Page Two P H Y S I O T H E R A P Y October, 1955 RECENT ADVANCES IN PHYSIOTHERAPEUTICAL METHODS By D R . W ILLIAM B E A U M O N T Director o f Physical Medicine, Westminster Hospital. IN T R O D U C T IO N . A L T H O U G H Physical Medicine is now a widely recognised form of treatm ent, it cannot be said that any dram atic o r revolutionary methods have been evolved to account for this changed attitude. Before the W ar, Physiotherapy was th e Cinderella o f therapeutic measures, an d the Physiotherapy D epartm ent was very largely a dumping ground fo r the unw anted but tenacious ou t­ patient. T rue there have been m arked advances in diag­ nostic methods, but these are the province o f the Physical Medicine Specialists, themselves one o f the most recent- additions to the C onsultants and Specialists G roup. Advancement has been made in tw o directions. Firstly in the design o f apparatus which is now based on the electronic valve. This modern development has displaced the old and wasteful spark-gap circuit for diatherm y and the induction coil, metal rectifiers, etc., circuits used for p ro ­ ducing the faradic, sinusoidal and galvanic currents. Secondly in regard to treatm ent. Basic physiotherapeutic technique has been adapted and employed in many spheres o f medicine and surgery, both old and new, so th a t fresh fields o f interest and usefulness have been opened up for the physiotherapists. Thoracic surgery is one of the most spectacular examples, but the wide-spread use o f pre- and post-operative treatm ent in general surgery, th e employment o f muscle relaxation exercises for psychia­ tric cases (Ref. 1.), an te and post natal exercises (Ref. 2.), the treatm ent o f respiratory conditions (Ref. 3.), the recog­ nised position of the physiotherapist in th e plastic surgery team (Ref. 4), are all indications of the modern trend o f expansion in the use o f physical methods. The writer has chosen two examples to illustrate recent advances in methods o f treatm ent. As this article is written specially fo r the physiotherapist, details o f technique will be given as fully as possible. THE SLOW HEALING W OUND. One of the more recent advances, but perhaps least known o r rarely used physiotherapeutic m ethods, is the one applied to tissue repair. In cases o f m alignant neoplasm far reaching excision o f tissue is the practice. In these and in some cases o f non-m alignancy, incisions, often quite deep through unaffected tissue, have to be made. M ost of them heal by first intention. Some, however, break down and healing is arrested. It is therefore o f interest to all to find a method, or methods, which will initiate or stim ulate tissue repair. A t one time it was thought th at healing was arrested by bacterial invasion, and chemical agents were used to sterilise the wound, but these were found to destroy not only in­ vading organism but healthy tissue cells, and so delayed healing. The discovery o f the new antibiotics was hailed as the solution to the problem , but tim e has shown th at these are not infallible. New avenues o f research, therefore, are being explored in the hope o f finding a means o f stim u­ lating tissue repair activities, with the result th a t an old an d alm ost discarded physiotherapeutic m ethod is being revived. Before describing this it will not be considered o u t of place, it is hoped, to outline the norm al process o f tissue repair. Mechanism of Granulation: The various stages by which granulation tissue is form ed need only be summarised very briefly. The area is flooded with a rich protein exudate which ultim ately coagu­ lates. A t first this forms a m atrix fo r the white cells, which migrate through the vessel walls, and for the connective tissue netw ork form ed by the fibroblasts. Coincident with this the neighbouring capillaries throw out projecting buds. These elongate, join with other similar buds, and form loops of new capillaries which become entangled in the! connective tissue network. The exudate coagulates, cement­ ing the whole together, and a new kind o f tissue is formed, highly vascular and easily damaged. This fills in the crevices and builds a structure filling in th e entire cavity. Ultimately the connective tissue netw ork contracts, epithelial islets appear on the surface, or push o u t from th e edges o f the skin, and complete the process o f repair. W hat initiates this complex tissue activity, and what means are a t o u r disposal for bringing this about, is based largely on hypothesis. In 1858 Virchow pointed out that healing was the result o f direct stim ulation o f cells by trauma. A fter a long interval the theory was revived. Wiesner suggested th at th e traum atic effect was a n indirect one, the injured cells releasing substances which stimulated norm al cells to proliferate. Eventually the nature o f this substance was determined and believed to be th at o f a ‘horm one’, and subsequently identified as tissue promoting. T he present view is th a t traum a is the prim ary causative agent, and the repair process results not from destruction, bur from partial dam age o f the cellular elements. Thus, for example, the surgeon’s knife destroys but leaves dam aged tissues in close proxim ity to th e incision, and from these the mechanism o f tissue repair is initiated, thus presenting a possible explanation of healing by first intention. Research in relation to th e effects o f the shorter ultra violet rays, given in non-destructive doses, has showitf th a t they damage but do not destroy cellular elements^ T he m ost effective wave length is believed to be in the region o f 2,000 A .U . Thus it would appear th a t radiations of this wave length operate as a traum atising agent (Ref. 5.) liberating a horm one-like substance w ithin the wound which is capable o f stim ulating, or re-starting, the process o f granulation in cases where it is inhibited o r even ceased to function. This horm one theory possibly does not fully explain th e entire process o f healing. The air ionising properties o f ultra violet radiations, the result o f exciting m olecular activity are certainly contributory factors. The smell o f ozone in the ultra violet radiation room is well know n, and is attributed to air ionisation (Ref. 6.). This ozone can be detected em anating from the skin of some persons after ultra violet irradiation and also in a wound after irradiation. This may account for the antibiotic effect. Increased oxygen production in the tissues has been attributed to this ionising action o f ultra violet radiation, resulting in the acceleration o f respiratory exchange within th e tissue cell, which it has been dem onstrated also has a beneficial effect on healing. Lastly, one o ther result o f re­ search has shown th at when cells are exposed to ionising radiations, variation in the cell nucleus takes place, result­ ing in changes in cell characteristics (Ref. 7.). It may well 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. ) herein lies a germ o f an idea which accounts for be that n ^ thg fibroblasts and the vascular budding appearan ntial fo rebears o f granualtion tissue. As has Hv heen stated the full explanation o f tissue healing already ^ hypothetical state and the above theories is aS Zjpnted as a probability and not as an etablished fact, are there can be little doubt th at the clinical results o b s e r v e d ’ have a rational and not purely empirical basis. Technique * This must follow a definite plan, form ulated o n the the site and the extent o f the wound, and w hether • t h e ^ simple o r complex w ound which has to be dealt th The plan m ust take into consideration also the need for supplementary treatm ent and the m ethod for pre­ ir ra d ia tio n cleaning and post-irradiation dressing. Supplem entary Treatm ents: M o v e m e n t o f surrounding tissue and jo in ts is essential to m a in ta in high m etabolic activity, and active exercise of the part does much to improve circulation and lym phatic drainage. It is often necessary to explain to the patient that movement will help in his recovery and so counter the tendency to immobilisation. W here the p atient’s general condition does not perm it o f voluntary movement, neuro-muscular stim ulation can be instituted to minimise muscle atrophy and jo in t stiffness and im prove circulation. Infra red will relieve the pain and stiffness following enforced im mobilisation and so make movement easier. It also assists in increasing local tissue metabolism. The part played by infra red irradiation must no t be under­ estimated, bearing in mind that any effective ultra violet r a d i a t i o n generator also emits a large percentage o f infra red (Ref. 8.). G eneral ultra violet irradiation can benefit materially the patient who is psychologically and consti­ tutionally at a low level. Pre-Irradiation Cleaning: This is best done with a few drops o f neat peroxide, followed by warm saline irrigation. Peroxide because it liberates oxygen, and warm saline because it closely resembles tissue fluid. Excess o f residual moisture should not be dealt with by m opping with wool o r gauze as particles are left behind and th e delicate new granulation tissue is damaged. D rying is best done by exposure to infra red and can be accomplished in 5 o r 10 mins. Post-Irradiation Dressing: To prevent the dressing sticking, gauze im pregnated with halibut oil, o r cod liver oil, is laid over the wound, but not pushed into it. W ool and bandages can be applied over this. G lucose pow der can be used for dry superficial areas. Irradiation Technique: The K rom ayer lamp, with suitable quartz applicators, and the disc type non-lum inous infra red generator, are the apparatus o f choice for all types o f slow healing wounds. An uncomplicated wound: By this is m eant one w ithout sloughs, a sinus, o r deep cavity. The site chosen for the initial irradiation should be damaged, but not destroyed, tissue as evidenced by existing granulation and not in close proxim ity to bone structure. I f such tissue forms the floor o f the wound, so much the better. A quartz electrode is necessary for deep wounds, and the plated type is best, except for cavity work, to be dealt with later. This localises irradiation and makes for better dosage control. It should be long enough to reach to within i o f an inch o f the chosen area. In shallow wounds th e applicator holder alone can be used. Dosage: Bearing in mind th a t the short ultra violet radiations are the most effective, distance is im portant, not because of the Inverse Square Law, but because o f air absorption and the need fo r th e maximum intensity o f rays falling on the area a t right angles. (Cosine Law). OttobenjW _̂________________ ___ P H Y S I O T H E R A P Y Page Three D istance therefore must be as near as possible w ithout contact, varying the distance to th e irregularities o f tissue level. Even mom entary contact will result in some o f the young granulation sticking to the electrode face. W hether the area be large o r small, the best m ethod is to keep the electrode moving all th e time. C oncentration on one spot can destroy th e vascular buds in a short space o f time. Time: T he effective time is m uch longer th an th a t required for skin lesions, and can be estim ated approxim ately at 1 - 3 mins. for each inch square, providing the applicator is kept moving. Judgem ent must be exercised in estim ating time as there is no m athem atical precision in the grow th o f granulation tissue. If the response is not good, increase the time, if the granulations lose their red glistening appearance, reduce the time as this is an indication of cellular destruction. A n ineffective dose, however, will not give good results. Complex Wounds: This term is used to describe a wound in which there is sloughing, a sinus, or a cavity, o r all three. In dealing with such a wound it is the m ore o r less healthy tissue to which irradiation must be directed to produce the cell traum a already referred to. Sloughs: Very large and thick patches o f sloughing must be removed surgically. Smaller areas are best attacked in­ directly. Snip away any loose edges and then irradiate the m arginal tissue so exposed, after cleaning with peroxide and saline. A dopt the standard unit dose and use the electrode which is most suitable, the plated curved one usually is required. As the slough recedes, attack the new m argin exposed. A Sinus: This also must be attacked separately. Cleaning may have to be done before treatm ent for several days at first. Time must be allowed for drying by absorption and infra red, not ‘m opping u p ’. Also the tissue should be sensitised to counteract the inhibiting effects o f th e cleaning. A 1 /1000 solution o f Eosin, applied with a pipette will be found effective. Only a few drops are necessary, and allow time for the sensitiser to operate. To prevent surface closing the insertion and withdrawal o f the electrode should do all th at is required, but as the opening gets smaller, gauze wedged in between the edges for not more th an one quarter o f the total depth may have to be used. A small sinus, form ing part o f a large wound, will usually close in w ithout special attention, apparently taking p art in th e general tissue repair. The standard nasal applicator has m any disadvantages, chief o f which is very limited radiation emission. A modification, plated and of greater diam eter, has been designed, an d this gives increased radiation and can be used to stretch the opening. The larger sinus, which readily adm its o f a standard size electrode, is dealt with in th e following m anner after the cleaning process. B oth depth and direction m ust be determined before treatm ent by using a suitable electrode as a probe. The working depth is i an inch less th an th at obtained. The ‘bubble’ electrode is most useful and the time for the first three o r four treatm ents is ten minutes. As the sinus fills in, reduce th e distance and th e time. C are must be exercised as regards depth. If obstruction is felt at any time during treatm ent, withdraw the appli­ cator i a n inch. When granulation tissue becomes visible, discontinue insertion and follow th e lines laid down fo r a simple wound. A large, deep cavity: This also requires individual attention. Cleaning up before treatm ent is a problem. It is usually done by allowing the patient to have a bath, otherwise by daily irrigation of the cavity itself with warm saline. N on-.lum inous infra red is given until the cavity is dry and warm. Again use the sensitiser as previously described, do not flood the cavity, and dip the electrode into a pool o f sensitiser. 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 Four P H Y S I O T H E R A P Y October, 1955 Electrode: These cavities have a deceptively large surface area, quite irregular in depth. Scattered radiation is therefore necessary, and this is obtained from the bubble electrode. Intensity o f radiation is reduced and therefore 15 mins. m ay be necessary if the cavity is large, but 10 mins. is suffi­ cient for the size o f the cavity usually seen. Stimulation o f epithelium: W hen the granulation is within i an inch o f the sur­ rounding skin level, attention should be paid to the edges. These may need to be traum atised by scraping away the stratum corneum which has formed a protective covering. N o harm is done if this results in slight bleeding, in fact it is a good thing, it can be arrested easily and the edges can then be irradiated. Using a plated applicator and adopting the labile method, a quarter o f the unit dose, as regards time, can be employed. T he greatest care is necessary not to encroach m ore th an i an inch on norm al skin. A definite perceptible degree erythem a is all th a t is required. Wherever budding o f the epithelial m argins o r epithelial islets appear, encourage and carefully protect these points. Often it is possible, at this stage, to split a large superficial granulating area into one o r m ore sections by concen­ trating on this epithelial activity. This lessens the time for complete coverage and makes the work less tedious. Pressure sores: No special reference will be m ade to these as the technique o f treating them is the same as outlined for the uncomplicated wound. PE R IP H E R A L CIRCU LA TO RY D ISEA SE. This is a generic term applied to a group c f conditions with differences both as regards pathology, etiology and cause, but all m ay have a similar clinical syndrom e and term ination. They all have this in com m on, there is a disturbance o f the peripheral circulation, term inating in throm bosis and in some cases ultim ate pulm onary or cerebral embolism. T he technique described can be applied equally satisfactorily to all o f them , with such m inor modifi­ cations as are dictated by the individual case and comm on sense. Thrombo-Angiitis O bliterans: Better know n to all physiotherapists as Buergers Disease. The sym ptom syndrom e comprises interm ittent claudication, i.e. cram p-like pain coming o n after exercise, particularly walking, as the lower limbs are most often affected, cyanosis when the limb is hanging down and paleness when elevated, reduced o r absent pulsation nor­ mally felt where the dorsalis pedis branch o f the anterior tibial artery is superficial. In addition there are skin changes, a t first lowered local tem peratures, ‘chilblains’, later developing into ‘ulceration’. T he onset, m ore often th an not, goes unnoticed until it becomes an inflam matory lesion o f a vessel; i.e. phlebitis which leads to throm bosis, but embolism is not associated with this condition. The cause is unknow n. Thrombo-embolic Disease: This may be either a prim ary medical condition or secondary to surgical procedure. Like th e previous con­ dition the onset is characterised by phlebitis, throm bosis supervening at a later stage. U nlike Buergers the risk o f a pulm onary o r even cerebral embolism is a definite one, as the nam e denotes. The early stage, i.e. th ro m b o ­ phlebitis, is when physiotherapy is most useful, as little can be done in the acute phlebitic stage, and when embolism has occurred it is not uncomm only fatal if it be a pulm onary embolus. The incidence o f throm bo-em bolic disease is on th e increase and the cause, while not definitely know n in the non-surgical type, is attributed to the present way of life and the growing increase in the older age group. The post-operative condition is attributed to advances in surgical procedure m ade possible by m odern methods o f anaesthesia, long periods o f im mobilisation and inter­ ference with circulation o f the large vessels and the heart itself. The increasing use o f intravenous injections and the need for blood transfusion are believed to effect blood changes both in regard to volume and coagulability and so predispose to lowered blood pressure and inflammatory vessel changes. F ro m this brief outline o f the symptoms and the etiological factors it can be gathered th at the problem that presents itself is w hether physical methods can make any contribution, either directly o r indirectly, to the reversal o f a pathological state characterised by circulatory stasis, whether due to disease o f the vessels or mechanical inter­ ference. Let us consider the physiological response o f the various physical methods in general briefly and two in particular. T reatm ent: In the present state o f our knowledge treatm ent must be directed tow ards slowing coagulation rate a n d /o r compensation for loss o f natural contraction and dilation o f the vessels. The use o f anticoagulants, e.g. H eparin, is alm ost a routine where throm bosis is im minent o r estab­ lished. This is effective where the vessels are able to perform their n atural function, and when the blood has acquired its norm al or nearly norm al fluid state, in which case physical m ethods assist the physiological action o f the vessels. T he alternation o f rest and functional activity o f the vessels is provided by alteration in their calibre, the result o f autonom ic system action and the independant action o f voluntary muscle. The object o f the surgical procedure o f sympathectomy is to interrupt the vaso-constrictor mechanism under the control o f the autonom ic system. Before this operation was introduced the onjy method available for varying the calibre o f the vessels was by means o f external pressure. Before discussing this aspect of treatm ent it is well to review the orthodox physical methods o f massage, heat and exercise in the light o f our present day knowledge. M assage: This is definitely contra-indicated in the acute in­ flam m atory stage o f phlebitis and the pre-throm botic state. Opinions differ as regards its use when throm bosis is established. One reason is based on the assum ption th a t it might result in breaking up the throm bus and so initiate an embolus, the other is th a t massage can have no effect one way o r the other on throm bus form ation. H eat: It is a com m on frequent clinical observation th a t the application o f heat to the extremities o f patients suffering from organic arterial disease increases pain and especially where gangrene occurs, causes extension o f tissue necrosis. I t has been demonstrated th at local application o f heat produces deficiency o f circulation by increasing local tissue metabolism . D am aged vessels are unable to supply an adequate blood supply and local heat increases this dis­ proportion. H eat therefore is contra-indicated in obliterative vascular diseases and m ay accelerate the onset o f ulcerative process. In the inflam matory stage o f phlebitis it can be beneficial if the non-lum inous source o f infra-red irradia­ tion is used (Ref. 8.). Active E xercises: T here is universal agreem ent th a t active exercises im prove circulation and the well know n system o f Buerger’s exercises, if accurately carried out, is most valuable in all form s o f peripheral circulatory disease. Patients should be m ade to understand th at it is im perative for them to mem orise these exercises and practise them a t hom e o r at work as often as possible during the day as well as night and m orning, and W ard patients should be encouraged to practise for twenty minu'.es every tw o hours. It cannot be to o often repeated th at the role o f the physiotherapist is th a t o f a teacher and her supervision periods, whether in th e w ard o r the departm ent, are primarily for- perfecting technique and correcting faults. This system ' o f - active 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. ) Orteber, 1955 ______________________ P H Y S I O T H E R A P Y ___________________________ Page Five ercises is o f special im portance in post operative routine a n d in association with the use o f coagulants. Fnvironment Pressure. This is the nam e given to a system o f treatm ent designed to stimulate an adequate circulation through th e collateral arterial pathways by rythmically decreasing an d increasing air pressure about an affected extremity. A specially desi­ red apparatus called the Pavaex U nit is used. T he name is derived from PAssive VAscular Exercises. Briefly, the limb is placed in a Pyrex glass boot fitted w ith an inlet nipple to which is attached a rubber tube connected at the other end to an apparatus, the operative feature o f which is a m otor-driven pum p w ith rotary o r sliding, pressure operated, valve. By this device the limb can be subjected to controlled alternation o f the environm ental pressure within the boot. T he assum ption o n which this m ethod is based is th a t such alternating pressures external to the limb will result in alternating occlusion and dilation o f the vessels. The Pavex apparatus is rarely seen in a m odern­ ised departm ent, and the m ethod is rapidly disappearing and is being replaced by the following. MUSCLE STIMULATION. The m ethod to be described m ay be considered a recent innovation, o r a t least a n ad ap ta tio n o f a n old method put to a new use. In nerve lesions o r disuse .muscle wasting the application o f a faradic current to a m otor point is used fo r stim ulation o f a muscle o r small muscle group and it is im portant not to involve unaffected and particularly opposing muscles. The object o f using this m e th o d in the treatm ent o f peripheral circulatory disease is to obtain contraction an d relaxation, n o t o f a small group but the whole muscle mass in which affected vessels are embedded, irrespective o f th e prim ary function o f those muscles. The hypothesis on which this m ethod is based is briefly as follows: C ontraction o f muscles affords effective aid to venous return an d can be obtained by electrical stim u­ lation. This has been dem onstrated by experimental work on anim als (Ref. 9.) and th at elecrically pro­ duced contractions increase the venous outflow (Ref. 10.). From this it is deduced th a t by securing this electrical muscle response, the vessels will be alternately compressed an d relaxed. D uring the occlusion stage blood flow will be arrested, and released during re­ laxation with increased force and volume. In this way a cycle o f alternating vessel rest and activity is estab­ lished. Muscle contraction needs to be strong enough to occlude the lum en o f the vessel and th e tim ing o f the release Ito synchronise w ith the pum p action o f the heart. As yet the results on anim als have not been dem onstrated, for obvious reasons, o n hum an beings. Technique: Position o f the patient: In order to neutralise the effect o f gravity and so assist muscle action, the affected limb is elevated th roughout treatm ent. This is best done by reversing the norm al position o f a patient on a treatm ent couch. The feet an d legs resting on a pillow are supported by the raised headpiece o f the couch. Electrodes: These need to be flexible and thin to avoid localised pressure. Thin flexible alum inium sheet metal is suitable material to use. I t is easily cut to the desired shape and size and tw o layers o f lint can be stitched on to the metal. Metal foil backed w ith felt saves trouble, but does not last long. Alternatively, ‘electrode jelly’ can be sm eared on the surface o f the metal and applied directly to th e skin. This obviates the unnecessary use o f moist lint o r felt. One electrode forms a cuff roun d the calf muscles embracing the m ain portions o f the belly o f the gastrocnemius, soleus, peroneus longus, anterior tibial and extensor longus digitorum, but excluding th a t portion o f th e shaft o f the tibia which is usually superficial. T he o ther electrode is placed on the sole o f th e foot, excluding the toes and heel. Both are fixed in position by n arrow strips o f elastoplast. A thin rubber bandage is then applied evenly to the entire limb from toes to knee w ithout causing any sensation o f constriction. In cases where both limbs are affected, similar electrodes are applied to each limb, those on the feet being connected by a bifurcated lead to one term inal and those on the calves are connected in th e same m anner to the o ther term inal o f the current supply. Small thick, bulky pads m ust n o t be used as they cause localised pressure on the m ore superficial vessels. Current: T he sinusoidal o r interrupted galvanic was first used and som e w orkers consider the latter to be the best available at present, as the pulsation rate can be tim ed to synchronise w ith the pulse rate by means o f a m etronom e. This type o f apparatus is rapidly going o u t o f production. The m odern apparatus m ade by B ritish firms are electronic generators o f the rectangular current pulse o f controlled am plitude and duration, from which can be obtained a current o f 300 ms. a t 1 pulse per sec. T his is a far m ore pleasant current from the patient’s point o f view th an the interrupted galvanic. T he writer-is using all three types at present in the hope o f assessing the therapeutic value against the various disadvantages o f each. Dosage: This can be expressed in term s o f current, duration and frequency o f treatm ent. C urrent strength is o f the utm ost im portance and there can be no rule o f thum b. T he essential point is th e production o f visible strong contractions; w ithout these, treatm ent is ineffective. As regards the duration and frequency, workers in the U nited States who use a specially designed apparatus, with m any useful refine­ ments, give continuous treatm ent varying from twelve to tw enty-four hours (Ref. 11.). T he writer is unaw are o f any procedure com parable to this being used in G reat Britain. T he usual procedure is to give 30 mins. twice a day. A dm it­ tedly it is not ideal, b u t it is practical for in-patients if not for out-patients, for whom treatm ent is given daily. General observations: T he results o f using muscle stim ulation have been clinically satisfactory. Combined with Buergers exercises the results are better than either m ethod alone. Used alone it is m ost useful in post operative cases while the p atient’s general condition prevents active exercises. T he two conditions dealt with have been selected because th e methods advocated have given good results and either they are not know n o r for various reasons no t used. M oreover these new spheres for work fo r the physio­ therapist require the revival and adaptation o f some o f the older physiotherapeutic methods. L IST O F R EFE R E N C E S. 1. Muscle R elaxation: G . G a r m a n y , Actinic Press, London. 2. N atu ral C hildbirth: H . H e a r d m a n , E. & S. Livingstone L td., L ondon. 3. R espiratory F unction: R. D . T o n k i n , Actinic Press, L ondon. 4. Physical M ethods in Plastic Surgery: J. P. R e i d y , A ctinic Press, London. 5. Tissue R epair: L e o G . N u t i n i , G l a s s e r : M edical Physics, Chicago, Illinois. 6. Ozone. Effects o f U ltra violet R adiations on Cells: J. R . L o o f b o u r o w . Growth Symposia. 7. Effects o f U ltra violet R adiations o n M utation: M u l l e r & M a c k e n z i e . Nature, Jan. 14th, 1939. 8. Infra R ed Irradiation— 3rd E d .: Wm. B e a u m o n t , H . K. L e w i s , London. 9. Journal o f M edical Science. Oct. 1948. 10. Proceedings o f Experim ental Biology & Medicine, N ov. 1948. 11. Archives o f Physical Medicine, Jan. 1954. Throm bo- embolis disease. M a r t e l l a & O t h e r s . Chicago, Illinois. 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. )