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tunnel is bored through the muscle belly (in this instance the biceps) and widened sufficiently to admit the skin flap which has been sutured to form an epithelial lined tube (Fig. 128). A simple skin plastic completes the operation (Figs. 129 and 130). The canal is kept patent by means of a rubber drainage tube or ivory peg, and as soon as possible active exercise of the muscle (see Fig. 130) begun.

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Fig. 127.—The Sauerbruch method of producing a kinetic stump. First step of operation. A tunnel has been bored through the biceps muscle. A skin flap has been freed and is being sewed about a piece of rubber tubing with the epithelial surface turned inward.

Excellent though the operative results are, the practical benefit to the patient has thus far been slight, owing to the difficulty in constructing a prosthesis capable of utilizing the muscular force placed at its disposal. If this mechanical problem can be solved, the Sauerbruch procedure will constitute an important advance in our methods of treating the amputated.

Although Sauerbruch has, so far as I know, confined his operations to the upper extremity, its field of usefulness might well be extended to amputations of the thigh. Here voluntary control of the artificial limb by means of the quadriceps extensor, would be of great assistance to the patient, particularly to one whose work called for walking over uneven ground, hill climbing, and ascending or descending steps.

The Education of the Stump.—Even before the wound has healed, the physician must begin treating the stump with a

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Fig. 128.—The Sauerbruch method of producing a kinetic stump. Second step of operation. The epithelial-lined tube is being drawn through the channel in the muscle.

view to developing its function. The muscles should be massaged and the patient should be encouraged to move the limb. As soon as the wound has healed, more vigorous measures can be adopted. The stump should then be bathed daily with cold water, and in addition to the massage, graduated

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Fig. 129.—The Sauerbruch method of producing a kinetic stump. Third step of the operation. The sutures are being taken to unite the edges of the skin flap to the skin of the arm near the point of emergence from the muscular channel.

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Fig. 130.—The Sauerbruch method of producing a kinetic stump. Fourth step of operation. The operation is completed by uniting the skin edges as shown in the illustration. The canal is kept patent by running a piece of rubber tubing or an ivory peg through it.

exercises should be performed. These consist of simple movements—flexion, extension, abduction, adduction and rotation-against the resistance of a weight running over a pulley, or of the hand of a trained masseur. Bandaging the stump firmly helps remove fat and reduce the ædema. To

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Fig. 131.—The Sauerbruch method of producing a kinetic stump. The after-treatment. To exercise the muscle through which the channel has been bored, the ivory peg running through it is attached to a pendulum apparatus. The patient can by a voluntary contraction of the muscle cause the ivory peg to move upward and thus move the lever of the apparatus. By regulating the length of the pendulum the exercises can be graduated to meet the increasing muscular power of the patient.

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assist in the hardening process, leading to weight-bearing function, the patient should learn to rest the end of the stump against a chair or stool of suitable height. At first the chair is thickly padded; gradually the padding is removed, until the patient is able to bear his weight on the bare wood. He then begins to hammer with the end of the stump against the support, since a certain amount of this pounding motion is incidental to walking with the artificial limb. This treatment should, of course, be carefully graduated, otherwise the stump tends to become irritated instead of hardened.

Some authors have laid great emphasis on forming a deep circular furrow in the stump. This furrow serves for the attachment of the socket of the artificial limb, and does in some instances undoubtedly add to theļstability of the prosthesis. I have found that with rare exceptions, however, the method is not of particular value. The exception consists of those instances of short stumps of the calf (about 3 inches long) which it is difficult to grasp firmly with the artificial limb. In these cases, a furrow is of distinct assistance. The Esmarch bandage, or better still, a strong piece of rubber tubing about 38 inch in diameter, is applied to the stump under as much pressure as the patient can stand, and kept in place for an increasing length of time with each application. After several days the patient is usually able to stand the pressure for several hours. Within two weeks, a distinct furrow can be developed.

The greatest educator of the stump is the artificial limb itself. Therefore, it should be applied as soon as possible. The use of a crutch for the amputated is an indication of inadequate treatment. The early use of an artificial limb presents one great difficulty: the stump is still swollen, a large amount of fatty tissue is still present, and the muscles are usually flabby. With time, the stump changes its shape so markedly that the artificial limb, which fitted accurately when first applied, is no longer suitable. If this has been made of leather or wood, great expense has been involved, and the value of early training of the stump seems to be outbalanced by the economic waste of time and material involved in the construction of an artificial limb whose period of usefulness is so short-lived. Owing to this difficulty, the provisional or temporary prosthesis has been evolved. The evolution of these provisional limbs has been most interesting. At first they were constructed in the crudest way of a broom-stick or a piece of bamboo incorporated in a plaster shell fitting the patient's stump (see Fig. 132). Later, an iron framework was substituted for the

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