremities<b> </b>of patient<b> </b>as<b> </b>seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The patient operated a 24 hour telephone answering service at home with the help of his wife and one part time employee. He often worked the switchboard for eight hours without relief, writing down messages by means of a pencil inserted in a leather band worn on the below elbow stump. He also ran a baby sitting agency and from time to time recruited and managed telephone sales crews for special sales campaigns. His regular working day was 10 hours. His businesses were growing, but he felt handicapped by his inability to visit prospective clients. He had been fitted with artificial arms at the age of 21, but he found them in the way for the quick motions necessary in his work. Except for a wooden ladder used to reach chairs, toilets, and so on, he took care of all his vocational, avocational, and personal hygiene activities without the use of prostheses or special facilities.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed the above elbow stump to be limited lo 70 deg. of abduction, 95 deg. of flexion, and 5 deg. of extension, with no rotation at all. The arm on the below elbow side was limited to 80 deg. of abduction, 120 deg. of llexion, 15 deg. of extension, and 10 deg. of rotation, the elbow being fused at approximately 90 deg. The patient had never had physical therapy, and none was prescribed because his strength was satisfactory and it was felt that, in view of the fact that he was a congenital amputee, the muscles could not be stretched without severe pain.</p> <h5><i>Treatment</i></h5> <p>The new prostheses fitted to the patient (<b>Fig. 28</b>) were evaluated by him and shown by test to be excellent in relation to his old pair. But 20 hours of training led to the conclusion that interference with old habit patterns was insurmountable, especially because the subject wore the prostheses only six hours a week and was too busy to practice. At no time did his performance of test activities with the prostheses approach his performance with bare stumps. But he found the limbs useful for social occasions. His evaluation remained the same after a year of wearing the prostheses six hours a week.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Case 17 Prostheses provided Right prosthesis is cut out to accommodate characteristics of the below elbow stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>One benefit the patient received from his participation in the UCLA program was the design of a special pigeonhole device which served his filing needs far better than did the notebook system he had been employing. A specially designed prosthesis holder enabled him to put his arms on without help.</p> <h5><i>Summary</i></h5> <p>In the case of an amputee who combines severe limitations (by ordinary standards) with well established habit patterns that enable him to function quickly and efficiently without prostheses, training in the use of prostheses may be futile. This amputee, who in his vocation operated far better without prostheses than with, nevertheless appreciated prostheses for wear on social occasions.</p> <h3>Cases Presenting Unsolved Medical Problems</h3> <h4>Case 18, forequarter</h4> <p>Case 18, a 68 year old housewife, was seen in November 1953, seven months after her right forequarter amputation. The medical report obtained from her physician indicated that she had undergone a simple mastectomy of the right breast in October 1944, x ray therapy of the axillary areas in 1945 and 1947, and a left radical mastectomy for metastasis to the contralateral breast and axilla in 1950. Paralysis of the right arm had developed in 1952, and forequarter amputation was performed in March 1953.</p> <p>In view of the advanced age and history of malignancy, the clinic agreed that a functional prosthesis was contraindicated. A soft cosmetic shoulder cap was prescribed to meet the amputee's need for body balance and symmetrical appearance.</p> <h4>Case 19, Shoulder Disarticulation/Short Above Elbow Combinations</h4> <h5><i>History</i></h5> <p>Case 19, male, a 60 year old railroad pensioner, entered the clinic in November 1951. Ten years earlier, he had been run over by a boxcar. Shoulder disarticulation of the right arm, amputation of the left arm about 3 in. below the acromion, and application of a tibial graft to the above elbow stump had followed (<b>Fig. 29</b>). The stumps proved too sensitive to be fitted with prostheses, and the patient had been unemployed ever since, living on his railroad pension and dependent on others for his daily needs. Throughout that time, he had had intense sensation of phantom hands, with the "fingers" painfully pinched together and somewhat overlapped.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Case 19 Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Examination and Evaluation</i></h5> <p>In May 1952, the patient underwent with good results a partial resection of the pectoralis major tendon for the purpose of lengthening the above elbow stump. At the same time, three supposed neuromata, which turned out to be tender masses of scar tissue, were removed from the most sensitive areas. The operation was of some help, but the pain remained in the scar areas and in the distal 3 in. of the anterior aspect of the bone graft and prevented the amputee from sleeping and from wearing the prosthesis prescribed and fitted to him.</p> <p>Later in 1952, the patient was hospitalized for two weeks at the Pain Clinic at the University of California Medical Center in San Francisco. Under relatively mild sedation of phenobarbital and Seconal, he slept well and required only a few grains of codeine. Indefinite continuation of the mild sedation was recommended. The phantom pain disappeared after injections of sodium amytal, but the tender areas of the stump were not eliminated. Efocaine was ineffective, and treatment with a strong vibrator was not well tolerated. The intraspinous injection of sodium chloride solution as a counterirritant caused the trigger points to disappear only temporarily. Finally, in view of the patient's improved frame of mind, it was decided that minor pressure, such as would be exerted by the prosthesis, might be tolerated.</p> <h5><i>Treatment</i></h5> <p>Although pairs of prostheses of modern design were prescribed and fitted to the patient during the schools at the Prosthetics Training Center, his stump pain remained an unsolved problem. In April 1956, when the subject was 65 years of age, intensive research began on the case. The decision was made to fit the shoulder disarticulation side only and to make a reaction cap socket for the above elbow side rather than to make further attempts at bilateral fitting. Sectional plates were modified to form the UCLA manually controlled, friction type shoulder joint and skewed 20 deg. to the sagittal plane so as to enable passive flexion and abduction of the humeral segment. The arm rotation turntable was modified by addition of a Belleville washer for finer adjustment of tension, and a cable excursion multiplier was added. The use of nylon cable housing liners, which had been adopted as standard procedure at UCLA, greatly decreased cable friction and increased smoothness.</p> <p>Mechanically, the prosthesis enabled the patient to perform simple grooming and eating manipulations for himself. But pain under the left reaction cap intensified with the use of the prosthesis. Investigation showed that this problem was due partly to inadequate training. In addition to left shoulder flexion to stabilize the reaction cap, the amputee was employing flexion of the above elbow stump. Although training in the correct motion was given, it was not expected that the patient would overcome his faulty habit patterns, and a mechanical solution was sought.</p> <p>After several unsuccessful trials, a reaction cap was made from a wrap taken with the humeral segment snug against the body but with the distal end of the stump projecting slightly (<b>Fig. 30</b>). This expedient transferred the undesirable pressure to the anterior portion of the stump. To alleviate the pressure there, a cutout was made and margined with foam rubber padding.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Case 19. Patient as fitted unilaterally with specially designed opposite shoulder reaction cap. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Staff evaluation was that, while the mechanical results were very good, the potential functional regain would be somewhat limited by the patient's outlook and by his habits of dependence. It should be mentioned, perhaps, that this amputee supplemented his meager pension by earnings in part time employment at a men's club. With his prosthesis he carried a specially built tray for holding several drinks.</p> <h5><i>Summary</i></h5> <p>Here was a very complicated case in which intense phantom pain of 11 years' standing was eliminated but in which stump pain persisted. Mechanical problems were solved by the UCLA unilateral equipment for bilateral shoulder cases, but the amputee's habits and motivations limited full prosthetic effectiveness. At least this patient was enabled to earn some money for the first time in 15 years.</p> <h4>Case 20, Shoulder Disarticulation</h4> <h5><i>History</i></h5> <p>Case 20, male, a 26 year old Polish born Israeli plumber, well driller, and, after amputation, clerk, entered the project in August 1951. During the Arab Israeli War of 1948, when a jeep in which he was riding struck a land mine, he had suffered a crush injury to the left arm, which resulted in shoulder disarticulation. Afterward, the patient experienced intense and continuing phantom pain in the missing hand, in the distal third of the phantom forearm, and occasionally in the entire phantom arm. Usually the phantom hand was localized in the normal position, but sometimes it was perceived as telescoped to the phantom elbow.</p> <p>Paravertebral punctures had been employed, but the relief lasted only until the anesthetic wore off. Sympathectomy of the thoracic chain had no effect, nor did eight electric shock treatments administered by a psychiatrist. The patient was then sent by the Israeli Government to California for treatment.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed marked scoliosis (the left shoulder carried 1.5 in. higher than the right), an extreme anterior protrusion of the thorax, and lateral curvature of the spine (<b>Fig. 31</b>). The patient had never received physical therapy, and the left shoulder girdle was atrophied.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Case 20. Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>Exercises to correct scoliosis and to increase range of motion were prescribed, the Sayre head sling was used to stretch tight neck musculature, and self corrective mirror instruction in posture was given. When last seen in May 1952, the subject was still performing his exercises, and his posture and shoulder mobility had improved markedly.</p> <p>Case 20 was fitted with a standard shoulder disarticulation prosthesis (<b>Fig. 32</b>), which he valued highly and which he wore all of his waking hours despite the discomfort of a perineal strap, which, because of unhealed operative wounds, he preferred to an opposite shoulder loop. But his phantom pain continued to be disabling. Two stellate ganglion blocks were attempted but failed. In October 1951, a neuroma of the left brachial plexus was removed, and a marked fibrotic scalenus anticus muscle was cut and allowed to retract. The patient was pain free for 10 days during the next month, but thereafter the pain returned with even greater intensity. In December 1951, therefore, he was referred to the Pain Clinic at the University of California Medical School in San Francisco.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Case 20 Standard shoulder disarticulation prosthesis supplied to patient, </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>On examination, the staff of the Pain Clinic found a strip of complete anesthesia below the left clavicle (thought to be related to the scalenectomy) and generally poor sensation on the left side of the entire body, with reduction of urinary and sexual function. These deficiencies were gradually eliminated during the weeks of the patient's treatment at the Pain Clinic. But no relief whatever of the phantom pain was obtained by counterirritant injection of sodium chloride into the intraspinous ligaments, by injection of sodium amytal into the trigger point in the neck, by vibration treatment, or by intravenous injection of ponto caine. The amputee was enabled to sleep, however, by the use of phenobarbital, plus almost daily intravenous injections of 10 percent sodium amytal to the point of slight drowsiness. The latter did not eliminate the pain but seemed to relax the phantom hand and lower the pain to tolerable levels. On the clinic's recommendation, these injections were continued, but within a few weeks the patient proved refractory to the sodium amytal. When he left Los Angeles in May 1952, he was resigned to living with his phantom pain and hoped only to keep busy enough to keep his mind from it.</p> <h5><i>Summary</i></h5> <p>This case was a success prosthetically but a complete failure from the standpoint of relieving the amputee's phantom pain. Neurosurgery, drug therapy, and psychiatry were equally fruitless; the first resulted only in the additional pain of multiple operative wounds.</p> <h3>Cases Presenting Unsolved Psychosocial Problems<a style="text-decoration:none;">*</a></h3> <h4>Case 21, Very Short Below Elbow</h4> <p><i>History</i></p> <p>Case 21, male, age 52, entered the clinic in October 1951, five years after the explosion of an enemy mine resulted in the very short below elbow amputation of his right arm. A revision had been performed five months after the amputation. Before his wartime service as a captain and major, the patient had worked for a railroad for 20 years, his civilian occupation being given as trainmaster. Since his amputation, he had been unemployed much of the time, living on rental income and Federal pension benefits.</p> <p>While in an Army hospital in 1946, the patient had been fitted with a modern prosthesis with polycentric hinges. He was wearing it five years later and at that time stated that he wore it 12 hours a day. But he was not satisfied with the limb. During the four years between 1947 and the lime of the patient's appearance at the clinic, the VA paid for three additional prostheses and also for an extensive series of modifications. Finally, in January 1951, convinced that the amputee was not wearing any prosthesis regularly, and under pressure from him for a satisfactory prosthesis, the VA representative referred him to the UCLA Case Study.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed a stump 3 5/8 in. long measured from the medial epicondyle to the end (<b>Fig. 33</b>), the distal area of the stump being sensitive to pressure. The amputee had received physical and occupational therapy and prosthesis use training, all of which he evaluated as excellent. Strength and range of motion were good, and no exercises were prescribed.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. Case 21. Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>After the patient's first UCLA prosthesis (<b>Fig. 34</b>) had been fitted, revised several times, and worn for a short period, and after the amputee had complained of the same pressure pain as before, a special study of his forearm flexion was made. Thereafter the clinic prescribed a prosthesis with flexible insert hinges, thus sacrificing flexion step up in order to provide a comfortable fit. To obtain a useful range of flexion, the socket was so formed and the hinges so aligned as to place the forearm in 20 deg. of initial flexion. After wearing the second arm a short time, the amputee rejected it with the complaint that the outer wall of the socket was bent laterally about 15 deg. from the normal plane of flexion, thus preventing him from using it in driving a car. He complained also that the prosthesis lacked a stop to prevent him from hurting his stump on full extension. The staff was unable to relate these complaints to any objective measurements, and no stump soreness or discoloration was found.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. Case 21 First prosthesis provided at UCLA, using split socket and variable ratio step up hinges to increase forearm flexion Because the patient complained of pressure pain upon flexion, the step up hinges were later abandoned in favor of flexible insert hinges. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Investigation of the patient's Army and VA records revealed no personality disturbance that might explain a hypercritical attitude toward prostheses. The UCLA staff psychologist examined all of the amputee's previous prostheses (which, except for the first, were in nearly new condition) and obtained the patient's relative ranking of each. It was found that the amputee's rankings were consistently related to the degree of misalignment between the epicondylar axis and the elbow axis of the prosthesis.</p> <p>When, in 1952, the prosthesis last prescribed was fitted, the relationship of the prosthetic elbow center to the epicondylar axis was measured as a function of forearm flexion, and the greatest discrepancy was found to be 1 in. with the forearm fully flexed. It was explained that this degree of misalignment was within the unavoidable error of the best techniques then available. As before, the prosthesis passed all checkout tests, was taken home, and returned with little evidence of wear. The amputee complained of the same pressure pain as before. Since the staff's resources had been exhausted, the case was closed. The staff psychologist was of the opinion that the patient was unconsciously rejecting a satisfactory prosthesis to retain a disabled state that absolved him from the necessity of working at a lower level of prestige and authority than characterized his preamputation history as safety engineer, trainmaster, and field officer.</p> <h5><i>Summary</i></h5> <p>Case 21 was a frustrating case for everybody concerned. It raised many questions and provided no answers.</p> <h4>Case 22, Below Elbow With Biceps Cineplasty</h4> <h5><i>History</i></h5> <p>Case 22, male, a 30 year old unemployed right below elbow amputee, appeared before the cooperating VA hospital clinic in October 1954 requesting a cineplasty operation, although he had never had personal contact with any cineplasty case. His amputation three years earlier had resulted from an automobile accident, and there had been a reamputation six weeks later. The patient had never had a prosthesis and stated that he could not get a job without one. His previous employment record was poor.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed a man 6 ft. 2 1/2<i> </i>in. tall, weighing 155 lb., with a normal range of motion and no conditions requiring medical or physical therapy (<b>Fig. 35</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. Case 22. Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>The patient was referred to the Prosthetics Training Center to observe cineplasty wearers. There he served as an amputee subject, was fitted satisfactorily with a conventional below elbow prosthesis (<b>Fig. 36</b>), and impressed the staff favorably by his cooperative attitude. He returned to the VA hospital with even greater enthusiasm for cineplasty, and with some misgivings a biceps tunnel was prescribed and constructed in November 1954. Postoperative convalescence was uneventful but was marked by a multitude of vague complaints with no assignable physical foundation, a demand for attention, and unwillingness to leave the hospital until forced to do so. The amputee returned to the next prosthetics course, where a cineplasty prosthesis was fabricated about seven weeks postoperative. During training, it became evident that his attention span was poor; disassociation of elbow flexion from biceps contraction was slow, and he was an inept student.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. Case 22. Conventional below elbow prosthesis first fitted to patient. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>About three months after his operation, while in the laboratory, the subject induced an episode of hyperventilation during which he seemed to be choking. He was removed by ambulance to the Los Angeles County General Hospital, where a tracheotomy was performed, but he signed out on discovering that he was scheduled for a laryngoscopy. On his return, he informed all the laboratory staff that his tracheotomy was necessitated by cancer of the larynx. Thereafter he delighted in wheezing through his tracheotomy tube on every possible occasion until the tube was removed.</p> <p>It had previously been noted that the patient delighted in wearing short sleeved shirts and exposing his muscle tunnel to everyone with whom he came in contact. He also revealed himself as an inveterate fabricator, and psychiatric consultation disclosed him to be a dependent and insecure individual. About two months after the hyperventilation episode, he was admitted to the hospital with chest pain and unexplained fever. The hyperventilation was noted again in the hospital. His "fever" was explained when he was observed putting the thermometer on the radiator. Upon discharge, the patient disappeared.</p> <h5><i>Summary</i></h5> <p>The results of prosthetic fitting, which were in the main successful, were largely negated in this case by the extreme maladjustment of the amputee. Again the principle of careful selection in a cineplasty program was emphatically illustrated.</p> <h4>Case 23, Bilateral Below Elbow</h4> <h5><i>History</i></h5> <p>Case 23, male, an unemployed 31 year old bilateral below elbow amputee, was referred by the California State Department of Rehabilitation in October 1951. He had lost his hands in August 1949 in a punch press accident while learning to be a tool and die maker. He gave his previous work as coilspring winder and crane operator. He had been fitted with below elbow rotation prostheses (APRL Sierra) on both sides but with no wrist flexion device. He reported that he wore his prostheses 15 hours a day but that he found them inadequate for all but the simplest personal tasks and could not return to the trade he had been learning. He was anxious to dress himself, eat independently, drive a car, and so on.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed no postural abnormalities. The patient was well muscled and had a good range of motion. His right stump was 84 percent of estimated forearm length, his left 73 percent (<b>Fig. 37</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. Case 23 Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>Although the length of the left forearm placed the patient in the medium below elbow class, long below elbow prostheses were prescribed for both arms because both retained forearm rotation (160 deg. in the right, 110 deg. in the left). Wrist flexion units and Dorrance No. 5 hooks with rubber lined fingers were prescribed for both prostheses (<b>Fig. 38</b>). In mechanical tests, the new prostheses and the original pair made approximately the same scores.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. Case 23. Bilateral prostheses as fitted at UCLA. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although the amputee had had no prosthetic use training and was inadequate in the use of his original prostheses, after about four hours of training in the use of the prescribed prostheses he was judged proficient. His level of performance with either side was regarded by the trainer as excellent.</p> <p>Because the patient desired independence, much practice was given in opening doors and similar activities. When training was completed in October 1951, the subject stated that he felt independent and that he was going to move out of his parents' home and seek employment. After two weeks, he reported that he was totally independent and required no help in his everyday activities. He gave much of the credit to the wrist flexion units, with which he accomplished many activities formerly impossible for him.</p> <p>The day after the patient's discharge from the project in November, his picture was in the local newspapers under such headlines as <b>NAB HANDLESS BANDIT IN MARKET ROBBERY. </b>The stories revealed that he had had a brief notoriety as the "Paper Bag Bandit" in 1945, when a series of seven bank robberies in four months netted him approximately S10,000 and a 5 year to life term at Folsom Prison. There he had lost his hands in a license plate pressing machine. He had been on parole when referred to the clinic. To the humiliation of the UCLA amputee trainer, the subject was captured in the market parking lot as he struggled to open the door of the stolen stale vehicle he was using as his getaway car. The clinic staff which had discharged the patient with new prostheses one day earlier was surprised also to read his statement that he had turned to robbery because he ''needed money fast to replace a broken pull wire and a couple of rubber tips."</p> <h5><i>Summary</i></h5> <p>Does rehabilitation mean returning the patient to his former occupational status?</p> <h4>Conclusion</h4> <p>From the case histories given here, certain facts emerge. A primary feature is the individual nature of the problem, in which rules are only general guides. The amount of functional regain cannot always be predicted. Compare, for example, the results obtained with hree of the forequarler amputees (Cases 1, 15, and 16). Even in the abbreviated histories here, and far more in the actual case records, it is clear that the fitting of an arm amputee is a custom job usually involving a certain amount of experimentation and successive approximation before satisfaction is achieved.</p> <p>It is now obvious that by far the majority of arm amputees can be satisfactorily and usefully lilted with prostheses. The exceptions, as of this writing, are those amputees with long arm stumps who have so much residual function that they may not feel the need for mechanical assistance and, at the other extreme, amputees who are so handicapped that it is difficult to provide enough stability and body control motions. During the course of the UCLA study thus far, the titling of the shoulder amputee was raised from a marginal to a truly worthwhile procedure, as was the fitting of the bilateral high level amputee. The forequarler amputee remains, in most cases, an unsolved problem.</p> <p>At this lime, it appears that unilateral fitting of the bilateral high level amputee (shoulder and very shorl above elbow types) provides greater function than does bilateral fitting. A bilateral shoulder amputee can achieve considerable independence if equipped with the UCLA manually controlled, friction type shoulder joint, cable excursion multiplier, arm rotation turntable modified for constant tension by addition of a Belleville washer, and swaged cable fittings with nylon cable housing liner. The latter two apply to all arm amputees. Some cases of phantom pain are refractory to every therapeutic measure Yet painful pressure sensitive areas on the stump may often be dealt with by careful fitting techniques. In general, below elbow. biceps cine plasty cases were successful while other types involving cineplasty were not. The stories behind the development of now standard armamentarium components are drawn from the UCLA experience, and such background is therefore necessarily given only for UCLA developed items and not for the valuable developments of other agencies such as Northrop Aircraft, the Army Prosthetics Research Laboratory, and the commercial limb industry.</p> <h3>Acknowledgments</h3> <p>The authors wish to express their thanks both to the amputees whose records are presented here and also to the past and present members of the Engineering Artificial Limbs Project whose notations are found in the case files, particularly Tonnes Dennison, Jerry Leavy, Hyman Jampol, Gilbert M. Motis, Lester Carlyle, William R. Santschi, Harry E. Campbell, Jeannine F. Dennis, and William H. Henderson.</p> <p><b>References:</b></p> <ol> <li><p>Artificial Limbs, passim.</p> </li> <li><p>Canty, Thomas J., <i>Amputations and recent developments in artificial limbs</i>, Armed Forces Med. J., 3: 1147 (19S2).</p> </li> <li><p>Gottlieb, M. S., <i>Final report of the UCLA upper extremity amputee case study</i>, Department of Engineering, University of California (Los Angeles), in preparation 1957.</p> </li> <li><p>Henderson, William H., <i>Artificial arms for child amputees fabrication and fitting developments to July 1</i>, 1956, Department of Engineering and School of Medicine, University of California (Los Angeles), October 1, 1956.</p> </li> <li><p>Klopsteg, Paul E., Philip D. Wilson, et al., <i>Human Limbs and their substitutes</i>, McGraw Hill, New York, 1954.</p> </li> <li><p>Navy Prosthetic Research Laboratory, U. S. Naval Hospital, Oakland, Calif., <i>Interim Progress Report</i>, Research Project NM 007 084.26, <i>Cine plastic above elbow prosthesis</i>, 1 November 1954.</p> </li> <li><p>Taylor, Craig L., <i>The objectives of the upper extremity prosthetics program</i>, Artificial Limbs, January 1954. p. 4.</p> </li> <li><p>University of California (Los Angeles), Department of Engineering, <i>Manual of upper extremity prosthetics</i>, 2nd ed., W. R. Santschi and Marian P. Winston, eds., in press 1957.</p> </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Two of the three problem cases included in this section are clear cut. That Case 21 is placed in the category of psychosocial problems represents a judgment on the part of the staff and of officials of the Veterans Administration; from Case 21s viewpoint, his problem related to inadequate fitting and alignment.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Case 1, although classified as a forequarter, is excluded from this discussion because he retained most of the clavicle, which had a good range of motion.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Navy Prosthetic Research Laboratory, U. S. Naval Hospital, Oakland, Calif., Interim Progress Report, Research Project NM 007 084.26, Cine plastic above elbow prosthesis, 1 November 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Canty, Thomas J., Amputations and recent developments in artificial limbs, Armed Forces Med. J., 3: 1147 (19S2).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Klopsteg, Paul E., Philip D. Wilson, et al., Human Limbs and their substitutes, McGraw Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., W. R. Santschi and Marian P. Winston, eds., in press 1957.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Since these case histories are drawn from the UCLA experience, the devices presented as solving problems are those designed by this particular project. We were in no position to present the stories behind valuable components which emerged from other laboratories and limbshops.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Henderson, William H., Artificial arms for child amputees fabrication and fitting developments to July 1, 1956, Department of Engineering and School of Medicine, University of California (Los Angeles), October 1, 1956.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Artificial Limbs, passim.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Gottlieb, M. S., Final report of the UCLA upper extremity amputee case study, Department of Engineering, University of California (Los Angeles), in preparation 1957.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Taylor, Craig L., The objectives of the upper extremity prosthetics program, Artificial Limbs, January 1954. p. 4.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Marian P. Winston, B.A. </b></td></tr><tr><td class="clsTextSmall">Editor, Engineering Artificial Limbs Project, Department of Engineering, University of California (Los Angeles); formerly., Prosthetics Education Project, UCLA Medical Center,</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Craig L. Taylor, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Professor of Engineering and Physiology, University of California (Los Angeles); Project Leader, Engineering Artificial Limbs Project, Department of Engineering, University of California (Los Angeles); member, Committee on Prosthetics Research and Development, PRB, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Robert L. Mazet, JR., M.D. </b></td></tr><tr><td class="clsTextSmall">Clinical Professor of Orthopedic Surgery, University of California Medical School (Los Angeles); Chief of the Orthopedic Service, Wadsworth Veterans Hospital; member, Committee on Prosthetics Research and Development, PRB, NRC; Past President, American Board for Certification of the Prosthetic and Orthopedic Appliance Industry, Inc.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Marvin S. Gottlieb, M.A. </b></td></tr><tr><td class="clsTextSmall">Formerly Junior Research Engineer, Engineering Artificial Limbs Project, Department of Engineering, University of California (Los Angeles).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Some Experience with Prosthetic Problems of Upper Extremity Amputees Creator An entity primarily responsible for making the resource Marvin S. Gottlieb, M.A. * Robert L. Mazet, JR., M.D. * Craig L. Taylor, Ph.D. * Marian P. Winston, B.A. * https://staging.drfop.org/files/original/befcb86fff74a058e93e3af03fca5cb4.pdf 039187c0f904a1046950d24faf81834e https://staging.drfop.org/files/original/789116c760951063d9ff4663d56ebf11.jpg a9aab0226d3064cf534e81cdf298f8d4 https://staging.drfop.org/files/original/1d6f583a27b50e7e028c417b897f6e7b.jpg 15aa793539956fd62a25423d3bce7777 https://staging.drfop.org/files/original/9a407e0949fb0cacc06278d12c150165.jpg 2d7e8e8f2c1dc9463620a612fc5ec1ba DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1957_02_004.pdf Year 1957 Volume 4 Issue 2 Page Number(s) 4 - 21 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1957_02_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1957_02_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Past and Present Medical Significance of Hip Disarticulation</h2> <h5>Henry E. Loon, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Hip disarticulation, or amputation through the hip joint, is one of the most drastic surgical removals known to medicine. It is seldom justified as other than a last-resort, lifesaving measure and, as compared to other amputations, is seldom performed. Because of its severity, and because it has been used only for patients already on the verge of medical disaster, it has been attended by discouragingly high mortality rates throughout its 200-year history. By the same token, however, the record of the changing need for hip disarticulation is a record of medical progress against fatal disease and trauma of the lower extremity. Whereas hip disarticulation was first used extensively against gangrene or the ever-present threat of generalized infection, it is now most frequently one of the ultimate weapons against cancer. Moreover, the operation has lost much of its fearsomeness as general medical knowledge and surgical skill have increased and as the hope for prosthetic rehabilitation of these patients has become brighter.</p> <p>By presenting the medical aspects of hip disarticulation in historical perspective, it. is hoped to show here how the pathological conditions indicating hip disarticulation have changed as medical science has progressed, how the operative dangers of hip disarticulation have been largely overcome, and how the surgical fashioning of the stump (within the limits imposed by injury or disease) has helped in the prosthetic rehabilitation of patients. Finally, there is appended a discussion of the recent interest paid to systemic effects that may accompany any major loss of limb.</p> <h4>Historical Beginnings</h4> <p>Until the mid-eighteenth century, surgeons considered themselves helpless to treat complicated fractures or suppurative diseases of the upper part of the femur, let alone malignant growths in this region. Death from septic complications, gangrene, or, in the case of cancer, metastases, was the almost inevitable outcome of these conditions.</p> <p>Surgical disarticulation of the hip was apparently first conceived by Sauveur Francois Morand, a leading French surgeon of the early eighteenth century, and was formally proposed in 1739 by two of his pupils.<a></a> Long before the first true surgical disarticulation, however, the hip of a boy of 14 was nearly disarticulated by gangrene which resulted from his having eaten diseased rye. Observing the thigh to be connected to the trunk only by the round ligament, the sciatic nerve, and some shreds of tissue, the French surgeon Lacroix<a></a> cut these with scissors. The other leg, similarly affected, was cut from the hip in the same manner four days later, and the patient survived another 11 days. This case gave a great impetus to discussion of the matter. In 1759, the Royal Academy of Surgery offered a "double prize" for the best essay on the following subject: "Dans le cas ou l'amputation de la cuisse dans l'article paroitroit l'unique ressource pour sauver le vie a un malade, determiner si l'on doit pratiquer cette operation, et quelle seroit la methode plus avantageuse de la faire."<a style="text-decoration:none;">*</a> Of 44 essays submitted, 30 were in favor of performing the operation.<a></a></p> <p>Not until 1774 was it proved that death on the operating table was not a necessary consequence of this formidable operation. In that year, the first true surgical disarticulation of the hip was performed by William Kerr,<a></a> of Northampton, England, on an 11-year-old girl who had a tumor of the thigh and symptoms of pulmonary tuberculosis.<a style="text-decoration:none;">*</a> The disarticulation had probably not greatly influenced the course of the disease, and Kerr concluded his presentation optimistically (p. 342): "With regard to the expediency of the operation, I am so much convinced of it in certain cases, that in such I shall not, for the future, hesitate to perform it when they occur."</p> <p>Another disarticulation said to have been performed at about the same time by Henry Thomson at the London Hospital apparently terminated fatally<a></a> , and the operation was not reported again for nearly 20 years. The Wars of the French Revolution and the Napoleonic Wars brought with them a new series of hip disarticulations.</p> <h4>Shifts and Changes in Indication Over Two Centuries</h4> <p>Although the earliest hip disarticulations were performed for disease, in the following 100 years many more were done for gunshot wounds than for any civilian cause. Up to the end of the American Civil War, nearly two and a half times as many military as civilian operations had been reported from Europe and America, as recorded by Otis in <i>The Medical and Surgical History of the War of the Rebellion . </i><a></a> Since that time, the situation appears to have been reversed again owing to the decreased necessity for the operation fol- lowing battle injuries and its increased use to remove malignant growths. It would be instructive to be able to compare hip disarticulations of military and of civilian origin—as to exact incidences and indications—throughout the history of the operation, but unfortunately information is incomplete and many difficulties of interpretation arise. Nevertheless, a comparison of the indications given for each group points up the necessity of considering the two categories separately.</p> <h4>Indications in Military Surgery </h4> <p>The military surgeon has always been concerned mainly with trauma and ensuing infection, although infection plays a progressively less important role than formerly. In 1812, Dominique Jean Larrey,<a></a> the famous French surgeon and personal physician of Napoleon, who himself (Larrey) performed seven of the early disarticulations, stated the indications for the operation in military surgery as follows:</p> <ol> <li>A torn-off limb, or great laceration of the limb so close to the upper articulation that amputation in continuity would not be possible.</li><li>Fracture of the femur in the vicinity of the trochanters, accompanied by a rupture of the femoral artery or of the sciatic nerve.</li><li>Massive gangrene of the lower extremity extending to the vicinity of the upper articulation, as a result of extensive wounds of the soft tissues.</li></ol> <p>At the time of the American Civil War, these indications were still considered valid, and Otis<a></a> repeated the first two almost verbatim. Today, however, most severe fractures, and even many comminuted fractures, of the upper end of the femur, if not associated with irreparable vascular damage, can be treated conservatively. Most of the major amputations of extremities in World War II were the result of such extensive traumatic injury that no improvement in surgical technique could hope to effect repair. According to DeBakey and Simeone,<a></a> 69 percent of the 3177 major amputations performed in the European and Mediterranean Theaters were due to extensive trauma (by which was meant complete or nearly complete severance of the limb or part of the limb), 12 percent to infection, and 19 percent to major arterial injury.</p> <p>The relatively small percentage of amputations due solely to major arterial injury could probably now be reduced still more because of new techniques of repair and grafting of blood vessels. Some successful cases were reported from the Korean War, and knowledge is further advanced today.<a></a></p> <p>Statistics on the specific indications for the 56 recorded cases of hip disarticulation from World War II<a></a> are at present not available. The implications of the records seen is that the majority were traumatic amputations. For instance, of the 154 wounds of the hip joint observed between D-Day and VE-Day at the 802nd Hospital Center, none was treated by disarticulation. Regarding the incidence of infection, there was no report of rapidly spreading hemolytic streptococcic or staphylococcic infection, such as still occurred in World War I <a></a>. At the 802nd Hospital Center, infection occurred in 9 of 29 injuries of the femoral head or neck. Although these were cases of persistent, long-lasting infection, leading in two cases to death, no hip disarticulation was performed. Usually this tendency toward conservatism was justified, but in looking back, the Office of the Surgeon General has modified this attitude in the following statement:<a></a></p> <ol> <li>When there has been great mechanical destruction of the bone and soft parts and when retained foreign bodies carrying fragments of clothing cannot be removed, foci of infection are maintained for indefinite periods of time.</li><li>A prolonged delay before amputation merely results in exhaustion of the patient, so that, when the operation is eventually performed, it often poses a serious threat to life. ... It must be assumed that patients with large areas of mixed, penicillin-resistant infection deteriorate every day that they live and that their chances of survival after major surgery become progressively less as time passes. . . .</li><li>Observation of numerous instances of pyoarthro-sis of the hip joint at United States Army amputation centers made it clear that when the sciatic nerve is lacerated the indication for early disarticulation of the hip is particularly strong.</li></ol> <p>Fulminating gas gangrene is still an indication for amputation, but its incidence has been tremendously reduced by the employment of prompt and thorough debridement and the administration of antibiotics. It is impossible to determine from the available statistics whether any hip disarticulations were performed because of this infection.</p> <p>To sum up, in military surgery hip disarticulations-like other major amputations- appear to be performed today primarily when the limb is completely or almost completely severed from the trunk. To these traumatic amputations must be added those cases in which disarticulation is necessitated by major injury to the blood vessels or to the main nerve trunks (particularly the sciatic) and those in which multiple foci of antibiotic-resistant infection cannot otherwise be eliminated. That the number of hip disarticulations has not been greatly reduced in comparison with former wars is testimony to the increased destructiveness of modern weapons; the type of injury which used to necessitate hip disarticulation can usually be treated conservatively today.</p> <h4>Indications in Civil Surgery</h4> <p>The civilian surgeon has also always been concerned with trauma, but disease, and especially malignant disease, has played an increasingly important role. In 1839, Velpeau<a></a> stated the indications for hip disarticulation in peacetime as follows:</p> <blockquote><p>A comminuted fracture, a necrosis, caries, osteosarcoma, spina ventosa, or any incurable degeneration whatever, of the femur, extended above its shaft, or gangrene, or any other disease in fact which has progressed nearly as high up as the haunch, and which is of such serious character as to demand amputation, will claim disarticulation provided the cotyloid cavity and the bones of the pelvis are not affected.</p> </blockquote> <p>The major change in indications from the nineteenth to the twentieth century is best seen from a comparison of nonmilitary hip-disarticulation cases. It may be seen from <b>Fig. 1</b> that, although many of the conditions listed by Velpeau might today be considered indications for hip disarticulation, they do not in practice occur very often. Cancer is <i>the </i>indication now, whereas in the early period it was one among a number of causes. The indications given by Smith<a></a> for his historical survey of cases fall into the following categories: malignancy, 13; severe crushing injuries, 8; suppurative diseases of the femur, 7; tuberculosis, 4 (tubercular lesions of the bones, 3; tuberculoma of the thigh, 1); gangrene, 3; miscellaneous causes ("diseases of the femur," "coxalgia," pain, exostoses), 7.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Comparison of early and recent indications for hip disarticulation in peacetime. Data for the early period were taken from a compilation by Stephen Smith<a></a> of all known cases of hip disarticulation to 1852. Wartime operations and those for which the indication was not known were eliminated. Data for the recent period were derived from articles indexed under <i>Amputations </i>in the <i>Quarterly Cumulative Index Medicus </i>from 1935 through 1951 and in the <i>Current List of Medical Literature </i>from January 1952 through August 1957. Again, wartime operations and those for which the indication was not stated were eliminated. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Four of the tumors which Smith gave as indication were not classified by him as malignant. But from the description of the course of the disease they appear to have been, and they are therefore here grouped under malignancy. This is only one example of how difficult it is to determine with any certainty what the true indications for these early operations were. Another example is Kerr's case (page 5). Smith, following Kerr's own diagnosis, recorded the indication as tuberculosis; yet from the description of the case it seems conceivable that the patient had a malignant growth in the upper end of the femur and the innominate bone with metastases to the lungs.</p> <p>Methods of diagnosis are greatly improved today, but it is no less difficult to obtain reliable statistics on recent hip disarticulations. Cases that do not present striking medical or surgical aspects are no longer reported in the literature. In this country, unfortunately, no survey of the total number of amputees has ever been made, but even in countries like Germany or Great Britain, where the government has made such surveys for the larger categories of amputations, no information of the incidence of hip disarticulations, let alone the indications for them, seems to be available. </p> <p>In a literature survey covering the period from January 1935 through August 1957, there were reported (<b>Fig. 1</b>) 146 civilian hip disarticulations for which the indications were malignancy.<a></a> Two were done for tuberculosis<a></a> and one each for osteomyelitis following an injury<a></a>, phlegmon of thigh and general septicemia following an injury, <a></a> a suppurative process (etiology not stated) of the coxo-femoral articulation,<a></a> actinomycosis, <a></a> gangrene caused by thrombosis, <a></a> and paralysis and contracture caused by an extradural abscess. <a></a> It is a little surprising that, of all the reported civilian hip disarticulations, none was done primarily for trauma. I have myself seen one patient whose hip was disarticulated because of injuries in peacetime, and I am certain that there must have been a few others.</p> <p>Fortunately, not all malignant growths, even in the upper part of the thigh, call for such drastic treatment as disarticulation of the hip. In some cases wide excision of the neoplasm suffices to remove it entirely. The decision as to whether or not to disarticulate depends upon the site and the type of the neoplasm. The indications upon which modern surgeons agree are well stated by Pack and Ehrlich<a></a>, and the reader interested in these details is referred to that excellent paper.</p> <h4>Incidence Relative to All Leg Amputations</h4> <p>Comparison of the number of hip disarticulations with total numbers of lower-extremity amputations shows still more clearly how seldom hip disarticulation is performed. It has now become much rarer in military than in civilian practice. During the American Civil War<a></a> 86,413 wounds of the lower extremities were recorded. In 12,605 of these cases (less than 15 percent), the wounds resulted in major lower-extremity amputations. Of these, 66, or 0.5 percent of the amputations, were hip disarticulations (<b>Fig. 2</b>). In World War II<a></a>, 248,000 wounds of the lower extremities were recorded. Of these, 12,612 (5 percent) are estimated to have resulted in major amputation. Fifty-six, or 0.4 percent, of the amputations are estimated to have been hip disarticulations. Thus the percentage of hip disarticulations in relation to total lower-extremity amputations has changed very little; it has remained small. Both the number of hip disarticulations and the number of lower-extremity amputations have, however, decreased greatly relative to the number of wounded.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. One of the few survivors of disarticulation of the hip during the American Civil War. Note the large amount of soft tissue in the stump. From Otis<a></a>. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In civilian cases the ratio of the number of hip disarticulations to all major lower-extremity amputations is probably somewhat higher but still less than 2 percent. Thus, of 70 lower-extremity amputees who underwent amputation or were treated at the University of California Medical Center from 1941 to 1955, only one had had a hip disarticulation.<a></a> Of 663 patients with major lower-extremity amputations who have passed through the Veterans Administration Hospital in Oakland since the end of World War II, eight have had hip disarticulations.<a></a> Even the records of an institution treating predominantly cancer patients show a very small number of hip disarticulations. The Bone Tumor Service of the Memorial Center for Cancer and Allied Diseases in New York City reported only 15 hip disarticulations from 1930 to 1946,<a></a> a fact which suggests that even today this operation is done only to forestall certain death.</p> <h4>The Long Struggle to Reduce Mortality </h4> <p>There was good reason why hip disarticulation was not attempted, or even conceived, until the eighteenth century. The surgical skills which had been developed up to that time were still grossly inadequate for an operation attended by so much danger of hemorrhage and shock.</p> <h4>Operative Mortality </h4> <p>When we consider that the operation had to be done as fast as possible, without benefit of anesthesia or knowledge of asepsis, it is surprising how many of the earliest patients survived even a few days or weeks. Larrey, <a></a> who was probably one of the most skilled surgeons of his time, has recounted cases in which, after ligating the femoral vessels together, he completed the procedure in 14 to 15 seconds. To achieve this speed, he used only four knife strokes. He drove a blade perpendicularly between the base of the femoral neck and the tendinous attachments of the lesser trochanter until it emerged posteriorly and, with an oblique downward stroke, cut the medial flap; raised the flap proximally to expose the articulation and with a stroke of the bistoury cut the articular capsule; abducted the thigh (nearly dislocating the head of the femur) and in a stroke cut the interarticular ligament; and with a downward and outward stroke of a small straight knife cut the lateral flap. The remaining arteries were then ligated. Larrey did not consider it necessary to suture the muscles. If there was no "irritation," the subcutaneous tissues and the skin were approximated with a few retention sutures. The edges of the wound were further drawn together by compresses dampened with red wine, and a large bandage was applied.</p> <p>Larrey reported that his first patient survived the operation well but a few hours later had to follow the army in a 24-hour forced march in winter, so that he died presumably of cold and exposure. His second patient also seemed well on the road to recovery when, six days postoperative, a soldier with the plague was bedded on the same straw mat with him. Larrey's patient became infected and died within 24 hours.</p> <p>The fate of these patients, who died not as a result of the operation itself, shows how difficult it is to establish the date of the first "successful" hip disarticulation. These two, together with others in which death occurred within a year after operation, were in early mortality statistics classed as fatalities.<a style="text-decoration:none;">*</a> On the other hand, there are no verifiable records of several of the early hip disarticulations claimed by later authors to have been successful. Otis on whose two works<a></a> the early figures given here are based, pointed to other frequent sources of fallacies in surgical statistics. He said:<a></a></p> <blockquote><p>The desire for distinction of ambitious operators sometimes tempts them to report successful results prematurely, and to fail to record unfortunate cases. Feverish partizans of particular operative procedures, in accumulating statistics, not unfrequently evince an unpardonable disregard for the fundamental rules of evidence, and admit testimony abounding in transparent fallacies. Some writers, in their zeal to gather together numerous observations, group those that are very dissimilar, and deduce inferences from the collection that are pertinent only to particular cases.</p> </blockquote> <p>He stated that in his own report the authenticity of cases was scrutinized and that doubtful cases were rigidly excluded.<a></a> Insofar as the records of earlier operations Otis recorded have been checked, he was indeed conscientious; yet in evaluating his figures it is essential to bear in mind all the limitations of this early material.</p> <p>According to Otis <a></a>, 111 known civilian cases of hip disarticulation were reported from Europe and America to the end of the American Civil War. Of these, 46 were considered successful and 65, or 59 percent, terminated fatally. In military surgery <a></a>, 254 authenticated hip disarticulations were reported, with 28 recoveries, 225 deaths, and one result unknown-a mortality rate of 89 percent. Of the 187 patients who underwent hip disarticulation prior to the American Civil War, 17 survived, giving a mortality rate of 91 percent. In the 67 cases occurring during the Civil War, 11 of the patients recovered-a mortality rate of 84 percent.</p> <p>In spite of this extremely high mortality rate, disarticulation gave better results than did more conservative methods of treatment for complicated fractures of the upper end of the femur. Of 252 patients with intracapsular shot fractures who were treated conservatively during the American Civil War, three recovered, giving a mortality rate of 99 percent.<a></a> Fifty-five excisions of the femoral head resulted in a mortality rate of 91 percent.<a></a> The mortality rate did not improve materially until well after the general introduction of asepsis in the 1880's. In 1878, Farabeuf,<a></a> when presenting his method of disarticulation to the Societe de Chirurgie in Paris, cited a still-persisting death rate of 75 percent. The American surgeon Wyeth,<a></a> writing in 1890, mentioned "the terrible death-rate after hip-joint amputation."</p> <h4><i>Improvements in Surgical Technique</i></h4> <p>After deaths from complications of infectious processes had been somewhat brought under control by the general introduction of aseptic surgical procedures, surgical shock still accounted for a large number of the operative deaths. A main contributing factor was hemorrhage.</p> <p><i>Reduction of Hemorrhagic Shock. </i>The arteries to the upper part of the thigh and the gluteal region branch out from several main trunks (<b>Fig. 3</b>), so that it is much more difficult to control the flow of blood for a hip disarticulation than for a thigh or leg amputation. Methods attempted for control ranged from a high tourniquet placed about the upper end of the thigh to compression of the aorta.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Arterial system in the hip and upper part of the thigh. Redrawn, by permission, from <i>Gray's Anatomy, </i>26th ed., Lea &amp; Febiger, Philadelphia, 1954. The original appeared in Eycleshymer and Jones' <i>Hand Atlas of Clinical Anatomy, </i>Lea &amp; Febiger, Philadelphia, 1925. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>An ordinary touniquet is difficult to apply satisfactorily for a hip disarticulation. Placed about the thigh at the groin, it not only does not control bleeding from a number of the main vessels but it also slips out of place easily after enucleation of the promixal end of the femur. For this reason, there were developed various devices for holding a tourniquet in place, the best known being Trendelenburg's<a></a> and Wyeth's<a></a> systems of pins. In both procedures, long steel pins were driven through the soft tissues to prevent slippage of rubber tubing used to constrict the tissues.</p> <p>Of the more radical methods for compression of the parent trunks, some, such as a Davy's lever introduced through the rectum for the compression of the aorta, were dangerous, and they were not always reliable.<a></a> Other authors recommended making an abdominal incision and temporarily compressing<a></a> or lifting<a></a> or even permanently ligating<a></a> the common iliac artery. The latter procedure has been recommended as recently as 1954, <a></a> but it is not commonly used today. Many surgeons hesitate to add to the system an additional shock by making an incision into the abdominal cavity.</p> <p>In general, more conservative measures are and have been advocated. Although initial ligation of the femoral vessels does not provide a completely bloodless field (because of the many anastomoses from the obturator and gluteal arteries), it has usually been considered the most satisfactory method. As we have seen, Larrey in his early operations recommended preliminary ligation of the femoral artery and vein, and regardless of the type of incision this has been common practice to the present day. Farabeuf,<a></a> whose procedure is still widely used, especially in Latin American countries, recommended an anterior racquet incision. The stem of the inverted <i>Y</i> should be over the point at which the femoral vessels pass under the inguinal ligament, and the artery and vein are sectioned and ligated before proceeding with the operation. Farabeuf claimed that other arteries could satisfactorily be cut and compressed by assistants as they were encountered and then ligated before closing the wound. Marquardt<a></a> in a recent book stated that in Germany it is considered best to follow Angerer's two-stage procedure,<a></a> in which ligation of the femoral artery and vein is done through an incision in Scarpa's triangle one or two days before the proposed hip disarticulation. This expedient allows the vessels to become thrombosed so that there is little loss of blood during the disarticulation itself.</p> <p>Finally, blood may be conserved if, after ligation of the artery, the leg is elevated for several minutes to allow maximal drainage to the trunk before ligation of the vein.<a></a></p> <p>In addition to careful hemostasis, it is helpful to section the muscles, wherever possible, in the avascular areas close to the tendinous origins or insertions rather than through the muscle bellies. This principle, proclaimed by Callander<a></a> in 1935 for his amputation just above the knee, has been applied to hip disarticulations by Leriche,<a></a> Boyd,<a></a> Slocum,<a></a> and Piquinela.<a></a> In the days when speed of operation was the primary consideration, the principle was necessarily violated. If guillotine operations are excluded, it is hard to imagine a faster method than Larrey's, but cutting each flap with a single stroke, as Larrey did, meant sectioning the muscles through the richly vascularized bellies, thus contributing greatly to hemorrhage and shock. He was, of course, caught on the horns of a dilemma for those times, because speed, too, was essential to lessen shock.</p> <p><i>Other Techniques for Avoiding Shock. </i>Even in cases in which there has been no infection or excessive hemorrhage, shock often occurs. Bustos<a></a> gave this as reason for believing that conditions which could cause pain played the major role in causing shock. Gentle handling is considered essential by most modern surgeons. Layer-by-layer dissection, using a scalpel, was recommended by Petrovskii.<a></a> Caprio<a></a> recommended the use of an electric scalpel, with which he claimed that he could carry out the whole operation without even turning the patient over, as is usually done.</p> <p>Many surgeons have taken precautions to avoid shock that might result from overstimulation of the sciatic nerve. Since this large nerve trunk runs through the posterior portion of the thigh, it is ordinarily not sectioned until the latter part of the operation and is in the meantime subjected to a variety of tensions, particularly after the dislocation of the femoral head, when the half-severed limb hangs from the trunk, connected only by this nerve and associated soft tissue. Various methods for overcoming this problem have been suggested -proper support of the limb throughout surgery to avoid these tensions<a></a> ; injection of the nerve with procaine before sectioning it;<a></a> and even, in a debilitated case, section of the sciatic nerve (after injection with procaine) almost at the start of the operation<a></a>. In 1917, Morris, <a></a> using spinal anesthesia, began his operation by injecting the sciatic nerve with procaine through a small posterior incision and then proceeded through anterior incision with what is usually the first part of the operation. He stated that no shock was observed during the ensuing disarticulation.</p> <p>Recently, the use of spinal anesthesia has been questioned<a></a> on the grounds that hypotension results, which could be dangerous in view of the seriousness of hip disarticulation. However, hypotension does not occur routinely when the level of spinal anesthesia is so low that the splanchnic nerves are not anesthetized. <a></a> Injecting the sciatic nerve may appear superfluous if spinal block has been performed prior to the operation. It seems to be done as an additional precaution and as a means of blocking any afferent fibers that, traveling via the sympathetic chain, may enter the cord above the level of spinal anesthesia.</p> <p>A two-stage operation is sometimes advisable for patients who are in very poor condition. We have already mentioned Angerer's procedure of ligating the femoral vessels one or two days before the disarticulation, a method which aids in avoiding shock by reducing blood loss. Even a three-stage procedure has been recommended. <a></a> In most cases today, however, the operation is performed in one stage only.</p> <h4><i>Improvements in Adjunct Therapy</i></h4> <p>In the first quarter of the twentieth century, great progress in several fields decreased the risks of serious operations such as hip disarticulation. More careful debridement of wounds was supplemented by chemotherapy and the use of tetanus antitoxin. By the end of World War I, shock occurring in American Army soldiers was treated by fluid replacement and whole-blood transfusion.<a></a> Knowledge of the physiology and technique of blood transfusion was greatly advanced in the second quarter of the century. Methods of preserving whole blood and plasma were developed, although such problems as the occurrence of homologous-serum hepatitis virus in stored plasma remained unsolved and caused considerable damage. Surgical knowledge of the repair of fractures and of replacement of hopelessly damaged parts of bones by grafts of various types made conservative treatment possible in many more cases than before. The use of sulfa drugs and antibiotics greatly reduced the incidence of infection after severe wounds. Finally, psychotherapeutic measures to prevent psychic trauma and to facilitate recovery became an important adjunct to surgical care.</p> <p>Operative death has become rare, <a></a> but the extent of shock and the resulting damage to the system continue to deserve study.</p> <h4>Mortality From Cancer</h4> <p>Another mortality rate is, however, a matter of much greater concern today. As we have seen, most modern civilian hip disarticulations are performed for cancer. Since at the present time hip disarticulation is commonly not resorted to until other measures (radiation, wide excision) have failed, it often has only a palliative effect. The mortality, if studied for the 5-year-cure rate, is extremely high. Of a series of 52 patients operated upon at the Memorial Cancer Center in New York from 1926 to 1948, 44 (85 percent) died of cancer within five years.<a></a> Pack<a></a> and others<a></a> have emphasized that, if disarticulation is resorted to only at this late stage, the mortality rate in such cases will continue to be high. In a recent study of patients with malignant disease who underwent hemipelvectomy (an operation comparable to hip disarticulation for the purpose here), Lewis and Bickel<a></a> observed:</p> <blockquote><p>Twelve of the 18 patients who had had symptoms less than six months at the time of operation are still living (two with metastases), and 4 of the 6 who had had symptoms for six months to one year are still living (one with metastases), while only 8 of the 25 patients who had had symptoms for more than one year have survived the present follow-up periods, and one of these has evidence of metastases.</p> </blockquote> <p>Although there is sometimes justification for disarticulation as a palliative measure, it would be much more desirable to employ it as a cure. Disarticulation as a curative measure will, however, be possible only when surgeon and patient alike are willing to take this radical step at an early stage of the disease.</p> <p>To what extent will hip disarticulation be replaced by the even more drastic operation of hemipelvectomy? Hemipelvectomy is indicated if malignancy (or, for that matter, a severe crushing injury or a suppurative process such as that mentioned on page 8) has involved the tissues proximal to the coxofemoral joint. Leriche<a></a> went beyond this in 1937 when he predicted that hemipelvectomy would one day be considered the operation of choice for malignant growths of the upper part of the thigh. Lee and Alt<a></a> in 1953 compared hip-joint disarticulation with hemipelvectomy from the point of view of anatomy and surgical technique, extent of postoperative disability and use of prosthesis, and therapeutic effectiveness. They found that under modern conditions there was no great difference between the two operations so far as surgery or postoperative disability are concerned, whereas hemipelvectomy definitely offered better hope of a cure. They therefore considered hemipelvectomy the procedure of choice for high-grade soft-tissue or osteogenic malignant tumors of the upper thigh as well as of the pelvis.</p> <p>Not all modern surgeons go so far as this. Coley<a></a> has emphasized that it is essential to discriminate between cases, the decision depending upon the site and grade of malignancy of the tumor. Osteosarcomas and chondrosarcomas of the lower fourth of the femur do not call for hip disarticulation and are better treated by high thigh amputation, since then considerably less disability results.</p> <p>In sum, allowing a wider margin between the tumor and the incision is now generally recognized to be necessary to ensure elimination of all malignant cells. This means that the level of amputation has tended to move in a proximal direction. While some hip disarticulations have been replaced by hemipelvectomy, high thigh amputations have also been replaced by hip disarticulation, so that no appreciable decrease in the number of hip disarticulations is to be expected as a result of this trend.</p> <h4>Surgical Fashioning of Stumps</h4> <p>The surgical techniques of hip disarticulation practiced today have evolved as a result of this many-faceted experience. Throughout the history of the operation, the sequence of procedures has been dictated primarily by cumulative experience in combating hemorrhage and shock. The shape of the resulting stump has been affected primarily by the change in indication for the operation from predominantly traumatic to predominantly malignant cases. To a lesser degree, the shape has been affected by considerations of healing and subsequent fitting with a prosthesis.</p> <h4>THE LARGE SOFT-TISSUE STUMP</h4> <p>The large soft-tissue stump popular during the early history of hip disarticulation (<b>Fig. 2</b>) may originally have been developed through association with a high-thigh stump. Surgeons first experimenting with the dangerous operation of hip disarticulation may well have been loath to cut away too much soft tissue. But many of the early operations were actually done by first performing a circular high thigh amputation and then disarticulating the head of the femur through a lateral incision.<a></a></p> <p>During the latter half of the nineteenth century, many experiments were carried out with various kinds of subperiosteal amputations, in which a cuff of periosteum was left overlapping the end of the bone stump. Difficult as it was to perform, a subperiosteal hip disarticulation was done several times. Originally devised by Oilier of Lyons in 1859, it was carried out by James Shuter<a></a> of London in 1881. A circular amputation was first performed at the junction of the middle and upper thirds of the thigh. The vessels were ligated, and through a longitudinal incision on the lateral aspect of the thigh the remaining portion of the femur was dissected out, leaving the periosteum (peeled off up to the intertrochanteric line) in the flaps.</p> <p>The advantage of this method, according to Shuter and others who observed the patient over a year after operation, was that the residual periosteum provided a point of attachment for the muscles and caused a growth of what Shuter termed "new bone" but which other observers described as "a firm resisting cord",<a></a> cartilaginous rather than bony in character. Observers testified that this "cord" provided such a good attachment for the muscles that they were "in a high state of nutrition" and that the patient not only could flex, extend, adduct, and abduct the stump powerfully but also could communicate all these movements to the artificial limb. Durand<a></a> of Lyons had a woman patient who, more than four years after a similar operation, had a regenerative process resembling a tough fibrous stalk, which also provided an excellent attachment for the muscles. She was able, he stated, to lift a weight of 15 kg. with her flexed stump.</p> <p>In a modern case<a></a> the patient, although apparently not operated upon subperiosteally, was said to have had a stump with many of the characteristics claimed for the subperiosteal stumps. Disarticulation was done for osteomyelitis of the femoral shaft, trochanter, and neck, a sequel to extensive injuries of the thigh. The femur was carefully dissected out from the surrounding tissues, leaving a soft-tissue stump measuring 6 in. when relaxed. It was reported that "The muscles had become attached to each other by scar tissue, so that there was actiye flexion and extension of the stump if one grasped the muscles with his hands." The patient was able to wear a suction-socket prosthesis, which he could flex and extend at the hip joint "because of the fixation of the skin and muscles to the side of the socket by the suction exerted upon the distal end of the stump." This method of activating the prosthesis was compared to that used by crustaceans in activating their exoskeletons, and a point was made of the importance in this case of designing the socket so that, upon weight-bearing, the contracted muscle mass would be properly positioned on the ischial seat beneath the ischial tuberosity.<a style="text-decoration:none;">*</a> About the turn of the century, subperiosteal amputations were gradually abandoned, mainly because of the frequency of undesirable growths of new bone emanating from the periosteal cuff. Apparently only a few subperiosteal hip disarticulations were performed. In addition to the uncontrollability of new bone growth, other, even more important, reasons prevented the operation from becoming popular. One was the difficulty of stripping the periosteum from a healthy bone. Shuter's subperiosteal operation was done for a suppurative process of the femur, in the course of which the periosteum had already achieved a considerable degree of natural separation from the bone. Durand did not mention a similar condition in his patient, but his operation was done for tuberculosis, and possibly a suppurative process was present. Another reason, much more significant today, was that the retention of the periosteum made the procedure unsuited for any disarticulation done because of a malignant neoplasm.</p> <h3>The Compact Stump</h3> <p>After disarticulation for malignancy, the hip stump commonly fashioned today is compact, with the soft tissues reduced to a minimum. When involvement of the inguinal nodes is proved, or, in certain disease, even suspected, a radical groin dissection is also done, thus removing even more tissue from the body.</p> <p>Most incisions today, whether of the anterior racquet or semioval type, start just below the inguinal ligament and thus provide immediate access to the femoral vessels and nerve in Scarpa's triangle. These incisions create a long posterior flap and leave an anterior scar that is well removed from terminal and lateral pressure areas and from any possibility of fecal contamination before wound-healing is complete. The semioval incision has the advantage of eliminating the "handle" of the racquet, which, if carried too far, may easily invade a pressure area under the pelvic corset of the prosthesis. For this reason, it would seem to be the incision of choice for the use of the Canadian-type hip-disarticulation prosthesis, as may be seen from Fig. 11, page 37. This prosthesis is, however, very adaptable and can easily be modified to accommodate a larger or smaller amount of soft tissues (even dog-ears). Bony prominences are not necessary to anchor it. If the wound has healed by first intention, it is no longer critical whether the scar lies under a pressure area.</p> <p>For further information on the modern technique of hip disarticulation, the reader is referred to Slocum's procedure, which is detailed on pages 242-244 of his work, <i>An Atlas of Amputations .</i><a></a> The muscles are sectioned in the avascular areas close to their tendinous origins or insertions. Some additional precautions against shock, as already discussed, may be found desirable in certain cases. For cases in which involvement or suspected involvement of the inguinal nodes necessitates radical groin dissection, Pack and Ehrlich's standard method<a></a> can be followed. A racquet incision, with the handle of the inverted <i>Y </i>extending proximally, is recommended for this procedure, which is carried out before the hip disarticulation. The only problem here is that the large skin flaps, denuded of all underlying subcutaneous fat, lymphatic tissue, and fascia, are susceptible to necrosis and sloughing along their edges. Not much can be done about this, since in order to be effective the procedure has to be thorough. Since the wound does not ordinarily heal by first intention, the scar, extending as it does well above the line of the inguinal ligament, may present problems in the fitting of the Canadian-type hip-disarticulation prosthesis.</p> <h3>Possibility of Short Thigh Stump</h3> <p>Most cases of malignancy, as we have seen, require radical removal not only of the bone but also of as much soft tissue as possible. When the amputation follows trauma or disease other than cancer, however, the question may arise as to whether to disarticulate or to leave a very short thigh stump. The improvement of artificial limbs, as well as of surgical techniques, has made it possible to fit above-knee amputees of higher and higher amputation level with thigh prostheses rather than with hip-disarticulation prostheses. In 1930, Verrall<a></a> stated that any stump measuring less than 5 in. below the greater trochanter had to be fitted with a tilting-table (hip-disarticulation) prosthesis. In 1949, Slocum stated<a></a> that "When amputation approaches the level of the lesser trochanter, the function of this [hip] joint is nullified ..." and that therefore a patient with an amputation at this level or higher had to be fitted with some type of hip-disarticulation prosthesis. The possibility of fitting a suction socket depends, however, not only on the length of the residual bone but also on the volume of the soft tissues which provide the seal for holding suction. Indeed, in the case of the man with a completely boneless stump (cf. p. 14), the soft tissues alone enabled him to wear a suction-socket prosthesis.</p> <p>The leverage provided by even a small segment of the femur is, of course, a great advantage in activating a prosthesis. Tikhonov<a></a> reported interesting experiments to lengthen a short residual femur by bone grafts. He said that it was not possible to give an absolute measurement for the shortest thigh stump which could activate a thigh prosthesis, since this length depended also on the volume of soft tissues, which varied from stump to stump. Instead, he gave a formula based on the relation of length to circumference. He also noted that except for extreme cases a stump should measure somewhere between 8.5 and 13.5 cm. (3.3 and 5.3 in.) from the perineum in order to allow for piston action of 2 to 3 cm. (about an inch) yet still permit the prosthesis to be moved in any direction. For the patient with other handicaps in addition to the very short thigh stump (such as amputation of the contralateral extremity or an upper-extremity amputation), Tikhonov and his co-workers recommended that surgical lengthening of the short stump be considered as a means of increasing the patient's ability to get about.</p> <p>Tikhonov reported on the lengthening of three short thigh stumps by from 3 to 6 cm. (1.2 to 2.4 in.). A homoplastic graft, taken from the diaphysis of the fibula, was inserted into the medullary canal of the femur. After a maximum period of observation of 10 months, he reported that bony union had already been achieved in two of the lengthened stumps and that these were providing satisfactory additional leverage for activating a prosthesis.</p> <h4>Possible Systemic Effects of Major Loss of Limb</h4> <p>As more patients have survived these drastic operations and have become subjects for rehabilitation, increasing attention has been paid to the possible medical consequences of the loss of so large a part of the body. The entire limb can now be removed without great risk of operative death, the patient can be fitted successfully with a prosthesis, and appropriate attention can be given to his psychological and vocational readjustment. Then this question arises: What is the <i>medical </i>outlook for such a patient? The same kind of question has been raised in regard to many diseases and disabilities to which corrective measures have been applied. Frequently, all of the medical consequences of a selected course of therapy cannot be foreseen. The physician asks himself: Am I doing the right thing? Will the radiation therapy that appears so beneficial now give rise to untold medical harm later? In the recent literature of several European countries, there have been raised questions about possible systemic aftereffects of major amputation which could hold much significance for the rehabilitation of amputees. The answers have proved difficult. Many of the opinions expressed have been supported only by clinical impressions or by studies lacking in desirable controls. Many have been accompanied by enthusiastic but untested hypotheses. It appears that, before this mass of information can be evaluated properly and before definitive answers can be obtained, the questions may need to be rephrased and made the subject of carefully controlled studies.</p> <p>In their examinations of amputees, many physicians have observed signs and symptoms and have obtained in clinical tests results which have led them to suspect that amputation is followed by an increased incidence of systemic disease. The review of published observations made by Schulze in Germany in 1942 shows that major limb amputations had at that time already been thought capable of leading to a rather startling list of disorders, including obesity, abnormally increased perspiration, arteriosclerosis, enlargement of the heart, damage to the heart muscle, hypertension, pulmonary tuberculosis, aggravation of bronchial asthma, various disturbances of the digestive system, kidney disease, deformities of the healthy leg and foot, joint deformities, and worsening of varicose veins.<a></a> Some of these conditions are more likely to occur after major amputation than are others. Aside from further changes in the musculoskeletal system, the most frequently claimed effects have been cardiovascular disease- especially hypertension-and changes in the regulation of body heat-in particular, excessive perspiration. German authors have advanced hypotheses to explain the development of these clinically observed phenomena.</p> <p>Sturm appears to have been interested in these problems since 1940 and has published recently, with two colleagues,<a></a> a report of detailed clinical studies on 150 amputees. Of these patients, 130 were at Bad Nenndorf for a "cure." Medical histories were elicited from them by means of a questionnaire and were amended through interview and examination. In addition, various tests of cardiovascular function were made, with amputees appropriately grouped, in order to show that the incidence of cardiovascular abnormalities increases with the length of time since amputation. In an earlier paper, Sturm<a></a> described a syndrome characteristic of a few patients with long-standing amputations of the thigh and with a history of severe suppuration of the stump. Examination of such a patient showed a pale angiospastic face, a definite lability of pulse rate and blood pressure, marked dermographism, increased reflex activity, fine tremor of the hands, moist skin, and increased luster of the sclera. Most of Sturm's observations were offered in support of his hypothesis that "vegetative regulatory disturbances" in amputees result from chronic hypothalamic irritation, which in turn arises (by a stated neuro-physiological mechanism) from prolonged infection, pain, and vasoconstriction of vessels of the stump.</p> <p>Schneider, <a></a> who observed an increase of systolic pressure to over 140 mm. Hg in 20 percent, and of diastolic pressure to over 100 mm. Hg in 5 percent, of 67 amputees, developed Sturm's thesis further. He hypothesized that pain (triggered by a neuroma, long-lasting suppuration, deep-tissue scars, or even the pressure of the prosthesis) could, in constitutionally predisposed patients, excite the central sympathetic area of the hypothalamus and eventually create a central lesion with resulting hypertonia. Schneider also pointed out that the role of psychosomatic factors should not be underestimated. The frustration and resulting emotional conflicts experienced by amputees who were attempting to compete with normal individuals could contribute to an early development of essential hypertension.</p> <p>Another hypothesis concerns the heat-regulating mechanism of the body and the changes which result in it from the loss of a leg. Excessive perspiration in high-thigh and hip-disarticulation amputees has been frequently observed on a clinical basis. Schroder<a></a> com- mented on the role played by the extremities in the cooling system of the body in providing arteriovenous shunts to direct the flow of blood into deep or superficial vessels as needed and in providing a large surface area for evaporation. To him, the loss of a whole lower extremity would appear to mean the loss of a valuable part of the cooling system at the same time that extra demands on energy are being made, with resulting excessive production of heat. Such phenomena would indicate an unusual burden on the circulatory system.</p> <p>These views have excited interest and aroused controversy. Although clinicians may observe in amputees pathological conditions which strongly suggest themselves to be the aftereffects of amputation, analyses of government health records, and clinical studies based on them, have failed thus far to confirm these observations in amputees as compared with equivalent nonamputee populations.</p> <p>The difficulties of assessing the aftereffects of amputation are well reflected in the reports, annotated in <i>Lancet, </i><a></a> of the committee of the Ministry of Pensions in England which in 1950 was asked to find whether amputation of a limb, and subsequent wearing of a prosthesis, could initiate or aggravate cardiovascular disorder and whether such amputation reduces the expectation of life. The interim report of this committee in 1951, termed "somewhat inconclusive," revealed in living amputee pensioners a slight elevation of the mean blood pressure but no abnormal incidence of cardiovascular disease. A more detailed study of death certificates suggested, although not to the point of statistical significance, that patients with leg amputations died earlier, and more commonly from cardiovascular disease, than comparable pensioners with leg wounds not requiring amputation. The majority report of the committee in 1953 introduced a new factor—calling for further committee investigation—by suggesting that men who have suffered major sepsis, with or without amputation, have a higher late incidence of cardiovascular disease and an earlier average death. The committee then arranged for the medical examination of 5500 pensioners, of whom 4500 were to be amputees and 1000 were to be controls, but unfortunately so many of this sample "failed to attend" that no firm conclusions could be drawn. In 1955, however, the committee, after reviewing all of its evidence, made the following statement:<a></a></p> <blockquote><p>Limb amputations, and the subsequent wearing of a prosthesis do not, in time, produce effects on the body as a whole which may initiate, or aggravate, cardiovascular disorders to any significant extent. There is no material difference between the mortality rates of amputees, by reason of amputation, and that of the corresponding rates for pensioners who have suffered wounds not leading to amputation. Such excess as there is in both classes over that in the general population is quite small.</p> </blockquote> <p>For the German regional government of Schleswig-Holstein, Meyeringh and Stefani<a></a> sought to determine the incidence of hypertension in 794 above-knee amputees. They found a resting systolic blood pressure of over 150 mm. Hg in 9 percent, which they compared with an incidence of over 10 percent in the "average German population."</p> <p>In reviewing the articles pertinent to this controversy, one begins to suspect that a single careful distinction might do much to resolve it. This distinction would be between <i>(a) </i>asserting that systemic disease does occur in amputees and is due at least in part to the fact of amputation and <i>(b) </i>asserting that systemic disease occurs more frequently in amputees than in other persons. Conceivably, the same person who develops high blood pressure owing to physiological stresses imposed by amputation could also have developed high blood pressure for different reasons of physiological stress had he retained his leg. Whereas this explanation would seem too simple, it is not too difficult to imagine a complex of factors at work that could mask from certain types of statistical examination a true relation between amputation and subsequent disease.</p> <p>It would seem a pity should too much energy be expended in statistical quibble. The question of relative incidence of systemic disease in amputees and in normals is an important question for practical reasons-such as life insurance, pensions, and the allotment of research funds. Of more moment, however, to researcher, practitioner, and amputee alike, is the question of how and why systemic disease develops in amputees and whether it can be averted in rehabilitation. Furthermore, far from being dispensable, statistical analyses of data obtained from groups of amputees and from appropriate control groups would be a tool valuable to this elucidation.</p> <p>Many factors offering clues to the situation have been taken into consideration to a greater or lesser extent by individual authors-predisposition to hypertension, prolonged suppuration associated with amputation, difference in level of amputation or amount of body mass lost, age at amputation, and obesity. Owing to the differences-or obscurities-regarding the selection of subjects, the use of controls, and the criteria for systemic disease, the results of these authors cannot be compared satisfactorily or generalized. The possible importance of activity or inactivity, the wearing of a prosthesis, and the stresses attached to home and work environments has hardly begun to be considered from the medical viewpoint of systemic disease! Investigation into the systemic effects of amputation could lead to conclusions beneficial not only to amputees with hip disarticulations and high thigh amputations but also to amputees with less serious disabilities and even to persons suffering from other disorders.</p> <h4>Summary</h4> <p>Hip disarticulation is a drastic amputation used almost exclusively as a last-resort or life-saving measure. A review of the medical history of the operation during the last 200 years shows a number of changes. The one with the most far-reaching implications has been the major shift from operations indicated by injury or by disease other than cancer to operations indicated by malignant growth. Better methods for controlling hemorrhage and shock, together with progress in adjunct therapy, have reduced operative deaths from as high as 91 percent in pre-Civil War military cases to none in a recent American series done for malignancies. But the postoperative mortality in cancer cases continues to be extremely high (in the aforementioned recent series, 85 percent within five years of operation). For this reason some hip disarticulations, when indicated at all for cancer, may well be indicated much earlier in the course of the disease if the operation is to be therapeutic rather than merely palliative.</p> <p>The shift in indication has also influenced the surgical shaping of the stump to the extent that today, in contrast to earlier methods, a maximal removal of soft tissues as well as bone is considered essential in cases of malignancy. In the rarer cases in which the indication for operation is trauma or some other type of disease, it is advantageous to leave, whenever possible, a small segment of the femur and additional soft tissues in the stump, thus making possible the use of an above-knee rather than a hip-disarticulation prosthesis. With the Canadian-type hip-disarticulation prosthesis, the shape of the stump is not critical, because this device can readily accommodate any irregularities of body form.</p> <p>Whether disturbances of cardiovascular function, or of other functions such as thermoregulation, occur as a result of the loss of so large a part of the body is today a controversial subject. Although systemic disease has been noted frequently in amputees with major loss of limb, no controlled studies have demonstrated convincingly that the incidence of systemic disease is greater in amputees than in comparable nonamputees. Similarly, hypotheses that have been advanced to explain how systemic disease develops as a result of amputation are interesting but still without substantial verification physiologically. This area should be an attractive one for further research.</p> <h4>Acknowledgment</h4> <p>The author wishes to express his gratitude to the many members of the Biomechanics Laboratory whose generous help and cooperation made this paper possible. A particular debt is owing to our staff writer, Jean C. Lieberman, Ph.D., who was responsible for much of the historical research basic to the paper and for assistance in its composition.</p> <p><b>References:</b></p> <ol> <li><i>An account of the operation of amputating the thigh at the upper articulation, lately performed by Mr. William Kerr, Surgeon to the Royal Regiment of Horse-Guards Blue, and to the Hospital in North-hampton. Communicated to Dr. Duncan, by Dr. Toll, Surgeon to the Fourth Regiment of Dragoons, </i>M. &amp; Philos. Commentaries, 6:337 (1779).</li> <li>Angerer, H., <i>Ein einfaches Vorgehen zur Verrin-gerung der Operalionsgefahr bei Exartikulationen im Huft- und Schullergelenk, </i>Zentralbl. Chir., 69:1647 (1942).</li> <li>Beebe, Gilbert W., and Michael E. DeBakey,<i>Battle casualties: incidence, mortality, and logistic considerations, </i>Thomas, Springfield, Ill., 1952.</li> <li>Bolot, F., and P. Merz, <i>Disarticulation de la hanchepour un osteosarcome du fimur ayant envahi les parties molles et provoque une himorragie grave, </i>Maroc. med., 31:560 (1952). (Only title seen.)</li> <li>Boyd, Harold B., <i>Anatomic disarticulation of thehip, </i>Surg., Gyn., &amp; Obstet., 84:346 (1947).</li> <li>Brooks, Barney, <i>Exarticulation of the hip joint;with preliminary ligation of the common iliac artery, </i>J.A.M.A., 76:94 (1921).</li> <li>Bustos, Fernando M., <i>Desarticulacion coxofemoral(profilaxis del shock por seccidn primaria del cidtico), </i>Bol. y trab. Acad, argent, cir., 32:195 (1948).</li> <li>Callander, C. Latimer, <i>A new amputation in thelower third of the thigh, </i>J.A.M.A., 105:1746 (1935).</li> <li>Caprio, Gerardo, <i>Grandes desarticulaciones en laraiz de los miembros, </i>Bol. Soc. cir. Uruguay, 22:518 (1951).</li> <li>Coates, John Boyd, ed., <i>Orthopedic surgery in theEuropean Theater of Operations, </i>Office of the Surgeon General, Dept. of the Army, Washington, D. C, 1956.</li> <li>Coley, Bradley L., <i>Neoplasms of bone, </i>Hoeber,ew York, 1949.</li> <li>DeBakey, Michael E., and Fiorindo A. Simeone,<i>Battle injuries of the arteries in World War II, </i>Ann. Surg., 123:534 (1946).</li> <li>Durand, M., <i>De la disarticulation sous-periostee dela hanche et de ses avantages sur la methode ordinaire, </i>Rev. chir., Paris, 17:646 (1897).</li> <li>Farabeuf, [L. H.], <i>Communication orale sur ladisarticulation coxo-femorale, </i>Bull, et mem. Soc. de chir., 4:180(1878).</li> <li>Farabeuf, L. H., <i>Precis de manuel operatoire, </i>4thd., Masson, Paris, 1893-1895. pp. 648-678.</li> <li><i>The fate of the amputee </i>(Annotation), Lancet, 1:633 (1953).</li> <li>Ghitzesco, C. I., <i>La disarticulation de la hanche sousI'hemostase provisoire de l'artere iliaque primitive ou de I'hypogaslrique correspondante, </i>Presse meU, 43:243 (1935).</li> <li>Giles, Roscoe C, and William T. Keig, <i>The controlof bleeding in disarticulation of the hip by ligation of the common iliac artery and vein, </i>Illinois Med. J., 106:209 (1954).</li> <li>GUlis, Leon, <i>Amputations, </i>Heinemann, London, 1954.</li> <li>Grey, Jorge de Moraes, <i>Actinomicose do membroinferior e desarliculacao da coxa. Consideracoes clinicas e technicas em torno de duas desarlicu-lacaos da coxa, </i>Rev. brasil. cir., 11:159 (1942).</li> <li>Gross, S. D., <i>Report of the committee on surgery,</i>rans. Kentucky State Med. Soc, 2:99 (1853).</li> <li>Halsted, W. S., <i>The effect of ligation of the commoniliac artery on the circulation and function of the lower extremity. Report of a cure of ilio-femoral aneurism by the application of an aluminum band to that vessel, </i>Bull. Johns Hopkins Hosp., 23:191 (1912).</li> <li>Huard, P., <i>Etudes sur les amputations el disarticu-lations des membres, </i>Masson, Paris, 1940.</li> <li>Hutter, Charles G., <i>Suction-socket prosthesis for ahip-disarticulation amputee, </i>J. Bone &amp; Joint Surg., 35A:230 (1953).</li> <li>James, Arthur G., and Wesley Furste, <i>Radicalsurgery for cancer of the extremities, </i>Am. J. Surg., 85:503 (1953).</li> <li>Katz, Elias, Private communication.</li> <li>27. Kirk, Norman T., and Leonard T. Peterson,<i>Amputations, </i>Chapter 10 in Lewis' <i>Practice of surgery, </i>Prior, Hagerstown, Md., 1944. Vol. 3, pp. 84-87.</li> <li>Larrey, Dominique Jean, <i>Memoires de chirurgiemilitaire, et campagnes, </i>J. Smith, Paris, 1812. Vol. 2, pp. 180-195. Vol. 3, p. 350.</li> <li>Lee, C. Marshall, Jr., and Lewis P. Alt, <i>Hemi-pelvectomy and hip disarticulation for malignant tumors of the pelvis and lower extremity, </i>Ann. Surg., 137:704 (1953).</li> <li>Leriche, Rene, <i>A propos de 13 cas de disarticulationde la hanche, </i>Mem. Acad, chir., 63:1435 (1937).</li> <li>Lewis, Royce C, and William H. Bickel, <i>Hemi-pelvectomy for malignant disease, </i>J.A.M.A., 165:8 (1957).</li> <li>McBurney, Charles, <i>Direct intra-abdominal finger-compression of the common iliac artery during amputation at the hip-joint, </i>Ann. Surg., 25:610 (1897).</li> <li>Marquardt, Wolfgang, <i>Gliedmassenamputationenund Gliederersatz, </i>Wissensch. Verlagsges., Stuttgart, 1950. pp. 82-85.</li> <li>Maynard, R. L., <i>Hip-joint disarticulations, </i>Trans.ew England Surg. Soc, 24:248 (1941).</li> <li>Meyeringh, H., and H. Stefani, <i>Besteht nach einerAmputation des Oberschenkels eine Neigung zur Adipositas und zur Hypertension?, </i>Deutsche med. Wchnschr., 81:10 (1956).</li> <li>Morand, Sauveur Francois, <i>Opuscules de chirurgie,</i>esprez, Paris, 1768. Vol. 1, pp. 176-228.</li> <li>Morris, Robert T., <i>Hip joint amputation, ventralhernia, appendicitis, salpingitis, a clinic at the New York Post Graduate Medical School April 18, 1917, </i>West. M. Times, 37:1 (1917).</li> <li><i>Outlook for the amputee </i>(Annotation), Lancet, 1:89 (1955).</li> <li>Pack, George T., <i>Major exarticulations for malignantneoplasms of the extremities: interscapulothoracic amputation, hip-joint disarticulation and in-terilioabdominal amputation, </i>J. Bone &amp; Joint Surg., 38A:249 (1956).</li> <li>Pack, George T., and Harry E. Ehrlich, <i>Exarticu-lations of the lower extremities for malignant tumors: hip joint disarticulation (with and without deep iliac dissection) and sacro-iliac disarticulation (hemipelvectomy), </i>Ann. Surg., 123:965 (1946). Parts I &amp; II.</li> <li>Petrovskii, B. V., <i>Method of disarticulation of thehip, </i>Vestnik khir., 72:50 (1952). In Russian.</li> <li>Piquinela, Jose A., <i>Desarticulacion de cadera.-Sutecnica de acuerdo con los principios del metodo de Callander, </i>Arch. urug. med., 48:191 (1956).</li> <li>Pitkin, George P., <i>Conduction anesthesia, </i>2nd ed.,ames L. Southworth, Robert A. Hingson, and Winifred M. Pitkin, eds., Lippincott, Philadelphia, 1953.</li> <li>Richerand, cited in <i>60, </i>p. 8.</li> <li>Saltzstein, Harry C, <i>Osteogenic sarcoma of upperthird of femur; well ten years after disarticulation at the hip joint, </i>J. Michigan Med. Soc, 43:145 (1944).</li> <li>Schneider, K. W., <i>Zur Frage der Plethora und Hy-pertonic bei Amputierten, </i>Klin. Wchnschr., 31:697 (1953).</li> <li>Schroder, Joachim, <i>Zur Frage einer besonderenKreislaufbelastung bei Gliedmassenamputierten infolge einer Mehrbeanspruchung ihrer War-meregulation, </i>Deutsche med. Wchnschr., 81:1620 (1956).</li> <li>Schulze, Karl, <i>Uber den Einfluss grosser Amputa-lionen auf den Gesamtorganismus; eine Studie zur Frage der Spatschaden bei Oberschenkelampu-tierten, </i>Arbeit u. Gesundh., No. 41:69 (1942).</li> <li>[Shuter, James], <i>Subperiosteal amputation at thehip-joint, </i>Report of Clinical Society of London, Brit. Med. J., 1:314 (1883).</li> <li>Shuter, James, <i>Subperiosteal amputation at the hip-joint: formation of new bone in the stump: moveable stump: patient wearing an artificial limb, </i>Trans. Clin. Soc. London, 16:86 (1883).</li> <li>Slocum, Donald B., <i>An atlas of amputations,</i>osby, St. Louis, 1949. pp. 239-247, 402-410.</li> <li>Smith, Beverly Chew, <i>Disarticulation of the hip forendothelioma (Ewing's tumor): 31-year follow-up, </i>Ann. Surg., 115:318 (1942).</li> <li>Smith, S., <i>Statistics of the operation of amputation atthe hip-joint, </i>New York J. Med., 9:184 (1852).</li> <li>Stajano, C, <i>El mecanismo del "choc" en la desar-ticulacion de la cadera, </i>Arch. urug. med., 10: 642 (1937).</li> <li>Strauss, Kurt, <i>Exarliculatio coxae bei Schwanger-schaft und allgemeiner Sepsis, </i>Miinchen. med. Wchnschr., 86:1751 (1939).</li> <li>Sturm, Alexander, <i>Hochdruck nach Oberschenkelam-putation, </i>Med. Klin., 48:197 (1953).</li> <li>Sturm, A., W. Frisch, and H. W. Griinewald,<i>Interne Auswirkungen von Beinamputationen; Ergebnis einer Reihenuntersuchung, </i>Medizinische, No. 35:1132 (1954).</li> <li>Thomson, John, <i>Report of observations made in theBritish military hospitals in Belgium after the Battle of Waterloo, </i>Blackwood, Edinburgh, 1816. pp. 259-279.</li> <li>Tikhonov, V. M., <i>Short thigh stump in children, itslengthening and preparation for prosthesis, </i>Tr. Tsentr. Nauchnoissledov. inst. protez. Moskva, 72:258 (1949). In Russian.</li> <li>Tixier and Arnulf, <i>Auto-transfusion au cours d'unedesarticulation de la hanclie, en utilisant le sang du membre enleei. Disarticulation pour epithelioma diveloppt sur une ancienne brulure de la cuisse et de la /esse jusqu'd Vanus; anus de Pollosson (derivation totale) prealable, </i>Lyon chir., 32:443 (1935).</li> <li>Trendelenburg, F., <i>Ueber Exarticulation des Ober-schenkels, </i>Arch. klin. Chir., 26:858 (1881).</li> <li>U. S. Surgeon General's Office, <i>Circular No. 7: areport on amputations at the hip-joint in military surgery </i>[By G. A. Otis], U. S. Gov't. Print. Off., Washington, D. C, 1867.</li> <li>U. S. Surgeon General's Office, <i>The medical andsurgical history of the War of the Rebellion (1861-1865), </i>U. S. Gov't. Print. Off., Washington, D. C, 1870-88. Part 3, vol. 2: <i>Surgical history. </i>pp. 88, 89, 127-168.</li> <li>U. S. Surgeon General's Office, <i>The Medical De-partment of the U. S. Army in the World War, </i>U. S. Gov't. Print. Off., Washington, D. C, 1921-1929. Vol. II, <i>Surgery, </i>Part 1 <i>{General surgery, orthopedic surgery, neurosurgery).</i></li> <li>Velpeau, Alf. A. L. M., <i>New elements of operativesurgery, </i>1st American ed., from last [2nd] Paris ed. [1839], translated by P. S. Townsend, under supervision of Valentine Mott, S. S. &amp; W. Wood, New York, 1847. Vol. 2, pp. 637-653.</li> <li>Verrall, P. Jenner, <i>Some amputation problems,</i>roc. Roy. Soc. Med., 24:183 (1930).</li> <li>Wyeth, John A., <i>Bloodless amputation at the hipjoint, </i>New York Med. J., 61:528 (1890).</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Meyeringh, H., and H. Stefani, Besteht nach einerAmputation des Oberschenkels eine Neigung zur Adipositas und zur Hypertension?, Deutsche med. Wchnschr., 81:10 (1956).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Outlook for the amputee (Annotation), Lancet, 1:89 (1955).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">The fate of the amputee (Annotation), Lancet, 1:633 (1953).</td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Outlook for the amputee (Annotation), Lancet, 1:89 (1955).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">Schroder, Joachim, Zur Frage einer besonderenKreislaufbelastung bei Gliedmassenamputierten infolge einer Mehrbeanspruchung ihrer War-meregulation, Deutsche med. Wchnschr., 81:1620 (1956).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Schneider, K. W., Zur Frage der Plethora und Hy-pertonic bei Amputierten, Klin. Wchnschr., 31:697 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>56.</b> </td><td class="clsTextSmall">Sturm, Alexander, Hochdruck nach Oberschenkelam-putation, Med. Klin., 48:197 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>57.</b> </td><td class="clsTextSmall">Sturm, A., W. Frisch, and H. W. Griinewald,Interne Auswirkungen von Beinamputationen; Ergebnis einer Reihenuntersuchung, Medizinische, No. 35:1132 (1954).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>48.</b> </td><td class="clsTextSmall">Schulze, Karl, Uber den Einfluss grosser Amputa-lionen auf den Gesamtorganismus; eine Studie zur Frage der Spatschaden bei Oberschenkelampu-tierten, Arbeit u. Gesundh., No. 41:69 (1942).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>59.</b> </td><td class="clsTextSmall">Tikhonov, V. M., Short thigh stump in children, itslengthening and preparation for prosthesis, Tr. Tsentr. Nauchnoissledov. inst. protez. Moskva, 72:258 (1949). In Russian.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>51.</b> </td><td class="clsTextSmall">Slocum, Donald B., An atlas of amputations,osby, St. Louis, 1949. pp. 239-247, 402-410.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>66.</b> </td><td class="clsTextSmall">Verrall, P. Jenner, Some amputation problems,roc. Roy. Soc. Med., 24:183 (1930).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Pack, George T., and Harry E. Ehrlich, Exarticu-lations of the lower extremities for malignant tumors: hip joint disarticulation (with and without deep iliac dissection) and sacro-iliac disarticulation (hemipelvectomy), Ann. Surg., 123:965 (1946). Parts I &amp;II.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>51.</b> </td><td class="clsTextSmall">Slocum, Donald B., An atlas of amputations,osby, St. Louis, 1949. pp. 239-247, 402-410.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Cf. discussion of very short thigh stumps, page 15.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Hutter, Charles G., Suction-socket prosthesis for ahip-disarticulation amputee, J. Bone &amp;Joint Surg., 35A:230 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Durand, M., De la disarticulation sous-periostee dela hanche et de ses avantages sur la methode ordinaire, Rev. chir., Paris, 17:646 (1897).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Shuter, James, Subperiosteal amputation at the hip-joint: formation of new bone in the stump: moveable stump: patient wearing an artificial limb, Trans. Clin. Soc. London, 16:86 (1883).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Shuter, James, Subperiosteal amputation at the hip-joint: formation of new bone in the stump: moveable stump: patient wearing an artificial limb, Trans. Clin. Soc. London, 16:86 (1883).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Gross, S. D., Report of the committee on surgery,rans. Kentucky State Med. Soc, 2:99 (1853).</td></tr><tr><td class="clsTextSmall"><b>49.</b> </td><td class="clsTextSmall">[Shuter, James], Subperiosteal amputation at thehip-joint, Report of Clinical Society of London, Brit. Med. J., 1:314 (1883).</td></tr><tr><td class="clsTextSmall"><b>61.</b> </td><td class="clsTextSmall">Trendelenburg, F., Ueber Exarticulation des Ober-schenkels, Arch. klin. Chir., 26:858 (1881).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Coley, Bradley L., Neoplasms of bone, Hoeber,ew York, 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Lee, C. Marshall, Jr., and Lewis P. Alt, Hemi-pelvectomy and hip disarticulation for malignant tumors of the pelvis and lower extremity, Ann. Surg., 137:704 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Leriche, Rene, A propos de 13 cas de disarticulationde la hanche, Mem. Acad, chir., 63:1435 (1937).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Lewis, Royce C, and William H. Bickel, Hemi-pelvectomy for malignant disease, J.A.M.A., 165:8 (1957).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Coley, Bradley L., Neoplasms of bone, Hoeber,ew York, 1949.</td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">James, Arthur G., and Wesley Furste, Radicalsurgery for cancer of the extremities, Am. J. Surg., 85:503 (1953).</td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Lee, C. Marshall, Jr., and Lewis P. Alt, Hemi-pelvectomy and hip disarticulation for malignant tumors of the pelvis and lower extremity, Ann. Surg., 137:704 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Pack, George T., Major exarticulations for malignantneoplasms of the extremities: interscapulothoracic amputation, hip-joint disarticulation and in-terilioabdominal amputation, J. Bone &amp;Joint Surg., 38A:249 (1956).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Pack, George T., Major exarticulations for malignantneoplasms of the extremities: interscapulothoracic amputation, hip-joint disarticulation and in-terilioabdominal amputation, J. Bone &amp;Joint Surg., 38A:249 (1956).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Pack, George T., Major exarticulations for malignantneoplasms of the extremities: interscapulothoracic amputation, hip-joint disarticulation and in-terilioabdominal amputation, J. Bone &amp;Joint Surg., 38A:249 (1956).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>64.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, The Medical De-partment of the U. S. Army in the World War, U. S. Gov't. Print. Off., Washington, D. C, 1921-1929. Vol. II, Surgery, Part 1 {General surgery, orthopedic surgery, neurosurgery).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Huard, P., Etudes sur les amputations el disarticu-lations des membres, Masson, Paris, 1940.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Pitkin, George P., Conduction anesthesia, 2nd ed.,ames L. Southworth, Robert A. Hingson, and Winifred M. Pitkin, eds., Lippincott, Philadelphia, 1953.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Pack, George T., and Harry E. Ehrlich, Exarticu-lations of the lower extremities for malignant tumors: hip joint disarticulation (with and without deep iliac dissection) and sacro-iliac disarticulation (hemipelvectomy), Ann. Surg., 123:965 (1946). Parts I &amp;II.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>37.</b> </td><td class="clsTextSmall">Morris, Robert T., Hip joint amputation, ventralhernia, appendicitis, salpingitis, a clinic at the New York Post Graduate Medical School April 18, 1917, West. M. Times, 37:1 (1917).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Bustos, Fernando M., Desarticulacion coxofemoral(profilaxis del shock por seccidn primaria del cidtico), Bol. y trab. Acad, argent, cir., 32:195 (1948).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Boyd, Harold B., Anatomic disarticulation of thehip, Surg., Gyn., &amp;Obstet., 84:346 (1947).</td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Bustos, Fernando M., Desarticulacion coxofemoral(profilaxis del shock por seccidn primaria del cidtico), Bol. y trab. Acad, argent, cir., 32:195 (1948).</td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Caprio, Gerardo, Grandes desarticulaciones en laraiz de los miembros, Bol. Soc. cir. Uruguay, 22:518 (1951).</td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Coley, Bradley L., Neoplasms of bone, Hoeber,ew York, 1949.</td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Grey, Jorge de Moraes, Actinomicose do membroinferior e desarliculacao da coxa. Consideracoes clinicas e technicas em torno de duas desarlicu-lacaos da coxa, Rev. brasil. cir., 11:159 (1942).</td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Leriche, Rene, A propos de 13 cas de disarticulationde la hanche, Mem. Acad, chir., 63:1435 (1937).</td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">Maynard, R. L., Hip-joint disarticulations, Trans.ew England Surg. Soc, 24:248 (1941).</td></tr><tr><td class="clsTextSmall"><b>37.</b> </td><td class="clsTextSmall">Morris, Robert T., Hip joint amputation, ventralhernia, appendicitis, salpingitis, a clinic at the New York Post Graduate Medical School April 18, 1917, West. M. Times, 37:1 (1917).</td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Pack, George T., and Harry E. Ehrlich, Exarticu-lations of the lower extremities for malignant tumors: hip joint disarticulation (with and without deep iliac dissection) and sacro-iliac disarticulation (hemipelvectomy), Ann. Surg., 123:965 (1946). Parts I &amp;II.</td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Petrovskii, B. V., Method of disarticulation of thehip, Vestnik khir., 72:50 (1952). In Russian.</td></tr><tr><td class="clsTextSmall"><b>51.</b> </td><td class="clsTextSmall">Slocum, Donald B., An atlas of amputations,osby, St. Louis, 1949. pp. 239-247, 402-410.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>54.</b> </td><td class="clsTextSmall">Stajano, C, El mecanismo del 'choc' en la desar-ticulacion de la cadera, Arch. urug. med., 10: 642 (1937).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Caprio, Gerardo, Grandes desarticulaciones en laraiz de los miembros, Bol. Soc. cir. Uruguay, 22:518 (1951).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Petrovskii, B. V., Method of disarticulation of thehip, Vestnik khir., 72:50 (1952). In Russian.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Bustos, Fernando M., Desarticulacion coxofemoral(profilaxis del shock por seccidn primaria del cidtico), Bol. y trab. Acad, argent, cir., 32:195 (1948).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>42.</b> </td><td class="clsTextSmall">Piquinela, Jose A., Desarticulacion de cadera.-Sutecnica de acuerdo con los principios del metodo de Callander, Arch. urug. med., 48:191 (1956).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>51.</b> </td><td class="clsTextSmall">Slocum, Donald B., An atlas of amputations,osby, St. Louis, 1949. pp. 239-247, 402-410.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Boyd, Harold B., Anatomic disarticulation of thehip, Surg., Gyn., &amp;Obstet., 84:346 (1947).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Leriche, Rene, A propos de 13 cas de disarticulationde la hanche, Mem. Acad, chir., 63:1435 (1937).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Callander, C. Latimer, A new amputation in thelower third of the thigh, J.A.M.A., 105:1746 (1935).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Coley, Bradley L., Neoplasms of bone, Hoeber,ew York, 1949.</td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">GUlis, Leon, Amputations, Heinemann, London, 1954.</td></tr><tr><td class="clsTextSmall"><b> 25.</b> </td><td class="clsTextSmall">James, Arthur G., and Wesley Furste, Radicalsurgery for cancer of the extremities, Am. J. Surg., 85:503 (1953).</td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">27. Kirk, Norman T., and Leonard T. Peterson,Amputations, Chapter 10 in Lewis' Practice of surgery, Prior, Hagerstown, Md., 1944. Vol. 3, pp. 84-87.</td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Pack, George T., and Harry E. Ehrlich, Exarticu-lations of the lower extremities for malignant tumors: hip joint disarticulation (with and without deep iliac dissection) and sacro-iliac disarticulation (hemipelvectomy), Ann. Surg., 123:965 (1946). Parts I &amp;II.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Angerer, H., Ein einfaches Vorgehen zur Verrin-gerung der Operalionsgefahr bei Exartikulationen im Huft- und Schullergelenk, Zentralbl. Chir., 69:1647 (1942).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>33.</b> </td><td class="clsTextSmall">Marquardt, Wolfgang, Gliedmassenamputationenund Gliederersatz, Wissensch. Verlagsges., Stuttgart, 1950. pp. 82-85.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Farabeuf, L. H., Precis de manuel operatoire, 4thd., Masson, Paris, 1893-1895. pp. 648-678.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Giles, Roscoe C, and William T. Keig, The controlof bleeding in disarticulation of the hip by ligation of the common iliac artery and vein, Illinois Med. J., 106:209 (1954).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Brooks, Barney, Exarticulation of the hip joint;with preliminary ligation of the common iliac artery, J.A.M.A., 76:94 (1921).</td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Halsted, W. S., The effect of ligation of the commoniliac artery on the circulation and function of the lower extremity. Report of a cure of ilio-femoral aneurism by the application of an aluminum band to that vessel, Bull. Johns Hopkins Hosp., 23:191 (1912).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Ghitzesco, C. I., La disarticulation de la hanche sousI'hemostase provisoire de l'artere iliaque primitive ou de I'hypogaslrique correspondante, Presse meU, 43:243 (1935).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">McBurney, Charles, Direct intra-abdominal finger-compression of the common iliac artery during amputation at the hip-joint, Ann. Surg., 25:610 (1897).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>49.</b> </td><td class="clsTextSmall">[Shuter, James], Subperiosteal amputation at thehip-joint, Report of Clinical Society of London, Brit. Med. J., 1:314 (1883).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>67.</b> </td><td class="clsTextSmall">Wyeth, John A., Bloodless amputation at the hipjoint, New York Med. J., 61:528 (1890).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>61.</b> </td><td class="clsTextSmall">Trendelenburg, F., Ueber Exarticulation des Ober-schenkels, Arch. klin. Chir., 26:858 (1881).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>67.</b> </td><td class="clsTextSmall">Wyeth, John A., Bloodless amputation at the hipjoint, New York Med. J., 61:528 (1890).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Farabeuf, [L. H.], Communication orale sur ladisarticulation coxo-femorale, Bull, et mem. Soc. de chir., 4:180(1878).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, The medical andsurgical history of the War of the Rebellion (1861-1865), U. S. Gov't. Print. Off., Washington, D. C, 1870-88. Part 3, vol. 2: Surgical history. pp. 88, 89, 127-168.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, The medical andsurgical history of the War of the Rebellion (1861-1865), U. S. Gov't. Print. Off., Washington, D. C, 1870-88. Part 3, vol. 2: Surgical history. pp. 88, 89, 127-168.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, The medical andsurgical history of the War of the Rebellion (1861-1865), U. S. Gov't. Print. Off., Washington, D. C, 1870-88. Part 3, vol. 2: Surgical history. pp. 88, 89, 127-168.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, Circular No. 7: areport on amputations at the hip-joint in military surgery [By G. A. Otis], U. S. Gov't. Print. Off., Washington, D. C, 1867.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, Circular No. 7: areport on amputations at the hip-joint in military surgery [By G. A. Otis], U. S. Gov't. Print. Off., Washington, D. C, 1867.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, Circular No. 7: areport on amputations at the hip-joint in military surgery [By G. A. Otis], U. S. Gov't. Print. Off., Washington, D. C, 1867.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, Circular No. 7: areport on amputations at the hip-joint in military surgery [By G. A. Otis], U. S. Gov't. Print. Off., Washington, D. C, 1867.</td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, The medical andsurgical history of the War of the Rebellion (1861-1865), U. S. Gov't. Print. Off., Washington, D. C, 1870-88. Part 3, vol. 2: Surgical history. pp. 88, 89, 127-168.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Thus the figures that follow are not statistics of operative or even hospital deaths alone.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Larrey, Dominique Jean, Memoires de chirurgiemilitaire, et campagnes, J. Smith, Paris, 1812. Vol. 2, pp. 180-195. Vol. 3, p. 350.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Coley, Bradley L., Neoplasms of bone, Hoeber,ew York, 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Katz, Elias, Private communication.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Katz, Elias, Private communication.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, Circular No. 7: areport on amputations at the hip-joint in military surgery [By G. A. Otis], U. S. Gov't. Print. Off., Washington, D. C, 1867.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Beebe, Gilbert W., and Michael E. DeBakey,Battle casualties: incidence, mortality, and logistic considerations, Thomas, Springfield, Ill., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, The medical andsurgical history of the War of the Rebellion (1861-1865), U. S. Gov't. Print. Off., Washington, D. C, 1870-88. Part 3, vol. 2: Surgical history. pp. 88, 89, 127-168.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Pack, George T., and Harry E. Ehrlich, Exarticu-lations of the lower extremities for malignant tumors: hip joint disarticulation (with and without deep iliac dissection) and sacro-iliac disarticulation (hemipelvectomy), Ann. Surg., 123:965 (1946). Parts I &amp;II.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">Maynard, R. L., Hip-joint disarticulations, Trans.ew England Surg. Soc, 24:248 (1941).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">Maynard, R. L., Hip-joint disarticulations, Trans.ew England Surg. Soc, 24:248 (1941).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Grey, Jorge de Moraes, Actinomicose do membroinferior e desarliculacao da coxa. Consideracoes clinicas e technicas em torno de duas desarlicu-lacaos da coxa, Rev. brasil. cir., 11:159 (1942).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Bustos, Fernando M., Desarticulacion coxofemoral(profilaxis del shock por seccidn primaria del cidtico), Bol. y trab. Acad, argent, cir., 32:195 (1948).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>55.</b> </td><td class="clsTextSmall">Strauss, Kurt, Exarliculatio coxae bei Schwanger-schaft und allgemeiner Sepsis, Miinchen. med. Wchnschr., 86:1751 (1939).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Hutter, Charles G., Suction-socket prosthesis for ahip-disarticulation amputee, J. Bone &amp;Joint Surg., 35A:230 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Leriche, Rene, A propos de 13 cas de disarticulationde la hanche, Mem. Acad, chir., 63:1435 (1937).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Bolot, F., and P. Merz, Disarticulation de la hanchepour un osteosarcome du fimur ayant envahi les parties molles et provoque une himorragie grave, Maroc. med., 31:560 (1952). (Only title seen.)</td></tr><tr><td class="clsTextSmall"><b> 9.</b> </td><td class="clsTextSmall">Caprio, Gerardo, Grandes desarticulaciones en laraiz de los miembros, Bol. Soc. cir. Uruguay, 22:518 (1951).</td></tr><tr><td class="clsTextSmall"><b> 17.</b> </td><td class="clsTextSmall">Ghitzesco, C. I., La disarticulation de la hanche sousI'hemostase provisoire de l'artere iliaque primitive ou de I'hypogaslrique correspondante, Presse meU, 43:243 (1935).</td></tr><tr><td class="clsTextSmall"><b> 18.</b> </td><td class="clsTextSmall">Giles, Roscoe C, and William T. Keig, The controlof bleeding in disarticulation of the hip by ligation of the common iliac artery and vein, Illinois Med. J., 106:209 (1954).</td></tr><tr><td class="clsTextSmall"><b> 20.</b> </td><td class="clsTextSmall">Grey, Jorge de Moraes, Actinomicose do membroinferior e desarliculacao da coxa. Consideracoes clinicas e technicas em torno de duas desarlicu-lacaos da coxa, Rev. brasil. cir., 11:159 (1942).</td></tr><tr><td class="clsTextSmall"><b> 25.</b> </td><td class="clsTextSmall">James, Arthur G., and Wesley Furste, Radicalsurgery for cancer of the extremities, Am. J. Surg., 85:503 (1953).</td></tr><tr><td class="clsTextSmall"><b> 29.</b> </td><td class="clsTextSmall">Lee, C. Marshall, Jr., and Lewis P. Alt, Hemi-pelvectomy and hip disarticulation for malignant tumors of the pelvis and lower extremity, Ann. Surg., 137:704 (1953).</td></tr><tr><td class="clsTextSmall"><b> 30.</b> </td><td class="clsTextSmall">Leriche, Rene, A propos de 13 cas de disarticulationde la hanche, Mem. Acad, chir., 63:1435 (1937).</td></tr><tr><td class="clsTextSmall"><b> 34.</b> </td><td class="clsTextSmall">Maynard, R. L., Hip-joint disarticulations, Trans.ew England Surg. Soc, 24:248 (1941).</td></tr><tr><td class="clsTextSmall"><b> 39.</b> </td><td class="clsTextSmall">Pack, George T., Major exarticulations for malignantneoplasms of the extremities: interscapulothoracic amputation, hip-joint disarticulation and in-terilioabdominal amputation, J. Bone &amp;Joint Surg., 38A:249 (1956).</td></tr><tr><td class="clsTextSmall"><b> 41.</b> </td><td class="clsTextSmall">Petrovskii, B. V., Method of disarticulation of thehip, Vestnik khir., 72:50 (1952). In Russian.</td></tr><tr><td class="clsTextSmall"><b> 42.</b> </td><td class="clsTextSmall">Piquinela, Jose A., Desarticulacion de cadera.-Sutecnica de acuerdo con los principios del metodo de Callander, Arch. urug. med., 48:191 (1956).</td></tr><tr><td class="clsTextSmall"><b> 45.</b> </td><td class="clsTextSmall">Saltzstein, Harry C, Osteogenic sarcoma of upperthird of femur; well ten years after disarticulation at the hip joint, J. Michigan Med. Soc, 43:145 (1944).</td></tr><tr><td class="clsTextSmall"><b> 52.</b> </td><td class="clsTextSmall">Smith, Beverly Chew, Disarticulation of the hip forendothelioma (Ewing's tumor): 31-year follow-up, Ann. Surg., 115:318 (1942).</td></tr><tr><td class="clsTextSmall"><b> 54.</b> </td><td class="clsTextSmall">Stajano, C, El mecanismo del 'choc' en la desar-ticulacion de la cadera, Arch. urug. med., 10: 642 (1937).</td></tr><tr><td class="clsTextSmall"><b> 60.</b> </td><td class="clsTextSmall">Tixier and Arnulf, Auto-transfusion au cours d'unedesarticulation de la hanclie, en utilisant le sang du membre enleei. Disarticulation pour epithelioma diveloppt sur une ancienne brulure de la cuisse et de la /esse jusqu'd Vanus; anus de Pollosson (derivation totale) prealable, Lyon chir., 32:443 (1935).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Smith, S., Statistics of the operation of amputation atthe hip-joint, New York J. Med., 9:184 (1852).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Smith, S., Statistics of the operation of amputation atthe hip-joint, New York J. Med., 9:184 (1852).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>65.</b> </td><td class="clsTextSmall">Velpeau, Alf. A. L. M., New elements of operativesurgery, 1st American ed., from last [2nd] Paris ed. [1839], translated by P. S. Townsend, under supervision of Valentine Mott, S. S. &amp;W. Wood, New York, 1847. Vol. 2, pp. 637-653.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Coates, John Boyd, ed., Orthopedic surgery in theEuropean Theater of Operations, Office of the Surgeon General, Dept. of the Army, Washington, D. C, 1956.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Coates, John Boyd, ed., Orthopedic surgery in theEuropean Theater of Operations, Office of the Surgeon General, Dept. of the Army, Washington, D. C, 1956.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Beebe, Gilbert W., and Michael E. DeBakey,Battle casualties: incidence, mortality, and logistic considerations, Thomas, Springfield, Ill., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Coates, John Boyd, ed., Orthopedic surgery in theEuropean Theater of Operations, Office of the Surgeon General, Dept. of the Army, Washington, D. C, 1956.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">DeBakey, Michael E., and Fiorindo A. Simeone,Battle injuries of the arteries in World War II, Ann. Surg., 123:534 (1946).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, The medical andsurgical history of the War of the Rebellion (1861-1865), U. S. Gov't. Print. Off., Washington, D. C, 1870-88. Part 3, vol. 2: Surgical history. pp. 88, 89, 127-168.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Larrey, Dominique Jean, Memoires de chirurgiemilitaire, et campagnes, J. Smith, Paris, 1812. Vol. 2, pp. 180-195. Vol. 3, p. 350.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, The medical andsurgical history of the War of the Rebellion (1861-1865), U. S. Gov't. Print. Off., Washington, D. C, 1870-88. Part 3, vol. 2: Surgical history. pp. 88, 89, 127-168.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>58.</b> </td><td class="clsTextSmall">Thomson, John, Report of observations made in theBritish military hospitals in Belgium after the Battle of Waterloo, Blackwood, Edinburgh, 1816. pp. 259-279.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Or possibly a metastatic cancer of the lungs. At her death, 18 days after operation, an autopsy showed them to be almost totally reduced to matter.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">An account of the operation of amputating the thigh at the upper articulation, lately performed by Mr. William Kerr, Surgeon to the Royal Regiment of Horse-Guards Blue, and to the Hospital in North-hampton. Communicated to Dr. Duncan, by Dr. Toll, Surgeon to the Fourth Regiment of Dragoons, M. &amp; Philos. Commentaries, 6:337 (1779).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Morand, Sauveur Francois, Opuscules de chirurgie,esprez, Paris, 1768. Vol. 1, pp. 176-228.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">In a case in which amputation of the thigh at the articulation with the hip bone appears to be the last resort for saving the life of a sick man, to determine whether this operation should be performed, and what would be the most advantageous method of doing it.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Richerand, cited in 60, p. 8.</td></tr><tr><td class="clsTextSmall"><b>65.</b> </td><td class="clsTextSmall">Velpeau, Alf. A. L. M., New elements of operativesurgery, 1st American ed., from last [2nd] Paris ed. [1839], translated by P. S. Townsend, under supervision of Valentine Mott, S. S. &amp;W. Wood, New York, 1847. Vol. 2, pp. 637-653.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Morand, Sauveur Francois, Opuscules de chirurgie,esprez, Paris, 1768. Vol. 1, pp. 176-228.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Henry E. Loon, M.D. </b></td></tr><tr><td class="clsTextSmall">Research Orthopaedist, Biomechanics Laboratory, University of California Medical Center, San Francisco.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1957_02_004/aut57a-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1957_02_004/aut57a-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1957_02_004/aut57a-003.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Past and Present Medical Significance of Hip Disarticulation Creator An entity primarily responsible for making the resource Henry E. Loon, M.D. * https://staging.drfop.org/files/original/bb5505172d6f91d3b4c1078c76732cdd.pdf 5f258ce3f8db62c96aded278f4214167 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_01_001.pdf Year 1958 Volume 5 Issue 1 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1958_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Evaluation Revalued</h2> <h5>Robert E. Stewart, D.D.S. <a style="text-decoration:none;">*</a><br /></h5> <p>In any sound program of research and development, whatever the intended goal, there must inevitably come a time when extensive evaluation of the product is indicated. Less than fifty years ago, systematic tests of new concepts were performed more or less routinely by private inventors dedicated to proper self-appraisal as occasion warranted. In a period less sophisticated technologically, this fashion in science served its purpose adequately and well. But with the growth in a more modern era of the large and vastly more complicated system of scientific inquiry, such as we know it today in government and industry alike, the requirement for periodic assessment of experimental results has led to the development of the independent testing laboratory, either as a part of the basic organization or as a separate contracting institution. So indispensable has this phase of technical investigation become that now large sums of money are spent annually in support of evaluation groups who themselves commonly engage at least in part in research aimed at improving their own methods and techniques.</p> <p>With respect to these matters, the Artificial Limb Program has exhibited ostensibly no basic deviation from the general pattern now characteristic of other broad exploratory projects involving the cooperation of various specialists in otherwise distinct disciplines. But because of the peculiar nature of the amputee problem, the particular state of the art of limb prosthetics, especially in the upper extremity, and the demands of rather unusual external influences of one kind or another, the approach to systematic evaluation has in this case evolved out of a unique history and has, consequently, given rise to some valuable results in research and education of which the influence was not fully anticipated in the beginning.</p> <p>Although in that portion of ALP devoted to the upper extremity much of the initial investigation was directed toward all-purpose, or "ideal," prostheses for selected levels of arm amputation, it was soon recognized that the desired objectives would be served more effectively were a variety of components made available for assembly into various combinations the better to provide for the particular needs of the individual patient. As these components were developed, prototypes and, later, production units were subjected to systematic testing by the Prosthetic Devices Study, an organization established for this specific purpose within the Research Division of the College of Engineering of New York University.</p> <p>At this point, evaluation generally furnished much needed data concerning the usefulness and reliability of individual units in direct comparison with previous similar parts but without regard for the influence of socket fit, type of harness and harness adjustment, type and extent of training, individual amputee preference, and other factors. Because methods suitable for the evaluation of techniques had yet to be introduced, early evaluations of components brought with them the subtle dangers of misinterpretation owing to the indirect effects of pre-existing errors in socket or harness, to say nothing of the possibility of the influence of one component upon the performance of another used in conjunction. In these circumstances, a great deal was left to be desired in reference to the over-all problem of upper-extremity prosthetics.</p> <p>To fill the gap, there was initiated in 1950, in the Department of Engineering at the University of California at Los Angeles, the so-called "Case Study," with the purpose of bringing together all available information, of viewing systematically the results obtained by use of various combinations of devices and techniques, and thus of developing a set of general principles of management for the upper-extremity amputee. As the Case Study progressed, there arose an increasing awareness of the necessity for teamwork in the proper application of such knowledge as there was, and by 1952 the Prosthetic Devices Study was called upon to conduct an evaluation of the results of the UCLA Case Study.</p> <p>It was obvious that, if such an evaluation were to be conclusive, large numbers of cases under varying geographical conditions would be needed for observation and that therefore the services of a number of clinic teams throughout the country would be required. Although the Prosthetic and Sensory Aids Service of the Veterans Administration, long the chief sponsor of the Artificial Limb Program, had already established some thirty prosthetic clinic teams, and although these groups were readily available for participation, it was patently mandatory that they be trained in the latest methods before any reliable program of evaluation could be initiated. Accordingly, short-term courses for clinic team members physicians, therapists, and prosthetists were organized and conducted at UCLA beginning in 1953. The formation of new clinic teams outside the VA framework was encouraged, and these, along with a few private clinic teams already in existence, were invited to participate.</p> <p>The education program leading to the Upper-Extremity Field Studies, the name applied to this part of the NYU evaluation work, proved to be a pioneering effort in its own right. While results of research were being made available to clinic teams for general use in a remarkably short time after the initiation of laboratory work, the continued association of clinic personnel with the research program through participation in the Field Studies had a definite impact on those responsible for amputee care. Thus the Field Studies came to be a series of complex investigations designed not only to evaluate the usefulness of available upper-extremity prostheses but also to determine the effectiveness of the management procedures elucidated by the UCLA Case Study. Simultaneously, and almost unavoidably, the process of accumulating voluminous clinical data on one segment of the population led to a general upgrading of industry practices in amputee service and furnished the basis for further research into the needs, physical and mental, of the armless.</p> <p>Because the NYU Field Studies represent the first, and thus far the only, attempt in the United States to appraise the status of upper-extremity prosthetics directly and on such a broad scale, and because the results present such a wealth of information not available elsewhere, this and the following issue of Artificial Limbs are given over to presentation of a series of summary articles divided into two parts the first (this number) concerned with the educative aspects of the work, the second (Autumn 1958, Vol. 5, No. 2) with the research implications. For those who would undertake further study and interpretation in the interest of scholarship, the original data, far too detailed for thorough analysis by other than biostatisticians, are available in the College of Engineering of New York University, New York City.</p> <p>In reviewing the material offered here, it is appropriate to keep in mind that the Field Studies constituted a new voyage into an area in which both subject matter and method of approach were uncharted and unexplored. Understandably beset by all the problems of design, organization, and execution typical of adventures into the unknown, they now reveal certain deficiencies most readily viewed with benefit of hindsight. In all probability, the true value of the Field Studies remains to be had in the further application of the principles not only in the field of limb prosthetics but in other, more general areas of physical handicap as well.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Robert E. Stewart, D.D.S. </b></td></tr><tr><td class="clsTextSmall">Director, Prosthetic and Sensory Aids Service, U. S. Veterans Administration, Washington 25, D. C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Evaluation Revalued Creator An entity primarily responsible for making the resource Robert E. Stewart, D.D.S. *