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angle. By releasing screw A which controls the springs, the plunger is allowed to move backward and forward, allowing about 10° motion, but not beyond the limit set by the screw B. Pronation and supination are not possible in this type of

A

B

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FIG. 154.-Artificial arm in which a limited amount of springy motion can take place at the elbow by adjusting the screws A and B. (Model of Biesalski.)

arm except by rotating the tool which is inserted into the hollow barrel corresponding to the forearm.

Two types of working arm have been constructed after the pattern of the ball-and-socket joint devised by the young carpenter's apprentice already mentioned. To render the fixation at the elbow firmer, a screw is attached to the elbow

articulation which locks the upper and lower arm against the spherical surface of the intervening steel ball (see Fig. 155). Although these two arms are capable of withstanding great strain, they are not, so far as I have been able to judge, as advantageous as that pictured in Fig. 152, because the tool is not brought into sufficiently intimate contact with the stump.

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FIG. 155.-A working arm designed for amputations above the elbow (Rota arm). The joint at the elbow is so constructed that not only flexion and extension but pro- and supination are made possible. The portion corresponding to the lower arm consists of a tube into which tools of various kinds can be inserted. It can be fixed in any desired position by a turn of the screw just above the elbow joint.

As a rule, with practically no exceptions, the nearer the stump can be brought to the instrument which it is to control, the more effective is the amputated's use of the implement.

The Carnes arm already described in speaking of amputations of the forearm, is also applicable to amputations of the upper arm. The motor power is then derived by the movements of the shoulders (see Figs. 156, 157 and 158). The difficulty in learning to use the arm is increased when the amputation lies above the elbow, nor is it particularly well

suited to the use of the artisan. For æsthetic purposes, however, it is the most ingenious device of which I know.

The shorter the upper arm stump, the more difficult the attachment of the prosthesis, and the more difficult it is to

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FIG. 156. A case of double amputation, on the right side through the elbow, on the left 4 inches below the shoulder. In a case of this kind, unlike that pictured in Fig. 171, an artificial limb is necessary, since the two stumps cannot be approximated. The Carnes artificial arms are seen lying on the table. The patient can put these on without assistance and is then able to eat alone, dress, shave and use many tools. (See also Fig. 157.)

render the stump capable of doing its fair share of work. As a rule it is almost impossible to train a patient with a stump less than 4 inches long to be an independent farmer or artisan. An exception is pictured in Fig. 163. Despite

the short stump, this young boy was able to work skillfully in the machine shop (see Figs. 159 et seq.). The prosthesis shows the excellent shoulder device designed by Riedinger. As a rule the patient with the short upper arm stump can be made capable of doing lighter garden work (see Figs. 164 et seq.), or in suitable instances, he can be trained to work at a

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FIG. 157. The Carnes artificial arm for the patient shown in Fig. 156.

factory machine. For this latter purpose close coöperation is necessary between physician, machinist, and the manager of the factory.

Even when the entire arm has been disarticulated at the shoulder, a prosthesis can be applied with distinct benefit to the wearer. The artificial limb is controlled by the swing of the body, and enables the amputated to wield a broom, rake, etc. In these cases as well as in the higher amputations

of the upper arm, the simple device shown in Fig. 164 has proven most serviceable. It consists of a round piece of wood resembling a spool, with a strap passing over it fixed on the one side, ending in a catch on the other side, similar to that frequently used on ice or roller skates. The handle of the implement, spade, rake, wheelbarrow, etc., is fastened between the strap and the spool. There is sufficient fixation. for all purposes, and at the same time enough latitude of motion to allow the wheelbarrow to be tipped, or the angle of the rake to be changed.

The Life of the Amputated.-Care of the stump and the application of the artificial limb constitute only two of the numerous problems which confront the physician in the care of the amputated. Particularly in the case of those who have lost a hand, the entire mode of life must be modified. Nothing can be done as it was previously done, and the simplest actions of everyday life must be relearned. First, the amputated must be taught to dress and undress with one hand. The question of washing gave me considerable trouble, since the amputated were unable properly to cleanse the fingers and hand of the sound arm. The simple device pictured in Fig. 167, a board fitting over the wash basin, to which scrubbing brush and nail file could be attached, solved the problem. Lacing the shoes was another difficulty. Here I was aided by one of the amputated boys of the crippled children's hospital with which I was associated. He used a single, long lace, on the same principle as that employed in lacing a whipstock. One end was firmly attached to the lowermost eyelet of the shoe. The other end was then passed through the eyelets in the usual way, and then, allowing a loop long enough to be zigzagged between the hooks, was passed beneath the lacings back to the starting point. The loop was then caught zigzag from one hook to another, and the slack taken in by a vigorous pull on the end of the lacing projecting beyond the first eyelet.

In eating, the only difficulty was occasioned by the need of cutting and using the fork with the same hand. For this purpose a number of devices are on the market. These consist of a knife-blade terminating in a fork-like projection

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