The depth of these concavities is estimated when the limb is fitted.

Both the arm and the forearm may be cut away freely without any

resulting inconvenience, provided that the stump is long; but if the

stump is short and includes only the upper third of the forearm, it

is impossible to cut away the forearm socket sufficiently without

depriving the stump of a proper hold in the socket, so that movements

are not transmitted to the forearm lever with their proper force.

Consequently the socket for the forearm must be cut away very little,

and must be carried up to the level of the fold of the elbow when the

joint is flexed. The flesh in front of the elbow will not be pinched

if, the forearm being fitted very accurately, the muscles of the

upper arm are allowed free play, by cutting away the front of the

armlet to half its height, but in this case an indirect attachment to

the shoulder is essential.[12]

[12] Another difficulty in fitting a short forearm stump arises

from the fact that the antero-posterior diameter of the forearm

immediately below the elbow increases considerably when the joint is

flexed, because of the contraction of the muscles arising from the

condyles. If the forearm socket is made to fit closely when the elbow

is extended it will be too small when the joint is flexed and will

prevent full flexion. If it was made to fit with the elbow flexed,

there is risk of the stump slipping out of the socket when the joint

is extended. (Ed.)

[Illustration:

FIG. 132.--Bad apparatus for amputation in the upper third of

the forearm. The front of the arm piece is insufficiently cut away.]

[Illustration:

FIG. 133.--Good apparatus. The arm piece is well cut away,

consequently the flesh does not bulge out.]

2. _Construction of the Joint._--In most cases this is a simple

articulation between the steels of the arm and the forearm pieces by

two hinge joints.

[Illustration: FIG. 134.

FIG. 135.

FIG. 134.--Limb for amputation through the lower third of the

forearm, with elbow joint of strong leather.

FIG. 135.--Details of the joint.]

The objection to this is that the movements of pronation and

supination, if these are present in the stump, are abolished.

(_a_) _Long Stump._--When the stump is long (amputation in the lower

quarter) the following may be used: The steels of the forearm socket

are attached to the armlet, which is not furnished with steels, by two

straight strips of hard leather jointed at each end with rivets to

the corresponding piece of the limb. This allows a certain amount of

torsion so that pronation and supination are to some extent possible.

It is necessary to add an indirect attachment to the shoulder. Not

only must the armlet, not being closely moulded over the condyles, be

even when new laced so tightly as to be unbearable, but in addition

the inevitable loss of shape of the unsupported leather will in every

case soon interfere with proper support direct from the armlet (Figs.

134 and 135).

[Illustration: FIGS. 136 and 137.--Amputation through the

forearm above the upper third. The elbow joint does not flex beyond

the right angle.]

[Illustration: FIG. 138.--Limb for amputation through the

upper third of the forearm. (For a description of the ratchet see page

135.)]

This method is, moreover, scarcely applicable to patients who will

have to carry out heavy work.

(_b_) _Short Stump._--The stump of an amputation in the upper third of

the forearm is too short to be securely held in the forearm bucket.

There is consequently a loss of power in the movements communicated,

particularly in flexion, the arm of the lever being too short; in

addition, the elbow joint in these cases is often a little stiff, so

that flexion beyond a right angle is impossible (Figs. 136 to 138).

The chief functional difficulty depends upon the fact that, with the

elbow at a right angle, the anterior surface of the forearm stump

is too short to support a weight; for example, a basket held by the

handle. The stump escapes partly from the bucket when the forearm

extends. It is therefore well in such cases to fix the elbow at a

right angle by means of a ratchet identical with that used in the

artificial arm for amputation above the elbow (Fig. 138).

3. THE ARTIFICIAL HAND AND APPLIANCES

At the extremity of their forearm almost all patients wish in the

first place to wear something that is shaped like a hand. Many

people--and even many medical men--consider that this "artificial

hand" is really useful. In actual fact, by means of fairly simple

contrivances, it can be used to enable the patient to eat, to write,

to put on and take off his hat, but it is out of the question for it

to do real work. For that an appliance, a tool in fact, adapted for

use and not for appearance is necessary.

The limb, therefore, will, as a rule, end in a hand, but for workmen

this hand will be capable of being unscrewed and replaced easily by

one or more appliances.

Attempts have been made to construct so called universal hands and

forceps which will serve for any sort of work, but up to the present

none of these inventions have given satisfaction. And the practical

solution of the problem in the present state of affairs consists

in devising a special appliance for a particular trade, studying

carefully the movements necessary in this trade.

A workman who in the course of his occupation carries out a number of

different movements may thus have several appliances, which he selects

as he requires them. For example, a locksmith must be able to hammer,

to file, and to drill holes in succession.

We will describe first the hand properly so called, then the

appliances. The former is suitable for clerks, and it is for them that

the various improved patterns that we shall describe are made. The

latter are suitable for manual workers to whom should be given a hand

in which the mechanism is reduced to a spring thumb grip and one or

more special appliances.

These appliances will almost always be constructed to carry out the

movements made by the left hand in the course of the work, because the

first step in the re-education of a patient who has lost the right

hand should always consist in training the remaining left hand to

carry out the work hitherto entrusted to the missing right hand.

A.--THE ARTIFICIAL HAND.

The hand, which is screwed into the end of the forearm socket in such

a way that it is in semipronation when the arm hangs vertical, is

nearly always made of wood, but occasionally of aluminium.[13]

[13] Hands are nearly always made of lime wood, which has the

advantage of lightness, but the fingers are fragile and easily break.

Instead of using hornbeam, which is hard but heavy, as the fragility

only affects the fingers, some makers have overcome this difficulty by

reinforcing the fingers by what they call a "philippeau."

The finger is divided throughout its whole length by a mortise 1·5

millimetres in width, in which are glued two layers of veneering wood

(mahogany, rosewood, etc., extremely hard woods, or else a layer of

hornbeam).

It may be a simple show hand without any joint. This pattern is no

longer used. It may be jointed in one or in several fingers. We shall

first consider certain principles of construction which we can explain

by describing the chief mechanisms used.

_Simple Spring Grip Thumb._--The simplest and most useful articulation

is that of the thumb, which when at rest is kept by means of a spring

in the flexed position, with the grip against the index finger which

is partly flexed (as are also the other fingers).

In many cases the patient is content with this simple mechanism. He

opens the spring with the other hand and allows it to close on the

object he wishes to grip (Figs. 139-145).

[Illustration: FIGS. 139 to 142.--_Mechanism of the passive

spring thumb._

The thumb turns on the axle D upon a piece which fits by a tapered

extremity C into a hollow cut out in the thenar eminence. The base of

the thumb is rounded. The spring AB flexes the thumb.]

[Illustration: Figs. 143 to 145.--The Beaufort Thumb.

The model shown on page 98 is more mobile than this, in which the

thumb turns on the axis AB, and is fitted directly into the thenar

eminence. But in this type it will be seen that the spring CD which

keeps the thumb flexed, reaches right up to the wrist, and is

therefore longer and more powerful. The thumb is much stronger, and

this is the mechanism usually adopted. It has the inconvenience that

it requires a deep excavation of the thenar eminence, encroaching

upon the root of the index finger, so that it is impossible to

mount the thumb in this way when it is desired to fit a movable

metacarpo-phalangeal joint to the index finger, either with a spring

(Fig. 155) or without (Fig. 148).]

_The Automatic Thumb._--Active opening movement can be produced by the

mechanism shown in figure 146. A cord fixed behind the scapula of

the opposite side by a ring which passes over the clavicle and under

the axilla, extends down the posterior surface of the arm and forearm

pieces, running in pulleys which keep it in place. If the patient

bends the elbow and at the same time brings the arm and both shoulders

forward, rounding his back, the cord is tightened and pulls the thumb

into the position of abduction and extension.

This narrow grip, between the tips of the thumb and index finger only,

is not always convenient. A commercial traveller or a foreman could

not easily hold with it the order book, in which he has to write. But

if the thumb, held by a powerful spring, is parallel to the palm of

the hand and grips against the other fingers, which are stretched out

and not semiflexed, the grip will be strong and convenient, especially

if a mechanism is introduced between the forearm and the hand,

allowing the latter to be rotated at will into any position (Fig. 148).

As in the preceding case the thumb may have either a simple grip or an

automatic grip opened voluntarily by a cord from the shoulder.

The following is a very interesting method which allows a fork or

pen to be held, the automatic thumb being used. The fingers are half

flexed, the index being separated from the middle finger, so that the

handle of a pen can be inserted between them. The grip of the thumb is

not against the tip of the index finger but against the outer side of

the last phalanx of the middle finger, against which in consequence

the handle of the object held will be pressed (Fig. 147).

[Illustration:

FIG. 146--Appliance with automatic thumb. The cord is fixed

to a loop which passes round the sound shoulder. Abduction and forward

movement of the shoulder and flexion of the elbow open the thumb.]

[Illustration:

FIG. 147.--Hand with space between the index and middle

fingers, wide enough to take the handle of a fork, which is held by

pressure of the thumb against the side of the middle finger.]

The extended fingers are better placed for gripping than the

partially flexed fingers, although the latter are convenient to the

patient in certain ways. Ball and socket joints are inserted at the

interphalangeal joints. (Details are shown in figures 152 to 154.)

These are so stiff that they maintain the position in which they are

placed passively, as do the joints of an artist's lay figure.

[Illustration: FIG. 148.--Articulated hand for commercial

travellers. The thumb, lying parallel to the palm of the hand, takes a

secure hold of such an article as a memorandum book.

FIG. 149.--The usual pattern of hand. The grip is too small.]

[Illustration: FIG. 150.--The index finger is the same length

as the middle finger. The thumb and index fingers are furnished with

nails. A small ball can be picked up.

FIG. 151.--The middle finger being longer than the index, the

latter does not reach the surface of the table and the ball cannot be

picked up.]

If the fingers are rigid and in semiflexion it is possible to

articulate all the metacarpo-phalangeal joints, fitting them with a

spring, which keeps them flexed, and arranging for active extension as

already described for the thumb. All that is necessary is to terminate

the cord by five separate strings instead of one. In certain special

cases this arrangement may be useful (Figs. 155 to 157). It seems to

us useless to render the interphalangeal joints automatic.

As to the attempt which Beaufort appears to have made to give movement

to the wrist also, we do not believe that any practical result has as

yet been attained.

For the relative length of the fingers and the utility of a nail on

the thumb and on the index finger see figures 150 and 151.

_Shape of the Hand._

In the usual pattern (Figs. 149 and 151) the fingers are semiflexed

and the thumb grips against the index finger, which is shorter than

the middle finger as in the natural hand. If it is desired to pick

up a ball, for example (Fig. 151), it will be seen that the middle

finger projects and gets in the way. For this reason it is advisable

that the index finger be longer than the middle, and in addition it is

useful to furnish the thumb and index finger with a little projection

representing the nail (Fig. 150).

In figure 148 will be seen an arrangement which allows the thumb to

grip not by the tip, but by the whole length of its palmar surface (to

hold, for example, a notebook). The fingers of this hand have ball

and socket joints constructed in the way shown in figures 152 to 154.

The joints keep passively the position in which they are placed.

The attachment of the ball of the joint on an intermediate tenon is

similar to that of the thumb shown on page 98. The articulation of the

index finger prevents the sufficient excavation of the thenar eminence

for the insertion of the Beaufort thumb with its powerful spring. The

wrist rotates upon a bayonet joint.

[Illustration: FIGS. 152 to 154.]

The fingers shown in figures 155 to 157 are joined together into a

single piece, which articulates with the metacarpal part of the hand

upon a transverse axis.

They are held in a position of flexion at the metacarpo-phalangeal

joints by four palmar springs and they are opened away from the thumb

by the action of a cord which bifurcates from the thumb cord on the

back of the hand. The pull of this cord is exerted upon the upper

angle of a triangle from the lower border of which four cords pass on

to the back of the phalanges. Figure 156 shows detail of a finger. We

know that attempts have been made to isolate by surgical means the

masses of the extensor and flexor muscles in the end of the stump,

making from them little prominences, perforated with a tunnel which is

lined with skin. The cords pass through the tunnels, and in this way

are worked voluntarily. We are not sure that this is practicable.

[Illustration: FIGS. 155 to 157.--_Automatic fingers._

In figure 155 are seen the cavity in which the finger portion works

and the axis upon which movement takes place, also the four palmar

springs. In figure 157 the arrangement of the cords. In figure 158 the

attachment of the spring to the finger. This pattern, which we have

designed and which is not patented, seems to us to be simpler than

those in which the interphalangeal joints are also articulated and are

automatic. It gives a more accurate grip between the tips of the thumb

and index finger.]

_The Brunet Grip._--The Brunet grip is described here because of its

resemblance to the automatic thumb, both being worked on the same

principles.

[Illustration: FIGS. 158 and 159.]

[Illustration: FIG. 160.]

[Illustration: _Brunet's Grip._

Below the leather forearm piece, which laces up, the lateral steels

are continuous with each other in the form of an arch, to which the

grip is riveted.

The latter consists of a strong semicircular piece of metal facing

downwards, ending in a pair of wide and thick jaws, like those of a

locksmith's pliers. When the apparatus is at rest, these are kept in

contact by the pressure of two powerful fixed springs, attached to the

semicircle on the forearm above and to the jaws below. The external

and dorsal spring is attached to the tip of its jaw, the internal and

palmar (the side on which the manipulating cord is attached) to the

base of it.

The pliers are opened in the following way:--

Inside the semicircle to which the jaws are attached, lies a cylinder

with its ends cut obliquely; this rotates about a transverse axis,

and when at rest lies with its longer side upward. To the palmar edge

of the shorter side is attached a transverse eccentric, to which is

hooked a cord actuated as described in figure 146. When this is drawn

upward the cylinder rotates so that the wider side comes between

the jaws of the pliers and opens them; when the cord is relaxed the

springs turn the cylinder back again find the jaws close. Figures 158

and 159 show the appliance at rest and with the jaws open.

This appliance is patented and is made in one piece. We demonstrate in

figure 160 that it would be very easy to make the pliers detachable

from the forearm, with a screw connection, just as is done in the

various other appliances which will be described.]

The grip of the automatic thumb always lacks power, for two reasons.

There is no room in the thenar eminence to fit a powerful spring and

the grip has always a very narrow hold.

The Brunet grip is an actual pair of pliers, shaped like these and

furnished with a powerful spring. It is opened by a cord like that

of the automatic thumb. Figures 158 to 160 explain the mechanism.

It is an excellent appliance with which the wearer can carry out

the majority of the actions of everyday life. It has, however, the

disadvantage that it is not shaped like a hand--a point to which

patients attach much importance--and, moreover, it is a part of

a patented appliance, for which an interchangeable hand is not

manufactured. So that in order to have in addition an artificial hand,

which is capable of being removed and replaced by one or more of the

appliances which will be described later, it would be necessary for

the patient to possess two complete artificial limbs, and changing

from one to the other would evidently be inconvenient.

We generally prescribe this appliance for patients who have lost both

arms, for one side and as a supplementary appliance.

There are other similar models into details of which it is unnecessary

to enter. Those in which the grip is opened by movements of pronation

and supination are obviously only suitable for certain rare cases

(very long stumps, with free movement).

B.--APPLIANCES FOR USE IN PLACE OF THE HAND.

The general principle is to fit to the end of the forearm piece an

attachment which can be screwed on or unscrewed at will and which

carries an appliance which is adapted to the various more or less

specialised movements of the patient's trade.

Naturally the results thus attained must always be imperfect; but

however little perseverance and ingenuity he may possess, the patient

finds that he is able to educate the remaining arm, even when it

is the left, to replace the amputated one in a way that is often

remarkable. It is to this education that attention must be specially

directed in the workshops for the re-education of the maimed.

1. _Knife and Fork._--The first necessity is to be able to eat, and by

certain very simple devices a fork, spoon or knife may be fixed to a

wooden hand, whether the thumb be mobile or not.

[Illustration: FIG. 161.--Raynal's fork rest.]

As a general rule if the patient has one arm intact, he uses the sound

hand only for this purpose, but when both forearms have been lost an

appliance is indispensable.

We have already described how in the hand with an automatic thumb,

room can be left between the index and middle fingers for the handle

of a spoon or fork. A direct grip can also be obtained with the hand

shown in figure 147.

The hand with five automatic digits (p. 105) is usually arranged in

such a way that it is possible to hold a tumbler for drinking; but a

patient with an amputation of one hand drinks with the other, and one

who has lost both hands can drink with a straw.

[Illustration: FIG. 162.--The termination of the forearm is a

hemispherical piece of metal, furnished with a screw into which screw

at will the hand, the hook or the ring.]

These appliances have replaced that in which the knife or fork is

attached to a block of wood which can be fitted into the palm of the

hand when required. It is inconvenient to be obliged to carry these

special implements about.

Raynal's fork-rest has the advantage over the last mentioned that

it fits any fork. Figure 161 shows very clearly its construction and

the way in which it is used. The small special attachment, which is

screwed in place, is not cumbersome and can quite well be carried in

the pocket; it is, however, even more convenient to have an appliance

which is capable of gripping the fork directly like those described

previously.

[Illustration: FIG. 163.--Vine dresser's hook.

(Gripouilleau).]

[Illustration: FIG. 164.--The branch is held in the grip by a

leverage exerted by torsion.]

2. _Appliances for Workmen._--All the appliances that are attached

to the arms in place of the artificial hand for performing various

kinds of work are elaborated from two simple forms: the hook and the

ring (for catching hold and carrying a parcel, for holding a handle,

etc.). A glance at figure 162 will show the nature of these and the

way in which they are used. But it will also be understood that if

the simple ring and hook are useful for equally simple purposes they

are altogether insufficient for skilled labourers whose work entails

a certain special adroitness, e.g. joiners, locksmiths, agricultural

labourers, etc.

Many makers have realised this and have devised very ingenious

implements, some of which we reproduce, though we are obliged to limit

ourselves to certain types, for they can be varied in countless ways

according to the needs of particular cases. The same workman, as we

have already said, may have several appliances which he uses in turn

as he needs them in the course of his work.

These appliances are constructed in two ways; some are fixed to the

end of the forearm and are immobile, some are attached by means of a

joint or joints and are capable of rotation in various directions.

(_a_) _Fixed Appliances._--We illustrate here an appliance derived

from the simple hook, the _vine-dresser's claw_, devised some time ago

by Gripouilleau; branches of varying size can be held while the other

hand saws them or cuts them with the pruning shears (Figs. 163 and

164).

This appliance of Gripouilleau, with a series of hooks, forms the

basis of almost all the "pincer hands" constructed by M. Boureau and

characterised by--

(1) The closure of the upper hook which is thus transformed into a

ring, the two appliances being combined in one;

(2) The spring fixed to the straight side of the hook providing the

grip necessary for holding articles. If the free end of the spring is

turned up like the pointed toe of a mediæval shoe a sufficiently large

opening is left between it and the straight edge of the hook to enable

an object which is fixed mechanically or held by the other hand to be

pushed into and gripped by the spring.

The simplest type of this mechanism is the _postman's hand_ (Figs. 165

and 166).

[Illustration: FIGS. 165 and 166. Postman's hand.]

The left hand of the postman who sorts letters has for its work to

keep in the proper order the envelopes which are arranged in little

packets; the right hand has only to push the letter into place between

a flat spring, fixed to the wrist, and the back of the hook. If two

or three springs are supplied the postman can arrange two or three

packets of letters at the same time. He can also bind the packet with

string.

The _vine-dresser's hand_ is provided with this spring to hold

small flat objects, but the second spring is wavy in outline, so

that semilunar spaces are left between it and the first. Into these

branches slip when the spring is pressed against them, and they are

thus held more firmly, whilst being sawn or pruned, than by the

twisting action of the old pattern hook of Gripouilleau (Figs. 167 and

168).

[Illustration: FIG. 167.--Horticulturist's hand.]

[Illustration: FIG. 168.--Method of holding a branch.]

This thrust to seize the branch is somewhat rough, and is only

possible in holding hard wood which there is no fear of bruising.

For more delicate shoots (grafting vines indoors, preparation of

cuttings), a grip is necessary which can be opened before seizing

hold of the object. This is accomplished by prolonging the spring

towards the forearm as a handle, pressure upon which against the chest

(when standing), or against the knee (when sitting), opens the grip,

in which the graft, for example, is then placed in the opening of the

correct size.

_The packer's hand_ is very ingenious (Fig. 169). It has the hook

pierced by an eye enabling a thread to be passed through a basket

as with a curved needle. The jaws of the pincers are smooth at the

tips, but further back they have a series of graduated notches in

which tacks of different sizes can be held whilst they are driven in

with the hammer. But of course a workman can only work quickly if he

can hold a number of tacks of the same size in the palm of his hand,

placing one under the hammer, relaxing his hold of it after the first

gentle blow has fixed it, and getting the next ready while he drives

it home.

[Illustration: FIG. 169.--Packer's hand.]

_The plumber's hand_ (Fig. 170) is made in the shape of a pair of gas

pliers, and ends in cutting edges with which wires can be cut. With

them a bolt can be held whilst the other hand screws on the nut.

[Illustration: FIG. 170.--Plumber's hand.]

_The leather-cutter's hand_ (Figs. 171 and 172) should be able to

hold the skin which the other hand cuts: it consists of a plate with

a rough surface fixed to a ball and socket joint which allows it to

turn in any direction, so that the other hand can follow the line to

be cut which is often sinuous. This appliance may also be used to hold

a drawing paper, a rule for cutting cardboard, or sheets of paper for

binding.

[Illustration: FIG. 171.--Leather-cutter's hand.]

The examples that we have chosen amongst Boureau's appliances for

craftsmen will, we believe, be sufficient to explain the principles

of their construction. These consist in studying the movements which

are normally carried out by the passive hand (usually the left hand,

but the right in left-handed people) and to devise an appliance

accordingly, the sound hand always becoming the active hand.

[Illustration: FIG. 172.--Leather-cutter's hand.]

We could have described many more examples, but we shall only say a

few words about the _mechanic's hand_, which is simply an adjustable

spanner which can be automatically closed, terminating in toothed

pliers to hold circular objects without the necessity for being

screwed up. As a matter of fact, in all the work of a mechanic

(sawing, filing, drilling, tightening screws, hammering, forging, and

grinding) the left hand is only used for picking up and steadying

the article to be manipulated. M. Boureau rightly considers that it

is better to entrust this rôle to the artificial hand rather than to

contrive to make the latter capable of sawing or of filing by means of

the devices which we shall describe further on (p. 121 and following),

ingenious and interesting though these may be.

From these appliances, adapted to certain particular grips, others

have been devised for chair caning, soldering, and for enabling

factory hands to work starting levers and brakes.

Thus each case must be studied separately and the workman furnished

with one or several appliances according to his needs, making the

necessary modifications from the existing patterns.

Several of these appliances are attached by a ball-and-socket joint

like that described for the leather cutter: this is an intermediate

form between the fixed appliance and the jointed appliances which will

be described later.

Boureau recommends that the length of the forearm should be such that

the artificial appliance reaches only as far as the level of the sound

wrist. The work will then gain in precision. We believe that this

principle holds good even for the true artificial hand, which should

be made 3 to 4 centimetres shorter than the sound hand. But it must be

realised that we shall be met with a difficulty, which we have already

experienced. Comments are made upon the appearance of the arm and the

wearer may sometimes be made to believe that this is due to faulty

construction.

For certain special crafts the subject may be studied from another

standpoint and an actual tool constructed which carries out the

necessary actions like a machine worked by the forearm, so that in

these special cases the artificial hand is the active hand.

At the Valentin Hauy Institute for the blind, where there has long

been a brushmaking workshop, we have seen in use a very ingenious

tool of this description with a combined action for carrying out the

entire manipulation of the thread which fixed the little bundles of

bristles into the holes perforating the back of the brush. Results are

so good that a blind and maimed worker using this apparatus works

more quickly than his comrades who have the use of both hands. It

consists of a two-pronged claw surmounted by a small thimble-shaped

projection and with a small hook, like a crochet hook projecting in

front (Fig. 173). The hook first passes through one of the holes in

the back of the brush, catches up the thread and draws it through

the hole (Figs. 174 and 175). The thread is then looped around the

thimble, whilst the sound hand binds the little bundle of bristles

into a twist of the loop (Fig. 176), and finally the bundle is fixed

into the hole, the claw being used to draw the brush towards the

worker (Fig. 177).

[Illustration: FIG. 173.--Brushmaker's hook.]

[Illustration: FIG. 174.--First movement. The string is

picked up by the hook.]

[Illustration: FIG. 175.--Second movement. The string is

pulled through one of the holes perforated in the back of the brush.]

[Illustration: FIG. 176.--Third Movement. Catching the bundle

of bristles.]

[Illustration: FIG. 177.--Fourth Movement. The bundle is

fixed in the hole in the back of the brush.]

(3) In place of an actual tool the detachable part may consist of a

clamp on the principle of a ring into which the tool is inserted by

the handle. The two principal methods are the screw and the American

chuck. A glance at figures 178 and 179 will explain how the large

handle of a tool intended for heavy work is controlled by means of a

screw and rings.

[Illustration: FIGS. 178 and 179.--Nyrop's grip for hammer

and saw.]

At Rouen we have seen the disabled Belgians who had been re-educated

wearing an ingenious T-shaped clamp by means of which the handle of a

tool may be held either in the line of the axis of the forearm or at

right angles to this. This method is specially useful for manipulating

a file which is worked with one hand while the other, in this case

the sound hand, presses upon the free end. Usually the filing is done

backwards and forwards, working from base to tip of the file, but

sometimes, specially for final polishing, the file is held with both

hands and worked from side to side.

The American chuck consists of a pair of metal jaws fixed at their

base into a cylinder and appearing somewhat like the petals of a long

corolla. Another cylinder is screwed over the first to control the

opening and shutting of the jaws. When this cylinder is unscrewed

the jaws open and the handle of the tool can be inserted, when it is

screwed up it closes the jaws and makes them grip the handle.

[Illustration: FIGS. 180 to 185.--_The American Chuck._

The pincers are composed of two jaws with vertical cylindrical grooves

(to fit upon a handle), joined above by a ring (Fig. 185) and coupled

by a spring C which keeps them apart. The pincers fit into a piece

B (Fig. 182) cut on the outer side with a screw thread (Figs. 182

and 183) upon which the piece A is screwed up or down (Figs. 180 and

181). When screwed towards the point of the pincers it presses on the

two jaws and closes them. When screwed in the opposite direction the

pincers open automatically.]

If the jaws open widely, the wooden handle of a tool can be held, but

if the opening is small the unmounted tool must be fitted into them

(Figs. 186 and 187). This method is specially useful for files, as it

frequently happens that several files are required for the same piece

of work and they can be changed rapidly.

[Illustration: FIGS. 186 and 187.--File fitted into the

American chuck.]

It must, however, be insisted upon that the principle of giving a

passive rôle to the artificial hand is to be preferred.

(_b_) _Appliances with Mobile Joints._--In the course of work the

direction of the wrist is changing at every instant, flexion,

extension, pronation, and supination occurring, sometimes in order

to move around the object, sometimes in order to maintain a suitable

position when the movements of the shoulder and elbow vary the

direction of the forearm.

The consequence of this is that the worker learns to turn the piece of

work around with his sound hand. To get over this difficulty passive

joints are inserted at the wrist, which allow the appliance to move

when it is pressed against the piece of work and to take up the

direction which suits the inclination of the forearm.

[Illustration: FIGS. 188 to 190.--Agricultural hook and ring.

(Gripouilleau.)]

[Illustration: FIG. 191.--Combined hook and ring. (Boureau.)]

[Illustration:

FIGS. 192 to 194. 1. Tram driver's and chauffeur's bell. 2.

Method of use by a tram driver. 3. Management of a motor car lever.

Pressure at the extremity and traction.]

One of the simplest mechanisms--and one of the oldest, because it was

designed by Gripouilleau--is that of the _agricultural labourer's

ring_, intended to grip and manipulate the handle of a wheelbarrow

or a plough. The ring is mounted on a transverse axis and moves in a

horseshoe which in its turn revolves on a shank which is screwed into

the forearm. The ring is provided with a screw, which may be tightened

upon the handle if desired, but which is, however, rarely used (Figs.

188 to 190).

The _tram-driver's bell_, represented in figure 192, is devised on the

same principle. It moves on a transverse axis, and in figures 193 and

194 its utility in managing levers in driving a tram or a motor car

will be easily seen. The rotation of the horseshoe on the axis of the

forearm is not required.

_The "cardan" joint_ also allows movement in every direction: it

consists of two semicircles of metal, placed at right angles, each

working around a transverse axis, these axes being united in the form

of a cross. The construction and working will probably be understood

without further explanation by a study of figures 195 to 198. The

first two represent a system with a ball in the centre, which is well

known commercially. The last two represent the simple universal joint

generally used in orthopædic surgery. It is somewhat more cumbersome

than the previous model.

[Illustration: FIGS. 195 and 196.--Universal joint with ball.]

[Illustration: FIGS. 197 and 198.--Simple universal joint.]

[Illustration: FIG. 199.--Gardener's cylindrical spade

holder. A universal joint permits movements in every direction.]

The spade holder used at the agricultural centre at Limonest is

mounted on a cardan (Fig. 199).

The joint can be fixed by a compression screw which is easily and

quickly adjusted.

Where several tools are necessary each should be complete with its own

universal joint.

Other methods of terminal passive articulations are--

(1) Ball joints which have already been described in connection with

the fingers and which may be applied to the wrist.

(2) Bayonet joints which are only applicable to certain artificial

hands which are not subjected to any great strain.

[Illustration: FIG. 200.]

Figure 200 explains this mechanism as it is applied to the artificial

hand represented in figure 148.

_CHAPTER VIII_

ARTIFICIAL LIMBS FOR AMPUTATION THROUGH THE ARM

In this chapter we shall deal only with amputation of the arm below

the upper third, _i.e._ with cases in which the stump is long enough

to transmit movements to the artificial limb. Amputation through the

deltoid muscle must be considered in association with disarticulation

of the shoulder.

Below the arm socket is attached an artificial limb which represents

the elbow joint, forearm, and hand.

There are two types to be described:--

1. The artificial arm proper, which has the external shape of the

natural limb.

2. The worker's arm, a terminal appliance in which outward appearance

is not considered.

The considerations as to the arm socket and its attachment by a

shoulder cap are the same for the two types of appliance.

_Attachment and Arm Socket._--The surface over the acromion and

clavicle is the only point from which support can be given to an

appliance for an amputation through the arm; the attachment is made by

means of a shoulder cap.

The general shape of this shoulder cap and its attachment by means

of a strap passed under the opposite axilla are similar to those

described for appliances for amputation through the forearm.

[Illustration: FIG. 201.]

The larger the shoulder cap the more it extends forwards over the

anterior wall of the axilla, upwards over the supra clavicular fossa,

and backwards over the scapula, the more secure will be the support.

The appliance is heavy and has no support other than the axillary

strap. The latter has a tendency to ride upwards against the axilla

where it exerts a pressure which may be uncomfortable. This may be

relieved by attaching a vertical strap which is buttoned to the

trouser belt.

[Illustration: FIG. 202.]

But although this extensive enclosure of the thoracic region may not

hinder the movements of the stump forwards and backwards, it must

obviously interfere with the movement of abduction. No doubt this

movement is the less important of the two, but we ought to try to

preserve it as far as possible.

In short stumps we must abandon it. But if the stump is long and

consequently has no tendency to escape from the socket, even if this

slips down a little, movement may be retained by two methods.

The first consists in separating the arm socket from a large shoulder

cap, and inserting a joint between (see page 87); but the appliance

is then heavy and cumbersome. Moreover, although abduction can thus

be easily attained, thrusting and pulling movements require a light

appliance, and finally it is impossible to secure rotation.

[Illustration: FIGS. 203 and 204.--Shoulder fitting of small

extent allowing abduction.]

It is possible, on the other hand, by means of the other method, which

consists in ending the shoulder cap at a line continued vertically

upwards from the thoracic margin of the axilla. If the straps are

strong and carefully adjusted the result is better than with the

fitting over the scapula, so that this appliance is preferable. We

here illustrate a method of fitting the straps which we consider a

good one. From the posterior part of the ordinary axillary strap, a

Y-shaped branch passes to the upper border of the shoulder cap above

and in front of the clavicle, this makes up for the small extent of

the enclosure of the shoulder.

For the worker's arm a considerable enclosure without any joint is

essential, in order to secure stability.

The arm bucket, usually continuous with the shoulder cap, is made of

leather strengthened with steels.

The artificial arm is often abducted from the trunk, which constitutes

an inconvenience. This is sometimes due to a fault in the alignment,

the arm piece not being at right angles to the shoulder cap. It is,

however, more often due to the cylindrical shape given to the arm

bucket which forces it away from the trunk. The inner side of the

bucket should be flattened so that it may hang vertically close to the

thorax.

The details of construction are different for the true artificial arm

and the worker's arm.

1. ARTIFICIAL ARM

The arm and forearm pieces are both made of leather. There is no

object in making them to lace, the stump is enclosed in a socket in

which it need not fit very tightly, because, as we shall explain, this

appliance is unsuitable for heavy work.

These two parts are strengthened with steels, which are articulated by

hinge joints at the level of the elbow. We have to study--

1. The position of the steels and the direction of the axis of the

joint.

2. The lock to fix the elbow joint in a flexed position.

1. _Position of the Steels._--The stump can transmit to the arm socket

the various movements grouped under the name of circumduction, but its

hold does not enable it to transmit rotation.

It is therefore undesirable--although usual--to attach the steels

on the arm and forearm to the inner and outer sides of the limb. If

this is done, as rotation is impossible, flexion of the forearm at

the elbow can only be carried out in the sagittal plane. But this

movement is only exceptionally required; the elbow being flexed to the

right angle and fixed in this position by a ratchet the limb forms a

hook upon which an object may be hung, provided that the forearm lies

transversely in contact with the abdomen and not antero-posteriorly.

Flexion should therefore be in a plane which is almost the frontal

plane (20° or 30° in front of this), and not in the sagittal plane.

As there is no active rotation of the arm therefore the steels must

be almost in the sagittal plane (the anterior a little external, the

posterior a little internal).

In certain carefully constructed appliances the arm bucket is cut

transversely above the elbow and between the two parts a bayonet joint

is fixed where the arm can be rotated by the sound hand, so that the

direction of the elbow movement can be altered.

2. _Ratchet to fix the Elbow Joint in the Flexed Position._--When at

rest the forearm should hang vertically. But the hand can only be used

when the elbow is flexed to an obtuse angle or a right angle, the

latter position being more often used. Therefore when the patient has

bent the joint to the required angle with his sound hand, he must be

able to fix it in this position.

This fixation is effected by means of a ratchet attached to the outer

side of the elbow, which can be locked or unlocked at will.

This ratchet consists of a flat metal plate with a prolongation

upwards shaped like the handle of a fork. The end of this prolongation

is attached to the arm steel by a pin joint about 3 centimetres above

the axis of the elbow joint. The plate is pierced by a rectangular

opening, one border of which is notched; it lies against the forearm

steel, a catch projecting from which fits into the opening, this

catch, situated 6 centimetres below the axis of the elbow, is of

the same diameter as the notches with which it engages. The higher

the notch with which engagement takes place the more nearly flexion

approaches the right angle.

The width of the opening in the plate is twice the size of the catch,

so that the joint works freely when the catch glides on the smooth

edge and becomes fixed as soon as the catch engages in the notched

border.

It is only necessary to arrange a lock, manipulated through the

sleeve, to bring the smooth or the notched border in contact with the

catch.

Suppose that the handle of the ratchet is prolonged behind the point

at which it is hinged to the arm steel as a little lever furnished

with a button, and that an elastic cord or spring is stretched from

this button to a point on the postero-external border of the forearm,

then if the lever points upwards and the notches are on the upper edge

of the ratchet (as is the case in figure 205), the elastic, pulling

the lever forwards, will press the ratchet down and make the notches

engage with the catch on the forearm, if, on the other hand, the lever

points downwards the elastic traction will release the notches. The

reverse occurs if the notches are on the lower edge.

It is then only necessary to arrange a mechanism by means of which

this little lever can turn, with a stop which arrests it above at the

vertical position, below at a point 45° beyond the horizontal.

[Illustration: FIG. 205.--Elbow ratchet.]

A simple mechanism of this sort is shown in figures 206 and 207. The

joint surfaces of the ratchet and of the little lever each bear a

shoulder, the former in front, the latter behind, extending over such

a proportion of their circumference as will make them act as stops in

the desired positions above and below.

A lock is thus provided which can be manipulated with the other hand.

In the particular pattern illustrated, traction is made by an elastic

cord fixed to the centre of the back of the wrist and ending above

in a leather strap pierced with holes which fix on the button of the

lever. This arrangement allows of the adjustment necessitated by the

gradual stretching of an elastic which is subjected to continuous

tension.

A steel spring of this length (the whole length of the forearm) would

be too heavy if it were sufficiently powerful. If it is desired to use

this method the two ends of a powerful spring should be fixed, one to

the button on the lever, the other to the catch on the forearm with

which the ratchet engages.

[Illustration: FIGS. 206 and 207.--The elbow ratchet and mode

of action of its lock.]

The spring should always be in tension. As the distance between the

joint on the arm and any point on the forearm increases as the elbow

extends, it is better for the ratchet, with notches on its upper

edge, to be engaged when the button points upwards and free when it

points downwards. In the opposite arrangement, which is often used,

the tension is considerable without being useful when the forearm is

vertical, and the mechanism soon wears out.

3. _Hand and Other Appliances._--The hand attached to the end of the

forearm has a spring thumb which may be passive or automatic. In

the latter case, if the stump is long enough to allow considerable

movements of the arm, the cord works in the way described on page 87,

for amputation of the forearm. If the stump is short, traction must be

exerted by movement of the shoulders, rounding the back.

The hand with a mobile wrist is never used with these amputations

except in certain expensive appliances, in which in addition the four

fingers may be articulated, as described on page 101. For the ordinary

limb these delicate mechanisms are devoid of practical utility.

It is easy to replace the hand with interchangeable appliances, but

when the patient has to do hard work this is not a satisfactory method.

The arm with the ratchet at the elbow is in fact suitable for use

by a clerk. But it is not either strong enough or simple enough for

manual labour. In our opinion the functional and practical value of

an artificial arm, particularly for amputation above the elbow, is

often exaggerated, however it does exist, especially in many branches

of agricultural work. For the latter the slightness of the lateral

steels--and especially of the joints at the elbow--makes the appliance

insufficiently strong. The necessary delicacy of the ratchet and its

manipulation through the sleeve by the sound hand are additional

disadvantages.

2. WORKER'S ARM

If our object is to fit to an arm stump an appliance which will be at

the same time strong and flexible, capable of carrying out rough and

even vigorous work, we must abandon the attempt to imitate the natural

shape of the arm.

The movements and strength of the stump must be transmitted to the

object held by means of a rigid rod at the extremity of which the

appliance for gripping is fixed. It is possible to fix around this

rod a show arm with a hand and a passive spring thumb for wearing on

special occasions, in exactly the same way as we fit the show leg

round the peg. Figures 208 and 210 will show at a glance how this is

done.

But, as far as our present experience goes, this is only an accessory

added for æsthetic reasons. The true worker's arm consists of a strong

metal rod fixed to the arm socket in a way that we must now study.

1. _The Arm Socket._--We have already said that this must be continued

into a shoulder cap of considerable extent, which may be perforated

in the region of the point of the shoulder in order to render the

appliance lighter. Abduction at the shoulder is thus sacrificed.

The arm socket is made of leather, open down the front and laced. By

being laced it fits the stump more securely. It is strengthened by two

steels which may be fixed in the frontal plane because, as we shall

see, a passive rotation at the elbow joint is possible.

These steels are directly continuous below with a hemispherical steel

cap, which is pierced in the axis of the limb by a hole into which is

bolted the connecting piece to which the rod which represents the

forearm is attached.

2. _Articulation at the Elbow._--The forearm consists of simple metal

tube, attached beneath the arm socket by methods which depend upon the

following principles.

[Illustration: FIGS. 208 and 209.--_Worker's arm and show

arm._

The worker's arm consists of a metal rod which swings backwards and

forwards at the elbow and also rotates upon the arm socket. To the

end of this rod an appliance can be screwed (a ring and hook are here

shown). Around the worker's arm a show arm with a hand (Fig. 209) can

be fixed. They are shown in place in Figure 210.]

The only movements that the stump can transmit to the arm socket

are forward and backward movements hinging about the shoulder, and

abduction. The first of these movements is the only really useful one

for the workman. The downward pressure exerted by active extension of

the elbow no longer exists; in order to press upon an object the sound

hand must be used, for it is not practicable to make use of the weight

of the body thrown forward for this purpose.

[Illustration: FIG. 210.--Show arm in position.]

In backward and forward movements--considering, for example, the use

of the file--the angle at the elbow opens when the arm is thrust

forward and closes when it is pulled backwards. These passive

movements of the joint must not be impeded in any way, that is to say,

the forearm must swing freely below the arm upon a transverse axis and

it must also be able to rotate freely around a vertical axis.

These movements are secured in the ploughman's hand which was designed

sixty years ago by Gripouilleau and in which the joint which we

have shown as a method of attaching the mobile ring to the wrist is

utilised. The forearm rod attached by a strong transverse pin swings

freely in a little stirrup-shaped cap, which itself rotates around a

bolt by which it is firmly fixed into the metal or wooden hemisphere

which terminates the arm socket.[14]

[14] Wood, which was used by Gripouilleau, has been given up.

It is clear that this complete liberty of action has its

disadvantages; the elbow joint can never be made to assume a fixed

position against any passive resistance; moreover, in actual practice

the useful range of either of these movements is small. For this

reason attempts have been made to devise methods by which they can be

limited in the various worker's arms which have been designed since

the beginning of the war. In all these arms the mechanism of the elbow

joint is derived from that of the ploughman's arm of Gripouilleau.

Unfortunately none of these mechanisms in which a pressure screw is

used for fixation possess any strength. At first sight, in a new

appliance they appear attractive and work well, but it is well known

to all mechanics that the thread of a screw which is in constant use

quickly wears and then it is impossible to tighten it.

At the extremity of an artificial arm, whether it be an arm of natural

shape or a worker's arm simplified to the form of a jointed rod, any

of the appliances already described for forearm amputations can be

screwed on as required.

It is by the use of these appliances that Gripouilleau's old

ploughman's arm, which ended in an interchangeable hook and ring, has

been improved.

Apart from their actual economic value, results have been obtained by

use of these terminal appliances, in many different skilled trades,

which are of the greatest possible interest.

For reasons that we have indicated in describing the attachment of the

elbow, the various attempts that have been made to give to the wrist

a mobility that is under control have not so far led to the invention

of an appliance that is both strong and durable. For this reason we

consider that until something new is designed it is better to make the

terminal appliance a fixed one.

_CHAPTER IX_

ARTIFICIAL LIMBS FOR DISARTICULATION THROUGH THE SHOULDER JOINT AND

AMPUTATION THROUGH THE DELTOID MUSCLE

So far as function is concerned these operations are identical; a

short arm stump is incapable of transmitting movements to the socket

of the artificial limb.

That is to say, our appliance will be a purely passive one, and

at the present time it is useless to attempt to make any sort of

worker's arm. We must aim simply at supplying a limb which imitates

the external shape of the arm, with an elbow joint which can be locked

with a ratchet. At most it is possible by a movement of the opposite

shoulder to work an automatic thumb by means of a cord, as a rule,

however, a simple spring thumb is preferred.

Nothing need be added to what has been said in the previous chapter

about the elbow joint or the hand.

In the fitting of an attachment over the shoulder the amputation

through the deltoid presents an actual advantage. For in this case the

shape of the point of the shoulder is preserved, and the attachment

carried out as described on pages 87 and 130 fixes the appliance very

securely.

If the entire humerus has been removed a very extensive enclosure of

the front and back of the chest is essential and in order that the

axilla may be in close contact with the top of the limb it is a good

thing to stretch across this space a layer of some firm material.

These appliances can be used to steady a piece of paper upon which

the patient is writing, to carry a parcel which is not too heavy

with the elbow flexed, to grip an article with the thumb. A workman

who is being re-educated for some occupation which is possible

for a one-armed man, will usually--unless he is going out for

pleasure--leave his artificial arm at home in the cupboard.

_CHAPTER X_

SOME GENERAL PRINCIPLES IN THE RE-EDUCATION OF THE DISABLED

WHEN a disabled man has been fitted with an artificial

limb he has to learn a trade which will enable him to supplement

his pension and provide for himself and his family. In our opinion,

which we believe we have expressed more than once in this book, it is

nearly always advisable to determine what profession will ultimately

be possible before ordering the artificial limb. This principle is

perhaps not always thoroughly understood, although there are fitting

centres where it is fully recognised (a proof of this may be found in

a recent article by Nové-Josserand and Bouget).

It is unnecessary to repeat that whilst every effort must be made to

associate form with function, the latter is bound to take precedence

of the former. It is, however, not always easy to impress upon

patients, and more especially upon their protectors, that _form_ is

for Sundays and holidays, and _function_ is for workdays.

The grave problem of re-education of amputation cases, and in a more

general sense of all the maimed, now confronts us. We believe it to be

worth while to indicate the general principles so far as they are at

present understood.

I

At the outbreak of war the idea of the disabled in general, and

particularly of those who had had a limb amputated, was often to give

up any really active trade and to seek a "situation" generally as an

official with no actual manual labour. It must be confessed that many

people, especially the nurses, encouraged them in this, and possibly

the latter would not deny having done so.

It has rapidly become evident that there are too many maimed to

be supplied with situations as caretakers of public gardens or

doorkeepers, and that they will not be able to gain a living by making

tricoloured decanter-mats of string or raffia or artificial flowers,

when bazaars organised for their benefit by tender-hearted souls have

gone out of fashion.

One of us was present a short while ago at the following little

scene:--

In a hospital where there were two amputation cases, one through the

lower fourth of the thigh, the other through the middle of the leg,

both agricultural labourers, a distinguished man of letters, actuated

by the best intentions, asked them what they counted on being able to

do after they had been fitted with artificial limbs. The first replied

that he hoped to return to agricultural work, the second that he would

never be able to do that but would look out for a "situation." Our

friend was much surprised to hear us say that he would be ill employed

in using his influence to obtain his desire for the second patient,

because a man with only one leg could work on the land with almost

no diminution of his ordinary capacity, even with the old-fashioned

kneeling peg leg.

As Jean Camus has well said in a recent article in the _Paris

Médical_, "We are beginning to pass beyond the phase when re-education

of the maimed was left to chance. It is felt now that the frivolous

efforts of benefactresses who, acting with the best intentions but

without reflections, are delighted to be able to transform into a

shorthand typist an honest farm labourer who had a strong attachment

to the soil and could quite well return to it, must be avoided. Such

feats are both culpable and absurd."

These fantastic ideas must be got rid of, and all our efforts must be

co-ordinated, the complexity of the conditions to be dealt with being

duly weighed.

Given a maimed man the first care should be to educate to the maximum

all the uninjured and remaining parts. It is too often forgotten that

among the parts remaining the brain plays a leading rôle, even the

chief rôle, not only because it is the organ of "good will" without

which all attempts at re-education are fruitless, but also because

good will being given the intelligent man will succeed better and

will be able to adapt himself to more delicate work. "Physiotherapy

cannot be prescribed," says J. Camus, "as quinine is prescribed. The

malarial patient who takes the latter medicine benefits whether he

wishes to or not. The wounded man who submits each morning to his

mechanotherapeutic treatment does not recover unless he wishes."

It is very difficult to make the layman understand this. He invariably

takes for granted the good will of the patient, with all of whose

complaints he sympathises, without for a moment realising that they

sometimes degenerate into jeremiads, often with an ulterior motive.

An examination by a doctor--and an experienced doctor--is therefore

necessary in order to determine under what physical and mental

conditions an amputation case can be re-educated; so that he may

understand that it is entirely to his interest to work as quickly and

as well as possible, that begging is degrading, and above all that

private charity is temporary and exhaustible; and that in consequence

he must as quickly as possible put himself into a condition to

supplement by a salary justly earned the pension or gratuity which is

certain to be insufficient for his maintenance.

It can never be sufficiently insisted upon in dealing with the maimed

that by resuming work, and on account of the functional improvement

resulting from doing so, they need have no anxiety that their pension

will be reduced, because the amount of this is based on the extent of

the injury itself and on the man's rank, and not on his profession

before he became a soldier. In the same rank the pension is the same

for a surgeon or a lawyer, if both have lost a hand.

It is a deep-seated notion, instilled into the minds of injured

workmen by the often suspicious folk who advise them, that if they

begin work before their case has been settled their pension will be

less.

It must be acknowledged on the other hand that the civil expert

is often faced with a difficulty. As our law stands--and it is

unfair--work cannot be resumed partially with provisional half-pay

followed later by whole-time work with permanent salary. This

difference is important to our wounded soldiers, who have everything

to gain by a rapid and complete re-education and whose duty it is

to do whole or part-time work while their legal position is being

arranged and before the wound, in legal phraseology, has become

"consolidated," that is to say, before the completion of treatment.

It is only fair to add that the patients are not alone to blame and

that the administration has for long been guilty of an error against

which reaction is growing, viz. delaying re-education until the time

when the local condition has become permanent and the patient has been

discharged and has received his prosthetic apparatus.

This delay is deplorable, on both medical and social grounds. On

medical grounds because in very many cases before treatment is quite

complete the addition of carefully graduated and supervised work is

an important part of the treatment. On social grounds because it is

necessary to fight in every possible way against the common tendency

of the patient to fall into habits of laziness and intemperance.

This is now understood, and almost everywhere to-day the wounded

soldier can resume work in workshops attached to the centres of

physiotherapy, and thus begin his re-education while continuing his

treatment.

At a certain stage resumption of work becomes the best therapeutic

agent of all.

It is obvious that this resumption of work cannot supply the place

of certain special treatments such as electrical treatment during

the regeneration of a nerve, balneotherapy, or graduated gymnastic

exercises; but is it not true that work with its continual active

movement is infinitely superior to passive mobilisation by means of

apparatus however ingeniously the latter may be contrived? Morover it

is surely a more efficacious course of mechanotherapy when the patient

works for half or all the day than is provided by the special course

occupying only an hour or two.

The tendency to-day is in this direction, as, for example, at the

Grand Palais, thanks to the efforts of J. Camus, and also in the

agricultural centre of the XIIIth district under the direction of

Belot and Privat. At a given moment all treatment may be suspended and

the patient may devote himself exclusively to work with results the

excellence of which Nepper and Vallée have demonstrated.

The workmen are then eligible for work in a town in private workshops,

but so far this freedom has more inconveniences than advantages. A

man whose working capacity is much reduced, and more especially a man

who requires re-education, has no place in an ordinary workshop where

neither the proprietor nor the foreman nor his fellow-workmen are in

truth much inclined to concern themselves about him. Where actual

education is necessary this is best supplied in special workshops

where the patient will be among comrades handicapped like himself,

whose progress he will be able to watch and whose efforts he will

imitate, rather than among able-bodied workmen, by comparing himself

with whom he is bound to be discouraged.

The problem has been solved by the Belgians in a remarkable

establishment opened at Port-Villerz, and by the Austrians at Vienna

under the direction of Spitzy, as Nové-Josserand and Bouget inform

us, by delaying a maimed soldier's discharge from the army until his

re-education is as complete as possible. This method has proved to

be to the interest both of the individual and of the State, but we

do not seem to have considered this solution, and it is still to be

feared that it would accord ill with the independence of our national

character. The actual fact, though it has not been brought into

prominence, is that our usual system of "watertight compartments" has

been applied by adding to the centres of physiotherapy centres of

agricultural or industrial re-education, the results obtained in which

are dependent upon the efficiency of the director of physiotherapy.

This matter seems to have received very little special attention in

connection with amputation cases. It is, however, of great utility to

develop the strength and agility of the remaining limbs by suitable

gymnastic exercises, to teach a man with only one leg, for example,

to jump without an artificial limb and to climb a slippery rope or a

ladder; or to train the left hand of a man who has lost his right;

to develop the greatest possible strength in the stump by training

it in movement combined with the exertion of force. In addition to

this, early and provisional equipment with artificial limbs must

become general. These temporary limbs are undoubtedly rudimentary

contrivances, but they are functionally good and are useful on account

of their mere weight.

In this connection the temporary arms used by Nové-Josserand and

Bouget in their agricultural re-education centre are very interesting

models. The great advantage of using a temporary limb is that the

time required for the construction of the permanent apparatus, often

a considerable period, is not lost in idleness, the mother of all the

vices.

II

It was said at the beginning of the last chapter that whenever

possible a disabled man should be given a real trade and not one of

those frivolous and trifling occupations which were at one time the

fashion.

In the choice of a trade the ruling principle is that of aiming to

restore as nearly as possible the man's former occupation. This

principle should not, however, be carried to an extreme.

As Camus has justly said, by his previous work a man has stored up

a mass of ideas, a fact which is too little realised, especially by

himself. These include the manner of choosing, holding, and attacking

the materials upon which he works, and of appreciating their qualities

and faults; knowledge of their market value, of the value of the

labour, etc. This should be utilised in his future work even though it

be realised, as M. Bourillon has remarked, that the resumption of his

trade in its entirety may be impossible.

With the tools that have been described a man who has lost his forearm

may be able, for example, to undertake a locksmith's work and to

execute correctly all the movements required in plying the trade.

Granted; but how long will he take to make one piece, let us say,

as well as his neighbour? If he produces little he will not find an

employer to give him daily work, while if he does piecework, apart

from the fact that it is not in good repute among those who are the

actual leaders of the working classes, it will not be remunerative,

and to earn 3 frs. a day when a comrade earns 10 or 12 frs. is

practically an impossible solution.

The case may be cited of a woman suffering from congenital deficiency

of the hand with a very short rudiment of the wrist which is only

slightly mobile. By means of contrivances which we need not describe,

and with no prosthetic apparatus, she threads her needle and sews as

quickly and as well as anybody. This is not an argument, for: (1) it

is a congenital lesion and the educability of a child is well known;

(2) the woman is extremely intelligent, and unhappily this favourable

factor cannot always be counted upon. It would be wrong to conclude

from this that a case of amputation at the wrist should be put to

sewing.

It must never be forgotten that intelligence and will are factors of

the first importance, so that however little intellectual capacity

the disabled man may have, he is bound to profit by his passage

through the school of re-education in learning to read and write if

he is illiterate--this is more frequent than is usually believed--or

to improve his knowledge if he has already had some instruction. It

is, in fact, by brain work that many learn to replace their physical

defect. Let us take, for example, a disabled bricklayer. If he is

intelligent and is given a helping hand in the shape of the necessary

instruction, he may become a builder on his own account in a small way

when he knows how to make plans, work out estimates and keep accounts.

This is not a Utopian fancy. In the small towns and villages there

are many owners of businesses such as masons, decorators, joiners,

etc., workmen who cannot spell, but who are intelligent, have business

minds and a gift for overseeing, who have given up the trowel and will

build you a house as well as, or often better than, many "architects."

It is with similar aims to these in view that a bricklayer should

be re-educated when it is judged that his intellectual capacity is

sufficiently great.

Where there is no intelligence education can do little. There are in

civil life innumerable "casual labourers" with limbs intact who have

never been able to learn a regular trade and who earn a miserable

livelihood by doing what "turns up." Their situation becomes serious

when they lose some of their physical capacity. They can, however,

be rescued, particularly by encouraging them to become agricultural

labourers. It is indeed especially agricultural labourers who should

be urged to return to the land, and those mechanics who will be

unable to work in a factory for the future should also be encouraged

to take up this work. One reason for this is that the workman's

arm--especially if it has not been too much elaborated--is useful

for the execution of a considerable variety of work on the land. It

is unnecessary to speak of cases of amputation below the knee, since

their usefulness on the land may be taken for granted.

In the country as a matter of fact a man never dies of hunger; and

this cannot be said of the town. Apart from actual cultivation of the

land, which is in part impossible for the maimed, there are numerous

and important occupations of which a town dweller would not think. It

is when he goes to the centre of re-education in agricultural work,

first of all to view it and then to work, that the disabled man takes

note of what he can or cannot do, and of the work in connection with

agriculture which is open to him, such as poultry rearing or bee

keeping.

This applies to other employments than agriculture.

Apart from his actual trade which the workman can no longer ply with a

sufficient return for his labour, he may be able to work at one or two

of the accessory employments which would not of themselves bring him

in a living but which would yield a satisfactory supplementary income.

In certain re-education centres there seems to be a marked

predilection for crafts in which the apprenticeship is short

and the installation costs little, though these are in fact the

characteristics of those trades which give the labourer a poor return,

that is to say, time-work in a large or small workshop.

At the beginning of the war an attempt was made to show that there

would never be enough tinkers, sabot makers, shoemakers, or saddlers

in the country. It is quite a false idea that a disabled man can

gain a living at one of these crafts in a village. It is true that

he can do so if, working as an agricultural labourer, he can act

as a barber in his spare time, and is capable of executing small

jobs, especially repairs, which the villagers would readily give to

him rather than have to go several miles to get them done. When the

disabled man has this additional work in his hands he will gradually

be able to ascertain whether the needs of the countryside and his own

personal capacity are compatible with its development. In that case,

however, he will be, in fact, a small proprietor buying his own tools

and materials and fixing a retail price. But the great majority of

workmen have no notion of such calculations and such organisation

as are indispensable when a man runs a business even if he is

alone. It follows, therefore, that the education of his mental, and

especially his commercial, faculties must be considered, and it must

be ascertained whether the man is likely to profit by such education.

It is useless to install in a hamlet a shoemaker who is incapable

of working except as an assistant, and in the town at the actual

factories the prospects are poor.

Moreover, conditions of life in the disabled man's native place must

be considered as a matter of importance. A man from the Mediterranean

country has no idea beyond the cultivation of meadows, and one from

Picardy none beyond the making of cane baskets for packing flowers.

Judgment is difficult, and in order that the choice may be exercised

as reasonably as possible, the careful collaboration of the patient,

the doctor and the managers of the workshops is essential. We repeat

that this is one of the principal objects for which the centres of

re-education are useful. There are some efficient men, we know, who

without asking anything of anybody find quickly and unerringly the

exact work that suits them. There is no need of anxiety in such cases.

A certain metal worker from the invaded area suffering from

pseudarthrosis of the shoulder, whose wound we were treating, sent

for his wife, and they began to rear geese. We know two cases of

amputation of the right arm, an operative at an aeroplane works and

a worker in stucco, who during their stay at hospital and before

they had been supplied with artificial limbs, had taught themselves,

the one technical design the other ornamental design. Both of them,

as soon as they were discharged, have been taken on by their former

masters, who no doubt were fully conscious that they were thus

combining a good deed with good business. To come to a decision of any

value, however, cases of this sort must not be taken as a criterion,

for they are in fact exceptional. The majority of the men are in need

of guidance.

The procedure employed at the Belgian centre of re-education at

Port-Villerz consists in allowing the patient to frequent the

workshops at will for a few days, during which time he sees what is

going on and is not slow to make his choice, which it appears rarely

needs to be amended.

We have dealt chiefly with the conditions which are suitable for the

re-education of a man who has lost an upper limb, or, speaking more

generally, is disabled in one arm, for whom resumption of work in a

workshop will often be out of the question. The question is easier

of solution for the lower limb. Cases of amputation of the leg can

work standing, if supplied with an artificial limb, at practically

any trade. Cases of amputation of the thigh have numerous manual

occupations open to them in which they sit for at least part of

the time. It must be understood, however, that these professions

which require skill can, as a rule, only be learnt in well-equipped

workshops at the price of a fairly long apprenticeship. Two or three

years are necessary to make a good mechanic, a good watchmaker,

glass cutter, etc. This should not deter us in the case of fairly

young men. The difficulty is to organise special workshops, often with

a complicated equipment, where the maimed man can at least pick up

the rudiments of the work, for it is not to be thought of that he can

remain there during the whole time occupied in a complete training.

In conclusion, we should like to draw attention to the law of 1831,

which regulates the distribution of pensions by means of groups

classified according as the loss is of two limbs or of one. No

distinction is made with regard to the seat of the amputation. But

a man who has lost both legs and has been suitably equipped with

artificial limbs can earn a fair wage, whereas a man who has lost

both arms is completely disabled so that he cannot even wash or

dress himself. Among the amputation cases the difference is also

considerable in the lower limb, between amputation through the leg

and through the thigh, and even more in the upper limb, between an

amputation retaining the movements of the elbow and one in which they

are lost. There is, moreover, a great difference in the quality of

stumps and the consequent utility of the artificial limb. It is of

course impossible to allow with mathematical precision for all degrees

of disablement, but the several general distinctions which we have

enumerated could be taken into consideration without difficulty.

INDEX

American chuck, 122

Angle at which foot is set, 34, 49

Appliances for use instead of hand, 108

with mobile joint, 123

with universal joint, 126

Artificial hand, 96

spring grip thumb, 97

automatic thumb, 98

Beaufort thumb, 99

for commercial travellers, 102

automatic fingers, 105

Bearing points, 6

upon ischium, 13

upon condyles of femur, 62

upon tuberosities of tibia, 67

upon end of leg stump, 77

Bouget, 145, 151

Bonreau's appliances, 112

function of the artificial hand, 117

hook and ring, 124

length of artificial forearm, 118

Braces for suspension of artificial leg, 24

with extending sling, 43

for amputation below knee, 73

Brunet's grip, 107

Brushmaker's hook, 119

Camus, Jean, 147

Cardan joint, 126

Chauffeur's bell, 125

Combined mechanism for knee and ankle joints, 55

Combined suspension for artificial leg, 26

Condyles of femur, amputation through the, 60

Convertible peg leg, 58

Deltoid muscle, amputation through the, 143

Duplex foot, 54

Elbow joint, for above elbow amputations, 133

for below elbow amputations, 91

for below elbow amputations, short stumps, 95

for worker's arm, 139

Elephant boot, 79

Equilibrium in an artificial leg, 35

Federation leg, 33

Flexed knee, walking upon the, 66

Foot, construction, 35

with movable ankle, 50

with lateral mobility, 54

Foot, partial amputation of the, 81

Fork rest, Raynal's, 109

Frees' foot and knee, 57

Gripouilleau, vine-dresser's hook, 112

agricultural hook and ring, 124, 126

ploughman's hand, 141

Guyon's amputation, 78

Hip joint, disarticulation at the, 64

Hook and ring, agricultural, 124

Boureau's, 124

Index finger, length of, 102

Knee extending mechanism, 37

artificial muscle, 37

extending sling, 43

combined with ankle movement, 55

Knee joint, amputation through the, 60

Knee joint, for amputation through the leg, 73

Leather-cutter's hand, 116

Leg bucket, shape of, 67

material, 68

Marks' leg, 34

knee joint, 41

braces, 45

Materials for bucket, 3

for artificial arms, 84

Nové Josserand, 145, 151

Nyrop's grip, 121

Packer's hand, 115

Peg leg, 28

with joint at knee, 29

with show leg and foot, 31

conversion into leg with free knee joint, 58

Perineal concavity, 15

Plumber's hand, 115

Postman's hand, 113

Ratchet at elbow, 133

Re-education of amputation cases, 145

Rotation of artificial arm, prevention of, 89

Shoulder joint, disarticulation at the, 143

Spade holder, 127

Stop to limit extension of knee, 38

for amputation below knee, 76

Stump, length of, 3

condition of allowing end bearing, 7

Suspension of artificial arms, 85, 129

to condyles of humerus, 85

to shoulder, 87

for worker's arm, 138

Syme's amputation, 77

Thigh bucket, shape of, 13

wooden, 17

leather and steel, 20

for amputation through knee joint or condyles, 60

Thigh corset, 73

Thumb, spring grip, 97

automatic, 98

Beaufort, 99

Tram driver's bell, 125

Vine-dresser's hand, 113

Waist belt, 22

Worker's arm, 138

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THE TREATMENT OF INFECTED WOUNDS. By A. Carrel and G. Dehelly.

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THE TREATMENT OF FRACTURES. By R. Leriche, Assistant Professor in the

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FRACTURES OF THE ORBIT AND INJURIES OF THE EYE IN WAR. By Felix

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HYSTERIA OR PITHIATISM, AND REFLEX NERVOUS DISORDERS. By J. Babinski,

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with the after-effects of wounds received in war, the question

of sequelae presents itself, and will present itself more and

more. What has become--and what will become--of all those who,

in the hospitals at the front or in the rear, have hastily

received initial treatment, and what is to be done to complete a

treatment often inaugurated under difficult circumstances?

ARTIFICIAL LIMBS. By A. Broca, Professor in the Faculty of Medicine,

Paris, and Dr. Ducroquet, Surgeon at the Rothschild Hospital. Edited

and translated by R. C. Elmslie, M.S., F.R.C.S., etc.; Orthopædic

Surgeon to St. Bartholomew's Hospital, and Surgeon to Queen Mary's

Auxiliary Hospital, Roehampton; Major R.A.M.C.(T.). With 210

illustrations. Price 6/- net

The authors of this book have sought not to describe this or

that piece of apparatus--more or less "newfangled"--but to

explain the anatomical, physiological, practical and technical

conditions which an artificial arm or leg _should_ fulfil.

It is, if we may so call it, a manual of _applied mechanics_

written by physicians, who have constantly kept in mind the

anatomical conditions and the professional requirements of the

artificial limb.

TYPHOID FEVERS AND PARATYPHOID FEVERS (Symptomatology, Etiology,

Prophylaxis). By H. Vincent, Medical Inspector of the Army, Member

of the Academy of Medicine, and L. Muratet, Superintendent of the

Laboratories at the Faculty of Medicine of Bordeaux. Second Edition.

Translated and Edited by J. D. Rolleston, M.D. With tables and

temperature charts. Price 6/-net

This volume is divided into two parts, the first dealing with

the clinical features and the second with the epidemiology

and prophylaxis of typhoid fever and paratyphoid fevers A and

B. A full account is to be found of recent progress in the

bacteriology and epidemiology of these diseases, considerable

space being given to the important question of the carrier in

the dissemination of infection.

_The cost of postage per volume is: Inland 5d.; Abroad 8d._

LONDON: UNIVERSITY OF LONDON PRESS, LTD.,

18, WARWICK SQUARE, E.C.4

MILITARY MEDICAL MANUALS

From THE LANCET: "The names of the editors are sufficient

guarantee that the subject matter is treated with fairness and

discrimination."

DYSENTERIES, CHOLERA, AND EXANTHEMATIC TYPHUS. By H. Vincent, Medical

Inspector of the Army, Member of the Academy of Medicine, and L.

Muratet, Superintendent of the Laboratories at the Faculty of Medicine

of Bordeaux. With an Introduction by Andrew Balfour, C.B., C.M.G.,

M.D., Lieut.-Col. R.A.M.C. Edited by George C. Low, M.A., M.D., Temp.

Capt. I.M.S. Price 6/- net

This, the second of the volumes which Professor Vincent and

Dr. Muratet have written for this series, was planned, like

the first, in the laboratory of Val-de-Grâce, and has profited

both by the personal experience of the authors and by a mass

of recorded data which the latter years of warfare have very

greatly enriched. It will be all the more welcome, as hitherto

there has existed no comprehensive handbook treating these great

epidemic diseases from a didactic point of view.

ABNORMAL FORMS OF TETANUS. By MM. Courtois-Suffit, Physician of the

Hospitals of Paris, and R. Giroux, Resident Professor. With a Preface

by Professor F. Widal. Edited by Surgeon-General Sir David Bruce,

K.C.B., F.R.S., LL.D., F.R.C.P., etc., and Frederick Golla, M.B.

Price 6/- net

Of all the infections which threaten our wounded men, tetanus is

that which, thanks to serotherapy, we are best able to prevent.

But serotherapy, when it is late and insufficient, may, on

the other hand, tend to create a special type of attenuated

and localised tetanus; in this form the contractions are as a

general rule confined to a single limb. This type, however,

does not always remain strictly monoplegic; and if examples

of such cases are rare this is doubtless because physicians

are not as yet very well aware of their existence. We owe to

MM. Courtois-Suffit and R. Giroux one of the first and most

important observations of this new type; so that no one was

better qualified to define its characteristics. This they

have done in a remarkable manner, supporting their remarks by

all the documents hitherto published, first expounding the

characteristics which individualise the other atypical and

partial types of tetanus, which have long been recognised.

WAR OTITIS AND WAR DEAFNESS. Diagnosis, Treatment, Medical Reports.

By Dr. H. Bourgeois, Oto-rhino-laryngologist to the Paris Hospitals,

and Dr. Sourdille, former interne of the Paris Hospitals. Edited by J.

Dundas Grant, M.D., F.R.C.S.(Eng.); Major R.A.M.C., President, Special

Aural Board (under Ministry of Pensions). With many illustrations in

the text and full-page plates. Price 6/- net

This work presents the special aspects of inflammatory

affections of the ear and deafness, as they occur in active

military service. The instructions as to diagnosis and treatment

are intended primarily for the regimental medical officer. The

sections dealing with medical reports (_expertises_) on the

valuation of degrees of disablement and claims to discharge,

gratuity or pension, will be found of the greatest value to the

officers of invaliding boards.

_The cost of postage per volume is: Inland 5d.; Abroad 8d._

LONDON: UNIVERSITY OF LONDON PRESS, LTD.,

18, WARWICK SQUARE, E.C.4

MILITARY MEDICAL MANUALS

GUY'S HOSPITAL GAZETTE: "The series is a most valuable addition

to the medical literature of the war.... We deem it to be almost

indispensable to a medical officer, and have no hesitation in

unreservedly recommending it."

SYPHILIS AND THE ARMY. By G. Thibierge, Physician of the Hôpital

Saint-Louis. Edited by C. F. Marshall, F.R.C.S. Price 6/- net

It seemed, with reason, to the editors of this series that

room should be found in it for a work dealing with syphilis

considered with reference to the army and the present war. The

frequency of this infection in the army, among the workers in

munition factories, and in the midst of the civil population

where this is in contact with soldiers and mobilised workers,

makes it, at the present time, a true epidemic disease, and one

of the most widespread of epidemic diseases. Dr. Thibierge,

whose previous labours guarantee his peculiar competence in

these difficult and important questions, has, in writing this

manual, very notably assisted in this work. But the treatment of

syphilis has, during the last six years, undergone considerable

modifications; the new methods are not yet very familiar to all

physicians; and certain details may no longer be present to

their minds. It was therefore opportune to survey the different

methods of treatment, to specify their indications, and their

occasionally difficult technique, which is always important if

complications are to be avoided. It was necessary before all

to state precisely and to retrace, for all those who have been

unable to follow the recent progress of the therapeutics of

venereal diseases, the characters and the diagnostic elements of

the manifestations of syphilis.

MALARIA IN MACEDONIA: Clinical and Hæmatological Features. Principles

of Treatment. By P. Armand-Delille, P. Abrami, G. Paisseau and Henri

Lemaire. Preface by Professor Lavern, Membre de l'Institut. Edited by

Sir Ronald Ross, K.C.B., F.R.S., LL.D., D.Sc., Lieut.-Col. R.A.M.C.

With illustrations and a coloured plate. Price 6/- net

This work is based on the writers' observations on malaria in

Macedonia during the present war in the French Army of the

East. A special interest attaches to these observations, in

that a considerable portion of their patients had never had any

previous attack. The disease proved to be one of exceptional

gravity, owing to the exceptionally large numbers of the

Anopheles mosquitoes and the malignant nature of the parasite

(Plasmodium falciparum). Fortunately an ample supply of quinine

enabled the prophylactic and curative treatment to be better

organised than in previous colonial campaigns, with the result

that, though the incidence of malaria among the troops was high,

the mortality was exceptionally low. Professor Laveran, who

vouches for this book, states that it will be found to contain

excellent clinical descriptions and judicious advice as to

treatment. Chapters on parasitology and the laboratory diagnosis

of malaria are included.

An early announcement will be made in regard to further volumes under

consideration.

_The cost of postage per volume is: Inland 5d.; Abroad 8d._

LONDON: UNIVERSITY OF LONDON PRESS, LTD.,

18, WARWICK SQUARE, E.C.4

Transcriber's Note:

1. All obvious spelling and punctuation errors have been corrected.

2. Italics are shown as _text_ and bold as =text=.