War Surgery and Medicine
Second World War
At the beginning of the Second World War the experience in Britain had led to an evaluation of the different types and sites of amputation stumps and to the development of artificial limbs to fit them. At Roehampton, the heart of the British administration, there were surgeons with great experience in this matter, and also limb-fitting surgeons who had concentrated on the actual fitting of the artificial limb and did no surgery. The limbs themselves were made by private firms with factories clustered round the hospital, which was itself under the control of the Ministry of Pensions. Roehampton completely dominated the amputation and limb-fitting activities in Britain and accumulated a mass of experience, and we owe practically all our advances in knowledge to the men working there. They had found the long stump, particularly in the leg, very unsatisfactory. Circulatory changes were marked in the legs with frequent ulceration. Syme amputation had not stood the test of time and the large majority had had to be re-amputated. End-bearing stumps generally had also not stood up to the work.
The surgeons at Roehampton had laid down sites of election for all the different amputations as a definite guide to all surgeons at the beginning of the war. The below-knee site was five and a half inches below the joint line, and in the thigh it was from ten to twelve inches below the top of the great trochanter. In the forearm the site was seven inches below the tip of the olecranon and in the upper arm eight inches below the acromion process. These sites were well known to surgeons and had been freely accepted. It will be seen that the below-knee stump was shorter than it had been during the First World War, and that the thigh stump was now well above the knee, instead of being either an end-bearing Stokes Gritti, or transcondylar, as was common during the First War. The arm amputations were placed well above the joints so as to give room for the joint movement of the artificial limb.
A memorandum was issued by the Medical Research Council War Wounds Committee on Emergency Amputations in 1941, and this gives the general opinion at that time. It pointed out that the main indication for an emergency amputation was the irreparable interference with the blood supply. Occasionally when the injuries were grave, and the results of reconstructive surgery could not be better than those of amputation, and the patient possibly had to risk grave illness from infection, amputation might be justified; but, in general, the only justification was the imminence of gangrene from the destruction of the main vessels.
The memorandum pointed out that the surgeon who performed an amputation for severe local injury alone assumed a grave page 306 responsibility, and recommended that in these cases a second opinion should be sought. This is a clear and admirable presentation of the case.
The technique recommended was to complete a traumatic amputation by severing the remaining strands and excising portions of badly lacerated muscle. In less severe cases a guillotine amputation was advised, at the site of injury, preserving the maximum amount of bone. A secondary formal amputation was envisaged later.
In the ordinary case, especially in the first six to eight hours after injury, ‘the safe period’, a formal amputation at the site of election, with the skin flaps sutured in the normal manner and with drainage when necessary for twenty-four hours, was advised. It was recommended that the nerves should be simply cut as they lay in the wound, as the more elaborate treatment had proved unsatisfactory and useless.
If the wound was well below the site of election, a site-of-election flap operation with immediate suture might be safe, even with a greater time lag than six to eight hours, but that the risk of infection increased with every hour's delay, and primary suture might be dangerous particularly in the event of early evacuation. If the time lag was somewhat longer, a flap amputation was recommended with delayed skin suture, the sutures being inserted but not tied for two to ten days.
For later amputation the indications given were gangrene due to vascular thrombosis, massive gas gangrene, and danger to life from spreading infection or severe secondary haemorrhage. Warning was given that in these cases infection was almost inevitable and flap amputation with primary skin suture was unsafe and might be disastrous. The technique advised in cases where amputation could be done well below the site of election was either a guillotine or circular flapless amputation, or a flap amputation with flaps left wide open. (The Committee preferred the guillotine or circular amputation.) In cases where the amputations had to be at, or close to, the site of election either flap amputation with traction and secondary suture of skin flaps was recommended, or, if there was no viable skin below the level, a guillotine amputation with continued skin traction till the wound was healed. A strict guillotine was seldom necessary, and generally some sort of flaps could be cut.
It was pointed out that experienced surgeons did not perform true guillotine amputations but cut the tissues at different levels. The object of this type of operation was to save life in severe page 307 infections by rapid operation, leaving ample drainage and conserving lengths of stumps. A definitive amputation would be planned later. Warning was given against a guillotine operation at the site of election as it involved the sacrifice of too much skin and gave no room for re-amputation. Attention was drawn to the absolute necessity for skin traction within twenty-four to forty-eight hours of operation. Infrequent dressings were recommended and re-amputation was best deferred till all risk of sepsis was over and all oedema had disappeared. If treated by continued skin traction, a guillotine amputation gave a satisfactory stump, as proved by twenty years of experience at Roehampton. The Committee suggested that guillotine amputations might be used in desperate cases; in crush injuries; for severe infection or gangrene as a temporary measure; at the site of election to preserve the maximum of skin. However, flap amputations were preferred at or above the site of election when skin was available.
In summary, the Committee said that a second opinion should be sought before amputation of a limb was performed for the treatment of war wounds; and the type of amputation suited to a particular case depended upon (a) the time which has elapsed since injury; (b) the level at which amputation was indicated; (c) the general condition of the patient.
The memorandum was of great importance as it gave the lead, with great authority, to war surgeons in the early part of the war. In spite of the fact that the members of the sub-committee were largely men of very considerable experience in the First World War, the recommendations were largely influenced by the experience of civil surgery between the wars. Advice was given to perform site-of-election amputations with suture up to eight hours, and with delayed primary suture up to twenty-four hours.
Our own New Zealand experiences of amputations in the Second World War commenced in Greece and Crete, but our experience was limited and the majority of the cases did not reach Egypt. In Crete Major Christie recounts having performed several amputations of arm and leg. The usual indication was gross destruction of the bone and joint below the site of amputation. In some doubtful cases of vascular injury operation was delayed in the hope of a collateral circulation developing. No guillotine amputations were done, short anterior and posterior flaps being used. The site of election was used and, whilst the ends of the wound were sutured, the central part was left open for drainage. No tubes were used. Main vessels were double-ligated, nerves were page 308 neither cut short, pulled upon, crushed, ligated, nor injected. A tourniquet was used in the lower limbs, but digital compression in the upper. It will be seen that Major Christie, an orthopaedic surgeon, was using the site of election but not sewing up the wound completely.
During the second Libyan campaign many amputations were performed, both in the forward areas and at the Base. They were demanded by the severity of the injury and also by severe sepsis, and in some cases by severe secondary haemorrhage. Gangrene following vascular injury also necessitated amputation in several cases at the Base. Unfortunately in some patients the arm had had to be sacrificed in the treatment of secondary haemorrhage, and this caused much concern. Site-of-election amputations with primary suture were carried out and these all proved unsatisfactory. In very many cases the bone was protruding markedly through a septic wound. Skin traction had been largely neglected. Stumps with skin flaps stitched back had generally remained healthy. It seemed clear at that time that amputation should be carried out as low as possible and the wound left open as sepsis was to be expected.
Surgical Conference, Cairo, 1942
The results gave much concern, and a discussion on amputations was made a feature of the surgical conference held in Cairo in February 1942, when the New Zealand consultant surgeon was asked to read a paper on the subject. He reviewed the cases admitted to the New Zealand base hospitals, a total of 47, 27 being immediate amputations in the forward areas and 20 secondary at the Base. All the immediate amputations were done for gross damage to the limbs and a conservative attitude had been adopted, as was shown by amputation at the Base of seriously injured limbs given a chance of survival in the forward areas.
Of the 20 secondary amputations alone, 7 were through the upper arm, 1 was through the forearm, 6 were through the thigh, 2 were through the knee, 4 were through the leg.
The indications for secondary amputation were seen to be:
Damage to main vessels causing gangrene of the limb.
Infection: (a) gas gangrene, (b) life-endangering infection, especially that involving the knee joint.
Hopelessness of outlook for function of the limb, especially infected tarsal injuries.
Secondary haemorrhage, especially combined with severe sepsis.
Amputation for cases of gangrene was inevitable, but in dry gangrene operation was best delayed as long as possible unless sepsis intervened or the patient was in distress from pain or absorption. It was considered that greater risks in cases of infection should be taken in arm cases as the arm was incomparably more precious and absorption much less marked than in the lower limb, so that every means short of amputation had to be taken to combat sepsis.
Infection of the knee joint, especially if associated with bone injury, had necessitated amputations. Serious injuries to the foot involving skin and tarsus, with a hopeless outlook as regards eventual function and a probability of prolonged illness, were considered to warrant amputation. The performance of amputation for secondary haemorrhage was deprecated, especially in relation to the arm, and a plea made for closer observation and earlier operation in these cases with ligature of the bleeding vessel in the wound in preference to proximal ligation.
A circular type of amputation was suggested for temporary amputations, planned so as to save the maximum length of limb, especially in the leg and also in cases where in short stumps there was insufficient skin available to form flaps, and where skin traction would be required. When ample skin was available, flaps were recommended, especially if at the site of election. Nerves were simply cut across in the wound and the wound left open. In cases wherein sepsis was unlikely to arise, stitches could be inserted ready for suture in a week to ten days. Strapping extension was advised in all circular amputations after twenty-four hours. The maximum length available was recommended for primary amputation, especially in the lower limb. Amputation through the knee joint had been of value as a temporary measure in severely shocked cases. Stress was laid on the inadvisability of performing site-of-election amputation in the lower limb and preservation of the maximum length, the site-of-election amputation to be reserved for a secondary operation.
The certainty of infection under war conditions was stressed, as well as the disaster which had followed when infection had occurred. In late amputations for gangrene or infection it was still more important not to do site-of-election operations. Nine out of fifteen below-knee amputations required re-amputation, some following flap amputations.
An illustrative case was quoted. He had an amputation of both legs. His first amputation was performed the day after his wounding and was at the site of election. The flaps were completely sutured. Later the stump became grossly infected, the sutures were removed, free pus discharging. Then the end of the tibia page 310 protruded through the skin to the extent of an inch and re-amputation was required later. His amputation of the other leg, necessitated by severe sepsis in a badly shattered tarsus, was performed by guillotine operation three inches above the ankle, definitely as a temporary procedure to safeguard an aseptic amputation higher up at a later period.
In the after treatment skin traction was all-important, and its neglect had led to the pathetic sight of stumps with retracted skin and protruding bone. Spread of infection, especially posterior-ally in thigh amputations, had occurred, necessitating drainage. Secondary haemorrhage had been fairly frequent.
It was recommended:
Never remove a viable limb unless you are certain that a functioning limb will not result even in the distant future. Prefer loss of limb to loss of life. Amputate as low as possible, expecting sepsis to occur, and forget about the site of election except as a guide to the necessity of preserving at all costs the limb down to that level.
Remember that even under the best treatment and care re-amputation may be necessary and your site of election thereby hopelessly destroyed. Closing the wound is an invitation to infection which invariably occurs. If you spare the extension you spoil the stump. (Failure to recognise an infected knee joint may lose joint or limb.) In secondary haemorrhage if you neglect the warning stain of blood you may lose the limb. Go in early and tie the bleeding vessel before collapse makes amputation the easiest way out. Re-amputate only when the infection is quite forgotten and the patient's general condition completely recovered. No possible necessity for hurry exists and a further septic stump would be a disaster for which the surgeon is necessarily responsible.
‘I need not refer to the disability that so often arises in healed septic stumps, and to the frequent remodelling necessary, to stress the advantage of carefully planned deliberate secondary amputations.’
This paper provoked, as was intended, spirited discussion. The forward surgeons, especially the able surgeons attached to 62 General Hospital in Tobruk, strongly combated the criticism of performing site-of-election amputations in the forward areas, and claimed that their results were very good and fully justified the procedure. An appeal was made to the large audience, which contained representatives of probably all the base hospitals, to testify that the cases had done and were doing well. This appeal brought forth not a single supporter, but surgeon followed surgeon describing the serious condition of the stumps, the constant presence of sepsis, broken-down wounds, and protruding bone.
The discussion revealed a general consensus of opinion on matters of most importance, with some differences in details. There was page 311 agreement that nearly all stumps were septic on arrival at the Base and many showed protruding bone. It was agreed that the maximum skin and bone should be preserved and no site-of-election operations performed. Flaps were generally preferred, either stitched back or with stitches inserted for tying later. Greater risks were advised in infected cases in the preservation of the arm. Skin traction was agreed upon. In secondary haemorrhage ligature in the wound was preferred, but proximal ligature was held to be often necessary and amputation called for in desperate cases with severe local injury.
As a direct result of this discussion Army directions were issued to the effect that site-of-election amputations were not to be performed either as emergency or secondary operations. The fashioning of flaps was generally recommended. Traction was strongly advised, especially to circular amputations. The tying of the vessel at the bleeding site was also recommended whenever possible in secondary haemorrhage, and amputation was deprecated, especially in arm cases.
In the pre-Alamein fighting the New Zealand Division suffered many casualties, and amputations, some for gas gangrene, were fairly numerous. The wounds generally were clean and traction more satisfactorily applied. Light suturing over vaseline or tulle gras rolls had become the common type of dressing and, provided the tissues were healthy, gave good results. In incompletely excised traumatic amputations, however, the results were poor. Secondary sutures at about the tenth day were being carried out at the Base with success.
After the Alamein battle, 23 October to 3 November 1942, it was observed that the forward units had been conservative as regards amputation, and especially so in the badly damaged feet resulting from mine injuries which were very common at that time. (Many of the feet had to be amputated at the base hospitals.) The maximum of healthy tissue was retained and skin flaps were usually employed, loosely stitched over a vaseline pad. The necessity for thorough excision, or higher amputation, of the traumatic amputation stumps was being realised. Serious sepsis had so often developed if this had not been done. The traumatic amputation was ever afterwards regarded as a dangerous injury both as regards infection and toxaemia.
North African Review
In July 1943 it was reported by Colonel Fouche, consultant orthopaedic surgeon from South Africa, that all patients with septic page 312 compound fractures of the os calcis and tarsus transferred from the Middle East to South Africa had had to hive amputation performed. In the majority of infected fractures of the lower third of the tibia, amputation had also been carried out because of the chronicity of the bone infection and the involvement of the ankle joint. He stated that' once osteomyelitis, always osteomyelitis'. The question was discussed at a surgical conference held in Cairo at that time, and there was general agreement that amputation was generally advisable for septic injuries of the tarsus. Otherwise many of these patients with very prolonged and severe sepsis suffered, as a result, serious damage to general vitality, and probable shortening of life. Often their lives were endangered for a limb that was ultimately severely disabled. Lives had been lost in the vain endeavour to save a questionable limb.
With regard to amputations for septic fractures of the lower third of the tibia there was not the same agreement, though it was recognised that amputations might often be necessary in these cases.
The presentation of the South African view was very valuable and it produced much discussion afterwards. The considered view of our New Zealand surgeons was that many more of the mine injuries of the foot should be amputated in the forward areas, but that, we did not agree with the pessimistic attitude towards fractures of the leg or towards osteomyelitis, and that we should still continue to treat all the cases conservatively and only do secondary amputations when the life of the individual was endangered. Subsequent experience fortunately proved that our view at that time was correct. The South Africans saw only the bad cases (the others had by that time healed or become stabilised), and naturally they were struck by the depressing group of septic cases. As will be stated later, the view expressed by surgeons in Britain, surveying the final end-results of all cases, was that the majority of the cases treated conservatively had ended up with a functional limb vastly superior to any artificial limb.
During the Sangro battle, November 1943 to January 1944, conservative amputations were carried out, especially in the arm and hand. It was considered, however, that it was useless to preserve fingers with compound fractures of phalanges and damage to tendons, though any remnant of thumb was of great value. Cases had been observed with amputation through the knee joint in the presence of fracture of the lower end of the femur, when amputation through the fracture would have been preferable.
Penicillin was being utilised at that time, and delayed primary page 313 as well as secondary suture was carried out in all amputations with excellent results. In March 1944 the treatment had become stabilised and flaps were cut and later sutured about the fourth day at the Base. At that time it was observed that ‘if with the progress of wound treatment by penicillin and other substances the wounds continue to show less and less infection a reconsideration of our present plan of saving all possible length of limb may be modified so as to approximate the length of limb more to the ideal lengths desired by the artificial limb maker. Judgment would of necessity be required in choosing the cases for more radical removal of tissue.’
In October 1944 stress was again laid on the treatment of the traumatic amputation cases, and it was stated that amputation must be done through healthy tissue above the devitalised area as soon as possible to prevent toxic absorption and subsequent sepsis. The application of a tourniquet at the lowest possible level, as a first-aid measure to prevent bleeding and toxic absorption, was sometimes carried out. At this time, and all through the Italian campaign, the amputation of lower limbs, frequently both legs, was common. This was due to the wooden Schu mine which was used so liberally by the enemy during his retreat.
Penicillin was proving of value in preventing sepsis in the badly injured feet and so saving some cases from amputation. Stitching the flaps together in the forward areas was still deprecated.
From the experience of conditions in Italy it was obvious that amputation could now be carried out with a certainty of satisfactory healing and of absence of infection, following delayed primary suture. In that case it seemed wrong to subject a patient to a primary amputation that would make a secondary amputation inevitable. Complaints were also received from New Zealand from amputees who had the impression that they had not been properly operated on overseas and thereby had to go through with what should have been an unnecessary operation. The New Zealand surgeons also would not be able to appreciate the necessity for preserving all possible tissue when the cases were arriving back without any sepsis. Nevertheless it was still obvious that the original forward amputation should not be at the site of election as far as the leg was concerned, as, if any severe infection did occur, it would still be disastrous.
It was possible, however, to amputate high enough up the leg to make the wearing of an artificial limb satisfactory, and still conserve ample length in case of complications. Three inches are required by the limb maker for proper play of an artificial ankle joint, so it was decided that primary amputations in future should be three inches up from a joint.page 314
The Consultant Surgeon 2 NZEF discussed the matter in England with Brigadier Bristow, orthopaedic consultant to the British Army, and strongly urged that Army Instructions should be altered to give effect to these recommendations. Bristow promptly agreed, and as a result the following was issued from the'War Office:
It is now advised that the leg should be amputated 3′′ above the ankle joint, below the bulge of the calf, not 1′′ to 2′′ above the ankle. This is advised because the limb fitters require at least 3′′ clearance above the ankle joint in order to fit the most suitable prosthesis, one which includes a useful ankle-joint mechanism. If the stump heals, which it often does, such a prosthesis can be fitted, if not, there is ample room above for re-amputation. This operation of election will provide the ideal 5½′′-below-knee stump.
Admittedly the stump which is too long may also heal, but unless the patient agrees to an early re-amputation he will be deprived of the advantages of the better type of artificial limb. Once his stump is healed, a patient not unnaturally tends to object to the second amputation, often in spite of advice and argument. Any long stumps may, of course, require amputation in any case, some years later, should the circulation fail.
This then remained as the policy till the end of the war and resulted in extremely satisfactory results both from the surgical and the patient's point of view. With the utilisation of penicillin and the regular use of delayed primary suture, amputation stumps ceased to give any trouble. Thus the war ended with an Army routine which included adequate wound excision, conservative approach to the site of amputation, delayed primary suture of the stump, and resulted in an almost complete absence of sepsis and in healing in 90 per cent of the cases.
It is of interest to relate that at an orthopaedic congress in London in January 1945 the question of amputations was discussed. The opening speaker was a young surgeon in a base hospital in England, and he was followed by a leading Russian orthopaedic surgeon. The British surgeon gave an account of late repair of stumps, emphasizing the importance of suturing the fascia over the end of the bone.
The Russian gave an account of the Russian experience in the war and their technique. It was difficult to realise we were living in the same age. The Russian conditions were such as one might have expected a century ago with sepsis, secondary haemorrhage, and re-amputation as the common experience. British war surgery was undoubtedly supreme, and we were pleased that we had added our quota to the result.
The Amputee in New Zealand
With regard to the fitting of the artificial limbs, New Zealand had at the outset of the war a long-established central limb factory in Wellington, and splint workshops in the four main hospitals where page 315 repairs could be carried out. The limb factory was taken over by the Disabled Servicemen's League early in the war. There had always been close association with Roehampton, the main amputee centre in Britain, and New Zealand utilised the British limbs, though we made use of the McKay arm, invented and produced by one of our own amputees.
In August 1944 Lieutenant-Colonel J. K. Elliott was appointed adviser to the New Zealand Government with regard to the rehabilitation of amputees, including the provision of artificial limbs. After visiting the United States of America and England, and spending some time at Roehampton hospital obtaining full details of the surgical and limb fitting procedures adopted there, he returned to New Zealand and co-ordinated the treatment and limb fitting of the amputees.
His observations in America led him to the conclusion that the open-flap type of operation with skin traction was much superior to the guillotine amputation as practised by the Americans. There were very few Syme stumps, and the performance of this operation for most war injuries was impracticable. The Stokes Gritti stumps were satisfactory. Rehabilitation with active stump exercises and pressure bandaging was carried out in a similar manner to that adopted at Roehampton. The Americans fitted a temporary limb, which Lieutenant-Colonel Elliott considered unnecessary.
In his report on Roehampton Elliott pointed out that, after the surgical treatment was finalised, special limb fitting surgeons undertook the preparation of the stump for limb fitting and prescribed the appropriate type of limb and superintended the amputee and his limb for the rest of his life. He did not recommend this arrangement for New Zealand, but suggested that the orthopaedic surgeon and the limb-fitter together were all that was necessary.
Elliott set out his opinions in a report, among them being the following: The primary amputation stump should not be more than nine inches for the leg and three inches up from the joint elsewhere. Plaster pylons were of use in above-knee amputations to allow time for shrinkage. There was need for a proper technique for stump bandaging, and also for exercises and the prevention of contractions. Investigations showed that 60 per cent of the below-knee legs were fitted with willow sockets, the leather sockets being used mainly for the short stumps. Full tibial bearing was obsolete and full ischial bearing was irksome, so Roehampton was compromising by providing a long, blocked, leather corset with roll strap and buckle.
Above-knee stumps were fitted with metal sockets and metal limb and internal coil knee springs instead of the usual pick-up. Tilting table limbs were being fitted satisfactorily. Remarkably page 316 little surgery was necessary in the First War cases, but full ischial bearing became necessary in many of the older cases. With regard to the arms, a new improved arm had been brought out at Roehampton. A proper psychological approach to the amputee was necessary, with full explanation of the future and the use of the artificial limbs, and with no extravagant predictions.
The difference in the opinions held by the British and the Americans with regard to the value, and especially the lasting qualities, of the different amputation stumps is of considerable importance to our outlook in New Zealand. It had been suggested that climatic conditions are of considerable importance, and it may be that there is some important difference in the New Zealand climate.
Lieutenant-Colonel Elliott was of the opinion that the Roehampton opinion of the Syme and the Stokes Gritti and transcondylar thigh amputations could not be supported by our experience of the results of those amputations in New Zealand. Under New Zealand conditions there were many men from the First World War who had carried on satisfactorily with these stumps, and it had not been found necessary to re-amputate or to substitute remote-bearing for end-bearing in the limb.
He also considered that, in the very short leg stumps, removal of the head of the fibula had been of definite advantage. This opinion seemed to suggest that our New Zealand conditions were such that we could steer a course between the two extremes and under certain conditions still do the Syme amputation, and possibly also the Stokes Gritti and transcondylar. It would be, however, only on the rarest occasion that a Syme amputation would be able to be performed during war with any chance of success, and the same applied to the Stokes Gritti. With the control of infection by the bacteriostatics the conditions might possibly be modified in the future.
In the treatment of long-standing painful neuromata in the leg stumps, division of the external popliteal nerve in the popliteal space had been found to be the most effective measure.
Recommendations for the Future
In war surgery at the primary operation the indications for amputation are:
A non-viable limb due to destruction of the blood supply.
A limb so badly damaged that it is certain it will be less functionally useful than an artificial limb and may be the cause of severe illness to the patient. The gross destruction of the main nerves will be of importance in this respect.
It roust be understood that any part of a hand is better than any artificial limb, and that generally artificial arms are useless.
In carrying out a primary amputation it is essential to preserve the maximum length which can be fitted satisfactorily with an artificial limb. This means that amputation should be three inches above the joints, thus allowing for artificial joint action. Anterior posterior flaps should be cut, the muscles and nerves cut at the same level as the bone. In suturing, only the fascia and skin should be sutured over the bone. The wound should be left open and delayed primary suture undertaken about four days later, penicillin having been administered to combat infection. Adequate excision of the wound is essential, especially in traumatic amputations.
When there is any deficiency of skin, traction should be applied immediately after the operation.
When secondary amputations are performed later, the indications are:
Gangrene following destruction of the main blood supply.
Massive gas gangrene.
Severe and life-endangering infection.
Severely damaged and infected feet for which there is no hope of eventual satisfactory function.
The sites of amputation will be similar to those of primary amputation, and whether primary suture is possible will depend on the complete absence of any infection.
After-treatment, when healing has taken place, consists in early, continuous, and accurate bandaging, to get shrinkage of the stump, and early and full exercises to preserve joint movement and prevent contractions. The application of an artificial limb should be made at the earliest possible moment, that is, as soon as the stump is well healed and well shrunk and consolidated. This applies particularly to arm stumps when manual work is to be carried out. If the fitting of the limb is delayed there is grave danger that the remaining arm will adapt itself to carry out all the necessary functions. Unless the man is trained early for particular work and has the artificial arm fitted up to be useful at that work, the arm will be useless and will not be worn. In the lower limb, wooden buckets are better for the leg, metal for the thigh. Pylons are of use in thigh stumps.
Bearing should be taken partly on the tuberosity of the tibia and upper end of the fibula and partly on the ischium, some of the weight being taken by the thigh by means of a lace-up cuirass. Cineplastic stumps have proved unsatisfactory.page 318