Artificial Limbs

Part 1

MILITARY MEDICAL MANUALS

GENERAL EDITOR:

SIR ALFRED KEOGH, G.C.B., M.D., F.R.C.P.

ARTIFICIAL LIMBS

ARTIFICIAL LIMBS

A. BROCA

Professor of Topographical Anatomy to the Faculty of Paris

AND

DUCROQUET

Orthopædic Surgeon to the Rothschild Hospital

TRANSLATED AND EDITED BY

R. C. ELMSLIE, M.S., F.R.C.S.

Major R.A.M.C.(T.F.) Orthopædic Surgeon to St. Bartholomew's Hospital, Surgeon to Queen Mary's Hospital, Roehampton

WITH 208 ILLUSTRATIONS

UNIVERSITY OF LONDON PRESS, LTD. 18 WARWICK SQUARE, LONDON, E.C. 4.

PARIS: MASSON ET CIE 120 BOULEVARD SAINT-GERMAIN

1918

GENERAL INTRODUCTION

The infinite variety of injuries which any war presents to the surgeon gives to military surgery a special interest and importance. The special interest and importance, in a surgical sense, of the great European War lies not so much in the fact that examples of every form of gross lesion of organs and limbs have been seen, for if we read the older writers we find little in the moderns that is new in this respect, but is to be found in the enormous mass of clinical material which has been presented to us and in the production of evidence sufficient to eliminate sources of error in determining important conclusions. For the first time also in any campaign the labours of the surgeon and the physician have had the aid of the bacteriologist, the pathologist, the physiologist and indeed of every form of scientific assistance in the solution of their respective problems. The clinician entered upon the great war armed with all the resources which the advances of fifty years had made available. If the surgical problems of modern war can be said not to differ sensibly from the campaigns of the past, the form in which they have been presented is certainly as different as are the methods of their solution. The achievements in the field of discovery of the chemist, the physicist and the biologist have given the military surgeon an advantage in diagnosis and treatment which was denied to his predecessors, and we are able to measure the effects of these advantages when we come to appraise the results which have been attained.

But although we may admit the general truth of these statements it would be wrong to assume that modern scientific knowledge was, on the outbreak of the war, immediately useful to those to whom the wounded were to be confided. Fixed principles existed in all the sciences auxiliary to the work of the surgeon, but our scientific resources were not immediately available at the outset of the great campaign; scientific work bearing on wound problems had not been arranged in a manner adapted to the requirements, indeed the requirements were not fully foreseen; the workers in the various fields were isolated, or isolated themselves pursuing new researches rather than concentrating their powerful forces upon the one great quest.

However brilliant the triumphs of surgery may be, and that they have been of surpassing splendour no one will be found to deny, experiences of the war have already produced a mass of facts sufficient to suggest the complete remodelling of our methods of education and research.

The series of manuals, which it is my pleasant duty to introduce to English readers, consists of translations of the principal volumes of the "Horizon" Collection which has been appropriately named after the uniform of the French soldier.

The authors, who are well-known specialists in the subjects which they represent, have given a concise but eminently readable account of the recent acquisitions to the medicine and surgery of war which had hitherto been disseminated in periodical literature.

No higher praise can be given to the Editors than to say that the clearness of exposition characteristic of the French original has not been lost in the rendering into English.

MEDICAL SERIES

The medical volumes which have been translated for this series may be divided into two main groups, the first dealing with certain epidemic diseases including syphilis, which are most liable to attack soldiers, and the second with various aspects of the neurology of war. The last word on Typhoid Fever, hitherto "the greatest scourge of armies in time of war," as it has been truly called, will be found in the monograph by MM. Vincent and Muratet which contains a full account of recent progress in bacteriology and epidemiology as well as the clinical features of typhoid and paratyphoid fevers. The writers combat a belief in the comparatively harmless nature of paratyphoid and state that in the present war hæmorrhage and perforation have been as frequent in paratyphoid as in typhoid fever. In their chapter on diagnosis they show that the serum test is of no value in the case of those who have undergone anti-typhoid or anti-paratyphoid vaccination and that precise information can be gained by blood cultures only. The relative advantages of a restricted and liberal diet are discussed in the chapter on treatment, which also contains a description of serum-therapy and vaccine-therapy and the general management of the patient.

Considerable space is devoted to the important question of the carrier of infection. A special chapter is devoted to the prophylaxis of typhoid fever in the army. The work concludes with a chapter on preventive inoculation in which its value is conclusively proved by the statistics of all countries in which it has been employed.

MM. Vincent and Muratet have also contributed to the series a work on Dysentery, Cholera and Typhus which will be of special interest to those whose duties take them to the Eastern Mediterranean or Mesopotamia. The carrier problem in relation to dysentery and cholera is fully discussed, and special stress is laid on the epidemiological importance of mild or abortive cases of these two diseases.

Part 2

In their monograph on The Abnormal Forms of Tetanus, MM. Courtois-Suffit and Giroux treat of those varieties of the disease in which the spasm is confined to a limited group of muscles, e. g. those of the head, or one or more limbs, or of the abdomino-thoracic muscles. The constitutional symptoms are less severe than in the generalised form of the disease, and the prognosis is more favourable.

The volume by Dr. G. Thilbierge on Syphilis in the Army is intended as a vade-mecum for medical officers in the army.

Turning now to works of neurological interest we have two volumes dealing with lesions of the peripheral nerves by Mme. Atanassio Benisty, who has been for several years assistant to Professor Pierre Marie at La Salpêtrière. The first volume contains an account of the anatomy and physiology of the peripheral nerves, together with the symptomatology of their lesions. The second volume is devoted to the prognosis and treatment of nerve lesions.

The monograph of MM. Babinski and Froment on Hysteria or Pithiatism and Nervous Disorders of a Reflex Character next claims attention. In the first part the old conception of hysteria, especially as it was built up by Charcot, is set forth, and is followed by a description of the modern conception of hysteria due to Babinski, who has suggested the substitution of the term "Pithiatism," i. e. a state curable by persuasion, for the old name hysteria. The second part deals with nervous disorders of a reflex character, consisting of contractures or paralysis following traumatism, which are frequently found in the neurology of war, and a variety of minor symptoms, such as muscular atrophy, exaggeration of the tendon reflexes, vasomotor, thermal and secretory changes, etc. An important section discusses the future of such men, especially as regards their disposal by medical boards.

An instructive companion volume to the above is to be found in the monograph of MM. Roussy and Lhermitte, which embodies a description of the psychoneuroses met with in war, starting with elementary motor disorders and concluding with the most complex represented by pure psychoses.

SURGICAL SERIES

When the present war began, surgeons, under the influence of the immortal work of Lister, had for more than a quarter of a century concerned themselves almost exclusively with elaborations of technique designed to shorten the time occupied in or to improve the results obtained by the many complex operations that the genius of Lister had rendered possible. The good behaviour of the wound was taken for granted whenever it was made, as it nearly always was, through unbroken skin, and hence the study of the treatment of wounds had become largely restricted to the study of the aseptic variety. Septic wounds were rarely seen, and antiseptic surgery had been almost forgotten. Very few of those who were called upon to treat the wounded in the early autumn of 1914 were familiar with the treatment of grossly septic compound fractures and wounded joints, and none had any wide experience. To these men the conditions of the wounds came as a sinister and disheartening revelation. They were suddenly confronted with a state of affairs, as far as the physical conditions in the wounds were concerned, for which it was necessary to go back a hundred years or more to find a parallel.

Hence the early period of the war was one of earnest search after the correct principles that should be applied to the removal of the unusual difficulties with which surgeons and physicians were faced. It was necessary to discover where and why the treatment that sufficed for affections among the civil population failed when it was applied to military casualties, and then to originate adequate measures for the relief of the latter. For many reasons this was a slow and laborious process, in spite of the multitude of workers and the wealth of scientific resources at their disposal. The ruthlessness of war must necessarily hamper the work of the medical scientist in almost every direction except in that of providing him with an abundance of material upon which to work. It limits the opportunity for deliberate critical observation and comparison that is so essential to the formation of an accurate estimation of values; it often compels work to be done under such high pressure and such unfavourable conditions that it becomes of little value for educative purposes. In all the armies, and on all the fronts, the pressure caused by the unprecedented number of casualties has necessitated rapid evacuation from the front along lines of communication, often of enormous length, and this means the transfer of cases through many hands, with its consequent division of responsibility, loss of continuity of treatment, and absence of prolonged observation by any one individual.

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