Page 8 P H Y S I O T H E R A P Y June, 1967 CYSTIC FIBROSIS O R FIBROCYSTIC DISEASE T H E S W E A T T E S T F O R F IB R O C Y S T IC D I S E A S E B y T . D R E Y E R , B .S c ., M .B .C h .B ., D .P h y s .M e d . T h is c o n d itio n w h ic h is a lso k n o w n a s m u co visc id o sis is a n in b o rn o r g e n e tic d iso rd er a n d sh o w s a h igh fa m ilia l in cid en ce. D iffe r e n t m a n ife sta tio n s o f th e c o n d itio n m a y affect sib lin g s— fo r e x a m p le , in o n e ch ild o f a fa m ily th e lu n g s m a y b e m o r e affected a n d in a n o th er , th e sm a ll b o w e l a n d pan creas. T h e ea rliest m a n ife s ta tio n o f th e c o n d itio n k n o w n as m econ iu m ileu s in th e n e w -b o r n , m a y p resen t a s in te stin a l o b str u c tio n a n d n e c e ssita te surgical in te r v e n tio n . T h e ca u se o f th e o b str u c tio n is th e p r e sen ce o f v isc id , stic k y m u c u s in th e sm a ll b o w e l. In th e in fa n tile ty p e a n d in y o u n g ch ild ren , c h r o n ic p u lm o n a r y fibrosis is m o r e c o m m o n ly se en . T h er e is m ark ed v isc id ity o f m u c u s a n d sp u tu m . D y s p n o e a is c o m m o n a n d rep ea ted a tta c k s o f p n e u m o n ia , o fte n w ith fa ta l resu lts o c c u r . S o m e tim e s c a v itie s o ccu r in th e lu n g s or b ro n ch iecta sis d e v e lo p s. In th e o ld e r ch ild th e c o n d itio n m a y resem b le c o e lia c d ise a se a n d th e o ccu rre n c e o f b ro n ­ ch iecta sis in th is g ro u p is c o m m o n . C h ild ren su ffering fro m c y s tic fib r o sis are o fte n sm a ll a n d u n d e r -d e v e lo p e d , a lth o u g h m en ta lly n o rm a l. P h y sio th e r a p y p la y s a n im p o r ta n t part in th e treatm en t o f th e se c a se s a n d th e earlier it is sta rted , th e b etter; treatm en t m u st c o n tin u e fo r th e rest o f th e ir liv e s, and c o n sists o f in te n siv e c o u g h in g a n d d ra in in g o f th e lu n g s to g e t rid o f th e v isc id sp u tu m . T h is m u st be carried o u t at least three tim e s a d a y . T h e m o th e r s o f sm a ll ch ild ren sh o u ld b e sh o w n h o w t o drain th e lu n g s a n d s o be o f a ss ista n c e to th e p h y sio th e r a p ist. T h e so d iu m a n d ch lo r id e c o n te n t o f th e sw e a t, tears and sa liv a is in creased a n d th e m o th e r w ill o fte n rep o rt th a t the k iss o f th e a ffec ted c h ild ta ste s “ sa lty ” . T h is in crease in so d iu m a n d ch lo r id e fo rm s th e basis o f th e “ sw ea t te st” , th e d eta ils o f w h ic h are g iv en b e lo w . It is said t o be d ia g n o stic o f th is c o n d itio n . W h en in v o lv e m e n t o f th e p a n crea s occu rs, th e s to o ls are o ily a n d fo u l sm ellin g . T h e p r o g n o sis o f th e c o n d itio n is p o o r -p n e u m o n ia or so m e o th e r intercurrent in fe c tio n are th e u su a l c a u se s o f d e a th at a v ery y o u n g a g e . W ith in te n siv e p h y sio th e r a p y , ch ild ren h a v e b een k n o w n t o su rv iv e t o fo u r tee n o r seven teen years or o ld e r — th e o ld e s t su rv iv in g in d iv id u a l in E n g la n d to d a y , w ith th is c o n d itio n , is tw en ty -fiv e y ears— b ut p erh ap s w ith th e d e v e lo p m e n t o f a e r o s o l p e n icillin a n d dru gs t o a c t o n th e stick y m u c u s, th e o u tlo o k m a y b e c o m e m o r e h o p e fu l. T H E T E C H N I Q U E O F T H E S W E A T T E S T B y A I N S L I E I. B U R R , C .S .M .M .G ., M .E ., L .E .T . P h y sio th e r a p ist in C h a rg e, T r a n sv a a l M e m o r ia l H o s p ita l fo r C h ild ren , J o h a n n esb u rg . T h e te c h n iq u e o f sw ea t te stin g b y io n o to p h o r e s is u sed at th e T r a n sv a a l M e m o r ia l H o sp ita l fo r ch ild ren in J o h a n ­ n esb u rg , is b ased o n that u sed at G rea t O rm o n d Street, L o n d o n , w ith certa in m o d ific a tio n s. T w o m eta l e le c tr o d e s are u se d , o n e 2 b y in ch es a n d th e o th e r 2 } b y 1J in c h e s, w ith le a d s firm ly a tta c h e d . T h e e le c ­ tr o d e s are c o v e r e d b y 16 th ic k n e sse s o f lin t, fo ld e d a s u su a l fo r c o n sta n t cu rren t, e a c h p a d is 1 in ch larger th a n th e e le c tr o d e a ll r o u n d . T h e sm a ller o f th e tw o e le c tr o d e s is th e a n o d e . T h e a n o d a l p a d is so a k e d in a 0 - 2 p er c e n t so lu tio n o f p ilo c a r p in e h y d r o c h lo r id e . T h e so lu tio n is sto red in a refrigerator w h e n n o t in u se. T h e c a th o d a l p a d is so a k e d in w arm w ater. B o th p a d s are sq u e e z e d o u t u n til dam p on ly a n d th e sm aller p a d p la ced o v e r th e sm a ller e lectro d e. T h e se n so r y te st a n d furth er p rep a ra tio n o f th e patient a n d a p p a ra tu s is d o n e as usu al fo r c o n sta n t-c u r r e n t treat­ m e n ts. T h e a n o d e (a ctiv e) m a y be p la c e d o n th e flex o r su rface o f th e fo rea rm , a d d u c to r su rface o n th e th ig h , o r lo w er back a c c o r d in g t o th e siz e o f th e ch ild . T h e s e are th e sk in areas w h ic h sw ea t m o s t p r o fu se ly . T h e c a th o d e is p la c e d o p p o site o n th e lim b s b ut h igh er up b etw een th e sh o u ld ers o n th e back. T h e p a d s a n d e le c tr o d e s are b a n d a g ed o n w ith a firm even p ressu re th r o u g h o u t. T h e le a d s a re c o n n e c te d t o th e ter­ m in a ls o f a m a c h in e w h ich p r o d u c e s a d irect (galvanic) curren t ta k in g ca re th a t th e sm a ller e le c tr o d e is con n ected to th e p o sitiv e term in a l. T h e a p p a ra tu s is turned o n a n d th e in te n sity slow ly in crea sed , ta k in g o n e m in u te t o rea ch fo u r m illia m p s. It is m a in ta in e d at th is le v e l fo r six m in u te s an d then s lo w ly red u ced t o z e r o , ta k in g o n e m in u te t o d o so (8 m inutes in a ll). T h e m a c h in e is sw itch ed o f f a n d th e e le c tr o d e s and pads r e m o v e d . T h e area o f ery th em a u n d er th e a n o d e sh o u ld be c le a n e d u sin g d istille d w ater a n d dried w ith clea n , dry g a u z e . T h e area sh o u ld n o t b e to u c h e d b y h an d . T h is area is th e n co v e r e d w ith a p ie c e o f g a u z e w h ich h as previously b een w e ig h e d in th e la b o r a to r y . T h e g a u z e is co v e r e d w ith a p ie c e o f p o ly th e n e a little larger th a n th e a n o d a l pad . T he p o ly th e n e sh o u ld a ls o be c le a n e d , u sin g d istille d w ater, and th o r o u g h ly d ried . T h e p o ly th e n e is h e ld in p la c e and the e d g e s se a led a ll r o u n d w ith strip s o f z in c p la ster t o prevent air fr o m en terin g . T h is “ p a tc h ” is le ft o n fo r an h ou r, and th e n r e m o v e d b y th e la b o r a to r y te c h n ic ia n fo r a n alysis. L A B O R A T O R Y A N A L Y S I S B y A . C A E N A Z Z O , S e n io r T e c h n ic ia n , P a th o lo g y L a b o ra to ry , T r a n sv a a l M e m o r ia l H o s p ita l fo r C h ild ren , Jo h a n n esb u rg . A strip o f g a u z e fo u r layers th ic k is w ell w a sh e d in d ou b le g la ss d istille d o r d e io n iz e d w a ter a n d a llo w e d to air dry in a cle a n , c o v e r e d c o n ta in e r . A 15 m l c o n ic a l cen trifu g e tube, 25 m l c o n ic a l (E rlen m ey er) flask a n d ru b b er b u n g to fit are w ell w a sh e d a s a b o v e a n d a llo w e d t o d rain d ry o v ern igh t. A se c tio n o f th e c le a n , dry g a u z e , a p p r o x im a te ly 1 | b y H in c h e s in a rea is c u t o u t a n d p la c e d in th e flask b y m eans o f a p air o f cle a n fo r c e p s. T h e ru b b er b u n g is in serted a n d the flask is w e ig h e d t o th e fo u r th d ecim a l p la c e in gram s. A fte r io n to p h o r e s is th e sw e a t-so a k e d g a u z e is rem oved fr o m th e p a tie n t w ith clea n fo r c e p s, rep laced in th e flask and th e ru b b er b u n g re-in serted im m e d ia te ly t o p rev en t ev a p o ra ­ tio n . T h e flask is a ccu ra tely w e ig h e d a s b efo re. 5 - 0 0 m l d e io ­ n iz e d w a ter is a d d e d t o th e flask , th e rubber b u n g re-inserted a n d th e fla sk sw irled v ig o r o u s ly to m ix th e sw ea t w ith the w ater. W h en c o m p le te ly m ix e d , th e d ilu ted sw ea t is decanted in to th e cen tr ifu g e tu b e w h ich is cen trifu g ed at 3 000 r.p.m . fo r a fe w m in u te s t o se d im en t a n y g a u z e fibres present. D u p lic a te a m o u n ts o f 1 - 0 0 m l o f th e fluid is pipetted in to test tu b e s, 0 - 0 2 5 per cen t n itr ic acid (1 m l) a n d d iphenyl- c a r b a z o n e in d ic a to r (0 • 3 m l) a d d ed a n d th e c h lo r id e flitrated by S c h a le s an d S c h a le s m e th o d , u sin g h a lf-stren g th m ercuric n itr a te. A fu r th er a m o u n t o f 1 -0 0 m l o f th e fluid is pipetted in d u p lic a te in to 5 m l v o lu m e tr ic fla sk s, w h ich are then d ilu te d t o v o lu m e w ith d e io n iz e d w ater. T h e flasks are v ig o r o u sly sh a k en t o m ix th e c o n te n ts a n d th e so d iu m and p o ta s siu m c o n te n t e stim a te d b y flam e p h o to m e tr y , em p lo y in g sta n d a rd s t o c o v e r th e fu ll ra n g e o f p o ss ib le rea d in g s e.g. so d iu m 0 - 1 , 0 - 2 e tc . up to 2 - 0 m .Eq/1. C a lc u la tio n : C h lo rid e: 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. ) June, 1967 P H Y S I O T H E R A P Y Page 9 W e ig h t o f sw ea t + 5 m l w a ter (5 g ra m s) v ' W e ig h t o f sw ea t titr a tio n o f test fftration o f stan d ard S o d iu m (o r p o ta s s iu m ) : W e ig h t o f sw ea t + 5 m l w a ter (5 gram s) w e ig h t o f sw eat e a u iv a le n c e o f a b o v e stan d ard v a lu e s , , 1 0 0 _ „ £2------------------------jo---------------------------- X 1 “ mE^ L A n in crea se in th e so d iu m a n d ch lo r id e c o n te n t o f the sw e a t is p resen t in c a se s o f fib r o cy stic d isea se. T h e V e r s a t il it y o f F a r a d o - G a l v a n ic C u r r e n t s To th e E d ito r : M e d ic a l w o rk ers o f a ll c a te g o r ie s a c c e p t that there a re a ls o fa sh io n s in th e field o f trea tm en t. W o rld W ar I d id m u c h t o p o p u la r iz e m e d ic a l ele c tr ic ity , a n d m a n y w ill rem em b er th a t a t th e R a d c liffe Infirm ary, O x fo r d , 5 0 ,0 0 0 electrica l trea tm en ts w ere a d m in ister ed to w o u n d e d so ld iers. A fte r 1917 ex e r c ise th e ra p y b e c a m e in crea sin g ly p o p u la r and h a s a p p a r e n tly rea ch ed its p e a k a t th e p resen t tim e. T his is v e r y c o m m e n d a b le , b e c a u se it is m o s t d esir a b le for the p a tie n t t o u se h is o w n m u sc le s a c tiv e ly , w h en ev er p o s ­ sible. B u t th e rela tiv e d isu se in to w h ich m a n y o f th e o ld er tech n iq u es h ave fa lle n is regrettab le. T h e e x p o n e n tia lly p ro g ressiv e trea tm en t u n its h a v e g iv en a n ew im p e tu s to th e u se o f e lectrica l stim u la tio n in th e treatm en t o f e n e r v a te d m u scles. W ith th e recent a d v a n c e s in e le c tr o n ic s, th e use o f tran ­ sistors, e t c ., w e n o w c a n b u ild m a c h in e s c a p a b le o f a ch iev in g far m o r e th a n c o u ld h a v e b e e n a n tic ip a te d b y th e p io n eers in electro th era p y . In th is c o n n e c tio n it is in terestin g to recall that these tech n iq u es (p r o g ressiv e m u scu la r stim u la tio n ) w ere practised by L a p ic q u e 1, u sin g th e m o st p rim itiv e a p p a ra tu s. T h is sh o r t c o n tr ib u tio n d ra w s a tte n tio n to se v era l u ses to w h ich fa r a d ic a n d g a lv a n ic curren ts c a n a d v a n ta g e o u s ly be p u t. T u m b r e ll F ish e r , M e n n e l a n d m o r e r ece n tly C yriax h ave d e v e lo p e d , c o -o r d in a te d a n d p o p u la r ized trea tm en t by m a n ip u la tio n . It is la rg ely d u e t o th e se a n d o th e r w ork ers in this field th a t o r th o d o x p ra ctitio n ers o f p h y sic a l m e d ic in e and p h y sio th e r a p y are a b le t o p r o v id e a n e ffe c tiv e a n d safe altern a tiv e t o th e o fte n d ra stic a n d d a n g e r o u s p roced u res carried o u t b y e x p o n e n ts o f th e v a r io u s m a n ip u la tiv e cu lts. T h ese r a tio n a l sy ste m s o f m a n ip u la tio n w ith o u t gen eral a n a e sth e sia are g a in in g th e p r o m in e n c e a n d u sa g e th e y righ tly d ese rv e. It h a s b een o b se r v e d th a t in s o m e c a se s in w h ich fa ra d ic stim u la tio n h a d b e e n g iv e n , a n a n tic ip a te d m a n ip u la tio n had been ren d ered u n n e c e ssa r y , a n a lle v ia tio n o f th e a ilm e n t havin g re su lte d . I t is, o f c o u r se , p o ss ib le th a t s u c h ca ses w ere n o t d u e t o sp in a l n erv e p ressu re a n d ex e r c ise th erap y h as b een k n o w n t o p r o d u c e a sim ilar resu lt. H o w e v e r , i f ca refu l te c h n iq u e s o f p la c e m e n t o f e lectro d es are w o r k e d o u t, so m e e x c e lle n t resu lts m a y be a n tic ip a te d . T h e s e c o n sid e r a tio n s m a y be a p p lied n o t o n ly to the sp in a l, b u t a ls o t o m o s t o th e r jo in ts o f th e b o d y . In particular, the a r tic u la tio n s o f th e h a n d a n d f o o t a p p e a r t o resp o n d very w e ll t o e le c tr ic a lly stim u la ted rem ed ia l m o v e m e n ts. M a n y o f th e m o s t u sefu l m o v e s o f th e m a n ip u la tiv e sy stem s c a n be stim u la te d , n o t a s a r e p la cem en t fo r straight m a n ip u la tio n , b u t a s a n cillia ry t o su ch m ea su res. A t th e sa m e tim e se v era l o th e r a im s are a c h ie v e d : 1. Im p r o v e m e n ts o f m u s c le to n e a n d str e n g th e n in g o f w eak m u sc le s. 2 . A s sista n c e to a rterial a n d v e n o u s c ir c u la tio n ; p ro ­ m o tio n o f ly m p h a tic d rain age. 3. S tr etc h in g o f a d h e sio n s w ith resu ltin g im p r o v em en t in j o in t m o v e m e n t w h ere restricted . F o r th e se trea tm en ts a r ecip ro ca tin g cu rren t m a y s o m e ­ tim es be d esir a b le, b rin gin g a b o u t altern a te c o n tr a c tio n s o f flex o r a n d e x te n so r m u sc le s . 4. G y n a e c o lo g ic a l C o n d itio n s. It is c o m m o n t o g iv e stren g th en in g ex e r c ise s t o th e a b d o m in a l a n d p e lv ic flo o r m u sc le s . R e -e d u c a tio n in th e u se o f th e se m u sc le s m a y be u se fu lly a ssiste d b y sk ilfu l u se o f surged fa ra d ism . C o n ­ tr a c tio n s o f th e lev a to r a n i, th e g lu te a l m u sc le s a n d hip a b d u c to r s m a y b e stim u la ted . L a b o u r. T h e tim e t o p repare w e a k m u s c le s fo r th e rigors o f c h ild b ir th is b efo re th e c o n fin e m e n t. T h e n u m b er o f p a tie n ts referred fo r a n te -n a ta l c la s se s is n e g lig ib le co m p a red w ith th e n e e d ; h ere a g a in fa ra d ism in certa in c a se s c a n p la y a p art. M u c h ex p e r im e n t m a y b e n e cessa ry b efo re w e ca n a ssess th e p o ss ib ilitie s o f fa r a d ic a ssista n c e d u rin g labou r. T h is field s h o u ld cer ta in ly b e ex p lo r e d . M a c h in e s w ith m u ltip le o u tp u ts are n o w a v a ila b le , so m e w ith a s m a n y a s 15 o r m o r e pairs o f e le c tr o d e s. D e s ig n e d fo r u se p rim a rily a s a n a id t o w eig h t r e d u c tio n , su ch m a c h in e s, su ita b ly m o d ifie d and im p r o v e d , sh o u ld p r o v e in v a lu a b le in th e field s o u tlin e d . Su m m a r y F a sh io n s in th erap y in flu en ce th e c h o ic e o f treatm en t. A fte r 1917 ex e r c ise th e ra p y te n d e d to rep la c e e le c tr o ­ th erap y in so m e fields. E x p o n e n tia lly p ro g ressiv e trea tm en t u n its h a v e revived in terest in th e r a p e u tic e le c tr o -stim u la tio n . T h e te c h n iq u e s o f L a p ic q u e (1 9 1 5 ) a n d m o d e r n a d v a n c e s in e le c tr o n ic s, are c o m p a r e d . F a r a d o -g a lv a n ic w a v e fo rm s a s an a d ju n c t t o m a n ip u la tiv e p r o c e d u r e s are m e n tio n e d . U s e o f th e se w a v e fo r m s fo r a n te - a n d p o st-n a ta l trea tm en t are o u tlin e d . It is su g g e ste d th a t th e u se o f e le c tr o -stim u la tio n d u rin g labou r in sp ec ia l c a s e s sh o u ld be in v estig a ted . R ef e r e n c e 1. L a p ic q u e (1 9 1 5 ): A c a d . S c i. C o m p r . R e n d ., 22 N o v e m b e r . C . B . S r o k a , M .S .A .S .P . 103, M e d ic a l T o w e r s, 181, J ep p e S tr eet, J o h a n n esb u rg . A ck n o w led g em en t: R e p r in te d f r o m “ M e d ic a l P r o c e e d ­ i n g s 18th M a r c h , 1967, w ith th e a u th o r ’s p erm issio n . Please S U P P O R T OUR A D V E R T IS E R 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. )