Toileting self-care methods for bilateral high level upper limb amputees L. F R I E D M A N N Paediatric Occupational Therapy Department, Institute of Rehabilitation Medicine, New York

Abstract O n e of the most i m p o r t a n t problems for the bilateral u p p e r limb deficient patient is the inability to manage toileting activities. D e p e n d e n c e in this a r e a precludes schooling or w o r k . This p a p e r surveys available clothing types a n d a d a p t a t i o n s to facilitate doffing and donning clothing and devices for genital cleansing and m e n s t r u a l care. T h e devices are analyzed for suitability for different types and levels of high deficiency a n d purposes. I n d e p e n d e n c e requires intense motivation of the patient and elimination of overprotection by the parents. Introduction T h e p r o b l e m which is of greatest concern for the bilateral high level u p p e r limb a m p u t e e is the ability to take care of himself in toileting. T h e inability t o cleanse oneself after defecation, u r i n a t i o n , and m e n s t r u a t i o n , eliminates the possibility of attending school, independent travel, o r e m p l o y m e n t . While it is occasionally acceptable to consent t o being fed by someone else, it is degrading and destructive of selfconfidence for an individual to have to be cared for in t h e most intimate of activities, toileting. This aspect is frequently ignored by m e m b e r s of t h e rehabilitation team because toileting activities a r e considered "dirty". Rehabilitation requires that the rehabilitation team be c o n c e r n e d with successful function in this as in o t h e r abilities. T h e p r o b l e m exists mainly in congenital limb deficiency, although an occasional acquired a m p u t e e will have a similar problem. T h e principles are t h e s a m e , except that in the adult t h e range of m o t i o n of the lower limbs will generally be m o r e restricted.

T h e s e persons must be assessed individually. T h e precise length of the residual limbs, the r a n g e of m o t i o n of each joint, the muscle strength a n d agility remaining are crucial. For that reason, only general classifications can be given, and a series of trial m e t h o d s and devices may be required in an individual case. T h e p u r p o s e of this article is to attempt to disseminate the information that the author has g a t h e r e d over a prolonged period of time from m a n y sources, so that the therapist working a n y w h e r e will have the combined experience of many rehabilitation facilities. In t h e rehabilitation of t h e high bilateral u p p e r limb a m p u t e e , t h e success achieved is directly related to the motivation. T h e motivation of the child is to a great extent a reflection of the motivation of the parents. If the parents wish the child to attend school, then as a rule the child will be motivated t o attend school and to learn those things which are required in o r d e r for him to d o so. O n e of these is the ability to take care of himself in t h e toilet. T h e patient who is strongly m o t i v a t e d towards i n d e p e n d e n c e will usually succeed in being i n d e p e n d e n t despite very severe handicaps. If the parents want to keep the child d e p e n d e n t , they will generally succeed in so doing, often for life. This precludes i n d e p e n d e n c e in the activities of daily living, in schooling a n d in vocational training and placement.

Preparation for toileting activities Before toileting can be started, the clothing and underclothing must be r e m o v e d . F o r the young child clothing a d a p t a t i o n s are almost always required. W h e n t h e child reaches adolescence a n d starts to consider social activities, clothing a d a p t a t i o n s are frequently rejected because of their unsightly appearance. Clothing a d a p t a t i o n s should be as inconspicuous as possible. R e q u i r e d loops should be m a d e from

t h e material of t h e clothing so as to be inconspicuous; Velcro closures should be the same colour. A s few special devices as possible should b e used, so that they d o not have to be carried to school, to work, or while travelling. L o o s e clothing without elastic is desirable, to m a k e doffing and donning easier. In the male w h o needs to urinate, if the zipper c a n n o t be o p e n e d by the extremities, either without or with a loop o n the zipper pull, the trousers may be left partially o p e n . Provided the u p p e r part of the trousers is covered by an exterior shirt or jacket, the fly of the trousers may be left two-thirds open to allow a boy without arms to urinate independently. T h e individual will generally not wear underpants. T h e pants are suspended by m e a n s of suspenders r a t h e r than a belt. T h e cross of the suspenders in t h e back must be quite high to prevent sliding off, usually just below the seventh cervical v e r t e b r a . T h e tension must be just appropriate to suspend t h e trousers. T h e trousers are pulled d o w n by having t h e individual slip off one shoe a n d grasp the pants leg on the contralateral side with the toes and pull down the trousers, exposing the penis in t h e already open fly. In patients with partially functional upper limbs, the fly of the trousers may be entirely closed, to be o p e n e d by the upper limbs with or without a limb extender. This is generally facilitated by use of a small key ring in the zipper tab. F o r defecation the pants will have to be r e m o v e d completely. T h e pants can be closed with Velcro at the waistline, usually with a counter-pull through a D-ring or overlapping. Belt loops and occasionally other loops may be required for donning the pants either with the residual limbs or with a limb extender. Because this is difficult, it is preferable for the individual t o be trained to have a bowel m o v e m e n t either in t h e m o r n i n g before leaving the house or in the evening after returning, rather than during the school o r work day. T h e pants are generally d o n n e d by placing t h e m o n the floor or mattress. T h e patient inserts t h e feet into the trousers and raises his legs. Gravity and shaking cause the p a n t s to slide proximally while the patient lies supine. W h e n the pants are at the level of the hips, t h e patient utilizes friction between the m a t t r e s s o r floor a n d the trousers to hold them in place while wiggling t h e buttocks into the upper p a r t of the trousers. If suspenders are used to

hold up the trousers, o n e shoulder is inserted at a time u n d e r each suspender strap. This may be assisted by m e a n s of the contralateral foot and/ or use of the teeth or occasionally the chin. Sometimes the pants are pulled over the hips while standing, pulling up the suspenders with the teeth while rotating the hips with the legs in maximal abduction. Occasionally a boy wishes to wear his shirt inside his pants. This increases the difficulty in dressing. L o n g elastic straps should be sewn to the shirt at the hemline. These loops are held with the toes while the trousers are d o n n e d .

Fig. 1. Devices from the Rehabilitation Institute of Montreal. Left, clothing hook attached to mirror. Right, device for patients with short upper limbs (see text). Devices Devices may be utilized to facilitate doffing and d o n n i n g of clothing. T h e simplest one that will d o the j o b is best. T h e most useful is a clothing h o o k o n the wall at the appropriate level for the individual. T h e hook may be of any shape. It may be plain, r o u g h e n e d or have rubber tubing. M o n i q u e A u d e t at t h e Rehabilitation Institute of M o n t r e a l , C a n a d a , applies the h o o k to a mirror with a suction cup so that the individual can see w h e r e the h o o k is in relation to the clothing. (Fig. 1 left). They also developed a device for patients with short upper limbs, especially phocomelia. It is a forked rod to push the trousers d o w n . (Fig. 1 right). O n e side of the fork has a h o o k o n it to be used for pulling. T h e o t h e r e n d of the rod has a cup which the patient applies to his chin forcing the cup and rod down to lower the clothing. In addition, there are

dowels through the rod which are manipulated by the phocomelic extremity and assist in pulling o r pushing. A modification was described by R i n g (1972) which is a rod connected to an S s h a p e d curved h o o k with the S being o n its side t o push a n d pull. M. A . M e n d e z at Q u e e n Mary's Hospital, R o e h a m p t o n , L o n d o n , England, has developed many devices and m e t h o d s for these patients. Patients with upper limb phocomelia and normal lower limbs use a dressing stick with a hook, S—shaped as described by Ring, but retractable a n d lockable, or r o u n d . Patients with amelia who d o not have an u p p e r extremity with prehension use wall h o o k s and a dressing stick with a biting tip. She adapts the clothing using Velcro usually with counterpull, b u t occasionally overlap. She occasionally uses Velcro with two loops and a split ring. She illustrates a G e r m a n wall h o o k for dressing a n d undressing which is attached to a wall. This is a flat disc on a rod which is attached t o t h e wall for raising and lowering the clothing (Fig 2 ) . A n n G . Fisher, A r e a Child C e n t r e , G r a n d R a p i d s , Michigan, has used various shaped plastic limb extenders with a split at the distal e n d for pushing pants up and down.

m o t i o n of the hips a n d / o r severe shortening of the femur or of the tibia. T h e third category (C) is children w h o h a v e n o u p p e r limb function with n o r m a l lower limbs and with well developed foot function. A n y child w h o can m a n a g e to cleanse the groin a r e a without devices should d o so. F o o t usage is usually a d e q u a t e , with trunk motion where needed. (A) Short arms with grasp O n e may have t o extend the length of the upper limbs artificially using some type of limb e x t e n d e r for pushing clothing down and pulling it u p with an individually designed device for holding the toilet paper. If the devices cannot be collapsed for carrying, two sets are required, o n e for h o m e and one for school. Simple ones may b e m a d e from 1/2" (1 cm) d i a m e t e r dowel with an L - s h a p e d h o o k , covered with r u b b e r tubing, or with a c o a t - h o o k b e n t at an a p p r o p r i a t e angle depending on the configuration of t h e patient. Useful suggestions for wiping devices have b e e n received from many sources. Bridget D u c k w o r t h at t h e G . F . Strong Rehabilitation C e n t r e , in V a n c o u v e r , C a n a d a , has found useful a limb e x t e n d e r m a d e of stainless steel welding rod inserted into a plastic or w o o d e n handle. (Fig. 3). A J - c l o t h ( H a n d i or Easy Wipe) is inserted into the end and w r a p p e d a r o u n d the p r o n g s . T h e patient wipes with one part of the cloth, flips the end over and uses a clean part. M. A . M e n d e z uses a dowel handled extender which has a similar spring metal coil for inserting toilet

Fig. 2. Wall mounted disc for dressing and undressing used at St. Mary's Hospital, London.

Toileting T h e r e a r e three categories of patients w h o have toileting p r o b l e m s . T h e first is ( A ) children w h o have short u p p e r limbs, sometimes with true p h o c o m e l i a , with a d e q u a t e grasp and release, b u t w h o lack t h e limb length a n d reach t o cleanse after defecation. T h e second category (B) is children w h o have i n a d e q u a t e grasp and release in the u p p e r limbs, w h o have limited range of

Fig. 3. Stainless steel limb extender from the G. F. Strong Rehabilitation Centre, Vancouver (see text).

p a p e r . Black Notley Hospital, Braintree, E n g l a n d , use a toilet p a p e r holder m a d e out of a stainless steel knitting needle set in an aluminium tubing handle ( L o w m a n & Klinger, 1970). Y. C u p i d at t h e University of Saskatchewan University Hospital in Saskatoon, C a n a d a , r e c o m m e n d s a long-handled holder m a d e of coat hanger, wire with a coil into which toilet paper is placed, also similar t o the preceeding two. A second device which has been used by them is a pair of long-handled tongs b e n t t o the desired s h a p e . This is sometimes difficult to control if the patient uses a prosthetic terminal device. F o r travelling, D u c k w o r t h has used a washing aid consisting of a long towelling washcloth with o n e e n d h o o k e d to t h e shower head at the top a n d t h e lower e n d attached t o two large suction cups which are fixed about half the length of the b a t h t u b . With this, every area can be washed, including t h e perineal area. It is generally fixed in place by t h e feet o r prostheses. A s with most c e n t r e s , they find wrist flexion units helpful in manipulating trouser zippers if prostheses are used. T h e zipper tabs a r e fitted with a small split ring o r loop for additional assistance. T h e wrist flexion units a r e also helpful for extracting the penis. S o m e patients are agile enough to use the prosthetic hook for wiping. All wiping of the anus should be d o n e from the rear in females to avoid vaginitis. M . A u d e t uses a portable plastic stick or spatula with a slit o r hole at the functional e n d , into which toilet tissue is inserted. T h e limb e x t e n d e r is modified according to each child's special needs in length, shape, material, size, etc. A s with most centres, they find that collaboration between the therapist, the parents a n d t h e child is required for success with these devices, because many types need to be tried before a p p r o p r i a t e ones are finally developed. T h e y p r o d u c e devices that are simple, usable in most situations a n d easy to transport in a purse or schoolbag so that multiple devices are not required. H e l e n J. Scott of Princess Margaret Rose O r t h o p a e d i c Hospital in E d i n b u r g h , Scotland, uses a metal folding e x t e n d e r which has a metal ring attached t o its e n d . Stitched t o this is a r u b b e r o r plastic material which has a central hole with eight or more slits radiating out t o w a r d s t h e metal ring. T h e toilet paper is pressed into t h e central hole, where it is gripped by t h e plastic. T h e child utilizing this device can

reach from the rear for anal cleansing. T h e toilet p a p e r can be removed by the phocomelic digits and thrown away a n d a clean piece inserted for further cleansing. T h e device can be folded for carrying in the schoolbag o r purse. Proximal rings or assistive holding devices can be utilized where there is i n a d e q u a t e grasp. G r a n s t r o m (1976) has described two reaching devices. T h e first is essentially a bent plastic tube with a w o o d e n handle with a narrow slit at the e n d for holding t h e toilet tissue. T h e toilet paper is r e m o v e d after use by pulling t h e plastic holder against the rim of t h e toilet bowl forcing the p a p e r into t h e bowl. T h e second device is similar, b u t t h e ends of the slit are held close t o g e t h e r by m e a n s of a sliding plastic ring, securing t h e toilet tissue during the wiping process. W h e n the toilet tissue is t o be disposed, the plastic ring is pushed proximally and the tissue is removed by use of a spike within the r e m o v a b l e w o o d e n handle. A d e n i a Spencer of t h e Texas Scottish Rite Hospital for Crippled Children, Dallas, Texas, has tried a jointed rod held together by a wing nut for adjustment of t h e angle which has a foam covered rectangular plate attached to the e n d . T h e foam r u b b e r is covered by a terry cloth cover with a draw string which is used for wiping (Fig. 4).

Fig. 4. Adjustable toilet device used at the Texas Scottish Rite Hospital for Crippled Children, Dallas. The size may be adjusted to suit the patient.

Marion Shaw of the O n t a r i o Crippled Children's C e n t r e , T o r o n t o , C a n a d a , has d e v e l o p e d a folding rod with a cup and cover similar to the device described from the Princess M a r g a r e t R o s e Hospital. This device is hinged for portability and is held in the extended position by means of a sliding cylindrical lock. A removable p r o b e for removing the toilet tissue from the cup is inserted into a flat rectangular handle (Fig. 5).

applicator with elongated handles and rubber tubing covering the curved tips for better p r e h e n s i o n (Fig. 7, b o t t o m ) .

Fig. 5. Ontario Crippled Children's Centre folding rod device.

T h e Therafin C o r p o r a t i o n , C r e t e , Illinois, has d e v e l o p e d a toileting assist they call a HygieneA i d , cat. # A 1 3 1 . (Fig. 6, top). It is a rod which has two polyethelene h a n d straps to assist the patient with limited hand function in grasping the rod. T h e distal end has a gripping device with plastisol covered jaws which are held together by m e a n s of a r u b b e r b a n d . After wiping, the patient taps t h e release lever o n the inside of the toilet bowl to release the paper. This device is listed in the catalogue of the F r e d S a m m o n s C o . , Springfield, Illinois. A second toilet limb e x t e n d e r is shown "Short toilet a i d e " c a t . # B K 6014, which is a pair of curved handled tongs covered with plastisol, a positive grip device (Fig. 6, b o t t o m ) . K u h n (1970) of the University of Muenster, illustrates a reaching device which has a pincer to hold the toilet tissue. A button on the proximal e n d controls the pincer to lock or unlock the toilet p a p e r . It is used from the front. M . Z i m m e r m a n , Institute of Rehabilitation M e d i c i n e , N e w Y o r k City, uses a limb extender m a d e of two plastic rods, with smooth edged inter-locking teeth. T h e handles are squeezed to o p e n , a small spring u n d e r the expansile tension closes and holds the p a p e r (Fig. 7, t o p ) . T h e a u t h o r m a d e an extension device for an elbow disarticulation s t u m p out of an E - Z band

Fig. 6. Top, Therafin Corporation Hygiene-Aid (see text). Bottom, short toilet aid from Fred Sammons Co.

Fig. 7. Top, limb extender used at the Institute of Rehabilitation Medicine, New York. Bottom, the author's device for elbow disarticulation stump.

Elaine Trefler at the University of Tennessee C e n t r e for the H e a l t h Sciences in Memphis, T e n n e s s e e , uses a modified version of the O . C . C . C . toileting aid. It is m a d e of metal rather than plastic a n d utilizes a telescoping device r a t h e r than a folding o n e . She finds that this is lighter, smaller a n d m o r e useful for transporting t h e device. T h e proximal side has push and pull h o o k s for manipulating the pants. She asserts that a t t e m p t i n g to train children earlier than the teens in self care is unrewarding because most children younger t h a n the early teens are not a d e q u a t e l y motivated for independent toileting. In the a u t h o r ' s experience there are some children younger than 13 w h o are very interested in toileting i n d e p e n d e n c e and an attempt to train t h e child should be m a d e . (B) Hands with inadequate grasp T h e next category of patients are those with u p p e r extremities with inadequate grasp and release with, in addition, limited range of motion at the hips, knees a n d / o r severe shortening of the femur. T h e best solution is to place the toilet tissue with t h e h a n d or t h e foot o n the edge of the toilet bowl and rock t h e pelvis back and forth against the toilet p a p e r for cleansing the groin. T h e best type of toilet is of horseshoe shape, preferably with the seat open in front. Some therapists have used the toilet seat rather than t h e t o p of the bowl; in the author's experience t h e t o p of the bowl is better because it is n a r r o w e r and it is easier for anal cleaning to take place. If the above option is not feasible, a stationary device may be required, where ever the child n e e d s to use the toilet. Prof. E . M a r q u a r d t of the University of H e i d e l b e r g , G e r m a n y , utilizes a plastic device which m a y be attached to the toilet bowl by m e a n s of a spring-clip or to a wall (Fig. 8, top) so that it can swing out for use. A spring plate holds t h e toilet tissue in a location which the patient can reach with the perineal area. T h e paper is inserted a n d removed either by a phocomelic extremity o r by use of the feet while the child sits o n the toilet nearby (Fig. 8, b o t t o m ) . Evelyn Bloch of the Thorns Rehabilitation H o s p i t a l , I n c . , of Asheville, N o r t h Carolina, has described the use of a large diameter dowel fixed to the wall at groin height. T h e dowel is wrapped with toilet p a p e r using the toes. T h e toilet paper is sat o n to rub t h e appropriate area. A small

Fig. 8. Wall mounted plastic device from the University of Heidelberg; the device may also be attached to the toilet bowl by spring clips.

e n l a r g e m e n t may be a d d e d to the dowel near the wall to provide better contact in the anal area. M. A . M e n d e z describes two types of split h o o k s which are attached to a wall either by a suction c u p o r screws. Essentially they are two flat plates of plastic or metal between which the toilet p a p e r is placed. T h e a u t h o r has described a toilet attachment which h o o k s on to the edge of a bathtub ( F r i e d m a n n , 1975). This was modified later by Wright (1976) for use with a floor stand. Prof. G . G . K u h n , from the O r t h o p a e d i c Hospital of the University of Muenster, G e r m a n y , employs a bidet of the WC-O-Matic t y p e . In Scandinavia a n d in Scotland, the ClosO - M a t a u t o m a t i c bidet is utilized. (Orthopaedic Hospital, C o p e n h a g e n , D e n m a r k , found this unsatisfactory; it can only be used in the h o m e ) . (C) No hand function For patients with little or no upper extremity function o n either side with normal lower limbs with well developed foot function, the best

Solutions are holding t h e toilet paper between the toes and wiping the groin with foot and ankle m o t i o n while sitting o n the floor or the toilet bowl, rocking the pelvis back and forth if n e e d e d . A n o t h e r m e t h o d requiring less agility is to place the toilet p a p e r over the heel and squat d o w n so that the anal area rests on the paper on the heel. T h e patient then rocks, cleansing the anal area.

E d i n b u r g h , Scotland, suggests that sanitary napkins or towels with loops be held in the panties by m e a n s of a cloth strip with a plastic ring o n o n e e n d . T h e cloth strip is folded upon itself with two pieces of Velcro to enclose the l o o p o n each side of t h e napkin. It is held fast to t h e p a n t y by the stitched o n plastic ring. Exact positioning of the sewn straps is important to e n s u r e that t h e n a p k i n is not displaced during activity.

Urinary devices for boys Boys with phocomelic extremities have the p r o b l e m of removing the penis from the trousers for urination. Ann G . Fisher suggests the use of a rod with a loop to fish the penis from the trousers after t h e fly has been o p e n e d . T h e a u t h o r ' s modification involves attaching a Nyloplex cylindrical loop by m e a n s of an extension to two or m o r e sections of a folding ruler (Fig. 9). T h e resulting device is portable a n d inexpensive. Ring (1972) shows rods with rings or a gutter trough for holding t h e penis. Fig. 10. Sanitary napkin attached to panties by elastic strips.

Fig. 9. Simple, inexpensive urinary device modified by the author from the loop and rod aid suggested by the Area Child Centre, Grand Rapids, Michigan.

Menstrual care A very serious problem for the girl after puberty is cleanliness during the menstrual period. A n u m b e r of commercial devices may be utilized such as adhesive sanitary napkins inside the panties. A second solution is to use the standard sanitary napkin held inside the panties by means of two elastic strips or pockets (Fig. 10). In an active girl, if there is a problem of shifting, the use of sanitary panties or panties with a plastic crotch may be advisable. H e l e n J. Scott at the Princess M a r g a r e t R o s e O r t h o p a e d i c Hospital in

O n e useful m e a s u r e is to use pre-prepared p a p e r panties and adhesive sanitary napkins. T h e entire panty is thrown away after use. S o m e girls prefer the use of a tampon. W h e r e this is desired a mirror should be attached in front of the toilet bowl to assist insertion and removal. K u h n (1977) illustrated a device he d e v e l o p e d for insertion of a t a m p o n into the vagina (Fig. 11, top). It is o p e r a t e d by foot p u m p i n g which compresses air which is driven through a t u b e . T h e compressed air inserts the t a m p o n rapidly. For this reason there is some potential danger because of the possibility of d a m a g e to the skin or to the vaginal tissues. A simpler modification which is portable (Fig. 11, b o t t o m ) , has b e e n developed by Prof. E . M a r q u a r d t which is an additional tube attached t o t h e portable toilet device described earlier for use by phocomelics, with a metal loop for r e m o v a l . T h e t a m p o n string is elongated and at its e n d has a glass bead o r metal ring to hook o n t o t h e metal loop of the t a m p o n - a i d e . Evelyn Bloch sent an idea which she has not tried, which might prove useful. She r e c o m m e n d s that for removal of a t a m p o n , which has a double string with a knot dangling, a

small metal h o o k covered with polyurethane could be attached to a w o o d e n platform which is held down by t h e feet. T h e patient could squat o v e r it and catch t h e h o o k in the loop and then slowly stand, pulling the t a m p o n out of the vagina. She suggests t h a t perhaps a tube covered with plastisol could be attached to the same b o a r d at an angle which is p r o p e r for vaginal insertion. This is merely an idea which would n e e d further d e v e l o p m e n t . T h e Hygiene-Aid m a d e by the Therafin C o r p o r a t i o n is claimed to be successful for inserting and removing vaginal t a m p o n s (see Fig. 6, t o p ) .

Bilateral upper and lower limb involvement Patients with q u a d r i m e m b e r a l involvement have e x t r e m e difficulty in toileting. These patients need various devices for dressing and undressing, such as dressing sticks, wall hooks, etc. F o r perineal cleansing the bidet type of device is generally required. It is unfortunately not p o r t a b l e , and o n e must be obtained for each location that the child needs to d o toileting. T h e above survey of available aids is intended to serve as a working guide for therapists. These cases are fortunately r a r e , so no one has extensive experience and a continuing collection and dissemination of information on these devices would be of benefit to these patients.

Acknowledgements T h e a u t h o r is very grateful for the help that the sources m e n t i o n e d have given in sharing their experiences and h o p e that anyone having a new device or m e t h o d which proves successful will c o m m u n i c a t e with h e r for follow-up articles o n the same subject.

REFERENCES FRIEDMANN, L . (1975). Toileting device for high level upper limb amputees. Int. Clin. Inf. Bull., 14: 7-8, 25-27.

GRANSTROM, M. (1976). toilet paper holder. Information sheet A 2 . 2 3 - 9 , ICTA Information Centre, Bromma, Sweden. KUHN, G. G. (1970). Treatment of the child with severe limb deficiency. Int. Clin. Inf. Bull., 10-3s, 2-32.

KUHN, G. G. (1977). Vaginal tampon applicator. Int. Clin. Inf. Bull., 16:5-6, 1 3 - 1 5 . LOWMAN, E.

and

KLINGER, J. L. ( 1 9 7 0 ) . Aids

to

independent living: Self-help for the handicapped. McGraw-Hill, New York. RING, N. D. (1972). Miscellaneous aids for physically handicapped children. Int. Clin. Inf. Bull., 12:3, 1-12.

Fig. 11. Top, tampon insertion device developed in Muenster. Bottom, portable modification from the University of Heidelberg (see text).

WRIGHT, B. (1976). Independence in toileting for a patient having bilateral hemimelia. Int. Clin. Inf. Bull., 15:5-6, 2 1 - 2 4 .