1 20 142 http://23.254.134.177/the.oandplibrary.org/files/original/2004b9922067489189c4d3ae92485e41.pdf b5adf4cefb2c7793eaa0d0c236efe080 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Artificial Limbs: A Review of Current Developments Description An account of the resource The foundation of modern prosthetics can be directly traced to the coordinated efforts of the National Academy of Sciences under the various artificial limbs committees after the Second World War. America, at its height of post war efficiency and engineering acumen, set about to solve the burgeoning problem of amputees swelling an infrastructure of prosthetic delivery that was outmoded, outdated and unprepared. Artificial Limbs: A Review of Current Developments was an industry update of these research efforts and was published thirty-three times, spanning the years 1954 to 1972. DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_02_001.pdf Year 1954 Volume 1 Issue 2 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_02_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Limbs in Limbo</h2> <h5>Herbert Elftman, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>To stand on his feet and to walk with his legs wherever his heart desires are natural rights guaranteed to man by his own constitution. Heads may plan and hands may build, but only where legs and feet have brought them. Loss of the lower limb is therefore a major catastrophe.</p> <p>When loss of leg occurs, replacement becomes the primary hope. Ages past, an unknown man hobbled forth from his cave in search of a willow; with one of its limbs adopted as his own, he walked back with majesty. Since then the stage of history has resounded with the staccato echo of countless amputees marching with peg-leg, grit, and gumption.</p> <p>Rapid perfection of limb construction was to be anticipated after these early ventures had focused human ingenuity upon the problem. To the superlative talent which mankind has shown in the production of machinery both intricate and sturdy, the building of a mechanical leg would appear to offer little difficulty. Why is it, then, that artificial limbs have so generally belonged to the limbo of things undeserving either of unstinted praise or of utter condemnation? Failure of artificial legs to satisfy our hopes results less from the imperfection of their mechanisms than from the extravagance of our expectations. People who do not expect a glass eye to see or a prosthetic hand to play the piccolo are disappointed when an artificial leg squeaks while dancing the polka. Man has never commanded clear appreciation of his means of locomotion. From time to time he has been ecstatic about the eye and the liver, the heart, the brain, the hand. Legs have been referred to most frequently as symbols of neighboring functions, so lightly have their own merits been regarded.</p> <p>Why is the performance of the lower extremity so much less spectacular than that of the upper? Independence of the upper limb from obligation to the rest of the body allows it to indulge in ornamentation of movement, so impressive to the eye. The lower limb, sandwiched between the ground and the torso, must ever be responsive to the needs of the body as a whole. It cannot choose to support some parts of the body and not others or to walk with the body through only portions of each step. The intricacy of function of knee and ankle does not exhibit itself in capricious movements but excels when it modulates countless disturbing factors so that no tremor mars the stark simplicity of normal locomotion.</p> <p>No one can rightly expect an artificial limb to take over completely the functions of its predecessor unless it is endowed with an equivalent of muscular and nervous control. Difficult as it is to provide substitutes for bones and joints, such provision is simplicity itself compared with the incorporation within the prosthesis of its own control. Although considerable progress has been made in the field of decelerating mechanisms for lower-extremity prostheses, the leg amputee must still use his own resources when he needs to supply energy or to exercise discretion.</p> <p>The contribution which the amputee makes to the over-all prosthetic result far exceeds that of acting as a model for exhibiting the achievements of inventors. It is he who must finish creation of the new locomotor mechanism by reshaping the pattern of his muscular activity and establishing alertness to new sensory cues. The success of the artificial leg depends on how thoroughly it becomes a part of the form and the function of the amputee after he has blended its metal, wood, and plastic with his muscle and perception. It is only appropriate that the new mechanism, having superseded the natural limb, should contribute to amputee gait that special accent which identifies the supernatural walk.</p> <p>The complexity of human motion makes it inevitable that fundamental improvement in leg prostheses must come slowly, since it is based on factors so numerous that no one individual can comprehend them all. In addition to the profession of engineering, there is needed the cooperation of the physician, the physicist, the physiologist, the physiotherapist, the prosthetist, and the psychologist-to list them in alphabetical order—so that the patient may get the total care he deserves.</p> <p>The problems which need attention are of different degrees of complexity and must be approached by different methods. Choice of materials, details of construction, and provisions for repair require less consideration of the over-all characteristics expected in the rehabilitated amputee than do problems of fit and socket shape. More general considerations must be weighed in projects concerned with alignment, basic design of mechanisms, and evaluation of performance. For these there should be a conscious choice of a realizable objective, the attainment of which requires integration of man and machine into a functional unit.</p> <p>All of these are practical problems amenable to increasingly useful solutions year by year, provided we do not surrender to the impatience of those who must have the answer to the question of the century today and of the millennium tomorrow. It is necessary to preserve clear vision of long-term objectives, although some members of every team find the environment more familiar when details arise.</p> <p>Had trial-and-error and serendipity been able to produce truly satisfactory lower limbs, we would not still be waiting for such. It was left for the National Academy of Sciences-National Research Council to initiate the development of artificial limbs on a modern basis by creating the Committee on Prosthetic Devices and, later, its successor, the Advisory Committee on Artificial Limbs. By carefully balancing the fundamental and the practical in their program, these Committees have laid a firm basis for some progress today, much more tomorrow.</p> <p>This is the key to the future in lower-extremity prosthetics. Used wisely, it will allow us eventually to rescue the limb problem from limbo and to provide the amputee of the future with a fitting legacy.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Herbert Elftman, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Associate Professor of Anatomy, College of Physicians and Surgeons, Columbia University; member, Lower-Extremity Technical Committee, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Limbs in Limbo Creator An entity primarily responsible for making the resource Herbert Elftman, Ph.D. * http://23.254.134.177/the.oandplibrary.org/files/original/708fa372e3aa806c06ea2cec87c6d54d.pdf 9a1fac5f9d62e7f6b1c6180a01f964f8 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Artificial Limbs: A Review of Current Developments Description An account of the resource The foundation of modern prosthetics can be directly traced to the coordinated efforts of the National Academy of Sciences under the various artificial limbs committees after the Second World War. America, at its height of post war efficiency and engineering acumen, set about to solve the burgeoning problem of amputees swelling an infrastructure of prosthetic delivery that was outmoded, outdated and unprepared. Artificial Limbs: A Review of Current Developments was an industry update of these research efforts and was published thirty-three times, spanning the years 1954 to 1972. DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_01_001.pdf Year 1954 Volume 1 Issue 1 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Artificial Limbs-Today and Tomorrow</h2> <h5>F. S. Strong, Jr. <a style="text-decoration:none;">*</a><br /></h5> <p>Ours is an age of scientific research and development in almost every field of human interest. Some work to make man live longer, to make him more comfortable, more mobile, more informed. Some devise ways to maim or destroy him. This report and others to follow will tell the story of those who strive to replace what war, accident, or disease have removed, or what nature simply failed to provide. This is concerned with what modern science and engineering skill can do today-and what may be expected in the future-for the person in need of a substitute for normally standard equipment-an artificial limb for a missing arm or leg.</p> <p>From the dawn of history men have contrived replacements for lost extremities, particularly the lower. The loss of an arm, while causing inconvenience, has not resulted generally in serious handicap. But without a leg, a man becomes immobilized. Thus, over the years there has come about a considerable development until today some of the better types of artificial legs afford reasonably satisfactory service, always provided they are well fitted and aligned by qualified prosthetists. The same has not been true of upper-extremity devices. And so when young men returned from World War II with missing limbs, while the lower-extremity amputee could expect a replacement of some merit, the man who needed an arm was definitely in trouble. As a matter of fact, the entire field of artificial limbs needed serious attention to bring amputee service more in line with the scientific and engineering progress which has become synonymous with America in the modern world.</p> <p>To meet this need, not only for the benefit of veteran amputees, but also to help all similarly handicapped individuals everywhere, a program was established at the end of the war under the sponsorship of the Armed Services and the Veterans Administration and was later implemented on a permanent basis by the Eightieth Congress through Public Law 729. This act authorizes the expenditure of $1,000,000 annually "to aid in the development of improved prosthetic appliances ..." and designates the Veterans Administration as the appropriate agency for the administration of the funds thus made available.</p> <p>The activities encompassed within the framework of these endeavors have come to be known as the Artificial Limb Program. And since the field, though serving less than a million persons, of whom only some 27,000 are veterans, involves the cooperation of several scientific disciplines as well as various organizations both civil and military, a special structure had to be contrived for successful operation. This was done through a contract between the Veterans Administration and the National Academy of Sciences, by means of which an Advisory Committee on Artificial Limbs of the National Research Council has been established for general supervision and coordination, and through other contracts between the Veterans Administration and various educational and industrial organizations for research and development. In addition the Surgeons-General of the Army, Navy, and Air Force, and the Chief Medical Director of the Veterans Administration, have made available the services of certain laboratories and personnel in further support of the over-all program. While in the early stages of this undertaking, it was necessary to proceed generally on a broad front in order to explore and define the complete problem so that at one time as many as sixteen contracts were in force, at present the number has been reduced to three only, and an operational structure has been evolved through which a long-range plan can be followed with reasonable hope of success</p> <p>The word "prosthetics" has been found a convenient term to define the general field of amputee service. Since the problems of replacement in the lower extremity are quite different from those in the upper, the field is divided into two parts. Lower-extremity research and development are centered at the University of California, Berkeley Campus, while upper-extremity studies are similarly covered at the University of California at Los Angeles, all under a contract between the Veterans Administration and the University. Assisting in lower extremities is the Oakland Naval Hospital Artificial Limb Department while the Army Prosthetics Research Laboratory at Walter Reed Army Medical Center cooperates in the development of artificial arms and terminal devices Finally, through a contract with New York University, and with the cooperation of the VA Prosthetic Testing and Development Laboratory in New York well-defined methods of testing and field application assure that devices and techniques developed under the program are, before acceptance, in fact useful improvements in amputee rehabilitation.</p> <p>For general technical guidance in these two branches, standing committees, in lower- and upper-extremity prosthetics respectively, have been constituted, each composed of specialists in the fields of medicine, engineering, prosthetics, and the like, and each under the chairmanship of the leader of the appropriate University of California research project. These groups meet annually, or more frequently if necessary, to review progress, define requirements, and recommend action to the Advisory Committee on Artificial Limbs, to the artificial-limb industry, or to others interested in amputee rehabilitation problems. In addition smaller research and development panels have been appointed from these technical committees to supervise current activities between meetings of the larger groups. In this work, definite transition procedures have been adopted for orderly progress from the inception of ideas for improved devices and techniques to their final application in the limbshop or rehabilitation clinic.</p> <p>By these methods the results of some eight years of research and development are now being channeled as directly as practicable to the service of amputees, rather than indirectly merely through the issuance of reports or through publication in scientific journals. In order that physicians, prosthetists, rehabilitation specialists, insurance carriers, and other interested individuals and organizations may be informed of advances in this field as promptly as possible, this series of reports is being undertaken. While the Advisory Committee on Artificial Limbs has previously issued monthly progress reports on a limited basis to those immediately concerned, and although the various contractors and governmental laboratories associated with the program have contributed reports and other data on specific subjects, this will be the first organized attempt to disseminate timely information to a broad list of individuals and institutions interested in the rehabilitation of the amputee. This is being done in furtherance of the intent of the Congress which, in Public Law 729, authorizes the Administrator of Veterans' Affairs "to make available the results of his investigations to private or public institutions or agencies and to individuals in order that the unique investigative materials and research data in the possession of the Government may result in improved prosthetic appliances for all disabled persons."</p> <p>In offering these reports to the reader who has not been in a position to follow recent progress in this field as unfolded through the Artificial Limb Program it can be stated that the views and information to be set forth in this and Subsequent issues are the result of long and objective study by specialists in the various branches of science and engineering involved. These findings, therefore, can be accepted with considerable confidence as indications not only of the present state of the art but also as to future trends And where these findings may appear at variance with previous traditional concepts or the writings of earlier authorities, it can be said simply that the field of prosthetics is even today largely uncharted and untraversed-that it is a field where the marvels of modern science and engineering have yet to leave their mark.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>F. S. Strong, Jr. </b></td></tr><tr><td class="clsTextSmall">Executive Director, Advisory Committee on Artificial Limbs, National Research Council.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Artificial Limbs-Today and Tomorrow Creator An entity primarily responsible for making the resource F. S. Strong, Jr. * http://23.254.134.177/the.oandplibrary.org/files/original/75dc06cd0cb2f16f20c55049bd0bdbc7.pdf f76171ab4432c6a50cf6f259be7af891 http://23.254.134.177/the.oandplibrary.org/files/original/d81d51673f68ef5fe93f7930d455e5f8.jpg 7008a305e99a0abc591c52fc2411bb17 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Artificial Limbs: A Review of Current Developments Description An account of the resource The foundation of modern prosthetics can be directly traced to the coordinated efforts of the National Academy of Sciences under the various artificial limbs committees after the Second World War. America, at its height of post war efficiency and engineering acumen, set about to solve the burgeoning problem of amputees swelling an infrastructure of prosthetic delivery that was outmoded, outdated and unprepared. Artificial Limbs: A Review of Current Developments was an industry update of these research efforts and was published thirty-three times, spanning the years 1954 to 1972. DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_02_004.pdf Year 1954 Volume 1 Issue 2 Page Number(s) 4 - 7 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_02_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_02_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Objectives of the Lower-Extremity Prosthetics Program</h2> <h5>Howard D. Eberhart, M.S. <a style="text-decoration:none;">*</a><br /></h5> <p>Man depends upon his legs to support the body and to move it from place to place as occasion warrants. Since mobility is nearly indispensable to most human activities, the loss of part or all of a leg—through accident, war, or disease—imposes serious limitations and has always made a replacement of some sort more or less of a necessity. Accordingly, artificial legs of one kind or another have been made and used since the most ancient times. As a result of the long-continued effort, leg prostheses have undergone progressive, if slow, development through the centuries, so that many lower-extremity amputees have in the past been successfully restored to something resembling a normal life. With the advent of industrial development, and of improved tools and materials with which to work, the nineteenth century marked the appearance of many new lower-extremity devices and of new techniques in the medical treatment of amputations.</p> <p>Impetus provided by World Wars I and II gave rise to rapid advancement in all branches of technology and thus made possible a concerted attack on the problem of supplying the best possible artificial limbs. The term "lower-extremity prosthetics" has now come to mean the practice of rehabilitation of the leg amputee by providing him with an artificial limb that will restore lost functions to the greatest possible degree. But more than just the artificial leg is involved. The amputee himself is a most important part of the end-product, and amputees, like other people, are individuals with widely differing characteristics and abilities. Of course surgical procedures should be designed to secure a painless stump and to retain maximum function, and it would seem that the artificial leg, when properly fitted, should duplicate as closely as possible the normal activity of the lost part. Moreover, physical conditioning and gait training are both important phases of the whole rehabilitation process.</p> <p>This concept of lower-extremity prosthetics has developed during the years since the start in 1945 of the program of the Advisory Committee on Artificial Limbs, National Research Council. Initially, the primary objective was to develop improved devices, it being considered as obvious that, if a better prosthetic knee or ankle or foot could be devised, the amputee would benefit. Attempts to produce such items, however, made necessary the determination of functional requirements and thus immediately revealed the lack of necessary fundamental information. Basic research into the complicated phenomenon we call "locomotion" was therefore carried on simultaneously with the development of devices.<a style="text-decoration:none;">*</a> These investigations indicated a need for the application of basic mechanical principles to fitting and alignment of artificial legs. A three-pronged approach, all parts of which are complex and interrelated in various ways, has thus evolved. Basically, the three objectives are:</p> <ol> <li>To extend knowledge of the amputee, of lost and remaining functions affecting locomotion, and to collect information on the best possible medical treatment.</li><li>To improve fitting techniques and practices, including training, so that existing devices might be used with greater comfort and function.</li><li>To develop improved lower-extremity devices.</li></ol> <p>Relative emphasis on these three phases is shown in <b>Fig. 1</b>. Implied in such a program is the dissemination of information and techniques to those who serve the amputee. Many of the accomplishments to date are recorded, and fully documented with the report literature, in Klopsteg and Wilson's <i>Human Limbs and Their Substitutes </i>(McGraw-Hill, in press). In addition, various seminars and short courses for surgeons and prosthetists have been conducted throughout the program.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Trends in the lower-extremity prosthetics program, 1945-54, projected through 1956 </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Fundamental Studies</h3> <p>Detailed and comprehensive study of normal human locomotion is the basic key to improvement in all phases of the lower-extremity problem. Walking is to all appearances so natural and simple a process that it is difficult to conceive of its complexity. A knowledge of the behavior and the contribution of each anatomical part in providing the many services required of legs in normal use is essential to determine the functions that have been lost through amputation and the functions that still remain. The surgeon needs such information in order to provide the best amputation stump with maximum remaining function. The prosthetist must understand the limitations and potentialities of the amputee-prosthesis combination for optimum fitting, alignment, and adjustment. The designer needs detailed information on angles, displacements, velocities, accelerations, forces, energy requirements, and functions in order to improve existing devices and to develop new ones. And finally, the amputee himself has problems that require a fundamental approach. Causes and treatment of phantom or other pain, circulatory difficulties resulting from amputation, skin tolerance to pressure in areas never intended for such use, as well as the better understanding of the psychological problems of the amputee are examples of important areas of investigation.</p> <p>The objectives of the program of fundamental studies of the lower extremity may be summarized as:</p> <ol> <li>To study the phenomenon of locomotion in a sample of normal individuals and to analyze the results for use by the surgeon, the designer, and the prosthetist.</li><li>To develop design criteria for new or improved devices and as a basis for evaluating existing devices.</li><li>To develop an understanding of the compensatory mechanism of the human body and its ability to adapt itself to overcome functional deficiencies of its parts.</li><li>To provide a frame of reference for evaluating the degree of success obtained in replacing lost functions by means of an artificial leg.</li><li>To obtain information on the cause and possible treatment of phantom pain and other medical problems of the amputee.<a style="text-decoration:none;">*</a></li></ol> <h3>Development of Techniques of Fitting and Alignment</h3> <p>It appears obvious that, no matter to what degree an artificial leg is perfected mechanically, its effectiveness will depend upon the comfort afforded the wearer. Comfort is a function of the fit and alignment of the prosthesis.</p> <p>Although the artificial-limb industry has, through the years, developed reasonably successful techniques for fitting and aligning artificial legs, the results have been obtained mostly by trial-and-error methods; seldom have basic mechanical and anatomical principles been employed. It was found, for instance, that even among the most successful prosthetists there existed little agreement as to what constituted a satisfactory fit. For these reasons it appeared necessary to include in the lower-extremity program a project to develop fitting and alignment techniques based on sound scientific principles and to include, if necessary, the development of auxiliary tools and a study of materials and of methods of suspension.</p> <p>The study was launched with the following objectives in mind:</p> <ol> <li>To learn from the artificial-limb industry the procedures used in fitting and alignment of artificial legs.</li><li>To work with the industry in applying fundamental principles to the problem of fit and alignment and to formulate the guiding principles involved.</li><li>To develop mechanical aids to improve fit and alignment and to serve as tools to simplify shop operations.</li><li>To investigate and evaluate types of suspension as well as materials and methods used in socket fabrication.</li><li>To develop simplified methods of evaluating the amputee-limb combination-to be used as a check by the prosthetist, the surgeon, and the physiotherapist.</li><li>To improve methods of training the lower-extremity amputee in order to get better functional and more effective use of his prosthesis.</li></ol> <p>Out of this study have come such developments as the introduction of the above-knee suction socket and the University of California adjustable legs and alignment duplication jig. The study of fitting and alignment continues at the University of California, Berkeley Campus.</p> <h3>Development of Prosthetic Devices</h3> <p>New and improved devices have always been a major objective of the ACAL program. Great effort has been expended in this direction, often without the necessary or valid criteria. Although engineering designs can be made to accomplish nearly any specified function, the end result of any given design may be unsatisfactory if the specifications were unrealistic. The device may be too complicated, too heavy, uneconomical for the improvements obtained—or it may actually interfere with some service functions though improving others. Since the beginning of the ACAL research program, a number of outstanding industrial firms have engaged in development of devices. As a result of these activities, a great deal has been learned about what is possible—and about what <i>not </i>to do. Together with the fundamental studies, a body of knowledge has been developed to provide a realistic approach to design criteria. A number of devices based on this information are now in the development stage; they show promise for the future.</p> <p>Criteria for improved knee joints for above-knee amputees have undergone great changes as fundamental knowledge of locomotion has increased and as various knees, alleged to be improved ones, have been tested on amputees. Similarly, dependence of knee performance on ankle function, fit and alignment, training, and total coordination is becoming better understood. In the light of present knowledge, it seems clear that "super-devices" are not apt to be the solution to improved artificial legs and that considerations of natural appearance, minimum energy consumption, and simplicity of mechanism for maintenance and economy will in the end be the controlling factors. Of course no device should be made available for general distribution until it has been checked thoroughly for function, strength, maintenance requirements, life expectancy, and adaptability to different types of amputees. A complete testing program has there- fore been established under the direction of New York University to ensure the adequacy of each device approved under the program.</p> <p>Present objectives for the development of prosthetic devices may be stated as:</p> <ol> <li>To invent new mechanisms, improve and adapt existing mechanisms, and apply new materials so as to add functions, or to improve presently provided functions of prostheses, seeking in the end to provide better devices to meet the needs of every amputee type.</li><li>To perfect those functions involved in level walking, with the best possible solution for oilier services such as sitting down, walking on slopes and stairs, etc.</li><li>To adapt devices that take advantage of remaining functions in the amputee's stump.</li><li>To increase stability during the weight-bearing phase but to reduce the energy requirement during transition as well as during the entire cycle of walking.</li></ol> <h3>Clinical Study</h3> <p>Throughout the program, amputees have been fitted with experimental prostheses in order to conduct studies, trials, and tests of the equipment. Techniques and practices involved in fitting amputees are so varied, however, that some orderly means of investigating these areas became necessary. Accordingly, in 1952 a program of clinical studies was established under the project at the University of California, Berkeley, in space at the Artificial Limb Shop of the U. S. Naval Hospital at Oakland, California. Here an orderly approach can be made to a review and formulation of best practice in lower-extremity prescription, fabrication, fitting and alignment, and training in the use of the prosthesis. Complete documentation of each step in the process, as applied to a variety of amputee types, under the supervision of an advisory panel and with the cooperation of members of the limb industry in the San Francisco Bay-Area, will serve to close the gap between fundamental work in the laboratory and practice in the field. Besides this, it will serve to supply source material for the information of the various professions involved in physical rehabilitation of the amputee as well as to define areas where more information or new devices are required.</p> <p>In addition to establishing what is the best prosthetic practice, the objective of the clinical study is to develop, for distribution to each member of the rehabilitation team, including the amputee, information such as:</p> <ol> <li>Medical data for use by the surgeon in connection with amputee problems.</li><li>Criteria for use in proper prescription of a prosthesis.</li><li>Principles and practices of fabrication, fitting, and alignment of a prosthesis.</li><li>Suggested means of evaluating prosthesis and amputee, Including gait analysis, performance checks, and achievement tests for use by the prosthetist, the surgeon, and the physical therapist.</li><li>Suggested curriculum for training the amputee in the use of his prosthesis.</li><li>A comprehensive list of specific prosthetic appliances and devices, with descriptions of their individual characteristics and functions, for use in preparing prescriptions.</li><li>Suggested curriculum for training the prosthetist, the surgeon, and other members of the clinic team in lower-extremity prosthetics.</li><li>Data useful to the research and development laboratories in continuing their studies.</li></ol> <h3>Future Program</h3> <p>The investigation and development involved in a lower-extremity prosthetics program are complicated and time-consuming. And since it appears impossible to reach the ultimate goal of replacement of all functions that have been lost, the task must be considered as never-ending. For the immediate future it is contemplated that development of devices, the clinical study, fitting and alignment studies, and fundamental research will continue. The relative emphasis on each phase is projected on <b>Fig. 1</b> through 1956.</p> <p>As progress is reflected in the results of the clinical study, some means must be developed for effectively transmitting this information to orthopedic clinic teams throughout the nation. Whether this is to be accomplished periodically at a central location, or whether through field teams on a continuing basis, will depend to a large extent upon the results obtained in the clinical study during the coming year. Whatever method evolves, every effort will be made to ensure that any useful information is disseminated to the field as quickly and efficiently as possible.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">It should be noted that the work on phantom pain is applicable to both upper- and lower-extremity amputations.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">A more logical and systematic approach, had there been sufficient time, might have been to postpone device development until the results of the basic work became available. But the urgency of amputee demands at the end of World War II made such an approach less desirable than the one adopted.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Howard D. Eberhart, M.S. </b></td></tr><tr><td class="clsTextSmall">Professor of Civil Engineering, University of California, Berkeley; member, Advisory Committee on Artificial Limbs, National Research Council; chairman, Lower-Extremity Technical Committee, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_02_004/May-1954OCRBatch1-1.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Objectives of the Lower-Extremity Prosthetics Program Creator An entity primarily responsible for making the resource Howard D. Eberhart, M.S. * http://23.254.134.177/the.oandplibrary.org/files/original/b76e176eea5ade74fc19b1a4179ee035.pdf 70fa24e8024de93a3dac3ead7a24a4c3 http://23.254.134.177/the.oandplibrary.org/files/original/8d4e4395448b88c9f47146d10e2bd761.jpg e7aecd53a8fb74f0db642462ee9eacbc Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Artificial Limbs: A Review of Current Developments Description An account of the resource The foundation of modern prosthetics can be directly traced to the coordinated efforts of the National Academy of Sciences under the various artificial limbs committees after the Second World War. America, at its height of post war efficiency and engineering acumen, set about to solve the burgeoning problem of amputees swelling an infrastructure of prosthetic delivery that was outmoded, outdated and unprepared. Artificial Limbs: A Review of Current Developments was an industry update of these research efforts and was published thirty-three times, spanning the years 1954 to 1972. DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_01_004.pdf Year 1954 Volume 1 Issue 1 Page Number(s) 4 - 8 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_01_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_01_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Objectives of the Upper-Extremity Prosthetics Program</h2> <h5>Craig L. Taylor, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The upper-extremity prosthetics program, under the sponsorship of the Advisory Committee on Artificial Limbs, National Research Council, has been a growing and evolving program from its inception in 1945. Its initial objectives were limited to time and motion study of amputees and to device invention and development. But from the vantage point of 1954 we may list many additional objectives that have been assumed according to the necessities of a national program dedicated to the welfare of the amputee. As new activities have been added, none of the original have been abandoned, although certain of the original ones have been reduced in relative emphasis and expenditure.</p> <p><b>Fig. 1</b> illustrates in schematic form the major phases of the upper-extremity program as they have waxed and waned over the years from 1946 to 1953. The scope and magnitude of these activities represent a program with few parallels in our peacetime economy. As is evident in <b>Fig. 1</b>, not all the activities were started (or even conceived) at the outset. But, as has been pointed out by Strong,<a style="text-decoration:none;">*</a> no one could predict at the outset the ramifications of a program dedicated to the tangible goal of putting new and improved prostheses on amputees. The appropriateness of this program under the auspices of the National Research Council was underscored by President Bronk, who praised the ACAL program as a fitting example of the service to the public welfare for which NRC was founded.<a style="text-decoration:none;">*</a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Trends in the upper-extremity prosthetics program, 1945-53. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Fundamental Studies</h4> <p>The study of normal and amputee biomechanics underlies all improvement in prosthetic replacement. A continuous program of inquiry in this field is therefore essential. Although much of such research is undertaken without immediate practical goal, free inquiry brings to light ideas which find widespread application, as has already been demonstrated time and again. The continuous observation of arm motions and of prosthetic motions provides a nourishing bed of interest and information from which the application phases draw strength and purpose.</p> <p>The program of fundamental studies has featured research on normal motions, analyzed in terms of physical mechanics and in terms of industrial time and motion concepts. These investigations have built up a body of information on the patterns of motion, speeds, forces, and skills that is invaluable in conceiving, planning, and predicting the results of new developments. A special phase of this program has had to do with cineplasty, where the direct utilization of muscle force has remarkable potentialities for prosthetic replacement but where intimate knowledge of the mechanics of the muscle is required in order to obtain successful operation of the prosthesis. Knowledge of stump shrinkage, of finger forces, of external power controls, of accessory body mechanics, of mechanical stresses in the prosthesis during use—all these are fundamental to the proper assessment of normal and of amputee biomechanics.</p> <p>The objectives of the program of fundamental studies in the upper extremity may be summarized as:</p> <ol> <li>To study the performance of manipulative activities in normal individuals and to analyze the activities in terms of biomechanics and of time and motion criteria.</li><li>To compare the motions of amputees with pros-theses with similar motions of normals in order to define the erns of altered and substitute motions peculiar amputees.</li><li>To measure the forces and displacements of muscles and muscle groups in relation to cineplasty, harness controls, and external power controls.</li><li>To define the alterations in general body mechanics in amputees as a result of the asymmetrical loss body weight.</li></ol> <h4>Development of Prosthetic Devices</h4> <p>The "bread and butter" of the ACAL program is the development of improved prosthetic devices, and a major emphasis has always been placed upon this phase of the program. Development of each device originates in the need shown by fundamental studies or by experience with amputees. design, experimental fabrication, amputee test, and field evaluation are the successive steps through which each device must pass. The past and present development laboratories include Northrop Aircraft, Inc., the Army Prosthetics Research Laboratory, and the University of California at Los Angeles, but other agencies, such as New York University and many cooperating industry limbshops, function in the final evaluation phases.</p> <p>ACAL developments in prosthetic devices include new inventions and many adaptations of mechanisms and materials from other technical fields. Engineers have delved deep into the rich heritage of American technology to find applications of plastics, lightweight metals, and mechanisms that have immensely improved the structural and functional characteristics of upper-extremity prostheses. In short, the development objectives are:</p> <ol> <li>To invent, adapt, and apply new materials and mechanisms so as to add new functions, or to improve old functions of prostheses, seeking in the end to provide an armamentarium of devices to meet the needs of every amputee type.</li><li>To design and redesign prosthetic components for simplicity and ease of manufacture, and for durability, without loss of essential function.</li><li>To create a system of interchangeable components which may be singly prescribed for the individual amputee case, but which can be combined into a functionally integrated and an esthetically compatible prosthesis.</li><li>To incorporate cosmetic and anthropomorphic principles into basic design so that prostheses are not abnormally conspicuous and are pleasing from the standpoint of color, texture, and form.</li></ol> <h4>Industry Advisory Participation</h4> <p>From earliest days, ACAL has recognized the benefit that would accrue to its activities if the experienced "know-how" of the industry could be utilized in an effective way. To attain this goal, it was considered necessary to bring into the planning meetings of the ACAL group the counsel of leading prosthetists and limb manufacturers. Accordingly, three members of the limb industry were made members of the Upper-Extremity Technical Committee to serve at the national level, while in Los Angeles a local Industry Advisory Committee was set up to advise and aid the UCLA project. These cooperative ventures have proved to be of great mutual benefit, the objectives being briefly as follows:</p> <ol> <li>To learn from the industry the needs for device development, for advancement in prosthetics technology, and for improvement of amputee services.</li><li>To utilize the experience and judgment of members of the limb industry in determining policy and in planning cooperative ventures involving field application studies.</li></ol> <h4>Contributions to Prosthetics Technology</h4> <p>With the wealth of World War II technological development to draw upon, the ACAL program rapidly adopted new materials and practices, not only in the design and development of new prostheses but also in shop fitting and fabrication practices. Most outstanding of these innovations is the incorporation of plastics for prosthetic use. The principal laboratories under the program, APRL, Northrop Aircraft, Inc., and UCLA, have exemplified these uses, and their reports have been a source of information to the industry.</p> <p>The objectives are:</p> <ol> <li>To adapt new and different materials for use in fitting and fabrication.</li><li>To introduce into prosthetics practice methods of measurement and fabrication tending to improve quality of service and economic efficiency.</li></ol> <h4>Amputee Case Study</h4> <p>In the early stages, the ACAL program emphasized research and development on devices, and amputees necessarily were fitted with experimental prostheses in order to conduct studies, trials, and tests of the equipment. It soon became apparent, however, that established practices in prescription, fitting, and training of amputees were highly variable and that, to round out consideration of all factors bearing on amputee rehabilitation, these practices themselves should become the subject of investigation. This objective was strengthened by the knowledge that no single design of prosthesis is superior for all amputees but rather that, of many types of equipment, the most suitable selection for a given amputee depends upon his individual personal, social, and occupational needs and desires. Accordingly, the Case Study Program was initiated at UCLA in 1950 and continued until 1952. The large amount of information on the 70 amputees in this study is being reduced for publication; much of it has been directly transferred into the Educational Program (see below).</p> <p>The case study of cineplastic amputees at APRL has followed in its major outline the procedures at UCLA, and much valuable information is being gathered on this important class of amputee.</p> <p>These programs serve an especially important role in bridging the gap between fundamental work in the laboratory and practice in the field. Prosthetics involves, in unique degree, a combination of science and technology with the practical arts. Every amputee is to some extent a special case. It has therefore been . necessary to incorporate the case-study phase in order to ensure the applicability of technical improvements.</p> <p>In concise form, the objectives of the Case Study Program may be stated as follows:</p> <ol> <li>To investigate the application of prostheses to a wide range of amputee types so that a rational procedure for prescription for the needs of the amputee can be formulated.</li><li>To test and develop the elements of physical and occupational therapy that apply to amputee rehabilitation and prosthetic use.</li><li>To discover the effect of occupation, education, recreational interest, and other personal factors of the amputee upon his prescription, fitting, and training.</li><li>To determine effective methods for evaluation of amputee service, not only pertaining to the quality of mechanical equipment but also to the results of training, to the end that the amputee obtains a truly functional prosthesis.</li></ol> <h4>Prosthetics Education</h4> <p>It has been a cardinal principle of the ACAL group that the products of its research, investigation, and development should be speedily disseminated to all technical and professional groups interested in applying such knowledge for the welfare of the amputee. The scope of these activities has steadily in-creased. Early discoveries were conveyed by means of technical reports which were primarily useful to the other member laboratories and to manufacturers within the industry. Later, as case study and other application phases of the program developed, the broader responsibility was assumed of supplying educational materials dealing with many aspects of technical and professional prosthetics service. Two volumes have been prepared. <i>Human Limbs and Their Substitutes</i> (McCraw-Hill, in press) supplies an authoritative reference on prosthetics, while the Manual of Upper-Extremity Prosthetics (University of California at Los Angeles, 1952) has been issued to serve as a shop guide for the practicing prosthetist.</p> <p>Valuable as the printed material has proved to be, it was found that the needs of the prosthetist for advanced training could not be met with sufficient rapidity and thoroughness. These craftsmen, lacking formal institutional training in their specialty, and with the highly variable backgrounds of apprentice training, displayed great need for direct instruction to bring "them up to the standard required by the new technology. Two other professional groups most concerned in amputee service, physical and occupational therapists and physicians and surgeons, were no less in need of learning the newer knowledge of prosthetics. This condition made it imperative to offer an accelerated advanced training in the theory and practical arts concerned in prosthetics.</p> <p>Accordingly, the Prosthetics Training Program was instituted at UCLA with the following objectives:</p> <ol> <li>To give for selected groups of prosthetists advanced training in the skills and knowledge needed to make and fit upper-extremity prostheses using many of the most recent refinements arising from research.</li><li>To give for selected groups of physical therapists and occupational therapists advanced training in the skills and knowledge needed to assist amputees in adjusting themselves physically, mentally, and vocationally to the use of the newer developments in upper-extremity prostheses.</li><li>To enable physicians and surgeons to expand their understanding of the possibilities and limitations of the more recent developments in prostheses and of some effective procedures for taking advantage of these developments.</li><li>To encourage the acceptance and practice of the "team approach" to the problem of prosthetic prescription, in which the physician or surgeon, as captain of the team, is assisted by professionally qualified physical therapists, occupational therapists, and prosthetists.</li></ol> <h4>Field Research Studies</h4> <p>To test the usefulness of the knowledge gathered during the ACAL research program, a field research project was instituted in Chicago during 1952. The intent was to determine whether the local rehabilitation people concerned with the problems of prosthetics-the physician, the therapist, and the prosthetist-would benefit from the new knowledge. Accordingly, a group of Chicago physicians, therapists, and prosthetists were invited to attend a "pilot" course in upper-extremity prosthetics at UCLA, the content of the course being based almost exclusively upon the research performed under the ACAL program.</p> <p>Upon completion of the training, a clinic-was established in Chicago, where a group of 50 amputees was processed in accordance with the information taught at UCLA. The status of each amputee was carefully evaluated both before and after clinic treatment. Results showed a dramatic and clear-cut improvement in the functional and psychological attributes of this group of amputees. Thus, initial field evaluation clearly demonstrated the practical usefulness of the research results when applied to amputees in the local situation.</p> <p>Upon completion of the Chicago study, and in close coordination with the educational program already described, nationwide field studies were instituted under the supervision of the Prosthetic Devices Study, New York University. The purposes of these studies, which are presently going on, are as follows:</p> <ol> <li>To ensure the proper application of the research findings to upper-extremity amputee cases throughout the country.</li><li>To provide the local clinics throughout the country with administrative and technical consultation so that assistance may be provided in the resolution of difficult problems.</li><li>To evaluate the effectiveness of these procedures when applied to amputees, in order to determine where problem areas still exist and thus to direct future research toward the resolution of these difficulties.</li></ol> <p>It is anticipated that, upon conclusion of the present field research program, studies will have been conducted in conjunction with clinics operating in some 40 of our largest communities.</p> <h4>Conclusion</h4> <p>As a result of the upper-extremity prosthetics program, arm amputees can now be provided with reasonably comfortable, functional prostheses. Studies indicate that between 80 and 90 percent of the arm amputees fitted during the UCLA Case Study Program and the Chicago Project continue to wear and use their prostheses. When this is compared with the 10-percent figure estimated for arm amputees throughout the country who wear prostheses, it appears that some measure of success has been achieved. But it is apparent to workers in this field that the progress made to date is merely a step in the proper direction and that we can expect continued improvement in all aspects of upper-extremity rehabilitation.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Bronk, D.W., President, National Academy of Sciences. Address to the Advisory Committee on Artificial Limbs, Annual Meeting, Washington, May 1953.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Strong, F. S., Jr., The Artificial Limb Program: Five Years of Progress. Advisory Committee on Artificial Limbs, NRC, Washington, November 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Craig L. Taylor, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Professor of Engineering and Biophysics, University of California, Los Angeles; member, Advisory Committee on Artificial Limbs, National Research Council; chairman, Upper-Extremity Technical Committee, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_01_004/January-1954-1.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Objectives of the Upper-Extremity Prosthetics Program Creator An entity primarily responsible for making the resource Craig L. Taylor, Ph.D. * http://23.254.134.177/the.oandplibrary.org/files/original/892fdbb362b8e10138add9644e5ab5c1.pdf bea506cbf5df4cebb34bc4911c8becb0 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Artificial Limbs: A Review of Current Developments Description An account of the resource The foundation of modern prosthetics can be directly traced to the coordinated efforts of the National Academy of Sciences under the various artificial limbs committees after the Second World War. America, at its height of post war efficiency and engineering acumen, set about to solve the burgeoning problem of amputees swelling an infrastructure of prosthetic delivery that was outmoded, outdated and unprepared. Artificial Limbs: A Review of Current Developments was an industry update of these research efforts and was published thirty-three times, spanning the years 1954 to 1972. DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_03_001.pdf Year 1954 Volume 1 Issue 3 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_03_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_03_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Bioengineering- Blueprint for Progress</h2> <h5>Augustus Thorndike M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The limbs of man move in space and time, in response to systems of internal and external forces, and in accordance with the laws of mechanics. To restore to any satisfactory extent the functions lost through amputation of an extremity therefore requires intimate knowledge not only of the structure, form, and behavior of the normal limb but also of the techniques available for producing complex motions in substitute devices activated by residual sources of body power. Since adequate replacement of a natural limb with an artificial one requires successful integration of the human mechanism with a toollike device, the biomechanical features of the stump and the physical characteristics of the prosthesis must be wedded as nearly as possible into a single, functional entity.</p> <p>Two-sided as this problem would now obviously appear, it is only in comparatively recent years that the medical sciences of surgery, anatomy, and physiology and the physical one of engineering have been brought together in a unified attack upon the whole problem of amputee rehabilitation. Until recently, surgeons, with few exceptions, had little or no understanding of engineering problems. And heretofore the design and construction of artificial limbs has been conducted mostly by artisans who, however ingenious they may have proved to be, were mostly without formal education in engineering or anatomy. Besides this, except in isolated instances the two worked separately and alone. All of which no doubt accounts for the fact that, as late as World War II, the available artificial limbs fell far short of the standards of accomplishment attained in other fields of research and invention.</p> <p>In the research program coordinated by the Advisory Committee on Artificial Limbs, National Research Council, there have been brought together in harmonious working relationship the individual skills of surgeon and engineer in a sort of mutual bioengineering to produce truly functional artificial limbs. As a result, there has been in the field of prosthetics perhaps more progress during the past decade than in all the preceding 2000 years of limb-making.</p> <p>Because the lower limb is more essential to human activity than is the arm, and also doubtless because the basic functions of the leg are easier to replace than are those of the arm, progress in artificial arms and hands has from the earliest times always lagged far behind developments in artificial legs. This circumstance was reflected in the fact that, when the Artificial Limb Program was established in 1945, much more had already been accomplished in replacements for the lower extremity than in those for the upper. And consequently developments in the ACAL program to date have been most noticeable in upper-extremity prosthetics, despite extensive engineering studies of normal and amputee locomotion and refinements in the techniques of lower-extremity fit and alignment.</p> <p>In any case, the development of prosthetics had necessarily to follow the pattern of developments in surgery, and conversely the surgeon's philosophy with regard to "sites of election" and other matters was necessarily dictated by the character and availability of such prostheses as there were. Since the science of amputation surgery and the art of limbmaking proceed as one, the standards and practices in one field dictate standards and practices in the other, and vice versa. That each of these has now been brought to understand more fully the problems of the other may be looked upon as a major achievement in the art of prosthetics.</p> <p>In the following pages of this issue of Artificial Limbs is to be found substantial evidence that the engineering profession, working with the amputation surgeon, has provided new thoughts, new ideas, and new approaches to the problem of providing adequate functional replacements for the limbless. In the whole Artificial Limb Program there exists no better example of cooperation toward progress than is demonstrated here. In the first of two articles, a surgeon and an engineer collaborate in describing the latest devices and techniques arising from systematic research and the influence which these developments ought rightly to exert upon the philosophy of modern amputation surgery. In the second, an engineer outlines the methodology required in investigation of the normal limbs and in the design of useful replacements. Only through such teamwork in biomechanics can truly great advances in the field of prosthetics be expected. The development of the thirty Veterans Administration and other civilian orthopedic and prosthetic appliance clinic teams has resulted in the better distribution of new knowledge toward improved fitting and alignment of artificial legs and in the design and construction of improved artificial arms.</p> <p>The program of research coordinated by the Advisory Committee on Artificial Limbs involves the participation of government, university, and industrial laboratories. The Veterans Administration, the Army, and the Navy provide the necessary funds for the operation of their own establishments, while the VA provides the contractual authority with the funds necessary for work in the universities and in industrial laboratories. Out of this cooperative effort there have come within recent years improved functional prostheses for almost every level of amputation, particularly for those special amputee cases heretofore considered unsuited for an artificial limb. With the mutual cooperation of surgeon and engineer, there has resulted a cross-fertilization of ideas and a new set of modalities in the rehabilitation of amputees.</p> <p> Nevertheless, the presently available devices, though anthropomorphoid in form, are far from anthropomorphoid in function. Unfortunately, no artificial limb, however elaborate, can ever serve as an ideal substitute for a natural member unless it incorporates some of the features of sensory and muscular control characteristic of the limb it replaces. Therein lies the challenge of the future- to devise mechanisms which not only simulate the motions and the functions of normal limbs but which also provide appropriate feedback of information such as occurs in natural arms and legs. In our present state of knowledge, the ultimate goal of the limb designer is still a long way off. Further progress depends largely upon the continued cooperation of surgeon and engineer, of prosthetist and therapist, and of the amputee himself.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Augustus Thorndike M.D. </b></td></tr><tr><td class="clsTextSmall">Acting Director, Prosthetic and Sensory Aids Service, U.S. Veterans Administration, Washington 25, D.C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Bioengineering- Blueprint for Progress Creator An entity primarily responsible for making the resource Augustus Thorndike M.D. * http://23.254.134.177/the.oandplibrary.org/files/original/5a4fc207f88a465ad37dcf6b41150096.pdf 479c711e6dc5b0867b71528e3903ffe9 http://23.254.134.177/the.oandplibrary.org/files/original/d9ff1b62874d00a6e00a0d672fb43173.jpg 0e51c21a9139763ce305a13968b0cec8 http://23.254.134.177/the.oandplibrary.org/files/original/470d0172053dbf6511badf4a238ae5be.jpg 15352b6afae30f74a1a8e9f9ad3f67b6 http://23.254.134.177/the.oandplibrary.org/files/original/407855162477bbeecc14efd62661a52c.jpg 724072469eb262d7f443f6bfd29433f7 http://23.254.134.177/the.oandplibrary.org/files/original/ea665054cf74df0afd40296eaa419d88.jpg 18d5adb11fc47556e504851627efe5d5 http://23.254.134.177/the.oandplibrary.org/files/original/115a307852ee295ff5a6479530d3b830.jpg 57a34343d50ccf4fd7303046f6a9bdcc http://23.254.134.177/the.oandplibrary.org/files/original/e9eb5b5f48d616e1dd25a731a081527f.jpg f8fd1d577ec78d9e1f12a765caf2a199 http://23.254.134.177/the.oandplibrary.org/files/original/f751c384bf9fac833690768a5251a514.jpg 0f1756a2ea50caf1741b0411c7bdf878 http://23.254.134.177/the.oandplibrary.org/files/original/00a80e563c204095cf4122ec59ed733c.jpg 129961f2dc91933885eded5d7c503983 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Artificial Limbs: A Review of Current Developments Description An account of the resource The foundation of modern prosthetics can be directly traced to the coordinated efforts of the National Academy of Sciences under the various artificial limbs committees after the Second World War. America, at its height of post war efficiency and engineering acumen, set about to solve the burgeoning problem of amputees swelling an infrastructure of prosthetic delivery that was outmoded, outdated and unprepared. Artificial Limbs: A Review of Current Developments was an industry update of these research efforts and was published thirty-three times, spanning the years 1954 to 1972. DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_02_008.pdf Year 1954 Volume 1 Issue 2 Page Number(s) 8 - 19 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_02_008.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_02_008.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Contributions of the Lower-Extremity Prosthetics Program</h2> <h5>Edmond M. Wagner, M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>When, in 1945, the National Research Council launched its program for improvement of artificial legs, the original concept was that the major portion of the work would in all probability consist simply of devising mechanically improved artificial knees, ankles, and feet and of applying new materials to existing designs. But it soon became apparent that, if any appreciable success were to be had, the scope of the work would have to be broadened considerably. For new items that were designed failed Lo satisfy the amputee, and there were insufficient fundamental data on which to base improvements. Such information as was available on the mechanics of the lower extremity was either incomplete or else not presented in such form as to be useful to designers.</p> <p>The character of the fit was shortly found to be a matter of paramount importance in determining the success or failure of a given device. But fitting itself was based largely on the personal experience of individual fitters, and there were in existence no formalized standards or rules for guidance in obtaining proper fit. Moreover, the results of testing of devices were too often based on the impressions of only a few amputees and casual observers, either or both generally not qualified to express a competent opinion. There was not even general agreement on some of the principles involved in the surgery of amputations. Before any real progress could be made, information had to be secured in all these fields and coordinated with data from others.</p> <p>The task of obtaining the required information was assigned by the National Academy of Sciences to a number of subcontractors. At the outset, basic research on problems concerned in lower extremities, including studies on surgery, pain,<a></a> and fitting,<a></a> was placed with the University of California at Berkeley.<a></a> To assist designers and fitters, and to provide a record of the devices and techniques being used in the limb industry, a review of prior art was carried out at Northwestern University,<a></a> and the Surgeon General of the Army sent to Europe a commission<a></a> to study and report on the prosthetics art as practiced in various other countries. Solutions attempted in the past for many problems in leg design are cataloged and described in the Northwestern report<a></a> and in the report of the European commission .<a></a> Development of devices was undertaken by Goodyear Tire and Rubber Company;<a></a> Vickers, Inc.,<a></a> Detroit; C. C. Bradley and Son;<a></a> Catranis, Inc.;<a></a> Adel Precision Products;<a></a> A. J. Hosmer Corporation;<a></a> Northrop Aircraft;<a></a> the U.S. Naval Hospital at Oakland, California;<a></a> National Research and Manufacturing Company;<a></a> the Aero-Medical Laboratory of the U.S. Air Force, Wright-Patterson Air Force Base; the Army Prosthetics Research Laboratory, Walter Reed Army Medical Center; and the University of California at Berkeley . <a></a> Later in the program, the Denver Research Institute<a></a> of the University of Denver carried out an investigation of below-knee prostheses, some additional basic data have been supplied by New York University<a></a> and by the Prosthetic Testing and Development Laboratory of the Veterans Administration in New York City, and another commission<a></a> was sent to Europe to observe progress abroad after 1945. Testing and evaluation of devices has been developed and carried out at New York University,<a></a> and the Orthopedic Appliance and Limb Manufacturers Association has cooperated in general program guidance.</p> <h3>Development of Basic Data</h3> <p>Because prior to 1945 little study had been conducted on the characterislics of human locomotion, because of the complexity of the problem, and because of its highly specialized nature, it was necessary first to devise special equipment for collecting information which, ultimately, would lead to determination of the mechanical and physiological changes occurring during various activities of the lower extremity. A number of pieces of unusual apparatus, such as force plates, a glass walkway (<b>Fig. 1</b> and <b>Fig. 2</b>), and special photographic equipment were designed,<a></a> and from the data collected using this equipment it was possible to determine such factors as the forces and moments in human and artificial legs and the roles played by major muscle groups under a series of conditions. From such findings it has been possible to describe fully the phenomenon of human locomotion and thus to establish a set of realistic criteria for the design and evaluation of artificial-leg components. Aside from applicability to the field of prosthetics, the data collected are useful also to designers of leg braces and to the medical profession in the treatment of pathological gait.<a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. The University of California glass walkway. With this device, motion pictures taken from a single camera yield sufficient information to determine relative motions of various segments of the body during level walking. Subject shown here is wearing an above-knee experimental leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Normal subject prepared for participation in studies using the University of California glass walkway. Some targets are mounted on levers to amplify motions otherwise of small magnitude. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The major portion of this work was performed at the University of California, Berkeley, and many of the results have been documented in reports and in the journal literature. Of the many reports issued, most, such as those of Cunningham<a></a>, of Bresler and Berry<a></a> and of Radcliffe,<a></a> generally cover a single phase of the subject.</p> <h3>Creation of Design Objectives</h3> <p>From study of the basic data, and from careful review of current practices, it has been possible to set up a listing of design objectives for leg prostheses, it being understood that above all the prosthesis must satisfy the amputee. Arranged in generally decreasing order of importance, these requirements are as follows:</p> <ol> <li>Security from fall.</li><li>Minimum consumption of energy in normal walking</li><li>Appearance of the walking pattern to compare favorably with that of a normal person.<br /> a. Smooth swing phase, including deceleration of the prosthesis at the end of extension, control of heel rise at the end of flexion, and deceleration of the prosthesis just prior to heel contact.<br /> b. Smooth stancephase, includingattainmentof full extension without final snapping action.<br /> c. Ability to change gait to maintain smooth, normal-appearing gait.</li><li>Ability to extend the leg under load at any time.</li><li>Proper phasing of the locking action, if used, with all portions of the stance and swing phases.</li><li>Performance of incidental operations—such as going up and down stairs and ramps, turning, and sitting down—with reasonable ease and smoothness.</li></ol> <p>A listing of the features desired of leg prostheses at three functional levels (<b>Table 1</b>) has finally evolved.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Improvement of Fitting and Alignment</h3> <p>As a result of the early attempts to improve existing knee-brake devices, it was found that fitting and alignment were together often more of a determining factor in amputee acceptance than was the performance of the device itself. In the two trips to Europe,<a></a> various techniques and several mechanical aids for obtaining greater uniformity in fitting were observed. These techniques and devices have been analyzed, and from the resulting knowledge, together with information from the basic studies, improved methods of fitting and aligning above- and below-knee legs have been formulated. All of these observations have been published in a report of the University of California at Berkeley .<a></a></p> <p>In order to make these principles of fitting and alignment easier to apply, an adjustable leg (page 23) for above- and below-knee prostheses, with provisions for individual adjustment of major elements, was designed by the project at Berkeley and turned over to the limb industry. This leg, once adjusted, can be worn by an amputee for periods of a few days to determine if the fitting is satisfactory. To transfer to the permanent prosthesis the measurements thus determined by the adjustable leg, there has been designed a fixture which holds the elements of the prosthesis in position while they are being assembled with the predetermined alignment. With these two devices, which are now available commercially, fittings become quite exact. The ease with which minor adjustments can be made in the adjustable leg makes it possible to try variations in fitting which, previously, were avoided because of the time and expense involved. Moreover, the adjust- able leg has the psychological advantage of demonstrating to the amputee that the fit of the device he is obtaining is the optimum for him.</p> <h3>Methods Of Suspension</h3> <p>A major factor involved in fitting of both above- and below-knee legs is the socket. On the first trip to Europe,<a></a> a number of exceptionally well-fitted suction sockets (page 29) were observed in Germany. This type of suspension had been tried previously in the United States<a></a> and in England with poor results. The successful cases seen in Germany in 1946, however, prompted another trial of the technique in the United States. A thorough study of the shape of the socket and other features involved in fitting of suction sockets was undertaken at the University of California at Berkeley.<a></a> As a result of the successful conclusion of this work, the suction socket has since been widely applied by the United States limb industry and has been accepted by the Veterans Administration as an improved method of fitting prostheses for above-knee amputees where there are no contraindications. The knowledge gained in perfecting the technique of suction-socket fitting and in determining the optimum shape of the suction socket has contributed to improvement in the fitting of other sockets. Development work is now proceeding on suction sockets for below-knee amputees.</p> <p>In addition to the work on suction sockets, a "soft" socket for below-knee amputees, consisting of a thin, resilient pad under a conventional leather or plastic socket lining in a plastic or wooden socket, has reached the testing stage at New York University.</p> <h3>Schools for Prosthetists and Surgeons</h3> <p>Since the suction socket was as much a technique as a device, it was determined that, if the suction socket was to be as successful in general practice as it had been in the development period under the supervision of the University of California, the technique had to be taught to limbfitters throughout the United States. Accordingly, plans were laid for a series of schools to be held in various cities in the United States. A course of instruction was laid out, and under the auspices of the Veterans Administration, with the assistance of the Orthopedic Appliance and Limb Manufacturers Association, a series of schools was held throughout the country. The Veterans Administration, by requiring that fitters and surgeons have certificates from one of these schools before suction sockets could be provided beneficiaries, ensured that the best practices were provided. Establishment of these schools was an important advance, for it provided a mechanism for bringing to the commercial limb industry and medical pro- fession the new techniques and ideas developed. Their success has led to expansion of the principles of the clinic-team approach for handling both upper- and lower-extremity cases.</p> <p>In connection with the suction-socket schools, manuals were issued on how to fit suction sockets. They constituted the first attempt to present, in a manner that would be useful to the limbfitter, data developed in the program. Their success has led to the issuance of manuals on other subjects.</p> <h3>Amputation Surgery</h3> <p>In the early investigations, it became apparent that relative difficulty of fitting rather than surgical considerations often dictated the site of amputation. This circumstance led to a study of the sites of election and to a consideration of whether some changes might not be advisable. Studies have since clearly shown that the longer the stump the more function and control can be obtained-a matter that has not always been fully appreciated. In the above-knee amputee, the increased length of stump is particularly important, since it is one of the governing factors in obtaining stability of the prosthesis in abduction. In the above-knee amputation, it has also been found advantageous to tie the muscles together across the bottom of the stump or otherwise to attach muscles to the bone to aid in obtaining stability in abduction. These new concepts are leading to a revision of amputation practices. There will, no doubt, be other such advances in amputation surgery as more is learned about body mechanics.</p> <h3>Pain Studies</h3> <p>Pain, both phantom and real, has always been a troublesome problem in amputee management. In order to obtain a clearer understanding of and possible solutions to the pain syndrome, a project was instituted at the University of California. Although practical applications of methods to alleviate pain and eliminate phantom pain have been meager to date, the mechanism of pain radiation has been elucidated, and the results<a></a> form the basis for future work in this field.</p> <h3>New Devices</h3> <p>One of the most important parts of the lower-extremity program is the development of new devices. Consequently, device development has been one of the major efforts. In the early stages of the program especially, there was an urgent demand from new Service-connected amputees for improved devices. At the time, the data from the basic studies at the University of California were not available. But because of the urgent demand, a program for invention and development of devices was undertaken simultaneously with the program for developing basic data. While most of these devices were unsuccessful, the time, money, and effort expended developing them were not entirely wasted. For in trying these devices, much needed information was developed, and the need for long-range research on several items of a basic nature was pointed out. As the data were collected at the University of California, devices were pro- duced incorporating features which seemed desirable.</p> <p>A great deal of effort was expended in attempting to perfect a knee lock for above-knee amputees. But most of these designs were abandoned for one reason or another after a few models had been made and tried on amputees. The particular difficulty in obtaining smooth and reliable action in a knee lock was found to reside in the method of control. In addition to knee locks, considerable effort has been expended on coordinated motion between the knee and ankle, toe pickup, transverse rotation in the leg, and control of the swing phase. Numerous devices incorporating such features have been made. Both mechanical and hydraulic devices, with varying degrees of complexity, have been tried.</p> <p>Of all the knee locks tried to date, only two, the Stewart-Vickers (<b>Fig. 3</b>) and the Henschke-Mauch (<b>Fig. 4</b>), appear to have reached the point of having commercial possibilities. More recently, however, there have been indications that proper swing-phase control, coupled with alignment stability or limited stability over the first few degrees of flexion, are all that the average above-knee amputee may need. The more or less elaborate knee locks might therefore be indicated for special cases, for older persons, or for those who prefer "the best" and can afford it. Both Stewart and Henschke-Mauch have swing-phase control devices incorporated in their designs, and both have under test legs in which only the swing phase is controlled.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Schematic diagram of the Stewart-Vickers hydraulic leg incorporating knee lock, swing-phase control, and coordinated motion between ankle, shank, and thigh. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Schematic diagram of the Henschke-Mauch hydraulic leg incorporating knee lock and swing-phase control. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Another lower-extremity device now under test is the University of California four-bar-linkage or polycentric knee (<b>Fig. 5</b>). The four-bar-linkage knee is not a new idea, but the UC version has been so designed that the toggle action existing in prior designs to provide extreme stability as the knee approaches full extension has been eliminated. Instead, it depends for its stability on alignment in fitting. It has the advantage, like many other four-bar linkages, of providing at the start of flexion a pivot point about 6 in. above the actual knee joint-a feature which provides a very favorable mechanical advantage for the amputee to start the leg to flex.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Schematic diagram of the University of California four-bar-linkage (polycentric) knee showing change in center of rotation of shank as knee is flexed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the UC leg the swing phase is controlled by a radial-vane type of damping device in which hydraulic fluid passes from one side of the vane to the other through suitable needle valves. Hence this device is responsive to gait change and limits excessive heel rise as cadence is increased.</p> <p>The limbshop at the U.S. Naval Hospital, Oakland, California, has developed and had accepted by ACAL a complete above-knee leg featuring a very simple mechanical device for controlling the swing phase in connection with a more or less conventional knee bolt (<b>Fig. 6</b>). This type of swing-phase control is not nearly so responsive to gait change as are the hydraulic units, but it marks a definite advance in the design of artificial knees. Also featured in the Navy leg are a plastic shank and the so-called "Navy functional ankle." The latter (<b>Fig. 7</b>) uses a rubber block with different degrees of hardness at front and rear to provide for plantar flexion and dorsiflexion and at the same time to permit some rotation about the vertical axis of the leg. It is anticipated that the Navy above-knee leg will be available commercially early this summer.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. U.S. Navy variable-friction knee. As flexion takes place, projection <i>A </i>of the knee block rotates until it contacts lever arm C, which induces additional friction about the knee bolt to limit heel rise. As extension occurs, projection <i>B' </i>rotates to contact lever arm <i>D, </i>which induces additional friction to decelerate the shank (terminal deceleration). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. U.S. Navy functional ankle. Single cable extends through rubber block of different degrees of stiffness at front and back. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To summarize the work done on new devices for lower extremities, there is now available a large store of information on devices which have been tried and found lacking in one respect or another. With what is now known about performance desired in above-and below-knee legs, it is possible that a review of past developments, coupled with some changes based on present knowledge, may lead to the development of more acceptable leg prostheses. At this time, however, only the Navy functional ankle and the swing-phase control have been accepted as completed devices. Others appear very close to acceptance.</p> <h3>Testing and Evaluation</h3> <p>Throughout the early stages, the development of new devices in the lower-extremity program was retarded by the lack of techniques and organization for objective testing and evaluation. Until the data on the mechanics of walking had been developed, it was almost impossible to set up means for objective evaluation because no satisfactory standards of comparison were available. In addition to this lack of standards, it became apparent early in the program that some means had to be established for testing, under a controlled set of conditions, the devices which appeared ready for production. A testing laboratory at New York University was therefore set up. With its entry into the program, there was obtained a much better evaluation of the desirability of the devices proposed and a much better idea of their mechanical performance . <a></a> It was soon found that most of the devices submitted had minor mechanical shortcomings, and as a result many devices which two or three years ago appeared almost ready for release are only now approaching that point. The field-testing procedure has avoided premature release of several supposedly completed items and has indicated the need for more information on several basic points. It has thus proven to be a very valuable step in the development program, and the information gained in the field tests has fully justified the time and cost of field-testing.</p> <h3>Clinical Program</h3> <p>When the program for development of new devices had reached a certain stage, it became apparent that, if there could be instituted a clinical program to try devices on various amputees under as nearly identical conditions as possible, progress would be much more rapid. Information was also needed to confirm conclusions about the suitability of certain devices for various sites of amputations and for various physical and mental characteristics of the amputee and to determine new types of devices which might be needed under certain sets of conditions. Among others, such questions as the need for, or suitability of, a knee lock, or whether limited stability coupled with swing-phase control would be better, needed investigation and decision.</p> <p>A clinical study was therefore set up under the direction of the University of California at the U.S. Naval Hospital, Oakland, with certain facilities provided by the Surgeon General of the Navy. It is expected that, by providing a complete staff of surgeons, prosthetists, physiotherapists, engineers, and research workers, with the opportunity for controlled fitting and follow-up of patients, rapid progress will be made in improving fitting and alignment techniques, in surgical procedures, and in the development of improved devices.</p> <h3>Development Program</h3> <p>Since the establishment of the lower-extremity clinic, a development group, staffed with people skilled in lower-extremity prosthetic art, including representatives from the industry, has been established. This group has headquarters at the U.S. Naval Hospital at Oakland, California, in close proximity to the clinic. It is expected that they will complete the development of some of the devices partially completed in the past and develop new devices, possibly combining or utilizing some of the ideas and data resulting from development work on these new devices. It is expected that this group will bring the program for new devices somewhere near its required level within the next two years.</p> <h3>Conclusion</h3> <p>Because the improvement of leg prostheses has required research and investigation in many fields, and because of the broad scope of much of the work, its full usefulness will not be realized until some time in the future. Time and study are required to analyze the data and to apply the results of such analyses. Nevertheless, the basic data developed under the ACAL program have already been useful, not only in the design of above- and below-knee prostheses but also in the design of leg braces, and they have proved extremely helpful in the diagnosis of pathological gait. Among the developments of more or less immediate practical applicability are the new techniques introduced for fitting and aligning above- and below-knee prostheses. Devices to facilitate adjustments in fitting so that optimum results can be attained quickly have been developed and introduced to the industry, as has also the equipment for transferring the dimensions determined for the prosthesis.</p> <p>As a result of efforts of ACAL, the suction socket for the above-knee amputee has come into general use in the United States. In addition, the principles developed in the suction-socket program have helped to improve techniques used with other types of sockets, thus contributing generally to the well-being of the leg amputee. Experience gained in the suction-socket program has led either directly or indirectly to the development of the clinic-team concept which is proving so useful in the management of amputees of all types.</p> <p>Certain changes in the surgical procedures of amputation have been suggested, especially in regard to the so-called "sites of election" and to stabilization of the above-knee stump in adduction. Study of the nature and propagation of pain in stumps has yielded results which should be the basis for future advances in treatment and prevention of pain arising from amputation.</p> <p>Outgrowths of the lower-extremity clinical study may be expected to confirm, apply, and develop further the principles of fitting and alignment, to advance further the use of the suction socket, to improve the fitting of conventional above- and below-knee sockets and the "soft" socket for below-knee amputations, and to develop prostheses for other types of amputations. With the above-knee clinic established, the work in surgery, prescription, fitting, and training of the amputee is likely to advance even more rapidly than has been the case in the past.</p> <p>The development of devices with increased function, reliable enough and with benefit enough to the amputee to justify the increased complexity and cost, has proven difficult.</p> <p>Many devices have been built, tested, and found wanting in one detail or another mechanically or else have proven too costly to be practical at the present time. Although thus far only two devices, the Navy variable-friction knee and the Navy functional ankle, have been accepted by ACAL and made ready for distribution, several experimental ones appear to be almost ready for general use. The groundwork in the field of lower-extremity prosthetics has been laid. By 1956 we should see the appearance of many more, and more practical, accomplishments resulting from the preceding eight years of pioneering work.</p> <p><b>References:</b></p> <ol> <li>Adel Precision Products Corp., Burbank, Calif.,ubcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>The development of a hydraulically operated artificial leg for above knee amputations, </i>1947.</li> <li>Bradley, C. C, and Son, Inc., and Catranis, Inc.,yracuse, N. Y., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Artificial limb development for above-knee amputees including mechanical and hydraulic knee locks; suction socket and suction socket controls; knee lock controls operated by hip motion, stump muscles and fool position; toe pick up and foot providing lateral, plantar and dorsal flexion, </i>1947.</li> <li>Bresler, B., and F. R. Berry, <i>Energy characteristicsof normal and prosthetic ankle joints, </i>University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1950.</li> <li>Catranis, Inc., Syracuse, N. Y., Subcontractor'sinal Report to the Advisory Committee on Artificial Limbs, National Research Council, in preparation, 1954.</li> <li>Cunningham, D. M., <i>Components of floor reactionsduring walking, </i>University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, November 1950.</li> <li>Denver Research Institute, University of Denver,enver, Colo., Subcontractor's Final Report to the Advisory Committee on Artificial Limbs, National Research Council, <i>A program for the improvement of the below-knee prosthesis with emphasis on problems of the joint, </i>August 1953.</li> <li>Eberhart, Howard D., Verne T. Inman, and Borisresler, <i>The principal elements in human locomotion, </i>Chapter 15 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Eberhart, Howard D., and Jim C. McKennon, <i>Suc-tion-sockei suspension of the above-knee prosthesis, </i>Chapter 20 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954. 9. Feinstein, Bertram, James C. Luce, and John N. K. Langton, <i>The influence of phantom limbs, </i>Chapter 4 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Goodyear Tire and Rubber Company, Akron, Ohio,ubcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], <i>The development of a fool prosthesis incorporating a metal structure and a bonded rubber to metal ankle joint, </i>1947.</li> <li>Hosmer Corp., A. J , Santa Monica, Calif., Sub-ontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Hydraulic weight bearing knee lock for knee disarticulation amputations, etc., </i>1947.</li> <li>National Research and Manufacturing Company,an Diego, Calif , Subcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], <i>An investigation of low pressure laminates for prosthetic devices; design and fabrication of above-knee and below-knee artificial legs; preparation of a production survey for manufacture of artificial plastic legs, </i>1947.</li> <li>New York University, Prosthetic Devices Study, Report to the Advisory Committee on Artificial Limbs, National Research Council, <i>The functional and psychological suitability of an experimental hydraulic prosthesis for above-the-knee amputees, </i>March 1953.</li> <li>Northrop Aircraft, Inc., Hawthorne, Calif , Subcon-ractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>A report on prosthesis development, </i>1947.</li> <li>Northwestern Technological Institute, Evanston,11., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>A review of the literature, patents, and manufactured items concerned with artificial legs, arm harnesses, hand, and hook; mechanical testing of artificial legs, </i>1947.</li> <li>Parmelee, Dubois D., U. S. Patent 37,637, February, 1863, and reissue patents 1,907 and 1,908, March 4, 1865.</li> <li>Radcliffe, C. W., <i>Information useful in the design ofdamping mechanisms for artificial knee joints, </i>University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1950.</li> <li>Radcliffe, C. W., <i>Use of the adjustable knee and align-ment jig for the alignment of above-knee prostheses, </i>University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, August 1951.</li> <li>Saunders, J. B., V. T. Inman, and H. D. Eberhart, <i>The major determinants in normal and pathological gait, </i>J. Bone and JointSurg., <b>36A </b>(3):543 (1953).</li> <li>Stewart, John H. F., U. S. Patent 2,478,721, August 9, 1949.</li> <li>United States Naval Hospital (Amputation Cen-er), Oakland, Calif., <i>Construction, filling and alignment manual for the U.S. Navy soft socket below knee prosthesis, </i>printer's date 9-29-53.</li> <li>University of California (Berkeley), Prostheticevices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Fundamental studies of human locomotion and other information relating to design of artificial limbs, </i>1947. Two volumes.</li> <li>University of California (Berkeley), Prosthetic</li> <li>Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, <i>Summary of European observa-tions, summer, 1949 </i>[by H. D. Eberhart <i>el al.], </i>October 1949.</li> <li>University of California (Berkeley), Prostheticevices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, <i>The suction socket above-knee artificial leg, </i>3rd edition, April 1949.</li> <li>University of California (Berkeley), Prostheticevices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Studies relating to pain in the amputee, </i>June 1952.</li> <li>War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, <i>Report on European observations, </i>Washington, 1946.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Northrop Aircraft, Inc., Hawthorne, Calif , Subcon-ractor's Final Report to the Committee on Artificial Limbs, National Research Council, A report on prosthesis development, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Goodyear Tire and Rubber Company, Akron, Ohio,ubcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], The development of a fool prosthesis incorporating a metal structure and a bonded rubber to metal ankle joint, 1947.</td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prostheticevices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Eberhart, Howard D., and Jim C. McKennon, Suc-tion-sockei suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954. 9. Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs, Chapter 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prostheticevices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, 3rd edition, April 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Information useful in the design ofdamping mechanisms for artificial knee joints, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1950.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, Report on European observations, Washington, 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Saunders, J. B., V. T. Inman, and H. D. Eberhart, The major determinants in normal and pathological gait, J. Bone and JointSurg., 36A (3):543 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Summary of European observa-tions, summer, 1949 [by H. D. Eberhart el al.], October 1949.</td></tr><tr><td class="clsTextSmall"><b> 26.</b> </td><td class="clsTextSmall">War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, Report on European observations, Washington, 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Use of the adjustable knee and align-ment jig for the alignment of above-knee prostheses, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, August 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Bresler, B., and F. R. Berry, Energy characteristicsof normal and prosthetic ankle joints, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1950.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Cunningham, D. M., Components of floor reactionsduring walking, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, November 1950.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Stewart, John H. F., U. S. Patent 2,478,721, August 9, 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Eberhart, Howard D., Verne T. Inman, and Borisresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Northrop Aircraft, Inc., Hawthorne, Calif , Subcon-ractor's Final Report to the Committee on Artificial Limbs, National Research Council, A report on prosthesis development, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Summary of European observa-tions, summer, 1949 [by H. D. Eberhart el al.], October 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Northrop Aircraft, Inc., Hawthorne, Calif , Subcon-ractor's Final Report to the Committee on Artificial Limbs, National Research Council, A report on prosthesis development, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Denver Research Institute, University of Denver,enver, Colo., Subcontractor's Final Report to the Advisory Committee on Artificial Limbs, National Research Council, A program for the improvement of the below-knee prosthesis with emphasis on problems of the joint, August 1953.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study, Report to the Advisory Committee on Artificial Limbs, National Research Council, The functional and psychological suitability of an experimental hydraulic prosthesis for above-the-knee amputees, March 1953.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prostheticevices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Northwestern Technological Institute, Evanston,11., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, A review of the literature, patents, and manufactured items concerned with artificial legs, arm harnesses, hand, and hook; mechanical testing of artificial legs, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">National Research and Manufacturing Company,an Diego, Calif , Subcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], An investigation of low pressure laminates for prosthetic devices; design and fabrication of above-knee and below-knee artificial legs; preparation of a production survey for manufacture of artificial plastic legs, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Adel Precision Products Corp., Burbank, Calif.,ubcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, The development of a hydraulically operated artificial leg for above knee amputations, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Catranis, Inc., Syracuse, N. Y., Subcontractor'sinal Report to the Advisory Committee on Artificial Limbs, National Research Council, in preparation, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Bradley, C. C, and Son, Inc., and Catranis, Inc.,yracuse, N. Y., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Artificial limb development for above-knee amputees including mechanical and hydraulic knee locks; suction socket and suction socket controls; knee lock controls operated by hip motion, stump muscles and fool position; toe pick up and foot providing lateral, plantar and dorsal flexion, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">United States Naval Hospital (Amputation Cen-er), Oakland, Calif., Construction, filling and alignment manual for the U.S. Navy soft socket below knee prosthesis, printer's date 9-29-53.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Hosmer Corp., A. J , Santa Monica, Calif., Sub-ontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Hydraulic weight bearing knee lock for knee disarticulation amputations, etc., 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, Report on European observations, Washington, 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Parmelee, Dubois D., U. S. Patent 37,637, February, 1863, and reissue patents 1,907 and 1,908, March 4, 1865.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, Report on European observations, Washington, 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Parmelee, Dubois D., U. S. Patent 37,637, February, 1863, and reissue patents 1,907 and 1,908, March 4, 1865.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Saunders, J. B., V. T. Inman, and H. D. Eberhart, The major determinants in normal and pathological gait, J. Bone and JointSurg., 36A (3):543 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Goodyear Tire and Rubber Company, Akron, Ohio,ubcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], The development of a fool prosthesis incorporating a metal structure and a bonded rubber to metal ankle joint, 1947.</td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prostheticevices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Edmond M. Wagner, M.E. </b></td></tr><tr><td class="clsTextSmall">Consulting engineer, 930 Rosalind Road, San Marino, California; member, Lower-Extremity Technical Committee, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-2.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-3.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-4.jpg Figure 4 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-5.jpg Figure 5 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-6.jpg Figure 6 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-7.jpg Figure 7 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-8.jpg Figure 8 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-9.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Contributions of the Lower-Extremity Prosthetics Program Creator An entity primarily responsible for making the resource Edmond M. Wagner, M.E. * http://23.254.134.177/the.oandplibrary.org/files/original/affc6aca870d2691c532bcb1de52320b.pdf 6da74b52fefbfd84763702e128d153bc http://23.254.134.177/the.oandplibrary.org/files/original/4855abea0e973f4417c0b317f993c386.jpg ef252a1fdf4eaa98400bc4eafd5598f5 http://23.254.134.177/the.oandplibrary.org/files/original/5f532646ed4a4826e06c36271fd690b0.jpg 86bd762152af57f1311a4b7bda41f25e http://23.254.134.177/the.oandplibrary.org/files/original/f10066429e8178e00674e849efd5ad63.jpg 035865f6b9ab5f776a3d2d22e9eaef11 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Artificial Limbs: A Review of Current Developments Description An account of the resource The foundation of modern prosthetics can be directly traced to the coordinated efforts of the National Academy of Sciences under the various artificial limbs committees after the Second World War. America, at its height of post war efficiency and engineering acumen, set about to solve the burgeoning problem of amputees swelling an infrastructure of prosthetic delivery that was outmoded, outdated and unprepared. Artificial Limbs: A Review of Current Developments was an industry update of these research efforts and was published thirty-three times, spanning the years 1954 to 1972. DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_01_009.pdf Year 1954 Volume 1 Issue 1 Page Number(s) 9 - 14 Text Any textual data included in the document The Prosthetics Clinic Team <h5>Charles O. Bechtol, M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>With the increasing complexity of medicine and its related sciences, the day is past when a single man can cope successfully with all the specialized problems in the treatment of injury and disease. The "horse-and-buggy" doctor did an excellent job considering the limited number of drugs and facilities avail-able to him. His results, however, can in no way compare with those obtained at a well-conducted, modern clinic, where a team of physicians as well as representatives of all the allied medical specialties are available. A comparable situation now prevails in the field of artificial limbs.</p> <p>The basic Prosthetics Clinic Team is composed of a physician, a therapist, and a prothetist. Workers in other fields, say a psychiatrist or psychologist, a social worker, a vocational counselor, or an engineer, should be available for consultation when the basic team considers that such services are required.</p> <p>Each member of the team has been trained to perform one particular job well, and, despite the considerable education and experience of each of these team members, no one man could be expected to carry out the entire procedure beginning with surgery and ending with the fitting and training of the patient. Although it is not generally stated, the patient himself is also a member of the team, since during the period of fitting and training he must cooperate by carrying out the instructions of the various team members and at the same time make and convey his own observations on the good and bad qualities of the prosthesis.<br /><br /></p> <h3>Function of Each Team Member</h3> <h4>The Physician</h4> <p>The physician acts as the chief of the clinic team. His particular training has prepared him to coordinate various ancillary services in the solution of all types of medical and surgical problems and to follow the progress of the patient until the difficulty for which medical care was sought has been corrected. In the past, this has been known as the "end result idea," more recently as <i>Rehabilitation</i>. The physician, in addition to his specific duties, is able to act in this same supervisory capacity in the prosthetics clinic team.</p> <p>First, the physician can evaluate the general medical status of the patient and either carry out any necessary surgery or, if he is not a surgeon, refer the patient to a properly qualified one. Immediate postoperative care in the hospital is under his direction. Then the prescription for physical therapy, whether preoperative or postoperative, is in his hands, and he is also the person who assumes ultimate responsibility for prescribing the prosthesis.<a style="text-decoration: none;">*</a> Moreover, the physician supervises evaluation of the prosthesis and renders final approval. And lastly, it is his responsibility to ensure that adequate training in use of the prosthesis is provided, to the end that the amputee may be able to gain the full functional advantages offered by a properly constructed, modern prosthesis.</p> <h4>The Therapist</h4> <p>The particular field of the physical and occupational therapists lies in preoperative and postoperative training and physical conditioning. The therapist is almost solely responsible for training in use of the prosthesis and usually for details of the checkout and evaluation procedures. These functions, however, are no more important than are those of physical conditioning and training in use of the prosthesis. And hence the therapist is a most necessary consultant in decisions relating to time of fitting, type of prosthesis, and type of post prosthetic training.</p> <h4>The Prosthetist</h4> <p>The special problem of the prosthetist, of course, is the actual fabrication and fitting of the artificial limb. Thus he is an indispensable member of the team. His consultation is particularly valuable at the time of prescription of the prosthesis. Using the medical data supplied him by the physician and the therapist, he can give excellent advice as to the relative degree of function that can be offered by different artificial-limb components. With cooperation in this respect, later changes in the prosthesis can be held to a minimum and possibly avoided entirely.</p> <h4>Other Consultants</h4> <p>In complex cases, the team will often feel a need for the services of others. It may be necessary to call upon a psychiatrist or psychologist to determine whether the mental attitude of the patient is such that a prosthesis can be used. Or a design engineer may be able to devise a mechanism or component that will be useful in special cases. Finally, the services of a vocational counselor or social worker may be needed in determining some of the future requirements of the amputee.</p> <h4>Administrative Personnel</h4> <p>In addition to the professional services involved, it is mandatory that someone assume the usual administrative responsibilities. An orderly clinic cannot be conducted without someone to schedule the patients' visits, to maintain individual records, and to carry out other administrative functions. This is of course true of any type of clinic operation, but it is perhaps even more important here because of the many factors involved and the numerous disciplines required.</p> <h4>Procedures in the Clinic</h4> <p>An amputee appears before the team a minimum of three times, as shown graphically in <b>Fig. 1</b>. The first visit is for the purpose of preparing the prosthetics prescription, the second to evaluate the amputee and his prosthesis before training, the third to evaluate the amputee and his prosthesis after training.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 1. Steps in the clinic--Team procedure.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <h4>Visit No. 1</h4> <p>If, in the opinion of the team, the amputee is ready for fitting, a prescription is prepared. If for some reason—medical or otherwise—he is not ready, appropriate therapeutic measures are recommended.</p> <p>On hand is a preprescription form (<b>Fig. 2</b>) on which have been recorded such data as the cause of amputation, the patient's background, his physical limitations, and his desires for the future. Before attempting to prepare a prescription, each team member should be thoroughly familiar with the information given in the preprescription form. Unless the therapist is familiar with the case, it is desirable to check any existing physical limitations.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 2. Typical preprescription information form for upper-extremity amputation.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p>The prescription is prepared through the cooperative effort of the team and is signed by the physician. Fitting is then carried out by the prosthetist in accordance with the prescription. A prescription form for upper-extremity amputees is shown in <b>Fig. 3</b>.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Typical prescription form for upper-extremity prostheses.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <h4>Visit No. 2</h4> <p>Upon completion of the prosthesis, but before training, the amputee is brought before the clinic team a second time. Here emphasis is placed on "before training." Taken literally, this may mean that the amputee will have no conception of even the simpler control movements. In the final stages of fitting the upper-extremity amputee, however, it is necessary that the prosthetist instruct the amputee in basic control motions in order to ensure that the prosthesis is capable of function as fitted. Accordingly, the prosthetist must be thoroughly familiar with initial training procedures lest unnatural motions have to be unlearned.</p> <p>The primary purpose of the second clinic visit is to ensure that the amputee is ready for training. Included is an evaluation of his physical and mental condition as well as of the degree of comfort and function provided by the prosthesis. A simple but comprehensive series of tests has been developed to aid in evaluating functional aspects in upper-extremity cases, and a description of these appears elsewhere in this issue.</p> <p>When the team is satisfied that training is in order, the patient is referred to the therapist for this phase of the rehabilitation procedure. Although a patient and his prosthesis may meet all the criteria of the checkout procedures during the clinic session, quite often use of the prosthesis or changes of the stump during training make modifications necessary. Hence, the more familiar the therapist is with the functional aspects of the various components of the prosthesis the more quickly can he call such deficiencies to the attention of the team. Not only is time saved, but factors which tend to discourage many amputees are eliminated. The over-all result is added confidence in the prosthetics team.</p> <h4>Visit No. 3</h4> <p>Upon completion of training, the amputee is once more brought before the clinic team for a final evaluation of his ability to resume an active role in society. The patient should be encouraged to request the services of the team whenever required and also to report for follow-up examinations at regular intervals. The length of time between visits depends, of course, upon the peculiarities of each case, but as a rule it is best that the patient be examined at least once a year.</p> <h4>Conclusion</h4> <p>The concept of the Prosthetics Clinic Team is not a mere theory. Under the direction of Dr. Augustus Thorndike, the Prosthetic and Sensory Aids Service of the Veterans Administration has established 30 such teams since 1949. Others are in operation in private clinics and within the Armed Services. The initial success of these teams, often under very difficult operating conditions, has led the Advisory Committee on Artificial Limbs to stimulate development of evaluation techniques that can be used under clinical conditions and to encourage the use of the clinic-team approach for amputee rehabilitation generally.</p> <br /> <div style="width: 400px;"> <table style="background: #003399;"> <tbody> <tr> <td> <table> <tbody> <tr> <td style="text-align: left; padding: 3px;"> <table> <tbody> <tr> <td class="clsTextSmall" style="border-bottom: 1px #666666 solid;"><b>Footnote</b></td> </tr> <tr> <td class="clsTextSmall">It must be emphasized that these prescriptions, even though they be signed by the physician, should correctly be the product of consultation by the entire team. It is perhaps in the preparation of these prescriptions that the knowledge of each team member is utilized to the fullest.</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> <div style="width: 400px;"> <table style="background: #003399;"> <tbody> <tr> <td> <table> <tbody> <tr> <td style="text-align: left; padding: 3px;"> <table> <tbody> <tr> <td class="clsTextSmall" style="border-bottom: 1px #666666 solid;"><b>Charles O. Bechtol, M.D. </b></td> </tr> <tr> <td class="clsTextSmall">Assistant Clinical Professor of Orthopedic Surgery, University of California; Western Area Consultant for Prosthetic and Orthopedic Clinics, Veterans Administration; member of the Upper- and Lower-Extremity Technical Committees of ACAL.</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> Figure 1 http://www.oandplibrary.org/al/images/1954_01_009/January-1954-2.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_01_009/ReplacewithFig2.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_01_009/ReplacewithFig3.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Prosthetics Clinic Team Creator An entity primarily responsible for making the resource Charles O. 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Artificial Limbs: A Review of Current Developments Description An account of the resource The foundation of modern prosthetics can be directly traced to the coordinated efforts of the National Academy of Sciences under the various artificial limbs committees after the Second World War. America, at its height of post war efficiency and engineering acumen, set about to solve the burgeoning problem of amputees swelling an infrastructure of prosthetic delivery that was outmoded, outdated and unprepared. Artificial Limbs: A Review of Current Developments was an industry update of these research efforts and was published thirty-three times, spanning the years 1954 to 1972. DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_03_047.pdf Year 1954 Volume 1 Issue 3 Page Number(s) 47 - 76 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_03_047.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_03_047.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Prosthetics Research and the Engineering Profession</h2> <h5>Renato Contini, B.S.M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>In the establishment of any program in prosthetics,<a style="text-decoration:none;">*</a> whether it be a program devoted to research on and development of new and improved devices, or whether it be a program for the dissemination of knowledge in the application of these devices, guidance must come primarily from the medical sciences. In any such program, one can appreciate the role of the physician, either the surgeon involved in the amputation or the physiatrist concerned with the physical rehabilitation of the patient. To a lesser extent perhaps, the role of the physical and occupational therapist, in implementation of the prescription established by the physician for medical rehabilitation or re-education, also is generally appreciated.</p> <p>Since there can be no prostheses without a limbmaker, the role of the prosthetist cannot be underestimated. Certain attempts at the fabrication of artificial limbs may be traced back to the time of the Roman Empire. Several ingenious devices made during the sixteenth century (<b>Fig. 1</b> and <b>Fig. 2</b>) still are in existence. The major impetus, however, was received as a result of the Napoleonic Wars, of the War between the States, and of the Franco-Prussian War. Improvements in medical practice had by then made it possible to save a much larger number of men who had lost limbs than had been possible earlier. There thus developed a well-defined craft which reached its peak during World Wars I and II and which established with the medical profession a working relationship directed toward the fabrication of acceptable prosthetic devices.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Iron hand of Goetz von Berlichingen, a.d. 1509. From Faries,<a></a> by permission. See also Thomas and Haddan.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Leg of Ambroise Pare, a.d. 1561. From Faries,<a></a> by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To the efforts of these three professional groups - medicine, therapy, and limbmaking - there have been added in more recent rehabilitation programs the efforts of the social worker, of the psychologist, of the psychiatrist, and of the counselor in vocational guidance, the over-all purpose being to return the amputee to a more successful and better-adjusted position in society. The organization and functions of a modern prosthetics clinic team, as most usually accepted, have been fully and ably described by Bechtol.<a></a> </p> <p>Important as is the role of each of these disciplines, the progress that has been made in prosthetics in recent years may be attributed, in large measure, to the interest the problem has aroused in a substantial number of engineers. The role of engineering in a prosthetics program is not as yet well understood or fully appreciated by the general public. We speak of the role of engineering, rather than of the role of the engineer, because we are concerned more with the application of certain basic physical principles than with the particular individual who applies them. When these principles are well understood and applied by the physician, therapist, or prosthetist, each will function better in his own role. Unfortunately, in our present system of education no provision is made for imparting the basic principles of engineering in courses of instruction for any of these other disciplines. As a consequence, until recently such advances as were made in prosthetic devices came about primarily as a result of much trial and error rather than as the outcome of a planned approach.</p> <p>Any program directed to the development of new prosthetic devices may be divided into three major stages. The first is concerned with basic research. Second is the translation of knowledge gained in the basic research stage into a specific design for a particular device. And third is the application of the device to the amputee and the evaluation of functional gain. But of course a program does not necessarily proceed in such an orderly fashion. Before a device is finally accepted for general application, it may be necessary, and in fact it often is, to retrace the sequence not once but many times in order to gain additional information and understanding. We shall consider later the role of engineering in each of these stages.</p> <h4>The Background</h4> <p>Man performs activities in a variety of ways controlled by physical law. The manner in which he does so has thus interested scientists since the time of Leonardo da Vinci (1452-1519), who made the first systematic study of human movements and described them in his <i>Note on the Human Body.</i> <a></a> In 1679-1680, Borelli,<a></a> a pupil of Galileo, published <i>De Motu Animalium, </i>the first treatise which applied the sciences of physics and mathematics to human and animal activity. The mathematicians and physicists of the eighteenth century - Bernoulli, Euler, and Coulomb - tried to develop rational mathematical formulae for determination of the capacity of human work.</p> <p>The number of investigators increased greatly in the nineteenth and early twentieth centuries, and the two World Wars gave still greater impetus to research in the general field of human locomotion and activity. In Germany, France, England, Russia, and the United States, with different objectives perhaps but directed toward the same general problems, Fischer,<a></a> Fick,<a></a> Gilbreth,<a></a> Amar<a></a>, Martin,<a></a> Schlesinger,<a></a> Schede,<a></a> Bernshtein <a></a>, Steindler,<a></a> Elftman,<a></a> Henschke and Mauch ,<a></a> and the groups at the University of California<a></a> and at New York University<a></a> have studied human performance. Each, individually or as groups, contributed to the increasing knowledge both in the general areas of human activity and in the specific application of this knowledge to prosthetics.</p> <p>From the time of Leonardo, almost every investigator in this field either was primarily a physical scientist, or, if not, had a very intimate knowledge of physics and mathematics. In the later period particularly, the major contributors to the increasing knowledge of human performance have been engineers, physical scientists, or anatomists and physiologists with training in the physical sciences. A more comprehensive review of the investigators in this field is that of Contini and Drillis .<a></a> </p> <h4>Basic Research in Human Motions</h4> <p>In the design of any structure or mechanism, for whatever purpose, the engineer usually proceeds from a set of established specifications. These specifications may describe the function of the device, the space it may occupy, the activity it must perform, the forces which may be applied to it and which it must withstand, the chemical and physical damage to which it may be subjected, the working life expected of it, how often it should be overhauled or maintained, and what it may cost. To design a prosthetic device properly, similar specifications should be prepared. Some of the requirements for a satisfactory prosthesis may be developed from known data, that is, from information obtained empirically over extended periods of time and from the experience of countless amputees. Other information, however, and perhaps the more important in the design of prostheses, can come only after systematic experimentation. To supply this information, then, is the purpose of the program in basic research.</p> <p>Every human movement takes place in time and space and is controlled by external and internal forces and by the mass of the parts involved. The internal forces are generated in the muscles and transmitted through the limbs to tools, controls, instruments, or other objects. The external forces are those of gravity, inertia, ground reaction, and air resistance. When the body is at rest, the external and internal forces are in equilibrium; when it is in motion, the resultant of these forces has some value other than zero.</p> <p>Of course human movements may be observed and the pattern of movement described subjectively. But unless these movements can be recorded and measured precisely, no true understanding of the movement can be had, nor can repeated movements be compared objectively in the same individual or between different individuals. As technology has moved ahead, engineering knowledge has made it possible to develop instruments and techniques for recording and measuring movements and the forces which affect these movements. Although it would be interesting, as an historical aside, to review the methods used by earlier investigators, it is more profitable to describe some of the recent developments.</p> <h4>Methods of Measurement</h4> <p>The invention of photography in the middle of the nineteenth century, and the subsequent improvements in photographic techniques, have made it possible to record motions and displacements exactly (<b>Fig. 3</b>). The development of motion-picture photography, of interrupted-light photographic techniques, and of a combination of the two as obtained in the gliding cyclogram has made it possible to measure not only displacement but also the rate and change in rate at which movements occur. By these techniques, then, we can obtain displacement, velocity, and acceleration. Once these quantities are known, and when the mass of the total moving body or of its segments can be obtained by other measures, the forces acting on the body, the energy costs, and the power requirements can all be computed.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Walking with 75-lb. load. Subject photographed synchronously from three points of view. Time intervals: 0.075 sec. From Muybridge<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Motion-Picture Photography</i></p> <p>Of the photographic techniques mentioned, motion-picture photography is used perhaps most universally. By mechanical or electromechanical means, a light-sensitive film is transported at a known, fixed rate past a lens and shutter. The film-transport mechanism is synchronized with the shutter so that a picture is taken each time the film is advanced one frame. The speed at which pictures are taken may be varied between sequences to suit the particular need, and the shutter speed may be varied to stop the action down to the smallest fraction of time consistent with the particular apparatus and with the object being photographed.</p> <p>With conventional motion-picture equipment, frequencies of up to 128 frames per second have been photographed, action being stopped down to the order of one five-hundredth of a second. Within these limits most human activities may be photographed adequately. A timing device - in effect a large clock, driven by a synchronous motor, and with the dial subdivided into hundredths of a second - permits measurement of the variability in time between frames and in exposure time (<b>Fig. 4</b>). Sometimes x-ray and motion-picture photography have been combined. By this means it is possible not only to record the motion of a limb but also to observe any relative motion between the activating skeletal structure and the external surfaces.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Typical motion picture of walking. <i>Courtesy Prosthetic Devices Study, New York University.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although this method of motion recording has been used extensively, and even though it may be quite adequate for some measurements, it has certain disadvantages which detract from its general usefulness. In the reduction of data, for example, each frame must be registered in two of the three major coordinate axes, some point being maintained as a control. The location of each moving segment must be determined from a constant frame of reference, a matter which introduces possible sources for error. And it has been found that the transport mechanism does not always respond at the same rate, so that the interval of time between frames, on which the computations depend, may not always be constant.</p> <p><i>Interrupted-Light Photography</i></p> <p>When the activity to be recorded is not a repetitive one, as in jumping, or is repetitive but progresses along a linear axis, as is the case with the walking pattern of a leg amputee, interrupted-light photography can be used. In this system the film is stationary in the camera. The lens shutter is kept open, while a slotted disc, driven at the desired speed by a synchronous motor through a gear or pulley system, rotates before the shutter in such a way as to admit and exclude light alternately. The speed at which the disc rotates and the number of slits in the disc together determine the time increment between exposures. The width of the slit (that is, the size of the angle included in the slit) and the rotation speed of the disc determine the time of exposure. In the studies conducted at New York University in conjunction with the Veterans Administration's Prosthetic Testing and Development Laboratory, the disc rotates 20 revolutions per second and the slit is 14 degrees wide, so that the exposure time is of the order of one five-hundredth of a second and each revolution results in one exposure (<b>Fig. 5</b>). These conditions are optimum for the particular application, but they can be modified for other applications. In the system developed by the Prosthetic Devices Study, Research Division, New York University, working with the VA's PTDL, the light is supplied by a single photoflood bulb and is returned by reflective tape, such as <i>Scotch-lite, </i>which marks the points to be photographed. Similar results might be achieved with an open lens and a strobe-flash source of light.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Typical stick diagram of walking. <i>Courtesy Prosthetic Devices Study, New York University.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The obvious advantage of this system is that it provides a complete pattern of a total movement, such as the forward progression of an amputee for two or three strides, all of which may be recorded on one film. Reduction of data is greatly simplified, since the measures of vertical and horizontal displacement are taken directly from a single set of axes. The error then is only that which the operator may make in measuring. The time increment is as constant as permitted by the variation in speed of a synchronous motor.</p> <p><i>The Gliding Cyclogram</i></p> <p>When the motion to be recorded is repetitive in limited space, the interrupted-light method cannot readily be employed, for the pattern of points cannot then be distinguished as to occurrence in time. To overcome this difficulty, Bernshtein<a></a> in Russia and Drillis<a></a> in Latvia developed the gliding cyclogram. This method is similar to that previously described except that here the film is transported across the field at a constant rate but at one that may be varied to suit the particular activity being recorded. Under these circumstances, the position of any point can be identified both in space and time. Even if, in a repetitive motion, a point on a moving segment is returned to an original position, the image in the initial and succeeding instances will be displaced on the film by the distance the film has been transported in the elapsed time increment. If, for example, a point were moving in a circular path, its locus would appear on the film as a cycloid. Although this method increases the amount of work to be done in data reduction,<a style="text-decoration:none;">*</a> suitable graphic shortcuts reduce this work differential to a minimum. As will be apparent (<b>Fig. 6</b>), the gliding cyclogram has special advantages in recording the motion of arm activities, many of which are repetitive and overlapping.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Gliding cyclogram of the axe stroke in woodcutting. From Drillis.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>The Tachograph</i></p> <p>Although each of these methods permits the measurement of displacement, velocity, and acceleration, other methods of instrumentation give direct measurement of velocity and acceleration in certain situations. Velocities along one axis may be measured with a tachograph, a device consisting of a fine cable connected to a moving body, continuing in a closed loop, and driving the rotor of a generator (<b>Fig. 7</b>). Since the voltage is proportional to the angular velocity of the rotor, which in turn is proportional to the velocity of the body, the voltage generated is a direct measure of the linear velocity.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. The tachograph - a system for recording linear velocity. From an NYU report.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>The Accelerometer</i></p> <p>Another electrodynamic device, the accelerometer, measures accelerations directly. Essentially, this instrument consists of a small, compact mass supported by a spring device. When the mass is suddenly accelerated, its inertia deflects the spring by an amount dependent upon the acceleration and the spring constant. By suitable means, such as by differential transformers, the deflection is converted into a change in voltage proportional to the displacement and thus proportional to the acceleration imparted to the accelerometer. More recently, accelerometers have been devised employing strain gauges (see below).</p> <p><i>Direct-Recording Force-Measuring Devices</i></p> <p>Displacement and velocity permit us to describe a motion; acceleration and mass permit us to compute the forces which affect the motions. Sometimes it is possible and desirable to measure forces directly. A number of such force-recording devices have been made possible by technological advancement in the past 20 years.</p> <p><i>The Strain Gauge. </i>The strain gauge, which has been used in innumerable applications, is such a device. Essentially, it consists of a fine wire of known cross-sectional diameter and electrical resistance, arranged in a packet (not unlike a <i>Band-Aid</i>) so that it may be attached directly to some structural element. When the structural element is stressed, it either elongates or shortens, depending upon whether it is in tension or in compression. The filament of the strain gauge follows the structural element to which it is attached, and its cross-sectional area is reduced or increased, with consequent stretching or compression along its length. The electrical resistance is thus increased or decreased from the normal or zero-load position. By suitable electrical magnification and instrumentation, and with proper initial calibration, instantaneous changes in load can be measured and recorded.</p> <p><i>The Capacitor. </i>Another device for measuring loads or forces directly is the capacitor, a small capsule consisting of a dielectric material between two layers of electrical conducting material. When a voltage is applied across a capacitor, an electric charge is stored. The capacitance of the unit varies directly as the area of the surface plates and inversely as the thickness of the dielectric. When pressure is applied across the faces of the capacitor, the thickness of the dielectric is reduced and the capacitance is changed.</p> <p>Pressure gauges based on this principle have been developed at the Franklin Institute.<a></a> In these instruments, the construction is loose so that appreciable changes in spacing between the plates, and hence in capacitance, occur with changes in loading. Springiness is achieved by impressing a waffle pattern of indentations into the steel discs which serve as the plates of the capacitors. The gauge is used as one arm of a bridge circuit in which a high-frequency signal is supplied and the unbalance is amplified and recorded on an oscillograph. The degree of unbalance is calibrated in terms of load on the gauge.</p> <p><i>Other Force-Recording Devices. </i>Still other techniques for the measurement of loads have been used widely. For example, the principle of equal distribution of pressure in pneumatic and hydraulic systems has resulted in the development of various types of pressure gauges. The property of springs - leaf, helical, or torsion types - in maintaining, within certain limits, a direct ratio of load to deflection has been used in other force-measuring units. Still other devices have been developed making use of other known physical phenomena to obtain data desired in specific problems.</p> <h4>Experimental Adaptations</h4> <p>Many of these principles, techniques, or devices have been applied in the basic research program to obtain the data needed to develop new and better prostheses. The same applications also have been used to evaluate the prostheses on the amputee, and in some instances special adaptations of certain of these principles have been used as aids in amputee training. Some of the more important experimental units merit further elaboration.</p> <p><i>The Lower Extremity</i></p> <p>In 1945 the Prosthetic Devices Research Project at the University of California, Berkeley, initiated a program of basic research directed toward the gathering of information on locomotion, both in normal subjects and in leg amputees. It was desired to obtain data on the individual factors which contribute to the pattern of human gait - the displacements of the head, arms, and torso; the displacements and rates of displacement of the thigh, shank, and foot; the moments at the hip, knee, and ankle joints; the pressure at the point of ground contact; and the shift in apparent point of pressure application. Using the techniques already described, the engineers participating in this program developed a variety of ingenious devices.<a></a> </p> <p>To record the displacements of the segments of the body, motion-picture techniques were adopted. The appropriate control points on the body were identified by targets, in some instances the motions of small magnitude were magnified by target extensions, and in other instances the pattern of locomotion was photographed at intervals varying up to 3000 per second. To obtain the components of motion along the three axes of space, a glass walkway and tilted mirror were used. By this expedient, side and plan pictures were taken simultaneously on one film, thus minimizing the time required for reduction of data and also reducing the possibility of error as compared to the use of two synchronized cameras. From these photographs the motions of the leg segments, heel and toe rise, degree of knee flexion, phasing of the step, and all other desired details could be analyzed. Forces during the swing phase could be determined, as could also the moments at the joints.</p> <p>To measure ground reaction, two force plates were designed using strain gauges in various combinations to measure vertical, fore-and-aft, and lateral components of foot pressure at ground contact. Through appropriate electronic combinations, the strain pickup also could give the apparent instantaneous center of pressure and the torsional moments exerted by the rotation of the foot at ground contact. In a similar study conducted by the Research Division, College of Engineering, New York University, the same elements, strain gauges, and structural beams were combined in another variation of the force plate.<a></a> Both the UC and the NYU force plates represented a refinement of those conceived and used by Elftman,<a></a> who, in his earlier studies in human locomotion, had used springs and dial gauges to record components of forces.</p> <p><i>The Upper Extremity</i></p> <p>The University of California at Los Angeles, through its Engineering School, was entrusted with basic research in the upper extremity. To study the range of movement required by arm prostheses in the performance of selected daily activities, a photographic procedure was established. A subject was placed within an enclosure composed of vertical, horizontal, and lateral grids. Two mirrors permitted views in the horizontal and lateral planes (<b>Fig. 8</b>). When the subject was photographed, the motion of the targets on the joints could be pictured simultaneously in all three planes, together with the coordinate grids, thus permitting rapid data reduction. An ingenious mannikin enabled the duplication of motions photographed for further study of particular combinations of angular displacement of segments.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Three-dimensional grid system for analyzing motions in the upper extremity. From an NRC report.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Adaptations to Evaluation</i></p> <p>It is difficult to indicate clear boundaries between the basic research and the evaluation stages in the Artificial Limb Program, for many of the tools used to obtain basic data also are useful to the group at New York University engaged in the evaluation of prostheses. These techniques and others now being used in the evaluation program are discussed later (page 65). As the measuring and recording instruments become more generally applied, scientists other than engineers will become equally proficient in their use. When the need arises, the engineering profession undoubtedly will produce even more refined devices for measuring more complex performances.</p> <h4>Prosthetics Design</h4> <p>Important as is the role of engineering in the development of instrumentation and equipment for basic research in human motion, it is in the second stage of any prosthetics program - the design of the prosthetic device - that the engineer is pre-eminent. Among the many factors he must consider in the design of a prosthetic device we may include safety, function, control, efficiency, appearance, comfort, simplicity, and durability. These features can scarcely be assigned any order of importance; since they are all interdependent, the design usually must end up as a compromise.</p> <p>Safety, function, control, efficiency, and appearance require a knowledge of the means - mechanical, pneumatic, hydraulic, or electrical - by which the desired performance can be accomplished and also a knowledge of the forces available, of the forces applied, and of the proper distribution of masses in the device. Comfort requires a knowledge of the limits and distribution of pressure that can be tolerated by body tissues and vessels without damage and without distress to the amputee. Simplicity and durability, both important in the cost and maintenance of the device, require a knowledge of the breakdown that may occur owing to perspiration and body acids, continuous use, temperature changes, and abrasion and chemicals from external sources and, in addition, knowledge as to what materials and combinations of materials may be used to minimize such deterioration.<a style="text-decoration:none;">*</a></p> <p>This kind of problem is the true test of engineering. All the physical sciences which contribute to the substance of engineering may be called upon in evolving the final product. The mechanical engineer contributes his knowledge of mechanisms - cams and gears and linkages, which together may reproduce a motion. With the hydraulic and electrical engineer, he devises means for the operation or control of the prosthesis, for damping a swing, or for magnifying the power available within the amputee. The metallurgical engineer develops the alloys which go into the joints and prescribes methods of treatment to bring out the maximum qualities desired - strength or ductility or resilience or wear. The chemical engineer makes available the new synthetic substances which so handsomely replace the natural substances heretofore the only materials available. Plastics, whether they be the strong, structural resins used in the lamination of shanks and arms,<a></a> or whether they be the plastics used for cosmetic purposes,<a></a> have radically changed the appearance, weight, and sanitary properties of prostheses.</p> <p>The design engineer must combine all this knowledge into the most effective whole. He must bring to the job all of the experience and ingenuity he possesses so that the ultimate product will not only produce the desired function, be strong enough, and last an adequate period but will also be relatively inexpensive and simple enough to be maintained locally with a minimum of special tools. The making of artificial limbs can now be based on well-established scientific principles; it can cease to be empirical and can become a branch of engineering and medical activity. But without the necessary technical skills, progress in prostheses will return to the trial-and-error system from which it has so recently emerged. Some of the specific problems to be solved, and the methods for their solution, which have occurred in the design of upper- and lower-extremity prostheses, deserve to be discussed in some detail.</p> <h4>The Lower Extremity</h4> <p>The scientific basis for lower-extremity prostheses is provided by biomechanical investigation of the functions of the lower limb in human locomotion. Man is an erect biped, that is, he has two supporting limbs and the mass of his body is carried in a vertical plane. The human body, then, may be represented as an upper mass upheld by two supporting columns. The upper mass consists of the head, arms, and trunk. The supporting columns are the two lower limbs. Of complex character, they each consist of three segments, superposed and movable on each other. To meet the needs of standing, the three movable segments form a quasi-rigid column by virtue of their superposition.</p> <p>The standing position includes standing on both feet and standing on one foot, as in the stance phase during locomotion when the weight is borne on one foot only. The vertical line passing through the center of gravity of the body passes behind the line connecting the centers of the two hip joints and in front of the axes of the knee joints. Extension of the trunk relative to the thigh and of the thigh relative to the shank is thus maintained by gravity and limited by powerful ligaments. The two lower limbs therefore remain rigid with a minimum use of active muscle groups. But locomotion demands that the lower limbs be composed of movable, superposed segments. This requirement appears irreconcilable with the demands imposed by the standing position, but the natural arrangement of the lower limbs meets both requirements. Mobility of the hip and knee joints is essential in performing a normal step, a motion which can be divided into four alternating phases, two phases of support on both feet and two phases on each foot alternately.</p> <p>During single support on one foot, the supporting leg bears the weight of the body while the other swings in the sagittal plane like a pendulum suspended from the trunk. Since the two lower limbs are of precisely the same length, the swinging leg must become shorter than the supporting one, or else the swinging foot would drag on the ground. Shortening of the swing leg is effected by flexion of the thigh on the trunk, of the shank on the thigh, and of the foot on the shank.</p> <p>The geometry of the hip joint, and particularly that of the knee and ankle joints, is very complex. Not all authorities are in agreement as to the movements of the segments of the lower limb in flexion and extension, but enough is known to provide information as to how stability and mobility are provided both in standing and in walking. In the manufacture of artificial legs, it is desirable to reproduce insofar as possible the static and dynamic characteristics of the sound limb.</p> <p><i>The Above-Knee Case</i></p> <p>With notably rare exceptions, the design of artificial legs proceeded along a fairly well-defined pattern. Generally, until the middle of the nineteenth century, and now still so in many underprivileged countries, it was considered adequate to supply the leg amputee with a peg-leg. For above-knee amputations, it consisted of a pylon supported below a pad, corset, or socket, which in some fashion was attached to the stump or suspended from the shoulders. For below-knee amputees, the stump was flexed and the peg-leg attached below the flexed knee.</p> <p>Such an artificial leg satisfied completely one of the two functions of the normal leg. It provided a column which, together with the sound leg, allowed the individual to stand erect. It also enabled the wearer to walk, although, since there was no knee joint, it affected the amputee's gait considerably. In the swing phase, the wearer was required to raise the hip on the amputated side in order to swing through; in the stance phase he necessarily had to vault over the pylon. Although such a device is simple, strong, inexpensive, and quite serviceable, the amputee is subjected to excessive stress during walking, his gait is asymmetric and unnatural, his performance in walking is inefficient, and his physical appearance is far from cosmetic.</p> <p>Next in order of development was the so-called "conventional" leg (<b>Fig. 6</b>, page 11). In general, this prosthesis was made to look like the sound leg, that is, it possessed some cosmetic appearance. The knee was hinged and could be flexed, although in the earlier devices a knee lock was provided to assure stability in standing. The foot was attached to the shank with either a rigid or a jointed ankle.</p> <p>This order of devices had many advantages over the peg-leg, but it introduced other problems. Because of the knee hinge, it was possible to sit or kneel or to perform in a more natural manner other activities requiring knee flexion. Moreover, because of the knee joint, when not provided with a knee lock, the amputee was able to walk with a better gait. Knee flexion permitted a certain amount of leg shortening in the swing phase, thus reducing the amount of hip elevation required to clear the ground. But the knee and ankle joints introduced instability in the stance phase, particularly at heel contact. The free-swinging leg resulted in an exaggerated back swing and forward swing with a pronounced shock at each stop. Later compromises were effected by setting the knee bolt forward of the weight line of the body, by addition of check straps to decelerate the shank at toe-off and to provide some assistance at the beginning of the forward swing, by introducing friction devices at the knee bolt, by a combination of both, and by limiting ankle motion through the use of bumper blocks.</p> <p>With minor and individual exceptions, this was the general state of development at which the above-knee prosthesis had remained until the end of World War II. As a result of the research initiated thereafter, engineers began to devote time to the application of old and new knowledge to the design of lower-extremity prostheses. Among the features which had been demonstrated as desirable were flexion at the knee but with some stabilizing control at the time of heel contact and immediately thereafter, some measure of support in an emergency situation such as in stubbing the toe, a controlled swing of the leg, an ankle joint which would permit rotation in a horizontal plane as well as in the sagittal and transverse planes and yet not be so flexible as to increase instability, and a toe-lift device for ground clearance in the swing phase. All this was to be accomplished without substantially increasing weight, sacrificing durability, or increasing initial and maintenance costs of the device. By combining known engineering principles with newly developed materials, a substantial gain was achieved in the above-knee prosthesis, with consequent improvement in the performance of many leg amputees.</p> <p>The U.S. Navy above-knee leg <a></a> developed at the U.S. Naval Hospital, Oakland, California, is an example of such an improved prosthesis. Controlled swing with terminal deceleration was achieved by the use of friction devices which come into operation in the last portion only of the forward and backward swings. New plastics and molding techniques provide a much more natural appearance. New methods of bonding rubber and a new method of attaching the foot to the shank allow for greater flexibility at the ankle without serious problems of instability.</p> <p>Proper application of mechanical and hydraulic engineering principles have resulted in two improved devices, the Stewart-Vickers and the Henschke-Mauch hydraulic legs, both for above-knee amputees. The Stewart-Vickers leg (<b>Fig. 9</b>) provides some resistance to knee flexion and hydraulic damping or deceleration at the terminal portion of the forward and backward swings. By a controlled cycle of operation of valves and cylinders, it provides coordinated hip-knee-ankle flexion in the swing phase so that adequate ground clearance is obtained, gives to the gait a more natural appearance, and apparently results in less effort on the part of the amputee. Whenever it has been tried by an amputee, it has generally resulted in favorable acceptance.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. The Stewart-Vickers hydraulic leg incorporating knee lock, swing-phase control, and coordinated motion between ankle, shank, and thigh. <i>Courtesy Prosthetic Devices Study, New York University.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The Henschke-Mauch leg,<a></a> which most nearly duplicates the swing pattern of the sound limb, has been designed to provide stability at heel contact, both at the beginning of the stance phase or in the event of a sudden forward acceleration as in stumbling. A carefully designed, pendulum-type valve controls the passage of hydraulic fluid within a cylinder, the added stability being maintained long enough for the amputee to regain his balance but not long enough to impede knee flexion in the stance phase or to increase the risk of a fall. By other valving arrangements the hydraulic cylinder also controls the leg in the swing phase by providing adjustable constant friction in the full cycle plus terminal deceleration.</p> <p>The human knee joint flexes by a combination of rotation and sliding, so that a simple, single-axis joint cannot duplicate the relative positioning of the tibia and femur. A number of attempts have therefore been made to duplicate this articulation in so-called "anatomical" knees by means of various complex mechanical devices, of which one is the four-bar linkage. In <b>Fig. 10</b>, links <i>AD </i>and <i>BC </i>attach thigh to shank. Links <i>AB </i>and <i>CD </i>are formed by the shank piece and the thigh piece, respectively. <i>A </i>is the center of rotation of the ankle; <i>K </i>is the center of rotation of the knee; <i>H </i>is the center of rotation of the hip joint. The locus of the instantaneous center of rotation of the knee is 0-5-10-20-30-45-90, the centers being at the point of intersection of projections of the links <i>AD </i>and <i>EC. </i>Each number indicates the angle of knee flexion which places the instantaneous center at the point shown. As extension takes place, the effect is as if the shank were lengthened and the thigh shortened, a feature which aids stability in the stance phase and reduces the force required to start flexion at the beginning of the swing phase.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Polycentric knee based on a four-bar linkage. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the design shown, maximum elevation of the center of knee rotation occurs prior to full extension, so that initial knee flexion at toe-off is difficult. An improved design, with maximum knee elevation at full extension, is to be found in the University of California four-bar-linkage knee <a></a>. It attempts to simulate the path of the instantaneous centers of rotation of the knee joint so as to provide maximum stability and maximum flexibility at the proper times in the walking cycle.</p> <p><i>The Below-Knee Case</i></p> <p>It is this complex articulation of the knee joint that poses a major problem in the design of an adequate below-knee prosthesis. Since the below-knee amputee retains his natural knee, and since each individual knee follows an individual pattern in flexion, it has thus far been impossible to provide between the thigh corset and the below-knee socket an articulation that will not introduce some displacement between the stump and the socket.</p> <p><i>Methods of Suspension</i></p> <p>The suspension of the above- or below-knee prosthesis has been another area for research and design. Above-knee prostheses had been suspended either by shoulder harness or by some sort of pelvic band. The former did not maintain an adequate positioning between the stump and the socket, since by its very nature it could not adjust to the varying relationship between the shoulder and the leg in different activities. Although the pelvic band retained the leg more securely, it in turn imposed an artificial restriction on possible thigh movements, especially rotation and abduction.</p> <p>A novel method of suspension by suction was patented by Parmelee<a></a> in 1863, but the idea apparently was abandoned in this country although it continued to be used occasionally in Europe. Increasing experience with the suction socket in Germany after 1933 brought it to the attention of medical and engineering scientists in other countries, including the United States. After World War II, in a coordinated program sponsored by the Veterans Administration and directed by the Advisory Committee on Artificial Limbs of the National Research Council, all aspects of suction-socket suspension were studied carefully. The results of this study proved the merits of the suction-socket method of suspension, and it is gradually being adopted for all above-knee prostheses<a></a> where the limbmaker is certified to make such a socket and where there are no medical contraindications. A similar method of suspension is being worked out for below-knee prostheses with increasing evidence of success.</p> <h4>The Upper Extremity</h4> <p>The upper limb is the limb of contact. It consists of three segments - the hand, the forearm, and the arm. Of these, the hand is the most highly differentiated and the most important, since the essential upper-extremity function is grasp, which is mobile and variable in quality, power, and duration. Although its primary function is that of prehension, the hand is also one of our major sense organs. Through it we sense temperature, pressure, surface quality, and the shape of objects. For the blind it serves as substitute for the eyes by providing a sense for discriminating form and texture and, together with the forearm and arm, for determining spatial relationships. The forearm and arm serve merely as mobile attachment for positioning the hand in space. Since most of the hand movements and its different articulations are dependent on arm and forearm muscles, they provide a reserve of active power for hand activation. A detailed analysis of the functional mechanism of grasp <a></a> furnishes the basis for construction of the more scientifically conceived artificial hands.</p> <p><i>The Mechanism of Prehension</i></p> <p>The natural grasp and manipulation are wholly dependent upon the muscular action controlling movement of the fingers. The nature of muscular action therefore determines the nature of the grasp, and the two properties governing the mechanical phenomena of muscular function are contractility and elasticity. Contractility of the muscle is controlled at will. It can be graduated voluntarily in power, extent, and duration, so that the fingers can be closed firmly or gently, as in holding a tool or an egg, or partially or wholly, as in holding a book or a sheet of paper (<b>Fig. 11.</b>). Similarly, the fingers can be moved or closed for very short or very long increments of time, as in fingering the violin or in holding a telephone receiver. Muscle normally is in a state of tone, which may be defined as the property possessed by muscle of preserving, either by voluntary or by reflex action, a state of contractility. This contractility may be long or short in duration, greater or less in extent, strong or weak in power. By means of muscle tone, the hand can be kept in a convenient position for long periods of time.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Twelve basic types of grasp. After Schlesinger.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since the hand is so important in everyday activities, and since its functioning is so complex and so dependent for mobility on the two other segments of the upper limb, surgical and orthopedic treatment of the upper-extremity amputee is extremely important in restoration of functional loss. It should be directed toward preservation of the maximum amount of natural mobility. Since it is not yet possible to create artificial muscle, it is necessary to reproduce as well as possible by indirect processes the effects of normal muscle action on the fingers. Prostheses for this purpose are successful in such proportion as the mechanical effects produced approximate those of the natural limb.</p> <p><i>Substitute Power Sources</i></p> <p>Until the present, and even now with all the currently available technology, the most adequate substitutes for the lost muscle activators are muscular substitutes, self-powered agents which induce the movement of the artificial fingers by means of artificial tendons, that is, by control cords. The latter are, as a rule, attached by some appropriate means to the shoulder on the amputated side or on the normal side or both. The movement produced by them is thus entirely dependent upon the shoulder group of muscles. Improvements in surgical techniques<a></a> and extensive research in muscle physiology<a></a> recently have reawakened interest in the use of cineplastic procedures to provide other muscle motors (<b>Fig. 12</b>). Both the biceps and pectoral muscle groups have been used for this purpose.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Below-elbow biceps cineplasty control system. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since the action of the controlling muscles must continue for such periods as required for the particular grasp function concerned, the muscular substitute can become heavily burdened. It is therefore absolutely necessary to arrange for release of the muscular substitute once the fingers have been placed in the appropriate position. This is achieved by mechanisms which produce in the artificial fingers the same effect as that produced by muscle tone in the natural fingers.</p> <p><i>Prior Art in Upper-Extremity Prosthetics</i></p> <p>Although the basic concept of an artificial arm and its terminal device has not changed materially from that of the first arms made many years ago, recent technological developments in materials of construction and a better application of known mechanical principles have together resulted in arms of improved appearance and greatly improved function. As in the artificial leg, the materials most commonly used for the artificial arm and forearm have been wood and leather. Control was achieved by shoulder harness operating through control cords, usually leather, connected to the terminal device, which was usually a split hook, that is, a pair of iron or steel fingers bent in the shape of a hook and so hinged as to close on each other. For different applications the shape of the hook was modified as appropriate. Since in general the closed position required for grasping an object is of longer duration than is the open position for approaching the object, opening was effected by the shoulder muscles and closing was brought about by some spring or elastic medium. Cosmetic appearance was neglected or, in those few cases where it was attempted, a passive hand was the usual result.</p> <p>To return to the arm amputee some measure of productive capacity, there were devised a great many one-function terminal devices, each intended for some particular occupational need (<b>Fig. 13</b>). Such "tools" could be inserted and attached to the distal end of the artificial arm. The practice was predominantly European, and we see in their "armamentaria" hooks, rings, hammers, knives, brushes, and a multiplicity of other designs intended to enable the amputee to function in his customary occupation as smith or carpenter or metal worker .<a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Typical occupational-aid terminal devices, all European. The screened boxes indicate the devices recommended for the various activities. From a German report.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Present-day technology and a formal approach to the design of both arms and terminal devices has since effected vast improvements in upper-extremity prostheses. Although most of the newer designs have been described in detail in available literature,<a></a> it is appropriate here to review these developments in a very general way as they relate to engineering practice.</p> <p><i>New Arm Substitutes</i></p> <p>The developments in plastics and in methods of fabrication have resulted in greatly improved arms. By proper lamination, molding, and coloring, arms and forearms can be made lighter, stronger, and with much better cosmetic value.<a></a> Shoulder caps for high above-elbow amputations and for shoulder disarticulations (<b>Fig. 14</b>) can be molded successfully to provide a good base for attachment of the prosthesis. Similarly, plastics of a different character and with other molding methods produce the flexible artificial gloves which cover the active hand to provide natural appearance.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Shoulder-disarticulation harness. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>With regard to elbow and wrist articulation, basic research had indicated the desirability of certain ranges of arm motions.<a></a> To provide the necessary mobility, multipositioning elbows and wrists have been devised. The use of ratchet mechanisms, friction clutches, and alternator devices enable the above-elbow amputee to position the forearm by voluntary control through the shoulder harness. Wrist units have been designed both for positioning the terminal device in flexion and rotation and for quick disengagement of the terminal device.</p> <p><i>New Hand Substitutes</i></p> <p>The improvements effected by sound engineering approach are particularly evident in the terminal device (<b>Fig. 15</b>). Since control resides in the shoulder muscles, it appears logical that voluntary control should be available for closing the fingers rather than for opening the device. Such an arrangement, characteristic both of the APRL hook and of the APRL hand,<a></a> permits some measure of control of the force applied. An alternator mechanism provides for alternate opening and closing of the fingers, locks the fingers in the closed position with the desired pressure, and thus relieves stress on the shoulder muscles while an object is held. The extent of opening of the fingers can be set in either of two positions, depending upon the particular operation being performed, and in repetitive operations the lock can be eliminated, thus reducing the amount of work to be done by the shoulder muscles. The development of these voluntary-closing devices has, moreover, permitted the more successful fitting of cineplasty cases.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Types of grasp possible with the natural hand and those available in various designs of artificial hands. After Schlesinger.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For other situations, where an amputee may prefer a voluntary-opening hook, the Northrop two-load hook<a></a> is available. Using springs rather than elastic bands, it permits the fingers to close with either one of two available spring loads. The hook fingers of this terminal device as well as of the APRL hook were shaped in accordance with the findings of basic research into the frequency of hand prehension patterns.<a></a> </p> <p><i>Harnessing</i></p> <p>The whole technique of harnessing has undergone extensive revision as a result of applied engineering principles.<a></a> One feature concerns the fact that the power available at the shoulder should be transmitted to the terminal device with a minimum of loss, that is, with maximum efficiency. Replacing the older leather thongs is the Bowden cable adapted from the aircraft industry. The cable is attached to the harness, directed along the arm by an appropriate number of suitably located cable-housing retainers, and ends at the terminal device. In this circuitous path are friction losses owing to passage of the cable through its housing, especially at points of flexion around joints. Proper selection of points of load application, however, and judicious design of various components make it possible to reduce frictional losses to a minimum (<b>Fig. 14</b> and <b>Fig. 16</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Below-elbow figure-eight harness. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The successful harnessing of cineplasty cases requires the intelligent use of applied mechanics and biomechanics.<a></a> The terminal device and the control system by which it is operated must be adapted both to the end-uses desired by the amputee and to the physiological characteristics of his muscle motor.</p> <p><i>External Power Sources</i></p> <p>A more or less radical departure in the design of upper-extremity prostheses has been the application of engineering science to the utilization of external power sources for activation of arms and terminal devices. Although pneumatic and hydraulic applications have been attended with little success, the development of miniature, compact, and powerful electrical components has made it possible to develop an electrically actuated arm.<a></a> Elbow flexion, wrist rotation, and prehension can all be operated electrically, but thus far it has not been possible to develop completely suitable methods of control. The individual components, such as the electric elbow lock, may, nevertheless, have useful application in more conventional arms.<a></a> Study of such possible applications is now under way. There can be little doubt that, in some future study, with even newer materials and more advanced methods, externally powered arms, discretely controlled and respondent to the will of the amputee, may be developed.</p> <h4>Techniques of Evaluation</h4> <p>The real merit of a prosthesis cannot be judged solely on the basis of mechanical and cosmetic elegance of the design or by the number of functions it incorporates. It can be evaluated in true perspective only when it is fitted to the amputee and when his over-all performance with and acceptance of the device is appraised. In the Artificial Limb Program, the Prosthetic Devices Study, Research Division, College of Engineering, New York University, has been charged with the evaluation of prosthetic devices. To conduct this work, the roster of personnel includes physicians, psychologists, physiologists, therapists, and engineers, and the evaluations consider both the subjective and objective aspects of the biomechanical relationship.</p> <p>Although in much of ordinary engineering practice the objective evaluation of a mechanism is the only valid criterion, in prosthetics practice, because of the close relationship between the human and mechanical elements, the importance of subjective evaluations cannot be discounted.<a></a> As has been demonstrated repeatedly, what appears to be a very distinct and sound advance in a prosthesis may not in fact be acceptable to the amputee. A proper understanding of the attitudes of amputees, how they are affected by their own experience and by the characteristics of a device, and how these factors can be translated into the design is altogether necessary. The psychologist therefore has an important role in the evaluation process. So, too, the therapist, trained to observe human performance, and with a knowledge of the physiology and function of the human organism, can render a sound opinion with respect to the relative merits of various amputee-prosthesis combinations.</p> <p>But these methods of evaluation are subject to all the limitations of personal judgment. The experience and acuity of the particular observer, the relationship between the observer and the amputee, and other individual factors will in some way affect the evaluation. To a certain extent these variables are controlled by a comparison and correlation of judgments of different observers, but even under the most favorable conditions there may always be areas of disagreement as to what has been observed.</p> <p>When positive criteria of performance with a prosthetic device can be established, it becomes very important to be able to measure and record accurately those factors which constitute the criteria. Instrumentation and methods developed on the basis of engineering knowledge provide the tools for obtaining objective data. They enable the investigator to compare the performance of a particular amputee with different prostheses, of a given amputee with the same prosthesis at different times, or of different amputees wearing identical prostheses. The recording instruments and techniques available can record more rapidly, more accurately, and more permanently than can any human observer. All the devices useful in the basic research program are equally useful in the evaluation program.</p> <h4>The Lower Extremity</h4> <p><i>Symmetry in the Walking Pattern</i></p> <p>In establishing criteria for the evaluation of lower-extremity prostheses, it has been postulated that the pattern of normal locomotion is symmetrical and, therefore, that the behavior of the normal side may be the legitimate measure of performance of the affected side. That is to say, the more nearly the amputee achieves a symmetrical pattern of locomotion the better the prosthetic device and the better the adjustment to it. Further, it is assumed that, in the performance of activity, the human organism adjusts itself to perform at a minimal level of stress. The measure of performance of normals, then, can be a guide to the relative merits of amputee-prosthesis combinations. Such criteria as stability in the erect position, variability of stride time, and other biomechanical factors may be used as indices of performance. Lacking proper instrumentation, no objective evaluations of this character could be made.</p> <p><i>Energy Costs</i></p> <p>The investigations of Hettinger and Muller<a></a> indicate that the walking cadence favored by a normal human being is usually that which requires the minimum expenditure of energy. Deviations from this optimum cadence require increasing amounts of energy. Psychologists indicate that, in a repetitive operation which may be performed at varying tempos, the average person will perform the operation with least deviation at some one tempo best suited to him. On the strength of these two premises, the variations in stride time at different cadences were recorded and curves plotted (<b>Fig. 17</b>). The assumption is made that the nearer the curve of the affected leg approaches that of the normal leg, and the nearer the two curves approach those of a normal subject, the better the prosthetic device. Such data can be taken with the tachograph (<b>Fig. 18</b>), force plates, and interrupted-light photography.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Variability in stride time. <i>Courtesy Prosthetic Devices Study, New York University.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Velocities in level walking at normal speed (from tachograph records). <i>Courtesy Prosthetic Devices Study, New York University.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Fig. 19</b> represents a typical plot of vertical load versus time during ground contact from heel contact to toe push-off. By means of stick diagrams and force-plate records, this over-all curve may be resolved into one for heel-contact impact and another for toe push-off momentum. When the separation is correct, the area C should be equal to the area <i>D. </i>Used in conjunction with other criteria, these curves give useful information regarding the effect of a prosthesis on the amputee's gait.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Components of vertical force. Normal speed, level walking, mean of eight subjects.<i>Double-Support Time (delta t)</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Marey and Demeny<a></a> determined that the time of double support in the walking cycle is inversely proportional to cadence. The NYU studies indicate that it is also related to the ratio of swing-phase time to stance-phase time <i>r </i>and that, moreover, at optimum cadence the stance-phase time in normals is approximately twice the swing-phase time. A criterion was established that, given the relationship between double-support time and cadence, plotted against a family of curves for varying ratios of swing-phase time to stance-phase time, that amputee-prosthesis combination was best which enabled the amputee group more nearly to approach the normal group.</p> <p><b>Fig. 20</b> shows the average trend line for a group of normals and for a group of above-and below-knee amputees. From the equation indicated, a series of hyperbolas may be plotted for varying values of <i>r. </i>The observed double-support times for normals, for below-knee amputees, and for above-knee amputees at three different speeds were plotted, and straight lines were fitted to these observed points. A line for double-support time crosses each of the hyperbolas at two points. The mean abscissa of these points indicates optimum cadence. Since a deviation from this optimum causes an increase in energy consumption, the increase in the value of <i>r </i>can be used as an indicator of higher energy requirement. The validity of this criterion appears to be borne out, since the below-knee group, having more of their natural limbs, more nearly approach the normals. Again, such data can be obtained only because adequate instrumentation, force plates, tachograph, and camera are available.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Analysis of optimum cadence. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Vertical Stability</i></p> <p>Stability in the erect position is used as another criterion.<a></a> The normal individual keeps himself erect by the interaction of muscle and skeletal groups responding to sensory cues. In the amputee some of the normal cues have been destroyed and new ones, such as pressure on the stump, or pain, have been introduced. Besides this, the amputee has fewer muscle groups available with which to compensate for the effect of external forces tending to throw him off balance. Because the human anatomical structure is not truly rigid, the equilibrium of a normal erect subject will be disturbed by a force of lower magnitude than that which will unbalance a rigid body of the same general mass distribution and with the same general support base (<b>Fig. 21</b>). Since the amputee cannot compensate for the effect of unbalancing forces as readily as can a normal, and since in fact poor alignment or fit of the prosthesis may exaggerate the unbalancing effect, the measure of stability is highly important.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. The base of support. <i>C </i>represents the center of the support base. Shaded areas show the contact zones of feet and ground. The small trapezoid defines the limits of travel of the projection of the center of gravity. <i>P </i>represents the mean of all the readings of center-of-gravity projection. The distances <i>d1, d2, d3, </i>and <i>d4 </i>are the respective distances from the center <i>P.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Three methods are used for obtaining information on stability. In one, the subject is placed in a known position on one force plate and the center of the base of support on the force plate is determined geometrically. The extent and frequency of deviation in the sagittal and transverse planes are recorded simultaneously (<b>Fig. 22</b>). Mean values of recorded oscillations determine the location of the center of pressure, which at the same time is also the projection of the center of gravity on the force plate. Distances measured from the center of pressure of the axis of each foot give an indication as to how the body weight is distributed between the two legs.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Record of stability in standing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since the reduction of force-plate data alone is not sufficient for the purpose of determining stability constants, a simple device, the stability platform shown in <b>Fig. 23</b>, has been fabricated for imposing upon a subject known accelerations and recording that one at which he is unbalanced. The support base is known, the center of mass of the subject vertically above the platform can be established, the acceleration when the platform is suddenly released can be controlled by the known weights in the suspended basket, and thus it can be determined at what acceleration the subject is unbalanced. Stability trapezoids for normals and for above- and below-knee amputees (<b>Fig. 24</b>) have been prepared on the basis of available data. It will be noted that thus far only four positions have been recorded - accelerations tending to unbalance the subject in the forward, rearward, right, and left directions. No positions along intermediate axes have been studied, but it seems likely that, if more positions were measured, the envelope would assume some oval shape. This criterion too seems validated by results, since, although there are differences between individual amputees as well as between normals, as a group the below-knee amputees more nearly approach the normal group.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. The stability platform. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Stability polygon; mean values in percent of <i>g. Courtesy Prosthetic Devices Study, New York University.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Another simple device which has been used to corroborate acceleration data is the inclined platform. A kymograph records the increasing angle of tilt, and the recording is interrupted when the subject topples.</p> <p><i>Standardization of Fit and Alignment</i></p> <p>It is not amiss at this point to mention two devices, developed at the University of California, which are indispensable in the evaluation procedures. The alignment devices for above- and below-knee prostheses and the transfer jig<a></a> are tools useful in assuring that different prostheses on the same amputee are alike in physical dimensions and positioning, and they make it possible to measure the effects of known changes in position or alignment in the same prosthesis. A third device, developed at the Prosthetic Testing and Development Laboratory of the Veterans Administration, makes it possible to duplicate sockets, a matter of importance when shanks requiring different sockets are needed. The internal contours of the socket can be maintained and their effect on changes in performance thus minimized.</p> <p><i>Measurement of Force Distribution</i></p> <p>Engineering knowledge makes it possible also to study special characteristics of a device or of a method of fitting. In evaluating the relative merits of the "soft" and hard sockets for below-knee amputees, three new techniques have been evolved. It is desirable to observe changes which occur in the stump as a result of wearing the socket. Accordingly, there has been devised a jig which will hold the amputee in a given position while an impression or cast is made of his stump. Since a rigid pattern of posture is thus imposed, the impression or cast reflects only physiological changes over a period of time. The contours of the stump are then obtained by using a contour tracer or perigraph, also developed for this special purpose. Small variations in contours at known levels can be recorded and compared.</p> <p>The second technique involves the use of the capacitance gauges previously described. In a study at New York University, in cooperation with the Prosthetic and Sensory Aids Service of the Veterans Administration, they have been applied in an attempt to answer once and for all the question among limb-makers as to the proper distribution of forces within a below-knee socket. Several gauges are attached at points of particular interest on the stump of a below-knee amputee (<b>Fig. 25</b>). The subject then walks at different speeds for a distance of 30 to 40 feet while the unbalance of the gauge bridges is recorded. In this way, simultaneous indications of pressure are obtained at six points on the stump. Although it is still too early to make a general statement, it is evident that great differences exist in the forces exerted by the stump on the socket wall at different points. A composite record of the forces involved during a single stride (<b>Fig. 26</b>) shows the relative magnitudes of forces at a number of points. The maximum observed pressure was 65 lb. per sq. in. at the relatively insensitive patellar tendon. Eventually it is intended to map the total stump contact area for pressure distribution during different phases of the walking cycle.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Experimental arrangement for pressure measurement using capacitors. <i>Courtesy Prosthetic Devices Study, New York University.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Typical oscillograph record of forces in walking. <i>Courtesy Prosthetic Devices Study, New York University.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In addition to the research applications of the pressure gauge, it is likely to find use in the routine fitting of sockets. For this purpose, gauges would be attached to the stump at critical points, such as weight-bearing areas, sore spots, or relieved areas, when a new socket were tried on. A meter reading would give the magnitude of the pressure at the points in question and would tell objectively whether the pressure were excessively concentrated or well distributed when the subject stood or walked.</p> <p>The third technique specially developed makes use of the strain gauge also described previously. By means of this instrument it has been possible to attack the problem of determining the relative distribution of body weight between the sidebars and the socket of the below-knee amputee. In the experimental procedure developed, modified sidebars (<b>Fig. 27</b>) are substituted for the original ones of the test subject. So constructed that the subject's gait is unaffected by the substitution, these modified sidebars permit the mounting of the strain gauges so as to simplify determination of axial and bending strains. In the test procedure, wires are run from the gauges on the bars to a recording oscillograph by means of an eight-conductor cable. Stick diagrams and force-plate records are taken simultaneously with the recording of the dynamic sidebar strains (<b>Fig. 28</b>). Thus, at any particular instant, the position of the leg in space, the forces it exerts on the ground, and the strains in the sidebars all are known. From the knowledge of the axial sidebar loads, plus some logical assumptions and some simple kinematic relationships, the components of socket load along the axis of the shank and normal to the shank axis can be found. At the present time, runs have been made on two test subjects, one unilateral and one bilateral, both wearing conventional wooden sockets.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Conventional sidebar (left) and experimental modification for measurement of bending forces. <i>Courtesy Prosthetic Devices Study, New York University.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Axial load on sidebars. Body weight, 250 lb.; cadence, 120 steps per minute. <i>Courtesy Prosthetic Devices Study, New York University.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Upper Extremity</h4> <p>Engineering techniques have been employed in the evolution of upper-extremity prostheses also, though not to the same extent. The refinements in lower-extremity prostheses are such as to require discrete, fine, and rapid measurements, while those in the upper extremity are comparatively gross and subject, in many cases, to visual observation and judgment. Moreover, the increased performance with the newer arms and terminal devices can be appreciated quite readily by both the amputee and the observer. In the upper extremity, therefore, the employment of measuring devices is required only in those special situations where human observations fail.</p> <p><i>Control Systems</i></p> <p>The efficiency of an upper-extremity control system, from the point of load application at the harness to the point of pressure applied by the terminal device, cannot be obtained other than with measuring instruments. For such measurement, the strain gauge, applied to appropriately designed devices, can be used to measure the pressure at the tips of the fingers or the force applied at any point along the cable of an actuating system. In the course of some of the NYU studies, a channel-shaped structural element was designed in such a way that it could be inserted as a link in the cable system at different points along the cable. Tension in the cable causes deflection in the elements, and the extent of deflection is recorded as a change in voltage through strain gauges cemented to the crossbar of the channel.</p> <p><i>Finger Forces</i></p> <p>A similar principle has been used for measuring hook-finger pressures. Elements resembling tuning forks were designed, the beams being so shaped as to accommodate different grasps. Strain gauges cemented to the crossbar measure the bending stress in the fork, the stress being proportional to the pressure applied by the amputee at the tips of the hook fingers. With knowledge of the linkages involved in the system, it is possible to determine what harness combination is most efficient.</p> <p>At the Army Prosthetics Research Laboratory, a "grip" meter has been developed for the purpose of measuring normal grips and the grips that can be achieved by amputees with artificial hands. The grip is resisted by a spring calibrated to be read directly on a dial gauge.</p> <p><i>Range of Stump Motion</i></p> <p>During the course of development of the electric arm, an unusual instrument was developed by Alderson<a></a> to measure the range of motion of the various muscle groups which later were to actuate the controls of the electric arm. The <i>simul"arm"ator </i>permits the designer and fitter to estimate the range of control available to the amputee in the various muscle groups - biceps, triceps, pectoral, etc., and to allow for this range in designing the control switches of the prostheses.</p> <h4>The Future in Prosthetics Evaluation</h4> <p>As more and more improvements are incorporated into upper- and lower-extremity prostheses, the relative merit of one prosthesis as compared to another will become more and more difficult to evaluate without appropriate instrumentation and recording. The development of recording and measuring devices must therefore keep pace with the combinations to be evaluated. Hence the engineer must continue to function in his role in the evaluation phase of the program.</p> <h3>Conclusion</h3> <p>The contributions of engineers and the role of engineering in all stages of prosthetics design and application now have been well established. But this turn of events could scarcely have materialized without the cooperation of the Government. The program established by the U.S. Congress,<a></a> supervised by the Veterans Administration, and coordinated by the Advisory Committee on Artificial Limbs of the National Research Council assured a continuity of operations - of research, design, and evaluation - in which engineers and engineering groups could become interested.</p> <p>Theretofore engineers had been interested in prosthetics in a desultory fashion only, and engineering principles had been applied only to the extent that that knowledge was available to the individual limbmaker concerned. Engineers have brought to the Artificial Limb Program a curiosity as to the physical principles involved in human performance and an appreciation of the scientific method in approaching the problems. They have contributed their knowledge of measurement and of instrumentation to obtain necessary data, they have translated the results into terms of new needs, and they have applied their knowledge of materials and of mechanisms toward the fulfillment of those needs.</p> <p>It cannot be expected that the present program, born of World War II and under the pressure of veterans' demands, will continue indefinitely. And yet it may be anticipated that more and more amputees will continue to need truly functional artificial limbs. Records indicate that annually there arise from disease and other natural causes - industrial and traffic accidents and accidents in the home - many times more amputees than were produced in all Service-connected activities throughout World War II. And these include the weak and the old and the very young, not alone the average, healthy male represented by the veteran amputee. As in all science, the problems which yet require solution are much more numerous than are those already solved. Programs must therefore be established which will be broad enough in scope and long enough in duration to attract engineers. The limb industry must continue to upgrade itself, to create the positions which require engineering skills, and to offer commensurate rewards. Rehabilitation agencies and all those groups interested in the welfare of the disabled should consider how the role of the engineer and of the physical scientist can be integrated into their work.</p> <p>As an alternative it has been suggested that a cross-discipline should be evolved, with courses of instruction available to the engineer, the physician, and the rehabilitation specialist to enable each to understand each other's problems. Such a curriculum in biotechnology could offer the engineer instruction in physiology and psychophysiology useful as well in applications other than prosthetics. It could offer the physician and rehabilitation specialist instruction in the physical sciences, instrumentation, and measurement. For such an integrated course of instruction there are already precedents. Physicians have studied engineering for a better understanding of orthopedics. Engineers have studied the physiology of human activity to develop better operational methods in industry. In Europe, particularly in Germany, Russia, and the Scandinavian countries, a whole new science of "work physiology" or "work science" is being developed. In England the Ergonomics Society brings together physiologists, psychologists, and physical scientists interested in the problems of human performance, and their contributions are having effect on the design of equipment and operational processes. A scientist from whatever field, trained in biomechanics, can bring to a prosthetics program a much greater appreciation of the problems to be solved. He will be better equipped to evaluate the solutions that will be offered. But it seems inevitable that the solutions in their final development will be offered only by the engineer.</p> <h4>Acknowledgments</h4> <p>In the preparation of this article a number of people were exceptionally helpful. Special mention needs to be made of Rudolf Drillis, of the Prosthetic Devices Study, New York University, who provided much of the raw data and who was of particular assistance in review and discussion of the technical aspects of the material. Martin Koenig and Seymour Kaplan, both also of the staff of PDS-NYU, supplied the sections on capacitors and on be-low-knee sidebars, respectively. Various other members of the PDS-NYU staff read critically several sections of the manuscript. The Prosthetic Testing and Development Laboratory of the U.S. Veterans Administration supplied a number of the photographs, and George Rybczynski worked up all of the line drawings from rough sketches. To all these, and to others not mentioned specifically, sincere thanks are extended.</p> <p><b>References:</b></p> <ol> <li>Alderson, Samuel W., <i>The electric arm, </i>Chapter 13 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Alderson Research Laboratories, Inc., New YorkCity, Contractor's Final Report [to the U.S. Veterans Administration (Contract No. V1001M-3123)] on <i>Research and development of electric arms and electric arm components, </i>1954.</li> <li>Alldredge, Rufus H., Verne T. Inman, HymanJampol, Eugene F. Murphy, and August W. Spittler, <i>The techniques oj cineplasty, </i>Chapter 3 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Amar, Jules, <i>Le moleur humaine et les bases scientifiques du travail professionel, </i>H. Dunod, Paris, 1914.</li> <li>Amar, Jules, <i>Organisation physiologique du travail,</i>H. Dunod et E. Pinot, Paris, 1917.</li> <li>Bechtol, Charles O., <i>The prosthetics clinic team, </i>Artificial Limbs, January 1954. p. 9.</li> <li>Bernshtein, N., <i>Die Kymocyclographische Methode der Bewegungsunlersuchungen, </i>in <i>Hndb. d. biol. Arbeitsmethoden, </i>Lief. 263., Urban und Schwar-zenberg, Wien, 1928.</li> <li>Bernshtein, N., <i>et al., Investigations on biodynamics of locomotion, </i>Vols. 1 and 2, Moscow, 1935 and 1940. In Russian.</li> <li>Borchardt, M., <i>et al., </i>eds., <i>Ersatzglieder und Arbeit-</i><i>shilfen, </i>Springer, Berlin, 1919.</li> <li>Borelli, Giovanni A., <i>De motu animalium, </i>Romae,1679. Two volumes. To be found in <i>Pathologie de chirurgie, </i>Vol. 2 of 3 vols., by Jean Baptiste Ver-duc, Paris, 1727.</li> <li>Carlyle, Lester, <i>Fitting the artificial arm, </i>Chapter 19in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Catranis, Inc., Syracuse, N.Y., Subcontractor'sFinal Report to the Advisory Committee on Artificial Limbs, National Research Council, <i>Improved artificial limbs for lower extremity amputations, </i>June 1954.</li> <li>Committee on Artificial Limbs, National Research Council, Washington, D. C, <i>Terminal research reports on artificial limbs </i>[to the Office of the Surgeon General and the U.S. Veterans Administration] covering the period from 1 April 1945 through 30 June 1947.</li> <li>Contini, R., and R. Drillis, <i>Biomechanics, </i>Appl.Mech. Rev., 7:49 (1954).</li> <li>Drillis, R., <i>Chronocyclographische Arbeitsstudien, </i>in<i>Psychophysiologische Arbeiten, </i>1A, Riga, 1930.</li> <li>Drillis, R., <i>Investigation on axe and woodcutting,</i>Latvijas Lauksaimnieks, Riga, 1935. In Latvian.</li> <li>Drillis, R., <i>Investigations on stability, </i>unpublishedreport, Prosthetic Devices Study, New York University, 1954.</li> <li>Eberhart, H. D., and V. T. Inman, <i>An evaluation of experimental procedures used in a fundamental study of human locomotion, </i>Ann. N. Y. Acad. Sci., 51:1213(1951).</li> <li>Eberhart, Howard D., and Jim C. McKennon,<i>Suction-socket suspension of the above-knee prosthesis, </i>Chapter 20 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Elftman, H, <i>The measurement of the external force in walking, </i>Science, 88:152(1938).</li> <li>Elftman, H., <i>The force exerted by the ground in walking, </i>Arbeitsphysiol., 10:485 (1939).</li> <li>Elftman, H., <i>The basic pattern of human locomotion,</i> Ann. N. Y. Acad. Sci., 51:1207(1951).</li> <li>Faries, John Culbert, <i>Limbs for the limbless, </i>Institute for the Crippled and Disabled, New York, 1934.</li> <li>Fick, R., <i>Handbuch der Anatomic und Mechanik der Gelenke unter Berucksichtigung der bewegenden Muskeln, </i>G. Fischer, Jena, 1904-1911. Three volumes.</li> <li>Fischer, O., <i>Theoretische Grundlagen fur eine Mechanik der lebenden Korper, mit speziellen Andwendungen auf den Menschen, </i>B. G. Teubner, Leipzig and Berlin, 1906.</li> <li>Fletcher, Maurice J., <i>New developments in hands and hooks, </i>Chapter 8 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Fletcher, Maurice J., <i>The upper-extremity prosthetics armamentarium, </i>Artificial Limbs, January 1954.</li> <li>Fletcher, Maurice J., and A. Bennett Wilson, Jr.,<i>New developments in artificial arms, </i>Chapter 10 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Frank, Wallace E., and Robert J. Gibson, <i>New pressure sensing instrument, </i>J. Franklin Inst., in press 1954.</li> <li>Gilbreth, Frank B., and Lillian M. Gilbreth, <i>Motion study for the handicapped, </i>G. Routledge and Sons, Ltd., London, 1920.</li> <li>Haddan, Chester C, and Atha Thomas, <i>Status of the above-knee suction socket in the United States, </i>Artificial Limbs, May 1954. p. 29.</li> <li>Henschke, Ulrich K., and Hans A. Mauch, <i>The improvement of leg prostheses, </i>The Military Surgeon, 103(2) :135 (1948).</li> <li>Hettinger, Th., and E. Muller, <i>Der Einfluss des Schuhgewichtes auf den Energieumsatz beim Gehen und Lastenlragen, </i>Arbeitsphysiol., 15:33 (1953).</li> <li>Inman, Verne T., and H. J. Ralston, <i>The mechanics of voluntary muscle, </i>Chapter 11 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Kaplan, S., <i>Determination of dynamic loads and strains in below-knee artificial limbs, </i>unpublished report, Prosthetic Devices Study, New York University, 1954.</li> <li>Leonard, Fred, and Clare L. Milton, Jr., <i>Cosmetic gloves, </i>Chapter 9 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Leonardo da Vinci, <i>On the human body, </i>C. D.O'Malley and J. B. DeC. M. Saunders, eds. Schuman, New York, 1952.</li> <li>Marey, E., <i>Mouvement, </i>G. Masson, Paris, 1894.</li> <li>Marey, E.-J., and G. Demeny, <i>Eludes experimentales de la locomotion humaine, </i>Compt. rend. Acad. d. sc, 106:544 (1887).</li> <li>Martin, Florent, <i>Artificial limbs, </i>International Labour Office, Geneva, 1925.</li> <li>Muybridge, Eadweard, <i>The human figure in motion,</i>Chapman &amp; Hall, London, 1901.</li> <li>New York University, College of Engineering,Research Division, [Report to the] Special Devices Center, Office of Naval Research (Contract No. N6onr-279), <i>Investigations with respect to the design, construction, and evaluation of prosthetic devices, </i>June 1, 1949. Two volumes.</li> <li>New York University, Prosthetic Devices Study,(report to the) Advisory Committee on Artificial Limbs, National Research Council, <i>The functional and psychological suitability of an experimental hydraulic prosthesis for above-the-knee amputees, </i>March 1953.</li> <li>Northrop Aircraft, Inc., Hawthorne, Calif., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>A report on prosthesis development, </i>1947.</li> <li>Parmelee, Dubois D., U.S. Patent 37,637, February10, 1863, and reissue patents 1,907 and 1,908, March 4, 1865.</li> <li>Public Law 729, Eightieth Congress, Second Session,Approved June 19, 1948.</li> <li>Radcliffe, Charles W., <i>Alignment of the above-knee artificial leg, </i>Chapter 21 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Radcliffe, Charles W., <i>Mechanical aids for alignment of lower-extremity prostheses, </i>Artificial Limbs, May 1954. p. 20.</li> <li>Schede, Franz, <i>Theoretische Grundlagen fur den Bau von Kunstbeinen; Insbesondere fur den Ober-schenkelamputierten, </i>Ztschr. f. orthopad. Chir., Supplement 39, Enke, Stuttgart, 1919.</li> <li>Schlesinger, G., <i>Die Mitarbeit des Ingenieurs bei der</i><i>Durchbildung der Ersatzglieder, </i>Verein. Deutsch. Ingen., Berlin Ztschr., 61:6 (1917).</li> <li>Steindler, Arthur, <i>Mechanics of normal and pathological locomotion in man, </i>Charles C Thomas, Springfield, Ill., 1935.</li> <li>Taylor, Craig L., <i>Control design and prosthetic</i><i>adaptations to biceps and pectoral cineplasty, </i>Chapter 12 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Taylor, Craig L., <i>The biomechanics of the normal and of the amputated upper extremity, </i>Chapter 7 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Technical Institute, Charlottenburg, Report of theSpecial Commission for Accident Prevention, <i>Merkblatter der Prufungsstelle fur Ersatzglieder, </i>Berlin, 1916-1917.</li> <li>Thomas, A., and C. C. Haddan, <i>Amputation prosthesis, </i>Lippincott, Philadelphia, 1945.</li> <li>University of California (Berkeley), ProstheticDevices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Fundamental studies of human locomotion and other information relating to design of artificial limbs, </i>1947. Two volumes.</li> <li>Wagner, Edmond M., <i>Contributions of the lower-extremity prosthetics program, </i>Artificial Limbs, May 1954.</li> <li>Wagner, Edmond M., and John G. Catranis, <i>New</i><i>developments in lower-extremity prostheses, </i>Chapter 17 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Wilson, A. Bennett, Jr., <i>The APRL terminal devices,</i>Orthop. &amp; Pros. Appl. J., March 1952.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Public Law 729, Eightieth Congress, Second Session,Approved June 19, 1948.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alderson Research Laboratories, Inc., New YorkCity, Contractor's Final Report [to the U.S. Veterans Administration (Contract No. V1001M-3123)] on Research and development of electric arms and electric arm components, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Kaplan, S., Determination of dynamic loads and strains in below-knee artificial limbs, unpublished report, Prosthetic Devices Study, New York University, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Alignment of the above-knee artificial leg, Chapter 21 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>48.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954. p. 20.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Drillis, R., Investigations on stability, unpublishedreport, Prosthetic Devices Study, New York University, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Marey, E., Mouvement, G. Masson, Paris, 1894.</td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Marey, E.-J., and G. Demeny, Eludes experimentales de la locomotion humaine, Compt. rend. Acad. d. sc, 106:544 (1887).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>33.</b> </td><td class="clsTextSmall">Hettinger, Th., and E. Muller, Der Einfluss des Schuhgewichtes auf den Energieumsatz beim Gehen und Lastenlragen, Arbeitsphysiol., 15:33 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study,(report to the) Advisory Committee on Artificial Limbs, National Research Council, The functional and psychological suitability of an experimental hydraulic prosthesis for above-the-knee amputees, March 1953.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alderson, Samuel W., The electric arm, Chapter 13 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alderson Research Laboratories, Inc., New YorkCity, Contractor's Final Report [to the U.S. Veterans Administration (Contract No. V1001M-3123)] on Research and development of electric arms and electric arm components, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alderson, Samuel W., The electric arm, Chapter 13 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alderson Research Laboratories, Inc., New YorkCity, Contractor's Final Report [to the U.S. Veterans Administration (Contract No. V1001M-3123)] on Research and development of electric arms and electric arm components, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>52.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prostheticadaptations to biceps and pectoral cineplasty, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Carlyle, Lester, Fitting the artificial arm, Chapter 19in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper-extremity prosthetics armamentarium, Artificial Limbs, January 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Schlesinger, G., Die Mitarbeit des Ingenieurs bei derDurchbildung der Ersatzglieder, Verein. Deutsch. Ingen., Berlin Ztschr., 61:6 (1917).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>52.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prostheticadaptations to biceps and pectoral cineplasty, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., New developments in hands and hooks, Chapter 8 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper-extremity prosthetics armamentarium, Artificial Limbs, January 1954.</td></tr><tr><td class="clsTextSmall"><b>59.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., The APRL terminal devices,Orthop. &amp;Pros. Appl. J., March 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Leonard, Fred, and Clare L. Milton, Jr., Cosmetic gloves, Chapter 9 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Carlyle, Lester, Fitting the artificial arm, Chapter 19in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., New developments in hands and hooks, Chapter 8 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper-extremity prosthetics armamentarium, Artificial Limbs, January 1954.</td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., and A. Bennett Wilson, Jr.,New developments in artificial arms, Chapter 10 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>54.</b> </td><td class="clsTextSmall">Technical Institute, Charlottenburg, Report of theSpecial Commission for Accident Prevention, Merkblatter der Prufungsstelle fur Ersatzglieder, Berlin, 1916-1917.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Borchardt, M., et al., eds., Ersatzglieder und Arbeit-shilfen, Springer, Berlin, 1919.</td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Schlesinger, G., Die Mitarbeit des Ingenieurs bei derDurchbildung der Ersatzglieder, Verein. Deutsch. Ingen., Berlin Ztschr., 61:6 (1917).</td></tr><tr><td class="clsTextSmall"><b>54.</b> </td><td class="clsTextSmall">Technical Institute, Charlottenburg, Report of theSpecial Commission for Accident Prevention, Merkblatter der Prufungsstelle fur Ersatzglieder, Berlin, 1916-1917.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Verne T. Inman, HymanJampol, Eugene F. Murphy, and August W. Spittler, The techniques oj cineplasty, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Schlesinger, G., Die Mitarbeit des Ingenieurs bei derDurchbildung der Ersatzglieder, Verein. Deutsch. Ingen., Berlin Ztschr., 61:6 (1917).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Borchardt, M., et al., eds., Ersatzglieder und Arbeit-shilfen, Springer, Berlin, 1919.</td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Schlesinger, G., Die Mitarbeit des Ingenieurs bei derDurchbildung der Ersatzglieder, Verein. Deutsch. Ingen., Berlin Ztschr., 61:6 (1917).</td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Eberhart, Howard D., and Jim C. McKennon,Suction-socket suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Haddan, Chester C, and Atha Thomas, Status of the above-knee suction socket in the United States, Artificial Limbs, May 1954. p. 29.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>45.</b> </td><td class="clsTextSmall">Parmelee, Dubois D., U.S. Patent 37,637, February10, 1863, and reissue patents 1,907 and 1,908, March 4, 1865.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>57.</b> </td><td class="clsTextSmall">Wagner, Edmond M., Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>57.</b> </td><td class="clsTextSmall">Wagner, Edmond M., Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Catranis, Inc., Syracuse, N.Y., Subcontractor'sFinal Report to the Advisory Committee on Artificial Limbs, National Research Council, Improved artificial limbs for lower extremity amputations, June 1954.</td></tr><tr><td class="clsTextSmall"><b>57.</b> </td><td class="clsTextSmall">Wagner, Edmond M., Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954.</td></tr><tr><td class="clsTextSmall"><b>58.</b> </td><td class="clsTextSmall">Wagner, Edmond M., and John G. Catranis, Newdevelopments in lower-extremity prostheses, Chapter 17 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Leonard, Fred, and Clare L. Milton, Jr., Cosmetic gloves, Chapter 9 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Carlyle, Lester, Fitting the artificial arm, Chapter 19in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Northrop Aircraft, Inc., Hawthorne, Calif., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, A report on prosthesis development, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">In press as of this writing is a large collaboration on the general subject of deterioration prevention. Prepared by the Prevention of Deterioration Center, National Research Council, under the joint editorship of Glenn A. Greathouse and Carl J. Wessel, and titled Deterioration of Materials - Causes and Preventive Techniques, it is to be available this autumn from the publishers, Reinhold Publishing Corporation, New York. Many of the techniques described may find application in the field of prosthetics.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Committee on Artificial Limbs, National Research Council, Washington, D. C, Terminal research reports on artificial limbs [to the Office of the Surgeon General and the U.S. Veterans Administration] covering the period from 1 April 1945 through 30 June 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Elftman, H, The measurement of the external force in walking, Science, 88:152(1938).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>42.</b> </td><td class="clsTextSmall">New York University, College of Engineering,Research Division, [Report to the] Special Devices Center, Office of Naval Research (Contract No. N6onr-279), Investigations with respect to the design, construction, and evaluation of prosthetic devices, June 1, 1949. Two volumes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Eberhart, H. D., and V. T. Inman, An evaluation of experimental procedures used in a fundamental study of human locomotion, Ann. N. Y. Acad. Sci., 51:1213(1951).</td></tr><tr><td class="clsTextSmall"><b>56.</b> </td><td class="clsTextSmall">University of California (Berkeley), ProstheticDevices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Frank, Wallace E., and Robert J. Gibson, New pressure sensing instrument, J. Franklin Inst., in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study,(report to the) Advisory Committee on Artificial Limbs, National Research Council, The functional and psychological suitability of an experimental hydraulic prosthesis for above-the-knee amputees, March 1953.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Drillis, R., Investigation on axe and woodcutting,Latvijas Lauksaimnieks, Riga, 1935. In Latvian.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Since a constant valueâ€the distance the film is transported in an increment of time must always be subtracted from the measured horizontal displacement of a point.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Drillis, R., Chronocyclographische Arbeitsstudien, inPsychophysiologische Arbeiten, 1A, Riga, 1930.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Bernshtein, N., Die Kymocyclographische Methode der Bewegungsunlersuchungen, in Hndb. d. biol. Arbeitsmethoden, Lief. 263., Urban und Schwar-zenberg, Wien, 1928.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Muybridge, Eadweard, The human figure in motion,Chapman &amp;Hall, London, 1901.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Contini, R., and R. Drillis, Biomechanics, Appl.Mech. Rev., 7:49 (1954).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>42.</b> </td><td class="clsTextSmall">New York University, College of Engineering,Research Division, [Report to the] Special Devices Center, Office of Naval Research (Contract No. N6onr-279), Investigations with respect to the design, construction, and evaluation of prosthetic devices, June 1, 1949. Two volumes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>56.</b> </td><td class="clsTextSmall">University of California (Berkeley), ProstheticDevices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Henschke, Ulrich K., and Hans A. Mauch, The improvement of leg prostheses, The Military Surgeon, 103(2) :135 (1948).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Elftman, H, The measurement of the external force in walking, Science, 88:152(1938).</td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Elftman, H., The force exerted by the ground in walking, Arbeitsphysiol., 10:485 (1939).</td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Elftman, H., The basic pattern of human locomotion, Ann. N. Y. Acad. Sci., 51:1207(1951).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>51.</b> </td><td class="clsTextSmall">Steindler, Arthur, Mechanics of normal and pathological locomotion in man, Charles C Thomas, Springfield, Ill., 1935.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Bernshtein, N., et al., Investigations on biodynamics of locomotion, Vols. 1 and 2, Moscow, 1935 and 1940. In Russian.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>49.</b> </td><td class="clsTextSmall">Schede, Franz, Theoretische Grundlagen fur den Bau von Kunstbeinen; Insbesondere fur den Ober-schenkelamputierten, Ztschr. f. orthopad. Chir., Supplement 39, Enke, Stuttgart, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Schlesinger, G., Die Mitarbeit des Ingenieurs bei derDurchbildung der Ersatzglieder, Verein. Deutsch. Ingen., Berlin Ztschr., 61:6 (1917).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Martin, Florent, Artificial limbs, International Labour Office, Geneva, 1925.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Amar, Jules, Le moleur humaine et les bases scientifiques du travail professionel, H. Dunod, Paris, 1914.</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Amar, Jules, Organisation physiologique du travail,H. Dunod et E. Pinot, Paris, 1917.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Gilbreth, Frank B., and Lillian M. Gilbreth, Motion study for the handicapped, G. Routledge and Sons, Ltd., London, 1920.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Fick, R., Handbuch der Anatomic und Mechanik der Gelenke unter Berucksichtigung der bewegenden Muskeln, G. Fischer, Jena, 1904-1911. Three volumes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Fischer, O., Theoretische Grundlagen fur eine Mechanik der lebenden Korper, mit speziellen Andwendungen auf den Menschen, B. G. Teubner, Leipzig and Berlin, 1906.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Borelli, Giovanni A., De motu animalium, Romae,1679. Two volumes. To be found in Pathologie de chirurgie, Vol. 2 of 3 vols., by Jean Baptiste Ver-duc, Paris, 1727.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>37.</b> </td><td class="clsTextSmall">Leonardo da Vinci, On the human body, C. D.O'Malley and J. B. DeC. M. Saunders, eds. Schuman, New York, 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Bechtol, Charles O., The prosthetics clinic team, Artificial Limbs, January 1954. p. 9.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Faries, John Culbert, Limbs for the limbless, Institute for the Crippled and Disabled, New York, 1934.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>55.</b> </td><td class="clsTextSmall">Thomas, A., and C. C. Haddan, Amputation prosthesis, Lippincott, Philadelphia, 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Faries, John Culbert, Limbs for the limbless, Institute for the Crippled and Disabled, New York, 1934.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">A prosthetic device may be defined as one which attempts to restore, in function or appearance or both, any portion of the external human anatomical structure that has been impaired or removed owing to injury or to some degenerative process. In the broadest sense,therefore, artificial eyes and false teeth, as well as braces and artificial limbs, are prostheses. In the more commonly accepted sense, however, prosthetic devices usually refer to artificial arms and legs. The present discussion isconcerned with the role engineering must take in the development, fabrication, and application of artificial limbs.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Renato Contini, B.S.M.E. </b></td></tr><tr><td class="clsTextSmall">Research Coordinator, College of Engineering, New York University; member, Upper- and Lower-Extremity Technical Committees, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Artificial Limbs: A Review of Current Developments Description An account of the resource The foundation of modern prosthetics can be directly traced to the coordinated efforts of the National Academy of Sciences under the various artificial limbs committees after the Second World War. America, at its height of post war efficiency and engineering acumen, set about to solve the burgeoning problem of amputees swelling an infrastructure of prosthetic delivery that was outmoded, outdated and unprepared. Artificial Limbs: A Review of Current Developments was an industry update of these research efforts and was published thirty-three times, spanning the years 1954 to 1972. DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_03_004.pdf Year 1954 Volume 1 Issue 3 Page Number(s) 4 - 46 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_03_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_03_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Prosthetics Research and the Amputation Surgeon</h2> <h5>Rufus H. Alldredge, M.D. <a style="text-decoration:none;">*</a><br />Eugene F. Murphy, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Except in abnormal circumstances, man is born into his world with four mobile members which extend from his trunk like branches from a tree. These so-called "limbs" he uses in manifold complex patterns, first to serve his immediate personal needs and second to shape his own environment as best he can. Although in early life man reveals the history of the race by crawling about on all fours, he shortly assigns to two of the limbs chiefly, but not exclusively, the functions of supporting the body and of moving it from place to place. The "legs" thus become the principal weight-bearing members and the generally accepted means of locomotion.<a style="text-decoration:none;">*</a> To the more versatile "arms" man assigns most of the more complex functions of daily living and of creative activity. No doubt to this "division of labor" can largely be attributed the rather remarkable development of art and science and literature and industry and most of the other creative manifestations of human life.</p> <p>Because, however, the limbs extend from the body proper, they are particularly susceptible to damage, either from lack of nutrition and disease or by external forces of one kind or another. Since the limbs are not "vital" organs in the same sense as, say, the heart or the liver, it is possible under favorable conditions to remove one or more without loss of the whole living organism, especially since the advent of modern surgery, anesthesia, and the newer drugs and blood substitutes. That is to say, a man has a chance of living on, though a natural member be discarded. We thus have as a result of war, accident, and disease a sizable number of individuals lacking part or all of one or more limbs, and to these must be added those persons born with malformed or missing limbs. All these people, now known generally as "amputees," are obviously handicapped, to greater or lesser degree, in the performance of all those functions ordinarily carried out by the arms and legs, and in extreme cases there may be no residual function at all. To restore lost functions in as great a measure as possible has long presented a challenge to certain people, mostly, as might have been expected, to amputees themselves.</p> <h4>The Background</h4> <p>Early amputations undoubtedly were more often than not traumatic events leading to a prompt death. Occasionally, however, history records amputees who survived their bloody and painful experiences. One famous example was Hegesistratus, who, captured and chained by the Spartans, amputated his own foot in order to escape.<a></a> With the slow development, over the centuries, of surgery in general, amputations came to be performed more frequently. Typically they were desperate efforts to save life. Such works as those of Pare,<a></a> of the sixteenth century, described the techniques. In some cases, a tight tourniquet was applied and left intact until the distal portion was lost by spontaneous amputation. In others, the amputation was conducted with knife and saw, and bleeding was controlled by cauterization.</p> <p>From the beginning it seemed obvious that the amputation should be as distal as feasible in order to conserve the maximum bony lever. Many surgeons, however, preferred a disarticulation at a joint whenever that was possible. For they had found that infection was relatively unlikely to enter the bone through the normal surfaces which could be retained with disarticulation, whereas, in the days before aseptic surgery, osteomyelitis was all too common when the marrow cavity was opened by amputation through the shaft of a bone.</p> <p>Roughly a century ago the introduction of anesthetics made prolonged surgery possible, and not long after that the germ theory and antiseptic and aseptic surgery greatly increased the chances of surviving either accidental wounds or surgery. These factors made possible the comparatively long and complicated amputations now taken for granted, the revision of otherwise unsuitable stumps, and the elective amputations in cases of serious disease or deformity.</p> <p>At about the same time, wars involving European powers, and especially the American Civil War, led to large numbers of surviving amputees. Also, and again more or less simultaneously, the rapid development of heavy industry and of railroading resulted in many traumatic amputations in civilian life, especially in the United States. All these factors increased interest in amputation surgery and in limb-making for the large numbers of surviving amputees.</p> <h4>Amputation Surgery and the Art of Prosthetics</h4> <p>Artificial limbs of one kind or another date from antiquity. Particularly during the fifteenth, sixteenth, and seventeenth centuries, crudely functional artificial arms came to be made, chiefly by armorers, who were already experienced in a related field. Of many known examples, the arm and hand made about 1509 for Goetz von Berlichingen <a></a> is by far the best known (<b>Fig. 1</b>), numerous copies having been constructed for museums. In this and others of the period, joints were flexed by the other hand and locked by ratchets. Springs returned the joints when the ratchets were released by pressure on a projecting knob. In all such armorlike arms and hands, iron was used, sometimes with holes punched to reduce weight. Leather doublets or sockets, often with laces, commonly were used for several centuries.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> <p class="clsTextCaption"><br /> Fig. 1. Typical "sites of election" for amputation in the upper extremity, from well-known texts, by permission of the respective publishers. In general the sites became progressively less restricted. <i>A, </i>Recommendations of zur Verth,<a></a> as reproduced by Vasconcelos<a></a> reporting to the 3rd Brazilian and American Surgical Congress, Rio de Janeiro, November 1943. Original caption labels left drawing as representing functional values for an "intellectual," right drawing as for a "workman." Note that zur Verth favors more lever for a "working man." <i>B, </i>Recommendations of Langdale-Kelham and Perkins.<a></a> They state, ". . . but limb-makers are unable to fit a limb that allows the patient to pronate and supinate, for the circumference of the forearm changes its shape during rotation and the socket is either too tight to permit the change of shape or too loose to secure a firm hold on the stump. . . ." C, Recommendations of Kirk .<a></a> Note increasing emphasis on saving all length possible. Kirk's text suggests that wrist disarticulation is rather unsatisfactory and that few if any prostheses make use of pronation. The elbow disarticulation is tolerated but criticized. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Near the end of the eighteenth century, Klingert<a></a> introduced an above-elbow arm with most of the natural motions controlled by ten catgut cords fastened to a vestlike garment and moved individually by the sound hand. Since in most cases the sound hand might better have performed the intended action, this impractical prosthesis was a classic pioneer in exceeding what some nowadays call the "hardware tolerance" of the amputee. In 1818, Peter Ballif<a></a> of Berlin developed the first voluntary control by use of trunk and shoulder muscles. His hand was of the voluntary-opening type<a></a> with springs to close the fingers and thumb. To the Dutch sculptor, Van Peeterssen, is attributed the first above-elbow prosthesis with harness control permitting voluntary flexion of the artificial elbow joint.<a></a> </p> <p>As the art of armormaking declined, limb-making on the Continent came to be carried on usually in conjunction with the making of braces, and consequently the artificial legs produced there typically evidenced steel sidebars and molded leather corsets similar to those used in braces. At the time of the Napoleonic Wars, the wooden leg, used from earliest times, was provided, for example, by Potts of London for the Marquis of Anglesey and others.<a></a> Wood reinforced by rawhide was used customarily in the United States, although a variety of other structural materials has been suggested in the journal literature and in patents.</p> <p>Comte de Beaufort<a></a> invented a number of artificial arms as well as legs, some of which were approved for French veterans of the Crimean and Italian campaigns. In 1858, he presented to the French Academy of Medicine a hand with an alternator mechanism and a double-spring hook.<a></a> Dorrance<a></a> introduced in America the well-known voluntary-opening split hook with rubber bands to close a movable finger against a rigid one. He and others rapidly produced a variety of hook shapes intended for specific trades.</p> <h4>World War I</h4> <p>World War I led to a revival of interest in amputations and in artificial limbs, notably in Germany, Belgium, and England. All these countries had rather extensive programs involving the cooperation of surgeons, limb-fitters, and engineers. Publications based on World War I experience<a></a> indicated considerable progress in understanding of amputation techniques, of the need for prompt rehabilitation of amputees, and of the importance of fit and alignment of the prosthesis. The development of many new devices and components for artificial limbs for both upper and lower extremity was described perhaps most impressively in Ersatzglieder und Arbeitshilfen.<a></a> Martin's second book <a></a>, prepared for the International Labour Office, and Little's text <a></a> were particularly useful because they offered critical analyses following impartial descriptions of prostheses and mechanisms.</p> <p>The wooden leg came to be used widely throughout the Continent as well as in England and in the United States. Aluminum, introduced by Desoutter<a></a> in England in 1912, was used particularly in England and to a lesser extent elsewhere. The fiber leg was used by a substantial number of limbmakers, particularly in the United States. Despite the large number of knee locks and ankle joints permitting lateral motion, described in patents and in medical and technical literature, most above-knee amputees used a simple uniaxial hinge for the knee joint and a single-axis ankle joint. Rubber bumpers were used widely in place of the tendons popular in the nineteenth century. It is interesting to note that in 1922 Little remarked<a></a> that most leg amputees had to use at least one stick.</p> <p>For the upper extremity, a great many artificial arms, hands, and working tools were developed during World War I, as can be seen from the major books on prostheses of the period .<a></a> American designers generally used the split mechanical hook closed by rubber bands and separated from the forearm by a rubber washer which provided stability by friction but which at the same time permitted pronation-supination by means of the other hand. Europeans generally preferred passively operated clamps and special tools so designed as to be interchangeable by a disconnect at the wrist. Either a clamp, as on a machine tool, or a locking bolt engaging any one of a series of holes in a disc was used to fasten the tool in the selected position of pronation or supination. For working purposes, the attachment for the tool was often placed at the end of the socket, far above the normal hand level, so as to decrease the leverage of the load on the stump. For dress wear, a cosmetic forearm and terminal device could be attached in place of the tool.</p> <p>Various wooden hands, usually with spring-loaded or voluntarily controlled thumbs, were shown in the literature of many countries. Generally, it was assumed that such hands were for dress and for light office use only, either bare or covered with a leather or fabric glove. Often the fingers were curved permanently to carry a briefcase. The Carnes arms and hands,<a></a> patented in 1912, 1922, and subsequently, were widely sold in the United States for many years. During World War I they were widely admired abroad and were described in detail by Schlesinger<a></a> and to a lesser extent by Martin<a></a> and by Little.<a></a> </p> <p>Similar devices, under the general name "Germania," were built in Germany after entrance of the United States into hostilities. Most authors admired the dexterity achieved by the Carnes devices-particularly because of their ingenious construction, the passively adjustable wrist flexion, and the possibility of coordinating supination with elbow flexion to assist in eating-but criticism was leveled at complexity, relatively heavy weight, lost motion, and the restriction against interchange of a hook for the hand.</p> <h4>World War II</h4> <p>Surgical authorities during World War II advocated<a></a> typical "sites of election" <b>Fig. 1</b> and <b>Fig. 2</b>) based upon the extensive practical experience of the surgeons as well as on the advice of many of the more active limb-fitters, who were notably successful in fitting good stumps at these "sites of election" but who had encountered serious difficulty in fitting such stumps as the wrist disarticulation, the very short below-elbow stump, the knee disarticulation, or the Syme stump. Typical prostheses for the so-called "sites of election" are shown in <b>Fig. 3</b>, <b>Fig. 4</b>, <b>Fig. 5</b>, and <b>Fig. 6</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Typical "sites of election" for amputation in the lower extremity, from well-known texts, by permission of the respective publishers. <i>A</i>, Recommendations of Langdale-Kelham and Perkins.<a></a> These authors condemn the Syme. <i>B, </i>Recommendations of Kirk <i>. </i><a></a> Although Kirk does not show a Syme, he agrees with the Canadians that a properly fitted Syme's amputation is ideal for the "laboring man." </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Typical prosthesis for amputation below the elbow, made about 1945-47. Note modled leather socket, steel sidebars and single-axis joints permitting elbow flexion only, full upper-arm cuff with two straps, heavy leather shoulder saddle and webbing cheststrap, and double leather thong passing over pulleys at the elbow joint to open the voluntary-opening hook. Rubber bands closed the hook and determined the gripping force. Changing the number of rubber bands to vary the gripping force was possible but inconvenient. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans A administration.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Conventional prosthesis for amputation above the elbow, made about 1945-47. Note the molded leather socket (with the unusual rear opening and laces), wooden elbow shell and forearm, and push button projecting from lower surface of forearm to control elbow locking by pressure on table top through the sleeve or by use of the opposite hand. Such elbows provided a maximum of five locking positions. A relatively complex harness of cotton webbing supported the prosthesis on the stump and controlled a helically wound rawhide thong sliding through short lengths of stiff housing rigidly mounted above and below the elbow. Tension in the thong flexed the elbow when it was unlocked. When the elbow was locked, tension was transmitted to close the hand, which could be locked by means of the button projecting from the volar portion near the wrist. A desirable disconnect in the thong and a screw thread at the wrist permitted substitution of a hook for the hand. The harnessing pattern for a given level of amputation varied markedly among different limb-makers. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans Administration.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Conventional wooden prosthesis for amputation below the knee, made about 1947. Note the usual leather thigh corset, leather thong or lace, leather back-check to prevent hyperextension of the knee, single-axis mechanical knee and ankle joints, and wooden toe fastened to wooden foot by a belting hinge. Usually a webbing waist belt was connected by an elastic strap to an inverted Y-strap straddling the patella and attaching near the front brim of the shank to help suspend the prosthesis and to extend the knee. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans Administration.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Conventional wooden prosthesis for amputation above the knee, made about 1947. Note reinforced pelvic band and single-axis hip, knee, and ankle joints. Elastic straps from front and rear of pelvic band are joined by a leather strap passing under a roller ahead of the knee bolt so as to extend the knee from a flexed position. In other prostheses of the same type, refinements of workmanship included inlaying the hip joint into the wood and reinforcing it with rawhide, covering the metal pelvic-band reinforcement with leather, and providing a continuous leather-covered sponge-rubber layer on the sole of the foot. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans Administration.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It will be noted, for example, that all levels of forearm amputation, from the wrist disarticulation to the short below-elbow, were fitted with the same type of forearm composed of a molded leather socket, usually laced, extending into a cosmetic shell and reinforced by volar and dorsal metal sidebars which formed a crosspiece at the wrist supporting a screw thread or bayonet-type attachment for the hook or artificial hand. Typically, the terminal device could be rotated passively by the opposite hand against the friction of a rubber washer but could not be pronated or supinated actively. The metal sidebars were hinged in line with the humeral epicondyles to permit elbow flexion in relation to a buckled or laced cuff about the upper arm. Usually the terminal device was operated by a leather thong which passed over a pulley or through a short length of helical wire housing at the elbow joint so as to be independent of elbow flexion. Since the prosthesis did not provide for pronation-supination, whatever of this function was originally available in a stump amputated at the "site of election" soon disappeared owing to muscular atrophy.</p> <p>The elbow lock for above-elbow arms generally was operated, in the case of a unilateral amputee, by the opposite hand, or, in the bilateral arm amputee, by pressure against the body or against a table. It usually consisted of a sliding bolt engaging one of three or four holes in a metal strap surrounding the carved wooden elbow portion below the molded leather or fiber humeral socket. Cotton webbing and rather heavy leather shoulder saddles were commonly used in the arm harness, and leather thongs transmitted forces to flex the elbow and to operate the terminal device.</p> <p>During the period of World War II, the typical unilateral leg amputee in the United States, including many hip-disarticulation cases, walked without the aid of a cane, although the above-knee amputee usually walked with the relatively fixed cadence for which the fixed friction about the knee bolt was adjusted. Any attempt to walk faster or slower led to excessive heel rise or to a tendency to drag the toe. The below-knee artificial leg was often carved from a wooden block by trial-and-error fitting. Alternatively, a leather socket, molded over a modified plaster replica of the stump, was inserted into a fiber, metal, or occasionally a wooden shank. Sometimes, in an effort to increase conformity to the stump, a certain degree of softness or of ability to flow plastically was imparted by a thin lining of felt, wax, or relatively pliable leather.</p> <p>The above-knee leg was occasionally held to the body by suspenders, but by 1945 a large percentage of above-knee amputees used a pelvic band and metal hip joint. Usually the hip joint permitted the leg to swing in one plane only, although in some designs an additional axis permitted abduction and adduction. In England, and rarely in the United States, a third axis, substantially vertical, also permitted a limited amount of rotation, although about an axis outside the body several inches from the ball and socket of the natural hip joint.</p> <h4>Era of Antobacterial Techniques</h4> <p>During World War II, blood, plasma, and antibiotics came to be used widely to increase the chances of survival at the time of injury as well as to permit more extensive surgery. The Surgeon General of the U.S. Army ordered open amputation exclusively, to be followed by skin traction until a revision operation could be performed. This flat order unquestionably reduced the incidence of infection and gangrene<a></a> from combat injuries to U.S. Servicemen in World War II, as compared to experience in previous wars or to the experience of certain other military forces. It undoubtedly led also to the conservation of many stumps which, under other circumstances, would have been reamputated at the "site of election" above the next joint in order to avoid rapid spread of infection and gangrene. According to Veterans Administration records, for example, the U.S. forces had over two thirds of their lower-extremity amputations below the knee, whereas during the American Civil War and among the Filipino Scouts and guerrillas<a></a> and the Yugoslavian guerrillas<a></a> in World War II, it was estimated that at least half of all lower-extremity amputations were above the knee. Little, <a></a> in a sample of 1030 amputations among the English forces in World War I, found only 219 "leg" (below-knee) and 441 "thigh" (above-knee) stumps in a total of 723 lower-extremity amputations.</p> <p>On the other hand, there is no question that the order for open amputation, followed by traction and a second, or revision, operation, led to prolonged hospitalization for some cases which safely could have been performed primarily as closed amputations, particularly as antibiotics became available late in World War II. Furthermore, many of these "military" amputations, performed as they were far behind the lines, were really essentially civilian in nature. It seems very questionable that there would be a need for performing as many open amputations in civilian practice where risk of infection and gas gangrene is relatively low. The surgeon has a responsibility to use open amputation and traction when there is a clear risk, yet to consider prudently the much shorter care which will be needed with a primary closed amputation when it is feasible medically.</p> <h4>New Concepts in Rehabilitation</h4> <p>The large military amputation centers in World War II provided an excellent opportunity to study the entire problem of amputee rehabilitation.<a></a> Although civilian surgeons generally had been in the habit of dismissing the patient when the amputation scar had healed, leaving him to search for limbfitting services with only the guidance of the classified telephone directory and the perplexing visits of amputee salesmen and demonstrators, the military Services reawakened the responsibility of the surgeon for more complete rehabilitation through the stages of prosthetic fitting, training, and subsequent follow-up. Similarly, the Services assumed responsibility for the necessary vocational guidance and counseling.</p> <h4>Wartime Problems</h4> <p>Because of the dramatic concentration of hundreds of amputees in a single hospital, however, the large military amputation centers drew considerable public attention-both favorable and unfavorable and generally over-dramatic. In operating their limbshops, they encountered difficulties because of the scarcity of experienced personnel (P). This problem was partially corrected, though never completely solved, by diligent effort to locate limbfitters who had been drafted and to see that they were reassigned to limbshops at amputation centers. In every case, however, the bulk of the limb-shop staff was necessarily made up of men who perhaps had mechanical aptitude but who were without previous training or experience in the limb industry.</p> <p>At the same lime the commercial artificial-limb industry was kept very busy with its private cases from civilian life and with the veterans from previous wars, while some of its younger men were drafted into the Services. Besides this, the generally good business conditions during and immediately following World War II, together with the manpower shortage, led to the employment or advancement of a great many amputees who, during the previous depression, had had great difficulty in finding and holding jobs. Many of these people wished to procure new limbs, thus further overloading the commercial limb industry.</p> <p>To add to the difficulties, the industry was then neither certified nor licensed, and it consisted, as it does today, of several hundred relatively small workshops. While some of its members had had formal education in other fields, there had never existed in this country any means for formal training in the arts and sciences basic to limbmaking and limbfitting. The sudden release, within a limited number of months, of some 21,000 veterans from military amputation centers imposed upon the industry an exceptional burden. These men had been fitted in the military centers with a serviceable, adequate, but admittedly "temporary" prosthesis, with the understanding that soon after their release the Veterans Administration, through civilian contractors, would provide a permanent prosthesis. Indeed, an additional or spare permanent prosthesis also was provided as a matter of policy.</p> <p>The confused state of affairs about the end of World War II, and during the year or so immediately thereafter, was further complicated by a series of sensational stories in some of the newspapers concerning difficulties with the limbs provided by the military centers and covering a series of indictments and trials of certain members of the commercial limb industry for alleged violation of the Antitrust Acts. The rather emotional atmosphere then prevailing in regard to amputees led to dramatic stories but in many cases to neglect of the basic difficulties.</p> <h4>Casualities From Korea</h4> <p>Substantially all factors concerned have since been greatly improved, so much so in fact that there were no difficulties of this type over the treatment of amputees returning from the Korean conflict. The relatively calm and orderly handling of these casualties, with the close cooperation of all concerned, was a tribute to the progress which had been made since 1945 in both technical and administrative aspects. Much of this change has been due to the fine cooperation of the commercial limb industry, now emerging into a prosthetics profession. It also has been influenced by the greater interest of surgeons in amputations and amputee rehabilitation, by the development of the team concept in this area as in so many other areas of medicine (and indeed in science generally), by the contributions of many sound administrators, and by the results of much hard work in the research and development laboratories.</p> <p>Some of the major changes which have influenced the amputation surgeon have been proven clinically by experience with casualties from Korea. Concepts of level of amputation and certain of the techniques of surgery have been affected. Perhaps most important, there is now a greater interest in postoperative care and in the rehabilitation responsibilities of the medical profession.</p> <h4>Level of Amputation and Modern Prosthetic Replacement</h4> <p>The surgeon's first decision in amputating is the selection of the site. Perhaps the influence of the Artificial Limb Program, sponsored by the Government and coordinated by the Committee on Artificial Limbs of the National Research Council, can be shown most dramatically by a review of the changes in recommended level. From a few definite "sites of election," the development of new principles and devices has made possible reaffirmation of the policy<a></a> of "save all possible length." Every level, with the possible exception of the below-knee amputation, has benefited, particularly in the upper extremity, where it is now possible to define at least nine amputee types (<b>Fig. 7</b>), all of which can be fitted successfully. In many cases the new devices not only permit satisfactory fitting of longer stumps but often replace additional functions beyond the important increase in bony lever.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Definitions of upper-extremity amputee types. Lengths above elbow are measured as percentages of distance from acromion to epicondyles; lengths below elbow are measured as percentages of distance from epi-condyles to styloid. From <i>Manual of Upper Extremity Prosthetics.</i><a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Upper Extremity</h4> <h4><i>The Below-Elbow Cases</i></h4> <p><i>The Wrist-Disarticulation Case. </i><br /> The wrist-disarticulation prosthesis is a good example of the development of a simpler appliance which yet permits better appearance and additional function than did the conventional prosthesis of 1945. At the end of World War II, the wrist disarticulation, if retained at all and not later reamputated at a higher level, was fitted with a laced, molded leather socket supported by steel sidebars jointed at the elbow, quite similar to that shown in <b>Fig. 3</b>, with rather bulky harness and a leather thong for power transmission. Elbow flexion and terminal-device operation were the only functions provided, pronation-supination being prohibited by the single plane in which the elbow hinge operated. The entire appliance was bulky, the uncoated leather soon absorbed perspiration and became objectionable, and the almost complete encasing of the forearm made the prosthesis uncomfortable in warm weather. Because of the screw thread attaching it to the wrist, the terminal device, whether hook or mechanical hand, projected appreciably beyond the opposite natural hand, resulting both in limited function and in undesirable appearance. No cosmetic covering faired the gap between the mechanical hand and the wrist.</p> <p>In contrast, there has been developed under the program of the Advisory Committee on Artificial Limbs a light and sanitary plastic-laminate prosthesis (<b>Fig. 8</b>) which covers only the distal portion of the stump and extends only a short distance up the radial side to support tipping loads while still permitting pronation and supination. <a></a> Extending farther up the ulnar aspect, the socket provides adequate leverage and bearing area to permit comfortable resistance to large loads on the terminal device which tend to tip the socket about the stump when the forearm is in the horizontal position. The snug, "screw-driver" fit of the bony prominences at the wrist into the terminal portion ensures rotation of the socket and terminal device as the radius glides around the ulna. Since this rotation decreases progressively up the forearm until, at the elbow, there is no relative displacement, it is necessary to cut away as much as possible of the radial aspect from the socket. But removal of socket material decreases both the weight of the prosthesis and discomfort in warm weather. The plastic-laminate socket and nylon coating of any leather<a></a> used in this or any other prosthetic or orthopedic appliance will prevent absorption of perspiration and the consequent development of odors.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Cutaway views of light and simple plastic prosthesis for wrist disarticulation, with APRL hand attached to plate embedded in end of forearm to conserve length. The plastic cosmetic glove drapes neatly over the junction. A separate socket similarly attached to a hook (as in Figure 9) is easily substituted to avoid disconnecting the terminal device, as is customary in the usual forearm. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Very simple harness is adequate. For the rare amputee requiring only an extremely light-duty prosthesis, the socket can be held on the bulbous stump by a strap like that for a wrist watch to close a keyhole slot so as to clamp the socket firmly just above the bulging styloids. In this case, the only harness necessary is the cable and loop about the opposite shoulder. Practically all amputees, however, require a somewhat more secure, yet still minimum harness, as shown in <b>Fig. 9</b>, with a light triceps pad held by an inverted Y-strap whose fork is higher than the fully tensed biceps. A very simple figure-eight harness is used, and the steel Bowden cable transmits energy quite efficiently without stretching and without catching the shirt sleeve.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Prosthesis and harness for wrist disarticulation or long below-elbow stump. Note simple figure-eight webbing entirely across back, with no cheststraps. A steel Bowden cable transmits energy to the hook with improved efficiency. An open upper-arm harness, consisting of triceps pad and inverted Y-strap, leaves biceps free from pressure. Flexible leather straps as elbow hinges, suggested years ago but seldom used, permit pronation and supination as well as elbow flexion. The APRL hook case may be laminated into the forearm to conserve length. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To shorten the prosthesis markedly in order to match the length of the opposite arm, the proximal wall of the APRL No. 4C hand<a></a> may be fastened to a plate built into the distal wall of the plastic-laminate socket, as shown in <b>Fig. 8</b>. Thus the plastic cosmetic glove can readily bridge the gap between the hand and the prosthesis and extend up under the shirt or coat sleeve of the wearer. A similar plan can be followed with the APRL hook<a></a> by removal of the stainless-steel stud and plate by which the hook case is normally fastened to the wrist disconnect. On other types of hooks, the stainless-steel stud can be removed or shortened and a suitable fastening plate added by welding or brazing. For wrist friction, thin rubber 0-rings may sometimes be used instead of thicker rubber washers, thus further decreasing length.</p> <p>In many cases, it has been found entirely feasible, both technically and economically, to supply two sockets, one laminated to a hand and the other to a hook, to be worn interchangeably. The added length due to a conventional wrist disconnect and stud is thus avoided. Snap fasteners between the flexible leather elbow hinges and the forearm socket, plus the disconnect feature of the control-cable attachment post, permit interchange of prosthesis without changing the harness. Thus the amputee can make the interchange from hand to hook simply by rolling up his sleeve, it being unnecessary for him to remove his shirt.</p> <p><i>The Long Below-Elbow Case. </i><br />In many shorter below-elbow stumps, a similar type of prosthesis, but without the bulges for the styloids, can be applied to permit the amputee to use his remaining pronation and supination. The key factors are flexible elbow hinges and the "screw-driver" fit of the end portion of the stump in the socket with increasingly loose fit proximally. The fact that pronation and supination may be retained encourages the surgeon to make every effort to avoid fusion of the radius and ulna owing to bone spurs or similar causes and to instruct the amputee to participate in physical therapy designed to redevelop muscular control.</p> <p><i>The Medium Below-Elbow Case. </i><br />In the medium below-elbow stump, the limited amount of pronation and supination is worth retaining, yet it is inadequate to permit direct control of the prosthesis. Accordingly, the step-up type of rotation device (<b>Fig. 10</b>) has been developed. Early attempts at an automatic lock were frequently disappointing, particularly if the amputee tended to snap the prosthesis when used with a wrist-flexion unit, because the high inertia forces jammed the locking surfaces and caused permanent dents which thereafter caused chattering or even failure to lock. Instead, a simple lock has been supplied on an experimental basis, some mechanical problems remaining to be solved. A simple bolt in the stabilized outer socket engages one of a series of holes in the rotating portion of the wrist whenever the elbow is flexed more than a few degrees but is withdrawn at maximum elbow extension (<b>Fig. 10</b>, detail). This device is particularly desirable even with a short, almost conical below-elbow stump which, with elbow extended, participates in humeral rotation from the shoulder. The entire extremity rotates within the triceps pad and outer socket, which are stabilized by the harness. With the socket and terminal device rotated to the desired position, the amputee returns his stump to its normal position with the elbow axis parallel to the mechanical elbow hinges, flexes the stump, and thus locks the wrist in the desired position.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. APRL-Sierra wrist-rotation step-up unit showing details of locking mechanism and of hinges used in control of lock. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In such applications, step-up gears are normally provided to increase the rotation of the terminal device in relation to that of the socket. A lock is desirable partially to transmit torsional loads on the terminal device through the elbow hinges to the open humeral cuff, but it is particularly desirable with outside Bowden-cable control of the terminal device to permit the torsional component of tension in the cable, when it spirals about the forearm, to be transmitted to the upper arm without stress upon the stump. The mechanical advantage of torque at the terminal device or control cable over the stump is due, of course, to the step-up gearing used to increase rotation of the terminal device.</p> <p><i>The Short Below-Elbow Case. </i><br />For rather short below-elbow amputations, a geared poly-centric hinge (<b>Fig. 11</b>) has been developed. In some cases, it permits easier fitting of the socket and may hold the socket more firmly on the stump. For still shorter stumps, the socket may be attached to the link connecting the two axes of rotation, while the forearm is attached to the lower geared segment (<b>Fig. 12</b>), thus providing a <i>fixed </i>ratio of 2:1 between degree of flexion of the artificial forearm and degree of flexion of the below-elbow stump and socket. It has been found, however, that this fixed ratio has only limited application.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Hosmer PC-100 polycentric hinge, particularly suited for medium to short below-elbow stumps. By virtue of the mechanical linkage, it sometimes aids in permitting extreme flexion in cases where the stump retains a full range of motion so that step-up hinges are unnecessary. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Geared step-up hinge (Hosmer MA-100) for very short below-elbow stumps of limited range of motion. The stump socket is fastened to the center link connecting the two geared links, which in turn are fastened to the upper-arm cuff and the forearm shell. The ratio of flexion of the forearm shell to that of the short stump is thus 2:1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The short below-elbow stump is another example of the new principle of saving all possible length. Formerly, most surgeons and limbmakers would have agreed that such short below-elbow stumps could not be fitted satisfactorily. Such a stump tends to slip out of the conventional socket and also may exhibit no useful control of the elbow joint. Frequently, it was advised that such cases be reamputated at the "site of election" in the humerus. Late in World War II, however, both in Canada and in at least one U.S. Army amputation center, hinges were developed, similar to those shown in <b>Fig. 13</b>, which permitted a step-up of forearm movement as compared to stump movement, a <i>variable </i>ratio compensating roughly for the resistance encountered and the strength of the stump at various positions.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Typical occupational-aid terminal devices, all European. The screened boxes indicate the devices recommended for the various activities. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As seen in <b>Fig. 14</b>, the short below elbow, biceps are feasible.<a style="text-decoration:none;">*</a> Since there is no appreciable pronation-supination at this level, the biceps tendon remains in a fixed position rather than tending to migrate from medial toward lateral as it does when a longer stump moves from pronation to supination. The posterior rim of the socket is carried as high as possible, substantially to the olecranon. In some cases it is possible to hook the socket brim over the olecranon to help pull the stump into the socket during flexion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Prosthesis with variable-ratio step-up hinges for short below-elbow stumps. An above-elbow type of cable control assists in flexing the forearm shell. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The middle pivot of the step-up hinges is substantially opposite the humeral epicondyles, which define the anatomical elbow axis. The lower hinge moves in its slot during elbow flexion, as indicated in <b>Fig. 13</b>. The lower proximal end of the forearm shell must be cut out in order to clear the short stump at extreme elbow flexion. But since this type is used on short below-elbow stumps, there is no serious protrusion of the stump beyond the general line of the forearm socket and, therefore, no appreciable bulge in the coat sleeve.</p> <p>Customarily, an auxiliary lift for the forearm is provided by an above-elbow type of harness, with two separate pieces of cable housing attached to the forearm and to the triceps cuff but bare cable running from a space between the two separated pieces of housing, as shown in <b>Fig. 14</b>. By voluntarily controlling the position of the stump, the amputee can effectively "lock" the forearm as if by a mechanical elbow lock and can thus operate the terminal device by increased tension on the control cable without causing further flexion of the forearm. By means of stump action, he also can press downward firmly enough on the forearm to perform functions such as holding papers on a table or holding a fork to stabilize a piece of meat while it is cut by a knife held in the opposite hand.</p> <p><i>The Elbow-Disarticulation Case</i><br /> The elbow disarticulation was for many years frowned upon because of the difficulties of fitting it with a conventional prosthesis with laced molded-leather socket and elbow lock and joint requiring a bolt extending the full width of the elbow. In such a design, of course, the mechanical lock was necessarily fitted below the end of the stump, thus making an overly long humeral section and a correspondingly short forearm section, usually preventing the amputee from reaching his mouth with the terminal device, as well as creating an awkward appearance and difficulty in using the amputated elbow as a support on the desk top, and the like. Capable of end-weight-bearing, the elbow-disarticulation stump, however, is useful as a support without the prosthesis, as in rolling over in bed. Its bulbous and irregular shape serves as a key to stabilize the prosthesis against rotation about the long axis of the humerus.</p> <p>To conserve these functions, therefore, the external lock shown in <b>Fig. 15</b> and <b>Fig. 16</b> was developed to fit on the <i>outside </i>of the socket in line with the humeral epicondyles and the anatomical axis. The artificial forearm can thus be of a conventional length, and the terminal device can be brought to the mouth readily. The locking circle is, however, necessarily of a smaller diameter than would be available in a conventional above-elbow type of prosthesis, so that in the present model the number of locking positions is reduced to five (<b>Fig. 16</b>). Although numbering more than in the earlier conventional above-elbow or brace locks, the five positions are less than the 11 or even infinite number of positions provided by above-elbow locks which have been developed in the ACAL research program.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Prosthesis for elbow disarticulation, with APRL-Sierra external elbow lock (Figure 16) and same dual control as used on above-elbow prostheses. To accommodate bulbous humeral condyles, a channel may be left in the socket, a lacer may be used, or a slotted, flexible, plastic-laminate socket and clamping strap may be loosened and expanded enough to permit entry and withdrawal and yet provide adequate control during use. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Schematic diagram of APRL-Sierra external elbow lock, intended for elbow disarticulation but also useful with very short below-elbow stumps or with paralyzed arms. Top, locked position. Next pull on lock-operating cable in upper right withdraws locking plunger from the wedge-shaped notch in forearm piece and raises the alternator crosshead, thereby compressing the two helical springs. Pin on the thin leaf spring follows right side of inverted heart-shaped cam until it slips into notch at bottom of cam. Relaxing cable drops the alternator cross-head slightly until the pin and leaf spring hold the cam and locking plunger in the unlocked position (middle). Subsequent tension on the cable raises the alternator crosshead enough so that the leaf spring can straighten until its pin follows the left side of the heart-shaped cam back to original position. Meanwhile the helical springs force the crosshead down and push the locking plunger into a tooth in the lower portion attached to the forearm (bottom). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The APRL-Sierra outside-locking elbow hinge has another special application in the very short below-elbow stump where range of motion is insufficient to operate a forearm through a step-up elbow hinge but where a small residual motion is adequate to operate the locking mechanism diagrammed in <b>Fig. 16</b>. In the arrangement shown in <b>Fig. 17</b>, elbow locking is effected by stump motion rather than by motion of the shoulder, thus giving a more natural appearance and more freedom than could be obtained with an elbow disarticulation or an above-elbow stump.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Prosthesis for very short below-elbow stumps of such limited motion that step-up hinges are inadequate. The external elbow lock is controlled by a convenient cam, lever, or cable system triggered by the limited stump motion, and the forearm shell is flexed by an above-elbow type of harness. By this system the elbow lock is more easily operated than in a conventional above-elbow type of control. The Northrop-Sierra voluntary-opening two-load hook <a></a>shown here is usually considered to be a left hook, that is, as used on a right arm the operating lever is in the little-finger position rather than in the thumb position. This arrangement results in <i>a. </i>more nearly straight control cable of higher efficiency than is possible when the operating lever is on the medial side, in which case the cable must spiral over the forearm. More often, particularly in the case of bilateral arm amputees, voluntary-opening hooks are fitted with the operating lever, and also the control button for changing the load, located on the medial side. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The external elbow lock has already been used occasionally for applying artificial-arm principles to arm braces. The situation in that entire field should improve rapidly in the near future. Occasionally, patients have requested, or surgeons have recommended, amputation of an arm when disease or injury have left a flail elbow. It has seemed that improved artificial arms would actually provide the patient with more function. It must be remembered, however, that the damaged arm provides at least some support and perhaps sensation, and consequently every effort should be made to replace the lost functions of stability, control, and voluntary movement by suitable bracing. Polio cases, retaining sensation and an erratic distribution of muscle activity, offer a special challenge.</p> <p>The outside-locking hinge of <b>Fig. 16</b> is normally fitted as shown in <b>Fig. 15</b> and <b>Fig. 17</b> for control from the proximal joint. Presumably, though, it could be inverted and controlled from the distal end of the arm if some portion capable of even a little voluntarily controlled movement with very nominal forces were available in the hand or wrist. A ring on a finger or extreme hyperextension of the wrist could, for example, be used to trigger the elbow lock, thus simplifying the harnessing, particularly if the shoulder were also weakened.</p> <p>It may be noted parenthetically that some work has been done<a></a> both by rehabilitation centers and by prosthetists and orthotists to drive paralyzed fingers with mechanisms adapted from the artificial-hand field or to hyperextend a paralyzed hand on a "cock-up" wrist splint and substitute a hook on a rotary or even on a ball-and-socket mounting on the volar aspect of the wrist. Even with a quadriplegic there has been enough control of shoulder movement to provide the necessary voluntary control for the hook, supplementing at least a weak biceps action for forearm flexion and supination. The relatively heavy hook extending from the volar aspect of the wrist will provide by gravity forearm extension and a tendency toward pronation. Since the degree of paralysis and of loss of sensation may be so variable, in the entire field of arm bracing the role of the doctor is even more important than it is in rehabilitation after amputation. Correspondingly, there is an even greater challenge to the ingenuity of the prosthetist, the engineer specializing in prosthetics, and the manufacturer in adapting or developing special appliances for the individual case and to the patience of the therapist in redeveloping even faint voluntary movements which might control triggers for locking mechanisms.</p> <h4><i>The Above-Elbow Cases</i></h4> <p>In the above-elbow stump, as much as possible should be saved consistent with the nature of the injury or disease. Even a very short above-elbow stump may be useful as an anchor point, and in experimental work on electric arms<a></a> such a stump has been used to control the necessary switches and clutches (<b>Fig. 18</b>). A stump of nothing more than the head of the humerus helps to round out the shoulder and to provide a much more secure stabilization of the "shoulder-disarticulation" socket.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Shoulder cap for electric control by shoulder motion or by short humeral stump or both. From Alderson .<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Nevertheless there remains a challenge to the engineer and prosthetist in providing improved shoulder-disarticulation and very high-above-elbow arms with passive or voluntarily controlled humeral flexion and abduction. A number of designs were shown in the literature<a></a> after World War I, but none appears to have been practical. The sectional plates<a></a> used in the ACAL research program have facilitated independent construction of the socket and remainder of the prosthesis and their subsequent alignment. Sometimes they have been provided with rotation to facilitate donning of clothing with the humeral section flexed, followed by return of the humerus to a vertical position. Such joints of the humeral section to the shoulder cap have not permitted abduction, however, and have not normally permitted voluntary or passive forward flexion of the humeral section about the shoulder joint to bring the elbow forward and permit the terminal device to reach the mouth.</p> <p>The conventional sectional plates have been solid and thus have been suited only for a true shoulder disarticulation, but it should be feasible to leave an opening through which a very short stump, such as the head of the humerus and its surrounding socket, could protrude into the hollow humeral section. Provision of a sector of a complete circular track, rather than the elongated D-shape which has been used, would also result in better cosmetic appearance when the artificial humeral section is flexed forward. Possibly a simple lock to stabilize such humeral flexion could be controlled by a very short above-elbow stump, even if passive adjustment with the other hand, or by gravity in connection with torso movement, were necessary because of the weakness of the stump.</p> <p>Attempts to provide voluntary control of humeral abduction and rotation have been reported in the literature. Alderson <a></a> developed an experimental arm of the shoulder-disarticulation type in which shoulder lift against the anchorage of a groin strap generated either elbow flexion followed by humeral abduction or humeral abduction alone, depending on whether the elbow were free or locked. At least one commercial limb manufacturer recently has experimented with a "universal shoulder joint" permitting a combination of actively and passively controlled motions including upper-arm rotation by means of a turntable located in the humeral section.</p> <h4>The Lower Extremity</h4> <p>In the lower extremity, although there have been definite changes in techniques and devices, the influence of the Artificial Limb Program has not as yet markedly changed the levels of amputation. Work is, however, going forward rapidly, particularly at the Lower-Extremity Clinical Study operated at the University of California using facilities of the U.S. Naval Hospital at Oakland. It is to be expected that in the next few years more definite changes can be recommended.<a></a> Meanwhile, the principal effects of wartime experience and of the ACAL research program have been increased emphasis on the Syme and knee disarticulation and a better understanding of muscle functions, particularly in relation to the suction socket for above-knee amputees.</p> <h4><i>The Below-Knee Cases</i></h4> <p><i>The Syme Amputation. </i><br />While the Syme amputation is more than a century old, it has until recently been considered controversial, with firm advocates and bitter opponents. In some cases, criticism has rightly been directed toward very long below-knee stumps which, however, were not true Syme amputations with the normal heel flap and capable of full end-weight-bearing. Experience at military amputation centers during World War II seems to have confirmed the successful results which have been reported by the Canadians ever since World War I<a></a>. A recent Canadian report<a></a> on the Syme amputation describes surgical precautions, conventional and experimental Syme prostheses, and clinical experience.</p> <p>Although the Syme amputation requires meticulous surgery, in the absence of sepsis, and careful attention to all details, a successful result provides much greater freedom of action for the amputee and enables him to remain on his feet for long periods. The broad surface of tissues anatomically adapted to weight-bearing offers the Syme amputee a great advantage over the below-knee amputee with limited areas offering a wedgelike support for the stump and pressing upon tissue which has not been accustomed to weight-bearing.</p> <p>The prosthesis for the Syme has been improved, on an experimental basis, by the Canadians (<b>Fig. 19</b>) and, more recently, by the Prosthetic Testing and Development Laboratory of the Veterans Administration (<b>Fig. 20</b>). Both types use a plastic laminate in place of molded leather for greater sanitation as well as for greater strength with decreased weight and bulk. Both use Fiberglas extensively for high strength.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Prostheses for Syria's amputation. Above, conventional Syme prosthesis with typical bulky and unattractive design at ankle and with bothersome shank lacer. Below, Syme prosthesis developed by the Canadian.<a></a> Same stump in the two cases. Note improved cosmetic appearance and simplified method of donning. The Canadian model consists ol a perforated plastic-laminate shell with thin, cellular-rubber lining, the whole considerably lighter than the conventional design above. Rear portion can be opened to admit bulbous stump. yet material is effectively distributed to withstand large bending loads. No ankle joint is used, but the foot is formed of cemented layers of cellular rubber around a reinforcing tongue projecting from the socket to the ball of the foot. Pressure on heel compresses the rubber to give the equivalent of plantar flexion. <i>Photos courtesy Canadian Department of Veterans Affairs.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Experimental Syme prosthesis designed and tested at the VA's Prosthetic Testing and Development Laboratory on request of the Orthopedic and Prosthetic Appliance Clinic Team, New York. It combines a molded plastic-laminate shell with rear opening, thin sponge-rubber lining, and an adaptation of the U.S. Navy functional ankle <a></a> using two-durometer rubber block. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Considerable success has attended efforts to reduce the bulk at the ankle by eliminating the steel sidebars which, in earlier prostheses, projected beyond the malleoli on the medial and lateral aspects, thus adding thickness to a zone already the broadest portion of the ankle. The steel sidebars had, in any case, been mechanically rather ineffective in sustaining bending loads, as when the weight of the amputee is supported on the ball of the foot, because the material was close to the neutral axis or central portion of the bars.<a></a> In the newer designs, this portion over the malleoli is relatively thin, but bending moment is resisted more effectively by the most anterior portion, ahead of the tibial crest, and by the posterior portion at a greater lever arm than was available in the older, narrow, metal bars. To avoid fatigue failures, special care must be taken to achieve a smooth posterior cut in the shell-like prosthesis. The bulbous malleoli are introduced into the prosthesis by opening a posterior portion, which may then be closed either in trap-door fashion by a hinged portion of the shell or by a fabric- or nylon-coated leather portion held by a slide fastener, laces, or adjustable straps.</p> <p>The shell-like combination socket and shank section, with the end-bearing pad, is molded over a plaster model of the stump to attain uniform fit. A slightly soft lining may be used throughout the socket. Relief is provided along the sharpest portion of the tibial crest so as to maintain comfort when weight is carried on the ball of the artificial foot and there is a tendency for the socket to press sharply on the upper portion of the tibia. Under such conditions, firm counterpressure, distributed comfortably, is also required just above the malleoli on the posterior portion of the tibia and fibula. Ankle action may be provided by a laminated sponge-rubber heel which is compressed at heel contact, giving the equivalent of plantar flexion, or by a rubber-block ankle joint with a shallow V-shaped section removed to accommodate the long stump.</p> <p><i>The Short Below-Knee Case. </i><br />Short, badly scarred, below-knee stumps have heretofore sometimes been reamputated above the knee or have been used in a permanently flexed position in the so-called "bent-knee" or "kneeling-knee" prosthesis reminiscent of pirate tales. In either case, the advantages of voluntary control of knee-joint movement are lost.</p> <p>The U.S. Navy below-knee "soft" socket, <a></a> an outcome of recent research, consists of a plastic lining backed by a thin layer of sponge rubber and a rigid or, recently, a rather flexible shell (<b>Fig. 21</b>). An improvement on earlier commercial sockets with felt or wax lining, it may be fitted to any below-knee stump, but particularly it has permitted conservation of short, sensitive, badly scarred stumps. The weight-bearing impression of the stump dipped in plaster yields a much more accurate replica than do most wrapped plaster-bandage impressions. In general, it seems reasonable to believe that any technique for making a socket from a cast is likely to produce a more accurate fit more rapidly and with less discomfort than is a trial-and-error carving process.<a></a> The thin sponge-rubber lining giving the "soft" socket its name seems to be only one of several factors contributing to its usefulness.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. U.S. Navy "soft" socket for below-knee amputation, cut to show plastic sheet lining rolled over brim, thin (1/8-inch) sponge-rubber lining, and flexible plastic-laminate outer shell, all formed over male plaster model of the stump. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans Administration</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Careful location of the mechanical knee joints is always important. The work of the University of Denver<a></a> indicated the possibilities, for below-knee amputees in general, of improved fitting of conventional legs with single-axis knee joints by more careful location of the knee joints. Particularly recommended were fixtures and tools to ensure that the mechanical joints on opposite sides of the prosthesis are on a common axis. Poly-centric joints did not seem necessary. The report considered, however, the possibility of a mechanical joint of the single-axis type at the knee, but mounted high up on the thigh corset by a pivoting joint of limited angular range, in place of rigidly riveting the upper joint bar to virtually the full length of the corset. This idea has been proposed in the German literature.<a></a> In such a case, probably a reinforcing band should be mounted in the thigh corset to ensure that the upper joints are kept on a common axis.</p> <p>The very short below-knee stump, with the tibia amputated in the broad condylar area and with trabecular bone structure, is often suited to take a high fraction of weight-bearing on the distal end, in contrast to the usual below-knee stump of much smaller diameter, limited bearing area, and with thick, hard cortex surrounding a medullary canal. If the thickness of pads at the end of the stump is gradually increased, particularly if the pad in contact with the stump end is carefully molded to the irregularities of the stump, an increasing fraction of end-weight-bearing may often be tolerated.</p> <p>These circumstances deserve careful investigation before any thought is given to re-amputation above the knee, which in the past has often been suggested for such stumps. End-weight-bearing is both more nearly normal with respect to mechanical characteristics, promoting calcification, and is desirable in avoiding any tendency toward lordosis. The very short below-knee stump often can be fitted successfully by very careful forming of the socket. Special care is needed in shaping the posterior brim to accommodate the hamstring tendons, yet to rise into the popliteal space as much as possible without cutting off circulation. The "slip" socket, elastically supported to stay in contact with the stump during the swing phase, is an old idea often indicated for short stumps.</p> <p>Even if a very short below-knee stump cannot take appreciable weight-bearing on its end and on the flaring tibial condyles, it may be fitted with a long, ischial-supporting thigh corset and the sturdy external mechanical joints which would be used in a knee-disarticulation prosthesis. In this case the below-knee amputee, like the above-knee amputee, must rely upon mechanical stability of the prosthesis during the stance phase with the knee in full extension, but at a minimum he has proprioceptive sense of knee position and usually some limited ability to control slight knee flexion to return the knee to full extension, thus saving himself from some falls. Partial control of heel rise at the beginning of the swing phase and of knee extension at the end of the swing phase permit a more graceful gait and a better range of cadence than generally can be attained with above-knee prostheses.</p> <h4><i>The Knee-Disarliculation Case</i></h4> <p>The knee disarticulation, an old type of amputation, typically has been fitted with a molded leather socket provided with a lacer to permit the entry of the bulbous end of the stump. This type of prosthesis has mechanical joints and sturdy metal sidebars similar to those in the below-knee prosthesis. Normally, no mechanical friction has been used, and consequently gait tends to be limited to a single cadence. Any attempt to walk more rapidly leads to excessive heel rise and to "slamming" of the artificial shank into full extension just before heel contact.<a></a> Normally, extension is limited by thongs similar to the back-check in a below-knee artificial leg. Since the knee cannot be extended or stabilized voluntarily, the joints are arranged to give mechanical stability at full extension, as in an above-knee leg.<a></a> </p> <p>Many prosthetists have objected to the knee disarticulation as a level of amputation because of discomfort of the long, molded, leather socket, tendency toward breakage of the sidebars, and the lack of mechanical friction. Amputation at a higher level has frequently been advocated. The knee disarticulation, however, provides definite advantages over the above-knee amputation. If the end of the stump is properly fitted, a broad weight-bearing area is available. Normal transmission of weight through the shaft of the femur minimizes the tendency toward the lordosis often developed in above-knee amputees as the result of weight-bearing on an ischial support located back of the normal hip joint. <a></a> Clearly, disarticulation offers the maximum bony lever of any amputation at or above the knee.</p> <p>A recent informal survey of some of the knee-disarticulation cases performed under supervision of one of the authors (R.H.A.) at Thomas England General Hospital during World War II has indicated satisfaction of the patient with this type of amputation and prosthesis. In spite of the gait deficiencies noted, these knee-disarticulation amputees feel that they walk well, continue to prefer this level of amputation, and refuse any consideration of reamputation above the condyles to become more conventional above-knee amputees. Although some knee-disarticulation prostheses providing knee friction are reported in the literature, <a></a> much more needs to be done in this respect.</p> <h4><i>The Above-Knee Cases</i></h4> <p>In the above-knee amputation, at all locations as much length as possible should be conserved. Gritti-Stokes and similar end-bearing stumps have in many cases been fitted successfully with the suction socket,<a></a> although attachment of the muscles is then particularly important to avoid development of excessive negative pressure owing to displacement of muscle bulk in the necessarily limited clearance volumes available with long stumps and end-bearing pads. Some have found difficulties in fitting such cases with the suction socket and have preferred to rely on a conventional pelvic-band suspension, perhaps with a second hinge permitting abduction. In either case, the longer the above-knee stump the better.</p> <p>As regards the above-knee case, the principal development thus far of the Artificial Limb Program has been the reintroduction of the suction socket, with many far-reaching effects on stump shape, muscle conservation, socket fit, and alignment, accompanied by increased need for the cooperation of many disciplines and the launching of a program of education and certification. As for the first of these, the suction-socket program shifted emphasis from the excessively flabby, conical stump (<b>Fig. 22</b>) desired for the so-called "plug" fit to a more nearly cylindrical stump with firm muscles stoutly attached to the bone. In the suction socket, the muscles are needed both to control the newly found freedom about the hip join and to provide a gripping action by bulging against the walls of the socket, thereby decreasing the negative pressure required to carry the weight of the prosthesis. Similarly, introduction of the suction socket led to replacement of the typical conical socket of triangular or circular cross section (<b>Fig. 23</b>) by a more nearly rectangular socket (<b>Fig. 24</b>). The latter, developed in Germany within the last generation, has a better basis in physiological and anatomical fact, appears to be a necessity with the suction socket, and has, of course, also been used successfully with an increasing number of pelvic-band conventional limbs without use of suction.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. An above-knee socket with nearly circular cross section and steeply conical form intended to support a conical, atrophied stump by side-bearing. Typically, a substantial roll of flesh developed over the rim around most of the circumference. The straps were used with suspenders. Adjustment for atrophy and shrinkage of the stump was easily made by additional stump socks, since the stump was regarded as a jellylike mass whose shape was easily distorted, with little definite relation between socket shape and stump shape. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans Administration.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Conventional socket for "plug" fit of above-knee stumps, showing rounded, triangular top portion of prosthesis for right thigh (looking forward and laterally). Note shelving flare below gluteal crease and ischium and broad, horizontal flare through perineum and adductor region. A considerable roll of flesh develops over this flare also, as in Figure 22. Socket shown here is made of metal and perforated, but the style often was used in wooden sockets as well. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans Administration.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Substantially rectangular or quadrilateral plan of top of socket for left above-knee prosthesis (seen from the rear), typically used for the suction socket but also applicable with soft belt or mechanical hip joint and pelvic band. Note the definite but narrow ischial support, slightly sloping forward and down and well rounded on its forward edge. The medial wall is thinner than the flare in a "plug" fit, since it should <i>not </i>provide a shelf or support against vertical load but should, in order to provide horizontal support during the stance phase, reach into the perineum as high as feasible without striking the pelvis. A nearly square anteromedial corner provides relief for the prominent adductor tendons. A high forward wall keeps the ischium on its support. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans Administration.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As for alignment, introduction of the suction socket has forced the prosthetist to pay more attention to details, since, unlike the case of the conventional above-knee leg, errors in alignment cannot here be concealed by trial-and-error bending of the pelvic band and metal, single-axis hip joint which forced conventional legs to swing in a single plane regardless of their inertia and the gait of the amputee. With the suction socket in correct alignment, the amputee balances his weight completely on the leg, since he has no pelvic band and hip joint to lean against for support. Conversely, however, attention to better alignment has led to decreased stress in the hip joints and pelvic bands of those legs which, for one reason or another, are still fitted with pelvic bands. If one thinks of the suction socket as being fitted with an imaginary hip joint carrying zero stress, it is apparent that a comparable alignment will result in minimum stress in a real hip joint and pelvic band of a conventional leg and, therefore, to greatly reduced risk of breakage.</p> <p>In a very short above-knee leg, the suction socket <i>plus </i>auxiliary suspension, either the Silesian bandage (<b>Fig. 25</b>) or the conventional hip joint and pelvic band (<b>Fig. 6</b>), has permitted conservation of greater <i>effective </i>stump length than would be possible with the same stump in a conventional leg with hip joint and pelvic band but with a "plug" fit. In donning the suction socket, the flesh is pulled into the socket with stockinet, in contrast to the tendency of the conventional stump sock and "plug" fit to push the soft tissues upward and out of the socket. The auxiliary suspension provides greater control and stability than would be available in a pure suction socket. The more logical anatomical fit of the quadrilateral shape, including some ischial support, avoids the roll of flesh in the adductor region and the skin irritations and furuncles so commonly seen with the "plug" fit. Thus, some very short above-knee stumps fitted with this combination of suction socket and auxiliary suspension can function as if with a conventional above-knee leg without the necessity of flexing the stump permanently in a tilting-table type of socket such as would be used for a hip disarticulation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Model of German suction-socket prosthesis with Silesian bandage, or trochanteric belt, with padded horseshoe encircling the trochanter, soft leather belt posteriorly around the pelvis, and V-shaped strap from anterior of socket through ring of the belt. The pelvic belt aims to assure vertical support during the swing phase, while the V-strap provides support against unwanted abduction and external rotation. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans Administration.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Extremely short above-knee stumps, with little more than the neck of the femur, can be fitted in some cases with the "saucer" type of socket<a></a> in place of the tilting-table type generally used throughout the world with a true hip disarticulation.<a></a> Often the knee joint is locked during standing and walking, so that the amputee walks stiff-legged. In this case the prosthesis is often built shorter than the sound leg. Sometimes, however, adequate alignment stability can be obtained to permit a free knee joint. The thigh section is sometimes locked to the tilting-table socket so that the back muscle can function to stabilize a free knee as do the hip extensors in the above-knee amputee.</p> <p>Hiyeda, <a></a> in 1942, and independently the Canadian Department of Veterans Affairs<a></a> have used free joints at both hip and knee, with the hip joint farther forward and the knee farther to the rear than usual (<b>Fig. 26</b>). A posterior elastic strap helps to extend the hip joint. Either the saucer socket or the tilting-table type may be built of plastic laminate instead of from the older, molded leather, but if for some reason leather is used, the nylon coating developed at the Army Prosthetics Research Laboratory<a></a> will make it much more sanitary.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Hip-disarticulation prosthesis developed by the Canadian Department of Veterans Affairs. Anterior view-shows three points of suspension© and full width of hip joint. Lateral view shows standing and sitting positions. From McLaurin.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Partial Amputations</h4> <p>Wherever possible, of course, partial hand or foot amputations should be performed in preference to major amputations.<a style="text-decoration:none;">*</a> Much work was done during and immediately following World War II on the surgery of the hand,<a></a> and interest has been lively since the formation of the American Society for Surgery of the Hand. In the recent Korean conflict, a great many partial hand and partial foot amputations were performed safely, whereas in previous times many of these cases would have required major amputations, probably as below-elbow or below-knee amputations at the former "sites of election."</p> <p>In recent years, satisfactory cosmetic gloves have been developed by the commercial prosthetics industry<a></a>, at the Army Prosthetics Research Laboratory, <a></a> in the Navy,<a></a> and in the Veterans Administration's Plastic Artificial Eye and Restorations Clinics. These have made possible adequate cosmetic fitting of many partial hand amputations while retaining some function. Moreover, various operable terminal devices for partial hand amputations have been developed both commercially and on an experimental basis in the ACAL program. Sometimes a small hook is mounted on a molded socket and controlled by a conventional cable or by wrist movement. On an experimental basis, the mechanism and wrist plate of an APRL hand have been removed, the transmetacarpal stump allowed to fit within the hand shell, and the side frames of the mechanical hand hinged opposite the anatomical wrist joint to a light forearm cuff. Thus wrist flexion and forearm rotation are preserved. Such cases clearly present individual challenges to the prosthetics clinic team <a></a> and to the designer and manufacturer.</p> <h4>Recapitulation</h4> <p>Decision as to the level of amputation, then, can be recapitulated in terms of saving all length possible.<a style="text-decoration:none;">*</a> This policy is justified not only by new devices, developed predominantly in the Artificial Limb Program, but also by the spectacular advances in recent years in many fields of medicine and related sciences. Blood, plasma, and antibiotics have helped to control shock and infection and have made possible prolonged and precise operations. Medical schools and residency training programs are only beginning to give more attention to education in the broad field of prosthetics to make the new findings available to the practitioner. The various medical societies are now devoting to this broad field more and more time on their programs and more space in their exhibits. Special courses, such as those on the suction socket held at various locations throughout the country, and the Institutes on Upper-Extremity Prosthetics at UCLA,<a></a> are bringing specialized knowledge to the doctor, the prosthetist, and the therapist. More attention is given to individual prescription rather than to "sites of election," with increasing cooperation and expert consultation from the prosthetist as to devices available but without dictation of sites merely because they might be more convenient. Best of all, there is now greater interest in over-all rehabilitation and continued follow-up on the part of the medical profession to see that every amputee, regardless of level of amputation, achieves the greatest possible restoration to normal life.</p> <h4>New Techniques in Amputation Surgery</h4> <p>There is no need here to describe in detail the techniques of amputation surgery, since they are all so well presented in numerous other sources, for example, by Slocum.<a></a> Certain points reflecting the experience of the Artificial Limb Program<a></a> may, however, be worthwhile. These may first be illustrated in terms of a typical amputation with primary closure, chiefly that producing an above-knee stump for which suction socket is intended, followed by notes on some of the special conditions at other levels of amputation.</p> <h4>The General Case</h4> <p><i>Skin Flaps and Subcutaneous Tissue</i></p> <p>In general, the skin flaps are approximately equal on the anterior and posterior sides and are so curved as to meet neatly without undue skin tension but without leaving "dog ears." The usual amputation has a central scar, although in some of the special cases of weight-bearing stumps there is usually a longer flap on one aspect so as to move the scar out of the end-weight-bearing zone. Even for the belowknee amputation without end-weight-bearing, a longer posterior flap has sometimes been advocated to take advantage of the presumably richer blood supply and more liberal muscle and fascia, but the advisability of this technique has not yet been sufficiently evaluated for it to be recommended here. Since when divided the skin and other soft tissues retract, the skin flaps are initially outlined distal to the intended level for sawing the bone, thus compensating for the successive retraction of the various layers and permitting the bone eventually to be sawed through at the edge of spontaneously but temporarily retracted tissues.</p> <p>The subcutaneous tissue may be regarded as a gliding mechanism, enabling the skin to move freely over the deeper fascia and achieving the goal of freely movable skin without an adherent scar. The subcutaneous tissue is cut perpendicularly to the skin, without beveling, and both are allowed to retract as they are cut, without undermining.</p> <p><i>Fascia</i></p> <p>A complete fascial envelope is very desirable, primarily to secure the severed muscles to each other and to the bony lever. Besides this, as Lawrence<a></a> has suggested, piston action of the bone within the soft tissues of the stump may help to pump fluid from the stump. Presumably this action is more effective if the fascial envelope is completely closed in order to force fluid displacement upward through the veins and lymphatic channels. In contrast, an opening in the fascial envelope may permit a compensating pulsation of the soft tissues through the defect, thus failing to generate effective pumping action. Although as yet there is little direct evidence to support such views, the reasoning seems logical.</p> <p>A further advantage of the fascial envelope is to avoid bulging of muscle through a defect in the deep fascia. Accordingly, it is also desirable, when feasible, to repair traumatic defects in the fascia and to refrain from removal of fascia during any plastic operations intended to remove bad scars.</p> <p>The tough fascia lata plays a special role while the above-knee amputee is on the artificial leg during the stance phase. Acting as a guy wire at the most favorable leverage to balance body weight falling medial to the ischial support, it helps to support the pelvis in a substantially horizontal position with minimal expenditure of muscular energy. Hence every reasonable effort should be made to secure firm attachment of the severed end of the fascia lata to the bony lever and to the fascia on the medial side of the stump in order to replace its former anchorage below the knee, as in the intact leg.</p> <p>The incision through the fascia is parallel to the initial skin incision but at the level of the retracted superficial tissues. Like all aspects of amputation surgery, it should be clean and precise.</p> <p><i>Muscles</i></p> <p>The importance of muscles has been emphasized by the Artificial Limb Program in connection with the suction socket <a></a>as a vital part of the cineplasty studies<a></a> and in analysis of the forces, motions, and hence the energy costs of both normal and pathological gait.<a></a> Only from reattachment of the severed ends of the muscles is it possible to attain control of the stump, particularly when greater freedom of action is made possible by improved devices, as, for example, by the suction socket. Moreover, the muscles must be held at substantially their original "rest length" in order to attain the greatest force during contraction.<a></a> Appreciation of this fact was brought out especially in connection with the cineplasty program, but of course the principle applies to all other muscles. A brief review of muscle physiology, mostly of features known for over 50 years but re-emphasized by recent research, is in order.</p> <p><i>The Nature of Muscle Forces. </i></p> <p>The muscle studies at the University of California in connection with cineplasty <a></a> have re-emphasized the importance of the early studies by Blix <a></a> of force-length characteristics. Briefly, as shown in <b>Fig. 27</b>, the force developed by a muscle is related to the length of the muscle at the time the force is exerted. Any attempt to stretch a relaxed muscle beyond its rest length results in an increasing resisting force, as shown by the "passive-tension" curve. If the muscle is restrained at its rest length and then stimulated as vigorously as possible, a certain maximum force can be generated. Full excitation of all the fibers, as by electrical stimulation, yields this maximum force for isometric contraction, although in practical voluntary use only part of the muscle fibers are activated at a given instant, so that a much lower value is attained when the subject "tries as hard as possible."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Idealized length-tension curves for a typical muscle. Note that the passive-tension curve rises sharply when the relaxed muscle is stretched beyond rest length and that maximum voluntary force with isometric contraction is available at or near rest length. Clearly, use of a muscle in a contracted position yields both lower force and less available energy. From Inman and Ralston.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If now the muscle is allowed to shorten, that is, to move toward the left of the rest length in <b>Fig. 27</b>, stimulation results in some maximum isometric muscle force less than the value attained at rest length. Continued shortening results in decreasing forces measured isometrically until, at some value of contraction varying somewhat in different muscles but roughly 60 percent of the original length of the muscle, no force can be exerted.</p> <p>Beyond rest length, an increased total tension may be developed upon isometric contraction. The exact shape of the curve varies with the nature of the muscle, its past history of stretching or contraction <i>over </i>prolonged periods (especially noticeable in muscles in which the cineplastic operation has been performed), and with the individual case. When the passive-stretch force is subtracted from the total tension attained by isometric contraction, the resulting <i>net </i>force available voluntarily tends in general to decrease again as the muscle is elongated beyond the rest length. Thus the curve of the <i>net </i>force is roughly an inverted parabola with its maximum at or slightly beyond rest length. Since this curve varies with individuals and with training and exercise (which affect both the cross-sectional area of a muscle and the shape of the passive-stretch curve), examples can be found which depart markedly from this schematic pattern. Nevertheless, the general principle leads to a number of interesting conclusions relating to the surgery of both upper and lower extremities.</p> <p><i>Applications of Muscle Mechanics. </i></p> <p>It is immediately apparent from <b>Fig. 27</b> that, if a muscle is allowed to retract, temporarily or permanently, it cannot attain a voluntary force as great as would be possible at or near the original rest length. Prosthetic devices should be utilized, as far as practicable, with the appropriate muscles near, perhaps slightly beyond, the rest length. A cineplastic tunnel, for example, should be so harnessed that most objects will be picked up with the tunnel near the rest length.<a></a> As is well known, the hamstrings, if reattached to the end of the femur in an above-knee amputee, can serve as hip extensors. On the basis of known muscle mechanics, they will be most effective when the hip is somewhat flexed but will be considerably less effective when the hip is fully extended or when it is hyperextended just at the end of push-off. The amputee may then attempt to supplement hip extension by using his back muscles, thus producing lumbar lordosis. Alignment of the socket bore and condition of the back-check controlling extension of the thigh socket relative to the shank will both affect the length of the hamstrings and hence the ability of the amputee to stand securely and to push off forcefully.<a></a> Permanent contracture of a muscle will result in a movement of the passive-tension curve toward the left in <b>Fig. 27</b> and, in general, in a steeper shape of the curve, thus resulting in greater passive tension with only little stretching of the muscle. Thus the maximum force which can be attained voluntarily will be reduced substantially, and the effect may be more serious than the simple reduction in range of motion. Avoidance of contractures is thus mandatory.</p> <p>Workers at the University of California have studied the moment (or force X leverage) available about the hip joint in relation to the angle of adduction or abduction of the stump. Since the gluteus medius and tensor fasciae latae are at their rest length when the stump is in its normal position, under slight passive stretch with an adducted stump, but allowed to contract when the stump is abducted, it is not surprising to find that the available moment about the hip joint decreases markedly from the adducted into the abducted region. Forcible abduction of the stump against the socket wall is essential to keep the pelvis level during the stance phase ,<a></a> and consequently maximum available abduction moment about the hip is desirable to avoid an apparent gluteus medius limp. Therefore, workers at the University of California have reasoned, it is highly desirable to maintain as much adduction as feasible of the socket bore in space and in relation to the remainder of the prosthesis. Experiments with controlled fitting and alignment on the University of California adjustable leg<a></a> have indeed shown this reasoning to be valid. In contrast, fitting of the socket to an abducted stump and "straight" alignment of the shank to the socket result in an appreciable limp.</p> <p><i>Stump Muscles in Prosthetic Control. </i></p> <p>Muscles may have within a socket several actions particularly favorable in the above-knee suction-socket leg. General bulging of the muscle belly during contraction increases the diameter of the stump in the zone of the maximum muscle belly, thus helping to grip the walls of the socket and producing frictional forces which help to support the prosthesis. Muscle bulging and even the contour of the relaxed muscles help to key the correspondingly irregular socket against rotation about its longitudinal axis and thus aid in voluntary control of rotation of the prosthesis.</p> <p>Conversely, the muscles of the thigh sometimes become detached from the cut end of the bone and the overlying fascia but by some mischance become attached to the superficial tissues, as through the scar. Contraction of such muscles causes a pistonlike retraction of the end of the stump, a condition that may cause discomfort in any case, especially if simultaneous contraction of opposing muscles tends to stretch the scar, and one that is particularly undesirable in a suction socket. Pistonlike retraction of the stump end, analogous to withdrawal of the plunger from a hypodermic syringe, develops additional negative pressure in the space between the end of the stump and the floor of the socket. Such excessive negative pressure, far beyond that necessarily created by the weight of the prosthesis, may tend to cause edema.</p> <p>If stump retraction seems apt to occur, the physician should consider all factors carefully before prescribing a suction socket and, if he decides to proceed with one, should caution the limbmaker to leave adequate clearance volume between the end of the stump and the sealing floor. In that case, the change of volume owing to movement of the soft tissue will be only a small percentage of the original volume, so that the resulting negative pressure will be only a correspondingly small fraction of the barometric pressure. But with long above-knee stumps, because of the problem of locating the mechanical knee joint, it may not be feasible to allow adequate clearance volume, in which case the suction socket may be contraindicated.</p> <p>Movements of muscle bellies also may create a wedging action within a relatively conical socket, thus tending to force the socket off the stump and to increase negative pressure in a suction socket, but this effect is not likely to prove serious in the relatively cylindrical, well-muscled stump recommended.<a></a> Wedging action may, however, be desirable in the thigh muscles of a below-knee amputee so as to provide additional support on the somewhat conical thigh corset, thus relieving the below-knee stump of some of the pressure to which it would otherwise be subjected.</p> <p>Muscles or tendons passing over the brim of the socket may also tend to force the prosthesis from the stump when the muscles are tensed, again tending to increase negative pressure in a suction socket. This effect can be minimized by careful fitting of the socket.</p> <p>Muscle tissue acts as a pump to promote return circulation of blood and lymph, as is well known. Obviously, this effect is particularly important in the suction socket to reduce tendency toward edema, and hence vigorous muscle activity is doubly desirable.</p> <p><i>Securing Muscles at Rest Length. </i></p> <p>For all these reasons, it is highly desirable that the muscles be secured to the end of the stump at their rest lengths. Accordingly, the muscles are cut at the levels of the spontaneously retracted superficial tissue and fascia. If necessary, the cut muscles may be sutured to their overlying fascia. Later, when the fascia is closed and sutured over the end of the stump, the muscles will be carried back from their spontaneously retracted position substantially to their rest lengths. It is desirable to have not a mass of loose muscle tissue over the end of the stump but rather a neatly tailored muscle and fascial closure with the muscles restored to their rest length, that is, simply pulled back against the natural tone.</p> <p>To suture muscles to each other at the end of the stump, as has sometimes been recommended in the past, is unnecessary. In fact, the sutures would probably pull out of muscle alone. Suturing of the tough fascia is much more effective, so that it is unnecessary, as well as undesirable, to suture muscles to holes drilled in the bone.</p> <p>In a few special cases, the tendons of the muscles may be sutured together. For example, in the case of knee disarticulation, the tendons of the hamstrings and quadriceps may be sutured in the patellar notch. Generally, the intention is to secure, by healing and scarring processes, the cut ends of the opposing muscles to each other, to their overlying fascia, and to the bone.</p> <p><i>Bone</i></p> <p>With the possible exception of the below-knee amputation (see footnote, page 30), the surgeon will plan to save the maximum practicable length of bony lever. The saw line is made at the level of the naturally retracted soft tissues. Before the bone is sawed, the periosteum is cut cleanly around with a sharp scalpel, taking special care to avoid loose flaps of periosteum, which may later form bone spurs. The bone is then sawed off squarely. There is no need to remove a periosteal cuff, and there should be no attempt to elevate the periosteum.</p> <p>In general, it is not necessary to bevel the bone cortex.<a style="text-decoration:none;">*</a> Preliminary anatomical studies of bone ends at the U.S. Naval Hospital at Oakland, California, and at the University of California Prosthetic Devices Project have shown that the bone end, when treated as already described, may round over spontaneously within a few months so that the medullary cavity tends to become sealed <a></a>. This simply confirms clinical observations already made from amputation of long duration.</p> <p><i>Nerves</i></p> <p>The aim of the surgeon is to sever the nerves in such a manner that the inevitable neuroma will be embedded in soft tissue at a point where it will not be stimulated. Thus, it should not be permitted to reattach to scar or bone in such a manner that the fibrils of the neuroma become stretched at every step owing to piston action of the bone within the tissues or to movement of the scar as a result of muscular action. The neuroma should also be far enough up the stump so that it is not subjected to unusual pressure from use of the prosthesis.</p> <p>The most desirable technique, it has been realized for some years, is to dissect the nerve carefully from the neurovascular bundle, pull it gently from its sheath, and cut it cleanly with a sharp instrument. The severed nerve is then allowed to retract up its nerve sheath into soft tissue. The major cutaneous sensory nerves, which are less obvious, deserve the same careful attention given to the major nerve trunks.</p> <p>Contrary to the advice in some earlier texts, experience of the past decade has shown clearly that no injections of alcohol or other chemicals should be given. Rather, the nerve should be left entirely alone after it has retracted into the tissue. Much clinical experience, and recently the studies of the Pain Project at the University of California <a></a>have indicated that formation of a neuroma must be expected at every cut nerve. Resection of a neuroma once formed will therefore merely lead to development of another neuroma at a higher level. Difficulties are encountered from a neuroma only if it is stretched or compressed. Although phantom pain is sometimes triggered by the stimulation of a neuroma, there are so many other possible causes that repeated surgery to remove a neuroma each time one forms generally is not justified.</p> <h4>The Special Cases</h4> <h4><i>The Upper Extremity</i></h4> <p><i>The Wrist-Disarticulation Case. </i><br />In the wrist disarticulation, the distal joint between the radius and ulna must carefully be preserved to permit free motion of the radius over the ulna during pronation and supination. Occasionally it may be wise to round off any exceptionally sharp surfaces on the styloids, but in general the styloids can be accommodated by careful fitting of the molded plastic-laminate socket (<b>Fig. 8</b> and <b>Fig. 9</b>).</p> <p><i>The Long Below-Elbow Case </i><br /> Similarly, in the long below-elbow stump, every effort should be made to preserve free motion of the radius over the ulna to retain pronation and supination. Cutting of the bones permits the radius to approach the ulna, resulting in shortening, and hence weakening, of the pronator teres. Although with training the weakness can be overcome, the proximity of the radius to the ulna makes bone spurs or actual bony bridging between the two bones much more of a hazard to adequate pronation-supination. Thus careful, clean cutting of the periosteum is of particular importance.</p> <p><i>The Short Below-Elbow Case </i><br />Where there is the possibility of a very short below-elbow amputation, the short stump always should be preserved if at all medically feasible, in preference to amputation at or above the elbow. In some cases, for example where rolling and notching of the socket brim (<b>Fig. 14</b>) might be inadequate to prevent an intact biceps from pushing the socket from the stump during elbow flexion, the surgeon may consider cutting the biceps tendon to permit fitting the socket brim higher than usual. If biceps cineplasty is performed for such cases, the biceps tendon will, of course, be resected and the cut end carefully covered over or imbricated to prevent reattachment. In this case severing the biceps tendon may in some instances permit higher fitting of the socket while simultaneously preserving a useful function for the biceps muscle.</p> <p><i>The Elbow-Disarticulation Case </i><br />The elbow-disarticulation prosthesis with the new external lock (<b>Fig. 15</b>) has encouraged the preservation of the elbow-disarticulation stump whenever feasible medically. As with any end-bearing stump, it is probably desirable to place the scar line away from the weight-bearing area. The irregular shape of the humeral condyles may be retained to assist in anchoring the socket against rotation. Careful attention to the nerves is desirable to prevent formation of sensitive neuromata in the areas which will be subject to load during end-weight-bearing or as a result of bending loads upon the prosthesis when the elbow is locked.</p> <p><i>The Short Above-Elbow Case </i><br />The very short above-elbow stump should be preserved so far as medically feasible in preference to a true shoulder disarticulation or, worse, forequarter amputation. Even the short stump will serve to key the socket and provide greater stability. In some cases the short stump can be used for control of a lock. In experimental work on an electric arm, a very short above-elbow stump has been used to operate a keyboard of switches and clutches (<b>Fig. 18</b>) for control of the electrically driven motions as well as to control an electric elbow lock while a turntable lock above the elbow joint was controlled by a button pressed by the pectoral muscle.<a></a> </p> <p><i>Cineplasty Cases </i><br />In general, upper-extremity candidates for later cineplasty operations<a></a> can undergo the original amputation in the same manner as do those amputees who will use conventional prostheses. Thus far ACAL has accepted cineplasty in the intact biceps of a below-elbow amputee only (<b>Fig. 28</b>; see also <b>Fig. 12</b>, page 61), and in the case of a veteran prior approval from the VA Central Office is required. For many years cineplasty has been performed in a variety of locations and by many different techniques. In the Artificial Limb Program, it has been performed experimentally in a number of locations in various individuals, including the biceps in above-elbow amputees and the pectoralis major for short above-elbow and shoulder-disarticulation cases.<a></a> But before such procedures can be recommended, problems remain to be solved.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Typical biceps muscle tunnel in below-elbow case, six months postoperative. <i>Courtesy Army Prosthetics Research Laboratory.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The general principle is to preserve muscle length and attachment at the time of the original amputation so as to prevent permanent contraction. The distal end of the muscle is released only at the time of the cineplasty operation so as to permit prompt exercise and stretching of the muscle soon after the tunnel has healed. Special attention should, of course, be given to repair of any injuries proximal to the intended saw line in order to assure full innervation and blood supply and to avoid serious scarring of the remaining stump.</p> <h4><i>The Lower Extremity</i></h4> <p><i>The Syme Amputation. </i><br />In the Syme amputation, in contrast to amputation at many other levels, preservation of the normal heel flap permits weight-bearing on tissue normally accustomed to full body weight and impact. The incision has a special shape across the instep so as to permit the shelling out of the calcaneus from the heel flap and the later formation of a suture line across the anterior aspect of the stump. <a></a>To provide good bearing, the bones are sawed just above the articular cartilage and in such a plane that the cut surfaces will be parallel to the floor when the amputee stands (not necessarily perpendicular to the long axes, as, for example, in the case of a bowlegged or knock-kneed patient).</p> <p>To ensure preservation of circulation in the heel flap, little if any tailoring is performed. Dog ears left at each side of the heel flap will disappear with proper postoperative wrapping. Contrary to the usual rule, the tendons are simply cut and permitted to retract without attempting to suture the tendons in place or to attain fascial closure. If a good Syme stump cannot be obtained, the surgeon should perform a conventional below-knee amputation, since a very long below-knee stump extending to the lower third of the shank frequently breaks down from poor circulation.</p> <p> <i>The Knee-Disarticulation Case</i><br />In the knee disarticulation, an exceptionally long anterior flap is necessary for closure of the stump and so that the suture line may be posterior and out of the end-weight-bearing zone. In general, the cartilage is simply left in place. The patella, although routinely left in place, may be removed to give extra length to the anterior flap when needed for adequate closure. The patellar tendon is sutured to the hamstring tendons in the patellar notch between the femoral condyles, but no attempt is made to prevent the tendons from gliding.</p> <h3>Summary</h3> <p>Techniques advocated, partly as a result of World War II and subsequent experience and partly as a result of the ACAL program, may be summarized as follows:</p> <ol> <li>With the possible exception of the below-knec amputation, save all length of stump considered surgically feasible.</li><li>Preserve the muscles at their rest length.</li><li>Attempt to secure attachment of opposing muscles to each other and to the bony lever during the healing process through suturing of the opposing fasciae, without attempting to suture the muscles to each other or to the bone.</li><li>Avoid attachment of the muscles to the scar.</li><li>Secure a complete fascial envelope.</li><li>Secure a smooth and freely movable scar, usually central but displaced in the case of end-weight-bearing stumps (or possibly where skin on one side of the stump has a much better blood supply and gliding fascia than that on the other).</li><li>Sever a nerve cleanly and allow it to retract into soft tissue, without injection and with as gentle treatment as possible.</li></ol> <h4>Postoperative Care</h4> <p>The doctor should in every case maintain continuing supervision and responsibility for the postoperative care of the amputee. Just what are the relative responsibilities of the surgeon and of the doctor of physical medicine, where the latter is available, is subject to discussion and, in the present state of knowledge, will necessarily vary from place to place depending upon their respective interests, training, and available time for both professional and administrative duties. But it is important for the patient's welfare that there always be available some single physician who is familiar with the case and who can take responsibility for seeing that the patient receives maximum cooperative service from the nurses, therapists, prosthetist, vocational counselors, and others concerned.</p> <h4>Bandaging</h4> <p>Although the extremely shrunken, conical stump of former days is no longer desired, it is obvious that some muscles (such as the vastus group of the thigh in an above-knee amputation or the soleus in a below-knee case) will no longer have as important functions as before and can be expected to atrophy. It is desired that these muscles atrophy slowly without deposition of an equivalent amount of fat. Careful application of an adequately wide elastic bandage, in accordance with well-known techniques <a></a> will hasten the desired shrinkage.</p> <p>Immediately after the amputation, therefore, the wound is dressed and the stump wrapped with broad elastic bandage. But the bandage will become loose in a few hours and should be replaced by a fresh one, usually every four hours during the day. The used bandage is washed and dried, the usual precautions being taken to restore its elasticity. After a suitable interval, usually 10 to 14 days, sutures are removed, the wound re-dressed, and elastic bandage again applied. Meanwhile, the patient should be taught to cooperate in the application of the elastic bandage so that, when dressings are no longer needed, he may himself learn to reapply fresh elastic bandage several times a day as needed to prevent edema and to encourage shrinkage of tissues no longer functional.</p> <p>The bandage is made snug at the distal end, with no constriction at a higher point on the stump, and it must be carried above the next intact joint, for example up to the thigh in the case of a below-knee amputation or above the hip and around the waist as a hip spica in the case of the above-knee amputation. To avoid rolls of flesh, all parts of the stump must be bandaged, notably the adductor region high into the crotch in the case of the above-knee amputation. The patient must be cautioned against developing above the stump a local constriction which would lead to poor circulation. Likewise, bandaging should avoid a bulbous mass of soft tissue at the end of the stump, which would interfere with later fitting.</p> <h4>Bed Posture</h4> <p>Every effort should be made to restore full range of motion of the stump as early as possible without risk of tearing the muscles from their newly organizing attachments to the bone. The patient should be discouraged from remaining in a fixed position, such as sitting in a wheelchair with the hip and knee flexed, or lying in bed with the stump propped up on a pillow.<a></a> It should be carefully explained to him that some temporary discomfort and inconvenience will be necessary to ensure subsequent full range of motion and effective use of a prosthesis. The leg amputee should lie in bed with his legs parallel, without abduction and external rotation of a thigh stump or flexion of a below-knee stump.</p> <h4>Traction</h4> <p>In the event of a preliminary open amputation, the line of skin traction should be toward the center of the bed, and the patient should be checked frequently to be certain that he is lying with his pelvis parallel to the bottom of the bed. In no case should he be permitted to slant the pelvis and thus, in effect, to abduct the stump. In the more common closed amputation in civilian life, traction is seldom necessary unless, in an attempt to conserve greater bone length, exceptionally short skin flaps have been used and it is desired temporarily to remove tension from the suture line.</p> <h4>Exercises</h4> <p>Restoration of strength and of full range of stump motion can begin when the muscles have become adequately attached to the bone, with gentle voluntary exercises at first to prevent detachment. Restoration of strength will depend both upon developing maximum size of the cross section of the muscle and upon stretching of the muscle stump so that it operates near the amputation rest length, as already discussed. The role of a low passive-tension curve is particularly important, and of course exercises should be prescribed with due regard to the patient's general condition.</p> <p>Home exercises, conducted by the amputee first merely by setting the muscles and later by using simple and readily available apparatus, are particularly important. Much can be done with a flatiron, a pail filled with increasing amounts of water or sand, or other convenient weights attached by a piece of sash cord over a pulley or doorknob to a towel about the stump. Elaborate gymnasium equipment or exercise tables obviously are not essential, convenient as they may be for the well-equipped rehabilitation center. The amputee and his family should be convinced of the importance of sensible home exercises, not only immediately postoperatively but whenever indicated throughout the rest of the amputee's life to maintain good stump condition and to avoid the flabby, weak, and contracted stump so often seen in an amputee of long duration. The amputee should be convinced of the need for maintaining adequate range of motion and strength in order that he may use his prosthesis effectively, gracefully, and with minimum effort. But of course he should be discouraged from intermittent extremes leading only to exhaustion.</p> <h4>General Health</h4> <p>Finally, general body tone is important both for good health and good spirits as well as for effective use of a prosthesis. The leg amputee, for example, must have good triceps to use crutches when necessary and good abdominal muscles to minimize the risk of lordosis. The arm amputee will use muscles of the trunk and opposite shoulder in supporting, positioning, and operating his prosthesis. All young, healthy amputees should be encouraged to take part in swimming, skating, bowling, table tennis, or other sports as appropriate.</p> <p>Every amputee should be cautioned against obesity, which in the lower extremity increases the load on the stump and in any case increases the difficulties facing the prosthetist. Because of the difficulties encountered from alternate tightness and looseness of the socket, all wearers of prostheses, and especially those using the suction socket, should be cautioned against violent fluctuations of body weight. Where indicated, all possible conditions causing obesity should be corrected, and patients should be supervised by a physician to stabilize body weight at normal for the individual.</p> <h4>Rehabilitation Responsibilities</h4> <p>An important result of World War II military experience, of subsequent work under the ACAL program, and of the increasing numbers of amputation clinics both in the Veterans Administration and in private institutions has been the increased interest by the medical profession in its responsibilities for lifetime rehabilitation for amputees. These include not only the obvious medical responsibilities but also psychological aspects; pain and phantom sensations; teamwork with others concerned in the prescription, fitting, training, and checkout of the prosthesis; and referral for any necessary vocational counseling and retraining.</p> <p>Psychological aspects of amputation are particularly important.<a></a> In many cases the doctor can provide appropriate psychological services, but in other cases referral to a clinical psychologist or to a psychiatrist may be desirable. Sometimes preoperative discussion and psychological preparation may be possible, especially if the amputation is elective or if the need for amputation can be foreseen. The prospective amputee himself should, when possible, decide realistically that amputation is preferable to other alternatives and that it is not "the end of the road."</p> <p>In many cases the patient can be helped preoperatively or postoperatively to accept amputation and to begin a realistic estimate of the possibilities of worthwhile rehabilitation through discussion with other amputees of the same level who have been rehabilitated successfully. Clubs of amputees<a></a> are beginning more and more to provide, on request of doctors and hospitals, levelheaded, rehabilitated amputees for just this purpose. Such amputees are not to be confused with the overenthusiastic salesman type or with the psychologically disturbed exhibitionist, who so often has demonstrated his remarkable prowess without making the patient aware of the nature of his stump, the differences between his condition and that of the patient, and the fact that so much depends upon the general physical condition and the will power of the patient. Just as there are professional golfers, there are also professional amputees. These persons can often perform remarkable feats not ordinarily desirable in or to be expected of the average amputee and one, as is usually the case, unwilling to make a career of stunts with a prosthetic device. Realistic discussions of the responsibilities of the patient, yet of the many important and fascinating things which remain possible, will be most effective.</p> <p>A matter of great importance is attention to the attitudes of those associated with the patient. Members of the family will wish to help in every way, yet their efforts must be guided intelligently toward help in the real difficulties while avoiding overprotectiveness generated by pity, which all too soon might turn into rejection. The employer can be helped to realize that the amputee may again return to useful work, whether at his former job or at some other and perhaps better and more skilled job after suitable vocational guidance and retraining.</p> <p>Sometimes the handicapped person, perhaps for the first time receiving professional guidance and being forced to think carefully about his future, will aim at more education and a much higher economic level than before the amputation. After all, much of the heavy labor of industrial countries is being taken over by machines. Unaffected by the amputation, the patient's brain power and ability to make decisions and to control the machines will command a higher value.</p> <p>Friends and acquaintances too must learn to accept the amputee for the many qualities he has left and to admire his demonstrated fortitude and cheerfulness rather than to pity him or even to shrink from him because of past memories of an amputee beggar. Finally, society as a whole must learn to accept not only amputees but all handicapped and disabled persons on the basis of their inherent dignity, ability, and worth as human beings, not on the superficial basis of individual differences in physical condition due to crippling disease, congenital defects, or mutilating injuries. In the past, amputees, like members of other minority groups, have encountered unreasoning psychological prejudices unworthy of the brotherhood of man.</p> <h4>Pain and Phantom Sensation</h4> <p>The amputee will need counseling, both in the acute stage and perhaps occasionally throughout his life, about the nature of pain in the stump, phantom sensation, and phantom pain. Postoperatively, pain is handled as in the case of any other operation. But the amputee may be puzzled that he still has a sensation of the missing member, perhaps in some bizarre position. He can be assured that at least 85 percent of other amputees, and perhaps practically all amputees other than congenital, retain such feelings. Phantom sensations have long interested neurologists and psychologists and recently have come in for study in considerably more detail at the University of California.<a></a> It appears that such sensations are related to the continued activity of the cortex on which the missing limb was originally projected but which no longer receives the normal bombardment of constant new sensations of position, temperature, pressure, and so on.</p> <p>Phantom <i>pain </i>is rare. It occurs only in a small fraction of amputees. Sometimes it appears to be related to specific physical difficulties in the stump or in the remainder of the body, such as pressure on a neuroma or traction upon a neuroma which has, unfortunately, become caught in scar tissue and is stimulated by muscular movement or piston action of the stump in the socket. In other cases, it may be related to some cause further up the body which might have been sought immediately in a normal individual but which might be neglected in the amputee. For example, a ruptured disc in the spine immediately would be sought from certain classic patterns of pain radiating down the leg, but the same might be overlooked in an amputee who complains that pain radiates into his missing phantom limb.</p> <p>Studies at the University of California involved injecting salt solution, as a stimulant, into the various vertebral segments of both normal volunteers and amputees in order to produce radiation of pain which could be mapped systematically.<a></a> In some cases, radiation of the pain into the phantom limb of an amputee resulted in disappearance of the phantom sensation itself after a short period, concurrently with disappearance of pain in the rest of the body (<b>Fig. 29</b>). In other cases, distribution of phantom pain was altered, and in a few cases the phantom pain became worse. In general, however, workers at the University of California believed that phantom pain could be alleviated by one or more of a series of systematic attacks. No single remedy was found that applied to all cases.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Typical patterns of pain radiation in the phantom limbs of two subjects. <i>Courtesy University of California Medical School</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Prosthetics Clinic Teamwork</h4> <p>The duties of the physician on the prosthetics clinic team have been well outlined by Bechtol. <a></a>The increasing success of prosthetics clinic teams in overcoming the problems of the amputee, as well as those of the wearers of braces and orthopedic shoes, has brought a rapid expansion of amputee clinics in both government and private circles. Indeed, the teamwork concept has been utilized increasingly at many levels of rehabilitation for many kinds of disabilities and throughout scientific research generally. Each member of the team needs humble realization of his own limitations,<a style="text-decoration:none;">*</a> appreciation of the contributions to be made by each of the other members, and, of course, an understanding of the participation of the patient himself as a member of the team created in his behalf. Thus only can there be created a realistic basis for self-confidence in the total effectiveness of the team as an integrated unit. In the Veterans Administration's Orthopedic and Prosthetic Appliance Clinic Teams, the Chief of the Prosthetic and Sensory Aids Unit is the administrative "key" to the success of the individual clinic.</p> <h4>Lifetime Responsibility</h4> <p>The surgical responsibilities immediately after operation have, of course, long been obvious. But no more can the doctor dismiss the patient when the scar is healed-with advice to "look in the classified telephone book for a limbmaker." Rather, the doctor should serve as captain of the prescription team in its efforts to see that the amputee is provided with the best current prosthesis suited to the individual and with adequate training in its use, and he should assume continuing responsibility throughout the lifetime of the amputee.</p> <p>The doctor should, for example, have the clinic administrator arrange for periodic checkup examinations at proper intervals, perhaps once a year. Thus the amputee can be checked for adequate fitting and can be informed of new improvements as they become available, both from the commercial industry's own developments and from the Artificial Limb Program as it makes tested devices available to the industry. The gait of lower-extremity amputees can be observed, facility in the use of upper-extremity prostheses can be noted, and, if necessary, further periods of training may be prescribed. Other problems, such as obesity, spinal curvatures, skin difficulties, and so on can be detected and corrected before they become serious. Frequently, all the amputee needs is a reminder for encouragement to brush up on his old skills. Reassurance and renewed encouragement are of important psychological value to the amputee patient.</p> <p>Finally, the experienced patient, returning for his routine checkup, serves as an example to improve the morale of the more recent patients sitting in the waiting room. The successfully placed and well-rehabilitated patient, grateful for his own return to active life, will be glad to assist by visiting more recent patients in the hospital. He may be called upon whenever his unique physical condition, type of work, or hobby makes him especially suitable to help a person of similar circumstances.</p> <h4>The New Knowledge and the Medicla Profession</h4> <p>The challenge to the medical profession will thus be clear. There has been a rapid increase in knowledge of prosthetic devices themselves, in methods of performing amputations, and in the philosophy of amputee management. Medical education must somehow fit into the medical curricula and into the crowded training programs for interns and residents the new knowledge and changing viewpoint in amputee rehabilitation.<a></a> Exhibits at medical meetings and papers in the medical journals offer some of this new knowledge. The new 800-page collaboration, <i>Human Limbs and Their Substitutes </i>(see <i>Digest, </i>this issue, page 77) presents a much more extensive range of knowledge and broader point of view than is possible in a single article. The busy practitioner, especially the general surgeon to whom amputation is only a rather incidental part of practice, must somehow find time to keep abreast of new knowledge and philosophy while conserving the best principles he has learned in the past.</p> <p>Finally, there is a growing need for geographically spaced centers for performing amputations and to serve as bases for orthopedic and prosthetics clinic teams serving civilians as well as veterans. Perhaps only thus can those with specialized knowledge best serve the patients, especially those with unusual problems. Indeed, such centers could serve as agencies of the Artificial Limb Program, pointing out needs and priorities based on clinical experience and providing facilities for field tests and educational activities.</p> <h3>Conclusion</h3> <p>Thus, it can be seen that marked changes have taken place from the days of the few sharply delimited "sites of election" and the few types of prosthetic appliances available for them. The changes thus far have perhaps been most marked in the upper extremity, where a whole new armamentarium of appliances has been developed and rigorously tested both in the laboratory and in clinical studies. The findings have been made available to physicians, therapists, and prosthetists through a series of Institutes on Upper-Extremity Prosthetics at the University of California at Los Angeles. Even so, the present <i>Manual </i><a></a> shows interim devices which should be greatly improved in years to come. Improved function and appearance are certain, and perhaps there will be some limited sensibility of position, contact, and gripping force.</p> <p>In the meantime, however, a great deal of work also has been done on the lower extremity. Although relatively few new devices, such as the U.S. Navy above-knee artificial leg<a></a> and the suction socket have been accepted, a great many new devices and many changes in practice are being tested at the laboratory and clinical levels. It is to be expected that, in the next few years, <a></a> an equivalent to the upper-extremity armamentarium will be released in an array of new devices for the lower extremity, such as stable knees, means for preventing stumbling, and perhaps forcible ankle push-off. Current inventors' designs and test models eventually will be tested through a systematic transition procedure and released for routine use.</p> <p>To those close to the heart of the ACAL program for nearly a decade, the changes noted herein have occurred so slowly and so imperceptibly in the pressure of daily emergencies that they have not been realized fully. Until brought out by a systematic review or by a chance conversation with someone untouched by the genuine progress which has been made, the alterations lie buried in the seeming monotony of obvious "good practice." Yet all these little modified details in technique, new or revived appliances, and perhaps more profound changes in points of view and philosophy add up strikingly to benefit the individual amputee.</p> <h4>Acknowledgments</h4> <p>It is a pleasure to acknowledge the contributions received through past discussions with a host of associates in military amputation centers, Veterans Administration Orthopedic and Prosthetic Appliance Clinic Teams, the Artificial Limb Program, and private life. Some of the concepts described may be attributed particularly to Jerome Lawrence, of the Veterans Administration Clinic Team in New York; to Verne T. Inman, of the University of California; and to Herman Gladstone, Surgical Consultant to the Prosthetic and Sensory Aids Service of the Veterans Administration. Thanks are due George Rybczynski, who provided most of the line drawings. Photographs were supplied through the courtesy of the VA's Prosthetic Testing and Development Laboratory, the Army Prosthetics Research Laboratory, and the Canadian Department of Veterans Affairs.</p> <p><b>References:</b></p> <ol> <li>Abt, Lawrence Edwin, <i>Psychological adjustment of the amputee, </i>Chapter 5 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Alderson Research Laboratories, Inc., New York City, Contractor's Final Report [to the U.S. Veterans Administration (Contract No. V1001M-3123)] on <i>Research and development of electric arms and electric arm components, </i>1954. Fig. 11 and p. 40.</li> <li>Alderson Research Laboratories, Inc., <i>op. cit.</i> p. 20, Fig. 5</li> <li>Alldredge, Rufus H., <i>The management of war amputations in a general hospital, </i>N. Y. State J. Med., 44:1763 (1944).</li> <li>Alldredge, Rufus H., and T. Campbell Thompson,<i>The technique of the Syme amputation, </i>J. Bone &amp; Joint Surg., 28A:415 (1946).</li> <li>Alldredge, Rufus H., <i>Major amputations, </i>Surg.Gyn. &amp; Obstet., 84:759 (1947).</li> <li>Alldredge, Rufus H., <i>The cineplastic method in upper-extremity amputations, </i>J. Bone &amp; Joint Surg., 30A:359 (1948).</li> <li>Alldredge, Rufus H., <i>Amputations and prostheses,</i>Chapter XII in Christopher's <i>Textbook of surgery, </i>5th ed., Saunders, Philadelphia, 1949.</li> <li>Alldredge, Rufus H., <i>Recent developments and future trends in the field of orthopedic appliances, </i>Southern Med. J., 46:7 (1953).</li> <li>Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, <i>The techniques of cineplasty, </i>Chapter 3 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Alldredge, Rufus H., and Eugene F. Murphy,<i>The influence of new developments on amputation surgery, </i>Chapter 2 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Anderson, Miles H., <i>UCLA prosthetic course to open January 12, </i>Orthop. &amp; Pros. Appl. J., September 1952. p. 14.</li> <li>Anderson, Miles H, <i>A report on the prosthetics training center at the University of California, Los Angeles, </i>Orthop. &amp; Pros. Appl. J., December 1953. p. 27.</li> <li>Bechtol, Charles 0., <i>The prosthetics clinic team.</i> Artificial Limbs, January 1954. pp. 9-14.</li> <li>Bechtol, C. O., and E. F. Murphy, <i>The clinical applications of engineering principles to the problems of fractures and fracture fixation, </i>American Academy of Orthopaedic Surgeons, Instructional Course Lectures, Vol. IX, pp. 272-275, Edwards, Ann Arbor, Mich., 1952.</li> <li>Blix, M., Skandinav. Arch. f. Physiol., 5:150(1894).</li> <li>Borchardt, M., <i>el al., </i>eds., <i>Ersatzglieder und Arbeitshilfen, </i>Springer, Berlin, 1919.</li> <li>Borchardt, <i>op. cit. </i>pp. 397, 425, 509.</li> <li>Borchardt, <i>op. cit. </i>pp. 404-405.</li> <li>Borchardt, <i>op. cit. </i>pp. 523-528.</li> <li>Brunnstrom, Signe, <i>Physical therapy in aftercare of amputations of lower extremity, </i>U.S. Nav. Med. Bull., 43:634 (1944).</li> <li>Brunnstrom, Signe, <i>The lower-extremity amputee,</i>Chapter XIX in Bierman and Licht's <i>Physical medicine in general practice,</i>3rd ed., Hoeber, New York, 1952.</li> <li>Bunnell, Sterling, <i>Surgery of the hand, </i>2nd ed.,Lippincott, Philadelphia, 1949.</li> <li>Canty, Thomas J., <i>Construction, fitting and alignment manual for the U.S. Navy soft socket below knee prosthesis, </i>United States Naval Hospital (Amputation Center), Oakland, Calif., printer's date 9-29-53.</li> <li>Carnes, W. T., U.S. Patent 1,046,966, December, 1912.</li> <li>Carnes, W. T , U S. Patent 1,046,967, December, 1912.</li> <li>Carnes, W. T., U.S. Patent 1,402.476, January 3, 1912.</li> <li>Catranis, Inc., Syracuse, N. Y., Subcontractor'sFinal Report to the Advisory Committee on Artificial Limbs, National Research Council, <i>Improved artificial limbs for lower extremity amputations, </i>June 1954.</li> <li>Committee on Artificial Limbs, National Research Council, Washington, D. C, <i>Terminal research reports on artificial limbs </i>[to the Office of the Surgeon General and the Veterans Administration] covering the period from 1 April 1945 through 30 June 1947. See especially pp. 34-35.</li> <li>Denver Research Institute, University of Denver,Denver, Colo., Contractor's Final Report (Contract No. V-100-LM-4089) to the Advisory Committee on Artificial Limbs, National Research Council, <i>A program for the improvement of the below knee prosthesis with emphasis on problems of the joint, </i>24 August 1953.</li> <li>Department of Veterans Affairs, ProstheticServices, Toronto, Canada, <i>Syme's amputation and prosthesis, </i>January 1, 1954.</li> <li>Desoutter, E. R., <i>Back to activity, </i>DesoutterBrothers, Ltd., 73 Baker St., London W1, 1938.</li> <li>Dorrance, D. W., U.S. Patent </li> <li>1,042,413, October, 1912.</li> <li>Eberhart, Howard D., Verne T. Inman, and BorisBresler, <i>The principal elements in human locomotion, </i>Chapter 15 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Eberhart, Howard D., and Jim C. McKennon,<i>Suction-socket suspension of the above-knee prosthesis, </i>Chapter 20 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Feinstein, Bertram, John N. K. Langton, R. M.Jameson, and Francis Schiller, <i>Experiments on pain referred from deep somatic tissues, </i>J. Bone &amp; Joint Surg., A, in press 1954.</li> <li>Feinstein, Bertram, James C. Luce, and John N. K. Langton, <i>The influence of phantom limbs, </i>Chapter 4 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Fletcher, Maurice J., <i>New developments in hands and hooks, </i>Chapter 8 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Fletcher, Maurice J., <i>The upper-extremity prosthetics armamentarium, </i>Artificial Limbs, January 1954. p. 15.</li> <li>Gray, Frederick, <i>Automatic mechanism as applied in the construction of artificial limbs in cases of amputation, </i>2nd ed., R. Renshaw, London, 1857.</li> <li>Haddan, Chester C, and Atha Thomas, <i>Status of the above-knee suction socket in the United States, </i>Artificial Limbs, May 1954. pp 29-39, especially p. 34, Fig. 4; p. 36; and p. 37, Fig.7. </li> <li>Hiyeda, Masatora, <i>Work leg for the hip exarticulation, </i>J. Japanese Orthop. Surg. Soc, 17:935 (1942). In Japanese, with German abstract.</li> <li>Inman, Verne T., and H. J. Ralston, <i>The mechanics of voluntary muscle, </i>Chapter 11 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Kirk, Norman T., <i>Amputations, </i>a monograph from Vol. III of Lewis' <i>Practice of surgery, </i>W. F. Prior Company, Inc., Hagerstown, Md.,1944. Fig . 7, p. 22.</li> <li>Langdale-Kelham, R. D , and George Perkins,<i>Amputations and artificial limbs, </i>Oxford University Press, London: Humphrey Milford, 1944. Fig. 3, p. 9.</li> <li>Lawrence, Jerome, unpublished lecture, 34th Suction-Socket School, New York, May 7, 1954. </li> <li>Leonard, Fred, T. B. Blevins, W S. Wright, and M. G. DeFries, <i>Nylon-coated leather, </i>Ind. Eng. Chem., 45:773 (1953).</li> <li>Leonard, Fred, and Clare L. Milton, Jr., <i>Cosmetic gloves, </i>Chapter 9 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Little, E Muirhead, <i>A lecture on a new material (duralumin) for surgical appliances, </i>Brit. Med. J., 1:236 (1912).</li> <li>Little, E. Muirhead, <i>Artificial limbs and amputation stumps, </i>H. K. Lewis and Co., Ltd., London, and Blakiston, Philadelphia, 1922.</li> <li>Little, <i>op. cit. </i>pp. 6-7.</li> <li>Little, <i>op. cit. </i>pp. 7-8.</li> <li>Little, <i>op. cit. </i>p. 8.</li> <li>Little, <i>op. cit. </i>p. 10</li> <li>Little, <i>op. cit. </i>p. 24.</li> <li>Little, <i>op. cit. </i>pp. 110-113.</li> <li>Little, <i>op. cit. </i>p. 249.</li> <li>Martin, Florent, <i>La prothese du membre inferieur,</i>Masson et cie., Paris, 1918.</li> <li>Martin, Florent, <i>Artificial limbs, </i>International Labour Office, Geneva, 1925.</li> <li>Martin, <i>op. cit. </i>pp. 260-279.</li> <li>McLaurin, C. A., <i>Hip disarticulation prosthesis,</i>Department of Veterans Affairs, Prosthetic Services, Toronto, Canada, 19 March 1954.</li> <li>Mommsen, F., and K Buchert, <i>Kunstliche Glieder, Heft 1, </i>Enke, Stuttgart, 1932. pp 4-5.</li> <li>Mommsen and Biichert, <i>op. cit </i>pp. 86-97.</li> <li>Murphy, Eugene F., <i>The role of an amputee club,</i>summary in Bulletin of Amputees Alliance, Inc., Vol. 3, No. 5, New York, December 1952.</li> <li>Murphy, Eugene F., <i>The fitting of below-knee prostheses, </i>Chapter 22 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Naval Medical Research Institute, NationalNaval Medical Center, Report No. 1, Project NM-009003, <i>Description of a prosthetic hand appliance, </i>March 1, 1948.</li> <li>New York University, Prosthetic Devices Study,[Report to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Shakedown test of the Navy above-knee prosthesis, </i>May 1951.</li> <li>Northwestern Technological Institute, Evanston,Ill., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>A review of the literature, patents, and manufactured items concerned with artificial legs, arm harnesses, hand, and hook; mechanical testing of artificial legs, </i>1947. pp. 1.33-1.36.</li> <li>Pare, Ambroise, <i>Ouevres completes, </i>J.-F. Malgaigne, ed., G.-B. Balliere, Paris, 1840. Vol. 2, Pt. 2.</li> <li>Personal communication from Verne T. Inman,University of California.</li> <li>Personal communication from representatives ofUNRRA, 1946.</li> <li>Possibilities Unlimited, Inc., Cleveland, Ohio, <i>Possibilities unlimited, </i>Vol. II, Issue 2, 1950.</li> <li>Putti, Vittorio, <i>Historic artificial limbs, </i>Hoeber, New York, 1930. p. 7.</li> <li>Putti, <i>op. cit. </i>pp. 1-3.</li> <li>Radcliffe, Charles W., <i>Alignment of the above-knee artificial leg, </i>Chapter 21 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Radcliffe, Charles W., <i>Mechanical aids for alignment of lower-extremity prostheses, </i>Artificial Limbs, May 1954. pp. 20-28, especially p. 24,Fig. 11, and p. 26, Fig. 14.</li> <li>Ralston, H. J., V. T. Inman, L. A. Strait, andM. D. Shaffrath, <i>Mechanics of human isolated voluntary muscle, </i>Am. J. Physiol., 151:612 (1947).</li> <li>Renfro, Clarence A., U.S. Patent 2,563,618,August 7, 1951.</li> <li>Saunders, J. B., V. T. Inman, and H. D. Eberhart,<i>The major determinants in normal and pathological gait, </i>J. Bone &amp; Joint Surg., <b>35A(3) </b>:543 (1953).</li> <li>Schede, Franz, <i>Theoretische Grundlagen fur den Bau von Kunstbeinen; Insbesondere fiir den Oberschenkelamputierten, </i>Ztschr. f. orthopad. Chir., Supplement 39, Enke, Stuttgart, 1919.</li> <li>Slocum, D. B., <i>An atlas of amputations, </i>Mosby,St. Louis, 1949.</li> <li>Spittler, A. W., and I. E. Rosen, <i>Cineplastic muscle motors for prostheses of arm amputees, </i>J. Bone &amp; Joint surg., 33A:601 (1951).</li> <li>Taylor, Craig L., <i>Control design and prosthetic adaptations to biceps and pectoral cineplasty, </i>Chapter 12 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Taylor, Craig L., <i>The objectives of the upper-extremity prosthetics program, </i>Artificial Limbs, January 1954. pp. 4-8, especially p. 7.</li> <li>Tenenbaum, Milton, and Adele Tenenbaum, U.S.Patent 2,453,604, November 9, 1948.</li> <li>Thomas, A., and C. C. Haddan, <i>Amputation prosthesis, </i>Lippincott, Philadelphia, 1945.</li> <li>Thompson, T. Campbell, and Rufus H. Alldredge,<i>Amputations: surgery and plastic repair, </i>J. Bone &amp; Joint Surg., 26A:639 (1944).</li> <li>United States Army, Office of the SurgeonGeneral, Report 9940 TSU-SGO, <i>Philippine amputation and prosthetic unit, </i>n.d.</li> <li>University of California (Berkeley), ProstheticDevices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Fundamental studies on human locomotion and other information relating to design of artificial limbs, </i>1947. Two volumes.</li> <li>University of California (Berkeley), ProstheticDevices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Studies relating to pain in the amputee, </i>June 1952.</li> <li>University of California (Los Angeles), Department of Engineering, <i>Manual of upper extremity prosthetics, </i>R. Deane Aylesworth, ed., 1952. Section 7.3, Fig. 7.3-B.</li> <li>Upper-Extremity Technical Committee, ACAL,minutes of meeting at University of California, Los Angeles, February 5, 1953.</li> <li>Vard, Inc., Pasadena, Calif., Subcontractor'sFinal Report [to the] Committee on Artificial Limbs, National Research Council, <i>The development of artificial arms for amputees who have had the cineplaslic operation, </i>1947.</li> <li>Vasconcelos, Edmundo, <i>Modern methods of amputation, </i>Philosophical Library, New York, 1945.</li> <li>Wagner, Edmond M , <i>Contributions of the lower-extremity prosthetics program, </i>Artificial Limbs, May 1954. p. 16.</li> <li>Wagner, Edmond M., and John G. Catranis,<i>New developments in lower-extremity prostheses, </i>Chapter 17 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954. See especially pp. 484, 485, and 605 ff.</li> <li>War Department, Washington, D. C, TrainingManual 8-293, <i>Physical therapy for lower extremity amputees, </i>June 1946.</li> <li>Wilson, A. Bennett, Jr., <i>The APRL terminal</i><i>devices, </i>Orthop. &amp; Pros. Appl. J , March 1952.</li> <li>Wilson, A. Bennett, Jr., and Robert J. Pursley,<i>Fitting the wrist-disarticulation case, </i>Orthop. &amp; Pros. Appl. J., September 1952. p. 17. 100. zur Verth, M., <i>Die biologische Absetzung der menschlichenGliedmassen, </i>Muench. Med. Wschr., 82:525 (1935).</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>95.</b> </td><td class="clsTextSmall">Vasconcelos, Edmundo, Modern methods of amputation, Philosophical Library, New York, 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>67.</b> </td><td class="clsTextSmall">Naval Medical Research Institute, NationalNaval Medical Center, Report No. 1, Project NM-009003, Description of a prosthetic hand appliance, March 1, 1948.</td></tr><tr><td class="clsTextSmall"><b>95.</b> </td><td class="clsTextSmall">Vasconcelos, Edmundo, Modern methods of amputation, Philosophical Library, New York, 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>91.</b> </td><td class="clsTextSmall">University of California (Berkeley), ProstheticDevices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Recent developments and future trends in the field of orthopedic appliances, Southern Med. J., 46:7 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Websters definition of teamwork reads in part as follows: Work done by a number of associates, usually each doing a clearly defined portion, but all subordinating personal prominence to the efficiency of the whole!</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Bechtol, Charles 0., The prosthetics clinic team. Artificial Limbs, January 1954. pp. 9-14.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Eberhart, Howard D., and Jim C. McKennon,Suction-socket suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>37.</b> </td><td class="clsTextSmall">Feinstein, Bertram, John N. K. Langton, R. M.Jameson, and Francis Schiller, Experiments on pain referred from deep somatic tissues, J. Bone &amp;Joint Surg., A, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>90.</b> </td><td class="clsTextSmall">University of California (Berkeley), ProstheticDevices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies on human locomotion and other information relating to design of artificial limbs, 1947. Two volumes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>64.</b> </td><td class="clsTextSmall">Mommsen and Biichert, op. cit pp. 86-97.</td></tr><tr><td class="clsTextSmall"><b>72.</b> </td><td class="clsTextSmall">Personal communication from representatives ofUNRRA, 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Abt, Lawrence Edwin, Psychological adjustment of the amputee, Chapter 5 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Brunnstrom, Signe, Physical therapy in aftercare of amputations of lower extremity, U.S. Nav. Med. Bull., 43:634 (1944).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Brunnstrom, Signe, The lower-extremity amputee,Chapter XIX in Bierman and Licht's Physical medicine in general practice,3rd ed., Hoeber, New York, 1952.</td></tr><tr><td class="clsTextSmall"><b>97.</b> </td><td class="clsTextSmall">Wagner, Edmond M., and John G. Catranis,New developments in lower-extremity prostheses, Chapter 17 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954. See especially pp. 484, 485, and 605 ff.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and T. Campbell Thompson,The technique of the Syme amputation, J. Bone &amp;Joint Surg., 28A:415 (1946).</td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Department of Veterans Affairs, ProstheticServices, Toronto, Canada, Syme's amputation and prosthesis, January 1, 1954.</td></tr><tr><td class="clsTextSmall"><b>81.</b> </td><td class="clsTextSmall">Schede, Franz, Theoretische Grundlagen fur den Bau von Kunstbeinen; Insbesondere fiir den Oberschenkelamputierten, Ztschr. f. orthopad. Chir., Supplement 39, Enke, Stuttgart, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>82.</b> </td><td class="clsTextSmall">Slocum, D. B., An atlas of amputations, Mosby,St. Louis, 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., The cineplastic method in upper-extremity amputations, J. Bone &amp;Joint Surg., 30A:359 (1948).</td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasty, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>82.</b> </td><td class="clsTextSmall">Slocum, D. B., An atlas of amputations, Mosby,St. Louis, 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Alderson Research Laboratories, Inc., op. cit. p. 20, Fig. 5</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Eberhart, Howard D., and Jim C. McKennon,Suction-socket suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>37.</b> </td><td class="clsTextSmall">Feinstein, Bertram, John N. K. Langton, R. M.Jameson, and Francis Schiller, Experiments on pain referred from deep somatic tissues, J. Bone &amp;Joint Surg., A, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>90.</b> </td><td class="clsTextSmall">University of California (Berkeley), ProstheticDevices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies on human locomotion and other information relating to design of artificial limbs, 1947. Two volumes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>70.</b> </td><td class="clsTextSmall">Pare, Ambroise, Ouevres completes, J.-F. Malgaigne, ed., G.-B. Balliere, Paris, 1840. Vol. 2, Pt. 2.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The single exception is the anterior tibial crest in the below-knee amputation, where beveling is desirable but without extending the beveled surface to the medullary cavity. In special cases, such as the Syme, there will be modifications of the general surgical technique. See page 36.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Gray, Frederick, Automatic mechanism as applied in the construction of artificial limbs in cases of amputation, 2nd ed., R. Renshaw, London, 1857.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>76.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Alignment of the above-knee artificial leg, Chapter 21 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Gray, Frederick, Automatic mechanism as applied in the construction of artificial limbs in cases of amputation, 2nd ed., R. Renshaw, London, 1857.</td></tr><tr><td class="clsTextSmall"><b>75.</b> </td><td class="clsTextSmall">Putti, op. cit. pp. 1-3.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Gray, Frederick, Automatic mechanism as applied in the construction of artificial limbs in cases of amputation, 2nd ed., R. Renshaw, London, 1857.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>83.</b> </td><td class="clsTextSmall">Spittler, A. W., and I. E. Rosen, Cineplastic muscle motors for prostheses of arm amputees, J. Bone &amp;Joint surg., 33A:601 (1951).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Hiyeda, Masatora, Work leg for the hip exarticulation, J. Japanese Orthop. Surg. Soc, 17:935 (1942). In Japanese, with German abstract.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Blix, M., Skandinav. Arch. f. Physiol., 5:150(1894).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Hiyeda, Masatora, Work leg for the hip exarticulation, J. Japanese Orthop. Surg. Soc, 17:935 (1942). In Japanese, with German abstract.</td></tr><tr><td class="clsTextSmall"><b>77.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954. pp. 20-28, especially p. 24,Fig. 11, and p. 26, Fig. 14.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Hiyeda, Masatora, Work leg for the hip exarticulation, J. Japanese Orthop. Surg. Soc, 17:935 (1942). In Japanese, with German abstract.</td></tr><tr><td class="clsTextSmall"><b>77.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954. pp. 20-28, especially p. 24,Fig. 11, and p. 26, Fig. 14.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">1,042,413, October, 1912.</td></tr><tr><td class="clsTextSmall"><b>79.</b> </td><td class="clsTextSmall">Renfro, Clarence A., U.S. Patent 2,563,618,August 7, 1951.</td></tr><tr><td class="clsTextSmall"><b>89.</b> </td><td class="clsTextSmall">United States Army, Office of the SurgeonGeneral, Report 9940 TSU-SGO, Philippine amputation and prosthetic unit, n.d.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasty, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Hiyeda, Masatora, Work leg for the hip exarticulation, J. Japanese Orthop. Surg. Soc, 17:935 (1942). In Japanese, with German abstract.</td></tr><tr><td class="clsTextSmall"><b> 77.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954. pp. 20-28, especially p. 24,Fig. 11, and p. 26, Fig. 14.</td></tr><tr><td class="clsTextSmall"><b>83.</b> </td><td class="clsTextSmall">Spittler, A. W., and I. E. Rosen, Cineplastic muscle motors for prostheses of arm amputees, J. Bone &amp;Joint surg., 33A:601 (1951).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Eberhart, Howard D., Verne T. Inman, and BorisBresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Gray, Frederick, Automatic mechanism as applied in the construction of artificial limbs in cases of amputation, 2nd ed., R. Renshaw, London, 1857.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Langdale-Kelham, R. D , and George Perkins,Amputations and artificial limbs, Oxford University Press, London: Humphrey Milford, 1944. Fig. 3, p. 9.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and Eugene F. Murphy,The influence of new developments on amputation surgery, Chapter 2 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>81.</b> </td><td class="clsTextSmall">Schede, Franz, Theoretische Grundlagen fur den Bau von Kunstbeinen; Insbesondere fiir den Oberschenkelamputierten, Ztschr. f. orthopad. Chir., Supplement 39, Enke, Stuttgart, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Anderson, Miles H., UCLA prosthetic course to open January 12, Orthop. &amp;Pros. Appl. J., September 1952. p. 14.</td></tr><tr><td class="clsTextSmall"><b> 13.</b> </td><td class="clsTextSmall">Anderson, Miles H, A report on the prosthetics training center at the University of California, Los Angeles, Orthop. &amp;Pros. Appl. J., December 1953. p. 27.</td></tr><tr><td class="clsTextSmall"><b>84.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasty, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">An exception may be the below-knee amputation. At the present time, and until further information is available, the below-knee stump should not extend more than 6 in. below the tibial plateau.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Bechtol, Charles 0., The prosthetics clinic team. Artificial Limbs, January 1954. pp. 9-14.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>66.</b> </td><td class="clsTextSmall">Murphy, Eugene F., The fitting of below-knee prostheses, Chapter 22 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>48.</b> </td><td class="clsTextSmall">Leonard, Fred, T. B. Blevins, W S. Wright, and M. G. DeFries, Nylon-coated leather, Ind. Eng. Chem., 45:773 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>85.</b> </td><td class="clsTextSmall">Taylor, Craig L., The objectives of the upper-extremity prosthetics program, Artificial Limbs, January 1954. pp. 4-8, especially p. 7.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Bunnell, Sterling, Surgery of the hand, 2nd ed.,Lippincott, Philadelphia, 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">In general, partial amputations should be considered only when normal sensation and good blood supply can be retained.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>61.</b> </td><td class="clsTextSmall">Martin, op. cit. pp. 260-279.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">Lawrence, Jerome, unpublished lecture, 34th Suction-Socket School, New York, May 7, 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>61.</b> </td><td class="clsTextSmall">Martin, op. cit. pp. 260-279.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>42.</b> </td><td class="clsTextSmall">Haddan, Chester C, and Atha Thomas, Status of the above-knee suction socket in the United States, Artificial Limbs, May 1954. pp 29-39, especially p. 34, Fig. 4; p. 36; and p. 37, Fig.7. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Borchardt, M., el al., eds., Ersatzglieder und Arbeitshilfen, Springer, Berlin, 1919.</td></tr><tr><td class="clsTextSmall"><b>42.</b> </td><td class="clsTextSmall">Haddan, Chester C, and Atha Thomas, Status of the above-knee suction socket in the United States, Artificial Limbs, May 1954. pp 29-39, especially p. 34, Fig. 4; p. 36; and p. 37, Fig.7. </td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Little, E Muirhead, A lecture on a new material (duralumin) for surgical appliances, Brit. Med. J., 1:236 (1912).</td></tr><tr><td class="clsTextSmall"><b>59.</b> </td><td class="clsTextSmall">Martin, Florent, La prothese du membre inferieur,Masson et cie., Paris, 1918.</td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">Mommsen, F., and K Buchert, Kunstliche Glieder, Heft 1, Enke, Stuttgart, 1932. pp 4-5.</td></tr><tr><td class="clsTextSmall"><b>68.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study,[Report to the] Advisory Committee on Artificial Limbs, National Research Council, Shakedown test of the Navy above-knee prosthesis, May 1951.</td></tr><tr><td class="clsTextSmall"><b>80.</b> </td><td class="clsTextSmall">Saunders, J. B., V. T. Inman, and H. D. Eberhart,The major determinants in normal and pathological gait, J. Bone &amp;Joint Surg., 35A(3) :543 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Committee on Artificial Limbs, National Research Council, Washington, D. C, Terminal research reports on artificial limbs [to the Office of the Surgeon General and the Veterans Administration] covering the period from 1 April 1945 through 30 June 1947. See especially pp. 34-35.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Eberhart, Howard D., Verne T. Inman, and BorisBresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Gray, Frederick, Automatic mechanism as applied in the construction of artificial limbs in cases of amputation, 2nd ed., R. Renshaw, London, 1857.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>78.</b> </td><td class="clsTextSmall">Ralston, H. J., V. T. Inman, L. A. Strait, andM. D. Shaffrath, Mechanics of human isolated voluntary muscle, Am. J. Physiol., 151:612 (1947).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Eberhart, Howard D., Verne T. Inman, and BorisBresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>75.</b> </td><td class="clsTextSmall">Putti, op. cit. pp. 1-3.</td></tr><tr><td class="clsTextSmall"><b>96.</b> </td><td class="clsTextSmall">Wagner, Edmond M , Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954. p. 16.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Catranis, Inc., Syracuse, N. Y., Subcontractor'sFinal Report to the Advisory Committee on Artificial Limbs, National Research Council, Improved artificial limbs for lower extremity amputations, June 1954.</td></tr><tr><td class="clsTextSmall"><b>96.</b> </td><td class="clsTextSmall">Wagner, Edmond M , Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954. p. 16.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">McLaurin, C. A., Hip disarticulation prosthesis,Department of Veterans Affairs, Prosthetic Services, Toronto, Canada, 19 March 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Denver Research Institute, University of Denver,Denver, Colo., Contractor's Final Report (Contract No. V-100-LM-4089) to the Advisory Committee on Artificial Limbs, National Research Council, A program for the improvement of the below knee prosthesis with emphasis on problems of the joint, 24 August 1953.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>65.</b> </td><td class="clsTextSmall">Murphy, Eugene F., The role of an amputee club,summary in Bulletin of Amputees Alliance, Inc., Vol. 3, No. 5, New York, December 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Canty, Thomas J., Construction, fitting and alignment manual for the U.S. Navy soft socket below knee prosthesis, United States Naval Hospital (Amputation Center), Oakland, Calif., printer's date 9-29-53.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Bechtol, C. O., and E. F. Murphy, The clinical applications of engineering principles to the problems of fractures and fracture fixation, American Academy of Orthopaedic Surgeons, Instructional Course Lectures, Vol. IX, pp. 272-275, Edwards, Ann Arbor, Mich., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>95.</b> </td><td class="clsTextSmall">Vasconcelos, Edmundo, Modern methods of amputation, Philosophical Library, New York, 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Department of Veterans Affairs, ProstheticServices, Toronto, Canada, Syme's amputation and prosthesis, January 1, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Department of Veterans Affairs, ProstheticServices, Toronto, Canada, Syme's amputation and prosthesis, January 1, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and T. Campbell Thompson,The technique of the Syme amputation, J. Bone &amp;Joint Surg., 28A:415 (1946).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>95.</b> </td><td class="clsTextSmall">Vasconcelos, Edmundo, Modern methods of amputation, Philosophical Library, New York, 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alderson Research Laboratories, Inc., New York City, Contractor's Final Report [to the U.S. Veterans Administration (Contract No. V1001M-3123)] on Research and development of electric arms and electric arm components, 1954. Fig. 11 and p. 40.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Alderson Research Laboratories, Inc., op. cit. p. 20, Fig. 5</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>91.</b> </td><td class="clsTextSmall">University of California (Berkeley), ProstheticDevices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Borchardt, M., el al., eds., Ersatzglieder und Arbeitshilfen, Springer, Berlin, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alderson Research Laboratories, Inc., New York City, Contractor's Final Report [to the U.S. Veterans Administration (Contract No. V1001M-3123)] on Research and development of electric arms and electric arm components, 1954. Fig. 11 and p. 40.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alderson Research Laboratories, Inc., New York City, Contractor's Final Report [to the U.S. Veterans Administration (Contract No. V1001M-3123)] on Research and development of electric arms and electric arm components, 1954. Fig. 11 and p. 40.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Alderson Research Laboratories, Inc., op. cit. p. 20, Fig. 5</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>92.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952. Section 7.3, Fig. 7.3-B.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs, Chapter 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., New developments in hands and hooks, Chapter 8 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">In only apparent contradiction, Shallenberger, from experience in 1946-47 with two short-below-elbow amputees on whom the cineplastic operation had been performed, with consequent severing of the biceps tendon, recommended a high and almost horizontal front brim with adequate corners on the medial and lateral sides. He found that the flesh was thus restrained at the top and front of the stump and was instead forced out at the sides, where it could not interfere with elbow flexion. He thus found the bearing area to be much greater, with consequent relief of pressure on the stump. In general the same situation would not prevail in the ordinary below-elbow amputee whose biceps tendon is intact.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs, Chapter 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., New developments in hands and hooks, Chapter 8 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>98.</b> </td><td class="clsTextSmall">War Department, Washington, D. C, TrainingManual 8-293, Physical therapy for lower extremity amputees, June 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs, Chapter 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., New developments in hands and hooks, Chapter 8 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>98.</b> </td><td class="clsTextSmall">War Department, Washington, D. C, TrainingManual 8-293, Physical therapy for lower extremity amputees, June 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">Lawrence, Jerome, unpublished lecture, 34th Suction-Socket School, New York, May 7, 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>99.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., The APRL terminaldevices, Orthop. &amp;Pros. Appl. J , March 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>91.</b> </td><td class="clsTextSmall">University of California (Berkeley), ProstheticDevices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Major amputations, Surg.Gyn. &amp;Obstet., 84:759 (1947).</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Amputations and prostheses,Chapter XII in Christopher's Textbook of surgery, 5th ed., Saunders, Philadelphia, 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., The management of war amputations in a general hospital, N. Y. State J. Med., 44:1763 (1944).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>55.</b> </td><td class="clsTextSmall">Little, op. cit. p. 10</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>71.</b> </td><td class="clsTextSmall">Personal communication from Verne T. Inman,University of California.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>88.</b> </td><td class="clsTextSmall">Thompson, T. Campbell, and Rufus H. Alldredge,Amputations: surgery and plastic repair, J. Bone &amp;Joint Surg., 26A:639 (1944).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>87.</b> </td><td class="clsTextSmall">Thomas, A., and C. C. Haddan, Amputation prosthesis, Lippincott, Philadelphia, 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>45.</b> </td><td class="clsTextSmall">Kirk, Norman T., Amputations, a monograph from Vol. III of Lewis' Practice of surgery, W. F. Prior Company, Inc., Hagerstown, Md.,1944. Fig . 7, p. 22.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>45.</b> </td><td class="clsTextSmall">Kirk, Norman T., Amputations, a monograph from Vol. III of Lewis' Practice of surgery, W. F. Prior Company, Inc., Hagerstown, Md.,1944. Fig . 7, p. 22.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>56.</b> </td><td class="clsTextSmall">Little, op. cit. p. 24.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>60.</b> </td><td class="clsTextSmall">Martin, Florent, Artificial limbs, International Labour Office, Geneva, 1925.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Borchardt, op. cit. pp. 523-528.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Carnes, W. T., U.S. Patent 1,046,966, December, 1912.</td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Carnes, W. T , U S. Patent 1,046,967, December, 1912.</td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Carnes, W. T., U.S. Patent 1,402.476, January 3, 1912.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Borchardt, M., el al., eds., Ersatzglieder und Arbeitshilfen, Springer, Berlin, 1919.</td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Little, E Muirhead, A lecture on a new material (duralumin) for surgical appliances, Brit. Med. J., 1:236 (1912).</td></tr><tr><td class="clsTextSmall"><b>58.</b> </td><td class="clsTextSmall">Little, op. cit. p. 249.</td></tr><tr><td class="clsTextSmall"><b>59.</b> </td><td class="clsTextSmall">Martin, Florent, La prothese du membre inferieur,Masson et cie., Paris, 1918.</td></tr><tr><td class="clsTextSmall"><b>80.</b> </td><td class="clsTextSmall">Saunders, J. B., V. T. Inman, and H. D. Eberhart,The major determinants in normal and pathological gait, J. Bone &amp;Joint Surg., 35A(3) :543 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>57.</b> </td><td class="clsTextSmall">Little, op. cit. pp. 110-113.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Desoutter, E. R., Back to activity, DesoutterBrothers, Ltd., 73 Baker St., London W1, 1938.</td></tr><tr><td class="clsTextSmall"><b>49.</b> </td><td class="clsTextSmall">Leonard, Fred, and Clare L. Milton, Jr., Cosmetic gloves, Chapter 9 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>86.</b> </td><td class="clsTextSmall">Tenenbaum, Milton, and Adele Tenenbaum, U.S.Patent 2,453,604, November 9, 1948.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Little, E Muirhead, A lecture on a new material (duralumin) for surgical appliances, Brit. Med. J., 1:236 (1912).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>59.</b> </td><td class="clsTextSmall">Martin, Florent, La prothese du membre inferieur,Masson et cie., Paris, 1918.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Borchardt, M., el al., eds., Ersatzglieder und Arbeitshilfen, Springer, Berlin, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Borchardt, M., el al., eds., Ersatzglieder und Arbeitshilfen, Springer, Berlin, 1919.</td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Little, E Muirhead, A lecture on a new material (duralumin) for surgical appliances, Brit. Med. J., 1:236 (1912).</td></tr><tr><td class="clsTextSmall"><b>58.</b> </td><td class="clsTextSmall">Little, op. cit. p. 249.</td></tr><tr><td class="clsTextSmall"><b>59.</b> </td><td class="clsTextSmall">Martin, Florent, La prothese du membre inferieur,Masson et cie., Paris, 1918.</td></tr><tr><td class="clsTextSmall"><b>80.</b> </td><td class="clsTextSmall">Saunders, J. B., V. T. Inman, and H. D. Eberhart,The major determinants in normal and pathological gait, J. Bone &amp;Joint Surg., 35A(3) :543 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>33.</b> </td><td class="clsTextSmall">Dorrance, D. W., U.S. Patent </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>54.</b> </td><td class="clsTextSmall">Little, op. cit. p. 8.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Little, op. cit. pp. 7-8.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper-extremity prosthetics armamentarium, Artificial Limbs, January 1954. p. 15.</td></tr><tr><td class="clsTextSmall"><b>86.</b> </td><td class="clsTextSmall">Tenenbaum, Milton, and Adele Tenenbaum, U.S.Patent 2,453,604, November 9, 1948.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>52.</b> </td><td class="clsTextSmall">Little, op. cit. pp. 6-7.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs, Chapter 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>98.</b> </td><td class="clsTextSmall">War Department, Washington, D. C, TrainingManual 8-293, Physical therapy for lower extremity amputees, June 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Borchardt, op. cit. pp. 397, 425, 509.</td></tr><tr><td class="clsTextSmall"><b>51.</b> </td><td class="clsTextSmall">Little, E. Muirhead, Artificial limbs and amputation stumps, H. K. Lewis and Co., Ltd., London, and Blakiston, Philadelphia, 1922.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Borchardt, op. cit. pp. 404-405.</td></tr><tr><td class="clsTextSmall"><b>52.</b> </td><td class="clsTextSmall">Little, op. cit. pp. 6-7.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>45.</b> </td><td class="clsTextSmall">Kirk, Norman T., Amputations, a monograph from Vol. III of Lewis' Practice of surgery, W. F. Prior Company, Inc., Hagerstown, Md.,1944. Fig . 7, p. 22.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>94.</b> </td><td class="clsTextSmall">Vard, Inc., Pasadena, Calif., Subcontractor'sFinal Report [to the] Committee on Artificial Limbs, National Research Council, The development of artificial arms for amputees who have had the cineplaslic operation, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>100.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., and Robert J. Pursley,Fitting the wrist-disarticulation case, Orthop. &amp;Pros. Appl. J., September 1952. p. 17. 100. zur Verth, M., Die biologische Absetzung der menschlichenGliedmassen, Muench. Med. Wschr., 82:525 (1935).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>74.</b> </td><td class="clsTextSmall">Putti, Vittorio, Historic artificial limbs, Hoeber, New York, 1930. p. 7.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>69.</b> </td><td class="clsTextSmall">Northwestern Technological Institute, Evanston,Ill., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, A review of the literature, patents, and manufactured items concerned with artificial legs, arm harnesses, hand, and hook; mechanical testing of artificial legs, 1947. pp. 1.33-1.36.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>73.</b> </td><td class="clsTextSmall">Possibilities Unlimited, Inc., Cleveland, Ohio, Possibilities unlimited, Vol. II, Issue 2, 1950.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">It should be recalled that with a little practice man can walk on his hands, but it is not a very comfortable behavior or one that can long be continued.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Eugene F. Murphy, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Research and Development Division, Prosthetic and Sensory Aids Service (Central Office), Veterans Administration, 252 Seventh Avenue, New York City; member, Upper- and Lower-Extremity Technical Committees, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Rufus H. Alldredge, M.D. </b></td></tr><tr><td class="clsTextSmall">Formerly Chief, Orthopedic and Prosthetic Appliance Clinic Team, Veterans Administration Regional Office, New Orleans, Louisiana; member, Advisory Committee on Artificial Limbs, National Research Council.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_03_004/fig1A.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_03_004/fig2.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Prosthetics Research and the Amputation Surgeon Creator An entity primarily responsible for making the resource Rufus H. Alldredge, M.D. * Eugene F. Murphy, Ph.D. * http://23.254.134.177/the.oandplibrary.org/files/original/cd2773276c38e31c5de8654b32560573.pdf 87b82fb3ff0928e5a56676a56b7cbdcf http://23.254.134.177/the.oandplibrary.org/files/original/a78493f4da7fe644e100ca7cd8f56d1e.jpg e073105d25ced27a5e34a054493e1b9b Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Fig. 1. Common type of fitting stool in use as early as 1915. http://23.254.134.177/the.oandplibrary.org/files/original/08467dd5927652e3f141a24cfd88006d.jpg 6b207b6637a053feab492dfd5671d043 http://23.254.134.177/the.oandplibrary.org/files/original/70ce2e00269500442488030867f39c27.jpg 89f554cdd092a9be038f0d15dd877649 http://23.254.134.177/the.oandplibrary.org/files/original/dccd360bb421f24a14130d0561616df2.jpg 80c4e525bbf609f14fb7e4a1ab680320 http://23.254.134.177/the.oandplibrary.org/files/original/7fb4c0a612ed285e0c2e9087a7e28b62.jpg 76427ad85f7535e83fe3bfd90e193887 http://23.254.134.177/the.oandplibrary.org/files/original/0d84a2e1a512d5f9cb9193668acd65ae.jpg bed71c0fb716d2bdf7f019f1e9eb4b37 http://23.254.134.177/the.oandplibrary.org/files/original/97791855ac3600156a68a12b7c972dd5.jpg 2b164807888f99334218d0f7f47b8f17 http://23.254.134.177/the.oandplibrary.org/files/original/da317ff46ffe02bafb48463f608f475d.jpg 6810da6531996bb2b6c2be42269f130d http://23.254.134.177/the.oandplibrary.org/files/original/963ad811431eb69af334aa267224b273.jpg 1e1a95fac1029fec7c7f718ecb7e4a94 http://23.254.134.177/the.oandplibrary.org/files/original/2841d434985c67fafb98c4d6d708fb1d.jpg 674642f0b1ea2c951c02a34b642778c3 http://23.254.134.177/the.oandplibrary.org/files/original/4f883a6fd1a5b6708ec59964f8f2a42b.jpg 9c29c06be2efb1a6f591ec3270228eb0 http://23.254.134.177/the.oandplibrary.org/files/original/c80c09227dc29bd5b10a5c5d39e6a560.jpg 44accb51743d8c7c84cfc4df44fbde0b http://23.254.134.177/the.oandplibrary.org/files/original/c6663fb4bff4e66ca21d755e4fd2bce7.jpg 496e66c530a145b0109ce9a5596bc33e http://23.254.134.177/the.oandplibrary.org/files/original/d4d6515876785c9dc32270fdd4c7af27.jpg 1a33a5ea6da53b83e55a91265fa656e3 http://23.254.134.177/the.oandplibrary.org/files/original/4f02159f1f7aefd8f42f385c1a097c7a.jpg 9e0b9a2c892c1167b0652e3e195a4a8c Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Artificial Limbs: A Review of Current Developments Description An account of the resource The foundation of modern prosthetics can be directly traced to the coordinated efforts of the National Academy of Sciences under the various artificial limbs committees after the Second World War. America, at its height of post war efficiency and engineering acumen, set about to solve the burgeoning problem of amputees swelling an infrastructure of prosthetic delivery that was outmoded, outdated and unprepared. Artificial Limbs: A Review of Current Developments was an industry update of these research efforts and was published thirty-three times, spanning the years 1954 to 1972. DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_02_020.pdf Year 1954 Volume 1 Issue 2 Page Number(s) 20 - 28 Text Any textual data included in the document <h2>Mechanical Aids for Alignment of Lower-Extremity Prostheses</h2> <h5>Charles W. Radcliffe, M.S.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>If a prosthetic device is to give optimum service to the amputee, it must always be properly fitted, regardless of its mechanical excellence. This is especially true in the case of the lower extremity, where the prosthesis must function continually and where poor fit or alignment will lead quickly to rejection of the device by the wearer. Among prosthetists there seems to be general agreement that by far the most important factors in the success of any artificial leg relate to fit and alignment on the subject. Fit and alignment are usually considered together, since they are mutually interdependent.</p> <p>Over the years many different mechanical devices to aid in fitting and alignment of lower-extremity prostheses have been developed to help in the application of one or another particular set of alignment principles in use by individual fitters. Others of these devices are more general in application and are adaptable for use by any prosthetist regardless of the particular alignment principles he advocates. In every case, however, an attempt has been made to improve the fitting and alignment technique by adopting one definite set of principles and using a mechanical device to aid in the application of those principles.</p> <h3>Historical Background</h3> <p>In 1919 Franz Schede<a></a> wrote <i>Theoretische Grundlagen fiir den Bau von Kunstbeinen, </i>a work generally considered to be one of the first important contributions in the field of prosthetic devices. In this volume Professor Schede established for the alignment of lower-extremity prostheses a set of principles based on application of known laws of mechanics. He was particularly concerned with alignment of the joints in a lower-extremity prosthesis so as to provide sufficient stability during the stance phase. As a result of the interest in his work, there was developed the so-called "plumb-line" method of alignment, a method which, essentially, assumes that the prosthesis carries weight along a vertical plumb line, the elements of the prosthesis then being arranged using this line as a reference. Still in general use throughout Europe and the United States, this system involves the problem of determining the location of the plumb line in the socket so that it can be extended down to the foot and used as a reference. For this purpose, many mechanical devices have been used.</p> <h4>The Fitting Stool</h4> <p>One of the oldest devices to aid in the fitting of lower-extremity sockets is the common fitting stool (<b>Fig. 1</b>). This device was well known as early as 1915 and is still in general use. When it is used to aid in establishing a "weight line," wedges are employed to tilt the socket block until the desired orientation is achieved. The hydraulic fitting stool of Habermann (<b>Fig. 2</b>) is a recent refinement. It requires that the location of one point on the weight line be assumed, usually at the socket brim, and that the plumb line be drawn vertically downward from this point.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 1. Common type of fitting stool in use as early as 1915.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 2. Modern fitting stool with hydraulic height adjustment. Manufactured in Germany by Habermann.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p><i>Pivot-Point Balancing Devices</i></p> <p>In an attempt to eliminate the necessity for the assumption of one point on the weight line of the socket, various modifications of the standard fitting stool have been tried.<a></a> <b>Fig. 3</b> is a schematic diagram of a fitting stool which uses a fixed ball as the lower contact point. The point of contact of the ball locates one point on the plumb line, which is then extended upward through the socket.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 3. Point-balance fitting stool with a fixed ball as the supporting point</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p>In a further refinement of this technique, introduced into this country in 1947, the plumb line is located at the intersection of two vertical planes (<b>Fig. 4</b>). The lower edge of each plane is determined by use of a triangular block giving a line contact along the bottom of the socket.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 4. Line-balance fitting stool with triangular block as a support.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p>Another pivot-point balancing device (<b>Fig. 5</b>) locates a similar point near the top of the socket block by supporting the socket in a clamp which pivots about a fore-and-aft axis and allows the pivot point to be moved medially or laterally as desired. Weight is transmitted to the floor through a connecting pylon.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 5. Pylon-type fitting stand with support at a point near the top brim of the socket.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p><i>Vise-Type Fitting Stand</i></p> <p>Another school of thought in the alignment of the above-knee socket believes that establishment of a plumb line is not as important as is establishment of the proper inclination of the socket in space. In the vise-type fitting stand (<b>Fig. 6</b>) of Habermann<a></a>, the socket can be adjusted in inclination to any position desired. Once the proper inclination and height have been established, the socket is clamped rigidly in space, and the amputee "marks time" in the socket. If necessary, changes are made until the amputee is able to bear weight comfortably and to use his stump efficiently in the control of body movements. After an arbitrary plumb line has been assumed, the optimum socket orientation is incorporated into the final prosthesis.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 6. Vise-type fitting stand.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p>All of these mechanical aids have helped in the so-called "static alignment" of the prosthesis, a condition which determines the stability of the artificial limb in the stance phase. The "dynamic" factors, which affect the swing phase of the prosthesis, and which account for the differences between the static and dynamic conditions in the stance phase, are adjusted as necessary after the amputee is walking on the rough leg.</p> <h4>Schneider's "Gehmaschine"</h4> <p>Hans Schneider<a></a> of Nuremberg, Germany, has long advocated the use of an adjustable leg or "walking machine." Essentially, his method is to allow the amputee to walk on a trial prosthesis (<b>Fig. 7</b>), changes being made empirically until the alignment is considered satisfactory. Then, as the optimum alignment is being duplicated in the final prosthesis, various measurements are read from the adjustable leg and a measuring stand (<b>Fig. 8</b>). It is claimed that from these measurements the fit and alignment can be duplicated in additional prostheses ordered later.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 7. Schneider's "Gehmaschine."</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 8. Schneider's alignment stand.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <h3>The University of California Above-Knee Adjustable Leg</h3> <p>A study of methods for alignment of the above-knee suction-socket prosthesis was started at the University of California, Prosthetic Devices Research Project, in the autumn of 1946. As one of the first phases of investigation, two adjustable prostheses were designed and constructed. These experimental devices (<b>Fig. 9</b> and <b>Fig. 10</b>) allowed adjustment of a large number of variables, and data were collected having to do with the effect of a change in one of the many alignment variables upon the behavior of the prosthesis<a></a>. It soon became apparent that devices of this nature were not only useful as research instruments but that they might also have some practical use as limbshop tools. Accordingly, there was designed and constructed for limbshop purposes a series of models of a simplified device in- corporating only those adjustments found most important, as determined using the research devices.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 9. Experimental adjustable above-knee leg used for research at the University of California.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 10. Experimental adjustable below-knee leg (University of California).</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p>The initial effort was to develop a device for alignment of the above-knee suction-socket prosthesis. Out of this work came the above-knee adjustable leg shown in <b>Fig. 11</b>. Several units of this design were used in the experimental program at the University of California and were given shop trials in the San Francisco Bay Area. They were found very useful in the alignment of above-knee prostheses in the shops and, in addition, were widely used for demonstration of alignment principles. But use of the above-knee adjustable leg was then limited because of the difficulty in transferring the optimum relationships from the adjustable trial prosthesis to the final setup.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 11. The UC adjustable leg.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <h3>The UC Alignment Duplication Jig</h3> <p>To fill this need, the designers produced the Alignment Duplication Jig (<b>Fig. 12</b>), which is essentially a rather specialized set of clamps and an associated saw guide to maintain the socket, knee axis, ankle axis, and foot in a fixed position, thus permitting the temporary adjustable knee to be removed and replaced with wood, plastic, or metal structural members and joints. Three models of the alignment duplication jig were constructed and loaned, along with models of the above-knee adjustable leg, to the representatives of the Orthopedic Appliance and Limb Manufacturers Association who were then serving as the Technical Advisory Committee to the Lower-Extremity Technical Committee of ACAL. The representatives of the limb industry were unanimous in their conclusion that use of these devices offered considerable advantage to the prosthetist for alignment of all above-knee suction-socket prostheses.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 12. The alignment duplication jig.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p>On the basis of the experience gained, the above-knee adjustable leg was redesigned, as shown in <b>Fig. 13</b>, and drawings for both the adjustable leg and the duplication jig were made available to the artificial-limb industry.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 13. Revised design of the adjustable leg as released to the artificial-limb industry.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p>Devices similar to those shown in <b>Fig. 12</b> and <b>Fig. 13</b> are now being manufactured<a style="text-decoration: none;">*</a> and can be purchased by limbshops.</p> <h3>The UC Combination Adjustable Leg</h3> <p>Because of the acceptance of the above-knee adjustable leg during its trial period of limbshop use, the Technical Advisory Committee of OALMA recommended that a similar unit be developed for alignment of below-knee prostheses. As a result, the combination above-knee/below-knee adjustable leg (<b>Fig. 14</b>) was designed and constructed at the University of California. Its use as a below-knee alignment device is indicated in <b>Fig. 15</b>. The principal advantage of this unit over previous designs is that no tools are required in making adjustments.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 14. Combination above-knee/below-knee adjustable leg in use as a trial above-knee prosthesis</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 15. Combination above-knee/below-knee adjustable leg in use as a trial below-knee prosthesis.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <h3>Use of the Adjustable Leg and Alignment Duplication Jig</h3> <p>The basic difference in the use of the University of California alignment devices, as compared with Schneider's apparatus, lies in the manner of duplication of the optimum alignment. The adjustable leg is used in much the same manner as is Schneider's device. A set of guiding principles for filling and alignment has been established, and the adjustable leg is used as a means of applying these principles to the conditions existing with a particular amputee. But the devices serve as shop tools only, and any set of principles can be applied by the prosthetist.</p> <p>In the use of the alignment duplication jig, the (assumption is made that the optimum alignment will be influenced considerably by the fit of the socket. Since subsequent sockets for a particular amputee are not apt to be exactly alike, it is considered unnecessary to try to duplicate in all later prostheses the alignment of the first. Each socket is considered as a separate alignment prob- lem, and the alignment duplication jig helps in the construction of the final prosthesis rather than as a measuring instrument.</p> <p>In the prior art of lower-extremity limb-fitting, there has naturally been the tendency to stop making adjustments as soon as the prosthesis is just "good enough," especially so when a further change would mean breaking a glued connection or resetting a joint. The principal advantage of the UC alignment equipment is that, since all adjustments in the trial prosthesis are easily and quickly made, the prosthetist can make very small changes until both he and the amputee are satisfied that the best job has been done. The alignment of a leg prosthesis is especially critical in the swing phase and during the periods of transition from stance to swing. Very small changes in alignment can have very noticeable effects upon the performance of the prosthesis at these times. Since small adjustments can be made accurately using the adjustable leg, the prosthetist is able to obtain optimum performance where that is difficult, if not impossible, to achieve by trial-and-error methods. Besides this, the adjustable leg has found considerable use as an educational aid in teaching prosthelisls the fundamentals of limb alignment in suction-socket schools and in demonstration of alignment principles before groups of orthopedic surgeons, physical therapists, and others.</p> <p><b>References:</b></p> <ol> <li>Habermann, Alfred, <i>Mechanische Hilfsmittel fur denstatischen Aufbau des Kunstbeines, </i>Medizinische-Technik, 4(3) :60 (March 1950).</li> <li>Schede, Franz, <i>Theorelische Grundlagen fur den Bauvon Kunstbeinen; Insbesondere fur den Oberschenkel-amputierten, </i>Ztschr. f. orthopad. chir., Supplement 39, Enke, Stuttgart, 1919.</li> <li>Schnur, Julius, <i>BeinbelasiungsUnie und Schwerlinie,</i>edizinische-Technik, 5(3):54 (March 1951).</li> <li>Schnur, Julius, <i>Die Aquilibral-Kontakt Prolhese,</i>rthopadie-Technik, 4(2) :36 (February 1952).</li> <li>University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Functional considerations in fitting and alignment of the suction socket prosthesis, </i>March 1952.</li> <li>War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, <i>Report on European observations, </i>Washington, 1946. <b>p.92.</b></li> </ol> <br /> <div style="width: 400px;"> <table style="background: #003399;"> <tbody> <tr> <td> <table> <tbody> <tr> <td style="text-align: left; padding: 3px;"> <table> <tbody> <tr> <td class="clsTextSmall" style="border-bottom: 1px #666666 solid;"><b>Footnote</b></td> </tr> <tr> <td class="clsTextSmall">By the Plastic Fibre Limb Company, Minneapolis Minnesota.</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> <div style="width: 400px;"> <table style="background: #003399;"> <tbody> <tr> <td> <table> <tbody> <tr> <td style="text-align: left; padding: 3px;"> <table> <tbody> <tr> <td class="clsTextSmall" style="border-bottom: 1px #666666 solid;"><b>Reference</b></td> </tr> <tr> <td class="clsTextSmall"><b>5.</b></td> <td class="clsTextSmall">University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Functional considerations in fitting and alignment of the suction socket prosthesis, March 1952.</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> <div style="width: 400px;"> <table style="background: #003399;"> <tbody> <tr> <td> <table> <tbody> <tr> <td style="text-align: left; padding: 3px;"> <table> <tbody> <tr> <td class="clsTextSmall" style="border-bottom: 1px #666666 solid;"><b>Reference</b></td> </tr> <tr> <td class="clsTextSmall"><b>6.</b></td> <td class="clsTextSmall">War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, Report on European observations, Washington, 1946. p.92.</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> <div style="width: 400px;"> <table style="background: #003399;"> <tbody> <tr> <td> <table> <tbody> <tr> <td style="text-align: left; padding: 3px;"> <table> <tbody> <tr> <td class="clsTextSmall" style="border-bottom: 1px #666666 solid;"><b>Reference</b></td> </tr> <tr> <td class="clsTextSmall"><b>1.</b></td> <td class="clsTextSmall">Habermann, Alfred, Mechanische Hilfsmittel fur denstatischen Aufbau des Kunstbeines, Medizinische-Technik, 4(3) :60 (March 1950).</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> <div style="width: 400px;"> <table style="background: #003399;"> <tbody> <tr> <td> <table> <tbody> <tr> <td style="text-align: left; padding: 3px;"> <table> <tbody> <tr> <td class="clsTextSmall" style="border-bottom: 1px #666666 solid;"><b>References</b></td> </tr> <tr> <td class="clsTextSmall"><b>3.</b></td> <td class="clsTextSmall">Schnur, Julius, BeinbelasiungsUnie und Schwerlinie,edizinische-Technik, 5(3):54 (March 1951).</td> </tr> <tr> <td class="clsTextSmall"><b>4.</b></td> <td class="clsTextSmall">Schnur, Julius, Die Aquilibral-Kontakt Prolhese,rthopadie-Technik, 4(2) :36 (February 1952).</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> <div style="width: 400px;"> <table style="background: #003399;"> <tbody> <tr> <td> <table> <tbody> <tr> <td style="text-align: left; padding: 3px;"> <table> <tbody> <tr> <td class="clsTextSmall" style="border-bottom: 1px #666666 solid;"><b>Reference</b></td> </tr> <tr> <td class="clsTextSmall"><b>2.</b></td> <td class="clsTextSmall">Schede, Franz, Theorelische Grundlagen fur den Bauvon Kunstbeinen; Insbesondere fur den Oberschenkel-amputierten, Ztschr. f. orthopad. chir., Supplement 39, Enke, Stuttgart, 1919.</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> <div style="width: 400px;"> <table style="background: #003399;"> <tbody> <tr> <td> <table> <tbody> <tr> <td style="text-align: left; padding: 3px;"> <table> <tbody> <tr> <td class="clsTextSmall" style="border-bottom: 1px #666666 solid;"><b>Charles W. Radcliffe, M.S. </b></td> </tr> <tr> <td class="clsTextSmall">Acting Assistant Professor of Engineering Design, University of California, Berkeley; member, Lower-Extremity Technical Committee, ACAL, NRC.</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> Figure 1 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-10.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-11.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-12.jpg Figure 4 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-13.jpg Figure 5 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-14.jpg Figure 6 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-15.jpg Figure 7 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-16.jpg Figure 8 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-17.jpg Figure 9 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-18.jpg Figure 10 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-19.jpg Figure 11 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-20.jpg Figure 12 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-21.jpg Figure 13 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-22.jpg Figure 14 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-23.jpg Figure 15 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-24.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Mechanical Aids for Alignment of Lower-Extremity Prostheses Creator An entity primarily responsible for making the resource Charles W. Radcliffe, M.S. * http://23.254.134.177/the.oandplibrary.org/files/original/627090118e7550aef32b928f5cfc5097.pdf c7c3671e2f62151182aae56f91f5d70f http://23.254.134.177/the.oandplibrary.org/files/original/c7e92f6d5fe85c8d6ef8544614a97aa3.jpg e468493086048ce57199f393dee24774 http://23.254.134.177/the.oandplibrary.org/files/original/04ce23f2e2248f3d1d49330516618203.jpg 5ad71da0cd2407e65b1be1093f9dad0d http://23.254.134.177/the.oandplibrary.org/files/original/37a6c5bccac772225e463355b7ce5b99.jpg 5fdd10eb7e82869440f88ddc8281c621 http://23.254.134.177/the.oandplibrary.org/files/original/1df47c562dff18af23aea5737e89ad4f.jpg d057a4335966a37fed05ecf311b6fa49 http://23.254.134.177/the.oandplibrary.org/files/original/66602a6f594faa462098d6e7eae66228.jpg b1e3ac1eed82d64494c9acf1af76bd6f http://23.254.134.177/the.oandplibrary.org/files/original/beceed2ac3ba9eecfcc08cf2abe51169.jpg 9ae2a1c0df624061372096332c5fce03 http://23.254.134.177/the.oandplibrary.org/files/original/d308ea30b792e6fb6e57c9d43f2f66f5.jpg 8be6fb5bd0b864a1f0104a3e23affdd6 http://23.254.134.177/the.oandplibrary.org/files/original/5e8c8f8672d073a25e049c5a392e5ef1.jpg 5774196adae9a8c9364a6e9134b7bde9 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Artificial Limbs: A Review of Current Developments Description An account of the resource The foundation of modern prosthetics can be directly traced to the coordinated efforts of the National Academy of Sciences under the various artificial limbs committees after the Second World War. America, at its height of post war efficiency and engineering acumen, set about to solve the burgeoning problem of amputees swelling an infrastructure of prosthetic delivery that was outmoded, outdated and unprepared. Artificial Limbs: A Review of Current Developments was an industry update of these research efforts and was published thirty-three times, spanning the years 1954 to 1972. DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_02_029.pdf Year 1954 Volume 1 Issue 2 Page Number(s) 29 - 39 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_02_029.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_02_029.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Status of the Above-Knee Suction Socket in the United States</h2> <h5>Chester C. Haddan <a style="text-decoration:none;">*</a><br />Atha Thomas, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The above-knee suction socket constitutes a means of attaching an artificial leg to the stump of an amputee without necessity for the conventional pelvic band, a metal hip joint, or other types of suspension harness (<b>Fig. 1</b>). The leg is held on by the slight vacuum created in the socket each time the leg is lifted from the ground, the pressure usually being controlled by a valve installed in the lower portion of the socket. Accurate functional fit of the socket, as distinguished from the conventional "plug" fit, permits the creation of negative pressure, gives a wider range of muscular control of the leg, and provides comfort while walking or sitting. Because the conventional belt and hinge joint are eliminated, the suction socket gives the above-knee amputee more freedom and less interference with clothing. The leg feels more like an integral part of the body, a feature which tends to decrease the sensation of dead weight and to improve sense of position. Reduced piston action of the stump in the socket results in greater toe clearance during walking. No stump sock is necessary. Any adductor roll is corrected. And finally, active use of the stump muscles causes them to develop instead of becoming atrophied. For a complete discussion of the prescription, fabrication, fitting, alignment, and use of the above-knee suction-socket prosthesis, reference may be had to Bechtol,<a></a> to Eberhart and McKennon<a></a>, and to the so-called "suction-socket brochure" of the University of California.<a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Typical above-knee suction-socket leg before application of the usual rawhide finish. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Early History</h3> <p>The earliest known reference to the suction socket is in the form of a patent issued by the United States, February 10, 1863, to Dubois D. Parmelee<a></a> of New York City. Subsequent patents have been issued to George Beacock and Terence Sparham<a></a> of Brock-ville, Ontario, Canada, in 1885; to Justin K. Toles<a></a> of Stockton, California, in 1911; and to Ernest Walter Underwood<a></a> of Birmingham, England, in 1926. The fundamental principles of the Beacock and Spar-ham suction socket differed but little from those of the Parmelee method. Toles' description was basically the same but with the addition of a rubber lube and bag lining which could be inflated by air to assist in holding the socket on. The socket described by Under- wood had smooth helical grooves, which he claimed ventilated the stump as well as assisted in holding the socket in place.</p> <p>A search of the literature on above-knee suction sockets has revealed only a few articles prior to the last few years. In 1925 Muirhead Little<a></a> of England reported favorably on 11 amputees fitted with the suction socket after the design of Blatchford,<a></a> made of metal, and containing a smooth helical groove of a little more than one turn around the circumference of the socket. Some 30 cases were reported as fitted at Roehampton, England, following World War I using a metal socket with a helical groove as described by Blatchford.<a></a> It is not known whether these 30 cases included the 11 reported by Muir-head Little, but it is considered doubtful since during this period several different groups were using the suction socket in England. Use of the suction socket has been practically dormant in England since that time, although it has been revived in recent years.</p> <p>Pfau<a></a> of Berlin says the suction socket has been known in Germany for 30 years but that it was not popularized until Oesterle, in Ulm, started his work in the early '30s. Felix,<a></a> a surgeon of Diisseldorf, reported on above-knee sockets in 1941. He stated that the suction socket had been used in Germany to some extent since World War I but that it was not popularized until a satisfactory suction-socket valve had been developed in 1932. After this accomplishment, numerous selected cases were successfully fitted in Germany.</p> <p>As a result of the apparent reported success with artificial limbs in Germany, early in 1946 the Surgeon General of the United States Army sent to Europe a "Commission on Amputations and Prostheses" to observe foreign practice. One principal item of interest was the successful use in Germany of suction sockets for above-knee prostheses. Because of the favorable report<a></a> issued by the commission, the Advisory Committee on Artificial Limbs instituted, as one activity of its general plan of providing information on the best possible prostheses, a program to determine the possibilities and limitations of the suction-socket type of suspension for the above-knee leg.</p> <h3>Clinical Research in the United States</h3> <p>After extensive trials and studies in their own laboratory, workers at the University of California, Berkeley, prepared instructional material and started a nation-wide program to determine the feasibility of use of the above-knee suction-socket technique under field conditions in the United States. By September 1947, 52 subjects had been fitted in 10 widely separated localities by local prosthetists in their own shops with materials and devices normally employed but making use of supplementary information and supervision by University personnel.</p> <p>The success of this program led the Advisory Committee on Artificial Limbs, in October 1947, to recommend to the Veterans Administration the use of the suction-socket technique for above-knee amputees, its use being limited for the time being to further field tests within the VA under the direction of qualified surgeons. The recommendation was accepted and, from December 1947 through January 1949, 20 schools, each of one week duration, were held throughout the country to provide 250 orthopedic surgeons and 200 prosthetists with sufficient knowledge of the fabrication and application of the suction socket to introduce it on an experimental basis.</p> <p>By October 1949 comprehensive records had been made of over 500 cases, and ACAL felt that sufficient experience had been gained in the use of the suction socket to warrant its general application. Accordingly, a recommendation was made to the Veterans Administration, and the above-knee suction socket has since been in use routinely. The Orthopedic Appliance and Limb Manufacturers Association and the Veterans Administration, in a cooperative effort, have sponsored suction-socket schools from time to time to permit surgeons and limbfitters to gain sufficient knowledge in this field to qualify them to prescribe and fit the suction socket.</p> <h3>Surveys Of Amputee Acceptance</h3> <p>The enthusiasm with which the suction-socket above-knee leg has been accepted in the United States is indicated by the results of a number of surveys. Among them are the surveys of selected groups made by Thorndike and Eberhart <i>, </i><a></a> by Mazet, McMaster, and Hutter <i>, </i><a></a> and by Canty and Asbelle.<a></a> Results of three surveys, two by the Orthopedic Appliance and Limb Manufacturers Association, are shown in <b>Table 1</b>. The earliest data are from a University of California report<a></a> of April 1948. The 52 cases reported at that time had been carefully screened, selected, and fitted under the supervision of representatives of the Advisory Committee on Artificial Limbs. The results were carefully recorded. At the termination of this initial experimental program on April 15, 1948, of the 52 subjects fitted, 40 had been wearing their suction-socket legs routinely for 4 to 20 months. All were satisfied and had no intention of returning to the type of prosthesis worn previously. Six of the subjects, owing to improper fittings, nervous disorders, or lack of cooperation, were still alternating between the suction-socket leg and their previous legs. Six had been dropped from the program and were considered as failures.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In February 1949, the Orthopedic Appliance and Limb Manufacturers Association, in an effort to determine the extent of acceptance of the suction-socket leg in the United States, mailed questionnaires to approximately 200 limbshops. Of these, 159 shops reported. Eighty of those reporting had made no suction sockets at all; 79 shops had at that time fitted 1262 men, women, and children, with an amazingly small number of complete failures. A comparatively small group of 46 were converted to pelvic-belt-controlled legs, but many of these continued to use the suction-socket shape and some the suction valve, thus retaining many of the advantages of the suction-socket leg. The 1954 survey, also conducted by OALMA, with 72 firms reporting on 5882 cases, indicates similar conclusions. The 1954 OALMA questionnaire includes those firms reporting as few as three cases fitted and those reporting as many as 500 cases or more.</p> <p>Many of the limbshops reporting in both the 1949 and the 1954 OALMA questionnaires indicate that they have adopted the suction-socket method of fitting (that is, ischial bearing) as standard practice even though the amputee cannot actually wear the suction socket as such. Auxiliary supports, such as the Silesian bandage (<b>Fig. 2</b>), are used almost routinely by some limbshops. One of the most widely known and reputable shops in the United States reports the use of auxiliary supports on 300 out of 322 cases fitted. Another reports auxiliary supports applied in 300 out of 373 cases fitted. Another highly successful shop, in fitting 181 cases (of which 91 were children), used auxiliary supports on 90 cases. It is interesting to note that the firms reporting the largest number of cases also report the largest percentage of cases fitted with auxiliary supports.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Two forms of the Silesian bandage commonly used as an auxiliary support for the suction-socket leg, both in the United States and in Europe, particularly in Germany, where, according to Pfau, Hepp, and others <i>(13), </i>it is used almost routinely. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The surveys indicate that over 96 percent of all suction sockets fitted since the introduction of the program were fitted to stumps over 3 in. long. In the one shop that reported 90 children fitted, not a single one was fitted with a stump shorter than 3 in. It is to be noted that most of those fitted with the stump shorter than 3 in. were women; and some reported that, although they did not believe the fitting of a stump shorter than 3 in. to be practical, they were almost forced at least to attempt it because of pregnancy, a condition which precludes wearing the conventional pelvic belt.</p> <p>It may therefore be assumed that, except in very rare instances, generally it is impractical to prescribe the suction socket for stumps less than 3 in. long. A further observation is that of the large number of apparently quite successful cases of Gritti-Stokes amputations fitted, no failures whatever being reported in the case of amputation at this level.</p> <p>Another interesting feature brought out is that, while in 13 percent of the cases reported edema was present in the early stages of fitting, in only two cases did the edema persist and become a contributing cause of failure of the suction-socket leg. It is obvious from these data that, while edema may be common, it need not be considered a serious problem.</p> <p>An effort was made to determine the number of bilateral above-knee amputees fitted successfully with suction sockets, but reliable data were not obtained on this question. From the information received in the survey, however, it is believed that the number will probably be about 100, the percentage of failures being approximately the same as in the case of unilaterals.</p> <p>The overwhelming reason given for failure in the use of the suction socket comes under personality factors. An effort has been made in the surveys to obtain reliable data as to the definite reasons for failure. Personality factors are found to be predominant, with physical factors next in line, the condition of the stump third, and social and economic considerations fourth in importance. Thus tabulated, the causes of failure look about like this:</p> <blockquote><p> <i>1. Personality Factors</i><br />Unfavorable temperament<br />Poor cooperation<br />Inability to adjust<br />Discouragement<br />Lack of interest<br />Low order of intelligence<br />Insecurity<br /><i>2. General Physical Factors</i><br />Skin trouble<br />Age<br />Change in weight<br />Circulatory difficulties<br />Inability to bear weight on ischium<br />Buerger's disease<br />Overweight<br />Perspiration<br />Allergy<br />General weakness<br />Loose abduction<br />Unsocial noises<br /><i>3. Slump Characteristics</i><br />Inadequate length<br />Bone spurs<br />Interfering scars<br />Undue length<br /><i>4. Social and Economic Considerations</i><br />Insufficient time for proper fitting<br />Excessive distance from shop<br />Undue sales influence<br />Employer disapproval<br />Occupational requirement </p> </blockquote> <p>Another question asked the reporting firms was: "What percentage of above-knee amputees could, in your opinion, be fitted with a suction socket?". While the answers to this question range from a low of 30 percent of all amputees to as high as 100 percent, the average is 73 percent, a figure thought, in the opinion of the authors, to represent a realistic approach.</p> <p>Another question, asked because of the unusual amount of interest in children and the older age group on the part of the Committee on Artificial Limbs, was: "Is the socket suitable for amputees under five and over seventy?". Almost without exception the suction socket was said not to be suitable for the very young or the very old.</p> <p>Again, the question was asked: "When is the suction socket a practical approach to prosthetic fitting?". The following list of conditions, in the order of frequency with which they were mentioned, indicates the thinking prevalent among the reporting firms on this particular question:</p> <blockquote><p>Right personality factors and willingness to cooperate<br />Healthy, unscarred stump over 3 in. long<br />Under 65 years of age<br />New amputees not conditioned to suspenders or pelvic control<br />Easy access to facility<br />Good muscular reaction<br />Patient's enthusiasm<br />Good circulation<br />Good balance and coordination<br />Available training and therapy<br />Reasonable occupational demands</p> </blockquote> <h3>Factors in Suction-Socket Technique</h3> <p>Accumulated experience with fitting the suction-socket above-knee prosthesis over a period of seven years has clearly demonstrated its many advantages and its desirability over the conventional belt- or shoulder-suspended leg. On the other hand, the experience of the authors during the same period has convinced them that the suction socket is not suited for all above-knee amputees. This belief has been confirmed further by reports of survey studies previously conducted by others and by the results of the surveys reported here. In our opinion, there is considerable question as to the validity of the statement made by some to the effect that the suction socket can be used profitably by any thigh amputee who can wear the conventional type of prosthesis successfully. Experience has shown that there are certain amputees who cannot wear a suction-socket prosthesis successfully. If failures are to be avoided, all cases should be studied and screened carefully before a suction socket is prescribed.</p> <p>The factors to be considered are divided roughly into two groups, each often affecting the other-those relating to characteristics of the prosthesis itself, and those relating to the characteristics of the amputee. Chief among the mechanical considerations of the leg are alignment and socket shape. Factors relating to the amputee are the general physical and mental condition, the condition of the stump, and the condition of the opposite extremity.</p> <h4>Factors Relating To The Artificial Leg</h4> <p><i>Alignment</i></p> <p>With the suction-socket leg, which is controlled entirely by the stump muscles, alignment becomes much more critical than in the case of the pelvic-band suspension and therefore must be correct for proper control and comfort. If alignment is incorrect, there is a definite whip or rotation of the prosthesis during the swing phase. The problem of alignment has not yet been solved completely, and opinions differ a little as to what constitutes the ideal alignment of the prosthesis. Theoretically, it is desirable to incorporate as much adduction of the stump within the socket as is possible mechanically, since to do so tends to suppress body sway and to place the iliotibial band (or that portion of it which may remain intact) under tension.</p> <p>In the normal, the centers of hip, knee, and ankle joints coincide in the frontal plane with the mechanical axis of the lower extremity as a whole (<b>Fig. 3</b>). After amputation through the femur and fitting with a prosthesis, however, the body weight is no longer borne through the center of the hip joint but on the ischial tuberosity, which lies medial to the center of the hip joint. This would indicate, then, that the mechanical axis of the well-aligned above-knee prosthesis would more nearly coincide with a vertical line extending from the ischial tuberosity through the centers of the knee and ankle joints (<b>Fig. 4</b> and <b>Fig. 5</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Normal alignment in the frontal plane, showing how centers of hip, knee, and ankle joints coincide with the mechanical axis of the lower extremity as a whole. From Thomas and Haddan (14). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Forces acting on the stump and pelvis of an above-knee amputee during the stance phase. In the well-aligned prosthesis, the heel of the foot and the center of the knee should fall approximately on a vertical line (A-A') through the point of contact of the ischium (a). The tendency of the pelvis to rotate downward on the normal side owing to the body weight can be reduced by keeping the dimension (b) as small as possible. This is accomplished by an upward force through the ischium (a). Lateral rotation of the pelvis and side-sway in the shoulders and torso can both be minimized if the force in the abductor muscles (c) is sufficient to balance the body weight by lever action about the ischial seat <i>(a). </i>The stump must be anchored firmly and comfortably by pressure along the entire lateral side <i>(d). </i>Failure to do this results in discomfort at the crotch (e). From Haddan (8). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Posterior view of the above-knee prosthesis showing position of the socket in relation to the rest of the leg. The medial line (a) should be approximately vertical. The lateral line (b) is sloped downward and inward. From Had-dan <i>(8).</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the sagittal plane, the weight line in the normal person is a vertical line drawn through the centers of the shoulder, hip, knee, and ankle joints (<b>Fig. 6</b>, left). After amputation and fitting of a prosthesis, however, this vertical weight line must be shifted forward in order to obtain alignment stability (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Normal posture and two postural deviations which must be compensated for in fitting and aligning the prosthesis. Left, normal; center, slight deviation from normal presenting few difficulties in prosthetic fitting; right, extreme postural abnormality which, unless corrected by postural exercises, would present almost insurmountable alignment problems. From Gocht (7). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Alignment in the sagittal plane. The stump should be oriented in the socket with several degrees of initial flexion <i>(a) </i>to allow the stump to control knee stability over the widest range of hip motion possible. The ankle may be positioned either in front of or behind the knee. The dimension (i) will depend upon the individual amputee, his age, range of motion in the stump, stump musculature, and prevailing terrain. From Haddan (8). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If the amputee is young and agile, with no stump deformities and with strong and well-developed muscles in the back of the stump, the dimension <i>b </i>in <b>Fig. 7</b> may be reduced to zero. On the other hand, in the presence of flexion contracture in the stump, or weak musculature, this dimension may have to be increased to give sufficient stability. But to do so may result in the sacrifice of a normal gait and cause a tiring and awkward one. Similarly, postural abnormalities (<b>Fig. 6</b>, center and right) can make proper alignment very difficult to achieve.</p> <p>Such deviations in the weight line have upon postural stability and body alignment a biomechanical effect that is obvious. To complicate matters further, the amputee is deprived of a number of those sensory cues upon which every normal human being depends for the autonomous control of posture and motion. These include touch and pressure sensations from the soles of the feet and the never-ending bombardment of proprioceptive impulses that emanate from sensory receptors in the muscles, tendons, and joints of the weight-bearing limbs and sweep upward to the cerebellum. In the aggregate, these physiological and biomechanical deviations from normal appear formidible. Yet with proper fitting and alignment of his prosthesis, and with adequate training in the proper gait and posture, the average amputee can compensate for them to an amazing degree.</p> <p><i>Socket Shape</i></p> <p>Exactly what constitutes the most successful socket shape has not yet been fully determined owing to the many variables involved in the use of this technique. Several successful designs have been fully described in the literature <i><a></a><a></a><a></a><a></a>. </i>In these designs, weight-bearing occurs chiefly about the top posterior portion of the socket, particularly in the region of the ischial tuberosity, with a lesser amount on the gluteal muscle. The addition of a well-defined . . ischial seat reduces pis- ton action of the stump in the socket to a minimum and allows for a looser fit at the top of the socket. Incorrect shape, size, or location of the ischial seat leads to definite discomfort and frequent loss of suction, particularly when the wearer is sitting. In some very muscular stumps, the ischial seat may be reduced in size and in some cases removed entirely. Such amputees bear weight on their well-developed muscles, with the load distributed around the top portion of the socket. The socket is shaped the same except for the reduction or removal of the ischial seat.</p> <h4>Factors Relating To The Amputee</h4> <p><i>General Physical and Mental Factors</i></p> <p>A complete history and physical examination is the first step in determining the desirability of fitting the suction socket. Age is an important consideration, and as a rule elderly amputees are poor candidates for the for this reason it requires considerably more effort and muscular skill to learn to use it. If, therefore, the elderly amputee is, as is so often the case, debilitated and feeble, with muscles weak and flabby and with poor coordination and balance, he is a poor candidate for the suction socket. On the other hand, if he is strong, alert, and agile (that is, if he "appears younger than he is"), and if the stump is in proper condition and of adequate length, there is no reason why the elderly amputee cannot use a suction socket successfully.</p> <p>Experience has indicated that children as young as seven years can be fitted successfully.<a></a> The problem of lengthening and replacement as growth proceeds is no different from that with the conventional prosthesis.</p> <p>Before a suction socket is prescribed, every effort should be made to determine the psychological make-up of the amputee. All reports indicate that most failures have been due to suction socket. But old age <i>per se </i>is not a contraindication. Amputees over 70 years of age have been fitted successfully. As already noted, the suction-socket prosthesis is activated almost entirely by the muscles of the stump, and for this reason it requires considerably more effort and musulcar skill to learn to use it. if, therefore, the elderly amputee is, as is so often the case, debilitated and feeble, with muscles weak and flabby and with poor coordination and balance, he is a poor candidate for the suction socket. On the other hand, if he is strong, alert, and agile (that is, if he "appears younger than he is"), and if the stump is in proper condition and of adequate length, there is no reason why the elderly amputee cannot use a suction socket successfully.</p> <p>Experience has Indicated that children as young as seven years can be fitted successfully<a></a>. The problem of lengthening and replacement as growth proceeds is no different from that with the conventional prosthesis.</p> <p>Before a suction socket is prescribed, every effort should be made to determine the psychological make-up of the amputee. All reports indicate that most failures have been due to psychological or emotional difficulties. Learning to wear and use a suction-socket prosthesis requires cooperation, effort, patience, and perseverance. If the amputee is impatient, resentful, undependable, easily discouraged, unreasonable, or otherwise emotionally unstable, he most likely will be uncooperative and is apt to be a poor subject for the suction socket. Many failures can be attributed to the fact that the amputee is either unwilling or unable to devote the necessary time and effort to obtain a satisfactory fitting. As experience has been gained by the prosthetists, and with the additional aid of the recently developed alignment devices (page 23), the time required for construction and fitting has been considerably lessened in recent years. The interesting observation has been made that, when an amputee has to purchase his limb himself, he is likely to be much more cooperative than if he is given one by some agency.</p> <p><i>Slump Considerations</i></p> <p><i>Length. </i>Stump length is not so important a consideration as might be thought. Contour, muscle tone, and mobility are important determining factors in deciding whether or not a short stump can be fitted. Naturally, the longer the stump the better is the muscular control and the easier is the fitting and training problem. But stumps as short as 3 in. (measured from the crotch) have been fitted successfully. Usually the shorter stumps require the addition of an auxiliary suspension belt (such as the Silesian belts shown in <b>Fig. 2</b>) in order to stabilize the socket on the stump.</p> <p>End-bearing supracondylar and Gritti-Stokes amputation stumps can be fitted successfully with the suction socket, although in such cases the mechanical knee joint usually has to be placed at a level slightly below that of the opposite knee.</p> <p><i>Stump Contour. </i>With the conventional socket, a conical-shaped stump has always been considered desirable. Such is not the case with the suction socket. A stump of more cylindrical shape, with only slightly tapering sides and a fairly broad end, seems to maintain better suction and friction than does the conical or pointed stump. Most undesirable is a long, redundant, flabby mass of skin and fat extending beyond the bone end. Such a mass of tissue not only offers fitting problems but is prone to become edematous and swollen, thus making it difficult to don the leg or to remove the stump from the socket. In such cases, surgical revision is advisable before a suction socket is prescribed.</p> <p>Excessive subcutaneous fat or extreme flabbiness of stump muscles frequently results in marked changes in the contour of the stump after the suction socket has been worn for a while. Repeated modification of the socket thus becomes necessary. With excessive subcutaneous fat, the stump may shrink considerably after wearing the socket, necessitating the insertion of leather liners or even the making of a new socket. Muscles that are atrophied and flabby and of poor tone will develop and increase in size with the use of the suction socket, necessitating enlargement of the socket.</p> <p><i>Muscle Control and Strength. </i>Good muscular control and mobility of the stump are essential for successful use of the suction socket. Fixed deformities due to muscle contracture are very common in amputations above the knee, particularly in the older age group, and they not only present very serious fitting and alignment problems but also handicap the amputee in walking. Flexion and abduction deformities are the usual ones, and the shorter the stump, with resulting greater muscle imbalance, the more likely are they to occur. Once they do occur they are very difficult to correct. It is imperative, therefore, that every effort be made postoperatively to prevent such deformities. Studies in alignment conducted at the University of California<a></a> indicate that the most efficient gait with the suction-socket prosthesis is obtained by fitting the socket with the stump in adduction and slight flexion (<b>Fig. 7</b>). Severe flexion-abduction deformity of the stump makes such alignment very difficult, if not impossible, without producing marked tilting of the pelvis and excessive pressure on the stump.</p> <p>The adductor and hamstring muscles are important not only in controlling the limb but also in preventing flexion-abduction deformity by overcoming muscle imbalance. The shorter the stump, the less power remains in these muscles and the greater the tendency to deformity. It is well known that, in order for muscles to function at maximum efficiency, they must have a fixed insertion. In amputations through the thigh, the major muscles are sectioned well above their insertions, and all too often these muscles are allowed to retract upward, no attempt being made to fix their cut ends to fascia or over the end of the bone. Failure thus to fix the free ends seriously impairs muscle function in controlling the stump. In considering an amputee for a suction socket, the stump should be carefully examined to determine how well the thigh muscles are functioning and whether there are any fixed deformities. If any are present, active and passive exercises should be carried out to correct them as much as possible before the socket is fitted.</p> <p><i>Scars. </i>Deep linear scars near the socket brim may interfere with maintenance of suction. Tender, adherent scars in the weight-bearing area beneath the ischial tuberosity and over the buttocks may cause pain sufficient to prevent the wearing of a suction socket. Deep, folded, adherent, or puckered scars over the end of the stump, which so often cause difficulty with the conventional socket, rarely offer any problem with the suction socket. In fact, it has been observed repeatedly how often these scars smooth out and become more pliable after a suction socket has been worn for some time.</p> <p><i>Ulceration and Infection. </i>Open ulcers, draining sinuses, and active deep infection of the soft tissues of the stump, as well as active osteomyelitis, are definite contraindications to the use of the suction socket. With adequate surgery and use of antimicrobial drugs, these conditions can usually be eradicated readily.</p> <p><i>Bony Spurs. </i>Although in many thigh stumps bony spurs develop at the end of the femur, they rarely offer any difficulty in the fitting or wearing of a suction-socket prosthesis. Occasionally, however, a large spur will develop on the lateral side of the bone in a stump with a fixed abduction, thus producing painful pressure against the side of the socket. Relieving the socket at point of pressure, realigning the socket, or surgical removal of the spur usually solves such a problem.</p> <p><i>Skin Disturbances. </i>Skin sensitivity, irrita- tion, and infections are not uncommon in amputation stumps, and there appears to be considerable variation in the skin's resistance to pressure, friction, and irritation among individual amputees. Some are constantly troubled, while others have no difficulty. Der-matological complications are cited as a fairly common cause of failure in the use of the suction socket. Usually they can be prevented by proper hygienic care of the stump and good fitting, or else they can be relieved by derma-tologic treatment. Skin allergy and contact dermatitis, of rare occurrence with the suction socket, usually can be controlled readily. The troublesome adductor roll, with recurring "pressure boils" (suppurative hydroadenitis and folliculitis), so commonly encountered with the use of the conventional socket, rarely if ever occurs with the well-fitted suction socket. In fact, when such a condition exists with a conventional socket, and the socket is converted to a suction one, usually the roll and cysts rapidly disappear. This is one of the great advantages of the suction socket.</p> <p><i>Perspiration. </i>One troublesome problem occurs in individuals who perspire excessively and who also have a high bacterial count in their perspiration. Irritation or skin friction in such a situation leads to suppurative hydro-adenitis and furunculosis. Excessive perspiration is not uncommon when the suction socket is first worn, but it usually subsides after varying lengths of time. In alleviating these superficial skin infections, x-ray treatment is often of value. Autogenous vaccines have also been used with some success. Before any suction socket is discarded as a failure, every possible effort should be exerted to treat and eradicate such troublesome skin conditions. Some of them can be anticipated from previous history and careful examination and can be eliminated by proper treatment before the socket is fitted.</p> <p><i>Condition of the Opposite Extremity</i></p> <p>During the experimental program, and in the early suction-socket schools, abnormalities and disabilities in the opposite extremity were considered as constituting an important factor—and even as a probable contraindication—in determining the suitability of the amputee for a suction socket. Subsequent experience has shown that abnormalities in the opposite extremity, while still to be considered, are not necessarily contraindicative. Amputees with disabilities so great as to require permanent bracing of the opposite limb have been fitted successfully with suction sockets; many persons with below-knee amputations on one side are wearing above-knee suction-socket prostheses with ease and comfort on the other. In fact, in such cases the suction-socket leg appears to have several advantages over the conventional above-knee leg. Survey studies also reveal that some bilateral above-knee amputees have been successfully fitted with suction-socket prostheses. But of course it is apparent that all such cases must be selected only after a very thorough analysis of individual problems.</p> <p>Peripheral vascular disease which has necessitated amputation is in itself no contraindication to use of a suction socket, provided the opposite limb is not too seriously affected by the disease.</p> <h3>Conclusions</h3> <p>On the basis of the surveys reported upon, it appears quite definite that the suction-socket prosthesis has many advantages over the conventional belt- or shoulder-suspended leg. Approximately 75 percent of all above-knee amputees can be fitted successfully with the suction socket. Chief causes of failure, listed in decreasing order of importance, are psychological difficulties, general physical factors, stump abnormalities, and social and economic factors. Teamwork between physician, prosthe-tist, therapist, and amputee is an essential requirement in the successful fitting and wearing of the suction-socket prosthesis. Meticulous attention to fitting and alignment techniques is important, as is also adequate training.</p> <p>Research studies in gait and principles of alignment, and the development of new alignment devices and duplicating jigs, have been of great value in reducing the time involved in construction and fitting by eliminating, to a great extent, trial-and-error methods. Although many limb manufacturers in this country still do not appreciate the advantages of the suction-socket above-knee limb and make no attempt to fit it, the wide acceptance of the above-knee suction-socket prosthesis in the United States today indicates that it can no longer be considered an experimental device, its use limited to a few selected amputees. Use of the above-knee suction socket is now so prevalent that it can be safely stated—and fairly stated-that the majority of above-knee amputees can successfully be fitted with the suction-socket prosthesis.</p> <p><b>References:</b></p> <ol> <li>Aitken, G. T., and C. H. Frantz, <i>The juvenile ampu-tee, </i>J. Bone and Joint Surg., 35A:659 (1953).</li> <li>Beacock, George, and Terence Sparham, U. S. Pat-nt 329,880, November 10, 1885.</li> <li>Bechtol, C. 0., <i>The suction socket, </i>J.A.M.A., <b>146:625 (1951).</b></li> <li>Canty, T. J., and C. C. Asbelle, <i>Above knee suctionsocket prosthesis. </i>Final Technical Report No. 4, Amputation Center, U.S. Naval Hospital, Oakland, Calif., 1952.</li> <li>Eberhart, Howard D., and Jim C. McKennon, <i>Suc-tion-socket suspension of the above-knee prosthesis, </i>Chapter 20 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954,</li> <li>Felix, W., <i>Praktische Erfahrungen mil der Saugpro-these, </i>Ztschr. f. orthop., 72:352 (1941).</li> <li>Gocht, H., <i>Kunstliche Glieder, </i>Berlin, 1920.</li> <li>Haddan, C. C, <i>Alignment principles, </i>paper readefore a meeting of AAAS, Sec. M., Philadelphia, 1951.</li> <li>Little, E. M., <i>A new method of fitting artificial legsockets, </i>Brit. Med. J., 2:896 (Nov. 14, 1925).</li> <li>Mazet, R., P. E. McMaster, and C. G. Hutter<i>Analysis of one hundred and twenty four suction socket wearers followed from six to fifty five months, </i>J. Bone and Joint Surg., 33A:618 (1951).</li> <li>OALMA Journal, 3(3) :36 (Spring 1949).</li> <li>Parmelee, Dubois D., U. S. Patent 37,637, Febru-ry 10, 1863.</li> <li>Pfau, Heintz, personal communication.</li> <li>Thomas, A., and C. C. Haddan, <i>Amputation pros-thesis, </i>Lippincott, Philadelphia, 1945.</li> <li>Thorndike, A., and H. D. Eberhart, <i>Suction socketprosthesis for above knee amputations, </i>Am. J. Surg., 80:727 (1950).</li> <li>Toles, Justin K., U. S. Patent 980,457, January 3,1911.</li> <li>Underwood, Ernest Walter, U. S. Patent 1,586,015,ay 25, 1926. Also, British Patent 253,729, June 24, 1926.</li> <li>University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Committee on Artificial Limbs, National Research Council, <i>The suction socket above-knee artificial leg, </i>revised edition, April 1948.</li> <li>University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, <i>The suction socket above-knee artificial leg, </i>3rd edition, April 1949.</li> <li>University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Functional considerations in fitting and alignment of the suction socket prosthesis, </i>March 1952.</li> <li>War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, <i>Report on European observations, </i>Washington, 1946.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Functional considerations in fitting and alignment of the suction socket prosthesis, March 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Aitken, G. T., and C. H. Frantz, The juvenile ampu-tee, J. Bone and Joint Surg., 35A:659 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Aitken, G. T., and C. H. Frantz, The juvenile ampu-tee, J. Bone and Joint Surg., 35A:659 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, 3rd edition, April 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, revised edition, April 1948.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Eberhart, Howard D., and Jim C. McKennon, Suc-tion-socket suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954,</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Bechtol, C. 0., The suction socket, J.A.M.A., 146:625 (1951).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, revised edition, April 1948.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Canty, T. J., and C. C. Asbelle, Above knee suctionsocket prosthesis. Final Technical Report No. 4, Amputation Center, U.S. Naval Hospital, Oakland, Calif., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Mazet, R., P. E. McMaster, and C. G. HutterAnalysis of one hundred and twenty four suction socket wearers followed from six to fifty five months, J. Bone and Joint Surg., 33A:618 (1951).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Thorndike, A., and H. D. Eberhart, Suction socketprosthesis for above knee amputations, Am. J. Surg., 80:727 (1950).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, Report on European observations, Washington, 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Felix, W., Praktische Erfahrungen mil der Saugpro-these, Ztschr. f. orthop., 72:352 (1941).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Pfau, Heintz, personal communication.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Little, E. M., A new method of fitting artificial legsockets, Brit. Med. J., 2:896 (Nov. 14, 1925).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Little, E. M., A new method of fitting artificial legsockets, Brit. Med. J., 2:896 (Nov. 14, 1925).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Little, E. M., A new method of fitting artificial legsockets, Brit. Med. J., 2:896 (Nov. 14, 1925).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Underwood, Ernest Walter, U. S. Patent 1,586,015,ay 25, 1926. Also, British Patent 253,729, June 24, 1926.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Toles, Justin K., U. S. Patent 980,457, January 3,1911.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Beacock, George, and Terence Sparham, U. S. Pat-nt 329,880, November 10, 1885.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Parmelee, Dubois D., U. S. Patent 37,637, Febru-ry 10, 1863.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, 3rd edition, April 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Eberhart, Howard D., and Jim C. McKennon, Suc-tion-socket suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954,</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Bechtol, C. 0., The suction socket, J.A.M.A., 146:625 (1951).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Atha Thomas, M.D. </b></td></tr><tr><td class="clsTextSmall">Professor of Orthopedic Surgery, University of Colorado School of Medicine, Denver; member, Lower-Extremity Technical Committee, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Chester C. Haddan </b></td></tr><tr><td class="clsTextSmall">President, Gaines Orthopedic Appliances, Inc., Denver, Colorado; Past-President, Orthopedic Appliance and Limb Manufacturers Association; member, Lower-Extremity Technical Committee, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-25.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-26.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-27.jpg Figure 4 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-28.jpg Figure 5 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-29.jpg Figure 6 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-30.jpg Figure 7 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-31.jpg Figure 8 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-32.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Status of the Above-Knee Suction Socket in the United States Creator An entity primarily responsible for making the resource Chester C. Haddan * Atha Thomas, M.D. * http://23.254.134.177/the.oandplibrary.org/files/original/d1e6d37381974afea447207e5e2dcbe4.pdf 098f55530355bceeb283da47fcc350e7 http://23.254.134.177/the.oandplibrary.org/files/original/0666e268b5cec1356b0b7c65cbfadb51.jpg 34526111ef1e2eb773fafce8d671b491 http://23.254.134.177/the.oandplibrary.org/files/original/cc9fd87e23971d5b30a0750aca41f5a3.jpg 63bf988ca05ee052c35c60bac08961ea http://23.254.134.177/the.oandplibrary.org/files/original/85d3b8a378a156a011e468adb5269da1.jpg 5bf92dc7bf504dcff53808541d517251 http://23.254.134.177/the.oandplibrary.org/files/original/227e6156213f99f0da1e50d223dee8a0.jpg 3db61f11e3ba6a4f7e34e896d5442696 http://23.254.134.177/the.oandplibrary.org/files/original/9a578284ee6908603aea1c033d17b00a.jpg e8da77889765cbddc376316eae272fe9 http://23.254.134.177/the.oandplibrary.org/files/original/2cdd2bdc87a91cc20b1bd2e2c8de8fdb.jpg bc32bfecba3ba120e95537d67188be8d http://23.254.134.177/the.oandplibrary.org/files/original/08887b5a399d3835a423a7465e92c363.jpg b49025384d7feb416227e5c087356179 http://23.254.134.177/the.oandplibrary.org/files/original/3bdc683c4fd3a3b01dd291dcc05442a7.jpg dc3f77f6a7dc6e8f10d15f57a79b4bd5 http://23.254.134.177/the.oandplibrary.org/files/original/baa8c678a811a389abfecf5c63ec394a.jpg fadb2fb86dfab8eae20656c2668c41bf http://23.254.134.177/the.oandplibrary.org/files/original/8af81fcc4e2a1200c4b3ebacefd7dcdc.jpg 71e21b708994bac32da23d1191b72f33 http://23.254.134.177/the.oandplibrary.org/files/original/df8f5de5f6e51604721fe6c8eac18d00.jpg daf7122151ce6dea1bd294319637ca83 http://23.254.134.177/the.oandplibrary.org/files/original/fc36c0b09aa6f3af1a634440b2895b0c.jpg 737f8f6f58dd6ce0aa0bafb5bc333f08 http://23.254.134.177/the.oandplibrary.org/files/original/f23de5b7227d292fd049b5c53370ad5e.jpg 322c5646d98f492326ba9b2ad1189f10 http://23.254.134.177/the.oandplibrary.org/files/original/12807becbc364793ce64139f3ed19ca0.jpg 76b2ffd63899936900e983217326addb http://23.254.134.177/the.oandplibrary.org/files/original/c7c004b4cacc9f9a708a3486dc137efa.jpg d1ecb9180a51ca39aec2e6a1a746c16d http://23.254.134.177/the.oandplibrary.org/files/original/0b96ee4588a2a50ba8ae866ee38bd212.jpg 9ce093f92ed02602e5a59abd344d72a8 http://23.254.134.177/the.oandplibrary.org/files/original/6dca045beee9acf9d8ca40d95e842f26.jpg 261149ab340dc088401ee1852c05995d http://23.254.134.177/the.oandplibrary.org/files/original/1dfabfd667493e59ce35c164c328039a.jpg d22c081e2b4704fdbf8a951a6c62136a http://23.254.134.177/the.oandplibrary.org/files/original/70bc99ba51deb9adc1649fc859b83790.jpg 1315b524e4b6252efd9c727af36bddc5 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Artificial Limbs: A Review of Current Developments Description An account of the resource The foundation of modern prosthetics can be directly traced to the coordinated efforts of the National Academy of Sciences under the various artificial limbs committees after the Second World War. America, at its height of post war efficiency and engineering acumen, set about to solve the burgeoning problem of amputees swelling an infrastructure of prosthetic delivery that was outmoded, outdated and unprepared. Artificial Limbs: A Review of Current Developments was an industry update of these research efforts and was published thirty-three times, spanning the years 1954 to 1972. DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_01_015.pdf Year 1954 Volume 1 Issue 1 Page Number(s) 15 - 24 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_01_015.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_01_015.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Upper-Extremity Prosthetics Armamentarium</h2> <h5>Maurice J. Fletcher, Lt. Col., USA (MSC) <a style="text-decoration:none;">*</a><br /></h5> <p>The word "armamentarium" is defined as "the equipment, instruments, apparatus, or paraphernalia used by the practitioner of medicine." As applied to artificial limbs, it refers to the array of components necessary for the prescription fitting of prostheses in relationship to the site of amputation.</p> <p>In the prosthetics armamentarium, it is desirable that a complete range of components be available in order to provide satisfactory prostheses for all sites of upper-extremity amputations. A few gaps still remain in the present armamentarium of devices, but such temporary inadequacies are in the area of special cases, such as in transcarpal and fore-quarter amputations and in children's prostheses. The few remaining gaps are being rapidly filled, and supplementary components for fortifying the present armamentarium, such as additional hand sizes, are under consideration at the present time. The fact that devices now exist in each category of necessary arm components does not necessarily mean that they are the ultimate. They might even be interim devices, but they do permit prescription fitting of arm prostheses to a degree of efficiency heretofore unattainable. As a device is made available for each category of the armamentarium, improve-ments are attempted in these individual devices to increase their efficiency and useful-ness to the amputee. New models and methods of operation are being exploited in the hope of providing, eventually, even more efficient restorative prostheses. It is the purpose here to provide brief descriptions of the functions provided by the basic units of the present upper-extremity armamentarium. For a more detailed treatment of the devices and the philosophy underlying their design, reference may be had to <i>Human Limbs and Their Substitutes</i> (McGraw-Hill, in press) and to the <i>Manual of Upper-Extremity Prosthetics</i> (University of California at Los Angeles, 1952).</p> <h3>Terminal Devices</h3> <h4>APRL Model 4c Voluntary-Closing Hand and Cosmetic Glove</h4> <p>As the name implies, in the APRL voluntary-closing hand (<b>Fig. 1</b>) prehension force is obtained voluntarily by the amputee. Tension applied to a control cable closes the index and middle fingers against the thumb in a three-jaw-chuck pattern. These one-piece, hollow, metal fingers move through a 1 1/2-in. range, but since the thumb tip can be set in either of two positions 1 1/2-in. apart, objects up to 3 in. wide can be grasped. Finger angles are such that a grasped object is forced inward toward the palm. Security of grasp is further increased by the use of felt pads on the inner surfaces of the fingers and thumb. Any degree of prehensile force up to about 35 lb. can be obtained. The ring and little fingers are of cast latex and are attached so that they roughly conform to the shape of the object being handled.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. APRL model 4C voluntary-closing hand. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The actuating mechanism, shown in <b>Fig. 1</b>, consists of a cam-quadrant type of clutch which automatically locks the index finger and middle finger in place when tension in the control cable is released. Reapplication of tension automatically unlocks the mechanism, and a spring forces the fingers to the fully open position, at which point the mechanism is recocked and ready for another cycle. Backlash is eliminated in the lever system by incorporation of an auxiliary spring-and-lever system. In fact a certain amount of frontlash may be introduced into the system. The voluntary-closing type of mechanism permits fuller utilization of the potentialities of a cineplasty tunnel than any device heretofore available.</p> <p>The APRL hand is covered by a cast polyvinyl chloride glove of extremely natural appearance (<b>Fig. 2</b>). Developed especially for the APRL hand, it has been designed with particular regard to eliminating as much as possible the resistance to operation of the fingers. In order to reduce the necessarily high cost of coloring each glove on a custom basis, after careful experimentation six Caucasian and six Negroid shades have been provided. They satisfy the majority of amputees.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. APRL model 4C voluntary-closing hanc covered with APRL cosmetic glove. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>APRL Voluntary-Closing Hook</h4> <p>The APRL voluntary-closing hook (<b>Fig. 3</b>) contains essentially the same mechanism employed in the APRL hand. One hook finger is closed against a stationary hook finger, the two designed to accommodate objects up to 3 in. in size. A control button permits the engagement of a stop to limit hook opening to 1 1/2-in. so that the hook finger does not have to move through its full range before recocking of the locking mechanism takes place. Moreover, locking action in the l 1/2-in. open position can be eliminated at the will of the amputee when this is desired for repetitive tasks. The rubber-lined, lyre-shaped, aluminum hook fingers are specially designed to provide maximum function. The smooth exterior surfaces present the least amount of friction to aid in entering pockets, while the rubber linings provide friction to aid in handling objects. Duckbill finger tips lend facility in handling small objects. By removing the fingers and reinstalling them 180 deg. from the original position, a right hook can quickly be converted to a left, or vice versa.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. APRL voluntary-closing hook in open and closed positions. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Northrop-Sierra Voluntary-Opening Two-Load Hook</h4> <p>In the Northrop-Sierra voluntary-opening two-load hook (<b>Fig. 4</b>), designed primarily for bilateral amputees, tension on the control cable causes one hook finger to open against a spring force, which in turn provides prehensile force between the hook fingers when there is no tension on the control cable. The spring force is provided by two identical coil-type springs. When both are engaged, a prehensile force of approximately 7 lb. is available at the ringer tips. When only one spring is engaged, 3 1/2 lb. of force are available.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Northrop-Sierra voluntary-opening two-load hook. Schematic diagram (above) shows arrangement of hook thumb and enclosed coil springs. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The lyre-shaped fingers are the same as nose used in the APRL hook.</p> <h4>Dorrance Voluntary-Opening Hook</h4> <p>Prehension in the Dorrance hooks is provided by rubber bands which force the hook fingers together. Adjustment of the prehension force is accomplished by adding or removing bands. Hook fingers are available in many different sizes and shapes of both steel and aluminum. Dorrance hooks offer the extreme in ruggedness and simplicity. The model known as Utility #5, shown in <b>Fig. 5</b>, is very popular.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Dorrance #5 utility hook. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Length Adapters and Fairings</h4> <p>To provide a constant effective prosthetic length when terminal devices of different lengths are interchanged, as in the case of the APRL hook and hand, length adapters and fairings (<b>Fig. 6</b>) have been made available. The length adapter is simply a stud with male threads at one end and female threads at the other so that it may be inserted between terminal device and wrist unit. Also available is a plastic fairing which covers the length adapter and provides a smooth transition between the oval end section of the APRL hand and the circular section of the wrist unit.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Wrist fairing and length adapter for APRL model 4C hand. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Wrist Units</h3> <h4>Manual Friction-Type Wrist Units</h4> <p>Female threads receive the stud of the terminal device, the wrist-flexion unit, or the length adapter to permit attachment of these units to the arm. Compression of a rubber washer between the terminal device and the wrist unit provides sufficient friction to permit a certain amount of adjustment in the rotation of the terminal device without slippage under average operating conditions. SierraEngineering Company supplies the friction-type wrist unit in one size, 2 in. in diameter, suitable for the average adult male, while Hosmer supplies essentially the same unit in three sizes-2 in. in diameter for the average male, 1 3/4-in. in diameter for women and large children, and 1 3/8-in. in diameter for small children. All these units are designed to facilitate incorporation into plastic-laminate arms.</p> <h4>Manual Lock-Type Wrist Units</h4> <p><b>Hosmer F-M Wrist Unit</b></p> <p>Rapid interchange of terminal devices and positive locking of the terminal device in the pronation-supination plane are afforded by the Hosmer F-M (Fletcher-Motis) unit (<b>Fig. 7</b>). A serrated steel adapter with an annular groove is attached to the stud of the terminal device by threads. To connect the terminal device to the arm, the stud is forced into the wrist unit until a locking yoke and gear segment are engaged. To adjust the amount of rotation of the terminal device, the control button is depressed to the first detent, which releases the gear lock and permits rotation since the terminal device is retained by engagement of the locking yoke in the annular groove on the adapter. Further depression of the control button disengages the locking yoke and permits removal of the terminal device. A coiled compression spring attached to the end of the adapter facilitates operation of the F-M unit.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Hosmer F-M wrist unit, with exploded view showing arrangement of parts. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Hosmer Quick-Change Wrist Unit</b></p> <p>The Hosmer quick-change wrist unit provides essentially the same function as the F-M unit but is not quite as rugged and is more difficult to operate in some instances. The adapter and terminal device are released by rotating the forward portion of the wrist section, which disengages a detent-type lock. The quick-change unit is lighter in weight than the F-M unit and is used when weight is an important factor.</p> <h4>Northrop-Sierra Wrist-Flexion Device</h4> <p>The Northrop-Sierra Model B wrist-flexion device (<b>Fig. 8</b>), when used, is installed between the terminal device and the wrist unit. Consisting of a simple detent-type lock with three positions, it permits manual positioning and locking of the terminal device at 0, 25, and 50 deg. of flexion. Depression of a control button at the base of the unit disengages the lock to permit a change in the amount of wrist flexion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Northrop-Sierra model B wrist-flexion device. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Bilateral amputees find this device especially useful for working in areas close to the face and body, and some unilateral amputees have found it helpful in certain tasks necessary to their particular occupation.</p> <p>The APRL-Sierra below-elbow wrist-rotation unit (<b>Fig. 9</b>) has been developed to step up or multiply the residual pronation-supination of below-elbow amputees. A given rotation of the inner socket by the stump produces, through a planetary gear system, 2.3 times that amount of rotation in the terminal device. A locking mechanism, actuated by relative motion between the forearm and upper arm, and by which the unit is unlocked upon full extension of the forearm and locked upon flexion, is provided when desired.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. APRL-sierra wrist-rotation step-up unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Below-elbow amputees with little or no pronation-supination and nearly conical stumps have been fitted successfully with this unit, since rotation of the inner socket can be produced by rotating the humerus. In this case the lock must be provided so the stump may rotate relative to the socket upon flexion.</p> <h3>Below-Elbow Hinges</h3> <h4>Robin-Aids Flexible Hinges</h4> <p>Where no wrist-rotation step-up unit is used, the Robin-Aids flexible hinge (<b>Fig. 10</b>, bottom) is employed between the socket and arm cuff or triceps pad to impart axial stability to the entire prosthesis and yet to permit maximum use of the residual pronation-supination. The Robin-Aids hinge consists of a metal cable covered with a wrapped-wire housing and having flat terminal plates designed for firm anchoring in the plastic-laminate forearm and for fastening to the upper-arm cuff.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Below-elbow hinges. Top, Sierra insert hinge; center, Hosmer variable-ratio step-up hinge; bottom, Robin-Aids flexible hinge. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Leather-Strap Hinges</h4> <p>Nylon-coated leather straps may be fabricated in the shop and used in lieu of the Robin-Aids flexible hinge.</p> <h4>Single-Axis Hinges</h4> <p>Metal single-axis hinges specially designed for plastic fabrication are available from several manufacturers. This type of hinge is used where maximum stability is required, such as in short below-elbow cases and in heavy-duty arms.</p> <h4>Polycentric Hinges</h4> <p>Polycentric hinges may be substituted for the single-axis hinges. They are preferred by many prosthetists because less care is required in location to give the same amount of comfort to the patient. Instead of a single axis, two hinge points are provided in this unit, thereby exerting less pressure on the stump through the socket when the forearm is flexed and when some slight misalignment exists.</p> <h4>Northrop-Sierra Insert Hinges</h4> <p>Insert-type hinges might be classified as semiflexible hinges, since they provide a degree of stability somewhere between that offered by the flexible Robin-Aids hinge or the leather strap and the solid steel hinges. They are generally used on medium below-elbow prostheses where sufficient stability cannot be obtained with the flexible hinge but where the stump is long enough to provide sufficient stability so that the metal-strap hinges are unnecessary. Insert hinges are installed in "ears" on the distal end of a leather arm cuff so that the cuff may be hinged about the proximal end of the forearm socket. The method of assembly is illustrated in <b>Fig. 10</b>, top.</p> <h4>Step-Up Hinges</h4> <p><b>Hosmer MA-100 Hinges</b></p> <p>The Hosmer MA-100 step-up hinge (<b>Fig. 11</b>) was developed to permit full flexion of the prosthetic forearm when flexion of the stump is limited to 90 deg. or more. Step-up action is provided through two gears so that flexion of the stump 90 deg. results in 135 deg. of forearm flexion. The multiplication in motion results in a corresponding decrease in torque about the prosthetic forearm, and often an assistive lift is required for forearm flexion. This is accomplished by employing one of the above-elbow harnessing systems.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Hosmer MA-100 step-up hinge. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Hosmer Variable-Ratio Step-Up Hinge</b></p> <p>The Hosmer variable-ratio hinge (<b>Fig. 10</b>, center) provides approximately the same function as the MA-100 hinge but is usually preferred because the changing ratio of stump action to forearm action provided by the sliding lever system results in easier operation. This ratio in the fully extended position is 1:1.8, increases to 1:1.3 when the forearm is flexed 90 deg., and decreases to 1:1.8 at the 135-deg. position. Furthermore, because of the sliding action of the hinge, the stump does not extend as far below the forearm in flexion as in the case of the MA-100 hinge, a fact which in many instances eliminates the necessity for enlarging the sleeve of the garment covering the artificial limb.</p> <h4>Robin-Aids Stump-Actuated Elbow Lock</h4> <p>The Robin-Aids elbow (<b>Fig. 12</b>) was designed for short below-elbow cases where flexion of the forearm is limited to less than 90 deg. or for those cases where the torque about the elbow is too weak to offer sufficient stability. Full extension of the stump forces a lever into a detent on a segment about the elbow axis, locking the forearm in flexion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Robin-Aids stump-actuated elbow lock. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Elbow Units for Above-Elbow Cases</h3> <h4>Northrop Model C Elbow</h4> <p>An alternating-type control for the locking mechanism is the prominent feature of the Northrop Model C elbow (<b>Fig. 13</b>). The first pull on the control cable drops a lever into a detent on a sector, resulting in a positive locking action about the elbow axis. The next pull on the control cable removes the locking level from the detent, thereby making the forearm free to rotate about the elbow axis. Eleven locking positions are available. In the average above-elbow case, the control cable is generally actuated by humeral extension, leaving the other hand or prosthesis, as the case may be, free. The excursion required, about 3/8-in., is so slight that after some practice most amputees are able to operate the locking unit with a motion that goes unnoticed.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Northrop model C elbow unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Attachment to the upper arm is afforded by a single bolt in a turntable arrangement which permits the amputee to select at will the plane of forearm flexion and extension. A specially designed saddle for lamination into plastic is used for attaching the unit to the forearm.</p> <p>The Northrop elbow is presently available in one size only, 3 in. in diameter.</p> <h4>Hosmer Elbow Unit</h4> <p>Locking action of the Hosmer elbow unit (<b>Fig. 14</b>) is accomplished by permitting two tightly wound coil springs to wrap themselves around a shaft. Such an arrangement permits an infinite number of locking positions. Attachment to the arm and forearm and operation by the amputee follows the same pattern as in the case of the Northrop Model C.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Hosmer elbow unit, without turntable or forearm saddle attachments. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The Hosmer unit is available in two sizes, approximately 2 and 3 in. in diameter. Recently Hosmer has added to its line a smaller elbow designed for children.</p> <h4>Elbow-Disarticulation Prostheses</h4> <p>The APRL-Sierra side-locking elbow hinge (<b>Fig. 15</b>) was developed expressly for elbow disarticulation and for very long above-elbow cases where insufficient room exists for the fully enclosed type of elbow unit. An alternating-type locking unit on the outside of the inner hinges permits locking and unlocking of the elbow by humeral extension, as in the case of the standard above-elbow amputee. This unit may also be used on short below-elbow cases where use of the Robin-Aids forearm-actuated lock is not feasible.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. APRL-Sierra outside-locking elbow hinge. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Control Systems</h3> <p>For terminal-device operation and forearm control, Bowden-type controls, along with such parts as retainer and terminal fittings specially designed for use on artificial arms, are available from a number of sources for both the harness and cineplasty applications. This type of control system (<b>Fig. 16</b>), consisting of high-strength woven wire cable enclosed in a wrapped-wire housing, has proven infinitely more satisfactory than anything else used to date, mainly because of its resistance to stretching and its relatively high power-transmission efficiency.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Bowden-type control cable and attachments. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Below-Elbow Biceps Cineplasty Control Systems</h4> <p>Special control-system kits are available for below-elbow amputees with biceps cineplasty tunnels. The twin-cable system (<b>Fig. 17</b>), often referred to as the UCLA system, is available with either straight or ox-bow acrylic tunnel pins reinforced with a copper core. Provisions have been made for quickly attaching or removing the control cables with respect to the pin. Rapid selection of the initial tension on the muscle tunnel is made possible by the incorporation of a turnbuckle type of unit which controls the effective cable length. A single-cable system using a sheave-type equalizer and known as the APRL system is also available (<b>Fig. 18</b>). Cable-tension adjust-ment is provided by a single cable-length ad-juster installed between the sheave and the terminal device. Each of these systems is considered merely as a replacement for the shoulder-operated control system, since all other portions of the prosthesis are the same whether operated from the shoulder or from the muscle tunnel.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Twin-cable control system for below-elbow biceps cineplasty. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. APRL single-cable control system for below-elbow biceps cineplasty. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Nudge Control</h4> <p>For the shoulder-disarticulation case, in which it is impossible to provide from shoulder movement force and excursion necessary to operate the Northrop Model C or Hosmer elbow, there is available the Nudge Control, which permits the elbow lock to be controlled by chin movement. The nudge control (<b>Fig. 19</b>) is especially useful for bilateral shoulder-disarticulation cases.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Nudge control for operation of elbow lock in shoulder-disarticulation case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Conclusion</h3> <p>This, briefly, completes the basic items of the armamentarium of devices available for prescription fitting relative to sites of amputation. There are, however, many supplementary devices, available in the field and well known to the industry, which are used with the devices described.</p> <p>With the existence of the many devices now on the market, it is possible to custom-build prostheses to rare or irregular cases, and to increase the number of items in the armamentarium makes such custom-building more feasible. A number of improvements are constantly being made in the research establishments on existing devices, and these, of course, will be fed into the industry as they are developed to the point where they are considered commercially marketable and necessary items of the armamentarium.</p> <p>Needless to say, each existing armamentarium item is being accorded careful study by the various research groups in an effort to increase efficiency and utility. Many new devices are now in the research stage; some are approaching the transitional period; others are known to be necessary and steps have been taken to prove such devices and to production-engineer them to the point where they will be marketable from the standpoint of increased efficiency, decreased maintenance, and economics. To mention a few items, the goals sought include improved terminal devices, both hand and hook; the cosmetic glove; improved elbow-lock mechanisms and elbow mechanisms themselves; the cosmetic approach to the entire prosthesis, up to and including the shoulder; and improvement of the over-all control systems to make them more efficient and more durable than are those now available. Already existent items of the armamentarium, such as harnesses, harness materials, and fittings, have been passed by purposely in this discussion, since they are well known to the industry. The use of some of the new synthetic materials, such as nylon, orlon, and dacron webbing, is standard practice in most limbshops. These new webbings are perspiration-resistant and possess adequate strength to meet the requirements of modern prosthetic devices. New webbings of various types and structures are constantly under study and test. Steady improvement has been made in the process of weaving these materials to prevent stretching.</p> <p>It is hoped that, through the gradual improvement of all items of the armamentarium, the comfort and utility of upperextremity prostheses will be increased to the point where an amputee will continuously wear and use a prosthetic device and will no longer be considered by society as a handicapped person. It may then be realized that the amputee can perform his job as well as can the normal person. The prescription fitting of each individual case may become so precise and so efficient that there will no longer be a question as to the value of the prosthesis to the amputee in returning to his place in society. The continuous development of new items for the armamentarium, and improvement in items existing in the present armamentarium, will make available to the prosthetist a variety of components permitting the satisfactory fitting of each amputee in conformance to his own individual pattern of life and will permit the new amputee to resume many jobs without loss in efficiency.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Maurice J. Fletcher, Lt. Col., USA (MSC) </b></td></tr><tr><td class="clsTextSmall">Director, Army Prosthetics Research Laboratory, Walter Reed Army Hospital; member, Upper-Extremity Technical Committee, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-003.jpg Figure 4 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-004.jpg Figure 5 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-005.jpg Figure 6 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-006.jpg Figure 7 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-007.jpg Figure 8 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-008.jpg Figure 9 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-009.jpg Figure 10 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-010.jpg Figure 11 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-011.jpg Figure 12 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-012.jpg Figure 13 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-013.jpg Figure 14 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-014.jpg Figure 15 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-015.jpg Figure 16 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-016.jpg Figure 17 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-017.jpg Figure 18 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-018.jpg Figure 19 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-019.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Upper-Extremity Prosthetics Armamentarium Creator An entity primarily responsible for making the resource Maurice J. Fletcher, Lt. Col., USA (MSC) * http://23.254.134.177/the.oandplibrary.org/files/original/a266195253e839079dde8975e42d8087.pdf c594dc2a840e8199425e981f66117aec http://23.254.134.177/the.oandplibrary.org/files/original/7f05ccb8586557cc7b0183cdafe725aa.jpg 63616a4cd1eb71d495e9a1972785cec8 http://23.254.134.177/the.oandplibrary.org/files/original/34baa4d0c9f50173d122a1fc9f03237c.jpg 17ba15b4ce63bb3be5f4808d51a3ea39 http://23.254.134.177/the.oandplibrary.org/files/original/1c09d56923228c1e807060fe9577bb4b.jpg c44f04d953c3e6e8897a4cd1e4634223 http://23.254.134.177/the.oandplibrary.org/files/original/2cc047309ed120bc63aa3b83a308d3fb.jpg 725142c35120be7cfc9eeda3881c00aa http://23.254.134.177/the.oandplibrary.org/files/original/616d272e127cadd9ddfd4dfa00a6ada9.jpg aecf21517233b63d0e773199af09d87e http://23.254.134.177/the.oandplibrary.org/files/original/d91b0ee4dc2e5f1b5d29d240c9cc5019.jpg e4c5b9f5516409a4f2feb3f7440c342e http://23.254.134.177/the.oandplibrary.org/files/original/ab13b0cc1721ab18b7969a2d89777bff.jpg 6dda6cc8254a02d70975f70817cf72de Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Artificial Limbs: A Review of Current Developments Description An account of the resource The foundation of modern prosthetics can be directly traced to the coordinated efforts of the National Academy of Sciences under the various artificial limbs committees after the Second World War. America, at its height of post war efficiency and engineering acumen, set about to solve the burgeoning problem of amputees swelling an infrastructure of prosthetic delivery that was outmoded, outdated and unprepared. Artificial Limbs: A Review of Current Developments was an industry update of these research efforts and was published thirty-three times, spanning the years 1954 to 1972. DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_01_025.pdf Year 1954 Volume 1 Issue 1 Page Number(s) 25 - 29 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_01_025.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_01_025.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Artificial Arm Checkout Procedures</h2> <h5>Lester Carlye, M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>The story of civilization's slow but steady march of progress from the days of the Roman Empire, through the Industrial Age, and into the present Technological Age is the story of measurements. The standardization of such common units as the inch and the foot required thousands of years, but once that was accomplished, it paved the way for an almost unbelievably rapid technological advance. One need only compare the developments that have occurred since the metric system was devised in 1793 with those of all the preceding centuries. Replacement of the craftsman's personal art with clearly understood, standard methods has enhanced the lives of all of us my making simple necessities, as well as more luxurious items, available in more adequate quantities and at more reasonable prices.</p> <p>Just as mankind in general profited from measurement standardization, so can those who have lost a limb or limbs and those who devote themselves to replacing lost members. Every person concerned with the manufacture and fitting of a prosthesis-whether he be a prothetist, amputee, trainer, or representative of the paying agency-has felt the need for some set of standards to determine the worth of the prosthesis. Development of such a "yardstick of performance" was just as necessary to the advancement of the prosthetics industry as was the standardization of the inch to the Industrial Age. The so-called "checkout procedures" provide the prosthetist and other members of the clinic team with an invaluable tool for measuring the biomechanical effectiveness of all upper-extremity prostheses. Such questions as "Does this prosthesis fit as well as your last one?" or "Can you work it?" receive only a vague, often uncertain, answer, but such criteria are too often accepted as a measure of performance. One of the first steps in establishing a set of standards is to determine which variable factors can be measured accurately. In upper-extremity prosthetics, some of the measurable factors are ranges of motion with and without the prosthesis, control-system efficiencies, forces necessary to flex the forearm, live-lift of the forearm, socket stability, movement of the terminal device when locking the elbow, plus several others. Once the factors are determined, a test program must be set up and carried out. The results of such a test must first be analyzed, then a trial set of standards must be established, and finally the standards must be laboratory-tested on as great a number of amputee subjects as possible.</p> <p>To this end, a test station was established, and 29 amputees, selected at random from a mailing list, were tested. Approximately 30 tests were applied to these amputees and their prostheses. By combining the test data with research and practical experience, a preliminary set of liberal standards was drawn up. The standards were then applied to more than 70 amputees during the two-year existence of the Case Study Program at the University of California at Los Angeles. Certain modifications and refinements in the tests were made until the procedure attained present form.</p> <p>One of the prime requirements in establishing the tests was that their application be kept simple, with respect both to the equipment and to the procedures to be followed. Sufficient accuracy of measurement can be obtained with a ruler and a spring scale, and the test standards are liberal enough to allow minor inaccuracies without rejecting the prosthesis. The most important concern is, first, that all tests be applied in a similar manner and, second, that the results be compared to a universally acceptable standard.</p> <p>The tests and standards may be conveniently listed in three groups: general tests, applicable to all types of prostheses; tests for below-elbow prostheses; and tests for above-elbow prostheses.<a style="text-decoration:none;">*</a></p> <p>All tests should be performed with the amputee wearing his prosthesis. In the case of a bilateral amputee, each side should be tested separately, but the amputee should have almost complete independence of action on each side while wearing both prostheses.</p> <h3>General Tests</h3> <h4>Test No.1-Compression Fit and Comfort</h4> <p><i>Test</i>: Flex the forearm to 90 deg. (lock if AE). Push the prosthesis onto the stump while the wearer resists the push (<b>Fig. 1</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Test for compression fit and comfort. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Standard</i>: The amputee should feel no undue discomfort or pain when the prosthesis is forced onto the stump.</p> <h4>Test No. 2-Tension Stability</h4> <p><i>Test</i>: Straighten the prosthesis at the side (<b>Fig. 2</b>). Hook the scale over the terminal device and apply a force of 50 lb. straight down. (A force of 30 lb. is sufficient for children.) Standard: The prosthesis should not slip more than 1 in. in relation to the stump, and no part of the prosthesis or harness should fail when a 50-lb. distal load is applied.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Test for tension stability. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Test No. 3-Hook-Opening Facility (Normal Use)</h4> <p><i>Test</i>: Flex the forearm to 90 deg. (lock if AE). Have the wearer actively operate the terminal device.</p> <p><i>Standard</i>: The wearer should be able to obtain full range of terminal-device operation actively with the forearm flexed to 90 deg.</p> <h4>Test No.4-Hook-Opening Facility (At Mouth And Perineum)</h4> <p><i>Test</i>: Flex the forearm so the terminal device is near the mouth (lock if AE). Have the wearer actively operate the terminal device. Repeat this procedure with the terminal device near the perineum.</p> <p><i>Standard</i>: The wearer should be able to obtain at least 70 percent of full range of terminal-device operation actively at the mouth and perineum.</p> <h4>Test No. 5-Control-System Efficiency</h4> <p><i>Test</i>: a) Disconnect the control cable from the terminal device, and attach the scale to hook-operating lever or hand-operating cable (<b>Fig. 3</b>a). Place a 3/4-in. block between the fingers and pull until the block slips out of a voluntary-opening hook or until the fingers of a voluntary-closing hook or hand just close on the block. Note the force at this instant.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Test for control-system efficiency. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>b) Reconnect the control cable to the terminal device, and apply the scale to the T-bar. or terminal, at the other end of the control cable. Pull along the line of the harness unti. the block slips or the fingers touch, as before (<b>Fig. 3</b>b). Note the force at the instant this occurs.</p> <p>c) Multiply the force measured at the terminal device by 100. Then divide by the fora measured at the cable terminal as in the following formula:</p> <blockquote><p>Efficiency = (Force measured at terminal devices X 100)/(Force measured at cable terminal)</p> </blockquote> <p><i>Standard</i>: The control-system efficiency should be at least 70 percent.</p> <h3>Below-Elbow and Below-Elbow Biceps-Cineplasty Tests</h3> <p>All of the following tests apply to the conventional below-elbow prosthesis and to the below-elbow biceps-cineplasty prosthesis.</p> <h4>Test No. 1-Forearm Flexion</h4> <p><i>Test</i>: Compare the amputee's maximum range of forearm flexion with and without the prosthesis.</p> <p><i>Standard</i>: Active flexion with the prosthesis on should be as great as active flexion without the prosthesis.</p> <h4>Test No. 2-Forearm Rotation<a style="text-decoration:none;">*</a></h4> <p><i>Test</i>: Compare the amputee's maximum range of forearm rotation (extreme pronation the extreme supination) with and without the prosthesis (<b>Fig. 4</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Test for forearm rotation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Standard</i>: Active rotation with the pros-thesis on should be at least half that obtained without the prosthesis.</p> <h3>Above-Elbow and Shoulder-Disarticulation Tests</h3> <p>All of the following tests apply to the above-elbow prosthesis, and most of them apply to the shoulder-disarticulation prosthesis. Those which do not apply to the shoulder-disarticulation case are marked with an asterisk.</p> <h4>Test No. 1-Ranges Of Stump Motion*</h4> <p><i>Test</i>: Have the amputee straighten the prosthesis and lock the elbow. Then move his stump and prosthesis through the maximum ranges of flexion, extension, elevation, and rotation.</p> <p><i>Standard</i>: The amputee should be able to satisfy the following minimum requirements while wearing the prosthesis: flexion, 90 deg.; extension, 30 deg.; elevation, 90 deg.; rotation, 45 deg.</p> <h4>Test No. 2-Range of Forearm Flexion</h4> <p><i>Test</i>: Compare the amputee's maximum active range of prosthetic forearm flexion with the maximum manual range. Note the amount of initial forearm flexion built into the prosthesis.</p> <p><i>Standard</i>: The amputee should be able to flex actively to 135 deg. of forearm flexion, no more than 10 deg. of which should be due to initial flexion.</p> <h4>Test No. 3-Humeral Flexion Required to Flex Forearm*</h4> <p><i>Test</i>: Have the amputee flex the prosthetic forearm actively through its entire range using humeral flexion, and note the degrees of flexion of the humerus required to do so.</p> <p><i>Standard</i>: Humeral flexion required to flex the prosthetic forearm fully should not exceed 45 deg.</p> <h4>Test No. 4-Force Required to Flex Forearm</h4> <p><i>Test</i>: Tape the fingers of the terminal device closed and unlock the elbow. Insert the spring scale through the cable attachment, and flex the forearm to 90 deg. while holding the socket stationary. Pull along the normal line of the cable until further flexion of the forearm just starts, and note the force.</p> <p><i>Standard</i>: The force required to start flexion of the forearm from 90 deg. should not exceed 10 lb.</p> <h4>Test No. 5-Live-Lift</h4> <p><i>Test</i>: Tape the fingers of the terminal device closed and unlock the elbow. Hook the spring scale over the prosthesis at a distance of 12 in. from the elbow pivot using a leather strap if necessary (<b>Fig. 5</b>). Flex the forearm to 90 deg., and have the amputee actively resist while applying a straight-down pull on the scale. Note the scale reading when the amputee can no longer completely resist the pull and the forearm slips below 90 deg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Test for live-lift. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Standard</i>: The amputee should be able to resist actively a downward force of at least 3 lb. located 12 in. from the elbow center when the forearm is flexed to 90 deg.</p> <h4>Test No. 6-Involuntary Operation of the Elbow Lock*</h4> <p><i>Test</i>: Face the amputee and have him abduct the prosthesis 60 deg. Note whether or not the elbow lock operates. Then have him walk a short distance swinging the prosthesis in a normal manner, and note whether the elbow lock operates involuntarily or not.</p> <p><i>Standard</i>: The elbow lock should not operate involuntarily when the prosthesis is abducted 60 deg. nor during normal walking. In addition, a natural-appearing arm swing should be exhibited while walking.</p> <h4>Test No. 7-Movement of Terminal Device When Locking Elbow*</h4> <p><i>Test</i>: Have the amputee actively flex the forearm to 90 deg. Then have him actively lock the elbow. Note the movement of the terminal device as the elbow is locked.</p> <p><i>Standard</i>: The terminal device should not move more than 6 in. during active operation of the elbow lock when the forearm is flexed to 90 deg. (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Test for motion of terminal device when locking elbow. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Test No. 8-Socket Stability During Arm Rotation*</h4> <p><i>Test</i>: Flex the forearm to 90 deg. and lock the elbow. Have the amputee abduct the prosthesis 60 deg. and rotate his stump and prosthesis. Note any slippage of the socket about the stump.</p> <p><i>Standard</i>: The amputee should be able to control the prosthesis during arm rotation, and there should be no slippage of the socket about the stump (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Test for socket stability during arm rotation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Test No. 9-Stability of Socket Against Torque*</h4> <p><i>Test</i>: Flex the forearm to 90 deg. and lock the elbow. Hook the scale over the prosthesis at a distance of 12 in. from the elbow center, using a leather strap if necessary. Have the amputee resist while pull is applied, first laterally, then medially, on the socket with a force of 2 lb. Note any slippage of the socket about the stump, or of the turntable, which may occur.</p> <p><i>Standard</i>: The amputee should be able to resist both lateral and medial pulls of 2 lb. located 12 in. from the elbow center, and the turntable should not turn with this force.</p> <h3>Conclusion</h3> <p>That the test procedure has reached a sufficient degree of refinement to be used successfully in the field is evidenced by its widespread adoption. Such agencies as the United States Veterans Administration, the State Departments of Vocational Rehabilitation of California and Illinois, and others include fulfillment of the standards as a contract stipulation. It must, however, be borne in mind that these test procedures are not to be considered as the final answer. Additions, revisions, and general improvements constitute a never-ending project in the field of prosthetics evaluation.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">This test need not be applied when the stump is only half the normal forearm length or less.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">These tests and standards may not apply in cases where atrophy, bone blocks, loss of muscles, and the like are in evidence.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Lester Carlye, M.E. </b></td></tr><tr><td class="clsTextSmall">Engineer, Artificial Limbs Project, University of California, Los Angeles.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-003.jpg Figure 4 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-004.jpg Figure 5 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-005.jpg Figure 6 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-006.jpg Figure 7 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-007.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Artificial Arm Checkout Procedures Creator An entity primarily responsible for making the resource Lester Carlye, M.E. * http://23.254.134.177/the.oandplibrary.org/files/original/0713435cdc66e5d09afab0bd217b4263.pdf 11665dec8ad20d2b3e67e255dcf4c5e6 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Artificial Limbs: A Review of Current Developments Description An account of the resource The foundation of modern prosthetics can be directly traced to the coordinated efforts of the National Academy of Sciences under the various artificial limbs committees after the Second World War. America, at its height of post war efficiency and engineering acumen, set about to solve the burgeoning problem of amputees swelling an infrastructure of prosthetic delivery that was outmoded, outdated and unprepared. Artificial Limbs: A Review of Current Developments was an industry update of these research efforts and was published thirty-three times, spanning the years 1954 to 1972. DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_02_001.pdf Year 1955 Volume 2 Issue 2 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_02_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Engineering Hope of the Handless</h2> <h5>Eugene F. Murphy, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The human hand, with its elaborate control system centered in the brain, is doubtless the most widely versatile machine that has ever existed anywhere. Its notorious deficiency lies in its persistent inability to create a similar machine as versatile as itself. This circumstance accounts for the fact that, while there has been from earliest times a great need for hand replacements, all attempts to produce successful hand substitutes have thus far ended in only a rather crude imitation of a very few of the many attributes of the living counterpart. For want of complete knowledge of the natural hand-brain complex, and of the ingenuity requisite even to the most modest simulation of the normal hand, artificial hands have always resembled the natural model in a superficial way only. Voltaire is said to have remarked that Newton, with all his science, did not know how his own hand functioned.</p> <p>But the science of Newton, basic as it was, is itself remote from the advanced technology of our own day. Failure in hand prosthetics, though owing in part to the difficulty of replacing any living organ with an inanimate contrivance, stems also in part from failure to apply intensively the principles of modern science generally, and of engineering in particular, to the problems of artificial-hand design. Because in general the engineering profession had not theretofore been much concerned with the development of improved artificial limbs, the hand prostheses available a decade ago represented no appreciable improvement over those to be had at the end of World War I.</p> <p>In all fields of human endeavor, the problems for which men have found tentative solutions in the past often merit the attention of the engineer of today. A new look by competent technologists usually yields gratifying results, for the solutions found by our forebears, while seemingly adequate at the time, do not reflect the progress made in the development of methods of experimental analysis, in the measurement of behavioral characteristics, in the establishment of criteria, in the development of materials, and in the evolution of forming techniques for application of the materials to the needs of man. Just so in the field of prosthetics, where the problem of matching a device to the human system is particularly acute and where, consequently, the application of new methods holds special promise.</p> <p>Perhaps the most compelling reason today for the importance of engineering in prosthetics research lies in the approach and methodology now implicit in the profession. Introduction of the requirements of man in a quantitative manner without neglect of the qualitative, subjective aspects places design on a rational basis for the first time in history. During World War II there arose the problem of designing numerous complicated systems to be operable within the limits of human capabilities. In that urgent work, a substantial number of engineers had occasion to become acquainted with certain important physiological and psychological characteristics of man, so that by the end of the war the stage was set for the impact of the engineering profession on the development of prosthetic devices, which is, after all, a unique and particularly challenging field of biomechanics.</p> <p>When, therefore, in 1945, the then Committee on Prosthetic Devices undertook to conduct basic studies toward the provision of better hand substitutes, it enlisted the services of engineers to cooperate with the medical profession and others in developing the necessary data and in applying the results to improved hand design. In the Artificial Limb Program, principal responsibility for the development of improved hand substitutes has almost from the beginning resided with the Department of Engineering at the University of California, Los Angeles Campus, and with the Army Prosthetics Research Laboratory, Walter Reed Army Medical Center. Out of this cooperative effort have now come not only new and improved devices but also, and perhaps more important, a set of criteria which lay down the basic principles of hand design toward further improvements in the future.</p> <p>Because of the importance of the hand in all human activities, because of the critical nature of adequate hand replacement in the rehabilitation of upper-extremity amputees, and also because of the rather striking advances that have been made in the design of artificial hands in recent years, this issue of Artificial Limbs is devoted entirely to a little symposium on the hand and its substitutes. The mutual cooperation of the several contributors toward a unified approach to the whole subject is typical of the cooperation that has characterized the Artificial Limb Program since its inception.</p> <p>The work in prosthetics will, it is to be hoped, serve as a pattern for further investigations jointly by the medical and engineering professions wherever developments in materials, controls, and systems in general can be brought to bear to augment human functions which an individual can himself no longer provide. One continuing problem is that of convincing able young people now studying engineering that a satisfying future exists for them in such cooperative ventures with the medical profession designed to rehabilitate the less fortunate throughout the world. Those now engaged in prosthetics development can be of great help in presenting to these young men and women the perspective of the future in such a manner that fresh engineering graduates might elect to carry forward the work now already so well under way.</p> <p>Finally, it ought to be noted that, despite the distinct accomplishments evident at this, the tenth anniversary of the establishment of the Artificial Limb Program, only the first faltering steps have been taken toward the "ideal" prosthetic hand. Structural elements and prehensile function are not enough. It remains to provide some reasonable substitute for the sensory-motor apparatus which, in the living hand, is of such consummate perfection as to beggar description. A problem like this should charge the imagination of any young engineer in search of a field of application for service. To him belongs the future in prosthetics research.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Eugene F. Murphy, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Research and Development Division, Prosthetic and Sensory Aids Service (Central Office) Veterans Administration, 252 Seventh Avenue, New York City; member, Technical Committee on Prosthetics, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Engineering Hope of the Handless Creator An entity primarily responsible for making the resource Eugene F. Murphy, Ph.D. * http://23.254.134.177/the.oandplibrary.org/files/original/89e34b5363a6e2997d50157f759ed25d.pdf be2d67e33fc2cf47d7f30766ca9a7815 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Artificial Limbs: A Review of Current Developments Description An account of the resource The foundation of modern prosthetics can be directly traced to the coordinated efforts of the National Academy of Sciences under the various artificial limbs committees after the Second World War. America, at its height of post war efficiency and engineering acumen, set about to solve the burgeoning problem of amputees swelling an infrastructure of prosthetic delivery that was outmoded, outdated and unprepared. Artificial Limbs: A Review of Current Developments was an industry update of these research efforts and was published thirty-three times, spanning the years 1954 to 1972. DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_01_001.pdf Year 1955 Volume 2 Issue 1 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Prelude, Prophecy, and Promise</h2> <h5>John B. Dec. M. Saunders, M.B., F.R.C.S.(Edin.) <a style="text-decoration:none;">*</a><br /></h5> <p> than a dynamic mechanism. The degree of disappointment and measure of failure in these simple objectives, without change in fundamental concepts, is to be seen in the countless empirical modifications of initial designs which bestrew the literature on artificial limbs over the past hundred years and more. </p> <p> Earlier optimisms were gradually replaced by indifference and the inertia of failure, as is well known to those associated with the problem of the amputee after World War I. Locomotion, as we ordinarily understand it, is impossible on a single extremity. But it was realized insufficiently that, unlike the upper extremities, the two lower limbs together constitute but a single organ-the organ of locomotion. Consequently, the complexity of locomotion in relationship to prosthetics design never really was understood, and even where designs were in question the available information was inadequate to support newer developments of principle. </p> <p> Preliminary efforts in the study of human locomotion are to be found in the work, <i>De Motu Animalium, </i>of the Neapolitan mathematician and physician, Giovanni Borelli (1608-1679). As a pupil of Galileo, he was stimulated to take a mechanistic view of bodily function and to study locomotion as a problem in leverage, but his theories and those of his followers soon were reduced to absurdity in the attempt to apply the same mechanistic principles to the whole of medical practice. Continuation of Borelli's approach had to await the nineteenth century and the advent of the Weber brothers, Edward (1806-1871) and Wilhelm (1804-1891), physician and physicist respectively, who with primitive electrical apparatus made the first accurate measurements of gait and undertook its mathematical analysis. The development of photography as a method of recording enabled Etienne-Jules Marey (1830-1904) to avoid previous errors and to correct earlier ideas, and further improvements in photography led to the classical work of Christian Braune and Otto Fischer, <i>Der Gang des Menschen </i>(1895), which has constituted the main source in the formulation of principles for the construction of artificial legs, as in the well-known books of H. von Recklinghausen (1920) and Frederich Mommsen (1932). Over more than a decade (1933-1945) Elftman published the results of extensive locomotion studies. To these and many others we owe a great debt. </p> <p> Despite all these investigations, at the end of World War II our knowledge of human locomotion was still quite incomplete, and such knowledge as existed was only poorly understood. Thus it was that, when approached in September of 1945 by the then Committee on Artificial Limbs of the National Research Council, the representatives of the College of Engineering and of the Medical School of the University of California could point to the necessity of the adoption of a long-term outlook which envisioned the study of the fundamentals of human locomotion, of the amputee who must wear a lower-extremity prosthesis, and of the prosthesis itself. It could be shown that the experience of 400 years in trial-and-error techniques had offered little and that a firm basis for progress could be established only by a systematic approach. It was predicted that at least seven years of study would be required to collect the fundamental data necessary for improved design of artificial legs. </p> <p> That that prophecy was not needlessly pessimistic is revealed in the fact that only today can it be said with a degree of confidence that we are about to enter a period of practical development in the evolution of a truly satisfactory lower-extremity prosthesis. Within the next two or three years we should see the appearance of sound improvements based upon the preceding nine years of pioneering work. </p> <p> But the problems of the leg amputee are not wholly "prosthetic." Such a patient presents a clinical picture of considerable significance. The whole being the sum of its parts, the amputee can scarcely be looked upon as normal in the medical sense, however good general health may be. He is, indeed, quite abnormal, for from amputation of an extremity come changes in skeletal, muscular, and circulatory systems to be dealt with in the design and application of the prosthetic replacement. Complications of pain, real and phantom, and of skin disorders are other matters needing the skills and experience of the medical profession. </p> <p> Taking cognizance of this situation, the Advisory Committee on Artificial Limbs, in the spring of 1953, recommended that the University of California initiate an extensive clinical program to be integrated with the work already under way in the fundamentals of locomotion and in the techniques of lower-extremity fit and alignment. Utilizing space and services afforded by the U. S. Naval Hospital at Oakland and personnel from the University of California Medical and Engineering Schools, the Clinical Study aims to apply to the practical problems of difficult amputee cases the results of the earlier work on the Berkeley Campus. </p> <p> This issue of Artificial Limbs is concerned with two major factors in the management of the lower-extremity amputee-the solution of medical problems associated with the amputated state, and the proper application of the prosthetic replacement on the basis of established biomechanical considerations. In the first of two articles, an orthopedic surgeon and an engineer collaborate in describing the origin, observations, and objectives of the Lower-Extremity Clinical Study. In the second, an engineer develops the principles of alignment and socket fit so indispensable to comfort and function, and hence to the success, of the above-knee artificial leg. In this cooperative effort is reflected the whole basic philosophy of the Artificial Limb Program in approaching the problems of the amputee. </p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>John B. Dec. M. Saunders, M.B., F.R.C.S.(Edin.) </b></td></tr><tr><td class="clsTextSmall"> Professor of Anatomy, School of Medicine, University of California, San Francisco. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Prelude, Prophecy, and Promise Creator An entity primarily responsible for making the resource John B. Dec. M. Saunders, M.B., F.R.C.S.(Edin.) * http://23.254.134.177/the.oandplibrary.org/files/original/baa690570cdf9103498cc78a51072780.pdf efeb1aaeccfa288eeec9bc5ecd38a00c http://23.254.134.177/the.oandplibrary.org/files/original/02116dc22518c1eb39c68be56eeadcbe.jpg 8a184304fcba8cc4b1780900d847a8a3 http://23.254.134.177/the.oandplibrary.org/files/original/5d633c5174ca141632fa4a4f1e21747b.jpg 5e04ded931d40f7f74cd630cd3fa88fd http://23.254.134.177/the.oandplibrary.org/files/original/d54d587bc683285e12a948e28325014e.jpg 7ac002016da544b27b8905e5ce7e190c http://23.254.134.177/the.oandplibrary.org/files/original/2d411a366a5894b21122ede2a2d07a78.jpg c37bdd60e381a074882dba174d8ebb45 http://23.254.134.177/the.oandplibrary.org/files/original/b3276065c28d0d1acc9bd4fbbc1682bd.jpg 161db3ea42e5ab5ea0b8020149c71991 http://23.254.134.177/the.oandplibrary.org/files/original/634383156fceaec626e209462b0523ec.jpg 846701e1d084860d18e51ec6f7c5a191 http://23.254.134.177/the.oandplibrary.org/files/original/3534840b8b9014b939dcf553b7d798a6.jpg 4ccf1cb63eb1401e3b40b6c3e79e7463 http://23.254.134.177/the.oandplibrary.org/files/original/cd15263c33b6e8fe70f3974c54e1df63.jpg 0ea4cec660c63647ee6e63d27d767ee7 http://23.254.134.177/the.oandplibrary.org/files/original/5b000331efb05bcdc1dbbad2cfa91b16.jpg 3ca6176c57505618b576214526d5f2fd http://23.254.134.177/the.oandplibrary.org/files/original/721dba1469c7361d052d71dc63510353.jpg 45e5a147daaf98d9a8290c41165c37e9 http://23.254.134.177/the.oandplibrary.org/files/original/1693caaecd751197fb1a87e816bd59c1.jpg b812afdf152beffe304e924d2710b595 http://23.254.134.177/the.oandplibrary.org/files/original/7790ac1614e11c427aa22f45d0c2dd52.jpg 073ddc987fa51b9507a6a6c4ab2381e6 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Artificial Limbs: A Review of Current Developments Description An account of the resource The foundation of modern prosthetics can be directly traced to the coordinated efforts of the National Academy of Sciences under the various artificial limbs committees after the Second World War. America, at its height of post war efficiency and engineering acumen, set about to solve the burgeoning problem of amputees swelling an infrastructure of prosthetic delivery that was outmoded, outdated and unprepared. Artificial Limbs: A Review of Current Developments was an industry update of these research efforts and was published thirty-three times, spanning the years 1954 to 1972. DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_02_004.pdf Year 1955 Volume 2 Issue 2 Page Number(s) 4 - 21 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_02_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_02_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Anthropology and Social Significance of the Human Hand</h2> <h5>Ethel J. Alpenfels, D.Sc. <a style="text-decoration:none;">*</a><br /></h5> <p>A definitive study of the anthropology of the human hand has yet to be written. Certain investigators, notably Krogman<a></a>, Schultz<a></a>, Ashley-Montagu<a></a>, Clark<a></a>, and Huxley<a></a>, have done intensive work on specific aspects of the morphology of the human hand. Nevertheless, the paucity of published studies, the fragmentary nature of the research, and the failure to attempt any but the most general conclusions make it difficult to summarize in a short article the present status of the hand in human evolution. Authorities differ both in opinion and in practice as to the value of anthropometric measurements in tracing the lines along which specialization has moved in the evolution of the hand. Published materials on the social significance of the hand are, however, numerous, and the importance of the hand as an organ both of performance and of perception has been recognized in all fields of the social sciences.</p> <p>Man alone has a hand. He uses it as a tool, as a symbol, and as a weapon. A whole literature of legend, folklore, superstition, and myth has been built up around the human hand. As an organ of performance it serves as eyes for the blind, the mute talk with it, and it has become a symbol of salutation, supplication, and condemnation. The hand has played a part in the creative life of every known society, and it has come to be symbolic or representative of the <i>whole </i>person in art, in drama, and in the dance. Students of constitutional types have used the hand as a means of classification, and the correlation between mental ability and manual dexterity has been the subject of much research. At the University of Pennsylvania, Krogman, using x-rays of the hand, currently is demonstrating new and important aspects of the interrelation of a child's growth and mental age. Thus the hand, perhaps because it is also dominant in the world of action, has come to be interpreted and understood best in its social aspects.</p> <p>But in a sense the human hand is a paradox. Although it is said to be the highest achievement of primate evolution, research to date shows it to be no more than a variation of a primitive vertebrate plan. The successive stages of evolution give proof, if proof be needed, that our sensitive and mobile hands, with their opposable thumbs, are part of man's vertebrate ancestry.</p> <p>In the suborder Lemuroidea, both recent and extinct, are found pawlike hands. The fourth digit<a style="text-decoration:none;">*</a> is elongated and, together with the first digit, acts like a pair of pincers to grasp a bough. Hooten<a></a> has pointed out that this is an adaptation found in all the lemurs, enabling them to maintain a more secure hold on boughs of large diameter. In lemurs, all of the digits are flat-nailed (except in the aye-aye, which has kept a number of primitive anatomical features), and several modifications appear in the carpal pattern. <b>(Fig. 1)</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. One conventional method of identifying the digits of the hand. Some authorities prefer to think of the hand as possessing a thumb and four fingers. Both methods of nomenclature occur throughout this issue of Artificial Limbs. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the suborder Tarsioidea, entirely arboreal, specialization of the hind limbs for hopping frees the hands not only for grasping but for feeding as well. The hind limb is longer than the forelimb, all of the terminal phalanges are flat-nailed, and the terminal digital pads have curious discs, almost like suction cups, enabling the tarsier to support himself on a smooth surface.</p> <p>These and other adaptations foreshadow higher primate development (<b>Fig. 2</b>), but we must look further to find man's place in the primate scheme. The suborder Anthropoidea, the third and highest of the primate group, includes larger arboreal forms. Longer fore limbs, together with a relatively shorter thumb (approaching atrophy in some forms), provide a means of brachiation. It has been suggested that the short thumb is related to the specialization of the hand as a grasping mechanism, permitting a quick release of the hand in swinging from one branch to another. But in this suborder the hands still retain their primitive features, and only in certain of the Old World Monkeys do the proportions of the digits approach those of man. The emancipated hands of the anthropoids, with thumbs that rotate and oppose the other finger tips, are directed by a more complex nervous system and a larger and better developed brain. Liberation of the hand may have been one of the decisive forces in the descent of certain anthropoids to the ground.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Comparative proportions (not relative size) of the hands of man and of certain related ancestral forms. Top row, left to right, hands of a tarsier, of a lemur, and of a Rhesus monkey. Bottom row, left to right, hands of a chimpanzee, of a human with atypical simian characteristics, and of normal man. In all cases except that of the lemur, the digital formula is 3 &gt; 4 &gt; 2 &gt; 5 &gt; 1. From Jones<a></a>, by permission of Bailliere, Tindall, and Cox, Ltd. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The Evolution of the Hand</h3> <h4>Links with the Past</h4> <p>Man's hand retains the ancient pentadactyl pattern found in early vertebrates. Geological records show that, during the Devonian period of Silurian times, primitive sharks appeared having typical paired fins corresponding to the paired limbs in man, and these organs were destined to give rise to later and higher forms. But there is a great difference belween the paired limbs of the early forerunners of present-day fishes and the pentadactyl limbs of other vertebrates. All of the steps are not yet clear, and the gap between the ancient fishes and the amphibians has not yet been bridged, but it appears that in the early amphibians the migration from water to land led to adaptations and modifications, especially in the area of the shoulder and pelvic girdles.</p> <p>These early ancestors of the primates had short legs, which grew progressively longer in the mammalian stage<a></a> and they walked flat-footed. The ability of the limbs to rotate brought about changes in the entire body. Striking homologies can be found in the hand and arm of man, the wing of a bat, and the foreleg of the frog. Where there are fewer digits, as in the hoof of the horse or the wing of the bird, the reduction has been due to adaptation to special environmental conditions.<a></a> Such reductions make for greater speed in the specialized limbs of the horse.</p> <h4>Upright Posture and Differentiation</h4> <p>The release of the hand from the requirements of locomotion, accompanied by the specialization of the foot and hind limbs for that purpose, led to upright posture (<b>Fig. 3</b>). Evidences of divergent evolutionary trends in the primate order are clearly distinguishable in the primate hand, especially those relating to limb length and trunk length (<b>Fig. 4</b>). Only the mountain gorilla has a hand shorter than that of man, not only with respect to limb length but in relation to trunk length. The longest hands among the great apes are those of the gibbon, the orangutan, and the chimpanzee. Specialists in the evolution of the hand have attributed the long, slender hands of these genera to brachiation and suspension, behavior that elongates not only the arms but, the hands as well, especially the fingers and the metacarpal bones.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The evolution of the hand (top row) and foot (bottom row), as revealed in skeletal structure. A, a primitive reptile; B, C, mammal-like reptiles; D, a lemur, representing a primitive mammalian type; E, man. Note the reduction in the number of joints in the toes, the specialization of the proximal ankle bones in mammals, some reduction in the number of wrist and ankle bones, and the variations in the thumb and great toe From Romer<a></a>, by permission of The University of Chicago Press </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 4. Exact diagrammatic front views of the four largest primates at fully adult age, drawn from detailed measurements on actual specimens, hair omitted, and all reduced to the same trunk height. From Romer<a></a>, by permission of The University of Chicago Press. Originally constructed by A. H. Schultz. Note that, from orang to chimp to gorilla to man, both limb length and hand length generally decrease with respect to trunk height. Only the gorilla has a hand shorter than that of man. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As for the length of the thumb, man andthe other great apes show sharp divergence, especially when the thumb is considered with respect to hand length. As contrasted with the short thumb of the anthropoid apes, man's thumb is long and well developed. Attempts to explain this difference have led to an either-or position. Either the thumbs of the apes have atrophied as a result of their arboreal life or man's thumbs have lengthened in the evolutionary process.</p> <h4>The Shoulder and Upper Arm</h4> <p>In man the shoulder and upper arm are adapted for strength. As for the other portions of the arm down to and including the hand, the more distal the part the more it is adapted for complex and delicate functions and the less for strength. The pectoral girdle in man consists of three bones. The scapula is directed dorsally, the coracoid process extends forward and downward to meet the sternum, and, anterior to the coracoid, the clavicle connects scapula and sternum. Because the pectoral girdle is not joined directly to the spine, though it may articulate with the sternum, the structure permits great freedom of motion in the shoulder area. Briefly, the human arm, supported and controled by a large number of muscles, together with the elbow and wrist joints, gives freedom to a hand that has become the willing servant of the human intellect.</p> <h4>Man's Opposable Thumb</h4> <p>The powerful and well-developed thumb of man is one of his few uniquely human characteristics. Through successive stages of vertebrate evolution, the thumb has separated from the other fingers and developed specialized musculature. In the Anthropoidea, the feature of opposability led to greater tactile and exploratory facility. Man's thumb, comparatively twice as long as that of some of the anthropoids, reveals a steady increase in absolute and relative length (<b>Fig. 2</b> and <b>Fig. 4</b>) and, at the same time, the steady development of opposability, extensibility, and flexibility. When the "hand" of the ape is compared with the hand of man it becomes, in the words of Krogman<a></a> a "misnomer." In the ape, hands are hands by definition only. Although man's hand, the end-product of our evolutionary development, retains the basic, primitive, pentadactyl pattern common to all land vertebrates, it nevertheless is uniquely human. The earliest animal footprint known (from the Permian of the Tambach in Thuringia) is so similar in appearance to that of the human hand that the animal which left the fossil print was named "Cheirotherium," or the "handbeast" <a></a></p> <h4>Variations of the Human Hand</h4> <p>The morphological pattern of man's hand shows its affinity to the "hands" of other animals. But while man has kept the primitive pattern, other animals have specialized. In birds, for example, the hand has become a wing, in the horse a hoof, in the whale a flipper, in the dog a paw, and so on. According to Hooton<a></a>, Crawford has demonstrated the difference between tool-using, as in man, and tool-growing, as in most animals. Animals use no tools other than those developed out of the materials furnished by their own bodies. Man, however, was<a></a> "the first animal to grow a limb outside himself by making tools out of wood and stone." Furthermore, the limbs of animals are specialized for single purposes only. The horse can run, the mole can dig, but neither can climb; man makes instruments that are imitations of the body tools of other animals a digging stick, an awl, a scraper, or a dagger.<a></a> The power and versatility of the human hand rests, in part, upon its generalized pattern. But it is the human brain, with its intricate and elaborated nervous system, that coordinates man's eye and hand. Thus, man is born with a hand free to do the bidding of his expanded brain.</p> <h3>The Anthropometry of the Hand</h3> <h4>Early Studies</h4> <p>The past fifty years have seen a gradual increase in the literature devoted to the anthropometry of the human body. But until that time, individual investigators had gone their separate ways, and there was little concurrence on standardization of the measurements to be employed, on the way in which these measurements were to be taken, or on the instruments to be used. Furthermore, just as in the osteological studies conducted in anthropological museums, early research on living animals was devoted largely to the head and facial features, and only later was study extended to the remainder of the body. Hence the dearth of anthropometric studies on the hand is easy to understand. Lacking, also, are routine osteometric recordings and systematic measurements and indices that could provide the comparative anatomical data necessary for a definitive work on the evolution of the human hand.</p> <h4>The Lack of Data</h4> <p>Authorities appear to agree that no part of the human body has been as neglected as has the hand.<a></a> The reasons for this situation are many, but perhaps the most important one is the scarcity of fossilized primate hands, probably owing to the fact that these bones are small, fragile, and easily destroyed by the action of the forces of nature. Nor are the anthropological collections of complete hands of the modern anthropoids anywhere near adequate. During the past few years, individual investigators and museums have been attempting to increase the number of complete hands available for study, but the collections still are quite inadequate. Moreover, as was demonstrated at the University of Chicago, skeletons often turn out to be composites of many separate individuals and, therefore, of little use in anthropometric studies.<a></a> These handicaps, together with the complexity and the extreme variations found in the human hand, make it exceedingly difficult to get accurate results.</p> <h4>The New Focus</h4> <p>The early work in comparative anthropometry was devoted entirely lo race differentiation.<a></a> At the present time, however, that interest is lagging, and extensive growth studies of the epiphyseal closures of the metacarpals and the phalanges are being conducted at the University of Pennsylvania.<a></a> The x-ray technique, used for many years, has become the major tool by means of which the anthro-pometrist and anatomist can study living persons. It is dependable and important, especially in studying the highly differentiated parts of the human hand.</p> <h4>Classification</h4> <p>The morphology of the hand has proved useful in classifying hand types. Wechsler's system<a></a> is based upon four hand dimensions (<b>Fig. 5</b>). From all possible combinations of length and three breadths, he derives six index categories, as shown in <b>Table 1</b>. Thus, the long, narrow hand type in man would be, for example, 1-1-1-2-4-3, that of the short, broad hand 4-4-4-4-4-4.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Hand measurements according to Wechsler. From Krogman<a></a>, by permission of Ciba <i>Symposia</i>. </p><ol> <li><i>Stylion radiale, </i>at tip of radial styloid process.</li><li><i>Stylion idnare, </i>at tip of ulnar styloid process.</li><li><i>Interslylion, </i>mid-point of line connecting 1 and 2.</li><li><i>Daclylion III, </i>at tip of third finger.</li><li><i>Metacarpale radiale, </i>at metacarpophalangeal junction of index finger.</li><li><i>Metacarpale ulnare, </i>at metacarpophalangeal junction of little finger.</li><li><i>Proxindicion, </i>at proximal interphalangeal junction of index finger.</li><li><i>Ulnoquintion, </i>at intersection on ulnar side of little finger of line perpendicular <i>[sic] </i>to length dimension, drawn from 7.</li><li><i>Dislindicion, </i>at distal interphalangeal junction of index finger.</li><li><i>Ulnoquartion, </i>at intersection on ulnar side of ring finger of line perpendicular <i>[sic] </i>to length dimension, drawn from 9.</li></ol> <p></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1 </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Handedness in Man</h3> <h4>Right and Left - Good and Evil</h4> <p>The cultural world in which man lives, both in preliterate and in technologically advanced societies, tends to be a "right-handed" world. Cross cultural studies reveal that different sides of the body, the left or the right, are associated with different social activities. In India, the right side and the right hand perform tasks considered to be "clean," while the left side and the left hand perform tasks considered to be "unclean." The two types of activities are separated rigidly. The right hand, for example, is used for cooking and eating, whereas the left hand is used in bathing, elimination, or activities associated with sex. Indeed, it is common in many areas of the world to find food related to the right hand, while the left hand is associated with sex.<a></a></p> <p>The right and left hand have come to symbolize good as opposed to evil, gods as opposed to demons. Hence, they are considered as two forces constantly at war with one another. The shadow plays of the Balinese illustrate the widespread association of good and evil with the right and left side respectively. The mystic story teller takes the marionettes out one by one, placing the "good" and "noble" characters at his right side and, at the left, the "evil" and "sinister" characters. In the end, truth and goodness always win, which demonstrates the triumph of the magical powers of the right side. At all important life crisesbirth, death, marriage, initiation ceremoniesthis magic balance between left and right is maintained. Among the Tiv of Nigeria, the afterbirth of a boy child is always buried to the left of the door in order to propitiate the evil spirits residing there. In Bali, a boy's placenta is buried on the right and a girl's on the left side of the entrance to the house.<a></a></p> <h4>Caste and The Hand</h4> <p>The symbolism of the hands in ceremonial rites has, in various ways, come to indicate social class and caste. Among the Balinese, for example, it is a mark of social distinction to wear long nails, but only the priest may wear them on both hands. The giant-god of pre-Hindu times is believed to have carved out all of the caves with the fingernails of his left hand. The Indian caste system is noted for a unique feature in that many of the castes are divided into two sections called the "right-hand" (Balagai) and the "left-hand" (Yedagai) castes. Certain socially lower artisan castes, such as workers in leather, belong to the left-hand subgroup.<a></a> Among the Motu of Papua, the moieties are grouped by the left and right hand. Members of the right-hand moiety have senior status in matters of inheritance, while members of the left hand moiety have junior descent status.<a></a></p> <h4>Other Influences</h4> <p>Music for the piano usually is written in such a way that the melody is carried by the right hand. Threads in bolts, pipes, and even in glass jars are right-handed. Soup and gravy ladles, fish forks, and meat grindersin fact, the majority of our manufactured products are designed for the right-handed individual. Can the custom of men buttoning their coats on the right side and women on the left be a survival from our primitive past when the right was reserved for men because it was "good" and the left for women because it was "evil"? Our society is belatedly recognizing the right of sinistrodextral people to full participation in our culture. Banks are issuing left handed checkbooks, left-handed armchair desks have been introduced in schools, and left-handed scissors and other implements and tools now are available.</p> <h4>Handedness in Early Man</h4> <p>Whatever the reasons for associating right with "good" and left with "evil," the fact remains that man is predominantly right-handed, a fact that appears to have been true even in prehistoric times. Early writers explained the enigma of right-handedness in the Lamarckian sense of "use and disuse." They noted that, since the heart was located on the left side of the body, the warrior carried his shield in his left hand. The right hand was free and, through more frequent use, developed in both size and dexterity. This "acquired" characteristic was passed on to succeeding generations.</p> <p>During the nineteenth century, as the authenticity of plant and animal fossils was established, and with the growth of anthropology as a more exact science, numerous archaeological sites were excavated. By the beginning of the twentieth century, thousands of artifacts had been uncovered, more precise data were available, and the picture of life in prehistoric times began to emerge in greater detail. The oldest implement found in Europe was beveled for grasping between the right thumb and first finger. The implements of primitive Paleolithic sculptors were found to approximate in number and in form those of modern sculptors. All of the tools uncovered in a Spanish cave, said to have been inhabited during Solutrean times, are designed to fit the hand, and, from the almost perfect adaptation of these instruments, we may infer that these ancient artists were right-handed.<a></a> Based upon the frequency of left-handed flint tools found <i>in situ </i>in France, other authorities, Krogman<a></a> for example, note that the incidence of left-handedness increased during the New Stone Age.</p> <h4>Handedness in Apes</h4> <p>During the past three decades, handedness in the apes has been studied extensively in the United States. Yerkes <a></a>, in his classical work on the apes, found that handedness appears in chimpanzees. He points out that they use one hand consistently for certain purposes and the other hand for other activities. He says, however, that right-handed dominance has not been demonstrated and that the three types of motor activity found in man (right-and left-handedness and ambidexterity) occur with about equal frequency.</p> <h4>The Chick Embryo</h4> <p>The problem of left- and right-handedness in chickens has been reported. At about the 38th hour in the chick embryo, certain processes are initiated that result in what may be termed very loosely a "right-handed embryo." In certain chemicals, the molecular structure is "left-handed" in that it is of the nature of the mirror image of the "right-handed" counterpart. After a number of hours of incubation, fertile chicken eggs exposed to such "left-handed" chemicals evidence a "left-handed" type of flexure of the developing brain.</p> <h4>Asymmetry</h4> <p>Yerkes<a></a> holds with the current opinion that asymmetry of the left and right hand (<b>Fig. 6</b>) is related to a general asymmetry of the entire body. The right and left leg in man, for example, also differ in strength and in dexterity. Similarly, the right lung is slightly heavier, the abdominal viscera are heavier on the right side, both the spine and pelvic regions display asymmetry, and hence the center of gravity of the body is slightly to the right. Kahn<a></a> reports a number of experiments which demonstrate that, owing to this asymmetry, every blind wandering ends in a circle. Thus, man cannot write, nor walk, nor drive a car blindfolded without becoming a victim of his physical asymmetry.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Typical difference between the right and left hands of a single individual. The right has a shorter palm and longer fingers, and the long longitudinal line is more marked. From Wolff.<a></a> by permission of Methucn and Co., Ltd. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Endocranial casts of the brain cavities of fossil and of modern man support this evidence, and here too asymmetry appears. The left occipital portion of the brain predominates to produce right-handedness, a fact established by Smith.<a></a> One school of thought claims that this asymmetry of the brain represents a primitive character in the higher apes and man. According to Clark<a></a>, however, Keith maintains that, on the contrary, asymmetry represents an evolutionary advance.</p> <p>The general physical asymmetry of the body is associated with a social asymmetry in our human prejudice against the left side. The human preference for right-handed tools and artifacts has, somehow, invaded the social and moral life. There also is a <i>sinistra </i>and <i>dextera </i>view of the world now fixed in our vocabulary.</p> <h4>Handedness in Language</h4> <p>We speak of dexterity (from the Latin "dexter," connoting "right," "favorable") in referring to skill, and this idea has been traced back to Sanskrit, the ancient literary language of India. From the category of physical things, the right hand has reached out to influence many other areas of human life. To be "orthodox" is to follow the "right" or "true" opinion. The concept of legal justice comes from the French "droit," meaning "right" or "law." Contrariwise, the word "left" symbolizes "evil," "weak," "awkward." The word for "left" in French is "gauche," meaning "awkward." The Latin "sinister," meaning "left," rarely applies to that which threatens but, rather, to that which is known to act covertly or insidiously. The bar sinister is the heraldic symbol of bastardy. A man who marries below his social rank gives his left hand, not his right, to his bride. Thus, in our own culture today there survive in our language and customs the social implications that historically have characterized handedness in man.</p> <h3>The Hand as a Sensory Organ</h3> <h4>The Sensory Experience</h4> <p>Although prehension is the major function of the hand, the hand is, at the same time, one of man's primary sense organs. This tactile quality provides sensory experience that may be grouped into four general categories.<a></a> The first consists of "surface sensations" stimulation generated by touching tangible objects. The second is termed "space-filling" stimulation generated by pulling the hand through liquid substance. "Spacelike sensations," comprising the third category, relate to the touch of distinctively shaped objects felt through a heavy material. Finally, there are "penetrable-surface sensations," experienced, for example, by a physician as he palpates some part of the body to locate, through the outer layer of flesh, some abnormal condition in deeper tissue.</p> <p>Movement is indispensable in sensory experience, and experimentation demonstrates that even the "imaginary" touch sensations are located in the finger tips. According to Katz<a></a>, it is quite impossible to call up the image of touch without, in imagination, moving the hand. The moment we imagine our hands at rest, the image becomes uncertain or disappears.</p> <p>When body and ambient temperature are equalized, the hand may be used as an instrument for the perception of the relative levels of heat and cold. Preliminary determination of body temperature can be determined by placing the hand on the forehead. In folk society, for example, where accurate measures of determining fever temperature are not available, a normal hand placed upon the forehead is used to determine the presence of fever.</p> <h4>A Percussive Tool</h4> <p>The human hand can also be used as a percussion instrument. With an apparatus which he called "the percussion phantom,"<a style="text-decoration:none;">*</a> von Gotzen found that vibratory impulses generated by finger percussion can be felt even when the auditory sense is eliminated.</p> <h4>A Vibratory Tool</h4> <p>Vibratory sensations, as perceived by the hand, are of importance in teaching the deaf to speak. By placing one hand on the larynx of a speaker and the other hand on his own larynx, a deaf-mute learns the vibration patterns of speech sounds. When the patterns "heard" by his left and right hand are identical, the student has succeeded in imitating the sound. Helen Keller utilizes the vibratory phenomena when she "hears" music by placing her hand on the piano.</p> <h3>The Human Hand in Art</h3> <p>Through the ages the human hand has appeared in all of the creative arts of every culture.<a></a> A single line, a schematic portrayal, a simple gesture of the hand, and character and personality stand revealed as clearly as they are seen in the human face. Recently, in the Kefauver investigation of crime in New York City, the television camera focused on the hands of a witness, and millions in the television audience watched while hands expressed feelings that man has taught his face to disguise.</p> <p>In the creative arts, the hand speaks, and one senses the tremendous power of the hand to convey human emotions. The hands are the organs of the body which, except for the face, have been used most often in the various art forms to express human feeling. The hands point or lead or command; the hands cry out in agony or they lie quietly sleeping; the hands have moods, character, and, in a wider sense, their own particular beauty. From prehistoric times to our own day, in every society known to science, the hands symbolize cultural behaviors, values, and beliefs.</p> <h4>Painting and Sculpture</h4> <p>Many studies of the hand appear in the traditions of western art. From schematic and conventional hand portraits, the artists of the fifteenth century began to draw anatomically correct hands, and, slowly but surely, the hand was seen as having a personality and a culture of its own. Albrecht Durer (1471-1528) devoted a lifetime to the study of anatomy, and in his studies of hands the lines, the curves, the veins, the wrinkles delineate the complexity of the human hand (<b>Fig. 7</b>). In another medium, the French sculptor Auguste Rodin (1840-1917) deliberately used the hands to create unmatched works of art.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Famed "Hands of an Apostle Praying," by Albrecht Diirer (a.d. 1471-1528). Courtesy The Public Library, Washington, D. C. The original hangs in the Albertina Museum in Vienna. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Prehistoric Artist</h4> <p>Early man left records in shallow caves, in rock shelters, and, in the great period of art during late Paleolithic times, on the walls of the innermost recesses of caves in France and Spain In the ancient engravings and the wall paintings found in caves in eastern Spain, the arms and legs perform animated gestures in running, in drawing a bow, in gathering honey, and in the dance.</p> <p>The human hand appears in quasi magico-religious silhouettes of complete or partially mutilated hands outlined in color on the walls of the grotto of Gargas in the Pyrenees Mountains. The fingers appear to be cut off at the distal end of the first phalanx, with one or more digits missing entirely. Curiously, the thumb never is amputated. The same type of finger mutilation is found in wall paintings in the caves of central Australia. Apparently the practice was customary among the early Aurignacian people of Paleolithic times, and it also is reported in other preliterate tribes. According to Osborn <a></a>, Breuil believes that painting had its beginning in these stencilled contours produced by laying the hands against the limestone walls and spreading red and black paint on the surrounding area. In other examples, the hand was covered with pigment and pressed against the wall.</p> <h4>The Dance</h4> <p>The formal patterns and definite movements of the dance make it one of the greatest of the interpretative arts. It is, apparently, also one of the oldest arts. Whether viewed from a recreational, religious, or aesthetic standpoint, this expression of culture has attained meaning and intensity through movement of the hands. Joint dances between the sexes are rare among primitive tribes, and the hand thus has been liberated for gestures and symbolic movements. In India, the hands can tell an entire story. In Australia, among one of the most technologically simple tribes, the movements of the hands make the dance merge into drama. Indeed, it is difficult to separate the dance from music and from drama, but in each of these art forms it is the hand that gives meaning to words spoken. Perhaps the rhythm produced by the hands in clapping and in slapping the body originally led to music and to the dance.</p> <h3>The Hand in Culture and Society</h3> <h4>Language Abstractions</h4> <p>Because the human hand is an organ of performance, it is not surprising that the hand should "manipulate" ("to lead by the hand") the human vocabulary. The hand receives the "mandate" (from Latin "manus," for "hand," plus "dare," "to give") from the brain, and to "manage" is to govern, direct, or control. Thus, man "commends" (which originally meant "to place in one's hands") and "commands," both words related to "mandate" and, therefore, to the Latin "manus," for "hand."</p> <p>With its basic movements for grasping objects (page 33), the human hand also is "handy" ("dexterous," "to have two right hands") for grasping ideas. To "comprehend" is to "seize" (Latin, "capere," "to seize"), from which we derive such words as "perceive," "conceive," and "receive." Thus, by various shades of meaning, the human hand not only "hands down" information but "picks" it up. The human hand also is an organ of perception and thus lends itself to the most abstract concepts. "Handsome" originally meant "dexterous." "To feel" is connected somehow with the Greek word for hand, "palame." To say in Latin "dicere" means "to point." We touch, feel, handle, finger, thumb, paw, grope, palpate, and stroke objects.</p> <h4>One and One Are Two</h4> <p>Man's hand not only manipulates and grasps, and makes and points, but it counts as well. Counting is very different from what we loosely term "number sense," an attribute that man shares with other animals. In its real connotation, counting appears to be an exclusively human characteristic, and numbers, like so many abstractions, begin with the human body. The old Roman numerals I, II, III, and IIII<a style="text-decoration:none;">*</a> are thought to be representations of the fingers. In certain of the less well-known languages, the word for hand gives us the word for five. "Five" also has come to mean "hand," and in English the slang expression "give us five" once meant "to shake hands."</p> <p>One example of the use of hands in counting is that of the Mafulu mountain people, who do not use pebbles or sticks but instead use the hands and feet.<a></a> Here counting is accomplished by the use of two numerals, "one" and "two." In indicating "one," the hand first is stretched open to indicate "nothing," the thumb then is closed down meaning "one," the first digit closed down meaning "two," and so on, until all of the fingers of one hand are closed. The process is repeated with the other hand, and, to count to 20, the clenched fist points to the feet and to all of the right and left toes. If the count is above 20 (usually only when important occasions demand, such as counting pigs for a ceremony) another man is called to stand beside the first. If the number goes as high as 83, five men join. Four men go through the entire process, and the last man closes the first three digits.</p> <h4>Man the Measuree</h4> <p>Equally important has been the use of the hand as a unit of measurement. Tables showing the use of body organs as units of measure have been established for volume, surface. width, and length (<b>Fig. 8</b>). The earliest records show that the use of the index finger for indicating length was a widespread custom. In Europe the height of a man was estimated by a definite number of finger lengths based upon the measurement of the middle finger. In Latvia, the length of the middle finger was used to measure lengths for women's stockings or woolen socks (three times the length of one's middle finger). Sixteen times the length of the middle finger equals the normal human stride. The hand and thumb were used to measure width, 12 thumb widths being equal to one foot. Tools were made by the eldest member of the family and adjusted to the hand grasp. Thus, a scythe blade for an adult man was as long as nine or ten widths of the clenched hand, eight for an adult woman, and seven or eight for an adolescent (<b>Fig. 9</b>). The same pattern is found through much of eastern and northeastern Europe today.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Natural units of measure, still in use by Latvian and other European peasants. From Drillis.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. The method, common among Latvian and other European peasants even today, of arriving at the proper dimensions for farm tools using the hand as the unit of measurement. From Drillis.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Some Tribal Customs</h4> <p>In the Sun Dance of the Plains Indians of the United States, finger joints were occasionally pledged as a thank-offering for recovery from illness or to ensure revenge for a slain relative.<a></a> Cole<a></a> reports that individual warriors among the tribes of Mindanao carried home a hand as evidence of a successful fight and that at such times festivals were held to celebrate the event. Among the Tinguian tribes of the Philippine Islands, joints of the little fingers were added to ear lobes and brains to make a liquor that was served to the dancers. Here, as in most areas of the world, the brew was consumed not for nourishment but in order to secure that part of the enemies' bodies thought to house strength and valor.</p> <p>Such reports may throw light upon the presence of the mutilated hands found on the walls of the European caves and dating from late Paleolithic times. The scarcity of drawings of the human form in cave paintings may be related in some way to the belief, still found among certain of our "primitive" contemporaries, that realistic portraits might give an enemy magic power. Possibly, through some similar process of sympathetic magic, the hand has already become a symbol to be portrayed realistically in religious ritual.</p> <h4>The Fingerprint</h4> <p>Human hands have been used in various cultures as a means of positive identification. In ancient China, fingerprints were used to sign or to autograph paintings. They are doubly valuable as "signatures" because they cannot be altered or forged, and the intricate patterns of whorls, circular and folded loops, and arches differ from finger to finger and from individual to individual. As the person grows, his individual fingerprint patterns increase in size but do not change in geometric proportions. In 1882, Bertillon, a young French anthropologist, began to develop his famous system for identification of criminals by a physical description based upon eleven anthropometric measurements, deformities, and impressions of lines and markings of the finger tips. The Bertillon system of fingerprints has been used internationally and has proved valuable for physical identification.</p> <h3>Some Other Considerations</h3> <h4>Occultism, Symbolism, and Ritualism</h4> <p>In an anatomical sense, each hand is unique. Every hand betrays its possessor by characteristic mo/ement patterns, by peculiarities of gesture, or by occupational stigmata arising from physical and mechanical causes. From these characteristics, palmistry and a branch of occultism known as "chiromancy" have, for centuries, attempted to read the past, present, and future of individuals. Since early antiquity, numerous scholars of repute have concerned themselves with studies in palmistry. According to D'Arpentigny<a></a>, Plato, Aristotle, Galen, Albertus Magnus, the Ptolemies, Avicenna, Averroes, Antiochus Tibertus, Tricasso (<b>Fig. 10</b>), Taisnier, Belot, and others have handed down lengthy treatises on the subject, and the observations of these early writers still prevail in our own modern times (<b>Fig. 11</b>). Palmists are interested chiefly in the surface of the handlines, stars, crosses, islandsand have divided the life line into seventy parts, each part symbolic of one of man's allotted seventy years of life. Chirognomists study the shape and form of the entire hand, in addition to surface characteristics.<a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Principal lines and mounts of the hand as charted by Patritio Tricasso da Cerasari (Tricassus the Mantuan), a celebrated chiromancer of the sixteenth century. From Lenssen<a></a>, by permission of The Studio Publications, Inc., New York City. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. The mounts and principal lines of the hand and the interpretative functions traditionally assigned to the several areas. Authorities differ in detail, but all follow the same general pattern. In palmistry, which dates from antiquity and which has been the subject of serious discussion by numerous scholars, including Aristotle, the relative development of the mounts and lines is considered to show the comparative ability of the subject to implement the talents and qualities associated with the individual features. Generally the mounts are seven in number, the eighth (Mount of Neptune) occurring in a comparatively small number of cases. Reference to the sun, moon, and planets relates, of course, to the influence which, in early philosophy, these celestial bodies were thought to exercise upon the course of an individual's life. Modern astrology calls upon similar relationships. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>But it is in the realm of quasi magic and symbolism that the hand reaches its highest cultural significance. For the great majority of mankind who think in concrete rather than in abstract terms, graphic representations of superhumanity are related to the human body. The Hindu of India symbolizes this super-humanity by the multiplication of the most important parts of the body, which, to him, are the head, the arms, and the hands. Since arms and hands are extremely useful, a twelve-armed god demonstrates the power and the strength denied a two-armed god. Such thinking may appear grotesque to the Westerner, but the Hindu, accustomed to symbolic thinking, knows that man is not so constructed, nor does he wish that he were. He simply recognizes that power and wisdom and strength may be expressed quantitatively.<a></a>The Moslem often wears a small image of the hand around his neck to ward off the evil eye.</p> <p>Not only in the eastern world does the hand play an important part in the ritual usages but in western culture as well. The pentagram, the five-pointed star, is said to have been derived from an ancient custom of covering the face with the open fingers of the hand. That practice gradually was replaced by invoking the numeral "five," a convention that persists today in countries in central Europe. In Latvia, for example, the pentagram now appears on barns as a protective device.</p> <p>Finally, the hand has become symbolic of human sentiment. We bless and we salute by raising the hand in various ways. The gentle laying on of hands is at once a symbol of benediction and, as among certain religious sects, the means of curing the sick and of drawing out the evil spirits that reside within the body. In legal practice, oaths are taken in court by the simultaneous use of both hands, right hand up and the left hand on the Bible. We close a bargain by shaking hands, we raise our hands in salutation, and a man takes a woman's hand in marriage. Contrariwise, the hand may express condemnation, malediction, and final judgment. In cursing we point the hand at the enemy. In ancient Rome, thumbs down ("pollice verso") sentenced the gladiator to death. Thus, the hand has become an expository of human sentiment. It can express love, hate, doubt, questioning, hospitality, judgment, rejection, or acceptance.</p> <h4>The Hand and Good Health</h4> <p>The handshake may become an index to personality and representative of the <i>whole </i>person. The cold, limp hand, the strong, firm grasp, the moist palm, the dry palm, all help us to create a mental image of personality. To the trained hand of the physician, the cold, moist, flabby handshake often reveals clues relating to physical condition. Such a handshake often is a symbol of physical illness or an indication of an emotional disturbance. To the trained eye of the doctor the hand tells even more. The coloring, texture, lines, and creases sometimes reveal sickness or health. A trembling, warm, moist hand may mean overactivity of the thyroid, redness may indicate gout, a bluish appearance may indicate a certain kind of heart disease, and bad cases of malnutrition and diet deficiency frequently are reflected in the hand. There are many variations in the appearance of each hand, but the danger signals can be read only by the skilled hand and eye of a physician.</p> <h4>The Hand in Expression</h4> <p>The hand has also become associated with certain ethnic and nationality groups, for specific hand gestures have been associated with certain cultural types. Indeed, it has been said of the Italians that they never speak a language, that they caress it. Because movement of the hands serves to emphasize the spoken word, all of us find it difficult to speak while our hands remain perfectly still. A dramatic presentation of the use of the hand in conversation was portrayed through the medium of modern dance in a performance by a group at New York University involving an interpretation of an adolescent the telephone (<b>Fig. 11</b>). talking over No word was spoken, but the wide variety of gestures made clear to everyone what the performer was saying. The cult and the culture of the "teen-ager" in our country was delineated as sharply through the dance as it could have been through the medium of the written word.</p> <h3>Conclusion</h3> <p>From its basic use, prehension, which grew out of anatomical development, the human hand gradually has evolved until it is now also an effective instrument for symbolic and aesthetic interpretation. Man's capable and sentient hand not only serves as a tool but it wields tools as well, and it has in addition the ability to take the place of other body organs. Because of its remarkable adaptability to functional requirements, as compared with the specialization in the forelimb of other animals, the hand is largely responsible for the creative manifestations that characterize the human species and that distinguish it from all other known forms of life. The hands are, as Kant is reported to have said, "man's outer brain."</p> <h3>Acknowledgment</h3> <p>For valued help in obtaining the illustrations which accompany this article, the author is indebted to Marian Blumler, staff member of the Library, National Academy of Sciences National Research Council, who conducted a search of source material and arranged for loan of the necessary documents.</p> <p><b>References:</b></p> <ol> <li>Adam, Leonhard, <i>Primitive art</i>, Harmendsworth Middlesex, Penquin Books, Ltd., rev. ed., 1949.</li> <li>Ashley-Montagu, Francis M., <i>On the primatethumb</i>, Am. J. Phys. Anthropol., 16(2):291 (1931).</li> <li>Boas, Franz, <i>Primitive art</i>, H. Aschehoug, Oslo, 1927. pp. 344, 349.</li> <li>Boyd, William C, <i>Genetics and the races of man; an introduction to modern physical anthropology</i>, Heath, Boston, 1950. pp. 16-17.</li> <li>Clark, W. E. Le Gros, <i>Early forerunners of man; a morphological study of the evolutionary origin of the primates</i>, Bailliere, Tindall, and Cox, London, 1934. pp. 103-140.</li> <li>Cole, Fay-Cooper, <i>Lectures</i>, University of Chicago, 1940-41.</li> <li>D'Arpentigny, C. S., <i>The science of the hand</i>, translated from the French by Ed. Heron-Allen, Ward, Lock, and Bowden, London, 1895.</li> <li>Drillis, Rudolf J., <i>Darba riki [Tools]</i>, in <i>Lalviesu konversacijas vardnica [Latvian encyclopedia]</i>, A. Gulbis, Riga, 1928-29. Vol. 3, p. 4611.</li> <li>Drillis, Rudolf J., <i>Mcri [Units of measure]</i>, in <i>Latvieiu konversacijas vardnica [Latvian encyclopedia]</i>, A. Gulbis, Riga, 1928-29. Vol. 14, p. 26691.</li> <li>Flory, Charles D., <i>Osseous development in the hand as an index of skeletal development</i>, Society for Research in Child Development, Monographs, Vol. 1, No. 3, National Research Council, 1936.</li> <li>Hodges, Paul C, <i>An epiphyseal chart</i>, Am. J. Roentgenol., 30(6): 809 (1933).</li> <li>Hooton, Earnest A., <i>Up from the ape</i>, Macmillan, New York, 1931.</li> <li>Huxley, J., <i>From fin to fingers: the evolution of man's hand</i>, Illustrated London News, December 1930. pp. 1138-39.</li> <li>Jones, Frederic Wood, <i>The principles of anatomy as seen in the hand</i>, 2nd ed., Williams and Wilkins, Baltimore, 1942.</li> <li>Kahn, Fritz,<i> Man in structure and function</i>, Alfred A. Knopf, New York, 1943. Vol. 1, pp. 1515-16.</li> <li>Katz, David, <i>On the psychology of the human hand</i>,Bulletin Vol. 32, No. 10, University of Maine Studies, Second Series, No. 14, <i>The vibratory sense and other lectures</i>, The University Press, Orono, 1930. pp. 75-78.</li> <li>Krogman, Wilton M., <i>The anthropology of the hand</i>, Ciba Symposia, 4(4):1294 (1942). '</li> <li>Lenssen, Heidi, <i>Hands in nature and art</i>, Studio Publications, New York, 1949.</li> <li>Mead, Margaret, el al., <i>Cultural patterns and technical change</i>, World Federation for Mental Health, UNESCO, Igsel Press, Ltd., Deventer, Holland, 1953.</li> <li>Mierzecki, H., <i>Symbolism and palhognomy of the hand</i>, Ciba Symposia, 4(4):1319 (1942). '</li> <li>O'Malley, L. S. S., <i>Indian caste customs</i>, Macmilan, New York, 1932. pp. 21-22.</li> <li>Osborn, Henry F., <i>Men of the Old Stone Age, their environment, life, and art</i>, 3rd ed., Scribner, New York, 1919.</li> <li>Personal communication from Margaret Cormack, Brooklyn College.</li> <li>Reininger, W., <i>The hand in art</i>, Ciba Symposia, (4):1323 (1942).</li> <li>Romer, Alfred Sherwood, <i>Man and the vertebrates</i>, University of Chicago Press, Chicago, 1933.</li> <li>Romer, Alfred Sherwood, <i>Man and the vertebrates</i>, 2nd ed., University of Chicago Press, Chicago, 1937. Especially pp. 27-28, 41-42, 363-70.</li> <li>Rosenstiel, Annette, <i>The Motu of Papua-New Guinea: a study of successful acculturation</i>, Ph.D. thesis, Columbia University, 1953. Microfilm.</li> <li>Schultz, Adolph H., <i>Characters common to higher primates and characters specific for man</i>, Quart. Rev. Biol., ll(4):425-455; ll(3):259-283, 434-437 (1936).</li> <li>Schultz, Adolph H., <i>The skeleton of the trunk and limbs of higher primates</i>, Human Biol., 2(3):303 (1930).</li> <li>Smith, Grafton E., <i>The evolution of man</i>; essays, 2nd ed., Oxford University Press, 1927.</li> <li>Wilder, Harris H., <i>A laboratory manual of anthropometry</i>, Blakiston, Philadelphia, 1920. pp. 84-109.</li> <li>Wiser, Charlotte V., and William H. Wiser, <i>Behindmud walls</i>, Harper, New York, 1930.</li> <li>Wolff, Charlotte, <i>The human hand</i>, Methuen, London, 1942.</li> <li>Wright, W. B., <i>Tools and the man</i>, George Bell and Sons, Ltd., London, 1939.</li> <li>Yerkes, Robert M., <i>Chimpanzees; a laboratory colony</i>, Yale University Press, New Haven, 1943.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Personal communication from Margaret Cormack, Brooklyn College.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Lenssen, Heidi, Hands in nature and art, Studio Publications, New York, 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Mierzecki, H., Symbolism and palhognomy of the hand, Ciba Symposia, 4(4):1319 (1942). '</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">D'Arpentigny, C. S., The science of the hand, translated from the French by Ed. Heron-Allen, Ward, Lock, and Bowden, London, 1895.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Cole, Fay-Cooper, Lectures, University of Chicago, 1940-41.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Wiser, Charlotte V., and William H. Wiser, Behindmud walls, Harper, New York, 1930.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Drillis, Rudolf J., Darba riki [Tools], in Lalviesu konversacijas vardnica [Latvian encyclopedia], A. Gulbis, Riga, 1928-29. Vol. 3, p. 4611.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Drillis, Rudolf J., Mcri [Units of measure], in Latvieiu konversacijas vardnica [Latvian encyclopedia], A. Gulbis, Riga, 1928-29. Vol. 14, p. 26691.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Cole, Fay-Cooper, Lectures, University of Chicago, 1940-41.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">IV is a later development.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Osborn, Henry F., Men of the Old Stone Age, their environment, life, and art, 3rd ed., Scribner, New York, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Adam, Leonhard, Primitive art, Harmendsworth Middlesex, Penquin Books, Ltd., rev. ed., 1949.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Boas, Franz, Primitive art, H. Aschehoug, Oslo, 1927. pp. 344, 349.</td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Reininger, W., The hand in art, Ciba Symposia, (4):1323 (1942).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Katz (16) describes the apparatus as a square wooden box, about 60 centimeters long by 8 centimeters deep, and open at the top. Around the top edge a strip of felt is fitted, and over the whole a thick cardboard square is fastened; this side of the box is clamped on with metal clips. The cardboard is strong enough to resist considerable pressure without sagging. On the underside of the cardboard, i.e., inside the box, objects of different shapesfor example, round, elliptical, or heart-shaped objectsare pasted to substantial pieces of lead which appear either as matrices or as patrices, i.e., they are cut into or cut out of lead. The thickness of the plate is chosen according to the degree of difficulty of the percussion task to be presented to the student. In general, the thicker the plate, the easier the task. The plates are so arranged that the figure is located in the middle of ihe underside of the cardboard. Each cardboard is fitted with one figure (if necessary, composed of two parts), so that there are as many cardboards as there are figures required for the test. Students were asked to determine, through percussion alone, the form of figures cut into or out of the lead plates.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Katz, David, On the psychology of the human hand,Bulletin Vol. 32, No. 10, University of Maine Studies, Second Series, No. 14, The vibratory sense and other lectures, The University Press, Orono, 1930. pp. 75-78.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Katz, David, On the psychology of the human hand,Bulletin Vol. 32, No. 10, University of Maine Studies, Second Series, No. 14, The vibratory sense and other lectures, The University Press, Orono, 1930. pp. 75-78.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Clark, W. E. Le Gros, Early forerunners of man; a morphological study of the evolutionary origin of the primates, Bailliere, Tindall, and Cox, London, 1934. pp. 103-140.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Smith, Grafton E., The evolution of man; essays, 2nd ed., Oxford University Press, 1927.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>33.</b> </td><td class="clsTextSmall">Wolff, Charlotte, The human hand, Methuen, London, 1942.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Kahn, Fritz, Man in structure and function, Alfred A. Knopf, New York, 1943. Vol. 1, pp. 1515-16.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Yerkes, Robert M., Chimpanzees; a laboratory colony, Yale University Press, New Haven, 1943.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Yerkes, Robert M., Chimpanzees; a laboratory colony, Yale University Press, New Haven, 1943.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Krogman, Wilton M., The anthropology of the hand, Ciba Symposia, 4(4):1294 (1942). '</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Osborn, Henry F., Men of the Old Stone Age, their environment, life, and art, 3rd ed., Scribner, New York, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Rosenstiel, Annette, The Motu of Papua-New Guinea: a study of successful acculturation, Ph.D. thesis, Columbia University, 1953. Microfilm.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">O'Malley, L. S. S., Indian caste customs, Macmilan, New York, 1932. pp. 21-22.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Cole, Fay-Cooper, Lectures, University of Chicago, 1940-41.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Mead, Margaret, el al., Cultural patterns and technical change, World Federation for Mental Health, UNESCO, Igsel Press, Ltd., Deventer, Holland, 1953.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Hodges, Paul C, An epiphyseal chart, Am. J. Roentgenol., 30(6): 809 (1933).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Krogman, Wilton M., The anthropology of the hand, Ciba Symposia, 4(4):1294 (1942). '</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Hodges, Paul C, An epiphyseal chart, Am. J. Roentgenol., 30(6): 809 (1933).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Boyd, William C, Genetics and the races of man; an introduction to modern physical anthropology, Heath, Boston, 1950. pp. 16-17.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Flory, Charles D., Osseous development in the hand as an index of skeletal development, Society for Research in Child Development, Monographs, Vol. 1, No. 3, National Research Council, 1936.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Ashley-Montagu, Francis M., On the primatethumb, Am. J. Phys. Anthropol., 16(2):291 (1931).</td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Wilder, Harris H., A laboratory manual of anthropometry, Blakiston, Philadelphia, 1920. pp. 84-109.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">Wright, W. B., Tools and the man, George Bell and Sons, Ltd., London, 1939.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Hooton, Earnest A., Up from the ape, Macmillan, New York, 1931.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Hooton, Earnest A., Up from the ape, Macmillan, New York, 1931.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Ashley-Montagu, Francis M., On the primatethumb, Am. J. Phys. Anthropol., 16(2):291 (1931).</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Clark, W. E. Le Gros, Early forerunners of man; a morphological study of the evolutionary origin of the primates, Bailliere, Tindall, and Cox, London, 1934. pp. 103-140.</td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Hooton, Earnest A., Up from the ape, Macmillan, New York, 1931.</td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Krogman, Wilton M., The anthropology of the hand, Ciba Symposia, 4(4):1294 (1942). '</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Krogman, Wilton M., The anthropology of the hand, Ciba Symposia, 4(4):1294 (1942). '</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Romer, Alfred Sherwood, Man and the vertebrates, University of Chicago Press, Chicago, 1933.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Romer, Alfred Sherwood, Man and the vertebrates, University of Chicago Press, Chicago, 1933.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Clark, W. E. Le Gros, Early forerunners of man; a morphological study of the evolutionary origin of the primates, Bailliere, Tindall, and Cox, London, 1934. pp. 103-140.</td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Huxley, J., From fin to fingers: the evolution of man's hand, Illustrated London News, December 1930. pp. 1138-39.</td></tr><tr><td class="clsTextSmall"><b> 26.</b> </td><td class="clsTextSmall">Romer, Alfred Sherwood, Man and the vertebrates, 2nd ed., University of Chicago Press, Chicago, 1937. Especially pp. 27-28, 41-42, 363-70.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Romer, Alfred Sherwood, Man and the vertebrates, 2nd ed., University of Chicago Press, Chicago, 1937. Especially pp. 27-28, 41-42, 363-70.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Jones, Frederic Wood, The principles of anatomy as seen in the hand, 2nd ed., Williams and Wilkins, Baltimore, 1942.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Hooton, Earnest A., Up from the ape, Macmillan, New York, 1931.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Meaning that digit corresponding to the ring finger in man. Among anatomists generally, at least two systems for identifying hand digits are in accepted scientific usage, often interchangeably by the same writer. A common convention is to number the digits from I to V, beginning with the thumb as digit I and ending with the little finger as digit V (Fig. 1). But many competent writers, thinking of the hand as having a thumb and four fingers, label the fingers as first, second, third, and fourth, meaning the index finger, the middle finger, the ring finger, and the little finger or pinkie, respectively. Throughout this issue of Artificial Limbs, it is considered that the normal hand has five digits, one of which is a thumb, the other four being fingers. A digit is here referred to with the understanding that digit I is the thumb Fingers are referred to as being numbered beginning with the index finger as the first finger.-Ed.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Huxley, J., From fin to fingers: the evolution of man's hand, Illustrated London News, December 1930. pp. 1138-39.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Clark, W. E. Le Gros, Early forerunners of man; a morphological study of the evolutionary origin of the primates, Bailliere, Tindall, and Cox, London, 1934. pp. 103-140.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Ashley-Montagu, Francis M., On the primatethumb, Am. J. Phys. Anthropol., 16(2):291 (1931).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Schultz, Adolph H., Characters common to higher primates and characters specific for man, Quart. Rev. Biol., ll(4):425-455; ll(3):259-283, 434-437 (1936).</td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Schultz, Adolph H., The skeleton of the trunk and limbs of higher primates, Human Biol., 2(3):303 (1930).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Krogman, Wilton M., The anthropology of the hand, Ciba Symposia, 4(4):1294 (1942). '</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Ethel J. Alpenfels, D.Sc. </b></td></tr><tr><td class="clsTextSmall"> Professor of Anthropology, New York University, New York City.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1955_02_004/table1.jpg Figure 7 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-12.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. 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Alpenfels, D.Sc. * http://23.254.134.177/the.oandplibrary.org/files/original/fcf5e10ffc3bff3cb89b517eb63ea5a2.pdf 0b8215ed539490f64e8cf75633dbb151 http://23.254.134.177/the.oandplibrary.org/files/original/5df5af90029daa1b7947c5ee33d08bc8.jpg 949b68f099a2ded1f6d45b1a93835af6 http://23.254.134.177/the.oandplibrary.org/files/original/e885e588918c3f3ed5fed4be446f6515.jpg 9c9edb182b521a4f3c55907aac2c12c4 http://23.254.134.177/the.oandplibrary.org/files/original/8ae9ef1f9e51a1ffe5839ee578fde9ec.jpg 3e30a207b5d92d01eaba842dbb9ce17e http://23.254.134.177/the.oandplibrary.org/files/original/dc315daacc177135b612f6d9d75dac9f.jpg 80cbacdea646e05d40116aa522d6538c http://23.254.134.177/the.oandplibrary.org/files/original/d6a0e71d869fdf811919200fc92af175.jpg 8af7b934c360f7d8be36455e7d27b56d http://23.254.134.177/the.oandplibrary.org/files/original/dcd15d5b2cb3600bbb9a16ceee230a8a.jpg b4bee6b427deadb2481ef102215ea90d http://23.254.134.177/the.oandplibrary.org/files/original/fbab7c843102fc1a6a56f0387d6474e7.jpg eecb06f6a79e8bf93b309fd4571aa73e http://23.254.134.177/the.oandplibrary.org/files/original/a36d8df923391175c131cc2503b2ad4f.jpg f12d7502edc79a9815ea0effa5a61252 http://23.254.134.177/the.oandplibrary.org/files/original/65c39b075e4ed74821b311f1425e07fe.jpg 33cdcc9406cbfccab6083b95a496cd32 http://23.254.134.177/the.oandplibrary.org/files/original/7ad63a3c7138be2c4aeadf85e67c3352.jpg 7f4f5ea9d217ef6cb6424c830141f675 http://23.254.134.177/the.oandplibrary.org/files/original/2c83de4880188f302b29099589602a5f.jpg c8b1c39cf8255f9580c8abf663fd469e http://23.254.134.177/the.oandplibrary.org/files/original/ae139375a47c70c260990878a1f0ae09.jpg 9e529d7b3beb3edc4fb97f0b018934f9 http://23.254.134.177/the.oandplibrary.org/files/original/dddd1109e0786871b6890b901ad89193.jpg f0c7d156e4cf6e475c16a3ffd9013a96 http://23.254.134.177/the.oandplibrary.org/files/original/43b8b6068ae6129c2d30f9f07c50ffce.jpg a10cd2406b8ed3c261645d2669705d61 http://23.254.134.177/the.oandplibrary.org/files/original/6fc43a0cc84ce447ae02214678f3688f.jpg f11a6615dd5d7161c615453a358094c1 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Artificial Limbs: A Review of Current Developments Description An account of the resource The foundation of modern prosthetics can be directly traced to the coordinated efforts of the National Academy of Sciences under the various artificial limbs committees after the Second World War. America, at its height of post war efficiency and engineering acumen, set about to solve the burgeoning problem of amputees swelling an infrastructure of prosthetic delivery that was outmoded, outdated and unprepared. Artificial Limbs: A Review of Current Developments was an industry update of these research efforts and was published thirty-three times, spanning the years 1954 to 1972. DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_01_035.pdf Year 1955 Volume 2 Issue 1 Page Number(s) 35 - 60 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_01_035.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_01_035.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Functional Considerations in the Fitting of Above Knee Prostheses</h2> <h5>Charles W. Radcliffe, M.S., M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>In the fitting of any artificial limb, the goal of the prosthetist is simply to restore to the amputee the ability to perform everyday activities in an easy, natural, and comfortable manner. The basic requirements are therefore three in number-comfort, function, and appearance, the latter embracing both cosmetic appearance and appearance in use. Unless a prosthesis is reasonably comfortable, the amputee will be unable to wear it. Unless it performs the necessary functions with reasonable ease and dexterity, the amputee is not apt to find the device very useful. Unless it is reasonably acceptable cosmetically, and unless it can be operated in a natural manner, the limb is likely to be disagreeable both to the wearer and to his friends and associates. But this seemingly simple set of requirements is vastly complicated by the fact that the three are all mutually interrelated. That is to say, the degree of satisfaction attained in one condition is influenced greatly by the situation prevailing with respect to the other two. Cosmetic appearance, for example, is necessarily limited by details of mechanism, and vice versa. No matter how elaborate a prosthetic device may be, it cannot be made to function properly unless it can be manipulated with ease and without discomfort. And conversely, no device can be comfortable in use unless its functional characteristics are properly integrated with the residual biomechanics of the wearer. Any change aimed at improvement in one condition unavoidably affects the other two-sometimes favorably, sometimes unfavorably.</p> <p>In the lower extremity, cosmesis presents no serious problem. Since it is comparatively easy to fashion an artificial leg to an external shape and appearance more or less like that of its normal counterpart, and since in both sexes the lower extremity may be concealed beneath some sort of clothing, the actual cosmetic properties of a lower-extremity prosthesis amount to refinements to be added after all other requirements have been met. More critical in the lower extremity are comfort, function, and appearance in use. The leg prosthesis is in almost constant service, and it must provide both adequate support and a natural-appearing gait with as modest consumption of energy as possible. In fitting an above-knee limb, therefore, correct practices based on established biomechanical principles are mandatory if success is to be had.</p> <p> Because during all activities the suction-socket above-knee leg<a></a> is controlled by the amputee through the use of remaining hip musculature, every effort must be made to ensure that these muscles are used to the fullest possible extent without causing discomfort. The intent here<a style="text-decoration:none;">*</a> is to present the basic concepts that apply to the fitting of all above-knee prostheses, regardless of type of suspension, but which have particular application to the suction-socket above-knee leg. Although the details of fitting must necessarily be modified as dictated by the individual case, the basic features apply to all cases.</p> <h3>The Principles of Above-Knee Alignment</h3> <h4> Mediolateral Stability</h4> <p>When one watches the walk of a typical above-knee amputee, two characteristics of gait often are particularly apparent. First, sidesway, <i>i.e.,</i> lateral movement of the torso from side to side, is exaggerated. Second, the amputee usually walks with his feet farther apart than does a normal individual of similar build. The average individual walks in such a manner that the lateral distance between successive points of heel contact is from 2 to 4 in. In order for the gait of an amputee to appear as normal as possible, therefore, he must walk with a base equally narrow. The amputee with a walking base of from 6 to 12 in. never can achieve a normal gait appearance. If such an amputee is asked why he walks with a wide base, he usually gives as the reason that it is more comfortable or that he feels more secure with his feet farther apart. </p> <p>This circumstance is accounted for by the fact that, as an amputee attempts to walk with his feet closer together, certain functional requirements are placed upon the fit of the socket and upon orientation of the socket in space. In general, these requirements are not fulfilled in a prosthesis aligned for a wide-base gait. If an attempt is made to use such a prosthesis with a gait of narrow base, difficulties arise because certain forces come into play that cannot be accommodated by the stump in a comfortable manner. Although a poorly fitted prosthesis may be reasonably comfortable for many months provided the amputee walks so as to compensate for errors in fit and alignment, the same prosthesis may be very uncomfortable if the wearer attempts to change to a more normal-appearing gait. It is, however, possible to construct for the average above-knee amputee a prosthesis that allows a reasonably normal gait, that is comfortable in all normal activities, and that eliminates common points of stump irritation such as those in the crotch area and near the end of the femoral stump.</p> <h5> <i>The Weight-Bearing Line</i> </h5> <p>One of the most common terms used by the prosthetist in the fitting and alignment of an above-knee prosthesis is the "weight-bearing line." It serves as the guide for many phases of setting up the prosthesis, but its exact position is subject to considerable difference of opinion. One prosthetist may use a weight line drawn from the ischial tuberosity through the center of the ankle joint; a second may select a line falling along the medial side of the foot; and a third may advocate use of a line drawn from the geometric center of the socket at the ischial level to the center of the heel. It is possible to get many other definitions of the weight-bearing line. As a matter of fact, they probably are all equally helpful in the alignment of prostheses. In considering the manner in which the weight-bearing line is used, it becomes apparent immediately that such a line actually serves as a "reference line" or "construction line."</p> <p> In the discussion that follows, the term "weight line" is used to establish a mental picture of a theoretical line in space along which the force of the body weight acts. This concept differs from "weight-bearing line" in that "weight" is due to the gravitational attraction of the earth, whereas "weight-bearing" refers to the transmission of a force through the structural elements of the anatomy and the prosthesis. Although it would appear difficult to establish any one line which accounts for the net effect of the weight of the various and widely separated parts of the anatomy, that can be done in a theoretical, idealized way by defining a point within the body at which the effect of all body weight can be assumed to be concentrated. This point is usually designated as the "center of gravity" of the body as a whole. With all the weight assumed to be concentrated at the center of gravity, the body weight must then always be considered as acting directly downward from this point, as though it were a plumb bob suspended on a string hanging from the center of gravity. The string would represent the body weight line. A short definition of the weight line as shown in Figure <i>A</i> might read as follows: <i>The weight line of the body is a line through the center of gravity along which the body weight can be assumed to act vertically downward at all times.</i> </p> <h5> <i>Variations in Vertical Force</i> </h5> <p>Thus far we have considered only the effect of the body weight acting downward. For either an amputee or a person with two good legs, the body weight must be supported by the contact between foot and floor. For many reasons, the force of contact between foot and floor is very difficult to measure accurately because, for either foot, the contact force is extremely variable over the short time the foot is supporting weight. Shortly after the heel strikes the floor, the leg receives an initial load which, because of the slight reduction in the rate of progression of the body as a whole, quickly increases to a value greater than body weight. During the mid-portion of the stance phase, as the center of gravity of the body is reaching the lowest point in its path of motion, the load on the leg decreases to a value somewhat less than that of body weight. As the body is being elevated and propelled forward into the next step, the load builds up again to a value greater than that of body weight.</p> <h5> <i>Forces in Shear</i> </h5> <p>While all this is occurring, the person also is swaying from side to side and varying in speed slightly as he walks. This condition requires that the contact force must also provide some horizontal frictional forces along the floor, as everyone has realized after slipping on ice or when making a sharp turn. The forces acting on the foot during walking are, then, of two kinds-those acting perpendicular to the floor, which support the body weight, and those acting parallel to the floor, which are necessary to provide resistance to the impetus of the body moving forward, backward, or sideways.</p> <h5> <i>Floor Reaction and Load Line</i> </h5> <p> The total force exerted on the sole of the foot-the combination of all these effects-is known as the "floor reaction." It acts along the same line as does the total force exerted by the amputee on the socket of the prosthesis. The floor-reaction force is the load which the leg, whether normal or prosthetic, must transmit upward from the floor. In general, the line of these forces, known as the "load line" ( <b>Fig. 1</b> <i>B),</i> is not perpendicular to the floor but is directed upward, inward, and forward or backward with an inclination that varies continually during the time either foot is supporting the body. It is very definitely not a line drawn from the center of the hip joint through the knee and ankle joints. A line so drawn should, instead, be designated as the "mechanical axis of the lower extremity." </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 1. Definitions in alignment of the lower-extremity prosthesis. A, The "center of gravity" of the body is a point at which all body weight can be assumed to be concentrated. The effective body weight passes through the center of gravity and acts vertically downward along the "weight line." B, The "load line" is a line along which the force between the foot and the floor acts. In general, it is not perpendicular to the floor surface, since this force has two effects. First, it supports the body weight in a vertical direction, and second, it provides the horizontal forces necessary to cause motion of the body in the forward and medial directions. C, The "support line" is a vertical line along which the effective supporting force exerted between the rim of the socket and the stump of the amputee is assumed to act. In general, the support line does not pass through the center of gravity or through the center of foot pressure.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5> <i>The Support Line</i> </h5> <p> An additional necessary concept is that of the "support line" (<b>Fig. 1</b>). In order to define the support line, it is necessary first to identify a "support point," which may be defined as the center of action of all the vertical supporting forces at the top rim of the socket, including the ischial-bearing force, support in the gluteal region, and support in other weight-bearing areas around the socket rim. Where such a point lies is very difficult to establish, its actual location depending largely upon the individual prosthetist's methods of fitting. In a typical ischial-bearing socket, the support point is probably somewhere anterior and lateral to the point of contact of the socket with the ischial tuberosity. The support line is defined as a vertical or plumb line, passing through the support point, along which the effective supporting force between the socket rim and the stump can be assumed to act. In general, the support line coincides neither with the weight line nor with the load line. </p> <h5> <i>Use of the Hip Abductors</i> </h5> <p> <b>Fig. 2</b> presents a rear view of an above-knee amputee, walking with a narrow base, at an instant during the walking cycle when the full weight is carried on the prosthesis. During the stance phase, the amputee, like the normal individual<a></a>, keeps his pelvis horizontal primarily by action of the hip abductors on the supporting side, as shown by abductor tension in <b>Fig. 1</b>. If, for one reason or another, the hip abductors are unable to exert the necessary force, the pelvis has a tendency to drop toward the unsupported side. When, therefore, the above-knee amputee stands upon his prosthesis, his pelvis may tend to drop toward the normal side owing either to inadequate hip abductors or to inadequate support on the lateral side of the stump-support which is necessary to stabilize the femur and to form a firm base for action of the hip-abductor musculature. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 2. Use of the hill abductors for lateral stabilization of the pelvis.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Dropping of the pelvis toward the normal side generally results in an increase in pressure in the crotch area. It often allows the pubic ramus to come into contact with the medial wall of the socket and .an therefore be extremely uncomfortable. Anticipating this action, the amputee makes appropriate compensation. He maintains his balance either by leaning over the prosthesis, which results in the familiar amputee list, or by walking with a wide base and swaying from side to side. In the alignment of an above-knee prosthesis, then, one of the most important objectives is to construct the prosthesis in such a way that the hip abductors may be used in a normal and comfortable manner to prevent this tendency toward pelvic drop, torso list, or sidesway, and to allow a reasonably normal and comfortable gait.</p> <h5> <i>The Pelvic Lever</i> </h5> <p> As indicated in <b>Fig. 1</b> <i>A</i>, the center of gravity of the body is defined as the point at which the entire weight would have to be concentrated were it to have the same effect on the body as a whole as does the actual weight distribution. On the strength of this concept, the pelvis can be assumed to act as a lever in the stance phase while the amputee supports his weight on the prosthesis <b>Fig. 3</b>. Using the ischium as a supporting pivot or fulcrum, the pelvic lever supports the body weight (which acts vertically downward through the center of gravity and along the weight line) by the balancing action of the hip abductors, the process being similar to normal hip action in which vertical support is through the hip joint. If this lever action is to prevent dropping of the pelvis toward the unsupported side, the tension in the hip abductors must be sufficient to balance the body weight. The abductor muscle force can perform this function only if abduction of the stump is prevented by firm contact against the lateral wall of the socket. Otherwise the muscle action would simply cause abduction of the femoral stump inside the socket. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 3. Lever action of the pelvis in stabilization of the torso.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5> <i>Distribution of Lateral Pressure</i> </h5> <p> The necessary stabilization of the stump against the lateral wall of the socket can be accomplished comfortably if the stabilizing pressure is distributed widely over the lateral side. For a stump of average length, stabilization is achieved by fitting the lateral wall snugly over its entire length. A slight flattening of the lateral wall, with relief near the distal end of the femur, usually ensures that the stabilizing forces are not only comfortable but that they are directed medially as required <b>Fig. 2</b>. If, with the stump improperly supported against the lateral wall, an attempt is made to use the hip abductors for pelvic stabilization, the result may be a gap around the lateral brim and a painful concentration of pressure near the end of the stump. </p> <h5> <i>Considerations of Mechanical Advantage</i> </h5> <p> Two other factors enter into the lateral stabilization of the pelvis by the hip abductors. First, in balancing the body weight on the ischial fulcrum, the tension in the hip abductors has greatest mechanical advantage when the lever arm between the abductor tension and the support point is as long as possible. Support of a substantial portion of the body weight by the ischial seat and of a smaller amount by the gluteal musculature gives the abductor tension sufficient mechanical advantage to balance the body weight with little or no conscious effort on the part of the amputee. The characteristics of this lever system are shown in the schematic diagram of <b>Fig. 3</b> , where the required tension <i>T</i> is reduced by decreasing the distance <i>x</i> and increasing the distance <i>y.</i> </p> <h5> <i>Adduction of the Stump</i> </h5> <p> A second factor in making allowance for normal use of the hip abductors is the degree of stump adduction in the socket. The "rest-length" theory of muscle action<a></a> has shown that the muscles of the body act most efficiently when they are at approximately their normal rest length. To make the action of the hip abductors efficient, the stump, when fitted in the socket, must be adducted in such a manner that the outward movement of the femur within the muscle mass of the stump is anticipated and that the normal pelvic-femoral angle is maintained as closely as possible while the body weight is being supported on the prosthesis. For the average amputee, this requirement can be met in a practical way by aligning the medial wall of the socket perpendicular to the floor, the lateral wall being sloped definitely inward. Although exceptions are necessitated on the basis of stump length, the short stump being aligned with less adduction, every effort should be made to adduct the stump as much as conditions permit. </p> <p> An additional advantage of alignment in adduction becomes apparent immediately. As a result of the accompanying decrease in tension of the adductor musculature, pressure in the crotch area is decreased. As a result of this relaxation, the pressure in the crotch or medial area (<b>Fig. 2</b>) is then predominantly lateral rather than vertical and no longer causes painful pressure on stretched adductor tendons or in the region of the ramus. It should be emphasized here that a socket properly fitted and aligned carries little or no weight on the medial wall. </p> <h5> <i>Foot Position</i> </h5> <p> Alignment of the foot in a medial position, a fundamental consideration if the amputee is to walk without excessive sidesway or torso list, helps to ensure that the body weight will be borne chiefly on the ischial seat. The average amputee walks well with the centerline of the foot located directly below the ischium during the time the prosthesis is supporting the entire body weight. But this rule-of-thumb, illustrated by the reference line shown in <b>Fig. 2</b>, must vary depending upon the capacity of the amputee to use his hip abductors. If an amputee with a very short stump attempts to use it for lateral stabilization, he cannot tolerate the increased and usually localized pressure resulting from the short stump length and the concentration of force in a small area. He must, therefore, walk with more limited use of his hip abductors, and compensation is effected by leaning over the prosthesis to shift the weight line closer to the support line and by walking with a wider base, an expedient which increases lateral stability but leads to excessive sidesway. Because of these factors, and because of the probability in such cases of some degree of abduction contracture, the amputee with a very short stump should have his prosthesis aligned to accommodate a gait of wider base. </p> <h5> <i>Recapitulation</i> </h5> <p>In summary, mediolateral stabilization of the pelvis accompanied by a decrease in the amount of sidesway and list can be achieved by alignment of the foot in a medial position relative to the socket, by fitting the stump in an adducted position where possible, and by providing firm support for the stump against the lateral wall of the socket to allow efficient use of the remaining abductor musculature of the hip.</p> <h4>Knee Control</h4> <h5> <i>Involuntary Control</i> </h5> <p> Generally, the tendency of the articulated knee joint of the above-knee prosthesis to collapse under load is controlled involuntarily through alignment or by mechanical devices which lock or restrain flexion while the body weight is being transferred through the prosthesis.<a></a> Although involuntary control is desirable as an aid in achieving a smooth and natural-appearing gait, a proper balance must be obtained between the amount of involuntary and voluntary control of knee stability, taking into account the amputee's coordination and age and the condition of his stump. </p> <p>Involuntary control of knee stability during weight-bearing is made possible by so placing the knee axis that it is at all times posterior to the load line of the prosthesis<a></a>. A prosthesis with the socket placed well forward on the knee block or aligned in hyperextension and with the knee joint located posterior to the ankle joint is said to have a high degree of "alignment stability." That is to say, under load the knee joint is forced to extend until the extension stop makes contact and prevents further motion. This expedient often is necessary for amputees who have a fear of falling or when it is required because of age, insufficient stump power, excessive weight, or the prevailing terrain. But it has the disadvantage of making the prosthetic knee hard to flex under even a light load and thus results in poor gait and difficulty in negotiating stairs and slopes. </p> <h5> <i>Voluntary Control</i> </h5> <p> An attempt should therefore always be made to minimize the amount of involuntary alignment stability and to provide for a maximum of voluntary knee control by stump action because this type of functioning results in the smoothest and most effortless gait possible. The average above-knee amputee has a reasonable amount of strength remaining in his hip flexors and extensors and is able to extend and flex his stump throughout an appreciable range of motion, and it is important that the fullest use be made of this musculature in voluntary control of knee stability. That this control may be exercised in the most efficient manner possible, the stump should never approach the limits of its motion as the amputee performs normal activities. If, for example, the stump is able to extend a maximum of 20 deg. to the rear, then at push-off any forced extension in excess of the 20 deg. results in a forward rotation of the pelvis. To compensate for such a forward pelvic rotation, the amputee must arch his back, an expedient which leads to the development of lordosis. Alignment of the socket in a position of initial flexion, as shown in <b>Fig. 4</b>, eliminates much of this difficulty. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 4. Influence of alignment on control of knee stability, socket aligned in initial flexion to avoid exces. sive pelvic rotation.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5> <i>Initial Flexion</i> </h5> <p>When the socket is aligned with initial flexion, several other advantages become apparent. Since the length of the hip extensors is increased by the additional degree of hip flexion, the amputee has greater control of knee stability during the entire stance phase of the walking cycle. Since the extensor muscles are thus elongated slightly, they are able to develop the required tension easily. With much less conscious effort on the part of the amputee, therefore, the stump is able to exert the force necessary to keep the prosthetic knee back against its extension stop.</p> <p> Again, in an amputee with overdeveloped hamstring musculature there often is a tendency, as the stump extends at push-off, for the muscles to force the tuberosity of the ischium off the ischial seat, thereby causing pressure on the hamstring muscle and attachments and against the anterior brim of the socket. Initial flexion of the socket reduces this tendency and allows a portion of the body weight to be borne comfortably upon the hamstring attachments.<a style="text-decoration:none;">*</a> </p> <p>If the same degree of alignment stability is to be maintained, initial flexion of the socket must be accompanied by a shifting of the socket anterior to the knee axis. Merely changing the extension stop to decrease knee extension never can achieve the desired end-results. But less alignment stability is necessary under these conditions because of the increased voluntary control of the knee. Anterior positioning of the socket relative to the knee axis allows the prosthetic knee to be flexed a great deal more easily as weight is transferred from the prosthesis to the normal leg at the end of the stance phase. The result is a smoother gait. Although increased use of the hip extensors owing to their greater working length produces some decrease in the power available in the hip flexors, the loss is not serious since during ordinary activities the hip flexors never approach the limit of their range of flexion and since the force requirements are small as compared with those of the hip extensors.</p> <h5> <i>Ankle Position and Toe Break</i> </h5> <p> Another important factor in achieving the proper amount of knee stability is the fore-aft position of the ankle joint relative to the knee joint. For the active above-knee amputee, it usually is desirable to have the ankle joint directly below or slightly posterior to the knee joint, as shown in <b>Fig. 4</b>. Such an arrangement has several effects. First, as the foot is moved to the rear, the distance out to the toe break decreases to give the foot more of a "rocker" action and to allow the knee to flex easily at the end of the stance phase. Second, the major portion of the weight can be carried on the ball of the foot while standing. And third, the amount of toe clearance during walking is greater for a given angle of knee flexion. To move the ankle joint too far to the rear, however, results in instability at heel contact and excessive shortening of the stride. </p> <p> Many of these advantages can be achieved by use of a double toe break <i>(i.e.,</i> a flexible forefoot), which also gives the foot more of a rocker action and decreases the amount of vaulting over the prosthetic foot. But too much flexibility or too short a distance from ankle to toe break causes the leg to feel too short at the time of push-off. </p> <h3>Dynamic Alignment</h3> <p>For the major part of the time that the amputee is supporting himself on the prosthesis during the stance phase, the motions are relatively smooth, and the forces act on the prosthesis in essentially the same way as if the amputee were standing still with all weight carried on the artificial leg. During the swing phase, however, and during the times of transition from stance to swing and from swing to stance, the behavior of the prosthesis is influenced largely by dynamic forces varying rapidly with time. It is often relatively easy to fit an amputee so that he is comfortable in the stance phase, but in many cases it is more difficult to construct the prosthesis so that the amputee is able to walk with a smooth, natural-appearing, effortless swing-through. The first requirement for a smooth swing phase is a smooth transition from stance to swing, since, if the prosthesis is to swing properly, it must be given a good start.</p> <h5> <i>Knee Stability and Toe Break</i> </h5> <p>Of particular importance during these transition periods are knee stability, as affected by alignment and by the stiffness of dorsi-fiexion and plantar flexion at the ankle, and the combined effect of toe-out and orientation of the toe break in the foot. For security, the knee axis should be positioned far enough behind the hip-ankle line so that the amputee is conscious of a stable knee while standing. The amount of security desired depends upon the particular amputee. If, as the amputee attempts to walk, the knee feels insecure, the dorsiflexion position and stiffness in the ankle should be investigated as a possible additional cause of knee instability.</p> <p>In general, placing a stiff dorsiflexion bumper in the ankle and having the foot plantar-flexed in the neutral position, close to the point where the amputee has the sensation of "walking over a hill," produces the most desirable knee stability and allows smooth flexion of the knee at the start of the swing phase. The amount of toe-out usually is adjusted to the individual amputee. In all cases, however, the toe break should be at right angles to the line of progression to prevent insecurity resulting from the rapid shifting of the center of pressure during push-off.</p> <h5> <i>Whip in the Swing Phase</i> </h5> <p> One of the more obvious indications of poor dynamic alignment is the so-called "whip" of the prosthesis during the swing-through (<b>Fig. 5</b>). This lateral movement of the knee accompanied by medial movement of the foot, or vice versa, usually is caused by an incorrect amount of adduction for the particular socket being fitted, an improper angle of the knee axis with respect to the frontal plane, the natural tendency of the femoral stump to twist inward as it is brought forward, or a combination of these factors. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 5. Common indications of incorrect alignment. A, Whip of the prosthesis during the swing phase. B, Mediolateral instability. C, Rotation at heel contact. For specific causes of these difficulties, see Radcliffe (10).</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>An above-knee prosthesis often is "knocked" at the knee to position the foot laterally for greater stability while standing. Sufficient two-leg standing stability thus can be attained, but a stable, narrow-base gait is not then possible. The tendency of the prosthesis to whip also is aggravated because, as it swings like a pendulum, the leg has a natural tendency to swerve medially after toe-off and then to swerve out again just before heel contact. A prosthesis having the foot aligned medially for a narrow base during the stance phase need only move forward in a straight line from toe-off to heel contact.</p> <h5> <i>Rotation of Knee Axis</i> </h5> <p> Studies of normal human locomotion<a></a> show that the femur rotates an average of 3 to 4 deg. medially as the hip is flexed to bring the knee forward. Medial rotation of the femur causes a lateral displacement of the foot, as can be verified easily by observation of a person standing and flexing the hip while the shank hangs vertically. Accordingly, the knee axis in an above-knee prosthesis usually is rotated laterally to compensate for the tendency of the femur to rotate medially as the hip is flexed.<a style="text-decoration:none;">*</a> When the prosthetic knee axis is aligned in a position laterally rotated with respect to the socket, the foot moves somewhat medially with knee flexion, thus compensating for lateral movement of the foot caused by the medial rotation of the socket during the swing phase and allowing the foot to travel in a straight path. </p> <h5> <i>Ankle Stiffness</i> </h5> <p>The stiffness of plantar flexion at the ankle determines, to a large degree, the stability of the knee at heel contact. A stiff ankle does not allow the foot to rotate forward into the stable flat position and thus tends to cause the knee to buckle forward as the weight is transferred to the prosthesis. An ankle joint with insufficient plantar-flexion stiffness, however, allows the foot to slap at heel contact. A proper balance between these two effects must therefore be attained for the individual amputee. Proper swing-through is achieved by proper dynamic alignment, which, in turn, is effected by a comfortable, stable, and functional prosthesis in the stance phase; a smooth transition from stance to swing phase; proper ankle stiffness; and adjustment of the knee axis in lateral rotation to compensate for medial rotation of the stump during hip flexion.</p> <h4>Socket Shape and Orientation</h4> <p>Considered thus far are the means by which the amputee can make most efficient use of the remaining hip musculature to control body movements and to control the prosthetic knee during the stance and swing phases. There are, however, many functional details of socket shape and fit which make it possible for the amputee to derive these benefits comfortably.</p> <h5> <i>The Lateral Wall</i> </h5> <p>As already indicated, for the amputee having sufficient stump length and power, sidesway and leaning over the prosthesis during the stance phase can be eliminated almost entirely by making provision in the socket for full use of the remaining abductor muscles of the hip, primarily the gluteus medius. This can be achieved in two ways. First, the stump is adducted in the socket so that the lateral wall is sloped downward and inward, the medial wall remaining essentially vertical. Second, a slight flattening of the lateral wall, and undercutting for relief of pressure points where necessary, ensures a comfortable distribution of the pressure directed medially against the stump. The hip abductors then can develop tension as needed because the excursion of the femur is blocked comfortably against the lateral wall of the socket. If, after the fit of the lateral wall is considered satisfactory, the socket is too tight, relief should be provided along the medial wall of the socket to avoid disturbing the fit required to block excursion of the femur.</p> <h5> <i>The Anterior Wall</i> </h5> <p>The lateral pressures, acting with the horizontal counterpressures in the upper portion of the medial wall, tend to maintain the ischium on its seat medially. To hold the ischium in place still more firmly, it is necessary to provide stabilization at the front of the socket. Accordingly, the anterior wall of the socket should fit the stump firmly in the area of Scarpa's triangle, and a very accurate measurement should be made of the distance from the ischial tuberosity to the tendon of the adductor longus so that the anteromedial apex may be fitted snugly around the adductor tendons. The socket brim should be rounded and fitted high on the anterior side. If fitted properly, the anterior brim usually can be brought up to the level of the inguinal crease without producing discomfort when the wearer is seated. The actual height of the anterior brim varies with the individual and is limited by contact with bony prominences. It usually extends from 2 to 2-1/2 in. higher than the ischial seat, but it should extend at least high enough so that the brim will press into the abdominal muscles rather than pinch a roll of flesh near the top of the stump. Distributed over the upper portion of the entire anterior wall of the socket, such anterior counter-pressure easily can prevent the ischium from sliding into the socket and can prevent the discomfort that would result in the crotch area.</p> <h5> <i>The Adductor Region</i> </h5> <p>Incorporation of the proper distance from the adductor tendons to the ischial tuberosity, combined with a well-fitted, high, anterior brim, usually eliminates entirely any unwanted pressure in the crotch area. Some lateral counterstabilization by pressure in the crotch area is unavoidable, but it should be predominantly by lateral rather than by vertical pressure, and it can be tolerated comfortably if distributed over the widest possible area. Flattening the medial wall of the socket is one means of ensuring a comfortable distribution of pressure in the adductor region.</p> <h5> <i>The Anteroposterior Dimension</i> </h5> <p>Weight-bearing in the gluteal region makes it possible to reduce the size of the ischial seat. If the anteroposterior dimension is shortened, the socket may be widened in the mediolateral dimension, a feature having several advantages. First, it allows a greater area for gluteal weight-bearing on the posterior rim of the socket. Second, the ischium is moved laterally, allowing the ramus to be carried within the brim of the socket and thus easing a major source of irritation. Finally, because the ischium bears no weight in the posteromedial apex, there is less tendency for crowding of the adductor and hamstring musculature. Relaxation in this area owing to stump adduction also helps to relieve uncomfortable vertical pressures.</p> <h5> <i>Shape at Ischial Level</i> </h5> <p> As a result of these functional requirements, the socket shape shown in <b>Fig. 6</b> has evolved. When coupled with the proper alignment, it has proved to be extremely beneficial to the average amputee. As with any method of fitting, variations in shape must be made in accordance with the muscular development and condition of the individual stump. The influence of muscular development at the ischial level is shown in (<b>Fig. 7</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 6. Anatomical features of an above-knee stump in weight-bearing, shown in cross section 1/2 in. below schial level.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 7. Influence of stump muscular development on socket shape at ischial level.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Entrances of the adductor tendons in the anteromedial apex, shown as <i>A</i> in <b>Fig. 6</b>, can be made more comfortable by a slight flaring of the socket brim in this region. Flaring of the socket brim in the hamstring area <i>B</i> has no function while the amputee is walking, but it contributes remarkably to his comfort while sitting. Many amputees experience a burning sensation while sitting because the hamstring attachments attempt to stretch over an ischial seat located high or medially, especially when the ischial seat has been placed diagonally across the posteromedial apex. The socket shape shown in <b>Fig. 6</b>, however, allows the ischial seat to be placed laterally to provide relief in the hamstring region and does not disturb the functioning of the limb during walking. </p> <h3>Construction of the Socket</h3> <h4>Stump Examination and Measurements</h4> <p>Before construction of an above-knee prosthesis is started, it is essential that a very careful evaluation be made of the amputee and his stump. A prosthesis may thus be planned and constructed to take full advantage of the individual patient's capabilities. Of particular importance is a thorough examination of the stump with regard to its functional characteristics. Answers to the following questions are helpful in planning the prosthesis, and they should be included in the examination data:</p> <ol> <li> What degree of stump flexion contracture is present? </li><li> What degree of stump abduction contracture is present? </li><li> Is the stump musculature soft, average, or hard? </li><li> Is the hamstring group soft, average, hard, or prominent under tension? </li><li> Is the gluteal group soft, average, hard, or prominent with stump extension? </li><li> Is the stump contour along the lateral side convex, concave, or essentially flat? </li><li> Is the rectus femoris muscle prominent with stump flexion? </li><li> Is the adductor longus soft, average, or hard? </li><li> Is the ischium toughened, pressure sensitive, padded with muscle, or prominent? </li><li> Has the amputee been accustomed to ischial-bearing? </li><li> What is the amount and location of redundant tissue? </li><li> What is the extent, location, and adherence of scars? </li><li> Are there areas of prior irritation as shown by blisters, boils, pimples, scars, darkened skin areas, and so forth? </li><li> Are there areas which are sensitive because of bone spurs or other prominences? </li><li> Is there any prior history of edema? </li></ol> <p> In addition to this general information about the condition of the stump, which can be recorded on a form such as <b>Fig. 8</b> <i>8A,</i> the series of measurements indicated in <b>Fig. 8</b> <i>8B</i> should be recorded carefully. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 8A. Form used at the University of California for recording stump characteristics and measurements in above-knee fitting.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Planning the Socket Shape</h4> <p>After the information gathered during the examination is recorded, the limbfitter is ready to begin planning the prosthesis, a phase essential to proper fit. The socket contours and the over-all alignment to be incorporated into any lower-extremity prosthesis depend upon the interrelation of many factors. First, the amputee's general physical condition must be determined. Will the amputee be an active walker? Will ease of walking be more important than knee security, or vice versa? Has the amputee developed gait habits that require corrective training? Second, the stump must be evaluated on a functional basis. In terms of its potential usefulness in control of the prosthesis and of body movements, is it classed as short, medium, or long? Is there a normal range of motion in all directions? Are there any sensitive areas that restrict stump function? The answers to these questions affect the alignment of the prosthesis as well as the fit of the socket.</p> <p> It is important to plan for alignment before the socket contours are considered because the orientation of the socket on the stump and the alignment of the socket on the prosthesis may affect considerably the method of fitting the socket. Shown in <b>Fig. 8B</b> are some general features of alignment based upon the functional capacity of the stump-short, medium, and long. There are exceptions, of course, and these illustrations should serve only as a guide. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Figure 8B.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> After the general type of alignment has been decided upon, the necessary features can be incorporated into the orientation of the socket on the stump, a matter requiring a decision regarding the approximate amount of initial flexion and adduction to be anticipated in the final alignment. The socket contours are determined by reference to the information on stump muscle development recorded during the examination. <b>Fig. 7</b> shows a typical socket shape for an amputee of average musculature and indicates the variations possible with different types of stump muscle development. Undersize patterns for use in roughing out the socket contours are shown actual size in <b>Fig. 9</b> and <b>Fig. 10</b>. The dimensions shown along the medial side of the patterns are typical measurements of the distance from the ischial tuberosity to the anterior aspect of the adductor longus tendon. The perimeter measurements shown correspond to actual stump dimensions. But these patterns may require modification to provide for individual stump characteristics, an example of such a pattern modification being shown in <b>Fig. 11</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 9. Variations in alignment to accommodate stumps of different functional lengths. With the short stump, the slow or hesitant walker, having limited use of the hip abductors and extensors, needs considerable alignment stability. The moderate walker, with stump of medium functional length, has average use of the hip abductors and extensors. Alignment for the long stump is for an active walker having good use of the hip abductors and extensors.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 10. Undersize socket patterns (shown actual size) for stump with soft or average musculature,</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 11. Undersize socket patterns (shown actual size) for stump with firm musculature.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Materials</h4> <p>The primary features required of a material to be used in making a suction socket are ease in forming to the proper shape, adaptability to a surface finish which is nonirritating and easy to keep clean, and ease in making alterations as required by changes in the stump. Wood and plastic laminates have, so far, proved to be the most satisfactory. But major changes in the size of the stump often take place during the first several months of wear. Hence, wood is recommended for the first socket because it is relatively simple to shape and allows alterations to be made as required. After the stump size is stabilized, a socket can be made of plastic laminates, which seem better than wood because of their flexibility, their ability to stand cleansing with soap and hot water, and their greater resistance to the action of perspiration.</p> <h4>Shaping the Wooden Socket</h4> <p> The three stages in shaping a typical socket are shown in <b>Fig. 12</b>. In the first, the posteromedial shelf is cut after laying out the socket pattern on the top of the socket block. The ischiogluteal shelf is cut in such a way as to be horizontal when the socket is oriented vertically in space. For the average socket, the medial wall is parallel to the vertical reference line ( <b>Fig. 2</b> ), and therefore the horizontal ischiogluteal shelf is cut at right angles to the medial wall of the socket. After the ischiogluteal shelf is cut, the missing portion of the socket pattern line is transferred down to the ischial level. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 12. Modification of socket shape to accommodate individual stump characteristics.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The second construction stage shows the roughed-out socket, where considerable extra wood has been left above the ischial level to allow for the protrusion and flaring of the anterior brim in this area. The finished socket is shown in the third stage with all areas of the socket brim flared and rounded to prevent irritation of the stump, especially important in the anteromedial apex where the adductor longus tendon enters the socket.</p> <p> <b>Fig. 6</b> indicates the principle muscle groups and other anatomical features considered in preparing the patterns used as a guide in the preliminary layout of the socket outline. Because of the atrophy of certain muscle groups in the above-knee stump, and because the cross section shows the stump in the weight-bearing condition, the shape differs slightly from that of the normal. When the stump is bearing weight, it is necessarily compressed slightly in areas of relatively soft tissue which support load, such as the gluteal channel. </p> <h5> <i>The Lateral Wall</i> </h5> <p>The lateral side is always higher than the level of the ischial seat. In most cases, it is possible to extend it over the trochanter. To do so is especially important when the slump is short and when the height of the socket in this region may be required to maintain suction. If the muscular development requires it, the lateral side of the socket is, in some cases, undercut above the ischial level. Examination of the amputee determines the amount of undercut required, and, if it is necessary, it should be done with caution. The lateral wall should taper in acutely below the ischial level to provide adduction and lateral support for the femur upon weight-bearing above the distal end. Because the femur has been established as the body stabilizer during the stance phase, an undercut below the ischial level may distribute the pressure unevenly and thus allow most of the pressure to be taken at the top of the socket and near the distal end of the stump. The lateral wall should be shaped to fit the stump accurately and should, if necessary, be flattened to distribute the lateral-support pressure over a large area so that it can be tolerated comfortably.</p> <h5> <i>The Medial Wall</i> </h5> <p> The length of the crotch-line area that receives the adductor longus, gracilis, and adductor magnus muscles should be determined accurately by skeletal measurements. As indicated in <b>Fig. 11</b>, the measurement from the anterior aspect of the adductor longus tendon to the weight-bearing portion of the ischial tuberosity, less about half an inch, gives the approximate length of the medial side of the socket. In general, the upper third of the medial wall is flattened, and the superior brim is flared to prevent skin irritation. </p> <p>In almost every case, the crotch-line height varies with respect to the level of the ischial seat, but it should always be as high as is tolerable. In the typical socket, the crotch area is from 1/8 to 1/4 in. lower than the ischial seat. A pelvic tilt lowers the ramus of the ischium and may require a lowering of the medial side of the socket. In a properly fitted ischiogluteal weight-bearing socket, little or no weight should be borne on the medial side. From the ramus to the anteromedial apex, the medial brim can be raised as governed by comfort. If a medial adductor roll is present, the socket is enlarged slightly (never lowered) on the medial side to accommodate the excess tissue, which then is pulled into the socket and eventually diminishes.</p> <h5> <i>The Anteromedial Apex</i> </h5> <p> The socket shape at the anteromedial apex (<b>Fig. 6</b>) should conform to the contour of the adductor longus and gracilis muscles. The shape varies in each case, however, because these muscles form a cordlike tendon which must be fitted accurately. Tightness in this region, a common source of irritation in suction sockets, usually is caused by excessive length of the medial side of the socket. This condition allows the ischium to slide forward into the socket and to wedge the stump into the anteromedial apex. If tightness in the anteromedial apex persists, it is apt to be due to inadequate support of the stump across the anterior brim and down the anterior aspect of the adductor group. </p> <h5> <i>The Anterior Wall</i> </h5> <p>The primary function of the anterior brim of the socket is to maintain the ischium in place on the ischial seat so that ischial weight-bearing causes no discomfort. In many cases of amputees who are unable to tolerate ischial weight-bearing, the trouble can be traced to improper contact between ischium and socket. Ischial bearing on the edge of a flat ischial seat is especially uncomfortable. To maintain the ischium in place properly, considerable counterpressure from the front of the socket is required. Since, by and large, the portion of the stump in contact with the region of the anterior brim is soft tissue, some compression of the stump is necessary. This is accomplished by a flattening and inward protrusion of the anterior brim in the area of Scarpa's triangle.</p> <p>The upper portion of the anterior brim is fitted 2 to 2-1/2 in. higher than the ischial seat and with a generous flare along the superior brim. When the socket is fitted with such a "high front," the anterior brim can hold the ischium in place comfortably. The high front does not interfere with sitting or with the amputee's ability to bend over far enough to tie his shoes. As the stump is flexed, the higher brim of the socket is accommodated by the abdominal musculature and does not pinch a roll of flesh on the upper portion of the thigh. The brim should be lowered only as necessary to prevent contact with bony prominences such as the anterosuperior spine. A channel should be provided below the brim for the rectus femoris muscle, which usually becomes prominent with stump flexion.</p> <h5> <i>The Posterior Wall</i> </h5> <p>The back of an ischial-bearing socket deserves particular attention. Channelization for the gluteus maximus muscle depends on the individual, but, in most cases where there has been little atrophy or distortion, this region of the socket should be kept on the same level as the ischial seat with a gradual enlargement in the posterolateral apex. The gluteus muscle should carry a considerable amount of body weight on a flared socket brim.</p> <p>Relief for the adductor muscles or the crotch line often can be made by relieving the gluteus maximus. Too tight a fit over the gluteus maximus can cause crowding of the adductor muscles in the crotch section. If the space for the gluteus muscle is lowered and widened, the ischial tuberosity can be moved posteriorly and laterally on the ischial seat of the socket. Lowering this section, however, increases pressure on the ischial tuberosity and should, therefore, be avoided. Should additional room be needed within the socket, the lateral side of the gluteal region can be made wider. The gluteal area should be widened instead of cut deeper posteriorly because a deeper section forms a hump or radius on which the leg rotates during sitting and thus causes a burning sensation of the skin over the ischial tuberosity.</p> <p>The outside shape of the socket in the posterior region is important to sitting comfort, but no attempt should be made to complete its shaping until the inside has been made comfortable and until the leg has been aligned properly and tested by walking. After these things are done, the back then is flattened for comfort and alignment while sitting.</p> <h5> <i>The Ischial Seat</i> </h5> <p>The ischial seat cannot be overemphasized. It should be located accurately under the ischial tuberosity, and, in the determination of its location, individual variations in anatomy must be taken into account. The seat should be adequate but not so wide as to cause discomfort while sitting. Slipping of the ischial tuberosity either to the inside or to the outside of the seat, conditions which create a great deal of discomfort, can be prevented by shaping the bearing surface in such a way that the seat slopes slightly toward the inside of the socket to render it more comfortable. Sloping increases the radius of the edge of the ischial seat and lessens the burning sensation of the skin in this region.</p> <p>If the ischial seat is too prominent, or if the ischium rides on the edge of the seat, a jabbing sensation or a marked increase in pressure is felt near the end of the stance phase. Lowering the ischial seat allows more weight to be distributed to the gluteal region and, if the ischial tuberosity is located properly on the seat, results in less discomfort and a shorter break-in period.</p> <p>Amputees with highly developed stump muscles may not require a well-defined ischial seat. In some cases, the muscles may push the ischial seat away from the tuberosity of the ischium and cause the weight to be carried by the muscles around the top of the socket. Such a condition is not objectionable, provided that the socket is designed with proper modification of the ischial seat. Indeed, such a design may be necessary in unusual cases, as for example those with end-bearing stumps.</p> <h4>Special Considerations in the Suction Socket</h4> <h5> <i>Tightness of Fit</i> </h5> <p> In the case of the suction socket, better results are obtained by having proper contours than by having a tight fit .<a></a> If, in the course of donning the leg, much difficulty is encountered in removing the sock, the fit is too tight. The superior brim of the socket should fit the contour of the stump while the muscles are tensed, and the fit should be so accurate that the socket can be suspended for short periods by skin friction without the aid of negative pressure <i>(i.e.,</i> without a valve). </p> <h5> <i>Free Space Below the Stump End</i> </h5> <p>The volume of unoccupied space at the lower end of the suction socket is not critical in obtaining sufficient suction. In most cases, it is convenient to have approximately 2 in. of space below the end of the stump to provide room for installation of the valve and for elongation of the soft tissue. In general, the smaller the volume in the end of the socket the less the excursion, but in itself the amount of free volume has no significant effect on the magnitude of the negative pressure.</p> <h5> <i>End Bearing</i> </h5> <p>If it can be tolerated, end-bearing is recommended because it relieves the load on the ischium. Felt or foam-rubber padding placed in the bottom of the socket permits comfortable end-bearing, the thickness of the padding governing the amount of weight carried on the end of the stump. Although little free space remains in the socket, adequate suction and control are not affected. For example, Gritti-Stokes amputations, which are principally end-bearing, have been fitted successfully.</p> <h5> <i>Inside Finish</i> </h5> <p>No single recommendation is made regarding adequate nonirritating finishes. Industrial and perspiration-resistant lacquers common to the limb industry are being used routinely. Some subjects have reported slipping of the socket because of perspiration. In some cases, perspiration also has caused the lacquer finish to deteriorate and to produce a roughness resulting in skin irritation. In general, however, these industrial lacquers have proved satisfactory when applied according to manufacturers' specifications. In cases of excessive perspiration, the socket may have to be refinished every few months. Whenever perspiration creates a severe problem, the amputee should be referred to a dermatologist for possible treatment.</p> <h5> <i>Bottom Seal</i> </h5> <p>The bottom of the socket should be sealed with a piece of hard wood 1/8 in. thick or more, cut so that the surface goes along the grain, and sealed with a waterproof glue. The bottom may be given additional protection by applying a thin coating of one of the thermosetting plastics common to the limb industry.</p> <h5> <i>Control of Negative Pressure</i> </h5> <p>Several different types of valves have been used in suction sockets with good results. A simple type of plug valve with a manual suction release is satisfactory. Automatic expulsion valves permit some change of air in the socket, a beneficial feature during hot weather and at times when the amputee perspires. They have proved successful in all cases and are now in general use.</p> <p>The valve opening should be positioned for ease in removing the fitting sock when the leg is donned and for convenience in operating the manual control, and it should be placed where the distal end of the stump is least likely to touch the inner face of the valve. The optimum location is toward the front on the medial side below the stump end.</p> <p> The magnitude of the negative pressure or suction required to hold a suction socket in place is only slightly greater than the value given by dividing the weight of the prosthesis by the cross-sectional area of the stump near the distal end-in most cases about 1-1/2 lb. per sq. in. With the additional support given by contracting the stump muscles during each step, a negative pressure of 1-1/2 lb- Per sq. in. is sufficient. Some amputees prefer somewhat greater suction, with its accompanying feeling of security, but excessive suction may cause edema. A negative pressure greater than 1-1/2 lb. per sq. in. indicates the presence of forces tending to pull or push the leg off the stump. This action may occur when the stump muscles are contracted, or it may be caused by an improper fit resulting in constriction of the muscles. Use of a gauge for measuring the maximum negative pressure at the time of the rough and the final fittings serves as a check on the quality of fit and is essential to good and consistent results. </p> <p> Accurate records should be made of the variations in pressure inside the suction socket during normal walking. With the automatic expulsion valve now in general use, these records should show a small positive pressure during weight-bearing and a negative pressure when the leg is in the swing phase. ( <b>Fig. 13</b> ) is a record of the pressure variations in a suction socket during two complete walking steps, the valve used during this test permitting automatic exhaust starting at a positive pressure of 1/2 lb. per sq. in.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 13. Three stages in the construction of a wooden socket. A, Block cut to form posteromedial shelf. B, Roughed-out socket. C, Completed socket with inside finished and rawhide covering on outside.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The stiffness of the spring in the valve has, in itself, no direct effect on the magnitude of the maximum negative pressure. It does, however, allow a greater or lesser amount of air to be expelled with each step and thereby affects the amount of positive pressure developed during weight-bearing. Fairly high positive pressure within the socket during the stance phase generally is found desirable because it increases the pavex action of the socket on the stump, with consequent benefit to the circulation. High positive pressures help to control edema and to give the amputee a sense of "walking on air." But, as already mentioned, too great a positive pressure in the stance phase may tend to push the leg off or to increase the piston action of the stump in the socket. Springs permitting expulsion at a positive pressure of 1/2 <i>, 1-1/2</i> or 2 lb. per sq. in. now are commercially available. The choice should be based upon individual circumstances. Some leakage generally occurs either in the valve or between the socket wall and the stump. A regulated amount of leakage is, however, desirable because it relieves the suction during periods of inactivity. If the leak rate is too great, the leg may fall off or the piston action may be excessive and cause discomfort. If the leak rate is too small, however, edema may result. A good test for leak rate is to measure the time required for the negative pressure to drop to half its initial value while the prosthesis is suspended on the relaxed stump. If the time is 50 to 80 sec, the leak rate is satisfactory, but if it is greater than 100 sec, the manual release should be used during periods of inactivity. </p> <p>Conclusion In summary, then, it may be restated that, in the construction of an above-knee artificial leg, the objective of the prosthetist is to provide the wearer with optimum security in standing and walking, the best possible walking pattern, a minimum requirement for expenditure of energy in usual activities, and a generally comfortable leg that can be used more or less continuously without injuring the stump and without causing undesirable postural deformities. The above-knee prosthesis is called upon to replace as nearly as possible the functions of the normal leg, but it must do so under the influence of a residual motor mechanism deficient in power and sensory control. The necessary features are therefore to be obtained only by observance of certain functional rules established on the basis of anatomical, physiological, and mechanical considerations.</p> <p>Of first importance is that the prosthetist well understand the mutual interdependence of the details of alignment of the various components and of the fit and orientation of the socket. Since, unlike the normal limb, support in the above-knee prosthesis is not through the shaft of the femur but through some other axis, due cognizance needs to be taken of the new set of musculomechanical relationships and of the influence of these relationships on the static and dynamic characteristics of the artificial replacement. When proper compensation for these factors is made by the limbfitter, undesirable compensation by the amputee is avoided, while the requirements of comfort, function, and acceptable gait are satisfied. In no other way can so much satisfaction be afforded the above knee amputee.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 14. Typical pressure variation in an above-knee suction socket during level walking. Body weight: 145 lbs.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li> <p>Buchthal, Fritz, and E. Kaiser, Optimum mechanical conditions for work of skeletal muscle, Acta Psychiat. et Neurol., 24:333 (1949).</p> </li> <li> <p>Eberhart, Howard D., Verne T. Inman, and Boris Bresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</p> </li> <li> <p>Eberhart, Howard D., and Jim C. McKennon, Suction-socket suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</p> </li> <li> <p>Haddan, Chester C, and Atha Thomas, Status of the above-knee suction socket in the United Stales, Artificial Limbs, May 1954. p. 29.</p> </li> <li> <p>Inman, V. T., Functional aspects of the abductor muscles of the hip, J. Bone and Joint Surg., 29:607 (1947).</p> </li> <li> <p>Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</p> </li> <li> <p>Libet, B., H. J. Ralston, and B. Feinstein, Effect of stretch on action potentials in muscle, Biol. Bull., 101:194 (1951).</p> </li> <li> <p>Radcliffe, C. W., Use of the adjustable knee and alignment jig for the alignment of above knee prostheses, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, August 1951.</p> </li> <li> <p>Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954. p. 23ff.</p> </li> <li> <p>Radcliffe, Charles W., Alignment of the above-knee artificial leg, Chapter 21 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</p> </li> <li> <p>Ralston, H. J., Mechanics of voluntary muscle, Am. J. Phys. Med., 32:166 (1953).</p> </li> <li> <p>Ralston, H. J., H. D. Eberhart, V. T. Inman, and M. D. Shaffrath, Length-tension relationships in isolated human voluntary muscle, Proc. 17th Internat. Physiol. Cong., Oxford, 1947. p. 110.</p> </li> <li> <p>Ralston, H. J., V. T. Inman, L. A. Strait, and M. D. Shaffrath, Mechanics of human isolated voluntary muscle, Am. J. Physiol., 151:612 (1947).</p> </li> <li> <p>Ramsey, R. W., and S. F. Street, Isometric length-tension diagram of isolated skeletal muscle fibers of frog, J. Cell. and Comp. Physiol., 15:11 (1940).</p> </li> <li> <p>Schede, Franz, Theorelische Grundlagen fur den Bau von Kunstbeinen; insbesondere fur den Oberschenkelamputierten, Ztschr. f. orthopad. Chir., Supplement 39, Enke, Stuttgart, 1919.</p> </li> <li> <p>Schnur, Julius, Beinbelastungslinie und Schwerlinie, Medizinische-Technik, 5(3):54 (March 1951).</p> </li> <li> <p>Schnur, Julius, Die Aquilibral-Kontakt Prothese, Orthopadie-Technik, 4(2) :36 (February 1952).</p> </li> <li> <p>University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes.</p> </li> <li> <p>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, 3rd edition, April 1949.</p> </li> <li> <p>Wagner, Edmond M., and John G. Catranis, New</p> </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall"> Eberhart, Howard D., and Jim C. McKennon, Suction-socket suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The amount of medial rotation in the stump depends upon the inherent physiological characteristics of the hip joint and upon the loss of muscular function after amputation. Some amputees have even been observed to have lateral rotation of the stump upon hip flexion.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall"> Eberhart, Howard D., Verne T. Inman, and Boris Bresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall"> University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Too much initial flexion results in a decrease in stride length, which may be undesirable in some cases.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall"> Radcliffe, Charles W., Alignment of the above-knee artificial leg, Chapter 21 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall"> Wagner, Edmond M., and John G. Catranis, New </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall"> Buchthal, Fritz, and E. Kaiser, Optimum mechanical conditions for work of skeletal muscle, Acta Psychiat. et Neurol., 24:333 (1949). </td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall"> Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall"> Libet, B., H. J. Ralston, and B. Feinstein, Effect of stretch on action potentials in muscle, Biol. Bull., 101:194 (1951). </td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall"> Ralston, H. J., Mechanics of voluntary muscle, Am. J. Phys. Med., 32:166 (1953). </td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall"> Ralston, H. J., H. D. Eberhart, V. T. Inman, and M. D. Shaffrath, Length-tension relationships in isolated human voluntary muscle, Proc. 17th Internat. Physiol. Cong., Oxford, 1947. p. 110. </td></tr><tr><td class="clsTextSmall"><b> 13.</b> </td><td class="clsTextSmall"> Ralston, H. J., V. T. Inman, L. A. Strait, and M. D. Shaffrath, Mechanics of human isolated voluntary muscle, Am. J. Physiol., 151:612 (1947). </td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall"> Ramsey, R. W., and S. F. Street, Isometric length-tension diagram of isolated skeletal muscle fibers of frog, J. Cell. and Comp. Physiol., 15:11 (1940). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall"> Inman, V. T., Functional aspects of the abductor muscles of the hip, J. Bone and Joint Surg., 29:607 (1947). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">It should be understood that no new theory of alignment is intended, that the aim is simply to explain logically some of the problems facing prosthetists in the construction of above-knee legs and to provide rational solutions for those problems. The views presented are the combined result of experience gained at the University of California Prosthetic Devices Research Project during limbshop trials of the adjustable leg and alignment duplication jig(8,9,10) of a study of methods presently in use by the artificial-limb industry, and of a survey of information presented in the German literature.(15,16,17)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall"> Eberhart, Howard D., and Jim C. McKennon, Suction-socket suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall"> Haddan, Chester C, and Atha Thomas, Status of the above-knee suction socket in the United Stales, Artificial Limbs, May 1954. p. 29. </td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall"> University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, 3rd edition, April 1949. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Charles W. Radcliffe, M.S., M.E. </b></td></tr><tr><td class="clsTextSmall">Acting Assistant Professor of Engineering Design University of California, Berkeley; member, Technical Committee on Prosthetics, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-22.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-23.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-24.jpg Figure 4 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-25.jpg Figure 5 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-26.jpg Figure 6 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-27.jpg Figure 7 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-28.jpg Figure 8 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-29.jpg Figure 9 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-30.jpg Figure 10 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-31.jpg Figure 11 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-32.jpg Figure 12 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-33.jpg Figure 13 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-34.jpg Figure 14 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-35.jpg Figure 15 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-36.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Functional Considerations in the Fitting of Above Knee Prostheses Creator An entity primarily responsible for making the resource Charles W. Radcliffe, M.S., M.E. * http://23.254.134.177/the.oandplibrary.org/files/original/704be8285e9e81b00a548f4079273dd0.pdf 8d139ddf679c176348350d328a543afd http://23.254.134.177/the.oandplibrary.org/files/original/49cf18e648ecc82d654ec1eff2291631.jpg c1cfed36a05f0a2fc50153fd5c760913 http://23.254.134.177/the.oandplibrary.org/files/original/75674097e4e35c77fdec5a976ff86d62.jpg 9f31ccdf0294986d2aea9d550887f50f http://23.254.134.177/the.oandplibrary.org/files/original/6e8abc5344c8c89a34bb7bb7e58e2657.jpg 6093fff8491a17af6fc0bb951f2df011 http://23.254.134.177/the.oandplibrary.org/files/original/37d0211a1c3964d660b5475199ef272d.jpg e15ab0ecdc3c30f04f9a0f88d1e7f911 http://23.254.134.177/the.oandplibrary.org/files/original/074ff2c61033b2276ba9ba6b32d533dc.jpg 18833eb4185b3218e31d0f5a35889396 http://23.254.134.177/the.oandplibrary.org/files/original/25f6feb898b3105da3d22efedaad8b5f.jpg 14cd923437e363674f1305376f929c93 http://23.254.134.177/the.oandplibrary.org/files/original/98c6f90be1d6a610b1532fee234863eb.jpg 77448c6435f7e839884d481f8bb7c0bc http://23.254.134.177/the.oandplibrary.org/files/original/bf8014ecf9aef0436238851fa1474e8e.jpg a485adc4c47126a56ef395422b794cc0 http://23.254.134.177/the.oandplibrary.org/files/original/a3f8fed82c099bfaf63d22effee25dc9.jpg 3aafbd4368cc3968a6ed5d0bf3d576af http://23.254.134.177/the.oandplibrary.org/files/original/63989f61bdf02ae37100a3e5d28a3065.jpg 3b2ff7b083f358ef57a6a637a5333dc6 http://23.254.134.177/the.oandplibrary.org/files/original/6a514f0e2ba1bfd9ba93437672e576c3.jpg 17049ac032017d5b129e9629dd56a9f4 http://23.254.134.177/the.oandplibrary.org/files/original/dd2a27378293b40a365d988be7038823.jpg 487fe803ef2ffdf12201d3e066227729 http://23.254.134.177/the.oandplibrary.org/files/original/79421da1d5927a2f575339efaaae587a.jpg 7727b475ea61106ccba34b7e0a8fea80 http://23.254.134.177/the.oandplibrary.org/files/original/85780afcefa210b16b3180eb1a8a32c7.jpg 0929c4e5349737a970d707389cc7e591 http://23.254.134.177/the.oandplibrary.org/files/original/80b1690efe4254fee0a6b928f0221b73.jpg b35fcbb513359778fadce4c9655b88ac http://23.254.134.177/the.oandplibrary.org/files/original/a7b48775e41332452941b1805803de4f.jpg 2d1f4f535f9b9df473d2a83b9a61d6db http://23.254.134.177/the.oandplibrary.org/files/original/354cad5e63e3f2ee432a2a43b8af480f.jpg f54280fbcdcd946cade07b9a0e67cf76 http://23.254.134.177/the.oandplibrary.org/files/original/8932dd244d2f177f348642bab3474157.jpg a9162486c8f3c0b05d8e402bb14cb9cc http://23.254.134.177/the.oandplibrary.org/files/original/172fcac01d1f6b60da95c9da079d9b0c.jpg 29f465e6e6425c776b16326e64e5ec8a Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Artificial Limbs: A Review of Current Developments Description An account of the resource The foundation of modern prosthetics can be directly traced to the coordinated efforts of the National Academy of Sciences under the various artificial limbs committees after the Second World War. America, at its height of post war efficiency and engineering acumen, set about to solve the burgeoning problem of amputees swelling an infrastructure of prosthetic delivery that was outmoded, outdated and unprepared. Artificial Limbs: A Review of Current Developments was an industry update of these research efforts and was published thirty-three times, spanning the years 1954 to 1972. DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_01_004.pdf Year 1955 Volume 2 Issue 1 Page Number(s) 4 - 34 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_01_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_01_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Lower-Extremity Clinical Study-Its Background and Objectives</h2> <h5>VerneT. Inman, M.D., Ph.D., <a style="text-decoration:none;">*</a><br />Howard D. Eberhart, M.S. <a style="text-decoration:none;">*</a><br /></h5> <p> If it may be postulated correctly that the most satisfactory artificial leg is the one which most nearly simulates the static and dynamic behavior of the natural limb it replaces, the successful practice of lower-extremity prosthetics poses a twofold requirement. The first is an intimate and detailed knowledge of the characteristics of the normal leg in all common activities, and the second is the ability to reproduce as nearly as possible, by a combination of design and fit of the substitute limb, the kinetic and kinematic features essential to normal locomotion. In the Artificial Limb Program, principal responsibility for fundamental studies in normal and amputee gait and in lower-extremity prosthetics has, since 1945, resided in the Prosthetic Devices Research Project at the University of California, Berkeley Campus. </p> <p> But the problems facing the leg amputee are not wholly prosthetic. Many, indeed, are clearly medical. For the amputee, being no longer the whole normal individual, manifests gross structural and physiological changes to be dealt with successfully only by the physician. </p> <p> The Lower-Extremity Clinical Study being conducted jointly by the Department of Engineering, University of California, Berkeley, and the University of California Medical School, San Francisco, and in cooperation with the U. S. Naval Hospital, Oakland, has as its chief objectives the analysis of medical problems inherent in the amputated state and the application of fundamental knowledge to practical problems in the management of lower-extremity amputees. Current techniques and practices in the fitting of leg amputees still are so varied from place to place and from prosthetist to prosthetist that some orderly means has been wanting for establishing what is, everything considered, the best prosthetics practice in the lower extremity. Designed to close the gap between basic work in the laboratory and work in the field, the Clinical Study is an outgrowth of the fundamental research in locomotion conducted earlier by the Berkeley Project. </p> <h3>The Background </h3> <p> For a number of years during World War II a group at the University had been conducting research in the field of biomechanics and had published data relating to the behavior of the upper extremity. In the autumn of 1945, therefore, the University was approached by a representative of Northrop Aircraft, Inc., a company which at that time was already engaged in prosthetics research<a></a> under contract with the then Committee on Artificial Limbs of the National Academy of Sciences- National Research Council. It was requested that the University group undertake an investigation aimed at providing information that could be utilized in the design and construction of lower-extremity prostheses. </p> <p>The suggestion having been taken under advisement, the entire Committee on Artificial Limbs met at the University shortly thereafter to consider the proposal and to evolve details of contractual arrangement. Out of this meeting came two basic observations. One was that, inasmuch as the financial support for the work was to come from public funds, any information derived from the contract would have to be shared with all other contractors participating in the Artificial Limb Program as well as with the general public. The other was that, in the opinion of the conferees, between five and seven years of study would be required before sufficient detailed and quantitative information could be accumulated to effect substantial improvement in lower-extremity prostheses.<a></a> At the outset, the University group insisted that it be kept free of the task of developing prosthetic devices-that it simply be permitted to investigate normal human locomotion and to furnish the collected data for others to use. The original concept of the scope of the project-as a program of basic research in human locomotion-has been adhered to up to the present time, the only deviations having involved development of experimental devices<a></a> needed to assist in the locomotion studies. </p> <p> The early years, then, were spent in working out techniques suitable for recording objectively the motions and the forces involved in the gait of man.<a></a> Of course, the investigators took advantage of all the previous work in this field, not only that done by other contractors<a></a> participating in the Artificial Limb Program but also that contained in material, particularly that of Elftman<a></a> published in the United States and in foreign countries over a period of many years. By 1947, enough data had been accumulated to publish a comprehensive report<a></a> on the walking pattern of normals and of leg amputees.<a style="text-decoration:none;">*</a> </p> <p> Attempts to translate the results of basic research into criteria for the improvement of prosthetic devices led to the second phase of the project, that is, to developmental research, an area that involves engineering and prosthetics technology. During the last few years, this phase of the project has been conducted on a relatively small scale. As devices were prepared for trials by amputees, the problem of fit and alignment had to be attacked, and hence fundamental studies were undertaken in this area in order to establish a set of basic principles and techniques.<a></a> Because fitting and alignment contribute most to the comfort and therefore to the success of any artificial leg, the validation of these principles and techniques formed the basis for embarking on the third phase of the project, the Lower-Extremity Clinical Study, an activity that provides a laboratory where medical and prosthetic problems can be handled under controlled conditions. It offers an opportunity to see how individual solutions may be obtained by applying a set of general principles based on biomechanical considerations. Until recently, the study group has been concentrating on the problems of the above-knee amputee because that case appeared to offer neither the most difficult nor simplest set of circumstances. </p> <h4> The Locomotion Studies </h4> <h5> <i>Muscle Physiology</i> </h5> <p> When the Prosthetic Devices Research Project first was organized, man was viewed as a machine, the object being to measure the displacements, accelerations, and forces required in human locomotion.<a></a> But man is more than a single machine. He is powered by a complicated system of many internal engines served by muscles. Accordingly, the study was broadened to include the field of muscle physiology.<a></a> Investigation of the behavior of the musculature during normal locomotion (<b>Fig. 1</b>) revealed the basic action of the various muscles involved<a></a> It was shown that in locomotion each muscle acts when it is near its rest length but that it acts for a very short period of time in each walking cycle.<a></a> This action makes the contraction essentially isometric and limits the activity of each muscle fiber to a few twitches. Under these conditions the muscle works with minimal energy and maximum tension, which helps to explain why a person can walk considerable distances without tiring. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Typical electromyographic summary curves, in this case for the hamstring group. Ten subjects. Cadence: 95 steps per minute, level walking. Data from UC studies 102. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Upon working out the speed of contraction, it was found that, if muscles are halved, their contractile velocities likewise are halved (<b>Fig. 2</b>). Utilizing a profile electromyographic recording (electromyogram rectified and dampened to give a relatively smooth line), and taking the maximum amplitude in a given cycle as 100 percent, the average durations with an amplitude greater than 75, 50, or 25 percent are approximately 0.04, 0.1, and 0.2 second, respectively.<a></a> Since it seems probable that the profile electromyographic amplitude largely indicates relative numbers of active motor units, it would appear that most of the units participating in this phasic action are active during bursts of 0.1 to 0.2 second only. According to Weddell<a></a>, at a repetition rate of 20 per second or less most motor units would fire in each cycle one to four times only. In such a case, any temporal summation taking place at neuromuscular junctions would not be effective fully, and the action of a motor unit, at least in a normal phasic pattern like locomotion, would not have the character of a sustained tetanus. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Relation between the maximum speed with which a muscle can contract and the weight with which it is loaded. When the length of the muscle is halved, its speed of contraction is also halved. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> As a result of these investigations, in 1947 the group at Berkeley, noting the earlier work of Blix<a></a>, was first to call attention to the length-tension relationships existing in human muscles<a></a> and thus laid the basis for the decision to use certain muscles for the cineplastic technique.<a></a> The characteristics of the length-tension diagram have since proved to be of fundamental importance in devising prosthetic aids for upper-extremity amputees.<a></a> The cineplastic muscle tunnel, comprising a skin-lined tube placed through the distal end of a muscle, permits an amputee to utilize effectively his own muscle forces for activating an artificial arm or hand. But in order to operate a cineplastic prosthesis efficiently, it is necessary that the muscle be near its rest length, so that it can generate a force sufficiently large and so that it can shorten enough to carry out necessary movements.<a></a> Appearing in publications as early as 1949, the work conducted at the University of California has been recognized by Buchthal<a></a> of the University of Copenhagen as the best so far done on normal human muscle dynamics. </p> <h5> <i>Energy Requirements</i> </h5> <p> In another study, an investigation was made of the dissipation of energy (<b>Fig. 3</b>) in human locomotion.<a></a> Results showed that approximately 50 percent of the energy consumed in walking is used simply in bouncing up and down, that is, in vaulting over one leg and then the other. The other half is used in the oscillations of the legs. It is therefore apparent that, if the amputee is not to be subjected to unduly large energy demands, he must have a smooth pathway of displacement of the center of gravity of the body.<a></a> Any deviation from the smooth, natural locus of the center of gravity means excessive dissipation of energy and consequent degradation into heat.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 3. Typical moment-angle diagram for the leg of a normal subject during level walking. From Bressler [sic] and Berry (14). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Contrary to much popular belief, man not only pushes his way through space. He also <i>pulls </i>his way.<a></a> Indeed, deceleration of the swinging leg, not push-off from the other toe, provides the greater part of the energy for locomotion, the proportion attributable to deceleration of the swinging leg being about 4, that attributable to push-off only 3. Energy is absorbed by the knee to decelerate the leg and foot during the swing phase, but not all of the energy so absorbed is lost.<a></a> A considerable portion is stored and returned to the system in the later part of the swing phase to impart continued forward acceleration at the time when most of the body's potential energy is lost.<a></a> Thus locomotion is due not only to the push of the member in support but also to the pull of the deceleration in the swinging knee. </p> <p> Because the above-knee amputee has no calf group, and therefore cannot contribute the equivalent of this force at push-off, it was suggested that some conservation of energy might be effected in a prosthetic device without an ankle joint.<a></a> That this was a correct deduction has since been demonstrated (<b>Fig. 4</b>) in the Stewart-Vickers leg,<a></a> in which the ankle is locked at toe-off until 20 deg. of knee flexion has occurred.<a></a> It has the highest net output and the lowest total input of all legs tried to date (<b>Fig. 5</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 4. Cadence changes observed in above-knee amputees asked to walk at "normal" speed first with a conventional limb and then with the Stewart-Vickers (locked ankle) prosthesis 114. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Energy characteristics of the normal ankle compared with those of the conventional leg and the Stewart-Vickers leg. Top, total input, total output, and net output of both ankles per stride. Bottom, input and output of each ankle per step. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Amputee Pain </h4> <p> Intimate contact with amputees led to the early investigation of pain as related to the amputee patient.<a></a> In 1946 a team of interviewers set out to question amputees in various hospitals, particularly in the Veterans Administration Hospitals and in the Naval Hospital then at Mare Island. Over a period of a year and a half, detailed histories were obtained from 80 patients. As a result of this review, further funds were provided by ACAL to establish a Pain Clinic at the University of California, primarily to evaluate pain as found in the amputee. Established in August 1949, the clinic functioned until January 1953. </p> <p> In June 1952, an analysis of 218 amputees was reported.<a></a> In this study, which constitutes one of the largest series on record, the type and frequency of pain in the amputee were explored. Because it was thought that perhaps deficiencies in stump circulation might contribute to the pain experienced by the amputee, circulatory studies were undertaken. Concurrently, innervation of the deeper tissues was studied.<a></a> Sections of tissue were taken from periosteum, muscle, and skin, and the nerve supply to these tissues was demonstrated by a methylene blue technique. </p> <p> One of the most intriguing aspects of this investigation was the work with normal individuals in whom irritative lesions purposely were produced in the deeper tissues.<a></a> With the authors, some 75 medical students, and three laboratory assistants serving as subjects, 0.5 to 1.0 cc. of 6-percent saline solution was injected systematically into the paravertebral muscles at each intervertebral level from the atlanto-occipital area to the lower sacrum. Five subjects were used in the testing of each injection site, a total of 140 individual observations being made. Although the distribution of pain approximated a segmental plan, it also overlapped considerably and differed in location from the conventional dermatomes. It was found that, in any irritation of deep somatic tissues, pain did not restrict itself to the area of injection but tended to radiate distally into the extremities. Injection of 6-percent saline into any given interspinous level produced in the normal a characteristic pain distribution that was remarkably constant from subject to subject. The distribution of pain referral from deep structures in the normal suggested similar investigations in the amputee. To elicit the sensation of the phantom limb, it was necessary to inject the salt solution into the appropriate interspace. In the normal, radiation of pain into the lower limb was most marked when the interspinous tissue between L4 and L5 was affected, and in the above-knee amputee the L4-L5 interspace also gave the best response. The immediate reactions of amputees resembled those reported by normals-a rapid onset of pain close to the site of injection and then, in the case of L4-L5 injection, radiation into the buttocks and the posterolateral aspect of the thigh. In nearly all instances there occurred a rapid "filling" of the absent areas of the phantom limb, the subjects usually evidencing surprise at the sudden totality of a phantom limb even though the new portions were seldom, if ever, immediately painful. </p> <p> Severe pain was a frequent feature in the portion of the phantom present before injection. After injection the pain often spread into the newly "filled in" portion of the phantom limb. Transient pain following injection occurred in phantom limbs regardless of the existence of preinjection pain. But in many cases involving pre-existing phantom pain, a secondary decrease in the amount of pain followed the injection, in some but not in all instances the decrease being preceded by a transitory accentuation of the pre-existing pain. Occasionally, the decrease reached the point where no pain was felt, so that the amputee experienced the first complete relief in many months. </p> <p> The decrease in pain is even more remarkable when one considers that it is brought about by the application of a noxious stimulus to a tissue remote from the phantom itself. For example, in an above-knee amputee who had undergone amputation two months before the investigation, there was a phantom sensation of the "foot" only, the phantom being very painful with the sensation of severe constriction of the great "toe" (<b>Fig. 6</b>). When saline was injected into the L4-L5 interspace, much of the intervening phantom limb was filled in almost immediately, the anterior aspect of the "leg" becoming the most prominent part. Soon after the phantom was "completed," the preexisting pain in the "foot" increased in intensity and area. This state continued for five or six minutes, whereupon the pain began to decrease and continued to do so until, in another five minutes, it had disappeared completely. Numbness, but not pain, remained in the "foot" only. In some instances even phantom awareness disappeared after saline injection. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Effect of interspinous injection of saline on the painful phantom limb of one subject. A, Phantom before injection. B, Radiation of sensation induced by injection of 6-percent sodium chloride solution. C, Residual sensation following injection. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In general, the saline injections had greater effects on phantom limbs than on real ones, a peculiar susceptibility best illustrated by the effects of mid-line injections. An accurately placed mid-line injection in a normal subject produces very little radiation, the severe pain being confined to a rather small area in the immediate vicinity of the injection. In the case of the amputee, however, such minimal radiation in the trunk is accompanied by profound effects on the phantom extremity. Every conceivable change in phantom form and phantom pain can result from interspinous injection of an irritating hypertonic saline solution, the changes probably stemming from the sudden increase in the sensory inflow at the particular segmental level. </p> <p> Out of these observations came, then, one method of treating phantom pain, for when a small amount of hypertonic saline was injected into the appropriate segmental interspinous ligament, the phantom experience was changed and pain occasionally was relieved. This finding led to the use of hypertonic saline for the treatment of various painful conditions. Although permanent cures resulting from such techniques are not numerous, the method may prove to be a valuable addition to the modern medicine chest, which is by no means rich in effective pain palliatives.<a></a> </p> <p> It deserves to be noted that, in seeking the origin of the phantom experience, one must look not only for direct involvement of the nerves of major nerve trunks. The entire segment of the extremity must be investigated for any irritative skeletal lesions arising from the joints, the muscles, or the connective tissues of the stump or from portions proximal to the stump. </p> <h3> Evolution of Basic Data </h3> <p> From the basic studies now has come much information of value in prosthetics. As early as 1947 it was determined<a></a> that in normal walking the leg rotates in space internally and externally about 15 deg. on the average (<b>Fig. 7</b>). That this horizontal rotation of the extremity might be of some importance in human locomotion has since been known as the "Berkeley fetish," and as far as is known no one has yet taken cognizance of the fact in any successful limb design. In 1950 it was suggested<a></a> that it would be of considerable value if deceleration at the end of the swing phase could be incorporated through some sort of variable-cadence knee joint. This has been done in at least one device, the U.S. Navy above-knee leg,<a></a> now available commercially (see <i>Digest, </i>this issue, page 65). Several others currently are under development. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 7. Typical relative rotations of the pelvis, femur, and tibia in normal, level walking. Data from UC studies </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> At the same time it was suggested that, inasmuch as the above-knee amputee can obtain no forward propulsion by contraction of the calf group, the ankle joint is of little use- that, indeed, if an ankle joint with rubber bumpers is used, energy is lost by hysteresis of the bumpers. As already mentioned, the improved performance of the Stewart-Vickers leg, in which the ankle is locked at toe-off up to 20 deg. of knee flexion, proves the validity of the original observation. Similarly, it was pointed out that, because of the interrelationship between the ankle-foot function and the knee-joint function, greater stability would be required of the knee joint were the articulated ankle to be abandoned. </p> <p> In 1953, Saunders, Inman, and Eberhart<a></a>, summing up the results of all the basic studies, pointed out that there is an interrelationship between all displacement patterns of all segments of the lower extremity, that there are six major determinants in locomotion, that modification of one results in modification of the others, and that any changes in the knee or ankle, either in normal or in amputee, are necessarily accompanied by compensatory changes in the remaining joints. Basically, locomotion is the translation of the center of gravity through space along a pathway requiring the least expenditure of energy (<b>Fig. 8</b>). The six major determinants of the pathway are pelvic rotation, pelvic tilt, knee flexion, knee extension, knee and ankle interaction, and lateral displacement of the pelvis. Serial observations of irregularities in these determinants provide insight into individual variation and a dynamic assessment of pathological gait, which may be viewed as an attempt to preserve the lowest possible energy consumption by exaggerating motions at unaffected levels. Compensation is reasonably effective with the loss of one determinant, that at the knee being the most costly. Loss of two determinants makes effective compensation impossible, the cost of locomotion in terms of energy then being increased threefold, with an inevitable drain upon the body economy. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. The sum of the effects of the six determinants of gait. The pathway of the center of gravity is a smooth curve in both horizontal and vertical planes. From Saunders, Inman, and Eberhart<a></a>, by permission of The Journal of Bone and Joint Surgery. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> With regard to the surgery of amputation, the studies in muscle physiology suggested that considerable improvement might be effected in lower-extremity prosthetics were muscles fixed in the distal end of the stump so that they could not retract.<a></a> As previously pointed out, retraction of these muscles means shortening, and shortening means an inability to develop natural tensions. More recently the studies have suggested that, in order to retain normal weight-bearing through the shaft of the femur, more attention should be paid to the possibility of end-bearing rather than to the more conventional method of weight transmission through the ischial seat. All of these ideas, derived from the results of the early studies on locomotion, were offered to the limb industry by the University group in the hope that designers or manufacturers would incorporate the recommended features into new prostheses. </p> <h3> The Clinical Study </h3> <p> In the spring of 1953, after years of basic study, the question arose as to what might be done toward applying to the amputee problem some of the knowledge gained. After several months of discussion, the UC Prosthetic Devices Research Project accepted a proposal to institute the so-called "Clinical Study," the principal objective being to draw upon the pool of fundamental knowledge, to attempt to apply it toward the solution of practical problems, and to see whether or not there would emerge certain definite devices or methods which could be passed on to the artificial-limb industry and to prosthetists. Last year, then, the clinical program was established, and currently it is the center of attention. </p> <p> To organize such a clinical study obviously required a limbshop and examining rooms. Through the kindness of the Navy, space was afforded at the Navy Prosthetics Research Laboratory at the U.S. Naval Hospital at Oakland, California. There the setup includes a small limbshop where prosthetics work is done, a medical examination room, fitting and training rooms, an evaluation and photography room, and conference rooms, the entire operation being conducted in cooperation with the limb industry. Through the Industry Advisory Committee, amputees are selected on the basis of referral by limbshops, by physicians, by rehabilitation agencies, by the Veterans Administration, and by direct personal contact. After preliminary screening by the Clinical Study Group, an individual is selected only with the approval of the Industry Advisory Committee, and all of the work is done with the knowledge, assistance, and cooperation of the artificial limb industry. </p> <p> Because it is concerned primarily with research, the Clinical Study is not a commercial operation, and consequently production is not high and is not supposed to be. Thus far only 16 subjects have entered the clinic. Of these, 10 are unilateral above-knee amputees ranging in age from the teens to the seventies, two are bilateral above-knee cases, one is a bilateral above-knee/below-knee case, two are hip-disarticulation cases, and one is a unilateral below-knee case. Five are in the follow-up stage, six in the postfitting adjustment stage, three in the fitting stage, and two in the pre-prescription stage. All save one have been complicated cases, presenting difficult problems that nobody else wished to tackle. From particular cases such as these have come practical answers for other difficult cases. </p> <p> A thorough and complete study-from the medical, biomechanical, and prosthetic points of view-is made of each case, and individual problems are diagnosed and corrected. To find the best possible solution in any particular case requires a knowledge of what attempts have been unsuccessful and why they failed, for sometimes a great deal more is learned by determining why one proposed solution failed than by determining why another was successful. </p> <h4> The Clinic Team </h4> <p> The clinic team consists of an orthopedic surgeon, a prosthetist, a physical therapist or amputee instructor, and sometimes an engineer<a></a>. This group makes the initial evaluation and provides a prescription<a></a> based on complete data including a medical history, an analysis of existing condition of the stump and of the rest of the body, and an evaluation of the old prosthesis. The prescription is reviewed by the Clinic Study Panel, including several orthopedic surgeons, a psychiatrist, a prosthetist from industry, and an engineer familiar with prosthetic problems. Once the prescribed device is fitted, the results are viewed by the Panel, and the reasons for success or failure are documented fully so that the case may serve as an example for future reference. No experimental devices are used in the clinic program. Only those devices available commercially are fitted to the subjects. </p> <h4> Industry Participation </h4> <p> Active participation by individual members of the artificial-limb industry has not yet started, but plans are now being made for such activity in the immediate future. That part of the program will involve working with prosthetists, screened by the industry, who will visit the clinic for a period of orientation. They will follow cases through the clinic study and then be assigned a shop case on a cooperative basis. The clinic team will act initially as a review committee in preparing the prescription, but the individual prosthetist will fill the prescription in his own shop. After fitting, the amputee and the prosthetist will return to the clinic for evaluation. This procedure provides a twofold check. It evaluates the prosthetist's degree of efficiency and tests the validity of the clinic's method of prescription. </p> <h4> Prosthetic Problems </h4> <h5> <i>Crotch Pressure</i> </h5> <p> Because enough time has now elapsed to be sure that more than temporary success has been achieved, some general ideas can be discussed with a fair degree of confidence. The most common complaint heard by the group relates to crotch pressure. In every instance, however, the condition has been eliminated. Correcting for excessive crotch pressure involves two things-the right socket shape and correct alignment (page 35). Proper socket shape is ensured by providing for ischial-gluteal bearing (which prevents sinking into the socket), by controlling the anteroposterior dimension, and by raising the height of the socket brim. </p> <h5> <i>Localized Socket Pressure</i> </h5> <p> The next most common complaint relates to edema. Rarely has there been a case of the suction socket where edema could be traced to high negative pressure alone. Excessive crowding or tightness invariably were contributing factors. Edema may result principally from a high rate of pressure change at any point along the length of the stump. Because emphasis has been placed on socket shape near the top brim, not enough attention has been given to good fit throughout the length of the stump. Any constrictions or ridges, including those formed by muscle groups, cause pressure changes that interfere with venous return. The inside finish of the socket also may be a factor. In one instance, for example, a severe case of edema was alleviated by providing the socket with a smooth, high-gloss finish. </p> <h5> <i>Socket Brim</i> </h5> <p> Skin irritation around the socket brim also is a source of annoyance and discomfort. Accordingly, dermatologists are cooperating in the program. They examine amputees having skin problems and outline procedures for therapy, including the taking of biopsies of the skin. Pigmentation is evaluated to determine whether or not it is due to capillary hemorrhage caused by decreased suction or whether it is merely a pigmentation that often occurs in areas of friction. Out of this study should come a routine test and a new modality of skin care for the leg amputee. </p> <p> Again, the condition can be eliminated by controlling the shape and height of the anterior and lateral brim above the ischial seat. Medial width also is a controlling factor because it determines the total amount of pressure exerted by the front of the socket to maintain stability on the posterior weight-bearing surface. And, as in the case of edema, the inside finish is important in preventing skin damage. Sitting discomfort, a complaint often heard, usually is relieved by using a flat back, by not having the inside edge of the seat too sharp, and by ensuring that any channel for gluteal relief is not too large. </p> <h5> <i>Alignment</i> </h5> <p> Alignment is a continuing problem, and the development of guiding principles is most important. Although general principles are comparatively simple to state, to understand them fully and to apply them to individual cases is difficult. One of the objectives of the clinical program is to apply to typical problem cases the alignment principles developed through fundamental research and to develop examples showing how these principles can be applied, why they work, and the end-results that can be obtained. Naturally, the best results are obtained when the stump is so oriented as to take full advantage of the remaining hip musculature. There is a growing body of information relating to a number of common problems-problems associated with changing from a pelvic belt to a suction-socket leg; problems concerning the very muscular stump with prominent hamstrings or with some particularly firm muscle or muscle groups isolated in the stump; problems of the short and the long above-knee stump; problems caused by the flabby stump; and problems of inside finish. </p> <h4> Medical Problems </h4> <p> Often the problems of the amputee, both in the lower extremity and in the upper, stem not from an ill-fitting prosthesis. More often the problems can more properly be termed medical. Accordingly, the Clinical Study includes investigation of those aspects of amputee rehabilitation related to physiological changes associated with loss of limb. </p> <h5> <i>Pain</i>-<i>Phantom and Real</i> </h5> <p> As pointed out long ago<a></a>, loss of the normal limb so often is followed by the appearance of some form of phantom limb that, when a patient does not acknowledge one, it is suspected that he is withholding information or that the phantom has been repressed. Statistics show that the phantom is a normal phenomenon in the sense that most amputees have it. It is pathological, however, in the sense that the amputee perceives something that actually does not exist. </p> <p> In general, awareness is a matter of degree and, to some extent, a matter of verbal conventions. Some amputees say that the phantom has the same unobtrusive quality as does the material counterpart, that it appears only when called upon. Sometimes the amputee has difficulty in remembering that the phantom is unreal and that it does not serve in the capacities of its living predecessor. The normal person is not particularly aware of his limbs unless his attention is drawn to them in some way. Except under the impact of a sudden stimulus, or when a special effort is made, preferably together with a movement, our awareness is potential and shadowy in nature. With the eyes closed, and with the limb at complete rest, awareness is, in fact, not too far removed from mere imagination. To make certain that the limb exists, we move it, look at it, or rub some part of it. The amputee cannot conduct such an empirical test. </p> <p> Sometimes the patient can sense his lost limb as acutely as he can the remaining real one, and he often can imagine that he can "move" the phantom. More often, however, the phantom draws attention to itself by some "abnormal" sensation which makes the amputee more aware of it than he is of his real limb. Fortunately, only a small percentage of all phantoms habitually are painful. Some typical ones are shown in (<b>Fig. 9</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. The phantom limb, a phenomenon of almost universal occurrence among amputees. A, Phantom toes and ankle, reported more frequently than are other phantom parts of the amputated lower extremity. B, Mild "tingling," characteristic of the painless phantom, is often described in terms of "crawling ants." C, The "telescoping" phantom, in which the foot, over a period of time, gradually approaches the stump and finally disappears within it. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Frequently the "foot" seems to shorten and approach the end of the stump. The patient illustrated in Figure <i>9C </i>experienced "telescoping" of the phantom, a phenomenon which, contrary to the observations of most other writers on the subject, was found infrequently in the Berkeley series. It is true that relatively undifferentiated parts like the calf and the forearm commonly are not felt. Some phantoms of distal parts are, from their onset, situated at the normal distance from the trunk. Others always seem to be located closer to the stump than normal. A few patients experience a gradual shrinkage of intermediate phantom parts, as has occurred over a period of years in the subject illustrated in (<b>Fig. 10</b>). In this case, all that remains of the shrunken ghost are the "toes," and these have come to lie not in empty space, as is the rule, but inside the stump. Not infrequently a phantom which has shortened may, on application of a prosthesis, lengthen and actually become identified with the artificial limb. Thus, in one instance, a young above-knee amputee felt as though the shortened "foot" were appended to the stump. When he wore his prosthesis, however, the phantom foot felt as though it were in the position corresponding to that of the artificial foot. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. A rare and peculiar form of phantom experience. Here the two "toes" seem to reside within the stump itself. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Awareness of the missing member may or may not be described as basically unpleasant, but it is subject to intermittent unpleasant sensations-itching, tingling, or pain (<b>Fig. 11</b>). As pointed out by Livingston <i>, </i><a></a> the pattern of the painless phantom bears no resemblance to the areas of distribution of the major peripheral nerves. Thus the partial nature of the phantom cannot be ascribed to the affection of certain nerve lesions in the stump. Rather, the pattern of the phantom seems to relate to the most mobile parts and to those serving the highest degree of sensory function. But a substantial number of amputees experience, at one time or another, some sort of painful phantom of varying duration (<b>Table 1</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. The painful phantom, of fairly common occurrence among amputees at one time or another. Only some 30 percent experience no phantom pain at any time. Probably about 10 percent face persistent and sometimes incapacitating pain. A, Among the similes used to describe a phantom pain is "as if my toes are being crushed by a hammer." B, Pain experienced at the site of an injury leading to amputation, such as a fracture, often persists as a part of the phantom pattern. C, The "hot wire" sensation and involuntary cramping of phantom toes are among the other frequent manifestations. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> How many amputees have pain? Taking into consideration the inadequacies of follow-up information, the subjective character of the pain experience, and the semantic difficulties beclouding the term "pain," a conservative estimate would be that 80 percent of all amputees are substantially free of pain and are either being trained for useful work or else are already actually so engaged. It is likely that, of the remaining group, possibly half are faced with severe intermittent or persistent pain. Because of persistent, incapacitating pain, approximately 10 percent of all amputees never get into a limbshop, never get out of the doctor's office. They become narcotic addicts and often commit suicide. Where pain enters the phantom syndrome, it may assume large clinical importance. If it is excruciating and persists for long periods, it may take a devastating toll of the whole personality and physical well-being. </p> <p> In describing severe pain, we all use a vocabulary taken from common objects known to produce injury. Lesser pains are described in terms of cutaneous and deep sensations. Thus we speak of "pressure," of "pins and needles," of "sharp" pains and "dull" aches, of "stabbing" and "shooting" pains. It seems unlikely that man at his present stage of evolution ever will devise a specific terminology for pain because he has no special organ for observing his discomforts. No matter how introspective a person may be, his account of pain always is phrased in imagery taken from other fields of experience. Nothing could be more real than these sensations, but we say "as if" to give them intelligible expression. The vocabulary is metaphorical. </p> <p> It is not surprising, therefore, to find amputees using language akin to that of the torture chamber when they try to do justice to their agonies. They hardly go further than anyone else in telling about physical sufferin. Nor do they hallucinate when they talk about "ropes" and "vises," for they remain aware of the imaginary character of these similies. It is possible, however, that, as the tearing and squeezing sensations are felt in a part of the body known to be missing, the suffering is heightened and the imagery made more vivid by the ghostly character of the phantom. </p> <p> It has been argued that phantom sensations are hallucinations because they entail a belief in the reality of an absent object, or that they are illusions because irritations of the stump are being misinterpreted, or that they are normal sensations because the cerebral representation of the once-present member still is intact. Some workers have correlated the type of sensation with the "level" of its origin in the nervous system, painful sensations being ascribed to pathological conditions of the cut nerve end in the stump or to mental aberrations. But classifications of either the amputee's descriptions or of the presumptive causes bringing about the sensations have thus far been unsatisfactory. The various frames of reference used in the statistical survey at Berkeley do, in fact, overlap. Duration and frequency of pain have some influence on the complaint of severity. Tingling and burning seem to be more superficial and, however annoying, more tolerable than do tearing, stabbing, cramping, squeezing, and crushing. It should be understood, however, that there are degrees of each of these and that, as such, intensities may, to a point, be compared with each other. </p> <p> It is obvious that a patient's account of his painful feeling is colored by his personality. The way a person describes such experiences depends not only on the abnormal processes causing them but also on his imagination, his previous experience, his learning, his cultural inheritance, and his vocabulary. But any view which discounts the abnormal physiological processes and credits only their "mental" interpretation is probably in error. The complexity of the nervous system and its integration into one functioning whole does not favor the idea that there is one chief recipient and executive who sorts out the messages from the various parts of the body and, in the case of pain, edits them as writhings and groans or as sentences made up of more or less colorful language. It seems improbable that there is simply one stimulus arising somewhere in the organism and that the ego reacts to this stimulus in a more or less stoic way. A so-called "neurotic" or "imaginative" disposition is likely to pervade the most "bodily" of processes, while a steadfast person is apt to have a stomach and blood vessels no more stable than his emotional display. </p> <p> Regardless of individual personalities, however, there is a certain uniformity in the complaints of pain-stricken amputees. Although the matter has not been explored from the point of view of psychophysiological typing, it appears that pain phenomena cannot be predicted either from the age of the patient or from the age of his phantom. By the same token, racial or cultural background and physical or mental make-up cannot be used to predict pain phenomena. Nor have the local pathological factors before, during, and after amputation-the factors that might be held responsible for the appearance of pain-been elicited. </p> <p> Aside from the problem of the painful phantom is that relating to painful stumps (<b>Fig. 12</b>). Amputees may have spontaneous stump pain. Or they may have so-called "trigger points," certain areas which, on slight pressure, tend to produce a flash of pain persisting for various intervals of time. Patients have complained of circumscribed areas of pain in the stump even though palpation revealed no corresponding point of tenderness. These two conditions usually are found together. Nodularities in the stump often are palpable, as indeed they are, on a minor scale, in other subcutaneous parts of the body. Some of these are tender, some are not; some are and some are not connected with phantom pain. In fact, separate places in the same stump may represent exclusive triggers-one for stump pain, the other for phantom pain. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Types of stump pain. About a third of the clinical reports of pain refer to discomfort in the stump rather than in a phantom part. Stumps may be painful to the touch (A) or spontaneously (B). Frequently present are "trigger points," pressure upon which gives rise to pain over a larger area, either in the stump or in a phantom or both (C). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> But the conditions prevailing at the end of the stump, including such nodules as the famous "amputation neuroma," do not provide a basis for intelligent speculation. The mere fact that stimulation of a presumptive neuroma often produces pain in the phantom is no proof for the theory that the "cause" of this pain lies solely in the periphery. In order to be disabused of such a notion, one has only to look at certain cases of known diseases of the central nervous system or at. complete transections of the spinal cord. In the latter, the brain receives no communications from the stump. In cases of painful diseases of the central nervous system, stimulation of the normal peripheral tissues having their nervous connections with the diseased part of the central nervous system often produces an abnormal sensation, including pain. This phenomena always is referred to the periphery. Nobody sounds convincing when he says that he feels pain in the brain or spinal cord. The central nervous system has no conscious sensory representation of itself. The mere description of a painful sensation does not permit detection of its origin. The origin has to be deduced from circumstantial evidence which, in the case of amputees, is lacking. Even where sensations are "triggered off" from the periphery, they can be completed only by participation of the central nervous system, and disturbances may occur anywhere along the line. </p> <p> We are confronted with the anomaly that stimulation of a certain trigger point within the stump arouses not a distant, painful phantom but one incorporated in the flesh of its own trigger. The specificity of this trigger further is illustrated by the fact that, on the opposite side of the same stump, there may be another tender spot, stimulation of which sets up increased local stump pain. </p> <h5> <i>Circulatory Problems</i> </h5> <p> Investigation of circulation in the amputee reveals that the stump acts as though it were poikilothermic, that is, it has no ability to change its temperature. Rather, the temperature of the stump matches that of the surroundings, as occurs in a cold-blooded animal. </p> <p> Studies concerning the relationship of the vascular system to pain in amputees have been conducted along three general lines. First has been evaluation of the status of the circulatory system in amputation stumps, both in patients suffering from phantom or stump pain and in amputees free of pain. The second has involved clinical and laboratory studies of selected nonamputee patients suffering from pain syndromes possibly related in pathophysiology to phantom pain. And finally tests have been conducted with various sympatholytic drugs and blocking procedures, first with respect to their effects on phantom-limb pain and related pain syndromes and second in regard to their effects on the circulation of blood in stumps and in painful limbs. </p> <p> Studied in detail were 43 amputees, 31 without known vascular disease (Group A) and 12 suffering from vascular disease either as the underlying cause of amputation or as a concomitant to the amputation (Group B). Pain in the stump or phantom limb was an important problem for 15 of the patients in Group A and for 8 of those in Group B. The remainder described varying degrees of phantom awareness but denied that pain existed or, if it did exist, that it was disturbing. </p> <p> One method of investigation was simple clinical examination. In that survey, stumps appearing to have an adequate blood supply were found, when exposed to air at room temperature, to be almost uniformly cold to the touch as compared with the opposite extremities. In oscillometric tests, the pulse of arterial blood into the stump was found to be significantly smaller than that into the normal limb (<b>Fig. 13</b>). In skin tests with histamine, the appearance of normal flares and wheals indicated that local denervation could not account for the failure of the skin to warm during generalized body warming. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Pulsations recorded during generalized vasodilatation in a below-knee amputee. Oscillometric records show a smaller amplitude of pulsation in the blood vessels supplying the stump (A) than in those supplying the sound limb (B). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> (<b>Fig. 14</b> and <b>Fig. 15</b>) indicate graphically the results of surface-temperature measurements on the normal extremities and on the stumps of two amputees. <a></a> Skin temperature was measured after initial exposure of the body to cool air in a room with controlled atmosphere, the subject being exposed until finger and toe temperatures were stabilized. Recordings were made by means of thermocouples taped to the skin of the stump and to the contralateral extremities at multiple points along the length of the limb, the thermocouples being applied symmetrically so that points equidistant from the trunk could be compared. All such measurements were made with the subject in a basal state and exposed to room air between 17deg and 21deg C, conditions leading uniformly to constriction of the cutaneous vessels of the extremities in normal subjects. Under such circumstances, a temperature gradient exists between the proximal and distal portions of a normal arm or leg, so that the surface temperature of a finger or toe is several degrees lower than the temperature at points near the trunk. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Surface temperatures in the upper extremities of a below-elbow amputee during cooling and subsequent warming and vasodilatation. Above, time-temperature relations. Below, length-temperature relations. Points along the extremities indicate the locations of thermocouples. Relative humidity constant at 65 percent. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Surface temperatures in the lower extremities of an above-knee amputee during cooling and subsequent warming and vasodilatation. Above, time-temperature relations. Below, length-temperature relations. Points along the extremities indicate the locations of thermocouples. Relative humidity constant at 74 percent. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Temperatures then were recorded during maximal vasodilatation induced by oral administration of whiskey and wrapping the trunk in an electric blanket. After vasodilatation, the gradient is abolished or reversed in the normal limb, finger and toe temperatures rising to 30deg C or higher. </p> <p> At the end of the initial cooling period, when subjects had been exposed to cool room air for periods of from 30 to 150 minutes, the surface temperature at the distal end of the stump almost invariably was cooler than was the skin at a symmetrical point on the corresponding intact limb. Analysis of the temperature gradients found after cooling showed further that, in at least a third of the Group A amputees and in half of the Group B amputees, the stumps were cooler than were the opposite extremities, not merely at the distal ends but for distances of from 20 to 55 cm. from the ends. </p> <p> In one instance a patient was put in a room at 18deg C with nothing across his body except a towel. Over a period of two hours the body temperature was lowered to a point just above that at which shivering occurred. The temperature of the toe in the normal extremity dropped to a low level. When the patient suddenly was given 2 ounces of whiskey and warm water and had an electric blanket placed across his chest, the temperature of the normal extremity rose rapidly. But the temperature of the stump remained constant during the entire procedure, a phenomenon characteristic of all amputation stumps. </p> <p> A total of 40 amputees (28 Group A, 12 Group B) were subjected to one or more vasodilatation tests, and the responses of 45 stumps were observed. Of these, nearly two thirds failed to warm significantly at a time when the skin temperature of the normal extremities had risen to 30deg C as a result of indirect or "reflex" vasodilatation. Only occasionally did stumps show evidence of significant vasodilatation. It occurred with higher frequency in those patients with underlying or concomitant vascular disease than in amputees of Group A. Thus, of 11 stumps in which the temperature rose to the same level as the corresponding point on the contralateral limb, or even to levels reflecting "ceiling" blood flow for skin, only six were among the 32 stumps of Group A patients, and five were among the 13 stumps of Group B patients. In brief, a smaller proportion of stumps showed vasodilatation in Group A patients (one fifth) than in Group B patients (two fifths). </p> <p> In the majority of trials, experiments with other methods of inducing vascular relaxation were equally ineffective in causing a rise in stump temperature. In a total of eight intravenous injections of vasodilator drugs, the temperature of the stump increasedonlyslightly on two occasions (2.5deg C or less). A rise in temperature was effected once with Priscoline (2-benzylimidazoline hydrochloride) and once with tetraethylammonium chloride. Injections of prccaine in the region of the lumbar sympathetic ganglia produced a significant warming of the stump in one of two cases only. No correlation was found between the degree of phantom or stump pain experienced by these patients and the extent to which slump temperature fell during the initial period of exposure or the extent of stump warming during generalized vasodilatation. Amputees rarely complained of stump or phantom pain during these experiments, even though they were subjected to extremes of temperature requiring rapid vasomotor adjustments. </p> <p> The ease with which stumps become cool on exposure to a cold environment can be attributed to two factors. First, surface-volume relationships in stumps favor cooling. Second, less blood passes through the stump than through comparable portions of the intact limb because, in the stump, distal tissues are absent. Apparently the shunts between the arterial and the venous side, which permit an increased volume of blood to flow through the extremity, are located distal to the wrist joint and to the ankle joint. In amputations at or above the wrist or ankle, therefore, flow of blood to the extremity is impaired. Normally, body heat is lost chiefly through radiation from hands, head, and feet. When the body is deprived of one of these radiating "fins," the remaining stump cannot be warmed. Neither can excess heat be radiated away, and for that reason an amputee often finds intolerable an environmental temperature that is quite acceptable to the normal. The amputee is distressed in a heated room, while the normal subject suffers no discomfort. Since the radiating mechanism is lost with amputation of an extremity, and since the only other means of cooling is through evaporation of sweat, the amputee is more likely to be troubled with problems of perspiration. </p> <h5> <i>Skeletal Changes</i> </h5> <p> In addition to problems of pain and changes in circulation, the amputee sometimes is troubled by decalcification of the stump and adjacent portions of the pelvis, a change that occurs when the body weight no longer is borne along the axis of the major articulations but along the prosthetic weight line (page 36). Because in an osteoporotic extremity the covering of the bone is more sensitive than is that in the normal, a decalcified bone often becomes exceedingly tender and develops spontaneous pain. </p> <p> An interesting fact is that the joint itself, in (<b>Fig. 16</b>) the hip joint, begins to show early degenerative changes because it no longer transmits weight. In future studies it should be possible to evaluate more closely what changes are to be expected in the proximal articulations of an amputation stump, and more particularly in the joint cartilage covering the articulations, as a result of elimination of normal weighi-bearing through thesearticulations. Obviously, the only way la preveni osteoporosis and increased sensitivity is to resort to some type of end-bearing. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16 Roentgenogram of an above-knee amputee, showing skeletal changes that occur when the hip and the remainder of the leg on the amputated side are deprived of the normal stimulation of weight-bearing </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In the younger leg amputee, moreover, especially in growing children, other bony deformities develop (<b>Fig. 17</b>). Instead of the normal curvature of the neck of the femur, there develops a valgus deformity as is seen in polio and in dislocated hips. And finally, of course, because of loss of the mass of the limb, one must expect to find scoliosis and other abnormalities in the spine (<b>Fig. 18</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Complicating deformities in juvenile amputees. When amputation is necessitated in childhood, defects often occur in the subsequent growth of related bony structures. Here, for example, the pelvis is smaller, and the pelvic-femoral angle larger, on the amputated side than on the sound side. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Scoliosis, a postural defect often a sequel to amputation of the lower extremity. Loss of the weight of the amputated limb leads to habitual compensatory positioning of other body elements and thus complicates rehabilitation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3> Summary </h3> <p> In summary, it may be said that, first, amputation produces changes in musculature, not only the familiar contractures and atrophy <i>{50,88) </i>but other changes as well. If a muscle is cut in half, its ability to shorten is decreased. A mid-thigh amputation decreases the effective normal range of motion of the hamstring group. If the hamstring group is cut in half, the velocity of contraction is halved, and an amputee thus afflicted cannot therefore perform certain functions with any degree of facility. </p> <p> The mechanism of normal level walking requires the expenditure and distribution of considerable energy, for which the body depends largely upon the leg musculature. Thus, the handicap resulting from loss of any part of the leg is due not only to the loss of support but also to the loss of power available from the muscles. The skeletal structure of a normal limb can more or less easily be simulated in a prosthesis, but such a device has little value without simultaneous provision for the necessary power. Accordingly, an understanding of the energy characteristics of normal level walking is important in considering the design criteria for artificial legs. Judging from the results of the energy studies at Berkeley, at a given pace an above-knee amputee uses two and a half to three times as much energy as does the normal. The adverse effect of this overexertion is only further complicated by the fact that heat production is increased at a time when the radiating mechanism has been impaired. In the manufacture of any lower-extremity prosthesis, then, an important consideration, is to design the substitute limb for maximum energy conservation. </p> <p> Medical problems are common to all amputees. Some of them, for example those related to circulation, cannot be solved, but proper surgical procedures help to preserve the musculature and skeletal structures of adjacent joints. Moreover, many things can be done to relieve pain, both spontaneous phantom pain and the tender trigger points occurring in stumps. All amputees suffer some discomfort at one time or another. They are bothered by skin changes occurring over the bony prominences, by edema at the distal end of the stump, and by attritional lesions occurring in the folds of the groin (<b>Fig. 19</b>). A minor skin lesion can disable a leg amputee completely, especially when it means staying off the leg or going on crutches. Increased perspiration and poor ventilation of the stump in the prosthesis may close the sweat glands and make the skin susceptible to fungal diseases, and contact dermatitis may result if the patient is allergic to certain materials used in the manufacture of the prosthesis. Such problems must be solved by socket fit, by alignment, or by other procedures. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Problems of fit. Among them are irritation and swelling in the crotch area, edema at the stump end, and tenderness at pressure points. Because such problems are more or less readily corrected by proper fit and alignment, they are less medical than prosthetic, although chronic skin irritation may need the attention of a dermatologist. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> From the Clinical Study have come valid recommendations concerning fit, alignment, and functional characteristics. As already noted, some horizontal rotation (between 9 and 15 deg.) is desirable in an artificial leg. Further, increased stability in the knee joint increases the leg amputee's sense of security. Some conservation of energy can be effected by eliminating the articulated ankle joint. And finally, the matter of appearance deserves consideration. In this regard, attention must be given to the color, contour, and texture of the artificial leg. </p> <p> In the last analysis, the problem of the leg amputee is more than that of providing him with a prosthetic device. He has many medical problems, including pain, abnormalities in circulation, heat intolerance, and skeletal and muscular changes. The prosthetic device itself raises other problems-conservation of energy, proper alignment, comfort, and cosmetic appearance. The Lower-Extremity Clinical Study is concerned with the solution of all these problems. The manner in which solutions are sought is shown in (<b>Fig. 20</b>), where the central area represents the pool of fundamental knowledge accumulated over a period of nine years. As the amputee moves around the circle, each problem is studied and solved before he is allowed to move into the next phase of processing. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Functional organization of theLower-Extremity Clinical Study:. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> To date, pain and skin irritation have been the predominant problems, and study groups are being organized to investigate these areas in detail. Study groups also have been organized to investigate skeletal and muscular changes. At each step in the process, the panel itself often is faced with difficult problems. For example, the question of evaluation always is present, and it is not easy to determine whether or not the amputee actually has benefited from the time and effort devoted to his case. But as each difficulty is solved, the information derived is placed at the disposal of all those concerned, not only those within the Clinic Study Group but also all others whose interests lie in the field of amputee management. Seminars are held weekly to ensure that the information is brought to the attention of all interested persons. Eventually, all of the problem-solving data stemming from the investigations will appear in educational publications and will be available to members of the artificial-limb industry. </p> <p> Finally, it may be said that the University group has no intentions of producing prosthetic devices and, indeed, makes excursions into that field only when it is necessary to develop experimental models pertinent to the study. </p> <p> The only function is to produce sound ideas that can be used by the artificial-limb industry in the manufactuie and fitting of improved prostheses. The study must, however, continue to be active until the basic scientific information can be translated into useful guides for the professions involved in the rehabilitation of the amputee. </p> <h3> Acknowledgments </h3> <p> For the illustrations appearing in this article, the authors are indebted to two people in particular. Thomas Raubenheimer, of the Department of Medical Illustration, University of California Medical Center, San Francisco, prepared the charcoal halftones. With the exception of <b>Fig. 8</b>, all line drawings were worked up by George Rybczynski, free-lance illustrator of Washington, D. C. </p> <p><b>References:</b></p> <ol> <li>Adel Precision Products Corp., Burbank, Calif.,Subcontractor's Final Report [to the] Committee on Artificial Limbs, National Research Council, The development of a hydraulically operated artificial leg for above knee amputations, 1947. </li> <li>Alldredge, Rufus H., The cineplaslic method in upper-extremity amputations, J. Bone and; Joint Surg., 30A:359 (1948). </li> <li>Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasty, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. 4.</li> <li>'Bartholomew, S. H., Determination of knee moments during the swing phase of walking and physical constants of the human shank, University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, January 1952. </li> <li>Bechtol, Charles 0., The prosthetics clinic team, Artificial Limbs, January 1954. p. 9. </li> <li>Bechtol, Charles O., The principles of prosthetic prescription, Chapter 6 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </li> <li>Berry, F. R., Jr., Angle variation patterns of normal hip, knee and ankle in different operations, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 21, February 1952. </li> <li>Blaschke, A. C, General energy considerations and determination of muscle forces in the mechanics of human bodies, University of California (Los Angeles), Department of Engineering [Contractor's Memorandum Report No. 9 to the Advisory Committee on Artificial Limbs, National Research Council], September 1950.</li> <li>Blaschke, A. C, and C. L.Taylor, Biomechanical considerations in cineplasty, University of California (Los Angeles), Department of Engineering, Special Technical Report 18, 1951. </li> <li>Blaschke, Alfred C, and Craig L. Taylor, The mechanical design of muscle-operated arm prostheses, J. Franklin Inst., 266:435 (1953). </li> <li>Blix, Magnus, Die Lange und die Spannung des Muskels, Scandinav. Arch. f. Physiol., 6:150 (1894). </li> <li> Bradley, C. A, and Son, Inc., and Catranis, Inc., Syracuse, N. Y., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Artificial limb development for above-knee amputees including mechanical and hydraulic knee locks; suction socket and suction socket controls; knee lock controls operated by hip motion, stump muscles and foot position; toe pick up and foot providing lateral, plantar and dorsal flexion, July 1947. </li> <li>Bresler, B., Use of energy methods for evaluation of prostheses, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, September 1951. </li> <li>Bressler [sic], B., and F. R. Berry, Energy characteristics of normal and prosthetic ankle joints, University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, April 1950. </li> <li>Bresler, B,, and F. R. Berry, Energy and power in the leg during normal level walking, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, May 1951. </li> <li>Brown, E., and N. Foreman, Studies of skin temperature and of indirect vasodilatation in amputation stumps, Am. J. Med., 10:112 (1951). </li> <li>Buchthal, Fritz, and E. Kaiser, Optimum mechanical conditions for work of skeletal muscle, Acta Psychiat. et Neurol., 24:333 (1949). </li> <li>Close, J. R., and V. T. Inman, The action of the ankle joint, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1952. </li> <li>Close, J. R., and V T. Inman, The action of the subtalar joint, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 24, May 1953. </li> <li>Contini, Renato, Prosthetics research and the engineering profession, Artificial Limbs, 1(3):47 (September 1954). p. 58. </li> <li>Cunningham, D. M., Components oj floor reactions during walking, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, November 1950. </li> <li>Eberhart, Howard D., The objectives of the lower extremity prosthetics program, Artificial Limbs, May 1954. p. 4. </li> <li>Eberhart, Howard D., Herbert Elftman, and Verne T. Inman, The locomtor [sic] mechanism of the amputee, Chapter 16 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </li> <li>Eberhart, H. D., and V. T. Inman, An evaluation of experimental procedures used in a fundamental study of human locomotion, Ann. N. Y. Acad. Sci., 51:1213 (1951). </li> <li>Eberhart, Howard D., Verne T. Inman, and Boris Bresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </li> <li>Elftman, H., A cinematic study of the distribution of pressure in the human fool, Anat. Rec, 69:481 (1934). </li> <li>Elftman, H, The measurement of the external force in walking, Science, 88:152 (1938). </li> <li>Elftman, H., The rotation of the body in walking, Arbeitsphysiol., 10:219 (1938). </li> <li>Elftman, H., The force exerted by the ground in walking, Arbeitsphysiol., 10:485 (1938). </li> <li>Elftman, H., Forces and energy changes in the leg during walking, Am. J. Physiol., 125:339 (1939). </li> <li>Elftman, H., The function of muscles in locomotion, Am. J. Physiol., 125:357 (1939). </li> <li>Elftman, H., The function of the arms in walking, Human Biol., 11:529 (1939). </li> <li>Elftman, Herbert, The work done by muscles in running, Am. J. Physiol , 129:672 (1940). </li> <li>Elftman, H., The action of muscles in the body, Biol. Symposia, 3:191 (1941).</li> <li>Elftman, H., Experimental studies on the dynamics of human walking, Trans. N. Y. Acad. Sci., 11:1 (1943). </li> <li>Elftman, H., The bipedal walking of the chimpanzee, J. Mammalogy, 25:67 (1944). </li> <li>Elftman, H., The carrying angle of the human arm as a secondary sex character, Anat. Rec, 91:49 (1945). </li> <li>Elftman, H., The orientation of the joints of the lower extremity, Bull. Hosp. Joint Diseases, VI-.139 (1945). </li> <li>Elftman, H., Torsion of the lower extremity, Am. J. Phys. Anthropol., N.S. 3:255 (1945). </li> <li>Elftman, H., The basic pattern of human locomotion, Ann. N. Y. Acad. Sci., 51:1207 (1951). </li> <li>Elftman, Herbert, The functional structure of the lower limb, Chapter 14 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </li> <li>Elftman, Herbert, and John T. Manter, The axis of the human foot, Science, 80:484 (1934). </li> <li>Elftman, Herbert, and John Manter, Chimpanzee and human feel in bipedal walking, Am. J. Phys. Anthropol., 20:69 (1935). </li> <li>Elftman, H., and J. T. Manter, The evolution of the human fool, with especial reference to the joints, J. Anat., 70:56 (1935). </li> <li>Feinstein, Bertram, John N. K. Langton, R. M. Jameson, and Francis Schiller, Experiments on pain referred from deep somatic tissues, J. Bone and; Joint Surg!, 36A:981 (1954) </li> <li>Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs, Chapter 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </li> <li>Felkel, E. O., Determination of acceleration from displacement-time data, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 16, September 1951. </li> <li>Felkel, E. O., Determination of accelerations of the human leg during locomotion, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Winter 1951. </li> <li>Goodyear Tire and; Rubber Company, Akron, Ohio, Subcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], The development of a foot prosthesis incorporating a metal structure and a bonded rubber to metal ankle joint, 1947. </li> <li>Gordan, G. S., B. Feinstein, and H. J. Ralston, Effect of testosterone upon atrophy of denervated skeletal muscle, Exper. Med. and; Surg., 7:327 (1949). </li> <li>Hosmer Corp., A. J., Santa Monica, Calif., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Hydraulic weight bearing knee lock for knee dis-articidation amputations; work arms for wrist disarticulations, below and above elbow amputations; work tools and devices for vocational rehabilitation; hydraulic control to actuate hooks and hands used on work arms; improved design hook, 1947. </li> <li>Inman, V. T., Functional aspects of the abductor muscles of the hip, J. Bone and; Joint Surg., 29:607 (1947). </li> <li>Inman, V. T., Theoretical requirements of a lower-extremity prosthesis, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, December 22, 1950. </li> <li>Inman, V. T., Innervation of the extremities, 3rd Biennial Western Conference on Anesthesiology, The California Society of Anesthesiologists and the Northwestern Society of Anesthesiologists, Los Angeles, 1953. p. 22. </li> <li>Inman, V. T., B. Feinstein, and H. J. Ralston, Some observations on electromyography, Am. J. Physiol., 155:445 (1948). </li> <li>Inman, Verne T., H. J. Ralston, J. B. deC. M. Saunders, Bertram Feinstein, and Elwood W. Wright, Jr., Relation of human electromyogram lo muscular tension, University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Report to the Advisory Committee on Artificial Limbs, National Research Council, November 1951. </li> <li>Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </li> <li>Inman, V. T., H. J. Ralston, J. B. deC. M. Saunders, B. Feinstein, and E. W. Wright, Jr., Relation of human electromyogram lo muscular tension, Electroencephalog. and; Clin. Neuro-physiol., 4:187 (1952). </li> <li>Levens, A. S., V. T. Inman, and J. A. Blosser, Transverse rotation of the segments of the lower extremity in locomotion, J. Bone and; Joint Surg., 30A:859 (1948). </li> <li>Libet, B., Neuromuscular facilitation by stretch, and the duration of muscular activation in locomotion, Proc. 19th Internat. Physiol. Cong., Montreal, 1953. p. 563. </li> <li>Libet, B., and B. Feinstein, Analysis of changes in electromyogram (EMG) with changing muscle length, Am. J. Physiol., 167:805 (1951). </li> <li>Libet, Benjamin, and Bertram Feinstein, Human electromyogram, Surg. Forum, W. B. Saunders Co., Philadelphia, 1952. p. 415. </li> <li>Libet, Benjamin, H. J. Ralston, and Bertram Feinstein, The effect of stretch on action potential in muscle, Biol. Bull., 101:194 (1951). </li> <li>Libet, B., and E. W. Wright, Jr., Facilitation at neuromuscular functions by stretch of muscle, Fed. Proc, 11:94 (1952). </li> <li>Livingston, Kenneth E., The phantom limb syndrome: a discussion of the role of major peripheral nerve neuromas, J. Neurosurg., 2:251 (1945). </li> <li>Mitchell, S. Weir, Phantom limbs, Lippincott's Mag. Pop. Lit. So, 8:563 (1871). </li> <li>National Research and Manufacturing Company, San Diego, Calif., Subcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], An investigation of low pressure laminates for prosthetic devices; design and fabrication of above-knee and below-knee artificial legs; preparation of a production survey for manufacture of artificial plastic legs, 1947. </li> <li>New York University, Prosthetic Devices Study, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Shakedown lest of the Navy above-knee prosthesis, May 1951. </li> <li>New York University, Prosthetic Devices Study, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The functional and psychological suitability of an experimental hydraulic prosthesis for above-the-knee amputees, March 1953. </li> <li>Northrop Aircraft, Inc., Hawthorne, Calif., Subcontractor's Final Report [to the] Committee on Artificial Limbs, National Research Council (Contract VAm-21223), A report on prosthesis development, 1947. </li> <li>Northwestern Technological Institute, Evanston, III., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, A review of the literature, patents, and manufactured items concerned with artificial legs, arms, arm harnesses, hands, and hooks; mechanical testing of artificial legs, 1947. </li> <li>Pare, A., from T. Johnson, The works of that famous chirurgion, Ambrose Parey, translated out of the Latine and compared with the French, Richard Cotes and Willi: Du-gard, London, 1649. </li> <li>Polissar, M. J., Concentration and potential pattern within the membrane and its relation lo penetration of ions and lo time constants of electrolonus and accommodation, Fed. Proc, 11:124 (1952). </li> <li>Polissar, M. J., Physical chemistry of contractile process in muscle. I. A physiochemical model of contractile mechanism, Am. J. Physiol., 168:766 (1952). </li> <li>Polissar, M. J., Physical chemistry of contractile process in muscle. II. Analysis of other mechano-chemical properties of muscle, Am. J. Physiol., 168:782 (1952). </li> <li>Polissar, M. J., Physical chemistry of contractile process in muscle. III. Interpretation of thermal behavior of stimulated muscle, Am. J. Physiol.. 168:793 (1952). </li> <li>Polissar, M. J., Physical chemistry of contractile process in muscle. IV. Estimates of size of contractile unit, Am. J. Physiol., 168:805 (1952). </li> <li>Radcliffe, C. W., Flexion stiffness of prosthetic ankle joints, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, May 1949. </li> <li>Radcliffe, C. W., Information useful in the design of damping mechanisms for artificial knee joints, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1950. </li> <li>Radcliffe, C. W., Use of the adjustable knee and alignment jig for the alignment of above knee prostheses, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, August 1951. </li> <li>Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954. p. 23ff. </li> <li>Radcliffe, Charles W., Alignment of the above-knee artificial leg, Chapter 21 in Klopsteg and Wilson's Humanlimbs andtheirsubstitutes, McGraw-Hill, New York, 1954. Especially pp. 686-688. </li> <li>Ralston, H. J., Muscle dynamics, Surgical Forum (1951), American College of Surgeons, Clinical Congress, W. B. Saunders, Philadelphia, 1952. p. 418.</li> <li>Ralston, H J., Isometric tension in the intact human quadriceps, Proc. 19th Internat. Physiol. Cong., Montreal, 1953. p. 692. </li> <li>Ralston, H. J., Mechanics o] voluntary muscle, Am. J Phys. Med., 32:166 (1953). </li> <li>Ralston, H. J., J R Close, V T. Inman, and B. Feinstein, Dynamical and electrical features of human isolated voluntary muscle in isometric and isotonic contraction, Fed. Proc, 7:97 (1948). </li> <li>Ralston, H. J., H. D. Eberhart, V. T. Inman, and M. D. Shaffrath, Length-tension relationships in isolated human voluntary muscle, Proc. 17th Internat. Physiol. Cong., Oxford, 1947. p. 110. </li> <li>Ralston, H J., B. Feinstein, and V. T. Inman Rate of atrophy in muscles immobilized at different lengths, Fed. Proc, 11:127 (1952). </li> <li>Ralston, H. J., V. T. Inman, B. Feinstein, and B. Libet, Human electromyogram, Am. J. Physiol., 163:743 (1950). </li> <li>Ralston, H. J., V. T. Inman, L. A. Strait, and M. D. Shaffrath, Mechanics of human isolated voluntary muscle, Am. J. Physiol., 151:612 (1947). </li> <li>Ralston, H. J., B. Libet, and E. W. Wright, Jr., Effect of stretch on action potential of voluntary muscle, Am. J. Physiol., 173:449 (1953). </li> <li>Ralston, H. J., and B. Libet, The question of tonus in skeletal muscle, Am. J. Phys. Med., 32:85 (1953). </li> <li>Ralston, H. J., M. J. Polissar, V. T. Inman, J. R. Close, and B. Feinstein, Dynamic features of human isolated voluntary muscle in isometric and, free contractions, J, Appl Physiol., 1:526 (1949). </li> <li>Ralston, H. J., E. W. Wright, Jr., B. Feinstein, and V. T. Inman, Effect of stretch upon action potential of voluntary muscle, Am. J. Physiol., 159:586 (1949). </li> <li>Ryker, N. J., Jr , Glass walkway studies of normal subjects during normal level walking, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 20, January 1952. </li> <li>Ryker, N. J., and S. H. Bartholomew, Determination of acceleration by use of accelerometers, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, September 1951. </li> <li>Saunders, J. B. deC. M., Verne T. Inman, and Howard D. Eberhart, The major determinants in normal and pathological gait, J. Bone and; Joint Surg., 35A(3):543 (1953) </li> <li>Schiller, F., Pain-controlled and uncontrolled, Science, 118:755 (1953). </li> <li>Spittler, A. W., and I. E. Rosen, Cineplaslic muscle motors for prostheses of arm amputees, J. Bone and; Joint Surg , 33A:601 (1951). 100. Strait, L. A., V. T. Inman, and H. J. Ralston, </li> <li> Sample illustrations of physical principles selected from physiology and medicine, Am. J. Physics, 15:375 (1947). </li> <li>Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasty, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York. 1954. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, Preliminary Report [to the] Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, September 1947. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, |Report to the] Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, revised edition, April 1948. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, Supplementary Report 2, The forces and moments in the leg during level walking, revised August 10, 1948. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, 3rd edition, April 1949. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Biceps cineplasty and prosthesis for below-elbow amputations, April 1950. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Functional considerations in fitting and alignment of the suction socket prosthesis, March 1952. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, Functional considerations in fitting and alignment of the suction socket prosthesis, 2nd ed., August 1953. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, The pattern of muscular activity in the lower extremity during wilking, September 1953. </li> <li>Wagner, Edmpnd M., Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954. p. 8. </li> <li>Wagner, Edmond M., and John G. Catranis, New developments in lower-exlremity prostheses, Chapter 17 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. p. 482. </li> <li>Wagner and Catranis, op. cit., p. 511. </li> <li>Weddell, G., B. Feinstein, and R. E. Pattle, Electrical activity of voluntary muscle in man under normal and pathological conditions, Brain, 67:178 (1944). </li> <li>Wohlfart, G., B. Feinstein, and J. Fex, Uber die Bieziehung zwischen electromyographischen und anatomischen Befunden in normalen Muskeln und bei neuromuskularen Erkrankungen, Arch. f. Psychiat. u. Ztschr. Neurol., 191:478 (1954). </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Brown, E., and N. Foreman, Studies of skin temperature and of indirect vasodilatation in amputation stumps, Am. J. Med., 10:112 (1951). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>65.</b> </td><td class="clsTextSmall">Livingston, Kenneth E., The phantom limb syndrome: a discussion of the role of major peripheral nerve neuromas, J. Neurosurg., 2:251 (1945). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>66.</b> </td><td class="clsTextSmall">Mitchell, S. Weir, Phantom limbs, Lippincott's Mag. Pop. Lit. So, 8:563 (1871). </td></tr><tr><td class="clsTextSmall"><b>72.</b> </td><td class="clsTextSmall">Pare, A., from T. Johnson, The works of that famous chirurgion, Ambrose Parey, translated out of the Latine and compared with the French, Richard Cotes and Willi: Du-gard, London, 1649. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Bechtol, Charles O., The principles of prosthetic prescription, Chapter 6 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Bechtol, Charles 0., The prosthetics clinic team, Artificial Limbs, January 1954. p. 9. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>88.</b> </td><td class="clsTextSmall">Ralston, H J., B. Feinstein, and V. T. Inman Rate of atrophy in muscles immobilized at different lengths, Fed. Proc, 11:127 (1952). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>97.</b> </td><td class="clsTextSmall">Saunders, J. B. deC. M., Verne T. Inman, and Howard D. Eberhart, The major determinants in normal and pathological gait, J. Bone and; Joint Surg., 35A(3):543 (1953) </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>97.</b> </td><td class="clsTextSmall">Saunders, J. B. deC. M., Verne T. Inman, and Howard D. Eberhart, The major determinants in normal and pathological gait, J. Bone and; Joint Surg., 35A(3):543 (1953) </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>68.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Shakedown lest of the Navy above-knee prosthesis, May 1951. </td></tr><tr><td class="clsTextSmall"><b>112.</b> </td><td class="clsTextSmall">Wagner, Edmpnd M., Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954. p. 8. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>79.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Information useful in the design of damping mechanisms for artificial knee joints, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1950. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>59.</b> </td><td class="clsTextSmall">Levens, A. S., V. T. Inman, and J. A. Blosser, Transverse rotation of the segments of the lower extremity in locomotion, J. Bone and; Joint Surg., 30A:859 (1948). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>98.</b> </td><td class="clsTextSmall">Schiller, F., Pain-controlled and uncontrolled, Science, 118:755 (1953). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>45.</b> </td><td class="clsTextSmall">Feinstein, Bertram, John N. K. Langton, R. M. Jameson, and Francis Schiller, Experiments on pain referred from deep somatic tissues, J. Bone and; Joint Surg!, 36A:981 (1954) </td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs, Chapter 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>109.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>54.</b> </td><td class="clsTextSmall">Inman, V. T., Innervation of the extremities, 3rd Biennial Western Conference on Anesthesiology, The California Society of Anesthesiologists and the Northwestern Society of Anesthesiologists, Los Angeles, 1953. p. 22. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>109.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>65.</b> </td><td class="clsTextSmall">Livingston, Kenneth E., The phantom limb syndrome: a discussion of the role of major peripheral nerve neuromas, J. Neurosurg., 2:251 (1945). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>114.</b> </td><td class="clsTextSmall">Wagner and Catranis, op. cit., p. 511. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Contini, Renato, Prosthetics research and the engineering profession, Artificial Limbs, 1(3):47 (September 1954). p. 58. </td></tr><tr><td class="clsTextSmall"><b>69.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The functional and psychological suitability of an experimental hydraulic prosthesis for above-the-knee amputees, March 1953. </td></tr><tr><td class="clsTextSmall"><b>112.</b> </td><td class="clsTextSmall">Wagner, Edmpnd M., Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954. p. 8. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>78.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Flexion stiffness of prosthetic ankle joints, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, May 1949. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>48.</b> </td><td class="clsTextSmall">Felkel, E. O., Determination of accelerations of the human leg during locomotion, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Winter 1951. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">'Bartholomew, S. H., Determination of knee moments during the swing phase of walking and physical constants of the human shank, University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, January 1952. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Bresler, B,, and F. R. Berry, Energy and power in the leg during normal level walking, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, May 1951. </td></tr><tr><td class="clsTextSmall"><b>102.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes. </td></tr><tr><td class="clsTextSmall"><b>105.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Supplementary Report 2, The forces and moments in the leg during level walking, revised August 10, 1948. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Inman, V. T., Theoretical requirements of a lower-extremity prosthesis, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, December 22, 1950. </td></tr><tr><td class="clsTextSmall"><b>97.</b> </td><td class="clsTextSmall">Saunders, J. B. deC. M., Verne T. Inman, and Howard D. Eberhart, The major determinants in normal and pathological gait, J. Bone and; Joint Surg., 35A(3):543 (1953) </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Eberhart, Howard D., Herbert Elftman, and Verne T. Inman, The locomtor [sic] mechanism of the amputee, Chapter 16 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Elftman, H., The basic pattern of human locomotion, Ann. N. Y. Acad. Sci., 51:1207 (1951). </td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Elftman, Herbert, The functional structure of the lower limb, Chapter 14 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Bresler, B., Use of energy methods for evaluation of prostheses, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, September 1951. </td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Bressler [sic], B., and F. R. Berry, Energy characteristics of normal and prosthetic ankle joints, University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, April 1950. </td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Bresler, B,, and F. R. Berry, Energy and power in the leg during normal level walking, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, May 1951. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Buchthal, Fritz, and E. Kaiser, Optimum mechanical conditions for work of skeletal muscle, Acta Psychiat. et Neurol., 24:333 (1949). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Buchthal, Fritz, and E. Kaiser, Optimum mechanical conditions for work of skeletal muscle, Acta Psychiat. et Neurol., 24:333 (1949). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Blaschke, Alfred C, and Craig L. Taylor, The mechanical design of muscle-operated arm prostheses, J. Franklin Inst., 266:435 (1953). </td></tr><tr><td class="clsTextSmall"><b>101.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasty, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York. 1954. </td></tr><tr><td class="clsTextSmall"><b>107.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Biceps cineplasty and prosthesis for below-elbow amputations, April 1950. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., The cineplaslic method in upper-extremity amputations, J. Bone and; Joint Surg., 30A:359 (1948). </td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasty, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. 4.</td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Blaschke, A. C, and C. L.Taylor, Biomechanical considerations in cineplasty, University of California (Los Angeles), Department of Engineering, Special Technical Report 18, 1951. </td></tr><tr><td class="clsTextSmall"><b>99.</b> </td><td class="clsTextSmall">Spittler, A. W., and I. E. Rosen, Cineplaslic muscle motors for prostheses of arm amputees, J. Bone and; Joint Surg , 33A:601 (1951). 100. Strait, L. A., V. T. Inman, and H. J. Ralston, </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>57.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">Libet, Benjamin, H. J. Ralston, and Bertram Feinstein, The effect of stretch on action potential in muscle, Biol. Bull., 101:194 (1951). </td></tr><tr><td class="clsTextSmall"><b> 64.</b> </td><td class="clsTextSmall">Libet, B., and E. W. Wright, Jr., Facilitation at neuromuscular functions by stretch of muscle, Fed. Proc, 11:94 (1952). </td></tr><tr><td class="clsTextSmall"><b>83.</b> </td><td class="clsTextSmall">Ralston, H. J., Muscle dynamics, Surgical Forum (1951), American College of Surgeons, Clinical Congress, W. B. Saunders, Philadelphia, 1952. p. 418.</td></tr><tr><td class="clsTextSmall"><b>84.</b> </td><td class="clsTextSmall">Ralston, H J., Isometric tension in the intact human quadriceps, Proc. 19th Internat. Physiol. Cong., Montreal, 1953. p. 692. </td></tr><tr><td class="clsTextSmall"><b>85.</b> </td><td class="clsTextSmall">Ralston, H. J., Mechanics o] voluntary muscle, Am. J Phys. Med., 32:166 (1953). </td></tr><tr><td class="clsTextSmall"><b>86.</b> </td><td class="clsTextSmall">Ralston, H. J., J R Close, V T. Inman, and B. Feinstein, Dynamical and electrical features of human isolated voluntary muscle in isometric and isotonic contraction, Fed. Proc, 7:97 (1948). </td></tr><tr><td class="clsTextSmall"><b>87.</b> </td><td class="clsTextSmall">Ralston, H. J., H. D. Eberhart, V. T. Inman, and M. D. Shaffrath, Length-tension relationships in isolated human voluntary muscle, Proc. 17th Internat. Physiol. Cong., Oxford, 1947. p. 110. </td></tr><tr><td class="clsTextSmall"><b>90.</b> </td><td class="clsTextSmall">Ralston, H. J., V. T. Inman, L. A. Strait, and M. D. Shaffrath, Mechanics of human isolated voluntary muscle, Am. J. Physiol., 151:612 (1947). </td></tr><tr><td class="clsTextSmall"><b>91.</b> </td><td class="clsTextSmall">Ralston, H. J., B. Libet, and E. W. Wright, Jr., Effect of stretch on action potential of voluntary muscle, Am. J. Physiol., 173:449 (1953). </td></tr><tr><td class="clsTextSmall"><b>93.</b> </td><td class="clsTextSmall">Ralston, H. J., M. J. Polissar, V. T. Inman, J. R. Close, and B. Feinstein, Dynamic features of human isolated voluntary muscle in isometric and, free contractions, J, Appl Physiol., 1:526 (1949). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Blix, Magnus, Die Lange und die Spannung des Muskels, Scandinav. Arch. f. Physiol., 6:150 (1894). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>115.</b> </td><td class="clsTextSmall">Weddell, G., B. Feinstein, and R. E. Pattle, Electrical activity of voluntary muscle in man under normal and pathological conditions, Brain, 67:178 (1944). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>55.</b> </td><td class="clsTextSmall">Inman, V. T., B. Feinstein, and H. J. Ralston, Some observations on electromyography, Am. J. Physiol., 155:445 (1948). </td></tr><tr><td class="clsTextSmall"><b>56.</b> </td><td class="clsTextSmall">Inman, Verne T., H. J. Ralston, J. B. deC. M. Saunders, Bertram Feinstein, and Elwood W. Wright, Jr., Relation of human electromyogram lo muscular tension, University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Report to the Advisory Committee on Artificial Limbs, National Research Council, November 1951. </td></tr><tr><td class="clsTextSmall"><b>58.</b> </td><td class="clsTextSmall">Inman, V. T., H. J. Ralston, J. B. deC. M. Saunders, B. Feinstein, and E. W. Wright, Jr., Relation of human electromyogram lo muscular tension, Electroencephalog. and; Clin. Neuro-physiol., 4:187 (1952). </td></tr><tr><td class="clsTextSmall"><b>61.</b> </td><td class="clsTextSmall">Libet, B., and B. Feinstein, Analysis of changes in electromyogram (EMG) with changing muscle length, Am. J. Physiol., 167:805 (1951). </td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">Libet, Benjamin, and Bertram Feinstein, Human electromyogram, Surg. Forum, W. B. Saunders Co., Philadelphia, 1952. p. 415. </td></tr><tr><td class="clsTextSmall"><b>89.</b> </td><td class="clsTextSmall">Ralston, H. J., V. T. Inman, B. Feinstein, and B. Libet, Human electromyogram, Am. J. Physiol., 163:743 (1950). </td></tr><tr><td class="clsTextSmall"><b> 116.</b> </td><td class="clsTextSmall">Wohlfart, G., B. Feinstein, and J. Fex, Uber die Bieziehung zwischen electromyographischen und anatomischen Befunden in normalen Muskeln und bei neuromuskularen Erkrankungen, Arch. f. Psychiat. u. Ztschr. Neurol., 191:478 (1954). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>60.</b> </td><td class="clsTextSmall">Libet, B., Neuromuscular facilitation by stretch, and the duration of muscular activation in locomotion, Proc. 19th Internat. Physiol. Cong., Montreal, 1953. p. 563. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Blaschke, A. C, General energy considerations and determination of muscle forces in the mechanics of human bodies, University of California (Los Angeles), Department of Engineering [Contractor's Memorandum Report No. 9 to the Advisory Committee on Artificial Limbs, National Research Council], September 1950.</td></tr><tr><td class="clsTextSmall"><b>52.</b> </td><td class="clsTextSmall">Inman, V. T., Functional aspects of the abductor muscles of the hip, J. Bone and; Joint Surg., 29:607 (1947). </td></tr><tr><td class="clsTextSmall"><b>111.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, The pattern of muscular activity in the lower extremity during wilking, September 1953. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>73.</b> </td><td class="clsTextSmall">Polissar, M. J., Concentration and potential pattern within the membrane and its relation lo penetration of ions and lo time constants of electrolonus and accommodation, Fed. Proc, 11:124 (1952). </td></tr><tr><td class="clsTextSmall"><b>74.</b> </td><td class="clsTextSmall">Polissar, M. J., Physical chemistry of contractile process in muscle. I. A physiochemical model of contractile mechanism, Am. J. Physiol., 168:766 (1952). </td></tr><tr><td class="clsTextSmall"><b>75.</b> </td><td class="clsTextSmall">Polissar, M. J., Physical chemistry of contractile process in muscle. II. Analysis of other mechano-chemical properties of muscle, Am. J. Physiol., 168:782 (1952). </td></tr><tr><td class="clsTextSmall"><b>76.</b> </td><td class="clsTextSmall">Polissar, M. J., Physical chemistry of contractile process in muscle. III. Interpretation of thermal behavior of stimulated muscle, Am. J. Physiol.. 168:793 (1952). </td></tr><tr><td class="clsTextSmall"><b>77.</b> </td><td class="clsTextSmall">Polissar, M. J., Physical chemistry of contractile process in muscle. IV. Estimates of size of contractile unit, Am. J. Physiol., 168:805 (1952). </td></tr><tr><td class="clsTextSmall"><b>92.</b> </td><td class="clsTextSmall">Ralston, H. J., and B. Libet, The question of tonus in skeletal muscle, Am. J. Phys. Med., 32:85 (1953). </td></tr><tr><td class="clsTextSmall"><b>100.</b> </td><td class="clsTextSmall"> Sample illustrations of physical principles selected from physiology and medicine, Am. J. Physics, 15:375 (1947). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">'Bartholomew, S. H., Determination of knee moments during the swing phase of walking and physical constants of the human shank, University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, January 1952. </td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Berry, F. R., Jr., Angle variation patterns of normal hip, knee and ankle in different operations, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 21, February 1952. </td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Bressler [sic], B., and F. R. Berry, Energy characteristics of normal and prosthetic ankle joints, University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, April 1950. </td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Bresler, B,, and F. R. Berry, Energy and power in the leg during normal level walking, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, May 1951. </td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Close, J. R., and V. T. Inman, The action of the ankle joint, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1952. </td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Close, J. R., and V T. Inman, The action of the subtalar joint, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 24, May 1953. </td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Cunningham, D. M., Components oj floor reactions during walking, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, November 1950. </td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">Felkel, E. O., Determination of acceleration from displacement-time data, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 16, September 1951. </td></tr><tr><td class="clsTextSmall"><b>48.</b> </td><td class="clsTextSmall">Felkel, E. O., Determination of accelerations of the human leg during locomotion, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Winter 1951. </td></tr><tr><td class="clsTextSmall"><b>96.</b> </td><td class="clsTextSmall">Ryker, N. J., and S. H. Bartholomew, Determination of acceleration by use of accelerometers, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, September 1951. </td></tr><tr><td class="clsTextSmall"><b>105.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Supplementary Report 2, The forces and moments in the leg during level walking, revised August 10, 1948. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>103.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Preliminary Report [to the] Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, September 1947. </td></tr><tr><td class="clsTextSmall"><b>104.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, |Report to the] Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, revised edition, April 1948. </td></tr><tr><td class="clsTextSmall"><b>106.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, 3rd edition, April 1949. </td></tr><tr><td class="clsTextSmall"><b>108.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Functional considerations in fitting and alignment of the suction socket prosthesis, March 1952. </td></tr><tr><td class="clsTextSmall"><b>110.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, Functional considerations in fitting and alignment of the suction socket prosthesis, 2nd ed., August 1953. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The 1947 report contains an extensive bibliography of earlier work, mostly German, on the mechanism of human locomotion and on related matters. It is available, either in photostat form or on microfilm, from the U. S. Armed Forces Medical Library, 7th Street and Independence Ave., S. W., Washington 25, D. C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>102.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Elftman, H., A cinematic study of the distribution of pressure in the human fool, Anat. Rec, 69:481 (1934). </td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Elftman, H, The measurement of the external force in walking, Science, 88:152 (1938). </td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Elftman, H., The rotation of the body in walking, Arbeitsphysiol., 10:219 (1938). </td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Elftman, H., The force exerted by the ground in walking, Arbeitsphysiol., 10:485 (1938). </td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Elftman, H., Forces and energy changes in the leg during walking, Am. J. Physiol., 125:339 (1939). </td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Elftman, H., The function of muscles in locomotion, Am. J. Physiol., 125:357 (1939). </td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Elftman, H., The function of the arms in walking, Human Biol., 11:529 (1939). </td></tr><tr><td class="clsTextSmall"><b>33.</b> </td><td class="clsTextSmall">Elftman, Herbert, The work done by muscles in running, Am. J. Physiol , 129:672 (1940). </td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">Elftman, H., The action of muscles in the body, Biol. Symposia, 3:191 (1941).</td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Elftman, H., Experimental studies on the dynamics of human walking, Trans. N. Y. Acad. Sci., 11:1 (1943). </td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Elftman, H., The bipedal walking of the chimpanzee, J. Mammalogy, 25:67 (1944). </td></tr><tr><td class="clsTextSmall"><b>37.</b> </td><td class="clsTextSmall">Elftman, H., The carrying angle of the human arm as a secondary sex character, Anat. Rec, 91:49 (1945). </td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Elftman, H., The orientation of the joints of the lower extremity, Bull. Hosp. Joint Diseases, VI-.139 (1945). </td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Elftman, H., Torsion of the lower extremity, Am. J. Phys. Anthropol., N.S. 3:255 (1945). </td></tr><tr><td class="clsTextSmall"><b> 42.</b> </td><td class="clsTextSmall">Elftman, Herbert, and John T. Manter, The axis of the human foot, Science, 80:484 (1934). </td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Elftman, Herbert, and John Manter, Chimpanzee and human feel in bipedal walking, Am. J. Phys. Anthropol., 20:69 (1935). </td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Elftman, H., and J. T. Manter, The evolution of the human fool, with especial reference to the joints, J. Anat., 70:56 (1935). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Adel Precision Products Corp., Burbank, Calif.,Subcontractor's Final Report [to the] Committee on Artificial Limbs, National Research Council, The development of a hydraulically operated artificial leg for above knee amputations, 1947. </td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall"> Bradley, C. A, and Son, Inc., and Catranis, Inc., Syracuse, N. Y., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Artificial limb development for above-knee amputees including mechanical and hydraulic knee locks; suction socket and suction socket controls; knee lock controls operated by hip motion, stump muscles and foot position; toe pick up and foot providing lateral, plantar and dorsal flexion, July 1947. </td></tr><tr><td class="clsTextSmall"><b>49.</b> </td><td class="clsTextSmall">Goodyear Tire and; Rubber Company, Akron, Ohio, Subcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], The development of a foot prosthesis incorporating a metal structure and a bonded rubber to metal ankle joint, 1947. </td></tr><tr><td class="clsTextSmall"><b>51.</b> </td><td class="clsTextSmall">Hosmer Corp., A. J., Santa Monica, Calif., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Hydraulic weight bearing knee lock for knee dis-articidation amputations; work arms for wrist disarticulations, below and above elbow amputations; work tools and devices for vocational rehabilitation; hydraulic control to actuate hooks and hands used on work arms; improved design hook, 1947. </td></tr><tr><td class="clsTextSmall"><b>67.</b> </td><td class="clsTextSmall">National Research and Manufacturing Company, San Diego, Calif., Subcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], An investigation of low pressure laminates for prosthetic devices; design and fabrication of above-knee and below-knee artificial legs; preparation of a production survey for manufacture of artificial plastic legs, 1947. </td></tr><tr><td class="clsTextSmall"><b>71.</b> </td><td class="clsTextSmall">Northwestern Technological Institute, Evanston, III., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, A review of the literature, patents, and manufactured items concerned with artificial legs, arms, arm harnesses, hands, and hooks; mechanical testing of artificial legs, 1947. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Eberhart, Howard D., The objectives of the lower extremity prosthetics program, Artificial Limbs, May 1954. p. 4. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Eberhart, H. D., and V. T. Inman, An evaluation of experimental procedures used in a fundamental study of human locomotion, Ann. N. Y. Acad. Sci., 51:1213 (1951). </td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Eberhart, Howard D., Verne T. Inman, and Boris Bresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>80.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Use of the adjustable knee and alignment jig for the alignment of above knee prostheses, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, August 1951. </td></tr><tr><td class="clsTextSmall"><b>81.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954. p. 23ff. </td></tr><tr><td class="clsTextSmall"><b>82.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Alignment of the above-knee artificial leg, Chapter 21 in Klopsteg and Wilson's Humanlimbs andtheirsubstitutes, McGraw-Hill, New York, 1954. Especially pp. 686-688. </td></tr><tr><td class="clsTextSmall"><b>95.</b> </td><td class="clsTextSmall">Ryker, N. J., Jr , Glass walkway studies of normal subjects during normal level walking, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 20, January 1952. </td></tr><tr><td class="clsTextSmall"><b>102.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes. </td></tr><tr><td class="clsTextSmall"><b> 112.</b> </td><td class="clsTextSmall">Wagner, Edmpnd M., Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954. p. 8. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>113.</b> </td><td class="clsTextSmall">Wagner, Edmond M., and John G. Catranis, New developments in lower-exlremity prostheses, Chapter 17 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. p. 482. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>70.</b> </td><td class="clsTextSmall">Northrop Aircraft, Inc., Hawthorne, Calif., Subcontractor's Final Report [to the] Committee on Artificial Limbs, National Research Council (Contract VAm-21223), A report on prosthesis development, 1947. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Howard D. Eberhart, M.S. </b></td></tr><tr><td class="clsTextSmall">Professor of Civil Engineering, University of California, Berkeley; member, Advisory Committee on Artificial Limbs, National Research Council, and of the Technical Committee on Prosthetics, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>VerneT. Inman, M.D., Ph.D., </b></td></tr><tr><td class="clsTextSmall">Professor of Orthopedic Surgery, School of Medicine, University of California, San Francisco; Professional Associate, Advisory Committee on Artificial Limbs, National Research Council; member, Technical Committee on Prosthetics, ACAL, NRC. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-12.jpg Figure 12 http://www.oandplibrary.org/al/images/1955_01_004/table01.jpg Figure 13 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Lower-Extremity Clinical Study-Its Background and Objectives Creator An entity primarily responsible for making the resource VerneT. Inman, M.D., Ph.D., * Howard D. Eberhart, M.S. * http://23.254.134.177/the.oandplibrary.org/files/original/e35faf467e1ea9e763ac08ddcf0dbfd3.pdf 1f9fe1e89568efceb15d185fd6f39011 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Artificial Limbs: A Review of Current Developments Description An account of the resource The foundation of modern prosthetics can be directly traced to the coordinated efforts of the National Academy of Sciences under the various artificial limbs committees after the Second World War. America, at its height of post war efficiency and engineering acumen, set about to solve the burgeoning problem of amputees swelling an infrastructure of prosthetic delivery that was outmoded, outdated and unprepared. Artificial Limbs: A Review of Current Developments was an industry update of these research efforts and was published thirty-three times, spanning the years 1954 to 1972. DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_03_001.pdf Year 1955 Volume 2 Issue 3 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_03_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_03_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Harnessing- Here and Hereafter</h2> <h5>John Lyman, PhD <a style="text-decoration:none;">*</a><br /></h5> <p>However well designed the other parts of an artificial arm may be, the functional success of the upper-extremity prosthesis must ultimately depend upon the adequacy of the coupling between the human being and the inanimate mechanism. Since this man-machine linkage is intended to hold the arm on the stump and to secure from residual body sources the mechanical power necessary for operation and control of the prosthesis, the technique of constructing it has come to be known simply as "harnessing." Because body harness is such ah intimate piece of apparel, and because arm amputees exhibit the same kinds of individual differences as characterize the rest of the population, it seems likely that proper harnessing will long remain a tribute to the personal skill of the prosthetist, despite all advances in prefabricated components. Although the clinic team may prescribe the specifications for a prosthesis within the existing framework of medical and engineering knowledge, the final result depends largely upon the prosthetist's talent for constructing and fitting the harness in such a way as to meet anatomical, physiological, and functional requirements.</p> <p>Functionally, the harness may serve one or more of three purposes: it may hold the prosthesis in place; it may transmit power and excursion to produce force and movement in operating components; it may convey to the wearer the intelligence needed for arm control. In conventional construction of upper-extremity prostheses, it has been customary to rely upon the harness for the performance of all three of these services and, further, to obtain them all from a single harness system. Such an arrangement is of course grossly unlike that of the normal limb, where the control function, mediated by the nervous system, is clearly separated from the functions of suspension and of power transmission. Only in externally powered prostheses, as for examples the TBM Electric Arm and the Vaduz hand, has an attempt been made to separate the control function from the power and suspensory functions. Although to date such devices have not proved to be as useful or reliable as simpler ones, they are representative of an approach which may, in the long run, lead to far more refined limb substitutes than can be contemplated by further development of a harnessing philosophy which stresses the combining of suspension, power transmission, and control.</p> <p>The use of body power for operating an artificial arm forms an inherent control link between the neuromuscular system and the prosthesis. To the extent that a "closed loop" is effected via the sensory feedback available to the power-producing muscles, control of force and excursion through the power-transmission system is possible without the aid of external sensory-feedback loops such as vision and hearing. While the latter cues are generally present, they can at best serve only in an auxiliary capacity. The rich sensations of touch, pressure, pain, and temperature, which have been lost with the natural limb, have no substitute beyond their dim reflection in the signals from harness strap or cineplasty muscle pin of present-day prosthetics technology.</p> <p>One can argue, with considerable sustaining evidence, that the modern arm prosthesis is quite functionally adequate in most respects and that the addition of refinements in the form of further sensory cues for improved control would only complicate harnessing unnecessarily. But to take this viewpoint is paying tribute to the adaptability of the human mechanism rather than to the adequacy of today's prosthetics research and development. As facts currently stand, it appears that no clear-cut assessment has been made of the importance of sensory losses to the amputee. The effort has been to achieve prosthetic replacement of motor function, and it still is not generally recognized that this goal has been approached with the present degree of success only because sensory control loops are established incidentally in the course of harnessing for power transmission. The major inadequacies leading to failure in externally powered prostheses can be traced directly to shortcomings in the design of control loops-loops which are intrinsic even in the crudest of body-powered prostheses.</p> <p>Since in the present state of the art the optimum connection between the amputee and the operating mechanism is still so indispensable to the proper functioning of the upper-extremity prosthesis, this issue of Artificial Limbs is devoted to a summary of current harnessing technology as developed under the auspices of the Advisory Committee on Artificial Limbs. Although progress in the improvement of body harness has been substantial since World War II, even the latest techniques fall far short of duplicating the neuromuscular mechanism of the normal arm. And consequently there is still a great deal of forward-looking to be done in the research, development, and production phases of upper-extremity prosthetics.</p> <p>Where will the technology come from that may make possible "sensory prostheses" with attendant refinements in the present "motor prostheses"? Probably not directly from current trends in artificial-limb research. As is common knowledge, a very real and dynamic revolution is under way in the modern engineering sciences. It is accompanied by a plethora of popular terms like"cybernetics," "servomechanisms," "information theory," "digital and analogue computers," and "automation," to name a few. From the developments that are taking place, many new materials and processes are becoming available. Just as the aircraft industry, through the Northrop design studies, has contributed the present lightweight plastic artificial arm and the Bowden-cable transmission system, so it may be anticipated that within a relatively few years the electronics and missile industries may make even greater contributions. Compact, reliable, and lightweight items like the famed transistor may become as commonplace in the control systems for artificial arms as is presently the case in hearing aids. New products from metallurgy and chemistry may eventually make it possible to realize direct attachment of prosthetic devices to remaining skeletal members of the body through the skin and surrounding tissue, with consequent elimination of the socket and of the suspensory elements of harness. Much of the theory and much of the methodology for accomplishing the direct coupling of man to mechanism, including the all-important link to the nervous system for control, are either available already or else are promised within the foreseeable future.</p> <p>Because in the field of amputee rehabilitation there are never apt to be available the amounts of research money now characteristic of other fields of science and invention, it is fortunate that a systematic plan for the advancement of limb prosthetics has become so well established in the decade since World War II. The Artificial Limb Program furnishes an organized means of following progress in other areas and of adapting to limb substitutes new approaches and new techniques that would otherwise lie far beyond the purse of prosthetics research itself. The future in design of limb replacements is thus perhaps now greater than ever before. Even so, no matter how sophisticated upper-extremity prostheses may become, the actual utility of any given artificial arm will continue to reside largely in the degree to which the fitter can attain the optimum sensory-motor association through accomplished harnessmaking. In no other known way can so much satisfaction be afforded the individual arm amputee.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>John Lyman, PhD </b></td></tr><tr><td class="clsTextSmall">Assistant Professor of Engineering, University of California, Los Angeles.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Harnessing- Here and Hereafter Creator An entity primarily responsible for making the resource John Lyman, PhD * http://23.254.134.177/the.oandplibrary.org/files/original/69dcd7caf7126245f67c576a23eed259.pdf b7b6157c3a00c22ce04eab5fcbcd9bd3 http://23.254.134.177/the.oandplibrary.org/files/original/cd52e34d44c4e57526a5fce138f7f698.jpg 7a198c7f047f773bbc6304cfba3cf5ca http://23.254.134.177/the.oandplibrary.org/files/original/5d7294a2a8e341f658d1da509204af9b.jpg 7bd95a76b3d734667480ec0dfa10627e http://23.254.134.177/the.oandplibrary.org/files/original/41aca07379059375c3292b724c20ad74.jpg 1d4152198663676bd39749aa3927f9a9 http://23.254.134.177/the.oandplibrary.org/files/original/67da595e2b69a4eddfa254d7f3e4af1b.jpg 37ef26f3aa707b94fe6ce8c247500085 http://23.254.134.177/the.oandplibrary.org/files/original/9b09d3285dd63986158fb6ad3ff17829.jpg 1834799a9a45cb6e9a6a14ebdaeaf347 http://23.254.134.177/the.oandplibrary.org/files/original/01becc70231689f01d3e23078ca3d426.jpg a30c1c89e6080e63e83f5a4d21259851 http://23.254.134.177/the.oandplibrary.org/files/original/c837aee0438447ad78993b03f0c6c200.jpg a8318e44f6a4c5f16bad1e856293ce4f http://23.254.134.177/the.oandplibrary.org/files/original/b42005d371ab6bcdfafd2938aebf111f.jpg e14968ee1a57f38cdb7f3d3f58869784 http://23.254.134.177/the.oandplibrary.org/files/original/6d838654a7a10c9c607154be00da4967.jpg 6487b2156f041d65856f1b7fbd7fce04 http://23.254.134.177/the.oandplibrary.org/files/original/c721165ea01198ee6aef4e31acd0fdac.jpg f2e09c1ac6e6f04fc5b0a5eb66bcbd18 http://23.254.134.177/the.oandplibrary.org/files/original/86e71ac88dc77c0fe807c5821fd82c2a.jpg c276be77977e747e8b61adff1578acb7 http://23.254.134.177/the.oandplibrary.org/files/original/594db7f923eba326a0a22d4a72240941.jpg 37b19234f934f0937579f96fc8254bfe http://23.254.134.177/the.oandplibrary.org/files/original/7911660ec28bd9831354b1be9725eb7d.jpg 83d75d5dd8bf9a0f175a066cfac8db09 http://23.254.134.177/the.oandplibrary.org/files/original/2ce46311925780543b5f166aae06734c.jpg 20250700f961fbca04d3a509217ae6f4 http://23.254.134.177/the.oandplibrary.org/files/original/51f64afd51e21f05fcb8be1cf6b566a6.jpg 78db7332d104e619ea0153d0faf72faa http://23.254.134.177/the.oandplibrary.org/files/original/67dbcbc2d6e97fce74975c8e5425df4d.jpg 9c9248069a2f1eeb39d500e952d2092d http://23.254.134.177/the.oandplibrary.org/files/original/d9cb0275b460dcb93313cf0a93e01dc4.jpg 1b87da727d718119cf9f5981c3028001 http://23.254.134.177/the.oandplibrary.org/files/original/bbe231086fad6f1a5604ed09094d496d.jpg 284ec9e3ade0dccb3ab0c62ed1ae442e http://23.254.134.177/the.oandplibrary.org/files/original/72335cd71fe5e3195663463b7ff672df.jpg 6e71c69d6cb6b4d01362c92378c81350 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Artificial Limbs: A Review of Current Developments Description An account of the resource The foundation of modern prosthetics can be directly traced to the coordinated efforts of the National Academy of Sciences under the various artificial limbs committees after the Second World War. America, at its height of post war efficiency and engineering acumen, set about to solve the burgeoning problem of amputees swelling an infrastructure of prosthetic delivery that was outmoded, outdated and unprepared. Artificial Limbs: A Review of Current Developments was an industry update of these research efforts and was published thirty-three times, spanning the years 1954 to 1972. DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_02_022.pdf Year 1955 Volume 2 Issue 2 Page Number(s) 22 - 35 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_02_022.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_02_022.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Anatomy and Mechanics of the Human Hand</h2> <h5>Craig L Taylor, Ph.D. <a style="text-decoration:none;">*</a><br />Robert J. Schwarz, M.D <a style="text-decoration:none;">*</a><br /></h5> <p>It is obvious to all that the human hand represents a mechanism of the most intricate fashioning and one of great complexity and utility. But beyond this it is intimately correlated with the brain, both in the evolution of the species and in the development of the individual. Hence, to a degree we "think" and "feel" with our hands, and, in turn, our hands contribute to the mental processes of thought and feeling.</p> <p>In any mechanism, animate or inanimate, functional capabilities relate both to structural characteristics and to the nature of the control system available for management of functions singly or in multiple combinations. Just so with the human hand. Analysis of normal hand characteristics therefore requires an understanding of both sensory and mechanical features. Of course whole volumes have been written on hand anatomy, and it is not possible in a short article to describe all elements in detail. It is helpful, however, to review the basic construction of bones and joints and of the neuromuscular apparatus for governing motions and forces. Twenty four muscle groups, controlled by the various motor and sensory nerve pathways, with their rich potentialities for central connection, and acting upon a bone and joint system of great mechanical possibilities, give to the hand its capacity for innumerable patterns of action.</p> <h3>The Functional Structure of the Hand</h3> <h4>The Bones</h4> <p>The bones of the hand, shown in (<b>Fig. 1</b>), naturally group themselves into the carpus, comprising eight bones which make up the wrist and root of the hand, and the digits, each composed of its metacarpal and phalangeal segments (<b>Table 1</b>). The carpal bones are arranged in two rows, those in the more proximal row articulating with radius and ulna. Between the two is the intercarpal articulation. The bony conformation and ligamentous attachments are such as to prevent both lateral and dorsal volar translations but to allow participation in the major wrist motions (<b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Bones and articulations of the hand, including the interosseus muscles. A, volar view; B, dorsal view. For nomencla ture, see Tables 1 and 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. Bones and Joints of the Hand and Wrist </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Angles of rotation about the wrist. A, extension (or dorsiflexion); B, flexion (or volar flexion); C, radial flexion; D, ulnar flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In each of the digits, the anatomical design is essentially the same, with exceptions in the thumb. Metacarpals II through V articulate so closely with the adjacent carpal bones of the distal row that, although they are capable of some flexion and extension, independence of motion is very limited. The metacarpal shafts are arched to form the palm, and the distal ends are almost hemispherical to receive the concave curvature of the proximal ends of the first phalanges.</p> <p>The metacarpophalangeal joint exhibits a pattern seen also in the interphalangeal joints. As shown schematically in (<b>Fig. 3</b>), the virtual center of rotation lies approximately at the center of curvature of the distal end of the proximal member. The lateral aspects of the joint surfaces are narrowed and closely bound with ligaments, so that lateral rotation is small in the metacarpophalangeal joints and lacking entirely in the phalangeal articulations. Hence, the latter are typical hinge joints. The thumb differs from the other digits first in that the second phalanx is missing and, second, in that there is greater mobility in the carpometacarpal articulation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Section through radius, lunate, capitate, and the bony structure of digit III, showing virtual centers of rotation of each segment upon the next more proximal one. When the fist is clenched, the prominence of the knuckles is formed by the head of the more proximal member of each articulation. For nomenclature, see Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Muscles and Tendons</h4> <p>Most of the muscles of hand and wrist (<b>Table 2</b>) lie in the forearm and, narrowing into tendons, traverse the wrist to reach insertions in the bony or ligamentous components of the hand. Generally, the flexors (<b>Fig. 4</b>) arise from the medial epicondyle of the humerus, or from adjacent and volar aspects of the radius and ulna, and then course down the inside of the forearm. They are, therefore, in part supinators of the forearm (<b>Fig. 5</b>).The extensors (<b>Fig. 6</b>) of wrist and digits originate from the lateral epicondyle and parts of the ulna, pass down the dorsal side of the forearm, and thus assist in pronation. The thumb shares in the general flexor extensor scheme, but its extensors and abductors originate from mid and distal parts of radius and ulna.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Flexors of wrist and digits. For nomenclature, see Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Forearm design as related to hand mobility. By virtue of this arrangement, the hand can be rotated through 180 deg., palm up to palm down, with the elbow flexed. With the arm fully extended, participation of shoulder and elbow allows the hand to be rotated through almost 360 deg., palm up to palm up. U, ulna; R, radius; P, pronation; S, supination. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Extensors of wrist and digits. For nomenclature, see Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The tendons of wrist and hand pass through bony and ligamentous guide systems, as shown schematically in (<b>Fig. 7</b>). Flexor tendons pass through a "tunnel" bounded dorsally by carpal bones, laterally by the greater multangular and the projection of the hamate, and volarly by the tough transverse carpal ligament. Similarly, the dorsal carpal ligament guides the extensor tendons, and a system of sheaths serves as a guide for flexor and extensor tendons through the metacarpal and phalangeal regions.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. The anatomy of prehension. Schematic sections through digits I and III show essential relations of muscles and bones. The letters LG indicate the presence of ligamentous guides which channel close to the wrist the tendons of muscles originating in the forearm. Guide line X—X indicates relative position of carpal bases of thumb and fingers. For rest of nomenclature, see Tables 1 and 2. From Taylor.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The intrinsic muscles of the hand, <i>i.e., </i>those with both origin and insertion confined to wrist and hand (<b>Fig. 8</b>), are, with the exception of the abductors of thumb and little finger, specialized for the adduction of the digits and for opposition patterns such as making a fist, spherical grasp, and so on.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Volar intrinsic muscles of the hand. For nomenclature, see Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Palmar and Digital Pads</h4> <p>The volar aspect of the palm and digits is covered with copious subcutaneous fat and a relatively thick skin so designed in a series of folds that it is capable of bending in prehension. The folds are disposed in such a way as to make for security of grasp, while the underlying fat furnishes padding for greater firmness in holding. Because, however, slipping of the skin over the subcutaneous fat would lead to insecure prehension, the folds are tightly bound down to the skeletal elements, much as mattresses and upholstered furniture are quilted or otherwise fastened to prevent slippage of the filler.</p> <p>In the hand, the volar skin is tied down by white fibrillar tissue connecting the sheaths of the flexor tendons to the deep layer of the dermis along the lateral and lower edges of the palmar fascia. The folds therefore vary with the relative lengths of the metacarpal bones and with the mutual relations of the sheaths of the tendons and the edge of the palmar fascia.</p> <p>The sulci, or furrows, are emphasized because the subcutaneous fat in any given area is restricted to the interval between the lines along which the skin is tied down. Thus pressure upon any individual montic ulus cannot displace the underlying soft tissue beyond the boundaries established by the fibrillar connections. The relative size of any particular eminence is an indication of the size of the muscle involved and of its relative development through usage, with the exception that the size of the hy pothenar eminence depends in part upon the prominence of the pisiform.</p> <h4>The Dorsal Integument</h4> <p>Unlike the volar surface, the dorsal side of the hand is covered with thin, soft, pliable skin and equally mobile subcutaneous tissue, both capable of yielding easily under tension. Because in flexion of the fingers and in making a fist the covering on the back of the hand must be able to stretch from wrist to fingernails, the dorsal skin is arranged in numerous minute redundancies, which, in the fiat of hand, are manifest in the typical transverse wrinkles, particularly over the phalangeal articulations. Special adaptations in the dorsal skin of the thumb accommodate the distinctive rotational planes of that digit about its carpometacarpal articulation. In the normal, healthy hand, the degree of redundancy in any given area is just such that all wrinkles are dispatched when the fist is clenched. Swelling in any area, dorsal or volar, inhibits flexion extension of the part affected.</p> <h4>Nerve and Blood Supply</h4> <p>Three principal nerves serve the muscles of the hand (<b>Fig. 9</b>). Nerve supply is indicated, except for minor variations and exceptions, in (<b>Table 3</b>). Each of these major nerve trunks diverges into countless smaller branches ending in the papillae of the palmar pads and dorsal skin, and the whole neuromuscular system is so coordinated in the brain that motor response to stimuli is ordinarily subconscious and reflex. Thus an object slipping from the grasp is automatically gripped more firmly, but not so firmly as to damage the hand itself. Noxious stimuli are rejected automatically, as when the fingers are withdrawn from an object uncomfortably hot.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Nerves supplying the hand. Top to bottom, ulnar nerve, median nerve, radial nerve. See Table 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The wrist and hand receive their blood supply from the radial and ulnar arteries, which run parallel with the bones concerned, enter the hand through the flexor "tunnel," and then join through a double arch system (<b>Fig. 10</b>). Small branches from the arches serve the digits. The major venous system comprises the basilic and cephalic veins superficially placed on the volar surface of the forearm.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Blood supply to the upper extremity. A, above, medial view of the elbow. A, bottom, dorsal veins of the hand. B, superficial veins of the arm. C, arteries of the arm. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The Resting Hand Pattern</h3> <p>The resting hand assumes a characteristic posture, a feature easily seen when the hand hangs loosely at the side. The resting wrist takes a mid position in which, with respect to the extended forearm axis, it is dorsiflexed 35 deg. (<b>Fig. 11</b>). It is worth noting that this is the position of greatest prehensile force (<b>Fig. 12</b>, bottom). The mid position for radial or ulnar flexion appears to be such that the metacarpophalangeal joint center of digit III lies in the extended sagittal plane of the wrist (<b>Fig. 11</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. The resting hand pattern. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12 Effect of forearm-hand angle upon wrist flexion and extension forces and upon prehension forces. Above, relationship between forearm-hand angle and maximum forces of wrist flexion and extension measured at the carpometacarpal joint. Heavy lines, flexion (volar flexion); light lines, extension (dorsal flexion). Solid lines, averages; dotted lines, standard deviations. Unpublished data, UCLA, 15 male subjects. Below, relationship between forearm-hand angle and maximum prehension force measured between thumb and opposing index and middle fingers grasping a 1/2-inch block. Right hand, eight normal male subjects. Solid line, average; dotted lines, standard deviations From a UC report.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Typically, the conformation of fingers and thumb is similar to that shown for palmar prehension (<b>Fig. 13</b>), the fingers being more and more flexed from index to little finger. The relations between thumb, palm, and fingers are such as to permit grasp of a 1.75 in. cylinder crossing the palm at about 45 deg. to the radioulnar axis. Bunnell<a></a> considers this "an ancestral position ready for grasping limbs, weapons, or other creatures."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Six basic types of prehension, as defined by Schlesinger.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Fixed Hand Adaptations</h3> <p>In thrusting or striking actions and the like, the hand may assume fixed and rigid postures while functioning with the arm in support. These represent nonspecialized functions in which the hand serves merely as an adapted "end of the arm." The various forms include the flat of hand, the clenched fist, the knuckle and digital support postures, and so on.</p> <h3>Wrist Mechanics</h3> <p>The wrist joint, composed of the radiocarpal and intercarpal articulations (<b>Fig. 1</b>), has an elliptical rotation field with the major axis in the dorsal volar excursion, the minor in the ulnar radial. No significant torsion occurs. Bunnell<a></a> gives the angular excursions about the radiocarpal and intercarpal articulation as shown in (<b>Table 4</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 4. Angular Extent of Wrist Flexions" </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The rotation within the carpal bones during these movements is too complicated for brief treatment. Not only do the rotations occur at several articulating surfaces, but the virtual axes of rotation lie distal to the contact surfaces owing to gliding motions in the convex concave structure of the joints. Idealization of the motions into those of a simple lever, rotating about a fixed center, as implied in diagrams such as <b>Fig. 2</b>, can be justified only as a convenient approximation.</p> <p>The muscles traversing the wrist include those inserting into the carpus and metacarpus and those mediating flexion and extension of the phalanges. The latter contribute to the wrist action, particularly under loads. In such cases, the finger muscles develop reaction against the object held (or within the hand itself if the fist is clenched) and add their forces to wrist action. The forces, action, and grouping of these muscles are given in <b>Table 5</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 5. <br /> ^a From Fick. <a></a> <br /> ^b The palmaris longus, absent in about 15 percent of cases, is omitted from the summed Fick forces of volar flexion.<br /> ^c Averages from measurements of maximum forces normal to the hand, applied at the metacarpophalangeal joint, on 15 young males at the University of California at Los Angeles (unpublished data). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Prehension Patterns</h3> <p>It is evident equally from a study of the muscle bone joint anatomy and from observation of the postures and motions of the hand that an infinite variety of prehension patterns is possible. For purposes of analysis, however, it suffices to describe the principal types. Seeking a logical basis for defining the major prehension patterns, Keller et al.<a></a> found that the object contact pattern furnishes a satisfactory basis for classification. From &gt;photographic observation of the prehension patterns naturally assumed by individuals when (a) picking up and <i>(b) </i>holding for use common objects used in everyday life, three types were selected from among those originally classified by Schlesinger.<a></a> These, appearing in (<b>Fig. 13</b>), are palmar, tip, and lateral prehension, respectively. The frequency with which each of these types occurred in the investigation cited is given in (<b>Table 6</b>). While the relative percentages differ in the two types of action, the order of frequency with which the prehension patterns occurred is the same.<a style="text-decoration:none;">*</a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 6. Frequency or Prehension Patterns </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Mechanical Anatomical Basis or Prehension Patterns</h3> <p>It is convenient to analyze digital mechanics in terms of flexion extension variations in the digits, thumb postures, and variations in the radioulnar axis.</p> <h4>Individuation of Digital Flexion Extension</h4> <p>Insertion of flexor and extensor muscle systems into several major segments along the proximal distal axis provides a variety of flexion extension patterns in the digits. In <b>Fig. 7</b>, the essential components are shown schematically for digits I and III. With these attachments, fixation of carpal and metacarpal segments by cocontraction of flexor and extensor carpi muscles provides a firm base for independent movements and fixations of the phalangeal segments. Individual flexions of the second and terminal phalanges stem from separate flexor muscle (<b>Fig. 13</b>). The counterbalancing digital extensor inserts into the two most distal phalanges and, on contraction, rigidly extends the entire finger. Coordinated action between extensor and flexor groups, however, permits fixed intermediate positions of each segment of the system.</p> <p>Two common postures of this system may be pictured. In palmar prehension (<b>Fig. 13</b>), the carpal and metacarpal segments commonly fix the wrist in moderate extension, while the digital configuration, mostly metacarpophalangeal flexion coupled with only slight phalangeal flexion, indicates action of the long flexors, strongly modified by the lumbricals and interossei, which are in position not only to contribute to the metacarpophalangeal flexion but also to maintain the phalangeal xtension. In tip prehension, the action of muscles upon carpal and metacarpal bones is similar, but distributed flexion in all phalangeal segments indicates predominant flexor activity.</p> <h4>Thumb Versatility Patterns</h4> <p>The versatility of the thumb lies, first, in the variety of its flexion extension patterns and, second, in the adjustable, rotatory plane in which flexion extension can take place. The first of these is directly analogous to the digital system for the other four fingers, in that for any given metacarpal position there are numerous possible positions of the phalanges. The second effect is due to the relative mobility of the carpometacarpal joint, which allows the thumb to act in any plane necessary to oppose the digits. The principal oppositions are semidirect, as seen in palmar, tip, and spherical prehensions. Actually, in these cases the plane of the thumb action is inclined 45 to 60 deg. to the palmar plane. In lateral prehension, the plane is approximately parallel to the palmar plane.</p> <h4>Variations in the Radioulnar Axis of the Hand</h4> <p>A third principal mode of variation concerns cross hand alignments. Thus the metacarpophalangeal joints may be drawn into line, and with abducted thumb a flat hand position is assumed. At the other extreme, the hand is cupped for spherical prehension (<b>Fig. 13</b>) as the opponens muscles of thumb and little finger, aided by other adductors and flexors, act to pull these digits toward each other. Similar alignment occurs when a fist is made.</p> <h3>Hand Movements</h3> <p>The large number of muscles and joints of the hand obviously provides the equipment for numerous and varied patterns of movement. Not so evident, but equally important in determining complexity and dexterity of motion, are the large areas of the cerebral cortex given over to the coordination of motion and sensation in the hand. Thus, in the motor cortex the area devoted to the hands approximately equals the total area devoted to arms, trunk, and legs.<a></a> This circumstance ensures great potentiality for coordinated movement and for learning new activities. Similarly, the sensory areas are large, so that they determine such advanced functions as stereognosis, the ability to recognize the shape of an object simply by holding it in the hand. The great tactile sensitivity of the hand is, of course, in large part due to the rich supply of sense organs in the hand surface itself. The threshold for touch in the finger tip, for example, is 2 gm. per sq. mm., as compared to <i>33 </i>and 26 for the forearm and abdomen respectively.<a></a></p> <p>The three major types of movement described by Stetson and McDill<a></a> are in part represented in the hand. They include fixation movements including cocontractions; movements ranging from slow to rapid with control of direction, intensity, and rate; and ballistic movements.</p> <h4>Fixation Movements</h4> <p>In all of the types of prehension described, the hand assumes a fixed position. If the prehended object is unyielding, reactions to the flexion forces are afforded by the object. If the object is fragile, or the hand empty, the hand is maintained in any required prehensile posture by cocontractions of the opposing muscle groups.<a style="text-decoration:none;">*</a></p> <p>The characteristics of balanced muscular action when supporting in the hand loads which produce moments at the wrist have been studied electromyographically by Dempster and Finerty.<a></a> In general, when average potential amplitudes are used to characterize the electrical activity of the muscle, the curves of load action potential are linear. Frequencies range from 35 to 65 per sec. but bear no clear cut relationship to load. Typically, each of the muscles traversing the wrist was found to function as agonist, lateral stabilizer, or antagonist as the moment load was shifted from direct opposition at zero deg. to the 90 deg. and then to the 180 deg. positions. The magnitude of the action potentials associated with each of these roles is approximately in the order 4:2:1.</p> <h4>Slow and Rapid Movements</h4> <p>In movements ranging from slow to rapid, with control of direction, intensity, and rate, there is always some degree of cocontraction to ensure control and to permit changes in force and velocity. A net force in the muscles causes motion. In this category is a long list of activities, such as writing, sewing, tying knots, and pressing the keys of musical instruments. Included are most actions involving differential or integrated motions of the digits.</p> <p>It is of interest to note that the full capacity for these motions is seldom developed by the average individual. With intensive practice, significant increases in the facility of manipulation, even with simple operations, may be achieved, although individuals differ markedly in the amount of training gain. The average individual has latent potential for development of skill, as shown by the feats of manipulation occasionally evidenced. Knot tying, cigarette rolling, and similar complex manipulations may be performed with one hand, as often demonstrated by accomplished unilateral arm amputees. According to Tiffin<a></a>, dexterity differences are correlated neither with mental ability nor with hand shape or dimensions, but Cox<a></a> points out that they have an important effect on the performance of industrial assembly operations.</p> <h4>Ballistic Movements</h4> <p>Ballistic movements are rapid motions, usually repetitive, in which active muscular contractions begin the movement, giving momentum to the member, but cease or diminish their activity throughout the latter part of the motion. It is unlikely that, of themselves, the fingers utilize this type of motion to any marked degree. Barnes<a></a> reviews evidence that in repetitive work finger motions are more fatiguing, less accurate, and slower than are motions of the forearm. Consequently, in repetitive finger activities in which there is a ballistic element, such as piano playing, typing, and operating a telegraph key, wrist and elbow motions predominate while the fingers merely position themselves to strike the proper key.</p> <h3>Hand Dynamics</h3> <p>The hand muscles, their actions, and contractile forces are given in (<b>Table 5</b>) taken from Fick.<a></a> The total Fick force equals the sum mated forces of the individual muscles participating in the action. For each muscle the force is equal to the physiological cross section <i>(i.e., </i>the total cross section of the muscle taken normal to its fibers) multiplied by the force factor of 10 kg. per sq. cm., estimated by Fick to hold for human muscle. These forces are produced along the axis of the muscle and its tendon, but since the effective moment arm upon any of the wrist or hand joints is small, the <i>measured </i>isometric forces are only about 10 percent of the total force.</p> <p>Among the wrist actions, total forces and measured isometric forces assume the same rank order. The variation,. with wrist angle, of both flexor extensor forces in the wrist and of prehensile forces in the hand is of practical importance as well as theoretical interest. The prehensile force reaches a maximum at a wrist angle of about 145 deg. (<b>Fig. 12</b>, bottom). This is approximately the angle at which the maximum forces of wrist flexion and extension occur (<b>Fig. 12</b>, top). It is common experience that the wrist assumes this angle when very strong prehension is required. The lessened forces at wrist angles toward the extreme positions of flexion or extension are attributable to the well known force reductions in the isometric length tension curve as a muscle is markedly stretched or slackened.<a></a> The exception to this rule, seen in the augmented force of flexion at wrist angle 85 deg., apparently means that this degree of wrist extension does not stretch the flexor muscles beyond their force maximum.</p> <h3>Conclusion</h3> <p>This, briefly, constitutes the anatomical basis of hand mechanics, from which it can be seen that normal hand function is the result not only of a highly complex and versatile structural arrangement but also of an equally elaborate and fully automatic system of controls. As will be seen later (page 78), such considerations lay down the principal requirements and limiting factors in the design of reasonably successful hand substitutes. When, in the normal hand, any functional feature, either mechanical or sensory motor, is impaired, manipulative characteristics are reduced correspondingly. In the arm amputee, hand structural elements have been wholly lost, and the most delicate neuromuscular features, those in the hand itself, have been destroyed. Although the lost bone and joint mechanism can be simulated, adequate replacement of the control system defies present ingenuity. Lacking control comparable to that in the natural hand, present day artificial hands are necessarily limited in the mechanical details that can be utilized, which accounts for the fact that the regain in function currently possible in hand prostheses falls far short of duplicating the natural mechanism.</p> <h3>Acknowledgment</h3> <p>The anatomical drawings which accompany this article are the work of John Cassone, medical illustrator at the University of California, Los Angeles.</p> <p><b>References:</b></p> <ol> <li>Barnes, R. M., <i>Motion and time study</i>, Wiley, New York, 1937.</li> <li>Best, C. H., and N. B. Taylor, <i>Physiological basis of medical practice</i>, Williams and Wilkins, Baltimore, 1937. p. 1256.</li> <li>Best and Taylor, op. cit., p. 1418.</li> <li>Bunnell, Sterling, <i>Surgery of the hand</i>, Lippincott, Philadelphia, 1944.</li> <li>Cox, J. W., <i>Manual skill</i>, Cambridge University Press, 1934.</li> <li>Dempster, W. T., and J. C. Finerty, <i>Relative activity of wrist moving muscles in static support of the wrist joint; an electromyographic study</i>, Am. J. Physiol., 150:596 (1947).</li> <li>Fick, Rudolf, Handbuch der Anatomic und Mechanik der Gelenke<i></i>, Dritter Teil, G. Fischer, Jena, 1911.</li> <li>Inman, Verne T., and H. J. Ralston, <i>The mechanics of voluntary muscle</i>, Chapter 11 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>Keller, A. D., C. L. Taylor, and V. Zahm, <i>Studies to determine the functional requirements for hand and arm prosthesis</i>, Department of Engineering, University of California at Los Angeles, 1947.</li> <li>Schlesinger, G., <i>Der mechanische Aufbau der kunstlichen Glieder in Ersatzglieder und Arbeitshilfen</i>, Springer, Berlin, 1919.</li> <li>Stetson, R. H, and J. A. McDill, <i>Mechanism of different types of movement</i>, Psych. Mono., 32(3): 18 (1923).</li> <li>Taylor, Craig L., <i>The biomechanics of the normal and of the amputated upper extremity</i>, Chapter 7 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>Tiffin, Joseph, <i>Industrial psychology</i>, Prentice-Hall, New York, 1947.</li> <li>University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Fundamental studies of human locomotion and other information relating to design of artificial limbs</i>, 1947. Vol. II.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Fick, Rudolf, Handbuch der Anatomic und Mechanik der Gelenke, Dritter Teil, G. Fischer, Jena, 1911.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Barnes, R. M., Motion and time study, Wiley, New York, 1937.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Cox, J. W., Manual skill, Cambridge University Press, 1934.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Tiffin, Joseph, Industrial psychology, Prentice-Hall, New York, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Dempster, W. T., and J. C. Finerty, Relative activity of wrist moving muscles in static support of the wrist joint; an electromyographic study, Am. J. Physiol., 150:596 (1947).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">There are many other examples of fixation stales, such as the open claw conformation of the fingers and the extended and rigid index finger for dialing a telephone.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Stetson, R. H, and J. A. McDill, Mechanism of different types of movement, Psych. Mono., 32(3): 18 (1923).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Best, C. H., and N. B. Taylor, Physiological basis of medical practice, Williams and Wilkins, Baltimore, 1937. p. 1256.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Best and Taylor, op. cit., p. 1418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Predominance of palmar prehension in both activities accounts for adoption of this pattern in the design of modern artificial hands (page 86).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Schlesinger, G., Der mechanische Aufbau der kunstlichen Glieder in Ersatzglieder und Arbeitshilfen, Springer, Berlin, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Keller, A. D., C. L. Taylor, and V. Zahm, Studies to determine the functional requirements for hand and arm prosthesis, Department of Engineering, University of California at Los Angeles, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Fick, Rudolf, Handbuch der Anatomic und Mechanik der Gelenke, Dritter Teil, G. Fischer, Jena, 1911.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Bunnell, Sterling, Surgery of the hand, Lippincott, Philadelphia, 1944.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Schlesinger, G., Der mechanische Aufbau der kunstlichen Glieder in Ersatzglieder und Arbeitshilfen, Springer, Berlin, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Bunnell, Sterling, Surgery of the hand, Lippincott, Philadelphia, 1944.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Vol. II.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Robert J. Schwarz, M.D </b></td></tr><tr><td class="clsTextSmall">Instructor in Otolaryngology, College of Medical Evangelists, Los Angeles; formerly Assistant in Engineering Research, University of California, l.os Angeles.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Craig L Taylor, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Professor of Engineering, University of California, Los Angeles; member, Advisory Committee on Artificial Limbs, National Research Council, and of the Technical Committee on Prosthetics, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-13.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_02_022/table01.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-14.jpg Figure 4 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-15.jpg Figure 5 http://www.oandplibrary.org/al/images/1955_02_022/table02.jpg Figure 6 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-17.jpg Figure 7 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-18.jpg Figure 8 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-20.jpg Figure 9 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-21.jpg Figure 10 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-22.jpg Figure 11 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-24.jpg Figure 12 http://www.oandplibrary.org/al/images/1955_02_022/table03.jpg Figure 13 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-25.jpg Figure 14 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-27.jpg Figure 15 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-29.jpg Figure 16 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-30.jpg Figure 17 http://www.oandplibrary.org/al/images/1955_02_022/table04.jpg Figure 18 http://www.oandplibrary.org/al/images/1955_02_022/table05.jpg Figure 19 http://www.oandplibrary.org/al/images/1955_02_022/table06.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Anatomy and Mechanics of the Human Hand Creator An entity primarily responsible for making the resource Craig L Taylor, Ph.D. * Robert J. Schwarz, M.D *