MILITARY MEDICAL MANUALS
GENERAL EDITOR:
SIR ALFRED KEOGH, G.C.B., M.D., F.R.C.P.
ARTIFICIAL LIMBS
ARTIFICIAL LIMBS
BY
A. BROCA
_Professor of Topographical Anatomy
to the Faculty of Paris_
_AND_
DUCROQUET
_Orthopædic Surgeon to the
Rothschild Hospital_
TRANSLATED AND EDITED BY
R. C. ELMSLIE, M.S., F.R.C.S.
_Major R.A.M.C.(T.F.)
Orthopædic Surgeon to St. Bartholomew's Hospital, Surgeon to
Queen Mary's Hospital, Roehampton_
_WITH 208 ILLUSTRATIONS_
UNIVERSITY OF LONDON PRESS, LTD.
18 WARWICK SQUARE, LONDON, E.C. 4.
PARIS: MASSON ET CIE
120 BOULEVARD SAINT-GERMAIN
1918
GENERAL INTRODUCTION
The infinite variety of injuries which any war presents to the surgeon
gives to military surgery a special interest and importance. The
special interest and importance, in a surgical sense, of the great
European War lies not so much in the fact that examples of every form
of gross lesion of organs and limbs have been seen, for if we read
the older writers we find little in the moderns that is new in this
respect, but is to be found in the enormous mass of clinical material
which has been presented to us and in the production of evidence
sufficient to eliminate sources of error in determining important
conclusions. For the first time also in any campaign the labours of
the surgeon and the physician have had the aid of the bacteriologist,
the pathologist, the physiologist and indeed of every form of
scientific assistance in the solution of their respective problems.
The clinician entered upon the great war armed with all the resources
which the advances of fifty years had made available. If the surgical
problems of modern war can be said not to differ sensibly from the
campaigns of the past, the form in which they have been presented
is certainly as different as are the methods of their solution. The
achievements in the field of discovery of the chemist, the physicist
and the biologist have given the military surgeon an advantage in
diagnosis and treatment which was denied to his predecessors, and we
are able to measure the effects of these advantages when we come to
appraise the results which have been attained.
But although we may admit the general truth of these statements it
would be wrong to assume that modern scientific knowledge was, on the
outbreak of the war, immediately useful to those to whom the wounded
were to be confided. Fixed principles existed in all the sciences
auxiliary to the work of the surgeon, but our scientific resources
were not immediately available at the outset of the great campaign;
scientific work bearing on wound problems had not been arranged in a
manner adapted to the requirements, indeed the requirements were not
fully foreseen; the workers in the various fields were isolated, or
isolated themselves pursuing new researches rather than concentrating
their powerful forces upon the one great quest.
However brilliant the triumphs of surgery may be, and that they have
been of surpassing splendour no one will be found to deny, experiences
of the war have already produced a mass of facts sufficient to suggest
the complete remodelling of our methods of education and research.
The series of manuals, which it is my pleasant duty to introduce to
English readers, consists of translations of the principal volumes of
the "Horizon" Collection which has been appropriately named after the
uniform of the French soldier.
The authors, who are well-known specialists in the subjects which they
represent, have given a concise but eminently readable account of
the recent acquisitions to the medicine and surgery of war which had
hitherto been disseminated in periodical literature.
No higher praise can be given to the Editors than to say that the
clearness of exposition characteristic of the French original has not
been lost in the rendering into English.
MEDICAL SERIES
The medical volumes which have been translated for this series may be
divided into two main groups, the first dealing with certain epidemic
diseases including syphilis, which are most liable to attack soldiers,
and the second with various aspects of the neurology of war. The last
word on _Typhoid Fever_, hitherto "the greatest scourge of armies
in time of war," as it has been truly called, will be found in the
monograph by MM. Vincent and Muratet which contains a full account
of recent progress in bacteriology and epidemiology as well as the
clinical features of typhoid and paratyphoid fevers. The writers
combat a belief in the comparatively harmless nature of paratyphoid
and state that in the present war hæmorrhage and perforation have been
as frequent in paratyphoid as in typhoid fever. In their chapter on
diagnosis they show that the serum test is of no value in the case of
those who have undergone anti-typhoid or anti-paratyphoid vaccination
and that precise information can be gained by blood cultures only. The
relative advantages of a restricted and liberal diet are discussed
in the chapter on treatment, which also contains a description of
serum-therapy and vaccine-therapy and the general management of the
patient.
Considerable space is devoted to the important question of the
carrier of infection. A special chapter is devoted to the prophylaxis
of typhoid fever in the army. The work concludes with a chapter on
preventive inoculation in which its value is conclusively proved by
the statistics of all countries in which it has been employed.
MM. Vincent and Muratet have also contributed to the series a work
on _Dysentery, Cholera and Typhus_ which will be of special interest
to those whose duties take them to the Eastern Mediterranean or
Mesopotamia. The carrier problem in relation to dysentery and cholera
is fully discussed, and special stress is laid on the epidemiological
importance of mild or abortive cases of these two diseases.
In their monograph on _The Abnormal Forms of Tetanus_, MM.
Courtois-Suffit and Giroux treat of those varieties of the disease in
which the spasm is confined to a limited group of muscles, _e. g._
those of the head, or one or more limbs, or of the abdomino-thoracic
muscles. The constitutional symptoms are less severe than in the
generalised form of the disease, and the prognosis is more favourable.
The volume by Dr. G. Thilbierge on _Syphilis in the Army_ is intended
as a _vade-mecum_ for medical officers in the army.
Turning now to works of neurological interest we have two volumes
dealing with lesions of the peripheral nerves by Mme. Atanassio
Benisty, who has been for several years assistant to Professor Pierre
Marie at La Salpêtrière. The first volume contains an account of the
anatomy and physiology of the peripheral nerves, together with the
symptomatology of their lesions. The second volume is devoted to the
prognosis and treatment of nerve lesions.
The monograph of MM. Babinski and Froment on _Hysteria or Pithiatism
and Nervous Disorders of a Reflex Character_ next claims attention. In
the first part the old conception of hysteria, especially as it was
built up by Charcot, is set forth, and is followed by a description of
the modern conception of hysteria due to Babinski, who has suggested
the substitution of the term "Pithiatism," _i. e._ a state curable
by persuasion, for the old name hysteria. The second part deals with
nervous disorders of a reflex character, consisting of contractures
or paralysis following traumatism, which are frequently found in the
neurology of war, and a variety of minor symptoms, such as muscular
atrophy, exaggeration of the tendon reflexes, vasomotor, thermal and
secretory changes, etc. An important section discusses the future of
such men, especially as regards their disposal by medical boards.
An instructive companion volume to the above is to be found in the
monograph of MM. Roussy and Lhermitte, which embodies a description of
the psychoneuroses met with in war, starting with elementary motor
disorders and concluding with the most complex represented by pure
psychoses.
SURGICAL SERIES
When the present war began, surgeons, under the influence of the
immortal work of Lister, had for more than a quarter of a century
concerned themselves almost exclusively with elaborations of
technique designed to shorten the time occupied in or to improve the
results obtained by the many complex operations that the genius of
Lister had rendered possible. The good behaviour of the wound was
taken for granted whenever it was made, as it nearly always was,
through unbroken skin, and hence the study of the treatment of wounds
had become largely restricted to the study of the aseptic variety.
Septic wounds were rarely seen, and antiseptic surgery had been
almost forgotten. Very few of those who were called upon to treat the
wounded in the early autumn of 1914 were familiar with the treatment
of grossly septic compound fractures and wounded joints, and none had
any wide experience. To these men the conditions of the wounds came as
a sinister and disheartening revelation. They were suddenly confronted
with a state of affairs, as far as the physical conditions in the
wounds were concerned, for which it was necessary to go back a hundred
years or more to find a parallel.
Hence the early period of the war was one of earnest search after
the correct principles that should be applied to the removal of the
unusual difficulties with which surgeons and physicians were faced. It
was necessary to discover where and why the treatment that sufficed
for affections among the civil population failed when it was applied
to military casualties, and then to originate adequate measures
for the relief of the latter. For many reasons this was a slow and
laborious process, in spite of the multitude of workers and the wealth
of scientific resources at their disposal. The ruthlessness of war
must necessarily hamper the work of the medical scientist in almost
every direction except in that of providing him with an abundance of
material upon which to work. It limits the opportunity for deliberate
critical observation and comparison that is so essential to the
formation of an accurate estimation of values; it often compels
work to be done under such high pressure and such unfavourable
conditions that it becomes of little value for educative purposes.
In all the armies, and on all the fronts, the pressure caused by the
unprecedented number of casualties has necessitated rapid evacuation
from the front along lines of communication, often of enormous
length, and this means the transfer of cases through many hands, with
its consequent division of responsibility, loss of continuity of
treatment, and absence of prolonged observation by any one individual.
In addition to all this, it must be remembered that in this war the
early conditions at the front were so uncertain that it was impossible
to establish there the completely equipped scientific institutions for
the treatment of the wounded that are now available under more assured
circumstances, and that progress was thereby much hampered until
definitive treatment could be undertaken at the early stage that is
now possible.
But order has been steadily evolved out of chaos and many things are
now being done at the front that would have been deemed impossible not
many months ago. As general principles of treatment are established
it is found practicable to give effect to them to their full logical
extent, and though there are still many obscure points to be
elucidated and many methods in use that still call for improvements,
it is now safe to say that the position of the art of military
medicine and surgery stands upon a sound foundation, and that its
future may be regarded with confidence and sanguine expectation.
The views of great authorities who derive their knowledge from
extensive first-hand practical experience gained in the field, cannot
fail to serve as a most valuable asset to the less experienced, and
must do much to enable them to derive the utmost value from the
experience which will, in time, be theirs. The series covers the whole
field of war surgery and medicine, and its predominating note is the
exhaustive, practical and up-to-date manner in which it is handled. It
is marked throughout not only by a wealth of detail, but by clearness
of view and logical sequence of thought. Its study will convince the
reader that, great as have been the advances in all departments in
the services during this war, the progress made in the medical branch
may fairly challenge comparison with that in any other, and that not
the least among the services rendered by our great Ally, France, to
the common cause is this brilliant contribution to our professional
knowledge.
A glance at the list of surgical works in the series will show how
completely the ground has been covered. Appropriately enough, the
series opens with the volume on _The Treatment of Infected Wounds_,
by A. Carrel and G. Dehelly. This is a direct product of the war
which, in the opinion of many, bids fair to become epoch-making
in the treatment of septic wounds. It is peculiar to the war and
derived directly from it, and the work upon which it is based is as
fine an example of correlated work on the part of the chemist, the
bacteriologist and the clinician as could well be wished for. This
volume will show many for the first time what a precise and scientific
method the "Carrel treatment" really is.
The two volumes by Prof. Leriche on _Fractures_ contain the practical
application of the views of the great Lyons school of surgeons with
regard to the treatment of injuries of bones and joints. Supported
as they are by an appeal to an abundant clinical experience, they
cannot fail to interest English surgeons, and to prove of the greatest
value. It is only necessary to say the _Wounds of the Abdomen_ are
dealt with by Dr. Abadie, _Wounds of the Vessels_ by Prof. Sencert,
_Wounds of the Skull and Brain_ by MM. Chatelin and De Martel, and
_Localisation and Extraction of Projectiles_ by Prof. Ombredanné and
R. Ledoux-Lebard, to prove that the subjects have been allotted to
very able and experienced exponents.
ALFRED KEOGH.
PREFACE
No attempt is made in this little book to describe all the artificial
limbs and appliances that have been invented. Before the war these
were very numerous, since then their number has become countless, and
not a day passes without the appearance of some new model of greater
or less ingenuity.
But all these special inventions, the utility of which we should not
think of denying, are only of real practical value if the makers have
followed out certain general principles in their manufacture. In the
following pages we have attempted to indicate what these principles
are.
Our experience has been gained in connection with the _Fédération
des Mutilés_, where hundreds of disabled men have been examined and
fitted, and where we have always tried to give to each that appliance
which is best suited to his work.
For this indeed is the vital principle, and great disappointments
will result if, for æsthetic reasons, every patient is given the same
appliance, whether it be the leg known as the American leg or an
elaborate artificial arm. More often than might be believed accurate
imitation of the external form of the natural limb is incompatible
with good functional use. This is particularly so in the upper limb.
Perhaps the readers of these pages will gain a clear understanding of
these principles; and we shall have attained our object if by enabling
them to understand certain typical appliances we make it possible for
them to devise others which are at the same time strong, shapely and
practical.
Throughout the volume it will be found that we express a preference
for the construction of artificial limbs for the lower limb out of
wood, the method adopted by the Americans. This procedure, because
strength and durability are so necessary, seems to us to constitute
a very real advance; these considerations are, however, of much
less importance in the case of the upper limb. It is a matter for
regret that the French official instructions have not compelled our
manufacturers to adopt this technique, too often the latter are
inclined to keep to their old routine, but they can be induced to
alter it, as we have proved by our success at the _Fédération des
Mutilés_.
There is nothing revolutionary in such a suggestion. It has been
adopted by the Belgian Government in the fitting centres which they
have established; this is also the case with the English authorities,
who, we understand, have even attracted from America special fitters
for this work. We should have thought that we, in France, might
have developed our national supply of artificial limbs in the same
direction.
INTRODUCTION TO THE ENGLISH EDITION
The details of the manufacture of artificial limbs naturally differ
greatly in different countries. So much so that at first sight it
might appear useless to introduce into England and America the
account given in this work of the methods adopted in France. But,
as the authors state in their preface, the principles remain the
same whatever the details of the methods used. In the lower limb the
essentials to be studied are the points upon which weight can be
taken, the "Bearing Points," the proper method of fitting the stump,
the principles of securing stability and the mechanism of the knee and
ankle joints. These remain unalterable whatever be the material used
and whatever be the details of manufacture.
In England it has for a long time been understood that every sailor
or soldier who has lost a limb has the right to expect that he will
be supplied with a good artificial substitute. And, further, it has
been taken for granted that this will, in the case of the lower limb,
be a full artificial leg and not a peg leg. Therefore the standard
pattern has in England been a full limb, and the peg has only been
supplied as a temporary appliance, and as an alternative appliance to
be used when the other limb requires alteration or repair. For this
reason the possibilities of the peg leg, except in its simplest form,
have perhaps been neglected in this country, and a study of the French
methods of making these peg legs, particularly the convertible peg
leg, is well worth while.
The introduction of American artificial legs into this country has
not been so revolutionary in its results as it is apparently in
France, for we have been accustomed for many years to make the bucket
out of a single piece of willow. The alterations in our methods
introduced recently from America are essentially the following--
1. The use of a sling which passing over the shoulders is attached
to the leg below the knee in such a way as to act as a mechanism for
extending the knee.
2. The manufacture of the leg portion out of a single piece of wood.
3. The abolition of the old tendon action for the ankle joint (which
resembled the mechanism described on page 57) and its replacement by
the ankle with movement limited by indiarubber buffers.
4. Covering the wooden part of the limb with a layer of raw hide or
parchment, which certainly adds to the strength.
The sole remaining problem in the design of artificial legs appears
to be the invention of a knee mechanism which will lock in any degree
of flexion when a strain is put upon it, so that the wearer does not
necessarily fall when his weight comes upon the limb with the knee
flexed. A recent invention, still on its trial, seems to indicate that
this problem is not incapable of solution.
In artificial arms the differences between the French and English
patterns are greater than in artificial legs. But here again the
principles remain the same. In England, also, we have _worker's arms_
and _show arms_, but the latter tend to be more elaborate than the
French patterns, mechanical movements being more developed. For this
reason this pattern is usually called, in England, the _mechanical
arm_. Instead of the single cord, looped round the opposite shoulder,
and used to open the spring thumb (see p. 101), at least three such
cords are used, actuated (1) by rounding the back; (2) by expanding
the upper part of the chest, and (3) by raising or lowering the
shoulder on the side of the amputation. These may be used for various
purposes, of which the chief are (1) flexing the artificial elbow;
(2) working the elbow lock, and (3) actuating the thumb, fingers or
appliances used instead of the hand. The chief other differences in
the methods adopted in England are--
1. A smaller enclosure of the shoulder region for purposes of
suspension, the limb being held on by a harness of straps. We, in
fact, value mobility of the shoulder, and gain it at the expense of
stability.
2. The use of various alternative patterns of elbow locks.
3. The appliances used instead of the hand are very different in
pattern, although the principles for their construction remain as
described here by the authors.
Much ingenuity has been expended on the design of mechanical
artificial hands, with results which are satisfactory so far as they
go, but which require much further development before the hand can
possibly replace even a few of the appliances which can be substituted
for it. For this reason it should be made an invariable rule that the
artificial hand, however ingenious and however apparently perfect it
may be, should be detachable, so that it may be replaced by other
appliances.
R. C. E.
CONTENTS
PAGE
GENERAL INTRODUCTION v
PREFACE xiii
INTRODUCTION TO THE ENGLISH EDITION xv
CHAPTER I
GENERAL CONSTRUCTION OF AN ARTIFICIAL LIMB 1