MARCH, 1973 P H Y S I O T H E R A P Y Page 7 found th a t w h e th e r th e p a tie n t is in sid e -ly in g o r su p in e , a sandbag p la c e d so t h a t th e h e a d is flexed f o r w a r d a little, c a n so m e tim e s re lie v e th e sp a sm . W h e n h e h a s been tu rn e d in to p ro n e -ly in g , lea v e h im f o r a s h o rt time w ith h is a rm s u p a b o v e h is h e a d . W h e re th e r e is a very sp a stic h ip o r k n e e , b rin g th e p a tie n t in s u p in e to the edge o f th e b e d a n d in a d d itio n to a s h a k in g o f the leg a n d a b d u c tio n o f th e h ip , b e n d th e k n e e o ver the edge o f th e b ed a s t h e to e s a re flexed. P la c e th e leg b ack o n th e b e d w ith th e k n e e s till b e n t a n d slo w ly increase h ip flexion. T h is , in tu r n , in c re a s e s th e k n e e flexion, b u t th e fu ll ra n g e m a y b e im p o s sib le . T h e lo n g ­ term case w ith th e t ig h t A c h ille s te n d o n is a g r e a t p r o b ­ lem (See illu s tra tio n N o . 3). I f th is ty p e o f p a tie n t starts to w a lk , a te n d o n le n g th e n in g o p e ra tio n m a y have to be d o n e d e sp ite a ll o n e ’s e ffo rts. I t is n o t sufficient just to m o b ilse th e lim b s. R o ta te th e h e a d ; m o b ilise the sh o u ld e r-b la d e s ; r o ta te th e tr u n k w h e n th e p a tie n t is on his sid e , o r, if th e legs a re n o t to o stiff, u se o ne as a fu lc ru m f o r r o ta tin g th e tr u n k w h e n su p in e . - Finally, re m e m b e r in all c a s e s:— W hen tip p in g a p a tie n t f o r c h e s t d ra in a g e a n d som eone else h a s to b e a tte n d e d to , p u ll b a c k th e c u rta in s so t h a t th e p a tie n t is u n d e r c o n s ta n t su r- veilance. N o h e a d -in ju re d p a tie n t s h o u ld b e left alone b e h in d c u rta in s , a s h e m a y o b s tru c t h is a ir ­ way o r h a v e a s e iz u re w ith o u t a n y b o d y b e in g a t hand. I t is im p o r ta n t t h a t th e fit c a n b e se e n b y a n y staff th e re , a n d th a t its fe a tu r e s b e n o te d : w h e th e r occurring ju s t in th e fa ce , o r w h e th e r th e a rm a n d leg a re a lso in v o lv e d , a n d th e e x a c t tim e it lasts. I f o n e w itn e sse s a fit, i t s h o u ld a lw a y s b e r e p o rte d t o th e s iste r im m e d ia te ly . 2. R e p la c e c o ts id e s o n th e b e d . A h e a d -in ju re d p a tie n t is so m e tim e s c o n fu s e d a n d v e ry re stle ss a n d m a y fa ll o u t o f b e d re p e a te d ly . 3. I t is n o t a lw a y s p o s s ib le to e x a c tly lo c a te th e b ra in lesio n , a n d w ith so m e in ju rie s th e p a tie n t is a b le t o ta k e in w h a t is b e in g s a id a r o u n d h im e ven th o u g h h e is q u ite u n a b le to in d ic a te th is. T h e r e ­ fo re , o n e s h o u ld b e v e ry c a r e f u l o f w h a t is said. A n y d e s p o n d e n t s ta te m e n t c a n b e le ft u n s a id u n til la te r. 4. T h e u n c o n s c io u s p a tie n t le a d s a v e ry lo n e ly life , so ta lk t o h im . B y s o d o in g , o n e stim u la te s h is m e n ta l a c tiv ity a n d t h a t is a v e ry im p o r ta n t p a r t o f th e to ta l h e a d in ju r y tre a tm e n t, a n d o n e c a n n o t b e g in to o e a rly . F in d o u t th r o u g h a r e la tiv e w h a t th e p a tie n t’s h o m e la n g u a g e is, b e c a u s e ev en if he c o u ld s p e a k se v e ra l la n g u a g e s p re v io u s ly , h e w ill re s p o n d b e s t a t first to h is n a tiv e to n g u e . I n c e rta in p a r ts o f th e w o rld , th is c a n in v o lv e th e p h y s io th e r a ­ p ist in c o n s id e ra b le lin g u istic d ifficulties, b u t it is a lw ay s w o r th th e a tte m p t! A C K N O W L E D G E M E N T S I w o u ld lik e to th a n k P r o fe s s o r 3. C . d e V illiers, C h ie f C o n s u lta n t, N e u r o -S u r g ic a l U n it, G r o o te S c h u u r H o s p ita l, v e r y m u c h for. h is h e lp in p re p a rin g th is a rticle, a n d f o r th e le n d o f h is p h o to g r a p h s . I n a d d itio n , th a n k s g o to M is s H e b le r f o r th e ty p in g o f th is article. THE TREATMENT OF PENETRATING STAB WOUNDS OF THE CHEST by J. M . H a y se -G r e g so n , D ip . P h y s . (U .C .T .) P h y s io th e ra p ist, B a ra g w a n a th H o s p ita l. Those o f us w h o h a v e h a d to tr e a t p a tie n ts w ith penetrating s ta b w o u n d s o f th e c h e s t, w ill a p p re c ia te that p h y sio th e ra p y p la y s a v ita l ro le in th e m a n a g e ­ ment of th e s e p a tie n ts . A t B a ra g w a n a th H o s p ita l C'proxim ately o n e t h o u s a n d five h u n d re d N o n - E u r o p e a n itients w ith s ta b b e d c h e s ts a re a d m itte d y e a rly . In addition th e s e p a tie n ts m ig h t p re se n t w ith a s ta b b e d abdomen re q u irin g a la p a ro to m y , w h ile n o t in fre q u e n tly , patients a re a d m itte d w ith a p e n e tra tin g s ta b in to th e heart, n e cessitating a th o ra c o to m y . H o w e v e r, fo r th e purpose o f th is a rtic le th e tre a tm e n t o f p a tie n ts w ith penetrating s ta b w o u n d s o f th e c h e s t re q u irin g in te r­ costal d ra in a g e o n ly , is discussed. Mechanism o f Injury The in tra p le u ra l p re s s u re w ith in th e c h e s t is less th a n atmospheric p re ssu re , v a ry in g fro m a p p r o x im a te ly m in u s nine to m inus tw elve c e n tim e tre s o f w a te r in in s p ira tio n , and from m in u s th r e e t o m in u s six c e n tim e tre s o f w a te r on expiration. T h u s e x p a n s io n o f t h e lu n g s is p a ssiv e ly maintained b y a p a r tia l v a c u u m w ith in th e p le u ra . W h e n a stab w ound is in flic te d w h ic h p e n e tra te s th e p le u ra l cavity, allow ing a ir t o e n te r, th e n e g a tiv e p re s s u re within the p le u ra l sp a c e is e lim in a te d , r e s u ltin g in collapse o f th e lu n g , t h e d e g re e o f c o lla p s e b e ing p r o ­ portional to th e a m o u n t o f a ir in th e p le u ra l sp a c e. Pressure w ithin th e p le u r a l sp a c e m a y in c re a s e p r o ­ gressively u n til it ex ceed s a tm o s p h e ric p re ssu re , c on- •tituting a severe te n s io n -p n e u m o th o ra x . T h is m a y a rise w h e n th e la c e ra tio n to th e c h e s t w a ll, tra c h e a , b ro n c h u s o r s m a lle r b r o n c h io le p re s e n ts a s a ‘flap v a lv e ’ w h ic h a llo w s t h e fre e p a ssa g e o f a ir in to t h e p le u r a l sp a c e o n in s p ira tio n , b u t tr a p s th e a ir w ith in t h e p le u r a o n e x p ira tio n . T h is in c re a s in g p re s s u re w ith in th e p le u ra l sp a c e w ill n o t o n ly to ta lly c o lla p s e th e lu n g o n the a ffe c te d sid e , b u t w ill c a u s e th e m e d ia s tin u m to s h if t to th e o p p o s ite sid e , w h ic h in tu rn w ill p r o d u c e c o m p re s ­ s io n o f th e g o o d lu n g . M e d ia s tin a l s h if t a n d d e v ia tio n o f th e tr a c h e a c a n b e c le a rly se e n o n X -R a y . T h is s ta te o f a ffa irs w ill n o t re v e rse u n til a n in te rc o s ta l d ra in is in s e rte d , w h ic h w ill a llo w t h e a ir w ith in t h e p le u ra l sp a c e to e sc ap e . T h e r a te a t w h ic h th e lu n g e x p a n d s is n o t p r o p o r tio n a l t o th e e x te n t o f t h e p n e u m o th o ra x , b u t d e p e n d s o n h o w q u ic k ly th e d a m a g e d lu n g tis su e seals itself. P le u r a l th ic k e n in g a n d th e p re se n c e o f o th e r p a th o lo g y in th e lu n g w ill r e ta r d e x p a n s io n . C lin ic a l signs o f p n e u m o th o r a x a re: (i) D e c re a s e d a ir e n try . (ii) H y p e r - r e s o n a n c e o n p e rc u ss io n . (iii) D e v ia tio n o f t h e tra c h e a a w a y fro m th e a ffected side. (S ee F ig . 1.) W hein th e lu n g tis su e o r th e in te rc o s ta l vessels a r e la c e ra te d , th e p a tie n t p re s e n ts w ith a h a e m o th o ra x . L a c e r a tio n o f lu n g tis s u e is th e m o s t c o m m o n c a u s e o f a h a e m o th o ra x , w h e n th e c lo ttin g o f v essels is u su a lly ra p id a n d e ffective, th u s r e n d e rin g s e c o n d a ry h a e m o r r ­ h a g e o r a p ro g re s siv e ly in c re a s in g h a e m o th o ra x a n u n ­ u s u a l o c c u rre n c e . N e v e rth e le s s a se c o n d X -R a y w ill fre - 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 8 P H Y S I O T H E R A P Y M A R C H , 1973 and they all add up to VERSATILITY 1. A D A P T A B L E T O E X I S T I N G E Q U I P M E N T H o riz o n t a l c e rv ic a l t ra c t io n o n e x is t in g x -r a y t a b le s, t re a t m e n t t a b le s, h o s p it a l b e d s a n d b e d s in the h om e . 2. V E R T IC A L C E R V I C A L T R A C T I O N W IT H T H E F T C - 2 0 “ T R U - T R A C ” F L E X IO N T R A C T I O N C H A I R f iv e a n g le a d j u s t m e n t s c o m p e n s a t e f o r th e fo rw a rd a n g le o f t h e n e c k , p o s it io n in g t h e c e r v ic a l s p in e in a s t r a ig h t lin e w it h t h e t ra c t io n p u ll, p r o v id in g i n ­ c r e a s e d fle x io n a n d g r e a t ly a d d in g to p a tie n t c o m ­ fort. 3. L U M B A R T R A C T I O N W IT H T H E R T - 9 9 " T R U - T R A C " T R A C T I O N & T H E R A P Y T A B L E R o lle r b e a r in g s in the l u m b a r s e c t io n o f the table e lim in a t e s Ir ic t io n w h ic h p r o v id e s e ffe c tive treat m e n t at lo w e r p o u n d a g e r e s u lt in g in a d d e d p a tie n t t o le ra n ce . 4 . H O R IZ O N T A L C E R V I C A L T R A C T I O N W IT H T H E R T - 9 9 ''T R U - T R A C " T R A C T IO N & T H E R A P Y T A B L E N in e v a r y in g a n g le c h a n g e s ( h o r iz o n t a l t o 4 5 de^ g r e e s ) p o s it io n s t ra c t io n p u ll in d ire c t lin e w it h t h e c e rv ic a l s p in e a n d a s s u r e s se le c t iv e fle x io n a n g le fo r th e p atie nt. T h e s e a r e j u s t f o u r a d a p t a t i o n s o j th e “T R U - T R A C " p o r t a b l e i n t e r m it t e n t tr a c tio n m a c h in e . T h i s v e r s a tile m a c lti/ie m a y a ls o b e m o u n t e d o n a n a i l f o r v e r tic a l c e r v ic a l tr a c tio n u se . If you have another application in mind write for descriptive brochure illustrating many additional accessories. Exclusive Distributors for Southern Africa PROTEA ELECTRO -M ED ICAL SERVICES (PTY.) LTD. A Subsidiary for Protea Holdings Limited Tel. Address: "M a n lu " Tel. 838-8351 (10 Lines) P.O. Box 7793, J O H A N N E S B U R G and C A P E T O W N — D U R B A N — E A S T L O N D O N — PR E T O R IA PO RT ELIZA B E TH — S A L IS B U R Y — W E L K O M — W IN D H O E K 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. ) IYIARCH, 1973 P H Y S I O T H E R A P Y Page 9 Fig 1. X -R a y sh o w in g r ig h t sided p h e u m o th o ra x . A rrow s in d ic a te o u tlin e o f p a rtia lly c o lla p se d lung. quently r ev ea l a n i n c r e a s e d a m o u n t o f fluid in t h e che st . This is u s u a l l y d u e t o b l o o d in t h e p l e u r a l s p a c e a c t i n g as an i r ri t a n t , t h e r e b y c a u s i n g th e p l e u r a t o p r o d u c e a serous e x u d a t e . T h e cl in ic al si g ns o f a h a e m o t h o r a x are: J i ) D u l l n e s s on p e r c u s s i o n , f j ) D e c r e a s e d a i r e n t r y . (ui) D y s p n o e a . (iv) S h o c k . (v) P ain. P at ie n ts m o s t c o m m o n l y p r e s e n t w it h a h a e m o p n e u m o - thorax, a l t h o u g h t h e o n e c o n d i t i o n m a y be p r e s e n t w i t h ­ out th e o t h e r . (See Fig . 2.) A.t B a r a g w a n a t h H o s p i t a l , t he e x t e n t o f a h a e m o ­ thorax o r p n e u m o t h o r a x is e x p r e s s e d a s a p e r c e n t a g e o f blood or a i r in t h e af fe cte d sid e o f th e ch e s t . T h i s is not an a c c u r a t e a s s e s s m e n t b u t s e rv e s as a r o u g h g u i d e as to t h e se v e ri t y o f h a e m o o r p n e u m o t h o r a x , a n d is classified a c c o r d i n g to fi gures 3 a n d 4. (See Figs. 3 a n d 4.) It s h o u l d be n o t e d t h a t a 157., t o 2 0 r/r h a e m o t h o r a x . which will a p p e a r on X - R a y as a n o b l i t e r a t i o n o f t h e co st o-p hr eni c a n g l e will r e p r e s e n t a p p r o x i m a t e l y o n e and a h a l f p in ts o f fluid w i t h i n t h e a d u l t ch e s t . It is often s u r p r i s i n g h o w m u c h fluid c a n be d r a i n e d f r o m a chest, w h i c h on X - R a y a p p e a r e d to c o n t a i n o n l y a j*nall a m o u n t , as it t a k e s a b o u t five h u n d r e d c c ’s o f Wood in t h e p l e u r a l c a v i t y t o p r o d u c e .r ad i o l o g ic a l a n d Physical e v i d e n c e o f a h a e m o t h o r a x . A h a e m o t h o r a x o f le?s t h a n 15% is u s u a l l y t r e a t e d c o n s e r v a t i v e l y - i.e. Without i n t e r c o s t a l d r a i n a g e . Fig. 2. X -R a y sh o w in g rig h t sided h a e m o th o ra x , in d i­ c a te d by b ro k e n a rro w . C lin ic al P ic tu re a n d P a th o -P h y s io lo g y : T h e c l i n i c a l p i c t u r e m a y i n c l u d e p a i n , r e s p i r a t o r y d i s ­ tr ess a n d s h o c k , a n d to a g r e a t e r o r les ser e x t e n t s h o w s t h e f o l l o w i n g signs : (i) P a l l o r . ((i) C y a n o s i s . 1 (iii) T a c h y p n o e a j — r e s p i r a t o r y di stress. (iv) D y s p n o e a J (v) H y p o v o l e m i c s h o c k — i.e. r a i s e d p u l s e r a t e , fall in b l o o d p r e s s u r e . P a l l o r a n d cl i n i ca l s h o c k a r e u s u a l l y d u e t o loss o f b l o o d , b u t a r e o f t e n g r e a t e r t h a n w o u l d b e e x p e c t e d f o r t h e a m o u n t o f b l o o d a c t u a l l y lost. T h e fal l in b l o o d p r e s s u r e s t i m u l a t e s t he c a r d i a c c e n t r e , w h i c h b r i n g s a b o u t a n i n c r e a s e in h e a r t ra te. R e s p i r a t o r y d i st r e s s is p r o d u c e d b y a n u m b e r o f f a c t o r s . T h e e l i m i n a t i o n o r d e c r e a s e o f t h e n e g a t i v e p r e s s u r e n o r m a l l y ex i s ti n g i n t h e p l e u r a l c a v i t y d i m i n i s h e s v e n o u s r e t u r n , a n d th i s, p l u s t h e r e d u c e d v o l u m e o f c i r c u l a t i n g b l o o d , r e s u l t s in r e d u c e d c a r d i a c o u t p u t . D e - o x y g e n a t e d b l o o d p u m p e d t o t h e l u n g s is o n l y e f fe ct iv e ly o x y g e n a t e d by o n e l u n g , as t h e a f fe c t e d l u n g is p a r t i a l l y o r t o t a l l y c o l l a p s e d . In a d d i t i o n , i n j u r y to t h e l u n g itsel f, t o t h e ch e s t w a l l , a n d p o s s i b l y t o t h e d i a p h r a g m , r e s u l t in p a i n a n d la c k o f ef fe ctiv e m o v e m e n t o f t he af fe cte d sid e o f t h e c he s t. In te rc o s ta l D ra in a g e : I n t e r c o s t a l d r a i n s w o r k o n t h e s i m p l e p r i n c i p l e o f a w a t e r s e al , as p e r d i a g r a m . (Se e F ig . 5.) T h i s a l l o w s t h e fr ee p a s s a g e o f b l o o d a n d a i r d o w n th e t u b e f r o m t h e p l e u r a l ca v i t y . P r o v i d e d t h e b o t t o m o f a t u b e (a) in t h e d i a g r a m is u n d e r t he w a t e r level 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 10 P H Y.S I O T H E R A P Y M ARCH , 1 9 7 3 MARE TOUR DAY A LITTLE EASIER! Y ou physios are a hard-worked group, we know. In the day’s work, environment and c o m f o r t b e c o m e m o r e a n d m o r e important — and while there’s not much we can do to help fix the background in which you work, y o u ’ll find a comfy, practical working rig in the new special- purpose uniform w e’ve designed with you _ _______ in mind. It’s a continental style dress, with Bermuda-type shorts to match. A side vent in the skirt and the generous cut, mean that y o u ’ll work more easily, and feel comfortable right through the hard day. Your option o f short or long sleeves, in drip-dry, hard-wearing fabric . . . white or saxe blue. Sizes 3 2 to 4 2 . Elegance and efficien cy. . . what more could you ask ? 4 t h F lo o r , P r itc h a r d H o u s e , 8 3 P r itc h a r d S treet, JO H AN NESBURG . T e le p h o n e 2 3 - 4 4 0 5 '. 87 M a r io n A v e n u e, G le n a s h le y , DURBAN. T e le p h o n e 8 3 - 7 2 2 6 . Fully illustrated catalogues and price lists o f our full range are available free to you. Just drop us a postcard (P.O. Box 7 ^ 2 , Johannesburg) or telephone 2 3 -4 4 0 5 ' any time, including nights, weekends and holidays. W e ’re also happy to execute phone orders, o f course. 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. ) INARCH, 1973 P H Y S I O T H E R A P Y Page 11 SO% 7S% 6 0 - 7 0 % F ig. 3. A ssessm en t of pneum othorax. F ig . 4. A ssessm en t o f h aem oth orax.’ in the b o ttle , a ir c a n n o t tra v e l u p th e tu b e . A s a ir is removed fro m th e p a tie n t’s c h est, a n d th e neg ativ e ’ J s s u re th e re in is re -e sta b lish e d , th e w a te r level in tu b e will rise slig h tly . T h is level sw ings w h e n th e p a tie n t breathes o r c o u g h s, a n d w ill c o n tin u e to d o so u n til the I'Jng is re -e x p a n d e d . P ro v id e d th e tu b e , is p a te n t, th e degree o f flu c tu a tio n o f th e w a te r level w ith in th e tu b e is a sensitive a n d a c c u ra te in d ic a to r as to th e e x te n t of re-expansion. T h e a m o u n t o f b lo o d d ra in e d can be accurately m e a su re d . (F igs. 6 a n d 7.) Patients p re se n tin g w ith a b ro n c h o -p le u ra l o r a lv e o la r- pleural fistu la a re p la c e d on n e g ativ e su c tio n , a tta c h e d t0 tube (b) in F ig . 5. T h is c o n d itio n m a n ife s ts by exces­ sive b u b b lin g in th e d ra in b o ttle o n b re a th in g a nd coughing, a n d f a ilu re o f lu n g e x p a n s io n . G e n e ra lly , suction is a p p lie d fro m o n e to th re e d a y s a n d is re m o v e d when th e r e is n o f u r th e r b u b b lin g , a n d e x p a n s io n is M a in ta in e d . Treatment: . Prior to W o rld Wair II, the p ra c tic e w as to a sp ira te Ijjst enough fluid to re liev e th e d y sp n o e a , a n d to re p la c e ‘ne fluid re m o v e d w ith a ir. T h e re a so n in g b eh in d this ^as that c o m p re ss io n o f th e in ju re d lu n g w o u ld p re v e n t ■urther bleeding. T h e p a tie n ts w e re on s tric t b ed rest, nd the c h est w as s tra p p e d to a v o id excessive m o v e ­ ment. C o u g h in g a n d u n n e c e ssa ry a ctiv ity w e re stric tly avoided. N o w a d a y s th e p rin c ip le s o f tre a tm e n t a r e so m e w h a t re v e rse d , th e e m p h a sis b e ing on e a rly e v a c u a tio n o f th e h a e m o th o ra x , a n d re -e x p a n sio n o f the lu n g as soon as p o ssib le . On A d m ission: T h e p a tie n t is first tre a te d fo r e x isting sh o c k by im ­ m e d ia te ly re p la c in g lost b lo o d by m e a n s o f in tra v e n o u s fluid. T h e p a tie n t is th e n ro u tin e ly X -R a y e d . D e p e n d in g o n th e e x te n t o f the h a e m o p n e u m o th o ra x , an in te r ­ c o sta l d ra in is in se rte d u n d e r lo c a l a n a e sth e s ia , a n d th e p a tie n t is th e n re -X -R a y e d . P h y s io th e ra p y is c o m ­ m en ced a s s o o n as p o ss ib le a f te r in se rtio n o f th e d ra in . A im s o f P hysiotherapy: 1. T o o b ta in e a rly e x p a n s io n o f th e lung. 2. T o b rin g a b o u t effective d ra in a g e o f th e h a e m o ­ th o ra x as so o n as p o ssib le , b e fo re the b lo o d clo ts w ith in th e chest. 3. T o p re v e n t a c c u m u la tio n o f se c re tio n s in th e lungs, th e re b y p re v e n tin g a te le c ta sis, p n e u m o n ia , etc. 4. T o p re v e n t c o m p lic a tio n s a sso c ia te d w ith th e p re se n c e o f a n in te rc o s ta l d ra in (p a rtic u la rly w ith lo n g term d ra in s , s u c h as w ith an e m p y e m a ) i.e. p o s tu ra l d e fo rm ity , w a stin g o f th e a rm a n d sh o u ld e r g ird le m uscles o f th e affected sid e d u e to disuse, a n d sp lin tin g o f the affected side o f th e chest. M ethods: 1. B re a th in g ex erc ises— (a) d ia p h ra g m a tic b re a th in g . (b) lo c a lis e d b re a th in g to th e a ffected side. b ila te ra l la te ra l c o sta l b re a th in g . 2. C o u g h in g . 3. A c tiv e exercise — a rm a n d sh o u ld e r e xercises, th o ra c ic m o b ility e xercises, v ig o ro u s a ctiv ities, e.g. ru n n in g , ju m p in g , etc. 4. P o s tu ra l d ra in a g e a n d p e rc u ssio n if necessary. T h e m a jo rity o f p a tie n ts see® a t B a ra g w a n a th H o s ­ p ita l a re y o u n g a n d o th e rw is e fit in d iv id u a ls, w h o se ch ests p r io r to in ju ry a r e n o rm a lly clear. H o w ev e r, b e c a u se th e lu n g re s p o n d s to c o lla p se by in cre asin g se c re tio n s, m a n y p a tie n ts w ill h a v e a p ro d u c tiv e c o u g h fo llo w in g t h e in ju ry . P o s tu ra l d ra in a g e is n o t given a s a r o u tin e , a n d o n ly to th o s e p a tie n ts w ith excessive se c re tio n s, o r p e rsiste n t a te le c ta sis. C o u g h in g c o n sti- 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 12 P H Y S I O T H E R A P Y M A R C H , 197; T H E p r e s e n t s - Minidyne mk III T R A N S I S T O R I S E D F A R A D I C U N I T ( V / l l N i D ,A «rA «e 8 ^ SH!flE R e p r e s e n t i n g a n o t h e r a d v a n c e in t h e e v o l u t i o n o f