JAN. 17, 1953
THE ELDERLY AMPUTEE
THE ELDERLY AMPUTEE
S. McKENZIE, M.B., Ch.B.
(From the Ministry of Pensions Limb Fitting Centre,
Since the advent of the National Health Service the
Ministry of Pensions Limb Service has been called upon
to treat large numbers of elderly patients, and it was
therefore felt that a more detailed study of the results
obtained by current methods would be of value and
perhaps form a guide to the minutiae of technique and
selection in future.
At the inception of the N.H.S. the experience of the
Limb Service in the rehabilitation of elderly patients
was not extensive, the technique of rehabilitation having
been evolved primarily in relation to active ex-Service
This technique had, however, met with success,
and we were encouraged to adopt the same methods,
modified only in so far as the programme was adapted
to the physical capacity of the higher age groups and
the more enfeebled.
Enough time has now elapsed to
respect of the first 6,000 N.H.S. patients accepted for
prosthetic treatment at Roehampton.
were "primary" cases-that is, patients who had not
yet worn a prosthesis-aged 65 or more, representing
some 30% of all the primary lower-limb cases received
during the same period.
4,000 to 5,000 major amputations are performed each
year in the British Isles in times of peace, so that the
Limb Service can expect some 1,350 new elderly patients
The wastage from death and intercurrent
portion are successfully equipped with prostheses; but
elderly patients requiring continued supervision by the
Limb Service throughout the years cannot be expected
to be less than 5,000 to 6,000 at any given time.
assess results in
Of these, 344
It has been estimated that
is, of course, considerable, and only a
The technique adopted in the treatment of this age group
has followed the same general plan as that used in the past.
Patients are seen as out-patients in the limb centre as soon
as possible after reference from hospital.
cases to be seen by the limb surgeon at an early stage,
while others wait until the patient has been discharged
to his home.
At first the limb surgeon makes
examination and assesses the capabilities.
or general treatment is indicated he will normally refer the
patient back to his hospital with suitable recommendations,
unless he feels that the special experience of the Roehamp-
ton staff is required.
At the earliest possible stage a pylon
is ordered for thigh cases, while below-knee cases normally
are fitted direct with the permanent prosthesis.
1950), and are very light.They can be made in a very
short time, and rehabilitation can begin at an early date
referred to this centre have not persisted with stump exer-
cises and bandaging, the details of which technique have
been published by the Ministry of Pensions (1951).
sion of this treatment, or failure to persist in
in a flabby stump with terminal oedema and general debility
with lack of muscular tone, and in delays and difficulties in
limb-training which are in some cases insuperable.
There seems to
a local and general
If further stump
are provided with "durestos" sockets (Scales,
so promote morale.
It is found that many patients
Training in walking is started as soon as possible after
delivery of the pylon. We find it better for morale if this
is carried out by daily attendances on an out-patient basis,
and only those who have too far to travel or have compli-
cating factors are admitted to the hospital.
between handrails, progressing to walking with sticks, stair-
climbing, walking on slopes and cambers, etc., and instruc-
tion in meeting all the ordinary needs of existence.
conjunction with this, group therapy is employed in the
form of suitably modified remedial exercises designed to
promote general improvement in muscle tone, to improve
reactions, and to stimulate morale.
tinued until the patient is fully independent or until no
further progress can be made.
knee amputee may have two weeks' and the double-thigh
subject four or more weeks' training.
After training, the patient is kept under observation by
a follow-up, and the permanent prosthesis
when function merits
Further training is given after
delivery of the permanent prosthesis.
The training is con-
Thus the single below-
An attempt has been made to assess results obtained in
the 344 cases under review in relation to the age and sex
of the patient, the site of amputation, the cause of amputa-
tion, and the presence or absence of complications.
habilitation was regarded as successful in 171 (49.7%). No
very exacting criteria have been taken, but cases were con-
sidered to be successful if appreciable and regular daily
use has been made of the prosthesis for a period of not
less than six months ftoin completion of fitting and instruc-
tion.Failure occurred in 101 cases (29.4%).
vened during rehabilitation procedures or within six months
of completion in 31 cases (9%).
in 16 cases (4.6%), the result remains uncertain in 5 cases
(1.5%), and follow-up has failed to trace 20 patients (5.8%).
Fitting was not attempted
TABLE I.-Results in Relation to Age
attempted. U= Uncertain.
Table I shows, as would be expected, an increasing failure
rate with age.
The high proportion of successes in the
oldest group is probably not significant, owing to the small
numbers involved, except to show that age itself is no bar
to successful rehabilitation. The o4dest patient to be treated
was a woman born in 1860 who had had the right leg
amputated' above the knee when she was 5 years old but
had never worn a prosthesis.
haps not strictly a primary case, as she had not recently
had a debilitating illness or undergone major surgery.
has been included, however, on the ground that it was her
first attempt with a prosthesis.
in November, 1948, and with an articulated prosthesis seven
She made uninterrupted progress despite
domestic difficulties, and when last seen in September, 1951,
she was "making better use of her leg than many half her
At the other end of the scale six of the youngest
attempted, and ovxer 25% have failed to learn to manage
The oldest double-thigh amputee to make
successful use of prostheses was 81.
To this extent she was per-
She was fitted with a pylon
JAN. 17, 1953
THE ELDERLY AMPUTEE
The incidence of failure has been higher in females.
Table II shows the relative figures.
mately twice as many males as females in the series.
There were approxi-
TABLE II.-Results in Relation to Sex Distribution
The death rate was appreciably higher amongst the males.
It may be that they approached their rehabilitation with
greater determination to overcome their disablement, in
many cases possibly through a feeling of economic com-
pulsion, which could explain the higher success rate at the
cost of shortening life in some of them.
not large enough for us to draw more than tentative deduc-
tions on this score, particularly as the death rate in general
in this age group is higher in males.
The numbers are
TABLE III.-Site of Amputation
(49.4%) (62-5%) (57-8%)
(33-3%) (100%) (100'%)
( 1*- %)
The preservation of the knee-joint is, of course, normally
However, the low success rate among those
who have suffered double amputation-one above and one
below the knee-the high death rate, and the high propor-
tion for whom limb-fitting could be attempted (Table II),
support the apparently paradoxical view held by me that
in patients of this age rehabilitation, at least to a measure
of independence, has been more readily effected among
those who have had a double amputation at or above the
employed in the latter case, because initial rehabilitation
is undertaken on short pylons, on which the patient is kept
as near the ground as is permitted by the longer of the
two stumps, and effort is minimized.
ment of this technique, not included in this series, is the
addition of rocker bases to the short pylon, which further
reduce the expenditure of effort. The results of this method
are most promising but it would be premature to give figures
at this stage.
(Note: The supply and use of short pylons
has been regarded as a successful outcome in the double
above-knee cases, although only five of them progressed to
full-length articulated limbs within the period of review.)
is in direct relationship with the technique
A recent develop-
Disarticulation at the Knee
Although the numbers are small, it is interesting to note
the high success rate of disarticulation at the knee.
The success of these cases tends to confirm the
impression gained that such patients learn to walk more
readily and gain balance and confidence more quickly than
those with the conventional above-knee amputation.
is probably because, with a disarticulation at the knee, end-
bearing can often be tolerated, thus permitting the axis of
the body weight to be borne through the femur instead of
through the ischium, and requiring less readjustment.
necessary to providea somewhat more cumbersomeprosthesis
for the disarticulation case owing to the bulbous extremity
of the stump, and it is probable that the gait can never be
so good as that obtained with the prosthesis designed for
the ideal stump, but it is felt that for the elderly these dis-
advantages are outweighed by the relative ease of the early
rehabilitation and, above all, by the fact that such an
operatio~n is the simplest one and is attended by the mini-
mum of shock.
In only one of the cases (the one classified as uncertain)
was there any breakdown of the stump, and it would seem
that disarticulation could be adopted with advantage for
many more patients in the age group under consideration.
The Stokes-Gritti stump has never proved very satisfactory
among ex-Service men from the limb-fitting point of view;
end-bearing is seldom tolerated, and the terminal soft tissues
are prone to circulatory deficiency, possibly owing to the
fact that the flaps may have been taken too high to obtain
advantage of the anastomosis round the knee.
no reason to expect better results in the higher age group
than in the younger patients we have seen in the past, and
the bone section involved would cause the very surgical
shock which one wishes to avoid. We therefore do not see
any place for the Stokes-Gritti amputation or any other
modification of the classical disarticulation at the knee for
the elderly patient.
Cause of Amputation
The most significant fact, as shown in Table IV, is that
diabetics have relatively poor prognosis with regard to both
rehabilitation and survival.
As might be expected, in the
TABLE IV.-Cause of Ampputation
Other forms of
(38 0%) (15 5%)
(50 6%) (30-9%)
(61 6%) (20-5%)
(55 6%) (22-2%)
(8*3%) (8.3%) (8*3%)
(5 6%) (11-1%)
(2 6%) (5-1%) (5-1%)
acute pyogenic and traumatic groups the success rate is
This is probably because they have not suffered from
prolonged debilitating illness.
concomitant disease or disablement is of more direct prog-
The presence or absence of
The complications (Table V) were in the main cardio-
vascular and respiratory, and disorders of locomotion.
latter include disabilities of the upper limbs, owing to the
fact that these patients have at least to learn to walk as
Specific complications, together with num-
bers of cases exhibiting each complication, are shown in
(63 4%) (24*7%/)
cations may have been coexistent in individual cases.
figures emphasize the importance of defects of the contra-
lateral leg, the arms, vision, heart disease, and deafness.
It will be appreciated that two or more compli-
TABLE VI.-Specific Complications
Defects of contralateral leg
Hernia and hydrocele
Defects ofupper limbs
Chronic bronchitis, with dyspnoea on
Previously treated neoplasm in breast
Scoliosis, peripheral neuritis
The last of these
the deaf person retires into himself and is difficult to bring
into g-roup therapy and into the atmosphere of optimism
one can cultivate in his more fortunate fellows.
has been less of a handicap than might have been expected.
is interesting, and
is probably explained by the fact that
its inclusion among
The results in these cases show that no single complica-
can be regarded
indication to limb-fitting.
On the other hand, one cannot
simply regard the elderly amputee as having a stump for
which all that is required is to
him to walk.
On the contrary, the stump is by no means
the most important part of the problem.
examination must be made of the patient's entire physical
and mental make-up, and suitable treatment of any con-
comitant disabilitv instituted in conjunction with prosthetic
The complicating factors
The environment to which the patient returns on dis-
patients who have made good progress and who
the walking school
to look after themselves fairly well.
when we see them on follow-up we find they have hardly
worn the prosthesis, and the musculature has lost tone to
extent that they
no longer control
reveals that they live alone, perhaps in an upstairs flat, or
it may be that they have simply lacked the incentive to
make the effort to persevere.
a problem of welfare which
Limb Service, and falls more within the province of the
social medicine specialist.
Again, we have had to contend with patients who have
be done for them.
They may be in poor physical condition,
and often their stumps may be flabby, neglected, and quite
unprepared for wearing a prosthesis.
convince some of them that they will not be able to manage
a prosthesis other than by letting them try for themselves
on a pylon.
The effect on morale of the inevitable failure
can be imagined.
We have known of patients admitting
that they had been prevailed upon to accept amputation by
the promise of easy function with a prosthesis.
logical approach from the limb surgeon's point of view is
much simplified if a more conservative briefing has been
given in the general hospital and the patient has been
as an absolute contra-
fit a prosthesis to enable
are, in fact, wider even than
is of vital importance.
We not infrequently
It would seem that here is
is outside the scope of the
an unwarranted optimism concerning what
to be provided with
It is impossible to
warned beforehand that he will have a prolonged and
strenuous programme before him, but that if he will make
the effort he should be able to walk.
should be initiated from an early date and maintained
throughout by a regime of active physiotherapy, directed
not only to the stump but to the whole bodily muscula-
ture, together with occupational and diversional therapy
suited to the intellectual standard of the individual.
programme can with advantage be phased, each phase
having a target which must be attained before the next
phase is started (Marjory Warren, 1950, personal communi-
This may seem a counsel of perfection unrelated
to the pressure on hospital beds in these days, but it is my
belief that there would actually be a saving of time, and
therefore of beds, if such a programme were in uniform use.
The following brief case histories illustrate some of the
Case 66.-A married woman aged 68.
amputation, the later amputation being performed on December
22, 1948, for gangrene of unspecified nature.
overweight. W.R. positive; prior to the amputation she had been
diagnosed as tabetic.
She made uninterrupted progress on short
pylons, and, although she did not progress to full-length articu-
lated limbs, she obtained enough function from the short pylons
for the result to be regarded as an unqualified success.
Case 69.-A man aged 81. Amputation of right thigh through
unreduced congenital dislocation of the left hip.
He learned to manage a " through hip"(tilting table)
prosthesis without difficulty, and in spite of his unfavourable home
circumstances continued to make good use of it.
Case 223.-A married woman aged
amputation as a result of old-standing osteomyelitis.
generalized seborrhoeic dermatitis, was deaf, and had defective
vision (6/60 R. and L.).
Despite this, she did well on a pylon
and also learned to manage an articulated prosthesis competently.
Four months later she was found to have given up the effort and
had reverted to a wheelchair existence.
Case 251.-A man aged 69.
Right above-knee and left below-
Despite his excessive weight he made an
uninterrupted and rapid rehabilitation, which was maintained.
The cause of death in the 31 patients who died during or
immediately following limb-fitting procedures was as fol-
coronary occlusion, six; hypertensive myocardial
failure, four; diabetic coma, three; pneumonia, hemiplegia,
and secondary carcinomatosis, two each; renal failure in
association with diabetes, diabetic gangrene of contralateral
leg, senile gangrene of contralateral leg, dissecting aneurysm
with renal suppression, and perforated gastric ulcer, one
In seven cases the cause of death could not be ascer-
Only one death occurred while the patient was
actually undergoing fitting of the prosthesis or training in
walking; this patient collapsed and died of acute cardiac
dilatation in the walking school.
In consideration of the fact that all cases in the series
were under observation for upwards of a year, the death
rate gives no cause for alarm or for modification of policy.
It is very doubtful if the effort of limb-fitting had any
material effect in shortening life, and, even if it did, the
majority of patients would prefer to make the attempt rather
than pass the rest of their life in a chair.
bad risks were not attempted.
She was grossly
He lives by
He was a hypertensive
A series of 341 consecutive primary amputees of
65 years or more who have been referred to Roehamp-
ton Limb Fitting Centre for a prosthesis has been
The results suggest that no single factor will deter-
mine the selection of patients suitable for limb fitting,
and that an assessment must be made of the entire
physical and mental make-up.
adverse factor, and there is no evidence that wearing
a prosthetic limb has shortened life significantly.
Age itself is not an
JAN. 17, 1953
THE ELDERLY AMPUTEE
JAN. 17, 1953
THE ELDERLY AMPUTEE
It is suggested that correct briefing and an energetic
and continued physical programme are of inestimable
value in preparing patients for wearing a prosthesis.
The subsequent care of the elderly amputee after
training in the use of the prosthesis is a problem in
social medicine as yet not adequately met.
I am indebted to the Director-General of Medical Services,
Ministry of Pensions, for permission to publish this paper. My
thanks are also due to Dr. R. Langdale Kelham for advice and
help in preparing the text, and to the staff of Roehampton Limb
Fitting Centre, in particular to Mr. D. Congalton, senior walking
instructor, without whose enthusiasm and untiring efforts many
of these patients would never have walked.
RehabUitatdon Following Amputadon.
Ministry of Pensions (1951).
cation No. M.P.M.414.
Scaies, J. T. (1950).
J. Bone Jt Surg., 32B. 60; and personal communication.
ORDER OF ST. JOHN OF JERUSALEM
The London Gazette has announced the following promo-
tions in, and appointments to, the Venerable Order of the
Hospital of St. John of Jerusalem:
Sir Horace Evans, K.C.V.O., M.D., F.R.C.P.,
Major-General F. A. Maguire, C.M.G., D.S.O., V.D., M.D.,
F.R.C.S., Brigadier R. M. Gorssline, D.S.O., M.B., Lieutenant-
Colonel E. A. H. Russell, O.B.E., V.D., M.B., Mr. A. Wai Tak
Woo, M.B., F.R.C.S., Drs. G. B. Peat and C. A. Verco.
Dame: Mrs. Katie Ardill-Brice, O.B.E., M.B.
(Brothers): Colonel T. E. Holland, M.D., Drs. Tseung Fat in,
B. H. Lodge, K. C. McGibbon, H. R. Mustard, and W. P.
Warner, C.B.E., D.S.C.
As Associate Commander (Brother):
Dr. K. Budeiri. As Commander (Sister): Dr. Ella P. Hopgood.
As Officers (Brothers): Surgeon Rear-Admiral F. H. Nimmo,
Brigadier C. W. Nye, O.B.E., E.D., M.B., Colonel W. A. Jones,
O.B.E., V.D., M.D., Colonel J. E. Snow, R.A.M.C., Lieutenant-
Colonel S. H. Heard, M.B.E., M.R.C.S., L.R.C.P., Major A. S.
Lewis, M.D., F.R.C.S., Messrs. D. P. McIntyre, F.R.C.S., H. H.
Barnett, M.B., F.R.C.S., A. Perry, O.B.E., M.B., F.R.C.S., C. D.
Gossage, O.B.E., M.D., F.R.C.S., W. H. C. Romanis, M.C.,
M.B., F.R.C.S., Drs. J. K. Thomas, J. Brown, T. P. Eddy, L. G.
Blaze, C. H. Drake, G. W. J. Bousfield, P. P. Lynch, W. G. Rich,
R. J. Brown, G. D. W. Cameron, E. Dwyer, H. J. Ferrier, J. L. R.
Gendron, H. D. Hebb, J. H. A. Paquette, W. S. Stanbury, M.B.E.,
H. H. C. Fuller, L. M. Comissiong, E. R. B. Murray, G. K.
Thornton, J. Prentice, R. Mc@. Paterson, N. L. Birkett, J. J. du
Pre Le Roux, R. S. Steel, H. H. Hurst, and T. C. James.
Officers (Sisters): Mrs. Ellen W. M. Shaw, M.R.C.S., L.R.C.P.,
Brothers: Surgeon Captain E. H. Lee, Captain A. F. McDonald,
M.B., Messrs. M. Backwell, M.B., F.R.C.S., D. R. Jennings,
M.B., F.R.C.S., Drs. R. G. Sprenger, I. B. McRae, Chang Hoey
Chan, C. L. Tessensohn, V. P. Robinson, R. N. Cumow, J. A.
Sacco. R. H. Blackburn, W. Isbister, A. Barlow, J. Crook, E.
MacD. Fogo, J. A. Mackay, J. J. MacRitchie, A. L. Peers, N. R.
Rawson, O.B.E., R. R. Strong, LI. H. Werden, T. H. N. White-
hurst, O.B.E., E. B. Figueiredo, D. P. K. Jockel, T. K. Abbott,
L. W. Fitzmaurice, O.B.E., R. D. K. Levy, P. D. A. Fowler,
H. W. Needham, E. T. Meyer, J. D. Allen, C. D. Bateman, R.
Swinburn, V. C. Dyring, N. J. Caldwell, and F. W. R. Lukin.
As Associate Serving Brothers: Drs. A. J. Thumboo, E. B. Israel,
R. A. Trope, S. Etzine, and H. Kaye.
Sophia M. R. Thomson, Margaret Owens, Winifred I. Robertson,
and Marguerite C. MacDonald.
As Serving Sisters: Drs.
The benefits of a chiropody service to old people are
emphasized by Dr. H. J. Rae in the Health Bulletin (January,
1953) of the Department of Health for Scotland.
time the service has been provided for the residents of old
people's homes belonging to the Aberdeen Corporation, and
other local authorities in Scotland have made similar provi-
sion. More recently the scheme has been extended to cover
old people in their own homes in Aberdeen.
not free, since experience has shown that chiropody treat-
ment given free at out-patient clinics was grossly abused.
A charge of 4s. per visit is therefore made, but it may be
remitted in whole or in part if circumstances so require.
The service is
Nova et Vetera
DR. JAMES GREGORY
NEW LETTER FOUND
James Gregory, who was born in January, 1753, is remem-
bered to-day only through the powder which bears his
name, although in his lifetime he was a most striking figure
in the Edinburgh School of Medicine.
at Edinburgh in 1774 and then spent some time under
Gaubius at Leyden.
His father, John Gregory (1724-73),
occupied the chair of practice of medicine at Edinburgh
from 1766 until his death. For 20 years previously Robert
of the institutes of
medicine, had been
the actual profes-
sor of the practicel
in 1769 his succes-
John Gregory joint
professors of medi-
cine, so that each
the theory and the
died, James Gre-
He graduated M.D.
the chair thus made
filled until June 19, 1776, when James was elected professor
of the institutes of medicine, becoming the fifth member of
the Gregory family 'to occupy a professorial chair at Edin-
Soon afterwards he published his textbook, Con-
spectus Medicinae Theoreticae ad Usum Academicum.
1792 he succeeded Cullen to the chair of practice of medi-
He was an accomplished Latin scholar, a great physi-
cian, and a brilliant and witty lecturer.
hanced the reputation of the Edinburgh school over a long
period, and his reputation was second only to that of Cullen.
He published a set of literary and philosophical essays in
Gregory was a friend of Robert Burs, and Raebut
painted his portrait in 1798 ; a part of it is reproduced here.*
He died in 182l1,
A letter, reproduced below, written by Gregory to an un-
known correspondent has recently been brought to light, and
the bicentenary of Gregory's birth is an appropriate occa-
sion for its publication.
The letter was discovered among
papers in the possession of Captain Sir James Paget, Bt.,
R.N., of Ballater, a grandson of Sir James Paget, the distin-
guished surgeon, and it has been presented to the British
as pro- i
His teaching en-
St. Andrew's Square
~~~~~~Wed:Night 22 Jan: 1817.
Inclosed I send you a Receipt for the same kind of Laxative
Pills, which by Dr. Macfarlane's advice you have been using of
*The illustration is taken from the reproduction of theRaeburm
portrait of Dr. James Gregory in History of Scottish Medicine
by John D. Conrie, 2nd-edition,vol. 2, 1932, by kind permission