June, 1968 P H Y S I O T H E R A P Y Page 7 w h ile h o ld in g a lo o p o f c o r d a t t a c h e d t o e ith e r e n d o f th e b o a r d , a n d b y h is s o u n d f o o t ’s p o s itio n in g th e b o a r d . I n th is w a y h e le a r n s a n d a c q u ir e s t h e s e n s o r y a s p e c t o f a n d e le m e n t jn t h e s e n s o r y - m o t o r a s s o c ia tio n o f t h r u s t i n g t h e h e e l o f t h e w e a k leg t o w a r d s t h e v e r tic a l b o a r d . T h is b o a r d is v a lu a b le : it h o ld s t h e b e d - c lo th e s o f f h is fe e t, w h ile it is h eld d o w n b y t h e w e ig h t o f th e c lo th e s . A h o r iz o n ta l m e m b e r a t e ith e r e n d o f t h e b o a r d h e lp s t o h o ld t h e b o a r d u p r ig h t. T h e s tr e n g th o f t h e p a t i e n t ’s f o o t a c t i o n s n e e d o n ly b e sm a ll. C o - o r d i n a t io n a n d t h e s e n s o r y - m o t o r a s s o c ia tio n a r e t h e a im s : th e s e a r e e n c o u r a g e d , if th e in d e x fin g e r o f t h e s o u n d h a n d feels t h e p r o x im a l b o r d e r o f t h e p a te lla e , as th e y b e g in t o m o v e . C O N C L U S I O N T h e e s s e n tia l f e a t u r e o f th is n e u r o lo g ic a l a p p r o a c h to r e h a b ilita tio n o f t h e s t r o k e p a t i e n t is its i m p a c t o n r e h a b ili­ t a t i o n o f h is m e n ta l a b ilitie s . T h e l a t t e r is e n c o u r a g e d b y th e lin k in g u p u n d e r f a v o u r a b le w o r k in g c o n d i t i o n s o f n u m e r o u s s e n s o r y - m o to r a s s o c ia tio n s . T h is m e n ta l r e h a b i l i ta t io n a p p r o a c h a p p lie s a ls o to o t h e r g e r ia tric c a se s. I t is n o t j u s t a flash in t h e p a n . I t w a s e x p la in e d in m y b o o k o n The A d ju stm en t o f M uscular H a bits (1933) a n d S ir W ilf re d L e G r o s C la r k p o in te d o u t in h is F o r e w o r d t h e r e t o t h e im p o r ta n c e o f th e p sy c h o lo g ic a l e le ­ m e n ts in th is ty p e o f s e lf-h e lp b y w h ic h t h e p a tie n t e n c o u r a g e s h im s e lf t o c o n t i n u e h is p ro g re s s . T h is a r tic le h a s d is c u s s e d s o m e p r a c tic a l m e th o d s b y w h ic h t h e p a t i e n t c a n b e t a u g h t t o g a in c o n t r o l o f s e n s o ry - m o t o r a s s o c ia tio n s d e s p ite th e u n f a v o u r a b le ite m s in his s e n s o ry field . T h e y c a n d o u b tle s s b e e x te n d e d a n d im p ro v e d b y o t h e r s . T h e e s s e n tia l f e a tu r e o f th is n e u r o lo g ic a l a p p r o a c h to r e h a b i l i ta t io n o f t h e s t r o k e p a t i e n t is its im p a c t o n r e h a b ilita tio n o f h is m e n ta l a b ilitie s . A s t h e g e n e ra l p r in c ip le s u n d e r ly in g t h e f o re g o in g r e m a rk s a n d r e c o m m e n d a t i o n s w e re d isc u sse d a t le n g th in m y la st little b o o k N a tu ra l M o v em e n t (1 9 6 2 , L ew is L o n d . 103 p p .) a n d w e re f o u n d in t h e w o r k s o f t h e n u m e r o u s w e ll-k n o w n a u th o r i ti e s q u o t e d th e r e in it is u n n e c e s s a ry f o r m e t o re p e a t th e m h e re . Giving those Fibrocytics the Bird (and other Treatments) A . B U R R , m .c .s .p ., S e n io r P h y s io th e r a p is t, T r a n s v a a l M e m o r ia l H o s p ita l f o r C h ild r e n , J o h a n n e s b u r g M a n y a r e t h e v ic iss itu d e s in g iv in g c h ild r e n w ith f ib r o ­ c y s tic d ise a se t r e a t m e n t w ith t h e B ird r e s p i r a t o r , a n d its a f t e r m a t h o f “ c o u g h in g a n d s p ittin g ” . I h a v e b e e n o n th is j o b f o r o v e r a y e a r n o w , a n d h a v e le a rn e d m a n y p r e c io u s p o in ts in th is tim e . T h e o b je c t o f th is a r tic le is n o t f o r t h e b e n e fit o f th o s e w ish in g t o k n o w t h e w h y s a n d w h e r e f o re s o f c o p in g w ith t h e a c t u a l d o w n t o e a r t h h a n d lin g o f t h e B ir d r e s p i r a t o r itse lf, o r a n y o t h e r ty p e o f t r e a t m e n t . O n t h e c o n t r a r y , m y w h o le id e a is t o p r e s e n t t h e p s y c h o lo g y in c o p in g w ith e a c h sp e c ific c a s e u n d e r t r e a t m e n t . I h a v e f o u n d th e s e c h ild r e n o n t h e w h o le p lu c k y , in te lli­ g e n t, c u r i o u s a n d la s t b u t b y n o m e a n s le a st, o b s t i n a t e t o t h e la s t f r u s t r a t i n g d e g re e . O f c o u r s e t h e r e a r e e x c e p tio n s t o e v e ry r u le , b u t I m y se lf, in th e 14 y e a r s I h a v e w o r k e d a t t h e C h ild r e n ’s H o s p it a l h a v e m e t o n ly tw o e x c e p tio n s t o th is o v e r a ll d e s c rip tio n . L e t m e e x p la in h e re t h a t , a l t h o u g h 1 h a v e o n ly b e e n g iv in g th e s e c h ild r e n t r e a t m e n t w ith t h e B ird r e s p i r a t o r fo r j u s t o v e r a y e a r , I h a v e s w e a te d m y h e a r t o u t w ith o t h e r fo rm s o f t r e a t m e n t p r i o r t o t h e i n t r o d u c ti o n o f t h e B ird . W h a te v e r tr e a t m e n t I h a v e g iv e n , I h a v e f o u n d th e ir o b s t i n a t e t r a i t t h e g r e a te s t s t u m b lin g b lo c k a n d h a v e le a r n e d t o tr e a d v e ry g e n tly in th is re s p e c t. A t t h e tim e o f w ritin g , th e r e is n o k n o w n c u r e f o r t h is d e v a s ta tin g d ise a se , s o th e s e c h ild r e n h a v e t o lo o k i n t o a f u tu r e w h e re “ c o u g h in g a n d s p i t t i n g ” is a p e r p e tu a l a n d d a ily M U S T . I h a v e f o u n d t h a t t h e m o s t e ffe c tiv e a t t i t u d e t o a d o p t is a t a k i n g f o r g r a n te d t h a t t h e y c o u g h a n d s p it j u s t a s r o u tin e ly a s th e y c le a n th e ir te e th a n d d o th e ir h a ir. P la y in g g a m e s ta k e s u p tim e a n d b e c o m e s b o r in g — “ F a n c y c o m in g a ll th is w a y t o p la y w h e n I c a n p la y m u c h m o r e h a p p ily w ith E g b e rt n e x t d o o r ! ” T h u m p i n g a n d b a n g in g a n d p o s t u r a l d r a in a g e , e tc ., a r e a ll v e ry w ell a n d v e ry o r t h o d o x , b u t , a f t e r a ll, t h e m a in iss u e is t h e am ount o f s p u t u m ra is e d a n d t h i s th e y m u st d o t h e m ­ selves. B y t h e tim e o n e h a s t h u m p e d , b r e a th e d , p e rc u s s e d , e x e rc ise d , p la y e d g a m e s a n d g iv e n t h e B ird , y o u a r e n o t lik e ly t o ra is e t h e s a m e a m o u n t o f s p u t u m a n d t h e t r e a t m e n t w o u ld n o t b e m u c h s h o r t o f a life s tr e tc h . T h e B ir d in h a l a t i o n s m a k e c o u g h in g e a s ie r a n d q u ic k e r , s o I c o n c e n t r a t e o n th is . M o t h e r c a n , a f te r b e in g c o a c h e d , d o t h e p e r c u s s io n a n d p o s tu r a l d r a i n a g e a t h o m e . I f s h e is n o t c o - o p e r a tiv e a b o u t th is , y o u m ig h t a s w ell c u t y o u r lo ss e s fo r s h e p r o b a b l y w ill n o t b e r e g u la r in b r in g in g t h e c h ild e ith e r , a n d y o u r o c c a s io n a l o d d t r e a t m e n t s w o u ld b e lik e t a k i n g a th im b le fu ll o f w a te r o u t o f a fish p o n d . S o n o w , w ith a r e a lly c o - o p e r a tiv e m o t h e r d o in g h e r s tu f f a t h o m e , I m a k e m y p a r t o f it a r o u tin e . I sit t h e c h ild d o w n in f r o n t o f t h e B ird a n d , r e g a r d le s s o f s n o t a n d t r a n e le t th e m k n o w t h a t th e y h a v e t o b r e a t h e in t h e i r a i r b r o n in th e m o s t efficien t m a n n e r t o t h e la s t d r o p a n d t h e n c o u g h a n d s p it 2 0 , 2 5 , 30 tim e s , e tc . I g r a d u a l l y r a is e th e m t o a b o u t 50 “ s p i t s ” a tim e . T h is , w ith m o t h e r ’s h o m e w o r k , se e m s t o k e e p th e m fa irly c le a r. O f c o u r s e , th is is n o rig id r u l e a n d s o m e a r e d e fin ite ly d r y b e f o r e 50, a n d o t h e r s c a n d o m o re . H o w e v e r , w h a te v e r I feel e a c h c h ild is c a p a b l e o f , I s tic k t o t h r o u g h t h i c k a n d th in u n til th e y k n u c k le d o w n t o t h e f a c t t h a t t h e s o o n e r th e y g e t g o in g a n d fin ish , t h e s o o n e r th e y c a n g o h o m e . For quality printing consult J. G. INCE & SON (PTY.) LTD. • PRINTERS • STATIONERS • BOOKBINDERS • RULERS • LITHOGRAPHERS P r in t e r s of this J o u r n a l P.O. Box 200, BOOYSENS, Transvaal Telephone 8 3 4-420 1 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 June, 1968 I t is u se le ss t o r e l e n t o r b r e a k y o u r r u le — th e y h a v e y o u u n d e r th e ir t h u m b f o r e v e r m o re — “ y o u le t m e o f f la s t tim e . W h y c a n ’t I g o e a r ly t o d a y ? ” “ Y o u o n ly m a d e m e d o 20 sp its la s t A p r il w h e n I s h o u ld h a v e d o n e 2 5 , w h y c a n ’t y o u le t m e o f f 5 t o d a y ? ” — (it n o w b e in g D e c e m b e r). I t is u se le ss t o th r e a t e n . Y o u c a n v isib ly se e t h e i r e x p re s s io n c h a n g e a n d g e t t h a t c lo s e d , o b s t i n a t e lo o k , a n d w o e b e tid e y o u if y o u p e r s is t, f o r o n c e th e y h a v e s a id “ A lr ig h t, n o w I w o n ’t c o u g h ” , y o u m ig h t a s w ell w r ite th e m o f f a s a d e a d lo s s f o r t h e r e s t o f t h e tim e . O n e n e e d s p a tie n c e a n d a n o n c h a l a n t a i r w ith r e g a r d t o tim e . I h a v e h a d th e m g o in g t h r o u g h v a r io u s sta g e s o f b o r e d o m a n d g r ie f f o r u p t o tw o h o u r s (w ith m e b itin g m y n a ils m e ta p h o r ic a lly a t t h e b a c k lo g o f m y o t h e r w o r k ) b u t, a f t e r se e in g t h a t I c a n o u t s i t th e m , a n d a m p r e p a r e d t o d o so c h e e rfu lly , th e y u s u a lly se ttle d o w n p r e tty q u ic k ly t o a r o u t in e w ith a n o c c a s io n a l b a d d a y n o w a n d th e n , w h ic h , a f t e r a ll, is a c o m m o n th in g w ith m o s t o f u s a n y h o w . T h e b a r g a in in g t e c h n iq u e c a n b e u s e d t o g r e a t effe ct in v a r io u s w a y s . F o r in s ta n c e , I fin d o u t t h a t th e y lik e b e in g r e a d t o a n d so I s tr ik e m y b a r g a in — th e y b r e a t h e w ith t h e B ird w h ile I r e a d a n d w h e n I r e a c h t h e b o t t o m o f t h e p a g e , th e y m u s t c o u g h s o m a n y tim e s. T h is w o r k s w ell f o r t h e to o c h a t t y ty p e , w h o k e e p s t a k i n g t h e m o u th p ie c e o u t t o a s k a q u e s t io n o r t o s t a r t u p a c o n v e r s a tio n . T h e y w ill b r e a t h e w ell a ll t h e tim e th e y a r e b e in g re a d t o , a n d w ill q u ite c h e e rfu lly s t a r t c o u g h in g a s s o o n a s I re a c h t h e b o t t o m o f t h e p a g e (w h ic h th e y c h e c k u p o n ) re g a r d le s s t h a t I h a v e s to p p e d in t h e m id d le o f a s e n te n c e . A n o t h e r p o p u l a r b a r g a in is t o d r a w s o m e th in g . “ A lr ig h t n o w , E r n o l p h u s , w h a t s h a ll I d r a w ? ” “ A c a t . ” “ A lr ig h t, y o u b r e a t h e n ic e ly w h ile I d r a w a c a t a n d t h e n y o u m u s t c o u g h five t im e s .” T h is is n o t a lw a y s s o g o o d — E r n o lp h u s is t h e c r itic a l ty p e a n d d o e s n o t feel t h a t y o u r c a t d e s e rv e s five c o u g h s , a n d h a s n o c o m p u n c tio n in te llin g y o u s o . N o t h a v in g a g r e a t o p i n i o n o f m y a r t y a b ility , I p r o b a b ly a g re e w h o le h e a r te d ly w ith h im a n d t h e b e st th in g t h e n is t o h u m b ly a s k h im h o w m u c h h e t h in k s it is w o r th , a n d g ra c e fu lly lo w e r y o u r s t a n d a r d . T h e n e x t th in g t o b e d r a w n h o w e v e r, y o u p la y h a r d t o g e t— “ Y o u w a n t m e t o d r a w y o u a h o u se , b u t a h o u s e is m u c h m o r e d iffic u lt t o d r a w t h a n a c a t a n d y o u o n ly s p a t th r e e tim e s f o r a c a t. I f y o u w a n t a h o u s e I m u s t h a v e fiv e c o u g h s before I d r a w i t ” . E r n o l p h u s is w illin g , a n d s o w e p r o g re s s . A l o t o f th e s e c h ild r e n ta k e a g r e a t i n te r e s t in t h e s p u tu m ra is e d , e s p e c ia lly w h e n th e y a r e g o in g t h r o u g h a b a d p a tc h w ith v io le n t fits o f c o u g h in g w h ic h e n d in t h e i r ' v o m itin g a n y t h i n g th e y m a y re c e n tly h a v e e a te n . W h e n th is h a p p e n s , y o u m u s t n a t u r a l l y b e in te r e s te d to o , a n d t h e f o llo w in g ty p e o f c o n v e r s a tio n t h e n ta k e s p la c e . “ L o o k , M is s B ., y o u see t h a t g r e e n s tu f f t h e r e ? ” M e , t a k i n g a q u ic k lo o k a n d fe e lin g g re e n m y se lf, “ Y o u m e a n th is h e r e o r t h a t t h e r e ? ” “ N o , th is d a r k g r e e n p a r t — t h a t ’s m y c a p s u le .” M e — “ O h , m y g o o d n e s s , w h a t a s h a m e , a r e y o u s u r e it is n ’t p u d d i n g ? ” “ N o , t h a t r e d b it t h e r e is m y p u d d in g — its je lly ” . “ R e v o ltin g ” y o u s a y w ith a s h u d d e r , a n d I h e a r tily a g re e , b u t a f t e r o n e h a s b a d g e r e d th e m t o c o u g h , w h e n y o u k n o w t h a t o n c e th e y h a v e s t a r t e d , th e y g o o n a n d o n u n c o n tr o la b ly , t h e le a s t o n e c a n d o is s h o w a h e a lth y i n te r e s t in t h e re s u lt. I h a v e o n e p a t i e n t w h o a lm o s t in v a r ia b ly c o m e s in e a tin g a n ic e c re a m . “ O h , f o r h e a v e n s s a k e , H ild e g a r d , y o u k n o w y o u a r e g o in g t o lo s e t h a t a n y m i n u t e n o w . W h y c o u l d n ’t y o u w a it a n d h a v e it a f t e r w a r d s ? ” “ O h , I d o n ’t m in d , a f te r a ll o n c e I ’ve h a d it, it d o e s n ’t m a t t e r w h a t h a p p e n s t o it .” S o th e n , n a tu r a lly , it b e c o m e s a m a t t e r o f a m u s e m e n t o n h e r p a r t t o p r o d u c e t h e ic e c re a m , a n d a m a t t e r o f s h u d d e r in g h o r r o r o n m in e , w h e n sh e d o e s so . T h e n th e r e is t h e b u s in e s s -lik e ty p e w h o lik e s t o k n o w e x a c tly w h e re h e s t a n d s “ H o w m a n y m u s t I c o u g h t o d a y ? ” “ W e ll, la s t tim e y o u c o u g h e d 4 5 . I t h i n k to d a y w e s h a ll d o 5 0 .” T h is is c o n s id e re d a n d a g re e d u p o n a n d h e w ill c h e e r ­ fu lly d o his 50, b u t w ill g o in to t h e m o s t g h a s tly c o n t o r t io n s , e y e s p o p p in g , c h e e k s b u lg in g , h a n d s p re ss e d t o m o u t h , in a d e s p e r a te a t t e m p t t o s t o p t h a t 5 1 st s p it t h a t h a s c r e p t u p o n h im in v o lu n ta rily . H a n d i n g h im a tiss u e in s te a d o f th e m u g s o m e tim e s d o e s t h e tr ic k , it b e in g ta c itly u n d e r s t o o d b y b o t h o f u s, t h a t s p ittin g in to a tis s u e is q u ite u se le ss a n d c a n o n n o a c c o u n t b e c o u n t e d . O th e r s e n d u p by s w a llo w in g it a n d a n n o u n c i n g th is w ith a “ o n e u p o n y o u ” n o te in th e ir v o ice. O n e b e c o m e s v e ry in te r e s te d a n d a t t a c h e d t o th e s e c h ild r e n , p e r h a p s b e c a u s e o n e h a s s o m u c h t o d o w ith th e m o v e r s u c h a lo n g p e r io d o f tim e , a n d th e y a r e re a lly a little r a c e a p a r t . E v e n w h e n th e y a r e in t h e la s t sta g e s a n d g a s p in g f o r b r e a t h , th e y c a n b e s o g a m e a n d in te r e s te d a n d a lw a y s s o fu ll o f g u ts . R e a lly , t h e m o r e I w r ite a b o u t th e m , th e m o r e d e lig h tfu l a n d a m u s in g I fin d th e m . I t is a g r e a t c h a lle n g e t o t r e a t th e m . I giv e o n e p ie c e o f a d v ic e t o th o s e w h o m ig h t b e c o n s id e rin g t a k i n g t o t h is ty p e o f w o r k , h o w e v e r. B e s u r e y o u h a v e th e n e c e s s a ry p a tie n c e , a m o s t u n u s u a l a n d r a t h e r lew d se n se o f h u m o u r , a n d a b o v e a ll, a s t r o n g s to m a c h ! Book Review P H Y S I O T H E R A P Y I N O B S T E T R I C S . B y M a r i a E b n e r. T h ir d E d itio n . P u b lis h e r s : E . & S. L iv in g s to n e L td ., T e v io t P la c e , E d in b u r g h . P ric e 2 2 s. 6 d . in U .K . T h is is, in f a c t, a n o t h e r e d itio n o f a b o o k w ell k n o w n to p h y s io th e r a p is ts , n a m e ly P hysiotherapy in O bstetrics and G ynaecology, b y H e le n H e a r d m a n . I t s p o r t s a v e ry p le a s in g n e w d u s t c o v e r, a n d r e ta in s m o s t o f t h e illu s tr a tio n s f ro m th e o r ig in a l H e le n H e a r d m a n e d itio n . I t is, o f e s se n c e , a w id e n e d view o f t h e p r e v io u s tw o e d itio n s , a n d in c lu d e s c h a p te r s b y M r . R . R . M a c d o n a ld , S e n io r L e c t u r e r in t h e D e p a r t m e n t o f O b s te tric s a t th e U n iv e r s ity o f L e e d s , o n T h e M e c h a n is m o f L a b o u r , E n d o ­ c r in e F u n c t i o n in N o r m a l P re g n a n c y , D e v ia tio n s f r o m th e N o r m a l D u r i n g a n d A f te r L a b o u r , a n d T h e U s e o f A n a l ­ g esics a n d A n a e s th e tic s . I t w ill b e se e n f r o m t h e title , t h a t t h e th i r d p a r t o f th e s e c o n d e d i t i o n o f th is b o o k , viz. P h y s io th e r a p y in G y n a e ­ c o lo g y , h a s b e e n in te n tio n a lly o m itte d , M r s . E b n e r c o n fin in g h e r s e lf p u re ly t o t h e o b s te tr ic a l a s p e c t. T h is b o o k is t o b e th o r o u g h ly r e c o m m e n d e d t o a ll p h y s io ­ t h e r a p i s t s in te r e s te d in t h e s u b je c t. R O S E M A R Y H A R T E , m .s .c .p . Book Received F O U N D A T I O N S O F A N A T O M Y A N D P H Y S I O L O G Y b y J a n e t S . R o s s , R . G . N . , R . F . N . a n d K a t h l e e n J . W . W ils o n , B .S c ., R . G . N . , S .C .M . T h ir d E d it i o n P u b lis h e d b y E . & S. L iv in g s to n L td ., E d in b u r g h a n d L o n d o n . 1968. P ric e 3 2 s. 6 d . P o s ta g e 3s. F o r R e v ie w la te r . 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. )