6 20 371 https://staging.drfop.org/files/original/caebe3f12ffbae3736dc0772ee55ae46.pdf 2c2ad2a01e8a4dc8c3905be963fdf48c DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1961_01_001.pdf Year 1961 Volume 6 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/1961_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1961_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>Syme's Amputation</h2> <h5>Walter Mercer <a style="text-decoration:none;">*</a><br /></h5> <p>This issue of Artificial Limbs is, and always will be, a classical contribution to everything pertaining to Syme's amputation, including, as it does, the most detailed and accurate description extant of the proper method of doing the amputation.</p> <p>It has to be remembered that Syme was the greatest of the pre-Listerian surgeons and, indeed, his operation was developed to combat the disastrous septic complications that so often beset the surgeon who dealt with compound fractures, especially where the bone was divided, in contrast to cases that were disarticulated. The fear of sepsis was no longer a real one after Lister's discovery, but that there were other and great advantages in this operation is proved by the fact that Syme's operation is still recognised by competent surgeons as a method of choice in the suitable case. But there have been criticisms of the operation. Harris has stated the reasons for this difference of opinion. He believes that these lie in the method of the operation and in the after-treatment. Various imperfections of the end-results and the methods of their avoidance are described. Most of these can be avoided by a careful technique, and if this were generally practised there would be fewer complications about this excellent operation.</p> <p>Harris reminds us of an important feature of anatomy not generally recognised. This is the specialised form of elastic adipose tissue developed between the calcaneum and the plantar aponeurosis which is resistant to pressure. There are here pockets of fat enclosed by dense septa of fibrous tissue. These fibrous tissue strands are in the form of the letter "U," with the open end of the "U" pointing towards the calcaneum. If this concept is true, it is obvious why the dissection of the heel flap should be close to the calcaneum, because if these little loculi are opened, as will happen if the dissection is through the subcutaneous layer, the fat content is extruded and an important weight-bearing mechanism rendered useless.</p> <p>All modifications, apart from Syme's own one, have detracted from the good qualities of the Syme stump and, indeed, have often ruined its weight-bearing qualities and brought the modified Syme's operation into disrepute. Kelham and Perkins, of the British Ministry of Pensions, are often quoted for their strong objection to this operation, and they concluded their article by expressing the hope that the modified operations would soon be as dead as the original Syme. But their remarks were not based on the original Syme, and so it is not remarkable that they hoped that their modified operation would become obsolete.</p> <p>Modifications like that of Elmslie only lead to failure by reducing the weight-bearing area and making the positioning and fixation of the heel flap more difficult. The plane of transection of the tibia should be so placed that the minimum of bone is removed and the largest possible cross-section of the tibia remains, and that, of course, should be parallel to the ground.</p> <p>It is good to know that the opinions of the British Ministry of Pensions at Roehampton are now very different. The Chief Medical Officer there believes that a Syme amputation is the operation of choice and he adds that "nobody would persuade me to have a below-knee amputation if I could have a Syme."</p> <p>Opinion on durability, too, seems to have changed. Many of the cases seen at Roehampton have had little or no trouble over 30 and 40 years. Shellswell quotes a case who had no trouble in 74 years of limbwearing and in his investigation of 305 Syme's amputations with an average follow-up of 29.6 years he found that 66 percent had satisfactory stumps.</p> <p>Harris points out that an imperfection that is commonly overlooked is the misplaced heel flap. So often after the operation the patient is sent out of the theatre to have the bandaging and the dressing completed. A little too much pull inwards or outwards produces-and permanently-a flap which is not exactly beneath the centre of the cut lower end of the tibia. Harris secured this correct position by strips of adhesive plaster. A plaster-of-Paris support has also been suggested, and a very secure method is to fix the stump by a nail or pin driven up through the lower end of the tibia.</p> <p>Gordon Dale, who has had an immense experience when in charge of all amputations for the Canadian Department of Veterans Affairs, discusses the use of the Syme amputation in peripheral vascular disease. This is an interesting review of the subject with a detailed description of typical cases. The first Syme amputation for thromboangiitis obliterans was done as far back as 1925, and since then it has been used in such cases whenever it seemed warranted. By 1940 this amputation had been used successfully for a wide variety of conditions, including perforating ulcers, in unrecovered sciatic lesions, cauda-equina lesions, frostbite, arterial occlusion, and gangrene from peripheral arterial disease. Dale showed by demonstration of actual cases the great value and durability of these amputations in active life, and in so doing was able to refute the views on durability expressed by the British Ministry of Pensions.</p> <p>The biomechanics of the Syme prosthesis are reviewed by Radcliffe and particularly the locomotion pattern and the manner of weight-bearing for a Syme amputee. In an analysis of the process of human locomotion, the walking cycle is divided into two phases-the stance phase and the swing phase-and these are reviewed. The energy curves are most interesting and give some insight into the complexity of knee-ankle interaction in normal human locomotion. Because of the inherent limitations in available space in the Syme prosthesis, attempts to introduce ankle action have been for the most part unsuccessful. Because in this limited space the Syme amputee cannot achieve the same degree of function as the above-knee or below-knee amputee wearing a SACH foot, the function will in general represent an improvement over the result to be had with the usual articulated joint. This is perhaps an understatement, for when the knee joint on the prosthetic side assumes a greater proportion of the shock-absorption function as evidenced by increased knee flexion under load just after heel contact there is much less deviation from the normal gait.</p> <p>The actual prosthesis is described in a further article. In a review of the history it is apparent that there has been a gradual improvement since the beginning of the century, though even in 1940 the device was bulky, uncomfortable, and generally subject to mechanical failure. With the introduction of plastic laminates into the practise of prosthetics, research workers have been able to alleviate to a great extent the shortcomings of the designs then currently in use, and now excellent and enduring results have been obtained in a large number of Syme amputations observed in Canada. There seems to be little doubt but that the results in Canada, superior apparently to those in Great Britain, have been due chiefly to adherence to the classical procedure of Syme. In this connection, it is said that "Syme was seldom if ever meticulous as to detail," which is hardly consistent with the views of a famous assistant of Syme's, Joseph Bell, in expressing the special character of Syme's method of operating, nor indeed with his reputation in Edinburgh.</p> <p>The present prosthesis is the result of research undertaken by the National Research Council of Canada, an activity initiated by Dr. Harris in 1944, though it was not till ten years later that the device had sufficient merit to warrant its general adoption. This is known as the "Canadian-Type Syme Prosthesis," or more simply, in Canada, as the "Plastic Syme." Among the essential features is a socket made of laminations of Fiberglas applied to a plastic mould of the stump and bonded with a rigid epoxy resin. It is lined with foam rubber, and the stump is inserted posteriorly. There is no ankle joint, and the foot is of the SACH type. This prosthesis is stronger, lighter, and much neater than anything produced before and is now in general use, and we have in the last two articles the considered opinion on it from Canada and America. It is stated in the first of these that its chief advantages lie in its improved appearance with reduced weight, its improved durability by virtue of a stronger structure, its freedom from mechanical troubles, and its reduced cost.</p> <p>This issue of Artificial Limbs leads one to the conclusion that the Syme's amputation is a very good one when properly carried out and properly cared for afterwards. The limb, too, that is in common use as described is a vast improvement on the older types and permits a gait that is not much short of normal.</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>Walter Mercer </b></td></tr><tr><td class="clsTextSmall">'Bidston,' 7 Easter Belmont Road, Edinburgh 12, Scotland.</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 Syme's Amputation Creator An entity primarily responsible for making the resource Walter Mercer * https://staging.drfop.org/files/original/387c7a200b8c8e82a1549ac460dc2643.pdf 6cdf715e6bd5043fe4e42bf3b3884a24 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_02_001.pdf Year 1958 Volume 5 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/1958_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_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>The NYU Field Studies-A Postscript</h2> <h5>Eugene F. Murphy, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <blockquote> <p>Well, one of the two (who will soon be here)—<br /> But <em>which</em> of the two it is not quite clear—<br /> Is the Royal Prince you married!<br /> Search in and out and round about<br /> And you'll discover never<br />A tale so free from every doubt—<br /> All probable, possible shadow of doubt—<br /> All possible doubt whatever!<br /> —- W. S. Gilbert, 1889</p> </blockquote> <p>In preparing a report on extensive research, a modern investigator faces the same problems as the Grand Inquisitor. He may be able to furnish explicit answers to all the minor questions and to delimit the possible solutions of major problems. Only in fortunate circumstances can he provide final answers to all the questions originally posed.</p> <p>This, the second of two issues of Artificial Limbs to be devoted to the NYU Field Studies of 1953-55 (see issue for Spring 1958), offers a wealth of censuslike information on fascinating problems revealed in the course of studying extraordinarily large samples of upper-extremity amputees and their prostheses. It answers with overwhelming affirmation a critical amd highly pertinent question; Do modern concepts of upper-extremity prosthetics truly represent substantial improvement over previous practices? But this favorable broad conclusion demands by virtue of its own importance respect for certain essential qualifications more or less obvious from the circumstances of study if not from the nature of the study itself.</p> <p>Largely because the samples in the NYU Field Studies included such high percentages of veterans of World War II and Korea, many of the amputees treated had already received organized care and training in military amputation centers. Moreover, many had already reaped some early benefits of the Artificial Limb Program. New and supposedly improved devices and techniques had already been developed and applied progressively over a period of half a dozen years, and the U. S. Veterans Administration was already operating Orthopedic and Prosthetic Appliance Clinic Teams in some 30 key cities. Though at the time members of these clinic teams were concerned largely with the suction-socket program and with lower-extremity problems generally, they were so stimulated by the special courses at UCLA, and so encouraged by the monthly visits of NYU field representatives, as to tackle problems in upper-extremity prosthetics and to expand their perspective from simple application of mechanical gadgets to genuine concern for all aspects of the resulting man-machine system. And consequently the results here given are clearly weighted by disproportionate inclusion of the comparatively young and otherwise healthy adult male with special advantages not ordinarily then to be had by the amputee population at large.</p> <p>The nature of the subject matter is something else again. In any investigation so intimately associated with the individual proclivities of human beings, and particularly one of the magnitude indicated, the variables to be controlled are many and diverse, and the data to be had are especially voluminous. Although census counts may provide clues to major influences, and although modern electronic computers may furnish effective correlations and satisfying proof of statistical significance, prosthetics problems in clinical practice are not apt thus to be fully solved because, as in polio, cancer, and numerous other kinds of human disorder, there is generally no single "necessary and sufficient condition" but instead a rather large number of interrelated factors which, added or subtracted in proportions variously weighted, may easily tip the balance for or against clinical usefulness and research success. Thus effective application of the present findings calls for the exercise of keen discrimination over and above that required by the limitations of the sample studied.</p> <p>Despite the existing correlations, therefore, the NYU Field Studies leave unsolved, or at best still subject to serious debate, some disquieting major questions. Why, for example, did a few amputees prefer their old arms over the newer ones? How well did the new prostheses pass the comfort aspects of the checkout tests required? Are the checkout standards adequate? Were complaints about terminal devices heavily correlated with mechanical failure? Of many such puzzlers, some might be resolved by further analysis and correlation of the mountainous data now embalmed in the form of 29 punched cards for each of several hundred amputees. Others indicate the need for further research in the social sciences, while still others constitute a continuing challenge for designers of devices, developers of techniques, and sponsors of research.</p> <p>Perhaps even more fascinating than the yet unsolved questions of physical and mechanical significance are the hints at the nature of amputee psychology. Still needed are thoughtful studies of the problems of realistic acceptance of amputation losses, of objective appraisal of the possibilities for rehabilitation, of the influence of amputee expectations on success in restoration, and of the potentialities for improvement through counseling and guidance both for the patient and for the public as regards attitudes toward what is still called "handicap." Serious consideration of some of the points raised in the present volume may be expected to temper success with humility and hence possibly to afford a degree of wisdom not otherwise to be had. Here, then, is a byproduct perhaps more valuable in the long view than are the actual conclusions it is now possible to formulate.</p> <p>In these investigations, NYU faced and overcame in the conduct of its own studies many practical difficulties in addition to the complex problems inherent in investigations in limb prosthetics. It recruited from a highly restricted labor force a field staff of persons able to observe and assess clinical procedures effectively and willing to travel two weeks in every four during a period of uncertain tenure. It thereby quickly established relationships with VA facilities throughout the country and, even more important, with the numerous private clinic teams that NYU helped to foster, and it maintained checkout standards despite differences in interpretation from one clinic to another. The correlations and insights here presented have all come from the very persons who helped to collect the data, and the summaries have all been prepared with the help of former field men who have since transferred to other NYU projects or who have now left the NYU facilities entirely.</p> <p>Recognizing residual deficiencies, facing unresolved problems, and yet expressing gratitude for the substantial achievements described in NYU's unprecedented two-number contribution to Artificial Limbs, we may now, in the acknowledged infancy of the art and science of limb prosthetics, justifiably substitute "books" for "babes" in the familiar characterization by the Grand Inquisitor:</p> <blockquote><p>Both of the babes were strong and stout,<br />And, considering all things, clever,<br />Of that there is no manner of doubt—<br />No probable, possible shadow of doubt—<br />No possible doubt whatever.</p> </blockquote> <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>Eugene F. Murphy, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Research and Development Division, Prosthetic and Sensory Aids Service, U. S. Veterans Administration, 252 Seventh Ave., New York 1, N. Y.</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 The NYU Field Studies-A Postscript Creator An entity primarily responsible for making the resource Eugene F. Murphy, Ph.D. * https://staging.drfop.org/files/original/6480fc01f37b5e97a22a6791c3a18bc9.pdf 8cadb11a4c01808e922c22cffe349ece DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_01_088.pdf Year 1958 Volume 5 Issue 1 Page Number(s) 88 - 93 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_088.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_01_088.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>Studies of the Upper-Extremity Amputee IV. Educative Implications</h2> <h5>Sidney Fishman, Ph.D. <br /></h5> <p>From the foregoing discussions, it will be apparent that one of the major purposes of the Upper-Extremity Field Studies was to introduce certain influences into the professional activities of the several groups (physicians, therapists, prosthetists) concerned with the care of the amputee and his reintegration into society. It was anticipated that changes in methods of patient care arising from these influences would in turn affect the welfare of the amputee group. In this sense, therefore, a major aspect of the Field Studies was the educative process involved in the attempt to change the operational patterns of those responsible for amputee care by strengthening the philosophies, attitudes, and skills which had been taught during the short-term courses of instruction. Continued encouragement, assistance, and guidance were required to habituate these groups to the procedures proposed during the instructional courses.</p> <p>The second phase of the Field Studies, the results of which will be discussed in the next issue of Artificial Limbs (Autumn 1958, Vol. 5, No. 2), is most properly considered a research activity. The purpose in this phase of the program was to attempt to evaluate the effects of these efforts on the over-all status of the amputee through the use of objective and subjective measurements. To accomplish this second phase, detailed studies were made of the status of the group of amputees prior to their treatment by the prosthetic clinic and again at a time after the completion of treatment.</p> <p>In approaching the task of estimating the effectiveness, or lack of effectiveness, of a two-pronged (research and education) program of this type, a number of problems arise. In this particular case, fortunately, we have the opportunity of deferring evaluation of the second phase, the research activities, until after those results are presented in a second installment.</p> <p>The results of the educative effort are perhaps best considered in terms of Jesus' parable of the sower, as set forth in <em>The Gospel According to St. Matthew </em> (Chapter 13):</p> <blockquote><p>3 ... Behold, a sower went forth to sow;<br /> 4 And when he sowed, some seeds fell by the way side, and the fowls came and devoured them up:<br /> 5 Some fell upon stony places, where they had not much earth: and forthwith they sprung up, because they had no deepness of earth:<br /> 6 And when the sun was up, they were scorched; and because they had no root, they withered away.<br /> 7 And some fell among thorns; and the thorns sprung up, and choked them:<br /> 8 But other fell into good ground, and brought forth fruit, some an hundredfold, some sixtyfold, some thirty fold.<br /> 9 Who hath ears to hear, let him hear.<br /></p> </blockquote> <p>In some few places and among some persons, no effects are to be noted. Among others minor temporary changes evolved, and in still other instances important permanent improvements were brought about. We may consider these effects under three broad categories-impact on the medical management of the amputee, impact on public and private rehabilitation agencies, and impact on social attitudes.</p> <h3>Impact on the Medical Management of the Amputee</h3> <p>It has been emphasized consistently throughout the foregoing sections that a "prosthetic-clinic approach" to the problem of the amputee was a basic tenet of the field-studies program. In this approach, the fundamental decisions relating to the rehabilitation of the patient were made in concert by a group consisting minimally of a physician or surgeon, a physical and/or occupational therapist, and a prosthe-tist. Whenever possible, vocational counselors and other personnel trained in the psychosocial aspects of rehabilitation also were included.</p> <p>The second aspect of the prosthetic-clinic approach involved an attempt at considerable standardization of the process of patient care and usually included eight more or less formal treatment steps-preprescription examination, prescription, preprosthetic therapy, prosthetic fabrication, initial checkout, prosthetic training, final checkout, and follow-up. As a consequence of these efforts, three major changes occurred in the medical care of amputees- introduction of prosthetic-clinic procedures, staff and patient education, and upgrading of existing services.</p> <h4>Introduction Of Prosthetic-clinic Procedures</h4> <p>Although similar clinical procedures have been developed and practiced in the treatment of other disabilities, and even occasionally in prosthetics, the attempt at systematic introduction of such procedures on a broad basis was a novel one. In addition, experimental exploration and validation of the essential adequacy of such procedures is hardly ever available. As a major outcome of the Field Studies, however, the basic validity of the clinical procedures in the field of upper-extremity prosthetics has been established. In addition to these accomplishments, certain other changes occurred with respect to the patient-care activities of each of the specific professions-the physician and surgeon, the physical and occupational therapist, and the prosthetist-concerned with the handling of the upper-extremity amputee.</p> <h5><i>The Physician and Surgeon</i></h5> <p>As a result of the principles and procedures instituted under the program, the period during which the amputee is considered a patient under medical management was extended significantly. Formerly an amputee was a patient during surgery and through a limited period of postoperative care. Today, the period of medical supervision continues through the entire process of limb prescription, fabrication, training, and evaluation.</p> <p>As an additional outgrowth, a subspecialty within the fields of orthopedic surgery and physical medicine has been developed. A limited number of physicians have become expert in the field of limb prosthetics. Since the amputee represents a relatively small portion of the total population requiring medical service, it is not feasible for large numbers of physicians to specialize in this field. But in order to provide competent service for amputees it was essential that a few physicians in each major population center be thoroughly equipped to provide the care required. Physician specialization in the very restricted field of prosthetic restoration has come about as a direct result of the program.</p> <p>Through the program the physician has learned much concerning the technical specifics of prosthetic restoration. As a result of this education, his respect for the contributions made by the skill and experience of the therapist and prosthetist in the process of amputee rehabilitation has increased. The interdisciplinary approach to the problem of amputation and prosthesis has become accepted and appreciated as a significant forward step in the medical management of the amputee. As a general consequence, the physician has been able to acquaint himself with, adapt, and then apply modern-and gradually higher-standards of prosthetic care for his patients. Knowing, perhaps for the first time, what constitutes and what is involved in providing a good prosthesis, the physician is now able to require a standard of service not previously possible.</p> <h5><i>The Physical and Occupational Therapist</i></h5> <p>For the therapist, the short-term courses in upper-extremity prosthetics filled a gap left by the usual curricula in schools of occupational and physical therapy. Perhaps for the first time, a systematic approach to the amputee problem was taught and practiced. As a result, the therapist has been able to carry out the major responsibility of amputee training with a background of general technical knowledge directly relating to artificial limbs. In addition, closer professional liaison developed between the therapist, the physician, and the prosthetist with regard to the amputee. As a result, in most instances upper-extremity amputees are now routinely referred to the therapist for instruction in the use of the artificial limb, whereas in the preprogram days the number of therapists qualified to give this service and the number of amputees availing themselves of it were both insignificant.</p> <h5><i>The Prosthetist</i></h5> <p>The program sought and helped to provide a proper professional role for the prosthetist. As a group, prosthetists were for the first time exposed to formal university instruction and to closer relations with medical, paramedical, and psychosocial disciplines. Thus the prosthetist has been helped toward a redefinition of his status on a higher professional level.</p> <p>This progress in the direction of a more professional role was aided in no small measure by the acquisition of a new technology involving the use of biomechanical principles, plastics fabrication, and principles of harnessing and controlling artificial limbs. This improved knowledge has resulted in improved service, increased status, and greater interprofessional satisfactions.</p> <p>One cannot say at this early stage in the evolution of this field just what the ultimate or proper interrelations may be between the professions concerned. Certainly the appropriate relationships will tend to vary from location to location, depending upon personnel and situational considerations. There can, however, be no gainsaying the facts that a period of growth has been stimulated, that the adequacy of the present treatment situation far surpasses that of the old, and that there has been developed a climate which gives every indication of providing additional professional status for the prosthetist.</p> <h4>Staff And Patient Education</h4> <p>A second value provided by the studies relates to the matter of staff and patient education. It is as true in limb prosthetics as in the other healing arts that there are no standard procedures which will apply with equal effectiveness to every patient. Moreover, limb prosthetics is still a field in which the contributions of each of the specialists are but partially understood by the others. Consequently, there is an important need for a cross-fertilization of ideas and a distillation of the best thinking for a given patient by the process of group activity. In this sense, an important achievement of the prosthetic clinic may be considered the intraclinic education of the team members.</p> <p>Equally important is the role that the clinic must play in the education of the patient. Most amputees, when arriving for prosthetic care, are subject to wide and varied misunderstandings and misinterpretations as to the procurement and ultimate use and value of a prosthetic device. Clinic personnel have become more effective in educating the patient concerning realistic goals and anticipations, in addition to providing him with the best type of prosthesis for his particular needs.</p> <h4>Upgraing Of Existing Services</h4> <p>In the process of applying and studying clinic procedures experimentally, the last important result evolved-that of an upgrading of existing services, as well as the establishment of services where none had existed previously. In this respect, the major contribution apparently has grown out of the introduction of a coordinated pattern of treatment.</p> <p>Previously, it had not been uncommon for a prosthetist, physician, and vocational counselor, for example, to proceed with the care of an amputee independently of one another. This procedure was often adopted in spite of the fact that in any situation where an individual is receiving treatment from more than one specialist, and where the anxieties are such as to provoke some degree of patient discontent, there is a noticeable tendency for some patients to distort the intentions and contributions of each profession in relation to the others. Such problems are further aggravated in those instances where the patient himself is called upon to act as the means of communication between the professions involved, since we may be sure that there will always be a certain degree of distortion of the patient's perceptions of the treatment processes. The clinic procedures were especially effective in reducing this troublesome method of communication between the specialists.</p> <p>We may also anticipate that the behavior and demeanor of the patient toward the pros-thetist will differ from that he exhibits toward the physician, therapist, or counselor. These differences in overt behavior patterns may easily and logically suggest different patterns of treatment to each of the individual professions. Yet it should be clear that these varying behaviors on the part of the patient are transitory and that the real solution lies in a uniform treatment plan rather than in a number of discrete ones. It therefore becomes clear that, in order to provide amputees with the best available medical and prosthetic service, the contribution of each of the professional specialties is best coordinated and amalgamated with that of each of the others. The prosthetic-clinic procedures, introduced through the studies, permitted a more uniform evaluation of the patient and assisted in circumventing the problems inherent in uncoordinated care.</p> <h3>Impact on Public and Private Rehabilitation Agencies</h3> <p>Many groups who have as their adopted or assigned mission the reintegration of the handicapped individual as a productive member of society have long been aware of the significance of the process of prosthetic restoration as a link in the over-all process of rehabilitation. As a direct consequence of this awareness, and as a necessary outgrowth of their over-all responsibilities in the rehabilitation field, federal agencies such as the Veterans Administration, the Armed Forces, and the Department of Health, Education, and Welfare, the state divisions of vocational rehabilitation, workmen's compensation, and health and public welfare, and such nongovernmental agencies as the state societies for crippled children and adults, rehabilitation centers, insurance companies, and a number of other private agencies have become the largest purchasers of prosthetic services in the United States.</p> <p>Through the NYU Field Studies these groups have been made increasingly aware of the potentialities of prosthetic restoration and have responded by raising their standards in the field of upper-extremity prosthetics. Having been provided with professionally competent avenues for the processing of their beneficiaries through prosthetic prescription, fabrication, training, and evaluation, these agencies have begun to insist that their clients be treated by special amputation teams headed by physicians who are experts in the field. Since these agencies may be considered "consumers" in the sense that they most frequently pay for the prosthetic services provided, they have been instrumental in raising the standards by rejecting prostheses and services that do not meet the minimum standards first set up through the program.</p> <p>A by-product is that the groups mentioned tend more and more to order prostheses from those prosthetists who have fully qualified themselves by virtue of training and experience. In a good many instances, these agencies have shown themselves willing to spend the additional monies required to obtain services of the highest quality. In some instances the program has been instrumental in stimulating the inauguration of local services to avoid the necessity for these rehabilitation agencies to contract for prosthetic services from distant sources. The widespread introduction of the clinic-team concept to the field of limb prosthetics provided the means for greater liaison between rehabilitation agencies and those persons medically responsible for the process of prosthetic restoration. Since the clinic-team meetings ordinarily involve a conference of all of the participants in a given case, the agency itself is frequently represented at such conferences by a professional staff member. This, of course, makes for considerable improvement in the continuity of the rehabilitation process.</p> <h3>Impact on Social Attitudes</h3> <p>Beyond their influence on the medical and rehabilitation agencies, the effects of the Upper-Extremity Field Studies also permeated through other facets of our social structure, although as one departs further and further from the professional groups directly responsible for the care of the amputee the impact of the effort becomes more diffused and less specific. Nonetheless, a number of significant effects remain to be noted. They may be viewed as influencing the attitudes and thinking of sponsoring agencies, scientists concerned with physical disability, other groups of disabled, and society at large.</p> <h4>Sponsoring Agencies</h4> <p>Perhaps one of the most important contributions was the demonstration that within a relatively brief period of time research and development can be accomplished and the benefits therefrom made available to the average patient with a disability. It should be recalled that the entire upper-extremity research program did not get under way until several years after the close of World War II and that the major prosthetic design improvements depended upon several years of fundamental biomechanical research. Thus the entire concept and technology of the care of the upper-extremity amputee has been revolutionized within a remarkably brief period of six or seven years.</p> <p>Such demonstrable progress is of inestimable value to those whose prerogatives require that they decide where substantial private or public monies should be spent in medical or rehabilitation research. Although it is always important to verify or evaluate the results of a broad program of research, this is not always possible. Yet this is precisely what the Upper-Extremity Field Studies have done.</p> <p>In the first instance, scientific evidence has been provided concerning the over-all value and contribution of the six or seven years of research and development. Secondly, and from a more technical point of view, information was brought forth concerning those aspects of the care of the upper-extremity amputee which had progressed most satisfactorily and those phases which require continuous improvement and attention.</p> <h4>Scientists Cconcerned With Physical Disability</h4> <p>The program of research and education also assisted in the general growth of scientific thinking on problems of human disability. Some detailed discussion of these research considerations will be included in the next issue of Artificial Limbs (Autumn 1958, Vol. 5, No. 2), which will deal with the research aspects of the studies. The discussion of the educative aspects of the Upper-Extremity Field Studies would be incomplete without note being taken of the progress that has occurred in the attitudes and thinking of researchers in the field of physical disabilities. These advances have been summarized at the recent conference on the Contributions of the Physical, Biological, and Psychological Sciences in Human Disability sponsored by the New York Academy of Sciences (page 125).</p> <h4>Other Groups Of Disabled</h4> <p>It is clear that a special service was performed for those individuals who have incurred disabilities related to, but not identical with, amputation. These groups are perhaps best typified by those disabilities which require functional restoration by use of braces or other orthopedic appliances.</p> <p>Until the time of these studies, there was very little overt expression of the need for progress in the field of bracing. The prevailing situation was one that had remained static for decades. With limited exceptions, personal unvalidated opinion, professional and otherwise, pervaded and still characterizes the entire field.</p> <p>Partially as a consequence of the broad educative aspects of the Upper-Extremity Field Studies, a spontaneous development of interest and desire for systematic progress arose in this related field, which is often served by the same doctors, therapists, and pros-thetists-orthotists. People who were suffering from these types of disabilities and those who cared for them generated a new feeling of hope and enterprise. The results of these changes in attitudes are just now being translated into planning for active research and education.</p> <h4>Society At Large</h4> <p>Further evidence was provided that the systematic treatment of the disabled is a fundamentally effective and socially desirable process. The "collective concern" which society experiences concerning the physically handicapped tends to be reduced with the knowledge that constructive things can be done, and have been done, for this group in an orderly, scientific manner. Associated with this growth in knowledge is a reduction in anxiety and prejudice concerning the physically handicapped and a corresponding increase in their acceptance by society.</p> <br /> 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 Studies of the Upper-Extremity Amputee IV. Educative Implications Creator An entity primarily responsible for making the resource Sidney Fishman, Ph.D.  https://staging.drfop.org/files/original/3ed6e858fb0862d7d2be1b23db392979.pdf 341e77544bf40d3db543a912bb5f0a44 https://staging.drfop.org/files/original/5bc396e4cedef13cf16a253eff163040.jpg ec592855cdba2557e088f78921c41388 https://staging.drfop.org/files/original/fdb6f406a2d352fb47a3cee9e8f38369.jpg 231b76d1408171ad64fae7742ecb2080 https://staging.drfop.org/files/original/7c0842c290468ef1fba4f4843d047f6e.jpg f826d6e153080c737808def1263cdd8b https://staging.drfop.org/files/original/e8a75b8ff67cee7bfa961096b4546fc2.jpg 1b87a973e8f3e3194184030a5e733712 https://staging.drfop.org/files/original/e9b74a814d560aa381bdccc572202d18.jpg 7e4403cff18523ddfb3120463a4be570 https://staging.drfop.org/files/original/ef75d0139e58c59e14d6dd35acdb17a2.jpg 70501d19f818f8d17d3b4ab798b5c8e3 https://staging.drfop.org/files/original/db9be3d7b4042ee252c02a83e44410f6.jpg 811f62d0d758421359d9516a636cc7f9 https://staging.drfop.org/files/original/9d40c9562a0fa9212368f1e2168e0414.jpg 2a71a8f8ae7d5478f89c2d59c2fd982b https://staging.drfop.org/files/original/79520afc4856b97de75b65ceca55ed6d.jpg c56d209e3cc0b131ddf0552ec40728ef https://staging.drfop.org/files/original/11938c318c7cf07237c990a66332d5e6.jpg e3023baa4d85b0b47a1f48737de7838c https://staging.drfop.org/files/original/b7f3d4881f3418405d87e322dad4c534.jpg 2d3c7a9b149b79c2b05043f12da68c06 https://staging.drfop.org/files/original/7f2f89a25a05551ade1e71a258885300.jpg 1c7361b6419e0d308961d5e58f72b6a2 https://staging.drfop.org/files/original/d8559825156298574f27b394d24be4e6.jpg 9c4e998131de15aafcc55e58721cf377 https://staging.drfop.org/files/original/251a6125624f21d3c3f26d9da96c3938.jpg 13d793d6f5c11a23a6232ac42f78aec2 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_01_073.pdf Year 1958 Volume 5 Issue 1 Page Number(s) 73 - 87 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_073.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_01_073.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>Studies of the Upper-Extremity Amputee III. The Treatment Process</h2> <h5>Warren P. Springer, M.A. <br /></h5> <p>The amputees who took part in the NYU Upper-Extremity Field Studies obtained their new prostheses through a treatment process characterized by seven clear-cut steps. These were preprescription examination, prescription, preprosthetic therapy (if indicated), fabrication of the prosthesis, initial checkout, training, and final checkout.</p> <p>The preprescription examination was conducted at the beginning of the treatment process in order to obtain information that would be useful in formulating the prescription and planning the entire treatment program for the patient.</p> <p>As for prescription, the research and educational program strongly encouraged the clinic-team approach, wherein the physician, as clinic chief, involved the prosthetist, the therapist, the patient, and frequently other individuals, such as the social worker or the vocational counselor, in the prescription process. The resulting prescription not only covered the strictly medicosurgical aspects of management but also specified the type of prosthesis and components that were to be used and the training the patient was to receive.</p> <p>The preprosthetic phase of treatment, when indicated, was directed toward providing the patient with the necessary strength and range of motion to operate his prosthesis and toward conditioning his stump for wearing it.</p> <p>In the fabrication process, the prosthetist, working with the patient, carried out the construction and fitting of the prosthesis in accordance with the specifications of the prescription.</p> <p>Initial checkout, which was done on a team basis, consisted of a systematic inspection and evaluation of the prosthesis to ensure that accepted standards of construction and function were achieved. This step was accomplished before the amputee received training and before he was permitted to wear his prosthesis for any extended period.</p> <p>Training consisted essentially of two parts—controls training and use training. The purpose of controls training was to develop the ability to open and close the terminal device, control prehension force, operate the wrist unit, interchange terminal devices, and, in the above-elbow cases, flex the prosthetic elbow and operate the elbow lock. Use training was designed to develop the ability to utilize the prosthesis in practical tasks related to daily-living activities and to occupational requirements.</p> <p>Final checkout was performed after the completion of training or after an initial period of wear. It paralleled initial checkout in that many biomechanical evaluation procedures were repeated to determine if wear had given rise to any difficulties or deficiencies. But in addition to the evaluation of the prosthesis itself final checkout also included an evaluation of training and of the amputee's ability to use the prosthesis at a practical level.</p> <p>This paper is primarily an account of the experiences and opinions pertaining to the treatment process as obtained from interviews with 359 adult, male amputees both at the beginning and at the end of their participation in the studies. The information concerning checkout and training is supplemented by clinical data from records of an additional 410 amputees who participated in clinical aspects of the study.</p> <p>The general characteristics of the research group of 359 amputees closely parallel those of the 1630 amputees in the survey group (Section II). Between the two groups there were no significant differences with respect to age, height, weight, marital status, cause of amputation, or strength and range of motion on the side of the amputation, although there were slight differences in educational level, in experience with arm prostheses, and in the relative frequency of below- and above-elbow types.</p> <p>In interpreting the data in this section, certain considerations should be kept in mind. First of all, a considerable portion of the information is based on the amputees' recollections of past events. The differences that may exist between the recollection of events and the events as they actually happened constitute a possible source of error. A second consideration has to do with the amputees' interpretations of the questions asked during the interviews, especially at the beginning of the study. Terms such as "clinic," "prescription," "checkout," "physical therapy," and "training" may have had widely varying meanings for different subjects. For example, a subject might have said that the prosthesis he was wearing at the beginning of the study had been subjected to a checkout when in reality it had been given only a cursory inspection instead of the systematic examination and evaluation that constituted a "checkout" in our meaning of the term.</p> <p>A third factor has to do with the number of amputees who were able to give meaningful responses to these questions. In some instances and for various reasons usable responses were not obtained from the entire group. In some cases questions were not answered. In most instances, however, classifiable responses were obtained from at least 80 percent of the group, and it seems reasonable that these responses are representative of the attitudes of the entire group.</p> <p>On the positive side, there is good reason to assign a considerable degree of importance to the opinions and reactions expressed by the subjects, since, in the last analysis, the amputee is the final judge of his prosthesis. The extent to which he accepts and approves of the process through which he obtains his prosthesis may have considerable bearing on the extent to which he accepts and uses the device.</p> <h3>Prescription</h3> <p>Prior to their participation in the research studies, only 17 percent of the amputees had ever received an arm that was prescribed by a clinic team (physician, limbfitter, and therapist). In the great majority of cases, decisions as to the type of limb and components had been made either on an individual basis by the limbfitter or the amputee or jointly by both limbfitter and amputee. Fifty-six percent of the amputees approved of this procedure, the most frequent reason (21 percent) given for approval being that they were consulted concerning their choice.</p> <p>In the group (44 percent) that did not approve of the preprogram procedure through which they had received a limb, 14 percent reacted negatively to the fact that they were not consulted. It was somewhat surprising to find that an additional 18 percent expressed the opinion that the amputee should not be consulted. Of the total group, 12 percent felt that the doctor should prescribe the prosthesis. Apparently a significant number of amputees prefer to trust the judgment of others in the matter of prosthetic replacement. Others (and the number probably increases with their prosthetic experience) prefer to become personally involved in the selection of components best suited to their needs.</p> <p>Since all of the prescriptions for the new prostheses and related treatments were arrived at on a clinic-team basis, the amputees were asked the following question to obtain their reactions to the team method of prescription: Do you think that prescription of a new arm by a clinic consisting of a doctor, limbfitter, and therapist is a good procedure? Ninety-four percent of the amputees answered in the affirmative. Compared to the mixed reactions concerning the preprogram procedures, the figure of 94 percent clearly indicates that the amputees preferred the new procedure. By far the most frequent reason given for this response was that the combined experience which could be obtained through the clinic procedure was useful. Typical comments were:</p> <blockquote><p>". . . more heads are better than one."</p> </blockquote> <blockquote><p>". . . experience of several people is helpful."</p> </blockquote> <blockquote><p>". . . no aspect is overlooked."</p> </blockquote> <p>Other reasons that were mentioned relatively frequently can be classified under these headings:</p> <blockquote><p>". . . prevents errors."</p> </blockquote> <blockquote><p>". . . team members act as a check on each other."</p> </blockquote> <blockquote><p>". . . amputee becomes involved in the prescription."</p> </blockquote> <p>Among the 6 percent who did not approve of the procedure, the most common reason offered was that:</p> <blockquote><p>"An old wearer knows what he needs."</p> </blockquote> <p>To obtain information on the parts the various clinic members played in prescription, the amputees were asked: Who was most influential in deciding the kind of arm you should havef The replies are summarized in the accompanying chart.</p> <h4>Terminal Devices</h4> <p>The next two charts show the relative frequency with which the various types of terminal devices were prescribed in the research study. For purposes of comparison, data on the hands and hooks that were being worn at the beginning of the study are included under the heading "Old Prosthesis."</p> <p>In interpreting the prescription data on hands and hooks, consideration should be given to the fact that it was a policy of the research program to encourage the prescription of APRL hands and hooks in order to obtain additional data for evaluation of these devices. This accounts for part, but by no means all, of the changes in terminal components of the old and the new prostheses. Other factors involved in the changes were related to an increasing tendency on the part of clinic groups to prescribe aluminum hooks and hooks with rubber or neoprene facings and to a natural interest in the possibilities of voluntary-closing terminal devices with their wide range of grasp forces. In the case of the APRL hand, the wide range of grasp forces was combined with improved appearance. This natural curiosity and interest in new devices is reflected in the increased use of the Sierra two-load hook also.</p> <h4>Wrist Units</h4> <p>The new prostheses showed a marked increase in the prescription of positive-locking wrist units with the "quick-change" disconnect. The chief reasons for this increase related to:</p> <ol> <li>Specific vocational or avocational indications for a positive lock to control rotation.</li><li>Prescription of both hand and hook for approximately four out of five subjects. A substantial majority of these cases required a wrist unit with a "quick-change" feature to facilitate interchange of hand and hook. (<b>Fig. 1</b>)</li></ol> <h4>Wrist-Flexion Units</h4> <p>There were only two wrist-flexion units on the old prostheses. Both cases were bilateral amputees. Twenty-two wrist-flexion units were prescribed in the research group. Ten were for bilateral amputees; six were for above-elbow, four for shoulder-disarticulation, and two for below-elbow amputees. (<b>Fig. 2</b>, <b>Fig. 3</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Below-elbow Hinges</h4> <p>A marked increase in the number of flexible hinges prescribed reflects the increased awareness of the value of utilizing residual rotation of the forearm stump whenever possible so that the need for pre-positioning the terminal device with the sound hand can be reduced or eliminated entirely. An additional advantage of flexible hinges is that they are less likely to damage the sleeves of the wearer's clothes.</p> <h4>Below-elbow Cuffs</h4> <p>Prescription for below-elbow cuffs showed a marked change toward smaller cuffs and elimination of straps. This change is a result of increased recognition of the desirability of providing a cuff large enough to give adequate stability and suspension but which would also have minimum bulk, would restrict motion as little as possible, and would give greater comfort.</p> <h4>Elbow Units</h4> <p>A guiding principle in the prescription of prosthetic elbow units for above-elbow and shoulder-disarticulation prostheses was that locking should be accomplished independently by controls attached to the harness, without recourse to operation of controls by the sound hand. The extent to which this principle was applied can be seen from the data, which show that all elbow units prescribed were harness-operated. This is a highly significant change from the data relating to the old prosthesis, which show that only 46 percent of the old elbow units were harness-operated.</p> <h4>Sockets</h4> <p>Practically all of the prescriptions for the new prostheses specified plastic laminate as the material to be used in fabricating the socket. The data on the socket material used in the old prostheses show that 37 percent were made of plastic, 28 percent were made of leather with a steel frame, and the remainder were made of fiber and metal, wood, or leather. Approximately four out of five of the new prostheses had double-wall sockets, as compared to less than one out of five of the old prostheses. Twelve percent of the old and 14 percent of the new below-elbow sockets were of the split-socket, step-up type in both the old and the new prostheses. (<b>Fig. 4</b>, <b>Fig. 5</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Harnesses</h4> <p>The data on harnesses show a highly significant increase in the number of figure-eight harnesses prescribed for below-elbow and above-elbow cases with the new prostheses as compared with the old. The reasons for this increase are related to the favorable attitude of the program toward this simple type of harnessing, except for cases wherein heavy lifting was expected. Practically all of the shoulder-disarticulation amputees had chest-strap harnesses on both the old and the new prostheses.</p> <p>Vinyon tape was specified in 96 percent of the prescriptions for new prostheses, and cotton webbing or nylon or dacron tape were prescribed in the remaining 4 percent. (<b>Fig. 6</b>, <b>Fig. 7</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the old prostheses, 83 percent of the harnesses were made of cotton webbing, 8 percent were of leather, and the remaining 9 percent were made of vinyon or nylon tape. The marked shift to the use of vinyon tape was due primarily to the presumably superior characteristics attributed to vinyon with respect to dimensional stability, washability, fraying, and resistance to bacteria and fungi.</p> <h4>Control Systems</h4> <p>All of the prescriptions for new prostheses called for the use of the Bowden cable in the control system. In the old prostheses, 58 percent utilized Bowden cable; the remainder utilized nylon cord, leather, or steel cable without a housing. The change to Bowden cable was effected to take advantage of its higher efficiency in transmitting forces.</p> <h3>Preprosthetic Therapy</h3> <p>Four out of ten subjects said they had received treatment by some form of exercise or other physical therapy prior to their entrance into the study. The same proportion of the group indicated that their stumps had been bandaged to bring about shrinkage.</p> <p>In response to the question, Do you think these [preprosthetic] treatments were helpful?, 79 percent replied in the affirmative and offered the following reasons (in order of decreasing frequency): increased strength, increased range of motion, helped stump shrinkage, reduced pain, improved function, reduced flabbiness.</p> <p>During the course of the research studies, preprosthetic exercise or other physical therapy was prescribed for 13 percent of the amputees treated. That only a relatively small proportion of the subjects received preprosthetic treatment is accounted for by the fact that most of the amputations occurred quite some time before the amputees participated in the program. In most cases, treatment consisted primarily of exercise to increase strength and range of motion of the stump. Other physical-therapy measures, such as diathermy, massage, and hydrotherapy, accounted for a relatively small proportion of treatments. Almost all of the subjects indicated that treatment was received daily. (<b>Fig. 8</b>, <b>Fig. 9</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Seven percent of the amputees had their stumps bandaged to cause shrinkage. About two thirds of this small group indicated that bandaging had been continued over a period of 4 to 12 weeks; the remainder of the group said that bandaging had been continued for more than 12 weeks.</p> <p>Of those who did receive preprosthetic treatment, 88 percent considered the treatments helpful. The reason given most frequently was that the treatments increased strength and range of motion. About one out of five subjects mentioned stump shrinkage as the chief beneficial effect.</p> <h3>Initial Checkout</h3> <p>With reference to arms worn prior to entrance into the program, the subjects were asked: Was your arm checked for fit, comfort, and function before it was delivered to youf Four out of five indicated that their prostheses had been subjected to some form of initial checkout or evaluation, even though this was not done on a formal basis. One third of this group said that the limbfitter had made the check. Thirteen percent designated the physician as having made the check, and 9 percent said the check was made at the hospital. The others did not provide specific information as to who performed the checkout or evaluation.</p> <p>A basic principle guiding operations in the Field Studies was that the amputee would not be permitted to wear his new prosthesis or proceed to training until initial checkout had been passed successfully. If deficiencies were encountered that would interfere with wear or training, recommendations for correction were made, and the amputee was scheduled to appear again so that initial checkout could be completed.</p> <p>Several factors serve to explain why a relatively large proportion of amputees had to appear before the clinic two or more times in order to pass initial checkout. One is that the checkout procedure proved to be highly effective in directing attention to the necessary corrections and adjustments in individual components and to the prosthesis as a whole. A second related to the relatively high and rigid standards established by the checkout procedure. A period of time was generally required before the prosthetic experience necessary to meet these standards was gained. The relatively greater frequency with which above-elbow and shoul-der-disarticulation amputees failed to pass initial checkout on the first appearance, as compared to below-elbow amputees, was for the most part due to difficulties in harnessing. In addition, the relatively small number of shoulder disarticulations seen meant that it took correspondingly longer to obtain substantial experience in their fitting and harnessing. (<b>Fig. 10</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>While a majority of prostheses passed initial checkout on the first presentation, this does not mean that no deficiencies were found at initial checkout in these cases. More often than not, a number of minor deficiencies were found, which resulted in a "provisional pass" rather than a "pass." When a provisional pass was given, recommendations were made for correction of the minor deficiencies found. When the amputee reported for his first training period, a check was made to see that the recommended changes had been effected.</p> <p>Among the below-elbow subjects, the most frequent deficiencies found at initial checkout were in connection with sockets. With above-elbow amputees, the deficiencies found most frequently were in connection with harnessing. The fewest deficiencies were encountered with wrist units. The charts show the order in which the various components ranked according to the number of deficiencies found.</p> <p>The amputees taking part in the study were asked: Do you think it was worth while that the new arm was checked for fit, comfort, and function before it was delivered to you? Ninety-four percent of the replies were yes. The most common reasons given for these replies were:</p> <blockquote><p>". . . to correct and prevent problems."</p> </blockquote> <blockquote><p>". . . provides a check on fit."</p> </blockquote> <blockquote><p>". . . provides a check on comfort."</p> </blockquote> <blockquote><p>". . . provides a check on prescription."</p> </blockquote> <p>Some of the comments of those few who did not think it was a good procedure were:</p> <blockquote><p>". . . made no necessary changes to arm."</p> </blockquote> <p>". . . am intelligent enough to decide for myself if it is comfortable."</p> <blockquote><p>". . . could be checked out at limbshop."</p> </blockquote> <blockquote><p>". . . had to wear it first to see if anything was wrong."</p> </blockquote> <h3>Training</h3> <p>The data pertaining to previous training showed that 42 percent of the amputees had received prosthetic training sometime prior to the beginning of the study. Eighty-nine percent of this group expressed the opinion that this training was helpful. Three fourths of the amputees who received no previous training said they thought training would have been helpful, while the remaining fourth thought it would have been of no use.</p> <p>Data obtained from the clinical studies showed that 81 percent of the subjects received training, that 14 percent received no training, and that owing to incomplete records the training status was indefinite for the remaining 5 percent. Among the amputees who received no training, the most common reasons offered were: the amputee had worn a prosthesis before and previous training was considered adequate; the amputee passed the prosthetic-use test without training; the amputee declined training. (<b>Fig. 11</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In response to a query concerning the value of prosthetic training, four out of five amputees replied in the affirmative. Among the most frequent reasons given for the affirmative answer were:</p> <blockquote><p>". . . training gives an idea of what can be done with the prosthesis."</p> </blockquote> <blockquote><p>". . . learned mechanical operation of components."</p> </blockquote> <blockquote><p>". . . expedited use of arm."</p> </blockquote> <p>Of the group who did not believe that training was valuable, there were proportionately twice as many below-elbow as above-elbow amputees. They offered such comments as:</p> <blockquote><p>". . . using an arm is easy."</p> </blockquote> <blockquote><p>". . . training was not well organized."</p> </blockquote> <blockquote><p>". . . I would rather learn my own way."</p> </blockquote> <blockquote><p>". . . amputee was left on his own too much."</p> </blockquote> <blockquote><p>". . . training helped very little."</p> </blockquote> <blockquote><p>". . . training was not long enough "</p> </blockquote> <p>In response to the question, Do you believe the training you were given in the use of your new prosthesis could be improved?, 41 percent answered in the affirmative. About one fourth of those who answered in the affirmative expressed the opinion that there should be more training in activities of daily living. An equal number thought that more time was needed. Among the group that expressed the opinion that more time was needed there were more than three times as many above-elbow amputees as there were below-elbow amputees.</p> <p>Other suggestions for improvement of training were:</p> <blockquote><p>". . . there should be more enforced training."</p> </blockquote> <blockquote><p>". . . provide a training manual which would allow the amputee to practice at home."</p> </blockquote> <blockquote><p>". . . adapt training to occupational needs."</p> </blockquote> <blockquote><p>". . . there is not enough supervision of training."</p> </blockquote> <p>The total training time for an individual amputee ranged from half an hour to 99 hours, but more than nine out of every ten amputees received less than 20 hours of training. Except for bilateral amputees, more than eight out of every ten amputees received 10 hours or less of training. The average number of hours of training for each amputee type is based on the great majority of amputees (94 percent) who required less than 20 hours of training. Of the small remaining group of amputees (6 percent), one half received from 21 to 30 hours of training; the other half received from 30 to 99 hours. It must, however, be emphasized again that the larger part of this group had had previous prosthetic experience. (<b>Fig. 12</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The average length of individual training sessions for the amputees in the clinical studies was one hour and forty minutes. There was no significant difference in the figures for below-elbow, above-elbow, shoulder-disarticulation, and bilateral amputees. For almost 50 percent of the amputees, the length of the individual sessions was one hour.</p> <p>In reply to the question, Did any difficulties arise in connection with the operation or comfort of your new prosthesis during training or the initial period of use?, 54 percent of the amputees replied in the affirmative. Among the below-elbow subjects, the socket was the most frequent source of difficulties relating to fit and comfort, while among the above-elbow group the harness constituted the major source of trouble. With respect to function, operation of terminal devices and the control system were the most troublesome. The control system was the most common source of difficulty with respect to maintenance.</p> <h3>Final Checkout</h3> <p>Prior to participation in the Field Studies, less than 30 percent of the amputees had had their prostheses rechecked for fit, comfort, and function after the period of initial wear or training. In accordance with the procedures</p> <p>described in Section I, all prostheses in the Field Studies were subjected to final checkout after the completion of training or the initial period of wear. At this time not only was the prosthesis given a systematic and thorough inspection and evaluation but, in addition, an appraisal was made of the patient's ability to use the prosthesis, and a careful examination was made to see if there were any medical or surgical problems that might interfere with successful wear and use. Clinics considered that an amputee had "passed" final checkout only when there were no further surgical, medical, or prosthetic problems of any kind that required attention.</p> <p>Sixty percent of the prostheses passed final checkout on first presentation, 26 percent passed on second presentation, and 14 percent required more than two appearances to pass final checkout. This compares with 69 percent, 24 percent, and 7 percent, respectively, for initial checkout.</p> <p>The decrease in the number of prostheses that passed final checkout on first presentation, as compared with initial checkout, was due chiefly to the results of wear of the prosthesis, the emphasis on the amputee's ability to use the prosthesis, the apparent need for additional training, and the need for modifications which had been overlooked at the initial checkout or on which judgment had been withheld until the effect of wear could be determined. The actual number of deficiencies found at final checkout was, however, smaller by far than the number at initial checkout. Among the below-elbow amputees, the total number of deficiencies recorded at final checkout was only 339 as compared with 801 at initial checkout. The corresponding figures for above-elbow amputees were 358 at final checkout and 970 at initial checkout. These figures show clearly that the prostheses were far better at final checkout than they were at initial checkout, even though it took a little longer to get through the checkout procedure. (<b>Fig. 13</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As was the case at initial checkout, the difficulties found most frequently at final checkout were related to socket fit for the below-elbow amputee and to harnessing for the above-elbow amputee. The fewest difficulties were encountered in relation to wrist units. The order in which various components ranked according to the number of deficiencies found is to be seen in the combined data for initial and final checkout.</p> <p>The effects of wear and use were to be seen in the continued difficulties with fit and comfort of the below-elbow socket at final checkout and also in the relative increase in deficiencies encountered with terminal devices. The more common deficiencies in the latter case were related to malfunctions of hand or hook, staining of or damage to the cosmetic glove, and excessive backlash with voluntary-closing devices.</p> <p>At both checkouts, deficiencies of the elbow unit rank fairly high on the list. Analysis indicates, however, that most of these difficulties were not with the internal mechanism but rather with other factors such as adjustment of the harness and control attachments that activate the elbow lock.</p> <p>In response to the question, Do you think it was worth while that your arm was rechecked for fit, comfort, and function after training and initial period of wear?, 90 percent of the replies were in the affirmative. The most frequent reason for this reply was that the recheck permitted problems to be corrected. Typical comments were:</p> <blockquote><p>". . . gives an opportunity to correct problems after wear."</p> </blockquote> <blockquote><p>". . . experts can see difficulties better."</p> </blockquote> <blockquote><p>". . . it is important to find out if arm still functions properly."</p> </blockquote> <blockquote><p>". . . it provides a general check."</p> </blockquote> <h3>Summary</h3> <p>The amputees' experience in the field-studies program differed quite markedly from their previous prosthetic experience with respect to prescription and final checkout. Prior to their participation in the study, less than one out of five had ever had a prosthesis that was prescribed by a clinic team, and less than one third had had their previous prostheses subjected to a final comprehensive checkout. (<b>Fig. 14</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The differences with respect to preprosthetic treatment, initial checkout, and training were less marked. Relatively fewer amputees received preprosthetic treatment in connection with the new prostheses than was the case in connection with the prostheses that were being worn at the beginning of the study. This, of course, can be accounted for by the lessened need for these services with increased prosthetic wear.</p> <p>Although a substantial majority of the amputees said that their previous prostheses had been subjected to some form of initial checkout or evaluation, these had not been done on any formal or systematic basis and had in general not involved the application of standards of acceptance.</p> <p>Forty-two percent of the amputees who had worn a prosthesis prior to the beginning of the study had received training in its use, although the nature or extent of this training is not clear from the data. More than eight out of ten subjects received training with the prostheses obtained in the research program.</p> <p>Amputee opinion pertaining to the treatment process, as indicated by the data gathered, was for the most part strongly in favor of the new procedures. Ninety-four percent of the amputees approved of the team method of prescription. Eighty-eight percent of those who received preprosthetic treatment said the treatments were helpful. Ninety-four percent were of the opinion that initial checkout was worth while.</p> <p>Four out of five amputees were of the opinion that the training they received in the use of their prostheses was valuable. But 41 percent of the group thought that training could be improved. The most frequent suggestions for improvement were to increase the amount of training time and the amount of training in meaningful activities of daily living.</p> <p>The final checkout to which all of the prostheses in the research studies were subjected was particularly comprehensive and designed to uncover any medicosurgical, prosthetic, training, or other factors that might interfere with successful wear and use. Nine out of ten amputees were of the opinion that this procedure was worth while.</p> <p>All in all, the treatment process inaugurated as part of the studies was considered valuable and achieved a high degree of amputee acceptance.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <br /> Figure 1 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-46.jpg Figure 2 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-47.jpg Figure 3 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-48.jpg Figure 4 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-49.jpg Figure 5 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-50.jpg Figure 6 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-51.jpg Figure 7 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-52.jpg Figure 8 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-53.jpg Figure 9 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-54.jpg Figure 10 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-55.jpg Figure 11 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-56.jpg Figure 12 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-57.jpg Figure 13 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-58.jpg Figure 14 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-45.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 Studies of the Upper-Extremity Amputee III. The Treatment Process Creator An entity primarily responsible for making the resource Warren P. Springer, M.A.  https://staging.drfop.org/files/original/128a4ee02ba99ec2b2f3383ebf4c5ee1.pdf 1d58a741d5b899bf3165aaee4a30b867 https://staging.drfop.org/files/original/2d1139a7a8b381922d685cedf6c247d6.jpg b1b7bf385524209a364b2a5d706e69f1 https://staging.drfop.org/files/original/0b625e54797b43090410315f51bb8d4d.jpg 5a4a4b7273c3c08e58009c0f1d7ac1c4 https://staging.drfop.org/files/original/6af1f53cf4a83727f1442c98daaf6325.jpg e59a5dce109a736b1220cea93df1d532 https://staging.drfop.org/files/original/ef39aec52d3f6f89d396d8de9b904348.jpg 43eb5113c3c8357bc66c5661da85c546 https://staging.drfop.org/files/original/43f4c2cfada99345789b214972118bb4.jpg 53c3f83b5e1afba21df1b455a5cf3d6b https://staging.drfop.org/files/original/cf564e482b2e846fe2bf016c153528c5.jpg 16165f4e12ab933aa6a4134f395ceaf4 https://staging.drfop.org/files/original/94ddb01505c6fd91d498912976af3048.jpg 9f4e4824217f753bbfc090061b775b86 https://staging.drfop.org/files/original/c3e6400840337b90c6265d9fdb31ba05.jpg 6c5c72cce2507fd840d11e5b01c72499 https://staging.drfop.org/files/original/5fe4651c4989ad661077ef728ce3dfc2.jpg f4589d3c099abf5c832d2f368ac04110 https://staging.drfop.org/files/original/c95654d14fbc139044f4f2c1d95cf838.jpg 02cf0e94fb1afe4a88464f018b0407b3 https://staging.drfop.org/files/original/50f3d635111e4062bd949a25d13d93b8.jpg f7f75243050a5c11088831cc5677c2d1 https://staging.drfop.org/files/original/defb3aa2f95589f1d808e5bbcdb5f068.jpg 92e2681beb7f96b1aafc78a0ee712bde https://staging.drfop.org/files/original/18540ad87543021e8ea0daf13b66a934.jpg 884df0195a3f5e4beba928039b604b8f https://staging.drfop.org/files/original/973afd8b16f8e2b86200850467e47aa9.jpg da85192551a55f89ecb5f68fbfba2f86 https://staging.drfop.org/files/original/8f08a4840fdbccaad732de3cf86c6656.jpg aa1650fd1dee2a737800610dea67e78e https://staging.drfop.org/files/original/b29824f38251a82718c4ee9151c706c1.jpg 0493e10fdd34899b9d3d60972263341f https://staging.drfop.org/files/original/babc4d6089681d0e63053e41f2891aad.jpg 45827d84a72fd1e1c6c812877bbfa404 https://staging.drfop.org/files/original/b80b8ef48cb874db384cb2177426b857.jpg 644927a521638fa7a65d2a0059ca0925 https://staging.drfop.org/files/original/6be0ab9c948daa999fee159e98b18731.jpg ff93ed94477dc598a4d1bdf910d8f292 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_01_057.pdf Year 1958 Volume 5 Issue 1 Page Number(s) 57 - 72 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_057.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_01_057.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>Studies of the Upper Extremity Amputee II. The Population (1953-55)</h2> <h5>Norman Berger, M.S. <br /></h5> <p>The number of upper-extremity amputees examined during the "Survey Studies" conducted by New York University probably represents the largest sample of a single type of disabled individual any research group has thus far had the opportunity to study. The size of the sample (1630 cases) offered a unique opportunity for assessing the status of the upper-extremity amputee on a nationwide basis during the years 1953-55 just prior to the widespread introduction of the devices and techniques promulgated by the Artificial Limb Program. The information that will allow us to form a picture of the arm-amputee population during those years is presented in the following pages under the headings:</p> <blockquote><p><em>General characteristics.</em> This section presents identifying data (such as age, height, weight, and educational level) as well as some general findings concerning causes of amputation, amputee types, and amputee vocations.</p> <p><em>Stump characteristics.</em> Here are found data concerning the strength and range of motion of various stump movements, characteristics basic to the control and use of a prosthesis.</p> <p><em>Extent of use of prostheses.</em> Under this heading is presented information dealing with the extent and type of prosthetic use in the common activities of daily living, data which permit inferences concerning the functional value of prostheses.</p> <p><em>Prosthetic components.</em> This section presents a description of the prostheses worn by arm amputees throughout the country.</p> </blockquote> <p>Within this outline, the data gathered are presented, where applicable, by amputee type, an arrangement which permits comparison of attributes between below-elbow, above-elbow, shoulder-disarticulation, and bilateral arm amputees.</p> <p>One should note at the very outset that this entire study deals with male amputees only. No female patients are included anywhere. It will also be noted that the tables and graphs which present the data contain a varying number of cases. Owing to such limitations as the fact that some amputees were not wearing their prostheses or could not remember details about their prosthetic experience, full information was not available for each case. Accordingly, the totals approximate, but are usually somewhat less than, 1630.</p> <h3>General Characteristics</h3> <p>Below-elbow amputees only slightly outnumber above-elbow amputees in the general population. This observation may be somewhat surprising in view of the widespread belief that below-elbow amputations occur much more frequently than do other types. Apparently, the latter is not the case, and it would therefore be unwise to direct research and development toward the one area at the expense of the other. The relative infrequency of shoulder disarticulations and of bilateral arm amputations also is noteworthy. (<b>Fig. 1</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Classification of arm amputees is based on stump length expressed as a percentage of the length of the same arm segment on the sound side. For example, a below-elbow amputee whose stump measures 6 in. from medial epicondyle to end and whose sound forearm measures 12 in. from medial epicondyle to ulnar styloid has a remaining stump length of 50 percent. The system of classifying arm amputees is thus based on percentage categories, each category indicating a progressively greater amount of loss of function. Because the remaining percentage of the length of the corresponding normal arm segment is an indication of the amount of functional loss occasioned by the amputation, the figure is an important one. (<b>Fig. 2</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the NYU survey, the number of amputees in each category was as indicated in the accompanying charts. Nearly half (45 percent) of all below-elbow amputations fall in the medium below-elbow range, while more than half of the above-elbow cases (66 percent) fall in the standard above-elbow category. Extremely short stumps tend to outnumber extremely long types in both above- and below-elbow cases. Of the below-elbow stumps, 10 percent are very short as compared to 8 percent that are wrist disarticulations; in the above-elbow group, 12 percent are shoulder disarticulations as compared to 7 percent that are elbow disarticulations. (<b>Fig. 3</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A very substantial portion of the amputees contacted during the survey studies were veterans whose amputations were service-connected and who were receiving prosthetic treatment through the Veterans Administration. This preponderance of veteran amputees should be borne in mind, since it may tend to affect the data in some respects. (<b>Fig. 4</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>With the large number of veterans in the sample, it is not surprising that over half of the amputations were caused by combat injuries. Aside from wartime casualties, most upper-extremity amputations result from trauma, less than 5 percent being either of congenital origin or due to disease.</p> <p>The average age of the group (<b>Table 1</b>) is 36 years, but in view of the large number of veterans in the sample it is difficult to say whether this age distribution is representative of the entire amputee population. It is likely that significant numbers of cases in the older age groups are not included in these data.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Table 2</b> and <b>Table 3</b> give respectively the heights and weights of the subjects studied. <b>Table 4</b> gives the residence of the subjects by state.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Almost four out of five of the amputees in the survey group were married (<b>Table 5</b>). There has been speculation about a possible relationship between the extent of handicap and marital status. In this regard, the following breakdown may be of interest: (<b>Fig. 5</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>While there is some indication of a trend in these figures, their significance must await additional data bearing on this point.</p> <p><b>Table 6</b> presents the educational level of the subjects, but here again the data may be biased by the fact that a large portion of the group was eligible for educational benefits through the Veterans Administration or State Vocational Rehabilitation Divisions. The effect of these influences on the data cannot be assessed without further study.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Amputation in the upper extremity apparently results in a definite occupational shift primarily away from agricultural and other forms of manual labor at all levels of skills and toward managerial, clerical, sales, and office work. Prior to amputation, professional-managerial, clerical, and sales jobs accounted for 14 percent of the sample's vocations, while agricultural, skilled, semiskilled, and unskilled jobs accounted for 64 percent. In contrast, the former groups of jobs include 41 percent of the postamputa-tion occupations (an increase of 27 percentage points), and the latter groups include 27 percent (a decrease of 37 percentage points).</p> <p>Another marked shift occurs in the rate of unemployment. Whereas only 1 percent of the group was unemployed prior to the loss of an arm, 19 percent were not gainfully employed when seen at amputee clinics.</p> <p>It is interesting to note that those amputees who were employed were occupied in a wide variety of jobs including agricultural and skilled vocations. This fact leads us to speculate as to the reasons for these occupational shifts. Are these trends actually caused by the physical inability of the amputee to perform and compete, or are there perhaps other social or psychological reasons for the occupational shift? Doubtless, a combination of factors is operative, but the relative importance of each is still unknown. (<b>Fig. 6</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Stump Characteristics</h3> <p>The stump characteristics with which we are concerned in this section are strength and range of motion. Information about these characteristics was obtained through gonio-metric measurements and standard muscle-testing techniques.</p> <p>In general, the below-elbow amputee retains somewhat more range of pronation than of supination (<b>Table 7</b>). The average amount of residual pronation in the entire sample is 38 deg., the average amount of supination being 33 deg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Besides retaining somewhat more range of motion in pronation than in supination, the below-elbow amputee tends to have somewhat greater strength of pronation (<b>Table 8</b>). The strength of pronation was rated good or excellent in 57 percent of the cases while 51 percent were rated good or excellent in supination. (<b>Fig. 7</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Of the total group, 75 percent were able to flex their elbows actively to an angle of 130 deg. or more (<b>Table 9</b>). Among below-elbow amputees, then, approximately three out of four cases retain a normal amount of elbow flexion on the side of the amputation. On the other end of the scale, however, it should be noted that a significant number of amputees have a restricted range of motion and require special prosthetic or medical attention in order to achieve a more normal flexion angle. Whereas somewhat more than 50 percent of the cases had good or excellent strength in pronation and supination, 90 percent had equivalent strength ratings in elbow flexion (<b>Table 10</b>), as would be expected since amputation through the forearm interferes less with the muscles and joints related to elbow flexion than with those related to pronation and supination.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When wearing a prosthesis, the above-elbow amputee rarely has occasion to move his stump beyond an angle of 80 deg. either in elbow flexion or in abduction of the humeral stump. On this basis, the majority of above-elbow amputees have more than adequate range of motion for present conventional prostheses. The data indicate that 94 percent of the cases had 80 deg. or more of flexion; 91 percent had 80 deg. or more of abduction (<b>Table 11</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The motion of extension at the shoulder joint is used primarily in locking and unlocking the prosthetic elbow. To perform this operation, an extension range of 40 deg. is more than adequate. In our sample, 82 percent of the cases could achieve an extension angle of 40 deg. or more.</p> <p>The majority of above-elbow amputees have no significant problem with regard to the strength of motions at the shoulder joint. In the total group, 90 percent of the cases had good or excellent strength in flexion, 81 percent had good or excellent strength in extension, and 90 percent had good or excellent strength in abduction (<b>Table 12</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Extent of Use of Prostheses</h3> <p>In assessing the extent of prosthetic use, information was obtained as to the length of time the prosthesis was worn, if at all, and as to the specific activities for which it was used in dressing, eating, work, and recreation. These data permit inferences to be made concerning the usefulness of the prosthesis in everyday life.</p> <p>A surprisingly large portion (62 percent) of the amputees indicated that they were prosthesis wearers at the time of the survey, but this figure may be deceivingly high because of the large number of veterans in the sample. Moreover, the term "present wearer," while it indicates daily wear, does not indicate the actual amount of time the prosthesis is worn. Some of these "present wearers" may use the prosthesis only a short time each day. Further information bearing on this point is to be found in the accompanying chart dealing with the number of hours per week the prosthesis was worn. (<b>Fig. 8</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is perhaps more informative to notice how the wear status varies with increasing severity of loss. While 75 percent of the below-elbow amputees were classified as present wearers, this figure drops to 61 percent for the above-elbow amputees and to 35 percent for the shoulder-disarticulation cases. Clearly there are considerably fewer unilateral arm amputees wearing prostheses as the level of amputation moves proximally.</p> <p>The same trend is found among amputees who had worn prostheses before but who had given them up and were nonwearers at the time of the survey. Among the below-elbow amputees, 9 percent were nonwearers although they had had previous prosthetic experience. Among the above-elbow amputees, this figure rises to 21 percent and reaches 35 percent among the shoulder-disarticulation cases.</p> <p>From these data, the inference is inescapable that, while the below-elbow prosthesis was a fairly widely worn device, the prosthetic replacement for the above-elbow case and that for shoulder disarticulation left more to be desired.</p> <p>A significant portion of those amputees who wear prostheses apparently use them full-time, i.e., 80 or more hours per week, which is about the equivalent of 12 hours a day, every day. In this respect there are, however, significant differences among the several amputee categories. For example, 71 percent of the below-elbow amputees were full-time wearers. But for the above-elbow and shoulder-disarticulation groups, this figure drops to 53 percent and 54 percent, respectively. Among bilaterals the figure rises to 88 percent; the bilateral is obviously more dependent on his prosthesis than is the corresponding unilateral amputee.</p> <p>The conclusion that the amount of wear decreases significantly as the level of unilateral amputation becomes higher is reinforced by the data pertaining to the percentage of amputees who wear their prostheses for relatively short periods each week. A wearing time of less than 40 hours per week was reported by 11 percent of the below-elbow group, 20 percent of the above-elbow group, 27 percent of the shoulder-disarticulation group, and 6 percent of the bilaterals. Judging from these data, individuals with amputations above the elbow do not receive sufficient value from their prostheses to wear them consistently.</p> <p>We come now to a consideration of the degree of actual use to which arm prostheses are put by those who wear them. The activities listed in the four accompanying charts have two important characteristics. First, they are extremely common, being performed several times daily by almost every active individual. They are an inescapable and integral part of normal daily life. Secondly, they are bimanual in nature, either requiring two hands directly or else necessitating the use of one hand while the other is occupied in an auxiliary role. For these reasons, the use or nonuse of the prosthesis in these activities can properly be considered an indicator of the value of the replacement.</p> <p>We have already seen that some amputees had never worn a prosthesis and that others had given one up after some trial period. While the situation is quite complex, these facts point out that, at least for a certain number of amputees, the prosthesis did not offer sufficient functional advantage to compensate for any inconvenience or discomfort involved in its use. But what of those amputees who did wear their appliance? Did they use their artificial arms to assist in the accomplishment of these common activities? (<b>Fig. 9</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the activities of dressing, we find that 42 percent of the below-elbow amputees did use their prostheses in tying shoe laces and in holding up the trousers while the sound hand adjusted buttons, zippers, or belts. This figure, however, is considerably reduced in the case of the above-elbow amputee and is even smaller for the shoulder-disarticulation cases. The information can be summarized by saying that, first, significantly less than half of those amputees who wear arm prostheses use them in dressing activities and, second, that use of an arm prosthesis in dressing decreases markedly the more proximal the level of amputation. (<b>Fig. 10</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although it is customary for the normal person to use a knife and fork in cutting food, apparently most arm amputees adopt some other method. It should be recalled that the use of two hands for eating activities is mandatory in only a few instances, such as in cutting tough meat or in buttering bread. The amputee can try to avoid these situations, can receive help from another person, or can use a special tool such as a combination knife-fork. At any rate, it seems clear that, in the area of eating, the prosthesis was not of great functional value to the sample group. The highest rate of use was only 23 percent (among the below-elbow and the bilateral subjects, who reported holding a fork in the prosthesis). (<b>Fig. 11</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Light grasp is differentiated from heavy grasp not only by the weight of the object but also in that precision is the essential feature of the former while strength of grip is paramount in the latter. Holding papers and writing implements are examples of light grasp; handling tools exemplifies heavy grasp. The word "support" is here used to indicate holding an object up, as in carrying a topcoat, not by grasping but by placing a terminal device or prosthetic forearm underneath it. "Weight" implies holding an object down in the fashion of a paperweight, again without grasping. (<b>Fig. 12</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As regards work activities, the data on use of an arm prosthesis present much the same picture as we have seen in connection with dressing and eating. The majority of the group still report no use of their prostheses, and again the amount of use at work declines at the higher amputation levels. It is interesting to note, however, that in this area there is much less decrease in use among above-elbow and shoulder-disarticulation amputees than is the case in the other two areas (dressing and eating). That is to say, the above-elbow and shoulder-disarticulation prosthesis was used more often for work tasks than for eating or dressing. This may be accounted for by the social and competitive pressures in job situations, or perhaps by the fact that work tasks are extremely varied as compared to the restricted number and type of activities in dressing and eating.</p> <p>As for activities involved in recreation, the number of amputees reporting use of the prosthesis for grasp of heavy objects is more than double the number reporting light grasp. This reversal of the data dealing with use of the prosthesis at work raises a number of questions. Does the amputee find himself placed in jobs whose demands are quite light physically? And, if so, is this a real or an imagined limitation, since apparently the amputee is able to and tends to do heavier activities for his own recreation than he does on the job? It may be that there is an existent prejudice, not in accord with the facts, concerning the kind of activity that an arm amputee can perform. Such a misconception, on the part either of the amputee or of other persons such as vocational counselors, could lead to placement in jobs requiring activity levels lower than those which the amputee is capable of producing. (<b>Fig. 13</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Prosthetic Components</h3> <p>In this section we are concerned primarily with the types of prosthetic equipment worn by arm amputees throughout the country just prior to the research studies. For convenience, we shall deal first with those prosthetic components that are common to all prostheses and then proceed to components that are specific to below-elbow and to above-elbow arms.</p> <p>At the time of this survey of upper-extremity amputees, the voluntary-opening Dorrance No. 5 was by far the most widely used hook. Over 32 percent of the group wore it. In all, the Dorrance hooks, of which there are numerous types, were worn by 70 percent of the subjects, the No. 8 and the No. 7 following behind the No. 5 in popularity. Other hooks that had a fairly widespread use were the APRL voluntary-closing hook (10 percent of all the amputees) and the Trautman hook (9 percent).</p> <p>The three hands that had been most widely dispensed were the Miracle (31 percent of the group), the APRL (24 percent), and the Becker (21 percent). In addition to the relative numbers of the various types of hands, it is interesting to note that 84 percent of the sample used active hands as compared to 16 percent who wore passive hands. Also, as one would expect, the total number of hands worn (728), while quite high, is substantially less than the total number of hooks (1010). Many amputees owned both a hand and a hook. (<b>Fig. 14</b>, <b>Fig. 15</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is clear that at the time of the survey the great bulk of arm amputees (70 percent) used friction wrist units. The positive-locking type of wrist unit was worn by 20 percent of the group, and approximately three out of four of these units were of the Hosmer WD-400 type. The proportion of positive-locking wrists remained fairly constant in all groups except that of the bilaterals, who would be expected to have difficulty in operating this unit. Among the arms worn by bilaterals, only two were equipped with positive-locking wrists.</p> <p>The remaining 10 percent of the sample wore the quick-change Dorrance "Butterfly" type of wrist, which is essentially a friction unit with provision for quick interchange of terminal devices.</p> <p>Considering the group as a whole, plastic sockets were used most extensively. Forty-three percent of the subjects wore this type as compared to 37 percent who wore sockets made of leather, 12 percent whose sockets were made of wood, and 9 percent with fiber sockets. Since plastic is the standard socket material today, it is interesting to note that 57 percent of the entire group did not wear plastic sockets at the time of the survey.</p> <p>There was, however, considerable variation among the below-elbow, above-elbow, and shoulder-disarticulation groups. The leather socket was used by a substantial portion of the below-elbow population (47 percent) but by smaller segments of the above-elbow and shoulder-disarticulation groups (23 percent and 35 percent respectively). Approximately half of this latter group (above-elbow and shoulder disarticulation) wore plastic sockets. (<b>Fig. 16</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is interesting to note that at the time of the survey there was still fairly prevalent use of wood for the above-elbow socket (19 percent of the cases) and of molded leather for the shoulder-disarticulation socket (35 percent of the cases). The data also indicate that over 79 percent of the below-elbow and over 86 percent of the above-elbow sockets were of single-wall construction. Double-wall sockets, which have many functional and cosmetic advantages, were not in general use. (<b>Fig. 17</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The harnesses worn by arm amputees at the time of the survey present quite different pictures in the below-elbow and above-elbow groups. The bulk of the below-elbow population (63 percent) used standard figure-eight harnesses, and an additional large group (25 percent) wore a single axilla loop. These two types of harnesses differ only in that the axilla loop does not contain the front suspension strap (commonly in the form of an inverted F) of the figure-eight harness. The other major style of below-elbow harnessing is the chest strap and shoulder saddle, which was worn by 12 percent of the sample.</p> <p>Turning to the above-elbow population, we find the situation reversed. Fifty percent of this group wore a shoulder saddle and chest strap, while another 24 percent wore the same harness plus an axilla loop to which the control cable was attached. Thus, three quarters of the above-elbow sample had shoulder saddles and chest straps as their basic suspensory harness. The remaining one quarter of all above-elbow amputees wore figure-eight harnesses, either with or without the over-the-shoulder strap. (<b>Fig. 18</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The most universally used elbow joint was the poly-centric rigid joint. It was found in 57 percent of the below-elbow arms (<b>Table 13</b>). If we add to this figure the three other types of rigid hinges listed in the accompanying table, we find that 70 percent of the below-elbow sample wore rigid elbow joints. The remaining 30 percent wore flexible or semi-flexible joints.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Beginning with the triceps pad, a relatively small section of leather located on the posterior side of the humerus, each type of upper-arm cuff is progressively larger. The half cuff covers approximately half of the upper-arm circumference, the full cuff completely encircles the arm, and the three-quarter cuff is between these two in size.</p> <p>A principle generally agreed upon is that the less cuffing used the more comfortable and convenient is the prosthesis, provided that stability and control are not impaired. It is noteworthy, therefore, that the smallest cuff, the triceps pad, was worn by only six percent of the cases. The half and full cuffs were worn almost exclusively (48 and 41 percent of the sample, respectively).</p> <p>Almost all of the half and full cuffs were worn with one or two billets. One of the factors accounting for the large number of full cuffs and supportive billets, which contrasts markedly with present practice, may have been the previously noted prevalence of the axilla-loop harness, which has no front suspension strap.</p> <p>Slightly more than half of all above-elbow amputees did not use automatic, harness controlled elbow units, which are considered standard equipment today. Of this group, 42 percent were manual locks operated by the remaining sound hand, while the remainder (12 percent) wore Fitch-type elbows, which do not contain a locking mechanism. (<b>Fig. 19</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Of the slightly less than half who did wear harness-operated elbow-locking units, 25 percent used Hosmer units (primarily the E-300 elbow) and 21 percent used Sierra units (the Model C elbow).</p> <h3>Summary</h3> <p>The past five years have witnessed a rapid change in the field of upper-extremity prosthetics, partly as a result of the education program and of the studies reported in this issue of Artificial Limbs. As a step in the measurement of the progress that has been and will be made, the survey studies were designed to provide a baseline describing the state of upper-extremity prosthetics prior to the introduction of new techniques, devices, and concepts of amputee management. (<b>Fig. 20</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To establish this baseline, information has been presented about a sample of 1630 amputees observed during the years 1953-55. The character and status of the entire upper-extremity amputee population in 1953-55 can reasonably be inferred from these data. The extremely large number of all types of male amputees who participated, the nationwide scope of the survey, the inclusion of wearers and nonwearers, and the wide variety of occupations represented make for confidence in the accuracy with which the state of the art has been depicted.</p> <p>The primary limiting factor in these data is the large number of veterans among the group, which undoubtedly influences the results. In addition, the data tend to characterize those amputees who reside in urban areas or within a 100-mile radius of the major metropolitan centers where the participating clinics were located. Hence it is likely that the rural resident is not fully represented.</p> <br /> Figure 1 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-12.jpg Figure 2 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-13.jpg Figure 3 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-14.jpg Figure 4 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-15.jpg Figure 5 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-17.jpg Figure 6 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-18.jpg Figure 7 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-19.jpg Figure 8 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-21.jpg Figure 9 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-22.jpg Figure 10 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-16.jpg Figure 11 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-23.jpg Figure 12 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-20.jpg Figure 13 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-25.jpg Figure 14 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-26.jpg Figure 15 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-24.jpg Figure 16 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-27.jpg Figure 17 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-28.jpg Figure 18 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-29.jpg Figure 19 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-30.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 Studies of the Upper Extremity Amputee II. The Population (1953-55) Creator An entity primarily responsible for making the resource Norman Berger, M.S.  https://staging.drfop.org/files/original/897efa93c8f0f30a250eccc724813589.pdf e53c2e6eef7da7fdb79521021433f7d8 https://staging.drfop.org/files/original/c6c0a9c17de4d27109310814707b7ea9.jpg a92870c95ef82139b0b52a743706a5d4 https://staging.drfop.org/files/original/29c0d4894d9c12cab8e7e6de799c2eed.jpg 5aae8022f80eabcc317cdfc744911e6b https://staging.drfop.org/files/original/6ef64458260bc2d1bde1e86f529b05fd.jpg 059fabe5ce19ca7120b4dca37de6a827 https://staging.drfop.org/files/original/3ffdcbb4b21055eba4533c885af8d30e.jpg bf323b08ef78be03b4cdd81505b1117f https://staging.drfop.org/files/original/570c0db690f8d4929a4e24a544499f04.jpg a75a3433b11e417be3aaf5931af55647 https://staging.drfop.org/files/original/25ba53d34e86878d89a422613a423219.jpg 49d279d5f622a33f7bab7e9a13941475 https://staging.drfop.org/files/original/86c9a5fc2e2c6424943c5d82967bca6b.jpg df44bcb9079a48fad702bd6ce8cbd7c2 https://staging.drfop.org/files/original/7f22825f726c7c3cd036fdc490fc0311.jpg 49b270cdb8ab4bf273e44b7ff0d6adcd https://staging.drfop.org/files/original/d7e9a11114bd8cf398078615dc266ef0.jpg effa0ef8f6e071995f4db91e16956da6 https://staging.drfop.org/files/original/c791f2953272b15882d258981a1009c6.jpg 63e16f08b2372dab80ba402c7ec179da https://staging.drfop.org/files/original/b4e99d6ae2d85be6de0ebef5d20927f6.jpg 2764e06e43929f9813a2330db858522a https://staging.drfop.org/files/original/c90405176cc45ad9822c08f2c83403fc.jpg fb0324acf3b3efcca91cc33616b2ac93 https://staging.drfop.org/files/original/78a8fc8bb5859084900fc76a87459fec.jpg 39d5fd4f9942eeadc11787a402d0ee30 https://staging.drfop.org/files/original/3b8caa354bfe35ea776768597c689ace.jpg 3f44ac3f0d0fede052be1900dd619aa4 https://staging.drfop.org/files/original/234a59503cb92f7f867861e34588d1de.jpg be8cf73cabbf52ac504564063d5273ab https://staging.drfop.org/files/original/2c09290f6e88d7d02270ca5e0c495f52.jpg 0e05933eba5072a94777c38b2af8a9ba https://staging.drfop.org/files/original/9ebc06a2cd39befeb223452a2fce202d.jpg b4d10db15d99610189bd994126d8059a https://staging.drfop.org/files/original/e68efc6c51e5847738a124ba8c0650bd.jpg 3ca5390d466efbb2cefeaa72e57341c0 https://staging.drfop.org/files/original/72a98fe700fcf3286ffce2026dbfe490.jpg 926e883f350b7cc4cc2ca3e4da92e8d4 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1957_02_039.pdf Year 1957 Volume 4 Issue 2 Page Number(s) 39 - 51 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_039.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1957_02_039.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>Construction and Fitting of the Canadian-Type Hip-Disarticulation Prosthesis</h2> <h5>James Foort, MASc. <a style="text-decoration:none;">*</a><br /></h5> <p>True hip disarticulation connotes removal of the femur at the acetabulum. But loosely within the hip-disarticulation category a residual length of femur, too short to control a prosthesis effectively, may be left. A much more drastic operation, the hemipelvectomy, removes all of the ischium, all of the pubis, and most or all of the ilium on the side of the amputation. In this discussion, a classical and idealized hip-disarticulation amputee is considered in outlining a method for making the Canadian-type hip-disarticulation prosthesis. Certain adaptations have been found suitable for the short-stump above-knee amputee and for the hemipelvectomy.</p> <p>Consider the remaining functions of the hip-disarticulation amputee. The gluteal muscles have been pulled anterior and fastened at the suture line to form a rugged pad which supports the body's weight. Support forces are transmitted through this gluteal musculature and the ischial tuberosity to the stable pelvic base. Movement of the pelvis relative to the normal leg permits the amputee to position the artificial foot at the beginning of the stance phase of walking and aids in flexing the knee at the end of the stance phase and in sitting down. Pelvic movement relative to the rest of the body enables him to secure balance on and to control the prosthesis. The tuberosity on the side of the amputation, the iliac crests, and the sacrum provide excellent keying points for securing the body in the socket. To minimize movement between the body and the socket for the most efficient transmission of forces, the socket must snugly enclose those areas providing support, suspension, and stabilization and must give relief for any sensitive areas or bony prominences.</p> <p>The socketmaking technique, as worked out by the Prosthetics Research Group at the University of California, Berkeley, is described in detail in the report by Foort and Radcliffe<a></a>. The socket is made by taking a female impression of the pelvis with plaster bandage, forming it into a check socket and making the necessary modifications, making a male model from the check socket, and using the model as a mold for the plastic-laminate socket to which the rest of the prosthesis is attached.</p> <h4>Taking the Cast</h4> <p>To provide relief pockets for the anterior-superior spines, the posterior-superior spines, the spinous processes of the vertebral column, and any other sensitive areas, patches of 1/4-in. skived felt are attached to the body with adhesive tape (<b>Fig. 1</b>). To protect the body from plaster, a covering of cotton stockinet is pulled up over the lower part of the torso and extended well beyond the area where the socket is to be shaped (<b>Fig. 2</b>). In order to define accurately the areas which may require modification, the iliac crests and those areas which have been covered with felt are marked on the stockinet covering with indelible pencil. A mark around the waist, marks on the front and back mid-lines, and a mark extending from mid-line to mid-line around the normal leg at the level of the inguinal crease will define the approximate trim lines of the plaster cast (<b>Fig. 3</b>). Metal strips may be placed over the mid-line marks to facilitate subsequent cutting of the wrap cast.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Application of skived felt patches over pressure-sensitive areas of the stump and torso. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Stockinet pulled over lower part of the torso well above the waist, tied at waist and around proximal end of sound thigh. Waist, mid-line, and bony prominences marked with indelible pencil. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Waist, mid-line, and bony prominences marked in the rear. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>One way to get a good, snug fit for the socket is to take the wrapping of the upper part of the pelvis with the subject lying on his back on a cast table (<b>Fig. 4</b>, <i>A). </i>This position causes the viscera to move upward and backward and flattens the abdomen, thus reducing the distance from the anterior to the posterior wall of the cast and more sharply defining the iliac crests (<b>Fig. 4</b>, <i>B </i>and <i>C). </i>The cast of the lower pelvis is taken as a second step (<b>Fig. 4</b>, <i>D). </i>Snug fit is achieved by having the amputee bear weight on the stump as the cast hardens (<b>Fig. 4</b>, <i>E). </i>Three or four layers of plaster bandage are wrapped firmly around the upper part of the pelvis <i>{i.e., </i>from about 2 in. above the iliac crests to just above the pubic symphysis) and then, with tension, diagonally over the iliac crest on the amputated side and under the crest on the normal side (<b>Fig. 4</b>, <i>A </i>and <i>B). </i>After the wrap is complete, a block of firm sponge rubber 2 in. thick is placed under the patient's lumbosacral region to force the back portion of the cast against the body (<b>Fig. 4</b>C). By molding over the iliac crests with the hands while the cast is setting, and by pressing in firmly while the cast hardens, the operator obtains good suspension hooks.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Taking the cast. <i>A, </i>Wrapping the waistband area of the pelvis, patient supine on cast table, cast table set apart to facilitate wrapping; <i>B, </i>diagonal wrapping for distortion of the cast over the iliac crest on the side of the amputation; C, rubber pad under patient's lumbosacral region to give firm fit in that area, cast table closed; <i>D, </i>wrapping the stump area, a separate operation, patient standing; <i>E, </i>patient "sitting" on rubber pad to give weight-bearing impression. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When the upper portion of the cast has set, the amputee stands, and the stump area is wrapped with plaster bandage. To unite the two portions completely, the bandage is applied back and forth over the stump with several turns around the upper section of the cast (<b>Fig. 4</b>, <i>D). </i>While the cast is setting, the amputee bears full weight on the sponge-rubber pad now placed under the stump area (<b>Fig. 4</b>, <i>E). </i>Weight-bearing at this time keys the body within the socket between the weight-bearing platform and the suspension hook over the iliac crest on the side of the amputation. Up-and-down motion of the body within the socket is thus minimized. There may be some gapping of the cast in the gluteal area and lateral to the pubic area, but such gapping will be closed with plaster when the cast is modified.</p> <p>When the cast has set, it is removed from the torso by cutting at the approximate midlines, front and back (<b>Fig. 5</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Cutting and removing the cast. <i>A, </i>Cast marked on mid-line, front view; <i>B, </i>cast cut along anterior and posterior mid-lines, rear view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Check Prosthesis</h4> <p>The cast is rejoined, reinforced, split again, hinged posteriorly, provided with a buckled closure anteriorly, and attached to a pylon base (<b>Fig. 6</b>). To rejoin the two sections, they are aligned in their original position, and plaster bandage is wrapped around the outside. Plastic laminate, consisting of polyester resin, stockinet, and glass cloth, is applied over the plaster cast to strengthen it. Two layers of glass cloth about 4 in. wide are laid over the outside on the posterior mid-line. One layer of 8- to 10-in. stockinet is then pulled over the cast and tied at the opening for the normal leg. Polyester resin is painted over the fabric and allowed to cure, after which excess material is trimmed away.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. The check prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The cast is now sawed along the posterior mid-line, and a hinge is fastened over the cut. When the hinge is secured, the cast is sawed along the front mid-line, and a buckle-and-strap arrangement is attached. A block of wood about 4x4x4 in., scooped out to fit the bottom of the cast roughly, is attached to the cast with "gunk," a mixture of resin and sawdust, to serve as the base for the pylon.</p> <p>The pylon must now be attached to the wood block in the proper alignment and the socket tried on the amputee for any necessary modifications. With the plaster socket on the amputee, marks are made on the side and front of the block to indicate the inclination of the peg. It should be so set that it will make the same angle with the floor at the beginning and end of the stance phase of walking and so that it will clear the normal leg in the swing phase. Typically, this will mean that the distal end of the pylon will be set somewhat forward as viewed from the side and somewhat lateral as viewed from the front. A hole is drilled in the middle of the block at the required angles, and a length of crutch-tipped dowelling is inserted.</p> <p>To test for discomfort, excursion, and restriction of body motion, the amputee now performs on the check prosthesis. He is asked to bend his body and normal leg in every direction, and the cast is cut down until there is complete freedom of motion. Taking care to leave the ischial seat intact, the medial side is cut away to relieve rubbing against the normal leg and the genitalia. The edges of the cast are then smoothed and flared with plaster, and gapping in the areas of the gluteus and pubis is similarly closed.</p> <p>If there is ramus contact, the amputee usually will complain of it. This detail can be checked by locating the ramus with a finger and having the amputee put full weight on the socket while dropping his pelvis on the normal side. If there is contact, the ischial seat and other weight-bearing areas should be built up with 1/8-in. layers of plaster until the ramus is sufficiently cleared. Fore-and-aft excursion can be detected by placing a finger alongside the tuberosity while the amputee steps back and forth on the prosthesis. Any fore-aft excursion will be reduced if the prosthetist slips a hand between the torso and either the anterior or the posterior wall of the socket. If the amputee then feels more secure, the anterior and posterior walls should be built up appropriately with plaster so laid that the forces are evenly distributed.</p> <p>If the body has not been sufficiently stabilized in the socket in the up-and-down direction, the prominences will move along and out of the relief pockets established for them, and chaffing and painful pressures will occur. As a final check on excursion, therefore, the amputee should be walked in the check socket. Two hours of walking is usually enough to prove any discomfort. Further refinements may then be necessary:</p> <ol> <li>If the musculature in the area of the iliac crest on the side of the amputation has atrophied, the extent of the hook in this region may need to be increased. An increase is indicated if a hand placed inside the socket under the hook makes the socket seem more secure on the amputee.</li><li>If, without causing discomfort, security is increased by inserting 1/8-in. pads between the stump and the weight-bearing area of the socket, the weight-bearing area should be built up accordingly.</li><li>If the body seems stabilized in the up-and-down direction but there is still pressure on the prominences, either the areas around the relief pockets must be built up with plaster, 1/8-in. at a time, or material must be sanded out of the pockets.</li></ol> <h4>The Male Model</h4> <p>A hollow model is now made in the check socket. After the inside of the cast has been coated with petroleum jelly, a section of 8-in. stockinet is pulled over the check socket and tied closed around the pylon base. Sufficient thin plaster is then poured into the cast through the waist opening to coat lightly both the check socket and the stockinet closing the end (<b>Fig. 7</b>). When the first layer of plaster has set, successive layers of somewhat thicker plaster are added until the model is approximately 1 in. to l 1/2 in. thick. When the shell has hardened, a quart more of plaster is poured in, the stockinet is pulled across the opening, and the cast is inverted and placed on a table so that the plaster seals the end. The completed male model is removed from the check socket and dried.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Making the male model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Plastic Socket</h4> <p>To prepare the model as a mold for construction of the plastic socket, a hole is cut in the top (the waist), and a mandrel of 1-in. pipe about 2 ft. long is inserted and fastened with "gunk." The edges of the mold are trimmed so that the flares are not more than 1/4 in., and the whole is smoothed with fine sandpaper. To the surfaces which will become the open ends of the completed socket wooden blocks approximately 1/2 to 1 in. are attached with "gunk" (<b>Fig. 8</b>). They will later be used to secure the layers of fabric to the mold. A 1/4-in. pad of dense sponge rubber is placed over what will be the weight-bearing area of the socket. This pad will later be transferred to the corresponding area of the completed socket. A truncated cone of polyvinyl alcohol film is then pulled over the cast and tied to the mandrel at one end and to the leg-opening surface at the other (<b>Fig. 9</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Wooden blocks bonded to the model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Truncated cone of polyvinyl alcohol film drawn over the model and fastened top and bottom. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <!--Page 44--> <p>To reinforce the polyester resin, da-cron tricot (a very strong fabric with one-way stretch) and glass cloth are used in construction of the socket. The dacron waistband will be limber enough to allow the socket to open, while areas of force concentration, reinforced with the glass cloth, will be strong and rigid.</p> <p>Six layers of dacron tricot are used, each layer being stapled into place individually. The six layers of dacron are cut with enough material to wrap around the cast horizontally and with an overlap great enough to span the distance between the crests. These are fitted and seamed to pocket the stump area (<b>Fig. 10</b>). Beginning at the vertical line of the normal iliac crest, the end of the material is stapled to the wooden blocks at either end of the model. As it is brought across the abdominal area, then around the back, continuing to its starting point, the dacron is stapled to the blocks (<b>Fig. 11</b>), the excess length of material being allowed to hang free. Alternating with the dacron, four layers of glass cloth are laid up over the stump area, extending upward to the crest (<b>Fig. 12</b>), and the lay-up is finished off with the final two layers of dacron tricot (<b>Fig. 13</b>). When all the fabric has been applied in this way, the loose sections of dacron are brought across the front and stapled into position over a sheet of polyvinyl alcohol film (<b>Fig. 14</b> and <b>Fig. 15</b>). The film separator prevents the overlap from bonding to the underlying section.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Dacron tricot tailored to fit the model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Securing the fabric to the model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Glass cloth applied over the stump area. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Final lay-up of dacron fabric. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Application of PVA funnel and film separator under overlap of waistband. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Film separator and overlapping fabric stapled into position. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In order to get resin to the fabric under the film separator, it is helpful to place a polyvinyl alcohol funnel, approximately 2 to 3 in. wide and 2 ft. long, under the film separator before it is stapled into position (<b>Fig. 14</b>). The mouth of the funnel will be at the mandrel. After the film separator and the overlapping material have been stapled to the wooden blocks in final position, two similar funnels are placed over the front and back surfaces of the lay-up with the mouths at the mandrel (<b>Fig. 16</b>). A final truncated cone of polyvinyl alcohol film is pulled over the entire mold and tied in the area of the wooden blocks at the stump end (<b>Fig. 17</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. PVA funnels applied to front and back of lay-up. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Truncated PVA cone placed over entire lay-up. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The required quantity of resin is weighed, mixed with catalyst, promoter, and pigments, and introduced into the fabric through the funnels, after which the funnels are removed (<b>Fig. 18</b>). The polyvinyl alcohol bag is tied closed at the mandrel, and the resin is squeezed through the fabric. When the fabric is completely saturated, excess resin and air bubbles are worked out toward both ends by "roping" (<b>Fig. 19</b>). Sponge-rubber pads are then bound over the undercut areas with Ace bandage in order to guarantee close adherence of the lay-up to the mold (<b>Fig. 20</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Resin introduced through the funnels, funnels ready to be removed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Saturation of the fabric and removal of air bubbles by "roping." </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Sponge-rubber pads applied to undercut areas to guarantee adherence to mold. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The socket is released from the mold by cutting around the waist and around the opening for the normal leg approximately 1/2 in. from the final trim lines (<b>Fig. 21</b>). Care should be taken not to cut the hands on the sharp edges of the overlapping sections (<b>Fig. 22</b>). After the socket has been removed from the mold, the edges are trimmed on a sanding drum.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Cutting the socket free of the mold. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Removing the socket from the mold. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <!--Page 46--> <h4>The Trial Leg</h4> <p>The fixtures are attached to the socket, the socket is attached to a thigh section through the hip-joint assembly, and the thigh section is attached to the adjustable leg and the foot (<b>Fig. 23</b>, <b>Fig. 24</b>, <b>Fig. 25</b>, and <b>Fig. 26</b>). Attachments for the socket are the weight-bearing pad (<b>Fig. 23</b>), the belt-and-buckle arrangement, and the wooden base for the hip joint (<b>Fig. 24</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Finished socket with weight-bearing pad installed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Socket with wood block attached. Dotted lines indicate the saw lines. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Hip-joint assembly. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Trial prosthesis set up on the UC adjustable leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Wooden Base</h4> <p>A block of wood 4 x 4 x 4 in. for the base, hollowed out to fit the front-bottom corner of the socket, is bonded in place with "gunk." When the resin has cured, the front-bottom corner of the block is cut off as close to the socket as possible to provide a surface to which to attach the hip - joint bearing. When the socket is in its normal position, this attachment surface will face downward and forward at a 45-deg. angle to the floor, so that when the hip-joint bearing is attached its axis will be approximately perpendicular to the line of progression and parallel to the floor (<b>Fig. 25</b>).</p> <h4>Hip-Joint Assembly</h4> <p>The hip-joint assembly (<b>Fig. 25</b>) consists of a special bearing, a shaft, and two metal side-straps. The bearing, which is lined with a bronze bushing, is machined out of a block of aluminum and includes four tabs with screw holes for attachment to the base of the socket. The shaft and sidestraps of the hip-joint assembly are from a 3 1/2-in. standard prosthetic-knee assembly.</p> <h4>Thigh Section</h4> <p>The thigh section is made from a 6- x 6-in. block of wood 12 in. long, with a core drilled from the middle at the edge of one end through the center of the block at the other. This hole facilitates pulling out wood from the interior of the thigh section later. A line is marked off 2 in. from the cored edge at one end, and, starting at this line, a diagonal cut is made to the opposite corner at the other end. The 6- x 6-in. face becomes the knee end, the 2- x 6-in. surface the hip end, and the vertical surface (6 x 12 in.) the front face of the thigh.</p> <p>The sidestraps of the assembled hip joint are traced on the front face of the block equidistant from the sides, and the block is cut along these lines to extend somewhat beyond the side-straps and to flare out toward the end. The straps are then attached to the cut sides flush with the front of the block at the bolt end and so that the axis of the bolt will be approximately 3/4 in. above the top surface of the thigh block. The portion of the block which extends behind the axis of the hip joint is sawed as necessary to provide the platform for the hip-stop bumper (<b>Fig. 24</b>). To position the hip joint on the base, the amputee dons the socket and sits down.</p> <p>Viewed from the front, the prosthetic thigh should be approximately parallel to the normal thigh and as close to the mid-line as possible, and the hip joint should be parallel to the floor and high enough on the base so that the back edge of the hip-stop platform is flush with the chair. The position of the bearing is traced on the block, and the free end of the thigh section is marked 2 in. back from the normal knee axis.</p> <h4>Trial-Leg Assembly</h4> <p>The socket is removed from the patient, the thigh section is cut where it was marked, and the components of the trial leg are assembled. The adjustable leg is attached to the knee end of the thigh piece, and the socket is attached to the thigh with screws through the hip-joint bearing. To prepare the trial leg for alignment checks, a temporary hip-stop bumper, a temporary hip-flexion control <!--Page 48--> strap, and a kick strap are attached to the leg, and the knee joint is located in a stable position (<b>Fig. 26</b>).</p> <h4>Temporary Bumper</h4> <p>A bumper of foam-crepe shoe-sole material is tacked temporarily to the hip-stop platform in such a manner that when the socket is against the bumper the vertebral spine will be in its natural position.</p> <h4>Hip-Flexion Control Strap</h4> <p>One end of the hip-flexion control strap is attached laterally to the socket 2 in. behind the hip joint; the other is attached to the shank 3 in. below and 1/2 to 1 in. ahead of the knee joint.<a style="text-decoration:none;">*</a> The distance between these attachments is adjusted to provide the correct stride length.</p> <h4>Kick Strap</h4> <p>The temporary kick strap is attached to the front of the shank at the same level as the hip-flexion control strap, passes over the knee in front, and attaches to the front of the socket 3 in. above the hip joint. The length of the strap is adjusted to provide the correct balance between heel rise and knee extension. Knee stability will be satisfactory if, when the knee is in full extension, the knee joint falls behind the line projected from the hip joint to the back of the heel.</p> <h4>Adjustments</h4> <p>The prosthesis is now ready for sitting, standing, and walking adjustments. When the amputee is sitting, the prosthetic shank should be vertical, the knee axis approximately level with the normal knee center and the toe-out equivalent to that on the normal side. In the standing position, with a 2- to 3-in. standing base, the length of the leg should be such that the hips are level. The thickness of the hip bumper is adjusted to eliminate humping or arching of the spine. The patient now walks on the trial leg, and checks are made of knee stability, width of walking base, stride length, toe clearance, whip in the swing phase, and swing-phase control.</p> <h4>Knee Stability</h4> <p>Although the knee has been stabilized on the bench, a number of factors may affect it in action. If the knee buckles, it may be that the hip bumper is contacting too soon and that its thickness needs to be reduced. A knee axis too far forward also will cause buckling.</p> <h4>Walking Base</h4> <p>With the toe-out of the prosthesis consistent with the natural toe-out, the medial distance between the heels is the walking base. If this base is found to be over 2 to 3 in., it should be made narrower by moving the foot in. If the feet are not clearing each other sufficiently, the base should be increased to 2 to 3 in.</p> <!--Page 49--> <h4>Stride Length</h4> <p>The distance between toe-off and heel strike should be approximately the same for the two legs. Stride length is adjusted by shortening or lengthening the hip-flexion control strap.</p> <p>The thickness of the hip-stop bumper affects stride length. If the thickness of the bumper is increased, the angle at which the leg inclines forward at the end of the stance phase is reduced, and the stride is shortened. But bumper thickness should never be changed to improve control and stride length at the expense of comfort.</p> <h4>Toe Clearance</h4> <p>A number of factors are involved in toe clearance-the length of the leg, the inclination of the foot, the amount of knee flexion in the swing phase, and suspension. Leg length is first adjusted, but the limb should not be shortened more than an inch. If scuffing persists, it is due to other factors. If the knee is not bending sufficiently, the toe will drag, and kick-strap tension should be reduced. If drop-off is causing the toe to scuff, a hand placed between the socket and the crest of the ilium on the side of the amputation should eliminate it. In this case, either the suspension hook over the crest should be enlarged or the weight-bearing area should be built up with pads and the length of the leg reduced equiva-lently. Correction of scuffing may make the clearance too great, in which case leg length must be readjusted.</p> <h4>Whip</h4> <p>Whip in the Canadian-type hip-disarticula-tion prosthesis typically takes a form comparable to circumduction in the above-knee prosthesis. Circumduction can be reduced by rotating the knee bolt externally. The degree to which the knee axis can be rotated is limited by the extent the foot will move medially in the sitting position. It may thus be necessary to effect at least some external rotation at the hip joint by cutting a wedge (with the apex medially) from the hip-joint base.</p> <h4>Swing-Phase Control</h4> <p>With alignment established, refinements can be made in swing-phase control. Heel rise at the beginning of the swing phase should be limited through adjustment of the kick strap rather than of the knee-friction units. The compound-pendulum system of the prosthesis does not allow the hip-disarticulation amputee to walk as fast as he would like, and it has been found that tensing the kick strap increases his speed more effectively than does increasing knee friction. This may mean that there will be some impact at the end of the swing phase, but it usually is quite tolerable because the hip joint flexes as soon as the knee comes against the extension stop, and the energy which would otherwise lead to impact is thus absorbed. Stride length may require periodic adjustment as changes are made in swing-phase control.</p> <h4>Finishing the Prosthesis</h4> <p>The leg is now ready to be used either as a training leg, or, after sufficient attention has been given to fit and alignment, to be duplicated.<a></a> The only difference between duplicating the Canadian-type hip-disarticulation prosthesis and a standard above-knee prosthesis is that in the case of the former the thigh section rather than the socket is clamped in the jig.</p> <!--Page 50--> <p>The thigh section, shank, and foot are shaped and reinforced according to standard techniques<a></a>. Weight of the thigh section is reduced by pulling wood from the inside. The hip joint is faired to the wooden base on the socket with "gunk" and tied to the base with three layers of resin-impregnated glass cloth extending about an inch beyond the wooden block. This reinforcement is smoothed and finished with a light coat of lacquer. For ventilation, the socket is perforated with 1/8-in. holes at 1-in. intervals, and padded areas are covered with nylon-coated leather or leather substitutes. The permanent kick strap and hip-flexion control strap are installed, their connections to the limb being such as to allow the straps to rotate about the points of attachment. The hip-flexion control strap (<b>Fig. 27</b>) is made of 1-in. vinyon or dacron webbing sewed on either end of a 4-in. section of heavy elastic webbing. For attachment to the prosthesis, a piece of leather large enough to include a 1/4-in. metal grommet (such as is used in below-knee corsets) is sewed at each end of the hip-flexion control strap, and a clamping arrangement is installed on the webbing to permit length adjustment. The conventional kick strap is used, with the exception that it is attached proximally to the socket instead of to the thigh. Final adjustments are made to socket edges and to the permanent swing-phase controls.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Hip-flexion control strap. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The last step in the construction and fitting of the Canadian-type hip-disarticulation prosthesis is to provide a cosmetic fairing for the thigh section. A truncated cone of sponge rubber is made to fit over the thigh section so that it extends from just above the knee to the socket. The rubber cone is in turn covered with leather or a leather substitute extending beyond the rubber fairing at both ends, so that the covering can be attached to the thigh at the bottom and to the front and side of the socket with snap fasteners (<b>Fig. 28</b>). In order to make the fairing neat in both the sitting and the standing positions, a triangle with a 3-in. side and with the apex on the hip-joint axis may be cut from the lateral side of the covering and a piece of light elastic webbing substituted.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Cosmetic fairing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The procedures outlined for checking the prosthesis during construction and fitting can be applied equally well to the evaluation of hip-disarticulation prostheses.</p> <h4>Acknowledgment</h4> <p> The line drawings which accompany this article were prepared by Frank N. Todd, illustrator with the Biomechanics Laboratory at <!--Page 51--> the University of California at Berkeley. The halftones are by George Rybczynski, free-lance artist of Washington, D. C.</p> <p><b>References:</b></p> <ol> <li>Foort, J., <i>Fiberglas laminate reinforcement of wooden prostheses, </i>Prosthetic Devices Research Project, University of California (Berkeley), [Report tohe] Advisory Committee on Artificial Limbs, National Research Council, February 1956.</li> <li>Foort, J., and C. W. Radcliffe, <i>The Canadian typehip disarticulation prosthesis, </i>Prosthetic Devices Research Project, University of California (Berkeley), [Report to the] Prosthetics Research Board, National Research Council, March 1956.</li> <li>Radcliffe, Charles W., <i>Mechanical aids for alignmentof lower-extremity prostheses, </i>Artificial Limbs, May 1954. p. 23.</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">Foort, J., Fiberglas laminate reinforcement of wooden prostheses, Prosthetic Devices Research Project, University of California (Berkeley), [Report tohe] Advisory Committee on Artificial Limbs, National Research Council, February 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">Radcliffe, Charles W., Mechanical aids for alignmentof lower-extremity prostheses, Artificial Limbs, May 1954. 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>Footnote</b></td></tr><tr><td class="clsTextSmall">If the amputee is well adjusted to using a prosthesis and does not need the added stability offered by attaching the hip-flexion control strap below the knee, the distal end of the strap may be attached to the thigh section.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Foort, J., and C. W. Radcliffe, The Canadian typehip disarticulation prosthesis, Prosthetic Devices Research Project, University of California (Berkeley), [Report to the] Prosthetics Research Board, National Research Council, March 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>James Foort, MASc. </b></td></tr><tr><td class="clsTextSmall">Assistant Research Engineer, University of California Prosthetics Laboratory, U. S. Naval Hospital, Oakland, Calif.; formerly Research Engineer, Prosthetic Services Centre, Canadian Department of Veterans Affairs, Sunnybrook Hospital, Toronto.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-003.jpg Figure 4 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-004.jpg Figure 5 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-005.jpg Figure 6 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-006.jpg Figure 7 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-007.jpg Figure 8 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-008.jpg Figure 9 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-009.jpg Figure 10 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-010.jpg Figure 11 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-011.jpg Figure 12 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-012.jpg Figure 13 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-013.jpg Figure 14 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-014.jpg Figure 15 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-015.jpg Figure 16 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-016.jpg Figure 17 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-017.jpg Figure 18 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-018.jpg Figure 19 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-019.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 Construction and Fitting of the Canadian-Type Hip-Disarticulation Prosthesis Creator An entity primarily responsible for making the resource James Foort, MASc. * https://staging.drfop.org/files/original/49c94e40d4d54801334c52a842ace4ed.pdf dfd86192aa56e645f99a7c566fa941e8 https://staging.drfop.org/files/original/cce24bee2b5fe0991388af212606ef74.jpg ef1c0dca41b0ab7c44300e6d6091dd63 https://staging.drfop.org/files/original/199ca305134e9005ef91d638f8f25894.jpg 4d0d5f177626a693aa2a260770eb3efe https://staging.drfop.org/files/original/3b360735bbb0fa0e3625db6dd8935a67.jpg 8bdbbe6dafaf8a396b30924bdd787d52 https://staging.drfop.org/files/original/dc137a63c334eca56c849eda853b7319.jpg 7b8647f7d925ec33f9fa8a9a30a7d76f https://staging.drfop.org/files/original/58a988e3c29cc1d77b5365f3b12fe7d6.jpg 11bfd9c94220dbf30ca3160cb92e64f0 https://staging.drfop.org/files/original/4104cbcff18b94957f89ad19c3538698.jpg 8f1672e6e9c7dcacb675b2c54346f4cf https://staging.drfop.org/files/original/f86a93f16d5cf433387b83c39de6baa1.jpg 1ba6d10dde2dbe083655de3498ff8947 https://staging.drfop.org/files/original/fe9962a5d48a6f8a2f401747a9d789e2.jpg 18e845753cbf9ac4c03f05dccf0a62a0 https://staging.drfop.org/files/original/a69de05bc1f9b589ef237d17add3a5ea.jpg 5423422d8380b01fc0c804ba17696ffa https://staging.drfop.org/files/original/bd3186304f87a62dee0927d9e017c4a7.jpg 323ef747f37e5e92fd66564ce31dd76b https://staging.drfop.org/files/original/221f45275c014c8446f733e660935c09.jpg 9104d70c79a83ac6f37205e2e6128e18 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1957_02_029.pdf Year 1957 Volume 4 Issue 2 Page Number(s) 29 - 38 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_029.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1957_02_029.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 the Canadian-Type Hip-Disarticulation Prosthesis</h2> <h5>Charles W. Radcliffe, M.S., M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>Establishment of a rational procedure for the proper fitting of a leg prosthesis to an amputee at <i>any </i>level of amputation requires careful consideration of many factors. The process of evolution of a new and satisfactory method of fitting of prostheses has generally been a lengthy one involving trials on amputees by a number of experimenters over a period of many years. Recently, both in the United States and in foreign countries this process has been accelerated through the efforts of research teams, which through a combination of the skills of personnel from the fields of medicine, prosthetics, and engineering have attempted to solve problems in a more logical, scientific manner. The Canadian-type hip-disarticulation prosthesis is an excellent example of an improved device that has resulted from the efforts of organized research in limb prosthetics.</p> <p>In a technical discussion of the principles of fitting of <i>any </i>prosthesis, it is often convenient first to describe the biomechanics involved, the term "biomechanics" referring both to the residual functional anatomy and to the mechanical implications of wearing a prosthesis applied to the stump. The biomechanical analysis establishes the pattern of force trans- mission between the prosthesis and the stump. Once the force pattern is known, physiological and anatomical factors must be considered in determining whether or not the proposed areas of force transmission are pressure-sensitive or unsatisfactory for other reasons. If there are no physiological contraindications, it then becomes the responsibility of the pros-thetist to fit and align the prosthesis in a functional and comfortable manner as dictated by the biomechanical and physiological requirements. Comfort is generally achieved by a distribution of any individual contact force over an area of the socket large enough to reduce the pressure on the stump to a tolerable magnitude.</p> <p>The biomechanical analysis of the Canadian-type hip-disarticulation prosthesis can be divided conveniently into two parts: first, an evaluation of the stump-socket forces required to support the torso in the stance phase and, second, a review of the dynamic behavior of the combined amputee and his prosthesis in level walking.</p> <h4>Principles of Mechanics</h4> <p><b>Force</b></p> <p>A "force" is the physical action of one body upon a second body which tends to change its position in space (<b>Fig. 1</b>). In interpreting the diagrams to follow, it will be necessary to consider the concept of force as a vector quantity. Force vectors, for example that shown in <b>Fig. 2</b>, must be specified by magnitude (indicated by length of a particular force arrow), sense or direction (indicated by the <!--Page 30--> arrow head), and the line of action (indicated by location of the shaft of the arrow).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. "Force" defined. A "force" is the physical action of one body upon a second body. It may be either a push (compression) or a pull (tension). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. The "force vector." The one shown here represents a 100-lb. force applied by a "second body." The force acts to the right, through point <i>A, </i>along a line inclined 10 deg. from the horizontal line <i>AB. </i>The scale factor for this force vector is 100 lb. per inch of length. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>PRESSURE</b></p> <p>"Pressure" is a measure of the distribution of force over an area. Since pressure is defined as force per unit area, it is calculated by dividing the force by the area over which it acts. This would give an "average" pressure. Pressure is seldom uniform, and its variation is often indicated by a series of pressure vectors such as shown by the smaller arrows in <b>Fig. 3</b>. Where both force and pressure vectors are shown on the same diagram, the force vector indicates the "resultant," that is, the sum of the effects of the distributed pressures in a particular region.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. "Pressure" defined. "Pressure" is force supported per unit area. A broad area of support results in lower values of average pressure. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>EQUILIBRIUM</b></p> <p>In force analyses, use is made of two fundamental principles of analytical mechanics: the concept of "force equilibrium" and the concept of "moment equilibrium."</p> <p><i>Force Equilibrium</i></p> <p>The principle of force equilibrium, first stated by Newton, can be interpreted in the following form: In order for a body to remain at rest (fixed, relative to a point in space) the vector sum of all forces acting upon it must be zero (<b>Fig. 4</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. "Force equilibrium" defined. In force equilibrium, the vector sum of all forces is equal to zero. The force diagram must form a closed polygon. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <!--Page 31--> <p><i>Moment Equilibrium</i></p> <p>A "moment" is the product of a force acting through some perpendicular distance from a reference point or "moment center." A moment tends to cause a physical body to rotate. In the simple lever shown in <b>Fig. 5</b>, the force <i>F </i>exerts a moment <i>F </i>X <i>a </i>about the point <i>O. </i>In order for the body to have no tendency to rotate, the sum of all moments acting upon it must be zero, such as when a force <i>P </i>on one end of the lever, acting through distance <i>b, </i>balances a similar force <i>F </i>on the opposite end, acting through distance <i>a, </i>as in <b>Fig. 5</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. "Moment equilibrium" defined. For moment equilibrium, the moments acting about a center of rotation must be in balance. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>FREE-BODY DIAGRAMS</b></p> <p>Another useful concept is the "free-body diagram" used extensively in engineering mechanics. When a system or structure involves more than one distinct physical body, the parts are often shown separately, as in <b>Fig. 6</b>, and the effect of each mating part is accounted for by a vector representing the force exerted by it on the part being considered as a free body.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Free-body diagrams of the individual, isolated bodies, with the action of the second body represented by a force vector. Note that "action" on one body results in a "reaction" on the second. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Functional Description of the Canadian-Type Hip-Disarticulation Prosthesis</h4> <p>The functional features of the original design of the Canadian-type hip-disarticula-tion prosthesis are shown in <b>Fig. 7</b>, which is reproduced from the Canadian report of March 1954. Although there has since been minor modification of the methods for fitting and <!--Page 32--> alignment of the device, its functional features remain unchanged (<b>Fig. 8</b>). They include:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Original design of the Canadian-type hip-disarticulation prosthesis. From McLaurin <i>(1).</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. The Canadian-type hip-disarticulation prosthesis as modified at the University of California (Berkeley). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <blockquote><p><i>A continuous, laminated-plastic socket-waistband. </i>The socket-waistband is fitted so as to provide three reaction points (points of suspension), as shown in <b>Fig. 7</b>. The weight-bearing area of the socket is constructed of rigid plastic laminate, while the waistband is made flexible to permit easy donning of the prosthesis.</p> <p><i>Alignment stability. </i>A unique arrangement of joint locations results in improved security against buckling of the knee in any normal walking situation, the hip joint being located below and forward of the normal axis of the hip (<b>Fig. 7</b>). With the hip joint so located, the effective length of the leg is the same in both standing and sitting. A reference line extended through the hip and knee joints passes a minimum of 1 in. behind the heel, so that as long as the prosthesis bears weight the load transmitted between the foot and the hip joint always passes ahead of the knee joint, thus ensuring knee security. When required, flexion of the knee is initiated by contact of the elastic hip bumper (attached to the bottom of the socket) with a stop on the upper posterior portion of the thigh. As long as the hip bumper is not in contact, the knee joint is always completely stable.</p> <p><i>Full-width hip joint. </i>The full-width hip joint allows a much stronger connection between socket and thigh. The hip joint is similar to a prosthetic knee joint and is highly effective in resisting lateral bending at the connection between socket and thigh piece.</p> <p><i>Hip-joint motion. </i>In level walking, the hip joint allows approximately IS deg. of relative motion between socket and thigh. The amount of motion is limited by the hip-flexion control strap (shown as "elastic band" in <b>Fig. 7</b>). This arrangement allows the leg to assume a natural inclination at heel contact without backward tilting of the pelvis.</p> </blockquote> <!--Page 33--> <h4>Functional Sequence in Use of the Prosthesis</h4> <p>The manner in which the amputee walks on the prosthesis can be described by dividing the stance phase of walking into three parts: heel contact, mid-stance (roll-over), and push-off.</p> <p><i>Heel Contact</i></p> <p>As the leg swings forward preparatory to heel contact, the hip-flexion control strap limits the free hip-joint motion to approximately 15 deg. This hip-joint motion, in combination with a slight pelvic motion, allows the leg to assume a natural backward inclination as the heel makes contact. The amputee moves forward over the prosthesis, and the heel is planted on the floor without hesitation.<a style="text-decoration:none;">*</a> The weight-bearing prosthesis is extremely stable owing to the alignment of the hip, knee, and ankle joints, and the objective is to attain knee security by having an appreciable amount of force transmitted through the prosthesis at the instant of heel contact. Where additional security is desired, the amputee leans forward slightly at the time of heel contact. Doing so results in an increased tension in the hip-flexion control strap, which helps to hold the knee in full extension.</p> <p><i>Mid-Stance (Roll-Over)</i></p> <p>As the amputee rolls over the extended prosthesis during the mid-portion of the stance phase, knee security is increased as the weight-bearing line moves forward toward the ball of the foot. Hip-joint motion causes the hip-flexion control strap to relax, and the amputee rides forward with the socket balanced on the free hip joint. Pelvic stability is maintained by the momentum of the torso.</p> <p><i>Push-Off (Start of Knee Flexion)</i></p> <p>At the end of the stance phase, the prosthesis must be propelled forward into the swing phase. The amputee using a tilting-table prosthesis does this by a lifting and internal rotation of the pelvis on the side of the amputation. A normal individual achieves knee flexion at the time of push-off by combined hip and ankle action. The amputee using the Canadian-type hip - disarticulation prosthesis initiates flexion by a method somewhat similar to that used by an above-knee amputee wearing a suction socket. As the prosthesis inclines forward with the weight borne through the ball of the foot, the angle of hip flexion is reduced until contact is made between the elastic bumper system at the rear of the hip joint. As the socket continues to progress forward in a straight line (without pelvic rotation), continued forward inclination of the thigh causes an increase in the compression in the bumper system. The moment thus developed about the hip joint eventually disturbs the knee stability and causes the knee to flex forward into the swing phase. By proper adjustment of the stiffness and point of contact of the hip-bumper system, a very natural knee flexion at the time of push-off can be achieved. The amputee should never lift the pelvis and swing the leg forward by internal pelvic rotation. Rather, the recommended action is exactly the opposite. The amputee "sits hard" on the prosthesis in order to start the knee flexing. Where more rapid knee flexion is desired, a slight backward rotation <!--Page 34--> of the socket to increase the compression of the hip bumper will propel the prosthesis forward forcibly. If weight is transferred to the natural leg simultaneously, there should be no feeling of insecurity at this time.</p> <h4>Action of the Socket in Lateral Support of the Torso</h4> <p><i>Foot Position</i></p> <p><b>Fig. 9</b>, a series of free-body diagrams, shows, as viewed from the front, the rather simple force system which is acting when an amputee is walking on a Canadian-type hip-disarticulation prosthesis, the situation depicted being the period of mid-stance on the prosthesis when mediolateral dynamic effects are negligible. <b>Fig. 9</b>A shows the system of externally applied forces acting on the prosthesis alone. <b>Fig. 9</b>B shows the forces acting on the combination of the amputee and the prosthesis.<a style="text-decoration:none;">*</a> <b> Fig. 9</b>C shows the external force system acting on the amputee considered as an isolated free body.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Mediolateral force diagram of the Canadian-type hip-disarticulation prosthesis. <i>A, </i>Forces acting on the prosthesis (exerted by floor and stump); <i>B, </i>forces acting on combination of amputee and prosthesis (exerted by floor and gravity); <i>C, </i>forces acting on amputee (exerted by prosthesis and gravity). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Fig. 9</b>B involves the simplest force system and is therefore discussed first. Two forces are involved-the supporting floor reaction and the downward force of the body weight. The vertical component of the floor reaction is equal in magnitude to the downward force and hence just balances the body weight. The body can therefore be assumed to be in force equilibrium in the vertical direction. But the floor reaction, being inclined generally inward, has an inward component along the floor, which means that the entire body is being accelerated toward the sound side. This acceleration would result in a change in direction of motion of the torso, that is, in a movement toward the amputee's normal side. Such mediolateral oscillating motion of the body as a whole is characteristic of normal subjects as well as of amputees. To maintain mediolateral motion within normal limits in the amputee, the inclination of the floor reaction to the plane of progression must be minimized, and the hip-disarticulation prosthesis is therefore aligned to give a narrow walking base. Experience has shown that the walking base should be less than 4 in. from heel center to heel center.</p> <p><i>Stump-Socket Forces as Viewed from the Front</i></p> <p>The consideration of forces acting on the stump, which result in part from the requirement of a narrow walking base, is more complicated. As can be seen in <b>Fig. 9</b>C, four forces act on the combined stump and torso of the hip-disarticulation amputee-the downward force of the body weight acting through the center of gravity, the distributed vertical support pressures acting upward on the ischial-gluteal region, and distributed socket pressure between stump and socket-waistband acting on both normal and amputated sides. A single force vector is used when necessary to approximate the effects of the actual pressure distribution.</p> <p><b>Fig. 9</b>A shows the forces acting on the prosthesis considered as an isolated free body. It is to be noted that the body weight, that is, the effect of the downward pull of gravity, does not act on the socket <i>per se. </i>The effect of the body weight is made apparent by the opposite reaction (acting downward) of the vertically upward ischial-gluteal support seen acting on the stump-torso in <b>Fig. 9</b>C. If the body weight and ischial-gluteal support forces were the only two forces acting on the torso, the body would have a tendency to rotate about the point of support and to drop toward the unsupported normal side. This tendency is counteracted by the moment of the couple formed by the two mediolateral forces <i>H </i>and <i>S. </i>For moment equilibrium, taking the summation of moments about point 2 equal to zero, <i>W </i>X <i>b = H </i>X <i>a. </i>Or,<br /> <b>H=(b/a)W</b><br /> Thus the magnitude of the reaction against the normal hip, or the tension in the waistband, or both, can be reduced by increasing the distance <i>a. </i>Moving the concentration of lateral forces on the stump to a lower level by alteration of fit is practical only within certain limits. Too low a position would result in shear forces along the bottom of the stump and in considerable relative motion between stump and socket. It is also apparent that, owing to the limitations on increasing dimension <i>a, </i>the lateral forces <i>H </i>and S are of the same order of magnitude as the vertical forces <i>W </i>and <i>I</i>, since dimensions <i>a </i>and <i>b </i>would be approximately equal.</p> <p><i>Stump-Socket Forces as Viewed from the Side</i></p> <p><b>Fig. 10</b> shows the pattern of forces acting on the amputee and/or his prosthesis as viewed from the side during level walking. <b>Fig. 10</b>A indicates the force system acting on the prosthesis isolated as a free body at heel contact. <b>Fig. 10</b>B shows the forces exerted by the socket on the stump-torso, plus the action of the body weight, during the three major divisions of the stance phase in level walking-heel contact, mid-stance, and push-off. <b>Fig. 10</b>C is a free-body diagram of the isolated prosthesis at push-off. Again the use of free-body diagrams allows a clear distinction between forces acting on the amputee and forces acting on the prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Anteroposterior force diagram of the Canadian-type hip-disarticulation prosthesis. <i>A, </i>Forces acting on prosthesis at heel contact; <i>B, </i>forces acting on stump at heel contact, mid-stance, and push-off; C, forces acting on prosthesis at push-off. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>At the time of heel contact on the prosthesis, the normal leg is completing push-off. The force acting on the normal foot is then transmitted through the normal leg to the pelvis. This thrust of the normal leg is shown in <b>Fig. 10</b>B acting on the normal side of the pelvis. Shown in addition to the force from the normal leg are the force of body weight and the distal, posterodistal, and anteroproxi-mal stump-socket forces. The floor-reaction force is not transmitted directly to the stump but results in the system of stump-socket forces shown acting on the socket in <b>Fig. 10</b>A and <b>Fig. 10</b>C. For example, the isolated prosthesis must be in equilibrium under the action of stump contact forces plus the floor reaction. The same system of stump contact forces <i>react </i>to appear as forces applied in the opposite sense in the diagrams of <b>Fig. 10</b>B. Because of the offset lever arm between body weight and the line of vertical support through the ischium, as shown in <b>Fig. 10</b>B, a counter- acting stabilizing force is required in the anteroproximal region. The thrust of the normal leg tends to increase the unbalanced moment about the distal point of support and hence to increase the need for anteroproximal counterpressure in the inguinal region.</p> <p>In the mid-stance phase, the normal leg is off the floor, and the four forces shown in the middle diagram of <b>Fig. 10</b>B are acting. The anteroproximal pressure on the stump is reduced as compared to that existing in the heel-contact phase. This circumstance indicates that errors in fitting would be more noticeable at the time of heel contact than in the succeeding mid-stance phase. If the dynamic effects of acceleration are ignored, two forces are acting on the combined amputee and <!--Page 37--> prosthesis during the mid-stance phase- the body weight and the upward floor-reaction force on the sole of the foot. This situation prevails until the normal foot again contacts the floor ahead of the prosthesis.</p> <p>At about the same time that the normal foot strikes the floor, the hip-bumper system in the prosthesis makes contact and tends to flex the knee forward. During this push-off phase, there is again a thrust on the pelvis from the normal leg, this time from the front, as shown in <b>Fig. 10</b>B. The thrust of the normal leg counteracts the offset body weight and further reduces the need for anteroproxi-mal support from the socket. This feature gives the amputee a greater degree of perceptive control of the prosthetic knee, since the stump-socket forces are reduced and the effects of the hip-bumper force acting on the bottom of the socket are therefore more readily distinguishable. With a properly adjusted hip-bumper system, the amputee is able to exercise a more than adequate control and timing of knee flexion even though some of the body weight is still being carried by the prosthesis at this time.</p> <p>Owing to the ever-changing nature of the stump-socket force system as viewed from the side, it is necessary to fit the distal portion of the socket snugly in the posterior region in order to prevent relative motion between stump and socket in the more highly stressed areas of vertical support under the ischial tuberosity.</p> <h4>Surgical Implications</h4> <p><b>Fig. 11</b>A and <b>Fig. 11</b>B show front and side views of a typical hip-disarticulation stump. Cross-hatching on the surface of the stump indicates those areas where biomechanical analysis shows a functional need for supporting or stabilizing contact pressure between stump and socket. Clearly indicated are those areas where surgical incisions should be avoided, in particular the ischial-gluteal, inguinal, and lateral-distal areas. The incision and resultant scar should be located along the anterodistal portion of the stump, as shown in <b>Fig. 11</b>A. This area is not required to tolerate localized pressure and is generally relieved during the fitting process in order to avoid pressure-sensitive areas over bony prominences in the pubic region.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Typical dynamic pressure distribution on the hip-disarticulation stump when wearing the Canadian-type hip-disarticulation prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Implications for Fitting</h4> <p>Biomechanical force analysis shows certain regions over the stump where particular attention must be paid to socket fit. They include the ischial-gluteal, inguinal, and waistband contact areas.</p> <p>In the ischial-gluteal area, functional pressures must be developed on a bony prominence and a neighboring area of atrophied gluteal musculature. This requirement calls for careful location and fitting of the bony prominence of the tuberosity. In order to develop pressure on the soft tissues, considerable modification of the cast is required. This displaces the soft tissues upward in the socket, and the necessary functional contact pressure is achieved. The pressure in the gluteal area is an absolute necessity in order to stabilize the distal end of the stump on the bottom of the socket. Otherwise chafing due to shearing motions between stump and socket will result.</p> <p>The inguinal region must provide a major contribution to the anteroposterior stabilization of the torso. An inaccurate fit in this region will result in concentration of pressure at a lower level in the generally sensitive pubic areas. The soft tissues of the inguinal and abdominal areas must be displaced inward if the proper functional stump-socket pressure is <!--Page 38--> to be achieved. This is most easily accomplished by wrapping the cast in this region while the patient is supine.</p> <p>The mediolateral force which must be transmitted by the waistband extending around the normal hip approaches the body weight in magnitude. The waistband must be fitted very carefully to avoid local concentration of pressure on bony prominences.</p> <h4>Training Implications</h4> <p>Training a hip-disarticulation amputee to walk on a properly fitted, aligned, and adjusted Canadian-type prosthesis is not a difficult or time-consuming process. If the therapist is thoroughly acquainted with the functional principles of the prosthesis and with the methods of fitting and adjustment, a well-coordinated amputee should walk unaided, without a cane, after less than 10 hours of training. Proper adjustment of the hip bumper, hip-flexion control strap, and ankle-foot characteristics is absolutely essential for efficient use of the prosthesis. For this reason, therapist and prosthetist should work together during the initial training sessions.</p> <p>Particular points which should be stressed by the therapist in working with the amputee are:</p> <ol> <li>Develop confidence in the stability of the knee at heel contact. Emphasize the necessity for a confident placing of the prosthetic heel and simultaneous weight-bearing. Show that the knee stability will increase in direct proportion to the amount of force transmitted by the prosthesis.</li><li>Show the action of the three-point mediolateral support of the torso. Do not allow the amputee to bend his trunk over the prosthesis. If painful pressure develops over a bony prominence, have the prosthetist provide relief or padding.</li><li>Place considerable emphasis on the timing and use of the pelvis to propel the prosthetic knee forward. Remember that the amputee "sits" to flex the knee while the prosthesis continues to bear a portion of the body weight. The amputee should not lift the prosthesis off the floor and then propel it forward by internal rotation of the pelvis.</li></ol> <h4>Summary</h4> <p>A biomechanical analysis is presented for the forces involved when an amputee stands and walks with a Canadian-type hip-disarticulation prosthesis. The results of the analysis are applied to the specialized topics of stump surgery, socket fitting, and training of the amputee.</p> <p><b>References:</b></p> <ol> <li>McLaurin, C. A., <i>Hip disarticulation prosthesis, </i>Report No. 15, Prosthetic Services Centre, Department of Veterans Affairs, Toronto. Canada, 19 March 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>Footnote</b></td></tr><tr><td class="clsTextSmall">In Fig. 9B contact forces between stump and socket are internal forces which cancel out when the combined system of amputee and prosthesis is considered.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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 foot should not swing up and then snap back into contact with the floor.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Associate Professor of Engineering Design, University of California, Berkeley; member, Committee on Prosthetics Research and Development, PRB, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-003.jpg Figure 4 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-004.jpg Figure 5 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-005.jpg Figure 6 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-006.jpg Figure 7 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-007.jpg Figure 8 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-008.jpg Figure 9 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-009.jpg Figure 10 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-010.jpg Figure 11 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-011.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 the Canadian-Type Hip-Disarticulation Prosthesis Creator An entity primarily responsible for making the resource Charles W. Radcliffe, M.S., M.E. * https://staging.drfop.org/files/original/e71416996352556efb023812c4eedec5.pdf 25ebf46eaf69e9b152e2c190d46f2a77 https://staging.drfop.org/files/original/b6c5c1116f50d1110f991f8a6c0e582b.jpg 53141fda199ab171208acf35d095a73d https://staging.drfop.org/files/original/42e04c9ddf407f09592f368dc9ff1c12.jpg 651ea138a11022d6edf8e33366739adf https://staging.drfop.org/files/original/bcdce6329da04a8a8f4710fbe3957aec.jpg 227b1bc4f43139dc742e5cfc3434f264 https://staging.drfop.org/files/original/061a0c8f6051439279c49121003e4252.jpg e92f1b105cd71be2e26422d8ed541101 https://staging.drfop.org/files/original/220a179b1734ff365426e6b757fbf1a4.jpg 106d747231911de3f7ab6a749818955f https://staging.drfop.org/files/original/a030df8afdd8d496ea38ff35eb10a376.jpg 099981a8288aa53e4f8ab7a1afcf3ec3 https://staging.drfop.org/files/original/06b6efdef352c9a36c19e593016d0058.jpg 5cf35916d68ebab5f2fa7015770d5ec5 https://staging.drfop.org/files/original/e33abac33eb28c4425dc5ba7d3d9829f.jpg bbf0ffd1753ca99e90634ba88f777e5b https://staging.drfop.org/files/original/741aaf7774c9fb485c220490dfa15d66.jpg 104b74ab4ce49065ab443a4973decc68 https://staging.drfop.org/files/original/c7f5624a84623a65da53be9b14b7ad50.jpg 0d835a39d62f5c64705c7b7f85ff2696 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_01_004.pdf Year 1958 Volume 5 Issue 1 Page Number(s) 4 - 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/1958_01_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_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>Studies of the Upper Extremity Amputee. I. Design and Scope.</h2> <h5>Edward Peizer, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Man's increasing dominion over his natural environment has been ascribed to three specific characteristics a highly developed brain, binocular vision, and an apposable thumb. Although not particularly specialized from a biological viewpoint, these three attributes have enabled him to adapt to a varied physical environment and, perhaps more important, to alter the physical environment to suit his needs. Loss of any one of them deprives him of fundamental human capacities and seriously inhibits his ability to compete, to interact, and to manipulate the objective world around him. Impaired brain function is usually irreversible, and in the case of vision loss heroic measures are often required to obtain even a modicum of functional restitution. But the situation is somewhat different today with respect to the loss of an upper extremity. New concepts and developments in the field of limb prosthetics have increased the potentialities of arm amputees. Not all the problems are solved. Far from it. But systematic and concerted efforts in medicine and engineering are being applied toward reducing the limitations attendant upon the loss of an arm. It is perhaps ironic that historically these constructive efforts have been stimulated by the destructive forces of war.</p> <h3>Historical Development</h3> <p>In the aftermath of World War II, a grateful nation spared no effort to alleviate the condition of those who had been wounded or maimed in its defense. Among its many other services, the Veterans Administration undertook the task of providing prosthetic and rehabilitation services to all veteran amputees. In pursuit of this goal, it soon became clear that existing artificial limbs fell far short of meeting the needs and expectations of their users. Perhaps because of the greater dependence of the leg amputee upon adequate service, and because of the consequent emphasis on attention to his problems, the major needs were found among upper extremity amputees. Arm prostheses were found to be heavy, uncosmetic and unsanitary, and possessed of very limited function (<b>Fig. 1</b>) and (<b>Fig. 2</b>). Too often they were relegated to the closet. Generally accepted standards of prosthetic quality were lacking. Better materials, improved design, new prosthetic components, and improved fitting and fabrication techniques were clearly required.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Typical below-elbow prosthesis, vintage World War II. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Typical above-elbow prosthesis, vintage World War II. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Not generally recognized was the need for highly individualized training to develop proficiency in the use of an artificial arm so that vocational and other skills could be acquired. Without a common ground of experience, the physician rarely took part in the prescription and fitting of prostheses. Thus, even the most skilled prosthetist, faced with the task of providing his patient with a well fitting, comfortable, and highly functional prosthesis, sometimes found himself in the unfamiliar role of psychologist, therapist, and/or vocational counselor. In short, sound, complete, systematic rehabilitation programs for amputees were lacking. Officials of the Army, the Navy, and the Veterans Administration wasted little time in hand wringing. Authority was soon forthcoming, and funds were made available for a broad attack on these problems. The resources of science, applied during the war years to destruction and demoralization, were now directed toward the restoration of human loss and the enrichment of human life. The first step was the establishment, in 1945, of the Committee on Prosthetic Devices of the National Academy of Sciences National Research Council, which later became the Advisory Committee on Artificial Limbs and which is today the Prosthetics Research Board. This led to the inception of the Artificial Limb Program and to the establishment of research projects for the scientific study of the problems involved. At the University of California at Los Angeles fundamental studies were undertaken of the biomechanical principle involved in normal prehension and of the problems of using artificial arms. At the same time, the industrial laboratories of Northrop Aircraft, as well as the Army Prosthetics Research Laboratory, were creating new materials, new devices, and new fabrication techniques, while New York University was assigned the task of evaluating these developments. The scientific facilities of both industry and government were thus employed to reduce the problem through efforts in basic and applied research.</p> <p>The earliest results indicated that solving the problems and fulfilling the needs of the upper extremity amputee was a task vastly greater than that of improving the mechanical aspects of fitting and fabricating prostheses. The finest artificial limb is of little value without training in its use. Further, the loss of a limb was seen to create important disturbances in the personality as a result of functional loss and distortion of the self concept. The amputee entertains doubts as to how he will appear to and be accepted by his family and friends. He wonders, often with misgivings, about his economic potential. He has what appear to him to be insuperable problems, and he needs help in restoring his self confidence as well as his lost function. In order to meet these amputee needs, a complete and rational system of rehabilitation programming was required, and since 1945 considerable progress has been made in developing such an approach to this problem.</p> <p>After several years of organized effort, a great deal of research information became the basis for an all around approach to the treatment of upper extremity amputees. Through the development of models, the testing of hypotheses, and the experimental treatment of a number of arm amputees of all types, it became possible to indicate with some confidence how certain types of patients should be fitted, how their arms should be constructed, and how they should be trained to use them. As an added result, it is becoming a commonplace that all the amputee's needs cannot be served by a single individual, regardless of his professional status or training. With recognition of individual needs and the variety of amputee problems, it became clear that successful rehabilitation of these patients demanded the highly qualified and specialized services of a number of disciplines. Prosthetists, therapists, and physicians each have vital contributions in this enterprise, as may also nurses, social workers, vocational counselors, and psychologists. The modern concept then became the "team approach," the team consisting minimally of the doctor, the prosthetist, and the trainer and including such other specialists as each case required.</p> <p>In order to evaluate these findings, a series of studies, which came to be known as the "NYU Field Studies," was conceived in 1951 at the Prosthetic Devices Study at New York University.</p> <h3>Goals of the Upper Extremity Field Studies</h3> <p>The NYU Field Studies of upper extremity prosthetics developed as the logical consequence of two main preconditions the laboratory research program and the prosthetics education program. As for the first, out of the laboratories had come a whole series of new devices which, on the basis of preliminary testing on relatively small groups, gave promise of being significantly improved components. Before some of them could be considered "proved" items of a prosthetic armamentarium, more definitive testing on broader, more representative samples under varying conditions seemed essential. But more than gadget testing was involved. New fabrication techniques employing plastics had also been developed, and although arms made according to these procedures seemed superior to older types, it remained to be seen if the procedures could be mastered by limbmakers all over the country and economically and conveniently applied to the production of all types of artificial arms.</p> <p>The second factor to be considered in planning the studies was the matter of broad and speedy dissemination of the new knowledge and skills. It was clear that the new procedures could not be evaluated in clinics whose personnel were not completely familiar with their use. Moreover, considerable urgency prevailed about making new developments and improvements available to all amputees as soon as possible. To fulfill this requirement, a prosthetics education program was organized to train clinic team personnel. But it was generally observed that additional assistance was required in significant numbers of clinics before they could begin to process patients effectively.</p> <p>For all of these reasons, the NYU Field Studies were designed in 1953 with three main objectives in view:</p> <ol> <li><i>To evaluate the utility and acceptability of specific prosthetic materials, components, and treatment procedures</i>. In order to appraise the usefulness of prostheses provided amputees by the program, and in order to gauge the reactions of the patients to the new arms, a comprehensive evaluation procedure was to be developed. The comfort and appearance of a prosthesis and the confidence it inspires in its user are as important in prosthetic service as are structural and mechanical adequacy. Each of these areas was explored.</li><li>To provide direction for future research in relation to practical field needs. Field study operations should provide access to large representative samples of upper extremity amputees. Clinical contact with these patients would furnish a means for determining existing prosthetic problems and, even more important, for evaluating the importance of these problems to amputees themselves. With this information available to the developmental laboratories through a feedback arrangement, their efforts could be directed toward the problems of most immediacy and importance.</li><li>To extend the educational process by rendering administrative and technical assistance to newly organized prosthetics clinics. Shortly after graduation from the prosthetics courses at the University of California at Los Angeles, potential clinic teams were to be visited by NYU representatives, the purpose being to encourage and aid in the establishment of a clinic procedure along the lines taught in the courses. The expeditious organization of a clinic served two functions amputees would have early access to modern treatment, and a clinic treating patients according to these procedures was a potential participant in the field studies and a source of research data.</li></ol> <p>Before these concepts could be tested in the crucible of clinic practice throughout the nation, several preliminary steps were necessary. First, meaningful and reliable methods had to be found for evaluating the effect of prosthetic treatment procedures. Second, a number of clinics had to be organized to participate in the studies if valid inferences about the general utility of the experimental procedures were to be drawn. Third, training in the new prosthetic techniques and procedures had to be given to those who dealt directly with amputees. Actually, all three of these steps were undertaken at approximately the same time.</p> <h4>Inauguration of the Upper Extremity Field Studies</h4> <p>The staff of the Prosthetic Devices Study of New York University had been engaged in developing on a generally theoretical basis a philosophy and methodology for evaluating the status of arm amputees. The problem was approached directly, attempts being made to determine the most important outcomes in prosthetic restoration and to measure the extent to which the newer management procedures provided them. Accordingly, procedures and instruments were devised for determining the extent of residual function and the degree of adjustment to physical disability (<b>Fig. 3</b>). The status of the patient after treatment could thus be compared with his pretreatment condition as a basis for evaluation. But before these instruments could be applied on a broad scale it was necessary to test their reliability and administrative feasibility as well as to refine the procedures for their application. For this purpose, a preliminary "pilot" study was planned, and Chicago was selected as the test site.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Calibrated grid for measuring the arm movements required to perform certain common activities. Use of top and side mirrors provides information in three dimensions simultaneously. Clocks record time data. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Chicago "Pilot" Study</h4> <p>The pilot study carried out in 1952 called for a small number of surgeons, therapists, and prosthetists from the Chicago area to attend a special four week course of instruction in upper extremity prosthetics at the University of California at Los Angeles in order to familiarize the participants with the devices, fabrication techniques, and clinical procedures to be evaluated.<a></a> Upon their return to Chicago, they were joined by representatives of NYU's Prosthetic Devices Study, and the pilot study was launched.</p> <p>This field trial of research instruments and procedures involved the screening of a number of amputees in the Chicago area and the selection of a group for treatment in the Veterans Administration clinic. To enable the clinic properly to prescribe the new prosthesis, each of the selected subjects was given a comprehensive evaluation prior to other treatment. In addition, research evaluations were conducted by NYU representatives to provide baseline data against which the effects of the rehabilitation procedures could be evaluated. The new arm for each participant was then prescribed in accordance with the prescription procedure taught in the UCLA course and was to be fabricated precisely as prescribed and according to the mechanical and cosmetic standards formulated. When the arm was complete, it was brought to the clinic for a checkout which consisted of a detailed examination by the clinic staff to assure themselves of the adequacy of the product. If revisions were required, they were made before the patient was given the arm; if none were needed, the clinic prescribed appropriate training treatments to be administered by the therapist.</p> <p>After training was completed, the amputee was again seen by the clinic team; if the arm were still satisfactory and maximum results had been achieved through training, the patient was to wear the arm routinely in daily living. At the end of a two month period of daily wear, the subjects were re evaluated in a manner similar to the pretreatment evaluation.</p> <p>As a result of the Chicago study, valuable experience was gained in the processing of patients. Research techniques were refined, clinic procedures were crystallized, methods for administering questionnaires and for taking measurements were standardized, and instruments were revised and augmented. With the end of the pilot phase, expansion of the upper extremity field studies to national proportions began, an expansion made possible by the participation in the program of a number of widely distributed private clinics as well as Veterans Administration clinics.</p> <h4>Organization Of Participating Clinic</h4> <p>The unprecedented nature of the projected field studies made the selection of a number of clinics a formidable task. It was first necessary to locate interested and qualified clinic personnel. Then it was necessary to orient them as to the nature of the program as well as to the need for special training. Steps for integrating the clinics into the field program required explanation, and specific operating procedures had to be worked out with individual groups. This task was undertaken by the Director of the Prosthetic Devices Study, Dr. Sidney Fishman.</p> <p>After completion of the pilot study in Chicago early in 1953, and continuously for two years thereafter, Dr. Fishman and Dr. Miles H. Anderson, the Director of the Prosthetics Education Project at UCLA, visited many large population centers throughout the country in order to meet with medical and paramedical personnel interested in the treatment of arm amputees. On the basis of expressions of interest, and of an appraisal of the available facilities and potential case loads, a number of clinical facilities were invited to participate. During these discussions, research procedures were described, expected outcomes were explained, and the roles of the clini members and of the NYU research workers were defined. Arrangements were made for members of each clinic staff to attend the courses in upper extremity prosthetics at UCLA (see below).</p> <p>It was quickly realized that financial problems would be encountered both by private clinics and by participating limbshops. In the former, the newer training procedures called for increased services of therapists and doctors. In the latter, the employment of newer fabrication and fitting techniques required an initial investment on the part of the prosthe tists in components, equipment, and materials. In addition, the checkout of an arm by the clinic team often resulted in revisions adding to initial fabrication costs. For these reasons, certain fiscal arrangements were indicated. Monies were made available to clinic teams to pay the training fees for amputee cases participating in the work. In order to spur the fabrication of the new type arms and to permit participation in the program by the prosthe tists, arrangements were made to purchase five experimental limbs from each shop participating in the studies. As a result of these efforts, 75 clinics representing 30 states and the District of Columbia (<b>Fig. 4</b>) participated in the field program. Each treatment center was directed and staffed by graduates of special upper extremity prosthetics training courses. Of the total number of clinics involved, 28 were Veterans Administration installations and 47 were other public and private institutions.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Location of the participating clinics See facing page. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Prosthetics Education Program</h4> <p>The new knowledge and techniques, organized into courses of instruction and revised after the pilot school, were offered in a series of 12 schools (<b>Fig. 5</b>) conducted at UCLA, the chief purpose being to familiarize doctors, therapists, and prosthetists with the new developments and to encourage the team approach to the prosthetic rehabilitation of the upper extremity amputee. It thus became possible to teach to those with primary interest new concepts for the management of upper extremity cases.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Students and instructors of one of the 13 courses in upper-extremity prosthetics offered at the University of California at Los Angeles. This particular course was held in the autumn of 1954. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In effecting the transfer of information and skill to the primary amputee treatment grou consisting of the doctor, the therapist, and the prosthetist, academic tradition was broken. It seemed plain that if the "team approach" were to be taught, the members of the team should go to school together. Accordingly, in a unique educational enterprise, orthopedic surgeons, specialists in physical medicine, physical and occupational therapists, and prosthetics craftsmen became classmates. The six week course offered at UCLA began with a three week session of instruction for prosthetists only. During this portion of the course, prosthetists were exposed to a highly concentrated educational dose of prosthetic design and construction principles, plastics technology, anatomy, and kinesiology. Then they tested their knowledge by fitting patients under the direct supervision of their instructors.</p> <p>In the fourth week, the prosthetists were joined by the therapists. This group began with a concentrated portion of mechanics, biomechanics, and the characteristics of a wide variety of both newly developed and the older prosthetic components. Under the supervision of the instructors, they also received experience in training the patients previously fitted by the prosthetist students.</p> <p>At the beginning of the sixth week, the prosthetists and therapists were joined by the physicians and surgeons, who were given several days in which to review and digest the course materials. Practice clinic teams, consisting of the doctor as clinic chief and of at least one therapist and one prosthetist, were then organized. The entire class then proceeded to operate as clinic teams until graduation, whereupon each of the individuals returned home, a potential participant in the soon to follow upper extremity field studies. The new knowledge and skills were broadly disseminated by these educational efforts, but their utility and effectiveness on patients could not be clearly seen until large numbers of varying types of patients had been treated and evaluated.</p> <p>The Prosthetic Devices Study, charged with the responsibility for following up the program concepts, designed studies to evaluate the modern treatment methods. The central questions to be answered were deceptively simple: Are upper extremity amputees better served by means of the program procedures? In what specific areas can improvement, detriment, or indifference be found?</p> <h4>Areas of Research</h4> <p>In relatively unexplored fields, the formulation of meaningful research questions is often laborious, unsure, and time consuming. Merely selecting the most scientifically promising problems from the many questions which arise is in itself an important research task. Many possible approaches to the field must be evaluated, and those selected for study must give promise of becoming part of and contributing to the solution of larger problem areas. The research plan developed at the Prosthetic Devices Study to achieve the objectives of the field study program evolved in this way. It provided for three major interrelated study areas to be exploited concurrently.</p> <p>The first of these, a census of amputees, called for interviewing large numbers of upper extremity amputees in order to begin the organization of a broader body of knowledge concerning them and to provide a large population from which to select a sample for more detailed study. This was the "Survey Phase." Secondly, a segment of this population was selected for clinic treatment by means of the rehabilitation procedures under study. These efforts of the field operations, referred to as the "Clinical Studies," were designed to provide information about the feasibility of clinic procedures and prosthetic fabrication methods. The third study area provided for the pre and post treatment evaluation of a portion of the sample selected for clinic treatment. This approach, called "Evaluation Studies," was intended to elicit more detailed information about a smaller number of amputees than was possible in the survey and to provide a basis for evaluation of the methods and materials employed in the treatment procedure.</p> <p>In its final form, the research plan provided for trips by NYU field representatives to attend the monthly meetings of each participating clinic. Consequently, a given member of the staff would be in the field approximately two weeks out of each month, and a routine field trip often took him to five or six cities, where he would visit perhaps six or eight clinics and observe 20 to 30 amputees under treatment. With 75 participating clinics to serve, a field staff of 10 representatives directed by two field supervisors was organized. Since clinic meeting dates and times were quite firmly fixed, and since the time required to be spent with each subject varied from fifteen minutes to four hours, depending upon the stage of treatment, the trips required considerable planning. To minimize loss of time, schedules were arranged by correspondence, and confirmed when possible, before each trip. Despite the difficulty of control, the attrition rate when the studies ended was low. Some what less than 10 percent of those initially selected failed to complete the full treatment course and follow up studies.</p> <p>The NYU representative served two main functions: he established liaison among the treatment centers in the field and between them and New York University, which resulted in interchange of information and coordination of effort, and he was responsible for the collection of the research information. These data were gathered in the field by means of interviews, questionnaires, tests, and measurements.</p> <h4>Survey Studies</h4> <p>Each arm amputee referred to a participating clinic was considered a prospective research subject, and each was given a screening interview, the purpose being to obtain pertinent information concerning the patient, his prosthesis, and his needs and aspirations. Initially, clinics screened only those amputees who were immediately in need of treatment. The information thus gleaned contributed to the survey to be made of the status of upper extremity amputees in the United States and was also useful in the selection of subjects for more detailed study. On the basis of the screening data, two classes of subjects were selected. One group was to be treated only in the clinic by the prescribed procedures. The other, in addition to the clinic treatment, was to undergo a detailed pretreat ment evaluation and a similar post treatment procedure.</p> <p>At the screening interview, the purposes and general procedures of the program were explained to the prospective participant, and information of an administrative and medical nature was collected. The common vital statistics dealing with age, height, weight, and marital and occupational status were recorded. In addition, the date, cause, and site of amputation were obtained, and the length, range of motion, shape, and condition of the stump were described. Detailed descriptions were compiled of prostheses worn by candidates, and their quality and the subjects' ability to use them were evaluated. The data contributed by each amputee were recorded on forms developed for this purpose (Appendices IA and IB).</p> <p>The selection of amputees to be processed at the first and subsequent prescription meetings was made at the Prosthetic Devices Study on the bases of available information and the sampling requirements of the study. Factors taken into account in the selection of the subjects included type of amputation, general health and physical condition of stump, and motivation of patient (his interest and willingness to participate). The entire census included 1630 male upper extremity amputees, of whom 826 were below elbow cases, 668 had amputations above the elbow, 89 had disarticulations at the shoulder, and 47 were bilateral amputees of all types. The findings arising from these survey studies are described in the article by Berger.</p> <h4>Clinical Studies</h4> <p>The idea of the clinic team was the key concept of the newly developed management procedures. The clinic was viewed as a means and a method for focusing the special skills of all the necessary medical and ancillary specialists on the specific problems of providing the amputee with the best possible replacement for the lost member. The primary service group consisted of physicians and surgeons, therapists, and prosthetists. Other specialists, such as administrative personnel, vocational rehabilitation counselors, social service workers, or psychologists, were added according to the special needs of individual cases. The fundamental nature of the clinic was emphasized by the requirement that each of the basic members be present before an "official" meeting of the clinic could be opened. It was at these clinic meetings that the treatment concepts to be evaluated were applied. There were six basic steps in the clinic procedure prescription, preprosthetic treatment, fabrication of the prosthesis, initial checkout, training, and final checkout. Of these, three prescription, initial checkout, and final checkout required meetings of the full clinic team.</p> <h5><i>Prescription</i></h5> <p>Prescription, during these studies, called for the selection of specific components from an armamentarium of tentatively approved devices for assembly into an individual prescribed prosthesis. Most of these components were designed for specific types of cases or uses and were to be prescribed in accordance with their design purposes. The final prescription was to be the concensus of the clinic members as to the most applicable components in each case. In practice, however, the medical, surgical, and physical therapy needs of each patient were considered, as were also personal and vocational indications for specific components and materials. Required was a written prescription specifying every component to be used, and all deviations from standard applications were avoided unless expressly written into the prescription. To standardize the type and quality of the information collected at these meetings, the prescription form in Appendix IIA was developed. This procedure not only was the first treatment step but it also permitted the collection of research data describing the specific devices fitted to the subjects. On the basis of subsequent acceptability and utility to the amputees, inferences could be drawn as to the worth of these components.</p> <h5><i>Preprosthetic Treatment</i></h5> <p>As part of the prescription process, the patient was examined for conditions which might produce difficulty in wearing or using an artificial arm. Particular efforts were made to institute treatment prior to fitting a limb and thereby to avoid the influence of these factors upon the acceptance and use of the prosthesis. Medical and surgical problems involving disease, infection, inflammation, redundancies, bone overgrowth, neuromata, and plastic alterations were referred to the physician for treatment. Muscular weakness and limitations in joint mobility considered amenable to treatment were referred to the therapist.</p> <h5><i>Fabrication of the Prosthesis</i></h5> <p>When the prescription was completed, instructions were given to one of the attending prosthetists to fabricate the arm. With strict adherence to the details of the prescription, the limbmaker produced the arm by use of the techniques of fitting taught by the program. He was encouraged to inspect the completed arm by means of a checklist embodying the structural, functional, and cosmetic standard that his product would have to meet at the next clinic meeting.</p> <h5><i>Initial Checkout</i></h5> <p>When the arm had been fabricated, it was brought to the clinic prior to being worn by the subject. At this clinic meeting, called "initial checkout," the standards developed in the program were applied. The initial checkout included an objective and subjective appraisal to see that the device fulfilled the prescription requirements and that it met established standards of fit, comfort, function, and appearance (<b>Fig. 6</b>). The information thus obtained described the ranges of motion available with the arm, the forces required to operate it, and stability, fit, comfort, and weight. In addition, some 30 items dealing with details of fabrication, appearance, color, specific components, and general quality were checked. These standards were considered to represent minimal levels of prosthetic adequacy. All the appropriate measurements and checks were recorded on a form similar to that shown in Appendix IIB.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. A typical clinic meeting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>These data were used to control the quality of the arms in order to permit valid generalizations about their worth. In addition, when compared with the outcomes of the treatment procedure, these data provided the basis for evaluation of the standards themselves.</p> <p>The checkout was performed at a regular meeting of all members of the clinic. If the arm failed checkout, it was referred to the prosthetist for appropriate revisions (<b>Fig. 7</b>). Consequently, it was sometimes necessary for the subject to appear at the clinic more than the minimum of three times. If the prosthesis met all the requirements, the amputee was permitted to wear the arm regularly and was scheduled for training by the therapist, the next step in the clinic procedure.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Checkout. Final harness adjustments are made on a new arm prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Training</i></h5> <p>The training given to each subject by the therapist was organized in two parts controls training and use training.</p> <p><i>Controls Training.</i> In the preliminary step, the objective was to familiarize the amputee with the mechanics of his appliance and to develop his ability to control its movements.</p> <p>First he was taught to operate the arm freely so as to learn by kinesthetic reaction the motions and forces required to control it. Then various objects with abstract forms and of varying consistencies were introduced t develop prehension skill. When, in the opinion of both therapist and amputee, these control motions were adequately developed, the next training phase began.</p> <p><i>Use Training.</i> Once the basic operating techniques were learned, they were applied to performing the practical activities of daily living, including self help, home tasks, and vocational and social activities (<b>Fig. 8</b>). The training objectives were now to give the amputee confidence in his ability to use the arm by exploring a variety of activities and to achieve proficiency in performing them. In this connection, it was necessary to recognize that the prosthesis cannot replace the lost member and that at best it becomes an auxiliary of the remaining arm.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Use training. The therapist explains how to approach, grasp, and manipulate a variety of common objects. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>By application of this fairly standardized sequence of activities, it was possible to collect research information relating to achievement levels and to the number of hours of training required to achieve satisfactory performance. When the amputee seemed capable of satisfactory performance with his prosthesis, the therapist arranged for him to reappear at the clinic for a final checkout.</p> <h5><i>Final Checkout</i></h5> <p>The final checkout concluded the process of providing the amputee with an arm. In a fashion similar to the pretraining initial checkout, it was conducted at a regular meeting of the clinic, all members present. The purpose at this time was threefold to recheck the mechanical and functional adequacy of the arm after use in training, to assure the clinic that satisfactory proficiency levels had been attained, and to be sure that nothing further in the way of service could be offered the patient if the first two conditions were met.</p> <p>The objective and subjective appraisal was again accomplished by means of the standardized checkout procedure (Appendix IIB). The arm was carefully inspected for signs of wear, and evidence was presented that the amputee was adequately trained. If the condition of the arm and proficiency of the subject in its use were deemed satisfactory, he was discharged with instructions to use the arm in accordance with his daily needs.</p> <h5><i>Recapitulation</i></h5> <p>Altogether, the group treated in the clinics included 378 below elbow, 321 above elbow, 46 shoulder disarticulation, and 24 bilateral amputees. Of the total of 769, 410 received no further treatment, while 359 were extensively studied prior to and after completion of the treatment procedures.</p> <p>The complete procedures employed in these studies are rather too complex for convenient presentation here in more than outline form. The full description and explanation of the most recent modification of these procedures is the subject of short term courses of instruction currently being offered at the University of California at Los Angeles and at New York University. The manuals used in these courses<a></a> contain detailed descriptions of the procedures and may be referred to for further information.</p> <p>The results of these clinic studies are presented in the article by Springer.</p> <h4>Evaluation Studies</h4> <p>The prosthesis for an upper extremity amputee is a necessarily limited means of providing those motions lost through amputation prehension, pronation supination, wrist flexion extension, and, in the case of the above elbow amputee, the additional function of flexion extension of the forearm. The chief goals of the evaluation procedures were to determine the extent to which a prosthesis provided functional as well as cosmetic replacement. A corollary purpose was to discover additional parameters of prosthetic utility and acceptability by increasing our knowledge of why an amputee accepts and uses more readily and efficiently one prosthesis in preference to another.</p> <p>The extent to which prosthetic restoration is successful is dependent upon what each subject brings to the appliance in terms of physical and mental characteristics and on what the appliance brings to him in terms of functional capabilities and qualities of comfort and cos mesis. Evaluation procedures were, therefore, aimed at the analysis and understanding of both the human and the mechanical variables that are involved in the successful use of an arm prosthesis. Although the potential significance of the pre injury personality was recognized, it was not investigated because of the difficulty of obtaining such information in a field study of this nature.</p> <p>Some of the significant evaluation factors lent themselves to objective measurement; others, of a more personal and subjective nature, could be obtained only from the amputee himself. For this reason, the evaluation procedures and instruments were designed to collect both objective measurements and more subjective data dealing with the reactions and responses of the amputee.</p> <p>In this connection, the measurement rationale underlying the collection of data should be understood. Quantitative data are convenient for systematic analysis. But quantification can be meaningful only within well developed and clearly defined evaluation areas. The appraisal, for example, of certain functional characteristics of an arm lends itself readily to objective or quantitative measurement, since the problem area is defined by the extent to which the prosthesis replaces certain lost motions. The problem here is clear; the ranges of motion and the forces applied can actually be measured. In much the same way, an evaluation of performance may be made by scoring such objective aspects as speed, errors, and even some types of quality. On the other hand, in dealing with those effects of treatment procedures relating to feelings, attitudes, emotions, comfort, and fit, the parameters to be measured are not at all clear. For this reason, in such obscurely defined areas qualitative data deriving from interviews and from both structured and unstructured responses of the subject tend to be more valuable in outlining and clarifying the areas of study. Once this is done, the particular factors may become amenable to quantitative measurement.</p> <p>Actually, only three possible sources of data were available objective measurements describing events, the expert opinions and judg ments of qualified observers, and the reactions of the subjects. Each of these sources was exploited. Specific mechanical and biomechani cal factors were measured by objective methods. Prosthetic quality and proficiency in performance with an arm were appraised by trained observers whose reliability was periodically checked and re established. Finally, the amputee himself provided information relating to his reactions to the arm, its quality, and its usefulness to him. Within two broa categories, the human and the mechanical, the following were studied:</p> <h5><i>Biomechanical Data</i></h5> <ol> <li>The strength and ranges of motion of the arm and shoulder girdle and the general physical condition of the amputee.</li><li>The ranges of motion permitted by the prosthesis, its efficiency, and the forces required to operate it.</li></ol> <h5><i>Performance Pattern</i></h5> <ol> <li>Proficiency in accomplishing the basic activities of prehension, transportation, and release in various planes and at different levels.</li><li>Quality of performance of practical daily life activities.</li><li>The range of activities in which prostheses are used and the extent of their importance.</li></ol> <h5><i>Amputee Reactions</i></h5> <ol> <li>Importance and extent of use of prostheses in daily living.</li><li>Reactions to treatment procedures.</li><li>Appraisal of prostheses and components.</li></ol> <h5><i>Psychological Reactions</i></h5> <ol> <li>Personal meanings of amputation and prosthetic restitution.</li><li>Social consequences of loss of limb and of prosthetic replacement.</li></ol> <h5><i>Biomechanical Data</i></h5> <p>It is reasonable to assume that an upper extremity prosthesis which affords the amputee a greater range of motion and which requires a minimal amount of energy or force for operation will be a more desirable appliance. While much more information is necessary before final judgment can be made, comparative data on these factors formed one of the bases for the evaluation of arm prostheses. This kind of data was obtained through direct measurement using such instruments as rulers, spring scales, and goniometers. They were used to measure pinch force between hook or hand fingers; efficiency of force transmission through the cable system; ranges of pronation, supination, and forearm flexion; socket displacement under axial load; and weight of the prosthesis. In the case of the above elbow amputee, additional information was collected on force input required to flex the forearm, angular deflection of the humerus needed to produce given ranges of forearm flexion, and ranges of motion at the shoulder. These measures were recorded on th instrument shown in Appendix IIIA. The outcome of these evaluations will be presented in an article in the next issue of Artificial Limbs (Autumn 1958; Vol. 5, No. 2).</p> <h5><i>Performance Patterns</i></h5> <p>The performance of the subjects in standardized, specially designed activities was observed and analyzed. This procedure was employed to provide information concerning the effectiveness and appearance of the performance patterns. Two approaches to the evaluation of performance were taken. Both abstract and practical function were evaluated. In the former, the ability accurately to grasp, transport, and release objects of varying sizes, shapes, weights, and consistencies was graded (<b>Fig. 9</b>). In the evaluation of practical function, amputees were graded on their performance of meaningful daily life activities (<b>Fig. 10</b>). Proficiency scores and time and motion data were recorded on the forms appearing in Appendix IIIB, while activities were tabulated as shown in Appendix IIIC.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Evaluation of abstract function. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Evaluation of practical function. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Amputee Reactions</i></h5> <p><em>Analysis of Importance and Extent of Use of Prosthesis in Daily Living.</em> In an attempt to appraise the importance of the prosthesis to the amputee, and to determine some of the specific ways in which prostheses were used, the interview technique was utilized. The subjects were asked if they used their prostheses in specific activity areas, including work, home tasks, social life, dressing, and eating. If thei response was positive in any area, they were asked to specify the particular use they made of the arm. They also were asked to rate the importance they placed on their prostheses in each of the activity areas.</p> <p>The extent to which a subject used his prosthesis to accomplish the tasks of daily life seemed to be a significant factor in appraising the degree of functional restoration afforded by the prosthesis. For this reason information was gathered about the frequency with which the prosthesis was used in ordinary two handed activities. In order to make this more meaningful, additional information was collected concerning the frequency with which each activity was encountered in the course of the daily life of the particular amputee. Additional information about common activities which were not done and the reasons therefor also was gathered.</p> <p>The following key questions were used:</p> <ol> <li>How often does the occasion arise for the amputee to perform each of a number of typical two handed activities?</li><li>How often does the amputee use his prosthesis in performing each activity?</li><li>If the need for an activity arises more often than the prosthesis is used in accomplishing the task, why does the amputee not use his prosthesis?</li><li>What is the relative importance of each of a number of activities?</li></ol> <p>These evaluations were made by means of the instrument shown in Appendix IIIC. The results of this study will appear in an article in the next issue of Artificial Limbs (Autumn 1958; Vol. 5, No. 2).</p> <p><em>Reactions to Amputation and Prosthetic Experience.</em> The subjective reaction of an amputee to his prosthesis was deemed an important factor in its evaluation. Apart from his feelings about the characteristics of the prosthesis, his experiences in securing it and wearing it are also contributing factors in his acceptance or rejection of the arm, and information in this regard may be important to an understanding of his status. This type of information was obtained through the use of interviews and questionnaires. By these means, data were gathered relating to:</p> <ol> <li>Time lapse between amputation and first prosthesis.</li><li>Preprosthetic physical therapy.</li><li>Procedures in prosthetic prescription.</li><li>Services of prosthetist.</li><li>Procedures in initial checkout of prosthesis.</li><li>Training in the use of the prosthesis.</li></ol> <p>The article by Springer describes the findings of this study.</p> <p><em>Amputees' Appraisal of Prosthesis and Components.</em> An evaluation of the prescribed components was an essential aspect of the studies. An armamentarium had been developed, and components had been prescribed on the basis of their design features. In order to appraise the relative value of these components, the amputees were asked to comment on specific characteristics of all the components of their prostheses and to describe the suitability or inconvenience of any device with which they were familiar. The following information was elicited:</p> <ol> <li>The extent of his acquaintance with prosthetic components.</li><li>His appraisal of certain specific characteristics of each device with which he was familiar.</li><li>His expression of the suitability of prosthetic components for activities.</li><li>A comparison of currently and previously worn prostheses.</li></ol> <p>These opinions and experiences were recorded as shown in Appendix HID. The results and significance of this study will appear in an article in the next issue of Artificial Limbs (Autumn 1958; Vol. 5, No. 2).</p> <h5><i>Psychological Reactions</i></h5> <p>It is frequently observed that some amputees fail to wear or use a prosthesis which seems to be well fitted and functional. Others, with properly prescribed and well fitted arms, and even those with inadequate prostheses, accept and use them extensively. These reactions were attributed to the varying, highly personal meanings of amputation and prosthetic restoration. For this reason, a psychological analysis by means of interviews and questionnaires was undertaken to explore the significance of these factors.</p> <p>The instruments used included a 57 item multiple choice questionnaire (Appendix HIE) developed by the Prosthetic Devices Study. Completed by the subject in the presence of an NYU representative, it was designed to provide information about the feelings and behavior of amputees relative to amputation and prosthetic restoration. The following reactions were elicited: feelings of functional adequacy, acceptance of loss, sensitivity about disability, ability to cope with social situations, feelings of independence, and attitudes toward prostheses.</p> <p>Another questionnaire (Appendix IIIF) contained nine open end questions. This provided an opportunity for the subject to express his feelings about the effects of his condition and treatment upon his personality and social activities. It supplemented the more highly structured 57 item questionnaire (Appendix IIIE).</p> <p>The third instrument (Appendix IIIG) was a novel (experimental) application of a projective device. It consisted of nine cartoons depicting common social situations in which the fact of amputation might lead to awkwardness or embarrassment. It permitted the amputee to select one of a number of possible responses to each potentially embarrassing situation. By his reaction, the patient was expected to express his feelings of independence, the degree to which he faced reality, hi acceptance of the amputation, and his sense of security. Each response represented a gradation of possible reactions to each situation.</p> <p>A fourth questionnaire (Appendix IIIH) was employed specifically to elicit information from subjects who had never previously worn prostheses. It consisted of 15 multiple choice questions relating to the amputee's knowledge of prosthetic components and his expectations regarding the functional, cosmetic, and comfort qualities of artificial arms. A series of open end questions was included to determine opinions of prosthetic usefulness and difficulties of prosthetic wear.</p> <p>Upon execution of these procedures, the evaluation of an amputee was complete, but the entire process was performed twice. The first appraisal, conducted by the NYU representative prior to the prescription meeting, provided a detailed description of the pre treatment condition of the patient with respect to his physical condition, functional capacity, experience as an amputee, quality and usefulness of his prosthesis, and his emotional reaction to disability. Approximately three months after a satisfactory final checkout, or six to nine months after fitting, the previously evaluated subjects were again processed for a post treatment evaluation, the procedures followed being essentially the same as in the pretreatment evaluation. The instruments used are given in Appendices IIIE, IIIF, IIIG, and IIIH.</p> <p>These data are analyzed and discussed in an article to appear in the next issue of Artificial Limbs (Autumn 1958; Vol. 5, No. 2).</p> <h3>Summary</h3> <p>Some of the problems involved in prosthetic service to amputees just after World War II, and the steps taken by governmental and private organizations toward their solution, have been described in this section. The development of the Artificial Limb Program has been traced briefly from its inception throug the initial studies in which problems were isolated and new methods and materials to solve them were developed. The dissemination of new knowledge through the organization of a prosthetics education program has been discussed, and the design and scope of the studies undertaken to evaluate the new developments have been described. "Survey Studies" were carried out to increase the available knowledge about amputees in this country. "Clinical Studies" were pursued to evaluate the effect of the newly developed treatment methods. And "Evaluation Studies" of the changes in amputees' conditions brought about by these treatments were planned and executed.</p> <p>The evaluation instruments and techniques have been described briefly in this section in the interest of presenting a clear overview of the whole process. A total of 359 amputees were studied by means of these procedures. This group contained 168 below elbow, 158 above elbow, 23 shoulder disarticulation, and 10 bilateral amputees.</p> <p>The upper extremity field studies represented a pioneering effort to apply special skills to special problems in a broad, only partially understood field. A multiplicity of interests, unique requirements, and a paucity of previous research combined to broaden the scope of the studies. The methods and instruments employed are considered a first step toward the establishment of more precise and valid methods for evaluating the condition of those with physical impairment. But despite the broadness of the field and the research requirements, service to the amputee was always a paramount consideration.</p> <p><b>References:</b></p> <ol> <li> Universeity of California (Los Angeles), Department of Engineering, <i>Manual of upper extremity prsthetics</i>, 2nd ed., W. R. Santschi and Marian Winston, eds., in press 1958. A preprint was used. </li> <li>New York University, Prosthetics Education Project, Post-Graduate Medical School, Prosthetic clinic procedures, 1956. Chapter I.</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"> Universeity of California (Los Angeles), Department of Engineering, Manual of upper extremity prsthetics, 2nd ed., W. R. Santschi and Marian Winston, eds., in press 1958. A preprint was used. </td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">New York University, Prosthetics Education Project, Post-Graduate Medical School, Prosthetic clinic procedures, 1956. Chapter I.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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"> Universeity of California (Los Angeles), Department of Engineering, Manual of upper extremity prsthetics, 2nd ed., W. R. Santschi and Marian Winston, eds., in press 1958. A preprint was used. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Edward Peizer, Ph.D. </b></td></tr><tr><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 1958. A preprint was used.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-10.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 Studies of the Upper Extremity Amputee. I. Design and Scope. Creator An entity primarily responsible for making the resource Edward Peizer, Ph.D. * https://staging.drfop.org/files/original/76322a13e4393e786aa6cf728e59d575.pdf 39fce9c7a6f2005a4ab1a72a880e7a96 https://staging.drfop.org/files/original/6e81640a2432fc3ff431c866ed257b5c.jpg 8a184d6c2cd09aa48d4deaf1a96a38e6 https://staging.drfop.org/files/original/228636863105038050c9d1327b56b149.jpg 35aa8e8f4be17cb772ee210e3491fe14 https://staging.drfop.org/files/original/0af8fc502d0a1e956ea8f14b47d06604.jpg b909a129f28f2159f8e8bab0032ca6fb https://staging.drfop.org/files/original/fd19c2ac9eecfb1b3389a8f532f8e987.jpg 0ca302e2ee4871004f9413e5fe7590ca https://staging.drfop.org/files/original/540b3a9d46612360fc39147886c0b410.jpg 12dadbf7283c4ddccd4be09443d58a54 https://staging.drfop.org/files/original/53ce02b8b45bc077a8134a1eef613649.jpg c21f7b4c2c06da48794cd9b0e5701f7a https://staging.drfop.org/files/original/70e664f9f3fea8b660104097849c1575.jpg e7f5d7ce8648e996a99440c72aa5073b https://staging.drfop.org/files/original/10ac518f74cc982aa6c1487671310f26.jpg 43f03940f4c5e6f5d6af345c6f3cf534 https://staging.drfop.org/files/original/83efde55b3303296ae07e3355a5c7f07.jpg 4ecf3ea6aae70e48f884aa146992d924 https://staging.drfop.org/files/original/c81ea73ab2a49c1dd9aa85e2b3707800.jpg 31d0ff6607e8608783a11d5e22f5e813 https://staging.drfop.org/files/original/a7525b0e8bcf6995ccb0702172c1a8d1.jpg 7996d249ebcb7bd84bef604b6341e2fb https://staging.drfop.org/files/original/b479e667bfc97de15ecaee15bf7da57d.jpg c65f98e9c63b8a48493f0ae7bdad8ca3 https://staging.drfop.org/files/original/74d334c8eaea06c0fd36087ec6c15ee3.jpg 9f96c0135add7753cc6cd00eae64cb3b https://staging.drfop.org/files/original/5ad5ea26960beed46a890e753e0587b6.jpg 33b17a56e9879d4754892185ca02332d https://staging.drfop.org/files/original/e1c7350ac7ddb0982d6b99fd1e5e0e6c.jpg e32301edc95c253b8417babecef0e710 https://staging.drfop.org/files/original/29f1c3079e19139973951937d38dbc96.jpg 1b5c5363292cde70bf72f725ca443206 https://staging.drfop.org/files/original/2b643269f7fa8020dd0bb4fd44dfdf3e.jpg 89774b2094aa1a19bdc55dce84a80489 https://staging.drfop.org/files/original/9c808215701b321e9407b27c9bc39d47.jpg fc644c56a0bc85f0c8cbff07ba6870fa https://staging.drfop.org/files/original/5292a74440790c92d38b23c86b501fe7.jpg 2ea50f3af857e6a92f61a0e0e77220c7 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1957_01_076.pdf Year 1957 Volume 4 Issue 1 Page Number(s) 76 - 104 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_076.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1957_01_076.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 Management of the Nonfunctional Hand Reconstruction vs. Prosthesis</h2> <h5>Sterling Bunnell, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>In the course of routine practice, the orthopedic surgeon is frequently confronted with the task of dealing with hands that are damaged by trauma or disease or that are otherwise nonfunctional owing to any of a variety of causes. In all such cases, he is called upon to decide whether or not to undertake amputation of parts of the hand or amputation through the wrist, with the expectation of later applying a suitable prosthesis, or whether, with the prospect of long continued treatment and the possibility of ultimate failure, to attempt surgical construction of a functional hand from such anatomical elements as can be saved. The considerations involved are many and varied, and rarely do two cases resemble each other in more than a remote way. Each individual case must therefore be evaluated on the basis of its own merits.</p> <p>There has been in the past dozen years a great advancement in the development of hand prostheses, so that in the case of major hand problems one might be inclined to choose wrist disarticulation over attempts at surgical reconstruction. But during the same period surgical reconstruction also has advanced remarkably, so that in judging any individual case there should be a careful analysis as to which procedure is the better to follow. Doing so usually results in a sort of compromise—reconstruction, if reasonably possible, being chosen first, a prosthesis being applied when proven necessary, major amputation being considered only as a last resort. It is the purpose here to attempt to extract from many years of clinical experience with hand surgery certain general principles that may offer guidance in making the choice. Generally, the current rule of "save all length possible," now applicable at most other levels of amputation, is applicable in the case of damaged hands also.</p> <p>The fundamental difference between a reconstructed hand and any present day hand prosthesis lies in the absence of direct sensation in the latter. Although the wearer of a modern hook or artificial hand may receive indirect sensory impulses through shoulder harness or cineplastic muscle pin, the conventional arrangement constitutes only a crude and inefficient signal system which must be supplemented and directed by sight. A hand prosthesis is of little use in the dark. In contrast, there is the exquisite appreciation we receive from the normal hand by feeling. By light touch, coarse touch, response to heat or cold, and compass point discrimination, we appreciate texture, and by muscle, joint, and tendon sense we appreciate size and shape. By combining these sense impressions in our cerebral cortex in the opposite parietal lobe, we can identify from memory an object held in the hand. This is stereognosis, a phenomenon replaced by no artificial hand now available. To quote Kirk,<a></a> "No hand is so badly crippled that, if it is painless, has sensation, and strong prehension, it is [not] far better than any prosthesis." This being the case, it is generally desirable to preserve any and all hand structures that can reasonably be counted on to have adequate nerve and blood supply. Eventual application of a prosthesis may or may not be indicated, depending upon individual circumstances and the particular demands of occupation.</p> <p>Before considering any hand amputation, then, one should weigh well the possibility of surgical reconstruction, especially with the idea of restoring natural sensation and strong prehension. Whenever reasonably feasible, surgical reconstruction of a damaged hand or arm should be attempted first. Often the result will be such that a prosthesis will not be necessary. In any case, a reconstructed hand stump is apt to be much better adapted to application of a prosthesis. As a matter of fact, reconstruction and use of a prosthesis are so interrelated that they should be considered together in each individual case. Every useful part of a limb, and every bit of skin that has sensation, should be preserved, thus giving more useful material for reconstruction and, finally, for the fitting, if necessary, of a prosthesis.</p> <p>Reconstruction may often be done in one operation; in other cases multiple operations are required over a period of a month to a year. But considering that the goal is to provide a useful hand for the remainder of an individual's life, it seems worth while. Nevertheless, it should not be undertaken unless there is reasonable assurance that a good practical result can be obtained.</p> <h4>Methods of Surgical Reconstruction</h4> <p>Although the hand does the work, the arm places and innervates the hand. Accordingly, if any particular hand is to be truly useful, it is necessary to have good shoulder, elbow, and wrist function and also good pronation and supination half furnished by the shoulder and half below the elbow. Because they supply the hand, the nerves of the arm are particularly important. In the hand itself there should be a good quality of sensation as well as mobile units that can work against each other with at least a pinch grasp or hook action to simulate normal prehension.</p> <p>Hands coming in for repair usually evidence partial amputations, stiffening in the position of nonfunction, flexion contracture from scar formation, malalignment of bones, loss of motion from injury to tendons and nerves, loss of sensation from injury to nerves, ischemic contracture, or painful states from vasomotor causes or from tender neuromata. Usually the surgeon's problem is composite, dealing with cover, joints, bones, nerves, and tendons.</p> <p>For each of these conditions there is much that can be done surgically.<a></a> For partial amputation, clefts between digits may be deepened, and digits can be built out and made to appose each other. Tender stumps may be corrected. For stiffening in the position of nonfunction, the joints may gradually be drawn around to the position of function by spring or elastic splinting and can be mobilized surgically. Scar tissue of flexion contracture can be replaced by good pliable skin giving good cover and improving nutrition. Malalignment of bones may be corrected so that the mechanics of tendon action are correct. Substitute thumbs may be formed. Tendons and nerves may be repaired or transferred, or new ones may be furnished. Ischemic contracture can be relieved so that a hand thus affected can regain some function. Painful states may be corrected by sympathectomy, and tender neuromata may be removed.</p> <h4>Partial Amputation</h4> <p>Arm stumps resulting from amputation through the wrist or through the carpometacarpal joint, or those without the thumb and with amputation through the metacarpals or proximal phalanges, require a prosthesis (<b>Fig. 1</b>). Hands retaining a good thumb working against one or more fingers (as in <b>Fig. 2</b>), or even against a surgically constructed post (as in <b>Fig. 3</b>), do not. Sometimes the usefulness of a sound thumb may be much enhanced by surgical procedures conducted on other remaining hand parts (as for example in <b>Fig. 4</b>). Other partial hands (like those shown in <b>Fig. 5</b> and <b>Fig. 6</b> for example) when reconstructed usually are more functional than a prosthesis. Some with a partial hand amputation use remnants of the hand for fine work and a prosthesis for heavy work.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Levels of hand amputation requiring prosthesis. A, Wrist disarticulation, including removal of the distal prominences of radius and ulna; B, amputation through the carpometacarpal joint; C, transmetacarpal amputation; D, amputation through all proximal phalanges In B, some useful wrist motion may be retained. In C, hand remnant may be used as a wrist motor to power a prosthesis or simply to point one. In D, hand stump may be made to work against some prosthetic device, residual sensation offering a substantial advantage over A, B, or C. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Examples of partial hands requiring no prosthesis. When the thumb can work against one or more fingers, function usually is better than can be obtained with a hand substitute. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Partial hand (A) and result of reconstruction (B), no prosthesis needed. When, in the absence of all the fingers and much of the palm, a good thumb remains, it is possible, by means of pedicle and bone graft, to build up a post for the thumb to appose. Function thus obtained is likely to be better than that to be had from a hand substitute. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Case M. S. Fingers lost between a sprocket and chain. Excised the tender neuromata of the stumps. Undermined and drew skin down for better coverage. Excised metacarpal of ring finger, covering sides of new digit by plastic maneuvers, in order to give more mobility (2 in.) to the metacarpal of the little finger. Deepened thumb cleft by Z plasty (Fig. 21, page 86). The patient obtained a strong and useful grasp between the thumb, the phalangized index and long "fingers," and the little "finger." From Bunnell, Surgery of the Hand, 3rd ed , Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Case P. L. Hand caught between two rollers. Debrided and skin grafted. Later, pedicle flap applied, then interdigitation. Sensation gradually returned throughout. A useful hand was obtained. From Bunnell, Surgery of the Hand, 3rd ed , lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Case B. P. Partial amputation by power saw. Split grafted next day. Pedicle graft applied and thumb cleft deepened. Index metacarpal removed for wider cleft. Rotary osteotomy done on all metacarpals for better apposition. Pinning with Kirschner wires. A good "hand," with good prehension, was obtained. From Bunnell, Surgery of the Hand, 3rd ed., Lippincott, Philadelphia, 1956. by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In partial amputations it is best, if possible, to retain the metacarpal heads and hence the full width of the palm for firm grasp of tools, but the metacarpal head of an index or of a little finger that has been amputated through the metacarpophalangeal joint is best beveled off so that it will not snag on entering a pocket. The metacarpal of an index or little finger off through the shaft is best removed obliquely at its base (<b>Fig. 7</b>). The interosseous muscle is then transferred to the adjoining digit to give abduction.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Typical example of loss of fourth and fifth rays through the shafts of the metacarpals. In such a case, it is best to delete the stub of the fifth metacarpal and round the stub of the fourth. A corresponding procedure is advisable in the event of loss of the second digit, or of the second and third digits, by transmetacarpal amputation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A hand amputated through all metacarpophalangeal joints or proximal phalanges may be improved by mobilizing the fifth metacarpal, cutting the transverse metacarpal ligament, and perhaps removing the metacarpal of the ring finger and covering the cleft by a plastic maneuver (<b>Fig. 4</b>). The ulnar side of the hand thus becomes a movable part. Motion may be increased as much as 2 in. If the second and fourth metacarpals are deleted, there will remain three digits, consisting of the metacarpals of the thumb and of the long and little fingers, and the thumb cleft will be wide and deep. Phalangizing the metacarpals gives considerable useful mobility so that one can dress oneself, use knife and fork, and so forth. The metacarpals of the thumb and little finger are cut across at the base and bent toward each other for better grasp (<b>Fig. 8</b>). A similar osteotomy may be performed on a hand having only two remaining digits, as for example thumb and little finger (<b>Fig. 9</b>), or even when only one complete digit remains, as in (<b>Fig. 10</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Reconstruction procedure for loss of all digits through the metacarpophalangeal joints. A, Second and fourth metacarpals are deleted, clefts are covered by plastic maneuver, first and fifth metacarpals are osteot omized. B, Functional three finger "hand" results </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Angulatory osteotomy of first and fifth metacarpals to aid apposition of thumb and little finger. Sometimes it is necessary to effect a tendon T transfer also. See Figure 31, page 91. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Angulatory osteotomy of first and fifth metacarpals to bring thumb and ulnar side of palm into easy apposition. Tendon T transfer may be needed here also (Fig. 31, page 91). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Frequently a finger or hand stump is so hypersensitive from poor terminal padding and sensitive neuromata that it prevents all of the remaining parts of the hand from functioning. Crushing injuries to fingers present the most difficulty because, in such cases, the fingers usually have been damaged well proximal to the site of amputation. In revising such stumps, the digits must often be shortened enough to give good, well padded cover, but it is possible to swing a visor flap from the dorsum over the end of the stump and then to skin graft the dorsum. Still another possibility of furnishing good tactile cover over the end involves use of a cross finger flap and then skin grafting the back of the donor finger. Nerves in hands and fingers have a special tendency to proliferate. If they terminate in scar tissue or close under the skin, the neuromata formed may be extremely sensitive and give, on slight tapping, the sensation of an electric shock. These are corrected by uncovering the nerve, dissecting it well back, and cutting it off in good tissue free from scar. Neither alcohol injection nor ligation is used.</p> <h4>Stiffening in The Position of Nonfunction</h4> <p>Following injury, infection, or paralysis, a hand frequently stiffens in the position of non function so that the digits can no longer touch each other and the hand is therefore useless. In the position of function (<b>Fig. 11</b>), the wrist is extended<i>35 </i> deg., the joints of the fingers are moderately flexed, and the thumb is in moderate apposition, as in holding a baseball. In the position of nonfunction (<b>Fig. 12</b>), the wrist is flexed, the metacarpophalangeal joints are hyperextended, the remaining finger joints are flexed, and the thumb is at the side of the hand or even back of it. Although such a hand is totally useless, in general it should not be amputated. For if the joints can be pushed around into the position of function, the available motion will be useful for picking up and holding objects, and the hand will be used more and more from then on.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. The position of function. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. The position of nonfunction. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The first approach to hands stiffened in the position of nonfunction involves use of a system of elastic or spring splinting by which joints can gradually be drawn around into positions of function. Usually the joints are kept active and are not damaged, and the muscles and all tissues are activated, a matter which greatly improves their condition. If, however, the response to such treatment is unsatisfactory, surgical means are resorted to, starting with capsulectomies (<b>Fig. 13</b>) and, where there is damage to bone structure, resorting to arthroplasties.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Case E. T. Top, preoperative position of nonfunction from shark bite on upper arm, severing nerves and vessels. Bottom, correction to a position of function by fusion of the wrist, capsulectomies and opening of the cleft of the thumb, and transfer of the extensors of the wrist to the flexors of the fingers. A tendon transfer through a pulley constructed at the pisiform was used to give apposition to the thumb. No prosthesis needed. From Bunnell, Surgery of the Hand, 3rd ed , Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Capsulectomies are usually performed on the meta carpophalangeal joints but sometimes also on the proximal interphalangeal joints. Usually the trouble is found to lie in the fact that the two collateral ligaments are too short and thick to permit the joint to flex. Excision of these structures makes flexion possible. Often it is necessary also to free the long extensor tendons (<b>Fig. 14</b>) and to clean out the volar pouch of the joint. In performing an arthroplasty, the metacarpal head is shortened and reshaped, and a hood of fascia is fastened over it.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Case J. D. Left, old dislocation of metacarpals on carpus, upsetting muscle balance, thus resulting in the useless position of nonfunction. Right, dislocation reduced, restoring muscle balance in the position of function. A pedicle graft was applied to the dorsum of the hand and to the open thumb cleft. Freeing of the extensor tendons, together with capsulectomies, allowed the proximal finger joints to flex. No prosthesis needed. From Bunnell, Surgery of the Hand, 3rd ed., Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Arthroplasty is not often done on the wrist joint; arthrodesis is used instead. In many cases, however, removal of a mass of scar tissue from the volar aspect of the wrist allows the wrist to extend. When pronation and supination are retained, arthrodesis of the wrist or of the proximal finger joints into the position of function gives very little disability (<b>Fig. 15</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 15 Case A B Hand useless from birth pals)". Several operations had been performed, including fusion of the wrist. The proximal finger joints were lax and bent backward out of use Patient could not abduct at the shoulder, and the forearm was in supination. The shoulder was arthrodesed lo enable placement of the hand, and by osteotomy the ulna was rotated into pronation. The proximal finger joints were arthrodesed into the position of function. Patient gained much use of the hand and became self supporting. From Bunnell, Surgery of the Hand, 3rd ed , Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Flexion Contractures and Furnishing New Cover</h4> <p>Most reconstruction commences with excision of a big plaque of scar tissue that is drawing the hand into flexion contracture and strangling the rest of the tissue (<b>Fig. 16</b> and <b>Fig. 17</b>). The skin is then undermined and allowed to retract, thus freeing the hand for better nutrition. New cover is then provided, sometimes by a free graft but usually by a pedicle graft from the abdomen (<b>Fig. 18</b>), thus giving good, pliable skin with a layer of soft fat beneath. Doing so releases the whole hand and makes it possible to reconstruct the deeper parts joints, bones, tendons, and nerves. Although the refinements of stereognosis never return to such skin, eventually sensation to light touch and pin prick develops.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Case J. M. From birth the cicatrix from a tear at the ulnar side of the wrist so distorted the growth of the hand that there was no function. The scar was excised, the ulna elongated, and a pedicle applied. Two years later osteotomies were done on all metacarpals, the thumb cleft was deepened, and a pulley operation was performed to improve apposition. Three years later the hand was reported to be quite useful. From Bunnell, Surgery of the Hand, 3rd ed Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Case D C. M. Hand severely burned in oil fire so that all digits pointed backward out of use. Fingers were webbed, and middle joints were exposed. There was no thumb cleft, the thumb being at the rear of the hand with the metacarpal arch reversed. In this position of nonfunction, the hand was entirely useless Excised all dorsal skin, including nails Sawed away exposed bone. Corrected webs. Established thumb cleft and positioned thumb. Positioned fingers by capsulectomies. Covered all with free skin graft. Patient returned to his job as locomotive engineer No prosthesis needed. From Bunnell, Surgery of the Hand, 3rd ed., Lippincott, Philadelphia. 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Case A. C. Hand badly crushed between rollers. Poor skin surface, position of nonfunction, entire hand and joints stiff, extensor tendons adherent, thumb at side, amputation contemplated. First operation: excised all skin from both dorsal and volar surfaces, covered with one large pedicle graft, and spread thumb from hand; brought joints around by elastic splints. Second operation: freed extensor tendons and placed fat beneath; did capsulectomies on proximal joints; used sublimis of long finger for apposition; freed flexor tendons, placing fat beneath; defatted pedicle. The hand made remarkable recovery in nourishment, function, and position. There was good grasping power and a complete change in the morale of the patient. No prosthesis needed. From Bunnell, Surgery of the Hand, 3rd ed , Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Skeletal Malalignment</h4> <p>The bones of the hand constitute the framework along which the muscles and tendons function in their proper planes. The joints allow the digits to flex and extend in their proper positions for adequate grasp. After fracture, bones often unite at such odd angles that the whole mechanics are thrown out of true. If, after healing, there is an angle of the bones along the length of the limb, the tendons over the convexity will be tight, over the concavity loose. Such a circumstance upsets the whole nicely adjusted muscle balance so that the joints are pulled into deformity all the way from the site of angulation to the end of the limb. To make the hand function properly again, realignment is necessary. The bones are chiseled or sawed across, a wedge being removed when necessary to place them in proper contact and alignment. They are then pinned so by Kirschner wires, the latter being withdrawn in two months when union is solid and the framework of the hand is restored.</p> <p>When the thumb does not entirely contact the ring finger or the little finger, the metacarpal of either or both may be severed at the base and the digits angulated toward each other in such a way as to provide for easy contact. Similarly, in the absence of a thumb, two or more fingers may be angulated and rotated to give them the ability to work against each other.</p> <p>When a metacarpal, including the soft tissues about it (tendons, nerves, interosseous muscles, and skin), is badly damaged, it may be excised. If it is one of the central rays, the metacarpal of the adjoining ray, either index or little, as the case may be, is cut across at its base, jogged over to the base of the excised metacarpal, and pinned near and parallel to the next ray (<b>Fig. 19</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Reconstruction procedure recommended in event of serious damage to (A) the fourth digit or to (B) the third digit. In A, delete the much injured fourth ray and jog fifth ray over to its place. In B, delete the much injured third ray and jog second ray over to its place. The result in either case is a functional four digit hand. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When a metacarpal head is missing, the lack of support causes the adjoining metacarpals to rotate so that the fingers cross on flexion. In such a case, the metacarpal can be excised and one of the adjacent ones jogged over. Or the proximal phalanx of the ray in question can be recessed, or set back, so that its head will take the place of the missing metacarpal head.</p> <p>Often it is advisable to arthrodese a joint to place it rigidly in the position of function. This procedure can be carried out on either of the two distal joints of the fingers but rarely on the proximal joints. It is done on the wrist and can be done on the elbow. In the latter case, the choice must be made between arthrodesis, a block operation, muscle transfers, or the wearing of a prosthesis to activate a flail elbow. When the arm cannot be abducted at the shoulder but when muscles around the scapula are good, arthrodesis of the shoulder will allow the arm to position the hand for useful function (<b>Fig. 20</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 20. Case L. M. W. As a result of polio, arm was flail at shoulder, and there were no flexors in the hand Arthrodesed shoulder and wrist simultaneously so that the patient could place the hand. Transferred extensor carpi radialis to flex fingers, palmaris longus to abduct thumb, the long extensor of the ring finger for apposition. Slit the proximal pulleys so that long flexors could flex the proximal joints. Patient gained much use of hand, was able to grasp a piece of paper or a tumbler, could place the hand well, and occupied a position in a bank. No prosthesis needed. From Bunnell, Surgery of the Hand, 3rd ed., Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Thumb Problems</h4> <p>So essential to prehension is the thumb that every possible bit of an injured one should be saved. Amputation of the thumb through the metacarpophalangeal joint results in a partial digit almost loo short to be useful, but a new thumb cleft can easily be made by a Z plasty operation (<b>Fig. 21</b>), meanwhile scraping the adductor origin down from the third metacarpal. The thumb is thus made relatively longer. If the shaft of the index metacarpal projects into the web so as to interfere with grasping, it should be excised at its base to widen and deepen the cleft (<b>Fig. 22</b> and <b>Fig. 23</b>). Whenever possible, the tip of the third metacarpal should be preserved to provide a concave palm for the remnant of the thumb to work against (<b>Fig. 22</b>). Preservation of the broad tip of the third metacarpal is particularly desirable when a complete thumb remains (<b>Fig. 24</b>). The range of motion of a normal thumb extends from a position at the side and slightly back of the hand, with the nail at right angles to the palm, through a wide ellipse toward the volar aspect until it is opposite the fingers, the nail being then parallel to the palm. In the latter position, the thumb is available to participate with the fingers in grasping large objects. The motion is effected by the ten muscles long and short that control the thumb. In paralysis of the median nerve, in injury to the thenar muscles, in stiffness of the carpometacarpal joint of the thumb, or in flexion contracture on the dorsum of the web, normal range of motion of the thumb is lost. If the other parts of the hand are mobile, the ability to appose the thumb can readily be provided by a simple tendon transfer that draws the thumb toward the pisiform bone and pronates it. When this is not possible, the thumb may be held permanently in a useful position by a bone graft at the base of the first metacarpal.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Phalangization of thumb cleft by Z plasty. Left, hand with short and more or less useless thumb stump. Middle, location of Z shaped incision; flap A is carried to fixed point X, flap B to fixed point Y, so that dorsal flap just covers defect on volar side while volar flap just covers defect on dorsal side; resulting suture line is as shown in insert. Right, end result, showing deepened thumb cleft. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Case C, H. Amputation by meat grinder. Thumb cleft deepened by Z plasty. Index metacarpal removed to give good grasp. From Bunnell, Surgery of the Hand, 3rd ed.. Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Case H. G. Amputation, by power saw, of all digits through proximal phalanges, leaving a mitten hand but no thumb cleft By a plastic maneuver and removal of the index metacarpal, a thumb cleft 3/4 in. deep was constructed. It opened 3/4 in and closed against the hand. Patient could write and hold objects Limited facility can be combined with the use of a prosthesis. From Bunnell, Surgery of the Hand, 3rd ed., Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Operative procedure for loss of the second and third digits. Excision of the second metacarpal, but with retention of the third, furnishes easy apposition for the sound thumb. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When a thumb is closely bound to the rest of the hand by scar, it can be spread away by excising the scar tissue and cutting across the cleft from a point opposite the hinge of the first two metacarpals on the dorsal side to the corresponding point on the volar side. The thumb is spread to the side and front of the hand, and the large denudation of skin is covered either by a large diamond shaped free skin graft or, better, by a pedicle graft from the abdomen. In three weeks, pedicle grafts are detached from the abdomen and laid smoothly on the hand.</p> <p>Although the thumb stump remaining after amputation through the metacarpophalangeal joint usually is not very serviceable, it may be built out by pedicle and bone graft. If a thumb is amputated proximal to the metacarpophalangeal joint, it should in any case be built out longer. If the thenar muscles and the stub of the metacarpal remain intact, the thumb will be quite movable. A short thumb is a good thumb. Various motions, such as apposition, extension, and flexion, may be furnished it by tendon grafts.</p> <p>In the case of total loss of the thumb, a new one can be supplied in various ways. The simplest approach is to raise a tube pedicle from the abdomen, attach the pedicle to the hand, and place in it a bone graft from the iliac crest (<b>Fig. 25</b> and <b>Fig. 26</b>). Although this expedient gives sensation, it does not provide much stereognosis. Nevertheless, a reconstructed thumb is apt to be very serviceable and considerably better than a prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Surgical construction of a new "thumb." A, Poorly functioning partial hand retaining digits four and five only. B, Serviceable partial hand made by constructing new "thumb" with pedicle and bone graft. Function is apt to be better than if a prosthesis were applied. </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 C. B. Injury from hand grenade. Pedicle graft covered the thumb, and arthrodesis was done on the trapezium by a graft from the ilium Abduction was furnished index finger by a proprius tendon graft A very useful hand resulted. No prosthesis needed. From Bunnell, Surgery of the Hand, 3rd ed., Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The graft should be grounded on some other bone rather than connected by a joint. It may be placed on the carpus to make a pad in the base of the palm, or it may be placed on the trapezium or on the stub of the metacarpal.</p> <p>The requirements of a new thumb are three in number—motion, sensation, and proper placement. The best new thumbs are made by pollicization of a finger, preferably the index linger but sometimes the long finger. Often, as part of the injury, the index finger is already somewhat shortened. In such a case, the finger, or a portion of suitable length, is transferred together with a bridge of skin and with its nerves, blood vessels, and tendons intact (<b>Fig. 27</b> and <b>Fig. 28</b>). It may even be transferred on a neurovascular pedicle circumscribing the skin all around (<b>Fig. 29</b>). When this procedure is possible, it makes for easy and exact placement. The tendons are brought over with the new "thumb" and joined up so as to give motion. The fingers should work directly against the new "thumb" and also, by their side motion, should pass to the side of it and close against the palm. Stereognosis and vascularization are provided by the neurovascular pedicle.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 27. Pollicization of index finger. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Case H. W. W. First (1929) physiological reconstruction of thumb by pollicizing remains of the index finger. Metacarpal lashed to trapezium, nerves and vessels carried over, and all tendons and muscles connected up. "Thumb" had strong motion and normal sensation and was well positioned. Patient worked well as a carpenter for 20 years. Superior to prosthesis From Surgery, Gynecology, and Obstetrics, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Pollicization of index finger by neurovascular pedicle. Skin is circumscribed, and the index finger is pinned on to the stub of the metacarpal of the thumb in proper position. Tendons furnish motion, vessels nutrition, and nerves sensation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Should a newly constructed thumb not have sensation in its tactile area, a flap of skin may be exchanged for the nontactile skin by a Z plasty. Or tactile skin can be furnished by using a neurovascular pedicle passed beneath the skin at the base of the thumb. A living thumb, with motion, sensation, and proper positioning, is, of course, far superior to any prosthetic thumb.</p> <h4>Tendon Repair</h4> <p>Tendons are frequently lacerated, thus losing their function of transmitting muscle power to provide motion in joints. They can, however, readily be repaired (<b>Fig. 30</b>), the most difficult cases being the flexor tendons in the digits and in the distal part of the palm, where the resulting juncture tends to adhere to the surrounding parts. Frequently a tendon graft must be used to bridge the tendon over areas where adhesions are likely to form. Adherent tendons may be freed, and slippery material, such as paratenon and fascia, may be grafted between them and the bones so as to allow the tendons to glide again. Defects in tendons are readily bridged by free tendon grafts from spare tendons in other parts.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Case F. E. Charge from a shotgun entered palm and emerged dorsally, shattering the carpus and the lower radius and severing many tendons, extensors of the wrist, thumb, and fingers, and the median nerve. Debrided, filetted the index finger, and skin grafted. Considerable infection followed. First operation: excised scar and placed a pedicle. Second operation: furnished tendon grafts plus paratenon to extend thumb and fingers; freed the flexor tendon of the thumb; did a pulley operation for apposition; sutured median nerve to its four branches. The wrist became fused. But sensation, motion, and apposition returned, so that there resulted a very useful hand requiring no prosthesis. From Bunnell, Surgery of the Hand, 3rd ed. Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The upper limb interdigitates at the ends of the metacarpals, and the tendons normally have individual motion. If either an extensor or a flexor tendon is sutured over a finger stump, it will hold back all of the tendons pulled from the same muscle. But when all of the tendons are cut at the end of carpal or metacarpal stump, they should all be sutured together over the end to provide for movement of the stump.</p> <p>Isolated digits may be made to provide prehension if they are furnished with new flexor and extensor tendons. To make the fingers appose each other, the tendons can be placed diagonally across the hand, or a tendon T transfer, which consists of one cross bar tendon from digit to digit and a longitudinal one looped about the first, can be made (<b>Fig. 31</b>). When the muscle concerned is contracted, the "T" assumes the shape of a "Y," and the two digits are drawn toward each other. This procedure is particularly useful in median and ulnar paralysis, where it will provide adduction of the thumb and little finger while curving the metacarpal arch of the palm. When some digits have been amputated, great strength can be given to the remaining fingers by transferring in the forearm the tendons of the amputated ones to those of the remaining ones.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Lobster hand formed by tendon T transfer. A, Arrangement of tendons to form the "T." B, Contraction of the longitudinal tendon converts the "T" to a "Y" and thus effects apposition of thumb and little finger. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Especially in paralysis are tendon transfers useful. Good, strong muscle and tendon are transferred to the tendons of the paralyzed muscles. This operation may be performed, without fusing the wrist, to give very good return of function so that splints are discarded. In the case of any two nerves paralyzed high in the arm, the wrist can first be arthrodesed in the position of function, an expedient which results in very little disability. Thereupon the five tendons previously wrist movers become available as digit movers, and the resulting motion is more natural than that obtained using a prosthesis. The patient soon learns to adapt so that the motion becomes natural. A rule is to decide what movements are needed and then to consider the number of muscles available for transfer. For paralysis within the hand—that is, from the median and ulnar nerves—many transfers are available to restore muscle balance, thus correcting the position of the claw hand by substituting for the paralyzed intrinsic muscles.</p> <p>Another principle is tenodesis, a procedure in which the tendons that move the digits are fastened to the forearm bones. Then, when the wrist is flexed, the extensor tendons tighten and extend the digits; when it is extended, the flexor tendons tighten and cause the digits to flex so that thumb and fingers appose each other. These automatic movements are useful when only one or two strong muscles are available. When no muscles are available, the hand can be converted to a useful hook by tenodesis of the flexor tendons to the forearm bones.</p> <h4>Nerves</h4> <p>Movement and sensation in the hand, which are its two most important functions and which are of equal value, depend entirely upon the nerves. The three large nerves that course down the arm (the ulnar nerve, the median nerve, and the radial nerve) control the hand, and any injury to them is as damaging to the hand as is an injury to the hand itself. When a nerve is severed, it should be rejoined at once. Otherwise fibrous degeneration in both the lower portion of the nerve and in the muscles supplied by it will be so progressive that, after two years, muscle action will not return and, after five years, neither will sensation. A gap of several inches can be overcome and the nerve sutured directly. Even the little nerves in the hand itself can be repaired.</p> <p>After nerve suture, there is about 80 percent of functional recovery. Nerves can be sutured directly, transferred, or even free grafted. All of these procedures are successful, but nerve grafts must be used from the same person; if grafted from another person, they will melt away. From loss of nerve supply, the hand if neglected goes into the position of nonfunction, stiffens, and atrophies. Splinting should be by spring or elastic splints sufficient just to substitute for the paralyzed muscles and to hold the hand in the position of function so it can work. When the nerves are irreparable, as for example when too great an interval has elapsed since the time of injury, muscle function in the hand can be provided by tendon transfers. Paralysis in the hand and forearm from ischemic contracture can be overcome to a considerable degree, although never completely cured. In vasomotor disorders, surgery seldom need be weighed against prostheses.</p> <h4>Prostheses for Partial Hands</h4> <p>The literature on prostheses for the partial hand is meager, and therefore when a hand is damaged there is a distinct preference on the part of prosthetists to have a wrist disarticulation or a long below elbow amputation. In the event they are confronted with a partial hand amputation, many limbfitters prefer to enclose the wrist immobile (as in <b>Fig. 32</b>) rather than to construct a partial hand prosthesis. Even those who furnish cosmetic glove prostheses (as in <b>Fig. 33</b>) prefer to enclose the whole hand in the glove and to substitute, for the missing parts, foam filler reinforced with pliable wire. Although a long below elbow amputation offers the advantage that many more or less standard terminal devices may be applied (a split hook, a mechanical hand, perhaps some special tools), a partial hand, whatever can be saved, can often be fitted with considerably more success. If the thumb alone is spared, a casing over the palm and wrist can support a pad or other suitable device against which the remaining digit can work (<b>Fig. 34</b>). If only the palm, perhaps with a few remnants of phalanges, remains, a casing over the forearm can support a similar pad against which the palm can be pressed by wrist flexion (<b>Fig. 35</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. One form of prosthesis for partial hand amputation thumb free, wrist encased, split hook activated by shoulder harness as in the case of the wrist disarticulation. The disadvantages are numerous. The long cuff virtually eliminates any possibility of wrist motion. Except in the thumb remnant, residual tactile sense is obviated, and the device as a whole is much too long </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. Cosmetic hand for partial amputation glovelike and zippered at the wrist. Fingers are filled out by foam filler and stiffened by armature flexible enough to hold any shape. Courtesy Prosthetic Services of San Francisco. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. Simple prosthesis for loss of all digits except the thumb. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. Simple prosthesis for major losses of most of the digits. Wrist serves as motor, hand working against prosthesis. Residual tactile sensation is utilized. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>By the combined talents of engineers, physicists, prosthetists, orthopedists, and others, there have been in the last ten years many advances in hand and arm prostheses. Accordingly, there has been developed the policy of saving as much of any limb as is likely to be functional and, particularly, as much of the hand as possible. Any portion of skin with sensation should be preserved because of the possibility of placing it in a functional part. Digits with sensation can do light work and, if necessary, a prosthesis can be applied to do heavy work (as in <b>Fig. 36</b>, <b>Fig. 37A</b>, and <b>Fig. 37B</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. Partial hand capable of prehension. Top and middle, digital motion for light work. Bottom, wrist motor for heavy work. From Bunnell, Surgery of the Hand, 3rd ed,, Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 37A. Case E. E. Top to bottom: Right hand pulled into hay chopper. Debridement and abdominal pedicle. Later a two digit hand was made with a tendon T operation for prehension and a spread of 1 1/2 in. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 37B. Case E. E. Top and middle: A prosthesis which enabled the hand to work against a hook. This was discarded because it was too unstable. Right, bottom: A prosthesis made by Robin Aids Manufacturing Company, Vallejo, Calif., that was very satisfactory. It preserved residual wrist motion and could be removed when fine digital motions were required. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For the wrist disarticulation, below elbow, above elbow, and shoulder disarticulation prostheses, many new devices have been developed. They include the alternator elbow lock for the above elbow case,<a></a> the outside locking elbow hinge for elbow disarticulation,<a></a> the polycentric elbow joint for below elbow cases,<a></a> the variable ratio step up hinge for the very short below elbow case,<a></a> the flexible cable units to allow pronation and supination for the very long below elbow and wrist disarticulation cases,<a></a> and the elbow coupled shoulder joint for shoulder disarticulation amputees.<a></a> For the arm amputee, these devices help to carry the terminal device (hook or artificial hand) to a place of usefulness. The <i>Manual of Upper</i> <i>Extremity Prosthetics </i><a></a> gives a full account of these and other devices that comprise a full armamentarium for upper extremity amputees. But the case of the partial hand amputation is not included.</p> <h4>Prostheses For One Digit Hands</h4> <p>For most practical purposes, loss of one or more distal phalanges does not require application of a prosthesis. Nevertheless, there are exceptions. An accomplished violinist, losing the distal phalanx of even one string finger, for example, is incapable of managing the strings properly. This could mean an occupational change for such a person. A good prosthetic replacement may enable him to continue his occupation. The same occasionally occurs with an organist, a pianist, a typist, or other person in any occupation where finger dexterity means the difference between success and failure. A suitable prosthesis for such a case can be made using thin stainless steel for the socket and extension framework and then dipping the device in flexible vinyl plastic to form the tip cushion and finger build up. The socket portion may be split along one side to allow it to expand and contract, thus ensuring snugness of fit.</p> <p>For amputation of all of the fingers at the metacarpophalangeal joint, or approximately half an inch distal thereto such that the volar crease of the metacarpophalangeal joint remains, a 1/8 in. rod framework of stainless steel can simulate the socket while leaving a maximum amount of exposed palm for traction and sensation (<b>Fig. 38</b>). The distal portion of the framework is bent to simulate the finger tips, the little finger side being curved to form a hook for pulling or lifting and the index side shaped to appose the thumb as would the first two fingers in three jaw chuck prehension.<a></a> This arrangement provides for prehension between the simulated index finger and the remaining thumb. A similar appliance can be made for an amputation proximal to the metacarpophalangeal joint, but in such a case the remainder of the hand must be fitted with a plastic, metal, or leather socket for attachment to the formed rod (<b>Fig. 39</b>). The notable disadvantage is the coverage of surfaces otherwise capable of sensation. In both instances, the rod framework is dipped in flexible vinyl plastic to provide a surface with adequate traction.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. Prosthesis for loss of all the fingers at, or slightly distal to, the metacarpophalangeal joint line. Metal ring, covered with vinyl plastic, is so shaped as to furnish one large hook, representing the index finger, and one small one, representing the little finger. Thumb works against ring throughout the range of the carpometacarpal articulation. Courtesy Robin Aids Manufacturing Company, Vallejo, Calif. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. Prosthesis for transmetacarpal amputation. Socket may be of leather, molded plastic, or hammered stainless steel. Metal ring, covered with vinyl plastic, is shaped to simulate fingers, as in Figure 38. Courtesy Robin Aids Manufacturing Company, Vallejo, Calif. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Fig. 40</b> shows a single stainless rod curved in hook fashion and mounted to a stainless steel plate, which in turn is attached to a molded hand and wrist socket. The hook is so positioned as to give apposition to the thumb, and the thumb is exposed to utilize its capability for sensation. This single hook, being small and smooth, allows easy entry into pockets and other tight places.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 40. Simple prosthesis for loss of most of the palm but with retention of the thumb. Wrist and hand stump are encased in a socket to which is attached a single stainless steel hook. The hook may be used by itself or as a member for apposing the thumb. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since the thumb is the most important single digit of the hand, it would seem a sound principle not to involve it as a motor for powering other mechanisms. A collar around the thumb would appear to diminish tactile surface, and any mechanical linkage would seem to lessen mobility and dexterity. In general, wrist flexion extension provides a far more desirable motor with less hindrance to function. But these principles have only general applicability and are not specific. For certain special needs, a thumb powered mechanism may be desirable. In any individual case, the selection of equipment must be left to the mutual judgment of the patient, the doctor, and the prosthetist. (<b>Fig. 41</b> and <b>Fig. 42</b>) illustrate the principles involved but show the distinct differences to be found in individual cases.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 41. Prosthesis for amputation of all fingers at the metacarpophalangeal joint line with retention of the thumb. Socket about wrist and hand stump supports split hook, which is powered by the thumb. Courtesy Navy Piosthelics Research Laboratory, U.S. Naval Hospital, Oakland, Calif. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 42. Prosthesis for loss of all digits but the thumb. Hinged at and powered by the wrist, this device provides for prehension by virtue of a thrust rod. Courtesy Robin Aids Manufacturing Company, Vallejo, Calif, </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the arrangement shown in (<b>Fig. 43</b>), the hand, wrist, and forearm socket give versatility for the accomplishment of either light tasks or heavy duty work. For light tasks, the thumb stump is free to appose the remainder of the hand or to contact a small metal post or spoon attached to the hook. The forearm socket allows freedom of wrist motion but provides hook stability for heavy duty work. Since the thumb stump is also free to appose the hook activating lever, no shoulder harness is required.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 43. Amputation of the fingers at the metacarpophalangeal joint line and of the thumb at the inter phalangeal joint; thumb phalangized for deeper cleft. Top to bottom: holding with thumb unassisted; use of hook (powered in this case by shoulder harness) as device to appose palm; holding with thumb, hook available for auxiliary function if needed; holding with hook, thumb as stabilizer. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For a hand retaining only the thumb, without fingers or even without their metacarpals, a special prosthesis designed by the United States Navy gives reciprocal motion and active prehension powered by the thumb (<b>Fig. 44</b>). To a simple hand cuff and wrist strap is attached a metal plate, which, on the radial side, supports a lever for the thumb to appose and, on the ulnar side, bears a metal finger pivoted on an axis near the base. Apposition of thumb and metal finger is effected by a linkage between the two lever systems.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. Prosthesis for transmetacarpal amputation with retention of the thumb. Power supplied by the thumb activates metal finger, which is otherwise held in extension by a spring at its base. Courtesy Navy Prosthetics Research Laboratory, U.S. Naval Hospital, Oakland, Calif. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Prosthetic Thumbs</h4> <p><b>Fig. 45</b> and <b>Fig. 46</b> illustrate fixed prostheses for partial or complete loss of the thumb. Two features are essential. First, the prosthetic thumb must furnish proper apposition to the fingers, and its lip should be of such material as to provide adequate traction. Second, the thumb must provide a shaft and a crotch so as to make it possible to hold objects too large for the fingers themselves to encircle. A two position thumb, such as the thumb from an APRL hand,<a></a> can be used on a prosthesis for disarticulation of the thumb at the carpometacarpal joint. The result is that a larger selection of objects can be held in the hand.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45. Prostheses for partial or complete loss of the thumb. Fingers work in apposition to fixed member. Above, prosthesis for amputation of thumb at metacarpophalangeal joint, thumb web deepened surgically to provide cylindrical stump proximal to site of amputation. Below, variation suitable for amputation of thumb at carpometacarpal joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 46. One form of fixed prosthesis for total loss of the thumb. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Fig. 47</b> depicts the application of a mobile artificial thumb, powered by the wrist, to a partial hand possessing only the little finger. Attached to a hand cuff, which in turn is hinged to a forearm cuff, the thumb pivots about an axis near its base. Linkage between thumb and wrist hinge is such that wrist flexion causes the thumb to approach the little finger. In the example shown, the small finger has been rotated surgically toward the radial side of the arm to give better placement for apposition.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 47. Prosthesis for loss of all digits except the little finger. Laminated plastic socket, hinged to leather or plastic forearm cuff, supports plastic covered metal thumb, which is so linked to forearm piece as to be driven by wrist motion. Little finger has been rotated surgically to provide better apposition with respect to prosthetic thumb. Courtesy Robin Aids Manufacturing Company, Vallejo, Calif. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Prostheses For Loss of All Digits</h4> <p>In the case of a hand too crippled or too paralyzed to be of much use in the direct operation of a prosthesis, a split hook may be attached to a forearm cuff and positioned in the palm. This arrangement (<b>Fig. 48</b>) allows the palm to work against the hook for some types of prehension and still provides for the hook to be operated by shoulder harness in the usual way. The stainless steel hand plate shown in <b>Fig. 49</b> provides a simple, light, and cool means of mounting a split hook to a hand stump that is too short to grasp objects without a prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 48. Prosthesis for virtual loss of all digits. Palm can work against hook, or hook can be operated in conventional way by virtue of cable attached to shoulder harness. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 49. Method of attaching a split hook to a short hand stump. Mobility of the wrist is maitained </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Still another way of accommodating for loss of all digits is to enclose the base of the hand in a leather cuff linked to a forearm cuff, a split hook being attached to the hand cuff (<b>Fig. 50</b>). The cuff and forearm members are connected by a rod working levers in such a way that, when the wrist is flexed, the split hook opens; extension of the wrist closes the hook.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 50. Prosthesis for loss of all digits. Wrist supplies power and excursion for operation of split hook. No shoulder harness needed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>New Devices for Paralyzed Arms</h4> <p>For the paralyzed arm, many new devices have come forth in the past five years. They all have the same essential purpose that of carrying the useful, or partially useful, hand to a place where it can operate to advantage. But in these cases there is an additional hurdle to be jumped. Whereas an arm prosthesis can be built to almost any desired weight, in the case of a paralyzed arm the weight of that arm must be overcome before motion can be reacquired. Equipment such as the shoulder suspension hoop, the locking lever arm brace, the alternator elbow lock arm brace, suspension slings, and single, double, or triple rocker feeders or arm balancers can do this job <i>.</i><a></a> </p> <p>Once a paralyzed arm can be positioned in a place of usefulness, hand function must be restored, either by surgical or by prosthetic means. Some of the terminal devices intended for arm amputees can be utilized for patients with paralyzed or badly disabled hands. A good example of the management of the paralyzed hand is to be found in the application of the "Handy Hook" <a></a>. It constitutes a simple but effective means of positioning a split hook in the palm of the hand and fastening it there to a metal or plastic palmar plate, which is held in place by straps around the dorsum of the hand (<b>Fig. 51</b>). In the event the wrist also is flail, a simple brace on the forearm constitutes a suitable modification (<b>Fig. 52</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 51. The "Handy Hook" as applied to a flail hand. Positioned in the palm by means of a plate passing over the dorsum, it is powered by shoulder harness. Hand sensation is preserved. Courtesy Robin Aids Manufacturing Company, Vallejo, Calif. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 52. The "Handy Hook" as applied to a flail hand when the wrist also is flail. Courtesy Robin Aids Manufacturing, Company, Vallejo, Calif. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For a hand that is lacking in one or more features of normal motor power but which retains valuable sensation, there is still another assistive device, the "Handy Hand"<a></a>. <b>Fig. 53</b> and <b>Fig. 54</b> show two variations out of numerous possibilities, each designed to accommodate specific motor losses (flexion or extension of fingers, flexion or extension of wrist, and so on). In <b>Fig. 53</b>, finger opening may be brought about voluntarily (or, if necessary, by rubber bands), closure being effected by shoulder harness. In <b>Fig. 54</b>, active wrist extension effects finger closure.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 53. The "Handy Hand" as applied to a flail hand when the wrist also is flail Extension of the fingers may be effected voluntarily or, if necessary, by rubber bands. Flexion of the fingers is brought about by means of shoulder harness Courtesy Robin Aids Manfacturing Company, Vallejo, Calif. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 54. The "Handy Hand" as applied when extensors of wrist and fingers are active, finger flexors inactive. Extension of the wrist , Courtesy Robin Aids Manufacturing Company, Vallejo, Calif. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Conclusion</h4> <p>So vast and so laden with potentialities is the subject of surgical reconstruction of the hand, and so also is that of partial hand prostheses, that a single article such as this can constitute only a very brief introduction to either. But even a brief review of some of the recent advances, both in reconstructive surgery and in prostheses for partial hands, may offer valuable guidance in selecting the best procedure for any given case. In the absence of a well developed literature, the whole field of work with partial hands is long apt to remain highly empirical and largely dependent upon the experience, judgment, and skill of individual surgeon and prosthetist. Since, unlike the more conventional amputation stump, the partial hand is invariably a special problem, the approach to its solution, whether surgical or prosthetic or both, also invariably calls for special departures. The most that can be said is that from long practice and much trial and error it is possible to extract certain principles generally applicable to the more common types of hand losses.</p> <p>In any event, it is apparent that the surgeon who would undertake reconstructive hand surgery ought first to be intimately familiar with the best that can be done with prostheses for partial hands. Similarly, the specialist in partial hand prostheses needs to be acquainted with what can be accomplished through surgery. Both, separately and together, must consider each case individually not only from the standpoint of the patient's life and work but also with a view toward his ability to afford the financial outlay incident to surgery and recuperation. Fortunately, insurance has in recent years played a large part in eliminating the economic considerations otherwise involved.</p> <p>The strongest argument that can be advanced for reconstructive hand surgery is that it preserves the highly desirable facility of tactile sensation. Among the disadvantages are the fact that the result does not always present the best cosmetic effect and the additional one that the reconstructed hand may not be able to perform heavy work as well as could a full prosthesis. The particular requirements of the individual therefore exercise a strong influence upon the choice between the partial hand and the wrist disarticulation. As has been seen, the most practical result is often best obtained through some combination of surgery and prosthetics, the two complementing each other in such a way as to provide a wide range of functional regain.</p> <p>Of course there will always be hands with too much wrong with them to justify attempts at reconstruction. Where such appears to be the case, amputation at the lowest possible level, followed by application of a good, functional prosthesis, obviously offers the best solution. But in the face of a rapidly growing technique in hand surgery including special manipulations with muscles, tendons, nerves, and vessels it would appear wise always to choose the most conservative course possible. That would mean reconstruction whenever the anticipated result is likely to serve satisfactorily the needs of the individual concerned. The possibilities outlined here are representative of what might reasonably be expected under a given set of circumstances.</p> <h4>Acknowledgment</h4> <p>For much valuable information on partial hand prostheses that have proved successful, the author is indebted to George B. Robinson, of the Robin Aids Manufacturing Company, Vallejo, Calif. The drawings accompanying 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, Prosthetics research and the amputation surgeon, Artificial Limbs, September 1954</li> <li>Bunnell, Sterling, Surgery of the hand, 3rd ed., Lippincott, Philadelphia, 1956.</li> <li>Fletcher, Maurice J., The upper extremity prosthetics armamentarium, Artificial Limbs, January 1954</li> <li>Fletcher, Maurice J , and Fred Leonard, The principles of artificial hand design, Artificial Limbs, May 1955.</li> <li>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.</li> <li>Kirk, Norman T., Amputations, a monograph from Vol. III of Lewis' Practice of surgery, W. F. Prior Co., Inc., Hagerstown, Md., 1944.</li> <li>Navy Prosthetic Research Laboratory, U.S. Naval Hospital, Oakland, Calif., Cineplaslic above elbow prosthesis (congenital bilateral arm amputation), Interim Progress Report [on] Research Project NM 007 084.26, 1 November 1954.</li> <li>Pursley, Robert J., Harness patterns for upperextremity prostheses, Artificial Limbs, September 1955.</li> <li>Robin Aids Manufacturing Co, Vallejo, Calif.,Functional arm bracing and artificial arms, 1956.</li> <li>Schottstaedt, Edwin R., and George B. Robinson, Functional bracing of the arm, J. Bone and; Joint Surg., 38A(3):477;38A(4):841 (1956).</li> <li>University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 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>9.</b> </td><td class="clsTextSmall">Robin Aids Manufacturing Co, Vallejo, Calif.,Functional arm bracing and artificial arms, 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>9.</b> </td><td class="clsTextSmall">Robin Aids Manufacturing Co, Vallejo, Calif.,Functional arm bracing and artificial arms, 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">Schottstaedt, Edwin R., and George B. Robinson, Functional bracing of the arm, J. Bone and; Joint Surg., 38A(3):477;38A(4):841 (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>References</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper extremity prosthetics armamentarium, Artificial Limbs, January 1954</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Fletcher, Maurice J , and Fred Leonard, The principles of artificial hand design, Artificial Limbs, May 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>4.</b> </td><td class="clsTextSmall">Fletcher, Maurice J , and Fred Leonard, The principles of artificial hand design, Artificial Limbs, May 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">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>7.</b> </td><td class="clsTextSmall">Navy Prosthetic Research Laboratory, U.S. Naval Hospital, Oakland, Calif., Cineplaslic above elbow prosthesis (congenital bilateral arm amputation), Interim Progress Report [on] Research Project NM 007 084.26, 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>8.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upperextremity prostheses, Artificial Limbs, September 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>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and Eugene F. Murphy, Prosthetics research and the amputation surgeon, Artificial Limbs, 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>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, 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>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and Eugene F. Murphy, Prosthetics research and the amputation surgeon, Artificial Limbs, September 1954</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper extremity prosthetics armamentarium, Artificial Limbs, January 1954</td></tr><tr><td class="clsTextSmall"><b>5.</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></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Fletcher, Maurice J., The upper extremity prosthetics armamentarium, Artificial Limbs, January 1954</td></tr><tr><td class="clsTextSmall"><b>5.</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></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Bunnell, Sterling, Surgery of the hand, 3rd ed., Lippincott, Philadelphia, 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>6.</b> </td><td class="clsTextSmall">Kirk, Norman T., Amputations, a monograph from Vol. III of Lewis' Practice of surgery, W. F. Prior Co., Inc., Hagerstown, Md., 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>Sterling Bunnell, M.D. </b></td></tr><tr><td class="clsTextSmall">516 Sutter Street, San Francisco 2, Calif.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-90.jpg Figure 2 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-91.jpg Figure 3 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-91b.jpg Figure 4 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-92.jpg Figure 5 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-93.jpg Figure 6 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-94.jpg Figure 7 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-95.jpg Figure 8 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-96.jpg Figure 9 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-98aa.jpg Figure 10 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-98b.jpg Figure 11 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-100.jpg Figure 12 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-101.jpg Figure 13 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-102.jpg Figure 14 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-103.jpg Figure 15 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-104.jpg Figure 16 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-105.jpg Figure 17 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-106.jpg Figure 18 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-107.jpg Figure 19 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-107b.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 Management of the Nonfunctional Hand Reconstruction vs. Prosthesis Creator An entity primarily responsible for making the resource Sterling Bunnell, M.D. * https://staging.drfop.org/files/original/d9df07ada71e9d7d83fffc2b3882605b.pdf dd5973e756028d4e9b05572ed933a126 https://staging.drfop.org/files/original/0f45aa6fc046dad209c2ecd2246d719d.jpg ef9ee0e2d6b75fb5a0f601219455c33c https://staging.drfop.org/files/original/d95df4afa4a2f4646ae80ab0c81b2c59.jpg eaf808db85894142fab323e6a395c193 https://staging.drfop.org/files/original/b6abea62fdee85f63c01f9f92f63427f.jpg 0cb011992156bd6cb8e3d2d0c7084ef2 https://staging.drfop.org/files/original/f0010ef48d7220a546c6825555e192d9.jpg 7d7fdedf615e168cb6806068e1c6ec9f https://staging.drfop.org/files/original/3b4551aa2727f7de686c9653c2e5a0a2.jpg 362acdaa1b00733aa29554d23964db97 https://staging.drfop.org/files/original/9d2755df918b9d45aa9be1ca6f563d0c.jpg 005f7f0338d752126218dd2d68eafbad https://staging.drfop.org/files/original/6c2c983e3d245d5c78f0820ce9ee4915.jpg 1d90a72444738f10f27abd1bac5c0faa https://staging.drfop.org/files/original/624b108ea7d5ee0507c22228b6f0d6a3.jpg 26f4ff3a54c4bccd797ca390cdf7ca5b https://staging.drfop.org/files/original/254ddecf8418d838cb6a8af9873a58de.jpg b4f775c186a69f8d2e53b158ac858068 https://staging.drfop.org/files/original/377df229bb696a03072dfd1c676bd050.jpg c0c4072b156f521d98c4f1354bbc325b https://staging.drfop.org/files/original/fd3e3ccdd2420ab18d0d0fffcbc9ab3c.jpg 0e72757a1dc47a5de48d7308461d5f6d https://staging.drfop.org/files/original/b5a660e0a92fcfe1dc39c8ff7fb409bf.jpg 2d614435d8ff3fe18ea8d22c8f3e3eb6 https://staging.drfop.org/files/original/bca83eadc2d6bdd1414a4a6220815d9b.jpg af655a4773be177a6f4c493d206128dd https://staging.drfop.org/files/original/a3377673f8480eff6b780ea492790238.jpg 31b69497a6c30f74af9e798ed25997b9 https://staging.drfop.org/files/original/14d1a5ad883e575f6f4ef41150d9abf1.jpg 3715824627641a0a6f1d6ee0636f59c2 https://staging.drfop.org/files/original/976df78ead28d770ef285a09c9bc0af9.jpg 423273a8db9972de7c0193e94f0f8bdc https://staging.drfop.org/files/original/cd85393dfea9ad19f0b6b560e893c1a6.jpg e2175b21b49484d983de253617cf5baf https://staging.drfop.org/files/original/59c142d232f6be2114140f4624655085.jpg 8e077cebc372f08ef05dd8002caf70d3 https://staging.drfop.org/files/original/efdc01af5dc1a7b942d551d17167eeca.jpg c00df2061434f0cde77ab3c22578b6b7 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1957_01_041.pdf Year 1957 Volume 4 Issue 1 Page Number(s) 41 - 75 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_041.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1957_01_041.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 Above Knee Amputees</h2> <h5>Charles W. Radcliffe, M.S., M.E. <a style="text-decoration:none;">*</a><br />Norman C. Johnson, M.D. <a style="text-decoration:none;">*</a><br />James Foort, M.A.Sc. <a style="text-decoration:none;">*</a><br /></h5> <p>For almost a dozen years the University of California has been active in prosthetics research. On the recommendation of the then Committee on Prosthetic Devices (now the Prosthetics Research Board) of the National Research Council, there was established in 1945, with the cosponsorship of the School of Medicine in San Francisco and the College of Engineering in Berkeley, the Prosthetic Devices Research Project (now the Lower Extremity Amputee Research Project), a program designed primarily for the purpose of conducting studies in several areas of importance to leg amputees, especially fundamental studies of the processes of human locomotion. Supported on a continuing basis with funds supplied by the Veterans Administration, the work has from the beginning been under the supervision of Howard D. Eberhart, Professor of Civil Engineering, and Verne T. Inman, Professor of Orthopedic Surgery.</p> <p>In the course of fundamental research, the need for experimental devices required the activation of an engineering design group, and consequently a small staff of design engineers, draftsmen, and technicians has been active since 1948. This group, working with the fundamental study groups, research prosthe tists, and amputee subjects, has designed improved prosthetic devices, developed mechanical aids to fitting and alignment, and assisted in the application of well known principles of engineering mechanics to the problems of fitting and aligning lower extremity prostheses.</p> <p>As correlation of the results of the various fundamental study groups progressed, and as the engineering design group developed improved devices, it became increasingly apparent that, in order to make their results useful to the members of the medical profession and to prosthetists serving amputees, a program of amputee application was indicated. Accordingly, there was organized in the spring of 1953 a Clinical Study aimed at providing increased opportunity for application of research results to the solution of typical prosthetic problems of leg amputees. The work in fundamental research had studied the "man"; the Clinical Study was needed to consider the 'man machine combination." Its objectives were to evaluate current prosthetic practice and to develop improved procedures where needed, to establish basic principles of fit and alignment for all levels of lower extremity amputation, to evaluate medical and prosthetic factors in the rehabilitation of amputees, and to develop methods for evaluation of lower extremity amputees and their prostheses.</p> <p>An immediate outgrowth of the Clinical Study was an increasing awareness of the need for additional research directed toward the solution of the medical problems of the amputee. At the present time, the Medical Division of the Lower Extremity Amputee Research Project, located at the Medical Center in San Francisco, includes groups active in the fields of stump dermatology, amputation surgery, skeletal changes, energy, neuroanatomy, psychology, and the physiology of pain. The Clinical Study provides an opportunity for the solution of the prosthetic problems associated with the medical studies and also of the purely prosthetics research problems connected with better materials and improved techniques of fitting. To date, most of the experience has been had with above knee amputees, as here reported, although more than 100 patients, presenting all levels of lower extremity amputation, are currently under study.</p> <h3>Procedures</h3> <p>Each amputee processed through the Clinical Study has certain unique problems, and each must therefore be considered on an individual basis. Initially, it was thought that it would be possible to process amputees in certain rather loosely defined groupings such as ''short stump above knee," "long stump below knee," and so on. But this procedure has not been found practical since each amputee is referred to the study as his particular problem arises. Largely because of the attendant requirements of time, travel, and inconvenience, it is difficult to induce an amputee to become a research subject when he considers his prosthesis to be comfortable and well fitted. The cases reported here have almost without exception been referred to the Clinical Study as "problem cases" and have had chronic difficulties upon referral. The sample does not, therefore, necessarily indicate a typical cross section of the amputee population. The prosthetic problems of the group as a whole, however, constitute what we believe to be a rather common group of problems facing above knee amputees.</p> <p>Each amputee referred to the Clinical Study is given a preliminary examination for the purpose of obtaining information as to the nature of his problems, if any. The preliminary examination includes:</p> <ol> <li>An interview with an amputee specialist <i>(i.e., </i>a trainer). The amputee specialist obtains a brief prosthetic history, explains the research program to the amputee, and records personal data.</li><li>Medical examination by an orthopedic surgeon. The orthopedic surgeon obtains a brief medical history and endeavors to classify the major complaints of the amputee.</li><li>Prosthetic evaluation by staff prosthetists and other specialists. A group consisting of three or more people examines the amputee's stump, his prosthesis, and his performance in order to analyze the fit, alignment, and functional behavior of the amputee with his prosthesis.</li></ol> <p>The results of each of these examinations are recorded in the form of a written memorandum report. Upon completion of the reports, a group discussion is held for the purpose of making recommendations as to the further handling of the case. For example, it may appear on preliminary examination that a particular amputee has a severe skin infection of unknown origin. In such a case, the recommendation might be to refer the patient to the Skin Study Group at the Medical Center in San Francisco before considering any work directed toward improving fit and alignment.</p> <p>Certain cases considered to be of interest to the research staff as a whole are referred to the Amputee Conference held at the Medical Center, San Francisco, on a regularly scheduled weekly basis. Amputees may be referred to the Amputee Conference by medical study groups as well as by the Clinical Study Group. Attendance at the conference is limited to University of California staff members, and not more than three amputees are presented for discussion at any one session. The Amputee Conference provides an opportunity for presentation of the results of the preliminary examination and, thereafter, a general group discussion. At this time a general plan of treatment, including broad research objectives, is formulated.</p> <p>If an amputee is accepted by the Clinical Study as a case of research interest, a more complete medical examination is required. Cases referred to the Clinical Study from the medical study groups or the Amputee Conference have usually been examined at the Medical Center prior to referral. The complete medical examination includes routine clinical tests, plus x-rays of the stump and pelvis.</p> <p>Before any actual treatment is undertaken, a plan of approach is worked out by a team consisting of an orthopedic surgeon, a pros thetist, an engineer, and an amputee specialist. The team discusses research objectives in detail, writes a prescription for one or more phases of prosthetic treatment, and lays out an estimated schedule. A report is then written summarizing the discussion and recommendations, and the team meets periodically, as necessary, to review progress and to make further recommendations. Each phase of the treatment of the amputee is reported in a memorandum which becomes a written record of progress. Permanent records embrace medical records, including x rays; evaluation records, including evaluation forms and 16 mm. motion pictures (100 ft. per evaluation); black and white still photographs; 35 mm. color transparencies; and memorandum reports on plans and progress.</p> <h3>General Principles of Above Knee Prosthetics</h3> <p>As already noted, one of the major objectives of the Clinical Study was to provide the means for additional amputee trials of certain principles of fitting and alignment which had been evolved during several years of fundamental research, evaluation of current practices, and amputee trials but which had been developed with a limited number of amputee subjects. The technique of fitting the suction socket prosthesis to an above knee amputee has been reported by the University of California in a series of publications<a></a> which have been revised periodically as new knowledge and techniques became available. The latest article<a></a> stressed the interdependence of the shaping and fitting of the socket and the biomechanics of alignment of the prosthesis. A rational basis for planning and fitting the above knee prosthesis was presented. All of the patients reported upon in the present paper were fitted in accordance with these principles. It is therefore well to offer here a brief summary of the more important considerations.</p> <p>The prosthetist is undoubtedly <i>the </i>person on the prosthetics team with the heaviest responsibilities. His skill with his hands is largely responsible for the eventual rehabilitation of the amputee. But in carrying out his assignment of providing the amputee with a satisfactory prosthesis, he is faced with something of a dilemma in the establishment of an order of procedure. In order of importance, he must provide the amputee with, first, comfort; second, function; and third, appearance. It can be argued that he should approach the solution of these problems in reverse order if optimum results are to be achieved. Actually, there are two separate and distinct phases of equal importance in the fitting of a leg prosthesis the planning phase and the construction phase. It is during the planning phase that the objectives listed above should be considered in the reverse order. One of the principal reasons for failure to achieve optimum results in the fitting of a suction socket above knee leg is lack of appreciation of, and hence failure to formulate, a working plan before beginning the construction of the prosthesis.</p> <p>In order properly to plan the fitting and alignment of a prosthesis, the clinic team must have in mind a rational sequence which will eventually result in a satisfactory fitting for the amputee. The order of the sequence is necessarily dictated by the type of problem to be solved at a particular stage. Let us consider, for example, the case of a typical leg amputee. During the medical and prosthetic examination by members of the clinic team, a careful analysis is made of the patient's potential as a wearer of a prosthesis. This analysis includes classification as to stump type, stump length, activity level, habit patterns, and special medical factors. It dictates in general terms the type of alignment to be incorporated in the amputee's prosthesis (<b>Fig. 1</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 1. 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. These figures serve as a guide to typical features of alignment once the amputee has been classified After Radcliffe (6). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The alignment of the prosthesis will in large measure establish the gait pattern of the amputee, assuming of course that he has been trained to use his prosthesis in a manner consistent with its alignment. A leg amputee can walk efficiently with a symmetrical, narrow based gait only if his prosthesis has been planned and constructed to achieve such a gait pattern. The type of alignment also affects the manner of fitting the socket. An amputee walking with a narrow base may require a distribution of contact forces between stump and socket entirely different from that of an amputee walking with a wide base <i>(i.e., </i>abducted gait).</p> <p>The distribution of stump socket contact forces is determined by the functions the socket must perform, the major functions of a typical above knee suction socket being as follows:</p> <ol> <li>Suspension of the leg in the swing phase of walking. This requirement dictates that an airtight seal be maintained between stump and socket, especially in the proximal third of the stump.</li><li>Vertical support of body weight in the stance phase. The only efficient areas of an above knee stump for weight bearing are the ischial tuberosity and the gluteus maximus. Attempts to use for weight bearing in a suction socket the attachments of the adductor musculature in the perineal area have been unsuccessful Almost without exception this procedure leads either to painful pressure on the pubic ramus or to skin irritation where there exists a definite roll of adductor musculature over the medial brim of the socket.</li><li>Stabilization of the ischial tuberosity on the posterior brim (ischial seat) of the socket. Failure to provide stabilization of the tuberosity will allow the pelvis to slide forward and down into the socket, a circumstance which causes chafing and irritation of the skin under the ischial tuberosity and, in addition, is a major source of crotch discomfort.</li><li>Provision of effective stump reaction points for utilization of hip musculature on the side of the amputation. Any attempt to use the hip musculature either for control of the torso above the hip joints or for control of knee joint movements below the hip joint will require that the stump transmit a moment, or torque. For lateral stabilization of the torso, there is required a pair of mediolateral reaction forces equal in magnitude but opposite in direction one acting on the lateral side of the stump, concentrated in the lower third, and a second acting horizontally against the medial side of the stump in the upper third. During those times when the stump acts to maintain knee stability by active stump extension, the reaction points are against the posterodistal and the anteroproximal areas of the stump.</li></ol> <p>On the basis of these functional requirements, the quadrilateral shape of suction socket shown in (<b>Fig. 2</b>) has been developed. It not only conforms to the anatomical skeleton and musculature but also provides the four functions already listed suspension, support, ischial stabilization, and torque reaction points.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Quadrilateral shape of suction socket, as developed at the University of California, showing anatomical features of an above knee stump in weight bearing. Cross section 1/2in. below ischial level. After Radcliffe (6). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Thus far the objectives of appearance and function have been accounted for. It has been stated that appearance is determined by proper alignment and use of the prosthesis and that function is dictated by proper alignment accompanied by a rational design of socket to provide the necessary accommodation of stump socket forces. These concepts can be restated in the following two principles:</p> <ol> <li>Gait and alignment establish a definite pattern of stump socket forces.</li><li>The force pattern, in combination with anatomical proportions, dictates a rational design of socket of a generally quadrilateral shape.</li></ol> <p>The third objective is to provide a completely comfortable socket which will be consistent with the functional requirements and yet allow the amputee to use his prosthesis for long periods. Comfort is achieved by application of three additional principles:</p> <ol> <li>Relative motion or rubbing between stump and socket should be held to a minimum.</li><li>Stump socket contact forces can never be eliminated. Contact forces can be tolerated most comfortably if distributed over a large skin area.</li><li>Where a contact force must be transmitted in an area of the stump involving both soft and firm tissues, a uniform distribution of the contact pressure is accomplished by a proportionately greater distortion of the softer tissues.</li></ol> <p>Application of the three principles relating to comfort have resulted in four features of socket shape at the brim that are of particular importance:</p> <ol> <li>The anteroposterior dimension of the socket must be determined with considerable accuracy from skeletal measurements. Any error in this dimension will be reflected in improper placement of the ischial tuberosity on the posterior brim of the socket.</li><li>To ensure distribution of vertical support over the entire posterior brim <i>(i.e., </i>to achieve ischial gluteal weight bearing), a rather flat posterior contour with a flare in the gluteal area is required.</li><li>An anterior wall extending into the inguinal area (the high front), when used with the proper anatomical dimension, is extremely efficient in stabilization of the ischium on the ischial seat.</li><li>A definite protuberance into Scarpa's triangle (the adductor area extending downward into the socket), accompanied by a channel to fit the belly of the rectus femoris, is necessary to ensure a uniform pressure distribution and an airtight seal across the anterior brim of the socket.</li></ol> <p>The following cases have been selected as illustrative of typical problem cases and as being informative to others engaged in the rehabilitation of above knee amputees. Treatment was not completed in all cases because considerable improvement over the previous condition sometimes caused the individual to believe the optimum had been reached and to be reluctant to devote additional time. The cases are in general indicative of the kind of results that can be obtained under the team approach to the problem of amputee rehabilitation.</p> <h3>Some Above Knee Cases</h3> <h4>Case 1, Lower Third of Thigh</h4> <h5><i>History</i></h5> <p>Case 1, a male, was 32 years of age, measured 5 ft. 8 1/2 in., and weighed 190 lb. His left leg had been amputated above the knee in October 1944 as the result of a wound. He was employed as a civil engineer. For two years after the amputation, he received intermittent physical therapy and exercise before being fitted with a conventional prosthesis with pelvic belt. The patient's second and third prostheses were similar. His fourth prosthesis, also a pelvic belt leg, was worn with fair results for 18 months. It was then converted to suction suspension in an unsuccessful attempt to increase comfort. The fifth prosthesis, also suspended by suction, was worn for a year with continuous stump trouble before the amputee was finally hospitalized.</p> <p>The patient was referred to the clinical study program in November 1953 following hospitalization for severe edema precipitated by his suction socket prosthesis. Treatment consisted of remaining off the prosthesis during and immediately following hospitalization.</p> <h5><i>Examination and Evaluation</i></h5> <p>The stump was 12 in. long, with limited tolerance to weight bearing on the end. Subcutaneous tissue was light and musculature soft, with some bunching of the hamstrings and slight atrophy at the distal end. X ray showed a healed but laterally displaced fracture of the distal 5 1/2 in. of the femur. The end of the femur was slightly rounded, was closed with new bone growth, and had a small medial spur. Approximately half an inch of muscle padding lay over the end of the femur. The ischial tuberosity was well padded, and the general health of the amputee was excellent.</p> <p>When the patient was admitted to the hospital, the end of his stump was severely edematous, open, and weeping. At the time of entrance to the study program, there was still some weeping and edema, and the end of the stump was discolored (<b>Fig. 3</b>). Follicular lesions were apparent in the area of the inguinal crease and of the crotch, and a small, healing abscess existed on the anteromedial portion of the stump 5 in. below the groin. Some rawness and irritation were still apparent in the crotch area. The distal area of the posterior aspect of the stump was tender, and there was a moderate adductor roll. Examination of the socket fit showed constriction of the stump, especially in the upper third. Weight was carried on a flesh roll at the brim of the socket (<b>Fig. 4</b> and <b>Fig. 5</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Case 1. Condition of the distal end of the stump on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Case 1. Prosthesis worn prior to referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Case 1. Shape of socket of prosthesis worn prior to referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>Interest in the case centered around the edema, roll formation, and skin problems, including discomfort in the crotch. Ischial gluteal weight bearing, with increased area of support at the anterior wall, particularly in the upper third, was expected to eliminate crotch discomfort, skin lesions and irritation, roll formation, and constriction of the proximal portion of the stump. A snug fit of the socket in the upper third was required to reduce the adductor roll, and a close fit of the distal two thirds of the stump was required to reduce remaining edema and to maintain fit as the edema subsided.</p> <p>The amputee was provided with a suction socket prosthesis using a Navy above knee set up,<a></a> including the variable cadence knee, the functional ankle, and the sponge rubber toe. The socket was made of willow wood reinforced with rawhide and finished inside with cellulose acetate lacquer, and an automatic expulsion valve with standard spring was used. A flat, leather covered, sponge rubber pressure pad was placed in the bottom of the socket to provide back pressure on the edematous tissue at the end of the stump.</p> <p>No special provision was made for relief of the adductor roll. The anterior wall provided no protuberance over the femoral triangle, and there was no special relief for the displaced section of the femur. The perimeter of the socket was 2 1/4 in. less than that of the stump at the proximal end, 3/4 in. less at the mid stump level, and equal to that of the stump at the end. The distance from the channel for the tendon of the adductor longus to the ischial seat was 4 1/2 in., the corresponding anatomical dimension being 3 3/4 in. This difference between medial socket width and anatomical measurement was subsequently found to be a major source of difficulty. Current practice is to have the medial width of the socket compare very closely with the anatomical measurement.</p> <p>Prosthetic evaluation showed some instability of the knee in ramp descent owing to reduced range of plantar flexion. Although there was drop off at the end of the stance phase because of the soft dorsiflexion stop and the soft, sponge-rubber toe, the amputee's performance was excellent.</p> <p>During the final fitting, the end of the stump turned red, but a sponge rubber pad placed in the bottom of the socket improved stump color markedly within two hours. One week after delivery of the prosthesis, the edema was reduced; three weeks after, there was no edema; nine months after fitting, some edema was evident at the distal end of the stump.</p> <p>Evaluation indicated that the ischial tuberosity was sliding anteriorly off the ischial seat so that the stump was settling deeper into the socket, with increased constriction at the proximal end. Several factors were involved. The stump had shrunk, and the anteroposterior dimension of the socket, especially in the medial third, which had been too great initially, had been increased in an unsuccessful attempt to relieve discomfort in the inguinal crease and in the weight bearing area of the stump. The edema was confined to the areas of the stump which extruded into the valve recess and into the gap between the pad and the socket walls. The valve recess was lowered, the pad was refitted so that more weight was carried on the end of the stump, and the space between the pad and socket walls was eliminated. The edema cleared up.</p> <p>Roll formation over the anterior brim of the socket was eliminated through extension of the anterior wall of the socket above the level of the ischial seat. The adductor roll was completely contained within the socket. Tightness of fit in the upper third was a source of minor discomfort immediately, but this problem decreased with reduction of the roll, which was complete within six months (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Case 1. Present prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Follicular lesions in the area of the crotch and the inguinal crease quickly cleared up with reduced forces from the socket brim and elimination of roll formation over the brim. One year after treatment began, the discoloration at the end of the stump was markedly decreased. Irritation of the skin over the posterior brim was a persistent problem directly related to decreased effectiveness of ischial gluteal weight bearing and wedging of the posterior aspect of the stump against the inside edge of the posterior brim of the socket. Attempts to increase weight bearing on the distal end of the stump showed that the amputee preferred ischial gluteal weight bearing because of discomfort experienced on the stump end with prolonged support of body weight.</p> <p>Reduced support on the ischial tuberosity followed stump and socket changes and caused discomfort on the ramus. The medial brim of the socket was lowered to provide relief. This expedient was partially successful, but the stump sank deeper into the socket after wear, and ramus discomfort has recurred.</p> <h5><i>Summary</i></h5> <p>The problems of edema, roll formation, skin lesions, and discomfort in the crotch were studied. Edema was originally caused by a tight fit of the stump with constriction of the proximal end. Definite ischial gluteal weight bearing, with increased area of anterior support, was the primary factor in clearing up the edema. A pressure pad under the end of the stump helped to reduce the edema. Stump and socket changes which allowed the ischial tuberosity to slide into the socket, with wedging of the stump proximally, caused edema to recur. Improved fit of the pressure pad, with increased end bearing, cleared up the edema. The adductor roll was brought about by weight bearing in the crotch on the tight socket. Ischial gluteal support, adduction of the femur in the socket with relaxation of the adductors, and extension of the medial brim to the level of the ischial seat, without provision of a relief pocket, eliminated the adductor roll. Discomfort due to tightness of fit for adductor roll reduction decreased as the roll reduced. The high anterior wall eliminated roll formation over the anterior brim of the socket. Skin lesions and irritation were caused by high force concentrations on the stump. Ischial Gluteal weight bearing, with increased area of anterior support, eliminated irritation and follicular lesions in the area of the crotch and the inguinal crease. Ramus discomfort following stump and socket changes was a sign of reduced effectiveness of ischial gluteal weight bearing, which allowed the stump to sink deeper into the socket. Discomfort in the weight bearing area posteriorly was caused by wedging of the stump against the posterior brim of the socket as the tuberosity slid inside the socket.</p> <h4>Case 2, Mid Thigh</h4> <h5><i>History</i></h5> <p>Case 2, another male, was 57 years of age, measured 6 ft., and weighed 187 lb. He was employed as a district manager for an insurance company. Amputation was through the right femur following a railway accident at the age of 17. He was referred to the clinical study in November 1953 by a local limbshop because of a history of problems. These included skin infections and irritations, fatigue, and low back pains which had persisted since amputation. At the time, the amputee considered his prosthesis satisfactory. The first prosthesis, with shoulder harness suspension, was fitted in 1913 and worn until 1928. Prostheses with shoulder harness suspension were worn until 1943, when a change was made to pelvic belt suspension. The pelvic belt was uncomfortable and aggravated the back pains, and prior to referral the prosthesis was converted to suction suspension.</p> <h4><i>Examination and Evaluation</i></h4> <p>General health and physical condition were good. The stump was 10 in. long and cylindrical, with light subcutaneous tissue and average musculature except for moderately prominent hamstrings. There was a lateral distal bone spur, a mass of redundant tissue at the lateral posterior end of the stump, and sensitive scar tissue which was adherent to the femur. Perspiration level was high. Skin irritations were present in the area of the crotch and the inguinal crease, and hard skin nodules existed in the ischial gluteal area (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Case 2. Lateral view of patient standing. Note scar on distal portion of stump over lateral and posterior aspects. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The prosthesis did not provide ischial gluteal weight bearing, and the tuberosity of the ischium was sliding inside the socket during weight bearing. This set of circumstances resulted in painful pressure on the ramus and wedging of the proximal portion of the stump against the anterior and posterior brims of the socket, with a high concentration of forces at the brim level. The medial brim had been lowered a half inch below the level of the ischial seat in an unsuccessful attempt to relieve the discomfort at the ramus. Walking with a narrow base increased the ramus discomfort because the femur was not adducted in the socket for stabilization of the pelvis. There was roll formation over the low anterior brim. Knee stability at the end of the stance phase was excessive owing to a long forefoot and posterior placement of the knee joint, which further increased the force concentrations at the socket brim. Insufficient security at heel contact was due to stiff plantar flexion action. A pelvic hike on the side of the amputation in the swing phase was noticeable, probably because of experience with shoulder harness and pelvic belt suspension.</p> <h5><i>Treatment</i></h5> <p>Problems of interest included skin lesions, horny nodules, ramus discomfort, fatigue, and backaches. It was decided that relatively standard procedures, including ischial gluteal weight bearing with increased support from the anterior wall, would be effective in eliminating roll formation and in reducing pressure concentrations on the stump, especially in the crotch, in the inguinal crease, and in the ischial gluteal area. Further reduction of vertical forces in the region of the crotch could be achieved by adduction of the femur in the socket, thus eliminating pelvic drop in the stance phase.</p> <p>The amputee was provided with a suction socket prosthesis which included a single axis constant friction knee, a plantar dorsiflexion ankle, and a foot with single toe break. Segments of the prosthesis were willow wood reinforced with rawhide. The socket interior was finished with cellulose acetate lacquer, and use was made of an automatic expulsion valve with standard spring.</p> <p>Since the ischial tuberosity was not adapted to weight bearing, the gluteal channel was held shallow to increase gluteal support. In addition, this arrangement offered increased sitting comfort by allowing a thinner posterior wall. Definite hamstring relief was provided by channeling the posteromedial apex of the socket (<b>Fig. 8</b>). The medial brim was approximately 1/4 in. lower than the posterior brim to provide clearance for the ramus. The medial socket width was 4 3/4 in. as compared to an anatomical measurement of 3 3/4 in., a difference subsequently found to be a major source of difficulty. As already mentioned, current practice is to have the medial width of the socket compare very closely with the anatomical measurement. The anterior wall was extended 2 in. above the level of the ischial seat and was relieved slightly over the femoral triangle. But this idea, which was tried for fear that pressure in the femoral triangle would interfere with circulation, has since been abandoned in favor of a definite protuberance into this area. Such a shape gives considerable distributed anterior support.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Case 2. Socket shape of prosthesis worn at present. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The socket was placed well forward on the knee block to allow initial flexion of the femur in the socket for increased voluntary control, reduced energy requirements, and decreased lordosis of the lumbar portion of the spine. Prosthetic evaluation indicated that there was excessive stability at the end of the stance phase owing to a long forefoot and the posterior location of the knee axis, the long forefoot having been dictated by the large foot size. In the swing phase, there was some whip, which was not removed during alignment trials on the adjustable leg,<a></a> but the gait was markedly improved on the new prosthesis. There was no ramus discomfort, no irritation, and no roll formation in the crotch or inguinal crease. The ischial tuberosity was close to the inside edge of the socket, so that the medial wall had to be lowered to prevent ramus discomfort.</p> <p>After stump shrinkage, ramus discomfort recurred. The medial brim was lowered, but this measure provided only temporary relief as the stump settled deeper into the socket. Skin irritations from the anterior brim were reduced but persisted, since wedging occurred owing to inefficient ischial weight bearing. Force concentration at the anterior brim was reduced somewhat by extension of the brim 2 in. above the level of the ischial seat. Undercut of the anterior wall over the femoral triangle reduced the effective area of anterior support.</p> <p>Skin lesions in the crotch cleared up initially but recurred with failure of ischial weight bearing. Formation of horny nodules in the weight bearing areas was unchanged because poor ischial support allowed the tuberosity to move in and out of the socket over the inside edge of the posterior wall, thus creating abrasive and wedging action. Excessive perspiration was considered a factor both in the formation of horny nodules and in stump irritation because of the deteriorating effect it had on the inside finish of the socket.</p> <p>Although the anterior and posterior brims were rolled and adjusted periodically to reduce discomfort from skin irritations in the inguinal crease and from nodules in the weight bearing areas, this expedient provided only temporary relief, since the forces involved were either unchanged or increased. Reduced alignment stability, with increased flexion of the stump in the socket, did not relieve the backache. Activity level was not noticeably changed, and fatigue also remained unchanged.</p> <p>In the course of treatment, redundant tissue at the lateral distal portion of the stump was a problem in fitting because of the sensitivity of the adherent scar tissue. A large pocket was provided to give relief. Doing so reduced the effective length of the femur available for stabilization of the pelvis.</p> <h5><i>Summary</i></h5> <p>Failure of ischial gluteal weight bearing resulted in ramus discomfort and skin lesions. Lowering the medial brim provided only temporary relief, since the stump settled further into the socket. With recurrence of vertical pressure in the crotch, skin lesions were again a problem. The need for effective anterior stabilization to maintain the ischial tuberosity on the ischial seal was definitely indicated.</p> <p>The high anterior wall eliminated roll formation and reduced skin infections in the inguinal crease. Undercut of the anterior wall over the femoral triangle reduced the anterior support area and increased the force concentration al the brim. Modifications of the anterior wall and of the posterior brim reduced discomfort temporarily only, since the force pattern was unchanged.</p> <p>Placement of the prosthetic toe break at the shoe crease provided excessive knee stability at the end of the stance phase. This result suggested that the conventional location of the toe break was too far forward.</p> <h4>Case 3, Mid Thigh</h4> <h5><i>History</i></h5> <p>Case 3 was another male, age 51, height 6 ft., weight 180 lb. He lost his left leg above the knee at the age of 17 after an injury sustained in a baseball game. Since his original surgery, he had had no further revision. For the first five years after amputation, he used crutches without a prosthesis. He had since worn three prostheses during his 34 years as an amputee. The first leg had a shoulder harness suspension. The leg worn upon his acceptance as a research patient had been converted in 1952 from an aluminum socket, pelvic belt leg to a wooden suction socket prosthesis a year and nine months previously. He was employed as an expediter in a shipyard, and the nature of his employment was such as to involve considerable standing and moving about over short distances. His chief complaint was concerned with persistent edema of the stump since conversion to suction suspension, and this was the reason for his referral to the clinical study program by a local limbshop in November 1952. The patient complained of occasional phantom pain but had no persistent local pain.</p> <h5><i>Examination and Evaluation</i></h5> <p>The patient was in good general health, with normal reflexes and above average musculature. The stump was cylindrical, with 6 1/2 in. of femur below the perineum and 2 1/2 in. of soft tissue over the end of the femur (<b>Fig. 9</b>). Stump musculature was not abnormally prominent, and subcutaneous tissue was light. On contraction of the muscles, the redundant tissue pulled upward without bunching. A large scar, adherent to the distal end of the femur, extended 6 in. up the lateral side of the stump (<b>Fig. 10</b>). There was severe, nonpitting edema in the redundant tissue. The skin in the edematous area was without hair, distended, discolored, and scaly, with an orange peel texture. Small cysts and horny nodules were evident in this region as well as in the inguinal area and in the crotch. The patient said that these cysts frequently enlarged and broke down, producing a pinkish yellow discharge.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9 Case 3. X ray of stump, mediolateral view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Case 3. Lateral view of stump. Note large, adherent scar. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>X ray revealed the usual finding that there was lessened bone density on the amputated side and that the femur tapered and curved medially toward the distal end, which appeared to be closed. Comparison of socket and stump perimeters showed the socket smaller than the stump by 1 1/4 to 2 in. at corresponding levels. The distance from the tendon of the adductor longus to the ischial tuberosity was 3 1/2<i> </i>in., as compared to the corresponding socket measurement of 5 in.</p> <p>The suction socket the patient was wearing, although of the ischial bearing type, did not achieve ischial bearing. The anteroposterior dimension was too large, the mediolateral dimension too small (<b>Fig. 11</b>). The socket was too tight, especially in the distal half, and the proximal end of the stump was constricted because of a wedging action precipitated by failure to establish ischial gluteal bearing. Weight was borne on the medial brim of the socket, which was 3/8<i> </i>in. below the level of the ischial seat and generously flared. There was a small adductor roll, and the anterior brim of the socket was level with the posterior brim, with some roll formation in the area of the inguinal crease. The anterior wall was undercut, a feature that caused localized high pressure on the stump at the anterior brim. The patient was well adapted to the use of the prosthesis, although a number of undesirable characteristics of gait were apparent, including a 7 in. walking base, considerable sidesway, and exaggerated arm swing on the side of the amputation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11, Case 3. Socket shape of prosthesis worn on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>This patient's chief problem was the severe edema. It was felt that this disorder, as well as the skin lesions, could probably be controlled adequately by proper fit and alignment. The question of prime interest to the study group was whether or not suction suspension was the cause of the edema in this case.</p> <p>The amputee was provided with a suction socket prosthesis with conventional components, including a single axis constant friction knee, a plantar dorsiflexion ankle, and a foot with a single toe break. Segments were made of wood and reinforced with rawhide. An automatic expulsion valve with a strong spring was used to increase positive pressure in the socket during the stance phase.</p> <p>The socket perimeters were 1 1/2<i> in.</i> less than corresponding stump dimensions in the top third and equal to stump dimensions below that.</p> <p>The distance from the tendon of the adductor longus to the ischial tuberosity was 3 1/2 in., and the corresponding socket dimension was 4 in. The anterior wall was relieved to avoid pressure in the area contacting the femoral triangle (<b>Fig. 12</b>), and a flat sponge rubber pad covered with soft leather was placed in the bottom of the socket to provide back pressure on the edematous tissue.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Case 3 Socket shape, present prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the patient had worn the prosthesis for six weeks, the edema in the redundant tissue had decreased markedly. The improvement was maintained over a nine month period, although at no time was the condition completely eliminated. About the ninth month, there was a sudden increase in the amount of edema. Three factors seemed to be involved. There was increased activity. A weaker valve spring had been installed to reduce loss of suction. And there had been stump shrinkage, as indicated by the experience of ramus discomfort. The thickness of the control pad was increased, but doing so did not alter the condition. Next, a stronger valve spring was provided to increase the positive pressure in the stance phase, and there was then a marked and immediate improvement in the edematous condition of the stump. To provide increased ischial weight bearing by reducing the anteroposterior dimensions of the socket, liners were added in the area of the socket contacting the femoral triangle. Although ischial weight bearing was improved, as evidenced by the elimination of ramus discomfort, there was no change in the edema.</p> <p>The decision was then made to provide the amputee with a socket that would make total contact with the stump end, thus exerting greater back pressure on the edematous tissue. After a four day trial period, the patient found that accumulated perspiration irritated the stump acutely, and the socket had to be discarded. At present the amputee continues to wear the first prosthesis provided and still has moderate edema.</p> <p>Skin infections initially present in the crotch area were cleared with provision of ischial gluteal weight bearing, but with stump shrinkage the condition recurred because of decreased effectiveness of such weight bearing. Provision of liners over the area of the socket contacting the femoral triangle increased the effectiveness of ischial gluteal weight bearing and reduced the skin problems. Throughout treatment, there was irritation on the weight bearing area of the stump, especially around the ischial tuberosity. Provision of a section of nylon stocking, fastened to the outside of the socket and draped interiorly over the weight bearing area, improved comfort considerably by reducing shear between the skin and the socket. The skin irritations were due primarily to excessive anteroposterior socket dimensions, especially along the medial wall. This situation allowed the tuberosity to slip into the socket and the entire stump to settle deeper, with consequent wedging of the stump against the posterior brim and the anterior wall, thus creating a high force concentration on the ischial tuberosity. A pressure pad was found very helpful in controlling edema when other elements of the fit were satisfactory.</p> <p>Minor skin irritations resulted from deterioration of the inside finish of the socket, but refinishing the socket cleared them.</p> <h4><i>Summary</i></h4> <p>Although treatment was never completely successful in eliminating this patient's edema, function and comfort were markedly improved, and the course of his prosthetic treatment served to demonstrate several principles. Provision of ischial gluteal weight bearing eliminated ramus discomfort, reduced edema, and cleared skin infections anteriorly and medially where the stump contacted the socket brim. The posterior brim caused irritation of the stump when ischial bearing was indefinite, with the tuberosity near the inside edge of the socket, or when the radius of curvature over the inside edge was too small, or when the ischial area was not conditioned for weight bearing. Use of liners to decrease the anteroposterior dimension increased comfort. When there was stump shrinkage and decreased ischial support, edema increased, and a pressure pad alone was not successful in controlling it. Use of a stronger valve spring, to increase the positive pressure, decreased edema. In spite of the failure to control the edema completely, the patient was able to perform at a high level of activity.</p> <h4>Case 6, Lower Third of Thigh</h4> <h5><i>History</i></h5> <p>Case 6, male, was 56 years old, stood 6 ft. <i>2 </i>in. tall, and weighed 142 lb. He lost his right leg above the knee as a result of a motor coach accident when he was 47. The patient's first prosthesis, fitted six months after amputation, used shoulder harness suspension. It was worn for two years. The next prosthesis provided pelvic belt suspension. It was being worn when he entered the Clinical Study in November 1953 (<b>Fig. 13</b>). Complaints included tightness of the socket, discomfort due to abrasion of the hip by the belt on the side of the amputation, and irritation in the distal lateral area of the stump. The prosthesis was in a state of general disrepair.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Case 6 Original prosthesis. Weight carried on adductor roll. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Examination and Evaluation</i></h5> <p>General health was good, and activity level was high both at home and at work. The stump was conical, with light subcutaneous tissue and very light musculature, muscular atrophy having been brought about by stump inactivity in the walking cycle. Tissue over the end of the stump was very thin. The lateral distal portion of the stump was scarred, and the ischial tuberosity was small, sharp, and lightly padded. Scars in the crotch area indicated periodic folliculitis and boil formation, and there was local pain posterodistally.</p> <p>A number of points were of interest in this case. They included a heavy adductor roll due to abducted gait and the plug fit; inexperience with suction suspension and ischial gluteal weight bearing; gait faults, including the abducted gait and pelvic hike on the side of the amputation; and the history of boils and folliculitis in the crotch due to weight bearing in that area (<b>Fig. 14</b>, <b>Fig. 15</b>, and <b>Fig. 16</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 14. Case 6, Relaxed position of stump prior to treatment </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15, Case 6. Adductor roll prior to treatment. </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 6. Triangular shape of original socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>The amputee was provided with a suction socket prosthesis which included a single axis knee with constant friction swing phase control, a plantar dorsiflexion ankle, and a foot with a single toe break. Segments were willow wood reinforced with rawhide (<b>Fig. 17</b> and <b>Fig. 18</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Case 6. New prosthesis, with ischial gluteal weight bearing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Case 6. Shape of socket of new prosthesis </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since the gluteus maximus was atrophied, the extensor channel and gluteal flare were fitted closely. No relief was provided for the heavy adductor roll, which was drawn completely into the socket as a part of the process of reduction. The socket perimeters at the brim of the socket were 3 in. less than stump dimensions. Two inches below the level of the ischial seat, socket perimeters were approximately half an inch less than stump dimensions. At the lower levels, socket and stump perimeters were identical. The distance from the ischial seat to the channel for the tendon of the adductor longus was 3 3/4 in., the corresponding anatomical measurement being 3 in.</p> <p>Adduction of the femur in the socket relaxed the adductors and permitted inclusion of the roll in the socket with less difficulty (<b>Fig. 19</b>). Initially a safety belt was provided to increase the amputee's sense of security, since he had a fear of losing the leg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 19. Case 6. Condition of subject one year after application of new prosthesis. Note reduced adductor roll. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For the first three months of treatment the prosthesis was worn three hours a day. During the next six months use of the prosthesis was increased to all day, the extended period of adaptation to use of the prosthesis being due to discomfort at the ischial tuberosity. After nine months there was marked increase in comfort, a circumstance which induced the amputee to discard the cane he had theretofore used regularly. A soft pad over the ischial seat reduced discomfort but was discontinued after two weeks in the expectation that adaptation would be accelerated.</p> <p>Tight fit of the proximal third of the stump for reduction of the adductor roll resulted in edema in the distal portion of the stump. But when the socket perimeters in the upper third were increased to reduce constriction, the edema cleared up. Two weeks later the adductor roll had shrunk, and there was loss of suction. A new socket was made and modified with liners at intervals for a period of a month as shrinkage continued. By this time, the perimeter of the stump at the perineum had been reduced 2 1/2 in., so that a new socket was required. The dimension of this socket from the ischial seat to the channel for the tendon of the adductor longus was reduced by half an inch, and a protuberance was provided over the area contacting the femoral triangle.</p> <p>Edema recurred after six months, and examination of fit showed considerable development of the hamstring muscles. Accordingly, the socket was opened at the posterior wall starting 2 in. below the ischial seat level; the edema cleared up.</p> <p>Further development of stump musculature resulted in edema at the end of the stump during the ninth month of treatment. Increased hamstring relief was provided, a stronger valve spring was installed, and a sponge rubber pad was placed in the bottom of the socket to increase back pressure on the end of the stump. Again the edema cleared up.</p> <p>Training was provided for a period of one hour a day for six weeks. Gait was excellent under observation, although there was some reversion to old habits when the amputee was not under supervision. Pelvic hike was particularly persistent. Those habits which were dependent on fit and alignment, including abducted gait, were gradually eliminated.</p> <h5><i>Summary</i></h5> <p>Problems studied included stump changes, particularly at the large adductor roll, adaptation to suction suspension, adaptation to ischial weight bearing, and gait faults. Boils and folliculitis did not recur during the process of treatment.</p> <p>Reduction of the large adductor roll formed in five years of weight bearing in the crotch with abducted gait required six months of treatment. During this period there was some edema owing to constriction of the proximal third of the stump. Edema was reduced by increasing the perimeters of the socket in this region. Edema resulted again owing to constriction following hamstring hypertrophy.</p> <p>Relief for this development, the use of a stiffer valve spring for increased positive pressure in the stance phase, and a sponge rubber pad in the bottom of the socket cleared up the edema.</p> <p>There was periodic loss of suction following stump shrinkage. The light subcutaneous tissue could be distorted very little. As a result, slight stump changes led to loss of suction.</p> <p>Initially some lateral instability and reduced control of the prosthesis, probably resulting from weakness of the gluteus medius, was experienced. With adaptation to suction suspension, there was increased stability and control as the gluteus medius became stronger. Adaptation was completed within the nine months required to stabilize the stump. The ischial tuberosity took more than nine months to condition for weight bearing, chiefly because of the lack of previous experience, the light padding over the tuberosity, and the especially sharp configuration of the bone.</p> <h4>Case 8, Mid Thigh</h4> <h5><i>History</i></h5> <p>Case 8, another male, was 42 years old, measured 6 ft., and weighed 175 lb. His right leg was amputated above the knee in December 1949 after a shotgun wound received in a hunting accident approximately a year previously. He had had only one prosthesis since amputation and was wearing it at the time he was accepted by the Clinical Study in January 1954. Although the prosthesis provided suction suspension, the components were conventional. The patient was dissatisfied with the prosthesis primarily on the basis of poor fit, but he felt that the alignment could be improved and that such improvement might give him more comfort and better function. He also complained of needlelike phantom pains in the ball or sole of the "foot," with persistent tingling.</p> <h5><i>Examination and Evaluation</i></h5> <p>General physical examination was normal. The stump was conical (<b>Fig. 20</b>), approximately 9 in. of femur remained below the perineum, and about an inch of tissue covered the end of the femur. Musculature of the stump was firm, but there was retracted muscle on the lateral side about 2 1/2<i> </i>in. from the tip of the femur. There was little subcutaneous fat. On the posterior aspect of the stump at the distal end was an inverted T shaped scar, and the distal end of the femur was sensitive to pressure. X ray showed a medioposterior spur arising from the end of the femur, curving upward, and tapering. There was edema and brown discoloration at the end of the stump (<b>Fig. 21</b>), and small follicular lesions were evident in the areas contacting the anterior and medial brims of the socket.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 20. Case 8 Stump molded by tight fit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Case 8. Socket shape of original prosthesis. Note edema and brown discoloration at the end of the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The prosthesis had a wooden socket reinforced with rawhide, a single axis knee with constant friction for swing phase control, an ankle providing plantar dorsiflexion action, and a foot with a single toe break 5 in. anterior to the ankle axis. Weigh t was carried through a roll of flesh at the brim of thesocket (<b>Fig. 22</b>), and the amputee walked with a wide based gait owing to crotch discomfort and out set of the foot. Knee stability was excessive because of the long forefoot and the posterior position of the knee axis, which fell approximately 1 in. posterior to the tro chanter ankle reference line. The prosthesis was short, but this detail was not too apparent since the ischial tuberosity was 1 1/2 in. above the posterior brim of the socket. Because of insufficient knee friction and excessive kicker action, there was heavy impact at the end of the swing phase, and there was whip during the swing phase, probably owing to muscle activity within the socket and to the vigorous stump action required to break the prosthetic knee at the end of the stance phase. Rotation at heel contact was due to excessive stiffness of the plantar flexion bumper.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Case 8. Original prosthesis. Plug fit, with roll formation over the socket brim. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Problems of interest to the Clinical Study included the edema encountered with use of suction suspension, skin infections, the adductor roll, the time and circumstances involved in conditioning the amputee to ischial gluteal weight bearing, and gait training.</p> <h5><i>Treatment</i></h5> <p>Reduction of the edema required reduced constriction of the proximal third of the stump through provision of ischial gluteal weight bearing, extension of the anterior wall above the level of the ischial seat, and close fit of the distal two thirds of the stump. Reduction of pressure on the proximal end of the stump from the superior brim of the socket was required to clear up skin infections. At the same time, snug fit, with adduction of the femur in the socket to relax the adductors, was required for reduction of the adductor roll. Improved fit and alignment, with training, were planned to correct gait faults.</p> <p>The amputee was provided with a suction socket prosthesis which included a single axis knee with constant friction swing phase control, a plantar dorsiflexion ankle, and a foot with a single toe break. Segments were of wood, reinforced with plastic laminate. The extensor channel was held shallow and flared minimally at the brim to increase gluteal weight bearing, since the amputee was not accustomed to ischial weight bearing. Xo relief was provided for the adductor roll. The anterior wall of the socket was slightly relieved over the area contacting the femoral triangle (<b>Fig. 23</b>). The toe break was cut 5 in. anterior to the ankle axis so as to coincide with the normal break of the shoe. To increase knee stability in the initial phase of the fitting, the knee axis was placed 3/4 in. behind the trochanter ankle reference line. Socket perimeters were 1 1/4 in.<i> </i>under stump perimeters at the proximal end and equal to stump perimeters at the level of the distal two thirds. The distance between the ischial tuberosity and the adductor longus tendon was 3 3/4 in., the corresponding socket dimension being 4 1/2 in.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Case 8 Socket shape, new prosthesis </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Evaluation following delivery of the prosthesis indicated that knee stability was excessive owing to the long forefoot and the posterior position of the knee axis. Training was required to improve balance and cadence symmetry and to overcome the vaulting as well as to reduce the width of the walking base. The ischial tuberosity was on the seat, and there was no ramus contact with the medial brim of the socket. The adductor roll was contained in the socket. Roll formation over the anterior brim of the socket was eliminated (<b>Fig. 24</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24 Case 8. New prosthesis. Note elimination of roll formation over the brim of the socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Initially there was some edema at the distal end of the stump owing to constriction proximally. As the flesh roll reduced, constriction and edema decreased, and finally the edema cleared up. After an illness which caused the patient to lose considerable weight, the stump settled deeper into the socket as the ischial tuberosity slipped inside. This circumstance allowed the ramus to contact the medial brim and caused the anterior and posterior brims to constrict the stump. But because the somewhat conical shape of both stump and socket maintained the snug fit over the entire stump as the latter settled down into the socket, and because, consequently, the pressure differential between the proximal and distal portions of the stump was not increased sufficiently, edema did not recur. Nevertheless, ramus discomfort decreased activity on the prosthesis. The problem was eliminated with provision of a new socket.</p> <p>Follicular lesions cleared up with effective ischial gluteal weight bearing but recurred when ischial support was decreased following loss of weight. Provision of a new socket with ischial gluteal weight bearing again cleared up the skin condition. With the first socket, poor stabilization of the ischial tuberosity on the seat contributed to skin irritation and to the formation of horny nodules in the weight bearing area. Comfort was greatly improved by reduced anteroposterior dimensions, with improved anterior support by provision of a protuberance on the anterior wall over the area contacting the femoral triangle.</p> <p>Gait training improved walking habits but focused attention on deficiencies of fit by forcing the amputee to walk according to a preconceived pattern rather than one that provided maximum comfort. Sixteen months after training was complete, evaluation indicated that, because of discomfort from loss of fit, gait was somewhat worse than before training. Since in any case the amputee adapted his gait pattern to provide maximum comfort, training was of doubtful value as compared with good prosthetic treatment. With the first prosthesis, excessive knee stability detracted from naturalness of gait, and this condition also was a factor in causing the discomfort in the ischial gluteal area and at the end of the femur anteriorly, where the stump showed the results of the force required to break the knee. Subsequent fit and alignment corrected these problems and greatly improved comfort. The length of the forefoot was reduced to approximately 3 1/2 in. to decrease knee stability, and the knee axis was placed on the ankle trochanter reference line.</p> <h5><i>Summary</i></h5> <p>The patient's edema on the prosthesis worn at the time of referral was apparently caused by constriction of the stump in the socket, especially in the proximal third. A contributing factor was weight bearing on the adductor roll over the medial brim. Provision of ischial gluteal weight bearing, with wide distribution of the pressure on the anterior aspect of the stump, had a number of consequences. The edema disappeared with the reduction of the adductor and anterior rolls and recurred only when fit and ischial support were lost with loss of weight from illness. Skin irritations in the crotch, along the gluteal fold, and around the ischial tuberosity were cleared up by reduction of shearing forces when positive support was provided. Reduction of alignment stability by shortening the toe break length and by moving the knee axis forward cleared up the skin irritation on the anterodistal aspect of the stump by reducing the force required to break the knee at toe off. Training appeared to have far less effect on symmetry of gait than did fit and alignment. When the patient was able to walk symmetrically with comfort, he did so. When last seen, the amputee reported a general increase in comfort and a corresponding increase in his level of activity.</p> <h4>Case 9, Bilateral Above Knee, Upper Third of Thighs</h4> <h5><i>History</i></h5> <p>Case 9, male, 27 years of age, weight 100 lb., underwent amputation at the age of eight as a result of crushing injuries to both legs sustained in a truck accident. He had had six pairs of legs since his amputation, the first pair having been fitted four months after surgery, without preliminary conditioning iherapy or exercise. That pair, employing shoulder harness suspension, was worn for four years. Between that time and 1948, he had had three sets of legs, all employing pelvic belt suspension and using conventional components. In 1948 he was fitted at the University of California with suction suspension. The prostheses were worn for two years and then discarded because of disrepair. New suction sockets, provided in 1950, were worn for two years. These were uncomfortable owing to tightness of fit. In 1953 a local limbshop fitted the patient with the suction socket prostheses he was wearing when referred to the Clinical Study in September 1953. The complaints included skin irritation with folliculitis, boils, and abrasion on areas of the stump contacting the socket brim; crotch discomfort; and edema in the ends of the stumps. Although working at essentially a sedentary occupation, he did a great deal of walking around his office.</p> <h5><i>Examination and Evaluation</i></h5> <p>There were no significant physical findings except as pertaining to the amputations. This young man was well nourished, healthy, and of average intelligence. The stumps were almost identical. They were approximately 6 in. long, measured from the perineum, and cylindrical, with approximately 2 in. of tissue over the distal ends of the femurs (<b>Fig. 25</b>). Hygiene of the stumps and prostheses was poor, perspira ation level high. There were boils, folliculitis, and abrasions on the stumps and the crotch areas, with boils and folliculitis in the inguinal creases. Both stumps had heavy, nonpitting edema and petechiae at the distal ends. The stumps were held in 28 deg. of abduction, but ranges of motion and muscle power were normal and equal. X ray showed medial curvatures of both femurs distally. The medullary cavities appeared to be closed, and there were no sensitive areas.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Case 9. Stumps relaxed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The prostheses (<b>Fig. 26</b>, <b>Fig. 27</b>, and <b>Fig. 28</b>) had rectangular suction sockets on single axis knees with constant friction swing phase control, plantar dorsiflexion ankles, and wooden feet with single toe breaks. Segments of the prostheses were made of willow reinforced with rawhide. No auxiliary suspension or control straps were used. Although the sockets were intended to provide ischial gluteal weight bearing, the ischial tuberosities were down inside the sockets so that weight was carried on the medial brims, which had been lowered in an unsuccessful attempt to provide relief, with severe wedging of the stumps against the anterior and posterior brims. This situation was a cause of irritation and infection of the stumps in the areas contacting the medial and posterior brims of the sockets and promoted edema by restriction of circulation. Excessive alignment stability due to posterior placement of the knee axes increased forces on the posterior aspects of the stumps as the amputee attempted to break the knees to initiate swing phase.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Case 9. Socket shape of prostheses worn at time of referral, medial walls nearest patient'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. 27. Case 9. Prostheses worn at time of referral, medial view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 28. Case 9. Pros theses worn at time of referral. posterior view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The patient walked with a wide based gait, at least partially because of the abducted position of his stumps. He customarily used a cane but was able to walk without it. Because the amount of friction in the swing phase control units was adjusted to provide minimum resistance to rotation, there was impact at the end of the swing phase. Rotation at heel contact was due to excessive stiffness of the heel bumper of the left prosthesis. Torso and pelvic list were due to shortness of the right prosthesis.</p> <h5><i>Treatment</i></h5> <p>The objectives of treatment in this instance were:</p> <ol> <li>Elimination of crotch discomfort and skin problems by providing definite ischial gluteal weight bearing ;</li><li>Elimination of irritation and follicular lesions in the inguinal areas by reducing force concentrations in these areas through use of high anterior walls and definite ischial gluteal weight bearing;</li><li>Reduced wedging of the stumps proximally through provision of definite ischial gluteal weight bearing and high anterior walls for increased area of support;</li><li>Close fit oi the slumps along their entire lengths, with decreased wedging of the stumps proximally, for reduction of the edema;</li><li>Reduction in energy consumption by providing increased voluntary control with flexion of the stumps in the sockets and reduced alignment stability; and</li><li>Study of the effect of narrow and wide base alignment on lateral stability, within the limits imposed by the abducted positions of the stumps.</li></ol> <p>In March 1954, the patient was provided with two suction socket prostheses (<b>Fig. 29</b>). A light webbing belt was furnished to aid suspension. Single axis constant friction knees, plantar dorsiflexion ankles, and wooden feet with rocker toe breaks and foam crepe shoe sole material in the toes were used. The prostheses were reinforced with rawhide, the inside surfaces of the sockets were finished with cellulose acetate lacquer, and automatic expulsion valves with standard springs were used. For knee stability, the reference line joining the ankle axis to the point of contact of the greater trochanter passed 1 in. ahead of the knee axis on both prostheses. The ankles were provided with stiff plantar flexion bumpers to increase anteroposterior stability.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Case 9. Present prostheses. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Within approximately a month from the time of fitting the initial prostheses, there was substantial improvement in comfort and skin problems in the crotch areas. The medial brims were not appreciably lower than the posterior brims. Skin problems in the inguinal creases were relieved by ischial gluteal weight bearing, by high anterior walls, and by provision of a protuberance over the region of the femoral triangle (<b>Fig. 30</b> and <b>Fig. 31</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Case 9. Socket shape, present prostheses. Ischial seats are at bottom center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Case 9. Present prostheses, medial view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Provision of ischial gluteal weight bearing and increased anterior support resulted in reduced wedging of the stumps proximally, and a close fit of the stumps over their entire length produced a prompt and marked reduction in edema. Irritation in the weight bearing area was a persistent problem in the early stages of fitting. At one point, the amputee had the sockets modified in a commercial limbshop in an attempt to relieve this discomfort. But these changes increased the anteroposterior adjusted to dimensions of the sockets medially in the upper third. The tuberosities slipped into the sockets, and edema recurred. New sockets were fitted to re establish ischial support. Irritation and discomfort in the area of the tuberosities disappeared after approximately two months of conditioning. Ischial gluteal weight bearing raised the stumps in the sockets and decreased voluntary control, but after four months the patient became this change. It was found that he could walk with adequate control and stability when using stiff plantar flexion bumpers, with the ischial seats well behind the projected lines through the ankle and knee axes, and with initial flexion of the stumps for voluntary control (<b>Fig. 31</b>). Because of long established habits of abduction, it was necessary to provide wide base a lignment of the second pair of prostheses. At the time of the final evaluation, the stumps were in excellent condition.</p> <h5><i>Summary</i></h5> <p>The patient's problems of edema and skin irritation in the areas of the crotch, the inguinal creases, and the gluteal folds responded well to the standard principles of fitting. Irritation in the weight bearing area was a temporary problem which cleared up with tissue conditioning. A wide walking base was required in this case for lateral stability. The stiff plantar flexion bumpers provided anteroposterior stability both standing and walking. Placement of the sockets well forward on the knees provided adequate security.</p> <h4>Case 10, Very Short Above Knee</h4> <h5><i>History</i></h5> <p>Case 10, male, was 51 years of age, weighed 150 lb., and was 5 ft. 7 in. tall. Amputation was through the left femur in the upper third. The original amputation had been carried out in December 1952 as a result of arteriosclerosis, and the stump had been revised in August 1953.</p> <p>This patient was referred by a local limb shop that was in the process of fitting him with a pelvic belt prosthesis converted from a suction socket because of failure to maintain suction. He was pessimistic about the use of suction suspension and was unwilling to attempt it except for the benefit of the research group. Because of pressure in the groin, insecurity at the knee, toe scuffing in the swing phase, and stump withdrawal when sitting, he was dissatisfied with the leg being fitted by the local shop.</p> <h5><i>Examination and Evaluation</i></h5> <p>Physiologically, the patient appeared older than his age, but he was alert and cooperative. The abdomen was severely scarred from surgical incisions for appendectomy and double sympathectomy, and scars also extended from the distal end of the stump up the antero medial aspect to mid groin. The medial scars were deeply adhered to underlying tissue. Subcutaneous fat was moderate and musculature firm, with prominent adductors and gluteus maximus. There were no sensitive areas. Skin was normal. The femur extended 1 1/2 in. below the perineum and 7 in. below the great trochanter (<b>Fig. 32</b> and <b>Fig. 33</b>). A spur extended upward on the medial side, and the stump showed some abduction contracture.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Case 10. Lateral view of the stump in the hanging position. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. Case 10. Stump in 90 deg. of flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This patient was of interest primarily because of the very short stump. Also of interest was the patient's inexperience, which offered an opportunity to study problems of adaptation and stump changes. Experience in prosthetic treatment of cases with circulatory impairment was also desired.</p> <h5><i>Treatment</i></h5> <p>The patient was provided with a suction socket prosthesis. At first a single axis knee with constant friction swing phase control, a plantar dorsiflexion ankle, and a foot with single toe break were used. Segments were of wood, reinforced with plastic laminate. Later the knee was changed to a friction stabilized type. The final socket was made of plastic laminate, and a SACH foot (solid ankle, cushioned heel) was used instead of the conventional foot.</p> <p>Two sockets were fitted within the first two months. With the second socket, all requirements for the successful application of suction suspension had been met, but, because of obscuring factors related to the amputee's attitude, this condition was not altogether understood at the time. A remolding process had brought about elongation of the stump, a feature which made suction easier to maintain.</p> <p>Successful application of suction suspension depended upon undercutting the posterior, medial, and anterior walls of the socket below the ischial seat level, maintaining the lateral wall above the level of the ischial seat, and holding the fit close in the proximal part of the stump. Because of the undercut medial wall, bunching of the adductors did not break the suction. Suspension aids, valuable in providing increased sense of security in the initial phase of treatment, were unnecessary once the amputee was adapted to the use o'f his prosthesis. Because of the limited amount of femur available, and also because of the abducted position of the stump, no attempt was made to adduct the femur in the socket. Flexion of the stump in the socket was designed to meet the natural requirements of the stump and spine rather than to provide voluntary control of the knee, since stump power was limited and undercutting of the anterior and posterior walls of the socket reduced the effectiveness of the stump in controlling the knee (<b>Fig. 34</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. Case 10. Rectangular socket provided for patient. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Initially the patient was provided with a conventional single axis knee with adequate knee stability. Fear of falling and buckling of the prosthetic knee due to weakness of the normal leg, inexperience, and other factors, however, led to use of a friction stabilized knee. But aligning the friction stabilized knee in accordance with the rules for the single axis conventional knee resulted in excess stability at the end of the stance phase. Accordingly, the knee was later aligned to provide decreased alignment stability with greater reliance on the friction mechanism.</p> <p>Although narrow based gait was not anticipated in the alignment of the limb, the amputee was able to walk with a 4 to 6 in. base. The prosthesis was made about 1 1/2 in. shorter than the normal limb (<b>Fig. 35</b>) because the amputee found that the shorter prosthesis permitted better control. Before prosthetic treatment started, the patient had back pains, and it was anticipated that the shorter leg might lead to recurrence. As a matter of fact, he had some recurrence of the back pains early in the fitting when a webbing belt was tried as a supplement to suction suspension. But this problem disappeared when use of the belt was discontinued.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. Case 10. New prosthesis, posterior view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Stump changes during the study were minimal. In the first two and a half months, stump shrinkage occurred, but the stump remained stable throughout the following two years of observation. After the patient had worn the first suction socket prosthesis a short time, the tissue of the stump started to extend, so that by the time the stump had stabilized there was an increase from 1 1/2 in. to 3 in. of tissue available below the perineum for effecting a suction seal. At no time was there more than a reddening of the stump in the weight bearing area, and, as the tissue became conditioned, the skin became dark and tough. There was no edema.</p> <h5><i>Summary</i></h5> <p>The problem in this case was to attempt application of suction suspension to a very short, heavy, above knee stump. Suction proved to be a practical means of suspension. All walls were concave, and relief was provided for bunching adductors to prevent the stump from being forced away from the socket in the medial apexes with consequent failure of the suction seal. For increased control and reduced effort, the amputee preferred the prosthesis approximately 1 1/2 in. shorter than the normal leg. There were no back pains. The stump shrank slightly during the first two months, and there was elongation of the stump, particularly on the medial side. Because of insufficient knowledge for adequate prosthetic treatment of the patient, and because of the poor adjustment of the patient to his amputation and physical condition, rehabilitation was a lengthy process. Once the patient was successfully treated, no changes in fit and alignment were required over a two year period.</p> <h4>Case 24, Lower Third of Thigh</h4> <h5><i>History</i></h5> <p>Case 24, female, was 41 years of age, stood 5 ft. 2 in. tall, and weighed 126 lb. She had undergone amputation at the level of the lower third of the left femur. There had been a congenital lymphangioma involving the tissues of the left leg from the knee down. Infection developed in the soft tissues over the anterior portion of the tibia, and subsequently there was an osteomyelitis of the tibia. Later a mass, which was diagnosed as carcinoma, appeared in the ankle. Amputation was performed in May 1954.</p> <p>The amputee had had only one prosthesis since amputation. It consisted of conventional components and a molded leather socket laced anteriorly (<b>Fig. 36</b>). When she entered the study program in January 1955, complaints included skin irritation and infection, with discomfort in the crotch, discomfort and restriction from the corset used to suspend the prosthesis, right sided backache, and excessive wear of hosiery.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. Case 24. Prosthesis worn on referral. Note lateral displacement of the socket on the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Examination and Evaluation</i></h5> <p>Normally a very active person, the patient had a rather low activity level owing to limitations imposed by her prosthesis. General physical condition was good, except for very flabby abdominal musculature, but the patient experienced phantom sensations as though the "leg" were "falling asleep." Phantom pains in the form of cramps in the ''calf" and shooting pains on the medial side of the "ankle" also were present. They lasted only a few seconds and were less frequent since she had been fitted with a prosthesis.</p> <p>The stump was cylindrical and 9 in. long measured from the perineum, including approximately 2 in. of redundant tissue over the end of the femur. Subcutaneous tissue was heavy but firm. Musculature was of average strength, with no group particularly prominent. There was no significant edema or skin problem in the distal end of the stump, but follicular lesions existed in the crotch, and areas of irritation were present on the torso from pinching and bruising by the corset stays.</p> <p>The prosthesis provided weight bearing on a flesh roll around the brim of the socket, in the crotch, and against the side walls of the socket (<b>Fig. 37</b> and <b>Fig. 38</b>). A pressure pad in the bottom of the socket did not provide appreciable support, and the patient walked with a wide base and with torso and pelvic list owing to excessive length of the prosthesis, wide base alignment, and discomfort in the crotch. Stride length, cadence, and arm attitude were unsymmetrical because of excessive stability of the prosthetic knee.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. Case 24. Socket shape at the brim, prosthesis worn on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. Case 24. Lateral view of the stump in the hanging position. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This amputee presented several problems of interest to the study group. They included skin infections, the relationship between redundant tissue at the end of the stump and edema with suction suspension, factors involved in changeover from corset to suction suspension, factors involved in changeover to ischial gluteal weight bearing, stump changes, the cosmetic problems of a female amputee, and use of the SACH foot with high heeled shoes.</p> <h5><i>Treatment</i></h5> <p>In September 1955, the patient was provided with a suction socket prosthesis consisting of a single axis constant friction knee, a SACH foot made for a high heeled shoe, and wooden segments reinforced with plastic laminate. An automatic expulsion valve with standard spring was used, and the inside surface of the socket was finished with phenolic resin varnish. A polyvinyl chloride acetate cosmetic cover was provided for the shank. Since the amputee was unaccustomed to ischial weight bearing, and also in order to increase sitting comfort, the gluteal flare and the extensor channel were fitted closely to provide increased gluteal support. The lateral wall was closed in over the stump above the ischial seat level, and the anterolateral apex was closed to reduce conspicuousness of the brim of the socket under the clothing.</p> <p>This socket was worn on the adjustable leg<a></a> for approximately a month and was then installed in a finished prosthesis. After a week, the redundant tissue at the end of the stump was moderately edematous. The only known difference between the prosthesis with the adjustable leg and the finished prosthesis was that the latter had five coats of "Platon" varnish on the inside of the socket. There were three possibilities related to the finish of the socket interior. The stump worked down into the socket through weight bearing, with increased effect of muscle activity on negative pressure and reduced positive pressure in the stance phase owing to reduced excursion of the stump in the socket. There was adherence of the stump to the walls of the socket and, hence, reduced massaging action at the distal end. Vacuum seal was improved so that negative pressure was maintained, especially during sitting.</p> <p>The edema cleared up after provision of a pressure pad in the bottom of the socket and after atrophy of the stump, which reduced constriction proximally. In addition there was, as a result of aging and lubrication of the surface finish by body oils, decreased adherence of the stump to the socket. Addition of liners to compensate for shrinkage did not cause edema with this socket.</p> <p>A second prosthesis was supplied in December 1955, the socket of this limb being fitted snugly in anticipation of further shrinkage of the stump. Six weeks after delivery of the prosthesis, examination showed edema at the end of the stump. A pressure pad was provided, but there was no reduction in the edema during the next two months. Pad thickness was then increased. When the amputee was examined next, six weeks later, the pad had been discarded owing to ineffectiveness in controlling the edema. Edema was reduced, and the stump had atrophied further. This development had reduced constriction of the proximal portion of the stump without reducing the effectiveness of ischial support, thus indicating that edema was caused by constriction of the proximal area and that the pressure pad was ineffective in reducing it so long as constriction persisted proximally. Six weeks later there was no edema, and the socket was looser. Liners were installed over the anterior and posterior walls to decrease perimeters of the socket in the upper third by one inch. Edema did not recur. Socket perimeters proximally were reduced another inch two months later as a result of stump atrophy. There was no edema before or after addition of the liners, and at no time was there failure of ischial support.</p> <p>The patient adapted very well to the changeover from corset to suction suspension and appreciated the comfort and freedom that resulted. Control of the prosthesis was excellent. Adaptation to ischial gluteal weight bearing was immediate, and skin lesions and discomfort in the crotch cleared up quickly. The shallow gluteal flare and extensor channel, with relief for hamstring attachments at the ischial tuberosity, provided sitting comfort. As the stump atrophied, proper weight bearing was maintained effectively by the addition of liners to the anterior and posterior walls of the socket as necessary (<b>Fig. 39</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. Case 24. Socket shape, new prosthesis. Note liners added for shrinkage adjustment. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Stump atrophy due to heavy subcutaneous tissue was a problem, and the stump had not stabilized at the end of a year. It was found that initial fitting of the socket snugly, in anticipation of shrinkage, was satisfactory practice and did not produce a serious amount of edema. Such edema as was produced subsided as stump atrophy proceeded. As further shrinkage occurred, liners were added without complications.</p> <p>Closing the lateral wall over the stump above the ischial seat level and curving the anterolateral apex improved appearance of the prosthesis under clothing. The SACH foot provided a good cosmetic junction between the shank and the foot and permitted use of high heeled shoes. The polyvinyl acetate cosmetic covers used were sufficiently durable (<b>Fig. 40</b>) and were acceptable in appearance until they become discolored. Staining was objectionable within about six months.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 40. Case 24. Anterior view of new prosthesis with cosmetic covering. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although the cosmetic effect of the SACH foot was appreciated by the amputee, there was objection to the decreased plantar flexion action and to the damage this caused to spike heeled shoes. As a result, the patient requested a foot with an articulated ankle. It was found that the decreased plantar flexion action was a problem down ramps only.</p> <h5><i>Summary</i></h5> <p>In spite of the excessive amount of redundant tissue at the distal end of the stump, it was possible to use successfully suction suspension embodying the principles and techniques previously outlined. Problems of edema, skin changes, and loss of suction that occurred during fitting and wearing of the prosthesis were successfully treated by controlling the fit and alignment. Proper fit and alignment were instrumental in promoting stump reduction to a more firm and functional state and in eliminating skin lesions and discomfort in the crotch due to the heavy subcutaneous tissue and steady stump reduction. With a properly fitted suction socket prosthesis, the patient was able to assume a more satisfactory level of activity without discomfort, and it was possible without difficulty to adapt this type of prosthesis to the requirements of cosmetic appearance. Foot and ankle function were suitable for use with high heeled shoes, but frequent examinations and modifications to socket fit were required to maintain comfort.</p> <h4>Case 28, Lower Third of Thigh</h4> <h5><i>History</i></h5> <p>Case 28, male, age 62, height 5 ft. 11 in., weight 121 lb., underwent amputation in the lower third of the left femur in June 1955 following circulatory failure. When he entered the Clinical Study in August 1955, he was wearing a plaster socket on a peg leg with shoulder harness suspension. He disliked the peg leg because of its appearance and because of discomfort in the crotch. Activity level postoperatively was very much less than prior to amputation and was a matter of great concern to the amputee, who had just retired to a small farm.</p> <h5><i>Examination and Evaluation</i></h5> <p>The amputee's physiological age was in advance of his chronological age. The stump was 11 in. long and cylindrical, with light subcutaneous tissue, average musculature considering the age of the patient, and full range of motion at the hip (<b>Fig. 41</b>). The end of the femur was adequately covered and tolerated considerable pressure. At the end of the stump there was persistent, mild pain not related to use of the temporary prosthesis, and there were diminishing shooting phantom pains. X ray showed a spur on the lateral distal end of the femur. Postoperative edema was slight. The plaster socket on the pylon leg had been furnished to aid in reducing the stump. As shrinkage proceeded, the number of stump socks used had been increased to adjust for it. Considerable stump shrinkage had occurred, a circumstance which, despite the added stump socks, allowed the stump to drop into the socket. Severe crotch discomfort was present, since ischial weight bearing was not used. The amputee walked with a circumducting gait, stride length on the prosthesis was shorter than that on the normal side, there was rotation around the pylon in stance phase, gait was abducted, and one cane was used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 41. Case 28. Stump in abduction, slack tissue on medial side. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Of interest to the research group were the effects of the temporary plaster socket and the peg leg, stump changes, the rate of rehabilitation of the amputee, and evaluation of suction suspension on an elderly amputee with circulatory deficiency.</p> <h5><i>Treatment</i></h5> <p>The patient was provided with a suction socket prosthesis which included a willow socket, a variable cadence friction controlled knee, a willow shank, and a SACH foot (<b>Fig. 42</b> and <b>Fig. 43</b>). Wooden segments were reinforced with plastic laminate, and the socket was finished inside with a phenolic varnish. The extensor channel was shallow, and there was minimal gluteal flare to ensure as much gluteal support as possible (<b>Fig. 44</b>). The anterior wall protruded over the area contacting the femoral triangle starting at the anterior brim and extending downward to a point one third the distance down into the socket. Evaluation of the finished prosthesis indicated that the forefoot was too long and that there was insufficient initial flexion of the stump in the socket.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 42. Case 28. Lateral view of new prosthesis. Note amount of initial flexion of the stump, as indicated by the angle between the shank and thigh sections Note also extension of the gluteus maxi mus over the brim of the socket, indicating weight bearing on the tendinous hamstring attachments. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 43. Case 28. Posterior view of new prosthesis providing ischial gluteal weight bearing and narrow based alignment. Knee is friction stabilized. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. Case 28. View of the crotch area of the stump and of the socket brim of the new prosthesis. Note the distance between the level of the ischial tuberosity and the very prominent tendon of the adductor longus. Note also the corresponding socket dimension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>At first the amputee found it difficult to don the prosthesis, partly because of his age and partly because of the snugness of fit, which was intended to aid in stump reduction. The difficulty decreased as the patient became more accustomed to the limb and as snugness was reduced with stump shrinkage. Because of the patient's age and physical condition, it was necessary to maintain a comparatively low activity level during fitting and training, a matter which resulted in minimum discomfort or abrasion of the skin from impact between the stump and socket. The single axis knee offered sufficient stability under normal circumstances, but the amputee felt insecure at such activities as gardening. As a result, he was provided with a friction stabilized knee, and alignment stability was reduced. Initial indications were that the friction stabilized knee was an advantage, especially at heel contact. More supervision during fitting and training was required than is usually the case with younger amputees. Suction suspension offered good control, but had the patient been weaker this method of suspension might not have been practical because of the difficulty of putting the leg on.</p> <p>Gait evaluation showed two faults. One, circumduction of the prosthesis, was probably carried over from the peg leg. The other, which consisted of stepping from the prosthesis to the normal leg as soon as the resistance of the prosthetic forefoot was felt, may also have been related to the use of the pylon. Training reduced but did not eliminate these characteristics of nonsymmetrical gait.</p> <p>There was consistent stump shrinkage over the first six months of treatment. The initially snug fit of the socket was of limited significance since shrinkage was extensive. Addition of liners as the stump shrank was a successful means of maintaining fit, although it eventually affected alignment. Most extensive shrinkage occurred in the proximal third of the stump. Postoperative edema was not a significant factor, nor was stump hypertrophy. To avoid excessive enlargement of the socket during adjustments, it was necessary to apply a shrinker bandage before prosthetic treatment was started.</p> <p>There were no fitting problems related to the limited time lapse between amputation and prosthetic treatment. Adaptation was rapid, and the cane used with the plaster pylon was discarded before delivery of the permanent prosthesis. Use of the prosthesis as part of the reduction treatment introduced the difficulty of frequent examinations and adjustments but was less troublesome and more effective than applying the shrinker, especially at the proximal end of the stump, which the amputee found difficult to wrap properly.</p> <p>At no time were there skin or circulatory problems with suction suspension, but initially there was moderate discoloration at the distal end of the stump owing to the snugness of fit at the proximal end. Loss of suction, a matter related to the lightness of the subcutaneous tissue, was a frequent problem. Only a small amount of stump shrinkage produced loss of suction, since the amount of tissue distortion possible prior to shrinkage was limited, which is to say that stump fit had to be maintained close to optimal at all times.</p> <p>Some end bearing was provided on a pad of foam crepe shoe sole material in the bottom of the socket. When end bearing was increased periodically as the stump dropped deeper into the socket with stump shrinkage, the stump end became sensitive and even painful.</p> <h5><i>Summary</i></h5> <p>Problems studied with this amputee included those involving his age, his experience on the peg leg, stump changes, rate of rehabilitation, use of suction suspension where there had been circulatory impairment, and training. Prosthetics treatment was more time consuming, but stump discomfort was not a problem since activity level was low. At first the patient found the leg hard to put on, but this problem was overcome with practice. Fitting and training schedules were less strenuous than would be followed with a younger amputee. Use of the friction stabilized knee increased the amputee's confidence, and voluntary control was thus improved because it was possible to provide more flexion of the stump in the socket. Use of the temporary prosthesis with plaster socket and peg leg attachment introduced gait problems which could not be eliminated entirely, but the plaster socket was effective as a means of reducing postoperative edema. There was, for example, almost no postoperative edema when treatment was started. It was therefore not a problem. Suction suspension caused no circulatory difficulties.</p> <h3>Case 37, Very Short Above Knee</h3> <h5><i>History</i></h5> <p>Case 37, male, age 39, height 5 ft. 11 in., weight 180 lb., underwent amputation through the right femur, 1 1/2<i> in.</i> below the perineum, as a result of an injury sustained in World War II. At various times, but without success, attempts had been made to fit him with above knee prostheses, including suction (<b>Fig. 45</b>) and belt suspension. These circumstances led to a proposal by the referring agency to have the patient fitted as a hip disarticulation case using the Canadian type of prosthesis.<a></a> A plaster cast check socket had been fitted as a preliminary, with apparent success.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45. Case 37. Unsuccessful suction socket worn on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Examination and Evaluation</i></h5> <p>The stump, though short, was powerful, and the end of the femur was covered by approximately 1 in. of muscle padding. Subcutaneous tissue was fairly heavy. The ischial tuberosity was broad and well padded, but there was pressure sensitive scar tissue on the lateral side of the stump and in the crotch (<b>Fig. 46</b>, <b>Fig. 47</b>, and <b>Fig. 48</b>). The distal end of the stump tolerated considerable pressure but, because of a trigger point on the anterodistal aspect, it was unsatisfactory for end bearing. Abduction and flexion contracture of the hip was typical of an above knee amputee with a short stump. Because of the habit of extending the knee when crutch walking, a practice which had reduced extensor control at the knee, the normal knee buckled occasionally under load in the flexed position. A triple arthrodesis of the normal ankle was an additional complication.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 46. Case 37. Posterior view of stump. Note scar on posterolateral apex. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 47. Case 37. Anterior view of stump. Note scars in crotch and on lateral side of anterior aspect. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 48. Case 37. Lateral view of stump in maximum flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>The problem presented was how to fit an amputee who was on the borderline between the above knee case and the hip disarticulation. Were the patient fitted as a hip disarticulation, there would be loss of stump function, and, since the amputee lived in a hot summer climate, the socket would present a particularly acute heat problem. Joint placement with the hip disarticulation prosthesis would also be a problem, since, when the stump was flexed, it extended 2 in. ahead of the usual anterior contour for a hip disarticulation amputee.</p> <p>An above knee type of prosthesis offered the advantage of preserving stump function, particularly where suction suspension could be used effectively, since with the use of suction there is reduced excursion and piston action of the stump in the socket. At the same time, the shortness of the stump, with the reduced area for effecting a suction seal, and the large volume change in the stump between the relaxed and the tensed states, accompanied by prominent bunching of the adductors, could cause difficulty in achieving a reliable suction seal. Moreover, the possibility existed that the close fit required could cause discomfort to the sensitive scar tissue in the crotch.</p> <p>It was decided to treat this patient simultaneously as an above knee and as a hip disarticulation amputee, first to check the possibilities of using suction suspension on such a short stump and, second, to check the Canadian hip disarticulation prosthesis as a method of treating very short above knee stumps. The amputee was successfully fitted with a plaster hip disarticulation check socket and walked for two hours with a peg leg attached. The socket constructed from this check socket would have provided sufficient clearance for installation of the hip joint, but the hip disarticulation fitting was discontinued at this stage because of success achieved with suction suspension.</p> <p>Within five days of the beginning of treatment the subject walked successfully on the adjustable leg using suction suspension. The first socket failed from loss of suction through the posterolateral apex because the socket had been enlarged in this area in an attempt to compensate for the action of the gluteus maxi mus, which tended to force the stump away from the socket. The second socket, modified in view of lessons learned from the first, held suction and was comfortable (<b>Fig. 49</b>). It was provided in a finished prosthesis. A short above knee pelvic harness, as designed at the University of California (<b>Fig. 50</b>), was added to assist in swing phase control and to maintain the prosthesis on the stump in the sitting position.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 49. Case 37 Successful suction socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 50. Auxiliary suspension for short stump above knee amputee (modified Silesian belt), as designed at the University of California. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Components incorporated into the finished prosthesis included a SACH foot, a wooden shank reinforced with plastic laminate, a friction stabilized knee, and a wooden socket providing definite ischial gluteal weight bearing. The tuberosity was located on the posterior edge of the seat, so that considerable weight was carried on the tendinous hamstring attachments, and the gluteal flare was fitted close to provide some gluteal support and to ensure a suction seal. The medial brim was held level with the posterior brim, while the anterior brim extended 2 1/2 in. above the ischial seat level. The socket protuberance into the area of the femoral triangle did not extend below the level of the ischial seat, and the lateral brim was held at the same level as the anterior brim. To aid in effecting a suction seal, the perimeter of the socket was enlarged below the brim level. The concavity of the anterior wall started 1 in. above the level of the ischial seat and extended downward, while the concavity of the lateral wall was above the ischial seat level. Concavity of the medial wall below the brim provided room for the prominent adductors, so that suction was not lost when the stump was tensed. At the brim, the socket perimeter was approximately 3 in. less than the stump perimeter. Alignment stability was reduced, inasmuch as a friction stabilized knee was provided.</p> <p>The short stump harness was successful in preventing loss of suction during sitting, the leg adhered firmly with tensing of stump musculature when the amputee walked, and there was no ramus discomfort. The scar in the crotch proved to be no problem in fitting and was not a source of discomfort. Except for a mild discomfort in sitting, which resulted in stretching of the skin, especially while sitting in soft seats, there was no discomfort from the posterior brim of the socket. Gait was satisfactory using one cane.</p> <p>Examination one month after treatment. was begun showed little change in the stump since the initial examination; it had simply elongated about 1/2 in. on the medial side. The ischial tuberosity tolerated weight bearing without difficulty, and the skin over that area was somewhat toughened. No edema, skin abrasion, or skin infection was evident. Six weeks after treatment started the amputee used the leg all day with one cane, but at a low activity level. Buckling of the normal knee was reduced as a problem when use of the knee increased with improved physical condition.</p> <p>Five months after treatment started the amputee wore the prosthesis from rising to retiring, and the stump was in excellent condition. Activity level was average, considering the level of amputation. One cane was used, although the patient was able to walk without it. There was some brownish discoloration in the weight bearing area. Stump shrinkage was not noticeable, and there was no further elongation of the stump. The tuberosity was firmly supported on the ischial seat, and there was no crotch discomfort, although there was slight skin irritation in the crotch due to roughness of the socket finish. The amputee considered the socket comfortable but wanted the leg lengthened. The rough area on the medial brim was covered with "Teflon" tape in an attempt to reduce friction. Elongation of the prosthesis by 5/8<i> </i>in. resulted in an improved gait appearance.</p> <h5><i>Summary</i></h5> <p>The problem in this case was to define prosthetic requirements correctly. Suction suspension with the above knee type of prosthesis, in conjunction with the short stump pelvic harness, was successful and, since it preserved usable function of the stump, seemed to offer for this amputee a method of treatment to be preferred over the hip disarticulation prosthesis. Difficulties encountered were minimal owing to the previous experience gained with Case 10 (page 64).</p> <p>Gait, more natural with the use of one cane, improved markedly over the five months of study. Weight bearing on the gluteus maxi mus, ischial tuberosity, and tendinous attachments of the hamstring musculature was satisfactory. Use of the high anterior wall, without a protuberance of the socket wall over the area in contact with the femoral triangle, except above the ischial seat level, was satisfactory. For retention of suction, it was necessary to make all walls of the socket concave, especially below the medial brim because of bunching of the adductors.</p> <h3>Conclusion</h3> <p>From working with a group of amputees such as has been reported here, or from work with any similar group, many lessons are to be learned. One of the most obvious is that considerable "tincture of time" is required to solve chronic problems. The hope is that, as a result of the considerable amount of time devoted by a relatively small group of research subjects at the University of California, prosthetics clinic teams will gain some insight into possible methods of solving the problems of many other amputees.</p> <p>The most common prosthetic problems of above knee amputees as a group are edema, formation of an adductor roll, discomfort in the perineum (ramus pressure), and skin lesions. It has been found possible to control edema by maintaining a relatively uniform contact pressure between stump and socket. The proximal third of the socket need be fitted only slightly tighter than the more distal areas while still maintaining an airtight seal. In the case of an edematous stump, it is important to recognize the necessity for skillful application of socket liners to maintain a functional socket fit as the edema is reduced. Such liners are usually applied along the anterior and lateral walls only.</p> <p>The adductor roll which typically occurs with plug fit requires considerable time before the change can be made to an efficient, well fitting suction socket. Almost without exception, such a condition requires a second socket to complete the fitting.</p> <p>Ramus pressure is a thing of the past. Use of the higher anterior brim and the proper anteroposterior dimension from Scarpa's triangle to the posterior brim will eliminate completely this most troublesome complaint of above knee amputees. No longer need the above knee amputee suffer in silence because he just naturally expects his leg to be uncomfortable in this area.</p> <p>Provision of an efficient supporting surface along the posterior brim of the socket and of a proper fitting of the lateral wall of the socket to provide femur stabilization will relieve common areas of skin irritation, such as at the anterior brim, at the ischial seat, at the medial brim, and at the lateral distal end of the stump. The most common sources of skin difficulties are poor stump hygiene or rubbing and abrasion. Abrasion can be minimized by a functional fitting of the socket.</p> <h3>Acknowledgments</h3> <p>The group that worked on the patients presented in this article comprises in fact the whole staff of the Lower Extremity Amputee Research Project. Even more than amputee treatment must be, this study has been the product of many minds and many labors. Particular mention should be made of the staff members who were especially concerned in the study of the patients here reported. Dr. Henry E. Loon, Coordinator of the Medical Division, served as medical consultant to the group through much of the work. Jack C. Bates, Prosthetic Specialist, served in the vital function of trainer, in addition to making all arrangements with patients. And Jim C. McKennon and William H. Hoskinson served as prosthetists and faced the task of interpreting the plans of the research group as fully as possible to the patients in the fitting room.</p> <p><b>References:</b></p> <ol> <li>Eberhart, Howard D., and Jim C. McKennon, <i>Suction socket suspension of the above knee prosthesis</i>, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw Hill, New York, 1954.</li> <li>Foort, J., and C. W. Radcliffe, <i>The Canadian types hip disarticulation prosthesis</i>, University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Prosthetics Research Board, National Research Council, March 1956.</li> <li>Radcliffe, C. W., <i>Use of the adjustable knee and alignment jig for the alignment of above knee prostheses</i>, 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., <i>Mechanical aids for alignment of lower extremity prostheses</i>, Artificial Limbs, May 1954.</li> <li>Radcliffe, Charles W., <i>Alignment of the above knee artificial leg</i>, Chapter 21 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw Hill, New York, 1954.</li> <li>Radcliffe, Charles W., <i>Functional considerations in the fitting of above knee prostheses</i>, Artificial Limbs, January 1955.</li> <li>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Committee on Artificial Limbs, National Research Council, <i>The suction socket above knee artificial leg</i>, revised edition, April 1948.</li> <li>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, <i>The suction socket above knee artificial leg</i>, 3rd edition, April 1949.</li> <li>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, <i>Functional considerations in fitting and alignment of the suction socket prosthesis</i>, March 1952.</li> <li>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Functional considerations in the fitting and alignment of the suction socket above knee prosthesis</i>, 2nd edition, August 1953.</li> <li>Wagner, Edmond M., <i>Contributions of the lower extremity prosthetics program</i>, Artificial Limbs, May 1954.</li> <li>Wagner, Edmond M., and John G. Catranis, <i>New developments in lower extremity prostheses</i>, Chapter 17 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw Hill, New York, 1954. See especially pp. 497 and 547.</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>2.</b> </td><td class="clsTextSmall">Foort, J., and C. W. Radcliffe, The Canadian types hip disarticulation prosthesis, University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Prosthetics Research Board, National Research Council, March 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>4.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower extremity prostheses, Artificial Limbs, May 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">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>4.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower extremity prostheses, Artificial Limbs, May 1954.</td></tr><tr><td class="clsTextSmall"><b>5.</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>References</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Wagner, Edmond M., Contributions of the lower extremity prosthetics program, Artificial Limbs, May 1954.</td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Wagner, Edmond M., and John G. Catranis, New developments in lower extremity prostheses, Chapter 17 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw Hill, New York, 1954. See especially pp. 497 and 547.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Radcliffe, Charles W., Functional considerations in the fitting of above knee prostheses, Artificial Limbs, January 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>1.</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>3.</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>4.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower extremity prostheses, Artificial Limbs, May 1954.</td></tr><tr><td class="clsTextSmall"><b>5.</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><tr><td class="clsTextSmall"><b>7.</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>8.</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>9.</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, March 1952.</td></tr><tr><td class="clsTextSmall"><b>10.</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 the fitting and alignment of the suction socket above knee prosthesis, 2nd edition, 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>James Foort, M.A.Sc. </b></td></tr><tr><td class="clsTextSmall">Assistant Research Engineer, Lower Extremity Amputee Research Project, University of California, Berkeley; formerly with Prosthetic Services Centre, Canadian Department of Veterans Affairs, Sunnybrook Hospital, Toronto.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Norman C. Johnson, M.D. </b></td></tr><tr><td class="clsTextSmall">Orthopedic Consultant, Lower Extremity Amputee Research Project, University of California, Berkeley.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Associate Professor of Engineering Design, University of California, Berkeley; member, Committee on Prosthetics Research and Development, PRB, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-39.jpg Figure 2 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-42.jpg Figure 3 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-43.jpg Figure 4 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-44.jpg Figure 5 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-45.jpg Figure 6 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-46.jpg Figure 7 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-47.jpg Figure 8 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-48.jpg Figure 9 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-49.jpg Figure 10 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-50.jpg Figure 11 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-51.jpg Figure 12 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-52.jpg Figure 13 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-53.jpg Figure 14 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-54.jpg Figure 15 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-54b.jpg Figure 16 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-55.jpg Figure 17 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-56.jpg Figure 18 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-57.jpg Figure 19 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-58.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 Above Knee Amputees Creator An entity primarily responsible for making the resource Charles W. Radcliffe, M.S., M.E. * Norman C. Johnson, M.D. * James Foort, M.A.Sc. * https://staging.drfop.org/files/original/7b641cc2c5efff0b13ea00554ff0524c.pdf 7625f33cbc3d4cfb83ec80cc57916490 https://staging.drfop.org/files/original/2b460a57bd7e3cefefc865722303cf8f.jpg f61aec4f5e8a68c88c0f3a7934ceba87 https://staging.drfop.org/files/original/158699aa9b82e6f73a8a2b652cb7d6fd.jpg fbdb3216dca3e4ba5c6f63d3222e452b https://staging.drfop.org/files/original/a68325f5b73646b5b593a8acb1bbd837.jpg f36901c352aad3d7bb8795ed8f2a6646 https://staging.drfop.org/files/original/cc30670084ad14b7609684a6454ac848.jpg 56d45a2b3659d1499e21a5da9829a307 https://staging.drfop.org/files/original/233ef95f73081b8f7c73a4ef388b3eae.jpg deffb0023ad714487dbd06e45b858dc0 https://staging.drfop.org/files/original/4696142a132cee2456d1fdc6faeb4ca9.jpg 89c9bf5a3b883b4293bb308ede78dbd4 https://staging.drfop.org/files/original/5bffdfe2ad0da8b9f5cc1981f71cf7c3.jpg fddc2597a8f63495c8c21845fe13d0a5 https://staging.drfop.org/files/original/d4520c3e41c8750ce3b30ffd8da8e2e5.jpg 71f93afbfae1921384420fd2c1e67617 https://staging.drfop.org/files/original/4fe5adb111706602874b94494623dc2d.jpg b885f7d3eededf4598d34efa04ba7d66 https://staging.drfop.org/files/original/8efb8897726cd8dd75a4539c0b6b2463.jpg e7714a18bbc9e8eacf2f3a4f34b3a9eb https://staging.drfop.org/files/original/0c9233c7ec883b727ccba3e73ba7b4db.jpg f5bcc44ab3a4478f32af9bf11055980c https://staging.drfop.org/files/original/03d2e12c78b332580cb171eb3d225e8f.jpg 83b50125b9d6bb8baff6767c478c78dc DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1957_02_022.pdf Year 1957 Volume 4 Issue 2 Page Number(s) 22 - 28 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_022.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1957_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 Evolution of the Canadian-Type Hip-Disarticulation Prosthesis</h2> <h5>Colin A. McLaurin, BASc. <a style="text-decoration:none;">*</a><br /></h5> <p>Not many people are amputees. Still fewer people are prosthetists. Not many amputees are hip-disarticulation cases. Hence, not many prosthetists are interested in hip-disarticulation prostheses except when occasion demands. That just about sums up the history of hip-disarticulation prosthetics.</p> <p>A more intensive look at the picture reveals two more or less standard approaches to the problem, but usually there are as many variations as there are limbshops. The accompanying illustrations (<b>Fig. 1</b>, <b>Fig. 2</b>, <b>Fig. 3</b>, <b>Fig. 4</b>, <b>Fig. 5</b>, and <b>Fig. 6</b>) indicate the practice, if not the principle, of conventional fitting, together with some of the variants. A study of the principles of conventional fitting is even more revealing. The guiding one seems to be this: Take one standard above-kn ee leg and build on to it until it can be strapped to the amputee. The practice certainly bears this out. Even the term "tilting-table prosthesis" suggests working from the leg up to the stump, instead of beginning with the amputee, who properly should be the focal point in any attempt at rehabilitation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Saucer-type prosthesis for hip disarticulation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Tilting-table prosthesis for hip disarticulation, basic design. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Variations in tilting-table prostheses: strap-and-roller medial support. Left, anterior view; right, medial view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Variations in tilting-table prostheses: latch-type medial support, cross-sectional view. Above, standing; below, sitting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Variations in tilting-table prostheses: hip joint below socket. Left, anterior view; right, medial view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Variations in tilting-table prostheses: track-and-roller joint. Left, anterior view; right, medial view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This back-handed approach to problems is not something unique among limbfitters. The plumber is more interested in joining pipes than he is in the water requirements of a household. The airplane pilot is more concerned with the trim of the aircraft than with the comfort of the passengers' seats. The prosthetist's main interest lies in making a leg he can fit on the customer, and in so doing he has shown a considerable amount of ingenuity. Perhaps had the variations not been local in nature, more progress could have been made. Many fitters have come surprisingly close to the Canadian-type prosthesis, and no doubt others actually envisioned the basic principles without achieving the mechanical design.</p> <p>Generally speaking, the hip-disarticulation case has been considered very unfortunate when compared with other above-knee cases. Perhaps some of this attitude is owing to the fact that a great many cases are not of traumatic origin and that therefore the life expectancy is short. In any event, the result is that the amputee is not encouraged to expect much from his prosthesis. The usual complaints are mechanical in nature-rattling in the joints and the need for frequent repair. Accordingly, most innovations in the prostheses have been directed toward solving these mechanical problems, and more by chance than by design functional advantages evolved.</p> <p>Conventional hip-disarticulation prostheses are usually classified into two main categories, the saucer type and the more common tilting-table type.</p> <h4>The Saucer-Type Prosthesis</h4> <p>The saucer type of prosthesis, shown in <b>Fig. 1</b>, is essentially a standard above-knee leg with a saucer-shaped socket on top of the thigh. Suspension is by means of a single-axis joint and pelvic band and may include fore and <!--Page 23--> aft straps that pass over the shoulder. This type is most suitable for short-femur amputations because adequate stability is difficult to achieve without the additional bone structure. In accord with common practice with above-knee legs, the hip joint is placed well forward, thus providing some measure of stability. A lock may or may not be used at the hip joint. If a lock is used, it is of the semiautomatic type. A lever is pressed to release the lock for sitting, and the lock engages automatically on full extension. The lock provides stability (at some loss of function), but it offers mechanical difficulties because all the loads are fun-neled through the relatively small joint.</p> <h4>The Tilting-Table Prosthesis </h4> <p>Although not so simple or as light as the saucer type, the tilting-table prosthesis is more generally used because of the additional support. <b>Fig. 2</b> shows a typical prosthesis. A socket, usually of leather, is made to fit the stump and attached by a belt around the pelvis and often with a strap over the shoulder. The socket is articulated on the thigh section with a metal joint lateral to the acetabulum. Again the joint may or may not have a semiautomatic lock. Without a lock, the wearer has little control over the limb, most of the stability during the stance phase being afforded by friction between the socket and the thigh section.</p> <p>Because it is extremely difficult to make a hip joint strong enough to bear the entire load, contact between the socket and the medial edge of the thigh section is essential in weight-bearing, and this expedient is of course equally important when a lock is used. <b>Fig. 3</b> and <b>Fig. 4</b> illustrate two methods <!--Page 24--> that have been tried. In <b>Fig. 3</b>, a strap is fastened to the socket and passed under rollers attached near the medial brim of the thigh. These rollers also take the downward thrust of the socket, and a metal track may be attached to the socket for the rollers to bear upon. <b>Fig. 4</b> illustrates a dead-center latch mechanism. When the hip joint is fully extended, the latch flips by dead center and secures the socket to the thigh. A hip lock is necessary with this arrangement.</p> <p><b>Fig. 5</b> illustrates a fairly common departure in design. The walking function is identical, but the hip joint has been lowered to a position beneath the socket where a full-width bearing may be made much lighter. Because of the position of the joint directly below the center of gravity, however, a lock must be used. Along with the usual inconveniences and mechanical difficulties, this type also has distinct disadvantages in sitting. The thigh section is much shorter than normal, and the bulk of the joint raises the socket about an inch above chair height.</p> <!--Page 25--> <p><b>Fig. 6</b> shows a rather interesting deviation. This design uses a track-and-roller mechanism in which the center of rotation is a few inches lower and anterior to the acetabulum. The actual model seen by the writer was heavy and crude in construction so that binding of the rollers on the tracks prevented free motion, but it is worth noting since in principle it is almost identical to the present Canadian type, and it seems to be designed with a view toward improving function.</p> <h4>The U.S. Navy Hydraulic Prosthesis</h4> <p>At the close of World War II, the U. S. Navy designed and fitted an hydraulic prosthesis with the primary purpose of improving function. <b>Fig. 7</b> illustrates the main features of the device. The very large ball-bearing hip joint was made strong enough to bear all the weight, thus obtaining a free joint. An extension controlled the motion about the knee joint. The cylinder in turn was controlled by a valve which was either automatically or manually actuated. Normal motion about the hip joint allowed the piston to move slowly, as in an automobile shock absorber, and the knee joint was thus permitted to flex and extend with some damping. But fast rotation about the hip joint (as in stumbling) caused the valve to close and thus stabilized the knee. The manual control also closed the valve and locked the knee in any position. There were two disadvantages of this device- cost and weight. In addition, the application of hydraulics to prosthetics usually introduces problems of noise, leakage, and occasional erratic behavior.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Navy hydraulic prosthesis for hip disarticulation, schematic. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Influence of Materials</h4> <p>A review of prosthetics practice in the hip-disarticulation case would be incomplete without reference to materials. The shank and thigh members are usually of wood covered with rawhide as in standard above-knee legs, but because of the saving in weight aluminum-alloy members are preferable when available. Steel is the almost exclusive medium for hip joints and locks, but in the Navy hydraulic prosthesis aluminum alloy was used to save weight. Sockets are usually made of two layers of leather, with Celastic core for stiffness. Aluminum alloy and monel (an alloy of copper and nickel) have been quite successful. They are usually lighter, more sanitary, and easier to attach to the joints. Plastic laminates are light, strong, sanitary, and easily molded to complex shapes, and it is not surprising to find them successfully used in hip-disarticulation sockets. It was the ease of <!--Page 26--> fabrication that made possible the plastic socket with the wrap-around pelvic band (page 33).</p> <p>Generally speaking, the materials and the mechanical designs were chosen with a view toward solving the mechanical problems, and it was with this thought in mind that design study was begun at Sunnybrook Hospital in Toronto. The highlights of this study are worth noting as an illustration of how an indirect approach to a problem can achieve results.</p> <h4>Evolution of the Canadian Design</h4> <p>The primary objective at Sunnybrook was to construct a hip-disarticulation prosthesis that would avoid the stress concentrations in conventional locks and to provide a simple method for releasing the locks. The first experimental prosthesis employed a four-link mechanism, as shown in <b>Fig. 8</b>. The links were about 4 in. wide to provide adequate lateral strength. The socket was plastic and the thigh section aluminum alloy. It was intended that a posterior strap be used to lock the leg in full extension, but initial trials indicated adequate stability without a lock owing to the fact that at or near full extension the effective hip center was well forward of the center of gravity and because the posterior brim of the thigh prevented hyperextension. In order to achieve simplicity in assembly and to increase mechanical rigidity, the forward link was lengthened and made strong enough to support all the main loads (<b>Fig. 9</b>). The rear link thus acted only as a guide and could be made light and adjustable.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Steps in the evolution of the Canadian-type hip-disarticulation prosthesis: four-link mechanism. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Steps in the evolution of the Canadian-type hip-disarticulation prosthesis: modified four-link mechanism. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>One difficulty remained-there was a chopping action between the top of the thigh and the socket such that serious pinching could result. Owing to the geometry of the linkage system, the gap between the thigh and the socket was present whenever the thigh was neither fully flexed nor fully extended.</p> <p>The next step in the evolution was to extend the front link to include the knee joint and to replace the rear link with a simple rubber stop to prevent hyperextension. This final configuration, shown in <b>Fig. 10</b>, permitted the use of a single broad joint without locks. At first it was felt that the position of the stop would be critical, and accordingly the first unit included a stop that could easily be adjusted by the amputee. It was soon found that this feature was not critical and that <!--Page 27--> initial adjustment by shimming or grinding was adequate. The most apparent difficulty was the tendency for too long and too slow a stride, and thus the elastic webbing was added to restrain hip flexion. Cosmetic appearance was improved by a floating thigh cover (<b>Fig. 11</b>) made of horsehide and attached to the socket only. A foam-rubber liner was glued to the horsehide to give it stiffness.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Steps in the evolution of the Canadian-type hip-disarticulation prosthesis: final design. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Steps in the evolution of the Canadian-type hip-disarticulation prosthesis: floating thigh cover for cosmesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Apart from the mechanical simplicity of the new prosthesis, functional advantages soon became apparent. Little effort was required in the swing phase, and a full stride was easily obtained. Previously, with a locked hip joint, hip flexion was simulated either by pelvic rotation or by motion of the socket on the stump. The resultant gait was usually jerky and tiring, although some amputees had learned to walk surprisingly well. Since the amputee is actually "sitting" in the socket, complaints of discomfort were not common, but obtaining adequate security in the socket was a different matter.</p> <p>Too seldom have the bony prominences of the ilium been used for secure fitting. Usually a broad, leather pelvic belt, as in <b>Fig. 2</b>, was used for lateral support and a shoulder strap was added to prevent the socket from dropping down during the swing phase. The excessive weight of many prostheses necessitated the shoulder strap. The ischial seat is nearly always available for direct weight-bearing, and the areas for taking pressure elsewhere are large. If the socket is extended in the form of a band across the back of the pelvis and around to the opposite iliac crest, then three points of the innominate bones are firmly gripped, as shown in <b>Fig. 12</b>. Since these <!--Page 28--> three points are well spaced, excellent lateral stability is obtained. It is undesirable to have the socket extend above the iliac crests since doing so causes restriction and discomfort. Adequate vertical support can be obtained by ensuring a close fit in the area between the crests and the anterior-superior spine of each ilium.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Anterior view of socket-waistband showing three points where the skeletal structure is firmly gripped. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Conclusion</h4> <p>The Canadian-type prosthesis has been fitted to many amputees at various centers and over a period of several years. Stability with the free hip and knee joints is adequate if correct alignment is attained and if some gait training is provided. In a fall, the prosthesis is usually safer, since the joints collapse and prevent vaulting. One amputee has sustained several falls without injury to himself or the prosthesis. There are, however, several improvements possible in walking characteristics of the prosthesis. The elastic check-strap prevents excessive hip flexion, but some means should be provided for cadence control. Without restraining forces at the knee and hip, the leg tends to walk at its own pace as determined by its pendulum properties. Correctly applied friction or hydraulic devices could enhance the swing characteristics so that various speeds and strides could easily be attained. Furthermore, stability at the knee joint depends upon hyperextension. This means that knee flexion requires effort. A knee which would provide adequate stability at heel contact and yet flex easily when required would offer a big advantage. No doubt several years hence the present device will seem crude and clumsy; in the meantime it provides a light, strong, and relatively efficient prosthesis.</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>Colin A. McLaurin, BASc. </b></td></tr><tr><td class="clsTextSmall">Assistant Director, Prosthetics Research Center, Northwestern University, 401 E. Ohio St., Chicago; formerly Research Engineer, Prosthetic Services Centre, Canadian Department of Veterans Affairs, Sunnybrook Hospital, Toronto.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-003.jpg Figure 4 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-004.jpg Figure 5 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-005.jpg Figure 6 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-006.jpg Figure 7 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-007.jpg Figure 8 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-008.jpg Figure 9 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-009.jpg Figure 10 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-010.jpg Figure 11 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-011.jpg Figure 12 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-012.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 Evolution of the Canadian-Type Hip-Disarticulation Prosthesis Creator An entity primarily responsible for making the resource Colin A. McLaurin, BASc. * 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. * 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/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/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/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/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/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/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/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. *