,,military ,,medical ,,manuals          
,,general ,,editor3                     
,,sir ,,alfred ,,keogh1 ,g4,c4,b41      
,m4,d41 ,f4,r4,c4,p4                    
,,artificial ,,limbs                    
,,artificial ,,limbs                    
,,by                                    
,a4 ,,broca                             
,professor of ,topographical ,anatomy   
to the ,faculty of ,paris               
,,and                                   
,,ducroquet                             
,orthopdic ,surgeon to the              
,rothschild ,hospital                   
,,translated ,,and ,,edited ,,by        
,r4 ,c4 ,,elmslie1 ,m4,s41 ,f4,r4,c4,s4 
,major ,r4,a4,m4,c47,t4,f47             
,orthopdic ,surgeon to ,st4             
,bartholomew's ,hospital1 ,surgeon to   
,queen ,mary's ,hospital1 ,roehampton   
,,with #bjh ,,illustrations             
,,university ,,of ,,london ,,press1     
,,ltd4                    #ah ,,warwick 
,,square1 ,,london1 ,e4,c4 #d4          
,,paris3 ,,masson ,,et ,,cie            

#abj ,,boulevard ,,saint-,,germain      
#aiah                                   
,,general ,,introduction      ,the      
infinite variety of injuries which any  
war presents to the surgeon  gives to   
military surgery a special interest and 
importance4 ,the  special interest and  
importance1 in a surgical sense1 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 seen1 for if we read  the older   
writers we find little in the moderns   
that is new in this  respect1 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  conclusions4 ,for the first  
time also in any campaign the labours of
  the surgeon and the physician have had
 the aid of the bacteriologist1  the    
pathologist1 the physiologist and indeed
 of every form of  scientific assistance

 in the solution of their respective    
problems4  ,the clinician entered upon  
the great war armed with all the        
resources  which the advances of fifty  
years had made available4 ,if the       
surgical  problems of modern war can be 
said not to differ sensibly from the    
campaigns of the past1 the form in which
 they have been presented  is certainly 
as different as are the methods of their
 solution4 ,the  achievements in the    
field of discovery of the chemist1 the  
physicist  and the biologist have given 
the military surgeon an advantage in    
diagnosis and treatment which was denied
 to his predecessors1 and we  are able  
to measure the effects of these         
advantages when we come to  appraise the
 results which have been attained4      
,but although we may admit the general  
truth of these statements it  would be  
wrong to assume that modern scientific  
knowledge was1 on the  outbreak of the  
war1 immediately useful to those to whom
 the wounded  were to be confided4      

,fixed principles existed in all the    
sciences  auxiliary to the work of the  
surgeon1 but our scientific resources   
were not immediately available at the   
outset of the great campaign2           
scientific work bearing on wound        
problems had not been arranged in a     
manner adapted to the requirements1     
indeed the requirements were not  fully 
foreseen2 the workers in the various    
fields were isolated1 or  isolated      
themselves pursuing new researches      
rather than concentrating  their        
powerful forces upon the one great      
quest4    ,however brilliant the        
triumphs of surgery may be1 and that    
they have  been of surpassing splendour 
no one will be found to deny1           
experiences  of the war have already    
produced a mass of facts sufficient to  
suggest  the complete remodelling of our
 methods of education and research4     
,the series of manuals1 which it is my  
pleasant duty to introduce to  ,english 
readers1 consists of translations of the

 principal volumes of  the ,horizon     
,collection which has been appropriately
 named after the  uniform of the ,french
 soldier4    ,the authors1 who are      
well-known specialists in the subjects  
which they  represent1 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
 literature4    ,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
 ,english4                              
,,medical ,,series    ,the medical      
volumes which have been translated for  
this series may be  divided into two    
main groups1 the first dealing with     
certain epidemic  diseases including    
syphilis1 which are most liable to      
attack soldiers1  and the second with   
various aspects of the neurology of war4
 ,the last  word on ,typhoid ,fever1    

hitherto the greatest scourge of armies 
in time of war1 as it has been truly    
called1 will be found in the  monograph 
by ,,mm4 ,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     
fevers4 ,the writers  combat a belief in
 the comparatively harmless nature of   
paratyphoid  and state that in the      
present war hmorrhage and perforation   
have been  as frequent in paratyphoid as
 in typhoid fever4 ,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 only4 ,the  relative     
advantages of a restricted and liberal  
diet are discussed  in the chapter on   
treatment1 which also contains a        
description of  serum-therapy and       
vaccine-therapy and the general         

management of the  patient4             
,considerable space is devoted to the   
important question of the  carrier of   
infection4 ,a special chapter is devoted
 to the prophylaxis  of typhoid fever in
 the army4 ,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 employed4    ,,mm4    
,vincent and ,muratet have also         
contributed to the series a work  on    
,dysentery1 ,cholera and ,typhus which  
will be of special interest  to those   
whose duties take them to the ,eastern  
,mediterranean or  ,mesopotamia4 ,the   
carrier problem in relation to dysentery
 and cholera  is fully discussed1 and   
special stress is laid on the           
epidemiological  importance of mild or  
abortive cases of these two diseases4   
,in their monograph on ,the ,abnormal   
,forms of ,tetanus1 ,,mm4               
,courtois-,suffit and ,giroux treat of  
those varieties of the disease in  which

 the spasm is confined to a limited     
group of muscles1 e4 g4  those of the   
head1 or one or more limbs1 or of the   
abdomino-thoracic  muscles4 ,the        
constitutional symptoms are less severe 
than in the  generalised form of the    
disease1 and the prognosis is more      
favourable4    ,the volume by ,dr4 ,g4  
,thilbierge on ,syphilis in the ,army is
 intended  as a vade-mecum for medical  
officers in the army4    ,turning now to
 works of neurological interest we have 
two volumes  dealing with lesions of the
 peripheral nerves by ,mme4 ,atanassio  
,benisty1 who has been for several years
 assistant to ,professor ,pierre  ,marie
 at ,la ,salptrire4 ,the first volume   
contains an account of the  anatomy and 
physiology of the peripheral nerves1    
together with the  symptomatology of    
their lesions4 ,the second volume is    
devoted to the  prognosis and treatment 
of nerve lesions4    ,the monograph of  
,,mm4 ,babinski and ,froment on         
,hysteria or ,pithiatism  and ,nervous  

,disorders of a ,reflex ,character next 
claims attention4 ,in  the first part   
the old conception of hysteria1         
especially as it was  built up by       
,charcot1 is set forth1 and is followed 
by a description of  the modern         
conception of hysteria due to ,babinski1
 who has suggested  the substitution of 
the term ,pithiatism1 i4 e4 a state     
curable  by persuasion1 for the old name
 hysteria4 ,the second part deals with  
nervous disorders of a reflex character1
 consisting of contractures  or         
paralysis following traumatism1 which   
are frequently found in the  neurology  
of war1 and a variety of minor symptoms1
 such as muscular  atrophy1 exaggeration
 of the tendon reflexes1 vasomotor1     
thermal and  secretory changes1 etc4 ,an
 important section discusses the future 
of  such men1 especially as regards     
their disposal by medical boards4    ,an
 instructive companion volume to the    
above is to be found in the  monograph  
of ,,mm4 ,roussy and ,lhermitte1 which  

embodies a description of  the          
psychoneuroses met with in war1 starting
 with elementary motor  disorders and   
concluding with the most complex        
represented by pure  psychoses4         
,,surgical ,,series    ,when the present
 war began1 surgeons1 under the         
influence of the  immortal work of      
,lister1 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
 possible4 ,the good behaviour of the   
wound was  taken for granted whenever it
 was made1 as it nearly always was1     
through unbroken skin1 and hence the    
study of the treatment of wounds  had   
become largely restricted to the study  
of the aseptic variety4  ,septic wounds 
were rarely seen1 and antiseptic surgery
 had been  almost forgotten4 ,very few  
of those who were called upon to treat  

the  wounded in the early autumn of     
#aiad were familiar with the treatment  
of grossly septic compound fractures and
 wounded joints1 and none had  any wide 
experience4 ,to these men the conditions
 of the wounds came as  a sinister and  
disheartening revelation4 ,they were    
suddenly confronted  with a state of    
affairs1 as far as the physical         
conditions in the  wounds were          
concerned1 for which it was necessary to
 go back a hundred  years or more to    
find a parallel4    ,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 faced4 ,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 
casualties1 and then to originate       
adequate measures  for the relief of the
 latter4 ,for many reasons this was a   

slow and  laborious process1 in spite of
 the multitude of workers and the wealth
  of scientific resources at their      
disposal4 ,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 work4 ,it limits the           
opportunity for deliberate  critical    
observation and comparison that is so   
essential to the  formation of an       
accurate estimation of values2 it often 
compels  work to be done under such high
 pressure and such unfavourable         
conditions that it becomes of little    
value for educative purposes4  ,in all  
the armies1 and on all the fronts1 the  
pressure caused by the  unprecedented   
number of casualties has necessitated   
rapid evacuation  from the front along  
lines of communication1 often of        
enormous  length1 and this means the    
transfer of cases through many hands1   
with  its consequent division of        

responsibility1 loss of continuity of   
treatment1 and absence of prolonged     
observation by any one individual4      
,in addition to all this1 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            
circumstances1 and that progress was    
thereby much hampered until  definitive 
treatment could be undertaken at the    
early stage that is  now possible4      
,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 ago4 
,as general principles of treatment are 
established  it is found practicable to 
give effect to them to their full       
logical  extent1 and though there are   
still many obscure points to be         
elucidated and many methods in use that 

still call for improvements1  it is now 
safe to say that the position of the art
 of military  medicine and surgery      
stands upon a sound foundation1 and that
 its  future may be regarded with       
confidence and sanguine expectation4    
,the views of great authorities who     
derive their knowledge from  extensive  
first-hand practical experience gained  
in the field1 cannot  fail to serve as a
 most valuable asset to the less        
experienced1 and  must do much to enable
 them to derive the utmost value from   
the  experience which will1 in time1 be 
theirs4 ,the series covers the whole    
field of war surgery and medicine1 and  
its predominating note is the           
exhaustive1 practical and up-to-date    
manner in which it is handled4 ,it  is  
marked throughout not only by a wealth  
of detail1 but by clearness  of view and
 logical sequence of thought4 ,its study
 will convince the  reader that1 great  
as have been the advances in all        
departments in  the services during this

 war1 the progress made in the medical  
branch  may fairly challenge comparison 
with that in any other1 and that not    
the least among the services rendered by
 our great ,ally1 ,france1 to  the      
common cause is this brilliant          
contribution to our professional        
knowledge4    ,a glance at the list of  
surgical works in the series will show  
how  completely the ground has been     
covered4 ,appropriately enough1 the     
series opens with the volume on ,the    
,treatment of ,infected ,wounds1  by ,a4
 ,carrel and ,g4 ,dehelly4 ,this is a   
direct product of the war  which1 in the
 opinion of many1 bids fair to become   
epoch-making  in the treatment of septic
 wounds4 ,it is peculiar to the war and 
derived directly from it1 and the work  
upon which it is based is as  fine an   
example of correlated work on the part  
of the chemist1 the  bacteriologist and 
the clinician as could well be wished   
for4 ,this  volume will show many for   
the first time what a precise and       

scientific  method the ,carrel treatment
 really is4    ,the two volumes by      
,prof4 ,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 joints4 ,supported
  as they are by an appeal to an        
abundant clinical experience1 they      
cannot fail to interest ,english        
surgeons1 and to prove of the greatest  
value4 ,it is only necessary to say the 
,wounds of the ,abdomen are  dealt with 
by ,dr4 ,abadie1 ,wounds of the ,vessels
 by ,prof4 ,sencert1  ,wounds of the    
,skull and ,brain by ,,mm4 ,chatelin and
 ,de ,martel1 and  ,localisation and    
,extraction of ,projectiles by ,prof4   
,ombredann and  ,r4 ,ledoux-,lebard1 to 
prove that the subjects have been       
allotted to  very able and experienced  
exponents4                              
,,alfred ,,keogh4                       
,,preface      ,no attempt is made in   
this little book to describe all the    

artificial  limbs and appliances that   
have been invented4 ,before the war     
these  were very numerous1 since then   
their number has become countless1 and  
not a day passes without the appearance 
of some new model of greater  or less   
ingenuity4    ,but all these special    
inventions1 the utility of which we     
should not  think of denying1 are only  
of real practical value if the makers   
have  followed out certain general      
principles in their manufacture4 ,in the
  following pages we have attempted to  
indicate what these principles  are4    
,our experience has been gained in      
connection with the ,fdration  des      
,mutils1 where hundreds of disabled men 
have been examined and  fitted1 and     
where we have always tried to give to   
each that appliance  which is best      
suited to his work4    ,for this indeed 
is the vital principle1 and great       
disappointments  will result if1 for    
sthetic reasons1 every patient is given 
the same  appliance1 whether it be the  

leg known as the ,american leg or an    
elaborate artificial arm4 ,more often   
than might be believed accurate         
imitation of the external form of the   
natural limb is incompatible  with good 
functional use4 ,this is particularly so
 in the upper limb4    ,perhaps the     
readers of these pages will gain a clear
 understanding of  these principles2 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 strong1 shapely and       
practical4    ,throughout the volume it 
will be found that we express a         
preference  for the construction of     
artificial limbs for the lower limb out 
of  wood1 the method adopted by the     
,americans4 ,this procedure1 because    
strength and durability are so          
necessary1 seems to us to constitute  a 
very real advance2 these considerations 
are1 however1 of much  less importance  
in the case of the upper limb4 ,it is a 

matter for  regret that the ,french     
official instructions have not compelled
 our  manufacturers to adopt this       
technique1 too often the latter are     
inclined to keep to their old routine1  
but they can be induced to  alter it1 as
 we have proved by our success at the   
,fdration des  ,mutils4    ,there is    
nothing revolutionary in such a         
suggestion4 ,it has been  adopted by the
 ,belgian ,government in the fitting    
centres which they  have established2   
this is also the case with the ,english 
authorities1  who1 we understand1 have  
even attracted from ,america special    
fitters  for this work4 ,we should have 
thought that we1 in ,france1 might  have
 developed our national supply of       
artificial limbs in the same  direction4
                                        
,,introduction ,,to ,,the ,,english     
,,edition      ,the details of the      
manufacture of artificial limbs         
naturally differ  greatly in different  
countries4 ,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 ,france4 ,but1  as   
the authors state in their preface1 the 
principles remain the  same whatever the
 details of the methods used4 ,in the   
lower limb the  essentials to be studied
 are the points upon which weight can be
  taken1 the ,bearing ,points1 the      
proper method of fitting the stump1  the
 principles of securing stability and   
the mechanism of the knee and  ankle    
joints4 ,these remain unalterable       
whatever be the material used  and      
whatever be the details of manufacture4 
,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         
substitute4 ,and1 further1 it has  been 
taken for granted that this will1 in the
 case of the lower limb1  be a full     
artificial leg and not a peg leg4       

,therefore the standard  pattern has in 
,england been a full limb1 and the peg  
has only been  supplied as a temporary  
appliance1 and as an alternative        
appliance to  be used when the other    
limb requires alteration or repair4 ,for
 this  reason the possibilities of the  
peg leg1 except in its simplest form1   
have perhaps been neglected in this     
country1 and a study of the ,french     
methods of making these peg legs1       
particularly the convertible peg  leg1  
is well worth while4    ,the            
introduction of ,american artificial    
legs into this country has  not been so 
revolutionary in its results as it is   
apparently in  ,france1 for we have been
 accustomed for many years to make the  
bucket  out of a single piece of willow4
 ,the alterations in our methods        
introduced recently from ,america are   
essentially the following--    #a4 ,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 knee4      
#b4 ,the manufacture of the leg portion 
out of a single piece of wood4    #c4   
,the abolition of the old tendon action 
for the ankle joint 7which  resembled   
the mechanism described on page #eg7 and
 its replacement by  the ankle with     
movement limited by indiarubber buffers4
    #d4 ,covering the wooden part of the
 limb with a layer of raw hide or       
parchment1 which certainly adds to the  
strength4    ,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 it1
 so that the wearer does not            
necessarily fall when his weight comes  
upon the limb with the knee  flexed4 ,a 
recent invention1 still on its trial1   
seems to indicate that  this problem is 
not incapable of solution4    ,in       
artificial arms the differences between 
the ,french and ,english  patterns are  
greater than in artificial legs4 ,but   

here again the  principles remain the   
same4 ,in ,england1 also1 we have       
worker's arms  and show arms1 but the   
latter tend to be more elaborate than   
the  ,french patterns1 mechanical       
movements being more developed4 ,for    
this  reason this pattern is usually    
called1 in ,england1 the mechanical     
arm4 ,instead of the single cord1 looped
 round the opposite shoulder1  and used 
to open the spring thumb 7see p4 #aja71 
at least three such  cords are used1    
actuated 7#a7 by rounding the back2 7#b7
 by expanding  the upper part of the    
chest1 and 7#c7 by raising or lowering  
the  shoulder on the side of the        
amputation4 ,these may be used for      
various  purposes1 of which the chief   
are 7#a7 flexing the artificial elbow2  
7#b7 working the elbow lock1 and 7#c7   
actuating the thumb1 fingers or         
appliances used instead of the hand4    
,the chief other differences in  the    
methods adopted in ,england are--    #a4
 ,a smaller enclosure of the shoulder   

region for purposes of  suspension1 the 
limb being held on by a harness of      
straps4 ,we1 in  fact1 value mobility of
 the shoulder1 and gain it at the       
expense of  stability4    #b4 ,the use  
of various alternative patterns of elbow
 locks4    #c4 ,the appliances used     
instead of the hand are very different  
in  pattern1 although the principles for
 their construction remain as  described
 here by the authors4    ,much ingenuity
 has been expended on the design of     
mechanical  artificial hands1 with      
results which are satisfactory so far as
 they  go1 but which require much       
further development before the hand can 
possibly replace even a few of the      
appliances which can be substituted  for
 it4 ,for this reason it should be made 
an invariable rule that the  artificial 
hand1 however ingenious and however     
apparently perfect it  may be1 should be
 detachable1 so that it may be replaced 
by other  appliances4                   
,r4 ,c4 ,e4                             

,,contents                              
,,page        ,,general ,,introduction  
v        ,,preface                      
xiii        ,,introduction ,,to ,,the   
,,english ,,edition                     
xv                                      
,,chapter ,i        ,,general           
,,construction ,,of ,,an ,,artificial   
,,limb                       #a         
,,chapter ,,ii        ,,general         
,,principles ,,of ,,fitting ,,for ,,the 
,,lower ,,limb                 #f       
,,chapter ,,iii        ,,artificial     
,,limbs ,,for ,,amputations ,,through   
,,the ,,thigh              #ab          
,i4 ,apparatus with bearing upon the    
ischium                  #ab            
#a4 ,the shape of the top of the bucket 
#ac           #b4 ,mode of suspension   
#ba           #c4 ,walking on a peg leg 
and similar appliances             #bh  
#d4 ,walking with free flexion of the   
knee                   #cc              
,,ii4 ,limbs without bearing upon the   
ischium                  #fj            

,,chapter ,,iv        ,,artificial      
,,limb ,,for ,,disarticulation ,,at     
,,the ,,hip ,,joint            #fd      
,,chapter ,v        ,,artificial ,,limbs
 ,,with ,,free ,,knee ,,joint ,,for     
,,amputation ,,through            ,,the 
,,leg                                   
#ff          ,i4 ,appliances with       
bearing upon the tuberosities of the    
tibia                                   
#fg         ,,ii4 ,appliances with end  
bearing only                         #gg
                                        
,,chapter ,,vi        ,,partial         
,,amputations ,,of ,,the ,,foot         
#ha                                     
,,chapter ,,vii        ,,artificial     
,,limbs ,,for ,,amputation ,,through    
,,the ,,forearm             #hd         
,i4 ,points of attachment               
#he         ,,ii4 ,elbow joint          
#ij        ,,iii4 ,the artificial hand  
and appliances                       #if
             ,a4 ,the artificial hand   
#ig             ,b4 ,appliances for use 

in place of the hand              #ajh  
,,chapter ,,viii        ,,artificial    
,,limbs ,,for ,,amputation ,,through    
,,the ,,arm                #abi         
,i4 ,artificial arm                     
#acb         ,,ii4 ,worker's arm        
#ach                                    
,,chapter ,,ix        ,,artificial      
,,limbs ,,for ,,disarticulation         
,,through ,,the ,,shoulder              
,,joint ,,and ,,amputation ,,through    
,,the ,,deltoid ,,muscle          #adc  
,,chapter ,x        ,,some ,,general    
,,principles ,,in ,,the ,,re-,,education
 ,,of ,,the ,,disabled    #ade          
,,index                                 
#aei                                    
,,artificial ,,limbs                    
,,chapter ,i                  ,,general 
,,construction ,,of ,,an ,,artificial   
,,limb      ,a prosthetic apparatus for 
any amputation is composed of two parts3
    #a4 ,the artificial limb4    #b4    
,the attachment of this limb to the     
trunk4    ,the artificial limb itself is

 divided into two parts3    #a4 ,a      
conical socket4    #b4 ,a part which    
replaces the missing limb and is in fact
 a terminal  functional appliance4      
,two conditions must be considered1     
whether or not there remains  attached  
to the trunk a segment of the limb      
capable of being fitted  into the base  
of the artificial limb1 to which it     
gives support1 and  to which1 in        
addition1 it can communicate movement4  
,accordingly the  artificial limb       
differs essentially for3    #a4         
,disarticulation of the shoulder and of 
the hip4    #b4 ,amputation of the arm  
and of the thigh4    ,in the first case 
we attach to the trunk an instrument    
which is  entirely passive4    ,in the  
second we attempt to turn to account the
 active movements of  the stump4        
,these various parts do not lend        
themselves to a general description     
applicable at once to the upper and     
lower limbs4 ,not only are  the modes of
 attachment and the functional          

artificial limb quite  different1 but   
the bucket does not serve the same      
purposes4    ,the position of the       
scar4--,the stump1 which fits the bucket
 exactly1  transmits to it two kinds of 
force3    #a4 ,the force of vertical    
pressure4    #b4 ,lateral force         
corresponding to the angular movements  
of the joint  above4    ,the lateral    
force is transmitted by the whole of one
 surface of the  stump to the           
corresponding lateral surface of the    
bucket3 by the  anterior and posterior  
surfaces only in the case of hinge      
joints such  as the elbow and the knee3 
by all surfaces in the case of joints   
with  movements of circumduction such as
 the shoulder and the hip4    ,vertical 
pressure exercised upwards or downwards 
may cause the limb to  press upon the   
bucket at two points3 7#a7 on the summit
 of the cone1  i4e4 on the extremity of 
the stump2 7#b7 on the base of the cone1
  i4e4 on the bony prominences around   
the last remaining joint4 ,the          

adjustment is never sufficiently        
accurate for the relief due to the      
fitting of the stump in the bucket to be
 of much importance4    ,we should take 
it as a general rule that a scar cannot 
stand pressure  or friction2 and that in
 consequence1 when we amputate under    
favourable conditions1 we should arrange
 to place the scar in such a  position  
that from our knowledge of the suitable 
prosthetic apparatus  these two evils   
will be avoided4 ,it should be added1   
however1 that  after perfect primary    
union1 the narrow and mobile scar is    
very  tolerant1 but it must also be     
remembered--especially as will be  seen 
in the lower limb--that this condition  
is rarely realised in war  surgery4     
,the length of the stump is often       
estimated by reference to that of the   
other limb2 amputation at the upper1    
middle1 or lower third of the  thigh1 of
 the leg1 of the arm1 or of the forearm4
 ,this is convenient1  starting from a  
certain minimum length1 but there is an 

absolute  minimum length below which the
 stump has insufficient leverage and    
tends moreover to escape from the       
bucket4    ,temporary and permanent     
apparatus4--,for the irregular          
amputations  of war surgery which have  
suppurated1 more often than for those of
  civil practice1 it is generally       
advisable1 particularly in the lower    
limb1 to use a temporary apparatus1 of  
fairly good fit1 for several  weeks or  
even months before the permanent        
apparatus of more precise  fit4 ,the    
stump has to soften and shrink          
gradually2 only when this has  occurred 
can we make an accurately fitting       
bucket1 by means of a cast  if          
necessary4    ,materials for making the 
bucket4--,the first method of           
construction  is that of leather        
reinforced with metal2 a sheath         
strengthened  with metal supports1 is   
laced around the stump2 the supports    
further  give attachment1 if there is   
room1 to the artificial joints4 ,this   

is an excellent principle1 either for   
stumps which are still likely  to       
diminish in size1 or for the upper limb 
where exact fit is of  secondary        
importance4    ,for buckets accurately  
fitted on a cast we employ3    ,blocked 
leather1 which loses shape and ought to 
be abandoned for  artificial limbs for  
the lower extremity4#a    #a ,this we   
have attained at the ,fdration des      
,mutils1 having  forced the makers to   
abandon their routine4 ,it seems to us  
therefore  that the same result might be
 attained for the appliances furnished  
by  the ,state1 which are still made of 
leather4    ,celluloid is the material  
of choice1 but it has the defect of     
requiring the hand of an artist2        
commercial attempts on a large scale    
have so far yielded mediocre results4   
,metal 7zinc1 sheet steel1 aluminium71  
the defect of which is that  the        
apparatus1 particularly for the lower   
limb1 is noisy4 ,this is also  an       
inconvenience in the metal joints of    

lateral steels of leather  appliances   
and of the spiral springs in certain    
wooden apparatus1  for this reason      
indiarubber is more often relied on for 
springs and  accumulators4    ,wood1 for
 many years used for the commoner types 
of limbs for the  lower extremity1 is   
now1 as the result of ,american         
influence1 utilised  for the making of  
apparatus hitherto termed de luxe1 but  
to-day  serviceable1 thanks to this     
technique4#b    #b ,working in wood1 to 
hollow out of a log of wood a bucket    
which  fits the stump accurately1 is no 
novelty4 ,some sixty years ago two      
,frenchman1 ,bailly1 then ,xavier1      
succeeded in such construction4 ,but    
these appliances1 like the common1 cheap
 unshaped peg leg1 split  easily and    
were only made strong when the          
,americans conceived the  idea of       
covering the outer surface with a layer 
of raw hide3 strong1  and therefore     
practical1 for though we may resign     
ourselves to the  frequent renewal of a 

peg leg at #be francs1 it is another    
matter with  an appliance costing #cjj  
to #djj francs4 7,prices in peace time47
    7,in ,england the standard patterns 
of artificial legs have for many  years 
been made out of wood4--,,ed47    ,the  
adjustment to the stump is very exact2  
the contact with the  surface where     
there is friction is soft and           
comfortable without  padding2 the       
appliance is light1 strong and silent4  
,the best woods  appear to be ,english  
willow and lime4 ,the bucket should not 
present  any flaw or knot1 this can be  
seen on the inner uncovered surface4    
,but we must emphasise the general fact 
that standardisation is  impossible when
 the bucket is made of wood4 ,for the   
other parts it  is possible but not for 
the bucket1 which must be made specially
 for  each patient1 hollows being made  
for each bony point1 which must be      
marked out and felt for with the        
fingers4 ,a plaster cast would appear   
more exact3 but by this means we do not 

mark out the bony points4 ,good  results
 cannot be obtained1 if1 as certain     
people have tried1 linear  measurements 
are sent to a workshop whence an        
apparatus is forthwith  despatched to a 
patient whom the maker has never seen4  
,,chapter ,,ii               ,,general  
,,principles ,,of ,,fitting ,,for ,,the 
,,lower ,,limb      ,whether we are     
dealing with an amputation of the leg or
 an amputation  of the thigh1 the       
principle function of the artificial    
limb is to  support the weight of the   
body4 ,the bucket must therefore give   
support  to this weight4 ,three bearing 
points are thus possible3 at the base1  
upon the surface and upon the end of the
 stump4    #a4 ,bearing upon the        
base4--,the principal bearing is that   
which  is taken by fitting the upper    
edge of the bucket under the bony       
prominences situated around the last    
joint preserved1 i4e4 the  tuberosity of
 the ischium for the thigh1 the head of 
the tibia for the  leg4    #b4 ,bearing 

upon the surface of the stump4--,certain
 makers attribute  to this an importance
 which we believe to be imaginary1 but  
which  leads them to erroneous          
conclusions4    ,it is evident that if a
 conical stump which is jointless and   
which  transmits the weight is fitted   
exactly1 point downwards1 into a        
conical bucket1 supported below by a    
vertical pillar1 the weight is          
transmitted by the friction of the part 
enclosed against the bucket1  without   
any pressure upon the free end4 ,whence 
it may be concluded  that1 as the end of
 the stump should not serve as a bearing
 point1 we  should prefer a terminal    
scar to lateral scars which might be    
rendered  painful or even ulcerated by  
friction against the bucket4    ,but    
experience shows us that if the pressure
 of the bucket at this  point is harmful
 to the lateral scars1 it is not less so
 for most  terminal scars4    ,the stump
 in its bucket is in fact a bone1       
furnished with soft parts  upon which we

 cannot exert vertical pressure1 without
 squeezing them  back towards the base  
of the stump1 thus exerting an upward   
tension  of the terminal soft parts over
 the end of the bone4 ,this is bound to 
occur unless there is a considerable    
length of soft parts beyond the  end of 
the bone1 that is unless more bone has  
been sacrificed than was  necessary4 ,in
 this way we get all the disadvantages  
of an end bearing  without its          
advantages4    #c4 ,direct end          
bearing4--,this is only the principal   
bearing in  certain special stumps which
 we shall indicate in due course2 in    
some  of these it is the sole bearing4  
,in the case of apparatus for the  usual
 amputations1 above the epiphyseal      
enlargements1 it is never more  than a  
complementary or accessory bearing1     
although a very useful one4    ,to take 
pressure upon the end of the stump it is
 only necessary to  stretch across the  
bucket at the right height a piece of   
material  covered with felt4 ,if the    

apparatus is made of leather1 the       
support is  taken upon a circular band  
of metal fixed to the lateral steels4   
,in order that direct pressure upon the 
stump may be possible1 two  conditions  
are indispensable3 that there is no     
terminal scar2 and  that the extremity  
of the bone is well covered with a thick
 and  nonadherent flap4 ,actually       
walking directly on the stump does not  
involve simply support by pressure1 but 
also inevitable friction1  of greater or
 less importance1 caused by the backward
 and forward  movement4 ,this is only   
realised under the most perfect         
conditions if  the skin is adapted by   
its structure to this movement4 ,this is
 the  case with the sole of the foot3   
where the epidermis and dermis are      
thick and the subcutaneous areolar      
tissue and deep fascia1 continuous  with
 it1 enclose little cavities filled with
 globules of fat2 these  form a cushion1
 like little globules of liquid gliding 
over each  other4 ,the skin of the point

 and of the posterior surface of the    
heel  is less suitable anatomically than
 that of the sole3 it is1 however1      
good1 and it is for this reason that    
after amputation above the  malleoli1 it
 is possible to walk directly upon the  
cut surface of the  tibia4              
,nevertheless skin which is not prepared
 in this way by its normal  structure   
can adapt itself to pressure and        
friction1 provided that  it is padded by
 a thick muscular layer1 sheathed       
whenever possible  with fibrous tissue4 
,a skin which is not so lined1          
especially in  fair and stout people1   
with thin and delicate skin1 ulcerates  
easily  as the result of friction or    
even of simple pressure1 and burs and   
callosities form4 ,see what happens to  
the skin on the dorsum and outer  side  
of the foot in the case of talipes      
equino varus4 ,the muscles of  the flap 
will not remain over the bone in the    
condition of muscular  tissue1 they     
become fibrous--but they are useful     

because3    #a4 ,they interpose a       
fibrous layer of greater or less        
thickness between  the bone and the     
skin1 so that the latter remains movable
 over the end  of the bone and is not   
directly compressed2    #b4 ,they adhere
 to the cut section of the bone forming 
a tendinous  insertion1 which renders   
their action on the bony lever more     
powerful4    ,a flap bears weight badly 
when the muscles have retracted around  
the  bone1 over which there is then     
nothing but skin4 ,it is the same when  
the flap is stretched tightly across the
 end of the bone1 the soft  parts must  
remain soft and free4    ,among the     
hundreds of cases of amputation of the  
leg or thigh that  have passed before us
 in being fitted at the ,fdration des   
,mutils1  there were many in which the  
presence of a terminal scar rendered the
  fitting of an apparatus difficult2 we 
have never found this the case  with a  
lateral scar2 we have never seen the    
latter ulcerate rapidly as  the result  

of pressure or friction in a properly   
made wooden bucket4  ,so that it cannot 
be admitted that the proper covering of 
a stump is  ever a matter of secondary  
importance4    ,consequently we should  
consider1 as a matter of principle1 the 
circular method of amputating only as a 
last resort1 and we ought to  arrange   
the section of the soft parts so as to  
cover the end of bone  as adequately as 
possible1 and to bring the scars to one 
side4    ,we realise that in practice   
war surgery often necessitates          
deviations  from the ideal4 ,we often   
find ourselves in a dilemma--either the 
stump  must be good but too short2 or1  
being long1 must be poor or even bad4   
,in the special case of the thigh1      
circular amputation in the lower  third 
when it is carried out through healthy  
tissue and has not  suppurated can be   
trimmed and sutured in such a way as to 
give an  excellent scar1 which is       
transverse and slightly posterior4 ,in  
this  situation after these routine     

amputations1 a linear scar which is     
supple and has healed by first          
intention1 separated from the bone  by a
 good cushion of muscular and fibrous   
tissue1 causes little  embarrassment1   
whatever its position2 at the end of a  
few months it  stands pressure and      
friction without harm4 ,but we are      
considering  war surgery and            
consequently we are often called upon to
 fit stumps  in which the cicatrix is   
large1 hard1 and more or less irregular1
 in  which the bone has suppurated and  
in which the neighbouring soft parts    
are indurated and scarred4 ,these stumps
 are not1 however1 the results  of the  
work of the worst surgeon4              
,amputating through infected parts1     
resigning himself to healing by         
granulation and subsequent trimming by  
operation1 he must take time  and       
trouble to attain in the end a result   
which is good functionally1  although at
 first sight unsightly4 ,but it is this 
surgeon who is on  the right road1      

rather than he who sends us good stumps 
which have not  suppurated1 because he  
has amputated through the thigh for a   
wound of  the middle of the leg1 or     
through the leg for a wound of the foot 
or  even of the front of the foot4      
,it is clear1 that for the stump        
effectually to play its part of a  lever
 in its bucket1 a certain definite      
length is necessary2 and we  ought to do
 everything possible to secure a length 
of at least #ae to  #bj centimetres in a
 thigh stump1 or #aj to #ab centimetres 
in a leg  stump4 ,but when this length  
is secured1 there is no great functional
  difference between1 for example1 an   
amputation of the leg in the  lower     
third or in the lower quarter1          
particularly if the fitter  understands 
how to utilise direct end bearing4 ,the 
knowledge of this  is of capital        
importance to the surgeon called upon to
 carry out  secondary operations upon   
imperfect stumps1 in determining whether
  it is possible to put an immediate    

stop to suppuration by drastic          
shortening1 or whether he must preserve 
length and lose time by  curretting the 
foci of inflammation in the bone4       
,,chapter ,,iii                         
,,artificial ,,limbs ,,for ,,amputations
 ,,through ,,the ,,thigh      ,there are
 two entirely different modes of        
fitting3    ,i4 ,for amputations above  
the condyles1 in which weight must      
always be  borne upon the tuberosity of 
the ischium through the top of the      
bucket4    ,,ii4 ,for amputations       
through the condyles 7or for            
disarticulation of  the knee7 in which a
 direct end bearing may suffice4        
,i4 ,apparatus with ,bearing upon the   
,ischium                                
7,amputation above the condyles47    ,in
 the construction of an artificial limb 
for amputation through the  thigh two   
entirely different principles may be    
used1 according as it  is desired to    
make the patient walk upon a rigid      
shaft1 that is to say  upon a peg1 or   

upon an artificial leg proper1 in which 
the knee bends  in walking 7known as the
 ,american leg74    ,but whichever      
principle is adopted1 whatever material 
is chosen1 wood  or leather1 and however
 exact the fit in the bucket may be1    
certain  common rules govern3--    #a4  
,the shape of the top of the bucket by  
which it is fitted to the  top of the   
thigh and its bearing upon the ischium4 
#b4 ,the attachment of the limb to the  
trunk4    ,to begin with we shall       
consider these two questions1 and then  
temporary and permanent apparatus1 the  
peg leg and the full artificial  limb1  
will be described4                      
,i4 ,,the ,,shape ,,of ,,the ,,top ,,of 
,,the ,,bucket    ,the tuberosity of the
 ischium is the sole bony point which   
can prevent  the ascent of the limb when
 weight is applied4 ,this tuberosity is 
situated in the posterior part of the   
perineum 7,fig4 #a71 the anterior  part 
of which is unable to stand pressure4   
,it is necessary1 therefore1  to clear  

this part by cutting down the inner     
border in its anterior  part1 forming a 
perineal concavity1 which rises         
posteriorly against  the ischium 7,fig4 
#c74    ,it is essential that the       
ischium should not be able to slip      
inside  the bucket1 otherwise the inner 
border will come in contact with the    
perineum3 therefore the diameter of the 
bucket must be less than that  of the   
limb1 so that the ischium may rest upon 
its upper edge4    ,if the bucket is too
 large1 the patient abducts the stump1  
so as  to lower the inner border and    
prevent pressure on the perineum2 he    
carries the leg away from the side as he
 walks1 and this is both  unsightly and 
fatiguing4    ,when an apparatus is     
completed1 it is very easy to ascertain 
the site  of the pressure on the        
ischium4 ,the limb being put on1 the    
ischium  is fixed between the thumb and 
first finger1 and it can then be        
ascertained whether it rests on the edge
 of the bucket or lies within  it4 ,this

 can be determined more exactly1 if     
whilst the fingers which  mark the      
position of the ischium are kept within 
the bucket1 the  patient is told to     
raise his stump4    ,if the bucket is   
sufficiently narrow1 it may be circular 
without the  excavation for the perineum
 7,fig4 #b74 ,but this shape is         
unsatisfactory  for another reason1     
because it results in a tendency for the
 limb to  rotate inwards4    ,at the    
moment when the artificial limb is      
coming in contact with the  ground as it
 takes a step1 the pelvis is oblique    
7the iliac spine of  the sound side     
lying posterior to that of the amputated
 side74 ,the  sound limb as it executes 
its step is carried forwards1 and the   
pelvis  which was oblique in one        
direction now becomes oblique in the    
opposite  direction4 ,this movement is  
transmitted to the femur in the stump1  
so  that the artificial limb turns      
inwards relatively to the stump4 ,with  
each step this rotation becomes little  

by little more perceptible1  and after a
 time the patient is obliged to correct 
it by turning the  artificial limb with 
his hand4    ,if1 on the other hand1 the
 front of the upper border of the bucket
  slopes downwards and inwards at an    
angle of about #de degrees1 when as  a  
result of its weight the bucket turns   
inwards as the limb is swung1  the base 
of the stump will come against a higher 
part of bucket2 but  when the pressure  
of the weight of the body returns1 the  
stump1 being  forced into the bucket1   
will descend again along this slope1    
that  is to say a passive external      
rotation of the artificial limb will  be
 brought about1 correcting at every step
 the tendency to internal  rotation4    
,illustration3 ,,amputations ,,through  
,,the ,,thigh      ,,fig4 #a4           
,,fig4 #b4      ,,fig4 #c4      ,in the 
upright position the rami of the pubis  
and ischium1 between    which stretches 
the perineum1 slope downwards and       
backwards at an    angle of about #de   

with the horizontal4 ,the tuberosity of 
the ischium    bounds the perineum      
posteriorly1 and is its lowest point4   
,the rami    of the pubis and ischium1  
corresponding to the genito-crural fold1
    mark the boundary between the thigh 
and the perineum4 ,these bones are      
unable to stand the pressure of an      
artificial limb4      ,if the top of the
 bucket is narrower than the            
circumference of the    top of the limb1
 measured below the ischium1 it may be  
circular and    still give support to   
the ischium1 which will not slip into   
it4 ,if    the ischium does slip into   
the bucket1 the result will be that it  
no    longer serves as the support1 the 
pressure coming instead upon the    rami
 of the pubis and ischium and upon the  
perineum4      ,the constriction thus   
exerted upon the top of the stump may   
easily    become insupportable4 ,the    
correct solution of the problem is to   
cut    down the upper border of the     
bucket opposite the perineum1 letting it

    rise again posteriorly beneath the  
tuberosity of the ischium1 and    gain a
 good support there4    ,the same slope 
may be given to both edges of the bucket
 7,fig4 #e74  ,this obliquity in the    
posterior part serves no useful purpose3
 it is  better on the contrary to lower 
the posterior border combining this     
semioblique fitting with a rise beneath 
the ischium and a depression  under the 
perineum 7,fig4 #f74    ,these          
conditions are easily carried out in a  
well-made wooden bucket1  represented in
 figures #h and #i1 in which it may     
further be seen that  from the front it 
is convex outwards2 from the side1      
convex forwards  7,fig4 #i74 ,this form1
 which is that of some good ,american   
appliances1  ought to be generally used4
    ,the curve outwards1 by drawing away
 the soft parts from it1 frees  the     
region of the ischium and allows the    
tuberosity of the ischium to  press upon
 the bucket 7,fig4 #h74    ,if the thigh
 piece is curved forwards1 and          

particularly if the limb  is built with 
a very slight flexion of the knee1 the  
stump remains  slightly flexed at the   
hip and the patient feels as if he is   
sitting  in the apparatus4    ,when the 
thigh piece is straight1 an             
uncomfortable pressure is  produced by  
the edge of the bucket against the      
ischium4 ,it may be  added that         
extension of the hip is very often      
impaired1 particularly  in patients with
 a short stump3 ,the extensor muscles   
being divided1  the flexors cause       
contraction into a flexed position1 the 
more so the  shorter the stump is4 ,if  
the thigh piece is straight1 the short  
stump  cannot follow the movement of    
extension necessary in walking2 it slips
  out of the bucket if the anterior lip 
of the latter is too low4    ,the       
principles are the same for the leather 
bucket1 known as the  ,french pattern4  
,illustration3 ,,fig4 #d4      ,,fig4   
#e4      ,,fig4 #f4      ,,fig4 #g4     
,,fig4 #h4      ,,fig4 #i4      ,figure 

#d shows the circular bucket 7almost    
always too large7 of the    poor man's  
peg leg1 attached to the body by a belt 
which is fastened    to a projection    
upwards from the outer side of the      
bucket4      ,figure #e shows the       
oblique bucket1 with symmetrical        
anterior and    posterior borders4      
,figure #f one with the anterior border 
oblique1 the    posterior border being  
cut away4 ,figure #g shows the double   
obliquity1    downwards and backwards1  
of the bucket4 ,the convexities of the  
bucket    and thigh piece1 in the type  
which we consider to be the best1 are   
shown in figure #h 7convexity outwards71
 and figure #i 7convexity    forwards74 
,in this the thigh piece is strengthened
 by two lateral steels 7to the  lower   
end of which is fixed the leg piece7    
joined posteriorly by a  semicircular   
cross piece on which the ischium should 
rest 7,fig4 #ac74      ,illustration3   
,,fig4 #aj4      ,illustration3 ,,fig4  
#aa4    ,the usual form hitherto has    

been that shown in figure #aj4 ,the     
cross  piece was horizontal and formed  
simply a posterior semicircle2 the      
lateral steels were straight4           
,consequently in this pattern these     
steels form a cone1 in which the soft   
parts are not compressed on  the inner  
side1 nor drawn outwards1 as in the     
apparatus previously  described4        
,further1 as long as the stump is not   
shrunken1 the ischium  covered on its   
inner side by soft parts sinks into the 
bucket1 and it  is the perineum which   
becomes the point of pressure 7,fig4    
#aa74 ,made  of leather1 the perineal   
concavity soon loses its shape and      
really  no longer exists4 ,finally the  
bucket is circular1 with the faults     
inseparable from that shape 7,fig4 #ab74
    ,in cases where it is felt necessary
 to employ leather1 all these  faults   
are easily corrected1 by giving the     
cross piece the shape  which we have    
described for the wooden bucket1 and by 
prolonging it  forwards through         

two-thirds of the corresponding         
circumference1 in  the shape of an      
oblique bucket4 7,dotted line in ,fig4  
#ab47    ,if it is not strengthened1 an 
oblique border of leather gives way1 and
  after a few months' use allows        
rotation4 ,the leather which extends    
from the termination of the metal       
ascends very steeply towards the        
trochanter1 whilst the posterior border 
of the bucket1 which is  horizontal1    
curves downwards on the inner side to   
form the perineal  concavity4           
,illustration3 ,,fig4 #ab4      ,,fig4  
#ac4      ,,fig4 #ad4      ,the ordinary
 leather bucket is mounted upon two     
lateral steels1 which    are joined by a
 posterior cross piece 7,fig4 #ac74     
,this framework is    shown in figure   
#aj1 and covered with leather in figure 
#ab4 ,if the    lateral steels are      
straight and divergent1 this has all the
 defects    of the straight circular    
bucket4 ,the concavity for the perineum1
 cut    out of the leather1 soon loses  

its shape4 ,it is1 however1 easy to     
shape the cross piece as shown in figure
 #ad1 with a perineal concavity    and  
the anterior border oblique1 following  
the dotted line in figure    #ab4 ,by   
doing this and curving the steel        
uprights appropriately1 the    correct  
form of the wooden bucket can be copied 
exactly in a leather    and steel       
apparatus4 ,such a correct apparatus is 
shown in figures #ae    to #ah4    ,in  
figure #ad is seen the metal framework2 
in figures #ae and #af that  of the     
apparatus covered with leather2 in      
figure #ag the support upon  the        
ischium2 and the possibility of making  
this appliance identical  with the      
wooden bucket will be observed 7,fig4   
#ah74      ,illustration3 ,,fig4 #ae4   
,illustration3 ,,fig4 #af4              
,illustration3 ,,fig4 #ag4              
,illustration3 ,,fig4 #ah4              
,,ii4 ,,mode ,,of ,,suspension          
,suspension of the thigh piece is       
essential1 and is all the more          

important when the stump is short and   
consequently more liable to  slip out of
 the bucket4 ,for this purpose support  
may be taken either  from the waist1    
upon the prominence of the iliac crests1
 or from  the shoulders by means of     
braces4 ,in the case of a long stump    
7amputation below the middle of the     
thigh7 only one of these methods  is    
necessary1 we shall describe the usual  
methods3    ,the waist belt 7,french    
system7 for leather appliances4         
,braces 7,american system7 for          
appliances of wood4    ,if the stump is 
short a combination of the two methods  
is best4      ,illustration3 ,,figs4 #ai
 and #bj4--,simple pelvic suspension1   
with details of the joint at the hip4   
,a4 ,,suspension ,,by ,,means ,,of ,a   
,,waist ,,belt4--,for the peg leg  made 
of leather the best method consists in  
placing a pelvic plate1  which is       
attached to the hip steel1 below the    
iliac crest 7,figs4 #bj to  #bd74 ,a    
belt attached to the extremities of this

 plate surrounds the  pelvis and passes 
above the iliac crest on the other side4
 ,the thigh  piece is attached to this  
support1 on the outer side1 by          
articulation  of the outer femoral steel
 with the hip steel2 on the inner side1 
by  a perineal strap4 ,braces complete  
the method of suspension of the         
apparatus 7,fig4 #ba74                  
,illustration3 ,,fig4 #ba4    ,the axis 
of the metal joint between the outer    
femoral steel and the  lower end of the 
,t piece should be directly above the   
great trochanter  7,fig4 #bj74    ,the  
femoral steel often breaks in the       
neighbourhood of this joint  7,fig4     
#bc72 we have got over this difficulty  
by adding immediately  beneath it a     
joint which allows of abduction 7,fig4  
#ai74 ,a perineal  strap limits this    
movement4      ,illustration3 ,,fig4    
#bb4      ,,fig4 #bc4      ,suspension  
from the pelvis4      ,a metal hip piece
 is fixed below the iliac crest and held
 in place    by a belt which passes     

above the iliac crest of the opposite   
side    7,figs4 #bj to #bd74 ,this piece
 is attached to the thigh bucket by a   
joint shown in figure #ai 7see also     
,fig4 #bb71 which allows both flexion   
and abduction of the hip1 and which     
forms the suspension of the    outer    
side of the limb4 ,the inner border is  
suspended by means of a    perineal     
strap1 shown in figures #ba and #bb4 ,in
 figure #ba is shown how    a suspending
 brace may be easily added4 ,figure #bc 
shows the action of    a single hinge   
joint1 allowing only flexion and        
extension at the hip    joint4 ,on page 
#bg will be seen similar joints which1  
however1 move on    the pelvic          
attachment as well as on the thigh      
piece4 ,the object of    this is to     
prevent the pinching of the abdominal   
wall by the top of    the thigh bucket  
when the patient sits4 ,it is           
indispensable in short    stumps4 ,on   
page #ba will be seen a joint which     
allows abduction of the    hip1 and thus

 relieves the strain upon the hinge     
joint2 without it the    latter is      
easily broken4    ,b4 ,,suspension ,,by 
,,means ,,of ,,braces 7,american        
method74--,the  ,american method of     
suspension has the advantage of leaving 
the pelvis  free2 the patient does not  
feel the pull of the hip piece4         
,besides1  when the belt is used1 if the
 patient sits down1 the buttock on  the 
side of the stump is raised1 to an      
extent corresponding to the  thickness  
of the bucket1 an obliquity of the      
pelvis1 which is both  uncomfortable and
 unsightly1 being produced4 ,the braces 
being relaxed  in the sitting posture1  
the patient can avoid this              
inconvenience2 for  the stump may be    
slipped partly out of its bucket1 the   
upper extremity  of which is then beyond
 the level of the edge of the chair4    
,this  position is very comfortable1    
because it is normal1 but the patient   
must replace his stump in the bucket    
whenever he stands up4                  

,illustration3 ,,fig4 #bd4      ,,fig4  
#be4      ,braces composed of straps    
passing over the shoulders and down the 
front1 attached to the bucket by        
buckles4 ,posteriorly they are joined   
together by a cross strap between the   
scapul1 and beyond this are    continued
 in the form of elastic straps4    ,this
 form of suspension is essential for    
those artificial limbs with a  free     
knee-joint1 in which1 as we shall see1  
the braces serve to extend  the joint4  
,we illustrate here two methods of      
attaching the braces to the thigh       
piece1 that which we use in the limb    
supplied by the ,fdration 7,figs4  #bd  
and #be7 and that which is used in the  
,american limb of ,marks  7,figs4 #bf   
and #bg74      ,illustration3 ,,fig4    
#bf4      ,,fig4 #bg4      ,,fig4       
#bf4--;,braces which end below in looped
 thongs of leather4      ,,fig4         
#bg4--,these loops1 held in to the thigh
 piece by passing    beneath a loop of  
leather1 pass over two pulleys about the

 middle of    the inner and outer sides 
of the thigh piece respectively4 ,the   
outer    brace tends to abduct the limb 
if it is tightened4    ,c4 ,,combined   
,,method ,,of ,,suspension4--,if the    
stump is short  the artificial limb must
 be attached both by a belt and by      
braces2 the  latter should be #e to #f  
centimetres wide4      ,illustration3   
,,fig4 #bh4      ,combined suspension   
for short stumps4      ,,fig4           
#bh4--;,complete appliance4      ,,fig4 
#bi and #cj show the value of a flexion 
pivot between the    hip piece and the  
pelvic plate4 ,if there is no such      
pivot1 the ,t piece    undoubtedly      
rotates upon the belt1 but not to a     
sufficient extent to    prevent the     
thigh piece in rising and pinching the  
abdominal wall    7,fig4 #bi74 ,if there
 is a double joint the hip piece becomes
 oblique1    thrusting the thigh piece  
forward and allowing the patient to sit 
erect 7,fig4 #cj74    ,in these cases   
also1 to prevent the stump escaping from

 the bucket  when the hip is flexed1 the
 front of the thigh piece is carried as 
high as possible2 but if the appliance  
is furnished with a metal ,t  piece1    
such as has been described 7,fig4 #bi1  
see also ,fig4 #bc71 then  this raised  
border prevents flexion of the hip by   
coming in contact  with the abdominal   
wall when the patient sits down4 ,this  
difficulty  can be got over by making   
the top of the ,t piece movable2 when   
the  patient sits down the vertical     
piece of the ,t becomes oblique1 the    
thigh piece comes forward1 allows the   
stump to escape a little way and  no    
longer presses against the abdominal    
wall 7,fig4 #cj74    ,the belt may also 
be replaced by a leather corselet1      
having fixed to  it the hip piece that  
we have just described4                 
,illustration3 ,,fig4 #bi4    ,the      
braces by themselves are a poor method  
of attachment for a short  stump4       
,illustration3 ,,fig4 #cj4    ,in the   
sitting position the stump easily       

escapes from the bucket4    ,when the   
patient is standing the stump remains   
abducted1 whilst the  apparatus1 as the 
result of its own weight hangs          
vertically1 in this  swaying position   
the lower extremity of the stump presses
 against the  outer side of the bucket1 
whilst the inner edge of the bucket cuts
  into the flesh at the top of the      
thigh4                 ,,iii4 ,,walking 
,,on ,a ,,peg ,,leg ,,and ,,similar     
,,appliances    ,the rigid peg and the  
jointed peg4--,the peg leg is a rigid   
rod1  ending in a slight enlargement1   
which transmits the weight of the  body1
 resting by means of the ischium upon   
the top of the bucket1  directly to the 
ground4    ,the erect position is thus  
very secure1 and stability in walking is
  also very good throughout the time    
when the artificial limb bears the      
weight4    ,to raise the limb from the  
ground and carry it forwards1 the       
patient  uses at the same time both     
flexion of the stump at the hip and     

movements of the pelvis 7elevation1 then
 rotation inwards7 varying to  some     
extent with his proficiency and with the
 length of the stump4    ,the           
old-fashioned peg leg1 called the poor  
man's peg1 consists  of a bucket        
continued into a rigid peg4 ,if the     
support beneath the  ischium is well    
made according to the principles        
described above1  it is an excellent    
temporary limb4#c ,this bucket of common
 wood1  which is not specially shaped to
 the stump1 is very economical2 its     
imperfect fit is an advantage in that   
the stump1 which is still  enlarged1    
cannot bear friction2 as the stump      
assumes its true shape  and diminishes  
in size1 the bucket is packed4 ,we would
 add that every  patient1 who is not    
rich enough to possess two complete     
artificial  limbs should have in reserve
 an emergency peg leg1 for occasions    
when  the artificial limb requires      
repair4    #c ,a number of temporary    
limbs have been designed1 with buckets  

of lattice work or of plaster4 ,the     
old-fashioned wooden peg1 which  is     
easily obtained1 avoids all this        
additional work without any             
disadvantage4    ,as a permanent        
apparatus1 with accurately fitted       
bucket1 the rigid  peg leg has two      
defects3 it has not the appearance of a 
leg and  foot1 and when the patient is  
sitting the rigid peg is unsightly and  
inconvenient to him and to his          
neighbours4 ,we have therefore designed 
and completed a jointed peg leg1 the    
principle of which is as  follows3      
,below the thigh piece the peg is       
attached by a transverse joint1  this   
joint being locked in the extended      
position when the patient is  upright4  
,the patient sets it free by            
manipulating the lock through the       
trousers1 when he sits down2 when he    
gets up again the locking in the        
extended position is automatic4    ,the 
fitting of this transverse joint may be 
carried out in two ways4    #a4 ,the    

upper end of the peg ends in a          
stirrup-shaped fork and the bolt  passes
 through the two ends of this fork and  
through the lower end of  the thigh     
piece 7,figs4 #ca to #cc74    #b4 ,the  
lower extremity of the thigh piece has  
cut in it a central  mortise into which 
fits a vertical plate1 prolonged upwards
 from the  middle of the leg piece4 ,the
 bolt passes through this artificial    
tibial spine and through the two sides  
of the mortise in the thigh  piece4 ,if 
the hole in the tibial spine through    
which this bolt passes  is square the   
hinge works securely 7,figs4 #cd to     
#cf74    ,in this form the axle turns   
with the leg1 in the first form this is 
also possible4 ,but most often when the 
forked attachment is used it is  fixed  
to a leather thigh piece1 and each end  
of the fork is jointed  independently to
 the corresponding end of the lateral   
steels of the  thigh piece1 without any 
complete transverse bolt4 ,it is then   
the fork  that revolves around these two

 joints4      ,illustration3            
,,figs4 #ca to #cc4--;,fixation of the  
stirrup of the leg 7,fig4 #ca7    by a  
transverse bolt 7,fig4 #cc71 the        
aperture for which in the thigh    piece
 is seen in ,fig4 #cb4 ,double lock     
7,fig4 #cb74      ,illustration3        
,,figs4 #cd to #cf4--;,attachment by    
mortise and tenon1 with a    bolt1      
square in section1 passing through the  
knee4 ,single lock on the    outer side4
    ,if there is a complete transverse  
bolt1 the joint can be securely  locked 
by a single lock at one of its          
extremities 7at the outer  extremity7   
7,figs4 #cf to #ci74    ,if there are   
two lateral joints the single lock is   
insufficient1 both  joints must be fixed
 at once2 unless this is done1 that     
which is not  fixed has a certain amount
 of play and is strained4    ,it is1    
however1 simple1 by means of a posterior
 semicircle1 to joint  the two locks and
 to work them together by a single      
movement 7,fig4 #cb74    ,for sthetic   

reasons the wooden leg piece may be made
 in the shape of  a leg and foot4 ,but  
if the principle of the peg leg has been
 adopted1  for an agricultural labourer 
for example1 on account of its          
stability1  it is better to use an      
appliance in which a show leg is fitted 
around the simple peg on days when      
appearance is more important than  work 
7,figs4 #cg to #de74 ,the limb is thus  
rendered lighter1 for the  false calf   
consists of a simple layer of felt and  
it is very easy to  replace the enlarged
 lower end of the peg by a foot4        
,illustration3 ,,figs4 #cg to           
#dj4--;,attachment by a mortise1 and    
show foot4    ,we show later two models 
of this sort1 one with an ,american     
thigh  piece of wood and a single lock  
upon a transverse axle1 the other with  
a leather thigh piece and a double lock4
 ,the first 7,figs4 #cg to #dj7 is      
shown with an attachment by braces1 and 
the second 7,figs4 #da to #dg7  with an 
attachment by means of a waist belt2 we 

have already explained  when these two  
must be combined4      ,illustration3   
,,fig4 #da4 ,,figs4 #db to #dg4         
,leather and steel peg leg1 with show   
foot4      ,figures #da to #dg 7leather 
appliance7 should be compared with      
figures    #cg to #dj 7wooden appliance7
 which complete them in certain points4 
,it    is unnecessary to refer further  
to the method of fitting the bucket to  
the suspension1 or to the method of     
attaching and locking the knee4         
,the peg--attached above by a stirrup or
 by a mortise1 it does not    matter    
which--ends below in a rectangular tenon
 which fits into a    corresponding     
excavation in the upper surface of the  
terminal piece1    whether peg or foot  
7,figs4 #ch and #dd74 ,a transverse     
bolt1 square in    section1 with a head 
at one end and a thread at the other1   
fixes these    two parts together4 ,by  
taking out this bolt the peg can be     
replaced by    the foot or vice vers4   
,if the attachment of the foot is made  

in the heel1 a fixed foot is    used    
7,figs4 #dc and #de71 but it is easy1 by
 making the attachment    higher1 to use
 a foot with movable ankle joint 7,fig4 
#dj74      ,the attachment of the show  
calf piece around the peg is shown in   
figures #dc and #de4    ,most often the 
wooden thigh piece is to be preferred2  
the limb is  lighter and may last four  
or five years instead of about two      
years4    ,we may add that leather loses
 its shape and the bucket becomes       
enlarged1 producing inconveniences      
already described on page #ah4    ,but  
leather--indespensable for certain      
stumps which cannot stand  a wooden     
bucket--has the advantage that it can be
 employed as a  temporary fitting4      
,during the first weeks1 sometimes even 
for the  first months1 the shrinking of 
the stump can be accommodated by lacing 
up the bucket1 and1 when shrinkage is   
complete1 the leg part of this  first   
apparatus can be attached to a wooden   
bucket which the improved  condition of 

the stump now renders possible4    ,this
 form is a little more expensive 7#hj   
frs47 than the poor man's  leg1 but ,i  
believe a great deal more comfortable4  
,it may be added1  that it is easy when 
the foot is fitted at the end of the    
apparatus  to render flexion of the knee
 free and to attain the ,american walk1 
of which we shall speak later4 ,all that
 is necessary is to attach in  front an 
artificial muscle of indiarubber1       
reaching from the thigh to  the leg and 
an extending sling like that in the     
,american limbs 7see  page #dg74        
,this appliance which we call the       
,fdration ,leg1 because we designed  it 
at the ,fdration des ,mutils1 has       
already been imitated without  its      
origin being acknowledged4              
,,iv4 ,,walking ,,with ,,free ,,flexion 
,,of ,,the ,,knee    ,a4 ,design4--,the 
oldest type1 which will suffice for     
studying the  general conditions of     
stability1 is that of ,marks1 with a    
fixed  foot shaped out of the same piece

 of wood as the leg3 the ankle          
joint--several types of which we shall  
describe later--does not affect  the    
question of stability4    ,the appliance
 is made entirely of wood2 it is strong 
and light4    ,nothing need be added to 
the description already given of the    
fitting  and method of attachment of the
 thigh piece1 which ends below in a     
curved condyle1#d which fits into the   
top of the leg piece4 ,it  is transfixed
 by a metal bolt1 from each end of which
 a metal plate  descends and is riveted 
into a corresponding groove in the      
leg4#e  ,this forms the axle which      
rotates in the thigh piece when the knee
  flexes or extends4 ,flexion of the    
knee is free4 ,extension is stopped     
just short of the straight line 7see p4 
#af74    #d ,the bucket and the condylar
 portion are made of two separate       
pieces of wood4    #e ,the hole through 
which the bolt passes being cut in soft 
wood  7willow or lime71 must be         
strengthened by a cylinder of metal1 of 

leather1 or of harder wood 7beech or    
service tree7 in which the axle         
revolves4      ,illustration3 ,,fig4    
#dh4--,marks leg with fixed foot4       
,illustration3 ,,fig4                   
#di4--;,construction of the foot4       
,the foot is in equinus at an angle of  
#be to #cj so that the heel  is #b or #c
 centimetres from the ground 7the usual 
height of the heel  of a boot74 ,the    
piece of wood which forms the instep and
 which is  continuous with the leg stops
 at a point corresponding to the middle 
of the metatarsus1 and is only half the 
thickness of the foot4 ,the  rest of the
 foot is shaped of indiarubber stuck on 
to the instep  piece2 the wood and      
rubber being enclosed in a sheath of    
leather4    ,the foot should also point 
slightly outwards1 as in the normal     
standing position4    ,to ascertain     
whether the limb is built so as to      
ensure equilibrium1  a thread is        
stretched against its side so as to pass
 through the axes  of the knee and ankle

 joints1 if this cuts the ischial       
bearing point  at its centre the        
equilibrium of the patient is assured4  
,equilibrium  will be better still if   
the cord lies entirely behind the       
ischial  bearing point1 leaving in front
 of it the greater part of the thigh    
piece4 ,the best method of ascertaining 
if the foot is properly mounted  is to  
hold the limb in front of one by the    
thigh piece1 with the knee  bent at a   
right angle2 it can then be seen whether
 the foot turns  outwards at the correct
 angle4    ,it is not necessary to say  
anything more about the shape of the    
thigh  piece 7page #ag74    ,the metal  
bolt which transfixes the knee must not 
allow any play2 the  hole through which 
it passes must be lined with hard wood  
or leather4    ,the indiarubber sole    
should be reinforced with several layers
 of  canvas incorporated in the rubber1 
as the latter if not so reinforced      
perishes and cracks4    ,the appliance  
must further be examined after it is    

applied4 ,the level  of the iliac spines
 must be compared3 the spine on the side
 of the  amputation should be #b cm4    
below that of the sound side4           
,examine the position of the point of   
the foot4 ,make the patient sit  down1  
see if the knees are on the same        
horizontal plane2 if the  sound knee is 
the higher the leg piece is too short4  
,the foot being  fixed in the equinus   
position the patient must wear boots    
while the  examination is being carried 
out4    ,b4 ,mechanism of walking4--,in 
walking1 a step being taken with the    
artificial leg1 the toe of the foot is  
the last to leave the ground1  the heel 
being raised and the knee straight4 ,the
 limb is swung forward  and raised by   
flexion of the hip3 active flexion of   
the knee is  impossible1 but passive    
flexion occurs1 owing to the weight of  
the leg  piece1 as the thigh is raised4 
,at this moment the leg piece is        
vertical1 forming an angle with the     
thigh1 from this position it must pass  

into one in which it is oblique         
forwards and downwards1 in a straight   
line with the thigh1 so that  the knee  
may be fully extended when weight is    
again borne by the limb  as the foot    
meets the ground4 ,if at this moment the
 knee is flexed the  limb will double up
 under the weight of the body4    ,the  
first contact of the limb with the      
ground should be at the heel  with1 as  
we have already said1 the knee extended4
 ,afterwards as the  limb1 which at     
first points obliquely forward and      
downwards1 passes  into the vertical    
position in which it must be at the     
period when it  bears the whole of the  
weight1 this complete extension becomes 
locked  and transforms the limb into a  
rigid column4    ,this is brought about 
as explained on page #dh by mounting the
 foot  in equinus1 and we must here     
describe the methods by which the       
commencement of the movement of         
extension may be communicated to the    
leg so that the heel may be the first   

part of the foot to touch the  ground4  
,these methods may be termed knee       
extending mechanisms4 ,they assist  the 
passive action of the weight of the leg4
    ,in fact the recurrence of extension
 is brought about by a pendulum         
movement of the leg1 which1 at first    
oblique downwards and backwards1  swings
 into a downward and forward obliquity4 
,but this movement  is slow 7the        
pendulum which marks one second is one  
metre long7  and incomplete4 ,the       
patient can make it complete with a     
little  instruction1 by extending the   
thigh slightly as soon as the foot      
touches the ground4    ,this may be     
sufficient if the stump is long2 the    
leverage is good1 and  while the hip is 
being flexed a swing can be given to the
 thigh piece  which accentuates the     
pendulum movement of the leg4    ,but   
with a short stump some special         
mechanism is essential to make  sure    
that extension will be complete1        
otherwise the patient will be  obliged  

to walk with short and calculated steps1
 to wait whilst the  pendulum action    
produces extension of his knee and      
allows him to put  weight upon his foot4
    ,c4 ,mechanism for starting         
extension of the knee during the time   
the  leg is swinging4--,there are two   
methods which are generally combined3   
#a4 ,elastic traction by an artificial  
muscle4    #b4 ,the extending sling4    
#a4 ,artificial muscle4--,the action of 
an artificial muscle made of  elastic   
7noiseless7 or of a coiled steel spring1
 is easily understood4    7a7 ,the      
simplest method 7that which is commonly 
used for infantile  paralysis affecting 
the quadriceps7 consists in fixing an   
elastic band  divided into two slips1   
one on either side of the patella       
between the  front of the thigh and of  
the leg1 about the middle of each4      
7,this is  represented in figure #ih in 
our convertable leg47    7b7 ,when the  
apparatus includes the regular          
artificial knee the makers  generally   

place this mechanism in the interior of 
the thigh and leg  pieces1 using methods
 which are often very ingenious4 ,of    
these we  illustrate some on pages #dj  
onwards1 with an explanatory            
description4    ,in describing these    
mechanisms1 which may be called         
intra-condylar1  it is necessary to     
speak at the same time of the stop to   
limit  extension because1 as will be    
seen1 it is combined with the extending 
spring4    ,we have already said that   
rigidity in extension when the limb is  
vertical is essential1 but whilst it is 
necessary for extension to be  complete 
at this moment it is also necessary to  
prevent the knee  being forced into the 
hyperextended position1 as this would   
quickly  strain the joint and render the
 limb useless4    ,this limitation of   
extension can be effected quite easily  
by the  tension of a popliteal cord 7see
 page #da4 ,the knee in ,marks leg71 or 
by carrying the anterior border of the  
leg piece upwards in front of  the thigh

 piece so that it impinges against the  
latter4    ,this method is not very good
 because it is noisy4    ,moreover1 the 
repeated impact against the leg piece   
may split the  wood1 so that if this    
method is adopted the stop must be      
reinforced by  a binding of several     
layers of parchment4    ,we will first  
describe a mechanism the association of 
which with the  extending sling will be 
seen on page #dh4    4 ,to limit        
extension of the knee all that is       
necessary is  to prolong the            
antero-posterior diameter of the knee   
bolt 7which  turns with the leg7 by a   
horizontal wing1 which engages with a   
corresponding notch in the femoral      
condyle4 ,we show here 7,figs4 #ej  and 
#ea7 a rather more complicated but still
 simple mechanism which  is interesting 
because it can be combined with the     
action of the  extending sling 7see page
 #dh74    ,it consists of a piece of    
metal curved on the flat1 ending above  
in a  cylinder through which the knee   

bolt passes1 continued below into a     
cylindrical tail piece1 which fits into 
a ring which is fixed inside  the top of
 the calf4 ,during flexion this plate   
moves in a median  posterior window in  
the femoral condyle1 becoming oblique at
 the same  time as the tail piece sinks 
into the ring2 during extension the tail
  piece rises in the ring and the       
interior flat surface engages against  a
 corresponding groove in the femoral    
condyle 7covered with leather to  secure
 silence74      ,illustration3 ,,figs4  
#ej and #ea4--;,internal mechanism to   
limit    extension of the knee4    4 ,in
 the ,marks knee an internal system of  
cords and springs  serves at the same   
time both to limit extension and to     
produce an  elastic extending force4 ,it
 is a system which is fairly simple and 
much used4    #a4 ,limitation of        
extension is secured by a ,u-shaped     
cord1 the  extremities of which are     
fixed to a wooden cross piece 7,t71     
fixed in  the thigh piece three         

centimetres above the axis of the joint4
 ,the  cords leave the thigh through two
 lateral openings in the back of the    
thigh piece1 and the loop passes through
 a ring halfway down the calf4    #b4   
,the extending force consists in a      
coiled steel spring the  mechanism of   
which is combined with that of this     
cord4 ,the lower half  of the spring is 
enclosed in a copper tube lined with    
chamois leather  to secure silence2 its 
upper half or rather more is coiled     
around a  wooden pin1 which terminates  
above in a head which is cup shaped3  it
 will be seen 7,fig4 #eg7 that if       
pressure is made on this head the       
spring is shortened and under           
compression4    ,this spring is fixed   
below 7by means of a tenon which allows 
antero-posterior movement7 upon a       
bracket in the calf which is  continuous
 with the ring through which passes the 
check cord4 ,the  cup-shaped upper end  
is in contact with a ball which projects
 from  the upper surface of the thigh   

piece between the two openings for the  
check cord 7,fig4 #ec74 ,it will be seen
 that when the knee is flexed  the      
spring1 the head of which lies below the
 axis of the joint1 will  be compressed 
at the same time as the check cord is   
relaxed so that  there is an elastic    
recoil tending to reproduce extension4  
,the ball  which rests on the top of the
 spring is fixed in such a manner as to 
be in the same horizontal plane as the  
axis of the knee3 that is to  say1 it is
 in the same vertical plane as this axis
 when the knee is  flexed to a right    
angle 7,fig4 #eb74 ,therefore in this   
position the  spring has no tendency to 
produce either extension or flexion1    
that  is to say the mechanism is now at 
dead point1 and when the patient is     
sitting flexion to the right angle is   
maintained without any effort4          
,illustration3 ,the ,marks knee4        
,,fig4 #eb4      ,,fig4 #ec4            
,,figs4 #ed to #eg4      ,,figs4 #eb and
 #ec4--,o1 knee bolt4 ,t1 cross piece of

 wood1    situated in the extended      
position above the knee bolt1 in the    
flexed    position behind it4 ,c1       
bracket fixed halfway up the interior of
 the    calf4      ,a ,u-shaped cord a  
passes through a hole in the bracket ,c 
and is    attached at each end to the   
cross piece ,t2 it limits extension4    
,the    two ends of the word enter the  
thigh piece by two apertures in the     
posterior surface1 between which is     
fixed a metal ball which projects    #b 
cms4 ,the extending spring is the rod b 
which is fixed to this ball    and to a 
socket in the upper surface of the      
bracket4 ,figs4 #ed to #eg    show the  
parts of this spring3 a tube1 a spiral  
spring1 and a rod with    cup-shaped    
head4 ,when the spring is in the tube   
and the rod in the    spring 7,fig4     
#eg71 it will be seen that pressure upon
 the head of the    rod increases the   
tension of the spring4    ,in the knee  
shown in figures #eh and #ei the        
extending mechanism is as  follows4     

,directly behind the axis of the joint  
is a metal crossbar1  upon which fits   
the grooved upper extremity of a piece  
of wood1 the  other end of which rests  
7like a lance7 in a pocket which is     
suspended  in the leg piece by an       
elastic band 7the latter being kept     
stretched  to a greater or less extent  
by a lace which emerges from the calf74 
,illustration3 ,,figs4 #eh and          
#ei4--;,elastic spring for extending    
the knee4    ,the elastic being slightly
 stretched when the knee is extended1 it
  will be seen that the crossbar turning
 round the axis of the knee  becomes    
lowered as the knee flexes1 so that the 
elastic is stretched  and consequently  
opposes flexion2 but when the knee is   
bent to a  right angle the axis of the  
joint1 the crossbar and the wooden rod  
are in the same vertical line2 the      
mechanism is at a dead point just  as we
 have already seen in the ,marks knee1  
and the tension on the  elastic presses 
the leg directly downwards without      

tending either to  flex or to extend it4
    ,leather pads deaden the noise of   
the impact4    ,extension is limited1 as
 will be seen by comparing figures #eh  
and #ei1  by the vertical wooden rod    
meeting flat surfaces in the thigh and  
leg  pieces simultaneously4    #c4      
,extending slings4#f--,to the sling     
which passes over the shoulder  on the  
side of the artificial limb1 is attached
 a strap which passes  down in front of 
the thigh piece and is attached to the  
upper third of  the leg4    #f ,this is 
an old ,french method used in           
,fouilloy's appliance1 which  has1      
however1 only become generally used in  
the suspending braces of  the ,american 
appliance4    ,when the patient raises  
the leg from the ground1 the weight of  
the  appliance makes it slip down the   
stump1 tension is thus produced upon    
this strap and as a result the knee is  
extended4 ,by an adroit movement  of the
 shoulder this extension can be carried 
out actively4    ,when the limb rests   

upon the ground the weight of the body  
presses the  stump down into the bucket1
 the tension on the strap is released   
and  consequently the knee is free to   
flex4    ,on pages #dd to #dh will be   
found figures showing the principal     
points  in this extending brace4    ,the
 braces1 whether they have or have not  
an extending strap1 may be  constructed 
in three ways3    a4 ,to ease the       
constant pressure exerted on the        
shoulders by the  strap which is        
stretched by the weight of the          
artificial limb1 the  brace may be made 
of elastic like the ordinary trousers   
brace4 ,but the  limb they carry is     
heavy1 so they rapidly become           
overstretched and it  is difficult to   
keep them properly adjusted4    b4 ,the 
stretching is naturally diminished if   
the upper part of the  brace is not     
elastic but an elastic section is       
inserted in its lower  third1 in front  
and behind4    c4 ,but the patients     
almost always say that better command of

 the  limb is obtained with inelastic   
braces4 ,if the strap is wide on the    
shoulder1 the pressure is well borne1   
and the lower attachment may be  made   
narrower1 consisting of a leather thong 
7,fig4 #fd74      ,illustration3 ,fig4  
#fj4      ,fig4 #fa4      ,fig4 #fb4    
,fig4 #fc4      ,fig4 #fj4--;,fouilloy's
 ,braces4 ,figs4 #fa to #fe4--,marks'   
braces4    ,fig4 #fa4--;,general        
construction of the braces4 ,figures #fb
 and    #fc4--;,attachment at the sides 
of the thigh piece4 ,figures #fd and    
#fe4--;,general view of the apparatus as
 worn4    ,to attach extension braces to
 the front of the leg piece the old  and
 simple method adopted by ,fouilloy may 
be used4 ,it consists in  attaching an  
elastic strap to the brace which passes 
over the shoulder  on the side of the   
amputation 7and which is fixed to the   
top of the  thigh piece alongside of the
 other brace74 ,the elastic strap ends  
in a  bifurcated leather thong each     
branch of which 7held in place by a loop

  of leather7 descends obliquely        
alongside of the patella surface to be  
attached to the corresponding side of   
the leg in its upper third 7,fig4  #fj74
    ,in ,marks' method the braces end   
below in loops made of a leather thong  
7,fig4 #fa74 ,these are held against the
 thigh piece by passing under  leather  
bands2 they reach as far down as the    
upper third on the inner  and outer     
sides of the thigh 7,figs4 #fb to #fe74 
,to each of the loops1 gliding on them  
by means of a pulley1 is  attached a    
leather strap which descends vertically 
to the upper third  of the corresponding
 surface of the leg1 being held in place
 by  passing under a leather band4      
,these two straps are attached to each  
other in front by a lace1 which draws   
them towards the middle line1  and in   
this way brings their line of action    
forwards4 ,the tighter the  lace is     
drawn the more powerful will be the     
extending force4      ,illustration3    
,,fig4 #fd4 ,,fig4 #fe4    ,instead of  

attaching the extension brace to the leg
 piece it may be  made to pass under a  
pulley in the interior of the knee4     
,what actually  happens is that the     
thigh piece drops1 owing to its weight1 
when  the limb is swung free2 this      
throws a strain on the brace which is   
transmitted to the leg piece by the     
following mechanism4 ,the metal  stop   
described on page #ci which limits      
extension of the knee during  the period
 of weight bearing1 is prolonged upwards
 and forwards  beyond the hole through  
which the axis of the knee passes1 this 
prolongation being furnished with two   
wooden pulleys 7,fig4 #fi74 ,the  loops 
attached to the braces enter the front  
of the thigh piece1 each  by a separate 
opening1 turn under the corresponding   
pulley and emerge  again posteriorly    
7,figs4 #ff to #fh74      ,illustration3
 ,fig4 #ff4 ,fig4 #fg4 ,fig4 #fh4       
,this mode of attachment has the        
advantage that when the limb is swung   
the movement does not take place upon   

the shoulders--which easily  become     
chafed by the ordinary suspenders--but  
upon the pulleys upon  which the leather
 thongs work4    ,the mechanism shown in
 figures #fi to #ga is interesting4     
,when the metal  lever moves around the 
axis of the knee joint1 its lower end   
and the  pulleys at the upper end travel
 in opposite directions3 in flexion  the
 pulleys move downwards and forwards1   
the lower end upwards and  backwards2 in
 extension they move in the opposite    
direction4 ,therefore  when the limb is 
swung and the knee bends 7,fig4 #ga71   
the thigh piece  drops of its own       
weight1 the braces tighten1 raise the   
pulley and  consequently make the lower 
end of the lever move downwards and     
forwards1 thus extending the knee joint4
      ,illustration3 ,fig4 #fi4 ,fig4   
#gj4 ,fig4 #ga4    ,d4 ,mechanism to    
secure rigidity of the knee during      
weight  hearing4--,during the time that 
the healthy limb is raised from the     
ground and carried forwards there must  

be complete rigidity of the  artificial 
limb in the extended position4 ,this is 
secured by mounting  the foot in the    
equinus position4 ,when it has been     
swung forwards1 in  taking a step1 the  
limb comes in contact with the ground   
heel first2  then1 as the leg becomes   
vertical the entire sole lies flat on   
the  ground2 if the foot is in equinus  
this position is only possible with  the
 knee hyperextended1 or with full       
extension it may be possible  for a very
 short period4 ,so that it is the weight
 of the body that  locks the limb in the
 extended position1 the sole of the foot
 sloping  obliquely downwards and       
forwards2 and the weight being taken on 
the  toe4 ,there is always a tendency to
 hyperextension1 and to avoid  straining
 the limb in this direction 7as occurs  
in a living knee which  is forced into  
the position of genu recurvatum by a    
talipes equinus7  it is as well1 as we  
have already said1 to oppose it by some 
passive  resistance1 either in the form 

of a simple popliteal check cord or by  
a stop fixed to the front of the leg4   
,illustration3 ,fig4 #gb4      ,fig4    
#gc4      ,fig4 #gd4      ,fig4 #ge4    
,in ,figure #gb the foot is fixed1 the  
weight comes upon the point of the      
foot1 and pressure upon the axis ,,ab   
tends to close the angle ,,abc1 i4e4    
to produce a genu recurvatum1 and so to 
lock the knee in extension4    ,if the  
foot is articulated1 equilibrium is     
secured in the same way4    ,figures #gc
 to #ge are intended to show that in    
order that the axis ,,abc    may not be 
vertical 7,fig4 #gc7 the axis ,b of the 
knee must be behind    the perineal     
concavity in the bucket1 and it is      
better if at the same    time the axis  
of the ankle joint ,c is carried        
forward4    ,this extension is unlocked 
automatically at the moment when the    
weight  is thrown forward on the healthy
 limb1 the artificial limb rising on    
its toe and the knee commencing to bend 
because the braces are relaxed4    ,e4  

,movable ankle4--,we have taken as our  
type a limb with a fixed  foot4 ,there  
are1 however1 a number of methods of    
attaching a foot with  a movable ankle  
joint4 ,the general principles and the  
mechanism for  securing stability are   
those which we have already studied1 but
 the  gait is more supple1 at the price 
it is true of somewhat delicate         
articulations and therefore of          
simplicity4    ,the foot is made of a   
single piece of wood2 it is divided     
transversely  at the level of the middle
 of the metatarsal bones1 and the       
anterior  part 7shaped like toes7 is    
attached by two pieces of leather1      
dorsal  and plantar1 between which are  
two indiarubber cylinders which keep    
the toe piece extended #ae to #bj when  
at rest1 and which allow1 when  the foot
 is pressed on the ground1 an extension 
to #de4    ,this foot is mounted on the 
leg at an angle of #de beyond the right 
angle1 with an interposed rubber        
cylinder1 which allows of the           

diminution of the angle to #be or #cj   
but no further4 ,it is important  that  
flexion to a right angle should not be  
possible4 ,in fact1 a  slight degree of 
equinus is essential in order to secure 
the locking  of the knee in extension1  
exactly as with the fixed foot 7compare 
figures #gc1 #gd and #ge with figure    
#gb71 and as on the shoe there is       
always a heel which makes us walk       
normally in slight equinus1 the  two    
feet will be similar in appearance1 the 
slight movement of the  artificial foot 
being sufficient to allow a rolling     
movement of the  sole upon the ground   
7,figs4 #gg to #hf74      ,illustration3
 ,,fig4 #gf4      ,illustration3 ,,fig4 
#gf;,a4    ,the figures #gf and #gf;,a  
show the simplest and best known        
mechanism4 ,on  the upper surface of the
 foot two cavities are hollowed1 one in 
front  and one behind the bolt of the   
ankle joint1 in each of these is placed 
a cylinder of rubber2 the posterior     
cylinder is about twice as thick  as the

 anterior4 ,above them the leg piece is 
fixed1 it ends in front  in a short     
instep which lies within the cavity     
hollowed out in the  foot4    ,the foot 
is attached to the leg piece by a bolt  
made as follows3 a  steel tube fitting  
into two corresponding grooves in the   
leg and foot1  is attached to the leg by
 being prolonged upward into a vertical 
rod1  which is secured by a nut inside  
the leg piece4    ,upon the steel tube  
moves a brass rod shaped like an        
inverted ,u1 the  two ends of which pass
 through the foot and fasten beneath it 
by two  nuts 7,fig4 #hb74    ,raising   
the point of the foot further compresses
 the anterior piece  of rubber1 lowering
 it relieves the pressure upon this     
piece and  compresses the posterior     
piece4 ,but the tension and the size of 
the  pieces of rubber are such that they
 are under slight compression in  the   
position of rest1 the foot being in #cj 
of equinus4 ,so that this  foot is never
 loose4 ,when pressure is made on the   

point of the foot it  may come to within
 #ae or #bj of a right angle1 but it    
returns to its  angle of #cj as soon as 
the pressure ceases4      ,illustration3
 ,figs4 #gg to #ha4      ,contact of the
 sole with the ground in normal walking4
 ,heel first then    toe1 with          
progressive dorsiflexion of the ankle   
joint4 ,compare with    the contact of  
the artificial foot in figures #hb to   
#hf4    ,with boots on1 with heels of   
#be centimetres the two feet are in the 
same position when the soles are flat on
 the ground4    ,the forepart of the    
foot 7representing the toes and the     
anterior part  of the metatarsals7 is   
kept in this position 7,fig4 #gf7 in    
slight  extension by a piece of rubber1 
compression of which allows an  increase
 of extension of #ae to #bj4    ,when a 
step is taken1 the heel of the foot     
first meets the ground1  the leg        
pointing downwards and forwards4 ,then  
the whole sole comes  to lie flat on the
 ground1 the degree of equinus being    

increased1  the posterior rubber        
compressed and the anterior relaxed     
7,figs4 #hb  and #hc71 but when the limb
 is vertical the sole still being flat  
on  the ground1 compression of the      
posterior diminishes and that on the    
anterior increases 7,fig4 #hd74 ,this   
remains unchanged up to the moment  when
 the foot leaves the ground1 whilst the 
heel rises and the weight  is borne on  
the toe piece of the foot1 which is     
forced into extension  7,figs4 #he and  
#hf74      ,illustration3 ,,fig4 #hb4   
,,fig4 #hc4      ,,fig4 #hd4      ,,fig4
 #he4      ,,fig4 #hf4    ,this method  
of using rubber cylinders is the        
simplest4 ,another  method1 good but    
more delicate1 is shown in figures #hg  
and #hh4 ,in the  leg below the calf are
 two cross pieces of wood2 the lower    
placed  transversely supports the upper 
which is antero-posterior and so        
increases its resistance to the cords   
which are attached to it4    ,the shape 
of these pieces of wood can be seen in  

the figures and  require no further     
explanation4 ,the bolt of the ankle     
joint is the  same as in the foot last  
described4 ,to the antero-posterior     
cross  piece are attached two cords1    
which pass through the foot and are     
attached beneath it1 one under the heel1
 and the other about the  level of the  
midtarsal joint4 ,the posterior cord is 
inelastic and  stops dorsiflexion of the
 foot4 ,the anterior has a section of   
elastic  in it2 it prevents the dropping
 of the foot whilst the limb is being   
swung4 ,a small pad of rubber placed in 
front beneath the anterior part  of the 
leg piece allows1 by its compression1   
the partial correction of  the equinus  
when the sole is pressed flat on the    
ground4      ,illustration3 ,,fig4 #hg4 
,illustration3 ,,fig4 #hh4    ,some     
appliances allow the foot a little      
lateral mobility1 by  rotation around an
 antero-posterior axis1 so that it may  
adapt itself  to irregularities of the  
ground4 ,we here illustrate the ,duplex 

foot1 which is very ingenious but which 
has the defect that after  a time the   
mechanism grates4 ,the ankle attachment 
is carried out in  the same way as in   
the limbs last described 7in this       
particular limb  it is attached by      
cords71 but the foot piece is divided as
 in a  sub-astragaloid amputation2 the  
lower surface of the astragaloid piece  
bears a median antero-posterior         
projection1 tapering posteriorly and    
enlarged into a knob anteriorly1 this   
lies in a corresponding groove  in the  
heel piece2 alongside this are two      
rubber cushions which are  alternately  
compressed and relaxed as the foot      
inclines to one or  other side4         
,illustration3 ,,fig4 #hi4--;,duplex    
,foot4                 ,combined        
mechanism for knee and ankle joints4    
,this very ingenious combination1 which1
 however1 necessitates a rather  complex
 mechanism1 was devised by ,palmer in   
#ahej4 ,it is carried out  in the limb  
made by ,frees1 the mechanism of which  

will be seen to  resemble that of the   
articulated foot shown on page #ed in   
figures #hg  and #hh4    ,above the axis
 of the knee joint and at right angles  
to it is a wooden  cross piece1 to which
 are attached three cords1 two behind   
the joint1  one in front2 these cords   
emerge from the thigh piece through an  
opening in its lower end 7,figs4 #ij to 
#ib74    ,the posterior of these cords1 
made of hemp1 ends inside the upper     
third of the leg4 ,it limits the        
extension of the knee1 exactly as       
described in the ,marks leg4    ,the    
other two cords extend down to the foot1
 which is attached in a  manner very    
similar to that shown on page #ed1 but  
with a single rubber  cylinder behind1  
and with the instep cut obliquely so    
that when the  joint is in the resting  
position of equinus there is an opening 
in  front amounting to an angle of #ae  
to #bj4 ,the posterior cord1 of  hemp1  
is attached in the heel2 the anterior1  
made of catgut with an  indiarubber     

section1 enters the foot obliquely and  
is fixed a little  in front of the      
middle of the sole4    ,when the knee   
flexes1 the wooden cross piece tilts1   
its posterior end  becoming lower1 its  
anterior higher 7,figs4 #ia and #ib71   
the elastic of  the anterior cord is    
tightened1 thus raising the front of the
 foot1  whilst at the same time the heel
 cord is relaxed4 ,thus the mechanism   
which produces extension of the knee    
acts at the same time upon  the foot2   
when the knee is straight the foot is   
plantar flexed to  #bj1 when the knee   
flexes the foot comes to a right angle4 
,thus the  foot becomes dorsiflexed at  
the same time as the knee flexes1 as in 
ordinary walking4    ,if the action in  
walking is watched1 it will be seen that
 as the limb  is swung forward1 the toe 
is raised so as to clear the ground4#g  
#g ,the mechanism of this artificial leg
 resembles that of the tendon  leg1     
which was in such common use in ,england
 before the present war  that it is     

often called the ,english               
pattern4--7,,ed47      ,illustration3   
,,fig4 #ij4      ,,fig4 #ia4      ,,fig4
 #ib4--7;,,figs4 #ij to #ib4 ,foot and  
,knee of ,frees47    ,in the sitting    
position the anterior cord is not       
relaxed1 there is no  dead point1 so    
that the knee always tends to extend4   
,this is somewhat  inconvenient4        
,conversion of the articulated peg leg  
into the leg with free knee             
movement and vice vers4    ,whatever    
advantage it may be thought to possess1 
in our opinion the  artificial leg with 
free knee joint is only suitable for    
sedentary  occupations2 it is not       
suitable for manual labourers and       
particularly  for agricultural labourers
 who are obliged to get about on rough  
ground4 ,hence it is not uncommon for a 
patient who has been provided  with an  
,american leg to come and ask for a peg 
leg4 ,in figures #ic  to #ie it will be 
seen that it is a simple matter to      
transform the  limb into an articulated 

peg4 ,it is only necessary to attach the
  stirrup-shaped fork of the peg to the 
thigh piece by the knee bolt1  and to   
add the double lock4 ,to this peg may be
 added1 if desired1 the  show calf and  
foot described on page #cb4 ,the full   
artificial leg can  be rebuilt whenever 
it is wished4      ,illustration3       
,,figs4 #ic to #ie4    ,on the other    
hand1 an articulated wooden peg leg1    
such as we have  described under the    
name of the ,federation leg1 can be     
easily adapted  for walking with a free 
knee4 ,it is only necessary to unlock   
the knee  joint and to add the          
artificial muscle or accumulator of     
elastic shown  in figure #ih4 ,this     
supplies the extending force1 the value 
of which we  have shown on page #cf4 ,we
 consider that this appliance is        
excellent  and we know patients who     
almost always walk upon the peg1 but who
  sometimes use a free knee for short   
walks4 ,the conversion is simple  and   
requires no special care4 ,under these  

conditions the fixed foot  is almost    
always used2 there is nothing to prevent
 the fitting of an  articulated foot1   
but we have already seen that there is  
no great  difference in walking between 
the old-fashioned fixed foot of the     
,marks leg and the more or less         
complicated articulated feet of more    
recent design4      ,illustration3      
,,fig4 #if4      ,,fig4 #ig4      ,,fig4
 #ih4                    ,,ii4 ,limbs   
without bearing upon the ,ischium       
,for amputations through the condyles of
 the femur1 and similar  amputations    
7disarticulation of the knee and very   
short stumps below                      
the knee74    ,certain orthopdists do   
not know how to fit an artificial limb  
to an  amputation through the condyles  
of the femur2 they come therefore to    
the conclusion that this is a bad       
operation1 and ought to be replaced  by 
an amputation above the condyles4       
,the two objections raised to this      
amputation are3--    #a4 ,that it is    

impossible to fit a wooden bucket       
because the bone at  the lower end of   
the stump is larger than it is at a     
higher level4    #b4 ,that it does not  
leave enough room to fit an artificial  
knee joint  at the right level4         
,these two objections are not valid1    
and1 on the other hand1 this  amputation
 allows us to fit an artificial limb    
with complete end  bearing1 and this is 
a great advantage4    #a4 ,fitting of   
the bucket4--,the first difficulty is   
easily got over4  ,all that is necessary
 is to cut away the front of the lower  
half  of the bucket1 and to cover in    
this opening with a lacing piece of     
leather4 ,the stump passes into the top 
of the bucket1 comes out of  this       
opening and then falls back into the    
enlarged lower end where it  takes a    
direct bearing 7,fig4 #ii74             
,illustration3 ,,fig4 #ii4--,limb with  
end bearing for amputation    in the    
region of the condyles of the femur4    
,anterior part of the thigh    bucket   

cut away to allow the insertion of the  
enlarged lower end of    the stump4     
#b4 ,level of the knee joint4--,it is   
clear that if the stump is too  long it 
is impossible to fit a knee joint with a
 bolt right through at  the same level  
as the opposite knee4 ,the thigh piece  
would have to be  prolonged downwards in
 order to allow of the insertion of this
 bolt4    ,this arrangement would not   
affect walking1 but would be unsightly  
in  sitting because of the inequality in
 the length of the thighs4    ,it is    
easy to overcome the difficulty by      
attaching the leg by two  independent   
lateral hinge joints1 without a bolt    
right through1 using  the stirrup-shaped
 fork and the double lock1 if a peg is  
used4 ,this  method1 as we have already 
stated1 is not so strong1 but this is to
 a  large extent compensated for by the 
possibility of getting a direct  end    
bearing4    #c4 ,direct end bearing and 
suspension4--,if the stump is well      
covered  with a good anterior flap and  

if the lower end of the bucket is       
accurately moulded upon it with an      
interposed layer of felt1 the  patient  
can walk directly upon the end of the   
stump1 without it being  necessary to   
carry the bucket up against the ischium1
 simple braces  being used as the means 
of suspension4    #d4 ,there is nothing 
special about the braces or about the   
extending  strap if the knee is free1   
nor about the method of attaching the   
foot4    ,these limbs for long stumps do
 not require any spring to extend the   
knee1 if one is wanted an artificial    
muscle is quite easily fitted4    ,we   
have taken as our type an amputation    
through the femoral condyles4    ,the   
covering of the stump is excellent1 and 
pressure is taken upon  tissues which   
are naturally adapted to it 7the thick  
skin and fibrous  tissue over the       
patella71 specially if it has been      
possible to keep  the patella in the    
flap and fix it across the cut surface  
of the femur  7,gritti's operation74    

,the mechanical points in the fitting of
 an artificial limb for an  amputation  
through the knee joint are the same4    
,but this amputation  seems to us to be 
inferior to that through the condyles4  
,the  sacrifice of three centimetres in 
length is of no importance in  an       
appliance with direct end bearing2 and1 
on the other hand1  disarticulation has 
several disadvantages3--    #a4 ,the    
enlargement of the femoral condyles1    
without any compensating  advantage4    
#b4 ,the bearing upon the two condyles1 
separated by a groove4    #c4 ,the      
insufficient covering of the condyles by
 the thin skin of the  front of the leg4
    ,the principles of fitting a limb   
are the same in amputations of  the leg 
in which we are obliged to make the     
patient walk upon the  bent knee 7too   
short a stump1 the position of the      
scars1 persistent  osteitis1 the        
impossibility of straightening the knee 
when it is  ankylosed or stiff in a     
flexed position71 as in the             

old-fashioned  kneeling pin leg4    ,a  
posterior transverse band1 passing over 
the bent stump helps to hold  the limb  
on4                                     
,,chapter ,,iv             ,,artificial 
,,limb ,,for ,,disarticulation ,,at     
,,the ,,hip ,,joint      ,attempts have 
been made to attach to the pelvis1 by   
means of a waist  belt or braces1 a     
wooden artificial limb whose upper end  
is fitted  directly on to the tuberosity
 of the ischium4 ,so far these have met 
with little success4 ,in our opinion1   
the only really practical method  is to 
enclose the whole stump and pelvis in a 
regular corset1 and to  attach the      
artificial limb to this corset4#h    #h 
,amongst ,english limb makers this      
moulded corset with the steel hip       
attachments is usually known as the     
tilting table4--7,,ed47    ,the moulding
 of this corset upon the stump must be  
accurate4    ,the tuberosity of the     
ischium is the only bony point in the   
stump upon  which pressure can be taken4

 ,the corset may be made of leather1    
but1  until a new order is issued1 the  
material of choice is celluloid1        
moulded upon a plaster of ,paris cast1  
in spite of the disadvantage  mentioned 
on page #d4    ,the limb is an          
articulated peg leg1 with convertible   
knee joint and  double lock1 exactly the
 same as in the limb for amputation     
through  the thigh4    ,it is attached  
to the pelvis 7i4e4 to the tilting      
table71 as shown  in figures #ajj and   
#aja1 by a joint with a double anterior 
lock1 which  allows the patient to sit  
down by flexing the hip4                
,illustration3 ,,fig4 #ajj4      ,,fig4 
#aja4    ,this general description and  
an examination of figures #ajj and #aja 
will suffice to explain this appliance4 
,it is comparatively rarely  required1  
and its construction is difficult2 we   
consider that the  forms shown in the   
illustrations are the best4 ,it is only 
possible  to fit such an appliance when 
the conditions are good1 when the scar  

is above and in front of the ischium1   
and when the latter is well  covered4   
,,chapter ,v     ,,artificial ,,limbs   
,,with ,,free ,,knee ,,joint ,,for      
,,amputation ,,through ,,the ,,leg      
,if the leg stump is ten centimetres    
long1 if the knee joint is freely       
mobile and capable of complete1 or      
almost complete1 active extension1  and 
if there are no adherent scars around   
the tuberosities of the  tibia1 the     
,american apparatus with free knee joint
 should be adopted4    ,walking on the  
bent knee 7as stated on page #fc7 with  
the poor man's  peg may be allowed as a 
temporary measure1 but the patient must 
be  advised to give his knee a rest     
frequently in order to lessen the risk  
of stiffness in a flexed position4      
,there are two methods of fitting1      
corresponding with those we have        
described for the thigh4    #a4 ,for the
 ordinary amputations with bearing upon 
the top of the leg4      ,illustration3 
,,fig4 #ajb4--,limb fitted upon the     

patient4 ,note that he       stands upon
 the toe1 and that the knee is flexed4  
,illustration3      ,,fig4              
#ajc4--,posterior view of the same limb4
      ,illustration3      ,,fig4        
#ajd4--;,anterior view of the same limb4
    #b4 ,for amputation very low down   
with end bearing upon the extremity  of 
the stump4          ,i4 ,,appliances    
,,with ,,bearing ,,upon ,,the           
,,tuberosities ,,of ,,the ,,tibia    ,an
 artificial limb for amputation through 
the leg with a free knee  joint is      
composed of two parts3 a leg piece 7with
 foot7 which is  fitted to the bony     
prominences around the top of the stump 
and  supports them2 and a suspensory    
apparatus which consists of a lacing    
thigh corset4    ,a4 ,,leg              
,,bucket4--,the points on which the top 
of the bucket  must be fitted are the   
internal tuberosity and the anterior    
tubercle of the tibia1 and the head of  
the fibula1 so that hollows             
corresponding to these must be carved   

out4    ,pressure upon the head of the  
fibula is often painful1 and a deep     
concavity is therefore carved out for   
it4 ,the pressure then comes upon  the  
external tuberosity of the tibia which1 
however1 ordinarily bears  little       
weight4    ,whenever possible direct end
 bearing upon the termination of the    
stump should be used as an accessory to 
relieve the weight upon the             
tuberosities of the tibia2 this is      
obtained as described on page #g4  ,it  
is only possible if the scar is lateral 
and if there is a good  thick posterior 
or external flap 7in the upper third of 
the leg74 ,an  anterior flap is the     
least satisfactory4    ,it is also      
advisable--    ,that the inner surface  
and the anterior border of the tibia be 
divided  obliquely1 and that the fibula 
be divided at a higher level than the   
tibia4    ,the fibula must not take     
weight1 it is too slender4 ,in high     
amputations it has a tendency to tilt   
outwards1 causing the double            

inconvenience of widening the stump and 
of projecting through the  skin4 ,if    
only #d or #e cms4 of the fibula remain 
it is perhaps best to  disarticulate and
 remove it4    ,with a fitting arranged 
in this way1 we consider that the       
convenience  of walking with a free knee
 can be assured to patients whose stumps
  measure only #aj cms4 from the lower  
border of the patella4    ,these        
principles can be applied to a limb     
constructed either of wood  or of       
leather4    ,the leather appliance      
7,french method7 is formed of a leather 
cylinder1 strengthened by two laternal  
steels which articulate at the  level of
 the knee joint with two similar steels 
in the thigh corset4  ,its upper edge   
may be strengthened anteriorly by a     
metal plate1 but  in practice the latter
 cannot be made to fit with precision   
the bony  prominences enumerated above4 
,it is actually the edge of the leather1
  adjusted by lacing1 which supports    
tibial tuberosities1 and therefore  the 

precision of the fit is soon lost4      
,for this reason1 for amputation below  
the knee1 the ,american method of       
construction with a wooden bucket is    
demonstrably superior4    ,these limbs  
are infinitely more durable than the    
,french4 ,they may  last three years1   
whereas the ,french limb used by a young
 and active  patient is worn out at the 
end of the first year1 and it was for   
this  reason that a limb with a free    
knee joint used to be considered a      
luxury4#i    #i ,that is the reason that
 amputation at four fingers' breadth    
below  the knee used to be called for   
the working class1 amputation at the    
seat of election1 a name which is no    
longer applicable and which is  liable  
to mislead the operator4    ,this wooden
 bucket is shaped very accurately to the
 bony prominences1  and by passing the  
fingers over its inner surface the three
 hollows  corresponding to the points of
 pressure enumerated above can be       
distinctly felt4    ,it is important to 

describe the shape of the upper edge of 
the bucket  in order to guard against   
two points which may interfere with     
flexion--       ,i4 ,pinching of the    
tissues behind the knee4       ,,ii4    
,the tendency of the stump1 when it is  
short1 to tilt forward     in the bucket
 7,fig4 #ajh74    ,pinching of the flesh
 behind the knee in flexion takes place 
between  the edge of the leg piece and  
that of the thigh corset4    ,if the top
 of the bucket is horizontal1 it must   
inevitably occur1 even  if the edge of  
the thigh corset is well cut away 7,fig4
 #ajf74    ,it can be avoided by cutting
 away these two edges into concavities  
opposite each other4      ,illustration3
      ,,figs4 #aje and #ajf4--,limb in  
which the upper edge of the leg         
bucket is almost horizontal2 in the     
sitting position 7,fig4 #ajf7 the       
flesh at the back of the thigh is       
pinched even if the lower end of the    
thigh corset is well cut away4    ,in   
the ,french limbs made of leather it is 

usual to make the leg piece  very high  
in front1 i4e4 as high as the middle of 
the patella4  ,this is quite useless4   
,the posterior border is cut down to a  
depth  of two fingers' breadth below the
 axis of the joint4 ,pinching is  thus  
avoided1 but the posterior support is   
insufficient1 the stump  tilts forward  
as described above and the bucket gapes 
in front 7,fig4  #ajh74 ,if the top of  
the bucket is horizontal--as in certain 
,american  limbs--there is1 as we have  
already said1 pinching of the popliteal 
tissues and compression of the popliteal
 vessels and nerves 7,fig4  #ajf74 ,a   
concavity is therefore necessary1 but   
one reaching to one  finger's breadth   
below the axis of the joint is          
sufficient4 ,in front  the edge of the  
bucket reaches up to the joint line1    
this is quite  sufficient to enclose the
 bony prominences 7,fig4 #aji74    ,the 
posterior concavity of the leg piece is 
combined with a concavity  in the thigh 
piece varied in accordance with the     

thickness of the  popliteal soft parts4 
,illustration3      ,,figs4 #ajg and    
#ajh4--;,if the leg bucket is hollowed  
out too    much at the back1 the stump  
is tilted obliquely forward 7,fig4      
#ajh71    the knee loses contact with   
the bucket1 and the flesh at the back of
    the thigh is pinched4    ,to        
diminish further the tendency of the    
stump to tilt forward the  posterior    
edge of the bucket is flattened so that 
the shape of the top  of the bucket is  
triangular with curved sides and angles 
much rounded  7the anterior angle over  
the tuberosity of the tibia being       
obtuse74  ,this is the natural shape of 
a section of the top of the calf4 ,in   
this  way the posterior muscles are     
flattened and no longer tend to escape  
from the bucket when the knee is flexed4
 ,in figures #aaj and #aaa are  shown   
two ways in which this flattened        
posterior margin may be shaped4         
,illustration3 ,,fig4 #aji4             
,illustration3 ,,fig4 #aaj4 ,,fig4 #aaa4

    ,b4 ,,suspension ,,apparatus4--,the 
leg is attached 7a7 by a  thigh corset  
taking its hold on the femoral condyles1
 and 7b7 by  braces over the shoulders4 
7a7 ,the thigh corset is made of leather
 laced in front4 ,two  lateral steels   
curving in sharply against the upper    
part of the  condyles 7,fig4 #aab7 form 
the most effective part of the support4 
,at  their lower ends they are          
articulated with two steels passing up  
from  the top of the leg to which they  
are attached4 ,the joint 7,fig4 #aac7   
is composed of a nut1 ,a1 into which    
fits a screw4 ,around the nut  is a     
copper ring made to move with the       
femoral steel by means of a  stop-notch4
 ,when the knee flexes and extends the  
wear comes upon this  copper ring4 ,the 
steels remain intact4 ,if the joint     
works loose it is  sufficient to renew  
the ring4      ,illustration3 ,,fig4    
#aab4      ,,fig4 #aac4      ,,fig4     
#aab4--,the thigh steels1 curved in     
above the condyles1    hold the limb on 

very securely4#aj      ,,fig4           
#aac4--;,details of the joint at the    
knee4    #aj ,in this illustration the  
joints are placed too low4 ,they should 
be opposite the centre of rotation of   
the knee joint1 i4e4 a  transverse line 
passing through the femoral condyles4   
7,,ed47    7b7 ,the braces are a very   
useful addition which ,french           
orthopdists should employ               
systematically4    ,they increase the   
stability of the limb and allow the     
thigh piece to  be laced less tightly1  
so that contraction of the thigh muscles
 is  facilitated4      ,illustration3   
,,fig4 #aad4      ,illustration3 ,,fig4 
#aae4    ,support may be given by a     
strap from a waist belt as shown in     
figure  #aag1 but proper braces are     
better4 ,these braces pass over the     
shoulder  of the sound side and are     
attached either to the thigh corset or  
to  the leg piece of the artificial     
limb4 ,attachment to the thigh corset   
is made by a single strap either in     

front and behind 7,fig4 #aad7 or on     
either side of the front lacing1 the    
ends of the strap crossing in  front of 
the groin 7,fig4 #aae74 ,it is a simple 
matter to add to the  brace an extending
 strap1 such as we have described for   
the artificial  limb for amputation     
through the thigh 7page #dd74 ,it is    
only necessary  to terminate the brace  
in a strap from which two branches pass 
down  in an inverted ,v and are fixed to
 the sides of the front of the leg      
piece 7,figs4 #aaf and #aag74 ,this is  
unnecessary if the stump is long1  for  
its leverage will then be good4 ,it is1 
however1 very useful for  short stumps  
which give little power to the action of
 the quadriceps4  ,in the case of       
patients with a long stump an attempt   
has been made to  abolish the thigh     
piece and suspend the limb exclusively  
by braces4  ,this method1 we believe1 is
 inadequate even if it is completed by a
  transverse band above the knee 7,figs4
 #aah and #aai74      ,illustration3    

,,fig4 #aaf4      ,illustration3 ,,fig4 
#aag4      ,illustration3 ,,fig4 #aah4  
,illustration3 ,,fig4 #aai4    ,c4 ,,the
 ,,foot4--,the foot1 usually            
articulated1 is fixed in  exactly the   
same way as in a limb for an amputation 
through the thigh1  i4e4 it is mounted  
in the equinus position4 ,but in this   
case1  however1 precautions must be     
taken against stretching of the         
posterior  ligaments of the knee joint1 
because the equinus mechanically        
produces  hyperextension of the knee1   
and a genu recurvatum may result4 ,for  
this  reason a strap must be fixed      
posteriorly between the thigh corset and
  the leg piece to prevent full         
extension of the knee 7popliteal check  
cord74 ,this means that we make the     
patient stand and walk with slight      
flexion of the knee and with a          
corresponding elevation of the heel of  
the shoe 7#b-c centimetres74            
,,ii4 ,,appliances ,,with ,,end         
,,bearing ,,only    ,these appliances   

are suitable for certain amputations    
very low down in  the leg which we must 
first define4    ,the orthopdist should 
consider the following operations as    
very low  amputations of the leg1       
allowing of walking with end bearing    
only1 and  suitable for the same type of
 appliance3--       ,supra-malleolar    
amputation4#aa       ,disarticulation at
 the ankle joint4       ,sub-astragaloid
 amputation4       ,osteoplastic        
amputations through the os calcis 7or   
amputation     in which the os calcis is
 retained entire after removal of the   
astragalus74    #aa ,in ,england1 of    
course1 this is always called ,syme's   
amputation4  ,it constitutes the type   
par excellence of the end-bearing stump4
  ,upon a good ,syme stump a patient may
 be able to walk ten miles without  an  
artificial foot1 wearing simply an      
elephant boot4 ,amputations  above the  
,syme level are not end bearing1 however
 long the stump may  be4 ,the other     
amputations in this region seen in      

,english war surgery  are the various   
types of osteoplastic amputations in    
which a part of  the os calcis is       
retained 7,pirogoff's amputation1 etc474
 ,these have  the following defects3--  
7#a7 ,there is often sepsis between the 
tibia and the os calcis1  necessitating 
re-amputation4 ,osteoplastic amputations
 are unsuitable  for septic surgery4    
7#b7 ,ankylosis between the os calcis   
and the tibia is often imperfect  so    
that the bulbous end of the stump is    
unstable4    7#c7 ,the stump is too long
 to allow of the fixation of a good     
artificial ankle joint beneath it4 ,a   
,syme's amputation leaves two to  two   
and a half inches clearance between it  
and the ground4    ,i have not yet seen 
a sub-astragaloid amputation in war     
surgery1 and  only once a               
disarticulation through the ankle joint1
 the latter could  not bear pressure and
 it was necessary to convert it into a  
,syme's  amputation4 ,in fact1 in this  
region there is ,syme's amputation and  

a number of other far inferior          
amputations which should never be       
considered when a ,syme's amputation is 
possible4 7,ed47    ,certain limb makers
 consider these operations are bad for  
the same two  reasons that we have      
already refuted in connection with      
amputation  through the condyles of the 
femur1 viz4--    7#a7 ,the stump being  
enlarged at its lower end will not fit  
into a  wooden bucket4    7#b7 ,the     
stump is too long to allow an artificial
 foot to be fixed  below it4    ,from   
this it simply follows3 #a4 ,that       
complete enclosure of the stump  in a   
wooden bucket is impossible2 #b4 ,that  
pressure must be placed  directly and   
exclusively upon the end of the stump4  
,the latter condition is only possible  
if the state of the soft parts  allows  
the cutting of a thick plantar flap to  
cover the cut surface of  the bone and  
if care be taken to resect the posterior
 tibial nerve in  the flap4    ,we      
therefore draw special attention to the 

excellent elliptical  supra-malleolar   
amputation with posterior flap 7,guyon's
 method7 in  which it is sufficient to  
retain a bare finger's breadth of skin  
from  the plantar surface in front of   
the point of the heel4 ,it bears direct 
pressure well1 perfectly if a layer of  
the os calcis is cut with the  scissors 
from the area adjacent to the           
tendo-,achillis and applied  under the  
cut end of the tibia4    ,for all these 
amputations the anterior flap is bad4   
,the thin dorsal  skin of the foot is   
incapable of withstanding the direct    
pressure  which is indispensable for    
this method of fitting4    ,even if it  
were true that under these long stumps  
it is impossible to  insert an          
artificial foot for lack of space1 the  
operations which we  have enumerated    
above should be recommended if the flap 
can be cut in  the way we have          
indicated4      ,illustration3 ,,figs4  
#abj and #aba4    ,their great          
advantage--and the reason for retaining 

as much length of  bone as possible--is 
that they allow walking directly on the 
stump  without an apparatus4 ,it is     
sufficient to have a circular shoe made 
by  any shoemaker consisting of a heel  
more or less thickened surmounted  by a 
lacing gaiter reaching halfway up the   
leg4 ,guyon's amputation  constitutes   
the limit up to which this elephant boot
 is possible4    ,it is an unsightly    
apparatus1 but its simplicity and       
cheapness should  be taken into         
consideration1 for it is quite possible 
that a manual  labourer1 especially a   
countryman1 to whom an artificial foot  
and an  elephant boot are given1 will   
reserve the former for ,sunday and use  
the other for his daily work4           
,,appliances ,,with ,,artificial        
,,foot4--,the wooden piece which  partly
 encloses the stump consists of a block 
carved to the shape of  the stump and   
padded with felt1 it is prolonged in    
front by an instep  reaching to the     
level of the middle of the metatarsus1  

and above by  a grooved piece which     
reaches halfway up the leg and encloses 
the  anterior half of the latter4 ,a    
leather gaiter is fixed at the sides    
and back and extends up the leg1 being  
laced in front over the wooden  piece as
 a field boot is laced over the leather 
tongue4 ,the foot  may be mounted at    
right angles to the leg1 but it is      
better mounted  slightly in equinus4    
,the sole and toes are of rubber as     
described on page #ce4    ,in studying  
figures #abj and #aba the following     
should be noted3--    #a4 ,the shape of 
the leg bucket in which an aperture     
behind permits the  introduction of the 
stump which is enlarged at its lower    
end4    #b4 ,the mechanism by which the 
posterior gaiter laced in front fixes   
this leg bucket4    #c4 ,the            
articulation of the foot on a transverse
 axis4                                  
,,chapter ,,vi                          
,,partial ,,amputations ,,of ,,the      
,,foot      ,this name should be applied

 to amputations in which the mobility   
of the ankle joint is retained1 i4e4    
,chopart's amputation  7midtarsal       
disarticulation71 ,lisfranc's amputation
 7tarso metatarsal  disarticulation71   
amputation of several toes with their   
metatarsal  bones1 or amputation of all 
five toes4    #a4 ,the amputations of   
,chopart and ,lisfranc4--,chopart's     
amputation  has a grave defect3 the     
anterior muscles have not sufficient    
leverage  to oppose this gastrocnemius  
and soleus1 and the posterior tarsal    
bones tilt forward so that the patient  
walks1 not on the lower  surface of the 
os calcis and the plantar skin1 but on  
the head of the  astragalus and of the  
os calcis and on a painful cicatrix4 ,if
 certain  precautions are taken 7careful
 preservation of the fibrous plantar    
flap and suture to it of the anterior   
tendons7 this defect is not  invariably 
present1 and it is an exaggeration to   
say that ,chopart's  amputation has     
never given anything but disappointment4

 ,it should1  however1 only be practised
 if the technique is well understood1   
and  even then it is rarely indicated1  
because it demands almost as much       
plantar skin as ,lisfranc's amputation4 
,nevertheless ,i have seen some good    
,chopart stumps the result of           
operations by myself or by other        
surgeons2 they should be fitted like    
the stumps resulting from ,lisfranc's   
operation4    ,with regard to the       
latter1 they can be easily and          
comfortably fitted1  provided that the  
scar is dorsal and is not stretched over
 prominent  bones4    ,if the first     
cuneiform is not well covered it can    
simply be removed1  no functional       
disability results4 ,it is mainly upon  
the plantar  surface of the stump that  
pressure is borne1 but pressure comes   
also  upon the anterior surface when the
 foot is tilted downwards4              
,illustration3 ,,fig4 #abb4    ,the fore
 part of the foot which constitutes the 
prosthetic apparatus  consists of a     

block of wood1 which reaches forward as 
far as the  middle of the metatarsus and
 ends in a vertical plate in front of   
the  stump4 ,this block of wood is      
carved to the shape of the stump and    
lined with felt4 ,it is attached to the 
leg by a leather gaiter which  laces in 
front4    ,anteriorly it is prolonged   
into an artificial toe piece similar to 
that already described for the          
artificial limb for amputation through  
the thigh4    ,this appliance is not    
indispensable4 ,it is sufficient to use 
a piece  of cork shaped to the anterior 
surface of the stump and filling up the 
anterior part of the boot1 its          
advantage1 however1 is that once the    
patient is fitted with this appliance he
 can wear an ordinary boot4    #b4      
,partial ,amputation of the ,fore ,part 
of the ,foot4--,these are--             
,transverse amputation through the      
metatarsal bones4    ,disarticulation of
 one or more toes with their metatarsal 
bones4    ,disarticulation of one or    

more toes4    ,for any of these         
amputations all that is required is an  
ordinary boot1  fitted with a cork1     
which is shaped to fit the stump and    
which fills  up the space left by the   
amputation4    ,in order that the       
patient may walk well the scar should be
 dorsal and  should not be tense4    ,we
 consider that the difficulty of        
maintaining equilibrium after  removal  
of the head of the first metatarsal1 or 
even of the whole of  this metatarsal   
bone1 has been much exaggerated4        
,removal of a marginal metatarsal bone  
7either alone or with its  neighbour71  
tends to make the foot tilt into varus  
or valgus2 so that  the boot needs to be
 stiffened and the sole thickened to    
avoid this4                             
,,chapter ,,vii             ,,artificial
 ,,limbs ,,for ,,amputation ,,through   
,,the ,,forearm      ,the constituent   
parts of an artificial arm are the same 
in principle  as for those of an        
artificial leg1 they are--    #a4 ,a    

means of attachment preventing the      
appliance from dropping as the  result  
of its weight4    #b4 ,a socket1 fitted 
to the stump and articulated with the   
last named  at the elbow4    #c4 ,the   
terminal appliance1 intended to replace 
as far as possible the  amputated hand  
and1 if possible1 resembling it in      
appearance4 ,in the  case of the upper  
limb the advantages that wood possesses 
in giving  strength and accuracy of fit 
do not apply1 and the arm and the       
forearm  pieces are made of leather1    
with lateral steels articulated at the  
elbow3 this joint is active in the case 
of amputations of the forearm  but      
purely passive in amputations of the    
arm4    ,we will commence by describing 
the appliance for amputation through    
the forearm1 taking as our type         
amputation in the lower half4 ,this     
will furnish an example which           
illustrates all the principles that     
should guide us1 the ends we should have
 in view1 and the means by  which we can

 attain them4    ,when once we have     
studied the apparatus by means of which 
the  functions of the hand can as far as
 possible be replaced1 a short          
description will suffice to explain what
 can be done when the loss  of movement 
of the elbow and then a shorter and     
shorter stump in the  upper arm oblige  
us to diminish the utility of the       
appliance4    ,we must study in turn3   
7#a7 ,the attachment of the upper arm   
socket2 7#b7  the joint between this and
 the forearm socket2 and 7#c7 the       
appliances  attached to the extremity of
 the forearm whether these take the     
shape  of a hand or not4                
#a4 ,,points ,,of ,,attachment    #a4   
,,suspension4--,in the exceptional      
amputation very low down1  in which the 
roots of the thenar and hyperthenar     
eminences remain1  the enlargement thus 
formed at the extremity of the forearm  
may be  used for the attachment of a    
wristlet which may suffice to support   
the  artificial appliance1 provided that

 the latter is not intended for  heavy  
work4 ,in the latter case an attachment 
from the elbow at least  must be added4 
,this method would evidently be out of  
the question in the usual class  of     
case1 viz4 ordinary amputations through 
the forearm4    ,in these the attachment
 may be made in two ways3--    7#a7 ,to 
the humerus above the condylar          
enlargements1 the epicondyle and  the   
epitrochlea1 the latter being much the  
more prominent4    7#b7 ,to the top of  
the shoulder1 i4e4 to the surface over  
the  acromion and clavicle4    ,a4      
,attachment to the ,elbow4--,the        
simplest method of attachment is  that  
in which pressure is exerted upon the   
condyles of the humerus  7,fig4 #abd74  
,a leather armlet laced in front is     
furnished with two  lateral steels1     
curved in above the condyles and        
articulated at the  level of the centre 
of rotation of the elbow joint with two 
similar  steels in the forearm piece    
7the socket74      ,illustration3       

,,fig4 #abc4--,the three regions used as
 points of support1 the    shoulder1 the
 elbow and the wrist4                   
,illustration3      ,,fig4              
#abd4--,suspension from the elbow4 ,the 
side steels of    the arm piece are     
curved in to fit upon the supra-condylar
 ridges of    the humerus4 ,a good      
method of suspension for long stumps1   
when the    appliance is not to be used 
for heavy work4 ,it should be           
supplemented    in other cases by direct
 suspension from the shoulder4    ,this 
direct method of attachment is          
sufficient for a low amputation1  in    
cases where the patient does not do hard
 work4 ,but if the stump  is short and  
if the patient has to carry fairly heavy
 weights  the appliance is only         
prevented from slipping by a            
considerable  constriction of the arm1  
which results in a serious interference 
with  muscular action4    ,b4           
,attachment to the ,shoulder4--,for this
 reason it is usually  advisable to     

supplement this by an indirect          
attachment to the acromion  and clavicle
 by means of a shoulder cap4            
,illustration3 ,,fig4 #abe4    ,the     
firmest and strongest pattern consists  
of a piece of blocked  leather1 moulded 
to the shoulder1 including the pectoral1
  supra-clavicular and scapular regions4
 ,this is kept in place by a  strap     
which passes under the opposite axilla4 
,it is cut away on the  outer side of   
the acromion1 the anterior and posterior
 borders being  continued downwards on  
either side of the deltoid as two       
tapering  straps to which the armlet is 
attached4 ,in this way full liberty of  
movement is allowed to the shoulder     
7,fig4 #abe74    ,this pattern is       
strong1 but cumbersome and heavy4 ,it   
can be lightened  by reducing it to an  
antero-posterior strap1 #f or #g        
centimetres wide1  over the clavicle and
 spine of the scapula1 ending in front  
and behind  at the level of the axillary
 folds in triangular enlargements4 ,in  

the  upper and inner angles of these are
 attached the ends of the axillary      
strap1 to the lower and outer angles1   
prolongations from the armlet  7,figs4  
#abf and #abg74      ,illustration3     
,,figs4 #abf and #abg4    ,the lightest 
method1 but obviously also the least    
secure1 consists in  suspending the     
armlet by two straps1 anterior and      
posterior1 which  cross above the       
clavicle and then pass in the form of a 
loop under the  opposite axilla 7,fig4  
#abh74      ,illustration3 ,,fig4 #abh4 
,the choice between these three methods 
of attachment depends upon the          
profession of the patient and the       
strength required by it4    #b4         
,,resistance ,,to ,,upward              
,,pressure4--,the artificial limb should
  be capable of resisting upward        
pressure1 when a thrusting force is     
exerted by the hand4 ,this is secured in
 the following three ways1 the  hand    
being presumed to hang vertically with  
the elbow straight3--    7#a7 ,by       

pressure of the end of the stump in the 
socket 7in amputations  low down with a 
palmar flap--for example1 in            
disarticulation at the  wrist joint74   
7#b7 ,by pressure of the top of the     
forearm socket on the enlargement of    
the forearm below the elbow4    7#c7 ,by
 pressure of the inner side of the upper
 edge of the armlet  against the axilla4
    ,but1 in actual work1 thrusting     
movements are nearly always made with   
the elbow bent to a right angle or      
almost so1 then the pressure            
transmitted through the forearm piece is
 borne almost entirely by the  steels of
 the armlet4    #c4 ,,resistance ,,to   
,,rotation4--,a well-adjusted artificial
 arm  cannot rotate on the limb         
because--    7#a7 ,the forearm is       
elliptical in section and not circular1 
this is  specially so in the lower      
third4    7#b7 ,flexion of the elbow is 
only possible if the artificial joint   
is in the same plane as the axis of the 
elbow joint--that is1 the  sagittal     

plane4    7#c7 ,the axillary strap of   
the shoulder attachment prevents        
rotation4      ,illustration3           
,,fig4 #abi4--,the three regions used as
 points of resistance to    upward      
pressure4      ,illustration3           
,,fig4 #acj4--,the three regions at     
which rotation of the    apparatus may  
be prevented4                           
#b4 ,,elbow ,,joint    #a4 ,the         
,concavity of the ,armlet4--,at the     
elbow joint the pinching of  the        
anterior soft parts on flexion is liable
 to take place in just the  same way as 
occurs at the back of the knee in       
amputations through the  leg4 ,to avoid 
this it is necessary--    7#a7 ,that the
 axis of the joint should lie in a      
prolongation of a line  passing through 
the epicondyle and the epitrochlea4     
7#b7 ,that the armlet and the forearm   
socket should be cut away in front  in  
crescent-shaped concavities4            
,illustration3 ,,fig4 #aca4--,limb for  
amputation in the middle    third of the

 forearm4    ,the depth of these        
concavities is estimated when the limb  
is fitted4  ,both the arm and the       
forearm may be cut away freely without  
any  resulting inconvenience1 provided  
that the stump is long2 but if the      
stump is short and includes only the    
upper third of the forearm1 it  is      
impossible to cut away the forearm      
socket sufficiently without  depriving  
the stump of a proper hold in the       
socket1 so that movements  are not      
transmitted to the forearm lever with   
their proper force4  ,consequently the  
socket for the forearm must be cut away 
very little1  and must be carried up to 
the level of the fold of the elbow when 
the  joint is flexed4 ,the flesh in     
front of the elbow will not be pinched  
if1 the forearm being fitted very       
accurately1 the muscles of the  upper   
arm are allowed free play1 by cutting   
away the front of the  armlet to half   
its height1 but in this case an indirect
 attachment to  the shoulder is         

essential4#ab    #ab ,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  flexed1 
because of the contraction of the       
muscles arising from the  condyles4 ,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 flexion4  
,if it was made to fit with the elbow   
flexed1  there is risk of the stump     
slipping out of the socket when the     
joint  is extended4 7,ed47              
,illustration3      ,,fig4 #acb4--;,bad 
apparatus for amputation in the upper   
third of    the forearm4 ,the front of  
the arm piece is insufficiently cut     
away4      ,illustration3      ,,fig4   
#acc4--;,good apparatus4 ,the arm piece 
is well cut away1    consequently the   
flesh does not bulge out4    #b4        
,construction of the ,joint4--,in most  

cases this is a simple  articulation    
between the steels of the arm and the   
forearm pieces by  two hinge joints4    
,illustration3 ,,fig4 #acd4      ,,fig4 
#ace4      ,,fig4 #acd4--,limb for      
amputation through the lower third of   
the    forearm1 with elbow joint of     
strong leather4      ,,fig4             
#ace4--;,details of the joint4    ,the  
objection to this is that the movements 
of pronation and  supination1 if these  
are present in the stump1 are abolished4
    7a7 ,long ,stump4--,when the stump  
is long 7amputation in the lower        
quarter7 the following may be used3 ,the
 steels of the forearm socket  are      
attached to the armlet1 which is not    
furnished with steels1 by two  straight 
strips of hard leather jointed at each  
end with rivets to  the corresponding   
piece of the limb4 ,this allows a       
certain amount of  torsion so that      
pronation and supination are to some    
extent possible4  ,it is necessary to   
add an indirect attachment to the       

shoulder4 ,not  only must the armlet1   
not being closely moulded over the      
condyles1 be  even when new laced so    
tightly as to be unbearable1 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 7,figs4  
#acd and #ace74      ,illustration3     
,,figs4 #acf and #acg4--;,amputation    
through the    forearm above the upper  
third4 ,the elbow joint does not flex   
beyond    the right angle4              
,illustration3 ,,fig4 #ach4--,limb for  
amputation through the    upper third of
 the forearm4 7,for a description of the
 ratchet see page    #ace47    ,this    
method is1 moreover1 scarcely applicable
 to patients who will  have to carry out
 heavy work4    7b7 ,short ,stump4--,the
 stump of an amputation in the upper    
third of  the forearm is too short to be
 securely held in the forearm bucket4   
,there is consequently a loss of power  
in the movements communicated1          

particularly in flexion1 the arm of the 
lever being too short2 in  addition1 the
 elbow joint in these cases is often a  
little stiff1 so  that flexion beyond a 
right angle is impossible 7,figs4 #acf  
to #ach74    ,the chief functional      
difficulty depends upon the fact that1  
with the  elbow at a right angle1 the   
anterior surface of the forearm stump   
is too short to support a weight2 for   
example1 a basket held by the  handle4  
,the stump escapes partly from the      
bucket when the forearm  extends4 ,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 7,fig4 #ach74                     
#c4 ,,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 hand4 ,many       
people--and even many medical           
men--consider that this artificial  hand

 is really useful4 ,in actual fact1 by  
means of fairly simple  contrivances1 it
 can be used to enable the patient to   
eat1 to write1  to put on and take off  
his hat1 but it is out of the question  
for it  to do real work4 ,for that an   
appliance1 a tool in fact1 adapted for  
use and not for appearance is necessary4
    ,the limb1 therefore1 will1 as a    
rule1 end in a hand1 but for workmen    
this hand will be capable of being      
unscrewed and replaced easily by  one or
 more appliances4    ,attempts have been
 made to construct so called universal  
hands and  forceps which will serve for 
any sort of work1 but up to the present 
none of these inventions have given     
satisfaction4 ,and the practical        
solution of the problem in the present  
state of affairs consists  in devising a
 special appliance for a particular     
trade1 studying  carefully the movements
 necessary in this trade4    ,a workman 
who in the course of his occupation     
carries out a number of  different      

movements may thus have several         
appliances1 which he selects  as he     
requires them4 ,for example1 a locksmith
 must be able to hammer1  to file1 and  
to drill holes in succession4    ,we    
will describe first the hand properly so
 called1 then the  appliances4 ,the     
former is suitable for clerks1 and it is
 for them that  the various improved    
patterns that we shall describe are     
made4 ,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 appliances4    ,these          
appliances will almost always be        
constructed to carry out the  movements 
made by the left hand in the course of  
the work1 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 hand4                
,a4--,,the ,,artificial ,,hand4    ,the 

hand1 which is screwed into the end of  
the forearm socket in such  a way that  
it is in semipronation when the arm     
hangs vertical1 is  nearly always made  
of wood1 but occasionally of            
aluminium4#ac    #ac ,hands are nearly  
always made of lime wood1 which has the 
advantage of lightness1 but the fingers 
are fragile and easily break4  ,instead 
of using hornbeam1 which is hard but    
heavy1 as the fragility  only affects   
the fingers1 some makers have overcome  
this difficulty by  reinforcing the     
fingers by what they call a philippeau4 
,the finger is divided throughout its   
whole length by a mortise #ae           
millimetres in width1 in which are glued
 two layers of veneering wood           
7mahogany1 rosewood1 etc41 extremely    
hard woods1 or else a layer of          
hornbeam74    ,it may be a simple show  
hand without any joint4 ,this pattern is
 no  longer used4 ,it may be jointed in 
one or in several fingers4 ,we shall    
first consider certain principles of    

construction which we can explain  by   
describing the chief mechanisms used4   
,simple ,spring ,grip ,thumb4--,the     
simplest and most useful articulation   
is that of the thumb1 which when at rest
 is kept by means of a spring  in the   
flexed position1 with the grip against  
the index finger which  is partly flexed
 7as are also the other fingers74    ,in
 many cases the patient is content with 
this simple mechanism4 ,he  opens the   
spring with the other hand and allows it
 to close on the  object he wishes to   
grip 7,figs4 #aci-ade74                 
,illustration3 ,,figs4 #aci to          
#adb4--,mechanism of the passive        
spring thumb4      ,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 eminence4 ,the    
base of    the thumb is rounded4 ,the   
spring ,,ab flexes the thumb4           
,illustration3 ,figs4 #adc to           
#ade4--,the ,beaufort ,thumb4      ,the 
model shown on page #ih is more mobile  

than this1 in which the    thumb turns  
on the axis ,,ab1 and is fitted directly
 into the thenar    eminence4 ,but in   
this type it will be seen that the      
spring ,,cd which    keeps the thumb    
flexed1 reaches right up to the wrist1  
and is    therefore longer and more     
powerful4 ,the thumb is much stronger1  
and    this is the mechanism usually    
adopted4 ,it has the inconvenience that 
it requires a deep excavation of the    
thenar eminence1 encroaching    upon the
 root of the index finger1 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 finger1 either with a spring 
7,fig4 #aee7 or without 7,fig4 #adh74   
,the ,automatic ,thumb4--,active opening
 movement can be produced by the        
mechanism shown in figure #adf4 ,a cord 
fixed behind the scapula of  the        
opposite side by a ring which passes    
over the clavicle and under  the axilla1
 extends down the posterior surface of  

the arm and forearm  pieces1 running in 
pulleys which keep it in place4 ,if the 
patient  bends the elbow and at the same
 time brings the arm and both shoulders 
forward1 rounding his back1 the cord is 
tightened and pulls the thumb  into the 
position of abduction and extension4    
,this narrow grip1 between the tips of  
the thumb and index finger only1  is not
 always convenient4 ,a commercial       
traveller or a foreman could  not easily
 hold with it the order book1 in which  
he has to write4 ,but  if the thumb1    
held by a powerful spring1 is parallel  
to the palm of  the hand and grips      
against the other fingers1 which are    
stretched out  and not semiflexed1 the  
grip will be strong and convenient1     
especially  if a mechanism is introduced
 between the forearm and the hand1      
allowing the latter to be rotated at    
will into any position 7,fig4 #adh74    
,as in the preceding case the thumb may 
have either a simple grip or an         
automatic grip opened voluntarily by a  

cord from the shoulder4    ,the         
following is a very interesting method  
which allows a fork or  pen to be held1 
the automatic thumb being used4 ,the    
fingers are half  flexed1 the index     
being separated from the middle finger1 
so that the  handle of a pen can be     
inserted between them4 ,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      
finger1 against which in consequence    
the handle of the object held will be   
pressed 7,fig4 #adg74                   
,illustration3      ,,fig4              
#adf--;,appliance with automatic thumb4 
,the cord is fixed    to a loop which   
passes round the sound shoulder4        
,abduction and forward    movement of   
the shoulder and flexion of the elbow   
open the thumb4      ,illustration3     
,,fig4 #adg4--;,hand with space between 
the index and middle    fingers1 wide   
enough to take the handle of a fork1    
which is held by    pressure of the     

thumb against the side of the middle    
finger4    ,the extended fingers are    
better placed for gripping than the     
partially flexed fingers1 although the  
latter are convenient to the  patient in
 certain ways4 ,ball and socket joints  
are inserted at the  interphalangeal    
joints4 7,details are shown in figures  
#aeb to #aed47  ,these are so stiff that
 they maintain the position in which    
they are  placed passively1 as do the   
joints of an artist's lay figure4       
,illustration3 ,,fig4                   
#adh4--;,articulated hand for commercial
    travellers4 ,the thumb1 lying       
parallel to the palm of the hand1 takes 
a    secure hold of such an article as a
 memorandum book4      ,,fig4           
#adi4--,the usual pattern of hand4 ,the 
grip is too small4      ,illustration3  
,,fig4 #aej4--,the index finger is the  
same length    as the middle finger4    
,the thumb and index fingers are        
furnished with    nails4 ,a small ball  
can be picked up4      ,,fig4           

#aea4--,the middle finger being longer  
than the index1 the    latter does not  
reach the surface of the table and the  
ball cannot be    picked up4    ,if the 
fingers are rigid and in semiflexion it 
is possible to  articulate all the      
metacarpo-phalangeal joints1 fitting    
them with a  spring1 which keeps them   
flexed1 and arranging for active        
extension as  already described for the 
thumb4 ,all that is necessary is to     
terminate  the cord by five separate    
strings instead of one4 ,in certain     
special  cases this arrangement may be  
useful 7,figs4 #aee to #aeg74 ,it seems 
to  us useless to render the            
interphalangeal joints automatic4    ,as
 to the attempt which ,beaufort appears 
to have made to give movement  to the   
wrist also1 we do not believe that any  
practical result has as  yet been       
attained4    ,for the relative length of
 the fingers and the utility of a nail  
on  the thumb and on the index finger   
see figures #aej and #aea4              

,shape of the ,hand4    ,in the usual   
pattern 7,figs4 #adi and #aea7 the      
fingers are semiflexed  and the thumb   
grips against the index finger1 which is
 shorter than  the middle finger as in  
the natural hand4 ,if it is desired to  
pick  up a ball1 for example 7,fig4     
#aea71 it will be seen that the middle  
finger projects and gets in the way4    
,for this reason it is advisable  that  
the index finger be longer than the     
middle1 and in addition it is  useful to
 furnish the thumb and index finger with
 a little projection  representing the  
nail 7,fig4 #aej74    ,in figure #adh   
will be seen an arrangement which allows
 the thumb to  grip not by the tip1 but 
by the whole length of its palmar       
surface 7to  hold1 for example1 a       
notebook74 ,the fingers of this hand    
have ball  and socket joints constructed
 in the way shown in figures #aeb to    
#aed4  ,the joints keep passively the   
position in which they are placed4  ,the
 attachment of the ball of the joint on 

an intermediate tenon is  similar to    
that of the thumb shown on page #ih4    
,the articulation of the  index finger  
prevents the sufficient excavation of   
the thenar eminence  for the insertion  
of the ,beaufort thumb with its powerful
 spring4 ,the  wrist rotates upon a     
bayonet joint4      ,illustration3      
,,figs4 #aeb to #aed4    ,the fingers   
shown in figures #aee to #aeg are joined
 together into a  single piece1 which   
articulates with the metacarpal part of 
the hand  upon a transverse axis4       
,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 hand4 ,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 phalanges4 ,figure #aef 
shows detail of a finger4 ,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 stump1  making from them little  
prominences1 perforated with a tunnel   
which is  lined with skin4 ,the cords   
pass through the tunnels1 and in this   
way  are worked voluntarily4 ,we are not
 sure that this is practicable4         
,illustration3 ,,figs4 #aee to          
#aeg4--;,automatic fingers4      ,in    
figure #aee are seen the cavity in which
 the finger portion works    and the    
axis upon which movement takes place1   
also the four palmar    springs4 ,in    
figure #aeg the arrangement of the      
cords4 ,in figure #aeh the    attachment
 of the spring to the finger4 ,this     
pattern1 which we have    designed and  
which is not patented1 seems to us to be
 simpler than    those in which the     
interphalangeal joints are also         
articulated and are    automatic4 ,it   
gives a more accurate grip between the  
tips of the thumb    and index finger4  
,the ,brunet ,grip4--,the ,brunet grip  

is described here because of its        
resemblance to the automatic thumb1 both
 being worked on the same  principles4  
,illustration3 ,,figs4 #aeh and #aei4   
,illustration3 ,,fig4 #afj4             
,illustration3 ,brunet's ,grip4         
,below the leather forearm piece1 which 
laces up1 the lateral steels    are     
continuous with each other in the form  
of an arch1 to which the    grip is     
riveted4      ,the latter consists of a 
strong semicircular piece of metal      
facing    downwards1 ending in a pair of
 wide and thick jaws1 like those of a   
locksmith's pliers4 ,when the apparatus 
is at rest1 these are kept in    contact
 by the pressure of two powerful fixed  
springs1 attached to the    semicircle  
on the forearm above and to the jaws    
below4 ,the external    and dorsal      
spring is attached to the tip of its    
jaw1 the internal and    palmar 7the    
side on which the manipulating cord is  
attached7 to the    base of it4         
,the pliers are opened in the following 

way3--      ,inside the semicircle to   
which the jaws are attached1 lies a     
cylinder    with its ends cut obliquely2
 this rotates about a transverse axis1  
and when at rest lies with its longer   
side upward4 ,to the palmar edge    of  
the shorter side is attached a          
transverse eccentric1 to which is       
hooked a cord actuated as described in  
figure #adf4 ,when this is drawn        
upward the cylinder rotates so that the 
wider side comes between    the jaws of 
the pliers and opens them2 when the cord
 is relaxed the    springs turn the     
cylinder back again find the jaws close4
 ,figures #aeh    and #aei show the     
appliance at rest and with the jaws     
open4      ,this appliance is patented  
and is made in one piece4 ,we           
demonstrate in    figure #afj that it   
would be very easy to make the pliers   
detachable    from the forearm1 with a  
screw connection1 just as is done in the
    various other appliances which will 
be described4    ,the grip of the       

automatic thumb always lacks power1 for 
two reasons4  ,there is no room in the  
thenar eminence to fit a powerful spring
 and  the grip has always a very narrow 
hold4    ,the ,brunet grip is an actual 
pair of pliers1 shaped like these and   
furnished with a powerful spring4 ,it is
 opened by a cord like that  of the     
automatic thumb4 ,figures #aeh to #afj  
explain the mechanism4  ,it is an       
excellent appliance with which the      
wearer can carry out  the majority of   
the actions of everyday life4 ,it has1  
however1 the  disadvantage that it is   
not shaped like a hand--a point to which
  patients attach much importance--and1 
moreover1 it is a part of  a patented   
appliance1 for which an interchangeable 
hand is not  manufactured4 ,so that in  
order to have in addition an artificial 
hand1  which is capable of being removed
 and replaced by one or more of the     
appliances which will be described      
later1 it would be necessary for  the   
patient to possess two complete         

artificial limbs1 and changing  from one
 to the other would evidently be        
inconvenient4    ,we generally prescribe
 this appliance for patients who have   
lost both  arms1 for one side and as a  
supplementary appliance4    ,there are  
other similar models into details of    
which it is unnecessary  to enter4      
,those in which the grip is opened by   
movements of pronation  and supination  
are obviously only suitable for certain 
rare cases  7very long stumps1 with free
 movement74                             
,b4--,,appliances ,,for ,,use ,,in      
,,place ,,of ,,the ,,hand4    ,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 trade4    ,naturally the      
results thus attained must always be    
imperfect2 but  however little          
perseverance and ingenuity he may       

possess1 the patient  finds that he is  
able to educate the remaining arm1 even 
when it  is the left1 to replace the    
amputated one in a way that is often    
remarkable4 ,it is to this education    
that attention must be specially        
directed in the workshops for the       
re-education of the maimed4    #a4      
,knife and ,fork4--,the first necessity 
is to be able to eat1 and by  certain   
very simple devices a fork1 spoon or    
knife may be fixed to a  wooden hand1   
whether the thumb be mobile or not4     
,illustration3 ,,fig4 #afa4--,raynal's  
fork rest4    ,as a general rule if the 
patient has one arm intact1 he uses the 
sound  hand only for this purpose1 but  
when both forearms have been lost an    
appliance is indispensable4    ,we have 
already described how in the hand with  
an automatic thumb1  room can be left   
between the index and middle fingers for
 the handle  of a spoon or fork4 ,a     
direct grip can also be obtained with   
the hand  shown in figure #adg4    ,the 

hand with five automatic digits 7p4     
#aje7 is usually arranged in  such a way
 that it is possible to hold a tumbler  
for drinking2 but a  patient with an    
amputation of one hand drinks with the  
other1 and one  who has lost both hands 
can drink with a straw4                 
,illustration3 ,,fig4 #afb4--,the       
termination of the forearm is a         
hemispherical piece of metal1 furnished 
with a screw into which screw    at will
 the hand1 the hook or the ring4        
,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 required4   
,it is inconvenient to be obliged to    
carry these  special implements about4  
,raynal's fork-rest has the advantage   
over the last mentioned that  it fits   
any fork4 ,figure #afa shows very       
clearly its construction and  the way in
 which it is used4 ,the small special   
attachment1 which is  screwed in place1 
is not cumbersome and can quite well be 

carried in  the pocket2 it is1 however1 
even more convenient to have an         
appliance  which is capable of gripping 
the fork directly like those described  
previously4      ,illustration3 ,,fig4  
#afc4--,vine dresser's hook4            
7,gripouilleau74      ,illustration3    
,,fig4 #afd4--,the branch is held in the
 grip by a    leverage exerted by       
torsion4    #b4 ,appliances for         
,workmen4--,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 forms3 the hook and the  ring    
7for catching hold and carrying a       
parcel1 for holding a handle1  etc474 ,a
 glance at figure #afb will show the    
nature of these and the  way in which   
they are used4 ,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        

adroitness1 e4g4 joiners1 locksmiths1   
agricultural  labourers1 etc4    ,many  
makers have realised this and have      
devised very ingenious  implements1 some
 of which we reproduce1 though we are   
obliged to limit  ourselves to certain  
types1 for they can be varied in        
countless ways  according to the needs  
of particular cases4 ,the same workman1 
as we  have already said1 may have      
several appliances which he uses in turn
  as he needs them in the course of his 
work4    ,these appliances are          
constructed in two ways2 some are fixed 
to the  end of the forearm and are      
immobile1 some are attached by means of 
a  joint or joints and are capable of   
rotation in various directions4    7a7  
,fixed ,appliances4--,we illustrate here
 an appliance derived  from the simple  
hook1 the vine-dresser's claw1 devised  
some time ago  by ,gripouilleau2        
branches of varying size can be held    
while the other  hand saws them or cuts 
them with the pruning shears 7,figs4    

#afc and  #afd74    ,this appliance of  
,gripouilleau1 with a series of hooks1  
forms the  basis of almost all the      
pincer hands constructed by ,m4 ,boureau
 and  characterised by--    7#a7 ,the   
closure of the upper hook which is thus 
transformed into a  ring1 the two       
appliances being combined in one2       
7#b7 ,the spring fixed to the straight  
side of the hook providing the  grip    
necessary for holding articles4 ,if the 
free end of the spring is  turned up    
like the pointed toe of a medival 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   
spring4    ,the simplest type of this   
mechanism is the postman's hand 7,figs4 
#afe  and #aff74      ,illustration3    
,,figs4 #afe and #aff4 ,postman's hand4 
,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  packets2 the right  
hand has only to push the letter into   
place between  a flat spring1 fixed to  
the wrist1 and the back of the hook4 ,if
 two  or three springs are supplied the 
postman can arrange two or three        
packets of letters at the same time4 ,he
 can also bind the packet with  string4 
,the vine-dresser's hand is provided    
with this spring to hold  small flat    
objects1 but the second spring is wavy  
in outline1 so  that semilunar spaces   
are left between it and the first4 ,into
 these  branches slip when the spring is
 pressed against them1 and they are     
thus held more firmly1 whilst being sawn
 or pruned1 than by the  twisting action
 of the old pattern hook of             
,gripouilleau 7,figs4 #afg and  #afh74  
,illustration3 ,,fig4                   
#afg4--;,horticulturist's hand4         
,illustration3 ,,fig4 #afh4--,method of 
holding a branch4    ,this thrust to    
seize the branch is somewhat rough1 and 
is only  possible in holding hard wood  

which there is no fear of bruising4     
,for more delicate shoots 7grafting     
vines indoors1 preparation of           
cuttings71 a grip is necessary which can
 be opened before seizing  hold of the  
object4 ,this is accomplished by        
prolonging the spring  towards the      
forearm as a handle1 pressure upon which
 against the chest  7when standing71 or 
against the knee 7when sitting71 opens  
the grip1  in which the graft1 for      
example1 is then placed in the opening  
of the  correct size4    ,the packer's  
hand is very ingenious 7,fig4 #afi74 ,it
 has the hook  pierced by an eye        
enabling a thread to be passed through a
 basket  as with a curved needle4 ,the  
jaws of the pincers are smooth at the   
tips1 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     
hammer4 ,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 hand1  placing one under the
 hammer1 relaxing his hold of it after  
the first  gentle blow has fixed it1 and
 getting the next ready while he drives 
it home4      ,illustration3 ,,fig4     
#afi4--,packer's hand4    ,the plumber's
 hand 7,fig4 #agj7 is made in the shape 
of a pair of gas  pliers1 and ends in   
cutting edges with which wires can be   
cut4 ,with  them a bolt can be held     
whilst the other hand screws on the nut4
      ,illustration3 ,,fig4             
#agj4--,plumber's hand4    ,the         
leather-cutter's hand 7,figs4 #aga and  
#agb7 should be able to  hold the skin  
which the other hand cuts3 it consists  
of a plate with  a rough surface fixed  
to a ball and socket joint which allows 
it to  turn in any direction1 so that   
the other hand can follow the line to   
be cut which is often sinuous4 ,this    
appliance may also be used to hold  a   
drawing paper1 a rule for cutting       
cardboard1 or sheets of paper for       
binding4      ,illustration3 ,,fig4     

#aga4--,leather-cutter's hand4    ,the  
examples that we have chosen amongst    
,boureau's appliances for  craftsmen    
will1 we believe1 be sufficient to      
explain the principles  of their        
construction4 ,these consist in studying
 the movements which  are normally      
carried out by the passive hand 7usually
 the left hand1  but the right in       
left-handed people7 and to devise an    
appliance  accordingly1 the sound hand  
always becoming the active hand4        
,illustration3 ,,fig4                   
#agb4--,leather-cutter's hand4    ,we   
could have described many more examples1
 but we shall only say a  few words     
about the mechanic's hand1 which is     
simply an adjustable  spanner which can 
be automatically closed1 terminating in 
toothed  pliers to hold circular objects
 without the necessity for being        
screwed up4 ,as a matter of fact1 in all
 the work of a mechanic  7sawing1       
filing1 drilling1 tightening screws1    
hammering1 forging1 and  grinding7 the  

left hand is only used for picking up   
and steadying  the article to be        
manipulated4 ,m4 ,boureau rightly       
considers that it  is better to entrust 
this rle 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 7p4 #aba and following71     
ingenious and interesting though these  
may be4    ,from these appliances1      
adapted to certain particular grips1    
others  have been devised for chair     
caning1 soldering1 and for enabling     
factory hands to work starting levers   
and brakes4    ,thus each case must be  
studied separately and the workman      
furnished  with one or several          
appliances according to his needs1      
making the  necessary modifications from
 the existing patterns4    ,several of  
these appliances are attached by a      
ball-and-socket joint  like that        
described for the leather cutter3 this  
is an intermediate  form between the    

fixed appliance and the jointed         
appliances which will  be described     
later4    ,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   
wrist4 ,the work will then gain in      
precision4 ,we believe that this        
principle holds good even for the true  
artificial hand1 which should  be made  
#c to #d centimetres shorter than the   
sound hand4 ,but it must be  realised   
that we shall be met with a difficulty1 
which we have already  experienced4     
,comments are made upon the appearance  
of the arm and the  wearer may sometimes
 be made to believe that this is due to 
faulty  construction4    ,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 forearm1 so that  
in  these special cases the artificial  
hand is the active hand4    ,at the     

,valentin ,hauy ,institute for the      
blind1 where there has long  been a     
brushmaking workshop1 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 brush4      
,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 hands4 ,it         
consists of a two-pronged claw          
surmounted by a small thimble-shaped    
projection and with a small hook1 like a
 crochet hook projecting in  front      
7,fig4 #agc74 ,the hook first passes    
through one of the holes in  the back of
 the brush1 catches up the thread and   
draws it through  the hole 7,figs4 #agd 
and #age74 ,the thread is then looped   
around the  thimble1 whilst the sound   
hand binds the little bundle of bristles
  into a twist of the loop 7,fig4 #agf71

 and finally the bundle is fixed  into  
the hole1 the claw being used to draw   
the brush towards the  worker 7,fig4    
#agg74      ,illustration3 ,,fig4       
#agc4--;,brushmaker's hook4             
,illustration3 ,,fig4 #agd4--;,first    
movement4 ,the string is    picked up by
 the hook4      ,illustration3 ,,fig4   
#age4--,second movement4 ,the string is 
pulled through one of the holes         
perforated in the back of the brush4    
,illustration3 ,,fig4 #agf4--,third     
,movement4 ,catching the bundle    of   
bristles4      ,illustration3 ,,fig4    
#agg4--;,fourth ,movement4 ,the bundle  
is    fixed in the hole in the back of  
the brush4    7#c7 ,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 handle4 ,the two principal      
methods are the screw and the ,american 
chuck4 ,a glance at figures #agh and    
#agi will explain how the large  handle 
of a tool intended for heavy work is    

controlled by means of a  screw and     
rings4      ,illustration3 ,,figs4 #agh 
and #agi4--,nyrop's grip for hammer     
and saw4    ,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 this4 ,this method  
is specially useful for manipulating  a 
file which is worked with one hand while
 the other1 in this case  the sound     
hand1 presses upon the free end4        
,usually the filing is done  backwards  
and forwards1 working from base to tip  
of the file1 but  sometimes1 specially  
for final polishing1 the file is held   
with both  hands and worked from side to
 side4    ,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      
corolla4 ,another cylinder is screwed   
over the first to control the  opening  

and shutting of the jaws4 ,when this    
cylinder is unscrewed  the jaws open and
 the handle of the tool can be inserted1
 when it is  screwed up it closes the   
jaws and makes them grip the handle4    
,illustration3 ,,figs4 #ahj to          
#ahe4--,the ,american ,chuck4      ,the 
pincers are composed of two jaws with   
vertical cylindrical grooves    7to fit 
upon a handle71 joined above by a ring  
7,fig4 #ahe7 and coupled    by a spring 
,c which keeps them apart4 ,the pincers 
fit into a piece    ,b 7,fig4 #ahb7 cut 
on the outer side with a screw thread   
7,figs4 #ahb    and #ahc7 upon which the
 piece ,a is screwed up or down 7,figs4 
#ahj and    #aha74 ,when screwed towards
 the point of the pincers it presses on 
the    two jaws and closes them4 ,when  
screwed in the opposite direction the   
pincers open automatically4    ,if the  
jaws open widely1 the wooden handle of a
 tool can be held1 but  if the opening  
is small the unmounted tool must be     
fitted into them  7,figs4 #ahf and      

#ahg74 ,this method is specially useful 
for files1 as it  frequently happens    
that several files are required for the 
same piece  of work and they can be     
changed rapidly4      ,illustration3    
,,figs4 #ahf and #ahg4--;,file fitted   
into the    ,american chuck4    ,it     
must1 however1 be insisted upon that the
 principle of giving a  passive rle to  
the artificial hand is to be preferred4 
7b7 ,appliances with ,mobile            
,joints4--,in the course of work the    
direction of the wrist is changing at   
every instant1 flexion1  extension1     
pronation1 and supination occurring1    
sometimes in order  to move around the  
object1 sometimes in order to maintain a
 suitable  position when the movements  
of the shoulder and elbow vary the      
direction of the forearm4    ,the       
consequence of this is that the worker  
learns to turn the piece of  work around
 with his sound hand4 ,to get over this 
difficulty passive  joints are inserted 
at the wrist1 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 forearm4      ,illustration3       
,,figs4 #ahh to #aij4--;,agricultural   
hook and ring4    7,gripouilleau47      
,illustration3 ,,fig4 #aia4--;,combined 
hook and ring4 7,boureau47              
,illustration3      ,,figs4 #aib to     
#aid4 #a4 ,tram driver's and chauffeur's
 bell4 #b4    ,method of use by a tram  
driver4 #c4 ,management of a motor car  
lever4    ,pressure at the extremity and
 traction4    ,one of the simplest      
mechanisms--and one of the oldest1      
because it was  designed by             
,gripouilleau--is that of the           
agricultural labourer's  ring1 intended 
to grip and manipulate the handle of a  
wheelbarrow  or a plough4 ,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 forearm4 ,the ring is provided
 with a screw1 which may be tightened   

upon the handle if desired1 but which   
is1 however1 rarely used 7,figs4  #ahh  
to #aij74    ,the tram-driver's bell1   
represented in figure #aib1 is devised  
on the  same principle4 ,it moves on a  
transverse axis1 and in figures #aic and
  #aid its utility in managing levers in
 driving a tram or a motor car  will be 
easily seen4 ,the rotation of the       
horseshoe on the axis of the  forearm is
 not required4    ,the cardan joint also
 allows movement in every direction3 it 
consists of two semicircles of metal1   
placed at right angles1 each  working   
around a transverse axis1 these axes    
being united in the form  of a cross4   
,the construction and working will      
probably be understood  without further 
explanation by a study of figures #aie  
to #aih4 ,the  first two represent a    
system with a ball in the centre1 which 
is well  known commercially4 ,the last  
two represent the simple universal joint
  generally used in orthopdic surgery4  
,it is somewhat more cumbersome  than   

the previous model4      ,illustration3 
,,figs4 #aie and #aif4--,universal joint
 with ball4      ,illustration3 ,,figs4 
#aig and #aih4--,simple universal joint4
      ,illustration3 ,,fig4             
#aii4--;,gardener's cylindrical spade   
holder4 ,a universal joint permits      
movements in every direction4    ,the   
spade holder used at the agricultural   
centre at ,limonest is  mounted on a    
cardan 7,fig4 #aii74    ,the joint can  
be fixed by a compression screw which is
 easily and  quickly adjusted4    ,where
 several tools are necessary each should
 be complete with its own  universal    
joint4    ,other methods of terminal    
passive articulations are--    7#a7     
,ball joints which have already been    
described in connection with  the       
fingers and which may be applied to the 
wrist4    7#b7 ,bayonet joints which are
 only applicable to certain artificial  
hands which are not subjected to any    
great strain4      ,illustration3 ,,fig4
 #bjj4    ,figure #bjj explains this    

mechanism as it is applied to the       
artificial  hand represented in figure  
#adh4                                   
,,chapter ,,viii                        
,,artificial ,,limbs ,,for ,,amputation 
,,through ,,the ,,arm      ,in this     
chapter we shall deal only with         
amputation of the arm below  the upper  
third1 i4e4 with cases in which the     
stump is long enough  to transmit       
movements to the artificial limb4       
,amputation through the  deltoid muscle 
must be considered in association with  
disarticulation  of the shoulder4       
,below the arm socket is attached an    
artificial limb which represents  the   
elbow joint1 forearm1 and hand4         
,there are two types to be described3-- 
#a4 ,the artificial arm proper1 which   
has the external shape of the  natural  
limb4    #b4 ,the worker's arm1 a       
terminal appliance in which outward     
appearance  is not considered4    ,the  
considerations as to the arm socket and 
its attachment by a  shoulder cap are   

the same for the two types of appliance4
    ,attachment and ,arm ,socket4--,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 arm2 the         
attachment is made by  means of a       
shoulder cap4    ,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 forearm4      ,illustration3
 ,,fig4 #bja4    ,the larger the        
shoulder cap the more it extends        
forwards over the  anterior wall of the 
axilla1 upwards over the supra          
clavicular fossa1  and backwards over   
the scapula1 the more secure will be the
 support4  ,the appliance is heavy and  
has no support other than the axillary  
strap4 ,the latter has a tendency to    
ride upwards against the axilla  where  
it exerts a pressure which may be       
uncomfortable4 ,this may be  relieved by

 attaching a vertical strap which is    
buttoned to the  trouser belt4          
,illustration3 ,,fig4 #bjb4    ,but     
although this extensive enclosure of the
 thoracic region may not  hinder the    
movements of the stump forwards and     
backwards1 it must  obviously interfere 
with the movement of abduction4 ,no     
doubt this  movement is the less        
important of the two1 but we ought to   
try to  preserve it as far as possible4 
,in short stumps we must abandon it4    
,but if the stump is long and           
consequently has no tendency to escape  
from the socket1 even if this  slips    
down a little1 movement may be retained 
by two methods4    ,the first consists  
in separating the arm socket from a     
large shoulder  cap1 and inserting a    
joint between 7see page #hg72 but the   
appliance  is then heavy and cumbersome4
 ,moreover1 although abduction can thus 
be easily attained1 thrusting and       
pulling movements require a light       
appliance1 and finally it is impossible 

to secure rotation4      ,illustration3 
,,figs4 #bjc and #bjd4--,shoulder       
fitting of small    extent allowing     
abduction4    ,it is possible1 on the   
other hand1 by means of the other       
method1 which  consists in ending the   
shoulder cap at a line continued        
vertically  upwards from the thoracic   
margin of the axilla4 ,if the straps are
  strong and carefully adjusted the     
result is better than with the  fitting 
over the scapula1 so that this appliance
 is preferable4 ,we  here illustrate a  
method of fitting the straps which we   
consider a  good one4 ,from the         
posterior part of the ordinary axillary 
strap1 a  ,y-shaped branch passes to the
 upper border of the shoulder cap above 
and in front of the clavicle1 this makes
 up for the small extent of  the        
enclosure of the shoulder4    ,for the  
worker's arm a considerable enclosure   
without any joint is  essential1 in     
order to secure stability4    ,the arm  
bucket1 usually continuous with the     

shoulder cap1 is made of  leather       
strengthened with steels4    ,the       
artificial arm is often abducted from   
the trunk1 which constitutes  an        
inconvenience4 ,this is sometimes due to
 a fault in the alignment1  the arm     
piece not being at right angles to the  
shoulder cap4 ,it is1  however1 more    
often due to the cylindrical shape given
 to the arm  bucket which forces it away
 from the trunk4 ,the inner side of the 
bucket should be flattened so that it   
may hang vertically close to the        
thorax4    ,the details of construction 
are different for the true artificial   
arm  and the worker's arm4              
#a4 ,,artificial ,,arm    ,the arm and  
forearm pieces are both made of leather4
 ,there is no  object in making them to 
lace1 the stump is enclosed in a socket 
in  which it need not fit very tightly1 
because1 as we shall explain1 this      
appliance is unsuitable for heavy work4 
,these two parts are strengthened with  
steels1 which are articulated by  hinge 

joints at the level of the elbow4 ,we   
have to study--    #a4 ,the position of 
the steels and the direction of the axis
 of the  joint4    #b4 ,the lock to fix 
the elbow joint in a flexed position4   
#a4 ,position of the ,steels4--,the     
stump can transmit to the arm socket    
the various movements grouped under the 
name of circumduction1 but its  hold    
does not enable it to transmit rotation4
    ,it is therefore                    
undesirable--although usual--to attach  
the steels  on the arm and forearm to   
the inner and outer sides of the limb4  
,if  this is done1 as rotation is       
impossible1 flexion of the forearm at   
the elbow can only be carried out in the
 sagittal plane4 ,but this  movement is 
only exceptionally required2 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 hung1 provided that the forearm  
lies  transversely in contact with the  
abdomen and not antero-posteriorly4     

,flexion should therefore be in a plane 
which is almost the frontal  plane 7#bj 
or #cj in front of this71 and not in the
 sagittal plane4  ,as there is no active
 rotation of the arm therefore the      
steels must  be almost in the sagittal  
plane 7the anterior a little external1  
the  posterior a little internal74      
,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 hand1 so that the  direction of   
the elbow movement can be altered4      
#b4 ,ratchet to fix the ,elbow ,joint in
 the ,flexed ,position4--,when at  rest 
the forearm should hang vertically4 ,but
 the hand can only be used  when the    
elbow is flexed to an obtuse angle or a 
right angle1 the  latter position being 
more often used4 ,therefore when the    
patient has  bent the joint to the      
required angle with his sound hand1 he  
must be  able to fix it in this         

position4    ,this fixation is effected 
by means of a ratchet attached to the   
outer  side of the elbow1 which can be  
locked or unlocked at will4    ,this    
ratchet consists of a flat metal plate  
with a prolongation  upwards shaped like
 the handle of a fork4 ,the end of this 
prolongation  is attached to the arm    
steel by a pin joint about #c           
centimetres above  the axis of the elbow
 joint4 ,the plate is pierced by a      
rectangular  opening1 one border of     
which is notched2 it lies against the   
forearm  steel1 a catch projecting from 
which fits into the opening1 this       
catch1 situated #f centimetres below the
 axis of the elbow1 is of  the same     
diameter as the notches with which it   
engages4 ,the higher  the notch with    
which engagement takes place the more   
nearly flexion  approaches the right    
angle4    ,the width of the opening in  
the plate is twice the size of the      
catch1  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  border4   
,it is only necessary to arrange a lock1
 manipulated through the  sleeve1 to    
bring the smooth or the notched border  
in contact with the  catch4    ,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 button1 and that
 an elastic cord or spring is stretched 
from  this button to a point on the     
postero-external border of the forearm1 
then if the lever points upwards and the
 notches are on the upper edge  of the  
ratchet 7as is the case in figure #bje71
 the elastic1 pulling  the lever        
forwards1 will press the ratchet down   
and make the notches  engage with the   
catch on the forearm1 if1 on the other  
hand1 the lever  points downwards the   
elastic traction will release the       
notches4 ,the  reverse occurs if the    
notches are on the lower edge4    ,it is
 then only necessary to arrange a       

mechanism by means of which  this little
 lever can turn1 with a stop which      
arrests it above at the  vertical       
position1 below at a point #de beyond   
the horizontal4      ,illustration3     
,,fig4 #bje4--;,elbow ratchet4    ,a    
simple mechanism of this sort is shown  
in figures #bjf and #bjg4 ,the  joint   
surfaces of the ratchet and of the      
little lever each bear a  shoulder1 the 
former in front1 the latter behind1     
extending over such  a proportion of    
their circumference as will make them   
act as stops in  the desired positions  
above and below4    ,a lock is thus     
provided which can be manipulated with  
the other hand4    ,in the particular   
pattern illustrated1 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  lever4  
,this arrangement allows of the         
adjustment necessitated by the  gradual 
stretching of an elastic which is       

subjected to continuous  tension4    ,a 
steel spring of this length 7the whole  
length of the forearm7 would  be too    
heavy if it were sufficiently powerful4 
,if it is desired to use  this method   
the two ends of a powerful spring should
 be fixed1 one to  the button on the    
lever1 the other to the catch on the    
forearm with  which the ratchet engages4
      ,illustration3 ,,figs4 #bjf and   
#bjg4--,the elbow ratchet and mode    of
 action of its lock4    ,the spring     
should always be in tension4 ,as the    
distance between the  joint on the arm  
and any point on the forearm increases  
as the elbow  extends1 it is better for 
the ratchet1 with notches on its upper  
edge1 to be engaged when the button     
points upwards and free when it  points 
downwards4 ,in the opposite arrangement1
 which is often used1  the tension is   
considerable without being useful when  
the forearm is  vertical1 and the       
mechanism soon wears out4    #c4 ,hand  
and ,other ,appliances4--,the hand      

attached to the end of the  forearm has 
a spring thumb which may be passive or  
automatic4 ,in  the latter case1 if the 
stump is long enough to allow           
considerable  movements of the arm1 the 
cord works in the way described on page 
#hg1  for amputation of the forearm4 ,if
 the stump is short1 traction must be   
exerted by movement of the shoulders1   
rounding the back4    ,the hand with a  
mobile wrist is never used with these   
amputations  except in certain expensive
 appliances1 in which in addition the   
four  fingers may be articulated1 as    
described on page #aja4 ,for the        
ordinary  limb these delicate mechanisms
 are devoid of practical utility4    ,it
 is easy to replace the hand with       
interchangeable appliances1 but  when   
the patient has to do hard work this is 
not a satisfactory method4    ,the arm  
with the ratchet at the elbow is in fact
 suitable for use  by a clerk4 ,but it  
is not either strong enough or simple   
enough for  manual labour4 ,in our      

opinion the functional and practical    
value of  an artificial arm1            
particularly for amputation above the   
elbow1 is  often exaggerated1 however it
 does exist1 especially in many branches
  of agricultural work4 ,for the latter 
the slightness of the lateral           
steels--and especially of the joints at 
the elbow--makes the appliance          
insufficiently strong4 ,the necessary   
delicacy of the ratchet and its         
manipulation through the sleeve by the  
sound hand are additional               
disadvantages4                          
#b4 ,,worker',s ,,arm    ,if our object 
is to fit to an arm stump an appliance  
which will be at  the same time strong  
and flexible1 capable of carrying out   
rough and  even vigorous work1 we must  
abandon the attempt to imitate the      
natural  shape of the arm4    ,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   

fixed4 ,it is possible to fix around    
this  rod a show arm with a hand and a  
passive spring thumb for wearing on     
special occasions1 in exactly the same  
way as we fit the show leg  round the   
peg4 ,figures #bjh and #baj will show at
 a glance how this is  done4    ,but1 as
 far as our present experience goes1    
this is only an accessory  added for    
sthetic reasons4 ,the true worker's arm 
consists of a strong  metal rod fixed to
 the arm socket in a way that we must   
now study4    #a4 ,the ,arm             
,socket4--,we have already said that    
this must be continued  into a shoulder 
cap of considerable extent1 which may be
 perforated  in the region of the point 
of the shoulder in order to render the  
appliance lighter4 ,abduction at the    
shoulder is thus sacrificed4    ,the arm
 socket is made of leather1 open down   
the front and laced4 ,by  being laced it
 fits the stump more securely4 ,it is   
strengthened by two  steels which may be
 fixed in the frontal plane because1 as 

we shall  see1 a passive rotation at the
 elbow joint is possible4    ,these     
steels are directly continuous below    
with a hemispherical steel  cap1 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 attached4    
#b4 ,articulation at the ,elbow4--,the  
forearm consists of simple metal  tube1 
attached beneath the arm socket by      
methods which depend upon the  following
 principles4      ,illustration3 ,,figs4
 #bjh and #bji4--,worker's arm and show 
arm4      ,the worker's arm consists of 
a metal rod which swings backwards and  
forwards at the elbow and also rotates  
upon the arm socket4 ,to the    end of  
this rod an appliance can be screwed 7a 
ring and hook are here    shown74       
,around the worker's arm a show arm with
 a hand 7,fig4 #bji7 can    be fixed4   
,they are shown in place in ,figure     
#baj4    ,the only movements that the   
stump can transmit to the arm socket    

are forward and backward movements      
hinging about the shoulder1 and         
abduction4 ,the first of these movements
 is the only really useful one  for the 
workman4 ,the downward pressure exerted 
by active extension of  the elbow no    
longer exists2 in order to press upon an
 object the sound  hand must be used1   
for it is not practicable to make use of
 the weight  of the body thrown forward 
for this purpose4      ,illustration3   
,,fig4 #baj4--,show arm in position4    
,in backward and forward                
movements--considering1 for example1 the
 use  of the file--the angle at the     
elbow opens when the arm is thrust      
forward and closes when it is pulled    
backwards4 ,these passive  movements of 
the joint must not be impeded in any    
way1 that is to say1  the forearm must  
swing freely below the arm upon a       
transverse axis and  it must also be    
able to rotate freely around a vertical 
axis4    ,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  utilised4 ,the forearm
 rod attached by a strong transverse pin
 swings  freely in a little             
stirrup-shaped cap1 which itself rotates
 around a  bolt by which it is firmly   
fixed into the metal or wooden          
hemisphere  which terminates the arm    
socket4#ad    #ad ,wood1 which was used 
by ,gripouilleau1 has been given up4    
,it is clear that this complete liberty 
of action has its  disadvantages2 the   
elbow joint can never be made to assume 
a fixed  position against any passive   
resistance2 moreover1 in actual practice
  the useful range of either of these   
movements is small4 ,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 war4 ,in all these arms the         
mechanism of the elbow  joint is derived

 from that of the ploughman's arm of    
,gripouilleau4  ,unfortunately none of  
these mechanisms in which a pressure    
screw is  used for fixation possess any 
strength4 ,at first sight1 in a new     
appliance they appear attractive and    
work well1 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 it4
    ,at the extremity of an artificial  
arm1 whether it be an arm of natural    
shape or a worker's arm simplified to   
the form of a jointed rod1 any  of the  
appliances already described for forearm
 amputations can be  screwed on as      
required4    ,it is by the use of these 
appliances that ,gripouilleau's old     
ploughman's arm1 which ended in an      
interchangeable hook and ring1 has  been
 improved4    ,apart from their actual  
economic value1 results have been       
obtained by  use of these terminal      
appliances1 in many different skilled   
trades1  which are of the greatest      

possible interest4    ,for reasons that 
we have indicated in describing the     
attachment of the  elbow1 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 durable4 ,for this reason we 
consider that until something new is    
designed it is better to make the       
terminal appliance a fixed one4         
,,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          
identical2 a  short arm stump is        
incapable of transmitting movements to  
the socket  of the artificial limb4     
,that is to say1 our appliance will be a
 purely passive one1 and  at the present
 time it is useless to attempt to make  
any sort of  worker's arm4 ,we must aim 
simply at supplying a limb which        

imitates  the external shape of the arm1
 with an elbow joint which can be locked
  with a ratchet4 ,at most it is        
possible by a movement of the opposite  
shoulder to work an automatic thumb by  
means of a cord1 as a rule1  however1 a 
simple spring thumb is preferred4       
,nothing need be added to what has been 
said in the previous chapter  about the 
elbow joint or the hand4    ,in the     
fitting of an attachment over the       
shoulder the amputation  through the    
deltoid presents an actual advantage4   
,for in this case the  shape of the     
point of the shoulder is preserved1 and 
the attachment  carried out as described
 on pages #hg and #acj fixes the        
appliance very  securely4    ,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 material4    

,these appliances can be used to steady 
a piece of paper upon which  the patient
 is writing1 to carry a parcel which is 
not too heavy  with the elbow flexed1 to
 grip an article with the thumb4 ,a     
workman  who is being re-educated for   
some occupation which is possible  for a
 one-armed man1 will usually--unless he 
is going out for  pleasure--leave his   
artificial arm at home in the cupboard4 
,,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 family4 ,in our opinion1  which we  
believe we have expressed more than once
 in this book1 it is  nearly always     
advisable to determine what profession  
will ultimately  be possible before     
ordering the artificial limb4 ,this     
principle is  perhaps not always        
thoroughly understood1 although there   

are fitting  centres where it is fully  
recognised 7a proof of this may be found
 in  a recent article by ,nov-,josserand
 and ,bouget74    ,it is unnecessary to 
repeat that whilst every effort must be 
made to  associate form with function1  
the latter is bound to take precedence  
of the former4 ,it is1 however1 not     
always easy to impress upon  patients1  
and more especially upon their          
protectors1 that form is  for ,sundays  
and holidays1 and function is for       
workdays4    ,the grave problem of      
re-education of amputation cases1 and in
 a more  general sense of all the       
maimed1 now confronts us4 ,we believe it
 to be  worth while to indicate the     
general principles so far as they are at
  present understood4                   
,i    ,at the outbreak of war the idea  
of the disabled in general1 and         
particularly of those who had had a limb
 amputated1 was often to give  up any   
really active trade and to seek a       
situation generally as an  official with

 no actual manual labour4 ,it must be   
confessed that many  people1 especially 
the nurses1 encouraged them in this1 and
 possibly  the latter would not deny    
having done so4    ,it has rapidly      
become evident that there are too many  
maimed to  be supplied with situations  
as caretakers of public gardens or      
doorkeepers1 and that they will not be  
able to gain a living by making         
tricoloured decanter-mats of string or  
raffia or artificial flowers1  when     
bazaars organised for their benefit by  
tender-hearted souls have  gone out of  
fashion4    ,one of us was present a    
short while ago at the following little 
scene3--    ,in a hospital where there  
were two amputation cases1 one through  
the  lower fourth of the thigh1 the     
other through the middle of the leg1    
both agricultural labourers1 a          
distinguished man of letters1 actuated  
by the best intentions1 asked them what 
they counted on being able to  do after 
they had been fitted with artificial    

limbs4 ,the first replied  that he hoped
 to return to agricultural work1 the    
second that he would  never be able to  
do that but would look out for a        
situation4 ,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     
patient1  because a man with only one   
leg could work on the land with almost  
no diminution of his ordinary capacity1 
even with the old-fashioned  kneeling   
peg leg4    ,as ,jean ,camus has well   
said in a recent article in the ,paris  
,mdical1 ,we are beginning to pass      
beyond the phase when re-education  of  
the maimed was left to chance4 ,it is   
felt now that the frivolous  efforts of 
benefactresses who1 acting with the best
 intentions but  without reflections1   
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
 it1 must be avoided4 ,such  feats are  

both culpable and absurd4    ,these     
fantastic ideas must be got rid of1 and 
all our efforts must be  co-ordinated1  
the complexity of the conditions to be  
dealt with being  duly weighed4         
,given a maimed man the first care      
should be to educate to the maximum  all
 the uninjured and remaining parts4 ,it 
is too often forgotten that  among the  
parts remaining the brain plays a       
leading rle1 even the  chief rle1 not   
only because it is the organ of good    
will without  which all attempts at     
re-education are fruitless1 but also    
because  good will being given the      
intelligent man will succeed better and 
will be able to adapt himself to more   
delicate work4 ,physiotherapy  cannot be
 prescribed1 says ,j4 ,camus1 as quinine
 is prescribed4 ,the  malarial patient  
who takes the latter medicine benefits  
whether he  wishes to or not4 ,the      
wounded man who submits each morning to 
his  mechanotherapeutic treatment does  
not recover unless he wishes4    ,it is 

very difficult to make the layman       
understand this4 ,he invariably  takes  
for granted the good will of the        
patient1 with all of whose  complaints  
he sympathises1 without for a moment    
realising that they  sometimes          
degenerate into jeremiads1 often with an
 ulterior motive4  ,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-educated2 so that he may  understand 
that it is entirely to his interest to  
work as quickly and  as well as         
possible1 that begging is degrading1 and
 above all that  private charity is     
temporary and exhaustible2 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      
maintenance4    ,it can never be        
sufficiently insisted upon in dealing   

with the maimed  that by resuming work1 
and on account of the functional        
improvement  resulting from doing so1   
they need have no anxiety that their    
pension  will be reduced1 because the   
amount of this is based on the extent of
  the injury itself and on the man's    
rank1 and not on his profession  before 
he became a soldier4 ,in the same rank  
the pension is the same  for a surgeon  
or a lawyer1 if both have lost a hand4  
,it is a deep-seated notion1 instilled  
into the minds of injured  workmen by   
the often suspicious folk who advise    
them1 that if they  begin work before   
their case has been settled their       
pension will be  less4    ,it must be   
acknowledged on the other hand that the 
civil expert  is often faced with a     
difficulty4 ,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 salary4 ,this  difference is  
important to our wounded soldiers1 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 wound1 in legal          
phraseology1 has become  consolidated1  
that is to say1 before the completion of
 treatment4    ,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 growing1 viz4 delaying
 re-education until the time  when the  
local condition has become permanent and
 the patient has been  discharged and   
has received his prosthetic apparatus4  
,this delay is deplorable1 on both      
medical and social grounds4 ,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 treatment4 ,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 intemperance4    
,this is now understood1 and almost     
everywhere to-day the wounded  soldier  
can resume work in workshops attached to
 the centres of  physiotherapy1 and thus
 begin his re-education while continuing
 his  treatment4    ,at a certain stage 
resumption of work becomes the best     
therapeutic  agent of all4    ,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 
nerve1 balneotherapy1 or graduated      
gymnastic  exercises2 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 contrived8 ,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 two4    ,the tendency to-day 
is in this direction1 as1 for example1  
at the  ,grand ,palais1 thanks to the   
efforts of ,j4 ,camus1 and also in the  
agricultural centre of the ,x,i,i,ith   
district under the direction of  ,belot 
and ,privat4 ,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 ,valle have           
demonstrated4    ,the workmen are then  
eligible for work in a town in private  
workshops1  but so far this freedom has 
more inconveniences than advantages4 ,a 
man whose working capacity is much      
reduced1 and more especially a man  who 
requires re-education1 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    
him4 ,where actual  education is        
necessary this is best supplied in      
special workshops  where the patient    

will be among comrades handicapped like 
himself1  whose progress he will be able
 to watch and whose efforts he will     
imitate1 rather than among able-bodied  
workmen1 by comparing himself  with whom
 he is bound to be discouraged4    ,the 
problem has been solved by the ,belgians
 in a remarkable  establishment opened  
at ,port-,villerz1 and by the ,austrians
 at ,vienna  under the direction of     
,spitzy1 as ,nov-,josserand and ,bouget 
inform  us1 by delaying a maimed        
soldier's discharge from the army until 
his  re-education is as complete as     
possible4 ,this method has proved to  be
 to the interest both of the individual 
and of the ,state1 but we  do not seem  
to have considered this solution1 and it
 is still to be  feared that it would   
accord ill with the independence of our 
national  character4 ,the actual fact1  
though it has not been brought into     
prominence1 is that our usual system of 
watertight compartments has  been       
applied by adding to the centres of     

physiotherapy centres of  agricultural  
or industrial re-education1 the results 
obtained in which  are dependent upon   
the efficiency of the director of       
physiotherapy4    ,this matter seems to 
have received very little special       
attention in  connection with amputation
 cases4 ,it is1 however1 of great       
utility to  develop the strength and    
agility of the remaining limbs by       
suitable  gymnastic exercises1 to teach 
a man with only one leg1 for example1   
to jump without an artificial limb and  
to climb a slippery rope or a  ladder2  
or to train the left hand of a man who  
has lost his right2  to develop the     
greatest possible strength in the stump 
by training  it in movement combined    
with the exertion of force4 ,in addition
 to  this1 early and provisional        
equipment with artificial limbs must    
become general4 ,these temporary limbs  
are undoubtedly rudimentary             
contrivances1 but they are functionally 
good and are useful on account  of their

 mere weight4    ,in this connection the
 temporary arms used by ,nov-,josserand 
and  ,bouget in their agricultural      
re-education centre are very interesting
  models4 ,the great advantage of using 
a temporary limb is that the  time      
required for the construction of the    
permanent apparatus1 often  a           
considerable period1 is not lost in     
idleness1 the mother of all the  vices4 
,,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  fashion4    ,in  
the choice of a trade the ruling        
principle is that of aiming to  restore 
as nearly as possible the man's former  
occupation4 ,this  principle should not1
 however1 be carried to an extreme4     
,as ,camus has justly said1 by his      
previous work a man has stored up  a    
mass of ideas1 a fact which is too      
little realised1 especially by  himself4

 ,these include the manner of choosing1 
holding1 and attacking  the materials   
upon which he works1 and of appreciating
 their qualities  and faults2 knowledge 
of their market value1 of the value of  
the  labour1 etc4 ,this should be       
utilised in his future work even though 
it  be realised1 as ,m4 ,bourillon has  
remarked1 that the resumption of his    
trade in its entirety may be impossible4
    ,with the tools that have been      
described a man who has lost his forearm
  may be able1 for example1 to undertake
 a locksmith's work and to  execute     
correctly all the movements required in 
plying the trade4  ,granted2 but how    
long will he take to make one piece1 let
 us say1  as well as his neighbour8 ,if 
he produces little he will not find an  
employer to give him daily work1 while  
if he does piecework1 apart  from the   
fact that it is not in good repute among
 those who are the  actual leaders of   
the working classes1 it will not be     
remunerative1  and to earn #c frs4 a day

 when a comrade earns #aj or #ab frs4 is
  practically an impossible solution4   
,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       
mobile4 ,by means of contrivances which 
we need not describe1  and with no      
prosthetic apparatus1 she threads her   
needle and sews as  quickly and as well 
as anybody4 ,this is not an argument1   
for3 7#a7 it  is a congenital lesion and
 the educability of a child is well     
known2  7#b7 the woman is extremely     
intelligent1 and unhappily this         
favourable  factor cannot always be     
counted upon4 ,it would be wrong to     
conclude  from this that a case of      
amputation at the wrist should be put to
  sewing4    ,it must never be forgotten
 that intelligence and will are factors 
of  the first importance1 so that       
however little intellectual capacity    
the disabled man may have1 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    
instruction4 ,it  is1 in fact1 by brain 
work that many learn to replace their   
physical  defect4 ,let us take1 for     
example1 a disabled bricklayer4 ,if he  
is  intelligent and is given a helping  
hand in the shape of the necessary      
instruction1 he may become a builder on 
his own account in a small way  when he 
knows how to make plans1 work out       
estimates and keep accounts4    ,this is
 not a ,utopian fancy4 ,in the small    
towns and villages there  are many      
owners of businesses such as masons1    
decorators1 joiners1  etc41 workmen who 
cannot spell1 but who are intelligent1  
have business  minds and a gift for     
overseeing1 who have given up the trowel
 and will  build you a house as well as1
 or often better than1 many architects4 
,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  
great4    ,where there is no            
intelligence education can do little4   
,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 up4      
,their situation becomes serious  when  
they lose some of their physical        
capacity4 ,they can1 however1  be       
rescued1 particularly by encouraging    
them to become agricultural  labourers4 
,it is indeed especially agricultural   
labourers who should  be urged to return
 to the land1 and those mechanics who   
will be  unable to work in a factory for
 the future should also be encouraged   
to take up this work4 ,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 land4 ,it  is unnecessary to
 speak of cases of amputation below the 
knee1 since  their usefulness on the    
land may be taken for granted4    ,in   
the country as a matter of fact a man   
never dies of hunger2 and  this cannot  
be said of the town4 ,apart from actual 
cultivation of the  land1 which is in   
part impossible for the maimed1 there   
are numerous  and important occupations 
of which a town dweller would not think4
 ,it  is when he goes to the centre of  
re-education in agricultural work1      
first of all to view it and then to     
work1 that the disabled man takes  note 
of what he can or cannot do1 and of the 
work in connection with  agriculture    
which is open to him1 such as poultry   
rearing or bee  keeping4    ,this       
applies to other employments than       
agriculture4    ,apart from his actual  
trade which the workman can no longer   
ply with a  sufficient return for his   
labour1 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 income4      
,in certain re-education centres there  
seems to be a marked  predilection for  
crafts in which the apprenticeship is   
short  and the installation costs       
little1 though these are in fact the    
characteristics of those trades which   
give the labourer a poor return1  that  
is to say1 time-work in a large or small
 workshop4    ,at the beginning of the  
war an attempt was made to show that    
there  would never be enough tinkers1   
sabot makers1 shoemakers1 or saddlers   
in the country4 ,it is quite a false    
idea that a disabled man can  gain a    
living at one of these crafts in a      
village4 ,it is true that  he can do so 
if1 working as an agricultural labourer1
 he can act  as a barber in his spare   
time1 and is capable of executing small 
jobs1 especially repairs1 which the     
villagers would readily give to  him    
rather than have to go several miles to 

get them done4 ,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 development4 ,in    
that case1  however1 he will be1 in     
fact1 a small proprietor buying his own 
tools  and materials and fixing a retail
 price4 ,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  alone4 ,it      
follows1 therefore1 that the education  
of his mental1 and  especially his      
commercial1 faculties must be           
considered1 and it must  be ascertained 
whether the man is likely to profit by  
such education4  ,it is useless to      
install in a hamlet a shoemaker who is  
incapable  of working except as an      
assistant1 and in the town at the actual
  factories the prospects are poor4     
,moreover1 conditions of life in the    

disabled man's native place must  be    
considered as a matter of importance4 ,a
 man from the ,mediterranean  country   
has no idea beyond the cultivation of   
meadows1 and one from  ,picardy none    
beyond the making of cane baskets for   
packing flowers4    ,judgment is        
difficult1 and in order that the choice 
may be exercised  as reasonably as      
possible1 the careful collaboration of  
the patient1  the doctor and the        
managers of the workshops is essential4 
,we repeat  that this is one of the     
principal objects for which the centres 
of  re-education are useful4 ,there are 
some efficient men1 we know1 who        
without asking anything of anybody find 
quickly and unerringly the  exact work  
that suits them4 ,there is no need of   
anxiety in such cases4    ,a certain    
metal worker from the invaded area      
suffering from  pseudarthrosis of the   
shoulder1 whose wound we were treating1 
sent  for his wife1 and they began to   
rear geese4 ,we know two cases of       

amputation of the right arm1 an         
operative at an aeroplane works and  a  
worker in stucco1 who during their stay 
at hospital and before  they had been   
supplied with artificial limbs1 had     
taught themselves1  the one technical   
design the other ornamental design4     
,both of them1  as soon as they were    
discharged1 have been taken on by their 
former  masters1 who no doubt were fully
 conscious that they were thus          
combining a good deed with good         
business4 ,to come to a decision of any 
value1 however1 cases of this sort must 
not be taken as a criterion1  for they  
are in fact exceptional4 ,the majority  
of the men are in need  of guidance4    
,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 days1 during which time  
he sees what is  going on and is not    
slow to make his choice1 which it       
appears rarely  needs to be amended4    

,we have dealt chiefly with the         
conditions which are suitable for the   
re-education of a man who has lost an   
upper limb1 or1 speaking more           
generally1 is disabled in one arm1 for  
whom resumption of work in a  workshop  
will often be out of the question4 ,the 
question is easier  of solution for the 
lower limb4 ,cases of amputation of the 
leg can  work standing1 if supplied with
 an artificial limb1 at practically  any
 trade4 ,cases of amputation of the     
thigh have numerous manual  occupations 
open to them in which they sit for at   
least part of  the time4 ,it must be    
understood1 however1 that these         
professions  which require skill can1 as
 a rule1 only be learnt in well-equipped
  workshops at the price of a fairly    
long apprenticeship4 ,two or three      
years are necessary to make a good      
mechanic1 a good watchmaker1  glass     
cutter1 etc4 ,this should not deter us  
in the case of fairly  young men4 ,the  
difficulty is to organise special       

workshops1 often with  a complicated    
equipment1 where the maimed man can at  
least pick up  the rudiments of the     
work1 for it is not to be thought of    
that he can  remain there during the    
whole time occupied in a complete       
training4    ,in conclusion1 we should  
like to draw attention to the law of    
#ahca1  which regulates the distribution
 of pensions by means of groups         
classified according as the loss is of  
two limbs or of one4 ,no  distinction is
 made with regard to the seat of the    
amputation4 ,but  a man who has lost    
both legs and has been suitably equipped
 with  artificial limbs can earn a fair 
wage1 whereas a man who has lost  both  
arms is completely disabled so that he  
cannot even wash or  dress himself4     
,among the amputation cases the         
difference is also  considerable in the 
lower limb1 between amputation through  
the leg  and through the thigh1 and even
 more in the upper limb1 between an     
amputation retaining the movements of   

the elbow and one in which they  are    
lost4 ,there is1 moreover1 a great      
difference in the quality of  stumps and
 the consequent utility of the          
artificial limb4 ,it is of  course      
impossible to allow with mathematical   
precision for all degrees  of           
disablement1 but the several general    
distinctions which we have  enumerated  
could be taken into consideration       
without difficulty4                     
,,index        ,american chuck1 #abb    
,angle at which foot is set1 #cd1 #di   
,appliances for use instead of hand1    
#ajh        with mobile joint1 #abc     
with universal joint1 #abf              
,artificial hand1 #if        spring grip
 thumb1 #ig        automatic thumb1 #ih 
,beaufort thumb1 #ii        for         
commercial travellers1 #ajb             
automatic fingers1 #aje                 
,bearing points1 #f        upon ischium1
 #ac        upon condyles of femur1 #fb 
upon tuberosities of tibia1 #fg         
upon end of leg stump1 #gg              

,bouget1 #ade1 #aea        ,bonreau's   
appliances1 #aab        function of the 
artificial hand1 #aag        hook and   
ring1 #abd        length of artificial  
forearm1 #aah        ,braces for        
suspension of artificial leg1 #bd       
with extending sling1 #dc        for    
amputation below knee1 #gc              
,brunet's grip1 #ajg                    
,brushmaker's hook1 #aai                
,camus1 ,jean1 #adg        ,cardan      
joint1 #abf        ,chauffeur's bell1   
#abe        ,combined mechanism for knee
 and ankle joints1 #ee        ,combined 
suspension for artificial leg1 #bf      
,condyles of femur1 amputation through  
the1 #fj        ,convertible peg leg1   
#eh          ,deltoid muscle1 amputation
 through the1 #adc        ,duplex foot1 
#ed          ,elbow joint1 for above    
elbow amputations1 #acc        for below
 elbow amputations1 #ia        for below
 elbow amputations1 short stumps1 #ie   
for worker's arm1 #aci        ,elephant 
boot1 #gi        ,equilibrium in an     

artificial leg1 #ce          ,federation
 leg1 #cc        ,flexed knee1 walking  
upon the1 #ff        ,foot1             
construction1 #ce        with movable   
ankle1 #ej        with lateral mobility1
 #ed        ,foot1 partial amputation of
 the1 #ha        ,fork rest1 ,raynal's1 
#aji        ,frees' foot and knee1 #eg  
,gripouilleau1 vine-dresser's hook1 #aab
        agricultural hook and ring1     
#abd1 #abf        ploughman's hand1 #ada
        ,guyon's amputation1 #gh        
,hip joint1 disarticulation at the1 #fd 
,hook and ring1 agricultural1 #abd      
,boureau's1 #abd          ,index finger1
 length of1 #ajb          ,knee         
extending mechanism1 #cg                
artificial muscle1 #cg        extending 
sling1 #dc        combined with ankle   
movement1 #ee        ,knee joint1       
amputation through the1 #fj        ,knee
 joint1 for amputation through the leg1 
#gc          ,leather-cutter's hand1    
#aaf        ,leg bucket1 shape of1 #fg  
material1 #fh          ,marks' leg1 #cd 

knee joint1 #da        braces1 #de      
,materials for bucket1 #c        for    
artificial arms1 #hd          ,nov      
,josserand1 #ade1 #aea        ,nyrop's  
grip1 #aba          ,packer's hand1 #aae
        ,peg leg1 #bh        with joint 
at knee1 #bi        with show leg and   
foot1 #ca        conversion into leg    
with free knee joint1 #eh               
,perineal concavity1 #ae                
,plumber's hand1 #aae        ,postman's 
hand1 #aac          ,ratchet at elbow1  
#acc        ,re-education of amputation 
cases1 #ade        ,rotation of         
artificial arm1 prevention of1 #hi      
,shoulder joint1 disarticulation at the1
 #adc        ,spade holder1 #abg        
,stop to limit extension of knee1 #ch   
for amputation below knee1 #gf          
,stump1 length of1 #c        condition  
of allowing end bearing1 #g             
,suspension of artificial arms1 #he1    
#abi        to condyles of humerus1 #he 
to shoulder1 #hg        for worker's    
arm1 #ach        ,syme's amputation1 #gg

          ,thigh bucket1 shape of1 #ac  
wooden1 #ag        leather and steel1   
#bj        for amputation through knee  
joint or condyles1 #fj        ,thigh    
corset1 #gc        ,thumb1 spring grip1 
#ig        automatic1 #ih               
,beaufort1 #ii        ,tram driver's    
bell1 #abe          ,vine-dresser's     
hand1 #aac          ,waist belt1 #bb    
,worker's arm1 #ach            ,printed 
in ,great ,britain for the ,,university 
,,of ,,london            ,,press1 ,ltd41
 by ,,richard ,,clay  ,,sons1 ,ltd41    
,london                                 
and ,bungay4                            
,,the ,,university ,,of ,,london        
,,press1 ,,ltd4       have pleasure in  
announcing the publication of the       
following     series which covers the   
whole field of ,war ,medicine and       
,surgery                                
,,military ,,medical ,,manuals4       ,a
 ,series of handy and profusely         
illustrated manuals translated     from 
the ,french under the general           

,editorship of                          
,,sir ,,alfred ,,keogh1                 
,g4,c4,b41 ,,ll4,d41 ,m4,d41            
,f4,r4,c4,p41 ,hon4 ,f4,r4,c4,s4        
,late ,director-,general ,army ,medical 
,service                                
,,and                       ,lt4-,gen4  
,t4 ,h4 ,j4 ,g4 ,,goodwin               
,c4,b41 ,c4,m4,g41 ,d4,s4,o4            
,director-,general ,army ,medical       
,service       ,each translation has    
been made by a practised hand and is    
edited by a specialist in the branch of 
surgery or medicine     covered by the  
volume4 ,it was felt to be a matter of  
urgent     necessity to place in the    
hands of the medical profession a       
record of the new work and new          
discoveries which the war has           
produced1 and to provide for everyday   
use a series of brief and     handy     
monographs of a practical nature4 ,the  
present series is     the result of this
 aim4 ,each monograph covers one of the 
many     questions at present of        

surpassing interest to the medical      
world1 is written by a specialist who   
has himself been in close     touch with
 the progress which he records in the   
medicine and     surgery of the war4    
,each volume of the series is complete  
in     itself1 while the whole will form
 a comprehensive picture of the         
medicine and surgery of the ,great ,war4
         ,from the ,,british ,,medical  
,,journal3 ,the books are short and     
practical1 and are founded upon the most
 recent clinical and     laboratory     
experience4     ,,the ,,treatment ,,of  
,,infected ,,wounds4 ,by ,a4 ,carrel and
 ,g4 ,dehelly4   ,translated by ,herbert
 ,child1 ,capt4 ,r4,a4,m4,c41 with      
,introduction by ,sir   ,anthony ,a4    
,bowlby1 ,k4,c4,m4,g41 ,k4,c4,v4,o41    
,f4,r4,c4,s41 ,surgeon-,general ,army   
,medical ,service4 ,with #ig            
illustrations in the text and six       
plates4   ,second ,edition1 with        
additions4                              
,price #f_/- net       ,is as fine an   

example of correlated work on the part  
of the     chemist1 the bacteriologist1 
and the clinician as could well     be  
wished for1 and bids fair to become     
epoch-making in the     treatment of    
septic wounds4           ,the cost of   
postage per volume is3 ,inland #e;d42   
,abroad #h;d4                  ,,london3
 ,,university ,,of ,,london ,,press1    
,,ltd41                        #ah1     
,,warwick ,,square1 ,e4,c4#d            
,,military ,,medical ,,manuals          
,,the ,,spectator3 ,it would be hard to 
imagine a better set of     books2 they 
are well written1 well translated1 well 
illustrated1     moderate in length1 and
 moderate in price4       ,,the         
,,psychoneuroses ,,of ,,war4 ,by ,dr4   
,g4 ,roussy1 ,assistant ,professor in   
the ,faculty of ,medicine1 ,paris1 and  
,j4 ,lhermitte1 sometime ,laboratory    
,director in the ,faculty of ,medicine1 
,paris4 ,edited by ,colonel ,william    
,aldren ,turner1 ,c4,b41 ,m4,d41 and    
,consulting ,neurologist to the ,forces 

in   ,england4 ,translated by ,wilfred  
,b4 ,christopherson4 ,with #ac full-page
   plates4                              
,price #f_/- net       ,the             
,psychoneuroses of ,war being a book    
which is addressed     to the clinician1
 the authors have endeavoured1 before   
all     else1 to present an exact       
semeiology1 and to give their work a    
didactic character4 ,after describing   
the general idea of the                 
psychoneuroses and the methods by which 
they are produced1 the     authors      
survey the various clinical disorders   
which have been     observed during the 
war4       ,,the ,,clinical ,,forms ,,of
 ,,nerve ,,lesions 7,vol4 ,i74 ,by ,mme4
 ,athanassio   ,benisty1 ,house         
,physician of the ,hospitals of ,paris  
7,salptrire71   with a ,preface by      
,professor ,pierre ,marie4 ,edited with 
a ,preface by ,e4   ,farquhar ,buzzard1 
,m4,d41 ,f4,r4,c4,p41 ,captain          
,r4,a4,m4,c47,t471 etc4 ,with #ha       
illustrations in the text1 and seven    

full-page plates4   ,price #f_/- net    
,in this volume will be found described 
some of the most recent     acquisitions
 to our knowledge of the neurology of   
war4 ,but     its principal aim is to   
initiate the medical man who is not     
a specialist into the examination of    
nerve injuries4 ,he will     quickly    
learn how to recognise the nervous      
territory affected1     and the         
development of the various clinical     
features2 he will be     in a position  
to pronounce a precise diagnosis1 and to
 foresee     the consequences of this or
 that lesion4       ,,the ,,treatment   
,,and ,,repair ,,of ,,nerve ,,lesions   
7,vol4 ,,ii74 ,by ,mme4   ,athanassio   
,benisty4 ,edited by ,e4 ,farquhar      
,buzzard1 ,m4,d41 ,f4,r4,c4,p41   ,capt4
 ,r4,a4,m4,c47,t471 etc4 ,with #fb      
illustrations in the text and four      
full-page plates4                       
,price #f_/- net       ,this volume is  
the necessary complement of the first4  
,it     explains the nature of the      

lesions1 their mode of repair1     their
 prognosis1 and above all their         
treatment4 ,it provides     a series of 
particularly useful data as to the      
evolution of     nerve-wounds--the      
opportunities of intervention--and the  
prognosis of immediate complications or 
late sequelae4         ,the cost of     
postage per volume is3 ,inland #e;d42   
,abroad #h;d4                           
,,london3 ,,university ,,of ,,london    
,,press1 ,,ltd41                        
#ah1 ,,warwick ,,square1 ,e4,c4#d       
,,military ,,medical ,,manuals          
,the importance of this comprehensive   
series can hardly be     exaggerated4   
,the ,french genius in its application  
to scientific     medicine will be      
discovered here at its best and it will 
be found to be a distinct gain to have  
had this method of     collaboration    
applied to so important an enterprise4  
,,the ,,treatment ,,of ,,fractures4 ,by 
,r4 ,leriche1 ,assistant ,professor in  
the   ,faculty of ,medicine1 ,lyons4    

,edited by ,f4 ,f4 ,burghard1 ,c4,b41   
,m4,s41   ,f4,r4,c4,s41 formerly        
,consulting ,surgeon to the ,forces in  
,france4 ,vol4   ,i4--,fractures        
,involving ,joints4 ,with #ig           
illustrations from original   and       
specially prepared drawings4            
,price #f_/- net       ,the author's    
primary object has been to produce a    
handbook of     surgical therapeutics4  
,but surgical therapeutics does not mean
     merely the technique of operation4 
,technique is1 and should be1     only a
 part of surgery1 especially at the     
present time4 ,the     purely operative 
surgeon is a very incomplete surgeon in 
time     of peace2 in time of war he    
becomes a public disaster2 for          
operation is only the first act of the  
first dressing4       ,vol4             
,,ii4--,fractures of the ,shaft4 ,with  
#aef illustrations from   original and  
specially prepared drawings4            
,price #f_/- net       ,vol4 ,i4 of this
 work was devoted to ,fractures         

,involving     ,joints2 ,vol4 ,,ii4     
7which completes the work7 treats of    
,fractures of the ,shaft1 and is        
conceived in the same     spirit--that  
is1 with a view to the production of a  
work on     conservative surgical       
therapeutics4       ,the author strives 
on every page to develop the idea       
that anatomical conservation must not be
 confounded with     functional         
conservation4 ,the two things are not so
 closely     allied as is supposed4     
,there is no conservative surgery       
save where the function is conserved4   
,the essential point     of the         
treatment of diaphysial fractures       
consists in the     early operative     
disinfection1 primary or secondary1 by  
an     extensive sub-periosteal removal 
of fragments1 based on exact            
physiological knowledge1 and in         
conformity with the general     method  
of treating wounds by excision4 ,when   
this operation has     been carefully   
performed with the aid of the rugine1   

with the     object of separating and   
retaining the periosteum of all that    
the surgeon considers should be removed1
 the fracture must be     correctly     
reduced and the limb immobilised4       
,,fracture ,,of ,,the ,,lower ,,jaw4 ,by
 ,l4 ,imbert1 ,national ,correspondent  
of the   ,socit de ,chirurgie1 and      
,pierre ,ral1 ,dentist to the ,hospitals
 of   ,paris4 ,with a ,preface by       
,medical ,inspector-,general ,fvrier4   
,edited by   ,j4 ,f4 ,colyer1           
,f4,r4,c4,s41 ,l4,r4,c4,p41 ,l4,d4,s4   
,with #ig illustrations in the   text   
and five full-page plates4              
,price #f_/- net       ,previous to the 
present war no stomatologist or surgeon 
possessed any very extensive experience 
of this subject4 ,claude     ,martin1 of
 ,lyons1 who perhaps gave more attention
 to it than     anyone else1 aimed      
particularly at the restoration of the  
occlusion of teeth1 even at the risk of 
obtaining only fibrous     union of the 
jaw4 ,the authors of the present volume 

take the     contrary view1 maintaining 
the consolidation of the fracture     is
 above all the result to be attained4   
,the authors give a     clear account of
 the various displacements met with in  
gunshot     injuries of the jaw and of  
the methods of treatment adopted1 the   
latter being very fully illustrated4    
,the cost of postage per volume is3     
,inland #e;d42 ,abroad #h;d4            
,,london3 ,,university ,,of ,,london    
,,press1 ,,ltd41                        
#ah1 ,,warwick ,,square1 ,e4,c4#d       
,,military ,,medical ,,manuals          
,,the ,,spectator3 ,for our physicians  
and surgeons on active     service      
abroad or in military hospitals at home 
these are the     very books for them to
 dip into1 if not to read through4      
,,fractures ,,of ,,the ,,orbit ,,and    
,,injuries ,,of ,,the ,,eye ,,in ,,war4 
,by ,felix   ,lagrange1 ,professor in   
the ,faculty of ,medicine1 ,bordeaux4   
,translated   by ,herbert ,child1       
,captain ,r4,a4,m4,c4 ,edited by ,j4    

,herbert ,parsons1   ,d4,sc41           
,f4,r4,c4,s41 ,temp4 ,captain           
,r4,a4,m4,c4 ,with #gg illustrations in 
the   text and six full-page plates4    
,price #f_/- net       ,grounding his   
remarks on a considerable number of     
observations1     ,professor ,lagrange  
arrives at certain conclusions which at 
many points contradict or complete what 
we have hitherto     believed concerning
 the fractures of the orbit3 for        
instance1     that traumatisms of the   
skull caused by fire-arms produce1 on   
the vault of the orbit1 neither         
fractures by irradiation nor            
independent fractures2 that serious     
lesions of the eye may often     occur  
when the projectile has passed at some  
distance from it4     ,there are1       
moreover1 between the seat of these     
lesions 7due     to concussion or       
contact7 on the one hand1 and the course
 of     the projectile on the other     
hand1 constant relations which are      
veritable clinical laws1 the exposition 

of which is a highly     original       
feature in this volume4       ,,hysteria
 ,,or ,,pithiatism1 ,,and ,,reflex      
,,nervous ,,disorders4 ,by ,j4          
,babinski1   ,member of the ,french     
,academy of ,medicine1 and ,j4 ,froment1
 ,assistant   ,professor and ,physician 
to the ,hospitals of ,lyons4 ,edited    
with a   ,preface by ,e4 ,farquhar      
,buzzard1 ,m4,d41 ,f4,r4,c4,p41 ,captain
 ,r4,a4,m4,c47,t471   etc4 ,with #cg    
illustrations in the text and eight     
full-page plates4                       
,price #f_/- net       ,the number of   
soldiers affected by hysterical         
disorders is     great1 and many of them
 have been immobilized for months     in
 hospital1 in the absence of a correct  
diagnosis and the     application of a  
treatment appropriate to their case4 ,a 
precise1     thoroughly documented work 
on hysteria1 based on the numerous      
cases observed during two years of war1 
was therefore a     necessity under     
present conditions4 ,moreover1 it was   

desirable1     after the discussions and
 the polemics of which this question    
has been the subject1 to inquire whether
 we ought to return to     the old      
conception1 or whether1 on the other    
hand1 we might not     finally adopt the
 modern conception which refers hysteria
 to     pithiatism4       ,,wounds ,,of 
,,the ,,skull ,,and ,,the ,,brain4      
,clinical forms and medico-surgical     
treatment4 ,by ,c4 ,chatelin and ,t4 ,de
 ,martel4 ,with a ,preface by the       
,professor ,pierre ,marie4 ,edited by   
,f4 ,f4 ,burghard1 ,c4,b41 ,m4,s41      
,f4,r4,c4,s41 formerly ,consulting      
,surgeon to the ,forces in ,france4     
,with #ig   illustrations in the text   
and two full-page plates4      ,price   
#g_/f net       ,of all the medical     
works which have appeared during the    
war1     this is certainly one of the   
most original1 both in form and     in  
matter4 ,it is1 at all events1 one of   
the most individual4     ,the authors   
have preferred to give only the results 

of their     own experience1 and if     
their conclusions are not always in     
conformity with those generally         
accepted1 this1 as ,professor           
,pierre ,marie states in his preface1 is
 because important     advances have    
been made during the last two years2 and
 of this     the publication of this    
volume is the best evidence4            
,the cost of postage per volume is3     
,inland #e;d42 ,abroad #h;d4            
,,london3 ,,university ,,of ,,london    
,,press1 ,,ltd41                        
#ah1 ,,warwick ,,square1 ,e4,c4#d       
,,military ,,medical ,,manuals          
,from ,,the ,,times3 ,a series of really
 first-rate manuals of     medicine and 
surgery 444 the translations are        
admirably made4     ,they give us in    
,english that clearness of thought and  
that     purity of style which are so   
delightful in ,french medical           
literature and are as good in form as in
 substance4       ,,localisation ,,and  
,,extraction ,,of ,,projectiles4 ,by    

,assistant ,professor   ,ombrdanne1 of  
the ,faculty of ,medicine1 ,paris1 and  
,m4 ,ledoux-,lebard1   ,director of the 
,laboratory of ,radiology of the        
,hospitals of ,paris4   ,edited by ,a4  
,d4 ,reid1 ,c4,m4,g41 ,m4,r4,c4,s41     
,l4,r4,c4,p41 ,major 7,temp47           
,r4,a4,m4,c4 ,with a ,preface on        
,extraction of the ,globe of the ,eye1  
by   ,colonel ,w4 ,t4 ,lister1          
,c4,m4,g44 ,with #bbe illustrations in  
the text and   #cj full-page            
photographs4                            
,price #aj_/f net       ,this volume    
appeals to surgeons no less than to     
radiologists4     ,it is a summary and  
statement of all the progress effected  
by     surgery during the last two and a
 half years4 ,,mm4 ,ombrdanne and       
,ledoux-,lebard have not1 however1      
attempted to describe all the           
methods in use1 whether old or new4     
,they have rightly preferred     to make
 a critical selection1 and--after an    
exposition of all     the indispensable 

principles of radiological physics--they
     examine1 in detail1 all those      
methods which are typical1              
convenient1 exact1 rapid1 or interesting
 by reason of their     originality3 the
 technique of localisation1 the compass1
 and     various adjustments and forms  
of apparatus4       ,,wounds ,,of ,,the 
,,abdomen4 ,by ,g4 ,abadie 7of ,oran71  
,national ,correspondent   of the ,socit
 de ,chirurgie4 ,with a ,preface by ,dr4
 ,j4 ,l4 ,faure4 ,edited   by ,sir      
,arbuthnot ,lane1 ,bart41 ,c4,b41       
,m4,s41 ,colonel 7,temp471 ,consulting  
,surgeon to the ,forces in ,england4    
,with #fg illustrations in the text     
and four full-page plates4              
,price #g_/f net       ,dr4 ,abadie has 
been enabled1 at all the stations of the
     army service departments1 to weigh 
the value of methods and     results1   
and considers the following problems in 
this volume3     7#a7 ,how to decide    
what is the best treatment in the case  
of penetrating wounds of the abdomen2   

7#b7 ,how to install the     material   
organisation which permits of the       
application of this     treatment1 and  
how to recognise those conditions which 
prevent     its application2 7#c7 ,how  
to decide exactly what to do in each    
special case--whether one should perform
 a radical operation1     or a          
palliative operation1 or whether one    
should resort to     medical treatment4 
,,wounds ,,of ,,the ,,blood-,,vessels4  
,by ,l4 ,sencert1 ,assistant ,professor 
in   the ,faculty of ,medicine1 ,nancy4 
,edited by ,f4 ,f4 ,burghard1 ,c4,b41   
,m4,s41   ,f4,r4,c4,s41 formerly        
,consulting ,surgeon to the ,forces in  
,france4 ,with #fh   illustrations in   
the text and two full-page plates4      
,price #f_/- net       ,hospital        
practice had long familiarised us with  
the vascular     wounds of civil        
practice1 and the experiments of the    
,val-de-,grce ,school of ,medicine had  
shown us what the wounds     of the     
blood-vessels caused by modern          

projectiles would be in     the next    
war4 ,but in #aiad these data lacked the
 ratification     of extensive practice4
 ,two years have elapsed1 and we have   
henceforth solid foundations on which to
 establish our     treatment4 ,in a     
first part1 ,professor ,sencert examines
 the     wounds of the great vessels in 
general2 in a second part he     rapidly
 surveys the wounds of vascular trunks  
in particular1     insisting on the     
problems of operation to which they give
 rise4         ,the cost of postage per 
volume is3 ,inland #e;d42 ,abroad #h;d4 
,,london3 ,,university ,,of ,,london    
,,press1 ,,ltd41                        
#ah1 ,,warwick ,,square1 ,e4,c4#d       
,,military ,,medical ,,manuals          
,,glasgow ,,herald3 ,the whole series is
 heartily commended to the     attention
 and study of all who are interested in 
and responsible     for the treatment of
 the injuries and diseases of a modern  
war4       ,,the ,,after-,,effects ,,of 
,,wounds ,,of ,,the ,,bones ,,and       

,,joints4 ,by ,aug4 ,broca1   ,professor
 of ,topographical ,anatomy in the      
,faculty of ,medicine1   ,paris4        
,translated by ,j4 ,renfrew ,white1     
,m4,b41 ,f4,r4,c4,s41 ,temp4 ,captain   
,r4,a4,m4,c41 and edited by ,r4 ,c4     
,elmslie1 ,m4,s41 ,f4,r4,c4,s42         
,orthopdic   ,surgeon to ,st4           
,bartholomew's ,hospital1 and ,surgeon  
to ,queen ,mary's   ,auxiliary          
,hospital1 ,roehampton2 ,major          
,r4,a4,m4,c47,t47 ,with #aab            
illustrations in the text4              
,price #f_/- net       ,this new work1  
like all books by the same author1 is a 
vital and     personal work1 conceived  
with a didactic intention4 ,at a time   
when all physicians are dealing1 or will
 shortly have to deal1     with the     
after-effects of wounds received in war1
 the question     of sequelae presents  
itself1 and will present itself more and
     more4 ,what has become--and what   
will become--of all those who1     in   
the hospitals at the front or in the    

rear1 have hastily     received initial 
treatment1 and what is to be done to    
complete a     treatment often          
inaugurated under difficult             
circumstances8       ,,artificial       
,,limbs4 ,by ,a4 ,broca1 ,professor in  
the ,faculty of ,medicine1   ,paris1 and
 ,dr4 ,ducroquet1 ,surgeon at the       
,rothschild ,hospital4 ,edited   and    
translated by ,r4 ,c4 ,elmslie1 ,m4,s41 
,f4,r4,c4,s41 etc42 ,orthopdic          
,surgeon to ,st4 ,bartholomew's         
,hospital1 and ,surgeon to ,queen       
,mary's   ,auxiliary ,hospital1         
,roehampton2 ,major ,r4,a4,m4,c47,t474  
,with #baj   illustrations4             
,price #f_/- 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 anatomical1          
physiological1 practical and technical  
conditions which an artificial arm or   
leg should fulfil4     ,it is1 if we may
 so call it1 a manual of applied        

mechanics     written by physicians1 who
 have constantly kept in mind the       
anatomical conditions and the           
professional requirements of the        
artificial limb4       ,,typhoid        
,,fevers ,,and ,,paratyphoid ,,fevers   
7,symptomatology1 ,etiology1            
,prophylaxis74 ,by ,h4 ,vincent1        
,medical ,inspector of the ,army1       
,member   of the ,academy of ,medicine1 
and ,l4 ,muratet1 ,superintendent of the
   ,laboratories at the ,faculty of     
,medicine of ,bordeaux4 ,second         
,edition4   ,translated and ,edited by  
,j4 ,d4 ,rolleston1 ,m4,d4 ,with tables 
and   temperature charts4               
,price #f_/-net       ,this volume is   
divided into two parts1 the first       
dealing with     the clinical features  
and the second with the epidemiology    
and prophylaxis of typhoid fever and    
paratyphoid fevers ,a and     ,b4 ,a    
full account is to be found of recent   
progress in the     bacteriology and    
epidemiology of these diseases1         

considerable     space being given to   
the important question of the carrier in
     the dissemination of infection4    
,the cost of postage per volume is3     
,inland #e;d42 ,abroad #h;d4            
,,london3 ,,university ,,of ,,london    
,,press1 ,,ltd41                        
#ah1 ,,warwick ,,square1 ,e4,c4#d       
,,military ,,medical ,,manuals          
,from ,,the ,,lancet3 ,the names of the 
editors are sufficient     guarantee    
that the subject matter is treated with 
fairness and     discrimination4        
,,dysenteries1 ,,cholera1 ,,and         
,,exanthematic ,,typhus4 ,by ,h4        
,vincent1 ,medical   ,inspector of the  
,army1 ,member of the ,academy of       
,medicine1 and ,l4   ,muratet1          
,superintendent of the ,laboratories at 
the ,faculty of ,medicine   of          
,bordeaux4 ,with an ,introduction by    
,andrew ,balfour1 ,c4,b41 ,c4,m4,g41    
,m4,d41 ,lieut4-,col4 ,r4,a4,m4,c4      
,edited by ,george ,c4 ,low1 ,m4,a41    
,m4,d41 ,temp4   ,capt4 ,i4,m4,s4       

,price #f_/- net       ,this1 the second
 of the volumes which ,professor        
,vincent and     ,dr4 ,muratet have     
written for this series1 was planned1   
like     the first1 in the laboratory of
 ,val-de-,grce1 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 enriched4 ,it will
 be all the more welcome1 as hitherto   
there has existed no comprehensive      
handbook treating these great           
epidemic diseases from a didactic point 
of view4       ,,abnormal ,,forms ,,of  
,,tetanus4 ,by ,,mm4 ,courtois-,suffit1 
,physician of the   ,hospitals of       
,paris1 and ,r4 ,giroux1 ,resident      
,professor4 ,with a ,preface   by       
,professor ,f4 ,widal4 ,edited by       
,surgeon-,general ,sir ,david ,bruce1   
,k4,c4,b41 ,f4,r4,s41 ,,ll4,d41         
,f4,r4,c4,p41 etc41 and ,frederick      
,golla1 ,m4,b4                          
,price #f_/- net       ,of all the      

infections which threaten our wounded   
men1 tetanus is     that which1 thanks  
to serotherapy1 we are best able to     
prevent4     ,but serotherapy1 when it  
is late and insufficient1 may1 on       
the other hand1 tend to create a special
 type of attenuated     and localised   
tetanus2 in this form the contractions  
are as a     general rule confined to a 
single limb4 ,this type1 however1       
does not always remain strictly         
monoplegic2 and if examples     of such 
cases are rare this is doubtless because
 physicians     are not as yet very well
 aware of their existence4 ,we owe to   
,,mm4 ,courtois-,suffit and ,r4 ,giroux 
one of the first and most     important 
observations of this new type2 so that  
no one was     better qualified to      
define its characteristics4 ,this they  
have done in a remarkable manner1       
supporting their remarks by     all the 
documents hitherto published1 first     
expounding the     characteristics which
 individualise the other atypical and   

partial types of tetanus1 which have    
long been recognised4       ,,war       
,,otitis ,,and ,,war ,,deafness4        
,diagnosis1 ,treatment1 ,medical        
,reports4   ,by ,dr4 ,h4 ,bourgeois1    
,oto-rhino-laryngologist to the ,paris  
,hospitals1   and ,dr4 ,sourdille1      
former interne of the ,paris ,hospitals4
 ,edited by ,j4   ,dundas ,grant1       
,m4,d41 ,f4,r4,c4,s47,eng472 ,major     
,r4,a4,m4,c41 ,president1 ,special      
,aural ,board 7under ,ministry of       
,pensions74 ,with many illustrations in 
the text and full-page plates4          
,price #f_/- net       ,this work       
presents the special aspects of         
inflammatory     affections of the ear  
and deafness1 as they occur in active   
military service4 ,the instructions as  
to diagnosis and treatment     are      
intended primarily for the regimental   
medical officer4 ,the     sections      
dealing with medical reports            
7expertises7 on the     valuation of    
degrees of disablement and claims to    

discharge1     gratuity or pension1 will
 be found of the greatest value to the  
officers of invaliding boards4          
,the cost of postage per volume is3     
,inland #e;d42 ,abroad #h;d4            
,,london3 ,,university ,,of ,,london    
,,press1 ,,ltd41                        
#ah1 ,,warwick ,,square1 ,e4,c4#d       
,,military ,,medical ,,manuals          
,,guy',s ,,hospital ,,gazette3 ,the     
series is a most valuable addition      
to the medical literature of the war4444
 ,we deem it to be almost               
indispensable to a medical officer1 and 
have no hesitation in     unreservedly  
recommending it4       ,,syphilis ,,and 
,,the ,,army4 ,by ,g4 ,thibierge1       
,physician of the ,hpital               
,saint-,louis4 ,edited by ,c4 ,f4       
,marshall1 ,f4,r4,c4,s4          ,price 
#f_/- net       ,it seemed1 with reason1
 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 war4 ,the     frequency of this 
infection in the army1 among the workers
 in     munition factories1 and in the  
midst of the civil population     where 
this is in contact with soldiers and    
mobilised workers1     makes it1 at the 
present time1 a true epidemic disease1  
and one     of the most widespread of   
epidemic diseases4 ,dr4 ,thibierge1     
whose previous labours guarantee his    
peculiar competence in     these        
difficult and important questions1 has1 
in writing this     manual1 very notably
 assisted in this work4 ,but the        
treatment of     syphilis has1 during   
the last six years1 undergone           
considerable     modifications2 the new 
methods are not yet very familiar to all
     physicians2 and certain details may
 no longer be present to     their      
minds4 ,it was therefore opportune to   
survey the different     methods of     
treatment1 to specify their indications1
 and their     occasionally difficult   
technique1 which is always important if 

complications are to be avoided4 ,it was
 necessary before all     to state      
precisely and to retrace1 for all those 
who have been     unable to follow the  
recent progress of the therapeutics of  
venereal diseases1 the characters and   
the diagnostic elements of     the      
manifestations of syphilis4             
,,malaria ,,in ,,macedonia3 ,clinical   
and ,hmatological ,features4 ,principles
   of ,treatment4 ,by ,p4               
,armand-,delille1 ,p4 ,abrami1 ,g4      
,paisseau and ,henri   ,lemaire4        
,preface by ,professor ,lavern1 ,membre 
de l',institut4 ,edited by   ,sir       
,ronald ,ross1 ,k4,c4,b41 ,f4,r4,s41    
,,ll4,d41 ,d4,sc41 ,lieut4-,col4        
,r4,a4,m4,c4   ,with illustrations and a
 coloured plate4                 ,price 
#f_/- net       ,this work is based on  
the writers' observations on malaria in 
,macedonia during the present war in the
 ,french ,army of the     ,east4 ,a     
special interest attaches to these      
observations1 in     that a considerable

 portion of their patients had never had
 any     previous attack4 ,the disease  
proved to be one of exceptional         
gravity1 owing to the exceptionally     
large numbers of the     ,anopheles     
mosquitoes and the malignant nature of  
the parasite     7,plasmodium           
falciparum74 ,fortunately an ample      
supply of quinine     enabled the       
prophylactic and curative treatment to  
be better     organised than in previous
 colonial campaigns1 with the result    
that1 though the incidence of malaria   
among the troops was high1     the      
mortality was exceptionally low4        
,professor ,laveran1 who     vouches for
 this book1 states that it will be found
 to contain     excellent clinical      
descriptions and judicious advice as to 
treatment4 ,chapters on parasitology and
 the laboratory diagnosis     of malaria
 are included4     ,an early            
announcement will be made in regard to  
further volumes under                   
consideration4         ,the cost of     

postage per volume is3 ,inland #e;d42   
,abroad #h;d4                           
,,london3 ,,university ,,of ,,london    
,,press1 ,,ltd41                        
#ah1 ,,warwick ,,square1 ,e4,c4#d       
,transcriber's ,note3    #a4 ,all       
obvious spelling and punctuation errors 
have been corrected4    #b4 ,italics are
 shown as text and bold as text4