When St. Thomas's Hospital ceased to be also the 5th London General War Hospital, it was decided that our clinic for the treatment of the wounded should be replaced by a fitting hospital for those who had suffered amputation. It became necessary, therefore, to try to find out how far it was possible to help patients to learn the use of an artificial limb. During the preliminary investigations, I was struck by the fact that all patients with an above-knee amputation had a more or less stereotyped limp, which seemed to me to be familiar. It was only after long and careful study that I discovered what it was of which this limp reminded me. I think there is no question that if we could imagine a tabetic to be ataxic on one side of the body only, that his gait would correspond very largely to that of a patient with an above-knee amputation, who is wearing an artificial limb, and which he has not learnt to use properly. The next consideration that arose was this: - The blind tabetic is never ataxic, except in the very latest stages of his illness. If it is possible for the blind man to call upon senses other than those comprised under the heading of joint and muscle senses, so as to maintain his co-ordination, is it not possible to train the sensations in a stump, so as to teach the patient co-ordination even in a lifeless limb?

From this small beginning there has developed a regular technique for re-education which has, I believe, proved of the utmost service.

Treatment, roughly speaking, may be divided into three main parts. Perfection of co-ordination in every muscle which has been left intact is the first consideration. The second is to educate sensation - tactile, muscular and joint - throughout the remaining portion of the limb, and the third to combine the first two so that the patient shall be able to perform definite and even complicated precision exercises.

Some patients seem to take to their artificial limbs without difficulty, and these require but little training. They learn to use the limb by the light of nature. Others do not, and these patients are in sore need of help. Explanation must be given of what is wrong and what it is desired to effect, and even definite anatomy lessons may be required. A short lecture on co-ordination is also not out of place.

Perhaps one of the most important things in the training is the re-education of joint and muscle sense, and education up to the highest pitch of perfection of the tactile sense.

When we consider that most lower limb amputation cases go about on crutches for a considerable period before they are fitted with an artificial limb at all, it is at once obvious that the intimate co-ordination in movement which exists between the two sides of the back is disturbed. Add to this that there is a constant tendency, when using crutches, to jerk the stump forward by contraction of the psoas, while the gluteus maximus remains almost functionless, and we see at once the possibility that a lamentable error in co-ordination may be established. The gluteus maximus also seems to waste more rapidly owing to a lack of function than does the psoas; and so, not only is the co-ordination of movement disturbed, but the relative balance of strength between the flexor and extensor of the hip is upset. The first step in training, therefore, should consist of general trunk exercises, designed to restore co-ordination between all the trunk muscles, not only of the back, but also of the abdomen. Every attempt must also be made to build up the strength of the gluteus maximus on the affected side by exercises, and, if necessary, by means of graduated faradic contraction. The main points in training of the muscles of the hip are to teach the gluteus maximus to act more strongly and more quickly, and the psoas less vigorously and by gradual contraction, as distinct from the sudden jerk. Attention must also be paid to the adductors, to ensure that when the patient first gets into his bucket he does not simply allow his stump to flop outwards into abduction. If he does so, the outer portion of the lower end of his bony stump presses on the outer side of the bucket, while the region of the adductors is pressed upon the rim. This is the invariable tendency, and one that must be eliminated by training if the patient is to use his limb properly.

When the patient first appears with his limb fitted, his attention must at once be drawn to this danger, and he must be taught to use his adductors in the standing position, so that the portion of the bone which is left assumes, within his bucket, a position which corresponds with that of the upper portion of the bone on the sound side. It must be remembered that in life the femur does not rest in the vertical position while standing. It has a marked inclination inwards, and, unless the patient learns to correct the alignment of his bone within his bucket, he will never learn to use his limb properly.

The next thing which he has to learn is to swing his limb forward and backwards with perfect rhythm, as already described in the chapter on the re-education in walking. The un-instructed patient always tends to jerk his stump forward far more vigorously than is actually required to secure full extension of the knee-joint at the end of the forward swing. He must learn to swing forward at the slowest pace which is compatible with bringing the heel down on to the ground after extension. He will never learn to do this with success unless he has regained perfect control over his gluteus maximus. The next stage is to teach the patient to rock to and fro, as already described in the former chapter. In order to keep the knee locked while transferring the body-weight forward, the gluteus maximus must be taught to act in unison with the adductors, thus bracing the stump back firmly throughout the whole of the forward step of the sound foot against the postero-internal aspect of the bucket.

As soon as he has learned to rock to and fro with the aid of two sticks, he is taught to do so with the aid of one only, and at this stage, if not before, it is wise that he should study his own movements in a full-length mirror. In this way he can be shown that he must not drop the shoulder on the side of his amputation while walking, and that he must not, so to speak, tend to sink into his bucket by faulty co-ordination between the back and abdominal muscles on the two sides. As soon as co-ordination while using a stick has been mastered, the patient is taught to practise the same routine while carrying his stick in his two hands in front of him. The tendency to the dropping of the shoulder and sinking into the bucket having been eradicated, the patient is taught to combine the natural swing of the arms with the ordinary movements of the legs while walking.

All this time the patient is encouraged to take very short steps, the heel being brought down to the ground very little, if any, in advance of the toe of the other foot. He is then allowed to increase the length of his stride. About this point regular drill should begin to the word of command. He should be taught to step off and to halt; to turn sharply to the right or to the left as if on parade, and then the command "right about face" can be given.

Balance exercises now take a prominent place in the treatment. Any of the ordinary trunk exercises in a standing position may be prescribed, together with combined trunk and leg movements, especially in the lunge position. It is almost essential that slopes of various gradients should be laid out, and the patient shown how important it is to take short steps with his artificial limb going uphill, and long steps going downhill. As soon as he has become fairly expert in manipulating these, he should be taught to walk over a loose plank, and to negotiate climbing over a stile. Rapidity of movement should be prohibited at least until this stage is reached. Almost every form of Swedish gymnastic apparatus can be utilised as well for the man with an above-knee amputation as for the man with two limbs. Jumping up and down on the bars, for instance, is an invaluable precision exercise. Throughout training, and indeed at every stage of training, once the patient has been taught to accomplish any particular prescription satisfactorily with his eyes open, he must be taught to do the same with his eyes closed. This is one of the essentials of treatment, and applies even to the jumping up and down on the bars. Every patient should practise kneeling down and getting up again, and various trunk movements whilst kneeling. He should learn to ride a bicycle, mounting and dismounting being practised until it is perfected. Walking upstairs, one foot before the other, and climbing ladders are by no means impossible feats for a patient who has only six inches of femur left. I do not yet know how long a stump is essential whilst wearing an artificial leg to sit a horse in comfort.

Very little ingenuity is required to devise many appropriate and useful exercises. The use of a scooter and the swinging of a golf club may be encouraged fairly early, while more advanced forms of exercise, such as playing tennis or squash rackets, should, of course, be prescribed very late in the treatment. As a means of perfecting co-ordination few things, perhaps, can equal dancing lessons, and no amputation below four inches from the top of the great trochanter should be considered as debarring a man from following almost any occupation or pastime to which he has previously been accustomed. He should be able to wear his limb all day in comfort, and, even with a 4-inch stump, be able to enjoy a day's shooting on heavy ground. The one essential, of course, is that the patient should be fitted with a strong and a light limb. The more the lever arm is shortened, the more essential does this become, but even with below-knee amputations the wearing of an unnecessarily heavy limb is inflicting on the patient an unnecessary exertion. For these patients, where weight may be of minor importance, it is, none the less, inflicting a very serious handicap to compel the patient to wear a heavier limb than is absolutely necessary. In above-knee amputations, to fit an unnecessarily heavy limb is to impose a burden which will act as a serious handicap throughout life. The lighter the limb, compatible with strength, the better. It has been pitiable, on many occasions, to see the joy and delight of a patient who has been accustomed to use a limb weighing eight or nine pounds to find himself the proud possessor of one weighing four and a half. On more than one occasion this alteration has brought the unsolicited testimonial that the reduction of weight has caused a complete change in the outlook on life.

It is impossible in a short space to do more than give a bare outline of the training of these patients. Some require little or none, others call for prolonged care and the exercise of consummate skill. Details have to be worked out for each patient's individual requirements, and I hope enough has been said to indicate the main lines which should be followed.

Cases of below-knee amputation rarely require any special training, and I have made no attempt to study the treatment of upper limb amputations. A very special knowledge of various arts and crafts is essential, and this I do not possess. Capt. Maxwell's work in this direction is too well known and appreciated to need mention here, but I cannot refrain from this passing tribute of admiration for his work.