Page Four P H Y S I O T H E R A P Y March, 1958. Physiotherapy and the South African Bantu By MARGARET ELLIS, M.C.S.P. Physiotherapy Department, Johannesburg Hospital. I N T R O D U C T IO N . Th e tre a tm e n t o f th e S o u th A fric a n B a n tu is o f p a rtic u la r in te re s t as, q u ite a p a r t fro m th e sa tis fa c tio n o f th e w o rk itself, a n o p p o rtu n ity is p ro v id e d o f seeing a n d c o m p a rin g differences w h ich exist b e tw ee n th is field o f w o rk a n d E u ro p e a n p h y sio th e ra p y . I t is im p o rta n t to k n o w w h e re th e s e differences lie a n d h o w th e y c a n a ffect o n e ’s a p p ro a c h to th is p a rtic u la r g ro u p o f p e o p le . T h is a rtic le is th e re fo re in te n d e d as a s u p p le m e n t t o :— P h y sio th e rap y in R elationship to th e T re a tm e n t o f N o n -E u ro p ea n P a tie n ts , given b y M iss L o is D y e r to th e W o rld C o n g re ss o f P h y s io th e ra p y in 1953, a n d p u b lis h e d in th e B ritish P h y s io th e ra p y J o u rn a l in M a y , 1954. E N V IR O N M E N T A L E F F E C T S T h e u rb a n is e d B a n tu , a lth o u g h k n o w in g a little o f th e w h ite m a n ’s civ iliz atio n , h a s a m u c h low er s ta n d a r d o f living, a n d his la c k o f k n o w le d g e o f fo o d v alu es a n d c a re in h y g ien e re n d e r h im su s c e p tib le to d isease. U n tr e a te d , h e is th e re fo re a s o u rc e o f d a n g e r to t h e h e a lth o f h is w h ite n e ig h b o u r. T u b e rc u lo s is , v e n ere al d isease, a n d m a ln u tritio n a re e specially c o m m o n , a n d m a y fo rm a c o m p lic a te d o v e rla y to o th e r c o n d itio n s. C lim a tic c o n d itio n s too' m ay influence h is h e a lth , a lth o u g h th e sw ea t glands, te m p e ra tu re re g u la tin g m e c h a n ism a n d a u to n o m ic n e rv o u s sy ste m se e m to h ave u n d e rg o n e c h a n g e s w h ic h a d a p t h im to th e h ig h a n d v a ry in g te m p e ra tu re s o f A frica .* I n a d d itio n , h is b e lie f in w itc h c ra ft a n d su p e rs titio n is still s tro n g e n o u g h to c a u s e se rio u s c o m p lic a tio n s in tre a tm e n t.. A lth o u g h th e u rb a n is e d B a n tu m a y p ro fe s s C h ristia n ity , h e is n e a r e n o u g h his trib a l b a c k ­ g ro u n d to b e r id d e n by a su b c o n sc io u s fe a r th a t e ith e r h is illness is a re s u lt o f b e w itc h m e n t, o r th a t b y c o n su ltin g a w h ite d o c to r h e h a s p ro v o k e d th e sp irits o f h is a n c e sto rs, w ith p ro b a b le re ta rd in g o f re co v e ry . T h is affects h is a ttitu d e to m e d ic a l tre a tm e n t o f a n y k in d in clu d in g p h y sio th e ra p y , w h ic h is fo re ig n to t h e B a n tu ’s c o n c e p tio n o f th e tre a tm e n t o f d isease. T h irty y e ars a g o su rg e ry w as in th e sa m e p o sitio n a s p h y s io th e ra p y is to d a y , a n d it w ill o n ly b e by d in t o f p ra c tic a l d e m o n s tra tio n s a n d m u c h h a r d p io n e e r w o rk th a t p h y s io th e ra p y w ill u ltim a te ly ta k e its rig h tfu l p la c e in N o n - E u r o p e a n H o s p ita ls . F o rtu n a te ly m a n y o f th e se m i-e d u c a te d u rb a n is e d B a n tu a c c e p t p h y s io th e ra p y as p a r t o f th e re c o g ­ nise d tre a tm e n t o f discease, b u t th e “ ra w B a n tu ” fro m th e re serv e s still re g a rd s it a s o n e o f th e w h ite m a n ’s m a d ideas. G r o u p exercises in th e w a rd s, a re la tiv e ly r e c e n t in n o v a tio n in th is h o sp ita l, a re in th e m a in re g a rd e d as a n a m u s e m e n t to w hile a w ay th e te d iu m o f a lo n g h o s p ita l d a y . O n e o ld m a n w h e n a sk e d a b o u t th e s e exercises sa id ‘. I t seem s to a m u s e th e w h ite lad y a n d I a m q u ite w illing to m a k e h e r h a p p y .” A n o th e r re g a rd e d th e m in a re lig io u s lig h t a n d th o u g h t th e y w e re a n a p p e a l to h is a n c e sto rs fo r c o -o p e ra tio n . T h e lo w e r s ta n d a rd o f living, th e p re v a le n c e o f d e b ilita tin g d iseases, a n d th e difficult p sy c h o lo g ic al b a c k g ro u n d , a ll h e lp to m a k e it difficult to give p h y s io th e ra p y its rig h t p lac e in th e tre a tm e n t o f th e B a n tu . A N A T O M IC A L A N D P H Y S IO L O G IC A L D IF F E R E N C E S M a n y differences in p a th o lo g y h a v e b e e n n o te d in c o m ­ p a rin g th e ev id en ces o f disease in th e w h ite sk in n e d a n d d a r k sk in n e d ra ce s. In th e p a s t th e s e h a v e b e e n re la te d to b a sic ra c ia l differences, b u t w ith in c re a sin g re se a rc h i t is b e in g re a lis e d th a t m o s t differences c a n b e a ttr ib u te d to e n v iro n m e n ta l c au ses su c h as m a ln u tritio n , d ie t, h a b its a n d c u sto m s. F o r in sta n c e it h a s b e e n k n o w n fo r m a n y years. th a t c a n c e r o f th e a n tr u m is m u c h m o re c o m m o n in the B a n tu , b u t it h a s o n ly re c e n tly b e e n d iscovered th a t the c a u se m a y b e in th e special snuffs th ey use, w hich h a v e been sh o w n to c o n ta in c a rc in o g e n s .t T h e re a re h o w e v er, c e rta in a n a to m ic a l a n d physiological differences w h ic h a ffect th e p h y s io th e ra p is t in his o r her w o rk . G E N E R A L C O N S ID E R A T IO N S . I. T he B a n tu ’s perception o f disability is m uch less m arked th a n t h a t o f th e E uropean. N u m e ro u s e x am p les o f th is c a n b e c ite d . A n a d u lt B a n tu i m ale a tte n d e d th e o u tp a tie n t d e p a rtm e n t c o m p la in in g o f a n ' u lce r o n h is little finger. I t w as ob v io u sly a tro p h ic ulcer d u e to a n u ln a r p a lsy a n d th e p a tie n t a d m itte d h a v in g been s ta b b e d in th e elb o w re g io n fo u r m o n th s e arlie r. H e had n o t n o tic e d t h a t h e w as c o m p le te ly a n a e sth e tic o ver th e ulnar n e rv e d istrib u tio n , a n d th e p a ra ly sis o f th e in te ro sse i had b e e n sh ru g g e d o ff a s a m in o r disability. A n o th e r p a tie n t a tte n d e d h o sp ita l fo r a h y d ro c ele, a n d on r o u tin e e x a m in a tio n it w as n o te d t h a t h e h a d a n o ld dislo­ c a te d sh o u ld e r, w h ic h h e a d m itte d h a d b e e n c a u se d by a fall seven y e ars e arlie r. II . T h is la c k o f perception o f d.sability is probably associ­ a te d w ith a h igher p ain threshold. A lth o u g h th e u rb a n is e d B a n tu is b eg in n in g to a p p ro a c h th e E u ro p e a n ’s a ttitu d e to p a in , th e re is n o d o u b t th a t on th e w h o le h e is m o re sto ic a l to p a in w hose cau se a n d origin is o b v io u s, fo r exam p le, w o u n d s a n d fra c tu re s. How ever, w h e n th e p a in is o f o b sc u re o rig in , such a s th a t o f pleurisy, h e is liable to a sso c iate it w ith th e p re sen c e o f a sn a k e or c ra b , d u e t o w itc h c ra ft, a n d u n d e r th ese c irc u m stan c es may d e velop a “ fe a r c o m p le x ” a n d b e even w o rse th a n th e average E u ro p e a n in h is re a c tio n to p a in . I I I . A fte r injury th e B a n tu re h ab ilitate s m ore quickly and overcom es his disability m ore easily. F o r ex am p le, a fte r im m o b ilisin g a n elb o w fo r fo u r or five w eeks in a c o lla r-a n d -c u ff sling fo r a su p ra co n d y la r fra c tu re , th e a v era g e B a n tu ch ild recovers full fu n c tio n in ai m u c h s h o rte r tim e w ith a m in im u m o f p h y sio th e ra p y . This* is so o b v io u s th a t m a n y cases in th e “ fra c tu re clinic” are n o t even se n t to th e p h y sio th e ra p y d e p a rtm e n t fo r treatm ent. S P E C IF IC C O N S ID E R A T IO N S . I. T he B a n tu ’s pigm ented skin. I t is a well k n o w n fa ct th a t th e T ra n s v a a l, situ a te d on a h ig h p la te a u h a s o n e o f th e hig h est incidences o f sk in cancer fo r E u ro p e a n s , w hereas th e freq u e n c y o f sk in c a n c e r fo r the B a n tu is very lo w .t T h is h ig h incidence in E u ro p e a n s is a lm o s t c e rta in ly d u e to th e a c tio n o f u ltra -v io le t ra y s which a re m u c h m o re p o te n t in th e h ig h e r a ltitu d e s w hereas the p ig m e n t in th e B a n tu ’s skiri a c ts as a filter. T h is protective m e c h an ism o f th e B a n tu ’s p ig m e n te d skin h a s its affect in th e p h y sio th e ra p y d e p a rtm e n t. T h e e ry th e m a d ose for U .V .R . is c erta in ly h ig h er, a n d seem s to v a ry trem endously a n d is som etim es difficult to ju d g e w h e n th e sk in is very d a rk . I I . H e a d In ju rie s: T h e re h a b ilita tio n o f B a n tu p a tie n ts w ith c e re b ra l injuries is a serious p ro b le m in th e p h y sio th e ra p y d e p a rtm e n t. His *Jokl. E. Clinical Proceedings. V ol: 3. N o . 7. Sept.: 1944. fK een . P. et al. British Journal o f Cancer. 1955. Vol. :IX Page 528. JC o h en L. et al. S.A . M edical Journal. Vol. 26. N oy. 1952. 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. ) March, 1958. P H Y S I O T H E R A P Y Page Five skull is not thicker th an that o f the E u r o p ea n , as is often imagined, bu t the thickness o f his scalp a n d wiryness o f his hair give him a certain pr ot ect io n to injury. T h e Ba ntu seems also to be able to recover fro m cere bral injuries which would be fatal to E ur ope an s, an d the resulting disabilities, h em i­ plegias, paraplegias, ap ha sia s a n d epileptic fits are a serious problem to the physio th era pi st. III. M usculature: The average Ba ntu has a relatively be tte r m usc ula r development t h a n the E u r o p ea n , but there are interesting differences in the relative p ow er o f muscle gr oups. T h is is particularly noticeable in the up pe r limb. W he r e as the muscles of the a r m an d for ear m are a b o u t 2 0 % stron ge r than in the E u ro p ea n , the intrinsic muscles o f the h a nd are if anything weaker, a n d ccrtainly less c o - o rd in a te d for finer movements. IV. W eight Bearing and L ocom otion. With regard to these, there are definate a na t o m ic a l an d physiological differences in the lower limbs. T hi s is m ad e clear in differences in path olo gy. Meniscal injuries o f the knee joint are almost u n k n o w n in the Bantu races. It is a well known fact th at the mining industry gives rise to m any meniscal lesions, a n d this is m ade clear in the R e ef gold mines where meniscal lesions are very c o m m o n in E ur o pe a n s, but despite al least ten times m o r e Ba ntu employees, meniscal lesions are a lm o st u nk n o w n in Africans e mp lo ye d in the gold mines. 1. The follow ing differences have been noted in the anatom y and physiology o f the k n ee joint. (i) The general sh ap e o f the knee jo in t is r o u n d e r in the Bantu, whereas the E ur op ea n knee jo in t is more oval in the transverse diameter. (ii) T he cruciate ligaments and collateral ligaments are more powerful in the Bantu. (iii) The medial co llateral ligament has a closer associ­ ation with the a d d u c t o r m ag n us te n do n , a possible expla natio n o f the relative frequency o f calcification in this area o f the Bantu. (Pellegrini- Streda lesion).* (iv) Hyperextension o f the knee jo in t is less frequent in the Bantu. This is specially noticeable in children who learn to walk with the knees in slight flexion and maint ain this a tti tu d e for a m uch longer period. Th e knee jo int , a hinge jo int , is not ideal for weight be aring a n d it would a p p e a r from the differences noted th a t the Ba ntu has m ain ta in ed to a greater extent the original propulsive m echanism o f the knee joint. 2. In the foot several im portant differences have been noted: (i) The arches in the foot are m or e mo bile in the Ban tu and arc m ore u nd er m u sc ul a r co ntrol. W he n the African put s his full weight on his foot, he a pp ea r s to have a “ flat f o o t " bu t as soo n as the weight is released the arches spring back into position. This is particularly noticeable in the a n te r io r arch where increases in the transverse d ia m e te r o f up to 2 c.m. have been noted d ur i n g weight bearing. T hi s is imp o rt an t in designing fo o tw ear for Africa ns and allowances sho ul d be m a d e for these differences. (ii) The E u r o p e a n takes most o f his weight on his heel and the heads o f ihe first two m eta tar sal s a nd the weight bearing ratio o f the m et a ta rs a ls is 1. 2. 3. 4. 5. In the B a n tu m uch m ore weight is take n on the 5th: m et ata rsa l and the weight bearing ratio is I. 2. 5. 4. 3. In practise this is revealed by the fact that fractures of the 5th: m eta tar sa l cause more disability in the Bantu. C O M M O N C O N D I T I O N S W H I C H M A Y IN V O L V E P H Y S I O T H E R A P Y . Traumatic. Recent injuries keep N o n - E u r o p e a n phy sio th era py d e p a r t ­ ments fully occupied, an d follow a certain pa ttern. Frac tures are of ten m ultiple a n d heal with slow callus form ati on, alt h o u g h stiffness a fte r long immo bi lis at ion is amazingly slight. M u ltip le K eloids fo llo w in g scarification by a witch doctor. T h e B a n tu 's inherent bellicose n a tu r e an d his childlike reaction to a r g u m e n ts and qua rre ls usually result in the use o f the k n ob k e r ry or the knife to finalise the dispute, and extensive fractures a n d severe sta b w o u n d s are very co m m o n . Severe br ain d a m a g e caus ing hemiplegias, meningitis and brain abscesses is c o m m o n , a n d pe ripheral nerve injuries are seen frequently. Thes e cause m uch difficulty in the ph y sio ­ th er a p y d e p a r t m e n t on a c c ou n t o f the long period o f trea tmen t required. St ab w o u n d s in the chest a nd a b d o m i n a l cavity of ten com pl ica ted by d i a p h r a g m a t ic lesions with su bs equ en t alte rat ion s in a b d o m i n a l an d th or aci c pressures, are very c o m m o n . M a n y o f these cases arrive late for tr eat m en t, an d despite m o d e r n surgical pro c ed ur e s sc ar he rnias are relatively co m m o n . Extensive burns, a result o f primitive c o o ki n g utensils and lack o f kn o wl ed g e a b o u t imfl am m abl e materials, are very c o m m o n . T h e gre ater tendency to keloid fo rm ati o n, well k n ow n in the B a n tu , of ten compl ica tes healing a nd causes s ubs equ en t co nt ra ctu re s. T h e tr ea tm e n t o f these cases is co mplic ate d a n d in most cases plastic surgery, skin grafting, x-ray th er a py a n d pro lo ng ed ph y si o th er a p y are necessary to m ak e the patient fit again. O rthopoedic. T h e frequency o f severe con gen it al deformities is m uch gre ater a m o n g Africans, an d a high p r o p o r t io n o f these, un tr ea te d at birth, arrive in hospital t o o late for phys io ­ th er a p y to have m u ch effect. G r o s s surgery is often necessary *K een P. Clinical Proceedings. V ol. 3. N o . 7. S e p t. 1944. 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 Six P H Y S I O T H E R A P Y March, 1958. S ta b wound in abdom en with herniation o f intestine. B reathing exercises given within 24 hours o f operation. before any for m o f r eh abi lit ati on can take place. How ever m uch is being d o n e to help the sick Afri can by m ean s of cripple care ho m es a n d o r t h o p a e d ic clinics. Os teom yelitis a n d bon e j o i n t tuberculosis, plus con dit io ns following cong enita l syphilis a re very c o m m o n , as are t u m o u r s o f b o n e a nd cartilage. D ef orm it ies following leprosy can be helped by surgery. Inflam m atory. T h e high p r o p o r t i o n o f venereal disease leads to a n u m b e r o f i nf la m m a to r y c o n di ti o ns which may c om e u n d e r the range o f phy sio th era py . C h i e f a m o n g pelvic co n di ti o ns is c hr on ic salpingitis which res po n ds to sh o r tw a ve d iat he rm y. Septic co n d iti on s o f all ki n d s are very c o m m o n , mainly due to the fact th a t the average pati en t waits for c om pl ica tio n to arise before a tt e n di ng hospital. Ga stri tis, cholecystitis, a n d peptic ulcer are relatively rare, possibly due to easy going a nd un hi bit ed t e m p e ra m en t o f the Bantu. Appendicitis, alm ost u n k n o w n in the Bantu thirty years ago, is be com in g m or e a n d m o re frequent in the urb a ni se d e d uc a te d Bantu, suggesting th at appen di cit is is possibly one o f the results o f civilisation. C irculatory. T h e B a n t u rarely suffers fro m c o r o n a r y disease a n d one of the theories p u t for wa rd , t h o u g h by n o m ean s pr oved, is the presence o f a n extra c o ro na r y vessel. Jn a d di ti o n, his simple diet, with its high st a r c h — low fat properties, c on tai nin g less cholesterol th an th a t o f the E u r o p e a n may reduce the possibility o f arteriosclerosis. Hyp er ten sio n, t h ou g h m ore c o m m o n , does not seem to pr o d u c e the sy m p t o m a t ic effects seen in Eu ro pe a ns . H e a r t diseases such as mitrol stenosis a nd end oca rd iti s are less c o m m o n but may follow rh e u m a tic fever which howe ver ru ns a milder cour se in Africa th an in E u ro p e a n countries. T h e high incidence o f syphilis, co n ge n i­ tal o r otherwise, d oes affect the he art a n d blo od vessels. Varicose veins with resulting leg ulcers are occasionally met. N ervous System . Di ss em in ate d sclerosis, tabe s dorsalis, a n d su ba c ut e c o m ­ bined de gen er ati on are hardly ever e n c o u n t e r e d in the Bantu. Poliomye.itis is of ten met in small children bu t rare a m o n g adults, p ro b a b ly because their unhyg ienic living co n di ti o ns give t h e m a gre ater degree o f imm un ity . W he n it do es occur, the response o f the a n te r io r h o r n cells to figh t the disease seems to be re duced leaving a parti cul ar ly flail limb. Pn e u ­ mococcal a n d syphilitic meningitis are fairly c o m m o n as also are delir iu m tremens, a result o f the high an d somewhat h a p h a z a r d alc ohol intake o f the Ba n tu , especially in urban a reas where m an y no xi ou s ad d iti on s are m ad e to the relatively harmless Kaffir beer. Ne rv ou s disorders such as anxiety neurosis a nd functional hysteria when occuri ng are usually severe, a n d a background o f wi tchcraft a n d m a la dj u s tm en t to a complex modern society is in these cases only to o painfully evident. Chest Conditions. T he re is a high incidence o f p u lm o na r y tuberculosis, bronchiectasis, lung abcess, an d e m p y e m a — pulmonary fibrosis a n d p leural effusions. Chest diseases run a more severe a n d ra pid course, possibly du e to low resistance and delay in att e n d in g for tr eat m en t. In largely po pu la te d urban areas, however, the mo st recent devel op men ts in chest surgery a r e av ailable to th e Ba ntu. Fo r e x am pl e the insertion o f plastic valves in ao rti c deficiency has been performed on N o n - E u r o p e a n s . Mobi le x-ray vans posted a t street corners for h o us e h o ld serv ants a r e d oi ng m u ch t o pr ev ent the spread o f chest tuberculosis. G o o d food a n d excellent medical con dit io ns in the “ min es ” c o m b a t oc cu p a tio n a l silicosis. Ma lig na n t Conditions. A l t h o u g h malig nan cy on the whole is pro b ab ly relatively ra re r in the Bantu, certain form s o f canc er are more frequent. N o te ab le a m o n g these is pri ma ry ca n c er o f the liver, cancer o f the nasal sinuses, a n d canc er o f the oesop ha gu s. Malignant m el a n om a is m o r e c o m m o n but runs a less virulent course. C a n c e r o f the cervix is very co m m o n . Various Conditions. D ia be tes is rare, bu t b eco m in g m or e frequent in urban areas. Th yro toxic osis, a n o t h e r stress disease, is rare and cretinism a n d niyxoed em a even m or e so. P S Y C H O L O G I C A L A S P E C T O F T R E A T M E N T It has been seen how the B a n tu will “ put o f f ” coming for tr ea tm e n t, until i nc ap aci tat ion , a n d the failure o f the witch d o c to r s m ak e this no long er possible.* On c e inside he becomes resigned a n d submissive, a n d this a tti tu de o f relax­ a ti o n u nd e r tr ea tm e n t, t og eth er with his high degree of patience a nd long-suffering renders phy si o th era py easier to c arry o u t ; a n d this in spite o f the language difficulties and the different type o f me nta lity o f the African patients. So much so, th at m any physio th era pi sts w h o have w or ke d for any length o f time a m o n g N o n - E u r o p e a n s , are of ten reluctant to go ba ck to E u r o p e a n work . Ma ny people believe that the Bantu is m or e stoical with regard to pain, but this is not entirely true a nd , as explained earlier, a clear distinction must be m ad e between the pain experienced with ordinary, tr a u m a due to wo un d s, fractures, etc., a n d the internal! “ invisible” pa in such a s occurs in pleurisy, renal colic, etc. F o r the latter type of pa in the Ba ntu has a lowered pain th res ho ld a n d if a fte r o p e r at io n he decides th a t his treatment is no t w o r t h the pain involved, he “ gives up the ghost" completely, a fte r which phy si o th era py is well nigh impossible. F o r tu na te ly , such cases a r e in the m inority. A n average patient, following f o r exam pl e a lung o p e ra tio n , responds well in the first few days, relaxing fully with a tube in the side o f his chest, c o ug h in g a n d b re at h in g to o rd er, a n d literally being “ push ed a l o n g ” at a stage when his Eu ropean n ei g h b o u r is still being cal m ed d o w n af ter the operation. Th en , when he shou ld really tu rn the co rner, his progression slackens off, his submissive fatalistic a tti tu de devitalises him; extra vigo rou s exercises are necessary to p ro du c e some sort o f body action, a n d the end result takes longer a q d is no t as g o o d as in the E ur o p ea n . G r o u p w o rk is m or e successful th an individual if there is a g o o d leader. T h e A fr ica n loves to imit ate a n d learns better this way, a fa cto r whi ch c om p e ns a te s for the language difficulties, a n d is mad e use o f in instructing him in various types o f wo rk . His sense o f r h y t h m is high, a n d exercises d on e to music are especially successful. * A l l e n J . C . a n d K e e n P . S ./4 . M e d i c a l J o u r n a l. V o l. 2 8 . D e c .1 9 5 4 . 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. ) March, 1958. P H Y S I O T H E R A P Y Page Seven A s a n o u tp a tie n t h e d o e s n o t alw ay s a tte n d re g u la rly o r com e fo r tre a tm e n t o n tim e. If, o n th e o th e r h a n d , in his own in te rests he is ta k e n o ff tre a tm e n t fo r a w hile, he m ay feel ‘.let d o w n ” in sp ite o f c are fu l e x p la n a tio n s. F o llo w up w ork is especially difficult, as he m ay su d d e n ly d ecide he is c ured— a n d d isc h arg e him self. I n th e field o f re h a b ilita tio n m uch is yet to be d o n e . T he A fric a n e n jo y s p la y in g gam es, b u t I have n o t yet n o tic e d any p a rtic u la r a p titu d e . In th e w earing o f app lia n ce s, a n d in le a rn in g to w a lk o n c ru tc h e s his p ro g ress is ra p id ; b u t c ru tc h p alsies m u st b e care fu lly g u arded a g ain st, o w ing to h is w eak w rists a n d lessend pe rce p tio n o f d isability. M A T E R N IT Y W O R K . A n te -n a ta l classes w o u ld n o t seem to b e as necessary as in the E u ro p e a n w h o is m u c h m o re rid d e n b y fe a r o f p re g ­ n ancy a n d delivery. P o s t-n a ta l exercises a re given, b u t ow ing to the v ast n u m b e rs o f A fric a n w om en h a v in g babies, m ost o f th e cases a ctu ally a d m itte d to h o sp ita l a re k n o w n a b n o rm a litie s. T h e in cre ased sp in a l lo rd o sis o f th e B a n tu fem ale, p ro d u c in g a difference in th e tilt, a n d su b s e q u e n t yshape o f th e pelvis, c a n c a u s e a b n o rm a l a n d difficult ^deliveries. E c to p ic p re g n a n c ie s o c c u r freq u e n tly , a re su lt and cause o f m u ch salpingitis. T R E A T M E N T O F C H IL D R E N . O nce o v e r th e ir p re lim in a ry ne rv o u sn ess, c h ild re n are usually very c o -o p e ra tiv e a n d en jo y th e ir tre a tm e n t, especially if it is given w ith o th e r c h ild re n , as, like a d u lts, they re sp o n d well to g ro u p o rg a n is a tio n a n d a re excellent m im ics. A serious p ro b le m how ever, is th a t o f m a k in g p a tie n ts u n d e r­ sta n d th e im p o rta n c e o f h o m e exercises. 1 he lan g u a g e difficulties to o c a n b e so h a m p e rin g th a t it is a g re a t h elp to the p h y s io th e ra p is t if she c an lea rn a few w o rd s o f th e ir language. T h e re su ltin g c o n ta c t g a in e d w ith th e ch ild a n d response achieved is well w o rth th e e ffo rt involved. C O N C L U S IO N . M y o w n exp erien c e o f N o n - E u r o p e a n h o sp ita ls is th a t th ey a re very h a p p y p laces in w h ich to w o rk . Staffed by E u ro p e a n s w h o h a v e g o n e th e re b e ca u se th ey really like tre a tin g th e B a n tu , a n d by A fric a n s w o rk in g a m o n g th e ir ow n p e o p le , a n a tm o s p h e re o f h a rm o n y a n d go o d w ill is c re a te d w h ich is v e r y J n d u c iv e to recovery o f h e a lth . T h e sm all n u m b e r o f really c h ro n ic c ases e n c o u n te re d , a n d th e a bsence o f th e ty p e o f p sy c h o lo g ic al o v e rla y ex p erien c e d in so m u ch E u ro p e a n w o rk , m a k e s N o n -E u ro p e a n p h y s io th e ra p y , in sp ite o f a ll its difficulties, c rea tiv e a n d hig h ly satisfying. A w o rk in g to g e th e r o f all d e p a rtm e n ts m e a n s th a t th e p a tie n t is seen as a w h o le p e rso n , a n d n o t ju s t as a p h y sio ­ th e ra p y case. In a d d itio n , he gets th e b e st tre a tm e n t possible, b ecause o th e r .d e p a rtm e n ts a re in te re ste d in h is p ro g re s s in o rd e r to fu rth e r th e ir o w n side o f th e tre a tm e n t. F in a lly th e g ra titu d e o f th e p a tie n t h im s e lf b rin g s its ow n re w ard . This article is the result o f observations a t the Johannesburg N on-E uropean H o spital. A C K N O W L E D G E M E N T S . I s h o u ld like to a ck n o w le d g e m y g ra titu d e to th e follow ing p e rso n s w ith o u t w h o se h elp th is a rtic le w o u ld n o t have been p ossible. D r. K. F. M I L L S , T he M e d ic a l Superintendant, Johannes­ burg H o s p ita l, fo r p e rm iss io n to p u b lis h th e article. D r. P. K E E N , T he M e d ic a l A d m in istra tiv e O fficer, the N on-E uropean H o sp ita l, Johannesburg, f o r a ssista n c e given in th e c o n s tru c tio n o f th e article , a n d in th e c h o o sin g o f p h o to g ra p h s . M is s L O I S D Y E R , P hysiotherapist, R oan A nte lo p e Copper M in e H o sp ita l, L uanshya, N . R hodesia, fo r re a d in g a n d a m e n d in g th e final d ra ft. C H R IS T M A S C A R D S R E C E IV E D , 1957. N a t. A ss. o f P h y s., Isra e l. D anske P y s io te rp e u te r. N o rth e rn T ra n s v a a l B ra n c h S .A .S .P . H eilgym nastiek M a ssag e & P h y sio te c h n ie k N e d . G e n o o ts k a p F .N .B .K . B russels. P ro te a H o ld in g s. M r. E . B ro o k e s. jMiss M a rg o ry C a tt. D r. A . L . L om ey. K uinnliga Leg. S ju k g y m n aste rs R ik s fo rb u n d . A u stralian P h y s io th e ra p y A ssn. F e d e ra l C o u n c il. A u stralian P h y s io th e ra p y A sso c ia tio n . New Z e a la n d Society o f P h y sio th e ra p ists. Miss B. H . S etzer. U nited C e re b ra l P alsy A ss. o f S.A . E x ec u tiv e a n d Staff. Z en tralv e rb an d e s K ra n k e n g y m n a stik . e.V. M r. A . R o th b e rg . Miss M . J. N e ils o n , S e c retary C .S .P . Miss G . M . G riffin . P re sid e n t W .C .P .T . N a tio n a l C o u n c il fo r C a re o f C rip p le s. N o rsk e S y k e g y m n aste rs L a n d s fo rb u n d . Miss Jo y c e C ro sb y . “ C olonial M u tu a l.” W estern P ro v in c e B ra n c h S .A .S .P . A m erican P hysical T h e ra p y A ssociation. “ A valon.” JO U R N A L S R E C E IV E D “ P h y s io th e ra p y .” C h a rte re d Society o f P h y sio th e rap y . S.A . M e d ica l J o u rn a l. : M e d ic a l P ro c e ed in g s. S.A . J o u rn a l fo r a d v a n c e m e n t o f M e d ic a l Science. R e h a b ilita tio n in S.A . P u b lish e d b y D e p t, o f L a b o u r fo r S.A . R e h a b ilita tio n C o u n c il. T h e P h y s io th e ra p y R e v ie w ., A m e ric a n P hysical T h e ra p y A sso c ia tio n . J u n e — N o v e m b e r, 1957. H e ilg y m n a stie k M a ss a g e en P h y s io te c h n ie k . N e d e rla n d sc h T y d sc h rift. S ju k g y m n aste n . K v in n lig a L e g itim e ra d e S ju k g y m n aste rs R ik s fo rb u n d . S y k e g y m n aste r. N o rs k e S y k e g y m n aste rs L a n d s fe rb u n d . F in la n d s M e d e k a lg y m n a st. T id s k rift fo r D a n s k e F y s io te ra p e u te r. R e v u e des K in e sith e ra p e u te s . O rg a n e d e la F e d e ra tio n des M a ss e u rs— K in e s ith e ra p e u te s d e F ra n c e e t de l’U n io n F ra n ? a is . K ra n k in g y m n a s tik . Z e n tra lv e rb a n d e s K ra n k e n g y m n a stik . e.V . - J o u rn a l o f S.A . L o g o p o e d ic Society. M e m b e rs w h o w o u ld c a re to r e a d a n y o f th e a bove jo u r n a ls m ay b o rro w th e m fo r a p e rio d o f o n e m o n th on a p p lic a tio n to th e E d ito r. A fte r th re e m o n th s th e y will b e sent to th e L ib ra ry , W itw a te rs ra n d U n iv e rsity . 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. )