January, 1957. P H Y S I O T H E R A P Y Page Five OBSERVATIONS ON THE RECENT POLIOM YELITIS EPIDEMIC IN EAST LONDON. B y M ISS P A D D Y C H A T T E R T O N . STATISTICS held by the Medical Officer o f H ealth reveal that, in the 13 years preceding 1956, a to ta l o f 64 cases of poliomyelitis were notified in the E ast L ondon area. This num ber was made up o f 56 Europeans, 4 Natives, 3 C oloureds and 1 Asiatic. In 1956, 2 E uropean cases were notified before M arch 17th, after which date the num bers rose steadily to reach a total by the end o f N ovem ber o f 64 E uropeans, 167 N atives, 11 Coloureds and 2 Asiatics. In the E uropean cases the ages ranged from 1 to 45 years, and in the non-E uropeans the oldest p atient was 9 years o f age. In the non-E uropean total of 180 cases, 137 were under the age o f tw o years. These figures are in direct contrast to the figures quoted in a W orld H ealth O rganisation M onograph issued in 1955 which states th a t the m axim um attack rate is between the ages o f 7— 15 years, and even 15—25 years. D uring 1956 there were 6 deaths am ong E uropean cases, 14 deaths am ong non-E uropean cases. O f th e E uropean cases, 5 died o f respiratory failure and the 6th was a bulbar case. O f the non-E uropean cases, 7 died of respiratory, failure and the others o f pneum onia, some with underlying tuberculosis; 1 died of gastro-enteritis.- Of the types o f cases, there were 2 pure bulbar, the second having m ade a com plete ■ recovery; 2 w ith pure facial paralysis; 2 w ith facial and limb paralysis, one having slight bulbar symptoms. The rem ainder o f the paralytic cases suffered paralysis o f one o r more limbs in varying degrees of severity. The num ber of cases left with extensive paraly­ sis is rem arkably small in com parison with the great num bers contracting the disease. The proportion o f non-paralytic cases adm itted to hospital was far greater am ong the E uropeans than the non-E uro­ peans. I t is feit however th a t there were a large num ber o f non-European cases, both paralytic and non-paralytic, which were never brought to the notice o f a . doctor, as several cases have since attended O rthopaedic Clinics, obviously having .had poliomyelitis. T he actual num bers therefore probably greatly exceed those quoted above. The virus was isolated by D r. G ear o f the S.A. Polio­ myelitis Research F o u n d atio n as being T Y PE 1 V IR U S .1 D uring A pril it became increasingly evident th a t the incidence o f poliomyelitis in th e area was reaching epidemic proportions. T he Isolation H ospital has a norm al capacity of 12 European and 8 non-E uropean infectious diseases beds, in addition to the tuberculosis beds, which num ber close on 100. A t this time the hospital was becoming crowded to capacity, especially the non-E uropean section, where one whole block was given over to poliomyelitis patients, and two TB wards and a long enclosed verandah were cleared to accomodate a host o f cots. As adm issions continued at the rate o f 1—4 cases a day (on one day there were 13 admissions), extra cots, m attresses, blankets, napkins, etc., had to be ordered, food supplies were increased, arid the laundry problem s with so many sick children were quite enormous. E xtra trained and untrained staff were engaged by the M atron, who also had the responsibility o f m aintain­ ing the rest o f the hospital in good order. D r. van Heerden, deputy M .O .H . and S uperintendent o f the Isolation H ospital, and D r. M aclldow ie, Senior M edical Officer in charge of th e L ocation D ispensary, who later assisted him fulltime, were on duty for exhaustingly long hours, examining and w riting up each new case, keeping a check on those already in, many o f w hom were very ill, and discharging others with a full clinical report on the 21st day. T heir trials in deciding on th e stage a t which to put a patient with respiratory failure into the iron lung, o r when to do a tracheotom y on a bulbar case,' and coping w ith the com plications o f pneum onia, tuberculosis, measles, d iarr­ hoea, skin infections, etc., will fill m any pages in their medical journal when they give their final report. U p to this tim e, the question o f physiotherapy treatm ent for the poliomyelitis patients in the Iso latio n H ospital had been discussed, but no arrangem ents had been made. W hen, on Saturday, 28th A pril, it was obvious th a t we were in the throes o f an epidemic, I was asked by the Medical Officer o f H ealth if I w ould undertake th e physiotherapy care in the Isolation H ospital. In accepting this request, I felt quite horrified a t w hat I had undertaken, but before I had had time to think much; I was in the thick o f it too. A t 2 p.m. th a t afternoon, D r. M aclldow ie and I, accom ­ panied by th e M atro n , m et a t th e hospital to survey the situation. We examined every patient, m aking notes as we went, finishing a t 6.30 p.m. L ater in the evening we dis­ cussed the situation with D r. van Heerden. N ext m orning I m ade a resum e o f o u r findings in order to decide upon a plan o f action. In the non-E uropean wards we found th a t there were over 50 patients, the oldest nine years and m ost under th e age o f 2 years, all in good condi­ tion, though m any were very chesty. Every case was well examined and carefully w ritten up. N ursing care consisted o f feeding, cleaning, charting, etc., and atten tio n to any com plications. M ost children had one o r both legs p a ra ­ lysed, only tw o had arm s affected, some had only slight weakness and there were a few non-paralytic. M ost had some degree o f neck rigidity, some were very rigid, and pain­ ful in the lum bar spine with considerable spasm in the limbs. M ost children were lying with hips abducted and outw ardly rotated, and feet dropped—an attem p t a t passive adduction, internal ro ta tio n and flexion o f the hips, and dprsiflexion o f the feet, was invariably painful, sometimes quite ex­ cruciating. O lder children seemed to be in more pain than younger ones. The beds and. cots varied, but m ost “ dunked” in the middle, except th e new ones. All the children had piUows under their heads and shoulders, and were covered by arm y blankets, doubled. There was no attem pt a t supporting the paralysed limbs—no one had time anyway! There were 8 E uropean patients where the situation was similar, though better. F ro m these findings it was possible to decide upon the line, o f treatm ent to be a d o p te d .. In th e acute stage o f the disease th e im p o rtan t considerations a re :—• (1) Provision o f com plete rest. (2) Relief o f painful muscle .spasm. (3) Prevention o f contracture. I t was obvious th a t boards m ust be p u t under all the m attresses to support the children’s backs, th a t the large pillows m ust be rem oved, (except where there were chest, com plications), th a t every bed required a foot-board to keep the heavy bedclothes off the child’s feet and th a t sandbags were needed to support the painful limbs. The question o f hot-packs was considered but discarded in view of the trem endous am o u n t o f w ork this w ould entail. I t was agreed th a t careful positioning and passive movements were all th a t could be considered a t present. As every mem ber o f the staff was fully occupied in his o r her own capacity, I had to cope with the physiotherapy alone. Therefore I h ad to decide upon a w orkable plan w hich, R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page Six P H Y S I O T H E R A P Y January, 1957. th o u g h n ot perfect by any m eans, w as a t least a definite effort to w a rd s each o f th e th re e m a in a im s o f tre a tm e n t. So, on M o n d a y m o rn in g 30th A pril, I saw the M edical Officer o f H e alth , D r. S in c la ir S m ith, w h o gave me c a rte b lanche to go a h ea d a nd o rd e r w h a tev e r I th o u g h t necessary. D u e to the k indly assista n ce o f m any friends, local firms and the h o sp ital staff, all the re q u ire m e n ts w ere so o n assem bled at th e ho sp ital. T h e b o a rd s w ere p u t u n d e r th e m attresses, and the fo o tb o a rd s placed in p o sitio n . T h e fo o tb o a rd s for beds w ere 21" high x 18" w ide w ith 3" sq u a re blo ck s a t each side w hich k e p t the b o a rd 3 " aw ay from the end o f the m attress, th u s a llow ing a gap fo r the p a tie n t’s heels w hen lying supine, o r fo refo o t w hen lying p ro n e . In plac in g the fo o tb o a rd s in the c o ts, (18" x 15" w ith 3 " blocks), it was soon found th a t restless little c h ild ren pulled th em over, and th a t u n tra in e d A frica n nurses found it e asie r to tuck the b lan k e ts in flat th a n p u t th em o v e r the fo o tb o a rd s ! So th e fo o tb o a rd s w ere tu rn e d ro u n d w ith the 3 " blocks a g a in st the end o f the c o t, and the b o a rd a g ain st the m attress, thus m ak in g it easy fo r the end o f the blan k e t to h a n g d o w n o ver th e end o f the fo o tb o a rd w ith in the c o t. T w o th in h a rd b o a rd feet tac k ed o n to the fo o tb o a rd lay u n d e r the m attress a n d k ept the b o a rd firm. D o zen s o f sm all b u n n y b lan k e ts w ere o rd e re d to tuck ro u n d the c h ild re n ’s legs to keep th em w a rm . W ith the b e d b o a rd s a n d foot b o a rd s, a rm y a n d b u nny b lan k e ts in p o sitio n , a n d no pillow s except w here necessary, a d e q u a te p ro v isio n w as then m ad e fo r c o m p le te rest. I th en s ta rte d p o sitio n in g e ach child w h o had p a in fu l m uscle sp a sm by e n d e a v o u rin g to p lac e his b o d y and lim bs in the best p ossible a n a to m ic a l p o sitio n w hich yet was c o m p a tib le w ith c o m fo rt. T h e tin y c h ild ren , all w ith n appies, were difficult to c o n tro l, but by plac in g the feet as n e ar as po ssible to the fo o tb o a rd , a n d p lacing a sa n d b a g u n d e r b o th knees, a n d a n o th e r from hip to knee d ow n the o u te r side o f each leg, a re aso n a b ly c o m fo rta b le and w ell-su p p o rted p o sitio n w as achieved. T h e nurses were e n co u ra g ed to tu rn these c h ild ren on th e ir tu m m ies a t intervals. A tte m p ts a t p lacing p a in fu l a rm s in a p o sitio n o f a b d u c tio n and slig h t o u tw a rd ro ta tio n w as seldom sa tisfa c to rily achieved with the n a tive c h ild ren , a lth o u g h a llp o s itio n in g a n d c h a n g in g o f p o sitio n s w as achieved w ith th e E u ro p e a n p a tie n ts. O ld e r c h ild ren a nd a d u lts were n a tu ra lly c o -o p e ra tiv e in m a in ta in in g goo d po sitio n s. T h e n a tiv e c h ild re n were so sm all, th e bu lk o f the A frican n u rse s were u n tra in e d a nd the n u m b ers o f p a tie n ts co n tin u e d to increase so ra p id ly , th a t the p o sitio n in g o f these c h ild ren was a p e rp e tu a l h e ad a ch e to me. It was n o t in fre q u e n t for Dr. van H e erd e n to disco v er a sm all m ite, a p p a re n tly w ith no p ain o r paralysis, sittin g on a pile o f sa n d b a g s in his c o t, o r using o ne as a w e ap o n , w hilst in the next c o t a little soul lay w h im p erin g in p a in w ith his legs com p le te ly u n su p p o rte d . H ow ever, we g ra d u a lly g ot the nurses tra in e d , b u t it required m uch p ersistence a nd a sense o f h u m o u r. W ith e ach child I c arried o u t as full a range o f passive m ov em e n ts as w as possible. W h ere th ere was painful spasm it becam e o b v io u s th a t h a rsh o r full m o v em en ts increased the p a in , a n d these m ov em e n ts th e re fo re had to be d o n e very gently, ta k in g c are n o t to stre tc h the m uscles in spasm . W ith the g reat n u m b ers o f p a tie n ts it w as im p o s­ sible to give the passive m ov em e n ts m ore th a n once a day, a n d also im possible u n d e r the c irc u m stan c es to tra in the A frica n nurses to give the passive m o v em en ts. M o st o f the c h ild ren had to have th e ir n a p p ie s ch an g e d so frequently th a t th a t in itself was a fo rm o f passive m ov em e n t! I so o n realised th a t I w as u n a b le to re m e m b e r the in d iv i­ dual p a tie n ts , th e ir c o ts were c o n tin u a lly being c hanged, an d in view o f the tre m e n d o u s n u m b ers, I had to w ork fast and could n o t spend tim e re-assessing each p a tie n t e ach day. So, P h y sio th e ra p y F o rm s were ro n e o ed a n d one w as placed in e ach c h ild 's c h a rt. I e x am ined e ach child as so o n a fte r ad m issio n as w as possible, m a k in g no tes o f th e ra n g e o f passive m o v em e n ts, a m o u n t o f a ctive m o v em e n t, and presence o f neck rigidity, back spasm a n d sp a sm o r tight- T R E A T M E N T IN W A R D B A T H . ness in in d ividual m uscles, n o tin g a lso the re q u ire m e n ts of each in d iv id u a l c hild. Every few days I a d d ed progress notes. By th is m ean s 1 w as a b le each d ay to glance quickly a t the form a n d see w h a t w as re q u ire d . A t the h e ight o f the e p idem ic th e re were o ver 90 p a tie n ts re q u irin g daily a tte n tio n . T h e m ain th in g th a t w o rrie d m e all a lo n g was how to c o p e w ith sp a sm a n d tightness o f the c a lf m uscles, leading to c o n tra c tu re o f th e T e n d o A chilles— it seem ed so bad to send a p a tie n t o u t o f th e Iso la tio n H o s p ita l w ith a tightness o f the T e n d o A chilles— so I p u t som e o f th e c h ild ren into b o o ts, c o n n ec te d a t th e heel by a b a r, w hich kept the feet vertical a n d c o rre c te d the o u tw a rd ro ta tio n o f th e hips. T h is certain ly did to a larg e e x te n t p revent a c tu a l con­ tra c tu re s o f th e T e n d o A chilles, b u t 1 so o n d isc ard e d this p ra ctic e as 1 becam e convinced th a t any p o stu re in which the child is fixed is u n c o m fo rta b le , a n d distressing to the c hild, a n d d oes little to relieve th e p a in fu l m uscle spasm. S p lin ts were never used at a n y tim e. U p to this stage 1 w as still learning a c o n sid era b le a m o u n t a b o u t p o lio m y e litis— a n d ch an g in g my ideas a lm o st daily! I w ro te to p h y sio th e ra p ists in this c o u n try and overseas for advice, I read every b o o k 1 co u ld lay m y h ands on, and talk e d a g re at d eal w ith local d o c to rs a nd p h y siotherapists. D r. van H e erd e n a nd D r. M a c lld o w ie were alw ays e n co u ra g ­ ing and helpful, a n d to le ra n t o f m y ch an g in g ideas, and the c o n clu sio n s to w hich we cam e finally were th e result o f our ow n p e rso n al o b se rv atio n s. I felt the re sp o n sib ility o f my task m o st a cutely, and a p a r t from being intensely interested in th e w ork, 1 was a n x io u s to a chieve the m ost useful effects u n d e r c irc u m stan c es w hich were far from ideal. As the d ays progressed, m o re a n d m ore cases were a d m itte d , a nd o n e had th e o p p o rtu n ity o f w itnessing each c h ild th ro u g h th e w hole c o u rse o f the a c u te stage o f the disease. I becam e m o re a n d m o re obsessed w ith the idea t h a t the only th in g th a t really m attere d as fa r as the physio­ th e ra p is t w as c o n ce rn ed in the a c u te stage o f the disease w as R E L IE F O F P A IN F U L M U S C L E SP A S M . Spasm led to tig h tn e ss, tig h tn e ss to c o n tra c tu re , a n d c o n tra c tu re to defo rm ity . T h e re sp o n sib ility o f the p h y sio th e ra p ist in tre a tm e n t o f polio m y e litis p a tie n ts is, n o tw ith s ta n d in g the d a m a g e d o n e to the nerve cells by the virus itself, to re h ab ili­ ta te th e p a tie n t as fully as possible, w ith o u t deform ity. H o t p a ck in g was still im possible, 1 tried ra d ia n t h eat and even gentle m assage on som e p a tie n ts— b u t n o th in g really seem ed to relieve the p a inful spasm . T h e n we decided to p u t one little girl, w hose te m p e ra tu re had ju st subsided, and w as in tre m e n d o u s p ain a n d terrified o f being touched, in a b a th o f w arm w ater. It w orked like a c h arm . Her m en ta l and physical ten sio n seem ed so o th e d at once, and as we c o n tin u e d th is daily, she was gra d u ally encouraged to m ove a little in the w ater, sit up, tu rn ov er on her tummy, a nd before she left the Iso la tio n H o sp ita l she even w a nted to sta n d . R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) January, 1957. P H Y S I O T H E R A P Y Page Seven Warm baths daily for all patients with painful spasm in back o r limbs then became the order of the day. The patient was given confidence by lying in the w ater w ith his head supported in a sling, which was suspended from the fram e­ work o f a bed-table, the wooden tray having been removed. This frame could easily be moved forward, back, from side to side, as the occasion demanded. We frequently had two children in the bath together, and they loved it. I t took a little while to m ake this daily bath a routine procedure among the great num bers o f native patients, b u t even th at was achieved in time, with great co-operation from the native staff. There were no ill effects from this procedure, which was only comm enced after the p atient’s tem perature had become stabilised. I found that, by giving gentle passive movements in the water, by playing games and encouraging active movements in the water, the spasm in every muscle seemed to relax. I no longer w orried a b o u t contractures in the T endo Achilles. W ith the encouragem ent o f active dorsiflexion where this was possible, o r assistance where it was not, the muscle gradually resumed its norm al length w ithout causing pain to the p atien t o r harm ful stretch to the muscle. The same was true o f every muscle group. Bending the knees to the chest, singly or together, actively o r assisted, aided back spasm, as also did a favourite game— sitting up and kissing the knees when flexed! H am string spasm was eased by a gradual effort to sit up and later to straighten the knees, all movem ents perform ed gently, with assistance, as a game. As the children continued to improve, and w anted to move, we used to take them from their cots and lie them together on a rug with their toys in the sun. In no time these little black bodies were turning over, o r crawling, or attem p t­ ing to walk. We kept a very special eye on those to whom such movement w ould be harm ful, and sitting up, crawling and walking were prevented in some, b u t definitely encour­ aged in others. In this way, many children were discharged home on the 21st day, quite fit. Severely paralysed patients and those with much spasm were naturally left in their beds. The children were far happier fo r this little play-time, and under constant observation they cam e to no harm at all. In the closing days of th e epidemic, when everyone had more time and a great affection fo r these little mites, they enjoyed it, and it definitely helped their recovery, in that cases with slight back spasm seemed to loosen up m uch quicker than if they had been left lying in their beds all day. It was interesting to note th a t most patient’s tem peratures had settled by the end o f th e first week, though some showed a slight rise during the second week. In many cases there was a spread o f paralysis after adm ission, but seldom any spread in paralysis after the first week. In some cases, a flaccid limb on admission regained full function during the Isolation period. The relation between spasm and flaccidity was often m ost m arked—where there was com ­ plete paralysis o f the left leg, there was invariably very acute back spasm, m ore m arked on the left side. As the back spasm improved, so very often, a certain am o u n t of power, sometimes full power, returned to the leg. In some cases where the spasm was so acute as to give the whole body a board-like stiffness, an alm ost full recovery has been made with very little residual weakness, in a rem arkably short time. I had always been aw are o f the acute illness o f poliomye­ litis, but it is not until one witnesses an epidemic in th e acute stage th at one becomes fully aw are o f the inadequacy o f medical science in treating poliomyelitis, and o f th e vital necessity o f good nursing and physiotherapy care in allevi­ ating the patient’s suffering. This care in th e acute stage influences considerably the p atien t’s eventual, recovery, and also his m ental outlook. A young child usually does not even question w hat his illness is, b u t he is miserable and in pain, which is aggravated by every attem pt a t move­ ment—he m ust feel terro r at finding th a t he is totally unable to move one o r m ore limbs—he cannot lie com fortably and he is am ongst a whole group o f com plete strangers, all clad in white. I t m ust be a terrifying experience in a young life which has probably always been surrounded by love and security. T o an ad u lt the shock o f the full realisation of his predicam ent is an equally terrifying experience as to him his whole future is suddenly shattered—the dreaded w ord poliomyelitis now applies to him —a p a rt from being ill, he is w orried and insecure. T he physical and m ental stress in th e three weeks isolation period in hospital is a trem endous psychological experience in the p atien t’s life, and when he is transferred to the general hospital, o r hom e, he has undergone a change, which m ust be accepted by the staff and relations who are to care for him T heir understanding, kindness and patience are essential in rebuilding the p atien t’s confidence in him self and in his future. This was particularly noticeable in the E uropean adults. As these patients left the Isolation H ospital, m ost were adm itted to the orthopaedic w ards o f the F rere H ospital. From here the m ajority o f the native patients went to the W oodbrook Convalescent H om e, an after-care hom e established and equipped a t short notice to cope with the victims o f the epidemic. N ative patients who were apparently fit a t the end o f their isolation period were discharged home, to retu rn a t intervals to be exam ined a t the O rth o ­ paedic O u tp atien t’s Clinic. M any E uropean patients were discharged home, some quite fit, others to continue tre a t­ m ent with private practitioners at their room s or in the patient’s own home. Every available physiotherapist in East L ondon has com e forward, to help in this great w ork— it has been m ost rew arding, and I feel sure th a t we have all learned a great deal, b u t the m ore one deals w ith these patients the m ore one realises how much there still is for us to know o f this dread disease. In the after-care o f these patients I feel th a t the aims o f the physiotherapist should be:— (1) Elim ination o f “ tightness” in every muscle. (2) R estoration o f as full muscle function as possible. (3) E stablishm ent o f good posture despite muscle im balances. Passive movem ents should be continued, giving a very slight stretch to the tightened muscles. Exercises in w ater are invaluable in giving the child a sense o f freedom, and thereby encouraging active m ovem ent. T his free active movem ent, as well as restoring muscle function, is the easiest, most enjoyable and m ost effective way o f elim inating tig h t­ ness, and especially if the passive movements and gentle stretchings are done by the physiotherapist in th e w ater as well. R e-education in water, free exercises, exercises in slings using springs o r weights fo r resistance, all contribute tow ards re-educating the strength o f individual muscles, b u t the encouragem ent o f group action o f muscles is by far the most useful m ethod o f re-education. W orking a muscle to the point o f fatigue is in no way harm ful, b u t care m ust be taken n o t to work the muscle beyond this point. Early am bulation I believe to be desirable, when possible. F rom th e start, in adopting erect posture— in sitting, standing and walking—great atten tio n m ust be paid by the physiotherapist to PO STU R E. A residual tightness in one side o f the back is so often th e forerunner o f a scoliosis, and an “ ap p aren t” shortening o f one leg. O ther postural defects, such as kyphosis and lordosis, frequently have their origin in back spasm, which has n o t been fully freed. T he use o f appliances is often necessary— to raise a dropped fo o t or stabilise a knee, etc. T he added weight and weak­ ness of one side are. com plicating factors in establishing good posture, bu t it invariably can be achieved w ith con­ tinued perseverance. D istribution o f th e weight equally between both legs, correction o f a forw ard tilt o f th e pelvis and an erect carriage of head and shoulders are probably the m ost im portant considerations. A ttention to posutre th roughout the child’s growing life is essential. I t is n o t possible here to discuss every aspect o f after-care, as with the wide variety o f patients contracting th e disease, R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page Eight P H Y S I O T H E R A P Y January, 1957. m any different p ro b lem s have been p resented. T h e y o u n g n o n -E u ro p e a n p a tie n ts , by v irtu e o f th eir b a c k g ro u n d , p re sen t m an y p ro b lem s all th e ir ow n. R e s p ira to r p a tie n ts w ere fo rtu n a te in th a t b o th h o sp itals a re p rovided w ith the m o d e rn D ra g e r iro n lungs. T h e use o f the positive p re ssu re d o m e in no w ay increased the p a tie n t’s distress, a n d this g reatly fa cilitated n u rsin g and p h y sio th e ra p y care. Passive m o v em en ts w ere easily p e r­ fo rm ed , w ith th e ex ce p tio n o f a b d u c tio n a n d ele v atio n o f th e sh o u ld e rs. O n e a d u lt E u ro p e a n p a tie n t, w ho suffered very extensive paralysis, has slowly b ut surely been w eaned from the lung, u n til now , six m o n th s late r, he o nly sleeps in it a t n ight. T h e m any benefits o f th e D ra g e r lung have c o n trib u te d m uch to his c o m fo rt a n d recovery. H is c o u ra g e a n d faith will c ertain ly h elp him to w a rd s th e g reatest possible recovery. T h e q u e stio n o f p ro g n o sis is o ne w hich still rem ain s undecided. M uscle c h a rts, using th e 0 - 5 gra d in g s, c arried o u t a t re g u la r in te rv als, give an e x te n t o f the p a raly sis a n d the g ra d u a l im p ro v e m en t, b ut in m ost cases a re n o t indicative o f w h a t the final result will be. T h e m o re o n e sees o f these p a tie n ts, the m o re o ne is a m a z e d a t w h a t th eir w eak m uscles a n d flail lim bs will achieve in tim e. O ne m u st form in o n e ’s ow n m ind a p ic tu re o f w hat o n e c a n expect from each p a tie n t, b u t tim e a lo n e will tell w h a t each in d iv id u a l m ak es o f his ow n p a rtic u la r disability. T o h ave w itnessed th is epid e m ic th ro u g h o u t its d u ra tio n w as a u n iq u e experience, a n d a lth o u g h we all fo u n d it in­ tensely in te restin g a t th e tim e, o n e h o p e s th a t, w ith the in tro d u c tio n o f th e polio m y e litis vaccine in this c o u n try , o ne will never w itness such a d isa ster a gain. I w ould like to th a n k D r. van H e erd e n a n d D r. M a c lld o w ie fo r th eir in te rest in p h y sio th era p y , a n d my a ssista n t M iss R e n d ell for her help th ro u g h o u t the epidem ic. T h e view s expressed in th is a rtic le a re sh a red by us all. BARFORD & JONES (S U R G IC A L S U P P L Y C O .) M akers of: ARTIFICIAL LIMBS and ORTHOPAEDIC APPLIANCES S U R G IC A L IN STR U M EN T R E P A IR E R S . P E R S O N A L A T T E N T IO N G IV E N T O A L L C A S E S . 5 2 , M O O I S T R E E T , (O f f M a in S t r e e t ) J O H A N N E S B U R G . Phone 22-5238 P.O. Box 5484. EASTER STAMPS FL O W E R S a n d su n sh in e no d o u b t help a dev o ted and efficient N u rs in g sta ff at a C rip p le C a re H om e, to p ro d u c e such a sunny sm ile! H ow ever, in a d d itio n to n ursing, the P h y s io th e ra p is t’s services will so o n be required in th is case. T h a n k s to the g e n ero u s p u b lic , a g ra n t from the E aster S ta m p F u n d (the fu n d -raisin g section o f the N a tional C o u n c il for the C a re o f C rip p le s), w as a ble to be made to p u rc h a se a H u b b a rd ta n k fo r th is H o m e ’s physiotherapy d e p a rtm e n t. T h e N a tio n a l C o u n c il for th e C a re o f C rip p le s in South A frica a n d its n in e C rip p le C a re A sso ciatio n s, w ith their su b -a sso ciatio n s, have re n d ere d o u tsta n d in g service in p ro m o tin g , helping to m a in ta in a n d e x p a n d in g existing o rth o p a e d ic services in the U n io n , since the inauguration o f th e C o u n c il in 1939. Before 1939 th ere w as p ra ctic a lly no o rth o p a e d ic per­ sonnel in th e U n io n , a n d very little w ork being d one for C ripples. T H IS H A S B E E N D O N E S IN C E 1939: S u b sid ize d training: O rth o p a e d ic surgeons, O rthopaedic nurses, te c h n ic ia n s fo r m ak in g a n d fitting O rthopaedic ap p lia n ce s. S u b sid ize d salaries: Q ualified W elfare W o rk ers and After­ c are S isters d o in g essential u rb a n , s u b -u rb a n a n d district C rip p le C a re w ork. G rants tow ards: tra n s p o rt o f a b o v e, e stab lish in g A fter-, c are H o m e s a n d m a in te n a n c e o f them , M ission' H o s p ita ls a n d o th e r In s titu tio n s engaged in O rthopaedic services, a n d to w a rd s e stab lish in g a n d maintaining O rth o p a e d ic C linics. N in e m ain C rip p le C a re A sso c ia tio n s have been formed, affiliated to C o u n c il, e ach w ith its sub-association, m ak in g a n e tw o rk o f C rip p le C a re activ ity throughout the U n io n a n d S o u th W est A frica. S T IL L T O B E D O N E : A ssistance is re q u ire d in : e stab lish in g m o re R ural Ortho­ p aedic C linics th ro u g h o u t the U n io n a n d S o u th W est Africa; tra in in g o f m o re O rth o p a e d ic n u rse s; e rec tin g m ore After-: c are H o m e s fo r c h ild ren a n d a d u lts ; a d d in g extensions to ex istin g “ H o m e s” ; o b ta in in g m o re R e h a b ilita tio n Centres a n d Sheltered W o rk sh o p s; n e g o tia tin g w ith m o re Employers to engage e m p lo y a b le C ripples. H O W Y O U C A N H E L P : B U Y E a s te r S ta m p s! S E L L E a s te r Stam ps! USE; E a s te r S ta m p s! P lace o n e on every L etter you p ost—and give us the p u b licity we need so m uch to H E L P CRIPPLES T O H E L P T H E M S E L V E S . R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )