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Before his disablement the young man played theclarinet. Loss of function of the right hand deprivedhim of this hobby ; but as soon as he realised whatcould be achieved by aids he determined to try to playan instrument which requires the left hand only, andselected the French horn. A stand with many jointswas then designed to hold and adjust it. He is now indemand by local amateur orchestras.

Being self-contained in his chair he is, for practicalpurposes, able to lead the life of an ordinary citizen.He has graduated at a university and has now taken hisplace in business.

DISCUSSION

The chair was designed from several years’ experiencein the daily use of a previous model in steel.The main considerations were that the chair should

be comfortable, easy to manipulate, easy to transport,and self-contained. Where there is wasting of musclesover an extensive area, pressure must be borne evenlyover the whole of the affected parts. For this reasonthe seat, back, and leg-rest were designed, when coveredwith a honeycombed rubber mattress 4 in. thick, toconform roughly to the anatomical shape of the body,a fine degree of adjustment being possible by altering thetension of the lacing. Provided all wrinkles are removedfrom the clothing when the disabled person is placed in thechair, comfort is not disturbed when the back is loweredfor change’ of position. The urinal is used with theback lowered ; the bedpan with it raised. To place thebedpan in position, the technique is to lower the back,raise the buttocks, slip the bedpan into position, thenraise the back, and cover the thighs with a carbon-impregnated cloth. Two attendants are required, thoughone can manage. :

For ease of manipulation all the moving parts are fittedwith ball-races. Without ball-races the moving parts soonwear out. Once wear sets in, with the amount of man-handling the chair is subjected to, the construction loses itsstability’. Ball-races are therefore not a refinement butessential. The design of the hinges and their method offixation make the chair rigid, though there is some whipin the material. The chair weighs 31 lb.

Ease of transport has been achieved by designing adetachable wheel-chassis with a simple attaching device.There is no difficulty in loading the chair into a car,any passer-by in the street can be called on to givea hand. The wheel-chassis weighs 39 lb. The weightcould be reduced slightly by fitting solid rubber tyresto the wheels ; but the pneumatic-tyred wheels, thoughheavier, are a great boon, especially for cross-countrywork, and make the chair look as if ’it had been builtfor a disabled person rather than an invalid.

The chair is self-contained as regards fittings, suchas writing-table, dining-table, head-rest, and arm-rest.These fittings are easy to carry and thus make it

possible for the disabled person to take his place in

society.This chair has passed through its users’ trials success-

fully and is giving satisfactory results. The cost of itsconstruction is difficult to estimate, because it was notmade in a commercial workshop, and each part wascut from raw material and shaped by hand. It took a

long time to make, but its usefulness is an adequate-reward for the time spent. The materials are not costly.In this article technical details have been purposelyomitted, but I will be pleased to give them to anyonewho may wish to construct a chair on similarlines.

I wish to thank my father, Major-General L. T. Poole,o.B., D.s.o., M.o., for his guidance, and Mr. B. N. H. Thornley,of the developments department of the Northern AluminiumCo. Ltd., for selecting the materials required.

’

Medical Societies

EDINBURGH OBSTETRICAL SOCIETY

Incoordinate Uterine Action

AT a meeting of this society on Feb. 9, with Dr. E. C.FAHMY, the president, in the chair, a paper on inco-ordinate uterine action in labour was presented by Prof.T. N. A. JEFFCOATE (Liverpool).

Professor Jeffcoate criticised the use of the term" uterine inertia " on the score that incoordinate uterineaction was often associated with high muscle-tone,especially in the middle and lower zones, or with spas-modic violent contractions, or with a constriction ring.The clinical picture was one of prolonged labour with slowdilatation of the cervix, despite the presence of stronguterine contractions and the absence of gross dispro-portion. Pain, which was unusually distressing, was feltpredominantly in the back ; sometimes, when it assumeda down-bearing nature before full dilatation of thecervix, it appeared to arise through spasm of the lowerbowel. All degrees of incoordinate action might be found ; -,and it was particularly liable to occur in the presence ofdisproportion.Of 101 cases observed in Liverpool, 62 were seen in

private practice and 39 in hospital. The incidence inhospital cases was 0 -6 % ; the condition was seen moreoften in private practice, but it was not possible to workout any very reliable figures of its incidence here. Thedisorder was almost entirely confined to primigravidpatients, but the setiological influence of advancing agehad been exaggerated. Premature rupture of the mem-branes did not appear to be a direct cause, since thisoccurred in only 22 cases, whereas in 56 the disorderedaction of the uterus was recognised prior to rupture.Indeed, even when the membranes were unrupturedthe uterine disturbance was sometimes enough to causeembarrassment of the foetus. The significance of theoccipitoposterior position as a cause of incoordinateaction had been confirmed, and delayed engagement ofthe head in occipito-anterior position was noted often.The maternal and fcetal dangers of this condition had

diminished with the introduction of chemotherapy,better general care of the parturient, caution over ances-thesia, and readiness to resort to caesarean section latein labour. Nevertheless, the dangers were still present,although in the two series no mothers died and the foetalloss by stillbirth and neonatal death was only 12 %.Professor Jeffcoate estimated that but for caesarean

section the foetal mortality would have been in theneighbourhood of 50 %.A further series of cases had been investigated in

respect of remote prognosis. Of 140 severe but non-fatal cases requiring csesarean section or forceps deliveryduring the years 1936-46, 91 had been traced. Asa result of their experiences more than one-third of thesepatients decided to avoid further pregnancy ; only halfhad further children. As regards this voluntary infertility,there was little difference between the caesarean-sectiongroup and that in which forceps had been used ; butall the women who had lost their first children triedsubsequently to conceive, while contraception was

practised only by those who had a living child. A fewwomen embarked on further pregnancy only whenpromised that delivery would be by elective csesareansection. In general terms the follow-up showed thatin a large proportion of cases the behaviour of the uteruswas much more efficient in the second labour, and thatwhereas csesarean section might be necessary in thefirst labour there was a good chance of vaginal deliveryin the second. The ease of the second delivery appearedto be to some extent proportional to the stage of dilatationreached by the cervix at the first labour. When fulldilatation had been attained, even if the baby had beendelivered dead and with difficulty, the second labourwas usually easy. Caution was therefore necessary inadvising elective caesarean section solely because of a "badobstetric history."

In the control of disordered uterine action, theadministration of analgesics and antispasmodics, parti-cularly morphine and pethidine, remained the chief lineof attack. Professor Jeffcoate reported generally dis-

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appointing results with intravenous magnesium sulphate,trinitroglycerin, and oestrogens. After intravenousadministration of dilute solutions of oxytocin in glucose-saline, as recently advocated by Theobald and others,two of his patients had suffered- most severe pain withoutany change in the nature of the contractions, whichremained incoordinate. In each of 11 cases tetraethyl-ammonium chloride had appeared to produce a strongand sustained uterine contraction, sufficient in ] case

to cause alarm for the foetus. When this contractionhad passed off, the patients experienced more frequent,and apparently stronger, uterine contractions for up toone hour ; but again there was no evidence of alteration

in the nature of the contractions, and 2 cases ofconstriction ring persisted.

Professor Jeffcoate criticised the contention that fearand emotional tension were important in the aetiologyof incoordinate uterine action; for this condition did notrecur in deliveries after the first, even ’when the firsthad been sufficient to daunt the stoutest heart. Hethought that an unnatural resistance of the soft tissuesof the lower part of the uterus might be more importantthan neuromuscularim balance resulting from fear. Inconclusion he classified inefficient uterine action underthe headings of (1) inertia proper, (2) incoordinateuterine action, and (3) cervical dystocia.

Reviews of Books

° Critical Studies in NeurologyF. M. R. WALSHE, M.D., F.R.C.r., F.R.S., physician toUniversity. College Hospital and to the National Hospitalfor Nervous Diseases, Queen Square. Edinburgh :E. & S. Livingstone. 1948. Pp. 256. 15s.

OF late years research in medicine has come to beregarded as almost synonymous with the discovery ofnew facts. As Dr. Walshe points out in the foreword ofthis book, the climate of opinion does not favour thecritical. The facts, however, need interpretation, and, ifthis is not consciously sought, an erroneous interpreta-tion is often unconsciously assumed. Thus the distinctionbetween critical and creative research is an artificial one,as was well shown by the work of Hughlings Jackson, inwhose discoveries it is impossible to separate the role ofreflection from that of observation. Hence, in his newbook Dr. Walshe is employing the Jacksonian method.All but one of these essays have previously been pub-lished in Brain, but it is to be hoped that, gathered thusinto one volume, they will reach a larger public. Thefirst, on the anatomy and physiology of cutaneoussensibility, contains a criticism of the views of Headand Rivers and an account of recent work chiefly on theperipheral organisation of sensation. This is followed bya study of the motor cortex and the pyramidal tract, inwhich Dr. Walshe discusses the attempt to delimit themotor cortex in terms of its cellular structure andreasserts his objection to Fulton’s view that there is afunctional difference between area 4 and area 6. Thethird essay, on the mode of representation of movementsin the motor cortex, is a study of the inferences whichcan be drawn from Jacksonian convulsions concerningthe functional organisation of the motor cortex. Dr.Walshe believes that movements are represented not bya mosaic of isolable points but " on a plan of wide andoverlapping fields, each of which has a focus wherein themovements of a given motile part are mainly, but notexclusively, localised." Then follow two shorter papersin which the same theme is developed, and the lastchapter is on the integration of medicine and is a discus-sion of those philosophical principles which have founda practical expression in the rest of the book. Differen-tiation and integration in the development’and activitiesof the organism are paralleled by observation andinterpretation in the sphere of the mind. These are thesystole and diastole of medical research-the oppositeswithout which, as Blake says, there is no progression.This is Dr. Walshe’s salutary message for our times, andhere he is both preacher and practitioner.

Detailed Atlas of the Head and NeckRAYMOND C. TBUEX, M.S., PH.D., associate professor ofanatomy, College of Physicians and Surgeons, ColumbiaUniversity, New York ; CARL E. KEMEB, artist in thedepartment of anatomy of the college. New York andLondon : Oxford University Press. 1948. Pp. 162. 75s.

THE most valuable atlases of anatomy have usuallyresulted from the cooperation of anatomists and artists.Such an association of Professor Truex with the artist CarlE. Kellner has been fully justified by the production of thisaccurate and attractive atlas of the anatomy of thehead and neck. All the drawings in the first part of thebook are from original dissections, and are notable fortheir clearness and their exact portrayal of successivestages in the dissection of particular regions. Out-

standing features are the representation of the anatomyof the junctional regions of the neck with arm and thorax,and the instructive approaches to the dissection ofvarious other regions (such as that through the middlecranial fossa and petrous temporal bone into the infra-temporal region). The second section contains someexcellent drawings of skeletal structures. Finally, a

series of coronal and transverse sections display in finedetail the topographical relations of structures in theneck and cranium. The large size of most of the draw-ings, together with a judicious use of colour for vessels,nerves, and (in the skull) separate bones and muscleattachments, make the various structures pleasinglydistinct and favour the rapid comprehension of relation-ships. This atlas will be welcomed by teachers ; it willalso be of real value to the student for reference, and tothe surgeon who wishes to review quickly the approachto cervical or cranial structures.

Anaesthesia for the Poor RiskW. W. Musaaz.r, M.B., D.A., director, department ofanaesthetics, Welsh National School of Medicine, Cardiff.Oxford : Blackwell Scientific Publications. 1948.

Pp. 65. 7s. 6d.

THis is an excellent little book. Lightly written, itallows the reader.to survey a wide range of anaestheticspleasantly in one evening by the fireside. These one-pageessays, the first of which gives its name to the book, teachnothing of technique, but much of philosophy, and evenmore of common sense. It could more helpfully havebeen entitled " The Intelligent Doctor’s Guide to Anaes-thetics " ; and every surgeon would be the better forreading it.

Tuberculosis

A Discltssion of Phthisisgenesis, Immunology, PathologicPhysiology, Diagnosis, and Treatment. FRANCIS MARIONPOTTENGER, A.--U., M.D., LL.D., F.A.C.P., emeritus professorof medicine, University of Southern California ; directorof the Pottenger Sanatorium and Clinic for Diseases ofthe Chest. London : Henry Kimpton. 1948. Pp. 597.60s.

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THE key to Dr. Pottenger’s book is his confession thatfifty years of medical practice have left him with verylittle phthisiophobia. He looks on tuberculosis as adisease which is only mildly infectious and which offersthe greatest possible opportunity for eradication. Theprimary infection is to him a vaccination, and, were itnot for the fact that it sometimes provides a focus fromwhich future metastases arise, it would be a desirableform of immunisation. Vith these basic conceptions inhis Inind and long practical experience to draw on, hesets out to portray tuberculosis as a sometimes destructivebut more often a localising and healing disease with ahopeful prognosis. In fact he has a sturdy faith in theresistance of the patient, in the great value of the goodsanatorium, and in the skill and guidance of a wisephysician—sometimes reinforced by a surgeon. In allthis the book is essentially clinical in its outlook, withthe emphasis on the good vintage of the ancient regime.There are separate chapters on each of the classical methods

of examination-inspection, palpation, percussion, andauscultation-and only the same allowance (and a shortone at that) for radiology. In discussing the search for thetubercle- bacillus, Dr. Pottenger rightly emphasises the valueof concentration methods of examining sputum ; but newermethods such as gastric lavage and laryngeal swab cultivationare not stressed. Morbid anatomy receives less attention