Page 4 P H Y S I O T H E R A P Y September, 1959 Physiotherapy and the African B Y P . K E E N , Surgeon, N on-European H ospital, Johannesburg. PH Y S IO T H E R A P Y h a s n o place in th e A fric a n ’s tra d i­tio n a l o u tlo o k on th e tre a tm e n t o f disease, a n d p hysio­ th e ra p is ts have a n u p hill ta s k in try in g to m ak e th e “ ra w ” A frica n realise th e v alue o f th is fo rm o f tre a tm e n t. T h is m ay seem a q u e e r sta te m e n t to m ak e a t th e b e g inning o f a n a rtic le a im in g to c re a te a b e tte r basis o f u n d e rsta n d in g , b u t a fte r all su rg e ry w as in th e sam e s itu a tio n n o t m any years ago. Influence of Witchdoctors. A p a rt fro m tra u m a a n d a few specific diseases, such as syphilis, tu b erc u lo sis, lep ro sy a n d , stra n g ely e nough, epilepsy, all o th e r illnesses a re d u e to w itch c raft o r su p e r­ n a tu ra l causes. T h is is u n fo rtu n a te as th e trib a l A frican will inev itab ly c o n su lt his ow n “ d o c to r” fo r m o s t disabilities b e fo re seeking th e a id o f th e “ w hite d o c to r” , a n d conse­ q u e n tly cases a rriv e a t the h o sp ita l in a n a d v an c ed stage o f the disease. T h is is p a rtic u la rly d isa stro u s in th e field o f cancer, a n d c u ra tiv e tre a tm e n t is ra re ly possible. F o r instance, a cc o rd in g to D r. B u rre ll in th e T ra n s k e i the cause o f c a rc in o m a o f the oeso p h a g u s, w ith th e c h ara cte ristic n a m e o f U n h la za -w o m b iz a o r u lce r o f th e gullet, is said to b e cau sed by a b la c k spider in tro d u c e d in to th e victim ’s beverage b y w itch c raft. S urgery has, to a larg e e xtent, b ro k e n d o w n the b arriers th o u g h th ere a re still m a n y difficulties to overcom e, b u t th e tid e h a s been tu rn e d n o t b y pre c ep t but b y exam ple. A d o c to r going t o a n a tiv e reserve, how ever well qualified a n d experienced, c a n o nly h o p e to gain th e confidences o f th e in h a b ita n ts by show ing his c apabilities, a n d m ore im p o rta n t still, h is goodw ill a n d sincerity. The only way to convince the raw A frican is to show him the value o f y our wares. Advice to Physiotherapist. T h e P h y s io th e ra p ist w ho w ishes to tre a t th e A frican th o ro u g h ly a n d a d e q u a te ly m u st, a p a r t fro m m o re th a n a v era g e skill, h a v e th e p a tie n ce o f Jo b , m u st be a good ju d g e o f h u m a n c h a ra c te r, m u s t have a s o u n d know ledge o f th e A fric a n ’s psychological b a c k g ro u n d , sh o u ld have a g ro u n d in g o f a t least o n e B a n tu language, a n d a b o v e all, be in u re d to d isa p p o in tm e n ts a n d failures. I n fa ct she m ust b e a su p e rw o m an , p re p a re d to c o m p ro m ise a n d m eet the A frica n half-w ay in his q u e er b u t tra d itio n a l a n d d e e p ro o te d beliefs. A n d w h a t d o we find in o u r la rg e r h o sp ita ls ? L ike all o th e r d e p a rtm e n ts, th e N o n -E u ro p e a n section o f th e P h y s io th e ra p y D e p a rtm e n t i s .th e “ C in d ere lla ” a n d is used as a ste p p in g sto n e to p ro m o tio n in th e m ain d e p a rtm e n t. P h y sio th e ra p ists sta y fo r a few m o n th s , get fed u p and a rra n g e a tran sfer. T h e re a re o f c o u rse e x ceptions, a n d th o se w h o h a v e re ally trie d have fo u n d th e w o rk re w ard in g a n d satisfying. W h a t a d e q u a te a dvice can o n e give to th e p h y sio th era p ist w o rk in g w ith A fric a n s ? I have a lre a d y given th e re q u ire ­ m en ts, a m o re th a n a verage skill, a g o o d ju d g e o f h u m a n c h a ra c te r, the pa tie n ce o f Jo b , a g ro u n d in g o f a t least one B a n tu lan g u a g e a n d a so u n d know ledge o f th e A fric a n ’s psychological b a c k g ro u n d . T h e first th re e I c a n n o t deal w ith, y ou e ith e r h a v e th e m by n a tu re o r y o u m u s t learn to develop th em by e x perience; w ith o u t th em d o n o t a tte m p t to t r e a t th e A frica n . I t is w ith th e last tw o a ttrib u te s I w o u ld like to d eal very briefly. • A g ro u n d in g o f a t least o n e B a n tu language is esse n tia l, Y o u d o n o t have to ta k e a c o m p lica te d c o u rse ; lea rn to greet th e p a tie n t, a sk a b o u t his w elfare a n d try to give th e sim pler in stru ctio n s in Z u lu o r S esutu, a n d even if y o u r clicks a re in a c c u ra te y ou will have gone p a r t o f the w ay to gain th e p a tie n t’s confidence. G e t to k now his o r her little h a b its, fo r exam p le w hen h a n d in g th e p a tie n t his o r h e r card d o it w ith b o th h a n d s instead o f one, a sim ple g esture, b u t o ne th a t e n genders a sy m p a th e tic a ttitu d e . T h e o rig in a l idea o f th is g esture w as to show th a t th ere w as no w e ap o n in th e o th e r h a n d a n d it is n o t necessary t o h o ld the c ard in b o th h a n d s, as lo n g as th e left h a n d rests on the rig h t fo re a rm . W h en I sta rte d , I m ad e a list o f q u e stio n s a n d answ ers a n d in stru ctio n s a n d h a d th em tra n s la te d , a n d w ith in a m a tte r o f weeks w as a b le to in itiate a c o n v ersa tio n a n d m ak e o c casional in te rjec tio n s w ith g ood effect. A sm all b o o k let o f th is n a tu re is b e ing p re p a re d by a g ro u p o f stu d e n ts a t the M edical S chool o f th e W itw a te rsra n d U n iv e rsity a n d sh o u ld p rove a b o o n to all p h y sio th e ra p ists w o rk in g w ith A fricans. The African’s Psychological Background. T h e m ain object, how ever, is to deal w ith th e A fric a n ’s psy c hological b a c k g ro u n d w ith special reference to p h y sio ­ th era p y , a n d it m ust b e m a d e c le ar th a t these views refer to th e raw trib a l A frica n a n d n o t to his so p h istica ted u rb a n cousin. M o s t o f the u rb a n ise d A frica n s u n d e rs ta n d to som e e x te n t th e v alue o f p h y sio th era p y , b u t even w ith th em it will be h e lpful to keep som e o f the views expressed in m ind. E ven th e m o st so p h istica ted A fric a n h a s a su b ­ c o n sc io u s trib a l b a c k g ro u n d w ith all its fears a n d ta b o o s . Som e o f o u r m arried nurses will b rin g th eir c h ild ren to h o sp ita l fo r tre a tm e n t, b u t will a t th e sam e tim e c o n su lt th eir A fric a n “ d o c to r” . T h ey h ave a lre a d y offended th eir a n c e sto rs by be co m in g n u rse s a n d acc ep tin g w e stern ideas, an d th ere is alw ays a sub c o n sc io u s fe a r th a t th e c h ild ’s illness m ay in p a r t be d u e t o su p e rn a tu ra l causes. I discussed th is a spect w ith o n e o f o u r nu rses a n d h e r a ttitu d e w as “ it is b e tte r to p lay fo r safety ” , a very n a tu ra l re ac tio n . Consultation with a “ doctor” . W h a t h a p p e n s if a trib a l A ric a n c o n su lts his “ d o c to r” ?/ Very o ften th e p a tie n t him self d oes n o t go, b u t is re p re se n ted b y several se n io r m em b ers o f th e fam ily. T h e p a tie n t’s tro u b le s a re n o t discussed a n d n o h isto ry is ta k e n . A n in­ term in ab le c o n v ersa tio n goes o n a b o u t all so rts o f topics, d u rin g w hich th e “ d o c to r” chew s m edicinal h e rb s, th e idea being to p la c a te th e a n c e sto rs o n b o th sides a n d e n co u ra g in g th e m to c o -o p era te . S u ddenly b y som e o u tw a rd sign such as g oing in to a tra n c e o r b e lching lo udly, th e “ d o c to r” a n n o u n c e s th e cause o f th e tro u b le a n d the line o f tre a tm e n t to be a d o p te d . I f w itch c raft is involved c o u n te r m ea su re s a re devised, if th e re a re in te rn al tro u b le s, a n d u sually a c rab , a sn a k e o r a spider is th e cause, c e rta in m ed ic am en ts are prescribed. T h e p a th o lo g y is th o ro u g h ly discussed a n d th e tre a tm e n t is th ra s h e d o u t in g re at d e ta il— sa c rification a n d in u n ctio n s, m edicines, e n e m a ta a n d th e in h a la tio n o f fum es a re the c o m m o n e st fo rm s o f tre a tm e n t. The Medical Examination. In c o n tra s t, w h a t d o we d o w ith a p a tie n t? W e ta k e a lo n g h isto ry , m ak e p ro lo n g e d e x a m in a tio n (fo rtu n a te ly th e ste th o sco p e still h a s sem i-m agical pro p e rties) a n d th en w ith o u t m u ch fo rm a lity give th e p a tie n t a p re sc rip tio n to ta k e to th e dispenser. T h is is a c o m p le te re v ersa l o f the 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. ) September, 1959 P H Y S I O T H E R A P Y Page 5 trib a l process. It is essential to e x plain th e so u rc e o f the p a th o lo g y , w h a t is h a p p en in g , a n d w h a t the tre a tm e n t i s 'to a ccom plish. T h e “ ra w e r” th e A fric a n th e m o re e x p la n atio n is re q u ire d , even if he d oes n o t really u n d e rsta n d . P h y sio ­ th e ra p is ts co u ld sh o w the p a tie n t h is X -ra y p ictu re, a n d th e tro u b le sh o u ld be p o in te d o u t, even if it m eans little to him , a n d th e “ w hy a n d w h e refo re ” o f the tre a tm e n t sh o u ld be d etailed. I f th e re is a h a e m a to m a t o b e dispersed, tell him it is to chase b a d b lo o d aw ay. If a n abscess is b e in g trea te d ta lk a b o u t “ b ad flesh” a n d b rin g in g “ g o o d b lo o d ” to the affected p a r t to m ak e it b e tte r— in fa ct a n y th in g to satisfy his m ental h u n g e r fo r e x p la n atio n s. Som e years a g o we sta rte d g ro u p exercises in th e w a rd s a n d I ask e d som e o f th e o ld er a n d ra w e r ty p es w h a t they th o u g h t a b o u t them . O ne o ld m a n said, “ I t seem s to am u se the lad y in w hite a n d I am q u ite h a p p y 'to h e lp ” . A n o th e r th o u g h t it w as p a rt o f a religious cerem o n y to p la c a te his a n ce sto rs, a n d a n o th e r th o u g h t it w as ju s t o ne o f th e w hite m a n ’s m ad ideas, in the sam e w ay as he re g ard e d th e ta k in g o f te m p e ra tu re s w ith a th e rm o m e te r. A sh o rt e x p la n atio n ro f th e aim s a n d objects o f th e v a rio u s exercises a t the tim e w o u ld m ak e all the difference. P hysiotherapy T rea tm e n t. T h e ra w A frica n w o uld prefer a b o ttle o f n a sty m edicine o r a n injection to a c ourse o f p h y sio th era p y , how ever beneficial. I alw ays see to it th a t m y m o re p rim itive p a tie n t gets a b o ttle o f m edicine d u rin g his p h y sio th e ra p y tre a tm e n t, h o p in g th a t he will feel th e beneficial effect o f th e tre a tm e n t by a c tu a l experience. T h e d a n g e r o f course, is th a t he will “ b lam e ” th e im provem ent o n th e b o ttle o f m edicine a n d n o t the phy sio th erap y , b u t it is a risk w o rth taking. H o w can p h y sio th era p ists help on these lin e s? T he use o f a p o w d e r, pre fe ra b ly w hite, fo r m assage is a goo d su b te r­ fuge p a rtic u la rly if th e p o w d e r d isa p p e a rs d u rin g tre a tm e n t. T h e p a tie n t will be convinced th a t th e m e d ic atio n h as p e n e ­ tra te d o n the sam e lines th a t his ow n “ d o c to r” uses sacrifi- c a tio n a n d in u n ctio n s. O ne p a tie n t c o m p la in e d th a t the new p h y sio th era p ist w as n o t u sing m edicine as h e r p re ­ d ecessor h a d d o n e d u rin g m assage. O ne o f th e m ost p o p u la r tre a tm e n ts is the fa ra d ic c u rre n t. T h e p a tie n t realises th a t so m e th in g has p e n e tra te d in to his system a n d is m ak in g him d o so m e th in g w h ic h he c a n n o t d o alone. T hese o b se rv atio n s m ay a p p e a r c h ild ish a n d laughable, b u t u se o f them has helped to get a m o re satisfac to ry a p p ro a c h to the raw A fric a n as fa r as p h y sio th e ra p y is c oncerned. A natom ical differences between two races. F in a lly it is essential to k n o w so m e th in g a b o u t a n a to m ic a l a n d p h y siological differences in th e tw o races. A t first sight th is w o u ld a p p e a r so m e w h a t rid ic u lo u s— a fte r all m uscles, b ones, ligam ents a n d jo in ts a re th e sam e w h e th er y o u r skin is w hite o r b ro w n , a n d w hy sh o u ld p h y sio th e ra p y be different in th e tw o races. T o a large e x te n t th is is tru e, b u t th e re a re c e rta in differences w h ich a re w o rth k e eping in m ind if the full benefit o f th e tre a tm e n t is to be achieved. G E N E R A L C O N S I D E R A T I O N S : There is no doubt in m y m in d that the raw A fric a n ’s perception o f disability is m uch less m a rke d , a n d that he has a g rea ter capacity to overcom e a ny disability. A g o o d exam ple o f th is w as a p a tie n t w h o c am e to h o sp ital w ith a tro p h ic u lce r on h is little finger w h ich w o uld n o t heal. I t w as o b v io u s t h a t h e h a d a n u ln a r palsy, a n d on q u e stio n in g he a d m itte d th a t he h a d been sta b b e d a b o v e th e e lbow th ree m o n th s previously. H e had c a rrie d o n w ifh his w o rk as a g a rd e n boy, and w as n o t u n d u ly w o rried a b o u t th e u ln a r claw h a n d a n d a n ae sth esia . N u m e ro u s cases o f u n re d u c e d d islo c a tio n o f th e sh o u ld e r o f several y ears d u ra tio n h a v e been seen w ith little a p p a re n t disability. A fte r p la s te r im m o b ilisa tio n fo r frac tu res th e A fric a n ’s jo in ts re-e sta b lish n o rm a l fu n c tio n m o re ra p id ly , a n d o ften p h y sio th e ra p y is h a rd ly necessary. Upper L im b . In th e u p p e r lim b th e re are re la tiv e differences in the m uscles masses. I n th e A frica n th e m uscles w hich c o n tro l th e a rm a re a b o u t 20 % m o re p ow erful th a n in th e E u ro p e a n , in th e fo re a rm th e difference is a b o u t 10% , w h e rea s th e in trin sic m uscles o f th e h a n d a re o n th e a v era g e 1 5% m ore p o w e rfu l in th e E u ro p e a n . T h ese differences a re n o t genetic, b u t e n v iro n m e n ta l, b u t nevertheless m u st be c o n ­ sidered. T h e A fric a n ’s sense o f rh y th m a n d m usic is well k n o w n , b u t A frica h a s yet to p ro d u c e a first c lass violinist, th o u g h the b a n jo w ith its c ru d e r finger m o v em e n ts has p ro d u c ed m any e xperts. T y p in g is a n o th e r a cc o m p lish m en t in w hich th e A fric a n finds difficulty in achieving speed. Low er L im b . T h e low er lim b h a s even m o re racial differences. T h e knee jo in t h as b een extensively stu d ie d a n d sh o w n several im p o rta n t differences. T h e A fric a n d oes n o t te n d to extend th e k nee as m u ch a s th e E u ro p e a n , h y p e rextension is ra re a n d th e locking m ec h an ism n o t so efficient. T h e cru ciate a n d c o lla te ra l ligam ents a re m o re pow erful in th e A frica n a n d several o th e r m in o r differences h ave re su lte d in th e ra rity o f m eniscal lesions in th e A frica n . O n th e o th e r h a n d , o ste o a rth ritis o f th e knee is m o re c o m m o n a n d occu rs at a n e a rlie r age in th e A frica n . T h e inte restin g p a ra -a rtic u la r ossification o f th e m edical c o lla te ra l ligam ent, th e Pelle- g rin i-S tie d a sy n d ro m e , is very c o m m o n in th e A frican, a n d is a lm o st c ertain ly c au sed b y a n a to m ic a l differences in the m edical c o lla te ra l ligam ent. Foot. T h e fo o t show s som e inte restin g differences. T h e big to e is sh o rte r in th e A fric a n a n d th e second to e p ro jec ts the fu rth e s t. T h e a rch e s o f th e fo o t a re m ore elastic a n d m o re u n d e r m u sc u la r c o n tro l th a n in th e E u ro p e a n . T h e a n te rio r a rch fla tte n s m u ch m o re w ith w eight b e arin g a n d th e re is a d istin c t w idening o f th e fro n t p a r t o f th e fo o t w hile w alking. W eig h t b e arin g is a lso different a n d th e A fric a n c arries m u ch m o re w eight on th e o u te r side o f th e f o o t th a n th e E u ro p e a n . I t d oes n o t re q u ire m u ch im a g in atio n to visualise th e effect o f o u r m o d e rn fo o tw e a r o n th e n e x t ge n era tio n o f A frica n s, if th e w e arin g o f shoes becom es u niversal. The Spine. W e a re still w a itin g fo r so m e o n e to e lu c id ate differences in th e spine. D isc lesions a re extrem ely ra re a n d it is p ro b a b le th a t a s in th e fo o t a n d k nee th e v e rte b ra l jo in ts a re m o re u n d e r m u sc u la r c o n tro l. A fric a n ’s Brow n S k in . W h a t a b o u t th e A fric a n ’s b ro w n sk in ? W h a t is the e ry th e m a d o se fo r u ltra v io le t ra y s ? D o in fra-re d rays p e n e tra te a s well th ro u g h th e A fric a n ’s b ro w n s k in ? W h a t a b o u t d ia th e rm y ? T h ese a re all q u e stio n s still t o b e answ ered b y som e e n th u sia stic p h y sio th era p ist. 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 6 P H Y S I O T H E R A P Y September, 1959 Sum m ary. F o r th o se in te rested in p h y sio th e ra p y in th e A frica n the fo llo w in g su ggestions m ay h e lp :— 1. T ry t o a c q u ire a g ro u n d in g in o n e o r m o re b a n tu languages, it need n o t b e p ro fo u n d , b u t e n o u g h to help b rid g e th e g a p a n d c re a te a n a tm o sp h e re o f sincerity. 2. T ry to a c q u ire som e kno w le d g e o f th e trib a l b a ck g ro u n d o f th e p a tie n ts in y o u r a re a . T h o u g h th e re a re c o m m o n basic beliefs a n d c u sto m s, e ach a re a h a s its ow n idiosyncrasies a n d these m u s t be assessed. 3. G iv e sim ple e x p la n a tio n s o f a ll th e p ro c e d u re s used in th e P h y s io th e ra p y D e p a rtm e n t a n d give an o u tlin e o f th e o bject o f th e tre a tm e n t. T h e m o re prim itiv e th e p a tie n t, th e m o re y o u m u s t ta lk , a n d a d o p t little subterfuges to m a k e th e tre a tm e n t p sy c h ologically m o re effective. I f y o u are in terested y o u w ill so o n find little tric k s to h elp. T h is a rticle h a s been w ritte n w ith th e o b ject o f helping p h y sio th era p ists in this p e rio d o f tra n s itio n , a t th e end o f w hich p h y sio th e ra p y m u st find its rig h tfu l p lac e in N o n - E u ro p e a n H o s p ita ls . T h e b a ttle h a s b een h a lf w on, b u t th e re a re still m a n y o b stacles to o vercom e, th e m ain o ne being th e A fric a n ’s re lu c ta n c e to a cc ep t p h y sio th e ra p y as a n essential a d ju n c t to surgery. W h a t a b o u t th e f u tu r e ? I c a n foresee th e d a y w hen th is a rticle will be ob so le te , w hen A frica n p h y sio th era p ists will tre a t th e ir ow n p eople. S teps a re a lre a d y b e ing ta k e n to m ak e th is d re a m c o m e tru e, b u t in th e m e a n tim e a b e tte r u n d e rsta n d in g o f th e A fric a n ’s aUi u d e is essential. T h e view s expressed in th is a rtic le a re p e rso n a l a n d m a y n o t m ee t w ith th e a p p ro v a l o f all. T h ey a re based on a long a n d v a rie d experience w ith th e A frica n , a n d if th e y have g iven som e food fo r th o u g h t, m y o bject w ill h a v e been a tta in e d . Essay Competition E x tr a c t fr o m a letter fr o m D r. P . K een, Surgeon, N on- E uropean, H ospital, Johannesburg. I d o n o t k n o w if yo u ev er h o ld c o m p e titio n s in y o u r J o u rn a l, b u t I th o u g h t th a t as a c o ro lla ry to m y a rtic le on “ P h y s io th e ra p y a n d th e A fric a n ” y o u m ig h t lik e to ho ld a n essay c o m p e titio n , fo r w hich I a m p re p a re d to offer a prize o f tw o guineas. I w o uld like th e essays to be invited on th e fo llow ing su b je c t:— “ W hy is i t th a t N egroes, while reg u larly winning gold m edals in th e sprints and jumping events, have never won an O lym pic title in any distance over 800 m eters? V ery little h a s b een w ritte n o n th e subject, b u t I th in k th a t th e re a re a n a to m ic a l a n d physio lo g ic a l differences w hich m ight a c c o u n t fo r th e a b o v e sta te m e n t. I w o u ld like to suggest t h a t th e c o m p e titio n sh o u ld be o p e n to P h y sio ­ th e ra p is ts a n d P h y sio th e ra p y stu d e n ts. Signed: P . K E E N . a new approach to vasodiiatation by the use of the potent new penetrative agent iN E W r Rubiguent F O R S P R A IN S , FIBROSITIS., ARTHRITIS, S T R A I N S A N D M U S C L E S P A S M R eg iste red User o f Trade M a r k a nd D istributors in S o u th A fric a : WYETH LABORATORIES (PTY.) LTD. 5 4 , STATION STREET, EAST LONDON. M ETH YL NICOTINATE in conjunction with the powerful vasodilator, histamine opens the way for the histamine to penetrate tissues rapidly. There it promotes prolonged, pain-relieving hyperemia, comforting analgesia and soothing warmth. Formula H ista m in e D ih y d ro c h lo rid e 0-1 % M e th y l N ic o tin a te 1 0 % G ly c o l M o n o s a lic y la te 1 0 -0 % C a p sic u m O leoresin 0 - 1 % T hese a re in c o rp o ra te d in a b lan d , co sm etica lly p lea sa n t vehicle. H o w Supplied— T u b e s o f P ric e — Inexpensive — 5 16 O ne O unce. p e r tu b e to y o u r p a tie n t. 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. )