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HX64058832 756 M31 1914 Manual of artitaal

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■MANUAL

OF

Aktifioial Limbs

COPIOUSLY ILLUSTRATED

Artificial Toes, Feet, Legs, Fingers, Hands, Arms,

for Amputations and Deformities, Appliances

for Excisions, Fractures, and other

Disabilities of Loioer and Upper

Extremities, Suggestions on

Amputations, Treatment

of Btump)S, History,

etc., etc., etc.

m EXHAUSTIVE EXPOSITION OF PROTHESIS

A. A. MARKS

701 Broadway, New York, N. Y., U. S. A. 1914

KD 756

19l|

Copyright, 1905, 1907, 1910, 1914

BY

A. A. MAEKS

PREFACE

Manual of Artificial Limbs is the title given to this book to distinguish it from the Treatise and all other publications which it succeeds and supplants. It is in no sense a catalogue, although con- taining the information usually given in catalogues; but it is a true manual of the subject of prothesis and the most exhaustive work ever produced on that topic. Prothesis or prosthesis is defined by Webster as "The process of adding to the human body some artificial part in place of one that may be wanting."

The Manual thus treats of all losses and impairments of the ex- tremities, whether caused by accident, disease or birth, shows what they are and clearly describes how they may be repaired by artificial methods.

The Manual is divided into chapters, each devoted to a distinct phase of the subject or to a particular part of the leg or arm under discussion.

The illustrations are designated by letters and numbers for con- venience of reference. For example, partial foot amputations are discussed in Chapter III, and the illustrations in that chapter all have the letter C and are numbered in order, 1, 2, 3, etc. Amputa- tions of different sections of the legs and arms are similarly divided and the illustrations numbered in the same manner. This gives definiteness and avoids confusions with earlier publications.

The need of the Prothesist becomes more and more urgent every day. Losses of limbs by accidents and injuries of every kind are constantly multiplying, and the demands made upon the thought- ful and skillful maker of artificial limbs and other surgical apparatus increase in the same proportion.

The successful maker cannot confine himself to the narrow methods of former times. Specific treatment is now called for in almost every case, the peculiarities of each requires closer study, separate methods must be devised by which complicated cases can be treated more skillfully and reparation more complete. These are advanced methods, called for by the progress of the science and necessitated by the importance of the work required. The skillful maker thus occupies a much more prominent position than can be filled by those who persist in clinging to archaic systems. It has been said by those most competent to judge that the house of A. A. Marks through persistent endeavor, broad enterprise, attentive study and a real sense of the importance of the work has earned and occu- pies the foremost position in its branch of inaustry.

4 Preface

While the loss of a limb is a serious personal deprivation, it is no longer regarded as a grievous or irreparable one. Tliere are many thousands of people who vralk, v^ork and mingle with other people without disclosing their own loss and without suffering. The ab- sence of a leg or an arm, therefore, is now regarded, and quite rightly, as one of the minor misfortunes. Testimonials substantiat- ing these statements, and explaining and endorsing the principles presented in this Manual for the construction of artificial limbs, will be found in copious numbers in Chapter XXXVII.

TABLE OF CONTENTS

PAGE

Preface ..... <....<> 3

Introduction ......... 15

CHAPTER I

How We Walk.

On natural feet ........ 17

On artificial feet with ankle-joints 19

On spring mattress rubber feet without ankle-joints . 19

CHAPTER II

Artifical Feet, Their Construction and Relative Merits.

The rubber foot 21

The spring- mattress . . . , . . . .21

Contrasts . . . 24

The sponge rubber foot . . . ■ . ■> . .24

The pneumatic foot . 24

The wood foot . . . 24

The ankle-joint rubber foot 25

The felt foot 25

Ankle joints when ordered . . . • . . .26

CHAPTER III

Partial Feet Amputations. Single-toe amputations Amputations at base of toes Instep amputations Ill-advised prothesis . Objections Practical prothesis Retracted heels . Aluminum sockets

27 27 28 28 29 31 33 35

Contents.

CHAPTER IV

Ankle-joint Amputations. Tibio-tarsal stumps End-bearing ..... Construction of suitable artificial leg Partially end-bearing Sensitive ends .... Peg legs .....

CHAPTER V

Below-knee Amputations. Long tibial stumps Enlarged non-end-bearing No pressure at the popliteal space . Tapering stumps . . . .

Ordinary and short tibial stumps . Artificial legs for tibial stumps Construction ....

Socket ......

Knee-connection ....

Steel joints .....

Test

Thigh part ..... Lacing methods .... Check strap ..... Sensitive stumps .... Non-end-bearing and end-bearing . Thighless legs

Dangers .....

Slip sockets versus wood sockets Slipping of the stump desirable An instance ....

Waterproof legs .... Bathing legs ....

Shortened thigh .... Lateral adjusting socket Contracted knee joints . Hypertrophied tibial stump . Anchylosed knee tibial stumps extended Peg legs ..... Peg legs should not be used permamently Ferrules for peg legs Rubber tip . Suspenders .....

Contents.	7
CHAPTER VI
	PAGE
Knee-bearing Stumps.
Definition .......	. 73
Knee-bearing legs	. 73
Bolt joint .......	. 75
Side joint .......	. 70
Peg legs ...... o	. 77
Incomplete restoratives ....	. 77
Suspenders	. 78
CHAPTER VII
Disarticulated Knee Stumps.
End-bearing and non-end-bearing stumps	. 79
Fittings	. 79
Peculiarities of stumps ....	. 80
Most favorable conditions ....	. 81
Suitable artificial legs .....	. 81

CHAPTER VIII

Thigh or Femoral Stumps.
Definitions ......... 84
Long or lower-third thigh stumps .			. 84
Stumps out of line			. 84
Construction of legs			. 85
Variety of middle-third thigh stumps			. 85
End and non-end-bearing			. 85
Thorough control			. 89
Knee spring ....			. 89
Helps knee motion when walking .			. 90
Spring strength can be regulated .			. 91
Knee lock .....			. 91
Hip joints .....			. 92
Waterproof and bathing legs			. 92
Legs without knee-joints			. 92
Peg legs			. 93
Suspenders .....			. 94
Straight shoulder straps			. 95
Belt attachment .....			. 96
Vest method .....			. 96
Suspenders for women . . . ,			. 96
Yoke method .....		. 96
Corset method .....			. 97

Contents.

CHAPTEE IX
	page
Hip-joint Amputations.
Bequirement ......	. 98
Muscle stump ......	. 98
Leg applied ......	. 100
CHAPTER X
Both Leg Amputations.
Ancient methods ......	. 101
Both feet partly amputated ....	. 102
Lower instep and leg amputation ..	. 103
Both feet amputated at the ankles	. 103
Ankle-joint and knee amputations	. 103
Upper instep and leg amputations	. 104
Both leg amputations .....	. 106
Practical results ......	. 106
Below-knee and knee-joint amputations	. Ill
Below-knee and above-knee amputations	. Ill
Engaging in former pursuits ....	. 112
Both legs and both arms amputated	. 113
Both legs amputated above the knees	. 113
CHAPTER XI
Artificial Feet and Legs for Deformities^ Paralysis	, Ex-
cisioNS^ Arrested Growth^ Shortened Growth	, ETC.
Short leg .	. 119
Talipes-equinus		. 119
Talipes with lateral weakness		. 120
Toe support . . . "		. 120
Congenital deformity		. 122
Talipes-varus		. 123
Leg deformities		. 123
Infantile paralysis		. 126
Obstructed growth . ' .		. 127
Both legs deformed		. 129
Drop foot ....		. 134
Knee joints locked		. 135
Limited knee motions .		. 135
Ununited fractures		. 137
Fractured knee caps, etc.		. 138

CHAPTER XII

Facts for Consideration.

Wooden feet substituted by rubber ones A wa^ to test the rubber foot

139 139

Contents.

PAGE

Fitting— an art 139

Only one way to fit . . . « . » . 140

When plaster casts are useless ..... 140

Machine fitting a failure ...... 140

When casts are necessary . . . . . .141

Wood sockets the best ....... 141

Weight 141

Rubber foot not heavy ....... 141

Odor 143

Temperature . . . . . . . .143

The mass of limb wearers are of small means . . . 143

How long will a leg last? ...... 144

Shoes and stockings ....... 144

How soon after amputation should an artificial leg be

applied? ........ 144

Treatment of stump . . . . . . .144

The gain of applying a leg immediately .... 146

Dangers in delay ....... 146

Cork legs ......... 146

CHAPTER XIII

Artificial Legs for the Aged

148

CHAPTER XIV

Artificial Legs for Infants and Children. The problem considered Support from the pelvis more natural Alterations for growth . Frequency of alterations The parents' moral obligation Deformities from the use of crutches Practical illustrations .

151 152 152 152 153 153 154

CHAPTER XV

Home Measurements.

Instructions when one leg is amputated Diagrams ......

Measurements .....

Instructions when both legs are amputated Plaster casts .....

165 165 167 170 172

CHAPTER XVI

Prices, Accessories, Terms of Payment. Accessories ..... Terms of payment Guarantee . , , , .

177

177

ITT

10

Contents.

CHAPTEK XVII

CHAPTEK XVIII

PA6B

Hands and Arms, Natural Compared with .	(Artificial.
History 1Y9
The demand greater				. 179
Simplicity . . . >				. 180
What an artificial arm must do				. 180
The natural hand a marvel				. 180
The brain ....				. 180
Self repairing				. 181
Sense of touch				. 181
Stories misleading				. 181

Is IT Profitable to Buy an Artifioal Arm ? Ornamentation .... Hygiene .....

183 184

CHAPTEK XIX

Old methods				. 188
New methods				.188
Ductile fingers				.188
Palm locks .			'	. 189
Wrist connections				. 189
Clamps				. 189
Flexion				. 190
Spring thumb				. 191
Gloves always to be worn			. 192
Choice of material for sockets		. 192
CHAPTEK XX
Partial Hand Amputations.
The loss of one finger	. 194
Materials .....	. 195
The loss of two or more fingers	. 196
Individiial fingers	. 197
Construction				. 197

CHAPTEK XXI

Wrist- joint Amputations. Plat ends Tapering ends

200 201

Contents. 1 1

CHAPTER XXII

Forearm Amputations. ^^^^"

Leather elbow joints ....••• 202

Steel elbow joints 205

Short stumps ......•• 200

Arms without hands .....•• 206

Suspenders . . • • • • • • • 206

CHAPTER XXIII

Elbow- JOINT Amputations.

Short radial stumps 209

Construction . . . • . • • • 209

Arms without hands ....... 210

CHAPTER XXIV

Above-Elbow Amputations.

Elbow lock o . .212

CHAPTER XXV Shoulder-joint Amputations ...... 213

CHAPTER XXVI

Double Arm Amputations . . . . . . 216

CHAPTER XXVII

Appliances for Deformities, Excisions, Weakened

Joints, etc. ........ 220

CHAPTER XXVIII Arm Implements 224

CHAPTER XXIX Utility 226

CHAPTER XXX

Directions for Taking Measurements for One or a Pair

OF Artificial Arms. 230

Arms fitted from measurements ..... 233

CHAPTER XXXI

Prices, Accessories.

Accessories ....... c . 236

12

Contents.

CHAPTER XXXII

Terms of Payment^ Installment Payments, Guarantee. Advanced payment avoids delay ....

How to make payments .....

Our reliability .......

Success most important to us

Advanced payments are in the interest of the wearers Artificial limbs on trial, prejudicial to success . Why correctly made limbs are not always pleasant at start ........

Patient endeavor brings its reward Money deposited in banks not acceptable Installment payments ......

Deferred payments must be guaranteed . Acceptable guarantors . .....

Our guarantee .......

PAGE

. 237

. 237 . 237 . 237 . 237

. 238

the

238 238 239 239 239 239 240

CHAPTER XXXin

Pensioners of the United States Army and Navy Furnished WITH Artipical Limbs at Government Expense.

The original law . . . . . . . . 241

The amended law ....... 241

The new law now in force ....... 241

Transportation free ....... 241

The bond 241

Advantages in registering with iis .... 242

CHAPTER XXXIV

Cheap Artificial Limbs.

Cheaply made limbs not safe Inviting disaster . Confidence necessary to success Selection of material

. 243 . 243 . 244 . 244

CHAPTER XXXV

Do THE Maimed Die Young ? A false belief What our records disclose Amputations revitalize the system Illustrations

Athletes ....

Compensation Gratitude ....

246

246 246

247 247 247 248

CHAPTER XXXVI

Awards «

Foreign Money Equivalents

249 256

Contents.

13

CHAPTER XXXVII

Testimonials

Panama Canal 39

PA on 257

CHAPTER XXXVIII

Stump Socks for Artificial Limb Wearers .

. 395

CHAPTER XXXIX

How to Reach Our Establishment.
Where we are located .....	. 397
We meet patrons . . ...		. 397
Business hours ....		. 397
Board and lodging		. 397
Where to have your mail addressed		. 398
Calls made to residences		. 398
Women in attendance .		. 398
Branches .....		. 398
Interior of the largest artificial limb manufactory-	in the
world	. 399
Caution ,	,	. 400

INTEODUCTION

In reviewing' " Manual of Artificial Limbs " and introducing same to the reader privilege is taken to advert briefly to the House itself and its enviable history.

The house of A. A. Marks was founded for the purpose of reliev- ing and helping the maimed and deformed. Established in the year 1853 it has had a continuous existence of more than half a century and has become the leading house of its kind in the world .

Its manufacturing plants, the factory and office in New York City, and the mills in Connecticut, occupy more ground and employ more help than any establishment elsewhere in the world devoted to the manufacture of artificial legs or artificial arms. The busi- ness is a large one, conducted in a large way and by men thor- oughly familiar with every detail of artificial limb manufacture; men who have brought to it the widest practical knowledge and years of the most attentive study and effort.

Their specialty is the making of artificial legs and arms with rub- ber feet and hands, of which they are the inventors and patentees. The spring mattress rubber foot and the rubber hand with ductile fingers are the most recent improvements. That the house has grown from a small shop to a vast manufacturing establishment with a hundred thousand correspondents located in all parts of the world is due not only to the intelligent way in which its business has been conducted, but to the inherent merits of its products. These are described at length in the pages which follow and the descriptions are supplemented by innumerable letters from grateful clients.

Modern skill has brought no more useful aid to humanity than the artificial limb which transforms a helpless member of society into a useful one.

The firm does not claim that every maimed and crippled person can be restored to the full use of his extremities by its apparatus. It is reasonable, however, to claim that its skill and facilities enable the firm to help the maimed better and more thoroughly than any other establishment in the world, and as the house has helped so many in the past there is abundant encouragement for the maimed of the future.

This book has been prepared not as an exposition of the fii'm's business, but as a guide and lielp to those seeking alleviation.

The firm manufactures limbs for simple amputations as well as for the most complicated and difficult ones. It has developed special types of limbs for groups of special cases, many of which are

15

16 Introduction

of utmost complexity" ; it has fitted and helped persons with delicate and tendex' stumps, also many with stumps of awkward shape and difficult forms; it has applied artificial limbs and appliances to per- sons with one sound limb as well as to those who have been deprived of both, and the volume of testimony it has on view received from its clients, filled with gratitude, stimulates it to con- tinued endeavors.

The book is destined to be an authority on the important subject of prothesis, a book of interest and concern to the surgeon and phy- sician as well as to the maimed. It contains not only a description of multifarious devices but much general matter both descriptive and ci'itical, and in a way didactic, bearing close relations to the work of the surgeon.

It is a matter of highest gratification and pride that in all the exhibitions in which the firm of A. A. Marks has been represented it has received forty-six first and highest awards, always in compe- tition with others. But the freely proffered expressions of regard and satisfaction from its clients, from the men and women who have been helped and whose lives have been aided and bettered through the use of its apparatus, are more stimulating, and the very highest measure of praise one can hope to receive. Numerous as are those that are printed, they constitute but a fragment of the kind and grateful words that have been uttered in its favor during its career.

The book will reach many readers. To them let us say one word. The firm of A. A. Marks has helped others. It surely can help you.

James Law, M. D.

CHAPTER I HOW WE WALK

On Natural Feet, — No two persons walk exactly alike. Every- one carries his mannerisms in his steps. The way in which he lands on his heel, rolls on the sole, lifts on the ball, throws himself to the right or the left, the uniformity and regularity of each joint's action, the angle at which the hip is checked, the range of articula- tion permitted in the knee and the angular motion of the ankle, — all form a part of his individuality and make it possible to dis- tinguish a friend from a stranger long before his features have come within the reach of vision. All sorts of forces — ^heredity, early habits, occupation, disease, injuries, and age — influence the movements of the leg and foot. A man in good health walks dif- ferently from an invalid, a farmer can be distinguished from a merchant, a bookkeeper from a railroad conductor, the sprightli- ness of youth, the infirmities of age are reflected in every step that is taken. Yet there are certain facts connected with walking that are common to all and which can be ascertained by observation and study. These facts are so universal that they become laws govern- ing locomotion; they form a necessary part of the limb-maker's education, and unless he is familiar with them and applies them thoughtfully to the construction of artificial limbs, he is not com- petent to work out the problems that are continually arising.

As this work is designed as a text-book on artificial limbs, it is essential, at the outset, to present the cardinal facts relating to natural walking, in order that the application of them to artificial aids may be clearly understood and appreciated.

Kinetoscopic photography affords the most valuable aid to an investigation of the actions of the knee and ankle joints when performing their functions. It shows that when a man walks slowly, say two miles an hour, the knee flexes but slightly and the ankle considerably. When walking three miles an hour, the knee joint acts through a greater range and the ankle joint through a lesser one. When walking moderately fast, say four miles an hour, the knee action becomes considerable and the ankle action scarcely perceptible. Wlien walking rapidly, say five miles an hour, the knee action is increased and the ankle becomes prac- tically rigid. When running the knee increases its activity, and the ankle reverses its action and throws the man forward by the ball of the foot.

The ratio that exists between the range of motion of the knee and that of the ankle is in proportion to the speed with which one moves. An impulse is had to walk slowly or rapidly, or to change

A. A.

Marks, Artificial Limbs, New YorJc City.

from one gait to another. The proper muscles and tendons instantly respond to the mind, and the required speed is attained. If the co-operation between the mind and muscles be disrupted the person becomes a paralytic and his steps are unreliable. The same may be said of a person walking on an artificial leg with ankle motion that is not under control.

Three miles an hour is the ordinary gait of a person occupied in

Cut A 2.

Cut A 3.

Cut A 4.

commercial life. Suecessive photographs of a man with natural legs, walking at this gait, show that there is but very little motion in the ankle joint; and limited as that motion is, it is of a charac- ter that cannot be imitated by mechanical means. The walker throws his left foot forward, barely touching the heel to the

Cut A 5.

Cut A 6.

Cut A 7.

Cut A 8.

ground, as shown in Cut A 1 ; instantly the right foot under con- trol of the tendo-Achilles extends and the heel is raised from the ground, throwing the weight of the body on the ball, supplying the impetus that urges the body forward. As the body is carried

A. A. Maries, Artificial Lirribs, New York Cily. 19

forward, the ball of the left foot reaches the ground at about the time the body is vertically over it, as shown in Cut A 2. At this point the right foot is in the act of leaving the ground, and, as shown in Out A 3, is passing the left which, still being flat on the ground, performs no function, except that of supporting the body, as shown in Cut A 4. The right leg is carried a little further forward when a slight amount of flexion is admitted in the left ankle joint, as shown in Cut A 5. But this is for a very brief period, as Cut A 6 shows that the tendo-Achilles instantly contracts and the foot extends and the entire body is lifted and thrown on the ball, and when the weight of the body is placed on the heel of the right foot, there is a slight flexion in the knee joint which permits the sole to reach the ground. At this time, the knee joint of the left is flexed and the foot of that leg is raised, as shown in Cut A 7, and when the weight of the body is prac- tically over the right foot the knee is extended, so as to support the weight securely, as shown in Cut A 8.

A study of these successive photographs shows that in making a complete step the soles of both feet are not on the ground at the same time, and at times when the weight of the body is placed equally on each foot, the heel of the advanced foot and the toes of the rear foot are only those parts that are on the ground. It also shows that propulsion is obtained by rising on the ball of the rear foot.

On Artificial Feet with Ankle Joints. — Similar photographs of a man walking with one or a pair of artificial legs with ankle joints set to act at a constant range of motion, show that he walks fairly well at a slow gait, but at a speed of three or more miles an hour his step becomes perceptibly awkward, and the effort re- quired to overcome the too liberal motion in the ankle is fati- guing. So far as the knee joint is concerned the motions of the artificial and natural legs are approximately the same, but the motions of the ankles are very different. The sole of the foot is flat on the ground for a considerably longer period with the arti- ficial ankle joint than with the natural. As the walker advances and strikes the heel of the artificial foot on the ground, almost immediately the front of the foot drops and the entire sole rests on the ground and remains there during the interval through which the body is passing over it.

Having made plain the movements of the natural foot in walk- ing, and contrasted them with the movements of the artificial foot articulating at the ankle, we now propose to carry the contrast to the spring-mattress rubber foot attached rigidly to the leg socket.

On Spring-Mattress Eubber Feet without Ankle Joints. — ^As the walker advances on the rubber foot he touches the heel to the ground. He applies his weight, and the sponge rubber in the heel compresses sufficiently to allow him to roll on the bottom of the foot; the moment the body is carried a little in advance, he rises on the ball very much the same as he does on the natural foot. There is no effort required to lift on the ball, as the weight

20 A. A. Marks, Artificial Lirribs, New Yorh City.

of the body, being in advance of its center of gravity, overcomes that apparent obstruction; not a muscle or tendon is brought into play; the weight of the body does the entire work.

These studies and comparisons of the movements in walking ■bring out very clearly the essential fact that with the artificial ankle joint the interval that the plantar surface rests on the ground is very much greater than that of the natural foot, while with the sponge rubber spring-mattress foot it is approximately the same, and, by compelling the wallcer to rise on the ball, pro- duces a very natural action, giving greater assistance in walking and dispensing with a vast amount of mechanism.

It is apparent also that the value of mental force in controlling the actions of the natural ankle joint cannot be overestimated. When these forces become inert, as they necessarily do in artificial joints, the embarrassments that follow are the same as with paralytics, locomotor ataxia, etc. The injured are obliged to walk cautiously, the affected foot is placed almost entirely by the sense of sight, and the step is made with meditation and progress must necessarily be slow.

If an artificial leg with ankle articulation be applied to a person who desires to walk at a gait faster than two miles an hour, he will find himself not only greatly hindered, but required to put more energy into the natural foot and leg in order to overcome the influence of the articulating ankle in retarding his progress. The rubber foot without ankle joint will assist rather than hinder rapid W&lking, and will not hinder slow walking when desired.

CHAPTEE II

. ARTIFICIAL FEET, THEIR CONSTRUCTION AND RELATIVE MERITS

The Rubber Foot. — With an experience of eight years in manu- facturing artificial legs with wood feet, articulating at the toes and ankles, A. A, Marks in 1861 invented the sponge rubber foot hereinafter described, to protect which the United States Govern- ment issued letters patent in 1863. Like all great inventions it passed through various stages of development.

The perfected form consists of a wooden core, carved to size and shape to secure the best results. The faint lines in Cut B 1

. A. MARKS, N. Y.

Cut B 1.

represent the core, which reaches to the ball of the foot, localizing the toe movement. The distance from the core to the floor at the heel is considerably greater than at any other part; this is done to obtain the proper degree of compressibility at the heel; the core is entirely surrounded with sponge rubber of great porosity which will yield under the weight of the wearer sufficiently to make the step realistic. Less rubber is placed at the ball so as to provide phalangeal support and make the wearer feel that there is a sup- porting medium at the front of the foot; ample, to steady him when standing, to keep him from limping, and to act as a lever to urge him forward when walking. A spring mattress is floated in the foot below the core, covering the entire distance from the back of the heel to the tips of the toes ; it is shown by the lines running lengthwise in Cut B 1. The spring mattress is formed by a series of composition strips embedded in strong sail duck, each having a pocket of its own, see Cut B 2; the strips occupy the pockets a a a a.

The Spring Mattress. — Is a device for giving additional resiliency for both the toes and heel. Every movement of the foot

21

22

A. A. Marks, Artificial Limbs, New Yorh City.

when in action applies pressure to the springs at the heel, ball, or on the sides. The counteracting tendency of the strips aids in forcing the foot back to its proper shape as soon as pressure is removed.

Cut B 3 represents the rubber foot with the weight applied at the ball as it is when the wearer is being urged forward, while walk-

A. A. MARKS, N. Y.

Cut B 3.

ing. The spring mattress is now forced upwards at the ball and the sponge rubber is compressed above and below the mattress. This pressure pulls the mattress forward in the foot. These move- ments— the yielding of the spring, the conxpressing of the rubber, and the pulling of the spring mattress forward — form a very powerful resultant force that brings the foot back to its normal lines as soon as the foot is relieved of weight.

The condition of the foot when under heel pressure, as it is when the wearer places the artificial limb forward and applies his weight

A. A. MARKS, N. Y.

Cut B 3.

upon it, is somewhat the same. The spring mattress is forced upward, the sponge rubber is compressed above and below, the heel becomes flattened, and the mattress being pulled lengthwise, all combine to force the foot to its shape as soon as pressure on the heel is removed. The compression of the heel permits the toes and the front part of the foot to reach the ground while the shaft of the leg is obliquely back of the vertical line.

Cut B 4 represents the foot on an inclined surface. On account of the yielding quality of the rubber, the up-hill side of the foot

A. A. Marks, Artificial Limbs, New Yorh City.

23

will compress and accommodate itself to the incline and allow the foot to remain on its base. This is accomplished without com- plicated mechanical lateral articulation.

The spring mattress not only forces the parts of the foot back to their proper shape, but obviates the exertion required to operate the antiquated articulated wooden foot.

The impression that one receives on the new spring-mattress foot is both pleasant and agreeable. This is especially the case to one who has worn an artificial leg with wooden articulating foot.

It can readily be seen that any motion in the ankle that cannot be controlled by the will must be mechanical in appearance as well as in action. The approach to nature is made more positive by their omission.

It is the experienced man, the man who has experimented with tnany kinds of artificial limbs, who is capable of appreciating the

A. A. MARKS. N. V..

Cut B 4.

principles involved in the rubber foot. He comprehends the reason why the wearers of artificial limbs with rubber feet walk further, faster, and with less fatigue, than those walking on ankle-jointed wooden feet.

The contrast between the two kinds is most striking in run- ning. With the rubber as with the natural foot the entire plantar surface is never on the ground. It is the heel-and-toe touch to the ground that distinguishes the walker from the runner. This is extremely difiicult with the ankle-jointed foot. When standing the immovably attached rubber foot furnishes a large base on which to balance; hence, a man with two artificial legs with immovably attached feet can stand restfuUy and safely without assuming awkward and unnatural positions, for he is not required to main- tain his equilibrium on a point.

The rubber foot with spring mattress provides the laborer a substantial substitute with which to support and brace himself when working at the bench, on the road, on the farm, or at what-

24 A. A. Marks, Artificial Linibs, New York City.

ever occupation lie may be engaged. There are no uncertain or treacherous movements to hamper him or make his position un- certain.

A painter who wears a Marks rubber foot says he can climb a ladder, stand on a scaffold, balance himself at any elevation with absolute safety. With an ankle-joint leg he would feel tottlish, and, when on his ladder, would have to depend more on the grasp of his hands than on his foot; but, with the rubber foot, his base is substantial and reliable.

A farmer who toils in the field can plod along over stony or muddy ground on a rubber foot with safety. The accumulation of mud on his shoes does not cause his toe to drop and trip him. Uneven surfaces will not throw him from his balance or violently jar his stump. We have thousands of testimonials on these points.

Contrasts. — There are two kinds of rubber feet. One is known as the sponge rubber foot; and the other as the pneumatic rubber foot. We will endeavor to make clear the difference between them.

When rubber is cured so that it possesses a great number of small air cells, the same as a sponge, it is called sponge rubber, and a foot made in this way is known as a sponge rubber foot.

A foot made of a sheet of rubber cast into the shape of a foot, possessing one or a limited number of large chambers into which air is pumped until sufficient pressure is obtained to maintain shape and possess resiliency is called a pneumatic foot.

The Sponge Rubber Foot. — Is composed of a vast number of cells, each charged with air created by the volatilization of a chemical while the rubber is being vulcanized. Each cell is sur- rounded by a wall of rubber possessing a sustaining power suf- ficient to maintain itself should it become deflated. In fact, if all the cells become deflated the foot would keep its shape on account of the presence of the sustaining walls, therefore the shape and resilience of the sponge rubber foot are not dependent upon the air in the cells.

The Pneumatic Foot. — Having but a limited number of large air chambers into which compressed air is forced, is wholly de- pendent upon the presence and retention of the compressed air for its stability. The sponge rubber spring-mattress foot receives no injury from puncture. The pneumatic foot will collapse and lose its sustaining power the moment the air chamber is pen- etrated. A protruding nail or peg in a shoe will puncture a pneu- matic foot and put it out of service until the puncture is patched and the foot pumped up again with air.

The sponge rubber spring-mattress foot never has to be re- charged with air.

The Wood Foot. — Is now somewhat antiquated. It no longer has the merit it was formerly thought to possess — the rubber foot has practically supplanted it: The wood foot is articulated at the ankle and at the toes. The mechanical methods employed in its manufacture are as numerous as the makers who supply them. Nearly every maker has a method of his own, yet all are essentially

A. A. Maries, Artificial Lirribs, New Yorh City.

25

the same. Some admit of a large range of ankle articulation, while others limit it so that there is but very slight motion. Some have side motion; others, equally as conscientious, condemn that motion and employ only front and back motion. Being convinced by most careful study and experimentation that an artificial leg is im- proved in proportion to the abridgment of its mechanical move- ments, we dissuade all from using the side motion. Some manufacturers employ rubber for springs in the ankle and toes; others prefer steel. One method has little advantage over the other.

The Ankle-Joint Kubber Foot. — Cut B 5 represents an ankle- jointed rubber foot after our preferred plan. Cut B 6 represents

Cut B 5.

Cut B 6.

the ankle articulation in sectional view. The axis on which the foot moves consists of a bolt that passes through the foot at the ankle, connected with steel strips riveted to the lower sides of the leg. A steel spiral compression spring, one end of which is placed in a cylinder and the other, receiving a piston, is placed in the ankle in such manner as to act on the rear part of the foot, im- pinging against the front interior part of the socket, forcing the heel downward and the front of the foot upward. The articulation at the ankle is limited by the check cord placed in the rear. It is made of the strongest flexible material. This method of articula- tion can be used with wooden feet as well as rubber ones. When rubber is used it is not necessary to have a mechanical articulation at the base of the toes as the rubber itself will furnish that motion. Cut B 7 represents the ankle at extension, the foot flat on the ground when the leg is thrown forward and weight applied. Cut B 8 represents the ankle at flexion and weight applied to the toes.

The Felt Foot. — Is so seldom used that it is only referred to here in order to make our descriptions complete. Its use is to be strongly condemned. Felt possesses no stability. It is an absorb- ent of moisture and lacks resiliency, and is therefore wanting in the most essential qualities that should characterize the material used in the construction of an artificial foot,

26 A. A. Marks, Artificial Lirribs, New Yorh City.

Ankle Joints when Preferred. — ^While many years of observa- tion and study have convinced us that the best results are obtained from artificial legs with rubber feet rigidly attached, it is neverthe- less true that some persons form prejudices that cannot be removed even by the most logical arguments. Another class, who may be put in the same group, are those who, for a long period, have worn artificial limbs with articulating ankles ; and have become so inured to them that a change, no matter how beneficial it might ultimately prove, would subject them to annoyance. We care not to antago- nize those who think and feel this way; we are therefore prepared

Cut B 7. Cut B 8.

to construct artificial legs for them that are similar in construction to those they have worn and have become accustomed to.

We frequently hear of persons who are inclined to patronize us on account of the reputability of the house, but who hesitate in doing so on account of their doubts as to whether they themselves would make a success with artificial legs without ankle articula- tions. The idea of the rubber foot is acceptable, but rigidity at the ankle is doubtful. The element of doubt hinders their entering into any experiment the success of which is entirely at their risk.

We are disposed to meet any such person on a basis of equity and will funish him with an artificial leg with rubber foot rigidly attached at the ankle with the understanding that, if after reason- able trial he feels that he would prefer the ankle joint, we will apply one for him without extra charge.

As we regard rubber feet rigidly attached at the ankle better for general purposes, we make limbs that way unless otherwise in- structed.

Prices are the same whether rubber feet are permanently attached pr made to articulate, whether feet are of wood, metal, or rvbber,

CHAPTEE III PAETIAL FEET AMPUTATIONS

Single-Toe Amputations. — The loss of a single toe, particularly if it be the great one, may or may not be the cause of inconvenience and discomfort, yet the application of an artificial part is often found necessary, both as an aid in walking and as a protection to the amputated surface.

If one or more of the interplaced toes are removed and the hiatus has been filled up by the union of the adjacent surfaces, there can be no gain whatever in applying artificial ones. If the great toe (see Cut C 1) or the small toe be removed, and the am-

A A. MARKS, N. Y.

Cut C 1. Cut C 2. Cut C 3.

putated surface is tender and painful to the touch, an appliance similar to that represented in Cut C 2 can be advantageously applied.

This appliance consists of a duplicate of the removed part, made of suitable material and secured to a plate shaped as the sole of the foot. It is held to the foot by an incasement of leather, laced down the front; when applied it is ready for the shoe, as shown in Cut C 3. This simple arrangement protects the amputated sur- face, assists in walking, fills the shoe, and prevents unsightly wrinkles in the leather.

Amputations at Base op Toes. — ^It is necessary to apply an arti- ficial part when all the toes have been removed, as shown in Cut C 4. It must be so constructed that it can be held in place and avoid pressure on the scarred surface. Shoes stuffed with cotton or with pieces of cork should never be used ; such expedients, having no support on the under sides, will eventually encroach on the amputated surfaces and permit the shoe to bend near the ends of the stumps.

An appliance illustrated in Cut C 5 is suitable for such an amputation; it is shown applied in Cut C 6. It can be made of wood or metal as may be required, and shaped to receive the foot in a comfortable manner ; tender points are protected by recesses pro-

27

28 A. A. Marks, Artificial Linibs, New Yorh City.

vided for them. Cut C 6 shows this apparatus applied and ready for the shoe. Usually the mate to the shoe worn on the natural foot can be used without alteration; in cases where more room is

A. A. MARKS, N. Y.

Cut C 4. Cut C 5. Cut C 6.

needed, almost any shoemaker can supply it by ripping off part of the upper and substituting a larger piece.

Instep Amputations. — These are termed tarso-metatarsal and medio-tarsal by the surgical profession, and are frequently des- ignated by the names of the surgeons who first performed them, as Chopart, Lisf ranc. Hays, Hancock, and many others. These amputations are performed, with the object of sacrificing as little of the foot as possible, and retaining the heel and a part of the foot as a base on which the patient is supposed to be able to walk or stand. Although a person with the front part of his foot removed may be able to get about with an ordinary shoe, it is not long before he discovers that something is lacking and his locomotion impeded by the absence of the removed part. He may pack the vacancy in his shoe with cotton, cork, or other material, and may re-enforce the sole with a steel plate; but he soon finds that only partial relief has been obtained, and that there is an imperative demand for a substitute for the ball of the foot which will enable him to rise on and elevate his heel from the ground. Something is needed having great strength and that can be firmly secured to the remaining part of foot and leg.

The construction of artificial feet for this class of amputations has taxed the ingenuity of artificial-limb-makers for many years. The absence of space between the bottom of the heel and the floor presented an obstacle to the construction of a helpful and durable appliance until aluminum was employed. It may be useful to re- view some of the devices used for such cases.

Cut C 7 represents a stump resulting from a partial foot amputa- tion.

Ill-Advised Prothesis. — Cut C 8 represents the way in which many manufacturers have endeavored to supply the want. The appliance consists of a leather shoe inclosing the stump and part of the ankle, the front of which is made of wood, rubber, or cork with a metal plate at the base, running from heel to toe, calculated to make the sole firm and unyielding at the ball. This apparatus gives a natural appearance to the amputated member, but fails to support the wearer in a helpful or substantial way. The stump will soon crowd forward, coming into impleasant contact with the

A. A. Maries, Artificial Limhs, New Yorh City.

29

appliance; the steel plate will bend or break and the shoe will yield where the stump terminates, creasing the shoe and making it rocker-shaped; consequently it utterly fails in supplying the want, because of the lack of firmness with which it is held to the remaining part; the heel, moreover, will yield to the constantly contracting tendency of the tendo- Achilles and become displaced.

Cut C 9 represents another ill-advised apparatus. It consists of a sheet of metal formed to receive the remaining plantar surface

A. MARKS, N. Y.

Cut C 7.

Cut C 8.

C ut C 9.

of the foot; bent up on either side, hinged at the ankle to steel straps thus providing a joint for ankle articulation ; the steel straps run up the sides of the leg and are held in position by a leather corset, shaped to inclose the leg. The front of the metal sole is secured to a part of a foot. The main objection to this device is the insecurity of the attachment; weight applied to the ball of the foot will cause the ankle to flex and permit the amputated surface of the stump to rub against either the front or the bottom plate, causing abrasions; a heel cord placed at the back connecting the leg section with the foot plate will not be effective in holding the appliance in its proper position at all times and checking the action of the ankle articulation at the proper angle.

Objections. — ^A glance will show that the legs illustrated in Cuts C 8 and C 9 must prove inadequate. When weight is applied to the ball of the foot the heel of the artificial part will remain on the ground, while the heel of the stump will lift away. The wearer will walk flat-footed and will press the delicate cicatrized surface against the attachment. These conditions will not only cause suffering but defeat the object of the artificial foot.

It might appear that an appliance constructed on the plan shown in Cut C 5 could be secured so firmly to the remaining part of a Chopart stump as to enable the wearer to rise on the ball. If this were possible the method of treatment would be greatly simplified ; unfortunately, however, the severity of the compression needful

30 A. A. Marks, Artificial Limbs, New Yorlc City.

to hold the appliance in place when weight is thrown on the ball, will stop the flow of blood in the heel, causing great pain, endanger- ing the health of the entire leg.

Cut C 10.

Cut C 11.

It is important to emphasize the fact that it is absolutely useless to apply any form of foot to a partial foot stump unless the artifi- cial part is held so firmly that the wearer may rise on the ball of the

.A, A MARKS. N. Y

Cut C 12.

Cul C 13.

foot, and not only support his weight while in that position but carr^ such additional weight and resist such strains as his habits or occupation demand.

Cut C 10 represents an amputation a little forward of the instep.

A. A. Marks, Artificial Lirribs, New York City.

81

The wisdom of the application of apparatus C 5 in this case is doubtful. It might prove adequate in the case of a person who does little walking and no lifting, and who places little demand on the front part of the foot; but for a laboring man, who has to lift and carry articles of weight, it would be a disappointment. It will be better considered, therefore, among instep amputations that re- quire the placing and distribution of the strain above the ankle joint.

Cuts C 11, C 12, C 13, and C 14 show instep amputations after the Lisfranc, Hancock, and Chopart methods. Cut C 15 shows an

Cut C 14.

Cut C 15.

amputation of the instep with all the tarsals removed, a part of the astragalus and the entire os-calcis retained and kept in their normal relations, a very unusual occurrence.

The remaining plantar surfaces of each of these amputations are of a character to permit the application of the weight of the wearer on them.

Cuts C 16 and C 17 show instep amputations in which the heels have retracted slightly, but not so much so as to prohibit the ap- plication of weight to the remaining plantar surfaces.

Practical Prothesis. — The only artificial limb that has ever been devised that adequately meets the needs of any of the above instep amputations is illustrated in Cut C 18. A half leg, or front, in- cluding the core of the foot, is made of aluminum, without articula- tion at the ankle. The rear half is made of leather, shaped to incase the leg and the aluminum shell and hold the appliance in place, as shown in Cut C 19. The sole of the foot, including the

32 A. A. Marls, Artificial Limls, Nciv Yorh City.

toes, is made of rubber with a spring mattress as described in Chapter II. Comfortable bearings are provided by proper fittings

Cut C 16. Cut C 17.

and suitable linings. The pressure needed to secure firmness is distributed over the entire leg from the ankle to the knee ; with this

Cut C 18.

Cut C 19.

leg the wearer can rise on the ball of the foot without endangering the amputated surfaces or straining the ankle joint. The shin-

A. A. Maries, Artificial Lirnbs, New York Oily. 33

bone is protected by the aluminum shell on the front, and, when dressed, presents an appearance very close to nature. When there is a tendency for the heel to retract, the leather sheath at the back is re-enforced with metal shaped to hold the heel down to its proper place.

This artificial leg can be worn without inconvenience or pain. The wearer walks gracefully, striking the heel first, then rolling on

A. A. MARKS, N. Y.

Cut C 30.

Cut C 21.

the sole until the ball is reached, and then rising on the ball he receives assistance in walking. Cut C 20 shows the leg applied and the wearer seated. Cut C 21 shows the leg applied with the shoe on and the wearer walking with the weight on the ball of the foot, similar to the position taken by the natural foot when in the act of throwing the body forward.

The method of meeting instep amputations, as just described, possesses many merits aside from those to which attention has been called.

Eetracted Heels. — Cuts C 22, C 23, C 24, show amputations in which the heels are retracted so that the amputated surfaces are directly under the legs, where the weight must be applied if the bearings are to be at the ends. These are unfortim.ate conditions. An artificial leg cannot be applied to a stump under such condi- tions that will permit any pressure on the scarred extremity; the weight, therefore, must be placed immediately below the knee or about the thigh.

34 A. A. Maries, Artificial Limhs, New Yorh City.

A A. MARKS, N. Y.

Cut C 23.

Cut C 23.

Cut C 24.

A limb constructed on the plan sLown in Cut C 25 is adaptable for some stumps with retracted heels; the rear half is made of

Cut C 25.

Cut C 2G.

metal, the front of leather, capable of being laced. This permits close fittings about the heel and tends to force it back to its proper

A. A. Marks, Artificial Limbs, New YorJc City. 35

position. If the sides of the leg are sloping, the fitting can be such as to apply all the weight on the leg immediately below the knee. Cut C 26 shows the leg applied and the wearer seated.

If the sides of a leg do not slope sufficiently to prevent settling into the artificial leg socket, it is necessary to introduce an annular top and possibly knee joints and thigh support. The annular top can be applied to a leg constructed as described; it then has the appearance of Cut C 27. It can also be applied to a leg constructed

Cut C 27,

Cut C 28.

on the plan of C 25. Knee joints and thigh support can likewise be applied to a leg constructed on the plan of either C 18 or C 25. Cut C 28 shows such additions applied to C 18 leg.. When the annular top is employed the support is calculated to be localized immediately below the knee. The leg is opened from the rear and the stump inserted; the annular top is laced firmly and the leather sheath is pulled over the entire apparatus and laced in front. When the knee joint and thigh support are required, as shown in Cut C 28, the lower section of the leg is made of aluminum, with the rear sheath of leather. The thigh part incases the natural thigh and holds it with sufficient firmness to carry the weight above the knee and so prevent the leg from slipping in the socket.

Aluminum Sockets. — The utilization of aluminum in the con- struction of artificial legs for instep amputations is especially advantageous. It can be worked to a very slight thickness, thus adding but little to the diameters of the large stump that it

36 A. A. Marks, Artificial Limls, New Yorh City.

incases. A wood socket would require a thickness of at least half an inch on each side, thus making the leg conspicuously bulky and objectionable.

During the past few years we have made many experiments ■ looking to the general application of aluminum in the construc- tion of artificial limbs for upper amputations, but have met with disappointment except in ankle-joint and partial-foot amputations. The characteristics of aluminum are low specific gravity and com- parative strength. Its weight is the least of all metals (one-quarter that of silver). Its strength is comparable with that of copper. It will not corrode when exposed to fresh water or to a moist atmos- phere.

We desire to correct the prevalent impression often expressed in the remark that aluminum is " lighter than cork and stronger than steel." As a matter of fact aluminum will sink in water, whereas cork or wood will float; it is therefore heavier and although aluminum is strong, it has but a fractional part of the strength of straight-grained wood. Its use in artificial legs is, therefore, nar- rowed down to sockets for long and large stumps, where the minimizing of bulk is an important feature.

We hold United States patents on artificial limbs with alumi- num sockets, and if we could make satisfactory use of that metal for general purposes we would unhesitatingly do so.

CHAPTER IV ANKLE-JOINT AMPUTATIONS

Tibio-Tarsal Stumps. — Amputations through the ankle articula- tions with or without the maleoli, flaps formed of heel tissues, provide stumps that can be fitted with artificial legs in an ad- vantageous way. Surgeons call these amputations tibio-tarsal or Symes, and if the os-calcis is retained and secured at the extremity of the tibia, it is known as Pirogoff's.

Usually ankle-joint amputations produce stumps that admit of weight being taken on their extremities. If cicatrices are on the

A. A. MARKS, N. Y,

Cut D 1.

Cut D 2.

bearing surfaces or nerve complications are present, they become non-end-bearing and artificial limbs must be applied that permit no pressure or contact on the tender extremities.

End-Bearing. — Cuts D 1 to D 6 show end-bearing tibio-tarsal stumps, with flaps favorable for the application of pressure and with cicatrices well away from the bearing surfaces. Cut D 7 illus- trates an artificial leg suitable for any of these types; Cut D 8 shows it applied with the wearer seated. Cut D 9 shows a Pirogoif stump with a suitable leg, patterned after style D 7. Cut D 10 shows the leg applied and the foot covered with stocking and shoe. Cut D 11 shows the wearer fully dressed. In walking his step is

S7

38 A. A. Marks, Artificial Limbs, New York City.

A MARKS. N. Y,

Cut D 5.

CutD

graceful, the foot imitates nature, there is no limping, and he is amply equipped to engage in any occupation, even the most la- borious.

A. A. Marks, Artificial Lirribs, New Yorlc City. 39

Cut D 9.

Cut D 10.

Cut D 11.

Construction of Scitable Artificial Leg.— The construction of D 7 style IS simple. The front, which is the resisting part, and the core of the foot, are cast in aluminum, the interior surface being

40 A. A. Maries, Artificial Lirribs, New YorJc City.

formed to receive the anterior surface of the leg from the knee down. It is so fitted that pressure will be distributed over the front area, the shin bone and tender parts of the leg being protected and not allowed to bear pressure. The rear part is of leather, shaped to fit the calf and the back of the leg. It is secured at its lower end to the aluminum socket, and when the stump is in place it incases the whole apparatus from the knee down, holding the leg in place with firmness, the pressure being regulated by- lacing. The foot is of sponge rubber, re-enforced with spring mat- tress as explained in Chapter II. Weight is taken by the end of

Cut D 13.

Cut D 13.

the stump resting on a surface of proper shape, covered by a suit- able pad. The strains resulting from rising on the ball of the foot are not permitted to come on the stump ; they are distributed over the leg, about the sides of the shin from the knee to the ankle. A stocking and shoe are drawn over the foot, and the apparatus is a counterpart in appearance to the sound leg.

This style of leg for ankle-joint amputation has received the most complimentary comments; it has given great satisfaction to those who have worn it ; and it has been quite generally adopted.

Occasionally conditions require the construction of a limb in a manner reverse to that just described, the stump is admitted from the front instead of the rear. In such cases limbs are built on the plan illustrated in Cut D 12. The construction is practically the same as D 7, except that the metal socket is placed at the back and the leather lace in front. The shin bone is protected by a padded

A. A. Maries, Artificial Limbs, New Yoric City.

41

loose fly-piece over which the lacing passes. Cut D 13 illustrates the leg applied.

If the end of the stump is small and has no prominences on the side, the socket and core of the foot, which are integrally one piece, are carved from a block of wood the grain of which curves on the line of greatest strains. When the end of the stump is large and it is desired to incase it in a socket of minimum thickness, aluminum must be employed for reasons given.

Partially End-Bearing. — If only a part of the weight of the wearer can be borne on the end of the stump the top of the socket must be made annular and fitted so that it will impinge against the sloping part of the leg below the knee. Cuts D 14 and D 16

Cut D 14.

Cut D 15.

illustrate suitable legs for the same and Cuts D 15 and D 17 show them applied. It is obvious that a stump, being inserted from the top of the socket of either, will not enter further than the top of the socket will permit, and this is just far enough, to limit pressure on the end or to avoid it altogether. When pressure can be taken on the end, it is regulated by the thickness of the pad placed in the bottom of the socket on which the end of the stump rests.

A socket that admits the stump from the front, as in Cuts D 12 and D 14, is objectionable when the end of the stump is very large. The material necessary for strength is on the sides of the stump and increases the diameter of the ankle. It also affords but little

42 A. A. Maries, Artificial Lirribs, New Torh City.

protection to the sharp or sensitive shin bone. Styles D 7 and D 16 are not open to this objection, but give a smooth, unbroken

Cut D 16.

Cut D 17.

front, which can be neatly dressed; they are lighter and stronger than D 12 or D 14, because the strain resulting from rising on the ball of the foot is carried forward from the point of contact to a point on line with the front of the leg : and as this point is usually halfway between the ball and the heel the strain is one-half of that applied in D 12, which throws the strain from the ball to the rear of the heel. For this reason the material on the sides of the stump and on the rear of the leg has to be as thick again as the material on the sides and front of the D 7. Hence the difference in weight.

Sensitive Ends. — There are tibio-tarsal stumps that are so sensitive at the extremities that no pressure whatever can be tolerated either on the ends or at the sides of the ends. Notwith- standing this condition, artificial limbs can be applied that will be helpful and comfortable. Cuts D 18, D 19, and D 20 represent stumps of this character.

If the surfaces immediately below the knee are sufficiently slop- ing to- offer resistance, D 14 or D 16 leg can be used, the pressure being placed on the sides of the upper half of the leg immediately below the knee. The stump from calf down hangs in space.

When a leg and stump are nearly uniform in size, the sides being parallel or nearly so, an artificial leg with knee joints and thigh piece must be used. Cut D 21 represents a leg suitable for such a case. Cut D 22 shows the same with knee flexed and sheath un-

A. A. Marhs, Artificial Limbs, New York City.

43

Cut D 18.

Cut D 19.

Cut D 20.

Cut D 21.

Cut D 22.

laced. The lower section is made of wood or aluminum, as the conditions of the stump demand. The rubber foot is attached in the usual way, and the leather sheath passes from the rear to the

44

A. A. Marks, Artificial Limbs, New York City.

front, holding the stump in place. The weight of the wearer is supported by side joints connecting the thigh parts with the lower portions.

Cuts D 23 and D 24 illustrate the front and side views of a leg constructed in a similar manner. It is fitted to receive the leg and stump from the front instead of the rear ; it contains no important advantage in construction, but is preferred by some persons.

Side joints and thigh supports are essential when stumps cannot

il

Cut D 23.

Cut D 24.

be supported on the sloping surfaces just below the knees, and when they are liable to become sensitive and irritable on account of impaired vitality.

Peg Legs. — Ankle-joint stumps should never use peg legs except when they need disciplining or shrinking. Some stumps with extremely sensitive ends, on which pressure cannot be immediately applied, give promise of improvement in course of time. There are also stumps that are cedematous — made up with soft, flaccid tissue which will pass away in a brief period. In such cases, an inex- pensive peg leg can be used to advantage. One may stump about on a peg leg applied to a stump reaching to the ankle joint, much the same as one who uses a peg leg on an upper amputation, but, having no foot, its functions are limited to that of a support.

CHAPTER V

BELOW-KNEE AMPUTATIONS

Long Tibial Stumps. — An amputation at any point above the ankle and below the knee produces a tibial stump, so termed by the surgical profession, because the tibia or shin bone has partly been saved.

Enlarged Non-End-Bearing. — ^Cut E 1 illustrates a stump reach- ing close to the ankle joint. The extremity, as is usual in long stumps, is poorly protected and incapable of bearing pressure, and.

A. A. MARKS. N. Y

Cut E 1.

Cut E 2.

on account of a slight enlargment at the end, an artificial leg must be made so that the stump can be placed in the socket from the front or rear instead of being inserted at the top. Cut E 2 repre- sents an artificial leg especially adapted to stumps of this descrip- tion; it is shown applied and the wearer seated. It has a socket that incases the rear half of the stump, with a front of leather that can be laced. The rubber foot with spring mattress is con- structed as described in Chapter II, and at the top of the socket are steel joints connecting the thigh supporter. The fitting of the leg avoids any weight or pressure on the extremity of the stump or near the end, and no pressure is applied at any point below the junction of the middle and lower thirds. Above this it is graduated

45

46 A. A. Marks, Artificial Limhs, Neio Yorh City.

to the knee, where the greatest amount of pressure is apphed, the interior sloping surface below the knee carrying most of the weight. The anterior prominences of the shin bone and the exterior prominence of the fibula are given ample room, so that no contact is applied ; the interior sloping surfaces below the knee carry most of the weight, the supporter above the knee carrying its share.

No Pressure at the Popliteal Space. — It is most important to avoid pressure at the back of the knee in long stumps. The pop- liteal space is the vascular area of the leg, and any undue pressure will interfere with the circulation and impoverish or strangulate the end of the stump.

The absence of ankle articulation in a leg for a long tibial stump affords an opportunity to give ample space for the end without

Cut E 3.

Cut E 4.

visibly increasing the external dimensions of the ankle. The rub- ber foot with spring mattress and yielding heel and toe provides every requisite for easy, lifelike, and noiseless walking without complicated connections. The absence of such connecting parts avoids the necessity of making the leg an inch or two longer than the natural one as is often necessary to obtain space for ankle mechanism used in other systems.

Artificial legs with wooden articulating feet for stumps that reach to any point in the lower third of the leg are impracticable. The ends of long tibial stumps are sensitive, easily irritated, and poorly nourished, and the slightest contact will cause abrasion, frequently necessitating reamputations,.

Tapering Stumps. — Cuts E 3, E 4, E 5, and E 6 illustrate long tibial stumps. Legs for such amputations must be constructed so

A. A. Marks, Artificial Limbs, New York City. 47

A. A. MARKS, N. Y.

Cut E 5.

Cut E 6.

there will be ample room for tHe extremities. In other words, the ends are suspended in space. As these stumps are tapering to the

Cut E 7.

Cut E 8.

ends they can be inserted from the tops of the sockets. The socket is hollowed out near the bottom of the heel and an abundance oi

48 A. A. Maries^ Artificial Limbs, New York City.

room provided, allowing a wholesome circulation of air ; the exterior diameters of the leg are not large enough to be conspicuous. The

Cut E 9.

Cut E 10.

leg socket and foot core are connected by an aluminum sheath riveted to each part in the most secure way.

A. A. MARKS, N. Y,

Cut E 11.

Cut E 13.

The rubber foot is attached to the core and the leg is finished so the exudations from the extremity of the stump cannot possibly impair the strength of the connected parts.

A. A. Marks, Artificial Limbs, New York City.

49

Cuts E 7 and E 8 show sectional views of a leg- for a long tibial stump; the foot and log parts arc so secured that they

A. A.MARKS, N.Y.

Cut E 13. Cut E 14.

are practically one. This method of construction admits of

Cut E 15.

Cut E 16.

excavating the socket well into the foot so as to provide ample air space. Substantial legs for such stumps cannot be made

50

A. A. Marks, Artificial Linibs, New Yorh City.

with ankle articulations, for cords, springs and bolts require space needed by the stumps. As metal becomes corroded by the exudations of the stumps, wood is the only material which will withstand these destructive agencies.

Ordinary and Short Tibial Stumps. — No difficulties attend the fitting of an artificial leg to a tibial stump reaching to any point

Cut E 17.

^§

Cut E 18.

between the junction of the middle and lower thirds and the knee, when the knee joint is mobile to not less than two-thirds of the normal range. Cuts E 9 to E 16 are typical below-knee stumps of a variety of lengths and conditions relative to flaps, cicatrices, etc. The location of the cicatrices and the character of the flaps hav^ little importance in non-end-bearing stumps.

Artificial Leg for Tibial Stump. — A leg suitable for a stump of two inches or more in length, with the knee articulating through a range of 90 degrees or more, is shown in Cut E 17. Cut E 18 shows it applied with the wearer standing. Cut E 19 shows it with the wearer seated. The action of the knee joint is clearly presented.

A. A. Maries, Artificial Limhs, New Yorlc Oily.

61

Construction. — The leg consists of four parts: the foot, the leg, which fills the space between the foot and the knee; the knee joints, and the thigh piece or that part that incases the natural thigh. As the foot has been explained in Chapter II it now re- mains to describe in detail the other parts.

SocKET.^The socket that receives the stump is made from willow or basswood, which is excavated to accommodate the stump. Bear- ings are permitted at places of toleration. No pressure whatever is put on the vascular parts of the stump or on sensitive or prominent bones. The end of the stump is usually required to hang

A. A MARKS, N Y.

Cut E 19.

Cut B 30.

free in space. The exterior of the leg is shaped to as near the natural form as the stump will admit. It is strongly banded and covered. The surface is enameled with a waterproof preparation having a soft flesh tint. Knee joints are of the ginglymoid pat- tern, and as recently improved have very durable wearing surfaces. The thigh piece is made of substantial leather shaped to the con- tours of the thigh.

Knee Connection. — Cut E 20 represents the upper section of the leg and the lower section of the thigh piece, with the knee joints disconnected at their articulations; aa are the screws that hold the bolts hh in place; cc are the bushings that work on the bolts and receive the wear; a lacing is used to regulate the action or me knee. The mechanical parts of the knee joints are cor pletely illustrated in Cut E 21.

Steel Joints. — Side joints, sometimes called hinge or ginglymoid joints, are used in legs for amputations below the knees. They are more durable and substantial when one of the parts is placed

52

A. A. Marks, Artificial Limbs, New YorJc City.

between the lips of the other and the two connected with bolts and screws.

It is nnmechanical and not lasting to place one section of a joint by the side of the other, holding them together by a screw, as is done by some manufacturers. Such joints wear irregularly side- wise aiid have a wabbling motion after limited service. This would not occur if the lateral strains on the upper sections could be kept the same at all times; but lateral pressure, causing unequal wear at the bearings, is brought about by contracting the thigh by lacing, in order to compress an emaciated thigh or distending it to

Cut E 31.

Cut E 32.

Cut E 23.

accommodate an enlarged one. These difficulties are only avoided by having one of the elements of the joints work between the lips of the other.

The greatest wear on any joint is on the bolt that holds the parts together, and as the attrition is the greatest when the wearer's weight is directly over the knee and becomes less as the knee is flexed, the bolt must necessarily wear irregularly. As the wearing surface on the bolt was formerly limited to the thickness of the section that worked on it, the wear was necessarily very rapid.

A. A. Marks, Artificial Limls, New Yorlc CiLy. 53

The object of the improved joint is to increase the wearing sur- face as much as possible and to make the wearing parts independent and removable. They can then be highly tempered and the non- wearing parts left untempered, so that the supporting parts will not become friable.

The wearing surfaces are increased more than double. They cover the entire surface of the bolt, and the inferior surfaces of the holes in the lips of the lower part. Cut E 21 shows the mechanism very clearly. AA is the upper part; BB the lower part; C is a long bushing which passes through the two lips of the lower part and the one of the upper; the lug D holds the bushing immovably fixed to the upper part. The bolt B passes through the long bushing and becomes immovably fixed to the lower part by means of a stop pin, which is fastened to the hub of the lower part, and fits a recess made in the head of the bolt. The screw A holds the bolt in place and clamps the joint.

A glance at the section, Cut E 22, will show how these parts work together. Every movement of the joint causes the long bushing to revolve about the surface of the bolt and in the lips of the lower part. This mechanism prevents any wear from taking place on either the upper or lower parts, and distributes what does take place over the entire area of the bolt. The bushing and bolt are made very hard, and can be removed and replaced with new ones at any- time that may be desirable. Cut E 23 shows a side view of the entire joints and ready to be attached to the leg.

Test. — ^A pair of these joints, subjected to a practical test equiv- alent to that of being worn by a man weighing two hundred pounds, walking an average distance of three miles every day for six consecutive years, failed to develop sufficient wear to cause noise. The joints are made from the most suitable steel, forged from solid material faced and slotted with absolute accuracy, drilled, reamed, and countersunk in templates, the parts being fitted to a nicety and thoroughly tested before being placed on a leg.

Thigh Part. — The thigh part of the leg is made of durable oak- tanned russet leather, formed to the shape of the thigh, and suitably lined inside. There are several methods by which it is made to compress the thigh ; buckles and straps are sometimes used ; metallic clamps are occasionally preferred ; but the greatest number of limb- wearers find the lacing method the most satisfactory, as it permits uniform adjustments and is neat and durable.

Lacing Methods. — Cut E 24 shows the double-eyelet method. A row of eyelets is placed on each front edge, and a strong buckskin lacing passed through them. This method has been in vogue for many years and is still preferred by many wearers.

Cut E 25 shows the lacing system more generally used at the present time. A row of hooks is placed on one edge and a row of eyelets on the other. On removing the leg the loops of the lacing are simply slipped off the hooks, the string remaining in the eyelet holes. When the leg is put on, the loops are put over the hooks and the cord is tightly drawn. Some wearers wish hooks on each edg&

54

A. A. Marks, Artificial Lirnbs, New YorJc Ciiy.

the same as on shoes. When this is wanted it should be specified in the order.

Cut E 26 shows a device for rapid application. A row of studs is placed on one edge of the thigh piece, and a row of eyelets on the other; a separate piece of leather has also a row of eyelets and a

Cut E 24.

Cut E 25.

Cut E 26.

Cut E 27.

row of studs. This is laced to one side of the thigh piece and buttoned to the other ; the lacing can be adjusted once for all. On removing the leg one side is unbuttoned, and the other remains laced, as shown in Cut E 2Y.

Check Strap. — The lacing at the back of the knee checks the knee action and is regulated by the wearer. It is a very strong leather thong, passing from the thigh piece to the leg part, as in Cut E 20. The more the thong is tightened the less becomes the

A. A. Marks, Artificial Limhs, New YorJc City.

55

motion in the knee, and the more weight will be placed on the ball of the foot and less at the heel.

The stump, in all cases, is inserted into the leg socket; the thigh piece is drawn around the thigh and laced tight enough to hold the leg firmly in place. The stump enters the socket comfortably. Bearings are only admitted about the sloping part immediately below the knee; the anterior surface of the tibia is always accom- modated by a channel; the bony prominence of the fibula is pro- vided for by a cavity; and the end of the stump hangs free in space, receiving no pressure whatever, either on the sides or at the end, except when conditions will permit.

Sensitive Stumps. — In cases of extreme sensitiveness the weight can be carried entirely above the knee, and the stump is only

Cut E 38.

permitted to perform the function of moving the lower leg forward and backward.

Non-End-Bearing and End-Bearing. — Weight can rarely be applied to the end of a tibial stump, and only when the end is pro- tected by bone flap or periosteal flap and well covered with muscle tissue. When such favorable conditions exist an end-bearing pad is placed in the socket of the leg, the thickness of which is adjus- table, so as to increase or decrease the amount of pressure on the extremity. The wearer, when dressed either with or without the end-bearing pad, is able to walk, run, sit, or lie down. Every posture will have the semblance of nature, every movement will be

56 A. A. Maries, Artificial Limbs, New Yorh City.

made with surprising naturalness. The loss of the natural leg is absolutely concealed, and the substitution by the artificial restores the wearer to his usefulness.

Thighless Legs. — Artificial legs for tibial stumps are sometimes made without knee joints and thigh pieces, dependence being

A. MARKS, N.Y.,

Cut E 29.

Cut E 30.

plaqed upon the socket when supporting the weight of the wearer, and resisting such lateral strains as may occasionally be brought upon the leg. Such a leg is shown in Cut E 28. Erom the knee down its construction is much the same as leg E 17. The socket is made of wood excavated to receive the stump properly. The foot is of sponge rubber with spring mattress, and the leg is covered substantially and finished in flesh-colored enamel. Straps at- tached to the leg in the region of the calf are made to pass around the thigh immediately above the knee cap. If these do not hold the leg .firmly in place auxiliary straps are attached, to pass over one or both shoulders.

Some manufacturers advocate the use of thighless legs whether the stumps are long or short, and pay little attention to the character of the extremities. They attach more importance to the absence of thigh constriction than they do to the danger of abra- sions on the stump or injury to the extremity.

\Yhile it is true that there are many cases in which thighless legs

A. A. Maries, Artificial Lirnbs, New York City.

57

are applied and worn with evident satisfaction, it must be clear that the absence of a thigh supporter entails a sacrifice of efficiency and protection. Metal knee joints and thigh supporters perform the very important functions of protecting stumps, avoiding side strains, injuries from concussions, and the tearing of cicatrices. Cut E 29 shows a thighless leg applied, the wearer standing; Cut E 30 the rear view of the same, Cut E 31 the side view, and Cut E

A. A. MARKS, N. Y,

Cut E 31.

Cut E 32.

32 the wearer seated. These cuts show the operations of the leg and the action of the suspenders.

Dangers. — When the wearer is standing with his weight on an artifi.cial leg of the thighless type the stump has to carry all his weight. This usually comes upon the sloping parts immediately below the knee. If the wearer makes a misstep and recovers him- self by his artificial leg the stump will receive a strain; if he carries a heavy weight his stump must resist a force that tends to push it further into the socket; and unless the sides of the stump are sufficiently sloping to oppose this there will be danger of injury to the flap and cicatrix.

One of the chief objections to the thighless leg is the difficulty that arises when the stump changes in size, as it so often does. If the stump becomes emaciated the socket of the artificial leg must be fi.lled up to compensate for the loss of flesh, and if the emacia-

58 A. A. Maries, Artificial Lirribs, New YorJc City.

tion is not uniform there will be considerable difficulty in padding the inner surfaces of the socket so as to avoid pressure on delicate parts.

One should never experiment with the thighless leg unless the stump has been accustomed to wearing an artificial leg for a considerable length of time, and has become so thoroughly dis- ciplined that further changes are not likely to occur. Those who insist on wearing thighless artificial legs, who have worn thera from choice, and who have their stumps sufficiently disciplined will be accommodated in their wishes.

Slip Sockets versus Wood Sockets. — Kival manufacturers have said and published much about the slip or sliding socket and con- siderable curiosity has been aroused among limb-wearers as to the merits of the idea. As the slip socket applies almost exclusively to artificial legs for tibial stumps, the subject may be introduced and discussed at this time.

We have given the matter much thought and subjected it to a most rigid investigation. We have, moreover, submitted the scheme to many tests and have conferred with several hundred persons who had worn slip sockets. Our investigations were planned to determine whether the scheme had sufficient merit to warrant us in adapting it to our work.

We have long been aware that a well-fitting socket of wood or any smooth hard material will never chafe the stump, even if the stump is permitted to move in it. On the other hand we have known that any socket made of a yielding material like leather will, from the constant pressure and heat of the stump, change in form and cease to be comfortable. Perspiration and other exuda- tions from the stump have deteriorating effect on any material that permits absorption. All exudations from the stump becomes putrid in a very short time and cause ofl:"ensive odors and bring effete matter in contact with the skin. This almost invariably in- fects the stump and causes unhealthy conditions. A hard highly polished surface is more pleasant for the stump than any form of soft yielding cushions.

The slip-socket idea is somewhat antiquated. In 1866 the United States Patent Office issued letters patent No. 55,645 to Daniel Gilson, covering the principle of the slip socket, consisting of a leather socket molded on a cast of the stump, then placed inside the artificial leg, and held in place by springs. Its object was to obviate the movement of the stump in the socket and to localize all the motion between the stump socket and the socket of the artificial leg. It was very soon found that the stump socket, being tightly held to the stump at all times, constricted the blood vessels and caused much trouble. The inventor, being conscientious, abandoned the manufacture of legs on that plan.

Quite recently, however, the slip-socket feature has been revived, and some insignificant modifications made on the original Gilson model, mainly in the mode of suspending the inner or slip socket. The idea has been extensively advertised and a considerable num-

A. A. Marks, Artificial Limbs, New Yorh City. 59

ber put in use. We have records of many of these cases, and we feel it a duty to the maimed community to disclose the effects a slip socket has had on many stumps.

It must be remembered that in order to carry out the principle of the slip or sliding socket the stump must remain under constant pressure, great enough to avoid any motion or friction between the stump and the socket. All the slipping and sliding due to the intermittent application of weight, as in walking, takes place between the slip socket and the socket of the artificial leg. Few stumps can tolerate this constant pressure without the blood vessels becoming strangulated; we therefore do all we can to dissuade clients from risking such a dangerous experiment.

Slipping of the Stump Desirable. — There is nothing so pleasant to a wearer of an artificial limb, no matter what kind of a leg he is wearing, as to be able to lift his stump from its bearings and give it a chance to rest and recover, exactly as one does when standing on natural legs. He throws his weight on one leg for a while and then on the other, and in this way both legs in their turn become rested. Every wearer of a wood-socket limb invariably does this. It is a source of comfort and relief; but it cannot be done with the slip socket, which clings to the stump like a leech.

The socket that is made to fit the stump so that pressure will be uniformly distributed over all its parts, is neither scientific nor tolerable. Every stump has parts that will bear pressure and parts that will not stand any at all. Parts where blood vessels and nerves are clustered, where the bones are close to the surface and poorly protected by tissue, must be prevented from impact. A flexible socket has a tendency to assume the shape of the stump and dis- tribute the pressure uniformly, bringing as much on the forbidden parts as elsewhere. Therefore the flexible socket is a dangerous one to wear.

A socket that fits properly will never chafe the stump, no matter how much it may slip, slide, or move in it. This is a fact ascer- tained by most careful, thoughtful, and conscientious investigation, and cannot be successfully controverted. We know from very ample experience and inquiry that there is no socket so pleasant to wear, so light, so cool, and so healthful for the stump as the wooden one, when properly and scientifically fitted. No material has ever given such permanently good results as wood.

An Instance. — Mr. Frank M. Talbot met with a railroad accident in 1890 which crushed his leg. Amputation was made below the knee, leaving a stump four inches in length. He obtained an artificial leg with wooden socket, which he wore for some time with efficiency. His stump, following the usual course, emaciated, and instead of having the leg refitted he was prevailed upon to order a new leg with a slip socket. He wore the leg for a while, but gradually the end of his stump became congested and painful. He went to his slip-socket leg-maker for relief, but was told that his stump was diseased and nothing but medical or surgical treat- ment would help him. The stump grew worse; he called in a

60 A. A. Marks, Artificial Limhs, New YorTc City.

physician, who by medication brought it to a healthy condition, but put him on his back for a while. Shortly after he resumed wearing the slip-socket leg, the trouble recurred. He came to New York, and under the impression that his stump was diseased, con- sulted several prominent surgeons. All agreed that the stump had been strangulated by the artificial leg, and unless the cause was removed the bone would soon become infected and re-amputation would be necessary.

Mr. Talbot called upon us, and on examination we found the end of the stump swollen and as blue as indigo. An abscess was form- ing. We told him that his trouble was due to pressure upon the blood vessels, and advised him to abandon the slip socket, and wear a wooden one, so fitted that it would not constrict the blood vessels nor permit any of the tender parts of the stump to take pressure. He yielded to our advice, and we made and applied a leg with wooden socket and our patent rubber foot. It was remarkable how quickly his stump recovered. As soon as the pressure was removed from the vascular parts, circulation was restored and the stump became healthy. This was eleven years ago and the stump at this writing is in a healthy condition, without the slightest indication of a recurrence of his trouble. We can cite hundreds of cases similar to this and will gladly furnish additional data to those desirous of investigating further.

Waterproof Legs. — There are some occupations that require limb-wearers to stand in damp and wet places, exposing their artificial legs to moisture, much to their injury. Farmers, miners, builders, woodsmen, raftsmen, trappers, oystermen, fishermen, watchmen, sailors, stablemen, chauffeurs and a thousand others are of this class.

Our method of constructing artificial legs enables us to meet the requirements of these people as they have never been met before. The foot is of sponge rubber with spring mattress, it is perma- nently secured to the leg and the whole is covered with suitable material coated with a waterproof preparation. This method is secured by Letters-Patent July 9, 1912.

Bathing Legs. — Persons who indulge in aquatic sports can use artificial legs of this kind; with them they can wade, bathe, or swim in salt or fresh water exactly as persons in possession of their natural limbs and without disclosing the fact that their limbs are other than those provided by nature. Cut E 7 is a sectional view on which waterproof legs are constructed. It will be seen that there are no parts that can be affected by moisture. The entire lower leg is capable of withstanding the severest strains and exposure.

Shortened Thigh. — Complicated conditions in tibial amputa- tions frequently present themselves and require specially designed artificial limbs. Cut E 33 illustrates a case in point. The injury to the patient, necessitating the amputation of the leg below the

A. A. Marks, Artificial Lirnbs, New Yorlc City.

61

knee, fractured the thigh and dislocated the hip. The femur became lapped and deflected and its head was permanently dis- placed. This occasioned a shortening of the thigh of several inches. In the artificial leg the shortening of the thigh was com-

.. A. MARKS. N. Y,

Cut E 33.

Cut E 34.

pensated for by lengthening below the knee. A leg constructed on the plan of E 17 is suitable for cases of this character. Its thigh piece is made to extend well up to the body and take in the gluteal folds and the entire external surface as far as the crest of the ilium, thus giving the necessary support to the fractured part.

Cut E 34 illustrates a case of shortened thigh of the left leg while the right was amputated. It resulted from a railroad acci- dent which crushed the right foot and ankle and fractured the opposite thigh. The right foot was amputated at the junction of the lower and middle thirds. Despite every effort to bring about the correct union of the fractured femur of the left leg, the bones slipped, resulting in a shortening of the thigh by several inches. An artificial leg constructed on the plan of E 17 was applied. The leg from the knee dovra. was as much shorter than the left as the thigh of the left was shorter than the right.

In both these cases the artificial legs necessarily caused a dis- parity in the lengths of the legs from the knees down, but the differences were not noticeable, even when the wearers were seated,

62

A. A. Marks, Artificial Limbs, New YorJc City.

except when closely scrutinized. In other respects there were no inconveniences experienced.

In ordering an artificial leg every peculiarity of the sound leg as well as the partly amputated one should be brought to the attention of the manufacturer.

The Lateral Adjusting Socket. — Changeable stumps are more frequent than generally known. By changeable stumps we mean those that remain large for a period and then became small and then large again. This characteristic is inherent in some stumps and cannot be controlled by any method of treatment. An artificial leg capable of being endured on a stump of this kind is

Cut E 67.

K''l

Cut E 68.

usually made large enough to receive the stump when it is at its largest dimensions, and when at its smallest additional socks are worn, or linings are put in the socket. There is some in- convenience and annoyance incurred in this way of adjusting.

Some manufacturers make sockets of leather, with lacings down the front, or rear, or both and claim that by drawing these lacings up or letting them out, the required adjustment can be made. It is easily seen that this method admits of adjustment from front to back only; the distance from side to side remains the same; the steel side joints, necessarily moving on the same axis, will not admit of any change in that direction. This is opposite to what it should be ; if the distance from front to back is lessened there is increased pressure on the shin bone as well as on the blood vessel back of the knee. The shin bone cannot endure

A. A. Marks, Artificial Limbs, NevJ York City.

63

pressure and the blood vessels back of the knee, if constricted for a length of time, will suffer from interference with the circulation, and trouble in the end of the stump will follow.

The Marks lateral adjustable socket admits of the adjustment in the right direction; this is made possible by giving the side joints an additional hinge so that they will move sidewise as well as front and back. With this hinge, and a socket slitted front and back, it is possible to draw the sides of the socket closer together or set them further apart, and still have the centers of motion in the knee joints work on the same axis.

This method of constructing artificial legs with provisions for

Cut E

Cut E 70.

lateral adjustment has been applied to changeable stumps since 1909. It has stood this thorough test and proved its efficiency in many cases. Patented July 9, 1912.

Cuts E 67 and E 68 present front and rear views of a leg with socket wide enough to accommodate a large stump, and cuts E 69 and E 70 present the same leg front and rear views with the socket made smaller by drawing together the sides, thereby accom- modating the same stump when it has become smaller.

Contracted Knee Joints. — Another class of leg stumps are those which are sufficiently long to control the knee movements of the artificial leg, but being partly contracted, the extension of the knee is somewhat limited, so that the use of the ordinary type of E 17 leg is impossible, while the contraction is not sufficient to make the knee joint inoperative in controlling the artificial leg.

64

A. A. Marhs, Artificial Limbs, New York City.

Knee joints of tibial stumps become contracted either from the results of the injuries that occasioned their amputation, or, more frequently, from neglect in permitting the stumps to remain in semi-flexed positions during the convalescent periods. Cut E 39

Cut E 39.

Cut E 40.

illustrates a partially contracted knee of a tibial stump which is capable of full flexion but of limited extension.

An artificial leg on the plan of E 17 with a slight modification of the socket, as shown in Cut E 40, meets the requirements of the case. By referring to Cut E 41 it will be seen that the stump is received in the socket while in a semi-flexed position. The socket is so made as to bring constant and gentle pressure upon the ham- strings every time a step is taken. The object of this is to induce the breaking up of the contraction and eventually restore full knee motion. The artificial leg is provided with a lacing attachment that passes over the rear part of the stump. As the stump im- proves in extension this lacing strap is tightened and greater pres- sure brought upon the stump.

A. A. Marks, Artificial Lirribs, New Yorlc City.

65

Although a stump may be contracted to a considerable angle a leg of this character can be worn and the wearer enabled to get about in an advantageous way, concealing his loss, walking in a graceful manner, and dispensing with the use of crutches.

We know of no more practical method for breaking up the con- traction in the hamstrings than wearing an artificial leg of this type. The wearer is permitted to engage in his usual occupations while the work of restoration of the knee motion progresses. When the knee has become corrected and the stump can be ex- tended to a straight line, the socket on the artificial leg can be removed and the regular socket, similar to that shown in Cut E 17, applied at a very slight expense.

Cut E 41 shows the leg applied to a contracted stump and the wearer walking. Cut E 42 shows it with the wearer seated. The

Cut E 41.

Cut E 43.

contraction of the hamstrings does not interfere with walking, standing, or sitting.

Cut E 43 illustrates a tibial stump with a contraction of the hamstrings considerably greater than in the last case, so great as to prevent the knee from extending beyond a right angle with the thigh. Cut E 44 represents an artificial leg suitable for this case.

A knee-bearing leg might be considered the more suitable, but when the fact is remembered that there is an angular motion in the knee, with the possibility of improvement, it is better to apply a leg that will keep up the action of the knee and bring a con- stantly increasing tension on the hamstrings. A leg constructed

66 A. A. Marks, Artificial Limbs, New Yorh City.

on the plan of that represented in Cut E 44 is made for this purpose.

Hypertrophied Tibial Stump. — Amputations through the tibia are sometimes necessitated by hypertrophy, with induration of the foot and ankle, as in the case of elephantiasis. Such cases usually

Cut E 43.

Cut E 44.

produce stumps that are much larger at their extremities than above, the extremities incapable of bearing pressure, and the sides able to tolerate only limited compression. Cut E 45 shows a stump of this character. It requires an artificial leg constructed upon the plan of E 46, with the rear open so as to receive the stump, the stump and socket are incased by a sheath holding the parts to- gether. Cut E 46 represents a side view of an artificial leg suitable for such cases. Cut E 47 presents the front view with leg applied.

In all the complicated cases previously described, the method of constructing artificial legs with rubber feet and spring mattress is especially advantageous. Great strength is obtained, durability is secured with minimum weight and bulk about the enlarged extremity.

Anchylosed Knee Tibial Stumps Extended. — Some tibial stumps are rigid when extended. That is, they cannot be flexed, owing to anchylosis of the knees resulting from the injuries that

A. A. Maries, Artificial Limbs, New York City.

67

Cut B 45.

Cut E 46.

Cut E 47.

Cut E 48.

Cut E 49.

caused the amputations, impairment of the knee tendons, calcareous deposits in the articulations, and many other causes. If there is an absence of mobility in the knee and the stump is extended, an

68 A. A. Marks, Artificial Lirnbs, New Yorh City.

artificial leg must be constructed so that the artificial knee articula- tion will be independent of the natural knee and operate on the sides of the stump approximately at the points where the natural articulation takes place. Cuts E 48 and E 49 represent tibial stumps extended, with knee joints anchylosed.

It will be observed that in Cut E 48 the sides of the stump and thigh are approximately parallel, or in other words they do not slope sufficiently to offer any sustaining surfaces. An artificial leg

Cut E 50.

Cut E 51.

constructed on the plan of Cut E 50 is intended for a stump of this character.

The top part of the thigh piece is annular and permits the stump and thigh to enter until the gluteal folds, the ischium, and the perineum come in contact with the top border of the socket, where the entire weight is applied, the same as if the amputation had been made in the middle of the thigh. Cut E 49 represents a stump the sides of which are tapering sufficiently to offer some opposition, sustaining in part the weight and lessening the amount

A. A. Maries, Artificial Limhs, New York City,

69

of pressure on the top border of the socket. An artificial leg con- structed on the plan of E 51 will meet the requirements of this case. Both of the above artificial legs are made to articulate at the knees.

The legs from the knees down are constructed practically the same as the E 17. The thigh piece is leather and wood; the rear of wood and the front of leather arranged for lacing, so that the required pressure will be brought upon the thigh to hold it in place. Leg E 60 differs from E 61 in the top of the socket, it be- ing annular with continuous border. It is held securely to the body by the lacing front, assisted by suspenders passing over the shoulders.

The knee joints of these legs are of the hinge style as illustrated in Cut E 21. Articulation at the knee is limited by a check cord

Cut E 53.

Cut E 53.

connecting the thigh and calf sections. Cut E 52 shows the leg applied, the wearer seated; and Cut E 53 shows it with the wearer standing. It will be seen that the knee articulation approximates very closely the action of the opposite leg and permits the wearer to stand, walk, sit, or kneel.

Peg Legs. — Peg legs suitable for tibial stumps are of three kinds. The simplest and least expensive is shown in Cut E 64. It consists of two wooden branches, one running up on the outside of the thigh, well up on the body, the other on the inner side reach- ing nearly to the crotch.

VO A. A. Marks, Artificial Limbs, New York City.

These branches unite below the point of bearing and continue to the ground, terminating in a rubber tip. A padded shelf is placed between the branches on which the knee rests when in a flexed position. The leg is held in place by leather straps passing around the thigh and body.

Cut E 55 shows a peg leg without knee joint or thigh support suitable for a tibial stump. The socket is shaped to receive the

Cut E 54.

Cut E 55.

Cut E 56.

stump from the knee down in a comfortable way. The base termi- nates with a rubber tip, and straps necessary to hold the socket on the leg are connected with the leg and passed around the thigh immediately above the knee cap. When necessary, suspenders are attached to help carry the weight.

Cut E 56 shows a peg leg suitable for a tibial stump constructed practically as E 17, except that there is no rubber foot, a rubber tip taking its place.

Peg Legs Should Not be Used Permanently. — Peg legs are worn as temporary expedients, for disciplining stumps, or to bridge over an impecunious period. We know persons, however, of ample means who have reached advanced years, who from childhood have

A. A. Marks, Artificial Lirribs, New Yorh City. 71

constantly worn peg legs, and doubtless will continue to do so, as long as they live.

It is quite possible to stump around on peg legs and do much hard work with them. They are immeasurably better than crutches, but they are very far from rendering the services that can be obtained from artificial legs with sponge rubber feet. The foot is an essential factor in helpful easy walking, and a means of opposing strains required in carrying heavy weights, ascending or descending stairs or elevations, and in walking long distances.

We disparage the use of peg legs, as we are keenly alive to the fact that they are inadequate to meet the demands that must be put upon them. Any form of peg leg that will keep the knee joint in a flexed position is liable to weaken the tendons of the knee, impair the knee movement, and limit its range of motion. They should, therefore, be used only as expedients.

Ferrules for Peg Legs. — Cut E 57 represents an aluminum peg-leg ferrule and rubber tip. Cut E 58 represents the aluminum ferrule separate, and Cut E 59 represents a pure gum rubber tip

Cut E 61.

Cut E 57.

Cut E 59.

separate, which screws into the ferrule. Cuts represent one-quarter size. The ferrule is permanently fastened to the peg leg, and the rubber tip screws into it.

Rubber Tip. — When the rubber tip wears down so that the metal ferrule touches the ground, it should be removed and a new one put in. The base of the rubber tip is 2 1-2 inches in diameter and the threaded shank is 1 1-2 inches in diameter.

Suspenders. — Suspenders for artificial legs for tibial stumps are of many kinds. Most persons with long and healthy stumps do not use suspenders at all, and a very small number retain them after they have become accustomed to their artificial legs.

As an aid for the beginner, however, we deem it advisable to put suspenders on every leg made for tibial amputation, whether the stump is long or short.

Cut E 60 shows a double suspender for a tibial stump leg. It

12 A. A. Marks, Artificial Limbs, New Yorh City.

consists of two-inch elastic webbing connected with the back of the thigh piece and running well up to the shoulder, where two non-elastic straps, each 1 1-2 inches wide, are attached which branch ■ so as to pass over the shoulder. They are connected with the iipper part -of the thigh piece in front, and adjusted by clamp buckles with snaps.

Cut E 61 presents a simple yoke suspender preferred by women. r It is made to fit the body immediately above and upon the hips.

Cut E 60.

Cut E 63.

Cut E 63.

It is seldom necessary to use shoulder straps. Straps running down from the belt connected with the upper part of the thigh piece are usually ample.

Cut E 62 shows a yoke suspender similar to the last, but pro- vided with shoulder straps. Elastic straps buckled into the attach- ments connected with the thigh piece are used to fasten the yoke to the leg. This method is necessary for small hips and in cases where entire support from the hips or pressure about the loins or over the abdomen cannot be tolerated.

The corset style is frequently preferred by women. It consists of strong elastic straps secured to the lower part of the corset, one in front and one at the back as shown in Cut E 63; they are buckled into straps secured to the upper part of the thigh piece.

CHAPTER VI

KNEE-BEARING STUMPS

Definition. — When the knee joints of tibial stumps are con- tracted at right angles, or when the stumps are so short that they are unable to control the artificial knee joint, they are termed knee- bearing stumps, and require artificial legs constructed to receive them in flexed positions.

It is sometimes problematical to determine whether a stum.p should be placed in this class or in the class requiring legs con- structed on the plan of E 17. The conditions to be considered in deciding the question are as follows: First, anchylosis or immobility of the knee joint when flexed. Second, length of the stump projecting back of the thigh when at right angles. If this is less than two inches the knee-bearing leg must be selected. Third, remediless contraction of the flexors, limiting the angular

Cut F 1.

Cut F 2.

range of motion to one-half the normal range, no matter how long the stump may be. Cuts F 1 to F 4 show typical knee-bearing stumps.

Knee-bearing Legs. — Cut F 5 shows a leg suitable for stumps of above character. The socket and leg part are made of wood covered with rawhide and enameled. The socket is excavated to receive the stump and thigh in a comfortable way, and the

73

74 A. A. Maries, Artificial Limbs, New Yorh City.

Cut F 3.

Cut P 4.

Cut F 5.

Cut F 6.

A. A. Marks, Artificial Lirnbs, New Yorlc City. 16

part from the knee down is hollowed out to reduce the weight. The exterior dimensions are as close to those of the natural log as conditions will admit. The foot is of rubber with spring mat- tress as previously described.

Bolt Joint. — Cut F 6 shows the knee mechanism with the parts separated: a is the knee-bolt which holds the leg and thigh sec- tions together, forming an axis for the knee. It is flanged on

Cut F 7.

Cut F 8.

one end and threaded on the other. When the bolt is passing through the metal ear which is riveted to the lower leg the head sinks into its bed and the threaded end screws into the ear riveted to the opposite side. The set screw h, placed into the flanged end, prevents the bolt from moving and working out; c is the check cord screw; d the check cord; g the spring piston; h the spiral spring; * the cylinder. The relations and functions of these parts can be understood from an examination of Cuts F 7 and F 8, which show the leg with the knee extended and fully flexed.

The action of the spring holds the leg at flexion when the wearer is seated, and urges the leg forward when walking. The

76 A. A. Marks, Artificial Limbs, New Yorh City.

range of articulation can be regulated by means of pads placed between the lower end of the check cord and the bridge under which it passes. These pads can be reached through the opening in the calf of the leg. The upper loops of the check cord rest in

Cut F 9.

Cut F 10.

their respective channels and through them a steel screw is passed and set.

The mechanism of the knee-bearing leg is very durable, and will stand severe use for years.

Side Joint. — The center of motion being placed below the natural knee, causes a disparity in the lengths of the two thighs; only noticeable, however, when the wearer is seated and subjected to close scrutiny. The durability of the knee-joint mechanism in style of leg shown in Cut F 5 fully compensates for excessive length of thigh, moreover, this mechanism admits of the minimum width of the knee. The choice of style remains with the wearer; if he prefers the wide knee to the long thigh, and is willing to sacrifice durability, he can have the leg constructed with side joints, as represented in Cut F 9, the center of knee motion of which is brought to the sides of the knee by means of hinge

A. A. Marks, Artificial Lirribs, New Yorh City.

11

joints, of the style shown in Cut E 23, page 52. The knee-chock cord is practically the same as that represented in Cut F G. Cut F 10 shows the leg applied, wearer seated with knees flexed.

Peg Legs. — 'Peg legs for knee-bearing stumps are of three kinds ; and will be considered in their order : Cut F 11 shows the cheapest form of peg leg for a knee-bearing stump; its construction is of

Cut F 11.

Cut F 13.

Cut F 13.

bent wood with metal ferrule, rubber tips, and leather strappings. Cut F 12 shows a peg leg with knee joint suitable for a knee-bearing stump.

Cut F 13 shows a peg leg without knee articulation for knee- bearing stump. The upper parts, F 12 and F 13, made of wood and leather, fitted to receive the stump, which is held in place by lacing.

The ends of peg legs are terminated by metal ferrules and rubber tips as described in Cuts E 57, E 58, and E 59, page 71.

Incomplete Restoratives. — For reasons heretofore given, we do not advocate peg legs for knee-bearing stumps and only fur-

78 A. A. Maries, Artificial Lirribs, New Yorh City.

nish them when they are especially ordered. It is far better for a person to procure a complete artificial leg with rubber foot, with spring mattress, one that will possess all the elements neces- sary for helpful and convenient walking, even if he has to deny himself in other ways in order to obtain one. A peg leg is a make- shift, and will in all probability weaken or destroy what knee motion remains.

Suspenders. — Suspenders suitable for knee-bearing legs are sub- stantially the same as those employed for tibial stump legs. The details are given in the preceding chapter.

CHAPTER VII DISARTICULATED KNEE STUMPS

End-Bearing and Non-End-Bearing Stumps, — Amputations through the articulations of the knees call for careful prothetical consideration. Stumps resulting from such amputations may be end-bearing or not; when they are covered with tissue flaps, free from cicatrices and nervous complications, they are end-bearing; if they are cicatrized, and sensitive, pressure must be applied else- where; if they are tapering to the ends or are broadened at the

Cut G 1.

Cut G 2.

extrepiities they must be treated accordingly. The presence of the patella, securely united in the intercondylar space, will im- prove the character of the stump, but if it is not united it is doubtful if the end will tolerate any weight whatever.

Fittings. — ^Artificial legs for knee-joint amputations must ad- mit of placing pressure only on parts capable of enduring it. Tender, delicate, sensitive, and irritable spots must be guarded, and non-end-bearing stumps must be provided with limbs that will

79

80 A. A. Maries, Artificial Limhs, New Yorh City.

take the weight at the ischial and perineal regions; if the sides of the stumps are sloping a share of the weight can be distributed over those parts. Sensitive condyles, bony prominences, and fascia must be properly cared for.

PeculL'^ities of Stumps. — Cut G 1 shows a type of stump result- ing from knee-joint amputations; the nodulous extremity due to the presence of condyles, together with ample coverings, provide desirable conditions. An artificial leg suitable for this stump is so fitted that the weight is carried on the end, which rests on a padded surface at the lower end of the socket, and held securely in place by the leather lacing. The shoulder suspension is greatly simplified when condyles are present in the stump. Cut G 2 shows

Cut G 3.

Cut G 4.

a side view of a stump favorable for end pressure. Cut G 3 shows a stump reaching to the knee, patella present and without cicatrices, thus admitting of end pressure.

Cut G 4 shows a thigh stump reaching to the knee and ex- tremely well protected, with cicatrices at the rear and well away from the end; bunches of sensitive tissue hanging from the ex- tremity prevent the application of weight at that point. Cut G 5 shows a thigh stump reaching to the knee with an end incapable of bearing pressure; the condyles and all the natural coverings of the bone were removed in the operation. Bunches of tissue and ganglia were gathered at the end back of the stump. The muscle tissue puckered considerably and the presence of cicatrices on and about the end prevents the application of weight there. Cut G 6 shows a stump reaching to the knee, condyles present, the extremity covered with integumentary folds, deep fissures and

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81

cicatrices, preventing the application of weight upon the eix- tremity.

Most Favorable Conditions. — These examples develop the fol- lowing points: Stumps extending to the knee with nodulous ex- tremities, capable of bearing weight, are the most favorable of all knee-joint stumps. They result from amputations through the

Cut G 5.

Cut G 6.

knee articulations, the condyles remaining untrimmed, or, if trimmed, the ends protected by bone and muscle flaps ; the natural coverings to the bones permitted to remain on the articulating surfaces; the patellas, if present, firmly united to the end of the femur; flaps well carried to the posterior and the cicatrices some distance from the ends. Stumps possessing these favorable con- ditions can be efficiently accommodated with artificial legs that will minimize the pressure about their upper borders and simplify the mode of suspension.

A stump reaching to the knee, with a nodulous extremity and incapable of bearing weight on the end, is capable of operating an artificial leg, but the means of attachment are necessarily more extensive and more severe than when the weight can be borne on the ends.

Inability to bear weight on the extremities of knee-joint stumps is not always due to surgery.

Sloughing, bone degeneration, hypera^sthesia, etc., frequently occur despite the most careful precautions of the operator.

Suitable Artificial Legs. — The foregoing cuts illustrate stumps that can be advantageously fitted with artificial legs eon-

82 A. A. Marks, Artificial Limbs, New York City.

structed upon plans of those shown in Cuts G 7 or G 8, according as the stump is tapering or straight, or whether the end can endure weight or not. The thigh of either leg is made partly of wood and partly of leather. The rear section is of wood, excavated to re- ceive the stump in the most comfortable way. The front portion is of leather arranged for lacing as shown. If the stump is tapering to the end there will be no advantage in having the front laced, the entire socket can be better constructed of wood.

Cut G V illustrates a leg made to place a large amount of the weight of the wearer directly on the extremity of the stump. Cut

Cut G 7.

Cut G 8.

G 8 shows a leg with annular top designed to hold the end of the stump away from the bottom of the socket, all the weight being distributed over the sides, above the knees and about the top borders of the socket. In both these styles every requirement for the comfort of the wearer and the efficiency of the leg is con- sidered.

The stump socket of either leg is of proper size and shaped t(? receive the stump and carry the weight of the wearer.

A. A. Marks, Artificial Limbs, New York City. 83

Both upper and lower sections are made of selected kiln-dried wood, carved to the shape of the stump with external proportions as near those of the natural leg as the conditions will admit. The lower leg is excavated to reduce weight. The foot is of rubber as heretofore described, and both leg and thigh are coverd with suit- able material properly enameled. The knee mechanism is the same as that illustrated in Cuts"F 6 and F 7.

Suspenders for legs for knee-joint amputations are the same as those applied to thigh amputations, and are fully treated in the following chapter.

We point with pride to many thousand persons who walk on artificial legs of either the above type with efficiency and natural- ness and who voluntarily bear witness to the excellence of the manner in which they have been fitted out, and their increased capabilities to perform their full share of work.

CHAPTER Vin

THIGH OR FEMORAL STUMPS

Definitions. — Thigh or femoral stumps are those that reach to any point above the knee joint; they are designated upper-, middle-, or lower-third thigh stumps, according to their lengths, in relation to the three divisions of the thigh.

Long or Lower-Third Thigh Stumps. — When a stump reaches to a point in the region of the lower third, it is commonly termed

Cut H 1.

Cut H 2.

a long thigh stump, a few of which are illustrated in Cuts H 1 to H 4.

Artificial legs suitable for such are illustrated in Cuts H 5 and H6.

In cases of long and flabby stumps the number G 7 leg, see page 82, can be applied to advantage.

Stumps out of Line. — Persons walking on crutches for a con- siderable length of time permit their stumps to incline forward. The flexors in the groin become contracted and the extensors yield to the influence, and the stump assuming the position, when hang- ing at ease, of that shovra. in Cut H 1, and occasionally that

81

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85

shown in Cut H 3. This condition should not cause anxiety on the part of the wearer, as it can be controlled and corrected by a suitably attached artificial leg.

Construction op Legs. — The thigh and leg sections of II 5 are constructed of wood of choice character. The socket is hollowed

Cut H 3.

Cut H 4.

out to receive the stump properly, and to receive the weight of the wearer where it can be tolerated.

The outside dimensions both above and below the knee are dressed down to the curves and dimensions of the natural leg as far as conditions will admit. The lower part excavated to mini- mize weight, both sections are covered with rawhide and enam- eled, the foot is of sponge rubber with spring mattress as hereto- fore described. The manner in which the knee joint is constructed is substantially the same as shown in Cut F 6, and described on page 74.

Variety of Middle-Third Thigh Stumps. — Thigh amputations through or above the middle thirds produce stumps that admit of the simplest form of knee-joint mechanism, called the T joint, explained further on.

Cuts H 7 to H 14 show thigh stumps of a variety of lengths with flaps and cicatrices of many characters.

End and Non-End-Bearing. — As a rule thigh stumps are in- capable of taking weight on their extremities, and as there is but little advantage in putting pressure on that point, and as the risk of doing so is very great, we rarely consent to construct limbs

86 A. A. Marks, Artificial Limbs, New YorJc City.

Cut H 5.

Cut H 6.

Cut H 7.

Cut H

A. A. Marks, Artificial Lirribs, New Yorh City. 87

in that way and only do so when we are positive that the ends of the stumps will not be injured. Cut H 15 shows the usual type

Cut H 9.

Cut H 10.

Cut H 11.

Cut H 13.

of artificial leg for a thigh stump. The thigh and leg sections are made of tough, light, bass or willow wood, shaped to the size and

88

A. A. Marks, Artificial Limbs, New YorJc City.

contours of the natural leg so far as conditions will permit. The thigh is excavated to receive the stump in the best way, permitting pressure only at admissable places. The end of the stump, together ■ with a few inches of the thigh, are, as a rule, required to hang in space, all the weight being applied to the upper borders of the thigh socket and along the sides of the stump immediately adjacent to the body. When weight can be prudently applied to the end a cushion is provided for that purpose. The lower section of the

Cut H 13.

Cut H 14.

leg is excavated to reduce weight. The whole is covered with rawhide and elegantly finished with a flesh-tinted enamel.

A rubber foot with spring mattress as heretofore described, is properly attached at the ankle. Cut H 16 represents the rear view showing the knee mechanism with parts together, and Cut H 17 represents the working parts of the knee separated. Cut H 18 shows the T joint, the spring, and their connections ; a is the T joint which is secured to the knee block located at the lower end of the stump socket. The two arms work in journals made in the leg section; hh are the cap screws that hold the T joint to its place; cc the caps; d the spring piston; e the spiral spring; f the cylinder ; g spring cover, and parts of the spring together ; Hi rep- resent the steel screws used to hold the T joint firmly to thigh. The joint a has the shape of an inverted T, hence its name, T joint. It is made of gun metal forged from one piece, turned,

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89

drilled, and finished on the lathe. When the leg and thigh sections are placed together the arms of the T joint rest in boxes and are held by two hardwood caps, cc, which are secured by long steel screws, hh, which depend for their security on steel nuts, imbedded in the front part of the leg.

Thorough Control. — The wearer has thorough command over this joint; the pressure of the caps on the joints can be regulated

Cut H 15.

Cut H 16.

by the screws, and thus any desired tension on the articulation be made.

Knee Spring. — The small steel lever with ball on the end, pro- jecting from the back of the joint, operates in the cavity of the hardwood piston d; the piston is inserted in one end of the steel spring, e, which has its lower part encased with leather g, and then placed in a drawn metal cylinder f. The lower convexed end of the cylinder is received on a bridge placed in the interior of the leg in the region of the calf.

90 A. A. Marks, Artificial Lirribs, New Yorh City.

Helps Knee Motion When Walking. — The operation of the spring is twofold; it urges the lower leg forward in walking, and

Cut H 19.

Cut H 20.

Cut H 21.

holds it at full flexion when sitting. This is done in the fol- lowing manner : When the leg is extended, the point at which the

A. A. Maries, Artificial Limbs, New Yoric City. 01

spring pressure is applied is on the end of a steel lever projecting an inch back of the center of motion in the knee. This urges further extension, as shown in Cut H 19, the lever revolves with the joint ; and when the leg is partly flexed, as shown in Cut 11 20, it has been carried to a neutral point where the spring neither urges flexion nor extension; but when the knee is further flexed, as shown in Cut H 21, the lever has passed forward of the neutral line and the spring forces the ball upward, urging greater flexion; and when the flexion is at its limit the leg is kept in that position by the spring. Thus the objection to the usual spring knee articula- tion is removed, that of the tendency of the leg to fly out when the wearer is sitting and unguarded.

Spring Strength Can be Regulated. — The power of the spring in the knee can be increased or diminished. If it is desired to increase it, a little packing can be tamped in the cylinder, or a longer spring can be substituted; and if it is desired to diminish it, a coil or two of the spring can be cut off or a shorter one sub- stituted. If the wearer does not want the spring he can take it out and discard it. When the leg is together and in working order, the knee movement is arrested by the striking of the vertical shaft of the T joint against a pad placed in the knee, which can be increased or diminished by the wearer, and the range of articulation in the knee made less or greater, as may be desired.

The center of motion of this knee is placed considerably back of the center of gravity of the leg in order to secure the knee against treacherous bending.

Knee Lock. — ^The knee lock is a device placed in the knees of artificial legs to keep them from flexing, or from flexing beyond a fixed limit. When the wearer wishes to sit the knee can readily be unlocked. It is not very often that knee locks are required, therefore they are only placed in artificial limbs when conditions demand.

Cut H 22 shows an artificial leg with knee lock for thigh stump ; a is a sliding bar that can be moved upwardly or downwardly. When down the leg is incapable of moving at the knee, or is permitted to move only through a limited angle, as shown in Cut H 23, When the sliding bar is pulled up, the lock is out of action, and the knee can be bent at right ankles as represented in Cut H 24,

This device is found to be of value to those who have short, weak, or deflected stumps, and is also used to advantage by eques- trians. We have a patron, a baptist clergyman, who finds the knee lock indispensable when performing the rites of immersion; because of the buoyancy of the lower leg the knee without the lock would flex the moment he enters the baptismal font. Knee locks are used to advantage by persons who are required to walk through obstructions, such as underbrush, heavy grass, snow, etc; without the locks these obstructions are likely to flex the knees inopportunely. Hip joints and waist belts are occasionally at- tached to the thighs of these legs.

92 A. A. Marks, Artificial Lirribs, New York City.

Hip Joints. — The knee lock, hip joint, and waist belt can be combined to advantage in legs applied to stumps that are deflected, abducted, or that in any way incline out of the normal lines. The knee lock places the knee beyond the influence of the partly flexed Stump, and the hip joint places the leg beyond the influence of

CutH

Cut H 23

Cut H 24.

the abducted stump. As these auxiliary parts complicate the con- struction of the leg, add weight, and more or less hamper graceful and natural walking, it is not considered desirable to add them unless the conditions of the stump or the occupation of the wearer demand.

Waterproof and Bathing Legs. — Persons wearing artificial legs on thigh stumps frequently find it desirable to use their arti- ficial legs while they are bathing or swimming in salt or fresh water. It is embarrassing to those who have but one leg to be viewed with curiosity while hopping or walking with crutches or hitching on hands and knees on the shore. This embarrassment often prevents them from indulging in the exhilarating and health- giving river, lake, or ocean bath.

An artificial leg especially designed for swimming and bathing purposes is constructed practically the same as those heretofore described, differing only in the fact that they are absolutely water- proof, the knee to articulate or not, as the wearer may elect. As the wearing parts of waterproof legs are made of composition in- stead of steel, they are not as durable as those made for ordi- nary purposes; they are therefore only made when especially ordered.

Legs Without Knee Joints. — ^We have on a number of occasions been required to construct artificial legs for thigh stumps without

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93

knee joints. Cut H 25 shows an artificial leg of this type. The entire structure, including the foot core, is carved from a single piece of wood, slightly curved at the knee so as to represent the natural leg when partly flexed, for better accommodation when sitting. The foot is of rubber with spring mattress as described. The leg is covered in the usual way and enameled or water- proofed if it is to be used in watery places.

Peg Legs — Peg legs are occasionally used on thigh stumps. They are practically artificial legs without feet. As already stated we do not advocate the use of peg legs, as they are of limited effi-

Cut H 25.

Cut H 26.

Cut H 27.

ciency. The foot is a very important part of an artificial leg. It assists in balancing, aids in walking, and restores the appearance.

Years ago before artificial legs with rubber feet and spring mattress were so generally used, the peg leg was more in evidence, but lately it is worn more as a means of disciplining the stump or as a makeshift to bridge an impecunious period.

Persons are able to stand, stump about, and perform a limited amount of labor on peg legs, which are unquestionably better than

94 A. A. Marks, Artificial Lirribs, New YorTc City.

crutches, but their restoration is not complete until they are wearing artificial legs with spring mattress rubber feet. Cut H 26 shows a peg leg for a thigh stump. It is made of suitable wood, excavated to receive the stump and reduce weight. The outside has the contours of nature as closely as the conditions will admit, the end terminating in a metal ferrule and rubber tip, as illus- trated on page Yl, Cuts E 57-58-59. Cut H 27 shows a peg leg with knee joint, for a thigh stump. It is constructed in all parts the same as H 15, heretofore described. The absence of the foot and the substitution of a rubber tip is the only difference.

Suspenders. — Suspenders suitable for legs for thigh amputa- tions, as well as for amputations in the knee joint are of various kinds to suit the habits and demands of the wearers. The style of suspender which is most generally adopted is that illustrated in Cut H 28, termed the roller suspender. While it has excellent

Cut H 28.

Cut H 39.

Cut H 30.

features it has limited application. It can be used to advantage on stumps reaching to any point from the middle of the thigh to the knee, but for shorter stumps and for hip- joint amputations a method that will hold the limb to the body more firmly is neces- sary. The roller suspender is the product of many experiments and years of experience, assisted by the kindly suggestions of our patrons.

The shoulder straps are usually of two-inch non-elastic webbing. A strip of webbing is attached to the right strap, and forms a loop through which the left strap passes. A piece of webbing stitched to the back of both straps holds them together. The front lower ends of the shoulder straps are received into buckles, and the back lower ends are terminated by snaps ; each hooks into the ends of the leather roller cords which pass around roUers attached to

A. A. Marks, Artificial Lirribs, New Yorh City.

95

either side of the leg. Any degree of pressure upon the shoulders can be obtained by means of the clamp buckles, and when obtained, the buckles are clamped and are never disturbed, unless the pressure on the shoulders needs further adjustment. When it is desired to remove the limb, the suspenders are detached by unsnapping both front and back.

Cut H. 29 shows a front view of a person wearing a pair of roller suspenders.

Cut H 30 gives the back view, and Cuts H 31, H 32, and II 33 side views.

These cuts show the relative positions of the rollers, as well as the effect of the loops in holding the shoulder straps in place and

Cut H 31.

CutH

Cut H 33.

in directing the leg. Elasticity is obtained by two pieces of elastic webbing attached to the backs of the shoulder straps a little below the shoulder blades.

The operation of the suspenders is illustrated in Cuts H 29- 30-31-32-33. All the traveling of the suspenders due to changes of position takes place about the rollers on the sides of the thigh, instead of on the shoulders of the wearer, whether the person is standing, stooping, walking, or sitting.

Straight Shoulder Straps. — Cut H 34 shows a style of sus- pender especially adapted to an artificial leg for a short thigh stump. It is the style very generally used before roller suspenders were devised. The shoulder straps are of fine elastic webbing, 2 inches wide.

The front straps are of two-inch non-elastic webbing; each front strap passes through a metal link attached to the lower end of the elastic shoulder strap. After passing through the metal link the front straps are received into a two-prong buckle. The sus-

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A. A. Marls, Artificial Limhs, New Yorh City.

penders are attached to the leg by means of leather tags and metal D's screwed to the back and front. The metal D admits of side motion, thereby insuring direct pull.

Belt Attachment. — Cut H 35 represents a belt and suspender combined. The shoulder straps and belt are preferably of non- elastic webbing. The straps running from the belt to the leg are

Cut H 34.

Cut H 35.

Cut H 36.

made of elastic webbing, 2 inches wide or less, as the case may demand.

Vest Method. — Cut H 36 illustrates the vest method. It is made of strong muslin, fitted to the person and worn under the shirt. Elastic straps are attached to the lower border and buckled into straps that arc secured to the leg. In order to obtain the best results, the vest must be made and fitted by a tailor. Persons who desire to have their artificial limbs constructed from measure- ments, and choose the vest suspender, are required to have vests made at home, and if sent to us, we will attach the straps and make the proper connections with the leg without additional charge.

Suspenders for Women. — ^For obvious reasons the means of sus- pending artificial limbs to women differ from those employed with men. When shoulder straps are used they must pass over the shoulders and not press upon the breasts. Yokes, girths, or bands must pass around the waists so as to place the burden all or in part on the hips.

Yoke Method. — Cut H 37 shows a combination of the roller straps with the yoke; rollers or pulleys are secured to the sides of the thigh, and leather cords pass around them. The yoke is made

A. A. Maries, Artificial Limbs, New Yorlc City.

91?

to fit the loins and hips, adjustable by lacing in front or on the sides, as may be preferred; the shoulder and roller straps are also

Cut H 37.

Cut H 38.

adjustable, so as to bring the proportionate weight about the shoulders and hips without displacing the yoke.

Corset Method. — As many women pride themselves on their trim waists and neat-fitting garments, it is especially desirable that means of leg suspension should be light and neat. Straps securely sewed to the corset, extending downward and connected with the artificial limb, admit of the neatest adjustment. Cut H 38 shows the corset method, which can be easily adjusted by the wearer.

CHAPTER IX

HIP-JOINT AMPUTATIONS

Requirement. — An amputation at the hip joint or close to the body requires an artificial leg identical in construction to either of the patterns heretofore described for thigh stumps, with the exception that some modifications are introduced in the knee and the means of suspension is more complex.

Muscle Stump. — Cuts I-l and 1-2 illustrate front and side views of amputations at the coxo-femoral or hip articulation, leaving a stump composed entirely of muscle tissue. A muscle

Cut I-l.

Cut L2.

Cut 1-3.

stump is capable of performing some functions, although limited, in the management of an artificial leg, and may be considered as more desirable than no stump at all. Cuts 1-3 and 1-4 represent a hip-joint amputation in which there is no protruding stump by which the artificial leg cfin be directed. The amputated surface at the base of the pelvis is capable of bearing pressure.

Leg Applied. — Cuts 1-6 and 1-6 show a leg applied to hip-joint amputation having muscle stump. The means by which it is suspended consist of a waist belt, shoulder strap, over each shoulder, flexion and extension elastic straps, a metal hip joint

A. A. Marhs, Artificial Limbs, New York City. 99

Cut 1-4.

Cut 1-5.

Cut 1-6.

Cut 1-7.

Cut 1-8.

Cut 1-9.

100 A. A. Marhs, Artificial Limbs, New YorTc City.

substitiiting the natural hip articulation, and an attachment by vvhicli the knee can be locked and made immovable, or capable of having but limited motion, these features have all been explained in the preceding chapter.

The hip joint is important as it keeps the artificial leg directly under the wearer. The waist belt with its elastic straps front and rear assists in flexing and extending the leg at the hip. The leg is held firmly to the body when standing or walking; it should be especially noted, that it is not' advisable to allow any knee motion while the wearer is learning to control the leg. During this period the knee motion is only for sitting convenience.

Cut 1-7 shows a leg with pelvic socket suitable for a hip-joint

Cut I-IO.

Cut I-ll.

Cut 1-13.

amputation where there is no protruding stump to control the artificial hip motion.

Cuts 1-8, 1-9, I-IO, I-ll, 1-12, show the leg applied and the wearer in many positions. The pelvic socket takes in a part of the pelvis and holds the artificial leg firmly to its place no mat- ter what positions the wearer may assume. The hip joint is controlled by throwing the body forward or backward of the cen- ter of gravity of the leg.

Artificial legs for hip- joint amputations support the amputated side in a very comfortable and natural manner. The leg, having little or no stump to control it, is thrown forward by means of a side motion of the body. Persons with reasonable perseverance soon learn to control legs under these conditions in an advan- tageous way.

CHAPTER X

BOTH-LEG AMPUTATIONS

The triumphs of artificial limb-making are shown to advantage in the restoration to active life of those who have had both of their lower extremities removed. When such persons are enabled to get about freely, walk gracefully, and engage in such labors as their callings in life require, a great and beneficial work has been accomplished, and the strongest possible evidence is presented to show that the mind of the prothesist has not been passive during

Cut J 1.

Cut J 2.

the past half century. The problems these cases present are pro- foundly difficult, thought and effort have never been given to more laudable purposes than to their solution. The amelioration of the conditions of these unfortunate persons commands the highest tal- ent and the most humane impulses.

Ancient Methods. — But a short time ago the loss of both legs was regarded as irreparable. The person who met with that mis- fortune was either consigned to a wheel chair, or obliged to hitch himself about on his knees or haunches. Cuts J 1 to J 4 show some of the various methods employed by those deprived of both their limbs. Formerly these methods were the only means fox

101

102

A. A. Marks, Artificial Limbs, New Yorh City.

locomotion the subject could employ. But at the present time the methods are used preliminary to obtaining and wearing arti-

Cut J 4.

Cut J 5.

Cut J 6.

ficial legs. When these methods are contrasted with those that are shown later on, the progress and developments that have been made in the adaptation of artificial legs will be in plain view. Both Feet Partly Amputated. — Cut J 5 shows a case in which

A. A. Marls, Artificial Limbs, Neiu York City. 103

both feet were removed at the insteps; a pair of artificial legs constructed on the plan of Cut C 18, page 32, was applied.

LoWEE Instep and Leg Amputations. — Cut J G shows an ampu- tation of the left foot at the instep and of the right leg at the junction of the lower and middle third. Artificial legs C 18 and E 17 were applied.

Both Feet Amputated at the Ankles. — Cut J 7 shows a double ankle-joint amputation with the extremities incapable of

Cut J 7.

Cut J 8.

bearing pressure. A pair of artificial legs, constructed on the plan of D 21 and described on page 43, was applied. Cut J 8 shows the same case with the legs applied and the wearer stand- ing. In this particular instance the amputations resulted from frostbite, and the extremities of the stumps were very sensitive and with impaired circulation. It was therefore necessary to avoid interference with circulation and to secure the absolute freedom of the extremities from contact.

Ankle Joint and Knee Amputations. — Cut J 9 shows an am- putation of the left foot at the ankle after the Pirogoff method, and the right leg at the knee joint after the Gritti operation;

104 A. A. Marks, Artificial Linibs, Neiv Yorlc City.

Cut J 9.

Cut J 10.

Cut J 11.

Cut J 13.

artificial legs D 12 and G 17 were applied. Cnt J 10 presents

the wearer with artificial legs applied and attired as in daily life.

Upper Instep and Leg Amputations. — Cut J 11 shows an am-

A. A. Marks, Artificial Lir)ibs, New York City. 105

putation of left foot at the. instep and the right leg at the middle third. Artificial legs C 18 and E 17 were applied. Cut J 12

Cut J 14.

Cut J 15. Cut J 16.

shows the wearer with the legs applied, engaging in his occupa- tion as oysterman. This person has been employed in that indus- try for many years, and finds himself unhampered in his work.

106 A. A. Maries, Artificial Limbs, New YorJc City.

Cut J 13 shows an amputation of the right foot at the instep

and of the left leg immediately below the knee. The right foot

was poorly nourished, and sensitive at the extremity, so much

so as to completely prohibit any pressure. Cut J 14 illustrates

■ the same case with D 21 and E 17 legs applied.

Both-Leg Amputations. — Cuts J 15 to J 21 illustrate amputa- tions of both legs at various points between the knees and ankles, ri covering many lengths, characteristics of flaps, and situations of

Cut J 17.

Cut J 18.

cicatrices. Artificial legs suitable for any of these amputations, as shovim in Cut J 21, are constructed on the plan of E 17. Cut J 22 shows the legs applied. The freedom with which wearers of legs for double amputations can get about, the naturalness with which they can sit, lie down, stand, walk, ascend elevations, ladders, ride bicycles, skate, and engage in almost any occupation are shown in Cuts J 22 to J 32.

Practical Results. — Persons wearing two artificial legs are so thoroughly in control of their means of locomotion that they go about much as other people. They readily resume their former occupations, no matter how arduous they may have been. Cut J 28 illustrates a case of double-leg amputations with artificial legs E 17 applied. A short time after obtaining the legs the wearer resumed his work of baggage master, lifting heavy trunks, carrying them about, and putting them on trains as one v^ould

A. A. Maries, Artificial Limbs, New York Cily. 107

Cut J 19.

Cut J 20

Cut J 21.

Cut J 23.

108 A. A. Marks, Artificial Lirnbs, New York City.

do with natural legs. Cut J 29 portrays a railroad man with two artificial legs operating a switch. He dismounts, attends to the

Cut J 23.

switch, frequently gets aboard while the train is in motion, a-nd performs the work of a brakeman. He moves about quickly, steps over ties, and appears to be on as firm footing as if he had never

Cut J 24.

Cut J 25.

been deprived of nature's extremities. Cut J 30 shows a young man wearing two artificial legs, plan E 17; he is a conductor on a railroad, performing his duties in a thoroughly efficient manner.

A. A. Marks, Artificial Limbs, New Yorh City. 109

He walks through the train when it is running at its greatest speed, collects tickets, and punches them. The cars jolt, pitch.

Cut J 26.

Cut J 27.

and sway, but he retains his balance with no perceptible effort or awkwardness.

At stations he alights, watches passengers, gives signals, and boards his train. It never occurs to anyone that his lower ex-

Cut J 28.

Cut J 29.

tremities are not real, and his actions never betray that fact. With wooden articulating feet it would be extremely difficult for

110 A. A. Marks, Artificial Limbs, New YorJc City.

Cut J 30.

Cut J 31.

Cut J 33.

A. A. Maries, Artificial Limbs, New York City.

Ill

him to discharge such duties. He would feel unsafe, tottlish, and unsteady, but with rubber feet with spring mattress, rigidly attached, he has sound footing, and is capable of the most difficult feats of balancing.

Below-Knee and Knee-Joint Amputations. — Cut J 31 rep- resents a case with both legs amputated; the right disjointed at the knee, and the left amputated three inches below the knee; Nos. E 17 and G 7 legs were applied. This man when in street

Cut J 33.

Cut J 34.

attire presents the appearance of a person with natural extremi- ties. He walks naturally, and never consents to use a cane. He is a member of the Knights of Pythias, and takes pride in parading with his lodge. Cut J 32 shows him in his uniform.

Below-Knee and Above-Knee Amputations. — Cut J 33 repre- sents ampTitations of both legs, the right below the knee and the left above the knee. Cut J 34 represents the same case, with E 17 and H 15 legs applied.

Cut J 35 ^hows a similar case; the right stump only five and one-half inches from the body, and the left one and one-half inches below the knee. E 17 was applied to the left side and H 15 to the right. The subject was restored to not only a natural appearance, but to the ability of walking without the aid of

112 A. A. Maries, Artificial Limbs, New Yorh City.

canes or crutches, and so naturally that he has associated with persons for long periods without betraying the fact that his lower limbs were artificial. This young man has walked half a mile

Cut J 35.

Cut J 36.

in eight minutes without great effort. He works at the bench during the day, and the evenings are frequently spent at the billiard table. Cut J 36 shows him as he appears on his artificial legs, and in street attire.

Engaging in Former Pursuits. — We have many patrons wearing E 17 and H 15 artificial legs for double amputations who exhibit remarkable skill in performing feats that require sound footing.

Cut J 37 shows a person with two artificial legs as above de- scribed in a rowboat, illustrating the manner in which he can brace himself while pulling a strong oar.

Cut J 38 shows another similarly equipped at the pool table, balancing himself on one foot while making a difiicult shot.

Cut J 39 represents another with thigh and leg amputation, on a ladder, at a great distance from the ground; his footing is sound, his arms are free; he can hold a paint can in one hand, while he applies a brush with the other.

Cut J 40 represents another riding horseback, securely seated in the saddle, and feet in stirrups. The spring mattress rubber

A. A. Maries, Artificial Limbs, New York City. 113

feet are used in all of these cases, and sound and reliable footing are due to the excellent feature obtained by that means.

Both Legs and Both Arms Amputated. — Cut J 41 represents a case in which both legs and both hands were amputated. A

Cut J 37.

pair of artificial legs, and a pair of artificial arms were applied. The wearer became able to walk about in a very natural way; his artificial arms enabled him to feed himself at the table, write,

Cut J 38.

and perform such work as does not depend upon delicate finger movements and the sense of touch.

Both Legs Amputated Above the Knees. — No matter how ex- tensively a person may be dismembered, prothetic science is ca-

114 A. A. Marks, Artificial Lirribs, New York City.

pable of rescuing him from a life of helplessness. Only a brief period has elapsed since it was considered rash to apply a pair of artificial legs to a person who had both of his natural legs amputated above the knees. Attempts to substitute such a large portion of the body depending on short thigh stumps for support, resulted in failures, and until modern ideas were introduced and appropriate means for attachments were devised, failure followed

Cut J 39.

Cut J 40.

every effort. In 1864 the fi.rst pair of artificial legs was applied to double thigh amputations; the subject was a soldier of the Civil War. Although he was able to sit, stand, and walk on his artificial legs, the effort was so great that the wearer soon tired of them and abandoned their use, and became the occupant of a wheel-chair, dependent on his family.

In 1879 Mr. Marks made his second attempt, and succeeded ad- mirably. The subject was a young man with two thigh stumps that reached nearly to the knees. This man soon acquired the art of balancing, and became so adept that he could walk about the house without the aid of canes or crutches, but when in the street he found it necessary to use a pair of canes. He has worn the pair of legs made in 1879 up to the present time. He is engaged in active business pursuits, and has reared and supported a large family.

Since the above date we have applied upwards of a hundred pairs of artificial legs to double thigh amputations. The manner

A. A. Maries, Artificial Limbs, New YorJc City. 115

Cut J 41

Cut J 43.

Cut J 43.

Cut J 44.

in which these limbs were constructed, the way in which they were applied and adjusted, and the methods employed to give better control of the movements have varied according to the conditions

116 A. A. Marks, Artificial Lirribs, New Yorlc City.

of each case. Each double thigh amputation presents problems of an individual character, and as there are seldom two alike,

Cut J 45.

Cut J 46.

Cut J 47.

these problems must be solved by the manufacturer. The solu- tion lies in the hanging of the legs, the method of suspension,

Cut J 48.

Cut J 49.

limiting the motion of the knees, and the absolute rigidity of the ankles. We cite a fevp cases.

A. A. Marks, Artificial Limbs, New Yorh City.

117

Cut J 42 represents double thigh stumps, produced by ampu- tations made to remove deformed parts. A pair of artificial legs of suitable construction was applied. The great lengths of these stumps gave such control over the artificial limbs that it w^as not necessary to apply hip joints or knee locks. The subject was a musician. In a brief time he was able to walk naturally, resum- ing his profession, and now has a national reputation as a clari- onetist. He walks on the stage, plays the instrument, acknowl- edges encores, and retires in the usual stage manner.

Cut J 43 represents a double knee joint amputation. A pair of suitable artificial legs are shown in the same cut. Cut J 44

Cut J 50.

Cut J 51.

shows the artificial legs applied, and the wearer in the act of walking.

Cut J 45 represents a child who had both legs amputated above the knees on account of a railroad accident. A pair of artificial legs with knee locks was applied to advantage. The child has, for a number of years, walked on the artificial legs very satis- factorily. He has been enabled to walk to school and indulge in childish pastimes. The manner in which the artificial legs were held in place is shown in Cut J 46, front view, and Cut J 47, rear view.

118 A. A. Maries, Artificial Limhs, New YorJc City.

Cut J 48 represents a double thigh amputation, the result of a railroad accident. Cut J 49 shows the application of a pair of artificial legs with the wearer seated. Cut J 50 represents the same person standing, and in Cut J 51 he is attired as he ap- pears when walking. This case is one of the most remarkable on record. The stumps only extended to about the middle of the thighs, but through the energy of the wearer and the efficiency of the artificial legs, he was able, in- a brief time, to walk about in a very natural way, and go up and down stairs; he uses no canes about the house. The artificial legs H 15 were applied with hip joints and automatic knee locks, but after a brief time the wearer dispensed with the locks and found that he could control the artificial knee joints without danger of treacherous flexing. Under earlier systems this case would have been considered hope- less, and the thought of applying artificial limbs would never have been entertained.

CHAPTEE XI

AETIFICIAL FEET AND LEGS FOR DEFORMITIES, PARALYSIS, EXCISIONS, ARRESTED GROWTH, SHORTENED LEGS, ETC.

Deformities of the feet or legs may be due to causes congenital, traumatic, or pathological. Appliances for such cases frequently partake of the character of artificial legs and call for the skill of the prothetician.

No matter how greatly distorted, deformed, or weakened one or both legs may be, there is reasonable hope that some appliance can be used that will aid locomotion, hide the affected parts, and restore a fair degree of symmetry to the person.

Short Leg. — The most frequent leg abnormity is that of short- ening, due to hip- joint troubles in infancy, or to paralysis.

Cut K 1.

Cut K 2.

Cut K 3.

Cut K 1 represents a case of shortened leg caused by hip dislo- cation. The front of the foot is dropped downwardly to enable the subject to walk on the ball of his foot.

Talipes-equinus. — Cut K 2 represents a case of talipes-equinus, leg shortened from one to three or more inches, due to paralysis. The ankle joints in K 1 and K 2 were normally strong and the knees and hips under thorough control. Cut K 3 shows an appli- ance suitable for either of the above cases. It is termed an extension foot, and is constructed from a wooden block, the upper surface shaped to receive the sole of the affected foot, with the front part dropped to a convenient angle (see dotted line). The

119

120 A. A. Marks, Artificial Limhs, New YorJc City.

under surface of the block is connected with the lower part of a rubber foot. The entire structure is covered with suitable leather, the upper of which runs well up on the leg, incasing the entire foot and ankle. Cut K 4 is a shoe, to be drawn over the foot and appliance. It is usually a part of the mate of the

Cut K 4.

Cut K 5.

Cut K 6.

shoe worn on the opposite foot, the quarter having been removed and a larger one put on having the shape and dimensions required to fit properly. This alteration in the shoe is easily made, and can be done by any shoemaker at slight expense. The extension, when complete and covered by a shoe, is shown in cut K 5. Cut K 6 shows it covered with the trousers. Persons with these appli- ances walk much better than they do with the old style, thick sole and high-heel shoe. They present a better appearance and are far more comfortable.

Talipes with Lateral Weakness. — Cut K 7 represents a short- ened leg with talipes and loss of control over the ankle joint, there being a strong tendency for the ankle to give way sidewise. A suitable appliance is shown in the same cut. It is constructed of wood, carved from a block with naturally curved grains, or made of aluminum, as conditions require. It receives the leg and foot in a comfortable way and holds them firmly in place. The heel and toes are of ru.bber. Cut K 8 represents the case with appliance in place and wearer walking. In cases of atrophy of the calf, which frequently accompanies these cases, the leg structure can be carved to approximate the contours and dimensions of the sound leg. There will scarcely be an appreciable increase in weight.

Toe Support. — An appliance of above type is helpful in holding the foot in correct position, and on account of the rigidity of the ankle the wearer obtains toe support that enables him to rise op. the ball of the foot when walking. This produces a natural

A. A. Maries, Artificial Limbs, New York Oily. 121

step, avoids limping, and enables the wearer to go up and down stairs and alight on elevations. It also aids him in balancing, and, as the point of resistance at the ball of the foot is in advance of the knee joint, the tendency of the knee to flex is counter- acted; this adds materially to the efficiency of the apparatus, giving the wearer a feeling of confidence and security. A person

Cut K 7.

Cut K 8.

with a paralyzed leg, using ordinary braces, usually finds it neces- sary to press his hand against his knee joint when his weight is on the affected leg. He does this to keep the knee from flexing and precipitating a fall, but with the appliance just described firmness of the knee joint is obtained by phalangeal support in the foot, and the wearer is not dependent on pressure placed in his knee joint, or on attachments going above the knee.

Cut K 9 shows a shortened leg with hip and knee joints under control; the ankle suffered a loss of strength and required sup- porting.

Cut K 10 represents a leg shortened by hip-joint trouble in youth, producing a deficiency in length of about ten inches; the knee and hip joints are under control and the bottom of the foot is capable of bearing weight. Cut K 11 represents a leg, designed for each of the above cases, the natural foot is dropped to the greatest angle that can be tolerated and made to rest on an

122 A. A. Marks, Artificial Limhs, New YorJc City.

inclined surface at the required distance from the floor. The leg is incased by a socket made of wood and leather. Cut K 12

Cut K 9.

Cut K 10.

Cut K 11.

represents the appliance in place, and Cut K 13 shows the patient properly and neatly attired.

Congenital Deformity. — Cuts K 14 and 15 illustrate the front and side views of a case of congenital deformity. The foot

Cut K 13.

Cut K 13.

appears to be attached to the external side of the tibia immedi- ately under the fibula. Weight can be borne on the sole only when the foot is held in position. Cut K 16 gives a side view of

A. A. Maries, Artificial Limhs, New Yorh City. 123

a suitable appliance constructed substantially the same as K 11. The displaced foot is held firmly in correct position and the wearer waU^s helpfully and quite naturally.

Talipes-varus. — Cut K 17 represents a case of talipes varus, resulting from paralysis — the knee joint being involved. A suit-

Cut K 14.

Cut K 15.

Cut K 16.

able appliance is shown in the same cut. Cut K 18 shows appli- ance in place and the wearer seated; with this appliance the wearer is enabled to walk acceptably.

Leg Deformities. — Cut K 19 represents a deformed right leg. From the knee down, the leg is diminutive, terminating in a

Cut K 17.

Cut K 18.

miniature foot, inclined inwardly and backwardly; the shortening due to arrested development amounts to eight inches. Cut K 20 shows a suitable leg. The deformed leg, from the knee down, is

124 A. A. Maries, Artificial Limls, New YorJc City.

received into the socket of the artificial leg and held there com- fortably. A rubber foot, with spring mattress placed at the required distance to restore length, fully equipped the child with means of locomotion.

Cut K 19.

Cut K 21.

Cut K 23.

Cut K 20.

Cut K 23.

Cut K 21 represents a right-leg deformity ; hip, thigh, and knee under normal conditions; the leg from the knee down undevel- oped, foot very small, terminating in a great toe growing from

A. A. Marks, Artificial TArribs, New York City.

125

the internal side. Cvit K 22 shows an artificial leg devised for the case. The deformed leg is received in the socket and laced. The toe is provided vpith a protecting pocket, the vs^eight is taken partly on the plantar surface of the miniature foot and partly about the leg below the knee and about the thigh. When first applied the leg only reached to the knee, but it was found that there was a weakness in the knee, with a tendency to abduct; knee joints and thigh support were added, which prevented yielding to lateral weakness. Cut K 23 shows the leg applied and the child standing. Since the application of the appliance the child has

Cut K 34.

Cut K 25.

Cut K 26.

Cut K 27.

grown rapidly in stature and weight, well developed, strong and healthy.

Cut K 24 represents a congenital deformity of the right leg, consisting of a malformed foot, miniature leg, and abnormal rela- tions of tibia and fibula. The tibia extends to the ankle, without connecting with the foot. The fibula connects with the foot but not with the leg, the two bones held in position by cartilage. When standing on the right foot the bones would slide by each other over an inch; there was also lateral weakness, rendering walking impossible without assistance. Cut K 25 represents an appliance constructed for the case, made of aluminum formed to receive the foot and leg in a comfortable way, terminating with a rubber foot. The weight, when standing or walking, was placed on the internal sloping surface of the tibia, immediately below the knee. The socket held the tibia and fibula in position. This appliance has been used for many years, enabling the wearer to engage in arduous labors, and capable of walking great distances without fatigue.

Cut K 26 represents a shortened and malformed leg. The shortening appears to have been located wholly in the leg between

126 A. A. Marks, Artificial Limhs, New YorTc City.

the knee and ankle. Cut K 27 represents a suitable leg. It is constructed to receive and hold the deformed member firmly in place. A rubber foot, placed under the foot-rest, gives the required length. The motion in the ankle made it possible to drop the toe to a concealable angle. Although the apparatus had the appearance of a double foot, there was no difficulty in con- cealing the deformity by the trousers.

Cut K 28 illustrates a deformity of the right leg. The hip and thigh are normal and an undersized foot appears to have grown

Cut K 38,

Cut K 30.

Cut K 31.

immediately from the knee. The patient was able to flex and extend the foot the same as a 1^, or, in other words, he had an articulation at the junction of the thigh and the foot, the tibial section being absent. Cut K 29 represents an artificial leg devised for the case. It is similar in its general construction to that represented in Cut E 17. The socket of the leg is excavated to receive the foot, the knee joints and thigh supporter give the foot control over the artificial part.

Cut K 30 represents a deformed left leg. From the knee down it was misshapen, contracted, and distorted. Cut K 31 represents a suitable artificial leg applied. The deformed parts were placed well up and out of the way, concealed by the dress.

Cut K 32 represents a deformed lower right leg, very similar to the one just described. The knee, however, admitted of more flexion, and the artificial leg was made to receive the thigh and deformed part in one socket and was held in place by means of a leather sheath passing from the rear and lacing to the front line of the thigh, as shown in Cut K 33.

Infantile Paralysis. — Cut K 34 represents an undeveloped left

A. A. Maries, Artificial Lirribs, New YorTc City. 127

leg, the entire limb considerably atrophied and the joints weak, caused by infantile paralysis. Cut K 35 represents an artificial leg especially designed for the case. The deformed leg is received in the socket and laced in place and the foot dropped to the greatest angle of toleration. The thigh piece incases the thigh

Cut K 32.

Cut K 33.

Cut K 34.

and the joints support the knee; a rubber foot is placed at the extremity. Cut K 36 presents a side view of a similar appliance with a knee lock, which is necessary in cases of loss of control in the joints.

Cut K 37 represents a deformity of the right leg; the hip, thigh, and knee normal and healthy, but the leg and foot diminutive in size, with foot rotated outwardly. Cut K 38 represents an arti- ficial limb especially devised for the case. The undeveloped leg is received into the socket, the foot protrudes through an aperture on the external side, the knee joints and thigh piece, placed above the knee, give support and strength about the thigh. A rubber foot, with spring mattress at the lower extremity, completes the apparatus and gives the required support.

Obstructed Growth. — Cuts K 39 and K 40 represent cases of obstructed growth, the hip joints normal, the thighs possessing nearly the proper lengths, terminating in short and misshapen legs. Cut K 41 represents a leg suitable for either case. Both these persons were enabled to walk nearly as well as if normal conditions existed. A slight enlargement of the trousers a little above the knee (necessary to accommodate the deformed leg) is the only noticeable difference in the two sides, and that differ- ence so slight as to be observed only by the critical eye.

128 A. A. Maries, Artificial Limbs, Neiv Yorlc City.

Cut K 39.

Cut K 40.

Cut K 41.

Cut K 42 represents a deformity consisting of an undeveloped femur and partially developed leg, the knee joint located very

A. A. Maries, Artificial Limls, New York City. 129

close to the hip. A suitable artificial leg is shown in same cut. The wearer walks so perfectly with this leg that his deformity is absolutely concealed.

Both Legs Deformed. — Cut K 43 represents a deformity, both legs atrophied, talipes-varus, feet abnormally large. Ampu- tation of both feet at the ankle joint after the Symes method was advised. This was done and the patient obtained a pair of legs, on which he walks and performs labor acceptably. Cuts K 44 and K 45 represent front and side views of a deformity of

Cut K 43.

Cut K 43.

both feet. From the hips to a little below the calves normal conditions were present; at about the calves there were false joints supplementary to the knee and ankle articulations. These false joints were under poor control, not sufficient to hold the feet in proper position. We advised the amputation of both limbs through the false joints. This was done, and the child had two excellent tibial stumps on which artificial legs, style E 17, were applied and worn with comfort and efficiency.

Cut K 46 represents a case of amputation of right leg and talipes-varus in the left. A suitable artificial leg for the right side and a helpful appliance for the left are shown in the same cut; Cut K 47 shows the limbs applied and the wearer standing erect. The disposition of the leg to rotate inwardly was controlled

130 A. A. Marks, Artificial Limbs, New York City.

by the appliance and the leg was compelled to operate in the line of progress.

Cuts K 48 and K 49 represent front and side views of a case

Cut K 44.

Cut K 45.

of congenital deformity of both legs, rendering walking very diffi- cult and more largely dependent upon crutches than on feet. We advised the amputation of both legs at the calves. The subject

Cut K 46.

Cut K 47.

submitted to the amputation of the right leg, but decided to retain his left, which appeared to have more sustaining power. Cut K 50 represents the case after the amputation of the right leg, and

A. A. Maries, Artificial Limbs, New YorTc City. 131

Cut K 51 ropresents him with the artificial leg applied, while Cut K 52 shows him dressed. The condition of the wearer was graailj improved by the removal of the right leg and the application of

Cut K 48.

Cut K 49.

an artificial one. The improvement would, have been carried further if he had submitted to a similar operation on the left side, thereby obviating the outward curve of the lower leg, which

Cut K 50.

Cut K 51.

Cut K 52.

is conspicuous even when covered with trousers. Cut K 53 rep- resents a case of paralysis of the right leg, knee slightly flexed. Cut K 54 represents the same with one of our instruments

132 A. A. Marks, Artificial Lirribs, New Yorh City.

applied; wearer seated. It was constructed with knee joint, pro- vided with automatic lock, preventing flexing with the weight, directly over the leg, permitting flexion when the wearer is seated. The foot is held in proper position for standing and prevented from flexing treacherously when walking.

Gut K 55 represents congenital deformities of both legs; branches grew from the inner surfaces of both femurs. That on the right thigh was ten inches in length, on the left not more than two. The knee joints were on the inner surfaces of the ends of

Cut K 53.

Cut K 54.

the femurs, feet everted and badly formed. In boyhood, loco- motion was obtained by moving about on his haunches; later he walked with the aid of crutches, bearing on the ends of his femurs and dragging the deformed legs. For twenty-five years he sub- mitted to these awkward and unsightly means for getting about. His attention was finally called to artificial limbs, and upon con- sulting well-informed persons he found that he could improve his condition by having the useless parts of the legs removed and artificial ones applied. We indicated points at which amputa- tions could be performed to advantage. After the operations his stumps presented the appearances shown in Cut K 56. We applied a pair of artificial legs, constructed on the plan of those represented in Cut G 8. When dressed, this man had the appear-

A. A. Marks, Artificial Limbs, New Yorlc City.

133

ance of a person with natural and well-formed legs. Cut K 57 is taken from a photograph, showing him as he appears in ordi- nary life.

Cut K 68 represents a case of arrested development. The child was well formed from the knees up, but from the knees down his deformity was pronounced and of a character to render walking

Cut K 55.

Cut K 56.

Cut K 57.

impossible. The child managed to get about rather awkwardly with crutches, permitting but little weight to come on his feet. As the joints in the ankles and knees were flexible, and as the feet were small, we found that we could incase the entire legs, provide knee motion, and place rubber feet at suitable distances below the deformed ones. This was done, and the lad was brought to his proper height, making a presentable appearance and walking in a very acceptable way, without the aid of crutches. He con- trolled the artificial knee joints by means of his feet and had little or no difficulty in balancing, walking, sitting, rising, ascend- ing or descending steps. Attention was given to ornamentation, and when dressed his deformity was entirely concealed, as shovsm in Cut K 59.

134 A. A. Marks, Artificial Limhs, New York City.

Drop Foot. — The drop foot, resulting from paralysis or arrested development, is a frequent infirmity. Usually the leg is of normal length, the knee joints contracted and weak, with loss of control at the ankles and lateral weakness or a tendency for the foot to bend sidewise, either varus or valgus. The only practical manner in which a leg of this sort can be rendered useful is by fixing the ankle joint artificially, thus providing a resistance at the ball of the foot, the concomitant for balancing, maintaining height when walking and serving as a lever for propulsion, and as a counteracting influence to the tendency of the knee to flex. Cut K 60 represents a case of this kind. Cut K 61 represents the

Cut K 58.

Cut K 59.

Cut K 60.

Cut K 61.

appliance we have devised for such. It is practically a form of splint, cast of aluminum to the shape of the leg and foot. The metal is carried under the entire foot, holding it at a proper angle for walking. The front is provided with leather, arranged for lacing. This appliance holds the ankle joint firmly and provides support at the ball of the foot, which is so far in advance of the center of motion of the knee that it prevents the knee from flexing when the weight of the wearer is directly over the foot. Persons with these appliances walk rapidly and quite naturally, seldom requiring any attachments above the knees.

In connection with appliances of this type for paralyzed lower extremities we may quote from the Cincinnati Lancet-Clinic of October 9, 1897. A prominent physician read a paper before the academy regarding the treatment of his own paralyzed leg:

"An illustrated catalogue fell into my hands, in which was pictured, among artificial legs, etc., an apparatus made of alumi- num, splint-like in character, with a rubber cushion under the foot to compensate for shortening. It was made for a case of congenital dislocation of the ankle. The more I studied it, the

A. A. Marks, Artificial Limbs, New York City. 135

more it appealed to me that such an apparatus could be made for my own comfort. I had reached a period when I was considering amputation and the substitution of an artificial leg for my para- lyzed one. Impressed with the illustration of this apparatus, I consulted a friend upon the subject. He was as much impressed with it as I was, but advised me to obtain the opinion of our surgical friends. They were likewise impressed with it and advised that I try the conservative measure first before I resort to the radical one. I went to New York and consulted the maker. After studying my deformity for a few minutes, he stated that an apparatus could be constructed that would materially improve my condition. The appliance was made and worn for four years. But those four years! How can I describe them? Pen and words fail me. It was like a beautiful oasis in a dreary desert of years of suffering. In connection with my deformity there was a weakness of the abductor muscles, which permits of a rotation outwardly of the thigh. This has been overcome by rubber abductor muscles. The one fastened to the outer side of the apparatus crossed the front part of the right thigh, crossing to the left side of the trunk, and is inserted into the harness. The one attached to the inner side of apparatus is inserted over the right posterior part of the harness, which is suspended from the left shoulder.

" Who are my benefactors ? Who are those who have given to me the comfort of four years' duration, with a bright future of many more? And, within such a short period, free from pain, caused the twenty odd years of suffering to disappear in the dim and misty past?

" Oh, for a trumpet of such power to herald to the world their name, that those who are needy may seek them! But instead, in gratitude do I raise my feeble voice and wish the cup brimful of happiness for the firm of A. A. Marks, New York City.

" ' By thy deeds shalt thou be known ! ' "

Knee Joints Locked. — Shortened and paralyzed legs are fre- quently accompanied with total loss of the power of extension and flexion in the knee joints. In such cases the mechanism of the artificial knee joints is provided with locks that hold the knees rigid when standing or walking. The joints are capable of being unlocked to admit of flexion when sitting.

Cut K 62 represents a shortened, atrophied, paralyzed leg. Cuts K 63 and K 64 show the same case, with apparatus in place. The apparatus consists of a socket that incases the leg, knee joints with locks that support the knee, thigh piece that takes the sup- port about the thigh, and a rubber foot placed under the deformed natural foot in order to obtain the proper length.

Limited Knee Motions. — Cut K 65 represents a shortened leg with limited motion in the knee, the knee capable of flexion, but incapable of extension beyond the angle represented in the cut ; the hip normal and the bottom of the foot capable of enduring pressure. Cut K 66 represents an £|jrtificial leg suitable for the ca§Q. It i?

136

A. A. Maries, Artificial Limbs, New York City.

made with a wooden socket, fitted to receive the leg. A comfortable shelf is provided for the foot to rest upon. Knee joints with pawl and

Cut K 62.

Cut K 63.

Cut K 64.

rack and thigh piece incasing the thigh are provided. The pawls at the knee joints are operated by levers which pass up the rear of

Cut K 65.

CutK

Cut K 67.

the thigh. When standing or walking, the leg is brought to the point of greatest extension, the pawls automatically drop into the rack and make the leg immovable at the knee. The moment the

A. A. Maries, Artificial Lirribs, New Yorh City. 137

wearer is seated, the lever will rest on the chair and force the pawls out of their racks, allowing the knee to flex (see Cut K 67). By this means the wearer is able to walk safely with rigid knee

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Cut K 68.

Cut K 69.

and bend the knee when sitting. The apparatus has a rubber foot with spring mattress placed at the proper distance below the paralyzed one.

Ununited Fractures. — Cut K 68 represents an ununited fracture of the tibia and fibula at a point a little above the ankle joint. Usually, in cases of this kind, it is deemed advisable to amputate, the wisdom of which we do not question. Occasionally, however, and particularly in the case here illustrated, the horror of the knife kept the patient from submitting to that alternative, and he came to us for help with a dangling foot, under no control whatever. He was young and in good health, and cherished the hope that if the fractured parts were held firmly in juxtaposition, nature might eventually, in her mysterious way, bring about a union. We constructed an aluminum socket, incasing the leg from the knee down and the entire foot, fixing the ankle. This appliance, shown in Cut K 69, was fitted when the tibia and fibula were in apposi- tion. Weight was communicated from the bottom of the appli- ance to the leg immediately below the knee. No weight what- ever was brought on the foot and no strains permitted to cause the bones to move out of the places in which they were held. The appliance has been worn advantageously for a number of years. The manner in which the wearer gets about, walks, and attends to his vocation is exceedingly gratifying.

Cut K 70 represents an ununited fracture of the right tibia, due to gunshot wound. All efforts to bring about a union failed. The fibula was not injured, but in consequence of failure of vmion in

138 A. A. Maries, Artificial Limbs, New Yorh City.

the tibia it was obliged to do the work of both bones. Being overtaxed, it gradually yielded and became curved, as shown in the cut. The dark spot immediately below the patella represents a deeply indented scar at the point of fracture. Cut K 71 repre-

Cut K 70.

Cut K 71.

Cut K 72.

sents a suitable brace for the case, made of wood and leather. A block of wood is excavated to receive the fractured member in its most comfortable position. The leg, when placed in this splint- like appliance, is held firmly by means of lacing. As the injury shortened the leg about one inch, a block of suitable thickness was hinged to the lower extremity of the splint on which the foot rested. Owing to the proximity of the fracture to the knee articulation, it was impossible to construct the brace that would admit of knee motion. The appliance has done its work for a great many years with great satisfaction to the wearer.

Fractured Knee Caps^ etc. — Resections of knee joints, frac- tures of knee caps, weakening of the patella ligaments, in fact any ailment that lessens or destroys control over the knee articulation is greatly benefited by appliances similar to that represented in Cut K 72. The socket below the joint is made of wood, with a leather front capable of being laced. The upper socket is made entirely of leather. The knee joints are made with stops, so that extension cannot be made beyond the proper limit. In cases of partly flexed knees, due to knee-joint disease, this appliance can be used to advantage, requiring knee locks in addition.

CHAPTER Xn FACTS FOE CONSIDERATION

Wooden Feet Substituted by Rubber Ones. — Artificial legs, manufactured with wooden articulating feet, are more or less troublesome and expensive to keep in order, and are deficient in supplying the requisite propulsive power in walking, it is there- fore often deemed advisable to remove them and substitute rubber ones. We have devised methods by which this can be done, whether the legs be constructed of wood, leather, or metal. Our charge is $20.00 in each case. We guarantee the attachment to be strong and lasting. A foot of any size or shape to meet the wishes of the wearer can be put on, and the leg can be made longer or shorter, as may be desired.

A Way to Test the Rubber Foot. — The attachment of a rubber foot to an old artificial leg is often done to test its merits. It gives an admirable opportunity for the wearer to try the rubber foot and ascertain for himself the advantages it has over those he has worn.

An experiment of this sort can only be successful when the socket of the old artificial leg fits correctly; if it does not, the leg cannot be worn comfortably and satisfactorily, no matter what kind of a foot it may have.

A cabinet maker, carpenter, or other mechanic, be his skill in his own line what it may, should not be expected to connect a rubber foot to an artificial leg with assurance of satisfactory results. The alignment, the set of the foot, the angle at which it should be placed relative to the shaft, are important factors and must be thoroughly understood and their relations to each other comprehended, or the results will be disappointing. This knowl- edge can only come from experience; we therefore dissuade per- sons from buying rubber feet and having them put on their arti- ficial legs by home mechanics. We therefore insist that artificial legs be sent to us for such work, and for which we make no extra charge.

Ease and comfort in wearing an artificial leg depend almost entirely upon the manner in which the socket receives the stump. No matter how correctly the leg vaay be constructed, or with what nicety the parts operate, it is worthless if it causes pain, abrades the stump, or interferes with the circulation.

Fitting — an Art. — The fitting of an artificial leg is an art, only acquired by thought and the experience of years. A thorough knowledge of the anatomy of the stump, the effects of pressure

139

^46 A. A. Marks, Artificial Limbs, New York City.

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(jn various points, the manner in which interference with the cir- culation or the displacement of tissues on the stump can be obviated must be understood, or the fitter is not qualified to be intrusted with such work.

Thfere are a great many artificial limb manufacturers in the world, but there are a very few fitters.

Only One Way to Fit. — There is. but one way in which a leg can be made to fit correctly, and that is to excavate a block of wood until it has the proper size and shape to receive the stump, so that pressure will be placed where it can be endured, there must be absolute freedom from contact on the blood vessels and exposed nerve areas.

A leg that puts pressure uniformly on the stump is not a com- fortable one to wear, for there are many places on every stump that cannot bear any pressure whatever. There are other places that can endure any amount of pressure; a socket to be comfort- able must, therefore, be made so as to apply pressure only where it can be endured.

When Plaster Casts are Useless. — A plaster cast of a stump and a plaster cast of the inside of a socket that fits the stump correctly are no more alike than the last on which the shoe is built is like the foot on which the shoe is worn. It is absurd to assume that a serviceable, comfortable socket can be made by molding a plastic material, such as leather, felt, or wax, on the cast of a stump or by molding it on the stump itself. Sockets so made are always irritating and cause pain and suffering. It is likewise an error to assume that a block of wood can be cut out to the contours of a plaster cast of a stump and fit the stump comfortably. If it were so, the fitting of an artificial leg would be reduced to a mechanical operation which could be conducted by inexperienced and inexpensive persons. If the work could be done in this way, the cost of an artificial leg might be considerably lessened.

Machine Fitting a Failure. — The irregular form turning lathe, with which all mechanics are familiar, carves a stick of wood to the exact shape of the model. Axe handles, gun stocks, shoe lasts, and many other articles are made in this way. A machine of this kind has been modified so as to excavate a block of wood so it will have the exact shape of a plaster mold of a stump. A socket for an artificial leg made in this way must be greatly modified by hand before it can be worn with comfort.

When we are reminded that the stump is bone covered with muscles, fat, blood vessels, nerves, tendons, and skin; that these coverings are not of uniform thickness : that they are soft, yield- ing, and easily displaced : that more pressure can be applied on the least sensitive parts, and that where the nerves and blood vessels are the most numerous less pressure can be endured, we will readily see that a socket, to fit properly and not injiire the stump, must be fitted by persons skilled in the work, who know the location of the large blood vessels, the character and disposition of the nerves,

A. A. Marks, Artificial Limbs, New York City. 141

and who are keenly alive to the necessity of avoiding pressure on the vascular parts. The skilled fitter does not always need the presence of the person who is to wear the leg he is fitting. Cir- cumferences and diagrams of the stump will guide him in doing more accurate work than is possible for an incompetent fitter, though he be supplied with plaster casts, or fits directly to the stump.

When Casts are Necessary. — Plaster casts are desirable in some cases. They convey contours, locate irregularities, promi- nences, and tender spots on abnormal stumps, or on those that reach to the knees, ankle joints or insteps, and in such cases are quite necessary, but, generally speaking, stumps that extend to any point between the articulations do not require to be repro- duced in plaster.

Wood Sockets the Best. — The advantages of wood sockets are many. Wood is light and firm, retaining the shape it receives from the skillful fitter. No matter what conditions may exist — the tender spots of a stump are always protected, weight is applied where it can be endured, and when the socket is highly polished there is absolutely no friction. A stump may move, slip, and slide without becoming blistered or abraded.

Weight. — The weight of an artificial leg varies from one to seven pounds, according to its size and the severity of the labor it is to perform. We have made artificial legs that weighed less than a pound for infants, and we have been obliged to make them seven or eight pounds in weight in order to be strong enough for active, three-hundred-pound persons. The only way to obtain strength is by the employment and proper disposition of suitable material. A small leg is not as heavy as a large one, and a strong leg must be heavier than a frail one.

KuBBER Foot not Heavy. — A leg with a rubber foot can be made from six to sixteen ounces lighter than the ordinary arti- ficial leg with articulating ankle. The lessening of weight is chiefly caused by the absence of the metallic ankle connection.

The notions of those wearing artificial legs are varied, there- fore they cannot be used as guides. One man says, make my leg as light as you can, even at the sacrifice of strength; I would rather have a light leg and renew it more frequently than to carry a heavy one. Another will say, do not make my leg too light; I have worn light and heavy ones, and I find that I can walk more steadily and step more naturally with a leg of moderate weight. The leg should act as a pendulum; the moment it is lifted from the ground it should swing forward of its own weight and not depend upon energy imparted by the stump. Still another will say, I do not care what the leg weighs so long as it is made strong: strength is the desideratum. If it weighs a pound or two more I will not object to it, as I can soon get used to that, but it must be strong and last a long time. I cannot afford to take chances on the leg breaking. The utmost diversity of opinion, therefore, exists on this subject.

142 A. A. Marks, Artificial Linibs, New Yorh City.

The greatest demand, however, is for the lightest leg, consistent with strength.

For light, delicate women, weighing less than a hundred pounds, a full-length leg weighing three pounds without attachments is as light as it is prudent to produce. So light a leg with ample sus- taining strength is almost a marvel. "We know of nothing calcu- lated to withstand equivalent strains that weighs so little. A leg weighing six pounds for a large, heavy person, who is likely to subject it to severe use, is not excessive, and should not be objected to.

Let us think, for a moment, of the weight of other instruments that are made to stand similar strains. The weight of the bicy- cle has been reduced from sixty to nineteen pounds, and it is generally conceded that a nineteen-pound bicycle is as light as prudence will allow. Persons marvel at a bicycle weighing so little, yet the nineteen-pound bicycle has no more work to perform and is not subjected to any more strains than an artificial leg weighing from three to six pounds. The bicycle, like the leg, has only to support the weight of the rider and resist such strains as may occasionally be brought upon it.

In constructing a leg it is essential to make it strong enough to sustain the weight of the wearer and not break under such sudden strains as it is likely to receive at times. If one slips and recovers himself with his artificial leg, some part receives a strain that is much greater than the weight of the wearer. In ascending or descending stairs the strains on the leg are greater than in walking. A leg should be made strong enough to meet these demands, and, in addition, must have a margin of strength that will enable the wearer to carry such articles and lift such weights as his vocation requires. No matter how crippled one may be, or what his station in life is, nor how delicate, there will be times when he will thoughtlessly lift, carry, push, or pull some weighty object. Should the leg break under any of these condi- tions, the maker would unquestionably be severely censured.

It is not wise to build an artificial leg so close to the danger line, especially for delicate persons, that when those persons become healthier, stronger, and heavier the leg will break. Condi- tions do not remain the same. " The weak of to-day are the strong of to-morrow." The light person frequently becomes heavy, and the careful limb maker, if he guards his reputation, wiU keep well on the side of safety.

The average weight of a substantial artificial leg, suitable for a thigh amputation, worn by a man weighing one hundred and fifty pounds, engaged in an ordinary occupation, may be placed at five pounds, less for a below-knee or foot amputation.

It is possible to localize the weight of a leg weighing six pounds so that it will feel lighter than one weighing half as much, improperly adjusted. Inadeqxiate means of attaching the leg to the body will make it feel heavy. A heavy lower part, with a light thigh piece, produces an apparently heavy leg, because

A. A. Marks, Artificial Limbs, New Yorh City. 143

the weight is distant from the stump and the frail thigh piece does not hold it in place securely. On the other hand, a strong, substantial thigh piece, which properly holds the leg in place, will lessen the apparent weight considerably.

Odor. — The contention that rubber emits a disagreeable odor is untrue. Sponge rubber has no more odor than wood; moreover, the rubber foot is incased with an air-tight material. Even if the rubber had a disagreeable odor — which it has not — it would not be possible for it to escape. On the other hand, the ankle joints of articulating feet have to be oiled very frequently, and the oil in time becomes rancid. No refined person can possibly tolerate such an odor.

Temperature. — The rubber foot will not alter its consistency on account of changes in temperature. Properly vulcanized rubber, such as is used in the manufacture of our rubber feet, will not lose its elasticity in any temperature the human body is capable of enduring. It requires 280 degrees of heat (Fahrenheit) to produce a change in rubber, and as there is no habitable place on the earth with a temperature half of that, the rubber foot is never in danger from heat; no human being could live in a tem- perature intense enough to harden pure rubber.

The Mass of Limb Wearers are of Small Means. — The greater number of wearers of artificial limbs are in limited circumstances. It is exceptional to find a wealthy person in need of one. The wage-earner, the laborer, the man who works in the mill, the engi- neer, fireman, brakeman, or the miner, the private in the army, those whose occupations place them in jeopardy and who are exposed to the dangers that destroy life or mutilate the body, these make the greatest number of limb wearers. This being so, it is the more important that artificial limbs should be durable and as inexpen- sive to wear as possible. The first cost, the purchase of the limb, should be the only important item to be provided for. An arti- ficial leg constructed with delicate machinery, or parts subject to friction, may be attractive to look at, but is ill-suited to the wants of the man who has to support himself and his family by daily toil. The loss of time in having repairs made, the cost of repairs, and the danger of breaking down at critical times, are serious matters, and the careful man will take them into con- sideration before making his selection.

We do not know an artificial leg with an ankle joint that is now made, that has ever been made, or, perhaps, ever will be made, that will not cost from five to twenty-five dollars a year to keep in repair. The delicacy with which an ankle joint must be con- structed in order to be light and small enough for its narrow limits, and the immense strain that it must resist at times, are conditions incompatible with durable mechanism.

The fact that persons walk, run, and perform all kinds of labor on artificial legs with rubber feet without ankle motion is evi- dence that the ankle mechanism is unnecessary. Men, women, and children with rubber feet run, walk, skate, and dance. Work,

144 A. A. Maries, Artificial Linibs, New York City.

regarded not many years ago as impossible, is now being daily performed with facility. The farmer follows his plow on a rubber foot, the blacksmith works at his forge, the sailor climbs his rigging, the builder erects houses, and persons of every voca- tion attend to their affairs with as little concern and hindrance, operating on one or a pair of our rubber feet, accomplishing as much as their associates who are in possession of all their natural limbs.

How Long Will a Leg Last? — The question is frequently asked, " Plow long will an artificial leg last ? " There is but one reply : it depends upon the care the leg receives. We have patrons who are still wearing artificial legs that were made for them twenty-five years ago, and the legs still appear to be in fair con- dition. These are exceptional cases and should not be referred to, any more than should the experiences of those who, through abuse and carelessness, destroy their artificial limbs in an unex- pectedly short time. An average made of the frequency -vt^ith which our patrons renew their substitutes, fixes the period at about eight years. This does not imply that a leg will not last longer. Necessity by no means occasions all renewals; wearers want new legs much the same as they want new coats, before the old ones are completely gone. Wearers become as proud of their artificial limbs as they do of articles of apparel; those financially able frequently supply themselves with several, so as to have u reserve for emergencies. Accidents are as likely to occur to the substitute as to the real ones. Men have been run over by vehicles and have had their artificial legs crushed instead of their natural ones. When accidents of this kind occur, the limbs must be sent to the manufacturer for repairs. The wearer who is fortunate enough to have a duplicate which he can put on is at a great advantage. Taking all these facts into consideration, and fixing the average life of an artificial leg at eight years is certainly estimating on a fair basis.

Shoes and Stockings. — ^AU artificial feet should be dressed with stockings and shoes, as are natural ones. The wear and tear on shoes and stockings, when the feet articulate at the ankles, are enormous and have been a source of complaint. This annoyance is removed by the use of rubber feet, for shoes on rubber feet look and wear like those worn on the natural, as the wrinkling at the toes and other parts is nearly identical in both. We have heard patrons say that in five years their rubber feet have saved them in the cost of stockings and shoes enough to buy a new leg.

How Soon after Amputation Should an Artificial Leg be Applied? — As soon as the stump is thoroughly healed and the patient has regained sufficient strength to go about on crutches, it is time for him to consider the matter of procuring an artificial leg. Before procuring one some attention should be given to the preparation of the stump.

Treatment of Stumps. — Tight bandages should be worn from

A. A. Mar/cs, Artificial .Limbs, New YorJc City. 145

the moment