Conception, Birth, Infancy and Adolescence of the Juvenile Amputee Program in North America
NEWTON McCOLLOUGH, MD1988 Presidential Guest Lecturer
Editor's Note: Joseph G. Matthews, MD provided a fascinating introduction to Dr. McCollough, as follows:
I was thrilled and pleased to learn that Dr. Newton McCollough was selected to give this year's Presidential Guest Lecture. I asked if I could help to introduce him for I have known and respected him for 36 years. I was his interne, his resident, and his partner for a dozen years, and his successor in the thirteenth juvenile amputee clinic in the country, the first in Florida.
Dr. McCollough's name is still remembered and highly regarded in central Florida, for he was an energetic, honest, practical orthopedic leader, loved by his grateful patients and appreciated by all of his colleagues. He started our resident training program which is still flourishing, and was very active in our state orthopedic society, serving as its president in the mid 1950's. Newt established the first participating juvenile amputee clinic in Florida and helped administer the Crippled Children's Program in central Florida for many years. He was active on the staffs of two children's hospitals, Elk's Hospital in Umatilla and the Eccelston Hospital in Orlando. His work on snakebite care radically changed the management protocol nationally. The number of amputations resulting from treated venomous snake bites has dropped to almost nil. He was an unpaid advisor to the Florida Industrial Commission for years, chosen because he was objective and unbiased. His son, Newton C. McCollough III, is now Medical Director of all Shriners Hospitals for Crippled Children and will probably be President of the American Academy of Orthopaedic Surgeons in the near future.
No one person or group can thank this unusual man adequately for all he has done for his profession and for this organization.
From 1934 to 1937 Thomas Aitken, MD of Indiana University and Charles Frantz, MD, from the University of Michigan, were fellow residents in the orthopedic program at Blodgett Memorial Hospital in Grand Rapids, Michigan. During their training they attended hospital clinics sponsored primarily by the Michigan Crippled Children's Commission. Upon completion of their residencies, both continued their relationship with the clinics of the Commission, particularly those involving patients presenting amputations. Aitken worked at Saint Mary's Hospital, while Frantz remained at Blodgett.
In the early 1940's, when wound healing was complete, the amputee was referred to the prosthetist. Often the surgeon never saw the patient again, unless wound breakdown occurred. Edema, erythema, weeping scars, bullae, and troublesome pressure points all fell under the auspices of the prosthetist who treated the problems either by enlarging the socket or adding moleskin or other padding. The sockets were all plug fit, suspended by straps or metal hinges joined to a belt for suspension. Individuals with short below-knee amputations frequently bore weight with a flexed knee on a pad attached to a pylon with a rubber, or sometimes a metal, tip. The prosthesis was suspended by a lateral board-like shaft attached to a pelvic band. A wooden foot was always used. It had a toe break which amounted to a separation of the anterior part of the foot, with a hinge used to give flexibility at the forefoot; the hinge usually was woven or webbed material. Above-knee amputees had single-axis knees made stable only in a noisy hyperextended locked position. The prosthetist not only cared for the health of the amputation limb, but was also responsible for establishing leg length and conducting gait training.
Aitken wrote that compared to the adult, juvenile amputees were a neglected lot with fittings at a late age. Small components were not commercially available and had to be contrived by the local prosthetist. There was little vigor in the treatment of child amputees. It was difficult to determine from the records whether prostheses had been applied, much less accepted. The lower-limb amputee was generally referred to a prosthetist merely to find whether anything could be done, while those with loss of an upper limb were usually ignored.
The marked inadequacy of treatment for juvenile amputees was explained to the Director of the Michigan Crippled Children's Commission, marking the conception in 1946 of our present mode of management of the juvenile amputee in North America. A child amputee center, therefore, was created by the Commission at Mary Free Bed Rehabilitation Center for the entire State of Michigan, under the direction of Frantz and Aitken. This choice was made because of the central location of the city in the state, adequate hospital facilities, presence of the Mary Free Bed Center, and the knowledge and enthusiasm of the two young orthopedic surgeons. Another great influence in this decision was the fine record of adult amputee centers during World War II which benefited patients by concentrating them in one hospital setting. This not only promoted excellence in surgical and prosthetic techniques, but also fostered training in the use of prostheses.
Aitken wrote later, "By involving the entire treatment of juvenile amputees in one clinical facility, the caseload would be increased to the point that clinical experience could be developed, that lessons could be learned, and a slowly evolving improvement in all phases of the work would develop."
An ideal situation came to pass. A team was brought together consisting of a clinical chief (physician); the patient (amputee); a prosthetist who usually served also as an orthotist, if necessary; physical and occupational therapists; the clinic nurse; and a social worker. In 1948, Aitken noted that all child amputees were seen by him or Frantz and the balance of the amputee team prior to surgery or prosthetic prescription. Children were checked again for fit of the prosthesis, and a directive was then issued for training and family counselling. All of this was done with one objective: to create a consistant user of the prosthesis. We may thus consider this to be the birth of the program of juvenile amputee care.
World War II produced amputees at such a rate that great stimulus was given the federal government to improve the quality of surgical and prosthetic care in amputee centers. Research advanced the science of prosthetics to a very high degree. As a result, two schools, one at University of California at Los Angeles (UCLA) and the other at New York University (NYU), were established to bring the knowledge to the medical community. The schools offered comprehensive courses in all phases of adult amputee management. We of the older generation gasped in amazement at the quadrilateral total contact suction socket and the patellar tendon bearing one, the SACH foot, the use of plastics in sockets, and unique and unusual types of suspension. Orthopedic surgeons, prosthetists, therapists, nurses, and social workers from all phases of amputee care attended the two universities and filled the courses enthusiastically. The names of Sid Fishman, Norm Berger, Cameron Hall, Harry Campbell, Charlie Bechtol, and Allen Russek were on the schedules, as well as some whom I have forgotten; all became our teachers and friends. The new knowledge and techniques were quickly applied to the juvenile amputee, for practically all management principles proved suitable.
On January 29 and 30, 1954, a meeting in Grand Rapids was attended by representatives of the Children's Bureau of the Department of Health, Education and Welfare, the two universities, and the Committee on Prosthetics Research and Development (CPRD). The consensus of the conferees was that a nationally organized program should be initiated to care for the problems of the juvenile amputee population. In December 1955, the Prosthetic Research Board appointed a steering committee with Frantz as chairman to study the problems of child amputees. In March 1956, the committee mailed a questionnaire to 84 prosthetists and 25 clinics throughout the United States. The response was prompt, indicating an interest in this population. At that time, however, no clinic, other than at Mary Free Bed, concentrated solely on child amputees. Two years later, the committee met at NYU, with Aitken, Frantz, and Fishman, as well as Milo Brooks and Ed Peizer. Discussion centered around a list of reasonable research problems to be presented to the proposed cooperating children's clinics, and the criteria by which such clinics would be selected. The committee also decided that Dr. Arthur Lesser of the Children's Bureau should develop a list of active child amputee clinics through contact with the directors of all state Crippled Children's Services. By December 1958, the committee had accepted thirteen clinics, with the first meeting held in Washington on June 1, 1961.
This group of clinics was to be the source of an accumulation and interpretation of developments to date. As advances increased, so would the advantage of meeting. All agreed that some interchange among all agencies and clinics was vital so together they could standardize and evaluate common limb deficiencies and report the success or failure of new components. The process would carry more weight and authority with a large number of children being treated by the widely spread clinical facilities. The group also found common, unanticipated problems and sometimes arrived at ingenious, unexpected solutions. Present at the first clinic chiefs' meeting were Cameron Hall and Milo Brooks, UCLA; Richard King, Atlanta; Claude Lambert, University of Illinois; Chester Swinyard, NYU; James Glessner, Jr., Newington; William Waldrop, Oklahoma City; Milton Wilder, Baltimore; Chestley Yelton, University of Alabama; Leonard Goldner, Duke University; Ernie Burgess, Seattle; William Eaton, Pittsburgh; and myself, Newton McCollough, Florida Crippled Children's Commission, Orlando. Frantz and Aitken represented Grand Rapids, with Frantz serving as chairman. Also present to help introduce new research features and to familiarize the chiefs with the administrative staff and important committee membership were Harold Glattley, Chairman of the Committee on Prosthetics Education and Information; Fishman and Hector Kay from NYU; Lesser from the Children's Bureau; Tom Lindsey, Michigan Crippled Children's Commission; Ben Wilson from CPRD; and Colonel Maurice Fletcher ("Fletch", as he was fondly known) from the Army Prosthetics Research Laboratory at Walter Reed Army Hospital, Washington. This first meeting marked the beginning of the adolescence of this organization. We had these characteristics: a little awkwardness (much was new), but we were intense, hardworking, and tireless. We could talk patients, prostheses and components, and the proper age of fitting, night and day without end. To a man we were enthusiastic about the entire project.
At the end of the session, one firm, unanimous request was made. We wanted a monthly or quarterly publication to bring us information gathered between our annual meetings. We all realized that an annual meeting never could cover the amount of cross-clinic information necessary for our success. Kay and Fishman took the job and produced a marvelous little mimeographed Inter-Clinic Information Bulletin. Our progress in all efforts to better the juvenile amputee was reflected in the little pamphlet. Initial publication was October 1961.
Another item we mulled over in the very beginning was overgrowth of the bone at the amputation level, whether the child had a surgical or congenital deficiency. We assumed we solved it by removing the tip and bursa, only to find in a year or two that we were in the same difficulty again. Frantz and Aitken added to the literature by studying this phenomenon. They proved by metal bone markers that it was appositional growth rather than growth from the epiphysis. I read a recent article in the Summer 1985 Journal of the Association of Children's Prosthetic-Orthotic Clinics, successor to the Inter-Clinic Information Bulletin, that Larry Friedmann succeeded with gentle traction at night in a socket, lengthening the soft tissues and often accommodating them to the extent that removal of the bony tip was unnecessary. This indeed may be a wonderful answer, simply and inexpensively achieved.
After receiving the invitation to write this paper, my soliloquies focussed on an issue which I have touched upon many times with clinic chiefs, namely the attractiveness, the intelligence, and the beautiful personalities of our children with quadrimembral limb deficiencies. Not that the other children were not pleasing, but those with four anomalies seemed to be so vivacious, so responsive and so bright that we all took notice. The question to which I have no answer, and have dwelled upon so much is what happened to these kids whom we left sitting in buckets on wheeled platforms or sockets and stubbies. Were they emotionally balanced as they grew? How could they be? What educational attainments did they reach? They certainly had the intelligence to do well. Did they achieve sexual maturity? Did they ever marry and bear children? What measures of self sufficiency could or did they achieve? We conjectured after a drink or two that if the patient displayed absence of all limbs, perhaps the additional blood and nutrients might have been shunted to the head, giving patients a larger brain to compensate. Could they thus develop the outstanding personal and intellectual characteristics I mentioned? After another drink we changed the subject.
Another issue which baffled us was the phantom limb. Was it completely absent in the juvenile amputee? Would it be possible that in amputations caused by congenital constricting bands that the phantom might be more likely? In a true congenital deficiency, could a phantom exist? These abstruse matters were topics of conversation without noticeable achievements.
In the 1960's we became international with the addition of the Ontario Crippled Children's Hospital (now the Hugh McMillan Medical Centre) of Toronto and the Rehabilitation Institute of Montreal; both have been very active ever since. The Campbell Clinic in Memphis also became a member of our group. The State Hospital for Crippled Children in Elizabethtown, Pennsylvania, and the Crippled Children's Hospital in New Orleans came aboard. Kay requested a clinic chief to accompany him for on-site inspections of proposed clinics to verify the patient census and the adequacy of training of the clinic chief and staff. We were then able to grow even further by adding clinics to enhance our clinic population. We were approaching a semblance of midadolescence.
A big part of our job from the beginning was field testing new components as they appeared from prosthetic engineers and manufacturers. Some I remember are the SACH foot for children; the infant passive mitten; the quadrilateral socket with belt suspension, then with suction suspension and total contact; and the patellar tendon bearing limb. The latter two were later used as temporary postoperative fittings. Also evaluated were voluntary-opening and voluntary-closing hands and hooks, cosmetic gloves, electrically powered elbows, the Michigan feeder arm, wrist units for children, and electrically and pneumatically powered arms. We applied sockets in the early weeks of life in an effort to prove to ourselves that a sense of body wholeness which became part of the conscious mind of infants so fitted would eventuate in the compulsive use of prostheses. This was a fascinating topic of conversation and, I think, was half accepted. We also studied whether the patellar tendon bearing socket altered bone growth adversely. We reported all our findings to CPRD through a subcommittee headed by Frantz and composed of Brooks, Fishman, King, Lesser, Carl Sumida, and me. Membership in the subcommittee varied over the years. Recommendations were eventually transmitted to the clinic chiefs for acceptance or rejection at the clinical level.
In the early 1960's, two prosthetics courses taught what we had all learned about the juvenile amputee. The efforts were led by Frantz Aitken, and Lambert at Northwestern University, and later at UCLA by Hall and Brooks.
As a signal of the completion of our maturity, an impressive four symposia were held and the proceedings published under the auspices of the National Academy of Sciences-- National Research Council. Papers were edited by the parent clinic chiefs in Grand Rapids. Acting as a group we had in one way or other created material to enable the chiefs to complete
- Normal and Embryological Development, Charles M. Frantz, editor. Chicago, 1966
- Proximal Femoral Focal Deficiency: An Anomaly, George T. Aitken, editor. Washington, 1968
- Selected Lower-Limb Anomalies, George T. Aitken, editor. Washington, 1969
- The Child with an Acquired Amputation, George T. Aitken, editor. Toronto, 1970
Since the deaths of Frantz and Aitken, many of the original chiefs have left this scene in the same manner or have retired. This is the obvious reason I was invited to bring you the history of the origin of our association and the story of its first 24 years. You have heard this morning, in essence, how two young orthopedists uncovered a serious deficit in the treatment of children with poorly described limb deficiencies. I have summarized how they achieved its recognition, classification, and management by enlisting state and national interest. They augmented the efforts by gaining prosthetic and orthotic engineering enthusiasm and their fellow orthopedists responded. By exerting themselves tirelessly, often at the expense of family ties and social relationships, they worked until their deaths without changing course. We honor them and their families and give this association high credit for continuing when the efforts of Frantz and Aitken ceased.
In the early 1970's, Leon M. Kruger of the Shriners Hospital in Springfield became the first President of the Association of Children's Prosthetic-Orthotic Clinics, carrying on the work with confidence and excellence, the fruit of his faithful service through the earlier years as chief of his clinic.
It is recognized that in addition to Fishman, Wilson, and Kay, scores of people have given much to the success of this organization. Time and chronology prohibit mentioning all of them, but their contributions are no less important. Bob Tooms and Charlie Epps are prime examples. I have heard that my son, Newton, whom I see little of (but do recall) may have attended one, if not even two, of your meetings. Incidentally, he, by mail and telephone, after threats of bodily harm, has helped tremendously with this presentation. He asked me to apologize for his absence, unavoidable, he said, something minor came up, I think, like the American Academy of Orthopaedic Surgeons.
It has been my privilege to review some issues of the Journal of the Association of Children's Prosthetic-Orthotic Clinics, including the reports of your annual meetings. They show clearly the course has not been changed and your contributions have been generous and modem beyond my ken. They are more discriminatory and more sophisticated than were ours, and I congratulate you.
My wife, Donna, and I have lived happily, some of the time, in southern Arizona for the past eighteen years. We participate in and teach emergency medicine to provide emergency medical technicians for about 400 square miles of high desert. We feed the chickens, gather eggs, beat the two dogs, and ride our horses. I haven't seen many children. Our local area houses many retired folks beyond the breeding age. Their only complaints are related to urination and defecation-difficulties or frequency of! Amazingly, the size of stool and even its color seems important. It is necessary to pick up the newspaper to identify which is the day of the week and now who is governor.
Thank you, President Yosh , and our co-hosts, Leon and Jim, for your kind invitation. This effort has literally taxed my brain beyond its limits. I do not look forward to any improvement in my state of progressive senility and think only of saddling a horse and riding west of our tiny ranch into the Tumacacori Mountains, counting the coyotes and jackrabbits flushed out in a three-hour ride. The acid test is being able to remember the animal count and where I have been. Must get a horse that will do this for me!
I acknowledge with thanks the assistance of Shirley Furgerson Edholm, Acting Historian of ACPOC and former Administrator of the Area Child Amputee Center, Grand Rapids, Michigan.
Tubac Regional Clinic, Box 1480, Tubac AZ 85646