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should be made to amputate the limb through the middlethird of the thigh, -fillet out the femur, and substitutefor it a plastic model of its upper half or two-thirds.This was done. Precise measurements of the normalfemur were first obtained from radiographs taken withprecautions to avoid magnification and distortion.

’Polythene’ was chosen as the material for the

prosthesis on account of its satisfactory, mechanical andchemical properties. Superficial alterations can readilybe made at the time of operation, which is hardly possiblewith more rigid materials such as ’ Vitallium ’ and’

Perspex.’ Polythene is a straight-chain (aliphatic)hydrocarbon containing 1000-2000 carbon atoms and

having only about one double bond ; it therefore hasthe stability and high resistance to chemical changecharacteristic of the ordinary paraffins, and it also

possesses considerable toughness and resistance to

fatigue strain. It further resembles paraffin wax inthat it has a non-wettable surface and that living tissuedoes not adhere to it. Polythene has already beenused in the human body, animal experiments havingdemonstrated its inertness and lack of toxicity.The prosthesis (fig. 1) was carved from a block measur-

ing 10 by 4 by 3 in. ; when finished it weighed 71/2 oz.and was 8 in. long. Channels were made in the prosthesisfor the attachment of the flexors and extensors of the

hip, the adductors, and vastus lateralis. From thenature of the deformity of the femur it was obviousthat the abductors of the hip would be useless, so noprovision was made for attaching them to the prosthesis.The operation was performed on Aug. 2, 1949, by

H. J. S. assisted by J. T. S., Mr. M. Albert, and Mr. D.Evans ; the anaesthetic was given by Dr. M. V. H.Denton, and during the course of the operation twopints of blood were transfused. The steps (fig. 2) wereas follows :

1. The external iliac artery was exposed and was thenoccluded by a loop of tape until the greater part of theoperation was over.

2. The usual long anterior and short posterior curvedincisions for amputation through the lower third of the

thigh were made, their lateral junction being continued as alongitudinal incision up to the trochanter.

3. The lateral incision was deepened posterior to thevastus lateralis and the femur dissected out by peeling offthe muscles with diathermy cutting. The flaps were completedand all vessels tied distally so that the vascularity of theflaps would be as great as possible.

4. The prosthesis was then inserted, after a good fit of thehead of the " femur " had been obtained by filing its surface.The tendon of the iliopsoas was led through the canal inthe upper part of the prosthesis and sutured to the tendonof gluteus maxiinus. The lower margin of the adductorswas similarly attached to that of vastus lateralis, the pointof attachment lying in the slot cut in the lower end of theprosthesis. By these means the prosthesis was secured

effectively, and there seemed some prospect of its becomingwell controlled by the more important muscle-groups. -

5. The remaining muscles were brought together with

interrupted sutures, and the skin likewise, around corrugatedrubber drains inserted at the upper and lower ends of the

longitudinal incision.The operation, which lasted for two hours, was a

formidable affair and during the last thirty minutesthe patient’s condition gave us some anxiety. However,with the aid 01 another pint of blood after operation,he improved rapidly. ,

Our chief anxiety was the avoidance of infection,for an enormous area of tissue was exposed during thecourse of the operation. Intramuscular injections of40,000 units of penicillin four-hourly were thereforegiven from July 29 (four days before operation) untilAug. 26. Even so there was a little deep infection ofthe end of the stump and a terminal slough 2 by 1 in.in diameter. Pyogenic staphylococci were found in thedischarge, as well as in the patient’s nose during the third

week after operation, and although these organisms weresensitive to penicillin it was decided to change to strepto-mycin (to which they were also sensitive) in view of thedisturbing persistence of diffuse tenderness and oedema.Systemic streptomycin was therefore given at the rateof 1 g. a day for one week. By Sept. 2 the stump washealthy and the ulcer at its tip almost healed ; and theusual after-treatment for an amputation through thethigh was started.

’

On Sept. 22 the state of the stump was normal. Theboy has been measured for an artificial limb and is

already walking on a temporary pylon.We are greatly indebted to Imperial Chemical Industries

Ltd. for supplying the block of polythene and to thede Havilland Aircraft Company for their help in making theradio sranhic measurements.

Royal National OrthopædicHospital, London.

Institute of Orthopædics,London.

H. J. SEDDOND.M., F.R.C.S.

JOHN T. SCALESM.R.C.S.

Medical Societies

ROYAL SOCIETY OF MEDICINE

Whither Antenatal Care ?

AT a meeting of the section of obstetrics on Oct. 21,with Mr. LESLIE WILLIAMS, the president, in the chair,a discussion on antenatal care was opened by Mr. ALECK

BOURNE.Mr. Bourne said he had been asked to keep the discus-

sion on a higher plane, so he deliberately avoided figures.The recorded history of antenatal care went back toAristotle, but it was Pinard who laid the real foundations.Pinard opened a home for abandoned pregnant womenin Paris in 1895 and noted an improvement in the babieswhose mothers came under his care. Ballantyne inEdinburgh had often been called " the father of antenatalcare " ; but this was inaccurate, for his main interestwas in stillbirth and foetal abnormality. He was not anobstetrician, but rather a teratologist ; he had lessinterest in antenatal health than in the deformed foetus.It was in later years that he instituted the system ofantenatal visiting, and such a system had already beenstarted some years before in Boston.

Mr. Bourne went on to recall how, in 1909, when hewas a student at Queen Charlotte’s, a small antenatalclinic was started by Harold Waller and others. Hereattention was focused first on presentation, secondly onthe contracted pelvis, and thirdly on albuminuria ; andan attempt was made to forestall dystocia. The war of1914-18 checked progress ; but in -1918 the Ministry ofHealth began to establish antenatal clinics, and therewere now over 1600 throughout the country. He dividedthe history of antenatal care into four phases : (1) thatfrom Aristotle to Pinard; (2) that introduced by Pinard : -,(3) that introduced by Ballantyne; and (4) that initiatedat Queen Charlotte’s Hospital.

Until lately the emphasis had been more on structurethan on function, except in regard to albuminuria. Thismechanical view encouraged unnecessary interference-for example, induction of labour where the head washigh. Herman had even given a list of the periods ofgestation at which induction should be carried out,according to the size of the conjugate. Induction byKrause’s bougies was the usual method. Between 1908and 1921 the induction-rate at Queen Charlotte’s hadrisen from over 2 % to over 7 %, and the maternal mortalitvhad steadily risen to 4-41 per 1000 in 1934, which was thehighest recorded since 1890. This was despite increasingantenatal care and better obstetrical training. It mightappear therefore that up to this point antenatal care hadfailed in its primary object. But much of this mortalitywas due to mismanagement in labour. In the 1930sexternal pelvimetry came to be regarded as useless, butthe mechanists got further encouragement from theintroduction of X-ray pelvimetry. Mr. Bourne deploredthe practice of basing obstetrical prognosis on the

radiological findings, and pointed out that the accepted

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limits of normality were far too narrow ; moreover, manyother factors-notably the ability of the uterus tocontract-had to be taken into account.

Since function was all-important, could this be pre-dicted or ensured ? Mr. Bourne felt that it could. Func-tional action of the uterus depended primarily on thepatient’s emotional reaction, and secondly on the typeof patient ; and he contrasted the gynaecoid with hereasy periods, her ready conception, her effortless preg-nancy, and her eutocia with-at the other extreme-theandroid type with her menstrual difficulties, her unsatis-factory obstetrical history, and her liability in labour toa maximum of pain with a minimum of effective function.In pregnancy unresolved fear was bound to lead toinertia. Physical constitution could not, of course, bealtered ; but much could be done with regard to fear,which should if possible be exorcised during pregnancy, inorder to secure good uterine function. Short of moderatemalnutrition, he did not think that diet had much effecton uterine function, except in the matter of prematurelabour. The chief value of antenatal exercises dependedon suggestion and the feeling engendered in the patientthat she was contributing towards her labour. Thetangible results of X-ray pelvimetry and other structuralsigns had been overemphasised at the expense of function.

Prof. W. C. W. N]EXON urged that the mechanisticapproach should be replaced by the holistic. Dr. Wrigleyhad pointed out that meddlesome midwifery had spreadfrom the labour ward to the antenatal clinic. It wasFairbairn who had coined the term " constructivehygiene " in relation to pregnancy, and the new attitudeto antenatal care was born in those days. Professor Nixonregretted the persistence in midwifery teaching ofemphasis on the abnormal. A food advice bureau, suchas had been established at University College Hospital,was a necessary part of an antenatal clinic. Nutritionalanaemia still prevailed, and all cases should have a routineestimation of their haemoglobin at their first attendanceand again at 36 weeks. This would help to reduce post-partum haemorrhage and its effects. X-ray examinationof the chest was done as a routine at University CollegeHospital, and this should be obligatory. He advocatedexternal version as a matter of course, where needed-with an anaesthetic only when an attempt without ananaesthetic had failed. One of his main concerns was theelimination of fear, and classes of training organised bythe anaesthetist to the obstetric unit did much to engenderconfidence. These courses were run in cooperation witha physiotherapist and a labour-ward sister. The physio-therapist talked of the value of relaxation as indicatedby Grantly Dick Reid. Breathing, posture, and exercisesmight all influence labour favourably, and the exercisesused were those of Mrs. Helen Herdman. These ideashad originated in Britain, but they were already betterexploited in the U.S.A.

Dr. A. J. WRIGLEY suggested that in the past thepatient’s general health had too often been ignored ; andhe deplored the practice whereby one worker did all theurine-testing, another rushed round with a sphygmo-manometer, and another laid hands on the abdomen,and yet none took any notice of the patient as a person.Hitherto results from remedial exercises were discour-aging ; two investigations had shown that these exerciseshad no significant effect on the nature or outcome oflabour. As regards version, this was seldom necessarybefore the 34th week ; no force should be used, parti-cularly if the patient was anaesthetised. Dr. Wrigleydeplored pointless and ineffective inductions for allegedpostmaturity, and held that less attention should begiven to the breast in pregnancy. Without wishing to beclassed as a mechanist, he felt that all primigravidaeshould have X-ray pelvimetry. In antenatal clinicsmany routine practices could be replaced if more commonsense were used. He referred to the present detachmentof the antenatal officer from the hospital officer as a greatevil which had evolved fortuitously with the growth ofantenatal clinics ; under the National Health Servicethis detachment was being aggravated-not abolished ashad been hoped-owing to the division of responsibilitybetween the local health authority and the regionalhospital board.

Mr. ARNOLD WAi.KBB welcomed the provocative notewhich Dr. Wrigley had introduced. He pleaded for less

condemnation of the work of antenatal officers. Nobodythought this system perfect, but it was the only way tofill an otherwise inevitable gap. Welfare-mindednesswas the spirit and essence of antenatal clinics, and it wasbacked by a knowledge of local conditions. These clinicsshould be integrated with the hospitals, though thiswould not be easy. In the clinics it was better to haveroutine than serious omissions.

Mr. A. W. PuRDiE said that the system of antenatalclinics worked well ; but the system might break downthrough routine ; toxaemia might be missed becausesupervision automatically ceased when the patient outranher theoretical gestation period.

Mr. J. M. WYATT thought that much fear was engen-dered by the publicity given to the difficulties of labourand all the measures to which the patient was subjectedto forestall these difficulties. The greatest source ofreassurance was the successful multipara who hadweathered six or more pregnancies without difficulty.

Reviews of Books

The Mammalian Adrenal Gland

GEOFFREY H. BOURNE, D.sc., D.PHIL., reader in histologyin the University of London at the London HospitalMedical College. London : Oxford University Press.1949. Pp. 239. 30s.

Dr. Bourne’s book is a well-documented comparativestudy of the anatomical position and histology of themammalian adrenal. It is introduced by a historicalreview of the gland and its histology, and containsdescriptions of the adrenals of more than 250 species.Many of the descriptions of the adrenals of the eutherianmammals have been collected from published work, andso are less complete than those derived from Dr. Bourne’sown observations (which are particularly extensive onthe marsupials). His study demonstrates that themammalian adrenal displays a remarkably constantstructure, and he concludes that an adrenal gland inwhich the medulla is in the main completely separatedfrom the cortex, and surrounded for at least three-quarters of its circumference by the latter, is as diagnosticof the mammalia as hair and nails. Only in the mono-tremes does the adrenal differ from the typical mammaliantype. The book ends with a general summary of mam-malian adrenals, including concise observations on thelipoids, pigments, and vitamin C of the adrenal, andthe relation of adrenal cortical structure to function.

A Twentieth Century PhysicianBeing the Reminiscences of Sir ARTHLTR HURST, D.M.,F.R.C.P. London: Edward Arnold. 1949. Pp. 200. 15s.

WHEN Sir Arthur Hurst died he left behind him hisautobiography in the making. Now, after four years,with the help of his friend Prof. John Ryle, it has beencompleted. If he had been given time Hurst would nodoubt have expanded the account here given of hislater activities to the scale on which his earlier life ispresented. Had he done so the story might have gainedin completeness but perhaps not in interest. For it isof the young, vital, ardent Hurst that we may be contentto read, before his asthnza had taken toll of his incom-parable energy and vitality. Nothing that he ever did,or wrote, was ddll or colourless, and here is the authenticvoice of his early days, with its curious deep buzzingnote of eager interest, determined to expose what heknew to be error and to demonstrate what he held-not always correctly or for very long-to be truth.Autobiography is apt to unfold itself on a fixed pattern :

childhood’s memories, school, college, initial difficultiesand setbacks, recognition and reward. Hurst’s does notdiffer from others except that there were no initialdifficulties, and no setbacks in the astonishing burst ofsuccess which was his from the first, and of which hehere makes so little. For within a few years he becamenot only a consultant whose opinion was widely sought,but the most popular and inspiring teacher of his greatmedical school and an acknowledged leader in theinvestigation of disease by the newer methods. For avariety of reasons, at the turn of the century, medicine