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Hansen's Disease in South India A student elective
Hansen’s Disease in South India A student elective JULIE DOYLE words: Leprosy. absorption. ulcer. SlImmtlrJY This paper reports the experience gained during a six-week elective clinical placement undertaken in a leprosy Mission hospital in Karigiri, South India.
Biography: Julie Doyle, who is now a final-year physiotherap)
student at the University of Ulster. spent h i x weeks working in Schieffelin Leprosy Research and Training Centre. She gaincd a scholarship from the National Physiothenpy ServiceKSP Charitable Trust scholarships, to aid the financing of the trip to India.
Introduction
PRIOR to my trip t o India I prepared myself as much as possible for my venture to a different culture. However, on my arrival in Madras after an 11-hour flight from London, I felt almost shell-shocked. I had not appreciated how different working in India would be compared with home. After a few days of ac;climatisation at the Schieffelin Leprosy Research and Training Centre I settled d o w n and began t o really enjoy working with the patients. The team of physiotherapy technicians were very friendly and gave me a great welcome. They introduced me to the routine of the hospital and made every effort t o make me feel at home. The centre started in 1955 and altogether 7,864 patients have completed multi-drug therapy there. Currently there are 112 doctors and 160 other staff caring for 180 in-patients, of whom 170 have leprosy, and 8,498 out-patients, of whom 2,221 have leprosy. Daily Routine Each day started off with morning devotions in a small stone church and many patients attended the service when it was conducted in Tamil, their local language. Work began at 8.30 am and finished at 4.30 p m w i t h an hour for lunch. The equipment in the physiotherapy department consisted of a wax bath, parallel bars, an ultrasound machine, one faradic current machine and one infra-red lamp.
In the foot the nerves most commonly affected are the posterior tibia1 nerve (fig I ) , which becomes swollen and tender for about three inches between the point of exit from beneath gastrocnemius t o its point of division behind and below the medial malleolus (Brand, 1966). This results in loss of sensation to the whole side of the foot and paralysis of all the intrinsic muscles, leading t o clawing of the toes and weakening of the arch of the foot. The peroneal or lateral popliteal nerve, is also commonly affected as it winds around the neck of the fibula behind the lateral part of the knee joint (fig 2). This produces drop foot and loss of all extensor power in the toes and peroneal muscles. Therefore no dorsiflexion and eversion are present while the plantarflexors and invertors remain normal, and many iiivertion deformities w i t h some plantar flexion arise. In the arm the ulnar nerve is most commonly affected either at the level of the medial epicondyle or at the wrist joint. This leads t o clawing of the little and ring fingers. More often, all four fingers are clawed as the median nerve is also involved at the wrist. The radial nerve is affected at the radial groove. Owing to the sensory nerve involvement there are obvious changes in the condition of the skin and w i t h the property of sweating being lost as in any nerve lesion, the skin becomes dry and cracked, losing its suppleness. This loss of skin sensation also produces much more serious complicatiuns. Many patients continually burn, cause blisters, c u t or apply grest amounts of pressure t o areas where they cannot feel any pain. This repeated abuse t o anaesthetic areas leads to the loss of finger or toe digits due t o multiple fractures and crumbling of bone. They are ‘absorbed’, n o t by the disease itself, but because of anaesthetic limbs. Ulcers, expecially on the feet, are a major problem. Many wards were filled w i t h patients confined t o bed with horrific looking ulcers, which could lead t o complications such as bone infection, the ulcer becoming malignant, or even possible amputation. One out-patient was found to have his
PERONEAL NERVE
SWELLING
Hansen’s Disease (Leprosy) Leprosy is caused by the presence of Mycobacteria leprae in the body. These bacteria attack the nerves and cause thickening, swelling and inflammation resulting i n denervation, leading t o loss of sensation and decreased muscle power. These t w o symptoms are diagnostic of leprosy. The disease affects distal extremities first - hands and feet, plus nose and earlobes, indicating that the bacteria which cause leprosy live and multiply best a t temperatures a little below normal body temperature.
Physiotherapy,July 1990, vol 76,no 7
FIBULA
MEDIAL MALLEOLUS -SWELLING
Fig 1
Fig 2
419
ulcer full of maggots. These patients are put on permanent bed rest. The other patients rarely left their wards as for every thirty or so there would be one wheelchair, sometimes with only three wheels. Once the ulcers eventually heal, or at least are clear of complications, the patients are sent t o the physiotherapy department where they are given a below-knee plaster of Paris boot with a metal rocker attached (fig 3). This prevents pressure or weight from being taken through ulcer on the sole of the foot, but transfers it through the metal bars along the side of the calf. Alternatively they can be given a plaster of Paris shoe (fig 4) which just encases the foot leaving the ankle free.
Fig 3
Fig 4
This would obviously not be given in cases of drop foot. When applying these plasters, special care and attention is given t o padding, especially over bony prominences, as the patient cannot feel any pressure. My efforts always gave me a great sense of satisfaction even though the first few specimens were a bit rough in places. New materials, such as cellulite rubber for footwear, are also being explored with very good results. This rubber has been shown'to distribute pressure more evenly over the whole foot. Leprosy patients usually have certain pressure points which take all the weight and abuse, but cellulite rubber shoes especially made to suit their own feet (as no leprosy patients have similar shaped feet and the degrees of absorption also vary) greatly reduce the likelihood of them getting that first ulcer. Muscle weakness, the second major symptom, causes many deformities - claw hand, ape thumb, wrist drop, foot drop and claw toes. Without attention these lead to further damage and absorption. Surgery involving tendon transfers plays a very major role in the treatment of leprosy patients in order to correct muscle imbalance and so eliminate the deformities such as claw hand or drop foot.
The patients' sensation of their arms, legs and sometimes Face are tested with a number six nylon thread bent t o 40° so as always to give the same pressure over the whole area. The physiotherapist would apply the pressure on a point and ask the patients t o point t o the area with their eyes closed. Their sensations were then mapped on t o a body chart. The patients are asked to perform the action of a particular muscle and then t o hold it against resistance given by the physiotherapist, and the muscle strength is graded on the Oxford Scale of 0-5. The physiotherapy techniques are extremely important both pre-and post-operatively. Many tendon transfers are performed each day. Pre-operatively claw hands, for example, need the fingers splinted with cylindrical splints t o maintain or even gain as full a range of extension as possible in both the proximal and distal interphalangeal joints. The patients must be taught the isolated function of the muscle tendon which is going t o be transferred, so that post-operatively when they try to perform this isolated movement the new function of the transferred tendon will eventually be performed. Electric stimulation is sometimes used for re-education of the transferred muscle. Post-operatively the patients are also taught t o massage their hands with oil, pushing their fingers out into extension with the hands both palm up and down. Exercises are also given t o strengthen any muscles which are showing some signs of recovery once early drug treatment has been administered. On the first day out of plaster, the proximal interphalangeal joint range of movement, active and passive, plus the web space range are recorded. Then once the cylindrical finger splints are applied the patients are allowed to do re-education exercises specific t o the transferred muscle. After t w o days the patients are started on wax treatment t o help make the skin soft and supple again after being
Physiotherapy Treatments The initial assessment of the patient is not only very important for future physiotherapy treatment but also for correct diagnosis. This muscle and sensory assessment i s done by the physiotherapist who then sends the results back t o the doctor, to clarify the diagnosis. The muscle assessment is quite detailed and takes a lo1 of patience, especially when the physiotherapist does no1 speak any Tamil. Sign language was an important mode ir Fig 5: Julie with a patient outside the hospital at Karigiri my communication.
420
Physiotherapy, July 1990. vol76, no 7
encased in plaster for a number of weeks.'Now they are given daily splinting and exercises. After ten days they are allowed t o start flexion of the interphalangeal joints and are also sent to occupational therapy to start their functional re-education. The cylindrical splinting is continued daily after occupational therapy. Complete flexion should be obtained at about twenty-one days, provided there are no complications, and the patients can then be discharged with night splints t o maintain the finger extension and so prevent the return of clawing. The drop foot post-operative regime follows roughly the same lines with re-education exercises. Weight bearing is begun, standing between parallel bar with the patients placing the operated foot on weighing scales and being instructed t o only allow 2 kg t o be put down through the foot. This is gradually increased in weight and duration until the patients are able eventually to walk.
Other Aspects Staff from the.mission hospitals also provide a service for leprosy patients in the community outside the mission grounds. I attended village clinics which meant a very early start in the morning, followed by an extremely bumpy journey for a few hours until arriving at the spot (under the shade of some large trees) where the clinic would usually be held. The people with leprosy who lived in the surrounding villages would come t o receive their medication in the form of prednisolone or dopzone tablets. People who suspected they might have leprosy from the tell-tale faded patch of skin somewhere on their body, would also come for further investigation. The fear could clearly be seen in their eyes. They were all very aware of the deformities of hands, feet and face that accompany this dreaded disease. This is how the terrible stigma of leprosy is kept alive; many think the deformities are inevitable but this is definitely not the case. If it is detected early and medication is given, the disease can be totally eradicted before any deformities arise. This important early detection is slowly becoming possible with more extensive village clinics and school surveys. Here all the children attending the school are examined for faded patches, swollen nerves or even deformities. Among these villagers and especially the schoolchildren, the true extent of the terrible poverty in India could clearly be seen. At least 90% of children had numerous skin conditions revealing vitamin and fatty acid deficiencies in
PhySioTherapy, July 1990, ~0176, I)O
7
:ig 6: A plaster cast is applied to the leprosy-affected limb of a ieggar Fig 7 (below left): Artificial limb centre at Karigiri Hospital Fig 8 (below right): Plaster cast being removed
the one school I saw. Scabies was extremely common. Fortunately I saw only one little girl who was found to have leprosy. She had faded patches of skin on her right leg and some sensory disturbances. A smear test from her ear would soon tell for sure if it was indeed leprosy. However, she was one of the lucky ones being detected so early. If she responded to drug treatment she had no need t o fear the terrible deformities.
42 1
neuromuscular facilitation techniques and the speed at which they learnt was phenomenal. I was really impressed with how up-to-date their training is; for some reason I had imagined it would not be so advanced as our training at home. I also attended a spinal rehabilitation centre at Chad on the outskirts of Vellore. I will never forget the happy atmosphere in this place; teamwork by staff and patients is the main reason for such high spirits, even though so many of the cases are extremely sad. Most of the paraplegic patients lie prone on beds which have t w o large wheels at the front to enable them t o move about the whole hospital, gaining some independence before they can even sit on a wheelchair. This has tremendous psychological as well as physical advantages. The running of the centre is based on a weekly routine. Every Monday the doctors, therapists and nurses meet to discuss all the patients, their progress and difficulties. Then on Tuesdays they talk to each patient individually t o see how they feel they are getting on. The whole centre is aiming at the re-education of each patient to the point of maximum independence. All the patients are trained in new jobs suited t o their interests and capabilities. The staff are all so kind and interested in their patients’ problems.
Conclusion
Fig 9: A little girl is given a sensory test and found to have leprosy
One man who attended the village clinics was found t o have 20 really deep fissures on the soles of each of his feet. These could have been prevented with daily soaking of his feet and scraping off the callus. However, this man had sewed the fissures tightly together, which would have caused him no pain at all. He explained that every time he walked the cracks would open and close and he had realised they would never heal unless he stayed off his feet for a considerable time or alternatively sewed them closed. The doctors thought he was a tailor because the job had been done so neatly, but in fact he was a farmer. He returned a few months later with all but t w o fissures perfectly healed and all the stitches removed. I also attended the out-patient department where people with leprosy came from as far away as Delhi and Bombay for help. The problems here are mainly horrific foot and leg ulcers, many of which have complications of infected bone and a few were even malignant. An Australian chiropodist called Judy, the only white member of the staff, showed tremendous dedication and patience in her work with the patients‘ feet in this department. I also spent a few days at a general hospital, the Christian Medical College Hospital in Vellore. The experience anyone could gain from this hospital would be brilliant. It has a school of physiotherapy with a three-year course plus six months internship. The physiotherapy students are so hungry for knowledge that they really put me t o shame. I was asked to give a twohour practical class t o demonstrate proprioceptive
422
My visit to India was a great learning experience. It has helped me t o appreciate how well off we are in the Western world. Although we have our problems we do not have the scourge of leprosy or the poor living conditions of the people in India. I was very impressed with how the Indian people coped in such adverse conditions. The physiotherapy technicians were really dedicated to caring for their patients’ who were highly appreciative. There is much that we in the Western world could do to help our fellow man in India. The Leprosy Mission of Great Britain is playing its part in both prevention and treatment. It would welcome physiotherapy students for elective placements in future years. It would also be wonderful if more experienced physiotherapists would consider working in the Third World for at least one or t w o years. It was an experience I will never forget and I would love some day t o visit India again and participate in the work. I very sincerely thank the National Physiotherapy Service and the Chartered Society of Physiotherapy Student Board for making my adventure possible. ACKNOWLEDGMENTS I would like to thank Miss P Drummond of the University of Ulster for arranging my elective clinical placement in India, and Mr C krguson of the Leprosy Mission in Belfast for co-ordinating
arrangements with India. I would also like to thank Mrs M P McCoy, senior course tutor for the bachelor of science degree in physiotherapy at the University of Ulster, for her patience and help in the compiling of this article. THE LEPROSY MISSION
The contact for England and Wales is Rev R J Findlay, Goldhay Way, Orton Goldway, Peterborough PE2 OG2. The Northern Ireland organiser is Mr C Ferguson, 44 Ulsterville Avenue, Belfast BT9 7AQ. BIBLIOGRAPHY Brand, P (1966). Insensitive Feet: A practical handbook on foot problems in leprosy (revised 1977) The Leprosy Mission, London. Brand, P (1966). Ten Fingers for God, (revised 1985) Hodder and Stoughton, London. PhVsiotherapy, July 1990, vd76, no 7
Biography: Julie Doyle, who is now a final-year physiotherap)
student at the University of Ulster. spent h i x weeks working in Schieffelin Leprosy Research and Training Centre. She gaincd a scholarship from the National Physiothenpy ServiceKSP Charitable Trust scholarships, to aid the financing of the trip to India.
Introduction
PRIOR to my trip t o India I prepared myself as much as possible for my venture to a different culture. However, on my arrival in Madras after an 11-hour flight from London, I felt almost shell-shocked. I had not appreciated how different working in India would be compared with home. After a few days of ac;climatisation at the Schieffelin Leprosy Research and Training Centre I settled d o w n and began t o really enjoy working with the patients. The team of physiotherapy technicians were very friendly and gave me a great welcome. They introduced me to the routine of the hospital and made every effort t o make me feel at home. The centre started in 1955 and altogether 7,864 patients have completed multi-drug therapy there. Currently there are 112 doctors and 160 other staff caring for 180 in-patients, of whom 170 have leprosy, and 8,498 out-patients, of whom 2,221 have leprosy. Daily Routine Each day started off with morning devotions in a small stone church and many patients attended the service when it was conducted in Tamil, their local language. Work began at 8.30 am and finished at 4.30 p m w i t h an hour for lunch. The equipment in the physiotherapy department consisted of a wax bath, parallel bars, an ultrasound machine, one faradic current machine and one infra-red lamp.
In the foot the nerves most commonly affected are the posterior tibia1 nerve (fig I ) , which becomes swollen and tender for about three inches between the point of exit from beneath gastrocnemius t o its point of division behind and below the medial malleolus (Brand, 1966). This results in loss of sensation to the whole side of the foot and paralysis of all the intrinsic muscles, leading t o clawing of the toes and weakening of the arch of the foot. The peroneal or lateral popliteal nerve, is also commonly affected as it winds around the neck of the fibula behind the lateral part of the knee joint (fig 2). This produces drop foot and loss of all extensor power in the toes and peroneal muscles. Therefore no dorsiflexion and eversion are present while the plantarflexors and invertors remain normal, and many iiivertion deformities w i t h some plantar flexion arise. In the arm the ulnar nerve is most commonly affected either at the level of the medial epicondyle or at the wrist joint. This leads t o clawing of the little and ring fingers. More often, all four fingers are clawed as the median nerve is also involved at the wrist. The radial nerve is affected at the radial groove. Owing to the sensory nerve involvement there are obvious changes in the condition of the skin and w i t h the property of sweating being lost as in any nerve lesion, the skin becomes dry and cracked, losing its suppleness. This loss of skin sensation also produces much more serious complicatiuns. Many patients continually burn, cause blisters, c u t or apply grest amounts of pressure t o areas where they cannot feel any pain. This repeated abuse t o anaesthetic areas leads to the loss of finger or toe digits due t o multiple fractures and crumbling of bone. They are ‘absorbed’, n o t by the disease itself, but because of anaesthetic limbs. Ulcers, expecially on the feet, are a major problem. Many wards were filled w i t h patients confined t o bed with horrific looking ulcers, which could lead t o complications such as bone infection, the ulcer becoming malignant, or even possible amputation. One out-patient was found to have his
PERONEAL NERVE
SWELLING
Hansen’s Disease (Leprosy) Leprosy is caused by the presence of Mycobacteria leprae in the body. These bacteria attack the nerves and cause thickening, swelling and inflammation resulting i n denervation, leading t o loss of sensation and decreased muscle power. These t w o symptoms are diagnostic of leprosy. The disease affects distal extremities first - hands and feet, plus nose and earlobes, indicating that the bacteria which cause leprosy live and multiply best a t temperatures a little below normal body temperature.
Physiotherapy,July 1990, vol 76,no 7
FIBULA
MEDIAL MALLEOLUS -SWELLING
Fig 1
Fig 2
419
ulcer full of maggots. These patients are put on permanent bed rest. The other patients rarely left their wards as for every thirty or so there would be one wheelchair, sometimes with only three wheels. Once the ulcers eventually heal, or at least are clear of complications, the patients are sent t o the physiotherapy department where they are given a below-knee plaster of Paris boot with a metal rocker attached (fig 3). This prevents pressure or weight from being taken through ulcer on the sole of the foot, but transfers it through the metal bars along the side of the calf. Alternatively they can be given a plaster of Paris shoe (fig 4) which just encases the foot leaving the ankle free.
Fig 3
Fig 4
This would obviously not be given in cases of drop foot. When applying these plasters, special care and attention is given t o padding, especially over bony prominences, as the patient cannot feel any pressure. My efforts always gave me a great sense of satisfaction even though the first few specimens were a bit rough in places. New materials, such as cellulite rubber for footwear, are also being explored with very good results. This rubber has been shown'to distribute pressure more evenly over the whole foot. Leprosy patients usually have certain pressure points which take all the weight and abuse, but cellulite rubber shoes especially made to suit their own feet (as no leprosy patients have similar shaped feet and the degrees of absorption also vary) greatly reduce the likelihood of them getting that first ulcer. Muscle weakness, the second major symptom, causes many deformities - claw hand, ape thumb, wrist drop, foot drop and claw toes. Without attention these lead to further damage and absorption. Surgery involving tendon transfers plays a very major role in the treatment of leprosy patients in order to correct muscle imbalance and so eliminate the deformities such as claw hand or drop foot.
The patients' sensation of their arms, legs and sometimes Face are tested with a number six nylon thread bent t o 40° so as always to give the same pressure over the whole area. The physiotherapist would apply the pressure on a point and ask the patients t o point t o the area with their eyes closed. Their sensations were then mapped on t o a body chart. The patients are asked to perform the action of a particular muscle and then t o hold it against resistance given by the physiotherapist, and the muscle strength is graded on the Oxford Scale of 0-5. The physiotherapy techniques are extremely important both pre-and post-operatively. Many tendon transfers are performed each day. Pre-operatively claw hands, for example, need the fingers splinted with cylindrical splints t o maintain or even gain as full a range of extension as possible in both the proximal and distal interphalangeal joints. The patients must be taught the isolated function of the muscle tendon which is going t o be transferred, so that post-operatively when they try to perform this isolated movement the new function of the transferred tendon will eventually be performed. Electric stimulation is sometimes used for re-education of the transferred muscle. Post-operatively the patients are also taught t o massage their hands with oil, pushing their fingers out into extension with the hands both palm up and down. Exercises are also given t o strengthen any muscles which are showing some signs of recovery once early drug treatment has been administered. On the first day out of plaster, the proximal interphalangeal joint range of movement, active and passive, plus the web space range are recorded. Then once the cylindrical finger splints are applied the patients are allowed to do re-education exercises specific t o the transferred muscle. After t w o days the patients are started on wax treatment t o help make the skin soft and supple again after being
Physiotherapy Treatments The initial assessment of the patient is not only very important for future physiotherapy treatment but also for correct diagnosis. This muscle and sensory assessment i s done by the physiotherapist who then sends the results back t o the doctor, to clarify the diagnosis. The muscle assessment is quite detailed and takes a lo1 of patience, especially when the physiotherapist does no1 speak any Tamil. Sign language was an important mode ir Fig 5: Julie with a patient outside the hospital at Karigiri my communication.
420
Physiotherapy, July 1990. vol76, no 7
encased in plaster for a number of weeks.'Now they are given daily splinting and exercises. After ten days they are allowed t o start flexion of the interphalangeal joints and are also sent to occupational therapy to start their functional re-education. The cylindrical splinting is continued daily after occupational therapy. Complete flexion should be obtained at about twenty-one days, provided there are no complications, and the patients can then be discharged with night splints t o maintain the finger extension and so prevent the return of clawing. The drop foot post-operative regime follows roughly the same lines with re-education exercises. Weight bearing is begun, standing between parallel bar with the patients placing the operated foot on weighing scales and being instructed t o only allow 2 kg t o be put down through the foot. This is gradually increased in weight and duration until the patients are able eventually to walk.
Other Aspects Staff from the.mission hospitals also provide a service for leprosy patients in the community outside the mission grounds. I attended village clinics which meant a very early start in the morning, followed by an extremely bumpy journey for a few hours until arriving at the spot (under the shade of some large trees) where the clinic would usually be held. The people with leprosy who lived in the surrounding villages would come t o receive their medication in the form of prednisolone or dopzone tablets. People who suspected they might have leprosy from the tell-tale faded patch of skin somewhere on their body, would also come for further investigation. The fear could clearly be seen in their eyes. They were all very aware of the deformities of hands, feet and face that accompany this dreaded disease. This is how the terrible stigma of leprosy is kept alive; many think the deformities are inevitable but this is definitely not the case. If it is detected early and medication is given, the disease can be totally eradicted before any deformities arise. This important early detection is slowly becoming possible with more extensive village clinics and school surveys. Here all the children attending the school are examined for faded patches, swollen nerves or even deformities. Among these villagers and especially the schoolchildren, the true extent of the terrible poverty in India could clearly be seen. At least 90% of children had numerous skin conditions revealing vitamin and fatty acid deficiencies in
PhySioTherapy, July 1990, ~0176, I)O
7
:ig 6: A plaster cast is applied to the leprosy-affected limb of a ieggar Fig 7 (below left): Artificial limb centre at Karigiri Hospital Fig 8 (below right): Plaster cast being removed
the one school I saw. Scabies was extremely common. Fortunately I saw only one little girl who was found to have leprosy. She had faded patches of skin on her right leg and some sensory disturbances. A smear test from her ear would soon tell for sure if it was indeed leprosy. However, she was one of the lucky ones being detected so early. If she responded to drug treatment she had no need t o fear the terrible deformities.
42 1
neuromuscular facilitation techniques and the speed at which they learnt was phenomenal. I was really impressed with how up-to-date their training is; for some reason I had imagined it would not be so advanced as our training at home. I also attended a spinal rehabilitation centre at Chad on the outskirts of Vellore. I will never forget the happy atmosphere in this place; teamwork by staff and patients is the main reason for such high spirits, even though so many of the cases are extremely sad. Most of the paraplegic patients lie prone on beds which have t w o large wheels at the front to enable them t o move about the whole hospital, gaining some independence before they can even sit on a wheelchair. This has tremendous psychological as well as physical advantages. The running of the centre is based on a weekly routine. Every Monday the doctors, therapists and nurses meet to discuss all the patients, their progress and difficulties. Then on Tuesdays they talk to each patient individually t o see how they feel they are getting on. The whole centre is aiming at the re-education of each patient to the point of maximum independence. All the patients are trained in new jobs suited t o their interests and capabilities. The staff are all so kind and interested in their patients’ problems.
Conclusion
Fig 9: A little girl is given a sensory test and found to have leprosy
One man who attended the village clinics was found t o have 20 really deep fissures on the soles of each of his feet. These could have been prevented with daily soaking of his feet and scraping off the callus. However, this man had sewed the fissures tightly together, which would have caused him no pain at all. He explained that every time he walked the cracks would open and close and he had realised they would never heal unless he stayed off his feet for a considerable time or alternatively sewed them closed. The doctors thought he was a tailor because the job had been done so neatly, but in fact he was a farmer. He returned a few months later with all but t w o fissures perfectly healed and all the stitches removed. I also attended the out-patient department where people with leprosy came from as far away as Delhi and Bombay for help. The problems here are mainly horrific foot and leg ulcers, many of which have complications of infected bone and a few were even malignant. An Australian chiropodist called Judy, the only white member of the staff, showed tremendous dedication and patience in her work with the patients‘ feet in this department. I also spent a few days at a general hospital, the Christian Medical College Hospital in Vellore. The experience anyone could gain from this hospital would be brilliant. It has a school of physiotherapy with a three-year course plus six months internship. The physiotherapy students are so hungry for knowledge that they really put me t o shame. I was asked to give a twohour practical class t o demonstrate proprioceptive
422
My visit to India was a great learning experience. It has helped me t o appreciate how well off we are in the Western world. Although we have our problems we do not have the scourge of leprosy or the poor living conditions of the people in India. I was very impressed with how the Indian people coped in such adverse conditions. The physiotherapy technicians were really dedicated to caring for their patients’ who were highly appreciative. There is much that we in the Western world could do to help our fellow man in India. The Leprosy Mission of Great Britain is playing its part in both prevention and treatment. It would welcome physiotherapy students for elective placements in future years. It would also be wonderful if more experienced physiotherapists would consider working in the Third World for at least one or t w o years. It was an experience I will never forget and I would love some day t o visit India again and participate in the work. I very sincerely thank the National Physiotherapy Service and the Chartered Society of Physiotherapy Student Board for making my adventure possible. ACKNOWLEDGMENTS I would like to thank Miss P Drummond of the University of Ulster for arranging my elective clinical placement in India, and Mr C krguson of the Leprosy Mission in Belfast for co-ordinating
arrangements with India. I would also like to thank Mrs M P McCoy, senior course tutor for the bachelor of science degree in physiotherapy at the University of Ulster, for her patience and help in the compiling of this article. THE LEPROSY MISSION
The contact for England and Wales is Rev R J Findlay, Goldhay Way, Orton Goldway, Peterborough PE2 OG2. The Northern Ireland organiser is Mr C Ferguson, 44 Ulsterville Avenue, Belfast BT9 7AQ. BIBLIOGRAPHY Brand, P (1966). Insensitive Feet: A practical handbook on foot problems in leprosy (revised 1977) The Leprosy Mission, London. Brand, P (1966). Ten Fingers for God, (revised 1985) Hodder and Stoughton, London. PhVsiotherapy, July 1990, vd76, no 7